Severe mitral regurgitation--relations between magnetic resonance imaging,echocardiography and natriuretic peptides

Objective - The validity of the Ross operation as freestanding root replacement in adult patients with bicuspid aortic valve disease has lately been questioned. We have analyzed retrospectively our results in 23 adult patients (19 males) operated for bicuspid aortic valve disease ad modum "Ross" employing a freestanding root replacement technique. Design - In 9 patients the dominant aortic valve lesion was stenotic (aortic stenosis group) and in the remaining 14 patients it was aortic insufficiency (aortic insufficiency group). The fate of the pulmonary autograft in the two groups was studied. The intraoperatively measured aortic and pulmonary annuli diameters from the two groups were compared with those from a population of normal looking aortic and pulmonary valves matched for body surface area. Results - The aortic insufficiency group needed significant reduction of the aortic annulus diameter to conform to the size of the pulmonary autograft. The pulmonary autograft annuli in this group were significantly larger in diameter than the ones in the aortic stenosis group. The mean pulmonary annulus diameter in the aortic stenosis group was, on the other hand, significantly smaller when compared with that in the normal matched population. After a mean follow-up period of about 19 months, the aortic insufficiency group showed significant dilatation of the neo-aortic sinuses. Between the two groups, the remaining echocardiographic variables remained either stable or improved at follow-up. Conclusion - Pre-existing larger diameters of the aortic and pulmonary annuli in the aortic insufficiency group combined with the significantly increased left ventricular end-diastolic diameters, may predispose these patients to significant dilatation of the unsupported aortic sinuses after a Ross operation. This dilatation does not, however, lead to increase in the autograft valve insufficiency at short-term follow-up if the aortic annulus and the distal ascending aorta are tailored to the size of the pulmonary autograft. Ross operation, employing freestanding aortic root replacement technique, may therefore be recommended in adult patients with bicuspid aortic valve disease with excellent short-term results.     

Ross operation for bicuspid aortic valve disease in adults: is it a valid surgical option?

OBJECTIVE: The validity of the Ross operation as freestanding root replacement in adult patients with bicuspid aortic valve disease has lately been questioned. We have analyzed retrospectively our results in 23 adult patients (19 males) operated for bicuspid aortic valve disease ad modum "Ross" employing a freestanding root replacement technique. DESIGN: In 9 patients the dominant aortic valve lesion was stenotic (aortic stenosis group) and in the remaining 14 patients it was aortic insufficiency (aortic insufficiency group). The fate of the pulmonary autograft in the two groups was studied. The intraoperatively measured aortic and pulmonary annuli diameters from the two groups were compared with those from a population of normal looking aortic and pulmonary valves matched for body surface area. RESULTS: The aortic insufficiency group needed significant reduction of the aortic annulus diameter to conform to the size of the pulmonary autograft. The pulmonary autograft annuli in this group were significantly larger in diameter than the ones in the aortic stenosis group. The mean pulmonary annulus diameter in the aortic stenosis group was, on the other hand, significantly smaller when compared with that in the normal matched population. After a mean follow-up period of about 19 months, the aortic insufficiency group showed significant dilatation of the neo-aortic sinuses. Between the two groups, the remaining echocardiographic variables remained either stable or improved at follow-up. CONCLUSION: Pre-existing larger diameters of the aortic and pulmonary annuli in the aortic insufficiency group combined with the significantly increased left ventricular end-diastolic diameters, may predispose these patients to significant dilatation of the unsupported aortic sinuses after a Ross operation. This dilatation does not, however, lead to increase in the autograft valve insufficiency at short-term follow-up if the aortic annulus and the distal ascending aorta are tailored to the size of the pulmonary autograft. Ross operation, employing freestanding aortic root replacement technique, may therefore be recommended in adult patients with bicuspid aortic valve disease with excellent short-term results.     

Surgical treatment of the dilated ascending aorta: when and how?

Background. The aorta is considered pathologically dilated if the diameters of the ascending aorta and the aortic root exceed the norms for a given age and body size. A 50% increase over the normal diameter is considered aneurysmal dilatation. Such dilatation of the ascending aorta frequently leads to significant aortic valvular insufficiency, even in the presence of an otherwise normal valve. The dilated or aneurysmal ascending aorta is at risk for spontaneous rupture or dissection. The magnitude of this risk is closely related to the size of the aorta and the underlying pathology of the aortic wall. The occurrence of rupture or dissection adversely alters natural history and survival even after successful emergency surgical treatment.

Methods. In recommending elective surgery for the dilated ascending aorta, the patient’s age, the relative size of the aorta, the structure and function of the aortic valve, and the pathology of the aortic wall have to be considered. The indications for replacement of the ascending aorta in patients with Marfan’s syndrome, acute dissection, intramural hematoma, and endocarditis with annular destruction are supported by solid clinical information. Surgical guidelines for intervening in degenerative dilatation of the ascending aorta, however, especially when its discovery is incidental to other cardiac operations, remain mostly empiric because of lack of natural history studies. The association of a bicuspid aortic valve with ascending aortic dilatation requires special attention.

Results. There are a number of current techniques for surgical restoration of the functional and anatomical integrity of the aortic root. The choice of procedure is influenced by careful consideration of multiple factors, such as the patient’s age and anticipated survival time; underlying aortic pathology; anatomical considerations related to the aortic valve leaflets, annulus, sinuses, and the sino-tubular ridge; the condition of the distal aorta; the likelihood of future distal operation; the risk of anticoagulation; and, of course, the surgeon’s experience with the technique. Currently, elective root replacement with an appropriately chosen technique should not carry an operative risk much higher than that of routine aortic valve replacement. Composite replacement of the aortic valve and the ascending aorta, as originally described by Bentall, DeBono and Edwards (classic Bentall), or modified by Kouchoukos (button Bentall), remains the most versatile and widely applied method. Since 1989, the button modification of the Bentall procedure has been used in 250 patients at Mount Sinai Medical Center, with a hospital mortality of 4% and excellent long-term survival. In this group, age was the only predictor of operative risk (age > 60 years, mortality 7.3% [9/124] compared with age < 60, mortality 0.8% [1/126], p = 0.02).

Conclusions. This modification of the Bentall procedure has set a standard for evaluating the more recently introduced methods of aortic root repair.     

Redo operations for recurrent aneurysmal disease of the ascending aorta and transverse aortic arch

Sixty-seven operations were performed in 59 patients for aneurysmal disease occurring after previous operations involving the ascending aorta and transverse aortic arch. The initial aortic pathological condition included the following: fusiform aneurysm due to medial degenerative disease in 34 patients, 12 of whom had Marfan's syndrome; aortic dissection in a previously undilated aorta in 23; and aneurysm persisting or occurring after brachiocephalic bypass in 2. One of the latter had an aneurysm because of aortitis. Various operations initially performed did not completely treat the disease, and certain complications occurred spontaneously, including infection and dissection. The residual pathological condition led to the development of aortic insufficiency, aortic dissection, coronary artery insufficiency, and progressive aneurysmal dilatation. These complications were treated by composite valve graft replacement of the aortic valve and ascending aorta or the transverse aortic arch or both, simple aortic valve replacement, graft replacement of the ascending aorta or arch or both, and suture of false aneurysm with viable tissue wrap. Twenty patients (34%) had an aneurysm of the distal aorta. The entire aorta was replaced in 3, thoracoabdominal segments in 9, and the abdominal aorta in 1. Of the 59 patients, 49 (83%) were early survivors and 40 (68%) were alive on January 1, 1985. Principles of therapy that may have prevented the complications leading to reoperation include aneurysm replacement at the time of aortic valve replacement and coronary artery bypass; total replacement of the ascending aorta and aortic valve in patients with Marfan's syndrome; the same procedure or aortic valve replacement and separate graft replacement in patients with non-Marfan's medial degenerative disease; ascending aortic replacement in all patients with dissection combined with valve resuspension, aortic valve replacement, or composite valve graft depending on the involvement of the aortic sinuses and the presence of aortic insufficiency.     

Aortic valve sparing operations: an update

Background. Aortic valve sparing operations in patients with ascending aorta and/or aortic root aneurysms have been performed for a decade in our institution. Initially only patients with normal aortic valve leaflets had these operations, but more recently we utilized them in patients with prolapse of a single leaflet and in those with a bicuspid aortic valve. This article is an update on the clinical results of these operations.

Methods. From May 1988 to December 1997, 126 patients with ascending aorta and/or aortic root aneurysms and aortic insufficiency underwent replacement of the ascending aorta with reconstruction of the aortic root and preservation of the native aortic valve. There were 85 men and 41 women, with a mean age of 54 years (range, 14 to 84). Thirty-two patients had the Marfan syndrome; 17 patients had acute and 10 had chronic type A aortic dissection; 23 had a transverse arch aneurysm; 26 had coronary artery disease, and 8 had mitral regurgitation. The aortic valve sparing operation consisted of simple adjustment of the sinotubular junction in 33 patients, adjustment of the sinotubular junction and replacement of one or more aortic sinuses in 60, and reimplantation of the aortic valve in a tubular Dacron (C.R. Bard, Haverhill, PA) graft in 33. Fifteen patients also had repair of aortic leaflet prolapse. Only 4 patients had a bicuspid aortic valve.

Results. There were 3 operative deaths due to cardiac failure. Patients were followed from 2 to 117 months, with a mean of 31. There were 11 late deaths: 7 cardiovascular and 4 from unrelated causes. The actuarial survival was 72 ± 8% at 7 years. Two patients required aortic valve replacement; the freedom from aortic valve replacement was 97 ± 2% at 7 years. Doppler echocardiography revealed absent, trivial or mild aortic insufficiency in most patients; only 9 patients had moderate aortic insufficiency.

Conclusions. Aortic valve sparing operations are feasible in most patients with ascending aorta and/or aortic root aneurysms who have normal or near normal aortic leaflets. The functional results of the repaired aortic valve are excellent, and the repair appears to be durable.     

Clinical outcomes after separate and composite replacement of the aortic valve and ascending aorta

Objectives

We sought to compare the clinical profile and outcomes of operations for aortic valve disease and ascending aortic aneurysm in patients treated with aortic valve replacement and supracoronary replacement of the ascending aorta or composite replacement of the aortic valve and ascending aorta (Bentall operation).

Methods

From 1990 through 2001, 133 patients had aortic valve replacement and supracoronary replacement of the ascending aorta, and 452 patients had Bentall operations. Aortic valve replacement and supracoronary replacement of the ascending aorta was performed in patients who had aortic valve disease and dilation of the ascending aorta, whereas the Bentall operation was performed in patients with aortic root abnormality and ascending aortic aneurysm. Mean follow-up was 4.6 ± 3.1 years and was 100% complete.

Results

Patients who had aortic valve replacement and supracoronary replacement of the ascending aorta were older (61 ± 13 vs 52 ± 16 years, P < .001) and more likely to have aortic stenosis, coronary artery disease, and mitral valve disease than those who had Bentall operations. The use of mechanical valves was equal in both groups (42% for aortic valve replacement and supracoronary replacement of the ascending aorta and 43% for the Bentall operation). Operative mortality was 5% for patients undergoing aortic valve replacement and supracoronary replacement of the ascending aorta and 4% for patients undergoing the Bentall operation (P = .45). Survival at 10 years was 57% ± 8% for patients undergoing aortic valve replacement and supracoronary replacement of the ascending aorta and 74% ± 4% for patients undergoing the Bentall operation (P = .04), but the type of operation had no effect on survival. Older age, moderate or severe left ventricular dysfunction, active endocarditis, previous cardiac surgery, and coronary artery disease were independent predictors of death. The freedom from reoperation at 10 years was 95% ± 5% for patients undergoing aortic valve replacement and supracoronary replacement of the ascending aorta and 94% ± 3% for patients undergoing the Bentall operation (P = .18). Reoperations were mostly because of tissue valve failure or endocarditis. The risk of valve-related complications was the same in both groups. No patient required reoperation for aortic root aneurysm after having aortic valve replacement and supracoronary replacement of the ascending aorta.

Conclusions

Aortic valve replacement and supracoronary replacement of the ascending aorta and the Bentall operation provide comparable long-term results. The Bentall operation is more appropriate for patients with aortic root abnormality and a dilated ascending aorta, whereas aortic valve replacement and supracoronary replacement of the ascending aorta is a perfectly acceptable operation for patients with aortic valve disease, normal or mildly dilated aortic sinuses, and a dilated ascending aorta.     

Anatomical mismatch of the pulmonary autograft in the aortic root may be the cause of early aortic insufficiency after the Ross procedure

Objective: Early aortic insufficiency can be a problem after the Ross procedure. Anatomical mismatch and an inexact surgical technique may lead to distortion of the normal pulmonary valve geometry and subsequent incorrect leaflet coaptation and valve insufficiency. In this study, we assessed the efficacy of changing and improving the surgical technique to minimize the early pulmonary autograft valve failure. The modifications and the strategy are discussed. Methods: From January 1995 to February 1999, a total of 77 adults underwent the Ross procedure for aortic valve replacement at Sahlgrenska University Hospital. The operative technique used was full free-standing aortic root replacement with a pulmonary autograft in all cases. In the first 24 cases, the diameter of the pulmonary roots was seldom measured, eye-balling was used to exclude anatomical mismatch due to a dilated aortic root, and only one attempt of correction was made, which failed. In the other 53 cases, the technique was improved by: (1) reducing the aortic anulus diameter in cases with moderate dilatation; (2) excluding cases with severe dilatation of the aortic annulus; (3) adjusting the diameter of the sinotubular junction of the aorta to the diameter of the sinotubular junction of the pulmonary artery; (4). reimplanting the left ostium in the autograft, and (5) changing the proximal anastomosis technique. Results: In this study, we had an early aortic incompetence of grade 2 in eight patients among the first 24 patients. In the other 53 patients, postoperative echocardiography at 1 week revealed aortic insufficiency of grade 2 in two patients. Conclusions: Aortic insufficiency after the Ross procedure can be minimized by patient selection, intraoperative correction of anatomical mismatch and improved surgical technique.     

Valve-sparing operation for aortic root aneurysm late after Mustard procedure

The aortic valve reimplantation technique leads to excellent clinical outcome in patients with aortic valve incompetence and aneurysms of the ascending aorta. This technique is now applied for aneurysms of ascending aorta, aortic dissection type A, and even dilatation of pulmonary autograft after the Ross operation. We report a case of aortic root dilatation late after a Mustard operation for transposition of the great arteries that was successfully managed by valve-sparing aortic root reimplantation.     

Mid-term results of the Ross procedure

Although the Ross procedure has been performed for over three decades, its role in the management of patients with aortic valve disease is not well established. This study reviews our experience with this operation. From 1990 to 1999, 155 patients underwent the Ross procedure. The mean age of 106 men and 49 women was 35 years. Most patients (85%) had congenital aortic valve disease. The pulmonary autograft was implanted in the subcoronary position in 2 patients, as an aortic root inclusion in 78, and aortic root replacement in 75. The follow-up extended from 9 to 114 months, mean of 45 +/- 28 months, and it was complete. All patients have had Doppler echocardiographic studies. There was only one operative and one late death. The survival was 98% at 7 years. The freedom from 3+ or 4+ aortic insufficiency was 86% at 7 years and the freedom from reoperation on the pulmonary autograft was 95% at 7 years. Dilation of the aortic annulus and/or sinotubular junction was the most common cause of aortic insufficiency. One patient required three reoperations on the biological pulmonary valve. Most patients (96%) have no cardiac symptoms. The Ross procedure has provided excellent functional results in most patients, but progressive aortic insufficiency due to dilation of the aortic annulus and/or sinotubular junction is a potential problem in a number of patients.     

Autologous tissue in complex aortic valve disease

Young patients with complex aortic valve disease involving the aortic root or ascending aorta are a challenge to manage. To use the Ross operation and realize its benefits, the operative technique must include aortic annulus reduction and fixation and replacement of ascending aortic pathology. Special techniques must be used when the cause of the complex disease is active endocarditis of the valve and aortic root. Surgical techniques that allow the use of the Ross operation in these settings and the midterm results in 84 patients are reviewed.     

Aortic root replacement versus aortic valve replacement: a case-match study

BACKGROUND: There is increasing evidence that patients with aortic valve disease and dilatation of the ascending aorta are at risk for later dissection or rupture of the aortic wall when the dilated ascending aorta is not replaced or reinforced at the time of aortic valve replacement. In order to find out whether the more complex surgical procedure of aortic root replacement carries a higher early or late postoperative risk than isolated aortic valve replacement, we conducted a matched-pair study with patients of both groups. METHODS: Between June 1993 and August 1998, 100 consecutive patients with aortic valve disease and ectasia/aneurysm of the ascending aorta underwent replacement of the aortic valve and the ascending aorta with a CarboSeal composite graft (CarboSeal; Sulzer Carbo-Medics Inc, Austin, TX). Identical bileaflet valve prostheses (CarboMedics; Sulzer CarboMedics Inc, Austin, TX) were implanted during the same time period in 928 patients for aortic valve disease. On the basis of various preoperative clinical variables 100 patients with aortic valve replacement were matched to the 100 patients with replacement of the aortic root. The duration of follow-up for both groups was similar with 37 + 17 months (range, 9 to 70) for the CarboSeal group and 38 + 14 months (range, 13 to 65) for the CarboMedics group. Survival and morbidity were calculated by Kaplan-Meier analysis and risk-adjusted mortality was evaluated by multivariate analysis in a Cox regression model. RESULTS: The early postoperative mortality of 1% in the CarboSeal group and 4% in the CarboMedics group was insignificantly different. Although the overall survival rate at 5 years was lower (60.7% vs 86.3%; p = 0.13) in the CarboSeal group, the freedom from cardiac mortality and valve-related morbidity was similar in the two groups. CONCLUSIONS: Replacement of the ascending aorta and aortic valve can be performed with similar operative risk, valve-related morbidity, and late cardiac mortality as isolated aortic valve replacement.     

Dilation of the pulmonary autograft after the Ross procedure

OBJECTIVE: Dilation of pulmonary autograft after the Ross procedure is being recognized with increasing frequency. This study was undertaken to examine the extent of this problem and factors that may be associated with it. METHODS: The clinical, operative, and echocardiographic data of 118 patients who underwent the Ross procedure were reviewed. The mean age of 79 men and 39 women was 34 +/- 9 years, range 17 to 57 years. Bicuspid or other congenital aortic valve disease was present in 81% of patients. The pulmonary autograft was sutured as a valve in the subcoronary position in 2 patients, as a root inside of the aortic root in 45, and was used for complete aortic root replacement in 71. Teflon felt was not used to buttress the proximal or the distal anastomosis of the pulmonary autograft. The diameters of the sinuses of Valsalva, aortic anulus, and sinotubular junction were measured early and late after the operation with echocardiography. The mean follow-up was 44 months. RESULTS: The diameter of the sinuses of Valsalva increased from 31.4 +/- 0.4 mm to 33.7 +/- 0.5 mm (P =.01). Analysis of covariance revealed a significant change over time in this diameter, as well as a difference between operative techniques, with replacement of the aortic root being associated with a higher risk of dilation (P =. 0006). In 13 patients the diameter ranged from 40 to 51 mm. The diameter of the aortic anulus decreased in most patients and increased in 15, but there was no interaction between these changes and the operative technique. The diameter of the sinotubular junction increased in patients who had aortic root replacement and decreased in patients who had aortic root inclusion (P =.007). Moderate aortic insufficiency developed in 7 patients, and 3 required replacement of the pulmonary autograft. All patients with moderate aortic insufficiency had dilation of the aortic anulus and/or sinotubular junction. CONCLUSIONS: Dilation of the pulmonary autograft after the Ross procedure may occur because of an intrinsic abnormality of the pulmonary root in patients with congenital aortic valve disease. The technique of aortic root replacement is associated with a higher risk of dilation of the sinuses of Valsalva and sinotubular junction than the technique of aortic root inclusion.     

Reduction of the sinotubular junction in patients undergoing ascending aortic replacement with coexisting aortic insufficiency

Abstract Background and Aim of the Study: Dilatation of the STJ may cause consequent aortic insufficiency (AI) in patients with normal aortic valve, in patients with ascending aortic aneurysm. In this study, we analyzed the results of ascending aorta replacement with STJ diameter reduction to correct consequent AI in patients with ascending aortic aneurysm. Methods: Forty‐five consecutive patients who had ascending aortic aneurysm underwent replacement of ascending aorta with reduction of the STJ diameter to correct AI. Mean age of the patients was 61.3 ± 5.2. Twenty‐six (57.8%) were female. Six patients had arch aneurysm. Postoperative echocardiographic studies were performed at discharge and annually thereafter. The mean duration of follow‐up was 4.6 ± 2.9 years. Results: Hospital mortality rate was 4.9% (n = 2). Three patients died during follow‐up. Three patients had late recurrence of AI that was caused by aortic root dilatation. One of these patients required aortic valve replacement because of severe aortic insufficiency. The five‐year survival and survival free from aortic insufficiency were 91.4%± 5.0% and 91.2%± 5.1%, respectively. Conclusions: Reduction of the diameter of STJ can be used to treat AI in patients with ascending aortic aneurysm with nearly normal aortic cusps. Midterm results of this procedure are encouraging. (J Card Surg 2011;26:88‐91)     

Impact of ascending aorta replacement combined with a Ross procedure on autograft root distensibility and function in patients with combined pathology of the aortic valve and ascending aorta

In this study we aimed to assess the autograft root dimensions, distensibility, and autograft valve function in patients after Ross operation combined with replacement of the ascending aorta compared to patients that underwent Ross operation only. Forty patients received a Ross operation, and in 12 of them an additional replacement of the ascending aorta was performed. Autograft root dimensions, distensibility, and valve function were assessed by echocardiography. There were no differences in root size, distensibility, and valve function between groups. Our preliminary results indicate that replacement of the ascending aorta with a noncompliant prosthesis has no effect on the autograft root.     

Results of aortic valve-sparing operations.

OBJECTIVE: To review the late results of valve-sparing operations in patients with aortic root aneurysm and in those with ascending aortic aneurysm and aortic insufficiency. METHODS: From May 1988 to June 2000, 120 patients with aortic root aneurysm and 68 with ascending aortic aneurysm and aortic insufficiency underwent aortic valve-sparing operations. Patients with aortic root aneurysm were younger, were predominantly male, and had less severe aortic insufficiency than patients with ascending aortic aneurysm, who were older and often had aneurysm of the transverse arch. Forty-eight patients with aortic root aneurysm had the Marfan syndrome. The prevalence of aortic dissection was similar in both groups. Reconstruction of the aortic root was performed by reimplanation of the aortic valve in 64 patients and by remodeling of the aortic root in 56. Patients with ascending aortic aneurysm and aortic insufficiency were treated by replacement of the ascending aorta with reduction in the diameter of the sinotubular junction. Approximately two thirds of the latter patients also required replacement of the transverse aortic arch. The mean follow-up was 35 +/- 31 months for patients with aortic root aneurysm and 26 +/- 23 months for those with ascending aortic aneurysm. RESULTS: There were 2 operative and 5 late deaths in patients with aortic root aneurysm and 1 operative and 9 late deaths in patients with ascending aortic aneurysm. The 5-year survival for patients with aortic root aneurysm was 88% +/- 4% and for patients with ascending aortic aneurysm, 68% +/- 12% (P =.01). Severe aortic insufficiency developed in 2 patients, and they required aortic valve reoperation. The 5-year freedom from aortic valve reoperation was 99% +/- 1% for patients with aortic root aneurysm and 97% +/- 4% for those with ascending aortic aneurysm. Seven patients had moderate aortic insufficiency at the latest echocardiographic study. The 5-year freedom from severe or moderate aortic insufficiency was 90% +/- 4% in patients who had aortic root aneurysm and 98% +/- 2% in those who had ascending aortic aneurysm. CONCLUSIONS: Aortic valve-sparing operations have provided excellent clinical outcomes and few valve-related complications. The function of the reconstructed aortic root remains unchanged in most patients during the first 5 years of follow-up.     

Plication of the sinotubular junction for aneurysm of the ascending aorta associated with aortic regurgitation: a case report

A 63-year-old woman with aneurysm of the ascending aorta associated with AR due to dilatation of the sinotubular junction (STJ) and with poor LV function, who did not have Marfan syndrome, underwent a plication of the STJ and replacement of the ascending aorta. In operation, we simultaneously performed the plication of dilated STJ (60 mm) and the replacement of ascending aorta using a 26 mm Woven Dacron graft. Post-operative angiogram (1 POM) showed no aortic regurgitation and good recovery of the LV function. This procedure is less invasive, and indicated for patients without significant elongation or thickening of the aortic valve, especially when the patients have higher risk.     

升主动脉瘤的外科治疗

目的探讨升主动脉瘤治疗经验。方法Marfan’s综合征12例,其中6例合并二尖瓣关闭不全。升主动脉夹层动脉瘤伴主动脉瓣关闭不全6例,升主动脉瘤合并主动脉瓣、二尖瓣关闭不全2例,单纯升主动脉瘤5例,行Bentall手术12例,Cabrol手术3例,Wheat手术5例;单纯升主动脉替换术5例。结果全组无手术死亡。结论Bentall手术是外科治疗升主动脉瘤的主要术式。早期诊断、早期手术是改善升主动脉瘤患者疗效的关键。     

A case of ascending aortic dissection after aortic valve replacement in congenital bicuspid aortic valve]

Congenital bicuspid aortic valve is a risk factor of aortic dissection, but the case is rare in Japan. Several reports described ascending aortic aneurysm after aortic valve replacement. In these reports, most of aneurysms were false aneurysm, but the cases of ascending aortic dissection were rare. In this case, dissecting aneurysm of the ascending aorta occurred 4 years after aortic valve replacement, which was performed with mechanical prosthesis because of infective endocarditis, and it was repaired successfully by the modified Cabrol's method. This case was congenital bicuspid aortic valve, and had already been complicated with moderate aortic dilatation in the ascending aorta. In patients of congenital bicuspid aortic valve with aortic dilatation, consideration of complete replacement of the ascending aorta with aortic valve replacement is important.     

Ross procedure with aortic replacement for aortic stenosis with ascending aortic aneurysm: report of a case

Bicuspid aortic valve (BAV) is a common congenital heart disease, and it is well known to be a risk factor for ascending aortic dilatation and dissection. We here report a case of 34-year-old woman who underwent Ross procedure with ascending aortic replacement under the diagnosis of subaortic stenosis and ascending aortic aneurysm. She was pointed out to have heart murmur soon after the birth diagnosed as patent ductus arteriosus. The ductus was ligated when she was 3-years-old, however, heart murmur remained. Further examinations revealed that she also had aortic stenosis with BAV. During her 20-year-follow-up, subaortic stenosis and ascending aorta ectasia were also progressed. Pathological examinations of resected ascending aortic wall showed mucoid degeneration and laceration of collagen fibers, suggesting the fragility of dilated aortic wall with BAV.     

Indications for and clinical outcome of the Ross procedure: a review

The Ross procedure has been used increasingly to treat aortic valve disease in children and young adults. The primary indication for the Ross procedure is to provide a permanent valve replacement in children with congenital aortic stenosis. More recently, it has been extended to young adults with a bicuspid aortic valve and small aortic annulus, especially women wishing to have children. Other possible indications include complex left ventricular outflow obstructive disease, native or prosthetic valve endocarditis, and adult aortic insufficiency with a dilated aortic annulus. Conversely, Marfan syndrome is considered to an absolute contraindication, and this procedure should be used with caution in patients with rheumatic valve disease and a dysplastic dilated aortic root because of the higher associated incidence of autograft dysfunction. The technique of total aortic root replacement has become the preferred method of autograft implantation, because it carries the lowest risk of pulmonary autograft failure. In patients with marked graft-host size mismatch, either concomitant aortic annulus reduction and fixation or aortic annulus enlargement (i.e., the Ross-Konno procedure) should be performed. The Ross Procedure International Registry data document that in the modern era (post-1986) the early and late mortality rate is 2.5% and 1%, respectively. Excellent long-term results have been reported, and the benefits of this procedure include optimal hemodynamics, low risk of endocarditis, resistance to infection in patients with active endocarditis, and nonthrombogeneicity and therefore few anticoagulation-related complications. The Ross procedure can be performed with acceptable early and mid-term mortality and excellent autograft durability. Further long-term follow-up will confirm the role of this procedure in patients with various types of aortic valve disease.