Aortic Valve Anuluplasty System

Designed by Khalil Fattouch, MD, PhD.

Aortic valve What we learn from the mitral valve?

Surgeons are not concerned about the valve, but with the

Aortic Functional Unit

Aortic anulus Cusps Valsalva sinus Commissures Sinotubular Junction Ascending aorta

Relationship between severals Aortic Root Components are important for normal valve function

AA > STJ (10-15%)

Coaptation high = 0.5-0.8 cm

High of opened leaflet = 70% of sinus

Tipo Ia- STJ Dilation

Functional Classification of AR

Tipo I:Normal leaflet motion

Tipo II:Excessive leaflets motion

Tipo III:Restrictive leaflets motion

• Ia – STJ dilation• Ib – dilation of valsalva sinuses• Ic – FAA dilation• Id – Perforation

• Prolapse• Dissection

• Calcification• Cusp fusion

Lesson from mitral valve repair

Anuluplasty is a fundamental step in mitral valve repair:

re-shape the anulus stabilize the repair improve long term results

Aortic AnulusWhat is the true valve anulus ?

Commissures

Nadir

Aortic Anulus

Interleaflet triangles

Basal circumference

Sinutubular ridge

commissures

Functional Aortic Anulus

FAA = (Anatomical anulus + STJ)

Ring for aortic valve repairmust:

1. re-shape the functional aortic anulus

2. Stabilize the continuity between the aortic valve annulus and the STJ.

The second point of viewInterleaflets Triangles

Are essentials for normal leaflets opening and normal distribuition of stress

Annulus

Mechanism of Opening:sequence of leaflets opening

Stellate orifice

Small triangle

Triangle

Circular orifice

From stellate orifice to small triangle

Increase in ventricular pressure through the interleaflet triangle causes an increase of diameter at the commissures (STJ) before the valve opens

Answer to the first paradox: “the valve opens before the presence of forward flow”

The second objective?

The ring for aortic valve repair must,

Leave the commissures and the interleaflets triangle free to move

during the cardiac cicle, that is essentialfor a normal leaflets motion and stress

distribuition

Today, what we do in aortic valve repair?Subcommissures plasty

Our idea, to re-shape the functional aortic anulus and preserve aortic leaflets motion

Re-shape the STJ

Re-shape the anatomical anulus

From inside LV outflow tract

From outside the aorta

a

b

Suture TechniqueLeave free the interleaflets triangles

Re-shape the sinotubular junction

Applied outside to the aorta at the level of the STJ and sutured to the aorta with the same suture line when we close the aortotomy using 4-0 prolene.

The 3 crown were sutured at the level of commissures and fixed to the internal ring using the same ticron U-stitch used previously.

The D shape of the annulus avoid blood turbolence under the aortic valve

Flexible zoneFree from suture

Suture Technique

Objective Re-shape and Stabilize the functional aortic annulus

Undersize the anatomical aortic annulus from inside ofLV outflow tract (improve leaflets coaptation).

Leave the interleaflets triangles and commissures free to move that is mandatory for a normal leaflets stress distribuition and motion (opening).

An external application of a ring may lead to cusps prolapse.

Thank for ……