Aortic valve repair with a newly approved geometric annuloplasty ring in patients undergoing proximal aortic repair: early results from a single-centre experience

Abstract

Objectives: Aortic insufficiency (AI) is common in patients with proximal aortic disease, but limited options exist to facilitate aortic valve repair (AVr) in this population. This study reports 'real-world' early results of AVr using newly FDA-approved trileaflet and bicuspid geometric annuloplasty rings for patients with AI undergoing proximal aortic repair (PAR) in a single referral centre.

Methods: All patients undergoing AVr with a rigid internal geometric annuloplasty ring (n = 47) in conjunction with PAR (ascending +/- root +/- arch) were included. Thirty-six patients underwent AVr with a trileaflet ring, and 11 patients underwent AVr with a bicuspid ring. The rings were implanted in the subannular position, and concomitant leaflet repair was performed if required for cusp prolapse identified after ring placement.

Results: The median age was 58 years [interquartile range (IQR) 46-70]. PAR included supracoronary ascending replacement in 26 (55%) patients and remodelling valve-sparing root replacement with selective sinus replacement in 20 (42%) patients. Arch replacement was performed in 38 (81%) patients, including hemi-arch in 34 patients and total arch in 4 patients. There was no 30-day/in-hospital mortality. Preoperative AI was 3-4+ in 37 (79%) patients. Forty-one (87%) patients had zero-trace AI on post-repair transoesophageal echocardiography, and 6 patients had 1+ AI. The median early post-repair mean gradient was 13 mmHg (IQR 5-20). Follow-up imaging was available in 32 (68%) patients at a median of 11 months (IQR 10-13) postsurgery. AI was ≤1+ in 97% of patients with 2+ AI in 1 patient. All patients were alive and free from aortic valve reintervention at last follow-up.

Conclusions: Early results with geometric rigid internal ring annuloplasty for AVr in patients undergoing PAR appear promising and allow a standardized approach to repair with annular diameter reduction and cusp plication when needed. Longer-term follow-up will be required to ensure the durability of the procedure.

Keywords: Annuloplasty ring; Aortic valve repair.

Figure 1:

Intraoperative photograph of postrepair trileaflet aortic valve using HAART 300 internal geometric annuloplasty ring. This patient did not require adjunctive cusp plication to restore valve competence.

Figure 2:

Intraoperative photograph of postrepair Sievers type I R/l congenital bicuspid aortic valve using HAART 200 internal geometric annuloplasty ring and cleft closure of conjoint cusp. This patient did not require free margin shortening/plication of the reference non-coronary cusp.

Figure 3:

Intraoperative photograph of patient with Loeys–Dietz syndrome undergoing remodelling valve-sparing root replacement with replacement of all 3 sinuses given the diagnosis of a connective tissue disorder. The HAART 300 ring has been placed, and the pathological sinus tissue excised with coronary buttons fashioned.

Figure 4:

Intraoperative photographs of a patient with Marfan syndrome undergoing remodelling valve-sparing root replacement with replacement of all 3 sinuses given the diagnosis of a connective tissue disorder. (A) The sinus portion of the Valsalva graft has been fashioned to create 3 scallops, which are being sewn to the aortic annulus incorporating the supra-annular pledgets of the valve ring. (B) The completed right sinus portion of the graft prior to reimplantation of the right coronary button.

Figure 5:

Mean ± standard error of the mean aortic insufficiency (A), New York Heart Association (NYHA) (B) and aortic valve gradient (C) data over the study period for patients with follow-up data available (aortic insufficiency: n = 32; NYHA: n = 45; gradient: n = 24).