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F S SADR MD FACS

AORTIC VALVE SURGERY

THE AORTIC VALVE DISEASE WILL CAUSE AORTIC STENOSIS (A.S) OR AORTIC INSUFICIENY (A.I)

THE SYMPTOMS OF AORTIC STENOSIS (A.S) DIFFERS FROM AORTIC INSUFICIENCY (A.I).

AORTIC STENOSIS

DIAGNOSIS:
ETIOLOGY:
CONGENITAL.
ACQUIRED.
THE ETIOLOGY OF ACQUIRED AORTIC STENOSIS HAS CHANGED DRAMATICALLY AS SOCIOECONOMIC AND HYGINIC CONDITIONS HAVE IMPROVED.
RHEUMATIC DISEASE WAS RESPONSIBLE FOR MOST CASES OF (A.S) AORTIC STENOSIS UNTIL FEW DECADES AGO,WHEREAS NOW MOST ARE DUE TO CALCIFIC DEGENERATIVE OR BICUSPID ETIOLOGIES, ( NORMAL AORTIC VALVE HAS THREE CUSPS ).

ONCE THE SYMPTOMS DEVELOP THE OUTCOME OF PATIENT WITH AORTIC STENOSIS ( A.S ) IS QUIET POOR.
IN EARLY STUDIES 50% OF SUCH PATIENTS WERE DEAD AT FIVE (5) YEARS AND 90% WERE DEAD AT 10 YEARS .

SYMPTOMS OF AORTIC STENOSIS (A.S)
THERE IS UNIFORM AGREEMENT THAT ONCE SYMPTOMS DEVELOP PATIENT WITH SIGNIFICANT AORTIC STENOSIS SHOULD UNDERGO VALVE REPLCEMENT.
MANAGEMENT OF THE ASYMPTOMATIC PATIENT WITH MODERATE TO SEVER A.S HAS BEEN MORE PROBLEMATIC.
AORTIC VALVE REPLACEMENT (AVR) SHOULD BE DEFERRED IN PATIENT WITH ASYMPTOMATIC AORTIC STENOSIS UNTIL THE ONSET OF SYMPTOMS. ALTHOUGH CARDIAC DEATH OCCURS IN APPROXIMATELY 2 % TO 4% OF THESE PATIENTS .SUDDEN DEATH COULD OCCURE EVEN IN ASYMPTOMATIC PATIENTS WITH SEVER AORTIC STENOSIS.
AORTIC VALVE REPLACEMENT IS TREATMENT OF CHOICE FOR ELDERLY PATIENTS WITH AORTIC STENOSIS ( A.S )
THE SURVIVAL OF PATIENTS DISCHARGED FROM THE HOSPITAL COMPARES FAVORABLY WITH A NORMAL POPULATION MATCHED FOR AGE AND SEX .
THE RESULTS OF AORTIC BALLOON VALVOLOTOMY HAVE BEEN DISAPPOINTING.
THEREFORE,CONTINUED UTILIZATION OF THIS TREATMENT METHOD MAY PRECLUDE ELDERLY PATIENTS ACCESS TO SURGERY.A MODE OF THERAPY THAT HAS WITHSTOOD THE TEST OF TIME.

AORTIC REGURGITATION.

LEFT VENTRICULAR (LV) SYSTOLIC FUNCTION IS AN IMPORTANT DETERMINANT OF LONG TERM PROGNOSIS IN PATIENT WITH CHRONIC AORTIC REGURGITATION .
IN PATIENTS UNDERGOING AORTIC VALVE REPLACEMENT ( AVR ),THOSE WITH PREOPERATIVE LV,DYSFUNCTION HAVE GREATER RISK OF POSTOPERATIVE CONGESTIVE HEART FAILURE (CHF),AND DEATH THAN DO THOSE IN WHOM PREOPERATIVE LV SYSTOLIC FUNCTION IS NORMAL.
SYMPTOMATIC PATIENTS WITH DEFINITIVE EVIDENCE OF IMPAIRED LEFT VENTRICLE (LV) FUNCTION SHOULD UNDERGO OPERATION WITHOUT WAITING FOR THE DEVELOPMENT OF SYMPTOMS OR MORE SEVER LV DYSFUNCTION .
ASYMPTOMATIC PATIENTS WITH NORMAL LV SHOULD BE FOLLWED BY SERIAL ECHOCARDIOGRAM AND UNDERGO OPERATION ONLY AFTER THE ONSET OF SYMPTOMS ,DEPRESSED LEFT VENTRICLE FUNCTION AT REST ,OR EXTREME LV DILATATION WITH DIASTOLIC DIMENSION LARGER THAN >80 MM,SYSTOLIC DIMENSION LARGER >THAN 55 MM.
THE OPERATIVE MORTALITY IS LOW AND LONGTERM POST OPERATIVE SURVIVAL IS EXCELLENT .
SYMPTOMATIC PATIENTS WITH LV FUNCTION (EF) BELOW THE NORMAL RANGE COMPRISE A HIGH RISK GROUP WITH REDUCED POST OPERATIVE SURVIVAL ,WHEARS THOSE WITH NORMAL INDICES OF LV PUMP FUNCTION (EF) HAVE AN EXCELLENT PROGNOSIS.

THE AORTIC VALVE CHOICES COULD BE :

THE MOST COMMONLY USED VALVES IN USA ARE ST.JUDE MEDICAL AND MEDTRONIC HALL VALVES.THE MECHANICAL VALVES REQUIRE LIFE TIME ANTICOAGULATION THERAPY.
BIOPROTHESIS ARE PREFERRED VALVES FOR ELDERLY AND THE PATIENTS WHO COULD NOT TAKE ANTICOAGULANT,FOR ANY MEDICAL REASON. BIOPROSTHESIS ( TISSUE VALVES ) HAVE SHORTER LIFE SPAN THAN MECHANICAL VALVES DUE TO STRUCTURAL DETERIORATION.THEREFORE HAVE TO BE REPLACE WHITHIN 8-12 YEARS .THE NEWER GENERATION ARE MORE PROMISSING.
homograft,and autograft ( ROSS PROCEDURE ) DO NOT REQUIRE ANTICOAGULATION AND MR ROSS POINTS TO this procedure as A "PERMANANT AORTIC VALVE.
REFERENCE: J OF CARDIAC SURGERY 1993.