Cardiac valve replacement in the elderly]

From January 1980 through December 1990, seventy one consecutive patients over 60 years of age (mean age 64 +/- 4 years) and 231 patients younger than 60 years underwent cardiac valve replacement procedures. In the elderly group, aortic valve replacement was performed in nineteen patients, mitral valve replacement in thirty-three patients both aortic and mitral valve replacement in sixteen patients, and both mitral and tricuspid valve replacement in three patients. Aortocoronary bypass was performed in four and tricuspid annuloplasty in 19 patients simultaneously. Two patients were operated on emergency. As for preoperative status, 63 patients (88.7%) were in New York Heart Association (NYHA) Functional Class III or IV. Mechanical valves were implanted in all aortic position and 16 mitral position. Bioprosthetic valves were placed in 34 mitral position and 3 tricuspid position. Mean follow-up period was 42 +/- 33 months. The early mortality rate was 11% (8 patients) and the actuarial survival rate was 88 +/- 5% at five years and 74 +/- 10% at ten years. Postoperative functional improvement was excellent in 85.7% of the survivors. In the younger age group, 77.9% belonged to NYHA class III or IV preoperatively. The early mortality was 3.0% (7 patients) and the actuarial survival rate was 95 +/- 2% at five years and 86 +/- 2% at ten years. And postoperatively 91.3% were in NYHA class I or II. In conclusion, cardiac valve replacement in the elderly can be performed with an acceptable mortality and excellent functional improvement.     

Myocardial revascularization with combined aortic and mitral valve replacements

Although the results of coronary artery bypass grafting plus single aortic or mitral valve replacement have been documented, the risk of myocardial revascularization with combined aortic and mitral valve replacement is not well defined. We present a series of 33 consecutive patients undergoing myocardial revascularization with combined aortic and mitral valve replacement during a period of almost seven years. There were 21 men and 12 women with a mean age of 67 years. All patients had congestive heart failure, and 21 (64%) had angina pectoris. Mean New York Heart Association functional classification was 3.4; eight patients (24%) had ejection fractions less than 0.40, and 13 patients (41%) had cardiac indices less than 2.0 L/min/m2. All operations were performed with hypothermic crystalloid potassium cardioplegia. The number of coronary arteries grafted varied from one to four (mean, 1.7 grafts per patient). Four patients died while in the hospital (12.1%). There were no perioperative myocardial infarctions. At a follow-up of 2 to 80 months (mean 40.7 months), death had occurred in eight (27.6%) of the 29 hospital survivors. Actuarial survival rate at 72 months was 60.7%. Although no preoperative factors predicted late death, early deaths were related significantly to severe mitral regurgitation, low ejection fraction, high New York Heart Association classification and extensive coronary artery disease (p less than 0.05). Myocardial revascularization with combined aortic and mitral valve replacement can be performed with an acceptable early mortality rate but with an appreciable late mortality rate.     

Reoperations for left-sided low-profile mechanical prosthetic obstructions

A series of 2,474 hospital survivors of primary mitral, aortic, and double mitral-aortic valve replacement were observed for a cumulative period of 11.945 years (mean, 4.2 years; range, 0.6-14 years). The linearized incidences of reoperations for thrombotic obstructions were 0.33 +/- 0.08% for mitral valve replacement, 0.36 +/- 0.1% for aortic valve replacement, and 0.42 +/- 0.1% for double valve replacement (p = not significant). Forty-one patients (16 mitral, 12 aortic, and 13 double valve replacements) underwent a total of 44 reoperations with a mean interval of 36 +/- 29 months (range, 0.25-85 months) between operations. Diagnosis was established invasively only in 13 patients (30%). Hospital mortality at reoperation was 18% (8 patients); 28 patients (63%) required emergency surgery. The choice surgical procedures were thrombectomy for clotted aortic prostheses (18 of 24) and valve replacement for obstructed mitral valves (22 of 25; p less than .001). Rethrombosis occurred in 3 patients (1 aortic and 2 double valve replacements). At hospital admission 17 patients (38%) had prothrombin times outside therapeutic ranges (between 20 to 30% of the normal value). The incidence of reoperations for thrombosis in low-profile mechanical prostheses was unaffected by valvar position and number of prostheses implanted. Rethrombosis occurred only in previously cleaned valves, although its occurrence was not significant. The present results indicate that, as experience is gained in the diagnosis and surgical management of this complication, hospital mortality can be reduced significantly (from 37% to 4%).     

More than ten years' follow-up of the Hancock porcine bioprosthesis in Japan.

From February 1975 through October 1981, 256 Hancock porcine bioprostheses (Johnson & Johnson Cardiovascular, King of Prussia, Pa.) (60 aortic, 169 mitral, and 27 pulmonary/tricuspid position) were implanted in 220 patients (104 male and 116 female, aged 9 to 67 years; mean 43.3) at Kyushu University Hospital in Japan. The procedures include 41 aortic valve replacements, 121 mitral valve replacements, 4 pulmonary valve replacements, 6 tricuspid valve replacements, and 48 combined valve replacements (31 aortic plus mitral, 13 mitral plus tricuspid, and 4 aortic plus mitral plus tricuspid). Hospital mortality was 6.4%. Follow-up was 98% during 8 to 14 (mean 10.5) years. Cumulative follow-up was 1836 patient-years and 2078 valve-years. At 10 years the overall actuarial survival rate, including hospital morality, was 70% +/- 3%, and freedom from valve-related mortality with sudden death was 87% +/- 3%. More than half of the current survivors required no anticoagulant therapy. Freedom from thromboembolism or anticoagulant-related hemorrhage (or both) and prosthetic valve endocarditis was common. Freedom from structural valve failure and reoperation declined more than 9 years after replacement of left-sided heart valves but not after replacement of right-sided heart valves. Sixty-seven patients underwent 68 repeat operations, and there were four deaths (5.9%). The rate of freedom from overall valve-related complications at 10 years was 62% +/- 8% for aortic valve replacement, 53% +/- 5% for mitral valve replacement, 80% +/- 13% for pulmonary/tricuspid valve replacement, and 42% +/- 9% for combined valve replacement. There was a significant difference between pulmonary/tricuspid valve replacement and combined valve replacement (p less than 0.05). The Hancock bioprosthesis is suitable for the replacement of valves in the right side of the heart but not for combined valve replacement.     

The Medtronic-Hall cardiac valve: 7 1/2 years' clinical experience

Clinical information on the Medtronic-Hall valve prosthesis was obtained by reviewing the records of 379 patients, 164 of whom had aortic valve replacement (AVR), 163 of whom had mitral valve replacement (MVR), and 52 of whom had double valve replacement over 90 months (1,225 patient-years) (mean follow-up, 42.01 +/- 1.3 months [+/- standard error]). Mean age was 53.8 +/- 12 years. One hundred ninety-three patients (50.9%) had some type of concomitant operation, such as tricuspid annuloplasty, coronary artery bypass grafting, or resection of ascending aortic aneurysm. Ninety-one percent were in New York Heart Association (NYHA) Functional Class III or IV preoperatively. Early mortality and late mortality were 7.7% (29 patients) and 13.5% (51 patients), respectively. The actuarial survival at 7 1/2 years was 74.1 +/- 2.7% for the total group and 69.0 +/- 4.5% for those having AVR, 81.0 +/- 3.2% for those having MVR, and 67.0 +/- 8.9% for those having double valve replacement. All patients but 2 were maintained on a regimen of chronic anticoagulation with warfarin sodium. Twenty-six thromboembolic episodes occurred (2.1/100 patient-years): 13 after MVR (2.3/100 patient-years), 11 after AVR (2.1/100 patient-years), and 2 after double valve replacement (1.4/100 patient-years). Four thromboembolic episodes were fatal; no valve thrombosis occurred. There were no structural failures. Of the 350 late survivors, 92% were in NYHA Functional Classes I and II. Total valve-related complications have been minimal.(ABSTRACT TRUNCATED AT 250 WORDS)     

二尖瓣主动脉瓣三尖瓣同时置换治疗重症风湿性瓣膜病

目的　总结二尖瓣主动脉瓣三尖瓣同期置换治疗重症风湿性心脏瓣膜病的手术疗效。方法　 1999年 6月至 2 0 0 1年 6月 94 1例病人进行瓣膜置换术 ,其中 2 4例同期进行二尖瓣、三尖瓣和主动脉瓣置换 ,占瓣膜置换病人的 2 5 5 %。 2 4例病人中女 17例 ,男 7例 ;年龄 18～ 5 9岁 ,平均 36岁 ;体重 37～ 5 6kg。其中 8例曾行二尖瓣闭式扩张术、11例合并左房血栓、16例病人合并有肝肿大 (肋下 2～ 8cm)和下肢水肿、8例合并有腹水。X线胸片示心胸比率为 0 6 6～ 0 91。超声检查示三尖瓣均有严重反流 ,反流面积为 4 2～ 34 0cm2 ,平均 (16 8± 9 3)cm2 。术前心功能III级 9例 ,VI级 15例。 6例病人因药物不能控制心衰而行急诊换瓣手术。结果　死亡 1例 ,死亡率为 4 2 %。术后 1周、3、6个月复查超声心动图示各心腔内径较术前明显缩小。出院者均得到随访 ,随访时间 2 0～ 36个月 ,平均 2 6 4个月。术后心功能I～II级2 0例 ,III级 4例。术后 3～ 12个月复查超声心动图未见机械瓣功能障碍及血栓形成。结论　对于联合瓣膜病变 ,三尖瓣有严重器质性病变的病人 ,在进行二尖瓣主动脉瓣置换的同时进行三尖瓣置换 ,有利于术后右心功能的恢复 ,能更好地改善心脏的血流动力学特性 ,改善心功能 ,并有利于术后病人的康     

Clinical experience with Sorin Bicarbon valve in patients with tight mitral valve stenosis and elevated pulmonary hypertension (early and mid-term results)

BACKGROUND: The results of mitral valve replacement (MVR) with Sorin mechanical valves in patients who had tight mitral stenosis with high pulmonary artery pressure were reviewed. METHODS: During a period of two years, from August 1998 to May 2000, a mitral valve replacement with a Sorin Bicarbon mechanical valve was performed in 51 patients with a diagnosis of tight mitral stenosis associated with severe pulmonary hypertension (preoperative mean systolic pulmonary artery pressure was 72+/-12 mmHg, range from 60 to 105 mmHg). There were 37 women and 14 men; mean age was 47.2+/-12 years. Forty-eight patients (94.12%) were in NYHA functional class III or IV. All the patients discharged from the hospital were submitted to a clinical follow-up program. A 100% follow-up was obtained with a mean of 12.6+/-6.4 months (range 2 to25 months). RESULTS: Operative mortality was 3.9%, 2 patients who had concomitant CABG died due to low cardiac output. Twelve patients (23.5%) needed an inotropic pharmacological support during the postoperative time. In one patient a re-exploration for bleeding was necessary, and in another one a cerebrovascular accident occurred 3 days after the operation. After 6 months, one patient was reoperated on because of mechanical valve dysfunction due to pannus formation. All survivors underwent a postoperative echocardiographic assessment. The systolic PAP decreased from a mean preoperative value of 72+/-12 mmHg to 39.9+/-12 mmHg. NYHA functional status significantly improved and 86% of the patients were in NYHA functional class I or II. CONCLUSIONS: The mitral valve replacement with Bicarbon mechanical valve prosthesis shows excellent results in patients with mitral valve stenosis associated with a severe pulmonary hypertension.     

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.     

Hematological complications with the St. Jude valve and reduced-dose Coumadin

We examined hematological complications in 415 patients having valve replacement with the St. Jude mechanical prosthesis (212, aortic valve replacement [AVR]; 159, mitral valve replacement [MVR]; and 44, AVR + MVR). There were 164 men and 251 women with a mean age of 59 years (range, 20 to 88 years). Preoperatively 386 patients were in New York Heart Association functional classes III and IV. There were 154 associated procedures (37%), the most common being myocardial revascularization. Overall hospital mortality was 7.5% (31/415), 7% after AVR, 8% after MVR, and 7% after AVR + MVR. All operative survivors were anticoagulated with Coumadin (crystalline warfarin sodium) to maintain the prothrombin time at 1.5 times control. During a mean follow-up of 21 months (range, 6 to 60 months), there were 29 late deaths (7.6%) and 5 patients (1.3%) lost to follow-up. No patient experienced structural valve degeneration. At 48 months, actuarial freedom from thromboembolism was 87% +/- 3% after AVR and 91% +/- 9% after MVR; from anticoagulation-related hemorrhage, 97% +/- 3% after AVR and 91% +/- 3% after MVR; and from hemolysis, 100% after AVR and 98% +/- 2% after MVR. Freedom from all valve-related morbidity at 4 years was 82% +/- 5% after AVR and 75% +/- 10% after MVR. Actuarial survival at 48 months was 80% +/- 4% after AVR and 65% +/- 7% after MVR.     

A five-year appraisal and hemodynamic evaluation of the Bj?rk-Shiley Monostrut valve

Two hundred forty-four Bj?rk-Shiley Monostrut valves were implanted in 225 consecutive patients from October 1983 to December 1988. Aortic valve replacement was performed in 90 patients, mitral valve replacement in 118, and double valve replacement in 16 patients. One patient had tricuspid valve replacement. There were 100 female patients and 125 male patients with a mean age of 54 years (range 2 to 71 years). Present data were completely available for all patients. The cumulative follow-up was 541 patient-years with a mean of 2 years, 5 months. The closing date for follow-up was July 1989, and the closing interval was 2 months. The early mortality rate was 3.1%, and the late mortality rate, 3.1%. The 5-year survival rate was 88% +/- 2.0%: 87% +/- 3.0% for aortic valve replacement, 91% +/- 3.3% for mitral valve replacement, and 75% +/- 9.6% for double valve replacement. The actuarial rates of freedom from thromboembolism at 5 years were 93% +/- 3.2% for aortic, 96% +/- 1.4% for mitral, and 94% +/- 6.1% for double valve replacement. There were no instances of structural valve deterioration. Actuarial rate of freedom from valve-related morbidity and mortality was 86% +/- 2.0% at 5 years: 86% +/- 9.5% for aortic, 87% +/- 3.3% for mitral, and 75% +/- 7.3% for double valve replacement. Effective valve areas (average) of 12 mitral and 12 aortic valve prostheses were calculated at rest and during bicycle exercise: 2.4 cm2 at rest and 2.8 cm2 during exercise in 27 mm aortic valves, 2.4 cm2 at rest and 3.0 cm2 during exercise in 25 mm aortic valves, 2.0 cm2 at rest and 2.4 cm2 during exercise in 27 mm mitral valves, and 2.6 cm2 at rest and 2.5 cm2 during exercise in 29 mm mitral valve. On the basis of our follow-up period of 5 years, we have judged the Bj?rk-Shiley Monostrut valve reliable, with a low incidence of valve-related morbidity and with acceptably satisfactory hemodynamic characteristics at rest and during exercise.     

Use of the Carpentier-Edwards porcine bioprosthesis: assessment of a patient selection policy.

The Carpentier-Edwards bioprosthesis was implanted in 369 patients (414 valves) between May 1977 and December 1987 (age 67.2 +/- 0.5 years); 242 had aortic valve replacement, 80 had mitral valve replacement, 44 had multiple valve replacement, of which 41 were aortic and mitral valve replacement, 2 had isolated tricuspid valve replacement, and 1 had a pulmonary valve replacement. The selection criteria were the following: shorter life expectancy (253 patients) or contraindications to anticoagulants for organic (113 patients) or psychologic (38 patients) reasons, or both. The early mortality rate was 11.1% (aortic valve replacement, 9.1%; mitral valve replacement, 12.4%; aortic and mitral valve replacement, 23.1%). Total cumulative follow-up was 1456 pt-yr (mean 4.4 years, range 1 to 148 months), and the patient evaluation was 99.5% complete. Late mortality was 4.9%/pt-yr. Five-year survival was 70.4% +/- 2.7% overall, 74.3% +/- 3.2% after aortic valve replacement, 60.9% +/- 6.2% after mitral valve replacement (p < 0.03), and 60.7% +/- 8.1% after aortic and mitral valve replacement. Eight patients were reoperated on for primary tissue failure, and freedom from reoperation for structural valve deterioration was 97.5% +/- 1.2% at 5 years and 95.6% +/- 1.8% at 8 years. Failing aortic bioprostheses were explanted in four patients (0.4%/pt-yr) and mitral bioprostheses in seven (1.6%/pt-yr). No patient whose valve was inserted after the age of 70 had to be reoperated on for structural valve dysfunction. The probability of freedom from thromboembolism after 5 and 8 years of follow-up was 93.1% +/- 1.6% and 92.2% +/- 1.8%, respectively. The prevalence of anticoagulant-related hemorrhage was 0.8%/pt-yr (major 0.6%, minor 0.2%). Anticoagulants had to be maintained in 16.3% of the patients: 5.9% after aortic valve replacement, 35.7% after mitral valve replacement, and 45.8% after aortic and mitral valve replacement, while 80.0% were on a regimen of antiplatelet drug therapy. Prosthetic valve endocarditis happened in five patients (0.3%/pt-yr). Freedom from all valve-related morbidity and mortality, including hospital deaths, was 71.0% +/- 2.7% at 5 years and 58.6% +/- 4.6% at 8 years and was significantly better in the aortic valve replacement group (61.3% +/- 6.6% at 8 years) compared with the mitral valve replacement group (54.4% +/- 7.7% at 8 years; p = 0.04). This study confirms the satisfactory performance of the Carpentier-Edwards valve after aortic valve replacement in elderly patients.(ABSTRACT TRUNCATED AT 400 WORDS)     

Heart valve operations in solid organ recipients: an 18-year single-center experience

BACKGROUND: We retrospectively analyzed the outcome of heart valve operations in solid organ recipients, who were referred for operation to our institution. METHODS: Over an 18-year period, 23 heart (group 1) and 16 renal (group 2) transplant recipients in New York Heart Association (NYHA) classes III and IV underwent valve operation. The mean interval from the time of transplantation to cardiac surgery was 77.9 months with a mean follow-up time of 34.6 months in group 1 and 87.2 months with a mean follow-up time of 39.2 months in group 2. RESULTS: Group 1 underwent tricuspid valve replacement (n=12), tricuspid valve reconstruction (n=7), aortic valve replacement (AVR, n=3), and mitral valve replacement (MVR, n=1). In group 2, mechanical valve replacement was performed in 14 patients (9 AVR, 3 MVR, 2 AVR and MVR) and tricuspid or mitral valve reconstruction in two patients. There was no operative death. During hospitalization, multiorgan failure due to sepsis was the main cause of mortality (2 in both groups). In the mean follow-up period of 41.2 months, there were four late non-cardiac-related deaths in group 1. Currently 29 surviving transplant recipients (16 heart, 69.6% and 13 renal, 81.3%) are in NYHA classes I and II. CONCLUSION: In heart and renal recipients, valve operations can be performed effectively and safely with acceptable mortality, low cardiac morbidity, and excellent clinical results, although infection is the most serious complication.     

Combined valve replacement and myocardial revascularization

Combining valve replacement with coronary artery bypass (CABG) for significant concomitant disease remains a controversial subject. To determine the operative results following combined valve replacement and CABG, we evaluated 201 patients seen consecutively between July 1977 and June 1982. CABG for vessels with greater than 70% stenosis was performed with aortic valve replacement in 106 patients, with mitral valve replacement in 82, and with aortic and mitral valve replacement in 13. There were 143 men and 58 women; the mean age was 67 years. Nine operative deaths (8.5%) occurred with aortic valve replacement and CABG: 5 of 25 (20%) when cardioplegia was not used and 4 of 81 (4.9%) with cardioplegia (p less than 0.01). The operative mortality rate for isolated aortic valve replacement without coronary disease during the same period was 5.9% (10 of 168). The late actuarial survival rate is similar for aortic valve replacement alone or aortic valve replacement and CABG. There were no operative deaths among patients having undergone aortic and mitral valve replacement and CABG; the rate was 15% (9 of 60) in patients having undergone aortic and mitral replacement and CABG. The operative mortality rate was 21.9% for mitral valve replacement and CABG (18 of 82). Rheumatic disease was present in 14 of these patients, two of whom had early deaths (14.3%), both after repeat mitral operations; 11 mitral valve replacements and CABG were done for degenerative mitral regurgitation with no deaths, and the remaining 57 patients had ischemic mitral regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Durability of porcine valves at fifteen years in a representative North American patient population.

Isolated aortic (n = 857) or mitral (n = 793) valve replacement with a porcine bioprosthesis was performed in 1650 patients between 1971 and 1980. Follow-up (total = 12,012 patient-years) extended to more than 15 years and was 96% complete. Patient age ranged from 16 to 87 years; mean age was 59 +/- 11 years (+/- 1 standard deviation) for the aortic valve replacement cohort and 56 +/- 12 years for the mitral valve replacement cohort. The operative mortality rates were 5% +/- 1% (+/- 70% confidence limits) and 8% +/- 1%, respectively, for the aortic and mitral subgroups. Estimated freedom from structural valve deterioration (+/- 1 standard error of the mean) after 10 and 15 years was significantly higher for the aortic than for the mitral valve replacement subgroup (85% +/- 0.4% and 63% +/- 3% versus 78% +/- 2% and 45% +/- 3%, respectively, p = 0.001). Reoperation-free actuarial estimates were also significantly greater for the aortic valve replacement cohort: 83% +/- 2% and 57% +/- 3% versus 78% +/- 2% and 43% +/- 3% for mitral valve replacement at 10 and 15 years, respectively. The mortality rate for reoperative aortic valve replacement was 11% +/- 1%; it was 8% +/- 1% for reoperative mitral valve replacement. Importantly, the estimates of freedom from valve-related death (including sudden, unexplained deaths) were relatively high at 10 and 15 years: 78% +/- 2% and 69% +/- 3% in the aortic cohort and 74% +/- 2% and 63% +/- 3% in the mitral cohort (p = not significant). Excluding sudden, unexplained deaths, these estimates were 81% +/- 3% (aortic) and 73% +/- 4% (mitral) at 15 years. Thromboembolism-free rates were 84% +/- 3% (aortic) and 78% +/- 6% (mitral) at 15 years, and freedom from anticoagulant-related hemorrhage was 96% +/- 1% and 89% +/- 2%, respectively. At the time of current follow-up, 13% of patients having aortic valve replacement and 50% of patients having mitral valve replacement were receiving warfarin sodium. The hazard functions for thromboembolism and prosthetic valve endocarditis were constant and remained less than 1%/pt-yr over the entire follow-up period.(ABSTRACT TRUNCATED AT 400 WORDS)     

Valve replacement in the elderly: a long term appraisal

From July 1972 through July 1983, 360 consecutive patients 70 years of age and older (mean age 74.1; range 70-88 years) underwent 362 valve replacement procedures. There were 122 isolated aortic valve replacements (33.7%; Group I); 70 isolated mitral valve replacements (19.3%; Group II); and 170 patients had combined procedures (47.0%; Group III), which included the replacement of at least one valve. Eighteen patients (5.0%) had previous cardiac surgery. Thirty-two patients (8.8%) were operated as emergencies. Three hundred and thirty-two (86.5%) of all valves implanted were porcine heterografts. Pre-operatively, over one-half (53.6%) of the patients were in New York Heart Association Functional Class IV. The overall hospital mortality was 13.8% (50 patients). The aortic valve mortality was 11.5%, the mitral valve mortality was 15.7%, and the combined procedures 14.7%. The follow-up period for hospital survivors (312 patients) extended from 2 weeks to 127.2 months, with a mean of 38.7 months or a total of 1,006 patient-years. The long term survival computed up to six years shows a 65 +/- 3.8% (standard error of the mean) for the entire group. The aortic valve group survival was 71 +/- 5.6%; the mitral valve group 60 +/- 8.2%; and the combined procedures group was 64 +/- 5.3%. Postoperative functional improvement was significant with 71.8% of the survivors in Class I and 19.6% in Class II. Based on these results, advanced age can no longer be considered a deterrant to cardiac surgery. The porcine heterograft appears to be the valve substitute of choice for this age group.(ABSTRACT TRUNCATED AT 250 WORDS)     

Mechanical valve replacement in children and teenagers

A previous study from this unit showed that only 19% of children with mitral bioprostheses were free from complications after 7 years and prompted us to review the performance of new-generation mechanical prostheses implanted in the same population group. In a 5-year period (1980-1985), 352 patients 20 years old and younger (mean age 15.3 +/- 4 years) with rheumatic valvular disease had 177 mitral, 62 aortic and 113 double (mitral + aortic) valve replacements with Medtronic-Hall or St. Jude prostheses. The overall early mortality was 6.3%. All survivors, followed up for a total of 1171 patient-years, received oral anticoagulation. The late mortality for mitral, aortic and double valve replacement was 4.1% per patient-year, 4.3% per patient-year and 8.0% per patient-year, respectively (P less than 0.05), and was valve-related in 46% of the cases. Twenty-nine patients, all but 2 in the mitral and double valve replacement groups, were reoperated upon (2.5% per patient-year), mainly for infective endocarditis (34%), for prosthetic thrombosis (33%) and for bland periprosthetic leak (31%). The incidence of thrombotic obstruction was 1.1% per patient-year: mitral valve replacement, 1.0% per patient-year; aortic valve replacement 0.5% per patient-year; and double valve replacement, 1.7% per patient-year; P less than 0.05) and was fatal in 33% of the cases. Major systemic thromboembolism occurred at the rate of 1.4% per patient-year, similar in the three groups. The incidence of prosthetic endocarditis was 0.9% per patient-year.(ABSTRACT TRUNCATED AT 250 WORDS)     

Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body: an analysis of clinical outcomes

OBJECTIVE: This study was undertaken to evaluate the late outcomes of reconstruction of the intervalvular fibrous body during aortic and mitral valve replacement. METHODS: Seventy-six consecutive patients underwent reconstruction of the intervalvular fibrous body with replacement of the mitral and aortic valves. There were 35 men and 41 women whose mean age was 58 +/- 12 years. Additional procedures were circumferential reconstruction of the mitral annulus in 27 patients, tricuspid valve repair in 21, coronary artery bypass in 15, and aortic root replacement in 4. Indications for the operation were active infective endocarditis with abscess in 15 patients, extensive calcification of the mitral annulus and interventricular fibrous body in 24, lack of fibrous tissue to secure a prosthetic valve in 17, and treatment or prevention of patient-prosthesis mismatch in 20. Fifty-five patients had undergone one or more previous valve operations, and 52 (68%) were in functional class IV. The mean follow-up was 47 +/- 47 months, and it was complete. RESULTS: There were 8 (10%) operative and 18 (24%) late deaths. The 10-year survival was 50% +/- 9%. There were 15 reoperations in 12 patients: 7 for prosthetic valve endocarditis (5 early, 2 late), 7 for patch or valve dehiscence (3 early, 4 late), and 1 for structural valve deterioration. All but 2 reoperations were re-reconstruction of the intervalvular fibrous body and double valve replacement. The 10-year freedom from reoperation was 73% +/- 7%. CONCLUSION: Reconstruction of the intervalvular fibrous body during double valve replacement is a technically challenging operation, but it is useful in patients with complex valve pathology for whom no alternative procedure is available.     

Heart valve replacement with the Sorin tilting-disc prosthesis. A 10-year experience.

From 1978 to 1988, 697 patients with a mean age of 48 +/- 11 years (range 5 to 75 years) received a Sorin tilting-disc prosthesis; 358 had had aortic valve replacement, 247 mitral valve replacement, and 92 mitral and aortic valve replacement. Operative mortality rates were 7.8%, 11.3%, and 10.8%, respectively, in the three groups. Cumulative duration of follow-up is 1650 patient-years for aortic valve replacement (maximum follow-up 11.4 years), 963 patient-years for mitral valve replacement (maximum follow-up 9.9 years) and 328 patient-years for mitral and aortic valve replacement (maximum follow-up 9.4 years). Actuarial survival at 9 years is 72% +/- 4% after mitral valve replacement, 70% +/- 3% after aortic valve replacement, and 50% +/- 12% after mitral and aortic valve replacement, and actuarial freedom from valve-related deaths is 97% +/- 2% after mitral valve replacement, 92% +/- 2% after aortic valve replacement, and 62% +/- 15% after mitral and aortic valve replacement. Thromboembolic events occurred in 21 patients with aortic valve replacement (1.3% +/- 0.2%/pt-yr), in 12 with mitral valve replacement (1.2% +/- 0.3% pt-yr), and in seven with mitral and aortic valve replacement (2.1% +/- 0.8%), with one case of prosthetic thrombosis in each group; actuarial freedom from thromboembolism at 9 years is 92% +/- 3% after mitral valve replacement, 91% +/- 3% after aortic valve replacement, and 74% +/- 16% after mitral and aortic valve replacement. Anticoagulant-related hemorrhage was observed in 15 patients after aortic valve replacement (0.9% +/- 0.2%/pt-yr), in 9 after mitral valve replacement (0.9% +/- 0.3%/pt-yr), and in 6 with mitral and aortic valve replacement (0.9% +/- 0.5%/pt-yr); actuarial freedom from this complication at 9 years is 94% +/- 2% after aortic valve replacement, 91% +/- 4% after mitral valve replacement, and 68% +/- 16% after mitral and aortic valve replacement. Actuarial freedom from reoperation at 9 years is 97% +/- 2% after mitral and aortic valve replacement, 92% +/- 4% after mitral valve replacement, and 89% +/- 3% after aortic valve replacement, with no cases of mechanical fracture. The Sorin valve has shown a satisfactory long-term overall performance, comparable with other mechanical prostheses, and an excellent durability that renders it a reliable heart valve substitute for the mitral and aortic positions.     

Late results of heart valve replacement with the Hancock II bioprosthesis

OBJECTIVE: To review the late clinical outcomes of patients who had isolated aortic or mitral valve replacement with the Hancock II bioprosthesis. METHODS: From 1982 to 1994, 670 patients underwent isolated aortic valve replacement and 310 underwent isolated mitral valve replacement with the Hancock II bioprosthesis (Medtronic Inc, Minneapolis, Minn). Mean age was 65 +/- 12 years in both groups. Most patients were in New York Heart Association functional classes III or IV, and concomitant coronary artery disease was present in 44% of patients in the aortic valve group and 41% of patients in the mitral valve group. Patients were followed up prospectively at periodic intervals. Mean follow-up was 87 +/- 45 months in the aortic valve group and 83 +/- 50 months in the mitral valve group, and it was 99% complete. RESULTS: Actuarial survival at 15 years was 47% +/- 3% in the aortic valve group and 30% +/- 5% in the mitral valve group. Older age, advanced functional class, impaired left ventricular function, active endocarditis, and coronary artery disease were independent predictors of late death. The freedom from thromboembolic complications at 15 years was 83% +/- 3% in the aortic and 87% +/- 3% in the mitral valve group. The freedom from infective endocarditis at 15 years was 96% +/- 1% in the aortic and 91% +/- 1% in the mitral valve group. At 15 years, the actuarial and actual freedom from structural valve deterioration was 81% +/- 5% and 90% +/- 3%, respectively, in the aortic group and 66% +/- 6% and 83% +/- 3%, respectively, in the mitral group. Younger age, mitral valve position, and poor ventricular function were independent predictors of structural valve deterioration. The freedom from repeat valve replacement at 15 years was 77% +/- 5% in the aortic group and 69% +/- 6% in the mitral. The vast majority of patients had functional improvement after valve replacement. CONCLUSIONS: The Hancock II bioprosthesis has provided good clinical outcomes and is a durable valve, particularly in the aortic position in older patients.     

The Ionescu-Shiley pericardial valve: results in 473 patients

From January 1, 1980, through December 31, 1985, 473 patients underwent valve replacement with an Ionescu-Shiley valve. Overall hospital mortality was 7.8%. Major associated procedures and preoperative New York Heart Association (NYHA) Classes IV and V influenced hospital mortality significantly. The mean follow-up was 2.6 +/- 1.3 years. Late mortality was 5.9%. Overall actuarial survival was 81% at 5 years. A chief cause of reoperation was cusp rupture of a mitral prosthesis in 5 patients (all after aortic and mitral valve replacement). The overall actuarial reoperation-free incidence was 93% at 5 years. Thromboembolic (TB) phenomena occurred at a linear incidence of 1.4 +/- 0.3% per patient-year or an actuarial thromboembolism-free incidence of 92% at 5 years. Univariate and multivariate analyses showed that postoperative NYHA Class, rhythm at follow-up, and anticoagulant therapy significantly influenced the incidence of TE phenomena.