title: Aortic prosthetic ring annuloplasty: a useful adjunct to a standardized aortic valve-sparing procedure?
abstract: OBJECTIVE
  Dilation of aortic annulus, sinuses of Valsalva, and sinotubular junction (STJ) diameters are the characteristic lesions of aortic root aneurysm. The remodeling technique reduces STJ diameter and creates three neosinuses of Valsalva. Alternatively, the reimplantation technique reduces both annulus and STJ diameters to the detriment of aortic root dynamics. Although the remodeling technique is recognized as the most physiological valve-sparing procedure, aortic annulus dilation may jeopardize its results. A standardized approach that combines an external subvalvular aortic prosthetic ring annuloplasty with the remodeling technique is suggested.
  
  
  METHODS
  Eighty-three patients underwent an elective aortic root remodeling procedure, either isolated (group 1, n=34) or combined with an external subvalvular aortic prosthetic ring annuloplasty (group 2, n=49). Preoperative aortic regurgitation was 1.59+/-1.1 (group 1) and 1.97+/-1.3 (group 2) (NS). The aortic annulus was more dilated in group 2 than in group 1 (27+/-2.77 mm vs 26.4+/-2.3 mm, p<0.01). Residual aortic regurgitation > or =grade II was the conversion criteria for aortic valve replacement.
  
  
  RESULTS
  Operative mortality was 3.6% (n=3). Intraoperative conversion for valve replacement was 32.7% in group 1 (n=11) versus 4.2% in group 2 (n=2) (p<0.001). In group 1, preoperative annulus diameter was larger for converted than for valve-spared patients (27.6+/-1.7 mm vs 25.2+/-1.5 mm, p<0.02). In group 2, implanted aortic ring significantly reduced annulus diameter (20.6+/-1.8 mm) without significant aortic valve gradient (8.3+/-3 mmHg). Follow-up was 17.2+/-13.4 months (group 1) and 10.41+/-7.95 months (group 2). Reoperation for recurrent aortic regurgitation was 13% in group 1 (n=3) versus 4.2% in group 2 (n=2). Echocardiographic follow-up found residual aortic regurgitation < or =grade I in 17 patients in group 1 (90%) versus 43 patients in group 2 (95.5%) and of grade II in two patients in group 1 (10%) and two patients in group 2 (4.5%).
  
  
  CONCLUSIONS
  The addition of external aortic prosthetic ring annuloplasty improves the remodeling technique's operative reproducibility and short-term results. Therefore, its use as a systematical adjunct to the remodeling procedure is suggested. However, further long-term evaluation comparing this valve-sparing procedure to composite graft replacement should define the best surgical strategy for aortic root aneurysm.
authors.affiliation: Department of Cardiovascular and Thoracic Surgery, Pitie Salpetriere University Hospital, Assistance Publique Hopitaux de Paris (APHP), Institut de Cardiologie, 47-83 Boulevard de l'Hopital, 75013 Paris Cedex, France. lansacema@hotmail.com
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Lansac
authors.forename: Isabelle
authors.initials: I
authors.lastname: Di Centa
authors.forename: Nicolas
authors.initials: N
authors.lastname: Bonnet
authors.forename: Pascal
authors.initials: P
authors.lastname: Leprince
authors.forename: Akthar
authors.initials: A
authors.lastname: Rama
authors.forename: Christophe
authors.initials: C
authors.lastname: Acar
authors.forename: Alain
authors.initials: A
authors.lastname: Pavie
authors.forename: Iradj
authors.initials: I
authors.lastname: Gandjbakhch
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001014:Aortic Aneurysm / Q000601:surgery*; D001021:Aortic Valve / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000000981:diagnostic imaging / Q000601:surgery*; D015150:Echocardiography, Doppler; D005260:Female; D005500:Follow-Up Studies; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D013536:Suture Techniques; D016896:Treatment Outcome