Repair of anterior leaflet prolapse by papillary muscle repositioning: a new surgical option.

BACKGROUND: Although mitral valve repair is considered the gold standard for treating mitral regurgitation, anterior leaflet prolapse may still remain a challenging problem. This challenge is even greater for posterior commissural prolapse. We have used papillary muscle repositioning to treat anterior leaflet prolapse and suggest it as an alternative technique for all other methods previously described. METHODS: From 1989 to 1999 we performed 253 mitral valve repairs, among which 132 involved anterior leaflet prolapse. In this population there were two groups: group I (n = 92) treated with papillary muscle repositioning and group II (n = 40) treated with chordal shortening. There was no statistical difference between the two groups concerning age, functional class, and left ventricular function. Etiology was similar in both groups, a degenerative process being predominant. At echocardiography, regurgitation was graded 3.4/4 in both groups. There was no statistical difference concerning preoperative ejection fraction, end-systolic and end-diastolic left ventricular diameter. RESULTS: There were one in-hospital death in group I and two deaths in group II not related to mitral valve repair. Mean follow up is 36.4 +/- 29.2 months in group I and 70.5 +/- 9.5 months in group II. No patient was lost to follow-up. Mean regurgitation at follow-up was 0.75 +/- 0.67 in group I and 0.8 +/- 0.8 in group II (p = not significant). There was no statistical difference between the two groups concerning postoperative ejection fraction, end-systolic and end-diastolic left ventricular diameter. There was no late cardiac death in either group and there were no thromboembolic events. Actuarial survival rate is 98.9% and 96.3% in group I and 92.5% and 88.1% in group II at 3 and 8 years, respectively. CONCLUSIONS: Therefore, we conclude that papillary muscle repositioning is a safe technique that provides excellent results at mid-term follow-up and facilitates treatment of anterior leaflet prolapse.

Antegrade cerebral perfusion with cold blood: a 13-year experience.

BACKGROUND: In 1986 we introduced the technique of antegrade selective perfusion of the brain with cold blood during surgery of the aortic arch. METHODS: Between January 1984 and March 1998, 171 patients (118 males and 53 females) aged 25 to 83 years (mean 56.5 +/- 17), underwent replacement of the transverse aortic arch with the aid of cold blood antegrade selective perfusion. One hundred twenty two patients (71.3%) with chronic lesions were operated on electively; 49 patients (28.6%) were operated on urgently for acute aortic dissection (42 patients) or for a ruptured chronic aneurysm (7 patients). Fifty-one patients (29.8%) had previously undergone a surgical procedure on the thoracic aorta. Mean duration of cardiopulmonary bypass was 121 minutes (range: 65-248); mean duration of cerebral perfusion was 60 minutes (range: 15-90), and mean duration of systemic circulatory arrest circuit was 32 minutes (range: 10-57). The electroencephalogram, routinely recorded, showed disappearance of electrical activity in a mean of 9 minutes (range: 3-16) initial return of electrical activity after a mean of 12 minutes (range: 1-35) and normalization in a mean time of 66 minutes. RESULTS: All patients but 7 (4%) showed signs of normal awakening within 8 hours postoperatively. Six patients (3.5%) had fatal neurologic complications, and 16 patients (9.3%) had a non-fatal neurologic complications. Twenty-nine patients (16.9%) died during the postoperative hospital course. There was a significant difference between patients aged less than 60 years (9%) and patients older than 60 years (mortality rate 26.4%, p < 0.02). There was also a significant difference between patients undergoing an isolated replacement of the arch, and those in whom the replacement was extended to the descending aorta in whom mortality was 36.4% (chi2, p < 0.02). Lesion and gender had no significant influence on the outcome of the patients, nor had the duration of cardiopulmonary bypass, circulatory arrest, and cerebral perfusion. In particular, no correlation could be established between the duration of cerebral perfusion and the occurrence of neurologic complications. CONCLUSION: The clinical results obtained throughout this experience have demonstrated that selective antegrade cerebral perfusion with cold blood provides excellent protection during surgery of the transverse aortic arch. In addition, it avoids the use of deep hypothermia and prolonged cardiopulmonary bypass and does not limit the time allowed to perform the aortic repair. In our opinion it is the technique of choice, especially in frail patients or those requiring a long and difficult procedure.

Surgery for acute type A aortic dissection: the Hopital Foch experience (1977-1998).

BACKGROUND: In 1977, we proposed the use of gelatin-resorcinol-formol (GRF) biological glue during surgery for acute type A aortic dissection. METHODS: From January 1977 to March 1998, 204 patients (146 men and 58 women) aged from 15 to 79 years (mean 54 +/- 11) underwent emergency operation for type A aortic dissection in our institution. One hundred sixty-five patients (84%) were operated on within 48 h after the onset of symptoms. Twenty-eight patients (13.7%) had Marfan's syndrome. In 43 patients (23%), the aortic valve was replaced either independently (6, 3%) or by means of a composite graft (37, 18.1%). Because of the location of the intimal tear, aortic replacement included the transverse arch in 60 patients (29.4%). RESULTS: Hospital mortality was 21% (39 patients): 25% in patients with arch replacement and 19.4% in patients without arch replacement (ns). One hundred sixty-one patients were discharged and followed from 2 months to 21 years postoperatively (mean 85 +/- 66 months). During this interval, 25 patients (15.5%) required reoperation for a total of 33 reoperations. Seven patients (28%) died at reoperation. Upon univariate analysis, presence of Marfan's syndrome (p < 0.05) and absence of arch replacement (p < 0.02) were risk factors for reoperation. Emergency operation (p < 0.01) and thoracoabdominal replacement (p < 0.04) were risk factors for death at reoperation. The actuarial freedom from reoperation (Kaplan-Meier, confidence interval 95%) is 96.1% (90.9%-98.2%) at 1 year, 87.6% (79.8%-92.7%) at 5 years, 80.9% (70.8%-88.1%) at 10 years, and 66.4% (51.1%-78.9%) at 15 years. A total of 39 patients (24.3%) died during follow-up. The presence of Marfan's syndrome (p < 0.01), reoperation (p < 0.02), stroke (p < 0.05), and cardiac failure (p < 0.05) were risk factors for late mortality. The actuarial late survival including hospital mortality is 71.5% (64.3%-77.8%) at 1 year, 66% (58.3%-73%) at 5 years, 56.4% (47.7%-64.7%) at 10 years, and 46.3% (36.4%-56.5%) at 15 years. CONCLUSIONS: The GRF glue has proven extremely useful during emergency initial surgery for acute type A dissection, making the procedure much easier and safer. As a result of this operative improvement, the use of the GRF glue seems to have had a beneficial influence on late results, but these also depend upon the patient's basic condition.

Hemopump 31, the sternotomy Hemopump: clinical experience.

BACKGROUND: Postcardiotomy cardiogenic shock remains a challenging situation. Many devices can be used although none of them directly unload the left ventricle except for the Hemopump. We report our clinical experience with the Hemopump 31 or sternotomy Hemopump. METHODS: From 1992 to 1994, 15 patients received a Hemopump 31. All suffered postcardiotomy cardiogenic shock either after coronary artery bypass grafting (n = 14) or after heart transplantation (n = 1). Patients enrolled had refractory heart failure despite the use of optimal inotropic support. Three groups can be identified: group 1 (n = 2 patients), double Hemopump right and left; group 2 (n = 4), patients with delayed insertion after intraaortic balloon pump failure; and group 3 (n = 9 patients), immediate insertion. The average support of duration for the survivors was 5 days. RESULTS: No mechanical failure or device-related complication was noticed. There were striking differences between groups 1 and 2 as opposed to group 3, as only 1 patient survived in group 2 and none in group 1, as opposed to 5 patients in group 3. Overall survival is 40%. All patients were discharged from the hospital. CONCLUSIONS: Factors showing adverse effect are biventricular failure, vasoconstrictor requirement, and delayed insertion. We believe the Hemopump is a more efficient device than the intraaortic balloon pump, and that early use after onset of heart failure achieves better results.

The autologous tissue cardiac valve: a new paradigm for heart valve replacement.

This is a report of early clinical experience with an autologous tissue cardiac valve, which demonstrates the feasibility of making a bioprosthesis in the operating room in 10 minutes at the time of the valve replacement operation. There were 30 implant patients (18 men, 12 women), with ages ranging from 32 to 83 years. Diagnoses included calcified aortic stenosis (n = 16), pure aortic insufficiency (n = 9), and mixed aortic stenosis and insufficiency (n = 5). Associated diagnoses have included chronic renal failure treated with dialysis (n = 1), coronary artery disease requiring concomitant coronary bypass (n = 1), ascending aortic aneurysm requiring resection (n = 3), and mitral insufficiency requiring concomitant mitral valvuloplasty (n = 2). All of the valve replacements were in the aortic position. These implanted patients are being followed up carefully according to the protocol that requires examination every 6 months for the first year and every 12 months subsequently. No patient has been lost to follow-up. Twenty-seven patients are alive and well from 1 to 22 months postoperatively. There were three deaths: two perioperative deaths (one perivalvular leak and one hemorrhage) and one infective endocarditis 1.3 years after valve replacement. All surviving patients were followed up by echocardiographic examination (mean gradient, 15.5 +/- 6.8 mm Hg at 1 year). In conclusion, the feasibility of this method and concept has been demonstrated with implants in 30 patients. The validity of the technique will be judged by clinical results and experiences in children.

Myocardial viability assessment in ischemic cardiomyopathy: benefits of coronary revascularization.

Patients with ischemic heart disease, congestive heart failure, and low ejection fraction are usually referred for orthotopic heart transplantation. Based on results of myocardial viability assessment, we have prospectively used either coronary artery bypass grafting or orthotopic heart transplantation. From January 1990 to June 1992, among 50 patients initially referred for heart transplantation, 46 showing myocardial viability underwent bypass grafting. Forty-five of these 46 patients were men, and the mean age was 58 +/- 12 years (range, 40 to 70 years). Congestive heart failure was present in all patients, and dyspnea was the main symptom in 80% (37/46). Patients were selected according to three criteria. (1) Myocardial viability was primarily assessed by thallium scintigraphy for up to 24 hours (28/46 patients). When results were negative, patients underwent positron emission tomography (20/46 patients). (2) Regional left ventricular function was assessed using gated blood pool single-photon emission computed tomography combined with (3) full hemodynamic evaluation. Results were as follows: end-diastolic volume, 129 +/- 35 mL/m2; ejection fraction, 0.23 +/- 0.06; cardiac index, 2.4 +/- 0.62 L.min-1.m-2; mean pulmonary artery pressure, 26 +/- 0.90 mm Hg; and mean pulmonary capillary wedge pressure, 16 +/- 1.10 mm Hg. Operative mortality was 2.17% (1/46). During follow-up (mean duration, 18 months), there were three late cardiac-related deaths (arrhythmias) and two noncardiac-related deaths. The 40 long-term survivors are in New York Heart Association class II. Angiography (15 patients) or gated blood pool single photon emission tomography (32) showed improvement in mean ejection fraction to 0.39 +/- 0.13 (range, 0.22 to 0.46).(ABSTRACT TRUNCATED AT 250 WORDS)