New horizons in aortic valve repair

Y. Joseph Woo, MD

Within this issue of JTCVS Techniques is a special series of original articles focusing on aortic valve repair. More than 20 years ago, Toby Cosgrove of the Cleveland Clinic came to the University of Pennsylvania as a visiting professor, and I had the privilege of operating with him as he performed a bicuspid aortic valve repair via resection and reapproximation of the prolapsed fused left–right cusp margin and right-non and left-non commissuroplasties. I vividly recall this operation, drawing parallels to an inverted mitral valve repair. Similarities and differences abound. Fundamentally, we seek to avoid unnecessary valve replacement. Just as mitral valve repair techniques and outcomes have advanced with knowledge and with time, so have aortic valve repair techniques, albeit perhaps several years if not decades behind—but accelerating. With a deeper understanding of functional anatomy, pathophysiology, and spatial geometric relationships, enhanced imaging, broader diversity of cusp and commissural repair and repositioning techniques, and recognition of the importance of annular and sinotubular junctional support, aortic valve repair has evolved into a safe, effective, reproducible, durable operation. Aortic valve repair continues to gain acceptance and hopefully, one day, will achieve widespread adoption and application, a goal that this JTCVS Techniques series aims to further.

Yuanjia Zhu here at Stanford begins with a detailing of our cusp repair techniques for bicuspid and tricuspid aortic valves. She also briefly references engineering research into the underlying biomechanics of aortic regurgitation and the repair operations. Lars Svensson at the Cleveland Clinic shares their center's vast experience with aortic valve repair and describes the clever elevating commisuroplasty, or Svensson stitch. Laurent de Kerchove, Gebrine el Khoury, and Jama Jahanyar from Cliniques Universitaires Saint-Luc in Brussels then delineate their approach to repairing the bicuspid valve with a focus on analyzing the extent of asymmetry and commissural geometry and realigning to a 180°/180° symmetric configuration whenever possible. Jochen Schaefers and his group at Saarland University in Homburg then describe the critical role of annular support and reduction and their vast experience with suture and ring annuloplasty techniques. The series concludes with Tirone David at Toronto General Hospital describing his eponymous operation and its utility in effecting aortic valve repair with simultaneous annular and sinotubular junctional support as well. This collection of 5 articles provides an anatomic and technical tour through the innovative contemporary operative repair the aortic valve.