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Ross F, Everhart K, Latham G, Joffe D. Perioperative and Anesthetic Considerations in Pediatric Valvar and Subvalvar Aortic Stenosis. Semin Cardiothorac Vasc Anesth 2023; 27:292-304. [PMID: 37455142 DOI: 10.1177/10892532231189933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Aortic stenosis (AS) is a common form of left ventricular outflow tract obstruction (LVOTO) in children with congenital heart disease. This review specifically considers the perioperative features of valvar (VAS) and subvalvar AS (subAS) in the pediatric patient. Although VAS and subAS share some clinical features and diagnostic approaches, they are distinct clinical entities with separate therapeutic options, which range from transcatheter intervention to surgical repair. We detail the pathophysiology of AS and highlight the range of treatment strategies with a focus on anesthetic considerations for the care of these patients before, during, and after intervention.
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Affiliation(s)
- Faith Ross
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Cardiac Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Kelly Everhart
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Cardiac Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Greg Latham
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Cardiac Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
| | - Denise Joffe
- Department of Anesthesiology and Pain Medicine, Division of Pediatric Cardiac Anesthesiology, Seattle Children's Hospital, Seattle, WA, USA
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2
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Kahraman N, Topal D, Coşkun G, Tiryakioğlu SK, Topal S, Altunal AM, Binicier NA, Demir D. Surgical treatment of recurrent subvalvular discrete membrane and left ventricular outflow tract stenosis in an adult patient with a history of congenital cardiac surgery. Echocardiography 2023; 40:279-284. [PMID: 36721975 DOI: 10.1111/echo.15531] [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: 12/24/2022] [Accepted: 01/08/2023] [Indexed: 02/02/2023] Open
Abstract
Left ventricular outflow stenosis can develop at the supravalvular, valvular, and subvalvular levels. Resection of strictures at the diffuse subvalvular level is very difficult. In such pathologies, Konno-Rastan procedure provides very successful solutions as an anterior aortoventriculoplasty method. In this article, we performed anterior aortaventriculoplasty surgical treatment for tunnel type left ventricular outflow tract stenosis, recurrent subvalvular discrete membrane, and aortic regurgitation in an adult patient with a history of partial atrioventricular septal defect repair and subvalvular discrete membrane resection operation in early childhood. The Konno-Rastan procedure, which we applied to the redo case, which is rarely used in adult patients and rarely seen in the literature, is shared.
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Affiliation(s)
- Nail Kahraman
- Department of Cardiovasculary Surgery, Bursa City Hospital, University of Health Sciences, Bursa, Turkey
| | - Dursun Topal
- Department of Cardiology, Bursa City Hospital, University of Health Sciences, Bursa, Turkey
| | - Gültekin Coşkun
- Department of Cardiovasculary Surgery, Bursa City Hospital, University of Health Sciences, Bursa, Turkey
| | | | - Serra Topal
- Department of Anesthesiology and Reanimation, Bursa City Hospital, University of Health Sciences, Bursa, Turkey
| | - Ayşe Merve Altunal
- Department of Cardiovasculary Surgery, Bursa City Hospital, University of Health Sciences, Bursa, Turkey
| | - Nöfel Ahmet Binicier
- Department of Cardiovasculary Surgery, Bursa City Hospital, University of Health Sciences, Bursa, Turkey
| | - Deniz Demir
- Department of Cardiovasculary Surgery, Bursa City Hospital, University of Health Sciences, Bursa, Turkey
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3
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Shar JA, Keswani SG, Grande-Allen KJ, Sucosky P. Computational Assessment of Valvular Dysfunction in Discrete Subaortic Stenosis: A Parametric Study. Cardiovasc Eng Technol 2021; 12:559-575. [PMID: 33432514 DOI: 10.1007/s13239-020-00513-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Accepted: 12/22/2020] [Indexed: 01/16/2023]
Abstract
PURPOSE Discrete subaortic stenosis (DSS) is a left-ventricular outflow tract (LVOT) obstruction caused by a membranous lesion. DSS is associated with steep aortoseptal angles (AoSAs) and is a risk factor for aortic regurgitation (AR). However, the etiology of AR secondary to DSS remains unknown. This study aimed at quantifying computationally the impact of AoSA steepening and DSS on aortic valve (AV) hemodynamics and AR. METHODS An LV geometry reconstructed from cine-MRI data was connected to an AV geometry to generate a unified 2D LV-AV model. Six geometrical variants were considered: unobstructed (CTRL) and DSS-obstructed LVOT (DSS), each reflecting three AoSA variations (110°, 120°, 130°). Fluid-structure interaction simulations were run to compute LVOT flow, AV leaflet dynamics, and regurgitant fraction (RF). RESULTS AoSA steepening and DSS generated vortex dynamics alterations and stenotic flow conditions. While the CTRL-110° model generated the highest degree of leaflet opening asymmetry, DSS preferentially altered superior leaflet kinematics, and caused leaflet-dependent alterations in systolic fluttering. LVOT steepening and DSS subjected the leaflets to increasing WSS overloads (up to 94% increase in temporal shear magnitude), while DSS also increased WSS bidirectionality on the inferior leaflet belly (+ 0.30-point in oscillatory shear index). Although AoSA steepening and DSS increased diastolic transvalvular backflow, regurgitant fractions (RF < 7%) remained below the threshold defining clinical mild AR. CONCLUSIONS The mechanical interactions between AV leaflets and LVOT steepening/DSS hemodynamic derangements do not cause AR. However, the leaflet WSS abnormalities predicted in those anatomies provide new support to a mechanobiological etiology of AR secondary to DSS.
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Affiliation(s)
- Jason A Shar
- Department of Mechanical and Materials Engineering, Wright State University, Dayton, USA
| | - Sundeep G Keswani
- Division of Pediatric Surgery, Department of Surgery, Texas Children's Hospital, Baylor College of Medicine, Houston, USA
| | | | - Philippe Sucosky
- Department of Mechanical Engineering, Kennesaw State University, 840 Polytechnic Lane, Marietta, GA, 30060, USA.
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4
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Massé DD, Shar JA, Brown KN, Keswani SG, Grande-Allen KJ, Sucosky P. Discrete Subaortic Stenosis: Perspective Roadmap to a Complex Disease. Front Cardiovasc Med 2018; 5:122. [PMID: 30320123 PMCID: PMC6166095 DOI: 10.3389/fcvm.2018.00122] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 08/17/2018] [Indexed: 12/13/2022] Open
Abstract
Discrete subaortic stenosis (DSS) is a congenital heart disease that results in the formation of a fibro-membranous tissue, causing an increased pressure gradient in the left ventricular outflow tract (LVOT). While surgical resection of the membrane has shown some success in eliminating the obstruction, it poses significant risks associated with anesthesia, sternotomy, and heart bypass, and it remains associated with a high rate of recurrence. Although a genetic etiology had been initially proposed, the association between DSS and left ventricle (LV) geometrical abnormalities has provided more support to a hemodynamic etiology by which congenital or post-surgical LVOT geometric derangements could generate abnormal shear forces on the septal wall, triggering in turn a fibrotic response. Validating this hypothetical etiology and understanding the mechanobiological processes by which altered shear forces induce fibrosis in the LVOT are major knowledge gaps. This perspective paper describes the current state of knowledge of DSS, articulates the research needs to yield mechanistic insights into a significant pathologic process that is poorly understood, and proposes several strategies aimed at elucidating the potential mechanobiological synergies responsible for DSS pathogenesis. The proposed roadmap has the potential to improve DSS management by identifying early targets for prevention of the fibrotic lesion, and may also prove beneficial in other fibrotic cardiovascular diseases associated with altered flow.
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Affiliation(s)
- Danielle D Massé
- Department of Mechanical and Materials Engineering, Wright State University, Dayton, OH, United States
| | - 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
| | | | - Philippe Sucosky
- Department of Mechanical and Materials Engineering, Wright State University, Dayton, OH, United States
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5
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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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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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7
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Kamioka N, Patel A, Lerakis S, Parastatidis I, Forcillo J, Corrigan F, Thourani V, Block P, Babaliaros V. Transcatheter Treatment of Subaortic Stenosis Via Transcaval Access. JACC Cardiovasc Interv 2017; 10:740-741. [PMID: 28330643 DOI: 10.1016/j.jcin.2017.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 02/03/2017] [Accepted: 02/03/2017] [Indexed: 10/20/2022]
Affiliation(s)
- Norihiko Kamioka
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Ateet Patel
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Stamatios Lerakis
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | | | - Jessica Forcillo
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Frank Corrigan
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Vinod Thourani
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia
| | - Peter Block
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia
| | - Vasilis Babaliaros
- Division of Cardiology, Emory University School of Medicine, Atlanta, Georgia.
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Pickard SS, Geva A, Gauvreau K, del Nido PJ, Geva T. Long-term outcomes and risk factors for aortic regurgitation after discrete subvalvular aortic stenosis resection in children. Heart 2015; 101:1547-53. [PMID: 26238147 DOI: 10.1136/heartjnl-2015-307460] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Accepted: 06/18/2015] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To characterise long-term outcomes after discrete subaortic stenosis (DSS) resection and to identify risk factors for reoperation and aortic regurgitation (AR) requiring repair or replacement. METHODS All patients who underwent DSS resection between 1984 and 2009 at our institution with at least 36 months' follow-up were included. Demographic, surgical and echocardiographic data were reviewed. Outcomes were reoperation for recurrent DSS, surgery for AR, death and morbidities, including heart transplant, endocarditis and complete heart block. RESULTS Median length of postoperative follow-up was 10.9 years (3-27.2 years). Reoperation occurred in 32 patients (21%) and plateaued 10 years after initial resection. Survival at 10 years and 20 years was 98.6% and 86.3%, respectively. Aortic valve (AoV) repair or replacement for predominant AR occurred in 31 patients (20%) during or after DSS resection. By multivariable analysis, prior aortic stenosis (AS) intervention (HR 22.4, p<0.001) was strongly associated with AoV repair or replacement. Risk factors for reoperation by multivariable analysis included younger age at resection (HR 1.24, p=0.003), preoperative gradient ≥60 mm Hg (HR 2.23, p=0.04), peeling of membrane off AoV or mitral valve (HR 2.52, p=0.01), distance of membrane to AoV <7.0 mm (HR 4.03, p=0.03) and AS (HR 2.58, p=0.01). CONCLUSIONS In this cohort, the incidence of reoperations after initial DSS resection plateaued after 10 years. Despite a significant rate of reoperation, overall survival was good. Concomitant congenital AS and its associated interventions significantly increased the risk of AR requiring surgical intervention.
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Affiliation(s)
- Sarah S Pickard
- Departments of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA Departments of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Alon Geva
- Critical Care Medicine, Boston Children's Hospital, Boston, Massachusetts, USA Department of Anesthesia, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberlee Gauvreau
- Departments of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA Departments of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Pedro J del Nido
- Cardiovascular Surgery, Boston Children's Hospital, Boston, Massachusetts, USA Department of Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Tal Geva
- Departments of Cardiology, Boston Children's Hospital, Boston, Massachusetts, USA Departments of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
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9
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Carneiro ALHDS, Braulio R, Nunes MCP. Echocardiography of a young man with dyspnoea. Subaortic membrane. Heart 2015. [PMID: 26209216 DOI: 10.1136/heartjnl-2014-307349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Renato Braulio
- Hospital das Clínicas, School of Medicine of the Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
| | - Maria Carmo Pereira Nunes
- Hospital das Clínicas, School of Medicine of the Federal University of Minas Gerais, Belo Horizonte, MG, Brazil
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10
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Azari A, Moravvej Z, Fazlinezhad A, Bigdelu L. Congenital coronary artery anomaly simulating a ventricular septal defect. Asian Cardiovasc Thorac Ann 2014; 23:1062-4. [PMID: 24719168 DOI: 10.1177/0218492314531422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Anomalous origin of the circumflex artery of the right sinus of Valsalva is a rare finding which may be present with other cardiac malformations. A 19-year-old man presented with syncope. A transthoracic echocardiogram revealed discrete subaortic stenosis with a small defect just below the aortic valve, suggesting a ventricular septal defect. Transesophageal echocardiography showed anomalous origin of the circumflex artery from the right sinus of Valsalva. This was confirmed by coronary angiography. The patient underwent successful web resection without concomitant coronary surgery. Failure to demonstrate a coronary artery anomaly can be misleading for surgeons and perilous for patients.
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Affiliation(s)
- Ali Azari
- Department of Cardiac Surgery, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran Atherosclerosis Prevention Research Center, Imam Reza Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Moravvej
- Cardiovascular Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran Students Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Afsoon Fazlinezhad
- Cardiovascular Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran Department of Cardiology, Ghaem hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Leila Bigdelu
- Cardiovascular Research Center, Ghaem Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran Atherosclerosis Prevention Research Center, Imam Reza Hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran Department of Cardiology, Ghaem hospital, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
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11
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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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12
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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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13
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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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14
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Abstract
Background—
Transluminal balloon tearing of the membrane in a thin discrete subaortic stenosis is an alternative to membrane surgical resection. However, the long-term outcome of patients with isolated thin discrete subaortic stenosis treated by transluminal balloon tearing remains unknown.
Methods and Results—
This 25-year study describes findings from 76 patients with isolated thin discrete subaortic stenosis who underwent percutaneous transluminal balloon tearing of the membrane and were followed up for a mean period of 16±6 years. The age at presentation had a wide range (2–67 years). The mean age at treatment was 19±16 years. Immediately after treatment, the subvalvular gradient decreased from 70±27 to 18±12 mm Hg (
P
<0.001). No significant postprocedural aortic regurgitation was observed. After a mean follow-up time of 16±6 years, 11 patients (15%) developed restenosis, 3 patients (4%) progressed to muscular obstructive disease, and 1 patient (1.3%) developed a new distant obstructive membrane. Twelve patients (16%) were redilated at a mean of 5±3 years after their first treatment, and 4 patients (5%) underwent surgery at a mean of 3±2 years after their first treatment. Fifty-eight patients (77%) remained alive and free of redilation or surgery at follow-up. Larger annulus diameter and thinner membranes were independent factors associated with better long-term results.
Conclusions—
Most patients (77%) with isolated thin discrete subaortic stenosis treated with transluminal balloon tearing of the membrane had sustained relief at subsequent follow-ups without restenosis, the need for surgery, progression to muscular obstructive disease, or an increase in the degree of aortic regurgitation.
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15
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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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Cho YK, Oh SM, Joo JW, Ma JS. Secondary subaortic stenosis after patch closure of subarterial ventricular septal defect. J Cardiovasc Ultrasound 2010; 18:52-4. [PMID: 20706569 DOI: 10.4250/jcu.2010.18.2.52] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 04/18/2010] [Accepted: 05/18/2010] [Indexed: 11/22/2022] Open
Abstract
Subaortic stenosis usually occurs without a previous heart operation, however, it can occur after heart surgery as well, with a condition known as a secondary subaortic stenosis (SSS). SSS has been reported after surgical repair of several congenital heart defects. There are only a few recorded cases of SSS after repair of ventricular septal defect (VSD). Here we report a rare case of SSS that occurred 3 years after surgical repair of subarterial VSD. A follow-up echocardiogram is essential for detecting SSS caused by the newly developed subaortic membrane in patients who had cardiac surgery.
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Affiliation(s)
- Young Kuk Cho
- Department of Pediatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
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Griffiths LG. Surgery for Cardiac Disease in Small Animals: Current Techniques. Vet Clin North Am Small Anim Pract 2010; 40:605-22. [DOI: 10.1016/j.cvsm.2010.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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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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Butany J, Vaideeswar P, David TE. Discrete subaortic membranes in adults--a clinicopathological analysis. Cardiovasc Pathol 2008; 18:236-42. [PMID: 18823798 DOI: 10.1016/j.carpath.2008.06.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2006] [Revised: 02/20/2008] [Accepted: 06/26/2008] [Indexed: 10/21/2022] Open
Abstract
INTRODUCTION A discrete subaortic membrane (DSM) is one of the causes of subaortic stenosis in children. The incidence, characteristics, and the therapeutic options for such membranes in adults have not been well documented. This report documents the clinical and pathological features of DSM in adults. METHODS DSMs, surgically excised over a 10-year period in a large adult tertiary care center, were reviewed with regard to the age and gender of the patients, clinical findings, and the morphological features. RESULTS Among the 19 adults, there were six males and 13 females, with age ranging from 26 to 75 years. The patients most often presented with dyspnea, fatigability, and palpitation for 3 months to 2 years. Four patients (21%) had other congenital heart disease in association with the DSM; in the rest, the membranes were isolated occurrences (79%). A cardiac murmur or the presence of membranes had been noted in childhood in four patients. Tissue growths over the ventricular surface of the anterior mitral leaflet were seen in 18 cases. Irrespective of the gross appearance, the stenosing lesions exhibited five tissue layers, beginning from the luminal aspect, endothelium, acid mucopolysaccharide-rich subendothelial layer, collagen-rich fibrous layer, fibroelastotic layer, and a smooth muscle layer. Twelve patients (63%) had aortic regurgitation, which necessitated repair or replacement in seven. Septal myectomy resulted in conduction abnormalities in nine. CONCLUSIONS The study describes the occurrence of DSM in adults. It is important to remember that it can occur following a repair of underlying congenital heart disease.
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Affiliation(s)
- Jagdish Butany
- Department of Pathology, Toronto General Hospital/University Health Network, Toronto, Ontario, Canada.
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Hage FG, Zoghbi GJ, Aqel RA, Nanda NC. Subaortic stenosis missed by invasive hemodynamic assessment. Echocardiography 2008; 25:1007-10. [PMID: 18771542 DOI: 10.1111/j.1540-8175.2008.00732.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
We present a case of 61-year-old man that was evaluated for possible aortic stenosis but did not show a left ventricular outflow gradient on invasive assessment in the catheterization laboratory. Transthoracic echocardiography showed subaortic stenosis secondary to a discrete membranous structure in the left ventricular outflow tract. This is the first case in the literature of a patient with discrete subaortic stenosis missed by invasive hemodynamic assessment.
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Affiliation(s)
- Fadi G Hage
- University of Alabama and Birmingham, Veterans Affairs Medical Center, Division of Cardiology, Birmingham, Alabama, USA.
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Geva A, McMahon CJ, Gauvreau K, Mohammed L, del Nido PJ, Geva T. Risk factors for reoperation after repair of discrete subaortic stenosis in children. J Am Coll Cardiol 2007; 50:1498-504. [PMID: 17919571 DOI: 10.1016/j.jacc.2007.07.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2007] [Revised: 05/30/2007] [Accepted: 07/01/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVES This study aimed to identify independent predictors of reoperation after successful resection of discrete subaortic stenosis (DSS). BACKGROUND Recurrence of DSS has been reported to range from 0% to 55% of patients. Factors associated with recurrence have not been adequately defined. METHODS Patients were included if they had a diagnosis of DSS, normal segmental cardiac anatomy, previous resection of DSS, and at least 36 months' follow-up. Demographic, surgical, and echocardiographic data were analyzed. Primary outcome was repeat resection of DSS in patients after successful primary resection. RESULTS Of 111 subjects who had successful surgical resection of DSS, 16 patients (14%) required reoperation. Median follow-up time was 8.2 years. Form of DSS and gender did not differ significantly between those with reoperation and those without. In multivariate analysis, independent predictors of reoperation that would be available before first surgery were <6 mm distance between the aortic valve (AoV) and the obstruction (hazard ratio [HR] 5.1; p = 0.013) and peak gradient by Doppler > or =60 mm Hg (HR 4.2; p = 0.016). If intraoperative variables are also considered, peeling of the membrane from the AoV or mitral valve at first surgery, <6 mm distance between the DSS and AoV, and peak gradient by Doppler > or =60 mm Hg were independent predictors of reoperation. CONCLUSIONS Proximity of the obstructive lesion to the AoV and severe obstruction determined by preoperative echocardiography, as well as involvement of valve leaflets requiring surgical peeling, predict recurrent DSS requiring reoperation.
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Affiliation(s)
- Alon Geva
- Department of Cardiology, Children's Hospital Boston, and Harvard Medical School, Boston, Massachusetts 02115, USA
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Gurel E, Karaahmet T, Tanalp AC, Mutlu B, Basaran Y. Discrete membranous subaortic stenosis complicated by infective endocarditis: a case report. Heart Surg Forum 2007; 10:E317-9. [PMID: 17599883 DOI: 10.1532/hsf98.20071020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Discrete membraneous subaortic stenosis is an uncommon cause of left ventricular outflow tract obstruction. Although its relationship to infective endocarditis is well defined, the expected site of vegetation is over the aortic valve. We report on a 46-year-old man who had a discrete membranous subaortic stenosis, complicated with infective endocarditis, in which the vegetation was over the subaortic membrane and the aortic valve was spared. To our knowledge, this is the first reported case of that entity.
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Affiliation(s)
- Emre Gurel
- Department of Cardiology, Kartal Kosuyolu Heart Education and Research Hospital, Istanbul, Turkey.
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Affiliation(s)
- Marie-Eve Nepveu
- Department of Anesthesiology, Montreal Heart Institute, Montreal, Quebec, Canada
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Mazzei V, Nasso G, Anselmi A, Salamone G, Mangano S, Grassi R. Correction of discrete subaortic stenosis with abnormal chordae tendineae. J Card Surg 2006; 21:271-3. [PMID: 16684058 DOI: 10.1111/j.1540-8191.2006.00230.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The case of a 52-year-old woman with subvalvular aortic stenosis and aortic regurgitation is presented. Mitral regurgitation was associated, due to insertion of two abnormal chordae tendineae at the apex of the anterior papillary muscle and at the free border of the subvalvular membranous annulus. This abnormality displaced the anterior papillary muscle, thus applying a traction at the mitral leaflet. The patient was operated on through a valve-sparing approach, in which the discrete subaortic stenosis was removed through aortotomy and the ectopic chordae were excised. Suture mitral annuloplasty completed the procedure. Aortic and mitral insufficiency almost disappeared at follow-up. From the examination of this case and from a review of pertinent literature it emerges that in event of similar complex congenital abnormalities without intrinsic valve disease, a conservative approach should be chosen so that valve replacement can be avoided.
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Affiliation(s)
- Valerio Mazzei
- Division of Cardiac Surgery, Ospedale Papardo, Messina, Italy
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