Mitral valve replacement with beating heart technique via right thoracotomy in a patient with previous Bentall operation.

Traditionally, reoperations for mitral valve replacement are carried out under cardioplegic arrest with cross-clamping of the ascending aorta via a median sternotomy. In this case, the mitral valve replacement operation was performed with an on-pump beating heart technique without cross-clamping the aorta and via a right thoracotomy because of diffuse adhesions around the ascending aortic tube graft. A 44-year-old male patient had undergone a Bentall operation via a median sternotomy for annulo-aortic ectasia 3 years ago. He was admitted to the hospital complaining of palpitation and dyspnea. Transthoracic echocardiography revealed 4th degree mitral insufficiency. Mitral valve replacement was carried out through a right thoracotomy using an on-pump beating heart technique without cross clamping the aorta. In conclusion, mitral valve replacement with an on-pump beating heart technique via a right thoracotomy offers a safe approach when excessive dissection is required to place a cross-clamp to the ascending aorta.

Redo valve surgery with on-pump beating heart technique.

AIM: Reoperations have become of increasing frequency in the last four decades. Redo surgery is more complex than primary surgery and is associated with higher mortality and morbidity. We present our immediate and mid-term results of mitral and aortic prosthetic valve replacement undertaken with beating heart technique. METHODS: The prospective study included 26 consecutive redo valve surgery patients who underwent valve re-replacement. The operation was carried out on a beating heart using normothermic bypass without cross-clamping the aorta for mitral valve surgery and retrograde coronary sinus normothermic noncardioplegic blood perfusion during cross-clamping the aorta for aortic valve procedures. RESULTS: Twenty-six patients (mean age 50+/-15 years) underwent reoperation with beating heart technique. Twenty (76.9%) mitral prosthetic replacements, 4 (15.4%) aortic prosthetic replacements, and 2 (7.7%) double valve replacements were achieved. Fourteen patients (53.8%) were operated for prosthetic valve dysfunction. Eighteen patients (69.2%) were in NYHA class III or IV preoperatively. Mean bypass time was 85+/-30 min. Mean duration of ventilation was 13.6+/-6 h, mean intensive unit stay was 2.8+/-6.4 days, and mean hospital stay was 8.3+/-7.2 days. Two (7.7%) patients required high dose inotropic support and in one patient (3.8%) intra-aortic balloon support was required. Pulmonary complication occurred in 1 patient (3.8%), low cardiac output in 1 patient (3.8%), and re-exploration for bleeding in 2 patients (7.7%). Operative mortality was not observed. CONCLUSION: Normothermic on-pump beating heart valve replacement offers a safe alternative to cardioplegic arrest in high-risk group. Complication rates are low and perioperative mortality is lower than with conventional surgery. Beating heart technique has the advantage of maintaining physiologic condition of the heart throughout the procedure.

A new technique of myocardial protection during aortic root replacement: antegrade/retrograde coronary perfusion.

Aortic root surgery has traditionally been performed with an arrested and cooled heart using cardioplegia. A new technique of myocardial protection was utilized in the treatment of ascending aortic aneurysm with severe aortic valve regurgitation requiring aortic root replacement with the Cabrol technique. Retrograde and antegrade perfusion of the heart with blood allowed the surgical operation to be performed safely while the heart was beating and eliminated the ischemic reperfusion injury which occurs during cardioplegic arrest and reinstitution of blood perfusion after removal of the aortic cross-clamping required in traditional techniques.

Dobutamine stress echocardiography and left ventricular mass changes of mechanical aortic valve replacement in four years follow-up.

AIM: The aim of this study was to investigate the differences in cardiac response to stress according to the size of the prosthetic valve in patients who underwent aortic valve replacement (AVR) and to evaluate the relationship between the size of the prosthetic valve and cardiac recovery-remodeling after the operation. METHODS: Thirty patients who had undergone AVR (12 patients) or double valve replacement (18 patients) underwent dobutamine-stress echocardiography 4.2 years after the operation to evaluate response to stress . They were divided into 2 groups according to valve prosthesis size. The small-size AVR group (group 1, n=17) had prosthetic aortic valves 21 pounds mm; the large-size AVR group (group 2, n=13) had valves >21 mm. Response to stress and preoperative and postoperative echocardiographic findings were compared. Pulsed and continuous-wave Doppler studies were performed at rest and at the end of each stage. Peak and mean aortic gradients, left ventricular diastolic and systolic functions were measured for each group. RESULTS: Dobutamine stress increased heart rate and blood pressure in both groups. Peak pressure gradient across the aortic valve prostheses was 42.1 mm Hg in group 1 and 20.9 mm Hg in group 2 (P<0.05) at rest. After dobutamine infusion, the peak pressure gradient across the aortic valve prostheses increased to 85.1 mm Hg in group 1 and 54 mm Hg in group 2 (P<0.05). Isovolumetric relaxation time returned to normal in both groups following dobutamine infusion; this decrease was significant only in group 1. Patients achieved a decrease in left atrium and left ventricular diameters and volumes, as evidence of remodeling following AVR. Left ventricular mass index (LVMI) decreased from 127.6+/-47.6 to 98.1+/-36.9 and from 159.9+/-16.1 to 125.3+/-10.1 in groups 1 and 2, respectively, but this decline was not statistically significant. CONCLUSIONS: Smaller valves have higher gradients and this significant difference increases under stress. Significant improvement in echocardiographic diameters, cardiac filling volumes and LVMI reflects the benefit of the operation. Cardiac remodeling is independent of valve size, although high transprosthetic gradients occur during stress conditions.

Beating heart mitral valve replacement with retrograde coronary sinus perfusion technique.

AIM: The aim of this study was to assess the efficacy and applicability of on-pump beating heart mitral valve replacement with Sorin Bicarbon prosthesis using retrograde coronary sinus perfusion. METHODS: The prospective study included 17 consecutive patients who underwent mitral valve replacement with Sorin Bicarbon prosthesis using retrograde coronary sinus perfusion. The operative variables and early outcome of this procedure are presented. RESULTS: Retrograde coronary sinus perfusion and venting the heart from the aorta and from the pulmonary vein provided good visualization of the operative field and performance of the operations without any difficulty. Partial oxygen pressures of coronary sinus perfusion blood and the returning blood from the coronary ostia were 299.7+/-30.7 and 37.6+/-6.2 mmHg respectively. Postoperative peak creatine kinase-MB and troponin T values were 58+/-28.5 IU/L and 1.5+/-0.4 ng/mL, respectively. No mortality or major complication was observed and all the patients were discharged from the hospital in good condition. CONCLUSIONS: On-pump beating heart mitral valve replacement with Sorin Bicarbon is a good surgical option, and it has the advantage of maintaining physiologic condition of the heart throughout the procedure.

Repair of postinfarction ventricular septal defect through the right atrium.

Repair of post infarction posterior ventricular septal defect has generally been performed with a ventriculotomy through the infarcted zone. This approach has a significant mortality and morbidity due to haemorrhage, extension of infarction or further compromise of ventricular function secondary to suture placement. We present a case with delayed repair of a post infarction posterior septal defect using a right atrial approach, where no discrete infarct or other abnormality of the free ventricular wall was found.