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Brucella abortus infection of the aortic valve caused acute aortic regurgitation leading to severe left ventricular failure in a 62-year-old man. He made an excellent recovery after emergency aortic valve replacement. This is the third reported case of successful heart valve replacement for Brucella endocarditis and the second such case involving the aortic valve.
We report a case of severe mechanical hemolysis occurring 8 years after insertion of a bioprosthetic mitral valve in a patient who also suffered from aortic valve stenosis. It is suggested that the coexistence of two malfunctioning valves may lead to hemolysis via hemodynamic and turbulence alteration and that this condition is more frequent than expected for isolated valve involvement.
Between August 1969 and January 1976, 561 patients underwent homograft replacement of the aortic valve (AVR). Isolated AVR was performed in 339 patients, ranging in age between 18 months and 74 years. The valves were sterilized in antibiotic solution and preserved at 4 degrees C in tissue culture medium. There were 11 early deaths (3.2%) and 23 late deaths (6.8%). Actuarial analysis showed 88% survival at 5 years and 85% at 6 years. Valve failure occurred in 13 patients (3.8%) due to prolapse of one cusp in five patients (1.5%), infective endocarditis in three and degeneration of the graft in five (1.5%). Degenerative valve failure was encountered after the fourth year with an incidence of 3.5% of patients at risk, and occurred only in grafts from donors over the age of 70 years. Diastolic murmurs were present in 22% of patients followed up for more than one month and increased very slightly with time. The clinical result was judged to be good or excellent in approximately 90% of the surviving patients.
Structural valve degeneration in a mechanical ball and cage prosthesis is a well-described entity. Here we describe an unusual case of structural valve degeneration of a cloth-covered composite-seat Starr-Edwards ball and cage valve prosthesis in the mitral position, where degeneration of the cloth covering of the seat of the valve led to significant intravalvular mitral regurgitation.
Transesophageal echocardiography is a crucial tool in intraoperative evaluation of newly implanted/repaired heart valves because suspected valvular malfunction needs to be identified and sometimes surgically corrected. Although color Doppler is often adequate in evaluating the expected regurgitant jets, as well as excluding pathologic paravalvular leaks, spectral Doppler techniques are the most commonly used methods for estimating transvalvular gradients in the operating room. However, these methods are subject to a variety of confounding factors, including subvalvular gradients and pressure recovery. Other methods of valve area estimation should also be used when evaluating a prostethic aortic valve, including the continuity equation and the left ventricular outflow tract/aortic valve velocity ratio.
Cardiac rupture after acute myocardial infarction (AMI) in patients with aortic valve stenosis (AS) is uncommon and only 2 survival cases after surgery have been reported to date. The present patient, a 69-year-old woman with aortic valve stenosis (AS), suffered an acute myocardial infarction and despite a successful baloon angioplasty to the proximal left anterior descending artery, the condition progressed into congestive heart failure. Echocardiography demonstrated AS with a valve area of 0.7 cm2 and a left ventricular aneurysm with a thin and dyskinetic anterior to apical wall. An urgent operation was performed and the opening of the pericardium revealed oozing rupture of the aneurysm. An endoventricular circular patch plasty combined with aortic valve replacement was successfully performed, and good results during 2-year follow-up were achieved. Physiological repair with exclusion of the infarcted area is essential to achieve a good long-term outcome in such a critical case. Special care should be taken with AMI in a patient with AS because of the possible occurrence of aneurysm and rupture of the left ventricle.
The issue of valve prosthesis-patient mismatch in small annular patients is still controversial. The hemodynamic function of bileaflet mechanical valves in the aortic position was examined using dobutamine-stress echocardiography. Forty-four patients were enrolled in the study and divided into 5 groups, according to prosthesis size, from 21 mm to 29 mm. The aortic peak pressure gradient (APG) increased significantly in all groups with dobutamine-stress and exceeded 50 mmHg in 83% of the 21-mm group, in 64% of the 23-mm group, and in 33% of the 25-mm group. The APG even exceeded 80 mmHg in 22% and 18% of the 21-mm and 23-mm groups, respectively. In these cases, the potential of 'valve prosthesis-patient mismatch' was considered. From the relationship between the APG and the prosthesis valve area index (VAI), 'critical VAIs' were found where patients were likely to enter the 'mismatch' status; that is, 1.22 and 1.77 cm2/m2, respectively, for the 5 and 10 microg/kg per min stages of dobutamine stress. This critical VAI range is useful in predicting the 'mismatch' patients preoperatively. Alternative procedures or prostheses should then be selected for them.
Limitations in the long-term results of medical treatment for mitral regurgitation are well recognized, but the advances in its surgical repair have produced good results. Therefore, early surgical intervention has been the focus of treatment in Europe and America. Increased surgical intervention depends on the development of technical skills in mitral reconstruction. This study investigated presurgical factors making surgical reconstruction difficult in 103 patients who underwent mitral operations performed from April 1994 to September 1997 in our hospital. Records were reviewed retrospectively for etiology, type of operation, and the immediate result of operation. The etiology of mitral regurgitation was prolapse in 65 patients (63%), restriction in 14, normal in 11, infectious endocarditis in 10, and others in 3. The type of prolapse involved the anterior leaflet in 22 patients (34%), posterior in 28 (43%), and both leaflets in 15 (23%). Valve repair was attempted in 74 patients, of which 16 were switched to valve replacement during operation. These included anterior leaflet prolapse in 9 patients, posterior leaflet in 1, both leaflets in 3, restriction in 2 and infectious endocarditis in 1. The success rate for reconstruction of anterior leaflet prolapse was not high. The cause of mitral regurgitation was mostly prolapse of the mitral valve, in our country as well as in Europe and America. Prolapsed posterior leaflet is much more common in Europe and America, and there is a high success rate reported for its valve reconstruction. In contrast, this study cannot recommend earlier surgical intervention because of difficult repair for anterior leaflet prolapse.
A 52-year-old man underwent aortic valve replacement with freestyle stentless xenograft, using subcoronary technique for active infective endocarditis in June, 2001. Eighteen month later he had late prosthetic valve endocarditis associated with aortic annular abscess due to Staphylococcus epidermidis infection. The abscess was debrided and gelatin-resorcin-formalin glue (GRF glue) was injected into the abscess cavity. Abscess cavity was closed with continuous running suture of 3-0 polypropylene stitches. Finally the aortic valve was replaced with ATS mechanical valve (20 mmAP). After administration of vancomycin and gentamicin for 4 weeks, he discharged on 57th postoperative day in good condition. We strongly suggest that GRF glue is essential to close the aortic annular abscess of combined with aortic regurgitation due to active infective endocarditis.
Mitral valve replacement with 19 mm St. Jude Medical mechanical valve was successfully performed for congenital mitral regurgitation in an infant aged 3 months. The infant had undergone ligation of ductus arteriosus at the first month of age. Ten days after the operation, he was discharged, though having systolic murmurs. One month later, however, he was re-admitted for progressive heart failure. After hospitalization, he had to be supported mechanical ventilation. The second operation was needed for intractable heart failure, that was considered to be caused by mitral regurgitation, on an emergency basis without cardiac catheterization. The mitral valve was hypoplastic and the leaflet and chordae were gelatinous. Therefore, mitral valvuloplasty was considered to be impossible, and consequently mitral valve replacement was chosen. Postoperatively the patient's condition remarkably improved. Anticoagulation therapy with sodium warfarin and dipyridamole was maintained after operation. At present the patient is growing without any symptom.
BACKGROUND AND AIM OF THE STUDY: Acquired isolated tricuspid valve insufficiency (TVI) is a rare condition, and tricuspid valve replacement (TVR) is reserved for those patients in whom operative repair is not possible. The long-term follow up of patients who underwent isolated TVR at the authors' institution was analyzed. METHODS: All patients (n = 107) who underwent TVR between January 1985 and December 2002 were identified from a clinical database. Among 87 multiple valve replacements, 20 consecutive patients (12 females, eight males; mean age 52.4 years) were encountered who underwent TVR for acquired isolated TVI. Preoperative and perioperative data were recorded retrospectively. The patients and/or their physicians were contacted directly to determine long-term outcome; the follow up was 100% complete. RESULTS: The mean follow up period was 40.8 months (range: 1-211 months). The cause of TVI was endocarditis (n = 6) or trauma (n = 1); two patients suffered from hypertrophic non-obstructive cardiomyopathy, and one patient had endomyocardial fibrosis. TVI was related to constrictive pericarditis (n = 1) and to prior heart transplantation (n = 3). Seven patients were in NYHA functional classes I/II, and 13 were in classes III/IV. TVR was performed with either a mechanical valve (n = 15) or a bioprosthesis (n = 5). One patient (5%) died perioperatively, and five (25%) died during the follow up period. Two patients underwent a redo-operation during follow up, one due to prosthetic endocarditis, and one after thrombosis of a mechanical prosthesis. There was no structural deterioration of biological prostheses, and no bleeding due to anticoagulation with mechanical prostheses. Among the surviving patients, 13 were in NYHA class I, and one was in class II/III at the time of follow up. CONCLUSION: Isolated TVR for acquired TVI is rarely performed. Among the present patients, perioperative mortality and morbidity were lower than previously reported in the literature. The long-term outcome appeared to be largely dependent on the etiology of the regurgitation.
A 12-month-old infant, weighting 6.7 kg, underwent mitral valve replacement with a 17 mm Björk-Shiley prosthetic valve for parachute mitral valve, and patch closure of the associated ventricular and coronary sinus septal defects. Progressive pulmonary artery hypertension and heart failure required surgical intervention. The diagnosis of parachute mitral valve and associated lesions was established by echocardiogram and angiogram. Postoperative recovery was uneventful and he is doing well 3 years after the operation. To our knowledge this is the first successful case to be reported in the literature with such combination of the congenital anomalies.
A case report is presented of a child in whom there was gross tricuspid insufficiency due to marked dysplasia of the tricuspid valve. This patient received prosthetic valve replacement in tricuspid position with excellent post-operative improvement. To the best of our knowledge, this is the first case report of a tricuspid valve replacement for a severely dysplastic tricuspid valve.
Thromboembolism after mitral commissurotomy (MC) was compared with that after mitral valve replacement (MVR). In 216 surgical cases of acquired mitral valve diseases, including combined operative cases of other valves, thromboembolic complications after MC were observed in 9/137 cases (13 times, 0.94%/patient-year), and those after MVR in 8/70 cases (11 times, 2.55%/patient-year). No thromboembolism occurred in 9 cases of annuloplasty. Thromboembolism-free period after MVR (49 +/- 44 months) was significantly shorter than that after MC (102 +/- 43 months, p less than 0.05). Postoperative CTR of thromboembolic cases (69.5 +/- 8.2%) was significantly larger than that of non-thromboembolic cases (61.4 +/- 9.9%) in MVR group (p less than 0.005), but no significant difference existed between thromboembolic and non-thromboembolic cases in MC group. Thromboembolism after MVR occurred in severe cases, but that after MC often occurred in mild cases. Postoperative echocardiogram of MC group showed significantly lower DDR in thromboembolic cases (1.9 +/- 0.7 cm/sec) than in non-thromboembolic cases (3.2 +/- 1.2 cm/sec, p less than 0.025). Mitral valve area (MVA) of all re-stenotic cases in thromboembolic cases after MC was under 1.5 cm2, comparing that in non-thromboembolic cases there were only two cases that had MVA under 1.5 cm2. After MC, careful management including anticoagulant therapy and reoperation is necessary especially in patients with atrial fibrillation, DDR under 2 cm/sec, and MVA under 1.5 cm2, even though they don't have cardiomegaly.
The incidence and prognostic significance of intraventricular conduction disturbances following aortic valve replacement was studied in a retrospective analysis of the records of 210 patients who had undergone aortic valve replacement for calcified aortic valve disease (dominant stenosis) between 05/01/1978 and 09/30/1983. Preoperatively, left anterior hemiblock was a common finding (9.6%), whereas LBBB, RBBB, and RBBB + LAFB were only found in 1.9, 1.0, and 1.0%, respectively. Following aortic valve replacement, the incidence of new conduction disturbances was 22.1% (n = 46): 19 LBBB, 16 LAFB, 6 RBBB, 3 RBBB + LAFB, 2 complete AV-blocks. In about half of the cases of LBBB and LAFB the ECG normalized within one week postoperatively. Thus, the incidence of persisting conduction disturbances was only 14.4%. Four patients died early (early mortality rate 1.9%), and 11 patients died later postoperatively during a 38 month follow-up. The 4-year cardiac survival rate of patients with pre- and/or postoperative conduction disturbances was similar to the 4-year cardiac survival rate of those patients who had never shown this complication (93.2 +/- 4.1 vs. 94.7 +/- 2.1%).
The effects of mitral valve replacement on ventilation, lung volumes, diffusing capacity and regional perfusion of the lungs were studied in eight patients with long-standing mitral valve disease. Eight patients of the same age with coronary artery disease who underwent coronary bypass operation were tested as controls. Preoperatively, the patients with mitral valve disease had significantly higher perfusion of the upper lung fields and the ratio of residual volume to total lung capacity than the control patients. Vital capacity, forced expiratory volume in one second and maximal expiratory flow at 50% of vital capacity were lower in comparison with the control group. Seven days after open heart surgery the values of all the parameters mentioned above had decreased significantly from the preoperative levels in both groups. Three months post-operatively, the values returned to preoperative levels. The abnormal overperfusion of the upper lung fields and other derangements in the ventilatory pattern did not subside even though cardiac haemodynamics were corrected by mitral valve replacement.
All postoperative complications, including transient ischaemic attacks (TIA) and cerebrovascular accidents (CVA) of 259 patients, in whom a total of 301 Monostrut tilting-disc valves were implanted between January 1985 and December 1991 were evaluated retrospectively. The follow-up was maximally 8 years, with a mean of 3.5 years, and totaled 914 patient-years. In this study we found no mechanical deterioration of the Monostrut valve and demonstrated the elimination of valve thrombosis in patients receiving adequate anticoagulation. The actuarial probability of being free of thrombo-embolism was 94.7% +/- 1.7% and free of anticoagulant related hemorrhage 95.4% +/- 1.5% at 8-years. In comparison with earlier reports by others, our findings show a lower ratio of thromboembolic and hemorrhagic events. We demonstrated a correlation (p < 0.05) between thrombo-embolic and hemorrhagic complications. In addition, a lower incidence of CVA's (0.22 per 100 patient-years), but a higher incidence of TIA's (0.66 per 100 patient-years) in comparison with the general Dutch population was found. At eight years follow-up, all patients were in Class I or II of the New York Heart Association Classification. Although the overall valve related event-free survival at eight years was only 47.9%, 93.5% of the patient were satisfied with their operative result. Predictive factors for late mortality were the occurrence of paravalvular leakage (p < 0.01), the age of the patient at the time of operation (p < 0.01) and the number of diseases coronary arteries (p < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
Aortic valve prosthetic replacement in children and adolescents helps to improve their haemodynamics, and favourably affects the course of the rheumatic process. The correction of the defect is indicated in the presence of appropriate subjective and objective symptoms of aortic valve insufficiency. The lumen of the aorta was so large in many children that it permitted the employment of prostheses for adults. Calcification of the aortic valve was found in 9 of the 31 patients, which contradicts the commonly accepted belief of a low incidence of calcification in this disease in children. Hospital mortality and postoperative complications rate did not exceed those in aortic valve replacement in adults. The comparatively fast reduction of the heart size and the positive dynamics of the functional parameters in children and adolescents may be due to the high plasticity of the cardiovascular system in this age-group.