Stentless full root bioprosthesis in surgery for complex aortic valve-ascending aortic disease: a single center experience of over 300 patients.

OBJECTIVE: The technically demanding full root aortic valve replacement necessitating coronary ostia reimplantation apparently leads to hesitation by some surgeons despite the superior hemodynamics and excellent long-term clinical performances of the stentless xenografts. Clinical data of stentless full root replacements was retrospectively analyzed in this perspective for validation. METHODS: From November 1999 to March 2007, 317 adult patients (male: 196, female, 121) underwent modified Bio-Bentall procedure using the Medtronic Freestyle xenograft as a full root replacement. Two hundred and three patients received an isolated root replacement or a root and ascending aortic replacement (ARR). In 114 patients a variety of concomitant procedures including coronary artery bypass grafting (n=32), mitral valve repair (n=11) and aortic arch replacement (n=36) were performed. (ARR+). RESULTS: Mean patient age was 70.3+/-10.2 years (range 17-94 years), 97 patients were 75 and older at time of procedure. Mean operative time for the ARR was 190+/-57 min with a clamp time of 88+/-27 min. Mean operative time for ARR+ group was 282+/-93 min with an average clamp time of 110+/-32 min. Overall operative mortality was 7.9% (25/317), for ARR it was 5.4% (11/203). Mean ICU stay was 4.9+/-8.1 days, mean hospital stay being 9.8+/-8.1 days. Necessity for bailout bypass surgery among patients with ARR was low at 1.5% (3/203) comparable to stented xenograft implantations. Echocardiography demonstrated excellent clinical results with low transvalvular gradients especially when a single suture inflow anastomosis technique was used. CONCLUSIONS: Full root stentless valve implantation preserving porcine root integrity is a valuable option in aortic valve/ascending aorta surgery. Though technically a more challenging operation, it does not lead to increased perioperative morbidity and mortality and can be beneficial mainly for elderly patients with small aortic roots with or without aortic root pathology.     

Aortic root replacement in patients with Marfan's syndrome: the Southampton experience.

BACKGROUND: The purpose of this study was to evaluate the early and late clinical outcome after aortic root replacement (ARR) in patients with Marfan's syndrome. METHODS: A total of 65 consecutive patients with Marfan's syndrome (mean age 41.7 +/- 10.7 years, range 15 to 76 years) undergoing ARR between 1972 and 1998 in Southampton were studied. Of the patients, 45 had a chronic aneurysm of the ascending aorta and 20 had a type A dissection (16 acute and 4 chronic). The operations were elective in 38 and nonelective in 27 cases (emergency in 22 and urgent in 5). Mean size of the ascending aorta was 6.3 +/- 1.4 cm (3.8 to 12 cm). A Bentall procedure was performed in 62 and a homograft root replacement in 3 patients. Mean follow-up was 8 +/- 4.1 years (0 to 22.9 years). RESULTS: Operative mortality was 6.1% (4 deaths) (for the elective vs nonelective procedures it was 2.6% vs 11%, p = 0.2). The 10-year freedom from thromboembolism, hemorrhage, and endocarditis was 88%, 89.8%, and 98.4% (0.9%, 0.9%, and 0.2% per patient-year) and from late aortic events it was 86.3% (1.3% per patient-year). Aortic root replacement for dissection was an independent predictor of occurrence of late aortic events (p = 0.01). Five patients had a reoperation with one early death. The 10-year freedom from reoperation was 89.2% (1.1% per patient year) (for elective and nonelective procedures, 90.8% vs 84.6%, p = 0.6). The 10-year survival, including operative mortality, was 72.7% (for elective and nonelective procedures, 78% vs 66.5%, p = 0.6). Late aortic events was an independent adverse predictor of survival (p = 0.02). CONCLUSIONS: In patients with Marfan's syndrome, elective ARR, usually for chronic aneurysm, is associated with a low mortality, low rate of aortic complications, and good late survival. Nonelective ARR, mostly for dissection, has a greater operative risk and a significantly higher incidence of late catastrophic aortic events. Early prophylactic surgery in these patients is therefore recommended. Long-term clinical and radiologic follow-up to prevent or to treat late aortic events is highly desirable.     

Aortic root replacement with the Carboseal composite valve graft: analysis of risk factors

This retrospective analysis of a selected series of Bentall-De Bono procedures was carried out in order to evaluate the performance of the Carboseal composite valve graft (Sulzer Carbomedics Inc, Austin, TX, USA). Between October 1997 and April 2004, 120 patients underwent aortic root replacement with the Carboseal Composite Valve Graft. The mean age of patients was 59.7+/-13.4 years (range, 21-83 years); 96 patients (80%) were male. Eighty-nine patients (74.2%) had annulaortic ectasia, 10 patients (8.3%) post-stenotic dilatation, 3 (2.5%) post dissection aneurysm, 2 (1.7%) acute type A dissection and 1 (0.8%) endocarditis. The average follow-up duration was 29.2 months (range 2-82 months). Hospital mortality was 1.7% (2 of 120 patients). The actuarial survival rate (including hospital mortality) was 97.2+/-1.5% at 1 year, 91.6+/-3.5% at 3 years and 84.0+/-8.0% at 5 years. Chronic renal failure was an independent risk factor for late mortality (P=0.02). The actuarial freedom from pseudoaneurysms at 3 years was higher among patients without Marfan syndrome (94.7+/-3.2% vs. 75.0+/-21.6% at 3 years, P<0.003). In our recent series, the Bentall-De Bono operation provided good results with low incidence of prosthetic related complications. Pseudoaneurysms requiring re-operation have a higher incidence among patients with Marfan syndrome.     

Rescue Coronary Artery Bypass Grafting (CABG) after Aortic Composite Graft Replacement

Abstract Background: Aortic root replacement (ARR) has been recognized as the standard therapy for diseases of the aortic root since its introduction into clinical practice. ARR currently provides excellent long‐term benefit with acceptable perioperative risk and excellent long‐term morbidity and mortality. During ARR, coronary button misalignment may produce myocardial ischemia, ventricular arrhythmias, and pump failure leading to death if unrecognized. Here we review our experience with coronary insufficiency after ARR. Methods: Between January 1995 and March 2006, 139 consecutive patients underwent ARR at Yale‐New Haven Hospital. A retrospective review of their medical records was conducted. The mean age of the patients was 54.5 years. Aortic root aneurysm was the indication for surgery in 123 patients, acute type A dissection in 14, and endocarditis in two. Results: All patients underwent a modified Bentall operation with a mechanical (87%) or biological (13%) valve prosthesis and coronary artery button reimplantation. The overall 30‐day mortality was 4.3% (six patients). Three patients (2.2%) underwent rescue coronary artery bypass grafting (CABG) to the left, right, or both coronary arterial systems for ischemia due to presumed coronary button misalignment. These patients presented with ventricular arrhythmias or hemodynamic compromise. All three showed excellent response to rescue CABG and remain alive and well in late follow‐up. Conclusion: Coronary insufficiency after reconstruction of the aortic root is an uncommon but acutely life‐threatening occurrence. This lethal condition may present with difficulty in weaning from cardiopulmonary bypass; echocardiographic signs of major wall motion abnormalities; and electrocardiographic evidence of ischemia, pump failure, and ventricular arrhythmias. Rescue CABG in this situation is life‐saving. Immediate rescue CABG should be performed if coronary ischemia is suspected after composite graft replacement of the aortic root.     

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.     

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.     

Composite graft replacement of the aortic root after previous cardiac surgery: a 20-year experience

BACKGROUND: An aging population and prolonged survival of patients after cardiac operations has meant that composite aortic root replacement after previous cardiac operation is being performed with increasing frequency. METHODS: From January 1979 to July 1999, 32 patients underwent "reoperative" composite replacement of the aortic root at our institution. Previous operations were 16 aortic valve replacement, 9 coronary artery bypass grafting, 5 repair aortic dissection, and 7 others. Indications for operation included ascending aortic aneurysm in 16 patients, ascending aortic dissections in 10 patients, and other in 6 patients. RESULTS: The unit elective mortality was 3 of 26 (11.5%). One surgeon's elective mortality was 1 of 22 (4.6%). The unit emergent mortality was 6 of 6 (100%). There has been one late death. Morbidity was low. CONCLUSIONS: Reoperative aortic root replacement is a technically demanding procedure, but expertise in the area achieves low elective mortality. Consideration should be given to aortic root replacement at the initial procedure. Close follow-up of postcardiac operation patients is necessary to proceed with elective aortic root replacement if indicated. Emergent presentation in the reoperative setting has a very poor prognosis.     

Diastolic heart failure in patients with aortic valve disease

From March 2002 to August 2005, 53 patients with age between 30 and 86 underwent surgical treatment for aortic valve disease. Preoperative diastolic heart failure was observed in 15 cases (28.3%). Operative procedures consisted of aortic valve replacement (AVR) in 42 cases [AVR and mitral valve replacement (MVR) in 3], aortic valve plasty (AVP) in 2, and aortic root replacement in 4. Concomitant procedures included maze procedure in 2 cases, coronary artery bypass grafting (CABG) in 6, mitral valve surgery in 15, and tricuspid valve annuloplasty (TAP) in 8. There were 7 cases for patient-prosthesis mismatch (PPM) [13.2%]. There were 2 hospital deaths (both were low-output syndrome). Among the surgical survivors, there were 2 late cardiac-related complications (all cases were cardiac failure). There was no recurrence or re-operation. Although all cases had severe diastolic failure, their systolic function was almost normal. Our study suggested that in patients with aortic valve disease, not PPM but diastolic heart failure correlated strongly with postoperative event and survival.     

Surgery for infective endocarditis: determinate factors in the outcome

AIM: The appropriate operative procedures for treatment of infective endocarditis (IE) are still controversial. The authors reviewed their own operative results focusing on preoperative risk factors, intraoperative findings and operative procedures. METHODS: The authors reviewed the cases of 40 adult patients who had undergone surgery since 1999. The mean age of patients was 58 years ranging from 31 to 78 including 30 males and 10 females. Thirty-three patients had native valve endocarditis (NVE) and the remaining seven patients had prosthetic valve endocarditis (PVE). Diseased lesions were located in the mitral valve (MV) in 21 patients, aortic valve in 15 and mitral plus aortic valves in four. Twenty-eight patients (70%) were operated on during the active phase of IE. Streptococcus, Staphyrococcus and Enterococcus species were predominant in the bacterial examination. RESULTS: Active vegetation was observed in 26 (65%) patients. Perforation of valve leaflets was observed in 11 (28%) cases. Changes of native MV leaflet were mild in 8 (40%) out of 20, which seemed to be reparable, while, changes of the native aortic valve leaflet were moderate to severe in 13 (87%) out of 15 patients. Valvular annuls were involved in the infection in 17 (43%) patients. Of the 33 NVE patients, prosthetic valve replacement was performed in 29 patients incduding 19 mitral and 15 aortic valves. MV plasty was performed in 4 patients. In seven PVE patients, prosthetic MV replacement was performed twice. In the aortic group, three patients underwent aortic root translocation, The Ross procedure and standard root replacement were performed respectively. Four patients died after surgery including one NVE case and three PVE cases. Three PVE patients who underwent aortic root translocation or the Ross procedure survived. The hospital mortality of NVE and PVE surgery was 3% and 43% (P<0.01), respectively. By univariant anlysis, there were no significant correlations between operative results and preoperative factors such as bacteria, infective phase, cardiac failure, renal failure, sepsis or brain morbidity. The only significant factor on hospital mortality was PVE. Three patients died of non-cardiac diseases during the follow-up period. CONCLUSION: Operative results of NVE were good after complete resection of infective sites including valve annulus. Both valve replacement and plasty were available for NVE patients. In PVE, new strategies are indispensable and aortic root translocation or the Ross procedure should be a treatment of choice.     

Early and late outcomes of 1000 minimally invasive aortic valve operations

OBJECTIVE: Minimal access cardiac valve surgery is increasingly utilized. We report our 11-year experience with minimally invasive aortic valve surgery. METHODS: From 07/96 to 12/06, 1005 patients underwent minimally invasive aortic valve surgery. Early and late outcomes were analyzed. RESULTS: Median patient age was 68 years (range: 24-95), 179 patients (18%) were 80 years or older, 130 patients (13%) had reoperative aortic valve surgery, 86 (8.4%) had aortic root replacement, 62 (6.1%) had concomitant ascending aortic replacement, and 26 (2.6%) had percutaneous coronary intervention on the day of surgery (hybrid procedure). Operative mortality was 1.9% (19/1005). The incidences of deep sternal wound infection, pneumonia and reoperation for bleeding were 0.5% (5/1005), 1.3% (13/1005) and 2.4% (25/1005), respectively. Median length of stay was 6 days and 733 patients (72%) were discharged home. Actuarial survival was 91% at 5 years and 88% at 10 years. In the subgroup of the elderly (> or =80 years), operative mortality was 1.7% (3/179), median length of stay was 8 days and 66 patients (37%) were discharged home. Actuarial survival at 5 years was 84%. There was a significant decreasing trend in cardiopulmonary bypass time, the incidence of bleeding, and operative mortality over time. CONCLUSIONS: Minimal access approaches in aortic valve surgery are safe and feasible with excellent outcomes. Aortic root replacement, ascending aortic replacement, and reoperative surgery can be performed with these approaches. These procedures are particularly well-tolerated in the elderly.     

Reoperations in valvular heart disease

Background Reoperations for valvular heart disease are associated with a higher overall mortality than the primary operations. In this retrospective analysis, we present our experience of reoperative valvular heart surgery over a period of 25 years. Methods From January 1975 to July 2000, 13039 operations were performed for valvular heart disease. Of these 665 were reoperations. The mean age of the patients at the primary operation was 24.0±10.2 years (range: 8 to 65 years) and at re-operation was 35.6±11.6 years (range: 9 to 65 years) with an interval of 9.4±2.2 years (range: 0.2 to 25 years) between the 2 procedures. Four hundred and forty reoperations were performed following a previous closed mitral valvotomy and procedures included, redo closed mitral valvotomy (n=28), mitral valve replacement (n=30), open mitral commissurotomy (n=51), mitral valve repair (n=9), homograft mitral valve replacement (n=2), double valve replacement (n=47), aortic valve replacement (n=2) and homograft aortic valve replacement plus open mitral commissurotomy (n=l). Eighty six patients underwent reoperations following mitral valve replacement. Valve thrombosis (n=50) and endocarditis (n=10) were principle causes of reoperation. Forty three patients required reoperation following failed mitral valve repair, 19 following open mitral commissurotomy and 8 following homograft mitral valve replacement. Sixty five patients underwent reoperation following aortic valve operations: prosthetic aortic valve replacement in 43, homograft aortic valve replacement in 5, aortic valve repair in 10, and Ross procedure in 7. Results Majority of patients were operated through midsternotomy. Aortic cannulation was possible in all but 4 patients in whom femoral artery cannulation was required. Operative mortality following reoperations was 7.5% (n=50). Peri-operative bleeding, low cardiac output and infective endocarditis were major causes of operative deaths. Other post-operative complications included cerebrovascular accident (n=3), acute renal failure (n=10) and jaundice (n=25). Fifteen patients developed significant wound infection. Conclusions Patients undergoing operation for valvular heart disease frequently require reoperation. Reoperative valvular heart surgery is safe and can be undertaken with acceptable mortality and morbidity.     

Aortic root replacement with coronary button re-implantation: low risk and predictable outcome.

OBJECTIVE: Cardiac morbidity in aortic root replacement often occurs through myocardial ischaemia. We analyzed a 10 year experience of all root replacement operations by one surgeon to determine the incidence of coronary complications and risk factors for early mortality. METHODS: The study included 140 aortic root replacement patients (aged from 2 to 77 years; median 53 years) operated between 1988 and 1999. Thirty-four had Marfan's syndrome. Eleven had root infection requiring homograft replacement. Nineteen were reoperations (14%). Concomitant procedures were arch replacement (16), mitral replacement (five), and coronary bypass (22). Mobilization and reimplantation of the coronary ostia was performed in 139 patients. We performed the distal graft anastomosis before right coronary reimplantation. RESULTS: There were eight hospital deaths (5.7%). Risk factors for hospital mortality were: preoperative NYHA class IV, shock, LVEF < or =30%, acute dissection, concomitant mitral valve replacement, pump time > or = 60 min, reentry for bleeding, and postoperative renal failure. Neither myocardial ischaemia nor right ventricular dysfunction contribute to mortality. There were 18 late deaths with an actuarial survival of 79% at 5 years. There were no late coronary false aneurysms. CONCLUSIONS: Button reimplantation with the sequence described is predictable and safe. Wrap-around is unnecessary. Coronary aneurysms have been eliminated.     

Intermediate-term results after the aortic valve replacement using bileaflet mechanical prosthetic valve in children.

OBJECTIVE: Intermediate/long-term results after aortic valve replacement using bileaflet mechanical valve in children should be clarified as a standard of treatment of aortic valve disease in children. METHODS: Forty-five patients aged under 15 years underwent 46 aortic valve replacements using bileaflet mechanical prosthetic valve. Patients' ages ranged from 1 to 15 years (9 years as a median value), and follow-up period was 9.2 years as a median value (maximum 19 years). RESULTS: In situ valve replacement was performed in 21 procedures, while annular enlargement was required in 25 procedures (Nicks 10, Yamaguchi 3, Manouguian 2, Konno 10). All patients except two received prosthesis 19mm or larger in size. There was one operative death and two late deaths. Two episodes of cerebral infarction, two valve thrombosis, two re-operations, one infective endocarditis, and one sudden death were recognized as valve-related complications in five patients. The reasons for re-operation were prosthesis-patient mismatch in one (Ross procedure) and valve thrombosis in one (re-replacement). At 15 years after the operation, re-replacement free rate, valve-related event free rate and actuarial survival rate were 94+/-4%, 86+/-6% and 92+/-4%, respectively. The transprosthetic flow velocity estimated by Doppler echocardiography at the final follow-up was well correlated with manufactured valve area index (cm(2)/body surface area). CONCLUSIONS: Although aortic annular enlargement was required in more than half of the cases, intermediate-term results after aortic valve replacement using bileaflet mechanical prosthetic valve in children was satisfactory. Indications for alternative treatment such as Ross procedure might be considered in limited cases.     

Use of stentless xenografts in the aortic position: determinants of early and late outcome

BACKGROUND: Whether to perform a stentless aortic valve replacement (AVR) is not well established. Our aim was to determine the outcome after AVR with stentless xenograft valves. METHODS: Between 1996 and 2001, a total of 404 patients (mean age 70.4 years) underwent a stentless AVR by one surgeon in our unit. Concomitant procedures were performed in 132 patients (33%). Twenty patients (6.4%) had undergone previous AVR. Eleven types of stentless xenograft valves were implanted: Medtronic Freestyle in 221 patients (55%), Shelhigh in 55 (14%), Shelhigh composite conduit in 33 (8%), Sorin in 26 (6%), Cryolife O'Brien in 25 (6%), Aortech-Elan in 17 (4%), Edwards Prima in 14 (4%), Toronto SPV in 7 (2%), and other valves in 6 (1%). A subcoronary implantation technique was used in 302 cases (76%), complete root replacement in 62 (15%), and a modified Bentall-De Bono procedure in 33 (8%). Mean follow-up was 19.4 months (range, 1.2 to 60.6 months). RESULTS: Overall hospital mortality was 4.2%. This was 2.4% for isolated AVR, 3.6% for AVR and coronary artery bypass grafting, 5.5% for replacement of two or more valves, and 12% for the modified Bentall procedure. On multiple logistic regression redo cardiac operation (p = 0.0006), cardiogenic shock (p = 0.001), left ventricular ejection fraction less than 0.30 (p = 0.01), modified Bentall procedure (p = 0.03), and endocarditis (p = 0.04) were predictors of in-hospital death. Five-year freedom from thromboembolism, hemorrhage, prosthetic endocarditis, structural valve deterioration, and reoperation was 97%, 99%, 99%, 98%, and 96%, respectively. Kaplan-Meier survival at 5 years was 88%. On Cox regression, cardiogenic shock (p = 0.001) and older age (p = 0.03) were adverse predictors of survival. At echocardiographic examination within 6 months from the operation, mean aortic valve gradients were 15 +/- 6 mm Hg, 12.8 +/- 3 mm Hg, 10.8 +/- 4 mm Hg, 9.3 +/- 3 mm Hg, 9.1 +/- 4 mm Hg, and 8.2 +/- 3 mm Hg for valve sizes of 19, 21, 23, 25, 27, and 29 mm, respectively. CONCLUSIONS: The availability of several stentless valve designs facilitates the surgical treatment of diverse aortic valve or root diseases with encouraging early and mid-term results. Patients requiring concomitant procedures may also benefit from the excellent hemodynamic characteristics of a stentless valve. We consider stentless AVR the treatment of choice for patients older than 60 years and those having small aortic roots.     

Aortic dissection late after aortic valve replacement

We experienced 3 cases of an aortic dissection occurring late after an aortic valve replacement, and sucessfully treated by an aortic root replacement. An aortic dissection involving the ascending aorta can develop late after an aortic valve replacement, and such an occurrence is associated with a high mortality and morbidity. The development of effective surgical strategies at the initial aortic valve surgery, strict control of blood pressure after aortic valve replacement, serial evaluations of aortic size, and the prophylactic replacement of the ascending aorta for patients with aortic dilatation after aortic valve replacement, all play clinically important roles in preventing an aortic dissection after aortic valve replacement. When an aortic dissection occurs in patients with a previous aortic valve replacement, an aortic root replacement should be performed in order to avoid leaving the fragile diseased aortic wall including the sinus of Valsalva.     

Aortic valve replacement in children: are mechanical prostheses a good option?

OBJECTIVE: The choice of the most appropriate substitute in children with irreparable aortic valve lesions remains controversial. The aim of this study was to assess early and late outcomes following aortic valve replacement (AVR) with mechanical prostheses in children. PATIENTS: Fifty-six patients (42 male, 14 female, mean age 11.2, range 1-16 years) undergoing AVR with mechanical prostheses between October 1972 and January 1999 were evaluated. Thirty-six patients (64.2%) underwent previous cardiac surgery. Disease aetiology was congenital in 47 patients (congenital aortic stenosis in 33, and other congenital abnormalities in 14) (83.9%), infective in four (7. 1%), rheumatic in two (3.4%), and three (5.3%) had connective tissue disorders. Haemodynamic indication for AVR was aortic regurgitation (AR) in 24 (42.8%), aortic stenosis (AS) in 22 (39.2%) and mixed disease in ten (17.8%). Twenty-eight patients (50.0%) were in New York Heart Association (NYHA) class III-IV before surgery. Concomitant procedures were performed in 31 patients (55.3%), including aortic root enlargement in 28 (50%). The mean size of implanted valves was 22.4 mm (range 17-27 mm). All patients received long-term anticoagulation treatment with sodium warfarin, aiming to maintain an international normalized ratio (INR) between 2.5-3.0. The mean follow-up was 7.3 years (range 0-26, total 405 patient-years). RESULTS: Operative mortality was 5.3% (three patients). Three patients developed complete heart block requiring pacing, two of them permanently. Late events included valve thrombosis (one), transient stroke (one), paravalvular leak of a mitral prosthesis (one), aneurysm of sinus of Valsalva (one) and pannus ingrowth (one). There was no major haemorrhagic event. Five patients required re-operation (8.9%), but none due to outgrowth of the valve. Regarding actuarial freedom from thrombo-embolism, any valve-related event and re-operation at 20 years was 93, 86.6 and 86. 4%. There were three late deaths. Actuarial survival, including operative mortality, at 10 and 20 years was 91 and 84.9%. The actuarial survival for the group of the patients with congenital AS (n=33) at 10 and 20 years was 93.5%, whereas for the children with other congenital heart problems (n=14) this was 85.7 and 64.3% (P=0. 09). At the latest clinical evaluation, 44 children were in NYHA class I and six were in class II. The mean gradient across the aortic prosthetic valve on echocardiography was 17.9 mmHg (range 0-47 mmHg). CONCLUSIONS: Mechanical AVR, with enlargement of the aortic root if necessary, remains an excellent treatment option in children. It is associated with acceptable operative mortality, low incidence of late events and re-operation, and provides good long-term survival. It clearly represents a good alternative to available biological substitutes, including the pulmonary autograft (Ross procedure).     

Valve replacement in the octogenarian

Twenty-five patients (11 men and 14 women) aged 80 to 88 years (mean age, 82 years) underwent valve replacement at St. Louis University from August 1980 to June 1988. Isolated valve replacement was performed in 11 patients. Combined procedures included valve replacement with myocardial revascularization (7 patients), multiple valve procedures (5 patients), and ascending aortic plication (2 patients). Fifteen patients (60%) were in New York Heart Association functional class III and 10 (40%) were in class IV preoperatively. The operative mortality was 20% and late mortality was 20% (mean follow-up, 36 months). Isolated valve replacement carried a 9% early and 0% late mortality, whereas combined procedures of any type had a 16% early and 20% late mortality. Only 7 patients (28%) had a completely uncomplicated postoperative hospitalization. Twenty patients were discharged after a mean hospital stay of 18 +/- 16 days. Their mean New York Heart Association functional class was 1.6 +/- 0.66. The 1-year and 2-year actuarial survival rate is 79% and 69%, respectively. A significant increase in operative mortality is seen when valve replacement is combined with myocardial revascularization or an additional valve procedure. Late clinical improvement, as judged by return to an independent life-style, justifies this approach for select patients.     

Aortic valve replacement in children associated with enlargement of aortic annulus

Between February, 1983 and August, 1987, twelve children, aged from 2 years to 16 years, underwent aortic valve replacement associated with enlargement of aortic annulus successfully. According to the form of the left ventricular outflow tract obstruction, enlargement of aortic annulus was performed by Konno procedure in eight cases, by Nicks procedure in three cases and by Manouguian procedure in one case. In Manouguian procedure, mitral valve replacement associated with enlargement of mitral annulus was carried out simultaneously. In Konno and Manouguian procedures, the diameter of aortic annulus was enlarged from 180% to 200% compared with the original annular size, whereas in Nicks procedure, the diameter was enlarged around up to 110%. St. Jude Medical valve, of which size ranged from 21mm to 25mm, was employed in these procedures. All these children survived operation, and the post-operative follow up period ranged from 1 month to 55 months. There was one late death eleven months after Konno procedure because of respiratory failure resulting from pulmonary hypertension which persisted postoperatively. The remaining eleven children are surviving well after procedure. These results suggest that aortic valve replacement associated with enlargement of aortic annulus is an acceptable procedure in children with small aortic annulus or sub-aortic stenosis.     

Valve-preserving surgery of the proximal aorta.

BACKGROUND: Surgical treatment of proximal aortic disease currently offers a variety of surgical options. Traditionally, replacement of the proximal aorta has been performed with a composite graft in most cases; supracommissural aortic replacement was the only alternative if preservation of the native aortic valve was attempted. Valve-preserving root operations currently allow us to avoid the disadvantages of prosthetic heart valves and completely eliminate aortic root pathology. METHODS: Between 10/95 and 5/99, 219 patients were treated for proximal aortic disease. The diagnoses included degenerative disease (n=158), acute dissection (n=48), and chronic dissection (n=13). Composite replacement of valve and root (n=99) was used only in patients with significant degeneration or stenosis of the aortic valve. For near-normal root dimensions supracommissural aortic replacement (n=44) was chosen. Root remodeling (n=60) and reimplantation of the valve within a vascular graft (n=16) were performed for aortic valve regurgitation and root dilatation. RESULTS: Overall hospital mortality was 5.7%; in elective operations, mortality was expectedly lower compared to emergency interventions (2.4% vs 16.3%; p<0.05). Hospital mortality for valve preserving procedures was similar (elective procedures 1.9%, emergency operations 9.5%). Two-year freedom from aortic regurgitation grade II or higher was 89% for remodeling and 92% for reimplantation. Freedom from reoperation for secondary and increasing regurgitation at two years was 96% for remodeling and 100% after reimplantation. CONCLUSIONS: Using current techniques of valve preserving surgery, combined disease of the aortic valve, root, and extended segments of the aorta can be corrected without the disadvantages of prosthetic heart valves in the majority of patients. Further experience will define the relative role of the different operative modifications.     

Long-term outcomes of aortic root operations in the United States among Medicare beneficiaries

ObjectiveThe best method of aortic root repair in older patients remains unknown given a lack of comparative effectiveness of long-term outcomes data. The objective of this study was to compare long-term outcomes of different surgical approaches for aortic root repair in Medicare patients using The Society of Thoracic Surgeons Adult Cardiac Surgery Database-Centers for Medicare & Medicaid Services–linked data.MethodsA retrospective cohort study was performed by querying the Society of Thoracic Surgeons Adult Cardiac Surgery Database for patients aged 65 years or more who underwent elective aortic root repair with or without aortic valve replacement. Primary long-term end points were mortality, any stroke, and aortic valve reintervention. Short-term outcomes and long-term survival were compared among each root repair strategy. Additional risk factors for mortality after aortic root repair were assessed with a multivariable Cox proportional hazards model.ResultsA total of 4173 patients aged 65 years or more underwent elective aortic root repair. Patients were stratified by operative strategy: mechanical Bentall, stented bioprosthetic Bentall, stentless bioprosthetic Bentall, or valve-sparing root replacement. Mean follow-up was 5.0 (±4.6) years. Relative to mechanical Bentall, stented bioprosthetic Bentall (adjusted hazard ratio, 0.80; confidence interval, 0.66-0.97) and stentless bioprosthetic Bentall (adjusted hazard ratio, 0.70; confidence interval, 0.59-0.84) were associated with better long-term survival. In addition, stentless bioprosthetic Bentall (adjusted hazard ratio, 0.64; confidence interval, 0.47-0.80) and valve-sparing root replacement (adjusted hazard ratio, 0.51; confidence interval, 0.29-0.90) were associated with lower long-term risk of stroke. Aortic valve reintervention risk was 2-fold higher after valve-sparing root replacement compared with other operative strategies.ConclusionsIn the Medicare population, there was poorer late survival and greater late stroke risk for patients undergoing mechanical Bentall and a higher rate of reintervention for valve-sparing root replacement. Bioprosthetic Bentall may be the procedure of choice in older patients undergoing aortic root repair, particularly in the era of transcatheter aortic valve replacement.