Dimitris P. Korkolis

Revascularization alone (without mitral valve repair) suffices in patients with advanced ischemic cardiomyopathy and mild-to-moderate mitral regurgitation.

BACKGROUND Whether or not to perform adjunctive mitral repair in patients undergoing coronary artery bypass grafting (CABG) for advanced ischemic cardiomyopathy with moderately severe mitral regurgitation (MR) remains controversial. METHODS We examine the clinical and echocardiographic outcome after isolated CABG in 49 patients with ischemic cardiomyopathy and 1+ to 3+ MR undergoing surgical revascularization. The patients were identified for analysis of mitral valve-related issues from a larger series of 183 patients with ischemic cardiomyopathy (MUGA ejection fraction < or = 30%) undergoing CABG by a single surgeon from 1986 to 1996. Patient age was 66.3 years (mean, range 45 to 83 years). There were 5 women (10.2%) and 44 men (89.8%). Mean ejection fraction was 22.4% with a range of 10% to 30%. Thirty-four patients had preoperative congestive heart failure (70%) and 12 (25%) had pulmonary edema. Number of grafts was 2.8 (mean, range 1 to 5). The MR was 1+ in 18 patients (37.5%), 2+ in 26 (52%) and 3+ in 5 patients (10.5%). RESULTS Hospital mortality was 2.0% (1 of 49 patients). Ejection fraction improved from 22.0% to 31.5% (p < 0.05) after CABG. Mean degree of MR improved with CABG alone from 1.73 to 0.54 (p < 0.05) as measured at a mean interval of 36.9 months from CABG. New York Heart-Association congestive heart failure class improved from 3.3 to 1.8 (p < 0.05). Long-term survival was 88%, 65%, and 50% at 1, 3, and 5 years postoperatively. No patient required subsequent mitral valve operation or heart transplantation in long-term follow-up. CONCLUSIONS We conclude that, in patients with advanced ischemic cardiomyopathy and mild-to-moderate MR, isolated CABG (without mitral valve, repair) suffices, producing dramatic improvement in ejection fraction, in congestive heart failure, and in degree of MR, with excellent (relative) long-term survival. The improvement in MR likely results from improved left ventricular function and size consequent upon revascularization.

Early bioprosthetic mitral valve “pseudostenosis” after complete preservation of the native mitral apparatus

An advantage of bioprosthetic mitral valve replacement in patients with normal sinus rhythm is avoidance of the need for long-term anticoagulation. Bioprosthetic valve thrombosis is a rare complication, supporting this approach. This case report represents an example of porcine mitral valve stenosis, likely secondary to thrombosis, in which all of the native mitral valve apparatus was left intact. This was successfully treated with standard anticoagulation therapy. This complication should be considered in patients in whom retention of the mitral valve apparatus has been performed. Such patients may benefit from long-term anticoagulation treatment to obviate this event.

Small Diameter Side-to-Side Interposition Portocaval Shunt

Indications: Control of acute hemorrhage from esophageal varices not amenable to or failing medical therapy, e. g., pharmacotherapy, balloon tamponade, endoscopic variceal sclerotherapy, in patients with liver cirrhosis and portal hypertension Control of bleeding gastric or intestinal varices Prevention of recurrent variceal bleeding after initial control Complicated Budd-Chiari syndrome Contraindications: Portal vein thrombosis, even with recanalization (cavernomatous transformation) Inferior vena cava thrombosis Extensive adhesions from previous operative procedures in the right upper quadrant (relative contraindication) Severe medical comorbidities (e. g., mitral regurgitation, severe aortic stenosis)

8MM Interposition Portacaval Shunt

Control of acute hemorrhage from esophageal varices not amenable to or failing medical therapy, e.g., pharmacotherapy, balloon tamponade, endoscopic variceal sclerotherapy, in patients with liver cirrhosis and portal hypertension Control of bleeding gastric or intestinal varices Prevention of recurrent variceal bleeding after initial control Complicated Budd-Chiari syndrome