Biomedical subjects
Gordon K Danielson
Publications and source records attributed to Gordon K Danielson.
Early and late results of the modified fontan operation for heterotaxy syndrome 30 years of experience in 142 patients.
OBJECTIVES: We sought to evaluate the early and late results of the modified Fontan operation for patients with heterotaxy syndrome, assess variables traditionally known to correlate with poor outcome, and assess current health status of survivors after the Fontan procedure. BACKGROUND: The natural history of unoperated cardiac lesions in heterotaxy is known to be poor. Therefore, the Fontan operation has been proposed to improve survival. METHODS: Patients with heterotaxy were identified from the Mayo Clinic Fontan database. Hospital and outpatient records were abstracted for preoperative, operative, and postoperative clinical and hemodynamic data. All patients not known to be deceased were sent health status questionnaires. RESULTS: A total of 142 patients with heterotaxy syndrome had a modified Fontan operation. Asplenia was present in 76 patients (54%). Median age at operation was 9 years (range 2 to 35 years). Median follow-up was 4 years (range 0 to 23 years). There were a total of 61 deaths (43%), with 32 (23%) within 30 days of operation or before hospital discharge. The 5-, 10-, and 15-year survival was 64%, 57%, and 53%, respectively. In the modern era (1995 to 2004) early mortality was 10%. Of the 81 survivors, questionnaires were available from 41 (51%). Eighty percent reported having no or mild symptoms. However, 19 (46%) had arrhythmias, 5 (12%) had a thromboembolic event, and 1 (2%) developed protein-losing enteropathy. CONCLUSIONS: Early survival has improved for heterotaxy patients after the Fontan operation; however, late morbidity and mortality remain substantial. Better strategies for long-term treatment of this high-risk group need to be identified.
Tricuspid valve repair for Ebstein's anomaly in young children: a 30-year experience.
BACKGROUND: The purpose of this study was to examine early and late outcome of tricuspid valve repair for Ebstein's anomaly in young children. METHODS: Between October 1974 and November 2003, 52 children (25 boys) underwent tricuspid valve repair and annuloplasty for Ebstein's anomaly. Mean age was 7.1 +/- 3.9 years (range, 5 months to 12 years). Concomitant procedures included atrial septal defect closure (n = 46), division of accessory conduction pathways (n = 4), ventricular septal defect closure (n = 3), and other (n = 7). RESULTS: Early mortality was 5.8% (3 of 52 patients; no mortality since 1984, n = 31). Risk factors were age younger than 2.5 years (p = 0.03) and weight less than 10.7 kg (p = 0.03). Morbidity included transient atrial (n = 11) and ventricular arrhythmias (n = 5), and early reoperation in 3 patients. There was no need for a permanent pacemaker. Mean follow-up was 12.2 +/- 7.4 years (maximum, 24.3 years). Actuarial survival at 5, 10, and 15 years was 92.3% +/- 3.7%, 89.9% +/- 4.3%, and 89.9% +/- 4.3%, respectively. Freedom from all reoperations at 5, 10, and 15 years was 91.0% +/- 4.3%, 76.9% +/- 6.8%, and 61.4% +/- 8.8%, respectively. Moderate (grade II) or more tricuspid regurgitation on dismissal echocardiogram was the only risk factor for reoperation (p = 0.04). Tricuspid stenosis did not occur in any patient. At late follow-up, 89% of patients were in New York Heart Association class I or II. CONCLUSIONS: Ebstein's anomaly in young children can now be repaired with low mortality and good tricuspid valve durability. Tricuspid regurgitation at the completion of operation should be mild or less to minimize need for reoperation. Tricuspid valve repair and annuloplasty did not result in stenosis despite somatic growth. Most patients enjoy an excellent quality of life.
Right-sided Maze procedure for atrial tachyarrhythmias in congenital heart disease.
BACKGROUND: Congenital heart disease (CHD) that causes right atrial dilatation is commonly associated with atrial flutter and/or fibrillation (AFl/F). To reduce late recurrence of AFl/F in patients undergoing repair of CHD, we utilized a concomitant right-sided maze procedure. METHODS: From 1993 to 2003, 99 patients with CHD and associated AFl/F underwent a concomitant right-sided maze procedure at the time of CHD repair. Ages ranged from 9 to 72 years (median, 43 years). Atrial flutter and/or fibrillation was paroxysmal in 81 and chronic in 18; duration ranged from less than 1 month to 39.5 years (median, 2.9 years). Primary cardiac diagnoses were Ebstein anomaly (n = 47), other congenital tricuspid regurgitation (n = 19), univentricular heart (n = 11), isolated atrial septal defect (ASD, n = 8), tetralogy of Fallot (n = 8), and other (n = 6). RESULTS: Other concomitant procedures included tricuspid valve repair or replacement (n = 70), ASD closure (n = 39), and pulmonary valve procedures (n = 18). There were 6 early deaths. At hospital dismissal, 83 patients were free of AFl/F and 63 were in sinus rhythm. Follow-up in 87 of the 93 early survivors extended up to 8 years (mean, 2.7 years). There were 4 late deaths, all from noncardiac causes. Of the 83 known late survivors, 77 (93%) were free of AFl/F. Eighty-two of the 83 survivors were in New York Heart Association class I or II. CONCLUSIONS: In patients with AFl/F associated with CHD, a concomitant right-sided maze procedure at the time of intracardiac repair is effective in reducing late recurrent AFl/F. Most patients enjoy an excellent quality of life.
Long-term results of the Konno procedure for complex left ventricular outflow tract obstruction.
OBJECTIVE: This study was undertaken to determine long-term clinical and echocardiographic outcomes after the Konno procedure. METHODS: Fifty-three patients who underwent the Konno procedure between January 1, 1980, and January 1, 2004, were reviewed. RESULTS: Mean age at operation was 19 years (range, 1-65 years). Indications were as follows: complex subaortic or tunnel stenosis in 22 (41%), multilevel left ventricular outflow tract obstruction in 20 (38%), and aortic valve stenosis or hypoplasia in 11 (21%). Before the Konno procedure, 66 operations were performed in 41 (77%) patients. Thirty-three (62%) patients had greater than New York Heart Association class I symptoms preoperatively. A mechanical aortic valve was implanted in 40 (75%), a homograft in 10 (19%), and a xenograft prosthesis in 3 (6%). Mortality at 30 days was 8% (n = 4). Survival at 10 years was 86%. Risk factors for overall mortality were New York Heart Association class (hazard ratio 2.22, P = .04) and longer bypass time (hazard ratio 1.93/hour, P = .04). The cumulative probability of aortic valve reoperation was 19% at 5 years and 39% at 10 years, occurring in 15 patients at a median of 3.8 years. The average left ventricular outflow tract mean gradients were 19 mm Hg at 1 year (n = 9), 13 mm Hg at 1 to 3 years (n = 9), and 13 mm Hg at 3 to 5 years (n = 5). Pulmonary regurgitation was detected in 6 patients. Pulmonary valve replacement was performed in 3 (6%). At the date of last contact, all patients for whom data was available were in New York Heart Association functional class I or II. CONCLUSION: The Konno procedure is effective, allowing both long-term reduction of left ventricular outflow tract obstruction and improvement in functional class. Prosthetic aortic valve and native pulmonary valve complications may necessitate reoperation.
Sinus venosus atrial septal defect: long-term postoperative outcome for 115 patients.
BACKGROUND: Sinus venosus atrial septal defect (SVASD) differs from secundum atrial septal defect by its atrial septal location and its association with anomalous pulmonary venous connection (APVC). Data on long-term outcome after surgical repair are limited. METHODS AND RESULTS: We reviewed outcomes of 115 patients (mean age+/-SD 34+/-23 years) with SVASD who had repair from 1972 through 1996. APVC was present in 112 patients (97%). Early mortality was 0.9%. Complete follow-up was obtained for 108 patients (95%) at 144+/-99 months. Symptomatic improvement was noted in 83 patients (77%), and deterioration was noted in 17 patients (16%). At follow-up, 7 (6%) of 108 patients had sinus node dysfunction, a permanent pacemaker, or both, and 15 (14%) of 108 patients had atrial fibrillation. Older age at repair was predictive of postoperative atrial fibrillation (P=0.033). No reoperations were required during follow-up. Survival was not different from expected for an age- and sex-matched population. Clinical improvement was more common with older age at surgery (P=0.014). Older age at repair (P=0.008) and preoperative New York Heart Association class III or IV (P=0.038) were independent predictors of late mortality. CONCLUSIONS: Operation for SVASD is associated with low morbidity and mortality, and postoperative subjective clinical improvement occurs irrespective of age at surgery. Postoperative atrial fibrillation appears to be related to older age at operation. SVASD repair achieves survival similar to that of a matched population and should be considered whenever repair may impact survival or symptoms.
Long-term effects of surgical septal myectomy on survival in patients with obstructive hypertrophic cardiomyopathy.
OBJECTIVES: This study sought to determine the impact of surgical myectomy on long-term survival in hypertrophic cardiomyopathy (HCM). BACKGROUND: Left ventricular (LV) outflow tract obstruction in HCM increases the likelihood of heart failure and cardiovascular death. Although surgical myectomy is the primary treatment for amelioration of outflow obstruction and advanced drug-refractory heart failure symptoms, its impact on long-term survival remains unresolved. METHODS: Total and HCM-related mortality were compared in three subgroups comprised of 1,337 consecutive HCM patients evaluated from 1983 to 2001: 1) surgical myectomy (n = 289); 2) LV outflow obstruction without operation (n = 228); and 3) nonobstructive (n = 820). Mean follow-up duration was 6 +/- 6 years. RESULTS: Including two operative deaths (procedural mortality, 0.8%), 1-, 5-, and 10-year overall survival after myectomy was 98%, 96%, and 83%, respectively, and did not differ from that of the general U.S. population matched for age and gender (p = 0.2) nor from patients with nonobstructive HCM (p = 0.8). Compared to nonoperated obstructive HCM patients, myectomy patients experienced superior survival free from all-cause mortality (98%, 96%, and 83% vs. 90%, 79%, and 61%, respectively; p < 0.001), HCM-related mortality (99%, 98%, and 95% vs. 94%, 89%, and 73%, respectively; p < 0.001), and sudden cardiac death (100%, 99%, and 99% vs. 97%, 93%, and 89%, respectively; p = 0.003). Multivariate analysis showed myectomy to have a strong, independent association with survival (hazard ratio 0.43; p < 0.001). CONCLUSIONS: Surgical myectomy performed to relieve outflow obstruction and severe symptoms in HCM was associated with long-term survival equivalent to that of the general population, and superior to obstructive HCM without operation. In this retrospective study, septal myectomy seems to reduce mortality risk in severely symptomatic patients with obstructive HCM.
Long-term results of the Fontan operation for double-inlet left ventricle.
The purpose of this study was to quantify and determine predictors of long-term survival and functional outcome in patients with double-inlet left ventricle (DILV) after the Fontan operation. The Fontan operation has become the procedure of choice for DILV. Early survival has improved, but mortality and morbidity persist. Record review and follow-up questionnaires were used to ascertain the status of 225 patients with DILV who had Fontan operations from 1974 to 2001 at the Mayo Clinic. The median age at operation was 9 years. The median follow-up period was 12 years (range 3 months to 25 years). There were 22 deaths (9.3%) <30 days after the operation. Early mortality decreased to 3% (2 of 70 patients) after 1989. Overall late survival was 78% (159 of 203 patients). Actuarial survival for the 203 early operative survivors at 5, 10, 15, and 20 years was 91%, 80%, 73%, and 69%, respectively. Forty-nine percent (99 of 203) had additional surgical procedures after the Fontan operation. Other frequent late events were atrial flutter or fibrillation (57%), protein-losing enteropathy (9%), and thromboembolic events (6%). Current health status was described as good or excellent by 84% of patients, fair by 18%, and poor by 12%. In conclusion, the Fontan operation for DILV is now performed with a low operative mortality rate. Long-term survival has improved, and most patients have good functional status.
Mechanisms for recurrent left ventricular outflow tract obstruction after septal myectomy for obstructive hypertrophic cardiomyopathy.
BACKGROUND: Left ventricular septal myectomy provides excellent outcomes for symptomatic patients with severe obstructive hypertrophic cardiomyopathy. However, in a few patients, left ventricular outflow tract obstruction may recur and require repeat myectomy. We reviewed this subset of patients to assess the mechanisms of recurrence. METHODS: From 1975 to July 2003, 610 septal myectomies were performed; 13 of these were repeat myectomies after classic myectomies performed at our institution (n = 6) or elsewhere (n = 7). Ages ranged from 4 to 70 years (mean, 32 +/- 22). The interval between initial myectomy and repeat myectomy ranged from 13 months to 11 years (mean, 5.0 +/- 3.7 years). RESULTS: Mechanisms for obstruction included limited myectomy at the initial myectomy (n = 11), septal hypertrophy at the midventricular level (n = 8), and anomalous papillary muscles (n = 3). Mean intraoperative pressure gradients decreased from 82 +/- 24 to 6.2 +/- 4.4 mm Hg. No mitral valve replacement was performed, and there were no early deaths. Mean follow-up was 5.8 +/- 5.8 years. There was one late death. All surviving patients were free from recurrence of outflow tract obstruction and were in the New York Heart Association functional class I or II. CONCLUSIONS: Mechanisms for recurrent obstruction included limited myectomy at the initial operation, midventricular obstruction, anomalies of papillary muscles, and ventricular remodeling, especially in pediatric patients. Repeat myectomy can be performed with excellent outcomes. Need for reoperation may be reduced with current surgical approaches that include a more extended resection of the midventricular septum, relief of papillary muscle anomalies, and routine use of intraoperative transesophageal echocardiography.
Septal myectomy for obstructive hypertrophic cardiomyopathy in pediatric patients: early and late results.
BACKGROUND: Symptomatic pediatric patients with obstructive hypertrophic cardiomyopathy (HCM) have a higher death rate (6% annually) compared with adults. Transaortic left ventricular septal myectomy provides excellent outcomes for adults with obstructive HCM. We sought to assess the effect of septal myectomy on late survival and outcome in pediatric patients with obstructive HCM. METHODS: From 1975 to 2003, 56 pediatric patients underwent septal myectomy for obstructive HCM. Mean age at diagnosis was 6.3 +/- 5.4 years. Ages at operation ranged from 2 months to 20 years (mean 11 +/- 5.6 years). Concomitant procedures included mitral valve repair (n = 7), closure of atrial septal defect (n = 3), and other (n = 5). RESULTS: After myectomy, mean left ventricular outflow tract (LVOT) gradient decreased from 103 +/- 34 to 16 +/- 12 mm Hg and mean degree of mitral regurgitation decreased from 2.0 +/- 1.0 to 1.0 +/- 0.3 (both p < 0.0001). There were no early deaths. Four patients underwent elective cardioverter defibrillator implantation and 1 patient received a permanent pacemaker. Follow-up ranged up to 29 years (mean, 8.6 +/- 6.2). Cardiac reoperations were required in 8 patients: heart transplantation (n = 2), repeat myectomy (n = 2), mitral valve repair-replacement (n = 2), Konno-Rastan procedure (n = 1), and aortic valve replacement (n = 1). Age 14 years or less at operation was the only predictor of late reoperation (p = 0.017). Two patients died late; one suddenly without residual LVOT obstruction and one from chronic rejection after heart transplantation. Ninety-six percent of surviving patients were in New York Heart Association functional class I or II. Survival estimates at 5 and 10 years were 97% and 93%, respectively. CONCLUSIONS: Septal myectomy is safe and effective in symptomatic pediatric patients with obstructive HCM. Late survivorship compares very favorably with the natural history of this disease.
Septal myectomy for obstructive hypertrophic cardiomyopathy.
Septal myectomy effectively relieves left ventricular outflow tract obstruction (LVOTO) and cardiac symptoms in both adults and children with obstructive hypertrophic cardiomyopathy (HCM). Abnormal attachments of the papillary muscles and chordae and other cardiac lesions can be repaired at the same time. Early mortality for isolated septal myectomy in both children and adults is low (0% to 2.5%). Median echocardiographic LVOT gradients at rest on late follow-up have been as low as 0 to 5 mm Hg. Symptomatic improvements after myectomy occurs in the majority; 90% of patients improve by at least one functional class, and most remain improved on late follow-up. Late survivorship compares very favorably with the natural history of nonoperated patients with symptomatic obstructive HCM. These results serve as a basis for comparison with newer nonsurgical alternatives.
Surgical management of Ebstein's anomaly in the adult.
Ebstein's anomaly is a rare cardiac malformation that affects the tricuspid valve, right ventricle, and right atrioventricular junction. These anatomical and functional abnormalities cause important tricuspid regurgitation that results in right atrial and right ventricular dilatation and atrial and ventricular arrhythmias. Diagnosis is made by echocardiography. Operation includes tricuspid valve repair or replacement, closure of any interatrial communications, and appropriate antiarrhythmia procedures. Repair of Ebstein's anomaly eliminates right-to-left intracardiac shunting, improves exercise tolerance and functional class, and reduces supraventricular arrhythmias. In addition, quality of life and longevity are improved.
Surgery for aneurysms of the aortic root: a 30-year experience.
BACKGROUND: This study evaluated long-term results of aortic root replacement and valve-preserving aortic root reconstruction for patients with aneurysms involving the aortic root. METHODS AND RESULTS: Two-hundred three patients aged 53+/-16 years (mean+/-SD; 153 male, 50 female) underwent elective or urgent aortic root surgery from 1971 to 2000 for an aortic root aneurysm: 149 patients underwent a composite valve conduit reconstruction, and 54 patients underwent valve-preserving aortic root reconstruction. Fifty patients had Marfan syndrome. In-hospital and 30-day mortality was 4.0% (8/203) overall: for a composite valve conduit procedure, the corresponding value was 4.0% (6/149) and for valve-preserving procedure, 3.7% (2/54) (P=NS). Morbidity included 3 strokes (1%), 10 perioperative myocardial infarctions (5%), and 8 reoperations for bleeding (4%). Actuarial survival at 5, 10, 15, and 20 years was 93% (95% confidence interval [CI] = 88% to 97%), 79% (95% CI = 71% to 87%), 67% (95% CI = 57% to 79%), and 52% (95% CI = 36% to 69%), respectively. Freedom from reoperation was 72% (95% CI = 54% to 86%) at 20 years. Complications with anticoagulation occurred in 29 patients; with valve thrombosis, in 2; and with hemorrhage, in 27 (4 life threatening and 23 minor). Freedom from thromboembolism was 91% (95% CI = 77% to 98%) at 20 years. Freedom from endocarditis was 99% (95% CI = 92% to 100%) at 20 years. Multivariate analysis revealed preoperative mitral valve regurgitation (+3 to 4) and older age to be significant predictors of late death (P< or =0.005), and Marfan syndrome, initial valve-preserving aortic root reconstruction, and need for a concomitant procedure at initial operation to be significant predictors of the need for reoperation (P< or =0.01). CONCLUSIONS: Aortic root replacement for aortic root aneurysms can be done with low morbidity and mortality. Composite valve conduit reconstruction resulted in a durable result. There were few serious complications related to the need for long-term anticoagulation or a prosthetic valve. Reoperation was most commonly required because of failure of the aortic valve when a valve-preserving aortic root reconstruction was performed or for other cardiac or aortic disease elsewhere.
Transient constrictive pericarditis: causes and natural history.
OBJECTIVES: This study was designed to elucidate the causes and natural history of transient constrictive pericarditis (CP). BACKGROUND: In some patients with acute CP, the symptoms and constrictive physiologic features resolve with medical therapy alone, a phenomenon that has been labeled "transient constrictive pericarditis." No large studies have examined the causes or natural history of transient CP. METHOD: Review of the Mayo Clinic echocardiogram database identified 212 patients who had echocardiographic findings of CP from 1988 through 1999. Demographic, clinical, and echocardiographic findings were identified in all patients. In 36 of these patients, follow-up echocardiograms showed resolution of the constrictive hemodynamics without pericardiectomy. RESULTS: The average age of the patients was 49 +/- 21 years, and 72% were men. The causes for the CP were diverse, the most common being prior cardiovascular surgery (25%). In a subset of 22 patients who were followed serially during the course of their illness, resolution of the constrictive physiologic features occurred at an average of 8.3 weeks after diagnosis. CONCLUSIONS: A subset of patients with CP experience resolution of the disorder without requiring pericardiectomy.
Late results of the peel operation for replacement of failing extracardiac conduits.
BACKGROUND: Pulmonary ventricle to pulmonary artery conduits have made repairing many complex congenital cardiac anomalies possible. Late patient outcome is adversely affected by the hemodynamic consequences of conduit failure and the need for reoperation for conduit replacement. METHODS: We retrospectively reviewed 102 patients (65 males, 37 females) who underwent operation with autologous tissue reconstruction ("peel operation") between May 1983 and November 2001, in which a prosthetic roof was placed over the fibrous bed of the explanted conduit. Ages ranged from 5 to 58 years old (median age 19 years old). Explanted conduits were Hancock (n = 54), homograft (n = 21), Tascon (n = 11), and other (n = 16). The conduit roof was constructed with pericardium (n = 91) and other (n = 11). A prosthetic pulmonary valve was utilized in 68 patients: porcine in 65 patients and mechanical in 3 patients. A nonvalved reconstruction was performed in 34 patients. Concomitant cardiac procedures were performed in 66 patients. RESULTS: Early mortality overall was 2% (n = 2) and was 0% for patients who underwent isolated conduit replacement (n = 36). Mean follow-up was 7.6 years (maximum, 19 years). Overall survival at 10 and 15 years was 91% (84.7, 97.2) and 76% (62.8, 91.7), respectively. Nine patients required reoperation related to the peel operation: regurgitation in nonvalved conduit (n = 7); moderate pulmonary bioprosthesis stenosis and regurgitation with atrial arrhythmia (n = 1); and pulmonary bioprosthesis endocarditis (n = 1). Overall survivorship free of reoperation for peel reconstruction failure at 10 and 15 years was 90.7% (82.6, 99.6) and 82% (69.4, 97.0), respectively. Survivorship free of reoperation for patients with a prosthetic valve was 93.7%, and for those with no prosthetic valve was 80.0% at 15 years (p = 0.57). At late follow-up, 89% of patients were in New York Heart Association functional class I or II. CONCLUSIONS: The peel operation simplifies conduit replacement, can be performed with low risk, and provides a generous-sized flow pathway. In our experience late results demonstrate a lower freedom from reoperation than conventional prosthetic or homograft conduits.
Mitral and tricuspid valve repair in patients with previous mediastinal radiation therapy.
BACKGROUND: The purpose of this study was to evaluate outcomes of mitral and tricuspid valve repair after mediastinal radiation therapy. METHODS: From 1976 to 2001, 22 patients (mean age 61 +/- 14 years) underwent mitral (n = 14), tricuspid (n = 6), or both (n = 2) valve repairs 15 +/- 9 years after mediastinal radiation therapy. Concomitant procedures included coronary artery bypass graft, 11 patients; valve replacement, 6 patients (4 aortic, 3 mitral, 1 tricuspid, and 1 pulmonary); and pericardiectomy, 4 patients. RESULTS: Total follow-up was 82.5 patient-years (mean 3.7 +/- 3.3 years). Early mortality was 3 patients. There were 7 late deaths, 4 of which were of cardiovascular origin. Of the 19 early survivors, 2 required subsequent valve replacements, and 1 required cardiac transplantation 3.4 +/- 2.8 years after valve repair. One patient died after reoperation. In 4 patients who did not undergo reoperation, echocardiographic examinations showed progressive deterioration of their repaired valve function. Overall survival, freedom from cardiac death, and freedom from valve reoperation or cardiac transplantation at 5 years for early survivors was 66%, 85%, and 88%, respectively. New York Heart Association functional class at follow-up was I or II in 8 of the 12 late survivors. CONCLUSIONS: Functional status was good in two-thirds of late survivors. However, severe dysfunction of the repaired valve developed in 32% of early survivors and 16% required further surgery. Valve repair is technically feasible in selected patients after mediastinal radiation therapy; however, the limited durability of repairs after mediastinal radiation in this series suggests that valve replacement might be preferable.
Is repair of aortic valve regurgitation a safe alternative to valve replacement?
OBJECTIVE: To assess outcome of valve repair in patients with aortic valve regurgitation with emphasis on incidence and risk of reoperation. METHODS: We retrospectively reviewed 160 consecutive patients (127 men) who underwent aortic valve repair between 1986 and 2001. Ages ranged from 14 to 84 years (mean 55 +/- 17 years). Patients were categorized according to the main etiology of valve disease; 63 patients (39%) had annular dilation leading to central leakage, 54 (34%) had bicuspid valve, 34 (21%) with tricuspid valve had cusp prolapse, and 9 (6%) had cusp perforation. Repair methods included commissural plication (n = 154, 96%), partial cusp resection with plication (n = 47, 29%), resuspension or cusp shortening (n = 44, 28%), and closure of cusp perforation (n = 10, 6%). RESULTS: There was 1 early death (0.6%). Two patients required re-repair of the aortic valve during initial hospitalization. During a mean follow-up of 4.2 years, there were 16 late deaths. Overall, 16 of 159 hospital survivors had late reoperation on the aortic valve (mean interval 2.8 years) without early mortality. Risks of reoperation on the aortic valve were 9%, 11%, and 15% at 3, 5, and 7 years, respectively. CONCLUSIONS: Aortic valve repair can be performed with low risk and excellent freedom from valve-related morbidity and mortality. Late recurrence of aortic valve regurgitation led to reoperation in 8.8% of patients, but mortality associated with subsequent procedures is low. Aortic valve repair appears to be a good option for selected patients, particularly young patients who wish to avoid chronic anticoagulation with warfarin.
Extended septal myectomy for hypertrophic obstructive cardiomyopathy with anomalous mitral papillary muscles or chordae.
OBJECTIVES: Transaortic left ventricular septal myectomy yields excellent results for most severely symptomatic patients with hypertrophic obstructive cardiomyopathy. However, associated anomalies of the mitral subvalvular apparatus may prevent complete relief of obstruction, and mitral valve replacement has been advocated. We reviewed our results of procedures designed to relieve obstruction with preservation of the mitral valve. METHODS: Among 291 patients undergoing septal myectomy from 1975 to 2002, 56 (ages 2-77 years) had anomalous mitral subvalvular apparatus including anomalous chordae (n = 28) and papillary muscles with direct insertion into mitral leaflets (n = 13) or fusion to septum (n = 31) or free wall (n = 12); 82% of patients were in New York Heart Association class III or IV. Operation included resection of anomalous chordae (28 patients), relief of papillary muscle fusion (36 patients), and extended septal myectomy, wider at the apex than the base. RESULTS: There were no early deaths and no patients required mitral valve replacement. Mean peak pressure gradients decreased from 70 +/- 28 to 4.9 +/- 8.4 mm Hg and mean mitral regurgitation grade decreased from 2.3 to 1.0 (P <.001). Mean follow-up was 2.8 +/- 2.6 years. Freedom from reoperation at 4 years was 95%. There were 3 late noncardiac deaths; 98% of patients were in New York Heart Association class I or II. CONCLUSIONS: Hypertrophic obstructive cardiomyopathy associated with anomalous mitral papillary muscles or chordae can be successfully treated without mitral valve replacement by surgical relief of the anomalies and an extended septal myectomy; early mortality is low, obstruction and mitral regurgitation are significantly reduced, and late results are excellent.