Late results after Starr-Edwards valve replacement in children

Selection of types of prosthetic heart valves for children remains controversial. The case histories of 50 children surviving valve replacement with Starr-Edwards prostheses between 1963 and 1978 were reviewed to evaluate the long-term performance of mechanical valves. The 31 boys and 19 girls ranged from 6 months to 18 years in age (mean 10.4 years); 19 patients had had aortic valve replacement, 24 patients had had mitral valve replacement, and one patient had had both. Among the six patients who had had tricuspid valve replacement, four had corrected transposition, so that the tricuspid valve was the systemic atrioventricular valve. Mean (+/- standard deviation) follow-up interval was 7.9 +/- 4.9 years (maximum 17 years). For all patients, the 5 year survival rate was 86% +/- 6%. At 10 years postoperatively, the survival rate (+/- standard error) was 90% +/- 7% after aortic valve replacement and 76% +/- 8% after systemic atrioventricular valve replacement. At follow-up, 39 patients were alive, and 38 were in New York Heart Association Class I or II. Of the 11 deaths, four were valve-related. Seven patients had major (requiring hospitalization) thromboembolic events, and five patients had minor transient neurological symptoms suggesting thromboembolism; 50% of these patients were not taking warfarin (Coumadin) at the time of the thromboembolic event. The incidence of late (greater than 30 days) thromboembolism was 5.3 per 100 patient-years after aortic and 2.0 per 100 patient-years after systemic atrioventricular valve replacement. At 10 years postoperatively, 66% +/- 15% of patients who had had aortic valve replacement and 91% +/- 6% of those who had had systemic atrioventricular valve replacement were free of thromboembolism. The excellent long-term survival, absence of mechanical failure, and relatively low rate of thromboembolism with this prosthesis contrast with our experience with biological valves, in which 41% of children required reoperation in 5 years. Currently, mechanical valves, such as the Starr-Edwards prostheses, are our preferred valves for pediatric patients.     

Late results after mitral valve replacement

Recent reports on mitral valve replacement (MVR) are reviewed and topics in this field are discussed. In addition to the widely used St. Jude Medical (SJM) valve, five other bileaflet prosthetic valves are now commercially available in Japan. The clinical performance of the new type of bileaflet valve appears similar to that of the SJM valve. The lincarized rate of thromboembolism occurrence for any bileaflet valve is less than a few %/patient-year in most reports. The actuarial and actual freedom from structural valve deterioration(SVD) 14 years after MVR with the Carpentier-Edwards pericardial valve was reported to be 69% and 83%, respectively, while the actuarial freedom from SVD 12 years after MVR with the Hancock II porcine valve was 82%. In Japan, the rate of use of bioprostheses is approximately 10%. When selecting a prosthetic valve, informed patient consent based on the most recent data is recommended. Numerous reports have been published on chorda-preserving MVR indicating the superiority of this technique over conventional MVR in terms of left ventricular function. There are several options for prescribing the chordae and for artificial chordae reconstruction. Improved methods for sparing the chordae are being investigated in animal models.     

Predictors of secondary tricuspid regurgitation after left-sided valve replacement

PURPOSE: To evaluate the risk factors of tricuspid regurgitation (TR) after left-sided valve replacement (LSVR) and plan the initial surgical treatment of TR. METHODS: Two hundred and forty-eight patients, including 217 patients in the LSVR group and 31 patients in the LSVR+DeVega group, were followed up. A retrospective analysis was performed on 14 characteristics in the LSVR group. Variables were used to evaluate predictors of TR progression after single LSVR by either a univariate or multivariate analysis. DeVega's tricuspid annuloplasty was evaluated on progress of TR by univariate analysis. RESULTS: The mean follow-up was 5.2 +/- 2.9 (range, 3-16) years after surgery. In a univariate analysis, atrial fibrillation, huge left atrium, long time from onset to surgery, tricuspid rheumatic changes, preoperative +2 or +3 TR, the degradation of left ventricular ejection fraction, augmented right atrium, and single mitral valvular disease were significant risk factors for TR development. A multivariate analysis indicated that the four items mentioned above were statistically significant predictors of TR after surgery. The progress of TR in the LSVR+DeVega group was significantly less than in the LSVR group. CONCLUSIONS: An aggressive repair of accompanying TR should be performed at the time of initial surgery in patients with a huge left atrium, atrial fibrillation, long time from onset to surgery, or tricuspid rheumatic changes. DeVega's tricuspid annuloplasty therefore helps prevent a progression of TR.     

Late results after mitral valve replacement with bileaflet mechanical prosthesis in children: evaluation of prosthesis-patient mismatch

BACKGROUND: Mechanical prosthesis is the choice of valve at the mitral position in children, although re-replacement of prostheses because of prosthesis-patient mismatch is almost inevitable when prostheses were implanted in small children. The methods to predict prosthesis-patient mismatch as a result of patients' somatic growth or pannus formation in children by noninvasive methods have not been well established. METHODS: Thirty-two children underwent mitral valve replacement with 37 bileaflet mechanical prostheses (26 St. Jude Medical prosthetic valves, and 11 CarboMedics prosthetic valves) and were followed up a mean of 6.8 years (maximum 18.3 years) with a complete follow-up rate of 94%. RESULTS: There were no operative deaths and 5 late deaths. Re-replacement of mitral valve because of prosthesis-patient mismatch was required in 5 patients. Freedom from valve-related events and re-replacement of mitral valve at 15 years were 32% +/- 23% and 54% +/- 18%, respectively. Actuarial survival rate was 63% +/- 19% at 15 years. Prosthetic valve orifice area index (manufactured geometric prosthetic valve area divided by patient's body surface area) was well correlated with maximum transprosthesis flow velocity estimated by Doppler echocardiography during follow-up, whereas valve orifice area index had no significant correlation with pulmonary artery wedge pressure assessed by cardiac catheterization. Maximum transprosthesis flow velocity had a significant correlation with pulmonary artery wedge pressure. CONCLUSIONS: Valve orifice area index itself was not a reliable index to predict prosthesis-patient mismatch. Maximum transprosthesis flow velocity was a useful index to predict pulmonary artery wedge. Invasive cardiac catheterization to determine re-replacement of the prosthesis should be considered when maximum transprosthesis flow velocity exceeds 270 cm/s.     

Midterm results after aortic valve replacement with the autologous tissue cardiac valve.

OBJECTIVE: To assess midterm results after aortic valve replacement (AVR) with an autologous tissue cardiac valve (ATCV). This new technique was developed to construct a tissue prosthesis for AVR using the patients pericardium, harvested at the time of operation with negligible effect on operating time. METHODS: Briefly, glutaraldehyde tanned pericardium is mounted on a stent requiring no suturing. Between March 1994 and December 1996, 87 patients, 44/43 M/F and aged 70 +/- 6 years had AVR for aortic stenosis (80%), aortic insufficiency (6%) and combined lesions (14%), one patient suffered from endocarditis. Additional coronary artery bypass was done in 25%, aortic root enlargement in 7%. Aortic cross clamp and cardiopulmonary bypass times were 69 +/- 21 and 93 +/- 29 min. All patients were followed by clinical examination and color flow Doppler echocardiography in 3-12 months interval. Follow up was 99% complete. RESULTS: There were five perioperative deaths (6%), none of them valve related. Eighty-one patients were followed up to a period of 52 months (mean interval 37.5 +/- 1.3 months), one patient was lost for follow up. Overall survival was 86, 81, 79 and 71% at 12, 24, 36 and 48 months, respectively. There were 14 late deaths with eight (10%) valve related (four cerebral deaths, four sudden deaths). Sixteen patients (20%) had to be re-operated due to severe valve incompetence. Freedom from reoperation was 98, 97, 90 and 63% at 12, 24, 36, and 48 months, respectively. Valve incompetence occurred suddenly, without previous signs in the follow-up examinations. Selection and preparation of the pericardium, the way of fixation of the tissue--brief immersion in glutaraldehyde--and engineering problems might be responsible for this disastrous outcome. CONCLUSION: Due to these results we must state, that the ATCV did not fulfill our expectations and presently we can not recommend it as an aortic valve substitute.     

Tricuspid valve replacement after cardiac transplantation

BACKGROUND: Tricuspid regurgitation (TR) occurs commonly in transplanted hearts. Although theoretically attractive, tricuspid valve replacement (TVR) has not been widely investigated as a possible therapy in post-transplant patients. The purpose of this study was to determine the safety of TVR in heart transplant patients and its effects on measurable clinical endpoints. METHODS: We acquired data by both retrospective chart review and prospective data collection in all patients who underwent TVR after cardiac transplantation. RESULTS: Nine patients were identified and followed for a period of six months. The age of patients at time of TVR was 62 +/- 6.1 yr and their average time since transplantation was 12 +/- 3.2 yr. Most patients demonstrated a reduction in their furosemide dose (105 +/- 63 mg/d pre-TVR vs. 67.5 +/- 65 mg/d post-TVR, p = 0.001) with a reduction in serum creatinine levels (188 +/- 72 micromol/L pre-TVR vs. 143 +/- 42 micromol/L post-TVR, p = 0.06). Additionally, we found a significant improvement in albumin values (32 +/- 5 g/L pre-TVR vs. 42 +/- 3 g/L post-TVR, p = 0.002) as well as an improvement in total bilirubin (35 +/- 18 micromol/L pre-TVR vs. 18 +/- 5 micromol/L post-TVR, p = 0.05). There was only one death in our series, in the only patient with known severe graft atherosclerosis. CONCLUSIONS: TVR appears to be a safe procedure in patients without severe graft atherosclerosis with improvements in serum creatinine, albumin and total bilirubin values, in addition to a reduction in furosemide dose. This may reflect improved forward flow, improved symptomatology from TR as well as possible beneficial effects on nutritional status.     

Intermediate-term results after the aortic valve replacement using bileaflet mechanical prosthetic valve in children.

OBJECTIVE: Intermediate/long-term results after aortic valve replacement using bileaflet mechanical valve in children should be clarified as a standard of treatment of aortic valve disease in children. METHODS: Forty-five patients aged under 15 years underwent 46 aortic valve replacements using bileaflet mechanical prosthetic valve. Patients' ages ranged from 1 to 15 years (9 years as a median value), and follow-up period was 9.2 years as a median value (maximum 19 years). RESULTS: In situ valve replacement was performed in 21 procedures, while annular enlargement was required in 25 procedures (Nicks 10, Yamaguchi 3, Manouguian 2, Konno 10). All patients except two received prosthesis 19mm or larger in size. There was one operative death and two late deaths. Two episodes of cerebral infarction, two valve thrombosis, two re-operations, one infective endocarditis, and one sudden death were recognized as valve-related complications in five patients. The reasons for re-operation were prosthesis-patient mismatch in one (Ross procedure) and valve thrombosis in one (re-replacement). At 15 years after the operation, re-replacement free rate, valve-related event free rate and actuarial survival rate were 94+/-4%, 86+/-6% and 92+/-4%, respectively. The transprosthetic flow velocity estimated by Doppler echocardiography at the final follow-up was well correlated with manufactured valve area index (cm(2)/body surface area). CONCLUSIONS: Although aortic annular enlargement was required in more than half of the cases, intermediate-term results after aortic valve replacement using bileaflet mechanical prosthetic valve in children was satisfactory. Indications for alternative treatment such as Ross procedure might be considered in limited cases.     

Tricuspid valve replacement after cardiac transplantation.

Tricuspid regurgitation, a fairly common finding after cardiac transplantation, is generally mild or moderate, and is not clinically significant. The etiology of tricuspid regurgitation is not entirely understood, and experience with valve replacement after cardiac transplantation is limited. We describe a case of progressively severe tricuspid regurgitation ultimately requiring tricuspid valve replacement. At operation, the ruptured chordae of the posterior part of anterior and septal leaflet with resulting partially flail leaflets were found. Examination of the papillary muscle showed origins of several of the ruptured chordae. Damage to the tricuspid subvalvular apparatus at endomyocardial biopsy appeared to be a possible cause. A 31-mm Carpentier-Edwards porcine valve was implanted. This was because replacement with a mechanical prosthesis would prevent future right-side heart catheterization and endomyocardial biopsy and in valve repair, the patient remains exposed to the risk of the recurrence of chordal rupture. We discuss proposed causes and choices in surgical technique.     

Lung mechanics after cardiac valve replacement.

Fourteen patients undergoing single aortic or mitral valve replacement had measurements made of lung volumes, static pressure-volume (P-V) relationships, and conductance-pressure relationships during deflation before operation and again between one and two years later. At follow-up, total lung capacity (TLC), functional residual capacity (FRC), residual volume (RV), and static tidal compliance (slope of static P-V deflation line for one litre above FRC) had increased significantly, in association with a decrease in heart size. There was a change in the shape and position of some P-V curves both in the aortic and mitral patients. In the patients with aortic disease P-V deflation curves shifted to the left after operation. In the patients with mitral disease the P-V deflation curves before operation crossed those measured after operation, so that at high lung volumes recoil became less after operation, but at low lung volumes recoil increased. Conductance had increased at high lung volumes. The data suggest that in longstanding pulmonary congestion, airways are more rigid making them less distensible at high and less compressible at low transpulmonary pressures than after operation when congestion has been at least partly relieved.     

Late results after mitral valve replacement with the Bj?rk-Shiley and porcine prostheses

The late results of isolated mitral valve replacement were retrospectively evaluated in 357 patients receiving a Bj?rk-Shiley (B-S) tilting disc prosthesis and 96 patients receiving a porcine bioprosthesis (PB) (Vascor or Carpentier-Edwards) between March, 1973, and July, 1978. The groups were comparable with regard to age, sex, New York Heart Association functional class, preoperative cardiac rhythm (sinus or atrial fibrillation), left atrial size (normal or enlarged), and presence of thrombus in the left atrium at operation. All of the B-S and 14 of the PB patients received long-term anticoagulant therapy. The median duration of follow-up was 46 months in the B-S group and 32 months in the PB group. At 5 years, survival was 70% for the B-S and 68% for the PB groups (NS). The percentage of patients free of thromboembolic episodes was 77% for the B-S and 78% for the PB groups (NS). Fifty-six percent of the B-S and 49% of the PB patients were alive and free of thromboembolism, complications related to anticoagulant therapy, or other valve-related complications (dehiscence, degeneration, or endocarditis) (NS). The presence of atrial fibrillation, enlarged left atrium, preoperative thromboembolic episodes, and left atrial thrombus had no effect on the incidence of thromboembolic complications with either prosthesis. From this analysis, it appears that the major advantage of the PB over the B-S prosthesis is its use in patients in whom long-term anticoagulation is contraindicated.     

人工心脏瓣膜置换手术后的远期随访

目的　随访 5 5 0 6例次人工心脏瓣膜置换术后病人的远期临床结果 ,全面评价远期疗效。方法　 1976年 5月至 1997年 5月 ,在阜外心血管病医院外科实施人工瓣膜置换手术 5 5 0 6例次 ,共 5 2 79例病人 ,其中男 2 76 8例 ,女 2 5 11例 ;平均年龄 (39 86± 10 73)岁。共置换人工瓣膜 6 816枚。总随访率为86 8% ,平均随访 6 5 9年 (0 80～ 2 2 5 8年 ) ,随访总人年次为 2 86 0 8 94病人 年。结果　手术总死亡率为5 98%。人工生物瓣膜结构性衰坏发生率 1 5 7%病人 年。全组血栓栓塞发生率 0 2 2 %病人 年 (机械瓣组为 0 2 8%病人 年 ,生物瓣组为 0 0 7%病人 年 ,P =0 0 0 0 0 )。出血事件发生率 1 0 0 %病人 年 (机械瓣组为 1 34%病人 年 ,生物瓣组为 0 15 %病人 年 ,P =0 0 0 0 0 )。再手术为 0 4 5 %病人 年 (机械瓣组 0 0 2 %病人 年 ,生物瓣组为 1 6 1%病人 年 ,P =0 0 0 0 0 )。再手术原因以生物瓣衰坏为主 ,占再手术 96 35 %。远期死亡率 0 79%病人 年 ,5年生存率 (96 34± 0 31) % ,10年生存率 (92 4 8± 0 5 8) % ,15年生存率 (87 97± 1 13) % ,2 0年生存率 (82 5 1± 2 94 ) %。远期瓣膜相关死亡率 0 6 0 %病人 年 ,5年免除瓣膜相关死亡(97 2 1± 0 2 7) % ,10年     

Late results after meniscectomy in children

Seventy-five children undergoing 77 meniscectomies have been reviewed from 1 to 30 years (mean 15) after operation in order to determine the late results of meniscectomy. Arthroscopy of the patients with a poor result was performed at the follow-up. In 30 per cent osteoarthrosis was diagnosed, all with follow-up times from 19 to 25 years. Delay in operation resulted in worse results. The younger the patient the worse the result. The benefit of operation was less in girls than in boys. Bucket-handle lesions and peripheral tears produced the best results after meniscectomy. Fifty-eight per cent of men and 26 per cent of women had symptom-free knees at follow-up. Removing a meniscus is not a benign procedure. Only 44 per cent of patients in whom a damaged meniscus and 17 per cent in whom a normal meniscus had been removed were without symptoms. These results stress the need for making an accurate diagnosis by careful examination and arthroscopy before embarking on meniscectomy in children. Efforts to preserve the meniscus in children must be made whenever possible.     

Late results after mitral valve replacement with Mosaic bioprosthesis in patients aged 65 years or younger

Open in a separate window OBJECTIVESAlthough in younger patients indications for biological prosthesis implantation in mitral valve replacement remain controversial, recently bioprostheses use increased considerably. We present late results obtained with the Medtronic Mosaic bioprosthesis in patients aged 65 years or younger. METHODSBetween 2007 and 2017, 67 mitral Mosaic bioprostheses were implanted in patients aged 65 years or younger (58.5 ± 6.4 years). Follow-up extended up to 13 years. Survival, freedom from structural valve degeneration, endocarditis, thromboembolic events and reoperation were considered as main clinical end points evaluated at 1, 5 and 10 years.RESULTSThe mean follow-up was 4.7 ± 2.8 years. Overall mortality rate was 12%. At 1, 5 and 10 years, survival was 94 ± 3%, 89 ± 4% and 77 ± 9%, respectively. Freedom from structural valve degeneration was 100%, 94 ± 4% and 71 ± 21%. Freedom from endocarditis was 95 ± 3%, 90 ± 6% and 84 ± 8%. Freedom from thromboembolic events was 94 ± 3%, 90 ± 5% and 90 ± 5%. Freedom from reoperation was 94 ± 3%, 87 ± 5% and 65 ± 19%.CONCLUSIONSMosaic bioprosthesis appears a valid mitral valve substitute even when employed in ≤65-year-old patients.     

Long-term results after Starr-Edwards mitral valve replacement in children aged 5 years or younger

BACKGROUND: Mitral valve replacement with prosthetic valves in infants and children requires consideration of multiple variables. When we examined our late follow-up, the effect of the growth of the patient relative to the size of the prosthesis placed was the most important variable predicting late successful results. We reviewed our experience with mitral valve replacement using the Starr-Edwards ball valve in children aged 5 years or younger, focusing on the effect of valve prosthesis-patient mismatch on the long-term results in the growing patient. METHODS: From August 1974 to June 1986, 8 patients aged 5 years or younger underwent mitral valve replacements using the Starr-Edwards prosthesis size OM in 3 patients and 1M in 5 patients. Model 6320 was used in 1 patient and Model 6120 in the remaining 7 patients. RESULTS: Follow-up was 100% from 15 to 27 years (mean, 20 years). No valve-related complications of thromboembolism, anticoagulant-related hemorrhage, or prosthetic valve endocarditis were seen. All patients normally developed to adult size. The range of the valve area index of the 3 patients who received the smaller Starr-Edwards valve (size OM) was 0.97 to 1.24 cm2/m2. Although this size valve was adequate for patient growth to adolescence, in each case valve replacement with a larger valve was required. CONCLUSIONS: Our long-term review of Starr-Edwards ball valve mitral valve replacement in children aged 5 years or younger shows that the Starr-Edwards ball valve (Models 6320 [1 patient] and 6120 [7 patients]) showed excellent durability, no thromboembolism, and no anticoagulant-related complications. Size OM valves required replacement for hemodynamic reasons because of patient growth; larger size 1M valves remained hemodynamically satisfactory in spite of patient growth.     

Mitral valve replacement six years after cardiac transplantation

A 33-year-old man found to have increasing mitral regurgitation and decreasing exercise tolerance 6 years after cardiac transplantation received a mitral bioprosthesis. For 8 months he has been without complications from the valve replacement and is clinically and hemodynamically considerably improved.     

Late results after heart valve surgery in the elderly

Heart valve surgery was performed in 133 patients over the age of 60 between 1976 and 1981. There were 54 men and 79 women. Their ages ranged from 60 to 74 years (mean age 64.3 years). In this study, 54 valve prostheses (15 porcine and 39 mechanical) in the aortic position, 79 prostheses (69 porcine and 10 mechanical) in the mitral position and 3 prostheses (3 porcine) in the tricuspid position were implanted in 121 patients. Fifteen patients (11.3%) died in the hospital. The hospital mortality was high in the cases of MVR (14.6%), MVR + TAP (12.5%) and emergency (50%). The mean follow-up was 37.2 months (range 4 to 129 months, total 367.3 patient-years). There were 10 late deaths (8.5%). Actuarial survival for hospital survivors at 5 years was 89.2 per cent. At follow-up, 95.8% of the surviving patients were in New York Heart Association functional class I or II. Valve-related complications were thromboembolism (2.0% pt/year), periprosthetic leak (1.7% pt/year), primary tissue failure (0.5% pt/year) and thrombosed valve (0.3% pt/year). Anticoagulant-related hemorrhage necessitating hospitalization occurred in 2 patients (1.0% pt/year). The freedom from all events at 5 years was 72.8 per cent. This study suggests that heart valve surgery in the elderly can be performed with an acceptable mortality. Advanced age alone should not be a contraindication to surgical management.