International Society For Minimally Invasive Cardiothoracic Surgery

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Minimally Invasive Aortic Valve Repair Using Geometric Ring Annuloplasty
Antonio Miceli1, Mattia Glauber1, Scott J. Rankin2, Diana Acher3, Tomislav Klokocovnic4, Roberto Rodriguez5, Vinay Badhwar2, Lawrence M. Wei2, Steffen Pfeiffer6, Theodor Fischlein6.
1Istituto Clinico Sant'Ambrogio, Milano, Italy, 2WVU Heart & Vascular Institute, Morgantown, WV, USA, 3Herz- und Gefäßzentrum, Bad Bevensen, Germany, 4University Medical Center, Ljubljana, Slovenia, 5Lankenau Medical Center/Thomas Jefferson University, Wynnewood, PA, USA, 6Klinikum Nürnberg Süd, Nuremberg, Germany.

Objective: As aortic valve repair (AVr) for aortic insufficiency (AI) progresses, minimally invasive (Mi) approaches increasingly are being applied. However, AVr can be difficult through small incisions, especially if aneurysm surgery is required. MiAVr using geometric ring annuloplasty could facilitate application, and this analysis provides the first followup data with this approach.
Methods: Thirty-four patients with significant AI underwent AVr through upper sternotomy third-interspace J incisions. Average age was 63±13 years (mean±SD), 23/34 (68%) were male, preoperative AI Grade was 3.9±0.3, NYHA Class was 2.7±0.6, and 22/34 (65%) had aortic aneurysms. Tri-leaflet rings were implanted in 27/34 (79%), and bicuspid rings in 7/34 (21%). Ring size was guided by measurements of leaflet free-edge length, and average ring diameter was 21.8±1.6 mm. Leaflet reconstruction, usually simple leaflet plication, was performed in 23/34 (68%), and in all bicuspids. Only aspirin anticoagulation was employed postoperatively, and all patients were followed long-term with echocardiography.
Ascending aortic replacement was performed in 22/34 (65%), using Dacron tube or Valsalva grafts 5-7 mm larger than ring size, with 10/34 (29%) having concomitant remodeling root procedures. No operative mortalities or major complications occurred. There were no operative conversions to full sternotomy, no repair to replacement conversions, and no new pacemakers, strokes, or thromboembolism. Average clamp time was 116±28 minutes (range 66-163 minutes), and 10/34 (29%) required blood transfusion. One patient required reoperation for bleeding. AI Grade fell to ≤ 1 after repair in all patients (p<0.0001), and mean systolic pressure gradients remained <15 mmHg throughout. At an average followup of 2.5 years (range 0.1-5.3 years), one late mortality occurred (precipitated by repair failure), and one reoperative valve replacement for ring suture untying occurred. No endocarditis, thromboembolism, obstruction, or other valve-related complications were observed. Thus, survival free of all complications was 94% at an average followup of 2.5 years.
Geometric ring annuloplasty appeared to be safe and effective for application to MiAVr. Hemodynamic improvements were significant, and clinical outcomes were excellent. Ring annuloplasty could standardize and facilitate MiAVr, but more patient experience and longer followup will be required for full validation.

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