Hybrid internal annuloplasty: ‘Ring and Belt on the outside’

Dear Editor,

There is an ongoing debate on the aortic annuloplasty and internal or external stabilization while repairing bicuspid aortic valve. Recently, Girdauskas et al. [1] from Augsburg published in EJCTS online an interesting practical approach to counteract complications they encountered during implantation of internal annuloplasty ring. The proposed modification is an externalization of sutures looping around the device. During 2-year time frame, there were 19 patients having implanted internal annuloplasty, while out of those, 13 patients underwent modified implantations. During follow-up, no complications in the form of heart block, perforation of perimembranous septum or leaflet tear were reported in the modified technique group, reaching statistical significance when compared to previous technique. This approach has been inspired and assimilated from multimedial tutorial describing similar method published in MMCTS by my group in 2023 [2]. The procedure was a simultaneous internal and external annuloplasty combining unique benefits of both techniques, calling this ‘Hybrid Annuloplasty’. Certainly, it seems to be a very appealing concept to external annuloplasty and reimplantation advocates, while maintaining unique internal ring features like dynamic VAJ remodelling and annular sizing based on leaflet dimensions [3]. Among benefits of externalization, there are direct ones like less material inside and as a result, lower risk for endocarditis, less distortion of the annulus, additional external strengthening and stabilization to the fibrous portion of the annulus mimicking so called ‘belt on the outside’. Apart from that, there are technical advantages due to elimination of risk of suture injury to the leaflets risk. It also helps to avoid the conduction system injury by better identification of perimembranous septum.

From mechanistic point of view, this approach may improve leaflet mobility by preserving height of fused commissura. Last but not the least, sinus can be replaced by suturing directly to annular tissue without interference from pledgets, endorsing separate sinus replacement as opposed to the total root replacement approach, as shown in the illustrative video as well as discussed frequently [1, 4, 5].

Girdauskas et al. has to be congratulated for the immediate technical modification as a response to complications during ring implantations. It still remains to be determined what the greatest potential benefit of secondary external stabilization is. I believe that significant strain due to large discrepancy between annuloplasty and annulus diameter, as well as facilitating aortic root sinuses replacement, may become quickly recognized indications.

Conflict of interest: Marek J. Jasinski is associated with Medtronic and Corcym as a proctor.

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