J Heart Valve Dis
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Randomized Controlled Trial Comparative Study Clinical Trial
Left ventricular function after mitral valve surgery.
This study examined the effects of various operative procedures on the mitral valve of patients with mitral regurgitation due to degenerative disease of the mitral valve. A randomized clinical trial on the type of annuloplasty ring used at surgery revealed that early postoperative left ventricular systolic function was better in patients who had a flexible ring than in patients who had a rigid ring. Two years after surgery there were no differences between these groups and most patients were found to have fairly normal left ventricular function. ⋯ Of those patients, 70 had had chordal preservation during surgery and 84 did not. These two subgroups were remarkably similar preoperatively, but the 10-year actuarial survival was 80% +/- 6% for patients who had chordal preservation and 63% +/- 6% for those who did not. The mitral valve should be repaired whenever possible; if replacement is necessary it should be performed with preservation of the chordae tendineae.
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This report describes the technique of Integrated Myocardial Management that combines the advantages of various cardioprotective strategies to compensate for their individual shortcomings. This approach co-ordinates the myocardial protective techniques with the continuity of the operation so that the surgical continuity of the procedure is never interrupted, and there is simultaneously (a) unimpaired vision, (b) avoidance of unnecessary ischemia and cardioplegic overdose, (c) aortic clamping as soon as cardiopulmonary bypass is started, (d) aortic unclamping and discontinuation of bypass very shortly after the technical procedure is completed, while (e) minimizing the duration of ischemia and cardiopulmonary bypass and (f) maximizing the positive attributes of the strategies available currently. ⋯ The preliminary results in 394 consecutive patients from three centers where surgeons who participated in the infra-structure of this method is presented. This has led to our adoption of this approach in all adult cardiac operations.
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A retrospective study of 219 consecutive patients who underwent mitral valve repair for mitral regurgitation or mixed mitral valve disease with at least moderate regurgitation was undertaken. The etiology was degenerative in 151 (68.9%) patients, endocarditis in 24 (10.9%), rheumatic in 22 (10.0%), ischemic in 13 (5.9%), congenital in five (2.3%) and cardiomyopathy in two (0.9%). The average age was 64.8 +/- 10.9 years, the average follow up 30.2 +/- 24.1 months. ⋯ There was nevertheless a significant incidence of postoperative left ventricular dysfunction in patients with satisfactory preoperative left ventricular function. In this group, five-year mortality and five-year combined mortality and morbidity due to left ventricular dysfunction were higher in patients who were in NYHA class III or IV preoperatively than in those who were not: 11.2% vs. 0% (NS) and 25.9% vs. 0% (p < 0.01) respectively, particularly if they also had early (3-10 days) post-operative left ventricular dysfunction: 20.4% (p < 0.001) and 41.7% (p < 0.001) respectively. Despite preservation of the mitral apparatus, left ventricular dysfunction remains a major cause of mortality and morbidity following mitral valve repair for mitral regurgitation.
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In recent years coronary artery bypass grafting (CABG) has been extended to include patients with very low left ventricular ejection fractions (LVEF), also frequently with co-existing mild to moderate mitral valve regurgitation (MR). The question is, should such a MR be corrected simultaneously with a myocardial revascularization or not? Between January 1989 and November 1994, 56 patients with preoperative LVEF < or = 25% and echocardiographic evidence of co-existing MR (Grade I: 41%, II: 46%, III: 13%) underwent primary CABG. None of them had simultaneous mitral valve surgery. ⋯ Coronary artery bypass grafting is a possible treatment for patients with very low LVEF, provided the patient has a two- or three-vessel disease with significant coronary artery stenosis (> 70%) and angina. Mortality and morbidity are low. Moderate co-existing MR (Grade I-III) seems to normalize after myocardial revascularization and should not be surgically corrected therefore at the primary operation.
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Despite improving surgical techniques, treatment of heart valve disease in children remains controversial. Growth of the child and adequate anticoagulation level are the main concerns when valve replacement is performed in the pediatric age. We reviewed the case histories of 29 children who underwent valve replacement with mechanical prosthesis from 1979 to 1994 in order to evaluate the performance of mechanical valves in this age group. ⋯ All operative survivors received oral anticoagulation with sodium warfarin. No thromboembolic event or bleeding occurred, no endocarditis developed in any patient; one reoperation was performed for patient/prosthesis mismatch. Mechanical valves offer excellent hemodynamic performances and a low rate of thromboembolism and/or bleeding in our experience, and are our first choice for heart valve replacement in children when reparative surgery is not feasible.