Concepts of Aortic Valve Repair
Aortic valve (AV) sparing and repair procedures are advantageous alternatives to valve replacement in patients with aortic aneurysm and/or aortic regurgitation. A successful sparing or repair strategy proceeds first from a clear understanding of the pecul
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Stefano Mastrobuoni, Laurent de Kerchove, Munir Boodhwani, Emiliano Navarra, and Gebrine El Khoury
42.1 Introduction During the past 15 years, important advances in the field of aortic valve (AV) repair have transformed it from an infrequent and anecdotal exercise to a feasible and attractive alternative to valve replacement in selected patients with aortic regurgitation (AR). These advances include a deeper understanding of the functional anatomy of the AV and pathophysiologic mechanisms of AR, the development of surgical techniques to restore normal geometry of the aortic root while sparing the AV, and the development of a common language that can be used by all clinicians to describe the lesions, discuss repair techniques, and compare immediate and long-term outcomes after AV repair. Aortic regurgitation and aortic root aneurism concern mainly adolescent and young adults with connective tissue disorders or other abnormal congenital valve diseases like bicuspid aortic valve (BAV). In these patients, aortic valve sparing and repair represent a particularly interesting S. Mastrobuoni (*) · L. de Kerchove · E. Navarra · G. El Khoury Cardiovascular and Thoracic Surgery Department, Saint-Luc’s Hospital, Catholic University of Louvain, Brussels, Belgium e-mail: [email protected]; laurent. [email protected]; emiliano.navarra@ uclouvain.be; [email protected] M. Boodhwani Cardiac Surgery Department, University of Ottawa Heart Institute, Ottawa, Canada e-mail: [email protected]
alternative to replacement because of the limitations of currently available aortic valve substitutes. On the one hand, bioprosthetic valves don’t need long-term anticoagulation therapy, but the high structural failure rate in young patients (up to 4% per year) expose to multiple re-replacements. On the other hand, mechanical valves have an excellent freedom from reoperation, but risks of thromboembolic events (1–2% per year) and anticoagulation-related hemorrhage (2% per year) can carry a significant burden in young patients because of the expected long exposure time. Further, the Ross operation is ideal for young patients with BAV stenosis because of its durability, excellent patient survival, and low risk of thromboembolic complications. However, the presence of aortic insufficiency and aortic root dilatation are considered as important risk factors for pulmonary autograft failure. This chapter attempts to describe the important principles of correction of AV regurgitation by focusing on functional anatomy and surgical techniques.
42.2 Anatomy of the Aortic Valve and Functional Aortic Annulus To understand the different mechanisms of AR and the potential surgical approaches, the AV should be considered as a functional unit composed of two structures: (1) the sino-tubular
© Springer-Verlag GmbH Austria, part of Springer Nature 2019 O. H. Stanger et al. (eds.), Surgical Management of Aortic Pathology, https://doi.org/10.1007/978-3-7091-4874-7_42
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junction (STJ) and the ventriculo-aortic
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