Abstract:The use of pulmonary autograft was first reported in 1967 by Ross for the treatment of aortic valve disease in adults. Since that time, Ross procedure has been applied to a variety of forms of aortic stenosis and left ventricular outflow tract obstruction and mitral valve disease, Ross procedure has undergone several modifications, such as the root replacement method, inclusion cylinder technique, annular reduction, Konno root enlargement procedures and replacement of the mitral valve with a pulmonary autograft （Ross-Kabbani procedure or Ross Ⅱ procedure）. Advantages of Ross procedure in women of childbearing age, children and young adults include freedom from anticoagulation, appropriate sizing, cellular viability with growth potential proportional to somatic growth, acceptable long-term durability, excellent hemodynamic performance and decreased susceptibility to endocarditis. Surgical technical aspects, indications, selection criteria for the Ross procedure and its modifications, their applicability in the surgical management of aortic stenosis, left ventricular outflow tract obstruction and mitral valve disease and clinical outcome of Ross procedure are reviewed in this article.
ObjectiveTo summarize the surgical strategy of reoperative aortic root replacement after prior aortic valve replacement (AVR), and analyze the early and mid-term outcomes.MethodsFrom April 2013 to January 2020, 75 patients with prior AVR underwent reoperative aortic root replacement in Fuwai Hospital. There were 54 males and 21 females with a mean age of 56.4±12.7 years. An emergent operation was performed in 14 patients and an elective operation in 61 patients. The indications were aortic root aneurysm in 38 patients, aortic dissection involving aortic root in 30 patients, root false aneurysm in 2 patients, prosthesis valve endocarditis with root abscess in 2 patients, and Behçet's disease with root destruction in 3 patients. The survival and freedom from aortic events during the follow-up were evaluated with the Kaplan-Meier survival curve and the log-rank test.ResultsThe operative procedures included prosthesis-sparing root replacement in 45 patients, Bentall procedure in 26 patients, and Cabrol procedure in 4 patients. Operative mortality was 1.3% (1/75). A composite of adverse events occurred in 5 patients, including operative death (n=1), stroke (n=1), and acute renal injury necessitating hemodialysis (n=3). The follow-up was available for all 74 survivors, with the mean follow-up time of 0.5-92.0 (30.3±25.0) months. Four late deaths occurred during the follow-up. The survival rate at 1 year, 3 years and 6 years was 97.2%, 91.4% and 84.4%, respectively. Aortic events developed in 2 patients. The rate of freedom from aortic events at 1 year, 3 years, and 6 years was 98.7%, 95.0% and 87.7%, respectively. There was no difference in rate of survival or freedom from aortic events between the elective patients and the emergent patients.ConclusionReoperative aortic root replacement after prior AVR can be performed to treat the root pathologies after AVR, with acceptable early and mid-term outcomes.
ObjectiveTo analyze long-term outcomes of aortic valve replacement (AVR) for patients with severe aortic regurgitation (AR) and left ventricular dysfunction (LVD). MethodsWe retrospectively analyzed clinical data of 44 patients with severe AR and LVD who received AVR in Drum Tower Hospital from January 2002 to December 2012. Left ventricular ejection fraction (LVEF) of all the patients was lower than 35%. There were 29 male and 15 female patients with their age of 23-78 (44±6) years and LVEF of 22%-34% (29%±3%). ResultsTwo patients died because of heart failure postoperatively. Cardiopulmonary bypass time was 57-92 (73±8) minutes, aortic cross-clamping time was 33-61 (48±6)minutes, and length of ICU stay was 2-15 (8±3) days. All the patients were followed up for 1-11 (4.3±2.9) years. Two patients died during follow-up because of heart failure and stroke respectively. One-year survival rate was 93% and five-year survival rate was 91%. ConclusionAVR can significantly increase long-time survival of patients with severe AR and LVD.
ObjectiveTo summarize the clinical experience of aortic valve replacement surgery with minimally invasive procedure. MethodsWe retrospectively analyzed the clinical data of 72 patients underwent isolated aortic valve replacement in our hospital between January 2011 and August 2013. The patients undergoing minimally invasive procedure were as a minimally invasive group(30 patients with 18 males and 12 females at age of 60.2±13.4 years). The patients undergoings conventional procedure were as a control group(42 patients with 27 males and 15 females at age of 61.3±14.5 years). The outcomes of the two groups were compared. ResultsThere was no death and severe complication in both groups. Postoperative echocardiography showed no paravalvular leakage, no valve dysfunction in both groups. There were no significant statistically differences between the two groups in cardiopulmonary bypass time, aortic crossclamping time, ventilation time, postoperative left ventricle ejection fraction, the length of ICU stay and hospital stay (P>0.05). Blood transfusion ratio, blood transfusion volume and blood loss volume were lower in the minimally invasive group than those in the control group (P<0.05). The length of incision, chest closure time, operative duration were shorter in the minimally invasive group than those in the control group (P<0.05). ConclusionUpper median sternotomy is a safe and feasible procedure for minimally invasive aortic valve replacement surgery. Compared with conventional aortic valve replacement, its advantages include less surgical trauma, stable sternum, rapid recovery, less blood loss and blood transfusion, and cosmetic outcomes.
ObjectiveTo investigate long-term outcomes of patients without warfarin anticoagulation after isolated prosthetic aortic valve replacement (AVR) and evaluate the feasibility of short-term instead of lifelong anticoagulation therapy for low-risk AVR patients. MethodsSeven patients who underwent prosthetic AVR in Guangdong General Hospital between 1996 and 1999 but discontinued warfarin anticoagulation 3 years after surgery were regularly followed up. There were 6 male and 1 female patients with their age of 25-75 (40.0±11.4) years. These patients received warfarin anticoagulation during the first 3 years after surgery but discontinued oral anticoagulant 3 years after surgery (discontinued anticoagulation group). Fifteen patients who underwent prosthetic AVR during the same period and continued warfarin anticoagulation were enrolled as the control group (continuing anticoagulation group). International normalized ratio (INR) was set between 1.8 and 2.5 during warfarin anticoagulation period in both groups. Survival rate and the incidence of severe adverse events were compared between the 2 groups. ResultsIn the discontinued anticoagulation group,1 patient was lost during follow-up. No thromboembolic event,death or prosthetic valve thrombosis was observed. All the patients were in NYHA class Ⅰ. In the continuing anticoagulation group,3 patients were lost during follow-up. Eleven patients were in NYHA class Ⅰ and 2 patients were in NYHA class Ⅱ. Severe anticoagulation-related bleeding events occurred in 3 patients with gastrointestinal bleeding. One patient died of massive outbreak of vomiting blood,and another patient had sudden death. Ten-year survival rate was 100.0% and 86.7% in the discontinued anticoagulation group and continuing anticoagulation group, respectively. ConclusionFor low-risk patients after isolated prosthetic AVR,short-term warfarin anticoagulation may be acceptable, which means warfarin is administered only in the first 3 years after surgery and discontinued 3 years after surgery.
Abstract： Objective To investigate the effects of βreceptor blocker on intraventricular pressure gradient and left ventricle remodeling after valve replacement for critical aortic stenosis. Methods Fifty-six patients with critical aortic stenosis underwent aortic valve replacement surgery from January 2008 to January 2010 in the First Affiliated Hospital of Zhengzhou University. Thirtytwo of them who were followed up were selected to be enrolled in this study. The patients were divided into two groups under the same basis of clinical features. Twelve patients in the experimental group received oral βreceptor blocker (Metoprolol, 6.2525.00 mg once, twice daily). The rest 20 patients in the control group had no βreceptor blocker. The various indicators of ultrasound cardiogram (UCG) shortly after operation (within a week) and long after operation (6-24 months) were compared between the two groups. Results No death occurred in both groups, and chest distress, shortness of breath and other symptoms were obviously alleviated. Although left ventricular endsystolic dimension (LVESD) and left ventricular outflow tract dimension (LVOTD) of both groups increased 6-24 months after operation, compared with the early postoperative period, only the increase of LVOTD in the experimental group showed statistical difference (t=-47.937, P=0.001). In both groups, interventricular septum thickness (IVST), left ventricular posterior wall thickness (LVPWT), filament band velocity of left ventricular outflow tract (V), intraventricular pressure gradient (G) and left ventricular mass index (LVMI) of the later period after operation were significantly lower than those of the early postoperative period. All these indicators in the experimental group showed significant differences (t=7.781, P=0.001；t=5.749, P=0.001; t=2.637, P=0.023; t=7.167, P=0.001; t=100.061, P0.001), while only V, G， and LVMI showed statistical differences in the control group (t=4.051, P=0.001; t= 4.759, P= 0.001; t=-0.166,P=0.001). EF in the experimental group also indicated significant difference compared with early period after aortic valve replacement (t=-6.621, P=0.001). EF between two groups indicated no significant difference (t=-0.354,P=0.726). But differences between the two groups in LVEDD, IVS, G， and LVMI were all statistically significant in the later period after surgery (t=-2.494, P=0.018; t=-3.434, P=0.002;t=-2.171,P=0.038; t=-2.316, P=0.028). Conclusion β-receptor blocker is a safe and reliable drug for those patients who have undergone aortic valve replacement surgery for critical aortic stenosis, and can decrease significantly the residual intraventricular pressure gradient and accelerate left ventricular cardiac remodeling.
ObjectiveTo analyze the safety and effectiveness of minimally invasive small incision through the right third intercostal and standard aortic valve replacement.MethodsThe clinical data of 123 patients with the first simple aortic valve replacement in our hospital from June 2013 to May 2020 were retrospectively analyzed. The patients receiving aortic valve replacement through the right third intercostal small incision were allocated to a minimally invasive group, and patients receiving aortic valve replacement through the median sternal incision were allocated to a common group. The clinical outcomes of the two groups were compared.ResultsThere were 40 patients in the minimally invasive group, including 11 (27.5%) females and 29 (72.5%) males, aged 54.60±9.98 years with the body mass index (BMI) of 23.16±2.48 kg/m2. There were 83 patients in the common group, including 27 (32.5%) females, 56 (67.5%) males, aged 58.77±9.71 years, with the BMI of 24.13±3.13 kg/m2. Compared with the common group, the aortic cross-clamping time, cardiopulmonary bypass time, and operation time were longer (P<0.05), the ventilator support time was shorter (P<0.05), and the blood loss, postoperative 24 h chest drainage volume and total expense were less (P<0.05) in the minimally invasive group. The ICU stay, postoperative hospital stay, and total hospital stay were not statistically different between the two groups (P>0.05).ConclusionThe aortic valve replacement through the right third intercostal small incision is safe and effective, with less blood loss, 24 h chest drainage volume and invasiveness.
ObjectiveTo assess early and mid-term outcomes and our clinical experience of reduction ascending aortoplasty (RAA) for patients with aortic valve disease and ascending aortic dilatation, and improve treatment effects. MethodsClinical data of 36 patients with aortic valve disease and ascending aortic dilatation who underwent aortic valve replacement and RAA in Fu Wai Hospital between January 2002 and August 2010 were retrospectively analyzed. There were 26 male and 10 female patients with their age of 7-72 (51±16) years. Ascending aorta diameter (AAD) was measured by echocardiography preoperatively, postoperatively, during follow-up and compared. ResultsThere was no perioperative death. Cardiopulmonary bypass time was 96.2±28.3 minutes, and aortic cross-clamp time was 69.2±22.1 minutes. Posto-perative hospital stay was 11.0±7.8 days. All the 36 patients were followed up after discharge for 1.1-9.0 (4.0±2.3) years. During follow-up, there was 1 death, but none of the patients needed reoperation. Echocardiography showed normal aortic valve function. Postoperative AAD was significantly smaller than preoperative AAD (36.4±6.1 mm vs. 46.8±4.6 mm, t=13.12, P=0.00). AAD during follow-up was significantly larger than postoperative AAD (40.8±6.8 mm vs. 36.4±6.1 mm, t=-2.64, P=0.01) but significantly smaller than preoperative AAD (40.8±6.8 mm vs. 46.8±4.6 mm, t=3.48, P=0.00). ConclusionEarly and mid-term outcomes of RAA are satisfactory for patients with aortic valve disease and ascending aortic dilatation, but long-term results need further observation.
Nowadays, aortic bioprostheses are used more and more widely in clinical practice, but the valve will experience structural valve degradation over time, and eventually lose its function, which is valve failure. Valve failure has become a significant challenge for aortic valve replacement and especially limits the expansion of indications for transcatheter aortic valve replacement. This review focuses on the current status and relevant evidence on the definition, risk factors, epidemiological characteristics, diagnosis and evaluation, treatment strategies of aortic bioprostheses failure. The purpose is to provide a basis for a more comprehensive understanding of aortic bioprostheses failure, finding better coping strategies and further improving the long-term durability of the valve.
Heart valve replacement is the major surgical treatment of severe valvular diseases. Due to the durability and reoperation-free, mechanical valves are widely used. Bioprosthesis valves became popular recently because of long service life and no demand for lifelong anticoagulation. However, how to choose the appropriate prosthetic heart valves, especially the application of bioprosthesis valves for patients at 55 to 65 years is still a major problem. This review focuses on more effective and scientific basis for rational choice of mechanical and bioprosthesis valve.