Double mitral homograft for recurrent bacterial endocarditis of the mitral and tricuspid valves.

A young patient suffering from acute bacterial endocarditis underwent reconstructive surgery of the mitral and tricuspid valves. One year later a recurrent endocarditis occurred that could not be controlled with antibiotic therapy. Two separate mitral homografts were used to replace both the mitral and the tricuspid valves. The homografts' papillary muscles were sutured side to side to the recipient's and a circumferential suture of the leaflet tissue was accomplished. Homograft implantation was associated with Carpentier ring annuloplasty of the atrioventricular valves. In the right sided position, the mitral homograft was oriented in an anti-anatomical manner and an inverted semi-rigid prosthetic ring of the mitral type was inserted. Clinical and echocardiographic follow up at four months was excellent.

[Mitral valve replacement with cryopreserved mitral homograft]. / Remplacement valvulaire mitral par homogreffe mitrale cryopréservée.

Mitral valve replacement using a cryopreserved mitral homograft was performed in a 49 year old patient with calcified mitral stenosis. The surgical technique is described. The postoperative course was uneventful. Transoesophageal echo performed 4 months later showed a normal function of the mitral homograft.

[Mid-term results of cardiomyoplasty]. / Résultats à moyen terme de la cardiomyoplastie.

Cardiomyoplasty (CMP) is a technique of circulatory assistance using a pediculated latissimus dorsi muscle wrapped around the heart and electrically stimulated during systole. Sixty-four patients, aged 15 to 69 years (average 50.8 +/- 13 years) with cardiac failure underwent CMP between January 1985 and July 1993. The causes of cardiac failure were : ischaemic heart disease (39 cases), dilated cardiomyopathy (18 cases), cardiomyopathy following valvular heart disease (2 cases), cardiac tumours (4 cases) and congenital heart disease (1 case). Twenty-four patients underwent an associated surgical procedure. Intra and postoperative intra-aortic balloon pumping was required in 27 cases. Hospital mortality (before latissimus dorsi stimulation) was 20.3% (13/64 cases). Evaluation of the survivors 12 months after surgery showed an improvement in functional class (1.,5 versus 3.3 before CMP ; p < 0.05), in isotopic ejection fraction (27 +/- 3% versus 17 +/- 6%, p < 0.05) and cardiac index (2.87 +/- 0.63 l/min/m2 versus 2.38 +/- 0.41 l/min/m2, p < 0.05). There was no significant change in cardiac filling pressures. The number of hospital admissions for congestive cardiac failure in operated patients was 0.4 per patient per year, compared with 2.5 per patient per year (p < 0.05) before CMP. The preoperative predictive factors for late mortality were: permanent functional Class IV (NYHA), severe cardiac dilatation (cardio-thoracic ratio greater than 0.60; left ventricular end diastolic dimension > 75 mm), an isotopic left ventricular ejection fraction < 15%, severe biventricular cardiac failure and irreversible pulmonary hypertension. The actuarial 4 year survival rate was 68.3%.(ABSTRACT TRUNCATED AT 250 WORDS)

[Use of the radial artery for coronary artery bypass. A new experience after 20 years]. / Utilisation de l'artère radiale pour les pontages coronaires. Nouvelle expérience 20 ans après.

Twenty years after its first introduction by A. Carpentier, the use of the radial artery (RA) for coronary bypass was reinvestigated because of unexpected good long term results in some patients. Since July 1989, 158 patients (pts) underwent myocardial revascularization using 189 RA grafts (31 pts received 2 grafts). The left internal mammary artery (LIMA) was concomitantly used as a pedicled graft in 151 cases and the right internal mammary artery (RIMA) in 31 cases, a free IMA graft was used in 29 cases and a saphenous vein graft in 40 cases. A mean of 2.8 graft/pt was performed. The target artery receiving the RA was: circumflex (n = 93), diagonal (n = 39), right coronary (n = 47) and LAD (n = 10). Two patients died (1.3%) and three presented a perioperative myocardial infarct (2.5%). Sternal wound infection was noted in three cases of double IMA implant. No ischemia of the hand was observed. All patients received diltiazem started intraoperatively and continued after discharge. In addition, aspirin (100 mg/day) was given at discharge. Early angiographic controls (< 3 weeks) were obtained in the first 60 consecutive patients and revealed: 73/73 patent RA grafts, 58/58 patent LIMA grafts, 16/16 patent RIMA grafts, 15/19 patent free IMA grafts and 10/11 patent vein grafts. Six patients presented a localized narrowing of the RA conduit unrelated to the anastomotic lines (spasm). Late angiographic control (6 to 24 months) was obtained after a mean follow-up of 11 months in 37 patients: 42/46 RA grafts were patent (91.3%) and free of spasm and 4 were occluded.(ABSTRACT TRUNCATED AT 250 WORDS)

Left ventricular outflow tract obstruction after mitral valve repair. Results of the sliding leaflet technique.

BACKGROUND: Left ventricular outflow tract obstruction (LVOTO) occurs in 4% to 5% of patients after prosthetic ring mitral valve repair. Major anatomic factors incriminated in the genesis of LVOTO include degenerative mitral valve insufficiency with excess leaflet tissue, nondilated left ventricular cavity, and narrow mitro-aortic angle. We have previously reported a 14% incidence of LVOTO after prosthetic ring mitral valve repair in this high-risk group of patients. Serial echo Doppler studies demonstrated an overlapping and/or inversion of the left ventricular functional compartments generating systolic anterior motion of the posterior leaflet and paradoxical opening (eversion) of the anterior leaflet. In an attempt to eliminate LVOTO after mitral valve repair, a new surgical procedure was developed in 1988 by Carpentier: the sliding leaflet technique, which reduces the height of the posterior leaflet. The purpose of this study was to analyze the results of the new technique in terms of the occurrence of LVOTO: METHODS AND RESULTS: Eighty-two patients undergoing prosthetic ring mitral valve repair between 1988 and 1991 and identified as high risk for LVOTO were operated on using the sliding leaflet technique. There were 52 men and 30 women. Ages ranged from 28 to 75 years. The surgical techniques used included prosthetic ring annuloplasty (n = 82), leaflet resection (n = 82), chordal shortening or transposition (n = 36), and other (n = 19). Intraoperative and/or immediate postoperative echo Doppler studies were obtained in all cases. Two patients (2.4%) died, and 2 (2.4%) required reoperation. Nonsignificant LVOTO was identified in 2 cases (2.4%), in whom instantaneous maximal subaortic gradients were 20 and 18 mm Hg, respectively. CONCLUSIONS: This study was not done on a concomitant series of patients but on patients with the same type of pathology. It demonstrates that (1) the sliding leaflet technique eliminates significant LVOTO in the high-risk patients; (2) the sliding leaflet technique is associated with a low mortality; and (3) no reoperations for mitral insufficiency were required in this series.

Transposition of chordae in mitral valve repair. Mid-term results.

BACKGROUND: Prolapse of the anterior mitral leaflet, unlike a posterior prolapse, is a difficult lesion to repair. Leaflet plication and triangular resection are satisfactory techniques only in case of a limited prolapse. Chordal replacement has also been proposed but uses foreign material. The purpose of this report is to assess the results of transposition of chordae for the correction of mitral regurgitation (MR) caused by anterior leaflet prolapse. METHODS AND RESULTS: Between January 1986 and December 1990, 44 adult patients with MR caused by anterior leaflet prolapse underwent repair with transposition of chordae as one of the techniques. This population was retrospectively studied to assess the early and late results of this procedure. Chordae were transferred from the posterior to the anterior leaflet (n = 25) or from an intermediary to a free edge position on the anterior leaflet (n = 21) (two patients underwent both procedures). Two patients died (4.5%). None required early reoperation. Follow-up was complete and ranged from 18 to 82 months (mean, 40.2 +/- 19 months). No patient died during follow-up. Two patients were reoperated on 6 and 8 months after surgery for recurrent MR unrelated to chordal transfer disruption. Doppler echocardiographic studies were available in 95% of the cases at latest follow-up and showed no or minimal MR (0 to 1/4) in 87.5% of the patients and mild MR (2/4) in 12.5%. CONCLUSIONS: Transposition of chordae appeared to be a simple and safe procedure for correction of anterior mitral prolapse. Transposition of chordae allowed extension of the indications of valve repair. A longer follow-up will be necessary to draw firm conclusions, but mid-term results are encouraging.

[Mitral valvuloplasty during the acute phase of endocarditis]. / Plasties mitrales au cours de la phase aiguë de l'endocardite.

Thirty-five patients were operated in the acute phase of mitral valve endocarditis between 1986 and 1991. The surgical indications were hemodynamic (22), echocardiographic (9), embolic (2) and infectious (2). There were pre-existing valve lesions in 45% of cases. The causal organism was identified in 90% of cases: streptococcus (19), staphylococcus (9) and Gram negative bacilli (4). Preoperative antibiotic therapy was prescribed for an average of 18 days. The aortic valve was infected in 9 patients and tricuspid valve in 1 patient. The mitral lesions were: abscess (11), vegetations (11), perforations (16), and ruptured chordae tendinae (22). All patients underwent Carpentier's mitral valvuloplasty. The operative mortality was 5.7% (2 patients). Early reoperation was required in 1 case. Follow-up was possible in 96% of cases for an average of 23 months. No recurrences of endocarditis were observed. One patient was reoperated and 3 died. All the others were in Classes I and II of the NYHA. None had significant mitral regurgitation or stenosis. These results show that mitral valvuloplasty is possible in the acute phase of endocarditis in 90% of cases. The mortality and morbidity are low and long-term results are stable.

Mitral valve repair using Carpentier techniques in patients more than 70 years old. Early and late results.

BACKGROUND: Mitral valve incompetence in elderly patients raises the problem of whether to replace or to repair the mitral valve. The purpose of this study is to review our experience with mitral valve repair in patients > 70 years old. METHODS AND RESULTS: Between 1986 and 1991, 79 consecutive patients > 70 years old underwent mitral valve repair by Carpentier techniques. The most frequent cause was degenerative valve disease (65 of 79). Preoperative echocardiography showed that 6% of the patients had type I, 88% type II, and 5% type III mitral valve dysfunction. Anatomic lesions encountered at surgery confirmed the preoperative echocardiographic findings, with 88% of the patients with a leaflet prolapse either of the posterior leaflet (56%) or of both the anterior and posterior leaflets (32%). Multiple surgical procedures were required in each patient. Posterior leaflet resection was the most common technique used (76%). Prosthetic ring annuloplasty was used in 96% of patients. Associated procedures were performed in 21.5% of cases. Three patients died, for an operative mortality of 3.8%. One patient (1.3%) required reoperation for residual mitral insufficiency. Nonfatal complications related to the patients' preoperative condition were noted in more than half of the patients. Echocardiography obtained before discharge revealed absent or minimal mitral insufficiency in 91% of patients and mild mitral insufficiency (2+/4+) in 9%. Follow-up was available for 74 of 76 patients (97.3%) and ranged from 3 months to 6 years (mean, 22 months). Two patients (2.6%) were lost to follow-up. Sixty patients (89%) were in New York Heart Association functional class I or II. Seven patients died and one required reoperation. Actuarial analysis of the results showed overall survival at 5 years 81 +/- 11%; freedom from thromboembolism, hemorrhage, and reoperation 97 +/- 5%, 97 +/- 5%, and 98 +/- 4%, respectively. Color-coded echo Doppler studies obtained in 67 patients at the time of follow-up showed absent or minimal MI (91%) (n = 61), and mild MI in 9% (n = 6). CONCLUSIONS: These data suggest that mitral valve repair using Carpentier techniques should now be considered as the procedure of choice in patients of any age referred for mitral insufficiency.

Revival of the radial artery for coronary artery bypass grafting.

Eighteen years after its first introduction for coronary artery revascularization, the radial artery (RA) was reinvestigated because of unexpected good long-term results in the early series. Since July 1989, 104 patients underwent myocardial revascularization using 122 RA grafts (18 patients received two grafts). The left internal mammary artery (IMA) was concomitantly used as a pedicled graft in 100 cases and the right IMA in 19 cases; a free IMA graft was used in 29 cases and a saphenous vein graft in 24 cases. A mean of 2.8 grafts per patient were performed. Nine patients underwent associated procedures: carotid endarterectomy (3), aortic valve replacement (3), Bigelow procedure (1), and mitral valve repair (2). The target artery receiving the RA was the circumflex (n = 59), diagonal (n = 29), right coronary (n = 27), and left anterior descending (n = 7). One patient died (0.96%) and 2 had perioperative myocardial infarct. Sternal wound infection was noted in 3 cases of double IMA implantation. No ischemia of the hand was observed. All patients received diltiazem started intraoperatively and continued after discharge. In addition aspirin (100 mg/day) was given at discharge. Early angiographic controls (less than 2 weeks) were obtained in the first 50 consecutive patients and revealed 56 of 56 patent RA grafts, 48 of 48 patent left IMA grafts, 11 of 11 patent right IMA grafts, 14 of 18 patent free IMA grafts, and 8 of 9 patent vein grafts.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac surgery in patients with human immunodeficiency virus infection: indications and results.

Ten patients with human immunodeficiency virus (HIV) infections underwent cardiac surgery using cardiopulmonary bypass. All were in Centers for Disease Control (CDC) group II. The cardiac involvement was either urgent or severely symptomatic in all cases. One patient died due to acquired immunodeficiency syndrome (AIDS) unrelated cause. No complications were encountered in this series. Eight of the nine survivors were available for follow-up. Three of these eight patients progressed to AIDS (CDC group IV) and subsequently died. Five patients are alive and in CDC group II. Prognosis of the HIV infection and the natural history of the cardiac disease are the two main elements to be considered whenever cardiac surgery is required.

Dynamic cardiomyoplasty for long-term cardiac assist.

The principle of cardiomyoplasty is long-term electrostimulation of a latissimus dorsi muscle (LDM) wrapped around the failing heart. Technically, this procedure consists of placing the left LDM flap around the heart via a window created by partial resection of the 2nd or 3rd rib, and subsequent muscle electrostimulation in synchrony with ventricular systole. The aim of cardiomyoplasty is to support ventricular function in ischemic or dilated cardiomyopathies, or to partially replace the ventricular myocardium after large aneurysm or tumor resections. Our clinical experience at Broussais Hospital involves 44 patients. The functional class and quality of life improved after cardiomyoplasty. Improvement of the ventricular performance and limitation of cardiac dilatation were demonstrated over the long-term. The actuarial survival at 6 years was 71%. Risk factors influencing perioperative mortality were: age > 65 years, associated surgical procedures, pulmonary vascular hypertension, and patients hemodynamically unstable or on inotropic drug support. Preoperative risk factors influencing the long-term mortality were: permanent NYHA functional class 4, cardiothoracic ratio > 0.60, LV ejection fraction < 15%, bi-ventricular heart failure, and atrial fibrillation. Cardiomyoplasty does not preclude the use of future orthotopic heart transplantation.

Traumatic mitral insufficiency following percutaneous mitral dilation: anatomic lesions and surgical implications.

Percutaneous mitral dilation is a widely accepted technique for treating pure mitral stenosis. Traumatic mitral insufficiency may occur secondary to this technique raising the problem of the feasibility of mitral valve repair. Twenty patients were operated on for traumatic mitral insufficiency following percutaneous mitral dilation. Three patients required emergency operations (within 6 h). In the other cases, surgery was carried out within the following days or weeks. Operative analysis of the mitral valves showed the following lesions: tear of the anterior leaflet (n = 4), tear of the posterior leaflet (n = 2), anterior (n = 4) or posterior (n = 9) paracommissural tear and papillary muscle rupture (n = 1). Associated chordal rupture was found in 3 patients. Septal perforation secondary to transseptal puncture was found in all cases. A septal tear of more than 10 mm was present in 4 patients. Surgery consisted of mitral valve reconstruction (n = 12) or mitral valve replacement (n = 8). Anatomic lesions following percutaneous mitral dilation may affect all the elements of the mitral valve apparatus. The possibility of repair depends more on the degree of calcification of the valve than on the extent of the leaflet tear.

[Traumatic mitral valve insufficiency after percutaneous mitral valve angioplasty. Mechanisms and surgical technique]. / Insuffisance mitrale traumatique après dilatation mitrale percutanée. Mécanismes et technique chirurgicale.

Eighteen patients underwent surgery for traumatic mitral regurgitation following percutaneous mitral valvuloplasty (PMV). Three patients required emergency surgery (delay less than 6 hours). In the remaining cases, the operation was performed one week after PMW (n = 11) or delayed for up to 3 months (n = 4). The operative findings were: ruptured papillary muscle (n = 1); torn anterior leaflets (n = 4), torn posterior leaflet (n = 1), anterior paracommissural tear (n = 3), posterior paracommissural tear (n = 9). Associated lesions included left atrial thrombosis (n = 2) and greater than 1 cm atrial septal defect (n = 4). Conservative mitral valve surgery was possible in over half the cases (n = 10), including two extensive tears of the anterior leaflet. The other patients required mitral valve replacement (n = 8). There were no postoperative complications in any of the patients.