2:00 p.m. Scientific Sessions - Grand Ballroom

26. A Comparison of Replacement and Reconstruction in Patients with Mitral Regurgitation

WILLIAM W. ANGELL, JAMES H. OURY*,

and PRAVIN SHAH*

San Diego, La Jolla and Los Angeles, California

The majority of patients with mitral regurgitation in our clinical practice present with degenerative valve disease. We are presently able to do mitral valve reconstruction in 78% of all patients who present with mitral regurgitation without mitral stenosis.

Several factors make mitral valve reconstruction an attractive alternative to replacement:

1. Increased valve orifice

2. Preservation of chordae and papillary muscles

3. Preservation of natural flexible annulus

4. Improved longevity over porcine xenografts

5. No requirement for chronic anticoagulation

A comparative series of patients operated over the same three year interval consisted of 34 patients with mitral valve replacement and 95 with mitral valve reconstruction. Valve areas studied by echo doppler were 2.0² cm for replacement and 2.3² cm for reconstruction (P =0.025). Valve failure secondary to spontaneous sterile degeneration was 0.9% per patient year for reconstruction and 2.4% per patient year for replacement (P = .01).

Operative time was 69 minutes for reconstruction and 44 minutes for replacement with a 17% and 18% hospital mortality and 19% and 24% morbidity.

In the first two years the reoperation incidence after reconstruction was 5%. The remainder of the patients, although clinically well, did exhibit varying degrees of stable, non-progressive mitral regurgitation. Thirty-four percent of the patients had mild mitral regurgitation and 33% of the patients had trivial regurgitation definitely detectable by echocardiographic studies.

The decision between mitral valve reconstruction and mitral valve replacement remains a highly controversial issue in most U.S. centers. Our data suggests that the advantages of reconstruction outweigh the increased time and incidence of post-operative mitral regurgitation particularly in those patients with compromised ventricular function.

2:10 p.m. Discussion

*By Invitation

2:20 p.m.

27. Biological vs. Mechanical Valves: Analysis of 1104 Valves Inserted in 1012 Adult Patients with a 4801 Patient-Year Follow-Up

GRAEME L. HAMMOND, ALEXANDER S. GEHA,

GARY S. KOPF* and SABET W. HASHIM*

New Haven, Connecticut

All surviving patients between 18-88 years of age receiving biological or mechanical valves at our institution from January 1974 through January 1985 were analyzed for thromboembolism, anticoagulation related hemorrhage, endocarditis, perivalvular leak, valve failure, need for reoperation and late cardiac death. The occurrence rates of these events were analyzed in linear (λ[%/pt-yr]) and actuarial terms over the 11 year period.

597 biological (325 Ao, 246 Mil, 22 Tri, 4 Pulm consisting of 469 C-Es, 111 Hanc. 17 1-S) and 507 mechanical (324 Ao, 179 Mit, 4 Tri consisting of 184 S-E, 163 B-S and 160 St.J) valves were inserted. The data are shown below.

	Biological (N = 597)		Mechanical (N = 507)
Event	λ(l pt-yr)	% free*	λ(l pt-yr)	% free*
Thromboembolism	.6%	97 ± 3.1% @ 7 yrs	1.9 %	90 ± 4.7% @ 7 yrs
Anticoagulation hemorrhage	.2%	98 ± 2.5% @ 7 yrs	.5%	95 ± 4.5% @ 9 yrs
Endocarditis	.87%	94 ± 4.4% @ 7 yrs	1.1%	90 ±3.4% @ 8 yrs
Replacement for PV leak	.35%	98 ± 3.9% @ 8 yrs	.84%	93 ± 4.7% @ 8 yrs
Replacement for valve failure	2.1%	88 ± 4.5% @ 6 yrs	.7 %	93 ± 5.3% @ 9 yrs
Valve failure without replacement	.19%	97 ± 4.1% @ 8 yrs	.17%	98 ± 4.7% @ 11 yrs
Cardiac death	4%	84 ± 4.3% @ 5 yrs	4.8 %	81 ± 5% @ 5 yrs
All morbidity and mortality	8.3%	65 ± 5.6% @ 5 yrs	10%	70 ± 5.1% @ 3 yrs
*95% confidence limits

Torn leaflets and calcification were the cause of most biological valve failures (65/597) with a sharply increased incidence occurring at 7 yrs. Clotting and leaflet jamming were the cause of B-S failures (8/163), while cloth wear and tissue ingrowth were the cause of most S-E failures (14/184). The incidence of mechanical failures was more or less evenly distributed throughout the study period. In general, the complication incidence of biological valves was less than mechanical valves; but the incidence of valve failure was higher in biological valves. In summary, little direct evidence strongly supports one type of valve over another.

2:30 p.m. Discussion

*By Invitation

2:40 p.m.

28. Clinical Experience with Stentless Pericardial Aortic Monopatch for Aortic Valve Replacement

RANDAS J. BATISTA*, A. DOBRIAMSKIJ*,

R.J. TIMI*, R. MOREIRA* and P.F. OLIVEIRA*

Curitiba, Brazil

Sponsored by: TOMAS A. SALERNO

Toronto, Ontario

Between August 1983 to October 1985, 49 consecutive patients were operated on for aortic valve disease. We used a sheet of glutaradehyde-preserved bovine pericardium sutured to the aortic annulus so as to form 3 new cusps. The age varied from 15 to 74 years (mean ± SD: 38 ± 16 yrs). There were 32 males and 17 females. The most common lesion was aortic insufficiency in 28 (51%), aortic stenosis in 7 (14%), and combined lesions in 14 (28%). 51% presented with associated lesions (mitral valve 13, mitral and tricuspid 3, ascending aortic aneurysm 3, infective endocarditis 3, coronary artery disease 2, and coronary artery disease + left ventricular aneurysm 1). Intraoperative valve gradients were measured in the first 20 patients and none were found. One patient in the pediatric age with a small aortic annulus had evidence of annulus growth after valve replacement. None of the patients received anticoagulants except for low dose Aspirin for six months. There was no incidence of major thomboembolic phenomena. 92% of the patients were in NYHA class III and IV preoperatively, but postoperatively, 92% were in class I and II, and 85% were in class I. There were 3 early deaths (6.1%) and 2 late deaths (4.1%).

We prefer this technique for aortic valve replacement since there is no need for anticoagulation, a larger effective valve area results, and in the cases of infective endocarditis, less prosthetic material is used. The possibility of pediatric use of this technique to allow further annular growth is very promising.

2:50 p.m. Discussion

3:00 p.m. Intermission - Visit Exhibits - Exhibit Hall

*By Invitation

3:40 p.m. Scientific Session - Grand Ballroom

29. Comparative Study of Coumadin vs. Antiplatelet Therapy in St. Jude Aortic Valve Patients

RENEE S. HARTZ*, JOSEPH LoCICERO, III*,

VINCENT KUCICH*, ARTHUR DeBOER*,

SUSAN O'MARA and LAWRENCE L. MICHAELIS

Chicago, Illinois

Although the recommended management of most patients (pts) with rigid heart valves entails chronic anticoagulation, the hazards of long-term use of Coumadin raise questions about the risk/benefit ratio of such therapy. The following study of 83 adult patients with the St. Jude Medical valve in the aortic position was therefore undertaken in order to compare Coumadin (Coum) versus non-Coumadin (usually antiplatelet) therapy (NCT). Follow-up was 100% and ranged between six and 73 months with a mean of 29 months (median 25). The two groups were similar with respect to sex, associated cardiovascular disease, and length of follow-up. The mean age of the Coum group was 52 yrs and of the NCT group 57 yrs.

Forty-one pts were treated with conventional long-term Coum therapy under the control of their referring physician/cardiologist at a dosage, recommended by us, to maintain the prothrombin time at 1½ times control. In this group there were three deaths and eight major, non-fatal, complications; four thromboembolic and four hemorrhagic.

Forty-two pts were not on chronic Coum therapy although 17 pts in this group received Coum temporarily after surgery and seven received it intermittently. Most, but not all, NCT pts were on some form of antiplatelet therapy. In this group there were two deaths and four complications; two thromboembolic and two instances of valve malfunction requiring reopera-tion. Both of these were secondary to ingrowth of pannus material without evidence of thrombus.

The late mortality rate of the two groups was similar; 2.7/pt-yr Coum and 2.05%/pt-yr NCT, but the incidence of serious morbidity was 7.3%/pt-yr in the Coum group compared to 3.2%/pt-yr in the NCT pts. These data confirm the high incidence of complications associated with chronic Coum therapy and suggest that antiplatelet therapy is as effective as Coum in preventing thromboembolism with the St. Jude Medical valve in the aortic position. Whether dysfunction of this valve secondary to fibrous tissue ingrowth can be prevented by Coum therapy remains in question.

3:50 p.m. Discussion

*By Invitation

4:00 p.m.

30. Aspirin Anticoagulation in Children with Mechanical Aortic Valves

EDWARD D. VERRIER*, ROBERT F. TRANBAUGH*,

SCOTT J. SOIFER*, EDWARD S. YEE*,

KEVIN M. TURLEY and PAUL A. EBERT

San Francisco, California

The optimal method of anticoagulation in children with mechanical heart valves is controversial. Between 1975 and 1985, aspirin or aspirin/persantine has been given to children receiving a mechanical aortic valve at the University of California, San Francisco. Forty-seven patients (age: 2-23 years; mean 13.4 years) were treated with aspirin (43) or aspirin/persantine (4), and followed a mean of 35.3 months (range 3-100 months). There were four late deaths; two from endocarditis, and two from other medical problems, but none related to thrombosis or emboli.

Careful follow-up was accomplished by direct contact with the patient or referring physician. Three patients (6.4%) were lost to follow-up. One postoperative neurological event occurred at the time of surgery and resolved spontaneously. There were no other thromboembolic events. No children recently studied had evidence of prior cerebral thromboembolic defects by computerized axial tomography or magnetic resonance imaging scans. There were three patients (6.4%) who had hemorrhagic complications: two patients had minor nose bleeds, and one patient had an upper gastrointestinal hemorrhage. Two patients were changed to warfarin anti-coagulation: the patient with upper gastrointestinal hemorrhage and a second patient because of physician's preference one year after uncomplicated aspirin therapy. There were no mechanical valve failures; although one patient required reoperation fifteen months later for a perivalvular leak.

These results show that children with mechanical aortic valves in normal sinus rhythm may be safely anticoagulated with aspirin (or aspirin/persantine) with little risk of thromboembolic events, valve thrombosis, or valve failure. Hemorrhagic complications due to aspirin are minor and easily treated. Thus, it would appear that a mechanical tilting-disk valve in the aortic position combined with aspirin anticoagulation is the valve of choice for children.

4:10 p.m. Discussion

*By Invitation

4:20 p.m.

31. Eleven-Year Experience with Composite Graft Replacement of the Ascending Aorta and Aortic Valve

NICHOLAS T. KOUCHOUKOS,

WILLIAM G. MARSHALL, JR.*

and THERESE A. WEDIGE-STECHER*

St. Louis, Missouri

Between September, 1974 and September, 1985, 125 patients had replacement of the ascending aorta and aortic valve with a composite graft (Dacron tube graft, aortic valve prosthesis). The mean age of the patients was 51 years (range 17-86 years) and 72% were males. Sixty-seven patients (54%) had annuloaortic ectasia, 42 (34%) had aortic dissection (12 acute, 30 chronic), 9 had recurrent aneurysms of the aortic sinuses following separate ascending aorta and aortic valve replacement, and 7 had other disorders (luetic aortitis, prosthetic endocarditis, post-stenotic dilation). Twenty-one patients (17%) had the Marfan syndrome. Hospital mortality was 4.8% (6 patients). Reoperation for postoperative bleeding was required in 14 patients (11.2%) and for prosthetic-related complications (endocarditis, false aneurysm, valve thrombosis or stenosis, conduit compression) in 13 (10.4%). Since adopting a technique of pre-clotting the prosthesis with whole blood or albumin plus autoclaving, and abandoning the inclusion technique, the reoperation rate for bleeding, false aneurysms, and other technical problems has declined substantially [18.6% (19/102) vs 4.3% (1/23), p = 0.09]. The mean duration of follow-up was 55 months (1-133 months). Actuarial survival at 7 years for the entire group was 63 ± 6%, for the patients with annuloaortic ectasia 71 ± 7%, for those with aortic dissection 61 ± 10%, and for those with the Marfan syndrom 43 ± 14%. Actuarial incidence of freedom from reoperation on the ascending aorta at 7 years was 81 ± 5%. The satisfactory results with extended follow-up support the continued use of the composite graft technique as a preferred method of treatment for all patients with annuloaortic ectasia or recurrent aneurysms of the aortic sinuses, and in selected patients with aortic dissection and associated aortic-valve incompetence.

4:30 p.m. Discussion

AN HISTORICAL VIGNETTE

LYMAN A. BREWER, III

Pasadena, California

4:40 p.m. Executive Session (Members Only) - Grand Ballroom

7:00 p.m. President's Reception - Grand Ballroom Tickets Required

*By Invitation