Mechanical Aortic Valve Replacement in Children and Adolescents After Previous Repair of Congenital Heart Disease

Mechanical heart valves and oral anticoagulation: a survey of the Italian Society of Cardiac Surgery

In the latest European guidelines for the management of valvular heart disease, mechanical valve prostheses maintain a strategic role, particularly for certain patient subsets and age groups. Despite the high number of devices implanted in clinical practice, particularly in non-European and North American regions, current scientific literature and debate seem to suggest a limited use of mechanical heart valves. The cardiac surgery community seems to be highly interested in biological and transcatheter valve prostheses but less interested in mechanical heart valves, including possible strategies for self-management of anticoagulation therapy. In this respect, the Italian Society of Cardiac Surgery (SICCH), in particular the Italian Group of Research for Outcome in Cardiac Surgery (GIROC), has promoted a survey among its members to stimulate the interest in this topic and express their opinion on this issue that, due to the prevalence of the affected population and the new treatment options for improving patients' quality of life, should be more appraised and debated in the cardiac surgery community. The recorded results, obtained on the answers to 111 questionnaires, seem to divide the specialists into 'pros' and 'contras' on a useful tool for the entire cardiac surgery community. For this reason, SICCH proposes in conclusion to declare its unified and institutional opinion on this topic.

Paravalvular leaks: mechanisms, diagnosis and management

AIMS

To understand the incidence, aetiology and mechanisms of paravalvular aortic and mitral leaks after valvular surgery; reviewing the best methods for diagnosis, procedural guidance and result assessment of these leaks, as well as describing the different approaches to their treatment.

METHODS AND RESULTS

A literature search was undertaken as well as an in-depth analysis of our own experience concerning different imaging modalities and various therapeutic strategies for aortic and mitral paravalvular leaks. The majority of patients were diagnosed using two- or three-dimensional transoesophageal echocardiography, useful in both guiding the procedure as well as assessing the procedural results. Haemoglobin, haematocrit, LDH and haptoglobin values were analysed to assess haemolysis. Procedural success for percutaneous closure of paravalvular aortic leaks are around 90% in the different series, with low complication rates. Mitral leaks have been approached by transfemoral and transapical access; the reported success of this procedure ranges from 75% to more than 90% in different reports. Complication rates at 30 days average 10% and mortality related to the procedure is around 1%. Late follow-up results depend on the initial anatomy, baseline clinical class and procedure results.

CONCLUSIONS

Paravalvular leaks after surgical valve implantation have a multifactorial aetiology, but are mainly related to specific anatomic characteristics of the valvular ring. Mitral leaks are three times more common than aortic leaks and the incidence increases after reoperation. Different percutaneous techniques with several devices have been explored for leak closure, but we are still lacking devices specifically designed to treat this pathology more effectively.

Aortic surgery after previous procedure of congenital aortic stenosis

Irrespective of previous procedure in congenital aortic stenosis, aortic surgery later in life may be indicated. The aim of the present study was the analysis of indications, risks, and outcomes of aortic surgery after previous aortic valve procedure. The data of patients who underwent aortic surgery after previous treatment of congenital aortic stenosis in a 10-year period (from 2000 to 2009) were retrospectively analyzed. Thirty-two patients (23 male and 9 female) underwent redo aortic surgery. The mean age at surgery was 13.5 ± 11.3 years. Seventeen patients had undergone initial aortic balloon valvuloplasty (BVP) and 15 patients open commissurotomy (COM). Nine cases had undergone the primary procedure at neonatal age and two patients had undergone cardiac surgery before the initial aortic valve procedure. Seven of the patients with previous COM (43.8%) had undergone concomitant surgery along with initial commissurotomy. A reintervention within the first year after the primary procedure was performed in seven patients (seven after BVP and none after COM; P < 0.05). The interval between the last intervention and the first redo aortic surgery was 7.5 ± 9.5 years (3.1 ± 3.5 years after BVP vs. 12.5 ± 11.7 years after COM; P < 0.05). A second redo surgery was performed in nine patients (four after initial BVP and five after COM). Congenital aortic stenosis is very often presented in combination with additional pathologies. These concomitant diseases along with the underlying disease give the indication for reoperation. Reinterventions are more often indicated after primary BVP. Long follow-up in specialized centers is mandatory.

The Switch Back Ross Operation: Report of Two Cases With Good Medium-to-Long-Term Follow-Up

Submitted July 20, 2011; Accepted October 6, 2011. Neoaortic root dilatation and neoaortic valve regurgitation following the arterial switch operation for transposition of the great arteries may ultimately require neoaortic root and/or neoaortic valve surgery. The ideal surgical approach to these lesions remains debatable. Hazekamp et al, in 1997, introduced the replacement of the neoaortic root by the neopulmonary autograft and named this procedure the switch back Ross operation. We report two patients who were successfully treated at our institution with the switch back Ross operation, with good results at, respectively, four- and five-year follow-up.