Left Ventricular Outflow Tract Obstruction of Double Valve Re-Replacement Using Bioprosthesis

We present a case of left ventricular outflow tract (LVOT) obstruction after double valve re-replacement with bioprostheses. A 72-year-old man, who had undergone double valve replacement (DVR) with bioprosthetic valves 9 years previously, underwent re-replacement of valves because of structural valve deterioration. However, owing to LVOT obstruction related to the bioprosthesis in the mitral position, acute pulmonary edema occurred immediately after surgery. LVOT obstruction was diagnosed by emergent cardiac catheterization. So prompt re-replacement surgery using a mechanical prosthesis was performed.     

老年风湿性二尖瓣病变行二尖瓣修复术与生物瓣膜置换术中期效果比较

目的比较60岁以上老年患者风湿性二尖瓣修复(MVP)与生物瓣膜置换(MVR)的中期效果。方法选取2014年1月至2016年1月北京安贞医院瓣膜外科诊疗中心行风湿性二尖瓣修复或生物瓣置换手术的60岁以上老年风湿性二尖瓣病变患者,包括同期行三尖瓣修复术及房颤射频消融术患者;排除合并主动脉瓣手术、冠状动脉旁路移植手术、二次手术患者,最终纳入患者82例。根据二尖瓣手术方式分为二尖瓣修复组(MVP组,25例)和生物瓣置换组(MVR组,57例)。采用Kaplan-Meier法进行生存分析并绘制曲线,通过Log Rank方法比较两组患者5年生存率的差异。结果围手术期全组患者平均年龄(66.37±4.41)岁。54.9%的患者心功能(NYHA分级)Ⅲ级。两组患者在体外循环时间(P=0.99),主动脉阻断时间(P=0.88),术后住院时间(P=0.76)差异均无统计学意义。MVR组3例患者住院期间死亡,病死率5.3%;MVP组无住院期死亡(P=0.24)。随访5年,最长随访63个月,平均随访47.03个月。MVR组6例死亡,其中4例死于心脑血管不良事件,2例死于非心脑血管不良事件。MVP组无死亡。两组均无再手术病例。结论风湿性二尖瓣病变的老年患者采用二尖瓣修复手术治疗能够获得较好的中期效果。     

Valve replacement in children

Between May 1979 and September 1998, 202 children underwent surgical treatment for valvular heart disease. Of these 23, who ranged in age from 25 days to 15 years, underwent valve replacement, including 1 reoperation. The valve replacement consisted of the aortic valve in 5 patients, the mitral valve in 3, the tricuspid valves in 9, including 5 systemic atrioventricular valves for atrioventricular discordance, the pulmonary valve in 6, 5 bioprostheses and 18 mechanical prostheses. There were 4 operative deaths, 1 hospital death and 3 late deaths. At the 10-years follow-up, the actual survival rate was 67.8%, the event free rate was 76.1% and the freedom from reoperation rate was 86.2%. Valve re-replacement was performed in only 1 patient due to a thrombosed tricuspid valve. These results suggest that there is a small risk of major complications and reoperation in children who undergo valve replacement, whether a bioprosthetic valve or a mechanical valve. The long-term results of younger patients should be followed more closely according to their growth.     

Mitral valve replacement in the first 5 years of life

Between 1976 and 1986, 19 children aged 1 month to 5 years underwent replacement of the mitral (systemic atrioventricular) valve. Indications for valve replacement included isolated congenital mitral stenosis (n = 2), valve dysfunction associated with a more complex procedure (n = 15), and failed valvuloplasty (n = 2). Seven different valve types were used; nine were mechanical valves and ten were bioprosthetic valves. There were 6 hospital deaths (32%; 70% confidence limits, 20% to 47%). Among the 13 survivors there were 3 late deaths at a mean of 14 months after operation. The late deaths were unrelated to valve malfunction. Thromboembolic events occurred in 2 patients, both with mechanical valves. One minor bleeding complication occurred among 10 patients on a regimen of Coumadin (crystalline warfarin sodium). Five patients, all with bioprostheses, required a second valve replacement. Indications for reoperation included prosthetic valve regurgitation (n = 1) and calcific stenosis (n = 4). No early or late deaths occurred after second valve replacement. Survival was 51% +/- 12% (standard error) at 112 months after valve replacement. Analysis failed to identify age, weight, sex, previous operation, underlying cardiac lesion, or prosthesis size and type as significant risk factors for mortality. Mechanical valves had a lower reoperation rate compared with bioprostheses. These data suggest that although mitral valve replacement within the first 5 years of life is associated with a high operative and late mortality, satisfactory long-term palliation for many patients can be achieved. Mechanical valves are superior to bioprosthetic valves, and offer the best long-term results.     

Aortic valve selection in the elderly patient

To determine the influence of valve selection on valve-related morbidity and mortality and patient survival, comparative long-term performance characteristics of mechanical (N = 68) and bioprosthetic (N = 73) heart valves were analyzed for 141 patients more than 70 years old who underwent isolated aortic valve replacement between 1970 and 1985. Cumulative patient follow-up was 491 patient-years (average, 4.3 years per patient). Hospital mortality was 18% and 19% for patients with mechanical valves and bioprosthetic valves, respectively. Survival at 5 years was 61 +/- 7% (+/- the standard error) and 67 +/- 10% for recipients of mechanical valves and bioprosthetic valves, respectively. Male sex (p = 0.014) and urgency of operation (p = 0.006) were independent risk factors for hospital mortality. Atrial fibrillation increased valve-related mortality (p = 0.01). No patient required reoperation or experienced structural valve failure. While anticoagulant-related hemorrhage was increased in recipients of mechanical valves (9.2 +/- 2.1%/patient-year) compared with recipients of bioprosthetic valves (2.3 +/- 1.1%/patient-year), it did not result in a death or lead to permanent disability. There was no difference in freedom from any valve-related complication at 5 years. However, when all morbid events are considered, recipients of bioprosthetic valves experienced fewer valve-related complications than patients receiving mechanical valves (10.7 +/- 2.3%/patient-year versus 17.6 +/- 2.5%/patient-year, respectively; p less than 0.05). The reduced incidence of anticoagulant-related hemorrhage and the infrequent need for warfarin sodium anticoagulation favor selection of a bioprosthetic heart valve in patients older than 70 years.     

Cardiac valve replacement in patients on dialysis: influence of prosthesis on survival

BACKGROUND: Mechanical valves have been recommended for patients on dialysis because of purported accelerated bioprosthesis degeneration. This study was undertaken to determine time-related outcomes in dialysis patients requiring cardiac valve replacement. METHODS: From 1986 to 1998, 42 patients on chronic preoperative dialysis underwent valve replacement; 17 received mechanical valves and 25 received bioprostheses. Age was similar in both groups: 54+/-18.5 years (mechanical) and 59+/-15.5 years (bioprosthetic, p = 0.4). Sites of valve replacement were aortic (27), mitral (11), and aortic and mitral (4). Follow-up was 100% complete. RESULTS: Survival at 3 and 5 years was 50% and 33% after mechanical valve replacement, and 36% and 27% after bioprosthetic valve replacement (p = 0.3). Four patients with bioprostheses required reoperation: 3 for allograft endocarditis and 1 at 10 months for mitral bioprosthesis degeneration. One patient who received a mechanical valve required reoperation. CONCLUSIONS: Prosthetic valve-related complications in patients on dialysis were similar for both mechanical and bioprosthetic valves. Because of the limited life expectancy of patients on dialysis, bioprosthesis degeneration will be uncommon. Therefore, surgeons should not hesitate to implant bioprosthetic valves in these patients.     

Prosthetic valve replacement in children

Between 1975 and 1998, 27 patients aged 3 months to 14 years underwent replacement of the aortic, mitral, tricuspid, and pulmonary valves. Five different types of prosthetic valves were used; three were mechanical valves and two were bioprosthetic valves. There were 3 hospital deaths. Among the 24 survivors there were 4 late deaths. Arrhythmia requiring pacemaker implantation occurred in 2 cases after AVR and TVR. Thromboembolic events occurred in 3 patients, all with mechanical valves in pulmonary position. Infective endocarditis occurred in 1 patient after PVR with a mechanical valve. No bleeding complication occurred among the patients on a regimen of Coumadin and Dipyridamole. Two patients, both with Hancock bioprosthesis, required a second valve replacement on account of severely calcified changes. Mechanical valves in left side heart had a satisfactory long-term performance. One patient who had undergone MVR for congenital parachute mitral valve received reoperation for growth. A larger sized prosthetic valve should be used at the first replacement, and special procedures including supra-annular positioning or annular augmentation are recommended for MVR or AVR respectively.     

Long-term results of bioprosthetic valves mounted on flexible stent]

From April, 1984 to April, 1989, 104 heart valve replacements were performed in 103 patients. The atrio-ventricular valves (97 mitral and 7 tricuspid valves) were replace by bioprosthetic valves mounted on the flexible stent made of Elgiloy. They included 91 porcine aortic valves and 13 bovine pericardial valves. Only 74 patients recovered and discharged from the hospital because of high operative mortality of re-replacement and double valve replacement (19 and 30 patients, respectively). These patients were followed-up for 8 to 68 months with a total follow-up period of 297 patient-years. Two patients developed cerebral embolism and two developed bacterial endocarditis. The incidence of the two complications was 0.67%/patient-year. No valve failure occurred. Long-term results of bioprosthetic heart valves mounted on flexible stent were better than those mounted on rigid stent.     

Aortic valve replacement in patients age 70 years and older: early and late results

This retrospective analysis was performed to determine the early and late outcome in patients 70 years and older undergoing aortic valve replacement (AVR). From October 1994 to May 2001, 49 patients (24 men and 25 women, age 70 to 88 years [mean 74 +/- 4.6 years]) underwent primary AVR with or without concomitant procedures. Twenty-one received mechanical valves and 28 bioprostheses. Age was different between both groups: 72 +/- 2.3 years (mechanical) and 76 +/- 5.1 years (bioprosthetic) (p = 0.0005). Aortic stenosis was present in 25 patients (51%). Follow-up was 100% complete at a mean follow-up of 2.9 years (range 0.3-6.5 years). Overall hospital mortality was 4.1% (2/49). There were no postoperative complications in 24% of patients. Postoperative hospital stay or hospital survival was 27 +/- 13 days. Survival at 3 and 5 years was 89 +/- 5% and 80 +/- 7%, respectively. Three late deaths were due to noncardiac causes and 1 each had a cardiac or valve-related cause (thromboembolism). Other valve-related complications such as anticoagulant-related hemorrhage, perivalvular leak, endocarditis, prosthetic valve failure, and reoperation were not noted in any of the 49 patients. The actuarial survival curve was similar in each group of bioprosthetic versus mechanical and septuagenarians versus octogenarians. Under the selection criteria for AVR currently applied in our hospital, geriatric patients showed a satisfactory early outcome and medium-term survival benefit.     

Simultaneous implantation of St. Jude Medical aortic and mitral prostheses

Since January 1980, 92 consecutive patients received St. Jude Medical aortic and mitral prostheses simultaneously. Mean age was 57.6 years (standard deviation 12.4); 14 were 70 years or older. Twenty-three had a previous cardiac operation and 22 had additional procedures performed at the time of double valve replacement. Before the operation 62% of the patients were in New York Heart Association functional class III and 29% were in class IV or required emergency operation. There were six (6.5%) deaths within 30 days. None of the hospital deaths were valve related; all occurred in patients who had additional risk concerns. Follow-up is 100% complete and ranges from 2 to 80 months, totaling 242 patient-years (mean 33.8 months). All except four hospital survivors reached class I or II and 40 patients (47%) remain asymptomatic. The actuarial survival rates are 82% at 1 year, 70% at 3 years, and 60% at 5 years. Causes of late death include heart failure (10), sudden, unexplained death (five), reoperation for coronary artery disease (one), noncardiac (four), and valve related (five). The linearized rate of fatal valve-related events is 2.1% pt-yr. A total of 22 valve-related complications (including five fatal) occurred is 18 patients, for a linearized rate or incidence of 9.1%/pt-yr. Eleven thromboembolic episodes (rate 4.6%/pt-yr) occurred in nine patients; three of these (1.2%/pt-yr) were fatal. Thromboembolic and bleeding complications represented 64% of all valve-related complications. Four patients had six episodes of prosthetic valve endocarditis (incidence 2.5%/pt-yr), of which one (incidence 0.4%/pt-yr) was fatal. Paravalvular leak contributed to the fifth valve-related death. At 5 years, 83% of patients were free of thromboembolic complications; 94% were free of anticoagulant-related hemorrhage; and 71% were free of all valve-related complications. There are few comparable data for patients who have had simultaneous replacement of aortic and mitral valves with other mechanical prostheses. The total incidence of valve-related complications for patients with bioprostheses ranges between 3.9%/pt-yr and 10.4%/pt-yr and is similar to the 9.1%/pt-yr observed in the present series. The type of valve-related complication (thromboemboli and bleeding versus valve deterioration) is the principal difference between St. Jude Medical and bioprosthetic valves in patients who require simultaneous replacement of aortic and mitral valves.     

Heart valve replacement in septuagenarians

Heart valve replacement was performed on 208 patients aged 70-80 years--aortic (AVR) in 172, mitral in 20 and both valves in 16 cases. All valves were of Bj?rk-Shiley type, and all but six patients received maintenance oral anticoagulant therapy. The 100% follow-up comprised 744 patient-years (mean 4.0 years). The early mortality was 9.6% and was related to the complexity and urgency of surgery: After elective AVR for pure aortic stenosis the rate was 3.9%. Actuarial survival (early mortality excluded) was 79% at 5 years and 73% at 8 years overall, and 87% and 80% after AVR for stenosis. In the AVR group the relative (age- and -sex-adjusted) survival rate indicated a normalized survival pattern after the first year, with 87%, 'cure' rate (early mortality included), and the incidence of thromboembolism and of fatal bleeding complications equalled figures for younger patients. Mechanical heart valve implantation and maintenance anticoagulation thus seems to be safe treatment even in elderly patients, and eliminates need for valve re-replacement due to bioprosthetic degeneration.     

Pediatric valve replacement, 15 years experience in Oman

Background Despite improving surgical techniques, treatment of heart valve disease in children remains controversial. Somatic growth and adequate anticoagulation are of concern when children undergo valve replacement. We conducted this study to evaluate the performance of valves in this age group. Methods 42 children under the age of 13 years who underwent valve replacement were included in this study. Totally, 50 valves were implanted in 42 patients: 48 were mechanical prostheses, two were bioprosthetic both in pulmonary position. 37 (74%) valves were implanted in mitral position, 10 (20%) in aortic position, 1 (2%) in tricuspid position and 2 (4%) in pulmonary position. Preoperatively, 14 (33,3%) patients were in New York Heart Association (NYHA) class IV, while 27 (64.2%) were in NYHA class III. Results There were 2 (4.7%) hospital deaths and 2 (4.7%) late deaths while 2 (4.7%) patients were lost to follow up. The mean follow up period was 9.4 yrs. 35 (83.3%) patients are in NYHA Class I and free of all medications except warfarin. 3 (7.1%) patients have undergone 5 successful pregnancies. The median INR was 2.23. Major thrombo-embolic episode occurred in 1 (2.3%) patient. Conclusions In view of the problems of sizing, anticoagulation and need for re-operation at an early age, there is a reluctance to replace valves in children. This study shows that despite these problems, valve replacement can be undertaken safely and successfully in children, when repair has failed or not technically feasible.     

Mitral Valve Replacement with Dura Mater Bioprostheses

Dura mater bioprostheses for cardiac valve replacement were first introduced in Brazil. They have been used since 1975 at the National Heart Hospital, London, as a mitral valve replacement instead of fascia lata valves or inverted aortic homograft valves. During this period 120 patients have had dura mater valves inserted in the mitral position; 29 also received an aortic valve replacement, 6 with dura mater, 20 with an aortic homograft, 2 with an aortic xeno-graft and 1 with a prosthetic valve. Perivalvular leaks occurred with seven of these mitral valves, and another seven presented with detached cusps. All but one of these 14 valves were replaced. Emboli have occurred in four of the patients, one of whom died after 35 months with thrombus on the aortic valve, but with an unaffected mitral valve. There were 15 early deaths, a hospital mortality of 12.5%. and 10 late deaths, a postoperative mortality of 9.5%. Actuarial analysis has shown a four-year postoperative survival of 78.970.     

Comparison of outcomes after mitral valve replacement with a mechanical versus a bioprosthetic valve in patients between forty and sixty years of age

Background  The American College of Cardiology/American Heart Association (ACC/AHA), guidelines for choice of prosthetic valve based on patients’ age are difficult to apply to the developing world because of a lower life expectancy and difficulty in maintaining correct levels of anticoagulation for a variety of reasons. While there is general agreement on the choice of prosthetic valves for patients below 40 years of age (mechanical) and above 60 years of age (biologic), the 40 to 60 age group remains a grey zone. The goal of our study was to compare outcomes after mitral valve replacement with a mechanical versus a bioprosthetic valve in patients between forty and sixty years of age. Methods  From Jan 2003 to July 2008, 250 patients between the ages of 40 and 60, undergoing mitral valve replacement at our institution were randomized to receive either a mechanical or a bioprosthetic valve. Outcomes in the form of incidence of valve thrombosis and thromboembolism, bleeding complications, incidence of prosthetic valve endocarditis and survival were compared in the two groups. Results  Out of 250 patients, 135 patients received mechanical valve and 115 patients were implanted with a bioprosthetic valve. Patients were followed up for a mean period of 3 years (range 6 months to 4.8 years). The incidence of valve thrombosis was higher in mechanical valve as compared to bioprosthetic valve (6% vs. 0.9%, p= 0.04). Similarly there was a higher incidence of thromboembolism in mechanical valves as compared to bioprosthetic valves (4.5% vs. 0%, p=0.03). Bleeding complications occurred more frequently in mechanical than bioprosthetic valve (6% vs. 0.9%, p=0.04). There was no significant difference in the incidence of prosthetic valve endocarditis (2.2% vs. 2.7%, p >0.05) or survival at three years (96.2% vs. 97.2%, p > 0.05) in the two groups. Conclusions  Patients in the age group of 40 to 60 years undergoing mitral valve replacement with a mechanical valve have a higher incidence of thrombotic and bleeding complications as compared to bioprosthetic valve, even though short term survival is similar. This favours implantation of a bioprosthetic valve in this age group.     

Durability of Bioprosthetic Valves in Patients on Dialysis

Purpose: This study focused on clarifying the durability of bioprosthetic valves in current practice.Methods: A total of 238 consecutive patients who underwent aortic valve replacement at a single institution from 2011 to 2020 were reviewed. We evaluated valve-related outcomes such as structural valve deterioration (SVD), especially in dialysis patients who received bioprosthetic valve.Results: Among the tissue valves implanted in 212 patients, 5 SVDs were recorded and 3 valves were replaced. All early valve failures occurred in relatively young dialysis patients and were recorded 3 to 5 years after the initial operation. Freedom from SVD at 6 years was 49.9% in patients on dialysis, compared with 100% in non-dialysis patients. Predictors of better survival in dialysis patients were better preoperative functional class and larger prosthetic valve size.Conclusions: The durability of bioprosthetic valves in the aortic position was suboptimal in dialysis patients. Mechanical valves can be an option for young, healthy dialysis patients with a large aortic valve annulus.     

心脏瓣膜术后心室辅助治疗

目的 总结瓣膜病变术后重症心衰病人置入心室辅助(VADs)装置时,心脏瓣膜或人工瓣膜处理方法及围术期抗凝管理的经验.方法 回顾1994年1月到2008年6月,宾夕法尼亚大学附属医院心脏中心157例置入VADs病人中,10例为瓣膜术后重症心衰者.对于二尖瓣和三尖瓣病变,无论成形或置换,置入VADs时均未处理原瓣膜或人工瓣膜(环).5例主动脉瓣病变病例置入VADs时,2例用生物瓣膜取代了原机械瓣膜,1例未处理原来生物瓣膜,1例未处理原机械瓣膜,1例取出机械瓣膜,用牛心包封闭主动脉根部.结果 所有病人置入VADs术后应用抗凝治疗.10例病人中,停VAD出院和VAD姑息治疗各1例;转心脏移植4例;4例死亡,3例为多器官衰竭,1例为血栓栓塞事件.结论 瓣膜病变术后置入VADs总的生存率是60%,与非瓣膜病心衰病人置入VADs相比,未增加手术风险.

Abstract：

Objective An increasing number of patients requiring ventricular assist devices (VAD) have had previous valvular corrections,including valve repair,and valve replacement with mechanical or bioprosthetic valves.The operative and peri-operative management of these patients has been varied.Methods A retrospective study of VADs between Jan 1994 and June 2008 revealed 10 patients with previous prosthetic valves requiring management during and after VAD placement.Three patients were supported post-cardiotomy after valve surgery.Two patients were supported due to cardiogenic shock postopera-tively.Four patients were supported as a bridge to transplantation.One patient was supported as a destination therapy.Results The mitral valve was left untreated during VAD implantation regardless of valve repair or replacement.For aortic valves,the mechanical aortic valve was replaced with tissue valve in two patients and left untreated in one case.One patient had tricuspid valve repair previously and was left untouched.All patients with prosthetic valves in aortic,mitral and tricuspid position during VAD support received anticoagulation therapy.There were 4 deaths,and 4 went on to transplantation.One patient weaned from VAD and discharge from hospital.One patient received HeartMate Ⅰ as destination therapy.The most common causes of death were multisystem organ failure and sepsis.One patient had a thromboembolic event.Conclusion The survival rate of 60% is encouraging when compared to overall survival rates.The most common cause of death was multisystem organ failure.Patients with prosthetic valves may be safely managed during VAD support.     

Valve replacement in the right side of the heart in children: long-term follow-up

Twenty-five patients (16 male, 9 female) underwent right-sided valve replacement (10 pulmonary valve replacement, 14 tricuspid valve replacement, 3 tricuspid plus pulmonary valve replacement, and 2 replacements of a single atrioventricular valve) at the University of Nebraska Medical Center from June 1977 to December 1986. Twenty-one patients (84%) are long-term survivors with 2,035 months follow-up (range, 41 to 143 months; mean, 96.9 months). Twenty-three Carpentier-Edwards bioprosthetic valves, one Ionescu-Shiley bioprosthetic valve, and nine St. Jude Medical valves were inserted. Follow-up of 17 patients with a Carpentier-Edwards valve ranged from 5 years 9 months to 11 years 9 months (mean, 8 years 11 months). To date there has been one reoperation after 3 years 4 months in this group. One patient who received an Ionescu-Shiley bioprosthesis required re-replacement at 20 months after operation. Three of 4 patients who received St. Jude mechanical valves and are long-term survivors have required replacement after 36 to 56 months. We conclude that the Carpentier-Edwards bioprosthetic valve is a viable option in the right side of the heart in the young age group when annular size is adequate to accommodate an appropriate bioprosthesis.     

Cardiac valvular surgery in dialysis patients: comparison of surgical outcome for mechanical versus bioprosthetic valves

Purpose  There has been a changing preference for bioprosthetic valves over mechanical valves in dialysis patients, but there is still much controversy. We reviewed our 17-year experience and assessed the influence of prosthesis choice. Methods  From 1990 to 2007, a total of 63 consecutive dialysis patients who underwent valvular surgery (64 operations including one reoperation) at our hospital were retrospectively reviewed. The mean age of the patients was 58.3 ± 9.0 years. The reasons for dialysis were glomerulonephritis (n = 32) and diabetes (n = 10). The major preoperative diagnosis was aortic stenosis (n = 44). The surgical procedures included aortic valve replacement (n = 44), mitral valve replacement (n = 7), double valvular replacement (n = 7), and mitral valve repair (n = 5). Prostheses for valve replacement were mechanical valves (n = 37) or bioprosthetic valves (n = 22). Follow-up was accomplished in 95.2%, and the mean follow-up period was 49 months. Results  Actuarial survivals at 1, 5, and 10 years were 85%, 64%, and 45% respectively. Freedom from cardiovascular events at 1 and 5 years was 61% and 41%, respectively. Mechanical valve patients had significantly higher early mortality than bioprosthetic valve patients (P = 0.03). However, both mechanical and bioprosthetic valve patients had similar survival and event-free rates (P = 0.87 and P = 0.27, respectively) in the midterm results. The mechanical group had a higher rate of bleeding events. There was no structural valve deterioration up to the 5-year follow-up. Conclusion  The choice of prosthesis did not influence the surgical outcome except for early mortality. Careful consideration of preventive measures against bleeding is important, and prosthesis selection should be based on the patient’s profile as well as the criteria for nondialysis patients.     

Risk of Reoperative Valve Replacement for Failed Mitral and Aortic Bioprostheses

Background. One factor influencing the choice of mechanical versus bioprosthetic valves is reoperation for bioprosthetic valve failure. To define its operative risk, we reviewed our results with valve reoperation for bioprosthetic valve failure.

Methods. Records of 400 consecutive patients having reoperative mitral, aortic, or mitral and aortic bioprosthetic valve replacement from January 1985 to March 1997 were reviewed.

Results. Reoperations were for failed bioprosthetic mitral valves in 219 patients, failed aortic valves in 153 patients, and failed aortic and mitral valves in 28 patients. Including 26 operations (6%) for acute endocarditis, 153 operations (38%) were nonelective. One hundred nine patients (27%) had other valves repaired or replaced, and 72 (18%) had coronary bypass grafting. The incidence of death in the mitral, aortic, and double-valve groups was respectively, 15 (6.8%), 12 (7.8%), and 4 (14.3%); and the incidence of prolonged postoperative hospital stay (>14 days) was, respectively, 57 (26.0%), 41 (26.8%), and 8 (28.6%). Only 7 of 147 patients (4.8%) having elective, isolated, first-time valve reoperation died. Multivariable predictors (p < 0.05) of hospital death were age greater than 65 years, male sex, renal insufficiency, and nonelective operation; and predictors of prolonged stay were acute endocarditis, renal insufficiency, any concurrent cardiac operation, and elevated pulmonary artery systolic pressure.

Conclusions. Reoperative bioprosthetic valve replacement can be performed with acceptable mortality and hospital stay. The best results are achieved with elective valve replacement, without concurrent cardiac procedures.     

Surgical management of valve replacement in children

From 1965 to 1990, 49 valve replacements were performed on 43 patients under the age of 15. Mitral valve replacements were performed on 21 patients, and re-replacements were done on 4 of them afterwards. In the first 9 mitral valve replacements before 1974, Starr-Edwards (S-E) ball valves were used. Five of these patients died in the hospital (early mortality rate was 56%). Since 1975, bioprosthetic valves were used in three cases, but all of these valves ceased to function due to primary tissue failure (PTF) within 3 years. Consequently, SJM valves are now used as a first choice. Ten aortic valve replacements were performed on 9 patients with the results of one early death, two late deaths, and one late re-operation. Tricuspid valve replacements were performed on 11 patients, 5 of whom utilized S-E ball valves. Three of the five patients died in the hospital. One patient was re-operated on, swapping the S-E ball valve for the SJM valve. SJM valves were used primarily in 2 patients, and bioprosthetic valves in 4. Two patients died, one with a SJM valve, and the other with a bioprosthetic valve. Two pulmonary valve replacements were performed, one employing a SJM valve, the other a bioprosthetic valve. Two adult patients with SJM valve in the right side of the heart had thrombotic complications, though the patients with bioprosthetic valves had none. Atrioventricular valve replacements were performed on 5 patients under the age of 3, but all of them died.(ABSTRACT TRUNCATED AT 250 WORDS)