WEDNESDAY AFTERNOON, MAY 2, 1979

2:00 P.M. Scientific Sessions - Ballroom

37. Surgery for Mitral Insufficiency Secondary to Coronary Artery Disease

JEROME HAROLD KAY, PABLO ZUBIATE*,

MICHAEL A. MENDEZ*, NEAL VANSTROM*,

TARO YOKOYAMA* and MOHAMMAD A. GHARAVI*,

Los Angeles, California

From September 1970 to December 1977, 61 patients were operated upon for significant mitral insufficiency secondary to coronary artery disease. Thirty-eight men and 23 women ranged from 44 to 71 years. Preoperatively, 48 had angina, 33 were in New York Heart Association (NYHA) Class IV and 28 in Class III. Ejection fraction (EF) ranged 0.15-0.70, mean 0.40. Nine had an EF of 0.20 or less. Twenty had EF of 0.25-0.40. Mitral regurgitation ranged grade 2/6 to 5/6, mean 3/6 (except for one patient with I/VI mitral insufficiency). Mitral repair was performed in 52 patients (85%) and valve replacement in 9 (15%). Ruptured or infarcted papillary muscle or torn chordae tendineae were present in 38 patients. Five internal mammary artery and 109 vein graft anastomoses were performed. There were 5 hospital deaths (8%) and 11 late deaths (18%). Of the 45 surviving patients, 4 have slight angina. Twenty-four are in NYHA Class I and 18 are in Class II. Of 25 vein grafts in 12 patients restudied, 20 are patent (80%). Mitral regurgitation decreased from a mean of 3.0 to 0.8 (p 0.001). Average improvement in EF was 0.08, p 0.01. Survivability was 74% at 7 years. The authors urge mitral repair rather than replacement when feasible.

*By invitation

38. Real Time Sound Spectroanalysis for Malfunctioning Prosthetic Valve

YUZURU KAGAWA *, SHINICHI NITTA *, NAOSHI SATOH*,

TADAYOSHI HONGOH*and HITOSHI MOHRI, Sendai, Japan

Materials and methods: Sound spectral analyses were carried out 220 times on 127 cases bearing prosthetic valves. Four of those had throm-bosed valves and other 7 cases experienced major cerebral embolization. The new system, which was developed in our institute, consists of a moving coil microphone, preamplifier, spectrum analyzer and display system. Valvular clicks are displayed on oscilloscope or X-Y recorder in 5 different modes. Section patterns, which represent transformation of the sound spectrum most directly, was used in this study. Maximal frequency taken at -30/36 db level (normalized maximal frequency, NMF) was used as a parameter.

Results: NMF values of the normally functioning valves with silastic poppet were significantly lower than that of the metal or high density polymer made poppet valves. Both opening and closing clicks of these valves registered almost same NMF values except tilting disc valves. No correlations were found between NMF values and postoperative time course.

NMF values were significantly low in 4 cases of thrombosed valve and 4 cases with cerebral embolization. Accuracy of the diagnosis of thrombosed valve by this real time sound spectral analysis, was proven at reoperating.

Conclusion: A newly developed real time sound spectral analyzer was very useful for diagnosis of the malfunctioning prosthetic heart valves and was thought to be superior to other methods such as phono-cardiography and echocardiography.

*By invitation

SESSION ON CONTROVERSIES

Mitral Repair Versus Mitral Replacement

39. Durability of Measured Mitral Annuloplasty: A Seventeen Year Study

GEORGE E. REED, RICHARD W. POOLEY*,

and RICHARD A. MOGGIO*, Valhalla, New York

This report deals with the result of measured mitral annuloplasty performed in 192 patients with isolated mitral valve disease in the 17 years between January 1961 and January 1978. Because tricuspid re-gurgitation usually results from advanced mitral disease, patients with this lesion were included. One hundred and seven patients (55%) have been followed for at least 10 years and 147 patients (75%) have been followed for up to 5 years. Ages ranged from 3 to 70 years and 51 patients were under 18 years of age.

That this is not a select, low risk group, is demonstrated by the distribution, according to operation, of all patients with isolated mitral disease (but including tricuspid regurgitation) seen during this period. There were 553 such patients. Of these, 98 (17.7%) had closed com-missurotomy, 27 (4.8%) had open commissurotomy, 192 (34.7%) had annuloplasty and 236 (42.8%) required mitral valve replacement.

The annuloplasty patients were divided into two groups: (1) 113 patients who had annuloplasty (with or without valvuloplasty) and (2) 79 patients who had commissurotomy and annuloplasty (with or without valvuloplasty). Valvuloplasty included various techniques for reefing the free edge of either leaflet (imbrication, plication, wedge resection), extension of the leaflets by insertion of a gusset, and debride-ment of calcium and fibrous tissue. There were 9 deaths for an overall mortality of 4.6% in these 2 groups of annuloplasty patients; 7 of these occurred in the first 4 years. Late mortality, from all causes, was 7.3%, considerably less than is reported for mitral replacement during this period. There were 6 arterial emboli during the 17 years. Thirteen patients (6.7%) required re-operation and in 5 of these, it was possible to again repair the valve. With rare exception, none of these patients was anticoagulated. This permitted unrestricted physical activity in the young age group, multiple uncomplicated pregnancies among the women of child bearing age and, liberal alcoholic intake in the older age group.

*By invitation

40. Conservative Surgery for Mitral Insufficiency. Critical Analysis Supported by the Postoperative Haemodynamics of 72 Patients.

CARLOS G. DURAN*, JOSE L. POMAR*, JOSE M. REVUELTA *,

JOSE POVEDA*, ALBERTO OCHOTECO*and

JOSE L. UBAGO*, Santander, Spain

Sponsored by Lawrence H. Cohn, Boston, Massachusetts

Since May 1974, 230 mitral reconstructions have been performed at our Institution. Forty-three Carpentier and 187 Flexible Rings were used. A critical analysis of this last group, with 58 predominant stenotic, 22 insufficient and 107 (57.3%) mixed lesions, is reported. 90.7% were of rheumatic origin. 65 tricuspid and 39 aortic valves were simultaneously repaired or replaced. 18 valves had calcific nodules and 19 patients atrial thrombi. The mean ischaemic time in the non-aortic group was of 43 miutes (our mitral replacement time is 44'). Reconstruction included 157 commissural, 14 cusp, 85 papillary and 26 chordal surgical manoeuvres. Valve anatomy was good in 53% of cases, medium in 38.5% and bad in 8.5%.

The routine intraoperative valve checking showed perfect closure in 157, non significant regurgitation in 30 and incorrect repair in 18 patients, (not included in this study) requiring valve replacement with a 55% increase in ischaemic time.

Three (1.6%) hospital and 3 late deaths occurred. No permanent anticoagulation was used (1 embolic accident) except in the high risk group (8 accidents). The postoperative resting (R) mean transmitral gradient was of 9.9 (± 4.1) mm Hg. and 13.7 (± 5.9) mm Hg. after volume load (L). The mean effective orifice area was of 2.42 (± 0.86) cm². The cardiac index was 2.9 1/min/m². The ejection fraction rose from 47.3% to 54.84%. Angiographically 17 cases (25.8%) had significant regurgitation, 8 requiring reoperation without mortality. 5 were due to ring dehiscence and 3 to an original defective technique. 80% of patients moved to Class I.

Our 143 isolated Hancock Mitral Replacements, had a mortality of 10.4% and 2.3%. There were no reoperations;mean transmitral gradients of 11.9 (R) and 15.5 (L) mm Hg. and mean effective area of 2.51 cm². Cardiac index was of 3.3 1/min/m². The ejection fraction moved from 54.4 to 47.0% in the 59 patients recatheterized.

We conclude that the reconstruction of the mitral valve, being more physiological than present day prosthesis, is - whenever possible - a superior surgical solution to the problem of mitral insufficiency.

*By invitation

41. Reconstructive Surgery of Mitral Valve Incompetence

ALAIN CARPENTIER*, ALAIN DELOCHE*, JOHN RELLAND*,

SYLVAIN CHAUVAUD*, JEAN-NOEL FABIANI* and

CHARLES DUBOST, Paris, France

Reconstructive surgery of the mitral valve raises 3 controversial questions: 1) Predictability of results, 2) Reproductibility of techniques, 3) Selection of patients.

Five hundred fifty-one cases of mitral incompetence were treated by reconstructive techniques between January 1969 to January 1978. Mitral valve incompetence (M.I.) was classified into 3 types according to leaflet pliability. Type I MI: normal leaflet motion, 150 cases. Type II MI: leaflet prolapse, 213 cases. Type III MI: restricted leaflet motion, 188 cases. Associated tricuspid valvular disease was present in 174 cases (31.5%) and treated by prosthetic ring annuloplasty.

The operative mortality was 5% (19/377) in the mitral group and 13.8% (24/174) in the mitral tricuspid group.

Follow-up data is available in 416 patients from 1 year to 9 years (mean 4.6 years). Late mortality was 3% (13/416). Actuarial curves show a 89% survival rate at 8 years. 27 patients (6.5%) underwent re-operation for either residual M.I. (19) or recurrent M.I. (8). Thrombo-embolism occurred in 12 patients (2.8%) in spite of the fact that 48% were not anticoagulated. According to the N.Y.H.A. classification 73% (275/376) of the patients were in Class I, 21% (79/376) were in Class II, 6% (22/376) were in Class III. Post-operative catheterization and angiocardiography are available in 42 patients. Comparison between the various groups shows that the best results were obtained in type II M.I. followed by type I M.I. and type III M.I.

This experience suggests the following answers to the 3 initial questions:

1) Predictable and stable long-term results have been achieved by techniques of valvular reconstruction with a low incidence of thrombo-embolism.

2) Reproductibility of the technique is predicated upon adequate training with cadaver and animal hearts.

3) Patient selection is based on the valvular pathology rather than age, physical condition or etiology.

Non calcified mitral valve disease should be considered for valve repair, but the final decision is made at operation. It requires accurate knowledge of both the lesions of the mitral valve and the limitations of the technique.

*By invitation

42. Long Term Results of the Mitral Plication Suture Technique

D. F. SHORE*, P. WONG*and M. PANETH*, London, England

Sponsored by Mortimer J. Buckley, Boston, Massachusetts

Our initial experience with 67 mitral valve repairs by use of the mitral plication suture technique was reported in 1977. Early follow-up indicated good clinical results could be obtained with a low mortality. In addition the overall rate and pattern of left ventricular filling determined by echocardiography was normal or near normal in all patients studied after mitral valve repair.

Encouraged by these early results a total of 246 patients have had attempted mitral valve repairs between January 1975 and September 1978. There were 38 operative failures. Five mitral valve replacements were performed during the early postoperative period. The hospital mortality was 5.7%. Of 190 patients discharged and considered to have had a successful repair, reliable follow-up information is available in 80 cases. These patients form the basis of this report and their average age of 54 years contrasts with the average age of 33 years of those patients from overseas and not included.

Fourteen patients have subsequently had a mitral valve replacement. There have been nine late deaths, four following mitral valve replacement. The clinical state of the remaining 62 patients as judged by symptomatic, clinical and radiological criteria is as follows: 34 patients have had a good result, and 19 patients a satisfactory result. In five patients the results have been unsatisfactory and it is difficult to assess mitral valve function in the remaining four.

An analysis of the results with reference to the surgical pathology and the echocardiographic assessment of mitral valve function and left ventricular filling will be presented.

These results have caused us to reconsider the place of conservative mitral valve surgery and in our hands the long-term results of this method of repair are unacceptable in this age group.

Adjournment

*By invitation