Asian Cardiovasc Thorac Ann 1999;7:182-185
© 1999 Asia Publishing EXchange Pte Ltd
Early and Midterm Results of Aortic Annular Enlargement
Hakki Aydo
an, MD,
Hakan Akay, MD,
Gökçen Orhan, MD,
Uur Filizcan, MD,
Nur
in Kaynarca, MD,
Okan Yücel, MD,
Yildirim Cömertolu, MD,
Serap Aykut-Aka, MD,
Ergin E Eren, MD
Siyami Ersek Thoracic & Cardiovascular Surgery Center
Istanbul, Turkey
|
|
For reprint information contact: Hakki Aydoan, MD Tel: 90 216 360 9530 Fax: 90 216 337 9719 Atilay Sok. Saadet Apt., 13/11 Feneryolu, Istanbul 81040, Turkey.
|
 |
Abstract
|
|---|
From November 1987 to May 1998, 16 patients with a small aortic annulus underwent patch enlargement of the aortic valve by Nicks' technique (in 9) or Manouguian's method (in 7). The mean age of the patients was 40 years (range, 22 to 58 years), mean body surface area was 1.54 m2 (range, 0.95 to 2.05 m2), and 11 were female. Concomitant procedures were mitral valve replacement in 4 cases, tricuspid commissurotomy and De Vega annuloplasty in 2, and one case each of patent ductus arteriosus ligation and coronary bypass. Aortic annular sizes were 15 to 19 mm (mean, 17.4 mm) preoperatively and 20 to 24 mm (mean, 22.1 mm) after the procedure. Two patients (12.5%) died in the early postoperative period. Peak pressure gradients across the prostheses were 15 to 22 mm Hg (mean, 19.4 mm Hg) on echocardiography. The mean duration of follow-up was 32.85 months (3 months to 8 years) and it was 92.8% complete. There were no late deaths. Mitral valve function was good except in one patient who had minimal mitral regurgitation after Manouguian's procedure. Both methods were found to be effective and reliable and should be performed when there is a risk of patient-prosthesis mismatch.
|
Introduction
|
|---|
Aortic valve replacement with a small prosthetic valve relative to the size of the patient may produce prosthesis-patient mismatch, resulting in complications such as persisting left ventricular dysfunction or hypertrophy, hemolysis, and thrombosis.l New designs of prosthesis may increase the flow area in smaller sizes and improve hemodynamic performance in patients with small aortic annuli.2–5 Alternatively, aortic annular enlargement may be used to implant a larger size of valve. Aortic annular enlargement is indispensable when the annulus is too small to insert the smallest size of valve prosthesis. We report our experience of posterior annular enlargement in 16 patients with small aortic annuli who underwent aortic valve replacement.
|
Patients and Methods
|
|---|
From November 1987 to May 1998, 16 patients with a small aortic annulus underwent patch enlargement by Nicks' or Manouguian's technique at our institution. Their ages ranged from 8 to 58 years (mean, 40 years). There were 11 females and 5 males. Body surface area ranged from 0.95 to 2.05 m2 (mean, 1.54 m2). The etiology of aortic valve disease and associated lesions are shown in Table 1
. Three patients had previous operations comprising closed mitral commissurotomy in 2 patients 10 and 12 years previously and aortic valvotomy in one patient 7 years previously. Fourteen patients were in New York Heart Association (NYHA) functional class III and 2 were in class IV. Preoperative aortic peak pressure gradients were between 70 and 110 mm Hg in stenotic patients.
A median sternotomy and standard cardiopulmonary bypass techniques were performed in all cases. Myocardial protection was achieved with cold crystalloid cardioplegia in 9 patients and cold blood cardioplegia in 7. In addition, systemic hypothermia (28°C) and topical cooling were employed in all cases. Patch enlargement of the aortic annulus was carried out by Nicks' technique in 9 patients and by Manouguian's technique in 7. In Nicks' method, an oblique aortotomy was extended to the noncoronary aortic annulus, the aortic cusps were excised, and the incision was extended to the mitral annulus. A diamond-shaped woven Dacron patch was sutured to the V-shaped defect in the aortic root with running sutures. The aortic prosthesis was sewn into place with interrupted pledgeted sutures and the aortotomy was closed. In Manouguian's technique, the aortic incision was performed toward the commissure between the noncoronary and the left coronary cusps and extended to the intervalvular fibrous trigone, to the center of the fibrous origin of the anterior mitral leaflet, and into the clear zone of this leaflet for a distance of 0.5 to 1 cm. Similarly, a diamond-shaped Dacron patch was sutured to the defect, the prosthesis was implanted, and the aortotomy was closed. The aortic valve prostheses were St. Jude Medical (St. Jude Medical, Inc., St. Paul, MN, USA) in 11 patients, Carbomedics (Sulzer Carbomedics, Inc., Austin, TX, USA) in 3, and Medtronic (Medtronic, Inc., Minneapolis, MN, USA) in 2 cases.
Concomitant procedures were carried out in 4 patients as shown in Table 2. In the patient who underwent coronary artery bypass grafting, the left anterior descending coronary artery, the right coronary artery, and the first obtuse marginal branch of the circumflex were bypassed using left internal mammary artery and saphenous vein grafts.
|
Results
|
|---|
The aortic annular sizes before enlargement ranged from 15 to 19 mm (mean, 17.4 mm). After the procedure, annular sizes were 20 to 24 mm (mean, 22.1 mm), giving a mean enlargement of 4.7 mm. Two patients received 19-mm prostheses and 7 had a 21-mm prosthesis with Nicks' procedure. With Manouguian's procedure, one patient had a 19-mm prosthesis and 2 each had 20-mm, 21-mm, and 23-mm valves implanted.
One patient died on the first postoperative day and another on day 14. The causes of early deaths were: low cardiac output in one patient who was in NYHA functional class IV and who underwent double valve replacement, tricuspid commissurotomy, and De Vega annuloplasty; and mediastinitis in the other patient who had undergone reoperation for bleeding. Perioperative mortality was 12.5%. Early complications in addition to reexploration for bleeding and mediastinitis in one patient, were low cardiac output in two and wound infection in one. Postoperatively, 10 patients were in NYHA functional class I and 6 were in class II. Peak pressure gradients across the aortic prostheses ranged from 15 to 22 mm Hg (mean, 19.4 mm Hg) in echocardiographic studies.
The duration of follow-up was 3 months to 8 years (mean, 32.85 months). Follow-up was complete in all except one patient who did not report for follow-up after 8 years, giving an overall follow-up of 92.8%. There were no deaths in the late postoperative period. Mitral valve function was evaluated by echocardiography. In one patient who underwent Manouguian's procedure, there was minimal mitral regurgitation; mitral valve function was good in the other patients.
|
Discussion
|
|---|
In spite of the deleterious effects of prosthesis-patient mismatch, good clinic results have been reported with some small aortic prostheses. Bojar and colleagues6 found that small (17-mm and 19-mm) Ionescu-Shiley valves in elderly patients produced excellent results. However, Teoh and colleagues7 recommended that 19-mm pericardial valves should not be used in active patients because of prohibitive gradients during exercise and they should be reserved for very small patients. Sawant and colleagues8 reported long-term results with 19-mm St. Jude prostheses in 104 patients and suggested that the body surface area did not affect long-term survival although most of their patients were older women. The long-term results of Arom and colleagues9 showed that 19-mm and 21-mm St. Jude valves had higher transprosthetic gradients but provided satisfactory performance in adults with a body surface area of less than 1.7 m2. Kratz and colleagues10 considered that implantation of a 19-mm or 21-mm valve when the body surface area was greater than 1.9 m2 increased the risk of late sudden death and recommended using a St. Jude HP (Hemodynamic Plus) valve or performing an annulus-enlarging procedure.
New designs of prosthesis such as the St. Jude HP valve or Medtronic-Hall and Carpentier-Edwards pericardial valves may improve the hemodynamic results in patients with small aortic roots.2–5 Carrel and colleagues2 reported that hemodynamic performance of the 21-mm St. Jude HP valve corresponded closely to that of the standard 23-mm St. Jude valve and could be recommended in a normal-sized adult patient with a narrow aortic annulus. Zingg and colleagues3 compared the hemodynamic charac-teristics and early clinic results of the 21-mm St. Jude Masters or HP valves with standard 21-mm and 23-mm St. Jude valves. They reported that the hemodynamic performance of the 21-mm Masters or HP valves corresponded closely to that of the standard 23-mm valve, thus reducing the need for aortic annulus enlargement.
Several aortic annular-enlarging procedures have been reported. Konno and colleagues11 described anterior annular enlargement by longitudinal incision of the aortic septum into the commissure of the right and left coronary cusp with a vertical incision in the outflow tract of the right ventricle to join the septal incision, prosthetic aortic valve replacement, and patch reconstruction of the outflow tracts of both ventricles with two layers of a fusiform Dacron patch. Manouguian and Seybold-Epting12 described posterior annular enlargement by extending an oblique aortic incision toward the commissure of the left coronary and noncoronary cusps, mitral annulus, and anterior mitral leaflet at midpoint, followed by re-construction of the defect with a diamond-shaped patch. Nicks and colleagues13 proposed patch enlargement of the aortic annulus by extending the incision to the noncoronary sinus through the aortic annulus. Mayumi and colleagues14 used a limited Manouguian incision to enlarge the aortic annulus, restricting the incision within the intervalvular fibrous trigone and preserving the mitral anterior leaflet, thereby allowing a prosthesis two sizes larger to be inserted without occurrence of mitral regurgitation. Aortic annular enlargement in two directions was carried out by Otaki and colleagues15 in patients for whom conventional posterior enlargement alone was not extensive enough to implant a prosthetic valve of acceptable size; initially, posterior annular enlargement was performed by Nicks' or Manouguian's procedure and then anterior enlargement by Konno's procedure, excluding the ventricular septum. The aortic annular diameter was increased by 68% after this two-directional enlargement.
The long-term results of aortic annular enlargement by Manouguian's technique in 15 patients were reported by Kawachi and colleagues16 who observed 62% actuarial survival at 10 years (including operative deaths) with 65% freedom from reoperation at 10 years; mitral regurgitation occurred in two patients. Our experience of annular enlargement by Nicks' or Manouguian's procedure, followed by replacement of the aortic valve with a standard prosthesis, indicates that these procedures are effective and reliable in patients with a small aortic annulus and we recommend that they should be performed in patients with a risk of prosthesis-patient mismatch.
|
References
|
|---|
-
Rahimtoola SH. The problem of valve prosthesis-patient mismatch. Circulation 1978;58:20–4.[Abstract/Free Full Text]
-
Carrel T, Zingg U, Jenni R, Aeschbacher B, Turina MI. Early in vivo experience with Hemodynamic Plus St Jude Medical heart valves in patients with narrowed aortic annulus. Ann Thorac Surg 1996;61:1418–22.[Abstract/Free Full Text]
-
Zingg U, Aeschbacher B, Seiler C, Althaus U, Carrel T. Early experience with the new Masters series of St Jude Medical heart valve: in vivo hemodynamic and clinical results in patients with narrowed aortic annulus. J Heart Valve Dis 1997;6:535–41.[Medline]
-
Ota T, Iwahashi K, Okada M, Nakamura K. Hemodynamics of 21 and 23 mm Medtronic-Hall valves by Doppler echocardiography. J Cardiovasc Surg 1992;33:472–8.[Medline]
-
Wiseth R, Levong OW, Tangen G, Rein KA, Skjaerpe T, Hatle L. Exercise hemodynamics in small (< or = 21 mm) aortic valve prostheses assessed by Doppler echo-cardiography. Am Heart J 1993;125:138–46.[Medline]
-
Bojar RM, Diehl JT, Moten M, Payne DD, Rastegar H, Stetz JJ, et al. Clinical and hemodynamic performance of the Ionescu-Shiley valve in the small aortic root. Results in 117 patients with 17 and 19 mm valves. J Thorac Cardiovasc Surg 1989;98:1087–95.[Abstract]
-
Teoh KH, Fulop JC, Weisel RD, Ivanov J, Tong CP, Slattery SA, et al. Aortic valve replacement with a small prosthesis. Circulation 1987;76(Suppl III):123–31.
-
Sawant D, Singh AK, Feng WC, Bert AA, Rotenberg F. Nineteen-millimeter aortic St. Jude Medical heart valve prosthesis: up to sixteen years' follow-up. Ann Thorac Surg 1997;63:964–70.[Abstract/Free Full Text]
-
Arom KV, Goldenberg TF, Emery RW. Long-term clinical outcome with small size standard St. Jude Medical valves implanted in the aortic position. J Heart Valve Dis 1994;3:531–6.[Medline]
-
Kratz JM, Sade RM, Crawford FA Jr, Crumbley AJ III, Stroud MR. The risk of small St. Jude aortic valve prostheses. Ann Thorac Surg 1994;57:1114–9.[Abstract]
-
Konno S, Imai Y, Iida Y, Nakajima M, Tatsuno K. A new method for prosthetic valve replacement in congenital aortic stenosis associated with hypoplasia of the aortic valve ring. J Thorac Cardiovasc Surg 1975;70:909–17.[Abstract]
-
Manouguian S, Seybold-Epting W. Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral leaflet. New operative technique. J Thorac Cardiovasc Surg 1979;78:402–12.[Abstract]
-
Nicks R, Cartmill T, Bernstein L. Hypoplasia of the aortic root. The problem of aortic valve replacement. Thorax 1970;25:339–46.[Abstract/Free Full Text]
-
Mayumi H, Toshima Y, Kawachi Y, Tokunaga K, Yasui H. Simplified Manouguian's aortic annular enlargement for aortic valve replacement. Ann Thorac Surg 1995;60:701–4.[Abstract/Free Full Text]
-
Otaki M, Oku H, Nakamoto S, Kitayama H, Ueda M, Matsumoto T. Two-directional aortic annular enlargement for aortic valve replacement in the small aortic annulus. Ann Thorac Surg 1997;63:261–3.[Abstract/Free Full Text]
-
Kawachi Y, Tominaga R, Tokunaga K. Eleven-year follow-up study of aortic or aortic-mitral annulus enlarging procedure by Manouguian's technique. J Thorac Cardiovasc Surg 1992;104:1259–63.[Abstract]
TOP
Abstract
Introduction
