Mitral valve repair in children with rheumatic heart disease

OBJECTIVE: The purpose of this study was to assess the long-term results of mitral valve repair in children with chronic rheumatic heart disease. METHODS: From January 1988 through December 2003, 278 children (153 male children) underwent mitral valve repair. Mean age was 11.7 +/- 2.9 years (range, 2-15 years). One hundred seventy-three children (62%) were in the New York Heart Association functional class III or IV. Congestive heart failure was present in 24 (8.6%). Reparative procedures included posterior collar annuloplasty (n = 242), commissurotomy (n = 187), cusp-level chordal shortening (n = 94), cusp thinning (n = 71), cleft suture (n = 65), and cusp excision or plication (n = 10). Associated procedures included atrial septal defect closure (n = 22), aortic valve repair/replacement (n = 13), and tricuspid valve repair (n = 3). RESULTS: Early mortality was 2.2% (6 patients). Preoperative left ventricular dysfunction was associated with greater mortality. Median follow-up was 56.5 months (mean, 58.9. +/- 32.3 months; range, 5 to 180 months). One hundred seventy-seven survivors (65%) had no or trivial mitral regurgitation. Sixteen patients (6%) required reoperation for valve dysfunction. There were 7 late deaths (2.6%). Actuarial, reoperation-free, and event-free survivals at a median follow-up of 56.5 months were 95.2% +/- 1.5%, 91.6% +/- 2.2%, and 55.9% +/- 3.5%, respectively; at 15 years, they were 95.2% +/- 1.5%, 85.9% +/- 5.9%, and 46.7% +/- 4.7%, respectively. CONCLUSION: Mitral valve repair in children with chronic rheumatic heart disease is feasible and provides acceptable long-term results.     

Ross procedure in rheumatic aortic valve disease.

OBJECTIVE: To assess the results of aortic valve replacement with the pulmonary autograft in patients with rheumatic heart disease. METHODS: From October 1993 through September 2003, 81 rheumatic patients with aortic valve disease, mean age 29.5+/-11.9 years (11-56 years) underwent, the Ross procedure with root replacement technique. Forty patients were 30 years of age or below (young rheumatics). Associated procedures included mitral valve repair (n=19), open mitral commissurotomy (n=15), tricuspid valve repair (n=2), and homograft mitral valve replacement (n=2). RESULTS: Early mortality was 7.4% (six patients). Mean follow-up was 92.3+/-40.9 months (7-132 months, median 109 months). Sixty of the 73 patients whose follow-up was available (82%) had no significant aortic regurgitation. Re-operation was required in seven (8.4%) patients for autograft dysfunction with failed mitral valve repair (n=3), autograft dysfunction alone (n=2) and failed mitral valve repair alone (n=2). No re-operations were required for the pulmonary homograft. There were six (7.5%) late deaths. Actuarial survival and re-operation-free survival at 109 months were 84.5+/-4.1% and 90.5+/-3.7%, respectively. Freedom from significant aortic stenosis or regurgitation was 78.4+/-5.2% and event-free survival was 64.6+/-5.8%. When compared to rheumatics above 30 years of age, the relative risk of autograft dysfunction was high in the young rheumatics. CONCLUSION: The Ross procedure is not suitable for young patients with rheumatic heart disease. However, it provides acceptable mid-term results in carefully selected older (>30 years) patients with isolated rheumatic aortic valve disease.     

Triple-valve treatment for prosthetic valve endocarditis occurring 20 years after implantation of a Carpentier-Edwards pericardial bioprosthesis in the aortic valve

A 68-year-old woman had undergone aortic valve replacement and open commissurotomy 20 years previously. At the beginning of 2008, fever, cold, and heart failure symptoms were noted. On blood culture, Streptococcus oralis was detected three times. Surgery was performed under a diagnoses of prosthetic valve endocarditis in the aortic valve, mitral stenosis and insufficiency, and tricuspid insufficiency. Techniques consisted of additional aortic valve replacement, mitral valve replacement, and tricuspid annuloplasty. Vegetation was macroscopically and pathologically observed in the extirpated Carpentier-Edwards pericardial bioprosthesis that had been placed in the aortic valve. There was no postoperative recurrent inflammatory response. The patient was discharged 32 days after surgery.     

Reoperations in valvular heart disease

Background Reoperations for valvular heart disease are associated with a higher overall mortality than the primary operations. In this retrospective analysis, we present our experience of reoperative valvular heart surgery over a period of 25 years. Methods From January 1975 to July 2000, 13039 operations were performed for valvular heart disease. Of these 665 were reoperations. The mean age of the patients at the primary operation was 24.0±10.2 years (range: 8 to 65 years) and at re-operation was 35.6±11.6 years (range: 9 to 65 years) with an interval of 9.4±2.2 years (range: 0.2 to 25 years) between the 2 procedures. Four hundred and forty reoperations were performed following a previous closed mitral valvotomy and procedures included, redo closed mitral valvotomy (n=28), mitral valve replacement (n=30), open mitral commissurotomy (n=51), mitral valve repair (n=9), homograft mitral valve replacement (n=2), double valve replacement (n=47), aortic valve replacement (n=2) and homograft aortic valve replacement plus open mitral commissurotomy (n=l). Eighty six patients underwent reoperations following mitral valve replacement. Valve thrombosis (n=50) and endocarditis (n=10) were principle causes of reoperation. Forty three patients required reoperation following failed mitral valve repair, 19 following open mitral commissurotomy and 8 following homograft mitral valve replacement. Sixty five patients underwent reoperation following aortic valve operations: prosthetic aortic valve replacement in 43, homograft aortic valve replacement in 5, aortic valve repair in 10, and Ross procedure in 7. Results Majority of patients were operated through midsternotomy. Aortic cannulation was possible in all but 4 patients in whom femoral artery cannulation was required. Operative mortality following reoperations was 7.5% (n=50). Peri-operative bleeding, low cardiac output and infective endocarditis were major causes of operative deaths. Other post-operative complications included cerebrovascular accident (n=3), acute renal failure (n=10) and jaundice (n=25). Fifteen patients developed significant wound infection. Conclusions Patients undergoing operation for valvular heart disease frequently require reoperation. Reoperative valvular heart surgery is safe and can be undertaken with acceptable mortality and morbidity.     

Open mitral commissurotomy in the current era: indications,technique, and results

BACKGROUND: The present retrospective study is focused on indications, techniques, and results of open mitral commisurotomy in the current era. METHODS: Of the 1,280 patients undergoing open-heart surgical procedures for rheumatic mitral stenosis between January 1990 and July 2000, 276 (21.6%) patients underwent open mitral commissurotomy. Major indications included presence of left atrial thrombus/clot (n = 82, 29.7%), severe subvalvular disease (n = 110, 39.8%), mitral valve calcification (n = 42, 15.2%), mild mitral regurgitation (n = 28, 10.0%), associated aortic valve disease (n = 55, 19.9%), organic tricuspid valve disease (n = 20, 7.2%), and failure or restenosis after closed or balloon mitral valvuloplasty (n = 55, 19.9%). Age of patients ranged from 7 to 67 years (mean, 30.2 +/- 12 years). The majority (76%) were in New York Heart Association class III or IV, and 6.9% were in congestive heart failure. Atrial fibrillation was present in 134 (48.6%) patients. Mitral valve area ranged from 0.3 to 0.7 cm2 (mean, 0.52 +/- 0.12 cm2). Mid-diastolic gradients across the mitral valve ranged from 8 to 34 mm Hg (mean, 14.5 +/- 6.2 mm Hg), and end-diastolic gradients ranged from 8 to 42 mm Hg (mean, 15.2 +/- 5.7 mm Hg). Open mitral commissurotomy was performed using standard cardiopulmonary bypass. Associated aortic valve procedure was performed in 55 patients, and either tricuspid valvotomy or repair was performed in 28 patients. RESULTS: There were four early deaths. All these patients had associated aortic valve procedure (Ross procedure in 2 and homograft aortic valve replacement in 2). Three patients developed severe mitral regurgitation in early postoperative period (< or = 30 days) and required reoperation. Predischarge echocardiography showed mitral valve area from 1.4 to 3.5 cm2 (mean, 2.6 +/- 0.6cm2) and moderate mitral regurgitation in 4 patients. Follow-up ranged from 1 to 130 months (mean, 64.5 +/- 28.6 months). There was no late death. There were three reoperations for mitral valve failure, and an additional 2 patients developed severe mitral stenosis (mitral valve area < 1.0 cm2). In operative survivors, freedom from mitral valve failure at 10 years was 87.0% +/- 3.5%. In patients with isolated open mitral commissurotomy, the incidence of thromboembolism was 0.5%/patient-year. CONCLUSIONS: Open mitral commissurotomy provides excellent early and long-term results in a selected group of patients.     

Closed mitral commissurotomy following pericardial strip posterior mitral annuloplasty.

We report a case of rheumatic multivalvular heart disease for whom closed mitral commissurotomy (CMC) was done four years after pericardial strip posterior mitral annuloplasty and aortic valve replacement (AVR). An 18-year-old male who presented initially with rheumatic mitral regurgitation and aortic regurgitation was treated with AVR and pericardial strip posterior mitral annuloplasty in 1997. One year postoperatively he presented with moderate to severe mitral regurgitation. On further follow-up, the patient developed mitral stenosis and as a redo procedure, CMC has been successfully done for the same.     

Reconstructive Techniques for Rheumatic Aortic Valve Disease

Aortic valve reconstruction is still at an early stage of development. We report techniques that can be applied in the repair of rheumatic aortic valve disease in patients with concomitant mitral valve disease. The techniques described are: (1) commissurotomy, (2) cusp free edge unfolding, (3) annuloplasty, and (4) supraaortic crest enlargement. Fifty patients operated on between January 1974 and January 1986 with a hospital mortality of 6% were followed for a mean period of 7.7 years. Reoperation due to failure of mitral surgery was required in twelve patients, tricuspid regurgitation in two, and significant aortic regurgitation in four. These techniques, although applicable to a limited number of patients, have enabled us to avoid the problems of aortic valve replacement in many patients.     

Valve reconstruction in the Heart Institute of São Paulo,Brazil

In the Heart Institute of University of S?o Paulo Medical School, between 1980 and 2000, were performed 712 mitral valve repair procedures, 39 aortic valve repairs and 469 tricuspid valve repairs. In our experience with mitral valve repair, the most performed techniques were quadrangular resection of the posterior leaflet, posterior annuloplasty with bovine pericardial sling and Carpentier ring annuloplasty. Quadrangular resection of the posterior leaflet is the technique of choice in mitral regurgitation due to degenerative disease, and repair is possible in 90% of the cases. Since 1994, we perform the quadrangular resection without ring annuloplasty, a modification in the technique called "Double Teflon" technique, with good results. Aortic valve repair is performed in specific situations. In congenital aortic insufficiency, we perform the suspention of the prolapsed leaflets in the comissures. In rheumatic aortic insufficiency, when we found leaflet retraction, we elongate the leaflets with bovine pericardial patchs. Our experience of aortic valve repair, between 1980 and 2000, consists of a small group of 39 patients. The results are satisfactory, but these techniques are feasible only in selected cases. Tricuspid insufficiency is generally a consequence of annular enlargement in patients with mitral valve disease and we prefer the De Vega annuloplasty in these cases. In cases with large annulus dilatation, we prefer to use the "Revuelta" or the "bicuspidization" techniques. In patients with previous tricuspid repair and annulus distortion, we prefer to use bovine pericardial sling or Carpentier ring annuloplasty.     

Triple valve repair for rheumatic heart disease

The onset of the clinical expression of rheumatic heart disease (RHD) is variable. Exercise or other states that necessitate increased cardiac output often precipitate symptoms. Mitral stenosis (MS) is present in 25% of patients with RHD, and 40% of patients have concomitant MS and mitral regurgitation. About two third of patients with MS have concurrent aortic insufficiency. Pulmonary and tricuspid insufficiency may occur from rheumatic involvement of these valves, or secondary to dilatation of valve annuli from pulmonary hypertension secondary to mitral and/or aortic valve disease. Pregnancy is associated with many hemodynamic changes including expanded intravascular volume, tachycardia, increased intracardiac dimensions, and valvular regurgitation. We report a case of a young female who developed flash pulmonary edema during parturition and was found to have abnormal rheumatic involvement of her aortic, mitral, and tricuspid valves. Successful triple valve repair was performed in a single operation. A review of rheumatic valvular abnormalities, and literature supporting multivalvular repair for rheumatic heart disease is provided.     

Long-term results of conservative repair of rheumatic aortic valve insufficiency

From July 1974 to January 1986, 50 patients underwent conservative repair for rheumatic aortic valvular disease at our institution. Eleven were male and 39 female, with an average age of 39.5 years (range 17-57). The aortic lesion was associated in all cases with a predominant mitral lesion. Twenty-five also had tricuspid disease which was surgically treated in 17. Twenty-six had aortic regurgitation and 24, a mixed lesion. The surgical techniques used were: (1) commissurotomy, (2) annuloplasty, (3) cusp free edge unfolding and (4) supra-aortic crest enhancement. Two patients had one cusp extended with pericardium. There were 3 hospital deaths (6%). Six patients were lost to follow-up at different periods. Maximum follow-up was 12.58 years with a mean of 7.78 years per patient. Twelve required reoperation with 3 deaths. Three reoperations were due to failure of the mitral bioprosthesis without reoperation on the aortic valve. Of the remaining 9 patients who had aortic and mitral dysfunction, 4 had severe aortic insufficiency. The actuarial freedom from reoperation at 13 years was 75% and the overall actuarial survival was 86%. It is concluded that these surgical techniques can be applied successfully in moderate rheumatic aortic valve disease accompanying a predominant mitral lesion. This is particularly relevant when a mitral reconstruction has been performed.     

Complex aortic valve repair as a durable and effective alternative to valve replacement in children with aortic valve disease

OBJECTIVE: This study was undertaken to determine the utility of aortic valve repair in children. METHODS: A retrospective analysis was conducted on aortic valve surgery from 1973 to 2004 at Children's Hospital of Wisconsin. RESULTS: Procedures were classified as simple repairs (blunt valvotomy, commissurotomy with or without thinning, n = 147), repair of aortic insufficiency with ventricular septal defect (n = 22), complex repairs (any combination of additional procedures including suspension of prolapsed leaflets, leaflet extensions, repair of torn or perforated leaflets, annuloplasty, reduction of sinus of Valsalva plasty, and concomitant repair of supravalvular or subvalvular stenosis, n = 57), and replacements (n = 57, 20 mechanical, 2 porcine, and 35 human valves). Freedoms from reintervention for simple repairs and repair of aortic insufficiency with ventricular septal defect at 10 years were 86% +/- 5% and 93.3% +/- 6%, respectively. For complex valve repair, freedoms from reintervention at 1, 5, and 10 years were 94% +/- 3%, 85% +/- 6%, and 44% +/- 15%, versus 96% +/- 3%, 77% +/- 9%, and 77% +/- 9% for valve replacement ( P = .3). At intermediate follow-up, patients with complex valve repair had a residual gradient of 20 +/- 21 mm Hg, and 94% were free of severe aortic insufficiency. Residual aortic stenosis ( P < .05) but not the preoperative diagnosis of combined aortic stenosis and insufficiency predicted the need for reintervention. CONCLUSION: Freedom from reintervention after complex valve repairs was not different from that after valve replacement, with acceptable residual aortic stenosis and insufficiency. Simple repairs and repair of aortic insufficiency with ventricular septal defect yielded excellent long-term freedom from reintervention.     

Valve extension with glutaraldehyde-preserved autologous pericardium. Results in mitral valve repair

Preliminary experimental studies in our laboratory have shown that autologous pericardium treated with glutaraldehyde prevents late deterioration and calcification of the tissue. For this reason, glutaraldehyde-treated autologous pericardium has been used in a series of 64 patients who underwent operations for leaflet extension of the mitral valve between 1980 and 1989. Ages ranged from 2.5 to 60 years (mean 19 +/- 15). The causes of mitral valve insufficiency were rheumatic fever (69%), bacterial endocarditis (17%), congenital (8%), endomyocardial fibrosis (4.5%), and trauma (1.5%). The autologous tissue was fixed in a 0.62% glutaraldehyde solution for 15 minutes and rinsed in saline for an additional 15 minutes. Patching techniques varied depending on the site and the extent of the lesion. Associated mitral valve repair techniques (Carpentier's techniques) were mandatory in all patients. The period of follow-up extended from 6 months to 9 years (mean 3.1 +/- 2.5 years). There were no operative deaths in this series, and there was one late death (2%). In the six patients (12%) who underwent reoperation, there has been no case of calcification of the pericardial patch. Postoperative mitral valve function was assessed by bidimensional color Doppler echocardiographic techniques. Mitral valve insufficiency was trivial or absent in 80% of the patients. This experience permits us to conclude that leaflet extension is a simple and safe technique in valve reconstruction, allowing repair of mitral valves that otherwise would need to be replaced. It permits use of an adult-size prosthetic ring in children. Glutaraldehyde-treated autologous pericardium is the material of choice for this type of repair.     

Outcomes of aortic valve repair according to valve morphology and surgical techniques

OBJECTIVES The aim of this study was to assess the impact of aortic valve morphology and different surgical aortic valve repair techniques on long-term clinical outcomes. METHODS Between February 2003 and May 2010, 216 patients with aortic insufficiency underwent aortic valve repair in our institution. Ages ranged between 26 and 82 years (mean 53?±?15 years). Aortic valve dysfunctions, according to functional classification, were: type I in 55 patients (25.5%), type II in 126 (58.3%) and type III in 35 (16.2%). Sixty-six patients (27.7%) had a bicuspid valve. Aortic valve repair techniques included sub-commissural plasty in 138 patients, plication in 84, free-edge reinforcement in 80, resection of raphe plus re-suturing in 40 and the chordae technique in 52. Concomitant surgical procedures were CABG in 22 (10%) patients, mitral valve repair in 12 (5.5%), aortic valve-sparing re-implantation in 78 (36%) and ascending aorta replacement in 69 (32%). Mean follow-up was 42?±?16 months and was 100% complete. RESULTS There were six early deaths (2.7%). Overall late survival was 91.5% (18 late deaths). There were 15 (6.9%) late cardiac-related deaths. NYHA functional class was ≤II in all patients. At follow-up, 28 (14.5%) patients had recurrent aortic insufficiency?≥?grade II. The freedom from valve-related events was significantly different between bicuspid and tricuspid valve implantation (P?相似文献   

Long-term results with triple valve surgery

BACKGROUND: Whether to use biological or mechanical prostheses and whether to repair or replace the tricuspid valve during primary and reoperative triple valve surgery remains controversial. The objective of the present study was to review our experience with primary and reoperative triple valve surgery using CarboMedics (CM) and Carpentier-Edwards (C-E) heart valves. METHODS: All 73 patients undergoing triple valve surgery since 1982 were prospectively followed at the Montreal Heart Institute valve clinic. Aortic valve replacement was performed with CM prostheses (57 patients) and with C-E prostheses (16 patients). Mitral valve replacement was performed with mechanical prostheses (56 patients) and with biological valves (14 patients). Mitral valve repair was done in 3 patients. Tricuspid valve annuloplasty or commissurotomy or both were performed in 66 patients and the tricuspid valve was replaced in 7 patients. Patient survival, complications, and the type of valve procedures were analyzed. RESULTS: Thirty patients averaging 62+/-10 years of age underwent primary triple valve surgery and 43 patients averaging 60+/-10 years of age underwent reoperative triple valve surgery (p = 0.5). Tricuspid repair consisted of annuloplasty with the Bex linear reducer (n = 47), the C-E ring (n = 13), or the De Vega technique (n = 5). Tricuspid valve replacement was done using the C-E pericardial prostheses. The 30-day mortality was 17% and 12% in patients with primary and reoperative surgery, respectively (p = 0.5) and patient survival averaged 80%+/-7%, 75%+/-8%, and 41%+/-15%, and 70%+/-7%, 57%+/-9%, and 50%+/-10%, respectively 1, 5, and 10 years following surgery (p = 0.5). The freedom rate from thromboembolism and from bleeding complications were 87%+/-6% and 95%+/-3% in primary and reoperative patients, respectively, 5 years following surgery. CONCLUSIONS: Triple valve surgery, either as a primary or a reoperative procedure, results in acceptable long-term survival with both mechanical and biological prostheses.     

Tricuspid annuloplasty: A modified technique

Fifty patients with rheumatic multivalvular disease underwent a modified form of semicircular tricuspid annuloplasty for acquired tricuspid insufficiency along with mitral or mitral and aortic valve procedures. The modification allowed simulataneous tying of annuloplasty sutures and digital assessment of the tricuspid regurgitation on unsupported normothermic beating heart. Early postoperative assessment showed 8 (17.3%) patients with no regurgitation, 36 (78.2%) with trivials to mild regurgitation and 2 (4.3%) with moderate regurgitation. There were 4 (8%) early deaths not related to the tricuspid lesion. Over a follow-up period of 6–84 (mean 38) months with around 70 per cent compliance, only three patients showed progression of tricuspid regurgitation. In all other patients the tricuspid regurgitation remained controlled. The study suggests that the modified annuloplasty technique used is an efficient way to achieve predictable annuloplasty results.     

Carpentier's flexible ring versus De Vega's annuloplasty. A prospective randomized study

To compare the efficacy of Carpentier's tricuspid annuloplasty with De Vega's, we prospectively randomized 159 patients, operated upon between January, 1977, and January, 1980, to one of the two techniques: 76 patients were assigned to the Carpentier group and 83 to the De Vega group. The criterion for inclusion in the study was the presence of moderate to severe tricuspid regurgitation. There were no significant differences in mean age, male proportion, type of mitral lesion, incidence of aortic valvulopathy, and other preoperative and perioperative characteristics between the two groups. However, organic tricuspid damage on macroscopic intraoperative examination was more common in the Carpentier group. At the end of follow-up (average 64 months) in patients with satisfactory left heart hemodynamics, there was a significant difference in the incidence of moderate or severe tricuspid insufficiency between the two groups (De Vega, 14/41; Carpentier, 4/40; p less than 0.01). In 76 patients (40 with Carpentier's annuloplasty and 36 with De Vega's technique), contrast right ventriculography was performed postoperatively and the degree of tricuspid regurgitation assessed semiquantitatively. In both groups, control of tricuspid regurgitation was poor in patients with either high total pulmonary resistances or organic tricuspid damage. If patients with these characteristics are excluded, then significant tricuspid regurgitation was encountered in only one patient in the Carpentier group but in nine of 19 in the De Vega group (p less than 0.01). In conclusion, in the treatment of tricuspid regurgitation, better results are obtained with Carpentier's than with De Vega's annuloplasty, especially if there is no organic tricuspid damage and pulmonary resistances decrease postoperatively.     

Intraoperative transesophageal echocardiography for the evaluation of mitral, aortic and tricuspid valve repair A tool to optimize surgical outcome

The present study reviews the clinical applicability and usefulness of intraoperative transesophageal echocardiography (TEE) during valve repair. Intraoperative TEE was performed in 48 consecutive patients, who were divided into three groups: 1. mitral valve repair (MVR), 2. aortic valve repair (AVR), 3. tricuspid valve repair (TVR). Residual valve regurgitation was assessed by color Doppler echocardiography on a scale from 0 to 4. The ratios of the jet area (JA) to the left- and right-atrial areas (JA/LAA and JA/RAA) were analyzed before and after cardiopulmonary bypass (CPB). In group 1, 14 patients were scheduled for MVR, of which 4 patients underwent valve replacement and 10 MVR. Post-repair TEE studies showed a significant decrease of mitral regurgitation. In 2 of the 10 patients, TEE demonstrated severe residual regurgitation requiring valve replacement during the same thoracotomy. In group 2, 11 patients underwent aortic commissurotomy. Post-repair TEE showed an increase in the systolic opening diameter and opening area of the aortic valve. One patient underwent valve substitution because of severe aortic regurgitation. In group 3, 23 patients were scheduled for TVR. In 3 of them TEE showed no significant regurgitation thus rendering tricuspid valve surgery unnecessary. Twenty patients underwent TVR of whom two showed unacceptable post-repair regurgitation requiring further surgery. Eighteen patients showed a significant reduction of valve regurgitation after TVR, and a further reduction was achieved by adjusting the tricuspid annuloplasty under TEE guidance.     

继发性三尖瓣关闭不全的外科治疗进展

继发于左心系统瓣膜病变的三尖瓣关闭不全,多为三尖瓣瓣环扩大导致的功能性三尖瓣关闭不全,也有少数患者同时合并三尖瓣风湿性等器质性改变。对三尖瓣反流的处理,目前主张如果能通过瓣膜成形方法恢复三尖瓣瓣膜功能,应尽量行三尖瓣成形手术。三尖瓣成形方法主要包括线性成形和人工瓣环成形技术,但目前各种手术成形方法的适应证选择和临床应用尚无统一的标准,多年来一直是困扰心脏外科医师的难题和研究热点,是否需要同期行三尖瓣成形术,采用什么成形方法才能达到最佳的三尖瓣成形效果。因此,对继发性三尖瓣关闭不全患者三尖瓣病变程度的判定、矫治标准及手术方法等进行综述。     

Heart valve replacement in children

Twenty children with heart valve disease were operated upon and underwent heart valve replacement between 1965 and 1968. Thirteen were girls and seven boys. At the time of operation their ages ranged from 3 to 16 years. All the patients were in classes III or IV prior to operation. Three children suffered from congenital valvular lesions and 17 from rheumatic lesions. In each patient left and/or right heart catheterization and angiographic studies were performed. Six patients underwent aortic valve replacement, 11 mitral, 1 tricuspid, and 2 double valve replacement. Mitral annuloplasty was performed in addition to aortic valve replacement in two patients, and tricuspid annuloplasty in addition to mitral valve replacement in another patient. In 19 patients a prosthetic valve was used and in one an aortic heterograft (pig). Two patients died in the early postoperative period (10%), and two later, two and nine months after surgery (10%). Postoperative thromboembolism occurred in four patients (20%). All have completely recovered. All the surviving 16 patients have been followed for a period of one to four and a half years and all showed significant clinical improvement; all children of school age have returned to school and/or other normal actitivies. The overall result has been encouraging and might justify a more aggressive approach in the management of valvular diseases in this specific group of patients.     

Outcomes of tricuspid annuloplasty with and without prosthetic rings: a retrospective follow-up study

Background

The efficacies of tricuspid valve repair, risk factors for treatment failure and postoperative quality of life have not been thoroughly evaluated in patients with tricuspid insufficiency associated with rheumatic heart disease (RHD). We therefore reviewed our experience with ring and non-ring tricuspid annuloplasty for the treatment of functional tricuspid insufficiency (TI) in RHD.

Methods

This retrospective, follow-up study involved 74 RHD patients who underwent either non-ring annuloplasty (De Vega procedure; 34 patients, 45.95 %) or ring annuloplasty (40 patients, 54.05 %) along with concurrent mitral or/and aortic valve replacement. Operation time, cardiopulmonary bypass time, aortic clamping time, intensive care unit stay and extubation time were recorded. Echocardiographic findings and Short Form (SF)-36 scores were compared between the two groups.

Results

In hospital mortality and complications were similar in the two study groups (P?=?0.6755). At 1 week, 1 month, 6 months, 1 year, 2 years and even longer after the operation, the Kaplan–Meier curve of freedom from mild and above recurrent TI showed significantly better efficacy in the ring annuloplasty group than the De Vega procedure group (log rank P?=?0.0377). Risk factors for recurrent TI included high pulmonary artery systolic pressure (PASP) and non-ring annuloplasty (PASP: hazard ratio?=?1.52; non-ring: hazard ratio = 1.42). The mental component summary score at 1 year after the operation did not significantly differ between the two groups (P?=?0.6446), but the physical component summary score was significantly better in the ring annuloplasty group (P?=?0.0037).

Conclusion

Compared with non-ring annuloplasty, ring annuloplasty was associated with improved survival, decreased TI recurrence and higher quality of life in RHD patients undergoing tricuspid valve repair combined with mitral and/or aortic valve replacement.