Prosthetic Mitral Valve Replacement Research Articles

Surgical management of Marfan syndrome in children.

Between August 1983 and January 1991, seven patients with Marfan syndrome underwent surgery for severe cardiovascular complications. The mean age at presentation was 5.7 months (range 4 to 9 months) in the infant group (n = 3), and 13.3 years (range 10 to 16 years) in a group of older children (n = 4). The primary indications for surgery in the infant group (performed at a mean of 3 years after diagnosis) were ascending aortic aneurysm with valvar regurgitation in one patient, and severe mitral valve prolapse with regurgitation in two. In the older group, surgical indications (performed at a mean of 2.8 years after diagnosis) were ascending aortic aneurysm with valvar regurgitation in three patients and acute aortic dissection in one. For aortic surgery, a composite valved conduit was used in four patients, and an aortic homograft in one. For mitral valve surgery, mechanical prostheses were used. All patients survived the primary operation. Over a mean follow-up of 17.5 patient-years (range 1 to 9 years), two patients in the infant Marfan group went on to further successful surgery (prosthetic mitral valve replacement and aortic root repair with aortic homograft) at a mean interval of 4.3 years after the initial surgery. Our results suggest that the major cardiovascular risk factors of Marfan syndrome in the young, even in those diagnosed during infancy, have been favorably changed by surgery with an encouraging medium-term outlook. The correct timing of surgery is aided by echocardiography.

Homograft aortic valve and root replacement for severe destructive native or prosthetic endocarditis.

Ten male patients with a mean age of 57.5 years (range 27-75 years) underwent homograft aortic valve or root replacement for destructive aortic valve endocarditis. Six patients had native valve endocarditis (one with associated native mitral valve endocarditis) and four had prosthetic valve endocarditis (one with associated prosthetic mitral endocarditis). Causative organisms were Streptococci in six patients, Staphylococci in one, Q fever in one and no organisms were isolated in the remaining two patients. All the patients were operated while on antibiotics (mean lengths of treatment 13 days; range 2-42). The main indication for surgery was cardiogenic shock in five patients, progressive cardiac failure in four patients and uncontrolled sepsis in one patient. Operative procedures involved homograft aortic root replacement with coronary reimplantation (seven patients; associated prosthetic mitral valve replacement in one patient), infracoronary homograft aortic valve replacement (three patients) and a number of other procedures were performed to reconstruct the disrupted cardiac anatomy. Patients were followed up for a mean of 13.2 months (range 2-21). One patient died 4 months postoperatively of an unrelated cause; all the others are asymptomatic with no evidence of recurrent endocarditis. We conclude that homograft aortic valve or root replacement is an effective method of managing destructive aortic valve endocarditis.

Prosthetic valves in children and adolescents

The purpose of this paper is to present the short-and long-term results of prosthetic valve replacement in children. During a 7-year period that ended in April 1985, 186 children, ages 1 to 20 years, underwent valve replacement; there were 55 (30%) aortic valve replacements, 95 (51%) mitral valve replacements, and 36 (19%) multiple valve replacements. Ninety-four percent of the lesions were rheumatic in origin, 4% were congenital, and 2% were infectious. Of 223 valves replaced, 175 (78%) were mechanical valves and 48 (22%) were heterografts; the latter were in the mitral position in all but three patients. Surgical mortality rates were 3.6%, 4.2%, and 19.4% respectively for aortic valve, mitral valve, and multiple valve replacements. Five-year actuarial survival was 91% for aortic valve replacement, 82% for mitral valve replacement and 60% for multiple valve replacement. Major events included reoperation in 34 (with three deaths), progressive myocardial failure that led to death in 10, sudden unexpected death in two, thromboembolic complications in 19 (death in five), subacute bacterial endocarditis in five (two deaths), and bleeding that required transfusion in two patients. Five-year complication-free actuarial survival rates were 83% for aortic valve replacement, 63% for mitral valve replacement, and 57% for multiple valve replacement. The respective five-year complication-free survival rates were 83%, 48%, and 43%. Significant morbidity and mortality rates are associated with valve replacement. Therefore every effort should be made to preserve the native valve by plastic reparative procedures. When prosthetic replacement of mitral valve is contemplated, our data would suggest that heterografts should not be inserted in children 15 years of age or younger, although heterografts may be used in children over 15 years of age with the expectation of valve survival comparable to that of mechanical valves. When complications that are associated with anticoagulant therapy were reviewed, platelet inhibiting drugs seem quite satis-factory in patients with aortic valve replacement; patients with mitral valve replacement seem to require warfarin therapy, and warfarin must be used in patients with multiple valve replacement to reduce the risk of thromboembolic complications.

Tracheobronchial calcification: an observation in three children after mitral valve replacement and warfarin sodium therapy.

Tracheal calcification in children may be congenital or acquired. The authors describe three children in whom tracheal or tracheobronchial calcification was noted on radiographs after prosthetic mitral valve replacement and after long periods of warfarin sodium therapy. Laryngeal and tracheal calcification has been known to occur in warfarin embryopathy. This suggests that possibility of warfarin sodium as an etiologic factor in the development of the tracheal or tracheobronchial calcification in these children. However, further investigation is necessary.

Detection of prosthetic mitral valve leak: A comparative study using transesophageal echocardiography, transthoracic echocardiography, and auscultation

Paravalvular leakage is a major complication of prosthetic valve dysfunction. Sixty-one subjects with valvular heart disease who had received prosthetic mitral valve replacement 5 months to 5 years before (43 received a porcine prosthesis and 18 received Bjork-Shiley valve prostheses) were evaluated for this complication. Careful auscultation was performed by two experienced cardiologists followed by transthoracic and transesophageal echocardiography. Physiologic leaks were detected in all Bjork-Shiley valves, but in only 30% of porcine valves using transesophageal echocardiography. These regurgitant jets were flame-like, with mean low velocities of 50 +/- 12.3 cm/sec and 48 +/- 18.2 cm/sec in the two types of valves. Neither transthoracic echocardiography nor auscultation could detect physiological regurgitant jets. Ten cases with paravalvular leak were detected by transesophageal echocardiography and subsequently demonstrated by left ventriculography (7 porcine, 3 Bjork-Shiley valves). Pathologic regurgitant jets were seen as high-velocity, systolic-retrograde turbulent flow across the prosthesis. However, only 6 cases of prosthetic valve dysfunction were detected by transthoracic echocardiography, 4 cases of mild paravalvular leakage went undetected. Thirteen of the 61 subjects had an apical systolic murmur and suspected prosthetic valve leakage; in 10 of the 13 cases the findings corresponded to those obtained by transesophageal echocardiography. In 3 cases of double valve replacement with Bjork-Shiley valves the magnitude of the leakage was overestimated by auscultation.

A CASE OF PREGNANCY PRESENTED WITH MILD HEART FAILURE AFTER

A 30-year-old woman, who had been received warfarin for anticoagulation after prosthetic mitral valve replacement, transiently aboided warfarin administration to success the conception. Then warfarin was reintroduced at 13th week of gestation.At late gestational period, she complained of mild heart faliure in NYHA class II following increases in HR, LV volumes, LA/Ao ratio and CTR. After 37th week of gestation warfarin was substituted for heparin (15, 600U/day), and cesarean section was performed keeping her APTT at 1.5 times the control value. The mother was free from thromboembolic complication, and the infant was free from embryopathy or hemorrhagic complication. The level of the infant indicated that warfarin should be stopped at least 10 days before labor. In this case methyl ergometrine caused a rapid increase in pulmonary-arterial pressure and bradycardia. Therefore methyl ergometrin Should be used carefully for a post MVR patient with the assessment of hemodynamic functions.

Mitral valvuloplasty

Mitral valvuloplasty is associated with low operative mortality, preservation of ventricular function, reduced valve-related complications, decreased requirement for anticoagulation therapy, improved long-term survival, and decreased cost. It should be undertaken after careful consideration of the individual patient's pathophysiology and pathoanatomy, including a thorough clinical and echocardiographic evaluation. In these selected cases, an excellent surgical result can be obtained with valve repair, eliminating the risks associated with prosthetic mitral valve replacement.

Congenital left ventricular inflow obstruction: is the outcome related to the site of the obstruction?

Between 1978 and 1987, 39 patients aged 1 day to 15 years underwent surgery for symptomatic left ventricular inflow obstruction. Four diagnostic groups were identified: cor triatriatum (6 patients), supravalvar mitral membrane (SVMM) with a normal mitral valve (7 patients), SVMM with an abnormal mitral valve (9 patients) and mitral stenosis (17 patients). Associated cardiac anomalies occurred in 26 patients (67%). There were 8 deaths (21%), 3 in patients with SVMM and an abnormal mitral valve and 5 in patients with mitral stenosis. Survival for patients with normal mitral valves was significantly better than that for patients with abnormal mitral valves (13/13 vs 18/26, P less than 0.05). There was also high morbidity in patients requiring prosthetic mitral valve replacement. These data suggest that the outcome of surgical treatment for left ventricular inflow obstruction may be predicted according to the site of the obstruction. This is best determined preoperatively by cross-sectional echocardiography which allows optimal planning of surgical strategy.

Echo-phonocardiographic evaluation of the Björk-Shiley mitral prosthesis

Ninety patients were studied with combined echophonocardiography after Björk-Shiley disc prosthetic mitral valve replacement. They were evaluated every 6 months (mean follow-up 6 years). Nine cases of left ventricular (LV) failure and 6 cases of prosthetic malfunction (5 paravalvular leaks and 1 thrombosis) were detected; 1 case was confirmed at necropsy and the other 5 cases were surgically verified and repaired. The following measures of prosthetic malfunction were evaluated: opening and closing velocity, maximal amplitude of the prosthesis, septal motion 6 months after operation, LV diastolic diameter, protodiastolic hump, variations during same record of the interval between aortic valve closure sound to the phono and mitral valve opening to the echo, and interval between aortic valve closure sound and maximal excursion of the LV posterior wall. All measures studied were useful for detecting prosthetic malfunction, but 2 are more useful in individual cases: variations of the Interval between second heart sound and mitral valve opening and the interval between the aortic valve closure sound and LV posterior wall motion. These 2 intervals also allow discrimination between normal function, prosthetic malfunction and LV failure.

Abbreviation of systolic time intervals in acute mitral regurgitation: Effect of prosthetic mitral valve replacement

Systolic time intervals were measured in 26 patients with mitral regurgitation (acute in 14 and chronic in 12). In 13 of these patients (7 with acute and 6 with chronic mitral regurgitation) systolic time intervals were also measured after mitral valve replacement. Total electromechanical systole corrected for heart rate (Q-S 2I) was of much shorter duration in the group with acute mitral regurgitation (472 ± 9 msec [mean ± standard error of the mean]) than in the group with chronic mitral regurgitation (516 ± 4.6 msec, P < 0.01). Before operation, the ratio of the preejection period (PEP) to left ventricular ejection time (LVET) and the angiographic ejection fraction did not differ in the groups with acute and chronic mitral regurgitation. The correlation between the PEP LVET ratio and ejection fraction was r = − 0.84, P < 0.01. Two weeks after operation, the PEP LVET ratio increased in all patients, but the increase was greater in those with lower preoperative values for this ratio. The mechanism of the early postoperative increase in the PEP LVET ratio is not clear, but serial studies performed over 6 months showed a return toward the preoperative value. It is concluded that preoperative systolic time intervals are useful for assessing left ventricular performance in all types of mitral regurgitation, but are especially useful for distinguishing between the acute and chronic varieties.

Rupture of the Ventricle Following Prosthetic Replacement of the Mitral Valve

40 cases, 36 from the literature and 4 of ours, of rupture of the posterior wall of the left ventricle following prosthetic mitral valve replacement are presented. Twelve of these patients survived. Possible causes of this complication, the therapeutic approach and its prevention are discussed.

Bleeding, clotting, and functional disability following Beall prosthetic mitral valve replacement.

The incidence of fatal and nonfatal thromboemboli and bleeding episodes was compared in 53 patients who received sodium warfarin and in 17 successive patients who received no sodium warfarin after Beall mitral valve replacement. Actuarial curves showed that by 12 months postoperatively patients not receiving sodium warfarin had a greater incidence of emboli (P less than 0.01). This significant difference remained when the combined incidence of emboli and hemorrhage was considered (P less than 0.05). Deaths due to emboli or hemorrhage, however, were not statistically different in the two groups. The quality of control of prothrombin times (percent of prothrombin times two to two and a half times control) did not significantly influence the incidence of ebmoli although the numbers were small. However, fatal and nonfatal hemorrhagic episodes which did occur were almost invariably associated with prothrombin times greater than three to eight times control. Results of pre- and post-operative graded treadmill exercise tests in 39 patients receiving a Beall mitral valve replacement showed significant postoperative improvement in exercise tolerance. Nevertheless, the patients' postoperative working capacity was only 55% to 57% of that of age- and sex-matched sedentary controls. The present study supports the use of sodium warfarin therapy and strict anticoagulation control in Beall mitral valve replacement patients. It also documents a significant residual impairment in physical working capacity.

Pulmonary varix regression after mitral valve replacement

Pulmonary varix is a rare finding; only 35 documented cases have been reported. The first case was described in 1843 as an incidental postmortem finding. The first clinical diagnosis was not made until 1951. In more than half of the 35 cases, the varix was present in the absence of congenital and acquired heart disease. Six patients have had concomitant mitral rheumatic heart disease. This communication describes the second patient with rheumatic mitral regurgitation in whom the pulmonary varix became radiographically invisible after prosthetic mitral valve replacement.

Mycotic Aneurysm of the Ascending Aorta Secondary to Serratia Infection: Differentiation from Prosthetic Valve Endocarditis

Twenty-one months after prosthetic aortic and mitral valve replacement, a 64-year-old man developed bacteremia secondary to a Serratia infection. Intensive investigatimi failed to reveal the origin of infection and gentamicin therapy did not eradicate the organisms from the bloodstream. The patient died. Postmortem examination revealed a large mycotic aneurysm arising from the aortotomy site but no evidence of prosthetic valve endocarditis. Late occurring bacteremia following valve replacement is discussed. Aortography may be necessary to delineate this problem.

Echocardiography in Active Infective Endocarditis.

Meeting Abstracts1 May 1973Echocardiography in Active Infective Endocarditis.Richard D. Spangler, M.D., F.A.C.P., J. Thomas Okin, M.D., Michael L. Johnson, M.D., Joseph H. Holmes, M.D., F.A.C.P., S. Gilbert Blount Jr, M.D.Richard D. Spangler, M.D., F.A.C.P.Search for more papers by this author, J. Thomas Okin, M.D.Search for more papers by this author, Michael L. Johnson, M.D.Search for more papers by this author, Joseph H. Holmes, M.D., F.A.C.P.Search for more papers by this author, S. Gilbert Blount Jr, M.D.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-78-5-822_2 SectionsAboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail ExcerptEchocardiograms were obtained in 9 patients with active infective endocarditis. Echocardiographic findings were confirmed by cardiac catheterization (6 patients) and cardiac surgery (6 patients). Echocardiography showed bacterial vegetations on the mitral leaflets in three patients with mitral stenosis. Open mitral commissurotomy showed multiple bacterial vegetations intermittently occluding a moderately narrowed mitral orifice. A 12-year-old patient presented with congestive heart failure and fever. Echocardiography showed congenital mitral valvular stenosis and questionable vegetations. Hemodynamic findings were confirmed by catheterization, and vegetations on the valve were seen at the time of prosthetic mitral-valve replacement. In two patients echocardiography showed bacterial vegetations on the... This content is PDF only. To continue reading please click on the PDF icon. Author, Article, and Disclosure InformationAffiliations: Denver, Colorado. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics 1 May 1973Volume 78, Issue 5Page: 822-822KeywordsCardiac surgeryCatheterizationEchocardiographyEndocarditisFeversHeart failureHemodynamicsMitral stenosisMitral valve replacementStenosis Issue Published: 1 May 1973 PDF downloadLoading ...

Prosthetic replacement of the mitral valve. Continuing assessments of the 100 patients operated upon during 1961-1965.

The late postoperative results of isolated mitral valve replacement in 100 patients operated upon from 1961 to 1965 are summarized. Eighty-three of the patients survived operation, and 52 are still alive. Seventy-six percent of patients surviving operation were alive 5 years later, and 64% after 8 years. Of the entire group of 100 patients operated upon, 63% were alive after 5 years and 51% after 8 years. Sixteen of the 31 late deaths were definitely attributable to the presence of the prosthesis: systemic arterial emboli (eight patients), valve thrombosis (two), perivalvular leak (one), ball variance (two), endocarditis (two), and intracerebral hemorrhage due to anticoagulants (one). Congestive heart failure was the primary cause of death in the remaining patients. Predominance of either stenosis or regurgitation preoperatively did not significantly alter late survival, nor did coexistent tricuspid regurgitation. High operative and early postoperative mortality was seen in patients with associated aortic regurgitation. Patients who were in class IV preoperatively had a higher mortality (50% alive at 5 years) than those in class III (70% alive), but no difference in mortality was noted between patients who preoperatively had normal sinus rhythm and those who had atrial fibrillation. Forty-nine percent of patients have sustained systemic emboli, and these have occurred throughout the postoperative period. Currnetly, 50% of patients are class I, 42% are class II, and only 8% are class III. Prosthetic mitral valve replacement has provided gratifying long-term symptomatic improvement in the majority of patients.

Mitral and aortic valve incompetence in endocardial fibroelastosis diagnostic and hemodynamic significance

Hemodynamic and angiocardiographic studies were performed in 20 infants and children whose initial clinical, electrocardiographic and roentgenographic findings were compatible with the clinical diagnosis of endocardial fibroelastosis. On the basis of right and left heart studies it was possible to separate these patients into 2 distinct clinical groups whose subsequent clinical courses differed strikingly. Patients in group 1, all of whom had a positive reaction to the mumps intradermal skin test, demonstrated moderate to marked mitral valve incompetency, mild to moderate aortic valve insufficiency, a thick left ventricular free wall showing poor systolic excursions, a dilated left ventricular cavity, increased left ventricular end-diastolic pressure and a noncompliant left ventricle. Their subsequent clinical courses were unfavorable and characterized by recurring bouts of cardiac decompensation and a short life expectancy. Prosthetic mitral valve replacement, successful in 2 patients, resulted in marked clinical improvement. On the other hand, patients in group 2 maintained cardiac compensation after initial treatment with digitalis and left and right heart studies were normal, the only finding being an equivocal increase in left ventricular wall thickness. All of these patients are living and all have normal electrocardiographic and roentgenographic findings. It is suggested that patients in group 1 had endocardial fibroelastosis (confirmed by necropsy observation and surgical observation in most) whereas patients in group 2 had a nonspecific or aseptic myocarditis that presented an initial clinical picture indistinguishable from that of endocardial fibroelastosis. The prognosis of these latter patients is good; the prognosis of patients with endocardial fibroelastosis is guarded. If the findings of this study are confirmed, left heart studies should be of value in confirming the antemortem diagnosis of endocardial fibroelastosis.

Paravalvular leaks and hemolytic anemia following insertion of Starr-Edwards aortic and mitral valves

Summary Paravalvular leaks were encountered in 27 of 203 patients (13 per cent) following aortic valve replacement and in 10 of 108 patients (9 per cent) after prosthetic mitral valve replacement. The diagnosis of paravalvular leaks and assessment of their significance was difficult and required a comprehensive survey of clinical, radiographic, hemodynamic, and angiographic studies. Hemolytic anemia developed in 11 patients in the aortic group, occurring most often in patients operated upon initially for calcific aortic stenosis. Congestive heart failure was not a significant problem except in 6 cases of persistent hemolytic anemia in which reoperation was necessary. In 4 patients, anemia regressed spontaneously. Sixteen of the 27 patients did not require second operations. Twenty of the 27 patients in this group are alive and well at the present time. Refractory congestive heart failure occurred in 9 of the 10 patients with mitral leaks. One patient died suddenly. Significant hemolysis was attributed to the mitral leak in 1 and, possibly, 2 cases. Reoperation was carried out in 7 patients, 4 of whom are living at present. Five patients with paravalvular regurgitation, secondary to a circumferentially torn mitral annulus, had ruptured chordae tendineae at their initial operation which raises the possibility that the chordae, annuli, and valves in such patients may have a defect in the matrix or ground substance which predisposes to the development of leaks.

Prosthetic mitral valve replacement in children

Nine children with severe mitral valvular disease of varied etiologies had replacement oftheir valve with a Starr-Edwards ball-cage prosthesis. There was one death in the immediate postoperative period due to clot formation within the prosthesis, and one late death of unknown cause. The survivors have had dramatic symptomatic and objective evidence of postoperative improvement. The causes of mitral valvular disease in childhood are discussed, and the hazards of artificial valve implantation are weighed against the benefits of the procedure.

Cardioversion following prosthetic mitral valve replacement.

Direct current conversion of atrial fibrillation has been attempted in 60 consecutive patients following prosthetic mitral valve replacement (Starr-Edwards prosthesis). Sinus rhythm was attained and persisted for at least 24 hours after the procedure in 68% (41 patients) and 40% of the entire group (24 patients) were still in normal sinus rhythm an average of 10 months later. Successful initial conversion and persistence of sinus rhythm occurred most frequently in patients whose duration of atrial fibrillation was less than 5 years and who had a small left atrium. Results differed little whether conversion was attempted 7 to 21 days or 1 to 15 months after open valve replacement. Atrial disease associated with a long period of antecedent atrial fibrillation and marked left atrial enlargement appeared to be the most important factors responsible for persistence of atrial fibrillation or early relapse. Attempts at cardioversion are recommended for all patients with persistent atrial fibrillation following mitral valve replacement in view of the high success rate and the safety of the procedure.