Repairing the degenerative mitral valve: ten- to fifteen-year follow-up.

From January 1969 to December 1992, mitral valve reconstructive operations were performed on 155 patients with degenerative mitral valve disease. There were 102 male and 53 female patients, with a mean age of 60.5 +/- 9.2 years, a mean duration of symptoms of 3.8 +/- 2.7 years, and 34% were in atrial fibrillation. All patients were in New York Heart Association functional classes III and IV before operation. The degree of mitral regurgitation was severe in 94% and moderate in 6%, and 50.9% of patients had moderate to severe impairment of left ventricular function. Emergency operation was undertaken in 7.1% of cases; 19% of patients underwent additional procedures. All patients had posterior mitral leaflet pathology and 19 patients had anterior mitral leaflet pathology. Ring annuloplasty was used in only 3% of cases. The operative mortality rate was 3.9%, 9% of patients had morbid events, and 4.5% of patients had repair failure within 6 months. All patients have been followed up with serial echocardiography for a mean time of 5.2 +/- 0.3 years (range 0.5 to 24 years). Immediately after operation, 92.9% had no mitral regurgitation to mild mitral regurgitation. At last follow-up, 96.9% had no mitral regurgitation to mild mitral regurgitation by echocardiography and 98% of patients were in New York Heart Association functional classes I and II. The actuarial survival at 15 years was 46% +/- 11%, freedom from reoperation was 84.9% +/- 11%, freedom from infective endocarditis was 96.0% +/- 11%, freedom from thromboembolism was 90.4% +/- 11%, and freedom from all valve-related events was 36.7% +/- 11%. It is well documented that repair of degenerative mitral valves offers excellent short-term and medium long-term benefits. This series represents the longest follow-up reported outside Europe. Our results beyond 10 years support our conclusion that an annuloplasty ring is not an absolute prerequisite for achieving successful repair of proven durability in most patients with degenerative mitral valve disease.

Intercostal lung hernia subsequent to harvesting of the left internal mammary artery.

We report a case of an intercostal lung hernia developing subsequent to harvesting of the left internal mammary artery. Intercostal lung hernia is extremely rare, with most cases reported after blunt thoracic trauma. In the absence of symptoms, this was treated conservatively.

Repair of the anterior mitral leaflet.

BACKGROUND: Repair rather than replacement of the diseased mitral valve has been the goal of the cardiac surgeon. Although well accepted for posterior leaflet pathology, a diseased anterior leaflet was believed by some to be irreparable. AIMS: To assess the result of reconstructive mitral valve surgery involving the anterior mitral leaflet in a selected group of patients. METHODS: Twenty consecutive patients with degenerative (19), ischaemic (one) and congenital/calcific mitral regurgitation were evaluated. There were five females and 15 males with a mean age of 62 +/- 12 years (41-75 years). The technique used to repair these valves included chordal transposition, leaflet plication commissuroplasty and a new technique we call leaflet repositioning. RESULT: There were no deaths, follow-up is complete with mean follow-up of 31 +/- five months (two-102) months. All patients have had 2DE and 13 TOE as well. There have been no reoperations due to failure of the repair, 95% of patients are in NYHA Class I-II post operative, while 15% have significant residual regurgitation.

Repairing the degenerative anterior mitral leaflet.

This is a consecutive, nonselected series of 18 patients with degenerative mitral regurgitation requiring a reparative operation on the anterior mitral leaflet. A new technique of double-breasting the two leaflets when flail septal segments are encountered is introduced.

Spontaneous dissection of the left main coronary artery: case report and review of the literature.

Primary coronary artery dissection is a rare cause of myocardial infarction. It should be suspected in young, healthy females. It is a condition which is treated by myocardial revascularisation.

An unusual cause of mitral incompetence: post-traumatic paraprosthetic mitral incompetence.

Nonpenetrating chest trauma, particularly that involving high-speed, may cause a variety of cardiac and aortic injuries. Cardiac valvular disruption following trauma is uncommon. Two cases of paraprosthetic mitral incompetence following blunt chest trauma are presented to document this entity and to discuss its investigation and management. Clinical examination and a high index of suspicion are foremost in making the diagnosis. Noninvasive tests may not confirm clinical diagnosis and cardiac catheterization has provided confirmation of clinical diagnosis.

Results of a technique of mitral valve repair.

A particular technique for mitral repair of the posterior leaflet prolapse of the mitral valve has been used at Royal North Shore Hospital over a 15-year period. The anatomical details, complications and results of repair, as well as mortality, are reviewed in a group of 49 patients. Surgery in this group was performed with three peri-operative deaths. Three patients required re-operation due to the failure of repair; one patient within one month of surgery and the others at 6.5 and 9 years. All patients improved symptomatically following mitral repair. This series demonstrates that the repair of posterior leaflet prolapse can be performed in all patient age groups with low mortality and morbidity rates. A low incidence of reoperation for failure of repair and other complications related to valve surgery can be anticipated.

Complications of ascending aortic intraaortic balloon pump cannulation.

Choice of a route of cannulation for intraaortic balloon counterpulsation during cardiopulmonary bypass is related to accessibility. In those patients in whom it is impossible to pass the intraaortic balloon pump (IABP) into the common femoral artery, ascending aortic cannulation is a rapid and direct method of insertion. Eight patients are described in whom ascending aortic IABP cannulation was undertaken to enable weaning from cardiopulmonary bypass after cardiac surgical procedures. The following problems were encountered: graft infection, aberrant cannulation of the left subclavian artery, left coronary artery embolism, and inability to close the sternum due to mechanical tamponade. A technique is described for insertion of the IABP using a polytetrafluoroethylene (Impra) graft and closed-chest decannulation. Although considerable morbidity and mortality are associated with ascending aortic cannulation, it is simple, fast, and effective, and should be considered for all patients requiring postoperative IABP support in whom peripheral vascular disease makes access difficult.