Assessment of percutaneous balloon pulmonary and aortic valvuloplasty

Percutaneous balloon pulmonary or aortic valvuloplasty was performed in 66 consecutive patients with no deaths. The transvalvular pressure gradient was reduced from 85 +/- 35 to 30 +/- 15 mm Hg (p less than 0.01) in 39 patients with congenital pulmonary valve stenosis and from 108 +/- 46 to 32 +/- 16 mm Hg (p less than 0.01) in 27 patients with congenital aortic valve stenosis. Subsequent mild aortic regurgitation occurred in seven patients and moderate regurgitation occurred in one patient. Operative evaluation of seven patients with pulmonary valve stenosis who had additional cardiac anomalies revealed the mechanisms of valve opening to be commissural splitting, cusp tear, or avulsion of the cusp from the anulus. Operative evaluation of two patients with residual high aortic valve gradients revealed minor degrees of commissural splitting. Although further evaluation is required to determine the long-term effects, early evaluation indicates that percutaneous balloon valvuloplasty may be useful in the definitive treatment of isolated pulmonary valve stenosis in some patients and of palliative value in others. The procedure is considered palliative in patients with aortic valve stenosis.     

Valve-sparing operation for balloon-induced aortic regurgitation in congenital aortic stenosis.

OBJECTIVE: Aortic regurgitation after balloon dilation of congenital aortic stenosis may be treated with valve repair as an alternative to replacement. METHODS: Charts and echocardiograms of all patients undergoing aortic valve operations after balloon dilation of congenital aortic stenosis at our institution between January 1988 and December 1999 were reviewed. RESULTS: Twenty-one patients underwent valvuloplasty for predominant aortic regurgitation 9 months to 15 years (mean, 6.1 years) after balloon dilation. The mean +/- SD age at the time of the operation was 11 +/- 7 years. Aortic regurgitation was caused by a combination of commissural avulsion (10), cusp dehiscence with retraction (9), cusp tear (5), central incompetence (2), perforated cusp (1), or cusp adhesion to the aortic wall (1). Repair techniques included commissural reconstruction with a pericardial patch (8), pericardial patch cusp augmentation (6), primary suture repair (6), raphae release and debridement (4), commissurotomy (4), commissural resuspension with sutures (3), and cusp release (1). There were no deaths. At a mean follow-up of 30.1 months (range, 9 months-8 years), all patients were asymptomatic, and the grade of aortic regurgitation had been significantly reduced (P <.001). Left ventricular end-diastolic dimension z scores and proximal regurgitant jet/aortic anulus diameter ratios were significantly reduced (P <.001) and remained so over time. Freedom from reoperation for late failure was 100%, and overall freedom from reintervention was 80% at 3 years. CONCLUSION: Aortic valve repair for balloon-induced aortic regurgitation is reproducible and durable at medium-term follow-up.     

Early cusp tear of the second-generation Trifecta valve with Glide Technology

We herein report a case of early cusp tear of the second-generation Trifecta valve with Glide Technology. A 69-year-old woman underwent aortic valve replacement with a Trifecta valve with Glide Technology and partial arch replacement for severe aortic valve stenosis caused by a bicuspid valve and ascending aortic and aortic arch aneurysms 2 years previously. During follow-up, she suddenly developed dyspnoea and a heart murmur. Echocardiography revealed severe aortic valve regurgitation caused by structural valve deterioration. We performed re-aortic valve replacement with a mechanical valve through re-median sternotomy. Intraoperative examination revealed a bottom tear of the left coronary cusp without infection or pannus formation.     

Combined traumatic avulsion of the aortic valve and rupture of the left common carotid artery.

A case of complete rupture of the left common carotid artery at the aortic arch and avulsion of a cusp of the aortic valve due to blunt trauma is presented. The ruptured carotid artery was reimplanted into the left subclavian artery, and the avulsed aortic valve cusp was successfully repaired by direct suturing.     

Acute type A dissection: conservative methods provide consistently low mortality

BACKGROUND: A wide spectrum of operative techniques are applied in acute type A dissection. Most convey hospital mortality between 10% and 20%. In this high-risk setting, we believe that a conservative approach to the aortic root and the complete resection of the primary tear are important. We reviewed the results of this policy from our aortic surgery database. METHODS: Between 1988 and December 2000, 95 acute type A dissection patients were operated on by one surgeon. They included 70 men and 25 women aged 37 to 81 years (mean 65 years). Six had Marfan syndrome. Aortic root restoration or replacement was performed during cooling, open arch repair during circulatory arrest, and hemostasis while rewarming. Eighty-seven patients had ascending aortic replacement with glue resuspension of the valve. Two others had had aortic valve replacement previously. Aortic root and partial arch replacement was performed in 6 Marfan patients. Eighteen patients had hemiarch replacement, and 6 had total arch replacement to excise the tear. RESULTS: Five patients died in hospital (5.3% 30-day mortality) and another after early readmission for mediastinal infection (6.3% total mortality). There were no deaths from bleeding. Two patients required aortic valve replacement for aortic regurgitation 2.5 and 3.0 years postoperatively. Two others required total arch replacement and thromboexclusion procedures, respectively. CONCLUSIONS: Our policy of primary tear excision and preservation of the native aortic valve has resulted in low overall mortality. We still prefer to replace the aortic root in dissected Marfan patients. In this high-risk condition, hospital survival is of paramount importance. A conservative "pathology-oriented" approach helps to achieve this aim.     

Successful management of traumatic aortic valve insufficiency; report of a case

A case of the successful management of traumatic aortic valve insufficiency is reported. A previously healthy 48-year-old man sustained multiple injuries in a traffic accident. One month after the accident, heart failure, derived from aortic insufficiency, was noted. Three years and 5 months after the injuries, aortic valve replacement was performed, and a large tear, approximately 7 mm in length, was found in the aortic right coronary cusp. This finding corresponded to the traumatic aortic valve insufficiency. Traumatic aortic valve insufficiency is rare, and early diagnosis may be difficult. Examinations for associated intracardiac injuries should be carefully undertaken.     

Ionescu-Shiley valve failure. I: Experience with 125 standard-profile explants.

A group of standard-profile Ionescu-Shiley valve implants, 357 aortic and 190 mitral, was reviewed for cases of failure requiring surgical explantation. To date, 90 (25.2%) of the aortic and 35 (18.4%) of the mitral valves have failed, and are the subject of this analysis. Observations of these explants confirm previous suggestions about the clinical and pathologic patterns of the Ionescu-Shiley valve's failure, but are extended in this study to allow more confident statistical analyses. Cusp tear with insufficiency remains the most important reason for explantation, precipitating removal to date of 19.1% of the aortic and 10.0% of the mitral valves implanted. This difference, aortic versus mitral, is significant (p less than 0.006) and the reverse of observations made in other studies of pericardial valves. In this review there is no significant difference in the proportion of aortic and mitral valves that failed with calcification (2.2% and 3.1%, respectively). Aortic Ionescu-Shiley valves failing with tears had a mean of 3.1 tears per valve, whereas mitral valves had 1.2. Aortic valves also showed considerably more pretear wear than did mitral valves. Although the large number of these Ionescu-Shiley valve failures has been a profound clinical disappointment, it has provided an opportunity to observe and detail the pathology of their failure.     

Primary Anastomosis for Acute Ascending Aortic Dissection

Intimal tear resection and primary anastomosis of the aorta were used for the treatment of eight patients with DeBakey I and II type acute aortic dissection. Five patients were of DeBakey I type, and three patients were of the II type. Moderate or severe aortic regurgitation (AR) was observed in six of eight patients. The site of the intimal tear was diagnosed by intraoperative echocardiography, and the adventitia corresponding to the intimal tear was transversely opened under total cardiopulmonary bypass. While resuspension of the aortic valve was performed on only one of six patients, AR disappeared in four, postoperatively. Two of eight patients died early postoperatively. The cause of death was postoperative cardiac tamponade in one patient and cerebral herniation in the remaining one. The other six patients have been observed for a mean period of 27 months. There is no late death, and they show no dilatation of the aortic root and deterioration of AR. We believe that this operative method is a simple and safe emergency procedure for DeBakey I and II type acute aortic dissection.     

Surgical treatment of traumatic rupture of the normal aortic valve

Blunt trauma followed by aortic valvular insufficiency is a rare occurence. In one case, a male high-school student who had sustained a non-penetrative chest injury suffered from aortic regurgitation resulting from the rupture of the normal aortic valve. A sizable tear in the non-coronary cusp caused aortic insufficiency. The case was treated successfully by surgical replacement of the aortic valve with a No. 21 SJM prosthesis.     

Avulsion of both posterior meniscal roots associated with acute rupture of the anterior cruciate ligament

A rare case of acute avulsion of both posterior meniscal roots concomitant with an acute anterior cruciate ligament (ACL) tear in a professional soccer player is described. While avulsion of the lateral meniscal root has been extensively reported in association with ACL injuries, medial root avulsion has never been reported in association with acute ACL. A review of the video documentation of the match accident revealed the exact mechanism of injury was a forceful external rotation of the standing limb.     

Surgical treatment of acute ascending dissection--a simplified operative method

Primary anastomosis for acute ascending aortic dissection was performed in 8 patients. Primary anastomosis included resection of the intimal tear where applicable, a circumferential suture line in the ascending aorta at the site of the tear, and wrapping of the anastomosis of the ascending aorta with Dacron vascular prosthesis. The aortic valve was resuspended in 1 of 6 patients associated with aortic regurgitation. In 4 patients, aortic regurgitation disappeared postoperatively. Two patients show minor non-progressive valve regurgitation. Two of 8 patients died early postoperatively. There was no late death and dilatation of the aortic root in the follow-up period of mean 27 months. On the basis of these results, we believe that primary anastomosis is a simpler and safer operative method for acute dissection of the ascending aorta.     

Surgical treatment of traumatic rupture of the normal aortic valve

The histories of 2 patients who had successful repair of traumatic injury to the aortic valve are reported, and the literature is reviewed. Various types of injury cause this lesion, but violent compression of the chest with high intrathoracic pressure appears to be a common feature. Valvular injuries include avulsion of commissural attachments and tears of the leaflets. Patients present with chest pain and severe congestive heart failure, and an unusually musical murmur of aortic insufficiency is sometimes heard. Attempts at valvuloplasty have not been uniformly successful, and prosthetic valve replacement is recommended.     

A case of successful reoperation for aortic root pseudoaneurysm ruptured into right ventricle after modified Bentall operation]

The patient was a 51-year-old man with Marfan syndrome who had simultaneously undergone modified Bentall operation (Carrel patch method) and coronary artery bypass grafting. Prosthetic valve endocarditis (PVE) occurred 19 months after the operation. PVE had thereafter been treated by antibiotic therapy for 3 months, but echocardiography revealed prosthetic valve detachment and aortic root pseudoaneurysm ruptured into the right ventricle which appeared to have been caused by PVE. At reoperation there were no laboratory or intraoperative findings indicative of ongoing inflammation or infection. The composite graft, therefore, didn't require replacing, and it was possible to simply re-suture the composite graft and directly close the tear. The postoperative course has been uneventful with no further evidence of endocarditis.     

Surgical treatment of traumatic rupture of the bicuspid aortic valve; report of a case

A 27-year-old man was injured during a motocross game. He was suffered from dyspnea, orthopnea, and hemoptysis. The to-and-fro murmur was noticed 3 days after the accident and then the patient was admitted to our hospital. Echocardiography revealed severe aortic regurgitation. Computerized tomography also showed severe pulmonary contusions. Seventeen days after the accident the aortic valve replacement was performed. The aortic valve was anterior-posterior type bicuspid valve (fusion of right coronary cusp and light coronary cusp) and the tear was detected in the anterior cusp. The postoperative course was uneventful. Rupture of the aortic valve due to a blunt chest trauma is rare and reported in 20 cases previously in Japan. This case is the second report of traumatic rupture of the bicuspid aortic valve.     

A successful emergency operation of acute aortic dissection (DeBakey I) with aortic root rupture and right coronary avulsion

We report a successful emergency operation for a patient of acute aortic dissection with cardiogenic shock. A 73-year-old man was admitted to our hospital with a complaint of severe chest pain. The emergency aortography and echocardiography demonstrated aortic dissection (DeBakey I) with aortic valve regurgitation and massive pericardial effusion. The emergency operation started 2 hours after the onset. We performed reconstruction of ascending aorta and aortic valve using composite graft, since the patient had aortic root rupture and right coronary avulsion. Subsequently, the right coronary bypass grafting of saphenous vein was performed in addition to the reimplantation of left coronary artery by carrel patch method. The postoperative course was uneventful and the patient remains asymptomatic.     

Failure of Hancock xenograft valve: importance of valve position (4- to 9-year follow-up)

To evaluate long-term durability of Hancock valves, we reviewed our results in 107 hospital survivors (120 valves) who were operated on during 1974 through mid-1979. Mitral valve replacement was done in 63 patients, aortic valve replacement in 20, and mitral valve replacement combined with other procedures in 24. The 7-year survival was 84 +/- 4% (standard error of the mean) for 91 patients and 97 valves. During a follow-up of 590 patient-years, 15 (12 mitral and 3 aortic) of 120 valves at risk (87 mitral, 32 aortic, 1 tricuspid) were removed from 14 patients. Six valves (3 mitral and 3 aortic) were removed because of bacterial endocarditis. One mitral valve was removed because of thromboembolism. Eight mitral valves were removed because of valve structural failure, which occurred at a mean follow-up of 42 months. These valves showed extensive calcification, leaflet perforation, or cusp tear. Structural failure was unrelated to valve size, year of implantation, or valve shelf-life. Structural failure was not seen after aortic valve replacement. Results show that structural failure of the Hancock xenograft valve in the mitral position is related primarily to valve position. After aortic valve replacement, valve failure is predominantly due to endocarditis. Although medium-term (mean, 6-year) durability of this xenograft valve compares satisfactorily with prosthetic valves, its high failure rate in the mitral position indicates the necessity for improvement in valve mounting, design, and preservation.     

Long-term effectiveness of operations for ascending aortic dissections

OBJECTIVE: To evaluate long-term effectiveness of a strategy for managing the aortic root and distal aorta according to the pathology in ascending aortic dissection. METHODS: From 1978 to 1995, 208 patients underwent operations for acute (n = 135) and chronic (n = 73) ascending aortic dissection. Surgical strategies included valve resuspension with supracoronary aortic root repair and ascending aortic graft for normal sinuses and valve (n = 135), composite valve and ascending aortic graft for abnormal sinuses and valve (n = 47), and valve replacement and supracoronary ascending aortic graft for normal sinuses and abnormal valve (n = 26). Resection extended into the arch only if the intimal tear originated in or extended to the aortic arch (n = 31). RESULTS: Hospital mortality was 14%. Cardiogenic shock (P =.002) and concomitant coronary artery bypass grafting (P =.001) were associated with increased risk; use of circulatory arrest (P =.0003) decreased risk. Survival was 87%, 68%, and 52% at 30 days, 5 years, and 10 years, respectively. Advanced age, earlier date of operation, composite graft, and arch resection were associated with decreased survival; residual distal dissected aorta was not. Reoperation was required for 5 proximal and 8 distal problems. CONCLUSIONS: In both acute and chronic ascending aortic dissections, (1) circulatory arrest is associated with low early mortality; (2) with normal sinuses and valve, supracoronary repair of the dissected aortic root and valve resuspension is effective long term; and (3) residual distal dissected aorta does not decrease late survival and has a low risk of aneurysmal change and reoperation for at least 10 years.     

Aortic regurgitation due to perforation of the right coronary cusp 10 years after implantation of a freestyle stentless bioprosthesis

Valve deterioration following aortic valve replacement using the Freestyle stentless bioprosthesis is related to cusp tear, operative injury, or infection. We report a patient with aortic regurgitation due to perforation of the right coronary cusp 10 years after implantation of a Freestyle stentless bioprosthesis in the absence of endocarditis.     

Successful surgical treatment of aortic regurgitation with coronary artery fistula due to blunt chest trauma--a case report

A Successful repair of aortic regurgitation with coronary artery fistula due to blunt chest trauma is reported. A 17-year-old boy was involved in a motor cycle accident, but there were neither open chest trauma nor rib fracture. On admission diastolic regurgitant musical cardiac murmur was noted. Color doppler echocardiogram showed severe aortic regurgitation. But any cardiac murmur had nerve been noticed before. CAG showed a fistula from the acute marginal branch of the RCA to the RV. But no shunt existed on calculation. The aortic valve was explored under cardiopulmonary bypass. There were a tear in the LCC and a fissure in the RCC. Otherwise the valve tissue appeared normal. The valve was excised and replaced with a integral of 21 mm Bj?rk-Shiley valve prosthesis. The fistula was left because there were no abnormal findings on the RCA and no significant shunt. The patient is up and well 1 year and 10 months after operation. This is the first report of aortic regurgitation with coronary artery fistula due to blunt chest trauma.     

Marfan syndrome as a predisposing factor for traumatic aortic insufficiency

Despite the increase in car accidents, aortic valve injury from blunt trauma remains rare. In one case, a 30-year-old Marfan male, who was under observation at our outpatient clinic, suffered from aortic regurgitation due to a tear in the left coronary cusp of a previously echocardiographically normal valve. Acute ventricular failure demanded surgical management within 3 days after an automobile accident. The case was successfully treated by replacement of the aortic valve with a no. 23 Sorin Bicarbon prosthesis. The patient fully recovered and experienced an uneventful 6 months of follow-up.