Very long-term results (more than 20 years) of valve repair with carpentier's techniques in nonrheumatic mitral valve insufficiency.

BACKGROUND: Mitral valve repair is considered the gold standard in surgery of degenerative mitral valve insufficiency (MVI), but the long-term results (>20 years) are unknown. METHODS AND RESULTS: We reviewed the first 162 consecutive patients who underwent mitral valve repair between 1970 and 1984 for MVI due to nonrheumatic disease. The cause of MVI was degenerative in 146 patients (90%) and bacterial endocarditis in 16 patients (10%). MVI was isolated or, in 18 cases, associated with tricuspid insufficiency. The mean age of the 162 patients (104 men and 58 women) was 56+/-10 years (age range 22 to 77 years). New York Heart Association functional class was I, II, III, and IV in 2%, 39%, 52%, and 7% of patients, respectively. The mean cardiothoracic ratio was 0.58+/-0.07 (0.4 to 0.8), and 72 (45%) patients had atrial fibrillation. Valve analysis showed that the main mechanism of MVI was type II Carpentier's functional classification in 152 patients. The leaflet prolapse involved the posterior leaflet in 93 patients, the anterior leaflet in 28 patients, and both leaflets in 31 patients. Surgical technique included a Carpentier's ring annuloplasty in all cases, a valve resection in 126 patients, and shortening or transposition of chordae in 49 patients. During the first postoperative month, there were 3 deaths (1.9%) and 3 reoperations (2 valve replacements and 1 repeat repair [1.9%]). Six patients were lost to follow-up. The remaining 151 patients with mitral valve repair were followed during a median of 17 years (range 1 to 29 years; 2273 patient-years). The 20-year Kaplan-Meier survival rate was 48% (95% CI 40% to 57%), which is similar to the survival rate for a normal population with the same age structure. The 20-year rates were 19.3% (95% CI 11% to 27%) for cardiac death and 26% (95% CI 17% to 35%) for cardiac morbidity/mortality (including death from a cardiac cause, stroke, and reoperation). During the 20 years of follow-up, 7 patients were underwent surgery at 3, 7, 7, 8, 8, 10, or 12 years after the initial operation. Valve replacement was carried out in 5 patients, and repeat repair was carried out in 2 patients. At the end of the study, 65 patients remained alive (median follow-up 19 years). Their median age was 76 years (age range 41 to 95 years). All except 1 were in New York Heart Association functional class I/II. CONCLUSIONS: Mitral valve repair using Carpentier's technique in patients with nonrheumatic MVI provides excellent long-term results with a mortality rate similar to that of the general population and a very low incidence of reoperation.

Does bilateral internal thoracic artery grafting increase surgical risk in diabetic patients?

BACKGROUND: The purpose of this study was to determine whether, with appropriate techniques, diabetic patients could benefit from the advantages of double internal thoracic artery (ITA) coronary bypass without an increased hospital risk. METHODS: Between January 1990 and December 1996, 207 consecutive diabetic patients underwent coronary artery bypass graft operations. In 74 patients both arteries (bilateral ITA group) were used, whereas 133 patients received one ITA and vein grafts or vein grafts alone (nonbilateral group). Patients in the bilateral ITA group were younger (p<0.0001), predominantly male (p<0.0001), and were operated on more electively. The internal thoracic arteries were harvested by skeletonization without electrocautery, and strict glycemic control was pursued. RESULTS: No death was observed in the bilateral ITA group, whereas 7 patients died in the nonbilateral ITA group (p<0.05). Deep sternal wound infection was observed in 2 patients in the nonbilateral ITA group (1.5%) and in none of the bilateral ITA group (p = NS). There was no significant difference in the morbidity rate between the two groups except for greater blood losses in the bilateral ITA group. CONCLUSION: Double ITA coronary revascularization in young diabetic patients was performed without increased morbidity and mortality. The low rate of sternal wound infections may be related to ITA harvesting by a skeletonization technique, but larger studies are required to confirm these data.