Proceedings: Importance of coronary artery disease in surgery of aortic valve disease.
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Angiography↗
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Results for “AORTIC VALVE DISEASES”
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Aortic valve disease with severe ventricular dysfunction: stentless valve for better recovery.
BACKGROUND: Stentless bioprostheses and homografts show better hemodynamic profiles compared with conventional stented bioprostheses and mechanical valves. Few data are available on stentless aortic valve implantation for patients with severe left ventricular dysfunction. The aim of this retrospective study was to assess the potential benefits of stentless aortic valve implantation for patients undergoing isolated aortic valve replacement with left ventricular ejection fraction < or = 35%. METHODS: From November 1988 through March 2000, 53 patients (45 men and 8 women, aged 64.2 +/- 15.2 years) with a LVEF < or = 35% (mean EF, 28.7 +/- 5.4%) underwent isolated, primary aortic valve replacement for chronic aortic valve disease. Twenty patients received stentless aortic valves and 33 patients received conventional stented bioprostheses and mechanical valves. Predictive factors for LVEF recovery at echocardiographic follow-up (36.2 +/- 32.1 months) were analyzed by simple and multiple regression analysis. RESULTS: There were no significant differences between groups in early and late mortality. Stentless aortic valve implantation required a longer aortic cross-clamp time (p = 0.037). The stentless aortic valve group showed a better LVEF recovery (p = 0.016). Stentless aortic valves had a larger indexed effective orifice area compared with conventional stented bioprostheses and mechanical valves (p < 0.0001). A smaller indexed effective orifice area (p = 0.0008), chronic obstructive pulmonary disease (p = 0.015), and implantation of a conventional stented bioprosthesis or mechanical valve (p = 0.016) were related to reduced LVEF recovery by univariate analysis. A larger indexed effective orifice area (p = 0.024) was an independent predictive factor for a better LVEF recovery by multivariate analysis. CONCLUSIONS: Stentless aortic valve implantation for patients with severe left ventricular dysfunction, even if technically more demanding, is a safe procedure that warrants a larger indexed effective orifice area leading to an enhanced LVEF recovery.
Aortic Valve↗
Etiology of aortic valve disease and recent changes in Japan:a study of 600 valve replacement cases.
BACKGROUND: Recent studies on the etiology of aortic valve disease in the US showed a decrease in rheumatic valve disease and an increase in age-related degenerative disease. The purpose of this study was to describe the etiology of aortic valve disease and its temporal changes in Japan, based on a large number of cases. METHODS: The medical charts of all patients who underwent aortic valve replacement at our institute between 1977 and 1999 were reviewed. Among the 600 patients analyzed, 213 (36%) had pure aortic stenosis, 265 (44%) had pure aortic regurgitation, and 122 (20%) had combined stenosis and regurgitation. RESULTS: The causes were rheumatic change (49%), degenerative change (19%), bicuspid valves (18%), infective endocarditis (5%) and others (9%). Rheumatic disease continued to be the most common cause of aortic stenosis, but its frequency decreased from 100% in 1977-1979 to 37% in 1995-1999. In contrast, the frequency of degenerative change among stenotic valves increased recently from 11% in 1990-1994 to 30% in 1995-1999. Similarly, rheumatic disease remained to be the leading cause of aortic regurgitation, with a decline in frequency from 46% in 1985-1989 to 27% in 1995-1999. The percentage of degenerative change among regurgitant valves did not change appreciably. CONCLUSIONS: There was a shift in the causes of aortic valve disease, with a decrease in rheumatic disease and an increase in degenerative disease. This trend was similar to that observed in the US. These findings suggest the increasing importance of aortic valve disease due to degenerative change.
Adult↗
[Treatment of aortic valve diseases].
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Aortic Valve↗
Asymmetric medial degeneration of the ascending aorta in aortic valve disease: a pilot study of surgical management.
BACKGROUND AND AIM OF THE STUDY: In structural aortic valve disease, medial degeneration is often associated with ascending aorta dilatation. This pathology is often asymmetric, with more severe involvement of the convex aspect of the ascending aorta. The condition can be managed with surgical excision of the diseased portion of the aortic wall and remodeling reconstruction at the time of aortic valve replacement (AVR). METHODS: Sixty-one patients underwent AVR and 'waistcoat aortoplasty'. Sinus dilatation was repaired by plicating the subcoronary redundant aortic wall using anchoring sutures of the valve prosthesis. The diseased aortic wall was removed via a triangular resection, and the aorta reconstructed with a double-layer technique, to achieve autologous reinforcement of the convex right posterolateral wall and stress reduction on the aortotomy suture line. Echocardiography was performed preoperatively, immediately postoperatively, and every six months thereafter. The significance of diameter variations was evaluated. RESULTS: There was no hospital mortality, and only low postoperative morbidity. Post-reduction diameters at the sinuses, sinotubular junction and ascending aorta were significantly less than preoperative values (p < 0.0001). During a mean follow up of 33.8 +/- 10.2 months (range: 13-50 months), no significant increase in root (p = 0.32), sinotubular (p = 0.15), or ascending diameter (p = 0.11) was observed. CONCLUSION: The 'waistcoat aortoplasty' should be considered when dealing with asymmetric ascending dilation secondary to aortic valve disease-related medial degeneration. However, additional studies with a longer follow up are needed to confirm these findings.
Adult↗
Effect of progression of left ventricular hypertrophy on coronary artery dimensions in aortic valve disease.
OBJECTIVES: The effect of progression of left ventricular hypertrophy on coronary artery dimensions was studied in patients with aortic valve disease. METHODS: Cross-sectional area of the left and right coronary arteries was determined by quantitative coronary arteriography in 12 control subjects and in 10 patients with aortic valve disease at baseline and after a follow-up period of 66 months. RESULTS: The cross-sectional area of the left coronary artery was larger in patients with aortic valve disease than in control subjects (left anterior descending artery 13 vs. 8 mm2, p < 0.001; left circumflex artery 13 vs. 6 mm2, p < 0.001). At the follow-up examination, cross-sectional area of the left coronary artery increased (left anterior descending artery 17 mm2, p < 0.01 vs. baseline; left circumflex artery 15 mm2, p < 0.01 vs. baseline). The cross-sectional area of the right coronary artery was not different in patients with aortic valve disease from that in control subjects. Left ventricular muscle mass was larger in patients with aortic valve disease both at baseline (269 g, p < 0.001) and after follow-up examination (339 g, p < 0.001) than in control subjects (136 g). The appropriateness of coronary artery size with respect to muscle mass was evaluated by normalizing cross-sectional area of the left coronary artery (left anterior descending plus left circumflex artery) per 100 g of left ventricular muscle mass (mm2/100 g). This index was 10.9 mm2/100 g in control subjects, and decreased in subjects with aortic valve disease from 10.3 mm2/100 g at baseline to 8.6 mm2/100 g at the follow-up measurement (p < 0.05 vs. control values). CONCLUSIONS: In patients with aortic valve disease, the progression of left ventricular hypertrophy is associated with an increase in left anterior descending and left circumflex coronary artery dimensions, whereas the size of the right coronary artery remains unchanged. Despite the enlargement of the left coronary artery, the cross-sectional area of the left coronary artery per 100 g of left ventricular muscle mass decreased. Hence, the increase in coronary artery size appears to be inadequate when the severity of left ventricular hypertrophy increases.
Adult↗
[Pulmonary hypertension in aortic valve disease].
144 surgical patients with isolated aortic valve disease were reviewed to determine the incidence and the mechanism of pulmonary hypertension (PH). The hemodynamic data revealed PH (pulmonary artery systolic pressure of 40 mmHg or more) in 18 patients (12.6%). There was a positive correlation between left ventricular end-diastolic pressure (LVEDP) and pulmonary artery pressure. After operation the pulmonary artery pressure normalized in all cases but 2 patients in early post-operative period. In patients with aortic stenosis with PH, LVEDP/LVEDVI ratio was higher than that of patients without PH, which showed left ventricular diastolic dysfunction. In patients with aortic regurgitation with PH, the cause of elevated LVEDP was not only severe long-standing regurgitation with ventricular dysfunction, but also the imbalancement of compensation by dilated ventricle with preserved left ventricular function.
Adult↗
[Diagnosis of aortic valve calcinosis with a view to the surgical treatment of aortic valve disease].
Combined roentgenologic/echocardiographic diagnosis of aortic valve calcinosis was made in 135 patients operated on for a rheumatic aortic heart disease. Four degrees of aortic valve calcinosis were identified: 1) isolated fine points of calcinosis, as revealed by echolocation and specific treatment of the removed valves; 2) small-focal calcinosis as revealed roentgenologically in 79.2% of cases and by echolocation, in 93%; 3) large-focal, and 4) wide-spread calcinosis, the latter two being detectable both roentgenologically and echocardiographically in all cases. The 4-degree classification of aortic valvular lesions allows a detailed assessment of the nature of the affection that is important for the choice of surgical procedure.
Aortic Valve↗
Mid-term results of aortoplasty for dilated ascending aorta associated with aortic valve disease.
BACKGROUND: Dilatation of the ascending aorta concomitant with aortic valve disease is occasionally associated with progressive enlargement of the ascending aorta or acute aortic dissection (AAD). However, surgical procedure of choice for the aorta and its indication are controversial. PATIENTS AND METHODS: From July 1995 to August 2001, 10 patients with a moderately dilated ascending aorta (mean diameter, 52+/-4.8 mm) underwent concurrent aortic valve replacement (AVR) and aortoplasty. The aortic valve was bicuspid in eight patients. To tailor the ascending aorta 30-35 mm in diameter, the aortic wall was partially resected along the aortotomy, and the aorta was directly closed. RESULTS: Operation time and most of other perioperative variables were comparable to those of patients who underwent isolated AVR. The aortic diameter was reduced to 36.1+/-4.1 mm. Nine patients survived to hospital discharge uneventfully, but one patient developed disruption of the suture line in the aorta and died. During follow-up, no patient suffered AAD but redilatation was observed in one patient. In the two problematic patients, the ascending aorta was larger than 55 mm, and its media was histologically abnormal. CONCLUSION: In patients with dilated ascending aorta less than 55 mm in diameter, aortoplasty can be a procedure of choice. However, a prosthetic graft replacement is recommended when the diameter of the ascending aorta is larger than 55 mm.
Adult↗
[Surgical strategies for aortic valve disease in elderly patients].
Population of elderly people is increasing and aortic valve disease due to degeneration with aging process, especially aortic stenosis (AS) is increasing in elderly patients. With development and great use of non-invasive diagnostic techniques, particularly echocardiography, the diagnosis and evaluation of aortic valve disease are even safer in these patients. Aortic valve replacement (AVR) is effective treatment for symptomatic AS, however, generally has a higher risk in elderly patients, especially 80 years and over patients. Several reports demonstrated acceptable operative mortality and morbidity in elderly patients. We performed AVR or AVR with other cardiac surgical procedures in 16 cases of 80 years and over patients from 1998 to 2004, and there were no operative or hospital death. Therefore, AVR in 80 years and over patients could be acceptable surgical treatment and age alone is not contraindication.
Aged↗
Computer-assisted two-dimensional echocardiography in preoperative evaluation of left ventricular function in patients with aortic valve disease.
Seventy-six healthy adults and 228 patients with aortic valve disease were studied by means of two-dimensional echocardiography (2D-EchoCG). Functional properties of the left ventricle in patients with aortic valve disease were studied by means of computer analysis of echocardiograms and patients requiring cardiac surgery were identified. It was found that an increased left ventricular (LV) end-systolic volume (110 ml and more), assessed by 2D-EchoCG, is an unfavourable prognostic sign, and elevated risk factor of cardiac surgery. It invariably proved to be related to LV dysfunction after the surgery. A decreased diastolic LV mass/volume ratio (1.255 and less), found in 16% of patients with pressure overload, means nonadequate development of hypertrophy and an elevated risk of cardiac surgery.
Adolescent↗
[Efficacy of aortic valve replacement with freestyle stentless valve in patients with aortic valve disease].
Stentless porcine aortic bioprosthesis has several potential advantages over conventional stented bioprosthesis. The Medtronic Freestyle aortic bioprosthesis, a stentless design analogous to an aortic allograft, has zero-pressure-fixed leaflets treated with an antimineralization agent, and has been shown to have benefits of superior effective orifice area, excellent flow characteristics and durability. To evaluate the early results for its efficacy in view of post-operative performance. The valve was implanted using the cylinder method, with subcoronary, root-inclusion techniques or full root techniques. No patients experienced any significant valvular regurgitation on echocardiography. The post-operative data of EDVI, ESVI and LVPWD decreased significantly as compared with the pre-operative data while ejection fraction remained unchanged. The average peak pressure gradient was 16.5 mmHg, and the average effective orifice area was 2.45 cm2. In conclusion, Freestyle stentless aortic bioprosthesis showed excellent hemodynamic function. It seems to be suited for the older patient with a small aortic annulus.
Aged↗
Quantitative ultrastructure of the myocardium in chronic aortic valve disease.
Light and electron microscopic morphometry was carried out in tissue samples which were obtained from the left ventricular free wall in 29 patients with chronic aortic valve disease during open-heart surgery. 6 patients had aortic stenosis, 9 had aortic insufficiency and 14 had a mixed aortic valve lesion. Hemodynamics were studied before operation. Patients with mixed aortic valve disease had a higher left ventricular mass, a lower ejection fraction and mean circumferential fiber shortening rate than patients with aortic stenosis. Peak systolic wall stress was comparable between groups. The intracellular content of contractile material was lower and the sarcoplasmic volume was higher in mixed aortic valve disease than in aortic stenosis. Mitochondrial volume and interstitial fibrosis were not different between groups. Patients with aortic insufficiency showed no significant difference of parameters as compared to both other groups. We conclude that an intracellular deficiency of myofibrils causes lack of contractility in advanced hypertrophy due to mixed aortic valve disease.
Aortic Valve Insufficiency↗
Fate of mild aortic valve disease after mitral valve intervention.
OBJECTIVE: This study was performed to assess the long-term outcome of untreated mild aortic valve disease present at the time of initial mitral valve intervention. METHODS: A total of 284 patients with rheumatic heart disease aged 7 to 62 years (mean, 23.5 +/- 12.2 years) who underwent mitral valve intervention and had mild aortic valve disease initially were followed up for 2 to 18 years (mean, 10.8 +/- 3.7 years). At initial intervention, 232 patients had pure mild aortic regurgitation, and 52 patients had mild aortic stenosis with or without aortic regurgitation. RESULTS: Among patients with mild aortic regurgitation initially, 11 (5%) patients progressed to moderate (n = 6) or severe (n = 5) regurgitation over an interval of 9 to 17 years (mean, 12.1 +/- 2.8 years), and 1 patient had moderate aortic stenosis and severe aortic regurgitation after 10 years. Freedom from development of moderate-severe aortic valve disease in patients who initially had mild aortic regurgitation was 100%, 97.0% +/- 1.7%, and 87.4% +/- 4.6% at 5, 10, and 15 years, respectively. Seventeen (35%) patients with initial mild aortic stenosis (with or without regurgitation) had moderate or severe stenosis (with or without moderate-severe regurgitation) after an interval of 4.9 +/- 3.8 years. Freedom from development of moderate-severe aortic valve disease in patients who initially had mild aortic stenosis was 75.6% +/- 6.2%, 61.5% +/- 8.5%, and 46.1% +/- 11.2% at 5, 10, and 15 years, respectively. Ten patients required aortic valve replacement for aortic valve dysfunction. CONCLUSIONS: Mild aortic regurgitation present at the time of mitral valve intervention progresses very slowly and less frequently requires reintervention. However, mild aortic stenosis diagnosed initially progresses more often and more rapidly and thus needs closer follow-up.
Adolescent↗
Aortic valve disease: current recommendations.
Aortic stenosis is a common valvular abnormality. Surgical valve replacement is the standard of care for symptomatic patients with severe aortic stenosis and is appropriate for certain asymptomatic patients. Statin therapy may slow progression of the disease. Contrary to conventional wisdom, vasodilator therapy may in fact be safe and effective in certain instances of severe aortic stenosis. Chronic aortic regurgitation is commonly treated with vasodilator therapy, which is certainly indicated for the asymptomatic patient with hypertension. Surgery is recommended for left ventricular dilatation, diminished ventricular systolic function, or symptoms.
Aortic Valve Insufficiency↗
Repair of asymptomatic aortic valve disease during other cardiac surgery.
Repair of asymptomatic aortic valve disease was performed in 12 patients (9 female, 3 male, mean age 57.5 years) undergoing other cardiac surgery. Stenosis was the predominant aortic valve lesion in 7 (group A) with a mean gradient of 33.4 mmHg and regurgitation of mean grade 1.4 was predominant in 5 (group B). Cusp debridement +/- commissurotomy was performed in 9; commissural resuspension in 6 and repair of cusp perforation in 2. Perioperative transoesophageal echocardiography was used to assess the adequacy of repair in 4 patients. Prospective precordial echocardiographic follow-up is complete (mean 4.3 months). In group A there has been a significant reduction is peak aortic pressure gradient (33.4 vs 22.1 mmHg, p less than 0.05) and in cusp thickness (2.25 to 1.64 mm, p less than 0.05). In group B the degree of incompetence has improved in 3 of the 5 patients. Three patients have worsened valve disease following repair; in all these there was mixed valve disease of rheumatic origin. Aortic valve repair of asymptomatic disease during other cardiac surgery is a feasible technique which does not accelerate the disease process in the short term. Long-term follow-up is in progress to assess the prognosis of this preventive intervention.
Adult↗
Ross procedure in rheumatic aortic valve disease.
OBJECTIVE: To assess the results of aortic valve replacement with the pulmonary autograft in patients with rheumatic heart disease. METHODS: From October 1993 through September 2003, 81 rheumatic patients with aortic valve disease, mean age 29.5+/-11.9 years (11-56 years) underwent, the Ross procedure with root replacement technique. Forty patients were 30 years of age or below (young rheumatics). Associated procedures included mitral valve repair (n=19), open mitral commissurotomy (n=15), tricuspid valve repair (n=2), and homograft mitral valve replacement (n=2). RESULTS: Early mortality was 7.4% (six patients). Mean follow-up was 92.3+/-40.9 months (7-132 months, median 109 months). Sixty of the 73 patients whose follow-up was available (82%) had no significant aortic regurgitation. Re-operation was required in seven (8.4%) patients for autograft dysfunction with failed mitral valve repair (n=3), autograft dysfunction alone (n=2) and failed mitral valve repair alone (n=2). No re-operations were required for the pulmonary homograft. There were six (7.5%) late deaths. Actuarial survival and re-operation-free survival at 109 months were 84.5+/-4.1% and 90.5+/-3.7%, respectively. Freedom from significant aortic stenosis or regurgitation was 78.4+/-5.2% and event-free survival was 64.6+/-5.8%. When compared to rheumatics above 30 years of age, the relative risk of autograft dysfunction was high in the young rheumatics. CONCLUSION: The Ross procedure is not suitable for young patients with rheumatic heart disease. However, it provides acceptable mid-term results in carefully selected older (>30 years) patients with isolated rheumatic aortic valve disease.
Adolescent↗
Timing of aortic valve replacement in elderly patients with symptomatic aortic valve disease using outpatient clinical parameters.
OBJECTIVE: To determine by how far worsening outpatient clinical parameters can affect outcome after aortic valve replacement, in patients with preserved left ventricular function and symptomatic aortic valve disease. PATIENTS AND METHODS: Five hundred patients with aortic valve disease underwent aortic valve replacement using a bioprosthesis. In 348 patients, another procedure was added. The preoperative outpatient parameters were investigated for their effect on hospital and long-term mortality. A Fisher exact, Kaplan-Meier univariate and Cox proportional hazard analysis were used. RESULTS: A retrospective follow-up of 2022 patient years was obtained. Five preoperative parameters were found to be more present in patients with a decreased left ventricular function: 1) severity of symptoms, 2) previous myocardial infarction, 3) conduction defects, 4) aortic valve regurgitation and 5) increasing need for medication. In patients with an ejection fraction of 50% or more, logistic regression analysis showed that hospital mortality increased with need for medication (p=0.004), previously performed CABG (0.015), increase in symptoms (p=0.018) and myocardial infarction (p=0.034). A Kaplan-Meier analysis revealed aortic valve regurgitation (p=0.017) and increased need for medication (p=0.012) as significant on long-term survival. Presence of a previous myocardial infarction showed a trend (p=0.062). A Cox' proportional hazard analysis showed for global mortality increased need for medication (p=0.010) and previous myocardial infarction (p=0.018) as independent factors and for long-term mortality, this was aortic valve regurgitation (p=0.001). CONCLUSIONS: Results after aortic valve replacement deteriorate with the presence of valve regurgitation, a preoperative myocardial infarction, increasing need for medication or severity of symptoms, even for an ejection fraction of 50% or more. Anamnesis with special care to the degree of symptoms and increasing need for medication early in the valve disease could lead to early referral, thereby reducing number of patients with severe symptoms and improving postoperative results.
Age Factors↗