Cengiz TÜRKAY, Atalay METE, İsa AK, Ömer BAYEZİD, İlhan GÖLBAŞI, Bülent ÇELİK

Romatizmal mitral kapak cerrahisinde reoperasyon sonuçlarımız

Kliniğimizde romatizmal mitral kapak hastalığı nedeni ile ikinci kez ameliyat edilen hastalar ile ilgili detay sunulacak ve erken dönem sonuçları bildirilecektir. Ocak 1993 ve Ocak 1998 tarihleri arasında, daha önce romatizmal mitral kapak hastalığı nedeni ile ameliyat edilmiş olan 59 hasta ikinci kez ameliyat edildi. İlk ameliyat ile ikincisi arasındaki süre ortalama 10.8±2.9 yıldır. İlk ameliyatta bu hastaların 35'ine (%59.3) kapalı mitral valvotomi, 17'ine (28.9) açık mitral valvotomi, 5 hastaya (%8.5) all carbon tilting disk protez kapak, 2 hastaya (%3.3) biyoprotez kapak implantasyonu yapılmıştı. Hastalara ameliyat sırasında kan transfüzyonunu azaltmaya yönelik olarak 560 mg aprotinin verildi ve ototransfüzyon uygulandı. Aort kros klemp süresinin kısa olmasına özen gösterildi. İlk 24 saatte ortalama drenaj miktarı 252.4±66.1 ml ve tranfüze edilen eritrosit süspansisyonu miktarı ortalama 1.2 ± 0.6 ünite oldu. Preoperatif fonksiyonel kapasitesi klas II ve III olan hastalar ve akut bakteriyel endokardit nedeni ile ikinci kez ameliyat edilenlerde, erken ve geç dönemde mortalite olmadı. Buna karşılık fonksiyonel kapasitesi klas IV olan iki hasta (%3.3) postoperatif erken dönemde kaybedildi. Kan korumaya yönelik önlemler, total myokardiyal koruma, peroperatif efor kapasitesini iyi olması, iyi bir cerrahi zamanlama reoperatif kapak cerrahisinin mortalite ve morbiditesini azaltır.

Our results on the rheumatic mitral valve reoperations

We present the details and early period results of the patients, with reoperated rheumatic mitral valve disease. Between January, 1993 and January, 1998, 59 patiens, had a second operation for rheumatic mitral disease. The average interval between their first and second operations was 10.8±2.9 years. At their first operation, closed mitral valvotomy in 35 patients (59.3), open mitral valvotomy in 17(28.9), allcarbon tilting disc prosthesis valve implantation in mitral position in 5(8.5%) and bioprosthesis valve implantation in mitral position in 2 (3.3%) had been done. All patiens were administered 560 mg of aprotinin to reduce blood transfusion besides autotransfusion during the operations. We expressly shortened the short aortic crossclamp duration. Within the postoperative 24 hours, while the average drainage volume was 252.4±66.1 ml, the average erytrocite suspansion volume to be tranfused indicated 1.2±0.6 units. No mortality was registered during either early or late stages in patiens with class II, III preoperative functional capacity and also in patients with acute bacterial endocarditis indication, whereas two patients (3.3%), in functional class IV, died postoperatively within the early period. Blood conservation, total myocardial protection, good timing and a good preoperative effort capacity are the factors which may reduce mortality and morbidity.

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1. Duran CG. Reoperations on the mitral and tricuspid valves. Stark J, Pacifico A.D; Reoperations in Cardiac Surgery, Springer-Verlag 1989.
2. Cohn LH, Aranki SF, Rizzo RJ, et al. Decrease in operative risk of reoperative valve surgery. Ann Thorac Surg 1993; 56: 15-21.
3. Lytle BW, Cosgrove DM, Taylor PC, et al. Reoperations for valve surgery: perioperative mortality and determinants of risk for 1.000 patients, 1958-1984. Ann Thorac Surg 1986; 42: 632-643.
4. Bidstrup BP, Royston D, Sapsford RN, Taylor KM. Reduction in blood loss use after cardiopulmonary bypass with high dose aprotinin (Trasylol). J Thorac Cardiovasc Surg 1989; 97: 364-72.
5. Jamieson WR, Dryden PJ, O′ Connor JP, Sadeghi H, ansley DM, Merrick PM. Beneficial effect of both tranexamic acid and aprotinin on blood loss reduction in reoperative valve replacement surgery. Circulation 1997; 96(9 Suppl): II-II96100.
6. Gundry SR, Razzouk AJ, Vigesaa RE, Vang N, Bailey LL. Optimal delivery of cardioplegic solution for redo operations. J Thorac Cardiovasc Surg 1992; 103: 896-901.
7. Braxton JH, Higgins RS, Schwann TA, et al. Reoperative mitral valve surgery via right thoracotomy: decrease blood loss and improved hemodynamics. J Heart Valve Dis 1996; 5(2): 169-73.
8. Antunes MJ, Magalhaes MP. Isolated replacement of a prosthesis or a bioprothesis in the mitral valve position. Am J Cardiol 1987; 59: 346-9.
9. Stewart S, DeWeese JA. The determinants of survival following reoperation on prosthetic cardiac valves. Ann Thorac Surg 1978; 25: 555.
10. Miller DC, Oyer PE, Stinson EB, et al. Ten to fifteen year reassessment of the perfomance characteristics of the Starr-Edwards Model 6120 mitral valve prosthesis. J Thorac Cardiovasc Surg 1983: 85; 1.
11. Ivert TSA, Dismukes WE, Cobbs CG, et al. Prosthetic valve endocarditis. Circulation 1984; 69: 223.
12. Jung JY, Saab SB, Almond CH. The case for early surgical treatment of left-sided primary infective endocarditis: A collective review. J Thorac Cardiovasc Surg 1975; 70: 509-518.
13. Wilcox BR. The role of surgery in the management of infective endocarditis. Roberts AJ; Difficult problems in cardiac surgery, Year Book Medical Publishers, Inc. Chica, 1985.
14. Larbalestier RI, Kinchla NM, Aranki SF, Couper GS, Collins JJ Jr, Cohn LH. Acute bacteriel endokarditis: Optimizing surgical results. Circulation 1992; 86 (suppl 2): 68-74.
15. Cohn LH, Koster JK, Vandevanter S, Collins JJ Jr. The in-hospital risk of re-replacement of disfunctional mitral and aortic valves. Circulation 1982; 66 (Suppl 1): 153-6.
16. Messmer BJ, okies JE, Hallman GL, Cooley DA. Mitral valve replacement with the Björk-Shiley tilting-disc prosthesis. J Thorac Cardiovasc Surg 1971; 62:938-46.
17. Vitale N, Paparella D, Ranieri VM, et al. Survival despite almost complete fibrous obstruction of a Sorin tilting- disc mitral prosthesis. Tex Heart Inst J 1996; 23: 167-9.
18. De Luca L, Vitale N, Giannolo B,et al. Mid-term follow up after heart valve replacement with Carbomedics bileflet prosthesis. J Thorac Cardiovasc Surg 1993; 106: 1158-65.
19. Arom KV, Nicoloff DM, Kestern TE, et al. Ten years experience with ST. Jude Medical valve. Ann Thorac Surg 1989; 47: 831-7.
20. Keenan RJ, armitage JM, Trento A, et al. Clinical experience with Metronic Hall valve prostehisis. Ann Thorac Surg 1990; 50: 758-63.
21. Klepetko W, Moritz A, Leaflet fracture in Duromedics-Edwards bileaflet valves. J Thorac Cardiovasc Surg 1989; 97: 90-4.
22. Moreno-Cabral RJ, Mc Namar JJ, mamiya RT, et al. Acuet thrombotic obstruciton with Björk-Shiley valves: diagnostic and surgical considerations. J Thorac Cardiovasc Surg 1978; 75: 321-9.
23. Kontos GJ, Schaff HV, Orszulak TA, et al. Thrombotic obstruction of disc valves. Ann Thorac Surg 1989; 48: 60-5.
24. Vitale N, Renzuli A, Cerasuolo F, et al. Prosthetic valve obstruction: Thrombolysis versus operation. Ann Thorac Surg 1994; 57: 365-70.
25. Lytle BW, Cosgrove DM, Loop FD, et al: Replacement of aortic valve combined with myocardial revascularization: determinants of early and late risk for 500 patients, Circulation 1983; 68: 1149.
26. Lytle BW, Cosgrove DM, Gill CC, et al: Mitral valve replacement combined with myocardial revascularization: early and late results for 300 patients, 1970 to 1983. Circulation 1985; 71: 1179.