Reoperative valve replacement in patients undergoing cardiac reoperation: a report of 104 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To review the experience of reoperative valve replacement for 104 patients.</p><p><b>METHODS</b>From January 2002 to December 2009, 104 patients underwent heart valve replacement in reoperations, accounting for 2.92% of the total patient population (3557 cases) who had valve replacement during this period. In this group, 53 male and 51 female patients were included with a median age of 46 years (ranged from 13 to 72 years). The reasons of reoperation included 28 cases suffered from another valve lesion after valve replacement, 10 cases suffered from valve lesion after mitral valvuloplasty, 19 cases suffered from perivalvular leakage after valve replacement, 18 cases suffered from valve lesion after previous correction of congenital heart defect, 7 cases suffered from bioprosthetic valve decline, 10 cases suffered from prosthetic valve endocarditis, 9 cases suffered from dysfunction of machine valve, and 3 cases suffered from other causes. The re-operations were mitral and aortic valve replacement in 2 cases, mitral valve replacement in 59 cases, aortic valve replacement in 24 cases, tricuspid valve replacement in 16 cases, and Bentall's operation in 3 cases. The interval from first operation to next operation was 1 month-19 years.</p><p><b>RESULTS</b>There were 8 early deaths from heart failure, renal failure and multiple organ failure (early mortality 7.69%). Major complications were intraoperative hemorrhage in 2 cases, re-exploration for mediastinal bleeding in 2 cases and sternotomy surgical site infection in 1 case. Complete follow-up (3 months-7 years and 2 months) was available for all patients. Two patients died, one patient died of intracranial hemorrhage, and another cause was unknown.</p><p><b>CONCLUSION</b>Satisfactory short-term and long-term results can be obtained in reoperative valve replacement with appropriate timing of operation control, satisfactory myocardial protection, accurate surgical procedure and suitable perioperative treatment.</p>

Aortic valve replacement: the experiences of 1026 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To study the changes in pathogenic causes and the prognosis of aortic valve replacement (AVR).</p><p><b>METHODS</b>The clinical data of 1026 patients undergoing AVR from December 1980 to December 2006 were analyzed retrospectively. The mortality, morbidity, changes in pathogenic causes and risk factors were analyzed.</p><p><b>RESULTS</b>The postoperative mortality and complication morbidity were 4.3% and 10.6% respectively within 30 days followed operation. Main causes of operative death were heart failure, multi organ failure and endocarditis. The major risk factors for operative death were left ventricle ejection fraction less than 0.4, endocarditis, valve regurgitation and emergency operation before AVR. Late mortality was 0.54% patient-year (3.4%), most of whom died of heart failure, endocarditis and arrhythmias. Patients underwent reoperation 0.22% patient-year (1.4%), with the causes of endocarditis and perivalvular fistula.</p><p><b>CONCLUSIONS</b>Morbidity of rheumatic damage in aortic valve has decreased, while valve degeneration has increased gradually in the recent years. Avoiding prosthesis-patient mismatch, good postoperatively guide and prevention of endocarditis can improve the prognosis of AVR.</p>

Experiences on surgical treatment of severe aortic valve stenosis: a report of 171 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the experiences on surgical treatment of severe aortic valve stenosis.</p><p><b>METHODS</b>From December 1990 to December 2006, 171 patients with severe aortic valve stenosis underwent aortic valve replacement (AVR). There were 135 males and 36 females aged from 10 to 75 years old, with a mean of (45.8 +/- 15.6) years old. The intervals between the first episode of exertion dyspnea and administration to operation were 2 months to 52 years. The pathological lesions of the group were rheumatic aortic valve stenosis in 75 cases, calcified aortic stenosis in 66 cases, bicuspid aortic valve in 26 cases and other congenital aortic valve stenosis in 4 cases. One hundred and twenty-four patients underwent AVR, 7 AVR combined with replacement of the ascending aorta, 5 AVR with coronary artery bypass grafting, 19 AVR with mitral valve plasty (MVP), 8 AVR with plasty of the ascending aorta and 8 AVR with enlargement of the aortic root.</p><p><b>RESULTS</b>The averaged operation time was (4.4 +/- 0.6) h. Cardiopulmonary bypass (CPB) time was (124.7 +/- 38.5) min and the aorta clamp time was (78.3 +/- 21.7) min. The averaged blood loss during operation was (754.5 +/- 518.4) ml. All the procedures were successfully performed and all patients were weaned off CPB uneventfully. The indication of early complications was 12.3% (21/171), including low cardiac output syndrome in 7 cases, multi-organ failure in 3 cases, endocarditis in 1 case, renal dysfunction in 4 cases, ventricular fibrillation in 1 case, excessive bleeding in 2 cases, III atrial-ventricular block in 2 cases, and mediastinal infection in 1 case. The total mortality was 5.8% (10/171) with the main causes as cardiac failure for 4 cases, arrhythmia for 1 case, multi-organ failure for 4 cases, and infectious endocarditis for 1 case.</p><p><b>CONCLUSIONS</b>Successful management of severe aortic valve stenosis requires sophisticated surgical techniques and experienced peri-operative care. Satisfactory results can be achieved if valve replace surgery is performed adequately.</p>

Study on expression of mineralocorticoid receptor in human atria during atrial fibrillation / 中华心血管病杂志

<p><b>OBJECTIVE</b>To investigate the mRNA and protein expression of mineralocorticoid receptor (MR) in patients with atrial fibrillation.</p><p><b>METHODS</b>Twenty-five patients with rheumatic heart valve disease, 12 in sinus rhythm and 13 in chronic atrial fibrillation (>or= 6 months), underwent transthoracic echocardiography and right and left atrial lateral wall tissue samples were obtained from these patients during mitral/aortic valve replacement operation. Realtime quantitative PCR and Western blot were used to determine the mRNA and protein expression of MR in atria specimens. The distribution of MR in human atria was analyzed by specific immunohistochemical staining.</p><p><b>RESULTS</b>The left atrial diameters increased markedly in atrial fibrillation group compared with that in sinus rhythm group (P<0.01). And the results showed that the level of mRNA and protein of MR were increased significantly in atrial fibrillation group compared with those in sinus rhythm group (P<0.01 or 0.05), whereas the expression of mRNA and protein of MR were found to be no difference between left atria and right atria both in fibrillation and sinus groups (all P>0.05). The special immunohistochemical staining demonstrated that MR was abundant in the human atrial myocardium and MRs were located mainly in the cytoplasm of atrial cells, which were more evident in atrial fibrillation group than those in sinus rhythm group.</p><p><b>CONCLUSION</b>These findings suggested that MRs were upregulated in atrial fibrillation and aldosterone antagonists may be effective in treating atrial fibrillation.</p>

Surgical interventions for complex native valve endocarditis / 中华外科杂志

<p><b>OBJECTIVE</b>To elucidate the early and long-term results of surgical treatment for complex infective endocarditis with prosthetic valve replacement.</p><p><b>METHODS</b>Fifty-seven patients of complex native valve endocarditis, including 25 cases of aortic valve, 16 of mitral valve and 16 of double valves, who underwent operative interventions with prosthetic valve replacement between December 1988 and June 2002, were analyzed retrospectively. Intraoperative findings demonstrated aortic annular abscesses (n = 19), root abscesses (n = 4), mitral posterior annular abscesses (n = 11), myocardial abscesses (n = 6), massive leaflet destruction (n = 32) and valvular vegetations (n = 55). Complex reconstruction of the aortic and mitral annulus was required in 35 patients. Associated procedures included Bentall's procedure (n = 4), aortic valve replacement (n = 21), mitral valve replacement (n = 16) and double valve replacements (n = 16).</p><p><b>RESULTS</b>The operative mortality was 11%. Complications included low cardiac output syndrome, recurrence of endocarditis, multiple organ failure, ventricular arrhythmia, bleeding, mediastinal infection, respiratory insufficiency and heart block. Follow-up was 100% complete at a mean of 5.93 years. There were five late deaths (3 prosthetic valve endocarditis, 2 valve-related). The NYHA functional status recovered to Class I in 17 patients, Class II in 27 and Class III in 2 at 1 year follow-up. Kaplan-Meier analysis showed the 5-year actuarial freedom from reoperation was (84 +/- 3)%, and actuarial survivorship at 5 years was (61 +/- 9)%.</p><p><b>CONCLUSIONS</b>Urgent or even emergency operation is advocated for complex infective endocarditis. Proper intraoperative reconstruction of the aortic and mitral annulus and optimized perioperative management, especially the strategy for prevention of recurrent endocarditis, are of great importance in achieving satisfied early and long-term clinical outcomes.</p>

Long-term results of mitral-aortic valve replacement in 1,154 patients with rheumatic valvular disease / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the early and long-term results after mitral-aortic valve replacement for rheumatic valvular disease and the determinant factors involved and subsequent therapies.</p><p><b>METHODS</b>1 154 patients receiving combined mitral-aortic valve replacement for rheumatic valvular disease from May 1981 to May 2001 were reviewed. The mean age of the patients was 41.48 +/- 10.00 years. Concomitant valve plasty was performed for associated tricuspid organic or significant functional lesions. Lateral tilting disc or bileaflet valve prostheses were used for replacement. New York Heart Association functional status showed Class III or IV in 91.77% of the patients. Moderate to severe pulmonary hypertension occurred in 29.38% of the patients. The duration of follow-up varied from 8 months to 20 years.</p><p><b>RESULTS</b>The hospital mortality was decreased from 6.50% to 4.45%. The 5-, 10- and l5-year survival rates were 89.46% +/- 1.35%, 86.50% +/- l.91% and 67.86% +/- 6.16%, respectively. The 5-, 10- and l5-year thromboembolic event free rates were 97.80% +/- 0.74%, 88.31% +/- 2.20% and 94.08% +/- 2.29%, respectively. the 5-, 10- and l5-year anticoagulant related bleeding free rates were 94.80% +/- 1.09%, 89.32% +/- 2.10% and 83.12% +/- 3.57% respectively. Cardiac functional status returned to Class II in 98% patients and to Class III in 2% during follow-up.</p><p><b>CONCLUSIONS</b>Both left and right ventricular functions may be impaired as a result of rheumatic valvular disease. Tricuspid valve should be explored during surgery and any significant tricuspid annular enlargement and regurgitation showed be corrected in concomitance. Long-acting penicillin regimen is needed for 3 - 5 years for the prevention of rheumatic fever relapse. A low intensity anticoagulant regimen after valve replacement with prothrombin time targeting at 1.5 - 2.0 times is advisable in lessening anticoagulant related bleeding yet optimizing sufficient prevention against thromboembolic complications.</p>

Long-term results of prosthetic mitral valve replacement with home-made tilting disc valve: a report of 125 cases / 中华外科杂志

<p><b>OBJECTIVE</b>To analyze the early and long-term results after mitral valve replacement for rheumatic valvular disease by using home-made tilting disc valve, and the determinant factors involved and subsequent therapies.</p><p><b>METHODS</b>One hundred and five patients, including 31 patients with rheumatic mitral stenosis, 92 patients with mixed mitral stenosis and regurgitation, and 2 patients with bacterial endocarditis, underwent prosthetic mitral valve replacement with home-made tilting disc valve from September 1978 to June 1982. Three patients had a history of mitral commissurotomy, and 5 patients had concomitant functional tricuspid regurgitation. All patients were operated on under cardiopulmonary bypass with implantation of 25 - 29 mm size home-made tilting disc valve prosthesis. The associated functional tricuspid lesions were treated at the same time with modified DeVega's valvuloplasty or Kays bicuspidate valvuloplasty.</p><p><b>RESULTS</b>Eleven patients died during the hospital stay with an early operative mortality of 8.8%. The major causes of the early death were low cardiac output syndrome (4 patients), respiratory failure (2), acute renal failure (2), extrinsic prosthesis dysfunction (1), ventricular arrhythmia (1), and left ventricular rupture (1). Ninety-eight survivors were followed up (total 1,162.2 years) for mean duration of 12.8 years. Eighty-nine patients (78%) survived over 10 years after operation, 58 (51%) over 15 years, and 55 (48%) over 20 years. There were 16 late deaths due to heart failure, anticoagulation related bleeding, thromboembolism and recurrence of rheumatic fever. The survival rates at 10 and 20 years were 82.3% and 51.1% respectively. Among the patients who survived over 20 years, 37 patients had the cardiac functional status returned to Class II, 13 Class III, and Class IV.</p><p><b>CONCLUSIONS</b>Severe post-rheumatic valve deformity may occur in younger patients in China. Long-acting penicillin regimen given for 3 - 5 years for the prevention of rheumatic fever relapse is advocated. A low intensity anticoagulant regimen after mitral valve replacement is advisable in lowering the incidence of anticoagulant related bleeding, while optimizing sufficient protection against thromboembolic complication. Proper operative timing (e.g. when the patient is in sinus rhythm and in NYHA functional class II) is of great importance in achieving satisfied long-term results.</p>