Morbidity and mortality seen in patients with a Hancock bioprosthesis, followed for more than 5 years. Experience at the La Pitié Hospital

Between 1975 and 1983, 305 Hancock bioprostheses were implanted at the La Pitié Hospital, Paris, including 133 on the aortic valve and 172 on the mitral valve. The operative mortality rate was 6 p. 100 in patients with isolated aortic valve replacement and 12.8 p. 100 in patients with isolated mitral valve replacement (including 4 reoperations for mechanical valve thrombosis). 245 patients were followed up for a mean period of 5 1/2 years. The actuarial survival rate, operative mortality excluded, was 77.5 +/- 4.4 p. 100 in the aortic valve group and 76 +/- 4.4 p. 100 in the mitral valve group (non significant difference). Later after surgery, 8 embolic accidents (5 in the mitral valve group, 3 in the aortic valve group) occurred, and 20 patients developed endocarditis. Forty-nine patients required reoperation, 33 of them for deterioration of the bioprosthesis. The probability of being free from such deterioration varied significantly according to the patient's age at the time of the operation. In the aortic valve group this probability at 8 years was 97 p. 100 +/- 2.7 p. 100 for patients over 35 and 63.3 p. 100 +/- 1.7 p. 100 for patients under 35; the corresponding figures at 8 years in the mitral valve group were 80 p. 100 +/- 3.8 p. 100 for patients over 35 and 55.2 p. 100 +/- 2.2 p. 100 for patients under 35. There was no significant difference between the mitral and the aortic valve groups with regard to the percentage of prosthetic valve deterioration. The operative mortality rate in reoperations was 14.2 p. 100 irrespective of the cause of death.     

Artificial chordae for mitral valve repair: mid-term clinical and echocardiographic results

BACKGROUND: This paper reports on the mid-term clinical and echocardiographic results of mitral valve repair with chordal replacement. METHODS: Sixty-nine patients (mean age 61 +/- 14 years) underwent mitral valve repair with chordal replacement. The etiology was degenerative in 53 (77 %), rheumatic in 7 (10 %), ischemic in 6 (9 %) and infective in 3 (4 %). Mean ejection fraction was 58 +/- 14. In 35 patients (51 %), a minimally invasive approach was used. Mean follow-up time was 45 +/- 27 months. RESULTS: Anterior leaflet chordae were replaced in 58 (84 %) patients. There were 3 operative deaths. Freedom from non-trivial recurrent mitral regurgitation (MR) was 81.3 +/- 8.7 % at 97 months. Follow-up echocardiographic controls showed mild recurrent MR in 5 (8 %) patients and moderate in 2 (3.2 %). These two patients required reoperation due to mitral annulus redilation after suture annuloplasty. Competent neochordae were found at reoperation. Freedom from reoperation at 97 months was 96.6 +/- 2.4 %. Four patients died during follow-up resulting in an actuarial survival of 87 +/- 6.2 %. CONCLUSION: The replacement of chordae tendineae with ePTFE sutures during mitral valve repair has shown good mid-term results. The implantation of the neochordae can be also performed safely using minimally invasive procedures.     

Surgical treatment for mitral regurgitation: mid-term outcome following mitral valve repair

Mid-term results of mitral valve repair for mitral regurgitation were evaluated in 173 consecutive patients (mean age 53 years, 107 males, 66 females) treated from July 1991 to March 1998. Pathological causes of the mitral valve disease were degenerative in 118 patients, infective endocarditis in 25, rheumatic in 13, and ischemic in 8 (ischemic cardiomyopathy in 7). The principal technique was chordal replacement with expanded polytetrafluoroethylene sutures for prolapse of the anterior leaflet, and Carpentier's sliding leaflet technique for prolapse of the posterior leaflet. Most patients received ring annuloplasty with a rigid ring and flexible band (physiological remodeling annuloplasty). Intraoperative transesophageal echocardiography was used after 1993. There were 7 operative deaths (4%) and 7 mitral valve replacements (4%) during the same operation. Successful repair was achieved in 96% of patients with mitral regurgitation. Mean follow-up was 35 months (range 2 to 78 months). Survival at 6 years was 85 +/- 10% of all patients, 98 +/- 2% in degenerative cases. Six patients required reoperation (1.2%/patient-year) and mean time interval between initial operation and reoperation was 33.1 months. Four patients with atrial fibrillation had thromboembolic events (0.8%/patient-year). There were no anticoagulant-related complications. Freedom from reoperation and all valve-related event at 6 years was 88 +/- 6% and 84 +/- 6%. Late postoperative Doppler echocardiography revealed satisfactory results in 93% of the patients. Mitral valve repair using chordal replacement, sliding plasty and ring annuloplasty provides excellent mid-term results.     

Valve dysfunction of the cloth-covered Starr-Edwards ball valve.

BACKGROUND: Between June 1968 and March 1977, Starr-Edwards cloth-covered ball valves were used for valve replacement on a routine basis. METHODS AND RESULTS: Among the 66 operative survivors who underwent an isolated aortic or mitral valve replacement, 20 patients required reoperation 22 times because of valve dysfunction, thromboembolic complication, paravalvular leakage, hemolytic anemia, and/or prosthetic valve endocarditis. Reoperation was performed at a mean of 15.9+/-9.8 years after initial replacement. Excised valves were examined and reoperation after initial operation was reviewed. Operative mortality was 10.0%. Freedom from reoperation for aortic valve replacement and mitral valve replacement was 56.2% at 34 years and 61.0% at 37 years after initial operation, respectively. Cloth wear or pannus formation were observed in all excised prostheses. Orifice cloth was more markedly worn in mitral valves than in aortic valves, particularly in mitral valves of more than 20 years old. Pannus overgrowth contributed to valve regurgitation in the older valves. CONCLUSIONS: Early diagnosis of valve dysfunction and reoperation are recommended as soon as symptoms appear.     

Late results of combined mitral valve replacement and coronary bypass surgery

The incremental risk of coronary bypass surgery was analyzed in 718 patients undergoing mitral valve replacement between 1971 and 1983. Ninety-eight patients (14%) had significant coronary artery disease requiring coronary bypass surgery. In 70 of these patients, the origin of the mitral valve disease was nonischemic, whereas 28 patients had ischemic mitral regurgitation unsuitable for conservative valve surgery. There were six operative deaths (9%) and four perioperative myocardial infarctions (6%) after mitral valve replacement and coronary bypass surgery for nonischemic mitral valve disease. Operative mortality was related to low output cardiac failure before operation or perioperative myocardial infarction. Actuarial curves predict survival (+/- standard error) of 55 +/- 7% at 5 years and 43 +/- 8% at 10 years. Preoperative functional class was the only significant predictor of long-term survival in this group (p less than 0.05). The actuarial survival of the 620 patients without coronary artery disease who underwent mitral valve replacement alone was 63 +/- 3% at 10 years. This was significantly better than that of the 70 patients who underwent mitral valve replacement and coronary bypass surgery for nonischemic mitral valve disease (p less than 0.001). Conversely, 5 year survival of the 28 patients with ischemic mitral regurgitation was 43 +/- 10%. This confirms the negative detrimental effect of an ischemic origin of mitral valve disease on survival after mitral valve replacement and coronary bypass surgery (p less than 0.0001).     

A prospective evaluation of the Bj?rk-Shiley, Hancock, and Carpentier-Edwards heart valve prostheses

From 1975 to 1979, 540 patients undergoing valve replacement were entered into a randomized trial and received either a Bj?rk-Shiley (273 patients) or a porcine heterograft prosthesis (initially a Hancock valve [107 patients] and later a Carpentier-Edwards prosthesis [160 patients]). Two hundred and sixty-two patients required mitral valve replacement, 210 required aortic valve replacement, 60 required mitral and aortic valve replacement, and eight also required associated tricuspid valve replacement (six mitral valve replacement; two mitral plus aortic valve replacement). Analysis of 34 preoperative and operative variables showed the treatment groups to be well randomized. In-hospital mortality was not significantly different among patients receiving the three prostheses for aortic valve replacement (7.6% overall) and mitral plus aortic valve replacement (10% overall), but there was a higher in-hospital mortality for patients undergoing mitral valve replacement with the Carpentier-Edwards prosthesis (15.5% compared with 8.8% overall; p = .03). This difference could not be explained on the basis of any preoperative or operative variable. Median follow-up was 5.6 (range 2.8 to 8.3) years. Actuarial survival after mitral valve replacement was 56.7 +/- 7.0% at 7 years, that after aortic valve replacement was 69.6 +/- 9.6% at 7 years, and that after mitral plus aortic valve replacement was 62.5 +/- 20.0% at 7 years. There was no significant difference in actuarial survival of patients receiving the three prostheses within the mitral, aortic, and mitral plus aortic valve replacement groups, nor was there a difference when these groups were amalgamated. Thirty-seven patients required reoperation for valve failure (15 with Bj?rk-Shiley, 12 with Hancock, and 10 with Carpentier-Edwards valves; p = NS) and 11 died at reoperation (four with Bj?rk-Shiley, four with Hancock, and three with Carpentier-Edwards valves; overall operative mortality 29.7%). Up to 7 years after surgery, there was no significant difference in the incidence of thromboembolism in patients with different prostheses undergoing mitral or aortic valve replacement. There were too few patients undergoing mitral plus aortic valve replacement for meaningful comparison. There was no significant beneficial effect of anticoagulants in patients undergoing mitral or aortic valve replacement with porcine prostheses, but patients were not randomly allocated to anticoagulant treatment. All patients with Bj?rk-Shiley prostheses received anticoagulants.(ABSTRACT TRUNCATED AT 400 WORDS)     

Mitral valve relpair and revascularization for ischemic mitral regurgitation: predictors of operative mortality and survival

BACKGROUND AND AIMS OF THE STUDY: Surgery for ischemic mitral regurgitation (IMR) is required in 4-5% of patients subjected to coronary artery surgery, and may be challenging. The study aim was to determine outcome following mitral valve repair and myocardial revascularization for moderate-to-severe IMR. METHODS: A total of 102 patients (mean age 68+/-7 years) underwent mitral valve repair for IMR between 1998 and 2001 at the authors' unit. Among patients, 28 had acute and 74 chronic mitral regurgitation (MR). Valve repair was achieved with an annuloplasty ring in all 102 patients, while 99 underwent concomitant myocardial revascularization. Preoperatively, 69 patients had MR grade III-IV, 62 had CCS angina class III-IV, 59 were in NYHA class II-IV, 81 had impaired left ventricular function, and 10 were in cardiogenic shock.Follow up was 100% complete (mean 14+/-7 months; range: 0-38 months). RESULTS: Overall operative mortality was 8.8% (n = 9) (17.8% for acute IMR, 5.4% for chronic, p = 0.048). On multiple logistic regression analysis, cardiogenic shock (p = 0.028) was the only significant risk factor for operative death. There were 11 late deaths. Kaplan-Meier survival at one and three years was 82+/-4% and 79+/-4%, respectively. On Cox proportional hazards regression model, preoperative left ventricular end-systolic diameter (LVESD) >4.5 cm (p = 0.01) and NYHA class III-IV (p = 0.02) were independent adverse predictors of survival. Three patients required reoperation. Kaplan-Meier three-year freedom from reoperation was 97+/-2%. CONCLUSION: Surgery for IMR carries a considerable, but acceptable, operative risk and provides satisfactory freedom from reoperation and mid-term survival. Cardiogenic shock before surgery is the major determinant of an unfavorable in-hospital outcome. LVESD >4.5 cm and poor preoperative NYHA status limit the probability of late survival. The study results support early surgical intervention for IMR, before ventricular dilatation occurs.     

Effect of prior aortic valve intervention on results of the Ross operation

BACKGROUND AND AIM OF THE STUDY: Patient-related factors, aortic insufficiency, bicuspid aortic valve, aortic annulus dilatation, ascending aortic dilatation or aneurysm, and aortic valve endocarditis have been suggested as affecting the results of the Ross operation. The study aim was to assess the impact of prior aortic valve intervention on early and late results of a Ross operation. METHODS: A total of 399 patients who underwent surgery between August 1986 and September 2000 were reviewed retrospectively. The patients were grouped as: no prior aortic valve intervention (NOAVI, n = 219); prior aortic valvuloplasty (AVP, n = 106); prior balloon aortic valvuloplasty (AVB, n = 40); and prior aortic valve replacement (AVR, n = 34). Details of operative and late mortality, autograft valve function, and homograft valve function were analyzed. RESULTS: Operative mortality was higher for AVB (10%; three deaths in neonates) than the other groups (from 2.3% to 5.9%) (p = 0.084). Freedom from autograft valve degeneration, defined as severe autograft valve insufficiency, non-endocarditis autograft valve reoperation or valve-related death, ranged from 93 +/- 3% for AVP to 76 +/- 8% for NOAVI at 10 years (p = 0.43). Freedom from homograft reoperation in the pulmonary position was 100% for AVB at six years, and 99 +/- 1% for AVP, 82 +/- 8% for NOAVI, and 70 +/- 13% for AVR at 10 years (p = 0.0026). CONCLUSION: There appears to be no significant difference between patients with and without prior aortic valve surgery, with respect to operative mortality or late autograft function. However, patients with prior AVR appear to have a significantly higher homograft reoperation rate after a Ross operation, the reasons for which are uncertain.     

Comparative study between valve repair and replacement for mitral pure regurgitation--early and late postoperative results

From May 1975 through December 1988, 91 patients (mean age 50.4 +/- 12.8 years) had first-time surgery for mitral pure regurgitation; 48 had mitral valve replacement (MVR) and 43 had valve repair. A majority of the patients had non-rheumatic valvular diseases. Those patients who underwent repair had less hemodynamic and functional derangement than those who underwent MVR. The operative mortality was 8.3% in the MVR group and 2.3% in the repair group. Seventeen percent of the MVR group and 2% of the repair group required intra-aortic balloon pumping support (p less than 0.03). A higher dose of dopamine and/or dobutamine during the early postoperative period was necessary in the MVR group (7.0 +/- 4.8 micrograms/kg/min) than in the repair group (5.1 +/- 3.1 micrograms/kg/min). Duration of respirator support for hospital survivors was longer in the MVR group (2.3 +/- 2.7 days) than in the repair group (1.4 +/- 1.0 days). There were 5 late deaths (2.2 +/- 1.0%/pt-yr) not counting 6 non-cardiac deaths in the MVR group and 1 (0.6 +/- 0.6%/pt-yr) in the repair group. There were 17 patients (7.5 +/- 1.8%/pt-yr) who experienced treatment failure in the MVR group and 5 (2.3 +/- 1.3%/pt-yr) in the repair group (p less than 0.02). Eight patients in the MVR group (3.5 +/- 1.3%/pt-yr) underwent repeat surgery in the late postoperative period, as did 3 (1.7 +/- 1.0%/pt-yr) in the repair group. There was no increase in the incidence of repeat surgery after valve repair. All the current survivors in the repair group, and 96% of those in the MVR group were in NYHA functional class I or II. These results indicate that mitral repair is the preferred operative procedure for pure mitral regurgitation, whenever it is possible.     

Is Posterior Leaflet Extension and Associated Commissurotomy: Effective in Rheumatic Mitral Valve Disease? Long-Term Outcome

In this prospective study, the long-term effect of posterior leaflet extension with glutaraldehyde-preserved autologous pericardium and associated mitral valve commissurotomy was investigated in patients with mixed mitral valve disease of rheumatic origin. Mitral commissurotomy and posterior leaflet extension using a pericardial patch were performed in 25 patients from 1 January 1994 through 31 December 1995 for mixed mitral valve disease. Preoperatively, no patient had chordal rupture or papillary muscle dysfunction. Four patients had left atrial thrombosis. The mean age was 35.7 +/- 15.4 years. Associated procedures were tricuspid annuloplasty in 4 patients, aortic annuloplasty in 3, aortic and tricuspid annuloplasty in 1, and aortic homograft replacement in 1. There were no early deaths. One patient died 2 years after surgery due to noncardiac causes. Mitral valve area increased from 1.53 +/- 0.63 cm2 to 2 +/- 0.33 cm2 (P = 0. 09), and left atrial diameter decreased from 5.8 +/- 1 cm to 4.86 +/- 1.27 cm (P = 0.07) after 6.1 +/- 0.7 years (range, 5.5 to 71 years). Mitral insufficiency was reduced significantly, from grade 2.65 +/- 0.9 to grade 1.2 +/- 0.9 (P = 0.007). Functional capacity improved in all patients (New York Heart Association functional class, 3 +/- 0.58 preoperatively vs 1.44 +/- 0.82 postoperatively; P = 0.001). Three patients required reoperation and valve replacement. This type of reconstruction may be a good alternative for patients who are not able to use anticoagulant therapy. Long-term results of this technique are acceptable; however, the risk of reoperation is an important disadvantage in these young patients.     

Minimally invasive video-assisted mitral valve repair: short and mid-term results

BACKGROUND AND AIM OF THE STUDY: Port-Access video-assisted surgery for mitral valve repair has become an alternative for mid-sternotomy. However, mid-term results are not yet available. METHODS: Between February 1997 and December 1999, 121 patients underwent mitral valve surgery through a 4- to 5-cm right anterolateral thoracotomy using the Heartport endovascular cardiopulmonary bypass system; among these patients, 77 (57 males, 20 females; mean age 59 years; range 31-84 years) underwent mitral valve repair. Severe (4+) mitral regurgitation (MR) was seen in 63 patients (82%). Mean NYHA class was 2.5+/-0.4. Standard Carpentier mitral valve repair procedures were used in all patients; 11 received PTFE chordae for anterior leaflet prolapse. RESULTS: Pathologies were degenerative (n = 69), chronic endocarditis (n = 4), annular dilatation (n = 3) and rheumatic (n = 1). Hospital mortality was 1.3% (n = 1). Two patients (2.6%) had conversion to sternotomy for aortic dissection caused by the Endo-Aortic Clamp. Nine patients (11%) underwent revision for bleeding. Mean cross-clamp and perfusion times were 103 min (range: 24-160 min) and 140 min (range: 75-215 min), respectively. Mean hospital stay was eight days (range: 4-36 days). During follow up (mean 31 months; range: 17-51 months) all patients improved their NYHA class; eight (11%) remained in class II. Left ventricular (LV) end-diastolic and LV end-systolic diameters decreased from 61+/-7.3 mm to 53+/-6.9 mm (p <0.01) and from 37+/-6.8 mm to 34+/-6.9 mm (p <0.05), respectively. Sixty-two patients (88%) had no or trivial MR, and nine (12%) had moderate MR (2+). There were two late valve replacements for endocarditis, and no late deaths. CONCLUSION: Port-Access mitral valve repair constitutes a valid alternative to the standard procedure, and has good mid-term results. Video-assisted mitral valve repair appears to be safe and reproducible.     

Double valve Implantation. Long-term evaluation of 8 different bioprostheses

From January 1976 through December 1987, 194 patients with a mean age of 43.3 +/- 13.7 years (range, 11 to 74 years) underwent double (mitral and aortic) replacement of native valves with 8 types of bioprostheses: Carpentier-Edwards, 127 valves; Hancock, 76 valves; Liotta-Bioimplant, 57 valves; Ionescu-Shiley, 53 valves; Vascor, 27 valves; Carpentier-Edwards Pericardial, 22 valves; Angell-Shiley, 20 valves; and Implamedic, 6 valves. Concomitant cardiac procedures were performed in 25 patients (12.8%). There were 18 operative deaths (9.27%). Our retrospective analysis was restricted to 352 bioprostheses implanted in the 176 patients who survived surgery and were considered at risk for valve tissue failure. The overall cumulative duration of follow-up was 1,174.1 patient-years (range, 1 to 13 years). The durations of follow-up for specific valves were: Carpentier-Edwards, 920.2 valve-years; Hancock, 383.8 valve-years; Liotta-Bioimplant, 310.2 valve-years; Ionescu-Shiley, 357.7 valve-years; Vascor, 131.2 valve-years; Carpentier-Edwards Pericardial, 52.0 valve-years; Angell-Shiley, 167.0 valve-years; and Implamedic, 31.0 valve-years. Thirty patients had thromboembolic accidents, for a linearized incidence of 2.5% per patient-year. At 13 years, the actuarial freedom from thromboembolic accidents was 85.8% +/- 10.7%. Nine patients had endocarditis, for a linearized incidence of 0.7% per patient-year. At 13 years, the actuarial freedom from endocarditis was 92.0% +/- 1.5%. Twenty-four patients had valve tissue failure, for a cumulative linearized incidence of 1.87% per valve-year. The cumulative actuarial probability of freedom from valve tissue failure was 78.6% +/- 3.7% at 10 years and 51.2% +/- 10.7% at 13 years. The 24 patients with valve tissue failure all underwent reoperation: 20 of these had double valve replacement, 3 had aortic valve replacement alone, and 1 had mitral valve replacement alone. The mean interval between initial valve implantation and reoperation was 66.9 +/- 28.8 months. At reoperation, the hospital mortality was 15.1% (5 patients). This study showed that the long-term results of valve implantation are not significantly influenced by either prosthesis design or material. Moreover, the incidence of degenerative change was similar in the aortic and mitral positions.     

Ventricular septal defect with congenital mitral valve disease: long-term results of corrective surgery

BACKGROUND: A retrospective analysis of the mortality, morbidity and long-term follow-up of patients undergoing corrective surgery for ventricular septal defect and congenital mitral valve disease is presented. METHODS AND RESULTS: Between January 1991 and December 2000, 69 consecutive patients aged 2 months to 45 years (median 18 months) underwent repair of ventricular septal defect and associated mitral valve disease. In 52 patients (75%), the ventricular septal defects were located in the perimembranous and subarterial area. Forty-six patients had congenital mitral incompetence and 23 had congenital mitral stenosis. The ventricular septal defect was repaired through the right atrium in all. Sixty-five patients underwent reconstruction of the mitral valve and 4 underwent primary mitral valve replacement. Another 4 patients underwent mitral valve replacement after a failed repair. Associated procedures included: patent ductus arteriosus ligation (n=12), aortic valve replacement (n=6), coarctation repair (n=13), interrupted aortic arch repair (n=1), atrial septal defect closure (n=17) and Takeuchi repair (n=1). There were 6 early deaths (8.6%). Three deaths were due to pulmonary arterial hypertensive crisis and one due to residual mitral stenosis. One death was due to intractable congestive heart failure. Another patient died due to persistent low cardiac output. Follow-up ranged from 6 months to 120 months (mean 64.4+/-33.6 months). Reoperation was required in 22 patients, mainly for recurrent/residual mitral valve dysfunction or hemodynamically significant left ventricular outflow tract obstruction. There were 4 late deaths, 2 due to residual mitral stenosis and the other 2 as a result of a thrombosed prosthetic valve. At 10 years, the actuarial survival rate was 850+/-5.0%, and freedom from reoperation was 45%+/-10.0%. CONCLUSIONS: Reconstruction of the mitral valve along with closure of VSD is possible in most cases. However, careful follow-up is recommended to detect changes in the mitral valve status over a course of time.     

Factors influencing survival after surgery of pure non-ischemic mitral insufficiency

Uni and multifactorial (Cox) statistical analysis of the results of surgery in a series of 247 patients operated between 1969 and 1988 for pure, non-ischaemic mitral regurgitation was undertaken to determine the factors influencing operative and late mortality. All but 3 cases were adults, average age 51 years, and very symptomatic (75 per cent Class III et IV of NYHA Classification). Dystrophic or degenerative lesions were responsible for 53 per cent of cases of regurgitation whilst rheumatic valvular disease was only observed in 30 per cent of cases. Mitral valve replacement was performed in 137 patients (96 mechanical and 41 bioprostheses) and conservative surgery was possible in 110 cases. There were 12 operative deaths (4.9%); the operative risk increased with age and with the practice of valve replacement. Eleven of the 235 survivors (4.7%) were lost to follow-up. During the follow-up period (average 58 months) there were 37 late deaths of which nearly a half were due to left ventricular dysfunction. Multifactorial analysis identified cardiothoracic ratio and atrial fibrillation as predictive factors of late mortality whilst left ventricular ejection fraction and the type of surgery were related to the development of left ventricular dysfunction. The postoperative left ventricular ejection fraction was significantly lower after valve replacement than after valvuloplasty (11 +/- 13% vs 3 +/- 13%; p less than 0.01). These results are therefore in favour of early correction of severe mitral regurgitation by conservative surgery whenever possible.     

Resuspension of the aortic valve in acute type A dissection: long-term results

BACKGROUND AND AIM OF THE STUDY: Preservation of the aortic valve during the repair of acute type A aortic dissection (AADA) is a viable option to prevent lifelong oral anticoagulation. The study aim was to assess aortic valve function following resuspension and supracoronary ascending aortic grafting. METHODS: Among a collective of 210 consecutive patients undergoing surgery for AADA, 140 (66.7%) with resuspension of the aortic valve and supracoronary ascending graft were analyzed. Of these patients, 83 (59.3%) had a complete follow up (mean 61.2 +/- 40.8 months), with 65 of the subgroup (78.3%) being followed by computed tomography scanning and echocardiography. RESULTS: Reoperation due to severe aortic valve regurgitation was required in seven patients (10.8%). The perioperative characteristics were similar in these patients; notably, no significant difference was evident with regards to the aortic annulus diameter and the severity of regurgitation at the time of surgery. The left ventricular mass index was significantly higher in patients requiring reoperation due to aortic valve regurgitation (219.3 +/- 146.6 versus 123.9 +/- 146.6 g/m2; p <0.05). None of the patients died as a result of reoperation. CONCLUSION: The long-term functional results following resuspension of the aortic valve in AADA were very good. A close echocardiographic follow up was necessary, as reoperation of the aortic valve was required in more than 10% of the collective, with an average follow up of five years. Reoperation was mainly related to secondary dilatation of the aortic root.     

Mitral valve repair for nonrheumatic mitral regurgitation

BACKGROUND: We studied the results of mitral valve repair in patients with severe mitral regurgitation of nonrheumatic etiology. METHODS AND RESULTS: Between January 1988 and April 2002, 116 patients, of which 59 were male and 57 female, with severe mitral regurgitation of nonrheumatic etiology, underwent mitral valve repair using a variety of techniques. Their mean age was 26.4 years (range 2-67 years). The cause of mitral regurgitation was congenital in 56 patients, myxomatous in 44, infective endocarditis in 7, and ischemic in 9. Ninety patients were in preoperative New York Heart Association class III, and 26 in class IV. Reparative procedures included posterior teflon felt collar annuloplasty (modified Cooley's) in 80 patients, chordal shortening in 37, cusp excision in 34, cleft closure in 8, chordal transfer in 6, and neochordae in 3. The early mortality was 3.4% (4 patients). Follow-up ranged from 1 to 167 months (mean 47 months), and was 95% complete. There were 2 late deaths (1.7%). Six patients (5.2%) underwent reoperation for severe mitral regurgitation post-repair. Of the remaining 104 patients, 90 (86.5%) had no or trivial mitral regurgitation at the last follow-up. Actuarial, reoperation-free, and event-free survival at 130 months was 93%+/-3.6%, 89.9%+/-6%, and 69.7%+/-13.7%, respectively. Ninety-two patients (88.5%) were in New York Heart Association class I at the last follow-up. CONCLUSIONS: Mitral valve repair in nonrheumatic mitral regurgitation patients provides satisfactory results with current surgical techniques, and is the preferred option in this subset of patients.     

Analysis of recurrent mitral regurgitation after mitral valve repair

Mitral valve repair was performed in 437 patients with mitral regurgitation from January 1994 to January 2002. The causes of mitral regurgitation were degenerative in 238 (54%), rheumatic in 134 (31%), and others in 65 (15%). The most frequently employed surgical techniques were ring annuloplasty in 417 (95%) cases, new chordae formation in 216 (50%), and quadrangular resection in 117 (27%). The mean follow-up was 29.04 +/- 22.81 months. There were 5 (1.2%) early and 5 (1.2%) late deaths. The reoperation rate was 1.6% with 41 (9%) cases of recurrent mitral regurgitation. Of these 22 were procedure-related: incomplete repair in 13, discordant new chordal length in 7, suture dehiscence and leaflet perforation in 1 case each. There were 19 cases of valve related failures: progression of rheumatic disease in 18 and subacute infective endocarditis in 1. Valve-related failure strongly correlated with progression of rheumatic disease. As initial operative success was the prime determinant of repair durability, intraoperative repair assessment with transesophageal echocardiography was essential.     

Mitral valve surgery in the presence of pulmonary hypertension.

Mitral valve surgery was performed in 59 patients with severe pulmonary hypertension (average systolic pulmonary artery pressure 77.1 +/- 18.6 mmHg; range 50-115 mmHg) between 1983 and 1990. Thirty-eight patients had been subjected to mitral valve replacement, 16 patients both mitral and aortic valve replacement, and 5 patients had open mitral commissurotomy, with an operative (30 day) mortality of 5.0%. These 3 deaths happened during the early postoperative period. Survivors were followed up for a period ranging from 6 months to 7 years with a mean of 36 months. Four late deaths (7.1%) occurred in patients with valve replacement. Actuarial survival was 93 +/- 3% at 5 years, and 90.7 +/- 4.4% at 7 years. Right ventricular catheterization was performed on 14 patients a mean of 38 months following operation. Systolic pulmonary artery pressure had decreased from a mean of 77.1 +/- 18.6 to 39.7 +/- 14.0 mmHg (p less than 0.001) and 90% of the survivors were in New York Heart Association Class 1 or II compared to 23.7% preoperatively. The clinical and hemodynamic findings in this series suggest that severe pulmonary hypertension is not a contraindication, and pulmonary hypertension decreases significantly after mitral valve surgery.     

Effect of additional valve lesions on left ventricular ejection time in aortic stenosis.

Rate-corrected left ventricular ejection time was measured from the aortic pressure tracings of 171 catheterised patients with aortic valve area less than or equal to 1.2 cm2. In 50 patients with pure aortic stenosis, left ventricular ejection time in increased with decreasing valve area and was significantly higher (468 +/- 5 ms, mean +/- SEM) than in 13 normal subjects (435 +/- 5 ms). Additional aortic regurgitation in 72 patients further increased the left ventricular ejection time to 484 +/- 4 ms. Significant mitral stenosis (mitral valve are less than or equal to 1.2 cm2) in 6 patients with aortic stenosis and 33 patients with aortic stenosis and regurgitation reduced the left ventricular ejection time to normal. Similarly, severe mitral regurgitation in 3 patients with aortic stenosis and regurgitation reduced left ventricular ejection time to normal, though slight or moderate mitral regurgitation in 4 of these patients did not. These data show that the prolonged left ventricular ejection time in aortic valve disease may be restored to normal in the presence of coexisting significant mitral disease.     

Mitral valve repair for ischemic mitral regurgitation in dilated cardiomyopathy

Ischemic mitral regurgitation contributes to poor survival in patients with heart failure. The intermediate-term outcome of mitral reconstruction in 15 patients who had ischemic dilated cardiomyopathy with mitral regurgitation requiring surgical intervention was studied. They underwent mitral valve repair along with coronary artery bypass surgery. The mitral valve coaptation depth was considered an important parameter in deciding on repair. Ages ranged from 43 to 72 years. Left ventricular ejection fractions were 15-38% (mean, 26.5% +/- 4.3%). The operative technique in all 15 patients was posterior annuloplasty using Dacron felt. At a mean follow-up of 4.6 +/- 1.2 months (1-8 months), postoperative transesophageal echocardiography revealed mild mitral regurgitation in 2 patients and none in 13. There was a significant improvement in New York Heart Association functional class from 3.9 +/- 1.1 to 1.9 +/- 0.3. Mitral valve repair by posterior felt annuloplasty provides favorable results in the intermediate-term in selected patients with ischemic cardiomyopathy and severe left ventricular dysfunction.