Mitral and tricuspid valve repair in patients with previous mediastinal radiation therapy

Background

The purpose of this study was to evaluate outcomes of mitral and tricuspid valve repair after mediastinal radiation therapy.

Methods

From 1976 to 2001, 22 patients (mean age 61 ± 14 years) underwent mitral (n = 14), tricuspid (n = 6), or both (n = 2) valve repairs 15 ± 9 years after mediastinal radiation therapy. Concomitant procedures included coronary artery bypass graft, 11 patients; valve replacement, 6 patients (4 aortic, 3 mitral, 1 tricuspid, and 1 pulmonary); and pericardiectomy, 4 patients.

Results

Total follow-up was 82.5 patient-years (mean 3.7 ± 3.3 years). Early mortality was 3 patients. There were 7 late deaths, 4 of which were of cardiovascular origin. Of the 19 early survivors, 2 required subsequent valve replacements, and 1 required cardiac transplantation 3.4 ± 2.8 years after valve repair. One patient died after reoperation. In 4 patients who did not undergo reoperation, echocardiographic examinations showed progressive deterioration of their repaired valve function. Overall survival, freedom from cardiac death, and freedom from valve reoperation or cardiac transplantation at 5 years for early survivors was 66%, 85%, and 88%, respectively. New York Heart Association functional class at follow-up was I or II in 8 of the 12 late survivors.

Conclusions

Functional status was good in two-thirds of late survivors. However, severe dysfunction of the repaired valve developed in 32% of early survivors and 16% required further surgery. Valve repair is technically feasible in selected patients after mediastinal radiation therapy; however, the limited durability of repairs after mediastinal radiation in this series suggests that valve replacement might be preferable.     

Coronary artery bypass grafting in patients with previous mediastinal radiation therapy.

OBJECTIVES: Our objectives were to characterize the outcome of coronary artery bypass grafting in patients with previous mediastinal radiation therapy and to identify special features of this condition that relate to surgical management. Patients and methods: We conducted a retrospective review of 47 patients (28 women, 19 men) with a mean age of 63.5 +/- 12.8 years (range 31.0-82. 9 years) from 1976 through December 1996 undergoing coronary artery bypass graft after mediastinal radiation therapy. RESULTS: The mean interval between mediastinal radiation therapy and coronary artery bypass grafting was 15.1 +/- 9.8 years (range 1.1-37.8 years). In the 44 patients with isolated coronary surgery, operative mortality was 3 patients (6.8%). Sternal wound infection occurred in 3 patients (6.8%). Actuarial survival at 1 and 5 years was 87.2% +/- 4. 9% and 71.6% +/- 7.1%, respectively. Total follow-up was 293.7 patient-years (mean 6.2 +/- 5.1 years). There were 17 late deaths (malignancy, n = 7; heart failure, n = 6; stroke, n = 1; other noncardiac causes, n = 2; and sudden death, n = 1). Twelve of 43 discharged patients had the development of valvular disease demonstrated by follow-up echocardiography. CONCLUSIONS: The early results of coronary artery bypass grafting for the treatment of ischemic heart disease after mediastinal radiation therapy are good. Late survival, however, is limited by malignancy, either recurrent or new, and the development of heart failure. Inasmuch as 25 other patients after radiation therapy required concomitant valve surgery and 12 of 43 (28%) discharged patients had later development of valvular disease, with 2 requiring reoperation, careful assessment of any valvular lesion is important during the initial coronary artery bypass grafting. Careful follow-up, including regular echocardiographic screening, is recommended in this patient population.     

Significance of solitary mediastinal shadow in patients with previous malignancy

Four patients are described with primary extrathoracic malignant tumors and a mediastinal shadow on chest x-ray, which proved to be a benign cyst at exploratory thoracotomy. The need for thorough investigation and exploration in order to obtain histological diagnosis of the mediastinal lesion is stressed. The correct staging of the primary tumor and the institution of appropriate treatment may alter the survival of patients with this specific association.

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Résumé Chez 4 malades atteints d'une tumeur maligne extrathoracique, la radiographie de thorax montrait une ombre médiastinale. La thoracotomie a révélé qu'il s'agissait de kystes bénins. De tels cas exigent des investigations complètes et, éventuellement, une exploration chirurgicale pour obtenir un diagnostic histologique de la masse médiastinale, préciser le stade de la tumeur primitive et fixer le traitement. Le pronostic peut en dépendre.

     

Outcome of previous tricuspid valve operation and arrhythmias in adult patients with congenital heart disease

Background. Tricuspid valve operation or replacement has been associated with high perioperative mortality and poor long-term results. The prevalence of atrial arrhythmias before and after operation in these patients is undefined.

Methods. We retrospectively examined the outcome and frequency of atrial arrhythmias in 85 adult patients (46% men) with congenital heart defects who underwent tricuspid valve operation between 1961 and 1995.

Results. The majority had either Ebstein’s anomaly (22%), congenitally corrected transposition (19%), tetralogy of Fallot (15%), atrial (13%), or ventricular (11%) septal defects. Forty-two (49%) patients had sustained arrhythmias within 1 year before operation. After tricuspid valve operation, 21 patients (50%) had recurrence of atrial arrhythmias, and 7 in preoperative sinus rhythm developed late rhythm disturbances. Multivariate analysis identified age at operation and preoperative arrhythmias as independent predictors of late arrhythmias. Perioperative mortality was 5%, and there were seven late deaths. Survival was 91% at 5 years, and 83% at 10 years.

Conclusions. Surgical intervention does not prevent recurrence of atrial arrhythmias. Tricuspid valve operation in patients with congenital heart disease can be performed with a low risk of perioperative mortality and good long-term outcome.     

Aortic root replacement in patients with previous heart surgery

OBJECTIVE: The objective was to review the operative risk and outcomes of redo aortic root replacement. PATIENTS AND METHODS: From July 1990 to December 2001, aortic root replacement was performed in 165 patients who had at least one previous cardiac operation. Their mean age was 49 +/- 16 years and 78% were men. Twenty-eight patients had a previous aortic root replacement. The principal indication for surgery was prosthetic aortic valve dysfunction. All the patients had a dilated, calcified, ruptured, or some other abnormality of the aortic root. The follow-up was complete and extended from 0 to 12.5 years, mean of 3.8 years. RESULTS: There were 12 operative (7%) and 20 late deaths (12%). The survival at 8 years was 68%+/- 6%. The principal cause of death was cardiovascular related. Age at increments of 5 years (risk ratio: 1.2; CI: 95%; 1.1 to 1.4) and preoperative New York Heart Association functional class IV (risk ratio: 2.2; CI: 95%: 1.1 to 4.7) were the only two independent predictors of death. Two patients had a stroke and died; two patients developed three episodes of prosthetic valve endocarditis and died. Three patients were reoperated on because of endocarditis in one, bioprosthetic valve failure in one, and dehiscence of a prosthetic mitral valve in one. The freedom from reoperation at 8 years was 93%+/- 5%. CONCLUSIONS: Redo aortic root replacement can be done with low operative mortality in elective patients and the risk increases in those who need emergent surgery and are older. The long-term results are satisfactory and similar to those for patients who have aortic root replacement for the first time.     

Beating heart mitral valve replacement in a patient with a previous Bentall operation

Today, mitral valve replacement is performed under cardioplegic arrest with cross-clamping of the ascending aorta. In the case reported here, mitral valve replacement was performed with an on-pump beating heart technique without cross-clamping the aorta because of diffuse adhesion around the tube graft. A 36-year-old man had undergone a Bentall operation (aortic root replacement + coronary reimplantation) via median sternotomy because of type I aortic dissection 4 years previously in our cardiac center. He was admitted to the hospital complaining of palpitation and dyspnea on mild exertion. Transthoracic echocardiography study revealed third-degree mitral insufficiency. Mitral valve replacement was carried out through re-median sternotomy with an on-pump beating heart technique without crossclamping the aorta. On-pump beating heart mitral valve replacement without a cross-clamp offers a safe approach when excessive dissection is required to place a crossclamp on the ascending aorta.     

Valvular heart operation is an independent risk factor for acute renal failure

BACKGROUND: Acute renal failure (ARF) after cardiac operation with cardiopulmonary bypass is associated with a high mortality rate. The purpose of this study was to determine and quantify whether valvular heart operation is an independent risk factor for developing ARF. METHODS: We retrospectively analyzed 5,132 consecutive patients who underwent cardiac operation involving cardiopulmonary bypass between April 1997 and March 2001. Patients with significant renal impairment (preoperative serum creatinine > 200 micromol/L) were excluded. A multivariable logistic regression model was constructed to identify independent risk factors for the postoperative development of ARF. RESULTS: In 151 (2.9%) patients ARF developed before hospital discharge. The crude incidence of ARF for isolated coronary artery bypass grafting, isolated valve(s) operation, and valve(s) with coronary artery bypass grafting operation was 1.9%, 4.4%, and 7.5%, respectively (p < 0.001). The results of the logistic regression analysis found that valve operation with or without coronary artery bypass grafting was an independent risk factor for the development of postoperative ARF (odds ratio 2.68, 95% confidence interval 1.89 to 3.79; p < 0.001). Other independent predictors of ARF were increased preoperative serum creatinine levels, urgent or emergent operation, insulin-dependent diabetes, and increased cardiopulmonary bypass time. CONCLUSIONS: Valve operation is an independent risk factor for postoperative ARF. This risk is further increased by prolonged cardiopulmonary bypass.     

Clinical evolution of heart transplantation in patients with previous valvular cardiomyopathy

OBJECTIVE: Heart transplantation (HT) due to valvular cardiomyopathy is rare, namely, about 3% of cases in the Registry of the International Society for Heart and Lung Transplantation (ISHLT). Usually, these patients present some risk factors such as previous valvular operations and pulmonary hypertension. Since there are few studies in the literature, we retrospectively analyzed our early and long-term results. MATERIALS AND METHODS: We studied our experience in 22 HT cases for valvular cardiomyopathy (9.3% of our total experience), namely, 12 men and 10 women, of overall mean age of 52.6 +/- 10 years. Five patients had mitral; 8, aortic; and 1, tricuspid valve disease; 7 had double valve disease and 1, triple valve disease. Nineteen patients (87%) had been operated previously between 1 and 4 times. The mean ejection fraction was 23% +/- 7.3% and the mean New York Heart Association (NYHA) functional class was 3.7. Fifty-three percent of the patients had pulmonary hypertension. Two patients were operated as an emergency "O." We used the standard HT technique. RESULTS: Four patients (18%) were reoperated due to hemorrhage. The hospital mortality was 2 cases (9%). Another patients (9%) died on follow-up due to cardiac allograft vasculopathy. All surviving patients have been followed to the end of 2006. The mean follow-up has been 72 +/- 53 months. They are functional class I or II. CONCLUSIONS: HT for this indication was more frequent in our experience than in the Registry of the ISHLT. The immediate and long-term results were good, with an 82% mean survival at 6 years. HT can be a good treatment for patients with valvular cardiomyopathy and bad ventricular function and/or multiple valvular reoperations.     

Surgical therapy for primary hyperparathyroidism in patients with previous thyroid surgery

BACKGROUND: In patients with primary hyperparathyroidism (HPTH) and previous thyroid operations, complications of parathyroidectomy are more frequent than in patients undergoing initial neck surgery. The aim of this study was to investigate the value of preoperative imaging with regard to its influence on the surgical strategy. METHODS: We retrospectively analyzed 17 patients with primary HPTH and previous thyroid surgery. Preoperatively 16 patients underwent sonography and/or scintigraphy. RESULTS: Sonography had an overall accuracy to correctly localize enlarged parathyroid glands of 80%, and scintiscanning had overall accuracy of 78.6%. The accuracy of localization was increased up to 84.6% if both diagnostic procedures were applied. In patients with normal thyroid residues the accuracy of sonography was 85.7%, and it was 100% if scintiscanning was used. CONCLUSIONS: Preoperative localization techniques in patients with primary HPTH and previous thyroid surgery have high accuracy. This allows for an imaging-directed operative strategy, thus preventing unnecessary bilateral neck explorations, which carry a high risk of recurrent laryngeal nerve injury.     

Valvular heart surgery in osteogenesis imperfecta

Osteogenesis imperfecta is a disease in which fragile bones readily cause fracture. Valvular disease concurrently develops. However, the surgery-related mortality rate is approximately 30%. In this study, we report 2 patients with osteogenesis imperfecta who underwent valvular heart surgery. Patient 1 was a 31-year-old male. He had previously been diagnosed as having osteogenesis imperfecta. Echocardiography suggested aortic valve insufficiency, and aortic valve replacement was performed. Patient 2 was a 59-year-old male. During admission, osteogenesis imperfecta was diagnosed. Echocardiography suggested mitral valve insufficiency, and mitral valve plasty was performed. In the 2 patients, intraoperative hemorrhage was marked. However, there were no fatal complications. We also reviewed the literature.     

Limited operation for lung cancer in combination with postoperative radiation therapy.

PURPOSE: Combination therapy of lung wedge resection and postoperative radiation was performed to confirm the procedure's feasibility as a curative therapeutic modality. PATIENTS AND METHODS: Among the patients with clinical stage I lung cancer, who could not undergo a standard lobectomy due to their poor pulmonary function, six cases were studied, who agreed with the experimental trial after the informed consent. One patient of clinical N0 with chest wall invasion (T3) was also included in combination with intraoperative chest wall radiation therapy. At first, a wedge lung resection was performed using an auto-suture technique or manual suturing. Two weeks after the surgery, concomitant radiation therapy of the area including the remnant lung around the cancer and the hilum was initiated. Total dose was 40-50 Gy. All of the patients were followed up for more than five years. RESULTS: All cases tolerated the procedure and survived more than five years. Six were cancer-free. Cancer recurred in only one case. Its manifestation was pleuritis carcinomatosa. Pleural dissemination, which was undetectable at the time of operation, was presumed to be the cause of the recurrence. CONCLUSION: This procedure was tolerated and feasible, preventing local recurrence following the limited surgery.     

Transbronchial needle aspiration under direct endobronchial ultrasound guidance of PET-positive isolated mediastinal adenopathy in patients with previous malignancy

Background  The diagnostic accuracy of endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of isolated mediastinal lymphadenopathy in patients with previous malignancy is not well defined. Positron emission tomography scanning has been proven to be a significant advance, but false-positive results are common. The purpose of this prospective and controlled study was to assess the yield of endobronchial ultrasound-guided transbronchial needle aspiration to reveal mediastinal lymph node metastases in patients with previous malignancy and possible mediastinal involvement on computed tomography and positron emission tomography. Methods  Seventy-three lymph nodes were tested by transbronchial needle aspiration on 48 consecutive patients, each patient underwent to mediastinoscopy or thoracoscopy immediately after needle aspiration for histological confirmation. A cytological sampling adequate for diagnosis was obtained in 45 patients (93.7%); the three cases of inadequate sampling resulted as negative for cancer. Results  The endobronchial ultrasound guided transbronchial needle aspiration gives a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 97.4%, 100%, 100%, 87.5%, and 97.7% respectively. Disease prevalence was 84.4%. All the endoscopic procedures were well tolerated and no immediate complications were recorded. Conclusions  Transbronchial needle aspiration under endobronchial ultrasound guidance is a valuable technique for cytological diagnosis of isolated mediastinal lymphadenopathy in patients with history of malignancy. Tissue sampling by invasive surgical procedures (mediastinoscopy or thoracoscopy) remains mandatory in case of inadequate or negative transbronchial needle aspiration cytology. This work has been performed at Thoracic Surgery and Lung Transplant Unit, Fondazione Ospedale Maggiore Policlinico, Mangiagalli e Regina Elena, Padiglione Zonda, Via F. Sforza 35, 20122 Milan, Italy.     

Intraoperative radiation therapy for patients with pancreatic carcinoma

The results of treatment with intraoperative and external beam radiation for patients with carcinoma of the pancreas are presented. Among patients treated with¹²⁵I implants for localized unresectable disease, local control rates ranged from 67% to 93% and median survival ranged from 7 to 12 months. In a series using intraoperative electron beam boosts, a 59% local control rate with a median survival of 16 months was achieved. Good palliation rates were achieved, although a high proportion of fatal complications occurred in one¹²⁵I series. Less promising results were seen in patients receiving intraoperative radiation following resections, with a local control rate of 50% and a median survival of 7 months in a series of 10 patients.

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Resumen Se presentan los resultados del tratamiento con irradiación intraoperatoria y con irradiación externa para carcinoma de páncreas.Entre los pacientes tratados con implantes de yodo-125 para enfermedad localizada no resecable, las tasas de control local oscilaron entre 67% y 93% y la supervivencia media varió entre 7 y 12 meses. En una serie en la cual se utilizó una sobredosis intraoperatoria con haz de electrones, se logró una tasa de control local de 59% con una supervivencia media de 16 meses. En una de las series con I-125 se obtuvieron buenas tasas de paliación, aún cuando hubo una elevada proporción de complicaciones fatales. Resultados menos promisorios fueron observados en una serie de 10 pacientes que recibieron irradiación intraoperatoria después de la resección, con una tasa de control local de 50% y una supervivencia media de 7 meses.

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Some of the material in this report was presented at the Annual Meeting of the American Surgical Association, Toronto, Canada, April 25–27, 1984, and published in the Annals of Surgery (in press). Supported in part by National Cancer Institute Contract No 1-CM-17481.     

心脏瓣膜病患者行腹腔镜手术的麻醉处理

目的：总结心脏瓣膜病患者行腹腔镜胆囊切除术(LC)的麻醉处理。方法：回顾分析18例心脏瓣膜病患者临床资料,及术前准备、术中术后的麻醉及手术处理。结果：18例患者麻醉诱导期、术中及拔管期血液动力学基本稳定。气腹后HR、SBP、DBP明显上升。PaCO2气腹后虽上升,但尚在正常范围内。结论：对合并有心脏瓣膜病的患者,术前充分准备,术中加强监测和管理,以及手术医师与麻醉师密切配合,可安全的完成LC。     

腹股沟疝注射治疗后手术问题探讨

目的:评估注射治疗对手术治疗腹股沟疝的影响并探讨处理方法.方法:回顾性分析曾行注射治疗之102例病人(计109例次腹股沟疝,其中7例属双侧疝)行无张力疝修补术的临床资料.107例次采用Lichtenstein修补术,2例次因嵌顿疝炎性渗出较多而采用Bassini手术.结果:1例择期手术1周后复发而予再次手术;9例次发生血肿或浆液肿,5例次切口感染.73例次采用局部麻醉者,16例次麻醉效果欠佳.术后产生并发症者16例次(14.68%).结论:对于有注射治疗史的病人,术前应该充分估计组织结构变性和瘢痕粘连程度、不宜常规采用局部麻醉.     

Laparoscopic assisted placement of peritoneal dialysis catheters for selected patients with previous abdominal operation.

Peritoneal dialysis is an established alternative method for the management of patients with end-stage renal disease. Recently, laparoscopy has been utilized in assisting the insertion of catheters under direct vision. The efficacy of the laparoscopic approach for patients with a history of abdominal surgery remains largely unknown. The purpose of this study is to evaluate laparoscopy in the placement of peritoneal dialysis catheters for selected patients with previous abdominal operation. Laparoscopic assisted placement of peritoneal dialysis catheters was performed in 20 patients, who were carefully selected preoperatively and who also underwent previous abdominal operation between April 1999 and July 2001. Previous abdominal operation included appendectomy, ovarian resection, hysterectomy, cesarean section, open cholecystectomy, segmental resection of the small intestine, and truncal vagotomy with pyloroplasty. The procedure was performed using two 10-mm and one 5-mm abdominal trocar. All of the patients tolerated this procedure without significant surgical complications. However, 3 patients developed temporary hemoperitoneum, and 1 patient developed dialysate leakage. The overall success rate of catheter function (> 30 days after laparoscopy) was 90%, except in 2 cases where the catheter functioned poorly due to severe intra-abdominal adhesions. Simultaneous laparoscopic adhesiolysis was successfully performed in 5 cases. Laparoscopic implantation of peritoneal dialysis catheters appears to be a straightforward procedure, even for patients with previous abdominal operation. We believe that this technique may extend the application of peritoneal dialysis treatment in patients with previous abdominal surgery after discreet evaluation preoperatively.