Biomedical subjects
Publications and source records attributed to J M Revuelta.
A 31-year-old patient without past history of cardiac disease presented with an atypical form of Streptococcus milleri endocarditis. The disease progressed in an unusually aggressive manner, with abscess formation in the apex of the left ventricular cavity. The cardiac valves functioned normally and were not affected by the disease.
Sixty-two patients with rheumatic mitral valve disease (mean age 42.2 +/- 10.2 years) underwent repair of chordae tendineae between June 1974 and May 1994. Chordal shortening was done in 38 patients, fenestration in 17, resection of secondary chordae in 3, replacement in 2, and transposition in 2. In 41 patients, mitral commissurotomy was also done. Ring annuloplasty was done in all patients. The mean follow-up was 10.2 years (range 2 months to 20 years). The completeness of follow-up during the closing interval (January to July 1994) was 100%. Hospital mortality occurred in four patients (6.5%) and nine patients died during the late follow-up. The actuarial survival curve at 20 years was 65.8% +/- 10%. Six patients with mitral valve dysfunction (restenosis 4, insufficiency 2) and one with aortic valve dysfunction (structural deterioration of bioprosthesis) underwent reoperation. The actuarial curve of freedom from reoperation at 20 years for mitral valve dysfunction was 73.1% +/- 10.5%. In the 49 surviving patients, a Doppler echographic study during the closing interval showed a mean mitral valve area of 1.9 +/- 0.3 cm2. In the 43 patients with a repaired native valve, absent or trivial mitral regurgitation was documented in 35 and mild or moderate regurgitation in 8. In conclusion, repair of chordae tendineae in rheumatic mitral valve disease when feasible is a stable and safe procedure with a low prevalence of reoperation. However, the type of reconstructive operation and experience of the surgical team are major considerations in successful repair of the mitral valve.
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The durability (structural deterioration-free interval) after valve implantation with the first-generation Carpentier-Edwards porcine bioprosthesis has been investigated. From 1978 through 1984, 420 patients (175 male, 245 female) underwent valve replacement with the Carpentier-Edwards standard bioprosthesis. Mean age was 50.6 years (range, 13 to 77 years). Isolated mitral valve replacement (MVR) was performed in 198 patients (47.1%), aortic valve replacement (AVR) in 136 (32.4%), and double valve replacement (DVR) in 86 (20.5%). Hospital mortality was 32 patients (7.6%), 7.5% for MVR, 5.1% for AVR, and 11.6% for DVR. Mean follow-up was 10.8 years (range, 9 to 15 years) and is 96.2% completed. Reoperation for structural deterioration was required in 143 patients. Actuarial curve free from structural deterioration at 15 years is 33.0% +/- 6.5% for MVR, 62.0% +/- 5.1% for AVR, and 44.2% +/- 8.2% for DVR (p < 0.03). Durability of the CE bioprosthesis for MVR was 101.6 +/- 34.5 months, 92.9 +/- 26.4 for AVR, and 84.3 +/- 25.3 for DVR (p = not significant). The regression logistic analysis between age at the time of surgery and durability of the bioprosthesis showed no correlation for the MVR group, but with the following predictive formula for AVR and DVR groups of patients older than 30 years" durability = 46.05 + 0.818 x age, for AVR (r2 = 0.43); durability = 15.81 + 1.122 x age, for DVR (r2 = 0.52). In conclusion, we have found a significant difference in the behavior of the CE porcine bioprosthesis between the mitral and aortic position.(ABSTRACT TRUNCATED AT 250 WORDS)
Manufacturing factors have seldom been implicated as a direct cause of structural deterioration of valvular bioprostheses; this phenomenon has generally been considered to be of a host-dependent origin. We analyzed the clinical and pathologic data from 12 Carpentier-Edwards mitral bioprostheses removed from 12 patients because of severe dysfunction and showing detachment of the porcine aortic wall from the stent in one commissure or more. These 12 prostheses were part of a group of 92 such valves that were explanted and displayed structural deterioration. They belong to a population of 405 Carpentier-Edwards bioprostheses implanted in the mitral position in our institution between May 1978 and November 1988. The patients included three men and nine women with a mean age of 54 +/- 13 years. One patient had a history of chronic renal failure, and two had systemic hypertension. Prosthesis sizes were 29, 31, and 33 mm (n = 4 for each size). The models of the valves were 6625 (n = 8) and 6650 (n = 4). Mean duration of implantation of the prostheses was 99 +/- 27 months (52 to 136 months) and did not differ depending on the model. There was no significant clustering of commissural detachments depending on valve size, year of implantation, or gender of the patient. No similar phenomenon was observed among 76 explanted aortic Carpentier-Edwards bioprostheses with structural deterioration from a population of 441 valves implanted during the same time frame. Native porcine aortic roots (n = 5) and aortic Carpentier-Edwards bioprostheses explanted because of structural deterioration (n = 4) were used as controls for comparison. Macroscopic examination showed single commissural dehiscence in 10 patients and double in two. Radiology disclosed no or mild mineralization in eight valves and no calcium in the area of aortic wall dehiscence, except for heavily calcified valves. Light microscopy evidenced a significant thinning of the aortic wall at the paracommissural level of mitral bioprostheses (351 +/- 68 microns) compared with either aortic bioprostheses (526 +/- 59 microns; p < 0.01) or control native porcine aortic roots (419 +/- 50 microns; p < 0.01). No difference was found in terms of aortic wall thickness between detached (322 +/- 42 microns) and intact (366 +/- 74 microns) commissures in mitral bioprostheses.(ABSTRACT TRUNCATED AT 400 WORDS)
Suppurative mediastinitis developed in 34 (0.9%) of 3,645 patients who underwent median sternotomy at the Hospital Marqués de Valdecilla in Santander, Spain, from 1985 through 1991. These cases were analyzed in a case-control study designed to identify risk factors for poststernotomy mediastinitis. The significant risk factors were (1) preoperative factors: heavy cigarette smoking and history of endocarditis; (2) intraoperative factors: emergency surgery, prolonged duration of surgery, prolonged bypass pump time, ventricular failure, and tearing of the aortic or femoral artery; and (3) postoperative factors: reoperation, prolonged mechanical ventilation, prolonged stay in the intensive-care unit, and tracheostomy. All patients had abnormal sternal wounds (i.e., signs of wound infection or serous discharge). Twelve patients were bacteremic. Thirty-eight organisms were recovered from 31 patients with mediastinitis; 23 of the isolates were gram-positive and 15 were gram-negative. The infections were treated with extensive debridement and appropriate antibiotics. Mortality was 35%. Chronic sternal osteomyelitis was documented in two cases.
To date, treatment of mitral valve disease with mitral homograft implantation has been unsatisfactory. We describe two cases of mitral valve repair in man with a cryopreserved partial mitral homograft. Massive mitral insufficiency was surgically corrected by replacement of the severely affected posterior leaflet and the subvalvular apparatus with their corresponding mitral-valve homograft tissue. 22 and 4 months after surgery, the repaired valves remain competent with flexible and normal functioning leaflets and subvalvular apparatus, and the patients are symptom-free.
The aortic valves of 43 subjects (14 females and 29 males, mean age 48.9 +/- 22.2 years, range 3-88 years), dying from accidental causes and without any previous record of cardiovascular disease, were studied. The whole aortic root was removed and morphological features recorded. Calcium content was determined by atomic absorption spectrophotometry. Calcium content sustained a positive significant correlation (p < 0.001) with age. Comparison of regression lines from subjects of different age groups disclosed a significantly greater slope in the regression line of persons older than 50 years than in those of the younger population (p < 0.05). The increase with age of calcium content displayed no significant differences between male and female nor between any of the three aortic cusps. The presence of Lambl's excrescences on the aortic leaflets became more frequent with age and was associated with a higher calcium content.
From May 1974 to December 1978, 159 patients with mitral stenosis underwent open mitral commissurotomy at our institution. Follow-up data were complete in 96.8%, with a mean follow-up of 13.7 years (range, 14 to 18 years). Preoperatively, most patients (n = 94) were in functional class III or IV. Valve calcification was found in 18 patients (11.3%), left atrial thrombosis was found in 21 (13.2%), and the subvalvular apparatus was affected in 105 (66%). When a residual insufficiency was detected during the operation, a mitral annuloplasty was performed (n = 43). There was one hospital death (0.6%) and 15 late deaths (9.5%). Actuarial survival at 15-year and 18-year follow-up is 89.4% +/- 3% and 75.2% +/- 10.8%. Fifteen patients (9.7%) had a thromboembolic episode 1 to 189 months after operation (mean, 104.3 months). Eleven patients (7%) required reoperation 3 to 183 months after operation (mean, 110.1 months). Freedom from reoperation at 18-year follow-up was 91.9% +/- 2.7%. Event-free actuarial survival at 15-year and 18-year follow-up was 73.4% +/- 4.2% and 54.3% +/- 10.5%. Most patients (n = 131) are in class I or II. Open mitral commissurotomy represents a safe surgical alternative for treating mitral stenosis, allowing a complete removal of atrial thrombosis if present. This long-term follow-up clinical study encourages us to persist in this successful surgical repair of mitral stenosis.
BACKGROUND: Mitral valve repair in rheumatic disease is technically more difficult, and there is little information on the long-term stability of this technique. METHODS AND RESULTS: From January 1975 to December 1990, 327 patients underwent mitral valve repair with the Duran flexible ring annuloplasty for rheumatic valve disease. Mean age was 45.4 +/- 12.6 years (range, 23 to 73 years). The techniques used for valve repair include a Duran flexible ring annuloplasty in all cases, commissurotomy in 272 (83.2%), papillary muscle splitting in 171 (52.3%), and subvalvular apparatus repair in 59 patients (18.0%). One hundred one patients required associated tricuspid valve surgery (30.8%). Hospital mortality was 3.36%, being lower for patients with isolated mitral valve repair (2.7%) than those with mitrotricuspid surgery (4.9%). Mean follow-up was 8.6 years (range, 1 to 17 years) and was 96.5% completed. Thirty-four patients required reoperation for severe mitral insufficiency in 12, mitral restenosis in 18, and aortic valve disease in 4. The actuarial curve free from reoperation for mitral cause at 16 years is 89.9 +/- 3.2%. Late mortality occurred in 42 patients (13.2%). Actuarial survival curve at 16 years is 84.0 +/- 3.2% for isolated mitral valve repair and 64.6 +/- 6.7% for mitrotricuspid patients. CONCLUSIONS: Mitral valve reconstruction with Duran flexible ring annuloplasty in rheumatic valve disease entails a low hospital mortality with satisfactory long-term clinical results.
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Early structural deterioration with the mitral Mitroflow pericardial valve requiring reoperation occurred in 6 patients. Clinical diagnosis of prosthetic failure was made 5 to 58 months after valve implantation (mean, 38 months). Re-replacement was carried out 22 to 80 months (mean, 55 months) after the initial operation. Mode of failures were cuspal tear without calcification in three valves and massive calcifications in the remaining bioprostheses. High incidence of early structural deterioration of the Mitroflow pericardial valve makes this new prosthesis an unsatisfactory alternative as a substitute in the mitral position.
Satisfactory long-term clinical results with heart valves have renewed the interest in the use of mitral homografts, despite the technical difficulties with their surgical implantation. This report describes the behavior and viability of the partial mitral homograft in the ortotopic position in a chronic sheep model (n = 25). The 20 surviving animals were studied hemodynamically and were anesthetized and electively put to death 3, 6, 9, and 12 months after the operation. All specimens had a normal mitral valve without signs of infection or thrombosis. Light, scanning, and transmission electron microscopy showed the presence of viable endothelial cells from the recipient covering the graft, signs of reendothelialization, and organized dense collagen tissue. The structural integrity was more evident in the fresh mitral homografts. This method may provide consider improvement in the viability of the mitral homograft, and it could be a valid alternative for repair of mitral valve localized pathology.
During the 1970s, initial clinical experience with bioprostheses determined their worldwide use. However, bioprosthetic reoperation (BPR) is now common, particularly in groups with extensive implantation of these valve substitutes. From January 1980 to December 1989, a total of 470 patients had a total of 618 reoperations for bioprosthetic dysfunction and were retrospectively analyzed. Eighty-seven patients required a second BPR, 21 a third BPR, 5 a fourth BPR and 1 patient a fifth BPR. Structural deterioration was the main cause of valve dysfunction for the first and second BPR. However, paravalvular leak and infective endocarditis were more frequent for the remaining additional reoperations. Hospital mortality was 12.6%, 14.9% and 37% after the first, second and third or subsequent BPR, respectively. Univariate statistical analysis shows as hospital mortality risk factors: age at the time of the surgery, preoperative NYHA functional class IV, emergency surgery, concomitant tricuspid surgery, double (mitro-aortic) valve dysfunction, active infective endocarditis as the cause of failure and prolonged aortic cross-clamping time. Hospital mortality declined from 19.8% to 11.8% for the first and second half decade, respectively (P less than 0.005). In conclusion, bioprosthetic valve reoperation entailed a higher hospital mortality, particularly in the risk group of patients. In our hands, surgical experience has determined the improvement of the clinical results in this group of patients.
Valve-related morbidity and mortality after heart valve replacement with the Hancock I porcine bioprosthesis has been retrospectively analyzed. From June 1974 through December 1976, 253 Hancock I bioprostheses (150 mitral and 103 aortic) were inserted in 220 selected patients who survived the operation and had follow-up until June 1989 (mean follow-up 13.5 years, with an accumulative follow-up of 2956.4 patient-years). One hundred seventeen patients had mitral valve replacement, 70 had aortic valve replacement, and 33 had combined mitral and aortic valve replacement. There were 27 thromboembolic events. The probability of being free from thromboembolism at 14 years was 81.0% +/- 7.4% for the mitral valve replacement group, 85.4% +/- 6.7% for the aortic group, and 67.1% +/- 18.4% for the mitral-aortic group. Fifteen episodes of prosthetic valve endocarditis occurred. There were 10 instances of nonstructural dysfunction (paravalvular leaks) in seven mitral valves (4.6%) and in three aortic valves (2.9%). One hundred twenty-two bioprostheses in 106 patients resulted in structural deterioration. The probability of freedom from structural deterioration at 14 years was 37.2% +/- 3.9% for the mitral group, 43.9% +/- 7.1% for the aortic group, and 30.1% +/- 8.9% for the mitral-aortic group. The logistic regression analysis between age at the time of operation and bioprosthetic life (structural deterioration-free period) demonstrates a linear regression curve (r = 0.53). There were 56 late deaths (27 patients died at reoperation). The actuarial survival rate (including hospital mortality) at 14 years was 57.2% +/- 5.4% for the entire series, with no statistically significant difference between groups. The probability of remaining free from valve-related morbidity and mortality at 14 years was 16.7% +/- 4.8% for the mitral group, 20.8% +/- 6.2% for the aortic group, and 14.0% +/- 7.0% for the mitral-aortic group. The long-term results of this series show that the clinical performance of the Hancock I porcine valve appears satisfactory during the first 6 years. The behavior of this bioprosthesis at 14 years' follow-up changes drastically, because only a minor group of patients is free from valve-related complications, justifying the restriction of its use for selected patients.
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From June 1984 to December 1987, an early postoperative angiographic study was performed in 247 patients who underwent isolated coronary artery bypass surgery. The average age of these patients was 58.6 years, range 31 to 75 years. Preoperatively 50.8% of patients had myocardial infarction and 43.2% of them had unstable angina before surgery. Early coronary artery bypass angiogram was performed in 683 grafts (2.76 grafts per patient): 74 internal mammary artery grafts and 609 saphenous vein grafts. The distribution, location and type of the stenosis, distal coronary artery diameter, segmental myocardial contractility, and distal angiographic coronary filling are analyzed with a matching statistical method. Multivariate analysis showed significant predictors of early graft occlusion to be right coronary and circumflex artery, poor or non visible distal angiographic filling, coronary arteries smaller than 1.5 mm. The univariate analysis associates as risk factors hypokinetic or akinetic territories and multiple stenosis coronary arteries. It can be concluded that the early angiographic study demonstrate that coronary arteries with multiple stenosis, poor distal angiographic filling, smaller than 1.5 mm in diameter, coronary arteries perfusing hypokinetic or akinetic territories and the right coronary and left circumflex artery grafts have significantly lower early cumulative patency rates.