Outcomes in nonagenarians after heart valve replacement operation

BACKGROUND: Changes in the age profile of the United Kingdom population and improvements in preoperative and postoperative care have resulted in increasing numbers of very elderly patients undergoing heart valve replacement (HVR) operations. Although HVR operations in nonagenarians are relatively uncommon, the demand for cardiac operations in this age group may increase over time. Outcomes after HVR operations in nonagenarians have not been well described yet. Therefore, the aim of this study was to determine outcomes in terms of early mortality and long-term survival in 35 nonagenarians after HVR operation. METHODS: Data from the United Kingdom Heart Valve Registry were analyzed and nonagenarian patients were identified. Additional analyzed data include gender, valve position, valve type, valve size, operative priority, follow-up time, and date and cause of death. Kaplan-Meier actuarial curves were calculated to determine accurate 30-day mortality and long-term survival. RESULTS: On average five HVR operations are performed annually in the United Kingdom in nonagenarians with equal numbers of males and females. Aortic valve replacement with a bioprosthetic valve was the most common operation and 86% were elective admissions. Fourteen patients died within the review period; mean time to death was 402 days. Overall 30-day mortality was 17%, which was higher for males compared with females; females also displayed better long-term survival. CONCLUSIONS: HVR operations in nonagenarians carry a significantly higher risk of early mortality and reduced long-term survival. Despite increases in the age profile of the population, elective HVR operation with patients aged 90 years or older is likely to remain an infrequent surgical procedure reserved for very carefully selected patients.     

Older patients fare better with the Ross operation

BACKGROUND: The Ross operation has an established position in young patients. We address the question of whether any age group profits most from the Ross operation, and we compare the results in various ages. METHODS: From February 1995 to August 2001 we performed 250 Ross operations. Group 1 consisted of 46 patients, ages 2 to 25 years (median age, 15 years). Group 2 consisted of 123 patients, ages 26 to 49 years (median age, 39 years). Group 3 consisted of 81 patients, ages 50 to 67 years (median age, 55 years). Echocardiography was performed perioperatively, at 2 to 6 months, and then yearly. RESULTS: Mean follow-up for the three groups was 32, 31, and 28 months, respectively (p = 0.36). One patient from group 2 died after 25 months caused by suppurative pneumonia and 3 patients from group 3 died (1 from suspected acute thoracic aorta dissection at 40 months, 1 from ventricular fibrillation after 25 months, and 1 from an undiagnosed sudden death at 5 months). Autograft replacement was necessary for 3 patients from group 2 and 1 from group 3. Autograft repair was necessary for 1 patient from group 2, and pulmonary homograft reoperation was necessary for 1 patient from group 1. All other autografts currently have physiologic gradients and clinically insignificant regurgitation. Median peak gradient across the right ventricular outflow tract was 23.6 +/- 18 mm Hg for group 1, 14.6 +/- 8 mm Hg for group 2, and 11.5 +/- 7 mm Hg, which was significantly lower for group 3 patients (p < 0.001). Eleven patients are under close follow-up for right ventricular outflow tract gradients > or = 40 mm Hg; eight of these patients are from group 1, 3 are from group 2, and there are none from group 3. CONCLUSIONS: Although the Ross operation provides excellent results in all age groups, the problem of right ventricular outflow tract stenosis has not been seen in patients older than 50 years, which implies that it offers superior results for aortic valve disease in middle aged and older patients.     

组织工程心脏瓣叶体外生成可行性研究

目的初步探讨组织工程心脏瓣叶体外生成的可行性。方法杂种猪6只，取主动脉。分离血管内皮细胞及成纤维、平滑肌细胞，予培养扩增。将成纤维、平滑肌细胞与内皮细胞按顺序种植在预湿处理的支架材料上，使用DMEM培养。以首次种植成纤维、平滑肌细胞为起点，28d送样本进行扫描电镜、组织学检查和羟脯氨酸测定。结果扫描电镜检测显示，瓣叶支架上可见大量细胞粘附，支架表面细胞融合成片，表面尚可见细胞基质形成。HE染色显示材料上可见大量细胞粘附，已长入材料中部。弹性纤维染色显示有弹性纤维合成。羟脯氨酸测定显示瓣叶材料有羟脯氨酸合成。结论使用体外分离、培养及传代的内皮细胞和成纤维、平滑肌细胞，经体外种植、培养，有可能生成具有活性的组织工程心脏瓣叶。     

Awake heart valve surgery in a patient with severe pulmonary disease

Cardiac operations may be performed in a conscious, spontaneously breathing patient, but it is difficult to justify an awake technique in patients undergoing coronary artery procedures with low operative risk. We describe an elderly patient with severe chronic obstructive pulmonary disease in whom general anesthesia was contraindicated. A valve procedure was performed under thoracic epidural anesthesia alone, thus avoiding intubation and mechanical ventilation. The patient had an uneventful postoperative course and excellent recovery.     

A rare presentation of tricuspid valve thrombus in a normal heart

A young woman presented with a presumptive diagnosis of tricuspid valve tumor in a structurally normal heart. She was recently started on oral progesterone for menorrhagia related to uterine fibroids. She underwent an excision of the mass attached to the tricuspid valve, which was found to be an organized thrombus. We suggest a clinical approach to this problem.