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\begin{document}

\title{Aortic annulus elevation for aortic valve and root replacement}



\author[1]{Jama Jahanyar}%
\author[1]{Stefano Mastrobuoni}%
\author[1]{Daniel E. Munoz}%
\author[1]{Gaby Aphram}%
\author[1]{Laurent de Kerchove}%
\author[1]{Gebrine Elkhoury}%
\affil[1]{Cliniques universitaires Saint-Luc}%


\vspace{-1em}



  
  \date{May 23, 2024}


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\selectlanguage{english}
\begin{abstract}
Aortic valve and root replacements require an in-depth understanding of
the aortic root and annulus. Both structures can be asymmetric at times,
and this needs to be recognized and taken into consideration when
peforming valve-sparing operations or other root-replacement procedures.
Moreover, the geometry of the aortic annulus can be altered, and when
performing an aortic root replacement this can distort the geometry of a
neo-aortic valve for instance, and lead to valve dysfunction, which is
difficult to reverse. We are describing an altered aortic annulus, which
required modification through annulus elevation before proceeding with
aortic root replacement with a graft-reinforced pulmonary-autograft.%
\end{abstract}%



\sloppy


\textbf{Introduction}

The technique for aortic root replacement was first described in 1968 by
Bentall and DeBono \textsuperscript{1}. The method was further refined
and additional valve-sparing operations, such as the remodeling and
reimplantation technique, were introduced later \textsuperscript{2-3}.
Today, different options for aortic root replacement exist, ranging from
valve sparing to valve replacing procedures. In 1967, replacement of the
native aortic valve with the pulmonary valve was
suggested\textsuperscript{4}. Although mainly utilized in the pediatric
population in the past, in recent years, it has gained more widespread
acceptance in adults as well \textsuperscript{5}.

Nevertheless, all the above-mentioned techniques are surgically
challenging and require a thorough understanding of the aortic root
anatomy and function. There is wide variability in aortic valve
phenotypes, which also affects the geometry of the aortic annulus and
aortic root \textsuperscript{6}. Herein, we are describing an abnormal
aortic annulus of the left coronary sinus, which was displaced into the
left ventricular outflow tract (LVOT), due to aneurysmatic changes of
the left coronary sinus. This occurred in the setting of a severely
calcified unicuspid aortic valve in an adolescent, with extension of
calcifications onto the mitral valve (Figure 1). Although the annular
displacement is a subtle finding, which can easily be overlooked (Figure
2A), it has the potential for serious consequences during an aortic root
replacement, when not adequately addressed. We know from Ross
procedures, that distortion of the neo-aortic valve, due to a prosthetic
graft alone can lead to valve dysfunction \textsuperscript{7}. This
distortion can not only occur when the pulmonary autograft is seated
into the prosthetic graft but can also occur when the prosthetic graft
itself is distorted during placement onto the aortic annulus. We are
therefore describing a surgical technique to remedy the displaced aortic
annulus, through elevation of the aortic annulus to the level of the
normal annulus, with a prosthetic graft in this case. This provided a
geometrically balanced foundation for the pulmonary autograft, without
subsequent distortion of the neo-aortic valve.

\textbf{Technique}

The surgical technique is illustrated in the Video (Video 1,
supplementary material). After excision of a severely calcified
unicuspid valve and debridement of aortomitral curtain calcifications
(Figure 1), we noticed the asymmetric aortic annulus with significant
displacement of the left coronary aortic annulus into the LVOT (Figure
2A). The leftover graft of a 28mm Cardioroot graft (Getinge, Sweden),
which was used for pulmonary autograft reinforcement, was sewn to the
aortic annulus of the left coronary sinus with a 4.0 Prolene suture
(Figure 2B). The autograft reinforcement technique has been previously
described in detail \textsuperscript{7}. The graft was sewn to the
aortic annulus effectively from the left/right- coronary commissure to
the non/left- coronary commissure. During the surgery, we started the
suture line in the middle of the sinus (Figure 2B) and completed the
suture line on the displaced annulus and towards each commissure. Once
the graft was seated and tied, it was cut and the free margin of the
graft was trimmed to align with the height of the normal annulus of the
non- and right coronary sinus (Figure 2C). An additional commissural
stitch was placed at each commissure to secure the graft at the 2
lateral edges (Figure 2D). Upon completion of this step, a balanced
aortic annulus was created with an even horizontal plane (Figure 3A),
which would match the horizontal plane of the graft reinforced autograft
(Video 1).

The pulmonary autograft was then sewn to the neo-aortic annulus with a
running 4.0 Prolene suture (Figure 3B,C). This allowed for seating of
the pulmonary autograft to an even and horizontally balanced aortic
annulus, without any graft or neo-aortic valve distortion (Figure 3D).

\textbf{Comments}

Aortic root surgery is among the most complex procedures in an already
technically demanding surgical specialty of cardiac surgery. A thorough
understanding of the anatomy, and subsequent appreciation of abnormal
findings, with avoidance of potential pitfalls is critical. Knowledge
and acknowledgement of these subtle details, however, comes with
experience. Thus, we are sharing our experience and highlight our
approach to restore a more physiologic anatomy, which allows for
execution of a standard technique without the risk of failure related to
this particular anatomic entity.

The underlying principle described here, is that we sewed the horizontal
plane of the graft-reinforced pulmonary autograft, to a newly created
horizontal and even plane of the aortic annulus. With this, we avoided
distortion of the prosthetic graft with subsequent distortion of the
neo-aortic valve. Distortion of the neo-aortic valve would lead to
aortic regurgitation, due to prolapse or cusp restriction, and
subsequent potential failure of the procedure despite a correct surgical
execution. The potential culprit for failure here, is not a lack of
surgeon skills, but an unusual anatomical detail, which potentially
wasn't recognized or taken into consideration.

Moreover, when regarding the quality of the tissues in the left coronary
sinus, it becomes evident that the tissues are quite thin and would not
be able to adequately hold the sutures of the pulmonary autograft. It
also lacks the ability to provide any annular support and may therefore
also compromise durability of the repair. Thus, the annular elevation
and reinforcement alleviates the weaknesses of the annulus and sinus
wall. We most commonly observe these changes in the non-coronary sinus.
But this case highlights the notion, that these changes can affect any
of the aortic root sinuses.

The principles we presented here, do not only apply to the pulmonary
autograft but are universally applicable to any aortic annulus or root
technique. The only difference is that some techniques, such as
prosthetic valve replacements for instance, are more forgiving. Despite
that, even earlier generations of bioprosthetic valves required
modifications from a horizontal plane of the sewing ring to a more
scalloped formed ring. Hence, the scalloped sewing ring is anchored to a
scalloped aortic annulus, the natural from of the aortic cusp insertion
line. This allows for a more physiologic placement of the prosthetic
valve and decreases the possibility for errors. Hence, the form of the
bioprosthetic valve sewing ring was adjusted to better fit the natural
anatomy of the aortic annulus. In this case however, we adjusted the
aortic annulus to the root replacement substrate. We chose a graft
reinforced autograft, which had an even plane to sew to. Of course, we
could have also performed a Bentall procedure, but in young patients we
prefer the pulmonary autograft due to the improved long-term survival
and better quality of life \textsuperscript{8}.

Recognizing and understanding these subtle details, however, is
important to avoid potential pitfalls when dealing with the aortic root
and annulus.

\textbf{References}

\begin{enumerate}
\tightlist
\item
  Bentall H, DeBono A. A technique for complete replacement of the
  ascending aorta. \emph{Thorax} . 1968;23:338-339.
\item
  Sarsam MA, Yacoub M. Remodeling of the aortic valve annulus. \emph{J
  Thorac Cardiovasc Surg.} 1993;105:435-438.
\item
  David TE, Feindel CM. AN aortic valve-sparing operation for patients
  with aortic incompetence and aneurysm of the ascending aorta. J Thorac
  Cardiovasc Surg. 1992;103:617-621; discussion 622.
\item
  Ross DN. Replacement of aortic and mitral valves with a pulmonary
  autograft. \emph{Lancet.} 1967;2:956-958.
\item
  Jahanyar J, El Khoury G, De Kerchove L. The Ross-procedure: a
  rekindled relationship. \emph{Ann Thorac Surg.} 2021 Jul
  2:S0003-4975(21)01158-9.
\item
  Jahanyar J, El Khoury G, De Kerchove L. Commissural geometry and cusp
  fusion insights to guide bicuspid aortic valve repair. \emph{JTCVS
  Tech.} 2021 Jan 29;7:83-92.
\item
  Jahanyar J, Munoz DE, Tamer S, El Khoury G, De Kerchove L. The Ross
  inclusion Dacron graft. \emph{Ann Cardiothorac Surg.} 2021
  Jul;10(4):549-551.
\item
  Mastrobuoni S, de Kerchove L, Solari S, et al. The Ross procedure in
  young adults: over 20 years of experience in our Institution.\emph{Eur
  J Cardiothorac Surg.} 2016;49:507-512\emph{;} discussion 512-503.
\end{enumerate}

\textbf{Figures}

\textbf{Figure 1.} \textbf{A.} Severely calcified unicuspid aortic
valve. \textbf{B.} \emph{Blue arrows,} extension of calcifications onto
the aortomitral curtain and anterior mitral valve leaflet.

\textbf{Figure 2. A.} \emph{Blue arrows,} depict displaced aortic
annulus of the left coronary sinus into the LVOT, and below the level of
the aortic annulus of the right- and non-coronary sinus.
\textbf{B.}Sewing of a prosthetic graft to the displaced aortic annulus
between left/right- to non/left- coronary commissure. \textbf{C.}
Trimming of the graft to align the cut free edge of the graft with the
aortic annulus of the right- and non-coronary sinus. \textbf{D.}
Anchoring of the lateral 2 edges of the graft to the commissures.

\textbf{Figure 3. A.} Elevation of the left coronary sinus annulus with
prosthetic graft material. \textbf{B.} \emph{Black and blue arrows} ,
depict the new aortic annulus. \textbf{C} . Graft-reinforced pulmonary
autograft is sewn to the aortic annulus. \textbf{D.} Seated pulmonary
autograft onto the neo-aortic annulus.

\textbf{Supplementary material}

\textbf{Video 1.} Aortic annulus elevation.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Annular-elevation-Collage-1/Annular-elevation-Collage-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Annular-elevation-collage-2/Annular-elevation-collage-2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Annular-elevation-Collage-3/Annular-elevation-Collage-3}

\end{center}
\end{figure}

\selectlanguage{english}
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