Mitral Valve Repair in Redo Cardiac Surgery

ABSTRACT An increasing number of patients are being referred for mitral valve repair in the redo cardiac surgery setting. The most common clinical scenarios involve prior coronary bypass surgery or aortic valve replacement, each presenting special challenges in terms of gaining valve exposure to enable repair while limiting dissection as much as possible. A right anterior thoracotomy approach is preferred in most patients, coupled with hypothermic fibrillatory arrest. A repeat sternotomy may be favored in select circumstances such as when there is a need for bypass grafting or moderate aortic insufficiency is present. Special attention to cannulation techniques, perfusion conditions, valve exposure, and de-airing maneuvers are all important to ensure good clinical results. Using a tailored approach we have performed mitral valve repair in 22 patients with a patent left internal mammary artery graft following coronary artery bypass grafting between July 1992 and February 2000 with acceptable morbidity and low mortality.     

Combining off pump coronary artery bypass with mitral valve replacement

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

Computer-enhanced "robotic" cardiac surgery: experience in 148 patients

OBJECTIVE: A computer-enhanced instrumentation system was used in 148 patients to minimize access in cardiac surgical procedures. METHODS: The da Vinci telemanipulation system (Intuitive Surgical, Mountain View, Calif) provides a high-resolution 3-dimensional videoscopic image and allows remote, tremor-free, and scaled control of endoscopic surgical instruments with 6 degrees of freedom. By April 2000, the system had been used in 131 patients for coronary artery bypass grafting and 17 patients for mitral valve repair. In the coronary bypass group, the system was used in one of three ways: (1) to take down the internal thoracic artery followed by a minimally invasive direct coronary bypass procedure (n = 81); (2) to perform the anastomosis between the internal thoracic artery and the left anterior descending coronary artery in standard-sternotomy coronary bypass (n = 15); or (3) for total endoscopic coronary artery bypass grafting to anastomose the left internal thoracic artery to the left anterior descending on the arrested heart (n = 27) or the beating heart (n = 8). In 17 patients with nonischemic mitral valve insufficiency the mitral valve was repaired. Closed-chest cardiopulmonary bypass with cardioplegic arrest (Port-Access technique; Heartport, Inc, Redwood City, Calif) was used for arrested-heart total endoscopic coronary bypass and mitral valve repair. RESULTS: The da Vinci system allows for precise tissue handling and enables the endoscopic performance of cardiac surgical tasks that require a high degree of dexterity (coronary anastomosis, mitral valve repair). No technical mishaps have occurred. The internal thoracic artery was successfully taken down in 79 of 81 patients in the group undergoing minimally invasive coronary bypass and, after a steep learning curve, is currently performed in less than 40 minutes. The postoperative patency rate is 96.3%. Total endoscopic coronary bypass was completed in 22 of 27 cases with 95.4% patency as demonstrated by angiography at 3 months' follow-up. Closed-chest endoscopic beating-heart bypass grafting was successfully performed in 2 out of 8 patients with the use of a new endoscopic stabilizer. In the group having mitral valve repair, primary endoscopic computer-enhanced repair was successfully completed in 14 of 17 patients; three others had to be changed to a standard endoscopic technique, including 1 who required valve replacement. At 3 months' follow-up, 1 additional patient underwent early reoperation for recurrent mitral insufficiency. Overall early and late mortality in this cohort of 148 patients was 2.0% and was not related to the use of the system. CONCLUSION: In conclusion, computer-enhanced endoscopic cardiac surgery can be performed safely in selected patients. Internal thoracic artery takedown is now routinely performed with good results. Total endoscopic coronary bypass is feasible on the arrested heart but does not offer a major benefit over the minimally invasive direct approach because cardiopulmonary bypass is still required. The early clinical experience with closed-chest beating-heart bypass grafting outlines the limitations of this approach despite some procedural success.     

Concurrent single stage repair of coarctation of aorta and associated cardiac pathology in adult patients

Background Thoracic aortic coarctation and associated intracradiac pathology including a concomitant valvular lesion or coronary artery disease is an uncommon combination in adult patients. The simultaneous operative management of both lesion is preferred to avoid a second redo surgery and the risks associated with it. Methods We describe a simultaneous operative management of six adult patients with coarctation of aorta and associated cardiac lesion. All six patients had heterotopic bypass (Dacron tube implanted between the ascending and descending aorta) to repair the coarctation and concomitant repair of the cardiac lesion. The associated procedures were aortic valve replacement in 3 patients, coronary artery bypass grafting in 2 patients and mitral valve replacement in 1 patient. Results There were no operative deaths and all patients are doing well on follow up with patent coarctation of aorta bypass graft at a mean follow up of 18 months. No graft related complications occurred, and there were no instance of stroke or paraplegia. All patients had an uneventful post operative course and are on routine out patient follow up. Conclusion A median sternotomy for repairing adult coarctation of aorta with concomitant cardiac lesion can be performed safely and readily managed as an excellent single stage approach.     

Minimally Invasive Approach for Redo Mitral Valve Surgery: A True Benefit for the Patient

ABSTRACT Objectives Redo mitral valve surgery via sternotomy is associated with a substantial morbidity and mortality. This study evaluated a minimally invasive technique for mitral valve redo procedures. Material and Methods: Out of a series of 394 patients undergoing mitral valve repair or replacement via a right minithoracotomy, 39 patients underwent redo mitral valve surgery (59 ± 13 years, 23 female). Previous cardiac surgeries included 17 patients with mitral valve repair, 6 patients with mitral valve replacement, 3 patients with aortic valve replacement, 2 patients with atrial septal defect closure, and 11 patients with coronary artery bypass grafting (CABG). In all cases, femoro-femoral cannulation was performed. The port access technique was applied in patients undergoing redo valve surgery. In patients with prior CABG, the operation was performed using deep hypothermia and ventricular fibrillation. Results: In all cases, sternotomy was avoided. The mitral valve was replaced in 20 patients and repaired in 19. Time of surgery and cross-clamp time were comparable with the overall series (168 ± 73 [redo] vs 168 ± 58 min and 52 ± 21 [redo] vs 58 ± 25 min). Mortality was 5.1%. One patient had transient hemiplegia due to the migration of the endoclamp. All other patients had uneventful outcomes and normal mitral valve function at 3-month's follow-up. Conclusion: Redo mitral valve surgery can be performed safely using a minimally invasive approach in patients with a previous sternotomy. The right lateral minithoracotomy offers excellent exposure. It minimizes the need for cardiac dissection, and thus, the risk for injury. Avoiding a resternotomy increases patient comfort of redo mitral valve surgery.     

Minimally invasive approach for redo mitral valve surgery: a true benefit for the patient

OBJECTIVES: Redo mitral valve surgery via sternotomy is associated with a substantial morbidity and mortality. This study evaluated a minimally invasive technique for mitral valve redo procedures. MATERIAL AND METHODS: Out of a series of 394 patients undergoing mitral valve repair or replacement via a right minithoracotomy, 39 patients underwent redo mitral valve surgery (59+/-13 years, 23 female). Previous cardiac surgeries included 17 patients with mitral valve repair, 6 patients with mitral valve replacement, 3 patients with aortic valve replacement, 2 patients with atrial septal defect closure, and 11 patients with coronary artery bypass grafting (CABG). In all cases, femoro-femoral cannulation was performed. The port access technique was applied in patients undergoing redo valve surgery. In patients with prior CABG, the operation was performed using deep hypothermia and ventricular fibrillation. RESULTS: In all cases, sternotomy was avoided. The mitral valve was replaced in 20 patients and repaired in 19. Time of surgery and cross-clamp time were comparable with the overall series (168+/-73 [redo] vs 168+/-58 min and 52+/-21 [redo] vs 58+/-25 min). Mortality was 5.1%. One patient had transient hemiplegia due to the migration of the endoclamp. All other patients had uneventful outcomes and normal mitral valve function at 3-month's follow-up. CONCLUSION: Redo mitral valve surgery can be performed safely using a minimally invasive approach in patients with a previous sternotomy. The right lateral minithoracotomy offers excellent exposure. It minimizes the need for cardiac dissection, and thus, the risk for injury. Avoiding a resternotomy increases patient comfort of redo mitral valve surgery.     

Transaortic delivery of the transmitral lesion in a complete maze procedure

A 68-year-old hypertensive diabetic woman with chronic atrial fibrillation presented with progressive congestive symptomatology. She was diagnosed with severe aortic stenosis, moderate mitral regurgitation, and critical right coronary artery stenosis. In addition to coronary revascularization and bioprosthetic aortic valve replacement, she underwent a mitral valve repair and a complete cryoMaze procedure through a transaortic approach. This technique obviates a separate left atriotomy for the mitral repair and Maze procedure. It affords excellent exposure, while reducing cross clamp and cardiopulmonary bypass time as well as avoiding the potential sequelae of bleeding and traction injuries resulting from a left atriotomy.     

Robotic mammary artery harvest and anastomotic device allows minimally invasive mitral valve repair and coronary bypass

Abstract   We report the case of a 60-year-old man requiring combined mitral valve repair and coronary artery bypass grafting. A unique minimally invasive approach was used combining robotic internal mammary artery harvesting, partial lower sternotomy, and single vessel coronary artery bypass grafting using an automated distal coronary artery anastomotic device. Issues in approaching the commonly encountered patient with mitral valve disease and coronary artery disease using minimally invasive techniques are discussed.     

Combined surgery for valvular and ischemic heart disease

Combined coronary artery bypass (CAB) and valve surgery is one of the most challenging surgical procedures, but the operative results have improved over the years. We discuss several important points in combined surgery. The first point is cardioplegia, which should be perfect in such complex operations. Sufficient antegrade cold blood cardioplegia should be used in combined CAB and mitral valve surgery. Continuous retrograde cardioplegia is required in CAB and aortic valve surgery. The second point is the prosthesis and grafts. A mechanical prosthesis and arterial grafts should be used in younger patients, while a bioprosthesis and vein grafts with a left internal thoracic artery graft should be used in older ones. Finally, the choice of valve repair or replacement must be considered in mitral surgery with CAB. Valve repair is the choice in patients with mitral prolapse due to chordal rupture, because a perfect repair can be achieved using a well-known procedure. In cases in which repair appears difficult, replacement must be carried out as soon as possible. In mitral valve replacement the continuity between the papillary muscles and the mitral ring must be preserved for good left ventricular performance.     

正中切口解剖外旁路移植术一期治疗主动脉缩窄合并心脏畸形

目的总结正中切口解剖外旁路移植术一期治疗主动脉缩窄合并心脏畸形的外科治疗经验,以提高手术疗效。方法1997年7月至2008年7月,采用正中切口解剖外旁路移植术一期治疗主动脉缩窄合并心脏畸形31例,其中男20例,女11例;年龄31．9±11．7岁。合并的心脏畸形包括：主动脉瓣狭窄或关闭不全22例,二尖瓣狭窄或关闭不全9例,动脉导管未闭5例,升主动脉瘤4例,室间隔缺损3例,冠心病2例。解剖外旁路移植术包括升主动脉-腹主动脉旁路移植术22例,升主动脉-心包后降主动脉旁路移植术9例。同期手术包括主动脉瓣置换术16例,主动脉根部置换术6例,二尖瓣成形或置换术9例,升主动脉置换或成形术4例,动脉导管未闭缝合术5例,室间隔缺损修补术3例,冠状动脉旁路移植术2例。结果住院死亡1例（3．2％）,术后39d死于感染性中毒性休克。术后上、下肢收缩压压差较术前明显下降（13．7±10．2mmHg vs．64．2±25．3mmHg,P〈0．05）。随访27例,随访时间4～73个月,无晚期死亡、与人工血管相关的并发症和再次手术患者。结论正中切口解剖外旁路移植术是一期治疗成人及青少年主动脉缩窄合并心脏畸形的一种安全有效的手术方法。升主动脉腹主动脉旁路移植术及升主动脉-心包后降主动脉旁路移植术均可获得满意疗效。     

Repeat heart valve surgery: risk factors for operative mortality.

BACKGROUND: Patients undergoing repeat heart valve operations are a diverse population. We assessed risk factors for operative mortality in patients undergoing a first heart valve reoperation. METHODS: A retrospective review of hospital records was performed for 671 patients who underwent first repeat heart valve operations between 1969 and 1998. Univariable and multivariable analyses were performed. RESULTS: Operative mortality was 8.6%. Mortality fell each decade to 4.8% in the most recent period (adjusted chi(2) for linear trend P <.0005). Mortality increased from 3.0% for reoperation for a failed repair or reoperation at a new valve site to 10.6% for prosthetic valve dysfunction or periprosthetic leak and to 29.4% for endocarditis or valve thrombosis. Concomitant coronary artery bypass grafting was associated with a mortality of 15.4% compared with 8.2% when it was not required. Mortality for aortic valve replacement was 6.4%, mitral valve replacement 7.4%, aortic and mitral valve replacement 11.5%, tricuspid valve replacement 25.6%, periprosthetic leak repair 9.1%, and isolated valve repair 2.2%. Among 336 patients requiring replacement of prosthetic valves, mortality was 26.1% for replacement of a mechanical valve compared with 8.6% for replacement of a tissue valve (P <.0005). Multivariable analyses identified year of reoperation, age, coronary artery bypass grafting, indication, and replacement of a mechanical valve rather than a tissue valve as significant explanatory variables for operative mortality. CONCLUSIONS: Heart valve reoperations can be performed with an acceptable operative mortality. However, we have identified several categories of patients in whom reoperation carries an increased risk.     

Temporary axillo-femoral bypass for abdominal aortic aneurysm repair in high risk patients.

Abdominal aortic aneurysm (AAA) is sometimes associated with coronary artery and valvular disease. We report the successful treatment of a 76-year-old woman diagnosed with an infrarenal AAA, associated with severe mitral regurgitation and double-vessel coronary artery disease. First, AAA repair, using temporary axillo-femoral bypasses on both sides was done. Second, after 77 days, we simultaneously undertook coronary artery bypass grafting (CABG) and mitral valve repair. This staged operation achieved an excellent result. This rarely used abdominal aortic surgical procedure contributed to minimizing variations in afterload, an important consideration in high risk cardiac patients.     

Initial report of the Veterans Administration Preoperative Risk Assessment Study for Cardiac Surgery

This study was authorized by the Department of Veterans Affairs to improve the quality assurance of cardiac surgery by assessing preoperative risk factors and relating them to operative mortality. Data were received on 10,480 patients over a 2-year period. Preoperative risk variables were subjected to univariate and multivariate logistic regression analyses. Significant variables for coronary artery bypass grafting after logistic regression analysis in order of importance are previous cardiac operation, priority of operation, New York Heart Association functional class, peripheral vascular disease, age, pulmonary rales, current diuretic use, and chronic obstructive pulmonary disease. For patients undergoing valve or other cardiac operations with or without coronary artery bypass grafting, those variables found to be significant after multivariate logistic regression analysis are priority of operation; age; peripheral vascular disease; great vessel repair; all other except aortic valve replacement, mitral valve replacement, and great vessel repair; mitral valve replacement; and cardiomegaly. By identifying these current risk factors and the coefficients from the multivariate stepwise logistic regression analysis, expected mortality can be calculated. We propose that the ratio of observed to expected mortality is a better measure of quality of care than unadjusted mortality.     

Coronary artery dissection, combined aortic valve replacement and coronary bypass grafting in osteogenesis imperfecta

Osteogenesis imperfecta is an inherited connective tissue disorder. Aortic root dilation, aortic insufficiency and mitral valve prolapse are uncommon cardiovascular manifestations of osteogenesis imperfecta. Cardiac surgery in patients with osteogenesis imperfecta involves a high risk of complication rate. We report a case of coronary artery dissection induced by coronary angiogram in a patient with osteogenesis imperfecta and severe aortic regurgitation. In this case, the dissection of a coronary artery was not completely sealed by coronary stenting, and followed by successful combined aortic valve replacement and coronary artery bypass grafting on an emergency basis.     

电视胸腔镜辅助的心脏外科

电视胸腔镜于90年代初开始在心脏外科应用，与传统的心脏外科手术相比具有创伤小、疼痛轻、恢复快、费用低以及美容效果好等优点。现将电视胸腔镜在非体外循环下的冠状动脉旁路移植术，体外循环下的房间隔缺损修补术，室间隔缺损修补术，二尖瓣瓣膜修复与置换术，三尖瓣瓣膜修复与置换术以及冠状动脉旁路移植术中的临床应用进行综述。     

Perfusion during coronary and mitral valve surgery utilizing minimally invasive Port-Access technology

Minimally invasive surgery has been used in the treatment of some cardiovascular diseases. Port-Access surgery is a new minimally invasive technique that utilizes cardiopulmonary by-pass and a specialized catheter system that provides cardiopulmonary support and myocardial preservation. Extrathoracic cardiopulmonary support is established with femero-femoral bypass with kinetic assisted venous drainage. An endovascular catheter system allows for all the benefits of mechanical support as well as myocardial preservation. This catheter system includes an endoaortic balloon catheter which functions as an aortic cross clamp and antegrade cardioplegia delivery catheter, endopulmonary vent, and endocoronary sinus catheter used for administration of retrograde cardioplegia. An initial cohort of 20 patients was treated by the Port-Access surgical approach with cardiopulmonary bypass. Ten patients had coronary artery surgery and 10 patients had mitral valve surgery. The average bypass times were 94.4 min (coronary artery) and 152.8 min (mitral valve). The mean aortic occlusion times were 49.7 min (coronary artery) and 112.6 min (mitral valve). All patients were weaned from bypass. This initial patient series demonstrated that Port-Access surgery was feasible in selected patients.     

Comparative morbidity of mitral valve repair versus replacement for mitral regurgitation with and without coronary artery disease

Mitral valve repair has been increasingly used at our hospital for mitral regurgitation with and without coronary disease. From January, 1984, to June, 1987, of 338 patients undergoing all forms of mitral valve surgery, 140 had first-time surgery for pure mitral regurgitation: 75 had valve repair, and 65 had valve replacement. Thirty-three of 75 (44%) had concomitant coronary bypass in the repair group, while 21 of 65 (32%) had coronary bypass in the replacement group. The mean functional class (3.4 versus 3.5), age (60 versus 61 years), and preoperative hemodynamics were similar in both groups. The cause of mitral regurgitation in the repair group was myxomatous change in 32 patients, ischemia in 27, rheumatic valve disease in 12, and endocarditis in 4. A Carpentier ring was used in 46, a Duran ring was used in 11, and none was used in 18. The operative mortality was 3 of 75 patients (4%) in the repair group, all with coronary artery bypass grafting, versus 2 of 65 patients (3%) in the replacement group, 1 of whom had undergone coronary artery bypass grafting. The mean postoperative functional class 15 months postoperatively was 1.12 in the repair group versus 1.15 in the replacement group. There were 7 late deaths in the replacement group and only 3 late deaths in the repair group. Actuarial survival at 30 months was 85 +/- 6% for the replacement group and 94 +/- 4% for the repair group. There were 5 late emboli (1 fatal, 4 nonfatal) after valve replacement and none after valve repair (p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)     

Damage to the circumflex coronary artery during mitral valve repair with sliding leaflet technique

We report a case of damage to the circumflex coronary artery during mitral valve repair using sliding leaflet technique in a patient with a posterior mitral leaflet prolapse and coronary artery disease who underwent mitral valve reconstruction using Carpentier’s technique and coronary artery bypass grafting. This case underscores the risk of circumflex coronary artery injury during mitral valve reconstruction, especially in patients with left coronary dominance or codominance, and therefore emphasizes the importance of knowing the coronary artery anatomy preoperatively. The use of intraoperative transesophageal echocardiography is mandatory for the evaluation of mitral valvuloplasty.     

Leakage test during mitral valve repair

Mitral valve repair is the preferred surgical treatment for mitral regurgitation. Cardiac surgeons must increasingly pursue high-quality mitral valve repair, which ensures excellent long-term outcomes. Intraoperative assessment of a competency of the repaired mitral valve before closure of the atrium is an important step in accomplishing successful mitral valve repair. Saline test is the most simple and popular method to evaluate the repaired valve. In addition, an “Ink test” can provide confirmation of the surface of coaptation, which is often insufficient in the assessment of saline test. There are sometimes differences between the findings of the leakage test in an arrested heart and the echocardiographic findings after surgery. Assessment of the mitral valve in an arrested heart may not accurately reflect its function in a contractile heart. Assessment of the valve on the beating heart induced by antegrade or retrograde coronary artery perfusion can provide a more physiological assessment of the repaired valve. Perfusion techniques during beating heart surgery mainly include antegrade coronary artery perfusion without aortic cross-clamping, and retrograde coronary artery perfusion via the coronary sinus with aortic cross-clamping. It is the most important point for the former approach to avoid air embolism with such precaution as CO₂ insufflation, left ventricular venting, and transesophageal echocardiography, and for the latter approach to maintain high perfusion flow rate of coronary sinus and adequate venting. Leakage test during mitral valve repair increasingly takes an important role in successful mitral valve reconstruction.     

Mortality and morbidity among patients who undergo combined valve and coronary artery bypass surgery: Early and late results

Aim: To describe mortality and morbidity early and late after combined valve surgery and coronary artery bypass grafting (CABG) as compared with CABG alone. Patients and methods: All patients from western Sweden in whom CABG in combination with valve surgery or CABG alone was carried out in 1988–1991. Results: Among 2116 patients who underwent CABG, 35 (2%) had this combined with mitral valve surgery and 134 (6%) had this combined with aortic valve surgery, whereas the remaining 92% underwent CABG alone. Patients who underwent combined valve surgery and CABG were older, included more women and had a higher prevalence of previous congestive heart failure and renal dysfunction but on the other hand a less severe coronary artery disease. Among patients who underwent mitral valve surgery in combination with CABG the mortality over the subsequent 5 years was 45%. The corresponding figure for patients who underwent aortic valve surgery in combination with CABG was 24%. Both were higher than for CABG alone (14%; P<0.0001 and P=0.003, respectively). In a stepwise multiple regression model mitral valve surgery in combination with CABG was found to be an independent significant predictor for death but aortic valve surgery in combination with CABG was not. Among patients who underwent mitral valve surgery in combination with CABG and were discharged alive from hospital 77% were rehospitalized during the 2 years following the operation as compared with 48% among patients who underwent aortic valve surgery in combination with CABG and 43% among patients with CABG alone. Multiple regression identified mitral valve surgery in combination with CABG as a significant independent predictor for rehospitalization but not aortic valve plus CABG. Conclusion: Among patients who either underwent CABG in combination with mitral valve surgery or aortic valve surgery or CABG alone, mitral valve surgery in combination with CABG was independently associated with death and rehospitalization, but the combination of aortic valve surgery and CABG was not.