External suture annuloplasty for mild to moderate and moderate aortic regurgitation due to an isolated type Ic lesion

Aortic Valve Repair in Annular Dilatation: External Versus Internal Suture Annuloplasty

BACKGROUND

Annuloplasty is essential in aortic valve repair. The most appropriate technique is, however, highly controversial. We aimed to evaluate changes in postoperative annulus diameter on serial echocardiography after external and internal suture annuloplasty.

METHODS

We retrospectively reviewed serial transthoracic echocardiography of consecutive patients from our institutional aortic valve repair registry who had received suture annuloplasty. Mid-systolic annulus diameter was measured on parasternal long-axis view preoperatively, at discharge, 3-6 months, 1, 2 and 3 years postoperatively. Primary endpoint was the prevalence of annulus re-dilatation. Secondary endpoints were the correlation between annulus re-dilatation and (1) external vs. internal technique and (2) reoccurrence of aortic insufficiency (AI)≥2.

RESULTS

A total of 70 patients (mean age 43±13 years, 91% male) underwent aortic valve repair including external (n=27) or internal (n=43) suture annuloplasty between February 2016 and November 2019. Mean follow-up was 17±11 (3-50) months. Mean preoperative annulus diameter of 29.7±2.8 (23.8-37.8) mm was significantly reduced to 22.7±2.9 (16.7-31.7) mm, p<0.001 at discharge and increased to 23.8±2.3 (20.9-27.0) mm, p=0.037 during follow-up. The mild increase in postoperative annulus diameter did not correlate with the reoccurrence of AI≥2. Preoperative annulus was significantly larger in the external group (external: 30.6±3.2 mm; internal: 29.1±2.5 mm; p=0.032). However, we found no significant difference in postoperative annulus increase rate between both techniques.

CONCLUSIONS

Although mild, a significant continuous increase of annulus diameter after suture annuloplasty was seen which did not correlate with the reoccurrence of AI≥2 at mid-term follow-up. Annulus re-dilatation was comparable between external and internal technique.

Aortic root destruction after aortic valvuloplasty for bicuspid aortic valve

Ultrasound cardiography showed severe aortic regurgitation (AR) due to bicuspid aortic valve with dilatation of the aortic annulus and sinotubular junction in a 27-year-old man hospitalized with loss of consciousness. He underwent aortic valvuloplasty combined with external suture annuloplasty using an expanded polytetrafluoroethylene (ePTFE) suture. Intraoperative findings revealed thickening and adhesion of the aortic root despite the first surgery. He developed recurrent AR 7 months later and underwent redo surgery. An ePTFE suture was found inside the aorta. Aortic root replacement with a mechanical composite graft was performed, as reconstruction appeared difficult because the aortic annulus was damaged and there were multiple holes on all cusps. Here, we report a rare case of aortic root destruction after external suture annuloplasty.