Recurrent Aortic Insufficiency Research Articles

Aortic Valve Procedures at the Time of Ventricular Assist Device Placement

Placement of a ventricular assist device (VAD) may lead to reduced or absent opening of the aortic valve and thus increase risk of thrombus formation in the aortic root as well as on the valve itself. The outcome of additional procedures to the aortic valve at the time of VAD placement is unclear. A retrospective analysis of 712 VAD patients from 1995 to 2009 was performed. Twenty-eight patients were identified who underwent aortic valve procedures in addition to VAD placement. Indication for VAD placement was bridge to transplant in 23 patients, destination therapy in 4, and postcardiotomy shock in 1. Aortic valve procedures were performed for preexisting mechanical aortic prosthesis in 8 (7 closure and 1 aortic valve replacement with biological prosthesis), and for moderate or severe aortic insufficiency in 20 patients (10 repair, 9 closure, and 1 aortic valve replacement with biological prosthesis). At the last follow-up, 16 patients had undergone heart transplant, 6 remained on VAD support, and 5 had died. While on VAD support, no adverse events related to the aortic valve procedures occurred. The 30-day operative mortality was 0.4%. No clinical thromboembolic events were observed. In 2 patients, there was evidence of thrombus formation in the explanted heart. Four patients had bleeding complications. Of the 9 patients who received aortic valve repair, 2 had recurrent aortic insufficiency on echocardiograms during an average follow-up of 118 days. Additional procedures to the aortic valve at the time of VAD placement are feasible. Overall outcomes are comparable to those seen in patients without the need for aortic valve manipulation at the time of VAD placement.

Assessment and repair of aortic valve cusp prolapse: Implications for valve-sparing procedures

Cusp prolapse causing aortic insufficiency is associated with unique echocardiographic, clinical, and surgical features. Recognition and appropriate surgical repair of this pathologic condition can not only treat affected patients but also improve results of aortic valve-sparing procedures, for which pre-existing or induced cusp prolapse is an important cause of failure. Of 428 patients undergoing aortic valve repair, 195 (46%) were treated for cusp prolapse, and 111 (57%) of those had trileaflet aortic valve and make up this cohort. Cusp disease was the sole mechanism for aortic insufficiency (isolated group) in 50 patients whereas aortic dilatation was contributory in 61 (associated group). In total, 144 cusps were repaired in 111 patients. Preoperative echocardiograms, intraoperative findings, and clinical and echocardiographic outcomes were reviewed. On preoperative echocardiography, presence of an eccentric aortic insufficiency jet, regardless of severity, had 92% sensitivity and 96% specificity for the detection of single cusp prolapse. A transverse fibrous band was characteristically identified on the prolapsing cusp (sensitivity 57%; specificity 92%), correctly localizing a prolapsing cusp in all cases. Freedom from aortic valve reoperation at 8 years was 100% in the isolated group and 93% ± 5% in the associated group (p = 0.33). Freedom from recurrent aortic insufficiency (>2+) at 5 years was 90% ± 5% in the isolated and 85% ± 8% in the associated group (P = .54). The choice of surgical technique did not affect aortic insufficiency recurrence at follow-up (P = .6). Recognition and repair of isolated aortic cusp prolapse provides durable midterm outcome. An eccentric aortic insufficiency jet and a fibrous band can aid in the diagnosis and localization of cusp prolapse associated with ascending aortic disease and may help to improve results of aortic valve-sparing procedures.

Aortic valve repair with ascending aortic aneurysms: associated lesions and adjunctive techniques

Patients with supracoronary ascending aortic aneurysms can have aortic insufficiency (AI) due to dilatation of the sinotubular junction and/or associated cusp pathology. The incidence and types of cusp lesions as well as the effect of AI severity and cusp repair techniques on outcome in this patient population is not well defined. Since 1996, 55 patients (mean age: 65 ± 13 years, 17 bicuspid valves) presented with supracoronary ascending aortic aneurysms and AI that was mild/moderate in 27 (49%) and severe in 28 (51%). Associated pathology included cusp prolapse in 18 (33%), cusp restriction in nine (16%) and both in three (5%). All patients underwent aortic replacement and remodeling of the sinotubular junction. Adjunctive techniques included subcommissural annuloplasty in 38(69%) and cusp repair in 28 (51%). AI severity was not significantly associated with the presence of cusp pathology (p=0.35). Cusp disease was present in 100% of bicuspid aortic valves compared with only 34% of trileaflet valves (p<0.001). There was no hospital mortality and overall survival was 94 ± 4% and 75 ± 10%, respectively, at 5 and 7 years. Freedom from re-operation was 100% at 7 years and freedom from recurrent AI (>2+) was 87 ± 7% at 5 years. Neither the presence of preoperative severe AI, nor the need for cusp repair was predictive of late outcome. Cusp pathology is frequently encountered in patients with ascending aortic dilatation and AI. Severe AI is not a contraindication to valve-preserving surgery, but careful identification and repair of cusp pathology, in addition to sinotubular junction reduction, is critical for durable, long-term outcome.

Transesophageal Echocardiographic Evaluation During Aortic Valve Repair Surgery

For patients with aortic valve (AV) disease, the classic treatment has been AV replacement and this remains true for aortic stenosis. In contrast, repair of isolated aortic insufficiency (AI), with or without aortic root pathology, is emerging as a feasible and attractive option to replacement. The AV is one of the elements of the aortic root. As such, AI can develop if one or more elements of the aortic root are diseased. Intraoperative transesophageal echocardiographic evaluation permits analysis of the mechanisms of aortic regurgitation as well as differentiation between repairable and unrepairable AV pathology. Immediate postrepair transesophageal echocardiography provides important information about the quality and durability of repair and identifies variables associated with recurrent AI.

Repair of regurgitant bicuspid aortic valves: A systematic approach

Patients with bicuspid aortic valves can present with aortic insufficiency caused by cusp disease or the aortic root pathology. We present our 13-year experience with a functional and systematic approach to bicuspid aortic valve repair. Between 1995 and 2008, 122 consecutive patients (mean age, 44 +/- 11 years) with bicuspid aortic valves underwent non-emergency valve repair for isolated aortic insufficiency (43%), aortic root dilatation (14%), or both (43%). Preoperative echocardiography identified aortic dilatation (n = 75), cusp prolapse (n = 96), and cusp restriction (n = 45) as mechanisms of aortic insufficiency. Raphé repair (n = 98) was performed by shaving (21%) or resection with primary closure (60%) or pericardial patch (18%). Functional aortic annuloplasty was performed using subcommissural annuloplasty (n = 51), ascending aortic replacement (n = 17), or aortic root replacement (n = 54) using a reimplantation (76%) or remodeling technique (24%). There was no operative mortality. Five patients underwent early aortic valve reoperation (3 re-repairs). At discharge, 93% of patients had aortic insufficiency grade 0/1 and 7% of patients had grade 2. Seven additional patients underwent aortic valve reoperation during follow-up (2 re-repairs). Overall survival was 97% +/- 3% at 8 years. At 5 and 8 years follow-up, freedom from aortic valve reoperation was 94% +/- 2% and 83% +/- 5%, respectively, and freedom from aortic valve replacement was 96% +/- 2% and 90% +/- 5%, respectively. Freedom from recurrent aortic insufficiency (>2+) was 94% +/- 3% at 5 years. Freedom from thromboembolism and bleeding was 96% +/- 2% at 8 years. A systematic approach to bicuspid aortic valve repair yields good early and midterm results. Repair of bicuspid valves for aortic insufficiency is a feasible and attractive alternative to mechanical valve replacement in young patients.

Effects of Preoperative Aortic Insufficiency on Outcome After Aortic Valve–Sparing Surgery

The presence of significant preoperative aortic insufficiency (AI) or the need for cusp repair has been suggested as a risk factor for poorer outcomes after aortic valve (AV)-sparing surgery. We analyzed the influence of these factors on the mid-term outcomes of AV surgery. Between 1996 and 2008, 164 consecutive patients underwent elective AV-sparing surgery. Severe preoperative AI (grade > or =3+) was present in 93 patients (57%), and 54 (33%) had a bicuspid valve. Root repair was performed with either the reimplantation (74%) or the remodeling (26%) technique, and cusp repair was performed in 90 patients (55%). Mean clinical follow-up was 57 months. Hospital mortality was 0.6%. Cusp repair was required in 52% of the patients with preoperative AI < or =2+ and in 57% of those with AI > or =3+ (P=0.6). Cusp repair was required more frequently in bicuspid versus tricuspid valves (91% versus 38%, P<0.001). Overall survival at 8 years was 88+/-8%. Freedom from AV reoperation at 8 years was similar with preoperative AI < or =2+ versus preoperative AI > or =3+ (89+/-11% versus 90+/-7%, P=0.7) and with versus without cusp repair (84+/-17% versus 92+/-8%, P=0.5). Freedom from recurrent AI (grade > or =3+) at 5 years was also similar between groups (90+/-10% versus 89+/-8%, P=0.9, and 90+/-8% versus 89+/-9%, P=0.8, respectively). By multivariate analyses, predictors of recurrent AI > or =2+ were preoperative left ventricle end-diastolic diameter and AI >1+ on discharge echocardiography. With a systematic approach to cusp assessment and repair, AV-sparing surgery for root pathology has an acceptable mid-term outcome, irrespective of preoperative AI or need for cusp repair.

Abstract 4281: Does Preoperative Aortic Insufficiency Affect Outcome Following Aortic Valve Sparing Surgery?

Aortic valve (AV) sparing surgery is an attractive option for the treatment of aortic root pathology. However, presence of significant preoperative aortic insufficiency (AI) or the need for cusp repair has been associated with poorer outcome. We analyze the influence of preoperative AI severity and the need for cusp repair on the early and mid-term outcomes of AV sparing surgery. From 1996 to 2007, 134 consecutive patients underwent elective AV sparing surgery. (mean age − 52±16 years; 84% male). Significant preoperative AI (3+ or 4+) was present in 83 patients (62%) and 46 (34%) had a bicuspid valve. Root repair was performed with either the reimplantation (67%) or remodeling technique (33%). A systematic approach was used for intraoperative valve assessment and cusp repair was performed in 74 patients (55%). Clinical and echocardiographic follow-up was complete in 100% and 96% respectively at a mean follow-up time of 57 months (range: 12–147 months). Kaplan-Meier curves, log rank test, and Cox regression analyses were used. Hospital mortality was 0.7%. AV cusp repair was required in 53% of patients without significant AI and in 57% with significant AI (p=0.9). Cusp repair was required more frequently in bicuspid versus tricuspid valves (89% vs. 38%, p = 0.005). Overall survival at 5 and 8 years was 94±5% and 86±10% respectively. Freedom from recurrent AI (&gt;2+) was similar with or without significant preoperative AI (90±10% vs. 86±10% at 5 years, p=0.5) and with or without cusp repair (87±11% vs. 89±10%, p=0.6; Figure 1). Freedom from AV reoperation at 5 years was similar with or without significant preoperative AI (94±6% vs. 89±8%, p=0.5) and with and without cusp repair (90±9% vs. 91±8%, p=0.8). With a systematic approach to valve assessment and cusp repair, AV sparing surgery for aortic root pathology has an acceptable early and mid-term outcome, irrespective of preoperative AI or need for cusp repair. Cusp repair is not predicted by presence of preoperative AI but is more frequent in bicuspid valves. Preoperative AI should not be considered a contra-indication for valve sparing surgery.

Repair of aortic leaflet prolapse: a ten-year experience☆

Leaflet plication (PL), triangular resection (TR), resuspension with running suture of Gore-Tex (GTx) and extension with autologous pericardial patch (PP) are different techniques to repair aortic leaflet prolapse (LP) for aortic insufficiency (AI). In this study, we report and compare the early and mid-term results of these techniques for aortic valve repair. From 1996 to 2006, 298 patients underwent elective aortic valve (AV) repair. In 146 of them, prolapse of one (n=72) or more than one leaflet (n=74) was found. LP was defined either as a longer or lower leaflet free margin compared to the other leaflet(s) or a relatively low coaptation level of all leaflets. When leaflet tissues were of good quality (thin and pliable), prolapse was treated by GTx (n=39), PL (n=25) or GTx+PL (n=23). When leaflet tissues were of poor quality (thickened, calcified), prolapse was treated by TR or PP (n=13) or TR or PP+GTx (n=47). There was no hospital mortality. During the initial hospitalization two patients required reoperation for recurrent AI and one for aorto-right ventricular fistula; of them, two were re-repaired. Median follow-up was 35 months (range 9-136). Three patients needed late reoperation for recurrent AI. At 4 years, overall survival was 99+/-1% and freedom from reoperation and from recurrent AI (grade >2) was 94+/-5% and 91+/-7% respectively. Freedom from recurrent AI was similar in patients having one versus more than one LP repair (88+/-11% vs 92+/-8%, p=0.2) and among the different techniques used to repair leaflet of good quality (PL: 95+/-8% vs GTx: 83+/-18% vs PL+GTx: 100%; p=0.37). When leaflet resection was needed, the addition of GTx significantly reduced the recurrence of AI (TR or PP: 82+/-18% vs TR or PP+GTx: 97+/-4%; p=0.026). Leaflet plication and Gore-Tex resuspension are both effective and durable techniques for aortic leaflet prolapse repair. The addition of Gore-Tex to triangular resection and pericardial patch repair techniques is efficient to reinforce the suture line and to improve the outcome of the repair. Multiple leaflet prolapse is not a prohibitive factor for successful repair even in the absence of a clear reference level such as a normal leaflet, as long as normal anatomical coaptation is achieved.

Timing of Repair in Ventricular Septal Defect with Aortic Insufficiency

Trusler's valvuloplasty technique and its modifications are the standard approach for the repair of aortic insufficiency in combination with ventricular septal defect. However, recurrent aortic insufficiency may occur after repair. The timing of surgical intervention in patients with ventricular septal defect and aortic insufficiency is still controversial. Between 1985 and 2000, 33 patients were analyzed retrospectively focusing on echocardiographic findings. For statistical analysis, the patients were divided into two groups according to the grade of preoperative aortic insufficiency: there were 5 patients with preoperative severe aortic insufficiency and 28 patients with mild to moderate aortic insufficiency. The mean age at operation was 6.05 +/- 3.61 years. The aortic valve was repaired by means of Trusler's valvuloplasty in the majority of the patients. All but three had patch closure of the ventricular septal defect, with a transaortic approach in 54 %. Mean follow-up was 5.1 years with a maximum of 16.9 years (168.9 patient years). Rates for freedom from reoperation at 1, 3, and 8 years were 90 %, 85 %, and 75 %, respectively. In 3 patients, a mechanical prosthesis was implanted at the time of reoperation. One sudden death occurred after 3.6 years. Patients with preoperative severe aortic insufficiency were reoperated significantly more often (P < 0.03). In patients with preoperative severe aortic insufficiency, the underlying pathology (insufficiency) was detected earlier on in life (8.4 +/- 10 months) than in patients (45.0 +/- 30 months) with mild to moderate aortic insufficiency at the time of intervention (P < 0.05). Severe aortic insufficiency at the time of operation has less favorable long-term results. Therefore, early surgical intervention, even in young patients, seems warranted to avoid potential reoperation or valve replacement.

Aortic Root Remodeling: Functional MRI as an Accurate Tool for Complete Follow-Up

After aortic valve-sparing procedures patients should be evaluated regularly because of the risk for further disease progression in the remaining aorta as well as recurrent aortic insufficiency. The purpose of this study was to evaluate the potential of functional MRI as a single examination for complete follow-up of these patients. Twenty-two patients with a mean age of 54 years (range 30 - 66) were prospectively examined at 1, 12, 24, 36, and 74 months postoperatively, following a Yacoub aortic root remodeling operation, using a 1.5 T MRI. The original disease was chronic aneurysm of the ascending aorta or root in 17, chronic dissection in 3, and acute dissection in 2 patients. Transverse graft diameters, regurgitant fraction, LVEDV, and cardiac index were measured using cine MRI. Results were compared to spiral computed tomography and transthoracic color Doppler echocardiography. Mean time of follow-up was 24.9 months and ranged from 1 to 74 months. There were 2 re-operations, 2 years after primary surgery, due to high aortic insufficiency. CT and MRI measurements of graft diameters correlated well (p = 0.4544). Mean graft diameter (mean +/- SD) was 30 +/- 3.7, 33 +/- 3.4, 36.5 +/- 1.5, 37 +/- 2.8, and 38.3 +/- 2.8 mm at 1, 12, 24, 36, and 74 months, respectively, indicating a significant increase of graft diameter (p < 0.0001). Mean regurgitant fraction as determined by MRI was 14 +/- 7, 12 +/- 9, 13 +/- 9, 15 +/- 7, and 14 +/- 9 % at 1, 12, 24, 36, and 74 months, respectively. Flow based grading of aortic insufficiency by MR imaging correlated well with color Doppler echocardiography (p < 0.0001). MRI provides an excellent, noninvasive, comprehensive tool for follow-up after valve-sparing aortic root reconstruction. The determination of regurgitant fraction, ventricular dimensions and functions, and graft diameters allows standardized imaging protocols with a high reproducibility, which may lead to this technique being favored for the follow-up of patients after aortic root remodeling.

Lunular hypertrophy and aortic valve disease

Cuspid malcoaptation secondary to abnormal hypertrophy in combination with stiffening involving the line of apposition (lunular hypertrophy) has not been recognized as a cause of aortic valve dysfunction. This entity was found in 50 adults (mean age, 62 years). Thirty-three had pure aortic valve insufficiency (≥3+, n = 13; <3+, n = 20), 13 had mixed aortic valve insufficiency and stenosis (≥3+, n = 2; <3+, n = 11), and 4 had pure aortic valve stenosis. Forty-one had a history of rheumatic heart disease and advanced mitral valve disease, and 7 had coronary artery disease. All underwent shaving of the hypertrophic protuberances, which in 26 patients constituted the entire aortic valve repair. In the remaining 24 patients, aortic valve repair included one or more additional procedures; there were 15 commissurotomies, 12 debridements of calcium deposits from the base of the cusps, and 5 cusp resuspensions. Concomitant mitral valve repair was performed in 26 patients, mitral valve replacement in 15, tricuspid valve repair in 11, coronary artery bypass grafting in 7, arid repair of an ascending aortic aneurysm in 2. In 2 patients, the attempt to repair the aortic valve was unsuccessful, necessitating valve replacement. There were S operative deaths (10%), but none were related to aortic valve repair. Forty-three patients entered follow-up (mean, 56 ± 57 months). Three patients (7%) suffered late recurrent aortic valve insufficiency (at 6,48, and 72 months). The remaining 40 patients (93%) had trivial or no recurrent aortic valve dysfunction. The 6-year actuarial freedom from aortic valve-related problems was 92%. We conclude that lunular hypertrophy may cause aortic valve dysfunction, primarily insufficiency. Long-term correction can be achieved through sculpturing of the involved cusps.

Preservation of the aortic valve in acute aortic dissection: Long-term echocardiographic assessment and clinical outcome

The aim of the present study was to determine the long-term status of the native aortic valve after surgical treatment of acute aortic dissection involving the ascending aorta. From 1972 to 1991, 93 patients underwent operation for type I or II aortic dissection. There were 76 men and 17 women. Mean age was 54 ± 13 years. Eighty patients (86%) had a conservative procedure regarding the aortic root and aortic cusps: 74 had prosthetic replacement of the ascending aorta and 6, complete replacement of the aortic arch. Thirteen patients (14%) had simultaneous replacement of the aortic valve and the ascending aorta. The overall hospital mortality rate was 29% (27/93). The overall actuarial survival rate was 60.2% ± 5.2%, 49.7% ± 6.1%, and 35.9% ± 8.1% at 5, 10, and 15 years, respectively. The survival rates for patients who had an ascending aortic procedure only were 63% ± 5.5%, 54% ± 6.5%, and 39% ± 8.5% at 5, 10, and 15 years, respectively, and for patients who required aortic valve replacement, 45% ± 14% and 22% ± 17.5% at 5 and 10 years, respectively. Fifty long-term survivors (94% follow-up) with preservation of the aortic valve and aortic root were studied. Among them, 9 (18%) died within a mean interval of 97 ± 46 months after operation. Causes of death were ischemic cardiac failure (2), aortic rupture or extension of dissection (4), renal disease (1), stroke (1), and sudden death (1). Forty-one patients had long-term clinical and echocardiographic evaluation. Severe aortic insufficiency developed in 7 patients in the years after operation, and 6 of them underwent reoperation for prosthetic valve replacement. Echocardiographic findings were judged to show no or mild residual aortic insufficiency in 22 patients and moderate aortic insufficiency with satisfactory left ventricular function in 12 (2 patients had aortic valve replacement because of concomitant mitral valve disease or coronary disease). In all, late aortic valve replacement was realized in 8 patients at a mean interval of 61.5 ± 51.2 months after the first operation. Actuarial freedom from aortic valve replacement was 83% ± 6% at 5 years and 79% ± 7% at 10 and 15 years. This study emphasizes the benefit of surgical procedures that preserve the aortic valve and aortic root in the repair of acute aortic dissection involving the ascending aorta, without additional risk of recurrent aortic insufficiency.

Valvuloplasty for aortic insufficiency

Twenty-eight consecutive patients underwent aortic valvuloplasty for aortic insufficiency caused by leaflet prolapse. The technique involved triangular resection of the free edge of the prolapsing leaflet, annular plication at the commissure, and resection of a raphe when present in bicuspid valves. Mean age of the patients was 46.8 +/- 14.4 years. Twenty-six (92.7%) were male. Seventy-five percent of the patients had a bicuspid aortic valve; the remaining valves were tricuspid. The extent of aortic insufficiency was 3.6 +/- 0.8 by aortography, 3.1 +/- 0.1 by preoperative Doppler echocardiography, and 3.4 +/- 0.7 by intraoperative Doppler echocardiography. The amount of aortic insufficiency decreased from 3.4 +/- 0.7 to 0.6 +/- 0.5 intraoperatively, immediately after repair (p less than 0.001). Mean transvalvular gradient by echocardiography was 12.9 +/- 6.8 mmHg. There was one death in a patient who had an intraoperative cerebral vascular accident. Mean follow-up was complete at 6.9 months. One patient had a cerebral vascular accident and one patient required reoperation for recurrent aortic insufficiency caused by partial suture line dehiscence. In 15 patients with late echocardiograms, aortic insufficiency did not progress (0.7 +/- 0.6 in the hospital and 0.8 +/- 0.5 late). Aortic valve repair for aortic cusp prolapse effectively eliminates aortic insufficiency without causing aortic stenosis. At early follow-up the repair has been stable.

Traumatic Hemolytic Anemia in Children with Rheumatic Heart Disease

ABSTRACT Fifty children (5 to 15 years of age) with inactive compensated rheumatic heart disease were screened for traumatic hemolytic anemia. Eleven patients (22%) had normocytic hypochromic anemi...

182 LONG-TERM RESULT OF AORTIC VALVOTOMY FOR ISOLATED CONGENITAL AORTIC VALVE STENOSIS IN CHILDREN

In this study we evaluated 77 patients (pt) operated upon over 1 year (y) of age who had isolated aortic valve stenosis (AS) and whose follow-up (FU) is at least 2y. There was no operative (op) death. Mean age at valvotomy was 10y (1-17y) and mean FU period was 9y (2-28y). In 50 pt who had postop (po) catheterization (cath), peak systolic pressure gradient between LV and AO (PSPG) decreased in all. In 5/50 PSPG was above 50 mgHg at initial po cath (persistent AS). Out of 15 pt who had two po cath,increased PSPG was demonstrated after apparently adequate initial relief of obstruction in 7 (recurrent AS). 20 pt (26%) required reoperation (reop) during this period at mean age of 18y (10-33y); 5 for persistent AS, 7 for recurrent AS and 8 for severe aortic insufficiency (AI). There was one op death and 2 late deaths. Most of pt who survived reop were in NYHA class I at FU.Of the 57 non-reop pt, 56 were asymptomatic. AI was present in 44 and was severe in 9 who may require valve replacement in future. In all of 32 non-reop pt who had po cath, PSPG was less than 50 mmHg. The reop group (Gp) had higher preop PSPG (75 vs 92mmHg), higher incidence of severe AI and had more symptoms of congestive heart failure after initial valvotomy than non-reop Gp. We conclude that majority of children improve following aortic valvotomy. However, by young adulthood,26% of pt require reop for recurrent or persistent AS and/or severe AI. Valvotomy in childhood did not prevent eventual valve replacement in these pt.

Aortic valvuloplasty during acute rheumatic fever: Hemolytic anemia due to recurrent aortic insufficiency

Aortic valvuloplasty during acute rheumatic fever: Hemolytic anemia due to recurrent aortic insufficiency

Surgical Treatment of Recurrent Aortic Insufficiency after Aortic Valve Replacement with the Starr-Edwards Ball Valve Prosthesis

Surgical Treatment of Recurrent Aortic Insufficiency after Aortic Valve Replacement with the Starr-Edwards Ball Valve Prosthesis