Early Failures Following Aortic Valve Repair Using an Internal Ring Annuloplasty: A Word of Caution

P0117 

Case Video Submission 

Elbert Williams (1), Busra Cangut (1), Charles Laurin (1), Lilyanne Chen (1), Ismail El-Hamamsy (1)

(1) Mount Sinai Hospital, New York, NY

Elbert Williams    -  Contact Me
Mount Sinai Hospital

Busra Cangut    -  Contact Me
Mount Sinai Hospital

Charles Laurin    -  Contact Me
Mount Sinai Hospital

Lilyanne Chen    -  Contact Me
Mount Sinai Hospital

*Ismail El-Hamamsy    -  Contact Me
Mount Sinai Hospital

Elbert Williams    -  Contact Me
N/A

Objective
In young patients with severe aortic valve regurgitation (AR), Aortic valve repair (AVr) is the ideal surgical option. Different techniques for AVr have evolved to address both cusp pathology and annular dilatation. To address the aortic annulus, different annuloplasty devices and techniques have been developed, including an internal ring. With the internal ring, concerns have been raised about the safety and efficacy. Here, we present two cases illustrative of early failure after internal ring placement.

Case Summary
Case 1: A 25-year-old patient with severe symptomatic bicuspid AR underwent AVr consisting of cusp plication, implantation of the HAART internal ring, and hemi-Yacoub root replacement at another institution. The patient now presented with severe recurrent AR requiring reintervention secondary to severe symptoms as well as a severely dilated left ventricle (indexed left ventricular end-diastolic volume of 177 mL/m2. On direct inspection in the operating room, there was a large perforation in the body of the aortic valve secondary to a ring suture as well as a dehiscence of the HAART ring along half the basal ring circumference. The patient underwent a successful prosthetic aortic valve replacement.
Case 2: A 55-year-old male with a history of bicuspid aortic valve who underwent AVr with an internal ring 1 year prior presented to our institution with severe recurrent AR. Workup revealed not only severe AR with a dilated left ventricle (indexed left ventricular end-systolic volume of 57 ml/m2) but also with moderate aortic stenosis. On inspection, there was a large hole at the base of the fused cusp, which was likely a result of the ring damaging the valve once dehisced. Additionally, the internal ring was partially dehisced from the left ventricular outflow tract. The patient then underwent a successful Ross procedure to correct their aortic valve disease.

Conclusions
The internal annuloplasty ring is quite appealing as it allows for basal ring stabilization without the need for deep external aortic root dissection. The device downsizes the annulus by pulling it inwards toward the ring. By the nature of this mechanism of action, it creates an inherent risk of dehiscence due to the large amount of stress on each suture that pulls the basal ring inwards. This effect is intensified in larger annuli. These cases are both illustrative of this mechanism of failure and raises questions of safety in the wide application of this device before longer follow-up is reported.

Other - Aortic Valve Repair