Pathology and etiology of 110 consecutively removed aortic valves.

OBJECTIVES: To study the pathology and determine the etiology and prevalence of aortic valve disease from surgically removed aortic valve specimens. MATERIAL AND METHOD: All the native surgically excised aortic valves (AV) received from June 1997 to March 1999 (22 months) were studied macroscopically including cuspal measurements and microscopically. By preoperative echocardiographic and macroscopic studies, they were classified into functional disorders of predominant aortic stenosis (AS), aortic stenosis with regurgitation (AS-AR) and predominant aortic regurgitation (AR). The patients' medical records were reviewed and the clinical information was extracted. The etiology was determined according to the macroscopic, microscopic and clinical findings. RESULTS: Among 110 AV (76 isolated AV and 34 with concomitant mitral valves from patients aged 15-96 years, mean age 47.54 years; male:female = 1.39:1) there were 25 AS (22.73%), 34 AS-AR (30.91%) and 51 AR (46.36%) cases. Eighty-four (76.36%) were tricuspid, 16 (14.54%) were bicuspid and 10 were undetermined. Cuspal measurements of each disease were provided and compared. All AS specimens were related to moderate to severe calcification and causes included postinflammatory disease (14 cases, 56%; age range 38-67 years, mean age 53.29 years, male:female = 0.56:1), degenerative calcific change (11 cases, 44%, age range 56-76 years, male:female = 1.2:1; mean age 69 years of 5 tricuspid AV and 60.83 years of 6 bicuspid AV). In AS-AR, 29 cases (85.29%; mean age 47.10 years; male:female = 1.23:1) were attributable to postinflammatory disease and 5 cases (mean age 70.20 years; male:female = 1.5:1) to degenerative calcific change. In pure AR, there were 21 cases (age range 15-65 years, mean age 29.76 years) of postinflammatory disease, 14 cases of infective endocarditis (IE) and postIE (age range 20-63 years, mean age 42.21 years; all 10 IE cases contained gram positive cocci), 1 case (age 55 years) of bicuspid calcific change, 8 cases of AV with dilated valve ring, 5 cases of miscellaneous causes and 2 cases of indeterminate etiology. Aschoff bodies were found in 3 AR cases. Four of 18 postinflammatory AS-AR and 4 of 14 postinflammatory disease AR cases had past history of rheumatic fever. One postinflammatory AS also had infective endocarditis from gram positive cocci without clinical sign. Severe degenerative calcific change had a higher incidence of underlying diabetes (3 of 15 cases, 20%), hypertension (8 of 14 cases, 57.14%) and dyslipoproteinemia (9 of 13 cases, 69.23%) in comparison with 3.37% (3/89) for diabetes, 9.09% (8/88) for hypertension and 30.99% (22/71) for dyslipoproteinemia in other AV diseases in combination. CONCLUSION: The three common causes of severe AV functional disorders were postinflammatory disease (58.18%), degenerative calcific change (15.45%) and IE-postIE (12.72%). Underlying diseases of severe degenerative calcific change included hypertension, dyslipoproteinemia and diabetes. Macroscopic and microscopic examinations together with clinical information, echocardiographic findings and operative details are important in evaluating the etiology of valvular diseases especially in severely calcified specimens.

Stent placement compared with balloon angioplasty for obstructed coronary artery disease in Thai elderly patients: initial result and 6 months follow-up.

Percutaneous Old Balloon Angioplasty (POBA) is accepted worldwide for the treatment of obstructive coronary artery disease because this technique is safe, and quick and the patient may return to work earlier than with bypass surgery (particularly elderly patients). But the major problem with POBA is restenosis which occurs between 20-40 per cent. Stent placement has been reported to reduce the restenosis rate to 10-20 per cent. OBJECTIVE: The purpose of this study was to compare the effects of stent placement with those of balloon angioplasty on clinical and angiographic outcomes in elderly Thai patients with obstructive coronary artery disease. METHOD: The study was a randomized controlled trial. The sample size was 45 lesions in 42 patients who were assigned into 2 groups; 23 in the balloon angioplasty group and 22 in the stent placement group (Crown Stent). Clinical information and coronary angiography were recorded and performed at the time of the index procedure and six months later. RESULTS: There was 100 per cent procedural success in 22 lesions treated in the stent group and 82.6 per cent in the 23 lesions treated in the balloon angioplasty group. Patients in the stent group had a lesser degree of stenosis immediately after the procedure (8.78 +/- 8.63 vs 30.92 +/- 9.01%, p < 0.001) and a greater minimal luminal diameter (MLD) (3.04 +/- 0.44 vs 2.15 +/- 0.33 mm, p < 0.001). There were no major complications in either group during the procedure or during their hospital stay. These were not maintained at the six months follow-up. (26.88 +/- 16.23 vs 33.82 +/- 14.63 mm, p = 0.19, 2.28 +/- 0.67 vs 2.01 +/- 0.51 mm, p = 0.17) for the degree of stenosis and the MLD respectively. The restenosis rate, which was the primary endpoint of the study, was 4.5 per cent in the stent group and 21 per cent in the balloon angioplasty group (p = 0.10). CONCLUSIONS: Stenting in Thai elderly ischemic patients has a higher procedural success rate when compared with balloon angioplasty. The restenosis rate of stenting is also lower than that of balloon angioplasty but did not reach statistical significance. However, both techniques had no major complications either during the procedure or in-hospital.

Efficacy and safety of percutaneous metallic mitral valvuloplasty in rheumatic mitral stenosis at Siriraj Hospital.

Mitral stenosis is an important problem that leads to heart failure and stroke in Thailand. The options of treatment at present are either surgical or balloon mitral commissurotomy. However, the cost of balloon is very expensive. To reduce the expense of the procedure, the authors prospectively did a study using a new device called the metallic valvulotome in symptomatic severe mitral stenosis to assess the safety, feasibility and immediate outcomes. Fifty-seven patients were included in the study. The successful outcome achieved by the metallic valvulotome was 96.2 per cent in patients in whom the procedure was actually performed. The mean transmitral gradient, left atrial pressure and pulmonary artery pressure were significantly decreased and the mitral valve area was also significantly increased. Three cases failed the procedure due to inappropriate position of the septal puncture. No death occurred in the study and complications of the procedure included only two cases of hemopericardium. In the future, it is believed that this new innovative device will provide improvement and reduce the cost of the procedure in patients with severe mitral stenosis.

Pathology and etiology of 154 mitral valve abnormalities surgically removed in Siriraj Hospital.

Objectives: To study the pathology, determine the etiology and prevalence of mitral valve disease from surgically removed mitral valve specimens. Materials and Methods: All the native surgically excised mitral valves (MV) received during June 1997 to March 1999 (22 months) were studied macroscopically and microscopically. By preoperative echocardiographic and macroscopic studies, they were classified into functional disorders of predominant mitral stenosis (MS), mitral stenosis with regurgitation (MS-MR) and predominant mitral regurgitation (MR). The patients' medical records were reviewed and the clinical information was extracted. The etiology was determined according to the macroscopic, microscopic and clinical findings. Results: Among 154 MV (120 isolated MV and 34 with concomitant aortic valves from patients aged 7-79 years, mean age 43.98 years) there were 68 MS (44.16%), 30 MS-MR (19.48%) and 56 MR (36.36%) cases. All MS cases (age range 10 - 65 years, mean age 45.37 years, male : female = 1:1.51), all MS-MR cases (age range 20 - 66 years, mean age 40.03 years; male : female = 1:1.31) and 20 of 56 MR cases (35.71% of MR cases, 12.98% of total cases, age range 8 - 63 years, mean age 31.21 years, male : female = 1.22 : 1) were attributable to post-inflammatory disease. Prominent calcification occurred in 76.47% of MS, 70% of MS - MR and 25% of post-inflammatory disease MR cases. Moderate to marked neovascularization was found in 34.32% of MS, 56.66% of MS-MR and 65% of MR cases. Aschoff bodies were found in 1 MS and 4 MR cases. Eight of 39 MS (20.51%), 4 of 16 MS-MR (25%) and 6 of 13 (46.15%) post-inflammatory disease MR cases had past history of rheumatic fever. Other causes of pure MR included floppy valves (18 cases, 32.14% of MR cases, age range 40 - 79 years, mean age 61.72 years, male : female = 3.5 : 1;15 cases with chordal rupture), infective endocarditis (IE) [7 cases including one with post-inflammatory disease MS and one post-IE (age range 20 - 50 years, mean age 34.12 years, male : female = 6 : 1) with gram positive cocci in all IE], papillary muscle necrosis (1 case), ruptured necrotic papillary muscle (1 case), miscellaneous and indeterminate cause (4 cases). In comparison with post-inflammatory MR, posterior leaflet in floppy MR had longer basal-free edge length (mean basal-free edge length of floppy valve = 16.65 mm. p <.0001)and more frequent chordal rupture. Among MS and MS-MR post-inflammatory valves, 90.81% were completely excised whereas partial specimens were received in 40% of post-inflammatory MR, 61% of floppy valves and 50% of miscellaneous cases. Conclusion: Post-inflammatory disease (presumably rheumatic fever associated) of MV is still a main valvular heart disease in Thai patients undergoing valvular operation as it accounted for 75.97% of all MV specimens. In pure MR, the three most common causes were post-inflammatory disease, floppy valve and infective endocarditis. Macroscopic and microscopic examinations together with clinical information, echocardiographic findings and operative details are important in the evaluation of the etiology of valvular disease especially in partial specimens.