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[Prosthetic valve endocarditis complicated with cardiogenic shock and disseminated intravascular coagulation; report of a case].

A 67-year-old man, who had been performed aortic and mitral valve replacement 3 years before, was admitted because of appetite loss, general fatigue and anemia. Although transthoracic echocadiogram showed no evidence of prosthetic valves failure, the patient fell in profound shock. He needed endotracheal intubation and inotropic support. Transesophageal echocadiogram revealed vegetation formation on the prosthetic mitral valve and massive periprosthetic valve leakage. The diagnosis of prosthetic valve endocarditis was established. Blood examination showed severe disseminated intravascular coagulation (DIC). The patient underwent re-mitral valve replacement and recovered well from shock and DIC.

Aged↗

Multiple revision for failed Charnley low-friction arthroplasty.

We reviewed 54 patients at a mean follow-up of 4 years 4 months after rerevisions for failure of Charnley low-friction arthroplasty. Rerevision for aseptic loosening in 26 hips was satisfactory; there were no clinical failures and at the latest radiological assessment only one stem and three sockets showed signs of loosening. By contrast, nine of 20 multiple revisions for recurrent dislocation failed, as did five of eight multiple revisions for deep infection. There was radiological evidence of loosening in one stem and nine sockets in the former group and in three stems and five sockets in the latter.

Adult↗

Management of failed and infected axillofemoral grafts.

PURPOSE: The purpose of this study was to review the treatment of patients with failed or infected axillofemoral bypass grafts and to determine the efficacy of remedial procedures in maintaining graft patency and limb preservation. METHODS: Thirty-four patients with 37 failed or infected axillofemoral grafts were retrospectively reviewed. In nine cases there was no attempt at revascularization, and in the remaining 28 cases, a total of 52 remedial procedures was performed. Nine were performed in patients with graft infection and 43 in patients with graft thrombosis. In patients with axillofemoral graft failure, 21 thrombectomies, 13 graft revisions, and 9 secondary reconstructions were performed. Eighty-eight percent of patients were monitored at least 2 years or until graft failure. RESULTS: Eight of nine patients receiving no remedial procedure required major amputation. The limb salvage rate was 64% +/- 11% at 30 months in the 25 patients undergoing remedial procedures. Twenty-eight percent of failed axillofemoral grafts remained patent at 2 years after initial failure with single or multiple thrombectomies or revisions. Life-table primary patency after secondary reconstructions (81% +/- 10.9% at 24 months) was significantly better than after thrombectomy alone (10% +/- 4.2% at 24 months) or graft revision (16% +/- 10.6% at 24 months) by log-rank test (p < 0.001 and p < 0.005, respectively). Patients undergoing reconstruction with descending thoracic aorta to femoral artery bypass had an 89% +/- 11% patency rate at 24 months. Graft infection resulted in a perioperative mortality rate of 22% and amputation in 57% of survivors. CONCLUSION: Axillofemoral graft failure most often results in limb loss without remedial procedures. Thrombectomy and revision procedures had poor long-term patency rates and salvaged only a minority of grafts despite multiple procedures. Reconstruction by use of an alternate source of inflow such as the descending thoracic aorta resulted in better long-term patency rates in patients well enough to tolerate a major reoperative procedure.

Amputation, Surgical↗

Poor clinical performance of the Wessex porcine heart valve bioprosthesis at nine years' follow up.

OBJECTIVE: To assess the long term performance of the Wessex porcine bioprostheses implanted in a consecutive series of patients. DESIGN: A retrospective case series. PATIENTS: Between January 1985 and July 1991, 184 Wessex bioprostheses (78 mitral, 102 aortic, and 4 tricuspid) were implanted in 150 patients. The patients were 55% (83/150) male and 45% (67/150) female; mean age was 60 (SD 10) years. RESULTS: Hospital mortality was 9.3% (14/150). Total follow up was 696 patient-years (mean 4.7 years per patient). Linearised rates (events per 100 patient-years (SEM) for postoperative complications for patients with isolated mitral valve replacement, isolated aortic valve replacement, and multiple valve replacement were, respectively: late mortality: 4.7 (1.6), 3.3 (0.9), and 4.9 (1.9); thromboembolism: 5.8 (1.8), 3.0 (0.9), and 2.8 (1.4); valve thrombosis: 1.0 (0.7), 0.3 (0.3), and 0.7 (0.7); structural failure: 5.8 (1.7), 1.9 (0.7), and 7.1 (2.2). Actuarial freedom from complications at nine years (70% confidence interval) was: late mortality: 61 (9)%, 57 (13)%, and 59 (12)%; thromboembolism and valve thrombosis: 71 (9)%, 79 (6)%, and 81 (8)%; structural failure: 33 (14)%, 50 (16)%, and 12 (14)%; all valve related morbidity/mortality: 31 (10)%, 21 (11)%, and 7 (9)%. Stent fractures appeared in 11 of 17 explanted prostheses; actuarial freedom from stent fracture at nine years was 66 (12)%. CONCLUSIONS: The Wessex bioprosthesis is associated with high thrombogenicity, early structural dysfunction, and a high valve related morbidity/mortality which justifies very close follow up of patients fitted with them.

Aortic Valve↗

Acetabular component revision with frozen massive structural pelvic allograft: average 5-year follow-up.

We evaluated the use of a hemipelvic acetabular transplant in 20 revision hip arthroplasties with massive acetabular bone defects. We report 65% good intermediate-term results at a mean follow-up of 5 years (4-10 years). A cemented cup (without a reinforcement ring) was entirely supported by the allograft in all procedures. There were 7 failures (5 aseptic loosening and 2 deep infections). Two dislocations occurred but did not require acetabular revision. There were 2 cases in which moderate acetabular migration occurred but then stabilised and did not progress. Thirteen of 20 acetabular reconstructions did not require revision. We believe that these are satisfactory intermediate-term results for massive acetabular defects too large for reconstruction with other standard techniques.

Acetabulum↗

Silver-coated prosthetic heart valve: a double-bladed weapon.

A St. Jude Medical Silzone was implanted in a 72-year-old female, suffering from mitral valve disease. Four months later, the patient had acute cardiac failure due to partial detachment of the prosthetic valve. The mitral annulus was ulcerated and there were multiple erosions in the myocardial tissue in contact with the prosthetic valve. Histological examination revealed chronic inflammation with hemosiderine deposits and giant cells. No allergy to silver ions was found. The silver-coated sewing cuff had caused a chronic inflammatory reaction due to a toxic reaction to silver. The Silzone valve was withdrawn from the market on January 2000.

Aged↗

Long-term results of revision hip arthroplasty. Survival analysis with special reference to the femoral component.

We report a clinical and radiological survival analysis of 148 consecutive revisions of hip arthroplasties. All patients referred were offered revision if it was indicated and they were medically fit. About one-third (32%) had had at least one previous revision, and about one-third had an established deep infection. The revisions were performed in ultra-clean air with body-exhaust suits. The usual method of fixation was by contained and pressurised cement of standard viscosity, to which appropriate antibiotics had been added in infected cases. Some patients had cementless revision. Clinical failure meant that one or both of the implants had been removed; radiological failure was assessed from serial radiographs. The clinical survival at ten years was 95%. The Merle D'Aubigné and Postel rating for pain improved from a mean of 2.9 to 5.2; and in Charnley group A and B cases, walking ability improved from 2.3 to 4.3. In contrast to some reports we also found good radiological survival; this was 90.5% for cemented femoral stems. Isoelastic revision stems inserted without cement gave poor results.

Adult↗

The Ross operation as a combined procedure and in complicated cases--is there an increased risk?

BACKGROUND: In this report we address the question whether the Ross operation can be recommended in combined and complicated cardiac procedures. METHODS: From February 1995 to July 2000, we performed 203 Ross operations, 129 with ideal clinical presentation (group 1: mean age 41 +/- 13 years, male 105). In 74 patients, the clinical presentation was complex (group 2: mean age 35 +/- 17 years, male 57), defined as previous aortic or cardiac operations in 32, active endocarditis in 8 or combined procedures in 40 patients. Follow-up is 95 % complete. RESULTS: Neither early mortality nor thromboembolic events were observed. Complications in group 1 vs. group 2 were prolonged ventilation in 1 vs. 1, pacemaker insertion in 1 vs. 2, minor myocardial infarction in none vs. 2 and postoperative bleeds in 2 vs. 3 patients. In group 1, one patient died of hemoptysis at 25 months, and in group 2 one sudden death occurred at 5 months. In the long term, two patients required reoperation for autograft failure in group 1, and one on group 2. Pulmonary stenosis required surgical treatment in one patient of group 2. Echocardiography revealed physiological gradients across the autograft with no significant regurgitation in either group. CONCLUSION: The Ross operation has excellent mid-term results and is a safe and attractive therapeutic approach, both in combined procedures and complex clinical presentations.

Adolescent↗

[Painful total hip arthroplasty].

The results of the total hip prostheses in terms of cost-efficiency make one of the surgical procedures the most efficient. Usually, the articular pains disappear completely and the patient function improves. Outside, turned out failures, which require a revision, some patients present residual pain persisting after the intervention or appearing secondarily. Considering the important number of total hip arthroplasties, this clinical situation is not so rare and the generalist, as the specialist, can be confronted there. The experience shows that the surgical revisions, in the absence of a precise diagnosis are disappointing and often do not improve the patient. This article presents the diagnostic and therapeutic steps advised to face this problem.

Arthroplasty, Replacement, Hip↗

Thoracic aorta transobturator bipopliteal bypass as eventual durable reconstruction after removal of an infected aortofemoral graft.

A 36-year-old man was referred with aortofemoral graft infection and perigraft duodenal erosion. The aortofemoral graft was removed, and bilateral axillo-superficial femoral grafts were constructed. Recurrent failures of these grafts prompted us to convert to a more-durable reconstruction. A straight graft was anastomosed to the lower thoracic aorta, routed retroperitoneally, and attached to an inverted U-shaped bilateral transobturator bypass graft, which was anastomosed to both above-knee popliteal arteries. After 3 years, the patient has remained well and the grafts are patent. This operation represents a durable in-line reconstruction that avoids all previously infected areas after removal of an infected aortofemoral graft.

Adult↗

Long-term follow-up of different models of mechanical and biological mitral prostheses.

Three hundred eighty-five valve prostheses were implanted between 1974 and 1981 in patients with isolated mitral disease: 157 caged-ball valves (156 Starr-Edwards; 1 Smeloff-Cutter) (group A), 107 tilting-disc valves (44 Bjork-Shiley, 49 Sorin, 14 Lillehei-Kaster) (group B), 121 porcine bioprostheses (45 Carpentier-Edwards, 66 Liotta, 10 Hancock) (group C). Perioperative mortality was 9.5% in group A, 11.2% in group B and 6.6% in group C. The follow-up was 86% complete. Actuarial freedom from complications was calculated as follows (linearised rates in brackets) in groups A, B and C, respectively: survival: 47.01% +/- 0.11 (3% patient/yr), 53.37% +/- 0.08 (1.8% patient/yr), 61.24% +/- 0.05 (2.2% patient/yr); thromboembolism: 67.94% +/- 0.09 (1.18% patient/yr); 73.07% +/- 0.06 (1% patient/yr); 97.43% +/- 0.02 (0.02% patient/yr); anticoagulation-related hemorrhage: 84.10% +/- 0.13 (0.18% patient/yr), 97.21% +/- 0.01 (0.12% patient/yr), 100%; prosthetic valve endocarditis: 100% in groups A and B, 95.76% +/- 0.02 (0.18% patient/yr) in group C; valve-related mortality: 87.52% +/- 0.03 (0.75% patient/yr), 87.96% +/- 0.03 (0.56% patient/yr), 82.53% +/- 0.04 (0.93% patient/yr); valve failure: 81.22% +/- 0.07 (0.56% patient/yr), 63.36% +/- 0.1 (1.06% patient/yr), 14.31% +/- 0.05 (4% patient/yr); treatment failure: 78.81% +/- 0.05 (1.12% patient/yr), 76.44% +/- 0.09 (0.62% patient/yr), 80.97% +/- 0.04 (1% patient/yr); all valve-related morbidity and mortality: 40.43% +/- 0.13 (1.93% patient/yr), 57.76% +/- 0.08 (1.43% patient/yr), 14.96% +/- 0.05 (4.18% patient/yr); all valve-related morbidity and mortality at 5 years: 91.97% +/- 0.02 (7.8% patient/yr), 87.06% +/- 0.03 (3.6% patient/yr), 90.27% +/- 0.03 (2.6% patient/yr); at 10 years: 80.4% +/- 0.03 (4.6% patient/yr), 75.91% +/- 0.03 (2.6% patient/yr), 37.44% +/- 0.05 (4.18% patient/yr).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

A second mitral valve replacement in a patient with hereditary hemorrhagic telangiectasia (Osler's disease).

A 62-year-old female with Osler's disease was admitted to our hospital because of fever and cardiac failure. The patient had undergone a mitral valve replacement (MVR) using a Carpentier-Edwards prosthetic valve 14 years earlier. A bacterial examination of arterial blood identified Streptococcus mitis. No arteriovenous malformations were detected in visceral organs. The patient underwent MVR using the same prosthetic xenograft after conservative treatment and management of repetitive epistaxis and decayed teeth. Intra- and postoperative bleeding were typical of a mitral valve reoperation. This is the first reported experience, to the best of our knowledge, of a second MVR in a patient with Osler's disease.

Endocarditis, Bacterial↗

Up to nine-years' experience with the Allcarbon prosthetic heart valve.

BACKGROUND AND AIM OF THE STUDY: The Allcarbon tilting disc valve has been used for valve replacement at the present authors' institution since 1993. Herein is reported their experience with Allcarbon valve implantation. METHODS: Between March 1993 and December 1998, Allcarbon valves were implanted in 599 patients (341 males, 258 females; mean age 36.2 years; range: 7-64 years). Among patients, 238 underwent mitral valve replacement (MVR), 217 aortic valve replacement (AVR), and 144 double valve replacement (DVR). The etiology of valve disease was rheumatic in 91% of cases. Follow up was 95.7% complete; cumulative follow up was 3,185 patient-years. RESULTS: Operative mortality was 2.2% (13/599). Actuarial survival at eight years was 96.6 +/- 1.2% after MVR, 96.1 +/- 1.3% after AVR, and 97.9 +/- 1.2% after DVR. Freedom from valve thrombosis at eight years was 97.0 +/- 1.3% after MVR, 100% after AVR, and 90.0 +/- 9.5% after DVR. Freedom from major bleeding at eight years was 90.0 +/- 2.7% after MVR, 93.5 +/- 2.6% after AVR, and 79.7 +/- 7.6% after DVR. There was one embolic episode after MVR. No structural valve failure was observed. Freedom from reoperation on implanted valves at eight years was 96.1 +/- 1.4% after MVR, 97.9 +/- 1.0% after AVR, and 97.9 +/- 1.5% after DVR. On completion of follow up, 91.3% of survivors were in NYHA class I, 8.5% in class II, and 0.2% in class III. CONCLUSION: Among a population of mostly young patients with rheumatic valve disease, the Allcarbon valve showed satisfactory clinical performance when implanted in the mitral and aortic positions.

Acenocoumarol↗