Long-term Outcomes After Surgical Intervention for Congenital Supravalvar Aortic Stenosis in Children

BACKGROUND

Primary supravalvar aortic stenosis (SVAS) is a rare congenital cardiovascular condition that can coexist with Williams-Beuren syndrome, coronary artery involvement, aortic coarctation, and pulmonary artery stenosis. SVAS repair can be achieved with low perioperative mortality, but long-term survival remains less well understood. We used the Pediatric Cardiac Care Consortium, a multicenter United States-based registry for pediatric cardiac operations, to assess long-term outcomes after SVAS repair.

METHODS

We used Kaplan-Meier plots and Cox proportional hazards regression to examine factors associated with postdischarge deaths. These included sex, age-group, weight z-score, coexisting conditions (Williams-Beuren syndrome, coronary artery involvement, coarctation, and pulmonary artery stenosis), surgical techniques, and era, defined as early (1982-1995) or late (1996-2003). Survival was assessed by matching with the National Death Index through 2021.

RESULTS

Of 333 patients who met inclusion criteria, 313 (94.0%) survived to discharge and 188 (60.1%) had identifiers for National Death Index matching. Over a median follow-up of 25.2 years (interquartile range, 21.1-29.4 years), 17 deaths occurred. The 30-year survival after discharge from SVAS repair was 88.7% (95% CI, 82.9%-94.8%). Infantile surgery and non-Williams-Beuren syndrome were associated with decreased 30-year survival. From the various repairs, the 2-sinus technique had better outcomes compared with all other types, except the 3-sinus technique (nonsignificant difference). Adjusted analysis revealed infantile age and type of repair as associated with postdischarge probability of death.

CONCLUSIONS

These data demonstrate favorable long-term outcomes after SVAS repair, except for the infantile group that was associated with more diffuse arteriopathy. As techniques continue to evolve, future studies are warranted to investigate their long-term outcomes.

Diagnosis of membranous supravalvular aortic stenosis with severe aortic valve insufficiency

Although the clinical manifestations of membranous supravalvular aortic stenosis (SVAS) are distinctive, its diagnosis remains challenging. Failure to initiate surgical treatment in a timely manner greatly increases the risk of sudden cardiac death. We report a case of membranous SVAS, detailing the clinical presentation and imaging manifestations.

Matrisome and Immune Pathways Contribute to Extreme Vascular Outcomes in Williams-Beuren Syndrome

BACKGROUND

Supravalvar aortic stenosis (SVAS) is a characteristic feature of Williams-Beuren syndrome (WBS). Its severity varies: ~20% of people with Williams-Beuren syndrome have SVAS requiring surgical intervention, whereas ~35% have no appreciable SVAS. The remaining individuals have SVAS of intermediate severity. Little is known about genetic modifiers that contribute to this variability.

METHODS AND RESULTS

We performed genome sequencing on 473 individuals with Williams-Beuren syndrome and developed strategies for modifier discovery in this rare disease population. Approaches include extreme phenotyping and nonsynonymous variant prioritization, followed by gene set enrichment and pathway-level association tests. We next used GTEx v8 and proteomic data sets to verify expression of candidate modifiers in relevant tissues. Finally, we evaluated overlap between the genes/pathways identified here and those ascertained through larger aortic disease/trait genome-wide association studies. We show that SVAS severity in Williams-Beuren syndrome is associated with increased frequency of common and rarer variants in matrisome and immune pathways. Two implicated matrisome genes (ACAN and LTBP4) were uniquely expressed in the aorta. Many genes in the identified pathways were previously reported in genome-wide association studies for aneurysm, bicuspid aortic valve, or aortic size.

CONCLUSIONS

Smaller sample sizes in rare disease studies necessitate new approaches to detect modifiers. Our strategies identified variation in matrisome and immune pathways that are associated with SVAS severity. These findings suggest that, like other aortopathies, SVAS may be influenced by the balance of synthesis and degradation of matrisome proteins. Leveraging multiomic data and results from larger aorta-focused genome-wide association studies may accelerate modifier discovery for rare aortopathies like SVAS.

Long-term surgical outcomes of congenital supravalvular aortic stenosis: a systematic review, meta-analysis and microsimulation study

OBJECTIVES

Congenital supravalvular aortic stenosis (SVAS) is a rare form of congenital outflow tract obstruction and long-term outcomes are scarcely reported. This study aims to provide an overview of outcomes after surgical repair for congenital SVAS.

METHODS

A systematic review of published literature was conducted, including observational studies reporting long-term clinical outcome (>2 years) after SVAS repair in children or adults considering >20 patients. Early risks, late event rates and time-to-event data were pooled and entered into a microsimulation model to estimate 30-year outcomes. Life expectancy was compared to the age-, sex- and origin-matched general population.

RESULTS

Twenty-three publications were included, encompassing a total of 1472 patients (13 125 patient-years; pooled mean follow-up: 9.0 (6.2) years; median follow-up: 6.3 years). Pooled mean age at surgical repair was 4.7 (5.8) years and the most commonly used surgical technique was the single-patch repair (43.6%). Pooled early mortality was 4.2% (95% confidence interval: 3.2-5.5%) and late mortality was 0.61% (95% CI: 0.45-0.83) per patient-year. Based on microsimulation, over a 30-year time horizon, it was estimated that an average patient with SVAS repair (mean age: 4.7 years) had an observed life expectancy that was 90.7% (95% credible interval: 90.0-91.6%) of expected life expectancy in the matched general population. The microsimulation-based 30-year risk of myocardial infarction was 8.1% (95% credible interval: 7.3-9.9%) and reintervention 31.3% (95% credible interval: 29.6-33.4%), of which 27.2% (95% credible interval: 25.8-29.1) due to repair dysfunction.

CONCLUSIONS

After surgical repair for SVAS, 30-year survival is lower than the matched-general-population survival and the lifetime risk of reintervention is considerable. Therefore, lifelong monitoring of the cardiovascular system and in particular residual stenosis and coronary obstruction is recommended.

Influence of Surgical Methods on Hemodynamics in Supravalvular Aortic Stenosis: A Computational Hemodynamic Analysis

We compared differences in the hemodynamic parameters of multiple surgical techniques for supravalvular aortic stenosis (SVAS). A three-dimensional model was reconstructed based on a patient's CT scan. Virtual McGoon, Doty, and Brom repairs were completed using computer-aided design (CAD). Hemodynamic parameters were calculated through computational fluid dynamics (CFD). The velocity profile and wall shear stress (WSS) showed the blood flow pattern. Energy loss (EL) and energy efficiency (EE) were calculated to estimate the cardiac workload. The perioperative blood flow ratio (BFR) of brachiocephalic vessels and coronary arteries was calculated. The preoperative flow velocity was abnormally high (> 5.0 m/s). High WSS was detected at the sinotubular junction (STJ), and its preoperative distribution in the aorta was uneven. High-speed flow disappeared after each of the three operations. The WSS distribution at the aortic root was consistent with the postoperative STJ structure of each operation. EL in the systolic phase decreased postoperatively (Original: 634 mW, McGoon: 218 mW, Doty: 278 mW, Brom: 255 mW). No significant difference in brachiocephalic BFR was detected among the different techniques. A slightly increased coronary BFR (Original: 7.56%, McGoon: 7.99%, Doty: 8.55%, Brom: 8.89%) was detected. McGoon, Doty, and Brom repair each effectively restored stable blood flow and greatly improved EE. The best WSS distribution and coronary blood supply were achieved after Brom repair due to its ability to reconstruct the symmetrical aortic root structure. CFD combined with a virtual operation is a promising method in surgical planning and optimization for SVAS.

Avoidance of malignant arrhythmia caused by displacement of the right coronary artery ostium in surgical correction of supravalvular aortic stenosis

Objective

This study was performed to identify the effects of different surgical approaches on the right coronary artery ostium in patients with congenital supravalvular aortic stenosis (SVAS) and to determine how to avoid surgically induced right coronary artery occlusion.

Methods

The surgical techniques and outcomes of 91 patients who underwent surgical treatment of SVAS from 2008 to 2015 in our institution were retrospectively reviewed to identify the causes of early death, reoperation, and extracorporeal membrane oxygenation (ECMO) support.

Results

Four perioperative deaths (Doty’s technique, n = 4), six cases of ECMO support (Doty’s technique, n = 4; Brom’s technique, n = 1; McGoon’s technique, n = 1), and eight reoperations (Doty’s technique, n = 5; Brom’s technique, n = 2; McGoon’s technique, n = 1) occurred. In cases of reoperation, adjustment of the shape and position of the right coronary sinus patch relieved the malignant arrhythmia.

Conclusion

Different surgical techniques have different effects on the right coronary artery. The shape of the patch inserted into the right coronary sinus should be carefully clipped to avoid distortion and ischemia of the right coronary artery.

Cardiac arrest related to anaesthesia in Williams-Beuren syndrome

Williams-Beuren syndrome is the clinical manifestation of a congenital genetic disorder in the elastin gene, among others. There is a history of cardiac arrest refractory to resuscitation manoeuvres in anaesthesia. The incidence of myocardial ischaemia is high during anaesthetic induction, but there are patients who do not have this condition yet also have had very serious cardiac events, and issues that are still to be resolved. Case descriptions will enable the common pathophysiological factors to be defined, and decrease morbidity and mortality. We report the case of a 3-year-old boy with cardiac arrest at induction, rescued with circulatory assistance with extracorporeal membrane oxygenation and hypothermia induced for cerebral protection.

Surgical Correction of Supravalvar Aortic Stenosis: 52 Years' Experience

OBJECTIVES

Supravalvar aortic stenosis (SVAS) is a rare congenital anomaly. The "single-patch technique," "'two sinus augmentation with an inverted Y-patch" (both nonsymmetrical corrections), "three-patch technique," and the "slide aortoplasty" (both symmetrical corrections) are the techniques implemented by the majority of surgeons for the correction of SVAS. In the few studies that compared these techniques, no technique was shown to be superior over another. The aim of the present study is to review the 52-year experience with the surgical correction of SVAS in two of four congenital cardiothoracic surgical centers in the Netherlands.

METHODS

We retrospectively reviewed all patient files of those who underwent an operation to correct their SVAS, between 1962 and 2014 in our centers. Patients were divided according to their operating technique. These groups were compared using the end points freedom from reoperation and mortality.

RESULTS

A total of 49 patients were included, 23 (46.9%) patients in the nonsymmetrical group and 26 (53.1%) patients in the symmetrical group. Survival after 20 years in the nonsymmetrical group was 80% (standard error [SE]: 0.091) and in the symmetrical group was 85% (SE: 0.085; P = .163). Freedom from reoperation after 20 years in the nonsymmetrical group was 88% (SE: 0.079) and in the symmetrical group was 71% (SE: 0.107; P = 0.313).

CONCLUSION

In this patient group, there is no significant difference in survival and freedom from reoperation between the different surgical techniques for SVAS repair. Compared to the survival in the general population, the survival of SVAS patients is remarkably low. Apparently, SVAS is not a benign disease and probably patients should be followed more closely for the rest of their lives.

Isolated Diffuse Supravalvular Aortic Stenosis with Severe Aortic Narrowing in a 41-Year-Old Man

Isolated supravalvular aortic stenosis in adults is a rare form of left ventricular outflow tract obstruction. We describe a case in a 41-year-old man in whom the supravalvular aorta had narrowed to approximately the size of the left anterior descending coronary artery. The patient underwent aortic surgery with replacement of the ascending aorta and repair of supravalvular aortic stenosis with a pantaloon graft. A postoperative echocardiogram showed substantial improvement: the mean gradient across the aorta had fallen from 48 to 8 mmHg. Surgery is the definitive treatment in symptomatic patients with supravalvular aortic stenosis.

Novel three-sinus enlargement technique for supravalvular aortic stenosis without aortic transection

BACKGROUND

Although repair of a supravalvular aortic stenosis (SVAS) can be performed with low mortality rates, surgery for the complex form of SVAS continues to be associated with a high incidence of residual stenosis.

CASE PRESENTATION

The patient was referred to our hospital at 1 month of age and was diagnosed with aortic valve stenosis (AS) by using echocardiography. Cardiac catheterization revealed moderate AS, and subsequent left ventriculography revealed discrete stenosis of the sino-tubular junction and a narrowed proximal ascending aorta. We performed a reconstructive operation for such heart defects involving novel three-sinus and ascending aorta enlargement without aortic root transection in a 6-month-old boy.

CONCLUSION

Our novel three-sinus enlargement technique is suitable for treating each type of SVAS and is a useful method for a baby particularly less than 10 kg without disturbing the growth of the ascending aorta.

Left coronary artery stenosis causing left ventricular dysfunction in two children with supravalvular aortic stenosis

Congenital supravalvar aortic stenosis (SVAS) is an arteriopathy associated with Williams-Beuren syndrome (WBS) and other isolated elastin gene deletions. Cardiovascular manifestations associated with WBS are characterized by obstructive arterial lesions such as SVAS and pulmonary artery stenosis in addition to bicuspid aortic valve and mitral valve prolapse. However, coronary artery ostial stenosis may be associated with SVAS, and it increases the risk of sudden death and may complicate surgical management. In this report, we present our experience with two patients having SVAS and left coronary artery ostial stenosis with associated left ventricular dysfunction.

Supravalvular aortic stenosis in adult with anomalies of aortic arch vessels and aortic regurgitation

The supravalvular aortic stenosis is a rare congenital heart defect being very uncommon in adults. We present a case of supravalvular aortic stenosis in adult associated with anomalies of the aortic arch vessels and aortic regurgitation, which was submitted to aortic valve replacement and arterioplasty of the ascending aorta with a good postoperative course.

Extended single-patch repair of supravalvar aortic stenosis: a simple and effective technique

BACKGROUND

The optimal surgical procedure for repair of supravalvar aortic stenosis (SVAS) remains uncertain. Proponents of multisinus repair techniques suggest improved outcomes compared with the single-patch technique. We evaluated the outcomes after an extended single-patch technique for relief of SVAS.

METHODS

A cross-sectional retrospective analysis was performed of all SVAS patients who underwent repair from 1996 to 2009. Patient, procedural, and hospital course data were obtained through a review of the medical records. At follow-up, patients were evaluated for residual SVAS gradient, valvar aortic stenosis, aortic insufficiency, and need for reintervention.

RESULTS

Twenty-two patients (mean age, 2.4 ± 2.4 years) underwent repair of SVAS (discrete form, 59%). Mean preoperative peak gradient was 77 ± 27 mm Hg (range, 20 to 139 mm Hg). There were no hospital deaths. Median postoperative length of stay was 5 days (range, 3 to 68 days). Mean follow-up was 4.1 ± 3.5 years (range, 0.7 to 13 years). Follow-up Doppler echocardiography revealed a peak left ventricular outflow tract gradient of 10 ± 12 mm Hg (range, 0 to 41 mm Hg). No patient had significant valvar aortic stenosis or insufficiency. Two patients (9%) required catheter-based reintervention that was unrelated to the SVAS repair.

CONCLUSIONS

This study demonstrates that a simple, extended single-patch technique for repair of SVAS provides excellent medium-term results. A durable reduction in gradient with low complication and recurrence rates can be achieved without the need for more complicated multisinus patch repairs.

Better late than never: diagnosis and successful treatment in late adulthood of supravalvular aortic stenosis secondary to Williams-Beuren syndrome

This is a case report of a patient diagnosed at age 50 with supravalvular aortic stenosis secondary to Williams-Beuren Syndrome and successfully treated with aortic valve replacement and excision of supravalvular tissue.

Supravalvar aortic stenosis in infancy

Supravalvar aortic stenosis (SVAS) is a rare anomaly of the aortic root caused by a genetically based deficiency in elastin production. Concomitant primary and secondary cardiovascular lesions complicate surgical management and impact early and late outcomes. Because SVAS is a rare lesion, surgical series are relatively small and span lengthy time periods. Consequently, risk factors that influence early and late outcomes are not well defined. Patients who come to surgery during infancy are particularly challenging, but little attention has been directed as to whether or not young age influences outcomes. This review suggests that complicating associated features of elastin arteriopathy are more prevalent in patients who require relief of SVAS during infancy, and that concomitant lesions significantly increase the difficulty and risk of treating younger patients with SVAS.

[Myers technique and patch enlargement of ascending aorta for diffuse supravalvular aortic stenosis]

A 6-year-old boy was diagnosed with aggravation of diffuse supravalvular aortic stenosis (SVAS). The pressure gradient between the sinus of Valsalva and ascending aorta was 48 mmHg. The diameter of the sino-tubular junction was 7 mm and the ascending aorta was hypoplastic. We performed Myers operation because 3 sinus reconstructions had resulted in superior hemodynamics and reductions in both mortality rate and need for reoperation. We avoided using autologous pericardium because of the possibility of shrinkage and aneurysm. We could easily perform patch enlargement of the ascending aorta by selective cerebral perfusion. The postoperative course was excellent and there was no SVAS or aortic regurgitation (AR). A catheterization showed the pressure gradient was 5 mmHg with trivial AR upon follow-up at 1 year.

Surgical management of supravalvular aortic stenosis: does Brom three-patch technique provide superior results?

BACKGROUND

Various surgical techniques have been proposed to repair supravalvular aortic stenosis. However, the optimal approach remains to be determined. The present study was undertaken to evaluate the results of surgery for supravalvular aortic stenosis and to compare the symmetric three-patch repair (Brom technique) with other surgical reconstructions.

METHODS

Between 1995 and 2007, 34 patients with supravalvular aortic stenosis underwent surgery. Fourteen patients (41%) had Williams syndrome. Supravalvular stenosis was discrete in 24 patients (71%) and diffuse in 10 (29%). Eight patients (23%) underwent one-patch repair; 3 patients (9%) had inverted bifurcated patch enlargement (Doty repair) and 23 patients (68%) had symmetric repair (Brom three-patch technique). Follow-up was complete and ranged from 6 months to 12 years (mean, 5.8 years).

RESULTS

There was one early and no late deaths. One patient (with one-patch repair) underwent reoperation for residual obstruction. At last follow-up, left ventricle to aorta peak gradient was 45 +/- 28 mm Hg after one-patch repair, 30 +/- 9 mm Hg after Doty operation, and 11 +/- 18 mm Hg after symmetric Brom procedure. Brom repair was associated with a low incidence of residual obstruction (peak gradient > or = 40 mm Hg) (2 of 22; 9.1%) and moderate aortic insufficiency (1 of 22; 4.5%).

CONCLUSIONS

Brom three-patch repair provides symmetric reconstruction of the aortic root in patients with supravalvular aortic stenosis. This may lead to improved midterm results in terms of relief of the obstruction and incidence of aortic insufficiency.

Discrete supravalvular aortic stenosis in children: Is it necessary to reconstruct the whole aortic root?

OBJECTIVE

Discrete supravalvular aortic stenosis (SAS) is known to involve the whole aortic root. Some surgeons have therefore changed their approach from relief of obstruction using a single-patch to symmetric reconstruction of the whole aortic root - three-patch technique. The advantages are said to be preserved long-term aortic valve function and allowance for growth. This is unproven. We compare growth and aortic root geometry in patients who have undergone relief of discrete SAS using either single-or three-patch technique.

METHODS

Twenty-five patients (14 male, 11 female, mean age of 11+/-4 years, range 4-18) underwent surgery for discrete SAS. No patients with diffuse SAS were included in this retrospective analysis. Twelve patients had features of Williams syndrome. Five patients had other concomitant procedures. A single-patch was inserted into the longitudinal incision, which passed across the stenosis into the non-coronary sinus in 14. A three-patch technique was used in 11 patients. Changes in aortic root following repair were documented in patients using both echocardiography and magnetic resonance imaging (MRI).

RESULTS

There were no operative deaths. The mean preoperative gradient was 66+/-17 mmHg (range 50-100 mmHg), which decreased to 14+/-7 mmHg (range 4-18 mmHg) early postoperatively. The late mean gradient was 15+/-5 mmHg. There was no significant difference in the incidence of postoperative aortic regurgitation or gradient across the repair between two techniques according to the echocardiograms and MRI findings.

CONCLUSION

According to our study, we cannot demonstrate any benefit in reconstructing the whole aortic root for discrete SAS. A single-patch technique is easy, safe and appears durable.

Supravalvular aortic membrane with severe aortic regurgitation: an unusual presentation in adults

Aortic stenosis due to supravalvular membrane usually presents in children. It may be associated with fusion of the left coronary leaflet and the supravalvular membrane, causing obstruction of the left coronary ostium, and resulting in myocardial ischemia. Despite the immobilization of the left coronary leaflet, these patients present in childhood with aortic stenosis and not regurgitation, with or without accompanying myocardial ischemia. The case is described of an adult patient with supravalvular aortic membrane presenting with severe aortic regurgitation and myocardial infarction due to fusion of the left coronary leaflet with the supravalvular membrane.

Surgical repair of supravalvular aortic stenosis with use of Brom's technique: short-term results in 9 children

There are few published reports of the results of supravalvular aortic stenosis correction with the use of Brom's 3-patch technique. Herein, we report our use of this procedure and the short-term results therefrom.From 2002 through 2007, 9 children underwent surgical correction of localized supravalvular aortic stenosis at our hospital. The patients ranged in age from 5 to 14 years, and 8 had Williams syndrome. All operations were performed by the same surgical team.No clinically significant associated cardiac anomalies were encountered. Each aortic repair involved the use of pericardium, Dacron, or both. One patient had an uncorrected right coronary artery obstruction and died postoperatively of refractory supraventricular tachycardia. In all 8 patients who survived, postoperative transaortic blood pressure gradients were improved (range, 0-16 mmHg), and no repeat operations were needed after 6 to 55 months' follow-up.We consider Brom's technique to be safe in the repair of supravalvular aortic stenosis. In our limited series, it produced effective anatomic restoration, with good short-term and potentially good long-term results.

Progressive discrete subaortic stenosis developed after successful primary repair of the supravalvular aortic stenosis in Williams syndrome

Discrete subaortic stenosis is a rare, late complication of the surgical repair of congenital heart defects. Secondary subaortic stenosis late after surgical repair of supravalvular aortic stenosis in Williams syndrome has not previously been described. A 20 year-old female patient with Williams syndrome became symptomatic eight years after subaortic membrane resection. A discrete subaortic stenosis was identified by echocardiography. She was indicated for a Konno operation with a 19-mm Sorin SL valve inserted in the aortic position, along with ventricular septal defect closure with a pericardial patch. She produced a transient slight hypocalcemia after the operation. She was discharged home in a good condition on the fourth post-operative day. Intracardiac morphological and hemodynamic factors have been suggested as responsible for such a late complication. Our case study suggests the need for regular follow-up in patients with Williams syndrome, even after primary surgical repair.

Ecg of the month. Unusual electrocardiogram 42 years after operation for supravalvular aortic stenosis and 6 years after aortic valve replacement. Sinus rhythm with first degree atrioventricular block

A 43-year-old man came to the hospital because of increasing dyspnea for two weeks. At age nine months the patient was evaluated for failure to thrive, and a diagnosis of valvular aortic stenosis was made. At operation the aortic stenosis was found to be supravalvular, and the ascending aorta was enlarged with a Teflon patch, the proximal end of which was placed in the noncoronary sinus of Valsalva. The aortic valve was bicuspid but otherwise appeared normal. Postoperatively the patient did well until six years ago when he developed increasing dyspnea on exertion, orthopnea, and paroxysmal nocturnal dyspnea. Echocardiography revealed a peak systolic pressure gradient across the aortic valve of 80 mmHg, severe aortic regurgitation, and moderate mitral regurgitation thought to be functional. Coronary arteriograms were normal. The patient underwent aortic valve replacement with a 23 mm Hancock 2 porcine heterograft prosthesis. He again did well postoperatively until a year before the current admission when dyspnea on exertion developed and culminated in two weeks of severe orthopnea and paroxysmal nocturnal dyspnea. The electrocardiogram (ECG) recorded on admission is shown in the Figure.

Cardiovascular spectrum in Williams-Beuren syndrome: the Mexican experience in 40 patients

In this study, we have identified and evaluated the cardiovascular anomalies associated with Williams-Beuren syndrome in children.In a retrospective, lineal, and observational study, we reviewed the files of children who were seen from 1980 through 2005 (25 years) after a clinical diagnosis of Williams-Beuren syndrome.Forty children were diagnosed with this syndrome at the National Institute of Pediatrics in Mexico City. Of these, 32 (80%) were found to have congenital heart defects. The male-to-female ratio was 1.3:1 and ages ranged from 6 months to 15 years (mean, 4.4 years) at the time of diagnosis. All of the patients had morphologic and genetic characteristics typical of the syndrome.We emphasize the cardiovascular aspects from a clinical point of view. Supravalvular aortic stenosis was our most frequent finding, in 18 of 32 patients (56%); gradient differences in these patients ranged from 14 to 81 mmHg. Five patients showed combined lesions, the most frequent being supravalvular aortic stenosis in combination with pulmonary artery brachial stenosis, or with atrial and ventricular defects. Patients with incomplete atrioventricular defect and bicuspid aortic valve, as were seen at our hospital, have not to our knowledge been reported in other studies.One of the patients was scheduled for balloon dilation; another was scheduled for surgery; a 3rd patient was operated on twice for the placement of an aorto-aortic bridge; another underwent ventricular septal defect closure; and yet another underwent aortoplasty, this last dying shortly after surgery.

Modified Simple Sliding Aortoplasty for Supravalvar Aortic Stenosis

We describe a modified simple sliding aortoplasty for supravalvar aortic stenosis. This technique is easier, has a more physiologic approach, and has the advantage of not using foreign material to provide aortic growth potential in children. For the patients presented in this study, the mid-term results of modified simple sliding aortoplasty have showed good results.

[The Williams-Beuren syndrome: reconstruction of the thoracic aorta combining surgery and endovascular treatment]

The Williams-Beuren syndrome is the association of elf-like facies, mental retardation with cardiovascular anomalies, the most common of which is supravalvular aortic stenosis. This lesion may be focal or associated with hypoplasia of the distal aorta. The treatment is surgical and the role of interventional cardiological treatment is poorly defined. The authors report the case of a child with typical Williams-Beuren syndrome. An initial, very localised surgical aortic repair was performed at 3 months of age for a discrete supravalvular aortic stenosis. Two months later, a second operation was required for a new stenosis of the distal anastomosis associated with marked hypoplasia of the aortic arch. The progressive constitution of an isthmic coarctation led to the percutaneous implantation of a stent followed by two balloon dilatations. Only the first two endoluminal procedures successfully reduced the transisthmic pressure gradient. An antihypertensive treatment was given and regular echocardiography allows monitoring of the adaptation of the left ventricle.

Modified Myers and coronary artery bypass grafting using free internal thoracic artery graft for complicated supravalvular aortic stenosis

The left main trunk stenosis with Williams syndrome and supravalvular stenosis is a cause of sudden death and a serious disease. We performed modified Myers procedure with patch aortoplasty concomitant with coronary artery bypass grafting (CABG) using a free right internal thoracic artery (ITA) graft for a 2-year-old patient with this disease. The proximal cuff of the free right ITA graft was implanted in the posterior wall of the reconstructed aorta. The postoperative clinical course was uneventful, and aortic regurgitation and ischemic signs were not detected. CABG using this technique is useful for coronary artery stenosis in infants and young children, and favorable long-term outcomes are expected.

Echocardiographic follow-up of children with supravalvular aortic stenosis

This study evaluates the course of supravalvular aortic stenosis (SVAS)-associated right ventricular outflow tract (RVOT) obstruction and the results of surgery in children. We reviewed the medical records of 24 patients diagnosed with SVAS at initial echocardiographic examination or during the following period of RVOT obstruction. Very mild SVAS was defined as a transvalvular Doppler peak systolic instantanous gradient (PSIG) less than 25 mmHg, mild stenosis as 25-49 mmHg, moderate stenosis as 50-75 mmHg, and severe stenosis as more than 75 mmHg. The mean age of the patients was 3.1 +/- 2.9 years (range, 7 days to 12.7 years), and 18 of the patients (72%) were male. Fifteen patients had Williams' syndrome. Seventeen patients (71%) were followed for a mean of 5.2 +/- 3.8 years (range, 7 months to 13.5 years). Among 17 patients with complete follow-up records, 1 (6%) had very mild, 5 (29%) mild, 3 (18%) moderate, and 3 (18%) severe aortic stenosis at initial echocardiographic examination. In a newborn patient with mild pulmonary valvular stenosis. SVAS became evident after 2 months and progressed rapidly. Supravalvular aortic stenosis was very mild in 4 patients (23%), mild in 3 (18%), moderate in 3 (18%), and severe in 7 (41%) at last echocardiographic examination. Of 17 patients who were followed, 11 (65%) had RVOT obstruction at initial echocardiographic examination. RVOT obstruction disappeared in 5 patients, regressed in 1 patient, and appeared in 1 patient over the follow-up period. Four patients underwent operation. It appears reasonable that patients with very mild and mild stenosis should be followed medically every 1 or 2 years and patients with moderate stenosis once a year. Newborns with SVAS should be followed for rapid progression of SVAS. In some patients, RVOT obstruction may disappear, and SVAS may develop in others with RVOT obstruction. Patients with RVOT obstruction (at the valvular, supravalvular, or peripheral pulmonary arterial level) should be evaluated carefully for development of SVAS at follow-up.

Severe supravalvar aortic stenosis in familial homozygous hypercholesterolemia

Familial homozygous hypercholesterolemia is a rare disease with diverse clinical presentations. Patients often present with cutaneous xanthomas, particularly in the Achilles' tendon. They may have significant cardiovascular involvement, including premature atherosclerotic coronary artery disease and valvar and supravalvar aortic stenosis. Standard therapy includes diet modulation, pharmacotherapy, and lipid apheresis. Rarely, patients require surgical intervention for coronary artery bypass grafting and/or relief of the aortic stenosis. We present the case of a patient with severe progressive supravalvar aortic stenosis that ultimately required surgical resection despite aggressive medical therapy.

[Successful repair of supravalvular aortic stenosis using Steinberg 3 sinuses reconstruction; report of a case]

Steinberg method is a modification of Doty extended aortoplasty for supravalvular aortic stenosis (SAS). This modification entails placement of an additional patch in the left coronary sinus. A 3-year-old boy was diagnosed as SAS with aortic valvular stenosis. He was noticed a systolic murmur from 1 month after his birth. Echocardiography showed left ventricular hypertrophy, and pressure gradient of 80 mmHg was measured between the ascending aorta and the left ventricle. Cardiac catheterization revealed severe aortic stenosis at the sino-tubular (ST) junction. We adopted Steinberg 3 sinuses reconstruction. After this operation, there was no pressure gradient at ST junction although aortic valvular stenosis remained and mild aortic valve regurgitation newly developed. As this method can produce a symmetric aortic root, it may reduce aortic valve deformity especially on the left coronary cusp.

Mild Supravalvular Aortic Stenosis With Left Coronary Obstruction in a Neonate

A premature infant with a large patent ductus arteriosus and mild supravalvular aortic stenosis had evidence of severe myocardial ischemia after ductus ligation. Urgent reoperation was required to relieve severe obstruction of the left coronary orifice and the supravalvular stenosis was repaired. This unusual presentation early in infancy emphasizes that left coronary artery obstruction should be suspected even in the presence of mild supravalvular stenosis.

[Surgical treatment of Williams syndrome combined with cardiovascular disease]

OBJECTIVE

To introduce the experience of diagnosis and surgical treatment of Williams syndrome combined with cardiovascular disease.

METHODS

Between October 1996 and June 2003, 8 patients of Williams syndrome with cardiovascular disease were admitted in Fuwai hospital. Seven patients underwent surgical correction. One didn't undergo surgical procedure. There were 6 male and 2 female ranging from 1.5 to 12.0 years old (medium age 6.4). Three had localized type supravalvular aortic stenosis and 5 diffused type supravalvular aortic stenosis. In them, 2 patients were combined with peripheral pulmonary stenosis. Single patch aortoplasty were performed in 6 cases, and inverted bifurcated patch aortoplasty in one patient.

RESULTS

One patient died and one patient suffered renal insufficiency. In the early postoperative period, the mean speed of flow was reduced to 1.7 m/s from 4.6 m/s, and the mean systolic pressure gradient was reduced from 91 mm Hg to 18 mm Hg. Six patients were followed up 16 to 91 months. There were 5 cases in NYHA function class I, and one in class II.

CONCLUSION

Satisfied result can be achieved in surgical treatment of Williams syndrome with supravalvular aortic stenosis, but it is not in combined with peripheral pulmonary stenosis.

Perioperative care of the patient with Williams syndrome

Williams syndrome, initially described by Williams, Barratt-Boyes, and Lowe in 1961, consists of characteristic dysmorphic features, congenital heart disease, and distinctive behavioral and emotional traits. In addition to acquired and congenital heart disease, manifestations in the renal, endocrine, musculoskeletal, and central nervous system may have implications during the perioperative period. Congenital and acquired heart disease can be a significant issue as sudden death, related to abnormalities of the coronary arteries, has been reported perioperatively in these patients. The authors present a 7-month-old infant, previously diagnosed with Williams syndrome, who required anesthetic care for repair of subaortic and supravalvular aortic stenosis. The potential perioperative implications of Williams syndrome are discussed.

Konno procedure using atrioventricular groove patch plasty after arterial switch operation

A patient with transposition of the great arteries accompanied by Shaher type 9 coronary anatomy experienced the development of progressive neoaortic valvular regurgitation with a small annulus, supravalvular stenosis, and neopulmonary valvular and supravalvular stenoses 15 years after an arterial switch operation. To implant a prosthetic valve clinically adequate in size, the Konno procedure was necessary. However, the right coronary anatomy precluded the original Konno procedure. My colleagues and I accomplished neoaortic anterior annular enlargement in this case by using atrioventricular groove patch plasty without jeopardizing the right coronary artery, and this resulted in a satisfactory outcome.

Valvular and Supravalvular Aortic Stenosis in Heterozygous Familial Hypercholesterolemia, A Case Report

Familial hypercholesterolemia (FH) is an autosomal dominant disorder characterized by a high level of LDL-cholesterol and frequent coronary atherosclerosis. We studied a 64 year old woman with heterozygous (hetero) FH, who showed symptoms of chest pain and dyspnea with no other coronary risk factors than post-menopause and hypercholesterolemia. Although her coronary symptoms didn't reveal significant stenosis on coronary angiography, she had severe aortic valvular and supravalvular stenosis at the ascending aorta, which qualified her for aortic valve replacement. Moreover, a coronary flow study revealed functional ischemia with a reduction of the coronary flow reserve. We report a case of valvular and supravalvular aortic stenosis corrected by aortic valve replacement, a rare complication of hetero FH.

[Congenital supravalvular aortic stenosis; report of a case]

We experienced a successful surgical case of extended aortoplasty by means of Doty's method (two sinus reconstruction) for congenital supravalvular aortic stenosis (SAS). Case was 12-year-old boy, who had no complaint except heart murmur. The retrograde aortography demonstrated localized stenosis just above the aortic valve, and it was an hour-glass type. The preoperative peak systolic pressure gradient between the left ventricle and ascending aorta was 56 mmHg, which was improved postoperatively. This case showed excellent results. Doty's aortoplasty was favorable method for SAS without deformity of aortic valve and coronary obstruction.

Open-heart surgery in pediatric patients with end-stage liver disease

Little is known about the safety of pediatric cardiac surgery in children with end-stage liver disease. We reviewed our experience with 4 patients with biliary atresia or Alagille's syndrome who underwent repair of ventricular septal defect and tricuspid regurgitation, atrioventricular canal, subaortic stenosis, or supravalvular aortic stenosis. One patient died on postoperative day 2. All other patients survived to discharge. At follow-up, 1 patient died at home awaiting liver transplantation and the remaining patients are doing well. One patient received a successful liver transplant. Pediatric cardiac surgery in children with end-stage liver disease can be done safely, albeit with a higher mortality.

Acute aortic insufficiency complicating stent treatment of supravalvular aortic stenosis: Successful release of trapped leaflets by wiring the stent

This report shows the findings observed in a 7-year-old boy patient having severe supravalvular aortic stenosis who was treated by stent implantation. Immediately after deployment, a severe acute aortic insufficiency developed due to leaflets trapped by the stent. Release was attempted percutaneously. After wiring the proximal stent, snaring the wire and pulling smoothly, the leaflets came free and valve competence was completely restored. The procedure was then successfully completed, with no residual gradient or aortic insufficiency.

Progressive diffuse aortic stenosis after localized supravalvular aortic stenosis repair

A 6-year-old boy presented with diffuse stenosis of the aortic arch. He had undergone patch augmentation for localized supravalvular aortic stenosis at 2 years of age. Before the initial operation, the aortic arch and descending aorta were noticed to be hypoplastic with a diameter of 60 to 73% of that of the aortic annulus, without a pressure gradient. 4 years later, progressive diffuse stenosis of the aortic arch with a diameter of 42% of that of the aortic annulus was found. Reoperation, consisting of patch augmentation of the aortic arch, was carried out. A pressure gradient of 40 mmHg distal to the repair was newly recognized, again. This is a rare case of supravalvular aortic stenosis, which required reoperation because of the progression of diffuse stenosis of the distal aorta.

Left ventricular outflow tract obstruction

Left ventricular outflow tract obstruction can occur at the supravalvar, valvar, or subvalvar level. Each level of obstruction is associated with distinct symptomatology, natural history, and operative approach. Reconstructive techniques can usually be used with low operative risk and excellent immediate and longer-term outcomes. Valve replacement for valvar obstruction is advised when reconstruction is not possible. The Ross procedure has greatly improved the results of valve replacement in children.

The operative outcome in children with supravalvular aortic stenosis

The authors present their experience in surgical treatment of children with supravalvular aortic stenosis (SAS). A retrospective analysis was carried out on 20 patients operated in the years 1980-1999. The group included 12 boys and 8 girls aged 0.9 to 14.5 years (mean 7.8 +/- 3.4 years). The diagnosis of Williams syndrome in 6 children (30%) was based on the typical face. The mean systolic pressure gradient across the SAS was 84.3 +/- 34.5 mmHg (range from 41 to 168 mmHg). Intraoperative studies allowed to determine that 16 (80%) children had the hourglass type, 2 (10%) tubular type and 2 (10%)--fibromuscular membrane type of stenosis. Sixteen (80%) children had anomalies of the aortic valve and/or coronary arteries, and in 13 (56%) children associated heart or great vessels anomalies were noted. All the patients were operated on using cardiopulmonary bypass and hypothermia. The associated anomalies were corrected simultaneously. There were no early and late deaths. Because of restenosis one child was reoperated. In the follow up the mean systolic pressure gradient between the left ventricle and ascending aorta revealed by echocardiography in 19 (95%) children to be 8 +/- 2 mmHg (range from 0 to 28 mmHg). Eighteen children are now in NYHA class I (New York Heart Association) and develop normally. Supravalvular aortic stenosis is a rare complex anomaly, which, because of life-threatening complications and low operative risk, should be fully repaired as soon as possible.

[Congenital aortic supravalvular stenosis. Frequency and results of surgical treatment in a third level hospital]

In a prospective study made between 1 September 1996 and 31 December 2001, pediatric patients with a diagnosis of supravalvular aortic stenosis confirmed by a reduction in the aortic inner diameter and a gradient > or = 50 mmHg were detected. Of 83 patients with aortic stenosis, only 7 (8.4%) had supravalvular aortic stenosis. All 7 patients underwent surgical treatment consisting of resection of fibrous tissue and reconstruction of the ascending aorta with a preclotted Dacron patch. One patient with severe, diffuse stenosis died and the another had perioperative heart failure, cardiac arrest and reversible neurological sequelae. A significant decrease in the postoperative gradient was obtained (p < 0.05). At present all surviving patients are free of symptoms. It was concluded that supravalvular aortic stenosis is infrequent in Mexico. In our experience, surgical treatment produced good results and success depended on the magnitude and type of stenosis.

Supravalvar aortic stenosis: clinical and hemodynamic profile, and surgical outcome

BACKGROUND

Supravalvar aortic stenosis is the rarest of left ventricular outflow obstructions. Data on this rare entity from India are scarce.

METHODS AND RESULTS

We retrospectively analyzed the data of 15 patients (13 males, mean age 15.5+/-10.18 years) with a diagnosis of supravalvar aortic stenosis confirmed by cardiac catheterization. Five patients had morphological features of Williams' syndrome. One patient had diffuse while the rest had discrete type of supravalvar aortic stenosis. Five patients did not have any associated lesions. A 9-year-old male had an ascending aortic aneurysm, and 3 patients had associated peripheral pulmonary artery stenosis. One child had a subaortic ventricular septal defect, and another had severe mitral regurgitation. Twelve patients had electrocardiographic evidence of left ventricular hypertrophy. Three patients had mild aortic valvar stenosis while 2 had aortic regurgitation. Six patients had dilated coronary arteries. Two patients with supravalvar aortic gradients of 20 and 40 mmHg were kept on close follow-up. One patient was not willing to undergo surgery while the other is awaiting surgery. Eleven patients underwent surgical correction. Dacron or pericardial patch aortoplasty was done in all the patients. In addition, one patient each underwent pulmonary artery plasty, ventricular septal defect closure, repair of ascending aortic aneurysm, and mitral valve replacement. The patient with diffuse type of supravalvar aortic stenosis underwent augmentation aortoplasty. Two patients died perioperatively. One was lost to follow-up. Two had moderate residual gradients. The rest of the patients were in New York Heart Association functional class I on follow-up of 6.3+/-4.7 years.

CONCLUSIONS

Repair of supravalvar aortic stenosis by single sinus aortoplasty is safe and produces good results.

Mitral regurgitation without supravalvular aortic stenosis in Williams syndrome

Isolated mitral regurgitation without supravalvular aortic stenosis is rarely identified in Williams syndrome. We describe the case of a 24-year-old man with isolated mitral regurgitation in Williams syndrome. Severe regurgitation due to prolapse of the anterior leaflet was noted in an echocardiogram and color Doppler, and a left ventriculogram showed grade IV regurgitation. No pressure gradient between the left ventricle and the ascending aorta was found. Mitral regurgitation had been noted since his birth, and pediatricians suspected Williams syndrome because of postnatal growth deficiency, mental deficiency, unusual personality, and unusual facial features in his childhood. The diagnosis was confirmed by demonstration of the hemizygous deletion of 7q11.23 in the karyotype by the fluorescent in situ hybridization technique after his admission to our department. The patient underwent mitral valve replacement, and microscopic examination of the excised valve revealed myxomatous degeneration.

Supravalvar aortic stenosis with supravalvar pulmonary stenosis and peripheral vascular stenoses

A non-dysmorphic 10 month old female was discovered at surgery to have severe vasculopathy of both the systemic and pulmonary arteries. These findings were confirmed by pathologic examination. Follow-up angiography has confirmed multiple sites of vascular obstruction which appear to be worsening. Angioplasty has only partially relieved these obstructions. The pathology and possible etiology are reviewed.

Surgical repair of congenital supravalvular aortic stenosis in children

OBJECTIVE

Supravalvular aortic stenosis (SVAS) is an uncommon congenital cardiac anomaly characterized by varying degrees of left ventricular outflow tract obstruction beginning distal to the aortic valve.

METHODS

Between March 1962 and December 2000, 101 consecutive patients underwent surgical correction for congenital SVAS at Riley Children's Hospital. There were 61 male (60%) and 40 female (40%) ranging in age from 3 month to 17 years (medium age, 6.1 years). Fourteen patients (14%) had Williams syndrome. Preoperatively, 11 patients were in New York Heart Association (NYHA) functional class I, 55 in class II, 28 in class III, and seven in class IV. Of the 101 patients, 73 (72%) had localized type SVAS and 28 (28%) diffuse type SVAS.

RESULTS

Those with localized SVAS were successfully treated with patch aortoplasty, whereas those with diffuse SVAS required either an apical aortic conduit or extensive endarterectomy with patch aortoplasty. The overall mean pressure gradient was reduced to 21 mmHg (P<0.001) in the early postoperative period. There were one early death (<30 days postoperatively) (1%), two (2%) late deaths, and 14 patients (14%) underwent one or two additional operation (n=17) in a follow-up period ranging from 6 months to 30 years (medium 9.4 years). Postoperatively, there were 72 patients (73%) in NYHA functional class I and 26 (27%) in class II. Overall survival including operative mortality was 98% at 10 years, 97% at 20 and at 30 years.

CONCLUSION

Good surgical outcome of congenital SVAS can be achieved with the appropriate method of treatment in patients with both localized and diffuse SVAS.

Evaluation of arterial stiffness in children with Williams syndrome: Does it play a role in evolving hypertension?

BACKGROUND

Pathologic studies and surgical observations of thickened aortic walls have suggested an increase in aortic stiffness in patients with Williams syndrome. However, in vivo objective evaluation of aortic and arterial stiffness in Williams syndrome are lacking. Moreover, systemic hypertension, although prevalent in Williams syndrome, does not have a well-defined mechanism in this syndrome. Therefore, the purpose of this study was to quantitate aortic stiffness and arterial compliance in an objective manner, as well as to determine their roles in development of hypertension, in children with Williams syndrome.

METHODS

We studied 13 patients with Williams syndrome (aged 3-12 years) and 16 age-matched control subjects. Aortic stiffness was calculated from the beta index as follows: beta = (ln[P(s)/P(d)])/ ([D(s) - D(d)]/D(d)), where P(s) and P(d) are systolic and diastolic blood pressures and D(s) and D(d) are systolic and diastolic aortic dimensions, respectively. Arterial compliance (C) was calculated by the area method: C= (A(d) x CO x CL) / (A(t) x [P(es) - P(d)]), where A(t) is the total area and A(d) is the area under the diastolic portion of the arterial pulse tracing, CO is the cardiac output, CL is the cycle length, and P(es) is aortic end-systolic pressure.

RESULTS

In patients with Williams syndrome, the beta index was 2-fold higher than in control patients (9.02 +/- 3.15 vs 4.43 +/- 0.96, P <.005). Moreover, there was a strong positive correlation between the beta index and the systolic blood pressure (r = 0.8 and P <.0001). Compliance was decreased by 42% (0.41 +/- 0.11 vs 0.71 +/- 0.10 mL/mm Hg, P <.05), suggesting decreased arterial compliance.

CONCLUSIONS

Our study indicates that in vivo arterial stiffness is increased in patients with Williams syndrome. We speculate that increased arterial stiffness may be the predisposing cause of systemic hypertension in Williams syndrome.