Mid-term follow up of mitral valve reconstruction due to active infective endocarditis.

BACKGROUND AND AIM OF THE STUDY: Mitral valve reconstruction in patients with acute endocarditis (AE) is a challenging operation which prompts the surgeon into immediate action. This report summarizes the mid-term results of 22 patients who required mitral valve reconstruction due to AE. METHODS: Mean patient age was 46 years (range: 20-79 years); mean follow up was 46 months (range: 1-90 months). Preoperatively, >70% of patients had severe mitral regurgitation and were in NYHA functional class III. Surgical techniques used were annuloplasty (n = 16; 10 with Carpentier ring, five Wooler-Kay and one Frater); suture closure of the perforation (n = 1), patch closure of the perforation (n = 5), leaflet resection with primary closure (n = 2), leaflet resection with patch closure (n = 8), and chordal transfer (n = 3). Additional surgery included CABG (n = 3) and De Vega plasty (n = 4). Aortic valve replacement or reconstruction (n = 9) included one mechanical valve, one bioprosthesis, one reconstruction and six homografts. Patients were followed up annually in our outpatient department and/or by questionnaires. RESULTS: Two patients died perioperatively due to either low output syndrome or uncontrolled sepsis. There were three reoperations; two of these were successful, and one patient subsequently died. In addition, one patient died six years after operation due to prostatic cancer, and one seven years later due to progressive heart failure. At the last follow up, 15 patients were in NYHA class I (68%) and five in class II (23%); no or only mild mitral insufficiency was seen on transthoracic echocardiography (91%). The estimated survival rate at 60 months was 87 +/- 12.7%, and 12 patients were followed up for >60 months. No incidence of recurrent valve infection occurred. CONCLUSION: Mitral valve reconstruction in patients with AE shows a low incidence of valve-related complications with promising postoperative functional results and mid-term survival. On this basis, mitral valve reconstruction for mitral insufficiency secondary to AE may be recommended as a valve salvage treatment, when it is technically possible.

Changes following in vitro endothelial cell lining of ePTFE prostheses: late morphologic evaluation of six failed grafts.

This paper describes the morphologic appearance during long term follow-up of in vitro endothelialised ePTFE grafts (IVECL) implanted in patients with crural reocclusions. Between June 1989 and December 1990, 13 femorocrural IVECL bypasses were implanted. Follow-up angiograms demonstrated stenoses in the middle of the graft in six patients. Two of these patients developed symptoms, and the grafts were biopsied approximately 1.5 years after implantation during a patchplasty procedure. The remaining four patients with asymptomatic stenoses refused elective reoperation and suffered a graft occlusion 53 to 619 days after implantation, all leading to amputation. Biopsy specimens and explanted grafts were examined with standard and electron microscopy. Both biopsies demonstrated multiple layers of degenerating myofibroblasts (MFB). The four explanted grafts also showed altered MFB in addition to necrosis of the graft surface. No endothelial cells were seen on any of the preparations. Long term follow up of IVECL protheses in the crural position has demonstrated that it is possible to lastingly bind cells on an artificial surface. Whether the MFB found are a substitute of lost endothelial cells, or are an end product of metaplastic and/or degenerative alterations, can only be clarified through further biopsy studies.

Prospective clinical study with in vitro endothelial cell lining of expanded polytetrafluoroethylene grafts in crural repeat reconstruction.

A nonrandomized prospective clinical study was undertaken to evaluate the technique and efficacy of in vitro endothelial cell lining of synthetic grafts. Twenty-six patients (10 men and 16 women with a mean age of 68.4 years; range, 49 to 80 years) with end stage chronic peripheral vascular disease requiring reoperation were entered into the study. In 13 patients venous endothelial cells were harvested 4 to 7 weeks before operation, grown to confluency in culture flasks, and seeded onto the inner surface of expanded polytetrafluoroethylene grafts. Thirteen patients received untreated expanded polytetrafluoroethylene grafts and served as a control. A scoring system with use of intraarterial angiography was used to assess disease severity. No statistically significant differences in angiographic score were seen between the two groups, indicating comparable severity of disease. Early secondary graft patency (0 to 30 days) was 92% for the in vitro endothelial cell lining group and 53% for control patients. The amputation rate after 18 months for the in vitro endothelial cell lining group was 15%, with a 31% rate in the control group. The functional performance of the in vitro endothelial cell lining bypasses was superior to that of untreated bypass grafts during the observed follow-up period. These early results suggest that in vitro endothelial cell lining is a method that can reduce the early occlusion rate now seen after repeat reconstruction of crural vessels.

[Embolic occlusion of arteries of the upper extremity]. / Der embolische Verschluss der oberen Extremitätenarterien.

Ninety-nine patients underwent embolectomy of upper extremity arteries; in 12% of the cases reoperation and in 4% amputation was necessary. Thrombosis is the cause of reocclusion of the brachial artery, based on endothelial lesions of the axillary passing into the brachial artery. At autopsy studies these andothelial lesions were verified by histological and electron-microscopical examinations in a high percentage. Therefore embolectomies should be performed very carefully by means of thin fogarty catheters. Postoperative anticoagulant therapy seems to improve the survival rate.

[Tumors of the heart and arterial embolisms]. / Tumory srdca a arteriálne embólie.

Tumors of the heart are a rare cause of embolism of the peripheral arterial system. A series of 26 patients operated on for heart tumor in the Institute of Cardiovascular Diseases in Bratislava over the years 1979-1988 was analyzed. Pseudomyxoma was histologically verified in 24 patients and rhabdomyoma and rhabdomyosarcoma in the other two patients. A total of 12 embolic events was recorded in 9 patients (34.6%). There were 8 instances of embolism in the central nervous system and 4 in the extremities. In all cases pseudomyxoma of the left parts of the heart was the source of embolism. In 21 cases diagnosis was established and operation indicated on the basis of ultrasonographic evidence. The authors recommend the biatrial transseptal approach. Early surgical removal of a heart tumor is the therapy of choice which prevents the development of potential complications from the heart and peripheral arteries.