Aortic valve repair using geometric ring annuloplasty in pediatric and congenital heart disease patients.

Aortic valve repair using geometric ring annuloplasty in pediatric and congenital heart disease patients.

Lancaster TS, Romano JC, Si MS, Ohye RG. J Thorac Cardiovasc Surg. 2023 Aug;166(2):294-303. doi: 10.1016/j.jtcvs.2022.10.017. Epub 2022 Oct 19.PMID: 36404145

Take Home Points:

  • Newly developed subannular ring (HAART ring) provided an excellent mid-term outcome.
  • The placement of the ring does not need extensive dissection of the aortic root, hence suitable for patients who previously had Ross or other type of aortic surgery.
Dr. Yasuhiro Kotani

Commentary from Dr. Yasuhiro Kotani (Okayama, Japan), chief section editor of Congenital Heart Surgery Journal Watch: 


This is a retrospective study from 2 institutions in the U.S., looking at all pediatric and adult congenital patients who underwent aortic valve repair with placement of a geometric annuloplasty ring. The study period was from July 2018 to April 2022 and included 36 patients. The median age was 17.4 years (range, 8-30 years) and 21 patients were younger than age 18 years. The most common primary diagnoses were neoaortic valve insufficiency or neoaortic root dilation, and congenital aortic stenosis with bicuspid or functionally unicuspid aortic valve. Of the 34 patients with procedural success, 31 (91%) had use of additional valve repair techniques and 26 (76%) had an additional concomitant procedure performed. Operative mortality was 0% (0/33), and major complication rate was 6% (2/33). The median follow-up time was 1.9 years (maximum, 3.8 years). The mean grade of aortic insufficiency was significantly reduced after repair, with no change in mean gradients. Freedom from reoperation over the follow-up period was 97% (33/34), and freedom from >3+ recurrent aortic insufficiency was 94% (32/34). A geometric annuloplasty ring can be used to help achieve consistently successful aortic valve repair with excellent perioperative and follow-up outcomes, even in pediatric and complex congenital heart disease patients.


This is a retrospective study for aortic valve repair with placement of a geometric annuloplasty ring done at Michigan. They used newly developed annuloplasty ring, named Hemispherical Aortic Annuloplasty Reconstructive Technology (HAART) ring. The ring sizes available are from 19 to 25mm. The ring is placed in subannular position. There are 2 types, tricuspid and bicuspid. Implantation technique is not complicated. After measurement of the size, the ring is implanted with the sutures which first involves placement of Cabrol-type horizontal mattress sutures at each commissure to secure the commissural posts of the ring, and then 1 to 4 looping sutures placed along the length of each sinus aspect of the ring. The leaflet coaptation is then assessed and plication may be necessary for the prolapsed leaflet due to the downsizing of the annulus (80% of population in this study). Advantages of this technique are as follows. First, it is less invasive. External annuloplasty needs an extensive dissection of the aortic root, even in the situation of reoperation which pose a risk of coronary injury and bleeding. Second, the technique is reproducible. After placement of the ring, the plication may be needed but this is relatively simple technique compared to complex leaflet plasty. Finally, this study showed no heart block after this procedure and no circumferential sutures may be the reason. The initial results are promising but need more long-term follow-up.