Valve Replacement For Aortic Regurgitation Research Articles

Transapical transcatheter aortic valve replacement for aortic regurgitation with a second-generation heart valve

ObjectiveTo report on the Chinese multicenter study of the J-Valve transcatheter heart valve for treatment of predominant aortic regurgitation. MethodsTransapical transcatheter aortic valve replacement with the J-Valve for treating high-risk severe aortic regurgitation was performed in 43 patients in 3 Chinese centers. The study was registered with the Chinese Clinical Trial Registry (ChiCTR-OPC-15006354). Procedural results and clinical outcomes up to 1-year were analyzed using Valve Academic Research Consortium 2 criteria. ResultsAll patients (mean age, 73.9 ± 5.7 years) were considered at prohibitive or high risk for surgical valve replacement (logistic European System for Cardiac Operative Risk Evaluation, 20.0% to 44.4%; mean, 25.5% ± 5.3%) after evaluation by an interdisciplinary heart team. Transapical implantation was successful in 42 patients (97.7%). The 1-year outcomes included all-cause mortality (4.7%), disabling stroke (2.3%), new permanent pacemaker (4.7%), and valve-related reintervention (7.0%). At the 1-year follow-up, postprocedural paravalvular regurgitation was none/trace in 30 of 39 patients and mild in 8 of 39 patients, and the mean transvalvular gradient after valve implantation was favorable at 10.4 ± 4.5 mm Hg. ConclusionsAfter an initial demonstration of feasibility, this multicenter study shows that the J-Valve transcatheter heart valve system is a reasonable option for patients with predominant aortic regurgitation.

Valved Conduit Attached to Left Ventricular Outflow Tract for Valve Detachment in Behçet’s Disease

Standard aortic valve replacement for aortic regurgitation caused by Behçet's disease is frequently complicated by postoperative recurrent prosthetic valve detachment. To prevent this, we have developed a modified Bentall procedure, in which the valved conduit is proximally attached to the left ventricular outflow tract instead of to the fragile annulus, based on the fact that the left ventricular outflow tract myocardium is rarely involved in Behçet's disease. This modified Bentall procedure was performed in 5 Behçet's disease patients with prosthetic valve detachment after primary aortic valve replacement, and satisfactory results were achieved.

A Case of Elderly Heart Failure Patient With Cardiac Cachexia; How Should We Improve Malnutrition?

A 78 year-old-man who was received aortic valve replacement for aortic regurgitation 36 years ago had attended our hospital for management of heart failure (HF) with reduced ejection fraction. He had suffered from decompensation of HF many times and repeated hospitalization, and dietary intake, body weight, and activity gradually decreased, which indicate progression of cardiac cachexia. He also suffered from the chronic obstructive pulmonary disease, and showed marasmus type of malnutrition. Although the status of HF has compensated in the past few years, we asked him to hospitalize for control of malnutrition and cardiac rehabilitation. After 10-days of hospitalization, dietary intake improved with the slight increase of body weight. On the other hand, his cognitive function mildly impaired by the changes of environment due to hospitalization. On the next day of discharge, he was transported to our emergency unit for acute decompensation of heart failure. Cognitive decline progressed and he died in spite of the intensive treatment 2 weeks after readmission. Cardiac cachexia is frequently observed among progressively increasing HF patients in the aging society, and are the prognostic factors. However, the consensus has not been reached on how to improve cachexia. In the present case, nutrition intervention for cachexia was supposed to be an exacerbating factor of HF, which shows us many clinical implications for management of cardiac cachexia.

Aortic valve replacement in a patient with left ventricular noncompaction

Left ventricular noncompaction is a rare cardiac pathology that results from an arrest in endomyocardial development in early embryogenesis. With great advances in imaging modalities, this pathological entity has been noted not only in the pediatric population but also in adults. Herein we report the case of a 62-year-old woman who successfully underwent aortic valve replacement for aortic regurgitation complicated by left ventricular noncompaction.

Left ventricular pseudoaneurysm after surgery for infective endocarditis

A 46-year-old man had undergone aortic valve replacement for aortic regurgitation due to active infective endocarditis in 2006. He had been followed by transthoracic echocardiography revealing results within normal limits except for a subannular depressed scar. In 2010, a giant left ventricular pseudoaneurysm was detected on three-dimensional computed tomography. We performed surgery for patch closure of the pseudoaneurysm and redo aortic valve replacement.

Aortic valve repair leads to a low incidence of valve-related complications

Aortic valve replacement for aortic regurgitation (AR) has been established as a standard treatment but implies prosthesis-related complications. Aortic valve repair is an alternative approach, but its mid- to long-term results still need to be defined. Over a 12-year period, 640 patients underwent aortic valve repair for regurgitation of a unicuspid (n=21), bicuspid (n=205), tricuspid (n=411) or quadricuspid (n=3) aortic valve. The mechanism of regurgitation involved prolapse (n=469) or retraction (n=20) of the cusps, and dilatation of the root (n=323) or combined pathologies. Treatment consisted of cusp repair (n=529), root repair (n=323) or a combination of both (n=208). The patients were followed clinically and echocardiographically; follow-up was complete in 98.5% (cumulative follow-up: 3035 patient years). Hospital mortality was 3.4% in the total patient cohort and 0.8% for isolated aortic valve repair. The incidences of thrombo-embolism (0.2% per patient per year) and endocarditis (0.16%per patient per year) were low. Freedom from re-operation at 5 and 10 years was 88% and 81% in bicuspid and 97% and 93% in tricuspid aortic valves (p=0.0013). At re-operation, 13 out of 36 valves could be re-repaired. Freedom from valve replacement was 95% and 90% in bicuspid and 97% and 94% in tricuspid aortic valves (p=0.36). Freedom from all valve-related complications at 10 years was 88%. Reconstructive surgery of the aortic valve is feasible with low mortality in many individuals with aortic regurgitation. Freedom from valve-related complications after valve repair seems superior compared to available data on standard aortic valve replacement.

Indexed Left Ventricular Dimensions Best Predict Survival After Aortic Valve Replacement in Patients With Aortic Valve Regurgitation

Indications for valve replacement in patients with aortic regurgitation include diminished ejection fraction and increased left ventricular dimensions. Our objective was to examine the effect of preoperative ejection fraction and left ventricular dimensions on survival and return of normal systolic function (ejection fraction > or = 0.50) after valve replacement for aortic regurgitation. Between 1996 and 2006, 301 patients had aortic valve replacement for moderate or greater chronic aortic regurgitation, and 29% had concomitant replacement of the ascending aorta. We reviewed clinical and echocardiographic variables as well as late vital status. Patients' mean age was 55.2 +/- 16.5 years, and 78% were male. The mean preoperative ejection fraction was 0.56 +/- 0.12, the mean left ventricular end-systolic dimension was 43 +/- 10 mm, and the mean left ventricular end-diastolic dimension was 63 +/- 9 mm. Operative mortality was 1.7%, and survival at 1, 5, and 10 years was 96%, 90%, and 77%, respectively. This was similar to an age- and sex-matched population (p = 0.214). The level of ejection fraction preoperatively did not predict late survival, nor did absolute values for left ventricular end-systolic dimension and end-diastolic dimension. Indexed left ventricular end-systolic dimension and end-diastolic dimension were predictors (p < 0.01) of late survival. Data from late echocardiography were available for 159 patients (56%) at a mean follow-up of 3.3 +/- 2.6 years. Preoperative ejection fraction, left ventricular end-systolic dimension, indexed end-systolic dimension, end-diastolic dimension, and indexed end-diastolic dimension were univariately predictive of late ejection fraction. In a multivariate model the only predictor of late normal ejection fraction was a higher preoperative ejection fraction (odds ratio, 2.85; p < 0.001). In patients who received a valve replacement for aortic regurgitation, decreased ejection fraction and increased left ventricular dimensions were not associated with late mortality. However, larger indexed left ventricular systolic and diastolic dimensions were associated with late mortality. Preservation of late ejection fraction is best if the operation is performed in patients with near normal preoperative left ventricular function.

Aortic Valve Replacement for Aortic Regurgitation in a Patient With Left Ventricular Noncompaction

We present a case of a 61-year-old man who underwent aortic valve replacement for aortic regurgitation complicated with left ventricular noncompaction. The pathogenesis of this condition remains unknown. In advanced form, left ventricular noncompaction produces marked disability and carries a poor prognosis. We underscore that familiarity with this disease entity will help to stimulate early diagnosis and timely treatment when necessary.

Invited commentary

The authors [1] have shown that passive containment does not influence reverse remodeling or left ventricular ejection fraction after aortic valve replacement for aortic regurgitation. Aortic regurgitation produces both a pressure overload and a volume overload on the ventricle in contrast with the pure volume overload seen in mitral regurgitation. As the authors mentioned, this might explain why results were different in the series reported by Acker and colleagues (see reference 5). The authors also consider whether passive containment might have detrimental effects on right ventricular function and do not successfully dismiss this concern.

Aortic valve replacement for aortic regurgitation in a patient with antiphospholipid antibody syndrome

Cardiac manifestations of antiphospholipid antibody syndrome (APLS) comprise a major complication. Herein we report our surgical treatment of aortic regurgitation in a patient with APLS. A 61-year-old woman was referred to our hospital with symptoms of congestive heart failure. Systemic lupus erythematosus had been diagnosed at the age of 36, and immunosuppressive therapy has been continuously performed. APLS was also diagnosed at the age of 55, after which cardiomegaly was noted on chest radiographs and aortic regurgitation was evident on echocardiography. Although immunosuppressive therapy had been continued, cardiac symptoms began to develop. With a presumed diagnosis of valvular disease associated with autoimmune disease, the aortic valve was replaced with a bioprosthesis. Noninfective endocarditis was confirmed in the excised specimen and was likely involved in APLS. The patient was discharged on postoperative day 26 without complications.

Impact of Left Ventricular Loading Conditions on Myocardial Deformation Parameters: Analysis of Early and Late Changes of Myocardial Deformation Parameters after Aortic Valve Replacement

Myocardial deformation imaging is used to assess regional left ventricular (LV) function. We sought to define the impact of changes in LV loading conditions on myocardial deformation parameters. Aortic valve replacement in patients with different aortic valve pathologies was used as a model to assess the impact of preload and afterload changes. In 53 patients scheduled for aortic valve replacement serial echocardiographic studies were performed preoperatively and postoperatively (within 7 days and at 6 months). Parasternal short-axis views were acquired. Using novel computer software radial and circumferential strain and strain rate were determined as parameters of myocardial deformation for each segment of the LV and were subsequently averaged. Immediately postoperatively there was a relative increase of radial strain by 4.5 +/- 1.8% after valve replacement for aortic stenosis (AS) (P < .001), a relative decrease of 9.4 +/- 7.7% after valve replacement for aortic regurgitation (aortic insufficiency [AI]) (P < .001), and unchanged radial strain after valve replacement for AS and aortic regurgitation. During the subsequent 6 months of follow-up, there was additional relative increase of radial strain by 5.2 +/- 3.1% in the AS group (P < .001), by 12.0 +/- 13.7% in the AI group (P < .01), and by 5.6 +/- 3.4% in the AS and AI group (P < .001). Similar changes were observed for the other strain and strain rate parameters. In conclusion, myocardial deformation parameters change significantly immediately after aortic valve replacement for AS or AI indicating a dependency of determined myocardial deformation parameters on LV preload and afterload.

Ascending aortic aneurysm following aortico-ventricular tunnel repair

Aortico-left ventricular tunnel is a very rare congenital anomaly. An 18-year-old boy had undergone tunnel closure at 3 years of age. A moderate degree of aortic regurgitation remained postoperatively. Seven years later, aortic valve replacement for aortic regurgitation was performed. Eight years later, the ascending aortic aneurysm had grown to 63 mm in diameter. This dilatation became an operative indication. Ascending aortic replacement was performed with a Dacron graft. Pathological examination of the resected aortic wall revealed cystic medial degeneration. We report a rare case of ascending aortic aneurysm following surgical repair of the aortico-left ventricular tunnel and aortic valve replacement.

Aortic valve perforation due to latent infective endocarditis

A 64-year-old man underwent aortic valve replacement for aortic regurgitation. The aortic valve was perforated in the noncoronary cusp. Pathological findings showed that the perforation probably occurred due to infective endocarditis. However, the patient had no obvious inflammatory signs preoperatively, to suggest latent infective endocarditis.

Valve Repair in Aortic Regurgitation without Root Dilatation - Aortic Valve Repair

Aortic valve repair was established in the context of aortic root remodeling. Variable results have been reported for isolated valve repair. We analyzed our experience with isolated valve repair and compared the results with those of aortic root remodeling. Between October 1995 and August 2003, isolated repair of the aortic valve was performed in 83 patients (REP), remodeling of the aortic valve in 175 patients (REMO). The demographics of the two groups were comparable (REP: mean age 54.4 +/- 20.7 yrs, male-female ratio 2.1 : 1; REMO: mean age 60.8 +/- 13.6 yrs, male-female ratio 2.4 : 1; p = ns). In both groups the number of bicuspid valves was comparable (REP: 41 %, REMO: 32 %; p = ns). All patients were followed by echocardiography for a cumulative follow-up of 8204 patient months (mean 32 +/- 23 months). Overall in-hospital mortality was 2.4 % in REP and 4.6 % in REMO ( p = 0.62). Systolic gradients were comparable in both groups (REP: 5.8 +/- 2.2, REMO: 6.5 +/- 3.1 mm Hg, p = 0.09). The mean degree of aortic regurgitation 12 months postoperatively was 0.8 +/- 0.7 after REP and 0.7 +/- 0.7 after REMO ( p = 0.29). Freedom from significant regurgitation (> or = II degrees ) after 5 years was 86 % in REP and 89 % in REMO ( p = 0.17). Freedom from re-operation after 5 years was 94.4 % in REP and 98.2 % in REMO ( p = 0.33). Aortic regurgitation without concomitant root dilatation can be treated effectively by aortic valve repair. The functional results are equivalent to those obtained with valve-preserving root replacement. Aortic valve repair appears to be an alternative to valve replacement in aortic regurgitation.

Predictors of Left Ventricular Performance After Valve Replacement in Children and Adolescents with Chronic Aortic Regurgitation

Aortic valve replacement has been recommended in patients who have severe symptoms, in patients with extreme left ventricle (LV) dilatation (end diastolic dimension >4 SD above normal) or LV ejection fraction <50%. However, the occurrence of advanced symptoms or severe LV dilatation raises concern about irreversible LV dysfunction. This study sought to determine the influence of preoperative symptoms, LV size and function on mortality, and postoperative LV performance in children and adolescence after valve replacement for aortic regurgitation (AR). A total of 49 patients 18 years old or younger (mean, 13.9 +/- 3) who underwent valve replacement for chronic AR between 1991 and 2001 were followed up for 1-10 years (mean, 3.3 +/- 2.1). Baseline and postoperative characteristics were compared between 13 patients (group 1) with extreme LV dilatation and 34 patients (group 2) with a lesser degree of LV enlargement. Preoperative low ejection fraction (p < 0.008), extreme LV dilatation (p < 0.05), and LV end systolic dimension >4 SD above normal (p < 0.05) were predictors of persistent LV dysfunction. Extreme LV dilatation (p < 0.0003), LV end systolic dimension (p < 0.0007), and reduced LV ejection fraction (p < 0.01) predicted persistent LV dilatation. In the setting of chronic AR, preoperative symptoms, LV systolic function, and LV internal dimensions are the main predictors for persistent LV dysfunction and dilatation. Surgical correction should be performed before LV systolic dysfunction and/or extreme LV enlargement occurs.

Aortic valve replacement for aortic regurgitation and stenosis, in patients with severe left ventricular dysfunction.

Aortic valve replacement for aortic valve stenosis (AS) and regurgitation (AR) in patients with severe left ventricular (LV) dysfunction contains an increased risk. Few data are available on the outcome of such patients. Fifty-five consecutive patients with severe LV dysfunction (ejection fraction, EF; <30%) and aortic valve replacement for AS (n=35) or AR (n=20) were investigated between 1994 and 2001. EF was 25+/-5%, mean transvalvular gradient 26+/-6mmHg (AS), aortic valve area 0.66+/-0.18cm(2) (AS), cardiac index (CI) 2.4+/-0.9l/min/m(2), enddiastolic LV diameter (LVEDD) 64+/-8mm and endsystolic LV diameters (LVESD) was 55+/-3mm. Ninety percent of patients were in New York Heart Association (NYHA) functional class III/IV at admission to the hospital. Concomitant coronary artery bypass grafts (CABG) were performed in 14 patients. Follow-up examinations including chest X-ray, echocardiography, exercise testing, were performed among survivors. The survival rates for AS were: 1-year 76%, 2-year 68.8%, 5-year 64.2%; for AR: 1-year 94.4%, 2-year 86.5%, 5-year 74.2%. NYHA functional class improved from 90% in class III/IV to 45 (AR group) and 24% (AS group) at follow-up (P<0.02). The LVEDD decreased to 54+/-8mm after 1 year. The EF improved to 38+/-4 (AR group) and 40+/-5% (AS group) at follow-up. Despite severe LV dysfunction, increased 1-year mortality especially in the AS group, aortic valve replacement was associated with improved functional status, symptoms and EF in both groups and in most patients. We, therefore, conclude that aortic valve replacement in patients with severe LV dysfunction can be performed with acceptable risk.

Ten-year clinical laboratory follow-up after application of a symptom-based therapeutic strategy to patients with severe chronic aortic regurgitation of predominant rheumatic etiology

ObjectivesThis study was designed to assess the feasibility and the long-term results of a symptom-based strategy of aortic valve replacement in a Brazilian population with predominant rheumatic etiology. BackgroundOptimal criteria for valve replacement in aortic regurgitation (AR) are still not entirely clear. The appearance of symptoms is an indication for surgery, but may be associated with myocardial damage. Although cardiac imaging data have provided a safer guide for such decisions, the use of symptom-based surgical indication has not been validated and might conceivably be better in populations with predominant rheumatic etiology and younger age. MethodsEchocardiography and rest-exercise radionuclide ventriculography were performed in 75 patients with severe AR, age 28 ± 9 years, over a period of 10 ± 0.69 years. Thirty-seven patients developed symptoms and underwent aortic valve replacement surgery within six months. Thirty-eight patients remained asymptomatic and were managed medically. ResultsSurvival was 100% in asymptomatic patients and 82% in symptomatic. Surgical treatment caused marked ventricular remodeling, with ventricular diameter involution and an improvement of rest-exercise ejection fraction percent variation. Multivariate analysis showed that the probability of developing symptoms within 10 years was 58% for a patient with a left ventricular end-diastolic diameter ≥70 mm and 76% for a patient with left ventricular end-systolic (LVESD) ≥50 mm. Logistic regression identified LVESD and age as the most predictive and specific, but not sensitive, indicators of symptom development. ConclusionsApplication of a standardized therapeutic strategy to patients with severe AR and predominant rheumatic etiology resulted in 90.6% survival after 10 years of follow-up.

Survival after valve replacement for aortic regurgitation: Prediction from noninvasive contractility measurement and comparison with census-expected survival

Survival after valve replacement for aortic regurgitation: Prediction from noninvasive contractility measurement and comparison with census-expected survival

Acute volume reduction with aortic valve replacement immediately improves ventricular mechanics in patients with aortic regurgitation

Objectives: Few data have been available regarding the immediate response in ventricular mechanics to acute volume reduction caused by aortic valve replacement for aortic regurgitation. Methods: We studied 9 patients in the operating room immediately before and after the institution of cardiopulmonary bypass. Left ventricular pressure and cross-sectional area (a surrogate of left ventricular volume) were measured with a catheter-tip manometer and a transesophageal echocardiographic system equipped with automated border-detection technology. Left ventricular pressure-area loops were constructed, and the caval occlusion method was used to obtain the slope of the end-systolic pressure-area relationship and the end-systolic area associated with 100 mm Hg. From the steady-state beats, stroke area was obtained by subtracting the minimum area from the maximum area. Effective arterial elastance, a measure of ventricular afterload, was calculated from end-systolic pressure, and stroke area as follows: effective arterial elastance equals end-systolic pressure divided by stroke area. Results: Reductions in maximum area (21.0 ± 8.5 to 16.0 ± 6.8 cm2 [SD])and minimum area (15.3 ± 8.4 to 12.0 ± 6.1 m2) shifted the baseline pressure-area loops to the left. The slope of the end-systolic pressure-area relationship (11.6 ± 4.8 to 16.0 ± 7.5 mm Hg/cm2) and afterload (effective arterial elastance, 17.9 ± 11.6 to 26.3 ± 16.4 mm Hg/cm2) were increased, and the end-systolic area associated with 100 mm Hg was reduced (18.3 ± 10.0 to 13.7 ± 5.8 cm2). Conclusion: Correction of volume overload reduced preload (minimum area), shifted the end-systolic pressure-area relationship to the left (decreased end-systolic area), and improved ventricular contractility (increased slope of the end-systolic pressure-area relationship). The result indicated that acute volume reduction favorably influenced ventricular mechanical parameters immediately after the operation.J Thorac Cardiovasc Surg 2003;125:283-9

Acute type A dissection: conservative methods provide consistently low mortality

Background. A wide spectrum of operative techniques are applied in acute type A dissection. Most convey hospital mortality between 10% and 20%. In this high-risk setting, we believe that a conservative approach to the aortic root and the complete resection of the primary tear are important. We reviewed the results of this policy from our aortic surgery database. Methods. Between 1988 and December 2000, 95 acute type A dissection patients were operated on by one surgeon. They included 70 men and 25 women aged 37 to 81 years (mean 65 years). Six had Marfan syndrome. Aortic root restoration or replacement was performed during cooling, open arch repair during circulatory arrest, and hemostasis while rewarming. Eighty-seven patients had ascending aortic replacement with glue resuspension of the valve. Two others had had aortic valve replacement previously. Aortic root and partial arch replacement was performed in 6 Marfan patients. Eighteen patients had hemiarch replacement, and 6 had total arch replacement to excise the tear. Results. Five patients died in hospital (5.3% 30-day mortality) and another after early readmission for mediastinal infection (6.3% total mortality). There were no deaths from bleeding. Two patients required aortic valve replacement for aortic regurgitation 2.5 and 3.0 years postoperatively. Two others required total arch replacement and thromboexclusion procedures, respectively. Conclusions. Our policy of primary tear excision and preservation of the native aortic valve has resulted in low overall mortality. We still prefer to replace the aortic root in dissected Marfan patients. In this high-risk condition, hospital survival is of paramount importance. A conservative “pathology-oriented” approach helps to achieve this aim.