Similar size formula for annulus, leaflet, and valsalva sinus in valve-sparing operations during bicuspid aortic valve repair

Simplicity is the ultimate sophistication.—Leonardo da Vinci The efforts to establish a robust and clinically validated algorithm for bicuspid aortic valve-related aorthopathy management are being published. The clinical importance relates to the high frequency and coincidence of aortic aneurysmal enlargement, which has resulted in a more liberal shift to the left in recommendations for aneurysmal segment resection. The presence of a mathematical formula may help in choosing the proper technique—and its reproducibility. Milewski and colleagues1Milewski K.C.R. Habertheuer A. Bavaria J.E. et al.Long-term outcomes of aortic root procedures for heterogeneous ascending aneurysm disease in bicuspid aortic valve syndrome.J Thorac Cardiovasc Surg. 2024; 167: 2063-2075.e4Abstract Full Text Full Text PDF Scopus (2) Google Scholar present a very interesting algorithm for aortic root management. It is based on the relationship between the sinotubular junction (STJ) and the aortic annulus diameter, with cutoffs of 1.5 to 1.8. Above the index of 1.8, root replacement is recommended. As a result, root replacement is recommended versus only STJ remodeling with ascending aorta replacement. The same index of 1.5 to 1.8 ratio between the free leaflet edge and annulus diameter has been found to be the optimal tradeoff between the lowest gradient and highest leaflets coaptation heights at the annulus plane.2Kaiser A.D. Haidar M.A. Choi P.S. Sharir A. Marsden A.L. Ma M.R. Simulation-based design of bicuspidization of the aortic valve.J Thorac Cardiovasc Surg. 2024; XX: XXX-XXXXhttps://doi.org/10.1016/j.jtcvs.2023.12.027Abstract Full Text Full Text PDF Scopus (3) Google Scholar It reflects a simple geometric correlation when half of the aortic annulus ring circumference is identical to the leaflet free edge and is easily applied with measuring devices, as I have recently described.3Jasinski M. Nowicki R. Kansy A. Functional aortic annulus 3D remodeling during bicuspid aortic valve repair. Complete external and internal annuloplasty.Multimed Man Cardiothorac Surg. Published online June 7, 2023; https://doi.org/10.1510/mmcts.2023.014Crossref Google Scholar,4Jasinski M. Jasinski J. Kansy A. Leaflet to annulus ratio of 1.5 proves superior and easy to adopt.J Thorac Cardiovasc Surg. Published online March 2, 2024; https://doi.org/10.1016/j.jtcvs.2024.02.01Crossref Google Scholar The same formula lies behind choosing annuloplasty ring diameter with the Hemispheric Anatomical Annuloplasty Ring HAART: required ring diameter = leaflet free edge length/1.5, which has been described by our group in detail.5Jasinski M.J. Rankin J.S. Mazzitelli D. et al.Leaflet dimensions as a guide to remodeling annuloplasty during aortic valve repair.Innovations (Phila). 2021; 16: 267-272https://doi.org/10.1177/1556984521997422Crossref PubMed Scopus (6) Google Scholar The hemispheric model of the aortic root, which is the geometric fundament of 1.5, can be applied to both the aortic valve and the aortic sinuses, as shown by Rankin and colleagues.6Mazzitelli G. Stamm C. Scott Rankin J. et al.Hemodynamic outcomes of geometric ring annuloplasty for aortic valve repair: a 4-center pilot trial.J Thorac Cardiovasc Surg. 2014; 148: 168-175Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Due to the linear correlation between annulus and diameter, this correlation works well for STJ circumference. This may be very practical because the sinus remodeling or replacement can be guided by measuring this circumference at the STJ level with 1.5 to 1.8 as the cutoff value for replacement, as shown in Figure 1. The same method is applied for leaflet, annulus, and sinus of Valsalva assessment at the same time during valve-sparing bicuspid aortic valve repair. In contrast to Milewski and colleagues,1Milewski K.C.R. Habertheuer A. Bavaria J.E. et al.Long-term outcomes of aortic root procedures for heterogeneous ascending aneurysm disease in bicuspid aortic valve syndrome.J Thorac Cardiovasc Surg. 2024; 167: 2063-2075.e4Abstract Full Text Full Text PDF Scopus (2) Google Scholar however, this correlation would relate to the adjusted, postoperative size of the annulus, which is probably more accurate during valve-sparing root replacement with annuloplasty. The clinical validation of a mathematical formula4Jasinski M. Jasinski J. Kansy A. Leaflet to annulus ratio of 1.5 proves superior and easy to adopt.J Thorac Cardiovasc Surg. Published online March 2, 2024; https://doi.org/10.1016/j.jtcvs.2024.02.01Crossref Google Scholar,7Gerdisch M.W. Reece T.B. Emerson D. et al.Early results of geometric ring annuloplasty for bicuspid aortic valve repair during aortic aneurysm surgery.J Thorac Cardiovasc Surg Tech. 2022; 14: 55-60Google Scholar may help establish an algorithm for determining the extent of root resection, which would largely improve current recommendations.8Marek J.J. BAV repair algorithm: 20 years experience [Algoritmo reparación válvula aórtica bicúspide tras 20 a˜nos de experiencia].Cirugía Cardiovasc. 2023; 30: S3-S4Google Scholar Dr Jasinski has affiliations with Medtronic and Corcym. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.