A history of the surgical treatment of aortic regurgitation

Aortic valve sparing strategies have a valuable potential to treat the patient's valvular disease. In contrast to the mitral and tricuspid valve, aortic repair is more difficult with respect to specific valve features. Authors give a historical overview of the evolution of surgical concepts to achieve the valve competency. Over the period of 70 years, manifold innovative approaches were tested in relation to contemporary level of knowledge in search of effective, standardized, safe and durable reconstructive procedures. Current focus on three geometrical components of aortic valve competency is a logical heir to this long-lasting effort.     

Percutaneous aortic valve replacement for severe aortic regurgitation in degenerated bioprosthesis: the first valve in valve procedure using the Corevalve Revalving system.

Percutaneous valve replacement for severe aortic stenosis has shown to be an alternative treatment option for non-surgical candidates. We report on the first successful valve in valve procedure in an 80-year-old patient with a severe regurgitation of a degenerated aortic bioprosthesis using the Corevalve Revalving system.     

升主动脉瘤合并主动脉瓣关闭不全的外科治疗

目的：回顾性总结自１９９１年１２月至１９９９年５月期间,３３例升主动脉瘤伴主动脉瓣关闭不全外科治疗的经验。方法：３３例升主动脉瘤中,１例为真性动脉瘤。３２例为夹层动脉瘤。夹层动脉瘤按ＤｅＢａｋｅｙ分型法,Ｉ型８例,ＩＩ型２４例,均伴主动脉关闭不全,均行Ｂｅｎｔａｌｌ手术,１０例合并二、三尖瓣关闭不全,做二、三尖瓣整形手术。１例合并冠心病,做内乳动脉与前降支搭桥术,结果：手术死亡率为６．０％（２／３３）,２例分别死于感染性心内膜为和吻合不可控制性渗血,２例有严重脑部并发症,随访时间１～５５个月,远期死亡２例,均系错迷窒息死亡,其余２９例心功能明显改善,眩动脉瘤无复发。结论：（１）升主动脉瘤合并主动脉瓣关闭不全行Ｂｅｎｔａｌｌ手术,采用良好的心肌保护方法,注意吻合技术防止出血,可以取得良好的手术效果。（２）对Ｄ     

Exacerbation of mitral regurgitation after tricuspid valve replacement for isolated tricuspid regurgitation

A 74-year-old woman, with a history of aortic valve replacement and open mitral commissurotomy due to rheumatic aortic and mitral stenosis, presented with dyspnea. She developed severe tricuspid regurgitation (TR), requiring tricuspid valve replacement (TVR). Despite an uneventful postoperative course, she was readmitted for dyspnea 2 months later. Trans-thoracic echocardiogram revealed severe mitral regurgitation (MR), despite mild MR at the time of TVR, which has not been previously reported. The main MR mechanism was increased left ventricular preload due to improved TR. Increased diuresis has controlled her congestive heart failure, but her MR remained moderate.     

Relationship of aortic regurgitant velocity slope and pressure half-time to severity of aortic regurgitation under changing haemodynamic conditions

The slope and pressure half-time of the aortic regurgitant velocityspectrum have been used as non-invasive markers of regurgitantseverity. Recent in vitro and theoretical work, however, hassuggested a confounding effect of systemic vascular resistanceand left ventricular compliance on these parameters. To studythis situation in vivo, we have investigated the determinantsof the aortic regurgitant velocity profile in an animal modelof aortic regurgitation in which the regurgitation was inducedsurgically and in which the afterload was varied pharmacologically.Specifically, we examined the relationship of slope and pressurehalf-time of the aortic regurgitant velocity profile to theseverity of aortic regurgitation under varying conditions ofafterload using multilinear analysis. Slope varied directlywith regurgitant orifice area and inversely with systemic vascularresistance and both left ventricular and aortic compliance (allP<0.001). Pressure half-time related to these variables inthe opposite direction. When the regurgitant orifice was variablein size, slope related directly (P<0.001) and half-time inverselyto the severity of the aortic regurgitation (the clinicallyexpected response). In contrast, when the regurgitant orificearea was constant, slope varied inversely (P<0.001) and half-timevaried directly (P<0.07) with the severity of the aorticregurgitation. Following nitroprusside infusion, slope tendedto increase (P=0.08) and pressure half-time tended to shorten(P=0.08) despite a significant reduction in the regurgitantfraction (P=0.009). Similarly, following dopamine infusion,a significant increase in regurgitant fraction (P=0.01) wasassociated with a slight fall in aortic regurgitation slopeand a lengthening of the half-time. The conventionally anticipated alterations in aortic regurgitationvelocity slope and pressure half-time predict the change inthe severity of aortic regurgitation when this is varied bychange in the size of regurgitant orifice but are unreliablewhen this is altered by pharmacological manipulation of theafterload.     

Ventricular energetics in aortic root replacement for annuloaortic ectasia with aortic regurgitation

Aortic root replacement (Bentall operation) is the standard operation for patients who have lesions of the ascending aorta associated with aortic valve disease. We analyzed the mid-term results for left ventricular energetics after the Bentall operation for annuloaortic ectasia with aortic regurgitation. We measured left ventricular contractility (end-systolic elastance; Ees), afterload (effective arterial elastance; Ea), and efficiency (ventriculoarterial coupling; Ea/Ees, and the ratio of stroke work and pressure-volume area; SW/PVA) based on transthoracic echocardiography data before, after, and approximately 1 year after the Bentall operation in 15 patients with annuloaortic ectasia with aortic regurgitation. Left ventricular volume was calculated by the Teichholz M-mode method. Ees and Ea were approximated as follows: Ees = mean blood pressure/minimal left ventricular volume, and Ea = systolic blood pressure/(maximal left ventricular volume — minimal left ventricular volume). Ea/Ees and SW/PVA were then calculated. Left ventricular volume was normalized with body surface area. Ees increased after the Bentall operation and around 1 year later (from 2.17 ± 1.09 to 3.92 ± 2.26 and 5.33 ± 1.90 mmHg·m²/ml, P < 0.001), thus resulting in an improvement in SW/PVA (from 68.8 ± 8.2 to 70.9 ± 9.5 and 74.7 ± 5.2%, P = 0.045). Ea also increased after the Bentall operation and 1 year later (from 1.77 ± 0.61 to 2.88 ± 1.28 and 3.54 ± 1.43 mmHg·m²/ml, P < 0.001). The mid-term results for ventricular contractility and efficiency after the Bentall operation for annuloaortic ectasia with aortic regurgitation are excellent and satisfactory.     

经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全

【摘要】 目的 探讨Venus-A支架瓣膜行经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全患者的可行性。方法 回顾性调阅2018年12月至2019年12月在阜外医院接受经股动脉经导管主动脉瓣置换术的15例单纯主动脉瓣关闭不全患者的床资料。其中男性12例, 女性3例,年龄68—83岁,平均年龄(74.65±5.52)岁。患者术前均有左心功能不全症状,且术前心脏超声诊断均为单纯主动脉瓣重度返流。结果 患者行经股动脉经导管主动脉瓣置换术。所有病例成功植入Venus-A支架瓣膜。全组病例无死亡。出院前对患者进行临床评估和超声心动图检查。术中行瓣中瓣治疗3例,少量瓣周返流2例。其余病人均无明显瓣周返流,并且顺利出院。结论 经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全患者是可行的,术后早期结果满意。     

Long-term follow-up by exercise radionuclide angiography of patients after valve replacement for aortic regurgitation

The long-term effects of valve replacement for chronic isolated aortic regurgitation as assessed by first-pass exercise radionuclide angiography have never been reported. We studied 20 males and 5 females before, 15 months postoperatively, and from 29 to 109 (mean 62 +/- 21) months following valve replacement with exercise radionuclide angiography. Mean peak heart rate did not change for the three studies. Peak systolic blood pressure decreased from 201 +/- 42 mmHg to 185 +/- 24 mmHg at 15 months and further declined to 177 +/- 32 mmHg by the long-term study (p less than 0.03). The mean resting left ventricular ejection fraction improved from 44 +/- 15% preoperatively to 57 +/- 18% at 15 months (p less than 0.002) with no further improvement by the long-term evaluation. The postexercise ejection fraction improved from 42 +/- 13% preoperatively to 61 +/- 21% at 15 months (p less than 0.002) also with no change by the long-term study. The duration of exercise improved from 9.7 +/- 4.6 min to 11.9 +/- 3.4 min (p less than 0.03) at 15 months with no additional improvement long term. Improvement in resting and postexercise ejection fraction and in exercise duration is maximal at 15 months. Accuracy and cost containment suggest that assessment of the maximal change in ejection fraction by exercise radionuclide angiography after aortic valve replacement in asymptomatic patients be limited to the 15-month interval.     

Transcatheter aortic valve replacement in pure native aortic regurgitation: when off-label indications match the patient’s requirements

Objective:In recent years, transcatheter aortic valve replace (TAVR) has revolutionized the interventional treatment of aortic stenosis, however, only scarce evidence considers it as treatment for Aortic Regurgitation (AR). At present, the treatment of Pure AR of Native Valve with TAVR does not fall within the recommendations of international guidelines, as it poses multiple challenges with immediate and long-term variable and unpredictable results. The objective of this paper is to present the case of a patient with prohibitive operative risk that benefited of TAVR treatment for AR.Materials and methods:We present the case of a 79-year-old male patient who has severe Pure Native Aortic Valve Regurgitation, considered inoperable. Based on the heart team’s decision, TAVR was planned with the use of an Edwards SAPIEN 3 valve. After TAVR, the patient developed complete heart block and a pacemaker was implanted. He improved to NYHA II functional class. At 15-month follow-up, he suffered intracranial hemorrhage and passed away.Results and Conclusions:Management of patients with severe symptomatic AR with high surgical risk continues to be a special challenge. They have high mortality if left untreated with valvular change, despite medical treatment. Even though it is strictly off-label, TAVR might be a reasonable solution for a select type of patients who are considered inoperable due to surgical high mortality risk.     

Quadricuspid aortic valve: a rare etiology of aortic regurgitation.

Quadricuspid aortic valve is a rare cause of aortic insufficiency. We report two unusual cases of this valvular pathology associated with a dilatation of the aortic root. The mechanism leading to this valve incompetence is incompletely understood and is discussed in regard to these cases.     

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.     

Transcatheter closure of ventricular septal defect in aortic valve prolapse and aortic regurgitation

ObjectiveTo report intermediate follow-up result of transcatheter closure of ventricular septal defect (VSD) in presence of aortic valve prolapse (AVP) with or without aortic regurgitation (AR).MethodThis is a retrospective review of 19 patients with VSD with AVP with AR who underwent transcatheter closure in between September 2011–July 2014. Mean age was 8 years (1–16 years, standard deviation [SD] 4.08 years) and mean weight was 26.03 kg (9–81.5 kg, SD 16.57 kg). Among them 2 had subarterial VSD, 6 had subaortic VSD and 11 had perimembranous VSD. All of them had mild AVP and 13 of them had AR (trivial or mild). Median VSD size was 4.3 mm (4–6 mm). Transcatheter closure was done either by retrograde technique using the Amplatzer Duct Occluder-II in 17 patients or antegrade technique using the Duct Occluder-I in 2 cases. Mean follow-up period was 18 months (12–36 months).ResultImmediate major complications were encountered in 2 (10.5%) cases. Significant aggravation of device related AR was seen in one case & device embolised to right pulmonary artery in another case and both of them were managed surgically.During follow up, 1 child had significant additional VSD requiring device closure. One child developed moderate AR, requiring surgery. None of the other had shown any increase in severity of AR.ConclusionDevice closure of VSD in presence of mild AVP and mild AR appears to be safe. Longer follow-up is necessary to draw final conclusion.     

Clinical utility of a predictive model for paravalvular aortic regurgitation after transcatheter aortic valve implantation with a self-expandable prosthesis

Background

A predictive model for Paravalvular aortic regurgitation (PAR) integrating the left ventricular outflow tract-to-ascending aorta angle (LVOT-AO) and depth to the non-coronary cusp (NCC) after TAVI with CoreValve prosthesis (MCP) was retrospectively identified (2 × ∠LVOT-AO + [depth to NCC-10]2; cutoff = 50). However, the validity and clinical utility of this model remain unknown.

经导管主动脉瓣置入手术在主动脉瓣狭窄合并二尖瓣反流治疗中的疗效分析

目的:分析经导管主动脉瓣置入术在主动脉瓣狭窄合并二尖瓣反流(MR)的疗效。方法:选取我院就诊的主动脉瓣狭窄合并MR流患者31例,所有患者均行经导管主动脉瓣置入术,按照患者的MR流严重程度分为A组(轻度)和B组(中度、重度)。比较两组的并发症发生率、术后1个月的LVEF、LVEDD、MR和NYHA分级,比较两组在术后1个月、3个月时的死亡率和生活质量。结果:两组的各并发症发生率差异无统计学意义(P>0.05);A组在术后1个月时的LVEF和日常生活能力量表(ADL)评分均明显高于B组(P<0.05);A组在术后1个月时的死亡率、LVEDD、MR和NYHA分级明显低于B组(P<0.05);两组患者在术后3个月时的死亡率和ADL评分均差异无统计学意义(P>0.05)。结论:经导管主动脉瓣置入手术可用于主动脉瓣狭窄合并不同程度MR流患者的治疗中,反流的严重程度对患者远期死亡率和生活质量恢复的影响较小。     

Systolic aortic regurgitation.

Aortic regurgitation is normally a diastolic phenomenon. Echocardiographic images of systolic aortic regurgitation in a patient with atrial fibrillation and heart failure are presented, and haemodynamic interpretation is provided.     

Urgent transcatheter aortic valve replacement for severe acute aortic regurgitation following open mitral valve surgery

Transcatheter aortic valve replacement (TAVR) is not currently approved for pure native valve aortic incompetence, and is typically performed on a compassionate basis in selected patients who are at high risk for conventional surgery. We describe the first use of TAVR to treat iatrogenic severe acute pure aortic incompetence following mitral valve surgery. A 71‐year‐old gentleman developed life‐threatening acute aortic regurgitation (AR) within hours of a very challenging fifth open heart mitral valve replacement. Careful inspection of echocardiographic and computed tomographic imaging identified the cause as a disrupted left coronary cusp at the commissure caused by the surgical mitral annular reconstruction. Medical management with afterload reduction failed with recurrent pulmonary edema, and a sixth open heart surgery was deemed prohibitively high risk. The lack of aortic annular calcium onto which anchors a transcatheter valve was a concern for TAVR. However, we postulated that the struts of the mitral valve bioprosthesis would offer some support to the TAVR valve. We opted for a self‐expanding system because of concerns about potential unfavorable interaction between the balloon onto which balloon‐expandable bioprosthesis is mounted and the struts of the mitral bioprosthesis, and because the Evolut R system has additional anchoring points at the crown which might enhance transcatheter valve stability in the non‐calcified annulus, compared with the Edwards Sapien system. Transfemoral TAVR, performed with a Medtronic Evolut R 34 mm system under general anesthesia and using moderately rapid ventricular pacing, was successful with minimal residual AR. On follow‐up 1 month later the patient was asymptomatic, and the aortic and mitral bioprostheses were functioning normally on echocardiogram.