Aortic Valve Repair

Heart valves undergo approximately 100,000 cycles daily, culminating in around 3 billion cycles over a 75-year life span, facing numerous stresses. Traditionally, the aortic valve was viewed as a "static" structure with the primary role of ensuring unidirectional blood flow from the left ventricle (LV) and assisting coronary perfusion. However, recent insights have transformed this view, recognizing the aortic valve as a functionally intricate regulatory system essential for the heart's optimal mechanobiological coupling (see Image. The Aortic Valve).

The aortic valve is a complex regulatory system crucial for the heart's optimal function, and it comprises several components, including the annulus, cusps, sinuses of Valsalva, and the sinotubular junction (STJ). These components form a biomechanical unit that efficiently manages the forces exerted during the cardiac cycle. The crown-shaped geometry of the semilunar valves enhances their efficiency and responsiveness during the cardiac cycle, allowing them to effectively manage the varying forces exerted upon them (see Video. Aortic Valve Movement). Aortic valve pathologies can severely affect the body due to perfusion deficits. Aortic valve insufficiency is primarily caused due to the underlying shear forces that lead to stretching, dilation, and valve rupture. Moreover, conditions of the aortic root, including coarctation, dissection, and aneurysm, can exacerbate aortic valve pathology by increasing the shear force of blood at the aortic valve, disrupting the laminar flow.

Managing aortic valve pathologies often involves either repair or replacement. Aortic valve repair is a surgical procedure designed to preserve the native valve and restore its function in patients with aortic valve insufficiency or disease. Aortic valve replacement with a biological or prosthetic valve has long been the cornerstone of treatment for these conditions. However, there is ongoing debate regarding the relative merits of aortic valve repair versus replacement in specific patient subsets. While aortic valve repair may offer advantages in certain scenarios, its efficacy and suitability must be carefully weighed against the established benefits of valve replacement (see Image. Recommendations for Aortic Valve Replacement).

Over the last decade, aortic valve repair and preservation have gained significant importance in treating aortic root disease, both with and without insufficiencies. These procedures have been successfully performed worldwide, although they account for less than 2% of all valve procedures due to the high level of expertise required. The low prevalence of aortic valve repair compared to mitral valve repair is partly because calcific aortic stenosis is the most common valvular pathology, making aortic valve replacement a more frequent intervention.

Aortic valve replacement, while seemingly simpler than repair, carries long-term complications such as structural deterioration, restenosis, infection, and bleeding due to the need for anticoagulation. These complications have led to a growing interest in aortic valve preservation procedures, which maintain the normal anatomy and physiology of the aortic valve functional unit and potentially avoid the complications associated with replacement. Consequently, aortic valve preservation is becoming a reasonable alternative to replacement, aiming to prevent long-term issues and improve patient outcomes.