Mitral valve repair: results and the decision-making process in reconstruction. Report of 275 cases.

From January 1975 to June 1988, 275 patients underwent mitral valve repair for mitral regurgitation, pure (148 patients) or associated with mitral stenosis (127 patients). Patients with pure mitral stenosis were excluded from this study. The cause of mitral regurgitation was rheumatic in 180 patients (aged 28.6 +/- 1.2 years, mean +/- standard error of the mean) and degenerative in 84 patients (aged 54.7 +/- 1.5 years). Fifty-nine percent of the patients were in New York Heart Association classes III and IV before the operation. Intraoperative assessment of the mitral valve led us to identify four major mechanisms of mitral regurgitation: (1) restriction of leaflet motion by fibrosis (group I, 63 patients); (2) enhancement of leaflet motion by leaflet and chordal extension and prolapse (group II, 139 patients), (3) combination of both (group III, 64 patients); and (4) isolated dilatation of the anulus (group IV, 10 patients). One hundred sixty-one patients had isolated mitral disease and 114 had associated aortic or tricuspid valve disease, or both. The hospital mortality rate was 4.0%. Follow-up was 96% complete and totaled 1247.47 patient-years. At 13 years' follow-up, the survival rate was 93.0% +/- 6.8% in group I, 90.0% +/- 6.0% in group II, and 96.6% +/- 4.6% in group III. Freedom from reoperation was 78.1% +/- 21.0%, 83.2% +/- 18.9%, and 79.6% +/- 16.2%, respectively. Freedom from embolism was 94.7% for the whole series. In patients with isolated mitral valve repair, the cumulative morbidity was significantly higher in groups I (6.3 +/- 2.0%/pt-yr) and III 6.3% +/- 1.7%/pt-yr) than in group II (2.5% +/- 0.9%/pt-yr, p less than 0.05). Multivariate analysis identified age and associated tricuspid valve disease as significant predictors of reoperation (p less than 0.01 for both factors). These results suggest that conservative surgery should be used with caution in group I and III patients. In contrast, indications for mitral valve repair should be extended in group II patients. This observation has important clinical implications since, in Western countries, valve prolapse tends to be a major cause of mitral regurgitation.

Surgical treatment of asymptomatic and mildly symptomatic mitral regurgitation.

OBJECTIVE: The purpose of this study was to review the risk-benefit ratio of mitral valve repair in patients with severe mitral regurgitation and no or mild symptoms. METHODS: From January 1989 to December 1994, 584 patients were operated on for mitral regurgitation. Of these, 175 patients were in New York Heart Association class I or II with grade 3 to 4 isolated chronic mitral regurgitation. They comprise our study population. Mean age was 51.3 +/- 14.3 years. Principal causes of mitral regurgitation were degenerative in 128 (73%) and rheumatic in 26 patients (15%). Leaflet prolapse was the mechanism responsible for regurgitation in 152 patients (86%). Mitral valve repair was performed in 174 patients, and one patient required initial valve replacement. Mean follow-up was 34.3 +/- 18.8 months. RESULTS: Three patients died, for an overall mortality of 1.7%. Five patients were reoperated on, for an actuarial freedom from reoperation of 97.0% +/- 0.8% at 5 years. Actuarial freedom from thromboembolism and endocarditis was 96.3% +/- 1.7% and 99.4% +/- 0.6%, respectively, for an event-free survival of 91.0% +/- 2.0% at 5 years. Left atrial diameter decreased from 54.3 +/- 11.6 mm to 43.6 +/- 10.5 mm (p < 0.001). Left ventricular end-systolic and end-diastolic diameters decreased from 40.0 +/- 6.8 mm and 64.8 +/- 7.0 mm to 34.6 +/- 6.7 mm (p < 0.001) and 52.7 +/- 7.4 mm (p < 0.001), respectively. Mean residual mitral regurgitation was 0.44 +/- 0.6. CONCLUSION: Mitral valve repair for chronic mitral regurgitation in patients having mild or no symptoms was performed with low mortality and morbidity, good valve function, and preserved late left ventricular performance. Early repair may be advocated on the basis of severity of regurgitation and valve repairability, regardless of symptoms.

Treatment of ruptured or elongated anterior mitral valve chordae by partial transposition of the posterior leaflet: experience with 29 patients.

We report a series of 29 patients, 5 to 75 years of age (mean age, 31.8 +/- 21.4 [SD] years), with pure mitral regurgitation caused by ruptured or elongated chordae of the anterior mitral leaflet. These patients underwent mitral valve repair by segmental transposition of the posterior leaflet with its attached chordae sutured to the free edge of the flail anterior leaflet. There were 2 hospital deaths. Follow-up ranged from 1 to 35 months (mean follow-up, 14.9 +/- 8.5 months). One patient is lost to follow-up. Two patients are in New York Heart Association Functional Class II; all others are in Class I. In 17 patients there is no detectable murmur; in 5 patients a mild to moderate systolic murmur can be detected, while 4 have a marked systolic murmur. The adequacy of the repair could be confirmed by Doppler echocardiography, which has shown no evidence of prolapse in 22 patients. A mild regurgitation jet is present in 4 patients, and a marked jet, in 3. Postoperative cardiac catheterization performed in 5 patients has confirmed the Doppler echocardiographic findings. Although longer follow-up is necessary, this technique appears adequate for repairing a major prolapse of the anterior leaflet caused by multiple ruptured or elongated chordae, therefore obviating the need for a prosthetic valve substitute.

The "physio-ring": an advanced concept in mitral valve annuloplasty.

BACKGROUND: A new annuloplasty ring has been developed with the aim of adding flexibility to the remodeling annuloplasty concept. Here we report its clinical use with special emphasis on segmental valve analysis and valve sizing. METHODS: From October 1992 through June 1994, 137 patients aged 4 to 76 years (mean age, 49.1 years) were operated on. The main causes of mitral valve insufficiency were degenerative, 90; bacterial endocarditis, 15; and rheumatic, 13. The indication for operation was based on the severity of the mitral valve insufficiency (90 patients were in grade III or IV) rather than on functional class (60 patients were in class III or IV). At echocardiography 6 patients had normal leaflet motion (type I), 119 leaflet prolapse (type II), and 12 restricted leaflet motion (type III). Surgical repair was carried out using Carpentier techniques of valve reconstruction. In 3 patients, inadequate ring sizing was responsible for systolic anterior motion of the anterior leaflet diagnosed by intraoperative echo. The valve was replaced in 2 patients. There were three hospital deaths, no late deaths, one reoperation for recurrent mitral valve insufficiency due to chordal rupture 1 month after repair, one reoperation for atrial thrombus formation 5 months after repair, one anticoagulant-related hemorrhage, and one thromboembolic episode. RESULTS: Mid-term follow-up between 6 and 18 months was available in 94 patients. Echocardiography showed trivial or no regurgitation in 93.2% of the patients and minimal regurgitation in 6.8%. The average transmitral diastolic gradient was 3.55 +/- 1.93 mm Hg. Left ventricular end-systolic diameter and volume decreased postoperatively, demonstrating an improved left ventricular function. CONCLUSIONS: This preliminary experience has provided promising results and allowed us to define the indications of the Physio-Ring versus the classic ring. It has also shown that valve sizing and proper ring selection are of primary importance.

Beyond cold cardioplegia.

One hundred fifteen consecutive patients were operated on for myocardial revascularization or valvular disease or both with continuous antegrade and retrograde aerobic warm (37 degrees C) blood cardioplegia. Mean cross-clamp time was 56.3 +/- 21 minutes (+/- standard deviation). Mean reperfusion time was 18.4 +/- 11.8 minutes (range, 5 to 81 minutes). Five patients (4.3%) died, and 15 (13%) needed inotropic support. Two (1.7%) required intraaortic balloon support. Two patients (1.7%) had evidence of perioperative myocardial infarction, and 98 (85%) returned spontaneously to normal sinus rhythm. Sixteen patients had a cross-clamp time greater than 80 minutes. All 16 of them had an uneventful postoperative course except for 1 patient who required inotropic drugs. This method of myocardial protection is now used for all open heart procedures in our institution.

[Comparison of segmental wall motion in electrocardiogram-gated myocardial scintigraphy and transthoracic echocardiography]. / Comparaison de la cinétique segmentaire entre la tomoscintigraphie myocardique couplée à l'électrocardiogramme et l'échocardiographie transthoracique.

ECG-gated myocardial scintigraphy (Gspect) is a recent method of assessing myocardial perfusion, left ventricular ejection fraction and regional wall motion in a single investigation. It reduces the time required for the evaluation of coronary patients by radionucleide cardiology. Many reports have validated the measurement of the left ventricular ejection fraction compared with other methods. However, there are fewer series reporting the results of regional wall motion. The authors compared segmental wall motion by Gspect after injecting Thallium or Mibi and by transthoracic echocardiography in 47 patients or 423 myocardial segments. The concordance of score (normal, hypokinetic, akinetic, dyskinetic) was 75% (Kappa = 0.538). If analysis was limited to a normal-abnormal differentiation (binary analysis) it increased to 83%. When perfusion was taken into consideration, it was 81% (normal perfusion), 63% (mild hypoperfusion) and 70% (moderate and severe hypoperfusion). This concordance improved in binary analysis respectively to 85, 74 and 86% respectively. When the typs of segment was taken into consideration, concordance varied from 57 to 100%. The concordances were 74% for Thallium and 78% for Mibi scintigraphy, improving to 82% and 85% respectively in binary analysis. Thus, analysis of LV regional wall motion by Gspect is comparable to transthoracic echocardiography. This result, completed by measurement of LV ejection fraction and of myocardial perfusion, provides a method of evaluation of coronary patients in a single investigation.

[Myocardiopathies and tricyclic antidepressants. Apropos of 3 cases]. / Myocardiopathies et antidépresseurs tricycliques. A propos de 3 cas.

The authors report three cases of cardiac failure induced or aggravated by chronic tricyclic antidepressant therapy. Tricyclic antidepressants have a negative inotropic effect both when administered acutely or chronically in animals. This action is related to plasma concentrations. However, the association of chronic tricyclic antidepressant therapy and cardiac failure is rare. The implication of these drugs in the cause of cardiac failure requires: --improvement of cardiac failure on withdrawal of therapy, as observed in our three cases; --the presence of underlying cardiac disease, as was the case in our patients; --abnormally high plasma levels of the antidepressant drugs despite normal dosage, as was verified in two of our patients. The measurement of plasma concentrations of antidepressant drugs would seem to be necessary when this form of treatment is to be administered to patients predisposed to cardiac failure.

[Treatment of anterior mitral valve prolapse by partial transposition of the posterior leaflet. Apropos of 7 cases]. / Traitement des prolapsus de la valve antérieure de la mitrale par transposition partielle de la valve postérieure. A propos de 7 cas.

Seven patients aged 8 to 62 years with massive mitral regurgitation due to anterior leaflet prolapse related to rupture or elongation of the chordae tendinae underwent reconstructive mitral valvuloplasty between June 1984 and September 1985, consisting in transposition of a bandlet of the posterior leaflet and its chordae to the free edge of the anterior leaflet. Medium term results with 2 to 16 months follow-up (average 8 months) showed all patients to have returned to Class I of the NYHA Classification; 5 patients had no systolic murmur, a mild systolic murmur 1 and 2/6 was present in 2 cases. The quality of the repair was confirmed by pulsed Doppler examination in all patients and by catheterisation and angiography in 3 cases. This surgical technique offers a good solution to the problem of mitral regurgitation due to severe prolapse of the anterior leaflet caused by rupture or elongation of the chordae tendinae.

[Role of peri-operative treatment in the surgery of advanced valvular cardiopathies]. / Rôle du traitement péri-opératoire dans la chirurgie des cardiopathies valvulaires évoluées.

Between January 1981 and October 1982, 100 consecutive patients with valvular heart disease (49 p. 100 polyvalvular disease) underwent surgery. All had severe lesions; Class III or IV of the NYHA classification; cardiomegaly with an average cardio-thoracic ratio of 59 +/- 7.7 p. 100; a cardiac index of less than 2.5 1/min/m2 in 70 p. 100 of cases; pulmonary hypertension (mean PAP : 31.93 +/- 12.17 mmHg) in 89 p. 100 of cases. Half the patients were in atrial fibrillation and all had been on chronic digitalo-diuretic therapy before surgery. Thirty of the 41 patients given preoperative venous vasodilator therapy had significant reductions of their cardiothoracic ratios (63 +/- 1.5 p. 100 vs 59.1 +/- 1.6 p. 100, p less than 0.001). Conservative surgical procedures were possible in 58 cases of mitral valvuloplasty and 5 aortic valvuloplasties. Correction of functional tricuspid regurgitation (34 p. 100) was systematic. Tricuspid regurgitation masked by salt and water depletion was detected by digital palpation after clamping the pulmonary artery. In 8 cases the aortic ring had to be enlarged. The low hospital mortality (6 p. 100) and the lack of postoperative complications (assisted ventilation for less than 24 hours in 92 p. 100 of cases) compare favourably with other reported series.

[Conservative surgery of the mitral valve. Immediate and late results]. / Chirurgie conservatrice de la valve mitrale. Résultats immédiats et à distance.

A consecutive series of 130 cases of pure or predominant mitral regurgitation underwent conservative mitral valve surgery between January 1975 and January 1982. The mean age of the patients was 30 +/- 17 years; 25 patients were under 15 years of age. The most common aetiology was rheumatic fever (112/130). Fifty nine patients had associated valvular lesions requiring surgical correction. The patients were divided into 4 groups, according to the surgical technique: Group I: valvular mobilisation (35 cases); Group II: reduction of the amplitude of valvular excursion (48 cases); Group III: mixed valvular mobilisation and reduction of amplitude of excursion (45 cases); Group IV: isolated annuloplasty (2 cases). Hospital mortality was 2.3% (3 patients). Five patients (3.8%) were lost to follow-up. The mean follow-up period was 38 +/- 27 months for the 122 patients followed-up. Seven patients needed reoperation. The long term mortality was 3.1% (4 patients). Four late thromboembolic episodes were observed; they were all transient and regressive in patients with atrial fibrillation. The 7 year actuarial survival rate for the whole series, including hospital mortality, was 92% (1.0 +/- 0.5 patients/year). It was 93.7 +/- 4.9% at 7 years for isolated mitral valvuloplasty and 89.9% +/- 5.6% at 5 years for combined mitro-tricuspid procedures. The actuarial percentage of patients without thromboembolic complications was 91.2% at 7 years with a thromboembolic risk of 1.0 +/- 0.5% patients/year. Eighty eight per cent of patients were not reoperated at 7 years and the reoperation rate was 1.7 +/- 0.7% patients/year.(ABSTRACT TRUNCATED AT 250 WORDS)

[Initial results of mitral valvuloplasty using the Physio-Carpentier-Edwards ring]. / Résultats préliminaires de la plastie mitrale avec l'anneau physio-carpentier-edwards.

The Physio-Carpentier-Edwards ring is a new prosthetic ring developed to allow mitral annuloplasty associating remodelling and flexibility of the native mitral annulus. The object of this study was to assess the feasibility and reliability of mitral valvuloplasty with the Physio ring. Between December 1992 and October 1995, 100 patients with an average age of 56.8 years suffering from mitral insufficiency underwent mitral valvuloplasty with a Physio ring. The mitral insufficiency was degenerative in 94% of cases. The degree of regurgitation was scored 3+ or 4/+4/+ in 94 patients. Mitral valve prolapse was observed in 83 patients. Mitral reconstruction was undertaken using Carpentier's techniques. One patient died in the immediate postoperative period. Two patients were reoperated for valve replacement because of systolic anterior motion (SAM). One patient had SAM which regressed with medical treatment. There were no deaths after the hospital period. There were no late reoperations of thrombo-embolic complications. The average follow-up period was 19 +/- 8 months; 77 patients were followed up for over 1 year and all underwent control Doppler echocardiography. Sixty-one patients had no residual mitral insufficiency: 15 patients had grade 1/4 regurgitation and one patient had grade 2/4 regurgitation. The average mitral valve surface area was 2.8 +/- 0.3 cm2. The average left ventricular end diastolic volume decreased from 186 +/- 59 cm3 before surgery to 129 +/- 37 cm3 at the last control (p < 0.001). The authors conclude that the Physio ring enables reliable and effective mitral valvuloplasty with excellent short term results. The benefits of the flexibility of the Physio ring remain to be evaluated by a randomised trial.

[Heart surgery in normothermia and aerobiosis: apropos of 530 patients]. / Chirurgie cardiaque en normothermie et aéorobiose: à propos de 530 patients.

Between February and October 1991, 530 consecutive patients underwent myocardial revascularization or valvular surgery with warm continuous antegrade and retrograde cardioplegia (37 degrees C). Three hundred and thirty three patients had isolated myocardial revascularization, 159 valvular surgery alone and 25 had combined valvular and coronary bypass. The global mortality was 5.1%, 3.7% for coronary bypass, 7.5% for valvular surgery and 8% for combined valvular and coronary surgery. A multivariate analysis identified the "reperfusion time" as the only predictive factor of hospital mortality (p < 0.001). Intraortic balloon counterpulsation was required postoperatively in 3.2% of cases, 5.2% of coronary bypass and 0.8% of the valvular patients. Inotropic drugs were used to come off cardiopulmonary bypass in 16.5% of coronary and 37.5% of valvular patients. There were 0.9% perioperative infarctions: 1.2% in the coronary bypass cases and 0.6% in the valvular cases. Spontaneous return to sinus rythm was observed in 87.9% of cases. The average "reperfusion time" was 20.48 +/- 0.7 mn. Analysis of the influence of aortic cross clamp time on cardiac morbidity in two groups of coronary patients (Group I: short cross clamp time less than 60 mn; Group II: long cross clamp time, 60 to 33 mn) showed that the hospital mortality, the prevalence of the use of inotropic drugs and balloon counterpulsation the postoperative cardiac index, the rate of spontaneous de fibrillation and the reperfusion time did not depend on the aortic cross clamp time. Cardiac morbidity.

[Coronary surgery of the beating heart. First year of experience in a series of 317 non-selected coronary patients]. / Chirurgie coronaire à coeur battant. Première année d'expérience sur une série de 317 patients coronariens non sélectionnés.

From May 1999 to May 2000, 317 unselected patients, representing 92.7% of all coronary artery surgery procedures, underwent open heart surgery of the beating heart by median sternotomy with the aid of a cardiac stabilising device. The main preoperative characteristics were: mean age = 66.1 years; men = 78.9%; left main stem disease = 31.8%; mean left ventricular ejection fraction = 54.1%; mean Parsonnet index = 16.9. These 317 patients were compared with a group of 303 patients who underwent coronary bypass surgery the year before by the same surgical team with cardiopulmonary bypass (CPB) and cardiac standstill. Seven hundred and eighty-six distal anastomoses were carried out in the beating heart group (2.48 grafts per patient) compared with 2.91 in the CPB group: p < 0.001). There were 10.1% single bypass, 37.5% double bypass, 47.3% triple bypass and 5% quadruple bypass procedures. A cardiopulmonary bypass was required in 13 patients (4.1%). The mortality at 30 days was 3.1% versus 4.6% in the CPB group (p = NS). The need for blood transfusion was reduced by nearly 40% in the beating heart group (23.7% versus 39.9%, p < 0.001). The incidence of cerebrovascular complications was reduced from 3% in the CPB group to 0.6% in the beating heart group (p = 0.06). The peak postoperative troponine I levels were much lower in the beating heart group (2.5 versus 6.4 ng/ml, p < 0.001). The authors conclude that surgery on the beating heart is feasible in most patients. Compared with conventional surgery under CPB, there seems to be less requirement for blood transfusion and a tendency to reduce the cerebral risk. Nevertheless, a large prospective randomised trial is required to validate the potential advantages and limitations of this technique with respect to conventional surgery and to determine the optimal indications of surgery on the beating heart.

[Postoperative infections after heart surgery under extracorporeal circulation]. / Infections postopératoires après chirurgie cardiaque sous circulation extracorporelle.

Postoperative infection is still an important cause of mortality and morbidity after cardiac surgery. The aim of this study was to assess its incidence and causes in order to optimise treatment. Between January 1996 and December 1997, 1,000 consecutive patients (253 women and 747 men) were operated for cardiac aortic pathology under cardiopulmonary bypass. The mean age was 66 +/- 11 years. The initial pathology was coronary artery disease (N = 663), valvular heart disease (N = 193), an association of the two (N = 94), thoracic aortic pathology (N = 38) or other pathologies (N = 12). The global postoperative infection rate was 4.9% (N = 49). The incidence of sternal and/or mediastinal infections was 0.7%, of bronchopneumonia 0.9%, urinary infection 2.1%, and septicaemia 1.7%. Nine patients died of the consequences of an infection. The hospital stay was significantly longer in infected patients, irrespective of the site of infection. Statistical analysis of the whole population did not show any predictive factor related to the preoperative clinical status of the patients. The only predictive factor demonstrated was the day on which surgery was performed: the infection rate in patients operated during the first 4 days of the week was 2.2% compared with 7.3% for the patients operated during the last 3 days (p = 0.004, odds ratio (OR) = 3.57). In those patients who had an urinary infection, the two identified risk factors were the female gender (p = 0.006, OR = 3.34) and an operation performed at the end of the week (p = 0.017, OR = 3.77). In patients with sternal and medistinal infections, the only identified predictive factor was combined coronary artery and valvular surgery (p = 0.009, OR = 7.43). With respect to pulmonary infections, the only predictive factor was recent preoperative myocardial infarction (< 1 month) (p = 0.004, OR = 7.5). Finally, no predictive risk factors were identified in those patients who developed septicaemia. In conclusion, this study showed that postoperative infection remains a serious complication of cardiac surgery. The prevention of these complications should be a priority for quality health care.

[Surgical mitral valvuloplasty in the treatment of mitral valve diseases]. / La place de la plastie mitrale chirurgicale dans le traitement des maladies de l'orifice mitral.

Mitral valve repair surgery, in presence of a pure mitral leakage or one associated to a stenosis, is not only possible but has been well codified for a decade. According to damage, there are two methods of operation: valvular mobilization surgery and valvular motion amplitude reduction surgery. They are usually associated to annuloplasty with a Carpentier prosthetic ring. The incidence of late mortality is of 0.6 p. 100 pt/yr, that is to say 91.7 p. 100 at 13 years. This late survival rate is about 20 p. 100 better than for a valvular replacement. Reoperations rate is 1.6 p. 100 pt/yr. The incidence of thromboembolic event occurrence is low: 0.5 p. 100 pt/yr. The ideal indications for mitral valve repair are represented by damage of prolapse from a degenerative origin for which results are better and more constant. For rheumatic damage, the valvular repair indication depend on the valvular tissue elasticity and area. The presence of calcification and extensive fibrosis remain on principle counter-indications.