COMBINED REPLACEMENT OF THE AORTIC VALVE AND ASCENDING AORTA IN JEHOVAH'S WITNESSES: REPORT OF TWO CASES

Two Jehovah's Witnesses with large ascending thoracic aortic aneurysms and aortic insufficiency secondary to annuloaortic ectasia underwent successful combined replacement of the aortic valve and the ascending aorta. One patient received a composite graft containing an aortic valve prosthesis, which necessitated supravalvular coronary ostia reimplantation; the other patient underwent separate aortic valve and left supracoronary ascending aneurysm replacement, with reimplantation of the right coronary ostium into the graft. No blood or blood derivatives were administered. Both patients had uneventful recoveries and continue to do well. To our knowledge, they represent the first reported cases of successful combined replacement of the aortic valve and ascending aorta in Jehovah's Witnesses.     

Earlier accumulation of calcium, phosphorus, and magnesium in the coronary artery in comparison with the ascending aorta, aortic valve, and mitral valve

To explore reasons for a high accumulation of Ca and P occurring in the coronary artery of Thai with aging, the authors investigated age-related changes of elements in the coronary artery, ascending aorta near the heart, and cardiac valves in single individuals, and the relationships in the elements between the coronary artery and either the ascending aorta or cardiac valves. After an ordinary dissection by medical students at Chiang Mai University was finished, the anterior descending arteries of the left coronary artery, ascending aortas, mitral valves, and aortic valves were resected from the subjects. The subjects consisted of 17 men and 9 women, ranging in age from 46 to 76 yr. The element content was analyzed by inductively coupled plasma-atomic emission spectrometry. The average content of Ca and P was the highest in the coronary artery and decreased in the order aortic valve, ascending aorta, and mitral valve. The Ca, P, and Mg content increased in the coronary artery in the fifties and in the ascending aorta, aortic valve, and mitral valve in the sixties. It should be noted that the accumulation of Ca, P, and Mg occurred earlier in the coronary artery than in the ascending aorta, aortic valve, and mitral valve. It was found that with respect to the Ca, P, Mg, and Na contents, the coronary artery correlated well with both the aortic valve and ascending aorta, especially with the aortic valve, but it did not correlate with the mitral valves. This finding suggests that the accumulation of Ca, P, Mg, and Na occurs in the coronary artery together with the aortic valve and ascending aorta, but not together with the mitral valve. Because regarding the accumulation of Ca, P, and Mg, the ascending aorta and aortic valve are preceded by the coronary artery, it is unlikely that the accumulation of Ca, P, and Mg spreads from the ascending aorta or aortic valve to the coronary artery.     

Combination of two pseudoaneurysms in a patient 6 years after ascending aorta and aortic valve replacement

BACKGROUND: We report successful treatment of a patient 6 years after ascending aorta and aortic valve replacement suffering from a combination of two pseudoaneurysms. The first of them originated from the coronary ostial suture line and the second pseudoaneurysm originated from the distal suture line. METHODS: We performed re-replantation of the left main trunk to the prosthesis and then we resected the pseudoaneurysm originating from the distal suture line and we replaced the entire aorta by a vascular graft. RESULTS: The postoperative convalescence was uneventful, the patient was discharged two weeks after the surgery. The patient is currently in a very good condition one year after the surgery. CONCLUSIONS: Coronary ostial pseudoaneurysm in patients after ascending aorta and aortic valve replacement with the use of "button technique" is a quite rare situation. The combination of two pseudoaneurysms originating from different suture lines in one patient seems to be unique in literature reviews.     

THE DIFFICULT PROXIMAL CORONARY ANASTOMOSIS

Two patients are presented in whom severe calcific aortitis made performance of satisfactory proximal coronary anastomosis impossible. Endarterectomy of the ascending aorta after aortic valve replacement, combined with aortocoronary bypass prior to performance of the proximal anastomoses, was successfully employed in one patient. The second patient underwent resection of an anterior segment of aorta, which was replaced by a woven Dacron patch into which the vein grafts were sewn.     

Sutureless aortic valve with supracoronary ascending aortic replacement as an alternative strategy for composite graft replacement in elderly patients

Netherlands Heart Journal - Aortic valve disease is frequently associated with ascending aorta dilatation and can be treated either by separate replacement of the aortic valve and ascending aorta...     

The Changing Pattern of Aortic Valve Repair

The changes and improvements in the surgical treatment of aortic valve disease in 296 patients, who were operated on between 1953 and 1965, are illustrated and discussed in general terms. Several of the early techniques, such as transventricular dilation, insertion of a homograft aortic valve in the descending thoracic aorta, fabric replacement of one cusp or the entire valve, and ice-chip arrest of the heart, are now obsolete. Total replacement with a ball-valve prosthesis or an aortic valve homograft while the coronary arteries are perfused with blood is the currently popular technique. The results of a hemodynamic follow-up study two years after surgery are also included.     

Bicuspid stenotic aortic valves: clinical characteristics and morphological assessment using MRI and echocardiography

Background

Bicuspid aortic valve (BAV) is one of the most common congenital heart defects with a population prevalence of 0.5% to 1.3%. Identifying patients with BAV is clinically relevant because BAV is associated with aortic stenosis, endocarditis and ascending aorta pathology.

Methods and Results

Patients with severe aortic stenosis necessitating aortic valve replacement surgery were included in this study. All dissected aortic valves were stored in the biobank of the University Medical Centre Utrecht. Additionally to the morphological assessment of the aortic valve by the surgeon and pathologist, echocardiographic and magnetic resonance imaging (MRI) images were evaluated. A total of 80 patients were included of whom 32 (40%) were diagnosed with BAV by the surgeon (gold standard). Patients with BAV were significantly younger (55 vs 71 years) and were more frequently male. Notably, a significant difference was found between the surgeon and pathologist in determining valve morphology. MRI was performed in 33% of patients. MRI could assess valve morphology in 96% vs 73% with echocardiography. The sensitivity of MRI for BAV in a population of patients with severe aortic stenosis was higher than echocardiography (75% vs 55%), whereas specificity was better with the latter (91% vs 79%). Typically, the ascending aorta was larger in patients with BAV.

Conclusion

Among unselected patients with severe aortic valve stenosis, a high percentage of patients with BAV were found. Imaging and assessment of the aortic valve morphology when stenotic is challenging.     

肥厚梗阻性心肌病的外科治疗

目的:总结肥厚室间隔切除术治疗肥厚梗阻性心肌病的手术效果,探讨外科治疗策略。方法:2002年3月至2010年10月,外科手术治疗33例肥厚梗阻性心肌病病人。其中男16例,女17例;年龄13～59岁,平均(42.7±13.6)岁;左室流出道压差(LVOTGP)70～120 mmHg(1 mmHg=0.133Kpa),平均(95.0±22.6)mmHg。其中合并二尖瓣关闭不全24例,主动脉瓣关闭不全7例,升主动脉增宽3例,冠心病2例。手术在全麻低温体外循环下完成,按常规经主动脉切口行室间隔心肌切除术,同期完成二尖瓣置换术(MVR)7例,二尖瓣成形术(MVP)7例,二尖瓣、主动脉瓣成形术(MVP+AVP)5例,二尖瓣、升主动脉成形术3例,二尖瓣、主动脉瓣成形、冠状动脉旁路移植术(MVP+AVP+CABG)2例。分析比较病人术前超声心动图(UCG),术中经食管心脏超声(TEE),以及术后1周、3月、6月、1年超声心动图结果。结果:手术死亡1例(3.0%,1/33例),主要死因为严重低心排综合症以及多脏器功能衰竭。二次开胸止血1例(3.0%,1/33例)。术中经食管心脏超声示所有病人二尖瓣前叶收缩期前向运动现象(SAM征)消失。存活病人手术效果良好,解剖狭窄解除,峰值压差降低,SAM现象基本消失。远期随访生存病人症状消失,生活质量明显改善,心功能I～II级,无远期死亡、并发症或再次手术。结论:外科治疗肥厚梗阻型心肌病具有良好的手术效果。了解病生理过程、术中仔细探察、手术切除彻底是手术成功的关键。     

肥厚梗阻性心肌病的外科治疗

目的：总结肥厚室间隔切除术治疗肥厚梗阻性心肌病的手术效果,探讨外科治疗策略。方法：2002年3月至2010年10月,外科手术治疗33例肥厚梗阻性心肌病病人。其中男16例,女17例;年龄13～59岁,平均（42.7±13.6）岁;左室流出道压差（LVOTGP）70～120 mmHg（1 mmHg=0.133Kpa）,平均（95.0±22.6）mmHg。其中合并二尖瓣关闭不全24例,主动脉瓣关闭不全7例,升主动脉增宽3例,冠心病2例。手术在全麻低温体外循环下完成,按常规经主动脉切口行室间隔心肌切除术,同期完成二尖瓣置换术（MVR）7例,二尖瓣成形术（MVP）7例,二尖瓣、主动脉瓣成形术（MVP＋AVP）5例,二尖瓣、升主动脉成形术3例,二尖瓣、主动脉瓣成形、冠状动脉旁路移植术（MVP＋AVP＋CABG）2例。分析比较病人术前超声心动图（UCG）,术中经食管心脏超声（TEE）,以及术后1周、3月、6月、1年超声心动图结果。结果：手术死亡1例（3.0%,1/33例）,主要死因为严重低心排综合症以及多脏器功能衰竭。二次开胸止血1例（3.0%,1/33例）。术中经食管心脏超声示所有病人二尖瓣前叶收缩期前向运动现象（SAM征）消失。存活病人手术效果良好,解剖狭窄解除,峰值压差降低,SAM现象基本消失。远期随访生存病人症状消失,生活质量明显改善,心功能I～II级,无远期死亡、并发症或再次手术。结论：外科治疗肥厚梗阻型心肌病具有良好的手术效果。了解病生理过程、术中仔细探察、手术切除彻底是手术成功的关键。     

老年Stanford A 型主动脉夹层外科治疗*

目的:总结老年Stanford A型主动脉夹层外科治疗经验,探讨手术方式的选择,以提高手术疗效。方法:2008年9月至2011年5月对31例老年Stanford A型主动脉夹层行手术治疗,根据夹层破口位置、累及范围、主动脉根部病变情况采取相应术式,W-heat手术2例,David+全弓置换+支架象鼻术3例,Bentall+全弓置换+支架象鼻术9例,改良Wheat+全弓置换+支架象鼻术1例,升主动脉+全弓置换+支架象鼻术16例。同时行冠状动脉旁路移植术4例,心包剥脱术1例。结果:全组体外循环(221±43)min,平均心肌阻断(132±41)min,深低温停循环(47±12)min。术后并发症12例(38.7%),其中2例死亡,8例治愈(66.7%),2例术后出现肾功能衰竭家属放弃治疗。全组病人出院前复查主动脉CTA,见升主动脉、弓部人工血管血流通畅,支架位置正常,无明显移位。支架远端降主动脉假腔闭合率87.1%。随访2~35个月,术后近期死亡1例(3.2%),无再次手术者。结论:对老年StanfordA型主动脉夹层这一高危人群,术中根据其病变部位施行最佳的外科手术方式,可明显降低死亡率,改善患者预后。     

Patient-specific simulation of transcatheter aortic valve replacement: impact of deployment options on paravalvular leakage

Biomechanics and Modeling in Mechanobiology - Transcatheter aortic valve replacement (TAVR) has emerged as an effective alternative to conventional surgical valve replacement in high-risk patients...     

Stentless aortic valve implantation through an upper manubrium-limited V-type ministernotomy

In this piece of work, we attempt to highlight our approach and early experience with minimally invasive aortic valve replacement with aortic Freedom Solo stentless bioprosthesis performed through an upper manubrium-limited ministernotomy in the second intercostal space. The novel suturing technique is required for stentless aortic bioprosthesis implantation, and this, in its turn, will predetermine and influence the surgeon's choice for operative access. In our department, the feasibility of the approach was first assessed; aortic valve was replaced by stentless bioprosthesis in a total of 23 patients (mean age 57 ± 12 years). In all cases, a cardiopulmonary bypass was established by a central ascending aorta cannulation and peripheral percutaneous venous cannula insertion. This approach was found to be technically reproducible and safe. The surgical technique used is described in this article.     

Helical flows and asymmetry of blood jet in dilated ascending aorta with normally functioning bicuspid valve

Bicuspid aortic valve (BAV) is associated with aortic dilatation and aneurysm. Several studies evidenced an eccentric systolic flow in ascending aorta associated with increased wall shear stresses (WSS) and the occurrence of an helical systolic flow. This study seeks to elucidate the connections between jet asymmetry and helical flow in patients with normally functioning BAV and dilated ascending aorta. We performed a computational parametric study by varying, for a patient-specific geometry, the valve area and the flow rate entering the aorta and drawing also a tricuspid valve (TAV). We considered also phase-contrast magnetic resonance imaging of four BAV and TAV patients. Measurement of normalized flow asymmetry index, systolic WSS and of a new index (positive helix fraction, PHF) quantifying the presence of a single a single helical flow were performed. In our computation, BAV cases featured higher values of all indices with respect to TAV in both numerical and imaged-based results. Moreover, all indices increased with decreasing valve area and/or with increasing flow rate. This allowed to separate the BAV and TAV cases with respect to the jet asymmetry, WSS localization and helical flow. Interestingly, these results were obtained without modeling the leaflets.     

Ionescu-Shiley pericardial xenograft valve: Hemodynamic evaluation and early clinical follow-up of 326 patients

Dissatisfaction with the hemodynamic characteristics of available porcine valves prompted a clinical trial of the Ionescu-Shiley percardial xenograft (ISPX) valve. Three hundred fifty-six ISPX valves were implanted consecutively in 326 patients. Operative mortality was 2.6% (2/75) for aortic valve replacement alone and 7.7% (12/155) for aortic valve replacements that included reoperations and combined procedures such as mitral commissurotomy, annuloplasty, and coronary artery bypass. Operative mortality for all patients who underwent mitral valve replacement was 9.5% (14/147). The mean peak systolic gradient pressure in the aortic position was 5.4 mm Hg overall and 4.27 mm Hg with the size 19 mm valve. There were no embolic episodes in patients who received the ISPX valve in the aortic position. The available data indicate that the rate of peripheral embolism with the ISPX valve compares favorably with that of porcine valves. Considering its hemodynamic advantage, if the longterm durability of the full-orifice Ionescu-Shiley pericardial xenograft valve continues to be confirmed by follow-up studies, it is our opinion that it is the biologic valve of choice.     

Intracardiac echocardiographic guidance for hemodynamic assessment in a patient with congenital abnormalities and a prosthetic aortic valve

In this case report, we present the use of intracardiac echocardiography (ICE) for guiding the cardiac catheterization and subsequent hemodynamic investigation in an unusual patient case with multiple congenital abnormalities (bicuspid aortic valve, left cervical aortic arch, two aortic coarctations) and two aortic valve replacement operations in the past. The ICE catheter (AcuNav) permitted us to accurately and safely puncture the interatrial septum and place the Swan-Ganz catheter in the left ventricle; additionally, visualization of the aortic coarctation in the ascending aorta was also achieved.     

Management of a protruding right coronary artery stent during aortic valve replacement for aortic stenosis

ABSTRACT: We describe the successful management of a stent protruding from the right coronary ostium into the aortic root in the setting of aortic valve replacement for aortic stenosis. Due to advances in medical care more elderly patients present for aortic valve surgery after percutaneous coronary intervention. Therefore, with an aging population due to advances in medical care, more patients will present for aortic valve surgery after percutaneous coronary intervention. We suggest a degree of caution before valve deployment in transcatheter aortic valve intervention or during annular manipulation in patients undergoing traditional aortic valve replacement with coexisting patent proximal stents.     

Ventriculo-aortic junction in human root. A geometric approach

With advances in tissue engineering and improvement of surgical techniques, stentless biological valves and valve-sparing procedures have become alternatives to traditional aortic valve replacement with stented bioprostheses or mechanical valves. New surgical techniques preserve the advantages of native valves but require better understanding of the anatomical structure of the aortic root. Silicone rubber was injected in fresh aortic roots of nine human cadavers under the physiological closing pressure of 80 mmHg. The casts reproduced every detail of the aortic root anatomy and were used to digitize 27 leaflet attachment lines (LALs) of the aortic valves. LALs were normalized and described with a mathematical model. LALs were found to follow a pattern with the right coronary being the largest followed by the non-coronary and then the left coronary. During diastole, the aortic valve LAL can be described by an intersection between a created tube and an extruded parabolic surface. This geometrical definition of the LAL during end diastole gives a better understanding of the aortic root anatomy and could be useful for heart valve design and improvement of aortic valve reconstruction technique.     

Assessment of valve implantation in the descending aorta as an alternative for aortic regurgitation patients not treatable with conventional procedures

Background:

Aortic Regurgitation (AR) produces the entrance of an abnormal amount of blood in the left ventricle. This disease is responsible for high morbidity and mortality worldwide and may be caused by an aortic valve dysfunction. Surgical and transcatheter aortic valve replacement (TAVR) are the current options for treating AR. They have replaced older procedures such as Hufnagel’s one. However, some physicians have reconsidered this procedure as a less aggressive alternative for patients not eligible for surgical or TAVR. Although Hufnagel suggested a 75% regurgitation reduction when a valve is placed in the descending aorta, a quantification of this value has not been reported.

Methods:

In this paper, CFD/FSI numerical simulation is conducted on an idealized geometry. We quantify the effect of placing a bileaflet mechanical heart valve in the descending aorta on a moderate-severe AR case. A three-element Windkessel model is employed to prescribe pressure outlet boundary conditions. We calculate the resulting flow rates and pressures at the aorta and first-generation vessels. Moreover, we evaluate several indices to assess the improvement due to the valve introduction.

Results and conclusions:

Regurgitation fraction (RF) is reduced from 37.5% (without valve) to 18.0% (with valve) in a single cardiac cycle. This reduction clearly shows the remarkable efficacy of the rescued technique. It will further ameliorate the left ventricle function in the long-term. Moreover, the calculations show that the implantation in that location introduces fewer incompatibilities’ risks than a conventional one. The proposed methodology can be extended to any particular conditions (pressure waveforms/geometry) and is designed to assess usual clinical parameters employed by physicians.

     

Selection of Reference Genes for Quantitative Real Time PCR (qPCR) Assays in Tissue from Human Ascending Aorta

Dilatation of the ascending aorta (AAD) is a prevalent aortopathy that occurs frequently associated with bicuspid aortic valve (BAV), the most common human congenital cardiac malformation. The molecular mechanisms leading to AAD associated with BAV are still poorly understood. The search for differentially expressed genes in diseased tissue by quantitative real-time PCR (qPCR) is an invaluable tool to fill this gap. However, studies dedicated to identify reference genes necessary for normalization of mRNA expression in aortic tissue are scarce. In this report, we evaluate the qPCR expression of six candidate reference genes in tissue from the ascending aorta of 52 patients with a variety of clinical and demographic characteristics, normal and dilated aortas, and different morphologies of the aortic valve (normal aorta and normal valve n = 30; dilated aorta and normal valve n = 10; normal aorta and BAV n = 4; dilated aorta and BAV n = 8). The expression stability of the candidate reference genes was determined with three statistical algorithms, GeNorm, NormFinder and Bestkeeper. The expression analyses showed that the most stable genes for the three algorithms employed were CDKN1β, POLR2A and CASC3, independently of the structure of the aorta and the valve morphology. In conclusion, we propose the use of these three genes as reference genes for mRNA expression analysis in human ascending aorta. However, we suggest searching for specific reference genes when conducting qPCR experiments with new cohort of samples.     

Iatrogenic ascending aortic dissection following cannulation for arterial return and for infusion of cardioplegic solution: Prevention and repair

Two patients are presented in whom dissection of the ascending aorta resulted from cannulation for arterial return and from the infusion of cardioplegic solution. The dissections were recognized promptly. Following dissection in the first patient, the femoral artery was used to reestablish systemic perfusion. The aortic valve and dissected ascending aorta were replaced, and three vessels were grafted. In the second patient, the dissected anterior wall of the ascending aorta was excised and replaced with a low-porosity Dacron patch into which the proximal aortocoronary anastomoses were inserted. Predisposing factors are discussed, along with preventive measures and methods of repair.