The Björk-Shiley valve prosthesis. Analysis of long-term evolution.

The long-term follow-up of 831 patients who underwent valve replacement with Björk-Shiley Delrin and standard Pyrolyte prostheses (341 aortic, 345 mitral, and 145 mitroaortic) between 1971 and 1980 is reviewed. The follow-up concluded in 1985. Cumulative follow-up amounted to 4724 years, with a mean of 5.68 years per patient. Data on survival were obtained in 754 patients (complete follow-up in 90.8% of cases). Perivalvular leak was the most frequent complication in aortic valve replacement, whether isolated or combined, with values significantly higher than those registered in isolated mitral replacement (p < 0.001 in both cases). No correlation was found between this complication and valve calcification, but it was statistically correlated with the size 19 model (p < 0.05). Prosthetic stenosis was more common in mitral than in aortic replacement (p < 0.001), and of the former, size 23 was that most often affected (p < 0.001). The earliest case of mitral pannus was diagnosed 20 months postsurgery, and from 45 months on this pathology was the cause of every case of stenosis. The risk of thromboembolism was similar in aortic, mitral, and double prostheses, while it was the single most frequent complication in isolated mitral replacement. Prosthetic thrombosis was triggered in all cases in which it occurred by discontinuance of anticoagulant therapy. Anticoagulant-induced hemorrhages were more frequent in double replacement than in mitral (p < 0.05) and aortic valve replacement. Endocarditis was the complication that produced the highest mortality rate in all groups; the frequency of this infection was higher among patients with double prostheses when compared with either aortic replacement (p < 0.05) or mitral replacement (p < 0.001). The risk of suffering endocarditis was correlated with the existence of active preoperative infection in patients with mitral prostheses and double prostheses (p < 0.001 in both cases). Overall morbidity was higher in the double replacement group with respect to the mitral group (p < 0.01). The rate of mortality was also higher among the double valve replacement patients when compared with both the aortic (p = 0.0002) and mitral (p = 0.006) groups.

Late sudden cardiac death in the follow-up of patients having a heart valve prosthesis.

Eight hundred thirty-one patients with Björk-Shiley prostheses (341 aortic, 345 mitral, and 145 double) had a mean follow-up time of 68.2 months per patient. Of these, 24 (16% of all deaths) died suddenly: six of 42 with aortic valve replacement (14.3%), 12 of 56 with mitral valve replacement (21.4%), and six of 36 with double valve replacement (16.6%). This correlated with evidence of premature ventricular complexes detected in multiple routine 12-lead follow-up electrocardiograms (p less than 0.001 for simple aortic or mitral valve replacements and p less than 0.01 for combined aortic and mitral valve replacements). Premature ventricular complexes were significantly more frequent among those who died suddenly than among survivors and those who died of other causes (p less than 0.001 in both cases); there were no significant differences between the latter two groups. The actuarial risk of sudden death was significantly greater among those patients who had premature ventricular complexes than among those who did not have this disorder (p = 0.0002). We conclude that the presence of premature ventricular complexes, as an independent variable, was correlated with the risk of sudden death.

Thrombectomy of the Björk-Shiley prosthetic valve revisited: long-term results.

Thrombotic obstruction of the Björk-Shiley prosthetic valve is a catastrophic complication, often leading to a fatal outcome. Worldwide experience with the Björk-Shiley valve supports the need for long-term anticoagulation to prevent entrapment of the disc. Replacement of the malfunctioning device is associated with a high mortality, and therefore a more expeditious method is desirable. It is our experience that simple thrombectomy may suffice in most occasions, even for the mitral position, and especially when done through a bicameral approach in order to visualize both supravalvular and infravalvular regions. The philosophy and results with thrombectomy and disc rotation in 12 cases of thrombotic occlusion of the Björk-Shiley valve are described. It is suggested that this method may be preferable to replacement of the thrombosed prosthetic valve in select patients.

Outlet-strut fracture and disc embolization in 27-mm and smaller Björk-Shiley convexo-concave valves: historical overview and 3 case reports.

Outlet-strut fracture leading to primary failure of Björk-Shiley convexo-concave disc valves has only recently been reported in valves of 27-mm size and smaller. We now report an additional 3 cases of outlet strut failure in smaller convexo-concave valves, in a series of 899 implantations (overall incidence, 0.33%) of convexo-concave valves in various sizes and in 2 variant opening angles (60 degrees and 70 degrees ), during a 6-year period. All failures were confined to lots implanted during 1981 and 1982. We describe these 3 cases within the context of an historical overview of the Björk-Shiley tilting-disc valve, and propose methods of surgical intervention when this life-threatening complication arises.

Special operative events in the first case of liver grafting after heart transplantation.

Combined heart-liver transplantation is the only therapeutic possibility for patients with familial hypercholesterolemia IIa. A 12-year-old boy with this metabolopathy underwent a double transplant in two steps (different donors). This original alternative was chosen to assure a safer procedure in this critical situation. Details of intraoperative events are described. Cholesterol and LDL decreased to physiologic levels after liver transplantation. The child's condition is optimal 1.5 years after surgery.

Combined transplantation of heart and liver from two different donors in a patient with familial type IIa hypercholesterolemia.

A 12-year-old child with terminal ischemic heart disease as a result of homozygotous familial type IIa hypercholesterolemia received an orthotopic heart transplant and, 21 days later, an orthotopic liver transplant. Six months after heart transplantation, the patient is asymptomatic and evidences normal liver function and cholesterol levels; there are no signs of heart rejection. To our knowledge, this is the first instance of two-step heart-liver transplantation with organs from different donors.

Rewarming rate of the myocardium during aortic cross-clamp time: variations with different levels of body hypothermia.

Twenty patients underwent elective cardiac valve replacement at 20 degrees C of body hypothermia. Temperatures of the ventricles of both walls were monitored on 12 different sites. Distribution of myocardial temperature ranged between 24.3 and 29.3 degrees C for patients of Group I before cardioplegia delivery and 13.2 degrees C in the septum after cardioplegic infusion. Average temperatures for the anterior and posterior wall were 13.6 C and 15 degrees C in the left ventricle and 14.7 and 15 degrees C in the right ventricle. Myocardial temperatures ranged from 26 to 28.7 degrees C for patients of Group II. After cardioplegic arrest, septal temperatures averaged 14.9 degrees C. The recorded sites of the anterior and posterior left ventricle were 14.1 and 13.1 degrees C. The effects of rewarming on the different myocardial areas occurred according to a logarithmic equation, which is faster in the first 10 minutes. The data suggest that the myocardium can be adequately protected with 25 degrees C hypothermia when the cross-clamp period is shorter than 60 minutes. When longer ischemic periods are expected, myocardial protection is best accomplished with 20 degrees C hypothermia.

Tratamiento quirúrgico de la hipertensión portal: analisis a largo plazo de 210 casos / Surgical treatment of the portal hypertensión: long term analysis of 210 cases

Se estudiaron 210 enfermos de hipertensión portal, en los que se practicaron 226 intervenciones. Se analizan sus etiologías, el tratamiento quirúrgico y los resultados obtenidos

Tratamiento quirúrgico de la hipertensión portal: analisis a largo plazo de 210 casos / Surgical treatment of the portal hypertensión: long term analysis of 210 cases

Se estudiaron 210 enfermos de hipertensión portal, en los que se practicaron 226 intervenciones. Se analizan sus etiologías, el tratamiento quirúrgico y los resultados obtenidos (AU)

Role of 201Tl in the management of cardiac transplantation.

Serial percutaneous endomyocardial biopsy is the standard for diagnosis of cardiac rejection; it is generally done on a weekly basis for the first month and then as indicated by ECG voltage; but, this method is invasive, can be done only in specialized centers, not available for the many patients who return home, requires 18-24 h before a result is obtained, delaying institution of therapy, and it is aggressive for the endomyocardium of the graft. A reliable, rapid, and noninvasive test for detection of cardiac rejection is still not available. The aim of this work was to determine whether 201Tl uptake was significantly correlated with the histological findings presenting in cardiac rejection. Auxiliary heart transplantation was carried out on 60 male rats. Graft viability was evaluated by direct palpation, ECG voltage, and 201Tl uptake during the study (from 4-6 h after transplantation to 1 month). Syngenic rats (without rejection) were used as a control group. Histological studies were done at the end of the isotope study in all animals. The statistical significance of all results was determined by means of Student's t-test. A very significant correlation between the severity of the histological findings of rejection and 201Tl uptake was found (P less than 0.001). Our results have demonstrated that 201Tl uptake detected rejection earlier than ECG voltage; moreover, 201Tl uptake was more sensitive in detecting a mild degree of rejection while ECG only detected a moderate degree. We believe that 201Tl uptake should be the screening method for the follow-up of cardiac transplantation; it offers to surgeons the opportunity to select patients for endomyocardial biopsy, with a higher accuracy than the other noninvasive methods.

A new surgical technique for aneurysmal right atrium.

A new surgical technique for reduction in size of aneurysmal right atrium (ARA) is described. The extracorporeal perfusion is based on extrapleural single stage caval return and profound hypothermia, with circulatory arrest. This method enabled us to diminish the cavity dimensions in the presence of a giant friable ARA, by excising the thinned portion of the free atrial wall and double-layer closure of the remaining edges (close to the AV groove) to the crista terminalis.

Long-term results of cardiac valve replacement with the Delrin-disc model of the Björk-Shiley valve prosthesis.

One hundred two Björk-Shiley valve prostheses with the Delrin-disc occluder were implanted in 83 patients between January, 1971, and July, 1972. Fifty-eight were in the mitral position, 42 in the aortic, and 2 in the tricuspid. Complete follow-up until 1981 was obtained in 93% of the patients (mean follow-up, 66.8 months). Hospital mortality was 18% and late mortality, 19%. Survival according to actuarial methods was 84.8% at 5 years and 78.1% at 9 years after operation. Thromboembolism was detected in 8.8% of patients but caused no deaths. The incidence was 1.2% and 1.5% per year in those patients treated with Coumadin and antiplatelet agents, respectively. Reoperation was necessary in 13% of the patients. Most survivors (72%) are in New York Heart Association Functional Class I, despite a preoperative status of Class III or IV in 57% of the patients. Hospital mortality may be due to poorer understanding of patient management and less refined techniques of myocardial protection. Long-term survival with this prosthesis is similar to that in more recent studies, and rates of thromboembolism and malfunction compare favorably with other prosthetic valves.

A new technique for reconstruction of the tricuspid valve ring in congenital tricuspid insufficiency.

A 50-year-old man was treated for a dysplasia-type congenital tricuspid insufficiency. The tricuspid valve ring was repaired with a perforated Teflon patch graft and the valve was replaced. The patient was discharged in good condition and is well after 18 months of follow-up.