A standardized approach to aortic valve repair is described associating a physiological remodeling of the root, with resuspension of cusp effective height and a subvalvular aortic annuloplasty using an external expansible ring. This device achieves a complete calibrated annuloplasty, in order to increase cups coaptation height and protect the repair.

This is a video-atlas describing the surgical steps of a physiological and standardized approach to aortic valve repair, to treat an aortic root aneurysm associated with grade III to IV eccentric aortic insufficiency on a 41-year old patient with a tricuspid aortic valve (Video 1). Ideal valve sparing root replacement procedure should treat dilatation of the aortic annular base, while preserving dynamics of the aortic root with vortices (neosinuses of Valsalva), root expansibility (interleaflet triangles) as well as restoring cusp coaptation (1-5).



Video 1

Valve sparing root replacement: the remodeling technique with external ring annuloplasty



The two original valve sparing procedures - remodeling of the aortic root and reimplantation of the aortic valve - focused on root reconstruction to reduce the dilated root diameters in order to restore proper valve function (6,7). The reimplantation technique performs external subvalvular aortic annuloplasty but withdraws the sinuses of Valsalva and includes the interleaflet triangles within a graft tube, thus impairing root dynamics (8-11). In contrast, the remodeling technique provides more physiologic movements of the cusps within three reconstructed neo-sinuses, thus preserving root expansibility through the interleaflet triangles, but without addressing annular base dilation (8-13). In vitro and in vivo studies have documented that cusp motion and flow patterns across the reconstructed aortic root are more physiologic (I) after remodeling of the aortic root than after reimplantation of the aortic valve, and (II) after procedures using a prosthetic conduit fashioned with neo- sinuses of Valsalva than without (9-11). Numerous technical variations have aimed to associate preservation of aortic root dynamics with the treatment of dilated native annulus (14,15). This resulted in a lack of standardization and limited their widespread application.

Furthermore, most failures with valve sparing techniques are due to residual cusp prolapse, either as a primary unrecognized lesion or secondary to an induced prolapse after root reconstruction (12,16). Schafers et al. proposed to address this issue with a dedicated caliper in order to restore cusp effective height up to 8-10 mm (1,4,12). Therefore we suggest a standardized approach of aortic valve repair addressing both the aorta and the valve, associating a physiological reconstruction of the aortic root according to the remodeling technique, with resuspension of cusp effective height and an expansible subvalvular ring annuloplasty (CAVIAAR technique) (Figure 1) (2,17-19).



Figure 1

Remodeling of the aortic root associated to an external subvalvular aortic annuloplasty (CAVIAAR technique), combining advantages of the original remodeling and reimplantation techniques



To address the need for a dedicated aortic annuloplasty device, we designed a new expansible aortic ring in order to achieve a complete and calibrated annuloplasty in diastole, while maintaining systolic expansibility of the aortic root (Extra-Aortic™, CORONEO, Inc., Montreal, QC, Canada) (19). As such, cusp coaptation height is increased, reducing stress on the cusps and protecting the repair.

/pdf/valve-sparing-root-replacement-the-remodeling-technique-with-zwcrwoujsq.pdf

Valve sparing root replacement: the remodeling technique with external ring annuloplasty.

Aortic root aneurysms are characterized by dilation of both functional aortic annulus diameters (aortic annular base and sino-tubular junction), preventing coaptation of otherwise pliable valves often associated with cusp prolapse. Multiple techniques of aortic valve sparing procedures try to restore the complex interplay of aortic valve and root function in order to improve durability of the repair. Ideally, procedures should treat dilatation of the aortic annular base, while preserving dynamics of the aortic root with vortices (neosinuses of Valsalva) and root expansibility (interleaflet triangles). We describe a standardized approach, combining the advantages of both the remodeling and reimplantation technique by adding an external subvalvular ring annuloplasty to the physiological remodeling of the aortic root. To address the need for a dedicated aortic annuloplasty device, a new expansible aortic ring was designed in order to achieve a complete and calibrated annuloplasty in diastole, while maintaining systolic expansibility of the aortic root.

Remodeling of the aortic root combined to an expansible aortic ring annuloplasty.

Experience with repair of isolated aortic insufficiency (AI) is increasing, encouraged by the results of valve-sparing procedures. Current techniques associate the treatment of cusp prolapse with the reduction of the almost constantly dilated aortic annular base diameter. Although few series provided satisfying mid-term results in selected patients, the lack of standardization limits their widespread use. We developed a standardized aortic valve repair procedure for isolated AI (sinuses of Valsalva ≪40 mm), combining cusp repair with a subvalvular external aortic ring annuloplasty. Alignment of cusp free edges and resuspension of the cusp effective height are performed prior to implantation of the external subvalvular ring. The prosthetic ring is of an open configuration to allow its placement externally to the aorta and below the coronary arteries without detaching them from the aortic wall. Ring size is undersized by one size relative to annular base inner diameter measured intraoperatively. The aim of the ring is to reduce the dilated aortic annular base diameter while increasing coaptation height.

An external open ring for isolated aortic valve repair.

Objectives The primary aim of this retrospective study was to evaluate short-term (one-to-six months) and mid-term (six-to-forty-eight months) results of aortic valve-sparing procedures. The second endpoint was to compare the results with the group of patients undergoing mechanical aortic valve replacement during the same period. Methods Between April 2008 and May 2012 at our institution, we treated 76 patients either with ascending aorta/root aneurysm/dissection or with isolated aortic regurgitation. A total of seventy-six patients undergoing aortic valve surgery. Results Analyzed parameters were divided into two parts as function of time. In the first part, i.e. during hospitalization, the mortality, duration of hospitalization, duration of extra corporeal circulation (ECC), and duration of cardiac arrest (CA) were compared and assessed. In the second part, i.e. during monitoring of the patients after their discharge from hospital (one-to-six months, and six-to-forty-eight months), the grade of postoperative AR aimed mainly at the group of aortic valve-sparing operations (subgroups A1, A2, A3), postoperative peak gradient, presence of thromboembolic and bleeding complications, postoperative endocarditis and need for reoperation or hospitalization due to cardiac reasons were analyzed. Conclusion Based on our first experience, we believe that in spite of higher technical difficulty, the aortic valve-sparing operations can be possibly performed with the same or respectively lower rate of postoperative morbidity and mortality. Presented results show that compared with the aortic valve replacement, the aortic valve-sparing operation is a promising method, and an interesting therapeutic alternative for patients. After proper indications, we consider it to be a method of choice (Tab. 6, Fig. 7, Ref. 28).

/pdf/aortic-valve-sparing-operation-versus-bentall-and-mechanical-4ul3b1fagc.pdf

Aortic valve-sparing operation versus Bentall and mechanical aortic valve replacement--midterm results.

Infective endocarditis is a serious disease that carries significant morbidity and mortality. Adequate treatment is based on a high degree of clinical suspicion, accurate microbiologic diagnosis, and high-quality imaging. Echocardiography has been shown to be a fundamental tool for diagnosis and management. Currently accepted Duke criteria include blood cultures and echocardiography. Transthoracic and transesophageal echocardiography play a critical role in the decision-making process, especially when surgical treatment is contemplated. Because infective endocarditis is considered a medical and surgical disease, and considering that the current rate of surgery is about 50%, echocardiography has definite value in preoperative diagnosis and surgical planning, intraoperative confirmation of lesions and quality of repair or replacement before and after cardiopulmonary bypass, and postoperative assessment.

Role of Echocardiogram in Decision Making for Surgery in Endocarditis

Imaging of the aortic root.- Perioperative imaging for assessing aortic and mitral valve diseases and surgical procedures.- Innovations in aortic valve surgery.- The aortic root.- Percutaneous transluminal aortic valve replacement: The CoreValve prosthesis.- Transapical aortic valve implantation - A truly minimally invasive option for high-risk patients.- From minimally invasive to percutaneous aortic valve replacement.- Sutureless equine aortic valve replacement.- The Ross operation: Aortic valve and root replacement with pulmonary autograft.- Pulmonary autograft or aortic allograft for surgical treatment of active infective aortic valve endocarditis: a review of the literature.- The Ross operation: two decades of clinical experience.- Aortic valve repair and valve sparing root procedures.- The bicuspid aortic valve.- From dynamic anatomy to conservative aortic valve surgery: the tale of the ring.- Yacoub/David techniques for aortic root operation: success and failures.- Aortic annuloplasty.- Correction of aortic valve incompetence combined with ascending aortic aneurysm by relocation of the aortic valve plane through a short-length aortic graft replacement.- Using BioGlue to achieve hemostasis in aortic root surgery.- Endocarditis.- Challenges in the surgical management of infective endocarditis.- Clinical results of the Shelhigh (R) stentless bioprosthesis in patients with active infective endocarditis:.- Double valve endocarditis and evolving paraannular abscess formation.- Aortic root abscess: reconstruction of the left ventricular outflow tract and allograft aortic valve and root replacement.- Implantation techniques of freehand subcoronary aortic valve and root replacement with a cryopreserved allograft for aortic root abscess.- Surgery for atrial fibrillation.- Cryoablation for the treatment of atrial fibrillation in patients undergoing minimally invasive mitral valve surgery.- Minimally invasive endoscopic ablation on the beating heart in patients with lone atrial fibrillation.- Hemodynamic evaluation of the bioprosthetic aortic valves.- Evaluation of bioprosthetic valve performance as a function of geometric orifice area and space efficiency- A reliable alternative to effective orifice area.- Long-term results of biological valves.- Stented and stentless aortic bioprostheses: competitive or complimentary?.- Edwards Prima Plus Stentless Bioprosthesis: Long-term clinical and hemodynamic results.- The Cryo-Life O'Brien stentless valve: 1991-2008.- Medtronic stentless Freestyle (R) porcine aortic valve replacement.- The ATS 3f Aortic Bioprosthesis.- The Vascutek Elan stentless porcine prosthesis - The Glasgow experience.- Sorin pericardial valves.- The changing role of pericardial tissue in biological valve surgery: 22 years' experience with the Sorin Mitroflow stented pericardial valve.- 20 years' durability of Carpentier-Edwards Perimount stented pericardial aortic valve.- Twenty-year experience with the St. Jude Medical Biocor bioprosthesis in the aortic position.- 20-Year durability of bioprostheses in the aortic position.- Clinical results including hemodynamic performance of the Medtronic Mosaic porcine bioprosthesis up to ten years.- Aortic root replacement with the BioValsalva prosthesis.- Valve replacement in renal dialysis patients: bioprostheses versus mechanical prostheses.- Replacement of bioprostheses after structural valve deterioration.- Predictors of patient's outcome.- Predicted outcomes after aortic valve replacement in octogenarians with aortic stenosis.- Predicted patient outcome after bioprosthetic AVR and the Ross operation.- Anticoagulation.- Anticoagulation and self-management of INR: mid-term results.- Tissue engineering.- Biomatrix-polymer hybrid material for heart valve tissue engineering.- Standards for the in vitro fabrication of heart valves using human umbilical cord cells.- Tissue engineering with a decellularized valve matrix.- Regularatory issues on tissue valves.- Human tissues for cardiovascular surgery: regulatory requirements.- Concluding remarks.- Concluding remarks.- Atlas of biological valves.- Atlas of biological valves.

Aortic root surgery : the biological solution

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Aortic root surgery : the biological solution