Intraoperative contrast transesophageal echocardiography using Albunex

This study was designed to investigate the effect of administration of the contrast material Albunex on intraoperative contrast transesophageal echocardiography for patients with mitral valve disease or coronary artery disease. We studied nine patients scheduled for elective coronary artery bypass grafting (CABG group) and nine patients scheduled for elective mitral valve replacement (MVR group), and used a transesophageal echocardiography probe and an echocardiographic system. During the period of stable hemodynamics before the start of cardiopulmonary bypass, Albunex in doses of 0.1 ml·kg⁻¹ was injected at a rate of about 1 ml·s⁻¹ from either the peripheral venous line or the distal lumen of the pulmonary arterial catheter, and the effect on contrast was compared. This effect was semiquantitatively assessed by using a grading scale from 0 to 3, with 0 indicating an absence of opacification and 3, full opacification of the cavities examined. In the CABG group, contrast resulting from administration of Albunex from the pulmonary arterial catheter was significantly better than that from the peripheral venous line, whereas in the MVR group, no improvement was found. Furthermore, when it was administered into the pulmonary artery, the effect on contrast for the MVR group was significantly lower than that for the CABG group. The efficacy rate of intraoperative contrast transesophageal echocardiography using Albunex was relatively low, and appeared to be affected by pulmonary circulation or many other factors such as the method of administration, including the route and injection pressure.     

A novel view for visualizing a left pulmonary artery thromboembolus with intraoperative transesophageal echocardiography

Visualization of thromboembolic material in the pulmonary artery is often difficult on transesophageal echocardiography, especially in the left pulmonary artery, because of the position of the left main bronchus. We present a case in which thromboembolic material within the midleft pulmonary artery was incidentally diagnosed using additional, modified transesophageal echocardiography views, in a patient undergoing mitral valve repair.     

应用彩色多普勒对二尖瓣置换术后三尖瓣功能的远期随访

目的应用彩色多普勒超声评价二尖瓣置换术后远期三尖瓣功能及形态变化。方法对接受二尖瓣置换术的903例病人术后三尖瓣功能进行了2～9年,平均(3.6±2.4)年的跟踪观察。所有病例术前均有不同程度的三尖瓣环扩大或关闭不全,其中未行三尖瓣成形术者201例;行Kay或改良DeVega成形术者686例;三尖瓣成形术同时加成形环者16例。结果未行三尖瓣成形术者术后2～3年有46例出现三尖瓣重度关闭不全;行Kay或改良DeVega成形术者,术后3～5年150例出现中重度三尖瓣关闭不全;三尖瓣成形术同时加成形环者仅1例术后2年出现三尖瓣轻-中度关闭不全。结论二尖瓣置换术后远期三尖瓣功能性关闭不全与三尖瓣环扩大、右心功能损害和严重肺动脉高压有关,三尖瓣环扩大是其重要的原因。对二尖瓣置换术者,手术中一旦发现有三尖瓣环扩大,即使无三尖瓣关闭不全,亦应行三尖瓣成形术,重度三尖瓣关闭不全、瓣环明显扩大者最好在环缩术的同时加成形环。     

A novel approach of tricuspid valve repair: mitralization of tricuspid valve

Open in a separate window OBJECTIVESThis study presents the mid-term results of a novel tricuspid valve (TV) repair strategy defined as ‘mitralization of TV’ (resection and plication of the posterior leaflet, ring implantation, optional leaflet procedures) applied for the correction of tricuspid regurgitation (TR).METHODSBetween 2017 and 2020, a total of 22 patients underwent concomitant TV repair using mitralization of the TV. Fourteen of the patients had functional TR (2 of them had severe tethering), 5 patients had prolapse and 3 patients had rheumatic involvement.RESULTSThere was no in-hospital mortality. Moderate or severe TR was not observed in any patient in echocardiographic evaluations before discharge. The mean follow-up duration was 30.9 + 6.2 months. Moderate-to-severe TR-free survival was 100% in the second year and 94.7% in the third year.CONCLUSIONSMitralization of the TV is a safe and effective treatment modality in terms of its mid-term results. This new technique provides an innovative perspective for the treatment of TR, especially in complex TV pathologies.     

经主动脉切口治疗主动脉根部瘤合并二尖瓣病变

目的 总结经主动脉切口治疗主动脉根部瘤合并二尖瓣病变的初步经验。方法 2009年3月至2010年12月,经主动脉瓣口行二尖瓣手术16例中男13例,女3例;年龄18～ 75岁,平均(40±10)岁。16例中Bentall+ MVR术12例,Bentall+ MVP术1例,Bentall+全弓置换+支架象鼻+MVP术1例,...     

Augmenting mitral valve repair evaluation with intraoperative left ventricle pressure measurements

Surgical mitral valve repair remains the gold standard treatment of mitral regurgitation due to degenerative disease. Surgery is performed on the quiescent heart; therefore, assessments of valve repair success can only be made following separation from cardiopulmonary bypass. Intra-ventricular pressure measurements are often made in percutaneous valve procedures but has yet been described at the time of surgical repair. As an example, the saline test, whereby normal saline is injected across the mitral valve from the left atrium into the left ventricle, on the arrested heart remains an integral component of surgical repair. However, the haemodynamics of the saline test have never been evaluated. We present a simple and novel technique to quantify the saline test by passing a 22-G catheter across the mitral leaflets during saline testing under maximal ventricle distension. The saline test may be less informative among patients in whom the maximum generated left ventricle diastolic pressure is low. These data may be of help to a surgeon interpreting intraoperative saline tests with the hope of a competent mitral valve. As well, it may provide support for intraventricular pressure monitoring at the time of mitral valve surgery.     

Mitral valve repair for broad, asymmetrical prolapse in the posterior mitral leaflet

We designed a mitral valve repair and successfully performed this repair for a case of broad, asymmetrical prolapse in the middle scallop of the posterior mitral leaflet. The repair procedure consists of making a fan-shaped leaflet by resecting the prolapsed portion in a trapezoid shape with detachment of the leaflet along the annulus and leaflet reapproximation by rotating this fan-shaped leaflet. This technique can utilize more leaflet tissue for filling the gap made by leaflet resection than the quadrangular resection and suture technique. As a result, it helps reduce tension on the suture lines, avoids the need for extensive annular plication, and also avoids leaflet distortion while making it easier to adjust the height of the leaflets that should be reapproximated. The essence of this mitral valve repair exists in the “resecting line of the leaflet,” which has not yet been reported.     

Ischemic mitral valve prolapse: mechanisms and implications for valve repair

Objective: The aim of this study was to assess the mechanisms of prolapse in ischemic mitral valve regurgitation (MR) and the techniques of valve repair. Methods: Out of 121 patients operated upon for ischemic MR, a prolapse was present in 44 patients (36.4%). The operation was performed emergently in four cases (9.1%) and electively in 40 patients (90.9%). Fifteen patients (34.1%) were operated upon within 60 days following acute myocardial infarction. Results: The diagnosis of prolapse had been overlooked by echography in five cases (11.4%). A commissural area was involved as the site of prolapse in 31 cases (70.4%). The mechanism of prolapse was a papillary muscle (PM) lesion in 38 cases (86.4%) (anterior PM: n=8, posterior PM n=36) or a chordal lesion in six cases (13.6%). PM injury was elongation (n=16), or rupture (total n=1, partial n=21, incomplete n=4). The operative technique was mitral valve repair with Carpentier's techniques in 42 cases (95.5%) or replacement in two cases (4.5%). Hospital mortality was 11.4% (n=4). The mean follow-up was to 44.7±29.6 months. Overall survival and freedom from reoperation were 68.3±9.0 and 89.9±5.7% at 5 years, respectively. Freedom from MR equal or > grade 2 was 69.7±9.5% at 5 years. Conclusions: The mechanisms of ischemic mitral valve prolapse were variable and tightly linked to the PM anatomy. A reliable mitral valve repair could be achieved in most cases with acceptable mid-term results.     

二尖瓣成形术临床应用542例及随访

目的回顾性总结542例二尖瓣成形术病人的手术疗效和20年随访结果。方法1985年至2006年，542例二尖瓣病变的病人接受二尖瓣成形术，男306例，女236例。474例随访1-240个月，平均（41．03±40．40）个月，随访率90．8％。结果手术死亡20例（3．7％），出院时病人心功能均为Ⅰ级或Ⅱ级。随访死亡20例，再次手术23例；7年、10年和15年生存率分别为91％、88％和70％；7年和10年二次手术免除率分别为94％和86％。结论二尖瓣成形治疗二尖瓣病变，死亡率低，远期效果好。     

"缘对缘"二尖瓣成形术治疗二尖瓣前叶脱垂的早中期随访

目的 回顾性分析"缘对缘"二尖瓣成形术的早、中期效果.方法 1999年8月至2007年7月完成了128例"缘对缘"(edge to edge)二尖瓣成形术,分析其围术期及随访结果.结果 全组无手术死亡.平均随访46.8个月(1～97个月),无二次手术率96.9%,生存率98.4%.5例(3.9%)复发二尖瓣中、重度反流,其中4例(3.1%)行二尖瓣置换,1例早期缝线撕脱二次手术后死亡,1例拒绝二次手术而死亡.3例(2.3%)轻度二尖瓣狭窄,心功能Ⅰ级,仍在随访中.其余120例二尖瓣反流明显减轻(术前3.4对术后1.1,P＜0.05),心功能(NYHA)级别明显改善(术前2.4级对术后1.1级,P＜0.05).术后二尖瓣口面积平均为(2.45±0.70)cm2.左室舒张末径显著缩小[术前(57.9±9.0)mm对术后(48.6±7.6)mm,P＜0.05].术后左心室射血分数无明显改变(术前0.61±0.08对术后0.60±0.06,P=0.03).结论 "缘对缘"二尖瓣成形术是治疗二尖瓣前叶脱垂的安全、有效方法,早、中期效果良好.远期效果尚有待于进一步观察.     

二尖瓣脱垂并关闭不全的外科修补

目的：总结二尖瓣脱垂的外科修复经验,方法：对44例二尖脱垂患者的临床资料进行回顾分析。44例患者中风湿性2例,非风湿性42例（22例合并先天性心脏病）,关不全中度24例,重度20例,腱索断裂或缺如12例,腱索过长32例,其中多根腱索过长6例,治疗行腱索移植10例,健索缩短25例（多根腱索短6例）,人工腱索1例,瓣叶折叠3例,瓣叶切除5例,同时行瓣裂缝合8例,瓣环成形28例（后环缝缩14例）,结果：结果：全组无手术死亡病例,1例风湿性患者术后1个月发生左心房血栓再次手术行瓣膜替换,二尖瓣功能正常34例（77．8％）,基本正常6（13．6％）,残留轻至中度关闭不全3例（6．8％）,随访1－18例（平均6．5年）,效果良好,结论：外科修复治疗二尖瓣脱垂是一种安全有效的手术方法。     

A transesophageal echocardiographic and cine-fluoroscopic evaluation of an ATS prosthetic valve opening

Purpose  The effectiveness of the ATS valves includes their durability and the quietness of the valve sound. However, a cine-fluoroscopic study revealed an incomplete opening of the valve leaflet. An overall evaluation of the ATS valve was conducted by transesophageal echocardiography. Methods  The patients were divided into two groups based on the opening angle (OA): Group A, with a maximum OA of 80° or greater and Group B, with a maximum OA of under 80°. Results  In Group A, the peak pressure gradient (PPG) sites of the anterior, central and posterior mitral commissure were 8.17, 8.05, and 8.09 mmHg, respectively, with no significant differences among the three sites. Similar results were obtained for Group B; the PPG at the three respective measurement sites were 8.59, 8.43, and 8.51 mmHg, and the differences were not statistically significant. No statistically significant differences were observed in the mean pressure gradient or pressure half time among the three measurement sites or between the two patient groups. Conclusion  Although, in many cases, the ATS valves did not open completely, the incomplete valve opening did not pose any problems in the valve function itself or in the cardiac functions of the patients.     

Successful valve repair for congenital bicuspid aortic valve and degenerated prolapsed mitral valve

A 54-year-old man with congenital bicuspid aortic valve underwent simultaneous valve repair for aortic and mitral regurgitation. Surgical technique consisted of plication of redundant aortic valve repair and mitral annuloplasty with chordal replacement. One-year follow-up transthoracic echocardiography showed no valve regurgitation. Valve repair for both bicuspid aortic valve and mitral valve regurgitation should be the first option in this subset of patients.     

瓣膜成形术治疗原发性感染性心内膜炎二尖瓣关闭不全

Ⅱ级3例.结论 二尖瓣成形术治疗感染性心内膜炎二尖瓣关闭不全的疗效较好,术后左心室明显减小.     

A lesional classification to standardize surgical management of aortic insufficiency towards valve repair

Objective: Aortic valve repair is an alternative to valve replacement for treatment of chronic aortic insufficiency (AI). In order to standardize surgical management, we suggest a classification based on echocardiographic and operative analysis of valvular lesions. Methods: Classification was based on the retrospective analysis of chronic AI mechanisms of 781 adults operated on electively between 1997 and 2003. Results: AI was isolated (406 patients (52%)), associated with supra-coronary aneurysm (97 cases (12.4%)), or with aortic root aneurysm (278 patients (35.6%)). Etiologies of valvular or aortic lesions were respectively rheumatic, dystrophic and atheromatous in 17%, 73.6% and 9.4% of cases. Lesional classification is based on the analysis of chronic AI mechanisms defining type I with central jet (354 cases, 45.3%) and type II with eccentric jet (54.7%). Type Ia is defined as isolated dilation of sino-tubular junction (47 supra-coronary aneurysms), and type Ib as dilation of both sino-tubular junction and aortic annular base (233 root aneurysms, 74 isolated AI). The type II associates dilation of sino-tubular junction and annular base to a valvular lesion: IIa cusp prolapse (95 aneurysms, 200 isolated AI); IIb cusp retraction (132 rheumatic AI), IIc cusp tear (endocarditis, traumatic). Conclusion: A lesional classification aims to standardize the surgical management of aortic valve repair: type Ia, by supra-coronary graft; type Ib, by subvalvular aortic annuloplasty associated with the aortic root replacement with a remodelling technique (root aneurysm) or double sub- and supravalvular annuloplasty (isolated AI). For chronic AI type II, aortic annuloplasty associated a remodelling technique or double sub- and supravalvular annuloplasty is combined with the treatment of the cusp lesion (cusp resuspension, cusp reconstruction with autologous pericardium).     

Impact of MitraClip™ therapy on secondary mitral valve surgery in patients at high surgical risk

Objective: Conventional or minimally invasive surgical mitral valve repair (MVR) is the gold-standard treatment for severe mitral regurgitation (MR) of any etiology. Given its good safety profile, trans-catheter MVR with the MitraClip™ device is used increasingly for high-risk or inoperable patients. We report our experience with failed MitraClip™ therapy and its impact on subsequent surgical strategies, such as the feasibility of MVR in high-risk patients. Methods: During a follow-up of 344 ± 227 days from the first 215 consecutive patients treated with the MitraClip™ device, six patients required surgical re-intervention due to failed repair (n = 3) or recurrent severe MR (n = 3) at 35.8 ± 47.7 (range 0–117) days after trans-catheter MVR. Feasibility of secondary surgical MVR was assessed with regard to prior clip therapy. Results: In three patients, secondary surgical MVR was successfully performed following the surgical strategy deemed optimal before trans-catheter treatment. Injury of the mitral leaflets caused by prior clip treatment was present in three other patients and influenced the surgical strategy toward more complex surgical techniques in one case and MV replacement in two others. One patient died 6 days after MV replacement. All other patients are alive with adequate valve function at the latest follow-up of 12.4 ± 7.4 months (range 4–22). Conclusions: Secondary surgical MVR was feasible in some patients after prior clip treatment, but led to valve replacement in others. At present, patient selection criteria for trans-catheter MVR should not be expanded toward more healthy patients, as primary trans-catheter MVR may complicate secondary surgery in certain cases and may even preclude reconstructive valve surgery.     

人工瓣环成形术与其联合"缘对缘"瓣膜成形术治疗重度三尖瓣关闭不全

目的 总结人工瓣环成形术与人工瓣环联合"缘对缘"瓣膜成形术的治疗重度三尖瓣反流(TR)的治疗效果.方法 2001年4月至2010年5月间因重度TR行三尖瓣成形术41例,其中单纯人工瓣环成形(R组)21例,人工瓣环联合"缘对缘"瓣膜成形(E组)20例.所有病人均经术前、术后早期(出院时)及术后中长期经胸超声心动图检查,观察三尖瓣瓣叶对合情况,以三尖瓣反流束面积(TRA)/右房面积(RAA)定量测定反流程度,三尖瓣口面积、肺动脉压及心功能测定.结果 出院时R组7例无或微量TR,12例轻度TR,2例中度TR,轻、中度者均有前、隔叶对合不良;E组13例无或微量TR,7例轻度TR.随访6～100个月,平均(54.8±26.7)个月,R组5例无或微量TR,11例轻度TR,4例中度TR、1例重度TR,轻至重度者均有前、隔叶对合不良,1例重度者再次实施"缘对缘"瓣膜成形术;E组无三尖瓣狭窄,10例无或微量TR,9例轻度TR,1例中度TR.人工瓣环成形联合"缘对缘"瓣膜成形术中长期TRA/RAA比值显著低于单纯人工瓣环成形术者(P<0.01).结论 对于三尖瓣瓣缘对合不良及其瓣环扩张引起的重度TR者,人工瓣环成形联合"缘对缘"瓣膜成形技术能够更有效地减少术后三尖瓣残余反流以及TR的复发.

Abstract：

Objective To analyze whether association of edge to edge valve repair to artificial ring annuloplasty would result in better results in patients with severe tricuspid regurgitation (TR).Methods From April,2001 to May,2010,41 patients underwent tricuspid valve repair to treat severe TR were studied.Twenty-one patients were done artificial ring annuloplasty alone (group R) and twenty patients were done artificial ring annuloplasty associated with edge to edge valve repair ( group E).All the patients received echocardiography before surgery,before discharge and in mid and long-term follow-up.The ratio between TR jet area (TRA) and right atrial area (RAA) was used to quantitatively evaluate the seriousness of TR.Movement of tricuspid valve leaflets,tricuspid valve orifice area,pulmonary artery pressure ( PAP),left ventricular ejection fraction ( LVEF) were obserbed to evaluate heart function.Results At discharge in group R,no or trivial TR was presented in 7 patients,mild TR in 12 patients and moderate TR in 2 patient.Bad apposition of the free edges of anterior and septal leaflets was observed in paients with mild and moderate TR.While in group E,no or trivial TR was presented in 13 patients and mild TR in 7 patients.The follow-up ranged from 6 months to 100 months[average (54.8 ±26.7) months].In group R,no or trivial TR was present in 5 patients,mild TR in 11 patients,moderate TR in 4 patients and severe in 1 patient.Bad apposition of the free edges of anterior and septal leaflets was observed in paients with mild to severe TR.Redo tricuspid valve repair was done in one patient in group R for recurrent severe TR and the edge-to-edge valve repair was utilized.In group E,no tricuspid stenosis was found.No or trivial TR was presented in 10 patients,mild TR in 9 patients and moderate TR in 1 patient.The ratio of TRA/RAA of group R was significantly higher than that of group E (0.25 ±0.16 vs.0.13±0.10,P < 0.01).Conclusion Association of edge-to-edge valve technique to artificial ring annuloplasty was safe and effective for treatment of severe tricuspid regurgitation due to bad apposition of free edges of tricuspid leaflets and dilatation of tricuspid annulus,.It could decrease the incidence of residual tricuspid regurgitation and prevent the recurrence of severe tricuspid regurgitation.