Jerome Harold Kay

SURGICAL TREATMENT OF TRICUSPID INSUFFICIENCY.

Surgical Treatment of Tricuspid Insufficiency Jerome Kay;Giuseppe Maselli-Campagna;Harold Tsuji; Annals of Surgery

Disease of the left main coronary artery. Surgical treatment and long-term follow up in 267 patients.

Of 4,196 patients undergoing coronary angiography, 297 (7 percent) had left main coronary arterial narrowing. In 188 (4.5 percent) the narrowing was greater than or equal to 70 percent and in 109 (3 percent) it was between 50 and 69 percent. Three patients (1 percent) died at cardiac catheterization. Saphenous vein bypass graft surgery was performed in 267 patients with an operative mortality of 7 percent: in 179 patients the left main coronary narrowing was greater than or equal to 70 percent (operative mortality 9 percent), and in 88 between 50 and 69 percent (mortality rate 2 percent). There was an average of 2.6 grafts per patient. The course of these patients was followed up for 4 3/4 years. At 1 year there was a 92.2 percent survival rate. The rate of survival at 2, 3 and 4 3/4 years, was 91, 89 and 86 percent, respectively. After saphenous vein bypass graft surgery, 75 percent of patients are angina-free and 22.4 percent are in improved condition. Grafts were studied in 51 patients and 85 percent of 128 grafts were found to be patent. It appears that there is improvement in survival and a reduction of symptoms after saphenous vein bypass graft surgery in patients with left main coronary arterial narrowing.

Mitral valve repair for significant mitral insufficiency

There has been skepticism since the early days of open heart surgery that good long-term or even short-term results were possible with repair of pure mitral insufficiency. The authors report 145 patients in whom a markedly insufficient mitral valve was repaired 6 months to 17 years previously and another 55 patients in whom repair of the insufficient mitral valve was performed along with myocardial revascularization from 6 months to 7 years previously. Comparative data with other published work reveals superior results with repair than with replacement with Starr-Edwards and Hancock glutaraldehyde-treated porcine valves and with far less emboli. Conservatism is urged in operating upon patients with mitral insufficiency. Repair of the valve rather than replacement is stressed for those patients requiring surgery.

Geometric and functional abnormalities of the left ventricle with a chronic localized noncontractile area.

Abstract Thirty-one patients with coronary artery disease, 25 of whom had a chronic localized noncontractile area in the anteroapical region of the left ventricle, were studied at rest by means of left heart catheterization, left cineventriculography and selective coronary arteriography. The left ventricular volume, stroke volume, ejection fraction, left ventricular end-diastolic pressure, cardiac output and the surface area of the noncontractile area were measured. The patients with a noncontractile area were classified in 4 groups according to the size of the noncontractile area relative to the end-diastolic left ventricular surface area. The relative size of the non-contractile area ranged from 5 to 47 percent. Six patients with uncomplicated coronary artery disease comprised the control group. The critical size of the noncontractile area beyond which significant functional derangement occurred appeared to be 20 to 30 percent of the left ventricular internal surface area. The end-diastolic volume increased significantly and the ejection fraction was reduced to less than half of normal when the regional noncontractile area was larger than the critical size. Neither the cardiac output nor the left ventricular end-diastolic pressure correlated closely with size of the noncontractile area. In contrast, the ejection fraction was a more sensitive indicator and correlated well with the extent of regional contraction abnormality. In this study, double vessel disease was most common, followed by single vessel disease. Obstruction of the left anterior descending coronary artery was significant in the formation of anteroapical noncontractile regions.

Left Ventricular Performance before and after Removal of the Noncontractile Area of the Left Ventricle and Revascularization of the Myocardium

The left ventricular volume and the internal surface areas of noncontractile regions were measured by cineangiocardiography at 60 frames/sec in nine patients with a chronic localized noncontractile area of the left ventricle. Arteriosclerotic heart disease was proven in eight patients by means of coronary arteriography. Left ventricular end-diastolic pressure, stroke volume, ejection fraction, mean circumferential shortening, and cardiac output were also measured before and after removal of the noncontractile area and revascularization of the myocardium.The noncontractile areas, measured at end-diastole, ranged from 12 to 40% of the internal surface area of the left ventricle. Generally, impairment of the left ventricular function depended on the size of the noncontractile areas. The end-diastolic volume was approximately 150 ml/m2 when the size of noncontractile areas exceeded 20-25% of the left ventricular surface area (r = +0.72; P < 0.05). The ejection fraction decreased as the size of the noncontractile areas increased (r = −0.81; P < 0.01). Following surgery, the left ventricular function, as well as the clinical condition, improved significantly, although the cardiac performance remained in the abnormal range in most patients. The ejection fraction increased (P < 0.05), and the percent circumferential shortening also improved (P < 0.05).Removal of the noncontractile area of the left ventricle and revascularization of the myocardium improved the cardiac performance and increased the sense of well being in these patients.

The surgical treatment of mitral insufficiency and combined mitral stenosis and insufficiency using the heart-lung machine

Abstract Open heart surgery now offers a method for correction of mitral insufficiency. The technic consists of posteromedial annuloplasty. The details of the operation are important in that only the annulus of the mural leaflet should be narrowed and not the annulus of the aortic leaflet. In retrospect in only three of the fortytwo patients would the use of a plastic valve be indicated. The surgical mortality was 15 per cent and the patients with good or excellent results comprised 86 per cent of the living patients.

Carcinoid heart disease. Surgery for tricuspid and pulmonary valve lesions.

The second known successful operation for carcinoid valvular heart disease is reported. The patient underwent tricuspid valve replacement and pulmonary valvotomy and has no symptoms of heart disease more than 1 year after operation.

Tricuspid Regurgitation Associated With Mitral Valve Disease: Repair and Replacement

Between January 1975 and June 1988, 156 patients with combined mitral and tricuspid valve disease underwent mitral and tricuspid valve repair or replacement. There were 127 (81%) patients with tricuspid valve repair and 29 (19%) patients with tricuspid valve replacement. Hospital mortality was 14% and was strongly influenced by preoperative pulmonary hypertension (systolic pressure greater than 65 mm Hg) and poor left ventricular function (ejection fraction less than 0.4). Five-year survival for the entire series was 57% +/- 5%; 12-year survival was 44% +/- 9%. Ejection fraction was the only age-adjusted risk factor for long-term survival. Of the patients who underwent tricuspid annuloplasty, 91% +/- 4% were free from reoperation after 10 years, indistinguishable from valve replacement (90% +/- 7%). Our tricuspid annuloplasty is simple and effective, and exhibits excellent long-term durability as well as immediate hemodynamic improvement.

A Further Look at Tricuspid Annuloplasty

Is it necessary to replace the tricuspid valve or insert a tricuspid ring for pure tricuspid insufficiency, or is repair satisfactory? In 96 of 113 patients with pure tricuspid insufficiency the tricuspid valve was repaired by converting the incompetent three-leaflet valve into a two-leaflet one. To avoid liver damage in these critically ill patients, the inferior caval tie was omitted during the open-heart procedure. There have been 5 deaths in the last 51 consecutive operations. Three patients developed recurrent tricuspid insufficiency secondary to failure of the mitral repair or replacement. It is concluded that tricuspid repair for pure tricuspid insufficiency is a simple and excellent method for treating severe, pure tricuspid insufficiency.

Surgery for Ebstein's Anomaly

Abstract The surgical treatment of Ebsteins anomaly is discussed from our experience with 5 patients who underwent successful operation together with 32 previously reported patients. Tricuspid valve replacement with a disc valve and primary closure of the atrial septal defect was performed in our 5 patients. In 3 patients plication of the atrialized ventricle with paradoxical movement was also employed. In the remaining 2 patients plication was not necessary. We believe that tricuspid valve replacement will usually be required for these patients. The low-profile Kay-Shiley disc valve with the Kay muscle guard is well suited for tricuspid valve replacement in patients with Ebsteins anomaly. The prosthesis should be placed above the coronary sinus to avoid injury to the conduction system. Elimination of the atrialized ventricle is an essential aspect of the procedure when paradoxical distention persists following repair or replacement of the tricuspid valve. Primary closure of the atrial septal defect also should be performed. All 5 of our patients were improved and remain in good condition four months, eleven months, one and one-half years, one and three-fourths years, and five years, respectively, following operation.