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Aortic valve replacement in octogenarians
Poster Presentations
P20 Aortic Valve Replacement in Octogenarians M. LASKAR, E. CORNU, P. VIROT, Ph. LACROIX, C. CHRISTIDES, F. ROLL and E. OSTYN, Limoges, France Cardiac surgery in octogenarians still represents a small part of the usual activity of a department of cardiac surgery. Nevertheless it can be performed with reasonable risk rates and, in 1994, 4% of our patients were over 80 years old (19/481). From 1986 to 1994 an aortic valve replacement was performed in 55 octogenarians, 32 female and 23 male, with ages from 80 to 86 years old (mean 81.8). This aortic valve replacement was associated in 11 cases with coronary revascularization, twice with a mitral valve replacement and once with replacement of the ascending aorta. The valves inserted in the aortic position were 20 Carpentier-pericardial, 14 Carpentier-porcin, 18 Mitroflow, I Ionescu and 2 St JudeMedical. Coronary revascularization was performed five times on a single coronary artery, four times on two coronary arteries and twice on three coronary arteries. The revascularization was performed with the internal thoracic artery for the left anterior descending coronary artery and with vein grafts for other arteries. The overall hospital mortality was five patients (9.1%) which is higher than the usual mortality in younger patients. The mid-term survival rate, including the hospital mortality, was 91% at 6 years: there were no deaths in the interval after hospital discharge. Aortic valve replacement considerably improves the life expectancy of octogenarians with calcified aortic stenosis, as the mortality without surgical treatment is 43% at one year and 75% at 3 years. It also improves their quality of life. The very high mid-term and long-term survival rates suggest a choice of very durable valves if one does not want to reoperate on extremely aged populations. P21
Aortic Aneurysm Developing Years After Indirect Isthmus Surgery for Aortic Coarctation S. SZABADOS Z.S. VERZ, R.G. BOG A TS and G. KOVACS, Szeged, Hungary In 1957 Vosschulte recommended two methods for surgical treatment of aortic coarctation: (1) direct surgery of isthmus (Vosschulte 1) - incising the constricted sections lengthways and resuturing diagonally; (2) indirect surgery (Vosschulte 2) - incising the aorta lengthways and implanting an oval-shaped prosthetic patch. Since 1967 we have performed 14 direct and 72 indirect isthmusplasties. Years after the surgery, three patients developed the serious complication of aortic aneurysm involving the operated part of the aorta. One patient, who formerly had no complaints, suddenly became symptomatic and died. At autopsy, rupture of the aneurysm was discovered. In the other two patients the aneurysms were found during follow-up examinations. These aneurysms were surgically corrected. We performed resection with implantation of an aortic prosthesis. The histology of the aneurysm revealed the structure of the aortic wall had totally disappeared with missing elastic fibers. Going from the lesion to the healthy areas, the original structure reappears gradually, with the old prosthetic patch in
CARDIOVASCULAR SURGERY SEPTEMBER 1995
the middle of thickened tissue. The resection of the aneurysm and interposition grafting cannot be performed by simply cross-clamping the aorta, because there is practically no collateral circulation. During surgery we use left-heart bypass between the left atrium and the iliac artery or descending aorta, without the use of an oxygenator. !722 Difficult Problems in Surgical T r e a t m e n t for Cardiac
Involvement in Be~het's Disease ]. AMANO, A. SUZUKI, M. SUNAMORI, T. SAKAMOTO and H. TANAKA, Tokyo, Japan Cardiac disease is a rare involvement in Beh~et's disease and there are many difficulties in surgical treatment since its underlying inflammatory disorder is still unknown. We studied retrospectively four patients who received surgical treatment for cardiac involvement in Beh~et's disease. The preoperative diagnosis of Beh~et's disease was made in only one patient, while the others were diagnosed by pathological analysis of the resected specimen obtained during surgery or the appearance of typical symptoms of Beh~et's disease after surgery. All the patients had aortic regurgitation, one also had mitral regurgitation and one had coronary artery stenosis. Initial surgery was performed with regular aortic valve replacement (rAVR) in three patients, and the one who was diagnosed preoperatively as Beh~et's disease received a modified AVR which consisted of subcoronary insertion of the composite graft by an inside-out fixation technique (mAVR). Two patients with rAVR received revisionary surgery due to valve detachment, one after 10 months with mAVR and the other at 1 year with rAVR. The patient who received the second rAVR needed further surgery with a translocation method. This patient died of heart failure 5 years after the last surgery, while the others have had no further complications with steroid therapy at 3-10 years follow-up. mAVR is an effective procedure for preventing complications in AVR for aortic regurgitation in patients with Beh~et's disease, and steroids should be administered for control of recurrence of the disease. P23
The Causes of Ischemic Mitral Regurgitation After Surgical Revascularization H. BABA, M. HASHIMOTO, S. KOIKE, Y. OKAWA and K. MURASE, Toyobashi, Japan INTRODUCTION: lschemic mitral regurgitation (MR) is a widely recognized complication of coronary artery disease. The causes of ischemic MRs are presumably due to left ventricular (LV) dilatation or regional asynergy at the site of papillary muscles. Rarely, patients develop severe of MR after isolated surgical revascularization. The aim of this study was to evaluate the reasons why ischemic MR can become worse after surgical revascularization. METHODS: From 1985 to 1994, eighteen patients had worse MR after surgical revascularization. They were assessed for mitral annulus diameter, hemodynamics and LV regional wall motion by echocardiography and radioscopic ventriculography using the centerline technique. RESULTS: No Q waves appeared on electrocardiography.
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P20 Aortic Valve Replacement in Octogenarians M. LASKAR, E. CORNU, P. VIROT, Ph. LACROIX, C. CHRISTIDES, F. ROLL and E. OSTYN, Limoges, France Cardiac surgery in octogenarians still represents a small part of the usual activity of a department of cardiac surgery. Nevertheless it can be performed with reasonable risk rates and, in 1994, 4% of our patients were over 80 years old (19/481). From 1986 to 1994 an aortic valve replacement was performed in 55 octogenarians, 32 female and 23 male, with ages from 80 to 86 years old (mean 81.8). This aortic valve replacement was associated in 11 cases with coronary revascularization, twice with a mitral valve replacement and once with replacement of the ascending aorta. The valves inserted in the aortic position were 20 Carpentier-pericardial, 14 Carpentier-porcin, 18 Mitroflow, I Ionescu and 2 St JudeMedical. Coronary revascularization was performed five times on a single coronary artery, four times on two coronary arteries and twice on three coronary arteries. The revascularization was performed with the internal thoracic artery for the left anterior descending coronary artery and with vein grafts for other arteries. The overall hospital mortality was five patients (9.1%) which is higher than the usual mortality in younger patients. The mid-term survival rate, including the hospital mortality, was 91% at 6 years: there were no deaths in the interval after hospital discharge. Aortic valve replacement considerably improves the life expectancy of octogenarians with calcified aortic stenosis, as the mortality without surgical treatment is 43% at one year and 75% at 3 years. It also improves their quality of life. The very high mid-term and long-term survival rates suggest a choice of very durable valves if one does not want to reoperate on extremely aged populations. P21
Aortic Aneurysm Developing Years After Indirect Isthmus Surgery for Aortic Coarctation S. SZABADOS Z.S. VERZ, R.G. BOG A TS and G. KOVACS, Szeged, Hungary In 1957 Vosschulte recommended two methods for surgical treatment of aortic coarctation: (1) direct surgery of isthmus (Vosschulte 1) - incising the constricted sections lengthways and resuturing diagonally; (2) indirect surgery (Vosschulte 2) - incising the aorta lengthways and implanting an oval-shaped prosthetic patch. Since 1967 we have performed 14 direct and 72 indirect isthmusplasties. Years after the surgery, three patients developed the serious complication of aortic aneurysm involving the operated part of the aorta. One patient, who formerly had no complaints, suddenly became symptomatic and died. At autopsy, rupture of the aneurysm was discovered. In the other two patients the aneurysms were found during follow-up examinations. These aneurysms were surgically corrected. We performed resection with implantation of an aortic prosthesis. The histology of the aneurysm revealed the structure of the aortic wall had totally disappeared with missing elastic fibers. Going from the lesion to the healthy areas, the original structure reappears gradually, with the old prosthetic patch in
CARDIOVASCULAR SURGERY SEPTEMBER 1995
the middle of thickened tissue. The resection of the aneurysm and interposition grafting cannot be performed by simply cross-clamping the aorta, because there is practically no collateral circulation. During surgery we use left-heart bypass between the left atrium and the iliac artery or descending aorta, without the use of an oxygenator. !722 Difficult Problems in Surgical T r e a t m e n t for Cardiac
Involvement in Be~het's Disease ]. AMANO, A. SUZUKI, M. SUNAMORI, T. SAKAMOTO and H. TANAKA, Tokyo, Japan Cardiac disease is a rare involvement in Beh~et's disease and there are many difficulties in surgical treatment since its underlying inflammatory disorder is still unknown. We studied retrospectively four patients who received surgical treatment for cardiac involvement in Beh~et's disease. The preoperative diagnosis of Beh~et's disease was made in only one patient, while the others were diagnosed by pathological analysis of the resected specimen obtained during surgery or the appearance of typical symptoms of Beh~et's disease after surgery. All the patients had aortic regurgitation, one also had mitral regurgitation and one had coronary artery stenosis. Initial surgery was performed with regular aortic valve replacement (rAVR) in three patients, and the one who was diagnosed preoperatively as Beh~et's disease received a modified AVR which consisted of subcoronary insertion of the composite graft by an inside-out fixation technique (mAVR). Two patients with rAVR received revisionary surgery due to valve detachment, one after 10 months with mAVR and the other at 1 year with rAVR. The patient who received the second rAVR needed further surgery with a translocation method. This patient died of heart failure 5 years after the last surgery, while the others have had no further complications with steroid therapy at 3-10 years follow-up. mAVR is an effective procedure for preventing complications in AVR for aortic regurgitation in patients with Beh~et's disease, and steroids should be administered for control of recurrence of the disease. P23
The Causes of Ischemic Mitral Regurgitation After Surgical Revascularization H. BABA, M. HASHIMOTO, S. KOIKE, Y. OKAWA and K. MURASE, Toyobashi, Japan INTRODUCTION: lschemic mitral regurgitation (MR) is a widely recognized complication of coronary artery disease. The causes of ischemic MRs are presumably due to left ventricular (LV) dilatation or regional asynergy at the site of papillary muscles. Rarely, patients develop severe of MR after isolated surgical revascularization. The aim of this study was to evaluate the reasons why ischemic MR can become worse after surgical revascularization. METHODS: From 1985 to 1994, eighteen patients had worse MR after surgical revascularization. They were assessed for mitral annulus diameter, hemodynamics and LV regional wall motion by echocardiography and radioscopic ventriculography using the centerline technique. RESULTS: No Q waves appeared on electrocardiography.
151