Annular reconstruction for mitral valve replacement in a destroyed or calcified mitral annulus

Mitral valve replacement in the presence of severe annular calcification and an infectious lesion may be complicated by atrioventricular rupture, left circumflex coronary artery injury, and recurrence of infective endocarditis. Confronted with these circumstances, we have developed a technique of annular reconstruction for mitral valve replacement. The prosthetic valve is made by enlarging the circumference of the sewing ring with a Dacron collar. The collar can be sutured to the left atrial wall above the mitral annulus. This technique has been employed in five patients: three had extensive annular calcification, and two had acute valve endocarditis with destruction of mitral annulus. In all cases, the circumferential or partial annular reconstruction permitted secure implantation of the prosthetic valve. The one postoperative death was related to hemodialysis due to chronic renal failure. There were no other fatalities during the postoperative course, and the valves functioned normally. Our results suggest that this technique can be performed in high operative risk patients when mitral valve replacement is impossible using conventional techniques.     

Surgical treatment of Ebstein's anomaly: valve replacement and reconstruction

Because of the relative infrequency of Ebstein's anomaly the type of effective surgical treatment remains controversial. Various authors have reported different results depending upon the type of surgical treatment involved. In TYIH between 1974-1987, 30 cases with Ebstein's anomaly have been operated upon; 12 cases underwent surgical repair and in the remaining 18 cases a tricuspid valve replacement was performed. Four out of the 12 reconstruction cases remained on cardiopulmonary by-pass (CPB) because of the failure of the right ventricle and artificial valves were implanted in these cases. One of these patients died. In all, 3 patients died as a result of annuloplasty and the postoperative courses of these patients were eventful. Among the remaining 18 patients with artificial valve replacement only one patient died and the remainder of the tricuspid valve replacement group had an uneventful postoperative period.     

心房纤维颤动的外科治疗

３例采用改良迷宫术探索进行心房纤颤外科治疗获成功。病人术前均为风湿性心脏病，心功能Ⅲ－Ⅳ级，心房纤颤病史３－１０年，左房直径５２－５８ｍｍ，心胸比率０．６４－０．７０。在进行改良迷宫术的同时，２例行二尖瓣替换，１例行双瓣替换及三尖瓣环缩。术后２例自动复跳，１例电击除颤复跳。３例术后早期均为窦性心律。２例术后３年恢复良好，正常心律，心功能Ｉ级；１例术后３个月死于脑血管意外。文中重点介绍了手术方法，提     

Anatomical mismatch of the pulmonary autograft in the aortic root may be the cause of early aortic insufficiency after the Ross procedure

Objective: Early aortic insufficiency can be a problem after the Ross procedure. Anatomical mismatch and an inexact surgical technique may lead to distortion of the normal pulmonary valve geometry and subsequent incorrect leaflet coaptation and valve insufficiency. In this study, we assessed the efficacy of changing and improving the surgical technique to minimize the early pulmonary autograft valve failure. The modifications and the strategy are discussed. Methods: From January 1995 to February 1999, a total of 77 adults underwent the Ross procedure for aortic valve replacement at Sahlgrenska University Hospital. The operative technique used was full free-standing aortic root replacement with a pulmonary autograft in all cases. In the first 24 cases, the diameter of the pulmonary roots was seldom measured, eye-balling was used to exclude anatomical mismatch due to a dilated aortic root, and only one attempt of correction was made, which failed. In the other 53 cases, the technique was improved by: (1) reducing the aortic anulus diameter in cases with moderate dilatation; (2) excluding cases with severe dilatation of the aortic annulus; (3) adjusting the diameter of the sinotubular junction of the aorta to the diameter of the sinotubular junction of the pulmonary artery; (4). reimplanting the left ostium in the autograft, and (5) changing the proximal anastomosis technique. Results: In this study, we had an early aortic incompetence of grade 2 in eight patients among the first 24 patients. In the other 53 patients, postoperative echocardiography at 1 week revealed aortic insufficiency of grade 2 in two patients. Conclusions: Aortic insufficiency after the Ross procedure can be minimized by patient selection, intraoperative correction of anatomical mismatch and improved surgical technique.     

Mitral valve replacement through right thoracotomy after previous coronary artery bypass grafting

The Usefulness of Brachial Artery Cannulation, Perfused Ventricular Fibrillation with Moderate Hypothermia, and Minimal Dissection Techniques It has been reported by several authors that a right thoracotomy for mitral valve surgery can be useful after previous coronary aortery bypass grafting (CABG). A 76-year-old man with mitral valve regurgitation after previous CABG underwent mitral valve replacement with some modified techniques. Cardiopulmonary bypass was established with right brachial artery cannulation and right femoral venous cannulation with the aid of vacuum-assisted venous drainage. Ventricular fibrillation (VF) was induced by rapid pacing of the ventricle, and mitral valve replacement was performed under perfused VF with moderate hypothermia. The patient’s postoperative course was uneventful. This method appears to be a safe and easy alternative mitral valve surgery for complicated cases of this type.     

Long-term outcomes after ascending aortic replacement and aortic root replacement for type A aortic dissection

 Open in a separate windowOBJECTIVESWe investigated whether the selective use of supracoronary ascending aorta replacement achieves late outcomes comparable to those of aortic root replacement for acute Stanford type A aortic dissection (TAAD).METHODSPatients who underwent surgery for acute type A aortic dissection from 2005 to 2018 at the Helsinki University Hospital, Finland, were included in this analysis. Late mortality was evaluated with the Kaplan–Meier method and proximal aortic reoperation, i.e. operation on the aortic root or aortic valve, with the competing risk method.RESULTSOut of 309 patients, 216 underwent supracoronary ascending aortic replacement and 93 had aortic root replacement. At 10 years, mortality was 33.8% after aortic root replacement and 35.2% after ascending aortic replacement (P = 0.806, adjusted hazard ratio 1.25, 95% confidence interval, 0.77–2.02), and the cumulative incidence of proximal aortic reoperation was 6.0% in the aortic root replacement group and 6.2% in the ascending aortic replacement group (P = 0.65; adjusted subdistributional hazard ratio 0.53, 95% confidence interval 0.15–1.89). Among 71 propensity score matched pairs, 10-year survival was 34.4% after aortic root replacement and 36.2% after ascending aortic replacement surgery (P = 0.70). Cumulative incidence of proximal aortic reoperation was 7.0% after aortic root replacement and 13.0% after ascending aortic replacement surgery (P = 0.22). Among 102 patients with complete imaging data [mean follow-up, 4.7 (3.2) years], the estimated growth rate of the aortic root diameter was 0.22 mm/year, that of its area 7.19 mm²/year and that of its perimeter 0.43 mm/year.CONCLUSIONSWhen stringent selection criteria were used to determine the extent of proximal aortic reconstruction, aortic root replacement and ascending aortic replacement for type A aortic dissection achieved comparable clinical outcomes.     

Reconstruction of right ventricular outflow tract with stentless xenografts in Ross procedure

To investigate whether the use of a stentless porcine aortic xenograft can be an alternative for right ventricular outflow tract (RVOT) reconstruction during the Ross procedure, 9 patients underwent the Ross procedure and RVOT reconstruction with a stentless xenograft since January 2000. After the aortic valve was replaced with a pulmonary autograft, a stentless xenograft with a xeno- pericardial roll was implanted in the RVOT. One patient required subsequent aortic valve replacement because of severe regurgitation of the pulmonary autograft. All patients recovered well from the operation. The right ventricle-pulmonary arterial pressure gradient was 18 +/- 7 mm Hg at discharge and was not significantly increased during the 2-year follow-up period. Although 1 patient died of ventricular arrhythmia 5 months after, his cardiac function was normal, and transpulmonary valve pressure was 19 mm Hg in the follow-up. The other 7 patients are currently in New York Heart Association functional Class I. Although long-term follow-up is required to explain the durability, the stentless xenograft with a pericardial roll is considered to be an alternative for reconstruction of the RVOT within 2 years after the Ross procedure.     

A new method for prosthetic valve replacement in congenital aortic stenosis associated with hypoplasia of the aortic valve ring.

The smallest commercially available prosthetic valve has an external diameter of 17 mm. Therefore, prosthetic valve replacement has been unfeasible in cases in which the diameter of the aortic valve ring is smaller than this size. A new operative method was used on 2 patients with congenital aortic valve lesions associated with hypoplasia of the valve ring. The procedure consists of a longitudinal incision in the aortic septum placed in the midportion of the two coronary ostia, a vertical incision in the outflow tract of the right ventricle to join the septal incision, prosthetic aortic valve replacement, and patch reconstruction of the outflow tracts of both ventricles by means of two layers of a fusiform Dacron patch. A 23-year-old woman with congenital aortic stenosis associated with hypoplattic aortic valve ring underwent prosthetic placement of the aortic valve and is well 1 year after the operation. Our other patient, a 3-month-old infant with congenital aortic regurgitation, died on the first postoperative day because of postperfusion lung. However, her hemodynamic status had been good in the immediate postoperative period.     

Surgically treated aortic root aneurysm following aortic valve replacement

A 65-year-old man with aortic regurgitation underwent aortic valve replacement with a St. Jude Medical prosthetic valve about 6 years ago. At that time, the aortic root was slightly dilated at about 40 mm in diameter and the ascending aorta was within the normal range. This year, the man was diagnosed with an aortic root aneurysm in regular follow-up echocardiography. Chest-enhanced computed tomography and chest aortography at our hospital demonstrated a pear-like aortic root aneurysm about 60 mm in diameter. Elective operation for the aortic root aneurysm was conducted September 29, 1999, based on the Bentall procedure. Composite graft replacement with coronary reconstruction was conducted using a 28-mm Hemashield prosthetic graft and a 23-mm St. Jude Medical prosthetic valve under cardiopulmonary bypass. An 8-mm Hemashield graft was interposed on the left main coronary artery and the right coronary artery was directly anastomosed using a Carrel patch method. The postoperative course was uneventful and post-operative examination demonstrated good surgical results. Histological findings of the aortic aneurysm wall showed cystic medial necrosis. Surgical cases of aortic root aneurysm after aortic valve replacement are rare, but serious complications with the possibility of rupture or dissection warrant surgical intervention.     

62例双瓣置换病人术后护理体会

目的总结风湿性心脏瓣膜病行二尖瓣、主动脉瓣双瓣置换术的护理经验,进而提高术后监护效果。方法对我院2011年4月至12月施行二尖瓣、主动脉瓣双瓣置换术的62例患者进行回顾性总结。结果手术均顺利完成,术后清醒时间168(60～180)min。瓣膜置换术后早期并发症:低心排量综合征6例,急性肾功能衰竭1例,大出血再次行开胸1例,心律失常6例,肺部炎症3例,其中死亡2例,死亡率为3.3%,死亡原因为术后出现低心排量综合征合并多器官功能衰竭。结论提高术后护理质量,加强对各项指标的监测,减少并发症的发生率,及早发现并处理并发症,是提高风湿性心瓣膜病患者二尖瓣、主动脉瓣双瓣置换术后近远期疗效的保障之一。     

A combination of reoperation for pseudoaneurysm following the Cabrol procedure and total aortic arch replacement in a patient with Marfan syndrome —A case with an aberrant right subclavian artery—

A 44-year-old male with Marfan’s syndrome had undergone an initial operation for DeBakey type I acute aortic dissection with annulo-aortic ectasia. He had undergone replacement of the ascending aorta and aortic valve with a composite graft and reconstruction of the coronary artery by the Cabrol procedure. At 5 years after the initial surgery he experienced chest pain and was subsequently examined. Computed tomography revealed a pseudoaneurysm in the ascending aorta and the residual aortic dissection. The maximum diameter of the pseudoaneurysm was 85 mm and the maximum diameter of the aortic arch was 55 mm. The aortic arch was associated with an aberrant right subclavian artery. Angiography revealed that the pseudoaneurysm was caused by leakage at the coronary ostium-graft anastomoses. We repaired the anastomoses and performed total aortic arch replacement with reconstruction of four arch branches. The postoperative course was uneventful without any complications. We report this case because there have been few reports regarding arch replacement in cases with an aberrant right subclavian artery.     

Left ventricular performance after mitral reconstruction for mitral regurgitation

Depressed left ventricular performance is often observed after mitral valve replacement for mitral regurgitation and is generally attributed to increased impedance to left ventricular ejection. We analyzed preoperative and postoperative catheterization data in 10 of 18 patients who underwent mitral reconstruction with preservation of the native valves and found a significant (p less than 0.05) fall in left ventricular end-diastolic volume index (from 143 +/- 39 to 84 +/- 21 ml/m2) and end-systolic volume index (from 50 +/- 24 to 32 +/- 12 ml/m2), with no significant change in ejection fraction (0.66 +/- 0.1 versus 0.62 +/- 0.1). These findings contrast with studies reported by others in comparable patients who had mitral valve replacement with no improvement in volume indices and a decline in ejection fraction postoperatively. We suggest that some of the left ventricular dysfunction observed after mitral replacement may be due simply to excision of the native valve. Mitral repair retains the tethering effect of chordal attachments and may thus prevent postoperative left ventricular dilatation and moderate the increase in wall stress that results from increased impedance to left ventricular ejection.     

Valve-sparing root replacement after the Ross procedure

ObjectivesThe Ross procedure is a preferred treatment for infants and children with aortic valve disease. Progressive neoaortic root dilation and neoaortic insufficiency can occur after the Ross procedure, and because of the young age of these patients, valve-sparing aortic root replacement procedures have advantages compared with the Bentall procedure. The aim of this study is to describe our experience with different techniques of aortic valve-sparing root replacement in this unique cohort of patients.MethodsPatients undergoing valve-sparing aortic root replacement with a history of the Ross procedure between January 2001 and March 2021 were identified. A retrospective chart review was performed, and clinical characteristics of these patients were analyzed. The results of different types of valve-sparing aortic root replacement were also compared.ResultsForty-two patients who had previously undergone a Ross procedure in childhood presented for reintervention for neoaortic root or valve pathology. Seventeen of these patients were considered for valve-sparing aortic root replacement but underwent bioprosthetic or mechanical valve replacement, and 25 patients underwent successful valve-sparing aortic root replacement. Patients who underwent valve-sparing aortic root replacement received a traditional aortic root remodeling procedure with or without suture annuloplasty (Yacoub technique, group 1, n = 7), an aortic root reimplantation procedure (David technique, group 2, n = 11), or a modified root remodeling procedure that also used a geometric annuloplasty ring (group 3, n = 7). Patient demographics and comorbidities were similar between groups. Mean follow-up for these 3 cohorts was 14 years, 4 years, and 1 year, respectively. Overall survival was good, with 1 early death due to hemorrhage in group 2 and 1 death due to malignancy in group 1. Eight patients (7 in group 1; 1 in group 2) required subsequent aortic valve replacements due to neoaortic insufficiency, whereas none in group 3 have required any reintervention. Overall, patients requiring valve replacement after valve-sparing aortic root replacement had lower grades of preoperative neoaortic insufficiency and higher grades of postoperative neoaortic insufficiency. Greater than mild postoperative neoaortic insufficiency was associated with the need for subsequent neoaortic valve replacement.ConclusionsValve-sparing aortic root replacement is safe in patients with a prior Ross procedure. Reimplantation offers superior durability compared with the traditional remodeling procedure. Greater than mild neoaortic insufficiency on postoperative echocardiogram should prompt additional attempts at valve repair. A modified remodeling procedure with geometric ring annuloplasty that is personalized to the patient's individual anatomy is safe with good short-term results, but longer follow-up is needed.     

Aortic root surgery does not increase the operative risk of acute type A aortic dissection

Controversy exists regarding aortic root reconstruction in the management of acute type A aortic dissection (AAD). One hundred fifty-four patients (mean age 56.9 ± 11.3 years) with AAD had surgical repair between 1996 and 2007. Group 1 (n = 110) required no aortic root surgery. Seventy-one patients had ascending aortic replacement. The aortic valve was repaired in 37 patients (34%) and replaced in one. Group 2 (n = 44) had aortic root surgery. Thirty-four patients had composite root replacement, and seven had a valve-sparing root replacement. Root reconstruction and separate valve replacement was accomplished in three. Hemiarch replacement was included in 39 (35.4%) Group 1 patients and in 12 (27.9%) Group 2 patients. Forty-nine of the 154 patients presented in cardiogenic shock. Multiple risk factors for operative mortality were analyzed. The overall operative mortality was 9.7 per cent: 11 per cent for Group 1 and 6.8 per cent for Group 2 (P = NS). By multivariate analysis, preoperative shock (P = 0.03, odds ratio [OR] = 5.48), postoperative ventricular arrhythmias (P = 0.002, OR = 4.62), and packed red blood cell transfusion (P = 0.002, OR = 1.15) were independent predictors of hospital death. Prompt surgical treatment of AAD before cardiogenic shock ensues can improve the outcome of patients. When indicated, aortic root surgery can be performed without increased mortality and morbidity.     

矫正型大动脉转位形态三尖瓣置换术及中远期结果

目的探讨矫正型大动脉转位（cTGA）患者行形态三尖瓣置换术的手术适应证及其术后中远期结果。方法1997年9月至2007年9月,阜外心血管病医院收治cTGA患者18例,男15例,女3例;年龄16~51岁（33.3±12.8岁）,体重47~90 kg（60.9±14.7 kg）。单纯形态三尖瓣关闭不全10例,合并室间隔缺损3例,合并室间隔缺损及肺动脉瓣狭窄2例,室间隔缺损修补术后形态三尖瓣关闭不全2例,形态三尖瓣置换术后机械瓣功能不良1例。术前形态右心室射血分数为56.2%±11.6%,心功能分级（NYHA）Ⅱ级12例,Ⅲ级6例。18例cTGA患者均施行形态三尖瓣置换术。术后随访患者的心功能、形态右心室射血分数等指标。结果手术死亡1例,死于术后低心排血量综合征。术后发生瓣周漏2例,分别于术后7 d和30 d行瓣周漏修补术后治愈。随访16例,随访时间57.0±40.7个月;随访时形态右心室射血分数与术前比较差异无统计学意义（52.8%±9.2%vs.56.2%±11.6%;t=2.062,P〉0.05）,心功能分级（NYHA）Ⅰ~Ⅱ级12例,Ⅲ级4例,与术前比较心功能分级Ⅲ级者所占百分比差异无统计学意义（χ2=1.532,P〉0.05）。结论cTGA形态三尖瓣置换术能防止形态三尖瓣关闭不全对形态右心室功能的进一步损害;其中远期结果满意;随访期间,形态右心室功能基本正常。     

Pulmonary artery versus left ventricular venting: a radioisotope study of left ventricular function

Radionuclide measurements of ejection fraction were used to assess immediate and late postoperative ventricular function after the use of either a pulmonary artery vent (group A) or a left ventricular vent (group B) in 20 patients undergoing aortic valve replacement for pure aortic stenosis. Ten patients were included in each group and anesthetic techniques, patient management, and septal temperatures were similar in all cases. No significant difference was found between the preoperative and immediate or 6-week postoperative ejection fractions, either taken overall or between the two groups (p greater than 0.05; Student's t test). No correlation was found between cross-clamp time, bypass time, or the occurrence of ventricular fibrillation and the immediate postoperative ejection fraction (p greater than 0.05; Student's t test). There was no significant difference in the incidence of ventricular fibrillation after each type of vent had been used (chi 1(0) = 3.32; p greater than 0.05). We did not demonstrate any abnormalities in regional wall motion associated with apical insertion of a left ventricular vent, and conclude that pulmonary artery and left ventricular vents are equally satisfactory in terms of postoperative ventricular performance.     

Esophageal Leiomyomatosis Combined With Intrathoracic Stomach and Gastric Volvulus

Case Report:

A 42-year-old female presented with longstanding symptoms suggestive of gastroesophageal reflux disease improved after proton pump inhibitor treatment. An upper endoscopy revealed an intrathoracic position of the stomach (type 4 hiatal hernia) with no mucosal abnormality. Barium swallow demonstrated gastric herniation with gastric volvulus without stenosis. A computed tomographic scan confirmed the intrathoracic location of the stomach associated with thickening and edema of the gastric wall due to gastric volvulus, but no evidence of malignancy. The patient was scheduled for laparoscopic gastric repositioning with anterior hemifundoplication. Due to the incidental intraoperative finding of a large distal esophageal tumor (frozen section: esophageal leiomyomatosis), the operation was converted to conventional distal esophagectomy and proximal gastrectomy with reconstruction using a Merendino procedure. Final histology revealed extensive circumferential leiomyomatosis of the distal esophagus with a diameter of 10 cm. Esophageal leiomyomatosis is an extremely rare pathological finding with <100 cases reported in the literature.

Conclusion:

Any surgeon performing laparoscopic fundoplication has to be ready to deal with such unexpected findings, ie, converting the procedure and doing reconstruction with minimal morbidity. The Merendino procedure is a well-established reconstructive surgical option in cases of tumor formation at the gastroesophageal region with fewer postoperative morbidities like reflux symptoms.     

Increased morbidity and mortality in patients with antiphospholipid syndrome undergoing valve replacement surgery

OBJECTIVE: Heart valve abnormalities are commonly found in patients with antiphospholipid syndrome but experience with valve replacement in such patients is limited. We analyzed the results of valve replacement in patients with this condition at our institution. METHODS: Between 1989 and 2002, 10 patients with antiphospholipid syndrome (8 women, 2 men; aged 38-73 years, mean 49 years) with severe mitral valve disease (n = 7), aortic valve disease (n = 2), or combined mitral-aortic disease (n = 1) underwent valve replacement. We reviewed retrospectively their clinical data, operative and postoperative courses, and the long-term results. Pathological reassessment was performed in all cases. RESULTS: Procedures performed included mitral valve replacement in 7 patients, aortic valve replacement in 2 patients, and combined aortic valve replacement plus mitral valve replacement in 1 patient. In addition, 2 patients underwent tricuspid annuloplasty. The immediate mortality was 20% (2 patients). Major complications occurred in 2 other cases. During a follow-up period of up to 8 years, 2 patients required repeat operation for valve-related complications (1 death). An additional patient died of cardiac causes 13 months after surgery. One patient had major thromboembolic events 3 and 10 months after the operation. The late outcome was uneventful in only 4 patients. CONCLUSION: Valve replacement in patients with antiphospholipid syndrome may carry significant early and late mortality and morbidity, particularly when such patients are referred with advanced valvular heart disease.     

Aortic Root Reconstruction with TachoSil Fibrin Sealant Patch in Acute Type A Aortic Dissection

Purpose: We propose a novel technique for reconstruction of the dissected aortic root with the use of TachoSil fibrin sealant patch.Methods: Patients with acute type A aortic dissection involving the aortic root were included. Appropriately prepared TachoSil fibrin sealant patch was placed between the dissected layers of the aortic root to achieve their durable fusion. Thus, the false lumen was eliminated, and the anatomical and functional structure of the aortic wall was restored.Results: In all, 13 patients mean aged 57 ± 10.3 years underwent surgery for acute type A aortic dissection with the use of TachoSil fibrin sealant patch. All patients survived the surgery. The mean follow-up time was 30.8 ± 16.4 months. Follow-up computed tomography angiography (CTA) scans confirmed no aortic root dissection in all patients.Conclusions: This technique ensures durable restoration of the aortic wall structure, eliminates the secondary aortic valve regurgitation, and allows for the preservation of patients’ native aortic valve.     

低位直肠癌行后盆腔脏器切除联合远端阴道及会阴体切除术后会阴重建的方式及体会

目的总结低位直肠癌累及远端阴道及会阴体时行后盆腔脏器切除及远端阴道及会阴体切除后会阴重建的各种方法的应用体会。方法总结我院2008年10月至2013年9月期间收治的10例直肠癌联合远端阴道及会阴体切除后的重建方式及围手术期的临床资料。结果10例患者中2例行子宫及阴道全切除,3例行子宫及阴道后壁切除,5例行单纯远端阴道和（或）会阴体切除。分别采用大网膜填塞（4例）、阴道前壁翻转缝合（3例）、子宫后倾（2例）、带蒂乙状结肠（2例）重建盆腔及阴道会阴缺损。1例患者盆腔严重感染,2例患者会阴部切口感染或裂开。结论女性低位直肠癌患者行后盆腔联合脏器切除后切口相关并发症率极高,可根据盆腔、会阴及阴道的缺损情况选用子宫或网膜填塞盆腔、带蒂肠段或肌皮瓣、生物补片等方法进行一期修复缺损,采用腹直肌或臀大肌肌皮瓣修复会阴巨大缺损成为目前主流的修复方式,但国内该技术报道极少,值得积极开展应刚。