Mild Aortic Insufficiency Research Articles

Recurrent aortic insufficiency after emergency surgery for acute type A aortic dissection with aortic root preservation

ObjectivePatients with acute type A aortic dissection demonstrate a wide range of aortic insufficiency. Outcomes after valve resuspension and root repair are not well studied in the long term. We evaluated the long-term effects of preoperative aortic insufficiency in patients undergoing emergency root-preserving surgery for acute type A aortic dissection. MethodsFrom 2002 to 2017, 558 of 776 patients with acute type A aortic dissection underwent native aortic valve resuspension and root reconstruction. Patients were stratified into 4 groups by preoperative aortic insufficiency grade (n = 539): aortic insufficiency less than 2+ (n = 348), aortic insufficiency = 2+ (n = 72), aortic insufficiency = 3+ (n = 49), and aortic insufficiency = 4+ (n = 70). Multivariable ordinal longitudinal mixed effects and multi-state transition models were used to assess risk factors for recurrent aortic insufficiency. ResultsThe prevalence of cardiogenic shock in patients presenting with preoperative aortic insufficiency less than 2+, 2+, 3+, and 4+ was 53 of 348 (15.2%), 12 of 72 (16.7%), 10 of 49 (20.4%), and 24 of 70 (34.3%), respectively (P = .002). Postoperatively, 94.0% of patients had aortic insufficiency 1+ or less at discharge. Operative mortality was 34 of 348 (9.8%), 10 of 72 (13.9%), 6 of 49 (12.2%), and 12 of 70 (17.1%) (P = .303). In an ordinal mixed effects model, preoperative aortic insufficiency was associated with more severe postoperative aortic insufficiency. The multi-state transition model demonstrated that severe aortic insufficiency was associated with progression from no to mild aortic insufficiency (hazard ratio, 2.14; 95% confidence interval, 1.35-3.38), and progression from mild to moderate aortic insufficiency (hazard ratio, 5.70; 95% confidence interval, 1.88-17.30). ConclusionsPreoperative aortic insufficiency is an important predictor of recurrent aortic insufficiency in patients undergoing valve resuspension with root reconstruction for emergency acute type A aortic dissection repair. Increased echocardiographic surveillance for recurrent aortic insufficiency may be warranted in this cohort.

Successful extracorporeal membrane oxygenation assisted revascularisation in ahigh-risk elderly patient refused surgical treatment.

Management of high-risk elderly patients requiring revascularisation remains aclinical challenge. We report acase of extracorporeal membrane oxygenation (ECMO) assisted complex percutaneous coronary intervention in a high-risk octogenarian. An 83-year-old female with signs of worsening heart failure was admitted to theemergency department of atertiary care facility. Transthoracic echocardiography revealed a decreased left ventricular ejection fraction of 20% with severe mitral regurgitation and mild aortic and tricuspid valve insufficiency. Three-vessel disease was found during coronary angiography. Due to thepatient's frailty, ahigh-risk surgery decision to proceed with ECMO assisted percutaneous coronary intervention was made during aheart team meeting. Following initiation of mechanical support, coronary lesions were treated with three drug-eluting stents. After theprocedure, thepatient was transferred to theICU on ECMO support, where she was successfully weaned from thedevice 9h later. Her ICU stay was four days. She was successfully discharged from thehospital after uneventful recovery. At one-year's follow-up, thepatient was clinically stable in an overall state of general well-being and with complete participation in routine activities; she had good exercise tolerance and no signs of ischemia. This report highlights thepossibility of use of ECMO during PCI in high-risk elderly patients.

Outcomes after anomalous aortic origin of a coronary artery repair: A Congenital Heart Surgeons’ Society Study

ObjectivesIt remains unclear when sudden cardiac event risk outweighs surgical risk for patients with anomalous aortic origin of a coronary artery. The Congenital Heart Surgeons' Society sought to characterize the surgical risks by determining the techniques, complications, and outcomes of repair. MethodsBetween January 2000 and September 2018, 682 patients with anomalous aortic origin of a coronary artery aged 30 years or less were enrolled. Demographic, morphologic, operative, imaging, and ischemia-related data were analyzed. ResultsThere were 395 of 682 (57%) surgical patients (45 centers, median follow-up 2.8 years). In addition to primary repair (87% unroofing, 26% commissural manipulation), 13 patients had 15 coronary-related reoperations. Of 358 patients with pre/postoperative aortic insufficiency assessment, 27 (8%) developed new mild or greater aortic insufficiency postoperatively, and 7 (2%) developed new moderate or greater aortic insufficiency. Freedom from mild aortic insufficiency differed in those with versus without commissural manipulation (85%/91% at 6 months, 83%/90% at 1 year, and 77%/88% at 3 years, respectively) (P = .05). Of 347 patients with preoperative/postoperative ejection fraction, 6 (2%) developed new abnormal ejection fraction (<50%) within 30 days of surgery which persisted. Although 64 of 395 patients (16%) had preoperative ischemia, after surgery 51 of 64 patients (80%) no longer had ischemia (13 = new postoperative ischemia, P < .0001). Four patients died postoperatively (preoperatively 2 asymptomatic, 1 symptomatic, 1 in extremis). Composite surgical adverse event rates were 7% to 13% in the entire cohort (increasing/decreasing by presentation/anatomy/repair strategy). ConclusionsAnomalous aortic origin of a coronary artery surgery may relieve ischemia with low mortality; however, it can result in a variety of important morbidities, varying by the group evaluated. Strategies avoiding commissural manipulation may decrease the risk of developing aortic insufficiency. Understanding these risks should inform surgical decision-making and support the need for standardized assessment and management.

Clinical Implications of Concomitant Surgical Intervention for Aortic Insufficiency with Left Ventricular Assist Device Implantation

Aortic insufficiency (AI) is a common problem in advanced heart failure and progression after left ventricular assist device implantation is well described. Patterns of care for AVP at the time of LVAD implantation and the associated outcomes remain poorly described. We included all patients in the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) who received a continuous-flow LVADs and at least mild AI from 2008 to 2017. AI was stratified by mild, moderate, or severe disease. Patients undergoing any AVP were compared to those of identical severity without intervention. Descriptive, Cox regression, and Kaplan-Meier analysis were performed to identify associations between intervention and clinical outcomes. Of 6,492 patients identified with any degree of AI, 5,457 (84.1%) had mild, 814 (12.5%) had moderate, and 221 (3.4%) had severe insufficiency. AVP rate increased with AI severity, from 3.7% of mild to 55.2% of severe insufficiency. AVP was not associated with a survival difference for moderate or severe AI. In mild AI, AVP was associated with decreased survival compared to mild without AVP (median 57.8 vs 58.9 months, log-rank test: P=0.0089, Hazard Ratio 1.5 [95% confidence, 1.1-2.2]). AVP was not associated with decreased adverse event rates, nor was AVP associated with improved quality of life metrics at 24 months follow-up for any degree of AI severity. AVP at time of LVAD implantation was not associated with improved survival for end-stage heart failure patients with mild, moderate, or severe AI and was not associated with improved quality of life. Additional evidence to define a role for AVP among patients receiving LVAD is needed.

Development of De Novo Aortic Insufficiency in Patients with HeartMate 3

Aortic insufficiency (AI) is common following continuous flow left ventricular assist device (CFLVAD) and is associated with morbidity and mortality. This study aims to assess the incidence of de novo AI in HeartMate 3 (HM 3) LVAD recipients and compare the outcomes with HeartMate II (HM II) patients. A retrospective review was conducted of clinical characteristics and serial echocardiograms (1 month, 6 months, and 1 year post implant) of 151 HM 3 patients implanted between Nov. 2014 and March 2019, as well as of 270 HM II patients implanted between April 2004 and Dec. 2015 at our center. Patients (n=30) were excluded from analysis for a history of aortic valve (AV) surgery, concomitant AV surgery with LVAD implant, or more than trace preoperative AI left untreated. De novo AI was defined as more than mild AI. In the HM 3 cohort, mean age was 58 ± 12 and 84% were male. 74% received HM 3 as destination therapy. Incidence and degree of de novo AI in each group is summarized in Figure 1. 4 patients were readmitted due to significant AI and heart failure symptoms. Cumulative incidence curves showed that the probability of de novo AI at 1 year was 8.4% in the HM 3 cohort vs. 13% in the HM II cohort (Figure 2, p=0.29). In both cohorts, patients who had AV opening on echocardiogram at 1 month post implant were significantly less likely to develop de novo AI (100% freedom from de novo AI at 1 year for HM 3 with open AV vs. 84% for HM 3 with closed AV, 97% for HM II with open AV vs. 76% for HM II with closed AV). The incidence of de novo AI is low and comparable between HM 3 and HM II patients at our center. AV opening at 1 month post implant appears to be protective of this complication.

Comparison of Repeat Exchange Rate after Axial-Flow to Centrifugal-Flow Left Ventricular Assist Device Exchange versus Axial-Flow to Axial-Flow Device Exchange

Patients who suffer from device malfunction after axial-flow left ventricular assist device (af-LVAD) implantation often require device exchange. Although af-LVAD to af-LVAD exchange is reported as a safe procedure, rate of recurrent malfunction remains high. We hypothesized that af-LVAD to centrifugal-flow LVAD (cf-LVAD) exchange is associated with lower rate of recurrent malfunction requiring repeat exchange compared to af-LVAD to af-LVAD exchange. We retrospectively reviewed all patients who underwent af-LVAD implantation between 5/2011 and 3/2019 at out institution. Of these, 31 patients underwent 43 device exchanges either to af-LVAD (AE group, N = 29) or to cf-LVAD (CE group, N = 14). Reasons of device exchange in the AE group were pump thrombosis in 19 (66 %), infection in 1 (3 %) and others in 9 (31 %), and those in the CE group were pump thrombosis in 8 (58 %), infection in 3 (21 %) and others in 3 (21 %). There was no difference in baseline characteristics between the groups except higher rate of more than mild aortic insufficiency in the CE group (CE; 50 % vs AE; 0 %, P < 0.001). Twenty-one patients (72 %) underwent device exchange through a subcostal approach in the AE group. Mean cardiopulmonary bypass time was longer in the CE group (CE; 134 mins vs AE; 31 mins, P < 0.001). The CE group required higher rate of prolonged ventilation support (CE; 79 % vs AE; 28 %, P = 0.002). Mortality at 30-day and one-year were 14 % and 36 % in the CE group, which were similar to those in the AE group. The CE group had higher freedom from recurrent pump thrombosis at one-year (CE; 92 % vs AE; 58 %, P = 0.029), and higher freedom from repeat device exchange at one-year compared with the AE group (CE; 100 % vs AE; 71 %, P = 0.014) CONCLUSION: Af-LVAD to cf-LVAD exchange is a safe procedure for af-LVAD patients who require device exchange, and possibly decrease recurrent device malfunction event requiring repeat device exchange.

VASCULAR MALADAPTATION IN CHRONIC THROMBOEMBOLISM COMPLICATING AORTIC ROOT ANEURYSM: A THERAPEUTIC CONUNDRUM

Management of aortic root aneurysm can become challenging in the presence of concomitant vascular and hematological abnormalities. A 63 year old male was referred for elective surgery for asymptomatic dilatation of the aortic root from 4.8cm to 5.3cm over 1 year with mild aortic insufficiency and

Aortic Valve Repair: Baku Experience

Objective: Aortic valve repair could represent an alternative to valve replacement resulting in optimal hemodynamic conditions and avoiding anticoagulation. We analysed our results of aortic valve repair due to leaflets and root pathology. Methods: Between 2004-2019, we operated 74 patients with aortic valve and aortic root disease. Mean age was 49.2±14.7 years. 10 (13.5%) of them were females and 64 (86.5%) males. 18 (24.3%) patients were admitted with isolated aortic valve pathology. 15 (20.3%) patients had urgent operation for type A acute dissection, 14 (18.9%) aortic root aneurysm and 21 pts (28.4%) aortic root and ascending aortic aneurysm. All patients had peri-operative transesophageal echocardiography (TEE). We performed 18 (24.3%) isolated aortic valve repair operations, 38 (51.4%) reimplantation procedures, 16 (21.6%) remodeling procedures and 2 (2.7%) aortic valve repair and extraaortic ring implantation. The spectrum of valve repair techniques included free margin plication, subcomissural annuloplasty, resuspension, autologuos pericardial patch, leaflet replacement, neocomissura, decalsification, and comissurotomy. Results: Post-operative TEE showed trivial or grade I regurgitation for all patients. There were 2 (2.7%) in-hospital deaths (both had David procedure in acute Type A aortic dissection). Mean hospital stay was 8±4 days. Mean follow-up period was 49±11 months. In this period, we lost 1 patient (1.3%). Late echocardiography in the remaining 71 patients revealed mild aortic insufficiency in 66 patients (92.9%), moderate in 4 (5.6%), and moderate-severe in 1 patient (1.4%). Echocardiography confirmed the durability of the valve repair. Conclusions: Aortic valve repair operations, either as an isolated valve repair or in combination with surgery of the root, is an effective procedure with excellent mid-term and long-term outcomes without significant valve-related complications. KEYWORD: e-PD-49 The authors do not declare any conflict of interest.

Aortic Insufficiency After Left Ventricular Assist Device Implantation: Predictors and Outcomes

The aim of this study was to evaluate the incidence, risk factors, and clinical impact of progression of aortic insufficiency (AI) after left ventricular assist device (LVAD) implantation. Patients undergoing primary durable LVAD implantation between 2004 and 2018 were included. Significant AI was defined as more than mild AI. Clinical and echocardiographic data were collected. Patients were stratified by degree of pre-LVAD AI into 3 groups: no AI, group I; trace AI, group II; and mild AI, group III. Three hundred sixteen eligible patients underwent LVAD implant, 229 patients (72.5%) in group I, 54 (17.1%) in group II, and 33 (10.4%) in group III. Median follow-up was 469 days. Forty-two patients (13.3%) progressed to significant AI during follow-up. Group III patients had the highest rate of developing significant AI (I, 10.0%; II, 13.0%; III, 36.4%; P= .002). Freedom from significant AI at 1 year after LVAD implant was 94.5% in group I, 86.1% in group II, and 62.4% in group III (P < .001). Predictors of developing significant AI included mild preoperative AI, ischemic cardiomyopathy, and shorter duration of LVAD support. Patients with significant AI after LVAD implantation had higher mortality compared with those without (59.5% vs 37.2%; P= .006). Although some patients supported with an LVAD develop significant AI, this risk is increased in those with mild AI preoperatively. This finding, in conjunction with the increased mortality risk once significant AI develops, suggests that closer follow-up and management of LVAD patients with mild preoperative AI may be prudent.

Valve-sparing root replacement in patients with bicuspid aortopathy: An analysis of cusp repair strategy and valve durability

ObjectiveValve-sparing root replacement using reimplantation techniques is increasingly applied to bicuspid aortopathy. Long-term durability of cusp repair is unclear. We analyze midterm results using a conservative approach to cusp repair. MethodsFrom 2006 to 2018, 327 patients underwent valve-sparing reimplantation, 66 with bicuspid valves. Leaflets were analyzed after reimplantation. A majority (51/66) required no cusp repair. Fifteen patients had cusp repair limited to closure of unfused raphe or central plication. Patients were followed by echocardiography. ResultsMean age of patients was 44.7 ± 12.3 years. The cusp repair group had a higher incidence of preoperative moderate (10% vs 40%) or severe (4% vs 33.3%) aortic insufficiency (P < .001). There was no operative mortality or major complication. Mean follow-up was 51.6 ± 40.8 months. On postoperative echocardiography, incidence of none, trace, or mild aortic insufficiency was 41.3% (19/46), 43.5% (20/46), and 15.2% (7/46) in the no cusp repair group and 40% (6/15), 40% (6/15), and 20% (3/15) in the cusp repair group, respectively (P = .907). Few patients progressed in degree of aortic insufficiency. No patients required reoperation. At 5 years, freedom from any aortic insufficiency was 46.9% versus 15.8% (P = .013), and freedom from greater than trace aortic insufficiency was 59.1% versus 36.9% (P = .002) due to the higher rate of postoperative trace and mild aortic insufficiency with cusp repair. There was no difference in freedom from greater than mild aortic insufficiency (92.1% vs 100%; P = .33). ConclusionsValve-sparing root replacement is reliably performed with bicuspid aortic valves whether or not cusp reconstruction is necessary. Few patients progress to greater than mild aortic insufficiency. Need for reoperation is rare in midterm follow-up.

ADAPT-treated pericardium for aortic valve reconstruction in congenital heart disease: histological analysis of a series of human explants.

Different types of patch materials are used for aortic valve repair in children with congenital aortic valve disease to avoid early valve replacement. CardioCel© (Admedus, Toowong, QLD, Australia) consists of bovine pericardium treated with the ADAPT method (Admedus' proprietary tissue engineering process). Our goal was to describe tissue reactions in 12 explanted aortic valve leaflet specimens (augmented or replaced with CardioCel patch material) (11 explanted surgically, 1 autopsy). Explantation was performed during reoperation after aortic valve repair, necessitated by aortic valve stenosis in 5, aortic valve insufficiency in 2, combined aortic valve lesions in 3 patients and endocarditis in 1 patient. One patient died of sudden left heart failure 28 months after aortic valve repair. At the last documented follow-up of this patient at 22 months, he showed mild aortic valve stenosis and insufficiency. Implantation time (time between implantation and explantation) of CardioCel patches was a median of 25 (range 11-47) months. Explants were examined using a uniform protocol with methylmethacrylate and/or paraffin embedding after fixation in formalin. Besides standard histological staining, von Kossa (for identification of calcifications) and immunohistochemical stains were applied with antibodies specific for muscular, inflammatory and connective tissue component antigens. Findings regarding the extent of appositional growth on top of the patch consisting of fibroblasts and extracellular matrix components, calcification, and inflammation were rated using a 4-grade scale (G0 no/G1 few/G2 moderate/G3 massive). Superficial endothelialization was demonstrated in all patients by immunohistochemical analysis. Nine specimens showed mild inflammatory cell infiltration (G1) (G2: n = 3). Significant appositional growth on top of the patch due to addition of fibroblasts and extracellular matrix components, was seen in all specimens (G1: n = 1; G2: n = 7; G3: n = 4). Ten of 12 samples with implant times of 23 months or longer revealed calcifications (G1: n = 6; G2: n = 3; G3: n = 1). Two specimens with the shortest implant times (11 and 20 months) showed no calcifications (G0). Thrombus apposition with granulocyte infiltration was demonstrated in the specimen of the patient with endocarditis. In our cohort, all CardioCel patches used for aortic valve repair in patients with congenital heart disease demonstrated appositional growth of fibroblasts and extracellular matrix components, and calcification after an implant time of at least 23 months.

Ruptured Aneurysm of Sinus of the Valsalva: Case Series

Introduction: We present three cases of ruptured sinus of Valsalva aneurysm concomitant with a cardiac lesion in 2 cases of ventricular septal defect and 1 case of bicuspid aortic valve with mild aortic insufficiency. Case presentation: In 2/3 cases, the site of ruptured sinus of Valsalva aneurysm originated from right coronary cusps and one from non-coronary cusps. Both ruptured sinus of Valsalva aneurysm from right coronary cusps communicated to right ventricle, and one that originated from non-coronary cusps ruptured to right atrium. All cases were diagnosed by transthoracic echocardiography and confirmed by transesophageal echocardiography. Two underwent the surgery, while one did not want to continue treatment. Conclusion: ruptured sinus of Valsalva aneurysm is a rare cardiac anomaly. In the Eastern countries, the most common associated anomalies with ruptured sinus of Valsalva aneurysm are ventricular septal defect and aortic regurgitation. Ruptured sinus of Valsalva aneurysm mainly originates from right coronary cusps and is ruptured into right ventricle. Transthoracic echocardiography and transesophageal echocardiography are employed to confirm the diagnosis. In this cohort, the coexistences of ruptured sinus of Valsalva aneurysm with ventricular septal defect and aortic regurgitation (case 1), ventricular septal defect (case 2), aortic regurgitation and bicuspid aortic valve (case 3) are observed.

Valvular Disease Management in Patients with Continuous-Flow Left Ventricular Assist Device

Purpose Concomitant surgical intervention for valvular disease in patients with continuous-flow left ventricular assist device (cLVAD) is controversial. In this study, we evaluated strategies for valvular disease in cLVAD patients treated at our institution. Methods We reviewed 191 consecutive patients [126 males (66%), mean age 43 years] who underwent cLVAD implantation between 2005 and 2018. The devices were Jarvik 2000 in 45 (21%), Heart Mate II in 74 (35%), Dura Heartin 42 (20%), EVAHEART in 33 (16%), and HVAD in 16 (8%) patients. The severity of aortic insufficiency (AI), mitral regurgitation (MR), and tricuspid regurgitation (TR) was classified as none, trivial, mild, moderate, or severe using echocardiography , with moderate and severe defined as significant. Results The mean cLVAD support duration was 701days. Preoperative echocardiography showed significant AI in 3 (2%), MR in 67 (39%), and TR in 50 (30%) patients. Concomitant valve surgery was performed in 20 (10%) for AI, 13 (7%) for MR, and 49 (26%) for TR. In patients who did not undergo concomitant valve surgery, significant MR or TR was immediately decreased after cLVAD implantation and sustained in late follow-up (MR: preoperative 40%, postoperative 10%; late follow-up 6%; TR: 16%, 4%, 5%, respectively), whereas significant AI was gradually increased (0%, 7%, 27%, respectively) and 10 patients required reoperation for AI. The rate of freedom from severe AI was 93±3%, from moderate AI was 65±5%, and from mild AI was 14±3% (Figure).Multivariable analysis revealed that severe AI [hazard ratio (HR) 3.4, 95% confidence interval (CI) 1.1-8.8, p=0.03] and severe TR (HR 8.6, 95%CI 1.3-31, p=0.03) were associated with reoperation, while severe AI (HR 7.5, 95%CI 1.5-34, p=0.02) was associated with readmission for heart failure. Conclusion Our current strategy of concomitant valve surgery for MR and TR seems to be acceptable, while that for AI should be carefully considered.

Aortic Insufficiency During Contemporary Left Ventricular Assist Device Support: Analysis of the INTERMACS Registry

ObjectivesThis study sought to evaluate the impact of moderate to severe aortic insufficiency (AI) on outcomes in patients with continuous flow left ventricular assist devices (CF-LVADs). BackgroundDevelopment of worsening AI is a common complication of prolonged CF-LVAD support and portends poor prognosis in single-center studies. Predictors of worsening AI and its impact on clinical outcomes have not been examined in a large cohort. MethodsWe conducted a retrospective analysis of patients with CF-LVAD in the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) study. Development of significant AI was defined as the first instance of at least moderate AI. Primary outcomes of interest were survival after development of significant AI and time to adverse events, including device complications and rehospitalizations. ResultsAmong 10,603 eligible patients, 1,399 patients on CF-LVAD support developed moderate to severe AI. Prevalence of significant AI progressively increased over time. Predictors of worsening AI included older age, female sex, smaller body mass index, mild pre-implantation AI, and destination therapy strategy. Moderate to severe AI was associated with significantly higher left ventricular end-diastolic diameter, reduced cardiac output, and higher levels of brain natriuretic peptide. Significant AI was associated with higher rates of rehospitalization (32.1% vs. 26.6%, respectively, at 2 years; p = 0.015) and mortality (77.2% vs. 71.4%, respectively, at 2 years; p = 0.005), conditional upon survival to 1 year. ConclusionsDevelopment of moderate to severe AI has a negative impact on hemodynamics, hospitalizations, and survival on CF-LVAD support. Pre- and post-implantation management strategies should be developed to prevent and treat this complication.

Sutureless aortic bioprosthesis replacement in elderly Asian patients with aortic stenosis: Experience in a single institution

BackgroundSutureless aortic valve replacement (SU-AVR) has emerged as a promising alternative for the treatment of patients with aortic valve stenosis. This study aims to assess the safety and efficacy of SU-AVR in an elderly Asian population. MethodsFrom June 2015 to May 2016, 15 adults with severe aortic stenosis (9 females) with a median age of 79 years underwent Perceval sutureless bioprosthesis (LivaNova, UK) implantation in a single Taiwanese institution; peri-operative recovery, clinical improvement, and valve performance were analyzed. ResultsThree (20%) patients underwent concomitant procedures (coronary artery bypass grafting, 1 patient; maze, 2 patients) and 6/12 (50%) patients underwent J-ministernotomy for isolated SU-AVR. Median cardiopulmonary bypass and cross-clamp time were 105 min and 69 min, respectively. All sutureless bioprosthesis were implanted successfully without conversion to a traditional valve, but 2 patients (13.3%) need intraoperative valve repositioning because of paravalvular leakage. Median extubation time and intensive care unit stay were 5 h and 2 days, respectively. One patient experienced in-hospital mortality due to sudden collapse thought secondary to high degree atrioventricular block. Serial echocardiographic evaluations were performed preoperatively and at 1, 3, and 6 months postoperatively. The final echocardiographic exams showed nothing greater than mild aortic insufficiency and the median mean trans-valvular gradient was 13.2 (range, 6.0–26.3) mmHg. ConclusionsBy simplified procedure and improved hemodynamics, SU-AVR can be implanted safely in elderly Asian population with excellent valvular performance.

Geometric Ring Annuloplasty for Aortic Valve Repair During Aortic Aneurysm Surgery: Two-Year Clinical Trial Results.

An aortic annuloplasty ring could be useful for aortic valve repair. This trial evaluated intermediate-term outcomes of internal geometric ring annuloplasty for repair of trileaflet and bicuspid aortic insufficiency associated with ascending aortic and/or aortic root aneurysms. Under regulatory supervision, 47 patients with aortic insufficiency and ascending aortic (n = 22) and/or aortic root (n = 25) aneurysms were managed with aortic valve repair and aneurysm resection. Valve repair was performed using trileaflet (n = 40) or bicuspid (n = 7) internal geometric rings, together with leaflet reconstruction. Ascending aortic and/or remodeling root replacements were accomplished with Dacron grafts 5 to 7 mm larger than the rings. An Echo Core Lab provided independent echocardiographic assessments, and changes over time were evaluated by Friedman tests. Mean ± SD age was 60 ± 14 years, 57% (27/47) were male, 15% (7/47) had bicuspid valves, 87% (41/47) had moderate-to-severe aortic insufficiency, and 13% (6/47) had mild aortic insufficiency. All patients had annular dilatation, with a mean ± SD of 26.5 ± 2.6 mm before repair, and mean ± SD ring sizes were 21.7 ± 1.7 mm. Follow-up was 42 months (mean = 27 months). No operative mortality or valve-related complications occurred. Two patients died beyond 1 year from nonvalve-related causes. One patient required valve replacement for repair failure. Survival free of complications or valve replacement was 94% at 2 years. Significant reduction in aortic insufficiency and New York Heart Association class were observed (P < 0.0001), and valve gradients remained low. No heart block or direct ring complications occurred. In preliminary regulatory studies, aortic ring annuloplasty seemed safe and effective during aortic aneurysm surgery. This approach could help standardize aortic valve repair.

Outcomes of surgical aortic valve replacement for mixed aortic valve disease.

Mixed aortic valve disease (MAVD) is associated with a poorer natural history compared with isolated lesions. However, clinical and echocardiographic outcomes for aortic valve replacement (AVR) in mixed disease are less well understood. Retrospective review of AVRs (n=1,011) from 2000-2016. Isolated AVR, AVR + coronary bypass, and AVR + limited ascending aortic replacement were included. Predominant aortic stenosis (AS) group was stratified into group 1 (n=660) with concomitant mild or less aortic insufficiency (AI), and group 2 (n=197) with accompanying moderate or greater AI. Predominant AI group was stratified using the same schema for concomitant AS into groups 3 (n=143) and 4 (n=53). Median follow-up was 3.1 and 4.4 years respectively for AS and AI groups. For the predominant AS group (n=857) preoperatively, group 2 had a larger preoperative left ventricular end diastolic diameter (LVESD) (51.0±8.4 vs. 48.6±7.2, P=0.02) and lower preoperative left ventricular ejection fraction (LVEF) (57.6% vs. 60.2%, P=0.043). No differences in left ventricular (LV) dimensions, LV or right ventricular (RV) function was evident at follow up (P>0.05). After propensity matching for age, operation, and comorbidities, there was no difference in survival (P=0.19). After propensity matching for the predominant AI group (n=196), survival was lower for group 4 compared to 3 (P=0.02). There were no differences in LV dimensions, LV or RV function preoperatively or on follow-up (P>0.05). Predominant AS associated with higher AI grades had larger LV dimensions and worse LV function preoperatively. These differences resolve after AVR with equivalent survival. However, predominant AI with more severe AS had reduced survival despite AVR.

Vasculitis of ascending aorta detected on FDG PET/CT in a patient with fever of unknown origin

A 59-year-old man was admitted for fever of unknown origin. Fever was associated with chills. His medical record revealed the history of aortic valve replacement 11 years earlier, as well...

Natural History of Mild Aortic Insufficiency at the Time of Left Ventricular Assist Device Implantation for Heartmate II and HVAD

Significant aortic insufficiency (AI) after continuous flow left ventricular assist device (CF-LVAD) implantation complicates the patient management. The progression of AI during CF-LVAD support is not well studied. We analyzed our single-cer experience with CF-LVADs to determine if mild aortic insufficiency (AI) at the time of LVAD implantation progresses to severe AI requiring surgical intervention.

Brom Aortoplasty for Supravalvular Aortic Stenosis

Controversy remains regarding the optimal surgical approach for children with supravalvular aortic stenosis (SVAS). Since 1997 we have used Brom three-patch aortoplasty for patients with SVAS. We prefer computed tomography (CT) imaging for preoperative evaluation rather than cardiac catheterization as it avoids the well-known morbidity of general anesthesia. The purpose of this study was to present our intermediate-term results of this strategy. Twenty consecutive patients with SVAS were treated with Brom aortoplasty. Mean age was 3.7 ± 5.9 years (median, 1.5 years). Twelve patients had Williams syndrome. Ten patients had preoperative advanced medical imaging (seven CT, three magnetic resonance imaging) and did not have cardiac catheterization. Mean times for cardiopulmonary bypass and cross-clamp were 172 ± 29 minutes and 110 ± 21 minutes, respectively. Ten patients had simultaneous pulmonary artery stenosis patching. Median length of stay was seven days. There was no operative or late mortality. Mean follow-up was 6 ± 5 years. There were no reoperations on the aortic root. Fifteen patients had mild or less aortic insufficiency (AI) and two had moderate AI. One patient who had infant balloon dilation of the aortic valve and postoperative subacute bacterial endocarditis had moderate-to-severe AI and aortic stenosis (AS). One patient had moderate residual SVAS; all others had no AS. No patients had late coronary insufficiency. Brom aortoplasty promotes restoration of normal aortic root geometry and relief of coronary ostial stenosis, which is important in preventing myocardial ischemia. Computed tomography imaging is our preferred diagnostic modality. Intermediate-term outcomes are excellent with no recurrent SVAS, coronary events, or reoperations on the aortic valve.