Julie Delianides

Minimally invasive mitral valve surgery: a 6-year experience with 714 patients.

BACKGROUND This study analyzes a single institutional experience with minimally invasive mitral valve operations of 6 years, reviewing short-term morbidity and mortality and long-term echocardiographic follow-up data. METHODS Seven hundred fourteen consecutive patients had minimally invasive mitral valve procedures between November 1995 and November 2001; concomitant procedures included 91 multiple valves and 18 coronary artery bypass grafts. Of these 714 patients, 561 patients had isolated mitral valve operations (375 repairs, 186 replacements). Mean age was 58.3 years (range, 14 to 96 years; 30.1% > 70 years), and 15.4% of patients had previous cardiac operations. Arterial cannulation was femoral in 79.0% and central in 21%, with the port access balloon endo-occlusion used in 82.3%. Cardioplegia was transjugular retrograde (54.1%) or antegrade (29.4%). Right anterior minithoracotomy was used in 96.6% and left posterior minithoracotomy in 2.2%. RESULTS Hospital mortality for primary isolated mitral valve repair was 1.1% and 5.8% for isolated mitral valve replacement. Overall hospital mortality was 4.2% (30 of 714). Mean cross-clamp time was 92 minutes and mean cardiopulmonary bypass time was 127 minutes. Postoperatively, median ventilation time was 11 hours, intensive care unit time was 19 hours, and total hospital stay was 6 days. Complications for all patients included permanent neurologic deficit (2.9%), aortic dissection (0.3%); there was no mediastinal infection (0.0%). Follow-up echocardiography demonstrated 89.1% of the repair patients had only trace or no residual mitral insufficiency. CONCLUSIONS This study demonstrates that the minimally invasive port access approach to mitral valve operations is reproducible with low perioperative morbidity and mortality and with late outcomes that are equivalent to conventional operations.

Aortic valve replacement in patients with impaired ventricular function

BACKGROUND Patients with reduced ventricular function undergoing aortic valve replacement have increased operative risks, but the impact of valvular pathophysiology and other risk factors has not been clearly defined. METHODS From June 1992 through June 2002, 1,402 consecutive patients underwent isolated aortic valve surgery with or without coronary artery bypass grafting; of these patients, 416 had an ejection fraction less than 40% and are the subject of this report. These patients (mean age, 68.6) had severe stenosis (62.5%), severe regurgitation (30.3%), or mixed disease (7.2%). Aortic valve replacement plus coronary artery bypass grafting was performed in 48.4% of patients, and 27% had previous cardiac surgery. Follow-up included echocardiography and survival analysis. RESULTS Hospital mortality was 10.1% (42 of 416), with no difference between aortic stenosis (9.6%) and regurgitation (11.1%). Multivariate analysis revealed that age (p = 0.002) and renal disease (odds ratio = 4.2; 95% confidence interval, 1.9 to 9.3; p = 0.001) were independently associated predictors of mortality. Valvular pathophysiology had no impact on mortality. Peripheral vascular disease, multivessel coronary disease, and renal disease were associated risks for any postoperative complication. Peripheral vascular disease (odds ratio = 12.3, p = 0.02), history of cerebrovascular disease (odds ratio = 4.8, p = 0.038), and diabetes (odds ratio = 2.7, p = 0.04) were associated risks for stroke. The ejection fraction was more than 40% in 52% of the patients who had postoperative echocardiography (mean follow-up, 6 months). Actuarial survival revealed no difference between pathophysiologic groups. CONCLUSIONS Aortic valve surgery in patients with impaired ventricular function carries an acceptable operative risk that can be stratified by age and comorbidities. The type of valvular pathophysiology does not significantly affect mortality.

Valve Repair Versus Replacement For Mitral Insufficiency: When Is A Mechanical Valve Still Indicated?

OBJECTIVES Although many advantages of mitral valve reconstruction have been demonstrated, whether specific subgroups of patients exist in whom mechanical valve replacement offers advantages over mitral reconstruction remains undetermined. METHODS This study examined the late results of mitral valve surgery in patients with mitral insufficiency who received either a St. Jude Medical valve (n = 514) or a mitral valve reconstruction with ring annuloplasty (n = 725) between 1980 and 1996. RESULTS Overall operative mortality was 7.2% in the patients receiving a St. Jude Medical mitral valve and 5.4% in those undergoing mitral valve reconstruction (no significant difference); isolated mortality was 2.5% in the St. Jude Medical group and 2.2% in the valve reconstruction group (no significant difference). The follow-up interval was more than 5 years for 340 patients with a mean of 39.8 months (98.5% complete). Overall 8-year freedom from late cardiac death, reoperation, and all valve-related complications was 72.8% for the St. Jude Medical group and 64.8% for valve reconstruction group (no significant difference). For patients with isolated, nonrheumatic mitral valve disease, 8-year freedom from late cardiac death and reoperation was better in the mitral valve reconstruction group (88.3%) than in the St. Jude Medical valve group (86.0%; p = 0.05). Furthermore, Cox proportional hazards regression revealed that mitral valve reconstruction was independently associated with a lesser incidence of late cardiac death (p = 0.04), irrespective of preoperative New York Heart Association class. However, the St. Jude Medical valve offered better 8-year freedom from late cardiac death, reoperation, and all valve-related complications than did mitral valve reconstruction in patients with multiple valve disease (77.0% vs 45.3%; p < 0.01). CONCLUSIONS Therefore, mitral valve reconstruction appears to be the procedure of choice for isolated, nonrheumatic disease, whereas insertion of a St. Jude Medical valve should be preferred for patients with multiple valve disease.

Late Results of Isolated Mitral Annuloplasty for “Functional” Ischemic Mitral Insufficiency

Background: Repair of functional ischemic mitral regurgitation (MR) due to annular deformity and leaflet restriction remains a challenge for the surgeon and lacks well‐documented outcomes. We investigated outcomes in the treatment of functional ischemic MR corrected by annuloplasty techniques alone. Methods: From May 1980 to July 1999, 174 patients underwent repair for functional ischemic mitral insufficiency with annuloplasty alone (128 ring annuloplasty; 46 suture annuloplasty). Acute insufficiency was present in 25 (14.4%). Concomitant procedures included CABG (n = 152;87.4%). Patients wisro studied longitudinally with annual follow‐up and echocardiograms. Results: Overall hospital mortality was 17.8% and was increased by NYHA Class 4 (23.8% vs. 8.7%; p = 0.011), diabetes (25.0% vs. 13.6%; p = 0.059), and chronic mitral insufficiency (16.4% vs. 8.0%; p = 0.070). Multiverlatis analysis revealed age (β= 0.099; p = 0.049) and ejection fraction < 30% (β= 1.260; p = 0.097) as significant predictors of hospital death. Mean postoperative mitral insufficiency was 0.84 ± 0.86 (scale of 0–4). NYHA Class 4 (β= 2.33; p = 0.034) and simple suture annuloplasty (β= 2.08; p = 0.07) were associated with increased risk of late cardiac death. Cumulative incidence of mitral reoperation was 7.7% at 5 years. At follow‐up, 89.7% of patients were in NYHA Class 1 or 2 with 83.4% having none or only mild mitral insufficiency. Conclusions: Ring annuloplasty is associated with a survival benefit when compared to simple suture repair in ischemic patients who require annuloplasty alone to correct the MR. Mitral re construction with a ring annuloplasty offers durable results in this homogeneous subset of functional ischemic MR patients. Ischemic mitral insufficiency is associated with significant late mortality.

Late results of mitral valve reconstruction in the elderly

BACKGROUND This study attempts to confirm favorable results with mitral valve reconstruction (MVP) in patients greater than or equal to 70 years of age and to examine complication rates by actual analysis. METHODS Between June of 1980 and December of 1997, 278 patients 70 years of age or older (mean, 75.2 years; range, 70 to 87 years) underwent MVP for mitral regurgitation. Most involved insertion of an annuloplasty ring. Concomitant procedures were performed in 72.3%, and 55.0% required coronary revascularization. RESULTS For isolated MVP, the in-hospital mortality rate was 6.5% and 17.0% when combined with coronary revascularization. The mortality rate when combined with another valve procedure was 13.2%. The 5-year freedom from late cardiac death was 100% in the isolated MVP group and 79.7% for MVP with a concomitant procedure (p = 0.006). Complications were analyzed using actual (cumulative incidence) analysis to eliminate the competing risk of noncardiac death. Mean NYHA class improved from 3.32 to 1.71 postoperatively. Repair failure was rare, with a 5-year freedom from reoperation of 91.2%. CONCLUSIONS These findings confirm the favorable outcome of MVP in elderly patients. Late repair failures are rare; comorbid disease is an important predictor of outcome.

Selective approach to descending thoracic aortic aneurysm repair: A ten-year experience

BACKGROUND A variety of surgical techniques has been developed to attempt to minimize the risk of paraplegia after descending thoracic aortic aneurysm repair. This study reviews our institutional experience with several basic techniques over a period of 10 years. METHODS Seventy-eight consecutive patients underwent repair of descending thoracic aortic aneurysm between 1983 and 1993. Two basic repair strategies were used: (1) distal perfusion with somatosensory evoked potential monitoring (n = 54) and (2) cross-clamping (n = 24), alone (n = 6) or with controlled distal exsanguination (n = 18). RESULTS The operative mortality rate was 6.5% for elective repair (n = 62), 25.0% for emergent repair (n = 16), and 10.3% overall. Univariate predictors of increased operative risk were emergent operation, rupture, and shock. Neither death nor paraplegia was related to the operative technique used. The incidence of paraplegia was 3.7% in perfused patients and 4.2% in cross-clamping patients (p > 0.05). Paraplegia did not occur after any elective operation (zero of 62) but occurred in 18.6% of emergent cases (p < 0.01). In perfused patients, paraplegia did not occur when the distal pressure was maintained above 55 mm Hg and somatosensory evoked potentials remained intact. When somatosensory evoked potentials were lost (n = 7) in perfused patients, the operative technique was altered successfully in 5 patients, whereas in 2 patients (28.6%), paraplegia developed. CONCLUSIONS The risks associated with elective descending thoracic aortic aneurysm repair were extremely low using an operative strategy that was flexible but skewed toward perfusion with somatosensory evoked potential monitoring. In perfused patients, paraplegia did not occur when distal pressure was greater than 55 mm Hg and somatosensory evoked potentials remained intact. However, the risks of death and paraplegia were primarily related to emergent presentation, not to technique, and the technique of cross clamping with controlled distal exsanguination was found to be valuable in unstable or in anatomically complicated subsets of patients.

Anterior leaflet procedures during mitral valve repair do not adversely influence long-term outcome

OBJECTIVES This study was done to assess the impact of anterior mitral leaflet reconstructive procedures on initial and long-term results of mitral valve repair. BACKGROUND It has been suggested that involvement of the anterior leaflet in mitral valve disease adversely affects the long-term outcome of mitral valve repair. Our policy has been to aggressively repair such anterior leaflets with procedures that include triangular resections in some cases. METHODS From June 1979 through June 1993, 558 consecutive Carpentier-type mitral valve repairs were performed. The anterior mitral leaflet and chordae tendineae were repaired in 156 patients (mean age 58 years). The procedures included anterior chordal shortening in 78 patients (50%), anterior leaflet resections in 44 (28%), resuspension of the anterior leaflet to secondary chordae in 42 (27%) and anterior chordal transposition in 27 (17%). Concomitant cardiac surgical procedures were performed in 75 patients (48%). RESULTS The operative mortality rate was 2.5% (2 of 81) for isolated mitral valve anterior leaflet repair and 3.8% (6 of 156) for all mitral valve anterior leaflet repair. Freedom from reoperation at 5 and 10 years was, respectively, 89.7% (n = 160) and 83.4% (n = 24) for the entire series of 558 patients, 91.9% (n = 51) and 81.2% (n = 10) for patients with anterior leaflet procedures, 88.8% (n = 109) and 84.4% (n = 14) for patients without anterior leaflet procedures and 91.7% (n = 118) and 88.9% (n = 18) for patients without rheumatic disease. Logistic regression showed that rheumatic origin of disease (odds ratio 2.99), but not anterior leaflet repair, increased the risk for reoperation. CONCLUSIONS These results demonstrate that expansion of mitral valve techniques to include anterior leaflet disease yields immediate and long-term results equal to those seen in patients with posterior leaflet disease.

Endoventricular remodeling of left ventricular aneurysm. Functional, clinical, and electrophysiological results.

BACKGROUND Recent advances in surgical techniques for the repair of left ventricular aneurysms (LVAs) include the use of an endoventricular patch to exclude the aneurysm cavity. This technique has replaced conventional linear plication of the aneurysm. The endoventricular patch technique remodels the left ventricular cavity to a more physiological geometry that improves function. METHODS AND RESULTS From December 1989 through November 1993, 45 patients underwent an LVA repair with an endoventricular patch. This procedure was performed in association with coronary artery bypass grafting in 40 patients. Twenty-eight patients (62.2%) also had nonguided encircling subendocardial incisions. Operative procedures included 7 emergency operations, 3 concomitant valve procedures, and a mean of 2.2 bypass grafts per patient. Eight patients had previous cardiac operations. Hospital mortality was 15.6% (7/45) for all patients and 9.1% (3/33) for nonemergent revascularization and LVA repairs. Ejection fraction improved from a mean of 25.8% preoperatively to 37.8% postoperatively; the mean New York Heart Association classification improved from 3.5 to 1.5. Of patients known to have preoperative arrhythmias (inducible or sudden death), 69% were not inducible postoperatively without antiarrhythmic medication. Survival from late cardiac death (including death of unknown origin) was 86.5% at 2 years. Freedom from documented ventricular arrhythmias was 94.3% at 2 years. CONCLUSIONS These results indicate that the patch endoaneurysmorrhaphy technique can provide an excellent functional and physiological outcome in patients with LVAs and severely impaired ventricular function.

Severe calcification does not affect long-term outcome of mitral valve repair

Some surgeons have suggested that the presence of severe calcification in the mitral valve annulus or leaflets precludes successful repair. Our institution has attempted to repair these calcified valves when good annular and leaflet mobility could be achieved by annular debridement and leaflet resection. From June 1979 through June 1993 558 mitral valve repairs were performed using Carpentiers techniques. When calcified valves were encountered, these techniques were modified to include annular debridement and mechanical leaflet decalcification. Calcification was identified preoperatively in 49 patients (8.8%) by either left ventricular fluoroscopy or echocardiography and was debrided in 64 patients (11.5%). This included 24 annular debridements, 28 leaflet debridements, and 12 annular and leaflet debridements. Patient ages ranged from 13 to 83 years (mean age, 62.3 years), and 25 patients (39.1%, 25/64) had concomitant cardiac procedures. Operative mortality was 6.2% (4/64) overall and 2.6% (1/39) for isolated mitral valve repairs. Calcium debridement was performed in 19.3% (23/119) of patients with a rheumatic cause compared with 9.3% (41/439) of the nonrheumatic patients (p < 0.01). Long-term follow-up revealed the necessity for reoperation in 7.8% (5/64) in patients with calcium debridement as compared with 7.7% (38/494) with no debridement (p = not significant). Cumulative freedom from reoperation at 10 years was 83.3% for all patients, 88.1% for debrided patients, and 82.6% for nondebrided patients (p = not significant). Cox proportional hazards analysis revealed that the presence of rheumatic disease significantly increased the risk of reoperation (odds ratio = 3.28; p < 0.001), whereas calcium debridement had no significant effect. These results demonstrate that when good annulus and leaflet motion can be achieved in calcified mitral valves, calcium debridement allows durable repairs.

Atrial Arrhythmia Following a Biatrial Approach to Mitral Valve Surgery

The biatrial approach to exposing the mitral valve during surgery has the potential for improving visualization of the valve with minimal cardiac manipulation. This procedure, involving a right atriotomy and an extended transseptal incision, may isolate the sinus node from its normal blood supply and autonomic innervation. Thirty‐eight consecutive patients undergoing this procedure were examined. Twenty‐two of these patients (58%) were admitted in normal sinus rhythm and 15 (40%) were in atrial fibrillation (AF) or atrial flutter. Of the 22 patients admitted in normal sinus rhythm, only 3 patients remained in this rhythm at discharge. Fourteen of the 22 patients were discharged in a slow, low atrial rhythm. All of the patients admitted in AF were discharged in AF. Of the 14 patients discharged in a low atrial rhythm, the rhythm persisted in eleven patients (80%) at a mean of 6‐month follow‐up. The routine use of this transseptal approach to mitral valve surgery needs further assessment in light of the predictable loss of the sinus mechanism.