Isolated Tricuspid Aortic Valve Repair With Double Annuloplasty: How I Teach It
2019; Elsevier BV; Volume: 108; Issue: 4 Linguagem: Inglês
10.1016/j.athoracsur.2019.07.008
ISSN1552-6259
AutoresPouya Youssefi, Pavel Žáček, Mathieu Debauchez, Emmanuel Lansac,
Tópico(s)Aortic Disease and Treatment Approaches
ResumoDr Lansac discloses a financial relationship with Coroneo, Inc.The Videos can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2019.07.008] on http://www.annalsthoracicsurgery.org.Once thought of as the gold standard treatment of aortic valve (AV) disease, prosthetic AV replacement is now known to significantly reduce life expectancy for non-elderly patients. Long-term data has shown survival and complications to be worse than expected. In a cohort of almost 10,000 patients, the 15-year mortality in the 45- to 54-year age group was 30.6% (bioprosthetic valves) and 26.4% (mechanical valves).1Goldstone A.B. Chiu P. Baiocchi M. et al.Mechanical or biologic prostheses for aortic-valve and mitral-valve replacement.N Engl J Med. 2017; 377: 1847-1857Crossref PubMed Scopus (332) Google Scholar Microsimulation studies from large meta-analyses showed that a 45-year-old patient undergoing a mechanical AV replacement has a life expectancy of 19 years, compared with 34 years for the general population.2Korteland N.M. Etnel J.R.G. Arabkhani B. et al.Mechanical aortic valve replacement in non-elderly adults: meta-analysis and microsimulation.Eur Heart J. 2017; 38: 3370-3377Crossref PubMed Scopus (67) Google Scholar Non-elderly patients remain a challenge because the younger they are at the point of intervention, the longer their exposure is to valve-related events such as degeneration, bleeding, and thromboembolism. Unlike aortic stenosis, aortic insufficiency (AI) is very common in younger patients with AV disease. More than half of all AI cases are in patients younger than 50 years of age, with impaired survival when compared with aortic stenosis.3Kvidal P. Bergstrom R. Horte L.G. Stahle E. Observed and relative survival after aortic valve replacement.J Am Coll Cardiol. 2000; 35: 747-756Crossref PubMed Scopus (401) Google Scholar Dr Lansac discloses a financial relationship with Coroneo, Inc. The Videos can be viewed in the online version of this article [https://doi.org/10.1016/j.athoracsur.2019.07.008] on http://www.annalsthoracicsurgery.org. Despite international guidelines recommending a "heart team discussion" for selected patients with "pliable, noncalcified tricuspid or bicuspid" AI "in whom aortic valve repair may be a feasible alternative to valve replacement" (class I C indication),4Falk V. Baumgartner H. Bax J.J. et al.2017 ESC/EACTS guidelines for the management of valvular heart disease.Eur J Cardiothorac Surg. 2017; 52: 616-664Crossref PubMed Scopus (9) Google Scholar only a minority of these valves are repaired. With advances in valve-sparing root replacement (VSRR) techniques, several important anatomic and geometric discoveries have paved the way for not only preserving "normal" valves in root aneurysms but also addressing and repairing mechanisms of AI. Central to these discoveries has been the importance of the annulus as well as the sinotubular junction (STJ). Contrary to what was previously believed, we know from multiple echocardiographic studies that the STJ is actually larger than the annulus by a factor of 1.1 to 1.3 in normally functioning roots. Maintaining this ratio, or indeed returning the ratio back to 1.1 to 1.3 in the dystrophic root, is key to producing a competent valve. Further to the size of the annulus and STJ, the geometric height (gH) and effective height (eH) of the valve cusps are also important in repairing a regurgitant valve. Recurrence of AI after AV repair involves elements such as an untreated dilated annulus (>25 to 28 mm) and residual cusp prolapse (native prolapse or induced prolapse). For a technique that is both reproducible and produces high-quality long-term outcomes, we developed a standardized AV repair approach that addresses the annulus, the aorta, and the valve cusps. This involves physiological restoration of root geometry by using a double subvalvular and supravalvular annuloplasty that maintains the ratio of the STJ to the annulus at 1.2. Along with this, we perform systematic eH assessment and resuspension. This is the third article of 4 in the series that are deep dives into the teaching of our standardized techniques of aortic root and AV repair, including root replacement in tricuspid AVs (TAVs) and bicuspid AVs (BAVs), as well as isolated repair of TAVs and BAVs (Figure 1). Previously we described root remodeling and annuloplasty in both TAVs and BAVs.5Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: tricuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 107: 1592-1599Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 6Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: bicuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 108: 324-333Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar In this third article, we describe our approach to teaching isolated AV repair using double subvalvular and supravalvular annuloplasty in TAVs. As a starting framework for their learning, the trainee learns the basic framework for the surgical approach and management of AI according to the aorta phenotype (Figure 1). Depending on the size of the sinuses of Valsalva and ascending aorta (whether ≥45 mm), the trainee must decide whether to perform VSRR (remodeling technique), tubular aorta replacement, or isolated AV repair (with double subvalvular and supravalvular annuloplasty). It is important for the trainee to understand that in each of these 3 scenarios, an annuloplasty is performed at both the subvalvular level and at the STJ. In the 2 scenarios of VSRR (remodeling technique) and tubular aorta replacement, the STJ annuloplasty is carried out using a synthetic graft.5Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: tricuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 107: 1592-1599Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 6Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: bicuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 108: 324-333Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar In isolated AV repair, an expansile external ring is used to perform the STJ annuloplasty. All 3 scenarios involve a subvalvular annuloplasty (if annulus ≥25 mm). By using the sizing algorithms (Table 1), the trainee learns that the physiological ratio of the STJ to the annulus of 1.2 will be restored. For example, if the annulus is measured intraoperatively at 29 mm, then according to the sizing algorithm, a 27-mm STJ ring and a 27-mm subvalvular ring (Extra-Aortic, Coroneo Inc., Montreal, Canada) will be used. Given that the aortic wall has negligible thickness, the resultant diameter at the STJ is assumed to be 27 mm. However, at the annular level, tissue thickness between the inside and the outside of the annulus measures 2.5 mm,7Khelil N. Sleilaty G. Palladino M. et al.Surgical anatomy of the aortic annulus: landmarks for external annuloplasty in aortic valve repair.Ann Thorac Surg. 2015; 99: 1220-1226Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar thus producing an annulus 5 mm smaller than the external ring. Therefore, in the foregoing example, the new STJ will measure 27 mm, but the new annulus will measure 22 mm (27 minus 5 mm), thereby preserving the 1.2 ratio of STJ to annulus. The trainee learns that the same ratio will be restored when carrying out a VSRR and subvalvular annuloplasty according to the sizing algorithms.5Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: tricuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 107: 1592-1599Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 6Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: bicuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 108: 324-333Abstract Full Text Full Text PDF PubMed Scopus (12) Google ScholarTable 1Sizing Chart for the Calibrated Subvalvular Aortic Ring and the Supravalvular Sinotubular Junction Annuloplasty Ring (Extra-Aortic Ring) According to Aortic Annulus Size MeasurementProsthesesAortic Annulus Diameter (Hegar dilator, mm)25-2728-3031-35≥36Subvalvular aortic ring (mm)25272931Sinotubular junction Extra-Aortic ring (Coroneo Inc, Montreal, Canada) (mm)25272931 Open table in a new tab The imaging assessment of the aortic root is vital for the trainee to learn. This includes both echocardiography and gated computed tomography (Video 1). In the case of isolated AV repair with double annuloplasty, assessment of the position of the coronary arteries by using gated computed tomography is vital. For the patient to be able to undergo isolated AV repair and double annuloplasty safely, both coronary arteries must arise below the level of the STJ (ie, below the peak of the commissures). If they arise above the STJ, then placement of an STJ ring would cause compression and obstruction of the coronary arteries. Finally, the trainee must analyze the coronary angiogram to look for a short left main coronary artery stem (see later). We have developed a standardized series of steps that creates a framework for the operation. The order of the steps follows a logical sequence:1.Transection of the aorta2.Valve assessmentInspectiongH measurementAnnulus diameter measurementCommissural assessment: fenestrations and diastasis3.Sizing of the external STJ ring and the subvalvular annuloplasty ring4.Dissection down to the subvalvular plane including beneath the coronary arteries5.Subvalvular U sutures6.Alignment of cusp free edges7.STJ ring implantation8.eH measurement and cusp resuspension9.Subvalvular ring implantation10.Aortotomy closure Trainees must first demonstrate sound knowledge of all steps of the procedure while assisting before they are helped to perform the steps themselves. The trainee must position the patient by using a sandbag under the shoulders with the patient in the supine position to bring up the aortic root and ascending aorta for better exposure. Trainees learn to perform a median sternotomy with limited skin incision or a mini-J sternotomy (into the third left intercostal space). Systemic heparinization is achieved, and arterial cannulation is always performed high up into the arch, in case a full root replacement is necessary on inspection of the valve. Venous cannulation of the right atrium is performed, although peripheral cannulation can also be used in the minimally invasive incision. Left ventricular drainage is carried out using a right superior pulmonary vein vent once the cross-clamp has been placed. In the following steps, we describe the operation for an isolated TAV repair using double subvalvular and supravalvular annuloplasty. Later, in the "Specific Lesion Sets" section, we describe the different steps for a tubular aorta replacement and subvalvular annuloplasty in cases where TAV AI is associated with an ascending aorta aneurysm. On placement of the clamp and insertion of the vent, a complete transverse aortotomy is performed 1 to 2 cm above the STJ. The trainee is reminded to make the aortotomy as transverse and orthogonal to the aorta as possible because the natural tendency is to stray toward the posterior left-non commissure. Direct antegrade ostial cardioplegia is administered into the coronary ostia by using Custodiol HTK cardioplegia solution (Essential Pharmaceuticals, Durham, NC) for 7 minutes. Once cardioplegia solution has been administered, a full valve assessment is carried out. The trainee is taught to first assess the relationship between the coronary ostia and the commissures, to be able to ensure that the coronary ostia arise below the commissures (ie, below the STJ) because this will allow safe placement of an external STJ ring without compressing the coronary arteries. If the coronary ostia are at the same level or above the commissures, then an isolated AV repair is not possible. In this case, a full VSRR (with coronary reimplantation) and subvalvular annuloplasty will need to be performed.5Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: tricuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 107: 1592-1599Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar Next, to expose the valve more clearly, 3 commissural stay sutures are placed. A 4-0 polypropylene suture is used to take a thick bite of the aorta, by entering and exiting the aorta 3 to 4 mm on either side of the tip of each commissure. These sutures are attached to the drapes under tension. The trainee must pull on each commissure at exactly 120 degrees to the others to expose the valve in a symmetrical way. The trainee must inspect the cusps and assess their tissue quality and mobility. The trainee must assess the commissures to look for a minor form of BAV where one of the three commissures is slightly lower than the other two (with the commissural orientation close to 120 degrees). The commissures must also be assessed for diastasis (or splaying apart), which may be involved in the mechanism of AI. Areas of calcification must be assessed for their effect on cusp mobility. Fenestrations must be carefully examined, and the trainee must make a plan on the basis of deciding which fenestrations are small and physiological (therefore left alone) and which are elongated or ruptured (requiring repair). We have observed that the largest proportions of fenestrations in the spectrum of dystrophic AI are found in isolated AI with TAV. The trainee must measure the gH of each cusp with a ruler. The trainee must grasp the nodule of Arantius carefully with forceps and gently stretch the cusp while the assistant is pulling the adjacent 2 commissures away from each other to open the cusp. The ruler is used to measure from the nadir of the cusp to the free edge. In TAVs, the cusp is considered retracted (and thus a potential risk for repair failure) if the gH is smaller than 16 mm8Schafers H.J. Schmied W. Marom G. Aicher D. Cusp height in aortic valves.J Thorac Cardiovasc Surg. 2013; 146: 269-274Abstract Full Text Full Text PDF PubMed Scopus (123) Google Scholar (Video 2). The trainee next uses a Hegar dilator to intubate the aortic root and measure the size of the annulus. The trainee must take great care to avoid tears to the cusps and must wet the dilator before use. On the basis of this measurement, the sizes of both the closed (for STJ) and open (for annulus) expansile external annuloplasty rings (Extra-Aortic, Coroneo Inc) are chosen (Table 1). Similar to the valve-sparing root procedures,5Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: tricuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 107: 1592-1599Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 6Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: bicuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 108: 324-333Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar deep dissection down to the subvalvular level must be carried out to be able to place a subvalvular annuloplasty ring. This deep dissection can be more challenging for the trainee compared with the valve-sparing root procedures because it involves dissection beneath the coronary arteries. Regardless, it is still one of the initial steps of the operation the trainee performs. The trainee must be able to demonstrate the anatomic structures that surround the aortic root. The trainee learns to perform this dissection using cautery, at the same setting as used for internal mammary harvest, although it can also be done using scissors. The aim is to dissect down below the level of the nadir of the 3 cusps. The trainee starts at the non-coronary sinus. They must dissect the plane between the roof of the left atrium and the aortic wall until reaching the level below the nadir of the non-coronary cusp. Next, the trainee must tackle the left sinus. This dissection must begin around the left-right commissure, to stay away from the left coronary artery. The plane between the left sinus and the pulmonary artery (PA) must be dissected in a tangential manner away from the operating surgeon. This avoids cutting through the aorta and entering the sinus or the left ventricular outflow tract. The aortopulmonary ligament will be encountered here and must be divided to reach the subvalvular plane. The trainee learns with time that this ligament is of varying thickness in different patients. The dissection plane can initially be fatty, but the trainee must keep dissecting deeper until no further fat is seen and only muscle is reached. Once the subvalvular plane has been reached, and having so far kept away from the left coronary artery, the trainee must now open up the roof of fascia that overlies the proximal left coronary artery corresponding to the upper limit of the transverse sinus. This fascia extends between the right PA and the left sinus. It is often a difficult plane for the trainee to visualize at first, but with time the trainee can recognize it clearly. To help identify where to dissect with cautery, the right PA should be followed from distally to proximally, to where it comes close to the aorta at the level of the left sinus. Here, if the aorta and the PA are pulled away from each other gently, the fascia between them can be easily seen. This fascia must be divided using cautery, staying close to the PA. Once it has been divided, the left main stem can be seen underneath it. Now that the left coronary artery is visualized, dissection underneath it can be carried out safely. It is important for the trainee to have analyzed the coronary angiogram to know which patients have a short left main stem. In these cases, the circumflex artery will arise early and should also be visualized separate from the left anterior descending artery. Now that the left coronary artery can be visualized, the plane underneath it can be safely dissected. The trainee must now carefully extend the dissection already carried out at the left sinus and continue it toward the left coronary artery. Trainees must continually check their distance from the coronary artery by looking inside the root to see the ostium. Once the coronary artery is reached, a right-angled dissector is gently passed underneath the left coronary artery, entering on the side away from the operating surgeon and exiting on the side towards the operating surgeon. The instrument must stay close to the aortic wall, to avoid catching the circumflex artery. The trainee finds that often the dissector passes more easily than expected. Once the dissector is all the way through, it must be carefully opened and gently pressed down to open up the plane underneath the coronary artery to a deep subvalvular level. Finally, the trainee tackles the right coronary sinus. The dissection that has already been carried out at the level of the left sinus and left-right commissure is continued toward the right coronary artery. This is the plane between the right sinus and the right ventricle or infundibulum. Now, instead of dissecting tangentially away from the sinus, the trainee must dissect very close to the aortic wall vertically downward. If the trainee strays away from the aortic wall here, it will inevitably lead to entering the infundibulum. This area of dissection can often be demanding for the trainee. Once trainees have dissected close to the right coronary artery, they must turn their attention to the other side of the right coronary artery, the right-non commissure. Here the membranous septum limits the dissection plane. Scissors must be used to dissect this area, to avoid burn injury to the bundle of His. Now a right-angled dissector can be passed underneath the right coronary artery. Once passed through, the dissector must be opened and pushed down, to widen the tunnel underneath the coronary artery to a deep subvalvular level (Video 3). At the end of the dissection, the venous line is clamped to check for any bleeding from the right ventricle, infundibulum, or PA. Once the subvalvular dissection has been carried out, the subvalvular sutures for the annuloplasty ring are inserted (Figure 2). Six horizontal mattress "U" sutures (Ethicon 3/8 25-mm pledgeted needle, Ethicon LLC, Johnson & Johnson, Somerville, NJ,) are inserted circumferentially in the subvalvular plane. The first suture is placed 2 mm beneath the nadir of the non-coronary cusp, entering inside the aorta and exiting the aorta at its lowest subvalvular dissection plane. The next U suture is placed at the base of the left-non interleaflet triangle, taking care not to pull up the mitral valve apparatus. The third suture is the most challenging for the trainee because it must pass underneath the coronary artery. The suture enters the aorta 2 mm below the nadir of the left cusp on the muscular septum just after the trigone and must immediately turn toward the operating surgeon to exit through the tunnel underneath the left coronary artery and come out on the surgeon's side. For a right-handed surgeon, this suture must be taken backhand. It is here that the trainee realizes the importance of previously dissecting the roof above the left coronary artery and fully visualizing the coronary artery for this maneuver. The subsequent U sutures are placed beneath the left-right commissure and the right cusp. The suture placed beneath the nadir of the right cusp should exit on the side of the right coronary artery that is opposite to the operating surgeon. The sixth suture is placed externally as a nonpledgeted suture on the left atrium wall at the lowest level of the dissection plane. This is because an internal suture beneath the right-non commissure risks damage to the bundle of His (Video 4). When the annulus is very large (ie, >28 mm), an extra suture is placed in the region of the left-right commissure into the muscular part of the annulus. The trainee must create a symmetrical valve before the STJ annuloplasty. To achieve this, the free edge lengths of all 3 cusps must be aligned. This corrects for any excess free margin length before STJ annuloplasty. A 5-0 polypropylene stay suture is inserted into the central nodule of Arantius of each cusp. Each stay suture is placed on a small, light mosquito forceps. Each hemicusp is compared with the neighbouring hemicusp. To do this, the left-right commissure is grasped by the assistant and pulled away, whilst the central stay sutures of the left and right cusps are pulled in the opposite direction. This will show any excess length in one of the hemicusps if present. Next, the right-non commissure is grasped and pulled away by the assistant while the central stay sutures of the right coronary cusp and non-coronary cusp are pulled in the opposite direction. Finally, the process is repeated with the left-non commissure and the left coronary cusp and non-coronary cusp. In any of the assessments, if any excess length is seen in one of the cusps, the free margin is plicated using 5-0 or 6-0 polypropylene, thereby reducing its length. The aim is to end up with 3 symmetrical free margin lengths (Figure 3; Video 5). Similar to the valve-sparing root procedures,5Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: tricuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 107: 1592-1599Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 6Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: bicuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 108: 324-333Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar the next step after alignment of cusp free margin length is to perform a supravalvular annuloplasty at the STJ level. In the valve-sparing root procedures, the annuloplasty is carried out by the graft. In isolated AV repair, an expansible external annuloplasty ring is used instead (Extra-Aortic, Coroneo Inc). As described earlier, it is important for the coronary ostia to lie below the level of the commissures, to avoid compressing the coronaries with the STJ ring. Like the U sutures of the subvalvular annuloplasty ring, the STJ ring also requires supravalvular U sutures. These are 5 horizontal pledgeted mattress sutures (Ethicon 3/8 25-mm pledgeted needle, Ethicon LLC, Johnson & Johnson,), one above each commissure and each coronary artery. The first U suture placed is at the left-non commissure. The pledgeted mattress suture is placed with each needle entering inside the aorta 2 mm above the tip of the commissure, with 3 to 4 mm of space between the 2 sutures of the pledget. This is repeated for the other 2 commissures. A U suture is also placed 2 mm above each of the coronary ostia. These sutures are placed to prevent the external ring from encroaching onto the coronary arteries. The selected sized ring is held on its holder. The ring has 3 marker lines spaced 120 degrees apart, thus indicating the location for the commissural U sutures. These sutures are placed through the ring, by inserting the 2 needles 1 to 2 mm on either side of each marker line. The U sutures above each coronary artery are placed around the ring. The ring is parachuted down, and the sutures are tied down (Figure 4; Video 6). One of the most important mechanisms of AI is cusp prolapse. This can be assessed by measuring the cusp eH using a dedicated cusp caliper (Fehling Instruments, Karlstein, Germany) according to the principles of Schäfers.9Schafers H.J. Bierbach B. Aicher D. A new approach to the assessment of aortic cusp geometry.J Thorac Cardiovasc Surg. 2006; 132: 436-438Abstract Full Text Full Text PDF PubMed Scopus (219) Google Scholar It is important for the trainee to understand why this is done after STJ ring implantation. An annuloplasty at the STJ level, whether carried out by an external ring or a tube graft (as in the case of valve-sparing root procedures, or tubular aorta replacement), increases the valve's coaptation height but also causes an induced symmetrical prolapse of the cusps (by 3 to 4 mm). Therefore, measurement of eH after the STJ annuloplasty would allow the surgeon to address any native cusp prolapse, as well as any induced prolapse. To measure eH accurately, a pressurized root must be simulated. This is achieved by pulling on the 3 commissural stay sutures and securing these sutures to the drapes. The trainee must ensure that the stay sutures are pulled exactly 120 degrees to each other. The caliper is set to 9 mm, and it is inserted into the root with the belly of the caliper reaching the nadir or hinge point of each cusp (Figure 5). If eH is less than 9 mm, the cusp's free margin must be plicated until 9 mm is reached. Plication is performed using 5-0 polypropylene sutures (Video 7). While waiting for production of an open version of the external annuloplasty ring (Extra-Aortic, Coroneo Inc), a Dacron tube graft is used to cut out a 5-mm wide ring of the appropriate size. The ring is then cut open so that it can be passed underneath the coronary arteries. The trainee must ensure that the open ring passes through all the subvalvular U sutures as well as underneath each coronary artery without twisting. The U sutures are passed around rather than through the ring so that the ring distributes itself symmetrically round the circumference of the annulus. The ring is closed at the level of the non-coronary sinus. Closure of the ring is carried out by first inserting each of the 2 U suture needles (from the middle of the non-coronary sinus) into each end of the open ring. Then a separate suture is used to close the ring by taking bites at each open end (Figure 6). The first U sutures to be tied down should be at the left-right commissure because this is the most fragile section of the root. The trainee is reminded not to use excessive tension when tying because the fragile aortic tissue may tear. If a tear occurs, it must be repaired (using pericardial pledgeted mattress sutures (Video 8). The final step is closure of the aortotomy using 4-0 polypropylene suture. De-airing is carried out, and the cross-clamp is released. Subsequent transesophageal echocardiography is used to assess the repair. Only grade I central AI is tolerated. If a residual jet is eccentric, it should not be left because it will lead to long-term repair failure and recurrence of AI. The cross-clamp must be reapplied and the aortotomy reopened. Reassessment of the valve is carried out, and, if appropriate, the lesion is repaired again. In the case of an unrepairable valve, both annuloplasty rings are cut and removed, and a new prosthetic valve is inserted. Several different valve lesions may be encountered that require specific management or slight alterations to the foregoing techniques. For management of fenestrations, commissural diastasis, calcification, and the minor form of BAV with close to a 120-degree commissural angle, please see the previous two articles in the series.5Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: tricuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 107: 1592-1599Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar, 6Youssefi P. Zacek P. Debauchez M. Lansac E. Valve-sparing aortic root replacement using the remodeling technique with aortic annuloplasty: bicuspid valves with repair of specific lesion sets: how I teach it.Ann Thorac Surg. 2019; 108: 324-333Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar In the case of a dilated ascending aorta (≥40 to 45 mm) associated with TAV AI, a tubular ascending aorta replacement and subvalvular annuloplasty will need to be performed. In this scenario, the tube graft performs the STJ annuloplasty instead of the expansile external ring. All the other steps of the operation are as previously described. The graft size chosen corresponds to the sizing algorithm and is based on annulus diameter measurement (Table 2). It is important when anastomosing the tube graft to the STJ that the 3 commissures are spaced out at exactly 120 degrees from each other on the tube graft, to keep the valve symmetrical (Video 9).Table 2Sizing Chart for the Ascending Aorta Tube Graft and Calibrated Expansile Annuloplasty Ring (Extra-Aortic Ring) According to Aortic Annulus Size MeasurementProsthesisAortic Annulus Diameter (Hegar dilator, mm)Tube graft (mm)26283032Extra-Aortic ring (Coroneo Inc, Montreal, Canada) (mm)25272931 Open table in a new tab Because dystrophic AI almost always leads to dilatation of the annulus (>25 mm) and STJ (>30 mm), we developed a standardized approach to AV repair with the aim of restoring the ratio between the STJ and the annulus. The phenotype of the aorta determines which procedure is used (Figure 1), but the same steps are carried out in each operation, to perform (1) alignment of cusp free margin, then (2) supravalvular STJ annuloplasty, followed by (3) cusp eH assessment, and finally, (4) external ring subvalvular annuloplasty (if the annulus is ≥25 mm). In root aneurysms, the STJ supravalvular annuloplasty is carried out by the remodeling root repair, which brings the commissures to the diameter of the tube; in ascending aorta aneurysms, it is performed by the supracoronary tube; and in isolated AI, the STJ supravalvular annuloplasty is performed using an expansible aortic ring. Between 2003-2017, we have operated on 482 patients by using this standardized approach in all aorta phenotypes.10Zakkar M. Bruno V.D. Zacek P. et al.Isolated aortic insufficiency valve repair with external ring annuloplasty: a standardized approach [e-pub ahead of print]. Eur J Cardiothorac Surg.https://doi.org/10.1093/ejcts/ezz193Date accessed: August 20, 2019Google Scholar We looked at the impact of STJ stabilization on long-term durability of isolated AI repair in 93 patients. Our results showed that use of the double-ring annuloplasty was associated with 100% freedom from recurrence of AI grade 3 or greater, compared with 70% in the single annuloplasty group at 6 years (P = .008). Use of double annuloplasty correlated with 97% freedom from AV-related reintervention compared with 74% in the single annuloplasty group at 6 years (P = .02). This technique showed results similar to those of the valve-sparing procedures at 7 years. Long-term survival after AV repair was excellent and was shown to be similar to the sex- and age-matched populations. Dr Youssefi receives funding from the SCTS Ethicon Fellowship, Royal College of Surgeons of England Research Fellowship, and Dunhill Medical Trust Research Fellowship. Dr Lansac has consultant agreements with Coroneo, Inc, in connection with the development of an aortic ring bearing the trade name Extra-Aortic. Data extracted from the Heart Valve Society AVIATOR database were funded by research grants from the Adetec Association and an Edwards Lifesciences educational grant. 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