Techniques of autologous pericardial leaflet replacement for bicuspid aortic valve endocarditis

BACKGROUND AND AIM OF THE STUDY

Valvular endocarditis constitutes high-risk cardiac surgery, with worse early and late results than for other disorders. Current data suggest that repairing endocarditis valves may produce better outcomes, but bicuspid endocarditis has been difficult to repair. Given the excellent early and late results now being achieved with autologous pericardial leaflet replacement, the present study involved complete pericardial leaflet replacement, a procedure that could facilitate the autologous reconstruction of bicuspid valves.

METHODS

Four patients with endocarditis of bicuspid valves, each exhibiting variations in anatomy and presentation, were included. All four patients had received antibiotics preoperatively and had been converted to culture-negative. All had infection of the fused leaflet, and three had retention of their normal non-fused leaflets for the repair. Using glutaraldehyde-fixed autologous pericardium, all damaged leaflets were fully replaced, employing bileaflet repairs in three patients and a trileaflet repair in one patient. One patient required both bicuspid leaflets to be replaced with two autologous pericardial leaflets because of concurrent calcification.

RESULTS

All four patients recovered uneventfully, and had fully competent valves with minimal gradients. All were subsequently managed without anticoagulation, and during up to two years of follow up the reconstructed valves functioned normally. None of the patients experienced any valve-related complications.

CONCLUSION

In an anatomic spectrum of bicuspid endocarditis, the preservation of normal leaflets and complete replacement of damaged leaflets with autologous pericardium has provided an excellent reparative solution. This method could allow a stable autologous reconstruction in the majority of patients, although more experience and follow up will be necessary to fully validate the procedure.

Bicuspid aortic valve aortopathy: genetics, pathophysiology and medical therapy

The association between ascending aortic aneurysm (AA) and bicuspid aortic valve (BAV) has been well established. Different genetic, haemodynamic and cardiovascular risk factors have been implicated in the development and progression of AA. However, to date, definite conclusions cannot be drawn regarding the exact molecular, cellular and haemodynamic mechanisms causing BAV-associated aortopathy. For this study, we performed a thorough electronic systematic review of the literature using MEDLINE (1960-2012) and EMBASE databases. MeSH terms included: 'bicuspid aortic valve and ascending aorta', 'bicommissural aortic valve and aneurysm', 'bicuspid aortopathy', 'bicuspid aortic valve pathophysiology', 'bicuspid aortic valve and genetics' and 'bicuspid aortic valve and treatment'. We aim in this review to discuss the mechanisms, pathophysiology, genetics and modern drug therapy in the context of BAV-associated aortopathy.

Aortic dilation in bicuspid aortic valve disease: flow pattern is a major contributor and differs with valve fusion type

BACKGROUND

Ascending aortic dilation is important in bicuspid aortic valve (BAV) disease, with increased risk of aortic dissection. We used cardiovascular MR to understand the pathophysiology better by examining the links between 3-dimensional flow abnormalities, aortic function, and aortic dilation.

METHODS AND RESULTS

A total of 142 subjects underwent cardiovascular MR (mean age, 40 years; 95 with BAV, 47 healthy volunteers). Patients with BAV had predominantly abnormal right-handed helical flow in the ascending aorta, larger ascending aortas (18.3±3.3 versus 15.2±2.2 mm/m²; P<0.001), and higher rotational (helical) flow (31.7±15.8 versus 2.9±3.9 mm²/s; P<0.001), systolic flow angle (23.1°±12.5° versus 7.0°±4.6°; P<0.001), and systolic wall shear stress (0.85±0.28 versus 0.59±0.17 N/m²; P<0.001) compared with healthy volunteers. BAV with right-handed flow and right-non coronary cusp fusion (n=31) showed more severe flow abnormalities (rotational flow, 38.5±16.5 versus 27.8±12.4 mm²/s; P<0.001; systolic flow angle, 29.4°±10.9° versus 19.4°±11.4°; P<0.001; in-plane wall shear stress, 0.64±0.23 versus 0.47±0.22 N/m²; P<0.001) and larger aortas (19.5±3.4 versus 17.5±3.1 mm/m²; P<0.05) than right-left cusp fusion (n=55). Patients with BAV with normal flow patterns had similar aortic dimensions and wall shear stress to healthy volunteers and younger patients with BAV showed abnormal flow patterns but no aortic dilation, both further supporting the importance of flow pattern in the pathogenesis of aortic dilation. Aortic function measures (distensibility, aortic strain, and pulse wave velocity) were similar across all groups.

CONCLUSIONS

Flow abnormalities may be a major contributor to aortic dilation in BAV. Fusion type affects the severity of flow abnormalities and may allow better risk prediction and selection of patients for earlier surgical intervention.

Subtypes of bicuspid aortic valves in coarctation of the aorta

Bicuspid aortic valves (BAVs) represent a wide morphologic and functional spectrum. In coarctation of the aorta, BAVs are common, but the proportion of BAV subtypes and their relation to aortic dimensions and development of late valve dysfunction are unknown. Sixty-two cardiovascular magnetic resonance investigations of patients with coarctation of the aorta were reviewed with respect to aortic valve morphology, aortic valve function, and aortic dimensions. BAVs were identified in 45 patients (72.6%), of which 13 (20.9%) were type-0 (two commissures), 28 (45.1%) type-1 (three commissures but fusion of one commissure with a raphe) and 4 (6.5%) valves were bicuspid but not possible to classify further. Patients with BAVs type-0 had larger dimensions in their sinus of Valsalva (35.5 ± 6.8 vs. 29.7 ± 2.7 mm, p = 0.002), ascending aorta (33.1 ± 6.2 vs. 26.0 ± 4.3 mm, p = 0.005) and sino-tubular junction (29.3 ± 7.4 vs. 24.2 ± 3.5 mm, p = 0.040) compared with tricuspid aortic valves (TAVs). Moderate and severe aortic valve disease was more common in BAV type-0 compared with BAV type-1 (p = 0.030) and TAV (p = 0.016). In a multivariate linear regression model BAV type-0 (p = 0.005), BAV type-1 (p = 0.011), age (p < 0.001), patient height (p = 0.009), and aortic valve disease (p = 0.035) were independently associated with increased diameter of the ascending aorta (R (2) of the model 0.54, p < 0.001). BAV type-0 is relatively common in coarctation of the aorta. Both BAV type-0 and type-1 are associated with increased diameter of the ascending aorta but this association is stronger for BAV type-0. Development of aortic valve disease is more common in BAV type-0 than in BAV type-1. Discrimination between BAV subtypes may potentially provide clinical and prognostic information in patients with coarctation of the aorta.

Dilatation of the remaining aorta after aortic valve or aortic root replacement in patients with bicuspid aortic valve: a 5-year follow-up

BACKGROUND

The natural history and management of ascending aorta (AA) and arch dilatation in patients with bicuspid aortic valve (BAV) after aortic valve replacement (AVR) or aortic root replacement (ARR) remains controversial. Our aim is to identify dilatation of the remaining aorta after AVR or ARR in patients with BAV compared with patients with tricuspid aortic valve (TAV).

METHODS

Three hundred ninety-five patients who underwent AVR or ARR between 2002 and 2009 were studied. Preoperative computed tomography (CT) and echocardiography were performed in 192 patients with BAV, and the results were compared with those of 203 patients with TAV. An AA diameter 4.5 cm or greater was regarded as aneurysmal. Postoperative echocardiograms, computed tomographic scans, and magnetic resonance images were compared with subsequent imaging at a median follow-up of 4.6 years (2.2-9.8 years).

RESULT

Median ages of patients with BAV and patients with TAV were 57 ± 14 and 65 ± 16 years, respectively (p < 0.05). Preoperative diameter of AA in the BAV group with no aneurysm (3.5 cm; range, 3.0-4.0 cm; n = 143) was significantly higher than in the TAV group (3.3 cm; range, 3.1-3.8 cm; n = 129) (p < 0.001). In both BAV and TAV groups with nonaneurysmal aortas who underwent AVR, there was no significant expansion of the AA and arch at 5 years' follow-up. In patients with aneurysmal aorta (BAV group, n = 49; TAV group, n = 74) who underwent ARR, there was also no significant difference in growth of the remaining aorta at 3 and 5 years' follow-up.

CONCLUSIONS

No significant dilatation of the AA or arch was observed after AVR or ARR, respectively, in patients when a cut-off diameter of 4.5 cm or greater was considered for replacement in patients with BAV compared with patients with TAV up to 5 years after operation. The need for aortic replacement at smaller diameters was not found.

Heritable retinoblastoma and accelerated aortic valve disease

Heritable retinoblastoma is associated with a germline mutation in the tumour suppressor gene RBI. The Rb protein (pRb) arises from the RB1 gene, which was the first demonstrated cancer susceptibility gene in humans. Second primary malignancies are recognised complications of retinoblastoma. Furthermore, pRb is implicated in valve remodelling in calcific aortic valve disease. We report a family with hereditary retinoblastoma and associated secondary primary malignancies. There are two interesting aspects to this family. The first is the concept of 'cancer susceptibility genes'; the RBI gene being the first reported in humans. A further feature of note is that two family members also have bicuspid aortic valves. We discuss a potential association between the gene defect responsible for retinoblastoma (with its associated propensity for further malignancies) and accelerated deterioration of the bicuspid aortic valve in the proband carrying this gene defect.

Short-term and mid-term results with the Sorin Freedom Solo aortic valve

BACKGROUND AND AIM OF THE STUDY

The study aim was to present the short- and mid-term results for patients who underwent aortic valve replacement (AVR) with the Sorin Freedom Solo third-generation stentless prosthetic valve.

METHODS

AVR with a Sorin Freedom Solo valve was performed in 14 patients between March 2006 and March 2011. Patients aged > or = 60 years (male:female ratio 6:8; mean age 73.28 +/- 5.42 years) who required AVR with the Sorin Freedom Solo valve according to the surgeon's choice were included in the study. The valvular prosthesis was implanted in the supra-annular position, using a single suture line.

RESULTS

Eight patients underwent an isolated AVR; combined interventions were carried out in the other patients due to concomitant cardiac disease. One patient died during the immediate perioperative period, and two more during the follow up, from non-cardiac causes. The mean maximum transvalvular gradient of patients with aortic stenosis was 88.1 +/- 20.2 mmHg, and this fell to 26.4 +/- 7.6 mmHg during the early postoperative period. The mean gradient at one year of follow up was further decreased to 19.4 +/- 5.3 mmHg. The left ventricular end-diastolic and end-systolic diameters were also significantly reduced, from 4.8 +/- 0.9 to 4.3 +/- 0.6 cm and from 3.2 +/- 0.6 to 2.8 +/- 5.3 cm, respectively. The average left ventricular ejection fraction was 60.2 +/- 4.9% preoperatively, and 63.2 +/- 2.1% at one year after surgery (p = NS). No paravalvular leakage, endocarditis, prosthesis failure or neurologic events were reported among patients.

CONCLUSION

The Sorin Freedom Solo stentless valve has provided good early and intermediate-term results. Implantation of the prosthesis is straightforward, with low rates of morbidity and mortality. However, these data require further support from larger patient series and long-term follow up.

Impact of smoking status on early and late outcomes after isolated aortic valve replacement surgery

BACKGROUND AND AIM OF THE STUDY

Currently, insufficient data exist relating to the impact of smoking status on outcomes after isolated aortic valve replacement (AVR) surgery.

METHODS

Data obtained prospectively between June 2001 and December 2009 by the Australian and New Zealand Society of Cardiac and Thoracic Surgeons (SCTS) Cardiac Surgery Database Program was analyzed retrospectively. Demographic and operative data were compared between patients who were non-smokers, previous smokers and current smokers, using chi-square and t-tests. The independent impact of smoking status on 14 short-term complications and long-term mortality was determined using binary logistic and Cox regression, respectively.

RESULTS

Isolated AVR surgery was performed in 2,790 patients; smoking status was recorded in 2,784 cases (99.8%). Of these patients 1,346 (48.3%) had no previous smoking history, 1,232 (44.3%) were previous smokers, and 206 (7.4%) were current smokers. The 30-day mortality rate was 2.3% in nonsmokers, 2.7% in previous smokers, and 0.5% in current smokers (p = NS). The incidence of perioperative complications was generally similar in the three groups, but current smokers were at an increased risk of pneumonia (p = 0.030) and postoperative myocardila infarction (p = 0.007). The mean follow up period for the study was 37 months (range: 0-105 months). After adjusting for differences in patient variables, the incidence of late mortality was not higher in previous smokers (HR 1.13; 95% CI 0.87-1.46; p = 0.372) or current smokers (HR 1.25; 95% CI 0.66-2.36; p = 0.494) compared to non-smokers.

CONCLUSION

Smoking status does not necessarily portend a poorer perioperative outcome in patients undergoing isolated AVR.

Outcomes of transcatheter aortic valve implantation compared to surgical aortic valve replacement following previous surgery

BACKGROUND AND AIM OF THE STUDY

Surgical aortic valve replacement remains the 'gold standard' treatment for aortic valve disease. An increasing number of elderly patients with multiple comorbidities are referred for transcatheter aortic valve implantation (TAVI), partly due to the perceived high risks of surgery. These include in particular patients who have had previous cardiac surgery. The study aim was to compare the outcomes of patients with aortic valve disease and previous cardiac surgery who underwent TAVI, with those who had redo surgery.

METHODS

Patients were identified with aortic valve disease and previous cardiac surgery referred to the authors' multidisciplinary meeting. Patient characteristics were noted, together with their allocation to either re-do surgery or TAVI. A total of 20 patients who had undergone previous cardiac surgery was allocated to TAVI; these were matched to 20 patients who had undergone previous surgery and subsequently had redo surgery. Treatment modalities were chosen for individual patients according to their EuroSCORE, together with other factors not accounted for in traditional scoring systems.

RESULTS

Between June 2008 and March 2010, a total of 191 patients was discussed; of these patients, 63 underwent TAVI, 20 of whom had undergone previous cardiac surgery. There was no significant difference in the EuroSCORE between groups (18 +/- 2 versus 19 +/- 3.0, p = 0.91). TAVI patients had a higher body mass index (27.1 +/- 3.9 versus 21.8 +/- 0.5 kg/m2, p = 0.0001). There were no deaths at 30 days in either group. One patient (5%) in the TAVI group had a transient ischemic attack following the procedure, and one (5%) had a hematoma at the site of arterial puncture. There were more pacemaker implantations in the TAVI group than in the redo group (25% versus 0%, p = 0.02).

CONCLUSION

Improved risk stratification and its understanding in patients with aortic valve disease and previous cardiac surgery is required. Despite the perceived high risks in the surgically treated group, there were no deaths and redo surgery patients had lower rates of stroke and pacemaker implantation than did those who underwent TAVI.

[Minimally invasive aortic valve replacement for isolated aortic valve disease: clinical analysis of 101 consecutive patients]

OBJECTIVE

To review the results for minimally invasive aortic valve replacement (AVR) through a 5 cm right anterolateral thoracotomy.

METHODS

From July 2009 to September 2011, 101 consecutive patients with isolated aortic valve disease (degenerative in 37 patients, rheumatic in 21 patients, congenital in 37 patients, endocarditic in 3 patients and aorta-arteritis in 1 patients) underwent AVR through the right anterolateral thoracotomy approach in the third intercostal space with a groin incision for femoral connection of cardiopulmonary bypass. The mean age was 45.7 years (ranging from 17 to 71 years). Sixty patients were male.

RESULTS

Operations were successfully performed in all but 1 patient (1.0%) who required intraoperative conversion to full sternotomy. Mean duration of cardiopulmonary bypass time and aortic cross-clamp time was (88 ± 24) minutes and (55 ± 18) minutes, respectively. Thirty-day mortality was 1.0% (1/101), this patient was found difficult in weaning off cardiopulmonary bypass and exhibited severe coronary artery plaque, although bypass graft was carried out immediately, the patient died of severe low cardiac output syndrome finally. No blood products were needed in 83.2% patients. Follow-up was performed in all patients at an average of (16 ± 7) months postoperatively. A good recovery was obtained in all patients except one who died of multiple organ failure caused by massive cerebral infarction 38 days after surgery.

CONCLUSIONS

Minimally invasive aortic valve replacement though the right anterolateral thoracotomy approach is safe and feasible, with good cosmetic results and rapid postoperative recovery. It is worthy of clinical elective application.

Large pseudoaneurysm of the sinus of Valsalva after surgery for aortic valve endocarditis

Patients who undergo prosthetic aortic valve replacement for infective endocarditis and have no recurrent infection after surgery, rarely develop pseudoaneurysm of either the aortic root or the sinus of Valsalva (SV). Pseudoaneurysm of the SV can have fatal complications, including rupture. The case is reported of a large pseudoaneurysm of the SV that developed after surgical intervention for aortic valve endocarditis, and which was successfully treated.

A pilot project of familial screening in patients with bicuspid aortic valve disease

BACKGROUND AND AIM OF THE STUDY

Bicuspid aortic valve (BAV) is a common congenital cardiac abnormality, is often familial, and is associated with dilatation of the aortic root. The risk of dissection is significantly higher than that in the general population, occurring at a younger age than in patients with idiopathic aortic aneurysms. Current ACC/AHA guidelines recommend familial echocardiographic screening which, to the present authors' knowledge, is not performed routinely and uniformly. The aim of this pilot project was to explore the practicalities of running such a program.

METHODS

An initial cohort of 47 patients who had undergone surgery for BAV disease and/or associated aneurysmal aortic dilatation were offered counseling and familial screening. Referred first-degree relatives (FDR) underwent aortic valve and root assessment by standard two-dimensional echocardiography.

RESULTS

Twenty-four index patients (51%) referred a total of 75 FDR (approximately three per patient) who wished to undergo echocardiography, of whom 52 (70%) attended for review. The pick-up rate of newly detected BAV was 8% (four of 52 relatives). One of these asymptomatic individuals had a significant ascending aortic aneurysm, which required prompt surgery. In the families of the 24 index patients, there was a total of eight cases (14% prevalence) of aortic valve disease, either known or newly detected via screening.

CONCLUSION

This pilot study confirmed the relatively high prevalence of BAV among FDR of patients who have undergone surgery for BAV-associated pathology. Patients should be made aware of the condition's pattern of inheritance, and familial screening should be actively pursued to reduce the potential morbidity and mortality associated with BAV and its related aortopathy. A number of important and practical considerations for setting-up a familial screening program are discussed.

Left ventricular diastolic function in children and young adults with congenital aortic valve disease

Young patients with congenital aortic valve disease are at risk of left ventricular (LV) diastolic dysfunction (DD). We evaluated LV remodeling and the prevalence of, and risk factors for, DD in patients with aortic stenosis (AS), pure aortic regurgitation (AR), and AS+AR. Patients aged 8 to 39 years with congenital AS (n = 103), AR (n = 36), or AS+AR (n = 107) were identified. Cross-sectional assessment of the LV remodeling pattern and diastolic function was performed. A diastolic function score (DFS; range 0 to 4) was assigned to each patient, with 1 point for an abnormal value in each of 4 categories: mitral inflow (E/A and E-wave deceleration time), tissue Doppler E', E/E', and left atrial volume. Patients with a DFS of ≥2 were compared to those with a DFS <2. Concentric hypertrophy was the most common remodeling pattern in those with AS (51%), mixed/physiologic hypertrophy in those with AS+AR (48%) and eccentric hypertrophy in those with AR (49%) predominated. In the entire cohort, 91 patients (37%) had a DFS of ≥2. Patients with AS or AS+AR had greater DFS than those with pure AR (p <0.001). On multivariate analysis, a greater LV mass z-score and previous aortic valve balloon dilation were associated with a DFS of ≥2. In patients with catheterization data (n = 65), E/E' correlated with LV end-diastolic pressure. Those with a DFS of ≥2 had a greater LV end-diastolic pressure and mean pulmonary artery pressure than those with a DFS <2. In conclusion, DD is common in young patients with AS and AS+AR but not in those with pure AR. A greater LV mass and previous aortic valve dilation were associated with DD.

Fertile eunuch syndrome in association with biventricular noncompaction, bicuspid aortic valve, severe aortic stenosis, and talipes equinovarus

Noncompaction of the ventricular myocardium is a congenital cardiomyopathy characterized by prominent ventricular trabeculations and deep intertrabecular recesses. In most cases, noncompaction is an isolated disease confined to the left ventricular myocardium. Fertile eunuch syndrome is a hypogonadotropic hormonal disorder in which the levels of testosterone and follicle-stimulating hormone are low. We report a case of biventricular noncompaction in association with bicuspid aortic valve and severe aortic stenosis in a 42-year-old man who was diagnosed with talipes equinovarus and fertile eunuch syndrome during childhood.

A Modified Technique to Safely Close the Arterial Puncture Site After TAVI

BACKGROUND

We describe a vascular closure technique, convenient in practice, that permits effective femoral artery closure after CoreValve (Medtronic) implantation during transcatheter aortic valve implantation (TAVI). Vascular complications of transfemoral access implantation have been associated with significantly increased patient morbidity and mortality, as well as with increased hospitalization, among patients undergoing TAVI.

TECHNIQUE

The crossover technique is performed while using the sheath dilatator in order to tightly grasp the crossover wire; a peripheral artery balloon is inserted in the iliac artery and inflated above the puncture site. The 18 Fr sheath is removed while hemostasis is achieved in that way. Minor vascular complications were observed in 10% (3 out of 30) of the patients treated with this vascular closure technique. No major vascular complications were observed.

CONCLUSIONS

The described vascular closure maneuver is operator friendly, without demanding special skills and can be added to the therapeutic quiver for minimizing vascular complications after TAVI.

[Functional properties of smooth muscle cells in ascending aortic aneurysm]

Thoracic aortic aneurism (TAA) develops as a result of complex series of events that dynamically alter the structure and composition of the aortic vascular extracellular matrix (ECM). The main elements that alter the composition of aortic wall are smooth muscle cells (SMC). The purpose of the present work was to study alteration of smooth muscle cell functions derived from the patients with TAA and from healthy donors. As it is supposed that TAA associated with bicuspid aortic valve (BAV) and with tricuspid aortic valve (TAV) differ in their pathogenesis, we compared the SMC and tissues samples from BAV-, TAV-patients and healthy donors. We compared TAA patients' derived tissues and SMC to healthy donors' ones in several parameters: SMC growth, migration and apoptotic dynamics; metalloproteinase MMP2 and MMP9 activity (zymography) and elastin, collagen and fibrillin content (Western blot) in both tissue samples and cultured SMC. Proliferation ability of both BAV and TAV SMC was decreased comparing to donors cells; migration ability in scratch tests was increased in TAV-derived SMC comparing to donor cells. BAV-cells migration ability was not changed comparing to donor-SMC. Elastin content was decreased in TAA SMC comparing to donor cells whereas the content of fibrillin and collagen was not altered. At the same time elastin and collagen protein level was significantly higher in tissue samples of TAA patients comparing to donor-derived samples. SMS proliferation and migration ability is differently affected in TAV and BAV-associated TAA that supports the idea of different nature of these two groups of TAA. Also our data show that SMC functional properties are altered in TAA patients and these alterations could play a significant role in the disease pathogenesis.

Serum levels of matrix metalloproteinases 2 and 9 and TGFBR2 gene screening in patients with ascending aortic dilatation

Development of ascending aortic dilatation (AAD) in about 10 % of patients operated for aortic valve disease (AVD) is probably based on intrinsic pathology of the aortic wall. This may involve an abnormality in the process of extracellular matrix remodelling. The present study evaluated the serum levels of specific metalloproteinases (MMP-2 and MMP-9) and investigated the gene for transforming growth factor receptor 2 (TGFBR2) in 28 patients with AVD associated with AAD (mean age 60.6 years), in 29 patients (68.9 years) with AVD without AAD, and in 30 healthy controls (45.3 years). The serum levels of MMPs were determined by ELISA. Further, we focused on genetic screening of the TGFBR2 gene. Plasma MMP-2 concentrations were significantly higher in the groups of patients compared to the controls: median 1315.0 (mean 1265.2 ± SD 391.3) in AVD with AAD, 1240.0 (1327.8 ± 352.5) in AVD without AAD versus 902.5 (872.3 ± 166.2) ng/ml in the healthy controls, in both cases P < 0.001. The serum levels of MMP-9 were significantly higher in AVD with AAD patients [107.0 (202.3 ± 313.0)] and in AVD without AAD patients [107.0 (185.8 ± 264.3)] compared to the healthy controls [14.5 (21.2 ± 24.8) ng/ml], in both cases P < 0.001. No significant correlation was observed between plasma MMP-2 and MMP-9 and ascending aorta diameter. Genetic screening did not reveal any variation in the TGFBR2 gene in the patients. Measurement of MMP levels is a simple and relatively rapid laboratory test that could be used as a biochemical indicator when evaluated in combination with imaging techniques.

Reoperation on aortic disease in patients with previous aortic valve surgery

BACKGROUND

Aortic valve replacement (AVR) is a safe and effective method in the treatment of aortic valve diseases. This study aimed to increase the understanding on re-treatment of aortic diseases after aortic valve surgery through a retrospective analysis of 47 related cases.

METHODS

Forty-seven patients (38 males and 9 females) with previous aortic valve surgery have received reoperation on aorta from January 2003 to June 2012, and the mean interval time of re-intervention to aortic disease was 6 years ((6.0 ± 3.8) years). The secondary aortic surgery included aortic root replacement (14 cases), ascending aorta replacement (10 cases), aortic root/ascending aorta plus total arch replacement with stented elephant trunk implantation (21 cases), and total thoracoabdominal aorta replacement (2 cases). All these patients have received outpatient re-exams or follow-up by phone calls.

RESULTS

After the initial aortic valve replacement, patients suffered from aortic dissection (25 cases, 53%), ascending aortic aneurysm (12 cases, 26%) or aortic root aneurysm (10 cases, 21%). Diameter in ascending aorta increased (5.2 ± 7.1) mm per year and aortic sinus (3.3 ± 3.1) mm per year. The annual growth value of diameter in ascending aorta was higher in patients with rheumatic heart disease than that in Marfan syndrome (P < 0.05). All 47 patients have received reoperation on aorta. One patient died in operating room because aortic dissection seriously involved right coronary artery. Seven patients had renal insufficiency after operation; neurological complications occurred in 14 patients including 7 patients with stroke and the others with transient brain dysfunction. All patients were followed up, the mean survival time was (97.25 ± 17.63) months, 95% confidence interval was 55.24-73.33 months. Eight cases were died during follow-up and five-year survival rate was 83%.

CONCLUSION

To reduce the aortic adverse events after first aortic valve surgery, it is necessary to actively treat and strictly follow-up patients with previous aortic operation especially patients with Marfan syndrome and rheumatic heart disease.