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ORIGINAL ARTICLE

Aortic valve insufficiency in chronic aortic dissection

Ricardo BeyrutiI; Noedir A. G StolfII; Luiz Felipe P MoreiraII; Paulo M Pêgo-FernandesII; Charles MadyII; Adib D JateneII

DOI: 10.1590/S0102-76381993000200005

ABSTRACT

From January 1980 to December 1989, 48 consecutive patients with chronic aortic dissection and aortic valve insufficiency underwent operation. They were analyzed in 2 groups (24 patients each) to evaluate the late clinical and echocardiography outcome of those in whom the aortic valve was preserved (Group A) compared with those having valve replacement (Group B). The overall preoperative characteristics of the two groups were similar except for the age (Group A 47.9 ± 10.8 versus Group B 40.2 ± 9.5 years, p=0.03). In the preoperative echocardiographic evaluation, Group B patients had significantly higher aortic root and left ventricle systolic and diastolic diameters (p<0.03), and aortic insufficiency grade (p=0.02). The hospital mortality was 12.5% in Group A and 4.2% in Group B and the seven years actuarial survival rate was respectively 75.7% ± 9.8% and 82.7% ± 7.9%. Postoperatively there was, in both groups, a significant improvement in all clinical parameters evaluated (dyspnea, chest pain, arterial hypertension, aortic insufficiency murmurs (p<0.001). There was also a marked reduction in the aortic root and left ventricle diameters in all patients compared to preoperative values (p<0.05) without statistical difference between the groups. Echocardiographic mild aortic insufficiency remained in 20% of the patients in whom the valve was preserved, without long term hemodynamic or clinical repercussion. Hence, we conclude that aortic insufficiency in chronic dissection can be equally treated with both techniques. Aortic valve preservation should, whenever possible, be attempted and considered as the procedure of choice.

RESUMO

Com o objetivo de avaliar os resultados clínicos e ecocardiográficos tardios obtidos com a correção da insuficiência aórtica decorrente da dissecção crônica da aorta proximal, foram estudados 48 pacientes consecutivos operados entre janeiro de 1980 e dezembro de 1989, separados em 2 grupos de 24 pacientes cada. Grupo A - pacientes nos quais a valva aórtica foi preservada pela "resuspensão comissural"; Grupo B - pacientes nos quais a valva aórtica foi substituída. Na avaliação ecocardiográfica pré-operatória, os pacientes do Grupo B apresentavam grau de insuficiência aórtica, diâmetros ventriculares (sistólico e diastólico) e da aorta ascendente significativamente maiores do que os do Grupo A (p=0,03), sendo comparáveis nos demais parâmetros. A mortalidade hospitalar foi 12,5% no Grupo A e de 4,17% no Grupo B e a sobrevida aos 7 anos, respectivamente, 75,75% ± 9,82% e 82,72% ± 7,87% (NS). A avaliação clínica mostrou que, no pós-operatório, houve melhora significativa (p<0,001) e semelhante dos parâmetros nos dois grupos. A comparação ecocardiográfica pré e pós-operatória tardia mostrou, da mesma forma, redução importante dos diâmetros sistólico e diastólico do ventrículo esquerdo e no diâmetro da aorta (p<0,05), mantendo-se inalteradas as frações de encurtamento e de ejeção ventriculares nos pacientes dos dois grupos. Nos pacientes do Grupo A, entretanto, houve persistência de insuficiência aórtica residual (p=0,03). Os autores concluem que, com as duas técnicas empregadas, o tratamento cirúrgico da dissecção da aorta ascendente com insuficiência aórtica associada permite sobrevida imediata e tardia satisfatórias e nítida melhora funcional. Nos pacientes do Grupo A, a insuficiência aórtica residual detectada à ecocardiografia não produziu sintomas ou repercussão hemodinâmica tardios e, desta forma, preconizam a preservação da valva, sempre que tecnicamente possível.
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REFERENCES

1. ANAGNOSTOPOULOS, C. E.; PRABHAKAR, M. J. S.; KITTLE, C. F. - Aortic dissections and dissecting aneurysms. Am. J. Cardiol., 30: 263-273, 1972. [MedLine]

2. APPELBAUM, A.; KARP, R. B.; KIRKLIN, J. W. - Ascending vs. descending aortic dissections. Ann. Surg., 183: 296-300, 1976. [MedLine]

3. AUSTEN, W. G.; BUCKLEY, M. J.; MCFARLAND, J.; DESANCTIS, R. W.; SANDERS, C. A. - Therapy of dissecting aneurysms. Arch. Surg., 95: 835-842, 1967. [MedLine]

4. BACHET, J.; GIGOU, F.; LAURIAN, C.; BICAL, O.; GOUDOT, B.; GUILMET, D. - Four-year clinical experience with the Gelatin - Resorcine-Formol biological glue in acute aortic dissection. J. Thorac. Cardiovasc. Surg., 83: 212-217, 1982. [MedLine]

5. BECKWITH, J. R.; MULLER, W. H.; WARREN, D.; WOOD, J. E. - Acute dissecting aneurysm of the aorta. Arch. Intern. Med., 104: 217-225, 1959.

6. BENTALL, H. & DE BONO, A. - A technique for complete replacement ofthe ascending aorta. Thorax, 33: 338-339, 1968.

7. DAILY, P. O.; TRUEBLOOD, H. W.; STINSON, E. B.; WUERFLEIN, R. D.; SHUMWAY, N. E. - Management of acute aortic dissections. Ann. Thorac. Surg., 10: 237-247, 1970. [MedLine]

8. DEBAKEY, M. E.; COOLEY, D. A.; CREECH Jr., O. - Surgical considerations of dissecting aneurysm of the aorta. Ann. Surg., 142: 586-612, 1955.

9. DEBAKEY, M. E.; HENLY, W. S.; COOLEY, D. A.; MORRIS Jr., G. C.; CRAWFORD, E. S.; BEALL Jr., A. C. - Surgical management of dissecting aneurysm involving the ascending aorta. J. Cardiovasc. Surg., 5: 200-211, 1964.

10. DEBAKEY, M. E.; HENLY, W. S.; COOLEY, D. A.; MORRIS Jr., G. C.; CRAWFORD, E. S.; BEALL Jr., A. C. - Surgical management of dissecting aneurysms of the aorta. J. Thorac. Cardiovasc. Surg., 49: 130-149, 1965. [MedLine]

11. DEBAKEY, M. E.; MCCOLLUM, C. H.; CRAWFORD, E. S.; MORRIS Jr., G. C.; HOWELL, J.; NOON, G. P.; LAWRIE, G. - Dissection and dissecting aneurysms of the aorta: twenty-year follow-up of five hundred twenty-seven patients treated surgically. Surgery, 92: 1118-1143, 1982.

12. DOROGHAZI, R. M. & SLATER, E. E. - Aortic dissection. New York, McGraw-Hill Book Company, 1983.

13. DOROGHAZI, R. M.; SLATER, E. E.; DESANCTIS, R. W.; BUCKLEY, M. J. - Long-term survival of patients with treated aortic dissection. J. Am. Coll. Cardiol., 3: 1026-1034, 1984. [MedLine]

14. GREY, D. P.; OTT, D. A.; COOLEY, D. A. - Surgical treatment of aneurysm of the ascending aorta with aortic insufficiency: a selective approach. J. Thorac. Cardiovasc. Surg., 86: 864-877, 1983. [MedLine]

15. HAVERICH, A.; MILLER, D. C.; SCOTT, W. C.; MITCHELL, R. S.; OYER, P. E. - Acute and chronic aortic dissections: determinants of long-term outcome for operative survivors. Circulation, 72 (Supl 2): 22-34, 1985.

16. HIRST Jr., A. E.; JOHNS Jr., J. V.; KIME Jr., S. W. - Dissecting aneurysm of the aorta: a review of 505 cases. Medicine (Baltimore), 37: 217-279, 1958. [MedLine]

17. HUME, D. C. & PORTER, R. R. - Acute dissecting aneurysms. Surgery, 53: 122-154, 1963. [MedLine]

18. JEX, R. K.; SCHAFF, H. V.; PIEHLER, J. M.; ORSZULAK, T. A.; PUGA, F. J. - Repair of ascending aortic dissection: influence of associated aortic valve insufficiency on early and late results. J. Thorac. Cardiovasc., 93: 375-384, 1987.

19. KIRKLIN, J. W. & BARRAT-BOYES, B. G. - Cardiac surgery. New York, John Wiley and Sons, 1986. p. 1471-1525.

20. KOSTER, J. K.; COHN, L. H.; MEE, R. B. B.; COLLINS Jr., J. J. - Late results of operation for acute aortic dissection producing aortic insufficiency. Ann. Thorac. Surg., 26: 461-467, 1978. [MedLine]

21. KOUCHOUKOS, N. T.; MARSHALL Jr., W. G.;WEDIGE-STECHER, T. A. - Eleven-year experience with composite graft replacement of the ascending aorta and aortic valve. J. Thorac. Cardiovasc. Surg., 92: 691-705, 1986. [MedLine]

22. KRAMER, M. S. - Clinical epidemiology and biostatistics: a primer for clinical investigators and decision makers. Berlin, Sringer-Verlag, 1988. 286 p.

23. LARSON, E. W. & EDWARDS, W. D. - Risk factors for aortic dissection: a necropsy study of 161 cases. Am. J. Cardiol., 53: 849-855, 1984. [MedLine]

24. LEU, H. J. & JULKE, M. - Thoracic aortic aneurysm: pathologico-anatomical analysis of 111 cases. Schweiz. Med. Wochenschr., 114: 593-595, 1984.

25. McCREADY, R. A. & PLUTH, J. R. - Surgical treatment of ascending aortic aneurysms associated with aortic valve insufficiency. Ann. Thorac, 28: 206-216, 1979.

26. MENG, R. L.; NAJAFI, H.; JAVID, H.; HUNTER, J. A.; GOLDIN, M. D. - Acute ascending aortic dissection: surgical management. Circulation, 64 (Supl. 2): 231-234, 1981.

27. MILLER, D. C.; STINSON, E. B.; OYER, P. E.; ROSSITER, S. J.; REITZ, B. A. - Operative treatment of aortic dissections: experience with 125 patients over a sixteen-year period. J. Thorac. cardiovasc. Surg., 78: 356-382, 1979.

28. MOREIRA, L. F. P.; STOLF, N. A. G.; VIANNA, C. B. - Fatores de risco na cirurgia de dissecções da aorta ascendente e arco aórtico. Rev. Bras. Circardiovasc., 2: 121-128, 1987.

30. PÊGO-FERNANDES, P. M.; STOLF, N. A. G.; MOREIRA, L. F. P.; BARRETO, A. C. P.; BITTENCOURT, D.; JATENE, A. D. - Management of aortic insufficiency in chronic aortic dissection. Ann. Thorac. Surg., 51: 438-442, 1991. [MedLine]

31. RAUDKIVI, P. J.; WILLIAMS, J. D.; MONRO, J. L.; ROSS, J. K. - Surgical treatment of the ascending aorta: fourteen years experience with 83 patients. J. Thorac. Cardiovasc. Surg., 98 (Parte 1): 675-682, 1989. [MedLine]

32. REUL Jr., G. J.; COOLEY, D. A.; HALLMAN, G. L; REDDY, S. B.; KYGER III, E. R.; WUKASCH, D. C. - Dissecting aneurysm of the descending aorta. Arch. Surg., 110: 632-640, 1975. [MedLine]

34. STOLF, N. A.; PÊGO-FERNANDES, P.; COSTA, R.; BARRETO, A. C. - Tratamento cirúrgico das dissecções crónicas da aorta torácica. Rev. Hosp. Clin. Fac. Med. São Paulo., 38: 3-7, 1983.

35. STRONG, W. W.; MOGGIO, R. A.; STANSEL Jr., H. G. - Acute aortic dissection: twelve-year medical and surgical experience. J. Thorac. Cardiovasc. Surg., 69: 815-821, 1974.

36. SYMBAS, P. N.; RAIZNER, A. E.; TYRAS, D. H.; HATCHER Jr., C. R.; INGLESBY, T. V.; BALDWIN, B. J. - Aneurysms of all sinuses of Valsava in patients with Marfan's syndrome: an unusual late complication following replacement of aortic valve and ascending aorta for aortic regurgitation and fusiform aneurysm of ascending aorta. Ann. Surg., 174: 902-907, 1971. [MedLine]

37. VILJANEN, T.; LANDTMAN, M.; LUOSTO, R. - Late results of the surgical treatment for aortic dissections. Thorac. Cardiovasc. Surg., 33: 8-15, 1985. [MedLine]

38. WEBB, W. R.; ECKER, R. R.; HOLLAND, R. H.; SUGG, W. L. - Aortic aneurysm with aortic insufficiency. Am. J. Cardiol., 26: 416-418, 1970. [MedLine]

39. WHEAT Jr., M. W.; HARRIS, P. D.; MALM, J. R.; KAISER, G.; BOWMAN Jr., F. O.; PALMER, R. F. - Acute dissecting aneurysms of the aorta: treatment and results in 64 patients. J. Thorac. Cardiovasc. Surg., 58: 344-351, 1969. [MedLine]

40. WHEAT Jr., M. W.; PALMER, R. F.; BARTLEY, T. D.; SEELMAN, R. C. - Treatment of dissecting aneurysms of the aorta without surgery. J. Thorac. Cardiovasc. Surg., 50: 364-373, 1965. [MedLine]

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