Reply from authors: Leave well enough alone

As inventor of the Valsalva, Prof De Paulis has received in the past royalties from Terumo Aortic. All other authors reported no conflicts of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. As inventor of the Valsalva, Prof De Paulis has received in the past royalties from Terumo Aortic. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. We thank Jasinski and colleagues1Jasinski M. Kosiorowska K. Manalo J. Berezowski M. Annuloplasty during aortic valve-sparing: “two heads (rings) are better than one.”.J Thorac Cardiovasc Surg. 2023; 166: e390-e391Google Scholar for their recent letter, which addressed the hot topic of optimal aortic annuloplasty. The authors suggest the introduction of a double aortic annuloplasty combining an external ring/suture with the internal HAART system (CORCYM, Inc). We are aware of the extensive experience of the Wroclaw group in aortic valve repair surgery and are certainly intrigued by their insights. The authors basically claim that, in specific cases, a simple aortic annuloplasty may not be sufficient to preserve the annulus from further enlargement, jeopardizing the durability of the valve repair. In our recent work,2Irace F.G. Chirichilli I. Salica A. D'Aleo S. Guerrieri Wolf L. Garufi L. et al.Aortic root anatomy after aortic valve reimplantation.J Thorac Cardiovasc Surg. 2023; 165: 1335-1342.e2Google Scholar we showed how in reimplantation procedures, the advocated asymmetry of the neoannulus, de facto, replicates the natural configuration of the aortic root. Indeed, in normal anatomy the ventricular-arterial junction is not perfectly co-planar with the virtual basal ring, and it is also well known that the sinotubular junction plane is slightly tilted in respect to the virtual basal ring plane.3de Kerchove L. Jashari R. Boodhwani M. Duy K.T. Lengelé B. Gianello P. et al.Surgical anatomy of the aortic root: implication for valve-sparing reimplantation and aortic valve annuloplasty.J Thorac Cardiovasc Surg. 2015; 149: 425-433Google Scholar A further finding, based on another study from our group, has clearly showed how the annular shape, which is naturally slightly elliptical in normal tricuspid aortic valves, is forced into a circular morphology with reimplantation.4Chirichilli I. Irace F. Weltert L. Tsuda K. Scaffa R. Salica A. et al.Morphological modification of the aortic annulus in tricuspid and bicuspid valves after aortic valve reimplantation: an electrocardiography-gated computed tomography study.Eur J Cardio Thorac Surg. 2019; 56: 778-784Google Scholar All these features are purely anatomical, and no implication was found with the valve function or with the patients’ prognosis in terms of recurrent aortic regurgitation (AR).5Chirichilli I. Scaffa R. Irace F.G. Salica A. Weltert L.P. D'Aleo S. et al.Twenty-year experience of aortic valve reimplantation using the Valsalva graft.Eur J Cardio Thorac Surg. 2023; 63ezac591Google Scholar We know from extensive data present in the literature6Schäfers H.J. Raddatz A. Schmied W. Takahashi H. Miura Y. Kunihara T. et al.Reexamining remodeling.J Thorac Cardiovasc Surg. 2015; 149: S30-S36Google Scholar that a recurrence of AR is demonstrated in remodeling procedures lacking annular stabilization, but there are no data to extend this concept to reimplantation or external ring annuloplasty. In this regard, we want to underline that the cited cardiac magnetic resonance functional study7Jasinski M.J. Miszalski-Jamka K. Kosiorowska K. Gocol R. Wenzel-Jasinska I. Bielicki G. et al.The evaluation of annuloplasty in bicuspid aortic valve repair using cardiac magnetic resonance.BMC Cardiovasc Disord. 2021; 21: 13Google Scholar showed a correlation between recurrent AR and aortic orifice area, not aortic annulus area. In conclusion, although we praise novel and courageous efforts to ameliorate long-term stability of aortic valve repair, we also recommend prudence in surgical overdoing, especially if it involves the use of an intravascular prosthetic material, with its related risk of valve damage, infections, or flow alteration, when the current evidence does not support a clear advantage. Annuloplasty during aortic valve sparing: “Two heads (rings) are better than one”The Journal of Thoracic and Cardiovascular SurgeryVol. 166Issue 5PreviewThe observed benefit of reimplantation is evidently related to the well-documented advantage of complete, circumferential annuloplasty, effectively avoiding further dilatation. However, more detailed insight, including enhanced imaging techniques, might be required to assess annuloplasty efficacy comprehensively. Full-Text PDF