Use of Autologous Aortic Wall for Leaflet Replacement During Aortic Valve Repair

It is now common to encounter patients who underwent complex mitral valve repair—incorporating mitral rings, leaflet patches, ultrasonic annular decalcification, and multiple sets of artificial chords—20-30 years ago with no more valve dysfunction. Such is the advantage of autologous valve repair. Instead of a “lifetime management” approach to valve disease, the goal of the valve repair surgeon is to perform a single autologous valve operation, with no further cardiac interventions required. 

The authors sought to apply Carpentier’s principle of geometric ring annuloplasty to the aortic valve and analyzed detailed CT angiograms of normal human aortic roots. From this research, geometric aortic annuloplasty rings were developed and validated for tri-leaflet and bicuspid aortic valve repair. While repair became applicable for 90 percent of pathologies, deficient leaflet tissue still posed a problem in approximately 10 percent of patients. Thus, the authors began to use patches of ascending aortic wall—which are readily available, nourished from luminal diffusion, immunologically consistent, accustomed to systemic pressure, and could be an ideal tissue to increase durable repair rates toward 100 percent.  

The authors have applied this method to more than 40 patients, including 10 with localized defects in bicuspid valves and others with ballooned or hypoplastic unicuspid valves, thin leaflets requiring cleft closure, single leaflet retraction or refractory prolapse, and three patients received complete bi-leaflet replacement in more extensively calcified bicuspid defects. The results have been excellent through two years of follow-up, with a formal outcome analysis planned in 2-3 years. Multiple case videos of aortic valve repair with this technique are shown, and general results with ring-based aortic valve repair have been positive, even in cases requiring aortic wall leaflet patches. Further follow-up and a detailed analysis of aortic wall patch patients are planned. 

To quote Carpentier, “The additional effort by the surgeon to acquire the necessary expertise for valve repair will be rewarded by the superior quality of life for the patients.” Hopefully, the long-term results experienced in mitral repair can be achieved across the full spectrum of patients with aortic valve disorders. 

References

1. Myers JL, Clark JB, James TW, Downs E, Hasan SM, Binford RS, McNeil JD, Rodriquez VM, Mascio CE, Wei LM, Badhwar V, Rankin JS. Use of aortic wall patches as leaflet replacement material during aortic valve repair. JTCVS Techniques 2023;19:30-7.
2. James TW, Mehaffey JH, Wei LM, Voeller RK, Badhwar V, Rankin JS. Repair of calcified bicuspid aortic valves using living autologous aortic wall leaflets. JTCVS Techniques, in-press.

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