RESUMO
BACKGROUND: Bioprostheses preserved with glutaraldehyde, both porcine and pericardial, have been available as second-generation prostheses for valve replacement surgery. The performance with regard to structural valve deterioration with the Carpentier-Edwards supra-annular (CE-SAV) porcine bioprosthesis and the Carpentier-Edwards Perimount (CE-P) pericardial bioprosthesis (Baxter Healthcare Corp, Edwards Division, Santa Ana, Calif) was evaluated to determine whether there was a difference in mitral valve replacement. METHODS: The CE-SAV bioprosthesis was implanted in 1266 overall mitral valve replacements (isolated mitral, 1066; mitral in multiple, 200) and the CE-P bioprosthesis in 429 overall mitral valve replacements (isolated mitral, 328; mitral in multiple, 101). The mean age of the CE-SAV population was 64.2 +/- 12.2 years and that of the CE-P population, 60.7 +/- 11.7 years (P =.0001). For the study, structural valve deterioration was diagnosed at reoperation for explantation. RESULTS: The freedom from structural valve deterioration was evaluated to 10 years, and the freedom rates reported are at 10 years. For the overall mitral valve replacement groups, the actuarial freedom from deterioration was significant (P =.0001): CE-P > CE-SAV for 40 years or younger, 80% versus 60%; 41 to 50 years, 91% versus 61%; 51 to 60 years, 84% versus 69%; 61 to 70 years, 95% versus 75%. The older than 70-year group was 100% versus 92% (no significant difference). The actual freedom from structural valve deterioration also demonstrated the same pattern at 10 years: 40 years or younger, CE-P 82% versus CE-SAV 68%; 41 to 50 years, 92% versus 70%; 51 to 60 years, 90% versus 80%; 61 to 70 years, 97% versus 88%; and older than 70 years, 100% versus 97%. The independent risk factors of structural valve deterioration for the overall mitral valve replacement group were age and age groups and prosthesis type (CE-SAV > CE-P). The prosthesis type either in isolated replacement or in multiple replacement was not predictive of structural valve deterioration. The pathology of structural valve deterioration was different: 70% of CE-P failures were due to calcification and 57% of CE-SAV failures were due to combined calcification and leaflet tear. CONCLUSION: The actuarial and actual freedom from structural valve deterioration, diagnosed at reoperation, is greater at 10 years for CE-P than for CE-SAV bioprostheses. The mode of failure is different, and the cause remains obscure. Long-term evaluation is recommended, because the different modes of failure may alter the clinical performance by 15 and 20 years.
Assuntos
Bioprótese , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Valva Mitral/cirurgia , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Seguimentos , Doenças das Valvas Cardíacas/mortalidade , Doenças das Valvas Cardíacas/cirurgia , Implante de Prótese de Valva Cardíaca/mortalidade , Humanos , Lactente , Recém-Nascido , Pessoa de Meia-Idade , Falha de Prótese , Fatores de Risco , Taxa de Sobrevida , Resultado do TratamentoRESUMO
The surgical relief of complex multilevel left ventricular outflow tract obstruction remains a challenging problem. We present a new operation that combines the concepts of aortoventriculoplasty, extended aortic root replacement, and the use of a pulmonary autograft. Fourteen patients underwent this operation: 9 patients after previous attempts to relieve diffuse subvalvular stenosis and 5 patients who had excessive gradients over an outgrown aortic valve prosthesis. All patients except 1 survived the operation. Complete heart block developed in 1 patient after a septal infarction. One patient remained in congestive heart failure and died suddenly after 17 months. All other patients are in New York Heart Association class I after a mean follow-up of 20 +/- 12 months. All patients showed excellent function of the autograft and homograft valve at follow-up. This operation might present a more durable or even a definitive solution in the management of these complex left ventricular outflow tract obstructions.
Assuntos
Valva Aórtica/cirurgia , Valva Pulmonar/transplante , Adolescente , Adulto , Criança , Pré-Escolar , Ecocardiografia Doppler , Humanos , Complicações Pós-Operatórias , Transplante Autólogo/métodos , Obstrução do Fluxo Ventricular Externo/diagnóstico por imagem , Obstrução do Fluxo Ventricular Externo/fisiopatologia , Obstrução do Fluxo Ventricular Externo/cirurgiaRESUMO
A case of a 53-year-old man with constrictive pericarditis due to the ingestion of a toothpick is presented. Computed tomography was unable to show the toothpick, and the diagnosis was made during the operation. Ingested toothpicks have often been reported as a cause of gastrointestinal injuries but in this rare case a toothpick actually migrated into the pericardium.
Assuntos
Candidíase/etiologia , Corpos Estranhos/complicações , Pericardite/etiologia , Pericardite/microbiologia , Pericárdio , Drenagem/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Derrame Pericárdico/etiologia , Derrame Pericárdico/terapia , Técnicas de Janela Pericárdica , PericardiectomiaRESUMO
BACKGROUND: The Hemopump was developed as a more powerful assist device for postcardiotomy support in patients in whom the intraaortic balloon pump is insufficient. METHODS: Over a 2-year period 21 (0.8%) of 2,585 patients undergoing cardiac operations needed a ventricular assist device because of postcardiotomy heart failure unresponsive to pharmacologic and intraaortic balloon support. Sixteen of these patients were assisted with the 24F transthoracic Hemopump left ventricular assist device. The aim of the mechanical support was myocardial recovery as the underlying conditions (age, arterial hypertension, diabetes, vascular and pulmonary disease) excluded heart transplantation. RESULTS: Hemodynamic improvement was apparent with a decrease in left atrial pressure (mean, 18.6 to 9.2 mm Hg), an increase in arterial blood pressure (mean, 54.1 to 70.1 mm Hg), and an increase in cardiac index. Five patients died within the first 24 hours because of low cardiac output. Although the heart was well unloaded (decrease in left atrial pressure of 8 +/- 4.69 mm Hg versus 9.3 +/- 5.51 mm Hg for the other patients), the increase in cardiac index was significantly lower (+0.516 versus +1.377 L.min-1.m-2; p = 0.027). Three of these 5 patients were known to have severe left ventricular hypertrophy. Of the remaining 11 patients, 2 were assisted for 1 week but failed to show recovery of the myocardium, 8 (50%) were weaned, and 4 (25%) were discharged. There were no device-related complications except the thrombosis of a cannula that was left for 10 days. CONCLUSIONS: The transthoracic Hemopump is an easy-to-use and reliable assist device. Left ventricular hypertrophy is a relative contraindication for the use of the Hemopump.
Assuntos
Baixo Débito Cardíaco/terapia , Coração Auxiliar , Idoso , Baixo Débito Cardíaco/mortalidade , Baixo Débito Cardíaco/fisiopatologia , Contraindicações , Feminino , Hemodinâmica , Humanos , Hipertrofia Ventricular Esquerda/fisiopatologia , Balão Intra-Aórtico , Masculino , Pessoa de Meia-Idade , Taxa de Sobrevida , Resultado do TratamentoRESUMO
BACKGROUND: Factors determining the outcome of operative correction of valvular abnormalities combined with coronary artery bypass grafting are still incompletely defined. METHODS: Determinants of early and late (more than 90 days) deaths and event-free survival were studied for combined valve operations and coronary artery bypass grafting in 741 patients using multivariate analysis. RESULTS: Ninety-day survival probability was 89% (95% confidence interval, 87% to 92%). Preoperative risk factors for early death were age, female sex, renal failure, New York Heart Association class IV or V, and mitral insufficiency. The operative risk factor was the duration of aortic cross-clamping. Five- and 10-year survival probabilities were 74% (95% confidence interval, 71% to 78%) and 43% (95% confidence interval, 36% to 50%), respectively. Preoperative risk factors for late death were age, preoperative renal failure, New York Heart Association class IV or V, vessel disease, and nonsinus rhythm. Five- and 10-year event-free survival probabilities were 57% (95% confidence interval, 53% to 61%) and 23% (95% confidence interval, 17% to 28%), respectively. Preoperative risk factors for non-event-free survival were age, female sex, reduced left ventricular function, mitral regurgitation, and pacemaker rhythm. CONCLUSION: The demographic factors of age and female sex; the comorbid condition of renal failure; the cardiac conditions of advanced New York Heart Association class, left ventricular function, mitral regurgitation, vessel disease, and cardiac rhythm; and the operative condition of ischemia time are the most important predictors of clinical outcome after combined valve operations and coronary artery bypass grafting.
Assuntos
Ponte de Artéria Coronária , Doença das Coronárias/cirurgia , Doenças das Valvas Cardíacas/cirurgia , Próteses Valvulares Cardíacas , Fatores Etários , Idoso , Valva Aórtica/cirurgia , Ponte de Artéria Coronária/mortalidade , Doença das Coronárias/complicações , Doença das Coronárias/mortalidade , Feminino , Doenças das Valvas Cardíacas/complicações , Doenças das Valvas Cardíacas/mortalidade , Mortalidade Hospitalar , Humanos , Falência Renal Crônica/complicações , Lidoflazina/uso terapêutico , Masculino , Pessoa de Meia-Idade , Valva Mitral/cirurgia , Análise Multivariada , Pré-Medicação , Modelos de Riscos Proporcionais , Fatores de Risco , Fatores Sexuais , Análise de Sobrevida , Resultado do Tratamento , Valva Tricúspide/cirurgia , Vasodilatadores/uso terapêuticoRESUMO
A case of an intrapericardial tumor diagnosed in utero at 26 weeks of gestation is presented. The prenatal echocardiographic follow-up of an incipient hydrops fetalis determined the management and the emergency surgical treatment. Histologically, the tumor appeared to be a benign teratoma, grade I. In the postoperative period an unexpected mediastinal tumor was found and removed later. This tumor also appeared to be a benign teratoma, grade 0. Both teratomas were independent and therefore primary.
Assuntos
Tamponamento Cardíaco/etiologia , Doenças Fetais/etiologia , Neoplasias Cardíacas/complicações , Teratoma/complicações , Adulto , Feminino , Humanos , Hidropisia Fetal/etiologia , Recém-Nascido , Masculino , Neoplasias do Mediastino/diagnóstico , Neoplasias Primárias Múltiplas/diagnóstico , Pericárdio , Teratoma/diagnósticoRESUMO
BACKGROUND: This multicenter study concerning the mitral PERIMOUNT valve previously reported clinical results at 12 years; this report updates the performance to 15 years postoperatively. METHODS: The 435 patients (mean age 60.7+/-11.6 years; 41.1% male) underwent implantation with the PERIMOUNT valve between 1984 and 1989 at seven institutions. Follow-up was complete for 96.1% of the cohort. The mean follow-up was 8.1+/-4.4 years (range 0 to 15.4 years) for a total of 3492 patient-years. RESULTS: There were 34 (7.8%) operative deaths, one (0.2%) valve related. The late mortality rate was 5.3%/patient-year (2.2%/patient-year valve related). At 14 years, the overall actuarial survival rate was 37.1%+/-3.3% (63.1%+/-4.4% valve related). Actuarial freedom from complications at 14 years was as follows: thromboembolism, 83.8%+/-3.2% (1.1%/patient-year); hemorrhage, 86.6%+/-3.2% (1.1%/patient-year); and explant due to structural valve deterioration (SVD), 68.8%+/-4.7%. Actual freedom from explant due to SVD was 83.4%+/-2.3%. Rates of structural failure decreased with increasing age at implant. CONCLUSIONS: The Carpentier-Edwards PERIMOUNT Pericardial Bioprosthesis is a reliable choice for a tissue valve in the mitral position, especially in patients more than 60 years of age.
Assuntos
Bioprótese , Próteses Valvulares Cardíacas , Valva Mitral/cirurgia , Análise Atuarial , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Causas de Morte , Criança , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/mortalidade , Desenho de Prótese , Falha de Prótese , Fatores de RiscoRESUMO
Eighteen patients suffering from acute left heart failure were selected as candidates for Hemopump support. In 6 patients, peripheral atheromatosis prevented insertion of the device. Of the remaining 12 patients, 9 had postcardiotomy shock, 2 had acute rejection after orthotopic heart transplantation, and 1 had acute myocardial infarction complicated by a large postinfarction ventricular septal defect. During Hemopump support, hemodynamics recovered in all patients. Major complications were related to mechanical pump failure, such as fracture of the drive cable and expulsion of the cannula out of the ventricle, or to hemolysis of variable degree. Seven patients (58%) survived and were discharged from the hospital: the 2 patients bridged to heart transplantation and 5 of the 9 postcardiotomy patients, including 1 who could not be weaned but later underwent successful transplantation. The patient with the postinfarction ventricular septal defect died after removal of the device because of hemolysis. These results indicate that the Hemopump is a relatively noninvasive and efficacious left ventricular system of moderate power.
Assuntos
Baixo Débito Cardíaco/terapia , Coração Auxiliar , Adulto , Idoso , Pressão Sanguínea/fisiologia , Débito Cardíaco/fisiologia , Baixo Débito Cardíaco/etiologia , Baixo Débito Cardíaco/fisiopatologia , Pressão Venosa Central/fisiologia , Desenho de Equipamento , Falha de Equipamento , Feminino , Rejeição de Enxerto/complicações , Transplante de Coração/efeitos adversos , Coração Auxiliar/efeitos adversos , Hemólise , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Choque Cardiogênico/complicações , Taxa de Sobrevida , Resultado do Tratamento , Função Ventricular EsquerdaRESUMO
The surgical relief of complex multilevel left ventricular outflow tract (LVOT) obstruction remains a challenging surgical problem. We present a new operation which combines the concepts of aortoventriculoplasty, extended aortic root replacement, and the use of a pulmonary autograft. Sixteen patients underwent this operation: 11 patients after previous attempts to relieve diffuse subvavalvular stenosis and 5 patients who presented excessive gradients over a previous aortic valve prosthesis. All patients except one survived the operation. One patient developed massive right ventricular infarction and underwent transplantation after 5 days. Another patient developed complete heart block and transient tricuspid regurgiation after a septal infarction. One patient remained in congestive heart failure and died suddenly after 17 months. All other patients are in NYHA class I after a mean follow-up of 23 +/- 12 months. One patient developed progressive dilatation of the neo-aortic root and underwent reoperation after 4 years. All other patients showed laminar flow in the LVOT and excellent function of the autograft and homograft valve at follow-up. This operation offers a more durable or even a definitive solution in the management of these complex left ventricular outflow tract obstructions.
Assuntos
Aorta/cirurgia , Valva Pulmonar/transplante , Obstrução do Fluxo Ventricular Externo/cirurgia , Adolescente , Adulto , Criança , Pré-Escolar , Humanos , Complicações Pós-Operatórias , Transplante Autólogo , Procedimentos Cirúrgicos Vasculares/métodosRESUMO
The surgical relief of complex multilevel left ventricular outflow tract (LVOT) obstruction remains a challenging surgical problem. We present a new operation which combines the concepts of aortoventriculoplasty, extended aortic root replacement and the use of a pulmonary autograft. Sixteen patients underwent this operation: 11 patients after previous attempts to relieve diffuse subvalvular stenosis and five patients who presented excessive gradients over an outgrown aortic valve prosthesis. All patients, except one survived the operation. One patient developed massive right ventricular infarction and was transplanted after five days. Another patient developed complete heart block and transient tricuspid regurgitation after a septal infarction. One patient remained in congestive heart failure and died suddenly after 17 months. All other patients are in NYHA class I after a mean follow up of 21 +/- 12 months. One patient developed progressive dilatation of the neo-aortic root and was reoperated four years after initial surgery. All other patients showed laminar flow in the LVOT and excellent function of the autograft and homograft valve at follow up. This operation might present a durable or even a definitive solution in the management of these complex left ventricular outflow tract obstructions.
Assuntos
Valva Pulmonar/transplante , Obstrução do Fluxo Ventricular Externo/cirurgia , Adolescente , Adulto , Estenose Aórtica Subvalvar/cirurgia , Valva Aórtica/cirurgia , Débito Cardíaco , Criança , Pré-Escolar , Dilatação Patológica/etiologia , Seguimentos , Bloqueio Cardíaco/etiologia , Insuficiência Cardíaca/cirurgia , Septos Cardíacos/patologia , Próteses Valvulares Cardíacas , Ventrículos do Coração/cirurgia , Humanos , Infarto do Miocárdio/etiologia , Complicações Pós-Operatórias , Reoperação , Taxa de Sobrevida , Transplante Autólogo , Transplante Homólogo , Insuficiência da Valva Tricúspide/etiologiaRESUMO
A prospective randomized study, comparing the clinical results between two groups of patients undergoing valve replacement with the Monostrut (MS) and Medtronic-Hall (MH) heart valve prosthesis was carried out between January 1985 and December 1988. A MS valve was implanted in 205, the MH in 198 patients selected randomly. Statistical analysis showed a perfect match between the two groups regarding preoperative and operative variables, including implantation site. All patients were given life-long anticoagulant therapy after operation. Follow up was 5.06 years (median) with a total of 1971.1 patient-years (pty) and 96.6% complete. The two groups showed no significant difference in the incidence of the following postoperative events: 30-day mortality, late mortality, reoperation, anticoagulant related bleeding, paravalvular leak, prosthetic valve endocarditis and thromboembolism (TE). Multivariate analysis indicated a borderline increased hazard of TE (2.1 +/- 0.4%/pty versus 0.7 +/- 0.2%/pty) (p = 0.0087, Bonferoni corrected significance) in the MS group. It is concluded that long term outcome is excellent with these two tilting disc valves. The marginally lower incidence of thromboembolism, however, favors the Medtronic Hall prosthesis.
Assuntos
Próteses Valvulares Cardíacas , Adolescente , Adulto , Idoso , Feminino , Próteses Valvulares Cardíacas/efeitos adversos , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Desenho de Prótese , Reoperação , Trombose/etiologia , Resultado do TratamentoRESUMO
BACKGROUND AND AIM OF THE STUDY: The Ross operation has become very popular during the last decade. However little is known about the cellular behaviour of a normally functioning pulmonary autograft. METHODS: This case report deals with a 14-year-old female who died from a non-valve-related cause 17 months after a Ross-Konno operation using a cryop-reserved viable pulmonary homograft for the right outflow tract. Comparison is made between the homologous and autologous pulmonary valves by macroscopic description, histology and immunohistochemistry. RESULTS: The autograft kept its cellular population-except for the dendritic cells which have disappeared, and developed a jet lesion on the ventricular aspect of one cusp as a likely adaptation to a transvalvular gradient. The homograft was extensively devitalized, its cusps being partially covered with a fibrous sheath of recipient origin; few inflammatory cells, consisting of macrophages and rare T lymphocytes were present. CONCLUSIONS: The most puzzling observation, which needs confirmation, is the selective disappearance of the dendritic cells from the viable autograft. It is disappointing that a viable cryopreserved homograft valve has devitalized in the midterm. This phenomenon seems to result from a clinically silent immune reactions.
Assuntos
Valva Aórtica/cirurgia , Cardiopatias Congênitas/cirurgia , Valva Pulmonar/patologia , Valva Pulmonar/transplante , Adolescente , Criopreservação , Células Dendríticas/patologia , Feminino , Cardiopatias Congênitas/patologia , Humanos , Fatores de Tempo , Transplante Autólogo , Transplante HomólogoRESUMO
Propionibacterium acnes, a constituent of the human cutaneous flora, infected both the native mitral valve and a Carpentier mitral annuloplasty ring in an adolescent patient. In the case of culture negative endocarditis, the incubation period of blood cultures should be prolonged to identify this pathogen.