Rheumatic mitral valve repair: 22-year clinical results.

BACKGROUND AND AIM OF THE STUDY: Rheumatic mitral valve disease presents a surgical and a medical challenge to surgeons in the developing and developed world. Comprehensive reproducible repair techniques of the anatomic units in individual patients are required to restore the normal mitral valve anatomy and function. METHODS: Between April 1986 and December 2009, a total of 2,211 patients underwent mitral valve repair at the authors' institution. Of these patients, 50 (32 women, 18 men) underwent repair at a median age of 45.6 years. Pure mitral stenosis was identified in four cases (8%), pure mitral regurgitation in 37 (74%), and mixed lesions in nine (18%). Posterior leaflet plication, Paneth posterior suture and autologous pericardial strip annuloplasty, chordal transfer and papillary muscle splitting were used to repair a rheumatically diseased mitral valve with leaflet prolapse, annulus dilatation and elongated or restricted chordae and malformed papillary muscle. RESULTS: Three deaths (6%) occurred in hospital (< or = 30 days), and 14 late deaths occurred between 60 days and 14 years. The overall survival was 94.1 +/- 3.3%, 87.5 +/- 4.8%, 84.7 +/- 5.4%, 66.9 +/- 7.9% and 50.2 +/- 9.3% at 30 days and one, five, 10 and 15 years, respectively. Successful repair was achieved in 39 cases (78%). Actuarial freedom from severe mitral regurgitation and reoperation at one, five and 10 years was 92.7 +/- 4.1%, 77.3 +/- 7.2% and 53.4 +/- 9.6%, respectively, and was 78% for Paneth posterior suture and autologous pericardial strip annuloplasty at five and 10 years. The linearized rate for reoperation in the age groups < 20 years and > 20 years was 4.5%/pt-yr (range: 2.0-10.2%/pt-yr) and 4.3%/pt-yr (range: 2.5-7.2%/pt-yr), respectively. CONCLUSION: Mitral valve repair in rheumatic disease is feasible, but the results are suboptimal. Pure mitral incompetence may be reparable and long-lasting, whilst mixed lesions may be reparable but fail subsequently. The predictability of repair and long-term functional results was determined by perioperative echocardiographic evaluation and the application of an appropriate repair technique to treat the complex pathology of the mitral valve apparatus.

Mitroflow aortic pericardial bioprosthesis--clinical performance.

OBJECTIVE: Advancing life expectancy with the increased prevalence of aortic valve degenerative disease brings the need for an aortic bioprosthesis with excellent haemodynamic performance and comparable durability. The Mitroflow bioprosthesis has been on the worldwide market, except in the United States, since 1982, while the current model (1991) has only recently gained regulatory approval in the latter country. This study was primarily performed to determine the durability of the current Mitroflow bioprosthesis. METHODS: The contemporary Mitroflow bioprosthesis was implanted in 381 patients in three centres. The mean age was 76.4 years (range 53-91 years) and the mean follow-up period was 5.4+/-3.4 years, a total of 2048.7 years of evaluation. Prosthesis-patient mismatch (PPM) was classified by reference effective orifice area index categories: normal > or = 0.85 cm(2) m(-2) (53.9%), mild 0.84-0.76 cm(2) m(-2) (33.9%), moderate < or = 0.75-0.66 cm(2) m(-2) (11.7%) and severe < or = 0.65 cm(2) m(-2) (0.5%). RESULTS: The survival, at 10 years, was 39.9+/-7.9% for 50-69 years, 27.0+/-3.7% for 70-79 years and 16.6+/-4.4% for > or = 80 years (p=0.011). There was a trend (p=0.063) influencing survival for moderate-to-severe PPM. Of the independent predictors influencing survival--moderate-to-severe projected effective orifice area index (pEOAI) (Hazard Ratio (HR) 1.6, p=0.0142) and left ventricular dysfunction (ejection fraction < 35%) (HR 1.9, p=0.0193) were included. The 10-year freedom from structural valve deterioration (SVD) at explant assessing the same age groups as survival was not different (p=0.081). The 10-year actual/actuarial freedom from SVD, at explant was for > or = 60 years--94.4+/-1.4% (85.2+/-3.9%), for > or = 65 years--94.2+/-1.4% (85.0+/-4.0%), for 61-70 years--97.4+/-2.6% (95.7+/-4.3%) and for > 70 years--94.0+/-1.5% (83.2+/-4.6%). CONCLUSIONS: The Mitroflow external mounted, pericardial aortic bioprosthesis with documented excellent haemodynamics (especially for the small aortic root), demonstrates that prosthesis-patient mismatch in moderate and severe categories can essentially be eliminated, with durability performance comparable to other heterograft (porcine and pericardial) bioprostheses.

Aortic valve replacement with the Mitroflow pericardial bioprosthesis: durability results up to 21 years.

OBJECTIVE: The study aim was to analyze the performance profile of a large series of Mitroflow pericardial valves (Sorin Group Canada Inc. Mitroflow Division) in the very long term. METHODS: Data from 1513 patients with isolated aortic valve replacement who received pericardial bioprostheses between 1986 and 2007 were analyzed. Cumulative duration of follow-up was 6164 patient-years with a maximum duration of 21 years. Actuarial rates of valve-related events were calculated by the Kaplan-Meier method and the Cox multivariate analysis to identify independent determinants of outcome. RESULTS: Hospital mortality for elective surgery was 2.5%. Late death was 40.6%. Reoperation was required in 86 (5.7%) patients and was valve related in 83: structural valve deterioration in 64 (4.2%) patients, prosthetic valve endocarditis in 17 patients (1.1%), valve thrombosis in 1, and periprosthetic leak in 1. Rates of 20-year actuarial freedom from valve-related morbidity were as follows: structural valve deterioration 84.8% (actual 96.6%) in patients 70 years of age or older; thromboembolism 94.1%; and prosthetic valve endocarditis 96.8%. Twenty-year actual risk of reoperation for structural valve deterioration was 11.4% in all patients and 3.4%, in patients 70 years or age or older. Advanced age, renal insufficiency, pulmonary disease, and low body mass index were independent risk factors for late outcome (P < .001). CONCLUSIONS: After 2 decades of follow-up, the Mitroflow pericardial aortic valve continues to be a valve of choice with a predictable low rate of valve-related events, particularly for patients over the age of 65 to 70 years and others with comorbidities.

Heart valve operations in solid organ recipients: an 18-year single-center experience.

BACKGROUND: We retrospectively analyzed the outcome of heart valve operations in solid organ recipients, who were referred for operation to our institution. METHODS: Over an 18-year period, 23 heart (group 1) and 16 renal (group 2) transplant recipients in New York Heart Association (NYHA) classes III and IV underwent valve operation. The mean interval from the time of transplantation to cardiac surgery was 77.9 months with a mean follow-up time of 34.6 months in group 1 and 87.2 months with a mean follow-up time of 39.2 months in group 2. RESULTS: Group 1 underwent tricuspid valve replacement (n=12), tricuspid valve reconstruction (n=7), aortic valve replacement (AVR, n=3), and mitral valve replacement (MVR, n=1). In group 2, mechanical valve replacement was performed in 14 patients (9 AVR, 3 MVR, 2 AVR and MVR) and tricuspid or mitral valve reconstruction in two patients. There was no operative death. During hospitalization, multiorgan failure due to sepsis was the main cause of mortality (2 in both groups). In the mean follow-up period of 41.2 months, there were four late non-cardiac-related deaths in group 1. Currently 29 surviving transplant recipients (16 heart, 69.6% and 13 renal, 81.3%) are in NYHA classes I and II. CONCLUSION: In heart and renal recipients, valve operations can be performed effectively and safely with acceptable mortality, low cardiac morbidity, and excellent clinical results, although infection is the most serious complication.

Surgical treatment of right-sided active infective endocarditis with or without involvement of the left heart: 20-year single center experience.

OBJECTIVE: The aim of this paper is to review the 20-year experience of surgical treatment of right-sided infective endocarditis at our institution, and in particular to compare the outcome of isolated right-sided endocarditis to right-sided endocarditis with involvement of the left heart. METHODS: Between April 1986 and April 2006, 84 operations had to be performed in 79 patients (49 men, median age 43.5 years). There were 72 (85.7%) cases of native and 12 (14.3%) of prosthetic valve endocarditis. In 57 (67.9%) cases, operation was for isolated right-sided endocarditis (RSE) and in 27 (32.1%) cases for combined right and left-sided endocarditis (RLSE). Follow-up was completed in all 91% of survivors. The median follow-up time at 448 patient years was 3.59 years (range 6 months-19.27 years). RESULTS: There was a highly significant difference between the survival rates of patients operated on due to RSE compared to RLSE: the 30-day, 1-, 5-, 10- and 20-year survival rate after RSE operation was 96.2%, 88.4%, 73.5%, 70.4% and 70.4%, respectively, compared to 72.0%, 67.8%, 50.8%, 35.6% and 35.6% after operation for RLSE (p=0.0093). Patients with RLSE more often underwent emergency operations (p<0.001), preoperatively were more often on high-dose catecholamines (p<0.006) and intraoperatively showed more abscess formation (p<0.001). Freedom from reoperation at 30 days, 1-, 5-, 10- and 20-year was 97.4%, 95.9%, 92.2%, 88.6% and 88.6%, respectively. Risk factors for early mortality were priority of surgery with an odds ratio (OR) of 5.13, age over 40 years (OR 1.04 and 3.24) and left heart involvement (or 2.54). CONCLUSIONS: Our surgical strategy for right-sided infective endocarditis is based on three principles: (1) debridement of the infected area or vegetectomy; (2) valve repair whenever possible, avoiding artificial material; (3) if valve replacement is unavoidable, use of a biological substitute without any artificial material that might become infected. Following these strategies surgery of right-sided infective endocarditis with or without left-side involvement can be performed with good early, mid-term and long-term results. Patients with involvement of the left side showed not only worse preoperative conditions but also a significantly poorer clinical outcome than those with isolated right-sided infective endocarditis.

Seventeen-year clinical results of 1,037 Mitroflow pericardial heart valve prostheses in the aortic position.

BACKGROUND AND AIM OF THE STUDY: It is generally believed that the pericardial tissue valve is associated with a greater propensity to early structural failure and subsequent valve-related complications. However, a modified valve design during recent years has considerably improved the clinical durability of this bioprosthesis. METHODS: Between April 1986 and December 2003, single Mitroflow pericardial valve prostheses were inserted in the aortic position in 1,037 patients (mean age 72.4 +/- 8.4 years). Coronary artery bypass grafting (CABG) was performed in 373 patients (36%). Preoperative echocardiographic findings of structural valve deterioration (SVD) were confirmed at reoperation. Total follow up was 5,022 patient-years (pt-yr) (mean 4.85 +/- 4.7 years) and was 99.7% complete (three patients lost). RESULTS: Early (30-day) mortality was 2.9% for elective surgery; 434 patients (41.9%) died during the follow up period. Actuarial survival at 17 years was 23.2 +/- 2%. Actuarial freedom from valve-related mortality at 17 years was 92.0 +/- 2.2%, whereas the linearized mortality rate was 0.4%/pt-yr. Linearized valve-related complications occurred at a rate of 3.6%/pt-yr (n = 122). SVD of Mitroflow bioprostheses occurred at a rate of 1.0%/pt-yr, and caused stenosis (36.7%), insufficiency (20.4%) and combined stenosis and insufficiency (42.9%). Actual freedom from SVD at 17 years was 95.3 +/- 0.7% for all patients, 96.2 +/- 0.6% for those aged > 60 years, and 99.0 +/- 0.4% for those aged > 70 years. CONCLUSION: The Mitroflow pericardial bioprosthesis, in the aortic position, provides an excellent clinical performance and a low rate of valve-related morbidity, mortality and reoperation for up to 17 years. The prosthesis also demonstrates satisfactory hemodynamic performance, and is therefore recommended for patients aged > or = 70 years and for those aged 60-69 years with comorbidities.