Long-term results with the Sorin Pericarbon valve in the aortic position: a multicenter study

BACKGROUND AND AIM OF THE STUDY

A multicenter study was designed to evaluate the Pericarbon pericardial bioprosthesis for up 10 years after implantation in the aortic position.

METHODS

Between January 1986 and November 1996, 321 patients (mean age 75.8 +/- 7.3 years) received 325 Pericarbon pericardial valves in the aortic position. Four patients underwent redo surgery and each received a second Pericarbon prosthesis. Associated cardiac procedures in 80 patients were mainly coronary bypass (n = 66). Follow up extended up to 10 years (cumulative follow up of 931.0 patient-years; mean follow up 3.1 +/- 2.2 years).

RESULTS

There were 19 late deaths, with seven valve-related. Twelve patients suffered an embolic complication (transient cerebral attack in four, peripheral in six and induction of a myocardial infarction in two). Of these complications, five occurred within 30 days of surgery and seven beyond the first year. Ten patients were reoperated on, six for primary tissue failure, two for prosthetic endocarditis and two for paraprosthetic leak. Primary failure was due in all cases to leaflet mineralization. No primary tear of the leaflet was reported. Actuarial freedom after 10 years from primary tissue failure was 83.9 +/- 7.4% and from major embolic events 97.6 +/- 1.0%. Freedom from valve-related mortality at 10 years was 92.1 +/- 4.9%.

CONCLUSIONS

These results indicate that, over a period of up to 10 years, the Pericarbon pericardial bioprosthesis compares favorably with other replacement valves.

Preservation of three-dimensional annular movement with the SJM-Seguin mitral annuloplasty ring

BACKGROUND AND AIMS OF THE STUDY

In order to achieve optimal annuloplasty during mitral valve repair, we developed a new device, the SJM-Seguin annuloplasty ring, with the aim of remodeling, correcting dilatation, and preserving physiologic annulus function. This ring has variable flexibility; that is, it is sufficiently rigid in its anterior region to maintain intercommissural distance, yet sufficiently flexible in its posterior region so as not to interfere with left ventricular function and to permit the natural three-dimensional annular mobility.

METHODS

Following successful studies in animals, 75 patients were operated on for mitral regurgitation between January 1994 and May 1996. The patients' mean age was 60.4 +/- 13.2 years; 53.8% were men. The cause of mitral insufficiency was degenerative in 77.4% of patients, rheumatic in 12%, ischemic in 5.3%, and infectious in 5.3%. Associated procedures were carried out in 36% of the cases.

RESULTS

There were no intraoperative deaths, but two in-hospital deaths and one late death, all of which were unrelated to the annuloplasty ring. Mitral regurgitation, monitored by transesophageal echocardiography decreased from +3.42 +/- 0.6 before repair to +0.31 +/- 0.12 after repair (p < 0.005). Follow up was 100% at a mean of 14.2 months (range: 3 to 26 months). There were no annuloplasty-related complications, and especially no echocardiographically discernible systolic anterior motion. There were no transient ischemic attacks. One reoperation was performed due to endocarditis at nine months after initial repair. The average transmitral gradient was 1.94 mmHg.

CONCLUSIONS

This new annuloplasty ring provides, with the absence of any valve-related complications, correction of annular dilatation and remodeling of the annulus while respecting physiologic annulus function such as natural three-dimensional mobility.

[Value of the superior trans-septal approach in mitral valve replacements]

Mitral valve exposure is widely improved by the superior-transseptal approach (STS). The diffusion of this technique has been restricted because of the possibility of detrimental effects of sino-atrial arrhythmias, especially in patients in sinus rhythm preoperatively. Between April 1991 and December 1992, we performed mitral valve replacement (MVR) on 55 patients by an STS approach. The mean age was 57.7 +/- 11.3 years (38-75 years). 21 were reoperations and 1 patient had been operated twice. The procedure consisted in 10 MVR with a bioprosthetic valve and 45 with a mechanical valve. Associated procedures were 5 tricuspid annuloplasties, 13 aortic valve replacements, 1 tricuspid valve replacement, 4 CABG, and 1 aneurysm resection. Overall hospital mortality was 9.1 +/- 3.8% (5/55). Mortality for isolated MVR was 6.2 +/- 4.2% (2/32). 51% (28/55) were in sinus rhythm (SR) preoperatively, 43% (12/28) of them had never presented atrial fibrillation. Postoperatively among those 28 patients in SR, 20 remained in SR, 7 were in atrial fibrillation, and 1 in atrial flutter. 3.6% (2/55) needed transient electrosystolic pacing for very slow atrial fibrillation 20% (11/55) have presented a transient sino-atrial dysfunction; None of these rhythmic events had any adverse effect. Finally, the very good visibility and accessibility are the major advantages of this approach, especially in mitro-tricuspid combined procedures, in small left atrium and repeat surgery. As sino-atrial arrhythmias are transient, we think this approach can be routinely employed in MVR.

Fibrin sealant for early repair of acquired ventricular septal defect

The trend toward early operation for acquired ventricular septal defects exposes the patient to major perioperative bleeding and residual shunt because of the fragility of the recently necrosed myocardium. To reduce these complications we have used a fibrin sealant to reinforce the cardiac tissues in addition to the usual closure of the defect with a Dacron patch through a left ventricular septum around the defect, area. During cardiac arrest fibrin sealant is applied on the ventricular septum around the defect, between the septum and the patch, and on the edges of the ventriculotomy. This technique was used in three patients (mean age 68.2 years) operated on for an acquired ventricular septal defect within 4 days of the infarction and within 24 hours of the occurrence of the defect. Low postoperative bleeding, absence of recurrent shunt, and good ventricular function indicated satisfactory surgical result in all three patients. We suggest that the use of fibrin sealant during operations for acquired ventricular septal defects, by reinforcing the necrotic and fragile tissues, may reduce perioperative bleeding and assure a more solid implantation of the patch.

Intrapericardial teratoma in infancy: a rare disease

Intrapericardial teratoma is a rare, and generally benign, tumor originating from the 3 germinal layers. It occurs in 60% of the cases in the first two years of life. Severe cardio-respiratory distress due to mediastinal compression and pericardial effusion are the main clinical symptoms. Echo-cardiography and cine-angiography confirm the diagnosis and early surgical removal brings immediate and durable improvement.

Omental transposition for closure of median sternotomy following severe mediastinal and vascular infection

Three patients suffering from severe sternal wound infection, underlying mediastinitis, and aortic sepsis were successfully treated by radical debridement of the infected tissues and mediastinal transposition of the greater omentum. Sternomediastinal antibiotic irrigation is an accepted treatment for postoperative sternomediastinitis, but appears insufficient when infection involves underlying vascular or cardiac structures. In such circumstances, extensive sternal debridement is mandatory and healthy tissue transposition, such as omentum, is a valuable alternative.

Aorto-right ventricular shunt and associated aortic valve injury resulting from a penetrating wound of the heart

A case of a traumatic aorto-right ventricular fistula associated with an aortic valve injury and subsequent successful treatment is reported. A possible delay in diagnosis necessitates follow-up of patients after penetrating thoracic wounds. Early surgical treatment is mandatory because of the risks of both heart failure and endocarditis and because of the low operative morbidity. An aortic approach appears to be preferable because it permits repair of both the fistula and the valvular injury. Reconstruction of valvular injuries is preferable since long-term competence without prosthetic replacement can be achieved.