Recurrent Aortic Regurgitation Research Articles

Valve repair improves the outcome of surgery for chronic severe aortic regurgitation: A propensity score analysis

For patients with aortic regurgitation (AR), aortic valve (AV) repair represents an attractive alternative to AV replacement (AVR), because it does not expose patients to the risk of prosthetic valve complications. Although the durability of AV repair has been documented, its prognosis has not yet been compared with prognosis of AVR. We performed a propensity score analysis to match patients who underwent surgical correction of severe AR by either AVR or AV repair between 1995 and 2012. After matching, 44 pairs of patients were compared regarding baseline characteristics; overall survival; operative survival; cardiac events, including reoperations; recurrent AR; and New York Heart Association functional class at final follow-up. Operative mortality was similar in the AV repair and AVR groups (2% vs 5%; P=.56). Kaplan-Meier survival analysis indicated a significantly better overall 9-year survival after AV repair than after AVR (87% vs 60%; P=.007). Cox proportional survival analysis demonstrated that the choice of treatment was an independent predictor of postoperative survival. Finally, AV repair resulted in a slight increase, albeit not statistically significant, in reoperation rate (8% vs 2%; log rank P=.35). AV repair significantly improves postoperative outcomes in patients with AR and whenever feasible should probably be the preferred mode of surgical correction.

Valve-sparing root replacement in children with aortic root aneurysm: mid-term results†

We aimed at evaluating the results of aortic valve-sparing root replacement (AVSRR) in children with aortic root aneurysm (ARA) due to genetic disorders in terms of mortality, reoperation and recurrent aortic valve regurgitation (AVR). Thirteen patients (mean age 9.7 ± 6.5 years, 10 months-18 years) underwent AVSRR for ARA between 2002 and 2011. Six of the 13 patients had Marfan syndrome, 3 Loeys-Dietz syndrome (LDS), 2 bicuspid aortic valve syndrome and 2 an unspecified connective tissue disorder. AVR was graded as none/trace, mild and severe in 5, 7 and 1 patient, respectively. The mean pre-operative root diameter was 45 ± 10 mm (mean Z-score 10.3 ± 2.0). Remodelling of the aortic root was performed in 4 patients, reimplantation of the aortic valve in 9 and a concomitant cusp repair in 4. The diameter of the prostheses used for root replacement varied from 22 to 30 mm (mean Z-score = 2.3 ± 3). The follow-up was 100% complete with a mean follow-up time of 3.7 years. There was no operative mortality. One patient with LDS died 2.5 years after the operation due to spontaneous rupture of the descending aorta. Root re-replacement with mechanical conduit was necessary in 1 patient for severe recurrent AVR 8 days after remodelling of the aortic root. At final follow-up, AVR was graded as none/trace and mild in all patients. Eleven patients presented in New York Heart Association functional Class I and 1 in Class II. In paediatric patients with ARA, valve-sparing root replacement can be performed with low operative risk and excellent mid-term valve durability. Hence, prosthetic valve-related morbidity may be avoided. Due to the large diameters of the aortic root and the ascending aorta, the size of the implanted root prostheses will not limit later growth of the native aorta.

The David Procedure in Different Valve Pathologies: A Single-Center Experience in 236 Patients

Reports of the long-term outcome after the David procedure in different valve pathologies are limited. We compared our results in patients with tricuspid and bicuspid aortic valves, including those who required additional cusp repair. Between 1997 and 2011, 236 patients (76% males; mean age, 56 ± 15; range, 12 to 79 years) underwent valve-sparing aortic root replacement (David procedure) for aortic regurgitation and were prospectively followed up clinically and echocardiographically. The follow-up was 94% complete. Cumulative follow-up time was 896 patient-years (mean follow-up time, 4.5 ± 2.7; range, 0.6 to 13.7 years). The 30-day mortality was 1.7% (4 of 236), and late mortality was 4% (10 of 232), with one cardiac-related death due to aortic valve regurgitation. Overall freedom from valve replacement was 94% and 87% at 5 and 10 years, respectively. In 201 patients with tricuspid aortic valves, freedom from reoperation was 94% and 90% at 5 and 10 years, respectively. This was comparable to the 53 patients with bicuspid aortic valves, with a freedom from reoperation of 97% at 5 years (p = 0.632). Forty-two patients (18%) required additional cusp repair and had a 100% freedom from reoperation at 5 years. Overall, 10 patients (4%) required reoperation, with a mean interval of 11.5 ± 10.7 months. Reasons for reoperation were recurrent aortic valve regurgitation grade II (n = 6), aortic stenosis (n = 2), endocarditis (n = 1), and a ruptured central plication (n = 1). The David procedure revealed excellent long-term outcomes independently from the valve morphology. Rates of reoperations and valve-related morbidity were acceptably low. Additional cusp repair was no predictor for failure of this procedure.

How to achieve an aortic root remodelling by performing an aortic root reimplantation

The aortic root remodelling procedure, introduced by Yacoub in the early 1980s, is the valve-sparing aortic root replacement procedure that better reproduces the anatomical and functional properties of the native aortic root. Long-term durability of the repair, in terms of freedom from recurrent aortic regurgitation, has been questioned and can probably be improved by appropriate patient selection. Reproducibility of the operation, however, depends on subjective evaluations and surgical skill. We report a simplification of the technique designed to possibly increase the reproducibility of the aortic root remodelling operation while retaining its functional advantages.

Causes and management of aortic valve regurgitation after aortic valve reimplantation

Recurrent aortic regurgitation can occur after valve-preserving aortic replacement. Little is known about the exact mechanisms of valve failure and the best reoperative strategies. We analyzed our experience with reoperation after aortic valve reimplantation. From November 1995 to August 2011, 13 patients (10 men; age, 18-58 years) underwent reoperation for valve failure after aortic valve reimplantation. The reason for reoperation was aortic regurgitation in 11 and endocarditis in 2 after 6 weeks to 13 years. The morphologic causes of regurgitation were cusp prolapse in 6, cusp retraction in 4, cusp perforation in 6, inadequate commissural height in 5, commissural dehiscence in 2, and inadequate valve configuration in 1, alone or combined. The patients were treated by valve replacement (n = 4) or cusp repair (n = 2). In 3 patients, composite replacement of the valve and root was necessary, in 1 with a pulmonary autograft. In 4 patients the aortic valve was spared. All patients were followed up regularly. No patient died early; 1 patient died 4 years after reoperation. One patient required reoperation 2 years after the cusp repair procedure. All patients with repeat valve-preserving root replacement had stable valve function postoperatively. The 5-year survival rate after reoperation was 86% ± 13%. The 5-year rate of freedom from valve-related complications was 78% ± 14%. Recurrent aortic regurgitation early after aortic valve reimplantation frequently involves cusp prolapse and a low commissural height; later, cusp retraction becomes more important. Reoperation within the first 6 postoperative months allows for preservation of the native aortic valve; however, beyond this period, valve replacement within the graft will mostly be required.

Fourth Recurrence of Aortic Annular Dehiscence Following AVR for Aortic Regurgitation

It is a report of an unusual case of recurrent periprosthetic aortic regurgitation which occurred four times in the same patient over a span of 26 years. After pre-operative stabilization, the patient was subjected to a fifth open heart surgery to replace the 4 th prosthetic aortic valve by an upsized 5 th prosthetic valve. Since endocarditis was excluded by repeated blood culture and paucity of vegetations, a working diagnosis of Behcet's disease was arrived upon. The fifth prosthetic aortic valve was implanted using a special suturing technique as described by Azumo, et al in 2009, which involves a sub-annular reinforcement by a Teflon ring. The patient was discharged after an uneventful recovery and is well on regular follow-up.

Factors Determining Outcomes of Aortic Valve Surgery in Patients with Aortic Regurgitation Due to Behçet's Disease: Impact of Preoperative Echocardiographic Features

Paravalvular leakage after open heart surgery is notoriously common in patients with aortic regurgitation (AR) due to Behçet's disease. The aim of this study was to test whether initial echocardiographic findings are useful to predict recurrent AR. Lesion severity on preoperative echocardiography was scored for redundant aortic valve cusp (0-2points), aortic pseudoaneurysm (0-2 points), and dissection of the adjacent interventricular septum (0-2 points) in 22 patients with severe AR due to Behçet's disease (13 men; mean age, 42.4 ± 11.5 years), which was confirmed by histologic examination after open heart surgery. Recurrent AR developed in 13 patients at a median of 12.6 months (range, 2.4-70.3 months) after the first operation, and 10, four, and one patient underwent second, third, and fourth surgery, respectively, to control recurrent AR; three patients died. Those patients with recurrent AR had a significantly higher incidence of repeat surgery or death (84.6% [11 of 13] vs 0%, P= .015). Multivariate analysis showed that perioperative immunotherapy (hazard ratio, 0.002; 95% confidence interval, 0.001-0.1761; P= .006) and total echocardiographic score (hazard ratio, 2.843; 95% confidence interval, 1.350-5.991; P= .006) were independent factors associated with recurrent AR. The 1-year, 3-year, and 5-year AR-free survival rates were 73 ± 10%, 46 ± 12%, and 39 ± 12%. The optimal cutoff value for total echocardiographic score was 3.0, and the 5-year AR-free survival rates were significantly lower in patients with scores ≥ 3 (20 ± 13% vs 50 ± 19%, P= .022). This retrospective study confirms that initial echocardiographic features can provide useful prognostic information in patients with AR due to Behçet's disease.

Are bicuspid aortic valves a limitation for aortic valve repair?

To compare the mid-term results after aortic valve (AV) repair in bicuspid AVs with those in tricuspid AVs. Between 2000 and 2010, 100 patients (mean age 47.2 years) underwent AV repair procedures for insufficient bicuspid AV (n=43) and tricuspid AV (n=57). Aortic regurgitation (AR) more than moderate was present in 31/43 and 21/57 patients in the bicuspid AV and the tricuspid AV group, respectively. Concomitant root replacement by either the reimplantation or the remodeling technique was performed in 42 patients (bicuspid AV 17/43, tricuspid AV 25/57). All patients were prospectively studied with postoperative and further annual clinical assessment and echocardiography. Follow-up was 99% complete with a mean follow-up time of 22 months. Three patients died during the initial hospitalization, all due to postoperative cardiac failure. Overall actuarial 3 years' survival was 93±4.2% without significant differences between the two groups. Overall actuarial 3 years' freedom from AV-related reoperation was 86±5.1% without significant differences between the groups (85±9.7% for bicuspid AV, 86±6.0% for tricuspid AV; log-rank test: p=0.98). Overall actuarial 3 years' freedom from recurrent AR≥moderate was 100% and AR>trace was 71.3±8.2% without significant differences between the groups (76.5±11.7% for bicuspid AV, 71.4±9.4 for tricuspid AV; log-rank test: p=0.97). The mid-term outcome in terms of survival, freedom from reoperation or recurrent AR is similar for both groups of patients after AV repair procedures. Therefore, we advocate valve repair also in patients presenting with an insufficient bicuspid AV.

Valve-sparing Aortic Root Replacement

The aortic root has a unique 3-dimensional configuration and the distinctive function of supporting the aortic valve and blood vessels. The sinuses of Valsalva are crucial to create appropriate eddy currents that are important in initiating and coordinating aortic valve closure and promoting coronary artery blood flow. Most aneurysms in the aortic root are associated with degenerative changes in the elastic media rather than atherosclerosis. Valve-sparing root repair has become widely accepted, although the Bentall procedure remains the gold standard. Because reimplantation using the Valsalva graft allows root geometry to be retained and theoretically and practically prevents recurrent aortic valve regurgitation, it is considered the most reliable and preferred technique among various valve-sparing aortic root repair procedures.

A Case of Successful Valve Repair for Aortic Insufficiency Associated with Discrete Subaortic Stenosis

Discrete subaortic stenosis (DSS) is an uncommon form of left ventricular outflow tract obstruction especially in adulthood. Moreover, aortic regurgitation (AR), which is a common sequence of DSS, requiring surgical correction is extremely rare. We report the case of a 33-year old man who had severe DSS accompanied with moderate aortic insufficiency. He underwent successful surgery including relief of DSS and aortic valve repair. Although careful follow-up is mandatory for recurrent AR and DSS, our approach was thought to be feasible for a young adult patient with DSS complicated with AR.

Everted leaflet of a bovine pericardial aortic valve

We report on an everted leaflet of a Carpentier-Edwards Perimount (CEP) valve in an aortic position. A 71-year-old female patient with aortic regurgitation underwent valve replacement with a 21-mm CEP valve. After aortic declamping, transesophageal echocardiography (TEE) revealed significant transvalvular regurgitation due to an immobilized non-coronary leaflet. Upon re-aortotomy, we found an everted leaflet without any structural damage to the valve. It was readily corrected and eversion did not recur spontaneously. The valve was not replaced because it had no intrinsic problems, eversion was unlikely to be induced by cardiac output, and there was no evidence that re-implantation would avoid further problems. Her postoperative course was uneventful without recurrence of aortic regurgitation during three months of follow-up after surgery. On TEE measurements, allocation of stent posts was slightly uneven. Since leaflet eversion was re-created by distortion of the stent in an ex-vivo model, a mild imbalance of sutures might increase the risk of this event. TEE was beneficial for detection, decision-making, and avoidance of an early reoperation. This case indicates that reimplantation or replacement of the valve is not always necessary for an everted valve leaflet. Although the patient has had an uneventful course thus far, careful follow-up is mandatory.

Mechanisms of Recurrent Aortic Regurgitation After Aortic Valve Repair: Predictive Value of Intraoperative Transesophageal Echocardiography

The aim of the present study was to examine the intraoperative echocardiographic features associated with recurrent severe aortic regurgitation (AR) after an aortic valve repair surgery. Surgical valve repair for AR has significant advantages over valve replacement, but little is known about the predictors and mechanisms of its failure. We blindly reviewed all clinical, pre-operative, intraoperative, and follow-up transesophageal echocardiographic data of 186 consecutive patients who underwent valve repair for AR during a 10-year period and in whom intraoperative and follow-up echo data were available. After a median follow-up duration of 18 months, 41 patients had recurrent 3+ AR, 23 patients presented with residual 1+ to 2+ AR, and 122 had no or trivial AR. In patients with recurrent 3+ AR, the cause of recurrent AR was the rupture of a pericardial patch in 3 patients, a residual cusp prolapse in 26 patients, a restrictive cusp motion in 9 patients, an aortic dissection in 2 patients, and an infective endocarditis in 1 patient. Pre-operatively, all 3 groups were similar for aortic root dimensions and prevalence of bicuspid valve (overall 37%). Patients with recurrent AR were more likely to display Marfan syndrome or type 3 dysfunction pre-operatively. At the opposite end, patients with continent AR repair at follow-up were more likely to have type 2 dysfunction pre-operatively. After cardiopulmonary bypass, a shorter coaptation length, the degree of cusp billowing, a lower level of coaptation (relative to the annulus), a larger diameter of the aortic annulus and the sino-tubular junction, the presence of a residual AR, and the width of its vena contracta were associated with the presence of AR at follow-up. Multivariate Cox analysis identified a shorter coaptation length (odds ratio [OR]: 0.8, p = 0.05), a coaptation occurring below the level of the aortic annulus (OR: 7.9, p < 0.01), a larger aortic annulus (OR: 1.2, p = 0.01), and residual aortic regurgitation (OR: 5.3, p = 0.01) as risk factors of repair failure. Our results demonstrate that intraoperative transesophageal echocardiography can be used to identify patients undergoing AR repair who are at increased risk for late repair failure.

Long-Term Results of the Leaflet Extension Technique in Aortic Regurgitation: Thirteen Years of Experience in a Single Center

We evaluated the effectiveness and durability of the leaflet extension technique for correction of aortic regurgitation (AR) and the long-term clinical results. Between March 1995 and August 2004, 41 consecutive patients were included. The mean age was 32.2 +/- 13.9 years. The causes of AR were rheumatic in 31 patients (75.5%), degenerative in 2 patients (4.9%), bicuspid aortic valve in 4 patients (9.8%), infective endocarditis in 1 patient (2.4%), and congenital in 3 patients (7.3%). Leaflet extensions were performed in three leaflets for 32 patients, two leaflets for 3 patients, and only one leaflet for 6 patients. The mean follow-up duration was 92.9 +/- 48.4 months. There were no early deaths and 2 late deaths. One patient died of cancer and the other patient died of infective endocarditis. The cardiac-related mortality was 2.4% (1 of 41 patients). During a mean follow-up of 7 years, severe AR was detected in 1 patient and moderate AR in 6 patients (17.0%; 7 of 41 patients). The causes of recurrent AR were infective endocarditis in 3 patients, disease progression in 3 patients, and Behçet's diseases in 1 patient. We performed 6 reoperations (14.6%), 3 in patients owing to infective endocarditis, 2 in patients owing to disease progression, and 1 in a patient owing to the suture dehiscence associated with Behçet's disease. The cumulative survival was 92.6% at 13 years. Freedom from recurrent AR was 97.5% at 5 years, 81.7% at 10 years, and 68.1% at 13 years. The long-term durability of the leaflet extension technique was acceptable. The reoperations increased with time, but pericardial leaflet dysfunction was not the cause.

Abstract 3179: Intraoperative Transoesophageal Echocardiographic Predictors of Recurrent Aortic Regurgitation after Aortic Valve Repair.

Background. Surgical valve repair for aortic regurgitation (AR) has significant advantages over valve replacement, but little is known about the mechanisms of its failure. This echocardiographic study examines the intraoperative features associated with “late failure” of valve repair, eventually necessitating reoperation. Method. Intraoperative transesophageal echocardiography (TEE) after cardiopulmonary bypass was performed in 168 consecutive patients (pts) undergoing valve repair for AR over a 10-year period. From this cohort, we carefully reviewed all clinical, pre-operative, intraoperative and follow-up TEE data of 62 pts (group A, 53 ± 13 years) with no or trivial AR at follow-up and 31 pts (group B, 46 ± 15 years) with recurrent severe AR at follow-up of whom 17 needed a re-operation. In these pts, echocardiography identified the cause of repair failure as rupture of a pericardial patch in 2 pts, residual cusp prolapse in 18 pts, restrictive cusp motion in 8 pts, aortic dissection in 2 pts and endocarditis in the remaining pt. Results. Pre-operatively, both groups were similar for aortic root dimensions and incidence of bicuspid valve (39 ± 4 % vs 35 ± 5 %, χ 2 = 0.4). Marfan disease and restrictive cusp motion or endocarditis were more frequent in group B than in group A (16 ± 4% vs 0% and 48 ± 5% vs 14 ± 3%, χ 2 = 0.001). After cardiopulmonary bypass, the coaptation length was shorter (2.2 ± 1.5 vs. 6.8 ± 2.8 mm, p&lt;0.001), the level of coaptation (relative to the annulus) was lower (0.0 ± 4.4 vs 6.9 ± 3.9 mm, p&lt;0.001), the aortic annulus was larger (27 ± 5 vs 22 ± 4 mm, p&lt;0.001) and the vena contracta was wider (2.4 ± 1.0 vs 0.05 ± 0.9 mm, p&lt;0.001) in group B than in group A pts. Interestingly, 13/18 (72%) pts in whom recurrent AR was due to a cusp prolapse, had eccentric AR jets before leaving the operating room. With multivariate analysis, only a coaptation length &lt; 5 mm (OR=13.1, 95%CI [2.4; 70.5] p=0.003), the presence of an eccentric jet (OR=8.02, 95%CI [2.1; 30.4] p=0.002) and the level of coaptation relative to the aortic annulus (OR=4.7, 95%CI [1.0; 21.6] p=0.049) were found to independently predict late AR recurrence. Conclusion. Our results demonstrate that intraoperative TEE can be used to identify pts undergoing AR repair who are at increased risk for late repair failure.

Aortic Valve Repair: The Functional Approach to Leaflet Prolapse and Valve-Sparing Surgery

Combined aortic valve repair and aortic valve-sparing surgery requires an approach determined by the leaflets and aortic root anatomy. Among patients referred for aortic root aneurysm, 114 patients underwent an aortic valve-sparing procedure in which a reimplantation or remodelling technique was used. The Gelweave Valsalva prosthesis (Sulzer Vascutek, Renfrewshire, UK) was used in 45 patients. Better molding of the prosthesis on the aortic annulus was achieved by a low proximal dissection and incisions on the prosthesis to respect the anatomy of the aortoventricular junction. The reimplantation technique was used in 58%, and 62% of all patients underwent an associated leaflet procedure. The operative mortality rate was 1%, with a 2% immediate reoperation rate. During the mean follow-up 50 +/- 35 months, 3 patients (2.6%) needed reoperation for recurrent aortic regurgitation (n = 2) or aortic stenosis (n = 1). At the end of follow-up, aortic regurgitation grade exceeding 2 had occurred in 2.6% of patients (n = 3), and 98.2% were in New York Heart Association functional class 1 or 2. Neither the early nor mid-term results showed any differences among the different surgical techniques used (reimplantation, remodeling, Valsalva prosthesis, additional leaflet repair). A complete approach to the different components of the aortic root allows good clinical results at mid-term.

Valve Repair for Bicuspid Aortic Valve Regurgitation: An Option?

Bicuspid aortic valve is the most common form of congenital heart disease. It is associated with both valvular pathology and aortic disease. Aortic regurgitation caused by a bicuspid aortic valve can be corrected by surgical valve repair, which has good short-term results. However, the significant rate of aortic regurgitation recurrence found on long-term follow-up remains a problem, partly because of the progressive aortic dilatation that is characteristic of this disease. We report three different cases of bicuspid aortic valve treated by surgical valve repair at our centre.

Echocardiographic Follow-Up of Children with Isolated Discrete Subaortic Stenosis

This study evaluates the progression of stenosis, onset and progression of aortic regurgitation (AR), and the results of surgical outcomes in children with isolated discrete subaortic stenosis (SAS). The medical records of 108 patients (mean age, 5.5 +/- 3.8 years; range, 3 days to 18 years) with isolated discrete SAS were reviewed. Patients with lesions other than AR were excluded. Very mild stenosis was defined as Doppler peak systolic instantaneous gradient (PSIG) less than 25 mmHg, mild stenosis as 25-49 mmHg, moderate stenosis as 50-75 mmHg, and severe stenosis as more than 75 mmHg. Seventy-eight of 108 patients were followed for 2 months to 14 years (mean, 4.8 +/- 3.7 years; median, 5 years) with medical treatment alone. In these patients, the mean PSIG at last echocardiogram was higher than the mean PSIG at initial echocardiogram (39 +/- 19 vs 31 +/- 12 mmHg, respectively; p < 0.001). Among 24 patients with very mild stenosis at initial echocardiogram, 10 had mild and 2 had moderate stenosis after a mean period of 5.6 years. Among 46 patients with mild stenosis at initial echocardiogram, 11 had moderate and 5 had severe stenosis after a mean period of 4.1 years. Only 1 patient among the 8 patients with moderate stenosis at initial echocardiogram had severe stenosis after a mean period of 2.7 years. Thirty-nine patients (50%) had AR (13% trivial, 33% mild, and 4% moderate) at initial echocardiogram. After a mean period of 4.8 years, 77% of the patients had AR (10% trivial, 53% mild, 9% mild-moderate, and 5% moderate). Twenty-four patients underwent surgery. Preoperatively, mean Doppler PSIG and AR incidence were 64 +/- 17 mmHg and 91% (22/24), respectively. The mean Doppler PSIG was 30 +/- 19 mmHg and AR was present in all of the patients a mean period of 4.1 years after surgery. Two patients underwent reoperation for recurrent SAS and AR. Patients with very mild or mild stenosis may be followed noninvasively every year. One patient of the 8 patients with moderate stenosis progressed to severe stenosis, and moderate AR developed in 2 patients after a mean of 2.7 years. We recommend that patients with moderate stenosis undergo careful evaluation to determine whether surgery is necessary due to the severity of stenosis and AR.

Aortic prosthetic ring annuloplasty: a useful adjunct to a standardized aortic valve-sparing procedure?☆

Dilation of aortic annulus, sinuses of Valsalva, and sinotubular junction (STJ) diameters are the characteristic lesions of aortic root aneurysm. The remodeling technique reduces STJ diameter and creates three neosinuses of Valsalva. Alternatively, the reimplantation technique reduces both annulus and STJ diameters to the detriment of aortic root dynamics. Although the remodeling technique is recognized as the most physiological valve-sparing procedure, aortic annulus dilation may jeopardize its results. A standardized approach that combines an external subvalvular aortic prosthetic ring annuloplasty with the remodeling technique is suggested. Eighty-three patients underwent an elective aortic root remodeling procedure, either isolated (group 1, n=34) or combined with an external subvalvular aortic prosthetic ring annuloplasty (group 2, n=49). Preoperative aortic regurgitation was 1.59+/-1.1 (group 1) and 1.97+/-1.3 (group 2) (NS). The aortic annulus was more dilated in group 2 than in group 1 (27+/-2.77 mm vs 26.4+/-2.3 mm, p<0.01). Residual aortic regurgitation > or =grade II was the conversion criteria for aortic valve replacement. Operative mortality was 3.6% (n=3). Intraoperative conversion for valve replacement was 32.7% in group 1 (n=11) versus 4.2% in group 2 (n=2) (p<0.001). In group 1, preoperative annulus diameter was larger for converted than for valve-spared patients (27.6+/-1.7 mm vs 25.2+/-1.5 mm, p<0.02). In group 2, implanted aortic ring significantly reduced annulus diameter (20.6+/-1.8 mm) without significant aortic valve gradient (8.3+/-3 mmHg). Follow-up was 17.2+/-13.4 months (group 1) and 10.41+/-7.95 months (group 2). Reoperation for recurrent aortic regurgitation was 13% in group 1 (n=3) versus 4.2% in group 2 (n=2). Echocardiographic follow-up found residual aortic regurgitation < or =grade I in 17 patients in group 1 (90%) versus 43 patients in group 2 (95.5%) and of grade II in two patients in group 1 (10%) and two patients in group 2 (4.5%). The addition of external aortic prosthetic ring annuloplasty improves the remodeling technique's operative reproducibility and short-term results. Therefore, its use as a systematical adjunct to the remodeling procedure is suggested. However, further long-term evaluation comparing this valve-sparing procedure to composite graft replacement should define the best surgical strategy for aortic root aneurysm.

Extended aortic valvuloplasty for recurrent valvular stenosis and regurgitation in children

Recurrent significant aortic valvular stenosis or regurgitation, or both, after balloon or open valvotomy in pediatric patients often necessitates aortic valve replacement. In an attempt to preserve the aortic valve, we performed extended aortic valvuloplasty in 21 children with recurrent aortic valve stenosis or regurgitation from January 1989 to March 1993. Previous related procedures were one open aortic valvotomy or more (n = 15), balloon valvotomy (n = 4), balloon valvotomy after surgical valvotomy (n = 1), and repair of iatrogenic valve tear (n = 1). Mean age at the time of the extended aortic valvuloplasty was 6 +/- 3.4 years. Mean pressure gradient across the aortic valve was 56 +/- 12 torr. Regurgitation was moderate (grade 2 to 3) in nine and severe (grade 4) in 12 patients. Extended aortic valvuloplasty techniques consisted of thinning of valve leaflets (n = 15), augmentation of scarred and retracted leaflets with autologous pericardium (n = 11), resuspension of the augmented leaflet (n = 14), release of the rudimentary commissure from the aortic wall (n = 5), extension of the valvotomy incision into the aortic wall on both sides of the commissure (n = 20), patch repair of the sinus of Valsalva perforation (n = 1), reapproximation of tears (n = 5), and narrowing of the ventriculoaortic junction (n = 2). No operative deaths occurred. The postoperative mean pressure gradient, assessed by most recent Doppler echocardiography or cardiac catheterization at a follow-up of 18 +/- 6 months, was 19 +/- 6 torr (p < 0.01 versus the preoperative gradient). Aortic regurgitation was absent in 13, mild in 6, and moderate-to-severe, necessitating subsequent aortic valve replacement, in 2. This short-term experience indicates that extended aortic valvuloplasty is a safe and effective surgical approach that minimizes the need for aortic valve replacement in children with significant recurrent aortic valve stenosis or regurgitation.

Reoperation after Aortic Valvuloplasty for Aortic Regurgitation Associated with Ventricular Septal Defect

Five patients underwent reoperations because residual or recurrent aortic regurgitation occurred after aortic valvuloplasty for aortic regurgitation associated with ventricular septal defect. The mean age at reoperation was 22 years old, and the mean time interval between initial and second operation was 6 years, 10 months. The pathological findings of the aortic valves showed tears and perforation of repaired leaflets in four patients and a giant pseudoaneurysm of the Valsalva sinus in one. Aortic valvuloplasties were performed again in three patients, and aortic valves were replaced with prosthetic valves in two. Slight to moderate regurgitant murmurs are still audible in patients who underwent these valvuloplasties. Ventricular septal defects should be closed before aortic regurgitation develops. If it has developed, however, valvuloplasty should be considered as a first choice in young patients. For adult patients, aortic valve replacement is recommended.