Minimally invasive mitral valve surgery

BACKGROUND: To reduce surgical trauma and the drawbacks associated with sternotomy, we performed robotically controlled, video-assisted mitral valve surgery, using either the port-access or the transthoracic clamp technique. METHODS AND RESULTS: Between September 1997 and September 2000, 221 patients (78 males, 143 females) underwent mitral valve surgery through a small right minithoracotomy using the port-access endovascular cardiopulmonary bypass system. Mitral valve exposure was facilitated with an endoscope attached to a voice-controlled robotic arm (AESOP 3000) allowing stabilization and voice-activated camera positioning. Twenty-six patients underwent mitral valve repair and 195 had valve replacement. In 197 patients, mitral valve surgery was the primary operation, while 24 were redo cases. Skin-to-skin mean operating time was 3.5 +/- 1.2 hours and aortic cross-clamp time was 58 +/- 16 min, mean intensive care unit stay was 22 +/- 7 hours and hospital stay 6.4 +/- 1.2 days. There was no re-exploration for bleeding. There was no late death or re-operation on mean follow-up of 16.4 +/- 12.2 months. Patients showed improvement in their NYHA functional class from 2.6 +/- 0.5 to 1.4 +/- 0.8 postoperatively. Outcomes were compared with those of our previous 220 patients who underwent mitral valve surgery with the median sternotomy approach. CONCLUSIONS: The use of video and robotic assistance in port-access mitral valve surgery not only minimizes the length of the incision, but also gives full visualization of the entire mitral valve apparatus. This approach provides comparable results with the sternotomy approach, as well as marked advantages of reduced intensive care unit stay. ,ower blood transfusion requirement, better cosmesis and earlier hospital discharge.     

Robotically controlled video-assisted port-access mitral valve surgery

From 1997 to 2000, 221 patients underwent mitral valve surgery through a mini-thoracotomy, using a port-access endovascular cardiopulmonary bypass system in 38 and a transthoracic clamp in 183. In 120 patients, exposure of the mitral valve was facilitated by an endoscope attached to a voice-controlled robotic arm (AESOP 3000). The mitral valve was repaired in 26 patients and replaced in 195; 24 were redo cases. Operating time was 3.5 +/- 1.2 hours, aortic crossclamp time was 58 +/- 16 minutes, intensive care unit stay was 22 +/- 7 hours, and hospital stay was 6.4 +/- 1.2 days. Median postoperative blood loss was 332 +/- 104 mL. There was 1 hospital death. On follow-up at 16.4 +/- 12.2 months, there was no late death or reoperation. New York Heart Association functional class improved from 2.6 +/- 0.5 to 1.4 +/- 0.8. Use of video and robotic assistance minimized incision length and allowed visualization of the whole mitral valve apparatus. The transthoracic clamp facilitated aortic crossclamping and injection of cardioplegia. These findings indicate that the procedure is safe and effective and suggest advantages over conventional surgery in terms of cost, cosmesis, blood loss, postoperative discomfort, intensive care unit and hospital stay.     

Results of video-assisted mitral surgery in a non-selected population

A prospective 'analysis of operative risk and results in video-assisted mitral valve surgery performed in a non selected population is reported. Seventy two consecutive patients (1997-2004) with mean age 60 +/- 12 years underwent a video-assisted mitral valve procedure using a femoral CPB. A transthoracic direct aortic clamping was done in 28 patients (TT) and an endo-aortic occlusion balloon was used in 44 patients (Endo). The surgical approach was a right lateral minithoracotomy in all cases; 16 patients had a previous cardiac surgery. The expected mitral operation (39 repairs, 33 replacements) was done in all cases, without conversion. There were 4 early deaths (1 st month), all in Endo group: 1 aortic dissection, 1 heart failure and 2 sudden deaths. Postoperative complication occurred in 17 patients with 5 reoperations for hemostasis of the thoracic wall. Cumulative rate of mortality and morbidity was 29% in Endo and 28% in TT (ns). Hospital stay was 8 +/- 2 days. At discharge, 4 patients had a residual grade 2 echocardiographic mitral regurgitation after valve repair. In January 2005, with a 1.8 years follow-up, there were 4 late deaths, 3 patients underwent a valve reoperation, 2 patients were still in NYHA class 3 and 5 patients had a residual grade 1 or 2 mitral regurgitation. The 3-year actuarial survival was 86 +/- 10% and the 3-year probability to be free of reoperation was 95 +/- 6%. In mitral valve surgery, video-assisted approach is reliable, the operative risk is controlled and midterm results are not compromised. Video-assisted mitral valve surgery is a new less invasive standard; it is the procedure of choice in valve replacement, in reoperation and in non complex valve repair with good cosmetic results.     

Port-access approach for cardiac surgical procedures: our experience in 776 patients

BACKGROUND: Recent advances in minimally invasive technology has expanded the application of the right thoracotomy approach for mitral valve surgery and atrial septal defect closure. The present study examines the feasibility, safety and efficacy of this technique. METHODS AND RESULTS: Between September 1997 and December 2004, 430 patients underwent mitral valve surgery through right anterolateral thoracotomy. The mitral valve was repaired in 62 patients, and 368 patients underwent mitral valve replacement. During same period, 336 patients underwent surgical closure of atrial septal defect. In all cases femoral artery and femoral venous cannulation was used for cardiopulmonary bypass. There was no approach-related limitation to surgical exposure, nor complication in cannulation of femoral vessels through the groin. Mean duration of cardiopulmonary bypass and cross-clamp time was 90 +/- 48 min and 51 +/- 29 min, respectively. Mean intubation time was 14.8 hours (range: 8-28 hours). Mean duration of intensive care andhospital stay was 26 hours (range: 18-38 hours) and 7 days (range: 5-17 days), respectively. In the atrial septal defect group, the mean cardiopulmonary bypass time and aortic cross-clamp time was 29 +/- 14 min and 19 +/- 8 min, respectively. Mean intensive care unit stay and mean hospital stay was 9.8 +/- 2.6 hours and 4.0 +/- 1.9 days, respectively. Hospital mortality was 0.46% (2/430) in the mitral valve group while there was no hospital mortality in atrial septal defect group. At a mean follow-up of 38.0 +/- 6.2 months there was one late death and two re-operations in the patients who underwent mitral valve surgery. CONCLUSIONS: Port-access approach is safe, offers faster recovery, cosmetic advantage, more patient satisfaction: it obviates the complications due to re-entry in redo cases and offers same efficacy as conventional operation. Furthermore, it is an excellent approach for mitral valve surgery in patients who had previous cardiac procedures. It has become our standard approach for repair of atrial septal defect and isolated mitral valve procedures.     

复发性心脏瓣膜病再次外科治疗效果及其相关因素

目的:回顾性分析对二尖瓣闭式扩张术、瓣膜成形术、瓣周漏、人工机械瓣功能障碍、生物瓣衰坏等原因引起的复发性瓣膜病变进行再次手术的效果和相关因素。方法: 复发性瓣膜病患者331（男143,女188）例,年龄12～73(46±12)岁,两次手术间隔时间2月～25(17±8)年。其中二尖瓣闭式扩张术后再狭窄143例,二尖瓣或主动脉瓣成形术后瓣膜病变复发53例,生物瓣衰坏32例,瓣周漏26例,换瓣术后其它瓣膜病21例,人工瓣膜替换或瓣膜成形术后心内膜炎17例, Ebstein畸形矫治术后三尖瓣关闭不全15例,人工瓣膜机械功能故障9例,室间隔缺损修补术并行瓣膜成形术后心内膜炎7例,完全或部分性心内膜垫缺损和矫正性大动脉转位术后二尖瓣或三尖瓣关闭不全6 例,二尖瓣球囊扩张术2例。再次手术方式为二尖瓣替换术,主动脉瓣替换术,二尖瓣和主动脉瓣替换术,三尖瓣替换术,瓣周漏修补术及三尖瓣成形术等。结果: 全组共死亡27例,占8.2％,早期主要死亡原因为低心排出量综合征、室性心律失常、多脏器功能衰竭、左心室破裂、感染性心内膜炎、肾功能衰竭。随访259例,随访期6月～21（10±7）年,心功能恢复至Ⅰ～Ⅱ级189例。复发性心脏瓣膜病再次手术的危险因素包括术前心功能差、重要脏器功能不全、急诊手术、主动脉阻断时间和体外循环时间长等。结论: 针对再手术相关的危险因素进行积极防治,适时而妥善的外科手术和围手术期处理仍可获良好效果。     

Aortic root replacement using an allograft for active infective endocarditis with periannular abscess: single center experience

OBJECTIVES: Results of aortic root replacement using an allograft for active infective endocarditis in the aortic position and periannular abscess were studied. METHODS: Aortic root replacement using a cryopreserved aortic allograft was performed 13 times in 12 patients (9 men, 3 women, mean age 52.8 years) at Saitama Medical School. Allografts were obtained from the Tokyo University Tissue Bank. Infection affected the prosthetic valve in 6 patients and the native valve in 7. Causative organisms were Staphylococci in 7 patients, Streptococci in 2, and unknown in 4. New York Heart Association functional class was II in 2 patients, III in 3, and IV in 8. Six patients required inotropic support. Four were mechanically ventilated. Two were in a state of profound shock. Four had multiple organ failure. Surgery was conducted under hypothermic cardiopulmonary bypass and cardioplegic arrest. Allograft was sewn into place by monofilament continuous sutures. Carrel patch technique was used for coronary artery reconstruction. Five patients underwent concomitant procedures (replacement of the ascending aorta in 2 patients, coronary artery bypass grafting in 1, mitral valve repair in 1, pulmonary artery reconstruction in 1). RESULTS: Duration of surgery, cardiopulmonary bypass, and aortic clamping were 507 +/- 154, 307 +/- 111, and 189 +/- 49 min, respectively. Two patients required intraaortic balloon pumping, and one required percutaneous cardiopulmonary support. Two patients in a state of shock died(hospital mortality: 15.4%). Duration of mechanical ventilation was 2.9 +/- 3.7 days. Intensive care unit stay was 4.6 +/- 5.5 days, and hospital stay was 61 +/- 26 days. One patient died of cancer 18 months later. One patient required reoperation 11 months later. Including operative death cases, cumulative survival at 2 years was 66.5% and freedom from cardiac events was 72.7%. CONCLUSIONS: Aortic root replacement with an allograft yielded acceptable clinical results.     

Is Posterior Leaflet Extension and Associated Commissurotomy: Effective in Rheumatic Mitral Valve Disease? Long-Term Outcome

In this prospective study, the long-term effect of posterior leaflet extension with glutaraldehyde-preserved autologous pericardium and associated mitral valve commissurotomy was investigated in patients with mixed mitral valve disease of rheumatic origin. Mitral commissurotomy and posterior leaflet extension using a pericardial patch were performed in 25 patients from 1 January 1994 through 31 December 1995 for mixed mitral valve disease. Preoperatively, no patient had chordal rupture or papillary muscle dysfunction. Four patients had left atrial thrombosis. The mean age was 35.7 +/- 15.4 years. Associated procedures were tricuspid annuloplasty in 4 patients, aortic annuloplasty in 3, aortic and tricuspid annuloplasty in 1, and aortic homograft replacement in 1. There were no early deaths. One patient died 2 years after surgery due to noncardiac causes. Mitral valve area increased from 1.53 +/- 0.63 cm2 to 2 +/- 0.33 cm2 (P = 0. 09), and left atrial diameter decreased from 5.8 +/- 1 cm to 4.86 +/- 1.27 cm (P = 0.07) after 6.1 +/- 0.7 years (range, 5.5 to 71 years). Mitral insufficiency was reduced significantly, from grade 2.65 +/- 0.9 to grade 1.2 +/- 0.9 (P = 0.007). Functional capacity improved in all patients (New York Heart Association functional class, 3 +/- 0.58 preoperatively vs 1.44 +/- 0.82 postoperatively; P = 0.001). Three patients required reoperation and valve replacement. This type of reconstruction may be a good alternative for patients who are not able to use anticoagulant therapy. Long-term results of this technique are acceptable; however, the risk of reoperation is an important disadvantage in these young patients.     

A prospective evaluation of the Bj?rk-Shiley, Hancock, and Carpentier-Edwards heart valve prostheses

From 1975 to 1979, 540 patients undergoing valve replacement were entered into a randomized trial and received either a Bj?rk-Shiley (273 patients) or a porcine heterograft prosthesis (initially a Hancock valve [107 patients] and later a Carpentier-Edwards prosthesis [160 patients]). Two hundred and sixty-two patients required mitral valve replacement, 210 required aortic valve replacement, 60 required mitral and aortic valve replacement, and eight also required associated tricuspid valve replacement (six mitral valve replacement; two mitral plus aortic valve replacement). Analysis of 34 preoperative and operative variables showed the treatment groups to be well randomized. In-hospital mortality was not significantly different among patients receiving the three prostheses for aortic valve replacement (7.6% overall) and mitral plus aortic valve replacement (10% overall), but there was a higher in-hospital mortality for patients undergoing mitral valve replacement with the Carpentier-Edwards prosthesis (15.5% compared with 8.8% overall; p = .03). This difference could not be explained on the basis of any preoperative or operative variable. Median follow-up was 5.6 (range 2.8 to 8.3) years. Actuarial survival after mitral valve replacement was 56.7 +/- 7.0% at 7 years, that after aortic valve replacement was 69.6 +/- 9.6% at 7 years, and that after mitral plus aortic valve replacement was 62.5 +/- 20.0% at 7 years. There was no significant difference in actuarial survival of patients receiving the three prostheses within the mitral, aortic, and mitral plus aortic valve replacement groups, nor was there a difference when these groups were amalgamated. Thirty-seven patients required reoperation for valve failure (15 with Bj?rk-Shiley, 12 with Hancock, and 10 with Carpentier-Edwards valves; p = NS) and 11 died at reoperation (four with Bj?rk-Shiley, four with Hancock, and three with Carpentier-Edwards valves; overall operative mortality 29.7%). Up to 7 years after surgery, there was no significant difference in the incidence of thromboembolism in patients with different prostheses undergoing mitral or aortic valve replacement. There were too few patients undergoing mitral plus aortic valve replacement for meaningful comparison. There was no significant beneficial effect of anticoagulants in patients undergoing mitral or aortic valve replacement with porcine prostheses, but patients were not randomly allocated to anticoagulant treatment. All patients with Bj?rk-Shiley prostheses received anticoagulants.(ABSTRACT TRUNCATED AT 400 WORDS)     

Up to nine-years' experience with the Allcarbon prosthetic heart valve

BACKGROUND AND AIM OF THE STUDY: The Allcarbon tilting disc valve has been used for valve replacement at the present authors' institution since 1993. Herein is reported their experience with Allcarbon valve implantation. METHODS: Between March 1993 and December 1998, Allcarbon valves were implanted in 599 patients (341 males, 258 females; mean age 36.2 years; range: 7-64 years). Among patients, 238 underwent mitral valve replacement (MVR), 217 aortic valve replacement (AVR), and 144 double valve replacement (DVR). The etiology of valve disease was rheumatic in 91% of cases. Follow up was 95.7% complete; cumulative follow up was 3,185 patient-years. RESULTS: Operative mortality was 2.2% (13/599). Actuarial survival at eight years was 96.6 +/- 1.2% after MVR, 96.1 +/- 1.3% after AVR, and 97.9 +/- 1.2% after DVR. Freedom from valve thrombosis at eight years was 97.0 +/- 1.3% after MVR, 100% after AVR, and 90.0 +/- 9.5% after DVR. Freedom from major bleeding at eight years was 90.0 +/- 2.7% after MVR, 93.5 +/- 2.6% after AVR, and 79.7 +/- 7.6% after DVR. There was one embolic episode after MVR. No structural valve failure was observed. Freedom from reoperation on implanted valves at eight years was 96.1 +/- 1.4% after MVR, 97.9 +/- 1.0% after AVR, and 97.9 +/- 1.5% after DVR. On completion of follow up, 91.3% of survivors were in NYHA class I, 8.5% in class II, and 0.2% in class III. CONCLUSION: Among a population of mostly young patients with rheumatic valve disease, the Allcarbon valve showed satisfactory clinical performance when implanted in the mitral and aortic positions.     

Six year clinical study of use of the Omniscience valve prosthesis in 219 patients

A 6 year experience of cardiac valve replacement with the Omniscience prosthesis is described. A total of 253 valves were inserted in 219 patients. The survivors were followed up for a total of 536 patient-years and for a mean of 2.8 years. The follow-up was 97.6% complete. Analyses were performed in accordance with recommended criteria regarding definitions of complications and grading thromboembolic events for severity and analysis of anticoagulant status. Results are described both in terms of actuarial and linearized rates. For the patients at risk, actuarial survival at the end of 5 years was 87.9 +/- 3.1% overall, 90.4 +/- 3.0% for single valve (aortic 88 +/- 5%, mitral 93.3 +/- 4%) replacement and 71 +/- 11% for multiple valve replacement. The actuarial rates of freedom from complications were as follows: endocarditis 95.7 +/- 1.8% (aortic 94 +/- 3.5%, mitral 100%), periprosthetic leak 98 +/- 1% (aortic 96.2 +/- 2.6%, mitral 100%), thromboembolism 95.2 +/- 2.3% (aortic 90.9 +/- 4.6%, mitral 96.7 +/- 3.3%), valve thrombosis 98.7 +/- 0.9% (aortic 100%, mitral 100%), anticoagulant-induced bleeding 90.3 +/- 2.6% and all valve-related complications 79.4 +/- 3.6% (aortic 78.8 +/- 3.6%, mitral 85.9 +/- 4.5%). The functional improvement in patients was very satisfactory and the risk of reoperation was 1.1% per patient-year. Over a 6 year time frame, the Omniscience valve has given excellent clinical performance.     

Valve dysfunction of the cloth-covered Starr-Edwards ball valve.

BACKGROUND: Between June 1968 and March 1977, Starr-Edwards cloth-covered ball valves were used for valve replacement on a routine basis. METHODS AND RESULTS: Among the 66 operative survivors who underwent an isolated aortic or mitral valve replacement, 20 patients required reoperation 22 times because of valve dysfunction, thromboembolic complication, paravalvular leakage, hemolytic anemia, and/or prosthetic valve endocarditis. Reoperation was performed at a mean of 15.9+/-9.8 years after initial replacement. Excised valves were examined and reoperation after initial operation was reviewed. Operative mortality was 10.0%. Freedom from reoperation for aortic valve replacement and mitral valve replacement was 56.2% at 34 years and 61.0% at 37 years after initial operation, respectively. Cloth wear or pannus formation were observed in all excised prostheses. Orifice cloth was more markedly worn in mitral valves than in aortic valves, particularly in mitral valves of more than 20 years old. Pannus overgrowth contributed to valve regurgitation in the older valves. CONCLUSIONS: Early diagnosis of valve dysfunction and reoperation are recommended as soon as symptoms appear.     

Reoperations in valve surgery. Apropos of 194 cases

Between 1970 and 1985, 194 patients underwent one or several reoperations after conservative valvular surgery (Group A) or valvular replacement surgery (Group B). Group A: comprised 141 patients with a previous history of closed heart mitral commissurotomy (114 cases), open heart mitral commissurotomy (20 cases), mitral valvuloplasty (5 cases) or aortic commissurotomy (2 cases) reoperated after an average period of 153 +/- 44 months. At reoperation, prosthetic valve replacement of the previously operated valve was systematic and another valvular procedure was also performed in 66 cases. Hospital mortality was 7.8 p. 100. Mortality was high in patients reoperated in functional Class IV of the NYHA classification, after closed heart mitral commissurotomy performed over 10 years before hand. The global mortality rate was 17 p. 100 (average postoperative follow-up of 70 +/- 44 months). The actuarial 5 year survival rate was 85 +/- 6 p. 100 and the 10 year survival was 70 +/- 13 p. 100; NYHA Class IV cardiac failure was a significant poor prognostic factor (p less than 0.05). The prognosis of reoperation after commissurotomy depended mainly on the interval between the relapse of symptoms and reoperation. Group B: comprised 53 patients with valvular prostheses reoperated after an average period of 58 +/- 41 months. The indications of reoperation were prosthetic valve dysfunction (31 cases), perivalvular leak (5 cases), prosthetic valve thrombosis (6 cases), infective endocarditis (7 cases), haemolysis (1 case) and associated valvular disease (10 cases). Reoperation concerned mechanical prostheses in 26 cases and bioprostheses in 24 cases. It consisted in valvular replacement (51 cases) or reinsertion (2 cases). Eight patients underwent second reoperation.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical treatment for mitral regurgitation: mid-term outcome following mitral valve repair

Mid-term results of mitral valve repair for mitral regurgitation were evaluated in 173 consecutive patients (mean age 53 years, 107 males, 66 females) treated from July 1991 to March 1998. Pathological causes of the mitral valve disease were degenerative in 118 patients, infective endocarditis in 25, rheumatic in 13, and ischemic in 8 (ischemic cardiomyopathy in 7). The principal technique was chordal replacement with expanded polytetrafluoroethylene sutures for prolapse of the anterior leaflet, and Carpentier's sliding leaflet technique for prolapse of the posterior leaflet. Most patients received ring annuloplasty with a rigid ring and flexible band (physiological remodeling annuloplasty). Intraoperative transesophageal echocardiography was used after 1993. There were 7 operative deaths (4%) and 7 mitral valve replacements (4%) during the same operation. Successful repair was achieved in 96% of patients with mitral regurgitation. Mean follow-up was 35 months (range 2 to 78 months). Survival at 6 years was 85 +/- 10% of all patients, 98 +/- 2% in degenerative cases. Six patients required reoperation (1.2%/patient-year) and mean time interval between initial operation and reoperation was 33.1 months. Four patients with atrial fibrillation had thromboembolic events (0.8%/patient-year). There were no anticoagulant-related complications. Freedom from reoperation and all valve-related event at 6 years was 88 +/- 6% and 84 +/- 6%. Late postoperative Doppler echocardiography revealed satisfactory results in 93% of the patients. Mitral valve repair using chordal replacement, sliding plasty and ring annuloplasty provides excellent mid-term results.     

Video-assisted mitral surgery through a micro-access: a safe and reliable reality in the current era

BACKGROUND AND AIM OF THE STUDY: Minimally invasive mitral valve surgery was introduced into clinical practice during the mid 1990s. The clinical benefits of the technique, namely a reduction of surgical trauma, increased patient comfort and shorter hospital stay, are achieved by using a video-assisted, minithoracotomy approach rather than a standard median sternotomy. Herein is described the authors' experience with video-assisted mitral surgery through a micro-access. METHODS: Between September 2003 and September 2006, 100 patients (mean age 65.7 years; range: 16-84 years; 29 aged >75 years) underwent video-assisted port-access mitral valve surgery through a 4- to 6-cm anterior mini-thoracotomy. Mitral valve repair was carried out in 36 patients (36%) and mitral valve replacement (MVR) in 64 (64%) for degenerative (n = 54), rheumatic (n = 44), functional (n = 1) or infective disease (n = 1). Redo procedures were performed in 14 patients. RESULTS: Peripheral extra-thoracic cardiopulmonary bypass (CPB) was used in all cases, and Endoclamp occlusion of the ascending aorta in 94%. The median intensive care unit and hospital stays were 20.0 +/- 30.8 h and 7.0 +/- 5.9 days, respectively. Hospital mortality was 4% (n = 4). No patient required conversion to sternotomy. Five patients (5%) underwent minimally invasive surgical revision for bleeding, and one patient (1%) had an early reoperation for MVR during the immediate postoperative course due to failure of a mitral valve repair. There were no perioperative myocardial infarctions, permanent strokes, major vascular complications, or peripheral ischemic events. Among the patients, 63% had no complications at all during the postoperative course, and no wound infections were observed. CONCLUSION: Video-assisted mitral surgery through a micro-access may be performed safely, at low risk of morbidity and mortality, and with results and quality standards similar to those reported for a sternotomy approach. Of note, older patients may be successfully treated using this technique.     

Cardiac surgery in octogenarians; peri-operative outcome and long-term results.

AIMS: Because the elderly are increasingly referred for operation, we reviewed the results of cardiac surgery in patients of 80 years or older. METHODS AND RESULTS: Records of 182 consecutive octogenarians who had had cardiac operations between 1992 and 1998 were reviewed. Follow-up was 100% complete. Seventy patients had coronary grafting (CABG), 70 aortic valve replacement, 30 aortic valve replacement+CABG, and 12 mitral valve repair/replacement. Rates of hospital death, stroke, and prolonged stay (>14 days) were as follows: CABG: 7 (10%), 2 (2.8%) and 41 (58%); aortic valve replacement: 6 (8.5%), 2 (2.8%) and 32 (45.7%); aortic valve replacement+CABG: 8 (26.5%), 1 (3.8%) and 14 (46.6%); mitral valve repair/replacement: 3 (25%), 1 (8.3%) and 5 (41.6%). Multivariate predictors (P<0.05) of hospital death were New York Heart Association functional class, urgent procedure, prolonged cardiopulmonary bypass time, and, after aortic valve replacement, previous percutaneous aortic valvuloplasty. Ascending aortic atheromatous disease was predictive of stroke, while pre-operative myocardial infarction was predictive of prolonged hospital stay. Actuarial 5-year survival was as follows: CABG, 65.8+/-8.8%; aortic valve replacement, 63.6+/-7.1%; aortic valve replacement+CABG, 62.4+/-6.8%; mitral valve repair/replacement, 57.1+/-5.6%; and total, 63.0+/-5.6%. Multivariate predictors of late death were pre-operative myocardial infarction, and urgent procedure. Ninety percent of long-term survivors were in New York Heart Association class I or II, and 87% believed having a heart operation after age 80 years was a good choice. CONCLUSION: Cardiac operations are successful in most octogenarians with increased hospital mortality, and longer hospital stay. Long-term survival and quality of life are good.     

Morbidity and mortality seen in patients with a Hancock bioprosthesis, followed for more than 5 years. Experience at the La Pitié Hospital

Between 1975 and 1983, 305 Hancock bioprostheses were implanted at the La Pitié Hospital, Paris, including 133 on the aortic valve and 172 on the mitral valve. The operative mortality rate was 6 p. 100 in patients with isolated aortic valve replacement and 12.8 p. 100 in patients with isolated mitral valve replacement (including 4 reoperations for mechanical valve thrombosis). 245 patients were followed up for a mean period of 5 1/2 years. The actuarial survival rate, operative mortality excluded, was 77.5 +/- 4.4 p. 100 in the aortic valve group and 76 +/- 4.4 p. 100 in the mitral valve group (non significant difference). Later after surgery, 8 embolic accidents (5 in the mitral valve group, 3 in the aortic valve group) occurred, and 20 patients developed endocarditis. Forty-nine patients required reoperation, 33 of them for deterioration of the bioprosthesis. The probability of being free from such deterioration varied significantly according to the patient's age at the time of the operation. In the aortic valve group this probability at 8 years was 97 p. 100 +/- 2.7 p. 100 for patients over 35 and 63.3 p. 100 +/- 1.7 p. 100 for patients under 35; the corresponding figures at 8 years in the mitral valve group were 80 p. 100 +/- 3.8 p. 100 for patients over 35 and 55.2 p. 100 +/- 2.2 p. 100 for patients under 35. There was no significant difference between the mitral and the aortic valve groups with regard to the percentage of prosthetic valve deterioration. The operative mortality rate in reoperations was 14.2 p. 100 irrespective of the cause of death.     

Artificial chordae for mitral valve repair: mid-term clinical and echocardiographic results

BACKGROUND: This paper reports on the mid-term clinical and echocardiographic results of mitral valve repair with chordal replacement. METHODS: Sixty-nine patients (mean age 61 +/- 14 years) underwent mitral valve repair with chordal replacement. The etiology was degenerative in 53 (77 %), rheumatic in 7 (10 %), ischemic in 6 (9 %) and infective in 3 (4 %). Mean ejection fraction was 58 +/- 14. In 35 patients (51 %), a minimally invasive approach was used. Mean follow-up time was 45 +/- 27 months. RESULTS: Anterior leaflet chordae were replaced in 58 (84 %) patients. There were 3 operative deaths. Freedom from non-trivial recurrent mitral regurgitation (MR) was 81.3 +/- 8.7 % at 97 months. Follow-up echocardiographic controls showed mild recurrent MR in 5 (8 %) patients and moderate in 2 (3.2 %). These two patients required reoperation due to mitral annulus redilation after suture annuloplasty. Competent neochordae were found at reoperation. Freedom from reoperation at 97 months was 96.6 +/- 2.4 %. Four patients died during follow-up resulting in an actuarial survival of 87 +/- 6.2 %. CONCLUSION: The replacement of chordae tendineae with ePTFE sutures during mitral valve repair has shown good mid-term results. The implantation of the neochordae can be also performed safely using minimally invasive procedures.     

Clinical application of cardioplegia in aortic cross-clamping periods longer than 150 minutes.

Out of more than 1000 patients operated upon by means of cardioplegia in profound myocardial hypothermia (15 degrees - 20 degrees C) aortic crossclamping time exceeded 150 min in 26 cases. The average clamping time in this group of patients was 169 +/- 22 min (150 to 227 min). The average duration of the cardioplegic coronary perfusion was 35 +/- 21 min (14 to 99 min). The following procedures were performed. Aneurysmectomy of the ascending thoracic aorta combined with valve replacement (n = 7); valve replacement combined with aorto-coronary bypass procedures (n = 9); multiple valve replacement (n = 3); multiple coronary grafting (n = 6) and one complicated reoperation. Three patients (11.5%) died, none intraoperatively and none as the result of a heart failure connected with the operation.     

急诊心脏瓣膜替换25例报告

目的:探讨急诊心脏瓣膜替换手术时机和围手术期处理措施。方法:1995年1月至2009年5月,对急性心脏瓣膜功能障碍致急性心肺功能衰竭施行急诊瓣膜置换25例,其中男性15例,女性10例,年龄12～64岁,术前心功能均为Ⅳ级。二尖瓣病变17例,其中二尖瓣机械瓣替换术后血栓形成致人工瓣膜功能障碍7例,人工瓣膜性心内膜炎并瓣周漏4例,感染性心内膜炎致急性二尖瓣腱索及乳头肌断裂并二尖瓣重度关闭不全5例,二尖瓣关闭不全并预激症1例。主动脉瓣病变8例,其中感染性心内膜炎并主动脉穿孔致急性心力衰竭(心衰)3例,血栓形成致人工瓣功能障碍2例,主动脉关闭不全并主动脉窦瘤破裂致急性心衰2例,外伤性主动脉瓣撕裂致主动脉瓣重度关闭不全1例。二尖瓣替换18例,其中再次心脏瓣膜替换11例,同时施行三尖瓣成形9例,异常传导束旁路切断1例。主动脉瓣替换8例。置入机械瓣22例,生物瓣3例。主动脉阻断时间34～80 min,转流时间70～160 min。结果:早期死亡1例,死于术后严重低心排综合征(低心排),其余病例术后恢复顺利,随访1～13年,心功能恢复良好。结论:及时、准确诊断,果断抉择手术时机,合理选择术式及良好围术期处理是进一步提高手术疗效的关键。     

Minimally invasive aortic valve replacement: echocardiographic and clinical results

BACKGROUND: Port access has been described for mitral and bypass surgery. The purpose of this study was to review the clinical and echocardiographic outcomes of aortic valve replacement by use of port access. METHODS: Between 1996 and 1999, 153 port-access aortic valve replacements were performed at our institution. The mean age was 63 years (range 16-91 years); 58% were male. The New York Heart Association mean class was III; 18% were in class IV. Thirteen percent had diabetes, 42% hypertension, 7% prior transient ischemic episode or stroke, 7% lung disease, 3% renal failure, and 13% previous surgery. Echocardiograms were obtained after valve replacement in 125 patients (96 intraoperative transesophageal and 97 transthoracic echoes). RESULTS: Median length of stay was 8 days. There were no intraoperative deaths; 10 patients (6.5%) died in the postoperative period. Stroke occurred in 4 (2.6%), sepsis in 5 (3.3%), renal failure in 5 (3.3%), pneumonia in 3 (2%), and wound infection in 1 (0.7%). Tissue prosthesis was present in 83 and a mechanical prosthesis in 42. No or trace regurgitation was seen on 94 of 96 (98%) postbypass intraoperative echocardiograms and mild on 2. On follow-up echocardiograms, moderate regurgitation was seen in 4 of 97 (4.1%), mild-to-moderate in 2 (2.1%), mild in 18 (18.6%), and no or trace in 71 (73.2%). Of those who had aortic regurgitation on intraoperative or follow-up echocardiograms, it was paravalvular in 8. CONCLUSIONS: Minimally invasive aortic valve replacement with a port-access approach is feasible, even in high-risk patients. Small incisions, a low infection rate, and a short length of stay are attainable. However, the complications associated with traditional aortic valve replacement still occur. Echocardiography is valuable both for intraoperative monitoring and follow-up of this new procedure.