An external open ring for isolated aortic valve repair.

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 aortic ring: from physiologic reconstruction of the root to a standardized approach for aortic valve repair.

OBJECTIVE: We suggest standardizing aortic valve repair using a physiologic approach by associating root remodeling with resuspension of the cusp effective height and external subvalvular aortic ring annuloplasty. METHODS: A total of 187 patients underwent remodeling associated with subvalvular aortic ring annuloplasty (14 centers, 24 surgeons). Three strategies for cusp repair were evaluated: group 1, gross visual estimation (74 patients); group 2, alignment of cusp free edges (62 patients); and group 3, 2-step approach, alignment of the cusp free edges and effective height resuspension (51 patients). The composite outcome was defined as recurrence of aortic insufficiency of grade 2 or greater and/or reoperation. RESULTS: The operative mortality rate was 3.2% (n = 6). Treatment of a cusp lesion was most frequently performed in group 3 (70.6% vs 20.3% in group 1 and 30.6% in group 2, P < .001). Nine patients required reoperation during a follow-up period of 24 months (range, 12-45), 6 patients in group 1 and 3 patients in group 2. At 1 year, no patients in group 3 presented with composite outcome events compared with 28.1% in group 1 and 15% in group 2 (P < .001). Residual aortic insufficiency and tricuspid anatomy were independent risk factors for the composite outcome in groups 1 and 2. The annulus diameter, the presence of Marfan syndrome, and cusp repair had no effect on aortic insufficiency recurrence or reoperation. CONCLUSIONS: A standardized and physiologic approach to aortic valve repair, considering both the aorta (root remodeling) and the valve (resuspension of the cusp effective height and subvalvular ring annuloplasty) improved the preliminary results and might affect their long-term durability. The ongoing Conservative Aortic Valve Surgery for Aortic Insufficiency and Aneurysm of the Aortic Root (CAVIAAR) trial will compare this strategy to mechanical valve replacement.