Midterm follow-up dynamic echocardiography evaluation after ascending aorta replacement and reimplantation of the aortic valve (David operation) in a matched control study Giuseppe D’Anconaa,*, Renato Ciofalob, Domenico Biondoa, Marco Follisa and Fabrizio Follisa a b
Department of CT Surgery, Mediterranean Institute for Transplantation and Advanced Specialized Therapies (ISMETT), Palermo, Italy Division of Cardiology, ARNAS, Palermo, Italy
* Corresponding author. Department of CT Surgery, ISMETT- Mediterranean Institute for Transplantation and Advanced Specialized Therapies and University of Pittsburgh Medical Center, Via Tricomi 1, 90127 Palermo, Italy. Tel: +39-091-2192111; fax: +39-091-2192354; e-mail:
[email protected] (G. D’Ancona). Received 25 June 2011; received in revised form 22 August 2011; accepted 25 August 2011
Abstract OBJECTIVE: Dynamic performance of the aortic valve (AV) after ascending aorta replacement with reimplantation of the native AV (David) was investigated. METHODS: We prospectively evaluated 17 patients who underwent David procedure. Rest/stress echocardiography follow-up was performed and results were compared with those of matched healthy controls. RESULTS: There were no significant differences in terms of age, height, weight, BSA, left ventricular mass, left ventricular ejection fraction (LVEF) and tele-diastolic volume between the David and control group. At rest echocardiography, patients in the David group had a lower indexed aortic valve area (IAVA) (1.1 ± 0.2 vs. 1.5 ± 0.2 cm2/m2, P < 0.0001), with comparable transvalvular gradients (TVG). At maximal physical stress, although the IAVA in the David group was significantly increased from the rest values (P = 0.001), the difference with the control group persisted (David 1.4 ± 0.3 vs. Control 1.7 ± 0.2 cm2/m2, P < 0.0001) maintaining similar peak TVG (David 13.6 ± 5.3 vs. Control 11.7 ± 4.5 mmHg, P = ns) and mean TVG (David 7.2 ± 3.0 vs. 6.2 ± 2.4 mmHg, P = ns). AV regurgitation in the David group was absent in five (29.4%), grade I in nine (52.9%) and grade II in three (17.6%) patients and remained unchanged during stress. At multiple linear regression, David operation was inversely correlated to rest IAVA (OR = −0.4; P = 0.01; CI: −0.7–0.1). CONCLUSIONS: Although IAVA is significantly smaller after David procedure in comparison with matched controls, no pathological increase in TVG is noticed. A significant increase in the IAVA during physical stress documents the preserved pliability/elasticity of the aortic unit after David procedure preventing pathological increase in the TVG even during strenuous effort. Keywords: David stress-echocardiography • Aortic valve area
INTRODUCTION Description of valve sparing procedures by Yacoub in 1979 [1] and David in 1988 [2], respectively, has sparked tremendous interest in reparative techniques of the aortic valve (AV), somehow neglected up to that time in comparison with the mitral valve. As a result, the anatomy and physiology and the importance of the aortic root complex as a single unit have been clarified in detail. Despite the outstanding results reported in the literature [3, 4], however, the fate of the AV complex after remodelling or reimplantation procedures remains an object of much debate [5]. On the other hand, exercise echocardiography has become an important tool in revealing the dynamics of the valve and the ventricle and unmasking functional disabilities in patients who often adapt by reducing their physical activity [6]. In the light of these considerations we became interested in studying by means of echocardiography the behaviour of the AV complex after a
reimplantation procedure, at rest and after exercise, in comparison with normal subjects.
MATERIALS AND METHODS Twenty-one consecutive patients underwent a reimplantation procedure (David I) between 2004 and 2009. All patients had anatomically normally shaped tricuspid AVs free from any sort of leaflet alteration. The diameter of the sinotubular junction determined the diameter of the graft, with an additional oversizing of 1–2 mm. Straight Dacron grafts, sized 26, 28 and 30, were used. One patient died of gastric cancer 1 year after the procedure and three patients were lost to follow-up. Seventeen patients were available for study. For every patient previously submitted to the David procedure, an adequate match for gender, age, body surface area (BSA) and LVEF% was found
© The Author 2011. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ADULT CARDIAC
ORIGINAL ARTICLE
European Journal of Cardio-Thoracic Surgery 41 (2012) 785–788 doi:10.1093/ejcts/ezr114 Advance Access publication 21 December 2011
G. D’Ancona et al. / European Journal of Cardio-Thoracic Surgery
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within the group of patients who are daily referred to our echocardiography clinic for a medical check-up. Patients in the two groups (David and Control), for this reason, belonged to the same referral area. A group of 18 subjects was identified for matching and comparison. The two groups were studied at baseline and after treadmill exercise according to Bruce’s protocol with the targets of 75% of predicted maximal heart rate or appearance of symptoms [7]. Measurements of left ventricular (LV) dimensions were made from 2D echocardiographic images in the parasternal long-axis view and M mode. LV volumes and ejection fraction (EF%) were calculated by modification of Simpson’s method with two apical views. AV regurgitation was graded on the basis of the regurgitant jet height/left ventricular outflow tract (LVOT) height ratio (mild (1+):
