Lewis, FJ

Starzl, TE

Name not available

Recent developments in aortic valve surgery

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4 Aortic Valve Surgery 4 I;Tl;!i >ucccssf~il operi~.tions had I)cen rlonc on A i11r 11iitra1 v;,lve it. ~n.:,s logici~l iliat, nttcn~pts +lir)i~l(l 111: rnadc to trcat nortic valvc tlist.nsc s111.- gic:~ll!.. 'I'hougl~ the prol)lcms hitve hccn gre:~tcl* here, some 1)rogrcss has 1)ccn miitlc. At first, I~lintl operations were c~mplo!-rd and ;I fcw surgcor1.i still tlcfcntl their use. Thr  trans\.entricl~lar ill)- proncl~ of I<i~iley' has been tried by many, and though i t  has been abandoned by its originator, o t h c r r ; " ~ ~ o n t i n ~ ~ e  this approach with a modified. Irss t ,ra~~mntic dialator and rcport a dccrcaccd nlortality rate. The blind transaortic i~ppronch to i h ~  aortic ralve, strongly ndvoc:i.tcd a few years ago. and st,ill nseci by SOIIIC," is not widely em- l'1oyc.d totli~y. As the inadcc1lrncy oC thcse blind opcr:~t.ior~s has 1)ccolnc nwrc ;11)11:n'cnt, ant1 as methods I'or iloing open operations have im- prorrd, more surgeons have studied and utilized open techniques for the aortic valve. 11-e hare used an open, direct vision operation lor over three years and can report that progress has been niade bobh in illethods that permit open surgery in this area and in  techniqu.es for alter- ing the diseased valve. Certainly, the open ap- proach is more rational than a closed operation, for - in  contrast with blind techniques - it permits the surgeon to do a meticulous operation on the diseased valve. Success has been gratify- ing in selected cases and many inore patients with t,his disease will be benefited in the future. Methods For Open Surgery on the Aortic Valve FIypothermia: The first successful open opera- iions on i;he aortic valve were clone with hy- pothermia and this may still be the best way to do this type of surgery in  some patients. With the ~~:~.tieni,  coolcrl to 28-C.-30'C. hy 511rfact t~noling, or n coml~inntion of hllrfil(:~ ;tnrl int ra- g:.;tstric c:oolirrg, thc chrst is opened thro11;rh a transverse or midline incision and thc haart cs- posed. After occl~ision of the caval and pulmo- nary inflow, the ascencling aorta is occludcd just proximal to the inominate artery and then opcncd wit,h a longitudinal incision extending down to the aortic valve. With this incision a good expo- sure of the aortic valve is obtained anrl the fuserl cusps may be separated accurately with a knife or scissors. Since our first use of this tcchniclue in Deccnl- I~er 13559n.e have cml~!oycd i t  on cight cases. There wvrc two operative ilcnths hui the othcr rix have shown significant clinical im~~rovcrncnt. I~ l h e  operation is best for congcnital stcnosis in which there is little or no valve calcification and here the results may be dramatic. I n  acquired stenosis the results ma.y be excellent if there is only minimal valve calcific a t '  ion. The limited time for the open procedure al- lowed by hypothermia (8-10 min.) has not seemed restrictive. There is not a great deal to do if the objective of the operation is simply to open the fused commissures accurately. This can be performed in a few minutes. ?Tonetheless, the short time is a serious limitation if more extensive valve revisions are to be attempted. Furthermore, with hypothermia, the heart may not p u n ~ p  effectively immcdiatcly after circula- tion has becn restarted. Additional circulatory support would be desirable a t  this t,ine, partic- ularly for patients with coronary sclerosis in addition to the aortic valve disease. Recently, in order to perinit more time and add circulatory support, we have used a pump-osygenator plus Froiit the Depart~ttent of Sfcrgery, ~Vortltweslern antigrade coronary perfusion in  three operations C'itizw-.rity dlcdical School, Passavarrt Mantorial Has- for aortic Steno~is. pita1 and V A  K ~ s e a r c h  Hospital. Pump-Oxygenator : The pump-osygenator we Si61'30rf~d its Part by PMblic Hcaltla Semire  have Used is a new t?pe of oxygenator Researclr Grant #H-2879 and grants front the Atireri- can Hcort Association and the Chicago Heart Asso- which we think has some advantages over other ciation. machines.? During the by-pass the blood has 198 Illinois dledicol Jo:crnol I , C ~ I I  t v ~ c r l ( > c i  \ ~ i t  11 ;I t~ooli l~q coil to t nlie ; ~ t l v ; i ~ l t i ~ ~ c  of 111c: ~1>t111t~t l  111c~taIwl ic r : ~ i ~ l  \~re)~-i~ltcci 11y 11y- ~)oihc~rrnia. r .  I he ;~sci.lldiny :loria is olrcucrl l o  expose t l ~ c  vnlw :111(i thi. ~~cc~.s . ; ;~ry  ~ I I S ~ I  ~ol):u;~t.ion t11c~11 !~crFor~ncci. 1Tcrc. part icularly i i ;I lon,c,.cr ]rc'rioci of  i~liIo\r ( ~ ~ ~ ~ ~ j i ~ s i n n  is 10  be IIS~>(] .  solllc c~t)rOll:lr~ ;~crf~:sion i.+ roq~iirci?. 'r11is has 1 ~ ~ 7 1 1  : ~ ~ ~ c o n ~ ~ r l i s l ~ c ~ d  :imply 1))- l\c>ri~~.;in:,. inio thc nriticr oi  tlic left coron:1rj7 :~rtc>ry \vil.l~ :I cann111;1, : ~ t i a c I ~ ~ l  lo rescrl-oir oC 11cy):lrinixc~c1 ltlood 11:lnging 100 cnl. ahove tlw opcr;~tivc fipld. IVl i~n the nortic ~,:ilve ~~rocedurc  I~ns  1)ecn conll)letecl the l~ca r t  is filled I wihh hlood or s;llinc. t.11~ sortie incision is closcd. : ~ n d  circ~~lacion i s T C F I I I I ~ C ~ .  \Vitli the 1~1111111-oxy- genntor. vali~;~I)lc i rc~~la tory  1;111)1)ort can 1~ added d ~ ~ r i n g  t,lic 1)criotl illst after c i rc~~la l ion 113s heen res(artc(1. 'l'l~is iype of cir(~lll:~tory P I I ~ I -  port also co111tl 1)r provided \\.ill1 1~111111s fi1011(: and no oxygcnnlor. I\',? hi~ve 11cc11 c*splorin:: s11(311 a s ~ s t e i n  c~xperinicntally. Pump B.v-P:~ss: This method of doing open aortic valve ,surgery without a n  oxygenator re- cluires t\vo l111111ps. One p l in~p  1)y-pn~ses the right heart. and the ot?ler I)\.-passes the left. nlood is drained hy gravity ho ln  the right a t r i u n ~  into n reservoir and an  automatic punlp rcturns this hlood to t.he pnln~onary artcry. T,cft atrial hlootl also drains hy qravity into a ~cconil  rei;ervoir and the ~econd  a ~ ~ t o n ~ n t i c  p111n1) rc t l~rns  this 1)looil into a systcnlic artpry. Cannulation is relatively easy and \\-it11 a n  automatic ~mnlping systcln there is no prohlrin in balancinq the right and left circulations. This system may prove to 1)e n better mcthod for iloing ope11 aortic valve s i~ r -  p r y  than t,hat provided hy the pump-oxygenator. It is clear that methods for allowing open cur- gery on the aortic valrc? will chanse and improve. Even now. good ~rorkable techniques are avail- able and in c,linical use. It \vould seen? that  the prob!em of 1~11at. may be clone to correct a de- formed valve ac~tnally is a more cthallel~ging one, !-ct ~rogressii : :  being made here also. Techniques For Correcting Deformed Valves S L I I ~ ~ ~ C - I L I  ~ I ~ - ~ ~ O I I I ~ I I ~ ~ I I I I I ( * I ~ ~  oti the ~itjrt iu v t t l ~ i 3  ~leprnt?.: greatlv upon the pathological anatolny of tllr ;~ar t icul i~r  deformity. At ])resent, the only ron,i\tently sati<fartory rcsults are among pa- t i d s  u,i;h m~ni~n , i l  ~ a l v c  ca1cific;llion. Cases of ( (inqc~nital i t ~ n o ~ l q  ;Ire o l  this type and among cilrrn results of olxn valve surgery have been c scrllcnt. All illal, n ( ~ ~ c 1  ))r! [ionc is to elivicic t.hc ~ ~ ~ I I I I I I ~ ~ ~ I I I * ( ~ ~  : I ( - ( ~ I I I ~ ; I I ~ ~ I ~ .  Si11(,c 1 . 1 1 ~  v ;~ iv t !  is tiexi- Ijlc, :lccu~.:~lc opc~nin:: o i  1 1 1 ~  c o ~ r ~ ~ n i s s l r r ~ s  \rill rclun.11 iis flln(~tio11 0 norrn:11 or nc~lrly norlnal. TI I  s o ~ n t ~  e;tsrs ;~(!(l~~ircti  .slc~iosi.~, c . ~ ~ ~ ~ ~ c i a l l y  ; I ~ I ~ O I I , :  ~ , I I I I I : V ~  a(111Its, ti117 111;1ssivc ;11(,i111yl (If?- 1)osiis t\l;rt arc cl~ar;~c,lt~ri.-l i t :  oC ill? tl ixc\ase in c~ltlcr 1)aticnls (60 !.e1;1~s oC ;Ign and c>ltlcr) have 11ot~ yet tle~vc,lol~ctl. I )iVi.&ior~ ol' ( 1 1 ~  i~l.scd com- ~ ~ ~ i s s u r c > s  I I I : I ~  cil't~c:t,iv~~ :1111onZ these 1);~ticllts i~ntl Ic:~tl to an  c~scc~llc~~l:  rcs ~lt. 'l'hc tlcgrcc of success is inversely corrclatcd with the n n l o ~ ~ n t  of calci~rni 1,rcscnt in tlic valve. :I fornlitlablc surgical problem is prescnicd by valves with very hcavy calcilim, no rcm;iir~il~:: Resibility, ; ~ n d  s small amol~n t  of regurgitation :~ddcd to the stcnosis. \\'c would he inclined a t  l w e s c ~ ~ t  to rorcgo surgery \vllen 1;hc sii.uxtion c:l.n 1)c ~ i ~ l ; i . ~ r i ~ ( ~ t ~ ) r i l ~  i(I(bntilir(1 prc0pcra1,ivclv. Spe- vial X-ray stl~ilics 11l.3~ I)c hclpf111 in this rcspcct. Some s~lrgeons continue to  use a blind trans- ventricular operation in  these cases. Because thcv do not oftcn see the rcsnlt,s of their work, Inany fail to rcalizc horn little can he accom- plished in this type of lesion ~v i th  simple mechan- ical dilatation. Other silrgcons are trying to es- cise this c a l r i ~ ~ m  and to makr some sort of plastic reconstn~dion of ihc remaining valve. For the fnturr. and this is the possibility that continues to intrigue cardiac surgeons, i t  ma,y be possible to remove the stcnosed valve and replace i t  with a.n artificial valve. Despite the tremendous amount of interest i n  this possibility, replacing n stenotic valve wit,h a satisfactory artificial one has not yet hecome feasible. It is n difficult re- gion in  which to place a prosthesis and a valve placed accurately may not remain exactly in the same position and continue to funct.ion as it was intended to. For the present and immediate future the concept of a plastic revision of the ~ a l v e  ticsue is more att.racti\re than that  of put- t ing in a new valve. This concept of a plastic revision also has merit in the wlrgical treatment of aort.ic insufficiency. Aortic Tncufficiency : For  insuficiencp, the ~ ~ ~ o r t  nt.trncl.i\.c! rlnw idch is  that of removing or defilnctionalizing the noncoronary cusp to con- rcr t  the aort,ic ralve into a bicuspid structure. Tn this procedure the  circumference a t  the valve is rcdllccd by one-t,hird. thus ilccrca~inp the arca a t  the valve orifice to approximately four-ninth3 the  original area. As only one leaflet is ren~ovetl Fig. 1 Orifice area = 1 Orifice area = 4/9 Leaflet area = 1 Leaf let area = 2/3 Figure 1: Diagrammatic illustration of the rela- tive changes in valve and orifice areas produced by bic~s~idization of the aortic valve. 11r dcf~inc~iollillizctl, tilo arcn of avnil;~l)lc valve tissue remaining sliol~ld I)c t\lro-thirds of the origiual valve. result i~ig in  n gain i n  the anlonnt (l(  ill rr l i~iio~~sli i 'p 113 .LII(? oriIicat! size (Fig- 11l.e 1). l ?c~ i l t i~c  t.11~ 111tilli:ilc~ ;~l~i~.lonlic dehcieric.y ill mnily l 'or~~i,< of  :\ortic rc,,c~~rsit;~titrn is iL dis- 1iarit.y l,(:i\c-c.rn 1~~;if ic~t 1rcl.z ;~ntl valve orificc ilrca, this ol)ikr;~tio11 niny Ilavc! e~olisi t l~~ri~l~lc nppli n- 1)ility ;II irpilt itlg (~linici11 V:IIVII iiir ins11 il'icicrlcy. 'I'l~r itlr!i~l canst. \volild I)c ollcl it1 \v l i i t~ l1  the  vnlvrt i(ln.llci*i nrltl thc a n l ~ l ~ l u ~ ~  ,irc1 not. 1,ivtvily c:ilc:ific~d. 'I'hc dctails of aortic l~ic~sgidiz:~t-,ion arc sllo\vn in  Figure 2. -1 linear incision in nlacle in  the iiortn :uid cstrnded into the lion-coronary sinus of 1-nlsiilva. ITnder dirrd. vision. the annnhls of tilc noilcoronnry c ~ s p  and a slibcr of the adja- rent aorta is rcinoved and a bicllspid valve is I cconstructrd. Approsinlately 10 minutes of open i3i l  rtliac time are rccluirerl. Jn experimental anirnalc. the procedure is at- tcwrled with n low lnortality (less than 10 per ( cnt ) . Thertl is no iminedia te or rlelayed critlence or' insutEcicncy. The rclntivc norlic stcnocis pro- illlccd by vnl\o l)icuspicliz,ztion is \\-ell tolcratc~d. .\ recent report 1)y 13ailcy inilicatcs Ihnt 111c prin- ciple oC aortic r:~lvc l ~ i c ~ ~ s ~ ~ i d i z a t  ion 1 1 ~ s  1)ccn tcstril in the trcaiment of paticn~. with aortic insufficiency with enco~~raging rc s~ i l t s .~  Importance of Accurate Diagnosis F l ~ t i l  the ,sllrgoon cmi rcpnir :.ntisfnciorily ;,ilnost nily:hing he encounters in  thc aortic \-:)i\-r. nccllraie clinglionis is csscnl.in1. 'I'l~roligh tlie 11.c of new and cornplc!s ici:hnicliic?,~. con,~idcral)lc iml,rovam~nt l ~ a s  hecn maile in tlic ability to mn.kc n p r ~ c i s r  cliiiposis. I\'it,h combined right. ;ind left heart catheterization, a sound evaluation Figure 2: Illustration of the technique for bicus- pidization of the aortic valve. The upper figure shows a cross-sectional view of the placement of the first stitch which defunctionalizes the non- coronary cusp. The larger figure shows the actual appearance of the operative field. of the: tl(lgrcc oC stcnosis is 110s.-il~le. Ir~s~ifhcirticy is Illore dificult to eva11:ilte 11ut mcthods for mnk- ing this iliagnosis are much 1)etter than they vrerc. S-~.ay stuclie~ give the only inethod for disiingnishing the amount of calcinm ~~resc i i t  and i h c ~  methods arc now fairly reliable. When cardiac cathcierizntion and s careful X-ray ex- nminat,ion arc i~dded to thc clinical evaluation, R souiid r e c o ~ i i ~ ~ i ~ ~ i d a t i o n  .to ffer or withhold silrgery can I)e mnrle. SUMMARY 1. I n  preference to the blind transrentriculnr or transaortic appronclips to the aortic valve. we favor an  open operation that  allows the surgeon lo ccc Ihc nortic valv?. 2. 'l'1101-c arc tlircc t c r l l i ~ i c ~ r ~ c ~ ~  I)y v l ~ i c h  open ol~cr;~tions ciin hc OOIIC on the aortic ralve: hypotherm is. p~~mp-oxy ,~cna i  or. or a pump S ~ S -  iem \vithont the o~!-g~niltor. 3. Surgery is ett'ective i n  relieving congenital aortic stenosis and acqnired stenosis in  which :no Illinois dlferlircrl lortrnc~l ing ,,\. ciI,c,rilii,,ll is orlc in \,.llic,l1 cllrp is I ! . ;  : I I I ~  S n r ~ i i ,  [ I .  S.: 'I'lir S I I ~ K K X I  (:orrwt!on o f  (::~lciltc .\ortic S~CII*).IS 111 .4,lt!llh. l<v?c11ts in &'lr'.I I i I O  (;on. r11111ovcd to co~~vc>ri  thc valve inlo :I 11ic11sl)id .,,.clltive .l.rallsar,rtic ~ . ~ l ~ , ~ l , , ~ , l ~ ~ t i ~ ~ ,  J .  . ~ ~ , , ; ~ ~ i ~  Sur . 36: 1.n l vr. 759-776, 19.5s. 0. l x w i s ,  F. 1.; S~III I I I~V;IV,  5 ,  E . ; ,YI;I?.~, S. A , ;  a11r1 1ir11. REFERENCES jn111i11, I<. 11.: A O I . ~ I C  V~LIVIIII~IOIII) .  r1111rr IJ irect  V l h i o l l  1 .  I l .~tlrs.  C .  l ' .;  I<c,ler!l,!o I < . I I I I I ~ ~ ~ ,  1 1 .  I * . ;  .1l16i I I I Z C I C ~ C .  I ) l t r i ~ l ~  l l Y l t o l l ~ v ~ - ~ ~ i i a ,  J .  '1'118>r:1~!(: S I I ~ K .  32:4NI-400, 1'15fi. 11. I!.: S I I ~ U I C ~ I  ' I ' r c , ~ t ~ t t r ~ ~ t  ( t f  A l j r t ~ c  Strr~ou\ ,  .l.;LM,,\, 7. I.cwi\, I:. I , ,  ~ I ~ I I V ~ I I I I ~ O ,  It.; : I I I G I  I J r ~ ~ ~ r t r a k o ~ t o t ~ l o ~ ,  N,: ISO:lr~J7-It~F.!. It).!. A New 1'111111~-C)xy~rt1att11' I < I I I ~ V ~ ~ ~ I I I K  I 'olyrll~vlrr~r Mrnl- 2. l la i l ry,  ('. I).: t ' e ~ r r w l ~ o ~ ~  of ,4ortic I t r ~ ~ ~ r ~ i t : t t i o ~ ~  I I ~  111. l ~ r a t ~ r s ,  c111art. J11111. N o r t I ~ w r \ l ~ r ~ ~  I l r i v ,  Alr~l. Scl~oi~l. v ~ ~ . s ~ b l d i z : ~ t i n ~ ~  01 111c Val \e ,  ('irc111atin11 l R : h ' ~ l l ,  1958. 32::2h3.2h7,  l'l5X. 3letharnplietamixle for epilepsy Jfetlia~lzplleti~nli~ic sulfate and 1)rv));d)ly otllcr :in~phctanlil~c,< sl io~~lrl  1)e coilritlerc~tl ;I..; a n  atl- j1111i:t ill the I I X ~ I I ~ ~ I ~ ( ~ I I I ( > I I ~  ol S P ~ Z I I ~ C  l)atiellts lnaniirsting ~ ioc . t l~ r~~ i i l  c'11iiel)tic attacks. A rtt- port i n  t 11c~ l i tc l r i~ l~~rc  of ollc l ) i ~ t i ( > ~ ~ t  wit11 110ct1lr- 11iil seizure.: colltrolivtl \\-it11 I:rnzcdri~~c is in ac- cordaucc \\-it11 our vl)rcrvntion. Sil~ce our !)rclinr- innry \vork *11gg:'o~ted a g g r a ~ i i t i ~ ~ ~  of ili~trl~ill seiz11rt3s 1)y n ~ t * t l ~ n ~ ~ ~ p l ~ e t a r n i n e ,  no att mpt \vas 111ar1e c~ithcr to give this drug (111rillfi tihe day or to \vitl~tlra\r the previous ~~~ct l ica t ion,  csccl~t  in t\ro c.nsc.s. I t  \\-;IS fount1 of at lvi~il tap~ to :~tllt~inis- ter the dr11g j w t  prior to the t,i~iic t11c 1)atic.iit 1':iIl.: asloc.1~. Ii, hxs 11ccn our espcricncc that  Pil- 1i~nt.s  wit11 nnc;t.~lrnai ,scizurcs I ' R ~ P I ~  ro1111)1ai11 ot' ;lily distlirl)a~~c~c~s ill the pattern o l  slc?cp j f  the c1r11,q is ailn~itii,~tmwl in this illnnllcbr. 'I'hc clrctrorn~~c~~)halo~r11~phic changes in the n~ajori iy of our p i l t ie~~i .~ ,  c11arac:tcrized hy hilat- of tlccp-sciltc>tl el~ileptogc~iiic lesions tliscliarging to hoth hemispheres. -\\'e \vere linai)le, ho\ve\art to tlistingt~isl~ any t>lcctri~ill abnormality ~) ;~thog-  non~onic for no!~l.iirnnl cl~il(>psy. 'I'hc n ~ c c i l ; ~ ~ ~ i s ~ ~ l  I I ~  vllich a~~ l l )h r !an l i~~c~s  ar  cd'Ct?ctire i n  I~xvlting 11oc~i11rni11 seixr~rcls, i ~ s  well iis ,the posil>ln 1)i1tlio~)lly"olo;i(: 1)ilttcrlls in- ~ o l v t ~ l  in nocturl~al epilrl)sy, \\.(>re discnqsed es- t~c11sivcl~ in our prelinlinary rcporr. .Is more re- cent studies indicate. the site of action of am- phetamines appcws to hr a t  the 1)raitl stc.111 retic- 111i1.r acti~at , ing syst,enl. I t  is 1)ossil)lc. tht~refore, t ha t  the indirectly i i l d ~ ~ c r d  di~xy~ichronizatio~l l' clcctroconical activit;!. hy st im~ili~iion of the i~c- tivating rcticnlnr sys t rn~ 11y thc ; ~ n i l ~ h ~ ~ r n ~ n i u t ~ s ,  ~wo(1~ccs a l i g l ~ t ~ r  sl~e!) iii~cl ~011sr1~11~rltly main- tenance of corlici~l inhihition over sl11)corticalIy- nrising epil(.>ptic tlischargcs. .John Logofh.etis, Jf. 1). 3tctliamphcfntr~inc kSu,lfnte in  tho Treatment nf Mocturnnl Ep i l ep t i c  Sc izurcs .  Jfiniaeaotn Jfcrl .  era1 paroxy.<~nal ])atterm, s ~ ~ g g c s t  the presence .Ifarch 1950. /11r 0 1  f , l l l f ~ l ,  1'1,;'~ 

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Recent developments in aortic valve surgery

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