title: An aortic ring to standardise aortic valve repair: preliminary results of a prospective multicentric cohort of 144 patients.
abstract: OBJECTIVE
  Multiplicity of aortic valve repair or sparing techniques results in a lack of standardisation, limiting widespread adoption of such procedures. To treat dilated diameters at the aortic annular base and sinotubular junction while maintaining root dynamics, we propose a standardised and physiological repair approach to the surgical management of aortic root aneurysms, consisting of root remodelling, cusp re-suspension and subvalvular aortic ring annuloplasty.
  
  
  METHODS
  From May 2003 to September 2009, 144 unselected patients with aortic root aneurysms underwent remodelling with external subvalvular ring annuloplasty in 13 centres (21 surgeons). Preoperative aortic insufficiency (AI) > or =grade 2 was present in 63.9% (92), Marfan syndrome in 12.5% (18) and bicuspid valve in 22.9% (33). Cusp repair was performed in 40.3% (58) patients.
  
  
  RESULTS
  Valve repair was successful in all but two cases. Repair of cusp prolapse was necessary in 58 patients, significantly more frequent in bicuspid (24/33, 72.7%) than in tricuspid (34/111, 30.6%) valves (p<0.05). Operative mortality was 2.8% (four). Subvalvular ring implantation produced a significant annular base reduction from 27.6+/-2.5 mm to 20.5+/-2.6 mm (p<0.01) without significant mean trans-valvular gradient (7.2+/-1.7 mmHg). During follow-up (median 2.2 years (0.75-4.4, maximum 6.25 years)), five patients died while eight required a re-operation. Six were operated on during our early experience. Strategy for cusp re-suspension evolved over three operative periods, with a significant increase in the rate of cusp repair. From May 2003 to December 2006: eye balling evaluation (15/67 (22.4%)); from January 2007 to August 2008: alignment of cusp free edges (17/38 (44.7%)); and from September 2008 to September 2009: a two-step standardised repair consisting of alignment of cusp free edges and effective height re-suspension (26/39 (66.7%) p<0.05). Freedom from AI> or =grade 2 was 91.3% (115) at the end of follow-up.
  
  
  CONCLUSIONS
  Implantation of an external aortic ring provides a reproducible technique for aortic valve repair with satisfactory preliminary results. The ongoing CAVIAAR trial (Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysm of the Aortic Root) will compare this standardised repair technique using an expansible aortic ring to mechanical valve replacement.
authors.affiliation: Hôpital Foch, Suresnes, France. e.lansac@hopital-foch.org
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Lansac
authors.forename: Isabelle
authors.initials: I
authors.lastname: Di Centa
authors.forename: Ghassan
authors.initials: G
authors.lastname: Sleilaty
authors.forename: Olivier
authors.initials: O
authors.lastname: Bouchot
authors.forename: Eric
authors.initials: E
authors.lastname: Arnaud Crozat
authors.forename: Dominique
authors.initials: D
authors.lastname: Blin
authors.forename: Christophe
authors.initials: C
authors.lastname: Acar
authors.forename: Mathieu
authors.initials: M
authors.lastname: Debauchez
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001014:Aortic Aneurysm / Q000601:surgery*; D001021:Aortic Valve / Q000002:abnormalities / Q000000981:diagnostic imaging / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000601:surgery; D058385:Cardiac Valve Annuloplasty / Q000295:instrumentation* / Q000379:methods; D017548:Echocardiography, Transesophageal; D005260:Female; D006801:Humans; D008297:Male; D008382:Marfan Syndrome / Q000601:surgery; D008875:Middle Aged; D011446:Prospective Studies; D019736:Prostheses and Implants; D012086:Reoperation; D016896:Treatment Outcome; D055815:Young Adult