Narrowing of the large aortic annulus: A word of caution.

The authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. We read with great interest the paper by Patlolla and colleagues1Patlolla S.H. Saran N. Dearani J.A. Stulak J.M. Schaff H.V. Greanson K.L. et al.Outcomes and risk factors of late failure of valve-sparing aortic root replacement.J Thorac Cardiovasc Surg. 2022; 164: 493-501https://doi.org/10.1016/j.jtcvs.2020.09.070Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar about long-term results after valve-sparing root repair (VSRR) performed in their center. Throughout the paper, the authors use the adjectives “large” and “dilated” as synonyms when referring to the aortic annulus (AA). It is not only confusing, but even inappropriate, because the term “dilated annulus” can suggest that it is progressively enlarged and should be surgically narrowed. Yet, a progressive dilatation of the AA as a primary cause of the development of aortic insufficiency (AI) has, to the best of our knowledge, never been described. Moreover, the AA is the most stable part of the aortic valve apparatus not only in a healthy population, but also in patients with a large or dilated root.2Vritz O. Aboyans V. D'Andrea A. Ferrara F. Acri E. Limongelli G. et al.Normal values of aortic root dimensions in healthy adults.Am J Cardiol. 2014; 114: 921-927Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar,3Tubrikar M.J. Labrosse M.R. Zehr K.J. Robicsek F. Aortic root dilatation may alter the dimensions of the valve leaflets.Eur J Cardiothorac Surg. 2005; 28: 850-856Crossref PubMed Scopus (72) Google Scholar However, there are 2 ways to improve cusp coaptation and to abolish AI: by enlarging the cusps or by narrowing the root (including the annulus) to bring the cusps closer together.4Marom G. Haj-Ali R. Rosenfeld M. Schäfers H.J. Raanani E. Aortic root numeric model: correlation between intraoperative effective height and diastolic coaptation.J Thorac Cardiovasc Surg. 2013; 145: 303-304Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Yet, we know from the Ross procedure and from other studies with the use of different annuloplasty techniques for narrowing the AA that the narrowed annulus has a strong tendency to return to its previous size5Abeln K.B. Schäfers S. Ehrlich T. Federspiel J.M. Schäfers H.J. Ross operation with autologous external autograft stabilization—long-term results.Ann Thorac Surg. 2022; 114: 502-510Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar,6Holst T. Petersen J. Sinning C. Reichenspurner H. Girdauskas E. Aortic valve repair in annular dilatation: external versus internal suture annuloplasty.Ann Thorac Surg. 2022; 113: 2036-2045Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar—and this is not a primary AA dilatation but a postprocedural dilatation. In contrast, in a considerable number of patients undergoing a VSRR, the indication for surgery is not an AI (In the paper by Patlolla and colleagues, 65% of patients had no or mild AI) but the size of the aortic root. Many such patients present with an ideally functioning aortic valve (Figure 1) and develop significant AI shortly after a change of the anatomophysiological root geometry by excessive narrowing of the complete root with a smaller tube (Figures 2 and 3). We have repeatedly referred to this iatrogenic form of AI7Urbanski P.P. Irimie V. Jankulowski A. Atieh A. Kucinoski G. Thamm T. et al.Long-term outcomes after aortic root repair using selective sinus replacement.J Thorac Cardiovasc Surg. September 25, 2021; ([Epub ahead of print]. https://doi.org/10.1016/j.jtcvs.2021.09.034)Abstract Full Text PDF PubMed Scopus (9) Google Scholar,8Irimie V. Atieh A. Kucinoski G. Jankulovski A. Zacher M. Urbanski P.P. Long-term outcomes after valve-sparing anatomical aortic root reconstruction in acute dissection involving the root.J Thorac Cardiovasc Surg. 2020; 159: 1176-1184Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar which, as demonstrated in some multicenter studies, is not just anecdotical.9Kari F.A. Doll K.N. Hemmer W. Liebrich M. Sievers H.H. Richardt D. et al.Residual and progressive aortic regurgitation after valve-sparing root replacement: a propensity-matched multi-institutional analysis in 764 patients.Ann Thorac Surg. 2016; 101: 1500-1506Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar,10Coselli J.S. Volguina I.V. LeMaire S.A. Sundt T.M. Connolly H.M. Stephens E.H. et al.Early and 1-year outcomes of aortic root surgery in patients with Marfan syndrome: a prospective, multicenter, comparative study.J Thorac Cardiovasc Surg. 2014; 147: 1758-1767Abstract Full Text Full Text PDF PubMed Scopus (89) Google ScholarFigure 2Angio-CT of a female patient with Marfan syndrome demonstrating an aortic root of 4.6 cm (A). Angio-CT of the same patient performed postoperatively because of the development of severe aortic insufficiency (shown in Figure 3e) shortly after the David procedure with a 26-cm tube. Notice the twisting of the cusps in the narrowed root (B). During reoperation, a cusp prolapse (despite free-margin plication) and twisting of severely deteriorated cusps were found (C, D).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 3Echocardiography of the patient presented in Figure 2e (with no aortic insufficiency before surgery) demonstrating severe aortic insufficiency that developed shortly after the David procedure.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Even if Patlolla and colleagues1Patlolla S.H. Saran N. Dearani J.A. Stulak J.M. Schaff H.V. Greanson K.L. et al.Outcomes and risk factors of late failure of valve-sparing aortic root replacement.J Thorac Cardiovasc Surg. 2022; 164: 493-501https://doi.org/10.1016/j.jtcvs.2020.09.070Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar do not provide the grade of the narrowing of the AA, eg, by determination of the diameter of the used aortic tubes, they described the technique of AA narrowing in their “Methods,” which was used in 90% of their patients. In contrast to other 2 large series published recently,8Irimie V. Atieh A. Kucinoski G. Jankulovski A. Zacher M. Urbanski P.P. Long-term outcomes after valve-sparing anatomical aortic root reconstruction in acute dissection involving the root.J Thorac Cardiovasc Surg. 2020; 159: 1176-1184Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar,11Giebels C. Fister J.C. Ehrlich T. Federspiel J. Schäfers H.J. Failures of valve-sparing aortic root replacement using the root remodeling technique.Ann Thorac Surg. 2022; 113: 2000-2007Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar the authors identified a large AA as a risk factor for reoperation. They speculate in their “Discussion” that the AA size can be “…a marker for greater cusp mechanical stress…” after the cusp structural deterioration was identified in most patients necessitating reoperation. Yet, and especially because the grade of preoperative AI was not associated with the need of reoperation, it could be very interesting to build a statistical model adjusting the AA diameter not only with age, sex, and concomitant cusp repair, but also with the grade of preoperative AI. Patlolla and colleagues1Patlolla S.H. Saran N. Dearani J.A. Stulak J.M. Schaff H.V. Greanson K.L. et al.Outcomes and risk factors of late failure of valve-sparing aortic root replacement.J Thorac Cardiovasc Surg. 2022; 164: 493-501https://doi.org/10.1016/j.jtcvs.2020.09.070Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar should be congratulated for their reported results, which clearly demonstrate that a VSRR can be performed with an excellent outcome. However, we would encourage the authors to continue searching for risk factors of VSRR failures, which can help in optimizing the VSRR techniques. Outcomes and risk factors of late failure of valve-sparing aortic root replacementThe Journal of Thoracic and Cardiovascular SurgeryVol. 164Issue 2PreviewRetention of the native aortic valve when performing aortic root surgery for aneurysmal disease has become a more common priority. We reviewed our experience in valve-sparing aortic root replacement (VSARR) to evaluate the long-term outcomes and the risk factors for reoperation. Full-Text PDF Reply From Authors: Aortic annulus in valve-sparing root replacement: Size does matter!The Journal of Thoracic and Cardiovascular SurgeryVol. 165Issue 4Preview“It does not matter how slowly you go, as long as you do not stop.”—Confucius Full-Text PDF