Aortic valve repair via neo-chordae technique: mechanistic insight through numerical modelling.

Recently, the neo-chordae technique (NCT) was proposed to stabilize the surgical correction of isolated aortic valve (AV) prolapse. Neo-chordae are inserted into the corrected leaflet to drive its closure by minimal tensions and prevent relapses. In a previous in vitro study we analysed the NCT effects on healthy aortic roots (ARs). Here we extend that analysis via finite element models (FEMs). After successfully replicating the experimental conditions for validation purposes, we modified our AR FEM, obtaining a continent AV with minor isolated prolapse, thus representing a realistic clinical scenario. We then simulated the NCT, and systematically assessed the acute effects of changing neo-chordae length, opening angle, asymmetry and insertion on the aorta. In the baseline configuration the NCT restored physiological AV dynamics and coaptation, without inducing abnormal leaflet stresses. This outcome was notably sensitive only to neo-chordae length, suggesting that the NCT is a potentially easy-to-standardize technique. However, this parameter is crucial: major shortenings (6 mm) prevent coaptation and increase leaflet stresses by 359 kPa, beyond the yield limit. Minor shortenings (2-4 mm) only induce a negligible stress increase and mild leaflet tethering, which however may hamper the long-term surgical outcome.

An atypical cause of aortic valve prolapse.

We encountered a surgical case of aortic valve prolapse caused by a fissure formed in the commissural region and coronary cusp, and we achieved a favorable outcome. On pathologic examination, the fissured valve was found to be myxoid degeneration with ruptured elastic fibers and clustering of foamy macrophages, and it was diagnosed as an atherosclerotic change not associated with rheumatic change. The fissure appeared to develop because of hypertensive stress in a region rendered vulnerable by atherosclerosis. Although this mechanism is atypical, it should be recognized that poorly controlled hypertension can cause aortic valve prolapse and induce acute heart failure.

Endoscopic observation following aortic cusp plication.

In valve-sparing operations for aortic root aneurysms, the dilated aortic root is replaced by a vascular graft. However, cusp disorders remain in some cases. We observed closed cusps endoscopically, and an improvement in the cusp coaptation was seen following plication. One of our cases of aortic valve plication is reported here. A rigid thoracoscope and cannula for cardioplegia delivery were inserted from the distal end of the aortic graft, and the graft was inflated with cardioplegic solution, providing an endoscopic view of the closed aortic cusps. We believe that endoscopic observation of closing cusps in this way may help surgeons to learn and master the techniques used in cusp repair more rapidly.

Valve-sparing aortic root replacement with repair of leaflet prolapse after Ross operation.

The need for reoperation remains a principal limitation of the Ross procedure and most commonly includes replacement of the neo-aortic valve. Valve-preserving aortic root replacement has recently evolved into an increasingly accepted treatment modality for patients with neo-aortic valve regurgitation. Leaflet prolapse, however, may be present, making composite replacement the most frequent choice. Alternatively, valve preservation may be combined with correction of leaflet prolapse. We describe the use of a valve-sparing procedure with correction of leaflet prolapse in a patient with progressive dilatation of the pulmonary autograft and severe regurgitation of the neo-aortic valve.

Ventricular septal defect closure in right coronary cusp prolapse and aortic regurgitation complicating VSD in the outlet septum: which treatment is most appropriate?

BACKGROUND: There is currently not a standardized technique for the sizing and shaping of surgical closure of the ventricular septal defect (VSD) patch in patients with right coronary aortic cusp prolapse and aortic regurgitation (AR) complicating VSD in the outlet septum. METHODS: Forty-six VSD patients who had aortic valve prolapse were divided into groups DC (direct closure, n=19), and SPC (small patch closure, n=27). Preoperative and postoperative echocardiography with Doppler color flow interrogation was performed on all patients. RESULTS: In the DC group, among seven patients who had aortic valve prolapse but no AR preoperative, one patient developed AR during postoperative follow-up period. In the remaining 12 patients who had mild AR associated with aortic valve prolapse prior to the procedure, AR was diminished in four and unchanged in six patients. However, AR was aggravated in two patients who required further operations for AV repair or replacement. In the SPC group, among the eight patients who had no preoperative AR, AR progressed in one patient postoperatively. In the remaining 19 patients who had mild AR, AR was diminished in 15 and unchanged in four. The outcome from the operative procedure was significantly better in the SPC group than DC group with mild preoperative AR (chi(2)=7.82; P<0.05). CONCLUSIONS: Small patch closure for this type of VSD is safer and more reliable in improving mild AR than that of direct closure, especially in patients with mild AR.

Repair of aortic valve prolapse: experience with 44 patients.

OBJECTIVES: In regurgitant tricuspid aortic valves, cusp prolapse may be isolated or associated with dilatation of the proximal aorta. Newly appearing cusp prolapse can also appear after an aortic valve sparing operation (AVSO) and be responsible for residual aortic regurgitation. In this report, we describe our experience in repairing prolapsing aortic cusps in 44 patients with aortic regurgitation. METHODS: Between 1996 and 2003, 260 patients had aortic valve repair or valve sparing procedures in our department. All patients had peri-operative TEE. Prolapse of one or more of the aortic cusps was identified by TEE and confirmed by careful surgical inspection before and after valve sparing surgery. Forty-four patients with cusp prolapse were identified. Fifteen had an isolated prolapse, with a normal root (group I), 18 had cusp prolapse associated with dilatation of the proximal aorta (group IIa), and 11 had a newly appearing prolapse after AVSO (group IIb). Correction of the prolapsing cusp was achieved by either free edge plication, triangular resection or resuspension with PTFE. This procedure was associated with an aortic annuloplasty in group I, and with AVSO in groups II and III. RESULTS: Post-operative TEE showed AR trivial or grade I regurgitation. At a mean of 23 months follow-up, one patient with recurrent regurgitation required an aortic valve replacement with a homograft. All remaining patients were in NYHA class I or II. Echocardiography confirmed the durability of the valve repair. CONCLUSIONS: Among the common causes of aortic regurgitation, isolated cusp prolapse is frequent and is amenable to surgical repair with excellent mid-term results. In particular, in patents who are potential candidates for AVSO, identification and correction of an associated prolapse, either pre-existing or secondary to the AVSO procedure, may further extend the indications for this technique, increase its success rates and improve its long-term outcome.

Evolution of ventricular septal defect with special reference to spontaneous closure rate, subaortic ridge and aortic valve prolapse.

The medical records of 685 patients with ventricular septal defect (VSD) were reviewed to determine spontaneous closure, left ventricular-to-right atrial shunt, subaortic ridge, and aortic valve prolapse. Patients had been followed for a mean of 3 +/- 2.5 years and median 2.2 years by echocardiography. VSD was perimembranous in 65.7% (450), trabecular muscular in 30.8% (211), muscular outlet in 2.3% (16), muscular inlet in 0.7% (5), and doubly committed subarterial in 0.5% (3). Defect size was classified in 76% (517) as small, in 18% (124) as moderate, and in 6% (44) as large. VSD closed spontaneously in 27% (186 of 685 patients) by ages 40 days to 13.7 years (mean, 2.1 +/- 2.2 years; median, 1.3 years). Sixty-six of 450 perimembranous defects (15%) and 120 of 211 trabecular muscular defects (57%) closed spontaneously (p <0.001). Defect size became small in 15% of patients with VSD at mean 2.9 +/- 2.3 years (median, 2.3 years). Aneurysmal transformation was detected in 56% (254), left ventricular-to-right atrial shunt in 8.4% (38), subaortic ridge in 5.8% (26), aortic valve prolapse in 11.7% (53), and aortic regurgitation in 7.3% (33) of 450 patients with perimembranous defect. There was no statistical significance between the age at closure and the age of detection of aneurysmal transformation in the patients with perimembranous defect (p = 0.25).

Aortic root replacement with anomalous origin of the coronary arteries.

Coronary arteries with anomalous origin from the aorta can be at risk during aortic valve procedures. We report a case of origin of the circumflex and left coronary artery from the proximal right coronary artery in a patient with a bicuspid aortic valve and aortic root aneurysm. Attention to the anatomic relationship of the anomalous arteries to the aorta allowed safe aortic root replacement.

Unruptured aneurysm of the sinus of Valsalva into the pulmonary artery.

Congenital aneurysms of the sinus of Valsalva are rare lesions. Because the aortic root is central, the aneurysm can rupture into any cardiac chamber, and virtually all combinations of sinus and chamber fistulas have been described. Rupture into the pulmonary artery, however, is very rare. We encountered a 14-year-old boy with conal ventricular septal defect and right coronary cusp prolapse with an unruptured aneurysm of the sinus of Valsalva into the pulmonary artery.

Echocardiographic evaluation of the development of aortic valve prolapse in supracristal ventricular septal defect.

UNLABELLED: The development and timing of aortic valve prolapse (AoVP) and aortic regurgitation (AR) was studied by two-dimensional echocardiography in 99 consecutive patients with supracristal ventricular septal defect (VSD). Thirty patients (30%) had aortic valve prolapse (VSD + AoVP group), and 31 patients (31%) had AoVP with AR (VSD + AoVP + AR group). In the VSD + AoVP group, AoVP was detected first by echocardiography at the age of 6.8 +/- 4.2 years (mean +/- SD). In the VSD + AoVP + AR group, the interval from detection of AoVP to the appearance of AR was 3.4 +/- 2.0 years. The configuration of the prolapsed aortic valve was echocardiographically classified into two types: tear-drop type (small) prolapse and box type (large) prolapse. The frequency of tear-drop type prolapse was not significantly different between VSD + AoVP and VSD + AoVP + AR groups (43% versus 32%, respectively), indicating that even minor AoVP can result in AR. Four infants (4%) had AoVP at the ages of 1, 5, 7, and 11 months, respectively. All infants had tear-drop type prolapse. Two infants developed AR by colour flow mapping at the ages of 3 and 11 months, and the interval from prolapse to AR was only 2 and 4 months, respectively. CONCLUSION: Aortic valce involvement can develop under the age of 1 year in supracristal VSD. Regular evaluation by two-dimensional echocardiography with colour flow mapping is important in the follow-up of children with supracristal VSD.

Acute aortic valve prolapse in Marfan's syndrome.

A 22 year old man with Marfan's syndrome died suddenly following acute aortic valve prolapse. Although aortic root involvement in Marfan's syndrome is common, we have found no previous description of this particular complication in the literature.