Early and Midterm Results of Aortic Root Enlargement Combined with Supra-annular Valve Implantation for Adult Patients with Aortic Stenosis and Small Aortic Root_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

CAOXiang-rong ,  ZHANGJian-qun , BOPing , ZHANGFu-en , LIJi-yong , LIWen-bin , CHENBao-tian

Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University & Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing 100029, P. R. China;

Corresponding?author：

ZHANGJian-qun, Email: doczjq@126.com

Keywords：

Small aortic root; Aortic valve replacement; Aortic root enlargement; Follow-up

DOI：

10.7507/1007-4848.20140128

Video：

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Objective To evaluate early and midterm outcomes of aortic root enlargement (ARE) combined with supra-annular valve implantation for adult patients with aortic stenosis (AS) and small aortic roots (SARs). Methods From January 2007 to July 2011, ARE combined with supra-annular valve implantation was performed for 38 adult patients with AS and SARs in Department of Cardiac Surgery of Beijing Anzhen Hospital. There were 12 males and 26 females with their age of 16-58 (38.6±21.0) years, body weight of 48-78 (58.5±12.0) kg, body height of 153-176 (162.8±12.0) cm and a mean body surface area (BSA) of 1.67±0.32 m². There were 19 patients with rheumatic AS, 11 patients with congenital bicuspid aortic valve and AS, 5 patients with degenerative AS and 3 patients with AS and infective endocarditis. Preopera-tively, 8 patients were in NYHA class Ⅱ, 29 patients were in NYHA class Ⅲ, and 1 patient was in NYHA class Ⅳ. Aortic annular diameter (AAD) was 15-20 (17.6±2.8) mm and trans-aortic pressure gradient was 53-75 (62.8±10.5) mm Hg. Results Cardiopulmonary bypass time was 83-145 (112±29) minutes, and aortic cross-clamping time was 58-116 (87±28) minutes. Intraoperative measurement of AAD was 15-20 (17.3±2.6) mm, AAD after ARE was 20-25 (22.6±2.3) mm. AAD after ARE was 12-17 (14.0±2.6) mm larger than AAD before ARE. Actual size of prosthetic valves was 2-3 sizes larger than predicted size without ARE in all the patients. There was no perioperative death or severe complication including bleeding. Length of ICU stay was 12-41 (26±14) hours, and length of hospital stay was 9-15 (12.5±3.2) days. A total of 37 patients (97.4%) were followed up for over 2 years after discharge. All the patients were in NYHA class Ⅰ. Grade 2/6 systolic murmur was heard in 3 patients. Electrocardiogram (ECG) showed significant improvement or complete disappearance of left ventricular hypertrophy in 35 patients, and mild left ventricular hypertrophy in 2 patients. ECG during follow-up didn't show any sign of myocardial ischemia, ventricular arrhythmia or severe atrioventricular block in any patient. Conclusion Early and midterm outcomes of ARE combined with supra-annular valve implantation for adult patients with AS and SARs are satisfactory, but long-term outcomes of this procedure need further follow-up.

Citation： CAOXiang-rong, ZHANGJian-qun, BOPing, ZHANGFu-en, LIJi-yong, LIWen-bin, CHENBao-tian. Early and Midterm Results of Aortic Root Enlargement Combined with Supra-annular Valve Implantation for Adult Patients with Aortic Stenosis and Small Aortic Root. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2014, 21(4): 452-456. doi: 10.7507/1007-4848.20140128 Copy

1.	Losenno KL, Gelinas JJ, Johnson M, et al. Defining the efficacy of aortic enlargement procedure:a comparative analysis of surgical technique. Can J Cardiol, 2013, 29 (4):434-440.
2.	Coutinho GF, Correia PM, Paupério G, et al. Aortic root enlargement does not increase the surgical risk and short-term patient outcome? Eur J Cardiothorac Surg, 2011, 40 (2):441-447.
3.	Castro LJ, Arcidi MJ, Fisher AL, et al. Routine enlargement of the small aortic root:a preventive strategy to minimize mismatch. Ann Thorac Surg, 2002, 74 (1):31-36.
4.	Rahimtoola SH. The problem of valve prosthesis-patient mismatch. Circulation, 1978, 58 (1):20-24.
5.	Head SJ, Mokhles MM, Osnabrugge RL, et al. The impact of prosthesis-patient mismatch on long-term survival after aortic valve replacement:a systematic review and meta-analysis of 34 observational studies comprising 27186 patients with 133141 patients-years. Eur Heart J, 2012, 33 (12):1518-1529.
6.	Bleiziffer S, Ali A, Hettich IM, et al. Impact of the indexed effective orifice area on mid-term cardiac-related mortality after aortic valve replacement. Heart, 2010, 96 (11):865-871.
7.	Ghosh P, Kumar S, Pandey S, et al. Small aortic annulus:a functional definition. Ann Thorac Cardiovasc Surg, 1998, 4 (5):251-261.
8.	David TE, Dden DE. Aortic valve replacement in adult patients with small aortic annuli. Ann Thorac Surg, 1983, 36 (5):577-583.
9.	Pibarot P, Dumesnil JG. Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention. J Am Coll Cardiol, 2000, 36 (4):1131-1141.
10.	Coutinho GF, Correia PM, Pauperio G, et al. Aortic root enlargement does not increase the surgical risk and short-term patient outcome? Eur J Cardiothorac Surg, 2011, 40 (2):441-447.
11.	Walther T, Rastan A, Falk V, et al. Patient prosthesis mismatch affects short-and long-term outcomes after aortic valve replacement. Eur J Cardiothorac Surg, 2006, 30 (1):15-19.
12.	Moon MR, Pasque MK, Munfakh NA, et al. Prosthesis-patient mism-atch after aortic valve replacement:impact of age and body size on late survival. Ann Thorac Surg, 2006, 81 (2):481-489.
13.	Mori T, Kawashima Y, Kitamura S, et al. Results of aortic valve replacement in patients with a narrow aortic annulus:effects of enlarg-ement of the aortic annulus. Ann Thorac Surg, 1981, 31 (2):111-116.
14.	趙國芳.改良Nicks法行小主動脈瓣環擴大及主動脈瓣置換術.醫師進修雜志, 2005, 28 (10B):40-42.
15.	李韜, 黃健宏, 吳全忠, 等.改良Nicks法瓣環擴大聯合環上瓣置入治療小瓣環主動脈瓣病變.中華胸心血管外科雜志, 2004, 20 (4):238.
16.	李繼勇, 張健群, 伯平, 等.小主動脈瓣環患者機械瓣置換術后中期療效分析.中國胸心血管外科臨床雜志, 2008, 15 (5):329-332.
17.	李凡東, 張廣福, 姜冠華.瓣環擴大術在小主動脈瓣環中的應用.中國胸心血管外科臨床雜志, 2005, 12 (6):429-431.
18.	王紅兵, 周更須, 鄭奇軍, 等.小主動脈瓣環患者主動脈瓣置換術41例.中國胸心血管外科臨床雜志, 2006, 13 (1):52-53.
19.	Koene BM, Soliman Hamad MA, et al. Impact of prosthesis-patient mismatch on early and late mortality after aortic valve replacement. J Cardiothorac Surg, 2013, 8 (1):96.
20.	Jamieson WR, Ye J, Higgins J, et al. Effect of prosthesis-patient mismatch on long-term survival with aortic valve replacement:asse-ssment to 15 years. Ann Thorac Surg, 2010, 89 (1):51-59.
21.	Tully PJ, Aty W, Rice GD, et al. Aortic valve prosthesis-patient mismatch and long-term outcomes:19-year single-center experience. Ann Thorac Surg, 2013, 96 (3):844-850.

1. Losenno KL, Gelinas JJ, Johnson M, et al. Defining the efficacy of aortic enlargement procedure:a comparative analysis of surgical technique. Can J Cardiol, 2013, 29 (4):434-440.
2. Coutinho GF, Correia PM, Paupério G, et al. Aortic root enlargement does not increase the surgical risk and short-term patient outcome? Eur J Cardiothorac Surg, 2011, 40 (2):441-447.
3. Castro LJ, Arcidi MJ, Fisher AL, et al. Routine enlargement of the small aortic root:a preventive strategy to minimize mismatch. Ann Thorac Surg, 2002, 74 (1):31-36.
4. Rahimtoola SH. The problem of valve prosthesis-patient mismatch. Circulation, 1978, 58 (1):20-24.
5. Head SJ, Mokhles MM, Osnabrugge RL, et al. The impact of prosthesis-patient mismatch on long-term survival after aortic valve replacement:a systematic review and meta-analysis of 34 observational studies comprising 27186 patients with 133141 patients-years. Eur Heart J, 2012, 33 (12):1518-1529.
6. Bleiziffer S, Ali A, Hettich IM, et al. Impact of the indexed effective orifice area on mid-term cardiac-related mortality after aortic valve replacement. Heart, 2010, 96 (11):865-871.
7. Ghosh P, Kumar S, Pandey S, et al. Small aortic annulus:a functional definition. Ann Thorac Cardiovasc Surg, 1998, 4 (5):251-261.
8. David TE, Dden DE. Aortic valve replacement in adult patients with small aortic annuli. Ann Thorac Surg, 1983, 36 (5):577-583.
9. Pibarot P, Dumesnil JG. Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention. J Am Coll Cardiol, 2000, 36 (4):1131-1141.
10. Coutinho GF, Correia PM, Pauperio G, et al. Aortic root enlargement does not increase the surgical risk and short-term patient outcome? Eur J Cardiothorac Surg, 2011, 40 (2):441-447.
11. Walther T, Rastan A, Falk V, et al. Patient prosthesis mismatch affects short-and long-term outcomes after aortic valve replacement. Eur J Cardiothorac Surg, 2006, 30 (1):15-19.
12. Moon MR, Pasque MK, Munfakh NA, et al. Prosthesis-patient mism-atch after aortic valve replacement:impact of age and body size on late survival. Ann Thorac Surg, 2006, 81 (2):481-489.
13. Mori T, Kawashima Y, Kitamura S, et al. Results of aortic valve replacement in patients with a narrow aortic annulus:effects of enlarg-ement of the aortic annulus. Ann Thorac Surg, 1981, 31 (2):111-116.
14. 趙國芳.改良Nicks法行小主動脈瓣環擴大及主動脈瓣置換術.醫師進修雜志, 2005, 28 (10B):40-42.
15. 李韜, 黃健宏, 吳全忠, 等.改良Nicks法瓣環擴大聯合環上瓣置入治療小瓣環主動脈瓣病變.中華胸心血管外科雜志, 2004, 20 (4):238.
16. 李繼勇, 張健群, 伯平, 等.小主動脈瓣環患者機械瓣置換術后中期療效分析.中國胸心血管外科臨床雜志, 2008, 15 (5):329-332.
17. 李凡東, 張廣福, 姜冠華.瓣環擴大術在小主動脈瓣環中的應用.中國胸心血管外科臨床雜志, 2005, 12 (6):429-431.
18. 王紅兵, 周更須, 鄭奇軍, 等.小主動脈瓣環患者主動脈瓣置換術41例.中國胸心血管外科臨床雜志, 2006, 13 (1):52-53.
19. Koene BM, Soliman Hamad MA, et al. Impact of prosthesis-patient mismatch on early and late mortality after aortic valve replacement. J Cardiothorac Surg, 2013, 8 (1):96.
20. Jamieson WR, Ye J, Higgins J, et al. Effect of prosthesis-patient mismatch on long-term survival with aortic valve replacement:asse-ssment to 15 years. Ann Thorac Surg, 2010, 89 (1):51-59.
21. Tully PJ, Aty W, Rice GD, et al. Aortic valve prosthesis-patient mismatch and long-term outcomes:19-year single-center experience. Ann Thorac Surg, 2013, 96 (3):844-850.

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Early and Midterm Results of Aortic Root Enlargement Combined with Supra-annular Valve Implantation for Adult Patients with Aortic Stenosis and Small Aortic Root

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