Posterior pericardial ascending-to-descending aortic bypass: an alternative surgical approach for complex coarctation of the aorta.

BACKGROUND: Coarctation of the aorta is commonly associated with recoarctation or additional cardiovascular disorders that require intervention. The best surgical approach in such patients is uncertain. Ascending-to-descending aortic bypass graft via the posterior pericardium (CoA bypass) allows simultaneous intracardiac repair or an alternative approach for the patient with complex coarctation. METHODS AND RESULTS: Between 1985 and 2000, 18 patients (13 males and 5 females, mean age 43+/-13 years) with coarctation of the aorta underwent CoA bypass through median sternotomy. Before operation, average New York Heart Association class was II (range I to IV), and 15 patients (83%) had systemic hypertension. One or more previous cardiovascular operations had been performed in 12 patients (67%); 10 patients had >/=1 prior coarctation repair. Two patients had prior noncoarctation cardiovascular surgery. Concomitant procedures performed in 14 patients (78%) included the following: aortic valve replacement in 9; coronary artery bypass surgery in 3; mitral valve repair in 2; and septal myectomy, mitral valve replacement, aortoplasty, subaortic stenosis resection, ventricular septal defect closure, and ascending aorta replacement in 1 patient each. All patients survived the operation and were alive with patent CoA bypass at a mean follow-up of 45 months. No graft-related complications occurred, and there were no instances of stroke or paraplegia. Systolic blood pressure fell from 159 mm Hg before surgery to 125 mm Hg after surgery. CONCLUSIONS: CoA bypass via median sternotomy can be performed with low morbidity and mortality. Although management must be individualized, extra-anatomic CoA bypass via the posterior pericardium is an excellent single-stage approach for patients with complex coarctation or recoarctation and concomitant cardiovascular disorders.

Very long-term survival and durability of mitral valve repair for mitral valve prolapse.

BACKGROUND: Mitral regurgitation (MR) due to mitral valve prolapse (MVP) is often treatable by surgical repair. However, the very long-term (>10-year) durability of repair in both anterior leaflet prolapse (AL-MVP) and posterior leaflet prolapse (PL-MVP) is unknown. METHODS AND RESULTS: In 917 patients (aged 65+/-13 years, 68% male), surgical correction of severe isolated MR due to MVP (679 repairs and 238 replacements [MVRs]) was performed between 1980 and 1995. Survival after repair was better than survival after MVR for both PL-MVP (at 15 years, 41+/-5% versus 31+/-6%, respectively; P=0.0003) and AL-MVP (at 14 years, 42+/-8% versus 31+/-5%, respectively; P=0.003). In multivariate analysis adjusting for predictors of survival, repair was independently associated with lower mortality in PL-MVP (adjusted risk ratio [RR] 0.61, 95% CI 0.44 to 0.85; P=0.0034) and in AL-MVP (adjusted RR 0.67, 95% CI 0.47 to 0.96; P=0.028). The reoperation rate was not different after repair or MVR overall (at 19 years, 20+/-5% for repair versus 23+/-5% for MVR; P=0.4) or separately in PL-MVP (P=0.3) or AL-MVP (P=0.3). However, the reoperation rate was higher after repair of AL-MVP than after repair of PL-MVP (at 15 years, 28+/-7% versus 11+/-3%, respectively; P=0.0006). From the 1980s to the 1990s, the RR of reoperation after repair of AL-MVP versus PL-MVP did not change (RR 2.5 versus 2.7, respectively; P=0.58), but the absolute rate of reoperation decreased similarly in PL-MVP and AL-MVP (at 10 years, from 10+/-3% to 5+/-2% and from 24+/-6% to 10+/-2%, respectively; P=0.04). CONCLUSIONS: In severe MR due to MVP, mitral valve repair compared with MVR provides improved very long-term survival after surgery for both AL-MVP and PL-MVP. Reoperation is similarly required after repair or replacement but is more frequent after repair of AL-MVP. Recent improvement in long-term durability of repair suggests that it should be the preferred mode of surgical correction of MVP whether it affects anterior or posterior leaflets and is an additional incentive for early surgery of severe MR due to MVP.

Surgical management of left-sided carcinoid heart disease.

BACKGROUND: Carcinoid involvement of left-sided heart valves has been reported in patients with a patent foramen ovale, carcinoid tumor of the lung, and active carcinoid syndrome with high levels of serotonin. The present study details the clinical features and surgical management of patients with carcinoid heart disease affecting both left- and right-sided valves. METHODS AND RESULTS: Eleven patients (7 men, 4 women) with symptomatic carcinoid heart disease underwent surgery for left- and right-sided valve disease between 1989 and 1999. Mean age was 57+/-9 years, and median preoperative NYHA class was 3. All patients had metastatic carcinoid tumors and were on somatostatin analog. Of 11 patients, 5 (45%) had a patent foramen ovale; 1 of these also had a primary lung carcinoid tumor. Surgery included tricuspid valve replacement in all patients, pulmonary valve replacement in 3 and valvectomy in 7, mitral valve replacement in 6 and repair in 1, aortic valve replacement in 4 and repair in 2, CABG in 2, and patent foramen ovale closure in 5. One myocardial metastatic carcinoid tumor was removed. There were 2 perioperative deaths. At a mean follow-up of 41 months, 4 additional patients were dead. All but 1 surgical survivor initially improved >/=1 functional class. No patient required reoperation. CONCLUSIONS: Carcinoid heart disease may affect left- and right-sided valves and occurred without intracardiac shunting in 55% of this surgical series. Despite metastatic disease that limits longevity, operative survivors had improvement in functional capacity. Cardiac surgery should be considered for select patients with carcinoid heart disease affecting left- and right-sided valves.

Severe aortic stenosis with low transvalvular gradient and severe left ventricular dysfunction:result of aortic valve replacement in 52 patients.

BACKGROUND: The outcome of aortic valve replacement in patients with severe aortic stenosis, low transvalvular gradient, and severe left ventricular dysfunction is not well known. METHODS AND RESULTS: Between 1985 and 1995, 52 patients with left ventricular ejection fraction (EF) < or =35% and aortic stenosis with transvalvular mean gradient <30 mm Hg underwent aortic valve replacement. The mean (+/-SD) preoperative characteristics included EF, 26+/-8%; aortic valve mean gradient, 23+/-4 mm Hg; aortic valve area, 0.7+/-0.2 cm(2); and cardiac output, 3.7+/-1.2 L/min. Simultaneous coronary artery bypass graft surgery was performed in 32 patients (62%). Perioperative (30-day) mortality was 21% (11 of 52 patients). Ten additional patients died during follow-up. Advanced age (P=0.048) and small aortic prosthesis size (P=0.03) were significant predictors of hospital mortality by univariate analysis. By multivariate analysis, the only predictor of surgical mortality was smaller prosthesis size. The only predictor of postoperative survival was improvement in postoperative functional class (P=0.04). Postoperative functional improvement occurred in most patients. Postoperative EF was assessed in 93% of survivors; 74% demonstrated improvement. Positive change in EF was related to smaller preoperative aortic valve area and female sex. CONCLUSIONS: Despite severe left ventricular dysfunction, low transvalvular mean gradient, and increased operative mortality, aortic valve replacement was associated with improved functional status. Postoperative survival was related to younger patient age and larger aortic prosthesis size, and medium-term survival was related to improved postoperative functional class.

Mortality and morbidity of aortic regurgitation in clinical practice. A long-term follow-up study.

BACKGROUND: The outcome of aortic regurgitation conservatively followed in clinical practice is poorly defined. METHODS AND RESULTS: Long-term outcome of 246 patients with severe or moderately severe aortic regurgitation diagnosed by color Doppler echocardiography was analyzed. With conservative management, mortality rate was higher than expected (at 10 years, 34+/-5%, P<0. 001) and morbidity was high (10-year rates of 47+/-6% for heart failure and 62+/-4% for aortic valve surgery). At 10 years, 75+/-3% of patients had died or had surgery and 83+/-3% had had cardiovascular events. In multivariate analysis, predictors of survival were age (P<0.001), functional class (P<0.001), comorbidity index (P=0.033), atrial fibrillation (P=0.002), and left ventricular end-systolic diameter corrected for body surface area (P=0.025). Ejection fraction was also an independent predictor of overall survival, including postoperative follow-up of surgically treated patients (P<0.001). High risk during conservative treatment, with mortality rate in excess of that expected, was noted among patients with severe, even transient, symptoms (24.6% yearly, P<0.001) but also in those with mild (class II) symptoms (6.3% yearly, P=0.02) and in asymptomatic patients with left ventricular ejection fraction <55% (5.8% yearly, P=0.03) or with end-systolic diameter normalized to body surface area >/=25 mm/m2 (7.8% yearly, P=0.004). Surgery performed during follow-up was independently associated with reduced cardiovascular mortality (adjusted hazard ratio, 0.54; P=0.048). CONCLUSIONS: Patients diagnosed with severe aortic regurgitation in clinical practice incur excess mortality and high morbidity, underscoring the serious prognosis of the disease. Surgery, which reduces cardiac mortality rates, should be considered promptly in high-risk patients.

Constrictive pericarditis in the modern era: evolving clinical spectrum and impact on outcome after pericardiectomy.

BACKGROUND: The clinical spectrum of constrictive pericarditis (CP) has been affected by a change in incidence of etiological factors. We sought to determine the impact of these changes on the outcome of pericardiectomy. METHODS AND RESULTS: The contemporary spectrum of CP in 135 patients (76% male) evaluated at the Mayo Clinic from 1985 to 1995 was compared with that of a historic cohort. Notable trends were an increasing frequency of CP due to cardiac surgery and mediastinal radiation and presentation in older patients (median age, 61 versus 45 years). Perioperative mortality decreased (6% versus 14%, P = 0.011), but late survival was inferior to that of an age- and sex-matched US population (57+/-8% at 10 years). The long-term outcome was predicted independently by 3 variables in stepwise logistic regression analyses: (1) age, (2) NYHA class, and most powerfully, (3) a postradiation cause. Of 90 late survivors in whom functional class could be determined, functional status had improved markedly (2.6+/-0.7 at baseline versus 1.5+/-0.8 at latest follow-up [P<0.0001]), with 83% being free of clinical symptoms. CONCLUSIONS: The evolving profile of CP, with increasingly older patients and those with radiation-induced disease in the past decade, significantly affects postoperative prognosis. Long-term results of pericardiectomy are disappointing for some patient groups, especially those with radiation-induced CP. By contrast, surgery alleviates or improves symptoms in the majority of late survivors.

Increased incidence of periprocedural complications among patients with peripheral vascular disease undergoing myocardial revascularization in the bypass angioplasty revascularization investigation.

BACKGROUND: Risks of coronary artery bypass graft surgery (CABG) or percutaneous transluminal coronary angioplasty (PTCA) may be different in the presence of peripheral vascular disease (PVD). METHODS AND RESULTS: We analyzed outcomes of 550 patients with PVD enrolled in the Bypass Angioplasty Revascularization Investigation randomized trial and registry. Compared with 1770 patients without PVD, those with PVD were older and had a greater prevalence of medical comorbid conditions. No significant differences in coronary anatomy or PTCA success rates were found. The risk of any major complication (death, myocardial infarction, stroke, coma, or emergency revascularization) after PTCA was significantly higher among patients with PVD (11.7% versus 7.8%, P=0.027). In multivariate analysis, this represented a 50% increase in the odds of having any major complication (multivariate odds ratio, 1.5; P=0. 032). Among patients undergoing CABG, the risk of major complications was found to be markedly higher for patients with PVD (12%) than those without (6.1%, P=0.003) even after controlling for baseline differences (multivariate odds ratio, 1.8; P=0.018). Major differences between the PTCA and CABG groups were related primarily to a higher risk of neurological complications in PVD patients who had CABG (multivariate odds ratio, 2.8; P<0.001). CONCLUSIONS: We conclude that patients with PVD are at high risk for periprocedural complications after myocardial revascularization, in particular neurological events.

Mechanisms of hemolysis after mitral valve repair: assessment by serial echocardiography.

OBJECTIVES: We sought to determine, using serial echocardiography, the hydrodynamic mechanisms involved in the occurrence of hemolysis after mitral valve repair. BACKGROUND: Recently, fluid dynamic simulation models have identified distinct patterns of mitral regurgitant flow disturbances in patients with mitral prosthetic hemolysis that were associated with high shear stress and may therefore produce clinical hemolysis. Rapid acceleration, fragmentation, and collision jets were associated with high shear stress and hemolysis whereas slow deceleration and free jets were not. METHODS: We reviewed serial echocardiographic studies of 13 consecutive patients with hemolytic anemia after mitral valve repair who were referred for mitral reoperation between January 1985 and December 1996 (group 1). Thirteen patients undergoing reoperation for mitral regurgitation after mitral valve repair but without hemolysis served as controls (group 2). RESULTS: The mitral regurgitant jet was central in origin in 12 group 1 patients and 9 group 2 patients (Fisher exact test, p= 0.3). The other patients had para-ring regurgitation. Group 1 patients had collision (n=11), rapid acceleration (n=2) or fragmentation (n=1) jets whereas group 2 patients had slow deceleration (n=11) or free jets (n=2) (Fisher exact test, p < 0.0001). One patient with hemolysis had both collision and rapid acceleration jets. The "culprit" jet could be identified on the postbypass transesophageal echocardiography (TEE) study in only 1 patient at the time of initial mitral repair. Twelve group 1 patients underwent reoperation, with subsequent resolution of hemolysis in all patients. At reoperation, the initial repair was found to be intact in 8 (67%) patients. CONCLUSION: Distinct patterns of flow disturbance associated with high shear stress were identified by color Doppler imaging in patients with hemolysis after mitral valve repair. The majority (92%) of these color flow disturbances were not present during intraoperative postbypass TEE study after initial mitral repair and subsequently developed in the early postoperative period.

Ultrasonic aortic valve decalcification: serial Doppler echocardiographic follow-up.

Serial two-dimensional and Doppler echocardiography was performed on 61 patients who had surgical ultrasonic aortic valve decalcification for calcific aortic stenosis. The mean patient age at the time of operation was 77.4 +/- 7.0 years; 93% had moderate to severe preoperative symptomatic limitation. Compared with preoperative studies, Doppler echocardiographic evaluation before hospital discharge revealed a significant reduction in the mean aortic valve pressure gradient (45.3 +/- 16.2 to 14.4 +/- 6.5 mm Hg, p less than 0.0001) and improvement in aortic valve area (0.62 +/- 0.17 to 1.33 +/- 0.33 cm2, p less than 0.0001). There was no initial change in aortic regurgitation grade. Follow-up Doppler echocardiographic evaluation was possible in 43 patients alive at 9.3 +/- 3.9 months. A small but statistically significant trend toward aortic restenosis was found; only one patient had severe restenosis. Severe aortic regurgitation had developed in 26% of patients and moderate aortic regurgitation in 37%. Aortic valve replacement was performed in six patients (14%) with severe symptomatic aortic regurgitation. Significant deficiency in central coaptation as a result of cusp scarification and retraction appeared to be the mechanism of postdecalcification regurgitation. Attempted salvage of the native aortic valve in severe calcific stenosis by ultrasonic decalcification adequately relieves stenosis but leads to an unacceptable incidence of significant aortic regurgitation at follow-up study.

Mitral regurgitation due to ruptured chordae tendineae in patients with hypertrophic obstructive cardiomyopathy.

Mitral valve regurgitation in association with hypertrophic obstructive cardiomyopathy is usually caused by the systolic anterior motion of the anterior mitral leaflet. Recently, five patients were encountered with hypertrophic obstructive cardiomyopathy who had mitral regurgitation due to ruptured chordae tendineae. The diagnosis was confirmed in all patients during operation for left ventricular septal myectomy-myotomy (Morrow procedure). Preoperative identification of ruptured chordae tendineae as the cause of mitral regurgitation was established by transesophageal echocardiography in the three most recent cases. All patients had successful septal myectomy-myotomy for relief of left ventricular outflow obstruction, and mitral valve competence was restored by valve repair rather than by prosthetic valve replacement. The clinical course of these patients illustrates important management considerations as well as the utility of transesophageal echocardiography for diagnosis. Chordal rupture should be considered in the differential diagnosis of mitral regurgitation in patients with hypertrophic obstructive cardiomyopathy, especially in those with acute hemodynamic deterioration.

Intracellular calcium transients in human working myocardium as detected with aequorin.

The calcium transients associated with contraction in human working myocardium were recorded by use of the bioluminescent protein, aequorin, a substance that emits light when it combines with calcium ion (Ca++). Small amounts of aequorin were microinjected into superficial cells of human atrial and ventricular muscle obtained from tissue routinely excised and discarded at the time of cardiac surgery. Light output, an index of intracellular Ca++, and isometric tension development were recorded at 37.5 degrees C at 1 to 5 second intervals of stimulation. Light increases much more quickly than tension and decreases toward basal levels by the time that peak tension is reached. The configuration and time course of the aequorin signal in human myocardium and its responses to inotropic interventions are similar to those recorded in lower mammalian species. The calcium transient appears to be dominated by the release and uptake of Ca++ from intracellular stores under all conditions studied. These results indicate that aequorin is a useful tool for studying the effects of drugs and disease states on cardiac excitation-contraction coupling in human beings as well as in lower animals.

Hypertrophic obstructive cardiomyopathy: preoperative echocardiographic predictors of outcome after septal myectomy.

OBJECTIVES: The purpose of this study was to determine whether two-dimensional and Doppler echocardiography are predictive of clinical outcome in patients with hypertrophic obstructive cardiomyopathy who undergo septal myectomy. BACKGROUND: Surgical myectomy provides excellent relief of symptoms in most patients with hypertrophic obstructive cardiomyopathy who are severely symptomatic despite medical therapy. There is a subset of patients who will remain symptomatic even after operation. Because comprehensive two-dimensional and Doppler echocardiography can define the range of anatomic and associated pathophysiologic abnormalities, it was hypothesized that preoperative echocardiographic variables may be predictive of clinical outcome after septal myectomy. METHODS: The clinical, electrocardiographic (ECG), echocardiographic and surgical data of 47 adult patients with hypertrophic cardiomyopathy who underwent isolated septal myectomy from 1986 to 1992 were analyzed. Specific symptoms were evaluated both preoperatively and at 1 year postoperatively. Electrocardiography and echocardiography were performed preoperatively and postoperatively. The ECG and echocardiographic variables were analyzed to determine whether any were predictive of residual symptoms 1 year postoperatively. RESULTS: The mean [+/-SD] age of the patients was 47 +/- 15 years. All were New York Heart Association functional class III or IV. Dyspnea was present in all 47 patients and was severe in 70%. Most patients experienced symptomatic improvement at 1 year; dyspnea persisted in 26 patients (55%). The preoperative echocardiographic variables of asymmetric hypertrophy, severe systolic anterior motion of the mitral leaflet(s) and prolonged isovolumetric relaxation time were independent predictors of mild or no residual dyspnea postoperatively. CONCLUSIONS: This initial study shows that the preoperative echocardiographic variables of asymmetric hypertrophy, severe systolic anterior motion of the mitral leaflet(s) and prolonged isovolumetric relaxation time can identify patients who are most likely to benefit from septal myectomy.

Cardiorespiratory response to exercise after the Fontan operation: a serial study.

OBJECTIVES: The purpose of this study was to assess whether there is deterioration of aerobic capacity over time after the Fontan operation in individual patients. BACKGROUND: We previously observed that maximal aerobic capacity after the Fontan operation was lower in older patients than in younger patients. It was unclear whether this represented a decrease in aerobic capacity with time after operation or was a function of studying patients of different ages at different times postoperatively. METHODS: All patients who had more than one postoperative exercise study were included. There were 25 patients (19 male, 6 female), aged 3.8 to 39 years at the time of the operation. The first exercise test was performed, on average, 2.2 years after the Fontan operation, and the last exercise test was performed, on average, 5.9 years (range 1.8 to 13) after the operation. In 11 patients, coronary sinus drainage was left on the pulmonary venous side. Five patients had had a previous Glenn operation. Exercise was performed to exhaustion with use of a 3-min incremental cycle protocol. RESULTS: Exercise duration, oxygen uptake, blood pressure, respiratory rate, minute ventilation, pulmonary blood flow index, exercise factor, ST-T wave changes and the prevalence of arrhythmias were similar during the first and last tests. Exercise systemic arterial blood oxygen saturation decreased from the first to the last postoperative test (p < 0.006) regardless of age. The percent of predicted heart rate, at rest and during maximal exercise, decreased more in older patients from the first to the last test (p < 0.05 for rest and exercise). CONCLUSIONS: In this select group of patients, exercise tolerance remained relatively unchanged over the range of 13 years after the Fontan operation. Heart rate at rest and during maximal exercise decreased more than predicted for age in older patients. A small but significant progressive decrease in systemic arterial blood oxygen saturation was found. The former might represent abnormal sinus node function in patients with functional single ventricle, and the latter might represent a tendency toward development of abnormal ventilation/perfusion patterns resulting from the development of small pulmonary arteriovenous fistulas or an effect of position of the coronary sinus postoperatively.

Early and late results of the modified Fontan procedure for double-inlet left ventricle: the Mayo Clinic experience.

Between May 1974 and March 1989, 155 patients with double-inlet left ventricle had the Fontan procedure performed at the Mayo Clinic. Age at operation ranged from nearly 2 to 41 years (median 10). The operative mortality rate from 1974 through 1980 (39 patients) was 21%, but from 1981 through 1989 (116 patients) it was reduced to 9%. The 17 late deaths were secondary to reoperation (n = 8), progressive myocardial failure (n = 5), sudden arrhythmia (n = 3) and bleeding varices (n = 1). Neither operative nor late mortality rate was significantly related to age at operation. At follow-up of 6 months to 11 years (mean 4.9 years) in 111 patients, 88% were in good or excellent condition and 12% were in fair or poor condition. The Fontan operation can be performed with a mortality risk of less than 10% in properly selected patients with double-inlet left ventricle. Late results are encouraging when contrasted with the clinical course of patients before this operative approach was utilized.

Cardiac surgery in the octogenarian: perioperative outcome and clinical follow-up.

The perioperative and follow-up results of cardiac operations employing extracorporeal circulation and cold cardioplegic arrest were examined in 191 consecutive patients greater than or equal to 80 years of age having surgery over a 5 year period (1982 to 1986). Most patients had severe preoperative symptoms with functional class III (39.8%) or IV (57.1%) limitation. The overall 30 day postoperative cardiac mortality rate was 15.7%. The total in-hospital mortality rate was 18.8%; the mean postoperative hospital stay was 16.4 +/- 13.3 days. The perioperative mortality rate for elective operations was as follows: coronary artery bypass (5.6%), aortic valve replacement (9.6%), aortic valve replacement with coronary bypass (17.9%) and mitral valve surgery with or without coronary bypass (21.4%). Urgent operations were performed in 39 patients (20.4%) with a total perioperative mortality rate of 35.9%; urgent coronary artery bypass was performed in 26 patients (67%) with an in-hospital mortality rate of 23.1%. Clinical evidence of left ventricular failure, functional class IV symptoms, left ventricular ejection fraction less than 50%, mitral valve repair or replacement for severe mitral regurgitation and urgent operation were associated with an increased perioperative mortality rate. Follow-up study in all 155 patients surviving postoperative hospitalization at 22.6 +/- 14.8 months showed significant improvement in symptom status in all surgical subgroups. There were 18 follow-up deaths (11.6%); 10 were noncardiac. The actuarial survival rate of the entire study group was significantly better than that in age- and gender-matched control subjects (p = 0.037).(ABSTRACT TRUNCATED AT 250 WORDS)

Exercise tolerance and cardiorespiratory response to exercise after the Fontan operation for tricuspid atresia or functional single ventricle.

To determine the impact of the Fontan operation on exercise tolerance and on the cardiorespiratory response to exercise, we compared the results of graded exercise to maximal effort of 81 patients with tricuspid atresia or single functional ventricle studied preoperatively with those of 29 patients studied postoperatively. Postoperatively, the values for total work performed, duration of exercise and maximal oxygen uptake increased significantly. Regardless of operative status, the maximal heart rate during exercise was reduced. The cardiac output and stroke volume response to exercise were subnormal after operation. Systemic arterial blood oxygen saturation was reduced markedly preoperatively both at rest and during exercise; postoperatively, it was significantly greater than the preoperative value but it remained slightly abnormal. The ventilatory response to exercise (respiratory rate, minute ventilation and ventilatory equivalent for oxygen) decreased toward normal after operation. Exercise tolerance and the cardiorespiratory responses to exercise improve after the Fontan operation. Formal exercise testing is essential to quantitate the degree of improvement.

Long-term follow-up of patients undergoing closed transventricular mitral commissurotomy: a useful surrogate for percutaneous balloon mitral valvuloplasty?

OBJECTIVE: The aim of this study was to determine the long-term outcome and multivariate predictors of late events in patients who underwent transventricular mitral commissurotomy at the Mayo Clinic in the early 1960s. BACKGROUND: Percutaneous balloon mitral valvuloplasty is an important new procedure for which long-term follow-up data are not yet available. However, such data do exist for patients who have undergone transventricular mitral commissurotomy, a similar but older and more invasive procedure. METHODS: Follow-up data (mean duration 13.9 years) for 207 women and 60 men who underwent transventricular mitral commissurotomy were obtained from medical records, referring physicians, questionnaires and telephone interviews. Survival and survival free of repeat commissurotomy or mitral valve surgery were estimated with the Kaplan-Meier method. Cox proportional hazards model was used to determine predictors of survival and repeat mitral valve surgery. RESULTS: Postoperatively, 92% of patients had symptomatic improvement, which was sustained for at least 3 to 4 years in 78%. At 10, 15 and 20 years postoperatively, 79%, 67% and 55%, respectively, of patients were alive and 57%, 36% and 24%, respectively, were alive and free of repeat mitral valve surgery. At 10 years, 90% of all patients were free of transient or fixed cerebrovascular events. In multivariate analyses, atrial fibrillation, age and male gender were independently associated with death, whereas mitral valve calcification, cardiomegaly and mitral regurgitation independently predicted repeat mitral valve surgery. CONCLUSIONS: Long-term results after transventricular mitral commissurotomy are excellent in selected patients with symptomatic mitral stenosis. Because of similarities in patient selection and mechanisms of mitral valve dilation, similar favorable long-term outcomes may be expected after percutaneous balloon mitral valvuloplasty.

Intraoperative evaluation of mitral valve regurgitation and repair by transesophageal echocardiography: incidence and significance of systolic anterior motion.

OBJECTIVE: This study was designed to delineate the utility and results of intraoperative transesophageal echocardiography in the evaluation of patients undergoing mitral valve repair for mitral regurgitation. BACKGROUND: Mitral valve reconstruction offers many advantages over prosthetic valve replacement. Intraoperative assessment of valve competence after repair is vital to the effectiveness of this procedure. METHODS: Intraoperative transesophageal echocardiography was performed in 143 patients undergoing mitral valve repair over a period of 23 months. Before and after repair, the functional morphology of the mitral apparatus was defined by two-dimensional echocardiography; Doppler color flow imaging was used to clarify the mechanism of mitral regurgitation and to semiquantitate its severity. RESULTS: There was significant improvement in the mean mitral regurgitation grade by composite intraoperative transesophageal echocardiography after valve repair (3.6 +/- 0.8 to 0.7 +/- 0.7; p less than 0.00001). Excellent results from initial repair with grade less than or equal to 1 residual mitral regurgitation were observed in 88.1% of patients. Significant residual mitral regurgitation (grade greater than or equal to 3) was identified in 11 patients (7.7%); 5 underwent prosthetic valve replacement, 5 had revision of the initial repair and 1 patient had observation only. Of the 100 patients with a myxomatous mitral valve, the risk of grade greater than or equal to 3 mitral regurgitation after initial repair was 1.7% in patients with isolated posterior leaflet disease compared with 22.5% in patients with anterior or bileaflet disease. Severe systolic anterior motion of the mitral apparatus causing grade 2 to 4 mitral regurgitation was present in 13 patients (9.1%) after cardiopulmonary bypass. In 8 patients (5.6%), systolic anterior motion resolved immediately with correction of hyperdynamic hemodynamic status, resulting in grade less than or equal to 1 residual mitral regurgitation without further operative intervention. Transthoracic echocardiography before hospital discharge demonstrated grade less than or equal to 1 residual mitral regurgitation in 86.4% of 132 patients studied. A significant discrepancy (greater than 1 grade) in residual mitral regurgitation by predischarge transthoracic versus intraoperative transesophageal echocardiography was noted in 17 patients (12.9%). CONCLUSIONS: Transesophageal echocardiography is a valuable adjunct in the intraoperative assessment of mitral valve repair.

Echocardiographic prediction of left ventricular function after correction of mitral regurgitation: results and clinical implications.

OBJECTIVES: This study attempted to determine the incidence, prognosis and predictability of postoperative left ventricular dysfunction in patients undergoing correction of mitral regurgitation. BACKGROUND: Left ventricular function in patients with mitral regurgitation is altered by loading conditions and is difficult to assess. Predictive value of preoperative variables on postoperative left ventricular function and the role of echocardiography are uncertain. METHODS: In 266 patients undergoing correction of mitral regurgitation between 1980 and 1989, left ventricular function was echocardiographically assessed preoperatively (within 6 months) and postoperatively (within 1 year). RESULTS: After correction of mitral regurgitation, left ventricular ejection fraction decreased significantly ([mean +/- SD] 50% +/- 14% vs. 58% +/- 13%, p < 0.0001). Postoperative left ventricular dysfunction (ejection fraction < 50%) was frequent (41% of patients) and carried a poor prognosis (at 8 years survival, 38% +/- 9% vs. 69% +/- 8%, p < 0.0001). Four preoperative echocardiographic variables showed good correlation with postoperative ejection fraction: preoperative ejection fraction (r = -0.70), systolic diameter (r = -0.63), diameter/thickness ratio (r = -0.64) and end-systolic wall stress (r = -0.62) (all p < 0.0001). With multivariate analysis, ejection fraction (p = 0.0001) and systolic diameter (p = 0.0005) were independent predictors of postoperative ejection fraction, and angiographic variables provided no incremental predictive power. In addition to echocardiographic variables, recent regurgitation, functional class and coronary artery disease were also independent predictors of postoperative ejection fraction. CONCLUSIONS: After surgical correction of mitral regurgitation, left ventricular dysfunction is frequent and carries a poor prognosis. Postoperative ejection fraction can be predicted by echocardiographic preoperative ejection fraction and systolic diameter. Recent onset of regurgitation, mild or no symptoms, and absence of coronary artery disease are independent and favorable predictors of postoperative ejection fraction. These results should lead to consideration of surgical correction at an earlier stage.

Comparison of dual-chamber pacing versus septal myectomy for the treatment of patients with hypertrophic obstructive cardiomyopathy: a comparison of objective hemodynamic and exercise end points.

OBJECTIVES: The purpose of this study was to compare the treatment effects of septal myectomy with dual-chamber pacing in patients with hypertrophic obstructive cardiomyopathy (HOCM). BACKGROUND: The optimal treatment for symptomatic patients with drug-refractory HOCM is unknown. Both dual-chamber pacing and surgical myectomy may result in subjective symptom improvement. However, no direct comparisons with objective end points have been reported. METHODS: Thirty-nine patients with symptomatic HOCM were analyzed in this concurrent cohort study. Twenty patients underwent surgical myectomy, and 19 received dual-chamber pacemakers based on patient preference. These patients had prospective baseline and follow-up evaluations including physician assessment, echocardiography and standardized metabolic treadmill exercise testing. RESULTS: Baseline symptom status, left ventricular outflow tract gradients, exercise times and maximal oxygen consumption peak were similar between the two groups. Left ventricular outflow gradient was reduced from 76+/-57 to 9+/-17 mm Hg (p = 0.0001) after myectomy, and from 77+/-61 to 55+/-39 mm Hg (p = 0.07) after pacing (p = 0.02 for comparison with myectomy). Ninety percent of myectomy patients experienced symptomatic improvement as compared with 47% in the pacing group. Exercise duration increased significantly from 6.6+/-2.8 to 8.7+/-3.0 min (p = 0.0003) after myectomy compared with a change from 6.4+/-2.1 to 7.0+/-2.2 min (p = NS) in the pacing group. Maximal oxygen consumption increased from 19.4+/-6.4 to 22.2+/-6.5 ml/kg/min after myectomy (p = 0.004), whereas the pacing group did not experience any significant change (19.6+/-6.5 vs. 20.1+/-6.5 ml/kg/min, p = NS). CONCLUSIONS: Surgical myectomy and dual-chamber pacing improve subjective measures of functional status in patients with symptomatic HOCM. In this nonrandomized study, myectomy offered greater reduction in left ventricular outflow tract gradients and larger improvements in objective measures of patient symptoms and functional status when compared with dual-chamber pacing.