Toward standardization of valve-sparing root replacement and annuloplasty

The current guidelines for surgical intervention of aortic regurgitation were developed by assuming aortic valve replacement. However, when aortic valve repair is considered, earlier intervention may provide more durable repair. Standardization of the procedures may be required to achieve stable outcomes. The possibility of standardization of valve-sparing root replacement (VSRR) and annuloplasty will be discussed.

The differences between the two VSRRs have decreased with technical modifications, reimplantation using a graft with sinuses, and remodeling with annuloplasty. The minor differences are the maintenance of root distensibility, less root dissection, shorter procedure time, and higher risk of bleeding in the latter. Stable outcomes may be expected by choosing the appropriate graft size according to the root dimensions in the former. In the latter, postoperative commissure height depends on the skill of the surgeon, which can be resolved using a graft with sinuses. There is still controversy regarding the equal arrangement of the commissure heights and angle, but it has been accepted in clinical use provided that postoperative effective heights of each cusp are set equally. External suture annuloplasty maintains the advantages of remodeling because it requires less root dissection and a shorter procedure time. It can accurately predict postoperative annulus diameter. External ring annuloplasty can stabilize the basal ring exactly, but it is time-consuming and postoperative annulus diameter cannot be predicted accurately.

Standardization of VSRR may be feasible, and VSRR is expected to be more widely adopted, which will improve the guidelines.