Massive Aortic Regurgitation Research Articles

Dissections aiguës de l'aorte : physiopathologie et diagnostic

Acute dissection of the aorta is defined by the sudden irruption of a pressurized blood flow trough a tear into the internal part of the aortic wall, resulting into longitudinal separation of the wall along its weakest constituent, and leading to the formation of two circulating channels. It represents the worst catastrophe affecting the human vascular network. Its spontaneous mortality, when the ascending aorta is involved, reaches 50% at 48 hours, 60% after one week and 90% after one month, due to aortic rupture, intrapericardial tamponnade, malperfusion of vital end organs or massive aortic valve regurgitation. Its prevalence is estimated between 4 and 10 for 100 000, and the male-female ratio is about 80%. Acute aortic dissections occur generally on aortas weakened by either hereditary dystrophic conditions such as Marfan’s syndrome or familial annulo-aortic ectasia, or congenital diseases such as bicuspid aortic valve or coarctation, or acquired diseases mainly related to atheroma. Arterial hypertension, either chronic or more often in the form of sudden thrust, plays a major role in the occurrence of acute dissection. The dissecting process extends more or less along the vessel but generally reaches the bifurcation and the iliac arteries. In most patients, the vascular damages, constituted within a few seconds or minutes, may explain the clinical symptoms, the observed complications and may determine the therapeutic strategy. The clinical patterns observed are highly heterogeneous. The most consistent symptom (present in 90% of the patients) consists in an intense thoracic pain which may be associated in a variable manner with cardiogenic shock, transient or permanent neurological disorders, peripheral ischemia, abdominal pain, etc… Any diagnostic suspicion must be confirmed by chest X ray, and above all by trans-thoracic echocardiography, a simple technique which can be performed easily even in emergency rooms or in non specialized units. In case of probable diagnosis, the patient must be referred to a cardio surgical ICU in order to confirm the acute dissection and to analyse its consequences. Presently, trans-oesophageal echocardiography and computerized tomography (CT scan) are the gold standard in terms of rapidity, safety, sensibility and specificity whereas, because of its invasive nature, aortography has lost its pre-eminence and Magnetic Resonance Imaging, although quite contributory, is difficult to perform on an emergency basis in patients with, generally, haemodynamic instability.

Pathogenetic significance of myxomatous degeneration in fenestration-related massive aortic regurgitation.

Aortic valvular regurgitation has several mechanisms and the present study investigated its clinicopathological correlations with aortic valve fenestration. Six male patients with massive regurgitation and enlarged fenestrations or ruptured fenestrated fibrous cords underwent aortic valve replacement. The clinicopathological features showed many similarities. Four cases had family histories of aortic regurgitation. All six patients showed moderate to severe myxomatous degeneration of the aortic valve and enlargement of aortic annulus. Four patients had 1-2 ruptured fibrous cords, located at the right coronary cusp. Echocardiographic examinations showed an abnormal fibrous cord attached to the prolapsing cusp in 3 cases with ruptured fenestrated valve and detailed examination by transesophageal echocardiography showed an intact fenestrated fibrous cord at the commissure in 1 case. Extensively fenestrated cusps with an enlarged aortic annulus because of myxomatous degeneration can cause chronic regurgitation or sudden deterioration after rupture of the fibrous cord. There is an increasing incidence of fenestration-related aortic regurgitation in the Japanese population. An important pathogenetic factor in male patients is myxomatous degeneration of the aortic cusp and annulus.

Extracardiac Unruptured Sinus of Valsalva Aneurysm Presenting with Aortic Incompetence

We report a case of extracardiac unruptured aneurysm of the noncoronary sinus of Valsalva presenting with massive aortic regurgitation and high fever. The preoperative evaluation, echocardiographic and cardiac catheterization findings, and surgical management of this rare condition are discussed.

Parasternal Approach for Minimally Invasive Aortic Valve Surgery

Aortic valve replacement for the stenotic or regurgitant aortic valve has been one of the major advances of medical science in the 20th century. Patients who have severe pressure gradients between the left ventricle and the aorta, or who have severely dilated hearts due to massive aortic regurgitation, are treated by insertion of a reliable mechanical or bioprosthetic device to relieve these hemodynamic abnormalities. This technique has saved hundreds of thousands of lives since the first successful aortic valve replacements by Harken et al,' and Starr et a12 in 1960. Since 1960, valve devices, incisions, and surgical techniques have evolved to the extent that, by the early 1990s, the risk of aortic valve replacement in patients without coronary disease was under 3% in most large centers in the world that do aortic valve replacement .3 The complete median sternotomy became the standard incision for aortic valve replacement in the late 1960s. This incision is flexible and relatively painless because it is a midline incision. It allows maximal exposure of all parts of the cardiac structure, and most importantly, enables physicians to effectively remove air from intracardiac structures. As interest in minimizing surgical trauma has increased, minimally invasive incisions for cardiac surgery are receiving increasing attention. The evolution of minimally invasive surgery in all surgical specialties began with Fogarty's conversion of the vastly complicated aortoiliac embolectomy to a balloon catheter technique via the groin vessels in the early 1960s. In orthopaedics, endoscopy for joint operations replaced open operations about 15 years ago. Approximately 10 to 15 years ago in general surgery, laparoscopic colocystectomy became the treatment of choice, replacing the open colocystectomy. In the last 5 years, the use of video-assisted thoracic surgery has been enormously important in redefining general thoracic surgical procedures to a much less invasive type of surgery for many pulmonary lesions. Minimally invasive cardiac surgery began with the use of techniques for the so-called direct-access coronary bypass, off cardiopulmonary bypass, performed through small incisions, primarily using the left anterior descending coronary artery and applied directly to it. At the same time, Port-Access systems, popularized by Heartport, Inc, Redwood City, CA,5 were developed to afford a minimally invasive incision for a coronary artery bypass graft that had the advantages of cardiopulmonary bypass, aortic cross-clamping by endoclamp, and cardioplegia for myocardial protection. Finally, the use of minimally invasive direct access incisions for cardiac valve surgery were developed in the early part of 1996, when investigators believed that small incisions, accessing only those chambers or vessels where the valve surgery would take place and aided by femoro-femoral bypass, would be an advantage for patients undergoing cardiac valve surgery without combined coronary These approaches have been extended widely, and include a Port-Access system9 for mitral but not aortic valve replacement.

Aortic valve replacement after aortic valvuloplasty for calcified aortic stenosis.

This study concerns patients who underwent one or several aortic balloon valvuloplasties at our institution and subsequently required cardiac surgery, either on an emergency basis after aortic valvuloplasty or due to the development of aortic stenosis. Between February 1987 and December 1993, 137 patients (73 male, 64 female, mean age 72 +/- 9 years) underwent aortic valve replacement for calcified aortic stenosis after several percutaneous balloon aortic valvuloplasties. Thirty-one patients were in NYHA stage II, 70 in stage III and 36 in stage IV. Seventy patients had angina (23 stage I or II, 47 stage III or IV) and 24 patients presented syncope or lipothymia. Twenty-three percent had at least two of these three symptoms. The indications for balloon dilatation were non-definitive surgical contraindication or high surgical risk (73), personal choice (49), refusal of surgery (9) and emergency (5:2 massive aortic regurgitation, 1 left ventricle perforation, 1 cardiogenic shock, 1 endocarditis in cardiogenic shock). Seven patients received preoperative aortic valvuloplasty due to a very high operative risk. The average time between dilatation and surgery was 472 days and there was clinical improvement for an average period of 261 days. The aortic valve replacements consisted of 58 mechanical prostheses and 79 xenografts with 22 concomitant procedures. Operative mortality was eight patients (5.8%). During the follow-up (17.4 +/- 9.2 months), four patients died (3.6%), 91.2% of the patients were in class I and II and 95% were without angina. The actuarial survival rate was 90.5 +/- 6.6% including hospital mortality. Both our experience and the literature show that balloon aortic valvuloplasty is followed by an immediate improvement in hemodynamic status with a decrease in valve gradient and an increase in valve area. However, the hemodynamic benefit is typically short-lived with a very high restenosis rate. Balloon aortic valvuloplasty is not an alternative to aortic valve replacement, which remains the best treatment for calcified aortic stenosis; the benefits and long-term results of aortic valve replacement are well established, even in the elderly.

Two-dimensional and Doppler echocardiographic findings in a case of subaortic "fibrous sac".

We described a 37-year-old man with a subaortic "fibrous sac", admitted for congestive heart failure. On 2-dimensional echocardiography a saccular structure was seen to extend from the left coronary cusp of the aortic valve to the outflow tract of the left ventricle. By color Doppler imaging, a grade 3 aortic regurgitation was recognized. Aortic regurgitant flow was recorded from the left coronary cusp to the saccular lesion. When congestive heart failure became exacerbated, the repeat examination showed the regurgitant flow passing through the perforated bottom of this lesion and reaching the left ventricular cavity. On microscopic examination of the excised valve, capillary proliferation and inflammatory changes were recognized near the annular region of the left coronary cusp. The edge of the valve leaflet and the other 2 cusps were intact. It is likely that our patient had a mycotic aneurysm near the aortic ring. We speculate that aortic regurgitation followed inflammation. It dilated the left ventricular cavity and contributed to congestive heart failure. Inflammation also weakened the tissue near the annulus, causing it to protrude into the subaortic region thus forming a small aneurysm. It may have grown to become a large saccular structure under high aortic pressure. That is, it became a "giant" endocardial pocket with inflammatory process. Finally, the rupture of this sac caused a massive aortic regurgitation, exacerbating congestive heart failure.

Unusual abnormalities of the aortic root or valve necessitating surgical correction in early childhood.

Abstract Unusual anomalies of the aortic root or valve, resulting in massive aortic regurgitation and left ventricular failure, were encountered in three patients between two and three years of age. The congenital defects present consisted of a tunnel between the aorta and the left ventricle, aortic-valve regurgitation secondary to annular ectasia (suggestive of Marfan's syndrome) and aortic regurgitation that followed aortic valvotomy performed in the neonatal period. All patients were successfully treated surgically.

Aortico-left ventricular tunnel: A cause of massive aortic regurgitation and of intracardiac aneurysm

The clinical, roentgenographic, hemodynamic and pathologic findings in a fourteen year old boy with aortico-left ventricular tunnel are presented. The accessory channel between the aorta and left ventricle resulted in massive aortic regurgitation, and the portion of the tunnel which traversed the ventricular septum was aneurysmal, displaced the posterior wall of the right ventricle and caused severe obstruction to right ventricular outflow. The presence of associated cardiovascular anomalies, in this and previously reported cases, suggests that the malformation is congenital rather than acquired. The clinical and hemodynamic manifestations of aortico-left ventricular tunnel are indistinguishable from those observed with the more common forms of aortic regurgitation, and the correct diagnosis can be established only by thoracic aortography. The malformation is usually recognized in childhood; since aortic regurgitant flow can be abolished by simple closure of the aortic ostium, and without aortic valve replacement, the indications for operative treatment differ from those which apply in aortic regurgitation due to a valvular anomaly.