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.     

Optimizing mitral valve exposure with conventional left atriotomy

The standard surgical approach to the mitral valve is accomplished through a longitudinal incision in the left atrium, posterior and parallel to the interatrial groove. Many other surgical approaches have evolved. This report describes a technique of optimizing mitral valve exposure via the standard approach. These modifications are simple, do not lengthen the procedure, and usually obviate the need for more complex maneuvers.     

Mitral valve repair through combined left atrial and ventricular approach for congenital mitral stenosis

A 3-year-old boy underwent mitral valve repair for congenital mitral stenosis through combined superior-septal atriotomy and apical left ventriculotomy. The operation was performed safely with excellent exposure of the subvalvular apparatus by the ventricular approach, while sufficient visualization of the valvular lesion was obtained by the atrial approach. Postoperative echocardiography demonstrated normal left-ventricular motion and no residual mitral stenosis.     

Late, intermittent obstruction of a mitral prosthesis by chordal remnants

A 59 year old male was admitted 10 weeks following insertion of a Medtronic Hall mitral prosthesis. He suffered recurrent episodes of electromechanical dissociation (EMD). Transthoracic echocardiography demonstrated that during the times of haemodynamic compromise, the mitral prosthesis was intermittently obstructed. Emergency surgical intervention revealed that chordae tendineae had prolapsed through the lesser orifice, obstructing the valve mechanism. The mitral remnants were excised, and as the valve functioned normally, it was not replaced. Postoperatively, the patient made an uneventful recovery. This case illustrates the Doppler echocardiographic features associated with extrinsic obstruction of a mitral prosthesis, and demonstrates that this unusual complication can be responsible for late valve dysfunction.     

Assessment of oxidative stress in a pancreatic warm ischemia-reperfusion model

A simple technique for minimally invasive valve operations is described. With a 10-cm midline skin incision, excellent exposure of both the mitral and aortic valves is achieved through a right-sided partial sternotomy, which enables us to perform easy repair or replacement of these valves.     

Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair

OBJECTIVE: This study compares the quality of valve replacement and repair performed through minimally invasive incisions as compared to the standard operation for aortic and mitral valve replacement. SUMMARY BACKGROUND DATA: With the advent of minimally invasive laparoscopic approaches to orthopedic surgery, urology, general surgery, and thoracic surgery, it now is apparent that standard cardiac valve operations can be performed through very small incisions with similar approaches. METHODS: Eighty-four patients underwent minimally invasive aortic (n = 41) and minimally invasive mitral valve repair and replacement (n = 43) between July 1996 and April 1997. Demographics, procedures, operative techniques, and postoperative morbidity and mortality were calculated, and a subset of the first 50 patients was compared to a 50-patient cohort who underwent the same operation through a conventional median sternotomy. Demographics, postoperative morbidity and mortality, patient satisfaction, and charges were compared. RESULTS: Of the 84 patients, there were 2 operative mortalities both in class IV aortic patients from multisystem organ failure. There was no operative mortality in the patients undergoing mitral valve replacement or repair. The operations were carried out with the same accuracy and attention to detail as with the conventional operation. There was minimal postoperative bleeding, cerebral vascular accidents, or other major morbidity. Groin cannulation complications primarily were related to atherosclerotic femoral arteries. A comparison of the minimally invasive to the conventional group, although operative time and ischemia time was higher in minimally invasive group, the requirement for erythrocytes was significantly less, patient satisfaction was significantly greater, and charges were approximately 20% less than those in the conventional group. CONCLUSIONS: Minimally invasive aortic and mitral valve surgery in patients without coronary disease can be done safely and accurately through small incisions. Patient satisfaction is up, return to normality is higher, and requirement for postrehabilitation services is less. In addition, the charges are approximately 20% less. These results serve as a paradigm for the future in terms of valve surgery in the managed care environment.     

Pannus resection through the tilting disc prosthesis: successful treatment preserving the prosthesis

A 59-year-old woman was admitted to our hospital because of heart failure. In 1988, she underwent aortic valve replacement with an Omnicarbon valve and mitral valve replacement with a bioprosthetic valve. She was doing well until July in 1996 when she developed heart failure. Echocardiography revealed massive mitral valve regurgitation, and cinefluoroscopy showed implanted Omnicarbon valve dysfunction with a leaflet opening angle of 35 degrees. At reoperation, it was revealed that pannus formation prevented the valve from functioning well. The pannus was resected through the major orifice, and the leaflet was rotated toward the right anterolateral orientation. The worn bioprosthetic valve was replaced with a mechanical one. Postoperative cinefluoroscopy of the rotated Ominicarbon valve showed the opening angle to be 61 degrees.     

Experimental principles for preserving annulo-ventricular integrity of the mitral valve

Despite numerous improvement in cardiac surgery the results in mitral valve replacement are still not satisfactory, since impaired left ventricular function continues to be a problem during the postoperative course. In order to investigate the effect of mitral valve replacement on left ventricular function canine experiments were performed: During extracorporeal circulation bileaflet mitral valve prostheses were implanted preserving the ventriculo-annular continuity. Flexible wires were slung around the chordae of the subvalvular mitral apparatus and brought to the outside through the left ventricular wall. Left ventricular diameters were measured by sonomicrometry, left ventricular stroke volume, left ventricular enddiastolic volume and ejection fraction by dye dilution technique as well as left ventricular and aortic pressure by catheter tip manometers. After finishing cardiopulmonary bypass control values were registered and different preload values achieved by volume loading with blood transfusions to left ventricular enddiastolic pressures of 12 mm Hg. Subsequently under normovolumic conditions the chordae tendineae of the anterior and posterior papillary muscles of the mitral valve were cut from the outside, while the heart was beating, by application of electrocautery on the steel wires. Following severance of the ventriculo-annular continuity of the mitral valve again function curves of left ventricular hemodynamics were made during volume transfusions. When the chordae had been divided the left ventricular enddiastolic diameter increased by 10% in the major axis, while in the minor axis no significant changes occurred. The systolic shortening was impaired substantially by reduction of 43% during the ejection phase when the subvalvular mitral apparatus had been severed. Left ventricular enddiastolic volume was increased by 18% at any preload level, while left ventricular ejection fraction was reduced by 16%. Consequently left ventricular stroke volume was decreased by 24% at any left ventricular enddiastolic volume, when the chordae had been divided. It can be concluded that left ventricular geometry is changed when the annulo-ventricular continuity has been interrupted at mitral valve replacement: The major axis of the left ventricle is increased and the enddiastolic volume is augmented. The left ventricle is only able to eject the same stroke volume at higher preload levels when the chordae tendineae have been divided. The same cardiac performance can only be achieved by volume loading and at the expense of higher wall tension, which leads to unfavorable conditions in terms of cardiac muscle mechanics with reduced exercise tolerance. These data speak for preservation of the annulo-ventricular continuity in mitral valve replacement. Provided that these results from acute canine experiments can be transferred to humans, one would suggest that preservation of the mitral subvalvular apparatus is of importance in patients with dilated hearts and with impaired left ventricular function.     

Three-dimensional transesophageal echocardiographic assessment for prosthetic valves

We evaluated three-dimensional transesophageal echocardiographic assessment of the implanted mechanical valves by rotational scanning method. Patients were 7 mitral valve replacement and one aortic valve replacement, 2 mitral and aortic valve replacement. In 2 cases of 7 mitral valve replacement, the prosthetic valve regurgitation was evaluated using by color Doppler echocardiography. In this study, multiplane transesophageal probe was used. It rotated at 2-degree intervals from 0 to 180 degrees and the three-dimensional reconstruction was performed by echo scan workstation system (TOMTEC Inc, Munich, Germany). In mitral valve replacement cases, the valve motion of bileaflet valve (St. Jude Medical valve and ATS valve) were showed very clearly. The struts was easily recognized in the St. Jude Medical valve (SJM valve) cases. In one of SJM valve cases, the pannus formation was revealed, but it did not disturb valve motion. The prosthetic valve regurgitation can be seen accurately. However, aortic valve and ball valve cases cannot be reconstructed because of artifact from prosthetic valve and ultrasonic direction. The prosthetic valve regurgitation, pannus formation which was difficult to be showed in two-dimensional echocardiography and relationship between annulus and sewing cuff can be evaluated by this three-dimensional echocardiography. In this study, this system has some problems, for example real-time evaluation is impossible, aortic valve and ball valve cases cannot be reconstructed. However, we think that this new technology is suitable for evaluating valve thrombus, valve dysfunction and paravalvular leakage. In conclusion, the three-dimensional echo-cardiography demonstrated, reliable and accurate examination, and it can evaluate various complications of prosthetic valve.     

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.     

Treatment of severe mitral stenosis with percutaneous balloon valvotomy in pregnant patients

BACKGROUND: Pregnancy can cause life-threatening complications in women with mitral stenosis. Frequently, there is an urgent need to increase the mitral valve area mechanically. In selected cases, percutaneous mitral balloon valvotomy (PMBV) has emerged as a safe and effective alternative to surgical commissurotomy. HYPOTHESIS: The study evaluates the effects of PMBV by the Inoue technique in nine pregnant patients with severe symptomatic mitral stenosis. METHODS: The patients were in New York Heart Association (NYHA) functional class II to IV and had echocardiographic scores of < or = 8. The mean gestational age was 24.8 +/- 6.1 weeks. The patient's pelvic and abdominal regions were covered with a lead apron to protect the fetus from radiation. A stepwise dilatation technique was used. Fluoroscopy time was kept to 10 to 15 min. RESULTS: One patient developed severe mitral regurgitation requiring emergency valve replacement. The remaining eight patients showed marked immediate symptomatic and hemodynamic improvement. After dilatation, the transmitral pressure gradient decreased from 20.8 +/- 6.5 to 7.3 +/- 1.4 mmHg (p = 0.001) and the calculated mitral valve area increased from 0.9 +/- 0.1 to 1.8 +/- 0.4 (p < 0.001). All patients had uneventful term deliveries of normal babies. On follow-up they were in NYHA functional class I. CONCLUSIONS: Percutaneous mitral balloon valvotomy is a safe and effective procedure for selected pregnant patients with severe mitral stenosis. The procedure is well tolerated by the fetus. Severe mitral regurgitation requiring immediate surgery may occur occasionally. The possible harmful effects to the fetus from its exposure to radiation during PMBV are unknown.     

Behavioral-neuroendocrine-immunologic interactions in myocardial infarction

We describe our experience with the transseptal approach for mitral valve replacement, a technique that we applied especially in cases of 3rd and 4th operations wherein numerous adhesions made the usual left atrial approach difficult. We report 39 cases of mitral procedures in which we used 3 slightly different transseptal approaches, depending on the cardiac anatomy and the preferences of the surgeon. There were no complications associated with any of these approaches. Indeed they made the mitral valve procedure easier, because they enabled full exposure of the mitral valvular and subvalvular apparatus. We also propose the transseptal approach as a very safe and reproducible technique for use in patients with friable tissues, heavily calcified mitral valves, or small left atria- and in patients who must undergo combined tricuspid and mitral procedures. In this series, there were no conduction abnormalities secondary to the approach, nor were there any procedure-related deaths.     

Valve repair versus replacement for mitral insufficiency: when is a mechanical valve still indicated?

OBJECTIVES: Although many advantages of mitral valve reconstruction have been demonstrated, whether specific subgroups of patients exist in whom mechanical valve replacement offers advantages over mitral reconstruction remains undetermined. METHODS: This study examined the late results of mitral valve surgery in patients with mitral insufficiency who received either a St. Jude Medical valve (n = 514) or a mitral valve reconstruction with ring annuloplasty (n = 725) between 1980 and 1996. RESULTS: Overall operative mortality was 7.2% in the patients receiving a St. Jude Medical mitral valve and 5.4% in those undergoing mitral valve reconstruction (no significant difference); isolated mortality was 2.5% in the St. Jude Medical group and 2.2% in the valve reconstruction group (no significant difference). The follow-up interval was more than 5 years for 340 patients with a mean of 39.8 months (98.5% complete). Overall 8-year freedom from late cardiac death, reoperation, and all valve-related complications was 72.8% for the St. Jude Medical group and 64.8% for valve reconstruction group (no significant difference). For patients with isolated, nonrheumatic mitral valve disease, 8-year freedom from late cardiac death and reoperation was better in the mitral valve reconstruction group (88.3%) than in the St. Jude Medical valve group (86.0%; p = 0.05). Furthermore, Cox proportional hazards regression revealed that mitral valve reconstruction was independently associated with a lesser incidence of late cardiac death (p = 0.04), irrespective of preoperative New York Heart Association class. However, the St. Jude Medical valve offered better 8-year freedom from late cardiac death, reoperation, and all valve-related complications than did mitral valve reconstruction in patients with multiple valve disease (77.0% vs 45.3%; p < 0.01). CONCLUSIONS: Therefore, mitral valve reconstruction appears to be the procedure of choice for isolated, nonrheumatic disease, whereas insertion of a St. Jude Medical valve should be preferred for patients with multiple valve disease.     

Echocardiographic features of congenital left ventricular inflow obstruction

The echocardiographic features of congenital left ventricular inflow obstruction are described in six patients. The echocardiograms in two patients with cor triatriatum were distinguished by normal mitral valve motion and an abnormal echo within the left atrium. In two patients with supravalvar mitral ring, in addition to abnormal mitral valve motion, an abnormal echo, presumably originating from the obstructive membrane, was located between the anterior and posterior mitral leaflets. In two cases of parachute mitral valve, mitral valve motion was abnormal. In one of these cases there were multiple mitral valve echoes similar to those found in supravalvar mitral ring. The echocardiographic identification of an obstructive membrane within the left atrium is difficult because of the occurrence of artifacts. However, membranes may be identified if careful scanning techniques are employed in patients in whom left ventricular inflow obstruction is suspected. The echocardiogram is useful in detecting mitral valve abnormalities in these patients and is valuable in cases where mitral valve replacement is contemplated.     

Early result comparison following mitral valve replacement with partial or entire subvalvular structure preservation

21 patients after mitral valve replacement with partial subvalvular structure preservation and 20 patients with entire subvalvular structure preservation were compared with 26 patients after mitral valve replacement with entire subvalvular structure excision. We found that patients after mitral valve replacement with partial or entire subvalvular structure preservation had a more uneventful postoperative course with less inotropic therapy and more decreased left atrial dimension when compared to those with conventional mitral valve replacement. But the patients after mitral valve replacement with entire mitral structure preservation had more decreased left ventricular dimension and short hospital stay when compared to those of the other two groups. The authors suggest that mitral subvalvular structure should be preserved, and we especially recommend the procedure of intravalvular implantation of mitral prosthesis with entire mitral subvalvular structure preservation.     

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.     

Prediction of change in mitral valve area after mitral balloon commissurotomy using cine computed tomography

RATIONALE AND OBJECTIVES: Mitral balloon commissurotomy (MBC) can successfully increase the mitral valve area (MVA) in mitral stenosis, but the outcome is variable. In multicenter studies, qualitative echocardiographic scores obtained before MBC are only weakly predictive of the increase in MVA after MBC. METHODS: To evaluate whether the change in MVA after MBC can be predicted by evaluating mitral valve morphology using cine computed tomography (CT), we studied 12 women with mitral stenosis and 11 female control subjects. RESULTS: In the patients with mitral stenosis, MVA increased from 1.13 +/- 0.24 to 1.93 +/- 0.56 cm2 (P < .0001) after MBC. A standard echocardiographic score assessment of mitral valve morphology before MBC was not associated with the change in MVA after MBC in these patients (P > .20). However, the total mitral valve morphology score evaluated by cine computed tomography was strongly associated with the change in MVA after MBC (r = -.87; P < .0005). In addition, the individual morphologic characteristics of mitral valve mobility (P < .0025), leaflet thickness (P < .05), and subvalvular disease (P < .05) were significant predictors of the change in MVA after MBC. CONCLUSION: Cine computed tomography may be useful for predicting immediate increases in MVA in patients after MBC and may be helpful for preoperative assessment of these patients.     

Refractory head and neck pain. A difficult problem and a new alternative therapy

Mitral valve repair was performed in six patients by transferring the posterior tricuspid leaflet with its sub-valvular apparatus onto the mitral valve. This new technique considers the tricuspid valve as the patients own tissue bank where the posterior leaflet and eventually the adjacent part of the anterior leaflet is used as a "donor" valve, based on the knowledge that the right atrio-ventricular valve can be efficiently repaired with a very low risk of significant dysfunction. The mitral repair consists of incorporating the tricuspid autograft by securing the tricuspid papillary muscle to the mitral papillary muscle and by suturing the leaflet tissue where required. A mitral annuloplasty ring reinforces the repair. The tricuspid valve is subsequently repaired by annular plication and leaflet suture. A tricuspid ring is necessary to maintain efficient remodeling. The six patients ages ranged from 20 to 70 years. A etiology, was rheumatic in the first case and degenerative in the following. In three cases, sterilised endocarditis was responsible for ruptured chordae and leaflet destruction. The mitral insufficiency was located in a commissural area in 4 cases, and was due to a widespread posterior prolapse in 2. Post-operative control transesophageal echocardiography confirmed the excellent results of the repair and proved that, in selected cases, the tricuspid leaflet inserted onto the mitral apparatus is very efficient in correcting mitral insufficiency, without causing significant tricuspid impairment. With a 3 to 7 month follow-up, the results are stable.     

Facile minimally invasive cardiac surgery via ministernotomy

BACKGROUND: The public's and surgeons' perception of minimally invasive operations are frequently at odds. Nevertheless, real or perceived benefits may result from limiting skin and skeletal trauma. METHODS: Beginning in January 1996, we began approaching most infant and pediatric open heart procedures through an upper sternal split incision using a 1- to 3-inch skin opening and then extended this technique using a 2.5- to 3.5-inch incision for adult aortic and mitral valve replacement. RESULTS: A total of 82 patients, 57 infants and children and 25 adults, have been operated on using this approach (age range, newborn to 81 years). Operations accomplished through ministernotomy have included aortic valvotomy, arterial switch, tetralogy of Fallot, atrial or ventricular septal defect closure, aortic valve replacement, mitral valve replacement and repair, redo aortic or mitral valve replacement, double valve replacement, aortic root replacement, and complex arch reconstruction. In adults, the sternum was divided and then a T incision was made at the second, third, or fourth intercostal space. The mitral valve was reached through the roof of the left atrium. In children, a lower sternal split was used for atrial septal defect repairs. All cannulas were introduced through the ministernotomy incision, eliminating femoral cannulation. No new instruments, retractors, or ports were used. Mediastinal drainage was accomplished through a Blake drain connected to Heimlich-valved grenade suction. All but 2 patients were extubated immediately. Hospital stay was from 1 to 20 days (median 2 days). Patient and family acceptance is very high. CONCLUSIONS: On the basis of this initial experience, we attempt all congenital cardiac and isolated adult valve operations through ministernotomy.     

Dermatoglyphic patterns in patients with mitral valve prolapse: a clue to pathogenesis

Fingerprints were obtained from 100 patients with mitral valve prolapse and compared with those of 100 control subjects matched for sex and race. Arches were found in 16.8 percent of all digital patterns in patients with mitral valve prolapse but in only 2.5 percent of all digits in the control group. Whereas no patient in the control group had four or more arches, 19 percent of patients with mitral valve prolapse had this finding. In addition, arches were found on 16 and 9 percent, respectively, of digits IV and V in patients with mitral valve prolapse but were not found on these digits in the control group. The finding of four or more arches or arches on digits IV or V may be important supportive evidence of mitral valve prolapse when evaluating patients with atypical chest pain and palpitations. Antenatal factors may be involved in the pathogenesis of mitral valve prolapse since it is possible that a genetic or environmental factor that interferes with the development of the mitral valve may also influence epidermal ridge patterns.