Valved conduit operation for aortic regurgitation associated with Behçet's disease

The surgical outcomes of aortic valve replacement in patients with aortic valve lesions caused by Behcet's disease: lessons we learned

Background

For Behcet’s disease patients with aortic root lesions, the disease often manifests as aortic valve regurgitation (AR). Following aortic valve replacement (AVR), many of these patients often suffer perivalvular leakage and valve dehiscence, requiring a second or third operation. In this study, we report the outcomes of 20 patients who underwent AVR to manage aortic root lesions caused by Behcet’s disease, and the lessons we learned.

Methods

From October 2013 to September 2019, a total of 50 patients with Behcet’s disease underwent AVR at our institution. Among them, isolated AVR was performed in 15 preoperatively undiagnosed cases. The other 5 patients were preoperatively diagnosed and underwent modified AVR. All patients were contacted for a follow-up. Valve function was evaluated using echocardiography.

Results

The 15 preoperatively undiagnosed patients [age: 38.4±12.6 years (range, 24–63 years); 9 males, 6 females] underwent isolated AVR as their primary procedure. Echocardiography revealed that valve dehiscence occurred in 13 (86.7%) patients postoperatively after a mean interval of 10.8±8.4 months. These patients accepted a second operation, and 1 of them accepted a third operation because of a pseudoaneurysm of the distal anastomosis site. For the other 5 patients [age: 38.8±9.5 years (range, 27–55 years); 4 males, 1 female] who underwent modified AVR, neither AR nor prosthetic valve detachment were observed during the echocardiography follow-up, and none required a secondary operation.

Conclusions

For behcet’s disease patients with AR, there was a high rate of valve dehiscence after isolated AVR. When compared with traditional AVR, we found that modified AVR was the optimal choice for patients who received standardized preoperative treatment.

Behcet's disease involved the root of aorta in the treatment with modified Bentall procedure: a case report

Background

Behcet’s disease (BD) is a multisystemic vasculitis of unknown etiology, the incidence of cardiovascular system involvement is rare, about1–5% (Sakane et al., N Engl J Med 341:1284–91, 1999). BD combined with aortic pseudoaneurysm and aortic valve regurgitation is usually need surgical treatment, but there is controversy about which surgical method to choose.

Case presentation

We report a case of BD combined with severe aortic valve regurgitation and two giant pseudoaneurysms of the aortic sinus. The patient underwent modified Bentall procedure (MBP) and use oral immunosuppressive as well as corticosteroid strictly, after 8 months follow-up, the patient recovered well.

Conclusion

For patient with aortic valve regurgitation and ascend aortic pseudoaneurysm caused by BD, we recommend modified Bentall procedure when rheumatism in a stable period. Corticosteroids and immunosuppressive drugs should be used before and after surgery.

Cardiac findings in patients with Behçet's disease: Facts and controversies

Behçet’s disease (BD) is a systemic vasculitis of unknown etiology. It is characterized by recurrent oral and genital ulcers, uveitis, and a number of systemic manifestations. Although the disease is recognized worldwide, its prevalence is highly variable. A detailed review and analysis of the worldwide published reports on BD showed that not only the prevalence of the disease but also its cardiac complications differ according to the geographic distribution of the studied population. With the exception of France, Greece, Spain, and Italy, very few reports and studies regarding BD have been published from the western countries. Cardiovascular complications are an important cause of poor outcome in patients with BD. Over the past few years, many case reports and studies have been published, providing more facts about these complications. For example, peculiar echocardiographic findings in patients with aortic valve regurgitation and intracardiac thrombi secondary to BD were recently described. The role of these findings in the initial diagnosis of the disease, however, remains to be evaluated. On the other hand, some reports present contradictory results, especially concerning the left ventricular diastolic function, pathogenesis of coronary artery disease, and proper management of the cardiac complications in BD. Importantly, management of these complications is based mainly on the discretion of the treating physician due to the absence of large controlled studies and clear guidelines. This approach sometimes creates inconsistent data and allows controversies to persist. The review presented here will discuss some of the facts and controversies related to cardiac complications in BD.

Valved Conduit Attached to Left Ventricular Outflow Tract for Valve Detachment in Behçet's Disease

Standard aortic valve replacement for aortic regurgitation caused by Behçet's disease is frequently complicated by postoperative recurrent prosthetic valve detachment. To prevent this, we have developed a modified Bentall procedure, in which the valved conduit is proximally attached to the left ventricular outflow tract instead of to the fragile annulus, based on the fact that the left ventricular outflow tract myocardium is rarely involved in Behçet's disease. This modified Bentall procedure was performed in 5 Behçet's disease patients with prosthetic valve detachment after primary aortic valve replacement, and satisfactory results were achieved.

Emergency Quadrido-Bentall Procedure for Aortic Rupture in a Patient with Behcet's Disease

Cardiovascular involvement in cases of Behcet's disease is a rare but life-threatening condition, and prosthetic valve detachment is a frequent and serious complication attributable to Behcet's disease following the surgical repair of aortic regurgitation. We report the case of a patient with Behcet's disease presenting with contained aortic rupture around the aortic root. The patient had previously undergone aortic valve surgery three times due to recurrent prosthetic valve detachment. An emergency operation was performed, consisting of aortic root replacement (ARR) using a composite valved conduit and the replacement of the hemiarch. ARR may be an appropriate surgical option for patients with Behcet's disease in order to prevent recurrence of the disease.

Aortic root replacement in Behçet disease

The patient presented with a history of recurrent aphthous stomatitis, genital ulceration, and a family history of positive for collagen disease. Echocardiography and retrograde aortography revealed aneurysm formation of the sinus of Valsalva, and dilatation of the aortic valve annulus with severe aortic regurgitation. On diagnosis of an aneurysm of the sinus of Valsalva and aortic regurgitation associated with Behçet's disease, aortic root replacement with the modified Bentall technique was successfully performed.

Recurrent valvular replacement due to exacerbation of Behcet's disease by Streptococcus agalactiae infection

Valvular heart complications in Behcet's disease are rarely reported. Moreover, the risk of dehiscence in postoperative valvular replacement is high in Behcet's disease. We report a case of recurrent aortic prosthetic dehiscence revealing Behcet's disease in a young woman. Each disease exacerbation was concomitant to a Streptococcus agalactiae infection. This infection appears to act as a trigger for Behcet's disease exacerbation. The patient was successfully treated with immunosuppression plus antibiotic therapy.