Congenital bicuspid aortic valve and an aneurysm of the ascending aorta

BACKGROUND: A congenital bicuspid aortic valve (BAV) in adults is known to be associated with aortopathy, specifically with aneurysms of the ascending aorta (AA). MATERIALS AND METHODS: Ten (16.7%) patients with congenital BAV had an aneurysm of the AA. Aortic valve replacement was performed in 58 patients, repair in two. Aneurysms were repaired by a vertical reduction (tailoring) aortoplasty (VRA) with or without external synthetic grafting (wrapping, wrap) in nine patients, replaced in one. RESULTS: There were no operative deaths. One patient died 87 months after the operation due to a noncardiac cause. Fifty-four patients are alive and well, without the evidence of recurrence of an aneurysm. CONCLUSIONS: A VRA with or without external synthetic wrapping appears to be a satisfactory alternative to replacement procedures for the AA aneurysm in older patients with BAV, and those with comorbid conditions.     

Management of the valve and ascending aorta in adults with bicuspid aortic valve disease

Bicuspid aortic valve (BAV) disease is the most common congenital cardiac malformation, being present in 1% to 2% of the population. It is heritable and is three to four times more likely to occur in men. The pathogenesis of BAV disease is unknown. Bicuspid valves progress to aortic stenosis or insufficiency in the majority of patients. BAV disease is associated with several anomalies of the aorta including coarctation, aneurysm formation, and dissection. Several lines of evidence suggest that aortic complications are caused by the same underlying factor that causes BAV disease, rather than being a consequence of turbulent blood flow through a stenotic valve. Several different surgical options exist for patients with BAV disease depending on the age of presentation and the size and appearance of the aorta. We herein describe our surgical management of the aortic valve and ascending aorta in patients with BAV disease.     

Reduction aortoplasty for dilatation of the ascending aorta in patients with bicuspid aortic valve

BACKGROUND: Individuals with bicuspid aortic valve tend to develop a dilatation of the ascending aorta. It is controversial whether the dilated ascending aorta should be replaced with a tube graft or whether the diameter of the aorta should be reduced by reduction aortoplasty. Furthermore, it is unclear whether an external prosthetic support of the reduction aortoplasty is necessary. The aim of this study is to analyze the results of reduction aortoplasty with and without external prosthetic support. METHODS: Between 1985 and 1999, a total of 115 patients with bicuspid aortic valve and dilatation of the ascending aorta underwent reduction aortoplasty in combination with other types of open-heart procedure at our institution. The diameter of the ascending aorta was measured before and early after surgery and then later between 12 and 144 months (mean 40 months) postoperatively using echocardiography and computed tomography. RESULTS: The reduction aortoplasty decreased the internal diameter of the aorta from 48.7+/-5.1 mm preoperatively to 36.9+/-3.6 mm early after surgery (p = 0.0001). During follow-up, there was no increase of the aortic diameter either in patients with external prosthetic support or in 97 of 106 patients without external prosthetic support. The diameter increased only in 9 (8.5%) of 106 patients without external aortic support by 4 to 8 mm. In patients with postoperative diameter increase, the aortic diameter after operation had been higher than in patients without a postoperative increase of the aortic diameter (41.4+/-3.1 mm vs 36.6+/-3.4 mm; p < 0.0001). CONCLUSIONS: Reduction aortoplasty showed good long-term results in patients with bicuspid aortic valve and dilatation of the ascending aorta. Redilation of the aorta occurred only in patients with a suboptimal diameter reduction.     

Reduction aortoplasty and external wrapping for moderately sized tubular ascending aortic aneurysm with concomitant operations

Background

Replacement of the ascending aorta with a prosthetic graft is the preferred surgical procedure for an ascending aortic aneurysm. The choice of external wrapping of the aorta is a simple, fast, and effective method for moderately sized ascending aortic aneurysms with concomitant operations. In this study, we present the midterm results of 62 patients undergoing reduction aortoplasty with external wrapping and different cardiac procedures.

Methods

The study group consisted of 48 male and 14 female patients with a mean age of 59.3 ± 6.0 years. Measurement of the ascending aorta diameters was obtained at three points: before surgery, during the early postoperative period, and during the follow-up. The mean preoperative aortic diameter was 52.7 ± 0.5 mm. In all patients, the ascending aortic aneurysm was repaired by reduction aortoplasty with external wrapping.

Results

Mean follow-up time was 39.6 ± 18.0 months. There was only one mortality (1.6%) as a result of septic multiple-organ failure and no major surgical complications in the 30-day postoperative period. Reduction aortoplasty of the ascending aorta with external wrapping resulted in a significant reduction of the ascending aorta in all patients (p = 0.000). There was an increase in the mean aortic diameter during the follow-up period (p = 0.000). Although this increase was statistically significant, all measurements of the follow-up period were still within normal range.

Conclusions

External wrapping of the aorta offers excellent results with very low mortality and morbidity, and it can be regarded as a safe and effective method for the treatment of ascending aortic aneurysm in selected patients. However, the patients should be carefully monitored for redilatation after the procedure.     

主动脉成形术治疗主动脉瓣病变伴升主动脉扩张的疗效分析

目的总结主动脉成形术治疗主动脉瓣病变伴升主动脉扩张患者的临床经验及疗效。方法1998年2月至2004年5月共对23例主动脉瓣病变伴升主动脉扩张的患者行主动脉瓣膜置换和纵行切除部分升主动脉壁的主动脉成形术,术后随访4～78个月,平均(36±25)个月,分别于术前、术后出院前及术后随访中,通过心脏超声检查测量主动脉直径。结果主动脉直径术前为(4.8±0.5)cm,术后出院前为(3.6±0.4)cm,两者比较差异有统计学意义(P<0.01)。术后随访中,主动脉直径为(3.7±0.4)cm,与术前比较差异有统计学意义(P<0.01),与术后出院前比较差异无统计学意义(P>0.05)。结论应用切除部分升主动脉壁的主动脉成形术治疗主动脉瓣病变伴升主动脉扩张或升主动脉瘤,中期疗效良好。     

Surgical approach to ascending aorta in bicuspid aortic valve

OBJECTIVE: Former studies have pointed out that hemodynamic stress imposed by associated valvular disease is the primary factor in the development of ascending aorta dilatation. At present, intrinsic wall pathology is blamed for dilatation and aneurysm formation in bicuspid aortic valve (BAV). MATERIALS AND METHODS: Aortic valve replacement (AVR) was performed on 78 adult patients with BAV. Patients were divided into two groups. Group I (n = 27) underwent only AVR. Group II (n = 51) underwent AVR and additional ascending aorta procedures such as Shawl-Lapel aortoplasty (n = 12) and tailoring aortoplasty (n = 9). Dacron wrapping was performed after both techniques were done. Ascending aorta replacement was done on 11 patients by using composite graft. Supracoronary graft replacement was performed in 3 patients after AVR. RESULTS: Ascending aorta diameter increment was 1.25 mm/year in normotensive and 2.80 mm/ year in hypertensive patients. Ascending aorta aneurysm (diameter > 55 mm) developed in eight patients in the postoperative period in group I. Ascending aorta dilatation did not develop in group II patients. Mean survival time +/- standard error (SE) was 128 +/- 11 and 99 +/- 4 months and survival possibility was 77.78% and 92.16%. Freedom from reoperation was 65.4% and 95.9% in 8 years in group I and group II, respectively. CONCLUSION: Aortic wrapping with or without aortoplasty has a beneficial effect not only in dilated ascending aorta but also in all nondilated BAV patients with normal-sized aortic diameter. Ascending aorta wrapping in BAV patients preserves the endothelial lining and prevents further dilatation, aneurysm formation, and dissection.     

Mid-term results of aortoplasty for dilated ascending aorta associated with aortic valve disease.

BACKGROUNDS: Dilatation of the ascending aorta concomitant with aortic valve disease is occasionally associated with progressive enlargement of the ascending aorta or acute aortic dissection (AAD). However, surgical procedure of choice for the aorta and its indication are controversial. PATIENTS AND METHODS: From July 1995 to August 2001, 10 patients with a moderately dilated ascending aorta (mean diameter, 52+/-4.8 mm) underwent concurrent aortic valve replacement (AVR) and aortoplasty. The aortic valve was bicuspid in eight patients. To tailor the ascending aorta 30-35 mm in diameter, the aortic wall was partially resected along the aortotomy, and the aorta was directly closed. RESULTS: Operation time and most of other perioperative variables were comparable to those of patients who underwent isolated AVR. The aortic diameter was reduced to 36.1+/-4.1 mm. Nine patients survived to hospital discharge uneventfully, but one patient developed disruption of the suture line in the aorta and died. During follow-up, no patient suffered AAD but redilatation was observed in one patient. In the two problematic patients, the ascending aorta was larger than 55 mm, and its media was histologically abnormal. CONCLUSION: In patients with dilated ascending aorta less than 55 mm in diameter, aortoplasty can be a procedure of choice. However, a prosthetic graft replacement is recommended when the diameter of the ascending aorta is larger than 55 mm.     

Repair of an ascending aortic aneurysm using reduction aortoplasty in a Jehovah's Witness

Reduction ascending aortoplasty has been advocated as a possible alternative to traditional graft replacement for treatment of aneurysms of the ascending aorta and root. We report a case of a 58-year-old Jehovah's Witness female, with a 5.5-cm ascending aortic aneurysm and critical aortic stenosis. She underwent aortic valve replacement and reduction aortoplasty buttressed with a Dacron graft. We reviewed the history and contemporary applications of this technique and concluded that aortic reduction with externally supported aortoplasty may represent a viable option to treat Jehovah's Witness patients with ascending aorta and root aneurysm.     

升主动脉置换术或成形术治疗主动脉瓣病变合并的升主动脉瘤样扩张

目的 对比分析主动脉瓣病变合并升主动脉瘤扩张在行主动脉瓣置换术(AVR)的同时施行升主动脉置换术(A组)或成形术(B组)的结果,探讨两种方法的临床效果及适应证.方法 A、B两组术前年龄、性别、心功能分级、主动脉瓣病变、左室射血分数等差异均无统计学意义.A组主动脉直径(49.45±3.96)mm,B组(49.31±3.68)mm,差异亦无统计学意义.行AVR后A组常规置换升主动脉,B组纵行切除部分升主动脉壁,缝合后包裹28～30 mm人工血管.结果 A、B两组术后均无死亡.A组主动脉阻断(71.70±17.13)min、体外循环(110.52±27.51)min,均明显大于B组的(57.13±16.32)min(P=0.025)和(97.31±19.46)min(P=0.004).两组术中及术后输血量、并发症发生率差异无统计学意义.结论 主动脉瓣病变合并升主动脉瘤样扩张,年轻病人主动脉直径≥40 mm时应积极手术处理扩张的升主动脉.升主动脉成形术,同时外包裹人工血管的方法较升主动脉置换术更为简单、安全,但升主动脉壁必须无粥样硬化或溃疡.     

Single-stage repair of aortic coarctation with concomitant bicuspid aortic valve and ascending aortic aneurysm

The optimal surgical management of patients presenting with an aortic coarctation together with other cardiovascular disorders is unclear. In this study, we report the case of an adult male with an aortic coarctation associated with a bicuspid aortic valve and an ascending aortic aneurysm. The patient underwent single-stage repair involving the Bentall technique and total arch replacement combined with stented elephant trunk implantation, which was performed through median sternotomy. We consider this procedure to be a suitable alternative for treating these complex cases.     

Single coronary artery with bicuspid aortic valve stenosis and aneurysm of the ascending aorta: report of a case

A 73-year-old man with a severely stenosed bicuspid valve and an aneurysm of the ascending aorta underwent valve and aortic surgery. Preoperative imaging revealed a single coronary artery arising from the right side of the sinus of Valsalva and a branch that perfused into the left side of the heart to pass through the front of the pulmonary artery. We replaced the aortic valve and ascending aorta, painstakingly avoiding damage to the coronary artery and obstruction of the sole coronary ostium.     

Management of an ascending aortic aneurysm associated with a bicuspid aortic valve and a coarctation in an adolescent

Ascending aortic aneurysms are commonly associated with bicuspid aortic valves in adults but are rarely seen in childhood. We now report the management of an ascending aortic aneurysm in a 12-year-old male with an associated bicuspid aortic valve and a coarctation.     

Options for repair of a bicuspid aortic valve and ascending aortic aneurysm

BACKGROUND: Intrinsic abnormality of the aortic wall may explain the association of bicuspid aortic valves with ascending aortic aneurysms. Separate valve and graft repair of such lesions, rather than composite valve graft replacement, is more straightforward but leaves potentially abnormal sinuses behind. METHODS: Between January 1985 and January 1998, 45 patients underwent separate valve and graft (n = 27) or composite valve graft (n = 18) for an ascending aortic aneurysm and bicuspid aortic valve. Perioperative events and late results were compared. RESULTS: Patients undergoing separate valve and graft were older (mean age, 60 +/- 13 vs 42 +/- 12 years, p < 0.001) and were more likely to have purely stenotic (48% vs 6%, p = 0.003) than purely regurgitant (11% vs 72%, p < 0.001) disease. They were also more likely to require concomitant coronary artery bypass grafting (56% vs 6%, p = 0.001). There were no significant differences in operative risk and no known late complications related to recurrent aneurysms. CONCLUSIONS: Root replacement with a composite valve graft can be accomplished with low operative risk and is the first choice for repair of this lesion. Separate valve and graft repair, however, yields satisfactory early and late results and remains an acceptable option, especially when the coronary ostea are not displaced or when concomitant procedures must be performed.     

主动脉瓣二瓣畸形与升主动脉形变的血流动力学关系

主动脉瓣二瓣畸形(BAV)是常见的先天性心脏病,BAV与升主动脉形变的血流动力学之间的关系至关重要,本文旨在对其进行综述。     

Safe wrapping of the borderline dilated ascending aorta during aortic valve replacement

Background  

Techniques of reduction aortoplasty are widely published in the literature with conflicting results. External support seems to be an important factor in preventing recurrence but, in some cases, this technique caused erosion of the aorta because of the wrinkles the prosthesis creates in the rear side of the aorta.     

Concomitant aortic valve and ascending aorta replacement with moderate hypothermic circulatory arrest to treat an aortic bicuspid valve with post-stenotic dilatation

We recommend concomitant surgery for aortic valve replacement (AVR) and ascending aortic replacement using moderate hypothermic circulatory arrest (CA) for post-stenotic dilatation complicated by an aortic bicuspid valve. Cardiopulmonary bypass (CPB) was established from the right atrium to the dilated ascending aorta. As soon as the rectal temperature decreased to 28?°C, CA was commenced and the open distal anastomosis of a polyester prosthesis, without any cerebral perfusion, was completed. AVR was then carried out during rapid re-warming with CPB using a side arm of the prosthesis. This procedure exhibited safe and satisfactory results. There are many benefits of carrying out the procedure in this way; it avoids the requirement for cannulation to a calcified aortic arch, provides a good operative field, for an easier distal anastomosis and suturing at the valve site, and reduces the risk of further dilatation or dissection of the residual ascending aorta in the later phase.