Ann Thorac Surg 2007;84:1953-1954. doi:10.1016/j.athoracsur.2007.08.058
© 2007 The Society of Thoracic Surgeons
Original Articles: Cardiovascular
Invited commentary
Yutaka Okita, MD
Department of Surgery, Division II, Kobe University School of Medicine, 7-5-1, Kusunoki-cho, Chuo-ku, Kobe 650-0017, Japan
(Email: yokita{at}med.kobe-u.ac.jp).
With aortic regurgitation in Takayasu’s arteritis it is believed that regurgitation develops primarily as a result of annular dilatation resulting from enlargement of the ascending aorta. The incidence of aortic regurgitation in Takayasu’s arteritis is 13% to 44%. Pathologically, the active phase was characterized by a granulomatous panarteritis with the lymphoplasmocytic infiltrate. Healed lesions showed progressive intimal and adventitial fibrosis. In Behçet’s disease, the cardiovascular complications related to aortic regurgitation and aortic or middle-sized arterial aneurysm formation were the leading cause of death. Aortic regurgitation is primarily due to valvulitis.
Adachi and colleagues [1] analyzed the surgical management of aortic regurgitation in patients with aortitis syndrome. In a group of 15 patients, incidence of prosthetic valve detachment or aortic root dilatation was higher after aortic valve replacement than after aortic root replacement. The authors suggested that lowering the threshold toward aortic root replacement may be justified in the surgical treatment of aortic regurgitation in patients with aortitis. After aortic valve replacement for regurgitation associated with Takayasu’s arteritis or with Behçet’s disease, valve detachment may occur requiring a redo operation in some patients. In our experience [2, 3], valve detachment was observed more often in the patients with Behçet’s disease (4 of 10; 40%) than Takayasu’s arteritis (3 of 65; 4.6%). These differences are probably due to the aortic wall in Behçet’s disease being more fragile as a result of recurrent and uncontrollable inflammation. The reoperation-free rate in patients with Takayasu’s arteritis after 5 years and 10 years due to the absence of valve detachment or false aneurysm formation in the suture line was 96% and 94%, respectively; however, the reoperation-free rate in Behçet’s disease was 64% and 43%, respectively.
To prevent valve detachment, technical improvements have been devised, including buttress sutures from the outside of the aortic wall for fixation of the prosthetic valve at the aortic annulus, placement of thick, belt-like Teflon felt, or the use of a valved conduit even in patients without annulo-aortic ectasia. Composite graft reconstruction is helpful because circumferential fixation outside the aortic wall and double fixation at the aortic annulus are possible, especially in patients with Behçet’s disease. The original Bentall operation for these diseases is not indicated because of a high risk of suture insufficiency. Both coronary arteries should be reconstructed by the button technique or by the interposition method using small grafts. A Cabrol’s modification is useful because sewing a graft skirt to the annulus and prosthetic valve being sutured above the annulus separately can reduce the mechanical stress on the annulus.
As for valve substitutes, the controversies do exist, such as usage of bioprosthetic valves or mechanical prostheses, and stentless, allograft valves or composite prosthetic valves. Tissue valves may be avoided because of their susceptibility to infection and poor durability, especially in patients on steroids. Stentless valves or allografts have advantages of better tissue adaptation to the annuls; however, potential enlargement of the diseased annuls may preclude their usage. Moreover, the autoimmune nature of the Takayasu or Behçet’s disease may deteriorate the allograft valve.
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References
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- Adachi O, Saiki Y, Akasakaa J, Odao K, Iguchi A, Tabayashi K. Surgical management of aortic regurgitation associated with Takayasu arteritis and other forms of aortitis Ann Thorac Surg 2007;84:1950-1954.[Abstract/Free Full Text]
- 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]
- 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]
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Surgical Management of Aortic Regurgitation Associated With Takayasu Arteritis and Other Forms of Aortitis
- Osamu Adachi, Yoshikatsu Saiki, Junetsu Akasaka, Katsuhiko Oda, Atsushi Iguchi, and Koichi Tabayashi
Ann. Thorac. Surg. 2007 84: 1950-1953.
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