Long-term results of conservative repair of rheumatic aortic valve insufficiency

Twenty-five years' experience with isolated bicuspid aortic valve repair: impact of commissural orientation

OBJECTIVES

Repair of the bicuspid aortic valve (BAV) has evolved in the past 25 years. The aim of this study was to review and analyse the long-term durability of isolated BAV repair with particular focus on commissural orientation (CO).

METHODS

All patients who underwent BAV repair for severe aortic regurgitation between October 1998 and December 2022 were included. The study group consists of all patients operated after 2009, i.e. since CO modification. The control group includes patients who were operated before 2009. CO was classified as symmetric, asymmetric and very asymmetric.

RESULTS

Overall, 594 adult patients (93% male; mean age 42 years) were included. At 15 years, survival was 94.8% [standard deviation (SD): 2.2]; freedom from reoperation was 86.8% (SD: 2.3). Freedom from aortic insufficiency ≥II was 70.8% (SD: 4.7) at 15 years. Modification of CO by sinus plication was performed in 200 (33.7%) instances. Using competing risks analysis, the absence of effective height measurement (P = 0.018), very asymmetric CO (P = 0.028), the presence of calcification (P < 0.001), the use of pericardial patch (P < 0.001), the use of subcommissural sutures (P < 0.001) and preoperative endocarditis (P = 0.005) were identified as independent predictors for reoperation. Follow-up was 97% complete (4228 patient-years); mean follow-up was 7 years (SD: 5).

CONCLUSIONS

Isolated BAV repair leads to good survival and durability in all morphologic types if cusp repair is guided by effective height, suture annuloplasty is performed, and CO is modified using sinus plication in asymmetrical valves. Very asymmetrical valves may should be treated with a lower threshold for replacement.

Aortic valve repair for isolated right coronary leaflet prolapse

Objectives

Isolated right coronary leaflet prolapse is a common cause of nonaneurysmal aortic insufficiency, but can rarely occur in patients with proximal aortic aneurysms. Standardized techniques for routine autologous repair of this disorder are presented.

Methods

Most aortic valve leaflet prolapse is isolated to the right coronary leaflet, with hypertension and annular dilatation being contributory. Echocardiographically, a posteriorly eccentric aortic insufficiency jet together with "fracture" of the right leaflet tip are diagnostic. Primary repair includes internal geometric ring annuloplasty to downsize and reshape the annulus, together with central plication of the prolapsing leaflet. Thickened, scarred, or retracted noduli are released using an ultrasonic aspirator. The goal is to achieve equivalent coaptation heights of ≥8 mm for all 3 leaflets.

Results

Three videos of 6 cases are provided to illustrate these techniques. In the first, 3 patients are shown with classic isolated right leaflet prolapse. In the second and third videos, alternative pathologies are presented for contrast. Applying the reconstructive approaches of geometric ring annuloplasty, leaflet plication, and ultrasonic nodular release, excellent early and late repair outcomes are obtainable in most patients.

Conclusions

The combination of aortic ring annuloplasty, central leaflet plication, and ultrasonic nodular release allows routine and standardized repair of right coronary leaflet prolapse, either isolated or concomitant with aneurysm surgery.

Rapid anticalcification treatment for glutaraldehyde-fixed autologous tissue in cardiovascular surgery

Background

Glutaraldehyde (GA)-fixed autologous tissues, including the pericardium, are widely used as patches and valve substitutes in cardiovascular surgery. However, GA treatment causes tissue calcification. No rapid anticalcification method has been established for use during surgery. Here, we aimed to establish a rapid anticalcification method using ethanol, as has already been demonstrated for bioprosthetic valves.

Methods

Thoracic aorta tissues were first fixed with GA for 3 min and then treated with ethanol for 0 (group 2), 10 (group 3), 20 (group 4), and 30 (group 5) min; untreated tissues (group 1) served as the control. The treated tissues were subdermally implanted into 3-week-old male Wistar rats and kept in place for 28 days. The calcification in each explant was semiquantitatively evaluated by annotating and measuring the area using virtual slides, and the data obtained were statistically analyzed.

Results

Semiquantitative analysis revealed that calcification of the implants from the untreated group (group 1; P = 0.0014) and groups 4 (P = 0.0014) and 5 (P = 0.0031) was significantly lower than that of implants from group 2. Moreover, implants from group 3 showed a tendency toward decreased calcification, although it was not significant (P = 0.0503).

Conclusions

A rapid ethanol treatment prevents calcification of GA-fixed tissues in a rat model of subdermal implantation. This method may facilitate effective and rapid anticalcification of autologous tissues for use during cardiovascular surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-022-01895-7.

Early Outcomes of Patients Undergoing Neoaortic Valve Repair Incorporating Geometric Ring Annuloplasty

OBJECTIVES

During congenital heart surgery, the pulmonary valve and root may be placed into the systemic position, yielding a "neoaortic" valve. With the stress of systemic pressure, the pulmonary roots can dilate, creating aneurysms and/or neoaortic insufficiency (neoAI). This report analyzes the early outcomes of patients undergoing neoaortic valve repair incorporating geometric ring annuloplasty.

METHODS

Twenty-one patients underwent intended repair at six centers and formed the study cohort. Thirteen had previous Ross procedures, five had arterial switch operations, and three Fontan physiology. Average age was 21.7 ± 12.8 years (mean  ±  SD), 80% were male, and 11 (55%) had symptomatic heart failure. Preoperative neoAI Grade was 3.1  ±  1.1, and annular diameter was 30.7  ±  6.5 mm.

RESULTS

Valve repair was accomplished in 20/21, using geometric annuloplasty rings and leaflet plication (n = 13) and/or nodular release (n = 7). Fourteen had neoaortic aneurysm replacement (13 with root remodeling). Two underwent bicuspid valve repair. Six had pulmonary conduit changes, one insertion of an artificial Nodulus Arantius, and one resection of a subaortic membrane. Ring size averaged 21.9  ±  2.3 mm, and aortic clamp time was 171  ±  54 minutes. No operative mortality or major morbidity occurred, and postoperative hospitalization was 4.3  ±  1.4 days. At discharge, neoAI grade was 0.2  ±  0.4 (P < .0001), and valve mean gradient was ≤20 mm Hg. At average 18.0  ±  9.1 months of follow-up, all patients were asymptomatic with stable valve function.

CONCLUSIONS

Neoaortic aneurysms and neoAI are occasionally seen late following Ross, arterial switch, or Fontan procedures. Neoaortic valve repair using geometric ring annuloplasty, leaflet reconstruction, and root remodeling provides a patient-specific approach with favorable early outcomes.

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

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

Aortic Valve Repair in Young Patients: A Single Patch Design for Leaflet Extension

The surgical treatment for young patients with aortic valve diseases has not been standardized because of differences in the patients' growth. We aimed to investigate short-term results of aortic valve repair with leaflet extension techniques. From October 2017 to June 2020, we performed aortic valve repair with leaflet extension technique in 15 consecutive patients with a median age of 13 years (range, 33 months-27 years). Among them, all had moderate or severe aortic regurgitation (AR), eight had concomitant aortic stenosis, and 12 underwent prior cardiac operations. The leaflet patch design has been modified from separate patch design to single patch design. No early and late deaths were reported, no re-operations were performed, and temporary ectopic atrial arrhythmia was the only early complication noted. The patients were discharged with less than moderate AR after a median postoperative period of 5 (range, 3-7) days. All the patients were New York Heart Association class I after a median follow-up period of 17.3 (range, 4.4-34.6) months. However, two patients progressed to moderate AR postoperatively at 6 and 30 months, respectively, after which one was treated with single patch technique. Among the remaining patients, six had trace, six had mild, and one had mild-to-moderate AR. Aortic valve repair with leaflet extension is acceptable in young patients. Our single patch design was easy to manipulate and showed good short-term results. Long-term follow-up is required to further confirm the efficacy of this technique.

Short-term outcomes of aortic valve neocuspidization for various aortic valve diseases

Objectives

Bioprosthetic valve deterioration remains a major limitation following aortic valve replacement. Favorable results have been reported with an autologous pericardium aortic valve neocuspidization.

Methods

Seventy patients (31 women and 39 men) (mean age, 62 ± 12 years) with aortic stenosis (n = 52 [74%]) or aortic regurgitation (n = 18 [26%]) underwent the aortic valve neocuspidization procedure. Thirty-four patients (49%) had a tricuspid valve, 35 (50%) had a bicuspid valve, and 1 (1%) had a monocuspid valve. European System for Cardiac Operative Risk Evaluation and Society of Thoracic Surgeons scores were, respectively, 2.2% ± 2% and 2.0% ± 1.8%. Four patients (6%) had active endocarditis and 2 (3%) had endocarditis sequelae. One patient (1%) had fibroelastoma. A combined procedure was performed in 33 patients (46%).

Results

The follow-up period was 24 ± 12 months. One patient (1%) died in hospital and 1 patient (1%) underwent conventional valve replacement for significant aortic regurgitation. Postoperative peak and mean pressure gradients were respectively 14 ± 5 and 8 ± 3 mm Hg. Aortic valve area was 2.5 ± 0.6 cm². During follow-up, no patients died. Reintervention occurred in 2 patients (3%). At last follow-up, peak pressure gradient was 13 ± 7 mm Hg, mean pressure gradient was 7 ± 4 mm Hg, and aortic valve area was 2.3 ± 0.7 cm². There was 1 recurrence of moderate aortic stenosis (1%). All patients were in New York Heart Association functional class I (90%) or II (10%). Freedom from major valve-related events was 92.1%, (98.5% for death, 95.2% for reintervention, and 95.2% for endocarditis).

Conclusions

In our experience, the midterm outcomes of the aortic valve neocuspidization procedure with autologous glutaraldehyde fixed pericardium were acceptable for survival, operative risk and valve-related complications, for our all-comer patient population with various aortic valve diseases.

Rheumatic Double Valve Repair Using Two Remodeling Annuloplasty Rings

Mitral valve repair is well developed, and it allows for successful reconstruction of selected rheumatic valve pathologies. Rheumatic aortic valve repair also has been successful, using techniques such as Nodular unfolding. Aortic ring annuloplasty is currently available, and when used in conjunction with appropriate leaflet procedures, it could promote rheumatic repair by restoring annular geometry and facilitating leaflet reconstruction. This report describes rheumatic double valve repair in a patient with rheumatic dysfunction of both the aortic and mitral valves.

Is autologous or heterologous pericardium better for valvuloplasty? A comparative study of calcification propensity

Pericardial calcification is detrimental to the long-term durability of valvuloplasty. However, whether calcification susceptibility differs between heterologous and autologous pericardium is unclear. In this study, we compared the progression of calcification in vivo between autologous and heterologous pericardium. We randomly divided 28 rabbits into 4 equal groups. Resected rabbit pericardium served as autologous pericardium, and commercial bovine pericardium served as heterologous pericardium. We subcutaneously embedded one of each pericardial patch in the abdominal walls of 21 of the rabbits. The 7 control rabbits (group A) received no implants. The embedded samples were removed at 2 months in group B, at 4 months in group C, and at 6 months in group D. Each collected sample was divided into 2 parts, one for calcium-content measurement by means of atomic-absorption spectroscopy, and one for morphologic and histopathologic examinations. When compared with the autologous pericardium, calcium levels in the heterologous pericardium were higher in groups B, C, and D (P <0.0001, P <0.0002, and P <0.0006, respectively). As embedding time increased, calcium levels in the heterologous pericardium increased faster than those in the autologous, especially in group D. Disorganized arrangements of collagenous fibers, marked calculus, and ossification were seen in the heterologous pericardium. Inflammatory cells-mainly lymphocytes and small numbers of macrophages-infiltrated the heterologous pericardium. The autologous pericardium showed a stronger ability to resist calcification. Our results indicate that autologous pericardium might be a relatively better choice for valvuloplasty.

In vitro study of a standardized approach to aortic cusp extension

PURPOSE

Cusp extension technique (CET) is a reparative surgical procedure for restoring aortic valve function by suturing patches to the compromised native leaflets. Its outcomes are strongly dependent on the ability of the surgeon. We proposed and tested a novel approach on an in vitro model, aimed at standardizing and simplifying the surgical procedure.

METHODS

A set of standard pre-cut bovine pericardium patches, available in different sizes, was developed. The surgeon can choose the leaflet-specific patches to be implanted according to the patient anatomy, using a geometrical model of the aortic valve whose inputs are the measured intercommissural distances. The hemodynamic performance of this approach was evaluated on porcine aortic roots in a pulsatile mock loop. Hydrodynamic and kinematic evaluation of the samples was provided.

RESULTS

After CET, mean and maximum pressure drops were 3.1±1.3 mmHg and 25.4±5.0 mmHg respectively, and EOA was 3.8±0.8 cm.

CONCLUSIONS

Our approach to cusp extension proved to be reliable and effective in restoring valve functioning, without significantly altering the physiological kinematics. The use of pre-cut patches considerably simplified the surgery, increasing standardization and repeatability.

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

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

Attitude after a mild aortic valve lesion during rheumatic mitral valve surgery

OBJECTIVE

We evaluated whether rheumatic aortic valve disease of mild degree should be treated in patients undergoing mitral valve surgery.

METHODS

From 1992 to 2010, 197 patients (aged 52 [19-82] years, male:female = 60:137) who had rheumatic mitral valve disease and mild aortic valve disease were enrolled. The aortic valve was untreated in 114 patients (no treatment group), repaired in 40 patients (aortic valvuloplasty group), and replaced in 43 patients (aortic valve replacement group).

RESULTS

Operative mortality occurred in 4 patients (2.0%). There were no differences in early mortality and postoperative complications among the 3 groups. Overall survival at 5, 10, and 15 years was 96.3%, 92.1%, and 85.7%, respectively. In the no treatment group, progression-free survival in significant aortic valve disease at 5, 10, and 15 years was 98.7%, 91.3%, and 81.1%, respectively. This was not superior in the aortic valvuloplasty group (85.9%, 77.6%, and 69.8%, respectively) than in the no treatment group. Freedom from aortic valve disease was lower in patients with aortic stenosis than in those with aortic regurgitation in univariate and multivariable analyses (P < .001). Reoperation was performed in 19 patients, including 2 aortic valve reoperations. Aortic valve-related event-free survival was similar among the 3 groups.

CONCLUSIONS

Mild aortic valve disease in patients undergoing rheumatic mitral valve surgery could be left untreated, because preventive aortic valve operation does not result in better clinical and echocardiographic outcomes.

Aortic valve repair--current status, indications, and outcomes

Aortic valve repair is a new development with old roots. In the past 20 years, marked progress has been made in understanding the normal anatomy of the aortic valve and the interrelation between cusps and root. Aortic dilatation is the single most frequent pathogenetic factor in aortic regurgitation, accompanied by cusp pathology, that is, prolapse or congenital anomaly in most industrialized countries. Frequently, aortic and cusp pathology coexist. Different operative techniques have been established for correction of aortic and cusp pathology. Experience has shown that the combined application of repair procedures will lead to good results if normal valve and cusp configuration is achieved. Some congenital anomalies may require design alteration of the aortic valve. Low-operative mortality rates have been reported consistently. When adequate repair durability is achieved, the incidence of valve-related complications is lower than what has been reported for valve replacement. Aortic valve repair is currently in transition from surgical improvisation to a reproducible operation and an option for many patients with aortic regurgitation. Current research focuses on some special aspects, such as stabilization of the basal ring, ideal material and technique for cusp replacement, and more objective information on ideal valve configuration.

Selective tricuspidization and aortic cusp extension valvuloplasty: outcome analysis in infants and children

BACKGROUND

Encouraging early outcomes of emerging aortic cusp extension valvuloplasty techniques have redirected attention to nonreplacement strategies in the management of younger patients with aortic insufficiency or aortic stenosis. Outcome analysis after aortic cusp extension valvuloplasty in infants and children was undertaken.

METHODS

From July 1987 to December 2008, 78 patients younger than 10 years of age underwent aortic cusp extension valvuloplasty in the form of pericardial cusp extension and selective use of tricuspidization. Sixteen (20.5%) patients were younger than 1 year of age. Twenty-seven had bicuspid aortic valve, 34, congenital aortic valve stenosis, and 17, congenital or acquired aortic insufficiency or aortic stenosis. Forty-two patients had balloon valvuloplasty or surgical valvotomy before aortic cusp extension valvuloplasty. Median follow-up was 12.4 years (range, 0.1 to 21.6 years). Freedom from aortic valve replacement (AVR) and determinants of outcome were analyzed.

RESULTS

There were no early or late deaths. During the follow-up period, 23 patients (29.5%) had Ross operation and 8 patients (10.2%) had other AVR. The z values of left ventricular end-diastolic dimension, aortic annulus, aortic sinus diameter, sinotubular junction diameter, and left ventricular wall thickness before AVR were 3.8 +/- 2.95, 2.1 +/- 1.15, 4.2 +/- 1.22, 1.78 +/- 1.24, and 2.92 +/- 1.31, respectively. Actuarial freedom from AVR at 1, 5, and 10 years was 97.3 +/- 2.0%, 71.3 +/- 5.8%, and 55.6 +/- 6.9%, respectively.

CONCLUSIONS

Aortic cusp extension valvuloplasty with tricuspidization allows left ventricular reverse remodeling with satisfactory long-term durability and freedom from AVR. Used selectively, it represents a reliable and effective approach in infants and children with congenital or acquired abnormal aortic valve.

Aortic cusp extension valvuloplasty with or without tricuspidization in children and adolescents: long-term results and freedom from aortic valve replacement

OBJECTIVE

Aortic cusp extension valvuloplasty is increasingly used in the management of children and adolescents with aortic stenosis or regurgitation. The durability of this approach and the freedom from valve replacement are not well defined. A study was undertaken to investigate outcomes.

METHODS

From July 1987 to November 2008, 142 patients aged less than 19 years underwent aortic cusp extension valvuloplasty in the form of pericardial cusp extension and tricuspidization (when needed). Three patients with truncus arteriosus and severe truncal valve insufficiency were excluded. From the available follow-up data of 139 patients, 50 had bicuspid aortic valves, 40 had congenital aortic valve stenosis, 41 had combined congenital aortic valve stenosis/insufficiency, and 8 had other diagnoses. Median follow-up was 14.4 years (0.1-21.4). Long-term mortality and freedom from aortic valve replacement were studied.

RESULTS

There were no early, intermediate, or late deaths. Z-values of left ventricular end-diastolic dimension, aortic annulus, aortic sinus diameter, and sinotubular junction diameter before aortic valve replacement were 4.2 +/- 3.11, 2.3 +/- 1.25, 4.4 +/- 1.23, and 1.84 +/- 1.28, respectively. During the follow-up period, 64 patients underwent aortic valve reinterventions. The Ross procedure was performed in 32 of 139 patients (23%) undergoing aortic cusp extension valvuloplasty. Other aortic valve replacements were undertaken after 16 aortic cusp extension valvuloplasties (11.5%). Freedom from a second aortic cusp extension valvuloplasty or aortic valve replacement at 18 years was 82.1% +/- 4.2% and 60.0% +/- 7.2%, respectively.

CONCLUSION

Aortic cusp extension valvuloplasty is a safe and effective surgical option with excellent survival and good long-term outcomes in children and adolescents. The procedure provides acceptable durability and satisfactory freedom from aortic valve replacement.

Cusp shaving for concomitant mild to moderate rheumatic aortic insufficiency

BACKGROUND

The aim of this study was to assess the early and mid-term results of patients who underwent cardiac operations due to cardiac pathologies other than aortic valve (AV) disease, but also had mild-to-moderate aortic valve insufficiency that was repaired during the same session.

METHODS

A total of 43 patients who underwent AV repair for mild-to-moderate aortic insufficiency between January 2003 and February 2009, in addition to the procedure performed for their main pathology necessitating the surgical intervention, were included in the present study. Cardiac function was evaluated, before and after the operation.

RESULTS

Hospital mortality rate was 4.6% (two patients). After the operations, significant improvements were observed in aortic insufficiency (0.57 +/- 0.50 vs. 2.86 +/- 0.48, p = 0.001), New York Heart Association class (1.08 +/- 0.28 vs. 3.03 +/- 0.44, p = 0.001), and left atrial diameter (47.37 +/- 9.28 vs. 42.35 +/- 7.02; p = 0.001). However, left ventricular end diastolic and end-systolic diameters remained unchanged. Two patients were re-operated for AV disease during the follow-up period; thus, at five years, the rate of freedom from re-operation due to AV pathology was 90.7 +/- 6.3%.

CONCLUSIONS

Cusp shaving is a feasible option that can be performed with low risk for concomitant aortic insufficiency.

Aortic Valve-Sparing Repair with Autologous Pericardial Leaflet Extension Has Low Long-Term Mortality and Reoperation Rates in Children and Adults

OBJECTIVES

We sought to establish whether there was a difference in outcome after aortic valve repair with autologous pericardial leaflet extension in pediatric and adult populations.

METHODS

In our study, 128 patients (pediatric and adult) underwent valvular pericardial extension repair at our institution from 1997 through 2006. The patients were divided into either the pediatric group (< or =18 years of age; n = 54/128, 42%), with a mean age of 8.4 +/- 5.4 (range, 0-17 years), or the adult group (n = 74/128, 58%), with a mean age of 48.9 +/- 19.7 (range, 19-85 years). The endpoints of the study were mortality and reoperation rates.

RESULTS

Thirty-day mortality for the adult group was 0, and for the pediatric group it was 1/54 (1.8%), with no statistical difference (P = .1) between the groups. Late mortality for the pediatric group was 2/54 (3.7%) and in the adult group was 2/74 (2.7%). There was no statistical difference (P = .12) between the groups. In the pediatric group, there were 6 total reoperations (6/54) in 5 patients, with one patient undergoing reoperation twice. From these 6 cases, 3 were re-repair and 3 had aortic valve replacement; the mean interval between original repair and reoperation was 4.3 +/- 2.5 years (range, 0.1-7.7 years). In the adult group, there were 5 total reoperations (5/74). From these 5 cases, 3 had aortic valve replacement and 2 re-repair; the mean interval between original repair and reoperation was 3.5 +/- 3 years (range, 0.1-7 years). There was no statistical difference in the reoperation rate between the 2 groups (P= .38). At late follow-up, 82% of all patients in the adult group had no aortic regurgitation or only a trace (grades 0 and 1) and 78% of all patients in the pediatric group had no aortic regurgitation or only a trace (grades 0 and 1). There was no statistical difference in either aortic regurgitation (P = .06) or aortic stenosis (P = .28) between the 2 groups.

CONCLUSIONS

Aortic valve repair with autologous pericardial leaflet extension has low mortality and morbidity rates, as well as good mid-term durability in both the pediatric and the adult groups.

Current Perspective on Aortic Valve Repair and Valve-Sparing Aortic Root Replacement

Aortic valve repair and valve-sparing aortic root replacement are attractive concepts because they offer the possibility of valve competence without structural deterioration due to nonviability and they preclude the need for anticoagulation. Enthusiasm for aortic valve repair has waxed and waned over the past 45 years due in part to the inherent technical difficulties and poor mid-term results. Renewed interest in the concept of aortic valve repair has paralleled the development of valve-sparing aortic root replacement over the last 20 years. A current perspective on aortic valve repair and valve-sparing aortic root replacement is presented in the following review. Historical background, indications for repair, technical considerations, and outcomes data are discussed.

Aortic Valve Repair for Rheumatic Aortic Valve Disease

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Aortic valve repair

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

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

OBJECTIVES

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Valve repair for aortic insufficiency: surgical classification and techniques

OBJECTIVE

Valve repair for aortic insufficiency may provide an alternative to aortic valve replacement in selected patients. This repair could be an attempt at permanent correction or palliation to allow the aortic annulus to grow and avoid the use of anticoagulation. Based upon a five-year experience, we proposed a classification according to valvular anatomy which could be a guide to patient and procedure selection.

METHODS

Between September 1989 and February 1995, 44 consecutive patients underwent aortic valvuloplasty for aortic incompetence at our institution. Patients' ages ranged from 19 months to 76 years with a mean of 33 years. The etiology of aortic incompetence was congenital in 30 patients, degenerative in 7 patients, rheumatic in 5 patients, and infective endocarditis in 2. Aortic valve lesions were classified into three different types: type I, aortic annular dilation (8 patients); type II, excessive aortic leaflet tissue (12 patients); and type III, restricted leaflet motion with or without deficient leaflet tissue (24 patients). Type I needed commissural plication in 7 patients; and aortic annuloplasty, which was simple in 6 patients, and pericardial-augmented in 2. Type II necessitated midleaflet excision in 11 patients and leaflet plication in 7. Type III required leaflet extension in 19 patients, leaflet replacement in 1 patient, aortic valve commissurotomy in 13 patients augmentation commissurorrhaphy in 2, leaflet shaving in 4, and repair of leaflet perforation in 2.

RESULTS

Postoperative echocardiography revealed a significant decrease in the degree of aortic incompetence. Mean follow-up was 2.6 +/- 1.4 years. There was no mortality. Patients improved as is evident by NYHA functional class postoperatively. Eight of the first 13 patients (18%) needed reoperation. Three of these reoperations were bail-out procedures, and 3 patients (7%) who underwent the leaflet extension technique were reoperated upon 19 months to 3 years later. Presently, 23 patients are without anticoagulation, 11 take aspirin and 2 receive coumadin for combined mitral procedures.

CONCLUSIONS

Aortic valve repair provides a low risk option with satisfactory intermediate-term results for the treatment of aortic insufficiency in appropriately selected patients. Patient and procedure selection may be based upon the echocardiographic anatomy of the aortic valve, and a comparative risk benefit appraisal with valve replacement.

Surgery for aortic regurgitation in women. Contrasting indications and outcomes compared with men

BACKGROUND

Indications for surgical correction of aortic regurgitation have been established mostly in men and have not been validated in women. The outcome of this surgical correction in women is unknown.

METHODS AND RESULTS

Baseline characteristics and postoperative outcomes were compared between 51 women and 198 men undergoing surgery for isolated aortic regurgitation between 1980 and 1989. Compared with men, women had surgery rarely for severe left ventricular enlargement (systolic diameter > or = 55 mm in 11% versus 27%, P = .031; diastolic diameter > or = 80 mm in 0% versus 16%, P < .0001) and more often for class III to IV symptoms (59% versus 32%, P < .0001). Operative mortalities were similar in women and men (3.9% and 4.5%, respectively). Among operative survivors, 10-year survival was worse for women than for men (39 +/- 9% versus 72 +/- 4%, P = .0002) and, in contrast with men, was worse than expected for women (P < .0001). Independent predictors of late survival were different for men (age and ejection fraction) and women (age and concomitant coronary bypass grafting). By multivariate analysis, female sex was an independent predictor of worse late survival (adjusted relative risk, 1.80; 95% CI, 1.04 to 3.11).

CONCLUSIONS

The generalization to women of the unadjusted left ventricular diameter surgical criteria established in men results in irrelevant criteria almost never reached in women, who often undergo surgery after developing severe symptoms. After surgery, women exhibit an excess late mortality, suggesting that surgical correction of aortic regurgitation should be considered at an earlier stage in women.

Color Doppler and two-dimensional echocardiographic determination of the mechanism of aortic regurgitation with surgical correlation

The character of the color flow Doppler jet provides information on the mechanism and pathologic elements of valve dysfunction. This has been useful in the evaluation of mitral regurgitation, a repairable problem, but has not been described comprehensively for the aortic valve. The purpose of our study was to correlate the color flow Doppler characteristics of the aortic regurgitant jet and two-dimensional echocardiographic findings of valve mobility with surgical pathology. Prepump intraoperative echocardiography and color flow Doppler echocardiography were performed on 124 patients with aortic regurgitation and used to categorize leaflet motion as excessive, restricted, or normal, jet direction as eccentric or central, and jet origin between the cusps as eccentric, central, or diffuse. Bicuspid disease and tricuspid aortic valve prolapse were associated with excessive valve mobility and eccentric jet direction and origin. Conversely, annular dilation, rheumatic disease, sclerosis, and perforation were associated with normal or reduced cusp mobility and a central jet direction and origin (p = 0.001). Overall, an eccentric jet direction occurred in 69% of patients with excessive cusp mobility, whereas 71% of patients with normal or reduced cusp mobility had a central jet (p = 0.001). Therefore color flow Doppler determination of the eccentricity of regurgitant jet direction and origin is useful in predicting the mechanism and disease of aortic valve dysfunction. These observations may suggest the presence of prolapse and thus the potential for aortic valve repair.

Pulmonary autograft for aortic valve replacement in rheumatic disease: a caveat

Pulmonary autograft replacement of the aortic valve offers an attractive option in the younger patient with growth potential and long-term survival. In our institution between January 1990 and August 1994, 78 patients have undergone this procedure. The mean age was 18.6 +/- 7.36 years (range, 1 to 41 years). The etiology was rheumatic in 63 patients (80.7%). Aortic regurgitation was the predominant lesion in 60 patients (76.9%). Significant mitral regurgitation requiring operation was present in 22 patients (28.2%). All patients underwent pulmonary autograft replacement of the diseased aortic valve and the mitral valve was repaired in 22 patients. There were no hospital mortality, endocarditis, or thromboembolism in the series up to date. There have been two late non-cardiac deaths. Five patients (6.4%) required reoperation, one for mitral repair failure and four for autograft failure. Acute rheumatic valvulitis was demonstrated in one of the reoperated patients. Echocardiography of 68 patients followed up more than 2 months show progression of aortic regurgitation more than 2/4+ in 12 patients (15.4%). Four of these patients have been reoperated without mortality. In conclusion, although the Ross procedure remains a safe and attractive alternative in aortic valve operation, the progression of aortic regurgitation, especially in the younger patient with rheumatic etiology, remains a concern.

New Trends in Aortic Valve Surgery: A critical Review of Standard Prosthesis v. Stentless Replacement and Repair

Different alternatives for the surgical treatment of aortic valve disease have been recently introduced. All consecutive patients who underwent aortic valve surgery between July 1988 and March 1994 were reviewed. There were 674 patients with a mean age of 32.4 years, mean preoperative functional class of 2.82, and rheumatic etiology in 59% of the cases. The patients were divided into 3 groups: Group I. standard aortic valve replacement with biological and mechanical prosthesis ( n = 313); Group II. stentless aortic valve replacement using homograft, pulmonary autograft and reconstruction with pericardium ( n = 145); and Group HI. aortic valve repair ( n = 216). The hospital mortality was 6.07% for the standard, 0.68% for the stentless, and 3.70% for the repair. Total follow-up was 1,304.75 patient years with a mean of 21.93 months. The actuarial survival at 66 months excluding hospital mortality was 85.24 ± 4.59% in the standard replacement, 92.63 ± 4.03% in the stentless, and 91.20 ± 3.02% in the repair group. The highest incidence of reoperation corresponded to the repair group with an actuarial freedom from reoperation of 74.26 ±7.03%, v. 92.52 ±4.52% in the standard and 85.11 ± 6.71% in the stentless group. There were no thromboembolic events in the isolated aortic valve survivors in both the stentless and repair groups and 1.28% patient years in the standard. We conclude that both the stentless aortic valve replacement and the aortic repair represent a good alternative v. standard replacement, especially for those young rheumatic patients in which anticoagulation and durability of the prosthesis is still a problem.

Aortic valve reconstruction in the young

Aortic valve replacement in the young patient, and particularly in women of child-bearing age, still represents a problem. Between July 1988 and August 1993, 644 aortic valve patients (mean age 32.5 years) were operated in our institution. Aortic valve reconstruction was performed in 274 (42.5%). A variety of repair techniques (valvuloplasty) was used in 202 patients (mean age 21.5 years). Concomitant mitral surgery was performed in 103 (51%). In 72 patients (mean age 27.7 years), a cusp extension was undertaken with glutaraldehyde treated bovine (27 pts) or autologous (45 pts) pericardium. In the "plasty" group, there were 8 (4%) hospital deaths and 8 (4.1%) late deaths with an actuarial survival of 86.05% +/- 3.97%. No thromboembolic events were detected in patients with isolated aortic surgery. There were 32 reoperations without mortality, 22 due to progressive rheumatic disruption of the mitral repair. There was severe aortic dysfunction in 17 (8.76%) cases. There was no hospital mortality among the 72 patients with cusp extensions. There were two (2.8%) late deaths and no thromboembolic events. No patient was anticoagulated. Four patients required reoperation on the aortic valve without mortality. The last echocardiographic follow-up showed stability of the reconstruction. These techniques offer a valid alternative to valve replacement in this difficult category of patients.

Lunular hypertrophy and aortic valve disease

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

Intraoperative echocardiography: techniques and current applications

Intraoperative echocardiography has opened new dimensions in the evaluation of cardiac surgical patients, and has contributed significantly to the improved surgical results. The use of intraoperative echocardiography has enabled the surgeon to image the working heart, to define the operative anatomy and physiology, and to evaluate the results immediately before the patients leave the operating room. This review summarizes the current status and applications of intraoperative echocardiography in the practice of cardiac surgery.

Repair of asymptomatic aortic valve disease during other cardiac surgery

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

Indications and limitations of aortic valve reconstruction

To elucidate the value of conservative operation for aortic regurgitation, all consecutive patients operated on between July 1988 and July 1990 were reviewed. Of 251 patients with aortic regurgitation, 107 (42.6%) had nonprosthetic operation. The mean age was 23 years, and 90 patients (84.1%) were rheumatic. Two techniques were used: repair (annular and leaflet plasties, 69 cases) and cusp extension with glutaraldehyde-treated pericardium (25 bovine, 13 autologous). There were two hospital deaths (1.8%), both in the repair group, and no late deaths or embolic events. Only 5 patients (4.7%) were anticoagulated. In the repair group there were 12 reoperations, four (5.9%) due to aortic and eight to mitral dysfunction. In the cusp extension group there were two reoperations due to mitral dysfunction. Echocardiographic follow-up showed better results with cusp extension. In conclusion, conservative operation for aortic regurgitation is possible in a high percentage of young rheumatic patients and does not require anticoagulation. Cusp extension is more reliable than repair in terms of early results, although its long-term durability is not yet known.