Surgery of aortic valvular disease with congenital bicuspid or quadricuspid aortic valve

Twelve patients (age 18 to 69 years old) with surgical treatment for congenital bicuspid aortic valve and one (age 26 years old) for quadricuspid aortic valve were reported. These 13 patients occupied 12.3% of the total number of patients with aortic valve replacement during the same period. Among the patients with bicuspid aortic valve, 10 patients were male (83%) and 2 were female (17%). Seven patients exhibited aortic stenosis and 5 showed predominant aortic regurgitation. The mean age of patients with aortic stenosis was higher than that of patients with aortic regurgitation. (63.3 years vs 32.0 years old). Infective endocarditis occurred in 2 patients (17%). Three patients had pure aortic regurgitation without evidence of endocarditis. One 26-year-old female patient who had a quadricuspid aortic valve presented with aortic regurgitation associated with PDA. All patients underwent aortic valve replacement with no early and late deaths.     

Surgery in children with hydatid disease of the spleen

Background/Purpose

Hydatid disease of the spleen is a rare disease, and it occurs in 1% to 8% of all children with hydatid disease. That difference in frequency depends on the social and economic status of the patients and the country. The aim of our study is to reveal its diagnosis and treatment.

Methods

From 1985 to 2004, 152 children with hydatid disease have been operated on at the Surgical Department of General and Pediatric surgery at the Medical University in Stara Zagora and Medical University in Plovdiv, Bulgaria. Of the 152 children, 15 (9.87%) had spleen localization: 6 males and 9 females, aged 10 to 18 years. A solitary cyst in the spleen was found in 10 patients, 8 children had an isolated cyst only in the spleen, 7 with involvement of other organs (5 in the liver, 2 in liver and lungs). All spleen cysts were “silent.” Abdominal sonography, computed tomography, and enzyme-linked immunosorbent assay tests proved the diagnosis. All children were operated on.

Results

A splenectomy was performed in 14 cases, and a cystectomy was possible in only 1 case. Patients with combined forms successfully underwent different variations of cystectomy: 6 omentoplasty, 5 capitonnages, and 4 invaginations.

Conclusions

Splenic involvement of hydatid disease has no specific clinical manifestation, the diagnosis is late and often leads to splenectomy. Organ-preserving procedures are possible only in cases with early diagnosis. It has to be suspected in a patient with a splenic cyst and has to be confirmed by ultrasonography and/or computed tomography, magnetic resonance imaging, and immunologic tests. The early diagnosis is a good precondition for better results.     

Surgery for peptic ulcer disease in children in the post-histamine2-blocker era

Background/Purpose

The aim of this study was to determine the presentation, treatment, and outcome of children requiring surgery for peptic ulcer disease (PUD) in the post-histamine₂-blocker era.

Methods

The charts of all children undergoing surgery for PUD in our institution since 1980 were retrospectively reviewed. Data were collected regarding clinical presentation, operative details, postoperative course, and outcome.

Results

Twenty-nine children (7.2 ± 7.5 years) required surgery for complications of PUD. Indications for operation were bleeding (n = 11), pneumoperitoneum (n = 13), peritonitis (n = 3), and gastric outlet obstruction refractory to medical therapy (n = 2). For those children with bleeding, 8 had simple oversew of the bleeding ulcer(s), 2 had oversew with vagotomy and pyloroplasty, and 1 required vagotomy and antrectomy. All patients with perforation (n = 16) were treated with simple closure with or without omental patch. One child with gastric outlet obstruction underwent vagotomy and antrectomy and 1 had vagotomy and pyloroplasty. Preoperative risk factors or comorbidities were present in 27 of 29 patients and included steroid or nonsteroidal antiinflammatory drug medications in 13 children (only 3 of whom were receiving antiulcer prophylaxis). Postoperative complications occurred in 11 of 29 patients. Three (10%) children required reoperation for persistent or recurrent ulcer disease and 4 children died.

Conclusions

PUD remains a highly morbid and mortal condition in children despite the availability of effective acid-reducing medications. Effective prophylaxis of children receiving steroids and nonsteroidal antiinflammatory drugs may play a role in decreasing the risk of PUD.     

Valve replacement for congenital valvular disease

Among 365 cases of mitral and aortic valve replacement (MVR, AVR) done in our institute during the period between 1968 and 1983, there were 20 congenital cases (5.5%), who were pointed out to have valvular disease since birth or early childhood and had no evident history of infectious disease. Mean ages at operation of MVR and AVR groups were 5.6 +/- 3.6 and 22.4 +/- 6.0 years respectively. Predominant pathology of mitral valve was regurgitation in 9 and stenosis in 2 cases. Seven cases were associated with other cardiac anomalies. Cumulative follow-up period was 34.3 patient-years (p-y). There were 3 late deaths resulted from xenograft calcification. In AVR group, predominant pathology of the valve was regurgitation in 8 cases and stenoregurgitation in one case. All cases were associated with other cardiac anomalies. There were 2 late deaths within the cumulative follow-up period of 39.5 p-y. Cumulative survival rates at 15 years, both in MVR and AVR groups were lower in congenital group than in the group of acquired disease. The incidences of prosthesis malfunction, prosthesis related complication and late death in the both MVR and AVR groups were higher in congenital group, when compared to that in the group of acquired disease.     

Operation for anorexigen-associated valvular heart disease

OBJECTIVES: Recently, valvular regurgitation has been observed in patients who have taken fenfluramine or dexfenfluramine with or without phentermine. This study describes the clinical, echocardiographic, and pathologic findings of anorexigen-associated valvular heart disease and the surgical interventions required to treat it. METHODS: We reviewed clinical information on 14 patients with severe anorexigen-associated valvular disease who underwent cardiac operations. RESULTS: Thirteen women (mean age 44.2 +/- 5.3 years) received fenfluramine, 58.5 +/- 22.3 mg/day, and phentermine, 32.1 +/- 11.4 mg/day, for an average of 12.1 +/- 7.3 months before presentation. One woman received dexfenfluramine, 30 mg/day for 13 months, and phentermine, 60 mg/day, concomitantly for 6 months. Presenting symptoms included dyspnea (12 cases), palpitations (3), and atypical chest pain (3). Six patients had heart failure, and 4 had a new murmur. Echocardiography demonstrated severe mitral valve regurgitation in all patients. Seven also had aortic regurgitation, and 4 had significant tricuspid regurgitation. Four patients had successful mitral valve repair, 1 with concomitant aortic valve repair. Ten additional patients eventually required mitral valve replacement, 5 with concomitant aortic valve replacement. Excised valves demonstrated a glistening white appearance with plaque-like encasement of leaflets and chordae. Focal surface proliferation and fibrosis with a "stuck-on" appearance was consistently found. CONCLUSIONS: Anorexigen use may lead to severe multivalvular regurgitation with characteristic echocardiographic and pathologic findings. Recognition of drug-induced valvulopathy is important because of widespread use of these medications and the uncertain natural history of the disease. Early surgical experience suggests that valve repair is possible in these young patients.     

Reoperations in valvular heart disease

Background Reoperations for valvular heart disease are associated with a higher overall mortality than the primary operations. In this retrospective analysis, we present our experience of reoperative valvular heart surgery over a period of 25 years. Methods From January 1975 to July 2000, 13039 operations were performed for valvular heart disease. Of these 665 were reoperations. The mean age of the patients at the primary operation was 24.0±10.2 years (range: 8 to 65 years) and at re-operation was 35.6±11.6 years (range: 9 to 65 years) with an interval of 9.4±2.2 years (range: 0.2 to 25 years) between the 2 procedures. Four hundred and forty reoperations were performed following a previous closed mitral valvotomy and procedures included, redo closed mitral valvotomy (n=28), mitral valve replacement (n=30), open mitral commissurotomy (n=51), mitral valve repair (n=9), homograft mitral valve replacement (n=2), double valve replacement (n=47), aortic valve replacement (n=2) and homograft aortic valve replacement plus open mitral commissurotomy (n=l). Eighty six patients underwent reoperations following mitral valve replacement. Valve thrombosis (n=50) and endocarditis (n=10) were principle causes of reoperation. Forty three patients required reoperation following failed mitral valve repair, 19 following open mitral commissurotomy and 8 following homograft mitral valve replacement. Sixty five patients underwent reoperation following aortic valve operations: prosthetic aortic valve replacement in 43, homograft aortic valve replacement in 5, aortic valve repair in 10, and Ross procedure in 7. Results Majority of patients were operated through midsternotomy. Aortic cannulation was possible in all but 4 patients in whom femoral artery cannulation was required. Operative mortality following reoperations was 7.5% (n=50). Peri-operative bleeding, low cardiac output and infective endocarditis were major causes of operative deaths. Other post-operative complications included cerebrovascular accident (n=3), acute renal failure (n=10) and jaundice (n=25). Fifteen patients developed significant wound infection. Conclusions Patients undergoing operation for valvular heart disease frequently require reoperation. Reoperative valvular heart surgery is safe and can be undertaken with acceptable mortality and morbidity.     

风湿性心脏瓣膜间质细胞的生物学特征

目的 观察风湿性心脏瓣膜间质细胞的生物学特征.方法 收集风湿性二尖瓣(22例)和正常二尖瓣(10例)标本,常规石蜡包埋后行苏木素-伊红(HE)和胶原纤维(VG)染色;新鲜标本分选瓣膜间质细胞分别行免疫细胞化学、Hoechst 33342染色和Western blot检测.结果 与正常瓣膜比较,风湿性二尖瓣表现为纤维化(22例)、钙化(20例).体外实验表明正常瓣膜间质细胞无特殊的生长形态,免疫表型为波纹蛋白[vimentin(+)]、α-平滑肌肌动蛋白[α-SMA(-)]、碱性磷酸酶[ALP(-)];风湿性瓣膜间质细胞易聚集生长成,免疫表型为vimentin(+)、α-SMA(+)、ALP(+).而且风湿性瓣膜间质细胞的Ⅰ型胶原纤维量(3倍)和凋亡细胞数(6倍)均明显高于正常瓣膜间质细胞(P＜0.05).结论 瓣膜间质细胞生物学特征的改变是导致瓣叶增厚、纤维化、钙化的主要因素.     

Surgical treatment for the valvular disease through partial sternotomy

213 patients who underwent surgical treatment for the valvular disease through partial sternotomy were studied. We started the minimally invasive valvular surgery in July 1997. All the valvular diseases were indicated for the minimally invasive surgery except for the annulo-aortic ectasia and the concomitant disease with coronary artery bypass surgery. Ascending aorta was selected as an arterial cannulation place if we could choice it through intraoperative echocardiography. Venous cannulae 22-24 Fr were inserted into the venae cavae directly or through right atrium. Negative pressure venous drainage (maximally 90 mmHg) was performed if necessarily. We did single approach as possible. Mortality rate was 3.8%. We could complete 96.2% of our series as a minimally invasive surgery. Post operative intensive care unit (ICU) stay and hospital stay through partial sternotomy were significantly shorter than those through full sternotomy.     

Efficacy of modified ultrafiltration in reoperation for valvular disease

We evaluated the efficacy of modified ultrafiltration (MUF) in reoperation for valvular disease. Fourteen patients were divide into two groups consisting of a control group (n = 6) and a MUF group (n = 8). MUF was carried out for fifteen minutes immediately after the completion of cardiopulmonary bypass. The blood flow through the ultrafilter was 300 ml/min and about 1,200 ml of water was removed. The hematocrit elevated significantly from 25% to 31% in the MUF group (p < 0.05). The percentage of the increase in body weight after the operation in the MUF group was significantly less than that in the control group (3.3 +/- 3.1% vs 8.3 +/- 4.3%, p < 0.05). The PaO2/FIO2 after the operation in the MUF group was significantly higher than that in the control group (376 +/- 125 mmHg vs 242 +/- 79 mmHg, p < 0.05). The duration of mechanical ventilation in the MUF group was significantly less than that in the control group (1.1 +/- 1.1 days vs 5.3 +/- 3.3 days, p < 0.05). In conclusion, MUF is useful to hemoconcentrate, reduce postoperative body weight gain and promote early recovery of pulmonary function in reoperation for valvular disease.     

Endourethral correction of valvular obstruction in children

Endourethral dissection of valvular cusps was carried out by means of an urethrotome in 34 boys with Type I and III valves of the posterior urethra. The indications for and the techniques of the dissection on depending on the type of the valve are discussed and measures for preventing complications are suggested. Endoscopic, radiological, and urodynamic methods of examination of the lower urinary tract determined the therapeutic tactics and help in evaluation of the efficacy of the operative treatment. The method allows correction in patients with valves to be performed in one stage in the compensated stage of the disease and after preliminary derivation of urine in the decompensated stage. The authors recommend optic urethrotomy for the treatment of children with valves of the posterior urethra.     

Current surgical treatment for acquired valvular heart disease

We discuss the current status of surgical treatment for acquired valvular heart disease. Mitral valve repair for organic and functional mitral regurgitation is the first choice instead of valve replacement. It is important that surgery for functional mitral regurgitation restores the geometry of the left ventricle and mitral valve. The reduction of mitral valve tethering for functional mitral regurgitation is a current topic of discussion. At present, the surgical procedure for both aortic stenosis and aortic regurgitation is valve replacement in most cases, although aortic valve repair has been attempted for aortic regurgitation in recent years. The early results of aortic valve repair are excellent, but the long-term results have not been clarified. The durability of valve repair in both the mitral and aortic position is a future issue and it may be improved by revising the indications for valve repair and using new surgical techniques.     

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.