De Vega Annuloplasty Research Articles

Extensive atrial wall resection in a patient with symptomatic idiopathic right atrial enlargement

Extensive atrial wall resection in a patient with symptomatic idiopathic right atrial enlargement

Posttraumatic Tricuspid Insufficiency Successfully Repaired by Conventional Technique

A 22-year-old man developed exertional dyspnea 2 years after blunt chest trauma due to a horse kick. Preoperative echocardiography showed severe tricuspid insufficiency (TI) caused by chordal rupture and prolapse of the anterior leaflet. A novel repair technique, the "clover technique," was applied, but was unsuccessful in this case. The valve was then repaired successfully using conventional techniques, that is, insertion of an artificial chordae, plication of the prolapsing leaflet, and DeVega's annuloplasty. We present here a brief review of posttraumatic TI, and discuss effective and less expensive techniques for repair.

Tricuspid Valve Repair with Papillary Muscle Shortening for Severe Tricuspid Regurgitation in Children

We describe tricuspid valve repair using papillary muscle shortening for severe tricuspid regurgitation due to leaflet prolapse in children combined with De Vega annuloplasty. The papillary muscle was shortened until the prolapsed leaflet was at the same height as the other nonprolapsed leaflets. Although echocardiographic tricuspid regurgitation tends to increase over time, it rarely requires long-term intervention.

Tricuspid regurgitation secondary to mitral valve disease: Tricuspid annulus function as guide to tricuspid valve repair

Methods. A prospective analysis was performed on 50 patients (pts) with rheumatic mitral disease and associate secondary tricuspid insufficiency who underwent mitral valve replacement from January 1995 to December 1998. Surgical indication to tricuspid annuloplasty was considered in patients with echocardiographic tricuspid annulus diameter >21 mm/m 2, regardless semiquantitative evaluation of tricuspid insufficiency. De Vega annuloplasty was performed in 33 out of 50 patients. Results. Hospital mortality was 2.0% (CL 0.3–3.6). The follow up of the discharged patients ranged from 3 to 48 months (mean 25±15.9). Three late deaths occurred (6.1% CL 2.8–9.2). Forty-two patients out of the 46 followed up (91.3% CL 84.9–93.8) were in I or II NYHA class. In eight patients (16.3% of discharged patients) the obtained result has been considered as ‘negative late results’: persisting moderate (three cases) or moderate-severe (five cases) TrI, together with congestive heart failure requiring a furosemide intake of >25 mg/day. No patients had severe TrI at follow up. The statistics analysis demonstrated the ‘preoperative fraction shortening of the tricuspid annulus’ ( P=0.038) as factor predictive of late negative result. The incidence of late negative result was 57.1% among patients with fractional shortening lower than 25% and 0% among those patients with fractional shortening greater than 25% ( P=0.0001). Conclusions. The choice to treat the tricuspid insufficiency according to indexed tricuspid annulus dimension (>21 mm/m 2) has been effective in terms of clinical efficacy and of late functional result. Fractional shortening of the tricuspid annulus, expression of right ventricular cardiomyopathy in patients with poorest prognosis, affects the postoperative evolution of tricuspid insufficiency.

Early and Midterm Results of Aortic Annular Enlargement

From November 1987 to May 1998, 16 patients with a small aortic annulus underwent patch enlargement of the aortic valve by Nicks' technique (in 9) or Manouguian's method (in 7). The mean age of the patients was 40 years (range, 22 to 58 years), mean body surface area was 1.54 m2 (range, 0.95 to 2.05 m2), and 11 were female. Concomitant procedures were mitral valve replacement in 4 cases, tricuspid commissurotomy and De Vega annuloplasty in 2, and one case each of patent ductus arteriosus ligation and coronary bypass. Aortic annular sizes were 15 to 19 mm (mean, 17.4 mm) preoperatively and 20 to 24 mm (mean, 22.1 mm) after the procedure. Two patients (12.5%) died in the early postoperative period. Peak pressure gradients across the prostheses were 15 to 22 mm Hg (mean, 19.4 mm Hg) on echocardiography. The mean duration of follow-up was 32.85 months (3 months to 8 years) and it was 92.8% complete. There were no late deaths. Mitral valve function was good except in one patient who had minimal mitral regurgitation after Manouguian's procedure. Both methods were found to be effective and reliable and should be performed when there is a risk of patient-prosthesis mismatch.

Long-term evaluation of treatment for functional tricuspid regurgitation with regurgitant volume: Characteristic differences based on primary cardiac lesion

Objectives: The aim of this study was to characterize differences in the long-term effects of treatment for functional tricuspid regurgitation based on the primary cardiac lesion. Methods: Ninety-six patients with valvular heart disease and 32 patients with atrial septal defects associated with tricuspid regurgitation were studied. The tricuspid annular diameter was associated with evidence of right heart failure. In valvular heart disease, a Kay annuloplasty was performed in 33 patients with a tricuspid annular diameter of ≥40 mm to 44 mm, a modified De Vega annuloplasty in 12 patients with a tricuspid annular diameter of ≥45 mm to 49 mm, and a modified De Vega annuloplasty, annuloplasty using a Carpentier ring, or tricuspid valve replacement in each of 4 patients with a tricuspid annular diameter of ≥50 mm. In atrial septal defects, a Kay annuloplasty was performed in 11 patients with a tricuspid annular diameter of ≥45 mm to 49 mm, and a modified De Vega annuloplasty was performed in 5 patients with a tricuspid annular diameter of ≥50 mm. A mean follow-up period was 79 months after operation. Results: In the patients with a tricuspid annular diameter of <50 mm, the hemodynamic and clinical findings and tricuspid regurgitation remarkably improved. In the patients with valvular heart disease with a tricuspid annular diameter of ≥50 mm, however, the right heart parameters also showed improvement but less so when compared with those patients with a tricuspid annular diameter of <50 mm. In addition, 4 patients undergoing a modified De Vega annuloplasty have had a gradual increase in tricuspid regurgitation and clinical manifestations late after the operation. In contrast, all 5 patients with atrial septal defects with a tricuspid annular diameter of ≥50 mm have shown remarkable improvement, similar to those with a tricuspid annular diameter of <50 mm. Preoperative analyses revealed that the right heart function in atrial septal defects had not deteriorated to the same extent as in valvular heart disease. Conclusion: In the patients with a severely dilated tricuspid anulus (≥50 mm), the postoperative change of tricuspid regurgitation differed between those patients with valvular heart disease and atrial septal defects. (J Thorac Cardiovasc Surg 1999;117:463-71)

Correction Of Functional Tricuspid Insufficiency By Means Of A Limited Posterior Crossed Suture Annuloplasty

J Thorac Cardiovasc Surg 1998;115:1378-81

Tricuspid Valve Repair for Functional Tricuspid Regurgitation

Tricuspid valve insufficiency can be caused by organic disease of the tricuspid valve (rheumatic disease, endocarditis, carcinoid, and so on); however, most tricuspid regurgitation encountered in clinical practice occurs in patients with chronic left-sided valvular lesions. Ten percent to 50% of patients with severe mitral valve dysfunction have significant tricuspid regurgitation. '3' In this situation, functional tricuspid regurgitation is attributable to pulmonary hypertension and right ventricular dilatati~n.~ Other factors that contribute to functional tricuspid insufficiency may include right ventricular-tricuspid valve disproportion with compromised function of the tricuspid valve apparatus' and depressed tricuspid annular shortening during systole. It is now generally accepted that moderate to severe functional tricuspid insufficiency should be addressed at the time of correction of left-sided valvular disease.6-8 Several surgical options have been used to treat functional tricuspid insufficiency. These include tricuspid valve replacement, bicuspidalization annuloplasty, DeVega suture annuloplasty, and ring annuloplasty (Carpentier [Baxter Healthcare, Irvine, CAI or Duran [Medtronic, Minneapolis, MN]). The first two options, tricuspid valve replacement and bicuspidalization annuloplasty, provide inferior results and should not be used in the setting of functional tricuspid regurgitation. Both the DeVega annuloplasty and the Carpentier ring annuloplasty provide excellent treatment of functional tricuspid reg~rgitation.~> ~-~ However, studies suggest that repair durability is better with the Carpentier annuloplasty, particularly in the setting of severe pulmonary hypertension.6*8 Other potential disadvantages of the DeVega annuloplasty include the possibility of complete repair dehiscence from the disruption of a single stitch and obligate semicircular deformation of the tricuspid annulus, which may impair long-term valvular function.6 Drawbacks to the Carpentier ring annuloplasty include increased cost, the introduction of foreign material with the attendant risk of endocarditis, and relative rigidity of the prosthesis, which fixes the annulus in the shape of the ring. Recent advances in understanding the physiology of the tricuspid valve have provided the rationale for the use of a new annuloplasty system to correct functional tricuspid ins~fficiency.~ Computer-based analysis of echocardiographic images of the tricuspid valve shows that the tricuspid annulus is a saddle-shaped structure that has sphincter action, being smaller in systole than in diastole. Anatomic studies show that five sixths of annular dilatation takes place at the base of the anterior and posterior leaflets.6 This understanding of the normal physiology and pathoanatomy of the tricuspid valve led us to use an annuloplasty system that is universally flexible and produces a measured plication of the annulus at the base of the anterior and posterior leaflets. Repair of the tricuspid valve using the flexible Cosgrove-Edwards Annuloplasty System (Baxter Healthcare, Irvine, CA) is described.

Double valve repair in a transplanted heart

The first case of mitral valve replacement after heart transplantation was published in 1991. Since then, three additional cases of mitral valve replacement (one in combination with a tricuspid valve repair), two aortic valve replacements, and 12 cases of tricuspid valve replacement have been reported. In all these cases the damaged valves were deemed beyond surgical repair and were replaced by either a porcine bioprosthesis or a mechanical valve prosthesis. In two instances bench mitral valve repair before heart transplantation was described. In seven patients tricuspid valve repair was performed (combined with mitral valve replacement in one, as just mentioned). 4 This report presents the first case of mitral and tricuspid valve repair in a transplanted heart. The patient was a 60-year-old man with a history of heart failure resulting from dilated cardiomyopathy for which he underwent orthotopic heart transplantation in April 1990. The donor was a 12-year-old boy with no history of heart disease, normal auscultatory findings, and normal electrocardiographic findings. The procedure was performed by means of the biatrial method with Prolene running sutures (Ethicon, Inc., Somerville, N.J.) for the atria and the great vessels. The operation was uncomplicated. Postoperatively the patient had bradycardia, for which he received isoproterenol (INN: isoprenaline) treatment for 11 days. Recovery was otherwise uneventful. Immunosuppressive therapy consisted of OKT3, followed by cyclosporine (INN: ciclosporin) and low-dose steroids as maintenance therapy. Echocardiography in the first postoperative weeks showed some pericardial effusion. From the first week on, some billowing of the anterior mitral valve leaflet was noted. There were no rejection episodes. A total of seventeen endomyocardial biopsies were performed in the first year after transplantation and seven in the following years. Follow-up by transthoracic echocardiography showed gradual progression of mitral regurgitation. In 1993 moderate tricuspid regurgitation was also found. Despite this the man enjoyed a productive working life without symptoms during these 5 years. At the yearly catheterization, mild regurgitation of the mitral valve was noted on cineangiography. In 1996, 6 years after cardiac transplantation, the patient began having easy fatiguability and dyspnea on exertion. On those occasions he also reported abdominal distention. Physical examination revealed a holosystolic apical murmur, no pulmonary abnormalities, and no hepatomegaly. Transesophageal echocardiography showed a nondilated hypertrophic left ventricle with good systolic function. Billowing of both mitral valve leaflets was noted, with a prolapse of the anterior leaflet and severe regurgitation. At that time, an insignificant tricuspid regurgitation was noted. Heart catheterization showed elevated filling pressures (right atrial pressure 15 mm Hg, pulmonary capillary wedge pressure 20 mm Hg, and left ventricular end-diastolic pressure 23 mm Hg), no significant stenosis of the coronary arteries, good left ventricular function, but severe mitral valve regurgitation (Sellers grade 3/4). Valve repair was proposed for this patient, and on February 4, 1997, he was operated on. A redo sternotomy was performed. Cardiopulmonary bypass with selective venous cannulation of both the superior and inferior venae cavae and moderate hypothermia with cardioplegic arrest were used. The mitral valve was well exposed via a right atrial, transseptal approach. Inspection revealed a prolapse of both valve leaflets adjacent to the posteromedial commissure resulting from papillary muscle elongation. The papillary muscle appeared to be unnaturally pale, as did other parts of the endocardial tissues. Marked myxomatous degeneration was noted on the right side of both valve leaflets. The left side was unaffected. The anulus was severely dilated. Papillary muscle shortening was performed by folding back the tip of the muscle onto its base and suturing it into place. The annular dilation was corrected by inserting a size 34 Cosgrove-Edwards ring (Baxter Healthcare Corp., Irvine, Calif.). Transesophageal echocardiography after closure of the atrial septum and the atrial wall showed a good result. However, at this time tricuspid valve regurgitation was considered more severe than previously appreciated because of two flail valve leaflets. Cardiopulmonary bypass was restarted and the tricuspid valve was exposed with a beating heart. The chordae of the posterior part of anterior valve leaflet, as well as chordae of the posterior leaflet, were ruptured, with resulting partially flail leaflets. The septal and posterior valve leaflets were sutured together to make a functionally bicuspid valve. A small prolapsing segment of the anterior leaflet was resected, and a partial De Vega annuloplasty at the base of the posterior leaflet and adjoining commissures completed the reconstruction. Transesophageal echocardiography showed a good result with minor regurgitation of both the mitral and tricuspid valves. Postoperative recovery was uneventful. Transthoracic echocardiography on the seventh day after operation From the Department of Cardiopulmonary Surgery and Cardiology, Thorax Center, University Hospital Rotterdam “Dijkzigt,” Rotterdam, The Netherlands.

Discussion

Discussion

Valvuloplasty for common atrioventricular valve regurgitation in cyanotic heart diseases

Valvuloplasty for common atrioventricular valvular regurgitation and bidirectional cavopulmonary shunt were successfully performed in 3 children with univentricular heart and double-outlet right ventricle. The free margins of opposite leaflets of the common atrioventricular valve were sutured together to restore coaptation of the leaflets, and Kay-Reed's or DeVega's annuloplasty was carried out. Postoperative examinations revealed significant reduction of atrioventricular valve regurgitation and improvement of general condition in all patients.

Vanishing De Vega annuloplasty for functional tricuspid regurgitation

Annuloplasty is performed for significant functional tricuspid regurgitation even if it is presumed that in some cases the regurgitation will regress spontaneously after correction of the left-sided lesion. In an attempt to avoid the drawbacks of a permanent annuloplasty, we used a reabsorbable De Vega annuloplasty in a selected group of patients. Of 73 patients with functional tricuspid regurgitation operated on between May 1989 and May 1991, 25 with pulmonary arteriolar resistance below 400 dyne.sec.cm-5 underwent a De Vega annuloplasty with 2-0 polydioxanone suture. The diagnosis of significant functional tricuspid regurgitation (mean 2.74 +/- 1.05) was established by transthoracic color Doppler echocardiography in all patients. The degree of functional tricuspid regurgitation and pulmonary arteriolar resistance were measured with the patients anesthetized. In 16 patients the regurgitation remained severe (3+ to 4+) and in 9 it was moderate (2+). Twenty-three patients had mitral (12 repairs, 11 replacements) and 9 had aortic (4 repairs, 5 replacements) valve operations. The immediate postbypass residual functional tricuspid regurgitation was 0 to 1+ in 23 and 0 in 2. There was 1 (4%) operative death. The maximum follow-up period was 24 months (mean 13.9 months). There were 2 (8.3%) late deaths. Six patients underwent reoperation because of mitral dysfunction. Four of them who were reoperated on between 2 and 5 weeks after the initial procedure showed no recurrence of functional tricuspid regurgitation. The other 2, reoperated on at 5 and 10 months after the first operation, had recurrence of functional tricuspid regurgitation. Visual inspection of these two tricuspid valves showed a dilated anulus with otherwise normal valves. All surviving patients are in New York Heart Association functional class I or II without significant functional tricuspid regurgitation (mean 0.78 +/- 0.56). We concluded that functional tricuspid regurgitation in patients with low pulmonary arteriolar resistance can be adequately treated by a vanishing De Vega annuloplasty, which will stent the tricuspid anulus for about 4 months.

De Vega's semicircular annuloplasty for tricuspid valve regurgitation

Moderate to severe functional tricuspid regurgitation was found in 26% of cardiac surgical patients with mitral or aortic valvular disease at Tri-Service General Hospital in Taiwan. Almost all patients were able to receive de Vega's annuloplasties. After a mean follow-up period of 20 months, none of the 63 patients had moderate or severe tricuspid regurgitation. There was no heart block or right atrial thrombosis; the single late death was not related to the heart disease. De Vega's tricuspid annuloplasty is considered to be a safe, effective, and durable procedure in the treatment of functional tricuspid regurgitation. Compared with tricuspid valve replacement and other types of annuloplasty, the de Vega is the first choice here.

Surgery for tricuspid insufficiency: long-term follow-up after De Vega annuloplasty.

Between 1975 and 1991, 97 consecutive patients underwent De Vega tricuspid annuloplasty either isolated or in combination with mitral, aortic, or mitral and aortic valve procedures. Preoperatively 96.9% of the patients were in New York Heart Association functional class III or IV. Causes of tricuspid insufficiency were functional tricuspid ring dilatation and a combination of dilatation and different organic tricuspid valve lesions. There were 17 early deaths (17.5%), primarily due to cardiac failure, none was related to the tricuspid annuloplasty. 80 perioperative survivors have been followed up for a mean of 4.7 +/- 4.1 years with a total of 462 cumulative patient-years. Actuarial 5-, 10-, and 15-year survival rates, including early deaths, were 64% +/- 5%, 48 +/- 6%, and 26% +/- 10%. Recurrence of tricuspid regurgitation was rated as moderate in 15% and severe in 18.8%. Ten patients required reoperation (2.2%/patient-year), of whom 8 were associated with tricuspid regurgitation (1.7%/patient-year). Although in all patients but one the De Vega annuloplasty was intact, the tricuspid ring was dilated; 4 patients had additional tricuspid organic valve lesions. 6 of the 8 patients had concomitant mitral valve or mitral prosthesis dysfunction. 26 patients died late (5.6%/patient-year) due to chronic cardiac failure in 50% and after reoperation in 7% of the patients. 4 patients had implantation of a permanent pacemaker (0.9%/patient-year). 54 patients (67.5%) are still alive, with 43% having no and 17.5% having only mild residual tricuspid regurgitation. De Vega annuloplasty is indicated with tricuspid insufficiency due to functional ring dilatation.(ABSTRACT TRUNCATED AT 250 WORDS)

Direct imaging of the tricuspid valve annular motions by fiberoptic cardioscopy in dogs: I. Does De Vega's annuloplasty preserve the annular motions?

Applying the technology of direct imaging by fiberoptic cardioscopy, physiologic and pathophysiologic motions of the tricuspid valve anulus were studied in 10 anesthetized normal dogs (control group) and in 9 dogs that had chronic tricuspid regurgitation (TR group). The heart was perfused with transparent modified Tyrode's solution by working heart method, and the anuli, outlined by sutured beads, were observed and recorded on a high-speed video system in real time. Tricuspid valve annular area was calculated at 14 points during the cardiac cycle. The control group was studied in the normal condition, and the tricuspid regurgitation group was studied during four interventions: nontricuspid annuloplasty group and three tricuspid annuloplasty groups with reducing tricuspid valve annular area to 80%, 65%, and 50% of that of the non-tricuspid annuloplasty group by De Vega's procedure. Tricuspid valve annular area in the control group increased by 7% during atrial systole and was reduced by 34% mainly during ventricular systole, in which the free wall annular area and the septal annular area narrowed by an equal 34%. Chronic tricuspid regurgitation lessened tricuspid valve annular area narrowing to 20% in percent reduction (p < 0.01). In the TR group the decrease in tricuspid valve annular area narrowing was attributed mainly to lessened narrowing of the free wall anulus (percent reduction of tricuspid valve annular area, 19%; p < 0.01). The amplitudes in tricuspid valve annular area narrowing were unchanged in the tricuspid annuloplasty groups even when tricuspid valve annular area, was reduced to 50% by De Vega's tricuspid annuloplasty (percent reduction of tricuspid valve annular area, 16%; not significant). These findings suggest that De Vega's tricuspid annuloplasty is a reasonable method that does preserve the physiologic annular motions in the opening and closing mechanism of the tricuspid valve.

Congenital cleft of the anterior tricuspid leaflet with severe tricuspid regurgitation in adults

Objectives and Background. Severe primary tricuspid regurgitation in the adult is a rare finding. This study describes the diagnostic findings and the treatment of an isolated congenital cleft of the anterior leaflet of the tricuspid valve as the morphologic substrate for severe tricuspid regurgitation.Methods. The clinical, echocardiographic findings and the follow-up findings of five patients (all male, 20 to 56 years old) with this disorder are described. Four of the five patients underwent cardiac surgery that confirmed the diagnosis.Results. In three of five patients, exertional fatigue was the limiting symptom (New York Heart Association functional classes II and III). The clinical findings included a holosystolic murmur and supraventricular arrhythmias in all patients. Cardiac catheterization, performed in four patients, yielded the incorrect diagnosis of Ebstein's anomaly in three. In one pattent the cleft was associated with an atrial septal defect of the secundum type. In four of five patients successful reconstruction of the tricuspid valve with a DeVega annuloplasty was performed. One patient had a partial excision of the right atrium, and one had a closure of a coexisting atrial septal defect. One patient refused operation.Conclusions. Tricuspid valve anomalies can be accurately identified by Doppler echocardiography. Surgical repair is the treatment of choice in patients with severe tricuspid regurgitation due to a congenital cleft of the anterior leaflet of the tricuspid valve.

Factors influencing the efficacy of DeVega's annuloplasty for secondary tricuspid regurgitation.

DeVega's annuloplasty was performed on 41 patients with tricuspid regurgitation (TR) associated with combined valvular disease and results were assessed based on Doppler echocardiographic findings in an attempt to examine the applicability of this surgical technique. TR was quantitatively evaluated via Doppler echocardiography before and after surgery. Clinical symptoms, cardiac function, and surgical results were assessed, and the severity of left ventricular myocardial degeneration was determined using electron microscopy. There were no differences in the following factors between the TR recurrence and TR improvement groups: previous heart surgery, number of involved valves, presence or absence of a giant left atrium, preoperative New York Heart Association (NYHA) functional class, and type of prosthetic valve (Björk-Shiley vs. St. Jude Medical). We found no differences between these two groups in TR severity and tricuspid annulus diameter measured during surgery. Severity of myocardial degeneration was closely associated with the recurrence of TR. Clinically, most had diminished cardiac function before surgery. DeVega's technique appears to be remarkably effective in patients with well-preserved myocardium because no TR recurrence was detected even in examinations with the most accurate Doppler echocardiography. However, such long-term effectiveness of DeVega's technique cannot be expected in patients with degenerated myocardium.

Modified De Vega's annuloplasty for functional tricuspid regurgitation--early and late results.

From 1978 through 1987, 321 patients who had functional tricuspid regurgitation (TR) associated with mitral or combined mitral and aortic valve disease underwent tricuspid annuloplasty with our modification of the original De Vega's annuloplasty technique. The modified De Vega's annuloplasty consisted of two separate semicircular sutures placed around the anterior and lateral aspect of the tricuspid valve. Preoperatively, 229 (71.3%) of the 321 patients were in New York Heart Association functional class III or IV. There were nineteen early deaths (5.9%), and 15 patients died during a follow-up period of 15 to 126 months (mean follow-up, 26 months). Five patients (1.5%) required reoperation because of biological mitral valve failure and recurrence of mitral stenosis. The severity of TR was evaluated by two-dimensional and pulsed Doppler echocardiography, and was classified on a scale of 0 to Grade 3 according to the maximal distance and the flow pattern of the regurgitant signals in the right atrium. Postoperative echocardiographic evaluation of TR was performed in 121 randomly selected patients late after operation. TR reduced to Grade 1 or less in 107 (88.4%) of the 121 patients after operation. Ninety-six percent of the survivors were in New York Heart Association functional class I or II, postoperatively. The actuarial survival rate for the 321 patients with the modified De Vega's annuloplasty including early deaths was 88.2% at 10 years and the actuarial rate of freedom from reoperation on the tricuspid valve was 97.6%. Our surgical experience indicated that the modified De Vega's annuloplasty, as the method of first choice, is a simple, reliable procedure and resulted in reduction of the severity of TR in 88.4% of the patients with functional TR.

Evaluation and treatment of secondary tricuspid insufficiency.

To define the role of functional tricuspid insufficiency and right ventricular (RV) failure in patients with mitral disease, the data of 121 patients with secondary tricuspid insufficiency that underwent mitral valve replacement (MVR) from January 1982 to December 1987 were analyzed. The mitral hemodynamic lesion was: stenosis in 41 patients (33.9%); insufficiency in 11 (9.1%) and mixed stenosis and insufficiency in 69 (57.0%). NYHA functional class was: II in 4 patients (3.3%), III in 78 (64.5%) and IV in 39 (32.2%). In 100 cases (group 1) with tricuspid insufficiency defined as moderate or severe, a De Vega annuloplasty was performed while in 21 (group 2) with mild tricuspid insufficiency, no tricuspid surgical procedure was performed. Hospital deaths occurred in 17 of 121 patients [14% (CL 10.8-17.0)]. There was no significant difference in hospital mortality between group 1 and group 2 (15% vs 9.5%; P = 0.75). Incremental risk factors for hospital mortality as determined by multivariate analysis, include: cardiothoracic ratio (P = 0.0016), total aortic cross-clamp time (P = 0.006), associated cardiac disease (P = 0.0209) and emergency operations (P = 0.0318). Mean follow-up of surviving patients was 50.1 +/- 28.1 months. Late deaths occurred in 16 patients [15.4% (CL 11.7-18.7)]. The actuarial survival rate was 85.6% and 73.8% at 5 and 9 years, respectively. Nine patients [8.6% (CL 5.9-11.3)] required reoperation. There was no significant difference between group 1 and group 2 in the rate of late cardiac related deaths (5.9% vs 5.3%, P = 0.66) and of tricuspid reoperations (4.7% vs 5.3%, P = 0.62).(ABSTRACT TRUNCATED AT 250 WORDS)

Endomiocardiofibrose: resultados do tratamento cirúrgico com conservação das valvas atrioventriculares

Entre abril de 1988 e janeiro de 1991, foram operados 25 pacientes consecutivos, para correção de endomiocardiofibrose, com técnica conservadora das valvas atrioventriculares. Dezenove pacientes eram do sexo feminino e seis do masculino. As idades variaram de 11 a 59 anos, com média de 40,6 anos. Dezesete pacientes apresentavam acometimento biventricular, seis com comprometimento do ventrículo esquerdo e apenas dois pacientes com lesão isolada do ventrículo direito. Todos estavam em grupos avançados de insuficiência cardíaca, sendo 19 em grupo IV da NYHA e seis no grupo III. No pré-operatório, 24 apresentavam insuficiência da valva tricúspide e 22 apresentavam insuficiência da valva mitral. Todos os pacientes foram operados com o auxílio de circulação extracorpórea e hipotermia sistêmica de 28ºC e pinçamento aórtico intermitente, para melhor exposição das cavidades ventriculares. A fibrose ventricular direita foi sempre ressecada através da valva tricúspide, enquanto que a fibrose do ventrículo esquerdo foi removida através de pequena ventriculotomia esquerda apical. Em todos os pacientes com insuficiência tricúspide, foi feita plástica anular do tipo DeVega. Dos pacientes com insuficiência mitral, sete tiveram correção espontânea após a ressecção da fibrose, e os outros 15 receberam anuloplastia. Houve apenas um (4%) óbito no pós-operatório imediato e nenhum óbito tardio. A recuperação funcional foi boa, estando atualmente 16 pacientes em grupo funcional I e 8 em grupo II.