[Valvular surgery].

OBJECTIVE: We sought to compare the clinical and echocardiographic outcomes of mitral valve repair for mitral regurgitation in patients with degenerative disease of the mitral valve with posterior, anterior, or bileaflet prolapse. METHODS: Patients underwent operations from 1981 through 2001: 359 had posterior (mean age, 60.4 years), 92 had anterior (mean age, 53.3 years), and 250 had bileaflet (means age, 56.4 years) prolapse. Patients with anterior prolapse were younger (P = .04) and had more associated aortic valve disease (P = .02), particularly bicuspid aortic valve disease (P < .001). Anterior prolapse was corrected by using chordal replacement with Gore-Tex sutures in most patients, but early on in this series, leaflet resection, chordal shortening, and chordal transfer were also used. Echocardiograms were done annually, and clinical follow-up was complete at a mean of 6.9 +/- 4.0 years (range, 0-23 years). RESULTS: The overall survival at 12 years was 75% +/- 5%, with no difference among the posterior, anterior, and bileaflet prolapse groups (P = .3). The freedom from reoperation at 12 years was 96% +/- 2% for posterior, 88% +/- 4% for anterior, and 94% +/- 2% for bileaflet prolapse (P = .019). Anterior prolapse was the only independent predictor of reoperation. The freedom from moderate or severe mitral regurgitation at 12 years was 80% +/- 4% for posterior, 65% +/- 8% for anterior, and 67% +/- 6% for bileaflet prolapse (P = .001). Anterior and bileaflet prolapse, age, ejection fraction of less than 40%, and aortic valve disease were independent predictors of recurrent moderate or severe mitral regurgitation. CONCLUSIONS: The pathophysiology of mitral regurgitation affects the durability of mitral valve repair for degenerative disease, and the results of posterior prolapse are better than those of anterior and bileaflet prolapse. This study indicates that rates of reoperation underscore the rates of failure of mitral valve repair.

Cardiac Surgical Procedures↗

PubMed2005

Laryngopharyngeal dysfunction after the Norwood procedure.

OBJECTIVE: We sought to evaluate the incidence and significance of recurrent laryngeal nerve and swallowing dysfunction after a Norwood procedure compared with that after biventricular aortic arch reconstruction. METHODS: From April 2003 through December 2004, 36 neonates underwent a Norwood procedure; 33 of 36 had postoperative fiberoptic laryngoscopy and modified barium swallow. Study results were used to guide the transition from nasogastric tube to oral feeding and placement of gastrostomy tubes. During the same time period, 18 neonates underwent aortic arch reconstruction as part of a biventricular repair. RESULTS: After a Norwood procedure, laryngoscopy showed left true vocal fold (cord) paralysis in 3 (9%) of 33 patients. The results of a modified barium swallow were abnormal in 16 (48%) of 33 patients, with aspiration in 8 (24%) of 33 patients. Of the 3 patients with vocal fold paralysis, 2 had a normal modified barium swallow result, and 1 had aspiration. Gastrostomy tubes were placed in 6 (18%) of 33 patients, all with an abnormal modified barium swallow result. Hospital stay was longer in patients with an abnormal modified barium swallow result: 34 +/- 13 versus 22 +/- 7 days (P < .01). After biventricular repair with aortic arch reconstruction, left true vocal fold paralysis occurred in 4 (25%) of 16 patients; results of a modified barium swallow were abnormal in 10 (59%) of 17 patients, with aspiration in 6 (35%) of 17 patients (all nonsignificant vs patients undergoing the Norwood procedure). Follow-up laryngoscopy in 4 patients with vocal fold paralysis showed no change in 3 of 4 patients and improvement in 1 patient. Follow-up modified barium swallow showed resolution of aspiration in 11 (85%) of 13 patients. Hospital survival was 32 (89%) of 36 patients for the Norwood procedure and 18 (100%) of 18 patients for biventricular repair. There has been 1 sudden death before second-stage palliation. CONCLUSIONS: After a Norwood procedure, swallowing dysfunction occurs in 48% of patients, with aspiration in 24%, and results in increased length of hospital stay. Left recurrent laryngeal nerve injury, seen in 9% of patients, is an uncommon cause of swallowing dysfunction. Postoperative aspiration generally resolves over time, whereas vocal fold paralysis does not. Systematic evaluation of swallowing function allows appropriate tailoring of feeding regimens and might contribute to decreased hospital and interstage mortality.

Cardiac Surgical Procedures↗