The elimination of periprosthetic leaks as a complication of mitral valve replacement

A technique for placement of a mitral valve prosthesis has been designed specifically to eliminate the development of periprosthetic leak as a complication of mitral valve replacement. This technique has been employed in 97 patients undergoing isolated mitral valve replacement. No incidents of periprosthetic leak have been discovered in this group, despite a careful search for the complication.This group of patients is compared to an earlier group in whom mitral valve replacement was performed using more common techniques. A 10% incidence of periprosthetic leak was found in this group. Periprosthetic leaks commonly cause severe congestive heart failure or pronounced anemia from excessive hemolysis. Reoperation for the repair of periprosthetic leaks has been associated with a high mortality. These leaks are regarded as a technical error and may be avoided by an appropriate change in the technique of mitral prosthesis insertion.     

Successful transcatheter aortic valve implantation through ascending aorta and total revascularization using Edwards SAPIEN Transcatheter Heart Valve System

Transcatheter aortic valve implantation has become an established alternative treatment method for patients with symptomatic aortic stenosis who are at high risk for conventional aortic valve replacement. Problems, however, persist when using this technique in patients with associated coronary artery disease. We describe a successful case of valve implantation via the transaortic route with simultaneous full revascularization.     

Aortic Valve Replacement with the Unique Suture Line Stentless USL Porcine Valve: A New, Simple, and Safe Stentless Valve Implantation Technique

The Stentless USL, Unique Suture Line porcine valve, is a stentless bioprosthesis developed following the advantages of the studies of the physiology of the aortic root as a functional unit. The direct suturing of the porcine tissue on the soft and elastic tissue of the host's aortic annulus and root gives the bioprosthesis the possibility to follow the physiological movements of the natural valve during the cardiac cycle. For the same reason, there is decreased stress on the valve tissue, especially at the commissural level. There is less technical demand for surgeons who have limited experience with the freehand or miniroot technique due to the limited availability of the homografts because the Stentless USL valve can be implanted with the same technique used with a conventional stented valve. The implant technique used for the Stentless USL valve has advantages, especially in the small aortic calcified annulus in elderly patients where the freehand technique can be difficult and the second suture line can be dangerous (i.e., coronary ostium near the aortic ring or in calcified aortic wall). Our experience with this stentless valve in approximately 200 patients (> 70 years old) shows it to have excellent hemodynamic results even in small valve sizes. The use of this valve and the simple implantation technique avoids the need for complicated aortic root enlargement procedures.     

Aortic valve replacement with a freestyle stentless valve using the modified subcoronary technique and hemiarch replacement for bicuspid aortic valve and ascending aortic aneurysma; report of a case

An association between bicuspid aortic valve disease and ascending aortic aneurysma has long been recognized. Root replacement with a composite valve graft for such disease is a well-established technique. But it may involve serious technical difficulties, and may be a more time-consuming procedure than separate valve replacement and graft replacement. We performed an aortic valve replacement with Freestyle stentless valve using the modified subcoronary technique and hemiarch replacement for a 72-year-old man with severe aortic stenosis and ascending aortic aneurysma. Angiographic studies after surgery showed no residual aortic regurgitation (AR) and no deformity of aorta. This technique is an acceptable option for an aortic disease and ascending aneurysma in elderly patients.     

Closure of the Right Atrioventricular Valve in the Modified Fontan Operation for Univentricular Heart

Surgical palliation of univentricular hearts by a modified Fontan operation has become a useful procedure for these complicated cases. Closure of the right atrioventricular valve is an important part of the operation. Patch closure has been the technique used by most surgeons. Heart block and dehiscence of the patch have been two common complications of this technique; both involve severe hemodynamic upset and often death to the patients in the early postoperative period. We closed the right atrioventricular valve by approximating the leaflets using pledgeted mattress sutures in two patients. Advantages of this type of closure are avoidance of the conduction system and secure closure of the valve.     

Annular reconstruction for mitral valve replacement in a destroyed or calcified mitral annulus

Mitral valve replacement in the presence of severe annular calcification and an infectious lesion may be complicated by atrioventricular rupture, left circumflex coronary artery injury, and recurrence of infective endocarditis. Confronted with these circumstances, we have developed a technique of annular reconstruction for mitral valve replacement. The prosthetic valve is made by enlarging the circumference of the sewing ring with a Dacron collar. The collar can be sutured to the left atrial wall above the mitral annulus. This technique has been employed in five patients: three had extensive annular calcification, and two had acute valve endocarditis with destruction of mitral annulus. In all cases, the circumferential or partial annular reconstruction permitted secure implantation of the prosthetic valve. The one postoperative death was related to hemodialysis due to chronic renal failure. There were no other fatalities during the postoperative course, and the valves functioned normally. Our results suggest that this technique can be performed in high operative risk patients when mitral valve replacement is impossible using conventional techniques.     

Ablation of atrial fibrillation with minimally invasive mitral surgery

With the advent of minimally invasive mitral valve surgery, transeptal exposure of the mitral valve has become increasingly popular. While this approach provides excellent exposure of the mitral valve, it necessitates development of novel strategies for concomitant ablation in patients with atrial fibrillation. We describe a technique for creation of a biatrial lesion set for atrial fibrillation ablation that is easily employed using the transeptal approach to the mitral valve.     

Valve-sparing replacement of the noncoronary sinus of Valsalva in patients with a bicuspid aortic valve

Progressive dilatation of the aortic root and ascending aorta is frequent in patients with bicuspid aortic valve, and isolated dilatation of the noncoronary sinus has been reported. We describe our technique for the selective replacement of the noncoronary sinus of Valsalva in patients with bicuspid aortic valve.     

Complete endocardial cushion defect: the late result of repair using the single-patch technique

Twenty-two patients have been followed for between 1 and 105 months after repair of a complete endocardial cushion defect. The mean period of follow-up is 3.5 years. The single-patch technique was used in every patient. The mitral valve was repaired with buttressed sutures in those seen more recently. The mean age at the time of operation was 15 months. Early in this experience, 4 patients had severe mitral valve incompetence after an initially satisfactory repair. In none of those patients had the mitral valve been repaired with pledgeted sutures. Two of those patients survived reoperation, and 2 died before a second operation could be performed. Every mitral valve is now repaired with pledgeted sutures, and there have been no failures of the mitral valve reconstruction. Each patient has been followed by the same pediatric cardiologist every 6 to 12 months after operation. The vast majority (17 of 20) are asymptomatic. Twelve have no mitral valve incompetence, and the remainder have only trivial or mild incompetence. Clinically, the pulmonary artery hypertension has resolved in 19 of 20 patients. Each patient remains in normal sinus rhythm. The long-term results following repair of complete endocardial cushion defect with the single-patch technique are excellent, but pledgeted sutures should be used in the mitral valve repair to insure its integrity.     

The Leipzig experience with robotic valve surgery

OBJECTIVES: The study describes the single-center experience using robot-assisted videoscopic mitral valve surgery and the early results with a remote telemanipulator-assisted approach for mitral valve repair. MATERIAL AND METHODS: Out of a series of 230 patients who underwent minimally invasive mitral valve surgery, in 167 patients surgery was performed with the use of robotic assistance. A voice-controlled robotic arm was used for videoscopic guidance in 152 cases. Most recently, a computer-enhanced telemanipulator was used in 15 patients to perform the operation remotely. RESULTS: The mitral valve was repaired in 117 and replaced in all other patients. The voice-controlled robotic arm (AESOP 3000) facilitated videoscopic-assisted mitral valve surgery. The procedure was completed without the need for an additional assistant as "solo surgery." Additional procedures like radiofrequency ablation and tricuspid valve repair were performed in 21 and 4 patients, respectively. Duration of bypass and clamp time was comparable to conventional procedures (107 A 34 and 50 A 16 min, respectively). Hospital mortality was 1.2%. Using the da Vinci telemanipulation system, remote mitral valve repair was successfully performed in 13 of 15 patients. CONCLUSION: Robotic-assisted less invasive mitral valve surgery has evolved to a reliable technique with reproducible results for primary operations and for reoperations. Robotic assistance has enabled a solo surgery approach. The combination with radiofrequency ablation (Mini Maze) in patients with chronic atrial fibrillation has proven to be beneficial. The use of telemanipulation systems for remote mitral valve surgery is promising, but a number of problems have to be solved before the introduction of a closed chest mitral valve procedure.     

Transcatheter aortic valve replacement

Aortic stenosis is one of the most common valve pathologies found in adults. Aortic valve replacement via a sternotomy and cardiopulmonary bypass is the treatment of choice for patients with symptomatic aortic stenosis with very acceptable risk. However, patients with advanced age and multiple comorbidities carry significant operative risk; operative mortality as high as 25% was reported by many groups. Many of these patients are deemed nonsurgical for conventional aortic valve replacement by their cardiologists and surgeons. Novel surgical technique and valve technology offers an alternative treatment for aortic valve stenosis. Endovascular transcatheter aortic valve replacement is an emerging and promising technique, and may lower the risk in this subset of difficult patients.     

Valve replacement in patients with huge heart]

In general, valve replacement for patients with big heart (cardiac-thoracic rate greater than 0.80) has been considered a contraindication. Mitral valve replacement was done in 11 patients with a C/T rate of 0.81 to 0.97. In addition, aortic valve replacement was performed in 2 patients and tricuspid valvuloplasty in 5. One patient died from low cardiac output after operation. The heart function of the survivor was improved from III or IV to II degree after operation. We consider that active pre- and postoperative management for preserving myocardial function and preoperative technique are important for the successful treatment of patients with huge heart.     

Redo valve surgery with on-pump beating heart technique

AIM: Reoperations have become of increasing frequency in the last four decades. Redo surgery is more complex than primary surgery and is associated with higher mortality and morbidity. We present our immediate and mid-term results of mitral and aortic prosthetic valve replacement undertaken with beating heart technique. METHODS: The prospective study included 26 consecutive redo valve surgery patients who underwent valve re-replacement. The operation was carried out on a beating heart using normothermic bypass without cross-clamping the aorta for mitral valve surgery and retrograde coronary sinus normothermic noncardioplegic blood perfusion during cross-clamping the aorta for aortic valve procedures. RESULTS: Twenty-six patients (mean age 50+/-15 years) underwent reoperation with beating heart technique. Twenty (76.9%) mitral prosthetic replacements, 4 (15.4%) aortic prosthetic replacements, and 2 (7.7%) double valve replacements were achieved. Fourteen patients (53.8%) were operated for prosthetic valve dysfunction. Eighteen patients (69.2%) were in NYHA class III or IV preoperatively. Mean bypass time was 85+/-30 min. Mean duration of ventilation was 13.6+/-6 h, mean intensive unit stay was 2.8+/-6.4 days, and mean hospital stay was 8.3+/-7.2 days. Two (7.7%) patients required high dose inotropic support and in one patient (3.8%) intra-aortic balloon support was required. Pulmonary complication occurred in 1 patient (3.8%), low cardiac output in 1 patient (3.8%), and re-exploration for bleeding in 2 patients (7.7%). Operative mortality was not observed. CONCLUSION: Normothermic on-pump beating heart valve replacement offers a safe alternative to cardioplegic arrest in high-risk group. Complication rates are low and perioperative mortality is lower than with conventional surgery. Beating heart technique has the advantage of maintaining physiologic condition of the heart throughout the procedure.     

Transseptal suture fixation in the management of prosthetic valve dehiscence

Valve dehiscence resulted from prosthetic valve endocarditis and aortitis is the most common cause of the reoperation after prosthetic valve replacement. In our experience, the results of reoperation has been far from satisfactory. For the successful management of prosthetic dehiscence, we have adopted the transseptal suture technique of accurately securing the prosthetic valve. Five patients with prosthetic valve dehiscence and one patient with native valve endocarditis were operated upon using the transseptal techniques. Left ventricular-aortic discontinuity was repaired using composite valve-tube graft together with this technique in two patients. All but one patient who succumbed to multiple organ failure induced by preoperative hemodynamic deterioration have survived the operation without recurrent infective endocarditis or valve dehiscence.     

Leaflet extension technique in a congenital aortic valve regurgitation

A 17-year-old boy who was diagnosed as congenital aortic valve regurgitation underwent the leaflet extension technique in 3 aortic leaflets using glutaraldehyde-preserved autologous pericardium. Intraoperative transesophageal echocardiography and postoperative cardiac catheter revealed grade I regurgitation and the patient has been doing well for more than 4 months after the surgery. The leaflet extension technique is considered to be an acceptable surgical treatment for aortic valve disease especially in young patients to whom valve replacement or Ross procedure might not be suitable. A careful long-term follow-up will be necessary to evaluate the durability of the leaflet extension technique with autologous pericardium.     

The mitral plication suture: a new technique of mitral valve repair.

During 1975, 67 patients underwent attempted repair of mixed mitral valve disease by use of the new mitral plication suture (MPS) technique. Ninety per cent had successful repair and 10 par cent required valve replacement. The MPS is a double, semicircular, buttressed annuloplasty suture that constricts the enlarged mitral annulus to correct mitral regurgitation (MR), supports mitral subunit repair procedures, and yet maintains the flexibility of the mitral annulus. The hospital mortality rate was 6 per cent. There were no late deaths during 10.4 months of follow-up. Six per cent of the patients who had valve repair required subsequent MVR. Their repair operations are considered late failures. Echocardiography, a useful technique for assessing the status of the patients postoperatively, demonstrated normal mitral valve and left ventricular function in the majority of patients; comparisons with replacement valves are documented. Death and morbidity was less frequent than in patients with MVR, both in the hospital and during follow-up. The aggressive policy of mitral valve repair has reduced the number of MVR's from 95 during 1974 to 52 in 1975. Although follow-up is short, we conclude that the new MPS is a valid surgical adjunct to the complete repair of the mitral valve.     

Modified techniques for improving the continent ileostomy

Most patients will elect to have a continent ileostomy over the conventional Brooke variety if given a choice. Incontinence from valve slippage has represented a major problem. Our technique for valve construction now includes the use of an isoperistaltic ileal segment, a Marlex mesenteric sling, stapling of the valve, and cauterization of the intussuscepted, serosal bowel surface. Utilizing these maneuvers, 22 consecutive continent ileostomies have been fashioned over a period of 5 years and none has necessitated reoperation for valve slippage. Half of these were done at the time of coloproctectomy, while the remainder were Brooke ileostomy conversions. The continent ileostomy is a viable surgical procedure and represents the anatomical arrangement of choice for many patients after coloproctectomy.     

Improved intraoperative evaluation of mitral valve operations utilizing two-dimensional contrast echocardiography

Whenever possible, precise mitral valve repair is preferable to valve replacement. Present methods for intraoperative detection of mitral regurgitation, primarily hemodynamic measurements and direct palpation, may underestimate or not detect the presence and severity of regurgitation. We have investigated two-dimensional contrast echocardiography as a means of improving our intraoperative assessment of mitral valve function both before and after repair or replacement. After exposure of the heart, a baseline two-dimensional echocardiogram (in modified long- and short-axis planes) is performed using a hand-held 5 mHz mechanical transducer. Five milliliters of agitated 5% dextrose in water is injected into the left ventricle through a transseptal needle to generate detectable microbubbles. In the absence of mitral regurgitation, virtually all microbubbles exit through the aorta; in the presence of regurgitation, a mass of microbubbles reflux into the left atrium. After repair of the mitral valve and immediately after bypass, the contrast echocardiogram is repeated and hemodynamic measurements are obtained. Forty-three patients (37 with mitral valve disease and six additional patients without mitral disease) undergoing cardiac operations were evaluated. Experience with intraoperative two-dimensional contrast echocardiography has accurately demonstrated relatively small degrees of mitral regurgitation when conventional techniques failed to do so and has allowed more precise repair of the residual regurgitation. Two commissurotomy and two annuloplasty patients who were thought to have satisfactory repairs underwent immediate second procedures because of significant residual mitral regurgitation demonstrated solely by this echocardiographic microbubble technique. No complications associated with this technique have developed. We conclude that intraoperative two-dimensional contrast echocardiography is a sensitive and safe technique that allows intraoperative detection of even small degrees of mitral regurgitation and provides a basis for precise repair of mitral valve lesions.     

保留主动脉瓣主动脉根部置换术的研究进展

多年以来,主动脉瓣和主动脉根部置换术被认为是主动脉根部瘤的标准治疗方法。随着人们对主动脉瓣置换术后并发症危害性认识的增加,和对主动脉瓣根部解剖及生理特点认识的深入,保留主动脉瓣主动脉根部置换技术有了较大发展。我们主要介绍主动脉瓣关闭不全的病因和分类、主动脉瓣保留技术及临床结果。     

Aortic valve replacement with the freestyle stentless bioprosthesis with respect to spacial orientation of patient coronary ostia

OBJECTIVE: This study evaluates our results for safety and efficacy of aortic valve replacement using the Freestyle bioprosthesis (Medtronic, Inc, Minneapolis, Minn) with a new modified subcoronary implantation technique. This technique takes into account the spacial orientation of the stentless bioprosthesis in the aortic root with respect to the patient's coronary ostia rather than the native commissures. METHODS: Fifty-two consecutive patients with predominant aortic valve stenosis underwent aortic valve replacement with a Freestyle bioprosthesis by means of the described modified subcoronary technique over a 15-month period. Fifty of them were followed up by means of echocardiography at discharge, 6 months, and 1 year. There were 19 men and 31 women, with a mean age of 76 +/- 7 years (range, 58-87 years). Valve size ranged from 21 to 27 mm. RESULTS: Patients with bicuspid aortic valves had a significantly larger angle between both coronary ostia than patients with tricuspid aortic valves (P =.0001). The peak and mean systolic gradients decreased significantly during the first postoperative year for each valve size (P 相似文献