Gregory John Matter

Comparison of the Structure of the Aortic Valve and Ascending Aorta in Adults Having Aortic Valve Replacement for Aortic Stenosis Versus for Pure Aortic Regurgitation and Resection of the Ascending Aorta for Aneurysm

Background— There is debate concerning whether an aneurysmal ascending aorta should be replaced when associated with a dysfunctioning aortic valve that is to be replaced. To examine this issue, we divided the patients by type of aortic valve dysfunction—either aortic stenosis (AS) or pure aortic regurgitation (AR)—something not previously undertaken. Methods and Results— Of 122 patients with ascending aortic aneurysm (unassociated with aortitis or acute dissection), the aortic valve was congenitally malformed (unicuspid or bicuspid) in 58 (98%) of the 59 AS patients, and in 38 (60%) of the 63 pure AR patients. Ascending aortic medial elastic fiber loss (EFL) (graded 0 to 4+) was zero or 1+ in 53 (90%) of the AS patients, in 20 (53%) of the 38 AR patients with bicuspid valves, and in all 12 AR patients with tricuspid valves unassociated with the Marfan syndrome. An unadjusted analysis showed that, among the 96 patients with congenitally malformed valves, the 38 AR patients had a significantly higher likelihood of 2+ to 4+ EFL than the 58 AS patients (crude odds ratio: 8.78; 95% confidence interval: 2.95, 28.13). Conclusions— These data strongly suggest that the type of aortic valve dysfunction—AS versus pure AR—is very helpful in predicting loss of aortic medial elastic fibers in patients with ascending aortic aneurysms and aortic valve disease.

Frequency of Congenitally Bicuspid Aortic Valves in Patients ≥80 Years of Age Undergoing Aortic Valve Replacement for Aortic Stenosis (With or Without Aortic Regurgitation) and Implications for Transcatheter Aortic Valve Implantation

The purpose of the present report was to determine the frequency of a congenitally bicuspid aortic valve in patients ≥80 years of age old with aortic stenosis (AS) severe enough to warrant aortic valve replacement. Transcatheter aortic valve implantation (TAVI) has traditionally been reserved for patients ≥80 years of age with severe AS involving a 3-cuspid aortic valve. Traditionally, AS involving a 2-cuspid aortic valve has been a contraindication to TAVI. We examined operatively excised stenotic aortic valves in 364 patients aged ≥80 years to determine the frequency of an underlying congenitally bicuspid aortic valve. Of the 347 octogenarians and 17 nonagenarians, 78 (22%) and 3 (18%) had stenotic congenitally bicuspid aortic valves, respectively. In conclusion, because the results of TAVI are less favorable in patients with stenotic congenitally bicuspid valves than in patients with stenotic tricuspid aortic valves, proper identification of the underlying aortic valve structure is important when considering TAVI as a therapeutic procedure for AS in older patients.

Valve Structure and Survival in Quadragenarians Having Aortic Valve Replacement for Aortic Stenosis (±Aortic Regurgitation) With Versus Without Coronary Artery Bypass Grafting at a Single US Medical Center (1993 to 2005)

The purpose of this study was to determine the effect of simultaneous coronary artery bypass grafting (CABG) and the influence of valve structure on both early and late survival in quadragenarians having aortic valve replacement (AVR) for aortic stenosis (AS) (with or without aortic regurgitation). We analyzed survival and valve structure in 48 adults (12 women), aged 40 to 49 years, having AVR for AS from 1993 through 2005 at Baylor University Medical Center, including 7 (15%) with and 41 (85%) without simultaneous CABG. Of the 48 quadragenarians, none died within 60 days of operation. Assessment of the relation between long-term survival and gender, aortic valve structure, preoperative severity of the AS, and concomitant CABG was not possible due to the low mortality. Four patients (9%) died >60 days after AVR: at 1.8, 6.3, 7.1, and 9.9 years, respectively. The aortic valve was congenitally unicuspid in 15 patients (31%), congenitally bicuspid in 32 (67%), and 3-cuspid in 1 (2%). In conclusion, of the 48 quadragenarians having AVR for AS, 47 (98%) had a congenitally malformed aortic valve, 60-day mortality was zero, and late mortality was low (8%).

Effect Of Body Mass Index On Survival In Patients Having Aortic Valve Replacement For Aortic Stenosis With Or Without Concomitant Coronary Artery Bypass Grafting

The purpose of this report is to describe the effect of body mass index (BMI) on 30-day and late outcome in patients having aortic valve replacement (AVR) for aortic stenosis (AS) with or without concomitant coronary artery bypass grafting. From January 2002 through June 2010 (8.5 years), 1,040 operatively excised stenotic aortic valves were submitted to the cardiovascular laboratory at Baylor University Medical Center at Dallas. Of the 1,040 cases 175 were eliminated because they had a previous cardiac operation. The present study included 865 adults whose AVR for AS was their first cardiac operation. Propensity-adjusted analysis showed that 30-day and late mortality were strongly and significantly associated with BMI. Decreased risk of 30-day and long-term mortality was observed for patients with BMI in the low 30s compared to patients with BMI in the mid 20s or >40 kg/m(2). In conclusion, the findings in this study indicate a strong and significant adjusted association between BMI and 30-day and long-term mortality in patients having AVR for AS with or without concomitant coronary artery bypass grafting. Better survival was observed in patients with BMIs in the low 30s compared to patients with BMIs in the mid 20s and >40 kg/m(2).

Effect Of Coronary Bypass And Valve Structure On Outcome In Isolated Valve Replacement For Aortic Stenosis

Reports differ regarding the effect of concomitant coronary artery bypass grafting (CABG) in patients who undergo aortic valve replacement (AVR) for aortic stenosis (AS), and no reports have described the effect of aortic valve structure in patients who undergo AVR for AS. A total of 871 patients aged 24 to 94 years (mean 70) whose AVR for AS was their first cardiac operation, with or without first concomitant CABG, were included. Patients who underwent mitral valve procedures were excluded. In comparison with the 443 patients (51%) who did not undergo CABG, the 428 (49%) who underwent concomitant CABG were significantly older, were more often male, had lower transvalvular peak systolic pressure gradients and larger valve areas, had lower frequencies of congenitally malformed aortic valves, had lighter valves by weight, had higher frequencies of systemic hypertension, and had longer stays in the hospital after AVR. Early and late (to 10 years) mortality were similar by propensity-adjusted analysis in patients who did and did not undergo concomitant CABG. Congenitally unicuspid or bicuspid valves occurred in approximately 90% of those aged 21 to 50, in nearly 70% in those aged 51 to 70 years, and in just over 30% in those aged 71 to 95 years. Unadjusted and adjusted survival was significantly higher in patients with unicuspid or bicuspid valves compared to those with tricuspid valves. In conclusion, although concomitant CABG had no effect on the adjusted probability of survival, the type of aortic valve (unicuspid or bicuspid vs tricuspid) significantly affected the unadjusted and adjusted probability of survival.

Preoperative exclusion of significant coronary artery disease by 64-slice CT coronary angiography in a patient with a left atrial myxoma

A 49-year-old man without any significant past medical history presented to the emergency department with complaints of diploplia, paresthesias in both arms, vertigo, tinnitus in the right ear, and dysarthria. Physical examination was unremarkable. A computed tomographic (CT) scan of the head was normal. These symptoms resolved within several hours, consistent with a transient ischemic attack. Magnetic resonance imaging of the brain revealed acute infarcts in the left cerebellar hemisphere and in the right occipital lobe, suggesting a thromboembolic source. Transesophageal echocardiography disclosed a 2 × 2-cm mass attached to the left atrial aspect of the atrial septum, and surgical excision was planned. As the patient was considered to have a very low risk for the presence of significant arterial narrowing, he underwent a 64-slice cardiac CT scan rather than invasive coronary angiography. The scan demonstrated minimal plaque in the coronary arteries (Figure ​(Figure11). The left atrial mass was also well visualized on both the axial slices and also with three-dimensional imaging (Figure 2a–c). Subsequently, the patients left atrial mass was excised without complication, and the mass was a typical myxoma (Figure 2d, e). This case demonstrates how, in the future, routine invasive coronary angiography may not be necessary as part of the workup for noncoronary cardiac surgery. In this instance, significant concomitant coronary artery disease was effectively excluded with multislice CT rather than an invasive procedure, thus allowing the surgery to proceed without a cardiac catheterization. In addition, CT imaging assisted with long-term prognostic information, as it suggested the need for the patient to be on cholesterol reduction therapy by demonstrating the early presence of coronary atherosclerosis. Figure 1 Three-dimensional reconstruction of the patients coronary arteries (3D) with multislice computed tomography. Curved reformat images of the left anterior descending (LAD) coronary artery, right coronary artery (RCA), and left circumflex coronary artery ... Figure 2 (a, b) Axial slices from the patients multislice computed tomographic scan demonstrating the myxoma attached to the left atrial aspect of the atrial septum (arrowheads). (c) The myxoma (arrowhead) shown via a “navigator” view inside the ...

Aortic valve replacement for stenosis with or without coronary artery bypass grafting after 2 previous isolated coronary artery bypass grafting operations

Aortic valve replacement following an earlier coronary artery bypass grafting (CABG) procedure is fairly common. When this situation occurs, the type of valve dysfunction is usually stenosis (with or without regurgitation), and whether it was missed at the time of the earlier CABG or developed subsequently is usually unclear. We attempted to determine the survival in patients who had had aortic valve replacement after 2 previous CABG procedures. We describe 12 patients who had aortic valve replacement for aortic stenosis; rather than one previous CABG operation, all had had 2 previous CABG procedures. Only one patient died in the early postoperative period after aortic valve replacement, and the remaining 11 were improved substantially: all have lived at least 11 months, and one is still alive at over 101 months after aortic valve replacement. Aortic valve replacement remains beneficial for most patients even after 2 previous CABG procedures.

Comparison of the quantity of calcific deposits in bovine pericardial bioprostheses in the mitral and aortic valve positions in the same patient late after double-valve replacement.

Among patients undergoing cardiac valve replacement, the aortic valve is most commonly replaced, the mitral valve next, and, infrequently, both the mitral and aortic valves. When the latter situation occurs and when the substitute valves inserted are both bioprostheses, it is possible to compare the rates of degenerative change because one bioprosthesis serves as a control for the other. In 1983, Warnes and associates reported on 5 patients with porcine bioprostheses in both the mitral and aortic valve positions from 18 to 107 months, and in each of the 4 patients in which the bioprosthesis was in place for greater than 18 months, the quantity of calcific deposits on the cusps of the bioprosthesis in the mitral valve position was much greater than that on the prosthesis in the aortic valve position. The present report was prompted by observing a patient who had a bovine parietal pericardial bioprosthesis in both the mitral and aortic positions explanted after they had been in place for 77 months; the quantity of calcium in the bioprosthesis in the aortic valve position was massive, and that in the bioprosthesis in the mitral position was minimal.