Preparations for heart surgery in an infant. A study now determines the most favorable time for surgery in patients with a leaking aortic valve., Wolfram Scheible für Nationales Register © Wolfram Scheible für Nationales Register

Medicine and Healthcare

Leaky Aortic Valve: When is it Time for Surgery?

A study to determine cutoff values

Scientific name of the study

Multicenter Study to Assess the Impact of Chronic Aortic Insufficiency on the Left Ventricle in Children, Adolescents, and Young Adults - The ALIVE Study.

The four heart valves fulfill a vital function for the cardiovascular system. They control the flow of blood that supplies the body and its organs with oxygen. Between the left ventricle and the aorta, the aortic valve performs this task. It consists of three crescent-shaped pockets. If they do not close properly, blood flows back into the left ventricle. In the long run, the left ventricle becomes overloaded by this blood volume, and it increases in size and its muscle thickens. This has an unfavorable effect on the left ventricular function and can lead to heart failure.

Aortic Insufficiency After Valve Replacement or Valve Reconstruction

Malformations of the aortic valve are among the more common congenital heart defects that often require treatment in childhood. Permanent leakage of this valve (also known as aortic insufficiency, aortic valve regurgitation or aortic regurgitation) occurs in many cases as a result of surgical treatment or cardiac catheterization of a previously narrowed aortic valve. However, aortic insufficiency can also occur in association with other heart defects or diseases such as endocarditis. Less commonly, permanent aortic insufficiency is congenital.

The Right Time Matters

Although aortic insufficiency is a well-recognized disease, it is not clear at what point in childhood, adolescence, and young adulthood aortic valve surgery should be recommended. Recommendations are largely based on adult cardiology experience and guidelines and have limited applicability to younger patients. This is complicated by the fact that many children, adolescents, and young adults have no symptoms despite higher-grade aortic insufficiency.

Study Determines Cutoff Values for the First Time

The right time for aortic valve surgery can be well deduced if it is known how the size and volume of the left ventricle and its function have changed under conditions of aortic insufficiency as well as after surgery. Cardiovascular examinations using echocardiography and magnetic resonance imaging (MRI) can provide reliable evidence of the degree to which normalization of the left ventricle can be expected after surgery. In a large-scale multicenter study, we are now identifying appropriate cutoff values for younger patients with the support of the National Registry and in collaboration with hospitals and centers specializing in congenital heart defects in children and adolescents.

Retrospective and Prospective

Children, adolescents and young adults under 26 years of age who suffer from chronic aortic insufficiency either exclusively or in connection with a congenital malformation of the aortic valve and other organ malformations and who need or have already undergone aortic valve surgery are included in the study.

On the one hand, we retrospectively evaluate the medical data of study participants with chronic aortic insufficiency who have already undergone aortic valve surgery. We are particularly interested in the results of the echocardiographic examination before and after surgery. The data to be collected by the hospitals and centers include left ventricular size, as well as biplane ejection fraction and parameters on the severity of aortic insufficiency.

On the other hand, in a second prospective study arm, we will consider the MRI and ultrasound values of study participants with chronic aortic insufficiency who are scheduled for aortic valve surgery or aortic valve reconstruction, before the procedure as well as one to three months and twelve months after surgery. The data will be collected at the participating hospitals and centers and pseudonymized in the National Registry for subsequent analysis by specialists.

Numerous Pediatric Heart Centers Participate

In addition to the Department of Congenital Heart Diseases and Pediatric Cardiology at the University Hospital Schleswig-Holstein, Campus Kiel, the following hospitals and centers are participating in this study so far: the Pediatric Cardiology and Intensive Care Medicine at the University Hospital Göttingen, the Department of Pediatric Cardiology and Congenital Heart Defects at the Heart and Diabetes Center NRW in Bad Oeynhausen, the Department of Congenital Heart Defects and Pediatric Cardiology at the German Heart Center Munich, the Department of Congenital Heart Disease and Pediatric Cardiology at the German Heart Center Berlin, the Department of Pediatric Cardiology, Pulmonology, Intensive Care Medicine at the University Hospital for Pediatrics and Adolescent Medicine in Tübingen, the Department of Pediatric Cardiology at the Hospital Stuttgart, the Department of Pediatric Cardiology and Congenital Heart Disease at the University Hospital Heidelberg, the Children's Heart Center at the University Hospital Bonn and the Department of Pediatric Cardiology at the University Hospital Erlangen. Participation of other interested centers is possible.

Improving Treatment and Enhancing Quality of Life

Establishing appropriate criteria and cutoff values will help prevent long-term adverse left ventricular damage in young patients with aortic insufficiency. The goal is to improve treatment, reduce postoperative mortality, and improve quality of life in those affected. We would like to thank all study participants for their valuable support.

Of course, we will report the results of the evaluation, also here.  

  • Good to Know

    The Large and the Small Circulation

    In the large circulation, the oxygenated blood accumulates in the left atrium. From here it is carried through the mitral valve and to the left heart chamber. The chamber then pumps the blood through the aortic valve and into the main artery (aorta). The aorta proceeds to transport the blood to the single somatic cells via the arteries, arterioles and capillaries, that is, the blood vessels leading away from the heart. Thus, the somatic cells are supplied with fresh oxygen. At this stage of the cardiovascular system, the blood gives off the oxygen to the somatic cells in the different organs, while, at the same time, taking up the carbon dioxide produced in the organs. The “used” deoxygenated blood is then taken to the right atrium of the heart by the venules, smaller and larger veins. In diastole the blood flows from the right atrium to the right heart chamber.

    This is where the pulmonary circulation starts. During systole, the right heart chamber pumps the deoxygenated blood to the pulmonary artery. This happens simultaneously to the left heart chamber pumping the oxygenated blood to the aorta. The pulmonary artery branches out into smaller arteries and arterioles and, eventually, into capillaries. The capillaries cover the pulmonary alveoli like a delicate net. Within the pulmonary alveoli, gas exchange happens: The blood gives off carbon dioxide and takes in fresh oxygen. The oxygenated blood flows through the pulmonary veins and into the left atrium. From here, the two blood circulations start anew.

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Die Studie wird gefördert von der Fördergemeinschaft Deutsche Kinderherzzentren e. V. © Fördergemeinschaft Deutsche Kinderherzzentren e. V.
Die Studie wird gefördert von der Fördergemeinschaft Deutsche Kinderherzzentren e. V.

In charge of the project:

  • Dr. med. Ulrike Bauer, Wolfram Scheible für Nationales Register © Wolfram Scheible für Nationales Register

    Dr. med. Ulrike Bauer

    Ulrike Bauer is the Scientific Managing Director of the National Register for Congenital Heart Defects and the Competence Network for Congenital Heart Defects. More

    Kompetenznetz Angeborene Herzfehler e. V.
    Netzwerkzentrale

    Augustenburger Platz 1
    13353 Berlin
  • PD Dr. med. Inga Voges, UKSH | privat © UKSH | privat

    Dr. med. Inga Voges

    PD Dr. med. Inga Voges is senior physician and head of Cardio-MRI at the Clinic for Congenital Heart Disease and Pediatric Cardiology at the University Hospital Schleswig-Holstein, Campus Kiel.

    Universitätsklinikum Schleswig-Holstein - Campus Kiel
    Klinik für angeborene Herzfehler und Kinderkardiologie

    Arnold-Heller-Str. 3
    24105 Kiel
  • Prof. Dr. med. Anselm Uebing, Alex Orrow © Alex Orrow

    Prof. Dr. med. Anselm Uebing

    Anselm Uebing, born in 1969, is Director of the Clinic for Congenital Heart Defects and Pediatric Cardiology at the University Medical Center Schleswig-Holstein, Campus Kiel. More

    Universitätsklinikum Schleswig-Holstein - Campus Kiel
    Klinik für angeborene Herzfehler und Kinderkardiologie

    Arnold-Heller-Str. 3
    24105 Kiel

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