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Ann Thorac Surg 2002;74:438-443
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Aortic cusp extension valvuloplasty for rheumatic aortic valve disease: midterm results

^a Department of Cardiac Surgery, Hôpital Européen Georges Pompidou, Paris University, Paris, France

Accepted for publication April 16, 2002.

* Address reprint requests to Dr Grinda, Department of Cardiac Surgery, Hôpital Européen Georges Pompidou, 21 rue Leblanc, 75908, Paris cedex 15, France
e-mail: jean-michel.grinda{at}egp.ap-hop-paris.fr

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. The surgical management of rheumatic aortic insufficiency in the young remains problematic owing to the drawbacks of prosthetic valve replacement at this age. In young foreign patients, for whom long-term anticoagulation therapy is unavailable, we have used a glutaraldehyde preserved autologous pericardium cusp extension technique to repair rheumatic aortic valve insufficiencies resulting from cusp retractions.

Methods. From September 1992 to December 2000, 89 consecutive patients with a mean age of 16 ± 5 years underwent triple pericardial aortic cusp extension valvuloplasty. Eighty patients had pure aortic insufficiency, 9 had mixed aortic disease. Twenty-nine patients (33%) had isolated aortic valve disease and 60 patients (69%) had combined aortic and mitral valve disease with significant tricuspid valve disease in 21 (24%). Aortic repair consisted of free edge aortic cusp extension using three rectangular strips of glutaraldehyde stabilized autolologous pericardium. Twenty-nine patients (33%) underwent an isolated aortic repair, 39 patients (44%) underwent combined aortic and mitral procedures (34 mitral repairs, 3 mitral homografts, and 2 prothesis replacements), and 21 patients (23%) underwent a triple valve repair.

Results. The hospital mortality was 2.2%. Primary failure of the aortic repair requiring immediate reoperation occurred in 2 patients. During follow-up (mean of 62 ± 22 months) 1 patient died and 7 underwent redo valvular surgery. At 5 years the actuarial survival rate was 96.4%, and 92.1% of the patients were free from redo valvular surgery. At 7 years 90% of the patients were free from valve-related complications. Among the 76 patients free from redo valvular surgery at follow-up, 6 had deterioration of the repair resulting in grade II aortic and mitral insufficiencies.

Conclusions. Our midterm results of glutaraldehyde stabilized autologous pericardial aortic cusp extension are encouraging and suggest that this technique should be considered as a viable alternative palliative procedure in a young rheumatic population, allowing for growth of the annulus and delaying to a less critical period the need for the lifelong anticoagulation therapy required for a prosthetic mechanical valve.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Surgical management of aortic insufficiency in the young remains a problem because of prosthetic valve replacement drawbacks at this age [1–5]. To face this problem, new surgical approaches have been evaluated such as aortic homografts [6–8] or autograft [9–11] replacement. Additionally, interest in aortic valvuloplasty as an alternative has been stimulated [12–17]. Duran and associates [18, 19] developed a method of aortic valvuloplasty: the cusp extension. Discussion remains concerning the identification of patient subgroups suitable for the extensions, on the choice of the material that must be used, and on the outcomes. This report reviews our initial experience with glutaraldehyde preserved autologous pericardium aortic cusp extensions in young patients with rheumatic aortic insufficiency resulting from cusp retraction.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
Patients
From September 1992 to December 2000, triple pericardial cusp extensions were attempted to achieve aortic repair in 89 consecutive patients suffering from rheumatic aortic insufficiency resulting from cusp retraction These 89 patients, 42 female and 47 male, with a mean age of 16 ± 5 years (range 6 to 32), underwent triple pericardial cusp extensions. Most of these patients came from underdeveloped areas in which long-term anticoagulation therapy is unavailable. The area were located in Eastern Europe (n = 9), North Africa (n = 11), Southeast Asia (n = 38), West Africa (n = 21), Central Africa (n = 8), or East Africa (n = 2). A humanitarian association for the surgical management of young foreign indigenous persons was in charge of 63 (71%) of these patients. The preoperative characteristics of the patients are summarized in Tables 1 and 2.

Eighty patients (90%) had pure aortic insufficiency, 9 had associated stenosis (10%). Most of the patients had aortic cusp retractions resulting in central aortic insufficiency without any cusp prolaps which corresponds to a Carpentier classification type III (restricted leaflet motion). This is typical of rheumatic aortic valvular disease resulting in a central triangular coaptation defect on echocardiography. All the patients had a tricuspid aortic valve.

Sixty patients (67%) had associated mitral valve disease including mitral insufficiency (n = 39), combined mitral valve insufficiency with stenosis (n = 13) and pure mitral valve stenosis (n = 8). According to the Carpentier classification, 11 patients had type I mitral valve insufficiency (normal leaflet motion), 13 patients had type II (leaflet prolapse), and 27 had type III (restricted leaflet motion). In fact, most of the patients had a mitral annular deformation with restriction of the posterior leaflet and some prolapse of the anterior leaflet (type III posterior and II anterior), which are the most common valvular dysfunctions in mitral rheumatic disease among the young.

Twenty-one patients (24%) had associated tricuspid valve disease, 13 of which were functional type I and 8, organic type III.

Operative procedure
The operation was performed under cardiopulmonary bypass with cannulation of the ascending aorta and both vena cava. Myocardial protection was achieved with cold crystalloid cardioplegia injected into the coronary ostia, topical cooling of the heart, and moderate systemic hypothermia (28°C). Procedures are listed in Table 3. Twenty-nine patients (36%) had isolated aortic repair. For these patients the mean aortic crossclamping time was 68 ± 22 minutes (range 40 to 100) and the mean cardiopulmonary bypass time was 76 ± 27 minutes (range 50 to 135). Sixty patients (64%) had a combined surgical procedure—39 had both aortic and mitral procedures and 21 had associated aortic, mitral, and tricuspid procedures. For this group of patients with combined procedures the mean aortic crossclamping time was 105 ± 35 minutes (range 45 to 180); the mean cardiopulmonary bypass time was 126 ± 46 minutes (range 60 to 240).

Aortic repair was then attempted using the technique described here. An autologous pericardium patch had been previously harvested, carefully thinned down, and stabilized with glutaraldehyde (8 minutes in a 0.62% glutaraldehyde solution) [21]. Three rectangular strips were tailored from it. The height of the three strips was fixed at 8 mm. This 8 mm height allows a sufficient extension of the native cusp to ensure efficient coaptation. The length of the strip was adjusted according to the length of the free edge of each aortic cusp. Each autologous pericardial strip was then sutured to the corresponding free edge of the aortic cusp using 7-0 Prolene sutures (Fig 1). Sutures were started at the midpoint of the cusp. At the commissure the sutures were extended along the aortic wall corresponding to the height of the strip. The sutures were then passed through the aortic wall to finally stop outside with the remaining thread used for the adjacent cusp. The new commissures were then elevated to the height of the autologous pericardial strip (8 mm). Before the suture of the strip, the free edge of the aortic cusp was resected in 5 patients (6%) because of excessive thickness. Cusp shaving was used in 6 patients, cusp decalcification in 4 patients, and commissurotomy in 4 patients. In 10 patients aortic annuloplasty using circular sutures (4 patients) or semicircular sutures (6 patients) was used [20]. The aorta was sutured without any distortion so as not to disturb the architecture of the aortic valve reconstruction.

View larger version (129K): [in this window] [in a new window]   Fig 1. Aortic cusp extension valvuloplasty showing the suture of glutaraldehyde stabilized autologous pericardium at the free edge of the aortic cusp.

Assessment of quality and durability of repair
The quality of the repair was assessed with diastolic arterial pressure after the patients were weaned off cardiopulmonary bypass. Intraoperative transesophageal echocardiography (TEE) was systematically performed for patients weighing more than 30 kg and for all patients since 1998. For patients who could not undergo TEE in the operating room because of their weight, transthoracic echocardiography (TTE) was performed in the intensive care unit and before discharge.

Follow-up
Patients or their referred cardiologist have been solicited to answer a questionnaire. For the patients of the humanitarian association who went back to their country after surgery, a referent local general physician or cardiologist of the association was able to assess the patient’s condition on the basis of a physical examination and, depending on the technical possibility, on the basis of TTE. Under such conditions we cannot provide uniform TTE follow-up as we would have liked. Follow-up data were collected during a 6-month period. Two patients with aortic repair were lost to follow-up because of political instability in their country. Mean follow-up was 62.5 ± 22 months (range 1 to 92) postoperatively.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
Mortality
Two patients died (operative mortality 2.2%). A 14-year-old child, preoperatively New York Heart Association class IV, with triple valve disease died on postoperative day 27 because of multiorgan failure syndrome (MOF) after a triple reconstructive procedure on that day. A 13-year-old child died on the first postoperative day because of cardiac failure after an isolated aortic valve reconstruction. One patient died of cardiac failure 36 months postoperatively. The actuarial survival rate at 5 years was 96.4% (Fig 2).

View larger version (11K): [in this window] [in a new window]   Fig 2. Freedom from death and freedom from valve-related complications in patients undergoing aortic cusp extension valvuloplasty for rheumatic aortic valve insufficiency. The solid line represents freedom from death; the dotted line represents freedom from valve-related complications (similar in this study to freedom from redo valvular surgery).

Echocardiogaphic data at discharge
All the patients underwent a TTE before discharge (85 patients with aortic valve extensions). Fifty-eight patients no longer had a trivial aortic insufficiency. Twenty patients had residual grade I and 7 patients grade II aortic insufficiency. Mean postoperative gradient on the extended valve was 9.1 ± 4.3 mm Hg. Mitral and tricuspid valve function were satisfactory on control. No patient had more than grade I mitral or tricuspid insufficiency with no significant transvalvular gradients noted.

Redo valvular surgery
Early failure
Primary failure of aortic repair occurred in 2 patients. They underwent immediate reoperation on the day of the initial repair. A 12-year-old child with a double aortic and mitral repair was reoperated on at postoperative hour 8 because of aortic and mitral regurgitation. At reoperation there was a distortion of the repaired aortic valve. The patient underwent a double aortic and mitral valve replacement. The second patient, a 15-year-old child, had an isolated aortic repair and was easily weaned off cardiopulmonary bypass with good results on intraoperative TEE. However the pericardial strip in front of the left coronary ostium seemed slightly redundant. One hour after the operation the patient underwent emergency reoperation after resuscitation resulting from ventricular fibrillation. The aortic repair showed no evident abnormality; a dynamic left main trunk obstruction was suspected and a prosthetic aortic valve replacement was performed. The outcome of these 2 patients was satisfactory.

Late failure
Seven patients underwent reoperation. In 2 patients reoperation was performed because of aortic bacterial endocarditis. They underwent successful aortic bioprosthetic valve replacement at postoperative months 26 and 48 respectively. The 5 other patients were reoperated on because of valvuloplasty deterioration. Two of them had a significant progression of rheumatic disease. One of the patients underwent an aortic replacement with an homograft and two unsuccessful mitral repairs followed by a mitral valve replacement at postoperative month 14. Another patient underwent a double valve replacement at postoperative month 34. The last 3 patients underwent prosthetic (n = 1) or homograft (n = 2) aortic valve replacement at postoperative months 14, 42, and 63 respectively. The actuarial rate of freedom from reintervention (92% at 5 years) was equal to the rate of freedom from valve related complication in this study. This actuarial rate was 92% and 90% at 5 and 7 years respectively (Fig 2).

Pathology
The explanted native aortic valves and pericardial patches were available for pathologic examination in 3 patients who underwent redo surgery. Histologic studies included three different colorations: the nuclei, cytoplasms, and extracellular matrix were analyzed with hematoxylin-eosin-safranor staining, the muccopolysaccharides with alcian blue staining, and the elastic fibers with orcein staining. In two extended aortic valves with severe sclerosis and important neovascularization and mononuclear inflammatory infiltration only elastic staining allowed distinction between native aortic cusp and pericardial patches.

The aortic reconstruction in the three extended aortic valve studied was clearly visible. Native cusp, suture, and patches were clearly distinguishable. The aortic cusp revealed chronic rheumatic progression. Patches demonstrated moderate retraction, fibrosis and rarely small calcifications (Fig 3). The pericardium contained numerous spindle cells with a fibroblast appearance along with on abundant extracellular matrix. An endothelial layer was not observed covering the surface of the pericardium.

View larger version (117K): [in this window] [in a new window]   Fig 3. Calcification at the edge of a patch.

Among the 75 patients with aortic repair at follow-up, echocardiographic examination was available in 59 patients. Trivial aortic regurgitation was observed in 33 of 59 (56%) patients; grade I and grade II aortic regurgitation was observed in 20 of 59 (34%) and 6 of 59 (10%) patients respectively. No patients had grade III or IV aortic regurgitation. Gradient on the extended aortic valve and the left ventricular diameter were not available. Evolution of the degree of aortic regurgitation between time of discharge and time of follow-up is reported in Figure 4. Grade I and II mitral regurgitation was observed in 17 and 6 patients respectively. No patient had grade III or IV mitral insufficiency. No patient had more than grade II tricuspid insufficiency. In fact 6 patients had moderate deterioration in valvular repair quality resulting in grade II aortic and mitral regurgitation. These 6 patients were evaluated at postoperative months 24, 37, 48, 58, 65, and 72 respectively. At discharge 4 of them had grade I and 2 had grade II aortic insufficiency.

View larger version (28K): [in this window] [in a new window]   Fig 4. Echographic evaluation of aortic regurgitaiton after aortic cusp extension. (NE = not evaluated, echocardiogram not available at follow-up; RS = redo surgery during follow-up; D = death.)

	Comment

Top Abstract Introduction Patients and methods Results Comment References

The material of choice for extension is still debated: heterogolous pericardium, fresh autologous pericardium, or glutaraldehyde stabilized autologous pericardium [23]. Being accustomed to the use of glutaraldehyde stabilized autologous pericardium in our unit [21], we naturally used this substitute when it was free from adhesion to perform cusp extensions. The follow-up duration in our series is not sufficient for allowing precise determination of the long-term durability of autologous pericardium in this setting. However, at present the reoperation rate is low considering the propensity for progression of rheumatic disease.

The other more conventional surgical options are not ideal solutions for these patients. Mechanical prosthetics require long-term anticoagulation therapy [2–5], which is not ideal for young patients particularly for those coming from developing countries. Bioprosthetic valves have a very high rate of early calcification and failure [1]. Stentless heterograft bioprosthesis, which are expected to have a longer durability than conventional bioprothesis because of stress reduction, will probably calcify in a young population. Homograft valves still have antigenic properties and less durability when implanted in the young compared with an adult population [6, 7, 11]. The Ross procedure is more technically demanding and more time consuming and raises concern regarding the issue of homograft pulmonary valve replacement [7, 8, 10, 11]. Moreover, the Ross procedure in the young rheumatic patient has not demonstrated an increased benefit [24].

The data from this experience suggest that midterm results of valvuloplasty using glutaraldehyde stabilized autologous pericardial cusp extensions for rheumatic aortic regurgitation resulting from cusp retraction are encouraging. Extension aortic valvuloplasty could be considered as a viable palliative alternative procedure in young rheumatic patients, allowing aortic annulus growth and awaiting a less critical period for lifelong anticoagulation therapy. In rheumatic patients autologous pericardial patch extensions of the aortic valve have permitted widespread use of reconstructive surgery even in patients suffering from double and triple valve disease.22

	References

Top Abstract Introduction Patients and methods Results Comment References

 

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