**8.2 Placement of the five anchoring subvalvular "U" stitches**

236 Aortic Valve Surgery

**7.7 Specific aspect of repair for aortic root aneurysms with bicuspid aortic valves**  Dissection of the subvalvular plane as well as sizing of the ring and graft are similar to tricuspid valves (Lansac et al., 2011b). Principle for repair, applicable to all types of bicuspid valves, consists of aligning the free edges of the two cusps, and placing the commissures in the neo-aortic root at 180° according to Schafers et al. Therefore, the Remodeling technique is performed by tailoring the Gelweave ValsalvaTM graft into two symmetrical sinuses of

Valsalva (Schäfers et al., 2010) (fig. 14-15).

Fig. 15. Bicuspid valves: Valve repair and suture of the remodeling

**8. Subvalvular aortic annuloplasty for isolated aortic insufficiencies** 

without detaching them from the aortic wall (Lansac et al., 2011a, 2011b).

**plane** 

Principle of isolated aortic valve repair associates cusp repair (alignment of cusp free edge + effective height resuspension) with subvalvular aortic annuloplasty. The expansible aortic ring is of an open configuration in order to allow placement below the coronary arteries

**8.1 Transection of the aorta and dissection of the aortic root down to the subvalvular** 

The aorta is completely transsected 1 cm above the sino-tubular junction. External dissection of the aortic root down to the aortic annular base is performed, passing under the coronary arteries, without detaching them from the aortic wall. The external aspect of the aortic wall Five "U" stitches (2.0 coated polyester fiber, 3/8 needle 25) are circumferentially placed from inside out in the subvalvular plane, below the nadirs of each cusp and at the base of each interleaflet triangles except the one situated between the right and noncoronary sinuses to avoid potential injury to the bundle of His and membranous septum.

#### **8.3 Valve repair: Alignment of adjacent cusp free edges followed by resuspension of the cusp effective height**

Commissural traction stitches are placed. Alignment of adjacent cusp free edges is performed. Excess cusp length is corrected by plicating central stitches if <5mm and limited cusp resection if >5 mm. Effective height cusp resuspension is then re-evaluated on the unfused cusp using a cusp caliper (Fehling Instruments, Karlstein, Germany). Plicating central stitches are added on the free edge of this cusp until an effective height of 10 mm is obtained. Re-alignment of the two cusps free edges is then performed by adding plicating stitches on the fused cusp (fig. 16).

Fig. 16. Aortic valve resuspension for repair of isolated aortic insufficiency

#### **8.4 Placement of the aortic prosthetic ring in subvalvular position and TEE control**

The subvalvular stitches are passed through the inner aspect of the 'open' subvalvular prosthetic ring, in order that it may be positioned below the coronary arteries. The ring is closed with a series of "U" stitches. Transsection of the aorta is closed in standard fashion with running suture (fig. 17).

An Expansible Aortic Ring for a Standardized and Physiological Approach of Aortic Valve Repair 239

independent risk factors for composite outcome in Group 1 and 2. Annulus diameter, Marfan syndrome and cusp repair had no effect on aortic insufficiency recurrence or reoperation. Repair of bicuspid valves showed better results than tricuspid valves anatomy. This might be partly explained by higher rate of cusp repair in bicuspid patients (72% of patients versus 28% of patients for tricuspid valves). Apart from high rate of cusp repair, better results in Group 3 also could reflect a learning curve or other confounding factors,

**10. Evaluation of the standardized approach to aortic valve repair: CAVIAAR trial and registry (Conservative Aortic Valve surgery for aortic Insufficiency** 

Few series have compared valve repair with composite valve and graft replacement (Bassano et al., 2001; De Oliveira et al., 2003; Karck et al., 2004; Patel et al., 2008; Volguina et al., 2009; Zehr et al., 2004). Conclusions remain controversial since they were often retrospective, based on selected patients (Marfan), and compare different operating time periods, techniques and learning curve periods. Overall, rates of thromboembolism, bleeding, and endocarditis after valve repair seem lower than those reported for prosthetic valves. A current prospective international registry just provided 30-day morbidity and mortality data and shows equivalent results after a composite valve replacement or a valvesparing procedure (despite various type of reimplantation) in a selected population of Marfan patients (National Marfans Foundation prospective aortic root replacement registry)

In order to evaluate the standardized approach of valve repair using the expansible aortic ring versus mechanical valve replacement, unselected population of patients with aortic root aneurysms (bicuspid and tricuspid valves) are currently enrolled in France in the ongoing prospective multicenter CAVIAAR trial (Conservative Aortic Valve surgery for aortic Insufficiency and Aneurysm of the Aortic Root), over the next 5 years. Aside from the trial, all patients operated according to the CAVIAAR technique outside France are enrolled in

Avoidance of anticoagulation and prosthetic related complications makes aortic valve repair an appealing procedure. Considering the increasing rate of cusp repair reported in the literature, conservative aortic valve surgery seems to be evolving from aortic valve sparing to aortic valve repair. However, the need remains for reliable long-term data comparing valve replacement and valve-repair procedures. A standardized management of dystrophic aortic roots towards a physiological approach to valve repair might improve long term durability of the results, and encourage more widespread adoption of these procedures.

We wish to thank the surgeons who operated the patients in the CAVIAAR trial: Pr C. Acar, Pr B. Albat, Dr E. Arnaud Crozat, Dr F. Baud, Pr D. Blin, Dr N. Bonnet, Dr O. Bouchot, Dr D. Chatel, Dr F. Doguet, Dr G. Fernandez, Dr JP Fleury, Dr T. Folliguet, Pr I. Gandjbakhch, Dr R. Hacini, Pr P. Leprince, Dr S. Lopez, Pr P. Menu, Pr P. Nataf, Pr A. Pavie, Dr A. Rama.

since these patients were operated later (Lansac et al., 2010a, 2010b).

**and Aneurysm of the Aortic Root)** 

(Volguina et al., 2009).

**11. Conclusion** 

**12. Acknowledgements** 

the prospective CAVIAAR registry.

Fig. 17. Placement of the aortic prosthetic ring in subvalvular position
