Unruptured, isolated giant aneurysm of the sinus of valsalva resulting from medial mucoid degeneration

We report a quite rare case of unruptured, isolated giant aneurysm of the sinus of Valsalva resulting from medial mucoid degeneration in a young adult woman. A 29-year-old Japanese female diagnosed as having an aneurysm of the sinus of Valsalva and severe aortic regurgitation with no clinical findings of Marfan's syndrome or Ehlers-Danlos syndrome. A modified Bentall's operation was performed successfully, and she was discharged with no complications. A pathological examination revealed marked medial mucoid degeneration of the aneurismal wall. In the literature, most giant aneurysms resulting from mucoid degeneration were found in African young adult females. In this case, there was much mucoid degeneration in the media with no focal destruction of elastic fibers, which was distinct from cystic medial necrosis in Marfan's syndrome. A careful follow-up will be required to detect any other aneurysmal formation in the future.

Echocardiographic and histological assessment of age-related valvular changes in normal rats

Aging is associated with morphologic and functional alterations of the rat's left ventricle. However, the time-course of valvular function and morphology in normal aging rats has not yet been studied. For this purpose, 30 male Wistar rats (318 +/- 5g, 10 weeks old) underwent serial echocardiograms for 58 weeks under sodium pentobarbital 50 mg/kg IP anesthetization followed by necropsy. Histopathology was also performed in two additional groups of 10 rats at 10 and 30 weeks of age. Regurgitations were considered as any retrograde flow on 2-D or M-mode color Doppler echocardiography. Tricuspid regurgitation was already found at 10 weeks of age and became more frequent with age. Pulmonary, mitral and aortic regurgitation was seldom observed at 10 weeks but became more frequent after 30 weeks. For the mitral and aortic valve, this was also associated with an increase in valvular thickness because of nodular or segmental myxoid leaflet changes. The severity of valvular regurgitations did not increase with age. In conclusion, aging leads to morphologic and functional valvular changes in normal rats. This is important when investigating models of valvular heart disease in small animals.

Natural history of aortic valve disease following intervention for rheumatic mitral valve disease

BACKGROUND AND AIM OF THE STUDY

A significant proportion of patients who require interventions for rheumatic mitral valve (MV) disease have coexisting aortic valve (AV) disease. To date, little is known of the natural history of AV disease in these patients.

METHODS

The details of a cohort of 200 patients (146 females, 54 males; mean age at MV intervention 30.3 +/- 9.9 years) with rheumatic heart disease were retrospectively reviewed. The patients had undergone an index MV intervention (either closed or balloon mitral valvotomy) or MV replacement between 1994 and 1996, and received long-term regular follow up examinations. The clinical and echocardiographic data at entry and at follow up were noted. Patients were allocated to two groups, based on whether the AV disease was absent (group I, n=98) or present (group II, n=102) at baseline. The AV disease was categorized as thickening only (group IIA), isolated aortic regurgitation (AR) (group IIB), or combined aortic stenosis (AS) and AR (group IIC). No patient had isolated AS at baseline.

RESULTS

The mean follow up period was 9.3 +/- 1.07 years; during which 10 patients in group I developed new AV disease, which included AV thickening only (n=2), trivial-mild AR (n=7) and mild AS with trivial AR (n=1). Of 16 patients in group IIA, 11 developed isolated AR, and one patient progressed to have mild AS and AR. Among 69 patients in group IIB, 22 (31.9%) developed AS, and all had either mild (n=8) or moderate (n=14) AR with mild AS. Group IIC included 17 patients with mild combined AV disease at baseline, except for moderate AS and moderate AR in one patient each. Among 16 patients with mild AS in group IIC, six progressed to moderate AS and two to severe AS. AR became moderate in 10 patients and severe in one patient. The two patients who progressed to severe AS requiring AV replacement had mild AS at baseline. No patient who developed new combined AV disease had lesions with severity more than mild AS or moderate AR. On logistic regression analysis of the variables predisposing to progression of AV disease, such as age, gender, history of rheumatic fever (RF) and recurrence, and interval from RF episode to symptom onset, only the initial AV gradient was identified as being statistically significant (beta coefficient 0.528, SE = 0.17, p < 0.0001).

CONCLUSION

Patients with no or mild AV disease at the time of MV intervention rarely develop severe AV disease, and seldom require AV surgery over the long-term follow up. The presence of mild AS at baseline is predictive in the minority of cases where AV disease will progress relatively more rapidly.

Aortic valve regurgitation in a patient affected by KBG syndrome

The KBG syndrome is a very rare condition characterized by developmental delay, short stature, distinct facial dysmorphism, macrodontia of the upper central incisors and skeletal abnormalities. Associated congenital heart defects have been described in 9% of patients. Herein is described a case of aortic root dilatation with significant regurgitation in a young patient affected by KBG syndrome. Surgical inspection showed a dilated aortic annulus, slightly dilated aortic sinuses, a tricuspid valvb with slightly thickened cuspal margins and central regurgitation. Histological examination showed a fibrous hyaline involution of the valvular leaflets. To the authors' knowledge, this is the first reported case of KBG syndrome affected by aortic root dilatation with severe regurgitation. Morphology of the aortic valve leaflets was relatively normal, but the annulus was dilated in the absence of any history of rheumatic fever, hypertension, connective tissue or rheumatic systemic diseases. The unusual findings in this young patient raised questions regarding the as-yet unexplained etiopathogenesis of the KBG syndrome.

Aortic valvar involvement in patients undergoing closure of ventricular septal defect via the pulmonary trunk

BACKGROUND

To determine how often the aortic valve is involved in doubly-committed ventricular septal defect in a surgical series, and when to intervene to minimize aortic valvar impediments.

METHODS

The defect was surgically closed in 415 patients via the pulmonary trunk, age at operation ranging from 2 months to 76 years old. In infants, pulmonary hypertension or pulmonary high flow was the exclusive indication. Any progressive deformity of the aortic leaflet or aortic regurgitation was an alternative principal indication in older children or adolescents. No additional manoeuvres were employed for the aortic root unless aortic regurgitation is more than slight. Otherwise, the aortic valve was repaired or replaced. When the sinus of Valsalva was significantly deformed or ruptured, the structure was surgically restored.

RESULTS

Significant aortic regurgitation or the ruptured sinus of Valsalva was increasingly found beyond the paediatric age. Bacterial endocarditis was seen in 8% of adults or adolescents. Silent herniation of the aortic leaflet was not uncommon after 4 years old, seen in more than 40% of patients. Need of aortic valvar repair was rare before 2 years old, and in approximately 10% between 2 and 15 years old. Freedom from reoperation was 89% at 10 years and 78% at 25 years after aortic valvar repair, and 91% and 84%, respectively, after replacement, versus 100% and 99.4%, respectively, after no additional valvar procedure.

CONCLUSION

Aortic valvar involvement was rare, and ventricular septal defect was closed without impediments, before 2 years old. Surgery should be arranged before any additional aortic valvar manoeuvre is needed.

Traumatic aortic valve rupture after a high-speed motor vehicle accident

The case is reported of a 32-year-old male who sustained an aortic valve injury after a high-speed traffic accident. Several non-cardiac concomitant injuries were present, none of which was life-threatening. Cardiac surgery was performed on day 2 due to a grade III aortic valve insufficiency. As a large tear of the non-coronary cusp was evident, together with several concomitant injuries, valve replacement was considered to be the most optimal treatment in this case.

Papillary Fibroelastoma of Aortic Valve: Diagnosis and Surgical Management

Papillary fibroelastoma (PFE) is a rare and benign cardiac tumour that mainly affects the valves. This tumour has the potential to cause serious life threatening thromboembolic complications. Herein, we describe successful excision of an aortic valve papillary fibroelastoma. The importance of valve sparing tumour resection is emphasised.

Toward predictable repair of regurgitant aortic valves: a systematic morphology-directed approach to bicommissural repair

OBJECTIVES

Our purpose was to investigate a new approach to bicommissural repair of regurgitant aortic valves.

BACKGROUND

Repair of regurgitant aortic valves is not widely accepted, but interest is increasing, particularly for bicuspid valves. We hypothesize that a systematic, segmental approach to morphology and corresponding morphology-directed repair will improve decision making and success.

METHODS

From December 2001 to July 2007, a systematic surgical approach to valve analysis and bicommissural repair was applied prospectively to 63 consecutive patients with pure aortic valve regurgitation, mean age 40 +/- 12 years. Cusp, commissure, and root morphologies were analyzed sequentially by direct inspection. Each abnormality was corrected by corresponding morphology-directed repair procedures. Retrospectively, 2 echocardiographic indexes--of tissue pliability (change in systolic to diastolic area) and coaptation deficiency (conjoint and reference cusp heights vs. "annulus" diameter)--were developed to evaluate repairability.

RESULTS

Forty-two (67%) valves were repaired and 21 (33%) replaced. Regurgitation was related primarily to cusp (prolapse, restriction) and commissure (splaying) morphology; root pathology was less important. Morphology-directed repair included cusp maneuvers in all, commissural maneuvers in 71%, and root procedures in 33%. Restriction and cusp tissue deficiency limited repairability. Echocardiography reflected this in greater tissue pliability of successfully repaired valves compared with replaced ones (conjoint cusp 61 +/- 16% vs. 34 +/- 17%; reference cusp 65 +/- 16% vs. 42 +/- 16%; p = 0.0001) and less coaptation deficiency (1.06 +/- 0.24 for repaired and 1.27 +/- 0.19 for replaced valves; p = 0.002).

CONCLUSIONS

Systematic segmental analysis of morphology and a logical morphology-directed surgical approach facilitate aortic valve repair. Initial application of this paradigm suggests sufficient mobile cusp tissue is a key determinant of repairability.

No greater incidence or worsening of cardiac valve regurgitation with somatostatin analog treatment of acromegaly

CONTEXT

Excess GH and IGF-I in acromegaly are associated with reduced life expectancy due to cardiovascular complications.

OBJECTIVE

The objective of the study was to investigate the prevalence, incidence, and severity of cardiac valve regurgitation before and after somatostatin-analog treatment in acromegaly.

DESIGN

This was a prospective, observer-blinded, multicenter, 12-month study.

SETTING

The study was conducted at 33 specialist centers.

PATIENTS

The study population consisted of 225 adult patients with acromegaly without significant cardiac valve abnormalities or prior valve-replacement surgery, matched for age, sex, and center/country/study.

INTERVENTIONS

Interventions included initiation/continuation of lanreotide (n = 107) or octreotide treatment (n = 118), tailored for optimal disease control.

MAIN OUTCOME MEASURES

Relative risk of new/worsening regurgitation in any valve at 12 months compared with baseline, was measured.

RESULTS

At baseline, almost 80% of patients had some degree of cardiac valve regurgitation, although none was severe. The risk of developing new/worsening regurgitation in any valve at 12 months was nonsignificant and similar for the cohorts [adjusted odds ratio 0.86; 95% confidence interval (CI) 0.41-1.82; P = 0.694; relative risk 1.04; 95% CI 0.67-1.60; risk difference 0.01; 95% CI -0.13 to 0.16]. For 54% of patients, the severity of regurgitation stayed the same during the study. At baseline, significant valve regurgitation occurred in 18% of patients (lanreotide cohort) and 13% (octreotide cohort) and at 12 months in 18% of each cohort.

CONCLUSIONS

The incidence of valve regurgitation did not change over 12 months of treatment with somatostatin analogs, and most cases were physiologic or mild in severity. There was no significant difference between somatostatin analogs in the risk of developing new/worsening valve regurgitation or significant regurgitation after 1 yr.

Aortic involvement in ankylosing spondylitis

Patients with ankylosing spondylitis (AS) may develop cardiovascular manifestations ranging from asymptomatic forms to life threatening conditions. The most important cardiovascular manifestation of AS is aortitis, which frequently involves the aortic root and the ascending aorta leading to valvular insufficiency. The extension of the subaortic fibrotic process into the interventricular septum may cause conduction abnormalities that represent the second common cardiovascular manifestations occurring in AS patients. More rarely, an involvement of coronary arteries and of thoracic and abdominal aorta could be present. Rheumatologists managing AS patients should carefully consider, both in late and in early phases of the disease, the occurrence of an aortic involvement in order to promptly administer adequate treatment.

Does minimal-access aortic valve replacement reduce the incidence of postoperative atrial fibrillation?

As the most common sequela of cardiac valvular surgery, atrial fibrillation (AF) has an important impact on postoperative morbidity. Minimal-access aortic valve replacement (AVR), with purported benefits on operative outcomes, has emerged as an alternative to conventional AVR. We used meta-analysis to determine whether minimal access influences the incidence of postoperative AF after AVR. Further, we sought first to evaluate via sensitivity analysis the impact of any differences and to identify the sources of possible heterogeneity between studies; second, we sought to evaluate any indirect effect of minimal-access AVR on other surrogate outcomes related to postoperative AF. We identified 10 studies from 26 comparative randomized and nonrandomized reports that documented the primary outcome of interest: new-onset AF. Overall meta-analysis showed no significant difference between minimal-access and conventional AVR in the incidence of postoperative AF (odds ratio, 0.85; 2,262 patients; P=0.24; 95% confidence interval, 0.66-1.11). Nor were there any apparent differences in surrogate outcome measures of intensive care unit stay, total length of stay, or stroke among studies that displayed a notable difference in AF incidence between groups. Sensitivity analysis that included only high-quality studies similarly showed no significant difference in the incidence of AF and further showed several intraoperative variables as potential sources of heterogeneity between studies. Therefore, minimal access may not have a significant effect on postoperative AF. Future randomized studies must take into account the potential sources of heterogeneity identified here to better demonstrate any differences between the 2 approaches in the onset of AF.

Prevalence of Unsuspected and Significant Mitral and Aortic Regurgitation

OBJECTIVE

We sought to determine the prevalence of unsuspected, pre-existing valvular regurgitation in a large, heterogeneous population of patients referred for an echocardiogram.

METHODS

The echocardiograms of 6851 consecutive individuals without suspected valve disease were reviewed. Regurgitant severity was graded using a clinical composite of published methods and multiple logistic analyses were used to model various clinical variables.

RESULTS

The overall prevalence of moderate or greater mitral regurgitation (MR) was 11.7% in male patients and 12.5% in female patients. For mild or greater aortic insufficiency (AI), the prevalence was 18.9% in male patients and 19.7% in female patients. Both MR and AI increased exponentially as a function of age. Female sex predicted MR, but AI was sex neutral. Regurgitant severity increased with decreasing ejection fraction and body mass index, a history of hypertension, the presence of left ventricular hypertrophy, and valvular abnormalities.

CONCLUSIONS

The prevalence of unsuspected MR and AI is substantial, increases exponentially with age, and is predicted by commonly used clinical variables.

Incidental mobile aortic valve lesion: a case of aortic valve fenestration

The case is reported of a 72-year-old patient with a mobile aortic valve lesion discovered incidentally by echocardiography performed in the setting of coronary artery bypass graft (CABG) surgery. Definitive identification of this lesion was not possible by transthoracic echocardiography or transesophageal echocardiography alone. Pathological examination of the excised aortic valve led to a diagnosis of aortic valve fenestration (AVF) bridging strand rupture. AVFs are common, usually asymptomatic, and of little clinical significance. However, rupture of a bridging strand can produce aortic insufficiency and require surgical correction.

Valve structure and survival in septuagenarians having aortic valve replacement for aortic stenosis (+/-aortic regurgitation) with versus without coronary artery bypass grafting at a single US medical center (1993 to 2005)

The purpose of this study was to determine the effect of simultaneous coronary artery bypass grafting (CABG) and the influence of valve structure on both early and late survival in septuagenarians having aortic valve replacement (AVR) for aortic stenosis (AS) (with or without aortic regurgitation). We analyzed valve structure in 424 septuagenarians having AVR for AS from 1993 through 2005 at Baylor University Medical Center, including 254 (60%) with and 170 (40%) without simultaneous CABG. Of the 424 patients, 8 (2%) had a congenitally unicuspid aortic valve, 179 (42%), a congenitally bicuspid aortic valve, 235 (55%), a 3-cuspid valve, and in 2 patients (1%) the valve structure was indeterminate. Survival data were available in 418 of the 424 patients: 23 (5.5%) died within 30 days of AVR and 9 other patients from 31 to 60 days after AVR (7.7% 60-day mortality). Sixty-day mortality was not affected by congenital valve abnormality (unicuspid/bicuspid 8.5% vs tricuspid 7.0%). In contrast, late survival (up to 13-year follow-up) was affected by valve structure: it was longer in the unicuspid/bicuspid valve structure group than in the tricuspid valve structure (hazard ratio 0.54, 95% confidence intervals 0.36 to 0.81). The hazard ratio was estimated after adjusting for concomitant CABG. In conclusion, aortic valve structure affected late, but not early survival in septuagenarians undergoing AVR for AS.

Correction of Aortic Insufficiency With an External Adjustable Prosthetic Aortic Ring

PURPOSE

Less invasive, valve-sparing options are needed for patients with aortic insufficiency (AI). We sought to evaluate the feasibility of reducing AI with an external adjustable aortic ring in an ovine model.

DESCRIPTION

To create AI, five sheep underwent patch plasty enlargement of the aortic annulus and root by placement of a 10 x 15 mm pericardial patch between the right and noncoronary cusps. An adjustable external ring composed of a nylon band was fabricated and placed around the aortic root.

EVALUATION

Aortic flow, aortic pressure, and left ventricular pressures were measured with the ring loose (off) and tightened (on). Mean regurgitant orifice area decreased by 86%, from 0.07 +/- 0.03 cm2 (ring loose, off) to 0.01 +/- 0.00 cm2 (ring tightened, on) [p < 0.01]. The regurgitant fraction decreased from 18 +/- 4% to 2 +/- 1% [p < 0.01]. The ring did not significantly affect stroke volume and aortic pressure.

CONCLUSIONS

An ovine model of aortic root dilatation resulting in acute AI has been developed. In this model, application of an external, adjustable constricting aortic ring eliminated AI. An aortic ring may be a useful adjunct in reducing AI secondary to annular dilatation.

Valve structure and survival in octogenarians having aortic valve replacement for aortic stenosis (+/- aortic regurgitation) with versus without coronary artery bypass grafting at a single US medical center (1993 to 2005)

The purpose of this study was to determine the effect of simultaneous coronary artery bypass grafting (CABG) and valve structure on both early and late survival in octogenarians having aortic valve replacement (AVR) for aortic stenosis (AS) (with or without aortic regurgitation). Although a number of reports are available in octogenarians having AVR for AS, none have described aortic valve structure. Most have limited numbers of patients and few have described late results. We analyzed survival and valve structure in 196 octogenarians having AVR for AS from 1993 to 2005 at Baylor University Medical Center, including 118 (60%) with and 78 (40%) without simultaneous CABG. Sixty-day mortality, which was identical to 30-day mortality, was similar (10% and 11%) in the groups with and without simultaneous CABG. Unadjusted analysis of late survival (up to 13 year follow-up) was not affected by gender (male vs female), aortic valve structure (bicuspid vs tricuspid) or preoperative severity of the AS (transvalvular peak pressure gradient > 50 vs < or =50 mm Hg), or by performance of CABG. Of the 196 patients, 54 (28%) had a congenitally bicuspid aortic valve, and 142 (72%) had a tricuspid aortic valve. In conclusion, gender, valve structure, preoperative severity of the AS, or performance of simultaneous CABG did not effect survival in octogenarians having AVR for AS.

An autopsy case report of annuloaortic ectasia with cardiac tamponade ruptured from an aneurysm of the right Valsalva sinus

Annuloaortic ectasia (AAE) is a clinicopathologic condition with primary or secondary dilatation of the aortic annulus and aneurysm of the proximal thoracic aorta, leading to aortic regurgitation. We herein report an autopsy case of a Japanese 57-year-old male with AAE who died of a cardiac tamponade rupture from the sinus of the right coronary. The wall of the aortic root, particularly that of the sinus of the right coronary Valsalva, underwent extensive fibrosis with loss or fragmentation of the elastic lamina in the medial layer and perforation directly into the pericardial space. The adventitia of the proximal aorta to the aortic arch was diffusely fibrotic with both acute and chronic hemorrhage and chronic inflammatory infiltrate. However, the ascending aortic media was largely intact, except for focal laminar necrosis at the center of the medial layer; no medial cystic necrosis, laminar necrosis, or mesoaortitis/panaortitis was present in the thoracic or abdominal aorta, nor in the main aortic branches, which was suggestive of Takayasu disease and giant cell arteritis. Thus, this patient was diagnosed to have idiopathic AAE with sustained peri-aortic hemorrhage, and he finally died of a cardiac tamponade resulting from an aneurysmal rupture.

A clinicopathological study on aortic valves in children

In order to investigate the clinicopathological characteristics of aortic valve disease in children, all the native surgically excised aortic valves obtained between January 2003 and December 2005 were studied macroscopically and microscopically. The patients' medical records were reviewed and the clinical information was extracted. According to preoperative echocardiography, intraoperative assessment, and postoperative pathology, combined with clinical symptoms and signs, aortic valve diseases were divided into three categories: aortic stenosis (AS), aortic insufficiency (AI), and aortic stenosis with insufficiency (AS-AI). The etiology was determined according to the macroscopic, microscopic and clinical findings. The results showed that among 70 aortic valves, patient age ranged from 6 to 18 years, with a mean of 15.4 years, and there were 56 boys and 14 girls (male: female=4:1). Forty-four children only had pure aortic valve disease, and the other 26 children had aortic valve disease associated with other heart valve diseases. There were 5 cases of AS (7.14%), 60 cases of AI (85.71%) and 5 cases of AS-AI (7.14%). The causes were congenital aortic valve malformation (32 cases, 45.71%), rheumatic disease (28 cases, 40%), infective endocarditis (7 cases, 10%), Marfan syndrome (2 cases, 2.86%), and undetermined (1 case, 1.43%). It was concluded that the common causes of aortic valve disease in order of frequency in children were congenital aortic valve malformation, rheumatic disease, infective endocarditis, and Marfan syndrome. AI was more common in children with aortic valve disease. Compared with adult patients, congenital bicuspid aortic valve in children was often AI. Histologically, the leaflets of congenital bicuspid aortic valve were mainly myxomatous, fibrosis and calcification less seen. AI was frequently found in rheumatic disease, mostly associated with other heart valve diseases. Macroscopic and microscopic examinations together with clinical information, echocardiographic findings and operative details were important in evaluating the etiology of aortic valve disease.

Role of inflammation in nonrheumatic, regurgitant heart valve disease. A comparative, descriptive study regarding apolipoproteins and inflammatory cells in nonrheumatic heart valve disease

BACKGROUND

Nonrheumatic aortic stenosis is the predominant cause of heart valve surgery in the Western world. Aortic and mitral regurgitation account for a lesser amount of the heart valve surgery. During the 1990s, inflammatory cell infiltrates have been demonstrated in nonrheumatic stenotic aortic valves. These findings suggest an inflammatory component in the pathogenesis of nonrheumatic aortic valve stenosis. However, nonrheumatic regurgitant aortic and mitral valves have not been investigated in this respect. The aim of this study was to compare nonrheumatic regurgitant aortic and mitral valves with stenotic aortic valves regarding the presence of T lymphocytes, macrophages, apolipoprotein B, and apolipoprotein A-I.

METHODS

Valve specimens were obtained from 42 patients referred to hospital for surgery because of significant heart valve disease. From these patients, 29 aortic stenotic valves, 9 aortic regurgitant, and 6 mitral regurgitant valves, all nonrheumatic, were obtained for the study. Fourteen valves collected from subjects undergoing clinical/medicolegal autopsy were used as control. In order to identify mononuclear inflammatory cells and apolipoproteins, sections were investigated with immunohistochemical analyses and then categorized semiquantitatively.

RESULTS

Regurgitant and control valves showed a significantly lower degree of inflammatory cell infiltrate and a lower degree of apolipoprotein deposition as compared to stenotic aortic valves.

CONCLUSIONS

The signs of inflammation seen in nonrheumatic aortic stenosis are not prominent features in the nonrheumatic, regurgitant valves. This is consistent with the multi-factorial pathogenesis of these conditions.

Acute aortic insufficiency after blunt chest trauma: a case report

Traumatic aortic valve regurgitation is a rare complication of non penetrating blunt chest trauma which usually requires surgical management. We describe a case of a 21 year old man with blunt chest trauma who was diagnosed with aortic valve regurgitation due to rupture of the right coronary cusp one month after falling from a high place. Rupture of aortic valve cusp was treated successfully with aortic valve replacement.

A classification system for the bicuspid aortic valve from 304 surgical specimens

OBJECTIVE

In general, classification of a disease has proven to be advantageous for disease management. This may also be valid for the bicuspid aortic valve, because the term "bicuspid aortic valve" stands for a common congenital aortic valve malformation with heterogeneous morphologic phenotypes and function resulting in different treatment strategies. We attempted to establish a classification system based on a 5-year data collection of surgical specimens.

METHODS

Between 1999 and 2003 a precise description of valve pathology was obtained from operative reports of 304 patients with a diseased bicuspid aortic valve. Several different characteristics of bicuspid aortic valves were tested to generate a pithy and easily applicable classification system.

RESULTS

Three characteristics for a systematic classification were found appropriate: (1) number of raphes, (2) spatial position of cusps or raphes, and (3) functional status of the valve. The first characteristic was found to be the most significant and therefore termed "type." Three major types were identified: type 0 (no raphe), type 1 (one raphe), and type 2 (two raphes), followed by two supplementary characteristics, spatial position and function. These characteristics served to classify and codify the bicuspid aortic valves into three categories. Most frequently, a bicuspid aortic valve with one raphe was identified (type 1, n = 269). This raphe was positioned between the left (L) and right (R) coronary sinuses in 216 (type 1, L/R) with a hemodynamic predominant stenosis (S) in 119 (type 1, L/R, S). Only 21 patients had a "purely" bicuspid aortic valve with no raphe (type 0).

CONCLUSIONS

A classification system for the bicuspid aortic valve with one major category ("type") and two supplementary categories is presented. This classification, even if used in the major category (type) alone, might be advantageous to better define bicuspid aortic valve disease, facilitate scientific communication, and improve treatment.

The Relationship Between Neo-Aortic Root Dilation, Insufficiency, and Reintervention Following the Ross Procedure in Infants, Children, and Young Adults

OBJECTIVES

The purpose of this study was to describe the relationship between neo-aortic root size, neo-aortic insufficiency (AI), and reintervention at mid-term follow-up.

BACKGROUND

Data on neo-aortic valve function and growth after the Ross procedure in children are limited.

METHODS

A total of 74 of 119 Ross patients from January 1995 to December 2003 had > or =2 follow-up echocardiograms at our institution and were included. Neo-aortic dimensions were converted to z-scores and modeled over time. Kaplan-Meier analysis was used to assess freedom from neo-aortic outcomes, and predictors were identified through multivariate analysis.

RESULTS

Median age at Ross was 9 years (range 3 days to 34 years). Over 4.7 years (range 3 months to 9.3 years) follow-up, there was disproportionate enlargement of the neo-aortic root (z-score increase of 0.75/year [p < 0.0001]). Neo-AI progressed > or =1 grade in 36% of patients and > or =2 grades in 15%. Nine patients (12%) had neo-aortic reintervention at 2.0 years (range 1.1 to 9.5 years) after the Ross procedure owing to severe neo-AI (n = 7), neo-aortic root dilation (n = 1), and neo-aortic pseudoaneurysm (n = 1). At 6 years after the Ross procedure, freedom from neo-aortic reintervention was 88%. Freedom from neo-aortic root z-score >4 was only 3% and from moderate or greater neo-AI was 60%. Longer follow-up time was associated with neo-aortic root dilation (p < 0.0001). Prior ventricular septal defect (VSD) repair predicted neo-AI (p = 0.02) and reintervention (p = 0.03). Prior aortic valve replacement (p = 0.002) also predicted neo-AI. Neo-aortic root dilation was not associated with neo-AI or reintervention.

CONCLUSIONS

At mid-term follow-up after the Ross procedure, neo-aortic root size increases significantly out of proportion to somatic growth, and neo-AI is progressive. Prior VSD repair and aortic valve replacement were associated with neo-AI and reintervention.

Aortic valve sparing and restoration with autologous pericardial leaflet extension is an effective alternative in pediatric patients

We sought to evaluate the durability and efficacy of aortic valve repair with autologous pericardial leaflet extension in children. From 1997 through 2006, 54 patients underwent aortic valve repair with autologous pericardial leaflet extension at a mean age 8.4 +/- 5.3 years (range, 0 to 17 years). Primary endpoints were early and late mortality, freedom of reoperation, and late valve function. Thirty-day and late mortality were one in 54 (1.8%) and two in 53 (3.7%), respectively. There were seven re-operations in six patients, and one patient was re-operated twice. Re-operations were re-repairs in four cases and replacements in three cases. The mean interval between original repair and re-operation was 4.3 +/- 2.5 years. Mean severity grade of post-repair intraoperative aortic regurgitation (AR) was 0.3 (range, grade 0 to 4). At late follow-up, 87.7% of all patients had no AR or only a trace (grade 0-1). Seven patients (12.9%) had mild AR (grade 2-3) and none severe (grade 4); 94.4% had no aortic stenosis or only a trace (grade 0-1), 5.5% had mild (grade 2-3), and none severe. This technique delays potential complications from other approaches to valve pathology and allows a normal growth of the aortic annulus. Although, our data show that this technique has a low mortality and morbidity, more studies are needed to elucidate durability and late outcome.

Endothelial nitric oxide synthase in bicuspid aortic valve disease

BACKGROUND

The pathogenesis of ascending aortic dilatation in the presence of a bicuspid valve is discussed controversially. Recent experimental evidence suggests that the expression of endothelial nitric oxide synthase (eNOS) may have an influence on aortic valve anatomy and aneurysmal dilatation of the aorta. We investigated the relationship among eNOS expression, valve anatomy, and aortic dilatation in the human aortic wall.

METHODS

Aortic wall specimens from 39 patients with aortic valve disease (bicuspid, n = 17; tricuspid, n = 22) were studied. The functional aortic valve pathology was regurgitation (n = 22), stenosis (n = 10), and combined aortic valve disease (n = 7). The specimens were obtained intraoperatively from the aortic wall above the noncoronary sinus. The eNOS protein expression was quantified by western blot analysis after immunoprecipitation from tissue lysates. The eNOS levels were analyzed for correlation with valve anatomy and ascending aortic diameters.

RESULTS

The eNOS protein expression of aortic endothelial cells was significantly lower in patients with bicuspid as compared with tricuspid aortic valves (4,615 +/- 489 vs 6,275 +/- 442; p = 0.017). In bicuspid aortic valves there was a significant correlation between eNOS expression and maximum aortic diameter (r = -0.530; p = 0.029) or sinotubular diameter (r = -0.520; p = 0.033). In patients with tricuspid aortic valves, no significant correlation between aortic size and eNOS expression was found.

CONCLUSIONS

Our results show an association between eNOS levels and aortic valve anatomy as well as aneurysm formation in patients with bicuspid aortic valves.

Clinical and echocardiographic assessment of the Medtronic Advantage aortic valve prosthesis: the Scandinavian multicentre, prospective study

OBJECTIVE

The aim of this report is the prospective, multicentre evaluation of clinical results and haemodynamic performance of the Medtronic Advantage aortic valve prosthesis.

METHODS

From April 2001 to June 2003, 166 patients (male:female 125:41; mean (SD) age 61.8 (11.8) years) received an aortic advantage valve prosthesis. Complete cumulative follow-up was 242.7 patient-years (maximum 3.2; mean 1.6 years). Postoperatively, patients underwent early (within 30 days) and 1 year transthoracic echocardiography.

RESULTS

30 day mortality was 2.4% (n = 4). Kaplan-Meier estimates of freedom from complications and linearised rates were as follows: 96.9 (1.6)% survival; 94.7 (1.3)% (2.06 patients/year) thrombo-embolism; 99.4 (0.6)% (0.4 patients/year) bleeding; 98.8 (0.9)% (0.8 patients/year) non-structural valve dysfunction; 98.8 (0.9)% (0.8 patients/year) reoperation. Valvular mean pressure gradients ranged from 16 (3) mm Hg for size 19 to 7 (2) mm Hg for size 27 and the corresponding effective orifice areas ranged from 1.2 (0.25) to 3.2 (0.66) cm(2). In all, left ventricular mass significantly decreased (p<0.001) and fractional shortening increased (p<0.001) from postoperative to 1 year echocardiography.

CONCLUSIONS

Haemodynamic performance and early clinical results of Medtronic advantage in the aortic position were satisfactory and comparable with those of other bileaflet valves in current clinical use.

Early changes in bioprosthetic heart valves following ventricular assist device implantation

Heart valve bioprostheses can undergo early post-implantation changes, including pannus and thrombus, which may be hastened by the presence of a left ventricular assist device (LVAD). We report the case of a 21 year-old male who was diagnosed with dilated cardiomyopathy and severe aortic insufficiency, and had his aortic valve replaced with a #25 BioPhysio valve (currently in clinical trials--Edwards Life Sciences, Irvine, CA, USA). His symptoms of congestive heart failure continued to worsen, and he received a Novacor LVAD (WorldHeart, Oakland, CA, USA), and subsequently, an orthotopic heart transplantation. The relevant pathologies of the heart, BioPhysio valve (in place for 4.5 months), and Novacor device are presented.

Prevalence and clinical correlates of isolated mitral, isolated aortic regurgitation, and both in adults aged 21 to 35 years (from the CARDIA study)

Aortic regurgitation (AR) and mitral regurgitation (MR) can result in serious clinical complications and death. The physiologic and clinical correlates of AR and MR in a free-living young adult population, however, have not been well defined. The prevalence and correlates of AR and MR were investigated in Coronary Artery Risk Development in Young Adults (CARDIA), a multicenter National Heart, Lung, and Blood Institute study of 4,352 men and women aged 21 to 35 years who had 2-dimensionally directed M-mode echocardiographic and spectral and color Doppler examinations. Isolated MR by color Doppler was detected in 10.4% (90.4% with trivial or mild severity). Isolated AR by color Doppler was present in 0.8% (37.7% with mild severity). Combined AR and MR occurred in 0.5%. There was no association between body mass index and the prevalence or severity of MR or AR. Left ventricular mass was greater in subjects with isolated AR (mean +/- SD 172 +/- 49 g) than in those with MR (155 +/- 48 g) and greater in both groups than in subjects without MR and AR (148 +/- 44 g). AR was associated with increased aortic root diameter, whereas subjects with isolated MR and those with AR and MR had increased left atrial dimensions and greater left ventricular internal dimensions. In conclusion, MR and AR detected by color Doppler echocardiography are relatively uncommon in a healthy young adult population, but both are associated with evidence of increased left ventricular dimensions and mass.

One year hemodynamic performance of the Perimount Magna pericardial xenograft and the Medtronic Mosaic bioprosthesis in the aortic position: a prospective randomized study

We compared the hemodynamic performance of the Edwards Perimount Magna (EPM) and the Medtronic Mosaic (MM) bioprostheses according to the patient aortic annulus diameter (AAD). Eighty-six patients undergoing aortic valve replacement were prospectively assigned to receive either an EPM-valve (n=43) or an MM-bioprosthesis (n=43). Randomization was performed after measuring the AAD and patients were grouped according to their AAD: <22 mm (n=12), 22-23 mm (n=31) and >23 mm (n=43). Echocardiographic assessment was performed one year postoperatively. The mean AAD (EPM 23.9+/-2.1 mm vs. MM 23.6+/-2.3 mm) and mean valve size implanted (EPM 22.6+/-2.1 mm vs. MM 23.3+/-2.1 mm) were comparable in both groups. The EPM-group showed significantly lower mean gradient (EPM 10.2+/-3.2 mmHg vs. MM 17.1+/-8.2 mmHg) and larger effective orifice area (EOA) (EPM 1.99+/-0.4 cm(2) vs. MM 1.69+/-0.4 cm(2), P<0.0001). The EPM-valve was superior with respect to mean pressure gradient and EOA in all AAD. This difference was statistically significant in AAD of 22-23 mm (EPM 9.6+/-3.0 mmHg vs. MM 18.2+/-8.6 mmHg; EPM 1.82+/-0.3 cm (2) vs. MM 1.51+/-0.2 cm (2)) and >23 mm (EPM 9.9+/-3.1 mmHg vs. MM 14.2+/-5.6 mmHg; EPM 2.18+/-0.4 cm(2) vs. MM 1.94+/-0.5 cm(2)). Patient-prosthesis mismatch was present in 26.8% (MM) vs. 6.9% (EPM) of the patients (P=0.01). When the same AAD is taken as a reference, the EPM-valve was hemodynamically superior to the MM-bioprosthesis. The EPM-prosthesis significantly reduced the incidence of PPM.

Sutureless Stented Aortic Valve Implantation Under Direct Vision: Lessons From a Negative Experience in Sheep

BACKGROUND AND AIM OF THE STUDY

Percutaneous aortic valve replacement has been proposed as a valid alternative to surgery in selected cases; however, it still has many problems. As a less radical preliminary step, we implanted a balloon-expandable stented aortic valve under direct vision in sheep.

METHODS

Under cardiopulmonary bypass (CPB) and through a transverse aortotomy, an aortic valve mounted in a long tubular balloon-expandable stent was implanted in six acute sheep. The leaflets were not excised and no anchoring sutures were used between stent and native annulus. Epicardial, two-dimensional color Doppler echocardiography was used to assess the function of the stented valve followed by macroscopic inspection at necropsy.

RESULTS

Direct visualization of the entire annulus when the collapsed, valved stent was placed within the aortic root was difficult in all animals. Valve deployment took less than 1 minute. The surgical procedure resulted in major complications in all cases. Migration (3/6), paravalvular leak (2/6), mitral conflicts resulting in mitral regurgitation (1/6), and coronary ostia obstruction (2/6) were the major events at the origin of the failure. Only three animals could be weaned from CPB but did not recover enough to survive the procedure.

CONCLUSIONS

Sutureless implantation of a stented aortic valve through standard CPB and aortotomy is far more complex than expected. Changes in stent design and surgical approach are indicated.

Aortic valvular insufficiency and postductal aortic coarctation with small aorta syndrome: one-stage surgical management using extra anatomic bypass through median sternotomy

A 30-year-old man who had undergone repair for coarctation of the thoracic aorta at age 7 and mitral valve annuloplasty at age 9 was admitted for shortness of breath and claudication of both lower legs. The pre-operative angiogram showed severe aortic regurgitation, moderate coarctation of the thoracic aorta beyond the left subclavian artery, a degree of hypoplasia of the infrarenal abdominal aorta, and total occlusion of both external iliac arteries. Aortic valve replacement, ascending-to-bilateral femoral arterial bypass, and end expanded polytetra fluoro ethylene (ePTFE) graft-to-descending aorta bypass was performed via a median sternotomy. Ascending-to-descending aortic bypass via the posterior pericardium allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation.

Valve-sparing aortic root replacement with repair of leaflet prolapse after Ross operation

The need for reoperation remains a principal limitation of the Ross procedure and most commonly includes replacement of the neo-aortic valve. Valve-preserving aortic root replacement has recently evolved into an increasingly accepted treatment modality for patients with neo-aortic valve regurgitation. Leaflet prolapse, however, may be present, making composite replacement the most frequent choice. Alternatively, valve preservation may be combined with correction of leaflet prolapse. We describe the use of a valve-sparing procedure with correction of leaflet prolapse in a patient with progressive dilatation of the pulmonary autograft and severe regurgitation of the neo-aortic valve.

Clinical and Morphologic Features of the Congenitally Unicuspid Acommissural Stenotic and Regurgitant Aortic Valve

Five adults, aged 30-75 years, are described with stenotic and regurgitant unicuspid acommissural aortic valves. Because none of these patients had clinical, echocardiographic or hemodynamic evidence of mitral valve disease, a case is made that these valves were congenitally malformed and not the result of an acquired condition.

Left Ventricular Wall Stress in Patients With Severe Aortic Insufficiency With Finite Element Analysis

BACKGROUND

Severe aortic insufficiency (AI) with preserved left ventricular (LV) function may be associated with a long asymptomatic period and unpredictable course on medical therapy. Since myocardial wall stress is closely related to both pathologic cardiac remodeling and ultimately to LV decompensation, a more accurate description of regional wall stress may improve our ability to appropriately manage these patients. The objective of this study was to define differences in instantaneous global and regional three-dimensional end-systolic maximum principal stress (ESS) between normal patients and patients with AI, both before and after aortic valve replacement (AVR) using magnetic resonance imaging (MRI) and finite element analysis (FEA).

METHODS

Magnetic resonance imaging was performed on 20 normal volunteers and 14 patients with moderate to severe AI with normal systolic function (ejection fraction: 57 +/- 0.6) before and after AVR. Finite element analysis was utilized to estimate global and regional ESS.

RESULTS

Both global (p < 0.001) and regional (p < 0.001 in all segments) ESS were significantly higher in the preoperative AI patients when compared with their postoperative values and normal controls. Postoperative ESS was significantly lower than the normal controls (p = 0.002).

CONCLUSIONS

Three-dimensional regional and global end-systolic LV wall stress can be determined by MRI and finite element analysis. Values of ESS in patients with chronic AI were elevated prior to AVR and normalized after AVR. This method may have considerable potential as a noninvasive, clinically applicable index of regional LV geometry and function that may help with the serial evaluation of patients with AI.

Successful aortic valve replacement for infective endocarditis in a patient with severe liver cirrhosis

Patients with liver cirrhosis are prone to the development of severe complications associated with high mortality rates after major surgery, especially cardiac surgery using cardiopulmonary bypass (CPB). We report the case of a 65-year-old man with acute infective endocarditis and aortic valve perforation, complicated by non-cardiac liver cirrhosis (Child-Pugh class B). After careful preoperative anti-inflammatory and systemic support treatment, we successfully treated infective endocarditis-induced aortic valve perforation by performing aortic valve replacement (AVR).

Ascending aorta dilatation in aortic valve disease: morphological analysis of medial changes

We investigated whether and how the severity of medial degeneration lesions varies along the circumference of the dilated intrapericardial aorta. Two groups of aortic wall specimens, respectively harvested in the convexity and concavity of ascending aorta in 72 patients undergoing surgery for dilatation of the intrapericardial aorta associated with aortic valve disease, were separately sent for pathology, morphometry, and ultrastructural examination. Cystic medial necrosis, fibrosis, and elastic fiber fragmentation were classified into three degrees of severity; their mean degree and morphometric findings in the convexity and in the concavity specimens were compared by paired t-test. Correlation between echocardiographic degree of aortic dilatation and severity of medial degeneration was assessed separately for each of the two groups of specimens. Morphologically, medial degeneration was found in all cases; a higher mean degree was found in the convexity group (2.39 +/- 0.58 vs 1.44 +/- 0.65 in the concavity group; P < 0.001). At morphometry normal smooth muscle cells in the convexity specimens were significantly reduced (P = 0.007); the length (P = 0.012) and number (P = 0.009) of elastic fibers reduced and increased, respectively. Moreover, in the convexity specimens a significantly smaller amount of smooth muscle cells and an increase of immunohistochemical labeling of apoptosis-associated proteins in the subintimal layer of the media was noticed. Correlation between aortic ratio and medial degeneration degree was significant in the convexity group (P < 0.001), but not in the concavity group (P = 0.249). Scanning electron microscopy analysis confirmed morphological results and allowed us to better distinguish the early pathological cavities from the microvessels, which were in the outer media in normal aorta and ubiquitous in aortitis or atherosclerosis. Electron transmission microscopy analysis showed changes in the extracellular matrix and smooth muscle cells, and these changes increased from the intima to the adventitial layer of the media. In dilated intrapericardial aorta, medial degeneration changes and expression of apoptosis-associated proteins are more marked in the ascending aorta convexity, likely due to hemodynamic stress asymmetry. Ultrastructural findings allow us to distinguish the early medial changes not yet evident on light microscopy.

Severity of Mitral and Aortic Regurgitation as Assessed by Cardiovascular Magnetic Resonance: Optimizing Correlation with Doppler Echocardiography

BACKGROUND

Cardiovascular magnetic resonance (CMR) is widely recognized as a non-invasive gold standard for quantification of ventricular volumes. In addition, it is an emerging diagnostic modality for clinical evaluation of mitral regurgitation (MR) and aortic regurgitation (AR). CMR facilitates accurate quantitation of regurgitation volumes and regurgitant fraction, but referring physicians are often more comfortable with qualitative measures, and few data exist for correlation of qualitative CMR regurgitation severity with that obtained by more conventional qualitative Doppler echocardiography. Because patients with AR and MR may commonly be assessed by both echocardiography and CMR modalities, consistency between qualitative gradient of regurgitation severity is important for follow-up. Therefore, we sought to define the CMR regurgitant fractions that best correlate with qualitative mild, moderate, and severe regurgitation by color Doppler echocardiography.

METHODS AND RESULTS

Data from 141 consecutive patients (age 53 +/- 15 yr; 43% female) with contemporary (median, 31 days) CMR and echocardiographic data, including 107 regurgitant valves and 70 normal valves, were compared. Thresholds were developed on an initial cohort of patients with 55 regurgitant valves, and subsequently tested on a later cohort of patients with 52 regurgitant valves. Regurgitation fraction (RF) limits that optimized concordance of CMR and echo severity grades were similar for MR and AR and were: mild < or = 15%, moderate 16-25%, moderate-severe 26-48%, severe > 48%.

CONCLUSIONS

The current study provides simple qualititative threshold grades for MR and AR severity that allows for standardized reporting of regurgitation severity by CMR and excellent correlation with clinical echocardiography.

Ventricular septal defect closure in right coronary cusp prolapse and aortic regurgitation complicating VSD in the outlet septum: which treatment is most appropriate?

BACKGROUND

There is currently not a standardized technique for the sizing and shaping of surgical closure of the ventricular septal defect (VSD) patch in patients with right coronary aortic cusp prolapse and aortic regurgitation (AR) complicating VSD in the outlet septum.

METHODS

Forty-six VSD patients who had aortic valve prolapse were divided into groups DC (direct closure, n=19), and SPC (small patch closure, n=27). Preoperative and postoperative echocardiography with Doppler color flow interrogation was performed on all patients.

RESULTS

In the DC group, among seven patients who had aortic valve prolapse but no AR preoperative, one patient developed AR during postoperative follow-up period. In the remaining 12 patients who had mild AR associated with aortic valve prolapse prior to the procedure, AR was diminished in four and unchanged in six patients. However, AR was aggravated in two patients who required further operations for AV repair or replacement. In the SPC group, among the eight patients who had no preoperative AR, AR progressed in one patient postoperatively. In the remaining 19 patients who had mild AR, AR was diminished in 15 and unchanged in four. The outcome from the operative procedure was significantly better in the SPC group than DC group with mild preoperative AR (chi(2)=7.82; P<0.05).

CONCLUSIONS

Small patch closure for this type of VSD is safer and more reliable in improving mild AR than that of direct closure, especially in patients with mild AR.