Extensive calcification of a bioprosthesis in the tricuspid valve position and minimal calcification of a simultaneously implanted bioprosthesis in the mitral valve position.
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Adult↗
Biomedical subjects
C L McIntosh
Publications and source records attributed to C L McIntosh.
Mechanisms of severe mitral regurgitation in mitral valve prolapse determined from analysis of operatively excised valves.
Certain clinical and mitral valvular morphologic findings are described in 83 patients (age 26 to 79 years [mean, 60]; 26 women [31%] and 57 men [69%]) with mitral valve prolapse (MVP) and mitral regurgitation (MR) severe enough to warrant mitral valve replacement. All 83 operatively excised valves were examined by the same person, and all excised valves had been purely regurgitant (no element of stenosis). No patients had hemodynamic evidence of dysfunction of the aortic valve. In each valve a portion of the posterior mitral leaflet was elongated such that the distance from the distal margin to basal attachment of this leaflet was similar to the distance from the distal margin of the anterior leaflet to its basal attachment to the left atrial wall. Two major mechanisms for the severe MR were found: dilatation of the mitral anulus with or without rupture of chordae tendineae and rupture of chordae tendineae with or without dilatation of the mitral anulus. Of the 83 patients, 48 (58%) had both dilated anuli (greater than 11 cm in circumference) and ruptured chordae tendineae; 16 (19%) had dilated anuli without ruptured chordae, and 16 (19%) had ruptured chordae without significant anular dilatation. In three patients the anulus was not dilated, nor were chordae ruptured, and therefore the mechanism of the MR is uncertain. Mitral chordal rupture was nearly as frequent in the 64 patients with clearly dilated anular circumferences as in the 19 patients with normal or insignificantly dilated anular circumferences (less than or equal to 11 cm).
Adult↗
Intrinsic failure of Hancock mitral bioprostheses: 10- to 15-year experience.
Hancock porcine bioprostheses have been implanted in the mitral position at the National Institutes of Health since July, 1970. Eight models (330, 330A, 330B, 330C, 332, 340, 341, and 342) were used during a 54-month period ending December, 1974, and 100 consecutive surviving patients were evaluated for subsequent bioprosthetic valve failure and prosthesis-related complications by annual clinic examinations and serial hemodynamic studies. Actuarial patient survival was 76 +/- 4%, 51 +/- 5%, and 30 +/- 6% after 5, 10, and 15 years, respectively. Intrinsic valve failure, defined as structural degeneration of bioprosthetic tissue or stent geometry alteration or both, in the absence of prior infection, occurred in 23 patients. The linear occurrence rate of bioprosthetic valve failure was 0.2%, 5%, and 15% per patient-year, and it affected 1 patient, 14 patients, and 8 patients at sequential 5-year milestones. The actuarial freedom from valve failure was 99 +/- 1%, 75 +/- 6%, 58 +/- 8%, and 40 +/- 12% after 5, 10, 12, and 14 years, respectively. The valve durability of early Hancock bioprostheses (models 330 through 341; N = 39) was not appreciably different from that of the current model 342 valves (N = 61). However, an increased incidence of intrinsic valve failure was observed for the first polypropylene-stented valve type (model 330) compared with the currently available model 342 valve (8/16, 50%, versus 12/61, 20%; p = 0.034). The yearly occurrence rate of prosthesis-related complications remained constant, but the rate of intrinsic valve failure increased in a progressive, nonlinear fashion. The high intrinsic failure rate of the Hancock porcine bioprosthesis after 10 to 12 years has moderated our initial enthusiasm for this valve in the mitral position, and has resulted in more frequent implantations of mechanical valve substitutes at this institution.
Actuarial Analysis↗
Operation for hypertrophic subaortic stenosis in the aged.
To determine if operative palliation of idiopathic hypertrophic subaortic stenosis (IHSS) is worthwhile in the elderly, hemodynamic, cardiac conduction, symptomatological, functional, and survival data were examined in 52 patients (39 women) 65 years old and older (mean age, 69 years; range, 65 to 81 years) who had a left ventricular myotomy and myectomy (LVMM) (Morrow procedure) alone or with concomitant operations. Seventy-four percent of all operative survivors underwent catheterization an average of 6 months postoperatively. The mean follow-up was 54 months (range, 5 to 120 months). The population was divided for analyses into those with coronary artery disease (CAD) (N = 11,21%) and those without (N = 41). The peak resting left ventricular outflow tract gradient was reduced from 65 +/- 16 mm Hg to 3 +/- 1 mm Hg (p less than 0.01) in the group with CAD and from 95 +/- 13 mm Hg to 17 +/- 9 mm Hg (p less than 0.001) in the group without CAD. Significant reductions in peak gradients in response to provocation also occurred in both groups. New conduction abnormalities occurred in 72% of survivors, 85% of whom showed improvement in regard to symptoms. The overall average New York Heart Association Functional Class was 3.2 +/- 0.1 preoperatively and at latest follow-up, 1.9 +/- 0.1 (p less than 0.001). The hospital mortality for LVMM alone in the absence of CAD was 8% with a 5-year actuarial survival of 75 +/- 8%. LVMM in the presence of CAD resulted in an operative mortality of 27% (N = 3); all deaths were related to an acquired ventricular septal defect.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. I. Prevalence, diagnosis, and comparison of preoperative clinical and hemodynamic features in patients with and without tricuspid regurgitation.
Most reports of clinical experiences with palliation of acquired tricuspid regurgitation have failed to address the issue of coexisting disease of the mitral or aortic valve, or both. To accurately determine the natural history and the effect of operative interventions, we studied patients with chronic, pure mitral regurgitation who had surgical treatment at the National Heart, Lung, and Blood Institute from 1968 to 1984. Forty-seven patients fulfilled the criteria of a documented history of mitral regurgitation for more than 1.5 years, minimal mitral diastolic gradient, severe mitral regurgitation by angiography, and no prior mitral or tricuspid operative procedure. Twenty-five of the 47 patients (53%) had evidence of tricuspid regurgitation. No statistical differences in age, sex, mean duration of symptoms of congestive heart failure, or functional class were found between those patients with and those without tricuspid regurgitation. However, patients with symptoms of congestive heart failure for more than 6 years were more likely to have tricuspid regurgitation. This increased prevalence also correlated with higher elevations of left ventricular end-diastolic, systolic pulmonary artery, and mean right atrial pressures. The severity of tricuspid regurgitation estimated preoperatively did not correlate statistically with that determined by digital palpation, although the presence of tricuspid regurgitation was reliably confirmed. These data demonstrate that tricuspid regurgitation is frequently present in patients with chronic, pure mitral regurgitation and is associated with prolonged symptoms of congestive heart failure and significant alterations in right heart dynamics.
Blood Pressure↗
Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. II. Nonoperative management, tricuspid valve annuloplasty, and tricuspid valve replacement.
The incidence, preoperative and intraoperative diagnosis, methods, and the clinical and hemodynamic features of patients with and without tricuspid regurgitation associated with chronic mitral regurgitation were presented in Part I. This study (Part II) compares the early and late results in patients with chronic, pure mitral regurgitation undergoing isolated mitral valve replacement, mitral replacement and tricuspid valve annuloplasty, and mitral and tricuspid valve replacement. The mean follow-up interval was 6 years. Those with the longest duration of symptoms (18 years) required tricuspid and mitral valve replacement (11 patients), whereas those with the shortest duration (8.1 years) had only mitral replacement (22 patients). Eight patients had minimal tricuspid regurgitation by digital palpitation, with no procedure performed, and six had tricuspid valve annuloplasty, only one of whom received a ring support. Operative mortality rate was similar in all groups (13% to 18%). All but two of the surviving patients improved by at least one New York Heart Association functional class, and no statistically significant differences were found between preoperative and postoperative hemodynamic data. There were no statistically significant differences in survival at 1, 5, or 8 years (85%, 70%, and 60%, respectively) for patients with or without TR. Only two of the surviving five patients who underwent tricuspid valve annuloplasty were alive 3 years after operation, whereas 70% to 80% of those with mitral replacement or mitral and tricuspid replacement were alive after the same time interval. It is not clear whether or not the pathogenesis of tricuspid regurgitation resulting from mitral regurgitation is different from that of tricuspid regurgitation resulting from mitral stenosis. It is our contention that whether tricuspid regurgitation arises because of anatomic destruction of the tricuspid valve or because of right ventricular dilatation with tricuspid annular enlargement, the underlying mitral valve lesion may determine the preoperative and postoperative courses of these patients. Therefore, when tricuspid valve disease is being evaluated, we urge that patients be categorized by the nature of their underlying mitral or aortic valve lesions.
Adult↗
Valve replacement in narrow aortic roots: serial hemodynamics and long-term clinical outcome.
No long-term data are available that correlate clinical outcome with serial hemodynamic studies for small-diameter (17-mm or 19-mm) aortic prostheses implanted without enlargement of the annulus. After insertion of these valves without annuloplasty, 52 patients underwent resting catheterization and were followed up at the Surgery Clinic of the National Heart, Lung, and Blood Institute for 295 patient-years (mean, 5.7 years per patient). At similar flow rates, peak systolic gradients across 17-mm Björk-Shiley aortic prostheses (N = 6) tended to exceed those of the 19-mm Björk-Shiley model (N = 38); these gradients averaged 30 +/- 6 mm Hg (mean +/- standard error of the mean) and 20 +/- 2 mm Hg, respectively (p = .053). Those patients with 19-mm Hancock (N = 4) and St. Jude Medical valves (N = 4) were studied, and the lowest prosthetic gradients were found with the St. Jude Medical prosthesis (mean, 3 +/- 2 mm Hg). Aortic gradient was independent of flow for 17-mm but not for 19-mm Björk-Shiley valves. There was no difference in calculated effective orifice area with respect to valve size. Effective orifice area and prosthetic gradients were stable during intervals of 2 to 12 years in 10 patients who underwent additional catheterizations. No association was found between prosthetic gradients, flows, or calculated orifice areas and early or late functional class. Actuarial survival was 86 +/- 5% at 5 years, 83 +/- 5% at 8 years, 71 +/- 9% at 10 years, and 60 +/- 12% at 12 years of complete follow-up. It is concluded that small aortic prostheses provide acceptable palliation for long periods and that resting hemodynamic studies have a limited predictive value for long-term prognosis.
Adult↗
Techniques for management of the calcified mitral annulus.
Mitral annulus calcification is most often associated with myxomatous degeneration of the mitral valve. It is characterized by a horseshoe-shaped area of mitral annulus calcification that extends into the ventricular cavity to varying degrees. Standard suture techniques may be associated with fracture of the calcification and subsequent paravalvular leak. Seventeen patients aged 54 to 85 (mean 68.1) had mitral valve replacement using four techniques: suture through calcified annulus (3); decalcification (6); onlay patch (5); and drill technique (3). There were no hospital deaths, and one 81-year-old patient with associated coronary artery disease and ascending aortic calcification succumbed to a cerebrovascular accident three months postoperatively. The remaining patients are living and active with functional improvement. Follow-up has ranged from seven months to seven years with a mean of 4.0 years. One patient has hemodynamically insignificant mitral regurgitation after use of an onlay patch technique. No one technique could be singled out as clearly advantageous over the others from this series of patients.
Aged↗
Survival and functional results after valve replacement for aortic regurgitation from 1976 to 1983: impact of preoperative left ventricular function.
Recent studies suggest that preoperative left ventricular function may no longer be an important determinant of survival or functional results after operation for aortic regurgitation because of improved operative techniques. To assess the effect of left ventricular function on prognosis in the current surgical era, we performed echocardiographic and radionuclide angiographic studies in 80 consecutive patients undergoing valve replacement from 1976 to 1983. No patient had associated coronary artery disease. For all patients, 5 year survival was 83 +/- 5%, significantly better than the 62 +/- 9% 5 year survival in our patients operated on from 1972 to 1976. Preoperative resting left ventricular ejection fraction (p less than .001), fractional shortening (p less than .001), and end-systolic dimension (p less than .01) were the most significant predictors of survival (univariate life-table analysis). Five year survival was 63 +/- 12% in patients with subnormal ejection fraction (n = 50) compared with 96 +/- 3% in those with normal ejection fraction (n = 30). Patients with subnormal left ventricular ejection fraction and poor exercise tolerance or prolonged duration of left ventricular dysfunction (greater than 18 months) comprised the high-risk subgroup (5 year survival 52 +/- 11%). Patients in this subgroup also had persistent left ventricular dysfunction after operation, with greater left ventricular end-diastolic dimensions and reduced ejection fraction (both p less than .001) compared with patients with normal preoperative left ventricular ejection fraction or a brief duration of left ventricular dysfunction (less than 14 months). Cold hyperkalemic cardioplegia was used for myocardial preservation in 46 patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Actuarial Analysis↗
Late (5 to 132 months) clinical and hemodynamic results after either tricuspid valve replacement or anuloplasty for Ebstein's anomaly of the tricuspid valve.
Late clinical and hemodynamic observations are described in 6 patients who had either tricuspid valve anuloplasty (TVA) (2 patients) or tricuspid valve replacement (TVR) (4 patients) 5 to 132 months earlier for Ebstein's anomaly of the tricuspid valve unassociated with right ventricular outflow obstruction. Of the 6 patients, 4 had improved postoperatively by 1 New York Heart Association functional class and 2 had improved by 2 functional classes. The cardiothoracic ratio decreased 5 to 12 months after either TVR or TVA in all 6 patients (from a mean of 0.72 to 0.62). Repeat cardiac catheterization 5 to 12 months after TVA or TVR disclosed that the right atrial mean pressure had increased from a median of 4.0 to 10.5 mm Hg (p = 0.05); the right ventricular peak systolic pressure had increased from 19.0 to 31.5 mm Hg (p = 0.02); the right ventricular end-diastolic pressure had increased from 5.0 to 9.0 mm Hg (p = 0.05); the systemic arterial peak systolic pressure had increased from 115 to 123 mm Hg (p = 0.03); and the cardiac index had increased (in all 4 patients in whom both pre- and postoperative values were available) from 1.7 to 2.9 liters/min/m2 (p = 0.06). Thus, the tricuspid valve operations in our 6 patients with Ebstein's anomaly were associated with a decrease in symptoms of cardiac dysfunction, a decrease in cardiac size, an increase in cardiac index and an increase in right ventricular and right atrial pressures. The elevation of the right atrial pressures postoperatively may have resulted from increased right ventricular filling pressures, persistent tricuspid regurgitation or bioprosthetic stenosis.
Adolescent↗
"Massive" calcification of a right ventricular outflow parietal pericardial patch in tetralogy of Fallot.
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Adolescent↗
Comparison of late (62 to 140 months) degenerative changes in simultaneously implanted and explanted porcine (Hancock) bioprostheses in the tricuspid and mitral valve positions in six patients.
A Hancock porcine bioprosthesis (PB) was simultaneously implanted in each of 6 patients aged 30 to 64 years (mean 45) in the tricuspid and mitral valve positions and both PBs were explanted 62 to 140 months (mean 102) later. Cuspal degenerative changes occurred in all 12 PBs. In 5 patients, the changes were more extensive on the PBs in the mitral position than in those in the tricuspid position. Cuspal calcific deposits, as determined by radiographs of the explanted bioprostheses, occurred in 5 PBs in the mitral position and in 3 in the tricuspid position: 1 patient with calcific deposits in the PB in the mitral position had no calcific deposits in the corresponding PB in the tricuspid position; 1 patient had heavy calcific deposits in the PB in the mitral position and only mild deposits in the PB in the tricuspid position; and 3 patients had similar but mild calcific deposits in both PBs. Cuspal tears occurred in 5 of the 6 PBs in the mitral position and in no PB in the tricuspid position. Thrombus was observed on the ventricular aspects of the bioprosthetic cusps in 1 PB in the mitral position and in 4 PBs in the tricuspid position. Thus, in our 6 patients, the degenerative changes were more extensive in the PBs in the mitral position than in those in the tricuspid position. These observations indicate that wear characteristics of simultaneously implanted PBs vary according to the site of implantation.
Adult↗
Reversal of left ventricular dysfunction after aortic valve replacement for chronic aortic regurgitation: influence of duration of preoperative left ventricular dysfunction.
Preoperative left ventricular systolic function is an important predictor of postoperative prognosis in patients with aortic regurgitation. Although left ventricular dysfunction is reversible after aortic valve replacement to a greater extent in patients with good preoperative exercise capacity compared with patients with impaired exercise capacity, not all patients with preserved exercise capacity demonstrate improved left ventricular function after aortic valve replacement. To determine the influence of duration of preoperative left ventricular dysfunction on postoperative reversal of left ventricular dysfunction, we studied 37 patients with aortic regurgitation who preoperatively had left ventricular dysfunction, defined as subnormal echocardiographic fractional shortening (less than 29%), and good preoperative exercise capacity, defined as completion of stage I of the NIH treadmill protocol without limiting symptoms. Eight patients were asymptomatic. In 11 patients left ventricular dysfunction was documented 18 to 57 months preoperatively (prolonged); in 10 patients left ventricular dysfunction developed in an interval of 14 months or less preoperatively (brief); in 16 patients duration of left ventricular dysfunction was unknown. Patients with brief vs those with prolonged left ventricular dysfunction did not differ with respect to severity of preoperative symptoms or exercise tolerance, echocardiographically determined left ventricular dimensions or fractional shortening (25 +/- 3% [SD] vs 25 +/- 3%), or radionuclide angiographic ejection fraction (42 +/- 5% vs 42 +/- 5%).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Wear of the metallic studs on the composite seat of the 2320 Starr-Edwards aortic valve and its clinical consequences.
The 2320 Starr-Edwards aortic valve has a composite seat with metallic studs that protrude through the cloth. Certain clinical and morphologic findings are described in 6 patients who had this prosthesis in situ for 50 to 144 months (mean 92). Considerable disruption of the cloth covering both struts and base, and varying degrees of wear of the metallic studs that line the luminal side of the prosthetic ring occurred in each. Excessive stud wear resulted in severe disruption of the cloth lining the interior of the prosthetic ring. Cloth disruption may be associated with hemolytic anemia, embolic consequences, or both. Of our 6 patients, 4 had severe hemolytic anemia, 4 had neurologic events compatible with emboli and 1 died suddenly. Stud wear as observed in the 2320 series Starr-Edwards prosthesis also may occur in the models 2310 and 2400 prostheses, which have the same composite seat.
Adult↗
Massive right ventricular outflow tract aneurysm after ventriculotomy for subvalvular pulmonic stenosis associated with peripheral pulmonary arterial stenoses.
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Adult↗
The natural history of asymptomatic patients with aortic regurgitation and normal left ventricular function.
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Adolescent↗
Improved myocardial function during exercise after successful percutaneous transluminal coronary angioplasty.
Fifty-nine consecutive patients with coronary-artery disease undergoing percutaneous transluminal coronary angioplasty were evaluated with radionuclide ventriculography at rest and during exercise before angioplasty (when possible) and afterward when it was successful. Thirty-eight patients (64 per cent) had an angiographically successful procedure. Three (5 per cent) had coronary occlusion as a complication. Arterial stenosis was reduced from 74 +/- 2 per cent to 31 +/- 3 per cent (mean +/- S.E.M.). The mean ejection fraction was 55 +/- 2 per cent at rest and 51 +/- 3 per cent during exercise before the procedure. After successful angioplasty, the ejection fraction was unchanged at rest but increased to 62 +/- 2 per cent (P less than 0.001) during exercise. Regional dysfunction was present during exercise in 94 per cent of the patients before the procedure and in only 8 per cent after successful angioplasty. Of the 38 patients in whom the procedure was successful, 19 had sustained improvement for over six months, and eight for three to six months. Eleven patients had recurrence of symptoms; the second angioplasty was initially successful in nine. In 24 patients remaining asymptomatic for six months (19 after the first procedure and five after the second), the left ventricular ejection fraction during exercise remained stable or improved.
Adult↗
Etiology of clinically isolated, severe, chronic, pure mitral regurgitation: analysis of 97 patients over 30 years of age having mitral valve replacement.
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Adult↗