Testing of mitral valve competence following combined mitral valve repair and aortic valve replacement

A simple, effective technique for testing the results of repair and reconstructive procedures on the mitral valve apparatus is described. This technique can be used in the operative setting of combined aortic valve replacement and mitral valve repair where other reported techniques for testing the valve apparatus are rendered unfeasible.     

Chylopericardium following mitral valve replacement.

A 49-year-old man with mitral regurgitation developed chylopericardium after mitral valve replacement. On postoperative day (POD) 1, the patient was started on a regular diet. On POD 2, drainage from retrosternal and intrapericardial tubes increased, becoming turbid and milky. Because the triglyceride concentration was high at 197 mg/dl, we diagnosed the condition as chylopericardium. The patient was given nothing by mouth for 2 days and, from POD 4, received a low-fat diet, after which drainage cleared and volume decreased. The 2 drainage tubes were removed on POD 6, and he was discharged without complications on POD 18.     

Intracardiac repair in left ventricular rupture following mitral valve replacement

Rupture of the left ventricle is one of the major lethal complications of mitral valve replacement. We have encountered 11 cases of this complication over a period of 19 years (1971, Apr.-1990, Mar.). Five of 8 cases of intraoperative rupture survived but no patient survived a delayed rupture. In the patients with intraoperative rupture external repair was performed in 6 cases, resulting in 3 survivors, two in type II and one in type I with formation of left ventricular false aneurysm. For selection of surgical treatment accurate recognition of types of rupture is important but the location and size of the endocardial and epicardial defects do not always correspond. Attempts to suture a ventricular rupture on the pressure-loaded beating heart were always unsuccessful and frequently extended the tear. Repair should be accomplished with aid of cardiopulmonary bypass on the decompressed and arrested heart. Recently, we chose internal repair with arrested heart in 2 cases of type I rupture, that is, reopening of the left atrial closure and repair from within the cardiac chamber with removal of the prosthetic valve. Both cases survived. In conclusion, we emphasized importance of intracardiac repair with removal of the replaced prosthetic valve in left ventricular rupture of type I and III following mitral valve replacement for better exposure, more secure repair, and prevention of injury to the circumflex artery.     

Haemolysis following mitral valve repair.

We report the unusual occurrence of severe intra-vascular haemolysis following mitral valve repair. Mild to moderate mitral regurgitation was detected after repair, but severe haemolysis was the only indication for re-operation. Following prosthetic valve replacement there was an immediate cessation of haemolysis. We postulate that a small regurgitant jet directed against the teflon pledgets used in the repair was the reason for the haemolysis.     

Meta-analysis of clinical outcomes following surgical mitral valve repair or replacement.

Although the use of mitral valve surgery has been successful at alleviating mitral valve disease, published studies on either replacement or repair have yielded mixed clinical outcomes regarding differences between repair and replacement. Meta-analysis of various outcomes from 29 published studies was conducted. Studies were separated into four groups by etiology of disease: ischemic; degenerative/myxomatous; rheumatic and mixed. The summary odds ratio for early mortality, comparing replacement to repair, was 2.24 (1.78-2.80), while the summary total survival hazard ratio was 1.58 (1.41-1.78), replacement compared to repair, indicating worse outcomes among those undergoing mitral valve replacement. The risk of thromboembolism was lower in the repair group (summary hazard ratio=1.86, replacement vs. repair), while there was no statistical difference in time to re-operation between the two treatment groups (hazard ratio=0.88 [95% confidence interval: 0.48, 1.62]). Analysis stratified by etiologic classification was able to detect strong evidence of differences in 30-day and total survival outcomes favoring repair for three disease groups (rheumatic, mixed and degenerative). Surgery for ischemic mitral valve had lower 30-day mortality for repair than replacement, but no statistically significant difference in the overall survival was detected. The reported information in the published studies used in the current work lacks sufficient detail to allow summary determination of outcomes by mitral valve repair techniques and by type of mitral valve replacement.     

Technique for repair and replacement of the mitral valve.

Whenever possible, the patient's own mitral valve mechanism should be preserved. Successful mitral valve repair offers excellent benefits in terms of hemodynamic function, clinical improvement, and longevity. Open mitral commissurotomy or valvuloplasty for localized defects or ruptured chordae tendineae constitutes our best reparative efforts. Today, mitral valve replacement can be accomplished with less than a 5 per cent operative mortality, but should be reserved for patients who are not in desperate terminal condition. In our experience, aggressive tactics undertaken at the endstage of the disease have had little or no long-term success. At the Cleveland Clinic, isolated mitral valve repair or replacement is performed under normothermic cardiopulmonary bypass and anoxic arrest. Generally, the valve is exposed through an atriotomy behind the interatrial groove. Valvular replacement is accomplished by interrupted suture technique, seating the prosthesis at the level of the annulus or below it. Risk is influenced mainly by the chronicity of the valve dysfunction. Patients who have not yet reached a Functional Class IV status or sustained massive cardiomegaly and low cardiac output fare better in both early and late follow-up periods.     

A clinical comparison of mitral valve repair versus valve replacement in ischemic mitral regurgitation

Severe mitral regurgitation caused by acute myocardial infarction has been a particularly difficult management problem with disappointing clinical results. Over a 75-month period, ending March 31, 1987, 611 patients underwent mitral valve operations at Duke University Medical Center. Within this group, 55 patients had clearly defined ischemic mitral regurgitation, and 37 of these required emergency operations. Thirty-one of the 55 patients had isolated posterior papillary muscle dysfunction, nine had papillary muscle rupture, and 15 had severe ventricular dysfunction and generalized annular dilatation. Thirty-two patients were treated with primary mitral valve replacement, and 23 had mitral valve repair. In 18, repair was accomplished by a transventricular approach, combining the techniques of commissural annuloplasty, papillary muscle shortening or reimplantation, and infarct exclusion. Transventricular mitral valve repair proved to be safe, expeditious, and effective in restoring valve competence. Although the repair and replacement groups were similar with respect to all relevant baseline characteristics, improved operative survival was observed after valve repair, as compared to replacement, both for the overall group (p = 0.03) and for acute papillary muscle dysfunction (p = 0.05). These data suggest that a policy of predominant mitral valve repair, when appropriately applied in patients with ischemic mitral regurgitation, offers the potential for improving therapeutic results.     

Transmitral endoventricular repair of left ventricular pseudoaneurysm following mitral valve replacement

Left ventricular (LV) pseudoaneurysm is a rare but serious complication of mitral valve replacement and is usually the consequence of atrioventricular separation. Although there may be a role for nonoperative treatment in the presence of a small false aneurysm and in the absence of paravalvular leak, the presence of a large false aneurysm usually mandates surgical intervention. This may be hazardous in patients with concomitant LV dysfunction. We report a case of a patient who presented with a large LV pseudoaneurysm following numerous attempts of mitral valve replacements for a variety of reasons, including endocarditis. Some of the technical details of aneurysm repair and aspects of myocardial protection are discussed. In our patient, avoidance of cardioplegic arrest may have contributed to the successful outcome.     

A technique to repair type I left ventricular rupture following mitral valve replacement

Rupture of the posterior left ventricle is a serious complication following mitral valve replacement. A successful method of repair is illustrated. The causes, other methods of repair, and means to prevent this complication are discussed.     

A comparison of repair and replacement for mitral valve incompetence

A total of 101 reparative and 389 valve replacement operations, isolated or combined with tricuspid annuloplasty or operations for coronary artery disease, were done for mitral incompetence (1975 to July 1, 1983). The patients undergoing repair as a group were younger and had less hemodynamic and functional derangement than those undergoing replacement. The prevalence of repair was less (p less than 0.001) for two surgeons than for the other four, even when possible differences in patient populations were taken into account by multivariate analysis. Five-year survival rate, including hospital deaths, was 76% after valve repair and 56% after valve replacement (p = 0.005). However, by multivariate analysis, valve replacement rather than repair was only possibly (p = 0.14) a risk factor. (Multivariate analysis in all patients undergoing mitral valve repair in the period 1967 to 1985 [n = 210] did not find the type of annuloplasty to be a risk factor.) The incidence of reoperation was no different after repair or replacement and there was no increase in the risk of reoperation late after repair. Endocarditis early or late after operation occurred in 11 of the 389 patients undergoing mitral replacement and in none of those undergoing repair (p = 0.08). The functional status of the patients was not different between the two groups. These data, and the experience of others, indicate the advantages of repairing rather than replacing the incompetent mitral valve whenever possible.     

Case-matched comparison of mitral valve replacement and repair

Carpentier's techniques of prosthetic ring mitral valve repair for mitral regurgitation offer the potential for immediate and long-term improvement in valve function without the necessity of replacing the native valve with a prosthesis. A consecutive, case-matched series of 65 patients with prosthetic ring mitral valve repair was compared with 65 patients undergoing mitral valve replacement for mitral regurgitation. The aortic cross-clamp time was 57 +/- 33 minutes in the repair operations and 41 +/- 25 minutes in the replacement operations (p = 0.003). The cardiopulmonary bypass time was 154 +/- 44 minutes in the repair operations and 113 +/- 41 minutes in the replacement operations (p = 0.0001). There were no myocardial infarctions in the hospital in either group. Hospital death was noted in 1.5% of repairs and 4.6% of replacements (p = not significant). Survival at 4 years was 0.84 for repairs and 0.82 for replacements (p = not significant). Freedom from reoperation to replace the mitral valve at 4 years was 62 of 65 patients in the repair group and 64 of 65 patients in the replacement group (p = not significant). In-hospital and midterm results in a closely matched population show that mitral valve repair yields results comparable with those of replacement despite a more difficult procedure. The benefits of maintaining the native valve with chordal and papillary muscle structure intact and avoidance of prosthetic valve implantation may then become apparent with longer follow-up.     

A device for ensuring the neochordae replacement in mitral valve repair

We have developed a new device for maintaining artificial chordae at the appropriate length during the tying of Gore-Tex sutures (W. L. Gore and Assoc, Flagstaff, AZ). This double-armed, double-hooked device is inserted through the loop formed by the neochordae, which is anchored in the papillary muscle and passed through the prolapsing segment. The device pulls up both leaflets and maintains the neochordae at the same length as that of the opposing normal chordae. The prolapsed leaflet is suspended at the same height as the facing leaflet, enabling the accurate and reproducible placement of neochordae.     

Durability and outcome of aortic valve replacement with mitral valve repair versus double valve replacement

BACKGROUND: The purpose of this study was to evaluate morbidity and mortality after double valve replacement (DVR) and aortic valve replacement with mitral valve repair (AVR + MVP). METHODS: From 1977 to 2000, 379 patients underwent DVR (n = 299) or AVR + MVP (n = 80). Actuarial survival and freedom from reoperation were determined by the Kaplan-Meier method. Potential predictors of mortality and reoperation were entered into a Cox multiple regression model. Propensity score was introduced for the multivariable regression modeling for adjustment of a selection bias. RESULTS: Survival 15 years after surgery was similar between the groups (DVR, 81% +/- 3%; AVR + MVP, 79% +/- 7%; p = 0.44). Freedom from thromboembolic event at 15 years was similar between the groups (p = 0.25). Freedom from mitral valve reoperation at 15 years was significantly better for the DVR group (54% +/- 5%) as compared with the AVR + MVP group (15% +/- 6%; p = 0.0006), primarily due to progression of mitral valve pathology and early structural deterioration of bioprosthetic aortic valve used for patients with AVR + MVP. After AVR + MVP, freedom from mitral reoperation at 15 years was 63% +/- 16% for nonrheumatic heart diseases, and 5% +/- 5% for rheumatic disease (p = 0.04). CONCLUSIONS: Although both DVR and AVR + MVP provided excellent survival, DVR with mechanical valves should be the procedure of choice for the majority of patients because of lower incidence of valve failure and similar rate of thromboembolic complications compared with AVR + MVP. MVP should not be performed in patients with rheumatic disease because of higher incidence of late failure.     

Acute renal failure in patients with malnutrition following mitral valve replacement

A retrospective study of 161 consecutive patients undergoing mitral valve replacement with or without other valve surgery was undertaken to examine the relation between cardiac cachexia and postoperative acute renal failure. The preoperative nutritional state was assessed according to percent of the ideal body weight (W/IW). There were 37 malnourished patients (W/IW<0.80) and 124 normally nourished patients (W/IW>=0.80). In nineteen in the malnourished group (51 per cent) and 37 of normal-nourished (28 per cent), postoperative acute renal failure developed. Malnourished patients showed a severe clinical picture preoperatively a complicated operative procedures had to be carried out. To match these clinical factors between the two groups, the observation was limited to the high risk patients who showed severe New York Heart Association Functional Class (III or IV) large cardiothoracic ratio (more than 65 per cent), and long cardio-pulmonary bypass time (exceeding 120 minutes). Even in this subgroup, malnourished patients were susceptible to renal failure (64 per centVersus 20 per cent, malnourishedversus normalnourished repectively). Thus when malnutrition is superimposed on diminished cardiac performance, acute renal failure may ensure.