Aortic annulus and the importance of annuloplasty

Abstract

Dystrophic aortic insufficiency accounts for the majority of Western cases of aortic insufficiency and can be divided into the three phenotypes of isolated aortic insufficiency, dilated aortic root, and dilated ascending aorta. Each of these phenotypes is associated with a dilated annulus and/or sinotubular junction. Recent international guidelines recommend reimplantation or remodeling with aortic annuloplasty for valve-sparing root replacement, as well as consideration of aortic valve repair in cases of aortic insufficiency. A dilated aortic annulus is a major risk factor for failure of aortic valve repair procedures, indicating the need to address the annulus at the time of aortic valve or root repair. Calibrated annuloplasty should be performed at sub- and supravalular levels in order to restore the ratio of the sinotubular junction and annulus and be adapted according to the phenotype of the root and ascending aorta. Standardization of aortic valve repair techniques with use of a calibrated annuloplasty will improve dissemination of techniques and rate of aortic valve repair. Current medical evidence shows that aortic valve repair is safe, produces better quality of life, and reduces valve-related mortality compared to prosthetic valve replacement.

Keywords: Aneurysm; Aortic annuloplasty; Aortic insufficiency; Bicuspid; Remodeling; Valve repair; Valve sparing root replacement.

Fig. 1

Algorithm of management of the aorta in aortic valve repair for AI. Drawing by Pavel Zacek (used with kind permission)

Fig. 2

The aortic root opened with the cusps removed. The blue line indicates the sinotubular junction. The green line indicates the aortic annulus. The dotted line shows the subvalvular dissection plane. The schematic three-dimensional aortic annular views at the bottom show the cusp insertion points (red line), plane of dissection (thick black line), and the aortic annulus (dotted line) viewed from each sinus

Fig. 3

Standardized steps in remodeling of the aortic root associated with cusp effective height resuspension and external expansible subvalvular (Extra_Aortic, Coroneo Inc., QC, Canada) aortic ring annuloplasty: a five “U” stitches are circumferentially placed, inside out, in the subvalvular plane except at the level of the commissure between the noncoronary and right coronary sinuses where a sixth stitch is placed externally to avoid damage to the membranous septum. Remodeling of the aortic root is then performed by scalloping a bulged graft. b Measure of cusp effective height with the caliper. c The anchoring “U” stitches are passed through the inner aspect of the prosthetic aortic ring and tied down externally in the subvalvular position

Fig. 4

Different external annuloplasty techniques by Taylor 1958 (a), Cabrol 1966 (b), Carpentier 1983 (c), Duran 1993 (d), Haydar 1997 (e), Lansac 2003 (Coroneo, Inc. Extra-Aortic Ring) (f), Schafers 2009 (suture annuloplasty) (g), Fattouch 2011 (h), Rankin 2011 (HAAR Ring) (i). Reprinted by permission from Springer Nature, Gen Thorac Cardiovasc Surg. Annular management during aortic valve repair: a systematic review. Kunihara T. 2016 [38]

Fig. 5

Standardized steps in isolated aortic valve repair with double ring repair: a 6 ‘U’ stitches are circumferentially placed in the subvalvular plane except at the level of the commissure between the non- and right coronary sinuses, where it is placed externally. b Alignment of cusp-free edges. c Sinotubular junction ring placement. d Cusp resuspension (effective height > 9 mm). e Open ring placement below the coronary arteries. f Aortotomy closed; final appearance. g Central plication of excess tissue for bicuspid repair. h In the case of asymmetric bicuspid commissural orientation < 170, a plication of the sinus at the level of the raphe is added. LCA: left coronary artery