A report of two cases of Carpentier-Edwards pericardial mitral valve malfunction due to neointimal overgrowth expanding to valve cusps

Two cases of Carpentier-Edwards pericardial mitral valve malfunction due to neointimal overgrowth were reported. Case one was a 51-year-old female undergone redo mitral valve replacement at nine years after first operation. Removed valve showed remarkable overgrowth of neointima expanding to the valve cusps. Case two was a 67-year-old male. A valve removed at nine years after first operation and at 1.5 years after recovery of prosthetic valve endocarditis. Removed valve also showed neointimal overgrowth expanding to the valve cusps. Although we experienced only two cases of neointimal overgrowth, these findings were considered being important in durability of Carpentier-Edwards pericardial valve.     

Twelve-year experience with the 19 mm Carpentier-Edwards pericardial aortic valve

BACKGROUND: The purpose of the present study was to investigate the therapeutic effectiveness of interleukin-2 (IL-2) and interferon (IFN), either alone or in combination, in comparable groups of patients affected by advanced renal cell carcinoma (RCC). PATIENTS AND METHODS: In order to limit selection biases, treatment was allocated on a random basis. Patients randomized to IL-2 alone were scheduled to receive eight rlL-2 24-hour i.v. infusion cycles, days 1 to 4, at a daily dose of 18 x 10(6) lU/m2 for a total of 25 weeks. Patients randomized to IFN alone were scheduled to receive rIFN-alpha at a daily dose of 6 x 10(6) IU/m2, days 1, 3 and 5, every week for a total of 52 weeks. Patients randomized to the combination of IFN and IL-2 were given the same drugs at the same daily doses for a total of 24 weeks. Drug dose was modified according to toxicity. RESULTS: Twenty-three percent (95% CI:+/-17.5) of patients treated with IL-2 alone showed an objective response to treatment (9% CR). The corresponding figures in patients treated with IFN alone or IFN plus IL-2 were 9% (95% CI:+/-11.9) and 9% (95% CI:+/-11.9), respectively. Complete responses were observed only in patients treated with IL-2. The median duration of response in the IL-2 arm was 18 months (range, 9.5-24). The duration of the two responses achieved by IFN alone was seven and nine months, respectively. The corresponding figures in the two patients responding to the combination of IFN with IL-2 were 19 and 27 months, respectively. Total IL-2 dose appeared to be a major predictor of response. Only a minority of patients experienced grade 3-4 toxicity, the incidence being higher in those treated with IL-2 or IL-2 plus IFN. CONCLUSIONS: Neither IFN nor IL-2 or the combination of the two appear to be very active in patients with advanced RCC, even when trial entry was restricted to patients with relatively indolent disease. This stresses the need for the development of new approaches.     

Acute endocarditis of the native aortic valve caused by Propionibacterium acnes

Propionibacterium acnes is often considered to be a contaminant but it has also been found to be the principal pathogen in serious infections. P. acnes is a rare cause of infective endocarditis. It has been suggested that aortic root abscesses are caused by bacteria that are particularly virulent. The strongest risk factor for serious infections by this bacteria is the presence of foreign bodies. A case is presented in which endocarditis of a native aortic valve caused by P. acnes was associated with an aortic root abscess. Transesophageal echocardiography is particularly helpful in the diagnosis of this severe complication of infective endocarditis. The literature for P. acnes endocarditis is reviewed.     

Cardiac tamponade caused by bronchial carcinoma metastasis to the pericardial sac

Thirty-four (8%) of 453 infants and children with urinary system malformations had cardiovascular malformations. Cardiac defects were seen frequently in Potter syndrome, unilateral renal agenesis, and horseshoe kidney. The most frequently encountered types of heart defects were ventricular septal defect (33%), endocardial cushion defect (15%), tetralogy of Fallot (12%), and patent ductus arteriosus (12%).     

Echocardiogram of the porcine aortic bioprosthesis in the mitral position

The sera from 48 female rabbits immunized by a series of multiple intradermal injections of washed epididymal, washed ejaculated, and beta-amylase-treated rabbit spermatozoa in complete adjuvant were examined for spermagglutinins by the Kibrick gel agglutination test and a slight modification of the Shulman capillary agglutination test. Control animals receiving the adjuvant or saline usually had no positive titers. All three antigenic preparations produced similar titers, positive at dilutions as high as 8192-fold with Kibrick test and 256-fold with the Shulman test. Maximal titer development was reached 4 to 6 weeks after starting the immunization, and positive sera were obtained from some does for 25 weeks. The correlation coefficients between positive titers obtained by the two tests were r = 0.91 during the first 10 weeks and 0.41 at 15 to 25 weeks after immunization.     

The Carpentier-Edwards porcine valve in the supra annular aortic position. Results after 12 years in a series of 1108 patients

In the decision concerning the choice of valvular prosthesis, certain prostheses are considered to be standards of reference: this is the case of the Carpentier-Edwards Supra Annular 2650 porcine bioprosthesis. This study reports the results in a series of patients followed up for 12 years. Between 1983 and 1995, 1108 patients were implanted with this prosthesis for isolated aortic valve replacement. The majority of patients was elderly (mean 78.3 +/- 8.3 years). The follow-up rate was 94%, representing a total of 3 925 patient-years (average 4 +/- 3 years). The survival at 5, 10 and 12 years, operative mortality included, was 70.7%, 46% and 28%. Thromboembolic events to dehiscence represented the commonest complication (0.7% per patient-year). Structural valve degeneration (21 cases) (0.5% per patient-year) was a low risk complication up to 10 years but increased suddenly at the 11th year: age and gender were risk factors for this complication. The actuarial complication-free rate was 94% at 10 years and 82% at 12 years. Other complications were much less common (infectious endocarditis, haemorrage). The Carpentier-Edwards Supra Annular porcine bioprosthesis is associated with a low risk of complications after 10 years' follow-up, especially of valve degeneration. It remains a competitive choice in the register of valve prostheses. As with the other bioprostheses, the main indications are observed in elderly patients.     

Insertion of prosthetic tricuspid valve two years after the tricuspid valvulectomy

A case of a 14-year-old boy who underwent a prosthetic tricuspid valve insertion two years after the tricuspid valvulectomy due to intractable right-sided active endocarditis is presented. At the initial operation, the tricuspid valve was thoroughly resected because of marked destruction and attachment of vegetations, and a concomitant ventricular septal defect was directly closed. When a prosthetic valve was placed in the tricuspid portion, a semicircular Dacron patch was attached to the right side of the interventricular septum in a fashion of up-chord and down-arc to cover the bundle of His. The straight edge of the patch was located near the AV node and was not sutured to the tricuspid valve annulus. A 31 mm of CarboMedics prosthetic valve was sutured to the tricuspid valve annulus and to the free edge of the patch at the position near the AV node to prevent AV block. Postoperative course was uneventful and ECG showed regular sinus rhythm.     

Idiopathic perforation of a porcine aortic bioprosthesis in the aortic position

The report of a failure of glutaraldehyde-preserved porcine aortic xenograft bioprosthesis in the aortic position after 13 months is presented. Severe aortic regurgitation resulted from three "idiopathic" perforations in one of the cusps, and a linear tear in another cusp. Light and electron microscopy showed generalized degeneration of collagen thoughout the faulty valve. The absence of a platelet-fibrin coat on edges of the tear suggested a recent origin, compatible with cardiac catheter manipulation during unsuccessful attempts to cross the valve. The histopathologic data from this valve correlate with previously reported failures with formaldehyde preserved xenograft valves.     

Hemodynamic function of the Hancock standard orifice aortic valve bioprosthesis

Reports that the hemodynamic performance of the standard orifice aortic bioprosthesis in less than optimal have prompted recommendations that mechanical prosthesis or anulus-enlarging procedures be used in adult patients with a small aortic root. The hemodynamic function of the Hancock bioprosthesis was evaluated in 77 patients who underwent cardiac catheterization of rest and with isoproterenol infusion (15 patients) an average of 6 months after operation. The average peak systolic gradient (basal conditions) was 7 mm Hg (range 0 to 37 mm Hg); 35 patients had no resting gradient. Fifteen patients received 21 mm diameter valves and had an average systolic valve gradient of 10 mm Hg (range 0 to 30 mm Hg); the average effective valve orifice area was 1.27 +/- 0.17 cm2 for 21 mm, 1.46 +/- 0.11 cm2 for 23 mm, 1.72 +/- k0.20 cm2 for 25 mm, and 1.97 +/- 0.06 for 27 mm bioprostheses. Isoproterenol infusion, elevating cardiac output 66%, increased the peak systolic gradient from an average of 11 mm Hg (range 0 to 37 mm Hg) to 44 mm Hg (range 10 to 85 mm Hg). It is concluded that small-diameter (21 and 23 mm) Hancock bioprostheses can be used with acceptable clinical and hemodynamic function in patients with a small body surface area.     

Right thoracotomy to approach mitral or tricuspid valve in reoperation

Four patients underwent mitral valve re-replacement, and required tricuspid annuloplasty in two, through a right thoracotomy. There was no major postoperative morbidity and recovery was full and uneventful. The indications for selection of this approach were isolated mitral valve disease or combined tricuspid and mitral valve disease, severe adhesion between heart and sternum on CT scan, intact aortic valve and no severe reduction of respiratory function. We recommend right thoracotomy to approach atrioventricular valves in selected situations in patients for reoperations.     

Hypoproteinemia caused by tricuspid regurgitation: report of a case

A case of tricuspid regurgitation (TR) complicated by severe hypoproteinemia is presented herein. A 68-year-old man who had undergone coronary artery bypass grafting (CABG) for postinfarction angina suffered repeated inferior myocardial infarction due to obstruction of the proximal right coronary artery, 3 years after which he developed systemic edema. Investigations revealed TR associated with hypoproteinemia; however, treatment consisting of aggressive diuretic therapy and albumin administration proved ineffective. The hypoproteinemia manifested as protein-losing enteropathy clinically, and the tricuspid valve was replaced to eliminate high venous pressure. The serum protein levels became normalized after the operation. Although TR is generally well tolerated in the absence of pulmonary hypertension, surgical management is recommended for patients with severe protein deficiency resistant to medical treatment.     

Suspension of straddling tricuspid valve chordae into the appropriate ventricle

In 2 children with an inlet ventricular septal defect and straddling chordae tendineae of the septal leaflet of the tricuspid valve to the posteromedial papillary muscle of the mitral valve and to an accessory papillary muscle in the left ventricle, the straddling chordae were excised with a wedge of posteromedial papillary muscle and with the top segment of the accessory papillary muscle, respectively. After patch closure of the ventricular septal defect, the papillary muscle segment with its group of chordae was anchored to the right ventricular septum with resulting competence of the tricuspid valve. In contrast to the traditional repair technique, the reported modification is applicable when the straddling chordae insert into a papillary muscle of the mitral valve. In addition, various disadvantages related to the construction of a complex baffle in the inappropriate ventricle are avoided.     

Ruptured chordae tendineae of the tricuspid valve due to nonpenetrating trauma. Echocardiographic findings

A case of traumatic tricuspid insufficiency is presented. In the diagnosis of ruptured chordae tendineae of the tricuspid valve, two-dimensional echocardiography was an essential diagnostic procedure, while M-mode echocardiography showed no specific findings. Ruptured chordae tendineae of the tricuspid valve were confirmed at operation.     

Ebstein's anomaly of the tricuspid valve: a case report

A case of Ebstein's malformation of the tricuspid valve with a complicating ventricular septal defect in a 3-year-old Black child is presented. A pre-operative diagnosis of an atrioventricular canal was made, and only at operation was it discovered to be an Ebstein's anomaly of the tricuspid valve. The clinical picture and diagnoses are reviewed, and the problem of a correct pre-operative diagnosis is discussed. The operative treatment and postoperative result in our patient is described.     

Infective endocarditis of the tricuspid valve in an orthotopic heart transplant recipient

A 43-year-old orthotopic heart transplant recipient had coagulase-negative staphylococcus endocarditis 26 weeks after the operation. A diagnosis of endocarditis was confirmed and followed up by serial transoesophageal echocardiography. Treatment with intravenous gentamycin and vancomycin cured her endocarditis, and a 2.5 cm vegetation regressed significantly. She has been well since and, at 14 months after transplantation, was back to her normal activities. Although repeated blood culture yielded only intermittent light growths of coagulase-negative staphylococci, there were several positive samples. In a setting of infective features, light growths of coagulase-negative staphylococcus should be taken seriously if repeatedly positive in heart transplant recipients or other immunocompromised patients. Transesophageal echocardiography offers significant advantages over the transthoracic modality in suspected endocarditis.     

Endocarditis of the tricuspid valve associated with congenital coronary arteriovenous fistula

A 17 year old girl with a congenital right coronary artery to coronary sinus fistula presented with recurrent septic pulmonary embolism secondary to tricuspid valve endocarditis. The diagnosis was made on the basis of echocardiography and cardiac angiography.