Combined valve and coronary artery bypass procedures in septuagenarians and octogenarians: results in 120 patients

A consecutive series of 96 septuagenarians (mean age, 74) and 24 octogenarians (mean age, 83) underwent coronary artery bypass (CAB) and valve operations using hypothermia and hyperkalemic cardioplegia in a 45-month period; there was a mean of 2.6 grafts per patient. Most patients were in New York Heart Association (NYHA) class IV (57% of the septuagenarians and 88% of the octogenarians) preoperatively. The early deaths were 19% for septuagenarians and 37% for octogenarians; late deaths were 9% and 6%, respectively, after a mean of 25 months. Of 92 survivors, 78% of the septuagenarians and 87% of the octogenarians improved by one or more NYHA class postoperatively. Of 58 patients with combined CAB and aortic valve replacement, 12 (21%) died; of 38 with combined CAB and mitral valve replacement 19 (50%) died; 2 of 9 (22%) with combined CAB and double valve replacement died; and 2 of 11 (18%) with CAB and MV repair died. In comparison, of patients with isolated valve replacement in the same period, 2 of 30 (7%) in the AVR group died, 5 of 17 (29%) died in the MVR group, 2 of 7 (33%) in the DVR group died. The risk of combined valve procedures and bypass surgery was significantly increased in the elderly and may warrant a less aggressive procedure, especially in the mitral position.     

Combined surgery for mitral regurgitation associated with extensive annular calcification and left main coronary artery disease

Although extensive calcification of the mitral annulus is encountered infrequently, it presents a formidable problem in mitral valve surgery. We describe a case of severely calcified mitral annulus associated with grade IV mitral regurgitation in addition to left main coronary artery disease. The patient was a 66-year-old woman who successfully underwent thorough excision of the calcified bar, annular reconstruction with a autologous pericardial strip, mitral valve replacement with a mechanical prosthesis, and double coronary artery bypass grafting using arterial grafts.     

Concomitant Mitral Valve Repair or Replacement and Coronary Revascularization

Patients undergoing combined mitral valve replacement and coronary revascularization require surgical skill and especially judgment for optimal results. In our hands, cardioplegia has not been a pivotal event in affecting survival, and this probably relates to our previous philosophy of limiting the hypothermic ischemic episodes to 15-minute intervals. Currently, we believe that valve repair, when it can be accomplished, is preferable to valve replacement, especially in the patient with ischemic mitral valve disease. When repair cannot be satisfactorily accomplished, replacement with retention of the posterior leaflet seems clinically to be associated with less disturbance of left ventricular function.     

Left ventricular rupture after mitral valve replacement.

BACKGROUND: What are the immediate and long term outcomes of patients who had rupture of the left ventricle after mitral valve replacement? METHODS: Experimental design: A retrospective study with a 20-year follow-up. Setting: Experience in a single tertiary referral cardiothoracic surgery hospital. Participants: 20 out of 3105 patients that received mitral valve replacement. INTERVENTION: All these 20 patients received re-exploration for a trial of repair of left ventricular rupture either by an internal or an external or a combined repair. MEASURES: Operative mortality and long term outcome of the survivals. RESULTS: Most patients (16.80%) were female and had rheumatic mitral valve disease. The mean age of the patients was 58.1 years. All patients underwent attempted repair, usually by removal of the prosthesis and reconstitution of the ventricle from within the left atrium (75%). Thirteen (65%) patients died. Two late deaths were of unrelated cause. One surviving patient developed a late ventricular false aneurysm but did not undergo repeat surgery. One patient developed severe mitral regurgitation due to tissue failure of the bioprosthesis 12 years after surgery and she underwent a successful reoperation. CONCLUSIONS: We believe that all patients should be placed back on cardiopulmonary bypass for an internal repair. The long term outcome of the survivals is satisfactory.     

Mitral valve prosthetic endocarditis: development of left ventricular-coronary sinus fistula following replacement

We report the history and course of a patient in whom a left ventricular-coronary sinus fistula developed following mitral valve replacement due to prosthetic endocarditis. Six months after the intervention the patient suddenly presented with deterioration of her symptoms, holosystolic murmur and signs of congestive heart failure. Transesophageal echocardiography showed a left-to-right shunt but did not show its exact location. At surgery, exploration of the right atrium revealed a left ventricular-coronary sinus communication due to discontinuation of the left ventricular free wall next to the coronary sinus; repair of the defect was successfully performed by direct suture. The postoperative course was uneventful and the patient recovered quickly. This case is reported to stress that debridement of the mitral annulus and removal of an old prosthesis must be very carefully performed and to facilitate the diagnosis of this rate but severe complication of repeated mitral valve replacement.     

In adult patients undergoing redo surgery for left atrioventricular valve regurgitation after atrioventricular septal defect correction, is replacement superior to repair?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'In adult patients undergoing redo surgery for left atrioventricular valve regurgitation after atrioventricular septal defect correction, is replacement superior to repair?' Altogether more than 109 papers were found using the reported search, of which eight represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes, and results of these papers are tabulated. We conclude that left atrioventricular valve (LAVV) repair should be the first line approach and the use of transesophageal echocardiography (TEE) in operating room is mandatory. When complex anatomy and multiple anomalies of the LAVV are present the risk of a suboptimal repair is high and is associated with elevated subsequent risk of early reintervention. Prosthetic valve replacement is suggested in these cases and there is no long-term survival difference compared to repair procedures. Unfortunately, the risk of complete heart block and permanent pacemaker (PMK) implantation is higher when replacement is performed. Prosthetic valve choice is in favor of mechanical valves, mainly due to the young age of the patients. In the selected articles the frequency of valve replacement ranged from 14 to 34% and a mechanical valve was used in nearly all cases in the presented series. We feel that for older patients or for those in whom long-term anticoagulation is a concern, biological prosthesis can be an option, also due to the growing and expanding experience of percutaneous/transapical valve-in-valve replacement in mitral position. Since in these patients the number of previous sternotomies is usually one or more and re-entry injuries can be a major source of perioperative mortality and morbidity, we believe that mini-thoracotomy approach can avoid potential damage; furthermore, arterial cannulation can be either central or peripheral according to the degree of visceral adhesions or surgeon's choice. Venous drainage should be provided by a percutaneous vacuum-assisted femoral double stage venous drainage, which is useful especially when concomitant tricuspid valve surgery is planned.     

Current surgical treatment for acquired valvular heart disease

We discuss the current status of surgical treatment for acquired valvular heart disease. Mitral valve repair for organic and functional mitral regurgitation is the first choice instead of valve replacement. It is important that surgery for functional mitral regurgitation restores the geometry of the left ventricle and mitral valve. The reduction of mitral valve tethering for functional mitral regurgitation is a current topic of discussion. At present, the surgical procedure for both aortic stenosis and aortic regurgitation is valve replacement in most cases, although aortic valve repair has been attempted for aortic regurgitation in recent years. The early results of aortic valve repair are excellent, but the long-term results have not been clarified. The durability of valve repair in both the mitral and aortic position is a future issue and it may be improved by revising the indications for valve repair and using new surgical techniques.     

Combined coronary artery bypass, mitral valve plasty, and abdominal aneurysmectomy in an 80-year-old patient: Report of a case

An 80-year-old man suffering from angina on exertion due to stenosis of the left main coronary artery, heart failure due to mitral valve regurgitation, and an abdominal aortic aneurysm (AAA) was successfully operated on with simultaneous surgical procedures. A coronary cineangiography revealed 90% stenosis of the left main coronary artery in segment 5, and 99% and 90% stenosis in segments 2 and 4AV, respectively, of the right coronary artery. Left ventriculography and aortography showed moderate mitral valve regurgitation and the presence of a fusiform-shaped AAA with a maximum diameter of 6 cm. It was thought that insertion of an intraaortic balloon pump (IABP) would prove difficult due to AAA; therefore, simultaneous surgery combining triple coronary artery bypass grafting (CABG), mitral valve plasty, and prosthetic replacement of the AAA was undertaken. The patient's postoperative course was uneventful, and subsequent angiography showed good patency of all coronary bypass grafts and the abdominal prosthesis, along with the disappearance of mitral regurgitation. This patient's clinical course suggests that an extended surgical procedure is effective for the treatment of complicated cardiovascular disease, even in very elderly patients.     

Concomitant mitral valve surgery with aortic valve replacement: a 21-year experience with a single mechanical prosthesis

Background  

Long-term survival for combined aortic and mitral valve replacement appears to be determined by the mitral valve prosthesis from our previous studies. This 21-year retrospective study assess long-term outcome and durability of aortic valve replacement (AVR) with either concomitant mitral valve replacement (MVR) or mitral valve repair (MVrep). We consider only a single mechanical prosthesis.     

腔镜不停跳术对左心瓣膜置换术后远期三尖瓣重度反流疗效分析

目的 总结左侧心脏瓣膜置换术后远期出现孤立性重度三尖瓣关闭不全患者的腔镜辅助不停跳三尖瓣手术治疗经验。方法 11例心脏瓣膜疾病患者行左心瓣置换术后远期发生重度三尖瓣关闭不全并右心衰竭,8例出现心脏恶病质综合征及肝肾功能不全,予行再次三尖瓣手术,包括人工瓣环成形术2例,行三尖瓣置换术9例,其中置换生物瓣5例,双在叶机械瓣4例;在腔镜辅助下行心脏不停跳再次手术5例,常规再次心脏停搏手术6例。结果 2例围术期死亡,均为停跳组瓣膜置换病人。术后心包引流液量心脏不停跳组明显少于停跳组（P<0.05）。停跳组术后严重低心排血量综合征4例,不停跳组1例。两组术后1月复查超声心动图,右心房、室均明显缩小,三尖瓣无或少量反流,两组间无明显差异。获长期随访5例、随访时间25~86月、心功能Ⅱ级3例、Ⅲ级2例。结论 左心瓣膜置换术后远期孤立性重度三尖瓣关闭不全合并右心衰的再次手术死亡率高、合理掌握手术指征、手术时机、积极开展微创不停跳手术和良好的围术期治疗是手术成功的关键。对于终末期病例,手术死亡率高,应积极开展针对右心系统的心脏超声及磁共振检测指标,综合评估手术风险,常规换瓣手术指征需慎重,必要时可考虑微创经皮导管瓣膜植入术。     

Preservation of subvalvular mechanism at mitral valve replacement

According to literature data there is no common approach to method of mitral valve replacement with preservation of subvalvular structures. Results of 175 operations of mitral valve replacement are analyzed. The preservation of fibrous-papillary contact must not be regarded as the goal itself, but it must improve the clinical effect of operation. Further study of left ventricle remodeling at mitral valve disease and repair of physiological function after surgery permits to predict and improve the functional results in early and long-term postoperative period.     

Combining off pump coronary artery bypass with mitral valve replacement

Background Conventional approach to combined coronary artery bypass grafting (CABG) and mitral valve replacement (MVR) is associated with longer cardiopulmonary bypass (CPB) and aortic cross clamp (ACC) time leading to high operative risk. Methods We conducted a retrospective review of nine consecutive patients undergoing coronary artery bypass grafting/mitral valve replacement combining the off pump technique with cardioplegic arrest. Elective intra aortic balloon pump (IABP) support was instituted in all cases. CABG was first done in all cases without cardiopulmonary bypass support. Mitral valve replacement was then done using conventional cardiopulmonary bypass and cardioplegic arrest using the superior septal approach. Results Nine consecutive patients underwent coronary artery bypass grafting with mitral valve replacement including three patients with acute myocardial infarction. Preoperative echocardiogram revealed a mean ejection fraction (EF) of 38.4 ± 6.0%. Intra aortic balloon pump was inserted in all patients preoperatively. The average number of grafts were 3.0 ± 0.7. Eight patients received bioprosthetic valve while one patient received mechanical prosthesis. The average length of stay in intensive care unit was 3.3 ± 0.5 days. There was no mortality. One patient had superficial wound infection. Conclusion The data suggest that the combined technique (off pump coronary artery bypass grafting and conventional mitral valve replacement) is a safe method to perform coronary artery bypass grafting/mitral valve replacement with minimal morbidity and mortality.     

二尖瓣闭合性损伤的诊断与外科治疗

目的二尖瓣闭合损伤临床少见。为引起大家的注意和重视。方法总结４例闭合性二尖瓣损伤的诊断与治疗的经验与教训。结果２例为外伤性二尖瓣腱索断裂，分别行二尖瓣瓣环环缩术加二尖瓣腱索修补术和二尖瓣置换术治愈。１例为外伤性二尖瓣瓣叶撕裂伤、左股动脉假性动脉瘤，合并感染性心内膜炎，急诊行二尖瓣赘生物清除、二尖瓣叶修补术、假性动脉瘤切除术、股动脉修补术治愈。１例为二尖瓣置换术后８年，外伤性人工机械瓣瓣钩断裂，致急性心衰，未及时手术而死亡，尸检证实诊断。结论作者认为闭合性二尖瓣损伤临床上易误诊。一旦诊断宜早期手术。发生急性心衰或合并感染性心内膜炎时，应急诊手术。     

Results after partial left ventriculectomy in a European heart failure population

BACKGROUND: Forty-nine consecutive patients undergoing partial left ventriculectomy (Batista) surgery between January 1995 and June 1998 were studied. METHODS: Patient ages ranged from 12 to 85 years, and all patients were in New York Heart Association functional Class III or IV. Thirty-three patients had ischemic cardiomyopathy, and 16 had idiopathic myopathy. Inclusion criteria were left ventricular end diastolic volume index of > 150 mL/m2, left ventricular ejection fraction of < 20%, or left ventricular end-diastolic diameter of > 70 mm. Sixteen patients were transplant candidates. Partial left ventriculectomy and mitral valve repair by means of a Cosgrove annuloplasty ring plus the Alfieri repair constituted only part of the complex cardiac reconstruction in 38 patients. RESULTS: Five patients died early and five patients died late between 3 and 30 months postoperatively. The actuarial 1-year survival rate was 81%. Twenty-seven patients with coronary artery disease underwent one to five bypass grafts when appropriate. In addition, three patients received aortic valve replacement, four received tricuspid valve repair, two received mitral valve replacement, and two underwent dynamic cardiomyoplasty. Left ventricular (LV) diameter could be reduced from a preoperative mean of 71 to 56 mm postoperatively. LV ejection fraction increased to 36% postoperatively. Ninety percent of patients are in New York Heart Association functional Class I or II. CONCLUSIONS: Patients with end-stage idiopathic or ischemic cardiomyopathies can be improved considerably with partial left ventriculectomy. Any cardiac comorbidity should be repaired simultaneously.     

The Superior Approach for Mitral Valve Replacement

A consecutive series of 98 patients ranging from 2 1/2 to 79 years of age underwent mitral valve replacement using the superior approach that entails an atriotomy done between the superior vena cava and the ascending aorta prolonging it into the left superior pulmonary vein. The technique opens the roof of the left atrium without dissection, frequently without the need for double cannulation of the right atrium. No mobilization of the heart is involved, which is left in its normal position. There were 62 patients undergoing replacement alone, 22 combined with coronary bypass surgery, 10 with simultaneous aortic valve replacement, 2 with coronary bypass and left ventricular aneurysm resection, and 2 others combined with ventricular septal defect (VSD) closure and placement of an extracardiac conduit. Forty-six were done for stenosis and 52 for regurgitation. No technical difficulties were encountered, and the valve can easily be replaced through an incision slightly larger than the diameter of the prosthesis being implanted. Since the heart is not mobilized, the ventricles remain immersed in the cold topical solution (4 degrees C) in addition to the administration of cardioplegia for myocardial protection. The access is simple and offers better exposure for the assisting surgeon than the usual inter-atrial groove approach. Important steps of the technique are clarified.     

Long-term survival rates after prolonged aortic cross-clamping with St. Thomas' Hospital cardioplegia

Prolonged aortic cross-clamping (in excess of 120 min) was necessary in 154 cardiac surgical patients. St. Thomas' Hospital cardioplegia was used for myocardial preservation. Quantitative polarization microscopy enabling quantitative birefringence measurements to assess the change in birefringence of the muscle fibres in response to the addition of buffer containing ATP and calcium (i.e. myocardial contractility) was used to detect whether there had been any deterioration in right or left ventricular myocardium during the bypass period. 30 day survival was 90%, long-term (60 months) survival was 80%. In single valve replacements, patients with aortic valvular replacement had 100% survival up to 92 months, whereas patients with mitral valvular replacement had survival rates of 83% after 12 months and 27% after 60 months. Survival rates after 60 months were 89% for coronary artery bypass grafting, 80% for multiple valve replacements, and 74% for combined valvular and coronary artery bypass grafting surgery. Quantitative birefringence assessment of function showed that in the surviving patients 5% had functional deterioration during bypass whereas in the non-surviving patients 70% had functional deterioration. It may be concluded that after cardiac surgery necessitating prolonged aortic cross-clamping--once the initial operative problems are overcome--reasonable long-term results can be obtained by using St. Thomas' Hospital cardioplegia.     

二尖瓣置换术后左室破裂

目的：探讨二尖瓣置换术后左心室破裂的预防措施,方法：对1994年1月－2000年6月二尖瓣置换术的3607例患者的临床资料进行回顾性分析。结果：9例患者发生左心室破裂（发生率0．25％）,其中3例 生手术中,6例发生于ICU;手术抢救成功3例,死亡6例,结论：左心皮裂修补困难,针对其发病机理,采取相应的预防措施可减少其发生率及病死率。预防措施包括：重视诱发因素;防止术中损伤;正确选择和安装人工瓣膜;纠正血液动力学的异常。     

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.     

Rupture of the posterior wall of the left ventricle after mitral valve replacement: etiological and technical considerations

Rupture of the posterior wall of the left ventricle after mitral valve replacement, although infrequent, may be a highly lethal complication. Controversy exists regarding the etiology of this complication. Suggested causative factors include the type and extent of the valvular disease, type and size of the prosthesis, and the surgical techniques used. Our experience over a 20-year period includes 10 patients with rupture of the left ventricle following mitral valve replacement. In all patients, both mitral leaflets were excised together with the attached chordae. Three patients survived after repair of the rupture. Repair consisted of compressing the area between the left atrium and the base of the papillary muscle using two strips of Teflon and deep mattress sutures passed beneath the coronary vessels in the atrioventricular groove. Since 1983 we have routinely preserved the posterior leaflet of the mitral valve with its attached chordae to maintain a "tethered loop" between the mitral valve and ventricle. No further ruptures have occurred. The technique used for repair represents reconstitution of the divided loop between the ventricle and the mitral valve.     

Left ventricular rupture following mitral valve replacement due to oversize prosthesis

Left ventricular rupture following mitral valve replacement is one of the most serious complications. We report our experience in successful treatment of type III left ventricular rupture following mitral valve replacement probably due to an oversize prosthesis. A 67-year-old woman, with the history of percutaneous transluminal mitral commissurotomy 11 years previously, underwent mitral valve replacement for mitral restenosis with a 27 mm CarboMedics mechanical bileaflet valve (Sulzer CarboMedics Inc., Austin, TX, U.S.A.). There were some difficulties in placing the entire prosthesis into the annulus at the posterior because of the oversize prosthesis. After the complete placement of the prosthesis, bulge of the left ventricular muscle was evident around the left lateral region. Following the cessation of cardio-pulmonary bypass, type III left ventricular rupture, half a circular rip between the papillary muscles and posterior mitral annulus, occurred. The rip was suture-closed and a 23 mm CarboMedics valve was placed. Postoperative ultrasonic cardiography showed no prosthetic stenosis, periprosthetic leak, left ventricular pseudoaneurysm, nor left ventricular asynergy. Under cardioplegic arrest, we should not select the oversize prosthesis to prevent left ventricular rupture.