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Case 1167 Congenitally Bicuspid Stenotic
Aortic Valves in Octogenarians
Stuart R. Lander, MD; Jeff E. Taylor, MD; William C. Roberts, MD
An 84-year-old white woman was apparently asymptomatic until about 2 months
before aortic valve replacement when she went to her physician because of developing
exertional dyspnea and chest tightness. Atransthoracic echocardiogram showed a
normally contracting left ventricle, a normal sized left ventricular cavity, and an
estimated aortic valve area of 0.6cm
was discussed with the patient but she declined operative intervention.
She was then in her usual state until nearly 2 months later when the dyspnea and
chest tightness worsened and she came to the hospital’s emergency room. Precordial
examination disclosed a grade 3/6 systolic ejection type murmur heard best along
the left sternal border with radiation into the neck. No diastolic murmur was heard.
Electrocardiogram disclosed sinus rhythm, nonspecic ST, T wave changes, and total
12 lead QRS voltage of 184mm (10mm= 1mV) (normal <175mm).
disclosed bilateral pleural effusions and mild cardiomegaly; no calcium was seen
in either the mitral valve region or in the aortic valve cusps. Cardiac catheterization
disclosed the following pressures: left ventricle 173/19mm Hg; aorta 122/54mm
Hg, yielding a peak systolic pressure gradient of 51; pulmonary artery, 33/14mm
Hg (mean 20), and pulmonary artery wedge mean 12. The aortic valve area was
calculated to be 0.51cm
2
and the valve area index, 0.3cm2/body surface area. The
patient weighed 145 lbs (68 kg) and was 63 inches tall (160cm). Coronary angiogram
disclosed a dominant right coronary system. The distal left anterior descending
coronary artery was narrowed up to 70% in diameter, the left circumex up to 30%,
and the right coronary artery <20%. The left main was normal.
On January 12, 1999, the aortic valve was excised and replaced with a Baxter
parietal pericardial 21mm bioprosthesis. Coronary bypass also was performed. The
operatively excised valve was congenitally bicuspid (Figure 1). Early postoperatively
the patient was transiently confused, developed atrial brillation, and had mild
levation in b
e
lood urea nitrogen. She went home the eleventh postoperative day.
By that time she was again in sinus rhythm, mentally alert, and had normal renal
function. Eight months after operation she was asymptomatic, and cared for herself
living alone.
The above case indicates that a congenitally bicuspid aortic valve can be seen
in octogenarians and that a stenotic one can be successfully replaced. The oldest
reported patient having aortic valve replacement for congenitally stenotic aortic
valve was a 92-year-old man.
2
few weeks before aortic valve replacement. Arecent study from the Mayo Clinic
described 527 patients >20 years of age with operative excision of congenitally
bicuspid aortic valves including stenotic ones (444 patients), purely regurgitant
ones without infection (67 patients), and infected ones (16 patients). Of the 527
patients >20 years of age, 28 (5.3%) were octogenarians. At Baylor University
Medical Center since January1993, 397 patients >20years of age have undergone
2
. The possibility of aortic valve replacement
1
Chest radiograph
The present patient was asymptomatic until just a
3
From the Baylor Cardiovascular Institute, Baylor University Medical Center, Dallas, TX
200 DOI: 10.1201/9781003409281-39
CASE 1167 CONGENITALLY BICUSPID STENOTIC AORTIC VALVES IN OCTOGENARIANS
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Figure 1 Operatively excised congenitally bicuspid stenotic aortic valve in the
84-year-old patient described herein.
Table 1: Published reports of aortic valve replacement with and without coronary
artery bypass in octogenarians
Actuarial
Number
First
Author
(Year)
Aranki
(1983)
Elayda
(1983)
Deiwick
(1997)
Schmitz
(1998)
* 2 year postoperative follow up; AVR=aortic valve replacement; CABG=coronary bypass
grafting.
isolated aortic valve replacement (no replacement of the mitral valve) (115 were
described elsewhere
Of
Patients
188 80–95
152 80–91
37 80–92
52 >80
Age
(Mean)
(-)
(93)
(81)
(-)
4
): the aortic valve in 169 (43%) was congenitally bicuspid; in 13
Procedure
(Number of
Patients)
AVR (83)
AVR + CABG (105)4%9%
AVR (77)
AVR + CABG (75)5%24% 18% 84% 79% 57%
AVR (23)
AVR& CABG (14)
AVR (33)
AVR + CABG (19)3%22%
Operative
Mortality
—
— 8% 88% 79%* 73%
30 Day
Mortality
(%)
—
—
—
—
(3%) it was unicuspid; in 211 (53%) it was tricuspid; and in 4 (1%) the valve structure
was unclear. Of the 169 patients with a congenitally bicuspid aortic valve, 60 (36%)
were <65years of age and 109 (64%) were aged 65 or over including 19 (11%) who
were octogenarians.
Survival
(Years)
1 3 5
—————
—
————87%
59%
201
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Only one major coronary artery in the above described patient was narrowed
>50% in diameter. As a rule, the cleaner the coronary arteries in older individuals
the greater the chance that a stenotic aortic valve will be congenitally bicuspid.
Recent reports of octogenarians undergoing isolated aortic valve replacement
with or without coronary artery bypass are reviewed in the Table.
mortality of combined valve replacement and coronary bypass was relatively high.
Of the 52 patients reported by Schmidtz et al,
9
81% of the early survivors stated
6–9
5
Operative
that their functional status had improved and 97% stated that the operation was
worthwhile.
Finally, as the population continues to age the frequency of aortic valve stenosis
will almost certainly increase. Congenital heart disease is not limited to the younger
population but indeed may occur in the elderly.
REFERENCES
1. Odom H II, Davis JL, Dinh H, Baker BJ, Roberts WC, Murphy ML. QRS voltage
measurements in autopsied men free of cardiopulmonary disease: A basis for
evaluating total QRS voltage as an index of left ventricular hypertrophy. Am J
Cardiol. 1986;58:801–804.
2. Karalis DG, Wahl JM, Mintz GS, Chandrasekaran K. Severe stenosis involv-
ing a congenitally bicuspid aortic valve in the tenth decade of life. Am J Cardiol.
1990;65:264–265.
3. Sabet HY, Edwards WD, Tazelaar HD, Daly RC. Congenitally bicuspid aortic
valves: Asurgical pathology study of 542 cases (1991 through 1996) and a literature review of 2,715 additional cases. Mayo Clin Proc. 1999;74:14–26.
4. Stephan PJ, Henry III AC, Hebeler Jr RF, Whiddon L, Roberts WC. Comparison of
age, gender, number of aortic valve cusps, concomitant coronary artery bypass
grafting, and magnitude of left ventricular-systemic arterial peak systolic gradient in adults having aortic valve replacement for isolated aortic valve stenosis. Am
J Cardiol. 1997;79:166–172.
5. Mautner GC, Mautner SL, Cannon RO III, Hunsberger SA, Roberts WC. Clinical
factors useful in predicting aortic valve structure in patients >40years of age with
isolated valvular aortic stenosis. Am J Cardiol. 1993;72:194–198.
6. Aranki SF, Rizzo RJ, Couper GS, Adams DH, Collins Jr JJ, Gildea JS, Kinchla NM,
Cohn LH. Aortic valve replacement in the elderly. Effect of gender and coronary
artery disease on operative mortality. Circulation. 1993;88:17–23.
7. Elayda MAA Hall RJ, Reul RM, Alonzo DM, Gillette N, Reul Jr, GJ, Cooley DA.
Aortic valve replacement in patients 80years and older. Operative risks and longterm results. Circulation. 1993;88:11–16.
8. Deiwick M, Tandler R, Mollhoff T, Kerber S, Rotker J, Roeder N, Scheld HH. Heart
surgery in patients aged eighty years and above: Determinants of morbidity and
mor tal it y. Thorac Cardiovasc Surg. 1997;45:119–126.
9. Schmitz C, Welz A, Reichart B. Is cardiac surgery justied in patients in the ninth
decade of life? J Card Surg. 1998;13:113–119.
202
CASE 1306 SEVERE LATE (16YEARS) DYSFUNCTION OF ABIOPROSTHESIS
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Case 1306 Severe Late (16Years) Dysfunction
of aBioprosthesis in the Mitral Valve Position
Without Dysfunction of aBioprosthesis
in the Aortic Valve Position
Paul A. Grayburn, MD, Baron L. Hamman, MD, and William C. Roberts, MD
A man who was born in 1939 underwent replacement of both mitral and aortic
valves with porcine bioprostheses in 1987 (age 48). Thereafter, he was asymptomatic
until 2003 (age 64), when he developed signs and symptoms of heart failure. Cardiac
catheterization in late 2003 disclosed the following pressures in mm Hg: pulmonary
artery, 70/31; right ventricle, 70/18; right atrial mean, 9; pulmonary artery wedge
mean, 30, with v waves averaging 54; left ventricle, 108/25; and aorta, 104/65. Left
ventricular angiography disclosed a normal-sized left ventricular cavity and severe
mitral regurgitation. Aortic root angiogram disclosed trace aortic regurgitation. The
preoperative echocardiogram and the operatively excised (late 2003) bioprosthesis,
which had been in the mitral valve position, are shown in the Figure. Coronary
angiography preoperatively showed insignicant coronary arterial narrowing.
Figure 1 Echocardiographic and gross anatomic images of the bioprosthesis in
the mitral valve position for 16years showing severe bioprosthetic regurgitation. (a)
Amidesophageal 4-chamber view showing 3 distinct defects in the porcine cusps
(arrows). (b) Amagnied image in the same projection showing multiple color ow
jets with severe mitral regurgitation through the cusps. There was no perivalvular
leak. (c) The excised bioprosthesis with 3 perforations in the cusps (arrows). This is a
classic example of structural porcine bioprosthetic deterioration.
From the Division of Cardiology, Department of Internal Medicine (Grayburn), Department
of Cardiothoracic Surgery (Hamman), and Department of Pathology and the Baylor Heart and
Vascular Institute (Roberts), Baylor University Medical Center, Dallas, Texas.
Corresponding author: Paul A. Grayburn, MD, Baylor Hamilton Heart and Vascular
Hospital, 621 N. Hall Street, Dallas, Texas 75226 (e-mail: PaulGr@bhcs.com).
DOI: 10.1201/9781003409281-40 203
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This case demonstrates that when bioprostheses are placed in both mitral and
aortic valve positions during the same operation, the bioprosthesis in the mitral valve
tends to degenerate more rapidly than a similar bioprosthesis in the aortic valve.
The likely reason is that the closing pressure exerted on the mitral bioprosthesis is
the left ventricular systolic pressure, whereas the closing pressure exerted on the
aortic prosthesis is the aorta’s diastolic pressure, which in general is about a third
lower than the left ventricular peak systolic pressure. In the present patient, the
left ventricular peak systolic pressure was 108mm Hg and the aorta’s end-diastolic
pressure was 65mm Hg, a 40% difference.
REFERENCE
1. Warnes CA, Scott ML, Silver GM, Smith CW, Ferrans VJ, Roberts WC. Comparison
of late degenerative changes in porcine bioprostheses in the mitral and aortic
valve position in the same patient. Am J Cardiol 1983;51: 965–968.
1
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CASE 1335 SEVERE REGURGITATION IMMEDIATELY AFTER REPLACEMENT
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Case 1335 Severe Regurgitation Immediately
After Replacement of a Dysfunctional
Bioprosthesis in the Mitral Valve Position
Hassan Farooq, MD, Paul Grayburn, MD, and William Clifford Roberts, MD
Severe regurgitation immediately after replacement of a cardiac valve with a
mechanical prosthesis or a bioprosthesis is a rare occurrence. Such, however,
was the case in the patient described. ©2005 by Excerpta Medica Inc.
(Am J Cardiol 2005;95:703–704)
A 74-year-old woman, who was born in September1929, had her purely regurgitant
mitral valve replaced with a bioprosthesis in 1986, when she was 57 years old.
Thereafter, she was asymptomatic until age 74, when exertional dyspnea appeared.
Four months later, she entered the hospital. She was 57 inches tall and weighed
115 pounds (body mass index 25 kg/m
heard over the cardiac apex, and it radiated into the left axilla. An echocardiogram
disclosed a normal-sized left ventricle, a dilated right ventricle, and severe
bioprosthetic regurgitation. At cardiac catheterization, the pressures in mm Hg
were as follows: pulmonary artery wedge “a” wave, 33, V wave, 43, and mean, 28;
right ventricle, 58/23, simultaneous left ventricle, 166/26, and aorta 162/ 92. Left
ventricular angiography disclosed severe (4+/4+) bioprosthetic regurgitation.
2
). Agrade 3/6 holosystolic murmur was
• • •
Reoperation on April 14, 2004, disclosed that 1 of the 3 bioprosthetic cusps had
prolapsed severely toward the left atrium, despite the absence of calcium in any
of the bioprosthetic cusps. The dysfunctional bioprosthesis in the mitral position
was replaced with another bioprosthesis (Carpentier-Edwards, 25mm, Edwards
Lifesciences, Irvine, California). At operation, the left atrium was opened by an
incision parallel to the atrial septum just anterior to right superior pulmonary
vein. After the excision of the initially inserted bioprosthesis and the insertion of
the newer bioprosthesis, the patient apparently came off cardiopulmonary bypass,
which lasted 68 minutes, without difculty.
When entering the intensive care unit, the patient’s blood pressure was
100/60mm Hg, and her heart rate was 92 beats/min. Her extremities were cool, and
the pedal pulses were barely palpable. Pulmonary artery pressure was 36/18mm
Hg. Later that day, the patient’s blood pressure decreased to 60/30mm Hg, and atrial
brillation appeared. Sinus rhythm was restored by cardioversion (50 J) but without
improvement in hemodynam ics. On postoperative day 4, the patient again reverted to
atrial brillation, but with amiodarone sinus rhythm returned. By day 8, she was still
intubated, sinus tachycardia (110 beats/min) persisted, her respirations were rapid
(25 breaths/min), and vasopressors were required to maintain adequate systemic
From the Baylor University Medical Center, Baylor Heart& Vascular Institute, Dallas, Texas.
Dr. Roberts’s address is: Baylor University Medical Center, Baylor Heart& Vascular Institute,
621 North Hall Street, Dallas, Texas 75226. E-mail: wc.roberts@baylorhealth.edu. Manuscript
received and accepted October29, 2004.
DOI: 10.1201/9781003409281-41 205
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arterial pressures. Arepeat echocardiogram (Figure1) showed severe bioprosthetic
regurgitation, and a third cardiac operation was performed on postoperative day 9
(April23, 2004). The left atrium was opened through the previous incision, and the
bioprosthesis in the mitral position was excised. The orice of the bioprosthesis was
found to be in a xed open position because of a single suture that had encircled 1
of the 3 stents, resulting in the tethering down of 2 cusps (Figure1). After excision
of the tethered bioprosthesis and replacement with another bioprosthesis, the
patient came off cardiopulmonary bypass easily, and her postoperative course was
relatively uneventful. She left the hospital on May14, 2004.
• • •
In the early days of cardiac valve replacement, certain technical complications
occurred fairly commonly simply because the procedure was new, and good
techniques had to be developed. In recent years technical complications of cardiac
valve replacement have been infrequent. The complication described in the
present patient, namely, the tethering down of 2 bioprosthetic cusps by a suture
tied down inadvertently on 1 bioprosthetic stent located on the ventricular aspect
of the bioprosthesis, was originally described and reported in 1983.
1
The present
case indicates that even 21years later, this complication has not yet been completely
eliminated. It is still a good idea before closing the left atrium after mitral
Figure 1 Transesophageal echocardiographic images (top panels) obtained in ven-
tricular systole (top left) and ventricular diastole (top middle) showing marked restric-
tion in the opening of 2 cusps. The top right shows mitral regurgitation by color
Doppler ow mapping. The vena contracta of the mitral regurgitation jet measured
0.9cm, a thickness consistent with severe mitral regurgitation. The bottom panels
show the bioprosthetic valve as seen from the left atrial aspect (bottom left) and from
the left ventricular aspect (bottom middle and bottom right). Asingle suture encircled 1
of the 3 stents, tethering down 2 cusps and resulting in an opened, roughly triangular orice in ventricular systole and diastole.
206
CASE 1335 SEVERE REGURGITATION IMMEDIATELY AFTER REPLACEMENT
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replacement to ensure that each bioprosthetic cusp is freely mobile. Intraoperative
transesophageal echocardiography should be used routinely to evaluate the valve
before leaving the operating suite.
REFERENCE
1. Silver MA, Oranburg PR, Roberts WC. Severe mitral regurgitation immediately
after mitral valve replacement with a parietal pericardial bovine bioprosthesis.
Am J Cardiol 1983;52:218–219.
207
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Case 1357 Mitral “Annular” Calcium Forming a
Complete Circle “O” Causing Mitral Stenosis in
Association with a Stenotic Congenitally Bicuspid
Aortic Valve and Severe Coronary Artery Disease
Kevin P. Theleman, MD,
1,3
Paul A. Grayburn, MD,
Calcic deposits in the epicardial arteries, mitral valve annulus, and aortic valve
cusps are common in older persons in the Western world.
1,3
William C. Roberts, MD
1
Recently, we encountered
1,2, 3
a patient with massive mitral annular calcium causing mitral stenosis in association
with a stenotic congenitally bicuspid aortic valve and heavy coronary calcic
deposits. The extent of the cardiac calcic deposits is unusual and prompted this
report.
A 73-year-old man had an orthotopic liver transplant for alcoholic cirrhosis
at age 60, a renal transplant at age 65, a dual-chamber pacemaker inserted for
sick sinus syndrome at age 72, and had corticosteroid-induced diabetes mellitus
and systemic hypertension. The present examination was prompted by the recent
onset of pedal edema. A grade 2/6 systolic ejection murmur that was loudest
over the right base of the precordium was present. His body mass index was
22 kg/m
2
. Echocardiography disclosed a 6-mm Hg mean diastolic gradient at
the mitral orice and a left ventricular ejection fraction of about 55% (Figure1).
Cardiac catheterization revealed a peak systolic pressure gradient between the left
ventricle and aorta of 50mm Hg (mean gradient, 38mm Hg) and an aortic valve
area of 0.6cm
2
. The left anterior descending artery was narrowed up to 70% in
diameter proximally, the second diagonal artery up to 80% proximally, and the
ramus intermedius artery up to 80% proximally. The left main coronary artery
was widely patent. The dominant left circumex artery was narrowed up to 50%
in diameter and was heavily calcied. The nondominant right coronary artery was
free of narrowing.
The aortic valve was replaced with a 21-mm Medtronic Mosaic (Medtronic,
Inc., Mineapolis, MN) bioprosthesis. The surgically removed aortic valve was
congenitally bicuspid (Figure2). Aortosaphenous vein grafts were placed to the left
anterior descending and the rst marginal coronary arteries. An intra-aortic balloon
pump was placed intraoperatively. Aortic cross-clamp time was 149 minutes. The
postoperative course was complicated by the low cardiac output syndrome, and
death occurred 5 days postoperatively.
From the Departments of Medicine (Division of Cardiology)1 and Pathology2 and the Baylor
Heart and Vascular Institute,
Address for correspondence: William C. Roberts, MD, Baylor Heart and Vascular Institute, Baylor
University Medical Center, 621 North Hall Street, Suite H-030, Dallas, TX 75226
E-mail: wcroberts@baylorhealth.edu
Copyright of American Journal of Geriatric Cardiology is the property of LeJacq
Communications, Inc. and its content may not be copied or emailed to multiple sites or posted
to a listserv without the copyright holder’s express written permission. However, users may
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208 DOI: 10.1201/9781003409281-42
3
Baylor University Medical Center, Dallas, TX
CASE 1357 MITRAL “ANNULAR” CALCIUM FORMING A COMPLETE CIRCLE “O”
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Figure 1 Echocardiogram. Left panel: parasternal long-axis view showing extensive calcication deposits of the mitral annulus (arrows) and aortic valve; right
panel: transmitral Doppler inow showing a peak velocity of 2.0m/sec and a mean
gradient of 6mm Hg.
Figure 2 Photograph of the operatively excised focally calcied, stenotic, congenitally bicuspid aortic valve.
At necropsy, the coronary arteries and mitral annular region were massively
calcied (Figure 3). The ventricular cavities were not dilated (Figure 4). The
bioprosthesis in the aortic valve position appeared to have functioned normally. The
venous conduits to the left anterior descending and obtuse marginal arteries were
patent.
The most prevalent site of cardiac calcic deposits is the epicardial coronary
arteries, followed by the mitral annular area and aortic valve cusps. The apical
portions of the left papillary muscles are the fourth most common area of the
heart to have calcic deposits.
in that the calcium deposits are actually located between the ventricular surface
1
The term “mitral annular calcium” is not accurate
209
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