Frequency and long term follow up of valvar insufficiency caused by retrograde aortic radiofrequency catheter ablation procedures.
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OBJECTIVE: To assess the frequency of valvar complications caused by left sided radiofrequency catheter ablation using the retrograde aortic technique. METHODS: 179 patients (118 male) with a mean (SD) age of 43 (17) years underwent 216 procedures at one centre. The target of the ablation was an accessory atrioventricular pathway in 144 patients, the atrioventricular junction in 29 patients, and a ventricular tachycardia in six patients. In 25 patients structural heart disease was identified before the procedure (ischaemic heart disease 10, cardiomyopathy nine, valvar three, other three). Echo/Doppler examinations were performed the day before the procedure and within 24 hours postablation; the investigations were all reviewed by the same investigator. Patients with identified valvar injury caused by the procedure were followed for 42 (7) months. RESULTS: Valvar injury caused by the ablation procedure was identified in four young (age 30 (8) years), otherwise healthy patients with left lateral atrioventricular accessory pathways. Mild mitral insufficiency with a central regurgitation jet was detected in two patients and remained unchanged at follow up. Mild aortic insufficiency was detected in another two patients. In one of these the regurgitation jet was central and remained unchanged at follow up. In one patient the regurgitation jet was located between the non-coronary and left cusps in relation to a loosely attached structure. Both the structure and the valvar regurgitation disappeared during follow up. No clinical complications occurred in any of the patients during follow up. CONCLUSION: In this study, the frequency of valvar complications after left sided radiofrequency catheter ablation using the retrograde aortic technique was 1.9%. (+info)
Impact of vascular adaptation to chronic aortic regurgitation on left ventricular performance.
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BACKGROUND: This investigation was designed to test the hypothesis that vascular adaptation occurs in patients with chronic aortic regurgitation to maintain left ventricular (LV) performance. METHODS AND RESULTS: Forty-five patients with chronic aortic regurgitation (mean age 50+/-14 years) were studied using a micromanometer LV catheter to obtain LV pressures and radionuclide ventriculography to obtain LV volumes during multiple loading conditions and right atrial pacing. These 45 patients were subgrouped according to their LV contractility (Ees) and ejection fraction values. Group I consisted of 24 patients with a normal Ees. Group IIa consisted of 10 patients with impaired Ees values (Ees <1.00 mm Hg/mL) but normal LV ejection fractions; Group IIb consisted of 11 patients with impaired contractility and reduced LV ejection fractions. The left ventricular-arterial coupling ratio, Ees/Ea, where Ea was calculated by dividing the LV end-systolic pressure by LV stroke volume, averaged 1.60+/-0.91 in Group I. It decreased to 0.91+/-0.27 in Group IIa (P<0.05 versus Group I), and it decreased further in Group IIb to 0.43+/-0.24 (P<0.001 versus Groups I and IIa). The LV ejection fractions were inversely related to the Ea values in both the normal and impaired contractility groups (r=-0.48, P<0.05 and r=-0.56, P<0.01, respectively), although the slopes of these relationships differed (P<0.05). The average LV work was maximal in Group IIa when the left ventricular-arterial coupling ratio was near 1.0 because of a significant decrease in total arterial elastance (P<0.01 versus Group I). In contrast, the decrease in the left ventricular-arterial coupling ratio in Group IIb was caused by an increase in total arterial elastance, effectively double loading the LV, contributing to a decrease in LV pump efficiency (P<0.01 versus Group IIa and P<0.001 versus Group I). CONCLUSIONS: Vascular adaptation may be heterogeneous in patients with chronic aortic regurgitation. In some, total arterial elastance decreases to maximize LV work and maintain LV performance, whereas in others, it increases, thereby double loading the LV, contributing to afterload excess and a deterioration in LV performance that is most prominent in those with impaired contractility. (+info)
Bileaflet mechanical prostheses for aortic valve replacement in patients younger than 65 years and 65 years of age or older: major thromboembolic and hemorrhagic complications.
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OBJECTIVE: To determine major thromboembolic and hemorrhagic complications and predictive risk factors associated with aortic valve replacement (AVR), using bileaflet mechanical prostheses (CarboMedics and St. Jude Medical). DESIGN: A case series. SETTING: Cardiac surgical services at the teaching institutions of the University of British Columbia. PATIENTS AND METHODS: Patients 2 age groups who had undergone AVR between 1989 and 1994 were studied. Group 1 comprised 384 patients younger than 65 years. Group 2 comprised 215 patients 65 years of age and older. RESULTS: The linearized rates of major thromboembolism (TE) occurring after AVR were 1.54%/patient-year for group 1 and 3.32%/patient-year for group 2; the rates for major TE occurring more than 30 days after AVR were 1.13%/patient-year for group 1 and 1.55%/patient-year for group 2. The crude rates for major TE occurring within 30 days of AVR were 1.04% for group 1 and 3.72% for group 2. The death rate from major TE in group 1 was 0.31%/patient-year and in group 2 was 0.88%/patient-year. Of the major TE events occurring within 30 days, 100% of patients in both age groups were inadequately anticoagulated at the time of the event, and for events occurring more than 30 days after AVR, 45% in group 1 and 57% in group 2 were inadequately anticoagulated (INR less than 2.0). The overall linearized rates of major hemorrhage were 1.54%/patient-year for group 1 and 2.21%/patient-year for group 2. There were no cases of prosthesis thrombosis in either group. The mean (and standard error) overall freedom from major TE for group 1 patients at 5 years was 95.6% (1.4%) and with exclusion of early events was 96.7% (1.3%); for group 2 patients the rates were 90.0% (3.2%) and 93.7% (3.0%), respectively. The mean (and SE) overall freedom from major and fatal TE and hemorrhage for group 1 patients was 90.1% (2.3%) and with exclusion of early events was 91.2% (2.3%); for group 2 patients the rates were 87.9% (3.1%) and 92.5% (2.9%), respectively. The 5-year rate for freedom from valve-related death for group 1 patients was 96.3% (2.1%) and for group 2 patients was 97.2% (1.2%). CONCLUSION: The thromboembolic and hemorrhagic complications after AVR with bileaflet mechanical prostheses occur more frequently and result in more deaths in patients 65 years of age and older than in patients years younger than 65 years. (+info)
Minimally invasive aortic valve replacement through a transverse sternotomy: a word of caution.
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OBJECTIVES: To compare aortic valve replacement (AVR) using a minimally invasive approach through a transverse sternotomy with the established approach of median sternotomy. DESIGN: Retrospective, case-control study. PATIENTS: Fourteen high risk patients (median age 78, Parsonnet score of 18%) who underwent AVR performed through a minimally invasive transverse sternotomy were compared with a historical group of patients matched for age, sex, and Parsonnet score who underwent AVR performed through a median sternotomy by the same surgeon. OUTCOME MEASURES: Cross clamp time, total bypass time, intensive care stay, postoperative in-hospital stay, morbidity, and mortality. RESULTS: There were two deaths in the minimally invasive group and none in the control group (NS). The cross clamp and total bypass times were longer in the minimally invasive group (67 and 92 minutes v 46 and 66 minutes, p < 0.001). There was a higher incidence of re-exploration for bleeding (14% v 0%) and paravalvar leaks (21% v 0%) in the minimally invasive group but these differences were not significant. The minimally invasive group had a longer postoperative in-hospital stay (p = 0.025). The incidence of mortality or major morbidity was 43% (six of 14) in the minimally invasive group and 7% (one of 14) in the matched pairs (p = 0.013). CONCLUSIONS: AVR can be performed through a transverse sternotomy but the operation takes longer and there is an unacceptably high incidence of morbidity and mortality. (+info)
Non-invasive assessment of left ventricular function after correction of severe aortic regurgitation.
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Twenty patients were studied with simultaneous left ventricular cavity echocardiograms and apex cardiograms during the first two weeks after correction of severe aortic regurgitation. Endocardial echoes and apex cardiograms were digitized, so that left ventricular dimensions, their rates of change, and echo dimension-apex cardiogram relations could be studied. After aortic valve replacement, there was an early reduction in end-diastolic dimension, within 2 days, from 7-0 +/- 0-8 cm to 5-7 +/- 1-0 cm (P less than 0-001), while peak normalized shortening rate (peak Vcf) dropped from 1-9 +/- 0-6 to 1-4 +/- 0-6 S-1 (P less than 0-01), and remained unchanged for the remainder of the study. Immediately after operation, striking abnormalities of isovolumic contraction and, to a lesser extent, of early relaxation, could be seen, which regressed over 4 to 7 days, except in 2 patients who developed a low output state. These changes in left ventricular dimension, Vcf, and isovolumic contraction could not have been described by an single "measure" of left ventricular function. (+info)
Syphilitic aortic regurgitation. An appraisal of surgical treatment.
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During the 10 years from 1964 to 1973, fifteen patients with severe syphilitic aortic regurgitation were treated surgically at the National Heart Hospital. In thirteen the valve was replaced and in two it was repaired. In addition four had replacement of an aneurysmal ascending aorta with a Dacron graft and seven some form of plastic repair to the coronary ostia. Three patients died within 1 month of surgery and a further six during the follow-up period which varied from 1 to 55 months (mean 25-5). The six survivors have been followed-up for an average of 33 months. Factors contributing to this high mortality were analysed and it was found that the mean duration of effort dyspnoea was 22 months in the survivors compared with 48 months in those who had died. Similarly the average duration of nocturnal dyspnoea was 4 months in the survivors compared with a mean of 8 months in those who had died. Only six out of the fifteen patients had angina; this was present in two of the survivors and in four of the fatalities. The pulse pressure, heart size, and haemodynamic findings were similar in the two groups. The prognostic value of an elevated erythocyte sedimentation rate was also examined. It was concluded that preoperative investigations should include aortography, coronary arteriography, an assessment of left ventricular function, and whenever possible myocardial biopsy. These data were interpreted as suggesting that patients should be referred for surgery at an earlier stage in the disease--certainly before the onset of cardiac failure and--and that if this more aggresive attitude was adopted, as it has been in non-syphilitic cases of aortic valve disease, the present high mortality in this group would be reduced. (+info)
Three-dimensional reconstruction of the color Doppler-imaged vena contracta for quantifying aortic regurgitation: studies in a chronic animal model.
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BACKGROUND: The purpose of this study was to investigate the use of 3-dimensional (3D) reconstruction of color Doppler flow maps to image and extract the vena contracta cross-sectional area to determine the severity of aortic regurgitation (AR) in an animal model. Evaluation of the vena contracta with 2-dimensional imaging systems may not be sufficiently robust to fully characterize this region, which may be asymmetrically shaped. METHODS AND RESULTS: In 6 sheep with surgically induced chronic AR, 18 hemodynamically different states were studied. Instantaneous regurgitant flow rates were obtained by aortic and pulmonary electromagnetic flowmeters (EMFs) as reference standards, and aortic regurgitant effective orifice areas (EOAs) were determined from EMF regurgitant flow rates divided by continuous-wave (CW) Doppler velocities. Composite video data for color Doppler imaging of the aortic regurgitant flows were transferred into a TomTec computer after computer-controlled 180 degrees rotational acquisition. After the 3D data transverse to the flow jet were sectioned, the smallest proximal jet cross section was identified for direct measurement of the vena contracta area. Peak regurgitant flow rates and regurgitant stroke volumes were calculated as the product of these areas and the CW Doppler peak velocities and velocity-time integrals, respectively. There was an excellent correlation between the 3D-derived vena contracta areas and reference EOAs (r=0.99, SEE=0.01 cm2) and between 3D and reference peak regurgitant flow rates and regurgitant stroke volumes (r=0.99, difference=0.11 L/min; r=0.99, difference=1.5 mL/beat, respectively). CONCLUSIONS: 3D-based determination of the vena contracta cross-sectional area can provide accurate quantification of the severity of AR. (+info)
Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study.
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BACKGROUND: The outcome of aortic regurgitation conservatively followed in clinical practice is poorly defined. METHODS AND RESULTS: Long-term outcome of 246 patients with severe or moderately severe aortic regurgitation diagnosed by color Doppler echocardiography was analyzed. With conservative management, mortality rate was higher than expected (at 10 years, 34+/-5%, P<0. 001) and morbidity was high (10-year rates of 47+/-6% for heart failure and 62+/-4% for aortic valve surgery). At 10 years, 75+/-3% of patients had died or had surgery and 83+/-3% had had cardiovascular events. In multivariate analysis, predictors of survival were age (P<0.001), functional class (P<0.001), comorbidity index (P=0.033), atrial fibrillation (P=0.002), and left ventricular end-systolic diameter corrected for body surface area (P=0.025). Ejection fraction was also an independent predictor of overall survival, including postoperative follow-up of surgically treated patients (P<0.001). High risk during conservative treatment, with mortality rate in excess of that expected, was noted among patients with severe, even transient, symptoms (24.6% yearly, P<0.001) but also in those with mild (class II) symptoms (6.3% yearly, P=0.02) and in asymptomatic patients with left ventricular ejection fraction <55% (5.8% yearly, P=0.03) or with end-systolic diameter normalized to body surface area >/=25 mm/m2 (7.8% yearly, P=0.004). Surgery performed during follow-up was independently associated with reduced cardiovascular mortality (adjusted hazard ratio, 0.54; P=0.048). CONCLUSIONS: Patients diagnosed with severe aortic regurgitation in clinical practice incur excess mortality and high morbidity, underscoring the serious prognosis of the disease. Surgery, which reduces cardiac mortality rates, should be considered promptly in high-risk patients. (+info)