Four Cases of Valvular Diseases Due to Nonpenetrating Cardiac Trauma

During the past 15 years we have managed four patients who suffered isolated valvular lesions from blunt chest trauma. Three patients were injured intraffic accidents and another fell from a height. Injured valves were mitral valves in three patients, tricuspid valves in two and aortic valve in one. One individual had a combination of aortic, mitral, and tricuspid valvular lesions.The procedures performed were mitral valve replacement in 2 patients and mitral repair in one, tricuspid valve replacement in one and repair in one, aortic valve replacement in one. The outcome of those patients were fairly well and all returned to their regular jobs&#65294;&#12288;</p

A case of complete atrioventricular block due to malignant lymphoma.

A case of malignant lymphoma associated with complete heart block in a 30-year-old woman is reported. The patient progressively deteriorated despite temporary pacing and died 24 days after being admitted. Microscopic examination of the heart revealed marked infiltration by lymphoma cells in the atrioventricular node and the bundle of His. A diffuse lymphoma (large cell type, B cell) was diagnosed. This case is considered to be rare, since complete heart block was the first and only manifestation of the malignant lymphoma.</p

Results of surgery for aortic regurgitation due to aortic valve prolapse.

The clinical, hemodynamic and pathological findings of 13 patients with aortic regurgitation due to aortic valve prolapse caused by advanced myxomatous degeneration were evaluated. Eleven patients showed a favorable outcome with no complications resulting from surgery. One patient died from aortic dissection, and another died suddenly from an unknown cause. Five patients had mitral valve prolapse as a complication. Ten patients (77%) had a long-standing history of hypertension. Twelve patients (92%) were male. None of the patients had the stigmata of Marfan's syndrome. All patients had marked myxomatous degeneration of the aortic valves without any inflammatory changes. Two patients showed microcalcification; 7 demonstrated moderate fibrosis. Five patients showed severe fragility of the cusps which appeared redundant, gelatinous and softened by degenerative changes. Myxomatous degeneration of the aortic valve is not rare, and, in fact, it may be one of the most common pathologic and clinical entities associated with pure aortic insufficiency.</p

Return to work after heart valve replacement.

One hundred patients who underwent heart valve replacement during the years 1977 to 1985 were reviewed an average of 57 months after surgery. The overall rate of reemployment after the operation was 78%. The most important factors influencing the return to work were the employment status before surgery, age at the time of surgery, the number and site of the diseased valve, the preoperative New York Heart Association (NYHA) functional class and the number of times cardiac surgery was performed. These factors were closely related to the optimal timing of heart valve replacement. It was suggested that the rate of return to work and the quality of life would be improved if the heart valve replacement had been performed at an earlier stage of the disease.</p

Factors influencing long-term survival after mitral valve replacement.

Thirty-seven consecutive cases of mitral valve replacement have been retrospectively reviewed. The prognostic significance of preoperative clinical, hemodynamic and quantitative angiographic factors for survival has been evaluated. In the Mitral stenosis (MS) group, all of the patients who showed small Stroke volume index (SVI) (less than 45 ml/m2) with pulmonary hypertension died from the low output syndrome. The prognosis was poor in patients who had large cardiothoracic ratio (CTR) in the MS group. Aortic valve replacement must be considered when moderate aortic regurgitation is associated with mitral valve disease. In the MR factors for predicting the survival. The eccentricity ratio is also a sensitive parameter for recognizing a patient who will have a poor prognosis after mitral valve replacement. The main mode of death was found to be heart failure due to myocardial impairment.</p

Two-Dimensional Echo-cardiographic Estimation of the Size of the Mitral Valve Annulus

The diameter of the mitral annulus as measured on the long axis by two-dimensional echocardiogram was found to correlate well with the size of the sewing ring used to replace the mitral valve in 35 consecutive patients. The size of the prosthesis which was used could be predicted within 1 mm of error in 83% of the mitral stenosis (MS) patients and in 76% of the mitral regurgitation (MR) patients in the study. Preoperative echocardiographic estimation of the size of the mitral valve annulus and prediction of the sewing ring size of the prosthetic valve used could reduce the incidence of valve prosthesis-patient mismatch.</p

Long-term results of surgery for mitral regurgitation due to mitral valve prolapse: a comparison of valve replacement and annuloplasty.

Patients with mitral regurgitation (MR) due to mitral valve prolapse operated at the Second Department of Surgery, Okayama University Medical School, between 1976 and 1986 were divided into two groups. The first consisted of 20 patients who had mitral valve replacement (MVR) and the second 15 patients who had mitral annuloplasty (MAP). Long-term results of surgery, cardiac function, hemodynamic status, and surgical findings were compared between the two groups. Before surgery, there were no significant differences in patient's clinical status and cardiac function between the two groups. However, after surgery statistically significant differences emerged between the two groups in ejection fraction (EF), cardiac index (CI) and mean circumferential fiber shortening velocity (mVcf). Left ventricular pumping function and myocardial contractile force tended to decrease after surgery in the MVR group and to remain unchanged or even increase in the MAP group indicating that valve preservation procedures should be selected as often as possible for the patients involved in mitral valve prolapse.</p

Improvement of left ventricular function after surgical correction of chronic aortic regurgitation.

Serial left ventricular (LV) echocardiographic studies were performed in 21 patients before and after aortic valve replacement for chronic aortic regurgitation. The effect of valve replacement on LV dimensions, cross-sectional area of the LV muscle and LV function was determined from the echocardiographic data. The relation between degeneration of the myocardium and surgical outcome was also investigated. The average LV end-diastolic dimension decreased from 66.0 +/- 8.3 mm to 46.3 +/- 5.7 mm twelve months postoperatively. The average LV end-systolic dimension also fell from 43.4 +/- 8.1 mm to 31.1 +/- 5.0 mm. The muscle cross-sectional area decreased from 33.1 +/- 5.1 cm2 to 24.5 +/- 4.0 cm2, indicating a decrease in LV mass. The indices of contractility (fractional shortening, ejection fraction and mean velocity of circumferential fibre shortening) had a tendency to decrease one month after surgery, but they subsequently increased to the normal level 12 months after surgery. Nineteen out of 21 patients showed a favorable outcome as to the functional status. The remaining two patients had a large LV dimension and subnormal contractility, and they failed to show a significant reduction in the follow-up period. The muscle score in the two patients was greater than 8 points, which indicated irreversible impairment of the myocardium. Patients with persistent postoperative LV enlargement have a poor prognosis and should be identified so that aggressive medical treatment can be instituted.</p

Effect of left atrial plication for the giant left atrium on left ventricular function.

Left atrial plication (LAP) following Kawazoe's method was performed on eight patients with mitral valve stenosis associated with a giant left atrium. To investigate the effect of LAP particularly on left ventricular function, the preoperative and postoperative left ventricular function in these patients were compared. The data were also compared to that of the non-left atrial plication (non-LAP) group with left atrial dimension of 60 mm or over. In the LAP group, there were significant differences between preoperative and postoperative data in the following parameters; New York Heart Association (NYHA) class, cardiothoracic ratio, mean pulmonary arterial pressure (PAP), left ventricular end-diastolic pressure (LVEDP), left atrial dimension, stroke volume index, ejection fraction and cardiac index. On the contrary, in the non-LAP group, there were significant differences between preoperative and post-operative data in the following two factors; NYHA class and PAP. The size of the left atrium in the non-LAP group remained unchanged over the course of long-term follow-up. Despite severe clinical symptoms and severely reduced cardiac function of the patients in the LAP group, cardiac function in all patients improved satisfactorily. This suggests that left atrial plication has a considerably beneficial effect on left ventricular function, and therefore, may be recommended for patients with a giant left atrium.</p

Indications and timing of surgery for cholelithiasis associated with valvular heart disease.

Twenty patients with cholelithiasis associated with valvular heart disease were studied to assess the need and the optimal time for cholecystectomy. Twelve patients (11 symptomatic and 1 asymptomatic patients) underwent cholecystectomy. The remaining patients were asymptomatic. The levels of the total bilirubin in 9 patients, and of LDH in 15, were higher than normal. In most of the patients, the serum transaminase levels were higher than normal, but in few cases, the levels were higher than 200 IU/l. These abnormal values, however, were not consistently observed in these patients. No clear association between the type and form of valvular heart disease was demonstrated. The type of prostheses used for valve replacement in these patients were ball, tilting disc and leaflet. No significant differences in efficacy were observed among different types of prostheses. The incidence of silent stones is high in patients with valvular heart disease and heart surgery often causes deterioration in patients with cholelithiasis. The recovery of the patients who underwent cholecystectomy before valve replacement were better than those who underwent cholecystectomy after heart surgery. In conclusion, therefore, patients showing any abnormal results in liver function tests should be assessed in detail by abdominal echography and should receive surgical treatment of biliary tract before heart surgery if necessary.</p