[Surgical treatment of congenital bicuspid aortic valve in 73 patients aged over 50 years]

OBJECTIVE

To summarize the clinical characteristics, surgical management and postoperative complications in patients with congenital bicuspid aortic valve (CBAV) over 50 years of age.

METHODS

From January 2009 to September 2011, 73 CBAV patients aged 51-76 years (mean 61.8∓0.73 years) were treated in our center. Except for 1 patient who underwent Bentall surgery and another having Wheat surgery, all the patients received aortic valve replacement (AVR), including 7 with double (mitral and aortic) valve replacement (DVR), 6 with mitral valvular plasty, 11 with tricuspid valvular plasty, 8 with coronary artery bypass graft implantation, 1 with aortic-left ventricular tunnel repair, 1 with atrial maze ablation, and 1 with left atrial thrombosis removal.

RESULTS

Two patients died after the surgery, with a perioperative mortality rate of 2.7%. The cardiopulmonary bypass time was 78-217 min (mean 131.9 ∓6.0 min) with an aortic blocking time of 56-158 min (mean 88.2 ∓4.8 min) and total postoperative ICU time of 23.0-647.4 h (mean 97.9∓10.5 h). The postoperative complications included low heart output syndrome in 5 cases, bleeding in 4 cases, wound debridement in 4 cases, and hemodialysis due to acute renal failure in 1 case. The left ventricular end diastolic diameter reduced significantly after the surgery (52.6∓1.7 vs 43.2∓1.0, P=0.001). No significant changes were detected in the left ventricular ejection fraction (62.3∓2.5 vs 65.5∓1.3, P=0.257).

CONCLUSION

Thorough preoperative examination, preoperative risk factor assessment, timely perioperative interventions, careful evaluation of patients' tolerance of surgery, and prevention of surgical complications are essential to decrease the perioperative mortality in elderly patients with CBAV.

[Dysfunction of aortic mechanical prosthetic valve - difficulties with establishing diagnosis]

We present 3 cases of the patients with aortic prosthetic valve dysfunction. These cases reflect difficulties with establishing a proper diagnosis which is crucial in choosing the way and urgency of treatment.

[Papillary fibroelastoma of the aortic valve in a 67-year-old patient after myocardial infarction]

We present a case of a 67-year-old female patient with diagnosed papillary fibroelastoma (PFE) of the aortic valve. Eight months before the tumour discovery a non-ST segment elevation myocardial infarction without essential coronary artery restriction was diagnosed. The tumour was excised (during the aortotomy under cardiopulmonary bypass at systemic hypothermia) without any aortic valve injury. The main symptoms of PFE along with diagnostic techniques and treatment were described.

Huge ascending aortic pseudoaneurysm 13 years after Bental surgery with tube graft

Pseudoaneurysms of the ascending aorta are rare, disastrous complications of surgical manipulation of the aorta and its surroundings. They frequently require emergency surgical intervention due to a high risk of sudden rupture and hemorrhage. We herein present the case of a pseudoaneurysm (130 mm in diameter) of the ascending aorta with a compressive effect on the left atrium and right coronary artery ostium at the site of a tube graft implanted 13 years previously via the Bental procedure in a 34 year-old man. The susceptibility of these pseudoaneurysms to silently increase in size through the years leads to a delayed diagnosis, with an increased risk of rupture and mortality, necessitating long-term follow-ups with a view to detecting it in the initial stages, when it is easier to perform surgical or endovascular interventions with a lower risk of mortality.

Successful repair of aortic insufficiency due to valvular fenestration

A case of dynamic aortic insufficiency due to valvular fenestration is described. The defect was successfully repaired with an Ivalon patch to close the fenestration plus the surgical creation of a bicuspid aortic valve.

DIAGNOSTIC VALUE OF THE FIRST AND SECOND DERIVATIVES OF THE ARTERIAL PRESSURE PULSE IN AORTIC VALVE DISEASE AND IN HYPERTROPHIC SUBAORTIC STENOSIS

The brachial arterial dp/dt was continuously computed by means of an electronic differentiating circuit in 117 patients and 23 normal subjects. The peak dp/dt averaged 1092±372 (S.D.) mm. Hg/sec. in 32 patients with idiopathic hypertrophic subaortic stenosis, 547±94 mm. Hg/sec. in six patients with discrete subvalvular subaortic stenosis, 811±185 mm. Hg/sec. in 23 normal subjects, 358±85 mm. Hg/sec. in 29 patients with valvular aortic stenosis, 724±212 mm. Hg/sec. in 25 patients with combined aortic stenosis and regurgitation, and 1736±530 mm. Hg/sec. in 24 patients with pure aortic regurgitation. It is suggested that the elevated peak dp/dt seen in patients with hypertrophic stenosis is due to the absence of obstruction to ejection early in systole. In contrast, patients with valvular and discrete subvalvular stenosis, who exhibit fixed obstruction to outflow throughout ventricular systole, had a peak dp/dt that tended to be lower than normal. Calculation of the second derivative (d 2 p/dt 2 ) of the arterial pressure pulse provided even better separation of the various groups of patients studied. The analyses of the dp/dt and of the d 2 p/dt 2 of the brachial artery pressure pulse afford a simple and reliable assessment of the nature and location of left ventricular outflow obstruction and are helpful in the differentiation of valvular aortic stenosis, combined stenosis and regurgitation, and pure aortic regurgitation.

THE CHANGING PATTERN OF THE AORTIC VALVE REPAIR

The changes and improvements in the surgical treatment of aortic valve disease in 296 patients, who were operated on between 1953 and 1965, are illustrated and discussed in general terms. Several of the early techniques, such as transventricular dilation, insertion of a homograft aortic valve in the descending thoracic aorta, fabric replacement of one cusp or the entire valve, and ice-chip arrest of the heart, are now obsolete. Total replacement with a ball-valve prosthesis or an aortic valve homograft while the coronary arteries are perfused with blood is the currently popular technique. The results of a hemodynamic follow-up study two years after surgery are also included.