Aortic annuloplasty: Subcommissural, intra-annular suture techniques, external and internal rings

Abstract

Aortic valve repair and valve-preserving root replacement have evolved into increasingly practiced procedures. With increasing experience, the need for an annuloplasty has become more evident, at least for pathologies that involve annular dilatation. To understand the effect of an aortic annuloplasty, it is necessary to know the details of aortic valve and root anatomy. Geometrically, the functional annulus is best defined as the virtual basal ring, ie, plane of the cusp nadirs. The sinotubular diameter also influences the aortic valve form, at least in tricuspid valves. Different annuloplasty concepts have been developed for isolated valve repair or in combination with root remodeling, such as subcommissural sutures, suture annuloplasty, external, and internal rings. Subcommissural sutures do not consistently provide durable annular stabilization. More positive results have been published for circular approaches, ie, suture annuloplasty, external, or internal rings. The results of different techniques are difficult to judge because most outcome data have not been analyzed with control of confounding predictors of repair failure. The evidence that annuloplasty improves aortic valve function and repair durability is best documented for isolated bicuspid aortic valve repair. In summary, the addition of annuloplasty to aortic valve reconstruction is probably a useful tool to improve valve competence and stabilize the repair. This is best documented for isolated bicuspid valve repair and circular approaches. The relative benefit of individual concepts is difficult to judge because of lack of both control groups and control of confounding factors.

Keywords: annuloplasty; aortic valve; aortic valve reconstruction.

Determinants of aortic valve and root geometry. gH, Geometric height; eH, effective height.

Figure 1

Geometric determinants of aortic valve form. Schematic drawing of the geometric determinants of aortic valve form. The anatomic annulus is a crown-shaped structure. The probably more important root dimensions are the virtual basal ring (= functional annulus) and sinotubular junction. gH, Geometric height; eH, effective height.

Figure 2

Localization of the ventriculoaortic junction. The anatomic ventriculoaortic junction differs from the functional annulus and is best seen by the extent of muscle in the sinus portion of the root. It is not infrequently more than 5 mm above the level of the annulus, particularly in the right sinus. NCC, Noncoronary cusp; LCC, left coronary cusp; RCC, right coronary cusp.