Clinical results of mitral valve surgery in children

The clinical results of mitral valve surgery in children were evaluated. Fifty children (age ranged between 1 month and 12 years) with mitral valve regurgitation have undergone valve surgery with low operative mortality (2%). Valve plasty using several techniques including annuloplasty have been performed with quite high success rate (92%), while valve replacement was required in four patients who had the prolapse of the anterior mitral leaflet (8%). Reoperation was required in 5 patients (10%), and there were 4 late deaths. Introduction of the reconstructive technique of the chordae tendinae using artificial chordae resulted 100% success rate of mitral repair for the prolapse of the anterior mitral leaflet without death and reoperation. The reoperation free rate and the actuarial survival rate at 15 years of the patients with mitral regurgitation were 70 +/- 12% and 85 +/- 7%, respectively. In ten patients with mitral valve stenosis (age ranged between 1 month and 5 years), 5 patients required valve replacement (50%), and 2 patients died (20%). The clinical results of the surgery for the mitral stenosis were still unsatisfactory, and the reoperation free rate at 2 years was 42 +/- 30% and the actuarial survival rate at 13 years were 32 +/- 18%.     

The long-term outcome of a surgical repair of sinus of valsalva aneurysm

BACKGROUND: In order to clarify the long-term outcome after surgical repair of a sinus of Valsalva aneurysm, we retrospectively assessed the operative results for patients treated in our institute. METHODS: The subjects were 27 patients who had undergone an operation between 1958 and 1996. For associated aortic regurgitation (AR) aortic valve repair was performed in 13 patients, 12 of whom had a ventricular septal defect (VSD); and an aortic valve replacement was performed in 3 patients, 1 of whom had a VSD. RESULTS: Five of the 13 patients who had aortic valve repair needed aortic valve replacement because AR developed after a period of between 7 and 13 years; those cases were complicated by VSD. Another 2 patients with mild AR also complicated by VSD are currently under observation. CONCLUSIONS: Although the postoperative outcome of the aortic valve repairs was good, cases that were complicated by VSD plus associated AR tended to develop AR later after surgery. Therefore, careful observation of the postoperative course is necessary.     

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)     

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.     

先天性心脏病术中心脏瓣膜的保护和矫治

目的 总结先天性心脏病术后因瓣膜功能不全再手术的经验。方法 回顾分析先天性心脏病术后再行瓣膜手术13例患者的临床资料,其中室间隔缺损修补术后8例,部分心内膜垫缺损修补术后3例,法洛四联症和房间隔缺损修补术后各1例。第1次手术时即存在二尖瓣轻～中度关闭不全6例,主动脉瓣关闭不全1例;新出现瓣膜功能异常6例,其中2例因补片漏致三尖瓣关闭不全,2例因前叶腱索断裂致三尖瓣关闭不全,1例因残留右心室流出道狭窄继发三尖瓣关闭不全,1例因伤及主动脉瓣并发二尖瓣和三尖瓣关闭不全。13例中,行二尖瓣置换6例,三尖瓣置换2例,主动脉瓣置换1例,行主动脉瓣置换并二尖瓣、三尖瓣成形1例,三尖瓣成形3例。同时修补残余漏,疏通右心室流出道。结果 术后发生低心排综合征3例。2例术后早期分别死于脑气栓和呼吸循环衰竭。11例术后痊愈出院,随访1～8年,心功能良好。结论 先天性心脏病矫治术中应注意心脏瓣膜的保护,合并的瓣膜功能异常应积极修补,及时地再手术可取得良好效果。     

Surgical repair of complete atrioventricular septal defect.

BACKGROUND: The objective of this study was to assess the outcome of complete atrioventricular septal defect repair from 1981 to 2000. METHODS: One hundred seventy-two consecutive patients with atrioventricular septal defect were operated on by a single surgeon using a consistent operative technique (single patch; "cleft" closure). The patients' age range was from 5 weeks to 9 years (mean, 10.8 +/- 1.2 months). RESULTS: Overall operative mortality was 15 of 172 (8.7%) and this decreased significantly from 12 of 73 (16.4%) in the first decade to 3 of 99 (3.0%) in the second decade (p = 0.0021) with no operative deaths in the last 51 patients. Operative mortality was related to decade of operation (p = 0.0021) and to use of crystalloid cardioplegia (p = 0.0047) by univariate analysis, and to decade of operation (p = 0.0016) and postoperative time on ventilator (p = 0.0023) by multivariate analysis. Actuarial long-term survival including operative deaths was 79.0% +/- 3.8% at 15 years. Ten of 157 (6.4%) operative survivors have undergone reoperation for late mitral regurgitation (9 mitral valve repair, 1 mitral valve replacement) with one death. Four of 8 patients surviving late mitral valve replacement have subsequently required mitral valve repair. Freedom from late reoperation for severe mitral regurgitation was 89.9% +/- 3.1% at 15 years. Freedom from late reoperation for mitral regurgitation did not decrease in the second decade (84.2% +/- 6.6% at 10 years) versus the first decade (94.5% +/- 3.1%) (p = 0.0679). CONCLUSIONS: Although operative mortality for repair of atrioventricular septal defect has decreased dramatically during the past decade, the incidence of late reoperation for mitral regurgitation has not improved, and better techniques to eliminate late mitral regurgitation are needed.     

Mitral valve repair and replacement for rheumatic disease

OBJECTIVES: Mitral valve repair may be technically feasible in patients with suitable anatomy, but the appropriateness of repair for rheumatic disease remains controversial. We evaluated our late outcomes after mitral repair and replacement for rheumatic disease. METHODS: Five hundred seventy-three patients underwent mitral valve surgery for rheumatic disease at our institution from 1978-1995. Follow-up was 98% complete (mean, 68 +/- 46 months). Survival and morbidity were evaluated by Kaplan-Meier analysis and Cox regression, including propensity score analysis. RESULTS: Mean age was 54 +/- 14 years, 55% of patients had congestive heart failure, 22% were undergoing redo mitral valve surgery, and 9% also underwent coronary bypass. Mitral stenosis was present in 53%, regurgitation in 15%, and both in 32%. Valve repair was performed in 25%, bioprosthetic replacement was performed in 28%, and a mechanical valve was placed in 47%. Patients undergoing repair were younger and less likely to be undergoing reoperation or to have atrial fibrillation than those undergoing replacement (P =.001). The operative mortality rate was 4. 2%. Better late cardiac survival was independently predicted by valve repair rather than replacement (P =.04) after adjustment for baseline differences between patients. Freedom from reoperation was greatest (P =.005) but that from thromboembolic complications was worst (P <.0001) after mechanical valve replacement. Twenty-three patients underwent reoperation after initial repair, with no operative deaths. CONCLUSIONS: Mechanical valves minimize reoperation but limit survival and increase thromboembolic complications. Patients undergoing valve repair had improved late cardiac survival independent of their preoperative characteristics. Rheumatic mitral valves should be repaired when technically feasible, accepting a risk of reoperation, to maximize survival and reduce morbidity.     

Mitral valve replacement in the first year of life

From 1973 through 1987 25 patients underwent mitral valve replacement in the first year of life for mitral stenosis and mitral regurgitation. The patients with mitral stenosis included two with mitral arcade, two with supravalvular mitral stenosis with hypoplastic mitral valve, and one with parachute mitral valve. Included in the group of patients with mitral regurgitation were 12 with atrioventricular canal defect, six with chordal and leaflet defects, one with Marfan's syndrome, and one with bacterial endocarditis. Prostheses included 12 Bj?rk-Shiley (17 mm), seven St. Jude Medical (19 mm in four, 21 mm in three), five stent-mounted dura mater valves (12 mm to 16 mm), and one porcine xenograft (19 mm). In four patients the valves were placed in the left atrium in a supraannular location. There were nine operative (atrioventricular canal defect seven, mitral regurgitation two) and five late (atrioventricular canal defect four, mitral stenosis one) deaths, giving actuarial 1- and 5-year survival rates of 52% and 43%, respectively. All 6 patients with tissue valves died; the four with supraannular mitral valve replacement survived. Since 1983 operative mortality has been reduced to 0% (70% confidence limits 0% to 24%). Nine patients required a second mitral valve replacement for prosthetic stenosis 5 to 69 (mean 30) months after the original mitral valve replacement (one operative death). Because of improvements in repair of atrioventricular canal defect in infancy, the need for mitral valve replacement at atrioventricular canal defect repair has decreased. Although valvuloplasty has been advocated for repair of congenital mitral valve disease and is applicable in some infants with mitral regurgitation, mitral valve replacement is frequently unavoidable for congenital mitral disease and can now be accomplished at a low operative risk, even when the prosthesis has to be positioned supraannularly.     

Repair of ventricular septal defect in adults

To evaluate the outcome of ventricular septal defect (VSD) with long duration of haemodynamic derangement, a retrospective study was made of 42 consecutive patients who underwent closure of VSD as adults (age range 15-48, mean 27 years). The mean systolic pulmonary arterial pressure was 53 mmHg, mean pulmonary vascular resistance 2.5 Wood units and mean pulmonary/systemic flow ratio 2.4. VSD was complicated by aortic regurgitation in 12 cases, mitral regurgitation in 4, and sinus of Valsalva fistula in 6 cases. There were 15 supracristal, 24 infracristal and 3 muscular VSDs. In addition to VSD closure, surgery included aortic valve replacement (7 cases), mitral valve replacement (2), valve repair by suture (7) and repair of Valsalva sinus fistula (6 cases). Two patients died in the early postoperative period and two during follow-up (1-10, mean 4.5 years). The early and the late mortality were related to large infracristal VSD, pulmonary hypertension and irreversible pulmonary vascular changes which could not be anticipated on the basis of high calculated shunt flow at preoperative catheterization. No patient with supracristal VSD died. Recurrent VSD was diagnosed in five patients, three of whom needed reoperation and recovered uneventfully. Reduction of heart size and improved exercise tolerance were the most pertinent follow-up findings. The results suggest that large supracristal VSD with aortic valve involvement can be successfully closed in adults, but that the prospect for large infracristal VSD is less favourable if correction is postponed until adulthood.     

Evaluation of long-term results of bicuspidalization annuloplasty for functional tricuspid regurgitation. A seventeen-year experience with 133 consecutive patients

Between 1968 and 1985, 133 consecutive patients underwent bicuspidalization annuloplasty for moderate to severe functional tricuspid regurgitation associated with mitral or combined mitral and aortic valve disease. Over this period, the incidence of tricuspid valve replacement was only 2.3% (3/136 patients). There were 18 early deaths (13.5%) in the entire series--three (5.0%) of 60 patients in the last 5 years of the study--and 10 late deaths (8.7%). Actuarial survival rate for the entire series, excluding early deaths, was 91.0% +/- 3.0% at 10 and 17 years. There were seven reoperations (6.1%) on the tricuspid valve, needed because of residual or recurrent mitral valve lesions after the initial operation. Actuarial rates of freedom from reoperation on the tricuspid valve were 93.6% +/- 3.0% (10 years) and 69.7% +/- 16% (17 years) for the entire series: 78% +/- 10% (15 years) for the open mitral commissurotomy plus tricuspid annuloplasty group (44 patients); 90% +/- 9.0% (15 years) for the mitral plus tricuspid annuloplasty group (10); 75.2% +/- 22% (17 years) for the mitral replacement plus tricuspid annuloplasty group (58); and 92.6% +/- 7.0% (16 years) for the combined aortic and mitral valve surgery plus tricuspid annuloplasty group (21). Ninety-eight percent of the survivors were in New York Heart Association class I or II postoperatively. Of 21 randomly selected patients investigated by pulsed Doppler echocardiography, 14 (67%) had no regurgitation or grade 1/4 tricuspid regurgitation and the remaining seven (33%) had grade 2/4 regurgitation postoperatively. Our experiences suggest that bicuspidalization annuloplasty can be a reliable method in the vast majority of patients with functional tricuspid regurgitation.     

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)     

A long-term prognosis of ventricular septal defect associated with aortic regurgitation

Fifty-one cases of ventricular septal defect associated with aortic regurgitation (VSD and AR) were examined for past twenty-two years. Only VSD closure was performed for AR cases under Sellers II regurgitation. After the average of 11.6 years' follow-up, 14 cases retained over 60 mmHg of diastolic pressure and belonged to NYHA functional class 1. VSD closure and aortic cusp suspension were performed for AR cases over Sellers II regurgitation. Three cases operated before 1969 died of cardiac failure and one case recently died of infectious endocarditis (IE). Because of residual AR, one case was performed re-aortic cusp suspension one year after the operation and another case was scheduled for re-aortic cusp suspension after three years and eight months. Eighteen cases with malfunctioned valve caused by calcification, etc. underwent the aortic valve replacement. Early death was due to low cardiac output syndrome (LOS). Five cases were followed up for eleven years on the average. Two cases were found atrial fibrillation and myocardial infarction, respectively. Four cases were VSD + AR with the past history of IE and one died of LOS after surgery. Two cases were postoperative IE. One died three months after the operation and the other is doing well after the re-surgery by translocation. A long-term finding of SV1 + RV5 by electrocardiogram showed a significant decrease in left ventricular overload. Significant decrease of cardiothoracic ratio was observed in AR group under Sellers II regurgitation. Pulse pressure was significantly decreased as well.     

Reoperations and survival after primary repair of congenital heart defects in children

OBJECTIVE: The objective of this article is to evaluate the incidence of reoperation and the associated risk and survival after primary repair of congenital heart defects using cardiopulmonary bypass in children. METHODS: We present a retrospective analysis of 1220 consecutive children under 16 years [649 (53%) under 1 year] operated on between 1976 and 2001 by 1 surgeon (J.L.M.). RESULTS: The early (30-day) mortality was 6.9%; 171 patients had 206 reoperations. The early mortality for the first reoperation was 10.4% and for second reoperation, 3.8%. Of the first-time reoperations 63% were inevitable, 15% were planned, and 22% were unexpected. The overall 20-year freedom from reoperation was 83% and survival (including early mortality) was 86%. The 10-year freedom from reoperation and survival, respectively, was as follows: aortic valvotomy, 77% and 92%; pulmonary valvotomy, 90% and 95%; atrial septal defect, 99% and 100%; partial atrioventricular septal defect (AVSD), 81% and 94%; complete AVSD, 74% and 70%; VSD, 95% and 97%; double-outlet right ventricle, 66% and 68%; truncus arteriosus, 54% and 71%; Mustard, 85% and 86%; arterial switch, 78% and 74%; Fontan, 77% and 66%; Fallot, 91% and 93%; and total anomalous pulmonary venous drainage, 89% and 84%. Of those undergoing aortic valvotomy, 53% were infants, but when aortic valve replacement became necessary an adult valve could be inserted. Introduction of the total cavopulmonary connection to the Fontan procedure in 1990 with prior cavopulmonary anastomoses has greatly improved outcome, with only 1 reoperation and no deaths since then. Patients with AVSD required 12 reoperations for mitral regurgitation, mostly through the "cleft," the closure of which in the past 5 years has provided promising results. CONCLUSIONS: The majority of reoperations after repair of congenital heart defects in children are inevitable, and their incidence varies for different types of procedures. These findings will help in informing parents about the possible outcome of surgery, but the introduction of newer techniques may reduce the need for reoperation further. The survival is encouraging.     

Mitral valve replacement in the first 5 years of life

Between 1976 and 1986, 19 children aged 1 month to 5 years underwent replacement of the mitral (systemic atrioventricular) valve. Indications for valve replacement included isolated congenital mitral stenosis (n = 2), valve dysfunction associated with a more complex procedure (n = 15), and failed valvuloplasty (n = 2). Seven different valve types were used; nine were mechanical valves and ten were bioprosthetic valves. There were 6 hospital deaths (32%; 70% confidence limits, 20% to 47%). Among the 13 survivors there were 3 late deaths at a mean of 14 months after operation. The late deaths were unrelated to valve malfunction. Thromboembolic events occurred in 2 patients, both with mechanical valves. One minor bleeding complication occurred among 10 patients on a regimen of Coumadin (crystalline warfarin sodium). Five patients, all with bioprostheses, required a second valve replacement. Indications for reoperation included prosthetic valve regurgitation (n = 1) and calcific stenosis (n = 4). No early or late deaths occurred after second valve replacement. Survival was 51% +/- 12% (standard error) at 112 months after valve replacement. Analysis failed to identify age, weight, sex, previous operation, underlying cardiac lesion, or prosthesis size and type as significant risk factors for mortality. Mechanical valves had a lower reoperation rate compared with bioprostheses. These data suggest that although mitral valve replacement within the first 5 years of life is associated with a high operative and late mortality, satisfactory long-term palliation for many patients can be achieved. Mechanical valves are superior to bioprosthetic valves, and offer the best long-term results.     

儿童感染性心内膜炎的外科治疗

目的：总结儿童感染性心内膜炎的外科治疗经验，以期掌握好手术时机及指征，提高手术成功率。方法：28例儿童心内膜炎病人，7例因急性心力衰竭、栓塞或严重败血症急诊手术；21例经抗生素治疗体温正常后择期手术。彻底清除赘生物后，同时行主动脉瓣瓣膜置换5例，主动脉根部拓宽、主动脉瓣瓣膜置换2例，室间隔缺损（室缺）修补5例，室缺修补、右室流出道疏通2例，室缺和佛氏窦瘤修补2例，室缺修补、主动脉瓣瓣膜置换2例，动脉导管缝扎3例，动脉导管缝扎、主动脉瓣瓣膜置换1例，二尖瓣瓣膜置换3例，二尖瓣瓣膜置换、左冠前降支取栓并搭桥1例，法洛四联症矫正、Rastelli手术和1例。同期行三尖瓣成形6例、肺动脉瓣成形7例。结果：手术死亡1例（3．6％），死亡原因为术后霉菌性感染不能控制、多器官功能衰竭。术后平均随访2．6年，心内膜炎复发2例，无远期死亡。结论：儿童感染性心内膜炎手术治疗的远期效果满意，其手术时机及指征的掌握对治疗效果至关重要。     

Long-term clinical results with the Ionescu-Shiley pericardial xenograft

From 1977 to 1987, 829 Ionescu-Shiley pericardial valves (Shiley, Inc., Irvine, Calif.) were implanted in 766 patients at the University of Ottawa Heart Institute. There were 476 patients who had aortic valve replacement, 234 who had mitral valve replacement, and 44 who had double valve replacement. The standard-profile design was used in 508 patients and the low-profile design in 321 patients. Follow-up was obtained for 97% of patients, with calculation of event-free probabilities. At 10 years the overall probability of freedom from structural failure was 48% +/- 7% after aortic valve replacement, 44% +/- 15% after mitral valve replacement, and 79% +/- 11% after double valve replacement. Although at 5 years the probability of failure was statistically lower with the low-profile design, this favorability was lost by 6 years. Freedom from structural failure was only 47% +/- 7% for the standard-profile valve at 10 years. Thus the probability of freedom from reoperation was only 46% +/- 7% after aortic valve replacement, 39% +/- 6% after mitral valve replacement, and 65% +/- 20% after double valve replacement at 10 years. Thromboembolism occurred in 69 patients, for a predicted freedom from this complication at 10 years of 79% +/- 3% after aortic, 73% +/- 7% after mitral, and 96% +/- 4% after double valve replacement. There were 31 cases of endocarditis. The 10-year predicted freedom from endocarditis, therefore, was 86% +/- 3% after aortic, 98% +/- 1% after mitral, and 97% +/- 1% after double valve replacement. A total of 221 operative and late deaths were recorded in this series. Prosthetic valve failure accounted for 27% of late deaths. The 10-year survival rates were estimated to be 56% +/- 5% (aortic valve replacement), 54% +/- 6% (mitral valve replacement), and 51% +/- 8% (double valve replacement). We concluded that the Ionescu-Shiley pericardial xenograft provides less than optimal clinical performance and its use has been discontinued.     

Late reoperations after repair of tetralogy of Fallot.

Twenty-two patients underwent 23 late reoperations after total correction of tetralogy of Fallot from 1965 to 1990. Indications for reoperation included: isolated ventricular septal defect (VSD) in 9 patients (41%), isolated right ventricular outflow tract (RVOT) obstruction in 3 patients (13.7%), VSD associated with a RVOT obstruction in 7 patients (31.8%), aneurysm of the pericardial RVOT patch in 1 patient (4.5%), aortic insufficiency with a residual VSD in 1 patient (4.5%), and tricuspid regurgitation in 1 patient (4.5%). The reoperation consisted of closure of a residual VSD in 17 patients, relief of a RVOT gradient in 11, insertion of a RVOT valve in 4, tricuspid valve replacement in 1 (reoperated twice), aortic valve replacement in 1, and excision of a RVOT aneurysm in 1. Two patients died in hospital (9%) but there were no early deaths in the 11 patients reoperated upon after 1978. Mean follow-up period was 135 months. There were 2 late deaths. The actuarial 20-year survival was 87%. Of the surviving patients, 16 (89%) were in New York Heart Association class I, 1 (5.5%) was in class II, and one (5.5%) was in class III. One patient required a second reoperation for tricuspid bioprosthesis degeneration and 1 patient had moderate recurrent RVOT gradient due to calcified pulmonary bioprosthesis. This study tends to support the policy of recommending reoperation in the presence of surgically significant residual defects. Reoperation is associated with a low early mortality and good long-term results.     

Mitral valve surgery in patients with extensive calcification of the mitral annulus

OBJECTIVES: The objective of this work was to examine the clinical outcomes of mitral valve surgery in patients with extensive mitral annular calcification. METHODS: Mitral valve surgery was performed in 54 patients (28 men and 26 women, mean age 63 +/- 14 years) with mitral regurgitation and extensive mitral annular calcification. Most patients (78%) were in New York Heart Association classes III and IV, 14 had coronary artery disease, and 9 had prior mitral valve replacement in which the calcium bar was not removed. The calcium bar was excised and a new mitral annulus was created by suturing a strip of pericardium onto the endocardium of the left ventricle from lateral to medial fibrous trigones and to the endocardium of the left atrium. The mitral valve was repaired in 12 patients and replaced in 42. In 23 patients the intervalvular fibrous body was reconstructed and the aortic valve was also replaced. Mean follow-up was 4.1 +/- 3.7 years and was complete. RESULTS: There were 5 operative deaths and 11 late deaths. Five-year survival was 73 +/- 7%. Four patients needed reoperation and each survived. Freedom from reoperation at 5 years was 89 +/- 6%. Three patients had a stroke and 4 had anticoagulation-related hemorrhage, one of which was fatal. Five-year freedom from valve-related mortality or morbidity was 75 +/- 8%. Most survivors were in New York Heart Association functional classes II and III. CONCLUSIONS: Resection of the calcium bar and creation of a new annulus with pericardium provided good clinical results in patients with extensive calcification of the mitral valve.     

Combined aortic root replacement and mitral valve surgery: The quest to preserve both valves

Objectives

Coexisting aortic root and mitral valve pathology is increasingly recognized among patients undergoing surgery. We characterized the pathology and surgical outcomes of patients with combined aortic root and mitral disease.

Valve replacement in children

Between May 1979 and September 1998, 202 children underwent surgical treatment for valvular heart disease. Of these 23, who ranged in age from 25 days to 15 years, underwent valve replacement, including 1 reoperation. The valve replacement consisted of the aortic valve in 5 patients, the mitral valve in 3, the tricuspid valves in 9, including 5 systemic atrioventricular valves for atrioventricular discordance, the pulmonary valve in 6, 5 bioprostheses and 18 mechanical prostheses. There were 4 operative deaths, 1 hospital death and 3 late deaths. At the 10-years follow-up, the actual survival rate was 67.8%, the event free rate was 76.1% and the freedom from reoperation rate was 86.2%. Valve re-replacement was performed in only 1 patient due to a thrombosed tricuspid valve. These results suggest that there is a small risk of major complications and reoperation in children who undergo valve replacement, whether a bioprosthetic valve or a mechanical valve. The long-term results of younger patients should be followed more closely according to their growth.