Mitral valve repair with aortic valve replacement in rheumatic heart disease

From 1992 to 2001, 609 patients with rheumatic heart disease underwent aortic valve replacement with either mitral valve repair (n = 201) or mitral valve replacement (n = 408). Follow-up extended to 10 years. Thirty-day mortality was 1.4% for mitral valve repair and 0.7% for mitral valve replacement (p = 0.4). Survival at 9 years was 96.5 +/- 1.4% after mitral valve repair and 89.7 +/- 7.8% after mitral valve replacement (p = 0.73). Freedom from major bleeding at 9 years was 94.8 +/- 2.4% after mitral valve repair and 81 +/- 7.2% after mitral valve replacement (p = 0.03). Freedom from other valve-related complications and from mitral valve re-operation was similar for the two groups. This study showed that in patients with rheumatic heart disease the results of mitral valve repair with aortic valve replacement were comparable to those of double valve replacement. Major bleeding was less frequent after mitral valve repair with aortic valve replacement. Therefore, whenever feasible, mitral valve repair should be attempted in patients with rheumatic heart disease who need concomitant aortic valve replacement.     

Mitral valve repair versus replacement in simultaneous aortic and mitral valve surgery

BACKGROUND:

Double valve replacement for concomitant aortic and mitral valve disease is associated with substantial morbidity and mortality. Excellent results with valve repair in isolated mitral valve lesions have been reported; therefore, whether its potential benefits would translate into better outcomes in patients with combined mitral-aortic disease was investigated.

METHODS:

A retrospective observational study was performed involving 341 patients who underwent aortic valve replacement with either mitral valve repair (n=42) or double valve replacement (n=299). Data were analyzed for early mortality, late valve-related complications and survival.

RESULTS:

The early mortality rate was 11.9% for valve repair and 11.0% for replacement (P=0.797). Survival (± SD) was 67±11% in mitral valve repair with aortic valve replacement and 81±3% in double valve replacement at five years of follow-up (P=0.187). The percentage of patients who did not experience major adverse valve-related events at five years of follow-up was 83±9% in those who underwent mitral valve repair with aortic valve replacement and 89±2% in patients who underwent double valve replacement (P=0.412). Age >70 years (HR 2.4 [95% CI 1.1 to 4.9]; P=0.023) and renal dysfunction (HR 1.9 [95% CI 1.2 to 3.7]; P=0.01) were independent predictors of decreased survival.

CONCLUSIONS:

In patients with double valve disease, both mitral valve repair and replacement provided comparable early outcomes. There were no significant differences in valve-related reoperations, anticoagulation-related complications or prosthetic valve endocarditis. Patient-related factors appear to be the major determinant of late survival, irrespective of the type of operation.     

Effect of prior aortic valve intervention on results of the Ross operation

BACKGROUND AND AIM OF THE STUDY: Patient-related factors, aortic insufficiency, bicuspid aortic valve, aortic annulus dilatation, ascending aortic dilatation or aneurysm, and aortic valve endocarditis have been suggested as affecting the results of the Ross operation. The study aim was to assess the impact of prior aortic valve intervention on early and late results of a Ross operation. METHODS: A total of 399 patients who underwent surgery between August 1986 and September 2000 were reviewed retrospectively. The patients were grouped as: no prior aortic valve intervention (NOAVI, n = 219); prior aortic valvuloplasty (AVP, n = 106); prior balloon aortic valvuloplasty (AVB, n = 40); and prior aortic valve replacement (AVR, n = 34). Details of operative and late mortality, autograft valve function, and homograft valve function were analyzed. RESULTS: Operative mortality was higher for AVB (10%; three deaths in neonates) than the other groups (from 2.3% to 5.9%) (p = 0.084). Freedom from autograft valve degeneration, defined as severe autograft valve insufficiency, non-endocarditis autograft valve reoperation or valve-related death, ranged from 93 +/- 3% for AVP to 76 +/- 8% for NOAVI at 10 years (p = 0.43). Freedom from homograft reoperation in the pulmonary position was 100% for AVB at six years, and 99 +/- 1% for AVP, 82 +/- 8% for NOAVI, and 70 +/- 13% for AVR at 10 years (p = 0.0026). CONCLUSION: There appears to be no significant difference between patients with and without prior aortic valve surgery, with respect to operative mortality or late autograft function. However, patients with prior AVR appear to have a significantly higher homograft reoperation rate after a Ross operation, the reasons for which are uncertain.     

Extended follow up after isolated aortic valve replacement in the elderly

The present paper reviews the extended follow up of all patients aged >/=70 who underwent isolated aortic valve replacement at our institution in the 1980s. Patients were identified from the surgical database and clinical information was gathered. Long-term follow up information was obtained from the patient, their family, or doctor. Ninety-three patients aged >/=70 years (median 73, range 70-80) comprised the study population. The indication for surgery was aortic stenosis in 68 patients (73%). Fifty-two patients (56%) received an allograft valve, 17 (18%) a bioprosthetic valve, and 24 (26%) a mechanical prosthesis. The median hospital stay was 12 days (range 0-105 days). Five surgical deaths occurred. Detailed follow up was obtained for the 71 patients who died later, and the 16 living patients (one patient lost). The median length of follow up was 6.8 years (range 0.1-18.9 years). Patients who received an allograft aortic valve had a significantly better long-term survival (median 10.6, 95% confidence intervals (CI) 8.1-13.8 years) compared to those receiving mechanical or bioprosthetic valves (median 6.5, 95% CI 4.7-11.9 years), P = 0.03. For the entire group, survival was similar to the age- and sex-matched population. Of the 16 patients alive at follow up (mean age 87, range 83-92), most were free of angina (12, 75%) and heart failure (10, 63%). The conclusion from the current study is that isolated aortic valve surgery in the elderly, particularly with an allograft valve, is associated with an excellent long-term outcome. A survival benefit was demonstrated comparing allograft aortic valve replacement to other valve types.     

The Ross operation for aortic valve disease: previous sternotomy results in improved long-term outcome

BACKGROUND AND AIM OF THE STUDY: Progressive pulmonary autograft dilatation and failure following a Ross operation continues to be of major concern. It is hypothesized that the pulmonary autograft may perform better over the longer follow up period if the Ross operation is performed as a reoperation rather than a primary operation. The basis for this hypothesis is that the epicardial and mediastinal fibrosis encountered at reoperation may inadvertently provide additional support for the pulmonary autograft during the follow up period. METHODS: To test this hypothesis, 281 patients (mean age 24 +/- 9 years) who underwent a Ross operation over a 16-year period were retrospectively analyzed. The patient population was divided into two subgroups in whom the Ross operation was performed: (i) as the first cardiac operation, through a sternotomy incision (primary-Ross; n = 180); and (ii) after the patient had undergone a previous sternotomy (prior-sternotomy; n = 101). A recent follow up examination was achieved in 93% of patients. RESULTS: Early and overall mortality was 2.1% and 6.4%, respectively, and there was no significant difference between the subgroups. At 12-year follow up, freedom from reoperation on the autograft, or valve-related death was 87 +/- 6% versus 71 +/- 9% in favor of the prior-sternotomy subgroup (p = 0.06). At 12-year follow up, freedom from valve-related death, or reoperation on the pulmonary autograft, or severe aortic regurgitation was 87 +/- 5% versus 71 +/- 7% (p = 0.03) in favor of the prior-sternotomy subgroup. CONCLUSION: The results of a preliminary analysis suggest that additional benefit is accrued when the Ross operation is performed during re-sternotomy. This should encourage surgeons to attempt repair of the aortic valve during the initial surgery, with the knowledge that - if needed - the Ross operation can be performed safely at later surgery, and with possible additional benefit to the patient during the follow up period.     

Aortic valve repair for congenital abnormalities of the aortic valve

BACKGROUND: Due to shortcomings of any valve replacement, repairing and retaining the native valve may be beneficial for congenital aortic valve disease. METHODS: Retrospective review of data and follow-up of aortic valve repair from a single institution. RESULTS: From 1993 to 2001, 56 patients underwent aortic valve repair [median age 13.4 years (range 1 day to 45 years)]. The predominant aortic valve lesion was mixed aortic stenosis/aortic insufficiency 25 (45%), aortic insufficiency 24 (43%) and aortic stenosis 7 (13%). Repair techniques included sub-commissural plication 36 (64%), commissurotomy 24 (43%), cusp plication 15 (27%), pericardial patch cusp extension 8 (14%) and resuspension of commissures 4 (7%). Most patients (88%) required a combination of techniques; 61% required additional procedures. Hospital survival was 55/56 [98%; (95% CI 91-100%)] no patient was discharged on anticoagulation for aortic valve pathology. Fifty-three patients [95%; (95% CI 85-98%)] remain alive after a median follow-up of 37 months; four survivors required aortic valve replacement and two required repeat aortic valve repair [84%; (95% CI 72-91%) reintervention-free survival]. CONCLUSIONS: (1) In this study, aortic valve repair for congenital abnormalities avoided reoperation in the majority of patients, avoided anticoagulation and retained growth potential of the valve. (2) Repeat aortic valve repair or replacement was used to treat subsequent valve deterioration.     

Outcomes of surgical bioprosthetic aortic valve replacement for aortic insufficiency

BackgroundResults and durability of aortic valve replacement in aortic stenosis are well known, but no study has focused on the results of aortic valve replacement in aortic insufficiency.AimThe aim of this retrospective study was to describe our mid-term outcomes after aortic valve replacement for aortic insufficiency.MethodsAll consecutive adult patients who underwent bioprosthetic aortic valve replacement for aortic insufficiency at two European centres (in France and Germany) between May 2005 and December 2020 were analysed.ResultsDuring the study period, 289 patients were included. Mean age was 56.9 ± 12.5 years. Overall operative mortality was 1.5%, and the 10-year survival estimate rate was 75.0%, which was significantly lower than in the age- and sex-matched general population, with a standardized mortality ratio of 2.88 (95% confidence interval 1.96–4.08; P < 0001). Freedom from aortic valve-related death was 87.6%, and from aortic valve-related reoperation was 87.4%. No patient aged > 60 years was reoperated on during follow-up. Freedom from severe structural valve deterioration at 10 years was 73.3%, and freedom from moderate structural valve deterioration at 10 years was 50.3%. Freedom from major adverse valve-related events at 10 years was 69.7%.ConclusionsAlthough bioprosthetic aortic valve replacement for aortic insufficiency shows good early results, 10-year mortality and major adverse valve-related event rates in young patients may be a concern, with a reduction in life expectancy compared with the general population.     

儿童主动脉瓣置换术近远期疗效分析

目的:探讨儿童主动脉瓣置换术的病因、瓣膜选择、近远期疗效、死亡和再次手术的危险因素及抗凝相关问题。方法:回顾性分析1990年1月至2014年12月在第二军医大学附属长海医院接受心脏瓣膜置换的62例患儿临床资料,包括男40例,女22例,年龄4~14岁,平均年龄(11.53±2.66)岁,其中先天性心脏瓣膜病41例,风湿性心脏瓣膜病2例,感染性心内膜炎10例,黏液性变心脏瓣膜病9例。62例主动脉瓣置换术均使用机械瓣膜,采用间断褥式缝合方法。部分患者术中采用主动脉根部加宽术(Nicks法4例、Manougnian法11例)。结果:本组住院死亡率为6.5%(4/62),死亡原因为术后严重低心排综合征3例,术中无法脱离体外循环1例。随访时间1.5~18年,平均(10.2±2.5)年,失访5例,随访率91.4%。随访期间死亡3例,1例为术后9个月死于严重心律失常,1例为术后8年不明原因猝死,1例为术后6年死于感染性心内膜炎。再次瓣膜置换2例。随访期间未发现与抗凝相关的严重并发症,也无因患者-人工瓣膜不匹配再次手术者;患者主动脉瓣膜功能良好,心功能均为Ⅰ~Ⅱ级。结论:儿童主动脉瓣机械瓣置换术近、远期效果良好,大多数患儿可置入较大的瓣膜,术后心脏结构和功能大多能恢复正常。     

Minimally invasive aortic valve replacement: echocardiographic and clinical results

BACKGROUND: Port access has been described for mitral and bypass surgery. The purpose of this study was to review the clinical and echocardiographic outcomes of aortic valve replacement by use of port access. METHODS: Between 1996 and 1999, 153 port-access aortic valve replacements were performed at our institution. The mean age was 63 years (range 16-91 years); 58% were male. The New York Heart Association mean class was III; 18% were in class IV. Thirteen percent had diabetes, 42% hypertension, 7% prior transient ischemic episode or stroke, 7% lung disease, 3% renal failure, and 13% previous surgery. Echocardiograms were obtained after valve replacement in 125 patients (96 intraoperative transesophageal and 97 transthoracic echoes). RESULTS: Median length of stay was 8 days. There were no intraoperative deaths; 10 patients (6.5%) died in the postoperative period. Stroke occurred in 4 (2.6%), sepsis in 5 (3.3%), renal failure in 5 (3.3%), pneumonia in 3 (2%), and wound infection in 1 (0.7%). Tissue prosthesis was present in 83 and a mechanical prosthesis in 42. No or trace regurgitation was seen on 94 of 96 (98%) postbypass intraoperative echocardiograms and mild on 2. On follow-up echocardiograms, moderate regurgitation was seen in 4 of 97 (4.1%), mild-to-moderate in 2 (2.1%), mild in 18 (18.6%), and no or trace in 71 (73.2%). Of those who had aortic regurgitation on intraoperative or follow-up echocardiograms, it was paravalvular in 8. CONCLUSIONS: Minimally invasive aortic valve replacement with a port-access approach is feasible, even in high-risk patients. Small incisions, a low infection rate, and a short length of stay are attainable. However, the complications associated with traditional aortic valve replacement still occur. Echocardiography is valuable both for intraoperative monitoring and follow-up of this new procedure.     

Medium-term follow up of pulmonary autograft aortic valve replacement: technical advances and echocardiographic follow up

BACKGROUND AND AIM OF THE STUDY: The Ross procedure (aortic valve replacement (AVR) with pulmonary autograft and pulmonary homograft replacement of pulmonary valve) was developed as a durable aortic valve substitute that avoids the need for anticoagulation and provides young patients with a long-lasting aortic valve substitute. Our seven-year follow up echocardiography data are reviewed. METHODS: Between May 1993 and March 2000, 40 adult patients (28 males, 12 females; mean age 33.3 years) underwent the Ross procedure at the Brigham and Women's Hospital for congenital aortic stenosis (n = 6), aortic insufficiency (n = 17) and mixed disease (n = 17). All patients had aortic root replacement with the pulmonary autograft and had no regurgitation after operation. Postoperative evaluation was conducted by transthoracic echocardiography, office visit and/or telephone interview. NYHA functional class, aortic and pulmonary valve function and aortic root dimensions were evaluated. RESULTS: One patient died postoperatively as a result of a low output state related to global left ventricular dysfunction. Four patients (10%) developed pulmonary homograft stenosis with a peak gradient >40mmHg; and six developed mild pulmonary stenosis. One patient had aortic insufficiency seven years postoperatively that required valve replacement. Eight patients developed mild dilatation (>37 mm) of the neoaortic root, and five of these had aortic insufficiency. One patient required transplantation at 40 months for restrictive cardiomyopathy. CONCLUSION: The Ross procedure is an effective means of AVR that can be accomplished with low perioperative morbidity and mortality if certain technical modifications are carried out. In this series of 40 patients with mid-term follow up, a significant number developed moderate pulmonary trunk stenosis, though echo characterization demonstrated good valve function.     

Current status of the Ross procedure in aortic valve surgery

The Ross procedure represents a unique surgical concept of unrepairable diseased aortic valve replacement by patient's own pulmonary valve (pulmonary autograft). After pulmonary valve removal, the right ventricle outflow tract is reconstructed by pulmonary allograft transplantation. Pulmonary valve in aortic position (pulmonary autograft) displays excellent haemodynamic features, viability with a growth-potential (in children) and a low risk of thromboembolism and infective endocarditis unparalleled to other heart valve substitutes. Despite the advantages of a pulmonary autograft the Ross procedures arouses controversies and surgical respect due to its technical complexity and involvement of another valve into a risk of complications and potential reoperation. Renaissance of interest in Ross procedure has been caused by recent operation standardisation, knowledge of critical procedural steps and confirmation of excellent long-term results. Ross procedure performed in dedicated centres with utmost attention to technical details securing long-term durability of both the autograft and allograft is an attractive option namely for young patients with aortic valve disease.     

Bioprosthetic valve replacement in the elderly

One hundred and ten patients aged more than 65 years (mean,73.4; range, 65–82) underwent successful bioprostheticvalve replacement (aortic, n = 71; mitral, n=32; both, n = 7)from 1979 to 1985. The valve was pericardial in 39 cases andporcine in 78. The mean follow-up was 75 months (total, 688patient-years; range, 2 months to 12 years). Actuarial patientsurvival was 79.4% at 5 years and 55.2% at 10 years. Thirty-sevenpatients died: 18 from valve-related causes and 19 from othercauses. Eight patients have been reoperated on for valve-relatedcomplications (1.17% per patient-year): five primary deteriorations,two paravalvular leaks and one case of endocarditis. One surgicaldeath occurred (12.5%). Twenty-five percent of the patientswere receiving anticoagulants because of atrial fibrillation,and 5.4% developed severe bleeding (3.8% patient-year). Mid-term follow-up of these patients aged more than 65 yearsand undergoing bioprosthetic valve replacement surgery revealeda low rate of documented primary structural deterioration (0.9%per patient-year), a low mortality rate on reoperation (12.5%)and a high mortality rate due to non valve-related causes (51.4%).     

Valve preserving surgery in patients with bicuspid aortic valve

Bicuspid aortic valve can be associated with clinically important aortic regurgitation and dilatation of ascending aorta. Aortic valve repair seems to be optimal therapeutic option how to avoid valve-related and anticoagulation-related complications. We have analyzed midterm outcomes of patients after bicuspid aortic valve repair.MethodsBetween January 2008 and December 2015, 91 patients (mean age 40.9 ± 12.2) with bicuspid aortic valve (type 0 or 1) underwent valve-sparing surgery for aortic valve insufficiency or aortic aneurysm. Urgent procedures and patients of age more than 65 were not included. The cohort of patients was retrospectively divided into two groups. Forty-nine patients underwent aortic valve-sparing procedure with root replacement (group 1). Forty-two patients underwent aortic valve repair without root replacement (group 2). The mean length of follow-up was 57.5 months.ResultsThere was no death in connection with aortic valve repair during follow up. Three patients from group 2 required in-hospital reoperation for early repair failure. Another seven patients (4 from group 1 and 3 from group 2) were reoperated for recurrent aortic insufficiency during follow-up period. Freedom from aortic valve reoperation at 5 years was 90% in group 1 and 87% in group 2. Freedom from recurrent aortic insufficiency (>2°) at 5 years was 85% in group 1 and 78% in group 2.ConclusionBicuspid aortic valve repair is a safe procedure, which can be performed with acceptable midterm results. Risk of repair failure depends on preoperative valve morphology and choice of repair technique. Repair technique needs to be tailored to the specific anatomy of the valve.     

The natural history of aortic valve disease after mitral valve surgery

OBJECTIVES

The present study evaluates the long-term course of aortic valve disease and the need for aortic valve surgery in patients with rheumatic mitral valve disease who underwent mitral valve surgery.

BACKGROUND

Little is known about the natural history of aortic valve disease in patients undergoing mitral valve surgery for rheumatic mitral valve disease. In addition there is no firm policy regarding the appropriate treatment of mild aortic valve disease while replacing the mitral valve.

METHODS

One-hundred thirty-one patients (44 male, 87 female; mean age 61 ± 13 yr, range 35 to 89) were followed after mitral valve surgery for a mean period of 13 ± 7 years. All patients had rheumatic heart disease. Aortic valve function was assessed preoperatively by cardiac catheterization and during follow-up by transthoracic echocardiography.

RESULTS

At the time of mitral valve surgery, 59 patients (45%) had mild aortic valve disease: 7 (5%) aortic stenosis (AS), 58 (44%) aortic regurgitation (AR). At the end of follow-up, 96 patients (73%) had aortic valve disease: 33 AS (mild or moderate except in two cases) and 90 AR (mild or moderate except in one case). Among patients without aortic valve disease at the time of the mitral valve surgery, only three patients developed significant aortic valve disease after 25 years of follow-up procedures. Disease progression was noted in three of the seven patients with AS (2 to severe) and in six of the fifty eight with AR (1 to severe). Fifty two (90%) with mild AR remained stable after a mean follow-up period of 16 years. In only three patients (2%) the aortic valve disease progressed significantly after 9, 17 and 22 years. In only six patients of the entire cohort (5%), aortic valve replacement was needed after a mean period of 21 years (range 15 to 33). In four of them the primary indication for the second surgery was dysfunction of the prosthetic mitral valve.

CONCLUSIONS

Our findings indicate that, among patients with rheumatic heart disease, a considerable number of patients have mild aortic valve disease at the time of mitral valve surgery. Yet most do not progress to severe disease, and aortic valve replacement is rarely needed after a long follow-up period. Thus, prophylactic valve replacement is not indicated in these cases.     

Aortic valve replacement for aortic stenosis in persons aged 80 years and over

Seventy-one patients aged greater than or equal to 80 years (mean +/- standard deviation 82 +/- 2) with aortic stenosis or mixed stenosis and regurgitation underwent aortic valve replacement alone (n = 35, group 1) or in combination with a coronary artery bypass procedure without any other valve procedure (n = 36, group 2). Preoperatively, 91% had severe cardiac limitations (New York Heart Association class III or IV). Hospital mortality was 12.7% overall (9 of 71), 5.7% (2 of 35) for group 1 and 19.4% (7 of 36) for group 2. Perioperatively, 1 patient (1.4%) had a stroke. Survival from late cardiac death at 1 and 3 years was 98.2 and 95.5%, respectively, for all patients, 100% for patients who underwent isolated aortic valve replacement, and 96.3 and 91.2%, respectively, for patients who underwent aortic valve replacement plus coronary artery bypass. Eighty-three percent of surviving patients had marked symptomatic improvement. Freedom from all valve-related complications (thromboembolism, anticoagulant, endocarditis, reoperation or prosthetic failure) was 93.3 and 80.4% at 1 and 3 years, respectively. Thus, short- and long-term morbidity and mortality after aortic valve replacement for aortic stenosis in patients aged greater than or equal to 80 years are encouragingly low, although the addition of coronary artery bypass grafting increases short- and long-term mortality.     

Aortic valve repair in patients with aortic regurgitation: Experience with the first 100 cases

IntroductionThe aim of this study was to analyze short- and mid-term results of aortic valve repair.Material and methodsOne hundred consecutive patients (24 females; mean age 50.3 years, range 23–77 years) with aortic regurgitation underwent aortic valve repair between November 2007 and October 2012. Sixty patients had bicuspid aortic valve, and 82 patients demonstrated aortic regurgitation greater than mild (> grade 2). The ascending aorta/aortic root was replaced in 67 patients. Aortic cusp repair was necessary in 74 patients and additional aortic annulus stabilization was required in 48 cases. Follow-up ranged from 1 to 59 months (cumulative of 220 patient-years, median 25 months) and was complete in 100%.ResultsThere was no 30-day mortality and two patients died in the follow-up. The overall 4-year survival was 98% and freedom from cardiac death was 99% at 4 years. During the follow-up eight patients underwent aortic valve-related reoperation due to progression of aortic regurgitation and another six patients showed aortic regurgitation more than mild (> grade 2). In both aspects there was no statistically significant difference between patients without and with aortic root replacement (p=0.402 and p=0.650). There were no significant bleeding or thromboembolic events during the follow-up.ConclusionsShort- and mid-term data analysis revealed an excellent survival and acceptable results of aortic repair, comparable with other larger published studies. We think, therefore, aortic valve repair should be a part of contemporary cardio-surgical armamentarium, especially in younger patients with an appropriate indication.     

Feasibility of the ross procedure: its relationship with the bicuspid aortic valve

BACKGROUND AND AIM OF THE STUDY: The feasibility of the Ross procedure, and which patients benefit most from its performance, have not yet been fully established. The study aim was to analyze the relationship between the etiology of aortic valve disease, the feasibility of performing the Ross procedure, and late pulmonary autograft performance. METHODS: Between June 1995 and June 2001, 117 patients (77 males, 40 females; mean age 37+/-12 years) underwent the Ross procedure at the authors' institution. Of these patients, 53 (45.3%) had severe aortic stenosis, 53 (45.3%) had significant aortic insufficiency, four (3.4%) had active endocarditis, two (1.7%) had subaortic stenosis, and five (4.3%) had prosthesis dysfunction. Eighty-one patients (69%) had a bicuspid aortic valve. Pulmonary autograft dysfunction was defined as regurgitation grade > or =2, as registered by Doppler echocardiography. RESULTS: The Ross procedure was successful in 100 patients (85.5%); hospital mortality was 2.6% (n = 3). The procedure was not feasible in 17 patients (14.5%); of these, seven had bicuspid pulmonary valve, six had >3 mm multiple pulmonary valve fenestrations, three had severe pulmonary insufficiency, and one patient had dissection-related pulmonary valve injury. Twelve of 16 patients presenting with pulmonary valve defects had bicuspid aortic valve (p = 0.04). At six-year follow up, the probability of not requiring reoperation was 93% (confidence interval 86-100%). During follow up (30+/-14 months; range: 2-72 months), six patients presented with grade 2 pulmonary autograft insufficiency, three with grade 3, and two with grade 4. Six of the latter 11 patients (p = 0.03) had a history of bicuspid aortic valve with aortic regurgitation. Freedom from autograft dysfunction was 87% (confidence interval 82-92%). Patients with bicuspid aortic valve and aortic valve regurgitation had a higher tendency towards autograft dysfunction than those with bicuspid aortic valve and aortic stenosis (65% versus 100%, p = 0.004). CONCLUSION: The feasibility of performing the Ross procedure is high, unless there is presence of bicuspid aortic valve. Patients with bicuspid aortic valve and a history of aortic insufficiency tend to develop moderate autograft dysfunction during long-term follow up.     

Fourteen years' experience with the CarboMedics valve in young adults with aortic valve disease

BACKGROUND AND AIM OF THE STUDY: Homografts and the Ross procedure are recommended by many surgeons for aortic valve replacement (AVR) in young adults. The study aim was to monitor patient outcome over a 14-year period after implanting mechanical CarboMedics prosthetic heart valves in young adults with aortic valve disease. METHODS: Between November 1987 and December 2000, 55 patients (42 males, 13 females; median age 33 years; range 15-40 years) each received a CarboMedics valve in the aortic position. All patients were included on a consecutive and non-selected basis. Concomitant surgery was performed in five patients. Anticoagulation was commenced on postoperative day 1. After discharge, patients were followed up by their cardiologist or general practitioner using questionnaires and telephone calls. Actuarial estimates of survival and freedom from morbid events were calculated using the Kaplan-Meier method. RESULTS: No patient died during surgery. Complete follow up data were available for all patients; total follow up was 404 patient-years (pt-yr). The 30-day mortality rate was zero. Actuarial survival at 14 years was 90 +/- 4.9%, and actuarial freedom from all valve-related events 92 +/- 3.7%. No valve thrombosis or major bleeding events were identified. Linearized rates per 100 pt-yr were: embolism 0.25; paravalvular leakage 0.25; prosthetic endocarditis 0.25; and reoperation 0.50. There was no hemolysis, prosthetic valve dysfunction, or structural deterioration. CONCLUSION: Over a 14-year period, implantation of the CarboMedics prosthetic heart valve has proven to be an excellent solution for AVR in young adults with aortic valve disease.     

Quality of life in aortic valve replacement: pulmonary autografts versus mechanical prostheses

OBJECTIVES: We sought to determine whether the quality of life (QoL) is different in patients after aortic valve replacement with mechanical prostheses or pulmonary autografts. BACKGROUND: Quality of life after mechanical valve replacement may be affected by the risk of thromboembolism and anticoagulation, and after autograft implantation, by the risk of degeneration and re-operation especially of the homograft. METHODS: Two groups of 40 patients each--one after the autograft procedure (group I) and one after mechanical valve implantation (group II)--were matched for age, gender and length of follow-up. At latest follow-up, all patients underwent routine echocardiography, the short-form health survey (SF-36) QoL survey and an extensive psychological investigation. RESULTS: Patients with an autograft showed better QoL scales, as compared with mechanical valve recipients. The difference was significant for both the physical (72.72+/-20.00 vs. 60.27+/-26.07, p = 0.021) and psychological health sum scores (74.71+/-21.03 vs. 64.71+/-23.49, p = 0.046) and for the subtests of physical functioning (73.72+/-22.44 vs. 62.77+/-25.42, p = 0.049), physical pain (88.39+/-19.13 vs. 73.36+/-27.08, p < or = 0.006), general health perception (64.37+/-17.88 vs. 51.86+/-22.86, p < or = 0.008) and health change (61.89+/-18.94 vs. 50.11+/-24.37, p = 0.02). The QoL variables did not correlate to pressure gradients, ejection fraction and New York Heart Association functional class. Psychometric tests revealed no meaningful differences between the groups. CONCLUSIONS: This study provides some evidence that patients with pulmonary autografts have greater benefit in terms of QoL, as compared with recipients of mechanical valve substitutes.     

Growth of pulmonary autograft after Ross operation in pediatric patients

The Ross procedure is being used increasingly to treat aortic valve disease in pediatric patients; however, there is an ongoing dispute about the durability of the autograft. From November 1996 to September 2003, 32 pediatric patients (mean age, 11 +/- 4.5 years) underwent the Ross procedure for various aortic valve diseases, using the root replacement technique. Clinical and echocardiographic follow-up was performed early (within 30 days), at 3 to 6 months, and yearly after surgery. There were no perioperative deaths. The patients were followed-up for up to 7 years with a median interval of 36 months. Actuarial survival at 7 years was 96% +/- 3% and there was 100% freedom from re-operation for autograft valve dysfunction or any other cause. The autograft annulus and sinus increased significantly in size during follow-up and the increase in size paralleled the increase in body surface area, with no evidence of disproportional dilatation. The hemodynamics at the latest follow-up were also similar to those at the time of discharge after surgery. Pulmonary autograft replacement of the aortic valve appears to be the ideal solution in pediatric patients, because of relatively low operative risk, excellent late valve function, and real potential for growth.