Symptomatic congenital aortic stenosis in the first year of life

A soft robotic sleeve mimicking the haemodynamics and biomechanics of left ventricular pressure overload and aortic stenosis

Preclinical models of aortic stenosis can induce left ventricular pressure overload and coarsely control the severity of aortic constriction. However, they do not recapitulate the haemodynamics and flow patterns associated with the disease. Here we report the development of a customizable soft robotic aortic sleeve that can mimic the haemodynamics and biomechanics of aortic stenosis. By allowing for the adjustment of actuation patterns and blood-flow dynamics, the robotic sleeve recapitulates clinically relevant haemodynamics in a porcine model of aortic stenosis, as we show via in vivo echocardiography and catheterization studies, and a combination of in vitro and computational analyses. Using in vivo and in vitro magnetic resonance imaging, we also quantified the four-dimensional blood-flow velocity profiles associated with the disease and with bicommissural and unicommissural defects re-created by the robotic sleeve. The design of the sleeve, which can be adjusted on the basis of computed tomography data, allows for the design of patient-specific devices that may guide clinical decisions and improve the management and treatment of patients with aortic stenosis.

Unicuspid aortic valve: a rare congenital anomaly

Unicuspid aortic valve (UAV) is a rare congenital aortic valve anomaly. It has two subtypes and often is associated with aortic valve dysfunction and corresponding clinical presentations. Echocardiography is the first choice of diagnostic method for UAV. Three-dimensional echocardiography has played an increasingly important role in diagnosis, intraprocedural guidance, and post-procedural assessment in recent years. There remain challenges in distinguishing UAV from bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV). Misdiagnosis is most resulted from raphes or leaflet calcifications. Multi-modality imaging has obvious advantages over single-modality imaging and is crucial for UAV diagnosis. Accurate identification of aortic valve morphology is important to choose the best treatment. Aortic balloon valvoplasty, surgical valvotomy, commissurotomy, Ross procedure, surgical valve repair and surgical replacement are most common treatment modalities of UAV. In this review, we aim to discuss UAV including epidemiology, definition, classification, diagnostic importance and necessity, valvular function, clinical presentation, associated disorders, non-invasive diagnostic modalities and therapeutic approaches.

Transcatheter aortic valve replacement in unicuspid aortic valve stenosis

Unicuspid aortic valve (UAV) offers unique challenges to transcatheter aortic valve replacement (TAVR), due to asymmetric expansion and apposition of the prosthesis during implantation. Although TAVR in bicuspid is now a well described experience, TAVR in unicuspid valve has not yet been described. A challenging case is described with TAVR in UAV using a Edwards Sapiens prosthesis via transapical approach. © 2016 Wiley Periodicals, Inc.

A Case of Severe Unicuspid Aortic Valve Stenosis: Valve Repair With Tricuspidization in an Adult

A 33-year-old male was referred to our institute with acute heart failure. The patient was found to have a unicuspid aortic valve (UAV) and severe aortic stenosis. He had been followed at a local university hospital during childhood. However, he stopped visiting the outpatient clinic after becoming an adult. His condition subsequently worsened, and he ultimately presented to our hospital with cardiogenic shock. In Japan, some adult congenital heart disease (ACHD) patients continue to be followed by pediatric cardiologists, though the patterns of practice are variable. This report describes the case of a patient who became lost to follow-up in early adulthood. We thus focus on this ACHD case as an example of the effects of inadequate communication among doctors and the need to establish better ACHD management protocols for treating this patient population.

An Adult Case of Unicommissural Unicuspid Aortic Valve Diagnosed Based on the Intraoperative Findings

We herein report an adult case of unicommissural unicuspid aortic valve (UAV). A 59-year-old man, who was noted to have a cardiac murmur at 31 years of age, was admitted to our hospital due to acute heart failure. Severe calcification in the aortic valve with severe low-flow/low-gradient aortic stenosis and moderate aortic regurgitation was observed and thought to be the cause of heart failure, however, the etiology of aortic valve dysfunction was not clear. Aortic valve replacement was subsequently performed, and unicommissural UAV was diagnosed according to the intraoperative findings. UAV is very rare congenital aortic valve disease which is rarely diagnosed preoperatively.

Symptomatic unicuspid aortic valve

A 22-year-old man with typical angina was seeking medical attention at primary health clinics for a couple of months. Owing to his young age and the absence of coronary artery disease risk factors, he was assured of no serious problem. Proper examination at a referral centre revealed weak peripheral pulses with diminished and delayed carotid upstroke. A normal S1 with a soft S2 were audible. A 3/6 late peaking systolic murmur was best heard in the aortic area radiating to the neck. Symptomatic bicuspid aortic valve disease was suspected. Diagnosis of unicuspid aortic valve was established by transoesophageal and three-dimensional echocardiography. The valve was successfully replaced with a mechanical prosthesis. The patient remains asymptomatic at 1 year follow-up.

Unicuspid unicommissural aortic valve: an extremely rare congenital anomaly

Unicuspid aortic valve is a rare congenital malformation that usually presents in the 3rd to 5th decade of life-and usually with severe aortic stenosis or regurgitation. It often requires surgical correction. Diagnosis can be made with 2- or 3-dimensional transthoracic or transesophageal echocardiography, cardiac computed tomography, or cardiac magnetic resonance imaging. We report the case of a 31-year-old man who presented with dyspnea on exertion due to severe aortic stenosis secondary to a unicuspid unicommissural aortic valve. After aortic valve replacement, this patient experienced complete heart block that required the placement of a permanent pacemaker.

Aortic valve function after bicuspidization of the unicuspid aortic valve

BACKGROUND

Unicuspid aortic valve (UAV) anatomy leads to dysfunction of the valve in young individuals. We introduced a reconstructive technique of bicuspidizing the UAV. Initially we copied the typical asymmetry of a normal bicuspid aortic valve (BAV) (I), later we created a symmetric BAV (II). This study compared the hemodynamic function of the two designs of a bicuspidized UAV.

METHODS

Aortic valve function was studied at rest and during exercise in 28 patients after repair of UAV (group I, n = 8; group II, n = 20). There were no differences among the groups I and II with respect to gender, age, body size, or weight. All patients were in New York Heart Association class I. Six healthy adults served as control individuals. All patients were studied with transthoracic echocardiography between 4 and 65 months postoperatively. Systolic gradients were assessed by continuous wave Doppler while patients were at rest and exercising on a bicycle ergometer.

RESULTS

Aortic regurgitation was grade I or less in all patients. Resting gradients were significantly elevated in group I compared with group II and control individuals (group I, peak 33.8 ± 7.8 mm Hg; mean 19.1 ± 5.4 mm Hg; group II, peak 15.8 ± 5.4, mean 8.2 ± 2.8 mm Hg; control individuals, peak 6.0 ± 1.6, mean 3.2 ± 0.8 mm Hg; p < 0.001). At 100 W peak gradients were highest in group I (group I, 62.7 ± 16.7 mm Hg; group II, 28.1 ± 7.6 mm Hg; control individuals, 15.4 ± 4.6 mm Hg; p < 0.001).

CONCLUSIONS

Converting a UAV into a symmetric bicuspid design results in adequate valve competence. A symmetric repair design leads to improved systolic aortic valve function at rest and during exercise.

Bicuspid aortic valve disease and ascending aortic aneurysms: gaps in knowledge

The bicuspid aortic valve is the most common congenital cardiac anomaly in developed nations. The abnormal bicuspid morphology of the aortic valve results in valvular dysfunction and subsequent hemodynamic derangements. However, the clinical presentation of bicuspid aortic valve disease remains quite heterogeneous with patients presenting from infancy to late adulthood with variable degrees of valvular stenosis and insufficiency and associated abnormalities including aortic coarctation, hypoplastic left heart structures, and ascending aortic dilatation. Emerging evidence suggests that the heterogeneous presentation of bicuspid aortic valve phenotypes may be a more complex matter related to congenital, genetic, and/or connective tissue abnormalities. Optimal management of patients with BAV disease and associated ascending aortic aneurysms often requires a thoughtful approach, carefully assessing various risk factors of the aortic valve and the aorta and discerning individual indications for ongoing surveillance, medical management, and operative intervention. We review current concepts of anatomic classification, pathophysiology, natural history, and clinical management of bicuspid aortic valve disease with associated ascending aortic aneurysms.

Incidental diagnosis of the unicuspid aortic valve with ascending aortic aneurysm in an asymptomatic adult

The unicuspid aortic valve is an extremely rare congenital anomaly. It usually presents with aortic stenosis and/or aortic regurgitation. Other cardiovascular complications, such as aortic dilatation and left ventricular hypertrophy can accompany it. Herein, we present a case report of a 50-year-old asymptomatic male patient with unicuspid aortic valve, complicated by ascending aortic aneurysm.

Bicuspid aortic valve disease

Bicuspid aortic valve (BAV) disease is the most common congenital cardiac defect. While the BAV can be found in isolation, it is often associated with other congenital cardiac lesions. The most frequent associated finding is dilation of the proximal ascending aorta secondary to abnormalities of the aortic media. Changes in the aortic media are present independent of whether the valve is functionally normal, stenotic, or incompetent. Although symptoms often manifest in adulthood, there is a wide spectrum of presentations ranging from severe disease detected in utero to asymptomatic disease in old age. Complications can include aortic valve stenosis or incompetence, endocarditis, aortic aneurysm formation, and aortic dissection. Despite the potential complications, 2 large contemporary series have demonstrated that life expectancy in adults with BAV disease is not shortened when compared with the general population. Because BAV is a disease of both the valve and the aorta, surgical decision making is more complicated, and many undergoing aortic valve replacement will also need aortic root surgery. With or without surgery, patients with BAV require continued surveillance. Recent studies have improved our understanding of the genetics, the pathobiology, and the clinical course of the disease, but questions are still unanswered. In the future, medical treatment strategies and timing of interventions will likely be refined. This review summarizes our current understanding of the pathology, genetics, and clinical aspects of BAV disease with a focus on BAV disease in adulthood.

Computed tomography and magnetic resonance imaging of patients with valvular heart disease

Although computed tomographic (CT) and magnetic resonance (MR) evaluation of patients with valvular heart disease is almost never performed as a first line of diagnostic intervention, their performance does provide important morphologic and physiologic information concerning the etiology and the current status of the valvular dysfunction. Evaluation of chamber and great artery size as well as ventricular wall thickness provide the basis for diagnosing and analyzing severity of valvular heart disease. Furthermore, additional findings, including calcification and evidence of interstitial pulmonary edema, increase diagnostic sensitivity and confidence in diagnosis. MR examination has the advantage over CT of providing direct demonstration of the signal void jets of dysfunctional valves, as well as a means of quantitating regional and global ventricular function and severity of valvular pressure gradients.

Transventricular balloon catheter aortic valvotomy in neonates

Surgical intervention for critical aortic stenosis in neonates is associated with an appreciable risk. Refinements in the technique of aortic valvotomy have been developed in an attempt to lower the operative mortality. This case report summarizes our experience with transventricular balloon dilation of critical aortic stenosis in 2 neonates. Both patients survived operation with objective evidence of hemodynamic improvement.

Congenital aortic stenosis secondary to dysplasia of congenital bicuspid aortic valves without commissural fusion

The hearts of nine children with clinical evidence of congenital valve stenosis and a congenital bicuspid aortic valve were reviewed. Aortic stenosis was diagnosed on the basis of cardiac catheterization data in four patients, operative findings in two and auscultatory findings in three. The patients were 1 month to 9 years old; six were male and three female. In each patient the two commissures of the valve were free to the aortic wall. The cusps were thickened, rolled and redundant; microscopic studies revealed that they consisted of immature loose connective tissue consistent with a dysplastic or incompletely differentiated valve. The valve orifice was obstructed by the dysplastic cusps, and dysplastic changes rather than the commissural fusion were responsible for the observed aortic stenosis. These valves do not appear amenable to valvotomy because obstruction is due to the abnormal valve tissue. These findings may explain the occasional poor results of valvotomy in infants and children with congenital aortic valve stenosis.

Congenital aortic stenosis resulting from a unicommisssural valve. Clinical and anatomic features in twenty-one adult patients

Clinical, electrocardiographic, phonocardiographic, radiographic, hemodynamic, and anatomic findings are presented in 21 adult patients with stenotic unicommissural aortic valves. Distinction between congenitally unicuspid and bicuspid aortic valves before operation or autopsy was not possible. Although the basic structure of the valve may render it inherently stenotic, the age at which a murmur was first noted (average, 19 years), the duration of a known murmur (average, 25 years), and the age of onset of first symptoms of left ventricular outflow obstruction (average, 41 years) strongly suggest that stenosis at least in part is acquired. The relationship of the true and false commissures to the coronary arterial ostia could be determined with certainty in 12 patients. The basic division of the aortic valve into left, right, and noncoronary cusps is maintained, but the raphes do not extend to the valve orifice. Because the aortic valve is attached to the ascending aorta at only one point (the true commissure), which is at the level of the orifice, valvotomy is hazardous, and valve replacement appears indicated when operative treatment becomes necessary in the adult patient with a stenotic unicommissural aortic valve.