Aortic valve repair for dystrophic ascending aorta with bicuspid or tricuspid valves

Aortic valve repair is indicated for patients a dystrophic ascending aorta and bicuspid or tricuspid valves. Although these lesions are amenable to valve repair, they are mainly treated with mechanical valve replacement whether isolated or combined with ascending aorta replacement (Bentall procedure). The superiority of mitral valve repair over replacement and a better understanding of ascending aorta dynamics has renewed interest for aortic valve repair. Three phenotypes of dystrophic ascending aorta can be identified depending on the diameter of the sinuses of Valsalva: aortic root aneurysms (empty set >= 45 mm), supracoronary aneurysms and isolated aortic insufficiencies (empty set < 40 mm). Echographic analysis of lesional mechanisms distinguishes central aortic insufficiencies (type I) due to isolated dilation of root diameters from eccentric aortic insufficiencies (type II) where dilation of diameters is associated with a valvular lesion. Each type of aortic insufficiency corresponds to a standardized and physiological approach adapted to each phenotype. This approach is based on the use of an expandible aortic ring. Intraoperative TEE evaluation is indispensable to obtain a durable repair. The multicentric CAVIAAR trial (conservative aortic valve surgery for aortic insufficiency and aneurysms of the aortic root) compares this standardized approach of aortic valve repair with mechanical replacement.