Fourteen patients with critical aortic stenosis (valve area 0.4 cm2/m2), a history of advanced congestive heart failure, left ventricular ejection fraction less than 0.45 (mean 0.28 d 0.03) and no other valvular lesions or obstructive coronary artery disease were studied to assess prognosis with aortic valve replacement. Eleven of 14 (79%) survived surgery; 10 of these 11 showed major clinical improvement postoperatively and form group 1. The three patients who died and the patient who did not improve form group 2. Although group 2 had higher preoperative values for aortic valve area and left ventricular end-diastolic volume and lower ejection fraction and cardiac output than group 1, none of these factors alone reliably predicted outcome. The mean systolic gradient was an important predictor of outcome: No patient with a mean systolic gradient 30 mm Hg had a good outcome, irrespective of valve area or other hemodynamic variables.Ejection fraction was plotted against left ventricular wall stress for both groups. For group 1, there was a close linear relation that could be extrapolated back to normal wall stress and normal ejection fraction. This suggested afterload mismatch as a major cause for this group's depressed ejection fraction. In group 2 ejection fraction was lower for any given wall stress, suggesting depressed contractility, rather than afterload mismatch, as the cause of the left ventricular dysfunction. Thus, either afterload mismatch or depressed contractility may result in depressed ejection fraction in patients with aortic stenosis; which one predominates may have major prognostic importance.
Operative correction of ischemic mitral regurgitation (IMR) is associated with high risk approach. The objective of this retrospective study was to examine the interaction between the various underlying pathophysiologic mechanisms, the operative procedure, and their influence on short- and long-term outcomes. Over a 10-year period starting January 1984, mitral valve repair or replacement was performed on 150 patients with IMR. The age range was 42-86, mean 67, years; 71 (47%) were females; 139 (93%) were in NYHA functional class III or IV; 23 (15%) were reoperations; and 30 (20%) were in atrial fibrillation. Functional IMR due to annular dilatation or restrictive leaflet motion was present in 106 (71%), and structural IMR due to ruptured chordae or papillary muscle in 44 (29%). Mitral valve repair was performed in 94 (63%) with an annuloplasty ring employed in 80 (85%) patients. Mitral valve replacement was performed in 56 (37%), with 40 (71%) receiving a bioprosthesis (32 Hancock and 8 Carpentier-Edwards valves) and 16 (29%) a St. Jude valve. Coronary artery bypass graft surgery was performed in 139 (93%) patients. The overall operative mortality (OM) was 14/150 (9.3%). The OM for repair was 9.5% compared to 8.9% for replacement (P = NS). There was higher OM in the elderly, particularly in the repair group (P = 0.053), and a trend towards reduced OM in the recent years of the study (P = NS). No predictors of OM were identified by multivariate logistic regression analysis. Long-term follow-up was 98% complete and ranged from 2-120, mean 31.2, months for a total of 935 patient-years. The overall 5-year survival rate was 71 +/- 6%, with 91 +/- 5% for the replacement group compared to 56% +/- 10% for the repair group (P = 0.01). The functional subset of IMR who had a repair had the worse long-term survival (43 +/- 13%) compared to the structural/repair (76 +/- 13%) and structural/replacement groups (89 +/- 8%), and 92 +/- 7% for the functional/replacement group ((P = 0.0049). Multivariate logistic regression analysis identified the functional/repair group (hazards ratio 4.4; +/- 95%, confidence interval 1.6, 11, (P = 0.0031); and earlier years of surgery (hazards ratio 4.7; +/- 95% confidence interval 1.021; (P = 0.046) to be predictors of worse long-term survival. These results suggest that, in IMR, the underlying responsible pathophysiologic mechanisms appear to be the major determinants of survival, rather than the choice of the operative procedure.
The myxomatous degenerated, prolapsed, or floppy mitral valve is the most common etiology of mitral regurgitation in North American populations. We performed mitral valve reconstruction for this diagnosis in 252 patients from 1984 to 1993. There were 165 males and 87 females ranging in age from 23 to 84 years (mean 64 years); 93 (37%) were > or = 70 years. One hundred eighty-six were New York Heart Association Functional Class III or IV and 29% (72) underwent concomitant coronary bypass operation. Operations included posterior leaflet resection, anterior leaflet resection treatment of chordal pathology by shortening or Gore-Tex replacement, and ring annuloplasty. There were five operative deaths for an operative mortality of 2%. The operative risk in patients under 70 years was 1 of 159 (0.6%) and 4 of 93 (4%) in patients older than 70 years. Ninety percent of patients are asymptomatic in a follow-up period extending 10 years, while structural valve degeneration requiring reoperation at 5 years was 85%. From 1990 to 1993 there has been a less than 5% absolute incidence of structural valve degeneration. Mitral valve reconstruction for complicated floppy mitral valve is feasible and offers excellent early and medium-term results.
Pituitary apoplexy in a pre-existing pituitary tumor can result in serious and permanent neurologic deficits following cardiac surgical procedures. Several factors related to the altered physiology of cardiopulmonary bypass (CPB) contribute separately or in combination to the development of this syndrome. Over the last year we have encountered two such cases in whom emergency and prompt decompression of the adenoma resulted in an improvement of the initial clinical presentation but nevertheless persistence of residual and devastating ocular manifestations. In the literature six similar cases have been reported following cardiac surgical procedures, with similar outcomes. In this report we describe our experience and management of these two patients, and that published in the literature. We propose a possible role for a staged cardiac and neurosurgical procedure as a prophylactic measure in patients with known pituitary tumor. The role of cerebral monitoring is also discussed.
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