Predictors of Unfavourable Outcomes in Children and Adolescents Submitted to Surgical Mitral Valvuloplasty Secondary to Chronic Rheumatic Heart Disease / Preditores de Desfecho Desfavorável em Crianças e Adolescentes Submetidos à Valvoplastia Mitral Cirúrgica Secundária a Cardiopatia Reumática Crônica

Abstract Background: Mitral valve repair in paediatric patients with chronic rheumatic heart disease is superior to valve replacement and has been used with good results. Objective: To identify predictors of unfavourable outcomes in children and adolescents submitted to surgical mitral valvuloplasty secondary to rheumatic heart disease. Methods: Retrospective study of 54 patients under the age of 16 operated at a tertiary paediatric hospital between March 2011 and January 2017. The predictors of risk for unfavourable outcomes were: age, ejection fraction, degree of mitral insufficiency, degree of pulmonary hypertension, presence of tricuspid insufficiency, left chamber dilation, preoperative functional classification, duration of cardiopulmonary bypass, duration of anoxia, presence of atrial fibrillation, and duration of vasoactive drug use. The outcomes evaluated were: death, congestive heart failure, reoperation, residual mitral regurgitation, residual mitral stenosis, stroke, bleeding and valve replacement. For all analyzes a value of p < 0.05 was established as significant. Results: Of the patients evaluated, 29 (53.7%) were female, with an average of 10.5 ± 3.2 years. The functional classification of 13 patients (25%) was 4. There was no death in the sample studied. The average duration of extracorporeal circulation was 62.7±17.8 min, and anoxia 50 ± 15.7 min. The duration of use of vasoactive drug in the immediate postoperative period has an average of 1 day (interquartile interval 1-2 days). The logistic regression model was used to evaluate the predictive variables for each unfavourable outcome. The duration of use of vasoactive drug was the only independent predictor for the outcomes studied (p = 0.007). Residual mitral insufficiency was associated with reoperation (p = 0.044), whereas tricuspid insufficiency (p = 0.012) and pulmonary hypertension (p = 0.012) were associated with the presence of unfavourable outcomes. Conclusion: The duration of vasoactive drug use is an independent predictor for unfavourable outcomes in the immediate and late postoperative period, while residual mitral regurgitation was associated with reoperation, and both tricuspid regurgitation and pulmonary hypertension were associated with unfavourable outcomes.

Resumo Fundamento: A plastia da valva mitral, em pacientes pediátricos com cardiopatia reumática crônica, é superior à troca valvar e vem sendo utilizada com bons resultados. Objetivo: Identificar variáveis preditoras de desfecho desfavorável em crianças e adolescentes submetidos à valvoplastia mitral cirúrgica secundária à cardiopatia reumática. Métodos: Estudo retrospectivo em 54 pacientes menores de 16 anos, operados em um hospital pediátrico terciário entre março de 2011 e janeiro de 2017. As variáveis preditoras de risco para desfecho desfavorável foram: idade, fração de ejeção, grau de insuficiência mitral, grau de hipertensão pulmonar, presença de insuficiência tricúspide, dilatação de câmaras esquerdas, classe funcional no pré-operatório, tempo de circulação extracorpórea, tempo de anóxia, presença de fibrilação atrial e tempo de uso de droga vasoativa. Os desfechos avaliados foram: morte, insuficiência cardíaca congestiva, reoperação, insuficiência mitral residual, estenose mitral residual, acidente vascular cerebral, sangramento e troca valvar. Para todas as análises foi estabelecido valor de p < 0,05 como significante. Resultados: Dos pacientes avaliados, 29 (53,7%) eram do sexo feminino, com média de idade de 10,5 ± 3,2 anos. A classe funcional de 13 pacientes (25%) foi 4. Não houve morte na amostra estudada. O tempo médio de circulação extracorpórea foi de 62,7 ± 17,8 minutos e de anóxia 50 ± 15,7 minutos. O tempo de uso de droga vasoativa no pós-operatório imediato teve mediana de 1 dia (intervalo interquartil 1-2 dias). O modelo de regressão logística foi utilizado para avaliar as variáveis preditoras para o desfecho desfavorável. O tempo de uso de droga vasoativa foi o único preditor independente para os desfechos estudados (p = 0,007). A insuficiência mitral residual foi associada à reoperação (p = 0,044), enquanto a insuficiência tricúspide (p = 0,012) e a hipertensão pulmonar (p = 0,012) se associaram à presença de desfechos desfavoráveis. Conclusão: O tempo de uso de droga vasoativa é um preditor independente para desfechos desfavoráveis no pós-operatório imediato e tardio, enquanto insuficiência mitral residual se associou à reoperação e tanto a insuficiência tricúspide quanto a hipertensão pulmonar foram associadas a desfechos desfavoráveis.

OPCABG for moderate cimr in elderly patients: a superior option?

Abstract Objective: To compare the early and late outcomes of off-pump coronary artery bypass grafting and coronary artery bypass graft + mitral valve repair in elderly patients with moderate chronic ischemic mitral regurgitation. Methods: One hundred and fifty elderly (age > 70 years) patients with moderate chronic ischemic mitral regurgitation who underwent off-pump coronary artery bypass grafting (n=95) or coronary artery bypass graft + mitral valve repair (n=55) between January 2007 and December 2014 were studied. They were subdivided according to presence or absence of high operative risk. Peri-operative variables and early operative outcomes were retrospectively studied. Survival, mitral regurgitation grade, and functional outcomes were prospectively analysed. Results: Both groups were comparable in terms of age (P=0.23), sex (P=0.74), left ventricle ejection fraction (P=0.6) and preoperative functional class (P=0.52). The mean number of grafts for off-pump coronary artery bypass grafting group was 3.14 and coronary artery bypass graft + mitral valve repair was 3.21. Off-pump coronary artery bypass grafting group had statistically significant better early operative outcomes i.e perioperative blood transfusions, intraaortic balloon pump usage, arrhythmias, renal dysfunction, liver dysfunction, sepsis, mean hours of ventilation, intensive care unit stay and operative mortality. On a prospective follow up of 5±2.33 years (1-9 years), coronary artery bypass graft + mitral valve repair in low operative risk subgroup had better improvements in mitral regurgitation grade than off-pump coronary artery bypass grafting. Both groups had similar improvements in functional class and cumulative survival was also comparable (63.2% vs. 54.5%). Conclusion: Off-pump coronary artery bypass grafting is a safer alternative to coronary artery bypass graft + mitral valve repair with better early operative outcomes and comparable late survival and functional outcomes in elderly patients with moderate chronic ischemic mitral regurgitation, especially those with higher operative risk.

Prospective evaluation of the mid-term results of posterior mitral annuloplasty using autologous pericardium for mitral valve insufficiency / 中国医师杂志

Objective To prospectively evaluate the mid-term results of mitral annuloplasty using autologous pericardium for mitral valve insufficiency.Methods From April 2004 to December 2011,48 patients underwent mitral annuloplasty using autologous pericardium,the average length of pericardial strips was (51.9 ±2.8)cm.Carpentier classification was class Ⅰ in 5 cases,class Ⅱ in 41 cases,and class Ⅲ in 2 cases.The mitral valve repair techniques included quadrangular resection in 30 cases,valve repair in 7 cases,chordae transposition in 4 cases,edge to edge technique in 2cases,and artificial chordae tendineae in 3 cases.Concomitant procedures included one case arotic valve replacement,11 cases tricuspid valve repair,9 cases coronary artery bypass grafting,1 case coronary artery muscle bridge resection,and 1 case permanent pacemaker implant.Datum on long-term outcomes were obtained by questionnaires and by phone interview [average follow-up time (62.2 ± 21.3) months].Results Compared with preoperative datum,the diameters of left ventricular end diastolic diameter (LVDD) and left atrial diameter (LAD) examined by echocardiography show significant reduction in postoperative [(58.6 ± 1.7) mm vs (45.1 ± 1.3) ram,t =12.85,P ＜0.01 ; (50.6 ± 1.6)mm vs (38.0 ± 1.4)ram,t =9.58,P ＜0.01].There was early postoperative death in one case,cerebral infarction in one case,but none of patients died in late postoperative period.One patient had moderate mitral valve regurgitation in long-term follow-up.None of patients had redo operation and hemolytic complications.Conclusions Mitral annuloplasty using an autologous pericardium was an acceptable technique with low anticoagulation complications,permanent,well left ventricular function maintenance,and an economic method.