Tomohide Kawamoto

Preoperative left ventricular function: minimal requirement for successful late results of valve replacement for aortic regurgitation

Postoperative survival and left ventricular function were studied in 62 patients who underwent aortic valve replacement for isolated, chronic aortic regurgitation between 1978 and 1985. The average follow-up period was 3.8 years. There were three in-hospital and six late deaths. Five (56%) of the nine postoperative deaths were of cardiac-related causes. The mean 7 year survival rate was 83 +/- 5%. Preoperative left ventricular end-systolic volume index was the most important indicator (p less than 0.001) for subsequent cardiac death. The 6.5 year survival rate was 92 +/- 4% for patients with an end-systolic volume index less than 200 ml/m2 compared with 51 +/- 16% for those whose index was greater than 200 ml/m2. None of the 48 patients with an end-systolic volume index less than 200 ml/m2 died of cardiac-related causes. Twenty-three of the 48 patients with an end-systolic volume index less than 200 ml/m2 (Group 1) and 6 of the 12 patients with a higher index (Group 2) underwent repeat catheterization 26 months postoperatively. Preoperative afterload, assessed by end-systolic wall stress, was elevated in both groups, but decreased postoperatively, becoming identical to the afterload in 20 normal control subjects. Although the preoperative ejection fraction was depressed in both groups, the great majority of patients in Group 1, compared with none in Group 2, exhibited normal ejection fraction postoperatively. Thus, in patients who recently underwent surgery for aortic regurgitation, satisfactory late results in both long-term survival and reversal of left ventricular dysfunction were obtained when the preoperative end-systolic volume index was less than 200 ml/m2.

Fate of right ventricular hypertrophy in tetralogy of Fallot after corrective surgery

To elucidate the reversibility of right ventricular (RV) myocardial hypertrophy in tetralogy of Fallot (TF), 30 patients underwent RV endomyocardial biopsies 1 to 25 years (mean 9.7 +/- 6.6) after corrective surgery. Myocardial cell diameter was evaluated by comparing histopathologic data with preoperative patients with TF and normal subjects. As a whole, postoperative cell diameter was smaller than that of age-matched preoperative patients with TF, and larger than that of age-matched normal subjects. In 7 patients without significant residual pulmonary stenosis whose preoperative data were also available, cell diameter significantly decreased after surgery (17.1 +/- 2.1 to 14.0 +/- 2.1 microns, p < 0.01). There was a positive correlation between postoperative cell diameter and age at study (p < 0.01). To negate the influence of age, cell diameter was expressed in terms of a percentage of age-matched normal values (percent cell diameter). There was no significant correlation between percent cell diameter and age at surgery, age at study or the follow-up periods. There were positive correlations between percent cell diameter and the following parameters: RV systolic pressure (p < 0.05), percent normal RV end-diastolic (p < 0.05) and end-systolic (p < 0.01) volumes. These results demonstrate that RV myocardial hypertrophy in TF can regress to some extent after corrective surgery if significant residual pulmonary stenosis is avoided.

Candida endocarditis with saddle embolism: A successful surgical intervention

A 43-year-old woman who had Candida endocarditis with saddle embolism underwent mitral valve replacement and resection of infected aorta. Only 7 persons with fungal endocarditis with saddle embolism have been reported in the literature, and all of them died. We report a case of successful treatment of this lethal complication of Candida endocarditis.

Timing of operation for aortic regulation: Relation to postoperative contractile state

With angiography and pressure measurement, we determined left ventricular volume, wall stress, and systolic performance in 30 patients with aortic regurgitation before and after successful aortic valve replacement. End-systolic wall stress was greatly elevated preoperatively and decreased to normal postoperatively. Systolic pump performance assessed as ejection phase indexes was severely depressed preoperatively and improved to normal or near-normal postoperatively in most patients. The ratio of end-systolic wall stress to end-systolic volume index (ESS/ESVI), an index of myocardial contractility, was greatly decreased before operation. Postoperatively, the ratio increased in all patients, becoming normal in 12 of the 13 patients who had a preoperative ESS/ESVI of 2.9 or greater. However, 15 of 17 patients in whom the ESS/ESVI ratio was less than 2.9 still had subnormal ratios, which indicates the presence of irreversible contractile dysfunction. Stepwise multivariate analysis showed that preoperative ESS/ESVI was the only independent discriminator of postoperative normalization of the contractile function as assessed by ESS/ESVI. After aortic valve replacement, myocardial contractile state does not return to normal in a considerable number of patients. It is important to offer aortic valve replacement for aortic regurgitation before the chance for a good functional result is lost. The ESS/ESVI ratio may be a useful index in determining the timing of operation in patients with aortic regurgitation.

Early clinical evaluation of a new Björk-Shiley valve prosthesis with integral monostrut

SummaryWe evaluated preliminary results of valve replacement with a new Björk-Shiley valve prosthesis with integral monostrut. Sixty-five valves were implanted in 56 patients (18 aortic, 30 mitral, 7 double, 1 triple). The age of the patients ranged from 30 to 62 years, and they were followed up for 7–17 months (mean, 12.5 months). There were three operative deaths (5.3%) not related to the prosthesis and no late deaths. Minor cerebral thromboembolism occurred in one patient 2 weeks after surgery despite anticoagulant therapy. Intraoperative transvalvular pressure gradients across the 23-mm aortic and 27-mm mitral valve prostheses were insignificant. Real-time two-dimensional echocardiography revealed no regurgitation at the moment of valve closure in 20 randomly selected patients. Though the data accumulated so far are still relatively incomplete and the follow-up periods short, the clinical results obtained here were satisfactory, warranting further use of this new Björk-Shiley valve prosthesis with integral monostrut for longer follow-up studies.