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Aortic Valve Sparing Surgery: The Use of the Coroneo Extra-Aortic Annuloplasty Ring

Róbert Novotný, Jaroslav Hlubocký, Petr Mitáš, Lenka Brlicová, Jaroslav Lindner

Abstract


Ideal prosthetic aortic valve should maintain excellent hemodynamic characteristics that are sustainable during varying hemodynamic conditions and demands, have minimal trans-aortic pressure gradients, should be durable in the long term, resist thrombus formation without the need for anticoagulation and be straightforward to implant. Unfortunately, the ideal prosthetic aortic valve does not yet exist. This review critically evaluates available-to-the-surgeon options.Critical evaluation of relevant literature sources available on PubMed with the emphasis on current situation and new trend in the aortic valve sparing procedures. Current prosthetic devices are associated with complications such as valve thrombosis and thromboembolic events, bleeding events associated with anticoagulation use and structural valve deterioration. Therefore native valve disease is replaced by prosthetic valve disease. Aortic valve sparing operations were developed to preserve the native aortic valve during surgery for aortic root aneurysm and ascending aortic aneurysm with associated aortic insufficiency, circumventing complications arising from prosthetic valve implantation by preserving the native aortic valve apparatus. There are two fundamental types of aortic valve sparing procedures: remodelling of the aortic root and reimplantation of the aortic valve. Evidence based medicine shows that reimplantation of the aortic valve is in long term associated with lower risk of developing aortic insufficiency. An alternative standardized approach  that combines an external subvalvular aortic prosthetic ring annuloplasty with remodelling technique was presented.  Implantation of an external aortic ring provides a reproducible technique for aortic valve repair with great preliminary results. 


Keywords


aortic root, aortic valve, valve sparing, Coroneo ring, annuloplasty

References


Sievers HH, Hemmer W, Beyersdorf F, Moritz A, Moosdorf R, Lichtenberg, et al., The everyday used nomenclature of the aortic root components: the tower of Babel? Working Group for AorticValve Surgery of German Society of Thoracic and Cardiovascular Surgery. Eur J Cardiothorac Surg. 2012 Mar;41(3):478-82. doi: 10.1093/ejcts/ezr093. Epub 2011 Dec 1

Loukas M, Bilinsky E, Bilinsky S, Blaak C, Tubbs RS, Anderson RH. The anatomy of the aortic root.,Clin Anat. 2013 Sep 2. doi: 10.1002/ca.22295.

Frater RW, Anderson RH. How can we logically describe the components of the arterial valves?, J Heart Valve Dis. 2010 Jul;19(4):438-40

Misfeld M, Sievers HH. Heart valve macro- and microstructure, Philos Trans R Soc Lond B Biol Sci. 2007 Aug 29; 362(1484):1421-36

Yacoub MH, Cohn LH , Novel approaches to cardiac valve repair: from structure to function: Part II. Circulation. 2004 Mar 9; 109(9):1064-72

Yacoub MH, Kilner PJ, Birks EJ, Misfeld M. The aortic outflow and root: a tale of dynamism and crosstalk. Ann Thorac Surg. 1999 Sep;68(3 Suppl):S37-43.

Thubrikar M, Skinner JR, Aouad J, Finkelmeier BA, Nolan SP.Analysis of the design and dynamics of aortic bioprostheses in vivo. J Thorac Cardiovasc Surg. 1982 Aug;84(2):282-90.

Hose DR, Narracott AJ, Penrose JM, Baguley D, Jones IP, Lawford PV .Fundamental mechanics of aortic heart valve closure..J Biomech. 2006; 39 (5):958-67.

Bellhouse BJ, Bellhouse FH, Reid KG. Fluid mechanics of the aortic root with application to coronary flow. Nature. 1968 Sep 7; 219(5158):1059-61

Sturla F, Votta E, Stevanella M, Conti CA, Redaelli A. Impact of modeling fluid-structure interaction in the computational analysis faortic root biomechanics. Med Eng Phys. 2013 Dec; 35(12):1721-30. doi: 10.1016/j.medengphy.2013.07.015. Epub 2013 Sep 1.

Izumoto H. Aortic valve repair for aortic insufficiency in adults: a contemporary review and comparison with replacement techniques. Eur J Cardiothorac Surg. 2006 May;29(5):854; author reply 854-5. Epub 2006 Mar 7.

Gleason TG. Current perspective on aortic valve repair and valve-sparing aorticroot replacement. Semin Thorac Cardiovasc Surg. 2006 Summer; 18(2):154-64

Miller DC. Valve-sparing aortic root replacement: current state of the art and where are we headed? Ann Thorac Surg. 2007 Feb; 83(2):S736-9; discussion S785-90

Svensson LG, Deglurkar I, Ung J, Pettersson G, Gillinov AM, D'Agostino RS et al. Aortic valve repair and root preservation by remodeling,reimplantation, and tailoring: technical aspects and early outcome. J Card Surg. 2007 Nov-Dec; 22(6):473-9.

Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Bärwolf C, Levang OW, 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 Jul; 24(13):1231-43

Gammie JS, Sheng S, Griffith BP, Peterson ED, Rankin JS, O'Brien SM, et al. Trends in mitral valve surgery in the United States: results from the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Ann Thorac Surg. 2009 May;87(5):1431-7; discussion 1437-9. doi: 10.1016/j.athoracsur.2009.01.064.

Rankin JS, Gaca JG. Techniques of aortic valve repair. Innovations (Phila). 2011 Nov;6(6):348-54. doi: 10.1097/IMI.0b013e31824641d7

Tian D, Rahnavardi M, Yan TD. Aortic valve sparing operations in aortic root aneurysms: remodeling or reimplantation? Ann Cardiothorac Surg. 2013 Jan;2(1):44-52. doi: 10.3978/j.issn.2225-319X.2013.01.14

Aicher D, Fries R, Rodionycheva S, Schmidt K, Langer F, Schäfers HJ. Aortic valve repair leads to a low incidence of valve-related complications. Eur J Cardiothorac Surg. 2010 Jan; 37(1):127-32. doi: 10.1016/j.ejcts.2009.06.021. Epub 2009 Jul 29

Bentall H, De Bonno A., A technique for complete replacement of the ascending aorta. Thorax 1968, 23:338-9

Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Bärwolf C, Levang OW, et al. A prospective survey of patients with valvular heart disease in Europe: The Euro HeartSurvey on Valvular Heart Disease. Eur Heart J. 2003 Jul;24(13):1231-43.

Lansac E, Di Centa I, Bonnet N, Leprince P, Rama A, Acar C, et al. Aortic prosthetic ring annuloplasty: a useful adjunct to a standardized aortic valve-sparing procedure? Eur J Cardiothorac Surg. 2006 Apr; 29(4):537-44. Epub 2006 Feb 2423

Yacoub M, Fagan A, Stassano P, Radley-Smith R. Result of valve conserving operations for aortic regurgitation [abstract]. Circulation 1983; 68 (Sup-pl.): III 321

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 Apr; 103(4):617-21; discussion 622

Van Son JA, Battellini R, Mierzwa M, Walther T, Autschbach R, Mohr FW. Aortic root reconstruction with preservation of native aortic valve and sinuses in aortic root dilatation with aortic regurgitation. J Thorac Cardiovasc Surg. 1999 Jun;117(6):1151-6.

Hopkins RA. Aortic valve leaflet sparing and salvage surgery: evolution of techniques for aortic root reconstruction.. Eur J Cardiothorac Surg. 2003 Dec;24(6):886-97.

Hetzer R, Komoda S, Komoda T. Remodeling of aortic root by annular reconstruction and plication of sinuses of Valsalva. J Card Surg. 2008 Jan-Feb;23(1):49-51. doi: 10.1111/j.1540-8191.2007.00505.x.

Yacoub MH, Gehle P, Chandrasekaran V, Birks EJ, Child A, Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root. J Thorac Cardiovasc Surg. 1998 May;115(5):1080-90.

David TE, Armstrong S, Maganti M, Colman J, Bradley TJ. Long-term results of aortic valve-sparing operations in patients with Marfan syndrome. J Thorac Cardiovasc Surg. 2009 Oct;138(4):859-64; discussion 863-4. doi: 10.1016/j.jtcvs.2009.06.014. Epub 2009 Aug 3.

Dias RR, Mejia OA, Fiorelli AI, Pomerantzeff PM, Dias AR, Mady C, et al. Analysis of aortic root surgery with composite mechanical aortic valve conduit andvalve-sparing reconstruction. Rev Bras Cir Cardiovasc. 2010 Oct-Dec;25(4):491-9.

Fattouch K, Murana G, Castrovinci S, Nasso G, Mossuto C, Corrado E, et al. Outcomes of aortic valve repair according to valve morphology and surgical techniques. Interact Cardiovasc Thorac Surg. 2012 Oct;15(4):644-50. Epub 2012 Jul 3.

Svensson LG, Cooper M, Batizy LH, Nowicki ER. Simplified david reimplantation with reduction of anular size and creation of artificial sinuses. Ann Thorac Surg. 2010 May;89(5):1443-7. doi: 10.1016/j.athoracsur.2010.01.058.

Bakhtiary F, Monsefi N, Trendafilow M, Wittlinger T, Doss M, Moritz A. Modification of the David procedure for reconstruction of incompetent bicuspid aorticvalves. Ann Thorac Surg. 2009 Dec;88(6):2047-9. doi: 10.1016/j.athoracsur.2009.02.100.

Iung B, Baron G, Butchart EG, Delahaye F, Gohlke-Bärwolf C, Levang OW, et al. A prospective survey of patients with valvular heart disease in Europe: The Euro HeartSurvey on Valvular Heart Disease. Eur Heart J. 2003 Jul;24(13):1231-43.

Kunihara T, Aicher D, Rodionycheva S, Groesdonk HV, Langer F, Sata F, et al. Preoperative aortic root geometry and postoperative cusp configuration primarily determine long-term outcome after valve-preserving aortic root repair. J Thorac Cardiovasc Surg. 2012 Jun;143(6):1389-95. doi: 10.1016/j.jtcvs.2011.07.036. Epub 2011 Sep 8.

le Polain de Waroux JB, Pouleur AC, Robert A, Pasquet A, Gerber BL, Noirhomme P, et al. Mechanisms of recurrent aortic regurgitation after aortic valve repair: predictive value of intraoperative transesophageal echocardiography. JACC Cardiovasc Imaging. 2009 Aug;2(8):931-9. doi: 10.1016/j.jcmg.2009.04.013.

Bierbach BO, Aicher D, Issa OA, Bomberg H, Gräber S, Glombitza P, et al. Aortic root and cusp configuration determine aortic valve function. Eur J Cardiothorac Surg. 2010 Oct;38(4):400-6. doi: 10.1016/j.ejcts.2010.01.060. Epub 2010 Mar 12.

Schäfers HJ, Bierbach B, Aicher D. A new approach to the assessment of aortic cusp geometry. J Thorac Cardiovasc Surg. 2006 Aug;132(2):436-8.

Schäfers HJ. Aortic annuloplasty: a new aspect of aortic valve repair. Eur J Cardiothorac Surg. 2012 May;41(5):1124-5. doi: 10.1093/ejcts/ezr284. Epub 2012 Jan 26.

de Kerchove L, Vismara R, Mangini A, Fiore GB, Price J, Noirhomme P, et al. In vitro comparison of three techniques for ventriculo-aortic junction annuloplasty. Eur J Cardiothorac Surg. 2012 May;41(5):1117-23; discussion 1123-4. doi: 10.1093/ejcts/ezr237. Epub 2012 Jan 6.

Fries R, Graeter T, Aicher D, Reul H, Schmitz C, Böhm M, et al. In vitro comparison of aortic valve movement after valve-preserving aortic replacement. J Thorac Cardiovasc Surg. 2006 Jul;132(1):32-7.

Soncini M, Votta E, Zinicchino S, Burrone V, Mangini A, Lemma M, et al. Aortic root performance after valve sparing procedure: a comparative finite element analysis. Med Eng Phys. 2009 Mar;31(2):234-43. doi: 10.1016/j.medengphy.2008.07.009. Epub 2008 Sep 10.

Hanke T, Charitos EI, Stierle U, Robinson D, Gorski A, Sievers HH, et al. Factors associated with the development of aortic valve regurgitation over time after twodifferent techniques of valve-sparing aortic root surgery. J Thorac Cardiovasc Surg. 2009 Feb;137(2):314-9. doi: 10.1016/j.jtcvs.2008.08.006. Epub 2008 Dec 19.

Anderson RH, Devine WA, Ho SY, Smith A, McKay R. The myth of the aortic annulus: the anatomy of the subaortic outflow tract. Ann Thorac Surg. 1991 Sep;52(3):640-6.

Lansac E, Lim HS, Shomura Y, Lim KH, Rice NT, Goetz W, et al. A four-dimensional study of the aortic root dynamics. Eur J Cardiothorac Surg. 2002 Oct;22(4):497-503

Lansac E, Di Centa I, Vojacek J, Nijs J, Hlubocky J, Mecozzi G, et al. Valve sparing root replacement: the remodeling technique with external ring annuloplasty. Ann Cardiothorac Surg. 2013 Jan;2(1):117-23. doi: 10.3978/j.issn.2225-319X.2013.01.15.

Lansac E, Di Centa I, Raoux F, Bulman-Fleming N, Ranga A, Abed A, et al. An expansible aortic ring for a physiological approach to conservative aortic valve surgery. J Thorac Cardiovasc Surg. 2009 Sep;138(3):718-24. doi: 10.1016/j.jtcvs.2009.05.024.

Lansac E, Di Centa I, Raoux F, Al Attar N, Acar C, Joudinaud T, et al.

A lesional classification to standardize surgical management of aortic insufficiency towards valve repair. Eur J Cardiothorac Surg. 2008 May;33(5):872-8; discussion 878-80. doi: 10.1016/j.ejcts.2007.12.033.

Epub 2008 Feb 6

Lansac E, Di Centa I, Sleilaty G, Bouchot O, Arnaud Crozat E, Blin D, et al. An aortic ring to standardise aortic valve repair: preliminary results of a prospective multicentric cohort of 144 patients. Eur J Cardiothorac Surg. 2010 Aug;38(2):147-54. doi: 10.1016/j.ejcts.2010.01.041. Epub 2010 Mar 7.

de Kerchove L, Boodhwani M, Glineur D, Poncelet A, Verhelst R, Astarci P, et al. Effects of preoperative aortic insufficiency on outcome after aortic valve-sparing surgery. Circulation. 2009 Sep 15;120(11 Suppl):S120-6. doi: 10.1161/CIRCULATIONAHA.108.841445.

David TE, Armstrong S. Aortic cusp repair with Gore-Tex sutures during aortic valve-sparing operations. J Thorac Cardiovasc Surg. 2010 May;139(5):1340-2. doi: 10.1016/j.jtcvs.2009.06.010. Epub 2009 Jul 17.

Aicher D, Langer F, Adam O, Tscholl D, Lausberg H, Schäfers HJ. Cusp repair in aortic valve reconstruction: does the technique affect stability?. J Thorac Cardiovasc Surg. 2007 Dec;134(6):1533-8; discussion 1538-9. Epub 2007 Oct 26.

Schäfers HJ, Langer F, Glombitza P, Kunihara T, Fries R, Aicher D.

Aortic valve reconstruction in myxomatous degeneration of aortic valves: are fenestrations a risk factor for repair failure? J Thorac Cardiovasc Surg. 2010 Mar;139(3):660-4. doi: 10.1016/j.jtcvs.2009.06.025. Epub 2009 Aug 18.




DOI: http://dx.doi.org/10.18103/mra.v0i2.61

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