Design Characteristics of a Three-Dimensional Geometric Aortic Valve Annuloplasty Ring

Abstract

Objective

A full geometric annuloplasty ring could facilitate aortic valve repair. The purpose of this report was to document the design of such a ring using mathematical analyses of normal human aortic valve computed tomographic angiograms.

Methods

One-millimeter axial slices of high-resolution computed tomographic angiograms from 11 normal aortic roots were used to generate high-density x, y, and z coordinates of valve structures in Mathematica. Three-dimensional least squares regression analyses of leaflet-sinus coordinates were used to assess geometry of aortic valve and root structures.

Results

Normal valve geometry could be represented as three leaflet-sinus general ellipsoids nested within an elliptical aortic root. Minor-major diameter ratio of the valve base was 0.60 ± 0.07, and elliptical geometry extended vertically up the commissures. By contrast, leaflet-sinus horizontal circumferences were fairly circular (diameter ratios, 0.82–0.87), and the left coronary/noncoronary commissural post was located at the posterior base minor diameter-circumference junction, with the center of the right coronary leaflet opposite. Post location on the circumference was symmetrical, with a deviation of only ±2% to ±3% from 33.3% symmetry. Commissural posts flared outward by 5 to 10 degrees, and leaflet areas were statistically equivalent (P > 0.10). From end diastole to midsystole, the aortic root became less elliptical (diameter ratio increased by 0.15), but root area expanded minimally (less than +5%). A one-piece rigid annuloplasty ring was designed with 2:3 base ellipticality, three 10-degree outwardly flaring symmetrical posts, and post height = base circumference/2π.

Conclusions

A three-dimensional aortic annuloplasty ring was designed that could prove useful for enhancing applicability and stability of aortic valve repair.

Keywords

Aortic valve repair Aortic valve geometry Annuloplasty

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References

Caceres

, Ma

, Rankin

J.S.

Trends and outcomes of aortic root surgery in North America. Submitted to Ann Thorac Surg.

Hammermeister

, Sethi

G.K.

, Henderson

W.G.

, Grover

F.L.

, Oprian

, Rahimtoola

S.H.

Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol. 2000; 36: 1152–1158.

Brennan

J.M.

, Edwards

F.H.

, Zhao

, for the DEcIDE AVR (Developing Evidence to Inform Decisions about Effectiveness–Aortic Valve Replacement) Research Team. Long-term safety and effectiveness of mechanical versus biologic aortic valve prostheses in older patients: results from The Society of Thoracic Surgeons Adult Cardiac Surgery National Database. Circulation. 2013; 127: 1647–1655.

Aicher

, Fries

, Rodionycheva

, Schmidt

, Langer

, Schäfers

H.J.

Aortic valve repair leads to a low incidence of valve-related complications. Eur J Cardiothorac Surg. 2010; 37: 127–132.

Price

, De Kerchove

, Glineur

, Vanoverschelde

J.L.

, Noirhomme

, El Khoury

Risk of valve-related events after aortic valve repair. Ann Thorac Surg. 2013; 95: 606–613.

Schäfers

H.J.

, Aicher

, Langer

Correction of leaflet prolapse in valve-preserving aortic replacement: pushing the limits?

Ann Thorac Surg. 2002; 74: S1762–S1764.

Aicher

, Langer

, Adam

, Tscholl

, Lausberg

, Schäfers

H.J.

Cusp repair in aortic valve reconstruction: does the technique affect stability?

J Thorac Cardiovasc Surg. 2007; 134: 1533–1538.

El Khoury

, Vanoverschelde

J.L.

, Glineur

Repair of aortic valve prolapse: experience with 44 patients. Eur J Cardiothorac Surg. 2004; 26: 628–633.

Boodhwani

, de Kerchove

, Glineur

, El Khoury

A simple method for the quantification and correction of aortic cusp prolapse by means of free margin plication. J Thorac Cardiovasc Surg. 2010; 139: 1075–1077.

10.

Cabrol

, Cabrol

, Guiraudon

Le traitement de l'insuffisance aortique par l'annuloplstie aortique. Arch Mal Coeur Vaiss. 1966; 59: 1305–1312.

11.

Rocache

, Cabrol

Résultats éloignés des annuloplasties aortiques. Arch Mal Coeur Vaiss. 1972; 65: 1123–1128.

12.

Navarra

, El Khoury

, Glineur

Effect of annulus dimension and annuloplasty on bicuspid aortic valve repair. Eur J Cardiothorac Surg. 2013; 44: 316–322.

13.

Aicher

, Kunihara

, Abou Issa

, Brittner

, Gräber

, Schäfers

H.J.

Valve configuration determines long-term results after repair of the bicuspid aortic valve. Circulation. 2011; 123: 178–185.

14.

Izumoto

, Kawazoe

, Oka

, Kazui

, Kawase

, Nasu

Aortic valve repair for aortic regurgitation: intermediate-term results in patients with tricuspid morphology. J Heart Valve Dis. 2006; 15: 169–173.

15.

David

T.E.

, Feindel

C.M.

, Webb

G.D.

, Colman

J.M.

, Armstrong

, Maganti

Long-term results of aortic valve-sparing operations for aortic root aneurysm. J Thorac Cardiovasc Surg. 2006; 132: 347–354.

16.

Kvitting

J.P.

, Kari

F.A.

, Fischbein

M.P.

David valve-sparing aortic root replacement: equivalent mid-term outcome for different valve types with or without connective tissue disorder. J Thorac Cardiovasc Surg. 2013; 145: 117–126, 127.

17.

Leshnower

B.G.

, Guyton

R.A.

, Myung

R.J.

Expanding the indications for the David Vaortic root replacement: early results. J Thorac Cardiovasc Surg. 2012; 143: 879–884.

18.

de Kerchove

, Boodhwani

, Glineur

Valve sparing-root replacement with the reimplantation technique to increase the durability of bicuspid aortic valve repair. J Thorac Cardiovasc Surg. 2011; 142: 1430–1438.

19.

Cameron

D.E.

, Alejo

D.E.

, Patel

N.D.

Aortic root replacement in 372 Marfan patients: evolution of operative repair over 30 years. Ann Thorac Surg. 2009; 87: 1344–1349.

20.

Shrestha

, Baraki

, Maeding

Long-term results after aortic valve-sparing operation (David I). Eur J Cardiothorac Surg. 2012; 41: 56–62.

21.

Leontyev

, Trommer

, Subramanian

The outcome after aortic valve-sparing (David) operation in 179 patients: a single-centre experience. Eur J Cardiothorac Surg. 2012; 42: 261–266.

22.

Urbanski

P.P.

, Zhan

, Hijazi

, Zacher

, Diegeler

Valve-sparing aortic root repair without down-sizing of the annulus. J Thorac Cardiovasc Surg. 2012; 143: 294–302.

23.

Svensson

L.G.

, Blackstone

E.H.

, Alsalihi

Midterm results of David reimplantation in patients with connective tissue disorder. Ann Thorac Surg. 2013; 95: 555–562.

24.

Lansac

, Di Centa

, Sleilaty

An aortic ring: from physiologic reconstruction of the root to a standardized approach for aortic valve repair. J Thorac Cardiovasc Surg. 2010; 140(suppl): S28–S35.

25.

Aicher

, Schneider

, Schmied

, Kunihara

, Tochii

, Schäfers

H-J

. Early results with annular support in reconstruction of the bicuspid aortic valve. J Thorac Cardiovasc Surg. 2013; 145(suppl): S30–S34.

26.

Rankin

J.S.

, Bone

M.C.

, Fries

P.M.

, Aicher

, Schäfers

H.J.

, Crooke

P.S.

A refined hemispheric model of normal human aortic valve and root geometry. J Thorac Cardiovasc Surg. 2013; 146: 103–108.

27.

David

T.E.

Surgical treatment of aortic valve disease. Nat Rev Cardiol. 2013; 10: 375–386.

28.

Guenther

, Noebauer

, Mazzitelli

, Busch

, Tassani-Prell

, Lange

Tricuspid valve surgery: a thirty-year assessment of early and late outcome. Eur J Cardiothorac Surg. 2008; 34: 402–409.

29.

Rankin

J.S.

, Gaca

J.G.

, Brunsting

III Increasing mitral valve repair rates with nonresectional techniques. Innovations. 2011; 6: 209–220.

30.

Rankin

J.S.

, Dalley

A.F.

, Crooke

P.S.

, Anderson

R.H.

A ‘hemispherical’ model of aortic valvar geometry. J Heart Valve Dis. 2008; 17: 179–186.

31.

Rankin

J.S.

An intra-annular ‘hemispherical’ annuloplasty frame for aortic valve repair. J Heart Valve Dis. 2010; 19: 97–103.

32.

Rankin

J.S.

, Conger

J.L.

, Tuzun

In vivo testing of an intra-annular aortic valve annuloplasty ring in a chronic calf model. Eur J Cardiothorac Surg. 2012; 42: 149–154.

33.

Mazzitelli

, Nöbauer

, Rankin

J.S.

Early results after implantation of a new geometric annuloplasty ring for aortic valve repair. Ann Thorac Surg. 2013; 95: 94–97.

34.

Mazzitelli

, Stamm

, Rankin

J.S.

Hemodynamic outcomes of geometric ring annuloplasty for aortic valve repair: a four-center pilot trial. J Thorac Cardiovasc Surg. October 8, 2013 [Epub ahead of print].

35.

Rankin

J.S.

, Beavan

L.A.

, Cohn

W.E.

Technique for aortic valve annuloplasty using an intra-annular “hemispherical” frame. J Thorac Cardiovasc Surg. 2011; 142: 933–936.

36.

Ozaki

, Kawase

, Yamashita

A total of 404 cases of aortic valve reconstruction with glutaraldehyde-treated autologous pericardium. J Thorac Cardiovasc Surg. December 7, 2012 [Epub ahead of print].

37.

Rankin

J.S.

, Crooke

P.S.

, Lange

, Mazzitelli

Techniques of autologous pericardial leaflet replacement for bicuspid aortic valve endocarditis. J Heart Valve Dis. 2013; 22: 724–731.

38.

Rankin

J.S.

, Crooke

P.S.

, Lange

, Mazzitelli

Autologous pericardial leaflet replacement for bicuspid aortic valve endocarditis. Surgical video presented at STS video session, 2012. Available at: http://www.jsrmd.com/ftp/63_PLR.m4v. Accepted for publication to CTSNet.org. Accessed November 16, 2013.

39.

Rankin

J.S.

, Mazzitelli

Autologous pericardial leaflet replacement for aortic valve reconstruction. Surgical video accepted for presentation at the STSA meeting, 2013. Presented at STSA meeting 2013 and available at: http://www.jsrmd.com/ftp/118_NAPAV_Compressed.mp4. Accessed November 16, 2013.