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Root Reimplantation and Aortic Annuloplasty With External Ring in Bicuspid Aortic Valve: An Anatomical Comparison

      Aortic annuloplasty has demonstrated to be a protective factor in valve-sparing root replacement and aortic valve repair. Both reimplantation for aortic root aneurysms and external ring annuloplasty for isolated aortic regurgitation have demonstrated good long-term results. The aim of this anatomical study is to compare aortic reimplantation with Valsalva graft with aortic external ring annuloplasty in bicuspid aortic valves, analyzing their morphological features with CT scan. We selected 56 patients with bicuspid aortic valve who underwent reimplantation procedure with Valsalva graft or external ring annuloplasty; after propensity-matching, 2 homogeneous groups of 10 patients each were obtained. Through multiplanar ECG-gated CT-Scan reconstructions, pre- and postoperative, aortic annular, and valve geometrical characteristics were compared (diameters, perimeter, area and ellipticity index for the annulus; effective height, coaptation length and commissural height for the valve). Aortic root volume was also analyzed. Postoperative comparison of the two groups showed similar geometric features of the aortic annulus in terms of major and minor diameters, perimeter, area and ellipticity index. Analysis of valve's parameters showed similar results in terms of effective height and coaptation length (respectively 10.9 ± 2.1 mm and 7.5 ± 1.9 mm in External Ring group and 10.1 ± 2.0 mm and 7.6 ± 1.6 mm in the Reimplantation group). Both techniques achieve an efficient annuloplasty with similar anatomical results on bicuspid the aortic valves. The stability of these results needs to be confirmed by long-term clinical and echocardiographic follow-up.

      Graphical Abstract

      Keywords

      Abbreviations:

      A (area), AR (aortic regurgitation), AVS (aortic valve sparing), BAV (bicuspid aortic valve), BSA (body surface area), cL (coaptation length), CO (commissural orientation), CT (computed tomography), ECG (electrocardiogram), eH (effective height), EI (ellipticity index), FAA (functional aortic annulus), md (minor diameter), MD (major diameter), nFC (non-fused cusp), P (perimeter), STJ (sino-tubular junction), TAV (tricuspid aortic valve), VBR (virtual basal ring), VSRR (valve sparing root replacement)
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      Linked Article

      • Commentary: Is Simpler Better?
        Seminars in Thoracic and Cardiovascular SurgeryVol. 34Issue 3
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          It is critical to understand the anatomy of the aortic root in aortic valve repair for aortic insufficiency. There are ten structure in the aortic root: One anatomical crown-shaped aortic annulus, 2 coronary ostia, 3 aortic sinuses and/or 3 cusps and/or 3 interleaflet triangles, and 4 rings: virtual basal ring (functional aortic annulus), ventriculo-aortic junction (VAJ), ring of the aortic sinuses (largest diameter of the aortic root), and sinotubular junction (STJ). Among the ten structures, 3 structures are critical for the competency of aortic valve (AV), including the functional aortic annulus (basal ring), the cusps and the STJ.
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