Isolated mitral valve replacement with the Hancock porcine bioprosthesis in rheumatic heart disease: analysis of 213 operative survivors followed up 4.5 to 8.5 years.

An analysis is presented of 236 patients aged greater than or equal to 20 years who underwent isolated mitral valve replacement for rheumatic heart disease with a glutaraldehyde Hancock bioprosthesis from June 1974 through June 1978. Of 213 patients discharged from the hospital, 3 were lost to follow-up study and are excluded from the analysis. The range of follow-up of the surviving patients was 54 to 102 months. There were 17 late deaths, an incidence of 1.3% per patient-year. The actuarial probability of survival of all patients at 102 months, excluding hospital mortality, is 88 +/- 6%. There were 24 thromboembolic events in 22 patients (1.8% per patient-year); none was fatal, and 3 patients were receiving coagulant therapy at the time. The probability of freedom from thromboembolism at 8.5 years is 84 +/- 9%. Primary tissue failure occurred in 17 patients (1.3% per patient-year). Average duration of the explanted valves was 70 months (range 55 to 90). Reoperation was undertaken in the 17 patients 2 days to 63 months (mean 9 months) after the appearance of a new murmur and 2 days to 23 months (average 4 months) after the onset of worsening symptoms. The probability of being free from primary tissue valve failure at 8.5 years of follow-up is 87 +/- 7%. Currently, 14 patients have valve dysfunction on the basis of the appearance of a new murmur 20 to 89 months after operation (average 5.2 years).(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of the amount of tricuspid valve anular dilatation required to produce functional tricuspid regurgitation.

To determine the critical anular dilatation required for functional tricuspid regurgitation (TR) and the role of systolic anular shortening in the severity of TR, 67 patients in whom right ventriculography had been performed were studied. These patients were classified into group I, control (n = 12), and the group II, patients with rheumatic valvular disease (n = 55). Group II patients were subclassified as follows: IIa, without TR (n = 19); IIb, with mild TR (n = 22); and IIc, with moderate to severe TR (n = 14). The angiographic maximal early systolic and minimal end-systolic diameters were measured. The shortening of the tricuspid anulus was expressed as percent reduction of the maximal diameter. The average maximal diameter (mm/m2) was: group I, 21 +/- 2; group IIa, 24 +/- 2; group IIb, 31 +/- 4; and group IIc, 37 +/- 4. The average minimal diameter (mm/m2) was: group I, 15 +/- 2; group IIa, 18 +/- 2; group IIb, 23 +/- 2; and group IIc, 31 +/- 3. The average percent shortening was: group I, 30 +/- 7%; group IIa, 25 +/- 7%; group IIb, 26 +/- 5%; and group IIc, 15 +/- 3%. The rheumatic patients had a larger maximal diameter than did those in the control group. Anular shortening was reduced only in the group with moderate to severe TR and preserved in the other groups, including those with mild TR. The critical diameter was determined to be between the maximal diameter in the rheumatic patients without TR and the minimal diameter in the patients with moderate to severe TR, or 27 mm/m2. Thus this easily measured parameter can determine the presence and significance of functional TR, adding objectivity to the angiographic diagnosis of TR.

Late clinical results with the use of heterologous pericardium for closure of the pericardial cavity.

In a limited series of 87 patients, the pericardial cavity was closed with a patch of heterologous glutaraldehyde-preserved pericardium. Five specimens have become available for macroscopic and microscopic study, with a postimplant time ranging between 1.5 and 59 months. The patches maintained their initial structure, but the reaction over the epicardial area facing the graft greatly impeded the recognition of the coronary vessels.

Glutaraldehyde-preserved heterologous pericardium for the repair of diaphragmatic defects: experimental study.

Glutaraldehyde-treated porcine and bovine pericardium was used to close diaphragmatic defects in 15 dogs. The animals were reoperated upon between 15 days and 15 months. There were no adherences between the heterologous patch and the adjacent structures in any dogs except one, in which the omentum was attached to the pericardium. Microscopically, the graft structure remained intact without cellular invasion. The graft was covered with a thin layer of fibrous tissue, more intense in the one case of omental adhesions. There were no macroscopic or microscopic differences detectable in the behavior of the bovine and porcine pericardium. Although the follow-up is relatively short, these materials appear to offer a valid nonadherent alternative for diaphragmatic repair.

Incidence of primary tissue valve failure with the Ionescu-Shiley pericardial valve. Preliminary results.

This report provides retrospective follow-up data on 88 patients who received an Ionescu-Shiley bovine pericardial valve in the aortic position between August, 1977, and June. 1980. Seven instances of primary tissue degeneration occurred in seven of the 65 patients followed up until June, 1984. Cumulative duration of follow-up was 335.5 patient-years. The linearized incidence of primary tissue failure was 2.08% per patient-year. The actuarial rate of freedom from valve failure for patients with an Ionescu-Shiley valve in aortic position was 79% +/- 8% at 7 years of follow-up. This series shows a higher incidence of primary tissue failure with this prosthesis than with the glutaraldehyde-preserved porcine xenograft in the aortic position at 7 years' follow-up.

The Ionescu-Shiley valve: a solution for the small aortic root.

Valve replacement in patients with a small aortic anulus can cause difficult technical problems or leave the patient with a significant residual transvalvular gradient. Between August, 1977, and June, 1983, 35 patients with a small aortic root (21 mm or less) underwent aortic valve replacement with Ionescu-Shiley pericardial xenograft valves. They ranged in age from 29 to 76 years (mean 52.8 years) and in weight from 64 to 91 kg (mean 76.3 +/- 3.6 kg). Preoperatively, 26 patients were in New York Heart Association Functional Class III-IV. The valve sizes used were 17 mm in three cases, 19 mm in 16 cases, and 21 mm in 16 cases. There were four hospital deaths (11.4%) resulting from sepsis or low cardiac output. There were no late deaths. Cumulative duration of follow-up was 819.4 patient-months. Twenty-four (78%) of the 31 surviving patients are asymptomatic. Up to the time of review, there have been no episodes of thromboembolism, infective endocarditis, perivalvular leak, valve thrombosis, or primary tissue valve failure. Fifteen patients were hemodynamically evaluated 2 to 47 months (mean 14.3 months) after operation. The average resting transvalvular gradients for 19 and 21 mm valves were 15.1 and 10.8 mm Hg, respectively. Our experience suggests that the Ionescu-Shiley pericardial xenograft valve is a valid alternative in the surgical treatment of patients with a small aortic root.

Conservative operation for mitral insufficiency: critical analysis supported by postoperative hemodynamic studies of 72 patients.

From May, 1974, through December, 1978, 255 mitral annuloplasties have been performed at our institution. Forty-three Carpentier rings and 212 flexible rings were used. Simultaneously, 307 patients with predominant insufficiency were treated with a Hancock bioprosthesis. A critical analysis of the flexible ring group versus the Hancock group is presented: The average ages were 41.3 versus 43.3 years. Preoperatively, 55% versus 60% were in Functional Class III and 9.6 versus 25.4% were in Class IV. The valve lesion was caused by rheumatic disease in 91.2% versus 93.9%. A multiple valve operation was required by 51% versus 60%. There was a significant difference in the operative mortality rates (1.8% versus 11.4%). This difference was maintained for each preoperative functional class and for the isolated and multiple valve groups. There was no significant difference in the late mortality rates (1.4% versus 3.7%). The total actuarial survival rates were of 96.4% and 81% (maximum follow-up times 4.0 and 4.5 years). The incidence of embolism was 2.4% and 4.1% per patient-year, with both groups being subjected to the same anticoagulation policy. The incidence of dysfunctions was equal (3.9% per patient-year). Postoperative hemodynamic evaluation of 72 patients having annuloplasty and 129 patients having Hancock valve replacement showed basal mean transmitral gradients of 10.98 +/- 3.6 and 9.66 +/- 2.73 mm Hg. The average effective orifice areas were 1.93 +/- 0.74 and 2.25 +/- 0.46 cm2. While the bioprosthesis behaves hemodynamically like a flow-related variable orifice, the reconstructed valve orifice is dependent upon its preoperative anatomy. In conclusion, the comparison of flexible ring annuloplasty and Hancock valve replacement for mitral valve disease shows a lower operative mortality for the former and comparable medium-term postoperative course. Since both techniques have a limited durability, longer follow-up periods will soon resolve this controversial issue.

Clinical and hemodynamic performance of a totally flexible prosthetic ring for atrioventricular valve reconstruction.

A new, totally flexible ring for atrioventricular annuloplasty is described. The technique for its insertion closely follows the principles of Carpentier's selective annulus reconstruction [4]. Ninety-nine such rings have been inserted (47 in the mitral and 52 in the triscuspid position); 45 valves were simultaneously replaced. There were 6 (4 hospital and 2 late) deaths. The thromboembolic incidence was 4.8%. No instances of dehiscence or late ring deterioration have been detected. Thirty-four patients have been recatheterized, 19 of them with mitral rings. The mitral gradients and angiographic findings show the correct functioning of the implanted ring. It is concluded that use of this flexible ring, which adapts to the continuous changes of the normal mitral annulus, produces a more physiological type of valve operation.

Twenty-year comparison of the human allograft and porcine xenograft.

This study compares a retrospective consecutive series of human allografts and concurrent porcine xenografts implanted over a 10-year interval. There were 571 allograft valves and 1,351 xenograft valves implanted in the aortic and mitral position with mean follow-up of 12.8 years for the allografts and 6.2 years for the xenografts. This study compares the incidence of structural deterioration over long-term follow-up. We found that there was no significant difference between four manufacturers of porcine xenografts, in spite of substantial differences in processing techniques. We found that there was a significant difference in allografts that were premounted on stents as compared with allografts that were not premounted on stents for aortic valve replacement. We found that there was no significant difference between allografts for aortic valve replacement that were not premounted on stents and porcine xenografts implanted in the aortic position. These findings are in marked contrast to those of other reported series with the use of allograft valves.

Persistent left superior vena cava: a simple technique for adequate drainage during cardiopulmonary bypass.

Persistent left superior vena cava is a frequent anomaly of the systemic venous return and usually drains into the right atrium through the coronary sinus. Inadequate drainage of this vessel during cardiopulmonary bypass can result in complications for the patient and problems for the surgeon. Various methods of draining this vessel, directly or indirectly through the coronary sinus, have been already described. Some surgeons temporarily occlude or even ligate this vessel. We describe here an alternative and simple method to drain this vessel during cardiopulmonary bypass.

Cardiopulmonary bypass in sickle cell anaemia. Report of five cases.

Five patients with sickle cell haemoglobinopathies underwent open heart surgery. At the start of the cardiopulmonary bypass the patient's circulating blood volume was separately drained into a bag, spun down and retransfused into the patient at the end of the operation. Moderate hypothermia, aortic cross clamping, topical hypothermia and cold crystalloid cardioplegia were used in all patients. None of the patients had transfusions in the postoperative period. No macroscopic or microscopic evidence of haemolysis were seen, nor haematuria or other clinical evidence of sickling. There was no evidence of wound infection and all were discharged home at a mean of 12.6 days. It is concluded that in cases of sickle cell anaemia exchange transfusion at the beginning of cardiopulmonary bypass followed by retransfusion of the red cell free blood can be used safely, permitting the performance of standard open heart procedures.

Reconstructive techniques for rheumatic aortic valve disease.

Aortic valve reconstruction is still at an early stage of development. We report techniques that can be applied in the repair of rheumatic aortic valve disease in patients with concomitant mitral valve disease. The techniques described are: (1) commissurotomy, (2) cusp free edge unfolding, (3) annuloplasty, and (4) supraaortic crest enlargement. Fifty patients operated on between January 1974 and January 1986 with a hospital mortality of 6% were followed for a mean period of 7.7 years. Reoperation due to failure of mitral surgery was required in twelve patients, tricuspid regurgitation in two, and significant aortic regurgitation in four. These techniques, although applicable to a limited number of patients, have enabled us to avoid the problems of aortic valve replacement in many patients.

Stability of mitral reconstructive surgery at 10-12 years for predominantly rheumatic valvular disease.

All consecutive patients who underwent Duran flexible ring annuloplasty in 1975 and 1976 were reviewed until June 1987. Eighty-seven annuloplasties were performed in 85 patients. Aortic, tricuspid, or both surgeries were simultaneously performed in 44.8%. The hospital mortality was 2.3% (two of 85). Ten patients were lost to follow-up within 2 years after surgery, and there were three late deaths. Thromboembolic events were detected in 18 patients (seven peripheral and 11 central with one death); nine patients had partial recovery, and eight had full recovery. At the time of the thromboembolic event, eight patients were receiving anticoagulants; four, antiaggregants; one, both anticoagulants and antiaggregants; and five, none. Thirteen patients (13 of 73, 17.8%) required reoperation between 1 month and 11 years postoperatively. The valve was replaced in 11 patients, and two underwent a new flexible ring annuloplasty. The cause for reoperation was regurgitation in eight patients (10.9%), for whom the mean interval between operations was 20.6 months (range, 1 month-11 years). Stenosis was the cause for reoperation in five patients (6.8%), for whom the mean interval between operations was 87.8 months (range, 4-11 years). We conclude that reconstructive surgery after 10-12 years of follow-up for this group of predominantly rheumatic patients has an incidence of failure of approximately 18% attributable to incorrect surgery (11%) and restenosis (7%).

Haemodynamic effect of supraaortic ridge enhancement on the closure mechanism of the aortic valve and its implications in aortic valve repair.

The presence of the sinus of valsalva plays an essential part in the closing mechanism of the aortic valve. High-energy vortices are initiated at the upper limit of each sinus or supraaortic crest, and last during the whole valve closing time. An attempt was made to prove this hypothesis in vivo by intermittent augmentation of each supraaortic ridge. In a series of five dogs without cardiopulmonary bypass, pledgeted sutures were placed at the level of each crest and passed through tourniquets. In a series of three sheep, similar sutures were placed under direct vision with cardiopulmonary bypass. The supraaortic crests were augmented or maintained normal by tightening or loosening the tourniquets repeatedly. Simultaneous aortic and ventricular pressures and 2D- and M-mode echocardiography were recorded. In the dog series the results were unpredictable due to variability in the supraaortic crest enhancement because the sutures did not correspond to the anatomical crest. In the sheep series the sutures were correctly placed and M-mode echocardiography demonstrated a significant (p less than 0.01) shortening in systolic time. These results suggest the use of enhancement of the supraaortic crest as an adjunct technique in aortic valve repair.

Balloon valvotomy for pregnant patients with severe pliable mitral stenosis using the Inoue technique with total abdominal and pelvic shielding.

Balloon valvotomy by means of the Inoue technique was attempted in seven pregnant (5 to 9 months) patients with severe mitral stenosis; the mean age of the patients was 32 +/- 8 years, and all had a two-dimensional echocardiographic mitral valve score of < 8. Indications for Inoue balloon valvotomy included severe symptomatic mitral stenosis with a Doppler mitral valve area < or = 1 cm2 and heart failure refractory to medical therapy, or absolute contraindications for the use of beta-blockade; Inoue valvotomy was also indicated for patients who lived a long distance from the hospital. Inoue balloon valvotomy was performed with no angiography and total pelvic and abdominal shielding; the balloon catheter was introduced into the right atrium without the aid of fluoroscopy, which was used for the transseptal puncture. Stepwise two-dimensional echocardiographic Doppler mitral valve dilatation was done. After Inoue balloon valvotomy the mean Doppler mitral valve area increased from 0.8 +/- 0.1 to 2.0 +/- 0.3 cm2 (p < 0.01) and by two-dimensional echocardiography from 0.8 +/- 0.2 to 1.9 +/- 0.3 cm2 (p < 0.01), with no significant Doppler residual stenosis (defined as mitral valve area < or = 1.5 cm2). The mean total fluoroscopy time was 16 +/- 7 minutes. The degree of mitral regurgitation increased in two patients from grade 1+/4+ to grade 2+/4+ and from grade 0+/4+ to grade 2+/4+, respectively. There was no mortality or significant morbidity. Pregnancy was uneventful in all patients, and all were delivered of normal babies without complications.(ABSTRACT TRUNCATED AT 250 WORDS)