Aortic prosthetic ring annuloplasty: a useful adjunct to a standardized aortic valve-sparing procedure?

OBJECTIVE: Dilation of aortic annulus, sinuses of Valsalva, and sinotubular junction (STJ) diameters are the characteristic lesions of aortic root aneurysm. The remodeling technique reduces STJ diameter and creates three neosinuses of Valsalva. Alternatively, the reimplantation technique reduces both annulus and STJ diameters to the detriment of aortic root dynamics. Although the remodeling technique is recognized as the most physiological valve-sparing procedure, aortic annulus dilation may jeopardize its results. A standardized approach that combines an external subvalvular aortic prosthetic ring annuloplasty with the remodeling technique is suggested. METHODS: Eighty-three patients underwent an elective aortic root remodeling procedure, either isolated (group 1, n=34) or combined with an external subvalvular aortic prosthetic ring annuloplasty (group 2, n=49). Preoperative aortic regurgitation was 1.59+/-1.1 (group 1) and 1.97+/-1.3 (group 2) (NS). The aortic annulus was more dilated in group 2 than in group 1 (27+/-2.77 mm vs 26.4+/-2.3 mm, p<0.01). Residual aortic regurgitation > or =grade II was the conversion criteria for aortic valve replacement. RESULTS: Operative mortality was 3.6% (n=3). Intraoperative conversion for valve replacement was 32.7% in group 1 (n=11) versus 4.2% in group 2 (n=2) (p<0.001). In group 1, preoperative annulus diameter was larger for converted than for valve-spared patients (27.6+/-1.7 mm vs 25.2+/-1.5 mm, p<0.02). In group 2, implanted aortic ring significantly reduced annulus diameter (20.6+/-1.8 mm) without significant aortic valve gradient (8.3+/-3 mmHg). Follow-up was 17.2+/-13.4 months (group 1) and 10.41+/-7.95 months (group 2). Reoperation for recurrent aortic regurgitation was 13% in group 1 (n=3) versus 4.2% in group 2 (n=2). Echocardiographic follow-up found residual aortic regurgitation < or =grade I in 17 patients in group 1 (90%) versus 43 patients in group 2 (95.5%) and of grade II in two patients in group 1 (10%) and two patients in group 2 (4.5%). CONCLUSION: The addition of external aortic prosthetic ring annuloplasty improves the remodeling technique's operative reproducibility and short-term results. Therefore, its use as a systematical adjunct to the remodeling procedure is suggested. However, further long-term evaluation comparing this valve-sparing procedure to composite graft replacement should define the best surgical strategy for aortic root aneurysm.     

Correction of leaflet prolapse in valve-preserving aortic replacement: pushing the limits?

BACKGROUND: For aortic dilatation with morphologically intact leaflets, valve-preserving aortic replacement has become an accepted treatment modality. Leaflet prolapse, however, may be present, making composite replacement the most frequent choice. Alternatively, valve preservation may be combined with correction of leaflet prolapse. The results of this approach should be comparable with those of valve-preserving aortic surgery in the presence of normal leaflets. METHODS: Between 1995 and 2002, 156 patients were treated by valve-preserving surgery. The aortic valve was bicuspid in 46, and tricuspid in 110 instances. In 88 aortic valves, apparently normal leaflet coaptation (normal, 12 bicuspid and 76 tricuspid), and in 68 instances, prolapse of one or more leaflets, was observed. Root remodeling (n = 133) or aortic replacement with valve reimplantation (n = 23) were performed. Leaflet prolapse was corrected by triangular resection (n = 16) or plicating sutures (n = 59), mostly placed in the central portion of the leaflet. RESULTS: Neither operative mortality nor 5-year survival were influenced by the additional correction of prolapse. Freedom from reoperation at 1 year (normal, 98.8%; prolapse, 96.5%) and 5 years (normal, 97.3%; prolapse, 96.5%) were comparable in both cohorts, as was freedom from aortic regurgitation > or = II at 1 year (normal, 98.8%; prolapse, 94.2%) and 5 years (94.4%). CONCLUSIONS: Surgical correction of leaflet prolapse in combination with proximal aortic replacement is feasible with good results. Midterm results are identical with those known for morphologically normal leaflets. Repair of prolapse allows for preservation of the native valve in most patients with aortic regurgitation and aortic pathology, and thus appears a beneficial addition to valve-preserving surgery.     

Aortic root dilatation may alter the dimensions of the valve leaflets

Objective: Valve-sparing surgery can be used in patients with dilated aortic roots and aortic insufficiency (AI) but has not become a common practice, in part because the spared valve may be incompetent. Our goal was to study how the dimensions of the aortic root and leaflets have changed in such patients. Methods: Fourteen patients with dilated aortic root and AI were examined by transesophageal echocardiography. The annulus diameter, sinotubular junction (STJ) diameter, sinus height, leaflet free-edge length, and leaflet height were measured. Correlations among these dimensions and with the AI grades were explored. Measurements were also made in 19 normal human aortic valves from silicone molds. Results: There was no evident change in the average diameter of the annulus between the normal valves and those in the dilated aortic roots. The STJ diameter was obviously increased in the dilated aortic roots; the aortic sinuses also appeared to be taller and the leaflets larger than normal. The leaflet free-edge length, the leaflet height, and the sinus height were found to increase with the dilated STJ diameter. The degree of AI was not found to correlate well with any of the dimensions measured. Conclusions: The dimensions of the leaflets may change parallel to aortic root dilatation with AI. Therefore, during valve sparing, it may be necessary to correct both the dilatation of the root and the leaflet free-edge length to achieve a competent valve.     

Is preservation of the aortic valve different between acute and chronic type A aortic dissections?

OBJECTIVES: In repair of acute type A aortic dissection, the type of proximal repair of the ascending aorta has been of great interest; however, very few reports are available regarding this issue in chronic aortic dissection. The surgical strategies for proximal repair in chronic dissection may not the same as those for acute dissection. We reviewed our 10-year experience of both acute and chronic type A aortic dissections in order to elucidate the validity of valve preservation and the long-term results of aortic regurgitation (AR). METHODS: From 1990 to 1999, 93 patients (55 acute and 38 chronic dissections) underwent operation for type A aortic dissection. Five Marfan patients were included in each group. The degree of AR was evaluated by echocardiography before and after (at hospital discharge and late follow-up) operation. RESULTS: In acute type A aortic dissection (n=55), 16 patients had AR grade II or greater (29%), of whom seven had AR grade III (13%). In 29 patients, dissection was found below the sinotubular junction (STJ) and 14 patients had AR grade II or greater (48%). The aortic valve was replaced in four patients (7%), of whom three had Marfan's syndrome. Only one non-Marfan patient required aortic valve replacement because of valve stenosis. In those whose aortic valve was preserved (n=51), three patients still had AR grade II at hospital discharge, while at late follow-up, AR had deteriorated to grade III in two of them, although no reoperation has been required so far. In chronic type A aortic dissection (n=38), 14 patients had AR grade II or greater (37%), of whom 11 had AR grade III or greater (29% vs. 13% in acute dissection; P=0.051). In 15 patients, dissection was found below the STJ and 12 patients had AR grade II or greater (80% vs. 48% in acute dissection; P=0.043). The aortic valve was replaced in eight patients (21% vs. 7% in acute dissection; P=0.051), including three Marfan patients. Of those whose aortic valve was preserved (n=30), two patients required reoperation for severe AR. The freedom from postoperative AR grade III or greater was 89% at 5 years for operative survivors with acute dissection and 92% for those with chronic dissection, respectively. CONCLUSIONS: This retrospective study suggests that preservation of the aortic valve in acute type A aortic dissection is feasible in non-Marfan patients regardless of the degree of AR. In chronic dissection, aortic root replacement needs to be considered when the degree of AR is greater than moderate because of a dilated STJ and/or annulus. In both acute and chronic dissections, satisfactory mid- to long-term results with a low incidence of reoperation were obtained in those whose aortic valve was preserved.     

Midterm results after aortic valve-sparing operation

OBJECTIVES: We have conducted aortic valve-sparing operation for patients having aortic root dilatation and almost normal aortic valve leaflets since August 1998, and here report midterm results. METHODS: Patients with dilated aortic annulus or Marfan's syndrome were treated with reimplantation, and the remaining patients with remodeling. Either 24 or 26 mm graft was selected based on aortic annular diameter and leaflet size. Aortic valve competence was assessed regularly with echocardiography. RESULTS: Five patients (age: 29 +/- 13 yr), including 4 with Marfan's syndrome, had undergone reimplantation, and 3 (age: 46 +/- 18 yr) remodeling by December 2000. Mean follow-up was 18 (range: 10-32) months, and no postoperative death has occurred and no reintervention has been required thus far. All the patients in the remodeling group showed only a small pressure gradient through the aortic valve and decreased left ventricular diameter. Two in the reimplantation group showed a pressure gradient exceeding 20 mmHg. Two Marfan's syndrome patients in the reimplantation group showed slightly increased diastolic left ventricular diameter and 3 slightly increased systolic left ventricular diameter. Although aortic regurgitation had diminished in all patients by discharge, moderate aortic regurgitation recurred in 1 non-Marfan's syndrome patient in the reimplantation group because of degenerated aortic valve. CONCLUSION: Although postoperative aortic valve function was not perfect in all patients undergoing reimplantation, midterm results after aortic valve-sparing operation were generally satisfactory. Proper selection of patients, procedures, and graft size was thought to be important to ensure a favorable surgical outcome.     

Tricuspidisation of the aortic valve with creation of a crown-like annulus is able to restore a normal valve function in bicuspid aortic valves

Objective: To evaluate the early results of a new method to repair malfunctioning bicuspid aortic valves by creating a tricuspid valve with a crown-like (i.e. anatomic) annulus. Material and methods: Twelve patients (ages from 10 to 27 years) with chronic regurgitation (and flow-dependent stenosis) of a bicuspid aortic valve underwent repair with the principle of creating a tricuspid valve and a crown-like annulus. The fused leaflets were trimmed and reinserted underneath the existing aortic annulus to create one new native cusp. The third leaflet was fashioned out of a xenopericard patch and was inserted underneath the existing annulus as well to restore the crown-like anatomy of a normal aortic annulus. A tricuspid aortic valve with a morphologically normal annulus was thus created, which resulted in improved coaptation of the leaflets. The repair was immediately assessed by transesophageal echocardiography (TEE) with the heart loaded at 50%. In two patients, a second run helped fine-tune the repair. Median cross-clamping time was 82 min. Follow-up ranged from 3 to 46 months (median 13 months). Results: No significant complication occurred. The function of the aortic valve was excellent with trivial or mild regurgitation in 11 patients and moderate regurgitation in 1 patient. There was no stenosis across the valve. The repair remained stable over time. Remodelling of the left ventricle occurred as expected. Conclusions: Aortic valve repair is feasible in some dysfunctioning bicuspid aortic valves. Tricuspidisation of the valve can result in excellent systolic and diastolic functions. The creation of a crown-like annulus results in improved coaptation of the cusps and could lead to more reliable outcome. Although long-term results are needed, this anatomic correction seems to be a good alternative to valvular replacement in certain sub-groups of patients.     

Intravalvular implantation technique for aortic valve replacement in aortitis syndrome

BACKGROUND: Paravalvular leakage is one of the most serious complications of aortic valve replacement in patients with aortitis syndrome. The purpose of this study was to compare the effectiveness of the intravalvular implantation technique in preventing paravalvular leakage with that of the conventional technique. METHODS: Since 1982, 14 patients with aortic regurgitation caused by aortitis syndrome have undergone aortic valve replacement at our institute. An intravalvular implantation technique was applied in 7 of the 14 patients. The technique consists of suturing a prosthetic valve to the aortic annulus and sandwiching the leaflets between exogenous felt pledgets and the inflamed aortic annulus. RESULTS: Paravalvular leakage occurred in 3 of 7 patients in the conventionally treated group and in none of 7 in the intravalvular implantation group. CONCLUSIONS: The intravalvular implantation technique is effective in preventing paravalvular leakage in patients with aortitis syndrome.     

Aortic root remodeling in atheromatous aneurysms: the role of selected sinus repair.

OBJECTIVE: Atheromatous ascending aortic aneurysms (AAA) frequently present with aortic regurgitation (AR) from dilatation of the sino-tubular junction (STJ) and extension of the pathological process into the root. Experience suggests that root dilatation begins in the non-coronary, then right coronary sinus. Rather than employ aortic root replacement or the David procedure, we have elected to replace the ascending aorta and remodel the STJ and involved sinuses. We studied the outcome after selective sinus replacement in 29 consecutive AAA patients between 1995 and 2001. METHODS: There were nine male and 20 females. Age ranged from 47 to 79 years (mean 67.5). Seven had arch aneurysms and four coronary artery disease. Nineteen were NYHA III or IV. Grade of AR was IV in 20, III in five and II in four. The STJ was dilated >50% of annulus diameter in each case (5.3-10.0 cm, mean 6.4 cm). All valves had three cusps. All patients underwent ascending aortic replacement. Seven had arch replacement and four coronary artery bypass. Seven had replacement of both right and non-coronary sinuses with re-implantation of the right coronary ostium. Twelve had replacement of the non-coronary sinus alone whilst nine had right coronary sinus replacement. One with dextrocardia had left coronary sinus replacement with ostial re-implantation. The graft size was within 2 mm of annulus size except for two patients (24 mm 12, 26 mm 11, and 28 mm six). Post operative echocardiographic studies were performed. None of the patients received anticoagulation. RESULTS: There were no hospital or late deaths and no thromboembolic or infective complications. Two patients had mild to moderate aortic regurgitation. These had a size 28 graft, which in retrospect was too large. Others had no significant regurgitation. CONCLUSIONS: The native aortic valve can be preserved in the majority of patients with AAA. Remodelling of the STJ and selective sinus replacement restores valve competence. Anticoagulation and prosthesis related complications are thereby avoided.     

In-vitro study on the relationship between progressive sinotubular junction dilatation and aortic regurgitation for several stentless aortic valve substitutes.

OBJECTIVE: Stentless aortic valves are widely used due to their excellent hemodynamic properties. However, if the subcoronary implantation technique is used later dilatation of the sinotubular junction (STJ) can cause regurgitation. The aim of the study was to determine the dilatation tolerance of two commercially available stentless xenografts and fresh aortic and pulmonary roots against such dilatation. METHODS: Four groups each comprising five specimens of fresh porcine aortic roots, pulmonary roots, Medtronic freestyle or Toronto SPV Xenografts were tested in a mock circulation using a special device for gradually increasing the diameter of the sinotubular junction. The smallest diameter D(r) where regurgitation occurs was measured and correlated with the starting diameter D(a) and expressed as per cent values. Opening and closing patterns were obtained by a high speed camera and flow characteristics were determined. RESULTS: The highest dilatation tolerance of STJ was found in the fresh porcine aortic roots (165%+/-10) followed by fresh pulmonary roots (146%+/-12), the Freestyle (143%+/-4) and the SPV (132%+/-5) bioprostheses. All differences were significant with P< or =0.05 except that between the fresh pulmonary roots and the two commercial available bioprostheses. CONCLUSIONS: Our results indicate that aortic homografts provide higher resistance against regurgitation induced by dilatation of the STJ than an autograft or the stentless xenografts, Freestyle xenograft followed by the Toronto SPV. The use of the full-root technique should be considered if aortic dilatation seems to be likely.     

Intraoperative transesophageal echo-Doppler evaluation of stentless aortic xenografts. Incidence and significance of moderate gradients

BACKGROUND: The aim of this study was to assess the utility of intraoperative transesophageal echocardiography (TEE) in the evaluation of patients undergoing aortic valve replacement with the CryoLife-O'Brien (CLOB) Stentless Porcine Aortic Bioprosthesis. METHODS: Between May 1994 and March 1995, 26 patients (15 men, mean age 68.4+/-10.78 years) had a CLOB valve in the aortic position. Transprosthetic gradients and valve regurgitation were detected by intraoperative TEE. Prosthetic regurgitation and transvalvular gradients were evaluated at six-month intervals using transthoracic echo-Doppler (TTE). RESULTS: The majority of implants resulted in low gradients (83.7%), with only four patients exhibiting a moderate gradient (15.3%). Color flow Doppler imaging showed central aortic regurgitation in only four of 25 patients (trivial, n=4; mild, n=1). There was one paravalvular leak (trivial, n=1). At follow-up examination (mean 37+/-12 months), 24 of 25 patients exhibited low mean gradients (7.25+/-2.81 mmHg). At follow-up one patient who had low velocities in the LVOT at perioperative evaluation exibited a moderate gradient (45 mmHg) with an effective orifice area of 0.8-0.9 cm(2). CONCLUSIONS: Intraoperative TEE was effective in assessing prosthetic stentless valve function.     

Valve-preserving aortic replacement: does the additional repair of leaflet prolapse adversely affect the results?

OBJECTIVE: Valve-preserving aortic replacement has evolved into an accepted therapeutic option for aortic ectasia with morphologically intact leaflets. Some patients, however, exhibit additional leaflet prolapse. We compared the results of established valve-preserving techniques with those of the combination of valve-preserving aortic surgery and additional repair of leaflet prolapse. METHODS: Between October 1995 and March 2000, 99 patients underwent valve-preserving root replacement by means of root remodeling or valve reimplantation for acute dissection (n = 25), chronic dissection (n = 4), or aneurysm (n = 70). In group A (63 patients) either root remodeling (n = 49) or valve reimplantation (n = 14) was performed with a standard technique. In group B (36 patients) valvepreserving aortic replacement (remodeling, n = 31; reimplantation, n = 5) was combined with repair of leaflet prolapse in the presence of bicuspid (n = 24) or tricuspid (n = 12) valve anatomy. Additional replacement of the aortic arch was required more frequently in group A (group A, n = 43; group B, n = 14; P =.006); otherwise, the groups were comparable. RESULTS: Cardiopulmonary bypass (group A, 133 +/- 31 minutes; group B, 117 +/- 30 minutes; P =.006) and myocardial ischemia times (group A, 96 +/- 25 minutes; group B, 88 +/- 20 minutes; P =.05) were significantly longer in group A. Mortality was not significantly different between groups (group A, 4.8%; group B, 0%). One patient in each group underwent secondary valve replacement, and all other patients had stable valve function. Freedom from aortic regurgitation of grade 2 or greater after 48 months was 93.0% in both groups. CONCLUSION: Repair of leaflet prolapse in conjunction with valve-preserving root replacement leads to midterm results that are equal to those of valve-preserving root replacement for morphologically intact leaflets.     

Durability of aortic valve preservation and root reconstruction in acute type A aortic dissection

BACKGROUND: The aim of this study was to determine the durability of aortic valve preservation and root reconstruction in type A aortic dissection with involvement of the aortic root. METHODS: From November 1976 to February 1999, 246 patients underwent surgical treatment for acute type A aortic dissection at our institution. In 121 patients (49%), all with acute type A dissection and aortic root involvement, the aortic valve was preserved and one or more of the sinuses of Valsalva were reconstructed. The mean age of this group was 59 +/- 11 years and 70 (58%) were men. Thirty patients (25%) were operated in cardiogenic shock. Criteria for aortic root reconstruction were technical feasibility and surgeon preference. Techniques used for reconstruction were valve resuspension in all patients and additional reinforcement of the aortic root with Teflon (L.R. Bard, Tempe, AZ) felt (n = 21), gelatin-resorcinol-formaldehyde-glue (GRF-glue, Fii, Saint-Just-Malmont, France) (n = 103), or fibrinous glue (Tissu-col, Immuno AG, Vienna, Austria) (n = 5). Mean follow-up was 43.5 +/- 46 months. RESULTS: The operative mortality was 21.5% (n = 26). Actuarial survival was 72% +/- 4%, 64% +/- 5%, and 53% +/- 6% at 1, 5, and 10 years, respectively. Median aortic regurgitation in patients with retained native aortic valve at follow-up was 1+. All root reoperations included aortic valve replacement (n = 12). Freedom from aortic root reoperation was 95% +/- 2% at 1 year, 89% +/- 4% at 5 years, and 69% +/- 9% at 10 years. The incidence of aortic root reoperation was 23%, 11%, and 40%, respectively, when Teflon felt, GRF-glue, and fibrinous glue were used for root reconstruction. Multivariate Cox proportional hazard analysis revealed the use of fibrinous glue (RR = 8.7; p = 0.03) as well as the presence of an aortic valve annulus more than 27 mm (RR = 4.2; p = 0.04) as independent risk factors for aortic root reoperation. CONCLUSIONS: Aortic valve preservation in acute type A dissection provides relatively durable results. The use of fibrinous glue for root reconstruction seems to compromise the long-term durability of the repair compared with Teflon felt and GRF-glue. A dilated aortic annulus requires a more extensive root procedure.     

Aortic valve reconstruction using self-developed aortic valve plasty system in aortic valve disease

Aortic valve disease is usually treated by prosthetic valve replacement. We have performed aortic valve plasty (AVP) using glutaraldehyde-treated autologous pericardium. AVP was performed for 88 patients from April 2007 through August 2009. Sixty-five patients had aortic stenosis, and 23 patients had aortic regurgitation (AR). Twenty-one patients showed bicuspid aortic valves, and one patient showed quadricuspid valve. There were 43 males and 45 females. Their mean age was 70.6±10.5 years old. First, diseased leaflets excised. Then, the distance between each commissure was measured. The new leaflet were trimmed with an original template from a glutaraldehyde-treated autologous pericardium sample. Finally, the annular margin of the pericardial leaflet was running sutured to each annulus. There was no operative mortality or embolic event. Postoperative echocardiography revealed a mean peak pressure gradient (PG) of 19.0±9.1 mmHg one week after surgery. Thirty-two patients had echocardiography one year after surgery. The peak PG became 12.9±5.8 mmHg. Ten patients showed no AR, 20 patients showed trivial AR, and two patients showed mild AR. Freedom from reoperation is 100% at three years follow-up.     

Mitral annulus calcification: determinants of repair feasibility, early and late surgical outcome.

OBJECTIVE: The aim of this study was to determine the factors influencing the feasibility of valve repair and the surgical outcome in patients with mitral annulus calcification. METHODS: In 124 patients with mitral annulus calcification undergoing surgery, two entities were distinguished: Barlow disease (myxomatous leaflets, n=60) and fibroelastic deficiency (FED) (normal leaflets, n=64). The calcification score was lower (1.9 vs 2.8); the annulus was more dilated (ring 35 vs 32 mm) and ruptured chordae were more frequent (77% vs 37%) in Barlow than in FED (p<0.001). The clinical profile was different: age (60+/-14 vs 73+/-8 years, p<0.001), systemic hypertension (22% vs 70%, p<0.001), chronic renal insufficiency (5% vs 22%, p<0.01), cancer (7% vs 25%, p<0.01). Multifocal atherosclerosis was less frequent in Barlow than in FED: carotid disease (17% vs 54%, p<0.001), aortic atheroma (21% vs 51%, p<0.001) and coronary disease (22% vs 56%, p<0.01). Echocardiography showed two different patterns in Barlow and FED: aortic valve stenosis (1.7% vs 31%), left atrial diameter (54 vs 49 mm), left ventricular end-diastolic diameter (62 vs 54 mm), interventricular septal thickness (11 vs 13 mm), and systolic pulmonary pressure (40 vs 56 mmHg), respectively (p<0.001). Bacterial endocarditis was observed in 24 cases (19%). RESULTS: The surgical technique was a valve repair in 68% and a replacement in 32%. The repair rate depended upon the extent of annulus calcifications (p<0.001) and the type of degenerative disease (95% vs 44% in Barlow and FED p<0.001). In-hospital mortality was 14% (Barlow: 5% vs FED: 23%, p<0.01). The mean follow-up was 50+/-41 months. Overall 5-year year survival was 76% (Barlow: 90% vs FED: 64%, p<0.001) and survival free from cardiac event was 69% at 5 years (Barlow: 87% vs FED: 52%, p<0.001). Five-year survival was higher following repair than replacement (84% vs 64% p<0.001). Chronic renal insufficiency and bacterial endocarditis were two predictors of early and late death (p<0.01). CONCLUSIONS: The aetiopathogeny of the degenerative mitral disease responsible for annulus calcifications corresponded to distinct anatomical, clinical and echographic patterns. It was a main determinant of repair feasibility, early and late surgical outcome.     

Midterm results of total aortic root replacement with pulmonary autograft (Ross operation)

Between February 1995 and December 1999, 18 patients underwent Ross operation. Age at the operation ranged from 2 to 31 years. Diagnosis includes congenital aortic stenosis and/or regurgitation in 15, and adult aortic regurgitation in 3. In all cases autograft was implanted by the method of total aortic root replacement, associated with annuloplasty for the dilated aortic annulus in 2 and aortoventriculotomy by the Konno procedure in 3 (Ross-Konno). Right ventricular outflow tract was reconstructed by a pulmonary homograft in 12, a xenopericardial conduit in 3, or the other reconstructive procedures with autologous tissue and outflow patch in 3. There was no operative and late death. Reoperation was needed in 1 patient due to stenosis of pericardial conduit 4 years after the initial operation. Pressure gradient across implanted autograft valve was negligible (4.8 +/- 0.5 mmHg), and echocardiography revealed no aortic regurgitation in 12 cases and trivial to mild in 6, over a mean follow-up period of 23 +/- 18 months (range 2 to 60 months), signifying excellent durability of implanted autograft. Right ventricular outflow tract reconstruction with the homograft resulted in excellent mid-term performance as showing pressure gradient of 9.0 +/- 4.6 mmHg and no regurgitation in 11 of 12 cases, whereas pressure gradient was 17.9 +/- 13.1 mmHg in the patients underwent the other reconstructive procedures. We conclude that Ross procedure associated with the concomitant procedures to adjust the size discrepancy between the native aortic annulus and autograft has provided good midterm results with excellent autograft durability. And this procedure was thought to be a preferable method for children as well as young adults with congenital aortic stenosis.     

Pulmonary homograft: should it be used in the aortic position?

OBJECTIVE: Retrospective analysis was performed to determine the suitability of pulmonary homograft as an aortic valve substitute. METHODS: From January 1994 through June 1999, 147 patients (mean age, 32.2 +/- 17.3 years) underwent aortic valve replacement with either an aortic homograft (group 1: n = 103, 25 fresh antibiotic preserved and 78 cryopreserved) or a pulmonary homograft (group 2: n = 44, 11 antibiotic preserved and 33 cryopreserved). In group 1 a scalloped subcoronary technique was used in 64 patients, and a root replacement technique was used in 39 patients. In group 2 the scalloped subcoronary technique was used in 34 patients, and the root replacement technique was used in 10 patients. RESULTS: There were 131 operative survivors (group 1 = 91; group 2 = 40). Follow-up ranged from 2 to 62 months. In group 1 none of the patients had significant aortic regurgitation during the hospital stay. Three patients (all having undergone the scalloped subcoronary technique) had moderate aortic regurgitation after 6 to 32 months. In group 2, 10 patients (9 having undergone the scalloped subcoronary technique and 1 having undergone the root replacement technique) developed significant regurgitation: 2 intraoperatively, 5 in the early postoperative period before discharge from the hospital, and 3 during late follow-up 6 to 12 months postoperatively. Among the various risk factors analyzed for overall homograft failure, use of a pulmonary homograft was the single independent predictor of valve failure (odds ratio, 8.6; 95% confidence interval, 1.9-39; P =.006). CONCLUSION: Pulmonary homograft, when inserted by means of a scalloped subcoronary technique, is not a suitable aortic valve substitute.     

A New Modification of Debridement Valvuloplasty for Acquired Aortic Valve Disease

A high speed electric rasp was used to remove fibrous thickening from the aortic valve in conjunction with aortic valve commissurotomy in ten patients. All patients had moderate rheumatic aortic valve disease combined with severe mitral valve disease, and were treated by mitral valve replacement and aortic valve repair. All patients survived the operative procedure. There were no deaths or complications during hospitalization related to the valve repair process. The transaortic valve gradient was relieved from an average of 21.0 ± 8.6 mmHg to 5.6 ± 4.0 mmHg (catheterization), and from moderate to less-than-mild stenosis (echocardiography). Aortic valve regurgitation was reduced from an average of 2.2+ to 0.7+ on a scale of 0 to 4+ (aortography), and from an average of 2.5+ to 1.1+ on a scale of 0 to 4+ (echocardiography). During the follow-up period, no patients were reoperated on because of aortic valve dysfunction. Follow-up echocardiographic study demonstrated that the transaortic pressure gradient and valvular regurgitation had not progressed, and immediate postoperative conditions were maintained. There were two late deaths not related to the aortic valve. One patient died of prosthetic valve endocarditis in the mitral prosthesis 14 months postoperatively, and the other of a cerebrovascular accident 21 months postoperatively. Based on these data, we believe that aortic valve repair with a high speed electric rasp can effectively relieve aortic stenosis, reduce valvular regurgitation, and provide an excellent hemodynamlc result at early and mid-term follow-up. (J Card Surg 1994;9:103–108)     

Relation between size of prosthesis and valve gradient: comparison of two aortic bioprosthesis.

OBJECTIVES: The outcome of patients undergoing aortic valve replacement (AVR) may be affected by the influence of prosthesis-patient mismatch on left ventricular mass regression. However, due to the discrepancies in labeled valve size, size of sizer and actual valve dimension, it is difficult to compare different valve types. In order to perform an objective comparison, this study was designed to compare the hemodynamics of the Edwards Lifescience pericardial (ELP) and the Medtronic Mosaic porcine (MM) bioprosthesis between patients receiving the same valve size and between patients with the same aortic annulus diameter. METHODS: This prospective, randomized study was performed on 81 hospital survivors out of 86 patients undergoing AVR with either the ELP (n=39) or the MM (n=42) bioprosthesis. Intra-operative randomization was performed after the surgeon had excised the aortic valve, measured the size of the aortic annulus with three different sizers (ELP, MM and a set of metric sizers), and decided which size he would implant for either of the valve types. All valves were implanted in supra-annular position with the same implantation technique. Echocardiographic follow-up was performed early postoperatively and 6 months thereafter. RESULTS: In 12 (31%) of the patients receiving the ELP-valve, as compared to 3 (7.1%) of the patients receiving the MM-valve, the labeled valve size was smaller than the aortic annulus diameter (P<0.05). Early postoperatively, mean (17.4+/-3.1 vs 20.3+/-3.6 mmHg) and peak gradients (30.1+/-4.8 vs 37.6+/-9.6 mmHg) for the 21 mm ELP-valve were lower than for the 21 mm MM-valve (P<0.05). All other hemodynamic parameters did not show significant differences at any time point. When the same aortic annulus diameter was taken as a reference, there were no significant hemodynamic differences between either valve type at any time point, regardless of the valve size implanted. CONCLUSIONS: This study demonstrates that the hemodynamic performance of the ELP and the MM bioprosthesis are comparable when the same aortic annulus diameter is taken as a reference. The significant variabilities between different valve types with regard to labeled valve size, valve-sizer size and actual valve size have to be taken into account, when hemodynamic comparisons are performed.     

Aortic valve replacement with frame-supported autologous fascia lata grafts. III. Haemodynamic and angiographic findings.

Thirty-two patients with a frame-supported, autologous, fascia lata graft implanted in the aortic annulus were investigated 11 to 36 months after the operation. The group comprised 7 patients with pure aortic stenosis, 10 with combined aortic stenosis and aortic incompetence and 15 with pure aortic incompetence. Six patients had concomitant mitral valve disease. The follow-up investigation included right heart and transseptal left heart catheterization, left ventricular angiocardiography through the transseptal route and a retrograde, supravalvular aortography with the cinétechnique. Cardiac output was essentially unchanged postoperatively. However, it had increased considerably in some patients in whom it was very low before the operation. Left ventricular systolic pressure decreased particularly in patients with pure aortic stenosis. Left ventricular enddiastolic pressure decreased from 12 to 7 mmHg at rest and from 25 to 18 mmHg during exercise. Left atrial (or pulmonary arterial wedge) mean pressure decreased from 14 to 2 mmHg at rest, and from 27 to 16 mmHg during exercise. In 76% of the patients a slight (grade I or II) central or paravalvular aortic regurgitation was observed on cinéangiograms. Regurgitation of grade III was found in one patient. Technical details in the construction of the valve, as well as structural changes in the fascia lata which may be responsible for stenosis and incompetence in some of these valves are discussed. Thus, although even patients with defective valves have shown considerable improvement, a close and continuous follow-up of these patients is necessary.     

Impact of valve prosthesis-patient mismatch on intermediate-term outcome and regression of left ventricular mass following aortic valve replacement with mechanical prosthesis

BACKGROUND: The impact of aortic valve replacement (AVR) with prosthesis-patient mismatch (PPM) on intermediate-term outcome and left ventricular mass (LVM) regression in patients with aortic stenosis (AS) was investigated. METHODS: One hundred fifty patients with AS (87 pure stenosis and 63 combined stenosis and regurgitation) were classified into a PPM group (n = 34, indexed effective orifice area (EOAI) >0.65 cm(2)/m(2) and < or =0.85 cm(2)/m(2); moderate PPM) and a non-PPM group (n = 116, EOAI > 0.85). Mean age, mean and peak aortic pressure gradient (PG) were not different between the groups (PPM, 99.7 +/- 37.2 and 54.9 +/- 23.2 mmHg; non-PPM, 95.9 +/- 29.2 and 54.4 +/- 16.0 mmHg). The absolute and relative regression in indexed left ventricular mass (LVMI) was estimated by preoperative and postoperative echocardiography (n = 98). RESULTS: Twelve patients died (valve-related death in 7) during 5 years of follow-up. Comparing the PPM and non-PPM groups, overall survival (78.7% vs. 87.8%) and survival free from valve-related death (96.8% vs. 92.1%) were not significantly different. New York Heart Association (NYHA) functional class improved in all patients and there were no patients in class III or IV. The postoperative mean PG was 14.6 +/- 6.1 mmHg in the PPM group and 9.4 +/- 3.8 mmHg in the non-PPM group (p = 0.0005), with an inverse correlation (r = -0.48, p < 0.0001) between EOAI and the postoperative mean PG. However, there was no significant difference in the absolute and relative LVMI regression between the two groups. Multiple linear regression analysis was performed and higher preoperative LVMI and mean aortic PG were independent predictors of greater LVMI regression after AVR. CONCLUSIONS: Moderate PPM does not appear to alter LVMI regression, NYHA class, or intermediate-term outcome in AS patients undergoing AVR with mechanical prostheses. In multivariate analysis, preoperative LVMI and mean aortic PG were important independent predictors of LVMI regression.