Fifty-one patients with a mean age of 31.2 years underwent aortic valve replacement with glutaraldehyde-treated autologous pericardium. Pure aortic regurgitation was present in 28 (54.9%), stenosis in 9, and mixed disease in 14. Simultaneous mitral valve repair was done in 17 patients and replacement in 1. There were no hospital and two late deaths. Three patients required reoperation because of failure of the pericardial valve as a result of infective endocarditis in two (5 and 31 months after operation) and commissural tear at 8 months in another. One patient underwent reoperation at 24 months because of failure of the mitral valve repair. The pericardial aortic valve, which had 2+ regurgitation since the first operation, was also replaced. Macroscopic and microscopic examination findings in the excised pericardium were excellent. No thromboembolic events have been detected and no patient received anticoagulation therapy except one after mitral valve reoperation and replacement with a mechanical valve. The actuarial survival was 84.53% +/- 12.29% at 60 months, freedom from failure of the aortic reconstruction 83.83% +/- 8.59%, and freedom from any event 72.59% +/- 12.79%. Doppler echocardiographic study at most recent follow-up showed a mean gradient of 12.56 +/- 8.10 mm Hg and mean regurgitation on a scale from 0 to 4+ of 0.80 +/- 0.66. Although the maximum follow-up is only 5 years, the results obtained so far encourage us to continue replacing the aortic valve with stentless autologous pericardium.

(1) the rate of repair is age dependent and inversely related; (2) repair in patients younger than 20 years of age carries a high reoperation rate; and (3) in this age group there is a higher survival tendency.

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Aortic valve replacement in the young patient, and particularly in women of child-bearing age, still represents a problem. Between July 1988 and August 1993, 644 aortic valve patients (mean age 32.5 years) were operated in our institution. Aortic valve reconstruction was performed in 274 (42.5%). A variety of repair techniques (valvuloplasty) was used in 202 patients (mean age 21.5 years). Concomitant mitral surgery was performed in 103 (51%). In 72 patients (mean age 27.7 years), a cusp extension was undertaken with glutaraldehyde treated bovine (27 pts) or autologous (45 pts) pericardium. In the "plasty" group, there were 8 (4%) hospital deaths and 8 (4.1%) late deaths with an actuarial survival of 86.05% +/- 3.97%. No thromboembolic events were detected in patients with isolated aortic surgery. There were 32 reoperations without mortality, 22 due to progressive rheumatic disruption of the mitral repair. There was severe aortic dysfunction in 17 (8.76%) cases. There was no hospital mortality among the 72 patients with cusp extensions. There were two (2.8%) late deaths and no thromboembolic events. No patient was anticoagulated. Four patients required reoperation on the aortic valve without mortality. The last echocardiographic follow-up showed stability of the reconstruction. These techniques offer a valid alternative to valve replacement in this difficult category of patients.

Repair of associated moderate AV lesion is worth considering even in a predominantly young rheumatic population.

Valve repair is an established form of treatment for mitral valve regurgitation. In order to elucidate the feasibility and results of aggressive repair in a young rheumatic population, all consecutive patients operated on between July 1988 and July 1990 for mitral regurgitation were reviewed. There were 203 patients with a mean age of 29 years; 91% were in functional classes III-IV. Pure regurgitation was present in 47.8%. Associated valvular surgery was performed in 56.2%. Forty-nine (24.1%) patients had a straight valve replacement (MVR), 18 (8.9%) had an unsuccessful attempt at repair and in 136 (67%) the repair was considered successful. Overall hospital mortality was 3.4%: 4% for MVR, 16.6% for the attempts, 1.4% for repairs. The thromboembolic rate for replacement was 6.0% pt-yr and for repair 0.87% pt-yr. There were five late deaths in the replacement group and one in the repair group. Seventeen patients required reoperation in the repair group (12.6%) with a mean age of 17 years. Six of these patients had active rheumatic carditis, either at first operation or in the postoperative period. The postoperative functional status of all patients was excellent. In conclusion, valve repair although possible in a high percentage of rheumatic regurgitation patients carried a penalty of unsuccessful attempts and reoperations. However, in the follow-up period the rate of thromboembolism and late mortality among the patients with prostheses offsets these disadvantages.