Preoperative Aortic Regurgitation Research Articles

Surgical treatment of ruptured aneurysm of the sinus of Valsalva

SummaryThis study reviews the results of the surgical management of 154 cases of ruptured aneurysm of the sinus of Valsalva. Of the patients0 73% were male, with an average age of 28 years. An associated ventricular septal defect was found in 40% and 23% had aortic valvar regurgitation. The aneurysms originated from the right coronary sinus in 79% and from the non-coronary sinus in the remainders. The aneurysms ruptured into the right ventricle in 73%, into the right atrium in 27% and into the left ventricle in less than 1%. Operative mortality was 4.5%. Long-term follow-up was achieved in 80% of patients, with a mean duration of 5.7 years and a range from two months to 29 years. Preoperative aortic regurgitation and preoperative functional class (NYHA III or IV) were both predictive of a worse long-term outcome. The optimal surgical approach was closure of the distal end of the fistula by direct suture together with reinforcement of the aortic sinus with a Dacron patch.

Doubly committed subarterial ventricular septal defects: Echocardiographic features and surgical implications

Doubly committed subarterial (supracristal, subpulmonary) ventricular septal defects are often complicated by aortic regurgitation resulting from aortic valve herniation into the defect. The clinical, echocardiographic and catheterization findings in 48 patients aged 0.3 to 46.4 years (median 9.5) with a doubly committed subarterial ventricular septal defect were reviewed. Aortic valve herniation was present in 38 (79%) and 55% of these had aortic regurgitation. The prevalence of both findings increased gradually with advancing age. The defect was closed surgically in 41 patients. Surgery during the first 2 years of life (median 0.4 year) was performed in 13 patients (group I), mainly because of a large shunt with a pulmonary to systemic flow ratio (Qp/Qs) 3.8 +/- 1.4 (mean +/- SD). Aortic regurgitation was present preoperatively in two patients (15%), persisted postoperatively in one patient and did not develop in any after repair (median duration of follow-up 2.3 years, range 0.1 to 7.4). In the other 28 patients (group II) surgery was performed between 4.8 and 46.4 years of age (median 11.5). These patients were generally less symptomatic and had a smaller shunt (Qp/Qs 1.5 +/- 0.5, p less than 0.001). Preoperative aortic regurgitation was present in 18 (64%). It persisted in 15 postoperatively, but in 13 of these it had diminished. Two-dimensional echocardiography in multiple views identified the site of the ventricular septal defect in all patients. Serial echocardiographic examinations demonstrated the progressive nature of aortic valve herniation, the partial occlusion of the defect by the herniated sinus and the development of aortic regurgitation. These findings suggest that timely surgical closure of these defects may prevent aortic regurgitation.

SYSTEMIC HYPERTENSION AFTER HOMOGRAFT AORTIC VALVAR REPLACEMENT A CAUSE OF LATE HOMOGRAFT FAILURE

116 patients undergoing successful aortic valvar replacement with an irradiated homograft valve have been followed up for periods of 6 months to 51/2 years. 39 of the patients (34%) have developed a diastolic pressure of greater than 90 mm. Hg, and in all but 1 of these the diastolic pressure exceeded 100 mm. Hg. In 4 patients hypertension was first noted in the immediate postoperative period, but the prevalence then rose until 53% were hypertensive 5 years after surgery. Neither preoperative hypertension nor impaired renal function were significantly associated with the development of postoperative hypertension. The frequency of hypertension in males (39%) was significantly greater than in females (15%), and patients with preoperative aortic regurgitation developed hypertension more frequently (50%) than those with dominant aortic stenosis (27%). The presence of hypertension was a major determinant of late failure of the irradiated homograft. Significant regurgitation has occurred in 14% of the patients and necessitated reoperation in 4·3%. In the patients with hypertension before starting hypotensive treatment the incidence of homograft failure was 40%, as compared to 8% in the normotensive group (P<0·02). The incidence of valvar failure in hypertensive patients receiving hypotensive therapy was 11%, which did not significantly differ from the normotensive group. Systemic hypertension is a common late complication of homograft aortic valvar replacement and requires early treatment to reduce the risk of valvar failure.

The hemodynamic results of surgery for aortic stenosis

1. 1. Nineteen patients with severe aortic stenosis have been studied by left heart catheterization before and after transaortic valvuloplasty. 2. 2. The cardiac index was normal in patients with pure aortic stenosis but tended to be reduced in the presence of associated aortic regurgitation, mitral or coronary disease. 3. 3. Severe aortic stenosis, as it progresses, may become associated with a reduced cardiac output and, therefore, a small systolic mean pressure difference across the aortic valve. 4. 4. There was a small but significant postoperative increase in calculated aortic valve area in 11 patients, associated with a marked fall of left ventricular systolic pressure, transvalvular pressure difference, and left ventricular work, while cardiac output remained unchanged. A residual pressure difference across the aortic valve persisted in all but one patient, who developed severe regurgitation. 5. 5. Eight patients showed no change in valve area. The left ventricular systolic pressure and transvalvular pressure difference in these was also decreased postoperatively, but this was found to be the result of reduced cardiac output. 6. 6. Associated mitral stenosis, mitral regurgitation, or coronary disease did not preclude successful surgery for aortic stenosis. 7. 7. Six of the 8 operative failures occurred among 7 patients with clinically “insignificant” preoperative aortic regurgitation as the only complicating lesion. Operation in this group either did not relieve the stenosis or increased the regurgitation in proportion to the relief of stenosis so that measurable benefit was not observed. 8. 8. The meaning of the term “insignificant” as it pertains to pure aortic regurgitation and to regurgitation associated with severe aortic stenosis is discussed. 9. 9. Indications and contraindications for surgery for aortic stenosis are discussed.