Moderate Aortic Valve Insufficiency Research Articles

The prevalence and prognostic impact of aortic valve diseases in heart failure with mildly reduced ejection fraction

Abstract Objective This study aims to investigate the prevalence and prognostic value of aortic valve diseases in patients hospitalized with heart failure with mildly reduced ejection fraction (HFmrEF). Background Limited data regarding the prognostic impact of aortic valve diseases in patients with HFmrEF is available. Methods A large retrospective study was used including all consecutive hospitalized patients with HFmrEF (i.e., left ventricular ejection fraction (LVEF) 41 – 49%) from 2016 to 2022 according to current European guidelines. The prognostic impact of moderate to severe aortic valve stenosis (AS) and aortic valve insufficiency (AI) was compared to patients without (i.e., non-AS and non-AI, respectively). The primary endpoint was the first heart-failure related re-hospitalization at 3 years. Secondary endpoints comprised amongst others in-hospital mortality. Kaplan-Meier, uni- and multivariable Cox regression analyses were applied for statistics. Results 800 consecutive patients with HFmrEF were included. The prevalence of AS was 10% (moderate 6% and severe 4%) and AI 8% (moderate 7% and severe 1%). The risk of first heart-failure related hospitalization was not significantly affected by the presence of AS (14% vs. 8%; log rank p=0.092; HR= 1.727; 95% CI 0.908 - 3.284; p=0.096), however, HFmrEF patients with moderate to severe AI were associated with an increased risk of heart-failure related re-hospitalization compared to patients without (18% vs. 8%; log rank p=0.010; HR= 2.270; 95% CI 1.193 - 4.317; p=0.012). Even after multivariable adjustment, the risk of heart failure related re-hospitalization was still significantly higher in patients with moderate to severe AI (HR= 2.022; 95% CI 1.030 - 3.969; p=0.041). Finally, patients with moderate or severe AS and patients with moderate or severe AI revealed no significant difference of in-hospital mortality (4% vs. 3%; p=0.807 and 3% vs. 3%; p=0.946). Conclusions In patients hospitalized with HFmrEF between 2016 and 2022, patients with moderate to severe AI – but not AS – had a higher risk of heart failure related re-hospitalization at 3 years.

P124 ECOCARDIOGRAPHIC DIAGNOSIS OF TYPE A AORTIC DISSECTION

Abstract Clinical case In August 2021, an 89–year–old woman with no previous cardiovascular history, suffering from systemic arterial hypertension under pharmacological treatment, dyslipidemia and M. di Parkinson came to our observation for syncopal episode. The clinical presentation was characterized by a syncopal episode in the absence of prodromes and reported chest pain upon awakening. At the time of arrival in PS the patient was alert, attentive, and oriented, asymptomatic, hemodynamically stable with PAS 90 mmHg, with normo–iso–sphygmic peripheral pulses. A cardiological evaluation was requested and the transthoracic echocardiography revealed dissection of the proximal ascending aorta with evidence of intimal flap starting from the aortic root and extending to the proximal tract of the aortic arch, moderate aortic valve insufficiency and moderate circumferential pericardial effusion (2 cm), with the presence of blood clots, in the absence of signs of hemodynamic compromise. CT angiography confirmed Stanford type A aortic dissection with intimal flap originating in the supravalvular site (maximum diameter 6 cm), longitudinally extended for about 6 cm at the level of the ascending aorta until the emergence of the epiaortic vessels which were not involved. Consequently, cardiac surgery teleconsultation was required which, based on the patient‘s advanced age, did not allow surgical treatment due to a prohibitive operative risk, considered comparable to the natural course of the disease. The patient was then admitted to intensive care where remained asymptomatic and in cardio–circulatory compensation until death occurred on the third day due to cardio–circulatory arrest from PEA. Conclusions Aortic dissection is a high–mortality condition that requires an immediate diagnostic–therapeutic approach. In the diagnostic process, transthoracic echocardiography represents the most promptly performed examination and not infrequently allows the diagnosis before radiological confirmation by angioTC.

Acute Arterial Ischemic Stroke in a Treated Child with Hunter's Syndrome: A Case Report and Review of the Literature

AbstractEnzyme replacement therapy (ERT) has limited therapeutic effects on neurologic, skeletal, and cardiovascular pathophysiology. We report an acute right-sided flaccid hemiparesis in an 11-year-old boy with the severe neuronopathic phenotype of Hunter's syndrome who was receiving weekly idursulfase ERT. Due to his psychomotor regression and epilepsy, his presentation to the hospital was delayed. Computed tomography scan of brain showed no acute changes or hemorrhage. Stroke code was not called as patient was already outside of the time window for tissue plasminogen activator (tPA) therapy. Brain magnetic resonance imaging (MRI) showed diffuse cortical and deep atrophy consistent with his baseline neurological status and restricted diffusion in the territory of the left-middle cerebral artery (MCA) consistent with recent infarction. T1-weighted MRI revealed low signal intensity of the left insular cortex, as well as volume loss, consistent with previous undiagnosed stroke in the same vascular territory. In addition, MR angiogram (MRA) demonstrated left terminal M1 segment MCA occlusion. Echocardiogram showed aortic root dilation and moderate aortic valve insufficiency. Patient was also noted to have bacteremia related to port infection. ERT is limited by blood–brain barrier and the underlying glycosaminoglycans (GAGs) extracellular tissue accumulation which produces a proinflammatory state. GAG and bacterial lipopolysaccharide (LPS) are known to activate toll-like receptor 4 (TLR-4). GAGs released in the extracellular space of intracranial vessels induce inflammation by activating the TLR-4 pathway which is exacerbated by bacterial LPS contributing to focal arteritis. Our case suggests the importance of GAGs in the activation of the TLR-4 pathway as a cause of stroke in Hunter's syndrome.

Abstract 14495: Clinical Outcomes of Transcatheter Aortic Valve Replacement for De Novo Aortic Valve Insufficiency After Left Ventricular Assist Device Implantation

Objective: This study aimed to assess clinical outcomes of transcatheter aortic valve replacement (TAVR) for de novo aortic valve insufficiency (AI) after left ventricular assist device (LVAD) implantation. Methods: We defined de novo AI as a new-onset moderate AI or greater after the index LVAD implantation. Survival rate in patients with de novo AI was compared with ones without de novo AI, and clinical outcomes of TAVR in the patients with de novo AI were assessed. Results: Between 7.2008 - 1.2020, a total of 513 patients underwent LVAD implantation. Among them, 460 patients who had postoperative cardiac echography data available were included in this study. Sixty one patients (13%) developed de novo AI (dAI group) and 399 patients (87%) were not (non-dAI group). Overall survival in the dAI group was significantly lower than that in the non-dAI group (at 1 year: 54±7 vs. 73±2%, at 3 years: 30±8 vs. 51±3%,Log-Rank P=0.0004). In the dAI group, seven patients underwent TAVR for severe de novo AI of the native AVs. Calcification in the AVs measured by preoperative computed tomography (CT) was non-calcification in 4 patients, mild in 1 patient, and moderate in 2 patients. Based on measurements from CT, Valsalva sinus was 35 [32,36]mm (median[25%tile,75%tile]). All TAVR procedures were performed via a femoral artery approach. Sapien3 was implanted in 4 patients (23mm (N=1), 26mm (N=1), 29mm (N=2)). CoreValve was implanted in 3 patients (31mm (N=1), 31mmх2 (N=1), 34mm (N=1)). As an intraoperative complication, CoreValve migrated into the left ventricle in 1 patient. The degrees of postoperative residual AI were none or trace in 5 patients who were discharged in a good condition, and severe (perivalvular leakage (PVL)) in 2 patients who died during the admission. The 2 patients, who had severe postoperative PVL, did not have calcification in the AVs. Overall survival at 1 year in the 5 patients, who were discharged alive, was 100%, and freedom from moderate or greater AI was 100% at 6 months and 60% at 1 year. Conclusions: De novo AI negatively affected the survival rate in LVAD patients. TAVR treatment for de novo AI in LVAD patients might be a reasonable option. However, careful patient selection would be necessary.

Significance of Aortic Valve Insufficiency with Left Ventricular Assist Device: Duration and Regurgitant Flow in a Mock Loop Study

In patients with left ventricular assist device (LVAD), aortic valve insufficiency (AI) could occur in longer period during the cardiac cycle, throughout the diastolic and part of the isovolumetric phases. As the result, the current echocardiographic evaluation of AI grade may underestimate the degree of AI in LVAD patients, especially those with significant AI. In this study, we investigated the differences in AI duration and regurgitant volume before and during LVAD supports (Off and On LVAD) using a mock circulatory loop. All measurements were performed using a mock circulatory system with a dilated silicone LV model attached to a HeartMate II LVAD (Abbott Lab), and pressure and flow measured in the LV, LVAD, and aorta. Baseline condition was established as no LVAD condition (Off LVAD setting) which has 17% ejection fraction, 62 bpm heart rate and 65 mmHg systemic pressure. LVAD condition (On LVAD setting) at 8,800 rpm with same ejection fraction, heart rate and systemic resistance (90 mmHg systemic pressure) was established, followed by testing at three AI severity conditions. AI severity was defined as mild, moderate, or severe based on effective regurgitant orifice area. AI conditions were created with small 3-D printed stents, which were nonobstructive to forward flow, but prevented the leaflets from fully closing. AI durations and regurgitant volumes were determined from the calculated backward flow through the aortic valve. With the constant systemic resistance in the On LVAD setting at 8,800 rpm, duration of AI increased by 8.3 % (75 to 83.3%) with mild AI, 5.6% (77.8 to 83.3%) with moderate AI, and 5.6% (77.8 to 83.3%) with severe AI compared to the Off LVAD setting. With the constant systemic resistance in the On LVAD setting at 8,800 rpm, regurgitant volume of AI increased by 0.11 L/min (0.12 to 0.23 L/min, 92%) in mild AI, 0.03 L/min (0.53 to 0.56 L/min, 5.7%) in moderate AI and 0.08L/min (0.78 to 0.86 L/min, 10.3%) with severe AI compared to the Off LVAD setting. This mock loop study demonstrated that AI duration was longer and regurgitant volume through the aortic valve was greater during LVAD support compared to same AI degree before LVAD. This suggests that clinical burden of AI may be underestimated in patients with LVAD.

Results of aortic valve repair using decellularized bovine pericardium in congenital surgery.

The search for an optimal patch material for aortic valve reconstruction (AVR) is an ongoing challenge. In this study, we report our experience of AVR using decellularized bovine pericardial patch material in congenital heart surgery. Data of 40 consecutive patients who underwent AVR using the CardioCel® patch (Admedus Regen Pty Ltd, Perth, WA, Australia) between February 2014 and August 2016 were retrospectively reviewed. The median age of the patients at operation was 9 (2-34) years, and 18 patients were younger than 7 years. Twenty-six patients initially presented with aortic valve insufficiency (AI) and 14 with stenosis. Clinical and echocardiographic data were available until August 2017 for a median postoperative follow-up (FU) of 22 (6-42) months. Nine of 40 (23%) patients experienced an event during FU (death: n = 1, 2.5%; reoperation: n = 8, 20%). Overall, the probability of freedom from reoperation or death was 97 ± 3%, 76 ± 9% and 57 ± 12% at 12, 24 and 36 months of FU, respectively. Reason for reoperation was stenosis in 3 (37.5%) patients, insufficiency in 4 (50%) patients and 1 (12.5%) patient was diagnosed with aortic valve endocarditis. Of the remaining 31 patients, 2 patients are scheduled for reoperation (aortic valve stenosis: n = 1 and AI: n = 1) and 9 patients exhibit worsening of aortic valve function with moderate AI. Freedom from developing combined end point [death/reoperation/moderate degree of aortic valve dysfunction (aortic valve stenosis, AI)] after AVR was 92 ± 5%, 55 ± 9% and 28 ± 9% at 12, 24 and 36 months, respectively. AVR using decellularized bovine pericardial patch material in patients with congenital aortic valve disease show unsatisfactory results within the first 3 years of FU.

Axial Flow Left Ventricular Assist Device is Associated with Progression of Aortic Valve Insufficiency

Aortic Valve Insufficiency (AI) in patients with Left Ventricular Assist Device (LVAD) can increase re-circulation causing inefficient forward blood flow, exacerbate RV failure and subsequently demand strict LV afterload control which may adversely affect on other end-organ function. Moreover, careful attention is required for moderate or more AI potentially necessitating valvular intervention or earlier heart transplant. However, risk factors for progression of AI in patients supported with LVAD are not well understood.

Prevalence of De Novo Aortic Valve Insufficiency in Patients After HeartWare VAD Implantation with an Intermittent Low-Speed Algorithm.

De novo aortic valve insufficiency (AI) is a frequent occurrence in patients supported with left ventricular assist device (LVAD). The European version of the HeartWare LVAD has intermittent low-speed software (lavare cycle) to facilitate intermittent aortic valve opening. We examined aortic valve opening status and prevalence of AI in patients supported with HeartWare LVAD and activated lavare cycle. HeartWare LVAD patients were prospectively monitored using serial echocardiograms at different time points after the LVAD implantation. Inclusion criteria were patients with no > mild AI and/or no aortic valve surgery at the time of LVAD implantation and at least 60 days of support. Three of 37 patients had aortic valve surgery and were excluded from the analysis. A total of 34 patients with mean age of 57 ± 12 years met the inclusion criteria. After median support duration of 408 days (77-1250 days), eight patients had trace/mild AI (24%) and one patient developed moderate AI (3%). An average pump flow, speed, and mean arterial pressure of 4.4 ± 0.6 L/min, 2,585 ± 147 rpm, and 88 ± 11 mmHg were documented, respectively. Aortic valve opening was persistently seen in 22 patients (65%). Aortic valve opening is frequent, and the development of > mild AI seems to be rare in patients supported with HeartWare LVAD.

Pulmonary artery atresia with ventricular septal defect, segmental pulmonary hypertension, major aortopulmonary collaterals (MAPCAs) and giant MAPCA aneurysm

A 32-year-old woman with pulmonary artery atresia with ventricular septal defect (VSD) was admitted because of New York Heart Association (NYHA) class worsening from II to III during the last 6 months. The patient presented resting cyanosis, short 6-minute walk test (6MWT) distance (370 m with desaturation – baseline: 84%, after 6MWT: 67%). N-terminal prohormone of brain natriuretic peptide (NT-proBNP) level was 194–262 pg/ml. She also suffered from significant kyphoscoliosis with stable chronic ventilation disturbances: forced vital capacity (FVC) = 1.38 l, forced expiratory volume in 1 s (FEV1) = 0.94 l, FEV1/FVC = 68%. Imaging methods (transthoracic echocardiography, transoesophageal echocardiography, magnetic resonance imaging – MRI, angio-computed tomography – CT) confirmed the presence of VSD (Figures 1 A, B), enlarged ascending aorta up to 49 mm above VSD and moderate aortic valve insufficiency. Angio-CT and MRI revealed occurrence of major aortopulmonary collaterals (MAPCAs) (Figure 1 C) with a giant aneurysm of one of them (Figure 1 D) and no pulmonary artery. Coronarography showed abnormality of the left artery descdending (LAD) orifice from the right coronary artery. We simultaneously excluded coronary and mammary artery to MAPCA shunts. The aortography followed by selective catheterization showed five MAPCAs: three on the left side (the one that supplied the left lower pulmonary lobe was stenosed in the proximal part) and two on the right side, among others a MAPCA creating a giant (6 cm) aneurysm (Figure 1 E). Each individual part of the lungs is supplied from a single source. In catheterization using a Swan-Ganz catheter we obtained the following outcomes: the mean collateral pressure was high in the MAPCAs that were not stenosed (69 mm Hg) and there was no response to iloprost (Figure 1 F); the mean collateral pressure was quite low in the stenosed MAPCA (14 mm Hg). According to single case reports and limited research [1, 2] and our hemodynamic outcomes, we prescribed bosentan, with quite a good clinical effect. During bosentan therapy the patient’s NYHA class decreased from III to II. The patient was disqualified from surgical treatment. In the literature we have found some reports of large MAPCA aneurysm diagnosed in vivo but not surgically treated [3] and one case concerning successful invasive treatment [4]. During 2-years follow-up we increased the dose of bosentan to 125 mg twice daily and we obtained a very good result. The patient is still in NYHA functional class II without any progression of pulmonary hypertension symptoms. There still remains the question whether the above described MAPCA aneurysm should be percutaneously occluded or surgically treated in prevention of aneurysm rupture and sudden death. Taking into account coexisting kyphoscoliosis and ventilation disturbances, the risk of interventions seems to be very high. Figure 1 Multimodality imaging: A – transthoracic echocardiography – parasternal long axis view, arrow: large VSD; B – CT scan, arrows: MAPCAs; C – CT scan, 3D reconstruction, arrow: MAPCA; D – CT scan, arrows: MAPCAs, arrow: ...

Transcarotid balloon valvuloplasty in neonates and small infants with critical aortic valve stenosis utilizing continuous transesophageal echocardiographic guidance: A 22 year single center experience from the cath lab to the bedside.

Utilization of continuous transesophageal echocardiographic guidance (cTEE) during transcarotid balloon valvuloplasty (TCBV) in neonates and small infants with critical aortic valve stenosis (AS) allows for continuous hemodynamic assessment and improved outcomes. Preferred method of intervention for critical AS remains controversial due to conflicting results. Since 1992, 30 neonates and small infants with critical AS and adequate left ventricular (LV) volumes underwent TCBV with cTEE. Critical AS was defined as ductal dependent systemic circulation, LV systolic dysfunction, or an echo gradient≥100 mm Hg with evidence of hypoperfusion. The median age at intervention was 4 days (range 1-54 days). Nineteen (63%) patients required PGE1 and 25 (85%) had LV dysfunction. All procedures were performed with cTEE guidance. The initial 15 patients were performed in the cath lab whereas the subsequent 15 patients were performed at the bedside without fluoroscopy. The peak systolic gradient decreased from 70 to 24 mm Hg (P<0.001). Four (13%) early deaths were secondary to associated cardiac anomalies although one patient developed severe aortic valve insufficiency (AI) immediately post intervention. At discharge, two patients (8%) had ≥moderate AI. At a mean follow-up of 9 years (range: 2.2-20 years), there were 15 additional aortic valve interventions. Freedom from aortic valve reintervention at 10 years was 55% and actuarial survival rate at 10 and 15 years was 82%. Bedsides TCBV with cTEE guidance is effective palliation for neonates and small infants with critical AS and allows for continuous hemodynamic assessment without the use of ionizing radiation. Our early and late results appear comparable to surgical valvotomy.

Mid-Term Follow-Up after Arterial Switch Operation for Complete Transposition of the Great Arteries

Purpose : Transposition of the Great Arteries has to be surgically corrected by an arterial switch operation. This complex surgical procedure has the potential for significant short- and long-term complications like dilation of the neo-aortic root, coronary and pulmonary artery (PA) stenosis. The aim was to determine a suitable follow-up algorithm for mid-term follow-up. Material and Methods : 26 patients (mean age 10±2 years) were examined using echocardiography, ECG-gated Computed Tomography Angiography (CTA) and functional Magnetic Resonance Imaging (MRI) with flow, cine and pulmonary perfusion measurements. Results : CTA was capable to visualize coronary arteries in all cases. Coronary stenosis did not occur. Echocardiography failed to visualize the coronary arteries in 81%. CTA revealed moderate PA stenosis (25-50% lumen reduction) in 41% and severe stenosis (>50%) in10%. Visualization of pulmonary arteries was possible by echocardiography in only 45%. Correlation between MR-pulmonary perfusion abnormalities and PA stenosis were not present. Doppler-echocardiography showed mild flow acceleration in the main PA (mean pressure gradient 34mmHg) in 4 patients, while MRI found an increased velocity in 9 patients. 10 patients had neo-aortic root dilatation detected with CTA. On echocardiography 8 patients had mild, 4 had moderate aortic valve insufficiency. On MRI amount of aortic valve insufficiency was too small to be quantified. Conclusion : Branch stenosis of the PA was the leading complication 10 years after surgery, coronary stenosis did not occur. Value of Echocardiography is minor in the visualization of coronary arteries and PA morphology and it is recommended only for the assessment of cardiac and valvular function. Additionally, CTA is method of choice for visualization of coronary arteries and PA morphology. In this study the value of MRI for assessment of the complete morphology was limited, but improves with technical advance.

Successful Surgical Intervention in Symptomatic Severe Hypertrophic Subaortic Stenosis

Successful Surgical Intervention in Symptomatic Severe Hypertrophic Subaortic Stenosis Subaortic stenosis is a scarce progressive entity causing left ventricular outflow tract obstruction leading to concentric left ventricular hypertrophy and carrying a considerable risk of morbidity and mortality. We report a 68-year old woman who was symptomatic for more than two years with signs of congestive heart failure and admitted for re-procedural pulmonary vein isolation because of paroxysmal atrial fibrillation. Echocardiography revealed a marked left ventricular outflow tract obstruction due to a fibromuscular membrane just below the aortic valve and moderate aortic valve insufficiency, compatible with a severe subaortic stenosis. Surgical resection of the subaortic membrane, myectomy of the basal septum, bioprosthesis aortic valve replacement and epicardial left atrial appendage closure were successfully performed. The patient was discharged from hospital in good clinical condition. This report is outlining the diagnostic challenge of the rare diagnosis of a symptomatic severe hypertrophic subaortic stenosis in adulthood which is known to carry a considerable risk of morbidity and mortality and surgical intervention as safe therapy of choice in this condition.

Ascending Aortic Aneurysm

A 14-year-old boy presented with an unusual bulging chest noted to be increasing slowly over the last few years. He had no other complaints. Cardiac echocardiography and cardiac magnetic resonance imaging (MRI) showed aneurysmal dilation of the ascending aorta with moderate aortic valve insufficiency and moderate pericardial effusion. The boy underwent reconstruction of his ascending aorta in the form of a Bentall procedure using a 25-mm Carbomedic valve conduit.

Drug-induced lymphadenopathy with eosinophilia and renal failure mimicking lymphoma disease: dramatic onset of DRESS syndrome associated with antibiotic treatment

Dear Editor,Here, we report a rare complication of antibiotic treatmentleading to lymphoma-mimicking lymphadenopathy withconcomitant eosinophilia, dermatitis, and acute renalfailure.A 30-year-old man was admitted for aortic valvereplacement because of endocarditis. The medical historyrevealed insulin-dependent diabetes mellitus (type 1),diabetic retinopathy, vascular disease, hypertension, andstage 2 chronic renal failure. Five weeks prior to admission,transesophageal echocardiography had revealed acuteinfectious endocarditis of the aortic valve and moderateaortic valve insufficiency. Blood cultures were positive forStreptococcus dysgalactiae and antibiotic therapy withpenicillin G and gentamycin was initiated. Penicillin Gwas replaced by vancomycin due to exanthema; gentamy-cin was stopped. Control echocardiography showed severevalve insufficiency, which prompted surgical valve replace-ment. Antibiotic treatment with vancomycin was continuouslyadministered.Ten days after successful surgery, the patient developedacute renal failure (creatinine, 637 μmol/l; reference range(rr), 74–110 μmol/l) requiring single-time hemodialysis.Concomitantly, the patient developed fever with a dailyintermittent pattern (max., 39.7°C) and an elevated whiteblood cell count (35.1/nl; rr, 4.4–11.3/nl) showing a leftshift in the differential count. C-reactive protein wassignificantly elevated (189 mg/ml). Antibiotic therapy withvancomycin, gentamycin, and ceftriaxone did not result inany improvement. The antibiotic therapy was changed tolinezolid/tigecycline; later, to rifampicin, cefuroxime, andfluconazole, without improving symptoms. Echocardiogra-phy showed no signs of acute infectious endocarditis. Bloodcultures were negative. Peripheral lymphadenopathy promp-ted further imaging studies, including a FDG–PET–CT scanwhich showed ubiquitous, highly metabolic, active lymph-adenopathy ranging between 7 and 25 mm in size (Fig. 1a).When the hematology consultant was called in fordiagnosis of suspected lymphoma, the leukocytes hadincreased to 40/nl, and the differential revealed 24%eosinophils. IgE levels were significantly elevated(42,684 kU/l; rr<120 kU/l). Lactate dehydrogenase waslikewise increased (8.1 μmol/l; rr<4.1 μmol/l). In addition,the patient presented with a generalized pruritic rash. Urineanalysis was evident for tubular proteinuria, indicatingtubulointerstitial renal disease. Lymph node biopsy showeda high proliferative activity (Ki-67, 60–80%), initially

Aortic root and cusp configuration determine aortic valve function☆

Normalisation of aortic root and cusp configuration is a prerequisite for successful aortic valve repair (AVR). Using transthoracic echocardiography, we studied aortic root dimensions relative to body size in normal subjects and AVR patients. Aortic roots of healthy volunteers (n=130, age 27.9 ± 16.9 years) were examined for aortoventricular (AV), sinus (S), sinutubular-junction diameters (ST) and effective height (height difference between the AV plane and central coaptation point, eH) by transthoracic echocardiography. In 651 patients, after AVR residual aortic valve insufficiency (AI) and eH were determined. The relationships between eH versus root dimensions and eH versus residual AI were analysed by analysis of variance with Bonferroni post hoc testing. Root dimensions correlated with each other and body size (r=0.74-0.91). In addition, a correlation between AV (r=0.73), sinus diameter (r=0.76), body height (r=0.77), body surface area (r=0.81) and eH was found. After AVR, eH was 9.8 ± 0.9 mm in 235 patients without postoperative AI, 9.4 ± 1.1mm in 370 with mild AI, 7.9 ± 1.4mm in 43 patients with moderate AI and 6 ± 1mm in three patients with severe AI. The difference in means of effective height between the groups was significant (p<0.005). Of 497 AVR patients with an eH ≥ 9 mm, 309 had no or trivial AI, 186 had mild AI and only two had moderate AI. Parameters of aortic root dimensions follow a seemingly constant pattern in humans of different sizes. Effective height has a constant relationship to root dimensions and body size. In AVR, normalisation of eH leads to a high probability of normal or near-normal aortic valve function.

Concomitant aortic valve-sparing operation and closed biatrial radiofrequency ablation for annuloaortic ectasia and paroxysmal atrial fibrillation

A 53-year-old woman was admitted for annuloaortic ectasia with moderate aortic valve insufficiency (AI) and paroxysmal atrial fibrillation. Concomitant aortic root replacement with a valve-sparing technique and closed biatrial procedure using bipolar radiofrequency ablation was performed successfully. Postoperative echocardiography showed trivial AI with regular sinus rhythm, which meant she could avoid anticoagulation therapy.

Impact of preoperative aortic root diameter on long-term aortic valve function after valve sparing aortic root reimplantation.

Valve sparing aortic root reimplantation technique in patients with aortic root aneurysm have shown excellent mid-term results. In conjunction with the diameter of the aortic root the mechanical leaflet stress increase, which might have an impact on long-term aortic valve function after valve sparing aortic root reimplantation. From July 1993 to October 2001, 168 patients with aortic root aneurysm underwent valve sparing aortic root reimplantation. Patients with type A aortic dissection were excluded. Thus, 123 patients were analyzed. We identified 47 patients with an preoperative aortic root diameter exceeding 60 mm (group A), 58 patients with an diameter between 50 and 60 mm (group B), and 18 patients with a diameter less than 50 mm (group C). The groups were compared regarding mortality, long-term survival, freedom from reoperation, freedom from severe and moderate aortic valve insufficiency (AI), and postoperative morbidity. Mean follow-up (group A 43+/-26 months, group B 40+/-25 months, group C 23+/-19 months; group C versus group A, P=0.005; group C versus group B, P=0.011) was shorter in group C. Perioperative mortality (group A 2.2%, group B 1.9%, group C 5.2%; P=ns) was comparable between the groups with each one patient. The 3-year survival for group A was 98+/-2%, for group B 96+/-3%, and for group C 100+/-0% (P=ns). Freedom from reoperation for group A was 98+/-2%, for group B 96+/-3%, and for group C 88+/-8% (P=ns). Four patients developed severe or moderate AI, thus freedom from severe and moderate AI for group A was 100+/-0%, for group B 88+/-8%, and for group C 94+/-5% (P=ns). During follow-up no thromboembolic or bleeding events were noticed. Our data show that the preoperative diameter of the aortic root has no impact on the longevity of the repair. Thus, the reimplantation technique can be recommended for all patients presenting with an aortic root aneurysm and normal leaflets regardless of the aortic root diameter.

Transcatheter embolization treatment of coronary arteriovenous fistulas.

Transcatheter coronary arteriovenous fistula occlusion was performed in 5 children with a median age of 5.3 years (range, 0.7 to 11 years). Surgical ligation had been carried out previously in one case, but recanalization occurred during follow-up. Dilation of the feeding artery was observed in 4 patients, with an additional aneurysm of the coronary artery in one of these. Occlusion was attempted three times in 1 patient, twice in 2, and once in the other 2. Detachable balloons were used in 2 procedures, and controlled-release coils in 3. Complete occlusion of the fistula was achieved in 4 patients. In the 5th patient, occlusion of one of two fistulas was unsuccessful, and mild to moderate aortic valve insufficiency developed due to catheter manipulation. Our experience indicates that transcatheter occlusion of congenital coronary arteriovenous fistula is at least as successful as surgical intervention. Multiple occlusion procedures can be avoided by selecting the optimal technique in each case.

Supravalvular Aortic Stenosis Combined with Right Coronary Artery Ostial Obstruction

Supravalvular aortic stenosis is an uncommon congenital narrowing of the ascending aorta that may be localized or diffuse, originating at the superior margin of the sinuses of Valsalva just above the level of the coronary arteries. The most common complication of supravalvular aortic stenosis is early onset of intimal hyperplasia and atherosclerosis of the coronary arteries. The coronary arterial lesions of supravalvular aortic stenosis are dilatation or coronary artery ostial obstruction. We experienced a case of supravalvular aortic stenosis combined with right coronary artery ostial obstruction. A 21 year-old female patient was admitted because of exertional dyspnea and chest pain for 2 months. Cardiac catheterization showed a narrowing of ascending aorta with prominent calcification in the lesion and moderate aortic valve insufficiency. The peak to peak left ventricular-supravalvular aortic pressure gradient was 54 mmHg. Selective coronary angiography revealed as a complete obstruction of the ostium of the right coronary artery. Surgical correction was performed successfully. Post left ventricular-supravalvular aortic pressure gradient was decreased to 22 mmHg. Postoperative clinical course was favorable and she was discharged with good condition. We present a case of supravalvular aortic stenosis combined with right coronary artery ostial obstruction with a review of literatures. (Korean Circulation J 2000;30(4):502-506)

Surgical Correction of Ruptured Aneurysm of the Sinus of Valsalva

Between January 1983 and December 1996, 108 patients with ruptured aneurysms of the sinus of Valsalva underwent surgical correction in Shanghai Chest Hospital. The aneurysms ruptured into the right ventricle in 91 patients, into the right atrium in 16, and into the left atrium in 1. The aneurysm originated from the right coronary sinus in 82 patients, from the noncoronary sinus in 25, and from the left coronary sinus in 1. Associated intracardiac defects included ventricular septal defect in 52, aortic valve insufficiency in 67, and patent ductus arteriosus in 2. A ruptured aneurysm of the sinus of Valsalva without aortic valve insufficiency was approached via the cardiac chamber into which it ruptured. When the aneurysm was associated with moderate or severe aortic valve insufficiency we preferred the transaortic approach for repair. The aneurysm was excised at its base and repaired with a Dacron patch regardless of the size of the base of the aneurysm. Active surgical management of aortic valve insufficiency was performed at the initial operation using valve suspension in 25 patients with moderate aortic valve insufficiency and replacement with a mechanical valve prosthesis in 6 cases of severe aortic insufficiency. The early mortality was 2.78%. The median follow-up period was 3.9 years. Of the 72 patients who were followed up, 67 are in New. York Heart Association functional class I or II and 5 are in class III or IV due to severe aortic valve insufficiency. Considering the pathoanatomic features and hemodynamic changes associated with ruptured aneurysms of the sinus of Valsalva in Oriental patients, we advocate repairing the defect with a patch in all cases and stress the importance of active surgical management for aortic valve insufficiency at the initial surgical correction.