Rossiter Sj

Surgical implications and results of combined aortic valve replacement and myocardial revascularization

Abstract To better define the indications for and results of simultaneous aortic valve replacement and myocardial revascularization, a cohort of 271 patients with angiographically defined coronary anatomy who underwent xenograft bioprosthetic aortic valve replacement were analyzed. Two hundred and twelve patients had predominant aortic stenosis, and 55 had pure aortic regurgitation. Discordance between the clinical assessment of angina and the angiographic assessment of coronary artery disease was apparent in 39 percent of the patients with aortic stenosis and 45 percent of the patients with aortic regurgitation. Thirty-seven percent of patients in the aortic stenosis subgroup without angina and 41 percent of patients in the aortic regurgitation subgroup without angina had hemodynamically significant coronary artery disease. Concomitant coronary artery bypass grafting and aortic valve replacement were performed in 101 patients. The incidence of perioperative myocardial infarction and operative death was significantly greater ( P It is concluded that angina pectoris in patients with aortic valve disease is not a reliable indicator of coronary artery disease and that patients with coronary disease who undergo aortic valve replacement have an increased risk. It is inferred from this study that preoperative coronary arteriography is advisable in most adults undergoing the evaluation of aortic valve disease and that simultaneous aortic valve replacement and myocardial revascularization may provide some protection against late attrition due to the combined effects of coexistent aortic valve and coronary artery disease.

Late Right Heart Reconstruction Following Repair of Tetralogy of Fallot

Twenty-two symptomatic patients underwent a total of 28 reoperative procedures after initial surgical repair of tetralogy of Fallot. Sixteen of the patients were considered to have unfavorable anatomy of the right ventricular outflow tract (RVOT) or pulmonary artery at the time of initial repair. Pulmonary or tricuspid valve replacement, or replacement of both valves, utilizing a xenograft bioprosthesis was performed in 1 of the 22 initial repairs, 7 of the 22 first reoperations, and 5 of the 6 second reoperations. Ultimately, 14 patients received transannular RVOT patches. The interval between the first and second reoperations for 6 patients who required 2 late reconstructive procedures was 5.8 years. No operative deaths occurred. There were 2 late deaths (1 sudden and 1 due to aspiration). Actuarial survival probability (+/- standard error of the mean) 16 years after initial repair was 72 +/- 21%. Eighteen of the 20 current survivors in the present series are completely asymptomatic without physical restrictions; the other 2 are considered to be in New York Heart Association Functional Class II. No xenograft bioprosthetic dysfunction has occurred to date, but cumulative valve follow-up is limited (13 patient-years). In selected patients, earlier pulmonary or tricuspid valve replacement or replacement of both of these valves can provide some degree of protection against recurrent deterioration.

Internal mammary artery versus autogenous vein for coronary artery bypass graft

Aortocoronary venous graft (ACVG) and internal mammary artery graft (IMAG) are currently the two most popular choices for coronary artery bypass. The morphologic alteration and susceptibility to atheromatous degeneration of the IMAG were compared with the ACVG. Six of 12 surviving dogs with IMAGs were fed a hyperlipidemic diet and six were placed on a regular diet. All dogs were sacrificed 3-15 months after surgery. Twelve of 28 long-term surviving dogs with ACVGs were also on hyperlipidemic diets, and all were sacrificed 3-18 months after surgery. Arteriography and electron microscopy were performed in selected cases, and histology was performed in all cases. All long-term IMAGs remained patent; 83 percent (5/6) “regular’ diet arteries were normal, with no intimal proliferation, while 33 percent (2/6) “hyperlipidemic’ IMAGs had diffuse atheroma. Eighty-two percent of ACVGs revealed significant atherosclerosis. Severity of arteriosclerotic involvement of the ACVG was far greater than that of the native coronary circulation; this was not true for the IMAG.It may be concluded that (1) in the normolipidemic condition the IMAG undergoes significantly less severe histologic change than the ACVG, (2) both the IMAG and the ACVG are more susceptible to atheromatous change than the native coronary circulation. In these series, patency was not influenced by severity of histologic changes, and no grafts were occluded by virtue of the arteriosclerotic process.