Aortic annuloplasty: towards a standardized approach of conservative aortic valve surgery

Dystrophy represents the most common etiology of aortic insufficiency and aortic root aneurysms in Western countries. Main characteristic lesions of dystrophic aortic roots are the constant dilation of the aortic annular base and sinotubular junction diameters, preventing coaptation of otherwise pliable bicuspid or tricuspid valves. Although these lesions are amenable to conservative aortic valve surgery, mechanical valve replacement remains the surgical standard. The multiplicity of current surgical techniques for conservative aortic valve repair substantiates the need for standardization. Analysis of the literature emphasizes two basic surgical objectives: the treatment of the lesions (dilation of aortic annular base and sinotubular junction) as well as the preservation of aortic root dynamics. From these findings, we suggest a standardized approach for conservative aortic valve surgery meeting both of these principles, based on the implantation of an expansible aortic ring. In the case of aortic root aneurysm, the remodeling technique is combined with a subvalvular external aortic annuloplasty. In the case of isolated aortic insufficiency, a double aortic annuloplasty (sub- and supravalvular) is performed.