Idiopathic dilated cardiomyopathy: computerized anatomic study of relashionship between septal and free left ventricle wall

Introduction

A feature of dilated cardiomyopathy is the deformation of ventricular cavity, which contributes to systolic dysfunction. Few studies have evaluated this deformation bearing in mind ventricular regions and segments of the ventricle, which could reveal important details of the remodeling process, supporting a better understanding of its role in functional impairment and the development of new therapeutic strategies.

Objective

To evaluate if, in basal, equatorial and apical regions, increased internal transverse perimeter of left ventricle in idiopathic dilated cardiomyopathy occurs proportionally between the septal and non-septal segment.

Methods

We performed an anatomical study with 28 adult hearts from human cadavers. One group consisted of 18 hearts with idiopathic dilated cardiomyopathy and another group with 10 normal hearts. After lamination and left ventricle digital image capture, in three different regions (base, equator and apex), the transversal internal perimeter of left ventricle was divided into two segments: septal and not septal. These segments were measured by proper software. It was established an index of proportionality between these segments, called septal and non-septal segment index. Then we determined whether this index was the same in both groups.

Results

Among patients with normal hearts and idiopathic dilated cardiomyopathy, the index of proportionality between the two segments (septal and non-septal) showed no significant difference in the three regions analyzed. The comparison results of the indices NSS/SS among normal and enlarged hearts were respectively: in base 1.99 versus 1.86 (P=0.46), in equator 2.22 versus 2.18 (P=0.79) and in apex 2.96 versus 3.56 (P=0.11).

Conclusion

In the idiopathic dilated cardiomyopathy, the transversal dilatation of left ventricular internal perimeter occurs proportionally between the segments corresponding to the septum and free wall at the basal, equatorial and apical regions of this chamber.     

Direct intramyocardial transthoracic transplantation of bone marrow mononuclear cells for non-ischemic dilated cardiomyopathy: INTRACELL,a prospective randomized controlled trial

Objective

We tested the hypothesis that direct intramyocardial injection of bone marrow mononuclear cells in patients with non-ischemic dilated cardiomyopathy can improve left ventricular function and physical capacity.

Methods

Thirty non-ischemic dilated cardiomyopathy patients with left ventricular ejection fraction <35% were randomized at a 1:2 ratio into two groups, control and treated. The bone marrow mononuclear cells group received 1.06±108 bone marrow mononuclear cells through mini-thoracotomy. There was no intervention in the control group. Assessment was carried out through clinical evaluations as well as a 6-min walk test, nuclear magnectic resonance imaging and echocardiogram.

Results

The bone marrow mononuclear cells group showed a trend toward left ventricular ejection fraction improvement, with magnectic resonance imaging - at 3 months, showing an increase from 27.80±6.86% to 30.13±9.06% (P=0.08) and returning to baseline at 9 months (28.78%, P=0.77). Magnectic resonance imaging showed no changes in left ventricular ejection fraction during follow-up of the control group (28.00±4.32%, 27.42±7.41%, and 29.57±4.50%). Echocardiogram showed left ventricular ejection fraction improved in the bone marrow mononuclear cells group at 3 months, 25.09±3.98 to 30.94±9.16 (P=0.01), and one year, 30.07±7.25% (P=0.001). The control group showed no change (26.1±4.4 vs 26.5±4.7 and 30.2±7.39%, P=0.25 and 0.10, respectively). Bone marrow mononuclear cells group showed improvement in New York Heart Association functional class, from 3.40±0.50 to 2.41±0.79 (P=0.002); patients in the control group showed no change (3.37±0.51 to 2.71±0.95; P=0.17). Six-minute walk test improved in the bone marrow mononuclear cells group (348.00±93.51m at baseline to 370.41±91.56m at 12 months, P=0.66) and there was a non-significant decline in the control group (361.25±90.78m to 330.00±123.42m after 12 months, P=0.66). Group comparisons were non-significant.

Conclusion

The trend of intragroup functional and subjective improvement was not confirmed when compared to the control group. Direct intramyocardial application of bone marrow mononuclear cells in non-ischemic dilated cardiomyopathy was not associated with significant changes in left ventricular function. Differences observed within the bone marrow mononuclear cells group could be due to placebo effect or low statistical power.     

Mitral valve repair in patients with end stage cardiomyopathy: who benefits?

Objective: Patients with end stage cardiomyopathy frequently present with additional severe mitral regurgitation. We analyzed the outcome of mitral valve reconstruction in this high risk patient group. Methods: Sixty-six patients with significant mitral regurgitation and an ejection fraction (EF) below 30% (dilated CARDIOMYOPATHY=53, ischemic cardiomyopathy (ICM)=13) were retrospectively evaluated from 07/96 and 02/02. All received annuloplasty ring implantation and additional repair (n=4) if required. Mean follow-up was 28±18 months. Results: Mitral valve repair (MVR) was technically feasible in all patients. Intraoperative transesophageal echocardiography (TEE) revealed none (n=60) or only trivial (n=6) residual mitral regurgitation. Thirty day mortality was 6.1%. Actuarial survival after 1 and 5 years was 86±4 and 66±8%, respectively. During follow-up seven patients were transplanted due to lack of clinical improvement after 10±7 months (range 1–23). Echocardiography revealed a significant improvement in EF (25±10.5% pre-op, 34±15% post-op) and a slight decrease in left ventricular end-diastolic diameter (69±10 mm pre-op, 67±13 mm follow up). Patients were in NYHA functional -class 3 (median) preoperatively and in class 2 at long term-follow-up. Gender, left ventricular enddiastolic diameter, preoperative ejection fraction or type of surgical approach (sternotomy, right lateral minithoracotomy) had no significant influence on patient outcome. Patients with ICM or patients older than 60 years showed an increased risk for clinical events both early post-operatively and at long-term follow-up. Conclusion: MVR can be performed with low perioperative morbidity and mortality even in patients with advanced heart failure, modifying selection criteria for potential candidates may further improve long term outcome.     

Influence of valve prosthesis type on early mortality in patients undergoing valve surgery

Objective

To evaluate the influence of the type of prosthesis in-hospital mortality in the post-operative period in patients who had valve replacement.

Methods

A cross-sectional data, such as gender, origin, age, etiology, echocardiograph data, the type of surgery performed and the prosthesis used in cases of valve replacement were analyzed retrospectively.

Results

We reviewed 353 charts of patients who underwent valve replacement surgery. The mean age was 41.87±17.9 years. Regarding gender, 52.8% were female. As for the origin, 61.1% came from small cities within the state. Of all patients, 58.5% suffered from rheumatic disease. Assessing the type of prosthesis implanted, 70% held replace by bioprosthesis and 30% metallic. The hospital mortality in this study was 11%, with no significant difference between the types of prosthesis utilized.

Conclusion

The type of implant used had no effect on in-hospital mortality.     

Selected ventriculoplasty for idiopathic dilated cardiomyopathy with advanced congestive heart failure: midterm results and risk analysis

Background: To treat advanced heart failure due to idiopathic dilated cardiomyopathy, surgical ventricular restoration with mitral reconstruction was conducted and evaluated. Methods: In 95 patients (81 men, mean age: 54 years), New York Heart Association class III/IV was 44/51, and 33 patients (36%) were inotropic dependent preoperatively. Mitral regurgitation (≥2+) was noted in all patients. All patients underwent left ventriculoplasty (septal anterior ventricular exclusion in 38, partial left ventriculectomy in 57) and mitral reconstruction (repair 53, replacement 42). Fifty-two patients (55%) had concomitant tricuspid repair. Intra-aortic balloon pumping and left ventricular assist device was used in 24 patients and two patients, respectively. Results: Hospital mortality was 11.6% (11 of 95), with 6.6% (5 of 76) in elective and 31.6% (6 of 19) in emergency operations. The ejection fraction and cardiac index increased from 22.3 ± 6.3% to 27.2 ± 8.0% and from 2.3 ± 0.5 ml/m²/min to 2.8 ± 0.5 ml/m²/min, respectively (p < 0.001). The endodiastolic volume index, endosystolic volume index and diastolic dimension decreased from 232.9 ± 56.1 ml/m² to 160.0 ± 49.8 ml/m², from 178.9 ± 46.7 ml/m² to 113.8 ± 44.7 ml/m² and from 82.0 ± 9.0 mm to 68.9 ± 11.6 mm, respectively (p < 0.001). Late death occurred in 27 patients with 22 cardiac deaths. The mean NYHA class was 1.7 among the survivors. One-, 3- and 5-year survival rates were 72.8%, 61.4% and 50.5%, respectively. In the 62 patients who were non-inotropic dependent preoperatively, 1-, 3-, and 5-year survival rates (81.8%, 73.7% and 62.9%) were significantly better than the inotropic-dependent group (55.3%, 37.3% and 28.0%). Patients with mitral annuloplasty showed a significantly higher 5-year survival rate than patients with mitral valve replacement (59.6% vs 43.6%) in univariate analysis. By application of the exclusion site selection method, the two different ventriculoplasty procedures did not show significant difference in survival rates. Multivariate analysis showed that preoperative inotropes and old age were significant predictors for postoperative mortality. Conclusion: The selected ventriculoplasty in combination with mitral annuloplasty is a useful option for patients with an extremely dilated left ventricle in idiopathic dilated cardiomyopathy. Surgery should be considered before inotropic dependency occurs when prior medical treatment has failed.     

Residual fibrosis affects a long-term result of left ventricular volume reduction surgery for dilated cardiomyopathy in a rat experimental study

Objectives: The aim of this study is to evaluate the relationship between left ventricular (LV) wall property and the results of LV volume reduction surgery (LVR) to treat dilated cardiomyopathy (DCM) in an experimental model. Methods: DCM was introduced in 18 Lewis rats by autoimmunization with cardiac myosin. Among them, 12 rats underwent LVR and the rest were served as controls. They were subjected to echocardiography and cardiac catheterization for dimensional and functional measurements. The animals were sacrificed 4 weeks after surgery, and the fraction of myocardial fibrosis was calculated in 4 divided parts of the LV wall. Results: Percent fibrosis varied widely from 4.7 to 45.2%. LV volume reduction surgery improved cardiac function immediately after surgery in all rats (E_max, 0.28±0.14 to 0.48±0.18 mmHg/μl; LV end-diastolic pressure, 21.0±6.1 to 13.3±5.1 mmHg, P<0.05, respectively). Four weeks later, 6 hearts remained in good shape with smaller LV end-diastolic dimension (Dd) than baseline values (LV Dd, 9.7±0.6 mm; fractional area change (FAC), 40.3±8.4%) and the other 6 had more redilation in diameter and more deterioration in function than baseline values (LV Dd, 10.9±0.6 mm; FAC, 25.8±6.9%; P<0.05, respectively). Percent fibrosis in the septum differed 11.1±3.4 vs. 27.8±2.8% between the two groups (P<0.01). There was a significant correlation between the ratio of LV redilatation after surgery and percent fibrosis in the septum (r=0.951, P<0.01). Conclusions: Although the initial benefit of LVR was confirmed, the long-term result was affected by the amount of residual fibrosis. This information suggests that surgical site selection is important to achieve a good result of LV restoration surgery for DCM.     

Mitral annulus morphologic and functional analysis using real time tridimensional echocardiography in patients submitted to unsupported mitral valve repair

Introduction

Mitral valve repair is the treatment of choice to correct mitral insufficiency, although the literature related to mitral valve annulus behavior after mitral repair without use of prosthetic rings is scarce.

Objective

To analyze mitral annulus morphology and function using real time tridimensional echocardiography in individuals submitted to mitral valve repair with Double Teflon technique.

Methods

Fourteen patients with mitral valve insufficiency secondary to mixomatous degeneration that were submitted to mitral valve repair with the Double Teflon technique were included. Thirteen patients were in FC III/IV. Patients were evaluated in preoperative period, immediate postoperative period, 6 months and 1 year after mitral repair. Statistical analysis was made by repeated measures ANOVA test and was considered statistically significant P<0.05.

Results

There were no deaths, reoperation due to valve dysfunction, thromboembolism or endocarditis during the study. Posterior mitral annulus demonstrated a significant reduction in immediate postoperative period (P<0.001), remaining stable during the study, and presents a mean of reduction of 25.8% comparing with preoperative period. There was a significant reduction in anteroposterior and mediolateral diameters in the immediate postoperative period (P<0.001), although there was a significant increase in mediolateral diameter between immediate postoperative period and 1 year. There was no difference in mitral internal area variation over the cardiac cycle during the study.

Conclusion

Segmentar annuloplasty reduced the posterior component of mitral annulus, which remained stable in a 1-year-period. The variation in mitral annulus area during cardiac cycle remained stable during the study.     

The ‘Valve Racket’: a new and different concept of atrioventricular valve repair

Objective: Mitral regurgitation due to prolapse of the mitral leaflets frequently compromises annuloplasty repair procedures. We present a new annuloplasty ring that overcomes this difficulty, preventing displacement of the leaflets into the atrium. Methods: The ‘Valve Racket’ is a prosthetic ring transformed into a racket by means of handmade mesh using expanded polytetrafluoroethylene (ePTFE Gore-Tex). After transection of the marginal chordae tendineae, five sheep had the new racket implanted in the mitral (n = 3) and in the tricuspid position (n = 2). The surviving sheep underwent postoperative evaluation. Results: After six months of operation, a standard transthoracic study showed competent valves without significant gradients and without residual valve regurgitation. The ring appeared encapsulated by a uniform fibrous tissue but the threads showed a completely denuded surface except in the zone proximal to the ring. Thrombi or calcification deposits in the ring, racket's mesh, or cardiac chamber were not observed. Conclusion: This initial experience confirmed the efficacy and simplicity of the technique.     

Transcatheter aortic valve implantation with balloonexpandable valve: early experience from China

Objective

The aim of the current study was to evaluate the early experience of the application of transcatheter aortic valve implantation with the balloon-expandable system in China. The transcatheter aortic valve implantation technology has been widely used for patients with inoperable severe aortic stenosis in the developed world. The application of transcatheter aortic valve implantation is still in the early stages of testing in China, particularly for the balloon-expandable valve procedure.

Methods

This was a retrospective study. All patients undergoing transcatheter aortic valve implantation with balloon-expandable system in our hospital between 2011 and 2014 were included. Edwards SAPIEN XT Transcatheter Heart Valve was used. The improvement of valve and heart function was evaluated as well as 30-day mortality and major complications according to the VARC-2 definition.

Results

A total of 10 transcatheter aortic valve implantation procedures with the balloon-expandable system were performed in our hospital, of which 9 were transfemoral and 1 was transapical. The median age was 76 years, and the median STS score and Logistic EuroSCORE (%) were 8.9 and 16.2. The implantation was successfully conducted in all patients, only 2 patients had mild paravalvular leak. There was no second valve implantation. Moreover, no 30-day mortality or complications was reported. Following the transcatheter aortic valve implantation procedure, the heart and valve functions had improved significantly. During the follow-up period of 3-34 months, one patient died of lung cancer 13 months after the operation.

Conclusion

This early experience has provided preliminary evidence for the safety and efficacy of transcatheter aortic valve implantation procedure with the balloon-expandable system in the developing world with an increasing aging population.     

Factors associated with moderate or severe left atrioventricular valve regurgitation within 30 days of repair of incomplete atrioventricular septal defect

Introduction

Left atrioventricular valve regurgitation is the most concerning residual lesion after surgical correction of atrioventricular septal defect.

Objective

To determine factors associated with moderate or greater left atrioventricular valve regurgitation within 30 days of surgical repair of incomplete atrioventricular septal defect.

Methods

We assessed the results of 51 consecutive patients 14 years-old and younger presenting with incomplete atrioventricular septal defect that were operated on at our practice between 2002 and 2010. The following variables were considered: age, weight, absence of Down syndrome, grade of preoperative left atrioventricular valve regurgitation, abnormalities on the left atrioventricular valve and the use of annuloplasty. The median age was 4.1 years; the median weight was 13.4 Kg; 37.2% had Down syndrome. At the time of preoperative evaluation, there were 23 cases with moderate or greater left atrioventricular valve regurgitation (45.1%). Abnormalities on the left atrioventricular valve were found in 17.6%; annuloplasty was performed in 21.6%.

Results

At the time of postoperative evaluation, there were 12 cases with moderate or greater left atrioventricular valve regurgitation (23.5%). The variation between pre- and postoperative grades of left atrioventricular valve regurgitation of patients with atrioventricular valve malformation did not reach significance (P=0.26), unlike patients without such abnormalities (P=0.016). During univariate analysis, only absence of Down syndrome was statistically significant (P=0.02). However, after a multivariate analysis, none of the factors reached significance.

Conclusion

None of the factors studied was determinant of a moderate or greater left atrioventricular valve regurgitation within the first 30 days of repair of incomplete atrioventricular septal defect in the sample. Patients without abnormalities on the left atrioventricular valve benefit more of the operation.     

影响腹膜透析患者心脏瓣膜钙化与左房增大相关因素分析

目的 探讨腹膜透析患者心脏瓣膜钙化及左房增大的患病率与相关危险因素分析,为有效预防瓣膜钙化及左房增大的发生提供依据.方法 入选深圳市第二人民医院腹透中心稳定的接受规律持续性非卧床腹膜透析(CAPD)的患者,采集患者的人口统计学资料,测定血压,检测生化指标,评估患者的残肾功能和透析充分性,记录用药情况,使用心脏多普勒超声仪检测患者的心脏瓣膜钙化及左房内径情况.采用Logistic回归分析心脏瓣膜钙化和左房增大的危险因素.结果 71例患者入选本研究,男性38例(53.5％),女性33例(46.48％).所入选患者平均年龄(51.7±15.7)岁,平均透析龄(30.04±18.69)个月.其中28例(39.4％)患者存在心脏瓣膜钙化,31例(43.7％)患者存在左房增大.与无心脏瓣膜钙化患者相比,心脏瓣膜钙化患者的年龄(P=0.000)、左房内径(P=0.017)较大;尿素氮(P =0.028)、CTNI(P=0.005)、BNP(P=0.026)较高;总KT/V水平(P =0.007)较低.与左房内径正常的患者相比,左房增大患者的CTNI(P=0.009)、BNP(P =0.005)较高;铁蛋白(P =0.002)、总Ccr (P =0.041)较低.相关性分析表明,左房内径与年龄、CTNI、BNP、心脏瓣膜钙化呈正相关关系(P＜0.05);而血清总钙、铁蛋白、总Ccr呈负相关关系(P＜0.05).多因素Logistic回归分析结果显示年龄(OR=1.151,95％ CI:1.072～1.237,P=0.000),肌酐(OR=1.003,95％ CI:1.000 ～ 1.006,P=0.026)与这些患者发生瓣膜钙化独立正相关.尿素氮(OR=1.401,95％ CI:1.119～1.752,P=0.003),心脏瓣膜钙化(OR=21.149,95％ CI:1.737～ 257.459,P=0.017)与这些患者发生左房增大独立正相关;而尿酸(OR=0.982,95％ CI:0.967 ～ 0.997,P=0.017),视黄醇结合蛋白(OR =0.944,95％ CI:0.899 ～ 0.992,P=0.023),铁蛋白(OR=0.986,95％ CI:0.977 ～0.996,P=0.004)与左房增大独立负相关.结论 腹膜透析患者心脏瓣膜钙化和左房增大患病率较高.年龄、血清肌酐水平是心脏瓣膜钙化的独立危险因素,血清尿氮与心脏瓣膜钙化是左房增大的独立危险因素,血清视黄醇结合蛋白、血清尿酸、铁蛋白水平是左房增大的保护因素.左房增大与心脏瓣膜钙化互为因果,密切相关.     

An improved pericardial bioprosthetic heart valve : Design and laboratory evaluation

The design and development of a new three-leaflet pericardial valve are described and its function and durability evaluated in the laboratory. The unique design allows the leaflets to be located on small radially projecting pins on a pericardial covered frame. Leaflets are easily interchanged on the frame to allow each set of leaflets to be matched during a function test prior to final assembly. The valve has similar hydrodynamic function to other pericardial valves and accelerated fatigue tests have shown improved durability with the elimination of leaflet tears caused by abrasion at the edge of the frame.     

Ventricular remodeling and mitral valve modifications in dilated cardiomyopathy: new insights from anatomic study

OBJECTIVE: The purpose of this study was to analyze the behavior of the mitral valve ring and the left ventricle in dilated cardiomyopathy. METHODS: We analyzed 68 fixed adult human hearts, divided into 48 hearts with dilated cardiomyopathy of ischemic or idiopathic origin and 20 hearts free of pathologic heart conditions. Digital images of the mitral ring perimeter, attachment of the anterior and posterior leaflets, and fibrous and muscular portions were collected. We also measured the internal perimeter of the left ventricle, the distance from the septum to the anterior and posterior papillary muscles, the distance between the papillary muscles, and the extension of interventricular septum. RESULTS: The analysis of the results showed proportional distribution of the ring's fibrous portion (r2 = 0.98) and muscular portion (r2 = 0.99) according to the degree of mitral valve dilation. Linear regression revealed that the perimeters of anterior and posterior leaflet attachments (r2 = 0.96 and r2 = 0.98, respectively) also had a proportional relation. We did not observe proportionality between the degree of dilation of the mitral ring and the left ventricle. It was observed that dilation of the left ventricle takes place globally in its segments. CONCLUSION: Differently from what was thought, in ischemic or idiopathic dilated cardiomyopathy, dilation of mitral ring is proportional and does not exclusively affect the posterior portion. The degree of left ventricular dilation does not determine the degree of dilation of the mitral ring because they are independent processes. These observations shed new light on the techniques used to correct mitral valve insufficiency in dilated cardiomyopathy.     

扩张型心肌病心力衰竭患者心肌细胞JP-2基因的表达

目的 探讨临床扩张型心肌病心力衰竭患者心肌细胞中连接蛋白(JP)-2基因的表达特点.方法 研究分为心力衰竭组:临床确诊扩张心肌病心力衰竭病例,心脏移植手术中取病变心脏左心室心肌标本;对照组:由于受体原因不能按计划进行心脏移植的供体左心室标本.使用电子显微镜观察心力衰竭细胞肌质网与细胞膜耦联距离,用蛋白质免疫印记Westernblot技术分析JP-2基因的蛋白表达,实时定量逆转录聚合酶链反应(RT-PCR)技术分析JP-2基因表达的变化.统计结果使用SPSS 12.0统计软件分析,P＜ 0.05为有显著差异.结果 14例重度心力衰竭病例入选心力衰竭组,空白对照组6例.电子显微镜超微结构观察平均100 μm2区域心肌细胞耦联子的数量,对照组和心力衰竭组分别为60和112个(P＜0.001).利用IDL统计方法,耦联子中基质网和细胞膜横小管的间距比较,对照组和心力衰竭组分别为(16.2±3.2)nm和(19.3 ±4.3) nm(P ＜0.001).Western blot结果显示,连接蛋白-2在对照组和心力衰竭组的相对甘油醛-3-磷酸脱氢酶(GAPDH)表达量分别为15.3％和7.2％(P＜0.05).RT-PCR的结果显示对照组和心力衰竭组的JP-2基因相对GAPDH的表达分别98.8％和37.5％ (P ＜0.01).结论 扩张型心肌病心力衰竭心肌细胞中JP-2基因表达和蛋白表达都明显减少,同时兴奋收缩耦联基质网和细胞膜横小管的间距明显增加.JP-2基因表达的变化可能是心力衰竭的早期分子机制之一.     

Tricuspid valve surgery: a thirty-year assessment of early and late outcome

Objective: Tricuspid valve (TV) surgery is usually performed as a concomitant reconstruction procedure in addition to the correction of other cardiac pathologies. Isolated tricuspid procedures are exceptionally rare. Prosthetic valve replacement is also seldom required. Generally, these patients face a high risk of operative mortality and long-term outcome is poor. In this study we reviewed our experience with TV surgery focusing on risk factors for operative mortality, long-term outcome and incidence of valve related complications Methods: Retrospective analysis of 416 consecutive patients >18 years with acquired TV disease operated on between 1974 and 2003. The follow-up is 97% complete (mean 5.9 ± 6.3 years). Three hundred and sixty-six patients (88%) underwent TV surgery with concomitant mitral (n = 340) or aortic (n = 100) valve surgery. The tricuspid valve was repaired in 310 patients (74.5%) and replaced in 106 (25.5%). A biological prosthesis was used in 68 patients (64%). Mean age at repair and replacement was 61 ± 12.5 and 50 ± 11.3 years, respectively (p < 0.001). Results: Overall 30-day mortality was 18.8% (78/416) and decreased from 33.3% (1974–1979) to 11.1% (2000–2003) (p ≤ 0.0001). Thirty-day mortality after TV repair and replacement was 13.9% (43/310) and 33% (35/106), respectively (p ≤ 0.001). Cox regression analysis revealed TV replacement as an independent predictor of 30-day mortality. Ten-year actuarial survival after TV repair and replacement was 47 ± 3.5% and 37 ± 4.8%, respectively (p = 0.002). Forty-five patients (10.8%) required a TV re-operation after 7.7 ± 5.1 years. Freedom from TV re-operation 10 years after TV repair and replacement was 83 ± 3.6% and 79 ± 6.1%, respectively (p = 0.092). Conclusions: Patients who require tricuspid valve surgery constitute a high-risk group. Tricuspid valve repair is associated with better perioperative and long-term outcome than valve replacement. However, patients undergoing replacement showed a significant higher incidence of risk factors for operative mortality. The incidence of re-operation is low with no significant difference when the tricuspid valve has been repaired or replaced. When valve replacement is necessary we recommend the use of a biological prosthesis considering the poor long-term survival.     

Mitral valve periprosthetic leakage: anatomical observations in 135 patients from a multicentre study

Objective: Prosthetic valve dysfunction after mitral valve replacement (MVR) may be caused by several factors, which often lead to repeated surgery. One of the most frequent determinants of reoperation is periprosthetic leakage (PPL). A few published reports have analysed PPL incidence and postoperative results after MVR, but no specific attention has been paid towards the potential relation between anatomical factors and PPL occurrence, particularly not bacterial-related. The aim of this study was to evaluate the location of PPL after MVR through a multicentre retrospective study. Methods: Between January 1985 and November 2005, 135 patients underwent reoperation at four institutions because of PPL after MVR and met the study inclusion criteria. The mitral valve annulus (MVA) was analysed in a clockwise format, indicating 12 o’clock as the mid-point of anterior annulus as viewed from the atrium. Results: Overall hospital mortality was 3.7% (five patients). Repair of PPL was carried out in 83 cases whereas prosthetic valve replacement was necessary in 52 cases. The total number of sectors involved in PPL was 244. PPL occurred more frequently between hour 5 and hour 6, and hour 10 and hour 11, with the risk of leakage being, 2.8 and 2.0 times higher, respectively, than in any other portion of the MVA. Conclusions: Our study suggests that PPL occurs more frequently at antero-lateral and postero-medial segments of MVA. This finding might be linked to unusual anatomical and functional factors of the MVA and may call for adjunctive care to these sectors of MVA when performing suture placement during MVR.     

Downsizing of the mitral valve and coronary revascularization in severe ischemic mitral regurgitation results in reverse left ventricular and left atrial remodeling

Objective: Data of combined mitral downsizing by restrictive prosthetic ring annuloplasty and coronary artery bypass grafting (CABG) in patients with ischemic cardiomyopathy and moderately severe to severe mitral regurgitation (MR) are rare, and little is known about the effect on reverse left ventricular (LV) and left atrial (LA) remodeling. Methods: Thirty-eight patients (70.6±8.3 years) with coronary artery disease, ischemic cardiomyopathy (LV ejection fraction [LVEF] 31±8%) and moderately severe to severe MR (grade 3.6±0.5) underwent CABG and mitral downsizing by 2–4 ring sizes. Clinical follow-up and serial transthoracic echocardiographic studies were performed after surgery (discharge, 3±0.5 months, 13±7 months) to assess survival, NYHA class, MR, leaflet coaptation height, LA and LV dimensions/volumes, fractional shortening (FS) and LVEF. Results: Early mortality (<30 days) was 2.6%, survival at follow-up was 92 and 85%, respectively. NYHA class improved from 3.3±0.6 to 1.5±0.6 (P<0.001). Residual MR at discharge and at follow-up was grade 0.5 and 0.6, respectively (P<0.001). Leaflet coaptation height was 8±1 mm and did not change over time. LV end-diastolic, end-systolic and LA dimensions decreased from 60±7 to 57±8 mm, from 47±9 to 42±9 mm and from 51±5 to 45±4 mm, FS increased from 23±9 to 28±10% (P<0.001); LV end-diastolic and end-systolic volumes decreased from 188±33 to 171±30 ml and from 129±35 to 105±33 ml, LVEF increased from 31±8 to 39±10% (P<0.001). Conclusions: Combined mitral downsizing and CABG surgery was performed with excellent clinical results: only minimal residual MR, a significant reduction of LA dimension and an increase of LV contractility due to reverse remodeling were observed.     

Histology of the tricuspid valve annulus and right atrioventricular muscle distance

Open in a separate window OBJECTIVESHistologically, the mitral valve annulus comprises a collection of collagen fibres. However, the existence of collagen fibres in the tricuspid valve annulus has not been elucidated. Our goal was to clarify the histology of the tricuspid annulus.METHODSFifty human hearts without heart disease that were autopsied at Osaka City University Hospital between January 2009 and December 2017 were examined. The tricuspid valve was sectioned at 12 sites around the annulus, and the atrioventricular junction distance was measured.RESULTSNone of the tricuspid valve annulus samples had a continuous aggregation of collagen fibres that could be called an annulus. The interventricular space between the right atria and ventricles was composed of adipose tissue only on the anterosuperior and inferior sides, and no adipose tissue was found on the septal side. Comparing the atrioventricular muscle distance of the anterosuperior and inferior sides, the distance at the inferior side was statistically significantly larger than that of the anterosuperior side in 47 cases (P < 0.0001).CONCLUSIONSThere was no continuous circumferential aggregation of collagen fibres in the right atrioventricular junction. The distance between the right atrial and ventricular myocardium was greater at the inferior side than that at the anterosuperior side, which might lead to more inferior annular dilation versus anterosuperior dilation. These anatomical features will be fundamental for future discussions of the suturing method used in prosthetic ring annuloplasty for tricuspid regurgitation.     

自体骨髓干细胞移植联合瓣膜手术治疗扩张型心肌病

目的 探讨瓣膜手术联合自体骨髓干细胞移植术对扩张型心肌病治疗效果.方法 2003年3月至2006年10月,选择8例扩张型心肌病病人,男5例,女3例;年龄15～56 岁.术前射血分数(EF)0.15～0.32,平均0.26±0.08.心功能(NYH) Ⅲ级4例;Ⅳ级4例.术日取病人自身骨髓50 ml,分离自体骨髓干细胞.5例行瓣膜置换术,3例行瓣膜成形术;瓣膜手术后,取培养的自体骨髓干细胞,左心室心肌内注射.结果 全组无手术死亡,未发生严重手术并发症.随访12～42 个月,平均18个月.术后6个月内EF改变不明显,但心功能明显改善,生活质量明显提高.术后1年EF开始改善.超声组织多普勒以及DISA心肌灌注/代谢显像显示心脏功能术后明显改善.结论 联合应用瓣膜手术加自体骨髓干细胞移植术可能改善扩张型心肌病治疗效果.