Valve-related complications in elderly patients with biological and mechanical aortic valves.

BACKGROUND: Controversy still exists about the choice of aortic prosthesis in elderly patients. This study investigates valve- and anticoagulant-related morbidity and mortality in elderly patients after aortic valve replacement (AVR) with a biologic (BP) or mechanical prosthesis (MP). METHODS: Between 1981 and 1995, 355 consecutive patients aged 70 years or older (mean, 74+/-4 years; range, 70 to 87 years) underwent isolated AVR. There were 222 (63%) replacements with an MP and 133 (37%) with a BP. Mean follow-up was 3.7+/-2.8 years (range, 3 months to 15 years), with a total follow-up of 1,214 patient-years. RESULTS: Hospital mortality was 7.6% (27 of 355), decreasing to 4.6% in the last 3 years. There were 55 late deaths, 33 in patients with MP and 22 in those with BP. At 10 years there was no significant difference between MP and BP recipients in the actuarial estimates of survival (51%+/-8% versus 33%+/-13%), freedom from valve-related death (82%+/-7% versus 72%+/-12%), and freedom from thromboembolism (84%+/-7% versus 94%+/-3%). In contrast, 10-year freedom from anticoagulant-related hemorrhages was 74%+/-8% for MP and 99%+/-1% for BP (p = 0.02). Only 1 structural deterioration occurred, in a patient with BP. CONCLUSIONS: Satisfactory early results can be obtained in elderly patients after AVR with both MP and BP. The comparable low late survival in the two groups was predominantly influenced by non-valve-related deaths. A higher incidence of anticoagulant-related hemorrhages limits the use of MP in elderly patients. Thus, in this population, BP should be preferred not just on the basis of their expected longer durability, but mainly to avoid the risk of anticoagulant-related hemorrhages.

Myocardial vitamin E is consumed during cardiopulmonary bypass: indirect evidence of free radical generation in human ischemic heart.

Although a role for free radicals in myocardial damage during cardiopulmonary bypass for open heart surgery has been postulated, direct evidence of free radical production as well as consumption of tissue antioxidants such as vitamin E is still lacking. Twenty patients (age 26-66 yr, mean 48) undergoing elective open heart surgery with moderate hypothermia, and cold crystalloid cardioplegia, were studied. Cardiopulmonary bypass time was 61.4 +/- 31.2 min. The specimens of atrial tissue collection before and after cardiopulmonary bypass, were immediately frozen in liquid nitrogen. Mean vitamin E atrial content, measured by reverse phase HPLC, was 355 +/- 249 pmol/mg of dry weight basally, 135 +/- 85 pmol/mg (p < 0.05) at the end of the ischemic period and 405 +/- 288 pmol/mg after the reperfusion period (p < 0.01). Microscopic examination of right atrial biopsies ruled out differences in fibrosis or cellular damage as the cause of vitamin E changes. Although a great basal variability in atrial vitamin E content was observed, which was independent of age, sex and clinical status, a reproducible and substantial decrease in atrial vitamin E content after cardiopulmonary bypass occurred (mean reduction 45 +/- 17% and 55 +/- 22%, respectively, after ischemia and after reperfusion). This was directly related to the aorta cross-clamping duration and partially to the minimum temperature achieved. In conclusion, apart from the great variability observed in basal vitamin E tissue content, vitamin E was always reduced during cardiopulmonary bypass, suggesting an oxidative stress on the myocardium during open heart surgery.

Mitral valve annuloplasty for degenerative disease: assessment of four different techniques.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair (MVR) is the treatment of choice in patients with degenerative valve disease. However, controversy persists as to whether mitral valve annuloplasty should always be included as part of the reconstructive procedure. METHODS: The records of 62 consecutive patients undergoing MVR for degenerative disease between January 1994 and December 1996 were reviewed. Four different annuloplasty techniques were associated with various MVR procedures: local posterior annuloplasty (group 1, n = 10), rigid Carpentier ring (group 2, n = 20), Duran ring (group 3, n = 17), and posterior annular plication with autologous pericardium (group 4, n = 15). The four patient groups were similar in terms of preoperative clinical and echocardiographic characteristics. Serial clinical and echocardiographic follow up was performed to assess functional status and stability of repair. RESULTS: There were no early or late deaths. Mean follow up in the entire patient series was 31 +/- 12 months. One patient in group 2 required reoperation 14 months after MVR. In all groups there was a significant improvement in NYHA functional class (from 2.7 +/- 0.6 to 0.9 +/- 0.5, p <0.001), with a reduction of left ventricular end-diastolic and end-systolic volumes (154 +/- 50 ml to 105 +/- 33 ml, p <0.001; and 64 +/- 23 ml to 52 +/- 22 ml, p <0.001). In patients of groups 2, 3 and 4, residual mitral incompetence at follow up (0.8 +/- 0.9 in group 2, 0.8 +/- 0.7 in group 3, and 0.2 +/- 0.6 in group 4) was not significantly different from discharge. However, in group 1, a higher degree of residual mitral regurgitation was present at discharge (0.9 +/- 0.6) with a trend to progress at follow up (1.6 +/- 0.5). CONCLUSION: In patients with degenerative mitral valve disease, MVR provides clinical and functional improvement. Techniques of stabilization of the entire posterior mitral annulus achieve better early and medium-term results, and should be always considered as part of MVR. Autologous pericardium appears to be an excellent annuloplasty material, though its apparent superiority over synthetic rings must be confirmed at longer follow up.

Chylothorax following cardiac surgery in children.

Eleven cases of chylothorax following cardiac surgery in children are described. Conservative treatment was carried out with success in all patients but one, who died because of the underlying cardiac pathology, with the chylothorax still present. Our results indicate that conservative treatment is effective in children, although surgery has been previously considered by some authors as the treatment of choice in this age group.

Quadricuspid aortic valve.

A case of quadricuspid aortic valve is described. The anomaly was unexpectedly found during operation for aortic valve replacement in a 70-year-old woman. Macroscopic and histological examinations of the valve showed no sign of previous inflammatory disease. Quadricuspid aortic valve must be considered, therefore, a malformation capable of leading to severe valve failure in later life.

Suitability of Doppler echocardiography for the assessment of right heart hemodynamics after De Vega tricuspid annuloplasty.

Cardiac Doppler Echocardiography is a suitable method for to evaluating right heart hemodynamics. However, the surgical correction of tricuspid valve annuloplasty changes valve geometry and might possibly lead to a technical obstacle to this estimation. The accuracy of Doppler echocardiography in the assessment of tricuspid regurgitation and systolic pulmonary pressure in patients who had undergone De Vega annuloplasty was evaluated in this study. Ten patients (9 females and 1 male), mean age 55.7 +/- 7.8 years, who had a previous De Vega annuloplasty for the treatment of tricuspid regurgitation due to a severe mitral stenosis, underwent a Doppler echocardiography study and, within two hours, right heart catheterization for a direct comparison of parameters calculated by different methods. Right ventricular-atrial maximal pressure gradient was found to be 32.6 +/- 11.07 mmHg by Doppler and 31.4 +/- 11.07 mmHg by catheterization. Pulmonary systolic pressure was 42.6 +/- 9.1 mmHg at Doppler and 39.1 +/- 11.3 mmHg at catheterization, with a highly significant correlation between the 2 techniques (r = 0.98%, p < 0.01). With semiquantitative Doppler evaluation 10 patients showed tricuspid insufficiency, which was mild in 8 and medium in 2. At catheterization all patients were found to have mild tricuspid insufficiency. Cardiac Doppler seems a reliable method in the evaluation of tricuspid regurgitation and of pulmonary systolic pressure even in patients who underwent De Vega annuloplasty.

[Cardiac myxoma in the elderly. Clinical study]. / I mixomi cardiaci nell'anziano. Studio clinico.

Cardiac mixoma in the elderly. A clinical study. The clinical features of 13 cardiac myxomas surgically resected are presented. The mean age at presentation was 68 years. Ten were in the left atrium, 5 near the fossa ovalis, 3 at the base of the atrial septum, 1 at the inferior wall and 1 on the anterior leaflet of mitral valve, 3 were in the right atrium, 1 of these was accompanied with a myxoma at the apex of left ventricle. The ECG and the chest X-ray were normal in 9 and in 8 patients, respectively. In 3 patients, the diagnosis was occasionally made by routine 2-dimensional echocardiography. 5 patients presented with fever of unknown origin, arthralgias, weakness, weight loss. None had intracardiac or extracardiac recurrence in the 73 months follow-up. The presentation with constitutional symptoms only like fever of UO, may mimic collagen and neoplastic diseases, vasculitis, lymphomas: the 2-dimensional echocardiography is mandatory to esclude a cardiac myxoma in the elderly.

[Hematoma of right ventricular outflow tract mimicking an infiltrating tumor as a consequence of acute aortic dissection]. / Dissecazione aortica acuta complicata da ematoma del tratto di efflusso ventricolare destro.

The aortic dissection may be associated with unusual complications such as fistula formation and vascular compression. We describe a case of a 71-year-old patient admitted to our Hospital because of acute chest pain; transthoracic and transesophageal echocardiography revealed the presence of a type A aortic dissection associated with a mass infiltrating the right ventricular outflow and proximal tract of the pulmonary artery. The ultrasonographic morphology and the surgical findings showed the presence of a hematoma which was consequent to acute aortic dissection and which mimicked a tumor infiltrating the right ventricular outflow.

Double outlet right ventricle, non-committed ventricular septal defect and pulmonic stenosis. Anatomical and surgical considerations.

A case of double outlet right ventricle with pulmonary stenosis, a non-committed muscular ventricular septal defect occupying the sinus and trabecular portions of the ventricular septum, an additional small subtricuspid ventricular septal defect, situs solitus, atrioventricular concordance and aortic d-position is described. Atrioventricular valvular canal type malformations, splenic, systemic or pulmonary venous anomalies, all frequently seen in double outlet right ventricle with uncommitted VSD, were not present.

[Isolated straddling tricuspid valve. Presentation of 2 cases operated on successfully]. / Valvola tricuspide a cavaliere isolata. Presentazione di due casi operati con successo.

During the period May 1977-September 1983 in the Department of Cardiac Surgery of Massa Hospital two patients with isolated straddling tricuspid valve were studied with cardiac catheterization and selective angiocardiography and subsequently underwent surgical correction. The first patient, a 38-month-old white boy presented with "complete straddling" according to Bharati and Lev classification; the second, a 39-month-old white boy presented with "peripheral straddling". In both cases at surgery the ventricular septal defect was closed with a Teflon patch, sparing the chordae tendinae and the "straddling" papillary muscle. Both patients survived operation. The first one developed a complete atrioventricular (A-V) block with a ventricular rate which never was below 80 beats/min, during the 30 days of in-hospital observation. No permanent pacemaker was therefore inserted. The follow-up controls (39 and 79 months respectively) shows both patients to be hemodynamically and functionally well.

Successful repair of delayed rupture of the left ventricular wall after mitral valve replacement. Report of two cases.

Rupture of left ventricular wall (LVWR) following mitral replacement (MVR) is rare (0.5 to 7.3% of all MVR). Two "types" of LVWR have been recognized and attributed to technical errors during MVR and/or to co-existing unfavourable conditions. The two types are precisely located, and appear "early" during operation, at discontinuation of cardiopulmonary bypass (CPB). Miller et al. have described a "third type" LVWR which depends primarily on local conditions, is located between the other two and occurs "late". Successful repair is rare. The outcome is favourably influenced by intraoperative recognition. This paper reports two LVWRs "type III" which occurred among 282 MVR (0.7%) done in our Department since 1977. Both were successfully repaired respectively 12 (and again 48) and 15 hours after MVRs. To the best of our knowledge these are the only cases of successful repair of a "type III" LVWR reported in the literature. On the basis of this experience some considerations are presented.

[Role of transesophageal echocardiography in mitral valve repair]. / Ruolo dell'ecocardiografia transesofagea nella ricostruzione valvolare mitralica.

This study was designed to prove the utility of intraoperative echocardiography in the mitral valve repair, that offers many advantages over valve replacement. We have assessed 21 consecutive patients, 12 with mitral incompetence and 9 with mitral stenosis, undergoing mitral valve surgery over a period of 6 months. Preoperative transthoracic and intraoperative transesophageal or epicardial echocardiography were performed in all patients. We have assessed, before and after repair, the valve morphology, the presence and the severity of mitral regurgitation, the pulmonary venous flow, the presence of left ventricular outflow tract obstruction. The intraoperative echocardiographic examination revealed a successful mitral repair in all patients except one in whom, for the persistence of severe mitral regurgitation after repair, valve replacement was performed. In none patient systolic anterior motion of mitral apparatus was observed. Intraoperative echocardiography seems to be a useful technique to assess the adequacy of mitral valve repair before chest closure and, in the case of failure, the need for further surgery (valve reconstruction or replacement).

Congenital coronary artery fistula: report of five patients, diagnostic problems and principles of management.

The detection of a coronary artery fistula (CAF) is usually by chance and, because of the to-and-fro characters of the murmur, a misdiagnosis of a patent ductus arteriosus is frequently made. Correct diagnosis can only be reached after hemodynamic investigation completed by angiography. This lesion is often accompanied by few or no symptoms in infancy, but may become symptomatic with aging even if the shunt is small: complications such as endocarditis, rhythm disturbances, aneurysmatic dilation and rupture have been reported. Five cases of CAF have been studied in our institution: 3 of them have been operated upon in extracorporeal circulation with good results. Principles of management are controversial: many authors advocate delay of treatment until symptoms appear: in our opinion, based on the natural history of the disease and on our experience, closure of the fistula in pediatric age, even in asymptomatic patients, is the treatment of choice.

Post-traumatic mitral regurgitation and ventricular septal defect in absence of left pericardium.

A six-year-old boy was hospitalized following a car accident. Cardiac catheterization demonstrated acute post-traumatic mitral regurgitation (MR) and ventricular septal defect (VSD). The patient was operated on for mitral valve replacement and closure of the VSD. On opening the chest absence of the left pericardium was noted. Cardiac catheterization performed in the postoperative period demonstrated a residual left-to-right shunt at ventricular level. The patient was reoperated on 10 months later for closure of the residual VSD. Six months after the last operation the patient is in good condition. The congenital absence of the pericardium is considered as favoring both the post-traumatic cardiac lesions and the postoperative pulmonary problems on the left side.

Ambulatory follow-up of aortic dissection: comparison between computed tomography and biplane transesophageal echocardiography.

UNLABELLED: Aim of the study was to assess the relative usefulness of transesophageal echocardiography (TEE) and X-ray computed tomography (CT) in the follow-up of patients who survived an aortic dissection. MATERIALS AND METHODS: We evaluated 44 patients (age = 57 +/- 12 years) with treated aortic dissection: 14 had a De Bakey type I, 20 a type II and 1 patient a type III dissection treated surgically: 1 patient had a type I, 1 a type II and 7 a type III dissection treated medically. All entered an outpatient follow-up program with serial evaluations at 1, 6 and 12 months after initial diagnosis by dual noninvasive imaging protocol. A contrast-enhanced CT scan and a TEE with biplane probe were performed on the same day and in random order. RESULTS: A total of 252 evaluations with both CT and TEE were considered. A completely normal study was found in 45 TEE and 48 CT evaluations. The following abnormal findings could be documented by one or both techniques: thrombus in the false lumen (TEE: n = 48; CT: n = 45 evaluations); intimal flap (TEE and CT: n = 68); aortic dilatation (TEE and CT: n = 15); pericardial effusion (TEE and CT: n = 3); aortic pseudoaneurysm (TEE: n = 2; CT: n = 3); isthmic coarctation (TEE and CT: n = 1). Regarding the presence or absence of these abnormalities, which are within the diagnostic domain of both imaging techniques, the results were fully concordant in 245 studies, and discordant in 7, with an overall agreement of 97%. In addition, some abnormal findings could be detected by TEE only: aortic insufficiency (n = 36); intimal tear (n = 25); spontaneous echocontrast effect in the false lumen (n = 39 evaluations). Other abnormal findings could be detected by CT only: a pleural effusion in 4, a truncus anonymous dissection in 1, a pseudoaneurysm due to suture dehiscence of the distal anastomosis of the ascending aorta in 1 evaluation (which yielded ambiguous results by TEE, with turbulent flow departing from the graft). CONCLUSION: Both CT and TEE are atraumatic, safe and accurate techniques for serial follow-up imaging of patients treated for aortic dissection. Information provided by CT is largely redundant, rather than additive, to that provided by TEE. The latter should be probably preferred for shorter imaging time, accuracy and convenience, although CT might still play a role in selected cases of ambiguous TEE results.

Prognostic value of the dipyridamole echocardiography test performed early after aortocoronary bypass surgery.

It has been demonstrated that high dose (up to 0.84 mg/kg over 10 min) dipyridamole echocardiography stress testing is feasible even in the first few hours after coronary artery bypass graft surgery and can be used to assess the beneficial physiological effects of coronary revascularization as well as graft patency. The aim of this study was to assess the role of dipyridamole echocardiography testing performed shortly after myocardial revascularization in the stratification of prognosis during follow-up. We studied 49 consecutive patients (45 males and 4 females; mean age 56 +/- 8 years) referred to our institute for elective myocardial revascularization. Six patients had single, 14 double, and 29 triple vessel disease. Forty-two left internal mammary artery grafts, 16 sequential venous grafts, and 45 single venous grafts were performed. All patients were submitted to dipyridamole echocardiography testing before (range 1-3 days) and shortly after (range 5-7 days) myocardial revascularization, always with the patients off antianginal medication. An arbitrary wall-motion score grading from 0 to 3 (normal, hypokinesia, akinesia, and dyskinesia) was applied to the seven regions into which the left ventricle was divided. Before surgery 48 patients showed wall-motion abnormalities during the test (47 patients also presented ECG changes). Angina occurred in 48 patients. One patient had ischemic ECG changes and angina. The mean wall-motion score was 3.11 per patient before and 6.5 per patient after the test (P less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)