Vanishing De Vega annuloplasty for functional tricuspid regurgitation

Annuloplasty is performed for significant functional tricuspid regurgitation even if it is presumed that in some cases the regurgitation will regress spontaneously after correction of the left-sided lesion. In an attempt to avoid the drawbacks of a permanent annuloplasty, we used a reabsorbable De Vega annuloplasty in a selected group of patients. Of 73 patients with functional tricuspid regurgitation operated on between May 1989 and May 1991, 25 with pulmonary arteriolar resistance below 400 dyne.sec.cm-5 underwent a De Vega annuloplasty with 2-0 polydioxanone suture. The diagnosis of significant functional tricuspid regurgitation (mean 2.74 +/- 1.05) was established by transthoracic color Doppler echocardiography in all patients. The degree of functional tricuspid regurgitation and pulmonary arteriolar resistance were measured with the patients anesthetized. In 16 patients the regurgitation remained severe (3+ to 4+) and in 9 it was moderate (2+). Twenty-three patients had mitral (12 repairs, 11 replacements) and 9 had aortic (4 repairs, 5 replacements) valve operations. The immediate postbypass residual functional tricuspid regurgitation was 0 to 1+ in 23 and 0 in 2. There was 1 (4%) operative death. The maximum follow-up period was 24 months (mean 13.9 months). There were 2 (8.3%) late deaths. Six patients underwent reoperation because of mitral dysfunction. Four of them who were reoperated on between 2 and 5 weeks after the initial procedure showed no recurrence of functional tricuspid regurgitation. The other 2, reoperated on at 5 and 10 months after the first operation, had recurrence of functional tricuspid regurgitation. Visual inspection of these two tricuspid valves showed a dilated anulus with otherwise normal valves. All surviving patients are in New York Heart Association functional class I or II without significant functional tricuspid regurgitation (mean 0.78 +/- 0.56). We concluded that functional tricuspid regurgitation in patients with low pulmonary arteriolar resistance can be adequately treated by a vanishing De Vega annuloplasty, which will stent the tricuspid anulus for about 4 months.     

Fine-needle aspiration cytology of the breast: a preliminary report on telepathology through Internet multimedia electronic mail

BACKGROUND AND AIMS OF THE STUDY: Tricuspid valve endocarditis traditionally has been treated with either valve resection or valve replacement. To avoid implantation of foreign material in an infected area and to circumvent anticoagulation, tricuspid valve repair was applied and the results assessed. METHODS: Tricuspid valve repair was performed in five patients with right-sided endocarditis. All patients had tricuspid regurgitation grade 3-4 on preoperative transesophageal echocardiography, and developed progressive deterioration associated with heart failure. The indications for surgery were congestive heart failure, persistent sepsis, recurrent emboli, concomitant left-sided endocarditis, and fungal infection. Surgical procedures included cusp resection, annular plication and annuloplasty, pericardial patch replacement, and construction of artificial chordae. RESULTS: There were no hospital deaths and major associated morbidity. Follow up is complete at a mean of 20.4 months. There were no reoperations or cases of recurrent infections. All patients are in NYHA class I-II. Postoperative echocardiography revealed no signs of major valvular dysfunction. CONCLUSIONS: Valve repair in right-sided endocarditis is a relatively new application for repair techniques, but may become an attractive alternative to tricuspid valve excision or prosthetic valve replacement.     

Durability of mitral valve repair for degenerative disease

BACKGROUND: Degenerative mitral valve disease is the most common cause of mitral regurgitation in the United States. Mitral valve repair is applicable in the majority of these patients and has become the procedure of choice. OBJECTIVE: This study was undertaken to identify factors influencing the durability of mitral valve repair. PATIENTS AND METHODS: Between 1985 and 1997, 1072 patients underwent primary isolated mitral valve repair for valvular regurgitation caused by degenerative disease. Repair durability was assessed by multivariable risk factor analysis of reoperation. It was supplemented by a search for valve-related risk factors for death before reoperation. Three hospital deaths occurred (0.3%); complete follow-up (4152 patient-years) was available in 1062 of 1069 hospital survivors (99.3%). RESULTS: At 10 years, freedom from reoperation was 93%. Among 30 patients who required reoperation for late mitral valve dysfunction, the repair failed in 16 (53%) as a result of progressive degenerative disease. Durability of repair was adversely affected by pathologic conditions other than posterior leaflet prolapse, use of chordal shortening, annuloplasty alone, and posterior leaflet resection without annuloplasty. Durability was greatest after quadrangular resection and annuloplasty for posterior leaflet prolapse and was enhanced by the use of intraoperative echocardiography. Death before reoperation was increased in patients having isolated anterior leaflet prolapse or valvular calcification and by use of chordal shortening or annuloplasty alone. CONCLUSIONS: Repair durability is greatest in patients with isolated posterior leaflet prolapse who have posterior leaflet resection and annuloplasty. Chordal shortening, annuloplasty alone, and leaflet resection without annuloplasty jeopardize late results.     

Adjustable tricuspid valve annuloplasty assisted by intraoperative transesophageal color Doppler echocardiography

Intraoperative transesophageal echocardiography (TEE) can play a major role in active guidance of cardiac surgery. This study describes a new application of TEE for assisting tricuspid suture annuloplasty. Twenty-five patients (aged 52 +/- 11 years) who underwent mitral valve replacement and tricuspid valve annuloplasty were studied intraoperatively by TEE. After cardiopulmonary bypass, the suture annuloplasty was adjusted on the beating heart until palpable regurgitation was eliminated. Further adjustment of the suture was performed under echocardiographic guidance until color Doppler flow imaging showed the most adequate correction of tricuspid regurgitation (TR). A significant decrease in the semiquantitative grade of TR, of regurgitant jet area and of the ratio jet area/right atrial area was obtained when the suture was adjusted under echocardiographic guidance. The peak inflow velocity and the gradient across the tricuspid valve did not show significant changes throughout the procedures. The results showed that the tricuspid suture annuloplasty guided by TEE enables a substantial reduction in residual TR without creating valve stenosis.     

Tricuspid valve surgery and intraoperative echocardiography: factors affecting survival, clinical outcome, and echocardiographic success

BACKGROUND: The impact of echocardiographic-guided treatment on outcome after tricuspid valve (TV) surgery is not well defined. OBJECTIVES: The purpose of this study was to determine clinical and echocardiographic factors associated with adverse outcomes after TV surgery and determine the role of intraoperative echo (IOE) in facilitating successful outcomes after TV surgery. METHODS: Four hundred and one patients (279 females, mean age 60 years) underwent TV surgery and other concomitant cardiac surgery at a single institution and were followed clinically and by echocardiography during a 10-year period. RESULTS: Decreased survival after TV surgery was associated with: preoperative increased New York Heart Association (NYHA) functional classification (relative risk [RR]=2.02), increased left ventricular dysfunction by echocardiography (RR=1.28), and use of a TV replacement strategy (RR=2.92). Decreased event-free survival after TV surgery was associated with concomitant coronary artery bypass grafting (RR=2.97). Late echocardiographic failure (3 to 4+ tricuspid valve regurgitation [TR]) after TV surgery was associated with increased severity of TR on preoperative echocardiogram (odds ratio [OR]=1.91). Decreased late echocardiographic failure after TV surgery was associated with the use of a TV annuloplasty ring with a repair strategy (OR=0.40). The surgical plan was altered at the time of surgery to insure a successful outcome in 32 (10%) of 335 patients based on IOE findings. CONCLUSIONS: Adverse outcomes after TV surgery can be predicted by several preoperative clinical and echocardiographic variables. IOE is useful in improving immediate, but not late, outcomes after TV surgery.     

Reoperation for valvular heart diseases

To elucidate the limitation of mitral valve reconstruction, 53 mitral disease patients (Mitral stenosis: 29, Mitral regurgitation: 24) undergoing reoperation late after valve reconstruction were studied, taking account of valvular lesions at initial operation. Reoperation rate after open mitral commissurotomy for mitral stenosis was higher in the patients with valvular regurgitation at initial operation than in those with severe subvalvular lesions or calcified valve. Reoperation rate for mitral regurgitation after mitral valvuloplasty was higher in the patients with stenotic fibrous degeneration or dilated annulus at initial operation than in those with torn chorda. Thus, these findings suggest that combined lesion of stenosis and regurgitation at initial operation may affect the reoperation rate in patients undergoing mitral valve reconstruction for either mitral stenosis or mitral regurgitation. Different approaches to the mitral valve through the left atrium and various techniques of the atriotomy have been practiced according to the need for a particular patients. The left atrium and the mitral valve can be exposed through median sternotomy followed by biatrial atriotomy or transplant approach. A correct approach and good exposure plays a key role in the success of redo surgical procedure for mitral valve disease.     

Valve repair with chordal replacement for traumatic tricuspid regurgitation

A 70-year-old woman who had fatiguability due to right heart failure seven years after receiving blunt chest trauma in a road traffic accident presented to our hospital. Preoperative echocardiography revealed severe tricuspid regurgitation resulting from prolapse of the anterior leaflet. The valve was repaired by chordal replacement with expanded polytetrafluoroethylene sutures and DeVega annuloplasty. At three months after surgery, the patient is in good clinical condition, and repeat echocardiography revealed only mild tricuspid regurgitation.     

Tricuspid valve replacement after orthotopic heart transplantation

Atrioventricular valvular regurgitation is a known complication after cardiac transplantation. In this communication, we describe a case of progressively severe tricuspid insufficiency that ultimately necessitated tricuspid valve replacement. The patient has done well clinically since valve replacement, and a postoperative cardiac catheterization demonstrated normal right heart hemodynamics. A discussion of proposed causes and a review of the literature are provided.     

Case of MPO-ANCA positive interstitial pneumonitis and necrotizing, crescentic glomerulonephritis

A 56-year-old female who was diagnosed incomplete endocardial cushion defect, underwent closure of ostium primum defect and repair of mitral cleft 2 years ago. Mitral and tricuspid ring annuloplasty was done 9 months after the first operation because of an increment of mitral and tricuspid valve regurgitation. The Third operation, mitral valve replacement by mechanical valve and tricuspid valve replacement by bioprosthetic valve, was performed because of the gradually increased mitral stenosis and tricuspid regurgitation. Post-operative course was uneventful. Resected anterior cusp of mitral and tricuspid valve revealed hypertrophy and shortness macroscopically, and revealed fibrosis and calcification histopathologically. It was considered that remarkable regurgitation was due to secondary change of both valves. We concluded that valve replacement should be performed for case of secondary change of atrioventricular valve in adult patient.     

The INK4a/ARF tumor suppressor: one gene--two products--two pathways

From 1987 to 1996 we operated on 263 patients for mitral insufficiency. Multiple valve operations were excluded, with the exception of tricuspid reconstruction for functional regurgitation. The perioperative mortality was 3%, while the late mortality rate during a mean follow-up period of 3.5 years amounted to 2% per patient year and 1.7% if only cardiac causes were considered. The prognosis for patients with rheumatic, endocarditic and ischemic valvular disease was much worse compared to that for a degenerative cause. The latter group consisted of 209 patients with an operative mortality of 1.4% and a late mortality rate per patient year of 1.4% and 0.9% for cardiac causes only. Further analysis showed a significant prognostic improvement for patients with a preoperative ejection fraction of more than 60% and a repairable valve.     

Results of left atrioventricular valve reconstruction after previous correction of atrioventricular septal defects

OBJECTIVE: The objective of this study was to determine causes of severe left atrioventricular (AV) incompetence and the factors leading to the success of valve repair later after correction of atrioventricular septal defects (AVSD). METHODS: A total of 28 patients aged 5 months to 38 years (mean age 6.7 years) were operated for significant (grade II-III) left AV valve incompetence (LAVVI), two months to twenty-five years (median 1.5 years) after correction of complete (11 patients) or partial atrioventricular septal defects. Fourteen patients had initially undergone surgery during infancy. RESULTS: At reoperation a completely open or partially sutured cleft was found in 16 patients combined with dysplastic valve tissue in four cases, with a fibrotic valve in three cases, with posterior leaflet prolapse in two cases, with a double orifice valve in three cases, and a parachute valve in two cases. Partial or complete reopening of a previously sutured cleft caused by suture dehiscence was found in 12 cases combined with a fibrotic valve in five cases, with a dysplastic valve in one case and with severe deformity of valve in one case. A combination of these anomalies was observed in seven patients in both groups. Left atrioventricular valve repair including cleft closure combined with annuloplasty and other surgical procedures resulted in the disappearance or significant diminishing of LAVI in 18 patients (64%). Severe SAVI persisted in six patients, five of them exhibiting a combination of several additional left AV valve anomalies (fibrotic or dysplastic valve, parachute valve). Five of these six patients underwent successful left AV valve replacement with a mechanical prosthesis 7 days to 2 years after reoperation. The presence of additional left AV valve anomalies was the single statistically significant factor for recurrent major LAVVI after reoperation (P = 0.0106). There were two postoperative deaths in patients with mild LAVVI after surgery, and no late deaths. CONCLUSION: An open cleft is the major factor of late severe SAVVI after correction of AVSD. Although suturing the cleft in conjunction with performing annuloplasty improved valvular function in most of the cases, the presence of severe left AV valve anomalies increased the risk of recurrent LAVVI and the need for valve replacement, thus playing a major role in determining the outcome of valve reconstruction in patients after reoperation.     

Determinants of reoperation after 960 valve replacements with Carpentier-Edwards prostheses

During the period of 1977 to 1990, 960 Carpentier-Edwards standard prostheses (Baxter Healthcare Corp., Santa Ana, Calif.) were placed in 875 operations. Freedom from reoperation at 10 years was 57% +/- 4%, 76% +/- 3%, and 95% +/- 5% for mitral, aortic, and tricuspid valve replacement, respectively. Age was the only independent determinant of reoperation for both aortic and mitral valves. Likelihood of reoperation decreased with age, with freedom from reoperation after 10 years in patients aged less than 60 years versus 60 or more years being 65% +/- 5% versus 90% +/- 4% after aortic valve replacement and 48% +/- 5% versus 75% +/- 6% after mitral valve replacement. For mitral valve replacement, larger valve size made reoperation more likely, with freedom from reoperation at 10 years being 71% +/- 6% for sizes median less than 31 mm and 57% +/- 5% for sizes 31 mm or larger. For aortic valve replacement, prior median sternotomy reduced freedom from reoperation at 10 years from 80% +/- 3% to 25% +/- 5%. The low prevalence of reoperation affirms the suitability of the Carpentier-Edwards prosthesis for selected elderly patients and for tricuspid valve replacement. Because of their influence on the probability of reoperation, valve size and prior cardiac procedures also merit consideration in the choice of valvular prosthesis.     

Congenital malformations of the mitral valve in children. Pathology and surgical treatment

A systematic study of congenital mitral valve malformations was undertaken on a surgical basis in an attempt to develop techniques of valvular reconstruction adapted to the various lesions. Forty-seven children between the ages of 4 months and 12 years (average 6 years, 4 months) have been operated upon between January, 1970, and March, 1976. Valvular lesions were classified into four group: Group I, mitral insufficiency owing to valvular lesions: Group II mitral insufficiency with subvalvular lesions; Group III, mitral insufficiency and stenosis; Group IV, stenosis. Associated lesions (ventricular or atrial septal defects, coarctation, or aortic valve stenosis) were present in 31 patients (65 per cent) and were corrected during the same operation. Valve reconsruction was possible in 38 patients whereas valve replacement was necessary in 9 patients. In the valve repair group there were three operative deaths (8 per cent), no late deaths, one reoperation for residual ventricular septal defect, and one myocardial infarction. In the valve replacement group of 9 patients, there were three operative deaths, three late deaths, and one case of repeated embolization. Thirty-one of 38 patients in the valve repair group were classified into Functional Class I after the operation (86 per cent), 2 were in Class II, and one in Class III. Minimal or moderate regurgitation and cardiomegaly persisted in the majority of the patients. Pulmonary artery pressure significantly decreased, however, as demonstrated by postoperative catheterization in 17 patients.     

Valve replacement in children

We report 27 children aged 2-14 years underwent valve replacement. Twelve patients underwent mitral valve replacement, 11 tricuspid valve replacement, and 4 aortic valve replacement. Of them, 16(59.3%) were associated with cardiac malformation, 23 were in NYHA functional class III and IV in preoperation. 13 patients required additional procedures. There were 3 hospital deaths (11.1%), 4 late deaths (16.6%), and 2 reoperation. Our experiment suggested that the greater type of mechanical valve be essential for valve replacement in children, but suture technique be modified for the children with small valvular ring. After replacement of mechanical valve, low concentration anticoagulation therapy is considered as a safe and reliable method.     

Valve repair in infective endocarditis

From 1985 to 1995, 12 patients with native valve endocarditis underwent valve repair instead of replacement. Mean age was 41.9 years (range from 5 to 79 years). Eight patients had active and 4 patients inactive infection. The mitral valve was involved in 6 patients, the aortic valve in 1, both valves in 2, the tricuspid valve in 2, and the mitral and pulmonary valves in 1. The pathological findings were as follows: leaflet perforation in 2 patients, chordal rupture in 3, and vegetations in 10. Valve sparing procedures were carried out on the mitral valve in 8 patients, on the aortic valve in 1, on the tricuspid valve in 2, and on the pulmonary valve in 1. The following repair techniques were used: vegetectomy in 10 patients, leaflet patching in 2, posterior mitral leaflet resection in 3, mitral annuloplasty in 4, and pulmonary valve repair in 1. Uncontrolled sepsis, progressive heart failure, peripheral embolism, and echocardiographically demonstrated vegetations were the indications for surgery. There was no operative or late mortality and all infections were cured with no recurrences. One patient required valve replacement following aortic valve repair because of progressive aortic regurgitation. Postoperative Doppler echocardiography showed trivial to no regurgitation in 11 patients after valve repair. The overall outcome was favorable during the mean follow-up period of 39.3 months (range from 1 to 120 months). Reparative or reconstructive approaches for native valve endocarditis should be considered and can be successfully performed. Their advantages include (1) improved hemodynamics, (2) no recurrence, (3) no mortality, and (4) favorable long-term results.     

25 years of aortic valve replacement using mechanical valves. Risk factors for early and late mortality

This study describes the changes that have taken place in patient characteristics in 25 years of aortic valve replacement using mechanical valves, and looks for risk factors for early and late mortality. During this period, 1449 mechanical valves were implanted. Overall early mortality (< 30 days) was 5.3% and for aortic valve replacement without concomitant procedures 3.9%. Overall survival rates at 5, 10 and 15 years were 80%, 63% and 49%, respectively. Despite an increased proportion of higher risk patients (older age, more reoperations, more concomitant coronary bypass surgery) survival rates improved throughout the study period. Early mortality was related to an early year of operation, urgency, reoperation and concomitant surgery to the tricuspid valve or ascending aorta. Late mortality was higher for patients of older age, with an early year of operation, male gender, concomitant coronary bypass surgery, mitral valve surgery or replacement of the ascending aorta. Aortic regurgitation did not have a major influence on early nor late mortality. The improvement in early and late mortality in more recent years was largely the result of the introduction of cardioplegia. A changing, non-proportional effect was observed for several risk factors during the follow-up period. This study illustrates the changes and improvements in medical care that have taken place in patients requiring aortic valve replacement.     

Detection of melanomas by digital imaging of spectrally resolved ultraviolet light-induced autofluorescence of human skin

AIMS: To evaluate the feasibility of papillary muscle shortening in a specific group of high risk patients with ischaemic mitral regurgitation undergoing mitral valve reconstruction. BACKGROUND: From January 1996 to December 1997, 712 (10.1%) out of a total of 7042 open heart patients underwent mitral valve surgery in our hospital. Mitral valve reconstruction was performed in 408 of these patients (57.3%) and valve replacement had to be performed in 304 patients (42.7%). METHODS: A specific technique of papillary muscle reconstruction was performed in 32 patients undergoing valve reconstruction (7.8%). These cases had degenerated and had developed fibrotic elongated papillary muscles, which resulted in prolapses of one or more parts of the mitral valve leaflets. The aetiology in this group of patients was ischaemic, requiring concomitant myocardial revascularization in 28 patients (87.5%) with a mean of 2.7 grafts/patient. All patients underwent papillary muscle shortening using a pericardium pledget-reinforced Polytetrafluoroethylene suture and annuloplasty with a Carpentier-Edwards Physio Annuloplasty Ring. Of these 32 patients, 17 (53.1%) were male, the mean age was 67.1+/-9.7 years (range 41 to 81 years) and all but one were in pre-operative NYHA class III or IV. RESULTS: There were two hospital deaths (6.2%). Postoperative Doppler echocardiography indicated satisfactory mitral valve function in all patients. Within the short mean follow-up period of 9.6+/-5.4 months (3 to 26 months) there was one non-cardiac-related death (3.1%). There was no need for reoperation, and no cases of thromboembolic and bleeding complications in the postoperative period. All patients were in NYHA functional class I or II at the time of follow-up. CONCLUSION: Our results indicate that mitral valve repair is a safe treatment for this group of high risk patients, and that papillary muscle shortening is a valuable tool in these patients with ischaemic mitral regurgitation undergoing surgery.     

Surgical treatment of patients with Wolff-Parkinson-White syndrome and associated Ebstein's anomaly

Ebstein"s anomaly is the most common congenital heart disease associated with the Wolf-Parkinson-White syndrome. Between November 1973 and March 1993, we surgically treated 42 patients with Wolff-Parkinson-White syndrome and Ebstein's anomaly. The patient's ages ranged from 5 months to 59 years (mean 35.3 +/- 14.0 years). There were a total of 52 accessory pathways, 48 of which were located in the right (65%) or posteroseptal (29%) area. A left-sided accessory pathway was seen in only two patients (3.8%). Division of all right-sided accessory pathways was done during normothermic cardiopulmonary bypass with the heart beating; cryocoagulation was applied together with scalpel dissection of the atrioventricular groove. Division of the left-sided accessory pathways was done with the use cold potassium cardioplegic arrest. Thirty-five of these patients underwent tricuspid valve operation for Ebstein's anomaly and 11 of them underwent tricuspid valve replacement with a bioprosthesis. All 52 accessory pathways were successfully divided, although two patients required reoperation because of tachycardia caused by accessory pathways in different positions. Three hospital deaths (7.1%) occurred. There were no late deaths during the follow-up period (mean 94.3 +/- 52.4 months), but two patients required repeat tricuspid operation because of progression of the tricuspid regurgitation. Because no repeat operations were required during long-term follow-up patients who underwent valve repair or valve replacement, correction should be indicated in some patients.     

Influence of pulmonic position on durability of bioprosthetic heart valves

BACKGROUND: The insertion of bioprosthetic valves into the pulmonic position is not performed commonly because of uncertainty concerning the necessity and durability of such valves. METHODS: We reviewed the long-term outcome of 10 patients who underwent pulmonary valve replacement with bioprostheses between March 1985 and March 1997. A Carpentier-Edwards supraannular bioprosthesis was used in 7 patients, a Hancock II bioprosthesis was used in 2 patients, and a Carpentier-Edwards pericardial bioprosthesis was used in 1 patient. The mean patient age at the time of pulmonary valve replacement was 38.9 +/- 16.3 years (range, 15 to 63 years). The diagnoses were pulmonary valvular regurgitation after corrective surgery for tetralogy of Fallot in 7 patients, right ventricular outflow tract stenosis and absent right pulmonary artery combined with a double-outlet right ventricle in 1 patient, pulmonary valvular regurgitation with pulmonary artery dilatation in 1 patient, and aortic valve stenosis treated with our modification of the Ross procedure using a pulmonary bioprosthesis in 1 patient. Survivors were followed up for a mean of 5 years and 5 months. RESULTS: One patient underwent reoperation because of infective endocarditis of the bioprosthesis. No bioprosthetic valve dysfunction has been observed on Doppler echocardiography during a maximum follow-up period of 12.2 years, except in the patient who underwent replacement at 15 years of age. CONCLUSIONS: Bioprostheses in the pulmonic position are durable in adult patients because they face a minimal hemodynamic load, but they may undergo early leaflet degeneration in younger patients.     

Infiltration of the central nervous system by a granulosa cell tumor immunostained by antibodies against inhibin

In most of the previously reported cases of isolated tricuspid regurgitation, both tricuspid leaflets and subvalvar tissue have been absent, hypoplastic, or fused. For this reason, tricuspid valvoplasty was difficult and valve replacement was adopted in many cases. In the present case of a 52-year-old man, however, the tricuspid valve showed no abnormalities other than a severely dilated tricuspid annulus. Ring annuloplasty was performed, and this resulted in a subsequent satisfactory course without anticoagulant therapy.