摘要:

Background Surgical valve repair for mitral regurgitation has significant advantages over valve replacement, but the durability of the technique varies according to the cause of mitral valve disease.In this study, we examined the long-term performance of this procedure in a young rheumatic population and also attempted to identify factors predicting a poor outcome.Methods and Results Between January 1981 and 1989, 308 patients underwent primary mitral valve repair for rheumatic mitral regurgitation at our institution.Forty-nine patients who failed to report after surgery and another 5 with discordant data were excluded from the analysis. Mitral regurgitation was pure in 182 patients (72%) and associated with mild commissural fusion in 72 patients (28%). Patient ages ranged from 6 to 52 years (mean, 18+-9 years). A total of 243 patients (96%) were in New York Heart Association class III or IV before surgery, and 66 (26%) had atrial fibrillation. Mean follow-up period was 60+-35 months (range, 1 to 132 months). Rheumatic activity was present clinically in 30% and macroscopically during surgery in 32%. Surgical techniques included insertion of a Carpentier ring (99%), chordal shortening (88%), leaflet resection (14%), chordal transposition (7%), and commissurotomy (28%). Operative mortality was 2.6%, late mortality was 15%, and the reoperation rate was 27%. At 5 years, 96.8% of the patients were free from thromboembolism, 97.7% were free from endocarditis, 74.9% were free from reoperation, 66% were free from valve failure, and 66.2% were free from major events. Multivariate analysis identified active rheumatic carditis as a significant predictor of reoperation, valve failure, and future events, while sinus rhythm and shorter bypass time at initial surgery were the only predictors of long-term survival. Patients with pure mitral regurgitation, sinus rhythm, and no active carditis at initial operation had the best overall 5-year results. Among the 148 survivors without reoperation, 142 (96%) were in New York Heart Association class I and II, and 107 (72%) were in sinus rhythm. Doppler echocardiographic studies showed absence of mitral regurgitation in 34 patients (23%), severe regurgitation in 23 (16%), and severe mitral stenosis in 6 (4%).Conclusions Mitral valve repair in this young rheumatic population is associated with a high long-term morbidity. Presence of active rheumatic carditis has a significantly adverse effect on the success of mitral valve repair. (Circulation. 1994;90(part II):II-167-II-174.)

ISSN:0009-7322    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background Aortic valve surgery for endocarditis remains a high-risk procedure. The objective of this study was to analyze the interaction between the various subsets of endocarditis (native, prosthetic, healed, and active), timing of surgery, and their influence on early and late outcomes.Methods and Results During a 20-year period starting January 1972, 200 patients underwent aortic valve replacement for infective endocarditis (age range, 13 to 88 years; median, 53 years). There were 51 (26%) females, and 109 (55%) were in New York Heart Association functional class IV before surgery. Native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE) were present in 132 (66%) and 68 (34%) patients, respectively. Surgery was required in 120 (60%) during the active phase (AE) and 80 (40%) during the healed phase (HE) of endocarditis. The main indication for surgery in the healed group was progressive congestive heart failure. The indications for the active group were congestive heart failure (68%), continuing active sepsis (70%), echocardiographic vegetation (28%), peripheral emboli (30%), and arrhythmias (13%). Streptococcal infections predominated in NVE, staphylococcal in PVE and AE; culture-negative endocarditis predominated in the healed group. Isolated aortic valve surgery was performed in 68% of the patients, and concomitant procedures (32%) included mitral valve and coronary bypass procedures. The overall operative mortality (OM) was 12.5%. The OM was 7.5% and 22% for NVE and PVE, respectively (P=.004), and 7% for HE versus 15% for AE (P=.06). The OM for early PVE was 33% versus 18% for late PVE (P<.05). Multivariate logistic regression analysis identified PVE and New York Heart Association functional class IV to be independent predictors for early death. Recurrent endocarditis occurred 26 times in 24 patients (11 early, 13 late), with three operative deaths in the early group, all due to residual staphylococcal infections. Freedom from recurrent endocarditis was significantly different between HE (96+-3% and 86+-6% at 5 and 10 years, respectively) and AE (89+-3% and 83+-4%, respectively) (P=.02). Long-term survival for discharged patients was 81+-3% and 63+-5% at 5 and 10 years, respectively, with no significant difference between NVE, PVE, AE, and HE.Conclusions These data suggest that for active endocarditis, surgery should be delayed to achieve a healed status provided there is no pressing need for immediate surgery.Patients with staphylococcal endocarditis, particularly on a prosthesis, should be operated on sooner and should be covered with antibiotics for an extended period to prevent recurrent PVE. This study stresses the need for aggressive antibiotic prophylaxis, particularly in the presence of a prosthesis. (Circulation. 1994;90(part 2):II-175-II-182.)

ISSN:0009-7322    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background To characterize gender differences in recovery of ventricular function and survival after aortic valve replacement (AVR), baseline characteristics related to outcome were analyzed in 1012 consecutive patients (329 women and 683 men) undergoing AVR in 1983 through 1990.Methods and Results Seventy-seven percent of patients had aortic stenosis (AS), 11% insufficiency (AI), and 12% mixed AS/AI; 42% underwent concomitant coronary artery bypass. Women as a group had a greater mean age (P<.0001), had AS more frequently than AI or AS/AI (P<.01), had coronary disease less frequently (P<.01), and had a higher preoperative left ventricular ejection fraction (EF) (P<.0001), although preoperative New York Heart Association (NYHA) functional class was similar (P=NS) compared with men. Male sex (P<.0001), advanced age (P<.0003), AI rather than AS (P<.01), and greater extent of coronary disease (P<.04) were independently associated with lower preoperative EF. Women with coronary disease were as likely as men (P=NS) to undergo concomitant coronary bypass, and completeness of revascularization did not differ (P=NS) by gender. Observed survival probabilities after AVR (expressed as 30-day/5-year) were.97/.81 overall,.94/.77 for women, and.98/.83 for men (P<.02). Cox model analysis showed advanced age, decreased preoperative EF, greater extent of coronary disease, requirement for annular enlargement, smaller prosthetic valve size, and advanced NYHA class (all P<.04) but neither female sex nor smaller body surface area (both P=NS) as multivariate risk factors for overall mortality. In 664 patients (66%), postoperative EF was measured a mean 1.4 years after AVR. In patients with preoperative EF <=45% (n=167), the change in EF after AVR was greater (P<.02) in women (from 33+-8% to 48+-15%, P<.001) than in men (from 32+-9% to 42+-15%, P<.001). By multivariate regression analysis, female sex (P<.02) and lesser extent of coronary disease (P<.05) were independent predictors of early improvement in EF. Improvement in EF conveyed an independent subsequent survival benefit to both women (P<.03) and men (P<.001), and the magnitude of benefit did not differ (P=.4) between the two groups.Conclusions These data suggest that gender-related factors importantly influence the adaptive and recovery response of the left ventricle to pressure and volume overload. However, gender differences in LV adaptation do not influence survival after AVR. (Circulation. 1994;90(part 2):II-183-II-189.)

ISSN:0009-7322    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background The late hemodynamic effects of preserving the papillary muscles during mitral valve replacement have not been evaluated.Methods and Results Sixteen patients who had chronic mitral regurgitation due to myxomatous degeneration were randomized to preservation (Pres group, n=8) or no preservation (No Pres group, n=8) of the chordae tendineae and papillary muscles during mitral valve replacement.Rest and exercise nuclear ventriculograms were performed early (3 months) and late (5 years) after surgery. Early after surgery, the No Pres group had lower ejection fractions and stroke work indexes (P<.05 by repeated-measures (rm) ANOVA) than the Pres group did at similar end-diastolic volume indexes. The No Pres group had similar cardiac indexes after exercise because heart rate increased (P<.005 by rm ANOVA). Late after surgery, ejection fraction was greater at similar end-diastolic volume indexes (P<.005 by rm ANCOVA), and preload recruitable stroke work indexes (P<.001 by rm ANCOVA) were better in the Pres group.Conclusions Preserving chordal attachments enhanced the late hemodynamic recovery after mitral valve replacement for mitral regurgitation.(Circulation. 1994;90(part 2):II-190-II-194.)

ISSN:0009-7322    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background With the widespread application of mitral valve reconstructive techniques, systolic anterior motion (SAM) of the anterior mitral leaflet causing left ventricular outflow tract obstruction has been recognized by several groups.SAM occurred in 9.1% of the first 441 patients operated on for mitral valve reconstruction at our institution. Fortunately, SAM subsided with medical therapy within 1 year for a majority of patients as reported in May 1993. Some surgeons, however, have considered abandoning repair for prosthetic replacement after SAM was detected on intraoperative echocardiogram.Methods and Results Since June 1991, a triangular anterior leaflet resection has been cautiously evaluated in patients with extensive anterior leaflet tissue.This has been performed in 23 of 119 patients.Conclusions The frequency of SAM in the 119 study patients has decreased from 9.1% to 3.4%. (Circulation. 1994;90 (part 2):II-195-II-197.)

ISSN:0009-7322    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background Prosthetic aortic valve endocarditis is a serious complication that carries a high morbidity and mortality.Aortic homografts have been used in this setting, but long- term results are not available.Methods and Results Over a 23-year period, 48 patients presented with infected aortic valve substitutes: 28 homografts, 15 mechanical, and 5 xenografts. Nineteen patients had emergency surgery, and the mean interval between the first and second operation was 5.9 years (range, 1 month to 22 years). In 28 patients, the preoperative New York Heart Association (NYHA) class was III or IV. Active endocarditis was present in 39 patients, and the microorganisms grown were Staphylococcus epidermidis (n=13), Staphylococcus aureus (n=6), Streptococcus viridans (n=6), Streptococcus faecalis (n=4), Candida albicans (n=5), and Gram-negative spp (n=2). Aortic root abscesses were found in 28 (58%) patients, and transesophageal echocardiography was 95% accurate in their localization. All patients received homograft aortic valves, 19 as root replacement and 29 using the freehand technique. There were four (8.3%) early deaths; poor left ventricular function and concomitant procedure were identified as risk factors. At a mean follow-up of 4 years (range, 2 months to 19 years) 95% of the patients were in NYHA class I or II without significant aortic regurgitation. The actuarial survival at 5 years was 97% (confidence limit, 84% to 100%), and freedom from endocarditis at 10 years was 97% (confidence limit, 84% to 100%). Multivariate analysis did not identify risk factors for these late events.Conclusions Homograft aortic valves offer good early and long-term results in patients with infected aortic valve substitutes. (Circulation. 1994;90(part 2):II-198-II-204.)

ISSN:0009-7322    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background Percutaneous balloon aortic valvuloplasty is limited by a high risk of procedural morbidity, transient clinical benefit, and a high restenosis rate.The management of patients with symptomatic aortic valve restenosis after percutaneous balloon aortic valvuloplasty is unclear. We hypothesized that aortic valve replacement would produce superior midterm survival compared with repeat balloon aortic valvuloplasty or medication alone in patients with symptomatic aortic valve restenosis after prior balloon aortic valvuloplasty.Methods and Results Baseline clinical, echocardiographic, and hemodynamic data were collected on 165 patients who underwent percutaneous balloon aortic valvuloplasty as treatment for symptomatic degenerative calcific aortic stenosis.In 144 of these patients (87%), aortic valve replacement was originally considered to carry excessive risk. The survival of three subgroups was calculated during a median follow-up period of 3.9 years (range, 1 to 6 years). Ninety-four patients (57%) had no further mechanical intervention (subgroup 1-BAV), 31 patients (19%) developed symptomatic aortic valve restenosis and underwent a repeat balloon aortic valvuloplasty (subgroup 2-BAV), and 40 patients (24%) subsequently underwent aortic valve replacement (subgroup BAV+AVR). Follow-up was 99% complete. Patients in subgroup BAV+AVR tended to be younger and have a lower prevalence of coronary artery disease or mitral regurgitation. Only 1 patient (2.5%) suffered a perioperative death during aortic valve replacement. The probability of survival 3 years from the date of the last mechanical intervention was 13% for subgroup 1-BAV, 20% for subgroup 2-BAV, and 75% for subgroup BAV+AVR. At the conclusion of follow-up, only 2 patients had symptoms of congestive heart failure or angina after aortic valve replacement.Conclusions Aortic valve replacement may be performed with a low mortality rate, excellent palliation of symptoms, and prolongation of survival in selected high-risk patients with a history of previous balloon aortic valvuloplasty. (Circulation. 1994;90(part 2):II-205-II-208.)

ISSN:0009-7322    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background Right ventricular volume overload (RVVO) occurring in conditions such as Ebstein's anomaly may result in depression of left ventricular ejection fraction (LVEF).This study tests this hypothesis by measuring LVEF in 10 patients with RVVO due to tricuspid valve resection for isolated tricuspid valve endocarditis and in 10 age-matched healthy persons.Methods and Results When the modified Simpson's rule was applied to echocardiographic images, LVEF for patients with RVVO measured significantly lower than for age-matched healthy subjects (51+-4% versus 60+-4%, P<.0001). Depression of LVEF does not result simply from reduced venous return to the left ventricle, since left ventricular end-diastolic volume was not significantly different between patients with RVVO and age-matched healthy persons (84+-26 versus 77+-20 mL, NS). Possible explanations for the depression in LVEF may relate to the decreased relative contribution of left atrial systole to left ventricular filling (demonstrated by transmitral pulsed Doppler) or to the mechanical effects of ventricular septal paradox (demonstrated by the abnormal leftward ventricular septal flattening and increase in short-axis cavity eccentricity at end diastole, which returns to normal at end systole) in patients with RVVO.Conclusions These findings suggest that surgical excision of the tricuspid valve results in isolated RVVO, which creates not only diastolic overload of the right heart but also depression of LVEF.(Circulation. 1994;90(part 2):II-209-II-213.)

ISSN:0009-7322    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background To identify the optimal use of anticoagulants after Carpentier-Edwards valve replacement, a retrospective study of all patients undergoing Carpentier-Edwards aortic (N=378) or mitral (N=370) valve replacement was done.Methods and Results At the time of hospital discharge, 103 patients were managed with warfarin, 509 with aspirin alone, and 136 with no anticoagulation or antiplatelet therapy.Over the first 90 days after aortic or mitral valve replacement, the linearized rate of hemorrhage was greater for warfarin than for aspirin or no therapy (16.7+-7.6%, 3.4+-1.7%, and 3.1+-3.1% per patient-year, respectively; P=.03). After aortic valve replacement, aspirin provided a low rate of thromboembolism (0.8+-0.2% per patient-year), not significantly different from warfarin or no treatment (2.9+-1.6% and 1.5+-0.6% per patient-year) (P=.07). After mitral valve replacement, no single treatment was most advantageous because the rate of hemorrhage over the first 90 days for warfarin was equivalent to the 90-day rate of thromboembolism with aspirin or no therapy.Conclusions Anticoagulation after Carpentier-Edwards mitral valve replacement may be best guided by individual patient characteristics. Within the limits of a retrospective analysis, these data support the routine use of aspirin alone after Carpentier- Edwards aortic valve replacement, both in the first 90 days and long-term. (Circulation. 1994;90(part 2):II-214-II-219.)

ISSN:0009-7322    

出版商:OVID    

年代:1994

数据来源: OVID

摘要:

Background To investigate the possibility of gender bias in the cardiac management of patients who undergo peripheral vascular surgery, we examined the hospital data and outcomes for 350 adult men and 128 women who underwent vascular surgery from September 1987 to December 1991.Methods and Results There were no significant differences between the two groups in age at operation, incidence of standard risk factors for myocardial infarction, or incidence or duration of episodes of perioperative silent ischemia.Nevertheless, a significantly lower percentage of women than men had undergone prior coronary bypass procedures (6.3% and 17.1%, respectively; P<.01), an apparent example of gender bias. However, there was no significant difference in the incidence of perioperative myocardial infarction in women (3.9%) compared with men (4.0%). Furthermore, actuarial analysis showed that at 24 months after operation a significantly higher percentage of women (77.9%) had escaped late cardiac death and cardiac complications than men (71.9%; P<.05).Conclusions These findings indicate that apparent gender bias in the preoperative cardiac management of this group of women who underwent vascular surgery may have had no detrimental effect on short-and long-term incidence of cardiac death and complications, and may represent sound clinical judgment rather than true bias. However, the possibility that female patients might have had even better short-and long- term cardiac results if they had undergone more preoperative cardiac revascularization cannot be discounted. (Circulation. 1994;90(part 2):II-220-II-223.)

ISSN:0009-7322    

出版商:OVID    

年代:1994

数据来源: OVID