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PubMed2006

Pathogenesis of calcific aortic valve disease: a disease process comes of age (and a good deal more).

BACKGROUND: Over the past 10 to 15 years, calcific aortic valve disease, which includes aortic sclerosis and aortic stenosis, has come to be recognized as an active process, based on: (1) epidemiologic studies demonstrating associations of specific risk factors with increased prevalence or rate of progression of aortic valve disease; (2) identification, in valve lesions, of histopathologic features of chronic inflammation, lipoprotein deposition, renin-angiotensin system components, and molecular mediators of calcification; and (3) identification of cell-signaling pathways and genetic factors that may participate in valve disease pathogenesis. These studies will be reviewed and organized into a proposed global hypothesis for the pathogenesis of calcific aortic valve disease.

Animals↗
PubMed1997

Pulmonary autograft procedure for aortic valve disease: long-term results of the pioneer series.

BACKGROUND: Pulmonary autograft replacement of the diseased aortic valve has not been widely practiced due to concerns regarding late autograft competence and the consequences of creating pulmonary valve disease. To investigate this, the fate of the pioneering series of patients has been determined. METHODS AND RESULTS: The 131 hospital survivors of the pulmonary autograft operation at the National Heart Hospital from 1967 to 1984 were identified and their outcomes determined to 1994. Age at operation was 11 to 52 years, and 109 patients were male. Autograft implantation was orthotopic subcoronary (107), free-standing root (20), or Dacron mounted (2). In 113 patients, homografts replaced the native pulmonary valve. Ten and 20 years after operation, survival was 85% and 61%, freedom from autograft replacement was 88% and 75%, and freedom from replacement of pulmonary position homografts was 89% and 80%, respectively. Causes of deaths (53) included chronic heart failure (13), complications of reoperation (12), and endocarditis (7). Autograft regurgitation, the most common indication for reoperation, appeared primarily technical in nature, usually due to cusp prolapse. Degeneration was found in only 3 of 30 explanted autografts, and the young patients showed no increase in late valve failure. Homografts outperformed other valve replacements in the pulmonary position, but patients with orthotopic subcoronary and root autografts survived similarly. CONCLUSIONS: The pulmonary autograft offers low rates of degeneration, endocarditis, and thromboembolism for a period lasting >20 years, particularly in the young, with reoperation mainly required for malpositioning of the autograft cusps. The capacity of the autograft to maintain viability with minimal degeneration is not matched by any other biological valve replacement.

Adolescent↗
PubMed2001

Autologous tissue in complex aortic valve disease.

Young patients with complex aortic valve disease involving the aortic root or ascending aorta are a challenge to manage. To use the Ross operation and realize its benefits, the operative technique must include aortic annulus reduction and fixation and replacement of ascending aortic pathology. Special techniques must be used when the cause of the complex disease is active endocarditis of the valve and aortic root. Surgical techniques that allow the use of the Ross operation in these settings and the midterm results in 84 patients are reviewed.

Adolescent↗
PubMed1976

Chest pain as a predictor of coronary artery disease in patients with obstructive aortic valve disease.

To clarify the association between chest pain and significant coronary artery disease in patients who have aortic valve disease, 76 consecutive candidates for aortic valve replacement were evaluated prospectively with use of a historical questionnaire and coronary arteriography. Of the 76 patients, 19 (25 percent) had no chest pain, 21 (28 percent) had chest pain that was not typical of angina pectoris and 36 (47 percent) had chest pain typical of anigina pectoris. In 18 of 19 patients the absence of chest pain correlated with the absence of coronary artery disease. The single patient without chest pain who had coronary artery disease had evidence of an inferior myocardial infarction in the electrocardiogram. Thus, absence of chest pain and the absence of electrocardiographic evidence of infarction predicted the absence of coronary disease in all cases. The presence of chest pain did not predict the presence of coronary artery disease, but the more typical the pain of angina pectoris the more likely were patients to have significant coronary artery disease. Of the 21 patients with atypical chest pain, 6 (29 percent) had coronary artery disease, but of the 36 patients with typical angina pectoris 23 (64 percent) had significant coronary artery disease. In addition, when patients with chest pain not typical of angina pectoris also had coronary artery disease, the diseased vessels usually supplied smaller areas of the left ventricle than when the pain was typical of angina pectoris. In 21 of 23 patients (91 percent) with typical angina pectoris and significant coronary artery disease, lesions were present in the left coronary artery. There was no systolic pressure gradient across the aortic valve that excluded the presence of coronary artery disease, although all patients with a calculated aortic valve area of less than 0.4 cm2 were free of coronary artery disease. Patients with severe left ventricular dysfunction were more likely to have normal coronary arteries.

Adult↗
PubMed1978

Relation of angina to coronary artery disease in mitral and in aortic valve disease.

Of 129 patients with either mitral or aortic valve disease angina was present in 55 (42%). It was more frequent in aortic (60%) than in mitral valve disease (33%). The standard 12-lead electrocardiogram was not helpful in distinguishing underlying occlusive coronary artery disease. Coronary arteriography demonstrated coronary artery disease in 26 patients (20%), only 2 of whom had no angina. The incidence of coronary artery disease was almost identical in both the mitral and aortic groups (22% and 17%, respectively), but the percentage of those with demonstrable coronary artery disease accompanying angina was much higher in the mitral group (67% as against 29%). Angina in mitral valve disorders is thus much more likely to be the result of disease of the coronary arteries. Coronary arteriography is mandatory in all patients in both groups who have angina. Otherwise it seems unnecessary as coronary artery disease was found in only 2 patients who did not have angina.

Adult↗
PubMed2001

Time course of aortic valve function and root dimensions after subcoronary ross procedure for bicuspid versus tricuspid aortic valve disease.

BACKGROUND: The freestanding aortic root, which is the currently preferred operative technique for pulmonary autografts, is reported to dilate and potentially promote aortic insufficiency, which has led to a controversial debate on the appropriate surgical technique, especially for congenital bicuspid aortic valve disease. Desirable data on the time course of valve function and root dimensions for the alternative subcoronary technique comparing bicuspid and tricuspid aortic valve disease are scarce. METHODS AND RESULTS: Echocardiographic examinations of 31 patients with congenital bicuspid aortic valve disease (group A; age 50.5+/-11.0 years) and 51 patients with acquired tricuspid aortic valve disease (group B; age 48.1+/-15.7 years) who were operated on between June 1994 and August 1998 were performed twice postoperatively. At first and second follow-up, respectively, maximum (mean) pressure gradients were 6.0+/-2.0 (3.6+/-1.0) and 5.1+/-2.1 (2.9+/-1.1) mm Hg in group A and 6.5+/-3.5 (3.9+/-1.9) and 5.0+/-1.7 (2.9+/-1.0) mm Hg in group B (P>0.05 between groups). In group A, grade 0 aortic insufficiency at first and second follow-up occurred in 8 and 7 patients, respectively, grade 0-I in 12 and 9 patients, grade I in 9 and 11 patients, grade I-II in 1 and 0 patients, and grade II in 1 and 4 patients; in group B, grade 0 aortic insufficiency occurred in 16 and 18 patients, grade 0-I in 16 and 8 patients, grade I in 17 and 21 patients, grade I-II in 0 and 1 patient, and grade II in 0 and 1 patient (P>0.05). Aortic insufficiency decreased in 10 patients (17%). However, there was an overall tendency for aortic insufficiency to increase over time (n=23, 38%), although it remained subclinical. Aortic root dimensions did not differ between groups and were constant during follow-up. CONCLUSIONS: This study provides some evidence that the function of the subcoronary pulmonary autograft in bicuspid aortic valve disease is excellent, with stable root dimensions, and is not different from that of tricuspid aortic valves at least up to 5.5 years postoperatively, which suggests the subcoronary technique should be reconsidered.

Adult↗
PubMed1980

Non-invasive diagnosis and assessment of aortic valve disease and evaluation of aortic prosthesis function using echo pulsed Doppler velocimetry.

Non-invasive recording of aortic blood flow velocity patterns in the ascending aorta and in the arch of the aorta was performed in 12 normal subjects, 38 patients with confirmed aortic valve disease, and 13 patients with aortic prostheses using pulse echo Doppler velocity recordings. In normal subjects, the velocity recordings correlated well with those obtained by other authors using invasive procedures. In patients with aortic valve disease, specific abnormalities of the velocity curves were found to correlate well both with the type of lesion (stenosis or regurgitation) and its severity on a three-point scale. Both sensitivity and specificity were found to range between 80 and 94 per cent. A less accurate grading of severity was obtained from patients with aortic regurgitation by the detection of turbulence in the left ventricular outflow tract than from the appearance of the aortic velocity curves. In the studies of patients with aortic prostheses, anomalies of the velocity pattern could be found in the ascending aorta in 53 per cent but no abnormalities of timing was found. In spite of some technical limitations, pulse echo Doppler velocity recordings provide a new non-invasive, reliable, and reproducible approach in assessing the presence and severity of aortic lesions and demonstrating flow abnormalities produced by prostheses.

Adolescent↗
PubMed2001

[New aspects in aortic valve disease].

Renewed interest for aortic valve disease has evolved in recent years. Aortic valve replacement has become the second most frequent cause of cardiac surgery, following coronary bypass surgery. In addition, the etiologic and physiopathologic knowledge of this disorder has improved. In the present paper we analyze three aspects of the disease which are, at present, the subject of study and controversy: first, we discuss the possible relationship between degenerative aortic stenosis and atherosclerosis; second, the involvement of the aortic root in cases of bicuspid aortic valve; and third, the surgical indications in asymptomatic patients with either aortic stenosis or regurgitation.

Adult↗
PubMed1982

Assessment of chronic aortic valve disease in adults.

Chronic aortic valve disease is often tolerated for a long period of time with little in the way of symptoms, but once symptoms develop, the downhill course is often rapid. Medical therapy may alleviate symptoms of congestive heart failure and angina, but does not alter the natural history of the disease. The recent advances of cardiac surgery have, however, considerably improved the prognosis of most patients. Some patients with aortic regurgitation, though, will develop progressive congestive heart failure despite aortic valve replacement. Others with severe aortic stenosis will die suddenly while awaiting surgery as will a small number who previously had been asymptomatic. The information that comes from cardiac catheterization as well as the non-invasive investigation of cardiological disease, greatly enhanced by the introduction of the echocardiogram, has provided the physician with a better understanding of the particular problems in question and, therefore, the potential to solve them. This article aims to review the means by which high-risk groups can be identified, in order that their outlook may be improved especially with respect to the timing of surgical intervention.

Aortic Valve Insufficiency↗
PubMed1999

Histologic abnormalities of the ascending aorta and pulmonary trunk in patients with bicuspid aortic valve disease: clinical relevance to the ross procedure.

OBJECTIVE: Bicuspid aortic valve disease is often associated with dilation of the aortic root and ascending aorta. This study examines the histologic features of the ascending aorta and main pulmonary artery of patients with and without aortic valve disease. METHODS: Samples from ascending aorta and main pulmonary artery were obtained at the time of the operation from 20 patients with bicuspid aortic valve and 11 patients with tricuspid aortic valve disease. In addition, samples were also obtained from autopsy cases with normal aortic valve. The histologic changes were graded from 1 to 3 according to severity of degenerative changes. RESULTS: In the ascending aorta, the severity of cystic medial necrosis (P =.001), elastic fragmentation (P =.002), and changes in the smooth muscle cell orientation (P =.002) were significantly more severe in patients with bicuspid than in those with tricuspid aortic valve disease. In the pulmonary trunk specimens, those 3 histologic features were also significantly more severe in patients with bicuspid than those with tricuspid valves (P =.001, P =.01, and P =.04, respectively). Seventy-five percent of patients with bicuspid aortic valve disease had grade 3 degenerative changes, whereas only 14% of those patients with tricuspid aortic valve disease had similar degrees of degenerative changes. CONCLUSION: Patients with bicuspid aortic valve disease have more severe degenerative changes in the media of the ascending aorta and main pulmonary artery than patients with tricuspid aortic valve disease. These findings may explain root and ascending aortic dilation in patients with bicuspid aortic valve disease and pulmonary autograft dilation in certain patients after the Ross procedure.

Adult↗
PubMed1982

Management of aortic valve disease.

The patient with severe aortic valve disease and significant symptoms is a clear-cut candidate for valve replacement surgery. Management of asymptomatic patients with aortic valve disease is less clear-cut. Because asymptomatic patients for the most part have a benign prognosis, careful individual evaluation for risk of progressive disease must be weighed against the risks of surgery.

Adult↗
PubMed2000

Congenital Heart Surgery Nomenclature and Database Project: aortic valve disease.

The extant nomenclature for aortic valve disease is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. Aortic valve disease has been subdivided into stenotic and regurgitant lesions. Stenotic lesions have been characterized by anatomic location: supravalvar, valvar, and subvalvar. Regurgitant lesions have been characterized as either congenital or acquired. A comprehensive database set is presented that is based on a hierarchical scheme. Data are entered at various levels of complexity and detail that can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented that will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Aortic Valve↗
PubMed1992

[Functional and morphologic changes of left ventricular myocardium in the course of aortic valve disease].

The mortality of patients with aortic valve disease is growing significantly from the time of manifestation of features of left ventricular heart failure. Probably, the causes of that situation are the irreversible changes in the myocardium. During the first, asymptomatic stage of aortic valve disease, the increase of preload and afterload is compensated by myocardial hypertrophy, concentric or eccentric respectively. The global heart function as a pump remains normal, in spite of decreased contractility of individual sarcomeres. Valve replacement at that stage of the disease gives the best effects, being the causal treatment. After having used up the compensation possibilities, of the myocardium, the features develop of left ventricular heart failure. The mortality of patients operated on in that stage of the disease is high. Valve replacement is often a palliative method.

Aortic Valve↗
PubMed2002

[Status of aortic valve reconstruction and Ross operation in aortic valve diseases].

BACKGROUND: At first glance the aortic valve is a relative simple valve mechanism connecting the left ventricle and the ascending aorta. Detailed analysis of the different components of the aortic valve including the leaflets and sinuses revealed a complex motion of each part leading to a perfect durable valve mechanism at rest and during exercise. Theoretically, the reconstruction or imitation of these structures in patients with aortic valve disease should lead to optimal results. Prerequisite is the exact knowledge of the important functional characteristics of the aortic valve. The dynamic behavior of the aortic root closely harmonizing with the leaflets not only warrants stress minimizing and valve durability, but also optimizes coronary flow, left ventricular function and aortic impedance. The newly discovered contractile capacity of the leaflets and the root components are important for tuning the dynamics. AORTIC VALVE RECONSTRUCTION: Isolated reconstruction of the aortic valve such as decalcification, commissurotomy, plication of ring or leaflets of a tricuspid aortic valve and cusp extension are seldom indicated in contrast to the reconstruction of the bicuspid insufficient valve. Proper indication and skilled techniques lead to excellent hemodynamic and clinical intermediate-term result up to 7 years after reconstruction. Latest follow-up revealed a mean aortic insufficiency of 0.7, maximal pressure gradient of 11.4 +/- 8.5 mm Hg with zero hospital or late mortality, reoperation or thromboembolic events in 22 patients. The reconstructive techniques for aortic root aneurysm and/or type A dissection according to David or Yacoub have become routine procedures in the last 10 years. The hemodynamic and clinical results are excellent with low reoperation rate and very low risk of thromboembolism. Generally, a maximal diameter of the root of 5 cm is indicative for performing the operation. In patients with Marfan's syndrome the reconstruction should be advanced even with smaller diameters especially if these are progressive and combined with aortic insufficiency. ROSS-OPERATION: The Ross-Operation includes the replacement of the diseased aortic valve with the pulmonary autograft and reconstruction of the right ventricular outflow tract using a homograft. The hemodynamic results are excellent regarding the autograft and also the clinical results with very low thromboembolic risk and acceptable reoperation rate. This method is especially indicated for active young patients, women, who desire children, athletes and patients in general, who like to avoid long-term anticoagulation. In some cases the homograft may develop a dysfunction predominantly a pulmonary stenosis requiring reoperation. In the author's series of 245 Ross-operations in 12 years the homograft had to be replaced in 4 cases without letality. Innovative, decellularized homografts with the potential to repopulate with autologeous cells show promising results after 1 year of clinical implantation without signs of antibody development. Probably these tissue-engineered modification may improve the homograft results. The reconstructive techniques of the aortic valve and the Ross-operation have a certain risk of reoperation that must be weighed against the advantages of very low hospital and late valve related death, excellent hemodynamics, very low risk of macro- and microembolism as well as bleeding, lack of long-term anticoagulation and unrestricted life-style.

Adult↗
PubMed1983

Left ventricular function in patients with ventricular arrhythmias and aortic valve disease.

Forty patients having aortic valve replacement were evaluated preoperatively for ventricular arrhythmia and left ventricular ejection fraction. Arrhythmias were classified as complex or simple using the Lown criteria on the 24-hour ambulatory electrocardiogram; ejection fractions were determined by radionuclide gated blood pool analysis and contrast angiography. The ejection fractions determined by radionuclide angiography were 59.1 +/- 13.1% for 26 patients with simple or no ventricular arrhythmias, and 43.9 +/- 20.3% for 14 patients with complex ventricular arrhythmias (p less than 0.01). Ejection fractions determined by angiography, available for 31 patients, were also lower in patients with complex ventricular arrhythmias (61.1 +/- 16.3% versus 51.4 +/- 13.4%; p less than 0.05). Seven of 9 patients showing conduction abnormalities on the electrocardiogram had complex ventricular arrhythmias. Eight of 20 patients with aortic stenosis had complex ventricular arrhythmias, while 2 of 13 patients with aortic insufficiency had such arrhythmias. It is concluded that decreased left ventricular ejection fraction, intraventricular conduction abnormalities, and aortic stenosis are associated with an increased frequency of complex ventricular arrhythmias in patients with aortic valve disease.

Aortic Valve↗
PubMed2001

[Patient-adapted valve selection: biological vs. mechanical heart valve replacement in aortic valve diseases].

Since the first aortic valve replacement performed by Harken in 1960, the operation of aortic valve disease by replacing the native valve with a heart valve prosthesis has become one of the most frequently performed procedures in cardiac surgery. For valve replacement there are biological (xenografts and homografts) and mechanical heart valve prostheses available. When choosing the most suitable prosthesis the limited durability of a biological prosthesis and the risks of lifelong anticoagulation for a mechanical prosthesis have to be balanced. In this article the indication for operation of aortic valve stenosis and aortic regurgitation are discussed first. Based on the literature of the last 2 years the advantages and disadvantages of mechanical and biological heart valve prostheses (xenograft, homograft and ROSS procedure) are discussed. In addition rarely used techniques like aortic valve reconstruction are presented. Due to the fact that a biological prosthesis has a durability of 12-15 years and the risk of bleeding complications under anticoagulation grows with increasing age, the choice of a biological prosthesis can be recommended from the age of 65 years. Results of long-term studies at to whether this limit can be diminished by using a stentless biological prosthesis have to be awaited.

Aged↗