Commentary: Getting to the art of the matter with aortic valve repair

Central MessageRepair of the regurgitant aortic valve is a difficult skill to attain, and “a one size fits all” approach is not an ideal strategy. Success in aortic valve repair can be mastered only though experience.See Article page 121. Repair of the regurgitant aortic valve is a difficult skill to attain, and “a one size fits all” approach is not an ideal strategy. Success in aortic valve repair can be mastered only though experience. See Article page 121. Surgical aortic valve replacement for aortic regurgitation using either a mechanical or bioprosthetic prosthesis is suboptimal due to the potential for structural degeneration and need for reoperation or the inherent risks of anticoagulation.1Otto C.M. Nishimura R.A. Bonow R.O. Carabello B.A. Erwin III, J.P. Gentile F. et al.2020 ACC/AHA guideline for the management of patients with valvular heart disease: executive summary: a report of the American College of Cardiology/American Heart Association Joint Committee on clinical practice guidelines.J Am Coll Cardiol. 2021; 77: 450-500Crossref PubMed Scopus (208) Google Scholar Aortic valve repair represents an attractive alternative that preserves native valve function. However, owing to alterations to aortic root geometry and the aortic cusps that may be needed to achieve valve competency, this procedure is complex. The specific components of the valve and root apparatus to target for intervention often can be difficult to determine. Dr Svensson's2Svensson L.G. The art of aortic valve repair.J Thorac Cardiovasc Surg Tech. 2021; 7: 121-125Scopus (5) Google Scholar extensive experience and expertise with aortic valve repair is on full display in this issue of the Journal. In his article, he advocates that the commissures, leaflets, annulus, sinuses, and sinotubular junction represent a single entity that must be considered as one unit and discusses how to identify which components require intervention based on underlying pathology. The techniques described have been used by his group to achieve repair rates that are both successful and durable, with repair rates and 10-year freedom from operation exceeding 90%.3Zeeshan A. Idrees J.J. Johnston D.R. Rajeswaran J. Roselli E.E. Soltesz E.G. et al.Durability of aortic valve cusp repair with and without annular support.Ann Thorac Surg. 2018; 105: 739-748Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar,4Svensson L.G. Al Kindi A.H. Vivacqua A. Pettersson G.B. Gillinov A.M. Mihaljevic T. et al.Long-term durability of bicuspid aortic valve repair.Ann Thorac Surg. 2014; 97: 1539-1548Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar He acknowledges that the results must be interpreted with caution, as the various techniques used have evolved over time. These results are comparable to what has been achieved by other groups in Europe and Canada.5David T.E. Feindel C.M. David C.M. Manlhiot C. A quarter of a century of experience with aortic valve-sparing operations.J Thorac Cardiovasc Surg. 2014; 148: 872-880Abstract Full Text Full Text PDF PubMed Scopus (131) Google Scholar,6Schneider U. Feldner S.K. Hofmann C. Schöpe J. Wagenpfeil S. Giebels C. et al.Two decades of experience with root remodeling and valve repair for bicuspid aortic valves.J Thorac Cardiovasc Surg. 2017; 153: S65-S71Abstract Full Text Full Text PDF PubMed Scopus (103) Google Scholar There are some notable differences, however, in that Dr Svensson and colleagues identified severe preoperative aortic insufficiency as a risk factor for repair failure, whereas other groups did not.7Beckerman Z. Kayatta M.O. McPherson L. Binongo J.N. Lasanajak Y. Leshnower B.G. et al.Bicuspid aortic valve repair in the setting of severe aortic insufficiency.J Vis Surg. 2018; 4: 101Crossref PubMed Google Scholar In addition, Dr Svensson's group also found the best durability with a figure of eight suture, whereas other groups have expressed concern about the durability of this technique.8Ehrlich T. de Kerchove L. Vojacek J. Boodhwani M. El-Hamamsy I. De Paulis R. et al.State-of-the art bicuspid aortic valve repair in 2020.Prog Cardiovasc Dis. 2020; 63: 457-464Crossref PubMed Scopus (27) Google Scholar Perhaps the most important take-away message of this article is that because of the technical complexity, aortic valve repair remains largely an “art.”9Lansac E. de Kerchove L. Aortic valve repair techniques: state of the art.Eur J Cardiothorac Surg. 2018; 53: 1101-1107Crossref PubMed Scopus (44) Google Scholar Readers are given guiding principles of aortic valve repair instead of the usual technical pearls stressed by other authors, which include prescribing commissural angles, leaflet heights, and other measurements.8Ehrlich T. de Kerchove L. Vojacek J. Boodhwani M. El-Hamamsy I. De Paulis R. et al.State-of-the art bicuspid aortic valve repair in 2020.Prog Cardiovasc Dis. 2020; 63: 457-464Crossref PubMed Scopus (27) Google Scholar There is further emphasis that only through experience, observation, and trial and error can one gain the “sixth sense” that is required to successfully perform aortic valve repair. It is clear that Dr Svensson has developed this “sixth sense” and like a skilled artist is able to achieve masterful results. We found this expert opinion to be educational and applaud Dr Svensson for his immense contributions to the field. However, for aortic valve repair to be disseminated beyond specialized centers, consistent and specific technical lessons are also needed. Only through a combination of technical expertise and application of surgical art will aortic valve repair ultimately be reproducible even by less experienced surgeons. The art of aortic valve repairJTCVS TechniquesVol. 7PreviewIn cardiac surgery, as with many endeavors, there is a point to which science can take you, and then art—namely observation, hands-on skill, craft, imagination, and mental imputation—must take over. And so it is with aortic valve repairs. Certainly, there are some important physics principles to note: (1) the greater the contact area of leaflet to leaflet apposition, the less leakage; (2) according to Poiseuille equation, small changes in the diameter of an orifice lead to large gradient increases by radius to the fourth power; (3) the longer the leaflets, the greater likelihood of turbulence and gradients (ie, increased shear over a longer distance at the boundary layer disrupting laminar flow); (4) tension and the risk of leaflet tear or perforation are increased with less apposition of leaflets to relieve linear edge stress; (5) greater leaflet height increases the contact area of apposition without sacrificing orifice area; and (6) there is increased stasis and likelihood of clot formation (Virchow's triad) with sinuses that are too deep, particularly with added pericardium. Full-Text PDF Open Access

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