Adult: Aortic Valve: Invited Expert Techniques Federspiel et al

Aortic annuloplasty: Subcommissural, intra-annular

suture techniques, external and internal rings
Jan M. Federspiel, MD, Tristan Ehrlich, MD, Karen Abeln, MD, and Hans-Joachim Sch€afers, MD

ABSTRACT Sinotubular junction

Aortic valve repair and valve-preserving root replacement have evolved into Cusp free margin

increasingly practiced procedures. With increasing experience, the need for an an-
nuloplasty has become more evident, at least for pathologies that involve annular
dilatation. To understand the effect of an aortic annuloplasty, it is necessary to Crown-like cusp
insertion line
know the details of aortic valve and root anatomy. Geometrically, the functional
annulus is best defined as the virtual basal ring, ie, plane of the cusp nadirs. The si- gH eH

notubular diameter also influences the aortic valve form, at least in tricuspid valves.
Virtual basal ring
Different annuloplasty concepts have been developed for isolated valve repair or in
combination with root remodeling, such as subcommissural sutures, suture annu- Determinants of aortic valve and root geometry.
gH, Geometric height; eH, effective height.
loplasty, external, and internal rings. Subcommissural sutures do not consistently
provide durable annular stabilization. More positive results have been published
CENTRAL MESSAGE
for circular approaches, ie, suture annuloplasty, external, or internal rings. The re-
sults of different techniques are difficult to judge because most outcome data Different annuloplasty concepts
have not been analyzed with control of confounding predictors of repair failure. have been proposed as adjunct
The evidence that annuloplasty improves aortic valve function and repair durability
to aortic valve repair when
is best documented for isolated bicuspid aortic valve repair. In summary, the addi-
tion of annuloplasty to aortic valve reconstruction is probably a useful tool to annular dilatation is present. At
improve valve competence and stabilize the repair. This is best documented for iso- this time, the evidence for their
lated bicuspid valve repair and circular approaches. The relative benefit of individual
effectiveness is still soft.
concepts is difficult to judge because of lack of both control groups and control of
confounding factors. (JTCVS Techniques 2021;7:98-102)
See Commentaries on pages 103, 105, and
107.

Repair of the regurgitant aortic valve has increasingly annuloplasty is in isolated aortic valve repair. For both re-
evolved into a reproducible alternative to aortic valve modeling and repair, the addition of an annuloplasty to
replacement, especially in young individuals. The goal of the repair aims at reducing/stabilizing annular dimensions
these procedures is the restoration of normal cusp and and improving the durability of the repair (at least if annular
root geometry. Of the different techniques, valve reimplan- dilatation is present preoperatively). The primary substrates
tation is designed to correct and stabilize all root dimen- are regurgitant tricuspid aortic valves (TAVs) and bicuspid
sions. Root remodeling is thought to provide inadequate aortic valves (BAVs); for the purpose of this review, unicus-
annular stabilization,1 even though recent data suggest pid and quadricuspid aortic valves will be spared because
similar annular stabilization using this technique with and they are geometrically different and rare.
without annuloplasty.2 The probably greatest need for an
ANATOMY OF THE AORTIC VALVE
From the Department of Thoracic and Cardiovascular Surgery, Saarland University To understand the concept of an aortic annuloplasty, it is
Medical Center, Homburg/Saar, Germany. important to know the anatomic details of aortic valve and
Supported by departmental funding. root. The aortic valve is a functional unit of cusps suspended
Received for publication Dec 9, 2020; accepted for publication Dec 14, 2020;
available ahead of print Jan 28, 2021. within the aortic root.3 Geometric alterations of either cusp
Address for reprints: Hans-Joachim Sch€afers, MD, Department of Thoracic and or root will influence aortic valve form and competence.
Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, The anatomic aortic annulus is best represented by the
Germany (E-mail: [email protected]).
JTCVS Techniques 2021;7:98-102 crown-shaped fibrous structure of the combined cusp inser-
2666-2507 tion lines (Figure 1).4 The caudal border of the root, con-
Copyright Ó 2021 The Authors. Published by Elsevier Inc. on behalf of The American necting the cusp nadirs in a horizontal plane, has been
Association for Thoracic Surgery. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). termed as virtual basal ring.4 It is best considered as the
https://doi.org/10.1016/j.xjtc.2020.12.044 true functional annulus because it determines basal valve

98 JTCVS Techniques c June 2021

Federspiel et al Adult: Aortic Valve: Invited Expert Techniques

Sinotubular junction annulus or more cranially4 (Figure 2). In normal TAVs,

the difference in location between annulus and VAJ is
Cusp free margin
generally limited.7 In BAVs, the distance between the func-
tional annulus and VAJ is usually larger than in TAVs, with
up to 15 mm.8 Similar findings may be present in patients
with root aneurysms.
The form of the aortic valve depends not only on root di-
Crown-like cusp mensions but also on dimensions of the aortic cusps. Geo-
insertion line metric height,3 ie, the distance from nadir to free margin,
and the length of the free margin,3 best defines cusp size.
gH eH A normal aortic valve has a characteristic height difference
between the free margins in diastole and the annular plane,
termed effective height.3 It can be measured intraopera-
Virtual basal ring tively and echocardiographically. The length of the free
FIGURE 1. Geometric determinants of aortic valve form. Schematic cusp margin is less well characterized. Last but not least,
drawing of the geometric determinants of aortic valve form. The anatomic the cusp dimensions differ between tricuspid and bicuspid
annulus is a crown-shaped structure. The probably more important root di- valves.3
mensions are the virtual basal ring (¼ functional annulus) and sinotubular
junction. gH, Geometric height; eH, effective height.
ANNULAR DILATATION: CLINICAL AND
SIMULATION EVIDENCE
geometry.5 This functional annulus, termed “annulus” for The size of a normal annulus varies considerably.9
the purpose of this review, should be the target for all annu- Empirically, an annular diameter of more than 25-29 mm
loplasty approaches; it also best corresponds to annular size has been considered as dilated.1,10 Annular dilatation is
determination by imaging techniques. frequent in aortic regurgitation11; it is almost invariably pre-
The sinotubular junction (STJ; Figure 1) determines the sent in regurgitant BAVs. It is also frequent in young
position of the commissures and thus contributes to the patients with tricuspid valves and root aneurysm.12 Annular
anatomy of the aortic valve, at least in TAVs.5 Its impor- dimension may be underestimated by echocardiography,
tance is less clear for bicuspid valves. The contribution of especially if annular size is determined in diastole, in which
dilatation of the STJ to aortic valve form has long been the annulus assumes an ellipsoid shape. In children and
known.6 adolescents, the STJ is generally 20% smaller than the
The ventriculoaortic junction (VAJ) is a different annulus,13 whereas in older individuals, it is larger as the
anatomic structure; it is the transition of ventricular diameter of the normal aorta increases with age.
myocardium to aortic wall.4 The VAJ has been considered The clinical effect of annular dilatation on repair dura-
as synonymous with the annulus,7 but this is potentially bility has been recognized in several studies.10,11 Annular
misleading. The VAJ can be located at the level of the dilatation was an independent risk factor for recurrence of

Sinotubular junction

LCC

RCC

NCC Ventriculo-arterial junction

Virtual basal ring

FIGURE 2. Localization of the ventriculoaortic junction. The anatomic ventriculoaortic junction differs from the functional annulus and is best seen by the
extent of muscle in the sinus portion of the root. It is not infrequently more than 5 mm above the level of the annulus, particularly in the right sinus. NCC,
Noncoronary cusp; LCC, left coronary cusp; RCC, right coronary cusp.

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Adult: Aortic Valve: Invited Expert Techniques Federspiel et al

regurgitation in isolated BAV repair.10 Stabilizing and/or will be associated with poor durability.15 The reconstructed
reducing the aortic annulus at the time of surgery has cusps should have a near-normal form, ie, effective
been shown to significantly improve the durability of height.3,10 Failure to measure effective height has been
BAV repair.11,14 Most clinical studies, however, have shown associated with suboptimal durability.1 In bicuspid valves,
only indirect evidence of the role of annular dilatation. At commissural orientation will also influence repair dura-
this time, prospective studies are lacking, and the best bility.10,14 The use of patch material for cusp repair has
evidence for the importance of annular dilatation has been been associated with an increased probability of failure.10,14
obtained from retrospective studies with BAV repair.10,11 Finally, certain types of repair, such as commissural repairs,
The geometric effects of annular dilatation have best also have limited durability.
been documented for the TAV through computer simula- In effect, an aortic repair procedure can thus be compared
tion; this has been shown for annulus and STJ.5 With with an equation with several variables, in which the annu-
increasing dilatation of the annulus or STJ, coaptation loplasty is one, while the other variables, ie, predictors of
height decreases and finally a central coaptation defect be- failure, will also influence the result. Keeping this in
comes apparent.5 These investigations have been performed mind, publications of repair and annuloplasty results must
with a tricuspid valve design; it is unclear to what degree be interpreted cautiously as long as there is no control for
these mechanisms apply to bicuspid valves. the confounding variables.

NONANNULAR DETERMINANTS OF AORTIC ANNULOPLASTY CONCEPTS

VALVE REPAIR DURABILITY Different annuloplasty concepts have been proposed over
In interpreting the results of studies on aortic valve repair, time by different groups (Table 1). It is currently unclear
one has to keep in mind that normal aortic valve form and how frequently the individual approaches are applied in
function depend on the geometry of both valve and root. clinical practice. In judging the results reported in the
In clinical studies, a number of confounding factors will in- different publications, the details described must carefully
fluence postrepair function and durability beyond annular considered. Most lack important information, as pointed
dilatation. In addition, the morphology of TAVs and BAVs out in Table 1.
differs, and it is unclear whether they have comparable Subcommissural sutures were first proposed by Cabrol
repair durability. and colleagues16 and later employed by others, including
In general, an aortic repair depends on the presence of our group. They are easy to use and commonly placed
sufficient tissue, ie, geometric height.3,15 Lack of tissue halfway between annulus and commissures, even though

TABLE 1. Summary of the reviewed series

Freedom from
AV Valve Mean reoperation,
Technique N [Ref] morphology assessment follow-up, mo 1-/5-y (%) Control Cusp repair
Subcommissural suture 166 [17] TAV V NA NA/NA þ þ
100 [10] BAV M 48 NA/88 – þ
External ring 177 [1] UAV, BAV M* 41 100/100 – þ
TAV 97/88
Internal ring 65 [18] TAV V 24 95/NA – þ
16 [19] UAV, BAV M NA NA/NA – þ
Internal/external ring 52 [20] TAV V 45 NA/NA – þ
Double external ring 37 [21] UAV, M* 18 90/75 þ þ
BAV, TAV
STJ remodeling 5 [6] TAV V 10 NA/NA – –
103 [12] NA V 68 NA/NA – þ
“Basal” suture 1024 [14] BAV M 56 97/94 þ þ
annuloplasty 164 [23] BAV M 27 96/93 þ þ
“Anatomical” suture 22 [25] BAV, TAV V NA NA – þ
annuloplasty
Data on follow-up and freedom from aortic valve reoperation refer to the annuloplasty group in each series. Control indicates control group without annuloplasty; þ indicates
present or was performed; and  indicates not present or was not performed. N, Number of individuals with annuloplasty; Ref, reference; AV, aortic valve; TAV, tricuspid aortic
valve; V, visual valve assessment; NA, not available; BAV, bicuspid aortic valve; M, objective measurement of valve configuration; UAV, unicuspid aortic valve; STJ, sinotubular
junction. *Not consistent within study.

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Federspiel et al Adult: Aortic Valve: Invited Expert Techniques

this level has never been standardized. Progressive annular similar to the external STJ ring.6 The procedure is techni-
dilatation has previously been observed with this technique cally easy, although the change of intercommissural dis-
after BAV and TAV repair,17 and they had been associated tance achieved by the procedure may also distort the valve.
with repair failure.10,17 With the apparent impression that Taylor and colleagues22 first designed the concept of a su-
subcommissural sutures do not provide sufficient and stable ture annuloplasty placed at basal level. We introduced a
annular support many surgeons including our group have modification of the original approach in 2009 into our
abandoned this technique. routine, mainly to accommodate the anatomic variability
An external ring was used clinically by Lansac and co- of VAJ in relation to the annulus and avoid deep myocardial
workers,1 primarily in conjunction with remodeling. An dissection.23 A polytetrafluoroethylene suture (Gore-Tex
open ring to be employed for isolated valve repair has CV-0; W. L. Gore & Associates, Munich, Germany) is
been produced by cutting a ring from a Dacron graft; others placed to stabilize the annulus at its functional level.23 In
have used a band primarily designed for mitral repair. The our experience, we have found that polytetrafluoroethylene
implantation of such an external ring requires dissection as suture material yields the best results. The insertion re-
similar to that of a reimplantation procedure and may thus quires some dissection, but less so than the external ring.
be challenging in the presence of discrepancy between Erosion of the membranous septum was observed in very
VAJ and annulus (Figure 2). few instances in the early experience and only with braided
Improved repair stability has been published with the use polyester as suture material, and obstruction of the circum-
of such an external ring compared with historical controls in flex occurred in a few instances early on. Positive results
root remodeling1 In view of the limited control of confound- were published in 2 series,14,23 in which subanalyses al-
ing factors, it is uncertain to what degree the results are lowed for determination of the annuloplasty effect.
related to the ring alone. Carpentier24 proposed a different suture annuloplasty,
An internal ring was developed based on geometric following the anatomic annulus; others proposed the same
studies of the aortic root in diastole.18,19 The resulting ellip- technique in a limited series.25 This variant is probably
soid rigid ring (for tricuspid or symmetric bicuspid valves) easy to perform. Carpentier reported no results. The other
has rigid extensions toward the commissures. It is to be im- series included limited information on results.25
planted below the cusp insertion lines and thus seemingly
simple to implant using a suture technique similar to im- CONCLUSIONS
plantation of a stented prosthesis. Aortic valve annuloplasty appears as an important
Good repair results have been published in a several se- adjunct to aortic valve repair to normalize the functional
ries with limited numbers and follow-up.18,19 Some early annulus, ie, basal plane of the aortic root. An annuloplasty
failures have been related to abrasion of cusp tissue from will only rarely normalize aortic valve form and function by
touching the sutures used for implantation18; also, ring itself, cusp repair is almost always needed.
dehiscence has been reported.18 For BAV repair, the effect of an annuloplasty has been
Fattouch and coworkers20 proposed a combination of an proven, whereas the evidence is less clear for tricuspid
internal and external ring. An internal circular Dacron ring valves. At this time, its benefit in conjunction with root re-
is implanted just below the annular plane, and a second, modeling for BAV is unproven. The evidence in root remod-
crown-like shaped Dacron ring is sutured externally to the eling for tricuspid valves is soft, even though computer
STJ. The 3 vertical extensions of the STJ ring are fixed to simulation studies indicate that it should improve cusp
the internal one. Little is known on ease of implantation coaptation and thus valve competence.
and the use of this approach beyond the initial authors. In judging the need for an annuloplasty and its clinical
More recently, the use of 2 external rings was proposed,21 benefit, one must consider the limitations in evidence.
with one ring for the annulus and one for the STJ. The STJ There is currently no generally accepted definition of
ring appears easy to implant, even though circumferential annular dilatation requiring correction. Sizing strategies
distortion of commissural position might lead to alteration vary, and there is the need to determine and standardize
of valve form. The study found superior results of the dou- ideal postrepair annular diameter. Finally, very different an-
ble ring compared with the single ring technique regarding nuloplasties have been proposed (Table 1). The benefit of
need of aortic valve related reintervention. Interestingly, subcommissural sutures is questionable, and the results of
right ventricular ischemia occurred in one instance, the other concepts are impossible to compare due to lack
possibly related to distortion of the right coronary artery of control of confounding predictors of valve durability
ostium. and inconsistency in published endpoints (Table 1). It is
The concept of the STJ ring in the double-ring approach thus impossible to make clear recommendations which
is similar to that of tubular aortic replacement for ascending technique to choose for which pathology.
aortic aneurysm and aortic regurgitation, so-called STJ re- Further computer simulation studies and clinical investi-
modeling.6 This procedure eliminates STJ dilatation, gations are necessary to better define the risks and benefits

JTCVS Techniques c Volume 7, Number C 101

Adult: Aortic Valve: Invited Expert Techniques Federspiel et al

of the different solutions. Future studies should consistently 11. Navarra E, El Khoury G, Glineur D, Boodhwani M, Van Dyck M,
Vanoverschelde JL, et al. Effect of annulus dimension and annuloplasty on
control for confounding variables and include sufficient bicuspid aortic valve repair. Eur J Cardiothorac Surg. 2013;44:316-22.
follow up, probably at least 5 years. 12. David TE, Feindel CM, Armstrong S, Maganti M. Replacement of the ascending
aorta with reduction of the diameter of the sinotubular junction to treat aortic
insufficiency in patients with ascending aortic aneurysm. J Thorac Cardiovasc
Surg. 2007;133:414-8.
Conflict of Interest Statement 13. Kunzelman KS, Grande KJ, David TE, Cochran RP, Verrier ED. Aortic root and
Hans-Joachim Sch€afers has a consultancy agreement with valve relationships. Impact on surgical repair. J Thorac Cardiovasc Surg. 1994;
Cardiac Research and Education, GmbH. All other authors 107:162-70.
14. Schneider U, Hofmann C, Sch€ope J, Niewald AK, Giebels C, Karliova I, et al.
reported no conflicts of interest. Long-term results of differentiated anatomic reconstruction of bicuspid aortic
The Journal policy requires editors and reviewers to valves. JAMA Cardiol. 2020;16:e203749.
disclose conflicts of interest and to decline handling or re- 15. le Polain de Waroux JB, Pouleur AC, Robert A, Pasquet A, Gerber BL,
Noirhomme P, et al. Mechanisms of recurrent aortic regurgitation after aortic
viewing manuscripts for which they may have a conflict valve repair: predictive value of intraoperative transesophageal echocardiogra-
of interest. The editors and reviewers of this article have phy. JACC Cardiovasc Imaging. 2009;2:931-9.
no conflicts of interest. 16. Cabrol C, Cabrol A, Guiraudon G, Bertrand M. Treatment of aortic insufficiency
by means of aortic annuloplasty. Arch Mal Coeur Vaiss. 1966;59:1305-12 [in
French].
We thank Shunsuke Matsushima, MD, for generating the 17. de Kerchove L, Mastrobuoni S, Boodhwani M, Astarci P, Rubay J, Poncelet A,
illustrations. et al. The role of annular dimension and annuloplasty in tricuspid aortic valve
repair. Eur J Cardiothorac Surg. 2016;49:428-37.
18. Mazzitelli D, Fischlein T, Rankin JS, Choi YH, Stamm C, Pfeiffer S, et al.
Geometric ring annuloplasty as an adjunct to aortic valve repair: clinical
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