Generic placeholder image

Current Cardiology Reviews

Editor-in-Chief

ISSN (Print): 1573-403X
ISSN (Online): 1875-6557

Mini-Review Article

Valve Repair in Aortic Insufficiency: A State-of-the-art Review

Author(s): Leandros Sassis*, Pelagia Kefala-Karli, Irene Cucchi, Ilias Kouremenos, Michalis Demosthenous and Konstantinos Diplaris

Volume 19, Issue 1, 2023

Published on: 25 August, 2022

Article ID: e270422204131 Pages: 11

DOI: 10.2174/1573403X18666220427120235

Price: $65

conference banner
Abstract

Aortic valve insufficiency (AI) describes the pathology of blood leaking through the aortic valve to the left ventricle during diastole and is classified as mild, moderate or severe according to the volume of regurgitating blood. Intervention is required in severe AI when the patient is symptomatic or when the left ventricular function is impaired. Aortic valve replacement has been considered the gold standard for decades for these patients, but several repair techniques have recently emerged that offer exceptional stability and long-term outcomes. The appropriate method of repair is selected based on the mechanism of AI and each patient’s anatomic variations. This review aims to describe different pathologies of AI based on its anatomy, along with the different surgical techniques of aortic repair and their reported results.

Keywords: Aortic insufficiency, aortic valve repair, aortic annuloplasty, aortic insufficiency classification, valve-sparing aortic root replacement, ventricular diastole.

Graphical Abstract
[1]
Patibandla S, Heaton J, Azzam JS. Aortic insufficiency. StatPearls 2021.
[2]
Maurer G. Aortic regurgitation. Heart 2006; 92(7): 994-1000.
[http://dx.doi.org/10.1136/hrt.2004.042614] [PMID: 16775114]
[3]
Singh JP, Evans JC, Levy D, et al. Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study). Am J Cardiol 1999; 83(6): 897-902.
[http://dx.doi.org/10.1016/S0002-9149(98)01064-9] [PMID: 10190406]
[4]
Dewaswala N, Chait R. Aortic Regurgitation. StatPearls 2021.
[5]
Al-Atassi T, Boodhwani M. Aortic valve insufficiency in aortic root aneurysms: Consider every valve for repair. J Vis Surg 2018; 4: 60.
[http://dx.doi.org/10.21037/jovs.2018.01.13] [PMID: 29682470]
[6]
Bentall H, De Bono A. A technique for complete replacement of the ascending aorta. Thorax 1968; 23(4): 338-9.
[http://dx.doi.org/10.1136/thx.23.4.338] [PMID: 5664694]
[7]
Boodhwani M, de Kerchove L, Glineur D, et al. Repair-oriented classification of aortic insufficiency: Impact on surgical techniques and clinical outcomes. J Thorac Cardiovasc Surg 2009; 137(2): 286-94.
[http://dx.doi.org/10.1016/j.jtcvs.2008.08.054] [PMID: 19185138]
[8]
Aicher D, Fries R, Rodionycheva S, Schmidt K, Langer F, Schäfers HJ. Aortic valve repair leads to a low incidence of valve-related complications. Eur J Cardiothorac Surg 2010; 37(1): 127-32.
[http://dx.doi.org/10.1016/j.ejcts.2009.06.021] [PMID: 19643618]
[9]
David TE, Feindel CM, David CM, Manlhiot C. A quarter of a century of experience with aortic valve-sparing operations. J Thorac Cardiovasc Surg 2014; 148(3): 872-9.
[http://dx.doi.org/10.1016/j.jtcvs.2014.04.048] [PMID: 24930611]
[10]
de Kerchove L, Boodhwani M, Glineur D, et al. Cusp prolapse repair in trileaflet aortic valves: Free margin plication and free margin resuspension techniques. Ann Thorac Surg 2009; 88(2): 455-61.
[http://dx.doi.org/10.1016/j.athoracsur.2009.04.064] [PMID: 19632393]
[11]
Price J, De Kerchove L, Glineur D, Vanoverschelde JL, Noirhomme P, El Khoury G. Risk of valve-related events after aortic valve repair. Ann Thorac Surg 2013; 95(2): 606-12.
[http://dx.doi.org/10.1016/j.athoracsur.2012.07.016] [PMID: 22959573]
[12]
Ozaki S, Kawase I, Yamashita H, Uchida S, Takatoh M, Kiyohara N. Midterm outcomes after aortic valve neocuspidization with glutaraldehyde-treated autologous pericardium. J Thorac Cardiovasc Surg 2018; 155(6): 2379-87.
[http://dx.doi.org/10.1016/j.jtcvs.2018.01.087] [PMID: 29567131]
[13]
Anderson RH. Clinical anatomy of the aortic root. Heart 2000; 84(6): 670-3.
[http://dx.doi.org/10.1136/heart.84.6.670] [PMID: 11083753]
[14]
Kunihara T. Anatomy of the aortic root: Implications for aortic root reconstruction. Gen Thorac Cardiovasc Surg 2017; 65(9): 488-99.
[http://dx.doi.org/10.1007/s11748-017-0792-y] [PMID: 28656518]
[15]
Sud A, Parker F, Magilligan DJ Jr. Anatomy of the aortic root. Ann Thorac Surg 1984; 38(1): 76-9.
[http://dx.doi.org/10.1016/S0003-4975(10)62195-9] [PMID: 6732352]
[16]
Anderson RH. The surgical anatomy of the aortic root. Multimed Man Cardiothorac Surg 2007; 2007(102): mmcts.2006.002527.
[http://dx.doi.org/10.1510/mmcts.2006.002527]
[17]
Bisleri G. Aortic valve repair. Curr Opin Cardiol 2016; 31(6): 581-4.
[http://dx.doi.org/10.1097/HCO.0000000000000334] [PMID: 27583375]
[18]
Khelil 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(4): 1220-6.
[http://dx.doi.org/10.1016/j.athoracsur.2014.12.034] [PMID: 25728963]
[19]
Matsushima S, Karliova I, Gauer S, Miyahara S, Schäfers HJ. Geometry of cusp and root determines aortic valve function. Indian J Thorac Cardiovasc Surg 2020; 36 (Suppl. 1): 64-70.
[http://dx.doi.org/10.1007/s12055-019-00813-2] [PMID: 33061186]
[20]
de Kerchove L, Momeni M, Aphram G, et al. Free margin length and coaptation surface area in normal tricuspid aortic valve: An anatomical study. Eur J Cardiothorac Surg 2018; 53(5): 1040-8.
[http://dx.doi.org/10.1093/ejcts/ezx456] [PMID: 29253123]
[21]
Faletra FF, Narula J, Ho SY. Atlas of non-invasive imaging in cardiac anatomy. 2020.
[http://dx.doi.org/10.1007/978-3-030-35506-7]
[22]
Prodromo J, D’Ancona G, Amaducci A, Pilato M. Aortic valve repair for aortic insufficiency: A review. J Cardiothorac Vasc Anesth 2012; 26(5): 923-32.
[http://dx.doi.org/10.1053/j.jvca.2011.07.014] [PMID: 22703946]
[23]
Misfeld M, Sievers HH. Heart valve macro- and microstructure. Philos Trans R Soc Lond B Biol Sci 2007; 362(1484): 1421-36.
[http://dx.doi.org/10.1098/rstb.2007.2125] [PMID: 17581807]
[24]
Subramanian S, Borger MA. Aortic valve reconstruction: Current status. Herz 2010; 35(2): 88-93.
[http://dx.doi.org/10.1007/s00059-010-3325-3] [PMID: 20376642]
[25]
Schäfers HJ, Schmied W, Marom G, Aicher D. Cusp height in aortic valves. J Thorac Cardiovasc Surg 2013; 146(2): 269-74.
[http://dx.doi.org/10.1016/j.jtcvs.2012.06.053] [PMID: 22853942]
[26]
Bierbach BO, Aicher D, Issa OA, et al. Aortic root and cusp configuration determine aortic valve function. Eur J Cardiothorac Surg 2010; 38(4): 400-6.
[http://dx.doi.org/10.1016/j.ejcts.2010.01.060] [PMID: 20219388]
[27]
Loukas M, Bilinsky E, Bilinsky S, Blaak C, Tubbs RS, Anderson RH. The anatomy of the aortic root. Clin Anat 2014; 27(5): 748-56.
[http://dx.doi.org/10.1002/ca.22295] [PMID: 24000000]
[28]
Hokken RB, Bartelings MM, Bogers AJ, Gittenberger-de Groot AC. Morphology of the pulmonary and aortic roots with regard to the pulmonary autograft procedure. J Thorac Cardiovasc Surg 1997; 113(3): 453-61.
[http://dx.doi.org/10.1016/S0022-5223(97)70357-X] [PMID: 9081089]
[29]
Charitos EI, Sievers HH. Anatomy of the aortic root: Implications for valve-sparing surgery. Ann Cardiothorac Surg 2013; 2(1): 53-6.
[PMID: 23977559]
[30]
Tretter JT, Spicer DE, Mori S, Chikkabyrappa S, Redington AN, Anderson RH. The significance of the interleaflet triangles in determining the morphology of congenitally abnormal aortic valves: Implications for noninvasive imaging and surgical management. J Am Soc Echocardiogr 2016; 29(12): 1131-43.
[http://dx.doi.org/10.1016/j.echo.2016.08.017] [PMID: 27742239]
[31]
Saremi F, Sánchez-Quintana D, Mori S, et al. Fibrous skeleton of the heart: Anatomic overview and evaluation of pathologic conditions with CT and MR imaging. Radiographics 2017; 37(5): 1330-51.
[http://dx.doi.org/10.1148/rg.2017170004] [PMID: 28820653]
[32]
Bleiziffer S, Ruge H, Hörer J, et al. Predictors for new-onset complete heart block after transcatheter aortic valve implantation. JACC Cardiovasc Interv 2010; 3(5): 524-30.
[http://dx.doi.org/10.1016/j.jcin.2010.01.017] [PMID: 20488409]
[33]
Nardi P, Pellegrino A, Scafuri A, et al. Permanent pacemaker implantation after isolated aortic valve replacement: Incidence, risk factors and surgical technical aspects. J Cardiovasc Med 2010; 11(1): 14-9.
[http://dx.doi.org/10.2459/JCM.0b013e32832f9fde] [PMID: 19829137]
[34]
Gray H, Standring S, Ellis H, Berkovitz BKB. Gray's anatomy: The anatomical basis of clinical practice 2005.
[35]
Crooke PS, Beavan LA, Griffin CD, Mazzitelli D, Rankin JS. A geometric model of the normal human aortic root and design of a fully anatomic aortic root graft. Innovations 2015; 10(1): 57-62.
[http://dx.doi.org/10.1097/imi.0000000000000125] [PMID: 25628255]
[36]
Loukas M, Andall RG, Khan AZ, et al. The clinical anatomy of high take-off coronary arteries. Clin Anat 2016; 29(3): 408-19.
[http://dx.doi.org/10.1002/ca.22664] [PMID: 26518608]
[37]
de Paulis R, Salica A. Surgical anatomy of the aortic valve and root-implications for valve repair. Ann Cardiothorac Surg 2019; 8(3): 313-21.
[http://dx.doi.org/10.21037/acs.2019.04.16] [PMID: 31240175]
[38]
Blanke P, Russe M, Leipsic J, et al. Conformational pulsatile changes of the aortic annulus: Impact on prosthesis sizing by computed tomography for transcatheter aortic valve replacement. JACC Cardiovasc Interv 2012; 5(9): 984-94.
[http://dx.doi.org/10.1016/j.jcin.2012.05.014] [PMID: 22995887]
[39]
Chirichilli I, Irace F, Weltert L, et al. Morphological modification of the aortic annulus in tricuspid and bicuspid valves after aortic valve reimplantation: An electrocardiography-gated computed tomography study†. Eur J Cardiothorac Surg 2019; 56(4): 778-84.
[http://dx.doi.org/10.1093/ejcts/ezz065] [PMID: 30859210]
[40]
Prêtre R, Kadner A, Dave H, Bettex D, Genoni M. Tricuspidisation of the aortic valve with creation of a crown-like annulus is able to restore a normal valve function in bicuspid aortic valves. Eur J Cardiothorac Surg 2006; 29(6): 1001-6.
[http://dx.doi.org/10.1016/j.ejcts.2006.01.068] [PMID: 16675251]
[41]
El Khoury G, Glineur D, Rubay J, et al. Functional classification of aortic root/valve abnormalities and their correlation with etiologies and surgical procedures. Curr Opin Cardiol 2005; 20(2): 115-21.
[http://dx.doi.org/10.1097/01.hco.0000153951.31887.a6] [PMID: 15711197]
[42]
Netter FH. Atlas of human anatomy. (6th ed.), Philadelphia, PA: Saunders/Elsevier 2014.
[43]
Akinseye OA, Pathak A, Ibebuogu UN. Aortic valve regurgitation: A comprehensive review. Curr Probl Cardiol 2018; 43(8): 315-34.
[http://dx.doi.org/10.1016/j.cpcardiol.2017.10.004] [PMID: 29174586]
[44]
Enriquez-Sarano M, Tajik AJ. Clinical practice. Aortic regurgitation. N Engl J Med 2004; 351(15): 1539-46.
[http://dx.doi.org/10.1056/NEJMcp030912] [PMID: 15470217]
[45]
Doherty JU, Kort S, Mehran R, et al. ACC/AATS/AHA/ASE/ASNC/HRS/SCAI/SCCT/SCMR/STS 2017 appropriate use criteria for multimodality imaging in valvular heart disease: A report of the American college of cardiology appropriate use criteria task force, American association for thoracic surgery, American heart association, American society of echocardiography, American society of nuclear cardiology, heart rhythm society, society for cardiovascular angiography and interventions, society of cardiovascular computed tomography, society for cardiovascular magnetic resonance, and society of thoracic surgeons. J Am Soc Echocardiogr 2018; 31(4): 381-404.
[http://dx.doi.org/10.1016/j.echo.2017.08.012] [PMID: 29066081]
[46]
Waroux J-BlPd, Pouleur A-C, Goffinet D, et al. . Functional anatomy of aortic regurgitation. Circulation 2007; 116(11) (Suppl.): I-264-9.
[47]
Koo HJ, Kang JW, Kim JA, et al. Functional classification of aortic regurgitation using cardiac computed tomography: Comparison with surgical inspection. Int J Cardiovasc Imaging 2018; 34(8): 1295-303.
[http://dx.doi.org/10.1007/s10554-018-1341-1] [PMID: 29564585]
[48]
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American heart association task force on practice guidelines. Circulation 2014; 129(23): e521-643.
[http://dx.doi.org/10.1161/CIR.0000000000000031] [PMID: 24589853]
[49]
Zoghbi WA, Enriquez-Sarano M, Foster E, et al. Recommendations for evaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr 2003; 16(7): 777-802.
[http://dx.doi.org/10.1016/S0894-7317(03)00335-3] [PMID: 12835667]
[50]
Nishimura RA, Otto CM, Bonow RO, et al. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: Executive summary: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol 2014; 63(22): 2438-88.
[http://dx.doi.org/10.1016/j.jacc.2014.02.537] [PMID: 24603192]
[51]
Ahmed T, Puckett Y. StatPearls Publishing 2021; LLC: 2021.
[52]
Lansac E, Di Centa I, Raoux F, et al. A lesional classification to standardize surgical management of aortic insufficiency towards valve repair. Eur J Cardiothorac Surg 2008; 33(5): 872-8.
[http://dx.doi.org/10.1016/j.ejcts.2007.12.033] [PMID: 18258445]
[53]
de Kerchove L, Boodhwani M, Glineur D, et al. Valve sparing-root replacement with the reimplantation technique to increase the durability of bicuspid aortic valve repair. J Thorac Cardiovasc Surg 2011; 142(6): 1430-8.
[http://dx.doi.org/10.1016/j.jtcvs.2011.08.021] [PMID: 21955470]
[54]
Le Polain De Waroux JB, Pouleur AC, Goffinet C, et al. Functional anatomy of aortic regurgitation: Accuracy, prediction of surgical repairability, and outcome implications of transesophageal echocardiography. Circulation 2007; 116(11) (Suppl.): I-264-9.
[55]
Harky A, Antoniou A, Howard C, Rimmer L, Ahmad MU, Bashir M. Valve sparing aortic root surgery: From revolution to evolution. J Vis Surg 2019; 5: 14.
[http://dx.doi.org/10.21037/jovs.2019.01.11]
[56]
David TE, Feindel CM. An aortic valve-sparing operation for patients with aortic incompetence and aneurysm of the ascending aorta. J Thorac Cardiovasc Surg 1992; 103(4): 617-21.
[http://dx.doi.org/10.1016/S0022-5223(19)34942-6] [PMID: 1532219]
[57]
Sarsam MA, Yacoub M. Remodeling of the aortic valve anulus. J Thorac Cardiovasc Surg 1993; 105(3): 435-8.
[http://dx.doi.org/10.1016/S0022-5223(19)34225-4] [PMID: 8445922]
[58]
Lansac E, de Kerchove L. Aortic valve repair techniques: State of the art. Eur J Cardiothorac Surg 2018; 53(6): 1101-7.
[http://dx.doi.org/10.1093/ejcts/ezy176] [PMID: 29718164]
[59]
de Kerchove L, Mastrobuoni S, Boodhwani M, et al. The role of annular dimension and annuloplasty in tricuspid aortic valve repair. Eur J Cardiothorac Surg 2016; 49(2): 428-37.
[http://dx.doi.org/10.1093/ejcts/ezv050] [PMID: 25721823]
[60]
Schäfers H-J, Raddatz A, Schmied W, et al. Reexamining remodeling. J Thorac Cardiovasc Surg 2015; 149(2) (Suppl.): S30-6.
[http://dx.doi.org/10.1016/j.jtcvs.2014.09.048] [PMID: 25439784]
[61]
Schneider U, Hofmann C, Aicher D, Takahashi H, Miura Y, Schäfers H-J. Suture annuloplasty significantly improves the durability of bicuspid aortic valve repair. Ann Thorac Surg 2017; 103(2): 504-10.
[http://dx.doi.org/10.1016/j.athoracsur.2016.06.072] [PMID: 27663792]
[62]
Lansac E, Di Centa I, Vojacek J, et al. Valve sparing root replacement: The remodeling technique with external ring annuloplasty. Ann Cardiothorac Surg 2013; 2(1): 117-23.
[PMID: 23977568]
[63]
Lansac E, Di Centa I, Varnous S, et al. External aortic annuloplasty ring for valve-sparing procedures. Ann Thorac Surg 2005; 79(1): 356-8.
[http://dx.doi.org/10.1016/j.athoracsur.2003.10.103] [PMID: 15620986]
[64]
Lenoir M, Maesen B, Stevens LM, et al. Reimplantation versus remodelling with ring annuloplasty: Comparison of mid-term outcomes after valve-sparing aortic root replacement. Eur J Cardiothorac Surg 2018; 54(1): 48-54.
[http://dx.doi.org/10.1093/ejcts/ezy016] [PMID: 29432524]
[65]
Tian D, Rahnavardi M, Yan TD. Aortic valve sparing operations in aortic root aneurysms: Remodeling or reimplantation? Ann Cardiothorac Surg 2013; 2(1): 44-52.
[PMID: 23977558]
[66]
David TE, David CM, Feindel CM, Manlhiot C. Reimplantation of the aortic valve at 20 years. J Thorac Cardiovasc Surg 2017; 153(2): 232-8.
[http://dx.doi.org/10.1016/j.jtcvs.2016.10.081] [PMID: 27923487]
[67]
Arabkhani B, Mookhoek A, Di Centa I, et al. Reported outcome after valve-sparing aortic root replacement for aortic root aneurysm: A systematic review and meta-analysis. Ann Thorac Surg 2015; 100(3): 1126-31.
[http://dx.doi.org/10.1016/j.athoracsur.2015.05.093] [PMID: 26228603]
[68]
Lansac E, Di Centa I, Sleilaty G, et al. Remodeling root repair with an external aortic ring annuloplasty. J Thorac Cardiovasc Surg 2017; 153(5): 1033-42.
[http://dx.doi.org/10.1016/j.jtcvs.2016.12.031] [PMID: 28187973]
[69]
Lansac E, Di Centa I, Sleilaty G, et al. Long-term results of external aortic ring annuloplasty for aortic valve repair. Eur J Cardiothorac Surg 2016; 50(2): 350-60.
[http://dx.doi.org/10.1093/ejcts/ezw070] [PMID: 27440158]
[70]
Mazzitelli D, Fischlein T, Rankin JS, et al. Geometric ring annuloplasty as an adjunct to aortic valve repair: Clinical investigation of the HAART 300 device. Eur J Cardiothorac Surg 2016; 49(3): 987-93.
[http://dx.doi.org/10.1093/ejcts/ezv234] [PMID: 26156945]
[71]
Rankin JS, Bone MC, Fries PM, Aicher D, Schäfers HJ, Crooke PS. A refined hemispheric model of normal human aortic valve and root geometry. J Thorac Cardiovasc Surg 2013; 146(1): 103-108.e1.
[http://dx.doi.org/10.1016/j.jtcvs.2012.06.043] [PMID: 22858429]
[72]
Papakonstantinou NA, Kogerakis N, Kantidakis G, Athanasopoulos G, Stavridis GT. A modern approach to aortic valve insufficiency: Aortic root restoration via HAART 300 internal annuloplasty ring. J Card Surg 2021; 36(11): 4189-95.
[http://dx.doi.org/10.1111/jocs.15947] [PMID: 34448500]
[73]
Rankin JS, Mazzitelli D, Fischlein T, et al. Geometric ring annuloplasty for aortic valve repair during aortic aneurysm surgery: Two-year clinical trial results. Innovations 2018; 13(4): 248-53.
[http://dx.doi.org/10.1097/IMI.0000000000000539] [PMID: 30138245]
[74]
Jawitz OK, Raman V, Anand J, et al. Aortic valve repair with a newly approved geometric annuloplasty ring in patients undergoing proximal aortic repair: Early results from a single-centre experience. Eur J Cardiothorac Surg 2020; 57(6): 1137-44.
[http://dx.doi.org/10.1093/ejcts/ezaa009] [PMID: 32011669]
[75]
Mazzitelli D, Pfeiffer S, Rankin JS, et al. A regulated trial of bicuspid aortic valve repair supported by geometric ring annuloplasty. Ann Thorac Surg 2015; 99(6): 2010-6.
[http://dx.doi.org/10.1016/j.athoracsur.2015.01.050] [PMID: 25865762]
[76]
David TE, Maganti M, Armstrong S. Aortic root aneurysm: Principles of repair and long-term follow-up. J Thorac Cardiovasc Surg 2010; 140(6) (Suppl.): S14-9.
[http://dx.doi.org/10.1016/j.jtcvs.2010.07.041] [PMID: 21092781]

Rights & Permissions Print Cite
© 2024 Bentham Science Publishers | Privacy Policy