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PubMed1993

[Prognosis after aortic valve replacement for aortic valve stenosis with or without associated coronary lesions].

With the increasing age of patients and the progression of degenerative pathologies, the management of aortic stenosis (AS) with coronary artery disease is becoming more frequent. Reported results of combined valve and coronary surgery are equivocal especially with respect to the increased risk compared with aortic valve replacement without coronary surgery. The authors assessed the results of combined surgery by comparing two groups of patients with AS operated between 1979 and 1991: 122 patients with coronary lesions undergoing combined valve and coronary surgery (Group I) and 122 patients without coronary artery disease undergoing isolated aortic valve replacement (Group II) and paired with Group I patients for 5 prognostic factors (age, sex, functional status, date of surgery and left ventricular ejection fraction). Pairing the patients provided comparable populations for these 5 factors. The average age was high (68 years in Group I with over 50% of patients over 70 years of age) and most patients were in functional classes III or IV (67% in Group I). In Group I, 67% of patients had multivessel disease (average 2 vessel disease). Aortic valve replacement was associated with an average of 1.7 coronary bypass grafts per patient. Myocardial protection was the same in all cases using cold potassium enriched cardioplegic solutions. Operative mortality was 10.6% in Group I compared with 4.9% in Group II (NS) and the respective perioperative infarction rates were 6.6% and 0.8% (p < 0.02). Seven year actuarial survival rates were 71.8% in Group I and 74.9% in Group II (NS) without any increased late mortality in Group II.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1993

[The limits for modified Fontan operations with AV valve regurgitation--the effect of AV valve regurgitation on the Fontan operation for single ventricle].

We performed a modified Fontan operation on 14 patients of single ventricle with AV valve regurgitation (single right ventricle: SRV 8, single left ventricle: SLV 6) until 1990. During the same period, 41 patients of single ventricle without AV valve regurgitation underwent the modified Fontan operation. To evaluate the effect of AV valve regurgitation on the Fontan operation, operative mortality, ventricular and pulmonary functions were compared between two groups. No significant differences were observed in operative mortality (7% vs 12%). There were also no significant differences of post-operative cardiac index (mean 2.6 L/min/m2 vs 2.6 L/min/m2), pulmonary vascular resistance (mean 2.3 U.m2 vs 2.2 U.m2) and preoperative ejection fraction (mean 54% vs 62%) between two groups. Therefore, the hemodynamic status of single ventricle following the Fontan operation remained almost unchanged irrespective of the presence of AV valve regurgitation. This suggested that AV valve regurgitation was not itself a contraindication of the Fontan operation, if the correct indices and time for operation were selected.

Heart Atria↗
PubMed1998

Right thoracotomy as an alternative for redo mitral valve replacement and concomitant repair of the tricuspid valve.

BACKGROUND: We report the results of a right thoracotomy for reoperation on the mitral plus concomitant procedures. Access to aorta or repair of other lesions by this approach is controversial. EXPERIMENTAL DESIGN AND SETTING: Retrospective study. Institutional practice (University of Tsukuba Hospital, Tsukuba Japan). METHODS: Until 1995, 9 patients underwent right thoracotomy for mitral reoperation. The indication for this approach was no retrosternal space with the pericardium left open. Seven patients had deteriorated bioprosthesis, 1 periprosthetic valve leakage, and 1 re-stenosis. Four were associated with moderate tricuspid regurgitation. Operations were performed under fibrillation. Cardioplegia was used in 1. RESULTS: Through thoracotomy, 4 underwent mitral valve re-replacement, and 4 mitral valve re-replacement plus tricuspid annuloplasty. One was abandoned because of severe pleural adhesion. No neurological injury, or perioperative myocardial infarction occurred. CONCLUSIONS: The right thoracotomy was an effective alternative to repeat sternotomy for redo mitral valve operation. Also, concomitant repair of the tricuspid valve could be safely done by this approach.

Aged↗
PubMed1997

[Comparison of mechanical properties between human aortic valve and pulmonary arterial valve].

We have investigated the mechanical properties of Chinese aortic and pulmonary valves by means of uniaxial tension. The parameters include the stress-strain curve, the maximum tangent modulus E (the slope of linear segment) in the curve, the tensile strength delta b, and the ultimate strain epsilon b. The results have shown that E, delta b, and epsilon b values between aortic valve and pulmonary valve exist significant differences (significant level = 0.01), but the mechanical property differences between circumferential direction and radial direction in the pulmonary arterial valve are not significant, that means, the valve appears small anisotropic behaviour.

Adult↗
PubMed2005

Transaortic double valve replacement in difficult mitral valve exposure.

Adequate open exposure of the mitral valve is necessary to accomplish reconstruction or replacement of the diseased mitral valve apparatus. The technique employed by most cardiac surgeons for mitral valve access involves median sternotomy and vertical left atriotomy posterior to the interatrial sulcus. However, certain conditions can somethimes make this approach very difficult. Different approaches are discussed with particular emphasis on our case in which the transaortic double valve replacement have been performed.

Aortic Valve↗
PubMed1992

[Surgical management of tricuspid regurgitation in patients undergoing mitral valve surgery--analysis of the amount of tricuspid valve annular dilatation].

As a means to determine whether correction for tricuspid regurgitation (TR) in mitral valve surgery is necessary, pulsed Doppler echocardiography was used to study 61 patients (age 49.5 +/- 9.5 years) who underwent mitral valve surgery. Early postoperative tricuspid regurgitation (average 9 +/- 3 postoperative days) was evaluated by a comparison with tricuspid valve annular dilatation and systolic annular shortening in preoperative right ventriculography. Kishimoto's method was used to measure the angiographic maximal early systolic (TVD) and minimal end-systolic diameters where as the shortening of the tricuspid annulus (STA) was expressed as a percent reduction in the maximal diameter by Ubago's methods. Patients were categorized into two groups, i.e., a group having had tricuspid annuloplasty (TAP group n = 23), and a NON-TAP group (n = 38). Preoperative right ventricular volume and hemodynamic indicator were studied with respect to both the TVD and the STA. Results are as follows: 1) The TVD significantly correlated with the end-diastolic right ventricular volume index (EDVI), regurgitant fraction of the tricuspid valve (RF), end-systolic right ventricular volume index (ESVI), pulmonary vascular resistance (PVR), mean pulmonary artery pressure (PAm), mean right atrial pressure (RAm), and right ventricular end-diastolic pressure (RVEDP) (p less than 0.01). 2) The STA was significantly correlated with EDVI, RF, ESVI, RAm and RVEDP (p less than 0.01). In the NON-TAP group, the TVD was significantly larger in patients with residual TR (average 32.5 mm/m2) than in patients having postoperative disappearance of TR (average 25.7 mm/m2) (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2006

Configuration of the ascending aorta in patients with bicuspid and tricuspid aortic valve disease undergoing aortic valve replacement with or without reduction aortoplasty.

BACKGROUND AND AIM OF THE STUDY: Patients with bicuspid aortic valves (BAV) tend to develop dilatation of the ascending aorta. The study aim was to analyze differences in aortic root diameter and configuration in patients with bicuspid and tricuspid aortic valve disease. METHODS: A retrospective analysis was conducted of the angiographies of 461 patients allocated to four groups with: (i) BAV disease with (n = 179) and (ii) without (n = 78) dilatation of the ascending aorta; (iii) tricuspid aortic valve disease (TAV) and dilatation of the ascending aorta (n = 154); and (iv) coronary artery disease (CAD), TAV and normal diameter of the ascending aorta (n=50). Diameters and distances in the aortic root region were measured, and the ascending aorta configuration analyzed. RESULTS: The diameter of the ascending aorta in patients with BAV and dilatation was significantly larger than in those with TAV and dilatation (26.6 +/- 5.22 versus 24.4 +/- 3.74 mm/m2, p = 0.002). Distances between aortic valve level and point of maximum diameter of the ascending aorta at the outer and inner curve of the vessel in patients with BAV without dilatation were greater than those of the CAD group (31.1 +/- 5.27 versus 28.0 +/- 4.86 mm/m2, p = 0.002 and for the indexed values 21.6 +/- 4.05 versus 20.0 +/- 2.71 mm/m2, p = 0.011). All patients with BAV and enlargement of the ascending aorta showed asymmetric dilatation of the vessel. CONCLUSION: All patients with BAV had an abnormal configuration of the ascending aorta. In cases with enlargement of the ascending aorta exclusively, asymmetric dilatation at the convexity of the vessel occurred. Patients with BAV and normal ascending aorta diameter showed an elongation of this vessel segment.

Adult↗
PubMed1985

Late (11 to 19 years) assessment of hemodynamic and prosthetic valve function in patients with Starr Edwards ball valves: a non-invasive study utilizing 99m-technetium pertechnetate scintigraphy.

This is an account of 2 groups of 10 patients each who received Starr Edwards ball valves in either the mitral (M) or aortic (A) position on average 14.7 +/- 3 or 14.9 +/- 2.4 years ago, respectively. Non-invasive scintigraphic studies were performed using the first pass of 18 to 20 mCi 99 m-Technetium Pertechnetate. Enddiastolic and endsystolic volumes were found elevated at rest: (M) EDV 135 +/- 50 ml, ESV 63 +/- 30 ml; (A) EDV 163 +/- 41 ml, ESV 69 +/- 25 ml. The response to maximum exercise--during which the heart rate increased from 85 +/- 23 min-1 to 133 +/- 33 min-1--was abnormal, since none of the volumes changed significantly. During exercise, therefore, the increase of the cardiac output was totally heart rate dependent: (M) 6.1 +/- 2.3 to 9.3 +/- 2.3 l/min; (A) 7.0 +/- 1.9 to 10.9 +/- 3.1 l/min. The dynamics of the rapid diastolic filling rate of the left ventricle (RFR) and the mean pulmonary transit time (MTT) served as functional parameters of the Starr Edwards ball valves in the mitral position. The rapid filling rate increased from 205 +/- 98 to 321 +/- 58 ml/sec, whereas MTT decreased from 7.4 +/- 1.4 to 5.4 +/- 2.1 sec. In patients with aortic valve replacement the left ventricular ejection rate was assessed, it rose from 233 +/- 80 to 459 +/- 232 ml/sec. The significant changes of the parameters proved that the Starr Edwards ball valve mechanism functions satisfactorily 11 to 19 years post-operatively.

Aortic Valve Insufficiency↗
PubMed1997

[Minimally invasive approach for mitral valve, aortic valve, and atrial septal defect surgery].

We successfully introduced minimally invasive cardiac surgery (MICS) to japan by performing thoracoscopic clipping of a patent ductus arteriosus in July 1992. MICS via a small right parasternal incision (Cosgrove procedure) was applied for one patients with severe rheumatic mitral stenosis, one with severe aortic regurgitation, and one with atrial septal defect (ASD). Mitral valve replacement (MVR), aortic valve replacement (AVR), and direct closure of the ASD were performed successfully by MICS for the the first time in Japan. All three patients required no blood transfusion and had no complications postoperatively, being discharged from hospital at 15, 13, and 9 days after their operations. MICS was satisfactory for mitral valve and ASD operations, but AVR by this approach took much longer than by standard midline sternotomy due to the poor surgical field obtained via the small right parasternal incision. A minimally invasive approach for surgery on the aortic valve and ascending aorta may require transection of the sternum or some other method. MICS has several advantages, including less trauma and pain, faster patient recovery, shorter ICU and hospital stays, a lower cost, and a better cosmetic outcome. Therefore, it is better for the patient when it is feasible. MICS should develop and be applied to more patients with cardiovascular disease in the future. Some of the standard cardiovascular operations may soon be replaced by MICS.

Adult↗
PubMed1998

Hemodynamics after aortic valve replacement with St. Jude Medical valve for patients with small aortic annulus and severe left ventricular hypertrophy.

BACKGROUND AND AIMS OF THE STUDY: Cardiac function after aortic valve replacement (AVR) for patients with small aortic annulus and increased left ventricular (LV) wall thickness has not been clearly defined. The study aim was to examine a potential relationship between postoperative catheterization data (or radionuclide LV cardiac function) and the size of the aortic valve ring of a small St. Jude Medical prosthesis. METHODS: Sixty-one patients with small prosthesis (< or = 23 mm) were allocated to three groups based on the diameter of the native aortic annulus or aortic valve ring of the prosthesis (group I, 19 mm; group II, 21 mm; group III, 23 mm). Pre- and postoperative cardiac function was evaluated from catheterization data and radioisotope (RI) ventriculography. RESULTS: There were no significant inter-group differences in preoperative pulmonary artery pressures (PAPs), total pulmonary resistance (TPR), LV ejection fraction, peak ejection rate (PER) and peak filling rate (PFR). The mean postoperative PAPs and TPR of group I were significantly elevated in ICU compared with those of groups II or III (PAP: group I, 20+/-5; group II, 17+/-4; group III, 14+/-4 mmHg; p <0.01. TPR: group I, 505+/-268; group II, 316+/-134; group III, 276+/-125 dynes.s.cm-5; p <0.05). Postoperative PAPs and TPR of group I at one month after surgery were decreased, and no significant difference was found between the three groups. Cardiac function by RI study showed that postoperative PER and PFR improved in all three groups compared with the preoperative values. CONCLUSIONS: Postoperative reversibility of PAPs and improvement of PER and PFR in patients with a prosthesis of 19 mm or 21 mm showed that a small-sized aortic SJM valve had hemodynamic advantages. However, careful postoperative management in the ICU must be applied to patients with a small aortic annulus of 19 mm and severe concentric hypertrophy.

Aged↗
PubMed2004

[Severe, non-infectious mitral valve endocarditis after mitral valve reconstruction in a 32-year old female with primary antiphospholipid syndrome].

BACKGROUND: A 32-year old female with primary antiphospholipid syndrome presented 8 months after mitral valve reconstruction with progressive exertional dyspnea and echocardiographically demonstrable critical mitral stenosis and regurgitation. Tachycardia, weight loss, sleep disturbances and increasing nervosity led to the diagnosis of concomitant hyperthyroidism. After the patient stopped the oral anticoagulation by herself, a 'catastrophic antiphospholipid syndrome' with multiple microthromboembolic events in several organs developed rapidly within a few weeks. Severe respiratory failure was observed 14 days after admission at our hospital because of a pulmonary edema. TREATMENT: Removal of the annuloplasty ring and alloplastic mitral valve replacement with a 25 mm bilifleat valve. Postoperatively, the patient was placed on oral anticoagulation. Several pre- and postoperative plasmaphereses lowered the level of antiphospholipid antibodies. The patient additionally underwent radioiodtherapy 5 months postoperatively. RESULTS: While hemodynamics and diuresis remained sufficient, ventilatory support with tracheostomy was necessary for 16 postoperative days to achieve stable respiration. Thirty months later, the patient is well and without further cardiac and neurological dysfunction. CONCLUSION: Secondary cardiac valve operations on patients with primary antiphospholipid syndrome may be successfully performed within a multidisciplinary approach. Oral anticoagulation remains the treatment of choice to prevent further thromboembolic events.

Adult↗
PubMed1994

Interaction of age and coronary disease after valve replacement: implications for valve selection.

The interaction of patient age and the presence of coronary artery disease (CAD) and its influence on survival were examined in 3,644 patients undergoing either aortic (AVR) or mitral (MVR) valve replacement with or without coronary artery bypass grafting (CABG) between 1974 and 1991. Emergency procedures were performed much more frequently in those undergoing MVR and CABG than in those undergoing AVR and CABG (18.8% and 6.7%, respectively). The adverse effect of CAD on median survival for patients of all ages undergoing either AVR or MVR was statistically significant (AVR without CAD 11.8 versus 8.7 years with CAD; MVR without CAD 12.7 versus 7.3 years with CAD; p < 0.0001). Survival in patients younger than 70 years without CABG who underwent either AVR or MVR was quite good (< 60 years: AVR, > 14 years; MVR, 15.4 years; 60 to 69 years: AVR, 10.4 years; MVR, 11.4 years). The most profound effect of CAD on patient survival after valve replacement was observed in patients 60 to 69 years of age who underwent MVR, in whom the median survival without CABG was 11.4 years versus 5.5 years with CABG (p < 0.0001). An emergency operative status was associated with a reduced early and late survival for those patients undergoing MVR, particularly those with CAD. By relating the Cox proportional hazard models for valve survival to patient survival, we found that, in those patients 70 years and older with and without CAD who underwent either AVR or MVR, the median patient survival was reduced sufficiently (5.5 versus 8.1 years) to justify use of a bioprosthetic valve.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed1995

The autologous tissue cardiac valve: a new paradigm for heart valve replacement.

This is a report of early clinical experience with an autologous tissue cardiac valve, which demonstrates the feasibility of making a bioprosthesis in the operating room in 10 minutes at the time of the valve replacement operation. There were 30 implant patients (18 men, 12 women), with ages ranging from 32 to 83 years. Diagnoses included calcified aortic stenosis (n = 16), pure aortic insufficiency (n = 9), and mixed aortic stenosis and insufficiency (n = 5). Associated diagnoses have included chronic renal failure treated with dialysis (n = 1), coronary artery disease requiring concomitant coronary bypass (n = 1), ascending aortic aneurysm requiring resection (n = 3), and mitral insufficiency requiring concomitant mitral valvuloplasty (n = 2). All of the valve replacements were in the aortic position. These implanted patients are being followed up carefully according to the protocol that requires examination every 6 months for the first year and every 12 months subsequently. No patient has been lost to follow-up. Twenty-seven patients are alive and well from 1 to 22 months postoperatively. There were three deaths: two perioperative deaths (one perivalvular leak and one hemorrhage) and one infective endocarditis 1.3 years after valve replacement. All surviving patients were followed up by echocardiographic examination (mean gradient, 15.5 +/- 6.8 mm Hg at 1 year). In conclusion, the feasibility of this method and concept has been demonstrated with implants in 30 patients. The validity of the technique will be judged by clinical results and experiences in children.

Adult↗
PubMed1997

Prosthetic mitral valve replacement: late complications after native valve preservation.

Preservation of the mitral valve leaflet and tensor apparatus during valve replacement is believed to maintain left ventricular performance. The routine use of this technique may lead to left ventricular outflow or inflow obstruction as illustrated in the present report. We recommend mobilization or excision of the anterior mitral valve leaflet and preservation of the posterior leaflet if replacement of the valve is contemplated for incompetence.

Aged↗
PubMed2003

Left ventricular mass index in aortic valve surgery: a new index for early valve replacement?

OBJECTIVE: Increased left ventricular mass index has been associated with higher mortality. We analyze the effect of increased left ventricular mass index on outcomes in patients undergoing aortic valve replacement. METHODS: Echocardiographic left ventricular dimensions were used to calculate left ventricular mass index in 614 patients who underwent aortic valve replacement between June 1993 and November 2001. Left ventricular mass index was considered increased if higher than the value of the superior decile (277 g/m(2) in males and 251 in females). RESULTS: Mean left ventricular mass index was: 178+/-111 g/m(2), and increased index was considered in 9.9% of patients. Postoperative complications (low cardiac output syndrome, respiratory failure, arrhythmias, pneumonia and mediastinitis), median length of hospital stay: 12 days (6-57) versus 11 days (5-51), and in-hospital mortality (11.4, 3.2%, P<0.01) were higher in patients with increased left ventricular mass index. Multivariable analysis identified increased left ventricular mass index (odds ratio: 5.6; 95% confidence interval: 1.2-25.0; P=0.02) and other three variables: age (P=0.04), history of chronic renal failure (P=0.03) and cardiopulmonary bypass time (P=0.004), as independent predictors of early mortality. CONCLUSIONS: Increased left ventricular mass index is associated with an in-hospital adverse outcome and a significantly higher in-hospital mortality in patients undergoing aortic valve replacement. Outcomes in asymptomatic patients could be improved before a clinically significant increase in left ventricular mass index. Further studies should be performed to determine the usefulness of this index in selecting patients for earlier aortic valve replacement.

Aged↗
PubMed1996

Is use of the pulmonary valve allograft justified as an aortic valve substitute?

Between January 1, 1990, and March 20, 1994, 56 patients had a homograft valve device placed in the aortic position. The mean age at operation was 53.3 years (range 5-77 years). Diagnosis included dominant aortic stenosis in 27 patients (48.2%) and aortic incompetence in 29 (51.8%). Thirteen patients (23.2%) had subacute bacterial endocarditis. Forty-three aortic homografts and 13 pulmonary homografts were placed. Concomitant procedures were performed in 12 patients (21.8%). The hospital mortality was 7.3% (four patients). On follow-up, three pulmonary valves have failed, two between 1 and 5 weeks post implantation. At reoperation a linear cusp fracture was found in all with no evidence of infection. All remaining patients have no, trivial, or mild, aortic regurgitation on echo and remain well. Pulmonary and aortic valves were compared for failure, P = 0.02 suggesting a significant difference between valve substitutes. In conclusion we advise caution in using pulmonary allografts in the aortic position.

Adolescent↗
PubMed2005

Management of the valve and ascending aorta in adults with bicuspid aortic valve disease.

Bicuspid aortic valve (BAV) disease is the most common congenital cardiac malformation, being present in 1% to 2% of the population. It is heritable and is three to four times more likely to occur in men. The pathogenesis of BAV disease is unknown. Bicuspid valves progress to aortic stenosis or insufficiency in the majority of patients. BAV disease is associated with several anomalies of the aorta including coarctation, aneurysm formation, and dissection. Several lines of evidence suggest that aortic complications are caused by the same underlying factor that causes BAV disease, rather than being a consequence of turbulent blood flow through a stenotic valve. Several different surgical options exist for patients with BAV disease depending on the age of presentation and the size and appearance of the aorta. We herein describe our surgical management of the aortic valve and ascending aorta in patients with BAV disease.

Adult↗
PubMed1979

Intraoperative and postoperative hemodynamic studies in patients undergoing aortic valve replacement with the Hall-Kaster cardiac disc valve prosthesis.

Intraoperative and postoperative hemodynamic measurements in the first patients to receive the Hall-Kaster cardiac disc valve prosthesis in the aortic position demonstrated the principal hemodynamic pattern of this new mechanical valve. These hemodynamic studies demonstrated favourable transvalvular gradient values and a degree of flow area utilization of the valve orifice which was close to its theoretical maximum. The Hall-Kaster prosthesis thus presented improved flow characteristics in patients undergoing aortic valve replacement, which is considered of particular importance to the patients with a narrow aortic root.

Adult↗