Indications and limitations of aortic valve reconstruction

Aortic valve repair for the treatment of rheumatic aortic valve disease: a systematic review and meta-analysis

Valvuloplasty for rheumatic aortic valve disease remains controversial. We conducted this study to explore whether aortic valvuloplasty is appropriate for the rheumatic population. A comprehensive search was conducted, and 7 eligible retrospective studies were identified from PubMed, Embase, Medline and Cochrane (up to April 7, 2020) according to the inclusion and exclusion criteria. The data for hospital mortality, 5-year survival, 5-year reoperation, aortic insufficiency grade (AIG) and aortic valve gradient (AVG) were extracted by 2 independent reviewers and were analysed to evaluate the safety and availability of aortic valvuloplasty for rheumatic patients. The heterogeneity of the results was estimated using the Q test and I² statistics. The fixed pooling model was used when I² ≤ 50%; otherwise, the random pooling model was selected. 7 articles with 418 patients were included. The pooled hospital mortality, 5-year survival and 5-year reoperation rates were 3.2%, 94.5% and 9.9%, respectively. The heterogeneities of the weighted mean differences (WMD) values of the AIG and AVG between preoperation and postoperation were extremely high (I² = 81.5%, p < 0.001 in AIG, I² = 97.6%, p = 0.003 in AVG). Subgroup analysis suggested that the AIG and AVG were improved by 3.03 grades (I² = 0%, p < 0.001) and 3.16 mmHg (I² = 0%, p < 0.001) in the European group, respectively. In the Asian group, the AIG and AVG were improved by 2.57 grades (I² = 0%, p < 0.001) and 34.39 mmHg (I² = 0%, p < 0.001), respectively. Compared with the values at discharge, the AIG was increased by 0.15 grades (I² = 0%, p = 0.031) and the AVG was still decreased by 2.07 mmHg (I² = 0%, p = 0.031) at the time of follow up. Valvuloplasty is safe and effective to treat rheumatic aortic insufficiency and stenosis, and the duration of maintenance required to improve stenosis was longer than that of insufficiency.

Long-term durability of bicuspid aortic valve repair: a comparison of 2 annuloplasty techniques

OBJECTIVES

To compare long-term outcomes after bicuspid aortic valve (BAV) repair utilizing the Cabrol annuloplasty versus valve sparing Reimplantation technique.

METHODS

From 1996 to 2018, 340 consecutive patients underwent BAV repair. Eighty underwent Cabrol annuloplasty and 189 underwent Reimplantation. Exclusion criteria were re-repairs (n = 6), active endocarditis (n = 4), no annuloplasty (n = 41) and ring or suture annuloplasty (n = 20). We compared both groups for survival, reoperations, valve related events and recurrent severe aortic regurgitation (AR > 2+). Inverse probability weighting (IPW) was used to balance the 2 groups. Cox regression analysis was used to identify outcome predictors.

RESULTS

After weighting, pre- and intraoperative characteristics were similar between groups, except for aorta replacement techniques and operative time, which was longer in the Reimplantation group (P < 0.001). At 12 years, overall survival was similar between groups (IPW: Cabrol 97 ± 2% vs Reimplantation 94 ± 3%, P = 0.52). Freedom from reoperation and freedom from AR > 2+ were significantly lower in the Cabrol group (reoperation IPW: 69 ± 9% vs 91 ± 4%, P = 0.004 and AR > 2+ IPW: 71 ± 8% vs 97 ± 2%, P < 0.001). The Reimplantation technique was the only independent predictor of reoperation (hazard ratio 0.31; confidence interval 0.19-0.7; P = 0.005).

CONCLUSIONS

In this study, comparing 2 annuloplasty strategies for BAV repair, we found statistically significant differences in long-term durability favouring the Reimplantation technique, and no differences in overall survival. The results support our current strategy of Reimplantation technique and repair of AR in patients with BAV. Cabrol annuloplasty is obsolete and should be generally abandoned in patients undergoing BAV repair for AR.

Endoscopy in aortic valve repair: does it worth it?

Background

Aortic valve repair (AVR) is a technically challenging procedure. Usually, the repaired valve is checked after weaning from cardiopulmonary bypass (CPB). We aimed to evaluate intraoperative and clinical outcomes of AVR patients in whom intraoperative aortic root endoscopy was applied.

Methods

The present study was a retrospective single-center study. An autoclavable video-scope was used to evaluate aortic valve. During endoscopy, crystalloid cardioplegia was administered to pressurize the aortic root. Primary endpoints were: need for Re-CPB after weaning from bypass and early postoperative aortic valve regurgitation. Secondary endpoints included: 30-day mortality and freedom from aortic regurgitation/reoperation during follow-up.

Results

A total of 66 consecutive patients who underwent AVR (05/2014-03/2017) were evaluated. Patients mean age was 53.5±14.5 years and 74.2% were male. Seventy-three percent of the patients were in New York Heart Association (NYHA) functional class III/IV. The main underlying aortic valve pathology was aortic valve regurgitation in 83.3%, 9.1% aortic stenosis and combination of both in 7.6%. A tricuspid or bicuspid aortic valve was observed in 48.5% and 43.9%, respectively, whereas 7.6% showed a functional unicuspid aortic valve. Intraoperative results revealed endoscopy as a helpful tool, where second time cross-clamp was avoided in most (58, 87.9%) of patients. Thirty-day mortality was 3.0%. During follow-up (28±10 months), 2 patients required re-operation due to recurrent aortic valve regurgitation.

Conclusions

The present analysis showed, that intraoperative aortic valve endoscopy is a helpful tool to evaluate AVR before weaning from bypass. This easy-to-use tool gives real-time information about the intraoperative result and might provide additional guidance to achieve optimal results after AVR.

Precise moulded autologous pericardial configurations for aortic cusp reconstruction

OBJECTIVES

In order to facilitate surgical repair of complex aortic cusp deformities and restoration of aortic valve competence, new moulds were developed to shape the glutaraldehyde-treated autologous pericardium into precise cusp-like configurations that can be used in aortic cusp reconstruction.

METHODS

The new moulds embodied the natural geometry of single aortic cusps, and a series of moulds were made available to correspond with all potential aortic cusp sizes. Aortic valve reconstruction using moulded autologous pericardial cusps was performed in 2 patients (both males, aged 14 and 19 years) with large outlet-type ventricular septal defects, extensive deformation of prolapsed right coronary cusps and severe aortic valve insufficiency. In each patient, the diseased right aortic cusp was excised and was replaced by a moulded autologous pericardial cusp that equalled the size of adjacent undiseased native cusps.

RESULTS

Excellent coaptation with adjoining native aortic cusps could be readily observed and intraoperative transoesophageal echocardiography confirmed satisfactory aortic valve repair (aortic insufficiency <1+ and low-transvalvular gradients). Follow-up transthoracic echocardiography confirmed that aortic valve function remained stable in both patients 2 years postoperatively.

CONCLUSIONS

Initial clinical experience indicated that constructing geometrically perfect cusp-like configurations was uncomplicated and implantation of the moulded autologous pericardial cusps restored adequate aortic valve competence. We believe that the simplicity and reproducibility of this approach may assist in the dissemination of aortic cusp reconstruction procedures.

Aortic Valve Reconstruction: Midterm Results from Central Chest Hospital

From September 1994 to September 1999, 50 patients underwent successful aortic valve reconstruction. Four were lost to follow-up, there were 2 early and 2 late deaths. The remaining 35 males and 11 females (mean age, 39.1 years) were followed up for 1 to 61 months (mean, 30.75 months). Most had rheumatic disease (27), the others had infective endocarditis (16) or degenerative disease (3). There was isolated aortic valve disease in 22 cases, double-valve disease in 16, triple-valve disease in 7, and 1 other. Preoperative aortic regurgitation was severe in most cases and the mean ejection fraction was 55.3%. Surgical procedures included subcommissural annuloplasty (14), cusp thinning (13), commissurotomy (10), and free-edge unrolling (10). Cusp extension with autologous pericardium was performed in 9 patients and aortic valve replacement with autologous pericardium in 22. Nine patients needed aortic valve replacement at a mean of 15.8 months postoperatively. The other 33 patients experienced marked improvements in aortic valve function. Aortic valve reconstruction is recommended in selected patients but reoperation remains an important problem. Long-term follow-up is needed to assess the role of this operation.

Aortic Valve Repair: Techniques and Results

Twenty-two patients underwent aortic valve repair for rheumatic aortic regurgitation (AR) from April 1991 to August 1993. Six patients were female. Thirteen patients required mitral valve repair and 3 patients underwent mitral valve replacement. One patient required tricuspid valve repair in addition to aortic and mitral valve reconstruction.

There was 1 early death and 5 early failures. Of these, 3 were considered unsatisfactory valves for repair and replaced after an attempt at repair. In 2 others, the aortic valve was replaced within a week of initial attempt at repair. There were 2 late failures, 1 of which had aortic valve replacement and another who is awaiting reoperation. Fourteen of 22 patients have been judged to have good results clinically and echocardiographically.

Aortic cusp extension valvuloplasty: repair with an extracellular patch

Introduction

The proportion of valve repair procedures is increasing in experienced centers. The aim of the study was to assess the clinical and echocardiographic outcomes after aortic valve reconstruction with a novel surgical technique.

Material and methods

The study group consisted of 30 patients (23 male and 7 female) at a mean age of 35 ± 14 years. In patients with aortic root aneurysm the reimplantation or Florida sleeve technique was used. A sub-commissural annuloplasty, plication of the free edge of the cusp, shaving, and commissurotomy were performed. At this stage of surgery aortic repair was then attempted by cusp extension. Since 2013 the strips have been tailored from extracellular matrix.

Results

The mean aortic cross-clamp time was 90 ± 32 min. The mean cardiopulmonary bypass time was 126 ± 38 min. There was no in-hospital death. Re-exploration for bleeding was required in 1 patient. During follow-up, 1 patient needed reoperation at 1 year due to endocarditis. All patients remained alive in New York Heart Association (NYHA) functional class I. The echocardiographic findings remained unchanged in all cases during follow-up.

Conclusions

Our modification of aortic valve repair results in a good outcome.

Aortic valve repair update

The key for successful valve repair is full understanding of the regurgitant mechanism and sufficient evaluation of the valve. Currently, multidetector computed tomography has been introduced for evaluation. The aortic valve can be analyzed in details preoperatively. The main causes of aortic regurgitation (AR) in the adult population are degenerative leaflet change and annulus dilatation. Restoration to normal structure can be accomplished mainly by plication. Central leaflet plication near the Arantius nodule is a simple technique for redundant tissue. For leaflet deficiency, pericardial patch plasty may be an option. No universal technique exists for plication of the aortic annulus. The valve-sparing aortic root replacement firmly stabilizes the ventriculo-aortic junction (VAJ) and assures repair durability even in patients with mild to moderate root dilatation. Subcommissural annuloplasty (Cabrol stitch) does not seem sufficient for the prevention of VAJ dilatation. Circumferential annuloplasties may have a greater potential. However, convenient device for annular plication is still in development. The bicuspid aortic valve is a congenital heart valve lesion. A basic technique is free margin plication of the fused leaflet. Aortic root dilatation may contribute to AR severity. Valve-sparing aortic root replacement may improve repair durability. Considering the great advances in valve repair, young patients with AR should be informed that valve repair is a promising option for surgical treatment.

Surgical options in rheumatic mitral valve disease in children: a surgeon's perspective

In children with rheumatic heart disease, conservative valve surgery is the best option whenever feasible. Surgeons must develop an attitude and interest in valve repair techniques that can be easily learned. Patients who undergo valve repair at an early age are at risk of requiring additional surgery over time. Mechanical valve replacement, nonetheless, should be reserved for situations where more conservative approaches are not feasible.

Aortic valve repair with patch in non-rheumatic disease: indication, techniques and durability†

OBJECTIVES

To analyse the long-term outcomes of aortic valve (AV) repair with biological patch in patient with non-rheumatic valve disease.

METHODS

From 1995 to 2011, 554 patients underwent elective (AV) repair; among them, 57 (mean age 45 ± 17 years) had cusp restoration using patch for non-rheumatic valve disease. Seven (12%) patients had unicuspid valve, 30 (53%) patients had bicuspid valve and 20 (35%) had tricuspid valve. Autologous pericardium was used in 26 patients (7 treated, 19 non-treated), bovine pericardium in 26, autologous tricuspid valve leaflet in 4 and aortic homograft cusp in 1. Patching was used to repair perforation (n = 20, 35%), commissural defect (n = 18, 32%), raphe repair (n = 17, 30%) or for cusp extension (n = 2, 3.5%). Echocardiographic and clinical follow-up was 98% complete and mean follow-up was 72 ± 42.5 months.

RESULTS

No hospital mortality. At 8 years, overall survival was 90 ± 5% and freedom from valve-related death was 96 ± 3%. Two patients (3.5%) needed early reoperation for aortic regurgitation (AR); they underwent re-repair and the Ross procedure, respectively. Late reoperation was necessary in 9 patients (16%) for AR (n = 4), stenosis (n = 3) or mixed disease (n = 2). They had the Ross procedure (n = 6) or prosthetic valve replacement (n = 3) with no mortality. At 8 years, freedom from reoperation was 75 ± 9%. Freedom from reoperation was slightly higher in tricuspid compared with non-tricuspid valves (92 ± 7 vs 68 ± 11%, P = 0.18) and slightly higher for bovine (95 ± 5%) compared with autologous pericardium (73 ± 11%, P = 0.38), but differences were statistically not significant. In tricuspid valves, freedom from reoperation was higher in perforation repair compared with other techniques (100 vs 50 ± 35%, P = 0.02). In bicuspid valves, freedom from reoperation was similar between different repair techniques (P = 0.38). Late echocardiography showed AR 0-1 in 30 (53%) patients, AR 2 in 12 (21%) and no AR ≥ 3. Three patients presented a mean transvalvular gradient of 30-40 mmHg. Thromboembolic events occurred in 2 patients (0.6%/patient-year), bleeding events in 1 (0.3% /patient-year) and no endocarditis occurred.

CONCLUSIONS

AV repair with biological patch is feasible for various aetiologies. The techniques are safe and medium-term durability is acceptable, even excellent for perforation repair in tricuspid valve morphology. Bovine pericardium is a good alternative to autologous pericardium.

Aortic valve repair with autologous pericardium for traumatic aortic valve regurgitation

We present a case of successful aortic valve repair for traumatic aortic valve regurgitation. A 26-year-old male who had a history of motor-cycle accident months prior to admission, was referred to our hospital for surgical treatment of severe aortic valve regurgitation. Intraoperative inspection revealed a tear in noncoronary cusp, with otherwise preserved valvular anatomy. Aortic valvuloplasty was successfully performed with closure using an autologous pericardium patch. Intraoperative transesophageal echocardiogram confirmed absence of residual regurgitation.

Aortic Cusp Extension for Surgical Correction of Rheumatic Aortic Valve Insufficiency in Children

Surgical management of aortic insufficiency in the young is problematic because of the lack of an ideal valve substitute. Potential advantages of aortic valve repair include low incidences of thromboembolism and endocarditis, avoiding conduit replacements, the maintenance of growth potential, and improved quality of life. Aortic valve repair is still far from fulfilling the three key factors that have allowed the phenomenal development of mitral valve repair (standardization, reproducibility, and stable long-term results); however, techniques of aortic valve repair have been refined, and subsets of patients amenable to repair have been identified. We have focused on the oldest technique of aortic valve repair, cusp extension, focusing on children with rheumatic aortic insufficiency. Among 77 children operated from 2003 to 2007, there was one early death from ventricular failure and one late death from sudden cardiac arrhythmia. During a mean follow-up of 12.8 ± 5.9 years, there were 16 (20.5%) reoperations on the aortic valve, at a median of 3.4 years (range, 2 months to 18.3 years) from repair. Freedom from aortic valve reoperation was 96.2% ± 2.2% at 1 year, 94.9% ± 2.5% at 2 years, 88.5% ± 3.6% at 5 years, 81.7% ± 4.4% at 10 years, 79.7% ± 4.8% at 15 years, and 76.2% ± 5.7% at 20 years. Although aortic cusp extension is technically more demanding, it remains particularly more suitable in the context of evolving rheumatic aortic insufficiency in children with a small aortic annulus as a bridge surgical approach to late aortic valve replacement with a larger valvular prosthesis.

Bicuspid aortic valve replacement with stentless autologous pericardial valve

Bicuspid aortic valve is a common congenital cardiac anomaly that poses a surgical challenge in young patients. We describe replacement of a bicuspid aortic valve with a stentless glutaraldehyde-treated autologous pericardial prosthesis in a 16-year-old girl.

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.

Transesophageal Echocardiographic Guidance for Surgical Repair of Aortic Insufficiency in Congenital Heart Disease

A total of 14 patients with congenital heart disease underwent aortic valve repair, with transesophageal echocardiograms performed to determine severity, mechanism, and direction of aortic insufficiency (AI) jet to tailor the surgical approach. Patient age was 13 +/- 10 years, and accompanying diagnoses were: truncus arteriosus, subaortic stenosis, ventricular septal defect, and tetralogy of Fallot. Repeat transesophageal echocardiography was performed after each cardiopulmonary bypass run to determine residual AI and mechanism. Aortic valve leaflet number ranged from 2 to 4. AI was graded 2 to 4+, and postoperatively 0 to 2+. Primary mechanisms were: cusp prolapse (7), leaflet holes (4), restricted leaflet motion (2), and annular dilation (3). Patients required 1 to 3 cardiopulmonary bypass runs until primary AI mechanism was abolished. In all, 12 of 14 patients were free from death or repeated surgery at 2 years. Surgical repair of congenital AI may be aided by transesophageal echocardiographic guidance, with repeat short cardiopulmonary bypass as needed. Long-term studies are needed to determine durability of repair.

Pericardial patch reconstruction of the congenitally diseased aortic valve

Congenital aortic valve disease manifests itself either in the course of its natural history or as a consequence of an intervention (balloon dilatation or surgery). In infancy, a congenital aortic valve presents with stenosis, in childhood and adolescence as slowly evolving regurgitation after primary intervention/surgery and in late adulthood, they re-emerge as stenosis due to natural degeneration and calcification of the fused leaflets. The surgical approach to a congenital aortic valve disease differs depending on whether it is a malformed or a normally laid down (tri-sinusoidal tricuspid) valve; it also differs depending on the type of deformity, dysfunction and valve tissue presenting at surgery. Acutely regurgitant aortic valve in a neonate or an infant after balloon dilatation of congenital aortic stenosis is an infrequently occurring difficult problem with few available options. This video presentation demonstrates a xenopericardial patch repair of the torn fused leaflet (fusion between the right and the noncoronary cusp) of a congenitally stenotic valve, followed by height augmentation of all the three leaflets. Because of the relative hypoplasia of the aortic annulus and the ascending aorta, the aortic root and proximal ascending aorta were enlarged by an oblong xenopericardial patch. The following text includes additional technical issues involved in congenital aortic valve repair. A brief summary of literature is presented.

Echocardiographic and hemodynamic characteristics of reconstructed bicuspid aortic valves at rest and exercise

Repair of diseased bicuspid aortic valves has gained increasing interest as an alternative to conventional valve replacement. Hemodynamic data at exercise have not been reported before. The aim of this study was to investigate the clinical and echocardiographic status of patients after bicuspid aortic valve repair at rest and exercise. Between 03/94 and 09/02 a reconstruction of an incompetent bicuspid aortic valve was performed in 25 patients (mean age 35+/-12.1 years, group A, mean insufficiency 2.8 preoperatively). Patients were investigated clinically and echocardiographically after 2.1+/-2.4 (0.1-8.9) years at rest and exercise and compared to 20 controls (group B). Clinical followup was complete. There were no deaths, reoperations, thromboembolic or bleeding complications. At last examination 21 patients were in NYHA class I, n=4 in NYHA class II and mean aortic valve insufficiency (AI) was 1.0 with one patient having an AI>II degrees. Maximum and mean pressure gradient (dPmax/mean) across the aortic valve at rest were 14+/-5.5/7+/-2.6 mmHg for patients of group A and 7+/-2.5/3.6+/-1.1 mmHg in group B. Mean AVA at rest was 2.6+/-0.8 (group A) vs 2.9+/-0.6 cm(2) (group B, p=0.025), valvular resistance 13.4+/-4.8 (group A) vs 13.6+/-2.9 dyn x s x cm(-5) (group B, p>0.05). All individuals were stressed up to 100 W (dPmax/mean 21+/-6.8/11+/-3.6, group A vs 11+/-2.9/6+/-1.3 mmHg, group B). 56% of group A and 85% of group B could be stressed up to 175 W with dPmax/mean 24.5+/-8.3/12+/-4.2 and 16+/-3.6/8+/-1.4 mmHg, respectively (p<0. 01). Heart rate and blood pressure behavior were comparable. Left ventricular mass regression (preoperatively 369.3+/-76.4 vs 277.3+/-80.7 g at last examination, p<0.01) was significant in group A but did not reach normal values (group B, 227.8+/-71.1; p<0.01). Bicuspid aortic valve reconstruction reduces left ventricular volume load significantly. Although residual mild subclinical obstruction and incompetence were observed, the behavior of hemodynamics at exercise was comparable to controls. The clinical relevance of these findings in long term follow-up has to be evaluated.

Aortic Valve Repair for Rheumatic Aortic Valve Disease

BACKGROUND

The aim of this study is to assess the long-term results of aortic valve repair in patients with rheumatic aortic valve disease.

METHODS

From April 1991 through December 2003, 61 patients with rheumatic aortic valve disease underwent aortic valve repair. Mean age was 23.7 +/- 9.3 years (range, 6 to 53 years). Thirty-nine (63.9%) patients were in New York Heart Association functional class III. Reparative procedures included cuspal thinning (n = 59), commissurotomy (n = 45), subcommissural annuloplasty (n = 24), commissural plication (n = 12), perforation closure using pericardium (n = 2), and decalcification of cusps (n = 2). Associated procedures included mitral valve repair (n = 36) and tricuspid valve repair with mitral valve repair (n = 5).

RESULTS

Early mortality was 4.9% (3 patients). Mean follow-up was 93.8 +/- 46.4 months (range, 6 to 160 months, median, 103 months). Forty-six survivors (65%) had no or trivial or mild aortic regurgitation. Four patients required reoperation for valve dysfunction. There were no late deaths. Actuarial and reoperation-free survival, at 160 months, was 95.2% +/- 2.8% and 85.4% +/- 6.7%, respectively. Freedom from significant aortic stenosis or regurgitation was 52.4% +/- 16.9%.

CONCLUSIONS

Aortic valve repair in patients with rheumatic aortic valve disease is feasible and yields gratifying long-term results.

Repair of Aortic Leaflet Prolapse: The “Sliding Leaflet Technique”

Valve-preserving aortic replacement has become an accepted therapeutic option for aortic dilatation with normal valve leaflets. The presence of a leaflet prolapse often induces the choice of a composite graft repair. In these cases, however, the repair of a leaflet prolapse is possible and represents a valuable alternative to a prosthetic valve. The conventional techniques of repair of a cusp prolapse are designed to restore coaptation through a reduction of free margin length. The sliding leaflet technique is an alternative procedure conceived to repair the prolapsed valve cusp by remodeling both the free margin and the annular insertion.

Functional classification of aortic root/valve abnormalities and their correlation with etiologies and surgical procedures

PURPOSE OF REVIEW

Patients with aortic root pathology may benefit from 'valve-conservation' surgery although application of this philosophy is limited by a lack of 'standardized' surgical techniques. A functional classification of aortic root and valvular abnormalities has been developed in 260 patients and correlated with the etiology of the pathologic process and the surgical procedure performed. Early outcome was assessed using hospital records and medium-term follow-up by cardiological review.

RECENT FINDINGS

From January 1995 until March 2001, 260 patients were operated on for aortic root pathology using valve-conserving surgical techniques. Hospital mortality was 2%; intra-operative echocardiography showed residual aortic regurgitation (Grade 1-2) in 11%, none in the remaining patients. Follow-up at a mean of 20 months (87% of patients) showed trivial or Grade 1 aortic regurgitation in 80%.

SUMMARY

Application of a simple functional classification for aortic root pathology and aortic valve disease allows the logical application of 'valve-conserving' surgical procedures with excellent early and medium-term results.

Complex aortic valve repair as a durable and effective alternative to valve replacement in children with aortic valve disease

OBJECTIVE

This study was undertaken to determine the utility of aortic valve repair in children.

METHODS

A retrospective analysis was conducted on aortic valve surgery from 1973 to 2004 at Children's Hospital of Wisconsin.

RESULTS

Procedures were classified as simple repairs (blunt valvotomy, commissurotomy with or without thinning, n = 147), repair of aortic insufficiency with ventricular septal defect (n = 22), complex repairs (any combination of additional procedures including suspension of prolapsed leaflets, leaflet extensions, repair of torn or perforated leaflets, annuloplasty, reduction of sinus of Valsalva plasty, and concomitant repair of supravalvular or subvalvular stenosis, n = 57), and replacements (n = 57, 20 mechanical, 2 porcine, and 35 human valves). Freedoms from reintervention for simple repairs and repair of aortic insufficiency with ventricular septal defect at 10 years were 86% +/- 5% and 93.3% +/- 6%, respectively. For complex valve repair, freedoms from reintervention at 1, 5, and 10 years were 94% +/- 3%, 85% +/- 6%, and 44% +/- 15%, versus 96% +/- 3%, 77% +/- 9%, and 77% +/- 9% for valve replacement ( P = .3). At intermediate follow-up, patients with complex valve repair had a residual gradient of 20 +/- 21 mm Hg, and 94% were free of severe aortic insufficiency. Residual aortic stenosis ( P < .05) but not the preoperative diagnosis of combined aortic stenosis and insufficiency predicted the need for reintervention.

CONCLUSION

Freedom from reintervention after complex valve repairs was not different from that after valve replacement, with acceptable residual aortic stenosis and insufficiency. Simple repairs and repair of aortic insufficiency with ventricular septal defect yielded excellent long-term freedom from reintervention.

Aortic valve repair

Aortic valve replacement options are limited in children, and all of them have disadvantages. Aortic valve repair techniques have evolved slowly and have not gained wide acceptance; however, large series using a variety of techniques demonstrate that valve repair is possible with excellent early hemodynamics and satisfactory intermediate durability. The results of aortic valve repair at the Children's Hospital of Wisconsin are presented. Simple repairs (blunt valvotomy, commissurotomy, or commissurotomy with leaflet thinning) directed at congenital aortic stenosis resulted in 86% +/- 5% freedom from reintervention at 10 years. Repair of aortic insufficiency with ventricular septal defect (VSD) resulted in 93.3% +/- 6% freedom from reoperation at 10 years. Complex repairs included a combination of techniques and yielded 5-year freedom from reintervention of 83% +/- 7% compared with 73% +/- 11% for patients undergoing aortic valve replacement (P = .62). Aortic valve repair provides an alternative to aortic valve replacement in selected patients. The utility of aortic valve repair and aortic valve replacement must be measured not only in freedom from reintervention but also in regression of left ventricular mass and exercise testing. Improvement in outcome depends on better patient selection and suitable bioprosthetic materials.

Current Status of Surgery for Rheumatic Carditis in Children

BACKGROUND

The incidence of rheumatic heart disease (RHD) has increased recently in the western United States. We reviewed our 18-year surgical experience with RHD in children to examine current surgical techniques and results.

METHODS

From 1985 until 2003, 596 children (<21 years) with rheumatic fever were seen at Primary Children's Medical Center. Rheumatic carditis was diagnosed in 366 patients (61.4%). Twenty-six with carditis (26/366, 7.1%) required operation for rheumatic valve disease including 8 for mitral regurgitation, 7 for mitral and aortic regurgitation, 4 for aortic regurgitation, 4 for mitral regurgitation and stenosis, 2 for combined mitral stenosis and regurgitation with aortic insufficiency, and 1 for mitral and tricuspid regurgitation.

RESULTS

Mean age at operation was 13.5 +/- 4 years. Three patients required operation during the acute phase of rheumatic fever (< 6 weeks), 2 during the subacute phase (< 6 months), and 21 during the chronic phase after the episode of rheumatic fever (6.7 +/- 3 years). Mitral valve repair was possible in 19 of 22 patients who required mitral operation. Aortic valve repair was possible in 4 patients whereas replacement was necessary in 9, including 2 Ross procedures. No operative deaths were recorded and 2 late deaths occurred at 4.6 and 10 years. Actuarial survival was 94% at 5 years and 78% at 10 years. Six patients required reoperation; actuarial freedom from reoperation was 78% at 5 years, 65% at 10 years, and 49% at 15 years. All survivors are in New York Heart Association class I or II.

CONCLUSIONS

Children with RHD in the United States uncommonly require valve operation. Mitral repair with a technique that allows annular growth is possible in most children with good long-term functional results. Long-term surveillance of children with RHD is necessary because of the possible need for late valve operation.

Midterm results of aortic valve repair with the pericardial cusp extension technique in rheumatic valve disease

BACKGROUND

The encouraging results of valve repair in the atrioventricular valves have influenced a decision about aortic valve (AV) reconstruction. We report our experience with pericardial cusp extension to repair rheumatic AV disease.

METHODS

From 1993 to 1998, 46 patients (25 women, 21 men) with a mean age of 31.5 +/- 12.2 years (range, 15 to 58 years) underwent AV repair. Twenty-two (47.8%) patients had moderate and 24 (52.2%) had severe aortic insufficiency (AI). Severe cusp retraction was repaired with glutaraldehyde-treated autologous pericardium. Twenty-one patients had more than one maneuver (mean, 1.8) to attain competence besides augmentation, which consisted of the release of stenotic commissures (in 11 cases), thinning of the AV cusps (in 10 cases), and resuspension of the cusps (in 17 cases). Simultaneous mitral valve repair was performed on 17 patients. Eight patients received triple valve reconstruction.

RESULTS

There was no early mortality. Thirty patients no longer had AI with any significant transvalvular gradients. Five patients were followed with mild residual AI, and 2 patients with moderate AI not requiring reoperation. Nine patients developing severe AI required AV replacement with a reoperation rate 19.6% (4.26%/patient-year). The mean interval between repair and reoperation was 28.2 +/- 18.3 months (range, 3 to 58 months). The mean observation time was 4.6 +/- 3 years (211.6 patient-years). Late mortality rate was 2.2% with 1 patient. The significant negative predictors of aortic reoperation determined by univariate analysis were preoperative New York Heart Association class (p = 0.002) and postoperative severe AI (p < 0.001). Cox hazard studies identified that all risk factors were insignificant for aortic reoperation. The actuarial rate of freedom from aortic reoperation was 76.1% +/- 7% at 7.5 years.

CONCLUSIONS

Although AV repair by extension with pericardium is worth considering with an acceptable solution to achieve a good geometry from unequal cusps, especially in young rheumatic patients for preservation of the native AV, the patients should be followed periodically for reoperation risk.

Outcome of aortic valve repair in children with congenital aortic valve insufficiency

OBJECTIVE

Surgical aortic valvotomy has a long history of providing excellent palliation for aortic stenosis in infancy and childhood. The fate of aortic valve repairs for dominant aortic regurgitation in this same age group is considerably less clear.

METHODS

From 1990 to 2000, a total of 21 patients underwent aortic valve repair for aortic regurgitation at our institution. Seventeen patients were younger than 17 years at the time of repair (3-17 years, mean 8.1 +/- 3.7 years). Of these 17 children, 6 (35%) had bicuspid valves and 11 (65%) had tricuspid valves. Type of repair varied with valve type, but repair generally consisted of commissure resuspension, partial commissure closure, triangular resection of redundant leaflets, or some combination.

RESULTS

There were no deaths. Follow-up ranged from 1 to 11 years (mean 5.3 +/- 2.4 years). At present 3 of 17 (17.6%) have mild aortic regurgitation according to echocardiography and 6 (35.2%) have moderate aortic regurgitation. In 8 of 17 cases (47.1%) the repair clearly failed, requiring reoperation from 0.5 to 73 months after the original operation (mean 18.9 months). Reoperation consisted of 6 Ross procedures and 2 mechanical aortic valve replacements. There were no deaths at the secondary operation.

CONCLUSION

Aortic valve repair in children with a dominant feature of aortic insufficiency tended to fail progressively and at a high rate. Leaflet thickening was associated with higher risk of repair failure in this series. The threshold for aortic valve replacement should remain low.

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.

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.

The Ross procedure is the procedure of choice for congenital aortic valve disease

OBJECTIVES

The Ross procedure has emerged as an attractive option for aortic valve replacement in children and young adults. Our objective was to review our experience with the Ross procedure in young patients with congenital aortic valve disease. We also sought for evidence of growth in the autograft.

METHODS

From January 1990 to July 2000, 260 patients underwent the Ross procedure for various aortic valve diseases. There were 136 patients less than 18 years of age. Fifty-three (38%) of these patients had congenital aortic valve disease. Ages ranged from 3 months to 18 years (mean, 8 plus minus 5 years; median, 9 years). Ten patients were less than 2 years of age. Pure aortic stenosis was present in 18 patients, mixed stenosis and regurgitation in 32, and pure aortic regurgitation in 3. The aortic valve was bicuspid in 29 patients. Twenty-nine patients had previous procedures, mostly balloon dilation of the aortic valve (n = 8) or surgical aortic valvotomy (n = 12).

RESULTS

In all patients immediate results demonstrated a normally functioning neoaortic valve with not more than trivial aortic valve regurgitation. In the patients with stenosis, all levels of obstruction were relieved, and the gradient across the left ventricular outflow tract was completely abolished. Hospital mortality was 3 (5.6%) of 53 (overall Ross mortality was 34 of 260 [1.5%]). The patients were followed up for a mean of 4 years and up to 10 years. One patient died late of a noncardiac cause. Actuarial survival at 10 years was 94% plus minus 2%, and freedom from all events was 93% plus minus 5%. Only 1 patient needed autograft replacement for endocarditis. Intervention related to right ventricle-pulmonary artery conduit was required in 3 patients: balloon dilatation in 2, and reoperation in 1. At last follow-up, all patients but one were classified as being in New York Heart Association functional class I or II with normal or near-normal autograft valve function. Serial measurement of the left ventricular outflow tract and aortic root showed that as patients grew, the size of the outflow tract increased. When indexed to body surface area, this increase correlated with the patients' expected somatic growth.

CONCLUSIONS

The Ross procedure for congenital aortic valve disease in children and young adults offers excellent hemodynamics, with the added advantage of real potential for growth. It should be considered the treatment of choice in this age group.

Creating a bicuspid valve from the aortic wall: a new surgical approach on aortic valve disease (in vitro study)

We described a new technique (called 'bicuspidization'), which is performed by using autogenous material, without replacement of the aortic valves for the surgical treatment of aortic stenosis and/or insufficiency and tested it in in vitro sheep model. Different stress conditions were simulated by applying three different flow patterns (hemodynamic challenge tests) successively by using a centrifugal pump. It was demonstrated that the competency of the new bicuspid valves was excellent (zero insufficiency). There was a 10-11 mm Hg-increase on trans-valvular gradient comparing the normal hearts. The autogenous bicuspid valve has not blocked the way of the coronary flow in the closed position.

Early and late results of fresh autologous pericardial valved conduits

The objective of this study was to evaluate the early and late results of an autologous pericardial valved conduit in the pulmonary circulation. Between 1983 and 1997, 86 autologous pericardial valved conduits were used to achieve venous ventricle-pulmonary artery continuity. The mean patient age at the time of implantation was 4.16 +/- 4.10 years (15 days to 24 years). All patients had two-dimensional postoperative and yearly Doppler echocardiograms in which the valve function and the presence of distal, valvar, and proximal stenosis were evaluated. There were 13 early deaths (15%). Twenty-one patients (24.4%) showed trivial, 54 (62.8%) mild, nine (10.4%) moderate, and two (2.3%) severe pulmonary regurgitation in the early postoperative period. The 73 survivors were monitored from 1 to 15 years (mean, 6.5 years; median, 7.1 years). There were five late deaths. The mean conduit diameter at the time of implantation was 15.8 mm, increasing to 18.21 mm at last evaluation (P <.0001). There were nine reoperations, with only one conduit replacement. Freedom from reintervention at 5 and 10 years was 89% and 80%, respectively. In conclusion, autologous pericardial valved conduits provide good early and excellent long-term results that compare favorably with those of other conduits. Copyright 1999 by W.B. Saunders Company

Pericardial leaflet extension for aortic valve repair: Techniques and late results

A modified technique to repair aortic valve is described. The technique consists of tailored extension of the old valve leaflets with gluteraldehyde treated autologous pericardium. The technique has excellent intermediate results and is an alternative to valve replacement in pediatric patients. Copyright 1999 by W.B. Saunders Company

Repair of moderate aortic valve lesions associated with other pathology: an 11-year follow-up

OBJECTIVES

The presence of moderate aortic valve (AV) lesions associated with other pathologies that require surgery presents a problem since ignoring or replacing the valve seems unsatisfactory. AV repair can be an attractive alternative if shown to perform satisfactory.

METHODS

To evaluate this possibility, all consecutive AV patients who underwent operation between July 1988 and July 1999 were reviewed. Out of 1764 AV patients, 239 (14%) underwent repair and 86 (study group) had moderate lesions associated with mitral (73), tricuspid (33), coronary disease (5) and others (8). Mean age was 28 years (range 2--66); 78% were rheumatic, 71% were in sinus rhythm and 71% in NYHA class III--IV.

RESULTS

There were seven hospital deaths (8%) and three patients were lost to follow-up (95% complete). Late mortality was 8% and 10-year actuarial survival was 86 +/- 4.5% (excluding hospital mortality). There were four (5%) embolic events (actuarial freedom 94 +/- 3.5%). Twenty-one patients required reoperation with two mortalities. The AV was not touched in five patients. In the remaining 16, the AV was replaced. Only one patient had isolated AV replacement while in all others, additionally, the mitral, tricuspid, or both required surgery. All reoperated patients had rheumatic etiology. Actuarial freedom from AV dysfunction at 8 years was 68 +/- 7.5%.

CONCLUSIONS

Repair of associated moderate AV lesion is worth considering even in a predominantly young rheumatic population.

Durability of combined aortic and mitral valve repair

BACKGROUND

This study was undertaken to determine the durability of combined aortic and mitral valve repair.

METHODS

From 1979 through 1999, 158 patients underwent simultaneous aortic and mitral valve repair. Multivariable, multi-phase hazard function analysis was used to determine risk factors for the outcomes of death and reoperation.

RESULTS

Hospital mortality was 3%. Survival after operation was 97%, 93%, 82%, and 62% after 30 days and 1, 5, and 10 years, respectively. Risk factors for late death included aortic stenosis (p = 0.0001), older age (p = 0.002), and abnormal left ventricular function (p = 0.007). Thirty-six patients required reoperation for valvular dysfunction, and freedom from reoperation was 94%, 82%, and 65% after 1, 5, and 10 years, respectively. Risk factors for reoperation included severe aortic regurgitation (p = 0.004), aortic cusp shaving (p = 0.05), mitral valve chordal transfer (p = 0.004), and bovine pericardial annuloplasty (p = 0.002). Five-year freedoms from endocarditis, thromboembolism, and hemorrhage were 97%, 98%, and 99%, respectively, with freedom from any of these valve-related morbidities of 99%, 95%, and 94% after 1, 5, and 10 years, respectively.

CONCLUSIONS

Double valve repair is associated with acceptable late survival and excellent freedom from valve-related morbidity, but limited durability. Therefore, double valve repair should be reserved for patients who cannot be anticoagulated, and should be used with caution in patients with aortic stenosis, rheumatic valve disease, or anterior mitral leaflet pathology.

Pulmonary homograft: should it be used in the aortic position?

OBJECTIVE

Retrospective analysis was performed to determine the suitability of pulmonary homograft as an aortic valve substitute.

METHODS

From January 1994 through June 1999, 147 patients (mean age, 32.2 +/- 17.3 years) underwent aortic valve replacement with either an aortic homograft (group 1: n = 103, 25 fresh antibiotic preserved and 78 cryopreserved) or a pulmonary homograft (group 2: n = 44, 11 antibiotic preserved and 33 cryopreserved). In group 1 a scalloped subcoronary technique was used in 64 patients, and a root replacement technique was used in 39 patients. In group 2 the scalloped subcoronary technique was used in 34 patients, and the root replacement technique was used in 10 patients.

RESULTS

There were 131 operative survivors (group 1 = 91; group 2 = 40). Follow-up ranged from 2 to 62 months. In group 1 none of the patients had significant aortic regurgitation during the hospital stay. Three patients (all having undergone the scalloped subcoronary technique) had moderate aortic regurgitation after 6 to 32 months. In group 2, 10 patients (9 having undergone the scalloped subcoronary technique and 1 having undergone the root replacement technique) developed significant regurgitation: 2 intraoperatively, 5 in the early postoperative period before discharge from the hospital, and 3 during late follow-up 6 to 12 months postoperatively. Among the various risk factors analyzed for overall homograft failure, use of a pulmonary homograft was the single independent predictor of valve failure (odds ratio, 8.6; 95% confidence interval, 1.9-39; P =.006).

CONCLUSION

Pulmonary homograft, when inserted by means of a scalloped subcoronary technique, is not a suitable aortic valve substitute.

Aortic valve repair after arterial switch operation

A patient with transposition of the great arteries and a ventricular septal defect underwent an arterial switch operation 15 months after pulmonary artery banding. At 12 years of age, severe neoaortic valve regurgitation, due to dilated aortic sinuses and poor leaflet coaptation, developed. Aortic valve repair involved placement of subcommissural sutures, elliptical excision and tailored reduction of two anterior aortic sinuses, with triangular patch expansion of the proximal ascending aorta. A good result was obtained.

Aortic valve repair by cusp extension with the use of fresh autologous pericardium in children with rheumatic aortic insufficiency

OBJECTIVES

Our goal was to evaluate the midterm results of aortic valve repair by a more sophisticated tailoring of cusp extension-taking into account the dimensions of the native aortic cusps-with the use of fresh autologous pericardium.

PATIENTS AND METHODS

Forty-one children who had severe rheumatic aortic insufficiency (mean age 11.5 +/- 2.7 years) underwent aortic valve repair by means of this cusp extension technique over a 5-year period. Twenty-four of them underwent concomitant mitral valve repair for associated rheumatic mitral valve disease. All children were then followed up by transthoracic echocardiography before discharge, at 3 and 6 months after the operation, and at yearly intervals thereafter.

RESULTS

Follow-up was complete in all patients and ranged from 3 months to 5 years (median 3 years). No operative and no early postoperative deaths occurred. Only 1 patient died, 9 months after the operation, of septicemia and multiple organ failure. Actuarial survival was 97% at 1 year and has remained unchanged at 3 years. On discharge, the degree of aortic insufficiency was grade 0 for 27 children and grade I for 14. Exacerbation of aortic insufficiency from grade I to grade II was observed in only 1 patient, and none of the children required reoperation for aortic insufficiency during the follow-up period. Mean peak systolic aortic valve gradients at discharge were lower than preoperative values (P =.04), and no significant increase in the peak systolic transvalvular gradient was detected thereafter during the follow-up period. Mean left ventricular dimensions were significantly reduced at discharge when compared with preoperative values (P <.0001).

CONCLUSIONS

Functional results of aortic valve repair with cusp extension using fresh pericardium have been satisfactory at medium term, particularly in children with a small aortic anulus at the time of initial repair, because the expansion potential of fresh autologous pericardium is equivalent to that of the growing sinotubular junction and aortic anulus diameters.

Replacement of ascending aorta with aortic valve reimplantation: midterm results

OBJECTIVE

Aneurysms of the aortic root lead to aortic valve incompetence due to dilatation of the sinotubular junction and annuloaortic ectasia. Reimplantation of the native, structurally intact aortic valve within a Dacron tube graft corrects annular ectasia as well as dilatation of sinotubular junction and aortic sinuses. Durability of this valve repair with respect to increased mechanical stress on valve cusps is discussed controversially and is yet unknown.

METHODS

Since 7/93, replacement of the ascending aorta with repair of the aortic valve was performed in 48 patients (34 male, 14 female; 47+/-20 years) with aortic insufficiency and aneurysm of the aortic root. Fifteen patients (31%) had Marfan's syndrome and five patients (10%) had an aortic dissection type A (two acute, three chronic). In 11 patients (23%), concomitant replacement of the aortic arch was necessary utilizing elephant trunk technique in two patients. Additionally, one patient required mitral valve repair and two other patients coronary artery bypass grafts. Clinical and echocardiographic follow-up was performed in 6-12 month intervals for a cumulative study period of 100 patient years.

RESULTS

There were no operative deaths. Two patients (4%) died 5 and 20 months postoperatively. One additional patient experienced a TIA within the first postoperative week. Three patients (6%) with an early postoperative aortic insufficiency (AI) > 1 required aortic valve replacement after 9, 11, and 14 months due to progressive AI. In these patients, distortion of the aortic root geometry led to valve incompetence. All other patients have no or mild aortic insufficiency. The repair now remains stable for up to 63 months (mean 25+/-18 months). Other valve related complications did not occur.

CONCLUSIONS

Our results demonstrate that this type of aortic valve repair achieves excellent results in selected patients. Perfect coaptation of valve cusps during the repair with no or only trace AI at initial echocardiography seems to be essential for durability.

Outcome of surgical closure of doubly committed subarterial ventricular septal defect

BACKGROUND

From 1986 to March 1997, 128 patients diagnosed to have doubly committed subarterial ventricular septal defects (VSD) were reviewed. Patients with aortic regurgitation (AR), and aortic valve (AV) deformity or a large left-to-right shunt across the VSD were offered operation. Forty-five patients (27 men, 18 women) agreed to surgical closure of their VSDs.

METHODS

Thirty-eight patients had VSD closure alone, and 7 had an additional AV repair. Other associated defects corrected at operation were closure of atrial septal defects, closure of other ventricular septal defects, ligation of patent ductus arteriosus, and repair of ruptured sinus Valsalva aneurysm.

RESULTS

There was no mortality nor major morbidity associated with operation. In the 26 patients with AR and AV deformity preoperatively, valve repair was performed in 6 patients. The condition of AR improved in 4, and remained unchanged in 22 patients. In the 10 patients with a deformity of the AV and no AR preoperatively, the condition remained unchanged in 5 patients, from whom 1 had valve operation, but progressed in 5 patients postoperatively at a mean follow-up of 6.4 years. In 9 patients with no deformity of the AV and no AR preoperatively, there was no postoperative AR and no progress of valve deformity.

CONCLUSIONS

Excellent results were obtained with VSD closure and AV repair. Surgical closure of VSD, if performed before the onset of AV deformity, may prevent progressive AR. If AV repair is performed after the onset of AV deformity, progressive AR may not always be prevented.

Intermediate-term durability of bicuspid aortic valve repair for prolapsing leaflet

OBJECTIVE

To determine the durability of repair of a bicuspid aortic valve with leaflet prolapse, and to identify factors associated with repair failure.

METHODS

From November 1988 to January 1997, 94 patients with a bicuspid aortic valve and regurgitation from leaflet prolapse had aortic valve repair. In 66 patients, the repair employed triangular resection of the prolapsing leaflet. The remainder underwent mid-leaflet plication of the prolapsing leaflet. Mean age was 38 +/- 10 years and 93% were male. Median follow-up was 5.5 years (range 0.2-9 years). Factors associated with aortic valve competence and durability were identified by multivariable logistic and hazard function analyses.

RESULTS

Early valve competence was more difficult to achieve in patients with large, poor functioning ventricles (P = 0.02). Aortic valve reoperation was necessary in 12 patients that included three re-repairs and nine aortic valve replacements. Freedom from reoperation was 95, 87 and 84% at 1, 5 and 7 years, respectively. The instantaneous risk of reoperation was highest immediately after operation, and fell rapidly to approximately 2% per year and less after 2 years. The only risk factor identified was the presence of residual aortic regurgitation (trace to mild in 35 cases) on immediate intraoperative post-repair transesophageal echocardiography. Late aortic regurgitation did not progress detectably across time (P = 0.3). There were no deaths, early or late.

CONCLUSION

Bicuspid aortic valve repair for prolapsing leaflet is a safe procedure with good intermediate-term outcome. However, any residual aortic regurgitation jeopardizes repair durability and initial repair achievement is more difficult in patients with dilated, poor functioning ventricles.

The role of intraoperative echocardiography in valve surgery

The widespread use and popularity of intraoperative echocardiography (IOE) has resulted from advances in cardiac surgery, reparative procedures for valvular heart disease and, most specifically, mitral valve repair. IOE has grown exponentially and is becoming an integral part of the planning and evaluation of many types of surgical procedures such that it is now considered standard of care especially for the perioperative management of patients undergoing mitral and aortic valve repair. This article discusses the application of intraoperative echocardiography and focus specifically on valvular heart disease as this represents the most widely accepted indication for the procedure in current clinical practice.

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.

Heparin in calcification prevention of porcine pericardial bioprostheses

Calcific degeneration is the main cause of failure of glutaraldehyde-treated xenograft heart valve substitutes implanted in humans. Coupling of heparin through an intermediate surface-bound substrate containing amino groups showed complete prevention of calcification of glutaraldehyde-treated porcine pericardium implanted subdermally in weanling rats for 5 months (heparin bonded pericardium: calcium, 0.625 +/- 0.24 mg g(-1); glutaraldehyde-only-treated pericardium: calcium, 228.32 +/- 37.39 mg g(-1); P < 0.0001). Conceivably, inactivation of unpaired aldehyde moieties present in bioprostheses after exposure to glutaraldehyde by amino compounds followed by blocking the potential binding sites of the graft with a surface modifying agent like heparin would be the key steps in the prevention of calcification and degeneration of glutaraldehyde-treated biological tissue grafts.

Is the dog a useful model for accelerated calcification study of cardiovascular bioprostheses?

Chitosan posttreatment has been shown to be effective in prevention of calcification of the glutaraldehyde treated bovine pericardium when implanted subdermally in rats for 12 weeks. The efficacy of chitosan posttreatment in complete calcium mitigation of the glutaraldehyde treated porcine aortic valves implanted in the right side of the heart in dogs was well-documented in our previous study. In this study, an attempt has been made to evaluate the merit of the chitosan posttreatment in prevention of calcification of the glutaraldehyde (GA) treated porcine aortic valved conduits in the systemic circulation in dogs for a period of 5 months. Eleven mongrel dogs underwent left thoracotomy. Porcine aortic valved conduits treated with 0.625% GA (n = 5) and GA-chitosan (n = 6) were implanted in the descending thoracic aortas of the dogs for 5 months. Gross histological observations showed no calcification in either the 0.625% GA treated or in the GA-chitosan treated valved conduits at 5 months. This was confirmed by results of quantitative analyses for calcium in each explant. There was no significant difference in calcium content between the GA only (Ca, 0.43 +/- 0.26 mg/g) and GA-chitosan treated (Ca, 0.51 +/- 0.19 mg/g; p = 0.5959) valved conduits. This study suggests that the dog is not a suitable model for evaluating the efficacy of a calcium mitigating agent in bioprostheses implanted in systemic circulation.

Commissurotomy and bileaflet pericardial augmentation-resuspension for bicuspid aortic valve stenosis

We describe a valve reconstruction technique for congenital bicuspid aortic valve stenosis employing a commissurotomy, resection of raphe between conjoint leaflets, and bileaflet augmentation-resuspension using a triangular strip of glutaraldehyde-preserved autologous pericardium. This maneuver relieves aortic valve stenosis, preserves the native valve leaflets, reproduces the natural trileaflet scalloping of the aortic valve annulus, and improves cusp coaptation.