Simultaneous aortic prosthesis implantation and renal transplantation

A 44 year old man with end-stage renal failure from nephro-angiosclerosis and with an abdominal aortic aneurysm involving also the common iliac arteries simultaneously underwent an abdominal aneurysmectomy using a standard Dacron graft and a living related renal transplantation. An original technic was used in order to prevent an anastomotic stenosis of the artery: the donor's renal artery was sutured end- to side on the Dacron prosthesis via a venous patch from the donor's renal vein. The post-operative course was uncomplicated; one year after the operation, the renal function is excellent (creatine: 1.6 mg/dl) and the blood pressure is normal.     

Mitral valvuloplasty and repair for infective endocarditis

The traditional therapy for acute bacterial endocarditis of the mitral valve refractory to medical treatment is valve replacement. Successful valvuloplasty may be feasible in selected cases, in which the infection is limited to a small portion of the mitral valve anulus. The following report describes a case in which valvuloplasty with excision of the affected valve was performed successfully with no recurrence of infection over a 3-year follow-up period.     

Late results following implantation of aortic bifurcation prosthesis]

From January 1976 to December 1986 181 patients with chronic arterial occlusive disease were provided with an Y-prosthesis of the aorta. In a retrospective study we reviewed the history of these patients. From 130 (72%) patients we obtained information about the further course of the disease, 83 (46%) patients were reexamined. Depending on the preoperative stage (Fontaine-Ratschow classification) of the chronic arterial occlusive disease, patients in higher stages had a greater benefit from the implantation by shifting into a more satisfactory stage. The majority of patients without any postoperative complaints (48%) belonged to the group, preoperatively classified into stage II B. Depending on the type of occlusion the best results were obtained in unique occlusions of the aorto-iliac vascular segment. 50% of the reexamined patients had no complaints although in 61% of these cases the superficial femoral artery was occluded in the mean time. 47 patients deceased during the interval of observation. In most cases death was caused by other manifestations of the basic disease (e.g. cardiac infarction or cerebral apoplexy). The 10-year-survival rate was 59%. The majority of patients with chronic occlusive disease of the pelvic arteries profited from the implantation of an aortal Y-prosthesis. The long-term success of this operation with its low lethality depends on the preoperative stage and the extent of the occlusive process.     

Early stenotic prosthesis failure after implantation of a stentless porcine aortic valve prosthesis

Stentless biological aortic prostheses are used routinely in aortic valve replacement surgery, offering beneficial hemodynamics compared to stented biological valves of similar size. We report here a rare case of early stenotic prosthesis failure of a RootElan stentless porcine aortic valve prosthesis due to swelling at the bottom of the right coronary cusp of the prosthesis.     

Mitral valvuloplasty complicated by catheter perforation of the right atrium and the aortic root

According to latest guidelines, percutaneous mitral commissurotomy (PMC) represents the first-line treatment for symptomatic severe mitral valve stenosis with favorable morphology. We report successful surgical treatment of a potential life-threatening complication occurred during PMC. Heart-team discussion and closed collaboration with centers are crucial for decision-making and cardiac surgery onsite should be ensured for high-risk procedures.     

Reoperation after aortic valvuloplasty for aortic regurgitation associated with ventricular septal defect

Five patients underwent reoperations because residual or recurrent aortic regurgitation occurred after aortic valvuloplasty for aortic regurgitation associated with ventricular septal defect. The mean age at reoperation was 22 years old, and the mean time interval between initial and second operation was 6 years, 10 months. The pathological findings of the aortic valves showed tears and perforation of repaired leaflets in four patients and a giant pseudoaneurysm of the Valsalva sinus in one. Aortic valvuloplasties were performed again in three patients, and aortic valves were replaced with prosthetic valves in two. Slight to moderate regurgitant murmurs are still audible in patients who underwent these valvuloplasties. Ventricular septal defects should be closed before aortic regurgitation develops. If it has developed, however, valvuloplasty should be considered as a first choice in young patients. For adult patients, aortic valve replacement is recommended.     

Long-term results of aortic valvuloplasty for aortic regurgitation associated with ventricular septal defect

Long-term results in 64 patients who underwent aortic valvuloplasty for aortic regurgitation associated with ventricular septal defect are presented. The average age of the patients was 10.2 years and the average cardiothoracic ratio was 0.57 at the time of operation. The average degree of aortic regurgitation, as classified by Sellers, was 2.7. The type of ventricular septal defect was subpulmonic in 31 patients, perimembranous in 20, and was a total conal defect in five patients. Valvuloplasty was performed at one end of an aortic cusp in 23 patients, at two ends in 33, at three ends in six, and at four ends in two patients. There was one operative death (1.6%). The follow-up period was 447.7 patient-years, and there were no late deaths. The actuarial survival rate was 98.3% at 5, 10, and 15 years. Postoperative cardiac catheterization was performed in 40 patients. Valvuloplasty failure was defined as the presence of a cardiothoracic ratio greater than 0.6, a loud regurgitant murmur (Levine grade 3/6 or greater), moderate or severe aortic regurgitation (Sellers grade 3 or 4), or the necessity of reoperation. There were 17 patients whose valvuloplasty failed. The freedom from valvuloplasty failure was 74.2% at 5 and 10 years and 55.3% at 15 years. Eight patients underwent reoperation because of residual aortic regurgitation, and all survived. The freedom from reoperation was 90.1% at 5 years, 80.5% at 10 years, and 63.7% at 15 years. Multiple regression analysis revealed that older age, a greater cardiothoracic ratio, perimembranous ventricular septal defect, and multiple valvuloplasties were significant contributing factors for residual regurgitation after aortic valvuloplasty.     

Early and late results following implantation of an aortic bifurcation prosthesis

Aorto-iliacal or aortofemoral bifurcation grafts were implanted to 351 patients for stenotic or occlusive diseases of pelvic and femoral arteries, between 1974 and 1986. The average age of patients was 62.7 years, and perioperative lethality amounted to 7.4 per cent. The average age of patients who died was 68.2 years. Intraoperative complications occurred in 18 cases, early postoperative problems in 103, and complications over more extended periods of time in 37 instances. Postoperative amputation was necessary for eight patients (2.3 per cent) with pre-existence of gangrene. Another 30 patients (9.2 per cent) had to undergo amputation later on. Second, third and more interventions were required in 75 patients. Postoperative follow-up periods were between three months and 13 years during which 51 patients died of cardiovascular diseases, 21 of malignoma, and 14 of other diseases. Adequate surgical results were established by follow-up checks in 80 per cent of the above cases. Twenty-four per cent complained about continued or recurrent claudication. Forty-six per cent of all survivors have continued to be smokers.     

二尖瓣成形术治疗感染性心内膜炎二尖瓣关闭不全

目的 评估二尖瓣成形术治疗感染性心内膜炎的可行性和疗效.方法 1990年10月至2007年7月,83例感染性心内膜炎致二尖瓣关闭不全的病人接受二尖瓣手术.男62例,女21例.41例(49.4%)行二尖瓣成形术(MVP),42例(50.60%)行二尖瓣置换术(MVR).同时行主动脉瓣置换术37例,三尖瓣成形术12例,室间隔缺损修补术4例,冠状动脉旁路移植术2例,主动脉瓣成形术1例,房间隔缺损修补术1例,股动脉取栓术1例.术中18例行食管超声检查评估二尖瓣反流情况.结果 MVP与MVR组病人比较,术前左室收缩末内径(41.63±8.60)mm对(37.69±6.38)mm,P＜0.05;术前射血分数0.62±0.07对0.66±0.76,P＜0.05;术前心功能分级平均(2.88±0.61)级对(2.45±0.71)级,P＜0.01.体外循环47～265min,平均(117.06±46.77)min;主动脉阻断26～210min,平均(86.95±39.07)min;呼吸机辅助呼吸5～120h,平均(21.49±16.06)h.MVP与MVR组病人体外循环和主动脉阻断时间均差异无统计学意义,MVP组气管插管和住ICU时间均显著低于MVR组(P＜0.05).MVR组病人瓣叶赘生物明显多于.MVP组病人(P＜0.05).MVP组术者相对固定.住院死亡3例(3.6%),均为二尖瓣置换病人.出院时病人心功能均为Ⅰ级或Ⅱ级.随访1～165个月,平均(39.33±39.76)个月,随访率95%.MVR组发生瓣周漏1例,反复胸腔积液1例,脑出血2例,其中1例死亡,10年生存率75%.MVP组无死亡,10年生存率100%.结论 感染性心内膜炎二尖瓣病变的病人瓣叶毁损不严重,如术者临床经验丰富,大多可行二尖瓣成形术,并取得良好手术结果.

Abstract：

Objective Valve replacement is a conventional therapy for the mitral insufficiency caused by IE. Mitral valve repair as an optional procedure for the disease has become feasible in recent years. However, concerns from surgeons about the recurrence of endocarditis after mitral valve repair remained. in this study we evaluated the long-term clinical outcomes of patients treated with surgery for the mitral insufficiency caused by infective endocarditis (IE). Methods Between July 1990 and July 2007, 83 consecutive patients (male 62, female 21) with mitral valve IE were enrolled in this study. Forty-one (49.4% )patients received mitral valve repair ( MVP,group A) and 42(50. 6% ) patients received mitral valve replacement ( MVR, group B). Thirty-seven cases had concomitant aortic valve replacement; 1 patient had aortic valve repair; 4 cases had ventricular septal defect repair; 1 case had atrial septal defect repair, 12 cases had bicuspid valve repair; 2 cases had coronary artery bypass graft and 1 case had femoral artery thrombus. Intraoperative transesophageal echocardiography were performed in 18 cases for the evaluation of mitral valve regurgitation. Mean cardiopulmonary bypass time, aortic clamping time and postoperative ventilation time were recorded and analyzed. Mid- and long-term clinical and echocardiographic outcomes were assessed.Results Preoperative left ventricular end systolic diameter, left ventricular ejection fraction and the classification of New York Heart Association in group A were significantly lower than those in group B (P ＜ 0. 05), but no difference was observed between the 2 groups in the cardiopulmonary bypass time and the crossclamping time. However, the intubation time and ICU time were shorter in group A than those in group B ( P ＜ 0.05 ). More vegetations were seen in the MVR group than in the MVP group. Three (3.6% ) patients died after the operation in group B. All patients were assessed as in NYHA Ⅰ-Ⅱ at discharge.A follow-up was done between 1 to 165 months (mean 39 months) with a mean follow-up rate of 95%. In the MVR group, peri-valvular leakage happened in 1 case, cerebral hemorrhage happened in 2 cases and repetitive pleura! effusion in 1 case. One death happened in the MVR group and none in the MVP group. The 10-year survival rate (100% ) in group A was nonsignificantly higher in group A than that (75% ) in group B(P =0.081). Conclusion Mitral valve repair is feasible for treating mitral valve lesions caused by endocarditis, and may provide an optimistic long-term outcome to the patients. The indication for mitral valve repair is mild to moderate mitral valve lesion. Experienced cardiac surgeons, use of antibiotics before and after the operations based on drug-sensitivity test and blood test, as well as follow-up the patients yearly, are important factors for the favorite outcomes.