Combined valve replacement and myocardial revascularization

Combining valve replacement with coronary artery bypass (CABG) for significant concomitant disease remains a controversial subject. To determine the operative results following combined valve replacement and CABG, we evaluated 201 patients seen consecutively between July 1977 and June 1982. CABG for vessels with greater than 70% stenosis was performed with aortic valve replacement in 106 patients, with mitral valve replacement in 82, and with aortic and mitral valve replacement in 13. There were 143 men and 58 women; the mean age was 67 years. Nine operative deaths (8.5%) occurred with aortic valve replacement and CABG: 5 of 25 (20%) when cardioplegia was not used and 4 of 81 (4.9%) with cardioplegia (p less than 0.01). The operative mortality rate for isolated aortic valve replacement without coronary disease during the same period was 5.9% (10 of 168). The late actuarial survival rate is similar for aortic valve replacement alone or aortic valve replacement and CABG. There were no operative deaths among patients having undergone aortic and mitral valve replacement and CABG; the rate was 15% (9 of 60) in patients having undergone aortic and mitral replacement and CABG. The operative mortality rate was 21.9% for mitral valve replacement and CABG (18 of 82). Rheumatic disease was present in 14 of these patients, two of whom had early deaths (14.3%), both after repeat mitral operations; 11 mitral valve replacements and CABG were done for degenerative mitral regurgitation with no deaths, and the remaining 57 patients had ischemic mitral regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Transcatheter mitral valve therapies: State of the art

Mitral regurgitation (MR) is one of the most prevalent valvular pathologies in the developed world. There continues to be a growing population of aging patients with MR who may be too high risk for surgical management. The rapid adoption and remarkable success of transcatheter aortic valve replacement (TAVR) generated enthusiasm for transcatheter mitral valve therapies; however, the complex anatomy and pathophysiology of the mitral valve confers several unique challenges for a fully percutaneous approach. Nevertheless, several devices are under development and in various phases of preclinical or clinical testing, both for transcatheter mitral valve replacement and repair. MitraClip (Abbott Vascular), which has received FDA approval, is the most established percutaneous repair strategy and has been performed in over 80,000 patients as of 2019. The following article serves as a review of the available and upcoming devices for the various etiologies of mitral valvular disease, as well as the unique challenges and potential complications of transcatheter mitral valve intervention.     

Triple valve repair for rheumatic heart disease

The onset of the clinical expression of rheumatic heart disease (RHD) is variable. Exercise or other states that necessitate increased cardiac output often precipitate symptoms. Mitral stenosis (MS) is present in 25% of patients with RHD, and 40% of patients have concomitant MS and mitral regurgitation. About two third of patients with MS have concurrent aortic insufficiency. Pulmonary and tricuspid insufficiency may occur from rheumatic involvement of these valves, or secondary to dilatation of valve annuli from pulmonary hypertension secondary to mitral and/or aortic valve disease. Pregnancy is associated with many hemodynamic changes including expanded intravascular volume, tachycardia, increased intracardiac dimensions, and valvular regurgitation. We report a case of a young female who developed flash pulmonary edema during parturition and was found to have abnormal rheumatic involvement of her aortic, mitral, and tricuspid valves. Successful triple valve repair was performed in a single operation. A review of rheumatic valvular abnormalities, and literature supporting multivalvular repair for rheumatic heart disease is provided.     

Long-term performance of prostheses in mitral valve replacement

The long-term performance of prostheses in mitral valve replacement (MVR) is now available with representatives of current generation prostheses to 15 years. Mechanical prostheses have been implanted for 33 years and bioprostheses for 22 years. The predominant complication of mechanical prostheses is hemorrhage from anticoagulation and reoperation for late structural valve deterioration of bioprostheses. Mitral valve (MV) reconstruction, over MVR, is recommended whenever possible, especially with the advancement of atrial fibrillation ablation techniques. The current indications for MVR are those valvular lesions that are unlikely to be repaired by most surgeons or which long-term results are suboptimal with reconstruction. Reconstruction is more common for degenerative disease, replacement for rheumatic disease and variable for advanced ischemic and infective disease. The recommendations for MVR for mitral stenosis (MS) are moderate to severe MS with advanced functional status and severe pulmonary hypertension when percutaneous balloon valvotomy or mitral reconstruction is not feasible. MVR is recommended in non-ischemic severe mitral regurgitation (MR) and for non-reparable acute symptomatic MR, advanced symptomatic status, systolic dysfunction and/or ventricular dysfunction. The recommendations for MV surgery in ischemic MR are acute post-infarction MR with cardiogenic shock, unstable angina with persistent moderate-severe and severe MR and chronic, dilated ischemic cardiomyopathy with moderate-severe and severe MR.     

Principles of reconstructive surgery in degenerative mitral valve disease

Degenerative mitral valve disease is the most common cause of mitral regurgitation (MR) in developed countries. The most common etiologies of valvular regurgitation are Barlow's disease and fibroelastic deficiency. The mechanism of MR is type II dysfunction (leaflet prolapse) due to chordae elongation or rupture in most patients. Associated annular dilation is a common lesion in almost all patients with chronic MR. By means of segmental valve analysis, isolated posterior leaflet prolapse (P2 segment) is often observed in patients with fibroelastic deficiency, whereas the prolapse of multiple segments or bileaflet prolapse is typically seen in patients with Barlow's disease. In patients with degenerative mitral valve disease and severe MR, reconstructive surgery should be performed before the occurrence of clinical symptoms, atrial fibrillation, pulmonary hypertension, and left ventricular dysfunction or enlargement. The goals of reconstructive surgery are preservation or restoration of normal leaflet motion, creation of a large surface of coaptation, and stabilization of the entire annulus with a remodeling annuloplasty. Today, reconstructive techniques are standardized, reliable, and reproducible, and therefore should be applied systematically to all patients with degenerative valvular disease.     

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 regurgitation. A comparison of nonoperative management, tricuspid annuloplasty, and tricuspid valve replacement.

The best means of managing tricuspid regurgitation associated with mitral or mitral and aortic valve disease is still to be determined. During the period 1972 to 1974, we treated 76 patients who had tricuspid regurgitation along with associated valvular dysfunction. Patients with mold regurgitation were treated conservatively, those with moderate regurgation underwent annuloplasty, and those with severe regurgitation had tricuspid valve replacement. We found the results to be less satisfactory in the group treated by annuloplasty than in the other two groups. We still manage conservatively those patients with mild regurgitation, but we believe it appropriate to replace the valve in an increasing number of subjects who have tricuspid regurgitation of moderate severity.     

Systolic anterior motion of the mitral valve and severe mitral regurgitation immediately after transcatheter aortic valve replacement

We report a high-risk patient with severe symptomatic aortic stenosis who showed systolic anterior motion of the mitral valve (SAM) and severe mitral regurgitation immediately after transcatheter aortic valve replacement (TAVR). The patient did not have either SAM or mitral regurgitation, but showed significant septal hypertrophy on preoperative transthoracic echocardiography which could be associated with the occurrence of SAM. Caution should be exercised in patients with significant interventricular septal hypertrophy before TAVR.     

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.     

Mitral valve repair--indication and late results

In recent years, mitral valve repair has become more widespread because it promises a reduction in both mortality and morbidity compared with valve replacement. As the incidence of rheumatic valve disease has declined in Japan, degenerative disease has become the most common cause of mitral regurgitation (MR), for which repair techniques can be successfully applied. The standard repair techniques, including artificial chordal implantation, increase the indications for valve repair to up to 95% of patients with MR and improve the long-term results. The indications for surgical intervention in patients with MR have evolved. Asymptomatic patients are considered for surgery when left ventricular function begins to deteriorate or atrial arrhythmias appear.     

Exercise echocardiography for structural heart disease

Since the introduction of transcatheter structural heart intervention, the term “structural heart disease” has been widely used in the field of cardiology. Structural heart disease refers to congenital heart disease, valvular heart disease, and cardiomyopathy. In structural heart disease, valvular heart disease is frequently identified in the elderly. Of note, the number of patients who suffer from aortic stenosis (AS) and mitral regurgitation (MR) is increasing in developed countries because of the aging of the populations. Transcatheter aortic valve replacement and percutaneous mitral valve repair has been widely used for AS and MR, individually. Echocardiography is the gold standard modality for initial diagnosis and subsequent evaluation of AS and MR, although the difficulties in assessing patients with these diseases still remain. Here, we review the clinical usefulness and prognostic impact of exercise echocardiography on structural heart disease, particularly on AS and MR.     

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.     

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.     

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)     

Fate of mild aortic valve disease after mitral valve intervention

OBJECTIVE: This study was performed to assess the long-term outcome of untreated mild aortic valve disease present at the time of initial mitral valve intervention. METHODS: A total of 284 patients with rheumatic heart disease aged 7 to 62 years (mean, 23.5 +/- 12.2 years) who underwent mitral valve intervention and had mild aortic valve disease initially were followed up for 2 to 18 years (mean, 10.8 +/- 3.7 years). At initial intervention, 232 patients had pure mild aortic regurgitation, and 52 patients had mild aortic stenosis with or without aortic regurgitation. RESULTS: Among patients with mild aortic regurgitation initially, 11 (5%) patients progressed to moderate (n = 6) or severe (n = 5) regurgitation over an interval of 9 to 17 years (mean, 12.1 +/- 2.8 years), and 1 patient had moderate aortic stenosis and severe aortic regurgitation after 10 years. Freedom from development of moderate-severe aortic valve disease in patients who initially had mild aortic regurgitation was 100%, 97.0% +/- 1.7%, and 87.4% +/- 4.6% at 5, 10, and 15 years, respectively. Seventeen (35%) patients with initial mild aortic stenosis (with or without regurgitation) had moderate or severe stenosis (with or without moderate-severe regurgitation) after an interval of 4.9 +/- 3.8 years. Freedom from development of moderate-severe aortic valve disease in patients who initially had mild aortic stenosis was 75.6% +/- 6.2%, 61.5% +/- 8.5%, and 46.1% +/- 11.2% at 5, 10, and 15 years, respectively. Ten patients required aortic valve replacement for aortic valve dysfunction. CONCLUSIONS: Mild aortic regurgitation present at the time of mitral valve intervention progresses very slowly and less frequently requires reintervention. However, mild aortic stenosis diagnosed initially progresses more often and more rapidly and thus needs closer follow-up.     

Percutaneous valve replacement and repair in the adult: Techniques and anaesthetic considerations

Standard treatment for valvular heart diseases such as aortic stenosis and mitral regurgitation includes replacement or repair of the valve. This will require median sternotomy and cardiopulmonary by-pass. In elderly patients with co-morbidity the risks from surgery increase and some patients may be classified as too high risk for surgery.Developments in percutaneous catheter delivered systems make it feasible that non-invasive valve repair and replacement can be performed. Those patients unsuitable for surgical treatment can be offered these procedures. We review the procedures available and the outcome data. We discuss the implications for anaesthesia and intensive care.     

Mitral valve repair with aortic valve replacement is superior to double valve replacement

OBJECTIVES: Double valve replacement has been advocated for patients with combined aortic and mitral valve disease. This study investigated the alternative that, when feasible, mitral valve repair with aortic valve replacement is superior. Patients and Methods: From 1975 to 1998, 813 patients underwent aortic valve replacement with either mitral valve replacement (n = 518) or mitral valve repair (n = 295). Mitral valve disease was rheumatic in 71% and degenerative in 20%. Mitral valve replacement was more common in patients with severe mitral stenosis (P =.0009), atrial fibrillation (P =.0006), and in patients receiving a mechanical aortic prosthesis (P =.0002). These differences were used for propensity-matched multivariable comparisons. Follow-up extended reliably to 16 years, mean 6.9 +/- 5.9 years. RESULTS: Hospital mortality rate was 5.4% for mitral valve repair and 7.0% for replacement (P =.4). Survivals at 5, 10, and 15 years were 79%, 63%, and 46%, respectively, after mitral valve repair versus 72%, 52%, and 34%, respectively, after replacement (P =.01). Late survival was increased by mitral valve repair rather than replacement (P =.03) in all subsets of patients, including those with severe mitral valve stenosis. After repair of nonrheumatic mitral valves, 5-, 10-, and 15-year freedom from valve replacement was 91%, 88%, and 86%, respectively; in contrast, after repair of rheumatic valves, it was 97%, 89%, and 75% at these intervals. CONCLUSIONS: In patients with double valve disease, aortic valve replacement and mitral valve repair (1) are feasible in many, (2) improve late survival rates, and (3) are the preferred strategy when mitral valve repair is possible.     

An experience of a case with perforation of an aneurysm in the anterior mitral cusp developing after aortic valve replacement.

Mitral valve aneurysm is a rare disease and in Japan, cases of perforation which is considered to be mainly caused by infectious endocarditis is usually only encountered through case reports. We experienced a case who received aortic valve replacement and mitral valve annuloplasty for combined valvular heart disease of aortic insufficiency and mitral insufficiency followed by mitral valve replacement for severe mitral valve regurgitation subsequent to perforation of the anterior mitral cusp, leading to recovery.     

Unexpected durability of Smeloff-Cutter aortic ball valve prosthesis

We report a case in which replacement of a Smeloff-Cutter aortic ball prosthesis was required 28 years after initial implantation. A 57-year-old woman underwent aortic valve replacement with a 21-mm Smeloff-Cutter ball prosthesis and open mitral commissurotomy for aortic stenosis, aortic regurgitation, and mitral stenosis in 1973. Severe aortic regurgitation occurred in April 2001, and aortic valve reoperation combined with mitral valve replacement was successfully performed. The patient's aortic ball valve was nearly intact with perivalvular leakage probably causing the aortic regurgitation. Our experience documents longer durability for the Smeloff-Cutter prosthesis than has been reported to date.     

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)