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Aortic annulus and the importance of annuloplasty

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Indian Journal of Thoracic and Cardiovascular Surgery Aims and scope Submit manuscript

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.

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References

  1. Falk V, Baumgartner H, Bax JJ, et al. 2017 ESC/EACTS guidelines for the management of valvular heart disease. Eur J Cardiothorac Surg. 2017;52:616–64.

    PubMed  Google Scholar 

  2. Schafers HJ, Raddatz A, Schmied W, et al. Reexamining remodeling. J Thorac Cardiovasc Surg. 2015;149:S30–6.

    PubMed  Google Scholar 

  3. Schneider U, Aicher D, Miura Y, Schafers HJ. Suture Annuloplasty in aortic valve repair. Ann Thorac Surg. 2016;101:783–5.

    PubMed  Google Scholar 

  4. Iung B, Baron G, Butchart EG, et al. A prospective survey of patients with valvular heart disease in Europe: the euro heart survey on Valvular heart disease. Eur Heart J. 2003;24:1231–43.

    PubMed  Google Scholar 

  5. Detaint D, Jondeau G. Dystrophic aortic insufficiency. Rev Prat. 2009;59:187–93.

    PubMed  Google Scholar 

  6. Stamou SC, Williams ML, Gunn TM, Hagberg RC, Lobdell KW, Kouchoukos NT. Aortic root surgery in the United States: a report from the Society of Thoracic Surgeons database. J Thorac Cardiovasc Surg. 2015;149:116–22 e4.

    PubMed  Google Scholar 

  7. Sievers HH, Hemmer W, Beyersdorf F, et al. The everyday used nomenclature of the aortic root components: the tower of babel? Eur J Cardiothorac Surg. 2012;41:478–82.

    PubMed  Google Scholar 

  8. Anderson RH. Demolishing the tower of babel. Eur J Cardiothorac Surg. 2012;41:483–4.

    PubMed  Google Scholar 

  9. Frater RW, Anderson RH. How can we logically describe the components of the arterial valves? J Heart Valve Dis. 2010;19:438–40.

    PubMed  Google Scholar 

  10. Anderson RH, Devine WA, Ho SY, et al. The myth of the aortic annulus: the anatomy of the subaortic outflow tract. Ann Thorac Surg. 1991;52:640–6.

    CAS  PubMed  Google Scholar 

  11. Sutton JP 3rd, Ho SY, Anderson RH. The forgotten interleaflet triangles: a review of the surgical anatomy of the aortic valve. Ann Thorac Surg. 1995;59:419–27.

    PubMed  Google Scholar 

  12. de Kerchove L, El Khoury G. Anatomy and pathophysiology of the ventriculo-aortic junction: implication in aortic valve repair surgery. Ann Cardiothorac Surg. 2013;2:57–64.

    PubMed  PubMed Central  Google Scholar 

  13. Lansac E, Di Centa I. Dynamic anatomy to aortic annuloplasty: the tale of the ring. In: Yankah C, Weng Y, Hetzer R, editors. Aortic root surgery: the biological solution. Berlin Heigdelberg: Springer-Verlag; 2010. p. 102–32.

    Google Scholar 

  14. Bierbach BO, Aicher D, Issa OA, et al. Aortic root and cusp configuration determine aortic valve function. Eur J Cardiothorac Surg. 2010;38:400–6.

    PubMed  Google Scholar 

  15. Marom G, Haj-Ali R, Rosenfeld M, et al. Aortic root numeric model: annulus diameter prediction of effective height and coaptation in post-aortic valve repair. J Thorac Cardiovasc Surg. 2013;145:406–11.e1.

    PubMed  Google Scholar 

  16. Lansac E, Lim HS, Shomura Y, et al. A four-dimensional study of the aortic root dynamics. Eur J Cardiothorac Surg. 2002;22:497–503.

    CAS  PubMed  Google Scholar 

  17. de Kerchove L, Jashari R, Boodhwani M, et al. Surgical anatomy of the aortic root: implication for valve-sparing reimplantation and aortic valve annuloplasty. J Thorac Cardiovasc Surg. 2015;149:425–33.

    PubMed  Google Scholar 

  18. Khelil N, Sleilaty G, Palladino M, et al. Surgical anatomy of the aortic annulus: landmarks for external annuloplasty in aortic valve repair. Ann Thorac Surg. 2015;99:1220–6.

    PubMed  Google Scholar 

  19. Lansac E, de Kerchove L. Aortic valve repair techniques: state of the art. Eur J Cardiothorac Surg. 2018;53:1101–7.

    PubMed  Google Scholar 

  20. Anderson RH, Mori S. Nomenclature of the components of the aortic root. Eur J Cardiothorac Surg. 2019;55:1020.

    Google Scholar 

  21. Lansac E, de Kerchove L. Reply to Anderson and Mori. Eur J Cardiothorac Surg. 2019;55:1020–1021.

    Google Scholar 

  22. Roman MJ, Devereux RB, Niles NW, et al. Aortic root dilatation as a cause of isolated, severe aortic regurgitation. Prevalence, clinical and echocardiographic patterns, and relation to left ventricular hypertrophy and function. Ann Intern Med. 1987;106:800–7.

    CAS  PubMed  Google Scholar 

  23. Sarsam MA, Yacoub M. Remodeling of the aortic valve anulus. J Thorac Cardiovasc Surg. 1993;105:435–8.

    CAS  PubMed  Google Scholar 

  24. David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg. 1992;103:617–21.

    CAS  PubMed  Google Scholar 

  25. Ranga A, Bouchot O, Mongrain R, et al. Computational simulations of the aortic valve validated by imaging data: evaluation of valve-sparing techniques. Interact Cardiovasc Thorac Surg. 2006;5:373–8.

    PubMed  Google Scholar 

  26. Lansac E, Di Centa I, Varnous S, et al. External aortic annuloplasty ring for valve-sparing procedures. Ann Thorac Surg. 2005;79:356–8.

    PubMed  Google Scholar 

  27. Lansac E, Di Centa I, Bonnet N, et al. Aortic prosthetic ring annuloplasty: a useful adjunct to a standardized aortic valve-sparing procedure? Eur J Cardiothorac Surg. 2006;29:537–44.

    PubMed  Google Scholar 

  28. de Kerchove L, Mastrobuoni S, Boodhwani M, et al. The role of annular dimension and annuloplasty in tricuspid aortic valve repair. Eur J Cardiothorac Surg. 2016;49:428–37.

    PubMed  Google Scholar 

  29. Lansac E, Di Centa I, Raoux F, et al. Aortic annuloplasty: towards a standardized approach of conservative aortic valve surgery. Multimed Manual Cardiothorac Surg: 2007;2007:mmcts.2006.001958.

  30. Lansac E, Di Centa I, Raoux F, et al. An expansible aortic ring for a physiological approach to conservative aortic valve surgery. J Thorac Cardiovasc Surg. 2009;138:718–24.

    PubMed  Google Scholar 

  31. Basmadjian L, Basmadjian AJ, Stevens LM, et al. Early results of extra-aortic annuloplasty ring implantation on aortic annular dimensions. J Thorac Cardiovasc Surg. 2016;151:1280–5.e1.

    PubMed  Google Scholar 

  32. Lenoir M, Maesen B, Stevens LM, et al. Reimplantation versus remodelling with ring annuloplasty: comparison of mid-term outcomes after valve-sparing aortic root replacement. Eur J Cardiothorac Surg. 2018;54:48–54.

    PubMed  Google Scholar 

  33. Oechtering TH, Hons CF, Sieren M, et al. Time-resolved 3-dimensional magnetic resonance phase contrast imaging (4D Flow MRI) analysis of hemodynamics in valve-sparing aortic root repair with an anatomically shaped sinus prosthesis. J Thorac Cardiovasc Surg. 2016;152:418–27.e1.

    PubMed  Google Scholar 

  34. de Kerchove L, Boodhwani M, Glineur D, et al. Valve sparing-root replacement with the reimplantation technique to increase the durability of bicuspid aortic valve repair. J Thorac Cardiovasc Surg. 2011;142:1430–8.

    PubMed  Google Scholar 

  35. Schafers HJ, Bierbach B, Aicher D. A new approach to the assessment of aortic cusp geometry. J Thorac Cardiovasc Surg. 2006;132:436–8.

    PubMed  Google Scholar 

  36. Youssefi P, Di Centa I, Khelil N, Debauchez M, Lansac E. Valve sparing root replacement: remodeling root repair with aortic ring annuloplasty. Ann Cardiothorac Surg. 2019;8:411–4.

    PubMed  PubMed Central  Google Scholar 

  37. Taylor WJ, Thrower WB, Black H, et al. The surgical correction of aortic insufficiency by circumclusion. J Thorac Surg. 1958;35:192–205.

  38. Kunihara T. Annular management during aortic valve repair: a systematic review. Gen Thorac Cardiovasc Surg. 2016;64:63–71.

    PubMed  Google Scholar 

  39. Duran CG. Reconstructive techniques for rheumatic aortic valve disease. J Card Surg. 1988;3:23–8.

    CAS  PubMed  Google Scholar 

  40. Cosgrove DM, Rosenkranz ER, Hendren WG, et al. Valvuloplasty for aortic insufficiency. J Thorac Cardiovasc Surg. 1991;102:571–6.

  41. le Polain de Waroux JB, Pouleur AC, Goffinet C, et al. Functional anatomy of aortic regurgitation: accuracy, prediction of surgical repairability, and outcome implications of transesophageal echocardiography. Circulation. 2007;116:I264–9.

    Google Scholar 

  42. Aicher D, Kunihara T, Abou Issa O, et al. Valve configuration determines long-term results after repair of the bicuspid aortic valve. Circulation. 2011;123:178–85.

    PubMed  Google Scholar 

  43. Navarra E, El Khoury G, Glineur D, et al. Effect of annulus dimension and annuloplasty on bicuspid aortic valve repair. Eur J Cardiothorac Surg. 2013;44:316–22.

    PubMed  Google Scholar 

  44. Carpentier A. Cardiac valve surgery--the "French correction". J Thorac Cardiovasc Surg. 1983;86:323–37.

    CAS  PubMed  Google Scholar 

  45. Haydar HS, He GW, Hovaguimian H, et al. Valve repair for aortic insufficiency: surgical classification and techniques. Eur J Cardiothorac Surg. 1997;11:258–65.

    CAS  PubMed  Google Scholar 

  46. Zakkar M, Youssefi P, Di Centa I, Khelil N, Debauchez M, Lansac E. Isolated aortic valve repair—how to do it and long-term results: external ring annuloplasty. Ann Cardiothorac Surg. 2019;8:418–21.

    PubMed  PubMed Central  Google Scholar 

  47. Fattouch K, Sampognaro R, Speziale G, et al. New technique for aortic valve functional annulus reshaping using a handmade prosthetic ring. Ann Thorac Surg. 2011;91:1154–8.

    PubMed  Google Scholar 

  48. Fattouch K, Castrovinci S, Murana G, et al. Functional annulus remodelling using a prosthetic ring in tricuspid aortic valve repair: mid-term results. Interact Cardiovasc Thorac Surg. 2014;18:49–54.

    PubMed  PubMed Central  Google Scholar 

  49. Schneider U, Hofmann C, Aicher D, et al. Suture Annuloplasty significantly improves the durability of bicuspid aortic valve repair. Ann Thorac Surg. 2017;103:504–10.

    PubMed  Google Scholar 

  50. Schomburg JL, Lahti MT, Ruth GR, et al. Internal aortic annuloplasty: a novel technique. J Investig Surg. 2011;24:222–6.

    Google Scholar 

  51. Rankin JS, Conger JL, Tuzun E, et al. In vivo testing of an intra-annular aortic valve annuloplasty ring in a chronic calf model. Eur J Cardiothorac Surg. 2012;42:149–54.

    PubMed  Google Scholar 

  52. Rankin JS, Mazzitelli D, Fischlein T, et al. Geometric ring Annuloplasty for aortic valve repair during aortic aneurysm surgery: two-year clinical trial results. Innovations. 2018;13:248–53.

    PubMed  Google Scholar 

  53. Lansac E, Di Centa I, Sleilaty G, et al. Long-term results of external aortic ring annuloplasty for aortic valve repair. Eur J Cardiothorac Surg. 2016;50:350–60.

    PubMed  Google Scholar 

  54. Lansac E, Di Centa I, Sleilaty G, et al. Remodeling root repair with an external aortic ring annuloplasty. J Thorac Cardiovasc Surg. 2017;153:1033–42.

    PubMed  Google Scholar 

  55. Lansac E, Bouchot O, Arnaud Crozat E, et al. Standardized approach to valve repair using an expansible aortic ring versus mechanical Bentall: early outcomes of the CAVIAAR multicentric prospective cohort study. J Thorac Cardiovasc Surg. 2015;149:S37–45.

    PubMed  Google Scholar 

  56. de Heer F, Kluin J, Elkhoury G, et al. AVIATOR: An open international registry to evaluate medical and surgical outcomes of aortic valve insufficiency and ascending aorta aneurysm. J Thorac Cardiovasc Surg. 2019;157:2202–2211.

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Acknowledgments

The authors thank Pavel Zacek for his artistic contributions and assistance.

Funding

P.Y. was supported by the Royal College of Surgeons of England Research Fellowship, Dunhill Medical Trust Research Fellowship, and SCTS Ethicon Fellowship. E.L. has consultant agreements with CORONEO, Inc. (www.coroneo.com), in connection with the development of an aortic ring bearing the trade name “Extra-Aortic.”

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  1. Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France

    Pouya Youssefi & Emmanuel Lansac

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  1. Pouya Youssefi
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  2. Emmanuel Lansac
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Correspondence to Emmanuel Lansac.

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Youssefi, P., Lansac, E. Aortic annulus and the importance of annuloplasty. Indian J Thorac Cardiovasc Surg 36 (Suppl 1), 88–96 (2020). https://doi.org/10.1007/s12055-019-00852-9

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