Simultaneous Mitral Valve Research Articles

Long-Term Survival Following Surgery for Endomyocardial Fibrosis

We report a successful follow-up after 28 years of a woman with obliterative restrictive endomyocardial fibrosis (EMF) that underwent complete surgical decortication with simultaneous mitral and tricuspid bioprosthetic valve replacement in 1982 and underwent successful reoperation for the structural failure of biological prostheses after 25 years.

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.

Simultaneous mitral valve and pectus excavatum repair with a Nuss bar

We present the successful management of an interesting case of a single-stage combined mitral valve repair plus repair of the pectus excavatum with a Nuss bar.

Simultaneous Right and Left Heart Real-Time, Free-Breathing CMR Flow Quantification Identifies Constrictive Physiology

The purpose of this study was to evaluate the ability of a novel cardiac magnetic resonance (CMR) real-time phase contrast (RT-PC) flow measurement technique to reveal the discordant respirophasic changes in mitral and tricuspid valve in flow indicative of the abnormal hemodynamics seen in constrictive pericarditis (CP). Definitive diagnosis of CP requires identification of constrictive hemodynamics with or without pericardial thickening. CMR to date has primarily provided morphological assessment of the pericardium. Sixteen patients (age 57 ± 13 years) undergoing CMR to assess known or suspected CP and 10 controls underwent RT-PC that acquired simultaneous mitral valve and tricuspid valve inflow velocities over 10 s of unrestricted breathing. The diagnosis of CP was confirmed via clinical history, diagnostic imaging, cardiac catheterization, intraoperative findings, and histopathology. Ten patients had CP, all with increased pericardial thickness (6.2 ± 1.0 mm). RT-PC imaging demonstrated discordant respirophasic changes in atrioventricular valve inflow velocities in all CP patients, with mean ± SD mitral valve and tricuspid valve inflow velocity variation of 46 ± 20% and 60 ± 15%, respectively, compared with 16 ± 8% and 24 ± 11% in patients without CP (p < 0.004 vs. patients with CP for both) and 17 ± 5% and 31 ± 13% in controls (p < 0.001 vs. patients with CP for both). There was no difference in atrioventricular valve inflow velocity variation between patients without CP compared with controls (p > 0.3 for both). Respiratory variation exceeding 25% across the mitral valve yielded a sensitivity of 100%, a specificity of 100%, and an area under the receiver-operating characteristic curve of 1.0 to detect CP physiology. Using a cutoff of 45%, variation of transtricuspid valve velocity had a sensitivity of 90%, a specificity of 88%, and an area under the receiver-operating characteristic curve of 0.98. Accentuated and discordant respirophasic changes in mitral valve and tricuspid valve inflow velocities characteristic of CP can be identified noninvasively with RT-PC CMR. When incorporated into existing CMR protocols for imaging pericardial morphology, RT-PC CMR provides important hemodynamic evidence with which to make a definite diagnosis of CP.

Left atrial reverse remodeling following surgical revascularization and mitral valve repair

The results from the analysis of the preoperative cardiac status and postoperative period of 140 patients with ischemic heart disease and significant ischemic mitral regurgitation (IMR) were presented. In 71 patients, surgical revascularization and simultaneous mitral valve repair was done (group A). The rest 69 patients were subjected to isolated coronary artery bypass procedure (group B). Control transthoracic echocardiographic examinations were performed before discharge from hospital and postoperative follow-up (mean 20 months) was accomplished. The emphasis was made on the left atrial morphology prior to the intervention as well as on the gradual changes following the two types of procedures. It is established that immediately after isolated revascularization, left atrial size decreases, but slightly and temporarily. Later on, dilatation goes on and at patient`s follow-up its mean size is bigger than preoperatively. On the other hand, combined coronary revascularization and mitral valve repair result in more prominent and durable left atrial reduction. Based on this a conclusion can be drawn that combined surgical revascularization and mitral repair may trigger a process of significant left atrial reverse remodeling thus lowering the risk of subsequent cardiovascular accidents.

Simultaneous Robotic-Assisted Mitral Valve Repair and Percutaneous Coronary Intervention

We present a case report of a robotic-assisted mitral valve repair with simultaneous percutaneous coronary intervention. A 58-year-old man presented with New York Heart Association class III symptoms from severe mitral regurgitation and significant stenosis of the right coronary artery. In a hybrid operating theater, the patient underwent placement of a bare metal stent in the right coronary artery followed immediately by robotic-assisted mitral valve repair. Both procedures were successful and occurred in a timely fashion. The patient experienced no immediate postoperative complications and was discharged home on postoperative day 5. At 2-week follow-up, he had returned to his normal activities of daily living and at 1 year remained asymptomatic. This case report demonstrates the benefits of minimally invasive robotic mitral valve repair in allowing for successful repair, early postoperative return to activity, minimal incision pain, and high patient satisfaction. It further highlights the potential benefit of a hybrid operating theater in allowing surgical and percutaneous coronary intervention procedures to be delivered in a safe and efficient manner.

Simultaneous Robotic-Assisted Mitral Valve Repair and Percutaneous Coronary Intervention

Simultaneous Robotic-Assisted Mitral Valve Repair and Percutaneous Coronary Intervention

Simultaneous Apicoaortic Conduit Placement and Mitral Valve Replacement in an Adolescent with Porcelain Aorta, Aortic Stenosis, and Mitral Stenosis

We describe the treatment of a 16-year-old girl with calcific aortic stenosis, porcelain aorta, and calcific mitral stenosis with insufficiency using a valved apicoaortic conduit and mitral valve prosthesis. Both valve replacements were porcine bioprostheses, and the apicoaortic conduit was implanted without the use of cardiopulmonary bypass. In cases in which the degree of aortic calcification pre-empts manipulation of the coronary ostia, an apicoaortic conduit may offer a viable solution to improve left ventricular outflow obstruction.

Simultaneous mitral valve and lung surgery for complicated endocarditis

A 48-year-old man developed severe sepsis after a chest trauma. The patient suffered from presternal and cervical abscesses, mediastinitis, septic arthritis of the right shoulder, abscesses in the right lung lower lobe and severe infective endocarditis of the mitral valve. After subcutaneous and mediastinal abscess-drainage, hemodynamic stabilization, and control of sepsis, biological mitral valve replacement and concomitant resection of the right lower lobe were performed. Restoration of the shoulder could be performed 22 days later. The patient was discharged after 4 weeks and is well 1 year after surgery.

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.

Surgical treatment of anomalous origin of coronary artery from the pulmonary artery

Anomalous origin of coronary artery from the pulmonary artery is a rare congenital cardiac malformation with a mortality rate of up to 90% within the first year of life without surgical intervention. Direct implantation of the anomalous coronary artery (ACA) into the aorta is successful in early life, but it may have increased surgical difficulty and risk with age. This retrospective study summarized our operative experience in direct implantation for treatment of this coronary anomaly in pediatric and adult patients. From August 2000 to January 2003, 4 consecutive patients aged from 9 months to 41 years underwent dual coronary repair. Among them, two children and one infant with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) and one adult was anomalous origin of right coronary artery from the pulmonary artery (ARCAPA). Coronary arteries were directly implanted into the ascending aorta in 4 patients. In a boy with ALCAPA associated with moderate mitral insufficiency (MI), whose ACA arose remotely from the ascending aorta, we created a tube-shaped graft using part of the pulmonary arterial wall in continuity with the origin of the left coronary artery (LCA). Concomitant moderate MI was repaired in 2 patients, including this boy, after a dual-coronary repair. All patients survived. There were no hospital or late deaths and no major complications as well. Echocardiography revealed that the left ventricular (LV) function including LV end-diastolic dimension (EDD) and ejection fraction (EF) was markedly improved at hospital discharge. At 3 - 6 years follow-up after surgery all patients were asymptomatic and currently in NYHA class I. The best results are achieved with direct implantation of the ACA into the ascending aorta and simultaneous mitral valve repair if needed. Direct implantation is feasible in pediatric and adult patients with ALCAPA or ARCAPA including the coronary artery in a location remote from the ascending aorta. It is a good procedure to lengthen the ACA by creating a tube-shape graft using part of the pulmonary arterial wall in continuity with the origin of ACA.

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

Moderate Ischemic Mitral Regurgitation: to Treat or not to Treat?

There is consensus of opinion that patients with moderately severe to severe (grade 3+ or 4+) ischemic mitral regurgitation (IMR) should undergo mitral valve surgery at the time of coronary artery bypass grafting (CABG), while trace to mild (grade 1+) IMR can probably be left alone. However, the management of moderate (grade 2+) IMR continues to be a subject of constant debate and controversy. In particular, as techniques of valvular repair continue to be refined; many surgeons have advocated mitral valve repair and concomitant CABG for these patients. Others, however, have continued to treat these patients with revascularization alone and close postoperative observation of the mitral valve. In their opinion, degree of concomitant mitral valve dysfunction in this group of patients does not justify the increased operative risks associated with simultaneous mitral valve correction. We are currently practicing in an era of evidence-based medicine (EBM) in which clinical decision-making has to be guided by current best available evidence from scientific, clinical studies. This review article attempts to tackle this controversial issue and find the best approach of dealing with moderate IMR at the time of CABG by evaluating current best available evidence.

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.

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.

Midterm results of aortic valve repair with the pericardial cusp extension technique in rheumatic valve disease

Background The encouraging results of valve repair in the atrioventricular valves have influenced a decision about aortic valve (AV) reconstruction. We report our experience with pericardial cusp extension to repair rheumatic AV disease. Methods From 1993 to 1998, 46 patients (25 women, 21 men) with a mean age of 31.5 ± 12.2 years (range, 15 to 58 years) underwent AV repair. Twenty-two (47.8%) patients had moderate and 24 (52.2%) had severe aortic insufficiency (AI). Severe cusp retraction was repaired with glutaraldehyde-treated autologous pericardium. Twenty-one patients had more than one maneuver (mean, 1.8) to attain competence besides augmentation, which consisted of the release of stenotic commissures (in 11 cases), thinning of the AV cusps (in 10 cases), and resuspension of the cusps (in 17 cases). Simultaneous mitral valve repair was performed on 17 patients. Eight patients received triple valve reconstruction. Results There was no early mortality. Thirty patients no longer had AI with any significant transvalvular gradients. Five patients were followed with mild residual AI, and 2 patients with moderate AI not requiring reoperation. Nine patients developing severe AI required AV replacement with a reoperation rate 19.6% (4.26%/patient-year). The mean interval between repair and reoperation was 28.2 ± 18.3 months (range, 3 to 58 months). The mean observation time was 4.6 ± 3 years (211.6 patient-years). Late mortality rate was 2.2% with 1 patient. The significant negative predictors of aortic reoperation determined by univariate analysis were preoperative New York Heart Association class ( p = 0.002) and postoperative severe AI ( p < 0.001). Cox hazard studies identified that all risk factors were insignificant for aortic reoperation. The actuarial rate of freedom from aortic reoperation was 76.1% ± 7% at 7.5 years. Conclusions Although AV repair by extension with pericardium is worth considering with an acceptable solution to achieve a good geometry from unequal cusps, especially in young rheumatic patients for preservation of the native AV, the patients should be followed periodically for reoperation risk.

Anomalous coronary artery origin from the pulmonary artery: correlation between surgical timing and left ventricular function recovery

Background This study investigates the correlation between surgical timing and 15-year longitudinal left ventricular and mitral valve function, after repair of anomalous coronary artery origin from the pulmonary artery. Methods Between 1987 and 2002, 31 patients (median age, 7.1 months) underwent repair for anomalous origin of the left (n = 28), right (n = 2), or both (n = 1) coronary arteries from the pulmonary artery. Repair was accomplished by subclavian interposition in 5 patients, intrapulmonary tunnel in 12, and direct aortic reimplantation in 14. Primary mitral valve repair was never associated with coronary revascularization. Total follow-up was 186.4 patient-years (mean, 77.2 months). Results Fifteen-year actuarial survival was 92.9% ± 4.9% for coronary transfer, 40.0% ± 21.9% for subclavian interposition, and 89.9% ± 7.5% for intrapulmonary tunnel ( p = 0.019). Five patients required further intervention for supravalvular pulmonary stenosis (n = 3), baffle leak (n = 1), and mitral valve replacement (n = 1). Coronary transfer allowed best freedom from long-term reoperation (92.3% ± 7.4%). Left ventricular shortening fraction increased from 17.3% ± 6.3% before operation to 34.1% ± 4.6% at last follow-up ( p < 0.01). Regression analysis demonstrated a linear relationship between age at repair and shortening fraction recovery ( r 2 = 0.573, p < 0.01). Patients younger than 6 months of age showed worse preoperative shortening fraction (15.9% ± 5.2%) and best longitudinal shortening fraction recovery (36.4% ± 5.1%; p < 0.001). Major improvement in mitral valve function was observed within 1 year from surgery in 90.4% of survivors. Conclusions Repair of anomalous coronary artery origin from the pulmonary artery in younger symptomatic infants offers the best potential for recovery of left ventricular function, despite a worse initial presentation. Coronary transfer is associated with superior long-term survival and freedom from reoperation. Most patients with patent two-coronary repair will recover normal mitral valve function; therefore, simultaneous mitral valve surgery seems unwarranted.

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.

Combined Minimally Invasive Mitral Valve Repair and Direct Coronary Artery Bypass: A New Alternative to Sternotomy

A case is presented in which significant single-vessel coronary artery disease and severe mitral valve regurgitation were successfully managed using combined minimally invasive direct coronary artery bypass and mitral valve repair. Although the management of coronary artery disease with simultaneous mitral valve disease has traditionally been approached using a median sternotomy, this combined minimally invasive approach led to a successful outcome and may serve as an alternative methodology for patients who are appropriate candidates.

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.