Aortic Valve Preservation Research Articles

Traitement chirurgical des dissections aiguës de l'aorte ascendante (20 ans d'expérience)

Purpose In 1977, the use of gelatine-resorcine-formaline (GRF) biological glue during surgery of acute type A aortic dissection was proposed. The present study retrospectively analyses the late results obtained with this adjunct in an experience extending over a 20-year period. Patients and methods From January 1977 to July 1997, 193 patients (139 males and 54 females) aged from 15 to 79 years (mean age: 53 ± 14 years) underwent an emergency operation for type A aortic dissection in our institution. All patients suffering from acute type A dissection and 162 (84%) were operated on within 48 hours after the onset of symptoms. Twenty-eight patients (15.2%) had Marfan's syndrome. In all patients the ascending aorta was replaced and the aortic stumps were reinforced with the GRF glue. In 43 patients (22.2%), the aortic valve was replaced either independently (5 cases — 2.5%) or by means of a composite graft (35 cases −19.5%). Recently three patients underwent a complete replacement of the ascending aorta and coronary reimplantation with preservation of the native aortic valve. Because of the location of the intimal tear, the aortic replacement was extended to the transverse arch in 58 patients (30%). Results Hospital mortality amounted to 21% (40 patients) (22.8% in patients with arch replacement and 20.3% in patients without arch replacement) (ns). The survivors were surveyed from 2 months to 20 years post-operatively (cumulative follow-up: 856 pt/years, mean follow-up: 85 ± 66 months). During this period of time, 23 patients (15%) had to be reoperated on for a total of 29 procedures. Six of those patients (26%) died at reoperation. At univariate analysis, presence of Marfan's syndrome ( P < 0.05) and absence of arch replacement ( P < 0.02) were determinant risk factors for reoperation. Emergency ( P < 0.01) and thoraco-abdominal replacement ( P< 0.04) were determinant risk-factors of death at reoperation. The actuarial freedom from reoperation (Kaplan-Meier, Cl: 95%) was: 96.5% (90.9–98.2), 87.6% (79.8–92.7), 80.9% (70.8–88.1), 66.4% (51.1–78.9) at one, 5, 10 and 15 years, respectively. A total of 36 patients (27.7%) died during follow-up. Presence of Marfan's syndrome ( P < 0.01), reoperation ( P < 0.02), stroke ( P < 0.05), cardiac failure ( P < 0.05) were determinant risk factors of late mortality. The actuarial late survival rate (Kaplan-Meier. Cl: 95%), including hospital mortality, was: 71.5% (64.3–77.8), 66% (58.3–73), 56.4% (47.7–64.7), 46.3% (36.4–56.5) at one, 5,10 and 15 years. Conclusion The GRF glue has proved to be extremely useful during initial emergency surgery for acute type A dissection, making the procedure much easier and safer. Through this operative improvement, the use of the GRF glue seems to have a beneficial influence on the late results which, however, depend mainly on the patient's basic condition.

Modified Konno-Rastan Procedure for Subaortic Stenosis: Indications, Operative Techniques, and Results

Background. Diffuse or unresectable subaortic stenosis (SAS) necessitates an aggressive surgical approach for the elimination of left ventricular outflow tract obstruction. In this article we report our experience with the modified Konno-Rastan procedure, with inherent preservation of the native aortic valve and annulus, in the treatment of diffuse or unresectable SAS. Methods. Sixteen children (age range, 21 months to 18 years) underwent the modified Konno-Rastan procedure through either a transventricular (n = 12) or a transatrial approach (n = 4) to the conal septum. Indications for operation were recurrent SAS (n = 3), hypertrophic obstructive cardiomyopathy (n = 3), tunnel stenosis (n = 2), SAS related to a canal (n = 3), and SAS after ventricular septal defect closure (n = 5). Eleven patients had undergone previous procedures and 5 underwent the modified Konno-Rastan procedure as their primary operation. Results. The mean preoperative left ventricular outflow tract gradient of 50 ± 17 mm Hg was reduced to 3 ± 7 mm Hg ( p < 0.001) after surgical repair. Postoperative complications included sternal infection ( n = 1), heart block ( n = 2), mediastinal bleeding ( n = 1), and renal and cerebral ischemia ( n = 1). There was 1 late postoperative death caused by pneumonia 2 years after operation (6.2% mortality rate). The mean follow-up period was 62 ± 39 months and all patients had complete relief of preoperative symptoms and were in New York Heart Association class I. One patient underwent a successful redo modified Konno-Rastan procedure 7 years after the first operation for residual left ventricular outflow tract obstruction immediately below the aortic valve. One patient is awaiting reoperation for aortic incompetence unrelated to conal enlargement 1.5 years after the first procedure. Conclusions. The modified Konno-Rastan procedure represents an excellent therapy for diffuse or unresectable SAS in patients with a normal aortic valve. In addition, it produces excellent results in a limited number of patients with hypertrophic obstructive cardiomyopathy, in whom the Morrow procedure traditionally has been performed. Although it usually is performed through a transventricular approach, the modified Konno-Rastan procedure also can be performed through a transatrial approach; this is particularly useful in patients who have had previous ventricular septal defect closure associated with SAS occurring proximal to the prosthetic patch.

AORTIC VALVE–PRESERVING PROCEDURE FOR ENLARGEMENT OF THE LEFT VENTRICULAR OUTFLOW TRACT AND MITRAL ANULUS

J Thorac Cardiovasc Surg 1998;115:1219-22

Preservation of the Native Aortic Valve in Children With Aortic Insufficiency

Preservation of the Native Aortic Valve in Children With Aortic Insufficiency

Preservation of the native aortic valve in children with aortic insufficiency

Preservation of the native aortic valve in children with aortic insufficiency

Remodeling the Aortic Root and Preservation of the Native Aortic Valve

Remodeling the Aortic Root and Preservation of the Native Aortic Valve

Technique of Aortic Valve Preservation in Acute Type A Aortic Dissection

Technique of Aortic Valve Preservation in Acute Type A Aortic Dissection

Aortic valve preservation in acute type a dissection: Is it sound?

A series of 200 consecutive patients with acute Stanford type A dissection (157 men, 78%; 43 women, 22%) was analyzed to assess the validity of aortic valve preservation or repair. Indication for the operation in most cases was based on echocardiographic examination alone, to reduce the delay. In the majority of patients (111/200, 56%) the aortic valve was preserved or repaired if necessary. Aortic root replacement with a composite graft was performed in 66 of 200 patients (33%), mainly because of an enlarged aortic anulus and sinus. Replacement of the aortic valve and the supracoronary ascending aorta was performed in 23 of 200 patients (12%) with a diseased aortic valve (e.g., bicuspid valve) but an acceptable aortic sinus. Follow-up totaled 656 patient-years (maximum 14 years). Actuarial analyses as a function of type of repair and type of aortic valve provided the following probabilities plus or minus errors (95%): overall survival of the 200 patients was 78.3% ± 2.9% after 30 days, 74.95% ± 3.1% after 1 year, 67.9% ± 3.6% after 5 years, and 48.5% ± 6.1% after 10 years. Actuarial probability of freedom from reoperation for valve failure in the complete series was calculated as 100.0% ± 0.0% after 30 days, 99.3% ± 0.7% after 1 year, 97.5% ± 1.5% after 5 years, and 95.1% ± 2.8% after 10 years. During long-term follow-up, there was no significant difference among groups with regard to structural deterioration, valve thrombosis, thromboembolic complications, anticoagulant-induced hemorrhage, and endocarditis. Freedom from valve failure and valve-related complications are similar for preserved, repaired, mechanical, and biologic valves. Valve-related reoperations are rare during at least 5 years of follow-up. Hence preservation or repair of the aortic valve can be recommended in the majority of patients with acute type A dissection. (J T HORAC C ARDIOVASC S URG 1996;111:381-91)

Early failure of aortic valve conservation in aortic root aneurysm

Early failure of aortic valve conservation in aortic root aneurysm

Radical aortic root enlargement in the infant and child.

Complex multilevel left ventricular outflow tract obstruction includes some of the more challenging problems in congenital cardiac reconstructive surgery. Preoperative studies must carefully delineate the level of obstruction that may be entirely below the aortic annulus (i.e., subaortic stenosis), at the level of the aortic annulus (i.e., aortic annular hypoplasia), may be related to valve leaflet obstruction due to rigid or fused valve leaflets (i.e., aortic valve stenosis), or may be at the level of the tips of the commissures of the aortic valve (i.e., supravalvar aortic stenosis). Frequently, variable contributions are present from all these potential levels of obstruction. An important underlying goal in planning surgical therapy should be preservation of the child's own aortic valve, whenever possible. Operative procedures should preserve growth potential and minimize the need for repeat surgical procedures. A number of surgical options that incorporate these goals will be described.

Long-Term Fate of the Aortic Root and Aortic Valve After Ascending Aneurysm Surgery

The authors determined in which patients tube graft replacement could be used. Tube graft replacement of ascending aortic aneurysms requires no coronary anastomoses and preserves the native aortic valve, but aortic insufficiency or aortic root aneurysms may develop requiring reoperation. Use of Bentall or Cabrol composite valve graft procedures obviates these problems but requires prosthetic valve replacement and coronary reattachment, both of which are associated with complications. These two procedures have been applied increasingly but because of renewed interest in aortic valve preservation and reconstruction, the authors determined in which patients tube replacement could be used. The authors analyzed the fate of 277 patients, mean age 49 +/- 14 years, operated on between 1953 and 1992 by techniques that preserved the aortic root. The most common pathology was atherosclerosis in 104 patients. Perioperative mortality since 1975 was 14%. Fifteen patients required reoperation on the ascending aorta or aortic root; ascending aneurysm reoperation (6 patients); aortic valve replacement (8 patients), and a combined procedure (1 patient). Of these 15 patients, 8 had Marfan's syndrome, 10 had dissections, and 5 had medial degeneration/necrosis. Simple tube graft replacement of the ascending aorta was a durable technique in patients without Marfan's syndrome or medial degeneration/necrosis and allowed preservation of the native aortic valve in many patients.

A insuficiência da valva aórtica na dissecção crônica da aorta proximal: troca ou reconstrução valvar?

Com o objetivo de avaliar os resultados clinicos e ecocardiograficos tardios obtidos com a correcao da insuficiencia aortica decorrente da disseccao cronica da aorta proximal, foram estudados 48 pacientes consecutivos operados entre janeiro de 1980 e dezembro de 1989, separados em 2 grupos de 24 pacientes cada. Grupo A - pacientes nos quais a valva aortica foi preservada pela resuspensao comissural; Grupo B - pacientes nos quais a valva aortica foi substituida. Na avaliacao ecocardiografica pre-operatoria, os pacientes do Grupo B apresentavam grau de insuficiencia aortica, diâmetros ventriculares (sistolico e diastolico) e da aorta ascendente significativamente maiores do que os do Grupo A (p=0,03), sendo comparaveis nos demais parâmetros. A mortalidade hospitalar foi 12,5% no Grupo A e de 4,17% no Grupo B e a sobrevida aos 7 anos, respectivamente, 75,75% ± 9,82% e 82,72% ± 7,87% (NS). A avaliacao clinica mostrou que, no pos-operatorio, houve melhora significativa (p<0,001) e semelhante dos parâmetros nos dois grupos. A comparacao ecocardiografica pre e pos-operatoria tardia mostrou, da mesma forma, reducao importante dos diâmetros sistolico e diastolico do ventriculo esquerdo e no diâmetro da aorta (p<0,05), mantendo-se inalteradas as fracoes de encurtamento e de ejecao ventriculares nos pacientes dos dois grupos. Nos pacientes do Grupo A, entretanto, houve persistencia de insuficiencia aortica residual (p=0,03). Os autores concluem que, com as duas tecnicas empregadas, o tratamento cirurgico da disseccao da aorta ascendente com insuficiencia aortica associada permite sobrevida imediata e tardia satisfatorias e nitida melhora funcional. Nos pacientes do Grupo A, a insuficiencia aortica residual detectada a ecocardiografia nao produziu sintomas ou repercussao hemodinâmica tardios e, desta forma, preconizam a preservacao da valva, sempre que tecnicamente possivel.

Diffuse subaortic stenosis: modified Konno procedures with aortic valve preservation

The Konno procedure provides adequate relief of diffuse subaortic stenosis but requires aortic valve replacement. This may be questionable in patients without aortic valve lesions. Eleven patients had diffuse subaortic stenosis and normal aortic orifice: tunnel subaortic stenosis (6 patients) or diffuse hypertrophic obstructive cardiomyopathy (5 patients). The mean age was 16 +/- 14 years (range: 3 months to 45 years). The mean subaortic gradient was 95 +/- 24 mmHg (range: 60 to 150 mmHg). Two patients had previously undergone resection of discrete subaortic stenosis. Modified Konno procedures were used: aortoseptal approach with aortic annulus division in 5 patients, conal enlargement without aortic annulus division in 6 patients. There was one early death (9%, 70% CL = 1%-27%) and no late deaths. Reoperation was required in two patients: one early for iatrogenic aortic regurgitation and one late for residual ventricular septal defect and mitral regurgitation. The mean follow-up was 3.8 +/- 4.2 years (range: 2 months to 10 years). The survivors were in functional class I (8/10), had a normal left ventricular function (9/10), were in sinus rhythm (10/10) and had left ventricular outflow tract gradients ranging up to 25 mmHg (mean = 6 +/- 10 mmHg). Residual surgery-related defects included ventricular septal defect (one) and aortic regurgitation (one). In patients with diffuse subaortic stenosis and normal aortic orifice, modified Konno procedures with aortic valve preservation are preferable, effective and can be safely performed in infants and children.

Surgical treatment of acute type A dissecting aneurysm, with preservation of the native aortic valve and use of biologic glue

We present an analysis of 59 patients operated on between 1983 and 1987 for acute type A dissecting aneurysm with aortic valve insufficiency. The ascending aorta was replaced with a Dacron tube, the layers of the dissection were unified with gelatin-resorcine-formaldehyde glue, and the natural aortic valve was preserved. Follow-up every 6 months was subject to actuarial analysis. The hospital mortality rate was 22%. The survivors were studied for 35.9 +/- 18.6 months (mean +/- standard deviation). Eight patients died (six of cardiovascular causes, one of cancer of the colon, and one of an unknown cause). Seventeen (36.9%) had aortic insufficiency, eight mild and nine moderate to severe. Four patients with severe insufficiency had reoperation with valve replacement. Excluding patients who have died or undergone reoperation, 29 of the remainder (90.6%) are free of symptoms. The follow-up survival rate is 61% +/- 6.93% (standard error) including hospital mortality. It is 55.4% +/- 7% (standard error) excluding reoperation and 44.2% +/- 7.1% (standard error) additionally excluding modest or severe aortic insufficiency. The use of gelatin-resorcine-formal glue allowed preservation of the native aortic valve, obviating the need for anticoagulants, and no embolic or hemorrhagic episodes were registered.

Conal enlargement for diffuse subaortic stenosis

Twelve patients underwent conal enlargement for diffuse subaortic stenosis over a 3 1/2-year period. The subaortic stenosis was due to tunnel outflow in 11 and malattached mitral valve in one. Mean age was 4.4 +/- 4 years and mean subaortic gradient was 50 +/- 21 mm Hg. Three infants had a malalignment ventricular septal defect. In eight patients significant obstruction occurred 2 to 7 years (mean 4 +/- 2) after simple resection of subaortic stenosis (n = 2), ventricular septal defect closure (n = 2), ventricular septal defect closure and subaortic stenosis resection (n = 2), and canal repair (n = 2). In three infants the tunnel outflow distal to a malalignment ventricular septal defect was enlarged and closed with the defect. In three patients with subaortic stenosis proximal to a previously repaired ventricular septal defect, transatrial conal enlargement through the ventricular septal defect was performed. Another patient without a ventricular septal defect had transatrial conal enlargement. The remaining five patients had the modified Konno procedure. Two patients had postoperative complete heart block and one infant had insertion of an apicoaortic conduit for aortic anulus hypoplasia 9 months later. One patient died of pneumonia during the follow-up period. Postoperative echographic outflow gradients up to 3 1/2 years (mean 1.2 +/- 1) ranged up to 25 mm Hg (mean 7 +/- 11) and were mainly at the aortic level. The 11 surviving patients are doing well up to 3 1/2 years of follow-up (mean 1.5 +/- 1). We conclude that conal enlargement procedures with aortic valve preservation are preferable, effective, and can be safely performed for diffuse subaortic stenosis in infants and children.

Tratamento cirúrgico da ectasia ânulo-aórtica com interposição de tubo sintético e conservação da valva aórtica

A ectasia ânulo-aórtica é lesão cujo tratamento preferencial compreende a substiuição da aorta ascendente dilatada por tubo sintético, acompanhada da substituição da valva aórtica. Essa substituição geralmente ocorre pela disfunção da valva graças à dilatação do anel e a prótese empregada nesses casos e, preferencialmente, mecânica. Dentre os vários autores empenhados na resolução dessa lesão, Cabrol vem contribuindo com inovações nesse campo. Os autores relatam sua experiência de dois pacientes do sexo masculino (34 e 62 anos), operados para correção de ectasia ânulo-aórtica, sendo o primeiro portador de síndrome de Marfan e dissecção aórtica crônica associada. A técnica cirúrgica empregada constou da substituição da aorta ascendente por tubo de "Dacron double velour". A valva aórtica foi preservada realizando-se, inicialmente, a ressecção das paredes aórticas comprometidas dos seios de Valsalva. O tubo de Dacron era implantado externamente à valva, sendo suturado abaixo do plano da valva com suspensão da valva aórtica no interior do tubo. Os ósticos coronarianos foram reimplantados no tubo, de maneira habitual. Os dois pacientes apresentaram boa evolução pós-operatória, encontrando-se assintomáticos após 45 e 120 dias de pós-operatório. Esta técnica vem se somar às outras para tratamento dessas doenças, devendo-se enfatizar a conservação da valva aórtica.

Preservation of aortic valve in type A aortic dissection complicated by aortic regurgitation

Two hundred fifty-two patients underwent operation for type A aortic dissection at Stanford University Medical Center from 1963 to 1987 and Duke University Medical Center from 1975 to 1988. Sixty-seven percent had an acute type A dissection and 33% had a chronic type A dissection. In addition to repair or replacement of the ascending aorta, 121 patients (48%) required an aortic valve procedure. Valve resuspension was performed in 46 (39 acute type A and 7 chronic type A), with an operative mortality rate of 13% +/- 5% (+/- 70% confidence limits), and aortic valve replacement in 75 (36 acute type A and 39 chronic type A), with an operative mortality rate of 20% +/- 5% (p = not significant versus resuspension). The operative mortality rate for patients requiring only repair or replacement of the ascending aorta was 32% +/- 4%. Indications for valve replacement included coexistent (nonacute) aortic valve disease, Marfan's syndrome, annuloaortic ectasia, and cases in which successful resuspension could not be accomplished. The overall actuarial survival rate for all patients was 59% +/- 3% (+/- 1 standard error of the mean), 40% +/- 4%, and 25% +/- 5% at 5, 10, and 15 years, respectively. Survival rates at these same times for patients with valve resuspension were 67% +/- 8%, 52% +/- 10%, and 26% +/- 19%, respectively; for patients who required aortic valve replacement, these survival rates were 70% +/- 5%, 39% +/- 8%, and 21% +/- 11%; finally, patients who received only an ascending aortic procedure had survival probabilities of 51% +/- 5%, 37% +/- 6%, and 23% +/- 6% (p = not significant versus resuspension versus aortic valve replacement). Multivariate analysis showed advanced age (p less than 0.001), previous cardiac or aortic operation (p less than 0.001), more preoperative dissection complications (p = 0.002), and earlier operative date (p = 0.038) to be the only significant, independent factors that increased the likelihood of early or late death. The type of aortic valve procedure (resuspension versus aortic valve replacement versus none) was not a significant predictor of mortality. Two of 46 patients with valve resuspension required late aortic valve replacement (freedom from aortic valve replacement: 100% and 80% +/- 13% at 5 and 10 years, respectively), as did 4 of 75 patients with initial aortic valve replacement (freedom from repeat aortic valve replacement: 98% +/- 2% and 73% +/- 13%, respectively).(ABSTRACT TRUNCATED AT 400 WORDS)

Late Results of Operation for Acute Aortic Dissection Producing Aortic Insufficiency

Since July, 1970, 8 patients with acute dissecting aneurysms of the ascending aorta producing aortic insufficiency have undergone immediate operation employing a technique in which the origin of the dissection is resected, the dissected base of the aorta is lined with nondistensible prosthetic cloth for support, and the native aortic valve is resuspended. Aortic continuity is then reestablished with end-to-end anastomosis or use of a short segment of woven graft (not necessarily circumferential). There were no operative deaths. Mean follow-up has been 60 months (range, 25 to 82 months). One late death has occurred (cerebral hemorrage at 48 months); of the remaining 7 patients, 2 have faint murmurs of aortic insufficiency, but all are in New York Heart Association Functional Class I. This technique of aortic reconstruction in acute ascending dissections allows preservation of the native aortic valve while preventing late aortic root dilatation or major valve insufficiency.

Reconstruction of the aortic valve. Correcting valve incompetence due to acute dissecting aneurysm.

A technique for reconstruction of the aortic base in persons with acute dissecting aneurysms of the proximal aorta involves insertion of a prosthetic cloth buttress into the dissection of the aortic base; this allows reconstruction of the aorta with preservation of the native aortic valve and offers protection against dilatation in the late postoperative period. Three patients operated on by this technique have been observed from 6 to 22 months after surgery with no evidence of aortic dilatation or significant aortic valvular insufficiency.

A simple method of aortic homograft valve sterilization and preservation

A simple method of aortic homograft valve sterilization and preservation