Echocardiographic Frequency and Severity of Aortic Regurgitation After Ultrasonic Aortic Valve Debridement for Aortic Stenosis in Persons Aged >65 Years Patrice A. McKenney, MD, Gary J. Balady, MD, Thomas J. Ryan, MD, and Richard J. She&x MD -

1111 echanical debridement of stenotic aortic valves was performed before the availability of prosthetic

valves, but was limited by recurrent stenosis.1~2 However, aortic valve debridement remains useful for patients with small aortic annulae unsuitable for a prosthetic valve or with contraindications to anticoagulation. Recently, the use of ultrasonic energy to decalcify the aortic valve suc- cessfully relieved obstruction, but aortic regurgitation (AR) developed during short-term follow-up.3-7 This study evaluates the long-term results of ultrasonic aortic valve decalcification for aortic stenosis.

Twenty consecutive patients (11 women and 9 men, mean age 77 f 5 years, range 67 to 85) undergoing ultrasonic aortic valve decalcification between 1988 and 1990 were evaluated. Mean preoperative aortic valve area was 0.8 f 0.3 cm2, with a mean gradient of 43 f 22 mm Hg at cardiac catheterization. No patient had more than trivial AR. Most patients (14 of 20) were limited by New York Heart Association class ZZZ to Wsymptoms of dyspnea. Mean ejection fraction was 56 f 16%. Selection for debridement was based on small aortic annular size, contraindications to anticoagulation, or at least moder- ate aortic stenosis when performed as an adjunct to coronary artery bypass grafting. Standard hypothermic extracorporeal circulation and cold cardioplegic arrest were followed by oblique aortotomy. The Cavitron Ul- trasonic Surgical Aspirator (Cavitron Surgical Systems, Inc., Stamford, Connecticut) was used to deliver ultra- sonic energy and disintegrate valvular calcium. Continu- ous irrigation suspended the particulate matter and cooled the site of debridement. Complete debridement was performed to restore normal leaflet mobility.

Echocardiograms obtained before discharge and at the most recent follow-up visit were analyzed in a blind- ed manner by 2 cardiologists. Maximal aortic velocity was obtained through continuous-wave Doppler sam- pling. The systolic left ventricular outflow tract diameter was measured in the parasternal long-axis view at the aortic hinge point, with velocity assessed in the apical 5- chamber view by pulsed Doppler sampling just below the aortic valve. Aortic valve areas were then calculated us- ing the continuity equation.8 AR severity was determined using 3 Doppler methods: color-flow analysis of the ratio of AR jet to left ventricular out’ow tract height (10.25 = trivial; 0.25 to 0.46 = mild; 0.47 to 0.64 =

From the Department of Medicine, Evans Memorial Department of Clinical Resebch, and Department of Cardiothoracic Surgery, Section of Cardioloav, Universitv Hospital. Boston Universitv Medical Center. -- 88 E. Newton Street, Boston; Massachusetts 02llk Manuscript rei ceived November 25, 1991; revised manuscript received and accepted March 6. 1992.

moderate: and 20.65 = severe)9; deceleration slope (cm/ s) (I2 = mild; >2 but <3.5 = moderate; and 23.5 = severe)‘O; and analysis of reversal of flow in the aortic lumen in the suprasternal view (absence of diastolicflow reversal = mild; presence in initial 50% of diastole = moderate; and holodiastolic = severe).‘t AR was then quantified as follows: 1 = trivial; 2 = mild; 3 = moder- ate; and 4 = severe. All charts were reviewed, andphysi- cians and their respective patients were contacted to ob- tain follow-up data including age, sex, New York Heart Association functional class, occurrence of cerebrovas- cular accident, endocarditis, reoperation or death.

Clinical and echocardiographic data for each patient are summarized in Table I. Data in the text are ex- pressed as mean f SD. The paired Student’s t test was used for analysis of variables, with a p level <0.05 con- sidered significant. Ultrasonic aortic valve decalcifica- tion was accompanied by coronary artery bypass graft- ing in 16 of 20 patients (80%) and by mitral valve repair in 3 (15y0). Perforation of aortic valve cusps needed pericardial patch repair in 9 patients (45%). Of 3 pa- tients (15%) who died before hospital discharge, 1 had a myocardial infarction after 2 days, and another had an embolic stroke immediately after surgery, with mild AR, myocardial infarction and ventricular fibrillation at 53 days (both confirmed at autopsy). The third patient died after 55 days, with congestive heart failure and ventricu- lar fibrillation. Seventeen patients survived and were discharged from the hospital.

Echocardiograms were obtained in 18patients within 2 weeks after surgery; however, analysis was limited to technically adequate studies. AR could be assessed in 17 patients. In 4 of 17 patients (24%), grade 2 AR was present, with none having L grade 3 AR. Aortic mean gradients were measured in 14 patients and decreased to a mean of 17 f 9 mm Hg from a mean preoperative gradient of 43 f 22 (p = 0.0001). Estimates of aortic valve area were obtained in only 8 patients owing to technical limitations, yielding a mean preoperative area of 0.8 f 0.3 cm2, which increased to 1 .I f 0.5 after surgery (p = 0.2).

The clinical status of all patients was assessed, with a mean follow-up of 12 months (range 2 days to 33 months). In addition to the 3 in-hospital deaths, 6 late deaths occurred, resulting in a total mortality of 9 of 20 (45%). Of the 6 late deaths, all had congestive heart failure, and 5 had mild to moderate AR. The presence of AR was undetermined in the sixth patient. One patient died after reoperation for AR, constrictive pericarditis and congestive heart failure (Table I, patient 3). In all, 3 patients (15%) needed reoperation for AR and conges-

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r TABLE I Clinical and Echocardiographic Results of Aortic Valve Debridement

Aortic Mean Severity Gradient (mm Hgl ofAR

Age (yr) Other Clinical Pt. No. & Sex Pre Post F/U Pre Post F/U Procedures Outcome

1 85F 67 13 16 1 1 4 CABG R 2 82F 39 30 - 0 0 - CABG D 3 79M 21 15 13 0 0 2 CABG R D 4 78F 49 - 33 0 0 3 - D 5 83M 95 15 18 0 2 3 CABG A 6 78F 19 13 17 1 2 3 CABG, MVR D 7 84F 70 13 22 0 0 3 - A 8 78M 35 3 34 0 0 2 CABG A 9 78F 36 22 - 0 2 - D

10 72M 23 - 9 0 0 2 CABG D 11 78F 30 - - 0 - - - D 12 72M 42 9 20 0 2 4 CABG, MVR R 13 78F 80 - - 0 1 - CABG D 14 80M 25 16 26 0 1 2 CABG A 15 67F 15 - 34 0 - 3 CABG A 16 83F 55 42 26 0 1 2 CABG A 17 72F 53 - 26 1 - 2 CABG A 18 69M 23 18 15 0 0 1 CABG A 19 80M 51 13 18 0 1 4 CABG, MVR A 20 72M 32 15 - 0 0 2 CABG D

A-alive: AR = aorticregurgitation; CABG = coronaryartery bypassgraftsurgery; D = dead; F/U = latefollow-up; MVR = mitral valve repair; R = reoperation.

TABLE II Comparison of Clinical Outcomes After Ultrasonic Aortic Valve Debridement I

Mean z No. F/U Moderate Reoperation Mortality

Investigators of Pts. (mos.) AR(%) (%) (%I

Schwinger et als 10 3 60 40 0 Scottet al4 8 6 0 13 0 McBride et als 22 6 87 9 23 CraveP 11 - - 27 36 Freeman et al7 61 9 63 14 22 Presentstudy 20 12 56 15 45

AR = aortic regurgitation; F/U = follow-up. I

change in valve area may not be representative of the entire group.

These findings are consistent with previous reports (Table II). Schwinger et al3 evaluated 10 patients at 26 days and found severe AR in 2 cases. At 99 days, 4 more patients developed severe AR. In all, 4 patients in that series needed subsequent aortic valve replacement. At 6 months, Scott et al4 found only a mild increase in the grade of AR, but McBride et al5 found the incidence of mild and moderate AR to increase from 50 to 87% of patients. Furthermore, Craver6 noted that 3 of 11 pa- tients (27%) needed aortic valve replacement owing to AR, total mortality was 36%. Freeman et al7 found severe AR in 26% of patients and moderate AR in 37% after 9

tive heart failure. Late embolic events needed anticoagu- lation in 2 patients. No patient developed endocarditis. Of the 9 patients who survived and did not undergo reoperation,.all are in New York Heart Association class I or II. Significantly, all 9patients have AR, and 4 (45%2 have > grade 3 severity.

After the 3 early postoperative deaths, 17 patients remained in the follow-up group. Echocardiograms were obtained in Idpatients at a meanfollow-up of 14 months (range 3 to 26) from the time of surgery. All 16patients had AR, and 9 (56%) had grade 3 to 4 severity. This represents a significant increase in AR compared with before surgery (p = 0.0001). The mean aortic gradient was successfully obtained in 15 patients and averaged 22 f 8 mm Hg, which was significantly reducedfrom before surgery (43 f 22; p = 0.005). Due to technical limita- tions, aortic valve areas were calculated in only 7 pa- tients. The mean preoperative aortic valve area of 0.8 f 0.3 cm2 in these patients was minimally increased to 0.9 f 0.4 at follow-up. Because aortic valve areas were ob- tainable in GO% of the follow-up group, the absence of

months of follow-up. Aortic valve replacement owing to severe AR was performed in 14% of these patients, The total mortality in that series was 22%.

Our study verifies the problem of progression of AR and its associated adverse clinical outcome after ultrason- ic valve debridement. Comorbid disease in this elderly population contributed to the high mortality rate of 45%. In addition to the 3 early deaths, there were 6 late deaths, all with congestive heart failure, and 5 with significant AR. All patients who underwent follow-up echocardiog- raphy had AR, with 56% having moderate to severe AR. A subset of 9 patients have done well and remain in New York Heart Association class I or II, but all have AR (45% moderate to severe AR). Because of the frequent occurrence of progressively severe AR, and the high re- operation and mortality rates, we have abandoned this procedure and recommend that other clinicians do so also.

1. Enright LP, Hancock EW, Shumway NE. Aortic debridement: long term follow-up. Surgery 197 1;69:404-409. 2. Hill DC. Long-term results of debridement valvotomy for Cal&tic aortic stene

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1990;16:623-630. 8. Zoghbi WA, Farmer KL, Soto JG, Nelson JG, Quinones MA. Accurate noninvasive quantification of stenotic aortic valve area by Doppler echocardiogra- phy. Circulation 1986731452-459. 9. Perry GJ, Helmcke F, Nanda NC, Bayard C, Soto B. Evaluation of aortic insufficiency by Doppler color flow mapping. J Am Co11 Cardiol1987;9:952-959. 10. Labovitr AJ, Ferrara RP, Kern MJ, Bryg RJ, Mrosek DG, Williams GA. Quantitative evaluation of aortic insufficiency by continuous wave Doppler echo- cardiography. J Am Coil Cardiol 1986;8:1341-1347. 11. Touche T, Prasquier R, Nitenberg A, Zuttere DD, Gourgon R. Assessment and follow-up of patients with aortic regurgitation by an updated Doppler echo- cardiographic measurement of the regurgitant fraction in the aortic arch. Circula- tion 1985;72:819-824.

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