Reoperation for a patient 25 years after a Starr-Edwards ball mitral valve was installed.

A 45-year-old female suffered from increasing dyspnea during exercise and edema of lower extremities from January 2000. She had undergone mitral valve replacement with Starr-Edwards ball prosthesis (model 6320) due to mitral valve regurgitation 25 years ago. The cardiac catheterization and echocardiography documented mitral, aortic and tricuspid valves regurgitation grade III. Left ventricular ejection fraction rate was 49% and the pressures of CVP, RA, RV and PA were also increased. Laboratory examination showed slight hemolytic anemia. Double valve replacement (ATS valve) and tricuspid annuloplasty were carried out in April 2000. Strut cloth wear was confirmed at operation. Her postoperative course was uneventful. We hereby review the published paper of all cases with an implanted Starr-Edwards ball valve who required redo valve replacement with over 15 years follow-up. We consider that cloth injury is the main cause for reoperation and it usually associated with hemolytic anemia; cloth wear not only involves the aortic position but also frequently involves the mitral position for over 15 years follow-up patients and can be corrected by reoperation. Cloth wear should be concerned for those surviving patients who have received the Starr-Edwards ball valve during long-term follow-up.     

Successful consecutive seven time's surgical repair of Marfan syndrome

We report a patient with Marfan syndrome who received successful 7 consecutive operations during 11 years. She underwent descending aortic replacement for chronic type B dissection at the age of 24. Mitral valve replacement (MVR) was performed for mitral regurgitation (MR) at the age of 30, and abdominal aortic replacement was done for persistent dissection at the age of 31, aortic root and arch replacement was done at the age of 34. The 9 months later, she received re-MVR for dysfunction of bioprosthesis and tricuspid valve anuloplasty (TAP) for tricuspid regurgitation (TR). But severe paravalvuler leakage of mitral valve necessitated direct closure of detachment. Thoracoabdominal replacement was performed for rupture of persistent dissection at the age of 35. She was discharged on the 54th day after the 7th surgery.     

左心瓣膜置换术后远期三尖瓣关闭不全的外科处理

目的探讨左心瓣膜置换术后远期三尖瓣关闭不全(TR)发生的可能机制以及外科治疗方法的选择和结果.方法 56例左心瓣膜置换术后远期发生TR行再次瓣膜手术的病人,10例人工瓣膜功能正常(A组)者中行二尖瓣置换(MVR)4例,主动脉瓣、二尖瓣双瓣置换(DVR)6例;46例人工瓣膜功能障碍(B组)者中MVR 36例,主动脉瓣置换(AVR)4例, DVR 6例.在A、B两组中,46例第1次手时三尖瓣未见明显异常,10例第1次手术时已行DeVega三尖瓣成形(TVP),第2次手术时发现缝线断裂3例,缝线撕脱7例.56例TR病人再次手术时9例行三尖瓣替换(TVR),其中6例三尖瓣呈风湿性改变;47例行TVP.结果 TVP和TVR各死亡1例,病死率3.6%.54例获随访,随访时间6～132个月,平均(79.4±34.8)个月.8例TVR病人术后心功能恢复良好,46例TVP者40例为轻度TR,5例出现中度TR,仍需强心、利尿药维持,1例再次出现重度TR.结论左心瓣膜置换术后远期TR可能与持续肺动脉高压、右心室不可逆损害、三尖瓣风湿性病变、左心功能的恢复情况以及持续心房纤颤有关.重度功能性TR和三尖瓣风湿性病变者行TVR的疗效可靠.随访发现部分TVP病人功能性TR仍有逐渐加重趋势.     

Aortic and tricuspid valve replacement in a case of corrected transposition of the great arteries

It is well known that corrected transposition of the great arteries (C-TGA) is accompanied with tricuspid valve regurgitation, but very few reports have described complication of this anomaly with aortic valve regurgitation (AR). We have performed aortic valve replacement (AVR) in a case of C-TGA associated with AR which had been evaluated the grade of 3/4 according to Sellers' classification, simultaneously done the valve replacement for the dysplastic tricuspid valve and annuloplasty for the right-side atrioventricular valve (mitral valve). The patient has a favorable postoperative course.     

Surgical strategy for tricuspid valve disease

The most common cause of tricuspid valve dysfunction is functional tricuspid regurgitation (TR) secondary to mitral valve disease. Annuloplasty is feasible in most patients with functional TR, and valve repair can also be performed in most patients with tricuspid valve dysfunction of other etiologies. Valve replacement is considered to be indicated only for those patients whose tricuspid valves have severe organic change or have been damaged by infective endocarditis. Although good long-term results of tricuspid valve replacement using bioprostheses have been reported, a bileaflet mechanical prosthesis may be an acceptable alternative in those patients who undergo concomitant valve replacement with a mechanical prosthesis in the mitral or aortic position or who may have persisting pulmonary hypertension after surgery.     

True Aneurysm of the Left Main Trunk in a Marfan Syndrome Patient at Remote Period after Bentall Operation and Total Arch Replacement: A Case Report

In 2002, a 37-year-old male with Marfan syndrome underwent the Bentall operation, total arch replacement, and aortobifemoral bypass for DeBakey type IIIb chronic aortic dissection, annuloaortic ectasia, and aortic regurgitation. In 2007, mild mitral regurgitation (MR) caused by mitral valve prolapse was identified. In April 2017, echocardiography revealed the worsening of MR and moderate tricuspid regurgitation (TR). Moreover, coronary angiography (CAG) revealed a coronary artery aneurysm in the left main trunk (LMT). In August 2017, the patient underwent mitral valve replacement (MVR), tricuspid annuloplasty (TAP), and coronary artery reconstruction. We reconstructed the LMT aneurysm using an artificial graft. True aneurysm of the coronary artery complicated with Marfan syndrome is a rare complication that has seldom been reported. This case highlights that it is essential to carefully follow-up patients with Marfan syndrome after the Bentall operation.     

Primary biventricular repair for interrupted aortic arch with left ventricular outflow tract obstruction and tricuspid valve regurgitation; report of a case

An interrupted aortic arch was diagnosed in a 10-day-old girl weighing 3.3 kg, as was perimembranous ventricular septal defect (VSD) and severe tricuspid valve regurgitation (TR). The subaortic diameter was 3.6 mm and the aortic valve (3.7 mm in diameter) was bicuspid. We chose definitive repair, modified Yasui procedure, because of severe TR and no straddling of mitral valve. In primary biventricular repair, we undertook extended aortic arch anastomosis. Left ventricular outflow tract reconstruction consisted of intracardiac rerouting from the VSD to the pulmonary artery by using expanded-polytetrafluoroethylene (ePTFE) and Damus-Kaye-Stansel (DKS) anastomosis. Right ventricular outflow tract reconstruction was performed by the Rastelli procedure with an ePTFE valved conduit. Moreover, we carried out semicircular annuloplasty for severe TR.     

Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. II. Nonoperative management, tricuspid valve annuloplasty, and tricuspid valve replacement

The incidence, preoperative and intraoperative diagnosis, methods, and the clinical and hemodynamic features of patients with and without tricuspid regurgitation associated with chronic mitral regurgitation were presented in Part I. This study (Part II) compares the early and late results in patients with chronic, pure mitral regurgitation undergoing isolated mitral valve replacement, mitral replacement and tricuspid valve annuloplasty, and mitral and tricuspid valve replacement. The mean follow-up interval was 6 years. Those with the longest duration of symptoms (18 years) required tricuspid and mitral valve replacement (11 patients), whereas those with the shortest duration (8.1 years) had only mitral replacement (22 patients). Eight patients had minimal tricuspid regurgitation by digital palpitation, with no procedure performed, and six had tricuspid valve annuloplasty, only one of whom received a ring support. Operative mortality rate was similar in all groups (13% to 18%). All but two of the surviving patients improved by at least one New York Heart Association functional class, and no statistically significant differences were found between preoperative and postoperative hemodynamic data. There were no statistically significant differences in survival at 1, 5, or 8 years (85%, 70%, and 60%, respectively) for patients with or without TR. Only two of the surviving five patients who underwent tricuspid valve annuloplasty were alive 3 years after operation, whereas 70% to 80% of those with mitral replacement or mitral and tricuspid replacement were alive after the same time interval. It is not clear whether or not the pathogenesis of tricuspid regurgitation resulting from mitral regurgitation is different from that of tricuspid regurgitation resulting from mitral stenosis. It is our contention that whether tricuspid regurgitation arises because of anatomic destruction of the tricuspid valve or because of right ventricular dilatation with tricuspid annular enlargement, the underlying mitral valve lesion may determine the preoperative and postoperative courses of these patients. Therefore, when tricuspid valve disease is being evaluated, we urge that patients be categorized by the nature of their underlying mitral or aortic valve lesions.     

Surgical treatment of rheumatic tricuspid valve disease

The rheumatic tricuspid valve is relatively rare in this country. We report the study on surgical treatment of 27 patients with rheumatic tricuspid valve. Surgical procedure on 7 cases out of them was tricuspid valve replacement (TVR) with bioprosthesis and tricuspid valvuloplasty (TVP) was performed in the remaining 20 cases. There were two operative deaths in TVR group, however, there were no major complications, such as thrombosed valve, the valve dysfunction or prosthetic valve endocarditis in the remaining five cases after the operation. The method of TVP in twenty cases consisted of two Kay's TAPs, six tricuspid commissurotomies (OTC), ten OTC with Key's TAPs and two OTC with DeVega's TAPs. Doppler cardiography (DCG) revealed residual tricuspid regurgitation (TR) more than 3/4 degrees in 7 cases of TVP group immediately after operation. Moreover, the increment of residual TR was seen in 7 cases during the following period and TVR was performed in 3 cases out of these 7 cases. In conclusion, it is suggested that TVR may be preferred to TVP for the rheumatic tricuspid valve because of severe residual TR in many cases of TVP group.     

应用彩色多普勒对二尖瓣置换术后三尖瓣功能的远期随访

目的应用彩色多普勒超声评价二尖瓣置换术后远期三尖瓣功能及形态变化。方法对接受二尖瓣置换术的903例病人术后三尖瓣功能进行了2～9年,平均(3.6±2.4)年的跟踪观察。所有病例术前均有不同程度的三尖瓣环扩大或关闭不全,其中未行三尖瓣成形术者201例;行Kay或改良DeVega成形术者686例;三尖瓣成形术同时加成形环者16例。结果未行三尖瓣成形术者术后2～3年有46例出现三尖瓣重度关闭不全;行Kay或改良DeVega成形术者,术后3～5年150例出现中重度三尖瓣关闭不全;三尖瓣成形术同时加成形环者仅1例术后2年出现三尖瓣轻-中度关闭不全。结论二尖瓣置换术后远期三尖瓣功能性关闭不全与三尖瓣环扩大、右心功能损害和严重肺动脉高压有关,三尖瓣环扩大是其重要的原因。对二尖瓣置换术者,手术中一旦发现有三尖瓣环扩大,即使无三尖瓣关闭不全,亦应行三尖瓣成形术,重度三尖瓣关闭不全、瓣环明显扩大者最好在环缩术的同时加成形环。     

Aortic and mitral valve replacement for calcified valvular annulus in a dialysis patient; report of a case

A 77-year-old man on hemodialysis was admitted to our hospital due to heart failure. Echocardiography showed aortic valve stenosis and regurgitation, mitral valve stenosis and regurgitaion, and tricuspid valve regurgitation. Catheter examination revealed severe calcification at aortic valve and mitral valve including their annulus. At the operation, the calcifications of the aortic and mitral valvular annulus was removed using a cavitron ultrasonic surgical aspirator (CUSA). Reconstructions of the defect of the posterior part of the mitral annulus and of the aortic annulus at the site of the left coronary cusp were achieved by patch technique using autologous pericardium. Aortic and mitral valve replacement and tricuspid valve annuloplasty were performed. The postoperative course was uneventful. Operative technique to remove calcification from valvular annulus using CUSA and reconstruct of the defect of the annulus with autologous pericardium is a very useful technique to prevent left ventricular rupture, perivalvular leakage and any other complications.     

二尖瓣主动脉瓣三尖瓣同时置换治疗重症风湿性瓣膜病

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

Enucleation of calcium core and in-situ valve replacement for massive posterior mitral annular calcification

A 67-year-old female was admitted to our hospital for surgical treatment of the aortic and mitral valvular disease. She had chronic renal failure and dialysis was started 13 years previously. A diagnosis of severe aortic stenosis and regurgitation with severe mitral stenosis was made, and she underwent aortic valve and mitral valve replacement. Because mitral annular calcification had deeply invaded into the subvalvular region, enucleation of calcified core was performed using the ultrasonic aspiration system. The posterior mitral annulus was reconstructed using equine pericardium and aortic and mitral valve replacement was performed. The postoperative course was uneventful.     

Tricuspid leaflet augmentation with an autologous pericardial patch for recurrent severe tricuspid regurgitation that occurred after suture annuloplasty

We, herein, report the use of tricuspid leaflet augmentation with an autologous pericardial patch to treat a patient with severe tricuspid regurgitation (TR) that occurred after suture annuloplasty. The patient underwent mitral valve replacement for rheumatic mitral disease and tricuspid suture annuloplasty for moderate TR 23 years ago. She developed right-sided heart failure associated with severe TR. Leaflet augmentation with an autologous pericardial patch and ring annuloplasty were applied at redo surgery. Postoperative echocardiography showed trivial TR with significant improvement of the patient’s symptoms. We have now performed this technique on three cases of severe recurrent TR that occurred after suture annuloplasty, and excellent early results were obtained in each case.     

"缘对缘"三尖瓣成形在纠治残留三尖瓣关闭不全的应用

目的总结“缘对缘”三尖瓣成形方法治疗重度残留三尖瓣关闭不全的经验。方法19例常规三尖瓣成形术后仍有重度残留三尖瓣关闭不全者接受“缘对缘”三尖瓣成形术。三尖瓣关闭不全的病因包括：风湿性心脏病7例、先天性心脏病8例、创伤性及退行性变各2例。结果住院死亡1例，9例术后无或仅有微量三尖瓣关闭不全，10例术后轻度三尖瓣关闭不全。随访3～60个月，平均36．6个月，16例为微量到轻度三尖瓣关闭不全，2例为轻度到中度三尖瓣关闭不全。结论“缘对缘”三尖瓣成形是纠治重度残留三尖瓣关闭不全的一种有效的辅助方法。     

A surgical case for severe hemolytic anemia after mitral valve repair.

We report a rare case of severe hemolytic anemia accompanied by moderate renal insufficiency after mitral valve repair. Although the degree of the residual mitral regurgitation was less than 1+ during the first three weeks after the operation, the maximum lactate dehydrogenase (LDH) was up to 7,430 U/l and the minimum hemoglobin was 4.9 g/dl. The mitral valve replacement successfully resolved the hemolysis, but the renal function did not completely recover.     

Influence of concomitant mitral valve dysfunction on survival after aortic valve replacement

Aortic valve pathology is the most common acquired valvular heart disease in the adults of western countries, and mitral regurgitation (MR) is often clinically present in patients with degenerative aortic stenosis or insufficiency. Many studies report an incidence of MR between 65-75% in patients evaluated for aortic valve replacement. Severe aortic valve disease may be associated with functional mitral regurgitation (FMR) defined as the failure of mitral valve to prevent systolic backward flow in the absence of any significant structural or intrinsic valvular disease. Increased afterload and left ventricular remodeling have been implicated to explain FMR in patients with aortic valve disease. Moreover, organic mitral valve disease can be associated with aortic stenosis and can be rheumatic or degenerative. We have examined the data of the literature to understand the evolution of MR, the impact of mitral regurgitation on the outcome of patients undergoing aortic valve replacement, and to determine clinical predictors of prognosis in patients with concomitant MR at the time of aortic valve replacement.     

Aortic valve papillary fibroelastoma in a patient with mitral valve regurgitation

Papillary fibroelastoma is a rare cardiac tumour. We describe a patient with mitral valve regurgitation and aortic valve papillary fibroelastoma. The patient was 62-year-old woman. She was referred to us for surgical treatment of mitral valve. Preoperative echocardiography showed rheumatic mitral valve regurgitation (Sellers grade III) and it also demonstrated mobile masses of the aortic valve. At operation, mitral valve was repaired by a posterior annuloplasty. Through the aortotomy, small tumors were found to be attached to each cusps of the aortic valve and they were successfully removed. The histopathologic diagnosis was papillary fibroelastoma of the aortic valve. The postoperative course was uneventful.     

Severe tricuspid regurgitation late after aortic and mitral double valve replacement; report of a case

A 59-year-old man had undergone aortic and mitral valve replacement (DVR) for rheumatic aortic and mitral valve stenosis 15 years ago. At that time, echocardiography did not detect tricuspid regurgitation (TR), and catheterization data showed right atrial pressure v wave of 8 mmHg and pulmonary artery pressure of 27/12 (17) mmHg. One year after DVR, hepatomegaly and jugular venous dilatation appeared, and after 5 years edema of both legs became apparent. After 7 years, chest X-ray showed an increase of cardio-thoracic ratio, and for the first time, echocardiography detected mild TR. Fifteen years after DVR, severe general fatigue, shortness of breath and hepatomegaly could not be controlled with medication. Catheterization data showed right atrial pressure v wave of 23 mmHg and pulmonary artery pressure of 28/13 (17) mmHg. Right ventriculography showed progression of severe TR. Tricuspid valve replacement (TVR) was performed using a St. Jude Medical 31 M mechanical valve under natural cooling and heart beating. The tricuspid valve was only slightly thickened and no subvalvular abnormalities were seen other than a severely dilated tricuspid annulus. Postoperative course was uneventful and he was discharged 44 days after the TVR. He is currently doing well 6 years after the TVR. All terms, he did not have pulmonary hypertension or left-side heart problems. We suspect that the cause of TR was not secondary, and was included in the category of isolated TR. If the left heart is completely treated, as in this case, it is important to follow-up for signs of right heart failure, before TR is detected.     

Surgery for the valvular disease in children

We report the results and long-term follow up in 34 children (17 girls and 17 boys, aged 12 days to 13 years, average age 3.3 years, average body weight 11.7 kg) who underwent valvular surgery in the period between May 1989 and November 1996. Operative mortality was 11.8%. Actuarial survival curves (including hospital mortality) indicate a 68.6% survival rate at 5 years and that 64.7% of patients are free from reoperation at 5 years. For aortic regurgitation two patients applied aortic valvuloplasty and four applied aortic valve replacement. Nine children had aortic stenosis, three of them had balloon valvuloplasty, seven had valvotomy, two had aortic valve replacement. Ten patients were treated for mitral regurgitation. There were nine valvuloplasty and four mitral valve replacement including three times of reoperation. One membranous pulmonary atresia and seven pulmonary stenosis children had valvotomy. There were four cases of tricuspid disease. One had tricuspid valve stenosis with pulmonary stenosis, three had severe tricuspid regurgitation who applied tricuspid valve replacement. Mortality was high in the critical AS, severe MR and TVR groups. Patients who survived the surgery and had no complications showed satisfiable results.