PubMed · 4091576
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P B Deverall, G Campalani, D R Anderson. 1985. Heart valve replacement.. https://doi.org/10.1136/adc.60.12.1111
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BACKGROUND: Right ventricle-to-pulmonary artery (RV-PA) homografts and bioprosthetic conduits are commonly used to palliate various types of complex congenital heart disease. These conduits frequently develop progressive obstruction and require surgical replacement. This report reviews our experience implanting balloon-expandable stents to relieve conduit obstruction and delay reoperation. METHODS AND RESULTS: A retrospective review identified 44 patients who underwent placement of 48 stents in obstructed RV-PA conduits. Median patient age was 6.9 years (range, 7 months to 30 years), and median follow-up time was 14.2 months (range, 0 to 48 months). Stent implantation initially decreased the RV-PA pressure gradient from 61.0 +/- 16.9 to 29.7 +/- 11.9 mm Hg (P < or = .001) and the right ventricular-to-systemic arterial pressure ratio from 0.92 +/- 0.17 to 0.63 +/- 0.20 (P < or = .001). The diameter of the stenotic region expanded from 9.3 +/- 3.5 to 12.3 +/- 3.3 mm in the anteroposterior view (P < or = .001) and from 6.6 +/- 2.9 to 10.9 +/- 2.5 mm in the lateral view (P < or = .001). During the follow-up period, 2 patients had their stents redilated, 7 had additional conduit stents deployed, and 14 underwent surgical replacement of their conduits. Actuarial freedom from conduit reoperation was 65% at 30 months postprocedure. Seven patients were found to have fractured stents on follow-up, suggesting an important role for external compressive forces in conduit failure. Recatheterization in 16 patients a median of 11.8 months (3 to 48 months) postprocedure demonstrated hemodynamic evidence of recurrent obstruction despite sustained enlargement at the previously stented sites. Complications included stent displacement (n = 1), bacterial endocarditis (n = 1), and false aneurysm formation (n = 1). One patient died awaiting conduit replacement surgery. CONCLUSIONS: Stent implantation in obstructed RV-PA conduits results in significant immediate hemodynamic and angiographic improvement. In a subgroup of patients, the procedure prolongs conduit life span by several years and increases the interval between conduit reoperations. Recurrent obstruction is caused by external compression and progressive stenosis outside the stented region.
The new stentless porcine mitral valve was developed to serve as an anatomically correct substitute for a diseased mitral valve. Extensive acute animal experimentation was performed, and from this the logical sequence for selecting the correct valve size and the specific technique for implanting it were determined. The following are the major steps to successfully implant a mitral stentless valve: First, mitral valve complex analysis must be done to determine the correct procedure to be performed and the feasibility of using the stentless mitral valve. Second, the correct size of stentless mitral valve must be chosen. Third, the papillary muscle anatomy must be assessed to determine the site and number of sutures necessary for securely holding the new origin of the new chordae. Fourth, the papillary muscle sutures must be anchored to the free pericardial edge of the new chordal origin. Fifth, the chordal alignment with both trigonal areas must be perfect. Sixth, the annulus may be sutured using either continuous or interrupted sutures. Perioperative echocardiography, preferably transesophageal echocardiography, should be done in every patient. Although reoperation was necessary in 5 patients (non-valve-related), the results in 74 patients (3 early and 3 late non-valve-related deaths excluded) followed up for at most 26 months (mean, 14 months) have been excellent. The quality of the results obtained in this initial clinical trial has reinforced our current preference for this valve in patients requiring mitral valve replacement. Longer follow-up is required to confirm that these good results continue.
Mitral valve replacement was performed through a right thoracotomy using femorofemoral bypass under profound systemic hypothermia in a 62-year-old man who had undergone coronary artery bypass grafting using both internal thoracic arteries. The right thoracotomy approach minimizes the risk of injury to the arterial grafts, and deep hypothermia obviates the need to interrupt the grafts to administer cardioplegia. This technique provides excellent exposure of the mitral valve while minimizing the operative risk.