Asian Cardiovasc Thorac Ann 2000;8:231-234
© 2000 Asia Publishing EXchange Pte Ltd
Aortic Valve Reconstruction: Midterm Results from Central Chest Hospital
Taweesak Chotivatanapong, MD,
Praditchai Chaiseri, MD,
Choosak Kasemsarn, MD,
Chaiwut Yotthasurodom, MD,
Vibhan Sungkahapong, MD,
Sireethorn Cholitkul, MD
Cardiothoracic Surgical Division
Central Chest Hospital
Nonthaburi, Thailand
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For reprint information contact: Taweesak Chotivatanapong, MD Tel: 66 2 588 3119 Fax: 66 2 589 9321 Cardiothoracic Surgical Division, Central Chest Hospital, Tivanonth Road, Nonthaburi 11000, Thailand.
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Abstract
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From September 1994 to September 1999, 50 patients underwent successful aortic valve reconstruction. Four were lost to follow-up, there were 2 early and 2 late deaths. The remaining 35 males and 11 females (mean age, 39.1 years) were followed up for 1 to 61 months (mean, 30.75 months). Most had rheumatic disease (27), the others had infective endocarditis (16) or degenerative disease (3). There was isolated aortic valve disease in 22 cases, double-valve disease in 16, triple-valve disease in 7, and 1 other. Preoperative aortic regurgitation was severe in most cases and the mean ejection fraction was 55.3%. Surgical procedures included subcommissural annuloplasty (14), cusp thinning (13), commissurotomy (10), and free-edge unrolling (10). Cusp extension with autologous pericardium was performed in 9 patients and aortic valve replacement with autologous pericardium in 22. Nine patients needed aortic valve replacement at a mean of 15.8 months postoperatively. The other 33 patients experienced marked improvements in aortic valve function. Aortic valve reconstruction is recommended in selected patients but reoperation remains an important problem. Long-term follow-up is needed to assess the role of this operation.
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Introduction
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Aortic valve reconstruction has recently gained more attention as an alternative treatment for aortic valve disease. It is of special interest in patients who are young, those desiring pregnancy, those who live in remote areas with problems of poor drug compliance, and in cases where long-term anticoagulation is contraindicated. This study reviewed the midterm results of aortic valve reconstruction at Central Chest Hospital, Thailand.
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Patients and Methods
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Between September 1994 and September 1999, aortic valve reconstruction was successfully performed in 50 patients; 4 were lost to follow-up and excluded from this study. Selection criteria included young age (under 65 years), poor drug compliance, desire for pregnancy, and contraindication to long-term anticoagulation. There were 35 males and 11 females, ages ranged from 14 to 64 years (mean, 39.1 years). Follow-up extended from 1 to 61 months with a mean of 30.75 months. Most patients (27) had rheumatic disease, 16 had infective endocarditis, and 3 had degenerative valve disease. Preoperative diagnoses are shown in Table 1
. Preoperatively, 5 patients were in New York Heart Association functional class II, 31 were in class III, and 10 were in class IV. Echocardiography showed degrees of aortic regurgitation (AR) of +4 in 18 patients, +3 in 14, and +2 in 14. The mean left ventricular end-diastolic diameter was 63.9 cm and mean left ventricular end-systolic diameter was 45.3 cm. The mean ejection fraction was 55.3%.
A median sternotomy was performed in all patients and cardiopulmonary bypass was instituted with moderate hypothermia (28°C to 30°C) and cold blood cardioplegia. Warm blood terminal perfusion was given prior to aortic declamping. The aortic valve was approached by a curvilinear incision in the ascending aorta. The valve was assessed to decide the most appropriate operation. If the pathology was mainly at the valve rim, it was repaired by the procedures described by Duran and colleagues.1,2 If the deformity involved more than one-third of the leaflet but the annulus and lower part of the leaflet were free, cusp extension was carried out using autologous pericardium treated with 0.65% glutaraldehyde. However, if the valve deformity involved the majority of the leaflet or if it was severely calcified, aortic valve replacement (AVR) with autologous pericardium was undertaken. The length of the annulus of each aortic valve cusp was measured carefully from commissure to commissure. A piece of glutaraldehyde-treated autologous pericardium was cut according to the length of each cusp, with the height of each cusp approximately 1 cm. The coaptation area of each cusp was increased to approximately 0.8 cm. The pericardial patch was fashioned as shown in Figure 1. The patch was sutured to the annulus using 5/0 Prolene (Ethicon, Somerville, NJ, USA) continuous suture, starting at the mid-cusp and finishing at the commissures on each side where it was tied. The commissures were then sutured to the aortic wall using 5/0 Prolene multiple interrupted sutures. The aorta was closed with 2 layers of 4/0 Prolene continuous suture. Additional procedures for associated diseases were carried out according to the pathology. Replacement of the mitral valve with a prosthesis precluded the use of autologous pericardium for AVR but not other aortic valve repair techniques. Intraoperative transesophageal echocardiography was routinely used to assess the valve. The operative findings, operations, and valve repair procedures are shown in Tables 2, 3, and 4. The mean cardiopulmonary bypass time was 182.7 minutes and the mean aortic crossclamp time was 143.4 minutes. Anticoagulation with warfarin for 12 weeks was given to patients in whom autologous pericardium was used, followed by aspirin 1 grain per day. Only aspirin was prescribed for the other patients.
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Figure 1. Autologous pericardial patch for use in aortic valve replacement. The length of each cusp from commissure to commissure is depicted as a', a'', and a'''. The height of each cusp (b) is 1 cm. The height of pericardium to ensure coaptation (c) is 0.8 cm.
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Results
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Hospital mortality occurred in 2 patients (4.3%) due to low cardiac output. Autologous pericardium was used for cusp extension in 1 and for total AVR in the other. There were 2 late deaths, 1 from cerebrovascular accident at 15 months postoperatively, the other from chronic obstructive pulmonary disease at 20 months. Nine patients needed AVR with a prosthesis because of deteriorating symptoms at a mean of 15.8 months postoperatively (range, 2 to 41 months). The average age of these 9 patients was 42.6 years (range, 25 to 63 years). Preoperatively, 5 had rheumatic disease, 3 had infective endocarditis, and 1 had degenerative disease. Aortic valve repair without auto-logous pericardium had been performed in 5 patients and the other 4 had undergone AVR with autologous peri-cardium. Redo AVR was needed because of progression of AR due to thickening and retraction of the native aortic leaflet (4) and the pericardial patch (1), reinfection (2), and disruption of the commissural suture (2). One patient required reoperation because acute AR developed one week after the initial operation. Disruption of the suture at the noncoronary cusp and the annulus was found. Resuturing gave a satisfactory result and he is currently stable.
The functional status of the remaining 33 patients (excluding hospital and late mortality and patients who needed redo AVR) was markedly improved: 18 were in New York Heart Association functional class I and 15 were in class II; whereas 8 were in class IV, 21 were in class III, and 4 were in class II before the operation. The degree of AR in these patients also improved post-operatively: 10 had +2 AR, 14 had +1, and 9 had no regurgitation. This was in contrast to the preoperative period in which 15 had +4, 10 had +3, and 8 had +2 AR. Echocardiography also showed improvements in mean left ventricular end-diastolic diameter to 57.3 mm and in mean left ventricular end-systolic diameter to 40.4 mm. Complications included transient ischemic attack in 1 patient at 10 months postoperatively. He recovered fully with conservative treatment. Wound infection occurred in 2 patients and responded to antibiotic therapy. Post-operative bleeding in 2 patients was controlled successfully by reoperation. Low cardiac output occurred in 1 patient. Mycotic aneurysm of the axillary artery was diagnosed in a patient who had preoperative bacterial endocarditis; the aneurysm was successfully excised and grafted.
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Discussion
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Several studies have shown encouraging early and medium-term results of aortic valve reconstruction.1–5 Use of glutaraldehyde-treated autologous pericardium as described by Duran and colleagues6 is an alternative technique for AVR. Repair techniques are particularly useful in selected patients. Because aortic homografts are not available in our hospital, we have no experience of aortic homograft or pulmonary autograft operations, which have been noted to provide good long-term results.7–9 As a result, the techniques of aortic valve reconstruction mentioned in this study seem to be very interesting alternative surgical procedures for correction of aortic valve dysfunction.
Our techniques of aortic valve reconstruction mostly followed those described by Duran and colleagues.1,2 However, in performing AVR with autologous peri-cardium, it was not uncommon to note that the aortic cusps are unequal in size, sometimes markedly different. Thus, we decided to measure each aortic cusp and tailor the pericardial patch to each patient individually. To test valve competency during surgery, the midpoints of the rim of each cusp are picked up together. If the cusps coapt nicely to the commissures, valve competency can be ensured. This will be confirmed by transesophageal echocardiography later.
In this study, lower hospital mortality was found among cases of aortic valve reconstruction without autologous pericardium (0/22) than in those with autologous pericardium (2/22). However, the reoperation rate appeared to be comparable in both groups (5 versus 4). It is interesting to note that of the 9 cases of redo AVR, 5 were due to progressive thickening and retraction of the native aortic leaflet and pericardial patch, resulting in severe AR. This may signify a continuing rheumatic process and reaction to the pericardial patch. It is a problem that surgeons must take into consideration, especially in young patients, when choosing the surgical option. Two of the redo AVR operations were due to a technical error that resulted in disruption of the commissural suture of the patch. This could be avoided with proper use of the technique. In 2 other patients, reoperation was caused by reinfection of the valve. This highlights the need for aggressive debridement, proper selection of the antibiotic treatment, and optimal timing of surgery before the infection becomes too advanced. One of the 2 hospital fatalities had undergone cusp extension. He had an abnormal position of the right coronary ostia, which was missed during direct coronary perfusion of cardioplegia. This resulted in inadequate myocardial protection and death. The other patient had mitral valve repair and AVR with autologous pericardium. Both valves were func-tioning well when assessed by intraoperative trans-esophageal echocardiography, however, the aortic cross-clamp time was prolonged, resulting in low cardiac output and death.
In patients who need concomitant mitral valve replace-ment, it is our policy to avoid AVR with autologous pericardium; other appropriate aortic valve reconstruction techniques are employed when feasible. This allows patients to benefit from correction of valve dysfunction without the risk associated with double-valve replacement that has less favorable long-term results than single-valve replacement. Whether the benefit of this approach will outweigh the risk of reoperation is an important issue that we must follow closely.
Based on these findings, it was concluded that aortic valve reconstruction may be used as an alternative treatment in selected patients with aortic valve disease. However, reoperation remains an important problem that surgeons must consider when deciding the best surgical option for each patient. Improved surgical techniques and patient selection should reduce the reoperation rate. Long-term follow-up is needed to define the role of this operation in the treatment of patients with valvular heart disease.
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References
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Duran C, Kumar N, Gometza B, Al Halees Z. Indications and limitations of aortic valve reconstruction. Ann Thorac Surg 1991;52:447–54.[Abstract]
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Al Fagin MR, Al Kasab SM, Ashmeg A. Aortic valve repair using bovine pericardium for cusp extension. J Thorac Cardiovasc Surg 1988;96:760–4.[Abstract]
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Cosgrove DM, Rosengranz ER, Hendren WG, Bartlett JC, Stewart WJ. Valvuloplasty for aortic insufficiency. J Thorac Cardiovasc Surg 1991;102:571–7.[Abstract]
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Fraser CD Jr, Wang N, Mee RBB, Lytle BW, McCarthy PM, Sapp SK, et al. Repair of insufficient bicuspid aortic valve. Ann Thorac Surg 1994;58:386–90.[Abstract]
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Duran CMG, Gometza B, Kumar N, Gallo R, Duran RM. Aortic valve replacement with freehand autologous pericardium. J Thorac Cardiovasc Surg 1995;110:511–6.[Abstract/Free Full Text]
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Ross D, Jackson M, Davies J. Pulmonary autograft aortic valve replacement: long-term result. J Card Surg 1991; 6(Suppl):529–33.[Medline]
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Gerosa G, Mckay R, Ross DN. Replacement of aortic valve or root with a pulmonary autograft in children. Ann Thorac Surg 1991;51:424–9.[Abstract]
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Abstract
Introduction
