anical failure of the
mtlons of aortic
later with the porcine hete
operation. Glutaraldebyde fixation and better stents have
increased the durability of p ne bioprostheses, particuny mechanical prostheses
larly in the aortic position.
‘EditOrids pubkd’iedin hun~a~ of rhe Arnericarl Co/k&V t~fCurdiology
reflect the views of the authors and do not necessarily represent the views of
JACC or the American College of Cardiology.
From the College of Medicine, Department of Surgery. Division of
Cardiothoracic Surgery, The Milton S. Hershey Medical Center. Pennsylvania State University. Hershey, Pennsylvania.
: David 6. Campbell. MD, College of Medicine. The
Milton S. Hershey Medical Center, Pennsylvania State University. Box 850.
Hershey, Pennsylvania 17033.
average mean
transaortic gradient decreased
632
CAMPBELL
EDlTORlAL
AND WALDHAUSEN
COMMENT
mm Hg and there was no increase in aortic fegUr&tiOn.
mortality rateat 1 month was 8.8%for the entire group,
which included patients with concomitant coronary artery
and other valve procedures.
Serial postoperative echocardiographic studies demonstrated progressive
aortic regurgitation in most patients and
multivariate analysis failed to incriminate any specific COm&id
factor or operative event. At a mean interval of 13.5
months after surgery, sudden death had occurred in 2
patients and 11 other patients had developed severe aortic
regurgitation, which mandated reoperation and aortic valve
replacement in 6. At the time of autopsy or reoperation,
there was a common pathologic finding in the valves examined. Granulationtissue and fibrous tissue were present with
thickening and retraction of valve leaflets that produced
central aortic regurgitation secondary to poor coaptation.
Recurrent calcification and stenosis were not dominant
problems. In the short interval after the ultrasonic debridement procedure, these results have prompted this group to
abandon further trials of ultrasonic decalcification.
A recent report by Craver (10)describes a similar experience in 11patients at the Emory Clinic. Immediategradient
reduction to <lo mm Hg was possible in all patients; of 10
operative survivors, 5 experienced progressive aortic regurgitation and sudden death occurred in 2. The pathologic
features of the excised valve were identical to those described by Freeman et al. (9). The Emory group also
concluded that this technique should be “held in reserve.”
Implications. With the poor results of percutaneous valvuloplasty and the disappointing results of decalcificationin
the present report (9), it seems that we have failed again in
the quest for a valve-sparingoperation for aortic stenosis. A
risk of sudden death (approximately 5%) in the study patients remains the same as had been noted with previous
manual decalcification attempts. The manual attempts of
nearly 30 years ago almost uniformly failed because of rapid
recalcification and recurrent critical aortic valve stenosis,
usuallywithin 4 years. In the current report, Freeman et al.
(9) point out some important limitations of their study; for
example, the application of the debridement device in the
operating room was not standardized; the instrument was
used at various power settings and by different surgeor.The
JACC Vol. 16, No. 3
September 1990:631-2
However, it is not technical sbo~comin~s of the device that
caused failure. The instrument etfectively eemove
but, in the process, changed the valve leaflet. Progressive
leaflet fibrosis, thickening and retraction (all hallmarks of
“healing”) constituted the body’s response to the procedure. The time course of these leaflet changes is generally
more rapid than the recdcification process observed after
manual debridement.
Although the results of aortic valve decalcihcation wi
current ultrasonic i
and none of the three in
the Emory series (10)who unde nt reoperation and aortic
valve replacement died of cardiac causes in the p
period. Aortic valve replacement, prescribed
for patients with symptomatic disease, remains the standard
by which alternative surgical procedures must be judged.
I. Hurley PJ, Lowe JB. Barratt-Boyes BG. Debridement-valvotomy
for
aortic stenosis in adults: a follow-up of 76 patients. Thorax 1%7;22:314-9.
2. Enright LP. Hancock EW. Shumway NE. Aortic debridement:
follow-up. Surgery 1%X69:404-9.
3. Hill DG. Long-term results of debridement valvotomy
stenosis. J Thorac Cardiovasc Surg 1973;65:70&11.
Joog-term
for calcific aortic
4. Weinstein GS. Reed WA, Killen DA. Aortic valvuloplasty for calcific
aortic stenosis in the adult. J Cardiovasc Surg (Torino) lYSG;21:675-80.
5. King RM, Plum JR. Giuliani ER. Piehler JM. Mechanical
of the aortic valve. Ann Thorac Surg 19X6:42:269-72.
6. Mindich BP. Guarino T. Goldman ME. Aortic valvuloplasty
aortic stenosis. Circulation 1986:‘74(suppl I)$-130-5.
decalcification
for acquired
7. Mindich BP, Guarino T, Krenz H, Li X-G, Gonzales E. Aortic valve
&age
utilizing high frequency vibratory debridement (abstr). J Am Coll
Cardiol 1988:l Itsuppl A):3A.
8. Freeman WK. Schaff HV. Orszulak TA. Ultrasonic aortic valve decdlcification: serial Doppler echocardiographic follow-up tabstr). Circulation
1988;78:379.
9. Freeman WK. Schaff HV. Orszulak TA, Tajik AJ. Ultrasonic aortic valve
decalcilication: serial Doppler echocardiographic follow-up. J Am Coll
Cardiol 1990:16:623-30.
IO. Craver SM. Aortic valve debridement by ultrasonic surgical aspirator: a
word of caution. Ann Thordc Surg 1990:49:746-53.