Closed commissurotomy versus balloon valvuloplasty for rheumatic mitral stenosis.

BACKGROUND AND AIM OF THE STUDY: Closed mitral commissurotomy (CMC) and percutaneous mitral balloon valvuloplasty (PMBV) were compared by their initial results and Doppler echocardiographic data obtained at one week and one year after the procedure. METHODS: Of 580 patients with severe rheumatic mitral stenosis, 280 underwent CMC and 300 PMBV. The mean pre-procedural transmitral gradient (TMG) was 21 +/- 6 mmHg in the CMC group and 20 +/- 5 mmHg in the PMBV group (p = 0.6); the mean mitral valve area (MVA) was 1.1 +/- 0.2 cm2 in both groups. RESULTS: Mortality was 0.7% after CMC and 0.3% after PMBV; the primary success rates were 98.3% and 89% respectively (p <0.0001). Two CMC patients and three PMBV patients underwent emergency mitral valve replacement. At the first week, the mean TMG was decreased to 4 +/- 3 mmHg in the CMC group, and to 5.8 +/- 2 mmHg in the PMBV group (p <0.0001). The mean MVA was increased to 2.5 +/- 0.5 cm2 after CMC, and to 2.1 +/- 0.4 cm2 after PMBV (p <0.0001). After one year, TMG was 5.4 +/- 4 mmHg in the CMC group (p <0.0001) and 7.1 +/- 3 mmHg in the PMBV group (p <0.0001); MVA was 2.3 +/- 0.5 cm2 (p <0.0001) and 1.9 +/- 0.4 cm2 (p <0.0001), respectively. The results of CMC were significantly better (p <0.0001) with regard to TMG and MVA at these times. A significant decrease was also seen in mean left atrial diameter and pulmonary artery pressure in both groups (p <0.0001). CONCLUSION: Although satisfactory results can be achieved using either approach, CMC provides a higher primary success rate, greater MVA augmentation, and better technical control during the procedure, while reducing the cost. PMBV shortens in-hospital stay and eliminates the risk imposed by thoracotomy and anesthesia. Therefore, in our practice, when surgical intervention is contraindicated due to associated problems, PMBV may be the preferred approach, but exposure to radiation may be of concern in pregnant patients.

Left ventricular aneurysm repair: an assessment of surgical treatment modalities.

OBJECTIVE: Different closure techniques (linear vs. circular), as well as the efficacy of revascularization in the left ventricular aneurysm repair, with regard to immediate and mid-term results, were assessed and factors having influence on the early mortality and morbidity and survival were analyzed. METHOD: Between January 1991 and November 1996, 248 patients underwent surgical repair for postischemic left ventricular aneurysm. A total of 26 of them were female (10.50%). Linear closure was employed in 121 patients (48.8 %) and circular (patch endoaneurysmorraphy) closure in 127 (51.2%). Coronary revascularization was added in 203 (81.9%) cases. Patients were followed for an average follow-up time of 39.3 months. RESULTS: Early mortality rate was 6% (15 patients). The difference in mortality rate by the repair method was not statistically significant (8.3% in the linear closure group and 3.9% in the circular closure group, P = 0.15). Absence of preoperative angina pectoris (P = 0.029), dyspnea as the presenting symptom, a preoperative left ventricular segmental wall motion scoring of 14 or greater, a cardiopulmonary bypass duration exceeding 2 h (P = 0.004), an aortic clamping time exceeding 1 h (P = 0.026) were associated with early mortality. Concomitant coronary revascularization had no effect on early mortality. However, low cardiac output state was less frequent in patients with concomitant coronary revascularization (P = 0.022). Functional status improved in both groups. Follow-up extending to 81st month revealed no difference in survival between the groups (84% for linear closure group and 92% in circular closure group, including operative mortality, P = 0.12). However, functional status improvement was better in the patients who underwent circular repair (P = 0.0077). Revascularization appeared as having no important influence on both survival and functional status. A preoperative left ventricular segmental wall motion scoring of 14 or greater was associated with a higher incidence of early mortality, low cardiac output syndrome and poor long-term survival. CONCLUSION: Left ventricular aneurysm repair is an important therapeutic intervention and can be performed with reliable results, regardless of repair method, either linear or circular. Long term results revealed better functional status in circular repair group. Concomitant coronary revascularization reduced the incidence of low cardiac output state. Performance of the unaffected regions of myocardium was found to be an important determinant of both early and late outcome.

Hemodynamic effects of acute intestinal ischemia.

Twelve animals entered in this study with the aim of documenting that superior mesenteric artery small occlusions lasting for one hour have adverse effects on the myocardium. Three hours after cross clamp removal CO decreased to 1.07 +/- 0.11 from 1.99-0.09 a preoperative value (p < 0.01) and PCWP increased to 17 +/- 3 from 8 +/- 3 a preoperative value. MOE reduced to 40-5% 3 hours after cross clamp removal. MLE was -0.21 +/- 0.11 three hours after clamp removal. Changes in MOE and MLE were commented as a defect in myocardial aerobic metabolism. As a result of this study it was concluded that toxic mediators are released from the intestine being reperfused after temporary occlusions of the SMA impair myocardial metabolism, resulting in decreased hemodynamic functions.