Thoracic aortic aneurysm associated with congenital bicuspid aortic valve.

Congenital bicuspid aortic valve is a relatively rare malformation. It is reported that the presence of this anomaly predisposes the patient to development of true aortic aneurysms or dissecting aortic aneurysms. Between 1981 and August 1997, 25 patients with an aneurysm of the thoracic aorta associated with congenital bicuspid aortic valve underwent surgical treatment at the authors' institution. There were 20 males and five females. The age of the patients ranged from 27 to 74 years (mean 53 years). There were 18 patients with true ascending aortic aneurysms (of which 10 presented with annulo-aortic ectasia) and seven with dissecting aortic aneurysms (four with DeBakey type I dissection, two with type II and one with type IIIb). These 25 patients constituted 2.6% (25/973) of all cases of surgical operations for aneurysms in the thoracic aorta. Aortic valve dysfunction was noted in 20 patients. The authors performed a valved conduit operation in nine patients, aortic valve replacement and wrapping of the ascending aorta in six, graft replacement of the ascending aorta in five, graft replacement of the ascending aorta and aortic arch in four, and graft replacement of the descending aorta in one. No hospital deaths occurred in the authors' patients. Pathological examination of surgical specimens of the aortic wall showed cystic medial necrosis in 11 patients and mucoid degeneration in nine. In patients with congenital bicuspid aortic valve, attention should be paid to aneurysmal dilatation and aortic dissection as complications in addition to valve dysfunction.     

升主动脉根部瘤的外科治疗

目的总结升主动脉根部瘤的外科治疗经验。方法101例升主动脉根部瘤患者（年龄14～72岁，平均年龄42．7岁）的主要病因为马方综合征（Marfan syndrome，58例），主动脉瓣环扩张症（34例），主动脉瓣二叶瓣畸形（5例），大动脉炎（4例）；术前有主动脉瓣关闭不全96例，主动脉瓣狭窄4例，术前合并有A型夹层26例，急性左心衰竭（5例）。手术类型：Wheat手术4例，传统或改良Cabrol手术13例，David手术1例，Bentall手术83例。同期行主动脉半弓置换术或降主动脉腔内支架植入术16例，全弓置换术或降主动脉腔内支架植入术4例，二尖瓣置换术或成形术14例，冠状动脉旁路移植术8例。结果全组手术死亡率为6．9％（7／101），2000年后降至3．6％（3／83）；术后主要并发症为低心排血量10例，呼吸功能不全9例，肾功能不全9例。术后随访94例，随访期间死亡1例，5例马方综合征患者术后出现B型夹层。结论Bentall手术是治疗升主动脉根部瘤的首选手术方法，术前左心功能及手术技术是影响手术效果的关键因素。     

Surgical treatment of ischaemic valve disease

Mitral valve regurgitation secondary to ischaemic heart disease carries a significant mortality even after open-heart surgery. In this study, 21 patients with mitral regurgitation associated with ischaemic heart disease were evaluated with respect to valvular pathology. Pathological examination of the mitral valve revealed chorda elongation or rupture in seven patients (group 1), papillary muscle dysfunction in 10 (group 2), and papillary muscle rupture in four (group 3). Significant preoperative characteristics in each group were subacute haemodynamic deterioration in group 1, chronic severe left ventricular failure in group 2, and a high incidence of acute renal failure associated with haemodynamic shock in group 3. Mitral valve plasty was performed in six patients and mitral valve replacement, using the St Jude Medical valve, in 15. Fourteen patients underwent mitral valve surgery combined with coronary artery bypass grafting. Mitral plasty was applied to the patients with low left ventricular function with mean(s.d.) fraction shortening of 19.2(6.2)% compared with 30.2(8.4)% in patients with mitral valve replacement. There were no operative deaths. Of four late deaths, two in group 1 resulted from infection and myocardial infarction, respectively, and one in group 2 resulted from arrhythmia. One patient in group 3 died from renal failure. It is suggested that incorporation of these therapeutic concepts may lead to satisfactory results in the surgical treatment of ischaemic mitral regurgitation.     

A case of aneurysm of the inferior left ventricular wall

Aneurysms of the inferior left ventricular wall represent only a small fraction of all aneurysms that have been reported in surgical series. And in comparison to anterior left ventricular aneurysms, a comparatively higher percentage of reported inferior wall aneurysms was classified as false. A 73-year-old male was admitted for acute inferior myocardial infarction. Three weeks after admission, cardiac catheterization was carried out. Coronary arteriography revealed triple vessel disease and left ventriculography showed an aneurysm of the inferior left ventricular wall, whose feature near the mitral annulus was multiple fenestrations. Left ventricular aneurysmectomy and aortocoronary bypass grafting to the left anterior descending artery were simultaneously performed under cardiopulmonary bypass with moderate hypothermia. The pathological feature was a true aneurysm. The postoperative course was uneventful.     

Mitral valve replacement in the first year of life

From 1973 through 1987 25 patients underwent mitral valve replacement in the first year of life for mitral stenosis and mitral regurgitation. The patients with mitral stenosis included two with mitral arcade, two with supravalvular mitral stenosis with hypoplastic mitral valve, and one with parachute mitral valve. Included in the group of patients with mitral regurgitation were 12 with atrioventricular canal defect, six with chordal and leaflet defects, one with Marfan's syndrome, and one with bacterial endocarditis. Prostheses included 12 Bj?rk-Shiley (17 mm), seven St. Jude Medical (19 mm in four, 21 mm in three), five stent-mounted dura mater valves (12 mm to 16 mm), and one porcine xenograft (19 mm). In four patients the valves were placed in the left atrium in a supraannular location. There were nine operative (atrioventricular canal defect seven, mitral regurgitation two) and five late (atrioventricular canal defect four, mitral stenosis one) deaths, giving actuarial 1- and 5-year survival rates of 52% and 43%, respectively. All 6 patients with tissue valves died; the four with supraannular mitral valve replacement survived. Since 1983 operative mortality has been reduced to 0% (70% confidence limits 0% to 24%). Nine patients required a second mitral valve replacement for prosthetic stenosis 5 to 69 (mean 30) months after the original mitral valve replacement (one operative death). Because of improvements in repair of atrioventricular canal defect in infancy, the need for mitral valve replacement at atrioventricular canal defect repair has decreased. Although valvuloplasty has been advocated for repair of congenital mitral valve disease and is applicable in some infants with mitral regurgitation, mitral valve replacement is frequently unavoidable for congenital mitral disease and can now be accomplished at a low operative risk, even when the prosthesis has to be positioned supraannularly.     

Posterior non-ischemic left ventricular aneurysm. Report of 2 surgical cases

Posterior non-ischemic left ventricular aneurysms are unusual aneurysms of different etiology that develop adjacent to the mitral valve annulus causing mitral regurgitation and progressive heart failure. Surgical correction is mandatory and involves repair of the aneurysm along with repair or replacement of the mitral valve. Two cases of posterior non-ischemic left ventricular aneurysms are reported. Both patients were females (19 and 9 years old) and they presented with symptoms of progressive heart failure. Definite diagnosis was made with transesophageal echocardiography (TEE) and confirmed with left ventriculography. Both patients were successfully treated by surgery. The first patient underwent repair of the aneurysm from inside the left ventricle and mitral valve replacement. The second patient had resection of the aneurysm through an extracardiac route. Both patients are in NYHA class 1, 5 and 4 years respectively after their operation with no evidence of mitral valve dysfunction. Posterior non-ischemic left ventricular aneurysms can securely be diagnosed by TEE and angiocardiography. Surgical treatment is mandatory in order to forestall potential life threatening cardiovascular events and should be tailored to the operative findings.     

二尖瓣脱垂并关闭不全的外科修补

目的：总结二尖瓣脱垂的外科修复经验,方法：对44例二尖脱垂患者的临床资料进行回顾分析。44例患者中风湿性2例,非风湿性42例（22例合并先天性心脏病）,关不全中度24例,重度20例,腱索断裂或缺如12例,腱索过长32例,其中多根腱索过长6例,治疗行腱索移植10例,健索缩短25例（多根腱索短6例）,人工腱索1例,瓣叶折叠3例,瓣叶切除5例,同时行瓣裂缝合8例,瓣环成形28例（后环缝缩14例）,结果：结果：全组无手术死亡病例,1例风湿性患者术后1个月发生左心房血栓再次手术行瓣膜替换,二尖瓣功能正常34例（77．8％）,基本正常6（13．6％）,残留轻至中度关闭不全3例（6．8％）,随访1－18例（平均6．5年）,效果良好,结论：外科修复治疗二尖瓣脱垂是一种安全有效的手术方法。     

Improved results in the operative management of ventricular tachycardia related to inferior wall infarction. Importance of the annular isthmus

Ventricular tachycardia associated with inferior wall myocardial infarction has had a lower surgical cure rate with localized subendocardial resection than ventricular tachycardia related to anterior infarction. Some investigators have advocated visually directed extensive subendocardial resection, including resection of the papillary muscles and mitral valve replacement, even without documenting the origin of ventricular tachycardia at these sites. We have operated on 46 patients (43 men and three women) for ventricular tachycardia associated with inferior wall myocardial infarction. Thirty-one consecutive patients (Group I) had standard localized subendocardial resection. Two patients in this group had mitral valve replacement for mitral insufficiency. Fifteen consecutive recent patients (Group II) underwent subendocardial resection plus focal endocardial cryoablation (3 minutes at -70 degrees C) of the annular isthmus. The annular isthmus is defined as the ventricular muscle between the basal end of the ventriculotomy and the mitral valve anulus. In Group I there were four operative deaths (13%). Ventricular tachycardia was noninducible in 15 of 27 operative survivors (56%) at postoperative electrophysiologic studies. In Group II there was one operative death (7%) and 13 of 14 survivors (93%) had no inducible ventricular tachycardia at postoperative electrophysiologic studies (p less than 0.01 versus Group I). No Group II patient required mitral valve replacement. Six operative survivors in Group II had intraoperative activation maps consistent with macroreentry incorporating the annular isthmus. Group I and Group II were indistinguishable in terms of preoperative hemodynamics, number of coronary arteries diseased, or the presence of left ventricular aneurysm. These results suggest that subendocardial resection with additional cryoablation of the annular isthmus results in improved control of ventricular tachycardia in patients with ventricular tachycardia associated with inferior wall myocardial infarction. Mitral valve replacement is not required unless intrinsic mitral valve disease is present. These data also suggest that the annular isthmus is a critical component of the reentrant circuit in these tachycardias.     

Immediate and long-term outlook for valve replacement in acute bacterial endocarditis.

The clinical course of 22 patients with acute endocarditis treated surgically less than six weeks after the onset of antibiotic therapy was reviewed. The aortic valve was infected in 13 patients, the mitral in six, the tricuspid in two, and one patient had both aortic and mitral valve involvement. The indications for surgical intervention before the completion of adequate antibacterial therapy included uncontrollable congestive heart failure, persistent sepsis, systemic embolization, and multiple septic pulmonary embolizations. The annulus was involved by the infectious process in five of the 13 patients with aortic valve endocarditis, in one of the two patients with tricuspid valve infection, and in none of the patients with mitral valve endocarditis. There were two surgical deaths, for a mortality of 9.1%. During the follow-up period, four patients died three months, seven months, four years, and seven years after surgery. The remaining patients have been followed up for a period of five months to 10 years. One patient has a hemodynamically insignificant paravalvular leak, and another developed paravalvular regurgitation and a false aneurysm of the left sinus of Valsalva two weeks after the initial operation. She subsequently underwent successful valve replacement and repair of the aneurysm. This study confirms that valvular replacement should be done for acute endocarditis as soon as indicated, and that the incidence of reinfection and/or the development of valvular or paravalvular problems is small even in the patients with incomplete antimicrobial therapy, whether or not the annulus is involved by the infectious process.     

Congenital left ventricular inflow obstruction: is the outcome related to the site of the obstruction?

Between 1978 and 1987, 39 patients aged 1 day to 15 years underwent surgery for symptomatic left ventricular inflow obstruction. Four diagnostic groups were identified: cor triatriatum (6 patients), supravalvar mitral membrane (SVMM) with a normal mitral valve (7 patients), SVMM with an abnormal mitral valve (9 patients) and mitral stenosis (17 patients). Associated cardiac anomalies occurred in 26 patients (67%). There were 8 deaths (21%), 3 in patients with SVMM and an abnormal mitral valve and 5 in patients with mitral stenosis. Survival for patients with normal mitral valves was significantly better than that for patients with abnormal mitral valves (13/13 vs 18/26, P less than 0.05). There was also high morbidity in patients requiring prosthetic mitral valve replacement. These data suggest that the outcome of surgical treatment for left ventricular inflow obstruction may be predicted according to the site of the obstruction. This is best determined preoperatively by cross-sectional echocardiography which allows optimal planning of surgical strategy.     

Rupture of posterior wall of left ventricle after mitral valve replacement

Possible aetiological factors, presentation, and management were reviewed in 18 patients with posterior left ventricular rupture complicating mitral valve replacement seen at one centre over six and a half years. The patients were elderly (mean age 57), predominantly women (16 of the 18), and suffering from mitral stenosis. Rupture was much more common after isolated replacement of the mitral valve (16 out of 797 operations) than after double valve replacement (one out 236) or mitral valve replacement and coronary artery bypass graft (one out of 70). A total of 1221 mitral valve replacements were performed over this period, with an overall incidence of rupture of 1.47%. Damage to the valve annulus occurred five times. On four occasions haemorrhage followed a vigorous response to a bolus dose of an inotrope. With the exception of these features, it was difficult to define specific risk factors. Eleven patients bled while still in theatre; one of them survived long term and another four lived for four to 10 days. Repair after restarting cardiopulmonary bypass made short term survival much more likely. In seven rupture developed after return to the intensive therapy unit; again only one survived long term. In nearly all cases bleeding was at, or just below, the atrioventricular groove. Rupture probably occurs after endocardial damage to a thin myocardium that has lost the internal buttress of the subvalvar apparatus. With the rise in intraventricular pressure at the end of bypass blood dissects into the myocardium, resulting in a large haematoma and eventual rupture.     

Mitral Valve Reconstruction and Mitral Valve Replacement for Ischemic Mitral Insufficiency

Abstract Background: Patients with ischemic mitral incompetence have a high operative risk whether the valve is repaired or replaced. The advantage of repair over replacement is unclear in this group of patients. Methods: Between April 1986 and December 1994, 232 patients underwent surgery for ischemic mitral valve insufficiency; mitral valve replacement was performed in 98 of them. Operative mortality was 13.3%. The actuarial survival rate after 5 years was 73.3%. The surgical risk in patients whose left ventricular ejection fraction (LVEF) was 10%-30% (operative mortality 50.0%) was higher than in those whose LVEF was greater than 30%. Valve reconstruction was performed in 102 patients. Operative mortality in this patient group was 14.7%. The surgical risk in patients whose LVEF was 30% was higher (operative mortality 42.9%). Results: The total actuarial survival rate of all patients was 64.4% after 5 years. Mortality during follow-up was higher in patients with residual mitral valve insufficiency greater than grade I after mitral valve reconstruction. Twenty-four patients with severly impaired left ventricular function underwent heart transplantation. Operative mortality in this group was 12.5%. Eight patients received left ventricular aneurysmectomy in addition to valve surgery, three of them died early. Conclusions: We conclude that patients with highly impaired left ventricular function and ischemic mitral insufficiency are at too great a risk for either valve reconstruction or replacement. Cardiac transplantation should be considered for this patient group. However, patients with ischemic mitral insufficiency and moderately impaired left ventricular function can undergo valve reconstruction or replacement with an acceptable prognosis. The goal of mitral valve reconstruction should be reducing mitral valve insufficiency to at least grade I. If this is not achieved, the prognosis after repair is worse than after valve replacement, therefore, the surgeon should replace the valve without delay.     

Simultaneous mitral valve replacement and bypass grafting for mycotic aneurysm of the femoral artery during the active phase of infective endocarditis: a case report.

A 52-year-old woman with a 3-week history of fever and cough was diagnosed as having bacterial endocarditis with vegetation and severe mitral valve insufficiency by echocardiography. Blood culture revealed Streptococcus mitis. After antibiotic treatment for 3 weeks, the patient noticed swelling with pain in her left groin. Computed tomography revealed an occluded aneurysm in the left common femoral artery. Simultaneous surgical treatments of mitral valve replacement and bypass grafting using a saphenous vein following resection of the mycotic femoral arterial aneurysm were performed. Pathohistological examination of surgical specimens revealed acute inflammatory findings, but no microorganisms were found, probably because of the preoperative antibiotic therapy. Her postoperative course was uneventful, and there was no recurrence of mycotic aneurysms in a period of 10 months after the operation. Prompt recognition and urgent simultaneous surgical treatments for mycotic aneurysms complicated with infective endocarditis were effective.     

Aortic root replacement with coronary button re-implantation: low risk and predictable outcome.

OBJECTIVE: Cardiac morbidity in aortic root replacement often occurs through myocardial ischaemia. We analyzed a 10 year experience of all root replacement operations by one surgeon to determine the incidence of coronary complications and risk factors for early mortality. METHODS: The study included 140 aortic root replacement patients (aged from 2 to 77 years; median 53 years) operated between 1988 and 1999. Thirty-four had Marfan's syndrome. Eleven had root infection requiring homograft replacement. Nineteen were reoperations (14%). Concomitant procedures were arch replacement (16), mitral replacement (five), and coronary bypass (22). Mobilization and reimplantation of the coronary ostia was performed in 139 patients. We performed the distal graft anastomosis before right coronary reimplantation. RESULTS: There were eight hospital deaths (5.7%). Risk factors for hospital mortality were: preoperative NYHA class IV, shock, LVEF < or =30%, acute dissection, concomitant mitral valve replacement, pump time > or = 60 min, reentry for bleeding, and postoperative renal failure. Neither myocardial ischaemia nor right ventricular dysfunction contribute to mortality. There were 18 late deaths with an actuarial survival of 79% at 5 years. There were no late coronary false aneurysms. CONCLUSIONS: Button reimplantation with the sequence described is predictable and safe. Wrap-around is unnecessary. Coronary aneurysms have been eliminated.     

Surgical bypass of the systemic atrioventricular valve in children by means of a valved conduit

The surgical approach to relief of mitral stenosis in children is still a controversial problem. We describe our experience with four severely symptomatic children in whom a valved conduit from the left atrium to the left ventricle was successfully used to bypass a hypoplastic systemic atrioventricular valve. A left atrial-left ventricular extracardiac conduit was implanted in these patients with a hypoplastic mitral anulus and an adequate left ventricular chamber. There were no early or late deaths. Postoperative cardiac catheterization performed in all patients 1 month after the operation showed reduced size of the left atrium, a reduction of the left atrial-left ventricular gradient from a mean of 14 mm Hg to a mean of 5 mm Hg, and an increase of the left atrial outlet from a mean diameter of 10.7 mm to 28.7 mm (including the diameter of the native mitral valve plus the internal diameter of the valved conduit). The application of this unconventional operation in children with congenital or acquired stenosis of the systemic atrioventricular valve should be considered when the mitral valve obstruction cannot be relieved by conventional valve repair or replacement. Furthermore, the left atrial-left ventricular conduit does not preclude future alternative surgical options.     

The feasibility of closed mitral valvotomy in pregnancy

Rheumatic mitral valve stenosis is an important nonobstetric complication of pregnancy in an African country. Between January 1965 and September 1985 41 closed mitral valvotomies with a Tubbs dilator were performed in 39 pregnant women (two first trimester, 22 second trimester, and 17 third trimester). All patients experienced symptomatic improvement from New York Heart Association Class 3.01 (average) preoperatively to 1.22 postoperatively. There were no deaths related to the operation and delivery. Fetal deaths were due to postoperative spontaneous abortion in two cases (4.9%) or premature labour in three cases (7.3%), for an overall survival of 36 babies (87.8%). Fetal morbidity was due to prematurity or dismaturity in three infants, all of whom survived. Thirty-three normal infants were delivered at term. Nine patients needed subsequent surgical procedures for mitral valve restenosis 5 to 17 years (mean 10.2 years) after the initial closed valvotomy: Repeat closed valvotomy was performed in three patients after 5, 8, and 10 years (the first two during subsequent pregnancies), an open procedure was performed in one after 6 years, and five patients underwent subsequent mitral valve replacement after 11 (two), 12 (two), and 17 (one) years. Two late deaths occurred; one after 10 years, as a result of pneumonia and meningitis, and the other after 12 years, before a mitral valve replacement for restenosis could be performed. None of the remaining patients has required further surgical procedures, but two have moderate symptoms. Closed mitral valvotomy gives satisfactory results in pregnant patients with severe mitral stenosis. When indicated during pregnancy, it should be performed at any stage of the pregnancy.     

Thrombosed Bj?rk-Shiley standard disc mitral valve prosthesis

Between April 1980 and June 1986, 274 patients underwent mitral valve replacement (MVR) with the Bj?rk-Shiley (BS) standard disc mitral valve prosthesis at the American University of Beirut Medical Center (AUBMC). Eleven patients (3.9%) presented 6-41 months after surgery with prosthetic valve dysfunction due to thrombosis. Inadequate control of anticoagulation was the major factor predisposing to thrombosis in all except one. All patients had documented rheumatic valvular disease. Nine patients were operated on an emergency basis and two died before any surgical intervention was possible. Thrombectomy was performed on six patients with four survivors and MVR in three with two survivors. Two patients died intraoperatively (22%). Three pregnant patients underwent mechanical declotting; pregnancy was terminated by abortion in 2 and by caesarean section and live birth in one. We conclude that implantation of the BS mitral valve prosthesis mandates emphasis on anticoagulation and the difficulty encountered with continuous anticoagulant therapy in pregnancy.     

Concomitant mitral valve repair and left ventricular reconstruction in a patient with chronic ischemic mitral regurgitation and inferior left ventricular aneurysm

The surgical approach to ischemic mitral regurgitation with concomitant inferior left ventricular aneurysm remains uncertain in terms of the indication for operation and the short-and long-term outcomes. We performed concomitant mitral valve repair, left ventricular reconstruction, and aortic valve replacement on a 71-year-old male with severe ischemic mitral regurgitation, inferior left ventricular aneurysm, and degenerative aortic regurgitation. Postoperative status was in New York Heart Association functional class I without mitral regurgitation 8 months after operation. We discuss, and review the procedures reported in the literature.     

Surgical repair of double-orifice of the mitral valve in cases with an atrioventricular canal defects

OBJECTIVE: A Double-orifice in the mitral valve is an uncommon congenital cardiac lesion which occurs as an isolated anomaly or in association with other cardiac malformation. This report deals with our surgical experience of a double-orifice of the mitral valve in cases with an atrioventricular canal defect. PATIENTS AND METHODS: From 1991 through 1999, ten patients were diagnosed to have a double-orifice of the mitral valve at Shizuoka Children's Hospital. Each patient had associated major cardiac malformations, among which atrioventricular canal defect underwent surgical management, with five of these undergoing complete correction with or without previous pulmonary artery banding. Of these 10, the five cases were enrolled in this study. Two of these had a complete type, and the other three had a partial type. The cleft in the left-sided atrioventricular valve was closed partially in four and left untouched in one. Bridging tissue, when present, was left intact. There was no regurgitation from any accessory orifice and no repair for an accessory orifice was needed. RESULT: There was no late death and no replacement of the valve with prosthesis. During follow-up ranging from 1 to 4 years, none of the patients developed severe stenosis or progressive regurgitation in the left-sided atrioventricular valve. CONCLUSION: Meticulous surgical management of a double-orifice in the mitral valve in association with atrioventricular canal defect an achieve an acceptable midterm result without developing severe dysfunction in the left-sided atrioventricular valve.