Progressive Aortic Insufficiency Research Articles

Balloon Aortic Valvuloplasty

Since the description by Lababidi in 1983 of balloon aortic valvuloplasty, it has been used extensively by several groups of workers for relief of valvar aortic stenosis of moderate to severe degree. The indications for the procedure are peak‐to‐peak gradients ≥ 50 mmHg with symptoms or ECG changes or a gradient of ≥ 70 mmHg irrespective of the symptoms and ECG changes. One or more balloon catheters are placed across the aortic valve, over an extra‐stiff guidewire and balloon inflated, producing aortic valvuloplasty. The recommended balloon: annulus ratio is 0.8:1.0. Immediate reduction of peak‐to‐peak gradient along with a fall of left ventricular peak systolic and end‐diastolic pressures occurs. Rarely, significant aortic insufficiency, particularly in the neonate, may develop. At intermediate‐term follow‐up, catheter‐measured peak‐to‐peak gradients and Doppler‐measured peak instantaneous gradients remain low for the group as a whole. However, nearly one‐quarter of the patients may develop restenosis, defined as peak‐to‐peak gradient ≥ 50 mmHg. The restenosis is successfully treated with surgical or repeat balloon valvotomy. Predictors of restenosis were age ≤ 3 years and an immediate postvalvuloplasty aortic valve gradient ≥ 30 mmHg. Comparison with surgical results is difficult, but overall, the balloon therapy appears to carry less morbidity. Long‐term follow‐up data are scanty. The limited data suggest low Doppler peak instantaneous gradients, minimal additional restenosis beyond what was observed at intermediate‐term follow‐up, and progression of aortic insufficiency in nearly one‐quarter of patients. Event‐free rates are 76% and 60%, respectively, at 5 and 10 years following initial balloon valvuloplasty. Based on immediate and intermediate‐term follow‐up data, balloon aortic valvuloplasty appears to produce reasonably good results, avoiding/postponing the need for surgical intervention. The late follow‐up data are of some concern in that significant aortic insufficiency with left ventricular dilatation may develop, and some require surgical intervention. Prospective studies on larger groups of children and careful comparison with long‐term follow‐up surgical data may be necessary to make a definitive recommendation that balloon aortic valvuloplasty is the therapeutic procedure of choice.

Aortic insufficiency after Arterial Switch Operation in Transposion of the Great Arteries

Background:The arterial switch operation(ASO) has become a procedure of choice for transposition of the great arteries(TGA) with or without ventricular septal defect(VSD). In spite of current low surgical mortality in immediate surgical period, there are potential problems of late morbidity and mortality. In this study, we evaluate the prevalence and severity of aortic insufficiency (AI) and associated factors with AI. Method:We retrospectively reviewed medical records and echocardiogram of 125 patients(M89, F36) underwent ASO for TGA at Seoul National University Children’s Hospital from July, 1987 to June, 1997. To evaluate for associated factors, we divided patients of TGA to four hemodynamic groups(Group I, simple TGA(n=53);Group II, associated with ventricular septal defect(VSD) (n=50);Group III, associated with VSD and PS(n=18);Group IV, associated with PS(n=4)). Grade of AI was assessed by color Doppler analysis(Perry’s et al). Results:Total prevalence rate of AI was 35.2%(31/88) and grade of AI were mild in 61%, moderate in 39%. The incidence of AI in each group was:Group I 25.0%(10/40), Group II 26.0%(9/36), Group III 92.0%(12/13). According to this study, pulmonary stenosis was the only significant factor to AI. During follow-up(39±24 Months), in spite of the normal left ventricular function in most patients with AI, a few patients(3 cases) suffered from progressive AI and some moderate AI patients(2 cases) showed slightly decreased LV function. Two moderate and progressive AI lossed.

Resultados imediatos e tardios da correção cirúrgica da dissecção aguda da aorta (tipo A)

Realizamos uma análise retrospectiva do tratamento cirúrgico da dissecção aguda da aorta do tipo A no período compreendido entre janeiro de 1986 a dezembro de 1996. Foram tratados 64 pacientes com idade média de 52,6 ± 10,9 anos, sendo a maioria do sexo masculino (64,1%). Em 17 casos (26,6%) havia rotura intrapericárdica da dissecção; a fenda de origem da dissecção encontrava-se na aorta ascendente em 58 pacientes (90,6%) e no arco aórtico nos demais (9,4%). O tratamento básico compreendeu a ressecção da aorta ascendente com substituição por prótese de pericárdio bovino, embora outras técnicas tenham sido empregadas em um pequeno número de pacientes, no início de nossa experiência. A hipotermia profunda com parada cardiocirculatória foi usada em 32,8% dos pacientes, de forma crescente nos últimos anos. A valva aórtica do paciente foi preservada em 76,5% das vezes. A mortalidade global foi de 28,1% (18 pacientes), porém significativamente menor nos últimos 4 anos (17,8%). Na evolução tardia houve 4 óbitos, sendo 2 de causa indeterminada e os outros 2 por AVC e embolia pulmonar, respectivamente. Reoperações foram necessárias em 7 pacientes, sem mortalidade, sendo a causa principal da reoperação a progressão da insuficiência aórtica. Nesse período de observação não houve falência estrutural das biopróteses nem dos enxertos de pericárdio bovino. Esta experiência nos reforça uma tática mais radical no tratamento das dissecções agudas do tipo A, com maior liberdade na substituição da valva aórtica e na utilização da hipotermia profunda em quase todos os pacientes.

Discrete Membranous Subaortic Stenosis: Improved Results After Resection and Myectomy

Background. Despite an adequate resection, a significant recurrence rate is encountered in patients undergoing operation for discrete membranous subaortic stenosis. The fibrous membrane and hypertrophied myocardium commonly are removed, but because of the involved risks, the resection may be inadequate and contribute to the recurrence rate. Methods. A review of the cases of 23 patients undergoing operation for discrete membranous subaortic stenosis from 1980 to 1994 was undertaken. Fourteen patients (61%) had coexisting cardiac lesions, all of which were concomitantly repaired. Results. The left ventricle–aorta gradient decreased from a preoperative mean of 63.39 ± 7.63 mm Hg to 15.17 ± 3.06 mm Hg postoperatively ( p < .001) during a mean follow-up of 3.32 ± 0.58 years. Aortic insufficiency decreased postoperatively in 8 patients (34.8%), remained unchanged in 6 patients (26.1%), and showed only insignificant progression in 4 patients (17.4%). There were no early deaths, and the single late death was not cardiac related. No patient had development of endocarditis or heart block or required a pacemaker. One patient (4.3%) had a recurrence, which required reoperation. Conclusions. Our results suggest that aggressive myectomy in concert with membrane resection constitutes safe treatment for discrete membranous subaortic stenosis and is associated with low rates of endocarditis, recurrence, and progression of aortic insufficiency.

Aneurysmal Dilatation of Ascending Aorta and Aortic Insufficiency in Juvenile Spondyloarthropathy

Aortic insufficiency is a well-recognized complication of adult spondyloarthropathy but rare in juveniles, and no report is associated with aneurysmal dilatation at any age. We describe rapidly progressive aortic insufficiency with aneurysmal dilatation of ascending aorta in a 15-year-old boy with juvenile spondyloarthropathy, necessitating a Bentall operation.

Progressive aortic valve insufficiency due to kawasaki disease

Progressive aortic valve insufficiency due to kawasaki disease

Implantation of the Unstented Bioprosthetic Aortic Root: An Improved Method

The problem of early onset aortic insufficiency as seen with the scalloped, subcoronary homograft aortic valve replacement is reduced with the use of a total root replacement. In addition, the naturally competent aortic root is more durable. From September 1985 to April 1991, 26 consecutive patients underwent aortic root replacement with 10 autografts, 14 homografts, and 2 xenografts using a modified implantation method. Twenty-five patients were discharged from the hospital. This partial inclusion root technique for implanting unstented valves in the aortic position decreases the probability of early failure secondary to technical malalignment at the time of implantation. In contrast to total root replacement, it avoids the need to destroy the recipient aortic root. A longitudinal aortotomy is performed to the aortic annulus in the mid-portion of the noncoronary sinus. The proximal suture line is interrupted with the valve oriented in the anatomical position. Circumferential running monofilament side-to-side anastomoses approximate the donor coronary ostia to the recipient. A running medial and lateral posterior suture line to the lateral superior portions of the aortotomy completes the integrity of the anterior wall of the implantation. One autograft attempt failed and one homograft patient died postoperatively. Follow-up ranges from 1 to 6 years in 24 patients. Postoperative aortic insufficiency was significant in one case due to inappropriate sizing of the proximal aortic suture line. There has been no evidence of progressive aortic insufficiency detected by the early onset of diastolic murmurs or echocardiograms as was our previous experience with the scalloped subcoronary method.

Long-term results of survivors of surgical valvotomy for severe aortic stenosis in early infancy

Long-term morbidity and mortality were evaluated in the 21 survivors of a cohort of 51 consecutive infants with severe aortic valve stenosis who underwent surgical treatment in the first 3 months of life during the period from 1958 to 1988. The 21 early survivors have been followed up from 3 to 27 years (median 7.5 years). There have been two late deaths: one at age 13 year from bacterial endocarditis and the other at age 14 years after dislodgment of a prosthetic valve. The calculated 10-year actuarial survival for this group is 100%, with a 15-year actuarial survival of 75% (standard error 15%). Seven repeat operations have been performed in six patients: Three had persistent stenosis and a repeat valvotomy was performed in two of them, aged 2 years and 15 years. The other underwent placement of a conduit from the left ventricle to the descending aorta at 2 years of age. Replacement of the aortic valve has been performed in four patients because of severe valvular insufficiency 13 to 27 years after the initial operation. One of these had required a repeat valvotomy at the age of 15 years. The calculated actuarial freedom from reoperation at 10 years is 90% (standard error 6%) and at 15 years, 67% (standard error 15%). Aortic insufficiency was progressive throughout the period of follow-up. No patient had more than moderate aortic insufficiency 3 to 5 years after the initial valvotomy, whereas aortic insufficiency was severe in five of the eight patients followed up for 11 or more years. Progression of aortic insufficiency and the need for reoperation were not related to the age at initial valvotomy. Survivors of surgical aortic valvotomy in early infancy have a relatively good long-term prognosis and a high freedom from reoperation in the period leading to adolescence. Aortic insufficiency in these patients is progressive, and valve replacement eventually may be required.

Pulmonary autograft replacement in children. The ideal solution?

Fifty-one children, aged 1.8 to 21 years (mean, 11.4) with aortic valve replacement using a pulmonary autograft are reviewed. Twenty-nine were intra-aortic implants and 22 were root replacements. There was one operative death, no late deaths, and two have required reoperation. Actuarial freedom from reoperation was 93% +/- 5.5 at 5.6 years. Freedom from progression of aortic insufficiency (AI) was 81% +/- 9 at 5.6 years in the intra-aortic implants and 86% +/- 10 in the root replacement. Enlargement of the pulmonary autograft was seen echocardiographically in both groups. This enlargement was consistent with somatic growth and not associated with progression of AI. Ten of 19 patients with aortic stenosis had an LV mass index suggestive of LV hypertrophy before operation. At 1 year, 18 of 25 had a normal LV mass index. Thirteen of 16 patients with AI had preoperative abnormal LV mass index. All but four returned to normal by 1 year. Low operative risk, excellent function, resolution of abnormal LV hemodynamics, and enlargement consistent with somatic growth suggest that the pulmonary autograft is the ideal replacement for the malfunctioning aortic valve.

Surgical management of the conal (supracristal) ventricular septal defect

Surgical management of the conal (supracristal) ventricular septal defect differs significantly from the management of the perimembranous (infracristal) ventricular septal defect. The absence of a portion of the conal septum can lead to prolapse of the right cusp of the aortic valve, which predisposes these patients to aortic insufficiency. Between January 1980 and December 1989, 36 children with conal ventricular septal defect underwent intracardiac repair. Diagnosis was by echocardiography, cardiac catheterization, and intraoperative exploration. Preoperative evaluation showed that 26 patients (72%) had aortic valve prolapse and 16 (44%) had aortic insufficiency. Pulmonary-to-systemic flow ratios ranged from 1:1 to 3.5:1 (mean 2.0:1.0). Ten patients (27%) were believed to have clinical congestive heart failure. Age at the time of operation ranged from 2 weeks to 18 years (mean 5.5 years). Operative exposure was through the pulmonary artery (26), aorta (4), right ventricle (3), or right atrium (3). Simultaneous aortic valve suspension for aortic insufficiency was performed in four patients. Operative survival was 100%. Follow-up is complete in all patients and ranges from 0.5 to 9 years (mean 4.3 years). All patients are in normal sinus rhythm. No residual ventricular septal defects have been identified. Twenty-three of 36 patients (64%) have no evidence of aortic insufficiency; 12 of 36 (33%) have trivial or mild aortic insufficiency. One patient with initial severe aortic insufficiency underwent repeat aortic valvuloplasty 3 years after ventricular septal defect closure and aortic valve suspension. No patients have required aortic valve replacement. Surgical management of the conal ventricular septal defect differs from that of the perimembranous ventricular septal defect in two critical aspects. The operative approach should be through the pulmonary artery. This allows the best exposure of the remaining conal septum and the pulmonary and aortic valve leaflets, facilitating closure of the defect without injury to the valves or conduction system. Conal ventricular septal defects should undergo early closure, regardless of shunt volume, to prevent progressive aortic insufficiency.

Subvalvar aortic stenosis: Timing of operation

Subvalvar aortic stenosis can be associated with progressive left ventricular outflow tract obstruction, aortic insufficiency, and infective endocarditis. We reviewed the records of 36 surgical patients who underwent 39 operations for subaortic stenosis. Seventeen patients had associated congenital cardiac anomalies. One perioperative death occurred in a patient with tetralogy of Fallot. The mean preoperative left ventricular outflow tract systolic pressure gradient was 64 ± 5 mm Hg (± standard error of the mean) and decreased to 9 ± 2 mm Hg postoperatively (p < 0.001). Reliable preoperative and postoperative information regarding aortic valve function was available for 27 patients. Aortic insufficiency was found in 17 (63%) of those patients preoperatively. Postoperatively, insufficiency increased in 3 patients and decreased in 4; none of these changes was major. Severity of preoperative aortic insufficiency increased significantly with age (p < 0.05), but did not correlate with left ventricular outflow tract gradient. The information from this study and previous studies suggests that resection of subaortic stenosis is safe and effective, and operation at the time of diagnosis, regardless of left ventricular outflow tract gradient or symptomatic status, is a reasonable therapeutic alternative.

Reversion of Mitral Valve Preclosure in Acute Aortic Insufficiency Secondary to Infective Endocarditis

A 59-year-old man presented with culture-negative endocarditis. Serial echocardiographic/Doppler studies disclosed progressive aortic insufficiency with resultant premature closure of the mitral valve. At the time the patient developed PMVC he was considered for emergent aortic valve replacement; ultimately, however, he was deemed inoperable because of his underlying medical problems. Surprisingly, the patient gradually improved on antibiotic therapy alone, with subsequent hemodynamic stabilization and reversion of the PMVC. This case represents the first description of reversion of PMVC in a medically treated patient with severe aortic insufficiency secondary to infective endocarditis, and underscores the importance of basing management decisions concerning aortic valve replacement in infective endocarditis upon the entire constellation of clinical findings rather than a single echocardiographic sign.

Pulmonary autograft: an American experience.

Pulmonary valve autograft replacement of the aortic valve has been performed in nine patients in an effort to duplicate in the United States the experience of Sir Donald Ross in London. Four male and five female patients ranging in age from seven to thirty-four years have been operated on for indications of aortic stenosis in six and aortic regurgitation in three. Three patients had associated procedures performed concomitantly. All patients survived the surgery and were clinically improved, however, one patient did require reoperation for progressive aortic insufficiency. Specific indications, results, and technical considerations are discussed and illustrated.

Idiopathic lymphoplasmacytic aortic valvulitis: Observations in two elderly women with unexplained aortic insufficiency

Two patients with a unique aortic valvulitis required aortic valve replacement. Both were elderly women who presented with evidence of systemic disease, including fever, arthralgia, myalgia, markedly elevated erythrocyte sedimentation rate, anemia, leukocytosis, hypoalbuminemia and renal insufficiency, in addition to progressive subacute aortic insufficiency. Histologic examination of the excised aortic valve revealed a lymphoplasmacytic infiltrate. Neither patient had evidence of other diseases that have been associated with aortic insufficiency. One should consider the judicious use of glucocorticosteroids for such patients.

Endocarditis Due to Veillonella alcalescens

A 60-year-old man with a history of a benign heart murmur for 25 years had evaluation of six months of unexplained fever and heart disease. The fever responded to nonspecific antimicrobial therapy, but progressive aortic insufficiency necessitated aortic valve replacement. Although numerous preoperative blood cultures were negative, Veillonella alcalescens was isolated in pure culture from the excised valve. The patient remained well after two weeks of intravenous therapy with cephalothin and three months of oral therapy with penicillin.

Operation for discrete subvalvular aortic stenosis

Over the past 20 years, 37 patients (31 children and six adults) have undergone operations for discrete subvalvular aortic stenosis. Prior to 1975, resection of the subvalvular membrane alone was the procedure of choice. However, the recurrence rate was high (36%). Since 1975, resection of the membrane plus left ventricular myectomy has been routine. The recurrence rate in this group has been lower (20%) but is still high. Overall, 11 patients (30%) have had significant recurrence (average gradient 63 mm Hg). Eight of these 11 have undergone a second operation with re-resection of a membrane and left ventricular myectomy. One patient died and in three others (42%) significant symptoms and gradients remained. One of these three has undergone a successful aortoventriculoplasty, and two patients are awaiting a similar operation. Lessons learned from this experience include the following: (1) Regardless of the type of initial operation, a significant rate of recurrence can be anticipated. (2) Progressive aortic insufficiency and fibromuscular tunnel stenosis occur commonly unless adequate relief of the obstruction is achieved by the first operation. (3) Because repeat resection with left ventricular myectomy is unlikely to be effective when aortic insufficiency and/or tunnel stenosis are present, aortoventriculoplasty should be employed as the definitive reoperative procedure.

Histoplasma capsulatum endocarditis

Endocarditis is a rare manifestation of disseminated Histoplasma capsulatum infection. A 22-year-old man presented with a seven month history of fever, weight loss, and progressive aortic insufficiency. The diagnosis of H. capsulatum was suggested by a diagnostic rise in complement fixation titers and positive echocardiographic findings. The diagnosis was confirmed prior to surgery by positive bone marrow culture. Progressive congestive heart failure necessitated replacement of the aortic valve which subsequently grew H. capsulatum. In this case, a combination of amphotericin B therapy and valve replacement was curative.

Role of Cardiac Catheterization in Infective Endocarditis

The benefits and hazards of catheterization and angiography were evaluated in 19 patients with acute aortic and/or mitral endocarditis and heart failure. In 14 patients (74%), the bedside diagnosis of valvular insufficiency and heart failure was proved correct. In three patients with both aortic and mitral valve disease, angiography (without hemodynamic measurements) was necessary to clarify the diagnosis. Angiography detected four aortic aneurysmal erosions that were unsuspected clinically, but missed three others. After angiography, heart failure worsened in two patients with severe progressive aortic insufficiency and one died. Thus, catheterization-angiography was of greatest value if more than one left-sided valve lesion was present, if extravalvular diseases mimicked heart failure, or if extravalvular infection was present. Patients with isolated, clear-cut mitral insufficiency usually do not need these diagnostic procedures, and they are probably contraindicated in patients with severe aortic regurgitation with rapidly progressing heart failure.

Ventricular septal defect and aortic insufficiency: Surgical treatment

Twenty-five patients with ventricular septal defect (VSD) associated with aortic insufficiency (AI) have been since 1964. Of these patients, one died suddenly without operation; in 2 patients, AI developed in the late postoperative period following VSD closure; and in 3 others, AI developed shortly after VSD closure. The remaining 19 patients are discussed in detail. The VSD was subpulmonic in 13 (68 per cent) and subcristal in 6 (32 per cent). Primary suture of the VSD was undertaken in 13 patients and patch closure in 6. Seven patients had aortic valvuloplasty and 2 had aortic valve replacement. There were no surgical deaths, and the long-term follow-up shows that VSD closure alone has been sufficient to arrest progression of AI in patients with mild insufficiency, particularly in those with subpulmonic VSD. Valvuloplasty, when necessary, was more effective when done at an early age.

Prosthetic aortic valvular endocarditis.

Infective endocarditis (IE) continues to be one of the most serious complications following cardiovascular surgery, particularly that for replacement of valves. In order to define more clearly the clinical course and the role of surgical therapy, clinical and necropsy data were reviewed in 16 adult patients with prosthetic aortic valvular endocarditis (PAVE) and compared with the experience cited in the literature. Positive blood cultures were obtained in each of the patients with bacterial endocarditis. Gram positive bacteria predominate and the onset of infection is usually later than 25 days postoperatively. In 11 of 16 patients, aortic insufficiency was recognized. Autopsy material demonstrated large perivalvular abscesses which loosened the attachment of the prosthetic valve in each case and which made successful operation unlikely. Aortic insufficiency appears to be of prognostic importance, since patients who developed aortic insufficiency early in the course of PAVE died. Survivors included patients who made an excellent response to medical therapy and who either did not develop aortic insufficiency or developed aortic insufficiency either late in the course or even after cure of PAVE, Poor response to medical therapy and progressive aortic insufficiency even in the absence of left ventricular failure appear to be indications for prompt surgical replacement of the prosthetic aortic valve.