Aortic valve repair for aortic stenosis in adults

Aortic cusp extension valvuloplasty for rheumatic aortic valve disease: midterm results

BACKGROUND

The surgical management of rheumatic aortic insufficiency in the young remains problematic owing to the drawbacks of prosthetic valve replacement at this age. In young foreign patients, for whom long-term anticoagulation therapy is unavailable, we have used a glutaraldehyde preserved autologous pericardium cusp extension technique to repair rheumatic aortic valve insufficiencies resulting from cusp retractions.

METHODS

From September 1992 to December 2000, 89 consecutive patients with a mean age of 16 +/- 5 years underwent triple pericardial aortic cusp extension valvuloplasty. Eighty patients had pure aortic insufficiency, 9 had mixed aortic disease. Twenty-nine patients (33%) had isolated aortic valve disease and 60 patients (69%) had combined aortic and mitral valve disease with significant tricuspid valve disease in 21 (24%). Aortic repair consisted of free edge aortic cusp extension using three rectangular strips of glutaraldehyde stabilized autologous pericardium. Twenty-nine patients (33%) underwent an isolated aortic repair, 39 patients (44%) underwent combined aortic and mitral procedures (34 mitral repairs, 3 mitral homografts, and 2 prosthesis replacements), and 21 patients (23%) underwent a triple valve repair.

RESULTS

The hospital mortality was 2.2%. Primary failure of the aortic repair requiring immediate reoperation occurred in 2 patients. During follow-up (mean of 62 +/- 22 months) 1 patient died and 7 underwent redo valvular surgery. At 5 years the actuarial survival rate was 96.4%, and 92.1% of the patients were free from redo valvular surgery. At 7 years 90% of the patients were free from valve-related complications. Among the 76 patients free from redo valvular surgery at follow-up, 6 had deterioration of the repair resulting in grade II aortic and mitral insufficiencies.

CONCLUSIONS

Our midterm results of glutaraldehyde stabilized autologous pericardial aortic cusp extension are encouraging and suggest that this technique should be considered as a viable alternative palliative procedure in a young rheumatic population, allowing for growth of the annulus and delaying to a less critical period the need for the lifelong anticoagulation therapy required for a prosthetic mechanical valve.

Lack of prevention of heart failure by serial electrical cardioversion in patients with persistent atrial fibrillation

OBJECTIVE

To investigate the occurrence of heart failure complications, and to identify variables that predict heart failure in patients with (recurrent) persistent atrial fibrillation, treated aggressively with serial electrical cardioversion and antiarrhythmic drugs to maintain sinus rhythm.

DESIGN

Non-randomised controlled trial; cohort; case series; mean (SD) follow up duration 3.4 (1.6) years.

SETTING

Tertiary care centre.

SUBJECTS

Consecutive sampling of 342 patients with persistent atrial fibrillation (defined as > 24 hours duration) considered eligible for electrical cardioversion.

INTERVENTIONS

Serial electrical cardioversions and serial antiarrhythmic drug treatment, after identification and treatment of underlying cardiovascular disease.

MAIN OUTCOME MEASURES

heart failure complications: development or progression of heart failure requiring the institution or addition of drug treatment, hospital admission, or death from heart failure.

RESULTS

Development or progression of heart failure occurred in 38 patients (11%), and 22 patients (6%) died from heart failure. These complications were related to the presence of coronary artery disease (p < 0.001, risk ratio 3.2, 95% confidence interval (CI) 1.6 to 6.5), rheumatic heart disease (p < 0.001, risk ratio 5.0, 95% CI 2.4 to 10.2), cardiomyopathy (p < 0.001, risk ratio 5.0, 95% CI 2.0 to 12.4), atrial fibrillation for < 3 months (p = 0.04, risk ratio 2.0, 95% CI 1.0 to 3.7), and poor exercise tolerance (New York Heart Association class III at inclusion, p < 0.001, risk ratio 3.5, 95% CI 1.9 to 6. 7). No heart failure complications were observed in patients with lone atrial fibrillation.

CONCLUSIONS

Aggressive serial electrical cardioversion does not prevent heart failure complications in patients with persistent atrial fibrillation. These complications are predominantly observed in patients with more severe underlying cardiovascular disease. Randomised comparison with rate control treatment is needed to define the optimal treatment for persistent atrial fibrillation in relation to heart failure.

The natural history of aortic valve disease after mitral valve surgery

OBJECTIVES

The present study evaluates the long-term course of aortic valve disease and the need for aortic valve surgery in patients with rheumatic mitral valve disease who underwent mitral valve surgery.

BACKGROUND

Little is known about the natural history of aortic valve disease in patients undergoing mitral valve surgery for rheumatic mitral valve disease. In addition there is no firm policy regarding the appropriate treatment of mild aortic valve disease while replacing the mitral valve.

METHODS

One-hundred thirty-one patients (44 male, 87 female; mean age 61+/-13 yr, range 35 to 89) were followed after mitral valve surgery for a mean period of 13+/-7 years. All patients had rheumatic heart disease. Aortic valve function was assessed preoperatively by cardiac catheterization and during follow-up by transthoracic echocardiography.

RESULTS

At the time of mitral valve surgery, 59 patients (45%) had mild aortic valve disease: 7 (5%) aortic stenosis (AS), 58 (44%) aortic regurgitation (AR). At the end of follow-up, 96 patients (73%) had aortic valve disease: 33 AS (mild or moderate except in two cases) and 90 AR (mild or moderate except in one case). Among patients without aortic valve disease at the time of the mitral valve surgery, only three patients developed significant aortic valve disease after 25 years of follow-up procedures. Disease progression was noted in three of the seven patients with AS (2 to severe) and in six of the fifty eight with AR (1 to severe). Fifty two (90%) with mild AR remained stable after a mean follow-up period of 16 years. In only three patients (2%) the aortic valve disease progressed significantly after 9, 17 and 22 years. In only six patients of the entire cohort (5%), aortic valve replacement was needed after a mean period of 21 years (range 15 to 33). In four of them the primary indication for the second surgery was dysfunction of the prosthetic mitral valve.

CONCLUSIONS

Our findings indicate that, among patients with rheumatic heart disease, a considerable number of patients have mild aortic valve disease at the time of mitral valve surgery. Yet most do not progress to severe disease, and aortic valve replacement is rarely needed after a long follow-up period. Thus, prophylactic valve replacement is not indicated in these cases.

Repair of nonsevere rheumatic aortic valve disease during other valvular procedures: is it safe?

OBJECTIVE

To investigate the long-term performance of aortic valve repair, we analyzed the results obtained in a 22-year period in patients who underwent repair of nonsevere rheumatic aortic valve disease during other valvular procedures.

METHODS

Fifty-three patients (mean 40 +/- 11.6 years of age) with predominant rheumatic mitral valve disease had concomitant aortic valve disease in association with serious tricuspid valve disease in 25 of them. Preoperatively, aortic valve disease was considered moderate in 47.2% of the patients and mild in 52.8%. All patients underwent reparative techniques of the aortic valve (free edge unrolling, 44; subcommissural annuloplasty, 40; commissurotomy, 36) at the time of mitral or mitrotricuspid valve surgery. The completeness of follow-up during the closing interval was 100%, with a mean follow-up of 18.8 years (range 8 to 22.5 years).

RESULTS

Hospital mortality rate was 7.5%. Of 49 surviving patients, 26 (53.1%) died during late follow-up. The actuarial survival curve including hospital mortality was 35.4% +/- 8.7% at 22 years. For patients who underwent mitral and aortic valve surgery, the actuarial survival curve at 22 years was 32.3% +/- 13%, whereas for patients who had a triple-valve operation the survival was 37.0% +/- 10.1% (p = 0.07). Twenty-five patients underwent an aortic prosthetic valve replacement. Actuarial free from aortic structural deterioration and valve-related complications at 22 years was 25.3% +/- 9.3% and 12.7% +/- 4.8%, respectively.

CONCLUSIONS

Long-term functional results of reparative procedures of nonsevere aortic valve disease in patients with predominant rheumatic mitral valve disease have been inadequate at 22 years of follow-up. According to these data, conservative operations for rheumatic aortic valve disease do not seem appropriate.

Aortic valve replacement after previous coronary artery bypass grafting

BACKGROUND

As the population ages, an increasing number of patients with previous coronary artery bypass grafting (CABG) will require subsequent aortic valve replacement (AVR). This study examined outcome of AVR after previous CABG and reviewed possible indications for valve replacement at the time of initial myocardial revascularization.

METHODS

Between March 1975 and December 1994, 145 patients had AVR after previous CABG. Sixty-three patients (43%) had their initial CABG elsewhere. Reoperation for AVR was the second cardiac procedure in 137 patients and the third in 8. Redo CABG with AVR was done in 66 (46%). There were 118 men and 27 women. The mean age at CABG was 64 +/- 7.9 years; for AVR this was 71 +/- 7.6 years.

RESULTS

In 2 young patients accelerated calcific aortic stenosis occurred in the setting of renal failure. Significant aortic stenosis did not appear to be addressed at initial CABG in 3 patients. Transaortic valvular gradient, as measured by cardiac catheterization, increased by 10.4 +/- 7.0 mm Hg/y. Twenty-four patients (16.6%) died. The mortality for AVR alone or for AVR + redo-CABG was 15 of 125 patients (12%). For patients having more complicated procedures, the mortality was 9 of 20 (45%). Nine patients (6.2%) suffered a postoperative cerebrovascular accident. Low preoperative ejection fraction measured by echocardiography, sternal reentry problems, complexity of operation, and prolonged cross-clamp and bypass times were significant factors associated with mortality. Age at AVR, interval between operations, the extent of underlying native coronary artery disease, the state of the previously placed bypass conduits, and methods of myocardial preservation were not significant predictors of operative mortality. On multivariate analysis there was only one significant value: prolonged cross-clamp time.

CONCLUSIONS

Aortic valve replacement after previous CABG is associated with a mortality that is higher than that seen after repeat CABG or repeat AVR. It seems prudent, therefore, to use liberal criteria for AVR in those patients who require coronary revascularization and who, at the same time, have mild or moderate aortic valve disease.

Management of asymptomatic mild aortic stenosis during coronary artery operations

BACKGROUND

Management of asymptomatic mild aortic stenosis at the time of coronary artery bypass grafting (CABG) remains controversial. We have retrospectively analyzed a cohort of patients requiring aortic valve replacement (AVR) subsequent to CABG and compared their operative morbidity and mortality with that of a group receiving CABG and AVR simultaneously at the first operation.

METHODS

Analysis is drawn from 28 patients who required AVR 8 +/- 4 years subsequent to CABG (group A) and 175 patients receiving AVR along with CABG at the primary operation (group B). Groups were similar with respect to age, sex, risk factors for cardiac disease, extent of coronary artery disease, left ventricular function, New York Heart Association class, aortic valve area, number of grafts, and size of prosthesis inserted.

RESULTS

Patients having AVR subsequent to CABG had a significantly prolonged aortic cross-clamp time and global myocardial ischemic time and incurred a twofold increase in operative mortality. The actuarial survival at 10 years was not significantly different between cohorts. In the 28 patients in group A, the aortic valve area during the period between operations decreased 0.05 mm2/y.

CONCLUSIONS

The operative mortality and morbidity of a second operation for AVR is high, but there is no significant difference in survival at 10 years. In at least a portion of patients having mild aortic stenosis at the time of CABG there will be progression of the stenosis necessitating reoperation at a later date.

Repair of insufficient bicuspid aortic valves

A technique for the repair of bicuspid aortic valves that includes resection of the flail segment of the prolapsing leaflet, annuloplasty, and resection of the raphe, when present, has been reported. To assess the efficacy of this technique in the repair of insufficient bicuspid aortic valves, the results in 72 consecutive patients were assessed. The mean age of the patients was 39 +/- 11 years; 94% were male. Fifty-six patients (78%) underwent isolated aortic valve repair, 9 (12.5%) underwent aortic and mitral valve repair, and 7 (9.7%) had other associated procedures. All patients underwent leaflet resection, including 35 (48%) at the raphe. The mean aortic occlusion time was 39 +/- 12 minutes. There were no operative deaths. The severity of aortic insufficiency, as assessed by Doppler echocardiography (graded from 0 to 4) preoperatively and intraoperatively and at late follow-up, was 3.6 +/- 0.6, 0.4 +/- 0.4, and 0.9 +/- 0.8, respectively, with a p value of < 0.0001 for the latter two values versus the preoperative one. There have been no postoperative deaths. Patients did not receive anticoagulation treatment and there were no strokes or episodes of endocarditis. Six patients have required reoperation; 3 underwent repeat repair. The Kaplan-Meier freedom from aortic valve reoperation probabilities at 12 and 24 months were 94% and 89.5%, respectively. We conclude that valvuloplasty for insufficient bicuspid aortic valves is technically safe, is associated with a low incidence of recurrent insufficiency, and has been associated with no other valve-related complications.

A new modification of debridement valvuloplasty for acquired aortic valve disease

A high speed electric rasp was used to remove fibrous thickening from the aortic valve in conjunction with aortic valve commissurotomy in ten patients. All patients had moderate rheumatic aortic valve disease combined with severe mitral valve disease, and were treated by mitral valve replacement and aortic valve repair. All patients survived the operative procedure. There were no deaths or complications during hospitalization related to the valve repair process. The transaortic valve gradient was relieved from an average of 21.0 +/- 8.6 mmHg to 5.6 +/- 4.0 mmHg (catheterization), and from moderate to less-than-mild stenosis (echocardiography). Aortic valve regurgitation was reduced from an average of 2.2+ to 0.7+ on a scale of 0 to 4+ (aortography), and from an average of 2.5+ to 1.1+ on a scale of 0 to 4+ (echocardiography). During the follow-up period, no patients were reoperated on because of aortic valve dysfunction. Follow-up echocardiographic study demonstrated that the transaortic pressure gradient and valvular regurgitation had not progressed, and immediate postoperative conditions were maintained. There were two late deaths not related to the aortic valve. One patient died of prosthetic valve endocarditis in the mitral prosthesis 14 months postoperatively, and the other of a cerebrovascular accident 21 months postoperatively. Based on these data, we believe that aortic valve repair with a high speed electric rasp can effectively relieve aortic stenosis, reduce valvular regurgitation, and provide an excellent hemodynamic result at early and mid-term follow-up.

Lunular hypertrophy and aortic valve disease

Cuspid malcoaptation secondary to abnormal hypertrophy in combination with stiffening involving the line of apposition (lunular hypertrophy) has not been recognized as a cause of aortic valve dysfunction. This entity was found in 50 adults (mean age, 62 years). Thirty-three had pure aortic valve insufficiency (> or = 3+, n = 13; < 3+, n = 20), 13 had mixed aortic valve insufficiency and stenosis (> or = 3+, n = 2; < 3+, n = 11), and 4 had pure aortic valve stenosis. Forty-one had a history of rheumatic heart disease and advanced mitral valve disease, and 7 had coronary artery disease. All underwent shaving of the hypertrophic protuberances, which in 26 patients constituted the entire aortic valve repair. In the remaining 24 patients, aortic valve repair included one or more additional procedures; there were 15 commissurotomies, 12 debridements of calcium deposits from the base of the cusps, and 5 cusp resuspensions. Concomitant mitral valve repair was performed in 26 patients, mitral valve replacement in 15, tricuspid valve repair in 11, coronary artery bypass grafting in 7, and repair of an ascending aortic aneurysm in 2. In 2 patients, the attempt to repair the aortic valve was unsuccessful, necessitating valve replacement. There were 5 operative deaths (10%), but none were related to aortic valve repair. Forty-three patients entered follow-up (mean, 56 +/- 57 months). Three patients (7%) suffered late recurrent aortic valve insufficiency (at 6, 48, and 72 months). The remaining 40 patients (93%) had trivial or no recurrent aortic valve dysfunction. The 6-year actuarial freedom from aortic valve-related problems was 92%.(ABSTRACT TRUNCATED AT 250 WORDS)

In vitro decalcification of aortic valve leaflets with the Er:YSGG laser, Ho:YAG laser, and the Cavitron ultrasound surgical aspirator

This study was designed to compare the efficacy of the erbium:yttrium-scandium-gallium-garnet (Er:YSGG) laser and the holmium:yttrium-aluminum-garnet (Ho:YAG) lasers in debriding calcium from freshly explanted aortic valve leaflets and to compare the Er:YSGG laser with the Cavitron ultrasonic surgical aspirator (CUSA). Aortic valve leaflets were freshly explanted from patients undergoing aortic valve replacement for aortic stenosis. Initially, 4 leaflets each were debrided with the Er:YSGG and the Ho:YAG lasers to attempt removal of calcium deposits while preserving the underlying integrity of the leaflets and minimizing thermal damage. The Er:YSGG laser was more effective in doing so with less thermal and photoacoustic damage when compared with the Ho:YAG laser. Twelve more leaflets each were then debrided with the Er:YSGG laser and the CUSA. The Er:YSGG laser again proved less injurious to the underlying leaflet. The CUSA-treated leaflets demonstrated shattering and disruption of adjacent tissue as well as collagen fiber exposure. These changes were not seen with the Er:YSGG laser. Because of these properties, the Er:YSGG laser merits further evaluation as a tool for aortic valvuloplasty procedures in selected patients with senescent calcific aortic stenosis.

Repair of asymptomatic aortic valve disease during other cardiac surgery

Repair of asymptomatic aortic valve disease was performed in 12 patients (9 female, 3 male, mean age 57.5 years) undergoing other cardiac surgery. Stenosis was the predominant aortic valve lesion in 7 (group A) with a mean gradient of 33.4 mmHg and regurgitation of mean grade 1.4 was predominant in 5 (group B). Cusp debridement +/- commissurotomy was performed in 9; commissural resuspension in 6 and repair of cusp perforation in 2. Perioperative transoesophageal echocardiography was used to assess the adequacy of repair in 4 patients. Prospective precordial echocardiographic follow-up is complete (mean 4.3 months). In group A there has been a significant reduction is peak aortic pressure gradient (33.4 vs 22.1 mmHg, p less than 0.05) and in cusp thickness (2.25 to 1.64 mm, p less than 0.05). In group B the degree of incompetence has improved in 3 of the 5 patients. Three patients have worsened valve disease following repair; in all these there was mixed valve disease of rheumatic origin. Aortic valve repair of asymptomatic disease during other cardiac surgery is a feasible technique which does not accelerate the disease process in the short term. Long-term follow-up is in progress to assess the prognosis of this preventive intervention.

Combined conventional mechanical and ultrasonic debridement for aortic valvular stenosis

Ultrasound decalcification of aortic valve stenosis was performed in 31 patients. There were 16 men and 15 women with a mean age of 71.03 +/- 9.6 years (range, 51 to 89 years). Each had severe calcific aortic stenosis with an aortic valve gradient greater than 40 mm Hg, aortic valve area (AVA) less than 0.6 cm2, and no serious insufficiency. Feasibility of aortic valve debridement was determined under direct vision. Intraoperative epicardial or transesophageal color Doppler two-dimensional echocardiography was used before and after the aortic valve debridement to evaluate aortic cusp motion and aortic regurgitation. Direct transseptal aortic valve gradient was measured on all patients before and after aortic valve debridement, and the AVA was determined. Aortic valve debridement was performed as the primary procedure in 17 cases and combined with other cardiac procedures in 14 patients. Preoperative aortic valve gradient was reduced from 72.5 +/- 22.5 mm Hg (range, 40 to 130 mm Hg) to 15.5 +/- 11.9 mm Hg (range, 2 to 50 mm Hg), and the average AVA of 0.41 +/- 0.10 cm2 (range, 0.22 to 0.63 cm2) was increased to 1.55 +/- 0.58 cm2 (range, 0.65 to 3.50 cm2) after ultrasound decalcification. There were two early deaths in octogenerian, high-risk patients, and two late deaths (6.45% early and 6.45% late mortality), none of them related to AVD. Postoperative follow-up included clinical evaluation and color Doppler echocardiography every 6 months. The aortic valve gradient was measured using a continuous-wave Doppler probe, and the AVA was calculated by the simplified continuity equation: AVA = aAOA x vLVOT/vAV.(ABSTRACT TRUNCATED AT 250 WORDS)