An expansible aortic ring to preserve aortic root dynamics after aortic valve repair

Abstract

Objectives: Aortic annuloplasty and preservation of root dynamics have been described as factors for durability of aortic valve repair. The objective of this study is to document the first clinical analysis of root dynamics after a standardized valve-sparing procedure for root aneurysms associating a calibrated expansible external aortic ring annuloplasty with a physiological remodelling of the aortic root (CAVIAAR technique: Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysm of the Aortic Root).

Methods: Of the 600 patients operated on with the CAVIAAR technique, 60 consecutive patients from a single team underwent double independent reading of the echocardiographic analysis performed in the operative period and yearly after discharge until a maximum of 5-year follow-up. Forty-four patients had preoperative aortic insufficiency (AI) ≥grade 2 (73.3%) and 29 patients (48%) had bicuspid valves.

Results: The expansible aortic ring (median size 27 (25-27) mm) significantly reduced the aortic annular base diameter (from 28 (25-29) mm to 23 (21-24) mm) (P < 0.001) without a significant median transvalvular gradient increase (P = 0.545). Cusp repair was performed in 55 patients (91.7%). Operative mortality was 1.7% (1). During the median 19-month (95% confidential interval [11-26]) follow-up, annular diameter and cusp effective height remained stable. There were no valve-related reoperations. One patient died at 6 months postoperatively from congestive heart failure. Freedom from AI ≥grade 2 was 100% at 1-year follow-up and 96.8% ± 3.2% at 3-year follow-up. Systolic root expansibility of the four echocardiographic diameters (aortic annular base, sinuses of Valsalva level, sino tubular junction and tubular aorta) was maintained, throughout the follow-up period with the aortic annular base expansibility coefficient having consistently higher values than the three other levels.

Conclusions: The expansible aortic ring achieved a complete calibrated external annuloplasty and maintained dynamics of the aortic root at mid-term follow-up. Whether this could be a factor for durability of aortic valve repair is currently under evaluation through the CAVIAAR study 10-year follow-up.

Keywords: Annuloplasty; Dynamic anatomy; Effective height; Expansible aortic ring; Remodelling of the aortic root; Valve sparing.