Simultaneous Mitral Valve Replacement Research Articles

Biological versus mechanical SAVR patient's age threshold: PARTNER II study influenced real world practice in a large French cohort

Abstract Background/introduction Published in 2016, PARTNER II study has shown TAVR to be non inferior to SAVR in intermediate risk patients. This result might influence the type of SAVR chosen in patients for whom a redo surgery would surely be a procedure at intermediate risk, based on estimated age at time for redo and taking into account ViV TAVI as a game changer for treating a degenerated biological prosthesis. Purpose To assess the choice of type of valve according to age in aortic position through the French National Database EPICARD before and after the publication of Parter II study. Methods We extracted from EPICARD all valvular patients operated on from 2007 to 2022 in 24 participating public or private centers chosen to represent a balanced representation of center sizes and geographical discrepancies. Patients with associated pathology of the aorta (aneurysm or dissection) and requiring a vascular aortic prosthesis were excluded. Results From the obtained representative study population of 101,070 valvular patients, we studied 72,375 SAVR (mean age 71.4 +/- 12.2). We observed a mechanical versus biological prosthesis ratio (MBPR) of 0.14 for the overall aortic SAVR population. Before 50 y-o, MBPR was >1.3 (p<0.001) while patients above 60 y-o received principally biological SAVR (p<0.0001). Concerning patients between 50-60 y-o patients, MBPR was 1.04 (p=0.03). Patients 50-60 y-o from the first and second quartile (before August 2015) received preferentially mechanical SAVR (p<0.001). We observed a shift towards more biological SAVR (p<0.001) for patients from the third and fourth quartile to reach a MBPR at 0.43 during the last years of the series. Incidentally, the choice of type of SAVR was influenced by associated procedures. Simultaneous mitral valve replacement were more common in case of mechanical SAVR (p<0.0001), while associated CABGs were more frequent in case of biological SAVR (p<0.0001). Conclusion In a large contemporary French patient population, real world practice showed that publication of the PARTNER II study was followed by a shift towards a lower threshold for biological SAVR as compared to ESC Guidelines.

Trends in SAVR with biological vs. mechanical valves in middle-aged patients: results from a French large multi-centric survey.

Currently, despite continued issues with durability ( 1), biological prosthetic valves are increasingly chosen over mechanical valves for surgical aortic valve replacement (SAVR) in adult patients of all ages, at least in Western countries. For younger patients, this choice means assuming the risks associated with a redo SAVR or valve-in-valve procedure. To assess the use of mechanical vs. biological valve prostheses for SAVR relative to patient's age and implant time in a large population extracted from the French National Database EPICARD. Patients in EPICARD undergoing SAVR from 2007 to 2022 were included from 22 participating public or private centers chosen to represent a balanced representation of centre sizes and geographical discrepancies. Patients with associated pathology of the aorta (aneurysm or dissection) and requiring a vascular aortic prosthesis were excluded. Comparisons were made amongst centers, valve choice, implant date range, and patient age. We considered 101,070 valvular heart disease patients and included 72,375 SAVR (mean age 71.4 ± 12.2 years). We observed a mechanical vs. biological prosthesis ratio (MBPR) of 0.14 for the overall population. Before 50 years old (y-o), MBPR was >1.3 (p < 0.001) while patients above 60 years-old received principally biological SAVR (p < 0.0001). Concerning patients between 50 and 60 years-old patients, MPVR was 1.04 (p = 0.03). Patients 50-60 years-old from the first and second study duration quartile (before August 2015) received preferentially mechanical SAVR (p < 0.001). We observed a shift towards more biological SAVR (p < 0.001) for patients from the third and fourth quartile to reach a MBPR at 0.43 during the last years of the series. Incidentally, simultaneous mitral valve replacement were more common in case of mechanical SAVR (p < 0.0001), while associated CABGs were more frequent in case of biological SAVR (p < 0.0001). In a large contemporary French patient population, real world practice showed a recent shift towards a lower age-threshold for biological SAVR as compared to what would suggest contemporary guidelines.

Успешное хирургическое лечение массивной тромбоэмболии легочной артерии с одномоментным протезированием митрального клапана

Успешное хирургическое лечение массивной тромбоэмболии легочной артерии с одномоментным протезированием митрального клапана

The Integrated Approach to Improving Efficiency and Safety of Anticoagulation Therapy in Patients With Prosthetic Mitral Valve

To assess advantages of integrated approach to improvement of efficiency and safety of warfarin therapy after heart valve replacement. We included in this study 118 patients who had undergone simultaneous mitral valve replacement and maze procedure. Group 1 patients (n=37) underwent just sinus rhythm restoration, group 2 patients (n=54) underwent sinus rhythm restoration and participated in a patient education program, group 3 patients (n=27) underwent sinus rhythm restoration, participated in a patient education program, and were subjected to pharmacogenetic testing for warfarin sensitivity. In examination of patients we used clinical, demographic, and instrumental methods. Estimation of the time in the therapeutic range (TTR) of an international normalized ratio (INR) was used as a measure of warfarin therapy quality, and the Kaplan-Meier method was applied for analysis of hemorrhagic and thrombotic complications. TTR was 42 % in group 1, 68 % in group 2 (p=0.0327), and 82 % in group 3 (p=0.0019). Application of integrated approach was associated with absence of hemorrhagic and thrombotic complications within one year after heart valve replacement. The integrated approach comprising restoration of sinus rhythm, patient education, and pharmacogenetic testing for warfarin sensitivity was associated with improved anticoagulation control, and prevention of hemorrhagic and thrombotic complications.

Less invasive cardiac surgery via partial sternotomy

BackgroundLess invasive cardiac surgery is widely adopted nowadays. Upper or lower partial sternotomy is an approach for less invasive cardiac surgery. We report results of less invasive cardiac surgery via partial sternotomy. MethodsFrom August 1, 2009 to September 30, 2010, 35 patients underwent cardiac surgery via upper or lower partial sternotomy. The preoperative characteristics, operative variables, mortality, and morbidity were reviewed retrospectively. ResultsThirty-five patients underwent cardiac surgery via partial sternotomy during the study period. Eleven patients (31%) were female. The mean age was 66 ± 11 years (range 38 to 88). Seven patients underwent aortic valve replacement via upper partial sternotomy. Simultaneous mitral valve replacement was done in one patient. Lower partial sternotomy was done in 28 patients. Sixteen patients received mitral valve replacement. Three patients underwent mitral valve repair. Concomitant tricuspid valve repair was done in eight patients. Two patients received aortic valve replacement. One patient had replacement of aortic and mitral valve replacement. One patient had repair of tricuspid valve. Two patients received LIMA anastomosis to the LAD. Two patients underwent emergent repair of the right ventricle. One patient had resection of myxoma in the left atrium. Direct cannulation of the aorta and right atrium was used for cardiopulmonary bypass in 15 patients (48%). Both antegrade and retrograde administration of cardioplegia solution was used routinely for myocardial protection. There was no mortality. Two patients developed respiratory failure. One patient suffered unstable sternum. One patient required conversion to full sternotomy. No patient suffered mediastinitis or groin wound infection. ConclusionUpper or lower partial sternotomy provides adequate exposure for various kind of cardiac surgery. Conventional cardiopulmonary bypass and cardioplegia solution administration can be used. The immediate preliminary outcome was acceptable.

Fully supported open stent grafting applied with a Matsui-Kitamura (MK) stent in treatment of distal arch aneurysm

Our purpose was to examine the use of fully supported open stent grafting (OSG) with a Matsui-Kitamura (MK) stent for treatment of distal arch aneurysm (DAA). Surgery was performed using a newly developed device in seven DAA patients (six men and one woman) from 58 to 86 years of age (mean, 73 years old) from August 2005 to June 2007. The aorta was transected at the arch between bracheocephalic artery and left subclavian artery under circulatory arrest with total cardiopulmonary bypass and selective cerebral perfusion; then the stent grafting (SG) system was inserted and positioned with a 14 Fr. pusher. The SG and a transected edge were then sutured and anastomosed with the arch graft. The surgery was completed by constructing three cerebral branches. The mean SG diameter and length were 34.6 mm (range, 32-38 mm) and 150 mm (120-200 mm), respectively. The mean time of circulatory arrest time and surgery were 41 min (35-55 min) and 358 min (269-450 min), respectively. Simultaneous mitral valve replacement was performed in one patient. All surgeries were completed successfully, and complete thrombosis of the aneurysm was obtained. Paraparesis and respiratory failure occurred in one patient each, and one patient died of brainstem infarction 1 month after surgery. These initial results suggest that the OSG method is a useful surgical procedure for the treatment of DAA.

Aortopulmonary Fistula Due to Perforation of the Aortic Wall of a Freestyle Stentless Valve

Aortopulmonary fistula occurring as a result of a rupture of the aortic wall of a stentless valve has not been previously reported. A 71-year-old woman suffered aortopulmonary fistula 15 months after replacement of the aortic root with a Freestyle stentless valve (Medtronic, Inc, Minneapolis, MN) and Dacron graft extension to replace the aortic valve and the ascending aorta to the aortic arch. We describe the successful repair of the fistula and simultaneous mitral valve replacement. The cause of deterioration of the aortic wall of the stentless valve, which gradually developed and ruptured, may have been primarily structural injury at the previous operation, with additional insult from the surgical adhesive used.

Current determinants of operative mortality in 1400 patients requiring aortic valve replacement

Background Determinants of operative mortality after aortic valve replacement vary with a changing patient population due to advances in operative management and increasing life expectancy. In order to predict current groups of high risk patients, a statistically valid large study population base recruited over a short period of time is required. Methods Between January 1996 and June 2001, 1408 aortic valves were replaced in 1400 patients (572 of them with simultaneous coronary artery bypass grafting). The data were analyzed by multivariate logistic regression to evaluate the operative risk. Mean age of the study population was 68 ± 11 years (range 19 to 90 years old, 44% female). Results Overall operative mortality (within 30 days) was 3.8%. Independent predictive factors for operative mortality were previous bypass surgery, emergency operation, simultaneous mitral valve replacement, renal dysfunction, more than 80 years old, simultaneous bypass surgery in female patients with a body mass index greater than 29 kg/m 2, and height smaller than 1.57 m for patients more than 71 years old. Simultaneous coronary artery bypass grafting in general ( p = 0.6), previous aortic valve replacement ( p = 0.59), and implantation of stented bioprostheses ( p = 0.39) or stentless bioprostheses ( p = 0.7) were not identified as independent risk factors. Conclusions Certain groups of patients with a high operative risk were identified: patients more than 80 years old, women with a body mass index greater 29 kg/m 2 undergoing simultaneous coronary artery bypass surgery, and “small” patients more than 71 years old.

Comparison of durability of bioprostheses in tricuspid and mitral positions

Background. Few reports have assessed differences in the durability of mitral and tricuspid bioprostheses after simultaneous implantation of the same bioprosthesis in both positions. We investigated the long-term outcome after simultaneous mitral valve replacement (MVR) and tricuspid valve supraannular implantation (TVSI) with the Carpentier-Edwards bioprostheses in patients with severe tricuspid regurgitation and advanced mitral valve disease.Methods. Between 1982 and 1998, 37 patients in our hospital underwent MVR and TVSI with Carpentier-Edwards bioprostheses. The mean age of the patients was 55 ± 11 years. The average postoperative follow-up was 7.9 ± 4.5 years after surgery (range 0 to 14.6 years, 315.1 patient-years). The follow-up rate was 100%. We evaluated the actuarial survival rate, the actuarial freedom from structural valve deterioration (SVD) and reoperation, and postoperative complications.Results. The overall actuarial survival rate at 13 years after the operation was 69% ± 31%. The actuarial freedom from SVD and reoperation in the mitral and tricuspid positions were 78 ± 22 and 100% and 70 ± 30 and 90% ± 10% (p = 0.03), respectively. No patient had systemic or pulmonary thromboembolism, or complications associated with fatal arrhythmia.Conclusions. These results suggest that the bioprostheses in the tricuspid position yield significantly better long-term results than those in the mitral position after simultaneous MVR and TVSI.

僧帽弁置換と低位前方切除の同時手術症例 Ｒｂ直腸癌を伴う感染性心内膜炎による僧帽弁閉鎖不全症の１例

僧帽弁置換と低位前方切除の同時手術症例 Ｒｂ直腸癌を伴う感染性心内膜炎による僧帽弁閉鎖不全症の１例

Durability of the hancock MO bioprosthesis compared with standard aortic valve bioprostheses

To compare the durability of the Hancock modified orifice (Hancock MO, model 250 [H-MO]) valve with two other commonly used standard aortic valve bioprostheses, a cohort of 1,602 patients undergoing aortic valve replacement using porcine valves between 1971 and 1990 (excluding simultaneous mitral valve replacement) was analyzed retrospectively using Cox model multivariate techniques. Five hundred sixty-one patients received a composite H-MO valve, 652 received a standard Hancock model 242 (H) valve, and 389 received a Carpentier-Edwards model 2625 (C-E) valve. Mean age was 60 +/- 15 years (+/- 1 standard deviation) (71% male). Follow-up (10,247 patient-years) extended to 15 years and was 97% complete. The main focus of this study was bioprosthetic durability, using The American Association for Thoracic Surgery/The Society of Thoracic Surgeons guidelines to define structural valve deterioration (SVD). Multivariate analysis revealed that (younger) age (p < 10(-5), liver disease (p = 0.02), and 1981 to 1985 operative period (p = 0.012) were the only significant, independent predictors of SVD. In concordance with previous reports, the SVD freedom estimate was greater than 90% at 15 years for patients older than 70 years of age. Hepatic dysfunction had an adverse effect on SVD (estimated freedom from event at 10 years was 34 +/- 17% [standard error of mean] versus 78 +/- 2% for those without liver disease), but this affected only 3% of patients. Interestingly, one operative period (1981 to 1985) was associated with a slightly higher risk of SVD compared to the three other 5-year time windows. Valve type did not emerge as a significant risk factor for SVD.(ABSTRACT TRUNCATED AT 250 WORDS)

Left atrial plication and mitral valve replacement for giant left atrium accompanying mitral lesion.

Between January 1982 and November 1992, 38 patients received simultaneous mitral valve replacement (MVR) and left atrial plication (LAP) because of giant left atrium accompanying mitral lesion. Their ages ranged from 33 to 70 years, and the mitral lesion was caused by rheumatic heart disease in all patients. MVR was performed with a St. Jude Medical prosthesis for all patients and the left atrial wall was plicated with running 3-0 Nespolene to reduce the width to 3 to 5 cm. Respiration requiring mechanical ventilation more than 48 hours after operation occurred in four patients (10.5%) and postoperative low cardiac output requiring a high dose of dopamine HCl or intraaortic balloon pumping in nine patients (23.7%). The left atrial diameter measured by echocardiogram was a mean of 7.3 +/- 1.0 cm before operation and 5.8 +/- 1.0 cm postoperatively. The cardiothoracic ratio on the chest roentgenogram registered a preoperative mean of 73.3% +/- 9.8% and was 65.7% +/- 8.4% after operation. The pre- and postoperative values were significantly different (p < 0.01). The postoperative exercise level was a mean of 5.3 metabolic units for 24 patients and the postoperative New York Heart Association functional classification indicated Class I or II for 37 patients with no evidence of left atrial thrombus except in the case of one early death. LAP with MVR for patients with giant left atrium due to mitral lesion appeared to result in improvement in respiratory and circulatory functions.

Mitral valve stenosis and pure tricuspid valve regurgitation: Comparison of necropsy patients having simultaneous mitral and tricuspid valve replacements with necropsy patients having simultaneous mitral valve replacement and tricuspid valve anuloplasty

Clinical and morphologic observations are described in 30 patients (23 [77%] of whom were in functional class III or IV) who underwent replacement of the mitral valve for mitral stenosis and either simultaneous replacement (13 patients, group I) or anuloplasty (17 patients, group II) of the tricuspid valve for pure tricuspid valve regurgitation. Comparison of the 13 patients in group I with the 17 patients in group II disclosed similar mean ages (55 vs 58 years), similar average preoperative right ventricular systolic pressures (64 vs 61 mm Hg), similar average right atrial mean pressures (10 vs 9 mm Hg), similar average left ventricular systolic pressures (126 vs 120 mm Hg), similar average pulmonary artery wedge-left ventricular mean diastolic pressures (16 vs 18 mm Hg), similar cardiac indexes (2.1 vs 2.0 liters/min/m 2), similar mean heart weights (507 vs 535 g), and similar percents with grossly visible foci of left ventricular necrosis (15% vs 12%) and fibrosis (23% vs 12%). Of the 13 patients in group I, 10 (77%) died early (≤60 days of tricuspid valve replacement) and 3 (23%) died late (29, 37 and 120 months); of the 17 patients in group II, 14 (82%) died early and 3 (18%) died late (4, 9 and 98 months). The causes of early death in the 2 groups were different: of the 10 patients in group I who died early, the cause was excessive bleeding in 5, low cardiac output of undetermined etiology in 3, dysfunction of both prostheses in 1 and cerebral insult in 1; of the 14 patients in group II who died early, none died from excessive bleeding, 4 from decreased cardiac output of uncertain cause, 5 from left ventricular inflow obstruction (produced by a Starr-Edwards ball-valve prosthesis in 4 and from a Starr-Edwards disc prosthesis in 1), 1 from left ventricular outflow obstruction (by a porcine bioprosthesis), 2 from technical mishaps (incision into left ventricular free wall with rupture in 1 and ligation of the left circumflex coronary artery with resulting acute myocardial infarction in 1) and 2 died suddenly for reasons not determined. Of the 6 patients dying >60 days after operation, 4 died from chronic congestive cardiac failure, 1 from a cerebral embolus and 1 from prosthetic valve endocarditis.

Coronary Artery Bypass Surgery in Peritoneal Dialysis Patients

Over the last two years, in the Toronto Western Hospital, five chronic renal failure patients suffering from severe symptomatic ischemic heart disease, who had been maintained on peritoneal dialysis underwent coronary artery bypass surgery. One of the five had simultaneous mitral valve replacement. Of the five, four survived with substantial improvement in symptoms, the fifth died soon after the operation. This paper describes the management of these patients and the dialysis technique used in the preand postoperative periods. Coronary artery bypass surgery (CABG) is effective in the treatment of symptoms of ischemic heart disease and under some circumstances it seems to improve life expectancy (1–4). Cardiovascular disease, which frequently is associated with chronic renal failure (CRF) remains the most common cause of death in dialysis patients (5, 6). Several workers have reported successful cardiac surgery in hemodialysis patients (7–10); however, we know of no relevant literature on similar operations in those maintained on peritoneal dialysis. During the last 5 years there has been a considerable increase in the number of CRF patients receiving peritoneal dialysis (11), and this paper describes five of our patients who underwent bypass operations while maintained on this fonn of therapy.

Early and 8 year results of aortic valve replacement: a clinical study of 232 patients.

The study concerns early and late results of aortic valve replacement (AVR) in 232 patients with aortic valve disease, using the Björk-Shiley tilting-disc prosthesis. Of the 232, 27 patients had some evidence of mitral valve disease with valvulotomy having been undertaken in 7 previously, and in 12 at the time of the aortic valve replacement. Patients who underwent simultaneous mitral valve replacement and/or aorta coronary artery bypass grafting are not included in this analysis. To establish predictions of early death and late survival the patients were divided into two groups (A and B), taking 6 pre-operative risk factors into consideration: systolic pressure gradient greater than or equal to 100 mmHg; NYHA class IV; depressed left ventricular function (heart failure); previous valvulotomy of the aortic valve; advanced age (greater than or equal to 70 years) and surgery during the acute stage of bacterial endocarditis. In group A, consisting of 132 patients with no preoperative risk factors, early mortality was 1.5% (2/132). In group B, with 1 or more risk factors, early mortality amounted to 15% (15/100), (P less than 0.01). Subdividing group B into patients with one of the first three risk factors and patients with two or three of these risk factors, mortality was 12% (9/73) and 27% (6/22), respectively. Actuarially determined survival curves showed an 8-year survival rate of 84.2% for patients in group A and 59.6% for patients belonging to group B. Corrected for early mortality, however, the difference in late mortality is not significant. Analysis showed that early mortality was related to myocardial preservation: results for coronary perfusion and cardioplegic arrest were similar, but results were far less good when hypothermic ischaemic arrest was applied. Late results were less favourable in patients who had prior mitral valve disease not requiring mitral valve replacement at the time of AVR, or in those who developed mitral valve disease. The results allow the authors to conclude that AVR is a relatively safe procedure with a low operative mortality and few postoperative complications in patients with no 'risk factors'.

Simultaneous Repair of Anomalous Origin of the Left Coronary Artery from the Pulmonary Artery and Mitral Regurgitation

A 20-month-old boy with anomalous origin of the left coronary artery from the pulmonary artery was successfully treated by combining aortic implantation of the left coronary artery and simultaneous mitral valve replacement. We describe our operative technique and emphasize that in the definitive treatment of this anomaly, it is advisable to not only correct the malformation but also repair the mitral valve damage caused by secondary changes due to infarction.

Massive Mitral Regurgitation from Chordal Rupture and Coronary Artery Disease

The precise mechanism that causes spontaneous rupture of chordae tendineae remains unknown. That it may occur in patients with no disease other than underlying or associated coronary artery occlusion has not been previously reported. Six patients with chordal rupture were found among 600 patients who underwent operation for mitral regurgitation in a 6-year period. All 6 patients without exception underwent simultaneous mitral valve replacement and coronary revascularization. The salient clinical features of these patients are summarized, and 1 case is reported in detail.