Aortic pain

With the exception of the pain of acute aortic dissection, the thoracic aorta is not usually considered as a pain-producing organ. However, nineteenth century clinicians considered the aorta as a source of cardiovascular pain in the presence of autopsy-documented inflammatory aortitis, aortic aneurysms, and arterial hypertension, whereas early in the twentieth century, aortic pain reactions were elicited in experimental studies involving distension of the ascending aorta or the application of stimulating substances to the outer surface of the aorta. More recently, increased attention to aortic elastic properties, and to aortic vascular biology at the molecular level refocused interest on the many facets of aortic function beyond that of a simple conduit. The recognition of pain of thoracic aortic origin now extends to patients with progressive aortic syndromes such as aortic intramural hematoma, aortic intimal tears, aortic penetrating ulcers, aortic root dilatation without dissection in connective tissue disorders, inflammatory aortopathies, and abnormalities of aortic distensibility. The occurrence of pain during balloon inflation at balloon angioplasty of aortic coarctation, which disappears immediately after deflation, is the modern equivalent of the early experimental studies. The authors present a consideration of thoracic aortic pain in light of contemporary concepts in cardiovascular medicine with roots in the rich historical reservoir of information about aortic function and disease.     

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OBJECTIVE: Little attention has been paid to the occurrence of aortic regurgitation after complete repair in patients with pulmonary atresia and ventricular septal defect or tetralogy of Fallot. To highlight the development of aortic regurgitation or aortic root dilation severe enough to necessitate aortic valve replacement with or without aortic aneurysmorrhaphy or aortic root replacement, we retrospectively reviewed the records of patients who underwent aortic valve operation at our institution subsequent to repair of pulmonary atresia and ventricular septal defect or tetralogy of Fallot. METHODS: We searched the Mayo Clinic database for patients with pulmonary atresia and ventricular septal defect or tetralogy of Fallot who subsequently had aortic valve or aortic root operations. The degree of aortic regurgitation before operation was noted. Aortic sinus and root dimensions were measured. RESULTS: Sixteen patients underwent complete repair at a median age of 17 years, followed by an aortic operation a median of 13.5 years later. All 16 patients had dilated aortic sinuses at the time of the aortic valve operation. These 16 patients had aortic valve replacement: 11 with mechanical prostheses and 5 with bioprostheses. Five of the 16 also had reduction of aortic dilation by lateral aneurysmorrhaphy, and 1 had graft replacement of the ascending aorta. Five patients had associated conditions (evidence of valvular damage, recurrent ventricular septal defect, or history of endocarditis) discovered at the aortic valve operation that have been reported to be related to the development of aortic regurgitation. The remaining 11 patients had progressive aortic regurgitation despite complete, uncomplicated repair. CONCLUSIONS: Progressive aortic regurgitation and aortic root dilation can occur despite complete repair of pulmonary atresia and ventricular septal defect or tetralogy of Fallot.     

Treatment of the aortic valve and ascending aorta. The significance of reconstructive methods on the aortic root

BACKGROUND AND OBJECTIVE: The standard surgical repair of disease of the aortic valve and the ascending aorta has been combined replacement, which includes the disadvantage of inserting a mechanical valve. We have investigated an individualized approach which preserves the native valve. PATIENTS AND METHODS: Between October 1995 and October 1997, a consecutive total of 101 patients (72 men, 29 women, aged 21-83 years) underwent operations for disease of the ascending aorta: aortic dissection type A in 34 patients, aneurysmal dilatation in 67. Dilatation of the aortic arch was associated with aortic regurgitation in 58 patients. There were 11 patients with aortic valve stenosis or previously implanted aortic valve prosthesis among a total of 46 whose aortic valve was replaced (group II). Supracommissural aortic replacement with a Dacron tube was performed in 16 patients (group I) with normal valve cusps and an aortic root diameter < 3.5 cm. In 28 patients with an aortic root diameter of 3.5-5.0 cm the aortic root was remodelled (group III). Resuspension of the native aortic valve was undertaken in 11 patients with aortic root dilatation of > 5.0 cm (group IV). RESULTS: Operative intervention was electively performed in 72 patients, without any death. Of 29 patients operated as an emergency for acute type A dissection four died (14%). In 55 of the 58 patients with aortic regurgitation in proved possible to preserve native aortic valve (95%). In the early postoperative phase and after an average follow-up time of 11.8 months, transthoracic echocardiography demonstrated good aortic valve function, except in one patient each of groups III and IV who developed aortic regurgitation grades I or II. CONCLUSION: The described individualized approach makes it possible to preserve the native aortic valve in most patients with aortic regurgitation, at a low risk. Follow-up observations so far indicate good results of the reconstruction.     

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The successful implementation of a reoperative Bentall procedure with concomitant total aortic arch replacement after ascending aortic replacement for acute aortic dissection is infrequently reported. We performed a modified Bentall procedure with total replacement of the aortic arch in a patient suffering from worsening aortic regurgitation (AR) and residual dissection. Our strategy involved the button method for coronary reconstruction, selective cerebral perfusion, the use of a composite graft with four branches for aortic arch replacement, and the administration of high-dose aprotinin to decrease bleeding.     

Aortic root abscess with fistula formation

Aortic root abscess is a common complication of aortic valve endocarditis. However, aortic root abscess and formation of a fistula from the aortic root to the right ventricular outflow tract in the setting of a native aortic valve and previous repair of an aortic dissection with a Dacron graft is an uncommon event. Transesophageal echocardiography is superior to transthoracic echocardiography for the diagnosis of aortic root abscess. To our knowledge, no studies have compared the diagnostic value of cardiac MRI with transesophageal echocardiography for this condition.     

Should a bicuspid aortic valve be replaced in the presence of subvalvar or supravalvar aortic stenosis?

BACKGROUND: A bicuspid aortic valve is commonly associated with other levels of left ventricular outflow tract obstruction. Providing the bicuspid aortic valve is competent and nonobstructive, repair of subvalvar or supravalvar stenosis usually focuses on the obstructive lesions, leaving the valve in situ. The aim of this report was to examine the impact of a bicuspid aortic valve on the risk of reoperation for patients undergoing operation for subvalvar or supravalvar aortic stenosis. METHODS: Since 1976, 47 patients with supravalvar or subvalvar aortic stenosis have undergone repair. The median follow-up is 5.1 years (range, 2 months to 20.1 years). Sixteen patients (34%) had a bicuspid aortic valve that was competent and nonobstructive, and 31 (66%) had a tricuspid aortic valve. RESULTS: Reoperation was required in 9 patients (56%) with a bicuspid aortic valve, in each involving aortic valve replacement with an autograft (3), homograft (2), or prosthesis (4). Six patients (19%) with a tricuspid aortic valve required reoperation, yet only 1 required aortic valve replacement. The freedom from valve replacement was 43% (70% confidence interval, 31% to 55%) in the bicuspid aortic valve group versus 100% (70% confidence interval, 94% to 99.5%) in the tricuspid group at 5 years (p = 0.0001). The freedom from any reoperation at 5 years was 43% (70% confidence interval, 31% to 55%) in patients with a bicuspid aortic valve versus 86% (70% confidence interval, 80% to 93%) in the tricuspid group (p = 0.02). CONCLUSIONS: The data suggest that patients with subvalvar or supravalvar aortic stenosis and a bicuspid valve may be better palliated with a more definitive operation such as the Ross or Ross-Konno procedure.     

Surgical implication of aortic dissection on long-term outcome in Marfan patients

We herein review our 17-year surgical experience for the treatment of ascending aortic aneurysm in patients with Marfan syndrome to clarify the risks of increased mortality and reoperation. The subjects consisted of 15 patients who had all undergone surgery for the aortic root and ascending aorta at Niigata University Hospital between July 1978 and January 1995. Aortic valve replacement and ascending aortic wrapping were performed in 5 patients, Bentall or Cabrol operation in 6, and combined aortic arch reconstruction and Cabrol operation in 2, as the initial surgery. Patients who had an aortic dissection (Stanford type A) at initial surgery were assigned to group I (n = 7), while those with an aortic root aneurysm were assigned to group II (n = 8). In group I, 3 patients required a second operation for the remaining aortic arch aneurysm, and 1 died due to a late rupture of the distal aneurysm. In group II, no patient needed a reoperation; however, 1 died due to an intracranial hemorrhage and another due to composite valve graft failure and distal dissection. The results thus indicate that aortic dissection seems to affect long-term outcome, and therefore the combined repair of the aortic root and transverse arch is recommended in Marfan patients with aortic dissection involving the transverse aortic arch.     

Mid-diastolic aortic valve opening in bacterial endocarditis of aortic valve

Echocardiographic features of acute aortic regurgitation resulting from bacterial endocarditis have been well documented (Nathan et al., 1980; Weaver et al., 1977; Wray, 1975a), and include thick shaggy echoes from aortic valve in diastole, fine diastolic flutter of aortic valves suggestive of rupture of cusps, and premature closure of mitral valves. Echocardiography being a sensitive noninvasive technique for detecting aortic valve vegetations is heavily relied on for earlier diagnosis and prompt therapy of these patients. Prognosis of echocardiographically positive endocarditis is known to be worse than for echo-negative patients. The following case is being presented because of an unusual echocardiographic manifestation with mid-diastolic aortic valve opening secondary to flail aortic valve from staphylococcal endocarditis of the aortic valve.     

A new procedure for aortic valve repair

A new technique is presented for aortic valve repair. This procedure involves shaving the surface of rheumatic aortic valves using a high-speed electric rasp. It is safer and more expeditious to shave the concave shaped aortic cusp at the base, and then shave the body of the cusp along the flexion stress line. In a patient treated using this procedure, aortic valve regurgitation decreased and the aortic valve gradient almost disappeared.     

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By attaching appropriate measuring devices to the wall of an intact aortic root at the level of leaflet coaptation, we have measured a 16 per cent diameter change during each cardiac cycle. The dimensional changes observed can by themselves explain aortic valve function and obviate the postulation that the leaflets shorten and lengthen during each cardiac cycle. The tissue composition of the aortic root and leaflets is more compatible with this theory than with other postulations. Such a dynamic aortic root may explain the longevity of the actual aortic leaflets, in that leaflet fatigue stress is minimized by changes in aortic root dimension.     

Repair of the aortic arch with fibrin glue in type A aortic dissection

Location of the intimal tear in the aortic arch in type A aortic dissection is for many authors an indication for replacement of the aortic arch, but this operation has a high in-hospital mortality rate: 20% to 40%. Instead, we suggest repairing the aortic arch by injecting fibrin glue, which contains a human sealer protein concentrate, between the two dissected layers under circulatory arrest while replacing the ascending aorta. To evaluate this technique, we reviewed 45 successive patients operated on for type A acute aortic dissection between January 1989 and July 1993, of which 6 had the intimal tear located on or extending into the aortic arch. Mean age was 71 +/- 4.2 years (range 68 to 74). After proximal supracoronary anastomosis with a collagen-impregnated graft, aortic arch repair was achieved by injecting fibrin glue between the two layers, using circulatory arrest at a mean temperature of 22 degrees C, with a mean duration of 24 minutes. This obliterated the dissection in the arch and also the intimal flap. The distal part of the graft was then anastomosed to the proximal portion of the aortic arch at the origin of the innominate artery under circulatory arrest. There were no early or late deaths. All patients were asymptomatic at a mean follow-up of 2.6 years. Follow-up angioscan showed obliteration of the dissection in the aortic arch in all patients; there were two patients with dilatation of the distal aortic arch of 40 and 45 mm.(ABSTRACT TRUNCATED AT 250 WORDS)     

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OBJECTIVES: To determine the appropriate indications and timing for surgery in children with either a perimembranous or a subarterial type of ventricular septal defect (VSD) associated with aortic cusp prolapse. DESIGN: Retrospective review of children with VSD and associated aortic cusp prolapse with or without aortic regurgitation. This review was based on data obtained from clinical findings, two-dimensional echocardiography, cardiac catheterization and angiocardiography. SETTING: Tertiary health care facility with two-dimensional and colour Doppler echocardiographic and cardiac surgery facilities, and a catheterization laboratory. PATIENTS: Forty-eight patients were found to have perimembranous or subarterial VSDs in association with aortic cusp prolapse with or without aortic regurgitation. INTERVENTIONS: All 48 patients had high resolution two-dimensional and colour Doppler echocardiography. Of the 19 patients who underwent surgical closure of their VSD, five also had an aortic valvuloplasty and one had an aortic valve replacement. Cardiac catheterization was performed in 16 of the 19 surgical patients and 12 of the 29 nonsurgical patients. MEASUREMENTS AND MAIN RESULTS: Annual clinical and echocardiographic assessments in the nonsurgical group did not demonstrate increasing aortic insufficiency. Two children in the nonsurgical group showed spontaneous resolution of aortic insufficiency. In the surgical group, four children with VSD and clinical aortic insufficiency had surgery at less than five years of age; two were found to be regurgitant-free, one had trivial clinical aortic insufficiency and the other had echocardiography-only insufficiency. Of the seven surgical patients older than five years with VSD and clinical aortic insufficiency, four were found to be regurgitant-free, one had echocardiography-only regurgitation and two were unchanged. Two children undergoing surgery with VSD and no aortic insufficiency had postoperative echocardiography-only regurgitation, presumably related to cusp deformity from presurgical prolapse. Children with large VSDs with or without aortic cusp prolapse required surgery for indications of shunt size and pulmonary resistance. CONCLUSIONS: For children with small perimembranous VSDs and cusp prolapse, surgery is indicated only if there is clinical evidence of aortic regurgitation and progressive left ventricular enlargement.     

Rupture of an abdominal aortic aneurysm following acute descending thoracic aortic dissection. Case report

The coexistence of an abdominal aortic aneurysm and an acute aortic dissection seems to be rare and only a few reports are to be found in the literature. We report a case of a patient with acute aortic dissection of the descending thoracic aorta that caused rupture of a pre-existing abdominal aortic aneurysm. The literature is also thoroughly reviewed.     

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The authors report the case of a young patient with an aneurysm of the ascending aorta and moderate aortic incompetence, who underwent a conservative operation at our institution. Dilatation of the sinotubular junction, particularly at the level of the non-coronary sinus of the aortic valve with loss of coaptation between the corresponding leaflet and the two coronary leaflets, was identified at the time of surgery as major cause of valve insufficiency. During surgery, the dilated ascending aorta and pathologic aortic sinus were replaced with a 26 Hemashield prosthesis tailored according to the David guidelines. An intraoperative post-repair transesophageal echo exam showed that the aortic valve appeared to be working competently. The post-operative course was uneventful and at one year, an echographic check of the aortic valve showed that it was fully competent, with normal leaflet motion. Conservative surgery can be a good option in selected patients with ascending aortic aneurysm and aortic valve insufficiency.     

Modified David''s operation for aortic regurgitation associated with annulo-aortic ectasia

Composite graft replacement of the ascending aorta and aortic valve has been indicated for aortic regurgitation (AR) associated with annulo aortic ectasia (AAE). 29-year-old female with AR due to AAE associated with Marfan's syndrome underwent the replacement of ascending aorta by sparing an aortic valve with good result. Under cardiopulmonary bypass, the proximal ascending aorta was dissected circumferentially down to the ventriculo-aortic junction. The aneurysmal aorta and the all three sinuses of valsalva were excised, leaving 7 mm of arterial wall attached to the aortic valve and small buttons of arterial wall around the both left and right coronary arteries. The aortic valve was reimplanted inside a 28 mm Dacron graft which was calculated by aortic valve leaflet height. The left coronary artery was reimplanted to the graft by interposing a short 10 mm Dacron graft between coronary ostia and graft and the right coronary artery was anastomosed directly to the graft (Piehler's procedure). We called these procedure "modified David's operation". The patient has survived the operative procedure without any complications. Postoperative aortogram showed a competent aortic valve and the peak systolic pressure gradient across the aortic valve was 20 mmHg. We believe this new procedure preserving the native aortic valve is useful for preventing from some complications associated with artificial heart valves.     

Replacement of aortic root with valved tubular prosthesis in a ten-year-old child with infective endocarditis--a case report

Aortic root abscess, aneurysm of sinus Valsalva, severe aortic valve insufficiency, and a fragile aortic wall caused by infective endocarditis were found in a 10-year-old child. Aortic valve replacement was intended as a preoperative strategy, but one of modifications of Cabrol had to be used urgently because of aortic root rupture between right atrial and aortic connection just after pericardiotomy.     

Planimetric quantification of aortic valve stenoses using multiplanar transesophageal echocardiography

Standard techniques used in order to quantify the severity of aortic valve stenoses in clinical practice comprise: transthoracic echocardiography, namely, by determining maximum and mean transvalvular gradients and evaluating aortic valve areas, as well as invasive techniques which quantify aortic valve areas through hemodynamic pressure measurements and application of the Gorlin formula. Since the introduction of the multiplane TEE technique, it has become feasible to scan the aortic valve in a strictly horizontal plane and quantify the aortic valve orifice by planimetry. In this study, we investigated 23 patients with various degrees of aortic valve stenoses. We compared aortic valve areas, which had been planimetrically determined by multiplane TEE scans, and mean aortic valve gradients (standard TEE technique) with pressure gradients and valve areas derived from hemodynamic measurements obtained during cardiac catheterization, and have found that the valve areas as well as the mean pressure gradients correlate well.     

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The technique of homograft aortic root replacement in our practice has evolved as our experience has increased. This technique is described and illustrated. In most cases, aortic annuli are reduced by using various suture techniques to match the homograft. This allows for a successful implantation of a normal-sized aortic homograft root in a patient with a diseased aortic valve and annular dilatation.     

Composite valve graft replacement in patients with type A aortic dissection--a modified cabrol procedure

Composite valve graft replacement of the ascending aorta and aortic valve is indicated for a variety of conditions affecting the aortic root. However, a major drawback in this operation is bleeding from the proximal suture line and coronary anastomosis especially in patient with friable root tissue involved by aortic dissection. We describe here a modified technique to take advantage of the aortic button and cabrol techniques to reattach the coronary artery ostia. We have experienced seven patients with the aortic root replacements for type A dissection using the described technique over the past two years. In view of our favorable experience, we recommend this technique especially for patient with acute dissection involving nondilated aortic annulus, in addition to the patients with Marfan syndrome or annulo-aortic ectasia.     

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The slow progression of valvular aortic stenosis enables the left ventricular myocardium to adapt itself to the increasing afterload. When myocardial adaption is exhausted, surgical intervention is urgent, the prognosis, however, is already limited. To quantify the hemodynamic severity of aortic stenosis, transaortic pressure gradients (dp) measured by Doppler echocardiography or hemodynamically are inappropriate, because dp is significantly dependent on the transaortic flow volume. In severe aortic stenosis, despite constant narrowing of the aortic valve area, the reduced stroke volume results in decreasing transaortic pressure gradients. With aortic valve resistance or transaortic pressure loss (PL)--the quotient of pressure gradient and stroke volume--the hemodynamic severity of aortic stenosis can be described accurately. If PL is known, a decompensated aortic stenosis (PL > 1 mm Hg/ml) may be differentiated from myocardial failure of another etiology and a concomitant left ventricular outflow tract obstruction. With respect to medical therapy, the prevention of bacterial endocarditis and thromboembolic complications is important. Knowing the potential danger of syncopies and ventricular arrhythmias during exercise with increasing severity of aortic stenosis, patients have to be informed about their limited functional capacity. The occurrence of typical symptoms during the natural history of chronic aortic stenosis (e.g. dizziness, syncopes, angina pectoris, arrhythmias) manifestation of ST-T-alterations or silent myocardial ischemias and demonstration of an inadequate myocardial adaptation to the chronic pressure overload in asymptomatic patients are accepted indications for a surgical intervention. If the indication for surgery remains uncertain, stress tests (e.g. radionuclidventriculography) may be performed to demonstrate an exhausted myocardial adaptation. If the PL and the severity of aortic valve/anulus calcification is known, the progression of a chronic aortic stenosis can be estimated. This might be important, if a cardiosurgical intervention has to be performed for other indications and aortic stenosis is co-existent but does not require an intervention at that time. For prognostic reasons myocardial decompensation due to aortic stenosis is an indication for an urgent surgical intervention. Attempts for medical recompensation or bridging strategies (e.g. balloon valvotomy) worsens the prognosis significantly.