Repair of moderate aortic valve lesions associated with other pathology: an 11-year follow-up.

OBJECTIVES: The presence of moderate aortic valve (AV) lesions associated with other pathologies that require surgery presents a problem since ignoring or replacing the valve seems unsatisfactory. AV repair can be an attractive alternative if shown to perform satisfactory. METHODS: To evaluate this possibility, all consecutive AV patients who underwent operation between July 1988 and July 1999 were reviewed. Out of 1764 AV patients, 239 (14%) underwent repair and 86 (study group) had moderate lesions associated with mitral (73), tricuspid (33), coronary disease (5) and others (8). Mean age was 28 years (range 2--66); 78% were rheumatic, 71% were in sinus rhythm and 71% in NYHA class III--IV. RESULTS: There were seven hospital deaths (8%) and three patients were lost to follow-up (95% complete). Late mortality was 8% and 10-year actuarial survival was 86 +/- 4.5% (excluding hospital mortality). There were four (5%) embolic events (actuarial freedom 94 +/- 3.5%). Twenty-one patients required reoperation with two mortalities. The AV was not touched in five patients. In the remaining 16, the AV was replaced. Only one patient had isolated AV replacement while in all others, additionally, the mitral, tricuspid, or both required surgery. All reoperated patients had rheumatic etiology. Actuarial freedom from AV dysfunction at 8 years was 68 +/- 7.5%. CONCLUSIONS: Repair of associated moderate AV lesion is worth considering even in a predominantly young rheumatic population.

Treated bovine and autologous pericardium for aortic valve reconstruction.

BACKGROUND: To determine the differences in clinical behavior of bovine versus autologous pericardium, all consecutive patients undergoing aortic valve reconstruction were reviewed. METHODS: Between October 1988 and December 1995, 91 patients (mean age 30 years) underwent reconstruction with bovine (n = 27) or autologous (n = 64) pericardium. RESULTS: There were 2 hospital deaths, 5 late deaths, and no embolic events. Dysfunction of the aortic reconstruction required reoperation in 6 bovine (infection 1, fibrocalcific 5) and in 5 autologous (infection 3, annulus dilatation 1, commissural tear 1). Actuarial survival and freedom from structural deterioration at 8 years were 82.2%+/-9.6% and 76.2%+/-10.7% for bovine and 91.05%+/-3.96% and 96.8%+/-2.25% for autologous pericardium, respectively. The last Doppler echocardiographic study showed a mean regurgitation (1 to 4+) and gradient in the bovine pericardium of 1.25+/-and 20.7 mm Hg and in the autologous pericardium of 1+ and 7.7 mm Hg. CONCLUSIONS: Aortic valve reconstruction with pericardium can be safely performed with low thromboembolic rate. At 8 years follow up, there is a difference in favor of the autologous pericardium.

Clinical and echocardiographic follow-up after aortic valve reconstruction with bovine or autologous pericardium.

Eighty-six patients, mean age 29 +/- 15 years, underwent aortic valve reconstruction with bovine or autologous pericardial tissue. Mean clinical follow-up was 35 months. Echocardiographic data were assessed in 65 patients with follow-up > or = 6 months. There were two in-hospital and three late deaths. Warfarin was not given, and no thromboembolic events occurred. Five (6%) patients needed reoperation because of severe aortic regurgitation. Peak aortic valve gradients remained low (26 +/- 14 mm Hg for the bovine group and 16 +/- 16 mm Hg for the autologous group). One patient is awaiting surgery for aortic stenosis after 76 months. Leaflet thickening at latest follow-up was marked in six (9%) patients. Left ventricular dimensions normalized postoperatively and showed only insignificant increase during follow-up. This technique is a promising alternative to valve prosthesis in selected patients; however, longer follow-up is necessary to assess long-term results.

Surgery for rheumatic mitral regurgitation in patients below twenty years of age. An analysis of failures.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair is less stable in rheumatic than in degenerative disease. This failure rate is inversely related to the age of the patient. Based on our clinical experience, we selected the group of patients with the worst results for this study: (i) rheumatic, (ii) age 20 or under, (iii) pure mitral regurgitation (MR), and, (iv) no aortic disease. MATERIALS AND METHODS: Between 1988 and 1995, 83 consecutive patients complied with these characteristics. No patient was excluded. Replacement (MVR) was performed in 26 and repair (MRp) in 57 (69%). RESULTS: There was one hospital death (1%) with an actuarial survival at 48 months of 74.8% +/- 19% for MVR and of 97.9% +/- 2.1% at 78 months for MRp. There were no thromboembolic events. Reoperation was required in one MVR (4%) and in 21 MRp (37%), within same admission in six, within three months in eight, under one year in three, and beyond in four cases. Severe MR appeared in five further cases. No statistical difference was found between the preoperative clinical data, operative findings and surgical maneuvers of those patients with successful and unsuccessful repair. The rate of failure was similar after Kay (14/29) and Duran (12/28) annuloplasty. All patients showed a rapid decrease in left ventricular dimensions. Early failures showed elongation of previously shortened chordae at reoperation, together with more reduction in systolic dimension than the other groups. Late failures were more related to progression of the rheumatic process. No clear relationship between rheumatic activity and failure rate was found. CONCLUSION: Rheumatic mitral regurgitation in the young remains a serious problem. The treatment of this frequent pathology in the developing countries needs a new approach based on the knowledge that it starts at the annulus. Earlier surgery at this level might prevent its further progression, avoiding the problems of secondary chordal elongation.

Ball valve (Smeloff-Cutter) aortic valve replacement without anticoagulation.

BACKGROUND: Because of the difficulty of permanent anticoagulation in our young population, Smeloff-Cutter ball valves have been used since 1986 at our institution for aortic valve replacement in selected patients without permanent anticoagulation therapy. METHODS: The availability of a satisfactory follow-up system since July 1988 suggested a study of all 47 patients operated on since then and followed for a mean of 43.2 months (range, 16 to 78 months). Mean age was 26.3 years, 98% were in sinus rhythm, and 16 patients (34%) had concomitant mitral repair. RESULTS: There were no hospital deaths. Three patients were lost to follow-up at a mean of 27 months. Four late deaths occurred (8.5%), two of them sudden, with actuarial survival at 6 years of 91% +/- 4.3%. There were a total of five embolic events (2.9%/patient-year). For isolated aortic valve replacement only, with antiaggregant therapy (n = 29), the incidence was 0.9%/patient-year. For all patients receiving antiaggregant agents (n = 43), it was 3.02%/patient-year. There were no known cases of valve thrombosis. Reoperation was required in 5 patients. CONCLUSION: Aortic valve replacement with the Smeloff-Cutter ball valve might be a valid alternative for young patients unable to maintain regular anticoagulation.

Pulmonary autograft for aortic valve replacement in rheumatic disease: a caveat.

Pulmonary autograft replacement of the aortic valve offers an attractive option in the younger patient with growth potential and long-term survival. In our institution between January 1990 and August 1994, 78 patients have undergone this procedure. The mean age was 18.6 +/- 7.36 years (range, 1 to 41 years). The etiology was rheumatic in 63 patients (80.7%). Aortic regurgitation was the predominant lesion in 60 patients (76.9%). Significant mitral regurgitation requiring operation was present in 22 patients (28.2%). All patients underwent pulmonary autograft replacement of the diseased aortic valve and the mitral valve was repaired in 22 patients. There were no hospital mortality, endocarditis, or thromboembolism in the series up to date. There have been two late non-cardiac deaths. Five patients (6.4%) required reoperation, one for mitral repair failure and four for autograft failure. Acute rheumatic valvulitis was demonstrated in one of the reoperated patients. Echocardiography of 68 patients followed up more than 2 months show progression of aortic regurgitation more than 2/4+ in 12 patients (15.4%). Four of these patients have been reoperated without mortality. In conclusion, although the Ross procedure remains a safe and attractive alternative in aortic valve operation, the progression of aortic regurgitation, especially in the younger patient with rheumatic etiology, remains a concern.

From aortic cusp extension to valve replacement with stentless pericardium.

Between 1988 and 1994, 82 consecutive patients (median age 24 years) underwent reconstruction of the aortic valve with glutaraldehyde-treated pericardium. Simultaneously, 29 of 30 mitral valves were repaired. The first 27 patients underwent resection of the free edges and suture of a single strip of bovine pericardium. Transient ischemic changes suggested the need for a change in technique. The subsequent 55 patients underwent total valve reconstruction with an autologous pericardium fixed with glutaraldehyde in the appropriate shape and size according to the patient's aortic annulus. There were one in-hospital and three late deaths. No patient received anticoagulation, and no embolic events were detected. Nine patients required reoperation as a result of failure of mitral valve repair in 4 and severe aortic regurgitation in 5 (endocarditis [n = 2], commissural tear [n = 1], root dilation [n = 1], calcification of one bovine cusp [n = 1] at 58 months). There were no reoperative deaths. Complete linear echocardiographic follow-up of these patients showed low gradients, valve competence, and no progressive deterioration. No difference between techniques was detected.

Aortic valve replacement with freehand autologous pericardium.

Fifty-one patients with a mean age of 31.2 years underwent aortic valve replacement with glutaraldehyde-treated autologous pericardium. Pure aortic regurgitation was present in 28 (54.9%), stenosis in 9, and mixed disease in 14. Simultaneous mitral valve repair was done in 17 patients and replacement in 1. There were no hospital and two late deaths. Three patients required reoperation because of failure of the pericardial valve as a result of infective endocarditis in two (5 and 31 months after operation) and commissural tear at 8 months in another. One patient underwent reoperation at 24 months because of failure of the mitral valve repair. The pericardial aortic valve, which had 2+ regurgitation since the first operation, was also replaced. Macroscopic and microscopic examination findings in the excised pericardium were excellent. No thromboembolic events have been detected and no patient received anticoagulation therapy except one after mitral valve reoperation and replacement with a mechanical valve. The actuarial survival was 84.53% +/- 12.29% at 60 months, freedom from failure of the aortic reconstruction 83.83% +/- 8.59%, and freedom from any event 72.59% +/- 12.79%. Doppler echocardiographic study at most recent follow-up showed a mean gradient of 12.56 +/- 8.10 mm Hg and mean regurgitation on a scale from 0 to 4+ of 0.80 +/- 0.66. Although the maximum follow-up is only 5 years, the results obtained so far encourage us to continue replacing the aortic valve with stentless autologous pericardium.

Performance of 96 CarboMedics valve replacements in 75 patients less than twenty-one years of age.

Valve replacement still represents a problem in the very young patient. Between July 1988 and November 1993, 96 CarboMedics mechanical valves were implanted in 75 patients with a mean age of 11.76 years (range, 5 months to 20 years). The mean preoperative New York Heart Association functional class was 3.2, and 89.3% of the patients were in sinus rhythm. The cause was rheumatic in 60%, congenital in 24%, and infective in 12%. Mitral valve replacement was undertaken in 43 patients, aortic in 11, and mitroaortic in 21. Among the 18 patients with congenital defects, 13 required simultaneous repair of their complex lesions. The hospital mortality was 12% (9 patients). Cause and age were significant factors responsible for mortality. The mortality was 27.8% for patients with congenital disease and 6.7% for those with rheumatic defects (p = 0.0365); it was 40% for patients younger than 2 years, 14.3% for those between 3 and 10 years old, and 5.9% for those older than 10 years (p = 0.0108). The maximum follow-up was 54 months (mean, 18 months). There were 10 late deaths (15.15%). No embolic events occurred. All patients were on anticoagulation therapy except 2 who were on antiaggregant therapy. One of them underwent successful reoperation for treatment of mitral prosthetic thrombosis. Three reoperations were performed: one for thrombosis, one for perivalvular leak, and one for endocarditis. The total actuarial survival was 68.19% +/- 7.02%. Freedom from embolism was 100%; from thrombosis, 96.72% +/- 3.22%; from severe hemorrhage, 94.94% +/- 3.67%, and from reoperation, 83.07% +/- 9.51%.

Pulmonary autograft for aortic valve replacement in rheumatic disease--an ideal solution?

The use of pulmonary autograft for aortic valve replacement (Ross procedure) offers an excellent option for the younger patient with its potential for growth and long term viability. We report our experiences of 61 patients with a mean age of 17.0 years undergoing Ross procedure over a four year period. Rheumatic disease was the cause of aortic valve disease in 48 (79.0%) patients. Mitral valve surgery was required in 18 (29.5%) patients. There was no hospital death, endocarditis or thromboembolism in the series. There was one late death from non-cardiac cause and three (4.9%) reoperations. Two of the reoperations were for progressive autograft regurgitation whilst the third was for mitral valve repair failure. Echocardiographic profiles of 37 of these patients followed beyond six months after surgery show a tendency towards progression of the autograft regurgitation. The long term effects of rheumatic disease on the transplanted valves remain to be evaluated.

Non-prosthetic aortic valve surgery.

Due to significant improvements in myocardial protection, old techniques are being re-explored today in search for the ideal solution for aortic valve disease. We reviewed all patients who underwent non-prosthetic aortic valve surgery between July 1988 and March 1994. There were 361 such patients with a mean age of 22.18 years, mean preoperative functional class of 2.65 and sinus rhythm in 89.75%. The etiology was rheumatic in 65.65% and congenital in 26.37%. Simultaneous mitral surgery was performed in 44% of the cases with repair in 76.73%. A homograft was used in 11 patients with one hospital death, no late deaths and no reoperations. A pulmonary autograft was used in 58 with no hospital deaths, one (1.72%) late death (car accident) and three (5.17%) reoperations due to progressive regurgitation in two. Reconstruction with pericardium was performed in 76 patients with no hospital deaths, three (3.95%) late deaths (one car accident) and four (5.26%) reoperations due to endocarditis in two and valve failure in two. Repair was done in 216 patients with eight (3.7%) hospital and nine (4.32%) late deaths, and 25 (12%) reoperations. Excluding those patients with mitral surgery, there were no thromboembolic events with only two patients (1.02%) anticoagulated. The total actuarial survival was 91.76 +/- 2.40% at 66 months. It is concluded that non-prosthetic aortic valve surgery offers a very attractive alternative for our patient population.

Aortic valve reconstruction in the young.

Aortic valve replacement in the young patient, and particularly in women of child-bearing age, still represents a problem. Between July 1988 and August 1993, 644 aortic valve patients (mean age 32.5 years) were operated in our institution. Aortic valve reconstruction was performed in 274 (42.5%). A variety of repair techniques (valvuloplasty) was used in 202 patients (mean age 21.5 years). Concomitant mitral surgery was performed in 103 (51%). In 72 patients (mean age 27.7 years), a cusp extension was undertaken with glutaraldehyde treated bovine (27 pts) or autologous (45 pts) pericardium. In the "plasty" group, there were 8 (4%) hospital deaths and 8 (4.1%) late deaths with an actuarial survival of 86.05% +/- 3.97%. No thromboembolic events were detected in patients with isolated aortic surgery. There were 32 reoperations without mortality, 22 due to progressive rheumatic disruption of the mitral repair. There was severe aortic dysfunction in 17 (8.76%) cases. There was no hospital mortality among the 72 patients with cusp extensions. There were two (2.8%) late deaths and no thromboembolic events. No patient was anticoagulated. Four patients required reoperation on the aortic valve without mortality. The last echocardiographic follow-up showed stability of the reconstruction. These techniques offer a valid alternative to valve replacement in this difficult category of patients.

Valve repair in rheumatic mitral disease: an unsolved problem.

UNLABELLED: Etiology plays an important role in the results of mitral valve repair. Although it is known that rheumatic disease is a negative factor, the possible influence of age has not been determined. In an attempt to study this factor, all consecutive Saudi patients operated for rheumatic mitral disease between July 1988 and December 1992 were reviewed. There were 537 patients (mean age 31.91 years). Replacement was performed in 231 patients and repair in 306. Follow-up was 98% complete with a maximum of 52 months (mean 20 months). The patients were divided by age into three groups: group I between 0 and 20 years (n = 145), group II between 21 and 40 years (n = 247), and group III older than 41 years (n = 145). The results showed repair rates of 76.6% (group I), 59.1% (group II), and 33.8% (group III). Actuarial survivals for repair were 95.87% (group I), 94.82% (group II), and 81.14% (group III), and for replacement were 88.33% (group I), 94.29% (group II), and 71.10% (group III). The reoperation rates for repair were 23.6% (group I), 9.6% (group II), and 8.7% (group III). There were only three reoperations in the replacement group. IN CONCLUSION: (1) the rate of repair is age dependent and inversely related; (2) repair in patients younger than 20 years of age carries a high reoperation rate; and (3) in this age group there is a higher survival tendency.

Heart valve surgery in a young predominantly rheumatic population.

Between August 1988G and August 1992G, 802 Saudi patients underwent 1,171 open valve surgical procedures at King Faisal Specialist Hospital and Research Centre (KFSH&RC). The mean age was 32.4 years (range one to 90). The etiology was rheumatic in 66.3%, congenital in 12.8%, degenerative in 8.7%, infective in 5.9% and ischemic in 2%. The mean preoperative New York Heart Association (NYHA) functional class was 2.94 and 74% of the patients were in sinus rhythm. Multiple valve procedures were required in 39.4% of the cases and 718 valves (64.6%) were repaired. The overall hospital mortality was 4.48%. The mortality for isolated mitral valve repair was 1.8% against 3.48% for replacement. For isolated aortic repair, it was 0 against 8.5% for replacement. The follow-up of our patients was 98.1%. During the follow-up period of 1,171.06 patient years, the total incidence of thromboembolic events was 2.35% or 1.53% pt-yrs. Reoperation was required in 7.3% of the patients. The main cause was dysfunction of the rheumatic mitral repairs in the young patients. The late mortality was 3.78%. The actuarial survival for the total 802 operated patients was 86.27%. This survival was 91.10% for those undergoing repair versus 82.10% for those with replacement (P<0.005). It is concluded that a careful and complete follow-up of our patients is essential to determine the value of the available surgical techniques. The young rheumatic patient, so prevalent in our population, remains a surgical challenge. New surgical alternatives are needed.

Vanishing De Vega annuloplasty for functional tricuspid regurgitation.

Annuloplasty is performed for significant functional tricuspid regurgitation even if it is presumed that in some cases the regurgitation will regress spontaneously after correction of the left-sided lesion. In an attempt to avoid the drawbacks of a permanent annuloplasty, we used a reabsorbable De Vega annuloplasty in a selected group of patients. Of 73 patients with functional tricuspid regurgitation operated on between May 1989 and May 1991, 25 with pulmonary arteriolar resistance below 400 dyne.sec.cm-5 underwent a De Vega annuloplasty with 2-0 polydioxanone suture. The diagnosis of significant functional tricuspid regurgitation (mean 2.74 +/- 1.05) was established by transthoracic color Doppler echocardiography in all patients. The degree of functional tricuspid regurgitation and pulmonary arteriolar resistance were measured with the patients anesthetized. In 16 patients the regurgitation remained severe (3+ to 4+) and in 9 it was moderate (2+). Twenty-three patients had mitral (12 repairs, 11 replacements) and 9 had aortic (4 repairs, 5 replacements) valve operations. The immediate postbypass residual functional tricuspid regurgitation was 0 to 1+ in 23 and 0 in 2. There was 1 (4%) operative death. The maximum follow-up period was 24 months (mean 13.9 months). There were 2 (8.3%) late deaths. Six patients underwent reoperation because of mitral dysfunction. Four of them who were reoperated on between 2 and 5 weeks after the initial procedure showed no recurrence of functional tricuspid regurgitation. The other 2, reoperated on at 5 and 10 months after the first operation, had recurrence of functional tricuspid regurgitation. Visual inspection of these two tricuspid valves showed a dilated anulus with otherwise normal valves. All surviving patients are in New York Heart Association functional class I or II without significant functional tricuspid regurgitation (mean 0.78 +/- 0.56). We concluded that functional tricuspid regurgitation in patients with low pulmonary arteriolar resistance can be adequately treated by a vanishing De Vega annuloplasty, which will stent the tricuspid anulus for about 4 months.

Surgery for organic rheumatic disease of the tricuspid valve.

The paucity of reports on the incidence and management of organic involvement of the tricuspid valve in rheumatic disease led us to carry out this retrospective study. Over a four and a half year period, of the 1052 patients undergoing valve surgery at our institution, 253 (24.05%) required tricuspid surgery. Organic involvement was noted in 115 (45.45%) of these patients. Definitive preoperative diagnosis was feasible by echocardiogram in only 48 (41.73%). Tricuspid regurgitation was present in all patients while detectable stenosis was present in 48 (41.7%). Annular dilatation was seen in 52 (45.2%). Primary repair was possible in 107 patients (93.0%). The reduction in tricuspid regurgitation remained stable at the last follow up in all but seven patients. Nine patients underwent reoperation in this study for failure of left-sided valve repairs, of which five needed reoperation on the tricuspid valve. All the five reoperated tricuspid valves had had dilated annuli at primary surgery. The presence or absence of annular dilatation did not cause any significant difference in early or late mortality. The presence of annular dilatation in the presence of left-sided valve lesions superimposed on organically involved tricuspid valves evokes the possibility of the presence of an organo-functional disease.

The Ross procedure in a young rheumatic population: early clinical and echocardiographic profile.

The use of pulmonary autografts for aortic valve replacement is nearing its third decade. It is showing promise as a permanent aortic valve with its ability to grow with age. We report our experience of 45 patients with a mean age of 16.89 years over a three year period. Rheumatic heart disease was the cause of aortic valve dysfunction in 38 (84.4%) patients. Sixteen (35.5%) patients also underwent mitral valve repair. Echocardiographic examination revealed early reduction of aortic regurgitation and left ventricular dimensions, which remained stable in the short follow up period. There were no early or late deaths. One patient required reoperation for a regurgitant pulmonary autograft at two years. We conclude that pulmonary autograft transplantation to the aortic root seems to offer a near permanent solution in a young population affected by rheumatic valve disease.

Triple-valve operation in the young rheumatic patient.

Multiple-valve operation for the young rheumatic patient remains a problem. There is a paucity of information on the results of repair versus replacement in this age group. Between July 1988 and December 1991, 242 patients less than 20 years of age underwent a valve operation for rheumatic heart disease at our institution. Twenty-four (9.9%) of them had simultaneous mitral, aortic, and tricuspid valve procedures. The mean age was 14.71 years. All 24 patients were in functional class III or IV preoperatively. Valvar regurgitation was the predominant lesion. Four patients (16.7%) had active rheumatic myocarditis at the time of operation. Valve repair was attempted in the absence of infective endocarditis. Triple-valve repair was possible in 12 patients (50%). The hospital mortality rate was 16.7%. Reoperation was performed after repair in 9 patients (45%) without any deaths. The reason for reoperation was failure of the mitral valve repair in all patients, and the cause was technical in 3 patients, progression or recurrence of rheumatic myocarditis in 5, and endocarditis in 1 patient. The three late deaths (15%) were in patients who had mitral valve replacement. Valve repair was associated with a higher reoperation rate, and replacement of left-sided valves was associated with a higher early and late mortality. In conclusion, although valve repair would be ideal in the young rheumatic patient, multiple-valve repair is associated with a high reoperation rate.

The challenge of valve surgery in a developing population.

Between August 1988 and October 1992, 1,052 patients underwent 1,522 valve procedures in our institution. Their mean age was 32.69 years (range 1-90). The etiology was rheumatic in 724 (68.8%), congenital in 120 (11.4%), degenerative in 99 (9.4%), infective in 58 (5.5%) and ischemic in 17 (1.6%). The mean preoperative functional class (NYHA) was 2.95 and 780 (74.1%) were in sinus rhythm. Repair was possible in 885 (58.1%) valves. The rate of repair versus replacement was 94.5% for the tricuspid, 56.2% for the mitral and 43.6% for the aortic valve. The total hospital mortality was 4.18%. For isolated mitral surgery it was 2.94%, for isolated aortic 4.12% and for isolated tricuspid 15%. Double valve surgery carried a mortality of 3% and triple valve surgery 13%. Hospital mortality for isolated mitral and isolated aortic surgery was lower for repair than for replacement (1.5% vs. 5% and 0 vs. 6.8%). The follow-up was 94.65% complete. The total incidence of embolic events was 2.93% with an actuarial freedom at 48 months of 92.71 +/- 5.35% for repair, 88.22 +/- 6.26% for replacement and 90.31 +/- 5.65% for patients with repair and replacement. Late mortality was 4.5%. The actuarial survival excluding hospital deaths was 94.89 +/- 2.10% for repair, 86.84 +/- 2.84% for replacement and 91.33 +/- 2.73% for the mixed group. The reoperation rate was higher for repair (13%) than for replacement (0.1%). This rate was highest for the rheumatic mitral patients with an age below 20 years (25.2%).(ABSTRACT TRUNCATED AT 250 WORDS)