Discussion

Presenter: Dr Erle Austin Dr James Quintessenza (St Petersburg, Fla). There is increasing interest for aortic valve repair predominantly for regurgitant lesions when valve leaflet substrate is suitable. There is increasing experience worldwide with techniques that are approaching standardization similar to how mitral valve repair began years ago. A fair amount of data have accumulated utilizing the aortic annuloplasty ring for both trileaflet and bileaflet reconstruction. This experience is mostly adults, fairly short term and admittedly with a significant learning curve that includes modifications to avoid complications. Dr Austin and the group from Louisville's video nicely demonstrates a case of aortic valve repair utilizing an aortic annuloplasty ring in a postoperative patient undergoing the Ross procedure with aortic dilatation and insufficiency. Whether one utilizes a ring or not, the basic tenets for successful aortic valve reconstruction seem to be the same with some minor differences or nuance one might say… The important points include ensuring adequate leaflet substrate and dimensions such as geometric length, free margin length, and ultimately effective height, as well as controlling the diameter of the aortic annulus (virtual basal ring) and management of aortic root pathology. I have a few questions regarding your technique. You mentioned the position of the ring placement some millimeters below the hinge points of the valve leaflets. Should we be concerned, long term, especially in younger patients, about the formation of panis or ingrowth onto the leaflets, such as we see with a subaortic membrane that would cause restriction of the leaflets? Dr Erle Austin (Louisville, Ky). All right, Jim. Thanks for the question. And, of course you mentioned this has been applied in more adults than in children. But on the other hand, the device we put in here was 19-mm. There are no smaller ones available. They come from 19 mm up to 25 mm and there have been more than 1000 implants and to my knowledge, there hasn't been a case report of anything such as a membrane developing. Dr Quintessenza. We create something similar to a subaortic membrane with turbulence, so just a concern, but it may not be a problem. In this video, you used 1 of the leaflets as the reference leaflet, and after placement of the placation suture, you use that to assess effective height of the others. And then later we saw the use of a Frater central stitches to create equal lengths of opposing leaflet components of the other leaflets. Can you expand a little bit on how you think it's best to assess effective height in our patients? And have you considered using the Schaefer caliper, which is a device that measures effective height in the open aortic state? Dr Austin. Yes. Well, we had the Schaefer caliper available, but we didn't use it. And you're referring to, obviously, a learning curve. I must say, this was at an early stage of my learning curve, and you can see that we spent a lot of time working on the leaflets. Now, I do think that the subannular ring was important because the leaflets had pulled apart and they didn't coapt. So, by putting the device in, it pulled them together and then we're sitting with a lot of valve tissue that all came to the middle but at different heights. And it's clear from watching the video that I spent a lot of time trying to figure out how to get them all at the correct height. The Schaefer caliper might have been helpful for us, but we pretty much used the eyeball technique and that's something that other people have talked about. I guess it can be done more scientifically but it's like a lot of things that we do in our business where the more you do, the better you get at it. I must say that this was early in our experience and I think putting the subannular ring in is straightforward and I think all of us could do that in the first or second time around. Dealing with how to get all the leaflets at the same height to get a competent valve, I think there's art in that and clearly, you're a better artist if you've been doing it more. Dr Quintessenza. I would agree. And maybe for folks just starting their experience with aortic reconstructive techniques, having something that gives them a measurement would be beneficial so you're not waiting until you come off bypass to realize it doesn't look very good. So I think certainly early on in your experience, it might be a nice aid. One final question: You describe the valve as an intermediate type and others would describe it as a severely asymmetric type with regard to the angle of the commissures of the nonfused leaflet. This valve looked like it had 3 sinuses, fairly equally sized, so that would be considered asymmetric. There are a fair amount of data in the adult literature and in the European literature about the more asymmetric the valve is, the less likely a bicuspid repair would be a durable repair. The idea of keeping it a trileaflet repair, as you did here, seems to correlate with better long-term outcomes, and that's without a subaortic annuloplasty ring. Do you think when using the ring, the more it looks like a trileaflet valve, the better off we are to leave it as a trileaflet valve. I ask this because I noticed your last comment was maybe we should have done this as a bicuspid repair. Dr Austin. Well, I thought about changing to the bicuspid repair so that I wouldn't spend so much time plicating leaflets, which you obviously saw, and that we could do it easier. I think your point is well taken, but I still think that the thing that made this repair possible was to decrease the annulus in this child. We had a ring that was big enough for him to last. Now he's still at a year and a half out and still has only mild regurgitation. Hopefully, it'll stay that way. But in all this business, with all the valves we're working on, it's valve longevity that counts. Dr Quintessenza. I would just say congratulations on your effort to do valve repairs. I think it's something that we as surgeons and especially our younger surgeons, need to master if possible. We're seeing more cath-based interventions being done on our patients, with longer-term outcomes yet to be determined. The more we can provide more durable, reconstructive techniques the better off our patients will be. If we can figure out how to do that and offer more of an optimal solution, we'll have some stuff to do and not everybody will get a transcatheter aortic valve repair. So congratulations. Dr Austin. I totally agree. Dr David S. Winlaw (Cincinnati, Ohio). As people are coming to the microphone, if I could ask you, of the 2 components of the repair, do you think all the work you did on the leaflets was as important as the annuloplasty? Like, if you just did the annuloplasty, what would you have ended up with? Dr Austin. Well, because the effective heights were different, I still think we would have had some degree of aortic insufficiency. I do think it was important to rein the annulus in, but then we had to spread out the leaflets in such a way that they would coapt. I mean, coaptation is still key for a successful repair of a semilunar valve. Dr Winlaw. Okay. Dr Sushi Kumar (New York, NY). Dr Austin, thank you. It's a beautiful video. Over the last 2 days, there have been quite a number of presentations on geometry of annuloplasty. And my question to you is, do you recommend combining this technique with all traditional valve-sparing root replacements? Because valve vegetation can happen either because of annular dilation or dilation of the sino-tubular junction. In most of the valve-sparing, the focus seems to be on adding a certain dimension to the root annulus size and we don't seem to pay so much attention to the annulus itself. So what's your recommendation? Dr Austin. Well, I think the potential advantage of this is that you don't have to dissect all the way down to where you have to re-implant coronaries. But I do think it could be used in that way. But it depends on, are you going to use the Yacoub technique? If you use the Yacoub technique, having that subannular ring may work just fine. If you use the David technique and you're going to dissect all the way down below the annulus, it probably would not be necessary. Dr Kumar. Okay. I was just curious about the formula. You said in your video you added 7 mm. Yeah. Dr Austin. Right. Obviously, we didn't make the coronaries so they could be re-implanted. We set it right on top of the sinotubular junction. And the size graft is based on studies of normal aortas. So going from the annulus size up to the sinotubular junction, 7 mm is what's been derived. Dr Kumar. Thank you so much. Dr Petros Anagnostopoulus (Madison, Wis). Thank you for this presentation. Now, if I understand it correctly, there was a geometrical dissymmetry or there were two of the leaflets were shorter than the third one. So you addressed the coaptation, you addressed the annular dilation, and you fixed the sinotubular junction, but you didn't address the sinuses of Valsalva dissymmetry with this. And I go back to a video that was presented like a couple of days ago on a [post switch?] dilation where there was an eloquent repair—and I don't remember who did that—but as part of this, there was some excision of the sinuses of Valsalva with placation. Do you think that this is a weakness of this technique that can show up later? And what do you think about either placating that noncoronary sinus or shortening it or exposing a piece and remodeling it? Dr Austin. I agree, and I heard that as well, Petros. And I do think our impression was that there wasn't that much asymmetry and that the sinuses were relatively the same. And again, I must say that when I did the Ross on this child, I didn't pick up on the fact that it was a bicuspid valve, and it wasn't until we got to this stage that we recognized it as an intermediate form of bicuspid valve. But we didn't really feel that the sinus in question was that much bigger than the others. I do think if you think it is, you can excise that, and then fashion the graft to go down into that, and you could plicate it if you need it be smaller in that sinus. Unidentified Speaker 3. Thank you so much. Great presentation. I have a question about the timing of this surgery. The Ross on this aortic regurgitation after the Ross is progressive because most of the time mechanism is under the rotation. And then I had a case that usually is starting a leak and then slowly getting worse and then cardiology asks us to wait and wait, wait, and then when we do the repair, it's already too late. It is really bad and difficult to repair. So I wonder if, especially this population, since we have a good technique for the repair, I wonder if we could do the surgery much earlier than usual indication for the aortic regurgitation or use annular dilatation of about 4 to 5 mm kind of range. So do you have any such earlier indication for this specific population? Dr Austin. So you're saying maybe we should have done it earlier? Is that what you're saying? Unidentified Speaker 3. That way we could preserve the valve better? Dr Austin. I can't answer that. Obviously, the first year after the Ross, he did fine, and then evidently, the degree of insufficiency started to increase to the point where he became symptomatic. And at that stage, he was at more than 30 mm at the annulus. And so, this was how we chose to proceed, but I'm sure there are other ways of dealing with it. This is a newer, innovative approach and we thought we would give it a shot. And at this point, we're happy with the outcome. Unidentified Speaker 3. Thank you. Dr Quintessenza. Let me just make 1 more comment. I think as we get better at doing these kinds of aortic valve repairs, and it becomes more standard and we prove that there is durability, I think the indications for doing these operations earlier before you get too many secondary changes, will occur, just like mitral valve reconstruction. So it behooves us to go to the adult literature, get those concepts figured out and bring them to the appropriate patients. Dr Austin. Jim. Thanks.