Trends in mitral valve surgery: a single practice experience.

BACKGROUND AND AIM OF THE STUDY: Mitral repair has evolved to a point where three methods can be used to address most pathologies: full ring annuloplasty (RA) for annular disease; Gore-Tex artificial chordal replacement (ACR) for chordal disease; and autologous pericardial augmentation (PA) for leaflet disease. The study aim was to assess the impact of the increasing application of these methods on operative results over time. METHODS: Of 328 consecutive mitral valve procedures, 34% involved myxomatous prolapse, 23% rheumatic, 13% ischemic, 12% pure annular dilatation, 7% prosthetic dysfunction, 6% endocarditis, 3% hypertrophic obstructive cardiomyopathy (HOCM), and 2% 'other'. All patients underwent RA. Myxomatous prolapse was repaired with ACR, and ischemic and annular dilatation with RA alone. Rheumatic, endocarditis, and HOCM etiologies were repaired with all three methods. Patients were allocated to two-year increments, and also to repair versus replacement groups. Operative outcomes over time were assessed with linear and binomial regression. RESULTS: Overall, 66% of mitral valves were repaired; the average operative mortality was 6% (2% for repair, 7% for replacement), and 18% involved multiple valve procedures (mortality 16%). The extent of repair increased over time, from 55% to 100% of all etiologies. Over the same period, operative mortality fell from 6% in 1994 to 0% over the past six years. Other variables, such as age, presentation status, left ventricular dysfunction and etiology were relatively constant over the period. Reoperation rates after repair have been only 2% over the past 10 years of follow up. CONCLUSION: With recent innovations, most mitral disease can be repaired with combinations of RA, ACR and PA. Today, operative mortality is approaching zero, and one factor may be the increasing application of repair to all mitral pathologies. These data support the trend of expanding valve repair across most mitral disorders.

A new approach to mitral valve repair for rheumatic disease: preliminary study.

BACKGROUND AND AIM OF THE STUDY: The initial application of repair to rheumatic mitral disease was fraught with unacceptable recurrence rates. For this reason, rheumatic valves primarily have been replaced in recent years. Early and late outcomes with replacement, however, have continued to be suboptimal, prompting a re-examination of repair. METHODS: All eight patients encountered by the authors with rheumatic mitral valve disease over the past three years were considered for valve repair. One patient had pure stenosis, three patients had pure regurgitation, and four had advanced forms of mixed stenosis and regurgitation. Because posterior leaflet retraction was a prominent and almost uniform feature of rheumatic disease, posterior leaflet glutaraldehyde-fixed autologous pericardial gussets were placed in all cases. In the five patients with stenosis, commissural calcium was debrided, the thickened chords to the anterior leaflet were resected, extended commissurotomies performed, and an anterior leaflet 'hinge' mechanism restored. The anterior leaflet then was reattached to the base of the papillary muscles using Gore-Tex artificial chords, and all eight patients had full ring annuloplasties. RESULTS: Postoperatively, all patients had negligible gradients and no residual leak. The first patient (with mixed stenosis and regurgitation) was restudied with transesophageal echocardiography after three years, and had continued excellent valve function. There have been no intermediate-term recurrences, complications or mortalities. Operative videos and echocardiograms from these patients are available at JScottRankinMD.com. CONCLUSION: A combination of pericardial posterior leaflet gusset, anterior leaflet chordal resection/GoreTex replacement, extended commissurotomy and full ring annuloplasty allows the repair of rheumatic valves over a full range of pathologies. Early and intermediate-term results appear satisfactory. Continued aggressive application of this type of repair to rheumatic mitral disease seems to be indicated.

A new mitral valve repair strategy for hypertrophic obstructive cardiomyopathy.

BACKGROUND AND AIM OF THE STUDY: Previously, surgery hypertrophic obstructive cardiomyopathy (HOCM) has consisted primarily of septal myectomy and/or resection of the anterior mitral leaflet with low-profile valve replacement. However, recent studies have shown that the anterior papillary muscle and chordal fan can contribute to obstruction, and also that significant mitral regurgitation (MR) may be encountered. Hence, a surgical procedure was devised to address all components of this disorder. METHODS: A 37-year-old man had a history of heart murmur and NYHA class IV symptoms, despite beta-blocker therapy. Echocardiography showed severe septal hypertrophy, systolic anterior motion (SAM) of the mitral valve, severe MR and a 185 mmHg resting outflow tract gradient. At surgery, the anterior papillary muscle was found to be medially displaced and contributing to outflow obstruction. The anterior papillary muscle and chordae were resected, a 'traditional' septal myectomy was performed, and a full annuloplasty ring placed. The mitral valve was repaired by connecting the left aspect of the leaflets to the posterior papillary muscles, using Gore-Tex artificial chords. RESULTS: The patient recovered uneventfully. Interval echocardiography at one year showed a negligible outflow gradient, relief of SAM and mild residual MR. The patient currently is active, essentially asymptomatic, and not receiving any medical therapy. CONCLUSION: Previous approaches to HOCM have been limited by a small incidence of recurrent outflow gradients, pacemaker requirement, persistent MR or complications of the prosthetic valves. By comprehensively addressing all components of outflow obstruction and mitral dysfunction, this combined procedure may produce better results in certain subsets of HOCM, with the excellent late prognosis of artificial chordal replacement.

Ten-year follow-up in patients with combined heart and kidney transplantation.

BACKGROUND: Combined heart and kidney transplantation has been documented, although data regarding immunosuppression, rejection episodes, and graft or patient survival have not been detailed. We evaluated our experience and more than 10-year outcome with patients selected for combined heart and kidney transplantation. METHODS: Eight patients aged 29 to 59 years were selected for combined heart and kidney transplantation. The indications were end-stage heart disease and underlying renal pathology, or secondary renal insufficiency, or renal failure. Six patients were dialysis dependent before transplantation. There were 7 simultaneous procedures and 1 staged procedure. The heart was transplanted first in all cases. All patients were maintained after transplantation on azathioprine (2 mg x kg(-1) x d(-1)) and whole-blood monoclonal cyclosporine levels at greater than 200 microg/L; prednisone was not decreased to less than 10 mg/d. RESULTS: Seven (87.5%) patients have survived a mean duration of 100.4 months (range, 51-144 months), and each allograft has continued to function. The only death was due to pulmonary emboli and was not related to allograft rejection or failure. Only 4 cardiac and 4 kidney allograft rejections have occurred. Five patients have been free of kidney rejection, 1 patient has been rejection free for more than 8 years, and no patient has had simultaneous rejection. CONCLUSIONS: In select patients, combined heart and kidney transplantation can provide long-term graft function and patient survival. The low rates of rejection support our current approach to immunosuppression. Our experience indicates that end-stage failure of either heart or kidney does not necessarily preclude dual-organ transplantation.

Survival and incidence of acute rejection in heart transplant recipients undergoing successful withdrawal from steroid therapy.

BACKGROUND: Steroid-free immunosuppression is feasible in selected patients after heart transplantation. Survival and incidence of acute rejection are important parameters to evaluate when weighing risks and benefits of steroid withdrawal. METHODS: One hundred thirty-seven patients were retrospectively reviewed who underwent heart transplant at Emory University between January 1988 and April 1994 and survived >1 year. Standard immunosuppression (cyclosporine, azathioprine and prednisone) without induction therapy was used. Weaning from steroids was attempted in all patients. Scheduled endomyocardial biopsy was used for long-term surveillance screening. RESULTS: Seventy-two patients (52.5%) underwent successful prednisone withdrawal (Group P0) at an average of 13 months after heart transplant, whereas 65 patients (47.5%) did not achieve steroid-free immunosuppression (Group P1). Group P0 had a mean of 1.3 treated rejection episodes (ISHLT Grade > or = 1b) during the first post-transplant year and Group P1 a mean of 2.3 (p <0.0001). In Group P0, 40 patients (55.6%) suffered a subsequent acute rejection with an ISHLT Grade > or = 1b, resulting in treatment. Of these, 15% were ISHLT Grade 1b, 47.5% Grade 2, 35% Grade 3a and 2.5% Grade 3b. The estimated risk of suffering from acute rejection of at least Grade 1b after achieving steroid-free immunosuppression was 50% at 21 months. Estimated survival at 5 years after heart transplant was 92.9% in Group P0 and 72.3% in Group P1 (p <0.01). Cox proportional hazard modeling revealed black recipient race as effect modifier of group status with decreased survival time in both groups. CONCLUSION: Steroid-free immunosuppression in white heart transplant recipients is associated with improved survival. A low acute rejection score during the first year predicts successful steroid withdrawal. Black recipient race appears to be negatively associated with survival and deserves further detailed study. Long-term surveillance screening using endomyocardial biopsy is recommended.