Optimal approach to valve-sparing root replacement and aortic valve repair in aortic insufficiency

Abstract

Despite the technically challenging nature of valve-sparing root replacement, restoration of aortic valve competence can be achieved through a complete understanding of the aortic root anatomy and pathophysiology. In this review, we discuss the physiology of normal aortic root function as well as pathophysiologic mechanisms contributing to aortic valve incompetence. Preoperative planning for valve-sparing root replacement is discussed, including the use of imaging to guide surgical decision-making. Pitfalls and pearls of the critical technical steps for both valve-sparing root replacement and repair of both tricuspid and bicuspid aortic valves are provided. Finally, current evidence guiding best practices in valve-sparing root replacement and aortic valve repair is presented to support decision-making for patient selection.

Keywords

Valve-sparing root replacement aortic valve repair aortic insufficiency bicuspid aortic valve

Introduction

Despite advancements in the engineering of prosthetic valve substitutes, the importance of preservation of native valve tissue is well-established, presuming that adequate valve function can be maintained or restored. The clinical benefit of preserving native atrioventricular valve anatomy is supported by multiple clinical studies and is pertinent in aortic valve disease as well, particularly considering younger patients with bicuspid aortic valve (BAV) and hereditary thoracic aortic disease (HTAD) in whom valve durability is a critical factor in selecting an optimal operative repair strategy. Thus, valve-sparing techniques emerged in the early 1990s as a key advancement to address both aortic root pathology and aortic insufficiency (AI) in carefully selected patients without aortic cusp degeneration. Herein, we review the development of valve-sparing root replacement (VSRR) operations, including current applications and technical considerations. Furthermore, we explore the concept of aortic valve repair for both tricuspid and bicuspid aortic valve-related disease. Exploration of long-term outcomes will highlight current best practices and outline potential areas for further investigation or innovation. Both VSRR and aortic valve repair are technically demanding procedures yet, with satisfactory results, allow for long-term durability with avoidance of the morbidity associated with either a bioprosthetic or mechanical aortic valve replacement.

History of valve-sparing surgery

Prior to the early 1990s, patients with concomitant aortic root dilatation and significant AI were managed with complete and full aortic root replacement, including valve replacement with a prosthetic valve and reimplantation of the coronary buttons within a tube graft.¹ In 1992, Tirone David and Christopher Feindel published their series of 10 patients with Marfan syndrome who underwent replacement of the aortic root with a tubular Dacron graft accompanied by reimplantation of the native aortic valve and reimplantation of the coronary buttons.² Preliminary results in this patient population were promising, with only one patient requiring subsequent valve replacement.² Subsequent iterations of this reimplantation technique have addressed both the annulus and sinotubular junction (STJ) as possible contributors to late development of valve insufficiency.³ Sir Magdi Yacoub subsequently introduced the remodeling technique in 1993, in which the Dacron tube graft is scalloped to recreate the sinuses and sutured to a rim of aortic tissue along the insertion of the leaflets.^4,5 The latter technique aimed at preserving physiologic root function and geometry.⁶

Both the reimplantation and remodeling techniques were able to address root pathology and make corrections to pre-existent annuloaortic ectasia as an isolated pathology contributing to the underlying preoperative AI. It was later recognized that many patients can have persistent AI following isolated VSRR due to intrinsic aortic cusp pathology and that a thorough understanding of principles of normal aortic valve leaflet dynamics must be utilized and applied to techniques of valve repair for restoration of aortic valve competency. In the latest 2020 ACC/AHA Guidelines, aortic valve repair of bicuspid AI received a Class 2b recommendation with the caveat that repair be performed in selected patients at a Comprehensive Valve Center.⁷

Aortic root anatomy and function

Understanding of the anatomy of the aortic annulus, sinuses, cusp anatomy, STJ, and their individual contributions to aortic valve competence is critical to restoring normal function. The relative diameters of the virtual basal ring and STJ should be obtained from preoperative imaging as dilatation of either of these measures may, in part or in whole, induce AI.⁸ A repair-oriented classification for AI⁹ based on the Carpentier classification for mitral valve regurgitation¹⁰ serves as a useful framework to categorize the mechanism of AI and plan for durable repair. Valve competence requires that the cusp-free margins have sufficient coaptation such that retrograde flow during diastole is impeded and the sinuses are filled with concurrent flow down the coronary arteries. Both effective height (distance between the free margin and the distal plane) and geometric height (height of the cusp tissue) of the cusps serve as metrics by which to diagnose and correct any cusp contribution to AI.¹¹ These principles apply irrespective of whether the valve is tricuspid or bicuspid as well as the number of sinuses and raphes that exist at baseline. The nature of the AI jet can also provide important clinical clues as to the etiology of the aortic valve insufficiency. A central leak on echo imaging suggests dilatation of the annulus or STJ as the etiology of AI and may only necessitate performing VSRR alone while an eccentric AI jet often suggests concurrent intrinsic leaflet pathology (along with aortic root pathology), which may necessitate additional cusp repair.

Diagnosis of AI and root dilatation

Patients with aortic root aneurysm and AI have typically already undergone transthoracic echocardiography (TTE) and cross-sectional imaging with either computed tomography (CT) or magnetic resonance imaging (MRI) prior to surgical consultation. The degree of AI, eccentricity of the AI jet, and structural integrity of the leaflets are important to note on TTE though some anatomic components may be difficult to ascertain depending on image quality and the patient's body habitus. Additional valve pathology and systolic function should also be assessed to provide an accurate assessment of baseline aortic root and cusp anatomy. Transesophageal echocardiography (TEE) provides a clear picture of baseline pathology and can be acquired pre-operatively to refine surgical planning. Regardless, intra-operative TEE should be comprehensively reviewed in the operating room to finalize the operative approach. Cross-sectional imaging provides useful information on the baseline aortic root and cusp pathology, degree and nature of AI, and any additional aortic pathology that may need to be concomitantly addressed, as well as the position and course of the coronary arteries.

Left and right heart catheterization can provide additional information with respect to AI as well as to identify coronary disease, including any aberrant coronary anatomy, and any right heart dysfunction. In cases of redo sternotomy, the importance of careful review of preoperative imaging cannot be understated. Genetic testing as well as cascade testing of family members should not be missed when indicated for possible HTAD.^12,13

Overview of surgery for VSRR and aortic valve repair

First and foremost, shared decision-making between the patient and surgeon should be utilized with an overview of all reasonable options for addressing the known pathology with a tailored discussion focusing on patient preferences, life expectancy, repair durability, and likelihood for reintervention, including the options for reintervention (i.e. endovascular or open) and associated risks. Indications for aortic root replacement have been well-defined in the current guidelines and should serve as the framework for this discussion.^7,12,13 In patients with suitable anatomy for VSRR approaches, valve selection in case of need for valve replacement should be discussed pre-operatively and documented. Patients who desire a VSRR approach should be referred to a high-volume center if their local institution is inexperienced with this approach.

VSRR has been applied for various indications. Since Tirone David first published his series of patients with Marfan syndrome, VSRR has been successfully performed in patients with other HTAD including Loeys-Dietz and BAV anatomy. Acute aortic dissection has emerged as another possible setting in which to consider VSRR, with excellent reported long-term outcomes.^14,15 These data demonstrate the feasibility of performing VSRR in multiple clinical settings including elective, urgent, and emergency cases. Additionally, redo sternotomy should not be considered a contraindication to VSRR.^16,17 These studies are certainly subject to selection bias and patients should be carefully screened for the appropriateness of VSRR in every clinical scenario.

Operative techniques

General conduct of the operation

Cardiopulmonary bypass can be initiated with arterial cannulation peripherally (e.g., right axillary cannulation) or central aortic cannulation depending on the need for concomitant aortic procedures and surgeon preference. The aorta is transected approximately 2 cm distal to the STJ allowing for full visualization of the root complex. A final surgical plan should be finalized at this time after thorough inspection of the aortic valve and root anatomy. Adequate annular stabilization in VSRR requires deep dissection of the aortic root to the virtual basal ring, as described by El Khoury.¹⁸ Care should be taken to avoid injury to surrounding structures, particularly the right ventricular outflow tract. Marking sutures should be placed at the commissures and the coronary buttons should be mobilized sufficiently to facilitate reimplantation. At this point, careful inspection of the valve cusp should again be performed for final decision-making with respect to the appropriateness of valve repair versus replacement. The aortic annulus should then be sized with commercially available sizers.

Multiple methods and various formulas have been applied^2,19,20 to determine optimal graft sizing. Although perhaps the simplest estimate of appropriate graft size is the length of the interleaflet triangle between the left and non-coronary cusps,²¹ our preferred method is to use a variation of the original David-Feindel formula given that it bases the graft size on cusp anatomy.² Although both oversizing and undersizing may result in persistence of AI,²² erring on the side of graft oversizing still allows persistent AI to be corrected both during creation of the secondary suture line as well as with the use of a smaller graft distally to narrow the STJ.²² Thus, selection of the proper graft size is one of the key steps of the operation. An area of ongoing debate is whether a straight tube graft versus a Valsalva Dacron graft is optimal however either have been associated with outstanding outcomes.²³ Proponents of the Valsalva graft argue that it recreates the sinus segments, thus allowing for eddy currents and physiologic cusp closure in diastole, which may translate to valve longevity though direct evidence of this is lacking.²⁴ The straight tube graft may be less complex to utilize and allows more flexibility in graft tailoring such as the ability to “neck” down the graft at the annulus and/or the STJ via suture plication to create custom neo-sinuses.²⁵

For the reimplantation technique, braided, horizontal mattress subannular sutures should be placed evenly spaced. The number of sutures and the use of pledgets can vary depending on surgeon preference. The graft should then be seated and the sutures tied. Following this, the commissural posts should be tacked within the graft at the appropriate height and angles to ensure adequate valve function. A hemostatic secondary suture line of running polypropylene is utilized to secure the rim of the aorta around the leaflet insertion to the Dacron graft in an undulating fashion at each sinus. Valve repair, which will be detailed below, should then be performed following assessment of the valve within the neo root. The coronary buttons are then reimplanted, and the distal graft anastomosis is performed in the standard fashion. An experienced echocardiographer should be available to provide quality images to assess for any residual AI. More than mild AI should prompt consideration of re-repair or replacement, and TEE imaging should be studied to identify potential areas of failure of repair prior to embarking on another cross-clamp.

The following sections will focus on step-by-step approaches to aortic valve repair.

Assessment of baseline aortic valve cusp and aortic root anatomy

Review of pre-operative imaging and intra-operative TEE should provide some indication as to whether the aortic valve is potentially sparable or repairable. Short-axis TEE views without color may be utilized to examine the symmetry of cusp opening/closing, free margin length, and any signs of degeneration. Long-axis TEE views with color are important to assess the nature of the AI jet and determine whether the leak is central or eccentric. This information provides clues to the potential corrective measures needed to restore valve competency. Long-axis TEE views without color can potentially detect cusp prolapse, which can be used to correlate cusp anatomy to the etiology of AI. While using color flow doppler to short-axis views does not provide much additional information regarding the etiology of AI, adding color to the short-axis views is especially helpful when weaning from cardiopulmonary bypass to both assess AI and determine the location of the leak for potential correction. Ultimately, direct inspection of the anatomy is the most critical modality to finalize the decision for performing aortic valve repair versus replacement as part of the aortic root operation.

Following initiation of cardiopulmonary bypass and cardioplegic arrest, the ascending aorta is opened, and the tissue is inspected for the quality of the aortic tissue as well as for any intimal pathology such as tears or atherosclerotic plaque. The aortic root should then be completely dissected and the abnormal sinus tissue resected while creating the coronary buttons. The aortic cusps should be gently inspected to assess for symmetry, length, pliability, and particularly fenestrations as these are hard to identify on TEE imaging. Any evidence of degeneration, cusp restriction, or cusp prolapse should be further explored to determine the mechanism of AI. Both the effective height and geometric height of the valve leaflets should be determined either with a ruler or with commercially available aortic cusp calipers (Genesee Biomedical, Denver, CO). Similarly, the annular diameter should be sized.

With the root fully dissected, gentle suction at the zone of cusp apposition should be applied to recreate native leaflet coaptation. The commissural posts can be manipulated to improve leaflet coaptation. In cases of cusp prolapse, the cusp is typically amenable to repair if the free margin is elongated, however, a shortened free margin, in our opinion, would necessitate valve replacement.

Determining valve is spareability

Proper functioning of the aortic valve relies on proper cusp coaptation. Measurement of the effective height and geometric height can be utilized to determine both feasibility and durability of AV repair. A normal effective height is about 9 mm and a normal geometric height is about 20 mm.²⁶ The distance over which the leaflets coapt is typically about 5 mm.²⁶ These metrics should be utilized as a benchmark to achieve a durable repair. In addition to adequate length of leaflet tissue, the cusps should be assessed for thinning, fenestrations, and calcification. It is important to consider patient age and life expectancy in combination with cusp anatomy when deciding on potential valve repair as well as to weigh the impact of an additional cross-clamp and bypass run should the repair be inadequate.

Techniques to address the aortic annulus

In the absence of a dilated root necessitating replacement (i.e., root <40–45 mm), a dilated aortic annulus can be reinforced with a variety of methods, including sutures, internal rings, and external rings.²⁶ With the reimplantation approach, the annulus is stabilized inside a Dacron graft by the subannular sutures that anchor the Dacron graft to the base of the heart preventing future dilatation, which may potentially contribute to recurrent AI. With the remodeling technique, however, the native annulus is left unsupported, and annular stabilization can be accomplished with an external ring of Dacron or an expansile external annuloplasty ring with satisfactory long-term durability.^27–29 While early reports omitted tailoring of the aortic annulus with remodeling,⁵ more recent work by Lansac and others has suggested long-term durability of AV repair is improved with the addition of external annuloplasty.²⁹

Techniques to address cusp pathology

Aortic cusp pathology may lend itself to repair rather than replacement. Small fenestrations can be closed with interrupted polypropylene sutures or in some cases patched. Fenestrations near the commissures may be amenable to plication. Those fenestrations that are not contributing to AI, particularly if small, should be left intact. Excess cusp length can be corrected with plication along the free margin with interrupted polypropylene suture to eliminate cusp prolapse and improve coaptation. Insufficient cusp height may be addressed with leaflet augmentation with either bovine or autologous pericardium. Cusp prolapse may also be corrected by wedge or segmental resection. A combination of these techniques can be employed concomitantly when indicated; however, it is important to recognize that highly complex leaflet pathology may be better served with valve replacement.

Techniques to address a BAV

Aortic valve repair for BAV can be somewhat more complex but should adhere to the principles of restoring near-normal valve physiology. A comprehensive review of all BAV repair approaches is beyond the scope of this manuscript; however, the general principles can be highlighted. With inspection of the valve and number of raphes, the symmetry of a bicuspid valve should be noted at the time of operative intervention. Valves with commissures that are oriented between 160° and 180° are considered to be symmetric and are more amenable to repair. Very asymmetric valves (i.e., 120°–139°) may be treated similar to tricuspid valves. In most patients with BAV and AI, it is the conjoined (or fused) cusp that is prolapsed due to an elongated free margin and creates AI. Correction of free margin length can involve resection of a central raphe, particularly if thickened or sclerotic, to improve mobility of the cusp tissue and provide an equivalent height to the reference cusp and level of coaptation. The free margin may also require central plication to optimize the effective height. Thickening of the cusp margins can be addressed by shave excision to improve pliability.

Outcomes

It is important to keep in mind that VSRR and aortic valve repair, particularly bicuspid repair, are typically performed at high-volume centers, and thus the reported excellent outcomes may not be generalizable to all centers. We have previously published our series of patients undergoing reimplantation in the setting of acute type A aortic dissection, severe AI, and redo sternotomy, demonstrating excellent outcomes with low operative mortality (2.2%) and high freedom from AVR of 98%.³⁰ Outcomes in the setting of acute dissection are particularly promising, with freedom from 2+ AI of 94%, which includes 14% of patients who had concomitant cusp repair.¹⁵ At 10 years, freedom from more than mild AI was 91% among acute type A dissection patients, which was significantly greater than that of patients undergoing isolated root repair (49%).¹⁴ Furthermore, there is data to suggest that VSRR may improve LV function through reverse remodeling in patients with severe preoperative AI.³¹ Factors predictive of late AV valve dysfunction include aortic root diameter >55 mm, BAV, and the need for cusp repair.³² Though these do not represent absolute contraindications, caution should be exercised in these populations.

Multiple groups have demonstrated that VSRR may provide superior outcomes when compared to bioprosthetic or mechanical root replacement. Our group published our series of 444 patients, 282 of whom underwent VSRR, which showed significantly improved survival at 7 years for VSRR when compared to mechanical Bentall (85.5% versus 73.6%).³³ Survival (VSRR 82.4% vs biologic Bentall 83.0%, p = 0.53) and freedom from reoperation (VSRR 97.4% versus biologic Bentall 95.8%, p = 0.48) at 7 years were found to be similar in VSRR when compared to biologic Bentall.³⁴

With regard to outcomes of AV repair, we have shown that excellent outcomes can be achieved regardless of the degree of preoperative AI³⁵ or the presence of a BAV.^36,37 These outcomes also hold true in patients with eccentric AI when compared to those with a central AI jet.^38,39 Repair may offer similar survival to replacement for AI.⁴⁰ Though late reintervention may be more common with AV repair, overall rates are low at 1–2% at 1 year in one series.^40,41 Others have suggested a survival benefit to AV repair when compared to replacement.⁴² VSRR has also been associated with improved survival when compared to both bioprosthetic and mechanical composite root replacement, and this effect is most notable among younger patients (i.e., <50 years old).^43,44 Among patients undergoing BAV repair, the risk of reoperation was found to be similar to bioprosthetic AVR; reintervention for both of these groups was elevated when compared with those patients who underwent mechanical AVR.⁴⁵ Ultimately, shared decision-making with patients and a comprehensive discussion of risks and benefits of the various approaches should guide the chosen technique.

Final thoughts and future directions

Correction of AI through VSRR and AV repair represents a feasible approach that avoids implantation of a prosthetic valve with the associated risks of degeneration and anticoagulation. In experienced hands, durable long-term repair can be achieved. Nevertheless, the technical complexity of the operation necessitates surgical expertise in root surgery and AV repair, particularly in bicuspid valves, may limit widespread adoption of this operation. Proper patient selection, recognition of abnormal root and cusp anatomy combined with application of appropriate surgical techniques are critical to achieving optimal clinical outcomes.

Footnotes

ORCID iD

Lauren V Huckaby

Ethical approval

Not applicable.

Informed consent

Not applicable.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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