Mastering aortic valve repair: A standardized step-by-step teaching approach of remodeling root replacement with external ring annuloplasty.

Abstract

By developing a reproducible step-by-step approach to aortic valve (AV) repair, we aim to increase the global rate of successful AV repair. Although valve-sparing root replacement is a Class I recommendation with level B evidence for root aneurysm, regardless of the degree of aortic regurgitation, its utilization remains limited. This study evaluated the feasibility, reproducibility, and effectiveness of a standardized AV repair performed by a fellow versus an expert. In this 10-year prospective cohort study (2013-2023), 653 patients were enrolled. The primary outcome was a composite of mortality, AV reintervention, reintervention for bleeding, reclamping for aortic regurgitation (>1), and clamp time. Data were collected from Epicard and the Heart Valve Society Aortic Valve database. Among 653 patients (mean age, 49 ± 15 years; 85% men), 457 underwent standardized AV repair by the expert surgeon (Expert group) and 196 by a fellow under the expert's supervision (Fellow group). The primary outcome showed no significant difference between the 2 groups (hazard ratio, 1.58; 95% CI, 0.96-2.6; P = .07). At 5 years, freedom from AV-related reintervention was 97.0% in the Expert group and 99.50% in the Fellow group (P = .08). Rates of in-hospital mortality, overall mortality, bleeding, thromboembolic events, pacemaker implantation, myocardial infarction, and atrial fibrillation were similar between groups. A standardized step-by-step teaching of AV repair with external aortic annuloplasty is a reproducible, effective, feasible, and safe technique for fellows learning it under the supervision of an expert. Promoting this method may broaden its adoption and increase the global rate of AV repair.