Takayasu's Arteritis with Aortic Insufficiency as Initial Presentation: A Case Report

Takayasu's disease is the first cause of inflammatory aortitis in young subjects. The disease preferentially affects the women. Takayasu's disease could be a mode of non-specific reaction of the aorta to various infectious or dysimmune etiological factors. Aortic insufficiency is present in 7 to 10% of cases. It is usually moderate. Its mechanism is not unambiguous: direct damage to the aortic valves or dilation of the aortic annulus. Coronary damage responsible for angina or even myocardial infarction are also possible. We report the case of a severe aortic insufficiency secondary to takayasu disease complicated by acute coronary syndrome in a 42-year-old woman.

Early outcome of transapical transcatheter aortic valve replacement for aortic insufficiency / 中国胸心血管外科临床杂志

@#Objective    To assess the early outcome of transapical transcatheter aortic valve replacement (TAVR) for patients with aortic insufficiency. Methods    The patients with aortic valvular disease who underwent transapical TAVR from October 2020 to October 2022 in the Department of Cardiac and Vascular Surgery, the First Affiliated Hospital of Anhui Medical University were enrolled in the current retrospective study. The patients with aortic stenosis were assembled in a group A, and the patients with aortic insufficiency were assembled in a group B. The improvements of heart function and complications were assessed for the two groups. Results    A total of 56 patients were enrolled, including 32 males and 24 females with an average age of 73.34±5.10 years. There were 31 patients in the group A and 25 patients in the group B. There was no statistical difference between the two groups in the age, gender, height, weight, hypertension, coronary artery disease, peripheral vascular disease, chronic obstructive pulmonary disease, renal disorder or classification of heart function (P>0.05). Also, there was still no statistical difference in the rate of permanent peacemaker implants, emergent open surgery, valve re-implants, or perivalvular leakage (P>0.05). After TAVR, the left ventricular diastolic diameter, left ventricular ejection fraction, complicated moderated mitral and tricuspid regurgitation were significantly improved in both groups compared with preoperative findings (P<0.05); however, there was no statistical difference in these parameters between groups (P>0.05). Conclusion    Interventional valve (J-Valve) in the treatment of patients with aortic insufficiency through transapical TAVR significantly improves cardiac function and reduces functional valve regurgitation.

Reemplazo valvular aórtico con prótesis biológica St. Jude Trifecta®. Evaluación posoperatoria a mediano plazo del comportamiento clínico y hemodinámico / Mid term posoperative evaluation of aortic valve replacement with St. Jude Trifecta™ bioprosthesis

Resumen Introducción: la válvula St. Jude Trifecta® es una bioprótesis diseñada para implante en posición aórtica supraanular. Objetivo: Evaluar el comportamiento hemodinámico de la válvula y el estadio clínico de los pacientes, entre 3 a 72 meses luego del implante. Materiales y método: Estudio de cohorte en el que se incluyeron pacientes mayores de 18 años, llevados a cambio valvular aórtico en quienes se implantó una bioprótesis St. Jude Trifecta® entre marzo de 2012 a diciembre de 2018, y se hizo un seguimiento mediante evaluación clínica y ecocardiográfica desde tres meses hasta seis años posquirúrgicos. Resultados: Se incluyeron 165 pacientes, 53.3% hombres. Edad promedio 69.6 años (30-90). El 66.7% con estenosis valvular aórtica y el 21.2% con insuficiencia. El promedio de EuroSCORE II fue 4.18 (0.56-24.35). En el preoperatorio, 60.6%, 29.6% y 9.69% de los pacientes se encontraban en clase funcional NYHA II, III y IV, respectivamente. Luego del implante, el promedio de área del orificio efectivo indexado fue 1.025 cm2/m2 para bioprótesis N.o 19 1.089cm2/m2, 1.085 cm2/m2 y 1.069 cm2/m2 para prótesis N.o 21, 23 y 25, respectivamente. El gradiente medio transvalvular en el posoperatorio inmediato (en sala de cirugía) fue 3.08 mmHg. Durante el seguimiento ecocardiográfico a 3, 6, 12, 24, 36 y 72 meses, el gradiente medio fue de 4.2, 5.7, 6.3, 7.1, 8.3 y 9.1 mmHg, respectivamente. La mortalidad quirúrgica fue del 2.42%. Ningún paciente presentó desproporción prótesis-paciente, accidente cerebrovascular o endocarditis. Durante el tiempo del estudio ninguno ha requerido reintervención por deterioro valvular estructural. Al seguimiento, 83.6% se encontraron en NYHA I. Conclusión: En el grupo estudiado, el reemplazo valvular aórtico con bioprótesis St. Jude Trifecta® demostró excelentes resultados clínicos (NYHA I, 83%) y hemodinámicos (no reoperación por deterioro valvular estructural, bajos gradientes transvalvulares y adecuado orificio efectivo indexado), durante el tiempo de evaluación clínica y ecocardiográfica (3 a 72 meses).

Abstract Background: The St. Jude Trifecta™ valve is a latest generation bioprosthetic designed for supra annular aortic placement. The study main objective is the evaluation of the hemodynamic valve performance and the 3 to 72 months post implantation clinical status of the patients. Method and materials: Cohort study on patients older than 18 years, undergoing aortic valve replacement with St. Jude Trifecta™biological valve prosthesis between march 2012 and december 2018. The follow up was made by clinical evaluation and serial echocardiogram from 3 months to 6 years after surgery. Results: 165 patients where included, 53.3% male. Mean age 69.6 years (30-90). The main indication for valve replacement was aortic stenosis (66.7%). Mean EuroSCORE II was 4.18 (0.56-24.35). Preoperative 60.6%, 29.6% and 9.69% of patients where in New York Heart Association functional class (NYHA) II, III and IV respectively. After the surgery, the mean effective orifice area index (IEOA) was 1.025 cm2/m2 for prosthesis N.o 19; 1.089cm2/m2 (prosthesis 21); 1.085 cm2/m2 (prosthesis 23) and 1.069 cm2/m2 (prosthesis 25). The mean transvalvular gradient was 3.08 mmHg at the immediate posoperative period, and the mean gradient at 3,6,12,24,36 and 72 months was 4.2, 5.7, 6.3, 7.1, 8.3 and 9.1 mmHg, respectively. 30 days mortality was 2.42%. None of the patients have a posoperative patient-prosthesis mismatch (PPM), neither thromboembolic events or endocarditis. There is no patients with re-operation for structural valve deterioration. After follow up, 83.6% of the patients are in NYHA I functional class. Conclusion: In this Study group, St. Jude Trifecta™ valve for aortic valve replacement provides excellent clinical (NYHA I, 83%) and hemodynamic outcomes (demostrated by no patients with re-operation for structural valve deterioration, a low post operative transvalvular gradients; IEOA that avoid PPM; excellent clinical and echocardiographic outcome during follow up (3 to 72 months).

Short-term outcomes of aortic root repair using a pericardial autograft for acute type A aortic dissection / 中华胸心血管外科杂志

Objective:To evaluate the short-term outcomes of aortic root repair using a pericardial autograft for acute type A aortic dissection.Methods:Between January 2020 and August 2021, 12 patients underwent aortic root repair using a pericardial autograft for type A aortic dissection. There were 8 males and 4 females, aged from 32.0 to 71.0 years, with a mean of (49.1±13.0) years, weight from 40.0 to 100.0 with a mean of (78.6±20.5) kg. Short-term outcomes were assessed by cardiopulmonary bypass time, cross-clamp time, circulatory arrest time, mechanical ventilation time, ICU time, postoperative stay time. The diameter of Valsalva sinus and aortic regurgitation were assessed before, after operation and during follow-up.Results:There were no postoperative and follow-up death. Cardiopulmonary bypass time was(256.4±60.6)min, ranging from 182.0 to 243.0 minutes; cross-clamp time was(195.0±52.5)minutes, ranging from 127.0 to 284.0 minutes; circulatory arrest time was(19.9±3.6)min, ranging from 15.0 to 25.0 min; mechanical ventilation time was (69.1±72.1)hours, ranging from 6.4 to 250.3 h; ICU time was (143.6±81.7) h, ranging from 56.9 to 288.0 h; postoperative stay time was (12.8±4.1) days, ranging from 8.0 to 20.0 days. One patient had transient paralysis (8.3%), and one patient needed hemofiltration due to acute kidney failure (8.3%), they all completely recovered before discharge. Follow-up time ranged from 10.0 to 21.0 months, with a median of 13 months. Heart function (NYHA) was I to II degrees. The mean diameter of aortic root was (36.7±5.8)mm(27.0-45.0 mm) preoperatively, (35.8±5.1)mm (25.0-44.8 mm) before discharge, and (35.7±5.9)mm (25.1-44.8 mm) during follow-up, respectively. There was no significant difference between them ( P>0.05). The preoperative aortic regurgitation was as follow: severe aortic regurgitation 2, moderate 1, mild to moderate 3, mild 1, trivial 1, none 4; postoperative aortic regurgitation: mild 2, trivial 2, none 8; follow-up aortic regurgitation: mild 3, trivial 1, none 8. Conclusion:Aortic root repair with a pericardial autograft is a safe and effective technique to treat acute type A dissection involving the sinus. Using this technique, residual dissection tissues could be significantly reduced, which subsequently decreases the risk of proximal bleeding, maintains the function of sinus, and increases long-term durability. Short-term results are satisfactory, and the long-term results need further follow-up.

Síndrome coronario agudo e insuficiencia mitral-aórtica grave en un paciente con rubeola congénita / Acute coronary syndrome and mitral-aortic insufficiency in a patient with congenital rubella

Resumen La rubeola es una enfermedad exantemática que se produce en la infancia. En caso de que se presente durante la gestación y hubiera afectación del producto, este puede desarrollar el síndrome de rubeola congénita, el cual incluye malformaciones cardiacas que se presentan en el 67% de los pacientes, de las cuales la más común es la persistencia del conducto arterioso, seguida de la estenosis valvular pulmonar y la comunicación interauricular. Se presenta el caso de un hombre de 20 años con diagnóstico de síndrome de rubeola congénita, quien desarrolló glaucoma congénito, insuficiencia aórtica grave, insuficiencia mitral grave y enfermedad miocárdica isquémica. Se realizó procedimiento quirúrgico de revascularización coronaria y recambio valvular mitral y aórtico. Los estudios encontrados durante el proceso de investigación mencionan el daño de los vasos sanguíneos y del miocardio producido por el virus. Con los datos obtenidos se corrobora la baja incidencia de presentación con compromiso coronario y valvular, por lo cual se hace énfasis en la importancia de este caso.

Abstract Rubella is an exanthematous disease that occurs in childhood. If it occurs during pregnancy and there is an effect on the product, it can develop congenital rubella syndrome. The congenital rubella syndrome includes cardiac malformations, which occur in 67% of patients, of which the most common is patent ductus arteriosus, followed by pulmonary valvular stenosis and atrial septal defect. We present the case of a 20-year-old man with a diagnosis of congenital rubella syndrome, presenting with congenital glaucoma, severe aortic insufficiency, severe mitral regurgitation and ischemic myocardial disease. In which a surgical procedure is performed by a coronary revascularization and mitral and aortic valve replacement. Studies found during the research process mention the damage to the blood vessels and myocardium produced by the virus. With the required data, the low incidence of presentation with coronary and valvular involvement is corroborated, which is why the importance of the present case is emphasized.

Outcomes of surgical treatment for congenital aortic stenosis in 145 children: A retrospective cohort study / 中国胸心血管外科临床杂志

@#Objective    To explore the experience of surgical repair for congenital aortic stenosis (AS) in our center. Methods    We retrospectively reviewed the clinical data of 145 children diagnosed with AS, who underwent aortic repair from 2008 to 2019, with or without aortic insufficiency (AI), including 104 males and 41 females with a median age of 2.9 (0.6, 7.8) years. The preoperative and intraoperative data, early and long-term valvular function, long-term survival rate and freedom from reoperation and aortic valve replacment (AVR) were analyzed. Results    There were 120 patients receiving commissurotomy, 15 valvuloplasty with extra pericardium patch, and 25 AVR. The mean follow-up time was 0.25-11.20 (4.2±2.8) years. Survival rate at 10 years was 92.3%. Freedom from reoperation and AVR was 63.2% and 60.4%respectively. Multivariate analysis revealed that using a patch during surgery (P=0.036) was an independent risk factor for reoperation. A history of preoperative balloon dilation (P=0.029) and significant preoperative AI (P=0.001) contributed to AVR. Conclusion    Surgical treatment of congenital aortic valve stenosis in children is a safe and effective method that provides enough time to achieve a more definitive solution. Using a patch during surgery increases reoperation hazard. A history of previous balloon dilation and significant preoperative AI may result in AVR during the follow-up.

Value of transthoracic echocardiography to monitor and evaluate aortic insufficiency after implantation of left ventricular assist device / 中国胸心血管外科临床杂志

@#Objective    To explore the value of transthoracic echocardiography (TTE) to monitor and evaluate aortic insufficiency (AI) within one year after the implantation of the left ventricular assist device (LVAD). Methods    We retrospectively collected and analyzed the TTE data of 12 patients who received LVAD implantation from 2018 to 2020 in our hospital. All patients were males, with an average age of 43.3±8.6 years. We analyzed temporal changes in the aortic annulus (AA), aortic sinus (AoS), ascending aorta (AAo), the severity of AI and the opening of aortic valve before operation and 1 month, 3 months, 6 months and 12 months after LVAD implantation. Results    All 12 patients survived within 1 year after LVAD implantation. One patient was bridged to heart transplantation 6 months after implantation, and two patients did not receive TTE after 3 and 6 months. Compared to pre-implantation, AoS increased at 1 month after implantation (31.58±5.09 mm vs. 33.83±4.69 mm). The inner diameters of AA, AoS and AAo increased at 3, 6 and 12 months after LVAD implantation compared to pre-implantation (P<0.05), but all were within the normal range except for one patient whose AoS slightly increased before operation. After LVAD pump speed was adjusted, the opening of aortic  valve improved. The severity of AI increased at 6 and 12 months after LVAD implantation compared to pre-implantation, and increased at 12 months compared to 6 months after LVAD implantation (P<0.05). Conclusion    TTE can evaluate aortic regurgitation before and after LVAD implantation and monitor the optimization and adjustment of LVAD pump function, which has a positive impact on the prognosis after LVAD implantation.

Numerical Analysis on Adaptability of Valve Leaflets after Single Valve Replacement in Children / 医用生物力学

Objective To explore the biomechanical mechanism of aortic insufficiency (AI) after single aortic valve replacement (SAVR) in children and propose the corresponding countermeasures. Methods The idealized aortic valve model and postoperative growth model were constructed. By changing the length of leaflet free edge, leaflet height as well as improving the design with a concave structure, the effects of different structure dimensions on movement synchronization and closing performance of the aortic valve after surgery were compared. Results The closure of the replacement leaflet lagged behind the autologous leaflet, which fitted 2 mm below free edge of the replacement leaflet. AI occurred 6 years after operation. Increasing leaflet height could not improve the postoperative effect and would increase the maximum stress of the leaflet. Increasing free edge length by 10% could improve the postoperative outcomes, while increasing free edge length by 15% would cause the leaflet to be too long, hence resulting in a poor fit of the aortic valve. Compared with the traditional structure, the concave structure was more beneficial for closing performance of the aortic valve, and it could effectively reduce the maximum stress by 20% with the best effect. Conclusions The leaflet movement will be out of synchronization after SAVR, the point of convergence will be shifted, and AI will appear 6 years after surgery. It is recommended to use a concave structure with free edge length increased by 10%, while increasing leaflet height is not recommended.

Aneurisma del seno de Valsalva derecho roto disecado al septum interventricular / Ruptured right sinus of valsalva aneurysm with dissection to the interventricular septum

Resumen Se presenta el caso de un paciente de género masculino, de 69 años de edad, con antecedentes de hipertensión arterial y cuadro de disnea de pequeños a mínimos esfuerzos; implante de cardio-resincronizador por bloqueo aurículo-ventricular completo y bajo gasto cardiaco. El ecocardiograma evidenció imagen quística en septum interventricular. El cateterismo cardiaco mostró aneurisma del seno de Valsalva derecho roto que se diseca hacia el septum interventricular dando lugar a un saco de 4 x 3,4 cm el cual deforma el anillo valvular aórtico y produce insuficiencia valvular aórtica severa. Se considera el cierre quirúrgico del aneurisma y el implante de prótesis aórtica biológica, procedimiento que se lleva a cabo con éxito. Se presenta un caso muy poco frecuente de disección del septum interventricular por aneurisma del seno de Valsalva derecho roto. Este tipo no está incluido en la clasificación de estas rupturas de los senos de Valsalva.

Abstract The case is presented on a 69 year-old male patient with a history of arterial hypertension and a clinical picture of dyspnoea on little or minimal effort, as well as an implanted cardiac resynchronization device due to complete atrial-ventricular block and low cardiac output. The echocardiogram showed an image of a cyst in the interventricular septum. The cardiac catheterisation showed a ruptured right sinus of Valsalva aneurysm that was dissected up to the interventricular septum, producing a sac of 4 x 3.4 cm that deformed the aortic valve ring and caused severe aortic valve insufficiency. The procedure for the surgical closure of the aneurysm and the implant of a biological aortic valve was performed successfully. A very rare case is presented of an interventricular septum dissection due to a ruptured right sinus of Valsalva aneurysm. This type is not included in the classification of sinus of Valsalva ruptures.

Implante percutáneo de válvula aórtica con apoyo de circulación extracorpórea en paciente con insuficiencia aórtica severa / Trans catheter aortic valve implantation with extra corporeal circulation support in a patient with severe aortic insufficiency

An 84-year man with prior coronary artery bypass surgery and endovascular repair of an abdominal aortic aneurysm developed congestive heart failu-re. He had calcific aortic valve disease with severe regurgitation. A #29 Edwards-Sapien aortic valve via trans-apical approach was implanted with the patient connected to extra corporeal circulation. The patient recovered successfully and remained in functional class II 8 months after hospital dis-charge.

Aneurisma del tronco de la coronaria izquierda e insuficiencia aórtica de origen sifilítico.: Reporte de un caso y revisión de la literatura / Aneurysm of the left main coronary artery and aortic insufficiency of syphilitic origin: Case report and literature review / Aneurisma do tronco da artéria coronária esquerda e insuficiência aórtica de origem sifilítico: Relato de caso e revisão da literatura

Los aneurismas de las arterias coronarias son muy raros. Ocurren más frecuentemente en la arteria coronaria derecha, seguidos por los de la arteria coronaria descendente anterior y circunfleja. Los aneurismas del tronco de la arteria coronaria izquierda son aún más raros. La enfermedad más frecuentemente asociada a esta entidad es la aterosclerosis coronaria con estenosis severas en las zonas adyacentes a los mismos. La sífilis terciaria con manifestaciones cardiovasculares puede producir aortitis, insuficiencia aórtica, miocarditis y aneurismas o estenosis de las coronarias. El estándar de oro para el diagnóstico de los aneurismas coronarios es la angiografía coronaria y su tratamiento dependerá de la etiología y localización de los mismos. El tratamiento antibiótico en sífilis terciaria es imperativo; sin embargo no existe consenso en cuanto al tratamiento de los aneurismas coronarios en ausencia de obstrucciones. El tratamiento a largo plazo con anticoagulantes orales puede estar recomendado en este tipo de pacientes.

Aneurysms of the coronary arteries are very rare. Occur more frequently in the right coronary artery, followed by those of the left anterior descending coronary artery and circumflex. Aneurysms of the left main coronary artery are even more rare. The disease most often associated with this pathology is coronary atherosclerosis with severe stenosis in the section adjacent to them. Tertiary syphilis with cardiovascular manifestations can produce aortitis, aortic insufficiency, myocarditis and aneurysms or coronary stenosis. The gold standard for diagnosis of coronary aneurysms is coronary angiography and treatment depends on the etiology and location thereof. Antibiotic treatment in tertiary syphilis is imperative; however there is no consensus on the treatment of coronary aneurysms in the absence of obstructions. The long-term treatment with oral anticoagulants may be recommended in these patients.

Os aneurismas das artérias coronárias são muito raros. Ocorrem com mais frequência na artéria coronária direita, seguido por aqueles da artéria coronária descendente anterior e circunflexa. Os aneurismas do tronco da artéria coronária esquerda são ainda mais raros. A doença mais frequentemente associado com esta entidade é a aterosclerose coronária com estenose grave nas áreas adjacentes aos mesmos. A sífilis terciária com manifestações cardiovasculares pode produzir aortite, insuficiência aórtica, miocardite e aneurismas ou estenose coronária. O padrão ouro para o diagnóstico de aneurismas coronários é a angiografia coronária e tratamento depende da etiologia e localização dos mesmos. O tratamento com antibióticos na sífilis terciária é imperativo; no entanto, não existe consenso sobre o tratamento de aneurismas coronários em ausência de obstruções. O tratamento prolongado com anticoagulantes orais pode ser recomendado nestes pacientes.

Cardiac papillary fibroelastoma; when, how, why.

We would like to present an interesting case operated on in our department and discuss the international bibliography about this issue. We also present some interesting images of this case. Our material is composed from a 68‑year‑old woman treated by the authors. She presented with a small murmur in the auscultation while she was asymptomatic and then she diagnosed with a tumor on of the left coronary cusp of the aortic valve with the characteristics of papillary fibroelastoma. On the basis of the potential embolic risk either of the mass itself or of associated thrombus and the possibility of further enlargement, the patient although asymptomatic at the time of diagnosis was referred for elective surgical excision of the mass. She underwent on median sternotomy and through extracorporeal circulation the mass has been excised with the preservation of the well‑functioning valve. Through this case, we would like to discuss the bibliography for the decision making in these cases. Hence, the aim of our study is that we have to keep in mind that this kind of friable mass may be the cause of embolism, stroke or coronary artery occlusion and must be excided in a conservative setting, sparing the aortic valve.

Veinte años de reparación de Ia válvula aórtica bicúspide insuficiente / Repair of the regurgitant bicuspid aortic valve: a twenty year experience

Introducción: La Insuficiencia Aórtica (IA) excepcionalmente es susceptible de reparación. Una de estas excepciones es la Válvula Aórtica Bicúspide (VAB). Objetivo: Analizar nuestros resultados de la reparación de la VAB insuficiente. Método: Se revisó la Base de Datos para el período enero 1994 a Julio 2014. Se identificaron 29 pacientes y se revisaron las fichas clínicas y protocolos operatorios. La supervivencia se certificó en el Registro Civil e Identificación de Chile. Resultados: Todos los pacientes fueron hombres. La edad promedio fue 39,4 años (19- 61 años). Cinco pacientes presentaban una endocarditis. El ecocardiograma preoperatorio demostró IA severa en 25 casos (86%) y moderada en 4. El diámetro sis-tólico fue 44 ± 7,1 mm y el diastólico 67,8 ± 6,7 mm. La fracción de acortamiento fue 35,96 ± 5,54%. En todos los casos la VAB presentaba fusión del velo coronariano izquierdo y derecho con rafe medio; en 3, el rafe era incompleto produciéndose un cleft. En 23 casos (79%) la IA era secundaria a prolapso del velo fusionado, en 3 a perforación de velo, en 1 a un cleft y en 2 a perforación y cleft. En 23 casos (79%) se efectuó una resección triangular y en 16 (55%) se complementó con una anuloplastía. En 3 se cerró una perforación y en otros 3 se efectuó un cierre primario de cleft. En 10 casos se realizó un procedimiento asociado. En todos los casos se realizó un ecocardiograma transesofágico intra-operato-rio. En 35% no hubo insuficiencia aórtica residual y en 65% esta fue mínima o leve. No hubo mortalidad operatoria. El seguimiento se completó en el 100%. Dos pacientes (7%) fallecieron por causas no cardiacas. Siete (24%) fueron re-operados, en promedio a los 7,14 años. La media de supervivencia fue 19,3 años (IC95% 17,6-21) y la supervivencia libre de re-operación 15,8 años (IC95% 13-18,7), a 20,6 años de seguimiento. El ecocardiograma efectuado en promedio a los 4,9 años demostró una reducción del diámetro sistólico de 6,15 ± 7,2 mm (p<0,05), del diastólico de 11,26 ± 8,7 mm (p<0,05) y de la fracción de acortamiento de 1,12 ± 5,57% (p<0,33). De los 22 pacientes no reoperados, 9 no tenían IA, en 6 esta era leve (1+) y en 3 leve a moderada (2+); 4 pacientes tenían una estenosis aórtica leve. Conclusión: La reparación quirúrgica de la válvula aortica bicúspide insuficiente tiene baja mortalidad peri-operatoria y excelente supervivencia alejada. Si bien el 24% de los pacientes requirió una re-operación, esta fue tardía en la mayoría de los casos.

Background: Aortic insufficiency (AI) is rarely amenable to surgical repair. One of the exceptions to that statement is the bicuspid aortic valve Aim: to analyze our results in the repair of a regur-gitant bicuspid aortic valve Method: A review of the cardiac surgery data base in the period January 1994 to July 2014 allowed the identification of 29 patients with AI and a bicuspid aortic valve submitted to surgical repair. The data from the clinical record and the surgical report was analyzed. Survival was established from the National Identification Service. Results: all patients were males. Mean age was 39.4 years (range 19-61). Five patients had infective endocarditis. Preoperative echocardiography revealed severe AI in 25 patients (86%) and moderate AI in 4. Left ventricular diastolic and systolic diameters were 67,8 ± 6,7 and 44 ± 7,1 mm, respectively. All patients presented fusion of the left and right leaflets with mid rafhe, and 3 patients had an incomplete rafhe with a cleft. AI was caused by prolapsed fu-sioned leaflet in 23 patients, leaflet perforation in 3, cleft in one and perforation plus cleft in 2 patients. Triangular resection was performed in 23 (79%) and complemented by annuloplasty in 16 (55%) patients. Three patients underwent closure of a perforation and 3 a repair of the cleft. An additional surgical procedure was performed in 10 patients. All patients underwent intra-operative TEE. 35% had no residual AI and 65% had minimal or mild AI. There was no surgical mortality. Follow up was completed in all patients. Two patients (7%) died from non cardiac causes. Seven patients (24%) had to be re-operated on, a mean of 7.1 years after the initial surgery. Mean survival rate was 19.3 (95% CI 17.6-21), and mean survival free from re-operation was 15.8 years (95%CI 13-18.7) at 20.6 years of follow up. Echo-cardiogram performed at a mean of 4.9 years after surgery showed a reduction of LV systolic diameter of 6,15 ± 7,2 mm (p<0,05), LV diastolic diameter of 11,26 ± 8,7 mm (p<0,05) and fractional shortening of 1,12 ± 5,57% (p<0,33). In the group of 22 patients who did not have a re-operation, AI was absent in 9, mild in 6 and moderate in 3; 4 patients had mild aortic stenosis. Conclusion: Surgical repair of the regurgitant bicuspid aortic valve has low peri-operative mortality rate and excellent late survival. Reoperation, required in 24% of patients, occurred late after the initial operation in most cases.

Ocular pressure waveform reflects ventricular bigeminy and aortic insufficiency.

Ocular pulse amplitude (OPA) is defined as the difference between maximum and minimum intraocular pressure (IOP) during a cardiac cycle. Average values of OPA range from 1 to 4 mmHg. The purpose of this investigation is to determine the source of an irregular IOP waveform with elevated OPA in a 48‑year‑old male. Ocular pressure waveforms had an unusual shape consistent with early ventricular contraction. With a normal IOP, OPA was 9 mmHg, which is extraordinarily high. The subject was examined by a cardiologist and was determined to be in ventricular bigeminy. In addition, he had bounding carotid pulses and echocardiogram confirmed aortic insufficiency. After replacement of the aortic valve, the bigeminy resolved and the ocular pulse waveform became regular in appearance with an OPA of 1.6–2.0 mmHg. The ocular pressure waveform is a direct reflection of hemodynamics. Evaluating this waveform may provide an additional opportunity for screening subjects for cardiovascular anomalies and arrhythmias.

"""No Touch"" ostial cardioplegia delivery for aortic valve replacement" / 中华胸心血管外科杂志

Objective To summary and explore the indications,safety and effectiveness of no touch ostial cardioplegia delivery method during aortic valve replacement(AVR) for severe aortic insufficiency(AI),in order to provide guidance for clinical application.Methods Between September 2012 and February 2015,63 cases were randomly divided into two groups,in study group we used this technique in 31 patients with a mean age of(58.0 ± 15.0) years and a range of 31 to 74 years old.The degree of AI averaged (3.5 ± 0.5) according to a semiquantitative 5-grade scale[1].32 patients were enrolled in control group with a mean age of(60.4 ± 9.4) years and a range of 22 to 73 years old.The degree of AI averaged (3.6 ± 0.5).The abnormal aortic cusps were sutured though the aortic incision,which would be closed temporarily.Blood cardioplegia was infused repeatedly into the coronary osita through the closed aortic incision during the remainder of the procedure except AVR,when the closed aortic incision was reopened.Results In the study group,spontaneous resumption of nodal and normal sinus rhythm shortly after the removal of aortic cross-clamp was achieved in all patients,no hearts had to be electrically defibrillated and electrocardiogram showed no obvious S-T segment elevation.The time from cross-clamp removal to sinus rhythm was(12.3 ± 7.7) minutes in the study group,versus (18.6 ± 8.2) minutes in the control group(P =0.037).No operative mortality occurred in both groups.There was a significant increase in left ventricular ejection fraction[from(0.54 ± 0.09) preoperatively to(0.62 ± 0.06) postoperatively] (P =0.005) in patients of the study group,which was not seen in patients of the control group.Conclusion Preliminary results have shown that the no touch ostial cardioplegia delivery method is a feasible method for cardioplegia infusion during aortic valve replacement in patients with severe AI.

Cirugía de preservación de la válvula aórtica con técnica de reimplante / Aortic Valve-sparing Operation with Reimplantation Technique

Introducción La cirugía de preservación de la válvula aórtica ofrece la única oportunidad de conservar la válvula en pacientes que requieren una intervención quirúrgica por enfermedad de la raíz aórtica. Objetivo Analizar los resultados a largo plazo de la cirugía de preservación de la válvula aórtica con técnica de reimplante en el Hospital Universitario Fundación Favaloro. Material y métodos Desde junio de 1998 a diciembre de 2011 se intervinieron 66 pacientes con cirugía de preservación de la válvula aórtica. Se incluyeron 53 pacientes operados con técnica de reimplante y se excluyeron 13 pacientes intervenidos con técnica de remodelación. Se realizó seguimiento clínico y ecocardiográfico. La insuficiencia aórtica se clasificó en: 0: ausente; 1+: leve; 2+: moderada; 3+: moderada-grave; 4+: grave. La supervivencia y la ausencia de insuficiencia aórtica > 2+ y de reoperación se analizaron con el método de Kaplan-Meier. Resultados La edad media de los pacientes fue de 45 ± 17 años, el 79% eran de sexo masculino, el 36% con síndrome de Marfan. La mortalidad hospitalaria y tardía fue del 3,8%. La supervivencia global a los 8 años fue del 91% (IC 95% 78-97%). La ausencia de insuficiencia aórtica > 2+ y de reoperación a los 8 años fue del 84% (IC 95% 66-92%) y del 90% (IC 95% 74-96%), respectivamente. La insuficiencia aórtica preoperatoria > 2+ no se asoció con insuficiencia aórtica > 2+ (RR 1,45; p = 0,16) ni con reoperación (RR 1,96; p = 0,4) durante el seguimiento. Conclusiones En nuestra experiencia, la cirugía de preservación de la válvula aórtica con técnica de reimplante en pacientes con patología de la raíz aórtica muestra resultados comparables a los de otras series internacionales publicadas. Esta técnica quirúrgica es una opción válida para pacientes seleccionados, correctamente informados sobre las diferentes técnicas quirúrgicas, y debe realizarse en centros con experiencia.

Introduction The aortic valve-sparing operation offers the unique possibility of preserving the native valve in patients who need surgical treatment for aortic root disease. Objective The aim of this study was to assess the long term outcome of the aortic valve-sparing operation with reimplantation technique at the Hospital Universitario Fundación Favaloro. Methods A total of 66 patients underwent aortic valve-sparing operation from June 1998 to December 2011. Fifty three patients operated on with the aortic valve reimplantation technique were included in the study and 13 patients operated with the remodeling technique were excluded. Clinical and echocardiographic follow-up was performed. Aortic insufficiency was graded as: 0: absent; 1+: mild; 2+: moderate; 3+: moderate-severe, and 4+: severe. Survival and freedom from aortic insufficiency >2+ and reoperation were analyzed using the Kaplan-Meier method. Results Mean age was 45±17 years, 79% of patients were men and 36% had Marfan syndrome. In-hospital and late mortality was 3.8%. Survival at 8 years was 91% (95% CI: 78-97%). Freedom from aortic insufficiency > 2+ and reoperation at 8 years was 84% (95% CI: 66-92%) and 90% (95% CI: 74-96%), respectively. Preoperative aortic insufficiency >2+ was not associated with aortic insufficiency >2+ (RR 1.45; p=0.16) or reoperation (RR 1.96; p=0.4) during follow-up. Conclusions In our experience, the aortic valve-sparing operation with reimplantation technique in patients with aortic root disease shows comparable results to other published international series. This surgical technique is a valid option for eligible patients duly informed about the different surgical techniques, and should be performed in experienced centers.

Transcatheter establishment of an animal model with acute aortic valve regurgitation：an experimental study / 介入放射学杂志

Objective To explore the feasibility and effectiveness of interventional transcatheter destruction of the aortic valve to establish an animal model with acute aortic valve regurgitation. Methods Eight healthy goats were used for this study. A limited sternotomy approach was used to access the apex of the heart. Puncturing of the apex of the heart was performed to establish a wire track, then, under fluoroscopic guidance a 10 F sheath was inserted along this track of hard wire until to the ascending aorta above the aortic valve. The internal sheath was removed. Via the 10 F sheath a 10 mm occluder of ventricular septal defect (VSD) was introduced into the ascending aorta above the aortic valve. The sheath was pulled back to the left ventricle, while the occluder remained in the ascending aorta above the aortic valve. Then the occluder was quickly pulled back into the left ventricle in order to make some certain damage to the aortic valve. And an acute aortic valve regurgitation model was thus established. Angiography of ascending aorta above the aortic Among the 8 animals, two died of acute left ventricular failure on the spot due to excessive regurgitation blood flow after the operation. Macroscopically, damage of the aortic valve was seen. In the six survivors, angiography of ascending aorta above the aortic valve and Doppler echocardiography showed that moderate degree of regurgitation was detected in 5 and small amount of regurgitation in one. Two experimental goats with moderate degree of regurgitation died of heart failure separately at seven days and fifteen days after the operation. The remaining four experimental goats survived for more than three months. Follow- up checkups with echocardiography suggested the presence of mild- moderate degree of regurgitation. Conclusion Acute aortic valve regurgitation model in experimental goats can be established through transapical transcatheter damage of aortic valve by quickly pulling back a VSD occluder which has been placed in the ascending aorta above the aortic valve. This method is clinically feasible, technically simple and repeatable, the result is reliable, and the degree of regurgitation is controllable.

Outcome and predictive factor analysis of functional mitral regurgitation after aortic valve replacement in patients with severe aortic insufficiency with left ventricular dilation and dysfunction / 中华胸心血管外科杂志

Objective Functional mitral regurgitation (FMR) refers to the systolic regurgitation of mitral valve secondary to compromised cardiac function or geometry abnormity with non-organic change of leaflets and ancillary parts of the valve.Severe aortic insufficiency (AI) with left ventricular dilation and dysfunction is clinically a complex heart disease and its postoperative complications and mortality are higher than usual valvular surgery.And such patients are often accompanied by FMR.It is generally acknowledged that FMR may improve after aortic valve replacement(AVR).This study follow up AI patients with left ventricular dilation and dysfunction and preoperative 2 + ＜ FMR≤3 + to evaluate the outcome of FMR after AVR.Preoperative clinical data is assessed by regression analysis.Methods From January 2000 to April 2011 our hospital treated 74 cases of patients with severe aortic regurgitation combined with left ventricular dilation (LVEDds ≥70 mm) and dysfunction (left ventricle ejection fraction,LVEF≤0.35) accompanied by 2 + ＜ FMR≤3 +.Postoperative follow-up was performed.Results The perioperative mortality rate was 8.1％.Average follow-up time was (14.9 ± 7.7) months and follow-up rate of 83.6％.5 patients died during follow-up.6 months after surgery,the average of FMR was (2.64 ± 1.17) (+),compared with preoperative data.LVEDd,LAD,CPMA,all P ＞ 0.05 compared with the preoperative data.LVEF,PAH,both P ＜ 0.05 compared with preoperative data.3.Multiple regression analysis:FMR pre/FMR post ratio is not correlated with age,gender,weight,LVEDd ≥ 75 mm,LVEF≤0.30,hypertension,ventricular arrhythmia and FMR postoperative improvement.However,PAH ≥ 50 mm Hg(1 mm Hg =0.133 kPa),LAD ≥ 50 mm,PAH≥50 mm Hg,CPMA ≥ 15mm,preoperative atrial fibrillation was negatively correlated with FMR postoperative improvement.Conclusion Severe AI with left ventricular dilation and dysfunction is a critical clinical heart disease and its postoperative complications and mortality are high.PAH ≥ 50 mm Hg,LAD ≥ 50 mm,PAH ≥ 50 nun Hg,CPMA ≥ 15mm,preoperative atrial fibrillation was negatively correlated with FMR postoperative improvement.Since patients with 2 + ＜ FMR ≤3 + usually do not improve or even worsen after AVR,those who have these above conditions preoperatively,should be treated on FMR during AVR.

A Case of Right Sinus of Valsalva Aneurysm Dissecting into the Interventricular Septum / 日本心臓血管外科学会雑誌

A 60-year-old man was referred to our hospital for surgical treatment of sinus of Valsalva aneurysm and aortic regurgitation. He had suffered from palpitation and leg edema since a month before. Echocardiography revealed right sinus of Valsalva aneurysm dissecting into interventricular septum complicated with aortic and mitral regurgitation. He successfully underwent patch closure of aneurysm, aortic valve replacement and ring annuloplasty of mitral and tricuspid valve. His postoperative course was uneventful.

Cardiopatía valvular en un paciente con granulomatosis de Wegener / Valvular cardiopathy in a patient with Wegener's granulomatosis

La granulomatosis de Wegener es una vasculitis necrotizante autoinmune cuya prevalencia reportada es de 3/100.000 habitantes. Tiene compromiso multisistémico, principalmente el tracto respiratorio superior e inferior, y el sistema nervioso central y renal. La frecuencia del compromiso cardiaco varía según las series estudiadas, pero oscila alrededor de 6%; sin embargo, las manifestaciones clínicas son poco frecuentes. El compromiso valvular se reporta como insuficiencia aórtica o mitral, secundaria a infiltración de las valvas o dilatación de la raíz aórtica. El tratamiento se basa en el control de la enfermedad, el manejo de la falla cardiaca y la intervención quirúrgica de la válvula comprometida según la indicación.

Wegener's granulomatosis is an autoimmune necrotizing vasculitis with a reported prevalence of 3/100.000 inhabitants. It is a multisystemic disease, involving mainly the upper and lower respiratory tract, the central nervous system and the kidneys. The frequency of cardiac involvement varies depending on the series studied, but oscillates around 6%; however, the clinical manifestations are rare. The valvular involvement is reported as aortic or mitral insufficiency secondary to infiltration of the leaflets, or as aortic root dilatation. Treatment is based on the control of the disease, the management of heart failure and surgical intervention of the involved valve, as directed. Palabras clave: granulomatosis de Wegener, insuficiencia mitral, insuficiencia aórtica, cardiopatía, vasculitis.