Editorial
Effectiveness of Prosthetic Ring Annuloplasty for Aortic Valve Repair
Khalil Fattouch*
*Corresponding author: Khalil Fattouch, Department of Cardiovascular and Thoracic Surgery, GVM Care and Research, Maria Eleonora Hospital, Italy
Published: 27 Aug, 2018
Cite this article as: Fattouch K. Effectiveness of Prosthetic
Ring Annuloplasty for Aortic Valve
Repair. Clin Surg. 2018; 3: 2087.
Editorial
Aortic valve repair (AVR) techniques have been growing fast in the last 2 decades. The geometric
relationship and dynamic behaviour of aortic root components have been seen to ensure valve
competence when leaflets have no structural lesions. Aortic leaflets lesions and/or dilatation of the
ascending aorta and root lead to aortic regurgitation that need surgical repair. Repair procedures
usually aimed to treat the leaflets dysfunction and restore the annulus.
The aortic annulus is the tightest part of the functional aortic annulus complex and is defined as
a virtual ring at the level of the hinge points of the aortic valve leaflets.
Since the introduction of the concept of valve repair in the field of cardiac surgery, the lesson
learned from mitral valve showed that the annuloplasty is an important component of valve repair
because serves to reduce annular dimension appropriately for leaflet coaptation and provides
annular stability to prevent late annular dilatation and repair failure.
Currently established aortic annuloplasty techniques include sub-commissural annuloplasty
and stabilization of the annulus by external or internal ring prosthesis. Each approach has its pros
and cons, and the decision regarding the ideal technique is made in the context of patient related
factors such as valvular and aortic root pathology or is made by surgeon’s preference.
Today, Sub-Commissura plasty (SC), described by Cabrol et al, represents the first surgical
choice in AVR [1]. Through this type of annuloplasty, only a component of the aortic annulus (the
nadir or aorto-ventricular junction) is corrected, leaving the other components (the sino-tubular
junction) untreated. On the other hand, closing the commissures by SC increase stress at the level
of cusps belly leading to early repair failure. It is probably the main reason why performing this
reparative technique is still controversial. During the SC plasty, is not clear how decide the exact
amount of the annulus diameter reduction. The surgeons just include and fix the commissures by
the sutures, always considering that their movements are fundamental to preserve valve motion and
reduce the stress on the aortic leaflets. Moreover, the suture placed in the sub-commissural position,
between the right coronary cusp and the other cusps, is placed at the level of the inter ventricular
septum, and so it could move down the ventricle muscle. All these situations can be considered
reasons why different authors experienced failure of the SC plasty.
In last decade, other surgical techniques were attempted as a possible key to provide stabilization
of the aortic annulus over time. Fattouch et al (internal ring, IR) and Lansac et al (external ring,
ER) propose two different techniques aimed to stabilize the aortic ring [2,3]. De Kerchove et al.
compared in vitro the 3 different techniques of aortic annuloplasty [4].
They showed that effective orifice area decreased significantly with each annuloplasty technique
compared with baseline but mean Trans valvular pressure drop was significantly higher in the ER
and IR vs. SCA. Annuloplasty reduced valve opening and closing time in comparison to baseline.
Echocardiography confirmed that the annulus experienced a greater reduction with the ER and IR
vs SCA. A narrowing of the lower third of the sinuses of Valsalva was observed after the ER, and
sub valvular narrowing was observed after the IR. Valve coaptation increased with all annuloplasty
techniques.
So, it’s clear that the external and internal ring annuloplasty have greater potential to reduce
annulus diameter in comparison to SCA. The IR induced a sub valvular remodeling, whereas the ER
induced a para valvular remodeling.
In conclusion, there is no evidence of the superiority of one technique over another. Few
annuloplasty devices have been used clinically and are now available in market. Although, aortic
valve annuloplasty are mandatory for the AVR to improve long
term outcomes further investigations are necessary to found the best
annuloplasty procedures. At the same time, there is uncertainty as to
the best mode of application of such a device (external vs. internal)
and the best type of material (expansible, flexible or rigid).
References
- Cabrol C, Cabrol A, Guiraudon G, Bertrand M. Treatment of aortic insufficiency by means of aortic annuloplasty. Arch Mal Coeur Vaiss. 1966;59(9):1305-12.
- Fattouch K, Sampognaro R, Speziale G, Ruvolo G. New Technique for Aortic Valve Functional Annulus Reshaping Using a Handmade Prosthetic Ring. Ann Thorac Surg. 2011;91:1154-8.
- Lansac E, Di Centa I, Bonnet N, Leprince P, Jault F, Rama A, et al. Aortic prosthetic ring annuloplasty: a useful adjunct to a standardized aortic valve-sparing procedure? Eur J Cardiothorac Surg. 2006;29(4):537-44.
- Laurent de Kerchove, Vismara R, Mangini A, Fiore GB, Price J, Noirhomme P, et al. In vitro comparison of three techniques for ventriculo-aortic junction annuloplasty. European Journal of Cardio-Thoracic Surgery. 2012;41(5):1117-24.