Rodney H. Herr

Multiple valve replacement. Review of five years' experience.

During the past 5½ years 152 patients have undergone multiple valve replacement in this clinic. The operative mortality is 12% and the late mortality 14%. The late complications and functional results of the 112 survivors are reviewed and discussed. Neither severe cardiovascular symptoms nor unfavorable hemodynamic findings are specific contraindications to an operation; however, irreversible disease coexisting in other organ systems is a possible contraindication. A decrease in recent operative mortality and fewer significant complications suggest that this experience should be extended.

Phonocardiographic Diagnosis of Aortic Ball Variance

Fatty infiltration causing changes in the silastic poppet of the Model 1000 series Starr-Edwards aortic valve prostheses (ball variance) has been detected with increasing frequency and can result in sudden death. Phonocardiograms were recorded on 12 patients with ball variance confirmed by operation and of 31 controls. Ten of the 12 patients with ball variance were distinguished from the controls by an aortic opening sound (AO) less than half as intense as the aortic closure sound (AC) at the second right intercostal space (AO/AC ratio less than 0.5). Both AO and AC were decreased in two patients with ball variance, with the loss of the characteristic high frequency and amplitude of these sounds. The only patient having a diminished AO/AC ratio (0.42) without ball variance at reoperation had a clot extending over the aortic valve struts. The phonocardiographic findings have been the most reliable objective evidence of ball variance in patients with Starr-Edwards aortic prosthesis of the Model 1000 series.

Hemodynamic Evaluation of a Cloth-Covered Starr-Edwards Valve Prosthesis

Hemodynamic studies were performed in 22 patients three to ten months after insertion of cloth-covered Starr-Edwards prostheses. The aortic valve was replaced in ten patients, the mitral in ten, and both valves in two. Moderate aortic systolic pressure gradients were found in all patients with aortic prostheses (range 17 to 68 mm Hg, mean 41 mm Hg), and the calculated valve orifice areas were small (average 0.92 cm2). Mitral diastolic pressure gradients in those with mitral prostheses averaged 9.4 mm Hg and were associated with persistently elevated left atrial pressure (average 18 mm Hg). These findings compare unfavorably with the hemodynamic characteristics of previous Starr-Edwards prostheses. Factors contributing to the functional stenosis appear to be smaller valve orifices and turbulent blood flow generated by the coarse cloth surfaces and a shorter excursion of the ball.

Sound Spectrographic Diagnosis of Aortic Ball Variance

Abnormalities in the silastic poppets of cardiac valve prostheses have been detected with increasing frequency. Ball variance can cause serious mechanical dysfunction of the prosthesis and can result in sudden death. Contour sound spectrograms were recorded on 12 patients with ball variance confirmed by operation and 25 controls. In ball variance the frequency of the aortic opening sound at the second right intercostal space was decreased, with the peak frequency recorded being below 1,300 cycles/sec in 11 of the 12 patients. The peak frequency was greater than 1,300 cycles/sec in 24 of the 25 control patients. The remaining patient had peak frequencies in both the normal and abnormal range. The diagnosis of aortic ball variance in patients with triple valve replacement remains difficult because of the nearly synchronous tricuspid closing and aortic opening sounds. The sound spectrographic findings have been the most reliable objective evidence of ball variance in patients with Starr-Edwards aortic prostheses of the Model 1000 series.

Hemodynamic Studies Following Pericardiectomy for Constrictive Pericarditis

Fourteen patients underwent right heart catheterization 5 to 86 months after pericardiectomy for constrictive pericarditis. Twelve had preoperative catheterizations, all with findings typical of constrictive pericarditis.All patients showed marked hemodynamic and symptomatic improvement after operation. Three patients had persistent mild elevation of right heart and pulmonary artery pressures; one of these had a low cardiac output. Two other patients developed pulmonary hypertension with exercise, and one man showed an inadequate increase in cardiac output with exercise. Twelve patients were asymptomatic postoperatively and two had exertional dyspnea.Patients with incomplete pericardiectomy over the ventricles had abnormal hemodynamic results, while decortication of the atria and venae cavae made no difference in the postoperative findings. A left anterolateral thoracotomy incision provided adequate exposure for pericardiectomy, and continues to be the incision of choice at this hospital. Younger patients and those who progressed from recognized acute pericarditis to pericardial constriction more frequently had normal results at cardiac catheterization after operation. Certain preoperative liver-function tests correlated well with the postoperative hemodynamic findings. The role of myocardial disease in producing residual hemodynamic abnormalities remains unresolved.It is concluded that excellent clinical results and normal hemodynamic findings can be achieved by pericardiectomy in most patients with constrictive pericarditis.

Aortic valve replacement with the Starr-Edwards ball-valve prosthesis: Indications and results☆

Abstract The results of aortic valve replacement with the Starr-Edwards prosthesis are reviewed in 86 patients. The total early and late mortality rate was 24 per cent. This fell to 13 per cent in 1964, and can be expected to decline further. Nearly all survivors are greatly improved by surgery. Detailed follow-up of 6 months to 3 years is available in 50 patients. All but one had symptoms prior to operation, and hemodynamic study preoperatively demonstrated gross abnormalities in most. Sixty-six per cent became asymptomatic, whereas mild limitation to exercise persisted in another 40 per cent. Angina pectoris disappeared in 32 of 34 instances. Sixty-eight per cent had a normal or only slightly enlarged heart after operation. Electrocardiographic evidence of left ventricular hypertrophy disappeared in 58 per cent. Postoperative hemodynamic studies usually demonstrated some mild residual hemodynamic abnormality, probably attributable to irreversible myocardial damage resulting from long-standing left ventricular hypertrophy and/or dilatation. Postoperative complications included regurgitation around the prosthesis, which was rarely of hemodynamic consequence, bacterial endocarditis (rare), traumatic hemolytic anemia (rare), and systemic arterial embolization. Thromboembolism remains the major unsolved problem of aortic valve replacement, and anticoagulant drugs have not been proved to be of value in preventing this. Indications for aortic valve replacement are discussed in terms of the current mortality rate and incidence of complications, the proved clinical and hemodynamic benefits, and the natural history of the various types of aortic lesions. All symptomatic patients with aortic stenosis, and all Class III or IV patients with aortic regurgitation are candidates for surgery. In addition, surgery is recommended in relatively asymptomatic patients with aortic stenosis who have a transvalvular peak systolic gradient of more than 70 mm. Hg, and in those with aortic regurgitation if there is gross cardiac enlargement, angina pectoris, or abnormal left heart dynamics. The possibility of underestimating the hemodynamic severity of a mixed aortic valve lesion was discussed.

Cardiac Catheterization Studies after Combined Tricuspid, Mitral, and Aortic Valve Replacement

Postoperative cardiac catheterizations were performed in eight patients within the first year following replacement of the tricuspid, mitral, and aortic valves with Starr-Edwards ball-valve prostheses. Two additional patients were studied who had mitral and tricuspid replacement. Before surgery the patients characteristically had distinct elevation of right and left atrial pressures, and markedly reduced cardiac outputs. Four individuals had marked pulmonary hypertension. At the postoperative catheterizations, consistent changes were an increase in cardiac output, a decrease in right and left atrial pressures, and a decrease in right ventricular systolic pressure. The last change was particularly notable in those individuals who had marked pulmonary hypertension before surgery.

Late, Heparin-Induced Bleeding after Retrograde Arterial Catheterization

Three patients with ball-valve prostheses were given heparin after percutaneous retrograde aortic catheterization from the femoral artery. The drug was given prophylactically in one case and because of the development of signs of systemic embolism soon after catheterization in the other two. After 3 or more days of heparin therapy, serious bleeding developed at the site of percutaneous catheter entry. The timing and incidence of this complication are in marked contrast to experience with this procedure in individuals who did not receive heparin.Preliminary experience is presented from right and left heart catheterizations in patients whose prothrombin-proconvertin times were allowed to remain in or near the therapeutic range. No hemorrhagic complications were observed.

Mitral commissurotomy with pump standby

Abstract Mitral commissurotomy has been performed on twenty-six patients, eight of whom have required mitral valve replacement as a result of incomplete opening or dilator injury. There was one death. It is believed that the essential pathologic condition in dilator injuries or incomplete commissurotomy is due to the subvalvular fusion of the chordae tendineae. With open commissurotomy the fusion can be relieved under direct vision without injury to the mitral leaflets. The greatest hazard from open commissurotomy is air embolus. This can be obviated by using the technic outlined. The long-term results from open commissurotomy remain to be determined.

Transposition of the great vessels: Recent experience with the Blalock-Hanlon procedure☆☆☆

Abstract An experience with twenty-one patients undergoing emergency palliative surgery for transposition of the great vessels with pulmonary overcirculation is presented. Banding of the pulmonary artery was performed as the only operative procedure in three patients and as the initial operative procedure in six patients. All but one failed to survive operation. The creation of an atrial septal defect by the Blalock-Hanlon operation was performed as the only operative procedure in fourteen patients with four deaths and a satisfactory late clinical result in all survivors. Thus, while the over-all results of palliative surgery for transposition are far from satisfactory, those patients suffering predominantly from severe cyanosis may expect a good result from a Blalock-Hanlon operation in terms of exercise tolerance, growth and development and the ease of subsequent medical management. Those patients suffering predominantly from associated cardiac defects with massive pulmonary overcirculation and only minimal cyanosis are poor candidates for palliative surgery and must be considered for total correction if survival is to be obtained.