Tetralogía de Fallot con síndrome de válvula pulmonar ausente: Presentación de un caso y revisión de la literatura / Tetralogia de Fallot com síndrome da valva pulmonar ausente: Relato de caso e revisão da literatura / Tetralogy of Fallot with absent pulmonary valve syndrome: Case report and literature review

La tetralogía de Fallot es la cardiopatía congénita cianótica más frecuente del adulto. El síndrome de válvula pulmonar ausente constituye una variante poco frecuente, que representa del 3% al 6% de los pacientes con tetralogía de Fallot. Presentamos el caso de un paciente masculino de 29 años de edad, con tetralogía de Fallot y síndrome de válvula pulmonar ausente, los hallazgos del examen físico y los principales exámenes complementarios; como así también su evolución y una revisión de la literatura.

The tetralogy of Fallot is the most frequent cyanotic congenital heart disease in adult. Absent pulmonary valve syndrome is a rare variant, representing 3% to 6% of patients with tetralogy of Fallot. We present the case of a 29-year-old male patient with tetralogy of Fallot and absent pulmonary valve syndrome, physical examination findings and major complementary examinations; as well as its evolution and a review of the literature.

A tetralogia de Fallot é a doença congênita cianótica mais comum cardíacas em adultos. A síndrome valva pulmonar ausente é uma variante rara, que representa de 3% a 6% dos pacientes com tetralogia de Fallot. Apresentamos o caso de um paciente masculino de 29 anos de idade, com tetralogia de Fallot e síndrome da valva pulmonar ausente, exame físico e os principais estudos complementares; bem como a sua evolução e uma revisão da literatura.

Rotura subaguda de la pared libre del ventrículo izquierdo en el contexto del infarto agudo de miocardio / Subacute rupture of the free wall of the left ventricle during acute myocardial infarction / Ruptura subaguda da parede livre do ventrículo esquerdo no contexto do infarto agudo do miocárdio

La rotura subaguda de la pared libre del ventrículo izquierdo es una complicación rara del infarto de miocardio, cuya incidencia se encuentra disminuida considerablemente en los últimos años, debido a las terapias de reperfusión. Presentamos el caso de un paciente de sexo masculino de 65 años de edad que ingresó a nuestro hospital, derivado de otro centro médico, con diagnóstico presuntivo de taponamiento cardíaco en el curso de un infarto ínfero-pósterolateral sin tratamiento de reperfusión. Se discute la presentación clínica, los factores de riesgo, los métodos de diagnóstico y la conducta quirúrgica.

Subacute rupture of the free wall of the left ventricle is an infrequent complication of myocardial infarction; the incidence is considerably diminished in the last few years due to reperfusion therapies. We report the case of a male patient aged 65 years was admitted to our hospital, derived from another medical center, with presumptive diagnosis of cardiac tamponade in the course of an infero-posterolateral infarction without reperfusion therapy. Clinical presentation, risk factors, methods of diagnosis and surgical management are discussed.

A ruptura subaguda da parede livre do ventrículo esquerdo é uma complicação rara do infarto do miocárdio, a incidência é diminuída consideravelmente nos últimos anos devido às terapias de reperfusão. Nós relatamos o caso de um paciente do sexo masculino com 65 anos internado em nosso hospital, derivado de outro centro médico, com diagnóstico presuntivo de tamponamento cardíaco no curso de um infarto ínfero-póstero-lateral sem terapia de reperfusão. Discutimos a apresentação clínica, os fatores de risco, os métodos de diagnóstico e o tratamento cirúrgico.

"No-touch" versus "endo" vein harvest: early patency on symptom-directed catheterization and harvest site complications.

OBJECTIVE: "No-touch" (NT) saphenous vein harvesting preserves the adventitial vasa vasorum, prevents medial ischemia, and is associated with an improved short-term and long-term vein graft patency. It may also be associated with a higher rate of harvest site complications. Endovascular vein harvesting (endo-vein) has a low rate of harvest site complications but also a tendency toward a lower patency rate. METHODS: During a 2-year period (2011-2012), we compared the vein graft patency at symptom-directed cardiac catheterization as well as wound complication rates in 210 patients who received either NT (87 patients) or endo-vein (123 patients). RESULTS: The recatheterization rate for the two groups was similar: 9 (10.3%) of 87 of the NT patients versus 11 (9.0%) of 123 of the endo-vein patients. There was a significant difference in vein graft patency between the groups: 15 (94%) of 16 NT vein grafts were patent versus 6 (27%) of 22 of endo-veins (P < 0.02). The endo-vein graft patency during this 2-year period was similar to the total endo-vein patency (37%) during a 4-year period. A comparison between a more experienced and a less experienced harvester revealed no difference in patency rate. Harvest site complications were significantly higher with the NT harvest: 18% of the NT patients requiring vacuum-assisted wound closure or intravenous antibiotics versus 2% of the endo-vein patients (P < 0.0001). The application of platelet-rich plasma did not significantly lower wound complication rates (P = 0.27). CONCLUSIONS: These results suggest that NT vein harvesting may be associated with improved graft patency, but methods should be developed to lower wound complication rates.

Adding an endovascular aortic surgery program to a rural regional medical centre.

BACKGROUND: Abdominal aortic aneurysms requiring surgical intervention are generally treated by endovascular means. Such procedures are not always offered in rural hospitals, possibly leaving patients underserved. We reviewed our experience initiating an endoaortic surgery program. METHODS: A surgeon in a rural centre was credentialed to perform endovascular aortic aneurysm repair through collaboration with a university centre and was proctored locally for the first 5 abdominal aneurysm repairs. Web-based image storage was used to review complex cases as part of an ongoing partnership. Referred patients were screened for multiple aneurysms and underwent long-term monitoring. RESULTS: In all, 160 patients were evaluated for 176 aortic pathologies. Twenty-five patients (17 men) aged 55-89 years underwent 26 endovascular abdominal (n = 23) or thoracic (n = 3) aortic procedures. Emergent endovascular procedures were not performed. There were no operative deaths, requirements for dialysis or conversions to open repair. Two endoleaks required early reintervention. The median length of stay in hospital for endovascular procedures was 2.5 days. Chronic endoleaks were observed in 7 patients. An additional 8 patients underwent open abdominal aneurysm repair locally and 15 patients were referred to the university program. CONCLUSION: Creation of an endovascular aortic surgery program in a rural hospital is feasible through collaboration with a high-volume centre. Patient safety is enhanced by obtaining second opinions using web-based image review. Most interventions are for abdominal aortic aneurysms, but planning for a comprehensive aortic clinic is preferable.

CONTEXTE: Les anévrismes de l'aorte abdominale justiciables d'une intervention chirurgicale sont généralement traités par voie endovasculaire. Ce type d'intervention n'est toutefois pas toujours pratiqué dans les hôpitaux ruraux. Les patients peuvent donc s'en trouver moins bien desservis. Nous avons passé en revu notre expérience après la mise sur pied d'un programme de chirurgie endoaortique. MÉTHODES: Grâce à une collaboration avec un centre universitaire, un chirurgien d'un centre rural a reçu l'agrément nécessaire pour effectuer la réparation endovasculaire des anévrismes de l'aorte et il a été supervisé localement pour les 5 premières réparations d'anévrisme de l'aorte abdominale. Une banque d'images sur le Web a permis de passer en revue des cas complexes dans le cadre d'un partenariat continu. On a fait subir aux patients adressés en consultation un dépistage d'anévrismes multiples et ils ont fait l'objet d'un suivi à long terme. RÉSULTATS: En tout, 160 patients ont été examinés pour 176 anomalies aortiques. Vingt-cinq patients (17 hommes) âgés de 55 à 89 ans ont subi 26 interventions endovasculaires de l'aorte abdominale (n = 23) ou thoracique (n = 3). Aucune autre intervention endovasculaire n'a été effectuée. On n'a eu à déplorer aucun décès en lien avec les interventions, aucun recours à la dialyse ni conversion vers une chirurgie ouverte. Deux endofuites ont nécessité une réintervention précoce. La durée médiane du séjour hospitalier dans les cas d'intervention endovasculaire a été de 2,5 jours. Des endofuites chroniques ont été observées chez 7 patients. Huit autres patients ont subi une réparation ouverte d'anévrisme abdominal localement et 15 patients ont été référés au programme universitaire. CONCLUSION: La création d'un programme de chirurgie de l'aorte endovasculaire dans un hôpital rural est réalisable grâce à une collaboration avec un centre dont le volume d'interventions est élevé. La sécurité des patients est renforcée par l'obtention de secondes opinions facilitées par une banque d'images sur le Web. La plupart des interventions concernent des anévrismes de l'aorte abdominale, mais il est préférable de planifier la mise en place d'une clinique où on pourrait intervenir sur toutes les portions de l'aorte.

Successful use of a pneumatic biventricular assist device as a bridge to transplantation in cardiogenic shock.

BACKGROUND: Mechanical circulatory support is a highly effective technology to maintain organ perfusion in patients with cardiogenic shock as a bridge to transplantation. Although implantation of a left ventricular assist device alone is often the preferred configuration, patients with biventricular failure and significant end-organ dysfunction often require biventricular assistance. METHODS: Between January 2000 and September 2008, 80 patients with severe biventricular failure were accepted for heart transplantation and received a pneumatic biventricular assist devices as a bridge to transplant. Patients were retrospectively divided into 2 groups: those successfully bridged to transplant (Group A) and those who died (Group B). Patients were also divided into 2 periods of implantation: Group X (2000-2005) and Group Y (2006-2008, which used a multidiscipline selection process). RESULTS: Overall success rate to transplantation was 71.3%, with Group Y demonstrating an 82% success to transplant rate vs 63% in Group X. One-year actuarial survival after transplant was 89% compared with 92% in patients without a ventricular assist device. There were no statistically significant laboratory parameters between Groups A and B identifying potential risk factors for poor outcome. CONCLUSION: Biventricular assist device therapy represents an effective and reliable means of supporting selected Interagency Registry for Mechanically Assisted Circulatory Support profile 1 patients as a bridge to transplantation, with excellent success to transplant rates and post-transplant survival.

A prospective, randomized, crossover pilot study of inhaled nitric oxide versus inhaled prostacyclin in heart transplant and lung transplant recipients.

OBJECTIVE: Inhaled nitric oxide has been shown to reduce pulmonary vascular resistance in patients undergoing cardiothoracic surgery, but it is limited by toxicity, the need for special monitoring, and cost. Inhaled prostacyclin also decreases pulmonary artery pressure, is relatively free of toxicity, requires no specific monitoring, and is less expensive. The objective of this study was to compare nitric oxide and prostacyclin in the treatment of pulmonary hypertension, refractory hypoxemia, and right ventricular dysfunction in thoracic transplant recipients in a prospective, randomized, crossover pilot trial. METHODS: Heart transplant and lung transplant recipients were randomized to nitric oxide or prostacyclin as initial treatment, followed by a crossover to the other agent after 6 hours. Pulmonary vasodilators were initiated in the operating room for pulmonary hypertension, refractory hypoxemia, or right ventricular dysfunction. Nitric oxide was administered at 20 ppm, and prostacyclin was administered at 20,000 ng/mL. Hemodynamic and oxygenation parameters were recorded before and after initiation of pulmonary vasodilator therapy. At 6 hours, the hemodynamic and oxygenation parameters were recorded again, just before discontinuing the initial agent. Crossover baseline parameters were measured 30 minutes after the initial agent had been stopped. The crossover agent was then started, and the hemodynamic and oxygenation parameters were measured again 30 minutes later. RESULTS: Heart transplant and lung transplant recipients (n = 25) were randomized by initial treatment (nitric oxide, n = 14; prostacyclin, n = 11). Nitric oxide and prostacyclin both reduced pulmonary artery pressure and central venous pressure, and improved cardiac index and mixed venous oxygen saturation on initiation of therapy. More importantly, at the 6-hour crossover trial, there were no significant differences between nitric oxide and prostacyclin in the reduction of pulmonary artery pressures or central venous pressure, or in improvement in cardiac index or mixed venous oxygen saturation. Nitric oxide and prostacyclin did not affect the oxygenation index or systemic blood pressure. There were no complications associated with nitric oxide or prostacyclin. CONCLUSION: In heart transplant and lung transplant recipients, nitric oxide and prostacyclin similarly reduce pulmonary artery pressures and central venous pressure, and improve cardiac index and mixed venous oxygen saturation. Inhaled prostacyclin may offer an alternative to nitric oxide in the treatment of pulmonary hypertension in thoracic transplantation.

Use of ventricular assist device as a bridge to cardiac transplantation: impact of age and other determinants on outcomes.

We sought to compare outcomes in patients > or = 60 years of age with those of their younger counterparts who underwent ventricular assist device implantation intended as a bridge to cardiac transplantation and also to identify retrospectively additional pre- and postoperative factors that might portend adverse outcomes.The medical records of 88 patients who were treated with bridge-to-transplantation ventricular assist devices from 1996 through 2007 were reviewed. Laboratory values, hemodynamic parameters, and the need for hemodynamic support were evaluated. Postoperative complications and bridge-to-transplantation success rates versus death rates were evaluated. Seventeen patients were > or = 60 years old and 71 patients were < 60 years old. In the older group, 59% of patients underwent successful bridging to transplantation, compared with 69% of the younger patients (P = 0.41). Multivariate analysis distinguished age > or = 60, female sex, earlier time period of operation, higher mean pulmonary arterial and central venous pressures, need for preoperative intra-aortic balloon pumps, and postoperative respiratory failure as independent risk factors for death. After orthotopic heart transplantation, survival to hospital discharge was 100% in the older group and 93.9% in the younger patients. Median lengths of stay were similar in both age categories.Multivariate analysis identified age as 1 of 6 independent risk factors for death in this study. Patients who successfully underwent cardiac transplantation, however, had similar survival statistics regardless of age category. Case-by-case evaluation is warranted when analyzing risk-benefit ratios of bridge-to-transplantation ventricular assist device therapy in the older patient population.

Use of hearts transplanted from donors with severe sepsis and infectious deaths.

BACKGROUND: The reluctance to use organs from donors who have died from severe infections is based on the potential transmission of an infectious agent to the recipient and on the uncertainty about allograft function in the setting of severe donor sepsis. METHODS: From 1999 to 2007, donor hospital records were reviewed which focused on microbiology cultures and sensitivity results; type and duration of antimicrobial therapy; hemodynamic data, results of echocardiogram, and imaging studies. Preliminary positive and negative results from pre-harvest blood, respiratory, urine, and cerebrospinal fluid cultures were verified with the procurement agency. The harvesting surgeon performed gross inspection of donor valvular structures. RESULTS: Nine donor hearts were transplanted from patients who expired from community onset infections with severe septic shock, meningitis, and/or pneumonia caused by Streptococcus pneumoniae (n = 4), Streptococcus milleri (n = 2), Neisseria meningitidis (n = 2), and unidentified gram- positive cocci (n = 1). Four donors had probable infection-induced intracranial hemorrhage, and all donors were vasopressor-dependent before organ procurement. No evidence of donor-transmitted infection, sepsis, or rejection was observed, and long-term function remained excellent; allograft dysfunction in three patients resolved after transplant. Our series of nine donors represents approximately 1.3% of successfully transplanted cardiac allografts during the respective period of review. CONCLUSIONS: Patients succumbing to severe infections (meningitis, pneumonia, and septic shock) should not be arbitrarily excluded for possible heart donation. Assessing the suitability of donors with severe infections requires flawless communication between the donor and transplant facility, including a comprehensive evaluation of donor infection and pathogen(s), severity of sepsis, adequacy of antimicrobial treatment, and the degree of sepsis-induced myocardial dysfunction.

Long-term outcomes of heart transplantation in older recipients.

BACKGROUND: Heart transplantation in the elderly is increasingly common. In the mid-1990s, 25% of recipients in our program were >62 years of age. We evaluated outcomes from one institution with the hypothesis that older recipients may be at higher risk of major complications associated with immunosuppression. METHODS: We analyzed results for 182 patients aged 62 to 75 years (mean +/- SD: 66.3 +/- 11.4 years) who underwent heart transplantation between January 1995 and July 2001 at a single institution. They were compared with a control group of 348 contemporaneous adult recipients aged 18 to 62 years (mean +/- SD: 48.2 +/- 11.4 years). All recipients in this consecutive cohort had a follow-up of at least at least 5 years. End-points studied were Kaplan-Meier survival, freedom from dialysis and freedom from malignancy at 100 months. Follow-up was 100% at 100 months. RESULTS: At 100 months, survival for the elderly was 55% (46 remaining at risk) and 63% (102 remaining at risk) for controls (p = 0.051, log-rank test). Re-transplant and dialysis, but not recipient age or malignancy, were predictive of survival by regression analysis (p = 0.003, p < 0.001, p = 0.53 and p = 0.84, respectively). Freedom from malignancy at 100 months was 68% for the elderly and 95% for controls (p < 0.001). Age predicted malignancy by regression analysis (p < 0.001). At 100 months, freedom from dialysis was 81% for the elderly and 87% for controls (p = 0.005). Pre-operative creatinine, but not age, was predictive of need for dialysis (p = 0.003 and p = 0.47, respectively). CONCLUSIONS: Although long-term survival of older heart transplant recipients is acceptable, it is significantly lower than in young recipients. The increased risk of renal failure and malignancy among elderly patients likely influences the difference in survival observed between the two groups. Pre-operative renal function warrants careful consideration. As ventricular assist device technology improves, it may be used to complement heart transplantation to avoid immunosuppression and its side effect of malignancy in older patients with advanced heart failure.

Proatherogenic high-density lipoprotein, vascular inflammation, and mimetic peptides.

Atherosclerosis is an example of an inflammatory disorder. During the acute phase and under inflammatory conditions, high-density lipoprotein (HDL), which is normally anti-inflammatory, can become proinflammatory. Reactive oxygen species generated by several enzyme systems can modify phospholipids and sterols, producing oxidized phospholipids and oxidized sterols that reduce the capacity of HDL to protect against undesirable oxidative modifications of molecules. In animal models of dyslipidemia, diabetes, vascular inflammation, and chronic rejection, it is observed that reducing oxidative and inflammatory pressure will help HDL regain its protective role. One way to accomplish this is through the use of apolipoprotein A-I mimetic peptides, which remove oxidation products from lipoproteins and cell membranes, returning normal structure and function to low-density lipoprotein and HDL. These mimetic peptides markedly reduce atherosclerosis in animal models. Published studies of apolipoprotein mimetic peptides in models of inflammatory disorders other than atherosclerosis suggest that they have efficacy in a wide range of inflammatory conditions.

Long-term results of mitral valve repair using autologous pericardium annuloplasty.

BACKGROUND AND AIM OF THE STUDY: The use of autologous pericardium for annuloplasty during mitral valve repair is a subject of controversy; hence, the study aim was to evaluate the authors' long-term results using this technique. METHODS: A retrospective review was conducted of 173 consecutive patients (mean age 59.6 +/- 16.3 years; range: 19-92 years) who underwent mitral valve repair complemented by annuloplasty between January 1998 and December 2003. The major causes of mitral regurgitation (MR) were annular dilatation and prolapse of the posterior leaflet. Annuloplasty was performed in all patients using a strip of pericardium treated with 0.6% glutaraldehyde for 10 min. Two rows of continuous horizontal mattress Gore-Tex sutures were used to secure the pericardium to the mitral annulus. Follow up continued for a mean period of 5.25 +/- 1.62 years (range: 1.97 to 9.43 years), and was complete. RESULTS: Three patients (1.7%) died within 30 days of surgery. Subsequently, five patients (2.9%) with MR (with or without mitral stenosis) underwent reoperation at a mean of 3.0 +/- 2.7 years after the initial surgery. At seven years after surgery the actuarial survival rate was 92.5%, and freedom from reoperation 97.1%. Follow up echocardiography was performed in 160 patients. Among these patients, no MR was detected in 34 (21.2%), while 88 (55%) had grade 1 MR, 35 (21.8%) grade 2, and three (1.8%) had grade 3. None of the patients had grade 4 MR. CONCLUSION: The study results indicated that autologous pericardium mitral annuloplasty of the mitral valve provides effective, durable and reproducible repair, and avoids the use of foreign materials.

Tratamiento crónico con inhibidores de la PDE-5 en pacientes portadores de insuficiencia cardíaca avanzada / Chronic treatment with PDE-5 inhibitors in patients with advanced heart failure

Introducción. La persistente elevación de las resistencias vasculares pulmonares (RVP) en los pacientes portadores de insuficiencia cardíaca avanzada (ICA) es el resultado de la disfunción del endotelio vascular pulmonar y del remodelado estructural del mismo. La disminución en la oferta de óxido nítrico (ON) y el aumento de las endotelinas (ET) potencian los fenómenos vasoconstrictores alterando el equilibrio presente con los mediadores de la vasodilatación. El sildenafil (un inhibidor selectivo de la fosfodiesterasa 5) puede constituirse en una herramienta válida para aumentar los niveles de ON y favorecer el descenso de las resistencias vasculares pulmonares en pacientes portadores de ICA.Material y métodos. Se seleccionaron 30 pacientes portadores de ICA en dos grupos de 15 (grupo sildenafil y control) con fracción de eyección ventricular izquierda (FEVI) de 31,08±3,1% en clase funcional (CF) III bajo tratamiento farmacológico completo, siendo evaluados mediante un ecocardiograma transtorácico 2D Doppler color (ETT) para la medición de la presión arterial pulmonar sistólica (PAPS), un test de la caminata de los 6 minutos (TC6M) y una prueba ergométrica con máximo consumo de oxígeno (PEG VO2) al inicio y a los 90 días de seguimiento. Durante este período se administró, al grupo sildenafil, una dosis oral promedio de la droga de 75,4±13 mg/día

Resultados. Se demostró mejoría en el grupo sildenafil para ambos tests funcionales: TC6M (grupo sildenafil: día 0: 144,2±42,1 m vs día 90: 171,5±56,8 m p: 0,052) y en la PEG VO2 (grupo sildenafil: día 0: 11,4±1,3ml/Kg/minuto vs día 90: 12,3±1,4 ml/kg/minuto; p: 0,001). También, se observó un descenso de la PAPS (grupo sildenafil: día 0: 36,2±6,9 mm Hg vs día 90: 33,8±6,1 mm Hg; p: 0,001); en la presión arterial sistólica -PAS- (grupo sildenafil: día 0: 124,6±13,2 mm Hg vs día 90: 116,2±9,5 mm Hg; p: 0,008) y la presión arterial diastólica -PAD- (grupo sildenafil: día 0: 70,8±4,9 mm Hg vs día 90: 65,3±4,3 mm Hg; p: 0,000).Conclusiones. El presente estudio demuestra que la administración de sildenafil oral en dosis promedio de 75,4±13 mg/día es segura y mejora en forma significativa el desempeño funcional de pacientes portadores de una ICA

Introduction. The persistent increase of pulmonary vascular resistances (PVR) in patients with advanced heart failure (AHF) is the result of pulmonary vascular endothelium dysfunction and its structural remodelling. Diminish of nitride oxide (NO) offer, and the increase of endothelins (ET) strengthen vasoconstrictors phenomenon altering the present equilibrium with the vasodilation mediators. Sildenafil (a selective inhibitor of phosphodiesterasa 5 -PDE5-) may turn into a valid way of increasing NO levels and favouring PVR decrease in patients with AHF.Material and methods. 30 patients with AHF where selected, and divided in two groups of 15 each (sildenafil and control group) with left ventricular ejection fraction (LVEF) of 31.08±3.1% in functional class (FC) III, undergoing complete pharmacological treatment, and being evaluated with 2D transtoracic echocardiogram-colour-Doppler (TCCD) in order to measure the systolic pulmonary arterial pressure (SPAP), with the 6-minute walk test (6MWT) and an ergometric test with maximal oxygen consumption (VO2) at the baseline and at the 90th day of the follow-up. Within this period the sildenafil group received an oral mean dose of the drug of 75.4±13 mg/day

Results. An improvement was shown in the sildenafil group for both functional tests: 6MWT (sildenafil group: day 0: 144.2±42.1 m vs day 90: 171.5±56.8 m p: 0.052) and in ergometric test with VO2 (sildenafil group: day 0: 11.4±1.3ml/Kg/minuto vs day 90: 12.3±1.4 ml/kg/minute; p: 0.001). A decrease in the SPAP was also seen (sildenafil group: day 0: 36.2±6.9 mm Hg vs day 90: 33.8±6.1 mm Hg; p: 0.001); also in the arterial systolic pressure -SAP- (sildenafil group: day 0: 124.6±13.2 mm Hg vs day 90: 116.2±9.5 mm Hg; p: 0.008); and in the diastolic arterial pressure -DAP- (sildenafil group: day 0: 70.8±4.9 mm Hg vs day 90: 65.3±4.3 mm Hg; p: 0.000).Conclusions. The present study shows that the administration of a mean 75.4±13 mg/day oral dose of sildenafil is safe and improves significantly the functional performance of patients with AHF

Tricuspid valve repair using autologous pericardium annuloplasty in adults.

Uncorrected functional tricuspid regurgitation can lead to long-term morbidity and mortality. To evaluate our results using autologous pericardium annuloplasty to treat tricuspid regurgitation, we retrospectively reviewed 59 consecutive adult patients aged 19 years to 83 years (58.7 +/- 15.5 years) who underwent tricuspid valve annuloplasty between 2000 and 2003. Concomitant procedures consisted of mitral valve surgery in 83% of patients, aortic valve surgery in 28%, coronary bypass in 31%, and atrial-septal defect correction in 28%. Annuloplasty was performed using a strip of pericardium treated in glutaraldehyde 0.6% for 10 min. Two rows of continuous horizontal mattress Gore-Tex sutures were used to secure the pericardium to the tricuspid annulus. Follow-up was performed in 100% of the patients, and the mean follow-up was 4.4 +/- 1.2 years (range, 2.4 to 7 years). Postoperative death within 30 days occurred in 1 of 59 patients (1.6%). None of the patients required reoperation related to tricuspid regurgitation or stenosis. The actuarial survival rate was 98.4% at 7 years after operation. Echocardiography was performed in 58 of 58 surviving patients (100%). Up to 7 years postoperatively, tricuspid regurgitation was trace in 67.2% of patients, mild in 31%, and moderate in 1.8%; there was no occurrence of severe regurgitation on follow-up. Our results indicate that autologous pericardium tricuspid annuloplasty is a useful procedure in patients with moderate or severe tricuspid regurgitation. This procedure provides a durable, reproducible annuloplasty of the tricuspid valve.

Modified inferior vena caval anastomosis to reduce tricuspid valve regurgitation after heart transplantation.

Postoperative tricuspid valve regurgitation is moderate to severe in 15% to 20% of heart transplant recipients despite use of the bicaval surgical technique. We hypothesized that the regurgitation might be partly due to increased tension on the donor right atrium. To study the right atrial distortion, we modified the standard bicaval anastomosis. Our technique involves augmenting the donor right atrial anterior wall with a flap of the recipient's right atrium, which is left attached in continuity with the anterior aspect of the inferior vena cava along 65% of its circumference. We measured tricuspid regurgitation, right atrial area, and right atrioventricular diameter in 7 consecutive patients who underwent orthotopic heart transplantation with the modified anastomosis. Tricuspid regurgitation was graded as follows: 1 = trace, <10%; 2 = mild, 10%-24%; 3 = moderate, 25%-50%; and 4 = severe, >50%. All patients were weaned from inotropic support within 1 week after transplantation with excellent ventricular function, no heart block, and 100% survival at 30 days. The median follow-up time was 173 days (44-358 days). Other median measurements included tricuspid valve regurgitation jet area, 0.30 cm(2) (0-1.90 cm(2)); right atrial area, 15.90 cm(2) (14.47-18.00 cm(2)); atrioventricular diameter, 2.70 cm (2.63-3.09 cm); and tricuspid regurgitation, 1.67% (0-12.42%). Mild regurgitation occurred in 1 recipient; in all others, it was trace. The modified inferior vena caval anastomosis is simple and safe. It eliminates moderate and severe tricuspid valve regurgitation without routine annuloplasty after orthotopic heart transplantation via the bicaval technique.