Pulmonary valve neocuspidisation with glutaraldehyde-treated autologous pericardium—A novel technique in pulmonary valve endocarditis

Infective endocarditis (IE) is a serious condition leading to heart failure, persistent sepsis. The management of IE involving valve is mainly excision of the infected valve and replacement with a heart valve; which are also at the risk of prosthetic valve endocarditis. Hence repair of the valve with autologous pericardium is much more physiological. We had a 20-year-old male presented with features of heart failure and high-grade fever not responding to optimum medical management. Two-dimensional echocardiogram revealed vegetation on pulmonary valve cusps with the erosion of the left and right cusps. Neo cusps with autologous pericardium offered good hemodynamics with trivial regurgitation. The patient is doing well with normal pulmonary valve function 3 months after surgery. This technique is reliable, economic, and easily reproducible.     

Pulmonary valve replacement for pulmonary thrombus formation after previous aortic valve replacement, Guillain-Barré syndrome and enterococcal sepsis

Acquired disease of the pulmonary valve requiring surgery is rare. We report the case of a 70-year-old male presenting with pulmonary valve insufficiency and pulmonary emboli originating from a thrombus formation adhering to the pulmonary valve occurring despite dicoumarol anticoagulation for previous aortic valve surgery. Two years ago he experienced Guillain-Barré syndrome and one year ago enterococcal sepsis which were treated medically. Apart from a previous prolonged ICU stay no predisposing factors for right sided endocarditis could be found. The pulmonary lesion was surgically corrected with removal of the thrombus and excision of the pulmonary valve. Reconstruction of the valve and pulmonary artery was performed with a semistentless xenograft valved conduit.     

Does intraoperative transesophageal echocardiography predict pulmonary valve dysfunction during the Ross procedure?

OBJECTIVE: To determine the value of intraoperative transesophageal echocardiography for the assessment of the pulmonary valve anatomy and the pulmonary autograft performance in patients undergoing the Ross procedure. DESIGN: Open, prospective, observational survey. SETTING: Favaloro Foundation, single institution. PARTICIPANTS: Consecutive patients undergoing elective Ross procedure (n = 87). INTERVENTIONS: Pulmonary valve function and anatomy were assessed by transesophageal echocardiography and the surgeon. Pulmonary autograft function was assessed after implantation. Regurgitation was considered mild (+/4), moderate (++/4), moderate-to-severe (+++/4), and severe (++++/4). Patients were restudied during midterm follow-up. MEASUREMENTS AND MAIN RESULTS: The Ross procedure was done in 74 patients (85%). Overall mortality was 3.4%. Mean follow-up was 24 +/- 13 months. The Ross procedure was not done in 13 patients (15%): 6 patients had a bicuspid pulmonary valve, 6 patients had >3 mm fenestrations, and 1 patient had regurgitation. The surgeon diagnosed anomalies in the pulmonary valve through direct observation. Transesophageal echocardiography was not sensitive enough to diagnose pulmonary valve defects in 12 of 13 patients with anomalies. Pulmonary valve regurgitation was identified by intraoperative transesophageal echocardiography in only 1 patient. Autograft regurgitation was 1.07 +/- 0.35 at postoperative evaluation. At 1, 6, and 12 months, it was 1.25 +/- 0.7 (p = 0.18), 1.27 +/- 0.9 (p = 0.185), and 1.29 +/- 0.8 (p = 0.17). The difference in values was not statistically significant. Four patients (5.4%) showed an increase in regurgitation during the first transthoracic autograft control. CONCLUSION: Intraoperative transesophageal echocardiography allows assessment of autograft performance after implantation. This method is not helpful, however, in detecting pulmonary valve anatomic anomalies.     

Are pulmonary homografts which were subjected to pulmonary hypertension more appropriate for aortic valve replacement than normal pulmonary homografts? A long-term multicentric echography study.

OBJECTIVE: To compare long-term results of the European Homograft Bank (LHB) cryopreserved pulmonary homograft in left ventricular outflow tract (LVOT) subjected to pulmonary hypertension with those subjected to normal pulmonary pressure. The mid-term study of this material published in 1997 showed different results. METHODS: Statistical analysis is calculated by the Kaplan-Meier survival curves, while differences in prevalence by the Log-Rank test. RESULTS: Follow-up (FU) was available in 69 cases (76.7%): 46 in group 1 and 23 in group 2. Five patients have been excluded from the study because of early homograft explantation (technical problems or early valve incompetence). Fourteen out of 43 cases of group 1 (32. 6%) and seven out of 21 cases of group 2 (33.3%) have been explanted after 2.5-88 months and 7-88 months, respectively. Significant echography changes have been found in 19 of 43 (44.18%) of group 1 and 11 of 21 cases (52.38%) of group 2 during the follow-up. Histology showed essentially wear and tear induced lesions. Mean FU was 36.9 (range, 6-88) and 41.3 months (range, 4-88) for group 1 and 2, respectively. No significant difference in the long-term outcome have been found between the two groups (P=0.38). CONCLUSION: Contrary to our previous echocardiography study of mid-term implants the long-term follow up of the PHGs implanted in the LVOT did not show better function of the pulmonary homografts subjected to pulmonary hypertension than those with normal pulmonary pressure. The high failure rate of the PHGs should discourage their use for LVOT reconstruction. Further echocardiography studies of remaining PHGs implanted in the LVOT, and gross and microscopic explant studies are required to judge on the definitive outcome of these grafts.     

Aortic root replacement with the pulmonary autograft: an invariably competent aortic valve?

BACKGROUND: Pulmonary autograft aortic root replacement was used in adults. Risk factors for aortic regurgitation (AR), and for pulmonary allograft valve stenosis are identified. METHODS: From February 1991 through April 1998, 80 adults (mean age 34.4 years) underwent pulmonary autograft aortic root replacement. Primary diagnosis was AR in 43 (53.7%) patients, aortic stenosis in 13 (16.3%) and mixed disease in 24 (30%) patients. A root reinforcement ring was used in 32 (40%) patients. RESULTS: There was no hospital mortality. Estimated patient survival is 100% at 7 years. A total of 3 patients underwent reoperation: 2 on the autograft for severe AR, 1 for pulmonary allograft stenosis. Freedom from reoperation on the autograft is 96.7 +/- 2.4% at 7 years. Multivariate analysis indicated bicuspid aortic valve disease as an incremental risk factor for AR at discharge (p = 0.036, odds 3.5). Univariate analysis identified operation for pure AR as risk factor for AR during follow-up (p = 0.041). Mild AR or more increased from 2.5% at discharge to 11.3% during follow-up (p = 0.008). Progression of AR was limited by the use of a reinforcement root ring (p = 0.031). Freedom from mild AR or more in patients with and without a reinforcement root ring was 100% and 72.9 +/- 9.3% respectively, at 5 years (p = 0.119). Pulmonary allograft stenosis occurred in 15 (22.5%) patients. Multivariate analysis revealed that large sized pulmonary allografts were less prone to stenosis (p = 0.048, odds 0.13). CONCLUSIONS: Pulmonary autograft root replacement can be performed with few complications. During follow-up, a significant increase in mild AR or more is observed. The use of a reinforcement root ring is effective in preventing progression of AR.     

Two cases of tetralogy of Fallot with absent pulmonary valve repaired by modified Kreutzer’s technique

Two severely symptomatic infants of tetralogy of Fallot with absent pulmonary valve successfully repaired by a modified Kreutzer’s technique are described. In addition to the standard repair of tetralogy of Fallot, our surgical technique consists of extensive pulmonary reduction arterioplasty, which allows tracheobronchial decompression. Both patients tolerated surgery and showed significant relief of airway compression and clinical symptoms, although they required prolonged mechanical ventilatory support. The modified Kreutzer’s technique is relatively simple and could be sufficiently efficacious even for symptomatic infants of tetralogy of Fallot with absent pulmonary valve.     

RV to PA conduits: impact of transcatheter pulmonary valve replacement in adults – a national register study

Objective: The use of a conduit is an established surgical method for reconstruction of the right ventricular outflow tract in congenital heart disease; however, its limited durability makes reintervention almost inevitable. We studied the trends in new implantation, reoperation, and transcatheter pulmonary valve replacement (TPVR) from a Swedish national perspective.

Design and results: The Swedish registry of congenital heart disease (SWEDCON) was used to collect data. From 2000–2014, there was an increase in adult patients with conduits from 122 to 536. There were 60 surgical conduit replacements, 40 TPVRs and 176 new conduit implantations in the study period. Perioperative mortality was <1%. The yearly number of new implantations and reoperations both doubled over the study period. Patients with new implantations were older (mean age, 36 years) compared with the reoperation and TPVR groups (mean age, 26 years) with the majority of patients having tetralogy of Fallot. The majority of conduit reinterventions were surgical also after the introduction of TPVR in 2007, with no significant difference regarding diagnosis, gender, age, or previous number or longevity of conduits.

Conclusion: The number of adults with conduits increased steadily with most conduit-related operations being new implantations in patients with tetralogy of Fallot. Surgical conduit replacements increased significantly and represented the majority of conduit reinterventions after the introduction of TPVR, indicating that TPVR is not used for the majority of patients with conduit failure. Diagnosis, gender, age, or previous number or longevity of conduits had no impact on choosing surgical replacement vs. TPVR.     

In patients with concomitant aortic and mitral valve disease is aortic valve replacement with mitral valve repair superior to double valve replacement?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: in patients with concomitant aortic and mitral valve disease is aortic valve replacement with mitral valve plasty (MVP) superior to double valve replacement (DVR) in terms of improved long-term survival? Altogether 156 papers were found using the reported search, of which seven represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Out of seven papers, that simultaneously compare these two treatment modalities, three favor MVP combined with aortic valve replacement (AVR) over DVR, two papers advocate the opposite and two failed to find any significant difference in long-term survival, freedom from reoperation and thromboembolic and bleeding complications between these two surgical options. All data presented derive from level 2b evidence. Critical appraisal of these studies is constricted by the large heterogeneity of the patients, diversity in treatment protocols and inherent selection bias. We conclude that currently the available evidence is insufficient to prove that AVR with MVP is superior to DVR in patients with double valve disease.     

Is prophylactic aortic valve replacement indicated during mitral valve surgery for mild to moderate aortic valve disease?

BACKGROUND: Determining the need for surgical treatment of coexisting mild to moderate aortic valve disease in patients referred for mitral valve surgery is often difficult. The purpose of this study was to assess long-term clinical outcome and the need for subsequent aortic valve replacement in patients with mild to moderate rheumatic aortic valve disease at the time of mitral valve surgery. METHODS: A total of 275 patients (90 men and 185 women, mean age 43 years) with rheumatic disease who underwent mitral valve surgery were followed up for an average of 9 years. Patients were classified into two groups: those with coexisting mild to moderate aortic valve disease at the time of mitral valve surgery (141 patients, group A) and those without (134 patients, group B). Primary outcomes (death and subsequent aortic valve surgery) were compared between the two groups. RESULTS: At the time of mitral valve surgery, 104 patients (74%) in group A had mild aortic regurgitation, 37 (26%) had moderate aortic regurgitation, 5 had (4%) mild aortic stenosis, and 2 (1%) had moderate aortic stenosis. At the end of follow-up, no patient had severe aortic valve disease. In all, 12 patients (5%) in group A had primary events (eight deaths and four subsequent aortic valve replacements), and 12 patients (9%) in group B had such events (12 deaths). According to Kaplan-Meier analysis, neither the survival rate nor the event-free survival rate differed significantly over the follow-up period between the two groups. CONCLUSIONS: In most patients who have mild to moderate rheumatic aortic valve disease at the time of mitral valve surgery, the long-term outcome is comparable to that of subjects without aortic valve disease at the time of mitral valve surgery. Subsequent aortic valve replacement is rarely needed after a long follow-up period.     

Is repair of aortic valve regurgitation a safe alternative to valve replacement?

OBJECTIVE: To assess outcome of valve repair in patients with aortic valve regurgitation with emphasis on incidence and risk of reoperation. METHODS: We retrospectively reviewed 160 consecutive patients (127 men) who underwent aortic valve repair between 1986 and 2001. Ages ranged from 14 to 84 years (mean 55 +/- 17 years). Patients were categorized according to the main etiology of valve disease; 63 patients (39%) had annular dilation leading to central leakage, 54 (34%) had bicuspid valve, 34 (21%) with tricuspid valve had cusp prolapse, and 9 (6%) had cusp perforation. Repair methods included commissural plication (n = 154, 96%), partial cusp resection with plication (n = 47, 29%), resuspension or cusp shortening (n = 44, 28%), and closure of cusp perforation (n = 10, 6%). RESULTS: There was 1 early death (0.6%). Two patients required re-repair of the aortic valve during initial hospitalization. During a mean follow-up of 4.2 years, there were 16 late deaths. Overall, 16 of 159 hospital survivors had late reoperation on the aortic valve (mean interval 2.8 years) without early mortality. Risks of reoperation on the aortic valve were 9%, 11%, and 15% at 3, 5, and 7 years, respectively. CONCLUSIONS: Aortic valve repair can be performed with low risk and excellent freedom from valve-related morbidity and mortality. Late recurrence of aortic valve regurgitation led to reoperation in 8.8% of patients, but mortality associated with subsequent procedures is low. Aortic valve repair appears to be a good option for selected patients, particularly young patients who wish to avoid chronic anticoagulation with warfarin.     

Should the tricuspid valve be replaced with a mechanical or biological valve?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether patients requiring tricuspid replacement should have a mechanical or a biological valve. Using the reported search, 561 papers were identified. Thirteen papers represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, weaknesses, results and study comments were tabulated. We conclude that there are no major differences between the insertion of a mechanical or biological tricuspid valve. Aggregating the available data it is found that the reoperation rate is similar with bioprosthetic degeneration rate being equivalent to the mechanical thrombosis rate. Conversely up to 95% of patients with a bioprosthesis still receive anticoagulation. Survival in over 1000 prostheses pooled by meta-analysis was equivalent between biological and mechanical valves.     

Is the valve OK or not? Immediate evaluation of a replaced aortic valve

Transesophageal echocardiography is a crucial tool in intraoperative evaluation of newly implanted/repaired heart valves because suspected valvular malfunction needs to be identified and sometimes surgically corrected. Although color Doppler is often adequate in evaluating the expected regurgitant jets, as well as excluding pathologic paravalvular leaks, spectral Doppler techniques are the most commonly used methods for estimating transvalvular gradients in the operating room. However, these methods are subject to a variety of confounding factors, including subvalvular gradients and pressure recovery. Other methods of valve area estimation should also be used when evaluating a prostethic aortic valve, including the continuity equation and the left ventricular outflow tract/aortic valve velocity ratio.