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Query: UMLS:C0033377 (prolapse)
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Brachial plexus injury is a typical complication after median sternotomy. A prospective study was performed on 1000 consecutive patients to determine whether preventive actions, including lower position and least possible opening of the sternal retractor, help to reduce the complication rate. Twenty-seven patients were observed with postoperative brachial plexus injury. Nerve conduction measurements and electromyography were performed. Patients without preparation of the internal mammary artery had a complication rate of less than 1%, whereas the complication rate of those patients with preparation of the internal mammary artery was as high as 10.6%. The main symptoms were continuous pain and motor and sensory disturbances. Most frequent were lesions corresponding to the roots C8-T1. Six patients had Horner's syndrome; three had ptosis only with no other signs of Horner's syndrome. Symptoms persisted in eight patients more than 3 months after the operation, and one patient still had intractable pain. Increasing use of internal mammary artery grafts in coronary artery bypass demands measures to protect the brachial plexus.
J Thorac Cardiovasc Surg 1991 Nov
PMID:Brachial plexus injury after cardiac surgery. The role of internal mammary artery preparation: a prospective study on 1000 consecutive patients. 168 32

The late results of 70 patients aged 1.96 to 35.9 (mean 10.1) years who had repair of ventricular septal defect and aortic insufficiency from 1968 to 1988 were reviewed. The ventricular septal defect was subcristal in 50 and subpulmonary in 20 patients. Two thirds were situated immediately below some part of the right coronary leaflet with prolapse of that leaflet. Most of the remainder were below the right commissure or the anterior part of the noncoronary leaflet with prolapse of one or both adjacent leaflets. Associated structural defects, usually including some fusion at a commissure, were present in 18 of the 70 patients and occurred more often with a ventricular septal defect in or below the commissure between the right and noncoronary leaflets (p less than 0.001). Follow-up ranged from 1.9 to 19.6 (mean 9.8) years. There were no early deaths or cases of atrioventricular block, but there were two late deaths. Patient survival rate was 96% at 10 years. Freedom from valvuloplasty failure and freedom from reoperation were 76% and 85%, respectively, at 10 years. The major predictor for failure by multivariate analysis was the presence of an associated structural defect (p less than 0.01). Age at repair and position of the ventricular septal defect were not significant risk factors. We conclude that aortic valvuloplasty produces good palliation in most children. The few failures occurred early and chiefly in patients with associated structural valve defects that occurred more frequently in children who had a ventricular septal defect in the right commissure, where both the right and noncoronary leaflets may be affected.
J Thorac Cardiovasc Surg 1992 Feb
PMID:Late results after repair of aortic insufficiency associated with ventricular septal defect. 173 93

Surgical management of the conal (supracristal) ventricular septal defect differs significantly from the management of the perimembranous (infracristal) ventricular septal defect. The absence of a portion of the conal septum can lead to prolapse of the right cusp of the aortic valve, which predisposes these patients to aortic insufficiency. Between January 1980 and December 1989, 36 children with conal ventricular septal defect underwent intracardiac repair. Diagnosis was by echocardiography, cardiac catheterization, and intraoperative exploration. Preoperative evaluation showed that 26 patients (72%) had aortic valve prolapse and 16 (44%) had aortic insufficiency. Pulmonary-to-systemic flow ratios ranged from 1:1 to 3.5:1 (mean 2.0:1.0). Ten patients (27%) were believed to have clinical congestive heart failure. Age at the time of operation ranged from 2 weeks to 18 years (mean 5.5 years). Operative exposure was through the pulmonary artery (26), aorta (4), right ventricle (3), or right atrium (3). Simultaneous aortic valve suspension for aortic insufficiency was performed in four patients. Operative survival was 100%. Follow-up is complete in all patients and ranges from 0.5 to 9 years (mean 4.3 years). All patients are in normal sinus rhythm. No residual ventricular septal defects have been identified. Twenty-three of 36 patients (64%) have no evidence of aortic insufficiency; 12 of 36 (33%) have trivial or mild aortic insufficiency. One patient with initial severe aortic insufficiency underwent repeat aortic valvuloplasty 3 years after ventricular septal defect closure and aortic valve suspension. No patients have required aortic valve replacement. Surgical management of the conal ventricular septal defect differs from that of the perimembranous ventricular septal defect in two critical aspects. The operative approach should be through the pulmonary artery. This allows the best exposure of the remaining conal septum and the pulmonary and aortic valve leaflets, facilitating closure of the defect without injury to the valves or conduction system. Conal ventricular septal defects should undergo early closure, regardless of shunt volume, to prevent progressive aortic insufficiency.
J Thorac Cardiovasc Surg 1991 Aug
PMID:Surgical management of the conal (supracristal) ventricular septal defect. 186 2

Twenty-eight consecutive patients underwent aortic valvuloplasty for aortic insufficiency caused by leaflet prolapse. The technique involved triangular resection of the free edge of the prolapsing leaflet, annular plication at the commissure, and resection of a raphe when present in bicuspid valves. Mean age of the patients was 46.8 +/- 14.4 years. Twenty-six (92.7%) were male. Seventy-five percent of the patients had a bicuspid aortic valve; the remaining valves were tricuspid. The extent of aortic insufficiency was 3.6 +/- 0.8 by aortography, 3.1 +/- 0.1 by preoperative Doppler echocardiography, and 3.4 +/- 0.7 by intraoperative Doppler echocardiography. The amount of aortic insufficiency decreased from 3.4 +/- 0.7 to 0.6 +/- 0.5 intraoperatively, immediately after repair (p less than 0.001). Mean transvalvular gradient by echocardiography was 12.9 +/- 6.8 mmHg. There was one death in a patient who had an intraoperative cerebral vascular accident. Mean follow-up was complete at 6.9 months. One patient had a cerebral vascular accident and one patient required reoperation for recurrent aortic insufficiency caused by partial suture line dehiscence. In 15 patients with late echocardiograms, aortic insufficiency did not progress (0.7 +/- 0.6 in the hospital and 0.8 +/- 0.5 late). Aortic valve repair for aortic cusp prolapse effectively eliminates aortic insufficiency without causing aortic stenosis. At early follow-up the repair has been stable.
J Thorac Cardiovasc Surg 1991 Oct
PMID:Valvuloplasty for aortic insufficiency. 192 33

Expanded polytetrafluoroethylene sutures have been used for replacement of diseased chordae tendineae during reconstructive procedures on the mitral valve in 43 patients. There were 28 men and 15 women whose mean age was 55 years, range 21 to 76. Three fourths of the patients were in New York Heart Association class III or IV. Replacement of primary chordae tendineae of the anterior leaflet was performed with 4-0 or 5-0 polytetrafluoroethylene sutures. A double-armed suture was passed twice through the fibrous portion of the papillary muscle head and tied down. Each arm of the suture was brought up to the free margin of the leaflet and passed through the area where the native chorda was attached. After the lengths of the two arms were adjusted, the ends were tied together on the ventricular side of the leaflet. Thirty patients had degenerative disease of the mitral valve; the incompetence was due to prolapse of the anterior leaflet in 14 patients and prolapse of the anterior and posterior leaflets in 16. Eleven patients had rheumatic mitral valve disease: four had stenosis, three had regurgitation, and four had mixed lesions. Two patients had ischemic mitral regurgitation caused by rupture of a papillary muscle head. There were no operative deaths. Patients have been followed up from 5 to 61 months, mean 13. Doppler echocardiographic studies were performed at regular intervals after the operation and revealed normal mitral valve function in most patients There were two failures that necessitated mitral valve replacement: one because of acute mitral regurgitation and the other because of hemolysis. There have been two late deaths, neither one valve related. Replacement of chordae tendineae with polytetrafluoroethylene sutures is simple and allows for reconstruction of the mitral valve in many patients who would otherwise require mitral valve replacement. Because our patients have been followed up for a limited time, the long-term results of this procedure remain unknown.
J Thorac Cardiovasc Surg 1991 Mar
PMID:Mitral valve repair by replacement of chordae tendineae with polytetrafluoroethylene sutures. 199 44

From January 1975 to June 1988, 275 patients underwent mitral valve repair for mitral regurgitation, pure (148 patients) or associated with mitral stenosis (127 patients). Patients with pure mitral stenosis were excluded from this study. The cause of mitral regurgitation was rheumatic in 180 patients (aged 28.6 +/- 1.2 years, mean +/- standard error of the mean) and degenerative in 84 patients (aged 54.7 +/- 1.5 years). Fifty-nine percent of the patients were in New York Heart Association classes III and IV before the operation. Intraoperative assessment of the mitral valve led us to identify four major mechanisms of mitral regurgitation: (1) restriction of leaflet motion by fibrosis (group I, 63 patients); (2) enhancement of leaflet motion by leaflet and chordal extension and prolapse (group II, 139 patients), (3) combination of both (group III, 64 patients); and (4) isolated dilatation of the anulus (group IV, 10 patients). One hundred sixty-one patients had isolated mitral disease and 114 had associated aortic or tricuspid valve disease, or both. The hospital mortality rate was 4.0%. Follow-up was 96% complete and totaled 1247.47 patient-years. At 13 years' follow-up, the survival rate was 93.0% +/- 6.8% in group I, 90.0% +/- 6.0% in group II, and 96.6% +/- 4.6% in group III. Freedom from reoperation was 78.1% +/- 21.0%, 83.2% +/- 18.9%, and 79.6% +/- 16.2%, respectively. Freedom from embolism was 94.7% for the whole series. In patients with isolated mitral valve repair, the cumulative morbidity was significantly higher in groups I (6.3 +/- 2.0%/pt-yr) and III 6.3% +/- 1.7%/pt-yr) than in group II (2.5% +/- 0.9%/pt-yr, p less than 0.05). Multivariate analysis identified age and associated tricuspid valve disease as significant predictors of reoperation (p less than 0.01 for both factors). These results suggest that conservative surgery should be used with caution in group I and III patients. In contrast, indications for mitral valve repair should be extended in group II patients. This observation has important clinical implications since, in Western countries, valve prolapse tends to be a major cause of mitral regurgitation.
J Thorac Cardiovasc Surg 1990 Apr
PMID:Mitral valve repair: results and the decision-making process in reconstruction. Report of 275 cases. 231 82

Among 206 consecutive patients having undergone mitral valve repair with a prosthetic ring between 1972 and 1979 in our institution, the 195 patients (94.5%) who survived the operation were studied to assess the long-term function of this method of repair. Patients' ages ranged from 18 to 79 years (mean age 48.7 years). Mitral valve insufficiency was due to degenerative disease in 113 patients (58%), rheumatic disease in 74 (38%), ischemia and other causes in eight patients (4%). A total of 188 patients (9.7%) were in New York Heart Association class III or IV preoperatively and 94 (48%) had atrial fibrillation. The patients were divided into three functional groups: type I (normal leaflet motion), 35 patients (18%); type II (leaflet prolapse), 147 patients (75%); and type III (restricted leaflet motion), 13 patients (7%). The techniques included prosthetic ring annuloplasty (185 patients), leaflet resection (158 patients), chordal shortening (89 patients), leaflet mobilization (10 patients) and papillary muscle reimplantation (2 patients). Long-term follow-up was available in 189 patients (96.8%), for a rate of 2316 patients per year. The 15-year actuarial and valve-related survival rates were 72.4% and 82.8%, respectively. At 15 years, 93.9% of the patients were free from thromboembolism, 96.6% free from endocarditis, 95.6% free from anticoagulant-related hemorrhage, and 87.38% free from reoperation. Actuarial rate of freedom from reoperation was higher in the group with degenerative disease (92.7%) than in the group with rheumatic disease (76.12%). Among the 157 survivors, 117 (74%) were in New York Heart Association class I and class II and 105 (66%) were in sinus rhythm. Doppler echocardiographic studies showed normal ventricular contractility in 134 patients (84.5%), absence of mitral regurgitation in 112 (74%), trivial regurgitation in 27 (17%), and significant regurgitation in 4 patients (2.5%).
J Thorac Cardiovasc Surg 1990 Jun
PMID:Valve repair with Carpentier techniques. The second decade. 235 39

From 1984 to 1988, 129 mitral valve reconstructions were done for primary pure mitral regurgitation. Sixty-two (48%) were done for myxomatous degeneration and prolapse of the mitral valve. Anterior leaflet resection was performed in seven patients, posterior leaflet resection in 46, anteroposterior resection in four; five patients received only a ring annuloplasty. Eight patients had coronary bypass grafts. Twenty-four patients received a Carpentier-Edwards annuloplasty ring, 24 a Duran ring, and 14 patients had no ring. Follow-up was 1 to 50 months (mean, 13 months). No patient was lost to follow-up. There was one operative death from gastrointestinal bleeding and two late deaths (one from suicide and one from a myocardial infarction), and the probability of survival at 48 months was 84% +/- 15%. There were no thromboembolic episodes or episodes of endocarditis. However, there were five reoperations (9%) with freedom from reoperation at 48 months of 85% +/- 5%. There was one major anticoagulant hemorrhage. Freedom from all morbidity at 48 months was 81% +/- 8%. Postoperative echocardiographic data in the three different groups of patients undergoing repair on the basis of annuloplasty treatment showed that the peak gradient was less and the valve area was slightly greater with no annuloplasty ring.
J Thorac Cardiovasc Surg 1989 Nov
PMID:Mitral valve repair for myxomatous degeneration and prolapse of the mitral valve. 281 29

Prolapse of the anterior leaflet of the mitral valve is the result of ruptured chordae, elongated chordae, or elongated or ruptured papillary muscle. Several techniques have been described for the correction of mitral valve insufficiency. However, when there is severe rupture of the chordae, the most widely accepted solution is valve replacement. We describe a technique for the creation of a neochorda with a strip of tissue from the anterior leaflet of the mitral valve. This technique was used in two patients with severe mitral valve regurgitation. Formation of a neochorda and placement of a Carpentier ring to remodel the anulus obviated the need for a valve replacement. Both patients had an uneventful recovery. Studies performed 3 and 4 months postoperatively showed competent and well-functioning valves. One patient required a valve replacement for acute mitral insufficiency 5 years later, but the other patient was doing well 3 years after the operation. Despite the limited experience, we believe this technique offers a reasonable alternative to valve replacement.
J Thorac Cardiovasc Surg 1988 Nov
PMID:A new technique for repair of mitral insufficiency caused by ruptured chordae of the anterior leaflet. 318 70

Surgically treated ventricular septal defect (VSD) was of supracristal type in 120 of 389 Chinese patients; 93 of the 120 were younger than 15 years. Concomitant aortic anomalies were present in 58 of the patients (regurgitation in 23 and cusp prolapse in 35). Corresponding figures among the 93 patients of the under-15 group were 40 (9 + 31). Direct suture or patch closure of the supracristal VSD and replacement or plication of anomalous aortic valves were the methods used. The results of direct closure were equal to those of patch closure. One patient died of subacute bacterial endocarditis, which had been present preoperatively. There were no other deaths. The postoperative observation period was 6 months to 7 years. As the incidence of associated valvulopathy increases with patient age, early operation for supracristal VSD, regardless of shunt volume, is advocated.
Scand J Thorac Cardiovasc Surg 1988
PMID:Surgical treatment of supracristal type of ventricular septal defect. 322 24


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