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[Reoperations on prosthetic heart valves: an analysis of 64 cases].

During the period of Fabruary 1988 to May 1996, 64 reoperations were performed for prosthetic valve malfunction. Degeneration of bioprosthesis occurred in 46 patients, failure of mechanical prosthesis in 9, and periprosthetic leakage without evidence of infection in 9. In accordance with the status of cardiac function, 9 patients with acute dysfunction of mechanical prosthesis received emergency operations, and the remaining 55 patients with bioprosthetic valve failure or periprosthetic leakage received selective operation. There were 8 early deaths with a overall hsopital mortality rate of 12.5%. Three of the deaths occurred among the 55 selective procedures for a mortality of 5.3% and 3 of the deaths occurred among the 9 emergence procedures for mortality of 33.3%. The 56 long-term survivors were followed up from 3 months to 7 years (mean 2.1 years). There were 3 late deaths (5.3%). Forty-eight patients have been living more than 1 year. Their cardiac function after reoperation was class I (42 patients), class II (5), and class III (1). The timing of reoperation and surgical technique were discussed.

Adult↗

Successful reoperation after Batista partial left ventriculectomy demonstrates patient's hemodynamic recovery.

We report an emergency reoperation due to mechanical valve thrombosis following a Batista partial left ventriculectomy and mitral valve replacement with a St. Jude prosthesis. We re-replaced the valve with an identical St. Jude device and counseled the patient on the importance of routine anticoagulation. To the best of our knowledge, this is the 1st reported case of a patient who has survived cardiac reoperation after a Batista partial left ventriculectomy. Moreover, our report demonstrates that the hemodynamic recovery achieved after a Batista operation can enable a patient to tolerate reoperation on cardiopulmonary bypass, even in the presence of acute pulmonary edema and cardiogenic shock.

Heart Failure↗

[Reoperation of tetralogy of Fallot for the transannular patch neo-intimal stenosis: a case report].

A 3-year-old male patient underwent right ventricular outflow tract reconstruction with a glutaraldehyde-preserved equine pericardium for tetralogy of Fallot. Because of progressive severe pulmonary restenosis with over systemic right ventricular pressure, tricuspid regurgitation, and abnormal high echoic shadow in the distal main pulmonary artery on echocardiogram, he required reoperation a year after the first correction. In the reoperative findings, the pseudointima was thickened heavily and detached from glutaraldehyde-preserved equine pericardial patch. The patch was removed and the right ventricular outflow was reconstructed widely to the pulmonary bifurcation with porcine pericardial patch again. Patho-histological findings showed foreign body giant cells and macrophages in the pseudointima. Four years after the reoperation, echocardiogram shows 41 mmHg for the right ventricular pressure and 22 mmHg for the pressure gradient of right ventricular outflow tract, and the patient is doing well now.

Cardiac Surgical Procedures↗

Carotid endarterectomy reoperations in a regional medical center.

Large, randomized prospective clinical trials have not addressed the safety of reoperation for recurrent carotid disease. Our purpose was to determine whether outcomes for carotid endarterectomy for recurrent disease were different from those for primary or contralateral carotid endarterectomy. We reviewed all carotid endarterectomies done in our regional medical center hospital from 1979 through 1997. We analyzed 1656 primary procedures, 377 contralateral carotid procedures, and 63 reoperations. Operation for recurrent disease was done in 3 per cent of those having primary operations. Patients in the three groups did not differ significantly with regard to age, race, or sex. Seventy per cent of patients were symptomatic with transient ischemic attacks, amaurosis, and reversible ischemic neurological deficit being most prominent. There were no deaths and three strokes in the reoperation group for a combined stroke and death rate of 4.8 per cent. This was not significantly different from that of 3.2 per cent for the stroke and death rate for the primary group and 3.5 per cent for the contralateral group. Carotid endarterectomy is a safe treatment for recurrent carotid artery disease.

Aged↗

Does hysterectomy without salpingo-oophorectomy influence the reoperation rate for adnexal pathology? A retrospective study.

OBJECTIVE: The aim of this study was to assess if the abdominal, vaginal and laparoscopic approach to hysterectomy can affect the incidence of ovarian or adnexal pathology after hysterectomy without salpingo-oophorectomy. METHODS: In this study 17 cases out of 617 hysterectomies were found to have development of adnexal pathology; reoperation rate was 2.75%. RESULTS: The reoperation rate was significantly different (p < 0.006) in the observed approaches to hysterectomy (TAH 5.67%, VH 0.69%, LH 3.18%). The greatest difference was found between the abdominal and vaginal groups. CONCLUSION: Our study results have sufficiently shown that the relationship of a number of factors (age, primary histologic findings, smaller peritoneal trauma) had an important impact on a significant difference in reoperation rate between vaginal, laparoscopic and namely abdominal hysterectomies in female patients with preserved adnexa.

Adult↗

Posterior thoracotomy for reoperative coronary artery bypass grafting without cardiopulmonary bypass: perioperative results.

BACKGROUND: This retrospective study evaluates morbidity and mortality of reoperative coronary artery bypass grafting (CABG) without cardiopulmonary bypass (CPB) using a posterior thoracotomy to revascularize the lateral aspect of the heart. METHODS: From January 1995 to July 1999, reoperative CABG without CPB was performed on 67 selected patients using a left posterior thoracotomy approach. Preoperative risk factors, postoperative mortality, and major complications were derived from the New York State database. RESULTS: All patients were operated on without CPB. A total of 1.3 grafts per patient were performed. Freedom from major complications was 95.5%. There were no postoperative cerebro-vascular accidents (CVA) or new neurological deficits. Two patients (3%) had a perioperative acute myocardial infarction. The actual mortality rate was 4.5% (3/67), the expected mortality was 5.1% and the calculated risk adjusted mortality was 2.1%. CONCLUSIONS: Reoperative CABG without CPB to revascularize selected coronary artery targets can be safely performed using a posterior thoracotomy approach.

Aged↗

Low-dose aprotinin in heart valve reoperations.

BACKGROUND AND AIM OF THE STUDY: Aprotinin is effective in promoting hemostasis, notably in cardiac surgery with cardiopulmonary bypass. Its efficacy has been shown in coronary bypass graft operations. However, few reports exist of aprotinin use in valve operations, and in those studies only the full dose was used. Thus, our aim was to evaluate the effects of low-dose aprotinin in patients undergoing heart valve reoperation. METHODS: Eighteen patients having reoperative valve surgery received 10(6) KIU aprotinin after induction of anesthesia, and a further 10(6) KIU in the pump prime. A group of 18 similar patients who were operated on but did not receive aprotinin were used as controls. RESULTS: A significant reduction in postoperative blood loss (approximately 470 ml) occurred in patients receiving aprotinin. These patients also presented less postoperative bleeding than untreated patients in 70.4% of cases. No adverse effects of the drug were noted, except for one case of allergic reaction. CONCLUSION: The systematic use of low-dose aprotinin should be considered in valve reoperation, except in cases of re-exposure to the drug, or allergic reaction.

Adult↗

Reoperative coronary artery bypass grafting with and without cardiopulmonary bypass: determinants of perioperative morbidity and mortality.

BACKGROUND: This retrospective study evaluates perioperative results of reoperative coronary artery bypass grafting (CABG) with and without cardiopulmonary bypass (CPB). METHODS: From January 1995 to March 1999 reoperative CABG was performed on 581 patients: 307 (52.84%) patients were operated upon on-CPB and 274 (47.16%) off-CPB. Median sternotomy was used in all patients on-CPB. Median sternotomy or alternative surgical approaches were used in the off-CPB group. Data was retrospectively reviewed. To identify the variables independently related to perioperative mortality and adverse outcome, multivariate analysis was performed in the overall population of 581 patients. RESULTS: Preoperative risk factors were comparable in the two groups. Critical lesions of the right and left circumflex coronary artery were more common in the on-CPB group (p < 0.005). A total of 2.7 grafts/patient was performed in the on-CPB group versus 1.3 grafts/patient in the off-CPB group (p = NS). Freedom from postoperative complications was higher in the off-CPB group (72% versus 90.9%, p < 0.005). Perioperative stroke and respiratory failure rates were more common in the on-CPB group (3.9% versus 0.7% and 5.9% versus 2.2% respectively, p < 0.005). Actual mortality was 5.9% in the on-CPB group and 3.6% in the off-CPB group (p = NS). Risk adjusted mortality was 2.2% and 1.3% in the on-CPB and off-CPB groups respectively. Although CPB was found to be independently related to adverse outcome (odds ratio (OR) = 2.89, p-value < 0.005), no correlation was found between mortality and CPB. CONCLUSIONS: Avoidance of CPB independently reduces adverse outcomes in reoperative CABG without affecting mortality rate.

Adult↗

[Two cases of reoperative coronary bypass grafting through a small left thoracotomy].

A reoperation by a MIDCAB (minimally invasive direct coronary artery bypass) was performed on 2 patients, including one who had undergone a surgical repair of a left ventricular rupture and another who had undergone a coronary artery bypass operation. In both patients, the left internal thoracic artery was isolated by a left small thoracotomy and then was anastomosed to the LAD (left anterior descending artery). One patient showed stenosis at the site of anastomosis and thus required coronary arterioplasty postoperatively, but was discharged without any further complications. When performing a reoperation by MIDCAB, complications such as injuries to the heart and patent graft during surgery and postoperative complications can be minimized by only performing a bypass to LAD. Such a bypass is usually sufficient in cases in which either marked adhesion is expected in the area of the circumflex artery or if anastomosable branches are not available in the area of the circumflex artery. This surgical technique was found to be an effective modality for a reoperation of the coronary artery, if suitable cases are carefully selected.

Aged↗

[Coronary reoperation through left thoracotomy without cardiopulmonary bypass: 3 case reports].

With the increasing number of patients who have undergone coronary artery bypass grafting, the incidence of reoperative coronary grafting is also increasing. Reoperative coronary artery bypass grafting is associated with morbidity and mortality rates greater than those of primary coronary operations. Left thoracotomy can provide access for reoperation when repeat median sternotomy is extremely dangerous. Coronary artery grafting on a beating heart and via left thoracotomy can be a good alternative strategy when redo coronary surgery is necessary in the circumflex or left anterior descending territories.

Coronary Angiography↗

[Reoperations in lumbar discopathies].

In the years 1976-1990 at the Neurosurgery Centre in Rzeszów 938 patients were treated surgically for lumbar discopathy. Reoperation was necessary in 5.4% of cases. In 0.6% of them purulent wound infection was the cause, in the remaining 4.8% lacking improvement or recurrence of sciatic pain after 1 month to 12 years. In 2.2% of cases the cause of pain recurrence was recurrent hernia at the same or other level, and after its removal sciatic pain disappeared. Root compression by cicatricial tissue or osteophyte caused reoperation in 1% and surgical decompression of the root gave only minor improvement. Lacking improvement after the first operation was due in 0.7% of cases to a fragment of the nucleus pulposus left in the vertebral canal and in 0.6% the cause was failure to recognize two-level discopathy. After reoperation in such cases all pains regressed. The analysis showed that the frequency of repeated interventions would be diminished by careful excochleation of the intervertebral space, operative revision of the space with comparison with the results of radiculography and clinical examination, and not too late decision of operation.

Back Pain↗

Noninvasive assessment of internal thoracic artery for reoperative coronary artery surgery.

To determine whether previous sternotomy alters internal thoracic artery (ITA) anatomy and flow characteristics, a duplex scanner was used for noninvasive evaluation of the ITA in 59 patients who were scheduled for reoperative coronary artery bypass surgery. The left ITA was insonated through the third intercostal space by use of a duplex scanner (5.0 MHz probe). Measurements of the ITA diameter (mm) and peak systolic velocity (cm/sec) were obtained; ITA flow was calculated from velocity and cross-sectional area. These findings were compared with the values obtained from 105 patients who were scheduled to undergo first-time (primary) coronary artery surgery during the same time period. In the reoperative group, preoperative mean ITA diameter was 2.26 +/- 0.06 mm; this was not significantly different from the primary group's mean ITA diameter of 2.15 +/- 0.04 mm (p = 0.09). Mean peak systolic velocity was 79.9 +/- 2.4 cm/sec and calculated systolic blood flow was 204.6 +/- 13.1 ml/min in the reoperative patients, as compared with 83.3 +/- 2.1 cm/sec and 189.5 +/- 8.6 ml/min in the primary group, respectively. Values were similar in both groups for the peak systolic velocity (p = 0.31) and calculated systolic blood flow (p = 0.32). These results suggest that previous heart surgery or sternotomy does not adversely affect ITA anatomy and flow characteristics. We conclude that ultrasonic imaging is an easily applicable technique for preoperative assessment of ITA in patients who have undergone previous sternotomy.

Aged↗

Reoperation for benign biliary tract diseases in 149 cases: causes and prevention.

BACKGROUND: Failure to diagnose and treat benign biliary tract disease relatively common surgical disease may cause serious consequences. Since the introduction of B-mode ultrasonography, CT, or MRI early and accurate diagnosis of the disease has been possible. In clinical practice, however, these methods have not been adequately used. Inappropriate surgical procedures can also lead to bile duct injury or stenosis after injury, residual cholecystitis, stenosis after cholangiojejunostomy, or stenosis of the Oddi's sphincter. But improvement of the diagnosis and treatment of benign biliary tract disease remains a great challenge to clinicians. METHODS: A total of 149 patients with benign biliary tract disease who had received reoperation from June 1988 to June 2001 were analyzed retrospectively. Among them 95 patients (63.76%) received operation twice and 38 (25.5%) underwent 3 operations. Sixteen patients (10.74%) needed 4 or more operations. The procedures for the first operation included cholecystectomy (71 patients, 47.65%), cholecystectomy with exploration of the common bile duct (42, 28.19%), cholangiojejunostomy (21, 14.1%), and laparoscopic cholecystectomy (15, 10.06%). RESULTS: The causes for reoperation included residual and recurrent bile duct stones in 53 patients (35.57%), bile duct injury or stenosis after injury in 41 (27.52%), residual cholecystitis with or without stones in 28 (18.8%), stenosis after cholangiojejunostomy in 17 (11.41%), stenosis of the Oddi's sphincter in 5 (5.35%), and others in 5 (5.35%). Four patients (2.68%) died after operation. CONCLUSIONS: To prevent reoperation for benign biliary tract diseases, the following measures should be taken to increase preoperative diagnostic rate, to understand conditions of the biliary tract by using imaging techniques and cholangiography, to examine comprehensively and carefully with choledochoscopy, cholangiography and B-mode ultrasonography intraoperatively, to choose appropriate operative procedures to decrease the rate of residual stones, and to decide the time for the first repair according to injury type of the bile duct. Roux-en-Y hepaticojejunostomy with cholangioplasty is the best operation for the reconstruction of the biliary tract.

Adolescent↗

[Radiation navigated reoperations of the thyroid gland in differentiated carcinoma].

Radiation-navigated reoperations of the thyroid gland for the differenciated carcinoma are reserved for such cases of the thyroid gland reoperations aiming to complete a total thyroidectomy and, also, to extirpate metastatically affected lymphonodes. The authors discuss this part of the above surgical procedure, its therapeutic prospects, as well as its cons. They recommend already the primary surgical procedure on the thyroid gland to be conducted carefully--i.e. to conduct at least a lobectomy of the thyroid gland followed by visualization and examination of the recurrent laryngeal nerve and the parathyroid glands. They recommend the reoperations to be concentrated in specialized centres.

Adult↗

[Reoperation after surgical treatment of lumbar spondylolisthesis].

OBJECTIVE: To study the causes of failure following surgical treatment of lumbar spondylolisthesis, procedures for redo surgery and the final result of reoperation. METHODS: 20 patients who had a repeat operation for lumbar spondylolisthesis were studied retrospectively. On average 24.3 months following the previous surgery, all of these patients had recurrence or progression of back and leg pain. All of 20 patients were reoperated by means of three different procedures. RESULTS: The causes of failure were post-operative destabilization (6 cases); progressive spondylolithesis (3 cases) implants failure (10 cases) and mistake segment (one case). After reoperation, a mean 34.1 months' follow-up was made. The excellent or good rate was 90%. Incorporation of graft was found in 18 cases with fusion by inter-transverse process and 2 cases by intervertebral space. New bone formation was found in 6 out of 8 cases that had a simultaneous intervertebral cage implant. No implant failure was found in all patients. CONCLUSIONS: Simple laminectomy or discectomy was not indication for lumbar spondylolithesis. No bone graft or union was the main causes of implant failure. Posterior instrumented fusion with laminectomy decompression can be used in the patients who had a prior surgery of simple discectomy or anterior intervertebral bone graft. Except for posterior instrumented fusion with extensive laminectomy decompression, Intervertebral fusion should be considered in the patients who had a prior surgery of laminectomy decompression with instrument, anterior intervertebral fusion (ALIF) was recommended for these cases.

Adult↗

[Prognosis of reoperation for prosthesis dysfunction].

Between 1969 and 1990, 75 adults living in mainland France underwent reoperation for bioprosthetic valve dysfunction. The average time between the initial operation and reoperation was 65 +/- 41 months. The average age was 44 years and half of the patients were severely symptomatic (NYHA Stages III or IV in half the cases). Dysfunction of an aortic valve prosthesis was observed in 65% of cases (N = 49) and of a mitral valve prosthesis in 35% of cases (N = 26). The causes of reoperation were: 50 primary degenerations (67%), 19 infectious endocarditis (25%) and 6 perivalvular leaks (8%). Valve replacement was performed in 74 cases and suture of the sewing ring in 1 case. An associated procedure was performed in 24 cases: 12 drainage of abscess, 10 double valve replacements and 2 tricuspid valvuloplasties. The operative mortality was 9.3% and early morbidity was 46%. Univariate and multivariate analysis identified two factors predictive of operative mortality: the duration of cardiopulmonary bypass and the cardiothoracic ratio. During follow-up, which lasted 36 +/- 31 months, there were 12 deaths, 4 of cardiac failure; 4 sudden deaths, 3 deaths related to the prosthesis and 1 extracardiac death. The 6 year actuarial survival rate was 71%. The cardiothoracic ratio, the preoperative ejection fraction and the bypass time were factors predictive of global showed bypass time and the cardiothoracic ratio to be prognostic factors. The 6 year survival without cardiac events was 40%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

[A case with cerebral embolism due to the recurrence of thrombotic valve five years after the reoperation].

Between April 1972 and May 1990, a total of 300 patients in our institution underwent insertion of a Björk-Shiley aortic valve prosthesis, and development of a thrombosed valve was observed only in 4 female cases. It was considered that the thrombosed valves in all 4 cases were caused by inadequacy of the anticoagulant agents. As reoperative procedures, thrombectomy, resection of the excessive granulation under the valve, and a method of turning the opening direction of the valve 180 degrees were used. These procedures were reported previously. One case died late in the day after the operation, while the remaining 3 cases progressed favorably. Although control of one of these three cases was favorably maintained after reoperation, a restriction of 43.2 degrees of the opening angle of the valve was again observed by valve-fluoroscopy performed in the 3rd postoperative year. However, progress of this patient was observed on an outpatient basis because flow velocity at the position of aortic valve was also within normal range. This was shown Doppler's test using ultrasonic waves and the patient showed no symptoms. However, this patient was admitted to our institute due to sudden right hemiplegia on May 1990 in the 5th year after reoperation. The cerebral embolism due to the recurrent thrombosed valve was diagnosed because a low density in the middle cerebral area was observed by CT, and increase of the opening angle of the valve (compared with that at ambulation) was also noted by valve-fluoroscopy. The hemiplegia remained even though this patient was saved from death. (ABSTRACT TRUNCATED AT 250 WORDS)

Aortic Valve↗

[Experience in reoperation of lumbar spinal surgery using posterior lumbar interbody fusion cage].

OBJECTIVE: To investigate the indications and surgical techniques of reoperative lumbar spinal surgery using posterior lumbar interbody fusion cage. METHODS: Seventeen cases underwent reoperative lumbar spinal surgery using posterior lumbar interbody fusion cage. The surgical methods included decompression of lumbar canal, dural and radicular conglutination release, discectomy, posterior insertion of lumbar interbody fusion cage, pedicle screw instrumentation, posterolateral lumbar fusion. Periodical follow-up was conducted for 18 months (12 - 43 months). The clinical effect was evaluated by the Macnab's criterion, and the outcome of lumbar interbody fusion was evaluated according to the Brantigan's criterion. RESULTS: Twenty-seven cages were implanted into twenty-three disc spaces (cage at L(3 - 4) in 5 cases, cage at L(4 - 5) in 8 cases, and cage at L(5)-S(1) in 4 cases). All postoperative patients ambulated after two weeks. No wound healing problems and nerve injury were found. Dural rupture occurred in 5 cases, but without occurrence of cerebrospinal fluid leakage. According to the Macnab's criterion, the preoperative lower extremity radicular symptoms and neurogenic claudication were effectively relieved in 15 cases (88.2%), and the outcomes were good or excellent in 15 cases (88.2%). According to the Brantigan's criterion no evidence of implant failure was found, and interbody fusion could be achieved about 6 months in all patients. No additional operation was needed for involved segments, and the surgical outcomes could be maintained. CONCLUSION: A good and effective method, use of posterior lumbar interbody fusion cage in reoperative lumbar spinal surgery eliminates neural compression and the discogenic pain, restore the lumbar alignment, and accomplish the internal fixation and anterior column fusion of lumbar vertebrae simultaneously.

Adult↗