Double Valve Replacement Surgery Research Articles

Technical exploration and early results of two-port total thoracoscopic aortic-mitral double-valve replacement

Objective: To examine the clinical outcomes of patients undergoing total thoracoscopic aortic-mitral double-valve replacement. Methods: This is a retrospective case series study. The clinical data of 50 patients who underwent double-valve replacement under a total thoracoscopic two-port approach from November 2021 to August 2022 in the Department of Cardiovascular Surgery, Fujian Medical University Union Hospital were retrospectively analyzed. There were 32 males and 18 females, with an age of (55.3±8.8) years (range: 21 to 62 years). Among them, 36 cases had rheumatic heart disease and 14 cases had infective endocarditis. The 3rd intercostal space between the right anterior axillary line and the midclavicular line was selected as the main operating hole, the total thoracoscopic double-valve replacement were successfully carried out. Baseline data, intraoperative information, surgical outcomes, and postoperative complications were collected for all patients. Results: The cardiopulmonary bypass time was (168.2±30.9) minutes (range: 125 to 187 minutes), the aortic cross-clamping time was (118.8±16.5) minutes (range: 96 to 147 minutes). Five patients received bioprosthetic valves, and 45 received mechanical prosthetic valves. Postoperative mechanical ventilation lasted (9.6±3.4) hours (range: 5.1 to 14.2 hours), the ICU stay was (24.8±7.3) hours (range: 16.3 to 30.1 hours), and the postoperative hospital stay was (6.5±1.2) days (range: 5.0 to 8.0 days). Four patients received red blood cell transfusions of (2.7±0.9) units (range: 2 to 4 units), and the postoperative chest drainage volume was (222.1±56.3) ml (range: 175 to 289 ml). No deaths occurred intraoperatively or in the early postoperative period. One patient required reoperation due to bleeding in the aortic incision. Three patients had mild to moderate paravalvular leakage around the prosthetic aortic valve, with no cases of third-degree atrioventricular block or conversions to median sternotomy. Conclusions: The early outcomes of total thoracoscopic double valve replacement surgery are satisfactory, demonstrating safety and efficacy. This surgical approach expands the scope of total thoracoscopic cardiac surgery, which warrants further investigation and research.

Methaemoglobinaemia in a patient scheduled for double valve replacement surgery - A case study.

Methaemoglobinaemia in a patient scheduled for double valve replacement surgery - A case study.

A Study for QOL and Surgical Incision Pain in Patients Undergoing Totally Thoracoscopic Combined Aortic and Mitral Valve Replacement Surgery.

In recent years, based on traditional median sternotomy surgery, totally thoracoscopic for aortic and mitral valve replacement surgery is increasingly being performed despite little published evidence. This study investigated postoperative pain and short-term quality of life (QOL) of patients undergoing double valve replacement surgery. From November 2021 to December 2022, 141 patients with double valvular heart disease who underwent thoracoscopic group (N = 62) and median sternotomy group (N = 79) were included. Clinical data were recorded, and a visual analog scale (VAS) was used to measure postoperative pain intensity. The medical outcomes study (MOS) 36-item Short-Form Health Survey assessed short-term QOL after surgery. Sixty-two patients underwent total thoracic double valve replacement, and 79 patients underwent median sternotomy double valve replacement. Both groups were similar in terms of demographics and general clinical data, as well as the incidence of postoperative adverse events. The VAS scores of the thoracoscopic group were lower than those in the median sternotomy group. The hospital stay time was significantly shorter in the thoracoscopic group than in the median sternotomy group (30.2 ± 12 days vs. 36 ± 19 days, p = 0.03). The scores of bodily pains and some of the subscales in SF-36 were significantly different between the two groups (p < 0.05). Thoracoscopic combined aortic and mitral valve replacement surgery can reduce postoperative pain and improve short-term postoperative QOL, which has specific clinical application value.

Long-term cardiac remodeling associated with heart failure following left-ventricular valve replacement surgery: A retrospective study.

To investigate long-term cardiac remodeling and prognosis of patients post-left-ventricular valve replacement, and explored related risk factors of heart failure and management strategies.Retrospective cohort of patients with left-ventricular valve replacement between 2005 and 2007. Major adverse cardiac events were recorded, including death, hospitalization, stroke, and New York Heart Association (NYHA) functional classifications. Cardiac remodeling was assessed by comparing pre-operative, post-operative, and follow-up echocardiographic images. (1)Two hundred fifty-seven patients who received left-ventricular mitral, aortic, or double-valve replacement surgery were followed up for 10.4 ± 1.5 years with an all-cause mortality rate 18.7% and an incidence of heart failure that significantly restricted daily life (NYHA III or IV) 21.3%.(2)There were no significant differences in classic cardiac-remodeling variables between baseline and long-term follow-up, such as left-ventricular diameter (47.9 ± 8.3 vs 49.9 ± 8.0 mm, P = .14) and left-ventricular ejection fraction (58.6 ± 9.6% vs 57.0 ± 10.3%, P = .34), whereas there were significant differences in terms of left-atrial anteroposterior diameter (LA) (39.7 ± 9.5 vs 49.0 ± 14.3 mm, P < .001) and tricuspid regurgitation (TR) (1.4 ± 1.0 vs 2.2 ± 1.2, P < .001). Multivariable logistic regression analysis showed that LA ≥ 50 mm (P = .011) and more than moderate tricuspid regurgitation (TR > 2) (P = .012) were associated with poor prognoses for long-term consequences of heart failure. Both LA and TR progressed with the length of time after surgery.LA enlargement and TR after left-ventricular valve replacement surgery were time-dependent events, which represented cardiac remodeling and were closely related to post-operative long-term consequences of heart failure. It is important to be cognizant of and to explore long-term preventive and treatment strategies for adverse cardiac events in patients following left-ventricular valve replacement.

English

BACKGROUND Valve replacement has become the mainstay of management for rheumatic heart diseases. However, an important and frequent complication of valve replacement is patient prosthesis mismatch (PPM). The present study was undertaken to evaluate a single institution experience on the clinical pattern and presentation of PPM, and the outcomes of double valve replacement surgery. METHODS This retrospective, regional study was carried out among 316 consecutive patients who underwent concomitant aortic and mitral valve surgery (with or without tricuspid annuloplasty) in this tertiary care hospital. Particulars regarding the clinical profile and procedure details (valve types and sizes and priority of surgery) of these patients were documented from the medical records. RESULTS In this institute, the valves used were predominantly mechanical (92.6 %) when compared to bioprosthesis in 7.4 % (47/632 valves - 23 mitral position and 24 in aortic position). The most common sizes used in the aortic and mitral position were 21 mm &amp; 27 mm respectively. In spite of the seemingly lower sizes used in the patients undergoing double valve replacement (DVR) the incidence of PPM is less owing to the fact that the population under study had a lower body surface area (BSA) and body mass index (BMI) - 1.17 ± 0.3 &amp; 19.86 ± 3.9 respectively. CONCLUSIONS It may be emphasized that if the valve size required to be implanted is derived based on the patient’s BSA and indexed effective orifice area, the incidence of patient prosthesis mismatch can be minimized drastically and with it the in-hospital mortality and morbidity. KEYWORDS Aortic Stenosis, Double Valve Replacement, Mitral Valve, Prosthesis, Rheumatic Heart Disease

Comparative Study Between Custodiol® versus Cold Blood Cardioplegia for Myocardial Protection in Double Valve Replacement Surgery

&#x0D; &#x0D; Background: Several cardioplegic solutions are available for myocardial preservation. The superiority of intracellular over extracellular cardioplegia is still debated. Our study aimed to compare the results of Custodiol® and blood Cardioplegia for myocardial protection in double valve replacement surgery.&#x0D; Methods: This is a prospective study that included 301 patients. We grouped the patient into; Group A (n= 135) had Custodiol® cardioplegia, and Group B (n= 166) had cold blood cardioplegia. We included patients who had double valve surgery and excluded redo, emergency procedures, and patients who had concomitant coronary artery bypass grafting.&#x0D; Results: Patients in Group A were significantly younger (43 ±9 vs. 47 ±10, P&lt;0.001). There were 72 females (53.3%) in Group A and 71 (43.4%) in Group B (P= 0.09). The total bypass time was higher in group B (217± 40 vs. 179± 35 min, P&lt; 0.001). The cross-clamp time was comparable between groups (90± 31 vs. 85± 29 min, P= 0.15). The duration of mechanical ventilation (7 ± 1 vs. 12 ± 2 h, P&lt; 0.001), ICU stay (3± 0.7 vs. 4± 0.9, P&lt; 0.001) and hospital stay (8± 1 vs. 13± 3, P&lt; 0.001) were shorter in Group A. Postoperative wound seroma (5 (26.6%) vs. 60 (36.1%), P&lt; 0.001) and mortality (2 (1.5%) vs. 11 (6.6%), p= 0.042) were lower in Group A.&#x0D; Conclusion: Custodiol cardioplegia could be safe during double valve surgery. A larger randomized trial is required to confirm our findings.&#x0D;

Single centre experience of double valve replacement using mechanical valves

Introduction: Cardiac valvular disease in India is most commonly caused by Rheumatic aetiology, many of which end up getting operated for the same. There is still existing controversy about the selection of ideal valves that can be used for replacement. Objective: Objective of this study was to retrospectively analyse the variable which can be easily assessed in the patients undergoing DVR (Double Valve replacement) using mechanical valves for its outcomes. Methods: All the patients who underwent DVR + Tricuspid valve repair/annuloplasty between October 2017 to January 2019, were identified and retrospectively their data was analysed. Results: 72 patients who underwent the procedure. Most common aetiology was Rheumatic. 69.4% were in NYHA (New York Heart Association) class II, 33.33% had chronic atrial fibrillation. 45.6% had associated tricuspid valve disease, and no chordae was preserved in 27.7%. Overall mortality was 5.5% Conclusion: The study revealed a favourable survival outcome after DVR surgery. The operative mortality in patients undergoing DVR depends on intra operative factors like total surgical time, bypass time and aortic cross clamped time and has improved remarkably over time, with the improvisation of extracorporeal circulation methods, myocardial protection techniques and postoperative management.

Infective Endocarditis Caused by Pseudomonas stutzeri: A Case Report and Literature Review

Pseudomonas bacteria are widespread pathogens that account for considerable infections with significant morbidity and mortality, especially in hospitalized patients. The Pseudomonas genus contains a large number of species; however, the majority of infections are caused by Pseudomonas aeruginosa, infections by other Pseudomonas species are less reported. Pseudomonas stutzeri is a ubiquitous Gram-negative bacterium that has been reported as a causative agent of some infections, particularly in immunocompromised patients but has rarely been reported as a cause of infective endocarditis. Here, we report a case of a 55-year-old female with no significant medical history who presented with exertional dyspnea, productive cough, and fever. She was diagnosed as a case of acute anterior ST myocardial infarction, underwent double valve replacement surgery, and was found to have infective endocarditis caused by Pseudomonas stutzeri.

Custodiol (Histidine-Tryptophan-Ketoglutarate) versus Modified St. Thomas Cold Crystalloid Cardioplegia: Short-term Results

Abstract Background: Myocardial protection refers to strategies used to avoid post-ischemic myocardial dysfunction. One dose approach for myocardial safety is attractive in long operations. Purpose: to assess differences among the custodial cardioplegia and the cold crystalloid cardioplegia according to myocardial protection in cases listed for Double Valve Replacement Surgery. Patient and methods: This prospective cohort trial included 50 cases had double valve replacement surgery between August 2017 and July 2019. Twenty-nine patients were males (58%), and the mean age was 57.66±8.81 years. The mean ejection fraction was 41.43±9.25 %. Results: The mean CPB time in custodial group was 99.4±8.46 while in cold crystalloid cardioplegia group was 95.6±12.27 minutes. The mean DC shocks that was required in custodial group was 9(36%) while in cold crystalloid cardioplegia group was 17 (68%) times. Mean days of ICU stay in custodial group were 1.28±0.46 while in cold crystalloid cardioplegia group were 1.72±0.61 days. The mean duration of mechanical ventilation in custodial group was 4.64±0.86 while in cold crystalloid cardioplegia group was 7.04±0.84 hours. Troponin elevation mean in the immediate post-operative: in custodiol group was 8.46±2.21 while in the cold crystalloid group was 10.08±2.18. Conclusion: This study showed that the evidence supporting the superiority of custodial over cold crystalloid cardioplegia are limited however, Custodiol cardioplegia is appealing as it gives lengthy myocardial protection with a single-dose. The present work demonstrated that Histidine-Tryptophan-Ketoglutarate cardioplegia is related with less ICU stay, mechanical ventilation, postoperative hospitalization and troponin T release in low-risk patients who had double valve replacement.

Initial Experience of Minimally Invasive Concomitant Aortic and Mitral Valve Replacement/Repair at a Tertiary Care Cardiac Centre of a Developing Country.

IntroductionMinimally invasive double valve replacement (DVR) surgery through a small transverse anterior thoracotomy is an alternate technique to sternotomy for concomitant aortic and mitral valve (AVR, MVR) surgery. The aim of this study was to evaluate the in-hospital and early outcomes of direct vision minimal invasive double valve surgery (DVMI-DVR) at a tertiary care cardiac center of a developing country.MethodsThis study was conducted at the National Institute of Cardiovascular Diseases Karachi, Pakistan from January 2018 to September 2018. Nineteen consecutive patients undergoing DVMI-DVR for aortic and mitral disease without any prior cardiac surgery were included in this study. For all procedures, access was obtained through small transverse anterior thoracotomy incision with wedge resection (Chaudhry’s Wedge) of sternum opposite to the third and fourth costosternal joints. Patients were observed during their hospital stay and the following variables were observed the length of hospital stay (LOHS), ventilator support, intensive care unit (ICU) stay, pain score, and mortality. The pain score was assessed using the visual analog scale (VAS).ResultsThe male/female ratio was 11:8 with a mean age of 35 ± 12 years with mean EuroSCORE of 6.6 ± 3.5%. The mean total bypass time was 129.8 ± 23.83 min (range: 98-181 minutes). The mean mechanical ventilation time was 3.16 ± 1.12 hours (range: 2-6 hours). The mean intensive care unit (ICU) stay was 41.84 ± 8.36 hours. The mean post-operative LOHS was 5.63 ± 1.12 days (range: 4-8 days). We had zero frequency of wound infection and surgical mortality. The mean pain score was 4.32 (on a predefined pain scale of one to nine with a high value indicating severe pain).ConclusionMinimally invasive DVR surgery is a safe and reproducible technique with comparable outcomes such as postoperative pain score (4.32 ± 2.05), ventilation time (3.16 ± 1.12 hours), ICU stay (41.84 ± 8.36 hours), and hospital stay (5.63 ± 1.12 days). In terms of mortality, operative times, ICU stay, and hospital stay, the minimally invasive DVR is at least comparable to those achieved with median sternotomy. Further prospective randomized studies are needed to validate our findings.

Differences in Biomarkers Pattern Between Severe Isolated Right and Left Ventricular Dysfunction After Cardiac Surgery

To find out if there are any differences in biomarkers between severe isolated right ventricular (RV) dysfunction and severe isolated left ventricular (LV) dysfunction after cardiac surgery using cardiopulmonary bypass. Observational study. Teaching hospital. A total of 46 patients who had severe isolated RV or LV dysfunction after cardiac surgery. The authors collected perioperative clinical and biomarker data. Severe isolated RV dysfunction patients (n = 20) had higher postoperative direct bilirubin (p = 0.030), total bilirubin (p = 0.044), glucose (p = 0.011), and international normalized ratio (INR) (p = 0.050) by repeated measure analysis of variance when compared with patients with severe isolated LV dysfunction (n = 26). The RV group also showed lower preoperative alanine transferase (19.3 ± 1.5 v 32.7 ± 4.2, p = 0.001), higher 4-hour INR (1.5 ± 0.3 v 1.4 ± 0.2, p = 0.008), and higher 48-hour INR (1.8 ± 0.4 v 1.4 ± 0.1, p < 0.001). None in the LV group died, whereas 4 patients in the RV group died (all of them had preoperative atrial fibrillation and underwent double valve replacement surgery). The authors observed biomarkers differences between severe isolated RV dysfunction and severe isolated RV dysfunction.

Rehabilitation Program in a Patient Undergoing Mitral and Aortic Valve Replacement Surgery

Heart disease due to valvular anomaly has increased prevalence along with increasing age. The operative management including reparation or substitution with prosthetic valve is the main therapy. Still becoming question mark either rehabilitation program is benefcience for patient undergoing valvular surgery. We report a patient with heart failure due to valvular heart disease and underwent double valve replacement surgery. Cardiac rehabilitation phase 1 and phase 2 was done. Patient feel physical condition is much better than before.

Factors influencing the outcome of double valve replacement surgery

Background: Data on the influence of surgical variables in mortality and morbidity of patients undergoing double valve replacement (DVR) surgery are scarce. Objective of this study was to identify preoperative, intra operative and post operative factors associated with mortality and morbidity of patients undergoing DVR surgery.Methods: Between 2010 and 2016, patients who underwent double (Mitral and Aortic) valve replacement at our institution were analyzed. These patients were studied retrospectively for preoperative data and postoperative outcome including causes of deaths and the data was analyzed statistically.Results: There were 150 patients, 107 were male (71.3%) and 43 were female (28.6%) Present study revealed a high mortality rate among female patient undergoing DVR surgery than males, which is statically significant at p&lt;0.05. Pre operatively 100 patients (66.6%) were class IV NYHA symptoms. This study finds a significant correlation between preoperative NYHA and hospital mortality with higher mortality rate in NYHA class IV patients with p-value &lt;0.00001 which is significant at p&lt;0.05. Long-term survival was also seen to be significantly dependent on the preoperative LVEF. Among intra operative parameter average total surgical time was 197.70 minutes (3.29 hours); average total cardio pulmonary bypass time was 82.67 minutes (1.37 hours) and average cross clamp time was 67.28 minutes (1.12 hours). Outcome groups (in-hospital death vs. hospital discharge) had a significant statistical difference in relation to variables, respectively: aortic cross clamp time (in minutes) of 77.66 and 67.40 (p=0.001); CPB 95.66 and 84.63 (p=0.006); and total surgical time 208.75 and 186.04 (p=0.002). Among the post operative complications, immediate complications occurring within 7 days of surgery were; low cardiac output syndrome in 9.3% (n=14), bleeding leading to exploration was 8% (n=12), refractory arrhythmias in 3% (n=5), sepsis in 4% (n=6) and acute renal failure in 2% (n=3). Inter mediate post-operative complications (7 to 30 days of surgery) were wound infection in 26 patients (17.3%). There was no incidence of stuck valve or pulmonary thrombo embolism Overall mortality was 8% (12 patients) all within 30 days of operation. There was no statistical difference between the outcome and the types of prostheses used, either biological or metallic (p=0.219).Conclusions: The study results have demonstrated a favourable survival outcome after DVR surgery. An advance age, female sex, a higher NYHA class, poor left ventricular function are associated with poor outcome. The operative mortality in patients undergoing DVR also depends on intra operative factors like total surgical time, CPB time and aortic cross clamped time and has improved remarkably over time, with the improvisation of extracorporeal circulation methods, myocardial protection techniques and postoperative management.

Blood conservation strategies in cardiac valve replacement

We aimed to evaluate whether blood conservation strategies including intraoperative autologous donation (IAD) could reduce perioperative blood transfusion for patients undergoing cardiac valve replacement including mitral valve replacement, aortic valve replacement (AVR), and double valve replacement (DVR).A total of 726 patients were studied over a 3-year period (2011–2013) after the implementation of IAD and were compared with 919 patients during the previous 36-month period (January 2008–December 2010). The method of small-volume retrograde autologous priming, strict blood transfusion standard together with IAD constituted a progressive blood-saving strategy.Baseline characteristics and preoperative information showed no statistically significant difference between IAD group and non-IAD group. Most of the postoperative morbidities are statistically the same in the 2 groups. Chest tube output (415.2 vs 1029.8 mL, P < 0.001) and postoperative respiratory failure (5.9% vs 8.6%, P = 0.039) favored the IAD group, whereas hematocrit levels were more favorable in the non-IAD group (30.3% vs 33.0% at the end of the operation, P < 0.001; 30.4% vs 31.5% at the time of discharge). The use of blood product transfusion was higher in the non-IAD group (22.6% vs 43.3%, P < 0.001). Binary multivariate logistic regression analysis showed that high age, non-IAD, DVR surgery, and absent smoking history are associated with a higher risk of intra-/postoperative blood transfusion.Blood conservation is effective and safe in cardiac valve replacement surgeries. The use of intraoperative autologous donation can lead to improved outcomes including a significantly lower rate of intra-/postoperative blood transfusion and postoperative complications.

English

English

Evaluation of variables responsible for hospital mortality in patients with rheumatic heart disease undergoing double valve replacement.

ObjectiveTo describe the hospital mortality and associated clinical and echocardiographic variables in patients with rheumatic disease who underwent double valve replacement surgery.MethodsThis is a cross sectional descriptive study of mortality, performed in a referral hospital in Salvador, Bahia. Records from patients with rheumatic disease who underwent double valve replacement surgery during the years 2007-2011 were analyzed.ResultsThe studied sample comprises 104 patients and 60 (57.7%) were male. The mean age was 38.04±14.45. Sixty five bioprostheses and 38 mechanical prostheses were used in these patients at the time of surgery. There were statistically significant differences between the two groups, when we analyzed the following variables: the mean age (36.30±13.03 vs. 45.35±17.8 years-old, P=0.011), mean hemoglobin (11.10±2.19 vs. 9.22±2.26 g/dL, P=0.002), mean hematocrit (34.22±5.86 vs. 28.44±6.62%, P<0.001). New York Heart Association functional class III and IV (NYHA) (P=0.022) was statistically associated with mortality.ConclusionWe concluded that the mean hemoglobin/hematocrit level and the NYHA functional class was the major variables associated to the mortality among these patients. Based on these data one may concern about the patient best moment for surgery and the patient hemoglobin level.

Device occlusion of pseudoaneurysm of ascending aorta

Pseudoaneurysm of ascending aorta is an infrequent but well-recognized and potentially fatal complication after cardiac surgeries. The complication can develop early, delayed or late, and the presentation is also varied. We are presenting here two cases of pseudoaneurysm of ascending aorta following cardiac surgery that were successfully managed by the transcatheter method. The first one occurred following coronary artery bypass surgery and the second one occurred following double-valve replacement surgery. The aortic openings of these aneurysms were occluded with 12 mm and 10 mm atrial septal occluders, respectively, with a good outcome. An immediate postprocedure angiogram showed no residual flow into the sac. Six months of follow-up of both cases also showed excellent results.

Acute hemodynamic effects of inhaled nitroglycerine, intravenous nitroglycerine, and their combination with intravenous dobutamine in patients with secondary pulmonary hypertension

The presence of pulmonary artery hypertension (PAH) affects the prognosis of patients; therefore, it is important to treat it. The aim of this study is to compare the acute hemodynamic effects of inhaled nitroglycerine (iNTG), intravenous nitroglycerine (IV NTG) alone and their combination with intravenous dobutamine (IV DOB) during the early postoperative period, in patients with PAH undergoing mitral valve or double valve replacement surgery. In the study, 40 patients with secondary PAH were administered iNTG 2.5 microg/kg/min, IV NTG 2.5 microg/kg/min, a combination of iNTG 2.5 microg/kg/min + IV DOB 10 microg/kg/min, and IV NTG 2.5 microg/kg/min + IV DOB 10 microg/kg/min for 10 minutes each following valve replacement surgery, in random order. The hemodynamic parameters were recorded before (T0) and immediately after the intervention. (T1). iNTG effectively decreased mean pulmonary arterial pressure (mPAP), pulmonary vascular resistance index (PVRI), and the PVR / SVR ratio, without affecting arterial pressures, systemic vascular resistance or mixed venous oxygen saturation (SvO2). IV NTG produced both systemic and pulmonary vasodilation along with a significant fall in SvO2. The combination of iNTG and IV DOB caused a significant decrease in mPAP and PVRI, with no significant change in SVRI, PVR / SVR ratio, and SvO2. A combination of IV NTG + IV DOB caused both pulmonary and systemic vasodilatation with a significant decrease in SvO2. None of the drugs caused any significant change in the cardiac index. All drugs were of similar efficacy in reducing the pulmonary vascular resistance index. Only iNTG produced selective pulmonary vasodilatation, while IV NTG and its combination with IV dobutamine had a significant concomitant systemic vasodilatory effect.