Ann Thorac Surg 2009;87:1775-1782. doi:10.1016/j.athoracsur.2009.03.008
© 2009 The Society of Thoracic Surgeons
Original Articles: Adult Cardiac
Long-Term Experience of Surgical Treatment for Aortic Regurgitation Attributable to Behçet's Disease
Dong Seop Jeong, MD, PhDa,
Kyung-Hwan Kim, MD, PhDb,
Jun Sung Kim, MDa,
Hyun Ahn, MD, PhDb,*
a Department of Thoracic and Cardiovascular Surgery, Seoul National University Borame Medical Center, Seoul National University Hospital, Seoul, South Korea
b Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, South Korea
Accepted for publication March 9, 2009.
* Address correspondence to Dr Ahn, Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, 28, Yeongeon-dong, Jongno-gu, Seoul, 110-744, Korea (Email: ahnhyuk{at}snu.ac.kr).
 |
Abstract
|
|---|
Background: Cardiac involvement in Behçet's disease is a rare but severe complication and presents challenges to cardiac surgeons as a result of late valve detachment or pseudoaneurysms of the aortic root after valve surgery. Few reports have been published on this topic. In this article, clinical data and surgical outcomes in patients with aortic regurgitation attributable to Behçet's disease were analyzed.
Methods: Nineteen patients with aortic regurgitation attributable to Behçet's disease were surgically treated between March 1986 and June 2008. There were 15 men and 4 women with ages ranging from 24 to 55 years (mean, 39 ± 7 years). Mean follow-up duration from index operations was 77.4 ± 68.1 months (range, 9 to 271 months).
Results: Overall mortality was 47.3% (9 of 19 patients), but no early deaths occurred at index operations. All deaths occurred after second operations, and the causes of death were low cardiac output (n = 6) and sudden aggravation of aortic regurgitation (n = 3). Erythrocyte sedimentation rates and C-reactive protein concentrations were negatively correlated with event-free period. Event-free survival at 13 years was 39.2% ± 14.1% in patients who underwent aortic root replacement, but this was 4% ± 3.9% in patients who underwent valve replacement (p = 0.001). Event-free survival at 13 years in patients who were administered immunosuppressive therapies was 33.7% ± 11.0% and 0% in patients not administered immunosuppressive therapy (p = 0.001).
Conclusions: The mortality in this condition was very high and was found to depend on levels of postoperative inflammatory markers. Aortic root replacement and postoperative immunosuppressive therapy may be helpful.
|
Introduction
|
|---|
Behçet's disease is a multisystem inflammatory disorder dominated clinically by recurrent oral and genital ulceration, uveitis, and erythema nodosum [1]. Furthermore, various systemic manifestations can occur, such as arthritis, gastrointestinal lesions, neurologic symptoms, and cardiovascular complications [2]. The International Study Group for Behçet's disease last revised the diagnostic criteria of Behçet's disease in 1990 [3]. Cardiovascular involvement in Behçet's disease is one of the most severe complications, and is more clinically relevant in the Orient as a cause of aortic regurgitation (AR) than in the West [4]. Of the known cardiovascular complications, AR occurs only rarely based on case reports. In addition, surgical treatment of this condition carries a high risk of postoperative morbidity as a result of valve dehiscence or pseudoaneurysms at anastomosis sites, because of the fragilities of aortic structures and tissue inflammation [5]. Few clinical reports have been issued. The study by Ando and colleagues [6] on results achieved by 10 patients during a 16-year follow-up period is one of the largest studies conducted to date. In this article, we analyzed clinical data and surgical outcomes in patients with AR attributable to Behçet's disease.
|
Material and Methods
|
|---|
Between March 1986 and June 2008, 19 patients with AR attributable to Behçet's disease were surgically treated. The clinical data of patents at index operations are detailed in Table 1. There were 15 men and 4 women, with ages ranging from 24 to 55 years (mean, 39 ± 7 years). Behçet's disease was diagnosed based on clinical symptoms, intraoperative findings, and pathologic examinations of the aortic valve and aortic wall. Clinical lesions related to Behçet's disease are listed in Table 2. Behçet's disease was diagnosed preoperatively in 7 patients, and immunosuppressive therapies (eg, azathioprine), including corticosteroids (eg, prednisolone), were administered. Four patients had mitral regurgitation, and 3 had infective endocarditis with an annular abscess at index surgery. Laboratory findings, including echocardiographic and specimen pathologic findings, and follow-up data were reviewed. Mean follow-up duration from index operations was 77.4 ± 68.1 months (range, 9 to 271 months). The study protocol was reviewed by the institutional review board of Seoul National University Hospital (approval number, H-0807-076-251), which waived the need for patient consent.
Operative Technique
We performed 46 cardiac operations including aortic valve replacement (AVR), aortic valvuloplasty, and Bentall type aortic root replacement (ARR) with a bioprosthesis. Intraoperative anesthetic management was uniform for all patients, and each operation was performed through median sternotomy. When routine median sternotomy was considered extremely dangerous owing to multiple pseudoaneurysms adjacent to the sternum, the sternum was opened under total circulatory arrest (Fig 1). In addition to moderate systemic hypothermia, cold-blood cardioplegia was administered in a retrograde fashion through the coronary sinus. Aortic valve replacement was performed using pledgeted 2-0 sutures to reinforce fragile annuli. In cases of interventricular dissection, aortic roots were reconstructed with bovine pericardium before inserting an aortic prosthesis, and then a prosthetic valve or homograft was inserted at the reconstructed annular position. We performed ARR in 17 patients. We tried to use homografts (n = 13) as much as possible when performing ARR, but other valved conduits (the Edwards Prima Plus stentless bioprosthesis, Baxter Healthcare Corp, Irvine, CA) were necessary in 4 patients because homografts were not available at the time of surgery. For AVR, we inserted porcine xenografts in 2 AVRs and mechanical valves in the others (n = 21). Two patients underwent aortic valvuloplasty as an index procedure. Patch repairs with bovine pericardium for pseudoaneurysm after ARR were performed in emergency cases (n = 4). Concomitant procedures included mitral valve replacement in 7 patients and coronary artery bypass grafting in 4 patients.
Statistical Analysis
All numeric variables are expressed as mean ± standard deviation. Statistical analysis was performed using SPSS software (SPSS for Windows, SPSS, Chicago, IL). Clinical and laboratory finding differences were tested using the Student's t test or Fisher's exact test. Relations between inflammatory markers and follow-up data were explored using Pearson's correlation analysis. Kaplan-Meier analysis was used to calculate event-free survival, and the log-rank test was used to check for intergroup differences. Probability values of less than 0.05 were considered statistically significant.
|
Results
|
|---|
Overall mortality was 47.3% (9 of 19 patients), but no early death occurred during index operations. All deaths occurred after second operations, and the causes of death were low cardiac output (n = 6) after cardiac surgery and sudden aggravation of AR (n = 3). When Behçet's disease was diagnosed, postoperative immunosuppressive drugs were given to reduce disease activity and prevent valve dehiscence. Rheumatologists were consulted in all cases concerning medical management. Valve detachment or paravalvular leakage requiring a reoperation occurred in 15 patients (78.9%). Seven patients (36.8%) underwent two or more reoperations for valve detachment. In a total of 46 operations, mortality among patients who underwent AVR at index operation was 76.9% (10 of 13 patients), but all patients who underwent ARR at index operation were alive at last follow-up visits (n = 4). Clinical courses and complications that occurred during follow-up are shown in Table 1 and Figure 2.
View larger version (20K):
[in this window]
[in a new window]
|
Fig 2. Diagram of clinical courses. (ARR = aortic root replacement; AVP = aortic valvuloplasty; AVR = aortic valve replacement.)
|
|
Echocardiographic and Pathologic Findings
Echocardiographic findings are summarized in Table 3. At index operations, redundant motion of elongated aortic cusps with aneurysmal change was detected in all patients (Fig 3). The mean diameters of aortic annulus, sinus of Valsalva, and sinotubular junction were 25.3 ± 2.1 mm, 34.1 ± 2.41 mm, and 32.7 ± 3.2 mm, respectively. Echocardiographic-free spaces were detected frequently (42.1%, 8 of 19 patients) around aortic annuli. At reoperation, echocardiographic-free spaces, aortic pseudoaneurysms, and interventricular septal dissections were found more frequently, but there were no masslike lesions. In 5 patients, the prosthetic aortic valve was severely displaced downward to the left ventricular outflow tract owing to interventricular septal dissection. In 4 patients, prosthetic valve endocarditis with an annular abscess was combined with valve dehiscence.
View larger version (76K):
[in this window]
[in a new window]
|
Fig 3. Cusp aneurysmal change with redundant motion: transesophageal echocardiographic finding (A); intraoperative finding (B).
|
|
Histologic examinations of aortic walls showed characteristic vasculitis with myxoid degeneration in the aortic valve. Medial narrowing and thickened adventitia with myxoid degeneration could explain the weak aortic wall common in this condition, and were found in most patients (94.7%, 18 of 19 patients). In vasa vasorum, lymphocyte infiltration and thrombotic occlusion were found (Fig 4A). Structures of vasa vasorum were destroyed as a result of inflammatory changes. In the patients who were administered preoperative steroids, inflammatory reactions were not as severe; lymphocytic infiltration in the aortic wall and valve was the predominant finding, but in patients not administered preoperative steroid therapy, the majority of infiltrated cells were neutrophils, suggesting an acute inflammatory reaction (Fig 4B). In 4 patients who had AR combined with prosthetic valve endocarditis, multiple microabscess formation and severe inflammatory reactions were evident.
View larger version (114K):
[in this window]
[in a new window]
|
Fig 4. (A) Perivascular infiltration of lymphocytes around vasa vasorum. An arrow indicates a vasa vasorum. (B) Vasculitis and active inflammation in acute-stage Behçet's disease. Lymphocyte infiltration is severe throughout the whole field (arrows). (H&E stain.)
|
|
Clinical Courses
After the 46 operations, delayed wound healing occurred in 2, prosthetic valve endocarditis in 4, conduction disturbance in 2, and a cerebral infarct in 1. All survivors have been doing well at last follow-up visits, except 1 who underwent AVR with a tissue valve 22 years previously. Two patients were followed up with cardiac medications for pulmonary regurgitation and arrhythmia. The other survivors (70%, 7 of 10 patients) did not require any cardiac medication and had a normal aortic valve function. We compared the clinical data of survivors and nonsurvivors. As shown in Table 4, mean age and sex were similar, and preoperative levels of inflammatory markers and the incidences of preoperative immunosuppressive therapy were no different, but infective endocarditis was combined more frequently in nonsurvivors. Survivors tended to have ARR and fewer reoperations, but mean durations between operations were not significantly different. During follow-up, postoperative immunosuppressive therapy was maintained in both groups, but levels of inflammatory markers were higher in nonsurvivors. The mean erythrocyte sedimentation rates, which were checked during follow-up, were found to be negatively correlated with event-free period, ie, death and a cardiac reoperation (p = 0.006; r = –0.673; Fig 5A). C-reactive protein (CRP) levels were also found to be negatively correlated with event-free period (p = 0.024; r = –0.579; Fig 5B).
View larger version (11K):
[in this window]
[in a new window]
|
Fig 5. (A) Relations between erythrocyte sedimentation rates (ESR) and event-free duration. (B) Relations between C-reactive protein (CRP) and event-free duration.
|
|
For all patients, the actuarial survival rate was 25.4% ± 7.2% at 5 years and 18.5% ± 6.7 % at 13 years. Mean event-free survival at 13 years was 39.2% ± 14.1% in patients who underwent a Bentall type operation, but was 4% ± 3.9% in patients who underwent AVR (p = 0.001). Event-free survival at 13 years in patients administered immunosuppressive therapy was 33.7% ± 11.0%, but it was 0% in patients not administered immunosuppressive therapy (p = 0.001).
|
Comment
|
|---|
Our analysis resulted in four main findings. First, the rate of prosthetic valve detachment after valve replacement in AR with Behçet's disease is high and depends on postoperative inflammatory marker levels. Second, the typical echocardiographic findings of Behçet's disease could be useful for differentiating AR from an unknown cause. Third, performing ARR as an initial operation could help prevent late valve detachment. Fourth, postoperative inflammatory markers were negatively correlated with event-free period irrespective of immunosuppressive therapy.
The incidence of cardiovascular complications in Behçet's disease has been reported to be about 30%, and these complications appear to be the main cause of death [7]. Among the cardiovascular complications of Behçet's disease, vascular involvement, including venous and arterial thrombosis, and aneurysm formation are well recognized [8–10]. Aortic regurgitation related to Behçet's aortitis occurs only rarely. The possible mechanisms of AR in Behçet's disease are believed to be annular dilatation and sinus Valsalva aneurysm secondary to aortitis rather than to abnormalities of the valve per se [11]. But according to the present study, cusp aneurysmal changes, echocardiographic-free spaces, and masslike lesions were more common rather than aortic root dilatation. Therefore, AR in Behçet's disease might be related to valvulitis causing a cusp prolapse. Our histologic findings supported both valvulitis and aortitis. In 94.7% (18 of 19) of patients, we found pathologic processes reflecting vasculitis, such as perivascular infiltration of lymphocytes in adventitia and vasa vasorum, focal medial necrosis, chronic active inflammation, and myxoid degeneration in valves.
Aortic valve replacement and ARR using a valved conduit have become the standard therapy in AR in Behçet's disease, but results have not been satisfactory [12, 13]. Because of tissue fragility and recurrent inflammation, paravalvular leakage, valve detachment, hemorrhage, and pseudoaneurysm formation occur frequently after valve replacement [5, 6, 14]. To reduce these complications, several methods, such as homografts [15], reinforcement of suture lines with Teflon felt, autologous pericardium, or normal leaflet tissue [16], and modified valve replacement [14], have been suggested. Yamamoto and coworkers [17] supported the use of a homograft in AR attributable to Behçet's disease because of its compatibility with the human body and the softness of the annular ring. According to our study, ARR with homograft was a good option for index operations. This was performed in 3 patients, and aortic valves functioned in homografts perfectly in all 3 during follow-up (mean, 6.7 years). We performed the ARR with a xenograft when a homograft was not available. The results of these patients were quite a good during follow up. But the longest follow up was only 2.5 years in contrast to above 10 years in homograft. However, in case of reoperations, the results of ARR were unsatisfactory, as shown Figure 2. Paravalvular leakage and pseudoaneurysm formation were the main causes of reoperation (17.6%, 3 of 17 patients), and 60% (9 of 15) of patients did not survive reoperations. Thus, we suggest that reoperations in this condition should be avoided and that ARR at index surgery is a good choice. When performing AVR, implanted prostheses were reinforced with pledgeted sutures routinely, but this was not sufficient to prevent valve detachment. Eighty percent (4 of 5) of patients with AVRs required more than one operation owing to valve dehiscence. Operative findings revealed pledgets had attached to sewing rings and that sutures had been severed. Modified valve replacement has been suggested by some authors. Okada and associates [14] used a translocated Bentall procedure in AR with Behçet's disease and reported tolerable results; 1 of 6 patients required a reoperation owing to valve detachment after this procedure. In our series, we reconstructed the aortic root with bovine pericardium in cases of interventricular septal dissection or multiple pseudoaneurysms after wide debridement, and then inserted an aortic prosthesis on reconstructed bovine pericardium to reduce direct stress on native tissue because of a rigid sewing ring. This procedure was performed in 5 patients, and no reoperation has been necessary owing to valve dehiscence.
Behçet's disease runs a chronic course with unpredictable exacerbations and remissions, the frequencies and severities of which may diminish with time. The disease generally runs an improving or stable course after the first 5 years [18]. In our series, 7 patients had been diagnosed to have Behçet's disease 5 years or more before surgery and had been administered steroid therapy up to surgery, and 71.4% (5 of 7) of these patients showed a stable clinical course during follow-up. The other 2 patients died of low cardiac output for reasons unrelated to Behçet's disease. These findings encourage us to agree with the proposition that clinical suspicion and adequate treatment to suppress the inflammatory phase before surgery beneficially affects clinical outcome in Behçet's disease.
Delaying surgery in cases with inactive phase inflammation and initiating immunosuppressive therapy before and after surgery have been recommended [19]. Inflammatory markers such as erythrocyte sedimentation rate and CRP, which reflect disease activity, are known to be helpful for determining the timing of surgery and for predicting the effectiveness of immunosuppressive therapy [20]. According to the present study, preoperative levels of erythrocyte sedimentation rate and CRP were relatively high (erythrocyte sedimentation rate, mean 27 mm/h; CRP, 3.3 mg/dL), but no significant difference was observed between survivors and nonsurvivors. Preoperative inflammatory markers could be changed according to the preoperative patient conditions such as congestive heart failure, hepatic dysfunction, and renal failure. We thought the difference was masked for this reason. The main reason for high preoperative levels of inflammatory markers was an inability to arrive at a correct diagnosis. Moreover, we were unable to postpone surgery in cases of medically intractable severe AR with congestive heart failure despite the presence of active phase inflammation. On the other hand, postoperative levels of erythrocyte sedimentation rate and CRP were near normal in survivors but much elevated in nonsurvivors (p < 0.05). Because postoperative immunosuppressive therapy was given to all patients diagnosed as having Behçet's disease, the effectiveness of postoperative therapy played an important prognostic role. Event-free period was found to be negatively correlated with inflammatory marker levels during follow-up in the present study, which is consistent with other reports [13]. The potential disadvantages of immunosuppressive therapy are an increased risk of infection and poor tissue healing [21], but in the present study, no patient had complications attributable to immunosuppressive therapy, which concurs with the findings of Ando and colleagues [6] for steroid therapy.
Echocardiography could be useful for the differential diagnosis of Behçet's disease before surgery. Its characteristic findings are aneurysmal change of the aortic cusp, echocardiographic-free space at left ventricular outflow tract, and frequent interventricular septal dissections, which are similar to those of aortic infective endocarditis. Actually, 36.8% (7 of 19) of our patients were suspected to have acute AR attributable to infective endocarditis based on echocardiographic findings and elevated inflammatory markers, but no definite vegetations were identified echocardiographically or intraoperatively, no multiple embolic events occurred, and no microorganisms were cultured from tissue or blood. As was reported by Song and coworkers [22], we observed masslike lesions at aortic cusps in 3 patients at index operations, but at reoperations, no masslike lesions were seen. These results suggest that masslike lesions in Behçet's disease are related to a redundant aortic cusp involved by valvulitis. According to our findings, the characteristic echocardiographic findings of AR caused by Behçet's disease are useful for the differential diagnosis of acute AR attributable to various causes.
The pathologic findings of our patients are similar to those of other forms of inflammatory aortitis, such as Takayasu's arteritis [22, 23]. During the acute stage, perivascular infiltration of lymphocytes and medial degeneration was massive, and we had to prescribe intensive immunosuppressive therapy. On the other hand, in the chronic stage, during which inflammatory marker levels are low, lymphocyte infiltration was mild and only chronic inactive inflammatory reactions were observed. However, in 1 patient who received preoperative and postoperative steroid therapy and did not show vasculitis or inflammation of the aortic wall, valve detachments necessitated two reoperations during follow-up. From these results, we suggest that pathologic findings may reflect disease activity at the aortic valve and aorta at the time of surgery but inadequately predict clinical course. Aortic regurgitation in Takayasu's arteritis is much different from AR in Behçet's disease in terms of typical symptoms, sites of vascular involvement, and better prognosis after valvular surgery.
Several limitations of the present study should be considered. First, this was retrospective study and the number of patients was small. However, cardiovascular involvement in Behçet's disease is rare, and, thus, a retrospective review was the only feasible means of study. Second, we did not perform all operations at our center; 26.3% (5 of 19) of the patients were transferred to our center from other hospitals after repeated AVR attributable to valve detachment, and therefore, operative methods differed. However, when patients were diagnosed preoperatively, we selected ARR as the standard operation. Before 1994, we performed AVR routinely because homografts were unavailable, and, thus, this study might suffer from selection bias because of different operative strategies.
Summarizing, 46 operations were performed on 19 patients, and 9 patients expired. Homografts have been available since 1994, which enabled us to perform ARR with a homograft. Subsequently, mortality decreased from 80% (4 of 5 patients) to 35.7% (5 of 14 patients), but this difference is not statistically significant because of small numbers (p = 0.141). In addition, it was found that inflammatory markers were negatively correlated with event-free period and that immunosuppressive therapy affected event-free survival. We suggest that early detection of Behçet's disease, ARR with a homograft at index operation, and the maintenance of an effective postoperative immunosuppressive therapy might provide the best means of improving clinical outcome in AR attributable to Behçet's disease.
|
Acknowledgments
|
|---|
We thank our pathologists in Seoul National University Hospital for advice on pathologic findings.
|
References
|
|---|
- James DG. Behçet's disease N Engl J Med 1979;301:431-432.[Medline]
- Ghate JV, Jorizzo JL. Behçet's disease and complex aphthosis J Am Acad Dermatol 1999;40:1-18.[Medline]
- International Study Group for Behçet's disease Criteria for diagnosis of Behçet's disease Lancet 1990;335:1078-1080.[Medline]
- Ueda H, Ishikawa K, Okabayashi A, Kirisawa N, Kusunoki T. Clinicopathology of aortitis syndromes Saishin Igaku 1968;23:181-188.[Medline]
- Suzuki A, Amano J, Tanaka H, Sakamoto T, Sunamori M. Surgical consideration of aortitis involving the aortic root Circulation 1989;80(Suppl 1)I-222-32.
- Ando M, Kosakai Y, Okita Y, Nakano K, Kitamura S. Surgical treatment of Behçet's disease involving aortic regurgitation Ann Thorac Surg 1999;68:2136-2140.[Abstract/Free Full Text]
- James DG, Thomson A. Recognition of the diverse cardiovascular manifestations in Behçet's disease Am Heart J 1982;103:457-458.[Medline]
- Salamon F, Weinberger A, Nili M, et al. Massive hemoptysis complicating Behçet's syndrome: the importance of early pulmonary angiography and operation Ann Thorac Surg 1988;45:566-567.[Abstract/Free Full Text]
- Di Eusanio G, Mazzola A, Gregorini R, et al. Left ventricular aneurysm secondary to Behçet's disease Ann Thorac Surg 1991;51:131-132.[Abstract/Free Full Text]
- Sakane T, Takeno M, Suzuki N, Inaba G. Behçet's disease N Engl J Med 1999;341:1284-1291.[Medline]
- Tai YT, Fong PC, Ng WF, et al. Diffuse aortitis complicating Behçet's disease leading to severe aortic regurgitation Cardiology 1991;79:156-160.[Medline]
- Comess KA, Zibelli LR, Gordon D, Fredrickson SR. Acute, severe, aortic regurgitation in Behçet's syndrome Ann Intern Med 1983;99:639-640.[Abstract/Free Full Text]
- Chikamori T, Doi YL, Yonezawa Y, Tanaka J, Kawamura M, Ozawa T. Aortic regurgitation secondary to Behçet's disease: a case report and review of literature Eur Heart J 1990;11:572-576.[Abstract/Free Full Text]
- Okada K, Eishi K, Takamoto S, et al. Surgical treatment of Behçet's aortitis: a report of eight patients Ann Thorac Surg 1997;64:116-119.[Abstract/Free Full Text]
- Motomura N, Kawazoe K, Kito H, Eishi K, Kawashima Y, Oka T. Application of cryopreserved allograft to aortic root replacement for detachment case due to aortitis Nippon Kyobu Geka Gakkai Zasshi 1993;41:1426-1430.[Medline]
- Kotsuka Y, Tanaka O, Takamoto S. Intravalvular implantation technique for aortic valve replacement in aortitis syndrome Ann Thorac Surg 1999;67:89-92.[Abstract/Free Full Text]
- Yamamoto T, Makuuchi H, Naruse Y, Kobayashi T, Goto M, Nonaka K. Aortic root replacement by cryopreserved homograft for prosthetic valve detachment case due to aortitis Jpn J Thorac Cardiovasc Surg 1998;46:565-569.[Medline]
- Bardak Y. Effects of age and sex on Behçet's disease J Rheumatol 1999;26:1008-1009.[Medline]
- Sugimoto T, Miyashita M, Ota T, Yamashita C, Okada M, Nakamura K. Surgical treatment of valvular heart disease associated with Behçet's disease Nippon Kyobu Geka Gakkai Zasshi 1990;38:2320-2325.[Medline]
- Noji S, Kitamura N, Yamaguchi A, Miki T, Shuntoh K. Relationship between postoperative prognosis and preoperative immunological factors in aortitis syndrome Nippon Kyobu Geka Gakkai Zasshi 1996;44:149-154.[Medline]
- Ando M, Kosakai Y, Okita Y, Nakano K, Kitamura S. Surgical treatment for aortic regurgitation caused by Takayasu's arteritis J Card Surg 1998;13:202-207.[Medline]
- Song JK, Jeong YH, Kang DH, et al. Echocardiographic and clinical characteristics of aortic regurgitation because of systemic vasculitis J Am Soc Echocardiogr 2003;16:850-857.[Medline]
- Erentug V, Polat A, Bozbuga NU, et al. Valvular surgery in Behçet's disease J Card Surg 2006;21:289-291.[Medline]
Related Article
-
Invited Commentary
- Makoto Ando
Ann. Thorac. Surg. 2009 87: 1782.
[Extract]
[Full Text]
[PDF]
This article has been cited by other articles:
|
|
|
|
 
M.-Y. Liang, J.-P. Yao, X. Zhang, and Z.-P. Wang
Surgical technique for aortic regurgitation attributable to Behcet's disease: modified aortic valve replacement with reinforcement of the aortic wall
Eur J Cardiothorac Surg,
November 3, 2011;
(2011)
ezr025v1.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. Tanaka, H. Ogino, H. Matsuda, and H. Sasaki
Reoperation for prosthesis dehiscence caused by aortitis
J. Thorac. Cardiovasc. Surg.,
November 1, 2011;
142(5):
1274 - 1275.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Ando
Invited Commentary
Ann. Thorac. Surg.,
June 1, 2009;
87(6):
1782 - 1782.
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
