Papillary muscle sling and overlapping cardiac volume reduction with aortic valve replacement for valvular cardiomyopathy

A 63-year-old male was admitted to our hospital because of severe aortic regurgitation. The left ventricle was extremely dilated and mild functional mitral regurgitation was detected because of outward displacement of papillary muscles. We used a papillary muscle sling with aortic valve replacement to correct the widened distance between the papillary muscles. A papillary muscle sling when used for reducing tethering at the mitral valve also reduces the posterior left ventricular volume. As well, a transmural longitudinal incision along the left anterior descending artery in the left ventricular free wall was sutured by an overlapping method to reduce the anterior left ventricular volume. The combination of papillary muscle sling and the overlapping method does not need any resection of the cardiac muscle and so would be beneficial for end-stage valvular cardiomyopathy.     

Sutureless aortic valve replacement with concomitant valvular surgery

Objectives

Sutureless aortic valve replacement (SU-AVR) is an alternative technique to standard aortic valve replacement. We evaluated our experience with the Perceval SU-AVR with concomitant mitral valve surgery, with or without tricuspid valve surgery, and aimed to discuss the technical considerations.

Aortic dissection after aortic valve replacement in patients with valvular aortic stenosis

Aortic dissection occurred after aortic valve replacement in two patients with valvular aortic stenosis. Clinical and necropsy findings are described.     

The Batista operation in patients with dilated cardiomyopathy

Between December 1996 and October 1998, 34 patients with nonischemic dilated cardiomyopathy (DCM) received cardiac volume reduction surgery. The patients' ages ranged from 14 to 67 years (mean = 48 years) and included 28 males and 6 females. Associated mitral regurgitation was present in 31 patients, tricuspid regurgitation in 19 patients, and aortic regurgitation in 4 patients. We performed a partial left ventriculectomy (PLV) using antegrade intermittent warm blood cardioplegia in 15 patients (group A), and in 19 patients (group B) PLV was performed using the on-pump beating heart technique. In group A, the mean aortic clamping time was 79+/-33 minutes and the total cardiopulmonary bypass time was 155+/-58 minutes. In group B the mean cardiopulmonary bypass time was 121+/-43 minutes. There were eight hospital deaths (five in group A and three in group B). Five of 10 survivors of group A required inotropic support for 13.8+/-25.3 days after the operation, while 5 of 12 survivors in group B required inotropes for 4.2+/-3.1 days. Hospital mortality was 86% in 7 emergent cases and 7% in 27 elective cases. Echocardiographic study showed that the left ventricular ejection fraction improved from a mean of 18.7% to 30.3% and the left ventricular diameter decreased from a mean of 80.2 mm to 62.3 mm after the operation. All 26 hospital survivors were followed for 1 to 20 months. Three patients died at early follow-up because of congestive heart failure, thrombosed valve, and hepatic failure, respectively. Nineteen patients were in New York Heart Association (NYHA) Class I or II and four were in NYHA Class III. In conclusion, cardiac volume reduction surgery is effective when the operative technique and proper judgment of patient selection are established, and emergent operation is avoided.     

Aortic valve replacement combined with endoventricular circulatory patch plasty (Dor operation) in a patient with aortic valve stenosis and severe ischemic cardiomyopathy.

A 58-year-old woman with ischemic cardiomyopathy and aortic valve stenosis, underwent aortic valve replacement and simultaneous endoventricular circulatory patch plasty (Dor operation). She underwent coronary artery bypass grafting for severe triple vessel disease 10 years ago. Recently she started to show severe congestive heart failure. Aortic valve stenosis with pressure gradient of 85-mmHg was also found. Coronary bypasses were all patent, but the left ventricle (LV) was severely dilated (LVDd/Ds=71/61 mm) and the ischemic cardiomyopathy was considered as the cause. She successfully underwent aortic valve replacement and endoventricular circulatory patch plasty. The initial postoperative course was complicated with intractable ventricular arrhythmia, but subsequent course was smooth and the patient was discharged with improved symptoms (NYHA Class II). Postoperative catheterization showed decreased left ventricular volume and improved contractility. This case implies the role of LV remodeling procedure in the ischemic cardiomyopathy combined with aortic valve lesion     

Emergency aortic valve replacement.

The aortic valve was replaced as an emergency in twenty-seven patients between July 1970 and December 1974. Twenty-two patients had critical aortic stenosis and five had acute aortic insufficiency. The indications for emergency surgery were cardiac arrest in five patients, low cardiac output in four patients, and medically intractable pulmonary edema in eighteen patients. Cardiac catheterization was not undertaken in ten persons because of their critical condition. The clinical diagnosis in these patients was supported by noninvasive maneuvers. No surgical deaths occurred. Twenty-five patients are well, active and NYHA Class I at five to thirty-three months after surgery. There has been one late death and one patient has some residual exertional dyspnea. One patient required reoperation to relieve a clotted prosthetic valve. These results suggest that the patient with aortic valve disease may be offered a reasonable chance for survival, even when desperately ill.     

Aortic root substitution after aortic valve replacement: a prosthesis-sparing operation.

Patients who underwent isolated aortic valve replacement could come to attention for new onset aortic disease or progression of borderline alterations not corrected at the first operation, especially in the subset of bicuspid valve disease. We describe our technique in redo operations for aortic root disease, using only a vascular graft and sparing the previously implanted valve prosthesis. In case of normally functioning mechanical prosthesis, we always left the valve in situ and substituted the aortic root with a Dacron conduit, extending the replacement if necessary to the other diseased portions of the thoracic aorta.     

Early experience with robotic aortic valve replacement.

We report our initial experience with aortic valve replacement using robotic assistance. All procedures were performed with peripheral cardiopulmonary bypass, transthoracic aortic cross-clamp, and antegrade cold crystalloid cardioplegia. One or two ports and a 5-cm intercostal incision in the right chest were used for access. All patients had aortic valve replacement performed robotically. Between February and September 2004, five patients underwent robotic aortic valve replacement. The mean age was 59 years (range 35-82 years). There were no incisional conversions, death, stokes, or reoperations for bleeding. Overall mean study times were as follows: procedure, 231.2 min (range 180-315 min); cardiopulmonary bypass, 121.5 min (range 83-173 min), and cross-clamp, 98.2 min (range 67-140 min). One patient developed postoperative pneumonia. Aortic valve replacement can be successfully performed with the da Vinci robotic system.     

Long-term results for aortic valve replacement with small aortic annulus

We determined whether aortic prosthesis size influences survival and hemodynamic function. Eighty-nine patients who underwent small aortic valve replacement were followed. The small internal orifice area index (IOAI) group was defined as having an internal orifice area/body surface area ratio of < or = 1.3 cm(2)/m(2) (n = 34). The control group was defined as having an IOAI >1.3 cm(2)/m(2) (n = 55). The actuarial survival rate at 10 years was 74.5% in the small IOAI group and 75% in the control group (NS). Freedom from valve-related impairment at 10 years was 87% in the small IOAI group and 85% in the control group (NS). Postoperative pressure gradients were higher in the small IOAI group (p < 0.05). Left ventricular mass index decreased in both groups (albeit nonsignificantly in the small group, but significantly decreased in the control group). The long-term results of aortic valve replacement for patients with small aortic annulus were satisfactory. However, the postoperative pressure gradient through the prosthesis and left ventricular hypertrophy remained at a high level in the small IOAI group.     

Mitral valve replacement with mounted aortic valve homografts

The clinical results of isolated mitral valve replacement with mounted aortic valve homografts undertaken in 29 patients is presented. In 15 of these patients haemodynamic evaluations were made before and after operation. The results attest to the haemodynamic suitability of the homograft aortic valve in the mitral position and it would appear from this initial study that there will be little difference in the durability of orthotopic and heterotopic aortic homograft valves.     

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

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

A fascial frustum valve for aortic valve replacement

The promising qualities of autologous fascia lata in heart valve replacement have resulted in a search for improved methods of fascial heart valve manufacture. This paper describes a simply made and inserted and reliably competent unsupported fascial valve for aortic valve replacement.     

A case of minimal invasive aortic valve replacement for quadricuspid aortic valve with aortic regurgitation]

Congenital quadricuspid aortic valve is rare, which may be a cause of sever aortic regurgitation. We report a case of a 55-year-old man who had severe aortic regurgitation with congenital quadricuspid aortic valve. Preoperative aortography showed severe aortic regurgitation. Preoperative trans-esophageal echocardiography revealed abnormal quadricuspid aortic valve. We performed minimal invasive aortic valve replacement with SJM # 21 mm HP prosthetic valve through the limited upper sternotomy. Skin incision was 9 cm. Aortic cross-clamping time was 92 min, cardiopulmonary bypass time was 108 min. At the operation, a quadricuspid valve with three equal cusps and one small cusp was noted. The postoperative course was excellent and he discharged 8 days after the operation.     

妊娠期瓣膜功能障碍患者再次换瓣的护理配合

目的总结机械瓣置换术后妊娠期患者机械瓣功能障碍再次行瓣膜置换手术的护理配合经验,为手术室护理提供参考。方法对9例机械瓣置换术后妊娠13~35周再次行机械瓣置换术患者,巡回护士做好术前访视、特殊物品准备、手术室环境准备、患者准备,术中密切观察患者,及时配合处理新生儿;器械护士做好开台、开胸插管准备,准确配合瓣膜置换及止血关胸操作,注意保护胎儿等。结果 9例患者再次机械瓣置换术成功,均康复出院;5例胎儿存活,顺利分娩。随访6个月至10年,9例患者心功能Ⅰ~Ⅱ级;5例婴儿生长发育正常。结论该类手术难度高,风险大;护士需具备丰富的手术经验、快速的配合技巧、敏锐的观察能力,与团队密切协作,保障手术成功。