Aortic regurgitation after surgical relief of subvalvular membranous stenosis. A long-term follow-up study

A postoperative follow-up study of 21 cases of discrete membranous subvalvular aortic stenosis is presented. The age at operation was 6-47 (mean 16) years, and the follow-up time 0.6-16 (mean 6.7) years. Preoperatively most patients were in NYHA function class II or III and had high peak systolic pressure gradient, left ventricular hypertrophy and/or cardiothoracic index greater than 0.50. At follow-up all but six patients were in NYHA class I, the Doppler-estimated peak systolic gradient was 0-36 (mean 18) mmHg, the cardiothoracic index unchanged and the mean left ventricular hypertrophy score had declined from 4.3 to 2.3. Of 13 patients without aortic regurgitation preoperatively, eight had regurgitation at follow-up (group I) and five did not (group II). The interval to follow-up was significantly longer and the preoperative peak systolic gradient was greater in group I than in group II. Aortic regurgitation may develop even after surgical relief of discrete membranous subvalvular aortic stenosis, possibly associated with high preoperative pressure gradient and time from operation. Regular postoperative Doppler echocardiography is therefore recommended.     

Aortic valve replacement for aortic regurgitation and stenosis, in patients with severe left ventricular dysfunction.

OBJECTIVE: Aortic valve replacement for aortic valve stenosis (AS) and regurgitation (AR) in patients with severe left ventricular (LV) dysfunction contains an increased risk. Few data are available on the outcome of such patients. METHODS: Fifty-five consecutive patients with severe LV dysfunction (ejection fraction, EF; <30%) and aortic valve replacement for AS (n=35) or AR (n=20) were investigated between 1994 and 2001. EF was 25+/-5%, mean transvalvular gradient 26+/-6mmHg (AS), aortic valve area 0.66+/-0.18cm(2) (AS), cardiac index (CI) 2.4+/-0.9l/min/m(2), enddiastolic LV diameter (LVEDD) 64+/-8mm and endsystolic LV diameters (LVESD) was 55+/-3mm. Ninety percent of patients were in New York Heart Association (NYHA) functional class III/IV at admission to the hospital. Concomitant coronary artery bypass grafts (CABG) were performed in 14 patients. Follow-up examinations including chest X-ray, echocardiography, exercise testing, were performed among survivors. RESULTS: The survival rates for AS were: 1-year 76%, 2-year 68.8%, 5-year 64.2%; for AR: 1-year 94.4%, 2-year 86.5%, 5-year 74.2%. NYHA functional class improved from 90% in class III/IV to 45 (AR group) and 24% (AS group) at follow-up (P<0.02). The LVEDD decreased to 54+/-8mm after 1 year. The EF improved to 38+/-4 (AR group) and 40+/-5% (AS group) at follow-up. CONCLUSIONS: Despite severe LV dysfunction, increased 1-year mortality especially in the AS group, aortic valve replacement was associated with improved functional status, symptoms and EF in both groups and in most patients. We, therefore, conclude that aortic valve replacement in patients with severe LV dysfunction can be performed with acceptable risk.     

Functional evaluation after aortic valve replacement

Preoperative and sequential postoperative bicycle exercise tests were compared with clinical and catheterization data in assessment of the functional outcome of uncomplicated aortic valve replacement (AVR) in 33 patients. The operation was done because of aortic stenosis (AS) in 14 patients and aortic regurgitation (AR) in 19. Both groups of patients showed improved NYHA functional class and peak achieved workload after AVR, but the results in these respects did not correlate. Nor did the regression in left ventricular (LV) hypertrophy and dilatation after AVR that was seen in both patient groups correlate with the changes measured in exercise tolerance. Preoperative exercise capacity was not predictive of the postoperative performance. In the AR patients, however, preoperative ability to raise the systolic blood pressure during exercise appeared to predict which patients were likely to show enhanced resting LV systolic pump function after AVR. It is concluded that objective tests of exercise tolerance alone permit reliable evaluation of the functional outcome of uncomplicated AVR. Indices of resting LV performance, though helpful in observation of the changes resulting from removal of the untoward LV burden after AVR, are likely to be less useful for evaluating changes in the LV exercise reserve. The response of the systolic blood pressure to exercise may be an additional predictive factor for postoperative resting LV performance in patients with AR.     

Differences in loading condition and its effects for valve replacement between chronic aortic and mitral regurgitation

In order to clarify the differences of left ventricular mechanics between chronic aortic and mitral regurgitation (AR and MR), 23 patients with AR and 17 patients with MR were studied by noninvasive techniques. There were no differences between two types of regurgitation in R/Th, LV dimension, LVEDVI, PWTd, LV mass I and mean blood pressure. However, the peak systolic wall stress (PSWS), ESVI and systolic blood pressure (sBP) of AR were significantly higher than that of MR. One month after valve replacement (VR), in AR all parameters decreased significantly expect increased PWTd. But in MR, blood pressure, LV systolic size and LV mass I were unchanged, although LVDd, LVEDVI, PSWS and R/Th decreased significantly. These results indicates that high PSWS in AR is diminished effectively after AVR by both effects of reduction of LV volume and sBP, although in MR, as a sBP is kept in low level, a drop of PSWS after MVR occurs only due to reduction of volume. Therefore, systolic function after MVR for MR with impaired myocardium may be more destroyed by relatively high afterload as it is difficult to diminish the volume, even if LV function was kept relatively in good condition before operation.     

Large pseudoaneurysm of left ventricle following cardiac surgery

A 75-year old female patient, with previous inferior acute myocardial infarction (AMI) in December 2000, was admitted in April 2001 with angina and heart failure. Transthoracic echocardiography (TTE) was suggestive of a postero-inferior pseudoaneurysm (PA) of the left ventricle (LV), with 61x49 mm. of size and mitral regurgitation. Cardiac catheterization was suspected of a PA of the LV and revealed a three vessels coronary artery disease. On 20th April she was submitted to cardiac surgery with resection of a large LV aneurysm (AN) and triple coronary artery bypass surgery. Afterwards, she was on NYHA class III and subsequent TTE and transesophagic echocardiography (TEE) were suggestive of a 90x60 mm LV posterior PA (confirmed by nuclear magnetic resonance) and severe mitral regurgitation, with good LV systolic function. She underwent a new cardiac surgery on 31st May 2002, with resuturing of the LV postero-inferior wall patch and removal of the PA. The patient is in good condition and on NYHA functional class I-II.     

Myocardial structure and left ventricular function in aortic valvular diseases]

In this study 13 patients with aortic stenosis (AS) and 19 patients with aortic regurgitation (AR) were analyzed to investigate the correlation between myocardial structure and left ventricular (LV) function. LV end-diastolic dimension (Dd), LV end-systolic dimension (Ds), LV Mass Index (LVMI), FS, mVcf and the normalized rate of change of LV dimensions during systole and diastole (-V/Dd, +V/Dd) were assessed using M-mode echocardiography before and after aortic valve replacement. The myocardial structures were investigated from the biopsied specimen in the operation using both light and electron microscopes. Then muscle fiber diameter (Diameter), the degree of interstitial fibrosis (%Fibrosis) and the myocyte volume fraction (%MF, %MT, %SA) were quantitatively evaluated by using a computerized system. And semi-quantitative analysis was made with electron microscopic score (EM-score). The results were as follows. 1. AS group: Left ventricular myocardial degeneration was mild. Significant positive correlationships were found between preoperative LVMI and Diameter (p < 0.01), and between the former and the volume fraction of the myofibrils (%MF) (p < 0.05). And significant positive correlationship was seen between Diameter and %MF (p < 0.05). However, no significant correlationship was seen between preoperative LVMI and %Fibrosis. Both LV systolic and diastolic function (-V/Dd, +V/Dd) showed significantly negative correlationship to LVMI preoperatively (p < 0.01, p < 0.05) and postoperatively (p < 0.05, p < 0.05). And in the patients with preoperative LVMI larger than 300 g/m2 and Diameter larger than 30 microns, +V/Dd was irreversible postoperatively. 2. AR group: EM-score in AR was significantly higher than that in AS (p < 0.05). Preoperative LVMI showed significantly positive correlationship to %Fibrosis (p < 0.01). And postoperative LVMI showed significantly positive correlationship to fibrous content (p < 0.01). Both LV systolic and diastolic function -V/Dd, +V/Dd) showed significantly negative correlationship to LVMI preoperatively (p < 0.05, p < 0.01) and postoperatively (p < 0.01, p < 0.01). And in the patients with preoperative LVMI larger than 300 g/m2 and %Fibrosis larger than 16%, both -V/Dd and +V/Dd were irreversible postoperatively. The above mentioned results indicated that preoperative LVMI and the morphologic parameters were useful to predict the reversibility of the postoperative LV function in both AS and AR.     

Intravenous iron without erythropoietin for the treatment of iron deficiency anemia in patients with moderate to severe congestive heart failure and chronic kidney insufficiency

OBJECTIVES: Iron deficiency anemia is a frequent finding in many patients with congestive heart failure (CHF). The purpose of this study was to assess the effect of intravenous (i.v.) iron on the anemia of CHF patients and on cardiac remodeling, New York Heart Association (NYHA) classification and renal function. METHODS: Thirty-two patients with well-treated CHF which was NYHA class III-IV, and with hemoglobin (Hb) persistently <11 g/dL, were treated with i.v. iron over 26 weeks. Echocardiographic, hematological and renal parameters were measured at the beginning and end of the study. RESULTS: Hb increased significantly from 10.7 +/- 0.4 g/dL to 13.7 +/- 0.4 g/dL and from 9.4 +/- 0.6 g/dL to 12.7+/- 0.8 g/dL in the NYHA III and IV groups respectively. Posterior wall thickness, septal thickness (ST), left ventricular (LV) end diastolic volume and diameter, LV end systolic volume and diameter, LV mass index and LV ejection fraction (LVEF) were all abnormal initially. All of these parameters improved significantly in the NYHA III patients, and all but ST and LVEF improved significantly in the NYHA IV patients. NYHA classification improved from III to II in 9 of 19 NYHA III patients (47.4%) (p<0.01) but did not improve in any of the 13 NYHA IV patients. CONCLUSION: Intravenous iron causes a marked increase in hemoglobin in anemic CHF patients, and this is frequently associated with an improvement in cardiac remodeling and NYHA classification.     

Mitral valve surgery in patients with severe left ventricular dysfunction.

OBJECTIVES: The objectives of this study were to determine (1) survival, (2) functional status and freedom from readmission for heart failure and (3) change in postoperative left ventricular (LV) dimensions and function following mitral valve repair or replacement in patients with severe LV dysfunction and mitral regurgitation. PATIENTS AND METHODS: Between 1990 and 1998, 44 patients with mitral regurgitation and a LV ejection fraction <35% (mean+/-SD, 28+/-6%) underwent isolated mitral repair (n=35) or replacement (n=9). The etiology of regurgitation was valvular in 18 (40%) patients, ischemic in 13 (30%) patients and dilated idiopathic cardiomyopathy in 13 (30%) patients. Every patient had been hospitalized one to six times for symptoms of heart failure (mean+/-SD, 2.3+/-1.5). All patients were receiving maximal drug therapy with 15 (34%) in New York Heart Association (NYHA) class III and 12 (27%) in class IV. Seven (16%) patients were initially referred for consideration of transplantation. The mean+/-SD duration of follow-up was 40+/-21 months. RESULTS: One (2.3%) patient died 9 days postoperatively of acute bronchopneumonia. The mean+/-SD duration of ICU and hospital stay was 41+/-34 h and 9+/-3 days, respectively. The 1-, 2- and 5-year survival rates were 89, 86 and 67%, respectively. Heart failure and sudden death accounted for 62% of the late deaths. The NYHA class improved for survivors from 2.8+/-0.8 preoperatively to 1. 2+/-0.5 at follow-up (P<0.0001). Freedom from readmission for heart failure was 88, 82 and 72% at 1, 2 and 5 years, respectively. No patient has been listed for transplantation. CONCLUSIONS: Mitral valve surgery offers symptomatic improvement and survival benefit in patients with severe LV dysfunction and mitral regurgitation. More liberal use of this surgery for cardiomyopathy patients is warranted.     

Change of c-Myc expression and cardiac hypertrophy in patients with aortic valve replacement

BACKGROUND: Long-term volume overload to the left ventricle (LV) due to aortic regurgitation (AR) tends to cause severe impairment in LV function that cannot be reversed even with aortic valve replacement (AVR). Recently, we reported that the protooncogene c-myc is related to the onset of the cardiac hypertrophy and LV dysfunction in patients with chronic AR. However, it is still unclear whether c-myc is related to reversibility of the cardiac hypertrophy or LV dysfunction after AVR. METHODS AND RESULTS: Twenty patients with isolated chronic AR who underwent AVR were included in this study. LV function was calculated before and after AVR. After AVR, end-systolic volume index (ESVI) and enddiastolic volume index (EDVI) were improved, but not mass index (LVMI). However, normalization of ESVI and EDVI was observed only in 12 and 9 patients, respectively. Preoperatively, c-Myc protein was expressed in the myocardium of 16 out of 20 patients with an average point count of 35+/-30%. After AVR, c-Myc protein was observed only in 2 patients. Preoperative ejection fraction (EF), ESVI, and postoperative end-systolic stress (ESS)/ESVI had significant correlation to postoperative cell diameter (CD). Percent c-Myc protein expression before the operation was significantly correlated to postoperative CD, ESVI, and ESS/ESVI. Average c-Myc expression was higher in patients who showed normalization of CD and ESS/ESVI after AVR than the patients who did not. CONCLUSIONS: These data suggest that preoperative expression of c-Myc can be indicative of the reversibility of myocardial cellular hypertrophy and LV dysfunction.     

Left ventricular mass: impact on left ventricular contractile function and its reversibility in patients undergoing aortic valve replacement.

BACKGROUND: We examined the relationships of left ventricular (LV) contractile state with LV geometry and hypertrophy in patients with aortic valve disease, and investigated the reversibility of LV hypertrophy and contractility following aortic valve replacement. METHODS: Preoperative data from quantitative cineangiography and pressure measurements in 132 patients with chronic aortic valve disease, of whom 82 aortic regurgitation (AR), 41 aortic stenosis (AS), and 9 had mixed stenosis and regurgitation (AS-AR), were reviewed. Late after surgery, 59 of the patients (39 with AR, 20 with AS) were studied to elucidate the postoperative reversibility of LV performance and regression of LV hypertrophy. RESULTS: Preoperatively, multiple comparison tests found significant changes in the variables of LV volumes and dimensions in relation to LV contractile state. In stepwise regression analysis, the LV mass index was initially incorporated into a multivariate regression model as an important correlate of LV contractile state. LV geometric variables showed either no or a poor correlation with contractile state. Following aortic valve replacement, improvement of LV contractile dysfunction and regression of LV hypertrophy were limited in many of the patients who had severe preoperative hypertrophy (LV mass index 200% of normal or greater). Further, a close association between LV hypertrophy and LV contractility persisted postoperatively. CONCLUSION: Our results suggest that the development of LV hypertrophy in terms of an increase in LV mass index, in contrast to changes in geometric patterns, is significantly associated with deterioration in contractile function. LV hypertrophy may become irreversible and pathological at equivalent degrees of hypertrophy (LV mass index >/=200% of normal), regardless of the type of aortic valve lesion.     

Left ventricle restoration in patients with non-ischemic dilated cardiomyopathy: risk factors and predictors of outcome and change of mid-term ventricular function.

OBJECTIVE: The partial left ventriculectomy (PLV) for end-stage dilated cardiomyopathy (DCM) which worked in some patients has been reported, although the hospital mortality is high. To reduce hospital mortality, we selected operative procedures of left ventricular (LV) restoration to improve the operative results. We analyzed the risk factors and predictors of outcome, and the mid-term changes of the LV function were determined. PATIENTS AND METHODS: Between December 1996 and September 2000, 74 patients with non-ischemic DCM received LV restoration. The age ranged from 14 to 76 years (mean, 49.0+/-14.0 years), and there were 63 men and 11 women. The etiology of the DCM was idiopathic DCM in 49 patients, and dilated hypertrophic cardiomyopathy in seven patients and others in 18. The preoperative New York Heart Association (NYHA) functional class was 29 in class III and 45 in class IV, in which 32 patients depended on inotropic support. PLV or septal anterior ventricular exclusion (SAVE) was selected depending on the akinetic lesion of the LV based on the intraoperative echo-test. Fifty-six patients received elective operations, and emergency operations were performed in 18 patients. The risk factors and predictors of outcome were analyzed in 74 patients, and in 35 patients who survived more than 1 year after receiving LV restoration, the mid-term cardiac function was examined by cardiac echogram and catheterization. RESULTS: PLV was performed in 62 patients and SAVE in 12 patients. Concomitant mitral surgery was performed in 66 patients (89%) and tricuspid annuloplasty in 42 patients (57%). There were 15 hospital deaths and 13 patients died after discharge from the hospital (cardiac deaths in nine and non-cardiac deaths in four). In the 46 late survivors, the NYHA class was I or II in 42 patients and III in four patients. Selection of the procedure of LV restoration (P<0.01), elective operation (P<0.05), and the preoperative volume of LV (endodiastolic volume index of <180 ml/m(2); P<0.05) were risk factors and predictors influencing hospital and late death. After the operation, the LV function improved significantly and the improvement was maintained at the mid-term period; the LV ejection fraction was 31.8+/-7.9% (P<0.01) at 1 year from 23.0+/-7.3% preoperatively, left ventricular diastolic diameter was 62.8+/-10.9 (P<0.01) from 81.7+/-8.2 mm and the LV endosystolic volume index was 88.5+/-45.8 (P<0.05) from 162.6+/-41.6 ml/m(2). CONCLUSIONS: The operative results improved with the selection of the procedures, with elective operation, and mitral plasty for less cardiac dilatation. The mid-term results of clinical status and LV function showed the effectiveness of the operation.     

Aortic valve repair with pericardial leaflet extension for aortic valve insufficiency

Background: This article presents our intermediate term results of pericardial leaflet extension used in various complex pathologies of the aortic valve leading to aortic regurgitation. Methods: Sixteen patients had aortic insufficiency/regurgitation with deficient leaflet tissues so that repair was performed with pericardial leaflet extension. The mean patient age was 26.6 years and 69% were male. Two patients (13%) were in NYHA class I, 12 patients (75%) were in class II and 2 patients (13%) were in class III preoperatively. Six patients (38%) had a bicuspid aortic valve and 10 patients (63%) had a tricuspid aortic valve. Eight patients (50%) had moderate and 8 patients (50%) had severe aortic insufficiency (AI) preoperatively. Two patients (13%) had associated cardiac procedures at the time of aortic repair. Results: There were no operative deaths but 3 patients died in the late postoperative period. Five patients underwent subsequent aortic valve replacement or a Ross procedure at re-operation. The most common finding during re-operation was thickening of the leaflet extension or rolling in of the edges of the leaflet extension. Freedom from aortic valve re-operation at five years postoperation was 68% (standard error 14). Late follow-up revealed that 9 patients (56%) were in NYHA class I and 7 patients (44%) were in class II. Ten (63%) patients had mild AI and 6 patients (37%) had moderate AI at most recent follow-up. Conclusions: Absence of hospital mortality, freedom from embolic events and echocardiography evidence of immediate competency of the valve are the reliable indicators of this surgical technique.     

Long Term Results and Predictors of Left Ventricular Function Recovery after Aortic Valve Replacement for Chronic Aortic Regurgitation

Objectives: In most patients with aortic regurgitation (AR), aortic valve replacement (AVR) improves left ventricular (LV) function, but some patients will not have favorable remodeling. Our objectives were to review long term clinical results of AVR for AR and to examine what factors affect the normalization of LV function after AVR for chronic AR.Methods: Between 1989 and 2010, 177 patients underwent isolated AVR for chronic pure AR. The patients were divided into 2 groups based on indexed end-systolic LV diameter (iESD): Group L (iESD) ≧25 mm/m²) (130 patients) and Group S (iESD <25 mm/m²) (47 patients).Results: There was no significant difference between groups in late mortality, freedom from cardiac-related death and rehospitalization for heart failure at late follow up after operation. At postoperative follow-up, 16% of patients had not recovered normal LV systolic function. By means of multivariate analysis, iESD and cardiac index (CI) were independent predictors of recovery of LV function and iESD >26.7 mm/m² and CI <2.71 l/min/m² were the best cut-off values.Conclusions: Early and late surgical results of AVR for chronic AR were good, but for the preservation of postoperative normal LV function, AVR for AR patients should be performed before iESD reaches 26.7 mm/m².     

Long-term results and analysis of multiple surgical approaches for ischemic cardiomyopathy with left ventricular reconstruction, including scarred endocardiectomy for arrhythmia therapy, and mitral valve surgery

Among 73 patients with ischemic cardiomyopathy [ejection fraction (EF) < 40%, left ventricular end systolic volume index (LVESVI) > 60 ml/m2], 65 patients with large scar underwent left ventricular reconstruction (LVR) including scarred endocardiectomy against arrhythmia and 13 with 3 + mitral regurgitation (MR) mitral valve surgery [mitral annular plasty (MAP): n = 9, mitral valve replacement (MVR): n = 4]. Eight-year survival including 1 perioperative death (1.4%) was 773% without death due to arrhythmia. 69 survivors revealed significant improvement in New York Heart Association (NYHA) class, and lefe ventricular (LV) function in pulmonary artery pressure (PAP) and EF. LV volume significantly reduced from 103.6 to 57.5 ml/m2 in LVESVI (44% volume reduction) [p < 0.0001]. Postoperative LV shape became significantly spherical [eccentricity index (EI) closer to 0], however, MR grade was significantly reduced from 2.0 to 1.6 (p < 0.0003). Freedom from all deaths including hospitalization for cardiac causes was 71.1% at 8 years. One patient required implantable cardioverter defibrillator (ICD) for spontaneous ventricular tachycardia (VT). Multivariate Cox's regression model showed that preoperative large left ventricular end diastolic volume index (LVEDVI) [hazard ratio (HR) 1.02], postoperative large LVESVI (HR 1.03) and preoperative high NYHA class (HR 3.05) were significant risk factors affecting all deaths including hospitalization for cardiac causes. Of 24 patients with 2.5 + MR, mitral valve surgery (MAP, MVR or MAP + LVR) demonstrated significant improvement of MR (3.6 to 1.3 in MAP/MVR and 3.5 to 1.0 in MAP + LVR) compared with isolated LVR (2.6 to 2.2), although, there was no significant change in LV volume reduction. Our surgical approach to ischemic cardiomyopathy revealed excellent long-term results without death due to arrhythmia. Risk factor analysis recommended earlier and more aggressive surgical approach to achieve both LV volume reduction, MR and arrhythmia control.     

Prognostic value of exercise left ventricular end-systolic volume index in patients with asymptomatic aortic regurgitation: an exercise echocardiography study

Background

Surgical timing of chronic aortic regurgitation (AR) remains a matter of debate because of limited data. This study assessed the prognostic value of exercise echocardiography in asymptomatic AR.

Methods

This prospective study included 60 consecutive asymptomatic patients with isolated moderate or severe AR (mean regurgitant volume 56.7 ± 11.8 ml) and preserved ejection fraction who underwent exercise echocardiography. The clinical outcomes were defined by the presence of major adverse cardiovascular events (MACE) and the indication for aortic valve replacement (AVR) with class I or IIa classification in the current guidelines.

Results

During the average follow-up of 731 days, 12 patients suffered from the clinical events, including two patients developing MACE (3%) and ten patients indicating for AVR (17%). No difference in left ventricular (LV) ejection fraction at rest was found between the patients with and without the clinical events. The indexed LV diameters and LV volumes were significantly dilated in the patients with the clinical events. The Cox proportional hazards regression analysis resulted that the exercise LV end-systolic volume index (LVESVi) was significantly associated with the clinical outcomes [hazard ratio, 1.116; 95% CI (1.032–1.205); p = 0.006]. The Kaplan–Meier analysis showed that exercise LVESVi was clearly stratified the event-free survival.

Conclusions

Exercise LVESVi might be an independent predictor of prognosis in patients with asymptomatic moderate or severe AR.

     

Aortic Valve Replacement with Cryopreserved Allografts: Mid-Term Results

Objective: Analysis of the clinical and echocardiographic mid-term results following aortic valve replacement (AVR) with cryopreserved allografts. Design and setting: A cohort study in a tertiary care center. Patients: Fifty patients underwent allograft AVR during the years 1987 through 1992. There were 44 men and 6 women with a mean age of 47.6 ± 12.2 years (range 22 to 72 years). Indications for operation included: aortic stenosis (AS) 15 patients, aortic regurgitation (AR) 24, and mixed 11. The etiology was: congenital 22, rheumatic 8, degenerative 5, senile calcific 4, malfunctioning aortic valve prosthesis 5, and active endocarditis 6. Outcome measures: Early mortality and morbidity; mid-term survival, functional class, and valve related complications; and two-dimensional Doppler echocardiography to assess valve structure and function. Results: Two patients (4%) died perioperatively of non-cardiac or valve related causes. Long-term follow-up ranged from 4 to 60 months (median 34 months), with no late mortality, recurrence of endocarditis, or thromboembolic events. Thirty-nine patients were in New York Heart Association (NYHA) Class 1 (83%) and 7 (15%) in Class II. Of these, echocardiogram showed trace or no AR in 42 (98%) and 2+ AR in 1. One allograft was re-replaced with a mechanical valve due to technical failure. One patient was in NYHA Class III with normal allograft function and 4+ mitral regurgitation. Conclusions: Replacement of the aortic valve by a cryopreserved allograft can be performed safely, and is particularly useful in the setting of active endocarditis and failed prior prosthetic valve. Mid-term clinical results and valve durability at 5 years are excellent. (J Card Surg 1994;9:292–297)     

Does cardiac resynchronisation therapy improve survival and quality of life in patients with end-stage heart failure?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether bi-ventricular pacing, also referred to as cardiac resynchronisation therapy (CRT), improves survival and quality of life in patients with severe (NYHA III/IV) symptomatic heart failure. Cardiac pacing can be achieved by stimulation of the right ventricle, left ventricle (LV) or by bi-ventricular pacing. This best evidence topic considers only bi-ventricular pacing. This involves placement of pacing leads in the right ventricle, epicardially on the LV with a lead typically placed in a branch of the coronary sinus and, unless the patient is in permanent atrial fibrillation, in the right atrium. Bi-ventricular pacing allows the optimisation of atrio-ventricular timing and resynchronisation of septal and postero-lateral left ventricular contraction. Symptomatic heart failure has a high morbidity and a poor prognosis. Patients with dyspnoea at rest or on minimal exertion (NYHA III/IV) are at high risk of death due to progressive heart failure, while those with less severe symptoms are more likely to experience sudden cardiac death. Up to 50% of patients with NYHA class III/IV symptoms have a prolonged QRS duration (>120 ms) on 12-lead ECG (usually in a LBBB pattern). This intra-ventricular conduction delay is a surrogate marker of mechanical dyssynchrony (an uncoordinated regional contraction-relaxation pattern) and is associated with reduced cardiac output and increased mortality. Bi-ventricular pacing can reduce the delay in activation of the LV free wall found in many patients with LV systolic dysfunction, thereby improving mechanical synchrony and cardiac output. It may also reduce pre-systolic mitral regurgitation. Three hundred and fifty-six papers were identified using the search method outlined, nine randomised controlled trials and a meta-analysis in addition to published guidelines presented the best evidence to answer the clinical question. Current best available evidence suggests that in patients with left ventricular systolic dysfunction (LVEF or=120 ms), and NYHA class III or IV symptoms despite optimal pharmacological therapy, bi-ventricular pacing significantly reduces the number of hospitalisations from heart failure, improves functional status (NYHA class, peak oxygen uptake and exercise tolerance) and improves health related quality of life. The CARE-HF study also demonstrated a reduction in mortality from progressive heart failure and all-cause mortality.     

Nineteen-millimeter prosthetic aortic valves allow normalization of left ventricular mass in elderly women

BACKGROUND: Implantation of small aortic valve prostheses has been reported to be associated with impaired left ventricular (LV) mass regression and incomplete resolution of symptoms although these data have been generated largely with male patients. Therefore we sought to determine the clinical and hemodynamic outcomes of female patients who received a 19-mm aortic valve. METHODS: Between May 1995 and December 2000, 38 female patients (average age 73 years, range 42 to 89) underwent isolated aortic valve replacement (AVR; n = 22) or AVR plus coronary artery bypass graft surgery (CABG; n = 16) with a 19-mm aortic prosthesis. The average New York Heart Association (NYHA) class was 3.08 and of the 26 patients who had angina, 47.2% were in CCS class III or IV. Clinical and echocardiographic follow-up was done an average of 33.4 months (8 to 72) after surgery. RESULTS: Operative mortality was 10.5%. Overall survival at an average of 33 months was 71.1%. The average NYHA class was 1.52 +/- 0.34 postoperatively (p < 0.001 versus preoperative) and 95% had no anginal symptoms or were in Canadian Cardiovascular Society class I. The LV mass index showed significant regression (114 +/- 11 g/m2 to 89 +/- 9 g/m2, p = 0.001) despite an effective orifice area index (EOAI) of 0.64 +/- 0.09 cm2/m2. CONCLUSIONS: Despite a very small EOAI, elderly female patients with 19-mm prosthetic aortic valves can experience a satisfactory improvement in symptoms and normalization of LV mass. This finding suggests that small prosthetic aortic valves continue to have an application in contemporary cardiac surgical practice. The current perception of patient-prosthesis mismatch may need to be reconsidered for select populations.     

Hemolytic anemia due to aortic valve regurgitation after mitral valve replacement

A 50-year-old woman was admitted to our hospital because of heart failure (NYHA III) due to mitral valve regurgitation (MR) with pulmonary hypertension (PH) and tricuspid valve regurgitation (TR). She had a history of chronic renal failure undergoing dialysis (peritoneal dialysis, homodialysis) since 1996. Cardiac catheterization and ultrasonic cardiography showed severe MR (Sellers III), severe TR and PH (mean pressure 33 mmHg). So we performed mitral valve replacement and tricuspid annuloplasty (DeVega). Frequent blood transfusion was needed because severe hemolytic anemia appeared after operation. Ultrasonic cardiography demonstrated moderate aortic valve regurgitation (AR) with no paravalvular prosthetic leakage. We diagnosed hemolytic anemia due to AR. We performed aortic valve replacement. Hemolytic anemia improved soon after second operation. We investigated the mechanical process of the AR. She had a very short subaortic curtain (5.9 mm) compared with the average (8.7 +/- 2.1 mm: mean +/- SD) of cardiac patients. We think that we must be very careful with suture to short subaortic curtain. In addition measurement of subaortic curtain before operation is very useful.     

Size and configuration of the functional aortic root after the arterial switch operation for complete transposition of the great arteries

Twelve patients with complete transposition of the great arteries who had arterial switch operation were investigated by postoperative cineangiogram to assess the size and configuration of the functional aortic root. Three patients underwent Damus-Kaye-Stansel operation and the remaining nine received Lecompte modification of Jatene operation. Aortogram showed trivial or mild aortic regurgitation in six patients who underwent Jatene operation but no regurgitation was detected in patients after Damus-Kaye-Stansel operation, arterial switch operation without coronary relocation. The patients were divided into two groups according to the aortographic findings: AR(-); patients with competent aortic valve, AR(+); patients with incompetent aortic valve. Comparison was made between these two groups, measuring new aortic root diameter at three levels. The systolic diameter of distal aortic root was significantly enlarged in AR(+) group as compared to AR(-) group. These results suggest that the relocation of the coronary arteries and the dilatation of aortic root may contribute to aortic regurgitation after Jatene operation.