主动脉瓣上狭窄的外科治疗(附21例报告)

目的 总结21例主动脉瓣上狭窄(SVAS)的外科治疗经验.方法 21例主动脉瓣上狭窄的患者接受了外科治疗.局限型15例、弥漫型6例、Willianms综合征3例;合并其他心脏畸形包括主动脉瓣狭窄6例、主动脉瓣关闭不全2例、冠状动脉畸形4例、动脉导管未闭3例、肺动脉瓣上隔膜1例、头臂动脉畸形5例、二尖瓣脱垂1例.均在全麻低温体外循环下应用补片直接行主动脉成形术.其中,同时行主动脉瓣成形4例,应用同种升主动脉左心尖与胸主动脉搭桥1例,升主动脉与腹主动脉架桥和主动脉瓣膜置换术1例,二尖瓣成形1例.结果 手术早期死亡2例,二次开胸2例.随访1～97(平均42.7)个月,所有患者狭窄解除满意,晚期死亡1例,存活患者的心功能为Ⅰ～Ⅱ级.结论 SVAS的外科治疗可以取得很好的治疗效果,补片扩大成形主动脉仍然是治疗局限型SVAS的重要方法 .     

升主动脉瘤合并主动脉瓣关闭不全的外科治疗

目的 :报告 46例升主动脉瘤合并主动脉瓣关闭不全患者的外科治疗经验。方法 :46例患者 ,男 33例 ,女 13例 ,年龄 2 9～ 70 (平均 45 9± 12 .8)岁。所有升主动脉瘤患者均合并有重度主动脉瓣关闭不全 ,升主动脉瘤的内径为 5 6～ 10 4cm(平均 7 3± 2 7cm )。病因 :马凡综合征 2 9例 (合并主动脉夹层 2 0例 ) ,动脉硬化性升主动脉瘤 4例 ,升主动脉夹层 8例 ,先天性主动脉瓣病变伴升主动脉瘤 5例。术前心功能 (NYHA)Ⅱ级 15例 ,Ⅲ级 2 4例 ,Ⅳ级 7例。主动脉弓部的手术 ,在深低温停循环 (DHCA)和上腔静脉逆行脑灌注 (RCP)下施行。本组施行Bentall手术 2 5例 ,Bentall+部分主动脉弓置换手术 5例 ,Bentall+全部主动脉弓部置换手术 1例 ,主动脉瓣、升主动脉及主动脉弓部置换 +“象鼻”手术 1例 ,主动脉瓣及升主动脉置换手术 11例 ,Cabrol手术 3例。同期施行的手术包括二、三尖瓣成形术和冠状动脉旁路移植术。结果 :术后早期死亡 3例 ( 6 5 % ) ,分别死于心室颤动、低心排血量和多器官衰竭。 43例随访 1个月～ 8年 (平均2 17年 ) ,晚期死亡 1例 ( 2 3% ) ,余 42例心功能Ⅰ级 32例 ,Ⅱ级 8例 ,Ⅲ级 2例。结论 :采用不同的手术方式治疗升主动脉瘤合并主动脉瓣关闭不全可取得良好的效果 ,手术关键是处理好     

先天性主动脉缩窄合并严重主动脉瓣病变的一次性外科矫治

目的 :探讨先天性主动脉缩窄合并严重主动脉瓣病变的外科治疗方法。方法 :采用升主动脉—腹主动脉人工血管转流术 +主动脉瓣置换术一次性治疗患者 9例 ,其中 4例对手术方法和体外循环技术进行了改进。结果 :术中死于体外循环意外 1例 ;术后部分肠梗阻 1例 ,8例患者痊愈出院。上肢收缩压术后较术前下降〔平均12 2 /78mmHgvs .178/6 5mmHg( 1mmHg =0 133kPa)〕 ,有显著性差异 (P <0 0 5 ) ,术后上、下肢血压无明显压差。左心室舒张末期内径术后较术前缩小 ( 4 9 40± 6 88mmvs .6 7 33± 17 2 9mm) ,有显著性差异 (P <0 0 5 )。结论 :该类患者采用升主动脉—腹主动脉人工血管转流术 ,在常规体外循环下行主动脉瓣置换术即简便又安全有效     

局限性主动脉瓣上狭窄的外科治疗

目的探讨局限性主动瓣上狭窄的外科治疗要点。方法1990年4月～2000年6月收治局限性主动脉瓣上狭窄的手术治疗患者7例,均具有典型的小精灵面容。超声心电图及左室造影发现起自主动脉嵴长约12～20mm膜样狭窄环,主动脉瓣环无缩窄,其中1例并发重度主动脉瓣关闭不全,2例主动脉弓降部轻度狭窄。1例右上肺动脉起始部狭窄,有3例冠状动脉扩张增粗。中度低温体外循环下进行手术,斜形切开升主动脉前壁,斜向无冠状窦,剪除狭窄环,取泪滴状补片以5-0prolene线或6-0prolene线连续缝合加宽主动脉壁,加宽材料1例为自体心包,3例为同种主动脉片,3例以Groe-Tex血管片,并发主动脉瓣重度关闭不全者不同期以ST.Jude23#双叶机械瓣置换,1例右肺动脉起始部狭窄以自体心包片加宽。结果无低心血输出量综合征及切口出血,术后跨环压差0～3mmHg,随访3～5年无假性动脉瘤形成。结论局限性主动脉瓣上狭窄的手术治疗,术前应详细检查了解并发畸形情况,手术重点是彻底解除狭窄,加宽主动脉,重视并发畸形的处理。     

细小主动脉主动脉瓣置换手术6例

主动脉瓣膜置换术是瓣膜外科常见的手术,对于细小主动脉瓣环的主动脉瓣置换办法亦有多种,我们1 999年5月～2 0 0 3年5月对6例细小主动脉瓣环的患者行主动脉根部拓宽,主动脉瓣置换,效果满意,现报告如下。1　对象与方法6例中男1例,女5例,年龄2 6～5 7(平均42 )岁,均为风湿性心脏病患者,二尖瓣狭窄伴关闭不全并发主动脉瓣狭窄5例,单纯主动脉瓣狭窄1例;心功能(NYHA)Ⅲ级2例,Ⅱ级4例;超声心动图提示主动脉瓣环1 5～1 8(平均1 6.5 )mm ;心电图示心房颤动4例,左心室肥厚2例。本组手术均在中度低温体外循环下进行。5例同期行二尖瓣置换术,行主动脉…     

主动脉左心室通道的外科治疗

目的 总结9例主动脉左心室通道的外科诊治经验.方法 回顾性分析我院2002年7月至2008年8月收治主动脉左心室通道患者9例,术前心功能(NYHA):Ⅱ级7例,Ⅲ级2例.9例患者中8例术前通过经胸超声心动图诊断,全部经术中食道超声确诊.结果 9例均于术中确诊并行手术治疗,主动脉侧直接缝合2例,其中1例缝合通道后行主动脉瓣置换术;自体心包片或涤纶片衬心包从主动脉侧修补5例,其中1例修补通道后行主动脉瓣置换术;自体心包从主动脉侧及左室侧修补1例;切开主动脉左心室通道行主动脉瓣置换术1例.1例术后2个月因感染性心内膜炎、急性心力衰竭死亡;随访3个月至6年,随访7例,失访1例,心功能(NYHA标准)Ⅰ级患者3例,Ⅱ级3例,Ⅲ级1例.超声心动图示主动脉瓣无或微量反流2例,1例少量反流,2例少到中量反流,主动脉瓣功能正常1例,瓣周漏1例,远期无死亡.结论 主动脉左心室通道是一类非常罕见的先天性心脏病,超声心动图在本病诊断方面有着明显的优势;手术是治疗的有效方式,单纯修补效果良好.     

主动脉根部扩张50例的临床观察及治疗分析

目的 :总结 5 0例主动脉根部扩张患者的临床特点、病因病理、影像学诊断、治疗与预后。方法 :分析了 5 0例主动脉根部扩张病人的临床资料 ,男性 36例 ,女性 14例 ,年龄 14～ 6 9岁 ,平均 42 0±12 2岁。病因中高血压者 10例 (2 0 % ) ,Manfan’s综合征 30例 (6 0 % ) ,特发性 3例 (6 % ) ,先天性二瓣畸形 1例 (2 % ) ,其余原因不明。主动脉根部内径 3 8～ 9 0cm ,平均 6 2± 1 5cm ,有中、重度主动脉瓣关闭不全 34例 ,均由主动脉根部扩张所致。其中升主动脉瘤 19例 (38% ) ,夹层形成 2 8例 (5 6 % ) ,主动脉窦瘤 3例 (6 % )。结果 :主动脉根部内径越大 ,发生破裂或形成夹层的比例越高。共 2 0例进行了手术治疗 ,手术死亡 5例。内科保守治疗 30例 ,其中死亡 6例 (心力衰竭死亡 2例 ,动脉瘤破裂 4例 ) ,因病重自动出院 7例。结论 :早期药物治疗能延缓病情发展 ,对高度扩张并引起主动脉瓣关闭不全或合并有夹层、破裂发生者应及时手术治疗     

先天性主动脉瓣狭窄的外科治疗

我院自1984年7月至1995年3月共收治48例先天性主动脉瓣狭窄患者，其中30例行外科治疗，占62．5％。22例主动脉瓣替换术（73．3％）中，同种动脉瓣13例，机械瓣9例。主动脉瓣交界切开术8例。术后随访1月至9年，每半年一次。治疗效果：术后早期死亡2例，死亡率6．7％；晚期死亡1例，术后1年死于感染性心内膜炎，占33％；27例随诊良好。结合先天性主动脉瓣狭窄的临床征象，对其诊断及外科治疗进行讨论。     

先天性主动脉瓣上狭窄的外科治疗

目的总结6例先天性主动脉辫上狭窄（SVAS）术前诊断和外科治疗中的经验、教训和疗效。方法2003年1月至2008年6月收治SVAS患者6例，男性3例，女性3例，年龄1．9-19．0（5．73±6．36）岁，局限性狭窄5例，弥漫性狭窄1例。Williams综合征3例，3例并发其他心脏畸形，其中1例同时合并动脉导管未闭、主动脉瓣下狭窄、主动脉瓣两叶畸形、二尖瓣狭窄关闭不全和细菌性心内膜炎，1例合并动脉导管未闭，还有1例合并肺动脉狭窄。术前超声心动图检查均有初步诊断，有2例患者手术前做了左心导管和造影，3例行64排螺旋CT扫描，对诊断和手术方案的确定很有意义。手术前检查发现跨狭窄环的压差为45-121mmHg。手术方法：单片法加宽3例，倒“Y”法3例，同期行主动脉瓣置换、二尖瓣置换、左室流出道疏通和动脉导管结扎1例，行肺动脉加宽1例，行动脉导管缝闭1例。结果本组手术无死亡，除合并细菌性心内膜炎及多种畸形的患者术后出现低心排和呼吸功能不全和感染，其余患者恢复顺利，所有患者痊愈出院。手术后有1例虽然主动脉瓣上狭窄解除理想，但是发现主动脉弓有弥漫性轻度狭窄。结论SVAS经术前超声心动图检查基本可以诊断，对Williams综合征患者术前应进行更为详细的检查，如果有条件应该考虑行无创伤的64排螺旋CT检查，可以发现合并的畸形如主动脉弓的病变，肺动脉狭窄等；一旦发现主动脉辫上狭窄应该积极手术治疗，否则可能引起心律失常和猝死。SVAS的手术治疗效果良好，目前不主张应用单片法进行矫治。     

手术治疗先天性主动脉瓣上狭窄的临床分析及远期结果

目的分析先天性主动脉瓣上狭窄的手术效果及远期疗效。方法收集阜外医院2008年9月至2014年9月先天性主动脉瓣上狭窄25例患者资料,进行回顾性分析,并长期随访。结果 25例患者经超声心动图检查明确诊断为先天性主动脉瓣上狭窄,其中男性17例(68%),女性8例(32%)。年龄为24-582(106.88±127.60)月,体重为10.6-60(24.45±13.92)公斤。患者经手术治疗后,主动脉瓣上狭窄处得以加宽,狭窄处流速、压差及左室舒张末内径较术前发生显著性差异(P 0.05),术后均恢复良好并顺利出院。Doty法和McGoon法矫治先天性主动脉瓣上狭窄均可获得满意的治疗效果。术后平均随访时间56.59±30.38月,随访患者20例(80%),目前均生存,无心功能不全症状;生长发育迟缓,身高及体重低于同年龄人3例(15%);智力低下者5例(25%),主动脉狭窄及压差偏高者3例(15%)。结论主动脉瓣上狭窄经手术治疗后,狭窄处流速及压差明显降低,左室舒张末内径显著变小,手术效果明显,远期疗效满意。     

Autograft or allograft aortic valve replacement in young adult patients with congenital aortic valve disease.

AIMS: We analysed the outcome of young adults with congenital aortic valve disease who underwent allograft or autograft aortic valve or root replacement in our institution and evaluated whether there is a preference for either valve substitute. METHODS AND RESULTS: Between 1987 and 2007, 169 consecutive patients with congenital aortic valve disease aged 16-55, participating in our ongoing prospective follow-up study, underwent 63 autograft and 106 allograft aortic valve replacements (AVRs). Mean age was 35 years (SD 10.8), 71% were males. Aetiology was 71% bicuspid valve, 14% other congenital, and 15% BV endocarditis. Twenty-two percent underwent previous cardiac surgery; 11% had an ascending aorta aneurysm. Two patients died in hospital. During follow-up six more patients died and 45 patients required valve-related re-operations. Thirteen-year survival was 97% for autograft and 93% for allograft recipients, 13 year freedom from valve-related re-operation was 63% for autograft and 69% for allograft patients. CONCLUSION: In patients with congenital aortic valve disease, autograft and allograft AVR show comparable satisfactory early and long-term results, with the increasing re-operation risk in the second decade after operation remaining a major concern.     

Outcome of reoperative aortic root or ascending aorta replacement after prior aortic valve replacement

BackgroundThere are limited data regarding the clinical outcomes of reoperative aortic root or ascending aorta replacement after prior aortic valve replacement (AVR). We aimed to analyze outcomes of reoperative aortic root or ascending aorta replacement after prior AVR.MethodsEighty patients with prior AVR underwent reoperative aortic root or ascending aorta replacement in our hospital. The indications were root or ascending aortic aneurysm in 36 patients, root or ascending aortic dissection in 37, root false aneurysm in 2, prosthesis valve endocarditis (PVE) with root abscess in 2, Behçet’s disease (BD) with root destruction in 3 patients. An elective surgery was performed in 63 patients and an emergent surgery in 17. The survival and freedom from aortic events during the follow-up were evaluated with the Kaplan-Meier survival curve and the log-rank test.ResultsThe operative techniques included ascending aorta replacement in 14 patients, ascending aorta replacement with AVR in 3, prosthesis-sparing root replacement (PSRR) in 35, Bentall procedure in 24, and Cabrol procedure in 4 patients. Operative mortality was 1.3% (1/80). A composite of adverse events occurred in 5 patients, including 1 operative death, 2 stroke and 3 renal failure necessitating hemodialysis. The mean follow-up was 35.5±22.1 months. Five late deaths occurred. The Kaplan-Meier survival at 1 year, 3 years and 6 years were 97.5%, 91.1% and 84.1%, respectively. Aortic events developed in 3 patients. The freedom from aortic events at 1-year, 3-year, and 6-year were 100%, 96.3% and 88.9%, respectively. There were no differences in survival and freedom from aortic events between the elective group and the emergent group.ConclusionsReoperative aortic root or ascending aorta replacement after prior AVR could be performed to treat the root or ascending pathologies after AVR, with satisfactory early and midterm outcomes.     

Long-term results of aortic valve replacement with Edwards Prima Plus stentless bioprosthesis: eleven years' follow up

BACKGROUND AND AIM OF THE STUDY: The Edwards Lifesciences Prima Plus stentless valve (ELSV) is a bioprosthesis manufactured from a porcine aortic root. The study aim was to evaluate late clinical outcomes after aortic valve replacement (AVR) with ELSV implanted as a miniroot in patients with aortic valve disease. METHODS: Between 1993 and 2004, 318 patients (232 males, 86 females; mean age 69 +/- 9 years; range: 37-83 years) underwent AVR with the ELSV. Preoperatively, 102 patients (32%), 162 (51%) and 54 (17%) were in NYHA classes I/II, III and IV, respectively. Aortic stenosis, aortic regurgitation and combined lesions were present in 124 patients (39%), 114 (36%) and 41 (13%), respectively. Twenty patients (6%) were referred for an acute aortic dissection, 20 (6%) for an aortic root aneurysm, and 139 (44%) had an associated aneurysmal dilatation of the ascending aorta. The ascending aorta was replaced in 159 patients (50%); aortic arch replacement was required in 10 (3%). Coronary artery bypass graft was performed in 86 patients (27%). The follow up was based on clinical data. RESULTS: Operative mortality was 5% (n = 17). There were 49 late deaths (5.2%/pt-yr). Valve-related mortality occurred in 10 patients (1%/pt-yr). Actuarial survival at five and 10 years was 78% and 33%, respectively. Actuarial freedom from valve reoperation and structural valve deterioration at 10 years were 100% and 64%. Actuarial freedom from embolic events and endocarditis at 10 years were 84% and 81%, respectively. CONCLUSION: The ELSV, when implanted as a miniroot, provided good early and long-term results in terms of survival and freedom from major complications.     

The Ross procedure as the surgical treatment of active aortic valve endocarditis

BACKGROUND AND AIM OF THE STUDY: The authors' experience is reported of aortic valve replacement (AVR) using the pulmonary autograft in patients with active aortic valve endocarditis, including an urgent Ross procedure in infants with the acute condition. METHODS: Nine patients aged between 8 months and 38 years, with a diagnosis of aortic valve endocarditis, have undergone AVR using the Ross procedure at the authors' institution since October 1997. The diagnosis was established by clinical and echocardiographic findings. Indications for surgery were severe aortic insufficiency and congestive heart failure in all patients, with the addition of thromboembolic events (n = 3), persistent hyperpyrexia (n = 3) and vegetations (n = 5). Four infants with no history of congenital cardiac malformation underwent urgent surgery because of acute bacterial endocarditis and rapid hemodynamic deterioration. Blood cultures were positive for Streptococcus pneumoniae in three patients, and Kingella kingi and Staphylococcus aureus in one patient each. Four patients were culture-negative. All patients were treated with intravenous antibiotics for four to six weeks postoperatively. RESULTS: There were no perioperative or late deaths, and no recurrent endocarditis at the implanted valves. Echocardiographic evaluation at discharge showed trivial to mild aortic insufficiency, with no stenosis at the left ventricular outflow tract. Similar findings were found across the right ventricular outflow tract. At follow up (range: 4 months to 5.5 years), none of the patients showed progression of aortic valve insufficiency or developed stenosis; three had mild and moderate homograft stenosis (Doppler gradient 20-40 mmHg), and all children had moderate homograft insufficiency. CONCLUSION: The Ross procedure is an excellent therapeutic option for active aortic valve endocarditis in young patients, and demonstrates low morbidity and mortality. Early surgery may be indicated in patients with acute aortic valve endocarditis because of the rapidly progressive nature of this disease.     

Frequency of cardiovascular events in women with a congenitally bicuspid aortic valve in a single community and effect of pregnancy on events

Pregnancy and congenitally bicuspid aortic valve (BAV) are thought to be risk factors for aortic dissection; however, the population-based risk for patients with the 2 risk factors remains unknown. We investigated the relation between pregnancy and ascending aortic events in women with congenital BAV living in Olmsted County, Minnesota. Our institutional echocardiographic database was searched for women residing in Olmsted County with congenital BAV diagnosed from 1980 to 1999. We reviewed medical records for end points of aortic events (dilatation, dissection, or surgery) and aortic valve replacement (AVR). Obstetric history and further outcome follow-up were collected by postal survey. We identified 88 women with BAV. Median age at diagnosis was 35 years. Obstetric history totaled 216 pregnancies and 186 deliveries. There were no aortic dissections. During follow-up (median 12.3 years), 24 patients underwent AVR (n = 14), ascending aortic surgery (n = 3), or AVR and ascending aortic surgery (n = 7). Pregnancy was not associated with dilatation of the aorta, aorta surgery, or AVR. At echocardiographic diagnosis of BAV, 5 patients (6%) had aortas >40 mm in greatest diameter and 1 patient has >50 mm. Of 60 patients with serial echocardiograms for comparison (median interval 10.7 years), 21 patients (35%) had aortas measuring >40 mm in greatest dimension and 2 patients had >50 mm. In conclusion, aortic dissection in women with BAV and pregnancy is rare in the community. There is a significant rate of progressive enlargement of the aorta, warranting longitudinal follow-up.     

Asymmetric medial degeneration of the ascending aorta in aortic valve disease: a pilot study of surgical management

BACKGROUND AND AIM OF THE STUDY: In structural aortic valve disease, medial degeneration is often associated with ascending aorta dilatation. This pathology is often asymmetric, with more severe involvement of the convex aspect of the ascending aorta. The condition can be managed with surgical excision of the diseased portion of the aortic wall and remodeling reconstruction at the time of aortic valve replacement (AVR). METHODS: Sixty-one patients underwent AVR and 'waistcoat aortoplasty'. Sinus dilatation was repaired by plicating the subcoronary redundant aortic wall using anchoring sutures of the valve prosthesis. The diseased aortic wall was removed via a triangular resection, and the aorta reconstructed with a double-layer technique, to achieve autologous reinforcement of the convex right posterolateral wall and stress reduction on the aortotomy suture line. Echocardiography was performed preoperatively, immediately postoperatively, and every six months thereafter. The significance of diameter variations was evaluated. RESULTS: There was no hospital mortality, and only low postoperative morbidity. Post-reduction diameters at the sinuses, sinotubular junction and ascending aorta were significantly less than preoperative values (p < 0.0001). During a mean follow up of 33.8 +/- 10.2 months (range: 13-50 months), no significant increase in root (p = 0.32), sinotubular (p = 0.15), or ascending diameter (p = 0.11) was observed. CONCLUSION: The 'waistcoat aortoplasty' should be considered when dealing with asymmetric ascending dilation secondary to aortic valve disease-related medial degeneration. However, additional studies with a longer follow up are needed to confirm these findings.     

Bentall procedure using cryopreserved valved aortic homografts: mid- to long-term results

The Bentall procedure is the standard operation for patients who have lesions of the ascending aorta associated with aortic valve disease. In many cases, however, mechanical prosthetic conduits are not suitable. There are few reports in the English-language medical literature concerning the mid- to long-term outcome of Bentall operations with cryopreserved homografts. Therefore, we reviewed our experience with this procedure and valved homografts. From January 1997 through December 2002, 21 patients underwent a Bentall operation with cryopreserved homografts at our institution. There were 14 males and 7 females; the mean age was 36 +/- 21 years (range, 15-74 years). Eleven patients had undergone previous aortic valve surgery. All patients had aortic dilatation or aneurysms involving the ascending aorta. Indications for surgery included aortic valve stenosis or insufficiency, and aortic valve endocarditis (native valve or prosthetic). One patient had Takayasu's arteritis and 3 had Marfan syndrome. There was 1 hospital death (due to sepsis), but no other major postoperative complications. The mean hospital stay was 14 +/- 7 days. Follow-up echocardiographic and computed tomographic scans were performed yearly. The mean follow-up was 34 months (6-72 months). Follow-up imaging revealed no calcifications or degenerative processes related to the homograft. Four patients had minimal valve regurgitation. Two patients died during follow-up. The 3-year actuarial survival rate was 85.7%. Our data suggest that the Bentall procedure with a valved homograft conduit is a safe procedure with excellent mid- to long-term results, comparable to results reported with aortic valve replacement with a homograft.     

Surgical experiences with inflammatory arterial aneurysms due to Takayasu's arteritis

This report shows clinical manifestations and provides aspects of surgical strategy for inflammatory aneurysms due to Takayasu's arteritis. Fourteen cases of inflammatory aneurysms among 81 patients with Takayasu's arteritis who underwent surgery in our institute were reviewed. The patient group consisted of six males and eight females, ages from 20 to 61 (mean 39.6±3.5) years. Aneurysmal lesions were located in the ascending aorta or aortic arch (type I) in six (42.9%) patients and the thoracic and/or abdominal aorta (type II) in six patients (42.9%). Type III distribution was determined for two patients (14.3%). Operative procedures for aneurysms included aortic replacement using prosthetic graft (n=6), aneurysmorraphy (n=1), patch angioplasty (n=1), Hardy operation (n=1), aortic valve replacement (AVR) (n=2), and AVR associated with mesh wrapping or aneurysmorraphy (n=3). Operative mortality was 21.4% (three cases) at initial operation and late deaths were found in five cases. Causes of late deaths included rupture of suture aneurysms, rupture of the aortic aneurysm at other aortic lesions, and sudden death due to acute perivalvular leakage. Aggressive surgical approach prior to rupture is required for cases with progressive aortic dilatation even if inflammation signs appear to be controlled. Careful long-term follow-up using periodical angiogram or computed tomography are essential to the best prognosis in pre- and postoperative periods.     

Late aortic dissection after aortic valve substitution. Considerations on 5 operative cases

This study analyses the clinical course of five patients who developed acute ascending aortic dissection 45.8 months (17-87 months) after aortic valve replacement (AVR) and underwent reoperation in our Department. All except one had aortic insufficiency with mild dilatation of the ascending aorta. No evidence of aortic wall degeneration was present at the time of AVR. Prostheses implanted were: Hancock 2, St. Jude 2, Bjork-Shiley 1. Associated procedures (coartectomy, coronary artery by-pass) were carried out in two patients. The dilated aorta was managed at the first operation by longitudinal resection in 3 of them. Emergent aortic dissection repair was performed: in 3 cases with composite graft according to the Bentall procedure, in one case with non valved dacron conduit and in the last case with teflon patch. Histological examination of the dissected aortic wall showed elastic fiber degeneration like cystic medial necrosis. Three patients survived surgical repair and are doing well at 22.4 months of mean post-operative follow-up. Surgical strategy of this complication is discussed; particular emphasis is given to the method of treatment of ascending aorta dilatation during AVR.     

Long-term risk of aortic events following aortic valve replacement in patients with bicuspid aortic valves

Bicuspid aortic valve (BAV) is associated with ascending aortopathy predisposing to aneurysmal dilatation and dissection, even after successful aortic valve replacement (AVR). There is, however, scant evidence on which to make recommendations for prophylactic replacement of the ascending aorta at the time of AVR. The medical records of patients who underwent AVR for BAV without aortic replacement or repair from 1960 to 1995 were reviewed. Follow-up was by review of the medical record and postal questionnaire. Among 1,286 patients, the mean age at operation was 58 ± 14 years. During the follow-up interval (median 12 years, range 0 to 38), there were 13 documented aortic dissections (1%), 11 ascending aortic replacements (0.9%), and 127 documented cases of progressive aortic enlargement (9.9%). Fifteen-year freedom from aortic dissection, enlargement, or replacement was 89% (95% confidence interval [CI] 87% to 91%) and was lower in patients with documented aortic enlargement at the time of AVR (85%, 95% CI 81% to 89%) compared to those whose aortic dimensions were normal (93%, 95% CI 90% to 96%) (p = 0.001). Multivariate predictors of aortic complications included interval (subsequent) AVR (hazard ratio [HR] 3.5, 95% CI 2.3 to 5.4, p <0.001), concomitant coronary artery bypass grafting (HR 2.6, 95% CI 1.7 to 4.0, p <0.001), enlarged aorta (HR 1.8, 95% CI 1.3 to 2.6, p = 0.001), and history of tobacco abuse (HR 1.8, 95% CI 1.2 to 2.6, p = 0.003). Aortic dilatation did not predict mortality. In conclusion, despite a true risk for aortic events after AVR for BAV, the occurrence of aortic dissection was low. Any incremental surgical risk imposed by prophylactic replacement of the ascending aorta must be equally low.