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Appiah LT, Gyabaah S, Adu-Boakye Y, Nkum BC. Undiagnosed sub-valvular aortic stenosis with an associated Ventricular Septal Defect (VSD) presenting late in a multi-parous woman. BMC Cardiovasc Disord 2023; 23:200. [PMID: 37072741 PMCID: PMC10111744 DOI: 10.1186/s12872-023-03242-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/13/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Sub-valvular aortic stenosis is a rare disorder that has a prevalence of 6.5% of all adult congenital heart diseases. The hemodynamic changes that occur in pregnancy with the resultant increase in cardiac output may not well be tolerated by a pregnant woman with sub-valvular aortic stenosis. CASE PRESENTATION We report the case of a 34-year-old para 7 (6 alive + 1 dead) who has been experiencing intermittent episodes of easy fatigability on moderate exertion since childhood and had survived 6 prior pregnancies. During her last pregnancy, she started experiencing chest pain, palpitations, dyspnea, orthopnea, and pre-syncope at 36 weeks and had a caesarean section at 37 weeks on account of fetal distress. The post-delivery cardiac evaluation showed severe sub-valvular Aortic stenosis and a ventricular septal defect. CONCLUSION Sub-valvular Aortic stenosis may progress slowly in adults and may be tolerated during pregnancy. Despite the rare presentation and contraindication of pregnancy in such a patient, she extraordinarily survived the pregnancy with a healthy baby. Routine cardiovascular assessment during prenatal, ante-natal and post-natal care is highly advocated particularly so in resource-poor settings.
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Affiliation(s)
- Lambert Tetteh Appiah
- Kwame Nkrumah University of Science and Technology, School of Medicine and Dentistry (KNUST-SMD), Kumasi, Ghana
- Komfo Anokye Teaching Hospital (KATH), P.O BOX 1934, Kumasi, Ghana
| | - Solomon Gyabaah
- Komfo Anokye Teaching Hospital (KATH), P.O BOX 1934, Kumasi, Ghana.
| | - Yaw Adu-Boakye
- Kwame Nkrumah University of Science and Technology, School of Medicine and Dentistry (KNUST-SMD), Kumasi, Ghana
- Komfo Anokye Teaching Hospital (KATH), P.O BOX 1934, Kumasi, Ghana
| | - Bernard C Nkum
- Kwame Nkrumah University of Science and Technology, School of Medicine and Dentistry (KNUST-SMD), Kumasi, Ghana
- Komfo Anokye Teaching Hospital (KATH), P.O BOX 1934, Kumasi, Ghana
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2
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Hahn RT, Saric M, Faletra FF, Garg R, Gillam LD, Horton K, Khalique OK, Little SH, Mackensen GB, Oh J, Quader N, Safi L, Scalia GM, Lang RM. Recommended Standards for the Performance of Transesophageal Echocardiographic Screening for Structural Heart Intervention: From the American Society of Echocardiography. J Am Soc Echocardiogr 2022; 35:1-76. [PMID: 34280494 DOI: 10.1016/j.echo.2021.07.006] [Citation(s) in RCA: 87] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Rebecca T Hahn
- Columbia University Irving College of Medicine, New York, New York
| | - Muhamed Saric
- New York University Langone Health, New York, New York
| | | | - Ruchira Garg
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | - Omar K Khalique
- Columbia University Irving College of Medicine, New York, New York
| | - Stephen H Little
- Houston Methodist DeBakey Heart and Vascular Center, Houston, Texas
| | | | - Jae Oh
- Mayo Clinic, Rochester, Minnesota
| | | | - Lucy Safi
- Hackensack University Medical Center, Hackensack, New Jersey
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3
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Saef JM, Ghobrial J. Valvular heart disease in congenital heart disease: a narrative review. Cardiovasc Diagn Ther 2021; 11:818-839. [PMID: 34295708 DOI: 10.21037/cdt-19-693-b] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 01/29/2021] [Indexed: 12/29/2022]
Abstract
Patients with congenital heart disease (CHD) are one of the fastest growing populations in cardiology, and valvular pathology is at the center of many congenital lesions. Derangements in valvular embryology lead to several anomalies prone to dysfunction, each with hemodynamic effects that require appropriate surveillance and management. Surgical innovation has provided new treatments that have improved survival in this population, though has also contributed to esotericism in patients who already have unique anatomic and physiologic considerations. Conduit and prosthesis durability are often monitored collaboratively with general and specialized congenital-focused cardiologists. As such, general cardiologists must become familiar with valvular disease with CHD for appropriate care and referral practices. In this review, we summarize the embryology of the semilunar and atrioventricular (AV) valves as a foundation for understanding the origins of valvular CHD and describe the mechanisms that account for heterogeneity in disease. We then highlight the categories of pathology from the simple (e.g., bicuspid aortic valve, isolated pulmonic stenosis) to the more complex (e.g., Ebstein's anomaly, AV valvular disease in single ventricle circulations) with details on natural history, diagnosis, and contemporary therapeutic approaches. Care for CHD patients requires collaborative effort between providers, both CHD-specialized and not, to achieve optimal patient outcomes.
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Affiliation(s)
- Joshua M Saef
- Division of Cardiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Joanna Ghobrial
- Division of Cardiology, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
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Papakonstantinou NA, Kanakis MA, Bobos D, Giannopoulos NM. Congenital, acquired, or both? The only two congenitally based, acquired heart diseases. J Card Surg 2021; 36:2850-2856. [PMID: 33908651 DOI: 10.1111/jocs.15588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/14/2021] [Accepted: 04/16/2021] [Indexed: 11/28/2022]
Abstract
Discrete subaortic stenosis (DSS) is a type of left ventricular outflow tract obstruction whereas double-chambered right ventricle is a form of right ventricular outflow tract obstruction. Both of these cardiac malformations share lots of similar characteristics which classify them as acquired developmental heart diseases despite their congenital anatomical substrate. Both of them are frequently associated to ventricular septal defects. The initial stimulus in their pathogenetic process is anatomical abnormalities or variations. Subsequently, a hemodynamic process is triggered finally leading to an abnormal subaortic fibroproliferative process with regard to DSS or to hypertrophy of ectopic muscles as far as double-chambered right ventricle is concerned. In many cases, these pathologies are developed secondarily to surgical management of other congenital or acquired heart defects. Moreover, high recurrence rates after initial successful surgical therapy, particularly regarding DSS, have been described. Finally, an interesting coexistence of DSS and double-chambered aortic ventricle has also been reported in some cases.
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Affiliation(s)
| | - Meletios A Kanakis
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Dimitrios Bobos
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece
| | - Nicholas M Giannopoulos
- Department of Pediatric and Congenital Heart Surgery, Onassis Cardiac Surgery Center, Athens, Greece
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5
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Moafa H, Alnasef M, Diraneyya OM, Alhabshan F. Subaortic Membrane and Patent Ductus Arteriosus in Rare Association-Case Series. J Saudi Heart Assoc 2020; 32:410-414. [PMID: 33299784 PMCID: PMC7721455 DOI: 10.37616/2212-5043.1199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 04/29/2020] [Accepted: 04/30/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND The combination of subaortic membrane (SAM) and patent ductus arteriosus is very rare. Subaortic stenosis is the second most common form of left ventricular outflow tract (LVOT) obstruction after valvular aortic stenosis. We are reporting the largest case series of SAM and PDA. METHODS We included all patients that were diagnosed with the combination of SAM and PDA at our cardiac center. We have reviewed patients echocardiographic studies, cardiac catheterizations, surgical notes and all the outpatients notes. RESULTS We have a total of 7 patients. The age at presentation was in the early childhood with 3 patients diagnosed in infancy. Four patients had severe and moderate LVOT obstruction with SAM being very close to the aortic valve and all required surgical intervention. The last three patients had mild LVOT obstruction 2 of them with the SAM being > 4mm away from the aortic valve. Six out of the seven patients had intervention while the last one is under clinical follow up currently. PDA closure did not change the outcome. There were no other postoperative complication like developing new AI or developing complete heart block. There was no relation between gender, height, weight or age at diagnosis to the SAM clinical course. CONCLUSION SAM and PDA association is very rare. The underlying pathophysiology is not well understood. When the SAM is closer to aortic valve (≤ 4mm), it carries higher risk of progressive LVOT obstruction. The interventions for SAM and PDA were safe procedures.
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Affiliation(s)
- Hussain Moafa
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Mohammed Alnasef
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - Obayda M. Diraneyya
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | - F Alhabshan
- Department of Cardiac Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
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6
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Shar JA, Brown KN, Keswani SG, Grande-Allen J, Sucosky P. Impact of Aortoseptal Angle Abnormalities and Discrete Subaortic Stenosis on Left-Ventricular Outflow Tract Hemodynamics: Preliminary Computational Assessment. Front Bioeng Biotechnol 2020; 8:114. [PMID: 32175314 PMCID: PMC7056880 DOI: 10.3389/fbioe.2020.00114] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 02/04/2020] [Indexed: 12/27/2022] Open
Abstract
Discrete subaortic stenosis (DSS) is an obstruction of the left ventricular outflow tract (LVOT) due to the formation of a fibromuscular membrane upstream of the aortic valve. DSS is a major risk factor for aortic regurgitation (AR), which often persists after surgical resection of the membrane. While the etiology of DSS and secondary AR is largely unknown, the frequent association between DSS and aortoseptal angle (AoSA) abnormalities has supported the emergence of a mechanobiological pathway by which hemodynamic stress alterations on the septal wall could trigger a biological cascade leading to fibrosis and membrane formation. The resulting LVOT flow disturbances could activate the valve endothelium and contribute to AR. In an effort to assess this hypothetical mechano-etiology, this study aimed at isolating computationally the effects of AoSA abnormalities on septal wall shear stress (WSS), and the impact of DSS on LVOT hemodynamics. Two-dimensional computational fluid dynamics models featuring a normal AoSA (N-LV), a steep AoSA (S-LV), and a steep AoSA with a DSS lesion (DSS-LV) were designed to compute the flow in patient-specific left ventricles (LVs). Boundary conditions consisted of transient velocity profiles at the mitral inlet and LVOT outlet, and patient-specific LV wall motion. The deformation of the DSS lesion was computed using a two-way fluid-structure interaction modeling strategy. Turbulence was accounted for via implementation of the k-ω turbulence model. While the N-LV and S-LV models generated similar LVOT flow characteristics, the DSS-LV model resulted in an asymmetric LVOT jet-like structure, subaortic stenotic conditions (up to 2.4-fold increase in peak velocity, 45% reduction in effective jet diameter vs. N-LV/S-LV), increased vorticity (2.8-fold increase) and turbulence (5- and 3-order-of-magnitude increase in turbulent kinetic energy and Reynolds shear stress, respectively). The steep AoSA subjected the septal wall to a 23% and 69% overload in temporal shear magnitude and gradient, respectively, without any substantial change in oscillatory shear index. This study reveals the existence of WSS overloads on septal wall regions prone to DSS lesion formation in steep LVOTs, and the development of highly turbulent, stenotic and asymmetric flow in DSS LVOTs, which support a possible mechano etiology for DSS and secondary AR.
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Affiliation(s)
- Jason A. Shar
- Department of Mechanical and Materials Engineering, Wright State University, Dayton, OH, United States
| | - Kathleen N. Brown
- Department of Bioengineering, Rice University, Houston, TX, United States
| | - Sundeep G. Keswani
- Division of Pediatric Surgery, Texas Children’s Hospital, Houston, TX, United States
- Department of Surgery, Baylor College of Medicine, Houston, TX, United States
| | - Jane Grande-Allen
- Department of Bioengineering, Rice University, Houston, TX, United States
| | - Philippe Sucosky
- Department of Mechanical and Materials Engineering, Wright State University, Dayton, OH, United States
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Theocharis P, Viola N, Papamichael ND, Kaarne M, Bharucha T. Echocardiographic predictors of reoperation for subaortic stenosis in children and adults. Eur J Cardiothorac Surg 2019; 56:549-556. [PMID: 30805587 DOI: 10.1093/ejcts/ezz046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 01/19/2019] [Accepted: 01/30/2019] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Subaortic stenosis (SAS) can present as various types of obstruction of the left ventricular outflow tract (LVOT) below the level of the aortic valve. Even though corrective surgery has been identified as the most effective treatment, SAS more frequently reoccurs requiring reoperation in a significant proportion of the patients. Previous studies have focused on predictors of recurrence in various subgroups of patients with SAS, but rarely in the overall population of patients with SAS. The aim of this study was to determine the predictors of recurrence of SAS after initial corrective surgery. METHODS Patients from the database of the Congenital Cardiology Department of the University Hospital of Southampton with significant SAS requiring corrective surgery were included in the study. Data retrieved were obtained and used to determine the predictors of SAS recurrence after the initial corrective surgery. RESULTS Eighty-two patients (paediatric, n = 72 and adult, n = 10) who underwent initial successful resection were included in the analysis. Thirty patients required reoperation for recurrent SAS. These were significantly younger (median age 3.0 vs 6.7 years, P = 0.002). The recurrence of SAS was more common in patients with an interrupted aortic arch (23.3% vs 3.8%, P = 0.010) and unfavourable left ventricle geometry (43.3% vs 7.6%, P < 0.001), with steeper aortoseptal angle (131.0° ± 8.7° vs 136.1° ± 8.6°, P = 0.030), shorter distance between the point of obstruction of the LVOT and the aortic valve annulus in systole and diastole (median 4.30 vs 5.90 mm, P = 0.003 and 3.65 vs 4.95 mm, P = 0.006, respectively) and in those who had higher residual peak and mean LVOT gradients postoperatively (29.3 ± 16.0 vs 19.8 ± 10.7 mmHg, P = 0.006 and 15.9 ± 8.3 vs 10.1 ± 5.8 mmHg, P = 0.002, respectively). Overall, the presence of an interrupted aortic arch [odds ratio (OR) 10.34, 95% confidence interval (CI) 1.46-73.25; P < 0.019] and unfavourable left ventricle geometry (OR 10.42, 95% CI 1.86-58.39; P < 0.008) could independently predict reoperation for SAS after initial successful resection. CONCLUSIONS Patients who have initial corrective surgery for SAS at a younger age, unfavourable left ventricle geometry, an interrupted aortic arch and higher early postoperative LVOT gradients are more likely to have recurrent SAS requiring reoperation.
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Affiliation(s)
- Paraskevi Theocharis
- Department of Paediatric Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Nicola Viola
- Department of Congenital Cardiac Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Markku Kaarne
- Department of Congenital Cardiac Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Tara Bharucha
- Department of Paediatric Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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8
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McGregor PC, Manning P, Raj V, Pipilas A, Zhang Y, Rasalingam R, Aragam J. Does Presence of Discrete Subaortic Stenosis Alter Diagnosis and Management of Concomitant Valvular Aortic Stenosis? CASE 2019; 3:77-84. [PMID: 31049485 PMCID: PMC6479215 DOI: 10.1016/j.case.2018.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Adults with SM have slower hemodynamic progression and more rapid AS progression. Changes in LVOT velocities are minimal over time. Presence of SM with AS poses challenges in determining hemodynamic significance. In general, surgery should be recommended when AS is severe and symptoms develop.
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9
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Abushaban L, Uthaman B, Selvan JP, Al Qbandi M, Sharma PN, Mariappa TV. Long-term follow-up and outcomes of discrete subaortic stenosis resection in children. Ann Pediatr Cardiol 2019; 12:212-219. [PMID: 31516277 PMCID: PMC6716322 DOI: 10.4103/apc.apc_120_18] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Background Studies of long-term outcomes of discrete subaortic stenosis (DSS) are rare. Therefore, we reviewed the long-term outcomes of subaortic membrane resection in children with isolated DSS over 16 years from a single institution. Materials and Methods We retrospectively reviewed the records of patients (n = 27) who underwent resection of DSS between 2000 and 2017. Patients with major concomitant intracardiac anomalies were excluded. Indications for surgery were mean left ventricular outflow tract (LVOT), Doppler gradient >30 mmHg, and/or progressive aortic insufficiency. Results The mean age at diagnosis was 3.77 ± 3.49 years (range, 0.25-13 years) and the mean age at surgery was 6.36 ± 3.69 years (range, 1-13 years). All patients underwent resection of subaortic membrane. The mean LVOT Doppler gradient decreased from 40.52 ± 11.41 mmHg preoperatively to 8.48 ± 5.06 mmHg postoperatively (P < 0.001). The peak instantaneous LVOT Doppler gradient decreased from 75.41 ± 15.22 mmHg preoperatively to 18.11 ± 11.44 mmHg postoperatively (P < 0.001). At the latest follow-up, the peak gradient was 17.63 ± 8.93 mmHg. The mean follow-up was 7.47 ± 3.53 years (median 6.33 years; range 2.67-16 years). There was no operative mortality or late mortality. Recurrence of subaortic membrane occurred in 7 (25.92%, 7/27) patients who underwent primary DSS operation. Four (14.81%, 4/27) patients required reoperation for DSS recurrence at a median time of 4.8 years (3.1-9.1 years) after the initial repair. Risk factors for reoperation were age <6 years at initial repair. Eighteen (66.66%, 18/27) patients had AI preoperatively and progression of AI occurred in 70.37% (19/27). This included 4 (22.22%, 4/18) patients who had worsening of their preoperative AI. Short valve-to-membrane distance was found to be prognostically unfavorable. One (3.7%, 1/27) patient had an iatrogenic ventricular septal defect, and 2 (7.4%, 2/27) patients had complete AV block following membrane resection. Conclusions Resection of subaortic membrane in children is associated with low mortality. Higher LVOT gradient, younger age at initial repair, and shorter valve-to-membrane distance were found to be associated with adverse outcome. Recurrence and reoperation rates are high, and progression of aortic insufficiency following subaortic membrane resection is common. Therefore, these patients warrant close follow-up into adult life.
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Affiliation(s)
- Lulu Abushaban
- Department of Pediatrics, Chest Diseases Hospital, Kuwait City, Kuwait.,Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Babu Uthaman
- Department of Pediatrics, Chest Diseases Hospital, Kuwait City, Kuwait.,Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - John Puthur Selvan
- Department of Pediatric Cardiology, Ministry of Health, Chest Diseases Hospital, Kuwait City, Kuwait
| | - Mustafa Al Qbandi
- Department of Pediatric Cardiology, Ministry of Health, Chest Diseases Hospital, Kuwait City, Kuwait
| | - Prem N Sharma
- Health Sciences Center, Faculty of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Thinakar Vel Mariappa
- Department of Pediatric Cardiology, Ministry of Health, Chest Diseases Hospital, Kuwait City, Kuwait
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10
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Mazurek AA, Yu S, Lowery R, Ohye RG. Routine Septal Myectomy During Subaortic Stenosis Membrane Resection: Effect on Recurrence Rates. Pediatr Cardiol 2018; 39:1627-1634. [PMID: 30310939 DOI: 10.1007/s00246-018-1941-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/23/2018] [Indexed: 11/30/2022]
Abstract
Recurrence of subaortic stenosis (SubAS) is up to ~ 19% following resection. Historically, treatment has consisted of membrane resection alone. This study investigated the effect of routine septal myectomy in addition to membrane resection. A single-center retrospective review was performed in all patients < 18 years of age undergoing membrane resection with septal myectomy for SubAS from 2003 to 2013. Demographic, perioperative, and follow-up data were collected. Freedom from reoperation and risk factors for reoperation were determined. 107 patients (median age 4.8 years) were included. There was one in-hospital death, five patients (5%) requiring pacemaker, and no iatrogenic ventricular septal defects. Follow-up was 80% complete and median follow-up was 4.9 years (range 0.5-12 years). Fourteen (16%) subjects required reoperation. Freedom from reoperation was 98% at 1 year, 86% at 5 years, and 69% at 10 years (Fig. 1). There was no difference in decrease of peak gradient between subjects who did and did not require reoperation (- 47 vs. - 40 mmHg; p = 0.59). In univariate analysis, chromosomal anomaly (hazard ratio [HR] 5.0, p = 0.02), smaller body surface area (HR 0.1, p = 0.03), and younger age at surgery (HR 0.7, p = 0.01) were significantly associated with reoperation. The routine use of myectomy with membrane excision did not result in a lower rate of reoperation or higher rates of complications compared to historical controls. Younger age, smaller size, and chromosomal anomaly were associated with increased risk for reoperation. Patients with these risk factors may benefit from more intensive long-term follow-up.
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Affiliation(s)
- Alyssa A Mazurek
- Massachusetts General Hospital, 2 Leighton Street, Unit 310, Cambridge, MA, 02141, USA.
| | - Sunkyung Yu
- Michigan Medicine Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Ray Lowery
- Michigan Medicine Congenital Heart Center, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Richard G Ohye
- Pediatric Cardiovascular Surgery, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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11
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Devabhaktuni SR, Chakfeh E, Malik AO, Pengson JA, Rana J, Ahsan CH. Subvalvular aortic stenosis: a review of current literature. Clin Cardiol 2018; 41:131-136. [PMID: 29377232 DOI: 10.1002/clc.22775] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2017] [Revised: 07/09/2017] [Accepted: 07/15/2017] [Indexed: 12/15/2022] Open
Abstract
Subvalvular aortic stenosis (SAS) is one of the common adult congenital heart diseases, with a prevalence of 6.5%. It is usually diagnosed in the first decade of life. Echocardiography is the test of choice to diagnose SAS. Surgical correction is the best treatment modality, and the prognosis is usually excellent. In this review, we describe the pathophysiology, diagnosis, prognosis, and management of SAS with a focus on different pathophysiologic mechanisms, diagnostic approach, and prognosis of the disease by reviewing the current literature.
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Affiliation(s)
| | - Eyas Chakfeh
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas
| | - Ali O Malik
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas
| | - Joshua A Pengson
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas
| | - Jibran Rana
- Department of Internal Medicine, University of Nevada School of Medicine, Las Vegas
| | - Chowdhury H Ahsan
- Division of Cardiology, University of Nevada School of Medicine, Las Vegas
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12
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Anderson BR, Tingo JE, Glickstein JS, Chai PJ, Bacha EA, Torres AJ. When Is It Better to Wait? Surgical Timing and Recurrence Risk for Children Undergoing Repair of Subaortic Stenosis. Pediatr Cardiol 2017; 38:1106-1114. [PMID: 28508142 PMCID: PMC5987763 DOI: 10.1007/s00246-017-1622-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 05/09/2017] [Indexed: 10/19/2022]
Abstract
Recurrence of subaortic stenosis (SAS) after surgery is common in children. The effects of patient characteristics and surgical timing on disease recurrence are largely unknown. We performed a retrospective study, assessing the relative effects of patient age and left ventricular outflow tract (LVOT) gradient on the need for reoperation for recurrent SAS. We included all children <20 years of age who underwent initial surgical resection of SAS at our center, January 2003-December 2013. Stratified logistic regression was performed, considering the effects of patient demographics, clinical characteristics, echocardiographic parameters, and operative technique, and clustering standard errors by surgeon. The multivariable model was used to simulate predicted probabilities of recurrent SAS for children at varying ages and baseline LVOT gradients. Sixty-three patients (38 males) underwent initial operation for SAS. Patients were followed for a median of 3.7 years (IQR 1.2-7.1). Twenty-one percent of patients (n = 13) underwent reoperation for SAS. Twelve were male. For every 10 mmHg increase in preoperative peak gradient in boys, the odds of reoperation for SAS doubled (OR 2.01, CI 1.5-2.72, p < 0.001), and for every additional 6 months of age, the odds of reoperation decreased by 14% (OR 0.86, CI 0.84-0.88, p < 0.001). Both younger age and higher preoperative outflow tract gradient are independently associated with risk of reoperation. Clinicians should consider the age and rate of LVOT gradient change-and not just the absolute gradient-in determining initial surgical timing.
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Affiliation(s)
- Brett R Anderson
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, 3959 Broadway, CH-2N, New York, NY, 10032-3784, USA.
| | - Jennifer E Tingo
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, 3959 Broadway, CH-2N, New York, NY, 10032-3784, USA
| | - Julie S Glickstein
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, 3959 Broadway, CH-2N, New York, NY, 10032-3784, USA
| | - Paul J Chai
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, USA
| | - Emile A Bacha
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York, USA
| | - Alejandro J Torres
- Division of Pediatric Cardiology, NewYork-Presbyterian/Morgan Stanley Children's Hospital, Columbia University Medical Center, 3959 Broadway, CH-2N, New York, NY, 10032-3784, USA
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13
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Ayoub C, Brieger D, Chard R, Yiannikas J. Fixed left ventricular outflow tract obstruction mimicking hypertrophic obstructive cardiomyopathy: pitfalls in diagnosis. Echocardiography 2016; 33:1753-1761. [PMID: 27613242 DOI: 10.1111/echo.13356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
We present a case series that highlights the diagnostic challenges with left ventricular hypertrophy (LVH) and left ventricular outflow tract obstruction (LVOTO). Fixed structural lesions causing LVOTO with secondary LVH may mimic hypertrophic obstructive cardiomyopathy (HOCM). Management of these two entities is critically different. Misdiagnosis and failure to recognize fixed left ventricular outflow tract (LVOT) lesions may result in morbidity as a result of inappropriate therapy and delay of definitive surgical treatment. It is thus necessary to identify the correct type and level of obstruction in the LVOT by careful correlation of clinical examination, Doppler evaluation, and advanced imaging findings.
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Affiliation(s)
- Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.,The University of Sydney, Sydney, NSW, Australia
| | - David Brieger
- The University of Sydney, Sydney, NSW, Australia.,Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - Richard Chard
- Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia.,Department of Cardiothoracic Surgery, Westmead Hospital, Sydney, NSW, Australia
| | - John Yiannikas
- The University of Sydney, Sydney, NSW, Australia.,Department of Cardiology, Concord Repatriation General Hospital, Sydney, NSW, Australia
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14
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Adler O, Kalidindi S, Butt A, Hussain KMA. Chordae Tendineae Rupture Resulting in Pulmonary Edema in a Patient with Discrete subvalvular Aortic Stenosis. Angiology 2016; 54:613-7. [PMID: 14565639 DOI: 10.1177/000331970305400513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This report concerns an apparently healthy elderly woman who presented with gradually worsening mitral regurgitation secondary to chordae tendineae rupture leading to pulmonary edema in the presence of discrete subvalvular aortic stenosis with a severe gradient reflecting the left ventricular outflow tract obstruction. The gradual worsening of heart failure took place parallel to the increase in severity of mitral regurgitation in a short period. The patient underwent successful mitral valve replacement with myectomy. Surgical inspection revealed rupture of the chordae tendineae to the posterior leaflets without any significant primary intrinsic disease of the mitral valve. The predominant mechanism of chordae tendineae rupture in this patient with discrete subvalvular aortic stenosis is a severe pressure gradient. It is suggested that increased awareness of chordae tendineae rupture as a cause of mitral regur gitation and the prompt use of appropriate diagnostic tools may facilitate the timely recogni tion of this potentially fatal, but treatable, cause of mitral regurgitation in patients with left ventricular outflow tract obstruction.
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Affiliation(s)
- O Adler
- Division of Cardiology, Department of Medicine, Conemaugh Memorial Medical Center, Johnstown, PA, USA
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15
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Bejiqi R, Bejiqi H, Retkoceri R. Echocardiography as a Predicting Method in Diagnosis, Evaluation and Assessment of Children with Subvalvar Aortic Stenosis. Open Access Maced J Med Sci 2016; 4:74-8. [PMID: 27275334 PMCID: PMC4884257 DOI: 10.3889/oamjms.2016.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2015] [Revised: 12/03/2015] [Accepted: 01/08/2016] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND: Obstruction to the left ventricular outflow of the heart may be above the aortic valve (5%), at the valve (74%), or in the subvalvar region (23%). These anomalies represent 3 to 6% of all patients with congenital heart defects (CHD), and it occurs more often in males (male-female ratio of 4:1). AIM: The purpose of this study was to determine the sensitivity and specificity of transthoracic echocardiography in diagnosis of discrete subaortic membrane, to determine convenient time for surgical intervention, and for identifying involvement of the aortic valve by subaortic shelf. MATERIAL AND METHODS: A retrospective review of the medical records and echocardiograms of 18 patients [14 male (77%) and 4 female (23%)] with discrete subaortic membrane, aged 11 month to 12 years, with mean age of 5 years and 3 month, diagnosed at the Pediatric Clinic in Prishtina, during the period September, 1999 and December, 2010 were done. RESULTS: Four patients, in neonatal age were operated from critical coarctation of the aorta and, initial signs of congestive heart failure were presented. 2 of them were operated in Belgrade, Serbia and 2 in Lausanne, Switzerland. CONCLUSION: In all presented patients bicuspid aortic valve was noted, but none of them subaortic membrane was registered.
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Affiliation(s)
- Ramush Bejiqi
- Division of Cardiology, Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Republic of Kosovo
| | - Hana Bejiqi
- Main Center of Family Medicine, Prishtina, Republic of Kosovo
| | - Ragip Retkoceri
- Division of Cardiology, Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Republic of Kosovo
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16
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Tefera E, Gedlu E, Bezabih A, Moges T, Centella T, Marianeschi S, Nega B, van Doorn C, Sasson L, Teodori M. Outcome in Children Operated for Membranous Subaortic Stenosis. World J Pediatr Congenit Heart Surg 2015; 6:424-8. [DOI: 10.1177/2150135115589789] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The optimal surgical procedure for treatment of fibromembranous subaortic stenosis has been a subject of debate. We report our experience with patients treated for membranous subaortic stenosis using membrane resection alone and membrane resection plus aggressive septal myectomy. Methods: Patients followed in the pediatric cardiology clinic of a university hospital, who had undergone surgery for subaortic stenosis between 2002 and 2013 were reviewed. Recurrence of subaortic membrane, residual left ventricular outflow gradient, and aortic valve function were analyzed. Results: Forty-six patients underwent surgery for subaortic membrane. Of these, 19 had membrane resection plus aggressive septal myectomy, while 27 had membrane resection alone. Mean age at surgery for the membrane resection group was 7.7 ± 3.9 years and 10.9 ± 3.6 years for the membrane resection plus aggressive myectomy group. Preoperative subaortic gradient for the membrane resection group was 75.5 ± 26.7 mm Hg and 103.2 ± 39.7 mm Hg for the membrane resection plus aggressive myectomy group. The mean follow-up left ventricular outflow tract gradient was 42.3 ± 31.3 mm Hg in the membrane resection group, while it was 11.6 ± 6.3 mm Hg in the aggressive septal myectomy group. Nine patients from the membrane resection group had significant regrowth of the subaortic membrane during the follow-up period, while none of the aggressive septal myectomy group had detectable membrane on echocardiography. Seven of the nine patients with recurrence of the subaortic membrane underwent subsequent membrane resection plus aggressive septal myectomy. Intraoperative finding in all these redo cases was recurrence (growth) of a subaortic membrane. Conclusion: Aggressive septal myectomy offers less chance of recurrence, freedom from reoperation, and an improved aortic valve function. This is especially important in sub-Saharan settings where a chance of getting a second surgery is unpredictable.
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Affiliation(s)
- Endale Tefera
- Department of Pediatrics and Child Health, Cardiology Division, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Etsegenet Gedlu
- Department of Pediatrics and Child Health, Cardiology Division, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Abebe Bezabih
- Department of Surgery, Cardiothoracic Surgery Unit, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tamirat Moges
- Department of Pediatrics and Child Health, Cardiology Division, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Tomasa Centella
- Department of Cardiovascular Surgery, Ramon y Cajal University Hospital, Madrid, Spain
| | - Stefano Marianeschi
- Department of Cardiothoracic Surgery, Pediatric Cardiac Surgery Unit, Niguarda Hospital, Milan, Italy
| | - Berhanu Nega
- Department of Surgery, Cardiothoracic Surgery Unit, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia
| | - Carin van Doorn
- Congenital Cardiac Unit, Leeds Teaching Hospital NHS Trust, Leeds, United Kingdom
| | - Lior Sasson
- Department of Cardiothoracic Surgery, Wolfson Medical Center, Holon, Israel
| | - Michael Teodori
- Department of Surgery, Pediatric and Adult Congenital Heart Surgery Division, University of Arizona, Tucson, AZ, USA
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17
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Qureshi A, Awuor S, Martinez M. Adult Presentation of Subaortic Stenosis: Another Great Hypertrophic Cardiomyopathy Mimic. Heart Lung Circ 2015; 24:e7-e10. [DOI: 10.1016/j.hlc.2014.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Accepted: 08/08/2014] [Indexed: 10/24/2022]
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18
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Dorobantu DM, Sharabiani MT, Martin RP, Angelini GD, Parry AJ, Caputo M, Stoica SC. Surgery for simple and complex subaortic stenosis in children and young adults: results from a prospective, procedure-based national database. J Thorac Cardiovasc Surg 2014; 148:2618-26. [PMID: 25156466 DOI: 10.1016/j.jtcvs.2014.06.091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 05/26/2014] [Accepted: 06/27/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To identify the outcomes of surgically treated subaortic stenosis in a national population. METHODS From 2000 to 2013, 1047 patients aged < 40 years underwent 1142 subaortic stenosis procedures. Of the 1047 patients, 484 (46.2%) were considered to have complex stenosis (CS) because at or before the first operation they had mitral valve (MV) disease, aortic valve disease, aortic coarctation or an interrupted aortic arch. RESULTS The 30-day mortality was 0.7% for simple stenosis (SS), 2.3% for CS (P = .06), and 1.6% overall. Age < 1 year (P < .01), MV procedure (P = .02) and an interrupted aortic arch at the index procedure (P < .01) were risk factors for early death. Konno-type procedure early mortality was 2.4%. The 12-year survival was 97.1%, with a significant difference between SS and CS (hazard ratio [HR], 4.53; P = .02). Having MV disease alone (HR, 4.11; P = .02), MV disease plus aortic coarctation (HR, 6.73; P = .008), and age < 1 year (HR, 6.72; P < .001) were risk factors for late mortality. Freedom from subaortic reintervention overall was 92.3% and 88.5% at 5 and 12 years, respectively, much greater with CS than with SS (HR, 4.91; P < .0001). The independent risk factors for reintervention were younger age at the index procedure (HR, 0.1/y; P = .002), concomitant MV procedure (HR, 2.68; P = .019), ventricular septal defect plus interrupted aortic arch (HR, 3.19; P = .014), and ventricular septal defect plus aortic coarctation (HR, 2.41; P = .023). Undergoing a concomitant aortic valve procedure at the index procedure was protective (HR, 0.29; P = .025). CONCLUSIONS Patients with SS had excellent outcomes. However, those with CS had worse long-term survival and freedom from reintervention, with morbidity and mortality greatest in young patients with multiple lesions. Additional evaluation in large-scale prospective studies is warranted.
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Affiliation(s)
- Dan M Dorobantu
- University Hospitals Bristol National Health Services Trust, Bristol, United Kingdom
| | | | - Robin P Martin
- University Hospitals Bristol National Health Services Trust, Bristol, United Kingdom
| | - Gianni D Angelini
- University Hospitals Bristol National Health Services Trust, Bristol, United Kingdom; Imperial College, London, United Kingdom
| | - Andrew J Parry
- University Hospitals Bristol National Health Services Trust, Bristol, United Kingdom
| | - Massimo Caputo
- University Hospitals Bristol National Health Services Trust, Bristol, United Kingdom; Rush University Medical Center, Chicago, Ill
| | - Serban C Stoica
- University Hospitals Bristol National Health Services Trust, Bristol, United Kingdom.
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19
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Ezon DS. Fixed subaortic stenosis: a clinical dilemma for clinicians and patients. CONGENIT HEART DIS 2013; 8:450-6. [PMID: 23947905 DOI: 10.1111/chd.12127] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/04/2013] [Indexed: 11/29/2022]
Abstract
Subaortic stenosis carries considerable morbidity and mortality. In most cases, patients have an underlying left ventricular outflow tract morphology that promotes turbulence at the outflow tract, which induces the development of subaortic fibromuscular tissue. A subset of patients will progress to develop severe stenosis and aortic regurgitation, but it has been difficult to determine which patients are at risk. While resection of the subaortic tissue improves immediate outcome, many patients have recurrence of both stenosis and regurgitation, questioning the efficacy of surgical intervention in asymptomatic patients. This review article describes the current understanding of the etiology, treatment, and prognosis of subaortic stenosis.
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Affiliation(s)
- David S Ezon
- Section of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex, USA
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20
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21
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van der Linde D, Roos-Hesselink JW, Rizopoulos D, Heuvelman HJ, Budts W, van Dijk APJ, Witsenburg M, Yap SC, Oxenius A, Silversides CK, Oechslin EN, Bogers AJJC, Takkenberg JJM. Surgical outcome of discrete subaortic stenosis in adults: a multicenter study. Circulation 2013; 127:1184-91, e1-4. [PMID: 23426105 DOI: 10.1161/circulationaha.112.000883] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Discrete subaortic stenosis is notable for its unpredictable hemodynamic progression in childhood and high reoperation rate; however, data about adulthood are scarce. METHODS AND RESULTS Adult patients who previously underwent surgery for discrete subaortic stenosis were included in this retrospective multicenter cohort study. Mixed-effects and joint models were used to assess the postoperative progression of discrete subaortic stenosis and aortic regurgitation, as well as reoperation. A total of 313 patients at 4 centers were included (age at baseline, 20.2 years [25th-75th percentile, 18.4-31.0 years]; 52% male). Median follow-up duration was 12.9 years (25th-75th percentile, 6.2-20.1 years), yielding 5617 patient-years. The peak instantaneous left ventricular outflow tract gradient decreased from 75.7±28.0 mm Hg preoperatively to 15.1±14.1 mm Hg postoperatively (P<0.001) and thereafter increased over time at a rate of 1.31±0.16 mm Hg/y (P=0.001). Mild aortic regurgitation was present in 68% but generally did not progress over time (P=0.76). A preoperative left ventricular outflow tract gradient ≥80 mm Hg was a predictor for progression to moderate aortic regurgitation postoperatively. Eighty patients required at least 1 reoperation (1.8% per patient-year). Predictors for reoperation included female sex (hazard ratio, 1.53; 95% confidence interval, 1.02-2.30) and left ventricular outflow tract gradient progression (hazard ratio, 1.45; 95% confidence interval, 1.31-1.62). Additional myectomy did not reduce the risk for reoperation (P=0.92) but significantly increased the risk of a complete heart block requiring pacemaker implantation (8.1% versus 1.7%; P=0.005). CONCLUSIONS Survival is excellent after surgery for discrete subaortic stenosis; however, reoperation for recurrent discrete subaortic stenosis is not uncommon. Over time, the left ventricular outflow tract gradient slowly increases and mild aortic regurgitation is common, although generally nonprogressive over time. Myectomy does not show additional advantages, and because it is associated with an increased risk of complete heart block, it should not be performed routinely.
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Affiliation(s)
- Denise van der Linde
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
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22
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van der Linde D, Takkenberg JJM, Rizopoulos D, Heuvelman HJ, Budts W, van Dijk APJ, Witsenburg M, Yap SC, Bogers AJJC, Silversides CK, Oechslin EN, Roos-Hesselink JW. Natural history of discrete subaortic stenosisin adults: a multicentre study. Eur Heart J 2012; 34:1548-56. [DOI: 10.1093/eurheartj/ehs421] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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23
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Kim KH, Kim HK, Chang SA, Oh S, Kim KH, Sohn DW. Subaortic membrane late after surgical correction of tetralogy of Fallot. Korean J Intern Med 2012; 27:455-8. [PMID: 23269888 PMCID: PMC3529246 DOI: 10.3904/kjim.2012.27.4.455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 07/28/2008] [Accepted: 08/22/2008] [Indexed: 11/27/2022] Open
Abstract
We herein report a rare case of subaortic stenosis in association with a previous tetralogy of Fallot (TOF) surgical repair, which was not taken into account as a differential diagnosis. Echocardiography plays a pivotal role in identification of this rare combination. Therefore, echocardiography should be performed periodically during follow-up of patients with surgically corrected TOF. Given the clinical complications that can result from subaortic stenosis (i.e., aortic regurgitation and infective endocarditis), early and aggressive management of this rare combination should be performed.
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Affiliation(s)
- Kyung-Hee Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Hyung-Kwan Kim
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Sung-A Chang
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Seil Oh
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
| | - Kyung-Hwan Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Korea
| | - Dae-Won Sohn
- Department of Internal Medicine and Cardiovascular Center, Seoul National University Hospital, Seoul, Korea
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24
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Ibrahim M, Kostolny M, Hsia TY, Van Doorn C, Walker F, Cullen S, Yacoub MH, Tsang VT. The Surgical History, Management, and Outcomes of Subaortic Stenosis in Adults. Ann Thorac Surg 2012; 93:1128-33. [DOI: 10.1016/j.athoracsur.2011.12.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2011] [Revised: 12/22/2011] [Accepted: 12/28/2011] [Indexed: 10/28/2022]
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25
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Saito T, Masai T, Takeda K, Sunagawa G, Sawa Y. A case of successful valve repair for aortic insufficiency associated with discrete subaortic stenosis. Ann Thorac Cardiovasc Surg 2011; 17:521-3. [PMID: 21881383 DOI: 10.5761/atcs.cr.10.01614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Discrete subaortic stenosis (DSS) is an uncommon form of left ventricular outflow tract obstruction especially in adulthood. Moreover, aortic regurgitation (AR), which is a common sequence of DSS, requiring surgical correction is extremely rare. We report the case of a 33-year old man who had severe DSS accompanied with moderate aortic insufficiency. He underwent successful surgery including relief of DSS and aortic valve repair. Although careful follow-up is mandatory for recurrent AR and DSS, our approach was thought to be feasible for a young adult patient with DSS complicated with AR.
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Affiliation(s)
- Tetsuya Saito
- Department of Cardiovascular Surgery, Sakurabashi Watanabe Hospital, 2-4-32 Kitaku, Umeda, Osaka, Japan.
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26
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Laksman ZW, Silversides CK, Sedlak T, Samman AM, Williams WG, Webb GD, Liu PP. Valvular Aortic Stenosis as a Major Sequelae in Patients With Pre-Existing Subaortic Stenosis. J Am Coll Cardiol 2011; 58:962-5. [DOI: 10.1016/j.jacc.2011.04.029] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 04/21/2011] [Accepted: 04/27/2011] [Indexed: 11/28/2022]
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27
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Drolet C, Miro J, Côté JM, Finley J, Gardin L, Rohlicek CV. Long-Term Pediatric Outcome of Isolated Discrete Subaortic Stenosis. Can J Cardiol 2011; 27:389.e19-24. [DOI: 10.1016/j.cjca.2010.12.051] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2010] [Accepted: 03/25/2010] [Indexed: 10/18/2022] Open
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28
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Yamamoto H, Motomura H, Yamachika S, Eishi K, Moriuchi H. Severe subaortic stenosis that progressed over a 12-year period after cardiac surgery. J Med Ultrason (2001) 2009; 36:211. [PMID: 27277442 DOI: 10.1007/s10396-009-0232-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Accepted: 06/11/2009] [Indexed: 10/20/2022]
Abstract
A 12-year-old girl who had undergone cardiac surgery for ventricular septal defect (VSD), atrial septal defect (ASD), and patent ductus arteriosus (PDA) in infancy was referred to our institution for fatigue and excessive sweating. Transthoracic and transesophageal echocardiographic studies revealed tunnel-type subaortic stenosis with aortic valvular stenosis, for which she underwent aortic valve replacement and myomectomy of left ventricular outflow tract. Progression of subaortic stenosis should be considered in patients with only mild aortic valve stenosis after previous cardiovascular surgery. Echocardiography contributed significantly to making the diagnosis and therapeutic decision in our patient.
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Affiliation(s)
- Hirokazu Yamamoto
- Department of Pediatrics, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan.
| | - Hideki Motomura
- Department of Pediatrics, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
| | - Shirou Yamachika
- Department of Cardiovascular Surgery, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Kiyoyuki Eishi
- Department of Cardiovascular Surgery, Nagasaki University School of Medicine, Nagasaki, Japan
| | - Hiroyuki Moriuchi
- Department of Pediatrics, Nagasaki University School of Medicine, 1-7-1 Sakamoto, Nagasaki, 852-8501, Japan
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29
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Bharucha T, Ho SY, Vettukattil JJ. Multiplanar review analysis of three-dimensional echocardiographic datasets gives new insights into the morphology of subaortic stenosis. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2008; 9:614-20. [DOI: 10.1093/ejechocard/jen008] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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30
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Yap SC, Roos-Hesselink JW, Bogers AJJC, Meijboom FJ. Steepened aortoseptal angle may be a risk factor for discrete subaortic stenosis in adults. Int J Cardiol 2008; 126:138-9. [PMID: 17434614 DOI: 10.1016/j.ijcard.2007.01.078] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Accepted: 01/03/2007] [Indexed: 10/23/2022]
Abstract
Discussion exists whether discrete subaortic stenosis (DSS) is a congenital or acquired cardiac defect. Currently, it is regarded an "acquired" cardiac defect presumably secondary to altered flow patterns due to morphological abnormalities in the left ventricular outflow tract, as have been shown by some studies in the pediatric population. In this report, we demonstrated a steepened aortoseptal angle in adults with DSS without previous cardiac surgery in comparison to controls. Our results strengthen the hypothesis that altered flow patterns due to a steepened aortoseptal angle are a substrate for development of DSS in adults.
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31
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Tournoux F, Laurenceau JL, Bellamèche M, Folliguet T, Vedel J. [Infective endocarditis: a potential complication of subaortic membranes]. Ann Cardiol Angeiol (Paris) 2005; 54:138-40. [PMID: 15991469 DOI: 10.1016/j.ancard.2004.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- F Tournoux
- Service de Cardiologie et Urgences Cardiovasculaires, Centre Hospitalier de Lagny-Marne-la-Vallée, 31, Avenue du Général-Leclerc, 77400 Lagny-Sur-Marne, France.
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32
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Freedom RM, Yoo SJ, Russell J, Perrin D, Williams WG. Thoughts about fixed subaortic stenosis in man and dog. Cardiol Young 2005; 15:186-205. [PMID: 15845164 DOI: 10.1017/s1047951105000399] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Robert M Freedom
- Department of Paediatrics, Division of Cardiology, The Hospital for Sick Children, University of Toronto, Tornto M5G 1X8, Canada.
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Giuffre RM, Ryerson LM, Vanderkooi OG, Leung AKC, Collins-Nakai RL. Surgical outcome following treatment of isolated subaortic obstruction. Adv Ther 2004; 21:322-8. [PMID: 15727401 DOI: 10.1007/bf02850036] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Surgical and nonsurgical patients with isolated subaortic stenosis (SAS) were compared to determine the important factors contributing to the timing of surgical intervention. This study reviews 49 consecutive patients (27 surgical and 22 nonsurgical) aged 1.8 to 15.9 years with isolated SAS. The preoperative peak left ventricular outflow tract (LVOT) gradient in surgical patients was significantly higher than the gradient in nonsurgical patients (59.0 +/- 30.4 vs 22.77 +/- 13.9 mm Hg, P = .0001). The progression in LVOT gradient analyzed by echo Doppler was significantly higher in the surgical group compared with the nonsurgical group (10.48 +/- 9.7 vs 1.56 +/- 6.5 mm Hg/y, P = .007). Repeat surgical intervention was required in 22% of patients in the surgical group for recurrence of SAS, and 4% needed a third surgery. The progression in the severity of aortic regurgitation (AR) was not significantly different in the surgical and nonsurgical groups. There was a significant association between the development of AR and patients undergoing surgery (P = .045). AR may not be a reliable indication for early operative intervention in isolated SAS as there was no significant difference in its progression with surgical and nonsurgical patients. Asymptomatic patients with isolated SAS may warrant surgical intervention on the basis of progression of LVOT gradient, rather than the development or progression of AR.
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Affiliation(s)
- R Michael Giuffre
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
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34
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Caldarone CA, Van Natta TL, Frazer JR, Behrendt DM. The modified Konno procedure for complex left ventricular outflow tract obstruction. Ann Thorac Surg 2003; 75:147-51; discussion 151-2. [PMID: 12537208 DOI: 10.1016/s0003-4975(02)03985-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Complex left ventricular outflow tract (LVOT) obstruction with normal aortic valve function requires aggressive resection in the subaortic region and preservation of the aortic valve. The modified Konno procedure allows generous exposure of the LVOT from the left ventricular apex to the inter leaflet trigones of the aortic valve. Widespread use of this procedure has been limited by concern over injury to the aortic valve, the conduction system, and possibility of residual ventricular septal defect (VSD). METHODS Retrospective analysis of pertinent data for all patients undergoing the modified Konno procedure (1994 to 2001) at the University of Iowa were reviewed. RESULTS The modified Konno procedure was used in 18 patients (age 1 to 31) for LVOT obstruction associated with diffuse narrowing of the LVOT (n = 7), a discrete fibrous ring (n = 7), or a fibrous ring associated with abnormal mitral attachments (n = 4). Eight patients had previously undergone LVOT resection. There were no perioperative deaths. Estimated LVOT peak gradients by echocardiogram were 70.4 +/- 24.2 mm Hg (preoperative) and 19.2 +/- 20.4 mm Hg (postoperative) at most recent followup (p < 0.001 vs preop). Aortic insufficiency was moderate in one patient (present preop) and mild or less in all other patients. There were no cases of permanent heart block. Small residual VSDs were present in five patients (28%). Median follow-up is 3.1 years. CONCLUSIONS The modified Konno procedure can effectively relieve complex LVOT obstruction and preserve aortic valve function. Extension of this procedure for use in the initial presentation of LVOT may be appropriate in cases at increased risk of recurrent LVOT obstruction.
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Affiliation(s)
- Christopher A Caldarone
- Division of Cardiothoracic Surgery, Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242, USA.
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Abstract
The discrete form of subaortic stenosis is thought to be an acquired lesion, the aetiology of which may be a combination of factors which include an underlying genetic predisposition, turbulence in the left ventricular outflow tract, and various geometric and anatomical variations of the left ventricular outflow tract. A review of hypotheses relating to its aetiology is provided
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Affiliation(s)
- A M Cilliers
- Division of Paediatric Cardiology, Department of Paediatrics and Child Health, Chris Hani Baragwanath Hospital, University of the Witwatersrand, Johannesburg, South Africa.
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Oliver JM, González A, Gallego P, Sánchez-Recalde A, Benito F, Mesa JM. Discrete subaortic stenosis in adults: increased prevalence and slow rate of progression of the obstruction and aortic regurgitation. J Am Coll Cardiol 2001; 38:835-42. [PMID: 11527642 DOI: 10.1016/s0735-1097(01)01464-4] [Citation(s) in RCA: 98] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVES We sought to determine the prevalence and rate of progression of left ventricular outflow tract obstruction (LVOTO) and aortic regurgitation (AR) in adults with discrete subaortic stenosis (DSS). BACKGROUND Discrete subaortic stenosis is an uncommon form of LVOTO, with rapid hemodynamic progression in children, but the prevalence and rate of progression in adults have not been studied so far. METHODS The prevalence of DSS was determined in 2,057 consecutive adults diagnosed with congenital heart disease (CHD). The relationship between LVOTO on Doppler echocardiography and patient age was analyzed. Sequential changes in LVOTO and AR were determined for patients with two or more Doppler echocardiograms obtained with at least a two-year interval. RESULTS A total of 134 adults (mean age 31 +/- 17 years) were diagnosed with DSS. The prevalence was 6.5% for all adults with CHD. Sixty patients (44%) had other associated CHD. The mean age of 29 patients who had undergone an operation for DSS during their adult life (56 +/- 15 years) was significantly higher than that of 64 patients (27 +/- 13 years) who had not required a surgical intervention (p < 0.0001). A significant relationship between LVOTO and patient age (r = 0.61, p < 0.0001) was found: 21 +/- 16 mm Hg in patients <25 years old, 51 +/- 47 mm Hg for those between 25 and 50 years old, and 78 +/- 36 mm Hg for those >50 years old. The LVOTO increased from 39.2 +/- 28 to 46.8 +/- 34 mm Hg (p = 0.01) during a mean follow-up of 4.8 +/- 1.8 years in 25 patients. The slope of the change in LVOTO was 2.25 +/- 4.7 mm Hg per year of follow-up. Aortic regurgitation was detected by color Doppler imaging in 109 patients (81%), but it was hemodynamically significant in <20%. An increase in the mean degree of AR over time was not significant (baseline: 1.3 +/- 0.8; follow-up: 1.5 +/- 0.9; p = 0.096). CONCLUSIONS The prevalence of DSS is increasing in adults due to the greater number of repaired CHDs that develop into evolutive DSS. In contrast to infants and children, adults with DSS show a slow rate of LVOTO progression. Aortic regurgitation is a common but usually mild and nonprogressive consequence. The current indications for surgical intervention should be revised.
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Affiliation(s)
- J M Oliver
- Adult Congenital Heart Disease Unit, Hospital Universitario La Paz, Madrid, Spain.
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Talwar S, Bisoi AK, Sharma R, Bhan A, Airan B, Choudhary SK, Kothari SS, Saxena A, Venugopal P. Subaortic membrane excision: Mid-term results. Heart Lung Circ 2001; 10:130-5. [PMID: 16352051 DOI: 10.1046/j.1444-2892.2001.00101.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Subaortic membrane (SAM) is a form of fixed subaortic obstruction in which a fibrous membrane is located below the aortic valve. AIM To determine the role of surgical treatment for patients with a discrete SAM. PATIENTS AND METHODS The hospital records of 45 patients (age range: 2-23 years; median 8 years) undergoing surgery for SAM between 1990 and 1998 at the All India Institute of Medical Sciences, New Delhi, India, were analysed. Preoperative echocardiographically calculated gradients across the left ventricular outflow tract ranged from 50 to 154 mmHg (mean: 86.5 +/- 33.2 mmHg). Nine patients had trivial aortic regurgitation (AR), 10 had mild AR and five had moderate-severe AR. The left ventricular ejection fraction (LVEF) ranged from 20 to 68% (mean 48 +/- 15%). Nineteen patients had significant left ventricular dysfunction (LVEF <50%). Transaortic resection of SAM was done in all patients along with excision of a wedge-shaped segment of septal muscle underlying the membrane. RESULTS There were no early or late postoperative deaths. On follow up (up to 113 months), only four patients had gradients >30 mmHg. LVEF improved to 45-70% (mean 58 +/- 7.7%). AR reduced to mild in four patients and trivial in four patients, and did not progress further. CONCLUSION Resection of SAM carries long-term benefits. Routine septal myectomy appears to be associated with a low risk of recurrence.
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Affiliation(s)
- S Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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French A, Luis Fuentes V, Dukes-McEwan J, Darke PG, Martin M, Corcoran B. Progression of aortic stenosis in the boxer. J Small Anim Pract 2000; 41:451-6. [PMID: 11072913 DOI: 10.1111/j.1748-5827.2000.tb03140.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Thirty-five boxers that had been referred to the Royal (Dick) School of Veterinary Studies between 1989 and 1994 with left heart base murmurs and aortic velocities greater than 1.5 m/second on Doppler echocardiography were recalled for clinical examination and Doppler echocardiography between 1995 and 1996. Five dogs (14 per cent) showed an increase in murmur grade on repeat visit. Six dogs (17 per cent) showed an increase in aortic velocity of greater than 20 per cent. Eight dogs (23 per cent) had developed aortic valvular or subvalvular two-dimensional echocardiographic changes that had not been present at the initial visit. Seven dogs (20 per cent) had developed aortic regurgitation, and three dogs (8 per cent) mitral regurgitation.
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Affiliation(s)
- A French
- Department of Veterinary Clinical Studies, Royal School of Veterinary Studies, Hospital for Small Animals, University of Edinburgh, Easter Bush Veterinary Center, Roslin, Midlothian
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Tutar HE, Atalay S, Türkay S, Gümüş H, Imamoglu A. Echocardiographic, morphologic, and geometric variations of the left ventricular outflow tract: possible role in the pathogenesis of discrete subaortic stenosis. Angiology 2000; 51:213-21. [PMID: 10744009 DOI: 10.1177/000331970005100305] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Although the clinical features and natural course of discrete subaortic stenosis (DSS) are well defined, the etiology remains speculative. The purpose of this study was to identify the echocardiographic, morphologic, and geometric variations of the left ventricular outflow tract associated with DSS in children and to determine whether these variations have a role in the pathogenesis of DSS. The aortoseptal angle (ASA), mitral-aortic valve separation (MAS), and the size of the aortic annulus were determined in two groups of children. Group 1 comprised 11 patients with isolated DSS, who were compared with an age- and body surface area- (BSA) matched healthy children (Group 1A, n: 20). Group 2 comprised 10 patients with DSS and ventricular septal defect (VSD). Group 2 was compared with an age- and BSA-matched patients with isolated perimembranous VSD (Group 2A, n: 22). Measurements were carried out from previously recorded echocardiographic studies. The ASA was steeper (119.3 +/- 6.1 degrees vs 137.5 +/- 5.6 degrees , p < 0.001), and the MAS was wider (6.1 +/- 1.6 vs 3.2 +/- 0.7 mm, p < 0.001) in patients with isolated DSS than in healthy control subjects. Similar differences were found between patients in Group 2 and Group 2A; the ASA was steeper (122.2 +/- 6.5 degrees vs 141.3 +/- 5.0 degrees, p < 0.001), and the MAS was wider (5.8 +/- 1.5 vs 3.8 +/- 1.1 mm, p < 0.001). The size of the aortic annulus was not different among the four study groups. Although the MAS was significantly wider in patients with DSS, there was significant overlap in MAS between patients and controls. However, if an ASA < or = 130 degrees was chosen as a predictive variable, it was found to be a highly sensitive, specific, and positive predictive marker for the development of DSS. This study demonstrates that DSS is associated with a steeper ASA, and a wider MAS, in patients with or without associated VSD. These morphologic abnormalities, especially a steeper ASA, may be risk factors for the development of DSS.
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Affiliation(s)
- H E Tutar
- Ankara University Faculty of Medicine, Department of Pediatric Cardiology, Turkey.
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Raff GW, Gaynor JW, Weinberg PM, Spray TL, Gleason M. Membranous subpulmonic stenosis associated with ventricular septal defect and aortic insufficiency. J Am Soc Echocardiogr 2000; 13:58-60. [PMID: 10625832 DOI: 10.1016/s0894-7317(00)90043-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
We present a case report of a patient with conal septal hypoplasia (supracristal) ventricular septal defect (VSD) complicated by aortic insufficiency (AI) and subpulmonic stenosis from a fibrous membrane. The development of AI with VSD is a well-recognized problem. However, the association of VSD, AI, and significant right ventricular outflow tract obstruction (RVOTO) is less common. Mechanisms of RVOTO include prolapse of an aortic valve cusp across the VSD, as well as infundibular hypertrophy or muscle bundles. Technical echocardiographic issues can make the diagnosis of VSD, AI, and RVOTO challenging. The presence of a discrete fibrous subpulmonary membrane is uncommon in this setting.
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Affiliation(s)
- G W Raff
- Divisions of Cardiothoracic Surgery and Cardiology, The Children's Hospital of Philadelphia, PA 19104-4399, USA
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Rohlicek CV, del Pino SF, Hosking M, Miro J, Côté JM, Finley J. Natural history and surgical outcomes for isolated discrete subaortic stenosis in children. Heart 1999; 82:708-13. [PMID: 10573499 PMCID: PMC1729222 DOI: 10.1136/hrt.82.6.708] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To document the natural history and surgical outcomes for discrete subaortic stenosis in children. DESIGN Retrospective review. SETTING Tertiary care paediatric cardiology centres. PATIENTS 92 children diagnosed between 1985 and 1998. MAIN OUTCOME MEASURES Echocardiographic left ventricular outflow gradient (echograd), and aortic insufficiency (AI). RESULTS The mean (SEM) age at diagnosis was 5.3 (0.4) years; the mean echograd was 30 (2) mm Hg, with AI in 22% (19/87) of patients. The echograd and incidence of AI increased to 35 (3) mm Hg and 53% (36/68) (p < 0.05) 3.6 (0.3) years later. The echograd at diagnosis predicted echograd progression and appearance of AI. 42 patients underwent surgery 2.2 (0.4) years after diagnosis. Preoperatively echograd and AI incidence increased to 58 (6) mm Hg and 76% (19/25) (p < 0.05). The echograd was 26 (4) mm Hg 3.7 (0.4) years postoperatively, with AI in 82% (31/38) of patients. Surgical morbidities included complete heart block, need for prosthetic valves, and iatrogenic ventricular septal defects. Eight patients underwent reoperation for recurrent subaortic stenosis. The age at diagnosis of 44 patients followed medically and 42 patients operated on did not differ (5.5 (0.6) v 5. 0 (0.6) years, p < 0.05). However, the echograd at diagnosis in the former was less (21 (2) v 40 (5) mm Hg, p < 0.05) and did not increase (23 (2) mm Hg) despite longer follow up (4.1 (0.4) v 2.2 (0. 4) years, p < 0.05). The incidence of AI at diagnosis and at last medical follow up was also less (14% (6/44) v 34% (13/38); 40% (17/43) v 76% (19/25), p < 0.05). CONCLUSIONS Many children with mild subaortic stenosis exhibit little progression of obstruction or AI and need not undergo immediate surgery. Others with more severe subaortic stenosis may progress precipitously and will benefit from early resection despite risks of surgical morbidity and recurrence.
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Affiliation(s)
- C V Rohlicek
- Division of Cardiology, Montréal Children's Hospital, 2300 Tupper Street, Montréal, Québec H3H 1P3, Canada
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Khoshnevis R, Barasch E, Pathan A, Christy GW, Massumi GA, Ott DA, Wilansky S. Echocardiographic diagnosis of left ventricular outflow tract obstruction caused by an acquired subaortic membrane after mitral valve replacement. J Am Soc Echocardiogr 1999; 12:319-23. [PMID: 10231618 DOI: 10.1016/s0894-7317(99)70053-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Although an acquired subaortic membrane has been reported as a cause of left ventricular outflow tract (LVOT) obstruction in various clinical settings, it previously has not been reported after mitral valve surgery. We describe 3 cases of acquired LVOT obstruction that resulted from development of a subaortic membrane after mitral valve replacement. This report emphasizes the role of an acquired subaortic membrane in LVOT obstruction after mitral valve replacement, the use of echocardiography in diagnosing this condition, and the importance of early intervention.
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Affiliation(s)
- R Khoshnevis
- Department of Cardiology, Texas Heart Institute and St Luke's Episcopal Hospital, Houston, Tex. 77030, USA
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Parry AJ, Kovalchin JP, Suda K, McElhinney DB, Wudel J, Silverman NH, Reddy VM, Hanley FL. Resection of subaortic stenosis; can a more aggressive approach be justified? Eur J Cardiothorac Surg 1999; 15:631-8. [PMID: 10386409 DOI: 10.1016/s1010-7940(99)00060-3] [Citation(s) in RCA: 62] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Discrete subaortic stenosis causes left ventricular outflow tract (LVOT) obstruction and often produces aortic regurgitation (AR) which alone may precipitate surgical intervention. Conventional resection relieves the obstruction, but the recurrence rate is high, and the AR is little changed as the thick fibrous membrane which extends onto the valve leaflets remains. We studied whether an aggressive surgical approach could reduce both the severity of AR and rate of recurrence of obstruction associated with discrete subaortic stenosis, and whether this aggressive approach could be justified. METHODS Between June 1992 and April 1996, 37 patients aged 0.5-35 years (median 7.5) underwent resection of a discrete subaortic membrane. Ten underwent re-operation for recurrent obstruction and eight followed previous ventricular septal defect closure. LVOT gradient was measured using the modified Bernoulli equation and AR was graded on a scale of 0-4 (0 = none, 4 = severe). Postoperative assessment was performed early (<7 days) and at mid-term (27.0 months; range 2-59 months). RESULTS There was significant improvement in AR from mild/moderate to none/trivial (P = 0.019) immediately postoperatively and LVOT gradient from 66.9+/-30.4 to 15.1+/-12.2 mmHg (P < 0.0001). By stepwise logistic regression preoperative gradient correlated significantly with postoperative mild/moderate AR (P = 0.015) and LVOT gradient (P = 0.0036). Preoperative mild/moderate AR also correlated with postoperative mild/moderate AR (P = 0.034). Five patients developed complete heart block, four undergoing reoperation for recurrent obstruction, and one preoperatively had right bundle branch block from previous ventricular septal defect repair. At mid-term follow-up there was no increase in AR or LVOT gradient (14.8+/-12.8 mmHg). Early post-operative AR was the strongest predictor of late mild/moderate AR (P = 0.02). Early post-operative gradient was a weaker predictor (P = 0.04). Pre-operative and early post-operative gradient were significant predictors of late gradient (P = 0.0038; <0.0001, respectively). No patient required reoperation for recurrent obstruction; one underwent late aortic valve replacement for severe AR. CONCLUSIONS An aggressive surgical approach to discrete subaortic stenosis produces excellent relief of obstruction and frees the valve leaflets, significantly reducing associated AR at early and mid-term follow-up with low morbidity for primary operation. Long-term follow-up is required to confirm whether this early benefit is maintained.
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Affiliation(s)
- A J Parry
- Department of Pediatric Cardiac Surgery, The University of California, San Francisco, USA
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Abstract
OBJECTIVE To determine the anatomic variables in the left ventricular outflow tract in patients with subaortic stenosis. METHODS Between 1982 and 1996, 36 patients were operated on with the 'discrete' form of subaortic stenosis (DSS). The mean time of follow up was 7.4 years with a range of 4 months-14 years. There were 25 male and 11 female patients. Mean age at operation was 7.1 years with a range of 9 months-47 years. RESULTS At the time of surgery, the mitral valve apparatus and interventricular septum were found to be rotated 60-90 degrees in a counterclockwise fashion with anterior displacement into the left ventricular outflow tract in 30 (83%) patients. Subaortic ridge resection with a deep septal myectomy was performed in 32 patients and the remaining four patients had subaortic ridge resection alone. The reoperation free rate at 5 and 10 years were 74+/-9% and 60+/-12%, respectively. Reoperations for recurrent disease were performed in 10 (27.7%) patients. No operative or late follow up deaths were encountered. CONCLUSION We conclude that DSS is an acquired disease due to a pre-existing anatomic alteration in the mitral valve apparatus and interventricular septum. In addition, recurrence rates are high and physicians should not be mislead by the benign nomenclature its name implies.
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Affiliation(s)
- T D Lampros
- Division of Cardiopulmonary Surgery, Oregon Health Sciences University, Portland 97201-3098, USA
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Thomas L, Foster E. Membranous subaortic stenosis presenting decades after surgical correction for tetralogy of Fallot. J Am Soc Echocardiogr 1998; 11:206-8. [PMID: 9517560 DOI: 10.1016/s0894-7317(98)70078-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Subaortic stenosis is rare in the middle-aged adult. Its association with tetralogy of Fallot is extremely rare. We report two middle-aged patients, presenting three decades after surgical repair of tetralogy of Fallot, with the rare association of subaortic stenosis. The clinical presentation in each patient mimicked residual pulmonary stenosis and insufficiency, but echocardiography revealed subaortic stenosis with associated valvular aortic regurgitation.
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Affiliation(s)
- L Thomas
- Division of Cardiology, University of California San Francisco, 94143-0214, USA
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Bezold LI, Smith EO, Kelly K, Colan SD, Gauvreau K, Geva T. Development and validation of an echocardiographic model for predicting progression of discrete subaortic stenosis in children. Am J Cardiol 1998; 81:314-20. [PMID: 9468074 DOI: 10.1016/s0002-9149(97)00911-9] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The clinical course of discrete subaortic stenosis (DSS) varies considerably between patients. This study was performed to identify echocardiographic characteristics of DSS that distinguish progressive from nonprogressive disease. The study included 100 patients from 2 institutions and was performed in 2 stages. In phase I, a prediction model was developed based on multivariate analysis of morphometric and Doppler variables obtained from the initial echocardiogram in 52 children with DSS from Texas Children's Hospital. In phase II, the performance characteristics of the prediction model were tested in 48 patients with DSS followed at Children's Hospital in Boston. Patients were divided into 3 outcome groups: nonprogressive, progressive, and intermediate progression. In phase I, multivariate analysis identified 3 independent predictors of progressive disease: indexed aortic valve to subaortic membrane distance, anterior mitral leaflet involvement, and initial Doppler gradient. The logistic regression equation--Probability = [1 + e-(-322+0.334X1+4.06X2-0.708X3)](-1), where X = initial gradient in mm Hg; X2 = absence (0) or presence (1) of mitral leaflet involvement; and X3 = indexed distance between aortic valve and subaortic membrane in mm/body surface area0.5 were used to predict progression. When the prediction model was applied to phase II study patients, none of the patients with nonprogressive DSS had a prediction value > 0.29 and none of the patients with progressive DSS had a prediction value < 0.58. Thus, a prediction value > 0.55 yielded a 100% sensitivity and 100% specificity for distinguishing progressive from nonprogressive DSS. Patients with intermediate progression were indistinguishable from progressive DSS but were clearly separable from nonprogressing patients. We conclude that progressive subaortic obstruction in children with DSS can be predicted from morphologic, morphometric, and Doppler echocardiographic analysis of left ventricular outflow.
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Affiliation(s)
- L I Bezold
- Department of Cardiology, Children's Hospital, Harvard Medical School, Boston, Massachusetts 02115, USA
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Cape EG, Vanauker MD, Sigfússon G, Tacy TA, del Nido PJ. Potential role of mechanical stress in the etiology of pediatric heart disease: septal shear stress in subaortic stenosis. J Am Coll Cardiol 1997; 30:247-54. [PMID: 9207650 DOI: 10.1016/s0735-1097(97)00048-x] [Citation(s) in RCA: 95] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The objective of this study was to show elevations in septal shear stress in response to morphologic abnormalities that have been associated with discrete subaortic stenosis (SAS) in children. Combined with the published data, this critical connection supports a four-stage etiology of SAS that is advanced in this report. BACKGROUND Subaortic stenosis constitutes up to 20% of left ventricular outflow obstruction in children and frequently requires surgical removal, and the lesions may reappear unpredictably after the operation. The etiology of SAS is unknown. This study proposes a four-stage etiology for SAS that I) combines morphologic abnormalities, II) elevation of septal shear stress, III) genetic predisposition and IV) cellular proliferation in response to shear stress. METHODS Morphologic structures of a left ventricular outflow tract were modeled based on measurements in patients with and without SAS. Septal shear stress was studied in response to changes in aortoseptal angle (AoSA) (120 degrees to 150 degrees), outflow tract convergence angle (45 degrees, 22.5 degrees and 0 degree), presence/location of a ventricular septal defect (VSD) (3-mm VSD; 2 and 6 mm from annulus) and shunt velocity (3 and 5 m/s). RESULTS Variations in AoSA produced marked elevations in septal shear stress (from 103 dynes/cm2 for 150 degrees angle to 150 dynes/cm2 for 120 degrees angle for baseline conditions). This effect was not dependent on the convergence angle in the outflow tract (150 to 132 dynes/cm2 over full range of angles including extreme case of 0 degree). A VSD enhanced this effect (150 to 220 dynes/cm2 at steep angle of 120 degrees and 3 m/s shunt velocity), consistent with the high incidence of VSDs in patients with SAS. The position of the VSD was also important, with a reduction of the distance between the VSD and the aortic annulus causing further increases in septal shear stress (220 and 266 dynes/cm2 for distances of 6 and 2 mm from the annulus, respectively). CONCLUSIONS Small changes in AoSA produce important changes in septal shear stress. The levels of stress increase are consistent with cellular flow studies showing stimulation of growth factors and cellular proliferation. Steepened AoSA may be a risk factor for the development of SAS. Evidence exists for all four stages of the proposed etiology of SAS.
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Affiliation(s)
- E G Cape
- Cardiac Dynamics Laboratory, Division of Cardiology, Children's Hospital of Pittsburgh, Pennsylvania 15213, USA
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Sigfússon G, Tacy TA, Vanauker MD, Cape EG. Abnormalities of the left ventricular outflow tract associated with discrete subaortic stenosis in children: an echocardiographic study. J Am Coll Cardiol 1997; 30:255-9. [PMID: 9207651 DOI: 10.1016/s0735-1097(97)00151-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES The purpose of this study was to examine the echocardiographic abnormalities of the left ventricular outflow tract associated with subaortic stenosis in children. BACKGROUND Considerable evidence suggests that subaortic stenosis is an acquired and progressive lesion, but the etiology remains unknown. We have proposed a four-stage etiologic process for the development of subaortic stenosis. This report addresses the first stage by defining the morphologic abnormalities of the left ventricular outflow tract present in patients who develop subaortic stenosis. METHODS Two study groups were evaluated-33 patients with isolated subaortic stenosis and 12 patients with perimembranous ventricular septal defect and subaortic stenosis-and were compared with a size- and lesion-matched control group. Subjects ranged in age from 0.05 to 23 years, and body surface area ranged from 0.17 to 2.3 m2. Two independent observers measured aortoseptal angle, aortic annulus diameter and mitral-aortic separation from previously recorded echocardiographic studies. RESULTS The aortoseptal angle was steeper in patients with isolated subaortic stenosis than in control subjects (p < 0.001). This pattern was also true for patients with ventricular septal defect and subaortic stenosis compared with control subjects (p < 0.001). Neither age nor body surface area was correlated with aortoseptal angle. A trend toward smaller aortic annulus diameter indexed to patient size was seen between patients and control subjects but failed to achieve statistical significance (p = 0.08). There was an excellent interrater correlation in aortoseptal angle and aortic annulus measurement. The mitral-aortic separation measurement was unreliable. Our results, specifically relating steep aortoseptal angle to subaortic stenosis, confirm the results of other investigators. CONCLUSIONS This study demonstrates that subaortic stenosis is associated with a steepened aortoseptal angle, as defined by two-dimensional echocardiography, and this association holds in patients with and without a ventricular septal defect. A steepened aortoseptal angle may be a risk factor for the development of subaortic stenosis.
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Affiliation(s)
- G Sigfússon
- Cardiac Dynamics Laboratory, Division of Cardiology, Children's Hospital of Pittsburgh, Pennsylvania 15213, USA
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Sharma S, Stamper T, Dhar P, Emge F, Bailey J, Kanter K, Williams W, Fyfe D. The Usefulness of Transesophageal Echocardiography in the Surgical Management of Older Children with Subaortic Stenosis. Echocardiography 1996; 13:653-662. [PMID: 11442985 DOI: 10.1111/j.1540-8175.1996.tb00951.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Subaortic stenosis is a complex lesion that often presents in older children and adolescents. A clear depiction of the lesion is required for optimization of surgery. Due to the large size of these patients, is not always possible from surface echocardiography. Intraoperative multiplane echocardiography (MTEE) has been performed at our institute in older children for several different congenital heart lesions including many patients with subaortic stenosis. A retrospective analysis of our experience with MTEE in patients with subaortic stenosis was performed to assess its usefulness in the preoperative diagnosis and postoperative assessment of repair. Our results show that intraoperative MTEE was useful preoperatively by correcting or confirming suspected diagnosis, and giving additional details of the lesion in many patients. Postoperatively, MTEE was highly useful in the assessment of repair. We strongly recommend the use of intraoperative MTEE in older children and adolescents with subaortic stenosis. (ECHOCARDIOGRAPHY, Volume 13, November 1996)
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Affiliation(s)
- Shiva Sharma
- The Children's Heart Center, 2040 Ridgewood Dr., NE, Atlanta, GA 30322
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