1. Aortic Valve Anuluplasty System Designed by Khalil Fattouch, MD, PhD.

2. 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

3. 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

4. Tipo Ia- STJ Dilation

5. 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

6. 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

7. Aortic Anulus What is the true valve anulus ?

8. Commissures Nadir Aortic Anulus

9. Interleaflet triangles Basal circumference Sinutubular ridge commissures Functional Aortic Anulus FAA = (Anatomical anulus + STJ)

11. Ring for aortic valve repair must: 1. re-shape the functional aortic anulus 2. Stabilize the continuity between the aortic valve annulus and the STJ.

12. The second point of view Interleaflets Triangles Are essentials for normal leaflets opening and normal distribuition of stress Annulus

13. Mechanism of Opening: sequence of leaflets opening Stellate orifice Small triangle Triangle Circular orifice

14. 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”

15. 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 essential for a normal leaflets motion and stress distribuition

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

17. Our idea, to re-shape the functional aortic anulus and preserve aortic leaflets motion Re-shape the STJ Re-shape the anatomical anulus

18. From inside LV outflow tract From outside the aorta

19. a b Suture Technique Leave free the interleaflets triangles

21. 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.

22. The D shape of the annulus avoid blood turbolence under the aortic valve Flexible zone Free from suture

23. Suture Technique

24. Objective  Re-shape and Stabilize the functional aortic annulus  Undersize the anatomical aortic annulus from inside of LV 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 ……