Aortic valve repair in dominant aortic regurgitation

Beginning and development of surgery for acquired valvular heart disease in Japan

The initiation and development of surgery for acquired valvular heart disease in Japan was reviewed. The first series of attempts at closed valvular surgery were performed in 1951-1952 by collaboration between the brothers Tohru and Shigeru Sakakibara in patients with pulmonary or mitral stenosis. During the popularization of closed valvular surgery, open heart surgery under direct vision was successfully performed by Shigeru Sakakibara with cooling of the body in 1954 and by using cardiopulmonary bypass (CPB) in 1956. With the development of CPB and artificial heart valves, closed valvular heart surgery was replaced by open surgery, which expanded rapidly during the 1960s and 1970s. Along with the serial introduction and improvement of mechanical vales thereafter, bioprosthetic valves were also introduced and were adopted for certain patients. Use of bioprosthetic valves in the aortic position exceeded 50% in 2005, along with the increase of elderly patients. Although trials of mitral valve plasty for mitral regurgitation were first done during the 1950s to 1960s in Japan, interest in valve plasty only increased during the late 1970s. Considering the patient's quality of life and the long-term results, mitral valve plasty became the major procedure (exceeding valve replacement) from 2004. In 2002, the Guideline for Surgical and Interventional Treatment of Valvular Heart Disease was published by a joint committee of the relevant academic societies, and it has made an important contribution to improving surgical outcomes.

Leaflet Suspension and Subvalvular Annuloplasty in Aortic Valve Prolapse

We have utilized the combined techniques of subvalvular annuloplasty and leaflet suspension since 1999 to repair prolapsing aortic valves. We reviewed our short-term results to assess perioperative echocardiographic changes and repair durability. Nineteen patients (15 men and 4 women; mean age, 60.7 years) underwent this operation between July 1999 and June 2002. All were interviewed to establish their latest functional status, reoperation and survival rates. After a mean follow-up of 40.1 months, all patients were alive and in New York Heart Association functional class I. The echocardiographic grade of aortic regurgitation decreased from 3.2 preoperatively to 1.6 at follow-up. Left ventricular end-diastolic dimension shortened significantly from 6.2 to 5.2 cm. Left ventricular end-systolic dimension decreased from 4.1 to 3.3 cm. Annulus size was also significantly less at 2.2 cm from 2.5 cm preoperatively. At 48 months, freedom from reoperation was 88.9% ± 7.4%. The follow-up was 100% complete. Repair of a prolapsing aortic valve with leaflet suspension and subvalvular annuloplasty is a good procedure and the short-term results are satisfying.

Intermediate-term results of repair for aortic, neoaortic, and truncal valve insufficiency in children

OBJECTIVE

Repair of aortic valve insufficiency is difficult, and durability is relatively unknown in children. This study evaluates the intermediate-term results of repair of the systemic semilunar valve, including the native aortic valve, neoaortic valve (anatomic pulmonary), and truncal valve.

METHODS

We reviewed the records of 54 children (aged 2 days to 18 years) who underwent repair of the functional aortic valve for moderate or greater insufficiency from 1991 to 2005. Valve anatomy was tricuspid aortic in 26 patients, bicuspid aortic in 11 patients, tricuspid neoaortic in 9 patients, bicuspid neoaortic in 1 patient, and truncal valve in 7 patients. Multiple surgical techniques were used in most of the 54 patients, including leaflet plication in 17, leaflet repair in 15, commissuroplasty in 32, pericardial cusp augmentation in 8, and sinus of Valsalva reduction in 3.

RESULTS

There was 1 early death and no late deaths. Actuarial freedom from reoperation was 68% at 5 years and 58% at 10 years. Freedom from aortic valve replacement was 82% at 5 years and 73% at 10 years. Duration of cardiopulmonary bypass was the most significant risk factor for reoperation with multivariate analysis. Of the 40 patients who have not undergone reoperation, 37 have had follow-up echocardiograms with the latest study (4.5 +/- 4.2 years) demonstrating trace to 1+ insufficiency in 23 patients, 1 to 2+ in 12 patients, 2 to 3+ in 1 patient, and 3 to 4+ in 1 patient.

CONCLUSION

Repair of the insufficient systemic semilunar valve offers acceptable 10-year freedom from reoperation and functional results, and should be considered for most children.

Aortic valve repair for aortic insufficiency in adults: a contemporary review and comparison with replacement techniques

In evaluating the goal of aortic valve preservation, there have been 11 reports of large series of aortic valve repair for aortic insufficiency in adults published in recent years. We sought to analyze the validity of these methods and compare them to published results for bioprosthetic valves, pulmonary autografts, and aortic homografts. From 1990 to 2002, 761 adult aortic valve repairs were reported. Perioperative morbidity ranged from 3.6 to 23% (mean 14%), early mortality 0-8% (mean 3.6%), and late mortality 0-8% (mean 2.8%). The 5- and 10-year freedom from reoperation rates for repair were 89 and 64%. Although early results are good, long-term analysis suggests that, as a group, the durability of repair is unclear. Patients with rheumatic valvular disease appear to have an increased incidence of recurrence and repair failure. Although suture line dehiscence continues to be both an early and late complication with repair, the long-term morbidity and mortality is low and valve repair may be an option in carefully selected patients. However, the inability to break down the results by techniques does not allow for a definitive conclusion. Further subanalysis is necessary as larger series are reported. Proponents must attempt to separate successful from unsuccessful techniques. Aortic valve repair is a technique in evolution.

Combined aortic and mitral valve repair

Six patients, median age 63.3 years (range, 54 to 68 years), underwent concomitant mitral and aortic valve repair from January 2000 to August 2001. Surgical reports and general clinical data were reviewed retrospectively. All patients had degenerative valvular disease, although one patient also had annuloaortic ectasia. There were no surgical complications. The 30 day survival rate was 100%, and the New York Heart Association classification score improved from 2.2 (range, 1 to 2) preoperative, to 1.0 (all patients) postoperatively (p = 0.03) As measured by intraoperative transesophageal echocardiography, the left ventricular end-diastolic diameter decreased from 6.0 cm (range, 5.4 to 6.3 cm) to 4.7 cm (range, 4.0 to 5.2 cm) and the left ventricular end-systolic diameter decreased from 3.7 cm (range, 3.4 to 4.1cm) to 3.1 cm (range, 2.9 to 3.7 cm). No patient developed endocarditis, thromboembolism or hemorrhage. There was no valve related morbidity during a 1 year follow up. Double valve repair is an acceptable alternative to valve replacement in selected patients with some types of valvular disease. Longer term follow up with greater numbers of patients is needed.