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.     

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.     

Use of ventricular assist devices in patients with mitral valve prostheses

Abstract Background: Use of ventricular assist devices (VADs) in patients with prosthetic valves may carry an increased risk of thromboembolism; however, clinical information is lacking. The aim of this study was to report our experience of the use of VADs in patients with prosthetic mitral valves. Methods: A retrospective analysis of 747 VAD patients from January 1995 to May 2010 was performed. Results: Thirteen patients with a prosthetic mitral valve (average age 56 ± 10 years of age, nine mechanical valve, four biological valve) were identified. Indications for VAD implantation were as a bridge to transplant in 11 patients and destination therapy in two patients. At the time of VAD implant, no intervention to the prosthetic mitral valve was performed. Eight patients received a HeartMate I (Thoratec Corporation, Pleasanton, CA, USA), three patients received a HeartMate II (Thoratec Corporation), and two patients received a Thoratec VAD (Thoratec Corporation). Among nine mechanical valve patients, six patients were anticoagulated with warfarin, and one patient with heparin, while two patients did not receive anticoagulation due to bleeding. Ten patients were successfully transplanted at an average of 123 days post‐VAD implant, one died after 48 days from multiorgan failure, and two remained on VAD support. No clinical thromboembolic events were observed. No intracardiac thrombus was detected by echocardiogram or on the pathology of the explanted hearts. Five patients had experienced a bleeding event (postoperative mediastinal bleeds, gastrointestinal bleedings, retroperitoneal hematoma, and subconjuctival bleeding). Conclusions: In patients with mitral valve prostheses who require VAD support, leaving the prosthesis intact does not increase the incidence of adverse events. (J Card Surg 2011;26:334‐337)     

Tricuspid valve involvement in combined mitral and aortic valve surgery.

BACKGROUND: Combined mitral and aortic valve disease requiring surgery may involve the tricuspid valve as well. Our treatment policy is conservative especially for tricuspid regurgitation which is operated on when severe only. METHODS: A retrospective study was performed at a tertiary and secondary referral center for cardiovascular disease. Over a 15-year period, 65 consecutive patients underwent aortic and mitral surgery with concomitant tricuspid regurgitation and/or stenosis. Fifty-five/65 (85%) patients were in NYHA class III-IV. Fifty-eight/65 (89%) patients had tricuspid regurgitation secondary to right chamber dilatation and 7/65 (11%) had tricuspid stenosis and/or regurgitation because of previous endocarditis. Twenty-two/65 (34%) tricuspid valves were operated on: 18/22 (82%) de Vega annuloplasty, 2/22 (9%) commissurotomies and 2/22 (9%) prosthetic valves. Mortality and complications were recorded during a mean follow-up of 5.3 yrs (range, 6 months-15.3 yrs). Event-free survivals were determined using the Kaplan-Meier method. RESULTS: Hospital mortality was 6.2% (4/65) and the complication rate was 18.5% (12/65). The freedom from late valve related mortality and morbidity at 5, 10 and 15 years was 86+/-5.5%, 81.9+/-6.8%, and 81.9+/-6.8% respectively. One valve related complication was due to the tricuspid valve. At last follow-up, 87% (47/54) of the survivors were in NYHA class I-II. CONCLUSIONS: With a conservative policy of tricuspid valve intervention, functional results of this patient population are good and long-term valve related morbidity and mortality are mainly related to the mitral and aortic valve procedures.     

Ventricular assist device support in patients with mechanical heart valves

Background. Due to potential thromboembolic complications, mechanical valves within the native heart are often considered contraindications to ventricular assist device (VAD) support.

Methods. A retrospective review of VAD cases between June 1982 and March 1998 showed 8 patients with mechanical valves who were supported with Thoratec (Pleasanton, CA) VADs.

Results. There were 6 males and 2 females ranging in age from 20 to 69 years (mean 49.8 ± 5.6). Four patients were supported when they could not be weaned from cardiopulmonary bypass after reparative procedures and were thought to have reversible injuries. Four patients were supported as a bridge-to-cardiac transplantation. Two patients had mechanical mitral valves, 2 had aortic valve replacements, 1 had an aortic homograft and mechanical mitral valve, 2 had mechanical aortic and mitral prosthesis, and 1 patient had aortic, mitral, and triscupid valves. The types of valvular prostheses were St. Jude (5 patients) and Bjork-Shiley (3 patients). Duration of support ranged from 3.0 to 150 days (mean 34 days). Four patients were supported with biventricular assist devices and 4 had left VADs. Dextran and intravenous heparin anticoagulation were used in the shorter duration patients, with warfarin being used in the bridge patients. One patient received warfarin and aspirin. At the time of autopsy or device removal, only 1 of the 12 mechanical intracardiac valves showed any evidence of thrombosis, including the aortic valves in 2 patients supported for 2 and 5 months. There were no clinical thromboembolic events. Four patients (50%) were discharged (1 weaned, 3 transplanted).

Conclusions. The 50% (4 of 8) survival rate compares favorably with the 44% (41 of 92) overall survival rate for our Thoratec patients (bridge plus recovery) who did not have mechanical prosthetic valves. These data suggest that patients with mechanical intracardiac valves can be supported for short durations with some additional risk, which is yet to be determined.     

Surgical treatment of infective valve endocarditis in children with congenital heart disease

Abstract Objective: This study assesses surgical procedures, operative outcome, and early and intermediate‐term results of infective valve endocarditis in children with congenital heart disease. Methods: Seven consecutive children (five females, two males; mean age, 10.8 years) who underwent surgery for infective valve endocarditis between 2006 and 2010 were included in the study. The aortic and mitral valves were affected in two and tricuspid in five patients. Indications for operation included cardiac failure due to atrioventricular septal rupture, severe tricuspid valve insufficiency, and septic embolization in one, moderate valvular dysfunction with vegetations in three (two tricuspid, one mitral), and severe valvular dysfunction with vegetations in the other three patients (two tricuspid, one mitral). The pathological microorganism was identified in five patients. Tricuspid valve repair was performed with ventricular septal defect (VSD) closure in five patients. Two patients required mitral valve repair including one with additional aortic valve replacement. Results: There were no operative deaths. Actuarial freedom from recurrent infection at one and three years was 100%. Early echocardiographic follow‐up showed four patients to have mild atrioventricular valve regurgitation (three tricuspid and one mitral) and three had no valvular regurgitation. No leakage from the VSD closure or any valvular stenosis was detected postoperatively. Conclusions: Mitral and tricuspid valve repairs can be performed with low morbidity/mortality rates and satisfactory intermediate‐term results in children with infective valve endocarditis . (J Card Surg 2012;27:93‐98)     

The transseptal approach to the mitral valve during multivalvular surgery

Abstract Aim: We investigated the short and mid‐term outcome of the transseptal approach to the mitral valve during multivalvular surgery. Methods: Within a three‐year period ending in May 2010, we used the transseptal approach in performing mitral valve surgery in 62 patients. Procedures performed were: mitral valve replacement and tricuspid annuloplasty in 40 patients, both aortic and mitral valve replacement with tricuspid annuloplasty in 13 patients, mitral valve and tricuspid valve replacement in eight patients and mitral valve repair and tricuspid annuloplasty in addition to coronary artery bypass surgery in one patient. Results: There were no complications associated with the transseptal approach. There were no conduction abnormalities, nor were there any procedure‐related deaths. Conclusion: We conclude that use of the transseptal approach for mitral valve operations is simple and safe in patients necessitating right atriotomy for concomitant procedures. (J Card Surg 2011;26:472‐474)     

LVAD support in patients with bioprosthetic valves

The presence of mechanical or bioprosthetic valves has traditionally excluded patients from mechanical circulatory support. However, several centers have now developed algorithms for the surgical management of native or prosthetic valve disease in patients requiring left ventricular assist device insertion. We report adverse events associated with bioprosthetic valves in the mitral and tricuspid positions in 2 patients who received long-term mechanical support. We recommend anticoagulation for all patients with prosthetic valves in the mitral or tricuspid position to avoid thromboembolism, inflow conduit occlusion, or valvular incompetence.     

Intraoperative transesophageal echocardiography for the evaluation of mitral, aortic and tricuspid valve repair A tool to optimize surgical outcome

The present study reviews the clinical applicability and usefulness of intraoperative transesophageal echocardiography (TEE) during valve repair. Intraoperative TEE was performed in 48 consecutive patients, who were divided into three groups: 1. mitral valve repair (MVR), 2. aortic valve repair (AVR), 3. tricuspid valve repair (TVR). Residual valve regurgitation was assessed by color Doppler echocardiography on a scale from 0 to 4. The ratios of the jet area (JA) to the left- and right-atrial areas (JA/LAA and JA/RAA) were analyzed before and after cardiopulmonary bypass (CPB). In group 1, 14 patients were scheduled for MVR, of which 4 patients underwent valve replacement and 10 MVR. Post-repair TEE studies showed a significant decrease of mitral regurgitation. In 2 of the 10 patients, TEE demonstrated severe residual regurgitation requiring valve replacement during the same thoracotomy. In group 2, 11 patients underwent aortic commissurotomy. Post-repair TEE showed an increase in the systolic opening diameter and opening area of the aortic valve. One patient underwent valve substitution because of severe aortic regurgitation. In group 3, 23 patients were scheduled for TVR. In 3 of them TEE showed no significant regurgitation thus rendering tricuspid valve surgery unnecessary. Twenty patients underwent TVR of whom two showed unacceptable post-repair regurgitation requiring further surgery. Eighteen patients showed a significant reduction of valve regurgitation after TVR, and a further reduction was achieved by adjusting the tricuspid annuloplasty under TEE guidance.     

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.     

Failure of Hancock xenograft valve: importance of valve position (4- to 9-year follow-up)

To evaluate long-term durability of Hancock valves, we reviewed our results in 107 hospital survivors (120 valves) who were operated on during 1974 through mid-1979. Mitral valve replacement was done in 63 patients, aortic valve replacement in 20, and mitral valve replacement combined with other procedures in 24. The 7-year survival was 84 +/- 4% (standard error of the mean) for 91 patients and 97 valves. During a follow-up of 590 patient-years, 15 (12 mitral and 3 aortic) of 120 valves at risk (87 mitral, 32 aortic, 1 tricuspid) were removed from 14 patients. Six valves (3 mitral and 3 aortic) were removed because of bacterial endocarditis. One mitral valve was removed because of thromboembolism. Eight mitral valves were removed because of valve structural failure, which occurred at a mean follow-up of 42 months. These valves showed extensive calcification, leaflet perforation, or cusp tear. Structural failure was unrelated to valve size, year of implantation, or valve shelf-life. Structural failure was not seen after aortic valve replacement. Results show that structural failure of the Hancock xenograft valve in the mitral position is related primarily to valve position. After aortic valve replacement, valve failure is predominantly due to endocarditis. Although medium-term (mean, 6-year) durability of this xenograft valve compares satisfactorily with prosthetic valves, its high failure rate in the mitral position indicates the necessity for improvement in valve mounting, design, and preservation.     

Thrombolytic Therapy with Recombinant Streptokinase for Prosthetic Valve Thrombosis

Abstract Background: Thrombosis is a serious complication of prosthetic heart valves, and management is often difficult. Thrombolytic therapy is a promising alternative to valve reoperation in the prosthetic valve thrombosis. Methods: Fifteen consecutive patients with prosthetic heart valve thrombosis (10 mitral, 3 aortic, 2 tricuspid) were treated with intravenous recombinant Streptokinase: 250,000 UI given over 30 minutes followed by an infusion an 100,000 UI per hour, always with clinical monitoring and echocardiographic examinations repeated at 24, 48, and 72 hours after starting thrombolytic therapy. Doppler echocardiography was the primary method use for diagnosis and was also used to follow the response to therapy Results: Fibrinolytic treatment was successful in 14 (93.3%) patients. Total response was achieved in 13 (86.6%)patients and partial response in 1 (6.7%) patient; one patient died of ventricular fibrillation. No major hemorrhagic events were observed, peripheral embolism occurred in two cases, and one case of minor peripheral bleeding occurred in another. Some patients experienced fever and chills. Conclusions: The present study demonstrates the feasibility, safety and efficacy of thrombolytic therapy, which may be considered as first‐line therapy for prosthetic heart valve thrombosis.     

Reoperations for valve surgery: perioperative mortality and determinants of risk for 1,000 patients, 1958-1984

One thousand consecutive cardiac reoperations for valve surgery in 897 patients were reviewed to determine in-hospital mortality and indicators of risk. Subgroups based on the number of previous cardiac procedures and the valve or valves replaced or repaired at reoperation (aortic valve, mitral valve, tricuspid valve, or multiple valves and mortality [deaths/number of procedures (% mortality)]) for those subgroups are as follows: (Table: see text) Predictors of increased risk for a first aortic valve reoperation were advanced age (p = .0002), endocarditis (p = .0018), female sex (p = .014), impaired left ventricular function (p = .039), and number of coronary vessels obstructed by 70% or more (p = .055). For a first mitral valve reoperation, the predictors were advanced age (p less than .0001), preoperative shock or cardiac arrest (p = .01), previous aortic or tricuspid valve operations (p = .02), type of mitral valve procedure (risk for repair of periprosthetic leak was greater than mitral valve replacement which was greater than mitral valve-conserving operation [p = .05]), and impaired left ventricular function (p = .059). For a first multiple valve reoperation, the predictors were diabetes (p = .04) and ascites (p = .02), whereas patients undergoing mitral valve replacement and tricuspid valve operations were at decreased risk (p = .01). Comparison of second reoperations with first reoperations indicates risk increases for multiple operations (p = .01) but not for aortic or mitral valve procedures. Rereplacement of a prosthesis (p = .007), coronary bypass grafting at reoperation (p = .006), and advanced age (p = .06) increased the risk for second reoperations. Age is the most consistent predictor of risk for patients undergoing valve reoperations.     

A New Modification of Debridement Valvuloplasty for Acquired Aortic Valve Disease

A high speed electric rasp was used to remove fibrous thickening from the aortic valve in conjunction with aortic valve commissurotomy in ten patients. All patients had moderate rheumatic aortic valve disease combined with severe mitral valve disease, and were treated by mitral valve replacement and aortic valve repair. All patients survived the operative procedure. There were no deaths or complications during hospitalization related to the valve repair process. The transaortic valve gradient was relieved from an average of 21.0 ± 8.6 mmHg to 5.6 ± 4.0 mmHg (catheterization), and from moderate to less-than-mild stenosis (echocardiography). Aortic valve regurgitation was reduced from an average of 2.2+ to 0.7+ on a scale of 0 to 4+ (aortography), and from an average of 2.5+ to 1.1+ on a scale of 0 to 4+ (echocardiography). During the follow-up period, no patients were reoperated on because of aortic valve dysfunction. Follow-up echocardiographic study demonstrated that the transaortic pressure gradient and valvular regurgitation had not progressed, and immediate postoperative conditions were maintained. There were two late deaths not related to the aortic valve. One patient died of prosthetic valve endocarditis in the mitral prosthesis 14 months postoperatively, and the other of a cerebrovascular accident 21 months postoperatively. Based on these data, we believe that aortic valve repair with a high speed electric rasp can effectively relieve aortic stenosis, reduce valvular regurgitation, and provide an excellent hemodynamlc result at early and mid-term follow-up. (J Card Surg 1994;9:103–108)     

Triple-valve treatment for prosthetic valve endocarditis occurring 20 years after implantation of a Carpentier-Edwards pericardial bioprosthesis in the aortic valve

A 68-year-old woman had undergone aortic valve replacement and open commissurotomy 20 years previously. At the beginning of 2008, fever, cold, and heart failure symptoms were noted. On blood culture, Streptococcus oralis was detected three times. Surgery was performed under a diagnoses of prosthetic valve endocarditis in the aortic valve, mitral stenosis and insufficiency, and tricuspid insufficiency. Techniques consisted of additional aortic valve replacement, mitral valve replacement, and tricuspid annuloplasty. Vegetation was macroscopically and pathologically observed in the extirpated Carpentier-Edwards pericardial bioprosthesis that had been placed in the aortic valve. There was no postoperative recurrent inflammatory response. The patient was discharged 32 days after surgery.     

More than ten years' follow-up of the Hancock porcine bioprosthesis in Japan.

From February 1975 through October 1981, 256 Hancock porcine bioprostheses (Johnson & Johnson Cardiovascular, King of Prussia, Pa.) (60 aortic, 169 mitral, and 27 pulmonary/tricuspid position) were implanted in 220 patients (104 male and 116 female, aged 9 to 67 years; mean 43.3) at Kyushu University Hospital in Japan. The procedures include 41 aortic valve replacements, 121 mitral valve replacements, 4 pulmonary valve replacements, 6 tricuspid valve replacements, and 48 combined valve replacements (31 aortic plus mitral, 13 mitral plus tricuspid, and 4 aortic plus mitral plus tricuspid). Hospital mortality was 6.4%. Follow-up was 98% during 8 to 14 (mean 10.5) years. Cumulative follow-up was 1836 patient-years and 2078 valve-years. At 10 years the overall actuarial survival rate, including hospital morality, was 70% +/- 3%, and freedom from valve-related mortality with sudden death was 87% +/- 3%. More than half of the current survivors required no anticoagulant therapy. Freedom from thromboembolism or anticoagulant-related hemorrhage (or both) and prosthetic valve endocarditis was common. Freedom from structural valve failure and reoperation declined more than 9 years after replacement of left-sided heart valves but not after replacement of right-sided heart valves. Sixty-seven patients underwent 68 repeat operations, and there were four deaths (5.9%). The rate of freedom from overall valve-related complications at 10 years was 62% +/- 8% for aortic valve replacement, 53% +/- 5% for mitral valve replacement, 80% +/- 13% for pulmonary/tricuspid valve replacement, and 42% +/- 9% for combined valve replacement. There was a significant difference between pulmonary/tricuspid valve replacement and combined valve replacement (p less than 0.05). The Hancock bioprosthesis is suitable for the replacement of valves in the right side of the heart but not for combined valve replacement.     

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.     

Acute endocarditis treated with radical debridement and implantation of mechanical or stented bioprosthetic devices

BACKGROUND: Operation for active infective endocarditis carries high mortality and morbidity rates, especially when the annulus is involved. Overall the literature favors the use of autograft and homograft valves because of better resistance to infection. In our clinic during the last 5 years we used an aggressive surgical approach to infective endocarditis in combination with implantation of mechanical or stented bioprosthetic devices. METHODS: From 1994 to 1999, 50 adults with aortic and/or mitral valve endocarditis underwent valve replacement. The median age of the 36 men and 14 women was 58 years (range, 17 to 78 years). All patients had active endocarditis at the time of operation. Native valve endocarditis was present in 48 patients and prosthetic valve endocarditis was present in 2 patients. The aortic valve was affected in 24 patients, the mitral valve in 21 patients, and both the aortic and mitral valves in 5 patients. Two of the patients with mitral endocarditis also had infection of the tricuspid valve. Annular destruction was present in 24 patients (48%). The patients were treated with radical excision of all infected tissue. The annular defects were closed, if possible, with direct sutures. Otherwise, a reconstruction was performed. Follow-up was 100% complete with a median follow-up period of 45 months (range, 6 to 66 months). RESULTS: The procedures were performed without lethal bleeding complications. Early mortality was 12% and the actuarial survival at follow-up was 80%. In none of the patients who died was death related to the prosthetic valve or recurrence of the endocarditis. Only 1 patient (2%) developed recurrence of the infective endocarditis and was reoperated with a Ross procedure. Three and a half years later the patient developed severe valve insufficiency of the autograft and was operated again with implantation of a mechanical device. CONCLUSIONS: Native and prosthetic valve endocarditis can be treated successfully with aggressive surgical debridement and implantation of mechanical or stented bioprosthetic devices with a low risk of recurrent endocarditis.     

Ventricular assist device in patients with prosthetic heart valves

Ventricular assist device (VAD) support inpatients with a prosthetic heart valve had previously been considered a relative contraindication due to an increased risk of thromboembolic complications. We report our clinical experience of VAD implantation in patients with prosthetic heart valves, including both mechanical and bioprosthetic valves. The clinical records of 133 consecutive patients who underwent VAD implantation at a single institution from January 2002 through June 2009 were retrospectively reviewed. Six of these patients had a prosthetic valve in place at the time of device implantation. Patient demographics,operative characteristics, and postoperative complications were reviewed.Of the six patients,four were male.The mean age was 57.8 years (range 35–66 years). The various prosthetic cardiac valves included a mechanical aortic valve (n = 2), a bioprosthetic aortic valve (n = 3), and a mechanical mitral valve (n = 1).The indications for VAD support included bridge to transplantation (n = 2), bridge to recovery (n = 1), and postcardiotomy ventricular failure(n = 3). Three patients underwent left ventricular assist device placement and three received a right ventricular assist device. Postoperatively, standard anticoagulation management began with a heparin infusion (if possible)followed by oral anticoagulation.The 30-day mortality was50% (3/6). The mean duration of support among survivors was 194.3 days (range 7–369 days) compared with 16.0 days(range 4–29 days) for nonsurvivors. Of the three survivors,two were successfully bridged to heart transplantation and one recovered native ventricular function.Among the three nonsurvivors,acute renal failure developed in each case, and two developed heparin-induced thrombocytopenia. This study suggests that VAD placement in patients with a prosthethic heart valve, either mechanical or bioprosthetic,appears to be a reasonable option.     

Obstruction of mechanical valve prostheses: Clinical diagnosis and surgical or nonsurgical treatment

Twenty patients underwent nonsurgical and/or surgical treatment for obstruction of mechanical prosthetic valves. The obstructed prosthetic valve was in the aortic position in 11 patients, in the mitral position in 5, and in the tricuspid position in 4. Twelve patients had a bileaflet valve (3 aortic, 5 mitral, 4 tricuspid), and 8 had a tilting disk valve (all aortic). The diagnosis of prosthetic valve obstruction was made by cineradiography and echocardiography. Thrombolytic therapy was instituted in a series of our 10 most recent patients (11 cases), except for one patient with acute renal failure, regardless of the position of the obstructed prosthetic valve. Successful thrombolysis was achieved in 6 cases (54.5%). Six patients required surgical treatment subsequent to either failed or incomplete thrombolysis, and one patient died of congestive heart failure 1 month after surgery. Nonfatal neurologic events occurred in 2 cases (18.2%). A total of 16 patients underwent surgical treatment. Two (12.6%) of the 16 patients died of causes unrelated to the operative procedures before discharge from the hospital. These results suggest that thrombolytic therapy appears to be an attractive nonsurgical alternative for valve thrombosis when the patient's clinical condition is not critical, and thus surgical treatment should only be performed in an emergency on seriously ill patients.