Late results of mitral valve repair for mitral regurgitation due to degenerative disease

From June 1981 to August 1992, 184 patients with mitral regurgitation due to degenerative disease underwent mitral valve repair. The mean age was 57 years, and 74% were men. One-third of the patients were in atrial fibrillation, and 71% were in New York Heart Association classes III and IV. The mitral regurgitation was due to prolapse of the posterior leaflet in 97 patients (53%), prolapse of the anterior leaflet in 42 (23%), and prolapse of both leaflets in 45 (24%). The degree of myxomatous changes was assessed intraoperatively as mild in 125 patients (68%), moderate in 27 (15%), and severe in 32 (17%). Mitral valve repair was accomplished largely by techniques described by Carpentier. Ring annuloplasty was performed in 160 patients (66 with Carpentier ring and 94 with Duran ring). There was one operative death, and 5 patients experienced life-threatening complications. Patients were followed up from 5 to 132 months (mean, 41 months). The actuarial survival at 8 years was 88% +/- 4%. The freedom from stroke at 8 years was 94% +/- 2%, and the freedom from transient ischemic attacks was 86% +/- 6%. Age greater than 60 years was the only factor associated with higher risk of thromboembolic complications by logistic regression analysis. The actuarial freedom from reoperation at 8 years was 95% +/- 2%. Advanced myxomatous changes in the leaflets of the mitral valve was the only significant factor associated with a higher risk of reoperation. Most patients were in New York Heart Association class I at the last follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)     

Primary repair is superior to initial palliation in children with atrioventricular septal defect and tetralogy of Fallot

OBJECTIVE:The objective was to explore the best management algorithm for atrioventricular septal defect in conjunction with tetralogy of Fallot. METHODS: We reviewed the cases of 38 children referred to our division (March 1981-August 1997) who had atrioventricular septal defect associated with tetralogy of Fallot; 32 (84%) had Down syndrome. Twenty-one received initial palliation with a systemic-to-pulmonary artery shunt; of these, 2 (9.5%) died before complete repair. Thirty-one children underwent complete repair; 14 of these (45%) had undergone initial palliation (mean age at shunt 20 +/- 24 months). Right ventricular outflow obstruction was relieved by a transannular patch in 22 (71%); 14 (64% of 22) had a monocuspid valve inserted. Four required an infundibular patch. RESULTS: Two children (6.4%) died early after repair; 1 had undergone previous palliation. Patients with palliation underwent repair at an older age (78 vs 36 months), required longer ventilatory support (8 vs 4 days) and inotropic support (8 vs 4 days), and had longer intensive care stays (11 vs 6 days) and hospital stays (24 vs 15 days). Eleven children (35%) underwent reoperation, 7 (58%) for right ventricular outflow reconstruction and pulmonary arterioplasty. Reoperation was more frequent in the palliation group than in the primary operation group (64% vs 12%). The single late death was related to a reoperation in the palliation group. CONCLUSIONS: Atrioventricular septal defect with tetralogy of Fallot can be repaired with a low mortality rate. Initial palliation with a shunt resulted in a more complex postoperative course and a higher reoperative rate. Primary repair is superior to initial palliation with later repair.     

Unidirectional valve patch for repair of cardiac septal defects with pulmonary hypertension

BACKGROUND: Congenital septal defects with a large left-to-right shunt often cause pulmonary hypertension, which complicates surgical repair of the defects. METHODS: Twenty-four patients with congenital cardiac septal defects and severe pulmonary hypertension had operation to close the septal defect using a unidirectional valve patch during a 3-year period. The ratio of systolic pulmonary artery pressure to systolic arterial blood pressure was near to or more than 1.0 in all patients. RESULTS: Two patients died in the hospital after operation, and there have been no deaths during intermediate term follow-up. Mean pulmonary artery pressure decreased from 80 +/- 12 mm Hg to 56 +/- 18 mm Hg. The ratio of pulmonary artery pressure to systemic arterial pressure dropped from 1.1 +/- 0.1 mm Hg to 0.7 +/- 0.1 mm Hg. The unidirectional valve patch functioned allowing right to left shunting in 4 patients with a systolic pulmonary artery pressure more than systolic arterial blood pressure immediately after closure of a septal defect. The patch sealed or was effectively closed by the third postoperative day. There was impressive improvement in symptoms and exercise tolerance after operation during the 3-month to 3-year (mean, 1.1 year) follow-up period. CONCLUSIONS: The unidirectional valve patch is useful for management of patients having operation to close cardiac septal defects in the presence of severe pulmonary hypertension.     

Transxiphoid approach without median sternotomy for the repair of atrial septal defects

BACKGROUND: Interest in minimally invasive procedures has recently increased because it results in less surgical trauma, decreased patient discomfort, short hospital stay, reduced costs, and better cosmetic appearance. Based on these facts, we have been using the transxiphoid process approach without sternotomy for the correction of atrial septal defects. METHODS: From July 1996 to January 1997, the xiphoid process window approach was performed in 10 patients with ostium secundum atrial septal defect. Ages ranged from 6 months to 14 years (mean, 5.3 years). In all patients, extracorporeal circulation was carried out by means of cannulation of the femoral artery and both caval veins and of aortic cross-clamping. Videothoracoscopy was used to improve visualization of the aorta. RESULTS: There were no intraoperative or postoperative complications, and in all but 1 patient, extubation was possible while in the operating room. CONCLUSIONS: The xiphoid process window, with no median sternotomy, permitted closure of the atrial septal defects with good results and could be used as a less invasive technique for their correction.     

Atrial septal defect with tricuspid valve regurgitation and heart failure in early childhood: report of a case with successful surgical management consisting of special patch closure technique and use of polydioxanone suture for the tricuspid annuloplasty

A management of surgery for infant having a small left ventricular cavity associated with atrial septal defect and tricuspid valve regurgitation was presented. A right upper part of the defect was remained in open during a patch closure of ASD and this portion was temporarily sutured by prolene stayed extracardialy through Waterston's groove. During 20 minutes after weaning from the cardiopulmonary bypass, left heart failure did not appear and then it was completely closed. DeVega's method was employed for the tricuspid valve regurgitation using a absorbale Polydioxanone suture, because of a growth of the sutured annulus. Postoperative course was uneventful and trivial tricuspid valve regurgitation was recognized in angiocardiographic studies performed in 2 weeks and 6 months after operation.     

Transcatheter closure of atrial septal defects within the oval fossa: medium-term results in children using the 'ASDOS'-technique

OBJECTIVES: The purpose of this study was to evaluate the safety and efficacy of the ASDOS-technique (Sulzer-Osypka GmbH, Germany) for transcatheter closure of atrial septal defects within the oval fossa. BACKGROUND: Although several attempts have been made to occlude defects within the oval fossa by transcatheter techniques, none of these has gained general acceptance. METHODS: Patients with a defect in the oval fossa measuring equal to or less than 20 mm diameter, with a residual septal rim of 5 mm or greater, body weight greater than 10 kg, with clinical indications for surgical closure were considered for transcatheter closure. Follow-up investigations were performed at discharge, after 1, 3, 6 and 9 months, as well as after 1 and 2 years. RESULTS: Of 78 patients considered for closure, a device was inserted in 41 patients (53%), with success being achieved in 40 patients (98%). The ages ranged from 1.1 to 15 years (7.8 +/- 1.92 years), the 'stretched' diameter of the defect from 10 to 20 mm (14.7 +/- 2.60 mm), and the diameters of the inserted devices from 25 to 45 mm (33.2 +/- 5.43 mm). Transient impairment of atrioventricular conduction occured in 4 patients. During the follow-up of 23.0 +/- 5.6 months elective surgical closure of a residual shunt was performed 26 months after insertion of the device in one patient. None of the other patients required surgery, hospitalisation or medical treatment, and none is requiring further treatment of the defect within the oval fossa. Fracture of one arm of the device occurred in 4 patients, but the fractured arms are in an unchanged and stable position after a period of at least 19 months. CONCLUSIONS: Our medium-term data show that transcatheter closure in children of defects within the oval fossa can be performed with a high efficacy and safety using the ASDOS-device.     

Closure of atrial septal defects with the Amplatzer occlusion device: preliminary results

OBJECTIVES: This study reports our clinical experience with transcatheter closure of secundum atrial septal defects (ASDs) in children, using the Amplatzer, a new occlusion device. BACKGROUND: None of the devices previously used for transcatheter closure of interatrial communications has gained wide acceptance. METHODS: We examined the efficacy and safety of the Amplatzer, a new self-centering septal occluder that consists of two round disks made of Nitinol wire mesh and linked together by a short connecting waist. Sixteen patients with secundum ASD met established two- and three-dimensional echocardiographic and cardiac catheterization criteria for transcatheter closure. The Amplatzer's size was chosen to be equal to or 1 mm less than the stretched diameter. The device was advanced transvenously into a 7F long guiding sheath and deployed under fluoroscopic and ultrasound guidance. Once its position was optimal, it was released. RESULTS: The mean ASD diameter by transesophageal echocardiography was 14.1+/-2.3 mm and was significantly smaller (p < 0.001) than the stretched diameter of the ASD (16.8+/-2.4 mm). The mean device diameter was 16.6+/-2.3 mm. No complications were observed. After deployment of the prosthesis, there was no residual shunt in 13 (81.3%) of 16 patients. In three patients there was trivial residual shunt immediately after the procedure that had disappeared in two of them at the 3-month follow-up. CONCLUSIONS: The Amplatzer is an efficient prosthesis that can be safely applied in children with secundum ASD. However, a study including a large number of patients and a longer follow-up period are required before this technique can be widely used.     

Long-term results of primary closure for ventricular septal defects in the first year of life

The long-term results of primary closure for large ventricular septal defects (VSDs) in infants under 1 year of age with severe symptoms were studied over a period of more than 10 years. Between January, 1971 and March, 1982, 49 infants underwent primary closure of a VSD through a right ventriculotomy using complete cardiopulmonary bypass with mild hypothermia. There were four hospital deaths but no late deaths. Two of four infants with residual shunts had a left ventricular-right atrial shunt which necessitated reoperation. Surgical heart block occurred in two infants who recovered sinus rhythm in the late period. The cardiothoracic ratio decreased from 60.5% preoperatively to 50.6% in the late postoperative period. Examination by cardiac catheterization revealed that the pulmonary-to-systemic pressure ratio (Pp/Ps) of 23 patients with a Pp/Ps of over 0.75 fell from 0.89 +/- 0.09 preoperatively to 0.42 +/- 0.12 by 1 month postoperatively, then to 0.27 +/- 0.05 in the late postoperative period. The latest values for the cardiac index and left ventricular ejection fraction were 3.4 l/min per m2 and 64.4%, respectively. More than 10 years after their operation, all the survivors were growing normally and maintaining a good quality of life, which supports our recommendation that primary repair should be performed in the first year of life for infants with large VSDs.     

The evaluation of the late results of destruction of the atrioventricular junction in patients with drug-resistant atrial fibrillation

Atrial fibrillation is a commonly seen form of disordered cardiac rhythm. Catheter-radio frequency ablation of the atrioventricular junction was found out to be an effective approach to control heart rate in continued drug-refractory cardiac fibrillation permitting the quality of the patients' life to be improved. The best results are achievable in patients presenting with chronic cardiac fibrillation.     

Pulmonary oedema associated with mitral regurgitation: prevalence of predominant right upper lobe involvement in children

OBJECTIVE: To evaluate the hypothesis that pulmonary venous congestion and oedema manifested predominantly in the right upper lobe in children with mitral regurgitation occur more frequently than previously thought. MATERIALS AND METHODS: Three radiologists retrospectively and independently reviewed the plain chest radiographs of 54 children (26 girls, 28 boys, age range 2 days-18 years, median 9.5 years) with mitral regurgitation admitted to our institution during a 5-year period. Radiographs showing pulmonary venous congestion and oedema manifested predominantly in the right upper lobe were identified. Clinical records of these patients were studied to exclude other causes of pulmonary disease. RESULTS: Radiographic signs of pulmonary venous congestion and oedema were present in all patients, with redistribution of flow and interstitial oedema in 39 patients (72 %) and alveolar oedema in 15 children (28 %). In 12 (22 %) of 54 children, these findings were localised or predominant in the upper lobe of the right lung; none of the children had predominantly left-sided involvement. CONCLUSIONS: Pulmonary venous congestion and oedema involving predominantly the upper lobe of the right lung in children with mitral regurgitation occur more frequently than previously thought. This finding is useful in the differential diagnosis of right upper lobe abnormalities, such as pneumonia.     

Surgical repair of the congenitally malformed mitral valve in infants and children

BACKGROUND: Mitral valve remodeling techniques were applied to 26 infants and children (mean age, 6.0 years, range, 0.4 to 15.9 years) with various forms of congenital mitral valve disease over a 7-year period. Patients with atrioventricular canal, L-transposition and single ventricle were excluded. Intraoperative transesophageal echocardiography (TEE) was utilized to assess the repair and guide the need for immediate intervention. METHODS: Twenty-one patients had mitral regurgitation: 10 with cleft anterior mitral leaflet, 7 with annular dilatation, 1 with normal leaflets with an obstructing cord, 2 with prolapsed leaflets and elongated cords, and 1 with restricted leaflet motion, normal papillary muscles, and shortened cords. Of the 5 mitral stenosis patients, 3 had supravalvular mitral ring, 1 had midvalvular mitral ring, and 1 had a parachute valve. Three of the mitral stenosis patients had additional stenotic lesions. Concurrent repair of associated lesions was performed in 21 patients (78%). RESULTS: Operative mortality was 3.8% (n = 1). There were no late deaths. Immediate rerepair in 4 patients resulted in improved function. All mitral stenosis patients improved. A total of 20 mitral regurgitation patients (95%) improved; 1 required mitral valve replacement. Mean follow-up is 31 months (range, 2 to 81 months). All patients are in New York Heart Association functional class I or II. CONCLUSIONS: Mitral valve repair can be successfully performed in infants and children with excellent short- and midterm results. Assessment using transesophageal echocardiography can guide the necessity for immediate rerepair to achieve improved function.     

Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures

OBJECTIVE: This study was carried out to evaluate the long-term results of mitral valve repair for mitral regurgitation caused by myxomatous disease of the mitral valve and the late effects of chordal replacement with expanded polytetrafluoroethylene sutures in this operation. METHODS: A total of 324 patients with mitral regurgitation caused by myxomatous disease underwent mitral valve repair from 1981 to 1995; the group comprised 241 men and 83 women whose mean age was 58 +/- 14 years. Chordal replacement with expanded polytetrafluoroethylene sutures has been performed in 165 patients since 1985. Most of the patients who had chordal replacement with expanded polytetrafluoroethylene sutures had prolapse of the anterior leaflet or prolapse of both leaflets, whereas most patients who had mitral valve repair without chordal replacement had prolapse of the posterior leaflet. Patients were followed up at annual intervals and had a Doppler echocardiographic study. The follow-up was complete and extended from 6 to 156 months (mean 36 +/- 30 months). RESULTS: Two operative and 21 late deaths occurred (14 cardiac and 7 noncardiac). At 10 years the actuarial survival was 75% +/- 5%, the freedom from stroke was 94% +/- 2%, the freedom from transient ischemic attacks was 92% +/- 4%, the freedom from endocarditis was 99% +/- 1%, the freedom from mitral valve reoperation was 96% +/- 1%, and the freedom from severe mitral regurgitation was 93% +/- 3%. Chordal replacement with expanded polytetrafluoroethylene sutures had no effect on any of these end points. CONCLUSIONS: Mitral valve repair was feasible in most patients with mitral regurgitation caused by myxomatous disease and it was associated with low rates of valve-related complications. Chordal replacement with expanded polytetrafluoroethylene had no adverse effect on the late outcome and was believed to have increased the probability of mitral valve repair.     

Comparison of transesophageal Doppler methods with angiography for evaluation of the severity of mitral regurgitation

Doppler evaluation of mitral regurgitation remains difficult; thus, a head-to-head comparison of the diagnostic accuracy of Doppler methods was undertaken. Fifty patients with native mitral regurgitation underwent multiplane transesophageal echocardiography within 5 days of catheterization. Angiographic grade of mitral regurgitation and, in 20 patients with grade II-IV regurgitation, invasively determined regurgitant stroke volume were compared with color Doppler area, regurgitant jet diameter, ratio of systolic to diastolic peak pulmonary venous flow velocities, and (based on the proximal convergence zone) maximal regurgitant flow rate and regurgitant orifice area. Rank correlation coefficients of angiographic grade with Doppler parameters were 0.61 for color jet area, -0.61 for pulmonary venous flow velocity ratio, 0.69 for color jet diameter, 0.79 for maximal regurgitant flow rate, and 0.78 for regurgitant orifice area (all P < .01). Convergence zone-based parameters also correlated best (r=0.73) with invasively determined regurgitant stroke volume. Receiver operating characteristic curve analysis confirmed higher diagnostic accuracy for proximal jet width and proximal convergence zone parameters than for color jet area or pulmonary venous flow velocity ratio. Proximal convergence zone parameters and proximal color jet diameter best distinguished severe from mild forms of mitral regurgitation.