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PubMedDate not supplied

Cardiac valve operations using a partial sternotomy (lower half) technique.

BACKGROUND AND AIM: Operations on cardiac valves are being performed more frequently through smaller incisions than traditional midline sternotomy. A variety of alternate incisions have been used, but most of the interest appears to focus on partial sternotomy. The purpose of the study was to review results using a partial lower sternotomy for cardiac valve operations. METHODS: A standard partial lower one-half or two-thirds sternotomy was used for cardiac valve operations in 112 patients. The sternum was divided transversely in the third or second intercostal space and vertically from that point through the xyphoid process. Standard instruments and retraction devices were used. This incision provided adequate exposure for even complex operations to be performed. Small cannulae were placed into the aorta and heart through the primary incision for cardiopulmonary bypass. Vacuum-assisted venous drainage was used. RESULTS: Seventy-four single valve operations were performed. There were 35 double valve and 5 triple valve operations (35.4%) performed. Operative mortality (5.3%) and major complication rates were comparable to full the sternotomy approach. CONCLUSIONS: Partial sternotomy (lower half) provides a smaller incision through which virtually all cardiac valve operations may be performed. Results achieved with this approach are similar to those associated with full sternotomy. The smaller incision is appreciated by patients.

Adolescent↗

PubMed1995

Cardiac valve replacement in relapsing polychondritis. A review.

Cardiac valve replacement is a rare but not exceptional eventuality in patients with relapsing polychondritis. One case requiring aortic and mitral valve replacement and its follow up is described. From the review of the literature an additional twenty patients who required cardiac valve replacement are analyzed. The mean delay between the first onset of relapsing polychondritis and operation was 6.51 years and the mean age at operation was 38.8 years. There was a preponderance of male patients (73.7%). Aortic and mitral valves were replaced in 100% and 28.5% of patients, respectively. During the four first postoperative years 23.8% of them were reoperated for periprosthetic leak or aortic aneurysm, and during the same period 52.6% died of a cardiovascular cause. Immunosuppressive agents should be employed in patients with relapsing polychondritis and cardiovascular involvement because they seem to be more effective than steroids in severe forms of the disease. Therefore, we recommend close and prolonged follow up: firstly because there can be early paravalvular prosthetic leakage due to the friability of the tissue to which it has been anchored; secondly because aortic aneurysms occur frequently in relapsing polychondritis, may be multiple, may involve all parts of the aorta and result in fatal rupture even in asymptomatic patients; and thirdly because there can be a fatal outcome due to other organ involvement, like airway obstruction, acute glomerulonephritis, or systemic vasculitis. Prophylactic composite graft replacement of the ascending aorta associated with replacement of the aortic valve and re-implantation of the coronary arteries could avoid the need for reoperation in these high risk patients.

Adult↗

PubMed1985

Mediastinitis after cardiac valve operations. Impact upon survival.

Mediastinitis after cardiac valve replacement is a dreaded complication with consequent mortality estimated as high as 70%. We have reviewed 2,491 patients with cardiac valve operations to assess the impact of mediastinitis upon mortality in our institution in the past 10 years. Mediastinitis developed after valve replacement in 36 patients (1.4%). All patients required operative intervention for mediastinal infection with positive bacterial cultures. Twelve of these patients had other perioperative problems associated with a high mortality independent of mediastinitis: bacterial endocarditis not cured by valve replacement (three), recent preoperative myocardial infarction (four), triple valve disease with biventricular failure (one), and severe perioperative cerebral damage (four). Ten of these high-risk patients died (83.3%). The impact of mediastinitis upon survival is best evaluated in the remaining 24 patients without high-risk perioperative problems. Eight of these patients were managed before 1980 with débridement and irrigation as the primary treatment, with two hospital deaths (25%). Pectoral or rectus muscle flaps were frequently used after 1980 (flaps in 11 of 16 patients), leading to a significantly shorter time between diagnosis of infection and hospital discharge free of infection (62 versus 385 days, p less than 0.05). Only one of these 16 patients died. Valve re-replacement for endocarditis was performed in three of these 24 patients although 13 of 24 had positive blood cultures. Mediastinitis after valve operations in the absence of other high-risk perioperative problems can be successfully managed. Early débridement and muscle flap closure has led to a 94% survival rate in 16 patients during the past 4 years.

Adult↗

PubMed1998

Clinical utility of cardiac valve Gram stain and culture in patients undergoing native valve replacement.

OBJECTIVES: To determine if routine cardiac valve culture is useful in diagnosing clinically unsuspected infective endocarditis in patients undergoing native valve replacement, to see if false-positive culture results have a deleterious effect on patient care, and to determine if microbiology and histopathology can be used to differentiate partially treated and untreated infective endocarditis from valve contamination. DESIGN: Case series. SETTING: Tertiary-care teaching hospital with 1125 beds. PATIENTS: Forty-eight patients with culture-positive cardiac valves after native valve replacement. RESULTS: A single unsuspected case of endocarditis was disclosed by microbiology over a 5-year period. Histopathology in this case was also positive, however, and the diagnosis should have been suspected clinically. Eighty-three percent of positive cultures were the result of contamination over an 18-month period; results were disregarded appropriately by clinicians. Clinical context or histopathology was required to categorize microorganisms correctly as pathogens or contaminants; only the presence of organisms on Gram stain had a good predictive value for endocarditis. CONCLUSION: Routine valve cultures in patients undergoing native valve replacement are not warranted. Although false-positive culture results had no deleterious effects on patient care in this study, misinterpretation of such results could lead to overtreatment. Microbiology results alone are not sufficient to distinguish endocarditis from contamination.

Adult↗

PubMed1998

Factors that predict the use of positive inotropic drug support after cardiac valve surgery.

UNLABELLED: Left ventricular dysfunction is common after cardiac surgery and is often treated with positive inotropic drugs (PIDs). We hypothesized that the use of PIDs after cardiac valve surgery would have significant associations with the valvular pathophysiology and surgical procedure, and unlike the case for patients undergoing coronary artery surgery, would be unrelated to duration of cardiopulmonary bypass (CPB) or of aortic clamping. One hundred forty-nine consenting patients undergoing cardiac valve surgery were studied. Patients with hepatic or renal failure, or New York Heart Association class IV cardiac symptoms, were excluded. Patients were considered to have received PIDs if they received an infusion of amrinone, dobutamine, epinephrine, or dopamine (> or = 5 microg x kg[-1] x min[-1]). PIDs were received by 78 patients (52%). In a univariate model, older age, history of congestive heart failure, decreasing left ventricular ejection fraction, longer durations of CPB, and concurrent coronary artery surgery significantly increased the likelihood of PID support. There was also significant variation by anesthesiologist in the administration of PIDs. The specific diseased valve and valvular stenosis or insufficiency did not influence the likelihood of receiving PID support. In a multivariable model, age, history of congestive heart failure, decreasing left ventricular ejection fraction, and anesthesiologist were significantly associated with the likelihood of PID support, but duration of CPB and concurrent coronary artery surgery were not. In conclusion, patient age and ventricular function, as well as physician preferences, predicted the need for inotropic drug support; however, neither the specific valvular lesion, nor duration of CPB were strongly predictive in a multivariable model. IMPLICATIONS: We evaluated factors related to use of positive inotropic drugs after cardiac valve surgery. The likelihood of a patient receiving these drugs increases with advancing age and with more severe preoperative left ventricular dysfunction, but was not influenced by the specific diseased valve or the duration of cardiopulmonary bypass.

Amrinone↗

PubMed2002

[Analysis of complications after cardiac valve replacement: report of 702 patients].

OBJECTIVE: To define the determinants of perioperative death and complications after cardiac valve replacement in 702 patients. METHODS: Clinical data of the patients after cardiac valve replacement were analyzed retrospectively. RESULTS: Perioperative mortality and morbidity correlated significantly with some of the perioperative variables, such as higher NYHA functional class (III or IV), large left ventricular end-diastolic diameter (>/= 70 mm), C/T >/= 0.70, prolonged aortic cross-clamping time and cardiopulmonary bypass time, unsatisfactory myocardial protection. CONCLUSIONS: Perioperative mortality and morbidity correlate significantly with some of perioperative variables, such as higher NYHA functional class, unsatisfactory myocardial protection, inappropriate surgical procedure, improper therapy of some complications after cardiac valve replacement. To avoid the occurrence of these independent predictors or to correct them timely might effectively decrease the perioperative mortality and morbidity after cardiac valve replacement.

Adolescent↗

PubMed1996

Assessment of immunogenicity and viability of homologous human cardiac valves in vitro.

Degenerative changes in a proportion of implanted homologous cardiac valves are considered to be due to the immunologic tissue reactions initiated by the donor valves. Sterilization and storage protocols can be used to modulate the immunogenicity of donor valves prior to implantation. Therefore, it is essential to assess the effect of treatment protocols on the immunogenicity and viability of donor valve tissue. The optimal conditions for two novel in vitro tests to assess the immunogenicity and viability of human cardiac valve tissue, the valve cusp cell/responder lymphocyte reaction to assess immunogenicity and the tetrazolium based colorimetric assay to assess viability of valve tissue, are described. The in vitro tests that have been developed in this study will be helpful in assessing the effect of various treatment protocols on the immunogenicity and viability of homologous human cardiac valves.

Analysis of Variance↗

PubMed1980

The clinical assessment and management of patients with prosthetic cardiac valves: A review of current practice at the Cardiac Clinic, Groote Schuur Hospital.

This review deals with the clinical assessment and management of patients with prosthetic cardiac valves. The types of prosthesis available are considered, with special reference to those which have been used frequently at Groot Schuur Hospital. The common complications encountered are described, as well as the clinical features of normally and abnormally functioning prostheses. The management of anticoagulant medication, pregnancy, infective endocarditis, systemic embolism and haemolysis in these patients is discussed. Particular emphasis is placed on the urgent referral to a cardiac department of patients with posthetic malfunction or conditions in which there is a potential for the development of malfunction.

Animals↗

PubMed1982

Evidence of remodeling in dura mater cardiac valves.

Subcellular changes in 12 dura mater cardiac valves (in the mitral or aortic position) surgically removed after 23 to 108 months of implantation owing to calcification, rupture, or endocarditis show signs of a remodeling process. Significant morphologic changes in the connective tissue fiber matrices and cell populations were noted in the recovered valvular leaflets. Macrophages were found within electronlucent (cleared-out) areas, and they seemed to play an essential role in the remodeling process by ingesting and digesting selected connective tissue components. Fibroblasts found within these "rebuilding" areas in the dura mater tissue possessed small cytoplasmic vesicles (65 nm in diameter) being extruded from the cell. Evidence of early collagen formation was also found in association with both peripheral filaments and peripheral condensations, as well as within the connective tissue matrices surrounding the cellular elements, where electron dense amorphous material was observed. In conclusion, the long-term durability of dura mater bioprosthetic cardiac valves may be directly related to (1) glycerin stabilization and preservation of the collagen fibers, (2) the viability of the fibroblasts and macrophages within the implanted valves, and (3) the unique morphology and fine structure of the double-layered dura mater encephali. We hypothesize that the fibroblasts or myofibroblast-like cells found within the implanted leaflets, no matter what their origin, are capable of giving form and organization to the early developing connective tissue.

Adolescent↗

PubMed2007

Dopamine agonists and the risk of cardiac-valve regurgitation.

BACKGROUND: Case reports and echocardiographic studies suggest that the ergot-derived dopamine agonists pergolide and cabergoline, used in the treatment of Parkinson's disease and the restless legs syndrome, may increase the risk of cardiac-valve regurgitation. METHODS: We used data from the United Kingdom General Practice Research Database to identify a population-based cohort comprising 11,417 subjects 40 to 80 years of age who were prescribed antiparkinsonian drugs between 1988 and 2005. We conducted a nested case-control analysis within this cohort in which each patient with newly diagnosed cardiac-valve regurgitation was matched with up to 25 control subjects from the cohort, according to age, sex, and year of entry into the cohort. Incidence-rate ratios for cardiac-valve regurgitation with the use of different dopamine agonists were estimated by conditional logistic-regression analysis. RESULTS: Of 31 case patients with newly diagnosed cardiac-valve regurgitation, 6 were currently exposed to pergolide, 6 were currently exposed to cabergoline, and 19 had not been exposed to any dopamine agonist within the previous year. The rate of cardiac-valve regurgitation was increased with current use of pergolide (incidence-rate ratio, 7.1; 95% confidence interval [CI], 2.3 to 22.3) and cabergoline (incidence-rate ratio, 4.9; 95% CI, 1.5 to 15.6), but not with current use of other dopamine agonists. CONCLUSIONS: In this study, use of the dopamine agonists pergolide and cabergoline was associated with an increased risk of newly diagnosed cardiac-valve regurgitation.

Adult↗

PubMed1994

General concepts in the morphologic assessment of operatively excised cardiac valves--Part II.

This 2-part article discusses general morphologic assessment of operatively excised cardiac valves and applies these principles to functional classifications. All cardiac valves are categorized into stenotic and purely regurgitant (no element of stenosis) groups based upon structural features: presence or absence of commissural fusion, calcific deposits, and degree and location of fibrosis. Of 2,980 operatively excised cardiac valves reviewed between 1962 and 1992, the most common lesion was aortic stenosis, followed by mitral stenosis and the combination of aortic and mitral stenosis.

Aortic Valve Insufficiency↗

PubMed2001

Cardiac valve replacement with mitral homograft.

The purpose of this study was to review the results of mitral and tricuspid valve replacement with mitral valve homograft. Twenty-two mitral homografts were used to replace cardiac valves in 20 patients. The mitral valve was replaced in 18 patients, applying the method described by Acar. The tricuspid valve was replaced in 2 patients, attaching one papillary muscle of the graft to the anterior papillary muscle and bringing the other papillary muscle of the graft through a tunnel in the anterior wall of the right ventricle. A concomitant Maze III procedure was performed in 3 patients. Accuracy of the repair was confirmed by intraoperative echocardiography. All patients survived operation and are currently alive. One patient was lost to follow-up. Patients have been followed for up to 3.25 years. All patients have good exercise ability (NYHA class I). Five homografts (25%) have been explanted from the mitral position and one from the tricuspid position. All events occurred during the first year after reoperation. Cardiac valve replacement with mitral valve homograft may be accomplished safely. A technically good operation does not guarantee that the valve will remain competent and an unacceptably high early explant rate may be expected. Use of mitral valve homograft for cardiac valve replacement should be restricted to young patients in whom anticoagulant medication is not indicated or undesirable and for those with resistant infection.

Adolescent↗

PubMed2006

[Surgical treatment of prosthetic endocarditic of cardiac valves].

Results of surgical treatment of patients with cardiac valves prosthetic endocarditis are discussed. General hospital lethality was 15.4%. Immediate results of operations using different type of prosthetic cardiac valves were analyzed. Biological grafts permits to decrease the rate of prosthetic endocarditic recurrence on hospital stage. Urgency of repeated surgery and also radical resection of infected focus with possible reconstruction of fibrous ring integrity influence hospital lethality.

Adult↗

PubMed1999

Effectiveness of continuous warm blood cardioplegia in cardiac valve re-replacement.

BACKGROUND AND AIM OF THE STUDY: In order to achieve better operative results, myocardial protection for cardiac valve re-replacement must be further improved. The aim of this study was to compare the efficacy of continuous warm blood cardioplegia (CWBC) with that of intermittent cold potassium cardioplegia (ICPC) in cardiac valve re-replacement. METHODS: A total of 49 consecutive patients underwent elective cardiac valve re-replacement via sternal re-entry; 27 patients received CWBC and 22 ICPC. During surgery, a narrower dissection of the heart was used in the CWBC group. The myocardial protective effects and operative outcome were analyzed in the two groups. RESULTS: Two ICPC patients died in hospital, one from cerebral bleeding and one from low output syndrome. The rate of spontaneous recovery of the heart-beat after aortic declamping was significantly higher in CWBC patients than in the ICPC group (92.3% versus 13.6%, p < 0.001). Postoperatively, maximum serum creatine kinase-MB levels were significantly lower in CWBC patients than in ICPC patients (25.5 +/- 6.0 versus 81.1 +/- 26.0 IU/l, p < 0.02). Left ventricular stroke work index in the CWBC group showed significantly better recovery in the early postoperative period compared with that in the ICPC group. Extraction of myocardial oxygen (range: 0.33 to 0.35) and lactate (range: -0.02 to 0.14) in CWBC patients was maintained within the normal range immediately after aortic declamping and in the early postoperative period. In contrast, in ICPC patients extraction of myocardial oxygen (range: 0.18 to 0.23) and lactate (range: -0.27 to -0.17) was impaired during the same period. Postoperative (24-h) blood loss was significantly less in CWBC patients than in ICPC patients (p < 0.02). CONCLUSION: In cardiac valve re-replacement surgery through sternal re-entry, and without wide exposure of the heart, continuous warm blood cardioplegia provides much greater myocardial protection than does intermittent cold potassium cardioplegia.

Adolescent↗

PubMed1987

Cardiac valve prostheses: pathological and bioengineering considerations.

Cardiac valve replacement with mechanical prosthetic or bioprosthetic devices enhances patient survival and quality of life. Nevertheless, prosthesis-associated complications are frequent and contribute significantly to outcome. Thromboembolic complications are the most important problems in patients with mechanical valves, necessitating chronic anticoagulation in all patients receiving them. In contrast, patients with bioprosthetic valves, composed of chemically treated animal tissues, generally do not require anticoagulants. However, bioprostheses fail frequently by degeneration, especially that involving cuspal calcification. This paper reviews the pathological and bioengineering considerations in the selection of cardiac prosthetic valves and the management of patients who have received these devices. The significance, morphology, and pathogenesis of the observed major complications and other alterations during function are described in detail. Contemporary investigative trends are summarized, including studies of inhibition of mineralization and other degenerative changes in bioprostheses, improved design rigid mechanical valves with pyrolytic carbon occluders and the development of central-flow, flexible polymeric leaflet valves.

Biomedical Engineering↗

PubMed1994

General concepts in the morphologic assessment of operatively excised cardiac valves--Part I.

This two-part article discusses the general morphologic assessment of operatively excised cardiac valves and applies these principles to functional classifications. All cardiac valves are categorized into stenotic and purely regurgitant (no element of stenosis) groups based upon structural features: presence or absence of commissural fusion, calcific deposits, and degree and location of fibrosis. Of 2980 operatively excised cardiac valves reviewed between 1962 and 1992, the most common lesion was aortic stenosis, followed by mitral stenosis and the combination of aortic and mitral stenosis.

Heart Valve Diseases↗

PubMed1988

[Cardiac valve surgery in the elderly].

Cardiac valve surgery was performed in 54 patients over the age of 60 between January 1982 and December 1986. This included 24 mitral, 23 aortic, 7 multiple valve surgery and 2 thrombectomies and 1 leakage repair of the aortic prosthetic valves. We reviewed these cases comparing with 60 younger patients under the age of 59 with particular emphasis on preoperative state, operative mortality, postoperative course and late results. In older patients, lower renal function and fewer red blood cell count than younger patients were revealed preoperatively. Postoperatively, tendency to have low cardiac output syndrome and have much more complications such as acute renal failure, respiratory insufficiency and psychosis were seen in older patients. There were 7 hospital deaths and 1 late death in older patients, but in 6 of 7 hospital deaths, the causes of deaths were non-cardiac. Clinical improvement was quite satisfactory in older patients equally to younger patients. So it was concluded that age alone should not be regarded as a contraindication to surgical treatment in older patients.

Acute Kidney Injury↗

PubMed1993

An adult case with multiple cardiac valve prolapse and regurgitation.

A 56-year-old female had pure regurgitation in all cardiac valves. Color Doppler echocardiography showed a regurgitant jet in all cardiac valves. The severity of regurgitation due to the prolapse in all valves was moderate. The patient had no history of rheumatic fever, ischemic heart disease, endocarditis or hypertension. Physical characteristics of the patient were neither of Marfan's nor Ehlers-Danlos' syndrome. The etiology of regurgitation in all cardiac valves of this patient may be due to multiple valve prolapse.

Aortic Valve Insufficiency↗