ADULT CARDIAC
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KHELIL ET AL SURGICAL ANATOMY OF THE AORTIC ANNULUS
2. Navarra E, El Khoury G, Glineur D, et al. Effect of annulus dimension and annuloplasty on bicuspid aortic valve repair. Eur J Cardiothorac Surg 2013;44:316–22. 3. David TE, Maganti M, Armstrong S. Aortic root aneurysm: principles of repair and long-term follow-up. J Thorac Cardiovasc Surg 2010;140:S14–9. 4. Hanke T, Charitos EI, Stierle U, et al. Factors associated with the development of aortic valve regurgitation over time after two different techniques of valve-sparing aortic root surgery. J Thorac Cardiovasc Surg 2009;137:314–9. 5. Lansac E, Di Centa I, Bonnet N, et al. Aortic prosthetic ring annuloplasty: a useful adjunct to a standardized aortic valvesparing procedure? Eur J Cardiothorac Surg 2006;29:537–44. 6. Aicher D, Schneider U, Schmied W, Kunihara T, Tochii M, Sch€ afers HJ. Early results with annular support in reconstruction of the bicuspid aortic valve. J Thorac Cardiovasc Surg 2013;145:S30–4. 7. Aicher D, Kunihara T, Abou Issa O, Brittner B, Gr€ aber S, Sch€ afers HJ. Valve configuration determines long-term results after repair of the bicuspid aortic valve. Circulation 2011;123:178–85. 8. Sch€ ollhorn J, Rylski B, Beyersdorf F. Aortic valve annuloplasty: new single suture technique. Ann Thorac Surg 2014;97:2211–3. 9. Mazzitelli D, N€ obauer C, Rankin JS, et al. Early results of a novel technique for ring-reinforced aortic valve and root restoration. Eur J Cardiothorac Surg 2014;45:426–30. 10. Lansac E, Di Centa I, Sleilaty G, et al. An aortic ring: from physiologic reconstruction of the root to a standardized approach for aortic valve repair. J Thorac Cardiovasc Surg 2010;140:S28–35. 11. Carpentier A. Cardiac valve surgery—the “French correction.” J Thorac Cardiovasc Surg 1983;86:323–37. 12. de Kerchove L, Vismara R, Mangini A, et al. In vitro comparison of three techniques for ventriculo-aortic junction annuloplasty. Eur J Cardiothorac Surg 2012;41:1117–24. 13. Sievers HH, Hemmer W, Beyersdorf F, et al. The everyday used nomenclature of the aortic root components: the Tower of Babel? Eur J Cardiothorac Surg 2012;41:478–82. 14. Anderson RH. Demolishing the Tower of Babel. Eur J Cardiothorac Surg 2012;41:483–4. 15. Frater RW, Anderson RH. How can we logically describe the components of the arterial valves? J Heart Valve Dis 2010;19: 438–40. 16. Anderson RH, Devine WA, Ho SY, Smith A, McKay R. The myth of the aortic annulus: the anatomy of the subaortic outflow tract. Ann Thorac Surg 1991;52:640–6. 17. Sutton JP, Ho SY, Anderson RH. The forgotten interleaflet triangles: a review of the surgical anatomy of the aortic valve. Ann Thorac Surg 1995;95:419–27.
Ann Thorac Surg 2015;99:1220–7
18. Sh€afers HJ, Schmied W, Psych D, Marom G, Aicher D. Cusp height in aortic valves. J Thorac Cardiovasc Surg 2013;146: 269–74. 19. de Kerchove L, El Khoury G. Anatomy and pathophysiology of the ventriculo-aortic junction: implication in aortic valve repair surgery. Ann Cardiothorac Surg 2013;2: 57–64. 20. Roman MJ, Devereux RB, Niles NW, et al. Aortic root dilatation as a cause of isolated, severe aortic regurgitation. Prevalence, clinical and echocardiographic patterns, and relation to left ventricular hypertrophy and function. Ann Intern Med 1987;106:800–7. 21. Kunihara T, Aicher D, Rodionycheva S, et al. Preoperative aortic root geometry and postoperative cusp configuration primarily determine long-term outcome after valvepreserving aortic root repair. J Thorac Cardiovasc Surg 2012;143:1389–95. 22. Luciani GB, Casali G, Tomezzoli A, Mazzucco A. Recurrence of aortic insufficiency after aortic root remodeling with valve preservation. Ann Thorac Surg 1999;67:1849–52. 23. Sch€ afers HJ. Aortic annuloplasty: a new aspect of aortic valve repair. Eur J Cardiothorac Surg 2012;41:1124–5. 24. Lansac E, Di Centa I, Raoux F, et al. An expansible aortic ring for a physiological approach to conservative aortic valve surgery. J Thorac Cardiovasc Surg 2009;138:718–24. 25. Yacoub M, Fagan A, Stassano P, Radley-Smith R. Result of valve conserving operations for aortic regurgitation [abstract]. Circulation 1983;68(Suppl):III321. 26. 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: 617–22. 27. Soncini M, Votta E, Zinicchino S, et al. Aortic root performance after valve sparing procedure: a comparative finite element analysis. Med Eng Phys 2009;31:234–43. 28. Sch€ afers HJ, Bierbach B, Aicher D. A new approach to the assessment of aortic cusp geometry. J Thorac Cardiovasc Surg 2006;132:436–8. 29. Marom G, Haj-Ali R, Rosenfeld M, Sh€ afers HJ, Raanani E. Aortic root numeric model: Annulus diameter prediction of effective height and coaptation in post-aortic valve repair. J Thorac Cardiovasc Surg 2013;145:406–11. 30. Wuliya M, Sleilaty G, Di Centa I, et al. An expansible aortic ring to preserve aortic root dynamics after aortic valve repair. Eur J Cardiothorac Surg 2014: http://dx.doi.org/10.1093/ejcts/ ezu174 [Epub ahead of print]. 31. David TE, Armstrong S, Manlhiot C, McCrindle BW, Feindel CM. Long-term results of aortic root repair using the reimplantation technique. J Thorac Cardiovasc Surg 2013;145(3 Suppl):S22–5.
INVITED COMMENTARY While human anatomy is often looked upon as long established, reconstructive procedures of the aortic valve have dramatically changed the surgical view of this valve and its anatomy as it requires a thorough understanding of the normal aortic valve geometry as the goal of surgery. Along these lines our knowledge of the normal anatomy of the aortic valve has expanded in the past 10 years. While we have more information on the normal cusp configuration [1] and size [2], the need for more knowledge has become clearer. For instance, there is little information on normal commissural height, even though an analysis of repair failures [3] has emphasized its importance. It has also become increasingly evident that
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
aortic annular size reduction and stabilization must be achieved [4], at least in the presence of annular dilatation. Currently, different concepts of annuloplasty are explored [4]. Any annuloplasty concept, however, has to accommodate the specific anatomic characteristics of the aortic valve and root. Anatomically the aortic annulus can be defined as the combination of the aortic cusp insertion lines as a complex structure [5]. Common sense indicates that the virtual “basal ring” [5] (ie, the level of the nadir of the 3 sinuses) comes closest to the root component that should be stabilized in aortic valve repair. The aortoventricular junction (ie, the transition of aortic and
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.01.001
Ann Thorac Surg 2015;99:1220–7
1227
external annuloplasty device can be inserted easily. The limitation, however, is that we need more knowledge of those scenarios that need an annuloplasty most. Hans-Joachim Sch€ afers, MD Department of Thoracic and Cardiovascular Surgery Saarland University Medical Center Kirrberger Str. 1 D-66421 Homburg/Saar, Germany e-mail: [email protected]
References 1. Bierbach BO, Aicher D, Issa OA, et al. Aortic root and cusp configuration determine aortic valve function. Eur J Cardiothorac Surg 2010;38:400–6. 2. Sch€afers HJ, Schmied W, Marom G, Aicher D. Cusp height in aortic valves. J Thorac Cardiovasc Surg 2013;146:269–74. 3. Giebels C, Aicher D, Kunihara T, Rodionycheva S, Schmied W, Sch€afers HJ. Causes and management of aortic valve regurgitation after aortic valve reimplantation. J Thorac Cardiovasc Surg 2013;145:774–80. 4. Sch€afers HJ. Aortic annuloplasty: a new aspect of aortic valve repair. Eur J Cardiothorac Surg 2012;41:1124–5. 5. Anderson RH. Clinical anatomy of the aortic root. Heart 2000;84:670–3. 6. Lansac E, Di Centa I, Raoux F, et al. An expansible aortic ring for a physiological approach to conservative aortic valve surgery. J Thorac Cardiovasc Surg 2009;138:718–24. 7. 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: 1220–7.
ADULT CARDIAC
ventricular tissue) may be close to the basal ring and has been proposed to be located within the 3 sinuses [5]. The difference between the location of the basal ring and the aortoventricular junction becomes important if annular stabilization is to be performed by placing a circular annuloplasty device from the outside of the root. An external ring [6] can obviously only be placed without major dissection into the myocardium if the basal ring is close to the level of aortoventricular junction. In the current publication [7] Dr Khelil and colleagues have provided new data on aortic root anatomy. In 20 human hearts with tricuspid aortic valve morphology they found a commissural height of 20 mm. More as part of their primary focus, they found that mean height difference between the basal ring and the aortoventricular junction was less than 4 mm. The height discrepancy between basal plane and the aortoventricular junction [4] was highest in the right sinus. Does this mean that an external annuloplasty ring can be placed in all circumstances? I hesitate to generalize the findings before further data exist. In our clinical experience we have seen aortoventricular junctions as high as 10 mm into the sinus, especially in bicuspid aortic valves. It is obvious that under these circumstances the placement of an annuloplasty device will be more difficult. As the authors point out, annular dilatation is probably most frequent in annuloaortic ectasia and bicuspid aortic valve anatomy. None of the specimens in the current study exhibited either bicuspid valve anatomy or annuloaortic ectasia. Thus, the good news is that in most patients with tricuspid aortic valves and normal root dimensions an
KHELIL ET AL SURGICAL ANATOMY OF THE AORTIC ANNULUS
1226
KHELIL ET AL SURGICAL ANATOMY OF THE AORTIC ANNULUS
2. Navarra E, El Khoury G, Glineur D, et al. Effect of annulus dimension and annuloplasty on bicuspid aortic valve repair. Eur J Cardiothorac Surg 2013;44:316–22. 3. David TE, Maganti M, Armstrong S. Aortic root aneurysm: principles of repair and long-term follow-up. J Thorac Cardiovasc Surg 2010;140:S14–9. 4. Hanke T, Charitos EI, Stierle U, et al. Factors associated with the development of aortic valve regurgitation over time after two different techniques of valve-sparing aortic root surgery. J Thorac Cardiovasc Surg 2009;137:314–9. 5. Lansac E, Di Centa I, Bonnet N, et al. Aortic prosthetic ring annuloplasty: a useful adjunct to a standardized aortic valvesparing procedure? Eur J Cardiothorac Surg 2006;29:537–44. 6. Aicher D, Schneider U, Schmied W, Kunihara T, Tochii M, Sch€ afers HJ. Early results with annular support in reconstruction of the bicuspid aortic valve. J Thorac Cardiovasc Surg 2013;145:S30–4. 7. Aicher D, Kunihara T, Abou Issa O, Brittner B, Gr€ aber S, Sch€ afers HJ. Valve configuration determines long-term results after repair of the bicuspid aortic valve. Circulation 2011;123:178–85. 8. Sch€ ollhorn J, Rylski B, Beyersdorf F. Aortic valve annuloplasty: new single suture technique. Ann Thorac Surg 2014;97:2211–3. 9. Mazzitelli D, N€ obauer C, Rankin JS, et al. Early results of a novel technique for ring-reinforced aortic valve and root restoration. Eur J Cardiothorac Surg 2014;45:426–30. 10. Lansac E, Di Centa I, Sleilaty G, et al. An aortic ring: from physiologic reconstruction of the root to a standardized approach for aortic valve repair. J Thorac Cardiovasc Surg 2010;140:S28–35. 11. Carpentier A. Cardiac valve surgery—the “French correction.” J Thorac Cardiovasc Surg 1983;86:323–37. 12. de Kerchove L, Vismara R, Mangini A, et al. In vitro comparison of three techniques for ventriculo-aortic junction annuloplasty. Eur J Cardiothorac Surg 2012;41:1117–24. 13. Sievers HH, Hemmer W, Beyersdorf F, et al. The everyday used nomenclature of the aortic root components: the Tower of Babel? Eur J Cardiothorac Surg 2012;41:478–82. 14. Anderson RH. Demolishing the Tower of Babel. Eur J Cardiothorac Surg 2012;41:483–4. 15. Frater RW, Anderson RH. How can we logically describe the components of the arterial valves? J Heart Valve Dis 2010;19: 438–40. 16. Anderson RH, Devine WA, Ho SY, Smith A, McKay R. The myth of the aortic annulus: the anatomy of the subaortic outflow tract. Ann Thorac Surg 1991;52:640–6. 17. Sutton JP, Ho SY, Anderson RH. The forgotten interleaflet triangles: a review of the surgical anatomy of the aortic valve. Ann Thorac Surg 1995;95:419–27.
Ann Thorac Surg 2015;99:1220–7
18. Sh€afers HJ, Schmied W, Psych D, Marom G, Aicher D. Cusp height in aortic valves. J Thorac Cardiovasc Surg 2013;146: 269–74. 19. de Kerchove L, El Khoury G. Anatomy and pathophysiology of the ventriculo-aortic junction: implication in aortic valve repair surgery. Ann Cardiothorac Surg 2013;2: 57–64. 20. Roman MJ, Devereux RB, Niles NW, et al. Aortic root dilatation as a cause of isolated, severe aortic regurgitation. Prevalence, clinical and echocardiographic patterns, and relation to left ventricular hypertrophy and function. Ann Intern Med 1987;106:800–7. 21. Kunihara T, Aicher D, Rodionycheva S, et al. Preoperative aortic root geometry and postoperative cusp configuration primarily determine long-term outcome after valvepreserving aortic root repair. J Thorac Cardiovasc Surg 2012;143:1389–95. 22. Luciani GB, Casali G, Tomezzoli A, Mazzucco A. Recurrence of aortic insufficiency after aortic root remodeling with valve preservation. Ann Thorac Surg 1999;67:1849–52. 23. Sch€ afers HJ. Aortic annuloplasty: a new aspect of aortic valve repair. Eur J Cardiothorac Surg 2012;41:1124–5. 24. Lansac E, Di Centa I, Raoux F, et al. An expansible aortic ring for a physiological approach to conservative aortic valve surgery. J Thorac Cardiovasc Surg 2009;138:718–24. 25. Yacoub M, Fagan A, Stassano P, Radley-Smith R. Result of valve conserving operations for aortic regurgitation [abstract]. Circulation 1983;68(Suppl):III321. 26. 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: 617–22. 27. Soncini M, Votta E, Zinicchino S, et al. Aortic root performance after valve sparing procedure: a comparative finite element analysis. Med Eng Phys 2009;31:234–43. 28. Sch€ afers HJ, Bierbach B, Aicher D. A new approach to the assessment of aortic cusp geometry. J Thorac Cardiovasc Surg 2006;132:436–8. 29. Marom G, Haj-Ali R, Rosenfeld M, Sh€ afers HJ, Raanani E. Aortic root numeric model: Annulus diameter prediction of effective height and coaptation in post-aortic valve repair. J Thorac Cardiovasc Surg 2013;145:406–11. 30. Wuliya M, Sleilaty G, Di Centa I, et al. An expansible aortic ring to preserve aortic root dynamics after aortic valve repair. Eur J Cardiothorac Surg 2014: http://dx.doi.org/10.1093/ejcts/ ezu174 [Epub ahead of print]. 31. David TE, Armstrong S, Manlhiot C, McCrindle BW, Feindel CM. Long-term results of aortic root repair using the reimplantation technique. J Thorac Cardiovasc Surg 2013;145(3 Suppl):S22–5.
INVITED COMMENTARY While human anatomy is often looked upon as long established, reconstructive procedures of the aortic valve have dramatically changed the surgical view of this valve and its anatomy as it requires a thorough understanding of the normal aortic valve geometry as the goal of surgery. Along these lines our knowledge of the normal anatomy of the aortic valve has expanded in the past 10 years. While we have more information on the normal cusp configuration [1] and size [2], the need for more knowledge has become clearer. For instance, there is little information on normal commissural height, even though an analysis of repair failures [3] has emphasized its importance. It has also become increasingly evident that
Ó 2015 by The Society of Thoracic Surgeons Published by Elsevier
aortic annular size reduction and stabilization must be achieved [4], at least in the presence of annular dilatation. Currently, different concepts of annuloplasty are explored [4]. Any annuloplasty concept, however, has to accommodate the specific anatomic characteristics of the aortic valve and root. Anatomically the aortic annulus can be defined as the combination of the aortic cusp insertion lines as a complex structure [5]. Common sense indicates that the virtual “basal ring” [5] (ie, the level of the nadir of the 3 sinuses) comes closest to the root component that should be stabilized in aortic valve repair. The aortoventricular junction (ie, the transition of aortic and
0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2015.01.001
Ann Thorac Surg 2015;99:1220–7
1227
external annuloplasty device can be inserted easily. The limitation, however, is that we need more knowledge of those scenarios that need an annuloplasty most. Hans-Joachim Sch€ afers, MD Department of Thoracic and Cardiovascular Surgery Saarland University Medical Center Kirrberger Str. 1 D-66421 Homburg/Saar, Germany e-mail: [email protected]
References 1. Bierbach BO, Aicher D, Issa OA, et al. Aortic root and cusp configuration determine aortic valve function. Eur J Cardiothorac Surg 2010;38:400–6. 2. Sch€afers HJ, Schmied W, Marom G, Aicher D. Cusp height in aortic valves. J Thorac Cardiovasc Surg 2013;146:269–74. 3. Giebels C, Aicher D, Kunihara T, Rodionycheva S, Schmied W, Sch€afers HJ. Causes and management of aortic valve regurgitation after aortic valve reimplantation. J Thorac Cardiovasc Surg 2013;145:774–80. 4. Sch€afers HJ. Aortic annuloplasty: a new aspect of aortic valve repair. Eur J Cardiothorac Surg 2012;41:1124–5. 5. Anderson RH. Clinical anatomy of the aortic root. Heart 2000;84:670–3. 6. Lansac E, Di Centa I, Raoux F, et al. An expansible aortic ring for a physiological approach to conservative aortic valve surgery. J Thorac Cardiovasc Surg 2009;138:718–24. 7. 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: 1220–7.
ADULT CARDIAC
ventricular tissue) may be close to the basal ring and has been proposed to be located within the 3 sinuses [5]. The difference between the location of the basal ring and the aortoventricular junction becomes important if annular stabilization is to be performed by placing a circular annuloplasty device from the outside of the root. An external ring [6] can obviously only be placed without major dissection into the myocardium if the basal ring is close to the level of aortoventricular junction. In the current publication [7] Dr Khelil and colleagues have provided new data on aortic root anatomy. In 20 human hearts with tricuspid aortic valve morphology they found a commissural height of 20 mm. More as part of their primary focus, they found that mean height difference between the basal ring and the aortoventricular junction was less than 4 mm. The height discrepancy between basal plane and the aortoventricular junction [4] was highest in the right sinus. Does this mean that an external annuloplasty ring can be placed in all circumstances? I hesitate to generalize the findings before further data exist. In our clinical experience we have seen aortoventricular junctions as high as 10 mm into the sinus, especially in bicuspid aortic valves. It is obvious that under these circumstances the placement of an annuloplasty device will be more difficult. As the authors point out, annular dilatation is probably most frequent in annuloaortic ectasia and bicuspid aortic valve anatomy. None of the specimens in the current study exhibited either bicuspid valve anatomy or annuloaortic ectasia. Thus, the good news is that in most patients with tricuspid aortic valves and normal root dimensions an
KHELIL ET AL SURGICAL ANATOMY OF THE AORTIC ANNULUS
