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OBJECTIVES: Time testing is essential with any valvular procedure, especially when a new concept is introduced such as the mitral stentless valve. Our purpose is to evaluate the results obtained over 4 years with this operation, particularly to attest the impact of preservation of annulo ventricular continuity on the long term results of these patients. METHODS: From March 1992 to August 1996, 120 patients had their mitral valves replaced with a porcine stentless mitral valve. The observation period was 54 months with total patients follow-up of 3424 months with a mean of 28.5 months. The age ranged from 11 to 72 years (mean 35.22 +/- 14.98). There were 73 females (60.8%) and 47 males (39.2%). The predominant etiology was rheumatic heart disease. Associated procedures were performed in 12 patients (10%), and the great majority of the patients were in functional class III and IV (NYHA). RESULTS: Hospital mortality occurred in seven patients (5.83%) non valve related except for one early case of endocarditis. Early reoperation related to technical failure were necessary in 4 patients without mortality. Follow-up was accomplished in 101 patients and ranged from 2 to 54 months. Late reoperations were required in 16 patients (nine due to mitral insufficiency, five because of endocarditis and two for mitral stenosis). Most reoperations were related to technical failure. Among the 82 patients presently in control, 72 showed a competent mitral stentless valve, eight with stable mild mitral regurgitation and in two a decreased mitral orifice. Hemodynamic performance of the valve has been excellent in this group, particularly in patients with left ventricular dysfunction. CONCLUSION: Although technical complexity remains the main cause of reoperations with this valve, experience has shown that it not only provides preservation of the left ventricular function but also promised significant increase of the ejection fraction in patients with poor left ventricular function.

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A surgical approach to the mitral valve is very important to visualize all valvular and subvalvular structures. We have used a transversal trans-septal biatrial approach in some mitral procedures. From January 1994 to May 1994, 11 patients were operated on using this technique. Patient ages ranged from 28 to 74 years. Five cases (45.5%) were cardiac reoperations and six (54.5%) were first operations. Three case (27.3%) were mitral reconstructions, 3 (27.3%) were mitral replacement due to mechanical mitral valve thrombosis, 1 (9.1%) as a result of bioprosthetic mitral valve degeneration, 4 (36.4%) were mitral valve replacements for calcified mitral valve disease one case (9.1%) was tricuspid valve replacement due to severe tricuspid insufficiency. There were 4 case (36.4%) of tricuspid valvuloplasties besides the mitral procedures. There was no operative mortality, and all patients preserved their preoperative cardiac rhythm. No important bleeding or supra-ventricular arrhythmias were seen in any case. Aortic cross-clamping and extracorporeal circulation times were comparable with the traditional approach through the left atrial alone. So, we think that this is a very easy and useful technique to expose the mitral valve during some procedures above it, overall when the left atrium is small and total visualization of the mitral is not possible with the traditional approach through the left atrial alone.

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Introduçao: após estudo experimental de implante de material biológico e carbono em átrio esquerdo e aorta, foi desenvolvida uma nova prótese, primeira válvula de carbono feita inteiramente no País. A finalidade foi conseguir uma válvula de sistema mecânico durável, de boa aceitaçao orgânica para facilitar a cicatrizaçao a partir do anel e isolar o máximo de material sintético da corrente sangüínea; o objetivo é conseguir menores índices de morbidade e mortalidade, alterando a história natural da prótese mecânica em relaçao a trombose, tromboembolismo, reoperaçoes e menor uso de anticoagulante. Material e Métodos: a válvula é do tipo disco basculante perfurado, fabricada em Carbolite (carbono polimérico endurecido).O anel apresenta haste com pino central para guiar e reter a movimentaçao do disco, batente e dois pinos para limitaçao do grau de abertura. O anel tem perfuraçoes para fixaçao do material biológico (pericárdio e veia). O conjunto é colocado entre dois anéis lisos acoplados revestidos de Poliester com aba de sutura externa. O batente tem aspecto denteado, formando plataformas onde se apóia o disco e entre os dentes existe continuidade do revestimento biológico. A prótese é toda revestida, exceto o pino, o disco, as plataformas do batente e a face interna do orifício menor. A prótese foi testada em duplicador de pulso em teste equivalente a dez anos, sem desgaste aparente com disco de carbono e poliacetal. Cada prótese, antes do implante, é testada individualmente durante cinco dias a 1.000 pulsaçoes por minuto com pressao média de 12 cmHg. Entao, é feita limpeza, esterilizaçao, revestimento de material biológico processado em glicerina, montagem e esterilizaçao final em formol ou gás ETO (conservaçao em glicerina). Existem 7 pacientes mitrais em observaçao com tempo médio de 7,8 meses (mínimo de 4 meses e máximo de 13 meses), sendo mantidos com anticoagulaçao oral. Resultados iniciais: como o número de pacientes é pequeno, destacam-se apenas algumas observaçoes iniciais: ausência de tromboembolismo, ausência de disfunçao mecânica primária, ocorrência de dois acidentes hemorrágicos maiores e um episódio de trombose em paciente com dois meses de evoluçao, por anticoagulaçao inadequada, com reoperaçao e mantendo a mesma prótese com achado de depósito difuso de fibrina e boa evoluçao após dez meses. Conclusoes: os resultados dos testes mecânicos do material e da válvula e os aspectos clínicos iniciais sao favoráveis, devendo-se ampliar a casuística, com proteçao anticoagulante mais efetiva e uniforme nos três primeiros meses. Após três meses, a presença do material biológico e as baixas doses de anticoagulante parecem ser eficientes no controle das complicaçoes pós-operatórias da válvula mecânica, contra a trombose, o tromboembolismo e os acidentes hemorrágicos.

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Se estudiaron con ecocardiografía, once pacientes sometidos a autotransplante de la válvula pulmonar a posición aórtica, con colocación de prótesis de pericardio bovino en posición valvular pulmonar. En todos se efectuó un ecocardiograma transtorácico previo a la cirugía. Durante el procedimiento quirúrgico se efectuó ecocardiograma transesofágico. Los estudios transtorácicos ayudaron a confirmar la viabilidad de esta cirugía. Los estudios transesofágicos ayudaron en la evaluación postquirúrgica inmediata. La ecocardiografía transtorácica y transesofágica son de utilidad para la evaluación pre, trans y post operatoria de pacientes sometidos a cirugía de Ross

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From March 1992 to August 1993, 50 patients underwent mitral valve replacement with the new heterologous stentless mitral bioprosthesis in our institution. The development of this heart valve substitute, its technique of implantation and the results observed in the first group of 50 patients have had us to review the initial experience. The surgical protocol included an accurate mitral valve complex analysis, adequate valve size selection, attachment of the papillary muscle to the new chordal origin and approximation of the stentless mitral to the patient's annulus. There was one hospital death (2%), not related to the valve or to the technique and four reoperations: two due to endocarditis, one because of a perivalvular leak and one due to a mismatched stentless valve. The late mortality (4%) was not valve-related. The follow-up has shown excellent valve performance with improved left ventricular function in the great majority of the patients. Based on the current analysis, it can be stated that reproducibility of the surgical technique and the excellence of the clinical follow-up may contribute favorably to a better quality of life and longer valve durability in patients requiring mitral heart valve replacement.

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In 12 patients with sinus rhythm (including 5 children and 6 young women), mitral valve replacement was performed with a microporous-surfaced valve similar to the Björk-Shiley Monostrut. After the first 3 months, permitting endothelialization of the suture ring to continue over the groove and adjacent metal valve ring, no long-term anticoagulant treatment was given. There was no thromboembolic complication in this group during follow-up for 6-8 years, during which four women gave birth to a total of seven children. In eight other cases, one mitral case with atrial fibrillation, anti-coagulant was not discontinued, and in the remaining aortic cases it was reinstituted. One of them (with atrial fibrillation) had hematuria during inadequate anticoagulant medication, but no thromboembolism. Of five patients with only aortic valve replacement, two had thromboembolic complications, one without residual symptoms and one with slight hand weakness. Another had a transient ischemic attack while on anticoagulant and acetylsalicylic acid was added. Two patients with aortic and mitral valve replacement died, one from heart tamponade and the other from venous thrombosis with pulmonary embolism.

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LA infusión de solución cardiopléjica por vía anterógrada tiene una demostrada efectividad protectora del miocardio durante la cirugía cardiaca. Sin embargo, en presencia de enfermedad coronaria grave, reoperaciones e hipertrofia ventricular esta efectividad puede ser limitada. Por otra parte, en cirugía valvular, interfiere con el desarrollo expedito dela operación. En estas circunstancias, la infusión retrógrada de solución cardiopléjica permite una mejor distribución de ésta en el miocardio. En 42 pacientes (32 hombres) operados entre septiembre de 1991 y septiembre de 1992 se utilizó para la protección del miocardio la infusión retrógrada solución cardiopléjica cristaloide, exclusiva o adicionada a la infusión anterógrada, a través de la canulación transauricular derecha del seno coronario, con un catéter especialmente diseñado. Veintidós casos correspondieron a revascularizaciones miocárdicas, y 20, a procedimientos valvulares. Nueve pacientes (21 por ciento ) tenían una disfunción ventricular severa, 8 estaban cursando un infarto miocárdico, y 7 casos fueron reoperaciones. No hubo ningún caso de infarto perioperatorio electrocardiográfico, pero 2 pacientes (4,8 por ciento ) presentaron elevación de CPK-MB significativa para injuria miocárdica. Once pacientes (26 por ciento ) requirieron inótropos en el postoperatorio (dopamina y/o dobutamina en 9 casos). Ninguno requirió balón de contrapulsación. No hubo morbilidad relacionada con la canulación del seno coronario ni con la infusión retrógrada de solución cardiopléjica. No hubo mortalidad hospitalaria. En esta experiencia inicial, la canulación transauricular derecha del seno coronario permite la infusión retrógrada de solución cardiopléjica en forma simple y efectiva, ofreciendo una buena protección miocárdica

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