title: Long-term results of external aortic ring annuloplasty for aortic valve repair.
abstract: OBJECTIVE
  An untreated dilated aortic annulus is a major risk factor for failure of aortic valve-sparing operations or repair of either bicuspid or tricuspid valve. Aortic annuloplasty efficiently reduces the annulus and increases the coaptation height, thus protecting the repair. This study analyses long-term results of 232 consecutive patients operated on with a standardized and physiological approach to aortic valve repair according to each phenotype of the dystrophic ascending aorta. Subvalvular aortic annuloplasty was systematically added using an external aortic ring to reduce annulus diameter when ≥25 mm.
  
  
  METHODS
  Data were collected into the multicentric international AVIATOR registry (AorticValve repair InternATiOnal Registry): 149 patients with root aneurysm underwent remodelling with an external ring; 21 patients with tubular aortic aneurysm underwent supracoronary grafts with an external open ring and 62 patients with isolated aortic insufficiency (AI) underwent double sub- and/or supravalvular external open ring annuloplasty. Preoperative AI ≥ Grade III was present in 58.6% (133), and the valve was bicuspid in 37.9% (88).
  
  
  RESULTS
  Cusp repair was performed in 75.4% (175) patients. The 30-day operative mortality rate was 1.4% (3). The mean follow-up was 40.1 ± 37.8 months (0-145.5). The actuarial survival rate at 7 years was 89.9%. The rate of freedom from reoperation at 7 years was similar among each phenotype, being 90.5% for root aneurysms, 100% for tubular aortic aneurysms and 97.5% for isolated AI with no difference between the bicuspid and tricuspid valve. The rates of freedom from AI ≥ Grade 2 and from AI ≥ Grade 3 at 7 years were, respectively, 76.0 and 93.1% for root aneurysms, 92.9 and 100% for tubular aortic aneurysms and 57.3 and 82.2% for isolated AI. Eye balling repair achieved suboptimal valve competency when compared with systematic cusp effective height assessment, which tended to improve the rate freedom from reoperation, respectively, from 85.8 ± 5.5% to 98.9 ± 1.1% and the rate of freedom from AI ≥ Grade 3 from 89.8 ± 4.9% to 100%. For isolated AI, an additional sinotubular junction ring (double sub- and supravalvular annuloplasty) tended to reduce recurrent AI when compared with single subvalvular annuloplasty.
  
  
  CONCLUSIONS
  External aortic ring annuloplasty provides a reproducible technique for aortic valve repair with satisfactory long-term results for each ascending aorta phenotype with bicuspid or tricuspid valve. Longer follow-up is ongoing with the AVIATOR registry.
authors.affiliation: Department of Cardiac Pathology, Institut Mutualiste Montsouris, Paris, France emmanuel.lansac@imm.fr.
authors.forename: Emmanuel
authors.initials: E
authors.lastname: Lansac
authors.affiliation: Vascular Surgery Unit, Hopital Foch, Suresnes, France.
authors.forename: Isabelle
authors.initials: I
authors.lastname: Di Centa
authors.affiliation: Department of Cardiac Pathology, Institut Mutualiste Montsouris, Paris, France.
authors.forename: Ghassan
authors.initials: G
authors.lastname: Sleilaty
authors.affiliation: Department of Cardiac Pathology, Institut Mutualiste Montsouris, Paris, France.
authors.forename: Stephanie
authors.initials: S
authors.lastname: Lejeune
authors.affiliation: Department of Cardiac Pathology, Institut Mutualiste Montsouris, Paris, France.
authors.forename: Nizar
authors.initials: N
authors.lastname: Khelil
authors.affiliation: Department of Cardiac Pathology, Institut Mutualiste Montsouris, Paris, France.
authors.forename: Alain
authors.initials: A
authors.lastname: Berrebi
authors.affiliation: Department of Cardiac Pathology, Institut Mutualiste Montsouris, Paris, France.
authors.forename: Christelle
authors.initials: C
authors.lastname: Diakov
authors.affiliation: Department of Cardiac Pathology, Institut Mutualiste Montsouris, Paris, France.
authors.forename: Leila
authors.initials: L
authors.lastname: Mankoubi
authors.affiliation: Department of Cardiac Pathology, Institut Mutualiste Montsouris, Paris, France.
authors.forename: Marie-Christine
authors.initials: MC
authors.lastname: Malergue
authors.affiliation: Department of Cardiac Pathology, Institut Mutualiste Montsouris, Paris, France.
authors.forename: Milena
authors.initials: M
authors.lastname: Noghin
authors.affiliation: Department of Cardiac Pathology, Institut Mutualiste Montsouris, Paris, France.
authors.forename: Konstantinos
authors.initials: K
authors.lastname: Zannis
authors.affiliation: Department of Cardiac Pathology, Institut Mutualiste Montsouris, Paris, France.
authors.forename: Suzanna
authors.initials: S
authors.lastname: Salvi
authors.affiliation: Department of Cardiac Pathology, Institut Mutualiste Montsouris, Paris, France.
authors.forename: Patrice
authors.initials: P
authors.lastname: Dervanian
authors.affiliation: Department of Cardiac Pathology, Institut Mutualiste Montsouris, Paris, France.
authors.forename: Mathieu
authors.initials: M
authors.lastname: Debauchez
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D058385:Cardiac Valve Annuloplasty / Q000379:methods*; D017548:Echocardiography, Transesophageal; D005260:Female; D005500:Follow-Up Studies; D005602:France / Q000453:epidemiology; D006350:Heart Valve Prosthesis; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D015996:Survival Rate / Q000639:trends; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult
keywords: Aortic ring; Aortic valve repair; Aortic valve sparing; Bicuspid aortic valve; Cusp repair; External annuloplasty