Minimally Invasive Aortic Valve Repair Using Internal Ring Annuloplasty

Objectives: Aortic valve repair by minimally invasive approach is becoming more and more widespread. While consensus is that ring dilatation needs to be fixed for a stable long-term result, the most appropriate method has not yet been identified. We investigated the feasibility and success of an internal ring in minimally invasive aortic valve repair.

Methods: From April 2013 to July 2018, 21 patients (68 ± 9 years; 67% male) with aneurysms of the ascending aorta and severe symptomatic aortic regurgitation (AR) [AR grade: 3.9 ± 0.4, NYHA class: 2.8 ± 0.6] underwent replacement of the ascending aorta and aortic valve repair through a partial upper sternotomy. In one-third (7/21) of the patients aneurysms involved the aortic root. Aortic valve morphology was tricuspid 19/21 (90%) or bicuspid 2/21 (10%).

Results: In all patients replacement of the ascending aortic was performed using a Dacron tube 5 to 7 mm larger than ring size. One-third of the patients (7/21; 33%) had concomitant remodeling of the aortic root. Trileaflet rings were implanted in 19/21 (90%), and bicuspid rings in 2/21 (10%) patients. Ring size was guided by measurements of leaflet free-edge length. Average ring diameter was 22 ± 1 mm. Additional leaflet plication, was performed in 15/21 (71%). Intraoperatively there was no conversion to full sternotomy and no repair to replacement conversion. Intraoperative transesophageal echocardiography showed good valve morphology in all patients with competent valves in 18 patients and AR grade I in 3 patients. One patient needed re-thoracotomy for bleeding (1/21; 5%). 14/21 (67%) patients required no blood transfusion. There were no thromboembolic events or AV-block postoperatively. In transthoracic echocardiography within 5 days postoperatively results remained stable. Mean systolic pressure gradients were 8 ± 3 mm Hg. At an average follow-up of 2.5 years (range 0.1–5.3 years) results continue to be stable, no patient died, no patient had to be reoperated, and no other valve-related complication (endocarditis, bleeding, thromboembolism) were observed.

Conclusion: Aortic valve repair by minimally invasive approach through a partial upper sternotomy appeared to be safe. Internal ring annuloplasty seems effective for fixation of the annulus. Hemodynamic improvements were significant, and clinical outcomes were excellent. However, more patient numbers and continued long-term follow-up will be needed to fully validate this approach.