ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1994.tb00828.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1994.tb00912.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

AbstractThe etiology of acquired aortic stenosis (AS) has changed dramatically as socioeconomic and hygienic conditions have improved and as the general population lives to an older age. Rheumatic disease was responsible for most cases of AS until a few decades ago, whereas now most are due to calcific degenerative or bicuspid etiologies. There is a long latency period from the initial discovery of a murmur and first onset of symptoms. In studies representing clinical experience prior to the 1960s, the mean age at symptomatic presentation was 48 years, while in series representing experience up the 1980s, it was 61 years. The changing etiology of AS has Important implications for following patients with AS, and monitoring those who are discovered to have significant AS in the absence of symptoms. AS has become more a disease of the elderly, and it is the elderly patient with AS, especially those with calcific degenerative AS, who develop the most rapid and significant progression of their disease, present with symptoms of left ventricular (LV) failure, and are most likely to have critical outflow tract obstruction at the time of their presentation. Once symptoms develop, the outcome of patients with AS is quite poor: in early studies approximately 50% of such patients were dead at 5 years and 90% were dead at 10 years. Symptoms that represent LV failure, e.g., dyspnea, are associated with a worse survival (average survival 2 years) compared to symptoms that represent LV hypertrophy, e.g., angina or outflow obstruction, syncope (average survival 3 years). There is uniform agreement that once symptoms develop, patients with Significant AS should undergo valve replacement. Management of the asymptomatic patient with moderate‐to‐severe AS has been more problematic. Early studies suggested that sudden death could occur in even asymptomatic patients with severe AS, and recommended that prophylactic valve replacement be considered in this group. More recent studies, however, confirm that in the absence of symptoms, overall survival of patients with AS is similar to that predicted for age‐ and gender‐matched control subjects. Although cardiac death occurs in approximately 2% to 4% of these patients, symptoms of AS have developed approximately 1 to 3 months before death in each documented case. The mortality associated with prophylactic aortic valve replacement is higher than the mortality associated with medical management of asymptomatic AS. In conclusion, aortic valve replacement should be deferred in patients with asymptomatic AS until the onset of symptoms. Patients with calcific degenerative AS and elderly patients with AS may have particularly rapid progression of AS and should have close follow‐up. Since the interval between the onset of AS symptoms and cardiac death may be quite brief, all asymptomatic patients with significant AS should be followed closely for the onset of symptoms. (J Card Surg 1994;9[Suppl

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1994.tb00913.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

AbstractA small proportion of patients with significant coronary artery disease referred for coronary artery bypass graft (CABG) surgery have coexistent congenital or valvular disease that, if isolated, would be inadequately severe to justify surgery. While there is general agreement that CABG should be performed for obstruction of major epicardial arteries even without ischemic symptoms in patients having aortic valve replacement (AVR) for aortic stenosis (AS), there has been little or no consideration of whether “mild‐to‐moderate” AS should be treated by valve repair or AVR at the time of CABG. Between 1975 and 1992, we performed AVR for symptoms or signs of severe AS without significant ischemia on 44 patients with previous CABG. None of thesepatients were considered to have serious AS at the time of CABG surgery 8 to 164 months (68 months) previously. At aortic surgery, ages ranged from 52 to 83 years (73); 38% were female. In 20 patients with available data, transvalvular gradients ranged from 0 to 23 (12) mmHg at CABG and 29 to 95 (62) mmHg at AVR. Aortic valve areas at CABG ranged from 0.9 to 2.2 (1.5) cm2and at AVR ranged from 0.3 to 1.7 (0.7) cm2. Appearance of symptoms and signs of severe AS occurred in 16% by 3 years; 45% by 4 years; and 75% by 5 years after CABG surgery. These data observations suggest that mild, asymptomatic valve deformity may progress to symptomatic, hemodynamically severe AS within a short time after CABG surgery, well before recurrent symptoms of coronary obstructive disease. Serious consideration of AVR should be entertained for patients with any degree of aortic valve obstruction who must undergo CABG surgery. (J Card Surg 1994;9[Suppl]:

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1994.tb00914.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

AbstractAortic valve replacement is the treatment of choice for elderly patients with aortic stenosis. It can be accomplished with excellent immediate and long‐term results with significant functional improvement.Unfortunately, the literature is replete with enthusiasticreports of aortic catheter balloon valvotomy. Initial findings were controversial and thelong‐term results have been poor due to early valve restenosis. A retrospective analysis of our surgical experience with aortic valve replacement in the elderly seems appropriate in an effort to put this Issue In proper perspective. From January 1973 to June 1993, 200 consecutive patients 70 years of age and older with severe aortic stenosis underwent surgical correction. There were 105 men (52.5%) and 95 women (47.5%), with a mean age of 76.2 years (range 70 to 89). Preoperatively, 195 patients (97.5%) were in New York Heart Association(NYHA) Class III or IV. Over one half (61.0%) of the patients experienced no hospital complications. The hospital mortality was 9.0% (18 patients). This included 14 patients in NYHA Class IV. The mean follow‐up was 69.3 months and ranged from 1 to 215 months. The actuarial survival for 182 patients discharged from the hospital was 70.8% 4.0% (SEM) at 72 months (73 patients at risk) and 35.2%± 5.4% at 144 months (20 patients at risk). Considering the advanced age and preoperative functional classification in this patient group, the results of aortic valve replacement have been excellent. The survival of patients discharged from the hospital compares favorably with a normal population matched for age and sex. The results of aortic balloon valvotomy have been disappointing. Therefore, continued utilization of this treatment method may preclude elderly patients' access to surgery—a mode of therapy that has withstood the test of time.(J Card Surg 1994;9[Suppl]

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1994.tb00915.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

AbstractMechanical aortic valves (AVs) are frequently implanted in small (19 and 21 mm) aortic roots because bioprosthetic valves have unacceptably high gradients and many surgeons do not implant allograft valves. Three mechanical valves in common use today in the United States are the Starr‐Edwards (SE), St. Jude Medical (SJ), and the Medtronic‐Hall (MH). Clinical hemodynamic studies reveal that the 21‐mm SE valve (size 8A) has peak systolic gradients of 13 to 58 mmHg (N = 6) with a calculated effective orifice of 0.7 to 1.4 cm2. The 19‐mm SJ valve has a gradient at peak pressure of 17 mmHg and a mean gradient of 22 mmHg (N = 6) with respective exercise gradients of 32 and 38 mmHg (N = 5). For the 21‐mm SJ valve the mean gradient was 5.2 ± 5.3 (N ± 12) and the gradient at peak pressure was 6.0 mmHg (N = 15). The 21‐mm MH valve had resting gradients at peak pressure of 10.5 (N = 3) and 12.4 mmHg (N = 9) and exercise gradients of 15.8 mmHg (N = 9). Six months after AV replacement with small SJ or MH (N = 14) or large (23 mm or greater) (N = 83) valves, cardiac output was 4.7 versus 6.4 L/min (p<0.03), percent reduction in left ventricular mass index (LVMI) was ‐8% versus ‐21% (p<0.01), exercise duration was 370 versus 555 seconds, and congestive heart failure (CHF) class was 1.9 versus 1.1 (p<0.0001). Change in LVMI and valve size were the only independent predictors of CHF class. Gradients for SE are excessive and for SJ and MH are comparable, but small sizes unfavorably affect outcome. (J Card Surg 1994;

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1994.tb00916.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

AbstractDurability is assessed with regard to valve position, patient age, and the techniques of graft preparation for each of the tissue valves. Design affects both durability and the effective orifice area. It is assessed for each of the available devices, with particular emphasis on the stentless porcine valve. The effect that differences between this glutaraldehyde fixed device and the allograft valve may have on techniques of implantation is analyzed. On the basis of this information, an attempt is made to grade the currently available tissue valves with a satisfactory intermediate‐term performance for use in the small aortic root. (J Card Surg 1994;9[Suppl]:158–

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1994.tb00917.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

AbstractComplex multilevel left ventricular outflow tract obstruction includes some of the more challenging problems in congenital cardiac reconstructive surgery. Preoperative studies must carefully delineate the level of obstruction that may be entirely below the aortic annulus (i.e., subaortic stenosis), at the level of the aortic annulus (i.e., aortic annular hypoplasia), may be related to valve leaflet obstruction due to rigid or fused valve leaflets (i.e., aortic valve stenosis), or may be at the level of the tips of the commissures of the aortic valve e., supravalvar aortic stenosis). Frequently, variable contributions are present from all these potential levels of obstruction. An important underlying goal in planning surgical therapy should be preservation of the child's own aortic valve, whenever possible. Operative procedures should preserve growth potential and minimize the need for repeat surgical procedures. A number of surgical options that incorporate these goals will be described. (J Card Surg 1994;9[Suppl]:165–16

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1994.tb00918.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

AbstractLeft ventricular(LV) systolic function is an important determinant of long‐term prognosis in patients with chronic aortic regurgitation. In patients undergoing aortic valve replacement (AVR), those with preoperative LV dysfunction have a greater risk of postoperative congestive heart failure and death than do those in whom preoperative LV systolic function Is normal. Patients with preoperative LV dysfunction are not a homogeneous group, however, but may be further stratified according to risk on the basis of the severity of symptoms, exercise intolerance, and temporal duration of LV dysfunction. Hence, asymptomatic patients with reproducible and definite evidence of impaired LV function should undergo operation without waiting for the development of symptoms or more severe LV dysfunction. Among asymptomatic patients with normal LV systolic function (normal ejection fraction and fractional shortening), the prognosis is excellent with only a gradual rate of deterioration during conservative, nonoperative management. The long‐term follow‐up experience of such patients indicates that the annual mortality rate is less than 0.5% and that less than 4% per year require AVR because symptoms or LV dysfunction at rest develop. Patients likely to require operation over a 10‐year period because symptoms or LV dysfunction develop can be identified on the basis of age, severity of LV dilatation by echocardiography, and progressive change in LV dimensions or resting ejection fraction during the course of serial follow‐up studies. Patients at risk of sudden death before surgery Is performed may be Identified by extreme LV dilatation (diastolic dimension>80 mm, systolic dimension>55 mm). If asymptomatic patients are followed carefully and undergo operation only after the onset of symptoms, depressed ejection fraction at rest, or extreme LV dilatation, the operative mortality is low, long‐term postoperative survival is excellent, and LV function after operation improves in virtually every patient. Hence, although asymptomatic patients with depressed LV contractile function at rest or extreme LV dilatation should undergo AVR before the onset of symptoms, the great majority of asymptomatic patients with normal LV contractile function at rest do not require “prophylactic” valve replacement to preserve LV function. AVR is justifiable in asymptomatic patients who manifest consistent and reproducible evidence of either LV contractile dysfunction at rest or extreme LV dilatation on noninvasive studies. (J Card Surg 1994;9

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1994.tb00919.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY

摘要:

AbstractElective replacement of the aortic root in patients with Marian syndrome is indicated to prevent aortic dissection and prevent left ventricular failure from aortic regurgitation. The two most important factors bearing on the patient's risk for aortic dissection are the maximal aortic root dimension and a family history of aortic dissection. Improvements In surgical technique, favorable long‐term postoperative results, and the observation that a substantial proportion of Marian patients die of aortic dissection with an aortic root dimension in the 50‐to 60‐mm range have led to new recommendations. Asymptomatic Marian patients may be followed annually with echocardiography. When the aortic root dimension reaches 50 mm, the interval between examinations should be shortened to every 3 to 4 months. Asymptomatic individuals with aortic root dimension between 50 and 55 mm should be referred for elective composite graft repair if one or more of the following additional factors are present: moderately severe aortic regurgitation, severe mitral regurgitation, a family history of aortic dissection, and a future need for other major operative procedures such as abdominal aortic aneurysm repair or spinal fusion. In the absence of these factors, asymptomatic individuals may be followed until the aortic root dimension is 55 mm and should then be referred for surgery. Symptomatic individuals with or without aortic root dilatation should be operated upon urgently If evidence of an aortic dissection is present. Postoperatively, all patients should be maintained on beta blockade indefinitely and receive prophylactic parenteral antibiotics before dental, genitourinary, or gastrointestinal procedures. (J Card Surg 1994;9[Suppl]:17

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1994.tb00920.x

出版商:Blackwell Publishing Ltd    

年代:1994

数据来源: WILEY