Thus, titanium was chosen for ring fabrication, and computerized milling techniques were developed to machine the three-dimensional coordinates of the device. The rings were covered with a thin layer of Dacron to promote endothelialization, and efforts were made to maintain a low profile (Fig. 7). Base ellipticality of the ring was rounded to a 2:3 minor-major diameter ratio (0.66), and the three posts were positioned equidistant on the base circumference. The post for the L/N coronary commissure was placed at the posterior base minor diameter, which positioned the R leaflet anteriorly. All three posts flared outward by 10 degrees, and post height was taken as the radius of a circle with equivalent circumference (ie, post height = base circumference/2π), as previously shown.29 Ring size was designated as the diameter of a circle with equivalent circumference to the elliptical rings, and sizes 19, 21, 23, and 25 mm were fabricated.
With the development of high-resolution CTA and with detailed mathematical modeling, the seemingly complex anatomy of the aortic valve and root simplified greatly.26 The normal aortic valve base was quite elliptical, as elliptical as the annulus of the mitral valve. Both the commissural posts and leaflets exhibited high degrees of symmetry on the elliptical circumference, varying by less than 2% to 3% from 33.3% symmetry. Simply observing commissural chord lengths of an elliptical structure might leave the contrary impression, and pathological enlargement of the sinuses and the annulus also might appear asymmetrical. However, it seems clear that the normal human aortic valve is characterized by an anatomic geometry that is highly reproducible and symmetrical. The commissural posts flared outward by 5 to 10 degrees, and post height was one radius of a circle with equivalent circumference.30 A three-dimensional titanium ring was developed on the basis of this geometry, and the ring has functioned successfully both in animals and in patients undergoing aortic valve repair.32–34 The low-profile nature of the ring allows it to be sutured into the dilated annulus and positioned beneath (and out of contact with) the leaflets.35 A sizing strategy based on leaflet size32 allows the pathological annulus to be reduced to a size appropriate for the leaflets while restoring normal elliptical coaptation geometry. The valve restoration provided by this device may allow further standardization of aortic valve repair and potentially more stable long-term results.
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This study by Dr. Crooke and his colleagues used computed tomographic angiography images and detailed mathematical modeling to define the complex anatomy of the aortic valve and root. They found that the normal aortic valve base was elliptical and that commissural posts and leaflets exhibited high degrees of symmetry. A three-dimensional titanium ring for aortic valve repair was developed using this geometry. This has been successfully implanted in animals and humans. This ring may add a new and important tool to our armamentarium to facilitate aortic valve repair techniques with the goal of allowing surgeons to repair the aortic valve with the same ease and reproducibility as is currently obtained with mitral valve repair.