Conservative surgical treatment for active infective tricuspid valve endocarditis according to the "clover technique".

AIMS: This prospective study was undertaken to analyze the outcomes of conservative surgery with the "clover technique" for active infective tricuspid valve endocarditis. METHODS: Five consecutive patients underwent surgery for active infective tricuspid valve endocarditis. The mean age was 36.6 years. Four of the patients were men. In all patients, the tricuspid valve had become mutilated and infected. One patient had associated mitral endocarditis, and one had aortic endocarditis. Staphylococcus aureus was the most common bacterial species. Conservative surgery was indicated in all patients with infection limited to the leaflets and/or subvalvular apparatus of the tricuspid valve. Total resection of infected tissues was achieved in all cases. The tricuspid valve was then reconstructed according to the clover technique. A tricuspid annular ring was used in 2 patients. RESULTS: All 5 patients survived surgery. Intraoperative transesophageal and predischarge transthoracic echocardiographic evaluations showed good results in all patients. The mean follow-up time was 26.4 +/- 12.5 months. No recurrent bacterial tricuspid endocarditis occurred during follow-up. All patients were in New York Heart Association functional class I. A transthoracic echocardiography evaluation at the latest control examination showed trivial leakage (3 patients) or no residual regurgitation (2 patients); no transvalvular gradient was found in any of the patients. No tricuspid valve calcification has been detected to date. Cardiac magnetic resonance imaging analyses showed no postoperative void flow and confirmed the preservation of right ventricular function and thus the reliability of this technique. CONCLUSIONS: This novel technique is indicated for tricuspid valve endocarditis and should be considered as an adequate approach in cases of uncontrollable infection involving the tricuspid valve that is responsible for extended valve destruction.

Chordal cutting VIA aortotomy in ischemic mitral regurgitation: surgical and echocardiographic study.

BACKGROUND: Chordal cutting through atriotomy has been proposed to treat significant resting ischemic mitral regurgitation (MR) due to anterior leaflet tenting. In addition, MR may exacerbate during exercise not only trough exercise-induced ischemia but also through an increase in tenting area. Accordingly, we aimed to perform chordal cutting through aortotomy in patients with exercise-induced ischemic worsening of MR. METHODS: Five patients with ischemic MR, due to anterior leaflet tenting, which worsened during exercise echocardiography were enrolled. All patients underwent cutting of the 2 basal chordae attached to the anterior mitral leaflet associated with myocardial revascularization. Three patients had additional mitral valve annuloplasty. Postoperative MR was evaluated using exercise echocardiography. RESULTS: Age ranged from 63 to 78 years and 4 patients were male. Preoperative LV ejection fraction averaged 39 +/- 3%. Chordal cutting was performed through aortotomy allowing comfortable access to the anterior mitral valve. Mitral effective regurgitant orifice at rest and at peak exercise was reduced by surgery (10 +/- 3 to 0.6 +/- 0.5 mm(2) at rest and from 20 +/- 3 to 6 +/- 2 mm(2) at peak exercise; p = 0.03). Mitral tenting area at rest and at peak exercise was concomitantly reduced by surgery (1.83 +/- 0.21 cm(2) to 0.50 +/- 0.4 cm(2) at rest and from 3.11 +/- 0.58 to 1.7 +/- 0.5 cm(2) at peak exercise; p = 0.03). Left ventricular size and function remained unchanged after surgery. CONCLUSIONS: Chordal cutting through aortotomy may be an effective option to treat ischemic MR due to anterior leaflet tenting. Associated with myocardial revascularization, it resulted in a decrease of MR at rest and during exercise through a decrease in tenting area without impairment of LV function.

Chordal cutting technique through aortotomy to treat chronic ischemic mitral regurgitation: surgical technique.

OBJECTIVE: To describe original surgical treatment in patients with ischemic mitral valve regurgitation due to tenting phenomenon. BACKGROUND: The optimal surgical treatment of ischemic mitral regurgitation (MR) in patients with coronary artery disease is controversial. The standard treatment is revascularization and reduction annuloplasty. We describe the first clinical application of an original technique to treat MR, through aortotomy. The chordal cutting technique was described first in experimental studies by Messas et al. METHODS: The procedure consisted in cutting the 2 strut chordae of the anterior mitral valve through a small aortotomy, using a brief conventional cardiopulmonary bypass. All the cases were controlled at the end of the procedure by transesophageal echocardiography (TEE). RESULTS: Five patients were treated using this technique; the procedure was brief, effective and safe in all the patients. TEE showed no mitral regurgitation. No preoperative morbidity or mortality occurred and post-operative course was uneventful. CONCLUSION: Chordal cutting technique through aortotomy is a safe and effective technique that should be considered to treat severe ischemic mitral regurgitation due to tenting phenomenon.

Cardiovascular risk factors as predictors of early and late survival after bioprosthetic valve replacement for aortic stenosis.

BACKGROUND AND AIM OF THE STUDY: Cardiovascular risk factors have been associated with aortic valve stenosis, which is considered as an atherosclerosis-like process. The study aim was to assess the effect of cardiovascular risk factors on early and late outcome after valve replacement with a bioprosthesis for aortic stenosis (AS), and the impact of these factors on the outcome of the bioprosthesis. METHODS: Preoperative clinical, biological and echocardiographic data were recorded in 222 patients (110 males, 112 females; mean age 73 +/- 8 years) who underwent surgery for severe AS between 1989 and 1993. The mean follow up was 7.3 +/- 4.7 years; total follow up was 1,621 patient-years (pt-yr). RESULTS: Overall 12-year actuarial survival rate was 36.1%. Independent predictors of mortality were age (hazards ratio (HR) 1.11; 95% CI: 1.08-1.14, p < 0.0001), diabetes mellitus (DM) (HR 2.53; 95% CI: 1.65-3.88, p < 0.0001), male gender (HR 2.17; 95% CI: 1.53-3.12, p < 0.0001), and NYHA class (HR 1.66; 95% CI: 1.17-2.34, p = 0.004). Other cardiovascular risk factors had no significant effect on survival. DM and NYHA class were also independent predictive factors for valve-related death and overall valve-related complications. The 12-year actuarial survival was 13% in DM patients compared to 38% in non-diabetic patients (p = 0.003), with a significant increase in cardiovascular death (p = 0.0028), and a non-significant increase in thromboembolic events (p = 0.08) in DM patients. The only independent predictive risk factor of structural valve failure in multivariate analysis was renal failure (HR 1.1, 95% CI: 1.03-1.16, p = 0.047). Cardiovascular risk factors such as hypercholesterolemia, DM, hypertension, tobacco smoking and obesity had no effect on the outcome of the bioprosthesis. CONCLUSION: Age, male gender, DM and NYHA class were the main predictors for long-term mortality after bioprosthesis implantation for AS. DM significantly impaired survival, with an excess of cardiovascular deaths and thromboembolic events. Other cardiovascular risk factors had no significant effect on either survival or bioprosthesis durability.

Extracorporeal membrane oxygenation in severe acute respiratory failure in postpartum woman with rheumatic mitral valve disease: benefit, factors furthering the success of this procedure, and review of the literature.

Pregnancy is a common decompensation factor for women with post-rheumatic mitral disease. However, valvular heart diseases causing severe acute respiratory distress are rare. Use of extracorporeal membrane oxygenation (ECMO) early in the event of cardiorespiratory failure after cardiac surgery may be of benefit. Indeed, ECMO cardiopulmonary bypass (CPB) support could help pulmonary recovery if the mitral pathology is involved. A 31-year-old female patient at 30 weeks of amenorrhea was admitted to the obstetrics department with 40 degrees C hyperthermia and New York Heart Association (NYHA) class 4 dyspnea. The patient's medical history included a post-rheumatic mitral stenosis. Blood gases showed severe hypoxemia associated with hypocapnia. The patient needed to be rapidly intubated and was placed on ventilatory support because of acute respiratory failure. Transesophageal echocardiography showed a severe mitral stenosis, mild mitral insufficiency, and diminished left ventricular function, hypokinetic, dilated right ventricle, and a severe tricuspid regurgitation. An urgent cesarean section was performed. Because of the persistent hemodynamic instability, a mitral valvular replacement and tricuspid valve annuloplasty were performed. In view of the preoperative acute respiratory distress, we decided, at the beginning of the operation, to carry on circulatory support with oxygenation through an ECMO-type CPB at the end of the operation. This decision was totally justified by the unfeasible CPB weaning off. ECMO use led to an efficient hemodynamic state without inotropic drug support. The surgical post-operative course was uneventful. Early use of cardiorespiratory support with veno-arterial ECMO allows pulmonary and right heart recovery after cardiac surgery, thus avoiding the use of inotropic drugs and complex ventilatory support.

Changes in cerebral vascular reactivity occur early during cardiopulmonary bypass in the rat.

BACKGROUND: Cardiopulmonary bypass (CPB) is known to cause cerebrovascular dysfunction. The etiology of these complications is complex, but disruption of normal cerebral endothelial function as a consequence of inflammatory or hypoperfusion phenomena have been implicated. The aim of this study was to investigate the effect of CPB time on cerebrovascular reactivity and to investigate the correlation of these findings with measured inflammatory markers. METHODS: Cardiopulmonary bypass was carried out for 30 or 60 minutes on two groups of rats. Sham groups underwent the same surgical procedure without CPB. The middle cerebral artery was harvested and prepared for assessment of induced endothelial and vascular smooth muscle cell responses. Systemic inflammation was evaluated by measuring tumor necrosis factor-alpha and immunohistochemical staining for intercellular adhesion molecule-1. RESULTS: Acetylcholine caused a dose-dependent vasodilation in the control groups that was absent in animals undergoing CPB (21.3% +/- 1.3% increase in diameter at 30 minutes in the sham group compared with 5.4% +/- 1.1% in the corresponding CPB group, p < 0.001). Significantly, this was apparent after only 30 minutes of CPB. Cardiopulmonary bypass did not alter the response to sodium nitroprusside (45.3% +/- 8.6% after 30 minutes in the sham group compared with 57.8% +/- 8.0% in the corresponding CPB group, p < 0.2). Furthermore, the contractile response to serotonin remained intact in all groups (32.9 +/- 4.6 and 27.6 +/- 2.6 at 30 and 60 minutes, respectively, in the sham groups compared with 23.1 +/- 1.6 and 28.0 +/- 4.4 in the corresponding CPB groups, p < 0.2). Cardiopulmonary bypass also led to an early and marked increase in tumor necrosis factor-alpha and overexpression of intercellular adhesion molecule-1. CONCLUSIONS: Cerebrovascular impairment appears early after the onset of CPB. The specific loss of acetylcholine-induced vasodilation suggests endothelial cell dysfunction rather than impaired vascular smooth muscle response to nitric oxide. This loss of endothelium-dependent regulatory factors after CPB may enhance vasoconstriction, impair cerebrovascular function, and contribute to neurologic injury after CPB.

Massive pulmonary valve insufficiency associated with double pulmonary artery and ascending aorta aneurysm.

A case is reported of aneurysm of both the ascending aorta and pulmonary artery, associated with massive pulmonary valve insufficiency. Pulmonary artery aneurysm is a rare condition of unknown natural history; therapeutic management has not yet been established. Pulmonary valve insufficiency is also rare, with reported etiologies comprising mainly pulmonary valve anomalies. A comparative review of the literature relating to the diagnosis and therapeutic management of the condition is provided.

Consequences of delayed surgical closure of patent ductus arteriosus in very premature infants.

BACKGROUND: Surgical closure of ductus arteriosus is commonly indicated in premature newborns. The aim of this study was to assess short-term and mid-term effects of delayed surgical closure of the ductus arteriosus on respiratory and digestive outcome in extremely preterm infants. METHODS: We retrospectively studied 58 infants less than 28 weeks gestational age who underwent surgical closure of ductus arteriosus between January 1997 and December 2002. Nine infants with intrauterine growth restriction and major congenital malformation were excluded from the study. Criteria for surgical closure of ductus arteriosus were: (1) medical treatment failure (ie, indomethacin or ibuprofen) and (2) hemodynamically patent ductus arteriosus: systemic arterial pressure less than gestational age in mm Hg, heart failure, left atrial-aortic root ratio greater than 1.6, mean velocity in the left pulmonary artery greater than 0.6 m/s, and ductus arteriosus diameter greater than 3 mm. Infants were divided into two groups: (1) the early group who had surgery before 21 days of life (n = 31), and (2) the late group who had surgery after 21 days of life (n = 27). Preoperative and postoperative criteria were compared between the two groups (ie, gestational age, birth weight, hemodynamic, ventilatory, and echographic [left atrial-aortic root ratio, mean velocity in the left pulmonary artery] parameters). RESULTS: Preoperative gestational age and birth weight did not differ between the two groups. In the early group, gestational age was 26 weeks (range, 23 to 28 weeks and birth weight was 800 g (range, 630 to 1,240 g). In the late group, gestational age was 26 weeks (range, 24 to 28 weeks) and birth weight was 840 g (530 to 1,130 g). Hemodynamic, ventilatory, and echographic parameters were similar in both groups. Rate of bronchopulmonary dysplasia was similar in both groups. However, at 24 hours post surgery, median FiO2 was higher in the late group (28% [range, 21% to 65%]) than in early group (21% [range, 21% to 60%]) (p < 0.05). Furthermore, full oral feeding was acquired later in the late group (57 days of life [range, 30 to 136 days]) than in the early group (37 days of life [range, 27 to 84 days]) (p < 0.01), and body weight at 36 weeks of post-conceptional age was higher in the early group at 1,800 g (range, 1,250 to 2,750 g) than in the late group at 1,607 g (1,274 to 2,200 g) (p < 0.05). CONCLUSIONS: Our findings show that early surgical closure of the ductus arteriosus (< 3 weeks of life) is associated with shortened delay for full oral feeding and improved body growth when compared with late surgical closure (> 3 weeks of life).

Endocardial radiofrequency ablation during mitral valve surgery: effect on cardiac rhythm, atrial size, and function.

BACKGROUND: Restoration of sinus rhythm is thought to lead to a reduction in left atrial size and to recovery of atrial contraction. We aimed to investigate changes in atrial size and function in patients undergoing radiofrequency ablation for atrial fibrillation during mitral valve surgery. METHODS: In a prospective study, 70 patients (64 +/- 10 years) with mitral valve disease and atrial fibrillation underwent mitral surgery and left atrial endocardial radiofrequency ablation. Evaluation was achieved before surgery, at 7 days, 5 months, and 22 months after surgery. Maximal right and left atrial areas, left atrial diameter, and volume were measured. Atrial filling fraction (ventricular filling related to atrial contraction to total ventricular filling ratio) was used as an index of atrial contraction. RESULTS: At the end of follow-up (22 +/- 10 months) most patients (91%) were in sinus rhythm. Actuarial freedom from atrial fibrillation recurrence was 62.5% after 2 years. Atrial size decreased, with a significant improvement in right (36 +/- 15 vs 10 +/- 20% preoperatively, p < 0.0001) and left (25 +/- 12 vs 7 +/- 14%, p < 0.0001) atrial filling fraction. Despite similar preoperative atrial size, at the end of follow-up atrial fibrillation recurrence was associated with a higher left atrial volume than in patients free of recurrence (41 +/- 14 vs 32 +/- 9 mL/m2, p = 0.004). Independent predictors of atrial fibrillation recurrence were previous mitral procedure (p = 0.029), left ventricular ejection fraction (p = 0.033), and mitral rheumatic lesion (p = 0.034). CONCLUSIONS: Left atrial radiofrequency ablation for atrial fibrillation during mitral surgery is an effective procedure restoring sinus rhythm. Right and left atrial size was significantly reduced, with a recovery in atrial contraction.

Modelling a regional reorganization of cardiovascular surgery provision.

The Nord-Pas-de-Calais region of France is under-served in terms of access to cardiovascular surgery services, as illustrated by relatively high levels of waiting list mortality. This prompted the decision to create a new surgical unit in the region's densely populated, former industrial heartland called the "Mining Basin". Geographical and epidemiological modelling was used prospectively to estimate the likely future level of activity of the existing public sector cardiovascular surgery units. Information on the regional population distribution and the likely pattern of service use enabled us to estimate the new unit's potential activity. Our simulations produced nine scenarios which describe variations in the existing public units' activity ranging from -54% to +95%. This type of approach should enable policy makers to improve the organization of healthcare provision.

Beating-heart approach and moderately delayed surgical management of postinfarction ventricular septal rupture: an advisable approach to improve results?

Early repair of postinfarction ventricular septal rupture is usually associated with significant mortality and morbidity. Assessing conditions to moderately delay the surgical intervention and reduce cardioplegic arrest may be an interesting approach to improve hospital results. Results of five non-selected patients in whom surgery was moderately delayed and performed according a policy of reducing the cardioplegic-induced ischemia were reviewed. Surgical options are discussed as well as observed advantages.

Right ventricular assist device thrombosis during biventricular heart assistance.

We report a case of total thrombosis of a right ventricular assist device in a patient during biventricular assistance. The thrombosis occurred 18 days following implantation and the right ventricular device was immediately removed without any complications. The patient was successfully transplanted after 3 months of left ventricular assistance.

Circumflex artery stenosis induced by intraoperative radiofrequency ablation.

We report a case of circumflex artery stenosis after intraoperative radiofrequency ablation for permanent atrial fibrillation in a patient who had a previous mitral valve replacement. The patient presented with acute pulmonary edema and severe angina 1 year after an uneventful recovery. The patient underwent a diagnostic angiography that showed the presence of stenosis of a long segment of the circumflex artery, adjacent to the radiofrequency ablation site, which was reopened successfully by angioplasty. Intraoperative radiofrequency ablation caused circumflex artery stenosis. We believe that this complication could have been avoided by applying the radiofrequency ablation more distally between the left pulmonary veins and the mitral valve.

Pasteurella multocida aortic valve endocarditis: case report and literature review.

Pasteurella multocida is a rare cause of infective endocarditis that occurs mostly in immunocompromised patients and is therefore associated with a high mortality rate. The case is reported of a 48-year-old male patient with liver cirrhosis, who developed aortic valve endocarditis caused by P. multocida. The infection was detected by blood cultures. The patient presented with generalized symptoms and initial neurologic symptoms suggestive of meningitis. Transthoracic echocardiography conducted after the discovery of a diastolic murmur revealed a large vegetation on the aortic valve, and notable insufficiency. These findings were confirmed at surgery, where-upon the patient underwent aortic valve replacement using a bioprosthetic valve. Subsequently he developed a recurrent episode of endocarditis that was successfully treated with antibiotic therapy. Other similar cases reported in the literature are reviewed.