Abstract： Objective To summarize our operative experiences of cardiac reoperation after mechanical valve prosthesis replacement and investigate the causes of reoperation and the perioperative techniques and operation methods. Methods From January 2001 to December 2008, we performed reoperation on 105 patients (59 males and 46 females, aged 50.2±10.6 years old) who had undergone mechanical valve prosthesis replacement. Among the patients, there were 31 cases of mitral valvular replacement (+ tricuspid valvular plasticity), 38 cases of aortic valvular replacement (+ tricuspid valvular plasticity), 11 cases of Bentall procedure, 7 cases of mitral and aortic bivalvular replacement (+tricuspid valvular plasticity), 8 cases of tricuspid valvular replacement, 6 cases of repairing of prosthetic leakage, and 4 others cases. The time interval between two operations was 3 months to 18 years (46.3 ±31.9 months). Before reoperation, the cardiac function (NYHA) of the patients was class Ⅱ in 27 patients, class Ⅲ in 53 patients, and class Ⅳ in 25 patients. Results There were 6 hospital deaths with a mortality of 5.71%(6/105). All others recovered to NYHA class ⅠⅡ. The causes of mortality included 1 case of multiple organ failure, 1 case of low cardiac output after operation, 1 case of aortic pseudoaneurysm rupture, 1 case of severe infection due to brain complication and 2 cases of prosthetic valve endocarditis (PVE). The causes for cardiac reoperation after mechanical valve prosthesis replacement were 67 cases of prosthetic leakage (63.80%), 16 cases of PVE (15.23%), 14 cases of prosthetic thrombosis (13.33%) and 8 cases of other valvular anomalies. Followup was done for 11 to 107 months, which showed two cases late deaths of cardiac arrest and cerebral hemorrhage. Conclusion Patients who have received mechanical valve prosthesis replacement may undergo cardiac reoperation due to paravalvular prosthetic leakage, paravalvular endocarditis, and prosthetic thrombosis. The keys to a successful cardiac reoperation include appropriate preoperative preparations, operational timing, and suitable choosing of cardiopulmonary bypass and operational skills.
A 12-year-old girl with double outlet of right ventricle, complete atrioventricular septal defect, pulmonary valve stenosis, single atrium, inferior vena cava-hemiazygos vein drainage and left isomerism, who had undergone surgical left superior vena cava-pulmonary artery connection was referred to our hospital. Echocardiography revealed thickening, crimping and malalignment of common atrioventricular valve, moderate-to-severe regurgitation mainly from the left side and the main pulmonary artery was poorly developed. We preserved the autologous valve and used the 31# mechanical mitral valve which was sutured to mitral annulus. After the main pulmonary artery was transected, proximal end was sutured and a 20# Gore-tex artificial vessel was anastomosed to the distal end of the main pulmonary artery. We excised hepatic vein from the right atrium which was then anastomosed to another artificial vessel. Postoperative oxygen saturation was 95%-100%. Echocardiography and CT showed that the function of mechanical valve and heart was good before discharge. Common atrioventricular valvuloplasty is the preferred choice of the management of impaired valve. However, when dysfunction of valve is too severe and valvuloplasty is more likely to fail, the risk of barely performing a valvuloplasty will increase dramatically. On this condition, the mechanical valve replacement should be performed.
Objective To investigate and evaluate the safety and efficacy of the aortic-mitral annular enlargement technique (double annular enlargement) in patients with small-size valve prostheses after prior valve surgery. MethodsThe clinical data of patients who underwent double valve annular enlargement in Wuhan Asia Heart Hospital from April 2020 to April 2022 were retrospectively analyzed. Results A total of 30 patients were collected, including 2 males and 28 females aged 9-78 (52.71±3.53) years. All patients had previous heart valve surgery, including 1 patient receiving the third heart surgery. All patients were operated on successfully and there were no postoperative in-hospital deaths. There was no postoperative bleeding which needed a secondary open-chest hemostasis, and one patient underwent permanent pacemaker implantation due to postoperative sick sinus syndrome. The mean diameter of the implanted prosthetic aortic valve was 24.23±1.60 mm, which was significantly larger than that of the preoperative aortic valve (21.03±1.90 mm, P＜0.001). The mean diameter of the implanted prosthetic mitral valve was 28.33±1.21 mm, which was significantly larger than that of the preoperative mitral valve (25.43±0.84 mm, P＜0.001). The mean peak gradient difference across the prosthetic aortic valve on postoperative echocardiography was 18.17±6.44 mm Hg, which was significantly lower than that of the preoperative aortic valve (82.57±24.48 mm Hg, P＜0.001). The mean peak gradient difference of the postoperative prosthetic mitral valve was 12.73±5.45 mm Hg, which was significantly lower than that of the preoperative mitral valve (19.43±8.97 mm Hg, P=0.003). Conclusion The double annular enlargement technique is safe and effective for reoperation in patients with a history of valve surgery with a small aortic root to obtain both a larger size prosthetic valve for a larger orifice area and stability of the mitral-aortic valve union, resulting in good postoperative hemodynamic characteristics and clinical outcomes.
Objective To analyze the incidence of valve prosthesis-patient mismatch (PPM) and ventricular remodeling of elderly patients after aortic valve replacement (AVR). Methods We retrospectively analyzed the clinical data of 134 patient aged over 65 years who underwent AVR for the aortic stenosis or regurgitation at our hospital between January 2016 and December 2016. There were 73 males and 61 females aged 69.7±3.6 years ranging from 65-79 years. The clinical and ultrasound cardiography data were evaluated. PPM was defined as an effective orifice area index (EOAI) of ≤0.85 cm2/m2. The incidence of PPM and the left ventricular remodeling after surgical AVR in the patients with aortic stenosis and aortic regurgitation was analyzed, and the outcomes of aortic valve mechanical prosthesis and aortic valve bioprosthesis were compared. Results The incidence of PPM was 32.5% in aortic stenosis and 13.0% in aortic regurgitation (P<0.05). One patient died in the early post-operation, and the incidence of severe PPM was 6.0%. Conclusion The incidence of PPM after AVR in the patients with aortic regurgitation is less than that in the patients with aortic stenosis.
ObjectiveTo discuss the influence of early postoperative hemodynamic, postoperative mortality and the incidence of adverse cardiovascular events with the phenomenon of prosthesis-patient mismatch. MethodsWe retrospectively analyzed the clinical data of 89 patients who had simple aortic valve replacement in our hospital bewteen January 2012 and January 2014. The 89 patients were divided into two groups including a match group (16 females and 48 males with average age of 58.1±10.4 years) and a mismatch group (15 females and 10 males with average age of 65.3±12.8 years). We compared early results between the two groups. ResultsThere is a statistic difference (P < 0.05) in aortic flow velocity, mean pressure gradient, and the maximum pressure gradient between the two groups. The survival rate of the match group is significantly lower than that of the mismatch group (P < 0.05). And there is a statistical difference in adverse cardiovascular event-free incidence between the two groups (P < 0.001). ConclusionThe phenomenon of prosthesis-patient mismatch can affect postoperative hemodynamic and lead to heart failure after surgery. And early mortality and the incidence of cardiovascular adverse events in patients are increased due to prosthesis-patient mismatch.
Objective To evaluate the effect of treating Ebstein ’s anomaly w ith tricuspid valve replacement (TVR), and analyze the indications and personali ze the surgical methods of TVR. Methods 35 TVR in 32 cases of Eb stein’s anomaly not amenable to repair from May 1993 to June 2007 in An zhen Hospital were retrospectively. The mortality and complication incidence wer e estimat ed and the KaplanMeier survival curves were constructed to estimate actual sur vival and freedom from thrombus embolism rate, and comparative studies were unde rtaken to e valuate the clinical effect between implanting the prosthesis in the original tr icu spid ring or above the coronary sinus, and between fold the atrialized ventricle or not, and between preserve the autologous tricuspid or not. The univariate an alysis and logistic regression were used to explore the early and late death ris k factors. Results There were 2 early hospital death (6.25%). Followup of 30 patients who survived 30 days ra nged up to 14 years (4.2±3.5years)，there were 3 TVR reoperation due to the pro sthesis deterioration. There were 2 late deaths（6.67%）, and the actuarial surv i val at 5,10 year was 92.1%±4.6%, 86.5%±5.8% respectively in KaplanMeier cu rve. There were 2 events of thrombus embolism that were cured through thromboly tic therapy, thus the freedom from thrombus embolism at 5 and 10 yers reached 91 . 3%±4.5%,82.3%±4.2% respectively. 24 late survivors were in New York Heart Ass ociation(NYHA) functional cl ass I, and 4 in NYHA functional class II. The incidence of atria ventricular nod e rhythm in patients with the prosthesis implanted in original tricuspid ring wa s statistically higher than that of prosthesis implanted above the coronary sinus,and the incidence of paradoxical ventricular septal motion in patients wi thout folding the atrialized ventricle was statistically higher that of with fol ding the atrialized ventricle, but the NYHA functional class was not affected by these factors.The univariate analysis and logistic regres sion revealed that preoperative functional right ventricle/atrialized ventriclelt; 1 and ascites were the independent risk factor for the early death (P=0.023, 0.025), whereas preoperative ascites and edema in lower extremities were the in dependent risk factors for late death (P=0.026, 0.019). Conclusion TVR is a good therapeutically option for Ebstein’s anomaly si nce the operative risk is low, the functional status improved in all patients an d the durability of prosthesis in tricuspid position has been good. In order to maximize the effect of the TVR in Ebstein’s anomaly, personalized procedure sho uld be adopted in deciding whether to fold the atrialized ventricle or not, to p reserve the autologous tricuspid valve or not, and to implant the prosthesis in the original tricuspid ring or above the coronary sinus.
Severe symptomatic native aortic regurgitation (AR) is associated with poor prognosis. Surgical aortic valve replacement is presently the main choice of treatment according to current guidelines. The data of safety and efficacy of transcatheter aortic valve replacement (TAVR) for patients with pure native AR were limited. In this paper, a case of AR patient with heart failure was reported. After preoperative CT evaluation and operation plan, the postoperative symptoms improved significantly. Bundle branch block and retroperitoneal hematoma appeared during hospitalization. After the treatment, the patient’s condition improved. Before the discharge, cardiac ultrasound indicated that the reflux was significantly improved, no perivalvular leakage was observed, and cardiac function was improved. AR remains a challenging pathology for TAVR. TAVR is a feasible and reasonable option for carefully selected patients with pure AR.
Objective To investigate whether the individualized anticoagulation therapy based on CYP2C9 and VKORC1 gene is superior to empirical anticoagulation therapy after artificial heart valve replacement surgery in Uygur patients. Methods From December 2012 to December 2015, 210 Uygur patients who underwent artificial heart valve replacement surgery at the First Affiliated Hospital of Xinjiang Medical University were randomly assigned to a genetic anticoagulation therapy group (group A, n=106, 41 females and 65 males, aged 44.7±10.02 years) or an empirical anticoagulation therapy group (group B, n=104, 47 females and 57 males, aged 45.62±10.01 years) according to the random number table. CYP2C9 and VKORC1 genotypes were tested in the group A and then wafarin of administration in anticoagulation therapy was recommended. Patients in the group B were treated with conventional anticoagulation. Patients in both groups were followed up for 1 month and coagulation function was regularly tested. Results The percentage of patients with INR values of 1.8-2.5 after 4 weeks warfarin anticoagulation treatment in the group A was higher than that in the group B (47.1% vs. 32.7%, P=0.038). The rate of INR≥3.0 in the warfarin anticoagulation therapy period in the group A was lower than that in the group B (21.6% vs. 26.5%, P=0.411). The time to reach the standard INR value and the time to get maintenance dose were shorter in the group A compared with the group B (8.80±3.07 d vs. 9.26±2.09 d, P=0.031; 14.25±4.55 d vs. 15.33±1.85 d, P=0.032). Bleeding occured in one patient in the group A and three patients in the group B (P=0.293). Embolic events occured in three patients in the group A and five patients in the group B (P=0.436). Conclusion Compared with the empirical anticoagulation, the genetic anticoagulation based on wafarin dosing model can spend less time and make more patients to reach the standard INR value. However there is no significant difference between the two groups in the ratio of INR≥3.0, bleeding and embolic events in the warfarin anticoagulation therapy.
In recent years, transcatheter aortic valve replacement (TAVR) has developed rapidly in China, and the number and quality of operations have increased significantly. TAVR has become an important treatment strategy for patients with severe aortic stenosis and regurgitation following surgical aortic valve replacement. Prosthesis-patient mismatch (PPM) is one of the main complications after TAVR, but the incidence of TAVR-related PPM is significantly lower than surgical aortic valve replacement. Most studies believe that PPM has no significant effect on the clinical prognosis of most patients after TAVR, and only increases postoperative mortality in a specific population. This article will review the incidence, influencing factors, impact on clinical prognosis and related coping strategies of PPM after TAVR.
Transcatheter aortic valve replacement (TAVR) for aortic stenosis has been confirmed to be safe and efficient, and its status has gradually increased with the continuous updating of guidelines. But for severe pure aortic valve regurgitation, it has long been considered a relative contraindication to TAVR. However, many elderly, high-risk patients with pure aortic regurgitation have also been treated with TAVR and prognosis was improved through off-label use of transcatheter heart valves due to contraindications to surgery or intolerance. But because of the complexity and challenging anatomic features, high technical requirements, limited device success rate, high rate of complications, and lack of randomized controlled studies to confirm its safety and efficacy, TAVR treatment of pure aortic regurgitation has been evolving in a debate. In recent years, with the application of new-generation valves and an increasing number of studies, some new insights have been gained regarding TAVR for severe aortic regurgitation, and this article will review the progress of research on TAVR for severe pure aortic regurgitation.