Clinical evaluation of the Björk-Shiley disc valve in the tricuspid position. Long-term results.

Between 1971 and 1981, 1210 Björk-Shiley prostheses were implanted. Of these, 79 were in the tricuspid position, comprising 30 triple valve replacements, 46 mitral plus tricuspid, and 3 isolated tricuspid replacements. The ages ranged from 10-55 years (mean 45 years). Sixty-three patients (80%) were in NYHA grades III or IV preoperatively. Thirteen patients died in hospital after surgery (16.5%). The 66 survivors have been followed for up to 16 years (mean 7.5 years). There have been 37 late deaths (7.5 per patient year). Twelve were valve-related: 4 tricuspid complications, 4 mitral complications, 2 prosthetic endocarditis, 1 aortic leak and 1 anticoagulant-related bleed. Twenty-one late deaths were not valve-related, and 4 causes of death are unknown. Expressed actuarially, survival at 5 years was 68%, and at 10 years, 49.4% +/- 12%. Freedom from valve-related death at 10 years was 80.7% +/- 7%. At last follow-up, 90% of the survivors were in NYHA class 1 or 2 with only modest signs of venous hypertension. The commonest life-threatening complication was obstruction of the tricuspid prosthesis by tissue ingrowth. This occurred in 7 patients (1.4% per patient year) 4 were re-operated upon and survived, 3 died. Doppler echocardiography has been carried out on 27 survivors of whom 5 had abnormal pressure-half times but only 3 of these were symptomatic. This series shows that function of the standard disc Björk-Shiley prosthesis in the tricuspid position compares favourably with other prostheses. The problem of tissue ingrowth can be diagnosed by echo Doppler and reoperation successfully carried out.

Doppler echocardiographic characteristics of normal and dysfunctioning prosthetic valves in the tricuspid and mitral position.

The Doppler echocardiographic characteristics of 70 prosthetic valves in 35 patients are reported. Twenty nine patients had a Björk-Shiley prosthesis in both mitral and tricuspid positions and six had Carpentier-Edwards valves in both sites. Five of the patients had abnormal tricuspid prostheses on the basis of clinical and echocardiographic criteria. Pulsed wave Doppler echocardiography was used in all examinations. The pressure half times for the normal tricuspid prosthetic valves, 105 (40) ms (Björk-Shiley) and 97 (53) ms (Carpentier-Edwards), were significantly longer than those of normal mitral prosthetic valves, 75 (18) ms (Björk-Shiley) and 83 (15) ms (Carpentier-Edwards). The range of pressure half times for the abnormal tricuspid valves (237-530 ms) was distinct from that of the apparently normal tricuspid prosthetic valves (38-197 ms). There was an increase in the peak velocity of the obstructed tricuspid prosthetic valves (1.69 (0.12) m/s) in comparison with normal prostheses (1.06 (0.26) m/s). The normal range of pressure half times for the Björk-Shiley and Carpentier-Edwards valves in the mitral position is not applicable to the same valves in the tricuspid position. The valve appears to function well with very long pressure half times but a pressure half time of greater than 200 ms coupled with a peak velocity of greater than 1.60 ms without significant valve regurgitation indicates tricuspid obstruction of the tricuspid prosthetic valve.

Heart valve replacement with the Björk-Shiley monostrut valve in patients over 60 years of age.

Over a period of five years (1983-88) 210 Björk-Shiley monostrut mechanical tilting disc prostheses were implanted in 176 patients over the age of 60. There were 61 aortic valve replacements, 86 mitral valve replacements and 29 multiple replacements. Patients were aged between 61 and 78 years (mean 65.5 years), 89% were in NYHA grades III and IV preoperatively and 34.6% had had previous cardiac surgery. Concomitant coronary surgery was performed in 15.9%. Early mortality was 9.1%. Follow-up is 100% complete. There were eight late deaths (3.1 per 100 patient years) of which three were valve-related (prosthetic endocarditis 2, periprosthetic leak 1). Actuarial survival at five years is 98% for aortic valve replacement and 93% for mitral valve replacement. There were no major embolic events and four possible minor embolic events. Overall freedom from anticoagulant complications was 88.9% at five years. No deaths occurred because of anticoagulant-related haemorrhage. There were no episodes of valve failure (thrombotic obstruction or mechanical disruption). Six patients were reoperated for complications: two for periprosthetic leak and three for prosthetic endocarditis. These results compare favourably with those of other valve substitutes and justify the continuing use of the Björk-Shiley monostrut tilting disc prosthesis in the elderly.

"Sore buttock syndrome": aseptic inflammation of the gluteal region following cardiopulmonary bypass.

Aseptic inflammation of the gluteal region is a not uncommon cause of early postoperative morbidity following open heart surgery in our patients. We believe that this condition may result from local ischaemia induced by pressure during the period of reduced perfusion on cardiopulmonary bypass. To date, this complication has not been described.

Follow-up after coronary revascularisation in patients with renal transplants.

Seven patients underwent coronary revascularisation 12-145 months (mean: 63.4 months) after receiving cadaver renal transplants. There was no operative mortality and in all patients satisfactory renal function was maintained perioperatively. Hospital stay ranged from 7 days to 10 days (mean: 8 days). During the period of follow-up (5-72 months, mean: 35 months): one patient remained angina-free at 7 months postoperatively; one patient developed meningitis with Listeria monocytogenes 9 weeks after surgery, and died of streptococcal septicaemia 11 weeks later. The other five patients (71.4%) developed recurrence of angina requiring antianginal therapy, and three of them sustained myocardial infarctions. Three patients developed intermittent claudication, two of whom sustained acute leg ischaemia. Two patients developed heart failure, one of whom died 38 months postoperatively. In four patients who were restudied with cardiac catheterisation and coronary angiography (2-17 months postoperatively) there was evidence of progression of the coronary arterial disease in three, although all coronary grafts were patent. Renal function remained satisfactory in 5 patients, and deteriorated in two patients; in one secondary to advanced heart failure; and in one as a terminal event secondary to septicaemia. Although patients with renal transplants can safely undergo open cardiac procedures, the long-term results of coronary surgery are adversely affected by the progressive disease from which they suffer.

Does low-dose propranolol reduce the incidence of supraventricular tachyarrhythmias following myocardial revascularisation? A clinical study.

During 1986, 343 consecutive patients who underwent isolated coronary bypass grafting were given 10 mg of propranolol three times daily for six postoperative weeks to help prevent supraventricular tachyarrhythmias. The incidence of these arrhythmias in this group was compared to that in a similar group of 337 consecutive patients who underwent coronary surgery in 1984 at the same institution and did not receive propranolol. There was no significant difference in the overall incidence of such arrhythmias between the propranolol group (10.8%) and the control group (10.4%). In preoperatively beta-blocked patients, the arrhythmia incidence in the propranolol group (9.9%) was lower than that in the control group (13.8%) but the difference did not achieve statistical significance. The two groups were also similar with respect to the ventricular response rates at the onset of the arrhythmia and the effectiveness of therapeutic intervention. These results suggest that propranolol in the above dosage does not significantly reduce the incidence of supraventricular tachyarrhythmias after myocardial revascularisation.

Heart valve replacement with the Björk-Shiley Monostrut valve: early results of a multicenter clinical investigation.

To evaluate the clinical performance of the Björk-Shiley Monostrut prosthesis, five centers combined their early experience. Between May, 1982, and June, 1985, 537 prostheses were implanted in 486 patients at these centers: 246 patients had aortic valve replacement (AVR), 163 underwent mitral valve replacement (MVR), and 47 had double-valve replacement (DVR). Thirty patients underwent other, more complex procedures. Concomitant cardiac procedures were performed in altogether 25%. Overall hospital (30 days) mortality was 5.1% (3.6% for AVR, 4.3% for MVR, 8.3% for DVR, and 16.6% for other procedures). The patients were followed up at 6- to 9-month intervals from 6 to 48 months (mean follow-up, 33 months). Follow-up was 99.6% complete. Late mortality was 7.2%. The three-year survival rate was 91.0% for AVR, 92.3% for MVR, and 76.2% for DVR. There was no structural failure of the prosthesis. No instances of valve thrombosis and fatal thromboembolism occurred in anticoagulated patients. The three-year incidence of freedom from thromboembolic events (including TIA) was 89.8% for AVR, 94.9% for MVR, and 90.2% for DVR. Preoperative and postoperative data for the assessment of mechanical hemolysis was available in 60% of the patients. The degree of mechanical hemolysis was low and did not change with time. Although the follow-up is still short, the Björk-Shiley Monostrut prosthesis appears to represent an improvement over previous Björk-Shiley models, particularly with regard to durability.

Mechanical versus biological heart valves: a ten-year comparison in a single centre.

Between January 1977 and December 1986, 1606 Bjørk-Shiley tilting disc prostheses (BS) and 1346 Carpentier Edwards porcine prostheses (CE) were implanted in 1300 and 1156 patients, respectively, at the same institution. During the time of implantation, both valves have developed: the BS through standard disc and convexo-concave to monostrut, and the CE valves from standard to supra-annular. Newer valve types were used where applicable as they became available. Preoperative status in respect of age and cardiac rhythm were similar. There were significantly more females (64% BS: 54% CE, P less than 0.001); worse NYHA grade (74% Grade 111 and IV-BS: 56% 111 and IV-CE, P less than 0.001) more closed heart surgery (26% BS: 18% CE, P less than 0.001) and more previous open heart surgery (11.6% BS: 8.9% CE, P less than 0.001) in the BS group. All BS patients were anticoagulated and 49% of mitral CE patients and 7% of aortic CE patients were anticoagulated. There was no significant difference between the two groups in hospital mortality (BS 7.2%: CE 6.3%), late mortality (BS 2.5%/patient year: CE 3.2%/patient year) overall incidence of systemic embolism (BS 1.3%/patient year: CE 1.4/patient year), prosthetic valve endocarditis (BS 0.7%/patient year: CE 0.9%/patient year), valve failure (BS 0.5%/patient year: CE 0.9%/patient year) or peri-prosthetic leak (BS 1.2%/patient year: CE 1.3%/patient year). The incidence of systemic embolism in the aortic position was lower with the BS prosthesis (BS 0.2%/patient year: CE 1.2%/patient year, P less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Endogenous digoxin-like immunoreactive substance in patients undergoing coronary surgery. Preliminary report.

Perioperative digoxin concentrations were measured in 20 unselected adult patients undergoing coronary surgery. None of the patients were receiving treatment with digoxin. A digoxin-like immunoreactive substance was found in 16 patients postoperatively. This substance, if pharmacologically active, may have important clinical implications in the management of patients after open heart surgery.

Stolen heart valves?

A patient having had both aortic and mitral valves replaced complained of triggering shop security alarms, attributing the problem to the prosthetic valves. It was demonstrated that the valves were not the cause of the problem and the source identified.

Valve-related events: a system of definitions.

A system of definitions for valve-related complications is proposed for use in the assessment of the clinical performance of prosthetic heart valves.

Björk-Shiley and Carpentier-Edwards valves. A comparative analysis.

Between January 1977 and December 1982, 986 Björk-Shiley and 744 Carpentier-Edwards valves were implanted in 774 and 620 patients, respectively, at the same institution. All Björk-Shiley patients and 57% of patients with a Carpentier-Edwards valve in the mitral position received long-term anticoagulation. Mean follow-up was 3.2 years (range 0 to 8.8) in the Björk-Shiley patients and 3.5 years (range 0 to 8.2) in the Carpentier-Edwards group. There was no significant difference between the two groups in hospital mortality (Björk-Shiley 7.6%; Carpentier-Edwards 6.0%), overall incidence of embolism (Björk-Shiley 1.4 per 100 patient-years; Carpentier-Edwards 1.6% py), endocarditis (Björk-Shiley 0.6% py; Carpentier-Edwards 0.8% py), periporsthetic leak (Björk-Shiley 1.6% py; Carpentier-Edwards 1.4% py), anticoagulant-related complications (Björk-Shiley 0.3% py; Carpentier-Edwards 0.1% py), valve failure (Björk-Shiley 0.78% py; Carpentier-Edwards 0.68% py), reoperation for complication (Björk-Shiley 1.68% py; Carpentier-Edwards 1.22% py), and late mortality (Björk-Shiley 3.1% py; Carpentier-Edwards 3.0% py). Actuarial freedom from valve-related events was similar in the two groups. In the aortic position, freedom from embolism was significantly better in the Björk-Shiley group than the Carpentier-Edwards group (Björk-Shiley 99% at 3 and 5 years; Carpentier-Edwards 96% and 92% at 3 and 5 years; p = 0.023). In the mitral position, the overall incidence of reoperation was higher in the Björk-Shiley group (1.78% py) than in the Carpentier-Edwards group (0.48% py) (p = 0.004). Actuarial analysis shows this difference to be confined to the first 6 years of follow-up. The commonest indication for reoperation was valve failure in both groups. However, when analysis is confined to this indication, the difference between the reoperation incidence in the mitral position becomes insignificant (Björk-Shiley 0.85% py; Carpentier-Edwards 0.29% py; p = 0.085). This study confirms the satisfactory performance of both the Carpentier-Edwards and Björk-Shiley valves in the short and middle term and indicates no clear-cut advantage for either prosthesis.

Recent clinical experience with percutaneous intra-aortic balloon pumping.

From January 1984 to August 1985, 51 out of 2138 patients undergoing cardiac surgery (2.38 per cent) had an intra-aortic balloon pump (IABP) inserted or an attempted insertion. The patients ranged in age from 24 to 68 years (mean 54.2 years). An IABP was inserted preoperatively in four patients, all of whom were in cardiogenic shock; peroperatively in 27 patients who could not be weaned from cardiopulmonary bypass; and postoperatively in 16 patients who had haemodynamic deterioration. Failed insertion occurred in a further four patients. Twenty-eight patients (59.6 per cent) had percutaneous insertion of the balloon, in 17 (36.2 per cent) the common femoral artery was exposed prior to insertion and in two (4.2 per cent) the balloon was inserted into the thoracic aorta. The overall survival rate was 38.3 per cent for patients with successful insertion. Major complications that threatened life or limb occurred in 10.25 per cent of patients. These complications were confined to females and in these patients the percutaneous technique for inserting intra-aortic balloons should be used with caution.

Cardiac surgery in patients with functional renal transplants.

The results of cardiac surgery in 7 patients with functioning renal transplants are reported. In all cases surgery was carried out using standard operative techniques whilst renal perfusion was enhanced where necessary by the use of a dopamine infusion. The immediate postoperative course was uneventful in all cases, though 2 out of 4 patients with ischemic heart disease have since experienced recurrent symptoms. Cardiac surgery may be performed in patients with functioning renal transplants with acceptable mortality and morbidity.