Left ventricular function after valve repair for chronic mitral regurgitation: Predictive value of preoperative assessment of contractile reserve by exercise echocardiography

Objectives.We evaluated the value of preoperative assessment of left ventricular contractile reserve in predicting ventricular function after valve repair for minimally symptomatic mitral regurgitation.Background.The optimal timing for operation in minimally symptomatic patients with significant mitral regurgitation is controversial. Accurate preoperative assessment of left ventricular function is difficult, and the ability to predict postoperative function is limited. Previous studies in patients undergoing mitral valve replacement may not be applicable in the present era of valve repair.Methods.We performed exercise echocardiography in 139 patients with isolated mitral regurgitation and no coronary disease, 74 of whom subsequently underwent uncomplicated valve repair. We measured rest left ventricular end-systolic dimension, end-systolic wall stress and positive first derivative of left ventricular pressure (dP/dt). End-diastolic and end-systolic volumes and ejection fraction were measured preoperatively at rest, immediately after exercise and postoperatively.Results.Ejection fraction decreased postoperatively to 55 ± 10% from a rest preoperative value of 64 ± 9% (p < 0.001). Compared with patients with a postoperative ejection fraction ≥50% (n = 56), patients with postoperative ejection fraction <50% (n = 18) had a significantly lower preoperative exercise ejection fraction (57 ± 11% vs. 73 ± 9%, p < 0.0005), a larger exercise end-systolic volume index (32 ± 8 vs. 18 ± 7 cm3/m2, p < 0.0005) and a lower change in ejection fraction with exercise (−4 ± 8% vs. 9 ± 10%, p < 0.005). Preoperative rest indexes, including dP/dt, end-systolic wall stress and end-systolic volume index were less predictive, whereas exercise capacity, rest ejection fraction and end-systolic dimension were not predictive of postrepair ejection fraction. An exercise end-systolic volume index >25 cm3/m2 was the best predictor of postoperative dysfunction, with a sensitivity and specificity of 83%.Conclusions.In minimally symptomatic patients with mitral regurgitation, latent ventricular dysfunction may be indicated by a limited contractile reserve, manifest at exercise as an inadequate increase in ejection fraction and a larger end-systolic volume. These variables may also be used to predict left ventricular function after repair

Surgical treatment of prosthetic valve endocarditis

AbstractFrom 1975 through 1992, we reoperated on 146 patients for the treatment of prosthetic valve endocarditis. Prosthetic valve endocarditis was considered to be early (<1 year after operation) in 46 cases and active in 103 cases. The extent of the infection was prosthesis only in 66 patients, anulus in 46, and cardiac invasion in 34. Surgical techniques evolved in the direction of increasingly radical débridement of infected tissue and reconstruction with biologic materials. All patients were treated with prolonged postoperative antibiotic therapy. There were 19 (13%) in-hospital deaths. Univariate analyses demonstrated trends toward increasing risk for patients with active endocarditis and extension of infection beyond the prosthesis; however, the only variables with a significant (p < 0.05) association with increased in-hospital mortality confirmed with multivariate testing were impaired left ventricular function, preoperative heart block, coronary artery disease, and culture of organisms from the surgical specimen. During the study period, mortality decreased from 20% (1975 to 1984) to 10% (1984 to 1992). For hospital survivors the mean length of stay was 25 days. Follow-up (mean interval 62 months) documented a late survival of 82% at 5 postoperative years and 60% at 10 years. Older age was the only factor associated (p = 0.006) with late death. Nineteen patients needed at least one further operation; reoperation-free survival was 75% at 5 and 50% at 10 postoperative years. Fever in the immediate preoperative period was the only factor associated with decreased late reoperation-free survival (p = 0.032). Prosthetic valve endocarditis remains a serious complication of valve replacement, but the in-hospital mortality of reoperations for prosthetic valve endocarditis has declined. With extensive débridement of infected tissue and postoperative antibiotic therapy, the extent and activity of prosthetic valve endocarditis does not appear to have a major impact on late outcome, and the majority of patients with this complication survive for 10 years after the operation. (J THORAC CARDIOVASC SURG 1996;111:198-210

Surgical management of left coronary artery ostial atresia and supravalvar aortic stenosis

Congenital atresia of the left main coronary artery ostium is a rare lesion, particularly when found in association with supravalvar aortic stenosis. This report describes the preoperative evaluation and surgical management of this lesion found in conjunction with a quadricuspid aortic valve in a 5-year-old child. Patch aortoplasty and left internal thoracic artery to left anterior descending coronary artery bypass were performed to correct this lesion