Replacement of the ascending aorta and aortic valve with a composite graft. Results and follow-up in 71 patients

Composite graft replacement of the ascending aorta and aortic valve was performed in 71 patients over an 8-year period. Degenerative lesions of the aortic root in Marfan's syndrome (annuloaortic ectasia) was the indication for operation in 51 cases. Other causes of aortic root dilatation and aortic valve disease were present in the remaining 20 patients. Overall hospital mortality was 8%. Reoperation was required in 6 of the 65 hospital survivors. Follow-up has ranged from 1 to 9 years (average 41/2 years). Four year actuarial survival was 77%. Composite graft replacement eliminates paraprosthetic leakage and the risk of aneurysm formation of the sinuses of Valsalva; postoperative hemorrhage is also reduced. It appears to be the method of choice for the aortic root complications of the Marfan's syndrome.     

Management of the ascending aorta in patients with bicuspid aortic valve disease

Bicuspid aortic valve (BAV) disease is the most common form of congenital heart disease, affecting 1-2% of the population. Only 20% of patients will maintain normal valve function throughout their life and more than 30% of patients will develop serious morbidity. It is a highly heritable condition, with transmission likely to be autosomal dominant. Patients with BAV have a 10-fold risk of aortic dissection when compared to the normal population. Management of BAV associated aortopathy represents a significant clinical challenge.     

Replacement of the aortic root and ascending aorta with a fresh antibiotic-sterilized homograft

The case of a 53-year-old male suffering from aortic stenosis and aneurysm of the ascending aorta treated by aortic root replacement with a fresh antibiotic-sterilized aortic homograft is presented. The technique and indications are commented on, focusing attention in the scanty results available in the literature with regard to this technique. We support the use of homografts in aortic root replacement in selected cases.     

Aortic valve repair of congenital bicuspid aortic valve associated with aneurysm of the ascending aorta

Two unusual cases of congenital bicuspid aortic valve associated with aneurysm of the ascending aorta are reported. One patient with a 7-cm ascending aortic dilatation and aortic regurgitation (AR) (II/IV), and another with a 6-cm ascending aorta and AR (III/IV), presented for treatment. Replacement of the ascending aorta and aortic valve repair were performed in both cases. Aortic valve repair included resection of the raphe, leaflet plication and subcommissural annuloplasty. Both patients had satisfactory results in the early postoperative period. Despite the promising outcomes after surgery in these patients, long-term changes in valve function and durability remain unknown. Additional close observation and monitoring are required before the procedure can be recommended as the standard of care.     

Approach to the patient with bicuspid aortic valve and ascending aorta aneurysm

Opinion statement Bicuspid aortic valve (BAV) disease is a common congenital heart valve abnormality accounting for a large number of valve replacements in the United States. Although still incompletely understood, the natural history of BAV disease is severe aortic stenosis and associated ascending aortic dilatation. In addition to the increased risk of endocarditis, aortic dissection and severe aortic valve dysfunction are responsible for most fatal complications. Thus, early and precise recognition of this condition is mandatory. The new American College of Cardiology/American Heart Association recommendations highlight the role of MRI and CT as complimentary tools to echocardiography for the diagnosis and surveillance of the morphology of the aortic valve and ascending aorta. Moreover, better understanding of the cellular mechanisms, including inflammation, bone formation, atherosclerotic-like processes, and aortic wall abnormalities, as well as the heritability and genetic predisposition for the disease, will define the potential for targeted medical therapies in the future. Currently, the treatment of this condition is primarily surgical. Although combined valve and ascending aorta replacement has been the most common surgical approach in the past, the increased cumulative risk of thrombotic and embolic events among these young patients has led to more conservative approaches. Several valve-sparing approaches with comparable mid-term results compared with the classic procedures have recently been reported. However, longer follow-up studies will be helpful to better define the advantages of these new surgical options. After a quick overview of the natural history of the BAV, this article provides an updated approximation of the current knowledge of the pathophysiology as well as the recommendations for the management and treatment of this disease.     

Long-term follow-up after separate replacement of the aortic valve and ascending aorta.

Between May 1974 and November 1991, 28 patients underwent a separate replacement of the aortic valve and the ascending aorta (20 male, eight female; 32 to 71 years old, x = 52 years). 23 patients were operated for ascending aortic aneurysm, three for chronic and two for acute aortic dissection type A. 17/18 patients living at the beginning of this study were re-investigated after a mean follow-up interval of 8.5 years postoperatively with DSA, thoraco-abdominal CT and echocardiography. 1/8 biological aortic valves and 1/20 mechanical valves had to be replaced (four years and two months postoperatively) for valve degeneration and paravalvular leakage respectively. Three patients developed a sinus of Valsalva aneurysm and were reoperated five, 9.2 and 9.3 years after primary repair. In all three patients histological signs of idiopathic degenerative media disease of the aorta were found. Two other patients presented with a perfused perigraft channel and therefore had to be reoperated. Patients with chronic aortic dissection type A and/or ascending aortic aneurysms presenting clinical or intraoperative signs of degenerative media disease of the aorta should undergo composite graft replacement to preclude formation of sinus Valsalva aneurysms.     

Comparison of aortic valve dysfunction and ascending aorta dimension between patients with different bicuspid aortic valve morphology

正Objective To compare the characteristics of aortic valve dysfunction and ascending aorta dimension in patients with different bicuspid aortic valve(BAV)morphology.Methods A total of 197 patients who underwent aortic valve replacement between April 2014 and March2015 and were diagnosed with BAV by patholgy were included,and their clinical data were retrospectively ana-     

Replacement of the ascending aorta with reimplantation of coronary vessels. Apropos of 81 cases

Between 1973 and 1985, 81 patients underwent Bentall's operation. 90 p. 100 of the patients had cystic medionecrosis, but only 24 showed signs of Marfan's syndrome. It must be noted that 12 patients were reoperation cases, 18 were operated upon in an emergency for tamponade (stage V) on acute dissection, and 7 had lesions that involved the aortic arch. The operative procedure was that described by Bentall; Cabrol's modification was used in only 26 patients. The most recent improvements concerned myocardial and (in case of aortic involvement) cerebral protection with an autonomous perfusion of blood at very low temperature. Mortality was low in patients with annulo-aortic ectasia (1 death in 53 cases; 1.8 p. 100) and rose to 34.5 p. 100 (33.3 p. 100 in reoperation cases) in patients with chronic dissection. Evaluation of mortality by stage showed virtually no risk in stages I and II, whereas 4 of the 9 stage IV patients died within the first post-operative month. Late mortality with a mean follow-up of 4 years was 14.2 p. 100; 2 of the 10 deaths were accidental, and 4 of the remaining 8 deaths were due to the anticoagulant therapy (death was precipitated in 2 cases by the presence of a cerebral aneurysm). No case of systemic embolism was observed, and the authors raise the question of whether long-term anticoagulant therapy should be abandoned. None of the patients who underwent Bentall's operation were reoperated upon, whereas 7 out of the 23 patients who had had supracoronary aortic replacement before 1976 had been reoperated upon within a few years.(ABSTRACT TRUNCATED AT 250 WORDS)     

Progressive dilation of the ascending aorta in children with isolated bicuspid aortic valve

Although patients with bicuspid aortic valves (BAVs) are predisposed to ascending aortic (AA) dilation, stenosis, and dissection, the development of aortic disease in children with BAVs is poorly described. The purposes of this study were to determine the rate of change of AA diameter in children with BAVs and to identify risk factors for the development of aortic dilation. The echocardiograms of 276 children aged<19 years (mean 8.5+/-5.3) with isolated BAVs were reviewed. Aortic measurements were normalized to z scores on the basis of body surface area. In a subset of 112 patients with serial examinations, aortic growth rates were calculated and risk factors for more rapid aortic growth determined. At presentation, 33 patients (12%) demonstrated marked AA dilation (z>4), and 70 (25%) were moderately abnormal (z between 2 and 4). The mean+/-SD AA diameter increased more than expected, at a rate of 0.18+/-0.30 z score per year (p<0.0001). In 61 patients with normal AA diameters on initial study, 22 (36%) had abnormal diameters, with z scores>2, at follow-up. Univariate analysis demonstrated right-noncoronary commissural fusion (p<0.02) and aortic valve gradient on initial examination (p<0.02) as significant predictors of AA growth. In multivariate analysis, however, the significance of gradient and valve morphology was diminished (p = 0.06 for both). In conclusion, the progression of AA diameter in patients with normal z scores on initial examination suggests that serial echocardiograms are required to screen for the development of significant aortic dilation.     

Natural history of a dilated ascending aorta after aortic valve replacement.

BACKGROUND: Little information is available regarding the incidence of aortic dissection or rupture in patients with a dilated ascending aorta after aortic valve replacement (AVR). The present clinical study aimed to demonstrate the incidence of aortic complications after AVR in patients with a dilated ascending aorta and to clarify those risk factors associated with the progression of a dilated ascending aorta or late aortic events. METHODS AND RESULTS: A total of 35 patients with a dilated ascending aorta at the time of AVR were enrolled. A dilated ascending aorta was defined as 40 mm or greater in diameter by preoperative computed tomography or operative findings. The baseline ascending aorta diameter ranged from 40 to 55 mm with a mean of 44.8+/-4.4 mm. There was a high frequency of bicuspid valve disease in patients with a dilated ascending aorta (57%). The mean follow-up interval was 8.1+/-3.5 years (range: 2.3-13). Aortic events occurred in 5 patients (aortic dissection in 1, rupture in 2, reoperation in 2) during the follow-up. One aortic dissection developed at a baseline aortic size of 42 mm, whereas 2 aortic ruptures occurred at baseline aortic sizes of 47 mm and 50 mm. There was no statistically significant univariate association between any of the patient clinical characteristics and late aortic events or ascending aortic progression. CONCLUSION: Although the clinical course of patients with a dilated ascending aorta is unpredictable, aortic events may occur even in patients with a baseline aortic diameter of <50 mm. Therefore, preventive aortic surgery at the time of AVR should be considered to prevent aortic dissection or rupture in patients with an even slightly dilated ascending aorta with a diameter of 40 to 50 mm, unless the patient has a high operative risk or older age.     

Pseudoaneurysm of the ascending thoracic aorta years after aortic valve replacement

Aortic pseudoaneurysm (PSA) formation post aortic valve replacement is one of the rare and devastating complications if left untreated. Aortic PSA can occur few weeks or month after surgery. The spectrum of symptoms varies from dyspnea, wide pulse pressure, and chest pain. However, in rare cases, aortic root PSA could be asymptomatic. Aortic PSA mortality could be as high as 70%, if left untreated. Therefore, High clinical suspicion and prompt surgical intervention is imperative. In this case, the patient presented with dyspnea years after Bentall procedure, and imaging studies revealed para-aortic PSA that was treated surgically.     

Relation of aortic wall alterations and ascending aorta diameter in patients with bicuspid aortic valve

Patients with a bicuspid aortic valve tend to develop local enlargement in the convexity of the ascending aorta. There is controversial discussion as to whether this is a dilatation caused by abnormal hemodynamic stress or an aneurysm due to a common developmental defect of the aortic valve and the aortic media. Systematic studies of aortic wall specimens from patients with different diameters of the ascending aorta have not been available until now. We investigated histologically (HE, E.v.G., alpha-Actin, Alcian blue/van Gieson) aortic wall tissue obtained from 107 patients (31 female, 76 male, mean age 60.9+/-12.8 years) with a bicuspid aortic valve. According to the preoperative measurement of the ascending aorta diameter, which was done by CT scan, angiography or echocardiography, the patients were divided into three groups [Group 1: ascending aorta diameter <3.8 cm; Group 2: diameter >/=3.8-4.9 cm and Group 3: diameter >/=5.0 cm]. We looked for histological signs of dilatation or more severe structural changes. All patients of group 1 showed normal findings in histological examination. In 23 of 43 patients in group 2 (65.1%), we found histological signs of dilatation. Histological signs of dilatation were present in all patients in group 3. We conclude that in patients with a bicuspid aortic valve histological signs of dilatation were more frequently found with increasing diameter of the ascending aorta. More severe histological changes, such as cystic media necrosis, were not present.