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Ann Thorac Surg 2007;84:1006
© 2007 The Society of Thoracic Surgeons

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New Technology

Invited commentary

Department of Cardiothoracic Surgery, Stanford University Medical Center, Falk Cardiovascular Research Center, 300 Pasteur Dr, Stanford, CA 94305-5247

(Email: jfann{at}stanford.edu).

To evaluate aortic insufficiency in the setting of aortic root dilation, Gogbashian and colleagues [1] at the Brigham and Women’s Hospital have developed an elegant animal model; in so doing they propose an innovative and intuitive method to address the problem of aortic insufficiency. The adjustable aortic ring permits a calibrated adjustment based on pressure, flow, and echocardiographic feedback. Precise adjustment is mandatory because over-adjustment or under-adjustment would lead to failure of such an approach. Implied in this study is the potential to use this model to study chronic aortic insufficiency and aortic root dilation, with the caveat that a reoperation may be difficult due to scarification.

Although the results in this study are compelling, the question is whether the patch aortoplasty model is representative of clinical aortic insufficiency, and importantly, whether this model is appropriate to evaluate an adjustable annular ring. Because the aortic annulus is divided between the right and noncoronary cusps followed by root enlargement with a patch, the resultant aortic insufficiency is eccentric. Thus this model does not reproduce annular dilation with central regurgitation as is often clinically appreciated. One can also conjecture that using an adjustable ring in this acute model would permit the preferential re-establishment of annular continuity at the point of division, and hence resolution of aortic insufficiency because the region of patch aortoplasty may be easier to reduce. Ironically, in the chronic setting, it may be that the adjustable ring may work less well in the presence of an eccentric jet than in cases of central aortic regurgitation.

The adjustable ring may be placed without cardiopulmonary bypass, and the authors indicate that the target patients are those with significant comorbidities for whom cardiopulmonary bypass is of high risk. Recognizing that the aortic root dilation is not surgically addressed, they propose the external adjustable aortic ring to be used as an adjunct to reduce aortic insufficiency. This approach on first pass is analogous to mitral annuloplasty for mitral regurgitation. However, just as annuloplasty alone does not serve all patients with mitral regurgitation, cinching the aortic annulus may not be efficacious for all patients with aortic root dilation and aortic insufficiency. Clinically, aortic insufficiency may be considered a three-dimensional problem with annular distortion and leaflet prolapse in some cases. A two-dimensional approach (such as with the adjustable ring) may not result in adequate leaflet coaptation and resolution of aortic insufficiency. Understanding the patho-anatomy of aortic insufficiency in the setting of aortic root dilation or aneurysm is of critical importance in designing a surgical treatment as emphasized by a number of investigators [2–4].

Nonetheless, Gogbashian and colleagues [1] are to be commended for developing a model of aortic insufficiency and aortic root dilation. Furthermore, their proposal for a potentially less invasive intervention to aortic insufficiency warrants further investigation based on the findings of their comprehensive evaluation.

	References

Top References

 

1. Gogbashian A, Ghanta RK, Umakanthan R, et al. Correction of aortic insufficiency with an external adjustable prosthetic aortic ring Ann Thorac Surg 2007;84:1001-1006.[Abstract/Free Full Text]
2. Yacoub MH, Gehle P, Chandrasekaran V, Birks FJ, Child A, Radley-Smith R. Late results of a valve-preserving operation in patients with aneurysms of the ascending aorta and root J Thorac Cardiovasc Surg 1998;115:1080-1090.[Abstract/Free Full Text]
3. David TE, Feindel CM, Bebb GD, Colman JM, Armstrong S, Maganti M. Aortic valve preservation in patients with aortic root aneurysm: results of the reimplantation technique Ann Thorac Surg 2007;83:S732-S735.[Abstract/Free Full Text]
4. Miller DC. Valve-sparing aortic root replacement: current state of the art and where are we headed? Ann Thorac Surg 2007;83:S736-S739.[Free Full Text]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): James I. Fann Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Fann, J. I. Search for Related Content PubMed PubMed Citation Articles by Fann, J. I. Related Collections Valve disease Related Article