External Fixation of an Internal Aortic Annuloplasty Device: Advancing the Technique

Background: Aortic annuloplasty using an internal ring enabled a standardization of bicuspid aortic valve (BAV) repair, making it more reproducible and independent of valve morphotype. The original device implantation technique includes subcommissural sutures fixing the commissural posts in a subannular position, followed by looping sutures to stabilize the device that is advanced in the corresponding aortic sinus 2 to 3 mm behind the hinge point of the aortic cusps. Limitations of this implantation technique include an increased complication risk due to extensive cusp manipulation and looping suture tails. Herewith, we propose a modified implantation technique by external fixation of the looping sutures.

Methods: Modifications of the original implantation technique include (1) an external dissection of the aortic root down to the annulus level without detaching the coronary arteries similar as required for external aortic annuloplasty, (2) external fixation of the looping sutures at the outside of the aorta, (3) sparing of the subannular area below both coronary ostia and the region of the left bundle branch as well as (4) the use of two Teflon strips as external support for the externalized looping sutures in the non-coronary area and between both coronary ostia. We reviewed all consecutive patients with BAV repair using internal ring annuloplasty (n = 22) since 08/2022. The original implantation technique (OT) was applied in the first 6 patients. In 09/2023, the modified technique (MT) was introduced and exclusively used thereafter (n = 16).

Results: No significant difference in procedural times and transvalvular hemodynamics at discharge was observed between both groups. However, complications (i.e., atrioventricular block, iatrogenic ventricular septal defect, aortic cusp perforation, or a combination) were reported in 50% of OT patients, whereas none of the MT patients experienced any complication (p = 0.013).

Conclusion: Our modified implantation technique for internal ring annuloplasty in BAV repair using an external fixation of the looping sutures shows potential to prevent complications associated with the original implantation technique. Our preliminary results should be confirmed in subsequent multicenter studies.

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Artikel online veröffentlicht:
11. Februar 2025