Surgical treatment of subaortic obstruction in adolescent and adults: long-term follow-up

Subaortic stenosis (SAS) is a wide spectrum of anatomical derangements ranging from a discrete fibrous membrane to tortuous fibrous tunnel with or without aortic annulus hypoplasia. We have reviewed 88 patients undergoing surgery for SAS over a 15-year period. There were 47 male and 41 female patients with a mean age of 19.8 +/- 10.6 years (range 11 to 39). Fifty-eight patients had discrete subaortic membrane, and 30 patients had diffuse tunnel subvalvular stenosis. The mean systolic pressure gradients were found to be 86.5 +/- 31.4 mmHg (range 48 to 145 mmHg). Ten patients had mild and 13 patients had moderate-to-severe aortic insufficiency (AI) preoperatively. Nine patients had bicuspid aortic valve. Forty patients (45.4%) had associated cardiac lesions. Isolated membranectomy was performed in six patients. Membranectomy associated with septal myectomy was done in 52 patients. Fifteen patients of them associated hypoplasia of the aortic orifice necessitated aortic valve replacement (AVR) using the Konno-Rastan procedure. Fifteen patients with tunnel SAS and normal aortic valves underwent a combined approach for valve sparing, a modified Konno procedure with patch septoplasty. Also eight patients required AVR because of the severity of AI and five patients aortic reconstruction procedures. Aortic commissurotomy was performed to relief of stenosis in four patients. There were three early deaths (3.4%) and one late death (1.1%) all after the Konno-Rastan procedure. Eight patients (9.1%) had permanent conduction abnormalities. Postoperative left ventricle-aorta gradient was significantly decreased at early postoperative period (p < 0.001) and ranged from 10 to 25 mmHg (mean 14.1 +/- 4.3). Fourteen patients (16.5%) were reoperated for recurrent obstruction or progression of AI. The mean reoperation interval was 4.4 +/- 1.7 years (range 2 to 8 years). Five-year reoperation-free survival was 88.0 +/- 3.6% and 12.5-year reoperation-free survival was 75.5 +/- 7.0%. Our results of aggressive surgical approach of subvalvular aortic stenosis produces relief of obstruction and frees the valve leaflets, significantly reducing associated AI with long-term survival and long-term adequate relief of left ventricular outflow tract obstruction.     

Extended aortic root replacement with aortic allografts or pulmonary autografts in children.

OBJECTIVES: To evaluate the early results and effectiveness of left ventricular outflow tract enlargement with aortic allograft or pulmonary autograft in children with complex left ventricular outflow tract obstruction. METHOD: The records of 30 children who underwent aortic root enlargement and replacement with either an aortic allograft (22 patients) or pulmonary autograft (8 patients) between January 1987 and June 1997 were reviewed. The predominant diagnosis was complex left ventricular outflow tract obstruction (n = 19), associated with aortic incompetence in 11 children. Before root enlargement, 27 children underwent surgical valvotomy (14 patients), balloon dilatation (10 patients), or both interventions (3 patients). Mean age at root enlargement was 5.4 +/- 3.5 years (range, 2 days-16 years). Most of the children (27 patients) underwent a Konno aortoventriculoplasty. Concomitant septal myectomy was performed in 4 children, mitral valve procedure in 5 children, and endocardial fibroelastosis resection in 1 child. RESULTS: Five children (17%) died in hospital. Four of these were infants less than 2 months old. All had acute aortic incompetence as the result of recent intervention necessitating urgent operation. The fifth child, aged 10 years, died of myocardial failure 2 weeks after the operation. During the follow-up period (mean length, 4.1 +/- 2.8 years), sudden death occurred in 1 child 3 months after the operation. Follow-up echocardiograms (obtained for 23 of the surviving 24 children within 3 +/- 2.3 years) showed a left ventricular outflow tract gradient reduced from a mean of 65 to 11 mm Hg (P =.001); Z value increased from a mean of -0.5 to 4.1 (P <. 001), and aortic incompetence was trivial or mild except in 2 children. CONCLUSION: Urgent aortic root enlargement in decompensating neonates carries higher mortality rates. In older children, the early results of root enlargement and implantation of allograft or autograft are good.     

Discrete subaortic stenosis: assessing adequacy of myectomy by transesophageal echocardiography

BACKGROUND: Membranectomy and myectomy are standard therapy for discrete subaortic stenosis (DS) and are associated with low rates of endocarditis, recurrence, and aortic insufficiency. Extensive myectomy increases risk of complications such as conduction tissue damage and iatrogenic ventricular septal defect (VSD). MATERIALS AND METHODS: Forty-five adult patients with DS underwent operations in Gulhane Military Medical Academy. Exertional dyspnea was the principal symptom in 29 (64.4%) patients. Transesophageal echocardiography (TEE) was performed routinely in all patients to assess the length and depth of needed myectomy during the perioperative period. Aortic insufficiency (AI) was also noted preoperatively in 31 (68.9%) and a history of aortic valve endocarditis was present in 4 (8.9%) patients. RESULTS: Myectomy was performed according to TEE measurements. An average of 10 mm in width, 10 mm in depth, and 2.3 mm in length of septal tissue was resected. The mean left ventricle-aorta peak systolic gradient decreased from 70.2+/-9.7 to 17.2+/-2.7 mmHg (p < 0.001). Aortic valve repair was performed in 8 (7.8%) patients and aortic valve replacement in 11 (24.4%) patients at the initial operation. Iatrogenic VSD did not occur in any of the patients. Average postoperative left ventricular outflow tract diameter was 21+/-1.5 mm. Temporary complete heart block occurred in three patients. There was an early residual gradient (36+/-8 mmHg) resulting from temporary hypercontraction that decreased (18+/-5 mmHg) in the first postoperative day. CONCLUSIONS: Myectomy under perioperative TEE measurement is safe and effective in the treatment of DS. TEE-guided myectomy reduces complications such as complete heart block and iatrogenic VSD.     

Reappraisal of localized resection for subvalvar aortic stenosis

Between June 1972 and August 1989, we operated on 45 patients with fixed subaortic stenosis. Discrete membranous stenosis was present in 28 patients and tunnel stenosis, in 13. Four patients had subvalvar stenosis complicating double-outlet right ventricle. There were 33 male and 12 female patients. Mean age at operation was 7.1 +/- 4.3 years (range, 6 months to 21 years). Local resection of the fibrous membrane was performed in 26 patients. Local resection was combined with myectomy in 18 patients. Aortoventriculoplasty (modified Konno procedure) was required at operation in 3 patients. There were three perioperative deaths at initial operation and two deaths at the time of reoperation. Follow-up ranges from 1 month to 17 years (average follow-up, 47.0 months). Reoperation for recurrent obstruction has been required in 12 patients (27%), and 3 patients have required a second reoperation. Mild to moderate aortic regurgitation was present in 17 patients. Subaortic stenosis is a spectrum of anatomical derangements ranging from a discrete fibrous membrane to a long, tortuous fibrous tunnel with aortic annulus hypoplasia. Successful removal of a discrete fibrous membrane can be followed later by recurrent stenosis necessitating myectomy or aortoventriculoplasty. Correction of subvalvar aortic stenosis can be followed by recurrent stenosis necessitating reoperation as long as 17 years after the initial procedure.     

Regression of Left Ventricular Hypertrophy After Arteriovenous Fistula Closure in Renal Transplant Recipients: A Long-Term Follow-Up

The long-term effects of hemodialysis arteriovenous fistula (AVF) closure on left ventricular (LV) morphology are unknown. Using echocardiography, we prospectively studied 17 kidney transplant recipients before, 1, and, 21 months after AVF closure (mean fistula flow 1371 +/- 727 mL/min). Eight kidney transplant recipients with a patent AVF, matched for age, time after AVF creation, and time after transplantation, served as controls. LV mass index (LVMI) decreased from 139 +/- 44 g/m2 before AVF closure to 127 +/- 45 g/m2 and 117 +/- 40 g/m2 at 1 and 21 months post-closure, respectively (p < 0.001), but remained unchanged in controls. LV hypertrophy prevalence (LVMI > 125 g/m2) decreased from 65% before, to 41% early, and 18%, late, after surgery (p = 0.008), mostly from a decrease in LV end-diastolic diameter. Consequently, the prevalence of LV concentric remodeling (relative wall thickness > 0.45 without hypertrophy) increased from 12% before, to 35% early, and 65% late, after surgery (p = 0.003). Diastolic arterial blood pressure increased from 78 +/- 15 mmHg before, to 85 +/- 13 mmHg early, and 85 +/- 10 mmHg late, after surgery (p < 0.015). In conclusion, closure of large and/or symptomatic AVF induces long-term regression of LV hypertrophy. However, residual concentric remodeling geometry as well as diastolic blood pressure increase may blunt the expected beneficial cardiac effects of the procedure.     

Surgical treatment of subaortic stenosis: a seventeen-year experience

OBJECTIVE: The aim of the study was to analyze the long-term results of subaortic stenosis relief and the risk factors associated with recurrence and reoperation. METHODS: One hundred sixty patients with subaortic stenosis underwent biventricular repair. Before the operation the mean left ventricle-aorta gradient was 80 +/- 35 mm Hg, 57 patients had aortic regurgitation, and 34 were in New York Heart Association functional class III or IV. Median age at repair was 10 years. For discrete subaortic stenosis (n = 120), 39 patients underwent isolated membranectomy, 67 underwent membranectomy with associated septal myotomy, and 14 underwent septal myectomy. Tunnel subaortic stenosis (n = 34) was treated by myotomy in 10 cases, myectomy in 12, septoplasty in 7, Konno procedure in 3, and apical conduit in 2. Aortic valve replacement was performed in 6 cases, mitral valve replacement in 2 cases, and mitral valvuloplasty in 4 cases. RESULTS: There were 5 early (3.1%) and 4 late (4.4%) deaths. Within 3.6 +/- 3.3 years a recurrent gradient greater than 30 mm Hg was found in 42 patients (27%), 20 of whom had 26 reoperations. According to multivariable Cox regression analysis survival was influenced by hypoplastic aortic anulus (P =.01) and mitral stenosis (P =.048); recurrence and reoperation were influenced by coarctation and immediate postoperative left ventricular outflow tract gradients. At a median follow-up of 13.3 years, mean left ventricle-aorta gradient was 20 +/- 13 mm Hg. Relief of the subaortic stenosis improved the degree of aortic regurgitation in 86% of patients with preoperative aortic regurgitation. Actuarial survival and freedom from reoperation rates at 15 years were 94% +/- 1.3% and 85% +/- 6%, respectively. CONCLUSION: Although surgical treatment provides good results, recurrence and reoperation are significantly influenced by previous coarctation repair and by the quality of initial relief of subaortic stenosis.     

Seven-year performance of the Edwards Prima Plus stentless valve with the intact non-coronary sinus technique

OBJECTIVES: Late results after stentless aortic valve replacement (AVR) may be jeopardized by progressive aortic dilatation. To define functional outcome using the intact non-coronary sinus technique, all patients operated using the stentless Edwards Prima Plus xenograft were assessed. METHODS: Between January 2000 and August 2007, 154 patients, aged 71 +/- 9 years, underwent stentless AVR using a technique, which replaces the non-coronary sinus and stabilizes two of three commissures. Indication was aortic valve stenosis (AS) in 103 (67%) patients: 33 (21%) had bicuspid valve and four endocarditis. Ninety-six (62%) patients were in NYHA III-IV, and 13 (8%) had LVEF <30%. Associated procedures were required in 59 (38%) patients (CABG, 34; ascending aorta, 22; others 3). Study endpoints were survival, freedom from valve-related events, clinical status, and graft function. RESULTS: There were two hospital and two late deaths during a 48 +/- 19 months (1-92) follow-up (97 +/- 3% survival at seven years). Seven-year freedom from structural failure, nonstructural failure, and endocarditis was 99 +/- 1%, 97 +/- 3%, and 98 +/- 2%. Follow-up NYHA (96 vs ten patients in class III-IV, p = 0.001), and cardiac function (13 vs one patient with LVEF <30%, p = 0.02) were improved. Xenograft performance was satisfactory: 0-2 + aortic insufficiency (AI) in 147 (98%) patients, mean trans-prosthetic pressure gradient 8 +/- 4 (0-25 mmHg). Aortic root diameters were comparable to postoperative values (sinus of Valsalva, 36 +/- 8 vs 35 +/- 9 mm, p = ns; sinotubular junction, 32 +/- 7 vs 34 +/- 8 mm, p = ns). CONCLUSIONS: Stentless AVR with non-coronary sinus replacement affords excellent late outcome and low rate of valve-related events, even in complex patients (bicuspid valve, LV failure, and endocarditis). Aortic root dimensions remain stable over time allowing rewarding xenograft function.     

Pulmonary autograft replacement in children. The ideal solution?

Fifty-one children, aged 1.8 to 21 years (mean, 11.4) with aortic valve replacement using a pulmonary autograft are reviewed. Twenty-nine were intra-aortic implants and 22 were root replacements. There was one operative death, no late deaths, and two have required reoperation. Actuarial freedom from reoperation was 93% +/- 5.5 at 5.6 years. Freedom from progression of aortic insufficiency (AI) was 81% +/- 9 at 5.6 years in the intra-aortic implants and 86% +/- 10 in the root replacement. Enlargement of the pulmonary autograft was seen echocardiographically in both groups. This enlargement was consistent with somatic growth and not associated with progression of AI. Ten of 19 patients with aortic stenosis had an LV mass index suggestive of LV hypertrophy before operation. At 1 year, 18 of 25 had a normal LV mass index. Thirteen of 16 patients with AI had preoperative abnormal LV mass index. All but four returned to normal by 1 year. Low operative risk, excellent function, resolution of abnormal LV hemodynamics, and enlargement consistent with somatic growth suggest that the pulmonary autograft is the ideal replacement for the malfunctioning aortic valve.     

Long-term results after myectomy in 64 patients with hypertrophic obstructive cardiomyopathy (HOCM). Morphological and hemodynamic aspects

BACKGROUND: The aim of this study was to observe the changes in left-ventricular morphology, the improvement in hemodynamics and the survival curves (according to Kaplan-Meier) of patients following transaortic myectomy. METHODS: From November 1985 to August 1997, transaortic myectomy according to Morrow's proposal was carried out at the Heart Center NRW in Bad Oeynhausen in 64 patients with isolated HOCM. At the time of operation, the patient group included 33 women and 31 men aged between 14 and 76 years (mean 52.56 years). A hemodynamically relevant aortic stenosis was excluded in all patients. Sixty-three patients (98.4%) were evaluated in total over a mean observation period of 4.6 years (4 months to 12 years). One patient lost touch with our hospital RESULTS: The clinical symptoms according to NYHA grade could be improved postoperatively from 3.4 +/- 0.33 to 1.36 +/- 0.6 (p < 0.001). The echocardiographic preoperative pressure gradient between the left ventricle and the aorta was 73.2 +/- 14.8 mmHg at rest and 139.6 +/- 21.2 mmHg after provocation by ventricular premature beats (VPBs). Postoperatively, the gradient was reduced significantly: 13.56 +/- 2.7 mmHg at rest and 23.3 +/- 10.7 mmHg after VPBs, respectively (p < 0.001). Perioperative complications occurred in 12 patients including 1 early death due to low-output syndrome, corresponding to an early mortality rate of 1.6%. Four patients died within a postoperative period of 1 year to 9.5 years, none of them due to cardiac causes, 2 due to non-cardiac causes and 1 of unknown causes. In 2 patients a recurrent HOCM occurred at 7 and 10 years after the myectomy and they were treated by catheter intervention with the alcohol induced septal infarction. CONCLUSIONS: Based on the 12-year survival rate of 76.640% in our study, transaortal myectomy according to Morrow represents a safe and reliable form of therapy, with relatively low perioperative mortality and complication rates, also in the long-term     

Myectomy versus myotomy as an adjunct to membranectomy in the surgical repair of discrete and tunnel subaortic stenosis

The results of membranectomy and deep myectomy in the left ventricular outflow tract were compared to those of membranectomy and myotomy in 42 patients who underwent surgical repair of discrete and tunnel subaortic stenosis. Fifteen consecutive patients (Group A) underwent membranectomy and myotomy, and 27 consecutive patients (Group B) underwent membranectomy and myectomy. Two patients of Group A and nine of Group B had tunnel subaortic stenosis. The preoperative mean (+/- standard deviation) peak systolic gradients across the left ventricular outflow tract in patients with discrete subaortic stenosis types I and II were 64 +/- 29 mm Hg in Group A and 52 +/- 3 mm Hg in Group B (p = not significant). In the patients with tunnel subaortic stenosis the preoperative mean gradients were 97 +/- 74 mm Hg in Group A and 73 +/- 26 mm Hg in Group B (p = not significant). In patients with discrete subaortic stenosis types I and II, postoperative catheterization at a mean follow-up of 21 months revealed residual mean gradients of 29 +/- 24 mm Hg in Group A and 10 +/- 13 mm Hg in Group B (p less than 0.01). In the patients with tunnel subaortic stenosis, the postoperative mean gradients were 25 +/- 7 and 30 +/- 30 mm Hg in Groups A and B, respectively (p = not significant). We conclude that in the surgical management of discrete subaortic stenosis types I and II, deep myectomy (in addition to membranectomy) produces better relief of the left ventricular outflow obstruction than do membranectomy and myotomy. In patients with tunnel subaortic stenosis myectomy is less effective than in the non-tunnel type but still produces acceptable results and may delay radical procedures to a later age.     

Aortic regurgitation after left ventricular myotomy and myectomy

Five hundred twenty-five patients with hypertrophic cardiomyopathy underwent left ventricular myotomy and myectomy (LVMM) from 1960 to 1990. Four hundred ninety-six had nonregurgitant trileaflet aortic valves before LVMM. In 19 (4%) of these patients, aortic regurgitation developed after LVMM. Age of the 19 patients ranged from 10 to 58 years (mean age, 35 +/- 3 [+/- standard error of the mean]]. Seven were male and 12, female. Five patients underwent LVMM followed immediately by aortic valve replacement or valvuloplasty. Aortic regurgitation developed in 14 patients at a later date. The average New York Heart Association functional class improved from 3.2 +/- 0.1 to 1.3 +/- 0.1 (p less than 0.05, Student's t test) after operation. The average peak systolic left ventricular outflow tract gradient at rest and with provocation decreased from 65 +/- 8 to 14 +/- 5 mm Hg (p less than 0.05) and 108 +/- 9 to 45 +/- 7 mm Hg (p less than 0.05), respectively, 6 to 8 months after operation. Aortic regurgitation occurred in 7 of the 14 patients at 6 months or less after operation, and 3 required operative repair. In the other 7 patients, aortic regurgitation developed 3 years or more after LVMM, and 3 of them also required operative repair. All 12 patients in whom aortic regurgitation developed at operation or within 6 months postoperatively had either a very small aortic annulus (less than or equal to 21 mm, 5 patients), a low mitral-septal contact lesion (greater than or equal to 35 mm below the aortic annulus, 3 patients), or both (4 patients).(ABSTRACT TRUNCATED AT 250 WORDS)     

Should Mild‐to‐Moderate and Moderate Ischemic Mitral Regurgitation Be Corrected in Patients with Impaired Left Ventricular Function Undergoing Simultaneous Coronary Revascularization?

INTRODUCTION: Mitral valve regurgitation (MR) occurring as a result of myocardial ischemia and global left ventricular (LV) dysfunction predicts poor outcome. This study assessed the feasibility of mitral valve (MV) surgery concomitant with coronary artery bypass grafting (CABG) in patients with mild-to-moderate and moderate ischemic MR and impaired LV function. MaTERIALS AND METHOD: From January 1996 to July 2000, 49 patients (group 1) and 50 patients (group 2) with grade II and grade III ischemic MR and LV ejection fraction (EF) between 17% and 30% underwent combined MV surgery and CABG (group 1) or isolated CABG (group 2). LVEF (%), LV end-diastolic diameter (EDD) (mm), LV end-diastolic pressure (EDP) (mmHg), and LV end-systolic diameter (ESD) (mm) were 27.5 +/- 5, 67.7 +/- 7,27.7 +/- 4, and 51.4 +/- 7, respectively in group 1 versus 27.8 +/- 4, 67.5 +/- 6, 27.5 +/- 5, and 51.2 +/- 6, respectively in group 2. Groups 1 and 2 were divided into Groups 1A and 2A with mild-to-moderate MR (22 [45%] and 28 [56%] patients, respectively) and groups 1B and 2B with moderate MR (27 [55%] and 22 [46%], respectively). In group 1, MV repair was performed in 43 (88%) patients and MV replacement in 6 (12%) patients. RESULTS: Preoperative data analysis did not reveal any difference between groups. Five (10%) patients in group 1 died versus 6 (12%) in group 2 (p = ns). Within 6 months after surgery, LV function and its geometry improved significantly in group 1 versus group 2 (LVEF, p < 0.001; LVEDD, p = 0.002; LVESD, p = 0.003; and LVEDP (p < 0.001) improved significantly in group 1 instead of a mild improvement in Group 2). The regurgitation fraction decreased significantly in group 1 patients after surgery (p < 0.001). There was an inverse strong correlation between postoperative forward cardiac output and regurgitation fraction (p < 0.001). LVEF and LVESD improved significantly in group 1 versus group 2 patients (p = 0.04 and p = 0.02, respectively). The cardiac index increased significantly in group 1 and 2 (p < 0.001 and p = 0.03, respectively). LV function and geometry improved significantly postoperatively in group 1B versus group 2B (LVEDD, p = 0.027; LVESD, p = 0.014; LVEDP, p = 0.034; and LVEF, p = 0.02), instead of a mild improvement in group 1A versus group 2A (LVESD, p = 0.015; LVEF, p = 0.046; and LVEDD and LVEDP, p = 0.05). At follow-up, 4 (67%) of 6 patients undergoing MV replacement died versus 5 (11.5%) of 43 patients undergoing MV repair in group 1 (p = 0.007). The overall survival at 3 years in Group 2 was significantly lower than group 1 (p < 0.009). Conclusion: MV repair and replacement-preserving subvalvular apparatus in patients with impaired LV function offered acceptable outcomes in terms of morbidity and survival. Surgical correction of mild-to-moderate and moderate MR in patients with impaired LV function should be taken into consideration since it yields better survival and improved LV function.     

The results of operation in patients with hypertrophic cardiomyopathy and pulmonary hypertension

The clinical course and hemodynamic results in patients undergoing operation for obstructive hypertrophic cardiomyopathy with preoperative pulmonary arterial hypertension were unknown. The hypothesis tested in this retrospective study was that operative relief of left ventricular outflow tract obstruction resulted in a substantial reduction in pulmonary artery pressures and mitral regurgitation without necessitating mitral valve replacement. Patients were included if their preoperative pulmonary systolic pressure was greater than 35 mm Hg and if they were without concomitant cardiac disease, with the exception of mitral regurgitation. Since 1962, 49 patients who fit our criteria underwent left ventricular myotomy and myectomy with 98% follow-up. Mean follow-up was 7.9 +/- 0.7 (mean +/- standard error of the mean) years with a range of 0.8 to 18.4 years. Early hospital mortality rate was 12% (n = 6); two deaths from low cardiac output and four from arrhythmia. There were 43 (88%) hospital survivors and 18 late deaths. Actuarial survival rate after operation was 87% +/- 5% (n = 31) at 5 years and 55% +/- 8% (n = 9) at 10 years. Thirty-nine of 43 survivors (91%) returned 9 +/- 1 months postoperatively for follow-up evaluation including cardiac catheterization. The majority (83%) were in New York Heart Association functional class I or II postoperatively. Cardiac catheterizations indicated a fall in pulmonary arterial systolic pressure from 62 +/- 3 (range = 36 to 105) to 38 +/- 2 (range = 21 to 65) mm Hg (p = 0.0001) with no difference in right atrial pressure or cardiac output. Pulmonary arterial wedge mean pressure decreased from 24 +/- 1 to 16 +/- 5 mm Hg (p = 0.0002) and preoperative mitral regurgitation improved or was abolished in 85% of patients studied (n = 13). Rest and maximal provocable left ventricular outflow tract gradients decreased from 81 +/- 7 and 103 +/- 5 to 14 +/- 3 and 45 +/- 8 mm Hg, respectively (p = 0.0001). Comparison of the above-mentioned patients, operated on since 1982, with a preoperatively matched group who underwent mitral valve replacement in the same interval showed no statistically significant difference in mortality, morbidity, hemodynamic outcome, or functional outcome with a mean follow-up of 2 years. We conclude that a consistent, significant reduction (mean = 40%) in preoperative pulmonary arterial systolic pressure, clinical symptoms, and mitral regurgitation occurs with relief of outflow tract obstruction by left ventricular myotomy and myectomy and that pulmonary hypertension and mitral regurgitation are not indications for mitral valve replacement in these patients.     

Aortic valve replacement for aortic regurgitation and stenosis, in patients with severe left ventricular dysfunction.

OBJECTIVE: Aortic valve replacement for aortic valve stenosis (AS) and regurgitation (AR) in patients with severe left ventricular (LV) dysfunction contains an increased risk. Few data are available on the outcome of such patients. METHODS: Fifty-five consecutive patients with severe LV dysfunction (ejection fraction, EF; <30%) and aortic valve replacement for AS (n=35) or AR (n=20) were investigated between 1994 and 2001. EF was 25+/-5%, mean transvalvular gradient 26+/-6mmHg (AS), aortic valve area 0.66+/-0.18cm(2) (AS), cardiac index (CI) 2.4+/-0.9l/min/m(2), enddiastolic LV diameter (LVEDD) 64+/-8mm and endsystolic LV diameters (LVESD) was 55+/-3mm. Ninety percent of patients were in New York Heart Association (NYHA) functional class III/IV at admission to the hospital. Concomitant coronary artery bypass grafts (CABG) were performed in 14 patients. Follow-up examinations including chest X-ray, echocardiography, exercise testing, were performed among survivors. RESULTS: The survival rates for AS were: 1-year 76%, 2-year 68.8%, 5-year 64.2%; for AR: 1-year 94.4%, 2-year 86.5%, 5-year 74.2%. NYHA functional class improved from 90% in class III/IV to 45 (AR group) and 24% (AS group) at follow-up (P<0.02). The LVEDD decreased to 54+/-8mm after 1 year. The EF improved to 38+/-4 (AR group) and 40+/-5% (AS group) at follow-up. CONCLUSIONS: Despite severe LV dysfunction, increased 1-year mortality especially in the AS group, aortic valve replacement was associated with improved functional status, symptoms and EF in both groups and in most patients. We, therefore, conclude that aortic valve replacement in patients with severe LV dysfunction can be performed with acceptable risk.     

The outcome of surgical treatment of hypertrophic obstructive cardiomyopathy. Experience over 15 years

From 1972 through 1987, 115 patients between the ages of 1 and 83 years (mean, 44.5 years) underwent operation for hypertrophic obstructive cardiomyopathy. Methods of relief of left ventricular outflow obstruction were septal myectomy/myotomy (n = 109), mitral valve replacement (n = 4), and myectomy/myotomy plus mitral valve replacement (n = 2); concomitant procedures included coronary artery bypass (n = 19) and aortic valve replacement (n = 9). Systolic gradient (peak-to-peak) from the left ventricle to the aorta decreased from 70 +/- 38 mm Hg (mean +/- standard deviation) to 9 +/- 11 mm Hg. There were six hospital deaths, for an overall operative risk of 5.2%; one death occurred among 83 patients less than age 65 years (operative risk, 1.2%), and five deaths occurred in 32 older patients (operative risk, 15.6%; p = 0.008 for difference between age groups). Four (22.2%) of 18 patients with a residual gradient greater than 15 mm Hg died, compared with two (2.1%) of 97 patients with a lower gradient (p = 0.003). Follow-up ranged from 0.5 to 16 years (mean, 5.1 years), and 5-year actuarial survival rate, including hospital deaths, was 84% +/- 4%. The 5-year survival rate was decreased in patients who had operative procedures other than myectomy/myotomy (69% versus 91%, p less than 0.005) and in patients aged 65 years or older (54% versus 93%, p less than 0.005). No correlation was found between preoperative symptoms, functional class, left ventricle-aorta pressure gradient, or mitral valve insufficiency and operative or late mortality. Preoperative symptoms were relieved in 57 (76%) of 75 patients with dyspnea, 49 (83%) of 59 patients with angina, and 22 (96%) of 23 patients with syncope. This experience confirms the effectiveness of operation for relief of symptoms in patients with the obstructive form of hypertrophic cardiomyopathy. The current operative mortality rate is low, especially in patients less than 65 years of age (1.2%). Our experience suggests that incomplete relief of left ventricular outflow obstruction may increase the risk of early postoperative death.     

Aortic valve replacement for aortic insufficiency: valve type as a determinant of systolic strain recovery

Abstract   Background and Aim: Left ventricular (LV) 3D systolic strain decreases in absolute value postoperatively and does not recover in patients who undergo aortic valve replacement (AVR) for chronic aortic insufficiency (AI). We investigated whether choice of valve prosthesis (mechanical [St. Jude], bioprosthetic [bovine pericardial], Ross procedure) had a significant impact on strain recovery in this surgical population. Methods: MRI with tissue-tagging was performed on 14 patients with chronic AI both before and 28 ± 13 months after AVR. Average values of LV systolic strain and end-systolic stress (ESS) were computed from MRI data for the LV. Three types of prosthetic valve were examined (Ross procedure n = 4, bovine pericardial n = 5, and St. Jude n = 5). Results: Overall, systolic strain, ESS, LV volumes, ejection fraction, and LV mass all changed significantly following AVR. Comparisons between individual valve types revealed no differences in any of these measurements. Patients who received a mechanical valve had a greater decrease in the absolute value of systolic strain following surgery compared to patients from the nonmechanical group (Ross procedure and bioprosthetic valve). Comparisons between the Ross group and the prosthetic group (St. Jude and bioprosthetic) produced no significant differences in strain, ESS, LV volume, and mass. Conclusions : These early results suggest that valve prosthetic type may be a factor in efforts to improve strain recovery after AVR for AI, although further investigation is warranted. MRI with tissue-tagging may be a useful tool for comparing the impact of prosthetic valve choice on incompletely recovered systolic strain following AVR for chronic AI.     

Reimplantation Valve‐Sparing Aortic Root Replacement for Aortic Root Aneurysm in the Elderly: Are We Pushing the Limits?

Abstract   Objectives: Reimplantation valve-sparing aortic root replacement has been increasingly performed with improving perioperative and midterm results. However, extending the age criterion in patient selection remains a debate. This study reviews the results of reimplantation valve-sparing aortic replacement in patients greater than 60 years of age. Methods: During a 51-month period, 63 patients with aortic root aneurysms underwent reimplantation valve-sparing aortic root replacement. The Gelweave Valsalva™ prosthesis (TERUMO CardioVascular Systems Corp., Ann Arbor, MI, USA) was used in all but one case. The patients were predominantly male, and the mean age was 67 years (range, 61–83 years). Four patients had congenital bicuspid aortic valves, and cusp repair was required in one patient. The mean follow-up was 25 months (range, 1–51 months). Results: There were one hospital and two late deaths. Overall survival at 51 months was 84 ± 9.9%. During follow-up, one patient developed severe aortic incompetence (AI) requiring an aortic valve replacement (AVR). Freedom from reoperation at 51 months was 92.8 ± 6.8%. Moderate AI was present at latest echocardiogram in one patient. Freedom from moderate or severe AI at 51 months was 90 ± 9.4%. There was no episode of endocarditis on follow-up. Univariate analysis demonstrated that no preoperative or intraoperative factor was a predictor for late reimplantation failure. Conclusions: Reimplantation valve-sparing aortic root replacement in patients greater than 60 years old can be performed with satisfactory perioperative and midterm results. Long-term results are needed to define the durability of this technique and its role in this subset of patients. (J Card Surg 2010;25:56-61)     

Nineteen-millimeter prosthetic aortic valves allow normalization of left ventricular mass in elderly women

BACKGROUND: Implantation of small aortic valve prostheses has been reported to be associated with impaired left ventricular (LV) mass regression and incomplete resolution of symptoms although these data have been generated largely with male patients. Therefore we sought to determine the clinical and hemodynamic outcomes of female patients who received a 19-mm aortic valve. METHODS: Between May 1995 and December 2000, 38 female patients (average age 73 years, range 42 to 89) underwent isolated aortic valve replacement (AVR; n = 22) or AVR plus coronary artery bypass graft surgery (CABG; n = 16) with a 19-mm aortic prosthesis. The average New York Heart Association (NYHA) class was 3.08 and of the 26 patients who had angina, 47.2% were in CCS class III or IV. Clinical and echocardiographic follow-up was done an average of 33.4 months (8 to 72) after surgery. RESULTS: Operative mortality was 10.5%. Overall survival at an average of 33 months was 71.1%. The average NYHA class was 1.52 +/- 0.34 postoperatively (p < 0.001 versus preoperative) and 95% had no anginal symptoms or were in Canadian Cardiovascular Society class I. The LV mass index showed significant regression (114 +/- 11 g/m2 to 89 +/- 9 g/m2, p = 0.001) despite an effective orifice area index (EOAI) of 0.64 +/- 0.09 cm2/m2. CONCLUSIONS: Despite a very small EOAI, elderly female patients with 19-mm prosthetic aortic valves can experience a satisfactory improvement in symptoms and normalization of LV mass. This finding suggests that small prosthetic aortic valves continue to have an application in contemporary cardiac surgical practice. The current perception of patient-prosthesis mismatch may need to be reconsidered for select populations.     

Midterm results of total aortic root replacement with pulmonary autograft (Ross operation)

Between February 1995 and December 1999, 18 patients underwent Ross operation. Age at the operation ranged from 2 to 31 years. Diagnosis includes congenital aortic stenosis and/or regurgitation in 15, and adult aortic regurgitation in 3. In all cases autograft was implanted by the method of total aortic root replacement, associated with annuloplasty for the dilated aortic annulus in 2 and aortoventriculotomy by the Konno procedure in 3 (Ross-Konno). Right ventricular outflow tract was reconstructed by a pulmonary homograft in 12, a xenopericardial conduit in 3, or the other reconstructive procedures with autologous tissue and outflow patch in 3. There was no operative and late death. Reoperation was needed in 1 patient due to stenosis of pericardial conduit 4 years after the initial operation. Pressure gradient across implanted autograft valve was negligible (4.8 +/- 0.5 mmHg), and echocardiography revealed no aortic regurgitation in 12 cases and trivial to mild in 6, over a mean follow-up period of 23 +/- 18 months (range 2 to 60 months), signifying excellent durability of implanted autograft. Right ventricular outflow tract reconstruction with the homograft resulted in excellent mid-term performance as showing pressure gradient of 9.0 +/- 4.6 mmHg and no regurgitation in 11 of 12 cases, whereas pressure gradient was 17.9 +/- 13.1 mmHg in the patients underwent the other reconstructive procedures. We conclude that Ross procedure associated with the concomitant procedures to adjust the size discrepancy between the native aortic annulus and autograft has provided good midterm results with excellent autograft durability. And this procedure was thought to be a preferable method for children as well as young adults with congenital aortic stenosis.     

Long-term results of the 19 mm low-profile bileaflet valve prosthesis in the small aortic anulus

Between April, 1979, and November, 1986, 20 patients underwent aortic valve replacement (AVR) in the small aortic anulus with either 19 mm St. Jude Medical valve prosthesis or 19 mm Duro-Medics valve prosthesis, which are relatively new, low-profile bileaflet valve prostheses. There were two male and 18 female patients ranging from 35 to 69 years old (mean, 54.7 years). Average body surface area was 1.37 +/- 0.11 m2 (range 1.20 to 1.55 m2). One patient died of arrhythmia at 22 postoperative day. The 19 survivors have been followed up for as long as 61 months (mean, 31.2 months). There were two late complications, cerebral infarctions, and event free ratio was 0.85 at five years. All long-term survivors were in New York Heart Association Functional Class I (15 patients) and Class II (three patients). Preoperative and postoperative echocardiograms demonstrated significant decreases in mean left ventricular end-diastolic diameter (LVDd) (48.9 +/- 8.3 mm vs 42.2 +/- 5.7 mm; p less than 0.01) and in left ventricular end-systolic diameter (LVDs) (32.2 +/- 8.2 mm vs 25.7 +/- 4.9 mm; p less than 0.01). Mean left ventricular wall thickness was decreased to 24.5 +/- 3.7 mm from 25.8 +/- 6.4 mm. The average peak systolic gradient at rest with Doppler ultrasound was 26.0 +/- 9.3 mmHg (range nine to 36 mmHg). Though transprosthetic gradient did occur in patients who received 19 mm low-profile bileaflet valves in narrow aortic roots, progressive prosthetic stenosis was not observed and small aortic prostheses provide acceptable palliation for long-term results clinically.