Mini-sternotomy for the treatment of aortic valve lesions.

OBJECTIVE: To compare inverted-L mini-sternotomy performed above the sternal furcula with conventional sternotomy in patients with aortic valve diseases who undergo surgical treatment. METHODS: We operated upon 30 patients who had aortic valve lesions that had clinical and hemodynamic findings. All patients underwent inverted-L sternotomy, which extended from above the manubrium of the sternum to the 3rd right intercostal space, without opening the pleural cavity. Their ages ranged from 32 to 76 years, and 18 were males and 12 were females. We used negative pressure in a venous 1/4-inch cannula, and the patients were maintained in Trendelemburg's position. Twenty-seven patients received bioprostheses with diameters ranging from 23 to 29mm. Three patients underwent only removal of the calcifications of the aortic valve leaflets and aortic commissurotomy. RESULTS: The mean duration of anoxic cardiac arrest was 63.11min. Access was considered good in all patients. One death was due to pulmonary and renal problems not related to the incision. All patients had a better recovery in the intensive care unit, got out of bed sooner, coughed more easily, and performed prophylactic physiotherapeutic maneuvers for respiratory problems more easily and with less pain in the incision. Early ambulation was more easily carried out by all patients. CONCLUSION: Mini-sternotomy proved to be better than the conventional sternotomy because it provided more comfort for the patients in the early postoperative period, with less pain and greater desire for early ambulation and all its inherent advantages.

Arterial distensibility as a possible compensatory mechanism in chronic aortic insufficiency.

OBJECTIVE: To evaluate elastic properties of conduit arteries in asymptomatic patients who have severe chronic aortic regurgitation. METHODS: Twelve healthy volunteers aged 30+/-1 years (control group) and 14 asymptomatic patients with severe aortic regurgitation aged 29+/-2 years and left ventricular ejection fraction of 0.61+/-0.02 (radioisotope ventriculography) were studied. High-resolution ultrasonography was performed to measure the systolic and diastolic diameters of the common carotid artery. Simultaneous measurement of blood pressure enabled the calculation of arterial compliance and distensibility. RESULTS: No differences were observed between patients with aortic regurgitation and the control group concerning age, sex, body surface, and mean blood pressure. Pulse pressure was significantly higher in the aortic regurgitation group compared with that in the control group (78+/-3 versus 48+/-1mmHg, P<0.01). Arterial compliance and distensibility were significantly greater in the aortic regurgitation group compared with that in the control group (11.0+/-0.8 versus 8.1+/-0.7 10(-10) N-1 m4, P=0.01 e and 39.3+/-2.6 versus 31.1+/-2.0 10(-6) N-1 m2, P=0.02, respectively). CONCLUSION: Patients with chronic aortic regurgitation have increased arterial distensibility. Greater vascular compliance, to lessen the impact of systolic volume ejected into conduit arteries, represents a compensatory mechanism in left ventricular and arterial system coupling.

Influence of the maze procedure on the treatment of rheumatic atrial fibrillation - evaluation of rhythm control and clinical outcome in a comparative study.

OBJECTIVE: The aim of this study was to evaluate the influence of the maze procedure on the treatment of rheumatic atrial fibrillation in patients with mitral valve disease. METHODS: Fifty-five patients (mean age 51 years; 47 females) with rheumatic mitral valve disease and associated atrial fibrillation in New York Heart Association functional class III or IV, preoperatively, were operated upon. Thirty-five had double dysfunction, 19 had stenosis, and one had mitral regurgitation. None had other associated heart diseases or previous operations. The patients were divided into two groups: GI, 20 patients were treated for mitral valve disease with associated maze procedure; GII, 35 patients were treated for mitral valve disease without the maze procedure. The preoperative echocardiogram showed a left atrial diameter in GI of 5.35 mm and in GII of 5.57 mm (P=0.779). The groups were considered clinically similar (P=0.759). Cardiopulmonary bypass was used in all patients. The mitral valve was replaced with a biological prosthesis in 24 patients and repaired in 31 patients. RESULTS: Three hospital deaths occurred, one in GI, two in GII. After cardiopulmonary bypass, 37.1% of patients in GII remained in atrial fibrillation. All patients in GI recovered regular rhythm (P<0.0001). In the ICU, atrial fibrillation was detected in 80% of patients in GII and maintained in 76.4% in a mean follow-up period of 38.5 months. In GI, atrial fibrillation occurred in 20% of patients in the ICU and maintained in 5.3% in 41 months of mean follow-up (P=0.0001). None of the patients in GI and 20.6% of patients in GII had a thromboembolic episode 1-63 months after the operation (P=0.041). Four late deaths occurred (two in each group), two being due to progression of valvular disease, one after an episode of pulmonary infection and one with no cardiac cause. CONCLUSION: The maze procedure is effective in treating atrial fibrillation in patients with rheumatic mitral valve disease. The results are sustained in the mid-term follow-up period, preventing postoperative thromboembolic episodes, and with acceptable morbidity and mortality.

Mitral valve repair in rheumatic patients.

BACKGROUND: There is controversy regarding the role of reparative techniques for rheumatic-mitral valve disease. We have analyzed the late results of mitral valve repair in a group of patients with rheumatic mitral valve insufficiency. METHODS: From March 1980 to December 1997, 201 patients with rheumatic fever underwent mitral valve repair at the Heart Institute, Hospital das Clínicas, Medical School, University of São Paulo. The mean age of patients was 26.9 +/- 15.4 years, with 59.7% of the patients being female. Other diagnoses were present in 67.7% of patients; the most common was tricuspid regurgitation (31.3%). Mitral valve repair techniques included: 1) Carpentier ring annuloplasty in 75 patients (37.3%); 2) posterior annuloplasty with bovine patch in 68 patients (33.8%); 3) posterior segmental annuloplasty in 16 patients (7.9%); 4) quadrangular resection of the posterior leaflet with ring plication in 11 patients (5.5%); 5) partial resection of the anterior leaflet in 6 patients (3%); 6) De Vega's annuloplasty in 6 patients (3%); 7) Kay's annuloplasty in 5 patients (2.5%); 8) Reed's annuloplasty in 4 patients (2%); and 9) miscellaneous techniques in 10 patients (4.9%). Combined techniques were used in 94 patients (46.8%), the most frequent of which was chordal shortening (48 patients, 23.9%). Other non-mitral cardiac procedures were performed in 113 patients (56.2%). Actuarial survival and event-free curves (Kaplan-Meier method) were compared by linear regression analysis. RESULTS: The in-hospital mortality rate was 2.0% (four patients). The causes of death were multiorgan failure in two patients and low cardiac output in the other two patients. In the late postoperative period, 83.9% of the patients were in New York Heart Association (NYHA) functional class 1. The actuarial survival was 93.9% +/- 1.9% at a mean of 125 months. Twenty-three patients were reoperated in the postoperative period at a mean interval of 35.7 months. Survival free from reoperation was 43.3% +/- 13.7% at 125 months. When analyzing the patients according to age, actuarial survival was 91.3% +/- 3.8% in the group of patients younger than 16 years (Group 1), compared with 95.6% +/- 2.7% in the group older than 16 years (Group 2), with a statistically significant difference of p < 0.0001. Survival free from reoperation was 50.8% +/- 16.9% in Group 1 and 47.0% +/- 14.9% in Group 2 (p < 0.0001). CONCLUSIONS: Late results obtained with mitral valve repair for rheumatic mitral valve insufficiency were satisfactory and exceeded those reported for mitral valve replacement in the same population.

Symptoms, left ventricular function, and timing of valve replacement surgery in patients with aortic regurgitation.

BACKGROUND: Because cardiac decompensation is subtle, the best time to perform aortic valve replacement surgery may be difficult to determine. We investigated the relation of symptoms to left ventricular (LV) function and the timing of valve replacement in patients with aortic regurgitation (AR) of largely rheumatic origin. METHODS: Sixty-eight initially asymptomatic patients (mean age 29 years) with severe chronic AR were monitored for 36 months. Assessments included baseline and yearly echocardiograms and radioisotope ventriculography (resting and exercise) and clinical examinations every 6 months. RESULTS: Forty-seven patients (69%) remained asymptomatic and 21 (31%) had symptoms develop after 24 to 36 months. Compared with symptomatic patients, asymptomatic patients had significantly (P <.05) lower baseline LV end-diastolic diameter, end-systolic diameter, end-systolic stress, and volume/mass ratio but greater shortening fraction and ejection fraction (EF) at rest. These variables remained stable without statistically significant change until surgical correction in symptomatic patients. Percent variation of EF from rest to exercise increased in patients who remained asymptomatic (EF 2.8% +/- 10.6%) but decreased in those who became symptomatic (EF -4.2% +/- 13%; P <.05). Twenty symptomatic patients (New York Heart Association class III/IV, angina and/or syncope) had valve replacement surgery, after which all were in New York Heart Association class I/II and had significant decreases of LV end-diastolic and end-systolic diameters and an increase on percent variation of EF from rest to exercise (P <.0001). CONCLUSIONS: Development of symptoms did not correlate with change in any ventricular function indexes. Surgery on appearance of symptoms restored LV function to near normal.

Mitral valve repair. Quadrangular resection of the posterior leaflet in patients with myxomatous degeneration.

OBJECTIVE - To analyze the immediate and late results of mitral valve repair with quadrangular resection of the posterior leaflet without the use of a prosthetic ring annuloplasty. METHODS - Using this technique, 118 patients with mitral valve prolapse who underwent mitral repair from January '84 through December '96 were studied. Age ranged from 30 to 86 (mean = 59.1+/-11.8) years and 62.7% were males. An associated surgery was performed in 22% of the patients, and coronary artery bypass graft was the most frequently performed surgery (15 patients - 12.7%). In 20 (16.9%) patients other associated techniques of mitral valve repair were used and shortening of elongated chordae tendineae was the most frequent one (6 patients). RESULTS - Immediate mortality was 0.9% (one patient). Long-term rates for thromboembolism, endocarditis, re-operation and death in the late postoperative period were 0.4%, 0.4%, 1.7% and 2.2% patients/year, respectively. The actuarial curve of survival was 83.8+/-8.6% over 12 years; survival free from re-operation was 91.8+/-4.3%, free from endocarditis was 99.2+/-0.8% and free from thromboembolism was 99.2+/-0.8%. In the late postoperative period, 93.8% of the patients were in functional class 1 (NYHA), with a complete follow-up in 89.7% of the patients. CONCLUSION - Patients with mitral valve prolapse who undergo mitral valve repair using this technique have a satisfactory prognosis over 12 years.

Mitral valve repair. Quadrangular resection of the posterior leaflet in patients with myxomatous degeneration.

OBJECTIVE: To analyze the immediate and late results of mitral valve repair with quadrangular resection of the posterior leaflet without the use of a prosthetic ring annuloplasty. METHODS: Using this technique, 118 patients with mitral valve prolapse who underwent mitral repair from January '84 through December '96 were studied. Age ranged from 30 to 86 (mean = 59.1 +/- 11.8) years and 62.7% were males. An associated surgery was performed in 22% of the patients, and coronary artery bypass graft was the most frequently performed surgery (15 patients--12.7%). In 20 (16.9%) patients other associated techniques of mitral valve repair were used and shortening of elongated chordae tendineae was the most frequent one (6 patients). RESULTS: Immediate mortality was 0.9% (one patient). Long-term rates for thromboembolism, endocarditis, reoperation and death in the late postoperative period were 0.4%, 0.4%, 1.7% and 2.2% patients/year, respectively. The actuarial curve of survival was 83.8 +/- 8.6% over 12 years; survival free from re-operation was 91.8 +/- 4.3%, free from endocarditis was 99.2 +/- 0.8% and free from thromboembolism was 99.2 +/- 0.8%. In the late postoperative period, 93.8% of the patients were in functional class 1 (NYHA), with a complete follow-up in 89.7% of the patients. CONCLUSION: Patients with mitral valve prolapse who undergo mitral valve repair using this technique have a satisfactory prognosis over 12 years.

[Comparison between percutaneous balloon valvuloplasty and open commissurotomy for mitral stenosis]. / Avaliação comparative entre valvoplastia percutânea e comissurotomia a céu aberto na estenose mitral.

PURPOSE: To compare immediate and late (12 months) follow-up of clinical and Doppler echocardiographic results between percutaneous mitral balloon valvuloplasty and open commissurotomy in a prospective and randomized trial. METHODS: Eighty eight symptomatic patients with severe mitral stenosis and favorable anatomy were randomized in a prospective trial comparing the two procedures. All patients were submitted to clinical and Doppler echocardiographic evaluation before the procedures and immediate and twelve months thereafter. RESULTS: Mean mitral gradient (mmHg) decreased from 12.2 +/- 5.8 to 5.80 +/- 2.7 (p < 0.001) in commissurotomy group (CG) and from 11.7 +/- 6.1 to 5.0 +/- 2.4 (p < 0.001) in the balloon valvuloplasty group (VG). Mitral valve are (cm2) increased from 0.98 +/- 0.21 to 2.52 +/- 0.46 in CG and from 1.05 +/- 0.25 to 2.18 +/- 0.40 in VG (p < 0.001). In both groups there was a slight decrease in mitral valve area at 12 month follow-up. There was no death in either group. One patient in the VG had moderate mitral regurgitation and underwent surgery. At the 12 month follow-up, all patients in CG and 97.7% of patients in VG were in New York Heart Association functional class I or II. CONCLUSION: Both procedures were safe and showed similar immediate improvement in mitral gradient and functional class. Mitral valve area had a greater increase immediately after commissurotomy, however, there was a significantly greater reduction in the CG after 12 months of follow-up, when compared to balloon valvuloplasty. In both groups, mitral gradient remained reduced and most patients did not change functional class during the follow-up.

Fisics-Incor bovine pericardial bioprostheses: 15 year results.

BACKGROUND: From March 1982 to December 1995, 2,607 Fisics-Incor bovine pericardial bioprostheses were implanted in 2,259 patients. Mean age was 47.2 +/- 17.5 years, and 55% were male. Rheumatic fever was present in 1,301 (45.7%) patients. METHODS: One thousand and seventy-three aortic valve replacements, 1,085 mitral replacements, 27 tricuspid replacements, 195 mitral-aortic replacements, and 16 other combined valve replacements were carried out. Combined procedures were performed in 788 (32.9%) patients, the most frequent being tricuspid valve repair (9.2%) and coronary artery bypass grafting (7.7%). RESULTS: Hospital mortality was 8.6% (194 patients), 8.6% for the mitral group, 4.7% for the aortic group, and 12.8% for double-valve replacements. The linear rates for calcification, thromboembolism, rupture, leak and endocarditis were, respectively, 1.1%, 0.2%, 0.9%, 0.1% and 0.5% patient-year. The actuarial survival curve was 56.7 +/- 5.4% in 15 years. Survival free from endocarditis was 91.92%, survival free from thromboembolism was 95 +/- 1.7%, survival free from rupture was 43.7 +/- 9.8%, survival free from leak was 98.9 +/- 4.5%, and survival free from calcification was 48.8 +/- 7.9% in 15 years. In the late postoperative period, 1,614 (80.6%) patients were in New York Heart Association functional Class I. CONCLUSIONS: We conclude that the results with the Fisics-Incor bovine pericardial prostheses were satisfactory in our group of patients.

[Results of aortic stenosis surgery in patients with severe ventricular dysfunction]. / Resultados da cirurgia da estenose aórtica em pacientes com disfunção ventricular grave.

PURPOSE: To study the short and long term clinical course of patients with severe aortic stenosis after surgical treatment of the valvular lesion. METHODS: Thirty survivors among 31 consecutive patients with severe left ventricular dysfunction (LVD) due to aortic stenosis (AS) were submitted to clinical and echocardiographic follow-up during a mean of 30 months after surgical treatment of the valvular lesion. Twenty five (83.3%) patients were male with a mean age of 50 years (25 to 74). Before operation the following parameters were obtained: diastolic left ventricular diameter (DLVD), shortening fraction (SF), left ventricular ejection fraction (LVEF), aortic valve area (AVA), left ventricular-aortic pressure gradient (PG) and NYHA functional class (FC). During the follow up, after the surgical procedure, FC, DLVD, LVEF and SF could be analysed and compared with previous data. RESULTS: A significant rise in SF (p = 0.001) and LVEF (p = 0.0001), as well as a decrease in DLVD (p = 0.001) were observed in the follow up. Symptoms lessened in severity in the majority of patients. Three of our patients died with progressive LVD and heart failure, after at least 36 months of follow-up. These results indicate that when operation is carried out in patients with AS and left ventricular failure, a significant improvement in left ventricular function and in symptoms takes place. Although the risk of surgical treatment is increased in this group of patients, LVD should not be considered a contraindication to the procedure. CONCLUSION: The left ventricular dysfunction is not a contraindiction for the surgical treatment of the aortic stenosis.

[Comparative study between inoue single balloon and double balloon in percutaneous mitral valvuloplasty. Immediate results and after 1 year follow-up]. / Estudo comparativo entre balão único de inoue e duplo balão na valvoplastia mitral percutânea. Resultados imediatos e após seguimento de um ano.

PURPOSE: To compare early and 12 months results of mitral stenosis (MS) correction by percutaneous balloon valvuloplasty (PMBV) using Inoue's single-balloon or double balloon techniques. METHODS: We submitted 139 consecutive patients to PMBV using Inoue single-balloon (n = 56, GI) or the double balloon technique (n = 83, GII). The two groups were similar, in: age, sex, functional class (FC), echocardiographic (ECHO) score, mitral valve area (MVA), and gradient (G) or presence of regurgitation. Clinical and ECHO data were compared before (PRE), immediately after (POI) and one year following the procedure (PO12M). RESULTS: PMBV was successfully performed in 53 (95%) patients of GI and in 79 (96%) of GII. Statistical analyses showed that the groups were similar at POI but different at PO12M (p < 0.002). ECHO immediately after PMBV showed that: MVA increased from 0.99 +/- 0.23 to 2.01 +/- 0.44cm2 (p < 0.001) in GI and from 0.94 +/- 0.23 to 2.09 +/- 0.35cm2 (p < 0.001) in GII and G decreased from 11.58 +/- 5.02 to 5.16 +/- 2.23mmHg (p < 0.001) in GI and from 12.48 +/- 4.89 to 5.96 +/- 3.21mmHg (p < 0.001) in GII. After one year 36 (64%) patients in GI and 62 (74%) in GII underwent an ECHO study. A comparison between immediate and one year follow-up results showed that MVA decreased from 2.01 +/- 0.4 to 2.00 +/- 0.3cm2 (NS) in GI and from 2.09 +/- 0.3 to 1.74 +/- 0.4cm2 (p < 0.001) in GII and G decreased from 5.16 +/- 2.2 to 5.50 +/- 2.9mmHg (NS) in GI and from 5.96 +/- 3.2 to 8.61 +/- 4.8mmHg (p < 0.001) in GII. There was therefore a sustained improvement of MVA and G after one year in GI and a significant decrease in MVA and G in GII. The FC after one year was similar and satisfactory in both groups. CONCLUSION: Both techniques are equally effective in relieving MS immediately after PMBV, but after one year, despite similar FC, Inoue-balloon technique seems to be superior to maintain MVA and G.

[Postoperative course of left ventricular function in aortic insufficiency]. / Evolução pós-operatória da função ventricular esquerda na insuficiência aórtica.

PURPOSE: To analyze the follow-up of left ventricular function (LVF) after surgical correction of severe chronic aortic insufficiency (AI). METHODS: Twenty-one out of 68 patients with AI, initially asymptomatic and that developed symptoms during the follow-up period of 24-36 months, were studied. Relationship between symptoms and LVF by echocardiogram and radioisotopic ventriculography at rest and in isotonic exercise were studied. Three clinical moments (CM) were assumed: CM-0- at the beginning of the study, when all patients were asymptomatic; CM-1- manifestation of the symptoms during 24-36 months; CM-2- corresponding to the late post-operative period of 8 months of 20 out of 21 patients (one refused the surgery). The analysis did not show any significant differences between the mean values of all echocardiographic variables (diastolic and systolic diameters, shortening fraction, final systolic stress, volume-mass ratio, contractility index) and the ejection fraction of the left ventricle (EF) obtained by the radioisotope ventriculography at rest and, including exercise, between clinical moments 0 and 1. RESULTS: In the CM-2, involution was verified for functional class I/II in all cases and absence of expressive complications or immediate or late postoperative mortality. Comparison between CM-2 and 0 showed expressive regression of the diameters at rest in the postoperative period and with significant improvement in the means mainly the percentual variation of the EF and total time of effort. CONCLUSION: Symptoms assembled patients with more advanced eccentric hypertrophy and did not coincide with any immediate change in findings studied at rest and at exercise. It represented a point of reference for surgical indication compatible with late postoperative involution of chronic adaptation of AI.