Papillary muscle rupture following acute myocardial infarction.

OBJECTIVES: Papillary muscle rupture following acute myocardial infarction (AMI), which rarely occurs, leads to catastrophic outcomes. We reviewed 6 patients who were diagnosed as having papillary muscle rupture. SUBJECTS AND METHODS: Between February 1986 and September 2002, 6 consecutive patients underwent mitral valve replacement (MVR) for acute mitral regurgitation due to postinfarction papillary muscle rupture (4 men and 2 women, mean age 67 years). Preoperatively, all were in New York Heart Association (NYHA) class IV. All patients had intraaortic balloon pumping, and one needed additional percutaneous cardiopulmonary support. Operations were performed within 1 to 19 days (mean 6.8) after the onset of AMI, and within 24 hours after papillary muscle rupture. Complete ruptures were found in 5 of 6 patients. Four patients had posterior papillary rupture and 2 patients anterior. All patients underwent MVR to preserve the posterior mitral leaflet. Concomitant coronary artery bypass grafting was performed in 5 of 6 patients (mean 1.6 grafts per person) and pulmonary venous isolation for atrial fibrillation in one patient. RESULTS: The cardiopulmonary bypass time ranged from 178 to 325 minutes (mean 236), and the aortic cross clamp time from 123 to 196 minutes (mean 155). Two patients died of low cardiac output syndrome. Of 4 operative survivors, 3 patients were in NYHA class I and one in class II. The mean follow-up term was 21 months. One patient with the pulmonary venous isolation has been in sinus rhythm. All survivors have been doing well without any valve related complications. CONCLUSION: Six patients underwent MVR for the papillary muscle rupture following AMI and the perioperative mortality rate was 33%. All survivors have been well with no cardiac events. We propose that in papillary muscle rupture following AMI emergent surgery should be undertaken as soon as possible, and that concomitant surgery should be performed as thoroughly as possible.     

Combining off pump coronary artery bypass with mitral valve replacement

Background Conventional approach to combined coronary artery bypass grafting (CABG) and mitral valve replacement (MVR) is associated with longer cardiopulmonary bypass (CPB) and aortic cross clamp (ACC) time leading to high operative risk. Methods We conducted a retrospective review of nine consecutive patients undergoing coronary artery bypass grafting/mitral valve replacement combining the off pump technique with cardioplegic arrest. Elective intra aortic balloon pump (IABP) support was instituted in all cases. CABG was first done in all cases without cardiopulmonary bypass support. Mitral valve replacement was then done using conventional cardiopulmonary bypass and cardioplegic arrest using the superior septal approach. Results Nine consecutive patients underwent coronary artery bypass grafting with mitral valve replacement including three patients with acute myocardial infarction. Preoperative echocardiogram revealed a mean ejection fraction (EF) of 38.4 ± 6.0%. Intra aortic balloon pump was inserted in all patients preoperatively. The average number of grafts were 3.0 ± 0.7. Eight patients received bioprosthetic valve while one patient received mechanical prosthesis. The average length of stay in intensive care unit was 3.3 ± 0.5 days. There was no mortality. One patient had superficial wound infection. Conclusion The data suggest that the combined technique (off pump coronary artery bypass grafting and conventional mitral valve replacement) is a safe method to perform coronary artery bypass grafting/mitral valve replacement with minimal morbidity and mortality.     

Papillary muscle rupture following acute myocardial infarction

Objectives: Papillary muscle rupture following acute myocardial infarction (AMI), which rarely occurs, leads to catastrophic outcomes. We reviewed 6 patients who were diagnosed as having papillary muscle rupture. Subjects and Methods: Between February 1986 and September 2002, 6 consecutive patients underwent mitral valve replacement (MVR) for acute mitral regurgitation due to postinfarction papillary muscle rupture (4 men and 2 women, mean age 67 years). Preoperatively, all were in New York Heart Association (NYHA) class IV. All patients had intraaortic balloon pumping, and one needed additional percutaneous cardiopulmonary support. Operations were performed within 1 to 19 days (mean 6.8) after the onset of AMI, and within 24 hours after papillary muscle rupture. Complete ruptures were found in 5 of 6 patients. Four patients had posterior papillary rupture and 2 patients anterior. All patients underwent MVR to preserve the posterior mitral leaflet. Concomitant coronary artery bypass grafting was performed in 5 of 6 patients (mean 1.6 grafts per person) and pulmonary venous isolation for atrial fibrillation in one patient. Results: The cardiopulmonary bypass time ranged from 178 to 325 minutes (mean 236), and the aortic cross clamp time from 123 to 196 minutes (mean 155). Two patients died of low cardiac output syndrome. Of 4 operative survivors, 3 patients were in NYHA class I and one in class II. The mean follow-up term was 21 months. One patient with the pulmonary venous isolation has been in sinus rhythm. All survivors have been doing well without any valve related complications. Conclusion: Six patients underwent MVR for the papillary muscle rupture following AMI and the perioperative mortality rate was 33%. All survivors have been well with no cardiac events. We propose that in papillary muscle rupture following AMI emergent surgery should be undertaken as soon as possible, and that concomitant surgery should be performed as thoroughly as possible.     

Eight year experience with the CarboMedics bileaflet valvular prosthesis.

Two hundred and two patients (97 female and 105 male; mean age: 45. 5+/-9 years) received CarboMedics bileaflet valves during a period of eight years. Ninety-one patients received mitral, 72 aortic and 39 aortic+mitral valve prosthesis. Tricuspid plasty and coronary artery bypass surgery were the concomitant operations in 17 and 12 patients, respectively. The mean follow-up period was 24.7 months and the ratio was 91%. Overall operative mortality was 3.96% (8 patients); 2.78% for aortic valve replacement (AVR), 3.29% for mitral valve replacement (MVR) and 7.7% for double valve replacement (DVR). The late mortality rate was 2.89% for AVR, 2.2% for MVR and 8. 3% for DVR. The main cause of mortality was low cardiac output. The overall survival rate was 91.5% in 2 years. The actuarial freedom from thromboembolism in 2 years was 97% for AVR, 95% for MVR and 84% for DVR. No mortality due to heamorrhagic events was observed. CarboMedics prosthetic heart valves may be used satisfactorily with a low incidence of valve-related morbidity and mortality.     

Cardiac operation and end-stage renal disease

From 1972-1979, 22 patients with end-stage renal disease underwent 23 cardiac operations involving the pump oxygenator. Fourteen patients had coronary artery bypasss, 2 had aortic valve replacement, 2 had mitral valve replacement (MVR), 2 had MVR with coronary artery bypass, and 2 had ascending aortic root replacement with a composite graft. One patient underwent successful reoperation for a false aneurysm of the left ventricle after MVR. There were 2 postoperative deaths, for a mortality of 9.1%. The patients undergoing coronary artery bypass had an average of 2.7 grafts and an average Functional Class improvement from New York Heart Association Class III or IV to Class I to II. Eighteen patients required preoperative and postoperative dialysis to control blood volume, potassium, and uremia. Four patients had functioning renal transplants, and 4 patients underwent subsequent successful renal transplantation. We conclude that: (1) patients who have transplants and require dialysis can be successfully managed for cardiac operation in spite of their complex associated medical problems; (2) functional and symptomatic improvement simplifies continued management of the patient needing dialysis; and (3) improvement of a cardiac disability can allow favorable renal transplantation in selected patients.     

Clinical experience with omniscience and omnicarbon prosthetic heart valves

Omniscience valves were implanted in sixty-two patients. Twenty-eight of these patients underwent aortic valve replacement (AVR), 15 had mitral valve replacement (MVR) and 8 had aortic and mitral valve replacement (DVR). Post-operative events occurred in nine (5.9%/patient year) of the AVR group, in three (1.7%/patient year) of the MVR group and in three (5.4%/patient year) of the DVR group. The actuarial freedom from all events at five years in the AVR, MVR and DVR was 74 +/- 8%, 88 +/- 6%, 67 +/- 16%, respectively. Cardiac death occurred in four (2.5%/patient year) of the AVR, one (0.6%/patient year) of the MVR and two (3.6%/patient year) of the DVR. The freedom at five years in the AVR, MVR and DVR was 88 +/- 6%, 96 +/- 4%, and 77 +/- 14%, respectively. Valve-related complications were noted in four patients. Post-operative cerebral hemorrhage was seen in three of the AVR. Maximum opening angle of the Omniscience valve was 39.1 +/- 4.5 degrees at the aortic position and 44.6 +/- 9.7 degrees at the mitral position. Omnicarbon valves implanted in ninety-five patients, fifty-eight of these patients underwent AVR, 24 had MVR and 13 had DVR. Events occurred post-operatively in four (2.6%/patient year) of the AVR group, in three (12.2%/patient year) of the MVR group, but in none of the DVR group. The freedom at five years was 89 +/- 6% in the AVR and 84 +/- 8% at three years in the MVR. Post-operative cardiac death occurred in one (0.7%/patient year) of the AVR and in two (8.1%/patient year) of the MVR.(ABSTRACT TRUNCATED AT 250 WORDS)     

A reoperation of adult-Type Bland-White-Garland syndrome

We present a 25-year-old female patient with Bland-White-Garland syndrome (anomalous origin of the left coronary artery from the pulmonary artery) who underwent mitral valve replacement (MVR) and coronary artery bypass grafting. She had previously undergone MVR and had been treated by the Takeuchi procedure for mitral valve regurgitation and a coronary artery anomaly, respectively, at 17 years of age. She was hospitalized with shortness of breath within 7 years of surgical intervention. Swan-Ganz catheterization revealed mild pulmonary hypertension and elevated mean pulmonary wedge pressure. Echocardiography revealed marked severe calcification of the bio valve and moderate mitral valve regurgitation. Coronary angiography revealed retrograde collateral blood flow from the right coronary artery to the left coronary artery, but intrapulmonary tunnel was not visualized by pulmonary arteriography. We performed MVR with a mechanical valve and coronary artery bypass grafting between the left internal thoracic artery and the left anterior descending artery. The postoperative course was unremarkable, and no complaints were reported during follow-up at the outpatient clinic.     

Clinical and hemodynamic assessment of the Hancock II bioprosthesis.

The Hancock II bioprosthesis was used for heart valve replacement in 614 patients from 1982 to 1990. Aortic valve replacement (AVR) was performed in 376 patients, mitral valve replacement (MVR) in 195, and aortic and mitral valve replacement (DVR) in 43. The mean age was 62.7 years, and 78% of all patients were in New York Heart Association functional class III or IV before operation. Coronary artery bypass graft was necessary in 232 patients and replacement of ascending aorta in 55. There were 31 operative deaths (AVR, 4%; MVR, 6%; DVR, 9%). Follow-up was complete in 98.5% of the patients and extended from 12 to 103 months, with a mean of 49 months. At the last follow-up, 85% of the patients were in New York Heart Association class I or II. The actuarial survival at 8 years was 79% +/- 3% for AVR, 68% +/- 4% for MVR, and 65% +/- 10% for DVR. The freedom from stroke at 8 years was 93% +/- 2% for AVR, 83% +/- 5% for MVR, and 90% +/- 5% for DVR. At the end of 8 years 96% +/- 1% of all patients were free from endocarditis, 92% +/- 1% were free from primary tissue failure, and 89% +/- 3% were free from reoperation. The actuarial freedom from valve-related death at 8 years was 98% +/- 1% for AVR, 86% +/- 5% for MVR, and 91% +/- 6% for DVR. Hemodynamic assessment was obtained by Doppler echocardiography in all operative survivors and demonstrated satisfactorily effective valve orifices and transvalvular gradients. The clinical results obtained with the Hancock II bioprosthesis have been gratifying, particularly in the aortic position. This bioprosthesis is our biological valve of choice.     

二尖瓣成形术治疗感染性心内膜炎二尖瓣关闭不全

目的 评估二尖瓣成形术治疗感染性心内膜炎的可行性和疗效.方法 1990年10月至2007年7月,83例感染性心内膜炎致二尖瓣关闭不全的病人接受二尖瓣手术.男62例,女21例.41例(49.4%)行二尖瓣成形术(MVP),42例(50.60%)行二尖瓣置换术(MVR).同时行主动脉瓣置换术37例,三尖瓣成形术12例,室间隔缺损修补术4例,冠状动脉旁路移植术2例,主动脉瓣成形术1例,房间隔缺损修补术1例,股动脉取栓术1例.术中18例行食管超声检查评估二尖瓣反流情况.结果 MVP与MVR组病人比较,术前左室收缩末内径(41.63±8.60)mm对(37.69±6.38)mm,P＜0.05;术前射血分数0.62±0.07对0.66±0.76,P＜0.05;术前心功能分级平均(2.88±0.61)级对(2.45±0.71)级,P＜0.01.体外循环47～265min,平均(117.06±46.77)min;主动脉阻断26～210min,平均(86.95±39.07)min;呼吸机辅助呼吸5～120h,平均(21.49±16.06)h.MVP与MVR组病人体外循环和主动脉阻断时间均差异无统计学意义,MVP组气管插管和住ICU时间均显著低于MVR组(P＜0.05).MVR组病人瓣叶赘生物明显多于.MVP组病人(P＜0.05).MVP组术者相对固定.住院死亡3例(3.6%),均为二尖瓣置换病人.出院时病人心功能均为Ⅰ级或Ⅱ级.随访1～165个月,平均(39.33±39.76)个月,随访率95%.MVR组发生瓣周漏1例,反复胸腔积液1例,脑出血2例,其中1例死亡,10年生存率75%.MVP组无死亡,10年生存率100%.结论 感染性心内膜炎二尖瓣病变的病人瓣叶毁损不严重,如术者临床经验丰富,大多可行二尖瓣成形术,并取得良好手术结果.

Abstract：

Objective Valve replacement is a conventional therapy for the mitral insufficiency caused by IE. Mitral valve repair as an optional procedure for the disease has become feasible in recent years. However, concerns from surgeons about the recurrence of endocarditis after mitral valve repair remained. in this study we evaluated the long-term clinical outcomes of patients treated with surgery for the mitral insufficiency caused by infective endocarditis (IE). Methods Between July 1990 and July 2007, 83 consecutive patients (male 62, female 21) with mitral valve IE were enrolled in this study. Forty-one (49.4% )patients received mitral valve repair ( MVP,group A) and 42(50. 6% ) patients received mitral valve replacement ( MVR, group B). Thirty-seven cases had concomitant aortic valve replacement; 1 patient had aortic valve repair; 4 cases had ventricular septal defect repair; 1 case had atrial septal defect repair, 12 cases had bicuspid valve repair; 2 cases had coronary artery bypass graft and 1 case had femoral artery thrombus. Intraoperative transesophageal echocardiography were performed in 18 cases for the evaluation of mitral valve regurgitation. Mean cardiopulmonary bypass time, aortic clamping time and postoperative ventilation time were recorded and analyzed. Mid- and long-term clinical and echocardiographic outcomes were assessed.Results Preoperative left ventricular end systolic diameter, left ventricular ejection fraction and the classification of New York Heart Association in group A were significantly lower than those in group B (P ＜ 0. 05), but no difference was observed between the 2 groups in the cardiopulmonary bypass time and the crossclamping time. However, the intubation time and ICU time were shorter in group A than those in group B ( P ＜ 0.05 ). More vegetations were seen in the MVR group than in the MVP group. Three (3.6% ) patients died after the operation in group B. All patients were assessed as in NYHA Ⅰ-Ⅱ at discharge.A follow-up was done between 1 to 165 months (mean 39 months) with a mean follow-up rate of 95%. In the MVR group, peri-valvular leakage happened in 1 case, cerebral hemorrhage happened in 2 cases and repetitive pleura! effusion in 1 case. One death happened in the MVR group and none in the MVP group. The 10-year survival rate (100% ) in group A was nonsignificantly higher in group A than that (75% ) in group B(P =0.081). Conclusion Mitral valve repair is feasible for treating mitral valve lesions caused by endocarditis, and may provide an optimistic long-term outcome to the patients. The indication for mitral valve repair is mild to moderate mitral valve lesion. Experienced cardiac surgeons, use of antibiotics before and after the operations based on drug-sensitivity test and blood test, as well as follow-up the patients yearly, are important factors for the favorite outcomes.     

Long-term clinical results after combined aortic and mitral valve replacement

The results after 282 consecutive double (aortic & mitral) valve replacements (DVR) are compared with our previously reported experience after mitral (MVR, n = 810) and aortic valve replacement (AVR, n = 1753). All but one patient received Bj?rk-Shiley valves. The follow-up which closed on August 1, 1985 was 99.3% and covered 16,869 patient-years (mean 6.3 years/patient). Autopsies were performed in 74% of all fatalities. Early mortality rates were identical in the three patient groups, and late mortality did not differ between MVR and DVR patients. The fraction of valve-related mortality was similar in all groups. Anticoagulant-related bleeding was equally common in all patient groups. The incidences of thromboembolism, reoperation and valve failure did not differ between MVR and DVR patients, but were significantly higher than among AVR patients. With the exception of a slightly increased incidence of prosthetic valve endocarditis, the results after DVR equal those after MVR. In cases with severe mitral valve disease but borderline aortic valve disease, primary DVR is clearly justified and eliminates the need for, and risks of, a secondary AVR.     

Is anterior mitral valve leaflet length important in outcome of septal myectomy for obstructive hypertrophic cardiomyopathy?

ObjectivesElongation of mitral valve leaflets is a phenotypic feature of hypertrophic cardiomyopathy, and some surgeons advocate plication of the anterior leaflet at the time of septal myectomy. The present study investigates mitral valve leaflet length and outcomes of patients undergoing septal myectomy for obstructive hypertrophic cardiomyopathy.MethodsWe reviewed the records and echocardiograms of 564 patients who underwent transaortic septal myectomy for obstructive hypertrophic cardiomyopathy between February 2015 and April 2018. Extended septal myectomy without plication of the anterior leaflet was the standard procedure. From intraoperative prebypass transesophageal echocardiograms, we measured anterior and posterior mitral valve leaflets and their coaptation length. For comparison, we performed these mitral valve leaflet measurements in 90 patients who underwent isolated coronary artery bypass grafting and 92 patients undergoing aortic valve replacement in the same period. Among patients with hypertrophic cardiomyopathy undergoing septal myectomy, we assessed left ventricular outflow tract gradient relief and 1-year survival in relation to leaflet length.ResultsMedian patient age (interquartile range) was 60.3 (50.2-67.7) years, and 54.1% were male. Concomitant mitral valve repair was performed in 36 patients (6.4%), and mitral valve replacement was performed in 8 patients (1.4%), primarily for intrinsic mitral valve disease. Patients in the hypertrophic cardiomyopathy cohort had significantly longer mitral valve leaflet measurements compared with patients undergoing coronary artery bypass grafting or aortic valve replacement (P < .001 for all 3 measurements). Preoperative resting left ventricular outflow tract gradients were not related to leaflet length (<30 mm, median 49 [21, 81.5] mm Hg vs ≥30 mm, 50.5 [21, 77] mm Hg; P = .76). Further, gradient reduction after myectomy was not related to leaflet length; patients with less than 30 mm anterior leaflet length had a median gradient reduction of 33 (69, 6) mm Hg compared with 36.5 (62, 6) mm Hg for patients with leaflet length 30 mm or more (P = .36). Anterior mitral valve leaflet length was not associated with increased 1-year mortality (P = .758).ConclusionsOur study confirms previous findings that patients with hypertrophic cardiomyopathy have slight (5 mm) elongation of mitral valve leaflets. In contrast to other reports, increased anterior mitral valve leaflet length was not associated with higher left ventricular outflow tract gradients. Importantly, we found no significant relationship between anterior mitral valve leaflet length and postoperative left ventricular outflow tract resting gradients or gradient relief. Thus, in the absence of intrinsic mitral valve disease, transaortic septal myectomy with focus on extending the excision beyond the point of septal contact is sufficient for almost all patients.     

梗阻性肥厚型心肌病的外科治疗

目的 总结肥厚室间隔切除联合二尖瓣置换术治疗梗阻性肥厚型心肌病的手术效果和经验体会.方法 2000年1月至2007年6月,共对22例合并有中度以上二尖瓣反流的OHCM患者实施肥厚室间隔切除联合二尖瓣置换术.其中男性20例,女性2例;年龄28～51岁,平均(36±5)岁.左心室流出道压差55～120 mm Hg(1 mm Hg=0.133 kPa),平均(88.0±15.8)mm Hg.分析比较患者术前超声心动图,术中经食管心脏超声,以及术后10 d,6个月、1年超声心动图的结果 .结果 术后因顽固性室性心律失常死亡1例.术中经食管超声示所有患者二尖瓣前叶收缩期前向运动现象消失.存活的21例患者均获随访,术后各时间点左心室流出道压差和室间隔厚度均较术前下降(P<0.01).结论 肥厚室间隔切除联合二尖瓣置换术治疗合并中度以上二尖瓣反流的梗阻性肥厚型心肌病,近中期手术效果可靠,并发症少.     

Midterm experience with the Sorin Bicarbon heart valve prosthesis for rheumatic disease

BACKGROUND: In this study, we present a single center experience with Bicarbon bileaflet valve in 307 patients with rheumatic heart disease. METHODS: Between August 1998 and September 2000, 307 patients underwent heart valve replacement using the Bicarbon bileaflet valve (Sorin Biomedica, Saluggia, Italy) with an average age of 47.19+/-13.21 years (range 14 to 80 years), consisting of 147 males and 160 females at Alkan Hospital, Cardiovascular Surgery Department. Aortic valve replacement (AVR) was performed in 77 patients, mitral valve replacement (MVR) in 156 patients and double valve replacement (DVR) in 74 patients. RESULTS: The early mortality rate was 3.3% (10/307) and there was no late mortality. The actuarial survival rate, including hospital mortality, was 96.74+/-1.01% for the whole group, 96.5+/-1.5% for the MVR group, 97.4+/-1.8% for the AVR group and 97.3+/-1.9% for the DVR group at 35 months. One patient had obstructive valve thrombosis with MVR. The 35 months actuarial freedom from valve thrombosis was 99.58+/-0.4% for the whole group. Four patients were reoperated and the 35 months actuarial freedom from reoperation was 98.53+/-0.7% for the whole group, 98.65+/-0.9% for the MVR group, 96.73+/-02% for the DVR group and 100% for the AVR group. No instances of perivalvular leak, hemolysis, endocarditis or embolism were observed during the entire follow-up period. Mean follow-up duration was 16.5+/-7.9 months (ranged 4 to 35 months). CONCLUSION: We have presented our mid-term results with the Sorin Bicarbon bileaflet valve in patients with rheumatic heart disease, which provided good clinical performance combined with meticulous patient care and advanced surgical techniques.     

Early and late arrhythmias in patients in preoperative sinus rhythm submitted to mitral valve surgery through the superior septal approach

BACKGROUND: It has been hypothesized that the use of the superior septal approach to the mitral valve can lead to postoperative loss of sinus rhythm. This study was undertaken to evaluate the early and mid-term alterations of the cardiac rhythm in patients with preoperative sinus rhythm (SR) submitted to mitral valve surgery through the superior septal approach. METHODS: Seventy-five cases in preoperative SR submitted to primary isolated mitral valve surgery through the superior septal approach constitute the study population. All patients underwent 12-lead electrocardiography on admission, every day after surgery until discharge and every year during the follow-up period. RESULTS: On admission in the intensive care unit, 46 cases maintained their preoperative rhythm, whereas 18 developed a junctional rhythm (JR) and 7 had a first- or second-degree atrio-ventricular block (AVB). Four cases arrived in the unit in atrial fibrillation (AF). On the first postoperative day, these proportions were substantially unchanged, with the only exception being a slight increase in the number of patients in AF. The day before discharge, only 35 of the 74 surviving cases maintained the preoperative SR, whereas 13 developed AF, 10 were in JR, and 16 were in AVB. During the follow-up period (mean, 26 +/- 14 months), the majority of cases (47/74) regained SR; 11 patients had AVB, 3 were in JR, and the remaining 13 were in AF. CONCLUSIONS: The use of the superior septal approach for mitral valve procedures in patients in preoperative SR is associated with minor, transient cardiac rhythm disturbances.     

Surgical management of aortopulmonary window.

OBJECTIVE: Aortopulmonary window is a rare congenital malformation involving a window-like communication between the ascending aorta and the pulmonary artery. Here, we present our experience regarding the surgical repair of an aortopulmonary window, and also assess the long-term outcome. METHODS: Thirteen children with an aortopulmonary window associated with various congenital lesions underwent a repair of the defect. The age at operation ranged from 3 days to 1 year (median age, 19 days). The patient's weight ranged from 2.1 to 7.0 kg (mean weight, 3.6 kg). The associated lesions included an interrupted aortic arch (5 patients), a ventricular septal defect (2), an atrial septal defect (1), mitral valve regurgitation (1), and tricuspid atresia [Ic] with mitral valve regurgitation (1). The aortopulmonary window was repaired with a cardiopulmonary bypass in 11 patients, and 2 patients were ligated without a cardiopulmonary bypass. RESULTS: One patient associated with tricuspid atresia died (mortality rate of 7.7%). There has been no late death during a mean follow-up of 7 years and 3 months. CONCLUSIONS: The surgical results for an aortopulmonary window are encouraging, even if such patients are associated with major cardiac anomalies and an interrupted aortic arch. Most have shown a good long-term outcome.     

Concomitant irrigated monopolar radiofrequency ablation of atrial fibrillation in adults with congenital heart disease

Atrial fibrillation is the most frequent form of atrial arrhythmias in adults with congenital heart disease. Some serious complications are related with the presence of atrial fibrillation after surgery. Because of the complexity and the risk of bleeding, the Maze III procedure has been largely replaced by alternative energy sources. Our experience in using irrigated monopolar radiofrequency ablation to treat atrial fibrillation in adults with congenital heart disease is reported. Seven patients with congenital heart disease and atrial fibrillation underwent irrigated monopolar radiofrequency ablation. All patients were confirmed in permanent fibrillation preoperatively. Six were adult atrial septal defect patients and one was an adult patent ductus arteriosus patient. All patients survived the procedure and discharged in sinus rhythm. There were no complications related to radiofrequency ablation. The time of ablation ranged from 17 to 22 min (average 19.5 min). Follow-up ranged from 3 to 48 months. One patient with mitral valve replacement (MVR) died of cerebral hemorrhage 13 months after surgery. The last electrocardiogram showed that six patients were in sinus rhythm and one patient in junctional rhythm. Irrigated monopolar radiofrequency ablation is an easy, effective, safe and economic concomitant operation to eliminate atrial fibrillation in adult patients with congenital heart defect and atrial fibrillation.     

Robotic minimally invasive mitral valve reconstruction yields less blood product transfusion and shorter length of stay

BACKGROUND: Robotic-assisted minimally invasive mitral valve reconstruction has gained popularity recently. Initial reports suggest that this approach can be used with relative safety and efficacy. Direct comparisons with a traditional sternotomy approach have not yet been explored extensively. METHODS: All mitral valve procedures that were performed by a single surgeon during a 3-year period of time were analyzed (n = 142 procedures). Patients whose condition required concomitant coronary artery bypass grafting or aortic valve surgery were excluded subsequently from analysis, because all of these patients were approached obligatorily by sternotomy (n = 71 patients). Six patients underwent right thoracotomy mitral valve procedures without robotic assistance, and 1 patient in cardiogenic shock underwent emergent mitral valve reconstruction by sternotomy. Of the remaining 64 patients who were eligible theoretically for sternotomy or robotic-assisted minimally invasive surgery, 39 patients underwent sternotomy, and 25 patients underwent right chest minimally invasive robotic-assisted surgery. Randomization between these 2 approaches would be almost impossible in the United States. The primary determinant for the choice of approach was request of the referring physician or patient. Multiple perioperative outcomes were then compared. RESULTS: Patients who underwent sternotomy and robotic-assisted surgery exhibited equivalent preoperative characteristics and experienced an equivalent degree of correction of mitral regurgitation in repairs and in need for replacement. Complex mitral valve repairs that entailed leaflet resection and reapproximation, annular plication, sliding annuloplasty, chordal transfer, and GoreTex neochordal construction were accomplished successfully with the robotic system. Cross-clamp and bypass times were longer for patients in the minimally invasive group (110 vs 151 minutes; P = .0015; 162 vs 239 minutes; P < .001, respectively). Mean packed red blood cell transfusion was lower among patients who underwent robotic-assisted surgery (5.0 vs 2.8 units; P = .04). Patients who underwent robotic-assisted surgeries experienced shorter mean duration of postoperative hospitalization (10.6 vs 7.1 days; P = .04). There was 1 death among the patients who underwent sternotomy, and no deaths among the patients who underwent robotic-assisted surgery. CONCLUSION: Patients can undergo mitral valve reconstruction with minimally invasive robotic assistance, avoid a sternotomy, require less blood product transfusion, and experience shorter hospitalization.     

Complicated unroofed coronary sinus syndrome

A young boy planned for the surgical closure of atrial septal defect (ASD) and mitral valve regurgitation (MR) was found peroperatively as having a complete unroofed coronary sinus (URCS). Intracardiac re-routing of left superior vena cava (LSVC) and mitral valve replacement (MVR) were performed concomitantly with success.     

Beating-heart mitral valve reoperation in a patient with a permanent pacemaker

A 60-year-old man with a history of a prior double-valve replacement (DVR) and permanent pacemaker implantation underwent mitral valve reoperation due to a paravalvular leak. Reoperation was performed on a beating heart (BH) on cardiopulmonary bypass, by perfusing the heart continuously with oxygenated noncardioplegic normothermic blood via the coronary sinus. We report the case of a patient who underwent mitral valve reoperation on a beating heart, 10 years after his first double-valve replacement and permanent pacemaker implantation.     

Septal myectomy, papillary muscle resection, and mitral valve replacement for hypertrophic obstructive cardiomyopathy: a case report

We report a case of hypertrophic obstructive cardiomyopathy (HOCM) successfully treated with septal myectomy and mitral valve replacement (MVR) combined with a resection of the hypertrophic papillary muscles. The patient, a 74-year-old woman, first underwent the conventional septal myectomy through aortotomy. The papillary muscles revealed a marked hypertrophy, but extended myectomy and precise resection of the hypertrophic papillary muscles were thought to be difficult through the aortotomy. Through the right-sided left atriotomy, MVR and resection of the papillary muscles were additionally performed. The patient was smoothly weaned from the cardiopulmonary bypass, and the postoperative course was uneventful. The outflow pressure gradient was relieved to 0 mm Hg, from 94. The mean pulmonary artery pressure was reduced to 27 mm Hg, from 42. The patient has been doing well in the New York Heart Association (NYHA) functional class between I and II during 45 months of follow-up, without complications related to the use of a prosthetic valve. Septal myectomy is the procedure of choice in the surgical treatment of HOCM for most cases, but some may require additional mitral valve procedures. In patients with marked hypertrophic papillary muscles, MVR and resection of the muscles may be an option of treatment to ensure a relief of the outflow obstruction and to abolish systolic anterior movement in units with limited experience.