Leaflet Extension Research Articles

Coronary ostial stenosis after aortic valvuloplasty (comprehensive aortic root and valve repair)

Comprehensive aortic root and valve repair (CARVAR) surgery using specially designed aortic rings was introduced as a new surgical technique for aortic valve disease. We present five consecutive cases of iatrogenic coronary ostial stenosis after CARVAR surgery in patients with aortic stenosis. The preoperative coronary angiography confirmed that all the patients had normal coronary arteries. They underwent aortic valvuloplasty by aortic leaflet extension and insertion of specially designed inner and outer rings at the level of the sinotubular junction. Within 6 months after surgery, all the patients complained of resting chest pain and dyspnea with changes of electrocardiography. Repeated coronary angiography demonstrated right coronary artery (RCA) ostial stenosis in one patient and left main (LM) ostial stenosis in the other four patients. Intravascular ultrasonography demonstrated severe ostial stenosis and extensive echogenic tissue in the extravascular area. Four patients with LM ostial disease successfully underwent coronary bypass graft surgery, and percutaneous coronary intervention with stenting was performed in one case of RCA ostial stenosis. Because the mechanism of this complication is not fully confirmed, more clinical study is required to confirm the safety issues of CARVAR surgery.

Truly stentless molded autologous pericardial aortic valve prosthesis with single point attached commissures in a sheep model☆

Aortic valve cusp extension and free-hand aortic valve replacement with autologous pericardium has been described. The long-term results were shown to be comparable with commercially available aortic bioprostheses. Nevertheless the relatively demanding surgical technique could not find wide acceptance. We developed a new design of a molded aortic valve, fashioned from autologous pericardium, treated briefly with glutaraldehyde, and simplified the implantation technique using single point attached commissures (SPAC). Molded autologous valve prostheses were implanted in the subcoronary aortic position in 10 sheep with the commissures connected to the aortic wall at three single commissural points (SPAC). The prosthesis mean size was 21.6+/-1.3 mm and the construction time (excluding 10 min glutaraldehyde treatment) was 6.2+/-1.2 min. Cardiopulmonary bypass and cross-clamp time was 111.1+/-12.4 min and 75.0+/-16.3 min, respectively. Six sheep were euthanized after 201.2+/-10.3 days (6 months) and four sheep were euthanized after 330.8+/-6.5 days (11 months) postoperatively. In all sheep, the valve was immediately competent. At sacrifice, SPAC has proven to be well anchored to the aortic wall and the pericardial valve to be pliable in all cases. The maximum transvalvular gradient after cardiopulmonary bypass and at sacrifice was 3.7+/-2.2 mmHg and 10.6+/-5.2 mmHg, respectively. This new truly stentless molded autologous aortic valve with simplified implantation technique (SPAC) makes a reliable implantation in a standard timeframe possible. The simplicity of construction, low cost and absent need for anticoagulation of this molded autologous aortic bioprosthesis offers an attractive alternative and not only for patients in the developing world.

Evolving Concepts and Technologies in Mitral Valve Repair

Over the past few decades, it has become apparent that mitral valve repair is preferable to mitral valve replacement for the majority of patients undergoing surgery for mitral regurgitation (MR). The advantages of mitral valve repair include low rates of thromboembolism, resistance to endocarditis, excellent late durability reported for as long as 25 years, and no need for anticoagulation in the majority of patients.1–5 Because of these advantages of repair over replacement, the threshold for performing mitral valve repair has been lowered to include patients with MR who have early symptoms or even those who are asymptomatic, assuming that the chance of successful repair is ≥90% according to the latest American College of Cardiology/American Heart Association guidelines.6,7 Recently, surgeons have evaluated new techniques to further improve mitral valve repair, and cardiologists and surgeons are increasingly interested in the potential for percutaneous approaches to mitral valve repair.8 Myxomatous MR affects 1% to 2% of the population and therefore is a common pathology for mitral valve surgery, but the complexity of the operation may be difficult, which leads to generally low rates of repair. In a recent review, only 44.3% of patients in the United States who required mitral valve surgery for MR received a mitral valve repair,9 and in the Euro Heart Survey, repair rates were similarly low (46.5%).10 The goals of mitral repair are to maintain leaflet mobility, remodel the annulus, and allow normal coaptation of the anterior and posterior leaflets. Recent advances in techniques and new concepts for mitral repair are important to cardiologists and other clinicians interested in the management of patients with mitral valve disease. Accordingly, an improved understanding of these concepts will aid in the development of innovative techniques to create safe, durable, reliable, and reproducible mitral valve repair techniques, both …

Posterior Leaflet Extension With an Autologous Pericardial Patch in Rheumatic Mitral Insufficiency

We describe our technique of posterior leaflet extension with an autologous pericardial patch in patients suffering from rheumatic mitral regurgitation. Several simple rules have allowed us to achieve satisfying long-term results.

Aortic Valve-Sparing Repair with Autologous Pericardial Leaflet Extension Has Low Long-Term Mortality and Reoperation Rates in Children and Adults

We sought to establish whether there was a difference in outcome after aortic valve repair with autologous pericardial leaflet extension in pediatric and adult populations. In our study, 128 patients (pediatric and adult) underwent valvular pericardial extension repair at our institution from 1997 through 2006. The patients were divided into either the pediatric group (< or =18 years of age; n = 54/128, 42%), with a mean age of 8.4 +/- 5.4 (range, 0-17 years), or the adult group (n = 74/128, 58%), with a mean age of 48.9 +/- 19.7 (range, 19-85 years). The endpoints of the study were mortality and reoperation rates. Thirty-day mortality for the adult group was 0, and for the pediatric group it was 1/54 (1.8%), with no statistical difference (P = .1) between the groups. Late mortality for the pediatric group was 2/54 (3.7%) and in the adult group was 2/74 (2.7%). There was no statistical difference (P = .12) between the groups. In the pediatric group, there were 6 total reoperations (6/54) in 5 patients, with one patient undergoing reoperation twice. From these 6 cases, 3 were re-repair and 3 had aortic valve replacement; the mean interval between original repair and reoperation was 4.3 +/- 2.5 years (range, 0.1-7.7 years). In the adult group, there were 5 total reoperations (5/74). From these 5 cases, 3 had aortic valve replacement and 2 re-repair; the mean interval between original repair and reoperation was 3.5 +/- 3 years (range, 0.1-7 years). There was no statistical difference in the reoperation rate between the 2 groups (P= .38). At late follow-up, 82% of all patients in the adult group had no aortic regurgitation or only a trace (grades 0 and 1) and 78% of all patients in the pediatric group had no aortic regurgitation or only a trace (grades 0 and 1). There was no statistical difference in either aortic regurgitation (P = .06) or aortic stenosis (P = .28) between the 2 groups. Aortic valve repair with autologous pericardial leaflet extension has low mortality and morbidity rates, as well as good mid-term durability in both the pediatric and the adult groups.

Surgical strategy for the bicuspid aortic valve: Tricuspidization with cusp extension versus pulmonary autograft

The congenitally bicuspid aortic valve is the most common etiologic factor associated with clinically significant aortic stenosis and/or regurgitation in pediatric patients. Beyond infancy, surgical intervention typically involves valve repair with cusp thinning and commissurotomy or valve replacement, primarily with pulmonary autograft in the current era. An aortic valve repair technique using tricuspidization with cusp extension was introduced in 1999. This study compares the midterm clinical outcome in patients undergoing valve repair by tricuspidization with cusp extension with those receiving a pulmonary autograft (Ross). A retrospective study was performed on all consecutive patients with symptomatic bicuspid aortic valve disease who underwent tricuspidization with cusp extension or a Ross procedure between 1999 and 2005. In both groups, all patients were at least 1 year of age at time of the operation. During this period, 21 children (median age 12.6 years, range 2.6-18 years) underwent tricuspidization with cusp extension (TCE group) and 25 children (median age 10.2 years, range 11.5 months-20.1 years) underwent the Ross procedure. Prior balloon valvuloplasty was performed in 5 (24%) of the children in the TCE group and 16 (64%) of the children in the Ross group. Prior surgical commissurotomy was performed in 4 (19%) TCE patients and in 9 (36%) Ross patients. During a median follow-up period of 36.4 months (range 2.5 months-7.4 years), 2 (10%) patients in the TCE group required valve-preserving early revision of the repair, 2 (10%) TCE patients required subsequent aortic valve replacement at 16 and 33 months, 1 (4%) Ross patient required subsequent valve repair at 5 years, and 1 (4%) Ross patient underwent cardiac transplantation at 46 months. At 36 months, the actuarial freedom from reintervention on the aortic valve or autograft was 90% in the TCE group, with 11 patients at risk, and 100% in Ross patients, with 13 patients at risk (P = .39); the freedom from moderate valve dysfunction or reintervention was 66% for TCE patients and 95% for Ross patients (P = .07). There were no deaths, and all but 1 Ross patient remain in New York Heart Association class I. Reintervention rates in patients undergoing tricuspidization with cusp extension or a primary Ross procedure are similar. Valve performance in the TCE group is satisfactory at midterm follow-up, but the Ross repair appears to provide greater stability of valve function. These results suggest that repair with valve tricuspidization and cusp extension provides reliable palliation of the symptomatic bicuspid aortic valve.

Echocardiographic Follow-up of Tricuspid Annuloplasty with a New Three-Dimensional Ring in Patients with Functional Tricuspid Regurgitation

A new tricuspid valve (TV) annuloplasty system, the MC3 ring, includes a three-dimensional structure designed to remodel the TV annulus and preserve physiologic annular function. We investigated the early- and mid-term outcomes of TV annuloplasty with the MC3 ring. A total of 136 patients with functional tricuspid regurgitation (TR) had two-dimensional echocardiography before and 5 +/- 5 days after TV annuloplasty with the MC3 ring. Twenty-eight patients were followed for more than 1 year after surgery. Echocardiography was used to assess response to surgical therapy, including measures of cardiac function and geometry and identification of factors predisposing one to recurrent TR. TR severity was improved early after surgery (P < .001). At 5 days after surgery, 16% had TR graded greater than moderate; among patients followed more than 1 year, this figure was 14%. Postoperative TR severity was associated with preoperative TR severity and tethering height. TV annuloplasty with the new physiologic MC3 ring is effective for the management of TR and may be superior to conventional techniques. However, patients with extensive leaflet tethering (>1.0 cm) require additional maneuvers to ensure valve competence.

Mitral Valve Repair for Extended Commissural Prolapse Involving Complex Prolapse

We reviewed our experience of mitral valve repair techniques for extended commissural prolapse involving complex prolapse of either or both leaflets, due to chordal rupture or elongation. Between June 1991 and January 2005, 21 of 210 patients who underwent mitral valve repair for mitral regurgitation had extended commissural prolapse involving either or both of the anterior and posterior leaflets. There were 17 (81%) patients with degenerative and 4 (19%) with infective endocarditis. The distribution of diseased mitral commissural lesions was: posteromedial commissure in 14 (67%) patients, anterolateral in 6 (29%), and bilateral in 1 (5%). Reconstructive techniques included leaflet folding plasty in 10, resection-suture in 6, the sliding technique in 2, commissuroplasty in 2, and chordal shortening in 1. There were no perioperative deaths; postoperative mitral regurgitation was none or trivial in 19 patients and mild in 2. The mean follow-up period was 54 months (range, 2-155 months), and no patient required re-operation. There was one late death from a noncardiac cause at 103 months. Mitral valve repair for extended commissural prolapse is satisfactory. We consider leaflet folding plasty and its modification to be effective in patients who require extensive leaflet resection in the commissural area.

Aortic Valve Sparing and Restoration With Autologous Pericardial Leaflet Extension is an Effective Alternative in Pediatric Patients

We sought to evaluate the durability and efficacy of aortic valve repair with autologous pericardial leaflet extension in children. From 1997 through 2006, 54 patients underwent aortic valve repair with autologous pericardial leaflet extension at a mean age 8.4 +/- 5.3 years (range, 0 to 17 years). Primary endpoints were early and late mortality, freedom of reoperation, and late valve function. Thirty-day and late mortality were one in 54 (1.8%) and two in 53 (3.7%), respectively. There were seven re-operations in six patients, and one patient was re-operated twice. Re-operations were re-repairs in four cases and replacements in three cases. The mean interval between original repair and re-operation was 4.3 +/- 2.5 years. Mean severity grade of post-repair intraoperative aortic regurgitation (AR) was 0.3 (range, grade 0 to 4). At late follow-up, 87.7% of all patients had no AR or only a trace (grade 0-1). Seven patients (12.9%) had mild AR (grade 2-3) and none severe (grade 4); 94.4% had no aortic stenosis or only a trace (grade 0-1), 5.5% had mild (grade 2-3), and none severe. This technique delays potential complications from other approaches to valve pathology and allows a normal growth of the aortic annulus. Although, our data show that this technique has a low mortality and morbidity, more studies are needed to elucidate durability and late outcome.

Aortic valve-sparing repair with autologous pericardial leaflet extension has a greater early re-operation rate in congenital versus acquired valve disease☆

We sought to establish whether there was a difference in outcome after aortic valve repair with autologous pericardial leaflet extension in acquired versus congenital valvular disease. One hundred and twenty-eight patients underwent reparative aortic valve surgery at our institution from 1997 through 2005 for acquired or congenital aortic valve disease. The acquired group (43/128) (34%) had a mean age of 56.4+/-20.3 years (range, 7.8-84.6 years) and the congenital group (85/128) (66%) had a mean age of 16.9+/-19.2 years (range, 0.3-82 years). The endpoints of the study were mortality and reoperation rates. Thirty-day mortality was 0/43 (0%) in the congenital group and 1/85 (1.1%) in the acquired group. Late mortality in the acquired group was 3/43 (7%) and 3/84 (3.5%) in the congenital group (neither early nor late proportion of mortality is significantly different between the two groups, according to the nonparametric Binomial test for proportions). There were 13 total reoperations among 11 patients: 1/43 (2.3%) in the acquired group and 10/85 (11.7%) in the congenital group (p=0.07). Two patients from the congenital group were reoperated on twice. The mean interval between original repair and reoperation was 3.6+/-5 years (range, 0-7 years) for acquired and 3.5+/-2.5 years (range, 0-7 years) for the congenital group (Wilcoxon 2-sample test, p=0.7). Total early reoperation rate (<30 days after first surgery) was 11/128 (8.5%); for the congenital group 9/85 (10.5%) and for the acquired group 2/43 (4.6%). Early reoperation rate was significantly higher among the congenital group (p=0.013). The remaining patients are well at mean follow-up of 2.8+/-2.4 years (range 0-7.9). In the acquired group, the mean postoperative aortic regurgitation and stenosis grade by echocardiography was 0.5+/-0.3 (scale, 0-4) and 0.3+/-0.1, respectively. In the congenital group, the follow-up, mean aortic regurgitation and stenosis were 0.9+/-0.8 and 0.5+/-0.3, respectively. There was no significant difference in early or late mortality and late reoperation rate between the two groups. Early reoperation rate was higher in the congenital versus the acquired aortic valvular disease group. This study supports the fact that the valve-sparing technique is safe and reproducible and repeatable in patients with acquired valve disease.

Short and Midterm Results of Aortic Valve Cusp Extension in the Treatment of Children With Congenital Aortic Valve Disease

We evaluated our experience with aortic valve cusp extension techniques to identify predictors of successful intraoperative repair and subsequent durability. Twenty-two children (ages 5-18 years) underwent aortic cusp extension with autologous pericardium between 1999 and 2005. Sixteen children had previous surgical or percutaneous intervention. Ten children had bicuspid aortic valves. Cusp extensions were performed on 1 cusp in 3 patients, 2 cusps in 3, and 3 cusps in 16. Serial echocardiographic measures (n = 81) were obtained during a 5-year period and underwent blinded review. Longitudinal trajectories of ventricular and aortic valve function were modeled using mixed linear regression analysis. There was no hospital or late mortality. Five-year freedom from valve replacement was 75%. Comparison of preoperative and post-repair echocardiograms demonstrated reductions in aortic insufficiency (decreased in jet-width/aortic valve diameter ratio from 0.39 +/- 0.12 to 0.22 +/- 0.11; p < 0.0001), aortic stenosis (decreased in peak aortic valve gradient from 41 +/- 25 mm Hg to 29 +/- 15 mm Hg; p = 0.04), and left ventricular end-diastolic dimensions Z-score (decreased from 1.39 +/- 0.38 to 1.16 +/- 0.34; p < 0.001). During the follow-up period, post-repair jet-width and aortic valve diameter increased nonlinearly (p < 0.001). Patients with postoperative peak aortic gradients greater than 30 mm Hg had progression of aortic stenosis, whereas those with lesser postoperative peak gradients tended to regress during follow-up (p < 0.001). The decrement in Z-score of the left ventricular end-diastolic dimensions remained stable during the follow-up period. Aortic valve cusp extension can result in acceptable hemodynamic results with stabilization of left ventricular geometry. However, residual lesions are common and progression and regression of these lesions can be predicted based on echocardiographic data.

Invited commentary

Invited commentary

Aortic Valve Repair for Congenital Abnormalities of the Aortic Valve

Due to shortcomings of any valve replacement, repairing and retaining the native valve may be beneficial for congenital aortic valve disease. Retrospective review of data and follow-up of aortic valve repair from a single institution. From 1993 to 2001, 56 patients underwent aortic valve repair [median age 13.4 years (range 1 day to 45 years)]. The predominant aortic valve lesion was mixed aortic stenosis/aortic insufficiency 25 (45%), aortic insufficiency 24 (43%) and aortic stenosis 7 (13%). Repair techniques included sub-commissural plication 36 (64%), commissurotomy 24 (43%), cusp plication 15 (27%), pericardial patch cusp extension 8 (14%) and resuspension of commissures 4 (7%). Most patients (88%) required a combination of techniques; 61% required additional procedures. Hospital survival was 55/56 [98%; (95% CI 91-100%)] no patient was discharged on anticoagulation for aortic valve pathology. Fifty-three patients [95%; (95% CI 85-98%)] remain alive after a median follow-up of 37 months; four survivors required aortic valve replacement and two required repeat aortic valve repair [84%; (95% CI 72-91%) reintervention-free survival]. (1) In this study, aortic valve repair for congenital abnormalities avoided reoperation in the majority of patients, avoided anticoagulation and retained growth potential of the valve. (2) Repeat aortic valve repair or replacement was used to treat subsequent valve deterioration.

Posterior mitral leaflet extension: An adjunctive repair option for ischemic mitral regurgitation?

Residual or recurrent mitral regurgitation frequently occurs after mitral valve repair for ischemic mitral regurgitation with an annuloplasty ring. Because annuloplasty primarily addresses annular dilatation, we studied an adjunctive technique that might correct restricted leaflet (Carpentier type IIIb) systolic closing motion, which often accompanies annular dilatation in patients with ischemic mitral regurgitation. Six sheep had radiopaque markers placed on the left ventricle, mitral leaflets and annulus, and mitral subvalvular apparatus. A pericardial patch was sutured into the middle scallop of the posterior mitral valve leaflet and furled in with a reefing stitch placed in the radial axis. Posterolateral left ventricular myocardial ischemia was created by using proximal circumflex occlusion to induce acute ischemic mitral regurgitation. Under open-chest conditions, 3-dimensional marker coordinates were measured by using biplane videofluoroscopy at baseline and during acute ischemia both before and after release of the reefing stitch (leaflet extension); transesophageal echocardiography was used to grade ischemic mitral regurgitation. Leaflet apical systolic tethering was not improved by leaflet extension, but ischemic mitral regurgitation decreased (control, 0.9 +/- 0.3*; ischemia, 2.4 +/- 0.3; leaflet extension, 1.5 +/- 0.3; *P < 0.002). Posterior mitral valve leaflet midline length (control, 1.45 +/- 0.09*; ischemia, 1.53 +/- 0.10; leaflet extension, 1.83 +/- 0.13*; *P < 0.001) and posterior mitral valve leaflet middle scallop area (control, 1.66 +/- 0.20 cm2*; ischemia, 1.91 +/- 0.22 cm2; leaflet extension, 2.36 +/- 0.22 cm2*; *P < 0.006) increased with leaflet extension because of patch unfurling (mean +/- 1 standard error of the mean; repeated-measures analysis of variance, Dunnet post-hoc test vs ischemia). Posterior mitral valve leaflet extension ameliorated acute ischemic mitral regurgitation but did not correct the abnormal apically restricted systolic posterior mitral valve leaflet closing motion. This technique might be a useful adjunct repair in combination with ring annuloplasty for ischemic mitral regurgitation, but the clinical role of this adjunct remains to be defined in patients.

Echocardiography is instrumental in second-order chordal cutting to relieve mitral leaflet tethering and reduce mitral regurgitation in patients with ischemic mitral regurgitation

Introduction: Chronic ischemic mitral regurgitation (IMR) is associated with apical displacement of papillary muscles leading to tethering of second-order chords and decreased leaflet coaptation [1]. Surgical division of second-order chords has been proposed as a novel method to counteract this mechanism [2]. Transesophageal and transthoracic echocardiography is instrumental for the diagnosis and surgical management of IMR. This study elucidates clinical and echocardiographic data which evaluate the efficacy of chordal-cutting in surgical management. Methods: We compared echocardiographic data in two groups of patients undergoing mitral valve repair, patients undergoing chordal-cutting procedure and those undergoing conventional mitral repair. TEE/TTE was utilized to measure tent height (the distance from the apex of the anterior mitral valve leaflet (AMVL) to the mitral annulus), tent area (the area of mitral leaflet extension into the left ventricle during systole) and distance between the AMVL apex and posterior left ventricular (LV) wall in IMR patients who underwent either chordal-cutting MV repair (n=15) or conventional MV repair (control, n=26) both preoperatively and postoperatively. Mitral regurgitation and LV ejection fraction (LVEF) were also measured. Results: Chordal-cutting patients were more likely to have an LVEF of less than 40% (100 vs. 41%, p<0.001), higher prevalence of peripheral vascular disease (40% vs. 7%, p=0.01), diabetes mellitus type II (53% vs. 22%, p=0.04), older age (69± vs. 63± years, p=0.05) and require urgent surgical management (67% vs. 37%, p=0.05) than control patients. Complication rates were similar for the two groups, perioperative mortality occurred with a solitary chordal-cutting patient (7% vs. 0% for control). Echocardiographic predictors of successful surgical management of chronic IMR were evaluated between the two groups. The chordal-cutting patients had greater reductions in tent area and in the distance between the AMVL apex and posterior LV wall (30% vs. 12%, p=0.003). Chordal-cutting patients had lower recurrence of MR in the early postoperative period in comparison to control patients (0% vs. 19%, p=0.05). Furthermore, chordal-cutting did not adversely affect postoperative LVEF (3% mean reduction in chordal-cutting patients vs. 1% in the control group, p=0.9). Discussion: Chordal-cutting decreases MV leaflet tethering and reduces early MR recurrence in patients with chronic IMR, without compromising LV function. Novel TEE/TTE measurements are instrumental in this procedure and should be familiarized by relevant cardiac anesthesiology professionals.

Mitral valve stiffening in end-stage heart failure: Evidence of an organic contribution to functional mitral regurgitation

Mitral regurgitation is a complication for many patients with congestive heart failure. Although this regurgitation is considered purely functional, we hypothesize that the alterations in cardiac geometry and function induce dysfunctional remodeling of the mitral valve, which can be demonstrated by alterations in the material behavior of the leaflets and chordae. Mitral leaflets and chordae from 23 valves from transplant recipient hearts (11 with dilated and 12 with ischemic cardiomyopathy) and from 21 normal valves (from autopsy) were mechanically tested. Radially oriented anterior mitral leaflet strips from failing hearts were 61% stiffer and 23% less viscous on average than those from autopsy control hearts. The mean stiffness of circumferentially oriented anterior leaflet strips was 50% higher than that of control hearts. Leaflet extensibility was reduced 35% overall. Likewise, the failing heart chordae were an average of 16% stiffer (all P < or = .05). Mitral valves in congestive heart failure have significantly altered mechanics that suggest that the tissue is permanently distended and fibrotic and might be unable to stretch sufficiently to cover the valve orifice. These material changes in the valve tissues accompany the biochemical alterations in extracellular matrix composition that we have previously reported. Our finding of leaflet and chordal remodeling suggests that mitral regurgitation in patients experiencing heart failure might not be purely functional and that these mitral valves should not be considered normal. Moreover, there are implications for strategies of mitral valve surgery or percutaneous approaches in this patient population.

Results of Aortic Valve-Sparing and Restoration With Autologous Pericardial Leaflet Extensions in Congenital Heart Disease

The purpose of this study is to evaluate the efficacy of aortic valve-sparing repair with glutaraldehyde-treated autologous pericardium in congenital valvular pathology. Sixty-two patients underwent reparative aortic valve surgery from January 1997 through December 2003. The mean age was 25 +/- 20 years (+/- standard deviation) (range, 10 days to 81 years). Fifty percent (31 of 62) were less than 19 years old at operation. The diagnoses included bicuspid aortic valve (39 patients), ventricular septal defect (14 patients), severe aortic stenosis (6 patients), subaortic stenosis (7 patients), bacterial endocarditis (7 patients), neonatal truncus arteriosus (2 patients), Shone's complex (2 patients), transposition complex (1 patient), double-chambered right ventricle (1 patient), and Marfan's syndrome (1 patient). Twelve patients (19 %) had prior sternotomy and cardiac operations. Valve-sparing techniques included pericardial leaflet extensions in 62 patients, creation of one or more pericardial neoaortic sinuses in 8, subcommissuroplasty in 8, pericardial patch of perforated leaflets in 9, Dacron mesh wrap (Boston Scientific, Wayne, NJ) of dilated ascending aorta in 12, and concomitant tricuspid and mitral valve repairs in 3 and 4 patients, respectively. There was one early death (1.6%). There were no late deaths at a mean follow-up of 25 +/- 16 (range, 0.1 to 72.5 months). Six patients required reoperation and prosthetic or homograft replacement for aortic valve incompetence. One out of 6 reoperations required re-repair. The remaining patients are well with a mean aortic regurgitation grade by echocardiography of 1.3 +/- 0.9 (scale, 0 to 4). Aortic valve repair with pericardial leaflet extension is a promising technique for the growing child.

Percutaneous Versus Surgical Treatment for Patients With Hypertrophic Obstructive Cardiomyopathy and Enlarged Anterior Mitral Valve Leaflets

The purpose of this study was to compare percutaneous transluminal septal myocardial ablation (PTSMA) and septal myectomy combined with mitral leaflet extension (MLE) in symptomatic hypertrophic obstructive cardiomyopathy patients with an enlarged anterior mitral valve leaflet (AMVL). Both PTSMA and myectomy reduce septal thickness and left ventricular outflow tract (LVOT) gradient; however, an uncorrected enlarged AMVL may predispose to residual systolic anterior motion (SAM) after successful standard myectomy or PTSMA. Myectomy with MLE previously demonstrated superior hemodynamic results compared with standard myectomy, but its value relative to PTSMA is unknown. Twenty-nine patients (aged 44+/-12 years) underwent myectomy with MLE, and 43 patients (aged 52+/-17 years) underwent PTSMA. Mitral leaflet area was similar in both groups (16.7+/-3.4 versus 15.9+/-2.7 cm2, respectively). After PTSMA, 2 patients died, 4 needed a reintervention, and 4 required a permanent pacemaker for complete heart block. After surgery, only 1 patient needed a reintervention. At 1-year follow-up, LVOT gradients did not differ between surgical and PTSMA patients (17+/-14 versus 23+/-19 mm Hg, respectively). Preinterventional mitral regurgitation grade was more severe in the surgical group, but with myectomy combined with MLE, the residual grade was similar to that of PTSMA. Mean SAM grade decreased significantly more after surgery (from 2.9+/-0.3 to 0.5+/-0.7 mm Hg versus from 2.8+/-0.5 to 1.3+/-0.9 [corrected], P<0.05). PTSMA in these selected patients with hypertrophic obstructive cardiomyopathy had more periprocedural complications and resulted in more reinterventions. Hemodynamic results (SAM grade and reduction in mitral regurgitation) were better in surgical patients.

Invited commentary

This paper from Frankfurt belongs to the sporadic number of papers that since the early 1960s have reported the results of aortic valve cusp extension in small groups of patients. The problems of aortic cusp extension are the need for a reliable surgical technique and the choice of the right material [1Duran C.M.G. Gometza B. Kumar N. et al.From cusp extension to valve replacement with stentless pericardium.Ann Thorac Surg. 1995; 60: S428-S432Abstract Full Text PDF PubMed Scopus (47) Google Scholar, 2Duran C.M.G. Gallo R. Kumar N. Aortic replacement with autologous pericardium. Surgical technique.J Cardiac Surg. 1995; 10: 1-9Crossref PubMed Scopus (38) Google Scholar, 3Duran C.M.G. Gometza B. Kumar N. et al.Aortic valve replacement with freehand autologous pericardium.J Thorac Cardiovasc Surg. 1995; 110: 511-516Abstract Full Text Full Text PDF PubMed Scopus (90) Google Scholar]. The authors have chosen extension of the fused leaflet of bicuspid valves with glutaraldehyde-treated autologous pericardium. Our early experience with single cusp extension was abandoned because of the practical impossibility of achieving a good geometric result. Although immediate competence was usually obtained, this was due to significant bending of the redundant new cusp, which was always larger than the other two cusps. We favor a trileaflet extension, where equal leaflets with similar coaptation areas are easier to achieve. In bicuspid cases, after excision of all valvular tissue, three equidistant commissures were constructed. This choice was also based on several studies showing the geometric superiority of a trileaflet over a bicuspid valve. However, the excellent clinical results of the Frankfurt group might disprove this assumption. The authors’ choice of autologous pericardium immersed for a few minutes in glutaraldehyde seems to me right [4Duran C.M.G. Gometza B. Shaid M. Al Halees Z. Treated bovine and autologous pericardium for aortic valve reconstruction.Ann Thorac Surg. 1998; 66: S166-S169Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar]. Synthetic materials rapidly calcify and fresh autologous pericardium undergoes fibrotic retraction. Glutaraldehyde-treated xenopericardium and autologous pericardium have been preferentially used. In our series of 92 consecutive young patients (mean, 30 years) glutaraldehyde-treated pericardium of bovine (n = 27) or autologous (n = 65) origin was used. Hospital mortality was 2%. At a maximum 14 years follow-up (mean, 7.5; range, 7 to 14), no thromboembolic events had been detected in spite of absence of anticoagulation. Overall survival at 14 years was 85 ± 4%. Freedom from structural deterioration was 58 ± 9% for the bovine and 76 ± 10% for the autologous pericardium. Freedom from reoperation was 47 ± 8% for bovine and 59 ± 9% for the autologous valves [5Al Halees Z. Shahid M. Al Sanei A. Duran C. Up to 14 years follow-up of aortic valve reconstruction with pericardium. 2004Google Scholar]. While the cause of failure of the bovine tissue was calcification, the autologous had failed because of tears or infection. Histology showed an acellular collagen matrix that had an epithelial layer in the autologous and was absent in the bovine specimens. In conclusion, although aortic valve cusp extension with glutaraldehyde-treated autologous pericardium is feasible, nonthrombogenic, and hemodynamically excellent, it is technically difficult and consequently unlikely to become widely accepted. Although its durability beyond 10 years is questionable, it offers a valid alternative in young patients, where anticoagulation with a mechanical valve and reoperation with a bioprosthesis are serious problems. Whether bicuspid valves should undergo single or triple cusp extensions must wait for a longer follow-up. In any case, the authors should be congratulated for their original contribution and for maintaining alive the flame of aortic cusp extension. Pericardial Patch Augmentation for Reconstruction of Incompetent Bicuspid Aortic ValvesThe Annals of Thoracic SurgeryVol. 80Issue 1PreviewReoperation rates after repair of bicuspid aortic valves are higher than for mitral valve reconstruction. Secondary changes and small coaptation surface render repair unreliable. Satisfactory results have been reported for patch augmentation for tricuspid aortic valves. We have applied this technique for the repair of bicuspid aortic valves. Full-Text PDF

Surgery for Aortic Insufficiency Associated with Ventricular Septal Defect

Aortic valve repair in children is a challenge. We have adopted a technique of single aortic cusp extension with an autologous pericardial strip in patients diagnosed with severe aortic insufficiency (AI) associated with a ventricular septal defect (VSD). The purpose of this study was to report the short-term outcomes. Seven patients were operated on between January 2002 and December 2003. The mean age was 11.28 +/- 2.1 years (range 8-14 years). The VSD was closed with a synthetic patch. Aortic cusp extension was performed at the right coronary cusp in 6 patients and the remainder had a non-coronary cusp extension. The mean diastolic arterial pressure increased from 35.71 +/- 6.09 to 74.28 +/- 7.31 mm Hg after the operation ( p < 0.001). The postoperative grade of AI was trivial in 4 patients, mild in 1 patient and non-existent in 2 patients. The mean follow-up period was 12.85 +/- 6.12 months (range 2-20 months). This technique is very effective in patients with severe AI associated with a VSD. However, long-term durability will need to be carefully followed.