title: An aortic ring: from physiologic reconstruction of the root to a standardized approach for aortic valve repair.
abstract: OBJECTIVE
  We suggest standardizing aortic valve repair using a physiologic approach by associating root remodeling with resuspension of the cusp effective height and external subvalvular aortic ring annuloplasty.
  
  
  METHODS
  A total of 187 patients underwent remodeling associated with subvalvular aortic ring annuloplasty (14 centers, 24 surgeons). Three strategies for cusp repair were evaluated: group 1, gross visual estimation (74 patients); group 2, alignment of cusp free edges (62 patients); and group 3, 2-step approach, alignment of the cusp free edges and effective height resuspension (51 patients). The composite outcome was defined as recurrence of aortic insufficiency of grade 2 or greater and/or reoperation.
  
  
  RESULTS
  The operative mortality rate was 3.2% (n = 6). Treatment of a cusp lesion was most frequently performed in group 3 (70.6% vs 20.3% in group 1 and 30.6% in group 2, P < .001). Nine patients required reoperation during a follow-up period of 24 months (range, 12-45), 6 patients in group 1 and 3 patients in group 2. At 1 year, no patients in group 3 presented with composite outcome events compared with 28.1% in group 1 and 15% in group 2 (P < .001). Residual aortic insufficiency and tricuspid anatomy were independent risk factors for the composite outcome in groups 1 and 2. The annulus diameter, the presence of Marfan syndrome, and cusp repair had no effect on aortic insufficiency recurrence or reoperation.
  
  
  CONCLUSIONS
  A standardized and physiologic approach to aortic valve repair, considering both the aorta (root remodeling) and the valve (resuspension of the cusp effective height and subvalvular ring annuloplasty) improved the preliminary results and might affect their long-term durability. The ongoing Conservative Aortic Valve Surgery for Aortic Insufficiency and Aneurysm of the Aortic Root (CAVIAAR) trial will compare this strategy to mechanical valve replacement.
authors.affiliation: Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France.
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: Eric Arnaud
authors.initials: EA
authors.lastname: Crozat
authors.forename: Olivier
authors.initials: O
authors.lastname: Bouchot
authors.forename: Rachid
authors.initials: R
authors.lastname: Hacini
authors.forename: Dominique
authors.initials: D
authors.lastname: Blin
authors.forename: Fabien
authors.initials: F
authors.lastname: Doguet
authors.forename: Jen-Paul
authors.initials: JP
authors.lastname: Bessou
authors.forename: Bernard
authors.initials: B
authors.lastname: Albat
authors.forename: Roland
authors.initials: R
authors.lastname: De Maria
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Villemot
authors.forename: Eric
authors.initials: E
authors.lastname: Portocarrero
authors.forename: Christophe
authors.initials: C
authors.lastname: Acar
authors.forename: Didier
authors.initials: D
authors.lastname: Chatel
authors.forename: Stéphane
authors.initials: S
authors.lastname: Lopez
authors.forename: Thierry
authors.initials: T
authors.lastname: Folliguet
authors.forename: Mathieu
authors.initials: M
authors.lastname: Debauchez
mesh_terms: D000328:Adult; D000368:Aged; D001014:Aortic Aneurysm / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D058385:Cardiac Valve Annuloplasty / Q000009:adverse effects / Q000401:mortality; D016009:Chi-Square Distribution; D005602:France; D006801:Humans; D053208:Kaplan-Meier Estimate; D008875:Middle Aged; D012008:Recurrence; D012086:Reoperation; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome; D014656:Vascular Surgical Procedures