Aortic and mitral valve replacement with reconstruction of the intervalvular fibrous body

AbstractObjective: The intervalvular fibrous body between the aortic and mitral valves can be damaged by infective endocarditis, degenerative calcification, or multiple previous heart valve operations, making double valve replacement difficult. We have managed this problem by approaching the aortic and mitral valves through the aortic root and the dome of the left atrium. After excising the aortic valve, the diseased fibrous body, and the mitral valve, we suture a properly tailored patch of Dacron fabric or bovine pericardium to the lateral and medial fibrous trigones and to the aortic root, reestablishing the aortic and mitral anuli. A prosthetic mitral valve is implanted and a separate patch is used to close the left atriotomy before implantation of a prosthetic aortic valve. This study was undertaken to determine the efficacy of this operation. Methods: Forty-three patients underwent reconstruction of the intervalvular fibrous body during aortic and mitral valve replacement because of infective endocarditis with abscess in 14 patients, extensive calcification in 9, lack of fibrous tissue because of multiple previous operations in 10, and to enlarge the aortic and mitral anuli in 10. The group comprised 18 men and 25 women with a mean age of 58 ± 12 years. Thirty-two patients had had one or more previous heart valve replacements. All patients were in New York Heart Association functional classes III and IV, and 9 patients were in shock before the operation. Results: Seven operative deaths occurred (16%). Early prosthetic valve endocarditis developed in two patients and necessitated reoperation. Follow-up extended from 4 to 108 months, with a mean of 38 months. No patient was lost to follow-up. Six late deaths occurred. The actuarial survival at 6 years was 56% ± 6%. A Doppler echocardiographic study revealed normal prosthetic valve function and anatomically intact anuli in all 30 long-term survivors. Conclusions: Reconstruction of the intervalvular fibrous body during aortic and mitral valve replacement is a satisfactory operative approach in patients with complex valve annular pathology. (J Thorac Cardiovasc Surg 1997;114:766-72

Custom-tailored valved conduit for complex aortic root disease

ObjectivesCommercially available conduits containing a valve are not always suitable for simultaneous reconstruction of the left ventricular outflow tract and replacement of the aortic root. We describe our experience with custom-made conduits for patients with complex disease of the aortoventricular junction.MethodsTwenty-seven patients with a destroyed aortoventricular junction resulting from endocarditis and/or multiple previous operations had reconstruction of the left ventricular outflow tract with a tailored tubular Dacron graft. The graft was tailored to correct the defect in the outflow tract and sutured with continuous polypropylene sutures directly to the interventricular septum and the intervalvular fibrous body or sewing ring of a prosthetic mitral valve. The coronary arteries were reimplanted as high as anatomically possible and a mechanical (16 patients) or bioprosthetic valve (11 patients) was implanted into the graft below the coronary arteries. Median age of the patients was 55 years. The follow-up was complete, with echocardiographic studies and a median period of 32 months.ResultsThere were 3 operative and no late deaths. One patient required early reoperation for dehiscence of a patch used to reconstruct the posterior mitral valve annulus. Twenty-four patients were alive at the last follow-up and had a normally functioning aortic valve prosthesis and no false aneurysms.ConclusionIntraoperatively tailored tubular Dacron graft for concomitant reconstruction of the left ventricular outflow tract and replacement of the aortic root is a useful and safe operative technique for patients with destroyed aortoventricular junction

Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures

AbstractObjective: This study was carried out to evaluate the long-term results of mitral valve repair for mitral regurgitation caused by myxomatous disease of the mitral valve and the late effects of chordal replacement with expanded polytetrafluoroethylene sutures in this operation. Methods: A total of 324 patients with mitral regurgitation caused by myxomatous disease underwent mitral valve repair from 1981 to 1995; the group comprised 241 men and 83 women whose mean age was 58 ± 14 years. Chordal replacement with expanded polytetrafluoroethylene sutures has been performed in 165 patients since 1985. Most of the patients who had chordal replacement with expanded polytetrafluoroethylene sutures had prolapse of the anterior leaflet or prolapse of both leaflets, whereas most patients who had mitral valve repair without chordal replacement had prolapse of the posterior leaflet. Patients were followed up at annual intervals and had a Doppler echocardiographic study. The follow-up was complete and extended from 6 to 156 months (mean 36 ± 30 months). Results: Two operative and 21 late deaths occurred (14 cardiac and 7 noncardiac). At 10 years the actuarial survival was 75% ± 5%, the freedom from stroke was 94% ± 2%, the freedom from transient ischemic attacks was 92% ± 4%, the freedom from endocarditis was 99% ± 1%, the freedom from mitral valve reoperation was 96% ± 1%, and the freedom from severe mitral regurgitation was 93% ± 3%. Chordal replacement with expanded polytetrafluoroethylene sutures had no effect on any of these end points. Conclusions: Mitral valve repair was feasible in most patients with mitral regurgitation caused by myxomatous disease and it was associated with low rates of valve-related complications. Chordal replacement with expanded polytetrafluoroethylene had no adverse effect on the late outcome and was believed to have increased the probability of mitral valve repair. (J Thorac Cardiovasc Surg 1998;115:1279-86

Hemodynamic benefits of the Toronto stentless valve

AbstractWe report on 254 consecutive patients (170 male, 84 female) undergoing aortic valve replacement with the Toronto SPV Stentless Valve (St. Jude Medical, Inc., St. Paul, Minn.). Mean age (± standard deviation) was 62.1 ± 11.6 years. Three patients (1%) received sizes 21 or 22 mm, 24 (9%) received size 23 mm, and 227 patients (89%) received sizes 25, 27, or 29 mm. Serial echocardiography was used to assess valve performance during a 3-year follow-up. Mean gradient decreased by 35.8% ( p < 0.0001; 95% confidence interval -39.6%, -31.7%) from postoperative values to the 3- to 6-month follow-up and by 6.1% ( p = 0.004; 95% confidence interval -10.1%, -2%) at each subsequent interval; effective orifice area increased by 17.2% ( p = 0.0001; 95% confidence interval 12.0%, 22.6%) initially and by 4.4% ( p < 0.001; 95% confidence interval 1.8%, 7.0%) thereafter. At 2 years of follow-up, mean gradient was 3.3 ± 2.1 mm Hg and mean effective orifice area was 2.2 ± 0.8 cm 2 . Studies on left ventricular mass were carried out on 84 patients. Left ventricular mass decreased by 14.3% (37.8 ± 57.9 gm; p < 0.0001; 95% confidence interval -53.7, -21.9 gm) and left ventricular mass index decreased by 15.2% (21.1 ± 30.5 gm/m 2; p < 0.0001; 95% confidence interval -29.5, -12.7 gm/m 2) from postoperative values to the 3- to 6-month follow-up interval. The reduction in residual gradient and potential regression in left ventricular hypertrophy may have a beneficial prognostic implication. We believe that the unique stentless design of the Toronto SPV Stentless Valve allows this to occur. (J T horac C ardiovasc S urg 1996;112:431-46