Surgical Treatment of Subaortic Obstruction in Adolescent and Adults: Long-Term Follow-up

Abstract

Subaortic stenosis (SAS) is a wide spectrum of anatomical derangements ranging from a discrete fibrous membrane to tortuous fibrous tunnel with or without aortic annulus hypoplasia. We have reviewed 88 patients undergoing surgery for SAS over a 15-year period. There were 47 male and 41 female patients with a mean age of 19.8 +/- 10.6 years (range 11 to 39). Fifty-eight patients had discrete subaortic membrane, and 30 patients had diffuse tunnel subvalvular stenosis. The mean systolic pressure gradients were found to be 86.5 +/- 31.4 mmHg (range 48 to 145 mmHg). Ten patients had mild and 13 patients had moderate-to-severe aortic insufficiency (AI) preoperatively. Nine patients had bicuspid aortic valve. Forty patients (45.4%) had associated cardiac lesions. Isolated membranectomy was performed in six patients. Membranectomy associated with septal myectomy was done in 52 patients. Fifteen patients of them associated hypoplasia of the aortic orifice necessitated aortic valve replacement (AVR) using the Konno-Rastan procedure. Fifteen patients with tunnel SAS and normal aortic valves underwent a combined approach for valve sparing, a modified Konno procedure with patch septoplasty. Also eight patients required AVR because of the severity of AI and five patients aortic reconstruction procedures. Aortic commissurotomy was performed to relief of stenosis in four patients. There were three early deaths (3.4%) and one late death (1.1%) all after the Konno-Rastan procedure. Eight patients (9.1%) had permanent conduction abnormalities. Postoperative left ventricle-aorta gradient was significantly decreased at early postoperative period (p < 0.001) and ranged from 10 to 25 mmHg (mean 14.1 +/- 4.3). Fourteen patients (16.5%) were reoperated for recurrent obstruction or progression of AI. The mean reoperation interval was 4.4 +/- 1.7 years (range 2 to 8 years). Five-year reoperation-free survival was 88.0 +/- 3.6% and 12.5-year reoperation-free survival was 75.5 +/- 7.0%. Our results of aggressive surgical approach of subvalvular aortic stenosis produces relief of obstruction and frees the valve leaflets, significantly reducing associated AI with long-term survival and long-term adequate relief of left ventricular outflow tract obstruction.

Short- and mid-term results of resection of discrete subaortic stenosis in children

“…[3,4] Progressively increasing aortic valve regurgitation due to the presence of stenosis also increases the risk for infective endocarditis. [7,12,13] Therefore, the timing of surgery should be planned in patients with discrete subaortic membrane, considering the gradient in the LVOT and progression of the aortic regurgitation.…”

“…[3,16] Although the optimal surgical approach is controversial, several aggressive methods such as simple membrane resection, [3,7,17] myomectomy, [10,18] and circumferential myomectomy and mobilization of right-to-left fibrous trigone [11] remain as surgical options. In our study, we performed limited resection of the hypertrophic muscle tissue in addition to the fibrous membrane resection in all cases.…”

“…Subvalvular aortic stenosis was defined as a lesion with a discrete fibrous, membranous, or fibro-muscular structure under the aortic valve in the LVOT in consistent with the literature data. [7] The diagnosis of discrete subaortic stenosis was performed by transthoracic echocardiography (TTE). Residual gradient and aortic valve competence were assessed by intraoperative transesophageal echocardiography (TEE) after cardiopulmonary bypass (CPB).…”

Tratamiento mediante dilatación con balón de un paciente con estenosis subaórtica por membrana: a propósito de un caso

“…El paciente puede presentar disnea de grado variable, así como mareos, dolor precordial y síncope. La lesión severa suele ocurrir generalmente en la edad adulta, con fallecimiento del paciente hacia la cuarta y quinta déca-da de la vida si la obstrucción no es tratada quirúrgicamente (8) . Sin embargo, en nuestro paciente la presentación de severidad fue más precoz, manifestán-dose sintomatología de insuficiencia cardiaca en un menor de 11 años, con compromiso severo de la función sistó-lica del VI, que además fue tratado por método intervencionista.…”

Secondary Subaortic Stenosis after Patch Closure of Subarterial Ventricular Septal Defect

“…Obstruction may be the result of either an actual ridge of fibromuscular origin or a fib-rous tissue that coats and tethers the aortic valve (AV) leaflets. 1)2) SAS can be divided into two main categories: discrete type and tunnel type. Discrete type is more common, and is caused by a discrete subvalvular membrane or muscular band.…”