A case of aortic prosthetic valve endocarditis with aortic root aneurysm]

A 72-year-old male who underwent patch closure of atrial septal defect and aortic valve replacement (AVR) 10 years ago was diagnosed as aortic prosthetic valve endocarditis for recurrent fever, coexisting paravalvular leakage and aortic root aneurysm by transthoracic and transesophageal echocardiography. Operative findings showed mechanical prosthesis was dehiscenced in part and limited subannular aneurysm that was healed macroscopically. The hole of the aneurysm was closed by direct suture. Re-AVR, mitral valve replacement and tricuspid annuloplasty for complicating mitral valve stenosis and regurgitation and tricuspid valve regurgitation was performed. The patient is now doing well for one year after the reoperation.     

A case of aortic prosthetic valve endocarditis with aortic root aneurysm

A 72-year-old male who underwent patch closure of atrial septal defect and aortic valve replacement (AVR) 10 years ago was diagnosed as aortic prosthetic valve endocarditis for recurrent fever, coexisting paravalvular leakage and aortic root aneurysm by transthoracic and transesophageal echocardiography. Operative findings showed mechanical prosthesis was dehiscenced in part and limited subannular aneurysm that was healed macroscopically. The hole of the aneurysm was closed by direct suture. Re-AVR, mitral valve replacement and tricuspid annuloplasty for complicating mitral valve stenosis and regurgitation and tricuspid valve regurgitation was performed. The patient is now doing well for one year after the reoperation.     

An operative case of left ventricular-right atrial communication complicated with aortic valve stenosis and regurgitation

A 70-year-old woman suffering from aortic valve stenosis and regurgitation and tricuspid valve regurgitation was admitted to our hospital. At the operation, the right atrium and both ventricles were dilated, and a thrill was felt over the aortic root and right atrium. The aortic valve was bicuspid and heavily calcified. After aortic leaflets were resected, a defect was seen in the left ventricle. Then the right atrium was opened. The defect was located in the atrioventricular membranous septum just above the septal leaflet of the tricuspid valve. The defect was diagnosed to be a left ventricular-right atrial communication (group I according to Riemenschneider's classification). The defect was repaired directly and then the aortic valve was replaced with a prosthesis. After the operation, the heart murmur disappeared. Eleven days after the operation, the patient developed a transient complete AV block for a month.     

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。     

Aortic and mitral valve replacement for calcified valvular annulus in a dialysis patient; report of a case

A 77-year-old man on hemodialysis was admitted to our hospital due to heart failure. Echocardiography showed aortic valve stenosis and regurgitation, mitral valve stenosis and regurgitaion, and tricuspid valve regurgitation. Catheter examination revealed severe calcification at aortic valve and mitral valve including their annulus. At the operation, the calcifications of the aortic and mitral valvular annulus was removed using a cavitron ultrasonic surgical aspirator (CUSA). Reconstructions of the defect of the posterior part of the mitral annulus and of the aortic annulus at the site of the left coronary cusp were achieved by patch technique using autologous pericardium. Aortic and mitral valve replacement and tricuspid valve annuloplasty were performed. The postoperative course was uneventful. Operative technique to remove calcification from valvular annulus using CUSA and reconstruct of the defect of the annulus with autologous pericardium is a very useful technique to prevent left ventricular rupture, perivalvular leakage and any other complications.     

Spurious tricuspid regurgitation: Three conditions mimicking tricuspid regurgitation diagnosed at operation

Brown, A. H., and Braimbridge, M. V. (1973).Thorax, 28, 495-497. Spurious tricuspid regurgitation: Three conditions mimicking tricuspid regurgitation diagnosed at operation. The diagnosis of tricuspid incompetence is difficult. Three patients are described in whom the diagnosis of tricuspid regurgitation was made but disproved by the findings at surgery. The first patient had aortic regurgitation, mitral regurgitation from chordal rupture, and constrictive pericarditis; the right atrium was compressed between the pulsating left atrium and the tight pericardium. The chordal rupture caused the mitral murmur to radiate parasternally. The second patient had severe mitral and aortic regurgitation and an interatrial septal defect with transmission of the left-sided `v' waves to the right atrium. The third patient had an iatrogenic Gerbode defect from a previously repaired ostium primum atrial septal defect. Intracardiac phonocardiography failed to distinguish the anatomical situation from tricuspid regurgitation. The best assessment of tricuspid valvular disease is still that of the surgeon at operation.     

Mechanical valve thrombosis in the tricuspid position--reoperative management of 2 cases

Because valve thrombosis occurred after the tricuspid valve replacement with the mechanical valve, we performed replacement of the mechanical valve with the bovine pericardial valve in two cases. Case 1: The patient, at 13 years old, received open-heart surgery to correct infundibular stenosis. At 23 years of age, decortication and tricuspid valve replacement (TVR) with a phi 31 mm Bj?rk-Shiley valve were performed due to constrictive pericarditis and tricuspid regurgitation developed after the initial operation. Thrombosis of the mechanical valve occurred after the TVR. Treatment with urokinase for the thrombolytic therapy failed to improve the valve opening. Finally 12 years after the TVR, replacement of the mechanical valve with a phi 27 mm Carpentier-Edwards bovine pericardial valve was performed. Case 2: The patient, at 21 years old, received open-heart surgery to close an atrial septal defect. At 40 years of age, mitral and tricuspid valve replacements were performed because regurgitation developed in both valves. The mitral and tricuspid valves were replaced with phi 27 mm and 31 mm St. Jude Medical valves, respectively. Thrombosis of the mechanical valve used for the TVR occurred 2 months after the replacement. The mechanical valve was replaced with a phi 27 mm Carpentier-Edwards bovine pericardial valve. In both cases, subjective symptoms improved and prosthetic valve complications did not occur after re-replacement with the bovine pericardial valve. These cases suggested that for TVR a bovine pericardial valve of sufficient size would be better to select than a mechanical valve.     

Surgical treatment of left ventricular-right atrial communication complicated with aortic and mitral valves regurgitation: report of a case

A 50-year-old man with a heart murmur from early childhood and a one year history of general fatigue was admitted. Cardiac examination showed a left ventricular-right atrial (LV-RA) communication, and aortic and mitral valve regurgitation (III/IV). At surgery, the LV-RA communication was located in the atrioventricular membranous portion 3 mm above the septal leaflet of the tricuspid valve. The etiology of the LV-RA communication was congenital and valvular diseases were acquired changes caused by sclerosis due to infected endocarditis or hypertension. The diameter of the LV-RA communication defect was 6 mm, and the fibrous tissue around the defect was closed directly. Next, double-valve replacement was performed safely. However, the day after surgery, the patient developed complete atrioventricular block and implantation of a DDD pacemaker was required. He was discharged without other complication. We recommend the careful closure of the LV-RA communication defect, if the defect is small and rich in fibrous tissue.     

A case report of a successful surgical treatment for infective endocarditis involving four valves in a elderly patient with ventricular septal defects

A 72-year-old female was examined because of acute congestive heart failure. Echocardiogram revealed vegetations on aortic and pulmonary valve, regurgitation of four valves, and perimembraneous ventricular septal defect. Aortic valve replacement, mitral valve replacement, repair of tricuspid valve using a Carpentier ring, partial resection of pulmonary valve, and direct closure of VSD was performed. Pathological finding of resected valves showed acute endocarditis. A patient resumed social activities after surgery.     

Volume reduction surgery for giant coronary sinus with valvular heart disease; report of a case

A 64-year-old male with giant left atrium and giant coronary sinus, who had aortic valve regurgitation, prosthesis valve paravalvular leakage in mitral position and prosthesis valve malfunction in tricuspid valve position, was successfully treated with double valve replacement, paravalvular leakage repair and volume reduction of left atrium and coronary sinus. Giant coronary sinus was about 70 mm in diameter and was thought to be induced by persistent left superior vena cava, high right atrium pressure and prosthesis valve malfunction in tricuspid valve position. Lung volume was so much increased by volume reduction of left atrium and coronary sinus and patient's symptoms were much improved.     

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)     

Hemolytic anemia due to aortic valve regurgitation after mitral valve replacement

A 50-year-old woman was admitted to our hospital because of heart failure (NYHA III) due to mitral valve regurgitation (MR) with pulmonary hypertension (PH) and tricuspid valve regurgitation (TR). She had a history of chronic renal failure undergoing dialysis (peritoneal dialysis, homodialysis) since 1996. Cardiac catheterization and ultrasonic cardiography showed severe MR (Sellers III), severe TR and PH (mean pressure 33 mmHg). So we performed mitral valve replacement and tricuspid annuloplasty (DeVega). Frequent blood transfusion was needed because severe hemolytic anemia appeared after operation. Ultrasonic cardiography demonstrated moderate aortic valve regurgitation (AR) with no paravalvular prosthetic leakage. We diagnosed hemolytic anemia due to AR. We performed aortic valve replacement. Hemolytic anemia improved soon after second operation. We investigated the mechanical process of the AR. She had a very short subaortic curtain (5.9 mm) compared with the average (8.7 +/- 2.1 mm: mean +/- SD) of cardiac patients. We think that we must be very careful with suture to short subaortic curtain. In addition measurement of subaortic curtain before operation is very useful.     

左心瓣膜置换术后远期三尖瓣关闭不全的外科处理

目的探讨左心瓣膜置换术后远期三尖瓣关闭不全(TR)发生的可能机制以及外科治疗方法的选择和结果.方法 56例左心瓣膜置换术后远期发生TR行再次瓣膜手术的病人,10例人工瓣膜功能正常(A组)者中行二尖瓣置换(MVR)4例,主动脉瓣、二尖瓣双瓣置换(DVR)6例;46例人工瓣膜功能障碍(B组)者中MVR 36例,主动脉瓣置换(AVR)4例, DVR 6例.在A、B两组中,46例第1次手时三尖瓣未见明显异常,10例第1次手术时已行DeVega三尖瓣成形(TVP),第2次手术时发现缝线断裂3例,缝线撕脱7例.56例TR病人再次手术时9例行三尖瓣替换(TVR),其中6例三尖瓣呈风湿性改变;47例行TVP.结果 TVP和TVR各死亡1例,病死率3.6%.54例获随访,随访时间6～132个月,平均(79.4±34.8)个月.8例TVR病人术后心功能恢复良好,46例TVP者40例为轻度TR,5例出现中度TR,仍需强心、利尿药维持,1例再次出现重度TR.结论左心瓣膜置换术后远期TR可能与持续肺动脉高压、右心室不可逆损害、三尖瓣风湿性病变、左心功能的恢复情况以及持续心房纤颤有关.重度功能性TR和三尖瓣风湿性病变者行TVR的疗效可靠.随访发现部分TVP病人功能性TR仍有逐渐加重趋势.     

全机器人心脏不停跳下房间隔缺损修补术

目的 总结使用"达芬奇S"(da Vinci S)机器人手术系统,心脏不停跳下房间隔缺损修补或房间隔缺损修补+三尖瓣成形术的经验体会.方法 2009年3月至2010年12月,使用da Vinic S机器人系统,心脏不停跳下完成继发孔型房间隔缺损修补或房间隔缺损修补+三尖瓣成形术40例.患者女23例,男17例;年龄平均(38±13)岁.房间隔缺损直径为1.5～3.5 cm,平均(2.8±1.3)cm,无右向左分流,伴有或不伴有三尖瓣重度关闭不全.手术经股动、静脉及右侧颈内静脉插管建立体外循环.于右侧胸壁打直径为0.8 cm的器械臂孔3个,直径为2 cm工作孔1个,术中不阻断升主动脉,经内窥镜套管持续给予二氧化碳,心脏跳动下,术者于操作台前遥控机器人进行房间隔缺损修补,三尖瓣重度关闭不全患者同期行三尖瓣成形术.其中直接缝合房间隔缺损22例,心包补片修补房间隔缺损18例,同期三尖瓣成形9例.术中食管超声评估修补及三尖瓣成形效果.对比不停跳与心脏停跳下全机器人房间隔缺损修补术的手术时间及体外循环时间.结果 所有患者均成功接受全机器人心脏不停跳下房间隔缺损修补术或房间隔缺损修补+三尖瓣成形术,无体循环气体栓子及残余分流等并发症.不停跳组的手术时间、机器人使用时间或体外循环时间少于停跳组.结论 机器人心脏不停跳下房间隔缺损修补术无需阻断升主动脉,简化了全机器人手术过程,手术效果安全可靠.

Abstract：

Objective To Summary the first 40 cases underwent robotic atrial septal defect (ASD) closure or atrial septal defect closure combined bicuspid valve plasty (TVP) using "da Vinci S" surgical System on beating heart. Methods 40 cases of atrial septal defect or combined sever tricuspid valve regurgitation were repaired using "da Vinic S" surgical system on beating heart from March 2009 to December 2010 in cardiovascular department of PLA general hospital. The average age was (38 ± 13) yeas old. 23 cases were female and 17 cases were male. All patients were ostium atrial septal defect with or without pulmonary hypertension. The atrial defect diameter was 1.5 -3.5 cm, and the mean diameter was(2. 8 ±1.3)cm. 9 patients had sever tricuspid valve regurgitation. Without sternotomy, the extracorporeal circulation was established through groin artery,groin vein and internal jugular vein cannulation with the guidance of transeophageal echocardiography. 3 ports of 8 mm and 1 working port of 2 cm were made in the right chest wall. After "da Vinci S" syetem was set up, with the assistant of bed-side surgeon, the surgeon completed the atrial septal defect closure or combined tricuspid valve plasty in the surgeon console with three dimensions visualization. During the operation, without cardioplegia administrated and aortic occlusion, the procedure was completed through right atriotomy. The pleural space was insufflated with carbon dioxide to avoid the air embolism. The direct suturing was used in 22 cases and pericardial patch were used in 18 cases. 9 patients accepted concurrent De Vega tricuspid valve plasty. The transesophageal echocardiography were used to evaluate the result of atrial defect closure or tricuspid valve repair. The operation time, robotic using time and cardiopulmonary time were compared with totally robotic atrial defect repair in arrested heart. Results All cases were accomplished successfully without complication. There was no residual shunt and air embolism. The operation time, robotic using time and cardiopulmonary time were less than the arrested group. Conclusion Robotic atrial septal defect closure or combined tricuspid valve repair on beating heart can avoid aortic ocllusion and can be utilized effectively and safely.     

Congenital aortic regurgitation caused by absence of the right coronary cusp.

We describe a patient with congenital aortic regurgitation, well documented from the age of 1 month. Surgery was performed at the age of 7 years, when echocardiography showed progressive dilatation of the left ventricle with decreasing shortening fraction. Inspection of the valve during the operation showed a basically tricuspid valve, but with a rudimentary right coronary cusp. At histological examination, myxoid dysplasia was found in all the cusps. An aortic homograft was inserted and the left ventricular internal dimensions returned to normal within 3 months after the operation.     

Primary biventricular repair for interrupted aortic arch with left ventricular outflow tract obstruction and tricuspid valve regurgitation; report of a case

An interrupted aortic arch was diagnosed in a 10-day-old girl weighing 3.3 kg, as was perimembranous ventricular septal defect (VSD) and severe tricuspid valve regurgitation (TR). The subaortic diameter was 3.6 mm and the aortic valve (3.7 mm in diameter) was bicuspid. We chose definitive repair, modified Yasui procedure, because of severe TR and no straddling of mitral valve. In primary biventricular repair, we undertook extended aortic arch anastomosis. Left ventricular outflow tract reconstruction consisted of intracardiac rerouting from the VSD to the pulmonary artery by using expanded-polytetrafluoroethylene (ePTFE) and Damus-Kaye-Stansel (DKS) anastomosis. Right ventricular outflow tract reconstruction was performed by the Rastelli procedure with an ePTFE valved conduit. Moreover, we carried out semicircular annuloplasty for severe TR.     

Surgical management of aortopulmonary window.

OBJECTIVE: Aortopulmonary window is a rare congenital malformation involving a window-like communication between the ascending aorta and the pulmonary artery. Here, we present our experience regarding the surgical repair of an aortopulmonary window, and also assess the long-term outcome. METHODS: Thirteen children with an aortopulmonary window associated with various congenital lesions underwent a repair of the defect. The age at operation ranged from 3 days to 1 year (median age, 19 days). The patient's weight ranged from 2.1 to 7.0 kg (mean weight, 3.6 kg). The associated lesions included an interrupted aortic arch (5 patients), a ventricular septal defect (2), an atrial septal defect (1), mitral valve regurgitation (1), and tricuspid atresia [Ic] with mitral valve regurgitation (1). The aortopulmonary window was repaired with a cardiopulmonary bypass in 11 patients, and 2 patients were ligated without a cardiopulmonary bypass. RESULTS: One patient associated with tricuspid atresia died (mortality rate of 7.7%). There has been no late death during a mean follow-up of 7 years and 3 months. CONCLUSIONS: The surgical results for an aortopulmonary window are encouraging, even if such patients are associated with major cardiac anomalies and an interrupted aortic arch. Most have shown a good long-term outcome.     

Surgical strategy for tricuspid valve disease

The most common cause of tricuspid valve dysfunction is functional tricuspid regurgitation (TR) secondary to mitral valve disease. Annuloplasty is feasible in most patients with functional TR, and valve repair can also be performed in most patients with tricuspid valve dysfunction of other etiologies. Valve replacement is considered to be indicated only for those patients whose tricuspid valves have severe organic change or have been damaged by infective endocarditis. Although good long-term results of tricuspid valve replacement using bioprostheses have been reported, a bileaflet mechanical prosthesis may be an acceptable alternative in those patients who undergo concomitant valve replacement with a mechanical prosthesis in the mitral or aortic position or who may have persisting pulmonary hypertension after surgery.     

Unexpected durability of Smeloff-Cutter aortic ball valve prosthesis

We report a case in which replacement of a Smeloff-Cutter aortic ball prosthesis was required 28 years after initial implantation. A 57-year-old woman underwent aortic valve replacement with a 21-mm Smeloff-Cutter ball prosthesis and open mitral commissurotomy for aortic stenosis, aortic regurgitation, and mitral stenosis in 1973. Severe aortic regurgitation occurred in April 2001, and aortic valve reoperation combined with mitral valve replacement was successfully performed. The patient's aortic ball valve was nearly intact with perivalvular leakage probably causing the aortic regurgitation. Our experience documents longer durability for the Smeloff-Cutter prosthesis than has been reported to date.     

A single-size band, 50mm long, for tricuspid annuloplasty.

A technique for tricuspid annuloplasty is presented, using a flexible 50mm long band, where the annular circumference is reduced to a fixed value of 78.5mm (circumference of #25mm sizer). From June to February 2007, 15 consecutive patients with tricuspid regurgitation (TR) underwent tricuspid repair using this technique. The first suture is passed at the level of the anteroseptal commissure, the last one in the zone of the septal annulus, 28.5mm from the first one. The remaining sutures are passed as usual. All the sutures are then adapted to a 50mm long band. After a mean of 5.4 months from surgery, all patients are alive and asymptomatic. One patient showed residual 2/4 TR, due to enlarged RV with high pulmonary pressure despite a well functioning mitral prosthesis. Mean gradient across the tricuspid valve was 2.5+/-0.4mmHg. This technique for tricuspid repair is simple and reliable, providing effective and reproducible results.