Mitral Replacement Research Articles

Surgical management of infective endocarditis. A retrospective morbidity and mortality analysis in 112 patiens. Follow up after 11 years

Objectives: Evaluation of the outcome after surgically treated patients with infective endocarditis. Methods: We reviewed 112 pts (79 male, 33 female, mean age: 59.15yrs, range: 20–85yrs) with proven infective native (n:104) or prosthetic valve (n:8) endocarditis operated on between 09/1996 and 08/2007. 60 pts (53.5%) underwent aortic replacement, 33 (29.5%) mitral replacement, 5 (4.5%) tricuspid replacement, 13 (11.6%) double and one (0.9%) triple valve replacement. In 51% we implanted mechanical, in 16% biological prostheses and 33% were reconstructive procedures. 65% of the pts. were preoperatively in NYHA-class III-IV. Follow up was 99% complete with a cumulative duration of 366 pts/yr (maximum: 11.25yrs). Results: Early mortality (30d) was 11.6% (n:13). Of these 13, 2 died from cerebral embolism and bleeding, 4 from low cardiac output, 5 from multiple organ failure, one patient developed cardiac arrest and the last one sepsis as well. Overall late mortality (11yrs) was 20.7% (n:23) of these. 6 pts died due to cardiac, 9 pts due to extracardiac and 3 pts due to unknown causes. Due to anticoagulation 5 pts developed lethal intracerebral bleeding. Kaplan Meier analysis revealed a cumulative survival rate of 52.8% (end of 11yrs, including early mortality); for AVR 52.7%, MVR 50.3% and DVR 70% (p:0.2). 70% of hospital survivors were postoperatively in NYHA-class I-II. None of them developed recurrent endocarditis. Conclusions: Surgical treatment of endocarditis presented increased but acceptable morbidity and mortality. The mid term prognosis is nearly similar to patients, who underwent elective valve replacement surgery.

Mitral Valve Repair Versus Replacement in Simultaneous Mitral and Aortic Valve Surgery for Rheumatic Disease

Mitral Valve Repair Versus Replacement in Simultaneous Mitral and Aortic Valve Surgery for Rheumatic Disease

Mitral valve myxomas: an unusual entity

Primary tumours of the heart are uncommon entities, cardiac myxomas being the most frequent. However, mitral valve myxomas are exceptionally rare. In the last 12 years, there have been 25 myxomas diagnosed at our institution, with only two of them originating from the mitral valve. Both patients were female, the first, 25, and the second, 72 years old. The younger patient was very symptomatic with a large mass, 4 cm long, which involved both leaflets causing significant obstruction to the left ventricular inflow. The second one had a smaller mass located at the atrial side of the posterior leaflet that only produced some flow divergence. Neither of them had constitutional nor embolic symptoms. Both patients were submitted to emergent surgical resection that in the first case involved the mitral valve and replacement with mechanical prosthesis. The macroscopic appearance of these tumours suggested a malignant aetiology which may represent somewhat different features of the myxomas when originating from the cardiac valves. Both patients are well reflecting the good prognosis of this illness after resection, although the younger patient was re-operated because of prosthetic valve obstruction and suspicion of recurrence that was not confirmed. Because of the illustrative images and different presentations, we found it interesting to report and discuss them together.

Analysis of 92 mitral pulmonary autograft replacement (Ross II) operations

Analysis of 92 mitral pulmonary autograft replacement (Ross II) operations

Operative strategy for open surgery after failed thoracic aortic stent grafting

Clinical Summary PATIENT 1. A 28-year-old woman with Marfan syndrome was found to have a root dilatation with severe aortic and mitral regurgitation. A bileaflet mitral repair, a Bentall procedure, and a hemiarch replacement were performed. Five months later, the patient underwent a proximal descending aortic resection for a dissecting aneurysm. Three months later, a false aneurysm at the distal anastomotic site was diagnosed on a computed tomographic (CT) scan. Considering the recent thoracotomy, the pseudoaneurysm was treated with a 24-mm Valiant stent graft (Medtronic, Inc, Santa Rosa, Calif). On the postoperative CT scan, an aortic dissection distal to the stent was demonstrated. Three months later, the patient was admitted for New York Heart Association class III/IV dyspnea caused by recurrent severe mitral regurgitation. Control CT scanning showed a significant type 1 endoleak (Figure 1). The patient underwent mitral replacement, TASG explantation with descending aortic replacement, and pectus excavatum repair through a clamshell incision. Because of the difficulty of clamping the proximal descending thoracic graft, the TASG was removed during deep hypothermia and circulatory arrest (DHCA). The aortic perfusion was re-established through the cannula in the arch. An open distal anastomosis with septectomy was performed. The postoperative course was marked by a 3-day intubation because of chest wall instability. The thoracic aorta is free from complications on CT at 8 months (Figure 2). PATIENT 2. A 61-year-old man with a known type I thoracoabdominal aneurysm was admitted for a contained rupture at the distal third of the descending thoracic aorta. Three 100-mm Talent (Medtronic, Inc) stent grafts were implanted (40 40, 44 44, and 46 46 mm). Control angiography showed no endoleak.

Analysis of 92 mitral pulmonary autograft replacement (Ross II) operations

The study objective was to find a mitral valve substitute that does not require lifelong anticoagulation and is not affected by tissue degeneration in the long term. Between July 14, 1997, and August 8, 2004, a total of 92 patients with irreparable mitral valve disease underwent mitral valve replacement with the pulmonary autograft encased within a Dacron tubing for support. In 4 patients, the autograft had to be sacrificed at the initial operation. Of the remaining 88 patients, 62 were female, and the age ranged from 4 to 64 years (mean 39 years). Eighty-six patients had rheumatic mitral disease, and 2 patients had congenital mitral disease. Operative transesophageal echocardiography initially showed adequate valve characteristics (mean valve area 2.8 cm2, mean gradient 3.9 mm Hg, no significant regurgitation) in all 88 patients. Operative mortality was 4.6%, and late mortality definitely related to the operation was 7.9%. Four patients were lost to follow-up; the mean follow-up was 60 months. Progressive regurgitation and stenosis developed in 9 patients over 2 to 5 years, 4 of whom had their grafts explanted. The autograft was explanted in 1 patient because of endocarditis. Mild pulmonic stenosis developed in 3 patients, and critical pulmonic stenosis developed in 1 patient. At 5 years follow-up, freedom from degeneration was 93.4%, freedom from reoperation was 94.2%, and freedom from all death was 86.0%. Although the Ross II operation is difficult and harbors significant risk, it remains an option for patients with irreparable mitral disease who have a long life expectancy and who cannot be placed on lifelong anticoagulation.

Tricuspid valve annuloplasty with a flexible prosthetic band

This study evaluates the application to the tricuspid valve of a flexible prosthetic band originally devised for mitral repair. Between March 2001 and May 2005, 53 consecutive patients (age 66.2+/-8.5 years) with significant tricuspid regurgitation and dilatation of the right-sided cardiac chambers underwent tricuspid valve annuloplasty with the band and concomitant mitral repair or replacement. Thirty-one patients (58.5%) were in NYHA class III or IV, and 33 (62.3%) had a history of right heart failure. Follow-up was 19.2+/-14.0 months. Three patients (5.7%) died before discharge, and one during follow-up. One late reoperation was required for mitral endocarditis. NYHA class decreased in survivors from 2.7+/-0.8 to 1.4+/-0.6 (P<0.0001), and the symptoms of right heart failure improved significantly after surgery. Tricuspid regurgitation was mild or absent in 44 survivors (89.8%) and moderate in 5 (10.2%). Regurgitation significantly decreased even in patients with risk factors for tricuspid repair failure or with persistent left ventricular dysfunction. The 4-year actuarial freedom from tricuspid regurgitation grade >1 was 88.7%. By univariable analysis, preoperative tricuspid regurgitation grade >2, right ventricular shortening fraction <35%, and permanent pacemaker were associated with the risk of recurrent moderate regurgitation, though only probably so (P=0.077, 0.061, and 0.097, respectively).

Left Atrial Malignant Mesenchymoma — Emergency Resection and Mitral Replacement

Cardiac mesenchymoma is a rare malignancy with a dismal prognosis. We present a case of left atrial mesenchymoma, obstructing the mitral orifice. An emergent tumor resection with mitral valve replacement was performed. Few reports deal with emergency resection of cardiac malignancies with mitral valve replacement. Surgery is the only effective treatment modality.

Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Failure in Postpartum Woman With Rheumatic Mitral Valve Disease: Benefit, Factors Furthering the Success of This Procedure, and Review of the Literature

Pregnancy is a common decompensation factor for women with post-rheumatic mitral disease. However, valvular heart diseases causing severe acute respiratory distress are rare. Use of extracorporeal membrane oxygenation (ECMO) early in the event of cardiorespiratory failure after cardiac surgery may be of benefit. Indeed, ECMO cardiopulmonary bypass (CPB) support could help pulmonary recovery if the mitral pathology is involved. A 31-year-old female patient at 30 weeks of amenorrhea was admitted to the obstetrics department with 40°C hyperthermia and New York Heart Association (NYHA) class 4 dyspnea. The patient’s medical history included a post-rheumatic mitral stenosis. Blood gases showed severe hypoxemia associated with hypocapnia. The patient needed to be rapidly intubated and was placed on ventilatory support because of acute respiratory failure. Transesophageal echocardiography showed a severe mitral stenosis, mild mitral insufficiency, and diminished left ventricular function, hypokinetic, dilated right ventricle, and a severe tricuspid regurgitation. An urgent cesarean section was performed. Because of the persistent hemodynamic instability, a mitral valvular replacement and tricuspid valve annuloplasty were performed. In view of the preoperative acute respiratory distress, we decided, at the beginning of the operation, to carry on circulatory support with oxygenation through an ECMO-type CPB at the end of the operation. This decision was totally justified by the unfeasible CPB weaning off. ECMO use led to an efficient hemodynamic state without inotropic drug support. The surgical post-operative course was uneventful. Early use of cardiorespiratory support with veno-arterial ECMO allows pulmonary and right heart recovery after cardiac surgery, thus avoiding the use of inotropic drugs and complex ventilatory support.

Acute poststaphylococcal glomerulonephritis superimposed on diabetic glomerulosclerosis

Acute poststaphylococcal glomerulonephritis superimposed on diabetic glomerulosclerosis

Endocarditis neumocócica en niño de 17 meses previamente sano

Invasive pneumococcal infection is a severe disease and its incidence may be increasing. Endocarditis due to Streptococcus pneumoniae is uncommon, particularly in children without risk factors. Etiologic diagnosis is difficult when cultures are negative. We report the case of a previously healthy, 17-month-old boy not vaccinated against pneumococcus who, during the course of pneumonia treated with beta-lactam antibiotics, developed cardiorespiratory deterioration and heart murmur. Mitral valve vegetation was identified by transthoracic echocardiography. Endocarditis was diagnosed and new antibiotics were given for 6 weeks (cefotaxime, gentamycin and vancomycin). Cultures were negative. Because of lack of improvement, prosthetic mitral replacement was indicated. S. pneumoniae was identified by polymerase chain reaction (PCR) in the pathological specimen. Outcome was favorable, and the patient remained symptom-free after 6 months of follow-up. The possibility of endocarditis as an invasive pneumococcal infection should be considered in children without risk factors. PCR is a useful technique to establish the etiology when cultures are negative.

Prolonged Transcutaneous Cardiopulmonary Support for Postcardiotomy Cardiogenic Shock

Percutaneous cardiopulmonary support can be set up quickly at the bedside and provides reliable temporary mechanical circulatory support for cardiogenic shock patients. This report includes the case of a woman, age 56 years, with postoperative cardiogenic shock due to right heart failure, secondary to severe pulmonary hypertension, after mitral and tricuspid valve replacement. This was accomplished by the use of femoro-femoral Levitronix Centrimag centrifugal pump with membrane oxygenator. Adequate cardiac function returned, and the patient could be successively weaned after 37 days of support. Nitric oxide (NO) and Epoprostenol inhalation were used to enhance weaning from cardiopulmonary support. The patient recovered with ambulatory status and acceptable cardiac performance. The patient died of septicemia on postoperative day 72. In conclusion, this case report describes the safety and reliability of the Levitronix Centrimag centrifugal pump as percutaneous cardiopulmonary support for cardiogenic shock.

Beating Heart Mitral Valve Replacement with a Bovine Pericardial Bioprosthesis for Treatment of Mitral Valve Dysplasia in a Bull Terrier

To describe an open, beating heart surgical technique and use of a bovine pericardial prosthetic valve for mitral valve replacement (MVR) in the dog. Clinical case report. Male Bull Terrier (17-month-old, 26 kg) with mitral valve dysplasia and severe regurgitation. A bovine pericardial bioprosthesis was used to replace the mitral valve using an open beating heart surgical technique and cardiopulmonary bypass. Successful MVR was achieved using a beating heart technique. Mitral regurgitation resolved and cardiac performances improved (left ventricular end-diastolic diameter decreased from 57.6 to 48.7 mm, and left atrium/aorta ratio returned to almost normal, from 1.62 to 1.19). Cardiopulmonary by-pass time and total surgical duration were decreased compared with standard cardioplegic techniques. Surgical recovery was uneventful and on echocardiography 6 months later valve function was excellent. Considering the technique advantages (no cardiac arrest, ischemic reperfusion injury, and hypothermia, or the need for aortic dissection and cannulation for administration of cardioplegic solution), short-term mortality and morbidity may be reduced compared with standard cardioplegic techniques. Based on experience in this dog, beating heart mitral valvular replacement is a seemingly safe and viable option for the dog and bovine pericardial prosthesis may provide better long-term survival than mechanical prostheses.

Intra-aortic Filtration is Effective in Collecting Hazardous Materials

Neurological complications after cardiac operations are mostly due to particle embolization. This case illustrates the embolic potential of any material. A 77-year-old lady underwent re-operation for homograft aortic regurgitation and mitral valve replacement. Intra-aortic filtration was used. After cardiopulmonary bypass the filter was found to have captured a pledget from a suture used to secure the mitral replacement device.

Invited commentary

Invited commentary

Left Ventricular Outflow Tract to Right Atrial Fistula Diagnosed by Intraoperative Transesophageal Echocardiography

A 68-yr-old male with increasing shortness of breath and a history of aortic stenosis was admitted. A transthoracic echocardiographic examination (TTE) revealed an aortic valve (AV) area of 0.62 cm2. The patient was subsequently scheduled for an AV replacement (AVR). Cardiac catheterization performed on the morning of surgery demonstrated single vessel coronary artery disease involving the right coronary artery. The patient underwent an uncomplicated AVR (#23 Carpentier-Edwards Magna) with a single vessel coronary artery bypass graft. His initial postoperative course was uncomplicated, but on postoperative day 3 he became febrile to 38.7°C. Blood cultures were positive for Staphylococcus aureus and antibiotic therapy was initiated. TTE at that time was inconclusive, however transesophageal echocardiography (TEE) performed in the intensive care unit on postoperative day 7 was interpreted as a fistulous communication between the aorta and right atrium (RA) associated with a periannular abscess in the vicinity of the AVR. The patient returned to the operating room where intraoperative multiplane TEE demonstrated that the fistula actually communicated between the left ventricular outflow tract (LVOT) and the RA. In the midesophageal four-chamber view at 0° rotation, the diameter of this tract was approximately 0.5–0.8 cm. (Fig. 1 Top). Color flow Doppler in the midesophageal (Fig. 1 Bottom) and deep transgastric long-axis (Fig. 2) views confirmed the presence of turbulent flow from the LVOT to the RA just above the tricuspid valve (see video loop for midesophageal TEE views available at www.anesthesia-analgesia.org). Therefore, the surgical approach was changed to a replacement of the original AV prosthesis and aortic root with a #22 homograft (LifeNet), and the fistula closed by sewing bovine pericardial patches to both sides of the tract. The patient was discharged from the hospital in good condition after a subsequent uneventful postoperative course.Figure 1.: Top: Midesophageal four-chamber transesophageal echocardiographic (TEE) view at 0° rotation demonstrating a fistula (→) from the left ventricular outflow tract (LVOT) to the right atrium (RA). Bottom: Midesophageal four-chamber TEE view at 0° rotation with color flow Doppler showing turbulent flow from the LVOT into the RA.Figure 2.: Deep transgastric transesophageal echocardiographic (TEE) view at 0° rotation showing a communication between the left ventricular outflow tract (LVOT) and right atrium (RA). Turbulent flow from the LVOT into the RA at the level of the tricuspid valve is demonstrated (→).Communications between the LVOT and RA are mostly congenital and are known as “Gerbode's defect” (1). This anomaly accounts for <1% of all congenital heart lesions. Similar acquired shunts may develop after chest trauma, mitral and AV replacement, or infective endocarditis (2). The communication results from a defect in the interventricular septum, inferior to the crista supraventricularis. Patients with this lesion can present with hemodynamic deterioration, myocardial injury, prosthetic valve dysfunction, or perivalvular leaks. Symptoms of right-sided heart failure dominate the clinical picture and depend on the magnitude of the shunt as a reflection of the size of the defect. Physical findings include a harsh holosystolic murmur and right ventricular heave. Only patients with small shunts remain asymptomatic. Collateral injury associated with a perivalvular infection can involve the subannular region and membranous interventricular septum (3). TTE often fails to identify the involvement of these subaortic structures (4). The creation of a TTE window to visualize the membranous septum can be technically challenging because of patient anatomy and beam orientation. An overlying aortic prosthesis that overshadows the lesion can also complicate transthoracic imaging. Therefore, a comprehensive TEE examination using two-dimensional and color flow Doppler imaging can be useful for delineating the location of the pathology and for guiding the surgical procedure.

Mitral Valve Repair Versus Replacement in Simultaneous Mitral and Aortic Valve Surgery for Rheumatic Disease

The purpose of this study was to compare the late results of combined mitral valve repair and aortic valve replacement with double valve replacement for patients with rheumatic heart disease. From 1981 to 2003, 128 patients underwent aortic valve replacement with either mitral valve repair (n = 47) or mitral valve replacement (n = 81) for rheumatic disease. Mean follow-up was 9.1 +/- 4.5 years. Rates of actuarial freedom from cardiac-related death (81.4% versus 75.9% at 12 years; p = 0.60), thromboembolism (79.8% versus 85.1% at 12 years; p = 0.78), and bleeding (97.3% versus 95.7% at 12 years; p = 0.77) were similar in both combined mitral valve repair and aortic valve replacement and double valve replacement. However, freedom from mitral valve reoperation was significantly lower in combined mitral valve repair and aortic valve replacement compared with double valve replacement (52.6% versus 76.8% at 12 years; p = 0.002). Mitral valve repair (p = 0.002) and mitral bioprosthesis (p = 0.0001) were independent risk factors for mitral valve reoperation. Potential advantages of preserving, rather than replacing, the native mitral valve, such as better cardiac survival or fewer thromboembolic complications, were not identified in combined mitral valve repair and aortic valve replacement compared with double valve replacement for patients with rheumatic disease. Indeed, combined mitral valve repair and aortic valve replacement was associated with a significantly higher incidence of mitral valve reoperation. Therefore, in double valve surgery for rheumatic disease, mitral valve repair should be limited to the correction of mitral valve lesions only when excellent durability can be expected.

Mitral valve surgery and acute renal failure

Mitral valve surgery and acute renal failure

Mitral mechanical replacement in young rheumatic women: Analysis of long-term survival, valve-related complications, and pregnancy outcomes over a 3707-patient-year follow-up

Mitral mechanical replacement in young rheumatic women: Analysis of long-term survival, valve-related complications, and pregnancy outcomes over a 3707-patient-year follow-up

A case of mitral valve plasty for Libman–Sacks endocarditis mimicking a cardiac tumor

quency maze lesion lines were unlikely to be a source leading to propagation onto the valve leaflets because there were no intraatrial clots and thrombus was laminar along all the valve leaflets. Intravenous heparin was started in this patient with a plan to commence thrombolytic therapy if heparin alone was ineffective. Although thrombolytic therapy is an established first-line treatment, this patient responded to heparin anticoagulation followed by warfarin. Several studies have reported good resolution of bioprosthetic thrombus after conventional anticoagulation. Concurring with these studies, we had a favorable result after 1 week of heparin and subsequent warfarinization. Clinically significant bioprosthetic valve thrombosis is rare, although the reported incidence in the study by Oliver and colleagues is 6.2%. It should be considered a possible cause of valve dysfunction when there is increasing transvalvular pressure gradient after anticoagulation is terminated. Treatment with conventional anticoagulation is unavoidable in such a setting.