摘要:

AbstractAmong the first 10,200 valvular replacements performed in our unit, 288 complex repairs of the ascending aorta were done for various aortic pathology. Aneurysms of the ascending aorta were the most frequent; 53 supracoronary artery aneurysms with aortic valvular insufficiency were treated by the separate replacement of the aortic valve and the supracoronary ascending aorta; 206 annulo‐aortic ectasia had total and combined replacement of the ascending aorta and the aortic valve with a personal modification of the Bentall's technique using an 8‐mm diameter Dacron graft to perform the reimplantation of the coronary arteries on the composite aortic grafts. The operative mortality for the first 100 patients was 4% and for the entire 206 patients, 6%. Late mortality during a follow‐up period ranging from 18 months to 8 years was 11%. The actuarial survival rate at 8 years is 75%; 25 patients restudied by angiography demonstrated satisfactory results with neither stenosis nor aneurysm on the coronary graft but a recurrent or persisting chronic distal aortic dissection in four patients.In 26 cases of aortic valvular endocarditis, large abscesses of the aortic annulus involved the aortic root. In 11, the aortic repair consisted of the insertion of a subcoronary valved conduit (two early deaths, two late deaths, one reoperation, seven good results – maximum follow‐up of eight years). Twelve patients had a supracoronary valved conduit with four early deaths, one late death, and two reoperations; seven are alive and well, two to six years later. Three patients previously operated had a left ventricular abdominal aorta valved conduit; two of them are alive and well up to six years later.In three patients with iterative aortic paravalvular leak (recurring three or four times), ablation of the aortic insufficiency was obtained by interposition of a composite valved graft in the ascend

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1988.tb00237.x

出版商:Blackwell Publishing Ltd    

年代:1988

数据来源: WILEY

摘要:

AbstractCardiac failure remains a life‐threatening complication for certain patients undergoing intracardiac repair. Despite improvements in surgical techniques, methods of myocardial protection, and postoperative care, patients are frequently at risk to develop postoperative low out‐put syndrome. Approximately 1% of cardiac surgical patients cannot be weaned from extracorporeal circulation in spite of adequate volume loading, the use of inotropic support, and initiation of intraaortic balloon pumping. In these cases, ventricular assist devices (VAD) can mechanically aid the failing heart and reverse the low output state.The concept of mechanical support for the failing left ventricle was first proposed by Clauss et al.1in 1961. By 1968, Kantrowitz and associates2had developed and refined the first intraaortic balloon pump (IABP). Through the efforts of Moulopolous and others,3this device evolved into the present‐day intraaortic balloon pump (IABP).Clinical evidence for the efficacy of left ventricular assist devices (LVAD) remained questionable until 1980, when the National Heart, Blood and Lung Institute evaluated short‐term LVADs by comparing various types of mechanical aids.1,4–8This report focused attention primarily on the failing left ventricle (LV). As the use of inotropic support, intraaortic balloon pumping, and LVADs improved, a small group of patients emerged who could not be separated from extracorporeal circulation due to a failing right ventricle. The failing right ventricle emerged as a unique clinical entity similar to postcardiotomy left ventricular failure that also benefited from mechanical cardiac assistance. Current therapy at major centers incorporating mechanical assist devices is based on the premise that the low output state will allow the failing heart to recover from a reversible injury. The frequent occurrence of postcardiotomy ischemia may be due to several factors such as poor myocardial protection, overdistension of the LV, emboli, coronary spasm or technical problems. Whatever the etiology, the end product of cardiac failure is a demand for oxygen consumption that cannot be met, thus leading to cardi

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1988.tb00238.x

出版商:Blackwell Publishing Ltd    

年代:1988

数据来源: WILEY

摘要:

AbstractComplete closure of the pericardium after cardiac operations has the advantage of avoiding injury of the heart and great vessels during reoperation. Between 1985 and 1987, the pericardium was closed with Gore‐Tex® Surgical Membrane (SM) in a selected series of 110 patients 1 month to 76 years of age. Fifty‐three patients had congenital heart lesions and 57 patients had acquired heart disease. Overall hospital mortality was 3/110 cases. In no instance was there a relationship between occurrence of death and pericardial closure with SM. There was one episode of cardiac tamponade on the seventh postoperative day. One patient developed fever and leukocytosis due to a mediastinal hematoma. During a mean follow‐up of 15 months,3–27four patients had to be reoperated upon three, four, eight weeks, and eight months after primary operation. The anterior wall of the heart had no adhesion with the SM and the other parts of pericardium could be dissected easily. Scanning electron microscopic examination of the explanted SM patches showed neither cellular ingrowth nor immunocompetent cellular elements.The Gore‐Tex® Surgical Membrane has the advantages of easy availability and lack of reaction between its surface and the epicardium and pericardium. We believe its routine use should be encouraged in patients with high probability of reoperation after repair of complex cardiac anomalies, implantation of bioprostheses, coronary revascularization for one‐ or two‐vessel disease, and repair of degenerative disease of the

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1988.tb00239.x

出版商:Blackwell Publishing Ltd    

年代:1988

数据来源: WILEY

摘要:

AbstractA consecutive series of 98 patients ranging from 21/2 to 79 years of age underwent mitral valve replacement using the superior approach that entails an atriotomy done between the superior vena cava and the ascending aorta prolonging it into the left superior pulmonary vein. The technique opens the roof of the left atrium without dissection, frequently without the need for double cannulation of the right atrium. No mobilization of the heart is involved, which is left in its normal position. There were 62 patients undergoing replacement alone, 22 combined with coronary bypass surgery, 10 with simultaneous aortic valve replacement, 2 with coronary bypass and left ventricular aneurysm resection, and 2 others combined with ventricular septal defect (VSD) closure and placement of an extracardiac conduit. Forty‐six were done for stenosis and 52 for regurgitation. No technical difficulties were encountered, and the valve can easily be replaced through an incision slightly larger than the diameter of the prosthesis being implanted. Since the heart is not mobilized, the ventricles remain immersed in the cold topical solution (4° C) in addition to the administration of cardioplegia for myocardial protection. The access is simple and offers better exposure for the assisting surgeon than the usual inter‐atrial groove approach. Important steps of the technique are clari

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1988.tb00240.x

出版商:Blackwell Publishing Ltd    

年代:1988

数据来源: WILEY

摘要:

AbstractWhile conventional mitral valve replacement (MVR) for patients with chronic mitral regurgitation has been associated with relatively high operative mortality rates and incidence of late postoperative left ventricular (LV) failure and death, chordal‐sparing mitral valve operations (valve repair/reconstruction or MVR with preservation of the chordae tendineae) subjectively appear to portend lower operative morbidity and mortality rates, better functional results, and improved long‐term survival rates. Such empirical clinical observations have provided the basis for the concept of valvular‐ventricular interaction, namely, that the intact mitral chordae are important mediators of more efficient and forceful ventricular contraction that enhances LV performance. This paper reviews the pertinent basic physiology and dynamics of the chordae tendineae and papillary muscles and examines critically the available experimental and clinical data regarding valvular‐ventricular interaction. The problems inherent in quantifying LV contractility are central to this discussion and are also examined. While earlier experimental studies have produced conflicting results, more recent experiments utilizing load‐independent measures of ventricular performance (particularly in isovolumic preparations) have conclusively demonstrated the importance of chordal integrity for optimal LV systolic function in normal animal hearts. The balance of the clinical evidence is also suggestive (although by no means conclusive) regarding the importance of valvular‐ventricular interaction. Recent experimental evidence suggests that the mitral chordae enhance LV systolic function by means of regional afterload reduction. The mechanism(s) responsible for valvular‐ventricular interaction, however, remains incompletely characterized at the present time, which underscores the urgent need for further experimental and, most importantly, cli

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1988.tb00241.x

出版商:Blackwell Publishing Ltd    

年代:1988

数据来源: WILEY

摘要:

AbstractThe closure of a median sternotomy incision requires secure bony approximation to prevent postoperative pain, sternal click, and/or nonunion of bone. The standard technique of sternotomy closure involves the use of stainless steel wires for reapproximation of the sternum. These wires occasionally break or pull through bone, resulting in instability of either a portion of the sternum or the entire sternum. Presented here is our technique for sternotomy closure that provides secure closure with reduced postoperative morbidity.

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1988.tb00242.x

出版商:Blackwell Publishing Ltd    

年代:1988

数据来源: WILEY

摘要:

AbstractSaphenous vein mapping by real‐time duplex ultrasound scanning allows for the confirmation of the presence of patent vein and determination of the anatomical course of the vein prior to aortocoronary bypass procedures. This technique has proven to be of value in patients whose veins are not evident by physical examination and in those whose length of conduit may be limited by previous vein stripping or thrombophlebiti

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1988.tb00243.x

出版商:Blackwell Publishing Ltd    

年代:1988

数据来源: WILEY

摘要:

AbstractRecent data suggests that the pressure‐flow relationship for normal bioprosthetic mitral valves is linear. If this is correct, the valve resistance may provide a better indicator of normal mitral function than the Gorlin valve area. We compared the Gorlin valve area to the valve resistance (calculated as flow/pressure) in order to determine which better separated normal and stenotic Hancock mitral valves.Measurements were made using left atrial and left ventricular catheters in 42 patients undergoing Hancock mitral valve replacement. Patients were studied during pacing and isoproterenol infusion for a total of 141 measurements. Stenotic Hancock mitral valve hemodynamics were obtained at cardiac catheterization from eight patients who were studied at rest and during atrial pacing and from an additional eight patients culled from the literature (a total of 23 stenotic measurements).The Gorlin valve area ranged from 1.1 to 4.4 cm2for the normally functioning Hancock valves and from 0.4 to 1.54 cm2for the stenotic valves. Six measurements in patients with confirmed stenotic valves yielded Gorlin areas larger than the lowest area found in the normal valves and no value of the Gorlin valve area correctly classified all of the normal and the stenotic valves. The valve resistances of the normal valves ranged from a minimum of 1.0 to a maximum of 5.1 (mean 2.9 ± 0.8) while the resistances of the stenotic valves ranged from 6.6 to 38 (mean 12.9 ± 8.2). There was no overlap of the normal and the stenotic measurements.The valve resistance, which is based on a model of normal mitral valve physiology, appears to better separate normal and stenotic Hancock mitral valves than the Gorlin area, which is based on a model of stenotic valvular f

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1988.tb00244.x

出版商:Blackwell Publishing Ltd    

年代:1988

数据来源: WILEY

摘要:

AbstractSince September, 1985, 20 patients have undergone implantation of a homograft valve in the pulmonary position (16 pulmonary, 4 aortic). There were 11 primary operations and 9 reoperations. In 7 of 11 primary operations the homograft valve was utilized as a composite conduit with a short Dacron extension. In four of five reoperations for a failed porcine valved conduit, a composite homograft conduit was used. Four patients underwent implantation of a free homograft in a previously repaired right ventricular outflow tract (RVOT).Age ranged from 15 days to 22 years. There was one operative death (5%), a seven‐week‐old infant with truncus arteriosus. Long‐term follow‐up ranges from 1 to 30 months. Clinical performance has been satisfactory in 18 of 19 patients. One patient undergoing free implantation of a pulmonary valve in the RVOT required replacement at 18 months with a porcine valve. In this patient, pulmonary insufficiency was caused by distortion of the annulus secondary to dilatation and pulmonary hypertension. Nine of 18 survivors do not require medication. Eleven of 18 have trivial to mild pulmonary insufficiency murmurs without symptomatology.The homograft valve is extremely useful in reconstruction of the right heart, however, early insufficiency murmurs have been noted. Distortion of the valve annulus may contribute to the early onset of a benign insufficiency murmur. Residual distal obstruction or pulmonary hypertension may be a contraindication to the use of a free homograft in the orthotopic p

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1988.tb00245.x

出版商:Blackwell Publishing Ltd    

年代:1988

数据来源: WILEY

摘要:

AbstractThe microstructure of 33 spontaneously degenerated porcine bioprosthetic valves was assessed by scanning electron microscopy in order to gather insight regarding the degenerative process. Twenty‐four mitral and 9 aortic valves were removed from 32 patients. The duration of insertion was 7.7 ± 2.4 years (mean ± SD). All valves showed denudation of endothelial cells and exposure of the subendothelial fibrous tissue. Fibroblas±like cells were occasionally seen. Platelet deposits were observed on 22 of 33 valves (67%). Leukocytes were observed on the surface of 27 of 33 valves (82%). Mononuclear leukocytes were the most common category of cells (66%). Crystalline material was present on the surface of some leukocytes, suggesting that they may serve as a nidus for calcification. Transmission electron microscopy showed leukocytes in the process of phagocytizing collagen fibers. Macrophages, by exerting their scavenger function seem to contribute to destruction of the collagen framework of the valves. Whether the observed lymphocytes and plasma cells reflect an immunological involvement is unc

ISSN:0886-0440    

DOI:10.1111/j.1540-8191.1988.tb00246.x

出版商:Blackwell Publishing Ltd    

年代:1988

数据来源: WILEY