Progressive diffuse aortic stenosis after localized supravalvular aortic stenosis repair

A 6-year-old boy presented with diffuse stenosis of the aortic arch. He had undergone patch augmentation for localized supravalvular aortic stenosis at 2 years of age. Before the initial operation, the aortic arch and descending aorta were noticed to be hypoplastic with a diameter of 60 to 73% of that of the aortic annulus, without a pressure gradient. 4 years later, progressive diffuse stenosis of the aortic arch with a diameter of 42% of that of the aortic annulus was found. Reoperation, consisting of patch augmentation of the aortic arch, was carried out. A pressure gradient of 40 mmHg distal to the repair was newly recognized, again. This is a rare case of supravalvular aortic stenosis, which required reoperation because of the progression of diffuse stenosis of the distal aorta.     

Aortoseptal approach for optimal resection of diffuse subvalvular aortic stenosis

The results of conventional operative resection of diffuse subaortic stenosis (tunnel subaortic stenosis and diffuse idiopathic hypertrophic subaortic stenosis) have been less than satisfactory. A new approach using the concept of aortoventriculoplasty was designed to allow adequate surgical resection of a diffuse subvalvular aortic stenosis. The aorta, the right ventricle, and the septum are incised in the same way as during aortoventriculoplasty , with the aortic anulus being divided carefully across the commissure between the left and right aortic cusps. The septotomy is extended beyond the limits of the stenosis, and fibrous and/or muscular tissue is removed from each edge of the septal incision. After adequate widening of the subvalvular area, the various incisions are closed and the aortic valve is reconstructed. This aortoseptal approach was studied experimentally in the dog and then carried out on two patients, both of whom had excellent hemodynamic and functional results. The aortoseptal approach may be the procedure of choice in the treatment of diffuse stenoses limited to the subvalvular area, whereas other procedures ( aortoventriculoplasty , and apico-aortic valved conduit) should be used when the valvular and/or supravalvular levels are involved.     

Surgical resection of enlarged calcification formed by idiopathic localized constrictive pericarditis during total aortic arch replacement for aortic dissection

A 75‐year‐old woman presented at a prior hospital with persistent cough and was treated conservatively for a thrombosed‐type aortic dissection (Stanford A). One‐year after discharge, follow‐up computerized tomography revealed a DeBakey type II, chronic dissecting aortic aneurysm enlarged to 54 mm. She was referred to our hospital with slight edema in the face and extremities and chest radiography showed calcification around the heart. Computerized tomography performed at the prior hospital showed a large spherical mass in the anterior pericardium in addition to the aortic dissection. We therefore resected the mass immediately before a total aortic arch replacement. Surgery was successful and uneventful with patient discharge on postoperative day 21. The final differential diagnosis was idiopathic, localized, constrictive pericarditis.     

Translocation of aortic valve for calcific aortic stenosis.

A 56-year-old man underwent surgery for treatment of severe calcific aortic stenosis. Because it was found after excision of the aortic valve that calcification of the annulus was too extensive for the placement of sutures, translocation of the aortic valve was performed. The results were satisfactory and indicate that translocation is a useful alternative in cases of severe calcification of the aortic valve which cannot be treated by ordinary valve replacement.     

Reappraisal of duct-to-duct biliary reconstruction in hepatic resection for liver tumors

BACKGROUND: Duct-to-duct reconstruction is theoretically suitable for short segmental defects of the bile duct. This technique would also be useful, without jeopardizing the curability, in selected cases with hepatic malignancies requiring concomitant liver and bile duct resection. METHODS: For biliary reconstruction after hepatectomy, duct-to-duct reconstruction was performed in 4 patients at our institution between 1994 and 2004. The surgical techniques used are presented, along with the results of evaluation of the outcome, including postoperative and long-term morbidity and survival. RESULTS: Duct-to-duct reconstruction was safely performed in the 4 patients with the defects ranging in size from 10 to 19 mm. None of the cases developed local recurrence at the anastomotic site. None of the cases developed stenosis of the anastomotic site either, but cholangitis occurred in 1 patient. CONCLUSIONS: Duct-to-duct reconstruction for short segmental defects after the removal of hepatic malignant tumors is feasible with less operative and long-term morbidity. It is essential to select patients carefully when thinking of performing duct-to-duct anastomosis without complication and cancer infiltration.     

Transventricular aortic valvotomy for critical aortic stenosis in infants

Ten infants with critical aortic stenosis underwent transventricular valvotomy between November 1983 and September 1984. The ages of the patients ranged from 1 to 38 days (mean 21.2 days). Three patients were less than 1 week of age. One had undergone a previous valvotomy performed with inflow occlusion. Most infants were critically ill when admitted to the hospital, six required inotropic and ventilatory support, and two had peritoneal dialysis before the operation. Transventricular valvotomy was performed through a left thoracotomy with Hegar dilators. Postvalvotomy peak-to-peak gradients ranged from 0 to 35 mm Hg. Three patients died at 2, 3, and 6 weeks after operation. A severe degree of endocardial fibroelastosis was present in one patient, and a second patient died of septicemia caused by wound infection, empyema, and a bronchopleural fistula. Severe left ventricular hypertrophy, with moderate fibroelastosis, was found at autopsy in the third patient. Aortic incompetence was not detected postoperatively. One patient required reoperation 7 months after the transventricular valvotomy. Transventricular valvotomy has proved to be a simple and effective technique to relieve aortic stenosis in sick infants. It permits the correction of associated coarctation of the aorta and avoids a median sternotomy. Results are comparable with the results obtained with either cardiopulmonary bypass or inflow occlusion as seen in both our experience and in the experience of others.     

经导管主动脉瓣植入术治疗重度主动脉瓣狭窄

目的 观察经导管主动脉瓣植入术（TAVI）治疗重度主动脉瓣狭窄（AS）的效果。方法 回顾性收集18例接受TAVI的重度AS患者,记录TAVI即刻成功率,观察治疗过程中及治疗后相关并发症;随访记录治疗后1、3个月瓣膜功能及心血管事件。结果 18例实施TAVI成功。对3例AS合并冠心病患者行一站式TAVI+经皮冠状动脉介入治疗,对2例冠状动脉阻塞高风险患者通过“烟囱”或“开窗”技术加以预保护。1例顽固性心力衰竭患者接受体外膜氧合器辅助下TAVI;1例尿毒症患者于TAVI前、后接受血液透析。TAVI即刻成功率100%（18/18）。TAVI过程中1例发生心脏压塞而转外科治疗;1例因中度瓣周漏而植入另1枚瓣膜。治疗后3例存在轻度瓣周漏,1例因三度房室传导阻滞而植入永久性心脏起搏器。未见严重并发症。治疗后即刻及1、3个月,超声心动图显示主动脉瓣口流速［（203.47±70.65）、（219.64±67.49）、278.00（188.50,289.00）cm/s］和跨瓣压差［（17.16±14.05）、0（0,20.50）、12.00（0,32.50）mmHg］均较治疗前［470.50（428.75,553.25）cm/s、79.50（53.25,112.50）mmHg］降低（P均＜0.05）。治疗后3个月内无死亡、卒中、急性冠脉综合征及新发房颤等严重心血管事件发生。结论 TAVI治疗重度AS安全,且短期疗效好。     

Repair of a penetrating ascending aortic ulcer with localized resection and extracellular matrix patch aortoplasty

Penetrating ascending aortic ulcers are rarely encountered, yet they present significant risk of hemorrhage and aortic dissection. Expedient recognition and repair is of vital importance. The current management of penetrating ulcer of the ascending aorta includes replacement of the ascending aorta with a prosthetic graft. We describe our technique of repairing a penetrating ulcer of the ascending aorta with localized ulcer resection and extracellular matrix patch aortoplasty.     

Late results of aortic valvotomy for congenital valvar aortic stenosis

Fifty-one patients, aged 1 to 18 years, having aortic valvotomy for congenital valvar aortic stenosis between 1956 and 1986 were followed up. The average age at operation was 11.5 years, with an operative mortality of 3.9%. The aortic valve gradient decreased from a mean preoperative value of 91 mm Hg to 27 mm Hg postoperatively. Current follow-up was 90% and averaged 16.8 years. Late cardiac mortality was 17.6%, with actuarial survival of 93.7% at 10 and 15 years, 81.8% at 20 and 25 years, and 70.9% at 28 years. Nineteen patients required reoperation (39%) at a mean of 17.7 years postoperatively, with a reoperation-free survival of 98% at 10 years. The reoperation rate accelerated in the following decade to 3.3% per year. Ten patients without reoperation were evaluated by continuous-wave Doppler echocardiography. The mean gradient was 21.6 mm Hg, and 90% had mild to moderate aortic insufficiency. This study confirms the efficacy of valvotomy in this age group and suggests that long-term survival and time to reoperation may be longer than previously reported.     

Long-term evaluation of aortic valvotomy for congenital aortic stenosis.

Aortic valvotomy (AV) for relief of congenital aortic stenosis (AS) is a palliative operation, and the purpose of this study was to determine the long-term benefit. After analyzing the symptoms at time of operation, 177 patients were separated by age at AV: newborns (1-14 days) 26, infants (2 weeks-1 year) 19, and children (greater than or equal to 1 year) 132. The newborn with critical AS typically presents with severe cardiac failure and the infant with moderate failure, whereas children may be asymptomatic. In the newborn group, final diagnosis has been made exclusively by noninvasive cardiac echogram since 1984. The presence of a hypoplastic left ventricle (HLV) and/or endocardial fibroelastosis (EFE) are the most important determinants of mortality. Operative survival was 11 of 13 (85%) in the newborn group if HLV/EFE were not present. No operative deaths for AV occurred after 1965 in children. When present, a preoperative electrocardiographic strain pattern resolved in 80% of patients. Of 33 reoperations (21%), four were required 1.0 (0.5-2) years later for newborns, five were required for infants 7.2 (1.5-20) years later, and 24 were required in children 11.0 (1.5-25) years later. These included 10 repeat valvotomies and 23 aortic valve replacements (AVRs) with a 91% survival rate. In summary, although valves of patients with congenital AS are morphologically abnormal, valvotomy is beneficial. It was found that (1) the operative survival rate has been 100% over the past 20 years for children and currently is greater than 80% in newborns in the absence of HLV/EFE; (2) reoperation rate is higher in newborns and infants; (3) benefit was shown by a sharp decrease in obstruction initially and improved ECG later; (4) long-term follow-up revealed a subset of patients who are asymptomatic and have only mild residual obstruction over 20 years after AV.     

Operation for discrete subvalvular aortic stenosis

Over the past 20 years, 37 patients (31 children and six adults) have undergone operations for discrete subvalvular aortic stenosis. Prior to 1975, resection of the subvalvular membrane alone was the procedure of choice. However, the recurrence rate was high (36%). Since 1975, resection of the membrane plus left ventricular myectomy has been routine. The recurrence rate in this group has been lower (20%) but is still high. Overall, 11 patients (30%) have had significant recurrence (average gradient 63 mm Hg). Eight of these 11 have undergone a second operation with re-resection of a membrane and left ventricular myectomy. One patient died and in three others (42%) significant symptoms and gradients remained. One of these three has undergone a successful aortoventriculoplasty, and two patients are awaiting a similar operation. Lessons learned from this experience include the following: (1) Regardless of the type of initial operation, a significant rate of recurrence can be anticipated. (2) Progressive aortic insufficiency and fibromuscular tunnel stenosis occur commonly unless adequate relief of the obstruction is achieved by the first operation. (3) Because repeat resection with left ventricular myectomy is unlikely to be effective when aortic insufficiency and/or tunnel stenosis are present, aortoventriculoplasty should be employed as the definitive reoperative procedure.     

Neonatal aortic stenosis

Aortic stenosis in the neonate has been associated in the past with a high operative mortality. As a result, in the current era of percutaneous balloon dilatation, the optimal mode of therapy remains controversial. An approach of stabilization with cardiopulmonary bypass, followed by relief of left ventricular outflow tract obstruction, was used at three institutions, and the results are presented. During the period 1983 to 1989, 40 neonates with isolated aortic stenosis and patent ductus arteriosus or coarctation of the aorta, or both, underwent operative therapy. Ages ranged from 1 to 30 days, median of 12 days, including 17 patients in the first week of life. There were 30 boys and 10 girls; weights ranged from 2.5 to 5.5 kg with a mean of 3.6 kg. Perioperative conditions included congestive heart failure in 38 and mitral regurgitation in 16; left ventricular-aortic gradients ranged from 15 to 130 mm Hg, with a mean of 67 mm Hg. There were 30 open valvotomies and 10 transventricular dilatations. The hospital survival rate was 87.5% (35/40) with no significant difference between the methods of valvotomy (9/10 in the transventricular dilatation group, 90%; 26/30 in the open valvotomy group, 87%). Although multiple methods of perfusion and valvotomy were used, the single unifying factor of cardiopulmonary bypass stabilization was present in all 40 patients. No significant difference in survival was noted between institutions, methods of cardiopulmonary bypass, cardiopulmonary bypass times, crossclamp times, or method of valvotomy. There have been five reoperations, with one late death in a patient requiring mitral valve replacement and an apical-aortic conduit. One sudden death occurred; autopsy revealed endocardial fibroelastosis. Results demonstrate that in the three institutions using the methods described, a high operative and late survival rate is possible. The results of this technique, against which percutaneous dilatation should be compared, are standard in the current era.     

Nonvalvar aortic stenosis

Seven cases of discrete nonvalvar aortic stenosis, three supravalvar and four subvalvar were treated between 1992 and 1994. Their ages ranged from 6 to 21 (mean 11.3) years. One patient had an associated supravalvar mitral membrane whereas another patient had the classical components of Williams — Beuren syndrome. The patients were investigated by echocardiography. Cardiac catheterisation and cineangiography were undertaken in four patients. Peak preoperative gradient was 27 to 110 (mean 52.3) mm Hg. All patients underwent surgical correction. Mean postoperative gradient was 28.1 (range 18 to 100) mm Hg. In a follow up of five months to two years, there has been no incidence of aortic insufficiency.