Triple Starr Valve Replacement

Of nine patients who have had triple valve replacements for organic rheumatic triple valve disease two died in the postoperative period from inadequate myocardial reserve, and a third died four months later from cerebral embolism originating from clot on the left atrial wall. The remainder are well and, except for one, leading normal lives. Though cardiac transplantation has been recommended and used successfully for triple valve disease by Cooley, it is suggested that the long-term outlook today of triple valve replacement is likely to be better than that of transplantation.     

Book Reviews

The findings in and experiences with 19 consecutive patients subjected to open mitral valve surgery are described. All patients underwent a right-heart catheterization. In order to exclude multivalvular heart disease, a left-heart catheterization was performed in 10 patients and angiographic studies of the aortic valve area in 12. Pulmonary function studies were performed on 11 patients. The FEV (0.75 sec.) and the MMFR were found to correlate well with existing pulmonary reserves.Fourteen of the 19 patients subjected to open mitral valve surgery survived the operation and have been followed up for three months to 2½ years. Four patients had a mitral valvuloplasty. Three of these four have deteriorated and will require a valvular replacement. Ten of 15 patients subjected to a mitral valve replacement are alive; five of these 10 have had signs and symptoms indicating peripheral embolization. Mitral valvuloplasty is preferable to a valvular replacement as far as embolic complications are concerned, while valvular replacements result in a more perfect and lasting hemodynamic repair. The high incidence of peripheral embolization following valvular replacements focuses attention on the need for improved mitral valve prostheses.     

Long-term Results of Aortic Valve Replacement with the Starr-Edwards Valve

Review of the 74 patients undergoing aortic valve replacement with a Starr–Edwards ball-valve prosthesis between October 1963 and December 1967 showed that 16 died during surgery or within the first month after operation, usually owing to myocardial failure; and there were nine late deaths. The remaining patients developed few major complications, and the long-term results of operation are considered satisfactory, no patient being grossly incapacitated and most of them are leading active, symptom-free lives.     

Successful aortic valve replacement in a patient with AIDS

In trying to assess the benefit of cardiac surgery in AIDS patients, the question arises whether a patient with a deficient immune system can tolerate open heart surgery well enough to make the operation worthwhile. Surgical procedures and cardiopulmonary bypass have been noted to alter immune function (Diettrich et al., Ide et al.). Therefore, the presence of clinical AIDS is often still regarded as a contraindication to cardiac surgery. In this report we describe an AIDS patient who developed endocarditis of the native aortic valve. The endocarditis was successfully treated with antibiotic drugs, but the patient was left with damaged valves. Over the months he developed a massive aortic insufficiency and underwent aortic valve replacement. The patient did well after surgery, and is alive and well 18 months after the operation, suggesting that cardiac surgery might be a good and valuable treatment option in AIDS patients.     

Surgical Treatment of Mitral Insufficiency

Sixty-four patients with pure mitral insufficiency were operated upon. Thirty of them had torn chordae tendineae. It was possible to repair the mitral valve in 57 patients and there were five operative deaths. One patient had a femoral artery embolus and another had a cerebral embolus. The incidence of peripheral embolization was 4 per cent compared with 40 per cent reported for ball valve replacement.Forty-eight of the 57 patients with repair (84 per cent) were living and well with at most a grade II/VI apical systolic murmur up to seven and a half years after operation. There has been no evidence of recurrence in these patients.In approximately 90 per cent of patients with pure mitral insufficiency, repair should be performed. When feasible, repair is more satisfactory than valvular replacement, with not only excellent long-term results, but far less morbidity than is reported with ball valve replacement.     

Replacement of the Aortic and Mitral Valves Using the Starr-Edwards Ball-Valve Prosthesis: A Report of 50 Cases

The aortic and mitral valves were replaced in 50 patients at the University of Alberta Hospital using the Starr-Edwards ball-valve prosthesis. The basis of the selection of 20 patients for isolated aortic valve replacement and 27 for mitral valve replacement using this type of prosthesis is presented, and the techniques of insertion of the aortic and mitral valve are described in detail. Of the 27 patients in whom the mitral valve was replaced by the Starr-Edwards prosthesis six died within 30 days of surgery and two after discharge from hospital at two and a half and four months, respectively. Left atrial thrombosis was the cause of death in four of these patients. In 20 patients in whom the aortic valve was replaced, four died in hospital and two died more than 30 days after returning home. Three of these six patients died from bleeding—the result of the use of anticoagulants. The difficulty in assessing whether or not anticoagulants are needed following replacement by a Starr-Edwards prosthesis is considered. It is felt, in our present state of knowledge, that anticoagulants should be used following mitral valve replacement but are probably not essential following replacement of the aortic valve. Two patients survived replacement of both aortic and mitral valves and have been followed up 18 months and seven months, respectively.     

二尖瓣成形术与二尖瓣生物瓣置换术治疗风湿性二尖瓣重度关闭不全的效果比较

目的:探讨二尖瓣成形术(Mitral valve plasty,MVP)与二尖瓣生物瓣置换术(Mitral valve replacement,MVR)治疗风湿性二尖瓣重度关闭的临床疗效和安全性。方法:选择我院2014年1月至2019年1月收治的因风湿性二尖瓣重度关闭而行二尖瓣成形术或二尖瓣生物瓣置换术的患者60例,其中二尖瓣成形术组(MVP组)27例,二尖瓣生物瓣置换术组(MVR组)33例。比较两组患者的围手术期各项指标,治疗前后的心功能指标(左心室射血分数,左心房内径、左心室收缩末期内径、左心室舒张末期内径)及二尖瓣反流情况以及术后并发症的发生情况。结果:(1)MVP组患者的手术时间、体外循环时间均明显长于MVR组(P0.05);而术中出血量、呼吸机使用时间、住院时间MVP组均显著低于MVR组(P0.05);(2)术后,MVP组的LVEF和LVEDD水平高于MVR组,而LAD和LVESD水平则低于MVR组(P 0.05);(3)出院前及末次随访时,MVP组二尖瓣反流发生率与MVR组相比差异均无统计学意义(P0.05)。(4)MVP组患者的术后并发症发生率低于MVR组(P 0.05)。结论:二尖瓣成形术治疗风湿性二尖瓣重度关闭的临床疗效和安全性优于二尖瓣生物瓣置换术,但术者需严格掌控MVP的手术适应症。     

Inoperable aortic stenosis in the elderly: benefit from percutaneous transluminal valvuloplasty.

Eight patients with severe symptomatic calcific aortic stenosis were considered to be unsuitable for valve replacement. Four were admitted with pulmonary oedema and three in cardiogenic shock and one had angina at rest. With the use of echocardiographic and radiographic guidance percutaneous transluminal aortic valvuloplasty was carried out. Aortic gradients were reduced by an average of 40%. All four patients who presented with cardiac failure improved immediately and remained well six months later. The patient with angina was symptom free at nine months. Two of the three patients who presented in cardiogenic shock improved immediately and were well nine and three months later. The other patient died four hours after the procedure. Doppler echocardiographic studies showed a slight initial increase in aortic incompetence, but this did not worsen and valvar gradients remained improved three and six months later. Percutaneous valvuloplasty of the aortic valve is an effective therapeutic option in patients with severe calcific aortic stenosis who are unfit for surgery. Its role as an alternative to surgery has not been considered and should be investigated in a controlled clinical trial.     

Surgical treatment of infective endocarditis with special reference to prosthetic valve endocarditis.

Patients with native valve endocarditis treated surgically between 1968 and 1978 (n = 15) and all patients presenting with prosthetic valve endocarditis during this period (n = 21) were followed up for at least four years. Five of the patients with native valve endocarditis required urgent early surgical intervention, of whom two died. The remaining 10 underwent valve replacement after a course of antibiotic treatment: all survived, though one required further valve replacement. The 21 patients with prosthetic valve endocarditis suffered 25 attacks. Nine were cured by medical treatment alone; two died before surgical intervention was possible; 11 required valve replacement, of whom three died; and two required valve replacement after a course of antibiotic treatment. The incidence of early prosthetic valve endocarditis--that occurring within two months of operation--was 0.67%, but that of late prosthetic valve endocarditis could not be determined. Medical treatment when started early should cure endocarditis in most patients, but vigilance should be maintained for the appearance of indications for surgery. When such indications exist surgery should not be delayed.     

Hybrid approach for complex coronary artery and valve disease: a clinical follow-up study

For patients suffering from complex coronary artery disease (CAD) with or without concomitant valve disease, no evidence is available in the current guidelines to propose a predefined treatment regimen. We sought to assess the clinical impact of an unconventional or extended definition of the hybrid approach that combines percutaneous coronary intervention (PCI) and cardiac surgery in subjects suffering from severe solitary CAD or combined with valve disease. Between July 2002 and August 2004, 18 consecutive patients with complex CAD with or without significant valve disease who qualified for a hybrid approach were enrolled in a clinical follow-up study. Four patients eventually did not complete the proposed interventions. One patient refused treatment after inclusion, one patient died before treatment could be undertaken and two patients died after surgery but before PCI. In the other 14 cases combined treatment was technically successful. After a mean follow-up period of 15±5 months two patients had died, one due to sudden cardiac death and one of a noncardiac cause. No other major adverse clinical events were reported. A marked increase in quality of life was reported in those alive. Hybrid approach had a favourable long-term outcome in patients with complex cardiovascular disease undergoing successful treatment; however, this was observed at the expense of significant periprocedural mortality in these high-risk subjects. Therefore we believe that hybrid approaches may provide an alternative for selected cases. (Neth Heart J 2007;15:329-34.)     

Emotional problems in children; the uses of drugs in therapeutic management

The repair of intracardiac defects under direct vision by opening the heart to expose the operative field, with the aid of hypothermia or a pump-oxygenator, is now a practical clinical method. Twelve patients were operated upon by this method. In eight patients an atrial septal defect was repaired during total circulatory occlusion under hypothermia. The seven patients in this group who had uncomplicated atrial defects survived the operation and are doing well after a short follow-up period. One patient with an unrecognized, associated ventricular defect died at the time of operation. Four patients were operated upon during total cardiac by-pass with the DeWall bubble-oxygenator. The first three patients survived operation and are continuing to do well after a brief follow-up period. In the fourth patient an atrioventricularis communis was repaired by the reconstruction of an atrial and ventricular septum with a plastic prosthesis. This patient died at the end of operation.     

Balloon dilatation of the aortic valve for inoperable aortic stenosis.

The place of balloon dilatation of the aortic valve in the treatment of calcific aortic stenosis is controversial. Thirty two patients (mean age 76) in whom valve replacement was contraindicated were followed up for three to 24 months (mean 8); 25 were in functional class III or IV according to the New York Heart Association''s classification. Major complications of the procedure occurred in four patients. Echocardiography and Doppler studies were performed before operation and before discharge in 28 patients, and the area of the valve was measured again six to 50 (mean 23) weeks after operation in 11 patients. The peak to peak aortic pressure gradient fell from a mean of 65 (SD 24) to 46 (20) mm Hg, but the area of the aortic valve, measured by Doppler echocardiography, in 18 patients showed a modest but significant increase, from 0.61 (0.16) to 0.74 (0.23) cm2. One month after dilatation, 29 patients were alive, of whom 17 had improved symptoms. Only two had lasting clinical benefit. Sixteen patients died, 12 of a cardiac cause. The estimated one year survival rate was 49%. Six patients underwent or required valve replacement because of persisting symptoms. In view of its limited long term efficacy balloon dilatation of the aortic valve should be used only for patients with severe symptoms whose life expectancy is limited by other disease or who are considered to be unsuitable for valve replacement. It may have a role in improving the condition of patients who present with cardiogenic shock or pulmonary oedema before valve replacement is undertaken.     

The Early Variation of Left Ventricular Strain after Aortic Valve Replacement by Three-Dimensional Echocardiography

Aortic stenosis (AS) and aortic incompetence (AI) are common aortic valve diseases. Both may deteriorate into irreversible myocardial dysfunction and will increase the risk of sudden death. In this study, we aimed to investigate the early variation trend of left ventricular function by three-dimensional speckle tracking echocardiography (3D-STE) in the patients who underwent cardiac surgeries for aortic valve disease. Twenty patients with severe aortic AS and 16 patients with severe AI were enrolled. All of them underwent the aortic valve replacement (AVR) procedures. The patients’ global longitudinal strain (GLS) and global circumferential strain (GCS) were evaluated by 3D-STE before surgery and at 1 week after surgery. In addition, GLS and GCS were followed at 1 month as well as 3 months after AVR. In AS patients, the GCS after AVR altered little both at 1 week (p = 0.562) and at 1 month (p = 0.953) compared with the data before the surgery. And it increased significantly at 3 months of follow-up observation compared to that before AVR (p<0.05). Meanwhile, GLS increased progressively after AVR and improved significantly at 3 months after surgery (p<0.05). For the AI patients, GLS as well as GCS decreased at 1 week after AVR compared to those data at baseline (p<0.05). However, these two parameters recovered at 1 month after AVR. Furthermore, GLS and GCS improved significantly at 3 months after the surgery (p<0.05). Therefore, both GLS and GCS were influenced by AVR and would be improved at 3 months after surgery both in AS patients or AI patients. GLS and GCS can be finely evaluated by 3D-STE, and they are helpful to determine the variation tendency of left ventricular function in patients with AVR.     

RESULTS OF MEDICAL AND SURGICAL MANAGEMENT IN TEN CASES OF CONGENITAL MEGACOLON

Of 20 patients under 15 years of age with proven diagnoses of megacolon, ten were treated surgically with either partial colectomy or resection of the entire colon down to the rectosigmoid junction after thorough trial of medical management. Follow-up shows five of these patients as 100 per cent relieved, one as 75 per cent relieved. Three were entirely well a few months after operation but have not been heard from since. One died of peritonitis on the 16th postoperative day.In four cases in which lumbar sympathectomy was done, the result was partial, temporary or no improvement.Of the patients not operated upon, several have been lost to follow-up, some are doing well on medical treatment, one died in early infancy, and resection is being considered for two.For children with congenital megacolon the authors recommend first a thorough trial of medical treatment consisting of diet, vitamins, drugs and enemas. This should be started as soon as possible after the diagnosis is made, in an attempt to prevent the distention and hypertrophy of the bowel from progressing. If distention remains after a reasonable trial period and the child is not gaining weight adequately, requires repeated hospitalization, and is three years of age or more, then resection of the affected portion of the colon is indicated. The risk of operation has been somewhat reduced with better supportive measures and chemotherapy now available. Since infants and extremely young children do not stand operation on the colon as well as older children, decision to operate should take into consideration the age of the patient. In the reported series, the patient who died following operation was the youngest—2½ years of age.     

Red Cell Survival after Heterograft Valve Surgery

Intravascular haemolysis was studied in 24 patients three to nine months after calf or pig valve heterografts had been inserted for severe valvular heart disease. No patient had haemolytic anaemia. In five of the 24 patients there was subclinical haemolysis, and in these five the haemolysis appeared to be related to residual aortic regurgitation or to the presence of other foreign material such as a Dacron aortic graft. The extent of postoperative haemolysis in these five patients was comparable to that observed preoperatively in patients with valvular heart disease.The results support the belief that, in contrast to artificial valve prostheses, heterograft valves behave similarly to human valves as regards haemolysis.     

Cardiac valve replacement in elderly patients.

Cardiac valve replacement in 65 consecutive elderly patients (aged 65 years and older) revealed that the indications for cardiac valve replacement in the elderly should be the same as those in the general population. These 65 patients represented 16% of the patients undergoing valve replacement. The mortality in the first 30 days after operation was 4.6% in the elderly group, compared with 0.9% in the group under 65 years of age. There were 26 significant but nonfatal early complications in the elderly patients, but their long-term functional status was excellent, most of the survivors ending up in either class I or class II of the New York Heart Association functional classification. The late mortality was 3.9% per patient year for aortic valve replacement and 15.1% for mitral with or without aortic valve replacement. The actuarial survival rates were 88% at 24 months and 55% at 54 months for the total elderly group, 86% at 36 months for those with aortic valve replacement, 85% at 24 months and 64% at 36 months for those with mitral valve replacement, 90% at 24 months and 77% at 42 months for the men, and 82% at 24 months and 68% at 42 months for the women. Aortic valve replacement was more common in the elderly than in the younger group because of the higher prevalence of congenital calcific aortic stenosis in the former, and this operation provided more gratifying results than mitral valve replacement in the elderly patients.     

华法林联合肝素对瓣膜置换术后患者微循环的影响

目的:研究华法林联合肝素对瓣膜置换术后患者微循环的影响,评价其有效性及安全性。方法:选择2014年1月-2015年6月我院收治的瓣膜置换术患者60例,随机分为实验组和对照组,每组30例。对照组患者瓣膜置换术后第二天口服华法林治疗,实验组患者瓣膜置换术后当天即皮下注射低分子肝素钙,术后第二天口服华法林抗凝治疗。两组患者均于术后7 d、14 d空腹取外周静脉血,检测红细胞比容、血沉、全血还原比粘度、血浆比粘度以及红细胞聚集指数。结果:与对照组相比,实验组患者术后7d、14 d血沉值、全血比粘度水平、全血还原比粘度水平、血浆比粘度和红细胞聚集指数均显著降低,差异具有统计学意义(P0.05);两组患者术后7 d、14 d血细胞比容比较,差异无统计学意义(P0.05)。结论:和单独应用华法林相比,瓣膜置换术后采用联合应用华法林及肝素能更好改善患者微循环,值得临床推广。     

High dose busulfan/etoposide as a preparatory regimen for second bone marrow transplants in hematologic malignancies

Five patients with hematologic malignancies who had relapsed between seven months and eight years after their primary bone marrow transplants were prepared with high dose busulfan/etoposide for second marrow transplantations from the same donors who had provided the marrow for the primary transplants. The preparatory regimen was well tolerated. All patients engrafted and entered complete remission. Two patients are alive and in continued remission two and ten months after second transplant. One patient died with acute respiratory failure after two months and two patients relapsed again eight and 17 months after second marrow transplantation. The combination busulfan/etoposide may prove to be a suitable preparatory regimen for second bone marrow transplant attempts in selected patients.     

自膨式支架辅助弹簧圈栓塞治疗颅内动脉瘤的疗效及安全性分析

摘要 目的：探讨自膨式支架辅助弹簧圈栓塞治疗颅内动脉瘤的疗效及安全性。方法：回顾性分析2014年1月-2019年1月我院采取自膨式支架辅助弹簧圈栓塞治疗颅内动脉瘤患者159例（A组）及采取单纯弹簧圈栓塞治疗颅内动脉瘤患者178例（B组）,比较两种手术方法治疗颅内动脉瘤的手术时间、术后住院时间、随访时间、手术相关并发症发生率并通过格拉斯哥（GOS）预后评分、Raymond分级比较2种治疗方法的安全性及有效性。结果：两组手术时间、术后住院时间、随访时间比较差异无统计学意义（P＞0.05）。两组术后出血及缺血事件发生率差异有统计学意义（P＜0.05）,脑积水、肺炎发生率、致死率及致残率差异无统计学意义（连续校正后P=1）。术后1月内及术后12个月随访GOS评分,A组评分高于B组,差异具有统计学意义（P＜0.05）;术后1月内及术后12个月随访Raymond分级,A组优于B组,差异具有统计学意义（P＜0.05）。结论：自膨式支架辅助弹簧圈栓塞治疗颅内动脉瘤栓塞效果明显且术后并发症少,对于颅内动脉瘤患者在弹簧圈栓塞基础上应用自膨式支架辅助可提高手术安全性及栓塞的疗效。     

Osteolytic lesion in chronic myelogenous leukaemia

Destructive bone lesion of the femur was observed in one patient from a series of 103 patients with CML. Numerous myeloblasts were seen on touch preparations of the fresh surgical specimen obtained by open biopsy of the affected area. Bone marrow and peripheral blood differential count were compatible with chronic phase of CML at this time. 5 months later blastic crisis developed. Local radiotherapy produced effective palliation of pain but did not prevent blastic transformation of CML. The treatment of blastic crisis was unsuccessful and patient died 3 years after diagnosis of CML, 6 months after the first clinical evidence of bone infiltration.