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El-Nashar H, Sabry M, Tseng YT, Francis N, Latif N, Parker KH, Moore JE, Yacoub MH. Multiscale structure and function of the aortic valve apparatus. Physiol Rev 2024; 104:1487-1532. [PMID: 37732828 DOI: 10.1152/physrev.00038.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 08/30/2023] [Accepted: 09/01/2023] [Indexed: 09/22/2023] Open
Abstract
Whereas studying the aortic valve in isolation has facilitated the development of life-saving procedures and technologies, the dynamic interplay of the aortic valve and its surrounding structures is vital to preserving their function across the wide range of conditions encountered in an active lifestyle. Our view is that these structures should be viewed as an integrated functional unit, here referred to as the aortic valve apparatus (AVA). The coupling of the aortic valve and root, left ventricular outflow tract, and blood circulation is crucial for AVA's functions: unidirectional flow out of the left ventricle, coronary perfusion, reservoir function, and support of left ventricular function. In this review, we explore the multiscale biological and physical phenomena that underlie the simultaneous fulfillment of these functions. A brief overview of the tools used to investigate the AVA, such as medical imaging modalities, experimental methods, and computational modeling, specifically fluid-structure interaction (FSI) simulations, is included. Some pathologies affecting the AVA are explored, and insights are provided on treatments and interventions that aim to maintain quality of life. The concepts explained in this article support the idea of AVA being an integrated functional unit and help identify unanswered research questions. Incorporating phenomena through the molecular, micro, meso, and whole tissue scales is crucial for understanding the sophisticated normal functions and diseases of the AVA.
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Affiliation(s)
- Hussam El-Nashar
- Aswan Heart Research Centre, Magdi Yacoub Foundation, Cairo, Egypt
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Malak Sabry
- Aswan Heart Research Centre, Magdi Yacoub Foundation, Cairo, Egypt
- Department of Biomedical Engineering, King's College London, London, United Kingdom
| | - Yuan-Tsan Tseng
- Heart Science Centre, Magdi Yacoub Institute, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Nadine Francis
- Aswan Heart Research Centre, Magdi Yacoub Foundation, Cairo, Egypt
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Najma Latif
- Heart Science Centre, Magdi Yacoub Institute, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Kim H Parker
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - James E Moore
- Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Magdi H Yacoub
- Aswan Heart Research Centre, Magdi Yacoub Foundation, Cairo, Egypt
- Heart Science Centre, Magdi Yacoub Institute, London, United Kingdom
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Kochav JD, Takayama H, Goldstone A, Kalfa D, Bacha E, Rosenbaum M, Lewis MJ. Left ventricular reverse remodeling after aortic valve replacement or repair in bicuspid aortic valve with moderate or greater aortic regurgitation. JTCVS OPEN 2024; 19:47-60. [PMID: 39015468 PMCID: PMC11247208 DOI: 10.1016/j.xjon.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/22/2024] [Accepted: 03/08/2024] [Indexed: 07/18/2024]
Abstract
Objective Bicuspid aortic valve (AV) patients with aortic regurgitation (AR) differ from tricuspid AV patients given younger age, greater left ventricle (LV) compliance, and more prevalent aortic stenosis (AS). Bicuspid AV-specific data to guide timing of AV replacement or repair are lacking. Methods Adults with bicuspid AV and moderate or greater AR who underwent aortic valve replacement or repair at our center were studied. The presurgical echocardiogram, and echocardiograms within 3 years postoperatively were evaluated for LV geometry/function, and AV function. Semiquantitative AS/AR assessment was performed in all patients with adequate imaging. Results One hundred thirty-five patients (85% men, aged 44.5 ± 15.9 years) were studied (63% pure AR, 37% mixed AS/AR). Following aortic valve replacement or repair, change in LV end-diastolic dimension and change in LV end-diastolic volume were associated with preoperative LV end-diastolic dimension (β = 0.62 Δcm/cm; 95% CI, 0.43-0.73 Δcm/cm; P < .001), and LV end-diastolic volume (β = 0.6 ΔmL/mL; 95% CI, 0.4-0.7 ΔmL/mL; P < .001), respectively, each independent of AR/AS severity (P = not significant). Baseline LV size predicted postoperative normalization (LV end-diastolic dimension: odds ratio, 3.75/cm; 95% CI, 1.61-8.75/cm, LV end-diastolic volume: odds ratio, 1.01/mL; 95% CI, 1.004-1.019/mL, both P values < .01) whereas AR/AS severity did not (P = not significant). Indexed LV end diastolic volume outperformed LV end-diastolic dimension in predicting postoperative LV normalization (area under the curve = 0.74 vs 0.61) with optimal diagnostic cutoffs of 99 mL/m2 and 6.1 cm, respectively. Postoperative indexed LV end diastolic volume dilatation was associated with increased risk of death, transplant/ventricular assist device, ventricular arrhythmia, and reoperation (hazard ratio, 6.1; 95% CI, 1.7-21.5; P < .01). Conclusions Remodeling extent following surgery in patients with bicuspid AV and AR relates to preoperative LV size independent of valve disease phenotype or severity. Many patients with LV end-diastolic dimension below current surgical thresholds did not normalize LV size. LV volumetric assessment offered superior diagnostic performance for predicting residual LV dilatation, and postoperative indexed LV end diastolic volume dilatation was associated with adverse prognosis.
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Affiliation(s)
- Jonathan D. Kochav
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Hiroo Takayama
- Division of Cardiothoracic and Vascular Surgery, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Andrew Goldstone
- Division of Cardiothoracic and Vascular Surgery, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - David Kalfa
- Division of Cardiothoracic and Vascular Surgery, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Emile Bacha
- Division of Cardiothoracic and Vascular Surgery, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Marlon Rosenbaum
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
| | - Matthew J. Lewis
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY
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Peigh G, Puthumana JJ, Bonow RO. Aortic Regurgitation and Heart Failure: Advances in Diagnosis, Management, and Interventions. Heart Fail Clin 2023; 19:285-296. [PMID: 37230644 DOI: 10.1016/j.hfc.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
This review discusses the contemporary clinical evaluation and management of patients with comorbid aortic regurgitation (AR) and heart failure (HF) (AR-HF). Importantly, as clinical HF exists along the spectrum of AR severity, the present review also details novel strategies to detect early signs of HF before the clinical syndrome ensues. Indeed, there may be a vulnerable cohort of AR patients who benefit from early detection and management of HF. Additionally, while the mainstay of operative management for AR has historically been surgical aortic valve replacement, this review discusses alternate procedures that may be beneficial in high-risk cohorts.
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Affiliation(s)
- Graham Peigh
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, 676 North St. Clair Suite 600, Chicago, IL 60611, USA.
| | - Jyothy J Puthumana
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, 676 North St. Clair Suite 600, Chicago, IL 60611, USA
| | - Robert O Bonow
- Division of Cardiology, Northwestern University, Feinberg School of Medicine, 676 North St. Clair Suite 600, Chicago, IL 60611, USA
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Sromicki J, Van Hemelrijck M, Schmiady MO, Greutmann M, Bonassin Tempesta F, Mestres CA, Vogt PR, Carrel TP, Holubec T. Twenty-five year experience with aortic valve-sparing root replacement in a single teaching center. Front Cardiovasc Med 2023; 10:1104149. [PMID: 36970369 PMCID: PMC10036903 DOI: 10.3389/fcvm.2023.1104149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 02/16/2023] [Indexed: 03/12/2023] Open
Abstract
ObjectivesAortic valve-sparing root replacement (AVSRR) is a technically demanding procedure. In experienced centers it offers excellent short- and long-term results, making the procedure an attractive alternative for aortic root replacement especially in young patients. The aim of this study was to analyze long-term results of AVSRR using the David operation in our institution over the last 25 years.MethodsThis is a single-center retrospective analysis of outcomes of David operations performed in a teaching institution not running a large AVSRR-program. Pre-, intra- and postoperative data were collected from the institutional electronic medical record system. Follow-up data were collected through direct contact of the patients and their cardiologists/primary care physicians.ResultsBetween 02/1996 and 11/2019, 131 patients underwent David operation in our institution by a total of 17 different surgeons. Median age was 48 (33–59), 18% were female. Elective surgery was performed in 89% of the cases, 11% were operated as emergency in the setting of an acute aortic dissection. Connective tissue disease was present in 24% and 26% had a bicuspid aortic valve. At hospital admission 61% had aortic regurgitation grade ≥3, 12% were in functional NYHA-class ≥III. 30-day mortality was 2%, 97% of the patients were discharged with aortic regurgitation ≤2. In 10-year follow-up, 15 (12%) patients had to be re-operated because of root-related complications. Seven patients (47%) received a transcatheter aortic valve implantation, 8 (53%) required surgical replacement of the aortic valve or a Bentall-De Bono operation. Estimated reoperation-free survival at 5 and 10 years was 93.5% ± 2.4% and 87.0% ± 3.5%, respectively. Subgroup analysis showed no differences in reoperation-free survival for patients presenting with a bicuspid valve or preoperative aortic regurgitation ≥3. However a preoperative left ventricular end diastolic diameter of ≥5.5 cm was associated with worse outcome.ConclusionDavid operations can be performed with excellent perioperative and 10-year follow-up outcomes in centers not running large AVSRR-programs.
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Affiliation(s)
- Juri Sromicki
- Department of Cardiac Surgery, University Zurich and University Hospital Zurich, Zurich, Switzerland
- Correspondence: Juri Sromicki
| | - Mathias Van Hemelrijck
- Department of Cardiac Surgery, University Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Martin O. Schmiady
- Department of Cardiac Surgery, University Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Matthias Greutmann
- Department of Cardiology, University Zurich and University Hospital Zurich, Zurich, Switzerland
| | | | - Carlos-A. Mestres
- Department of Cardiac Surgery, University Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Paul R. Vogt
- Department of Cardiac Surgery, University Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Thierry P. Carrel
- Department of Cardiac Surgery, University Zurich and University Hospital Zurich, Zurich, Switzerland
| | - Tomáš Holubec
- Department of Cardiovascular Surgery, Goethe University Frankfurt and University Hospital Frankfurt, Frankfurt, Germany
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Mitral and aortic valve regurgitation following surgical and transcatheter perimembranous ventricular septal defect closure in children and adolescents: midterm outcomes. BMC Cardiovasc Disord 2022; 22:315. [PMID: 35840901 PMCID: PMC9287911 DOI: 10.1186/s12872-022-02757-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Closure of perimembranous ventricular septal defects (pmVSD), either surgical or percutaneous, might improve or cause new-onset mitral regurgitation (MR) and aortic regurgitation (AR). We aimed to evaluate the changes in MR and AR after pmVSD closure by these two methods. MATERIAL AND METHOD We performed a comparative retrospective data review of all pediatric patients with pmVSDs treated at our institution with surgical or antegrade percutaneous methods from 2014 to 2019 and 146 consecutive patients under 18 years were enrolled. We closely looked at the mitral and aortic valve function after repair. Included patients had no or lower than moderate aortic valve prolapse and baseline normal mitral or aortic valve function or less than moderate MR or AR. RESULTS Out of 146 patients, 83 (57%) pmVSDs were closed percutaneously, and 63 (43%) pmVSDs were closed surgically. 80 and 62 patients were included for MR evaluation, and 81 and 62 patients for AR evaluation in percutaneous and surgical groups. The mean follow-up time was 40.48 ± 21.59 months in the surgery group and 20.44 ± 18.66 months in the transcatheter group. Mild to moderate degrees of MR and AR did not change or decreased in most patients. In detail, MR of 70% and AR of 50% of the valves were resolved or decreased in both groups. 13% of patients with no MR developed trivial to mild MR, and 10% of patients with no AR showed mild to moderate AR after pmVSD closure in both methods. There was no significant difference between the two methods regarding emerging new regurgitation or change in the severity of the previous regurgitation. CONCLUSION pmVSD closure usually improves mild to moderate MR and AR to a nearly similar extent in both percutaneous and surgical methods among children and adolescents. It might lead to the onset of new MR or AR in cases with no regurgitation.
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Yang T, Wen H, El-Hamamsy I, Ni Q, Sun Y, Zhu D. Relationship Between Leaflets and Root in Normal Aortic Valve Based on Computed Tomography Imaging: Implication for Aortic Valve Repair. Front Cardiovasc Med 2021; 8:731440. [PMID: 34881298 PMCID: PMC8645849 DOI: 10.3389/fcvm.2021.731440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 10/26/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: By assessing the normal dimensions and the relationship between the aortic root and leaflets in Chinese population, the objective of this three-dimensional computed tomography (3DCT)-based study was to establish a matching reference for leaflets and aortic root for aortic valve (AV) repair. Method: Electrocardiogram-gated multi-detector CT was performed on 168 Chinese participants with a normal aortic valve. Measurements of the aortic annuli and leaflets were obtained. The correlations between and the ratios of the specific root and leaflet measurements were analyzed. The references for the leaflet and root dimensions were suggested based on geometric height (gH) using a linear regression equation. The utility of the ratios was tested with CT images of 15 patients who underwent aortic valve repair. Result: The mean annulus diameter (AD), sino-tubular junction (STJ) diameter, geometric height (gH), effective height (eH), free margin length (FML), commissural height (ComH), inter-commissural distance (ICD), and coaptation height (CH) were 22.4 ± 1.7 mm, 27.3 ± 2, 0.4 mm, 15.5 ± 1.7 mm, 8.9 ± 1.2 mm, 32.0 ± 3.4 mm, 17.9 ± 1.9 mm, 23.1 ± 2.3 mm, and 3.1 ± 0.6 mm, respectively. The gH/AD, FML/ICD, and eH/ComH ratios were 0.69 ± 0.07, 1.38 ± 0.08, and 0.50 ± 0.07, respectively. The gH correlated with all other leaflet and root measurements (P < 0.01), whereas the FML demonstrated a better correlation with ICD compared with gH (R2 = 0.75, and R2 = 0.37, respectively). The FML/ICD and eH/ComH ratios might be used to assess leaflet-root mismatch and post-repair leaflet billowing. Conclusion: The normal aortic valve measurements based on 3DCT revealed a specific relationship between the root and leaflets; and this will guide the development of an objective method of aortic valve repair.
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Affiliation(s)
- Tianyang Yang
- Department of Cardiac Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Haini Wen
- Department of Pharmacy, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Qiming Ni
- Department of Radiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yanbin Sun
- Department of Radiology, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Dan Zhu
- Department of Cardiac Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai, China
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Ravalli F, Kossar AP, Takayama H, Grau JB, Ferrari G. Aortic Valve Regurgitation: Pathophysiology and Implications for Surgical Intervention in the Era of TAVR. STRUCTURAL HEART : THE JOURNAL OF THE HEART TEAM 2020; 4:87-98. [PMID: 32529168 PMCID: PMC7288848 DOI: 10.1080/24748706.2020.1719446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 01/16/2020] [Accepted: 01/17/2020] [Indexed: 10/25/2022]
Abstract
Aortic insufficiency (AI) or regurgitation is caused by the malcoaptation of the aortic valve (AV) cusps due to intrinsic abnormalities of the valve itself, a dilatation or geometric distortion of the aortic root, or by some combination thereof. In recent years, there has been an increase in the number of studies suggesting that AI is an active disease process caused by a combination of factors including but not limited to alteration of specific molecular pathways, genetic predisposition, and changes in the mechanotransductive properties of the AV apparatus. As the surgical management of AV disease continues to evolve, increasingly sophisticated surgical and percutaneous techniques for AV repair and replacement, including transcatheter aortic valve replacement (TAVR), have become more commonplace and will likely continue to expand as new devices are introduced. However, these techniques necessitate frequent reappraisal of the biological and mechanobiological mechanisms underlying AV regurgitation to better understand the risk factors for AI development and recurrence following surgical intervention as well as expand our limited knowledge on patient selection for such procedures. The aim of this review is to describe some of the putative mechanisms implicated in the development of AI, dissect some of the cross-talk among known and possible signaling pathways leading to valve remodeling, identify association between these pathways and pharmacological approaches, and discuss the implications for surgical and percutaneous approaches to AV repair in replacement in the TAVR era.
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Risk Factors for Late Aortic Valve Dysfunction After the David V Valve-Sparing Root Replacement. Ann Thorac Surg 2017; 104:1479-1487. [PMID: 28669506 DOI: 10.1016/j.athoracsur.2017.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 03/28/2017] [Accepted: 04/04/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Valve-sparing root replacement (VSRR) is an established therapy for aortic root pathology. However, late aortic valve dysfunction requiring reoperation remains a primary concern of this procedure. This study examines risk factors for late aortic insufficiency (AI) and aortic stenosis (AS) after David V VSRR. METHODS A retrospective review from 2005 to 2015 at a US academic center identified 282 patients who underwent VSRR. Cox proportional hazards regression analysis was used to identify risk factors for late AI and AS after VSRR. RESULTS The mean age was 46.4 years. Sixty-four patients (22.7%) had bicuspid valves, and 41 patients (14.5%) had Marfan syndrome. The incidence of reoperations was 27 (9.6%), and 42 cases (14.9%) presented with acute type A dissection. Operative mortality was 8 (2.8%). Seven-year survival was 90.9%. Seven-year cumulative incidence of reoperation, greater than 2+ AI and greater than moderate AS were 3.1%, 2.2%, and 0.8%, respectively. Multivariable analysis showed aortic root size 55 mm or larger (hazard ratio 3.44, 95% confidence interval: 1.27 to 9.29, p = 0.01) to be a risk factor for late AI whereas bicuspid valve (hazard ratio 16.07, 95% confidence interval: 3.12 to 82.68, p = 0.001) and cusp repair were found to be risk factors (hazard ratio 5.91, 95% confidence interval: 1.17 to 29.86, p = 0.03) for late AS. CONCLUSIONS Valve-sparing root replacement can be performed with low operative risk and good overall long-term survival even in complex clinical settings. Durable valve function can be expected; however, aortic root size 55 cm or more, bicuspid valve anatomy, and cusp repair represent independent risk factors for late aortic valve dysfunction after these procedures.
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Thudt M, Papadopoulos N, Monsefi N, Miskovic A, Karimian-Tabrizi A, Zierer A, Moritz A. Long-Term Results Following Pericardial Patch Augmentation for Incompetent Bicuspid Aortic Valves: A Single Center Experience. Ann Thorac Surg 2017; 103:1186-1192. [DOI: 10.1016/j.athoracsur.2016.08.082] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2016] [Indexed: 11/28/2022]
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Mahara K, Ota M, Kishiki K, Takanashi S. Acute Aortic Valve Regurgitation Due to Spontaneous Rupture of Fenestrated Cusp Treated With Aortic Valve Repair. Circ J 2017; 81:241-242. [PMID: 27746412 DOI: 10.1253/circj.cj-16-0959] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Szymanski T, Maslow A, Mahmood F, Singh A. Three-Dimensional Imaging of the Repaired Aortic Valve. J Cardiothorac Vasc Anesth 2016; 30:1599-1610. [DOI: 10.1053/j.jvca.2016.01.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Indexed: 11/11/2022]
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Miyahara S, Abe N, Matsueda T, Izawa N, Yamazato T, Nomura Y, Kitamura A, Sato S, Takahashi H, Inoue T, Matsumori M, Okita Y. Impact of positional relationship of commissures on cusp function after valve-sparing root replacement for regurgitant bicuspid aortic valve. Eur J Cardiothorac Surg 2016; 50:75-81. [DOI: 10.1093/ejcts/ezv438] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 11/17/2015] [Indexed: 01/08/2023] Open
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Kari FA, Kroll J, Kiss J, Hess C, Stiller B, Siepe M, Beyersdorf F. Progression of Aortic Regurgitation After Different Repair Techniques for Congenital Aortic Valve Stenosis. Pediatr Cardiol 2016; 37:84-9. [PMID: 26266328 DOI: 10.1007/s00246-015-1243-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 08/03/2015] [Indexed: 11/29/2022]
Abstract
We sought to characterize the incidence of AR progression and determine risk factors for AR progression in a consecutive series of infants and children after surgical correction of congenital aortic valvular and supravalvular stenosis. N = 30 patients underwent repair of the aortic valve for isolated congenital aortic valve stenosis (n = 14, 47 %) or combined with aortic regurgitation (AR, n = 16, 53%). N = 27 (90%) had a valvular and n = 3 patients (10%) presented with supravalvular pathology of their aortic valve. In n = 16 patients (53%) a bicuspid and in n = 2 (6%) patients, a unicuspid valve was present. Comparative survival was analyzed using the Cox model and log-rank calculations. Log-rank calculations were performed for variables reaching statistical significance in order to identify differences in survival between groups. Commissurotomy was performed in n = 20 patients, patch implantation in n = 4, cusp shaving in n = 8, cusp prolapse correction in n = 3, and cusp augmentation in n = 4 patients. In patients with combined dysfunction and preoperative AR, AR was successfully reduced by the initial procedure, and postoperatively the overall median AR grade was 1+ (range 0-2.5+, p = 0.001, for AR reduction among patients with any grade of preoperative AR). By the time of follow-up echocardiography, the median AR grade had significantly progressed toward 1.5+ (p = 0.004). At the time of mid-term follow-up at 3.2 years, none of the patients had moderate or severe AR grades >2.5+. Patients with a monocuspid aortic valve and patients who had some kind of patch implantation into their cusps or commissures or shaving of thickened cusps were more likely to present with progression of aortic regurgitation. Monocuspid aortic valve and patch implantation, as well as cusp shaving, are probably linked to AR progression. The standard procedure of commissurotomy results in an absolute rate of AR progression of 40 % over a medium-term follow-up period.
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Affiliation(s)
- Fabian A Kari
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Hugstetter Strasse 55, 79106, Freiburg, Germany.
| | - Johannes Kroll
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Jan Kiss
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Carolin Hess
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Brigitte Stiller
- Center for Pediatrics, University Medical Center Freiburg, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Hugstetter Strasse 55, 79106, Freiburg, Germany
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Kari FA, Doll KN, Hemmer W, Liebrich M, Sievers HH, Richardt D, Reichenspurner H, Detter C, Siepe M, Czerny M, Beyersdorf F. Survival and freedom from aortic valve-related reoperation after valve-sparing aortic root replacement in 1015 patients. Interact Cardiovasc Thorac Surg 2015; 22:431-8. [DOI: 10.1093/icvts/ivv354] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/16/2015] [Indexed: 11/14/2022] Open
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Kari FA, Doll KN, Hemmer W, Liebrich M, Sievers HH, Richardt D, Reichenspurner H, Detter C, Siepe M, Czerny M, Beyersdorf F. Residual and Progressive Aortic Regurgitation After Valve-Sparing Root Replacement: A Propensity-Matched Multi-Institutional Analysis in 764 Patients. Ann Thorac Surg 2015; 101:1500-6. [PMID: 26704413 DOI: 10.1016/j.athoracsur.2015.10.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/23/2015] [Accepted: 10/01/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Residual/progressive aortic regurgitation (rAR, pAR) after valve-sparing aortic root replacement (V-SARR) can lead to reoperations. We sought to characterize risk factors of mild rAR and pAR after V-SARR in a multicenter cohort. The effect of additional cusp repair on valve function was analyzed using propensity matching. METHODS A total of 1,015 patients after V-SARR were identified with (n = 288, 28%) or without additional cusp/commissure repair (n = 727, 72%) at four cardiac units in Germany. A total of 764 patients fulfilling transthoracic echocardiography follow-up-criteria comprised the study cohort. Logistic regression was used for risk factor analysis with endpoints rAR, new onset AR, and pAR. t tests and analyses of variance were used for between-group differences. The effects of additional cusp repair on valve function were studied comparing propensity-matched quintiles. RESULTS The incidence of rAR was 29%, with influencing factors aneurysm size (p = 0.07) and preoperative aortic valve function (p = 0.08). It was found more often among nonsyndromic patients (34% vs. 14%; OR, 0.4; p < 0.001). Progression of rAR was detectable in 30% after a mean of 4.3 years. The progression rate of rAR ∼ 0.3 grades per patient-year within the first 5 years. When quintiles identified by propensity score were compared, additional cusp repair was linked to new onset AR (p = 0.016) while it was not linked to rAR (p = 0.14) or pAR (p = 0.5). CONCLUSIONS The incidences of rAR and pAR are considerable after V-SARR. Patients should be operated on before large aneurysms are present. New onset AR after an initially good functional result is more likely after an additional cusp repair, while rAR and pAR are not influenced by cusp repair.
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Affiliation(s)
- Fabian A Kari
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany.
| | | | | | | | - Hans-Hinrich Sievers
- Department of Heart and Thoracic Vascular Surgery, University Hospital Lübeck, Lübeck, Germany
| | - Doreen Richardt
- Department of Heart and Thoracic Vascular Surgery, University Hospital Lübeck, Lübeck, Germany
| | | | | | - Matthias Siepe
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Martin Czerny
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
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Chambers J, Ray S, Prendergast B, Graham T, Campbell B, Greenhalgh D, Petrou M, Tinkler J, Gohlke-Bärwolf C, Mestres CA, Rosenhek R, Pibarot P, Otto C, Sundt T. Standards for heart valve surgery in a 'Heart Valve Centre of Excellence'. Open Heart 2015; 2:e000216. [PMID: 26180639 PMCID: PMC4499687 DOI: 10.1136/openhrt-2014-000216] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Revised: 03/22/2015] [Accepted: 04/10/2015] [Indexed: 12/15/2022] Open
Abstract
Surgical centres of excellence should include multidisciplinary teams with specialist expertise in imaging, clinical assessment and surgery for patients with heart valve disease. There should be structured training programmes for the staff involved in the periprocedural care of the patient and these should be overseen by national or international professional societies. Good results are usually associated with high individual and centre volumes, but this relationship is complex. Results of surgery should be published by centre and should include rates of residual regurgitation for mitral repairs and reoperation rates matched to the preoperative pathology and risk.
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Affiliation(s)
| | | | | | - Tim Graham
- Society of Cardiothoracic Surgeons of Great Britain and Ireland , UK
| | | | - Donna Greenhalgh
- Department of Cardiac Anaesthesia , Wythenshawe Hospital , Manchester , UK
| | | | | | | | - Carlos A Mestres
- Department of Cardiovascular Surgery , Hospital Clinico, University of Barcelona , Spain
| | | | | | - Catherine Otto
- Division of Cardiology , University of Washington , Seattle, Washington , USA
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18
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Toeg H, Boodhwani M. Review of anticoagulation options for mechanical valve prosthesis. Interv Cardiol 2015. [DOI: 10.2217/ica.15.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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19
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Suri RM, Schaff HV. Aortic valve repair: Defining the patient population and timing of the intervention. J Thorac Cardiovasc Surg 2014; 148:2477-8. [DOI: 10.1016/j.jtcvs.2014.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2014] [Accepted: 10/05/2014] [Indexed: 10/24/2022]
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20
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Kari FA, Beyersdorf F, Rylski B, Stephens EH, Russe M, Siepe M. David I reimplantation procedure for aortic root replacement in Marfan patients: medium-term outcome. Interact Cardiovasc Thorac Surg 2014; 19:743-8. [DOI: 10.1093/icvts/ivu244] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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21
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Holubec T, Zacek P, Jamaliramin M, Emmert MY, Tuna M, Nedbal P, Dominik J, Harrer J, Falk V, Vojacek J. Valve cuspidity: a risk factor for aortic valve repair? J Card Surg 2014; 29:585-92. [PMID: 24919866 DOI: 10.1111/jocs.12382] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of this study was to analyze short- and mid-term results after aortic valve (AV) repair with particular regard to the impact of valve cuspidity (bicuspid versus tricuspid aortic valve). METHODS One hundred patients with aortic regurgitation (AR) undergoing aortic valve repair between November 2007 and October 2012 were included in the study. Sixty patients had bicuspid AV (BAV group; 11 females) and 40 patients had tricuspid AV (TAV group; 13 females). AR > grade 2 was present in 47 (78%) patients in the BAV and in 35 (88%) patients in the TAV group. Follow-up was complete in 100% and median was 25 months. RESULTS Isolated aortic valve repair was performed in 27 (45%) of BAV patients and in six (15%) of TAV patients. Replacement of the ascending aorta and/or aortic root was performed in 33 (55%) of BAV patients and in 34 (86%) of TAV patients. There was no death within 30 days postoperatively, while two patients died (TAV group) during the follow-up period. There was no statistical difference between BAV and TAV groups with regard to the survival (100 ± 0% vs. 95 ± 4%, p = 0.102), the three-year freedom from AV-related reoperation (90 ± 5% vs. 89 ± 6%, p = 0.456), and the three-year freedom from AR grade > 2 (86 ± 6% vs. 82 ± 7%, p = 0.866), respectively. CONCLUSIONS This study demonstrates no difference in mid-term results after regurgitant bicuspid and tricuspid aortic valve repair, suggesting that bicuspid valve may not be a risk factor for aortic valve repair.
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Affiliation(s)
- Tomas Holubec
- Department of Cardiac Surgery, Charles University in Prague, Faculty of Medicine and University Hospital, Hradec Kralove, Czech Republic; Division of Cardiovascular Surgery, University Hospital Zurich, Zurich, Switzerland
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