Jorge Martinell

Reoperations for Left-sided Low-Profile Mechanical Prosthetic Obstructions

A series of 2,474 hospital survivors of primary mitral, aortic, and double mitral-aortic valve replacement were observed for a cumulative period of 11.945 years (mean, 4.2 years; range, 0.6-14 years). The linearized incidences of reoperations for thrombotic obstructions were 0.33 +/- 0.08% for mitral valve replacement, 0.36 +/- 0.1% for aortic valve replacement, and 0.42 +/- 0.1% for double valve replacement (p = not significant). Forty-one patients (16 mitral, 12 aortic, and 13 double valve replacements) underwent a total of 44 reoperations with a mean interval of 36 +/- 29 months (range, 0.25-85 months) between operations. Diagnosis was established invasively only in 13 patients (30%). Hospital mortality at reoperation was 18% (8 patients); 28 patients (63%) required emergency surgery. The choice surgical procedures were thrombectomy for clotted aortic prostheses (18 of 24) and valve replacement for obstructed mitral valves (22 of 25; p less than .001). Rethrombosis occurred in 3 patients (1 aortic and 2 double valve replacements). At hospital admission 17 patients (38%) had prothrombin times outside therapeutic ranges (between 20 to 30% of the normal value). The incidence of reoperations for thrombosis in low-profile mechanical prostheses was unaffected by valvar position and number of prostheses implanted. Rethrombosis occurred only in previously cleaned valves, although its occurrence was not significant. The present results indicate that, as experience is gained in the diagnosis and surgical management of this complication, hospital mortality can be reduced significantly (from 37% to 4%).

Successful stent-grafting for perforation of the thoracic aorta by an intraaortic balloon pump

Vascular complications associated with intraaortic balloon pump placement are quite common and predominantly related to femoral or iliac damage. Iatrogenic injury of the thoracic aorta is less usual and often fatal. Surgery for the lesions of the descending thoracic aorta still has a relatively high morbidity and mortality. Endovascular covered stentgraft prostheses have become a less invasive therapeutic approach to lesions of the thoracic aorta, especially in patients with high surgical risk. We describe a case of perforation of the thoracic aorta caused by an intraaortic balloon pump. The injury was confirmed by aortography and successfully repaired by implantation of an endovascular stent-graft via the left common iliac artery.

Surgical treatment of prosthetic valve endocarditis in patients with double prostheses: is single-valve replacement safe?

OBJECTIVE Bias against operating on patients with prosthetic valve endocarditis (PVE) who have multiple prostheses may preclude the use of life-saving valve replacement. We investigated the accuracy of the preoperative diagnosis of PVE in patients with both mitral and aortic prosthesis and the safety of single-valve replacement when only one valve seemed infected. METHODS Patients with a diagnosis of active PVE who had mitral and aortic prosthesis in place were assessed. We looked at the methods for diagnosis, causative agents, indication for valve replacement, operative findings and outcome. RESULTS Twenty patients, who had both mitral and aortic prostheses and a diagnosis of PVE, were assessed. Streptococci and staphylococci caused 70% of cases. By means of echocardiography, the valves involved were: mitral (11 patients), aortic (six patients), and in three cases both prosthetic valves seemed infected. Surgery was undertaken in 17 patients (85%). The positive predictive value of transesophageal echocardiogram (TEE) for the preoperative diagnosis of the site of infection was 100%. In 13 patients, only the prosthetic valve that seemed infected was replaced. Four of these patients died within a week after the procedure. Nine patients survived the surgical procedure, completed a course of antimicrobial therapy and were followed up for 15.78 months (95% CI: 12.83-18.72). All were considered cured and relapses were not observed. CONCLUSIONS TEE allowed a diagnosis of site involvement that did correlate with the anatomic diagnosis obtained during the operation. This fact contributed to the management of patients and was of great help in guiding the surgical intervention. Echo-oriented single-valve replacement may be a safe strategy for patients with PVE and double prostheses.

Technique and Results of Tricuspid Annuloplasty

Acquired lesions of the tricuspid valve may be either primary or secondary. Primary organic lesions of the valve can cause stenosis and regurgitation while secondary lesions are more frequent and invariably associated with rheumatic valvulitis of the mitral and/or aortic valves. In these cases, tricuspid incompetence is the consequence of an annular dilatation produced by right ventricular strain secondary to an increase in pulmonary vascular resistance. The surgical treatment of acquired lesions of the tricuspid valve includes valve repair techniques and prosthetic replacement in severely damaged valves. The suboptimal results obtained (Table I) with tricuspid valve replacement at our institution’ consisting of a high hospital mortality, poor long-term prognosis, and high incidence of prosthetic failures needing reoperations led us in 1972 to describe2 and perform3s4 a tricuspid annuloplasty technique in more than 600 patients who concomitantly underwent associated isolated mitral or combined mitral-aortic valve replacement.

Comparison of Reoperation and Complications in Double Valve (Mitral and Aortic) Implants with Mechanical or Biological Prostheses

A total of 1160 patients received a double valve implant, in the mitral and aortic positions, between January 1970 and December 1986. Either mechanical (984 patients) or biological (176 patients) valves were implanted. Operative mortality was 8%. Patients were followed-up for a total of 4641 patient-years (mean 5.12) in the mechanical valve group and a total of 1106 patient-years (mean 6.86) in the biological valve group. There was a significantly higher incidence of reoperation (p < 0.001) in the biological valve compared to the mechanical group because of a high number of primary tissue failures. An analysis of the actuarial data shows no significant difference in long-term survival. In conclusion, we think that the indications for double (mitral and aortic) biological valve implantation should be analyzed carefully. Given the freedom from reoperation after 12 years of only 28%, only very specific cases should be considered for biological valve implantation.