Presence Of Aortic Regurgitation Research Articles

Laubry-PEZZI Syndrome Surgical Repair in Adult: A Case Report

The presence of aortic regurgitation (AR) in the setting of the ventricular septal defect (VSD) has always been a management challenge. A 21-year-old male patient presented to the Cardiovascular surgery department with a restrictive perimembranous VSD with severe aortic regurgitation (AR). VSD was first diagnosed at 3 years of age. The surgical correction was decided when he was symptomatic of severe aortic regurgitation. Trans-aortic approach was performed to close the ventricular septal defect and correct the aortic regurgitation simultaneously. Surgical management was followed by a complete heart block.

Abstract 12766: Assessing the Economic and Clinical Impact of Surgical Aortic Valve Replacement on Patients With Symptomatic Aortic Valve Regurgitation

Hypothesis: The purpose of this study was to estimate the differences in mortality, healthcare utilization, and annualized cost among patients with symptomatic aortic regurgitation (sAR) who underwent surgical valve replacement (SAVR) compared with those that were managed non-operatively within 12 months of their diagnosis. Methods: Using the Optum® United Health Care Database, we identified 132,317 patients from 2016 to 2021 with a diagnosis of clinically symptomatic aortic regurgitation (sAR) who had a minimum of 6 months of continuous enrollment prior to sAR and at least 12 months of continuous enrollment following sAR and no record of aortic stenosis or transcatheter aortic valve replacement. sAR was defined as ≥ 2 visits for either heart failure, angina, dyspnea, or syncope in the presence of aortic regurgitation. Outcomes were all-cause mortality, healthcare utilization, and annualized cost. Inverse propensity score weighting (IPW) was employed to adjust for baseline differences and included patient demographics and comorbidities measured by the Elixhauser Comorbidity Index. Cox proportional hazards were used to model survival and general linear models were estimated for annualized healthcare utilization and total costs. Results: Among 132,317 patients identified with sAR, only 400 (0.3%) underwent SAVR within the first 12 months of their sAR diagnosis. They were younger on average 65 vs. 75 years (p<0.0001), more often male (71 vs 48%, p<0.0001), and had a slightly higher Comorbidity Index (5.1 vs. 4.8, p=0.0527). After IPW, sAR patients who had SAVR had lower mortality (HR 0.384; 95% CI 0.375-0.394; P<.0001), estimated annualized inpatient visits (0.33 versus 0.43; P=0.0039) and emergency department visits (0.54 versus 0.70; P=0.0002), hospital days (2.70 versus 3.14; P<.0001), and annualized cost ($33,744 versus $41,399; P<.0001). Conclusion: In this retrospective study, SAVR performed within 12 months of the diagnosis of symptomatic aortic regurgitation is associated with improved mortality and lower annualized healthcare utilization and costs. The clinical and economic benefits related to timely surgical management of aortic regurgitation should be considered when managing patients with symptomatic aortic regurgitation.

The impact of aortic valve regurgitation on the combination therapy of VA-ECMO and Imeplla support in severe cardiogenic shock: a simulation study

Background: The utilization of a combination of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) and Impella, ECPELLA, has become widespread among patients with cardiogenic shock. The utilization of VA-ECMO in the presence of aortic regurgitation (AR) can result in significant left ventricular (LV) distention. Additionally, the implantation of Impella via the aortic valve frequently induces AR clinically. We established a simulation model and evaluated the impact of AR on hemodynamics under ECPELLA. Furthermore, assuming that the reverse flow of AR is strongly determined by aortic pressure (AP) level, we simulated a scenario where AP was further decreased. Methods: We employed Simulink® (Mathworks, Inc.). The systemic and pulmonary circulations were modeled using a 5-element resistance-capacitance network. Four cardiac chambers were represented by time-varying elastance. We compared the aortic regurgitant flow (Far), total systemic flow (Ftotal), and LV pressure-volume relationship under various severities of AR and varying Impella (0-3.7 L/min) and VA-ECMO (0-5 L/min) flows. AR grades were adjusted by the regurgitant resistance and classified as mild, moderate, and severe, mimicking a clinical scenario. Results: Without AR, ECMO significantly increased Ftotal and raised LV end-diastolic pressure (LVEDP). Impella increased Ftotal and decreased LVEDP. The concomitant presence of AR exacerbated the increase of LVEDP by ECMO and the reduction of LVEDP by Impella. Under ECPELLA support (VA-ECMO: 3 L/min) with mild AR, the increase of Impella support (1 to 3.5 L) increased Ftotal and Far, while decreasing LVEDP, indicating the prevention of AR-induced LV distention. Additionally, the presence of mild AR prevented the Impella-induced left ventricular suction that is commonly observed under ECPELLA support with high-flow VA-ECMO. In the case of moderate AR, while the hemodynamic trends were similar to those observed under mild AR, Impella was unable to prevent the increment of LVEDP to a critical level (< 20 mmHg). However, by decreasing AP through reducing resistance (e.g. vasodilators), both Far and LVEDP were dramatically reduced and Ftotal was increased under ECPELLA support. Conclusion: The concomitant presence of AR in ECPELLA condition increased LV load, while prevented LV suction. The use of vasodilator in ECPELLA with AR could attenuate AR, increase systemic perfusion, and reduce LV load. The optimal control of Impella and VA-ECMO flows and AP can maximize the hemodynamic and LV unloading impacts of ECPELLA. no funding This is the full abstract presented at the American Physiology Summit 2023 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Discrete Subaortic Stenosis in an Elderly Patient

Discrete subaortic stenosis is an uncommon condition in the elderly population. Echocardiographic examination can be useful for diagnosis with high accuracy. We present a case report of an elderly female patient who presented with accelerated hypertension and was subsequently diagnosed with discrete subaortic stenosis on transthoracic echocardiography. A significant, non-dynamic, left ventricular outflow tract pressure gradient in the presence of aortic regurgitation should raise the possibility of this condition in patients of geriatric age group.

Contemporary Ross procedure outcomes: medium- to long-term results in 214 patients.

Our goal was to present 2 decades of our experience with the Ross procedure and its sequential modifications, adopted since 2010, to improve the reoperation rate. We performed a single-centre, retrospective review of database information and medical notes about the implantation technique: the freestanding root. We compared era 1 (1997-2009) and era 2 (2010-2019). Between 1997 and 2019, a total of 214 Ross procedures were performed (71% men, median age 24 years) [interquartile range (IQR) 15-38]. Of these, 87% had various forms of congenital-dysplastic aortic valves. The median cross-clamping and bypass times were 173 (IQR 148-202) and 202 (IQR 182-244) min. The median postoperative stay was 6 days (2-77). Thirty-day mortality was 0.5%. The median follow-up time was 8.2 years (IQR 3.9-13.2). Survival at 10 and 20 years was 97% and 95%; freedom from greater than moderate aortic regurgitation or aortic valve intervention was 91% and 80%; and 93% of the patients were in New York Heart Association functional class I. Twenty (21%) patients operated on during era 1 and 6 (9%) during era 2 underwent autograft reoperations. The median follow-up time was 14.3 (IQR 11.5-17.4) and 4.8 (IQR 2.5-7) years. Freedom from autograft reoperation was 87% and 69% at 10 and 20 years, with no significant difference between eras. Freedom from homograft reoperation was 96% and 76% at 10 and 20 years. The presence of aortic regurgitation, infective endocarditis and era 1 were predictors of autograft reoperation. Male gender and era 1 were predictors of neoaortic root dilatation. The contemporary modified Ross procedure continues to deliver excellent results and should remain part of the strategy to treat children and young adults requiring aortic valve replacement.

Quantitative analysis of mitral annulus morphology in aortic stenosis using real time 3-dimentional transesophageal echocardiography

Abstract Background Normal mitral annulus morphology is known to be saddle shape. There are a few reports regarding the relationship between flattening of the mitral annular saddle shape and mitral regurgitation. However, the relationship between aortic stenosis (AS) and mitral annulus morphology is unknown. Purpose To assess the impact of AS on mitral annular saddle shape using 3-dimentional transesophageal echocardiography. Methods A total of consecutive 83 subjects including 44 patients with severe AS (AS group) and 39 patients without AS (control group), who underwent real-time 3-dimentional transesophageal echocardiography of the mitral valve, were enrolled. The 3-dimentional geometry of the mitral annulus apparatus was evaluated by the parameters analyzed using dedicated quantification software such as anteroposterior diameter (APD), commissural width (CW), annular height (AH), mitral annulus (MA) area and annular height to commissural width ratio (AHCWR) as shown in Figure. We assessed the impact of severe AS on AHCWR, which is the key parameter showing flattening of the mitral annular saddle shape. These parameters were adjusted by body surface area (BSA). Exclusion criteria included left ventricular ejection fraction <50%, the presence of aortic regurgitation, mitral valve disease, pericardial or congenital diseases, endocarditis, cardiomyopathy, prior myocardial infarction, and paroxysmal or persistent atrial fibrillation. Results Comparisons of mitral valve geometry between AS group and control group are summarized in Table. AH/BSA and AHCWR were significantly lower in AS group compared with control group. Multiple linear regression analysis revealed severe AS to be a significant and independent predictor of lowering AHCWR (β=−0.39, t=−4.04, p<0.001) (adjusted with MA area, selected by stepwise analysis). Conclusions Severe AS might contribute to flattening of the mitral annular saddle shape, lead to the mitral annular structural remodeling. Assessment of the mitral annulus morphology might help evaluating severe AS. Mitral annulus 3-dimensional geometry Funding Acknowledgement Type of funding source: None

Bicuspid Aortic Valve: In Search of Valve Dysfunction and Aortic Dilatation Determinants

Bicuspid aortic valve is a common congenital heart abnormality, with moderate familial aggregation (1:8), which develops, with high heterogeneity, valvular dysfunction and aortic dilatation. Complications such as significant valve dysfunction, endocarditis or aortic aneurysm are present in more than 50% of these subjects. Recent imaging studies have shown determinant factors of these complications. Bicuspid aortic valve with right coronary-non coronary cusp fusion has a higher risk of calcification, aortic stenosis and distal ascending aorta and aortic arch dilatation, while in the case of left-right coronary sigmoid fusion it dilates the proximal segment of the aorta, mainly in the presence of aortic regurgitation. Improvement in understanding the pathogenesis of valve degeneration and aortic dilatation will favour new drug therapies, reducing surgical treatment requirements.

Reversibility of Cardiac Function Predicts Outcome After Transcatheter Aortic Valve Replacement in Patients With Severe Aortic Stenosis.

BackgroundReversibility of left ventricular (LV) dysfunction in high‐risk aortic stenosis patient and its impact on survival after transcatheter aortic valve replacement (TAVR) are unclear. We aimed to evaluate longitudinal changes of LV structure and function after TAVR and their impact on survival.Methods and ResultsWe studied 209 patients with aortic stenosis who underwent TAVR from May 2006 to December 2012. Echocardiograms were used to calculate LV end‐diastolic volume index (LVEDVi), LV ejection fraction, LV mass index (LVMi), and global longitudinal strain before, immediately (<10 days), late (1–3 months), and yearly after TAVR. During a median follow‐up of 1345 days, 118 patients died, with 26 dying within 1 year. Global longitudinal strain, LVEDVi, LV ejection fraction, and LVMi improved during follow‐up. In patients who died during the first year, death was preceded by LVEDVi and LVMi increase. Multivariable longitudinal data analysis showed that aortic regurgitation at baseline, aortic regurgitation at 30 days, and initial LVEDVi were independent predictors of subsequent LVEDVi. In a joint analysis of longitudinal and survival data, baseline Society of Thoracic Surgeons score was predictive of survival, with no additive effect of longitudinal changes in LVEDVi, LVMi, global longitudinal strain, or LV ejection fraction. Presence of aortic regurgitation at 1 month after TAVR was the only predictor of 1‐year survival.Conclusions LV reverse remodeling was observed after TAVR, whereas lack of LVEDVi and LVMi improvement was observed in patients who died during the first year after TAVR. Post‐TAVR, aortic regurgitation blocks reverse remodeling and is associated with poor 1‐year survival after TAVR.

Dilatation of the ascending aorta is associated with presence of aortic regurgitation in patients after repair of tetralogy of Fallot

To evaluate the association between aortic morphology and elasticity with aortic regurgitation in surgically corrected of tetralogy of Fallot (TOF) patients. We retrospectively identified 72 consecutive patients with surgically corrected TOF and 27 healthy controls who underwent cardiac MRI evaluation. Velocity-encoded cine MRI was used to quantify degree of aortic regurgitation (AR) in TOF patients. Ascending aorta diameters were measured at standard levels on MRA images. Aortic pulse-wave velocity (PWV) was quantified with MRI. Morphological and functional MRI variables were compared between groups of TOF patients with and without clinically relevant AR and controls. The association between aortic morphology and elasticity with the presence of AR was evaluated using univariate and multivariate logistic regression. The majority of TOF patients had only trace AR. Nine TOF patients (12 %) had an AR fraction higher than 15 %. Indexed aorta diameter at the sinotubular junction (p = 0.007), at the RPA level (p = 0.006), and low left ventricular ejection fraction (LVEF) (p = 0.015) showed the strongest associations with the presence of at least mild AR, which persisted after controlling for age and gender. Increased ascending aorta dimension is associated with AR in patients after repair of TOF. LVEF was also low in the group of patients with relevant AR compared to those without, suggesting even mild to moderate AR may contribute to LV dysfunction in these patients. Enlarged ascending aorta may be an indication for precise quantification of regurgitant fraction with MRI, since symptomatic patients may need aortic valve repair when moderate regurgitation is present.

Rheumatic fever recurrence: Risk factors and clinical characteristics

BackgroundRheumatic fever recurrence (RFrec) contributes to the worsening of rheumatic valve disease. There are few studies describing the factors associated with recurrence. ObjectivesTo analyze the potential risk factors for RFrec in an outpatient cohort. MethodsWe evaluated 148 patients from a cohort of 218 patients treated at rheumatic fever (RF) clinics of the University Hospital Prof. Edgard Santos (Salvador-BA), with at least two years of follow-up. ResultsThe mean age was 29.7±12.7years, with 64% female. RFrec occurred in 14.2% of patients. Patients with and without recurrence differed in age (23.4±9.9×30.8±12.7years, p=0.024), age≤23years (82.3% vs 39.6%, p=0.001), non-adherence to prophylaxis (36.8% vs 15.5%, p=0.027), prior heart failure (HF) (38% vs. 17%, p=0.03), presence of aortic regurgitation on echocardiography (71% vs. 44%, p=0.05) and diastolic dimension of the left ventricle (58.0±16.2×51.6±8.6mm, p=0.025). Estimated relative risk of RFrec were: age≤23years RR 5.6 (95% CI 1.7 to 18.5) — p=0.001; non-adherence to prophylaxis RR 2.6 (95% CI 1.1 to 5.9) — p=0.027; prior HF RR 2.4 (95% CI 1.1 to 5.2) — p=0.03. In multivariate analysis, these three parameters showed significant independent association with RFrec. ConclusionsRFrec occurred in 14.2% of patients. Age≤23years, lack of adherence to secondary prophylaxis and prior HF were independent predictors of recurrence.

Common Complication in an Uncommon Disease: Presence of Aortic Regurgitation in Patient with Quadricuspid Aortic Valve

Background: Congenital heart defect exists from birth but is usually detected in a later stage of life, as in case of quadricuspid aortic valve. A great majority of quadricuspid aortic valves do not have a normal function and often necessitate surgical treatment. Aim: To report a case with quadricuspid aortic valve accompanied with complications. Case Presentation: We present a case of a male detected with quadricuspid aortic valve of four equal sized cusps accompanied by abnormalities, yet managed successfully under conservative treatment. Conclusion: Patients with a quadricuspid aortic valve require careful clinical evaluation and close follow up.

Aortic Regurgitation Is Common in Ankylosing Spondylitis: Time for Routine Echocardiography Evaluation?

ObjectivesThe aim of this study was to assess the prevalence of aortic regurgitation and any relation to disease activity and specific human leukocyte antigen (HLA)-B27 subtypes in patients with ankylosing spondylitis. MethodsTransthoracic echocardiography was performed in 187 patients (105 men), mean age (SD) 50 (13) years, and mean disease duration 24 (13) years, and was related to demographic, clinical, radiographic, electrocardiographic, and laboratory data. ResultsAortic regurgitation was found in 34 patients (18%; 95% confidence interval [CI], 12%-24%): mild in 24, moderate in 9, and severe in one. The prevalence was significantly higher than expected from population data. Conduction system abnormalities were documented in 25 patients (13%; 95% CI, 8%-18%), and significantly more likely in the presence of aortic regurgitation (P = .005), which was related to increasing age and longstanding disease, and increased from ∼20% in the 50s to 55% in the 70s. It was also independently associated with disease duration, with higher modified Stoke Ankylosing Spondylitis Spine Score, and with a history of anterior uveitis. HLA-B27 was present in similar proportions in the presence vs absence of aortic regurgitation. For comparison, clinically significant coronary artery disease was present in 9 patients (5%; 95% CI, 2%-8%). ConclusionPatients with ankylosing spondylitis frequently have cardiac abnormalities, but they more often consist of disease-related aortic regurgitation or conduction system abnormalities than manifestations of atherosclerotic heart disease. Because aortic regurgitation or conduction abnormalities might cause insidious symptoms not easily interpreted as of cardiac origin, we suggest that both electrocardiography and echocardiography evaluation should be part of the routine management of patients with ankylosing spondylitis.

Abstract 155: Long-term Aortic Root Dilation in Kawasaki Disease with Coronary Aneurysm

Introduction: Aortic root dilation is a known finding in the acute/subacute phase of Kawasaki disease (KD). These changes may be inflammatory and related to the degree of coronary artery (CA) dilation, and may lag when compared to CA changes. Long-term changes in the aorta have not been previously reported. Methods: A retrospective review of patients with KD from our institution was conducted, identifying individuals with American Heart Association (AHA) Risk Level 3, 4 or 5 over a 20 year period (1994-2014). Aortic annular and root dimensions were measured at the most recent echocardiogram and converted to z-score measurements. When possible, ascending aorta dimensions were measured, and all studies were evaluated for the presence of aortic regurgitation. Time from KD diagnosis to the last echocardiogram was determined. Patients with disease processes predisposing to aortic dilation were excluded, as were those with duration of echocardiographic follow-up &lt;1 year. Results: Fifty-three patients were identified, with a median age at diagnosis of 29 months (SD 42, 1.2-162 months). Twenty-seven (51%) were AHA Risk Level 3, 20 (38%) Risk Level 4 and 6 (11%) Risk Level 5. The mean time from diagnosis to latest echocardiogram was 7.3 years (1.4-17.3 years). Aortic annular and root dimensions were obtained in all patients (mean aortic annular z-score -0.06, mean aortic root z-score 0.67). Four patients (8%) had a dilated (z-score &gt;2) aortic root, one also had a dilated annulus. Ten patients (19%) had borderline root dilation (z-score &gt;1.5). Ascending aorta dimension measurements were possible in 72% (38/53) of the cohort, of which only 1 (3%) had a z-score &gt;2 and 3 (8%) had a z-score &gt;1.5. Importantly, no patients demonstrated aortic regurgitation. Conclusion: In patients with history of KD and significant coronary artery involvement, borderline/mild dilation of the aortic root is not uncommon at intermediate to long- term follow-up, suggesting the possibility of a higher degree of aortic involvement in the acute and subacute phase of the disease process. The ascending aorta appears to be less affected and there was no evidence of functional derangements of the aortic valve. Accurate measurement of the aortic root dimension at all stages of KD is warranted.

Paediatric subvalvular aortic stenosis: a systematic review and meta-analysis of natural history and surgical outcome.

Sub-valvular aortic stenosis (SAS) is a common form of left ventricular outflow tract (LVOT) obstruction, which can lead to aortic valve damage. Although surgery for SAS is an accepted treatment, the timing of surgical intervention of SAS remains controversial. This review aims to establish an overview of the natural history and outcome after surgery and factors associated with prognosis in paediatric SAS patients. We searched PubMed and EMBASE for studies that reported factors that negatively affected the prognosis of patients with SAS. Studies were included if they were written in English, published between 1 January 1997 and 31 December 2012 and the mean patient age was <18 years at the time of study entry. Studies were excluded if the study size was <20 patients. A distinction was made between natural history and surgical cohorts. Twenty-four studies were included in this review, encompassing a total of 809 natural history and 1476 surgical patients. Fifty-one percent of natural history patients required surgery. After surgery, there was a substantial reoperation rate. Higher LVOT gradient and the presence of aortic regurgitation (AR) were identified as the foremost independent predictors of a worse outcome. Valve-to-membrane distance was also found to be associated with prognosis, although the results were contradictory. This systematic review underlines the importance of LVOT gradient, aortic valve-to-membrane distance and AR in surgical decision-making in paediatric SAS patients. There is need for collaborative effort to further study the optimal timing of surgery based on LVOT gradient, valve-to-membrane distance and the presence of AR.

TCT-691 Clinical Impact of the Presence of Aortic Regurgitation Following Transcatheter Aortic Valve Replacement:Insights into the Degree and Acuteness of Presentation

TCT-691 Clinical Impact of the Presence of Aortic Regurgitation Following Transcatheter Aortic Valve Replacement:Insights into the Degree and Acuteness of Presentation

Effect of isometric exercise on aortic regurgitation assessed by cardiovascular magnetic resonance

Purpose: Although the presence of aortic regurgitation (AR) may be a handicap for sport practice, the effect of isometric exercice (IE) on AR and ventricular function jointly has not been assessed previously. Cardiovascular magnetic resonance (CMR) may be useful on this purpose. Methods: We studied 20 asymptomatic patients with moderate or severe AR in the echocardiogram. We performed a CMR at rest and during the practice of a maximal IE (weight elevation with both legs). We analyzed changes in left and right ventricular function (by means of cineMR sequences) and in AR flow (by means of phase-constrast sequences). Results: During IE we noticed an increase in heart rate, systolic blood pressure and cardiac output. We observed a decrease in end-diastolic and end-systolic volume in both ventricles, without significant changes in ejection fraction. Flow analysis of ascending aorta showed a decrease in left ventricular stroke volume, whereas regurgitant volume and regurgitant fraction did not change significantly (Table 1). View this table: Table 1 Conclusions: In patients affected of AR, IE did not produce a left ventricle volume overload. CMR is useful for the evaluation of haemodynamic repercussion of IE.

Stentless bioprosthesis for treatment of traumatic aortic valve rupture

Aortic valve rupture after blunt trauma to the chest is an infrequent complication that should be considered at the outset in examination of an accident victim. The presence of aortic regurgitation with hemodynamic instability is an indication for surgery. We implanted a stentless bioprosthesis after aortic valve rupture due to chest trauma in a 31-year-old man with schizophrenia.

Sizing the annulus for transcatheter aortic valve implantation: more than a simple measure?

Accurate preoperative assessment of the aortic annulus dimension is crucial for the success of transcatheter aortic valve implantation (TAVI). All the available imaging modalities, however, have some weak points, and the ‘gold standard’ to be used is still under debate. In this context, the recent work by Dr Blanke and coworkers is a commendable attempt to develop a standardized, easy to reproduce method for the identification and measurement of the aortic annulus [1, 2]. A very interesting finding of this study is the close correlation found between the preoperative cross-sectional area (CSA) of the virtual ring passing through the nadir of the three aortic cusps and the postoperative CSA. This observation would suggest that preoperative determination of the CSA could help in predicting the final form and size of the aortic annulus in most TAVI patients [1]. However, the behaviour of the aortic root and aortic annulus is not always predictable based on the preoperative exams [3]. This is partly due to intrinsic anatomic properties of the aortic root—the ‘virtual ring’ is largely inhomogeneous, coursing through the muscular septum, the membranous septum and the mitro-aortic curtain. Moreover, leaflet and annular calcifications are often asymmetrical, adding further complexity to any attempt to predict the final shape of the prosthetic valve, the displacement of the native calcified leaflets and the sealing of the annulus around the prosthesis. A very good exemplification of this problem is given by the bicuspid aortic valve, which is usually ovoidal and heavily calcified, and may fail to adapt to the circular transcatheter valve [4]. For this reason, we have developed a simple method to analyse the reaction of the aortic root to the balloon inflation, and to obtain a dynamic measure of the CSA. In the uncertain cases (‘borderline’ annulus, important discrepancy between TEE and CT measurements, massive and/or eccentric calcifications), we proceed to a ‘calibrated’ balloon valvuloplasty. A conventional valvuloplasty balloon (Cristal Balloon, Balt, Montmorency, France) is inflated with a diluted contrast agent through a threeway stopcock. When the waist generated on the balloon profile by the aortic annulus is stretched, the stopcock is closed and an aortography is performed to exclude the presence of aortic regurgitation. The amount of contrast agent used to inflate the balloon is carefully recorded, and the balloon is deflated and withdrawn. On the bench, the balloon is inflated again to the same volume, and is then sized with a sizing plate (Amplatzer sizing plate, AGA Medical Italia, Milan, Italy). This simple manoeuvre allows us to accurately measure the aortic annulus, to estimate the risk of postoperative paraprosthetic leakage and to check the relationships between the dislocated aortic valve leaflets and the coronary arteries ostia. In our experience, this procedure has led to a change in the size of the percutaneous prosthesis in three patients, and to the conversion to transapical approach in two patients needing a 29 mm prosthesis. In conclusion, we believe that the CT protocol described by Blanke could greatly enhance our ability to evaluate the anatomy of the aortic root preoperatively. In doubtful cases, however, calibrated balloon valvuloplasty could add fundamental dynamic information, allowing us to ‘feel’ the aortic annulus while measuring it [3].

Resternotomy Using Hypothermic Arrest

Resternotomy during closed chest cardiopulmonary bypass in hypothermia with or without circulatory arrest has been the preferred method for cardiac reoperations with adherent structures to the sternum. Here, we report our experience with this method and the effects of omitting ventricular decompression during the cooling procedure. Twenty reoperations were performed in 19 patients. In half (n = 10) of the procedures aortic regurgitation was present. Cardiopulmonary bypass was instituted in all patients before resternotomy, and the re-entry into the chest was performed either under hypothermic low-flow cardiopulmonary bypass or circulatory arrest. The reason for this choice of technique was adherent structures to the sternum posing a substantial risk for rupture during resternotomy in all patients. Rupture upon re-entry into the chest occurred in five operations. No patient died due to re-entry injury. The overall hospital mortality was 15%. No differences in postoperative outcomes including heart failure, biochemical markers indicating myocardial damage, and three-month follow-up assessment of cardiac function were found between patients with aortic regurgitation and patients without aortic regurgitation. Based on our experience, omitting ventricular decompression in resternotomy in hypothermia and arrested circulation or low-flow cardiopulmonary bypass can be safely used, and the presence of aortic regurgitation does not seem to influence the outcome.

Surgery for subvalvar aortic stenosis - resection of discrete subvalvar aortic membrane

Discrete subvalvar aortic membrane is characterized by a fibromuscular shelf located at the area of aortomitral continuity with the extension toward the interventricular septum. As compared to other congenital heart defects, discrete subvalvar aortic membrane is virtually never recognized in early infancy, but appears to be an 'acquired' lesion, typically seen in patients with a more acute angle between the long axis of the left ventricle and the aorta. This angulation leads to imbalance in shear forces, which causes the proliferation of tissue that forms the membrane. The surgical intervention is considered when the gradient across the left ventricular outflow tract is 30mmHg or more. Surgery is also advocated in infants and children in the presence of aortic regurgitation even when there is no significant gradient. The circumferential excision of the fibrous ridge with septal myectomy is safe and provides efficient relief of obstruction. Aggressive resection of all structures causing flow turbulence and removal of pathological tissue from the valve leaflets might prevent development or progression of aortic regurgitation and might eliminate the substrate for recurrent obstruction. Nevertheless, recurrence still remains a problem, especially in the presence of a predisposing associated congenital heart defect.