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Ann Thorac Surg 1996;61:1697-1698
© 1996 The Society of Thoracic Surgeons

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Discussion

Discussion

See also page 1693.

DR DENIS H. TYRAS (New York, NY): Doctor Fiore, I enjoyed your report. I wonder if with the use of intraoperative transesophageal echocardiography evaluation of the characteristics of the valve might in fact be somewhat more predictive of the rapidity of progression. I do not know if retrospectively you had all those data, but if more recently you are using intraoperative transesophageal echocardiography it can help guide the decision about whether to do concomitant aortic valve replacement even though gradients may be minimal to moderate.

DR FIORE: We use intraoperative transesophageal echocardiography in our pediatric and adult patients regularly. As you suggest, this modality can be useful intraoperatively because valve anatomy could be more precisely defined. The presence of bicuspid or tricuspid leaflets and the degree of leaflet mobility and calcification could be better delineated. This is useful information because as we discussed in our report the rate of progression of aortic stenosis is greatest for bicuspid and degenerative calcific trileaflet valves and slowest for rheumatic valves. As you have suggested, echocardiographic analysis in conjunction with catheterization data will assist the surgeon in the decision-making process for aortic valve replacement.

DR CONSTANTINE MAVROUDIS (Chicago, IL): I enjoyed your presentation. Did you think that perhaps a mildly stenotic valve would respond better to decalcification procedures? Did you encounter any congenital lesions, and could you have done any alternative form of therapy short of valve replacement?

DR FIORE: That is a very good question. Valve repair using the CUSA ultrasonic device has been employed by some surgical groups, and published data are available for analysis. The use of the CUSA has been shown to result in recurrent aortic stenosis and aortic insufficiency within 5 years. Consequently you may be faced with reoperating on these elderly patients again. At the present time, the available data do not recommend decalcification using the CUSA. However, a small number of patients in our pediatric practice with congenital aortic insufficiency have had successful valve repair by employing techniques described by Cosgrove and Duran. I hope that this answers your question.

DR JOHN W. BROWN (Indianapolis, IN): Doctor Fiore, I enjoyed your report. In Indianapolis we have approached this dilemma a little differently, as you may remember. We have inserted apical aortic conduits in these elderly patients who have patent mammary arteries and patent bypass grafts. We insert the conduits through a left thoracotomy, and most of the time we use pump standby only. It is an easy way to bypass the problem of aortic stenosis with multiple patent bypass grafts. Most of these patients are candidates for tissue valves because of their age, anyway. You can put an apical aortic conduit in quite satisfactorily with any valve type you want. We now have follow-up of greater than 10 years in a few of these adult patients and are very pleased with the late results.

DR FIORE: Thank you, Dr Brown, for bringing to our attention a different approach to this problem. My one concern is that patients selected for this operation would have to be those not requiring repeat myocardial revascularization.

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Management of Asymptomatic Mild Aortic Stenosis During Coronary Artery Operations

Andrew C. Fiore, Marc T. Swartz, Keith S. Naunheim, Debra A. Moroney, David A. Canvasser, Lawrence R. McBride, Pamela S. Peigh, George C. Kaiser, and Vallee L. Willman
Ann. Thorac. Surg. 1996 61: 1693-1697. [Abstract] [Full Text]

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