Evaluation of the preoperative administration of sildenafil on operative and early postoperative outcome after mitral valve replacement in patients with pulmonary hypertension

Background: Mitral valve diseases are commonly associated with pulmonary hypertension. The aim of this study was to evaluate the effect of preoperative administration of sildenafil on the outcome after mitral valve replacement in patients with pulmonary hypertension. Methods: This prospective randomized study was carried out on 67 patients who had a mitral valve replacement and associated high systolic pulmonary artery pressure more than 50 mmHg. Patients were randomized into three groups: group A (n= 20) received preoperative sildenafil for one week, group B (n=22) received sildenafil for one month, and group C (n= 25) did not receive sildenafil. All patients had transthoracic echocardiography preoperatively, one week and one month postoperatively. Results: There was no difference in preoperative and operative variables among groups. Dobutamine support was required in 15 patients (60%) in group C vs. 6 patients (30%) in group A and 5 patients (22.5%) in group B (p= 0.012). Duration of mechanical ventilation was significantly longer in group C (389.2 ± 48.79 minutes) compared to group A and B (295.5 ± 17.01 and 281.4 ± 39.44 minutes, respectively, p<0.001). ICU stay was longer in group C (61.72 ± 13.69 hours) compared to groups A and B (53.55 ± 14.49 and 45.64 ± 13.43 hours, respectively, p=0001). The hospital stay was longer in group C (8.0 ± 1.80 days) compared to group A and B (6.05 ± 0.94 and 6.27 ± 1.24 days, respectively; p< 0.001). The transthoracic echocardiographic study one month after the operation showed that pulmonary artery systolic pressure significantly lower in groups A and B (28.30 ± 3.3 and 28.2 ± 4.98 mmHg, respectively) compared to group C (43.12 ± 4.99 mmHg) (p <0.001). There was no statistically significant difference between groups A and B regarding PASP after five days (p= 0.287) or one month (p= 0.939). Conclusion: We found that preoperative administration of oral sildenafil in patients with pulmonary hypertension undergoing mitral valve replacement may reduce pulmonary hypertension postoperatively. We could not find a difference in the administration of sildenafil for either one week or one month preoperatively.

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In Hospital Outcome of Mitral Valve Replacement with Severe Pulmonary Hypertension

Cardiovascular Journal ◽

10.3329/cardio.v14i1.55371 ◽

2021 ◽

Vol 14 (1) ◽

pp. 30-36

Author(s):

Rubaiya Reza Tumpa ◽

Al Masum Ziaul Haque ◽

Md Kamrul Hasan

Keyword(s):

Pulmonary Hypertension ◽

Mitral Valve ◽

Mitral Regurgitation ◽

Pulmonary Artery ◽

Valve Replacement ◽

Mitral Valve Replacement ◽

Severe Pulmonary Hypertension ◽

Group A ◽

Pulmonary Arterial ◽

Group B

Background: In patients undergoing surgery for mitral valve replacement (MVR) for valvular heart disease, pulmonary artery hypertension (PAH) has been considered a major risk factor. In this prospective study, we have studied the early hemodynamic changes and post-operative outcomes of MVR among patients with mild to severe PAH in Bangladesh perspective. Methods: Total 60 patients who underwent mitral valve replacement for predominantly mitral regurgitation (MR) and mixed lesion with mitral stenosis (MS) having pulmonary arterial hypertension ranging from mild to severe pulmonary artery pressure (PAP) were studied prospectively for immediate postoperative haemodynamic and outcome. The mean age of the patients was 36.23±9.18 years. Total 13 (21.66%) patients had mitral regurgitation and 47 (78.33%) had mixed lesion with mitral stenosis. Patients were divided into two groups based on preoperative pulmonary artery pressures. Group A patients with mild to moderate pulmonary hypertension (PASP 40-59 mm of Hg) and Group B patients with severe pulmonary hypertension (PASPe” 60 mm of Hg). Results: After mitral valve replacement, pulmonary arterial systolic pressure (PASP) decreased significantly in Group A to near normal levels (PASP41.25±7.25). In Group B also the PASP decreased insignificantly (PASP 61.85±9.12) but significant residual PAH remained. Operative mortality was nil (0%) in Group A and 6.7% in Group B. Conclusions: Mitral valve replacement is safe and effective at the presence of PAH as long as the PASP is below or equal to 60 mm of Hg. With PASP >60 mm of Hg, MVR carries a high risk of mortality and the patients continues to have severe PAH in the postoperative period. Cardiovasc j 2021; 14(1): 30-36

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Video-assisted Minimally Invasive Mitral Valve Surgery versus Conventional Mitral Surgery in Rheumatic Patients

The Egyptian Cardiothoracic Surgeon ◽

10.35810/ects.v1i1.113 ◽

2020 ◽

Author(s):

Ayman Badawy ◽

Mohamed Alaa Nady ◽

Mohamed Ahmed Khalil Salama Ayyad ◽

Ahmed Elminshawy

Keyword(s):

Mitral Valve ◽

Minimally Invasive ◽

Valve Replacement ◽

Mitral Valve Replacement ◽

Mitral Valve Surgery ◽

Valve Surgery ◽

Invasive Approach ◽

Video Assisted ◽

Group A ◽

Group B

Background: Minimally invasive mitral valve surgery became an attractive option because of its cosmetic advantages over the conventional approach. The superiority of the minimally invasive approach regarding other aspects is still debatable. The aim of our study was to determine the potential benefits of minimally invasive mitral valve replacement with intraoperative video assistance over conventional surgery. Methods: This is a single-center prospective cohort study that included 60 patients with rheumatic heart disease who underwent mitral valve replacement. Patients were divided into two groups: group (A) included patients who had conventional sternotomy (n= 30), and group (B) included patients who had video-assisted minimally invasive mitral valve replacement (n= 30). Intraoperative and postoperative outcomes were compared between both groups. Results: Mortality occurred in one patient in the group (A). Cardiopulmonary bypass time was 118.93 ± 29.84 minutes vs. 64.73 ± 19.16 minutes in group B and A respectively (p< 0.001), and ischemic time was 102.27 ± 30.03 minutes vs. 53.67± 18.46 minutes in group B and A respectively (P < 0.001). Ventilation time was 2.77± 2.27 vs. 6.28 ± 4.48 hours in group B and A respectively (p< 0.001) and blood transfusion was 0.50 ± 0.63 vs. 2.83 ± 1.34 units in group B and A respectively (p< 0.001). ICU stay was 1.73 ± 0.64 days in the group (B) vs. 4.47 ± 0.94 days in group A (p< 0.001). Postoperative bleeding was 353.33 ± 146.77 ml in the group (B) vs. 841.67 ± 302.03 ml in group A (p <0.001). No conversion to full sternotomy was reported in group B. In group (B), two cases (6.6%) required re-exploration for bleeding vs. four cases (13.2%) in group (A) (p=0.67). The hospital stay was 6.13 ± 1.59 days in the group (B) vs. 13.27 ± 7.62 days in group A (p< 0.001). Four cases (13.3%) developed mediastinitis in group A and in the group (B), there was one case of acute right lower limb embolic ischemia. Conclusion: Video-assisted minimally invasive mitral operations could be a safe alternative to conventional sternotomy with the potential of lesser morbidity and earlier hospital discharge.

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Evaluation of Safety and Efficacy of Combined Low Dose Aspirin and Warfarin Following Mechanical Heart Valve Replacement for Mitral Valve Disease

Bangladesh Heart Journal ◽

10.3329/bhj.v36i1.55514 ◽

2021 ◽

Vol 36 (1) ◽

pp. 24-31

Author(s):

Md Sorower Hossain ◽

Istiaq Ahmed ◽

Sanjay Kumar Raha ◽

Smriti Kana Biswas ◽

Md Kamrul Hasan

Keyword(s):

Mitral Valve ◽

Valve Replacement ◽

Mitral Valve Replacement ◽

Low Dose ◽

Thromboembolic Events ◽

Safety And Efficacy ◽

Dose Aspirin ◽

Low Dose Aspirin ◽

Group A ◽

Group B

Introduction: Warfarin is recommended following mechanical valve replacement to prevent thromboembolic complications. A combination of warfarin and aspirin may further reduce thromboembolic events in these patients. This study was designed to evaluate safety and efficacy of combined low dose aspirin and warfarin therapy following mechanical mitral valve replacement. Materials and Methods: Purposively selected 99 patients who underwent mechanical mitral valve replacement were divided into two groups. Patients of Group A (n=50) received combined low dose aspirin (75mg) and warfarin. Patients of Group B (n=49) received conventional dose of warfarin alone. International normalized ratio (INR) was targeted 1.8-2.4 for group A Patients and 2.5-3.5 for group B Patients. Post-operatively INR, thromboembolic events, anti-coagulation related haemorrhage and other morbidity and mortality were registered in both groups. Result: Patients were followed up postoperatively for 9 months. The mean dose of warfarin in group A and group B was 4.36 ± 0.31 mg and 5.57±0.52 mg respectively (p<0.001). The overall mean INR of two groups of patients were statistically different (P<0.001) with low INR in group A (2.19±0.13) patients compared to group B (3.03±0.31). The thromboembolic events in group A (0.02/patient year) were lower than those in group B (0.08/Patient year). There was no statistically significant (p=0.362) difference in bleeding episodes between two groups but data indicate proportion of minor bleeding manifestations were higher in patients treated with warfarin plus aspirin group. Conclusion: Following mechanical mitral valve replacement, a combination of aspirin (75mg) and low dose warfarin with an aim to maintain INR between 1.8 and 2.4 (lower than recommended 2.5-3.5) may provide satisfactory outcomes in term of thrombosis, embolism and bleeding without increase in mortality. Bangladesh Heart Journal 2021; 36(1): 24-31

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Effect of Nitroglycerin Inhalation on Patients with Pulmonary Hypertension Undergoing Mitral Valve Replacement Surgery

Anesthesiology ◽

10.1097/00000542-200310000-00017 ◽

2003 ◽

Vol 99 (4) ◽

pp. 855-858 ◽

Cited By ~ 28

Author(s):

Nurgul Yurtseven ◽

Pelin Karaca ◽

Mehmet Kaplan ◽

Vedat Ozkul ◽

Abdullah K. Tuygun ◽

...

Keyword(s):

Pulmonary Hypertension ◽

Mean Arterial Pressure ◽

Mitral Valve ◽

Pulmonary Artery ◽

Arterial Pressure ◽

Valve Replacement ◽

Mitral Valve Replacement ◽

Vascular Resistance ◽

Replacement Surgery ◽

Valve Replacement Surgery

Background The aim of this study was to investigate the postoperative hemodynamic effects of nitroglycerin inhalation on patients with pulmonary hypertension undergoing mitral valve replacement surgery. Methods Twenty patients who underwent mitral valve replacement surgery were included in the study. In the surgical intensive care unit, at T0 (before the inhalation of nitroglycerin), basal systemic and pulmonary hemodynamics were recorded. Then, 2.5 microg x kg-1 x min-1 nitroglycerin liquid nebulized by a 2-l gas flow of 40% oxygen and air mixture was administered to the patients who were diagnosed as having pulmonary hypertension (mean pulmonary arterial pressures > 25 mmHg). The same parameters were measured at the first (T1), third (T2), and fifth (T3) hours after the beginning of this treatment and 1 h after the end of nitroglycerin inhalation (T4). Results There were no statistically significant differences at T0, T1, T2, T3, or T4 with respect to heart rate, mean arterial pressure, systemic vascular resistance, cardiac index, mixed venous oxygen saturation, arteriovenous oxygen content difference, or arterial carbon dioxide tension. However, mean pulmonary artery pressure, pulmonary vascular resistance, and intrapulmonary shunt fraction were significantly lower, and the arterial oxygen tension/fraction of inspired oxygen ratio was higher at T1, T2, and T3 when compared to that of T0 and T4. Conclusion The results suggest that nitroglycerin inhalation produces a significant reduction in both mean pulmonary artery pressure and pulmonary vascular resistance in patients after mitral valve operations without reducing mean arterial pressure and systemic vascular resistance. Therefore, it might be a safe and useful therapeutic intervention during the postoperative course.

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Effects of Giant Left Atrium on Thromboembolism after Mitral Valve Replacement

Asian Cardiovascular and Thoracic Annals ◽

10.1177/021849230501300203 ◽

2005 ◽

Vol 13 (2) ◽

pp. 107-111 ◽

Cited By ~ 2

Author(s):

Veysel Kutay ◽

Kaan Kirali ◽

Hasan Ekim ◽

Cevat Yakut

Keyword(s):

Mitral Valve ◽

Left Atrium ◽

Valve Replacement ◽

Mitral Valve Replacement ◽

Hemodynamic Parameters ◽

Group A ◽

Giant Left Atrium ◽

Atrial Fibrillation Group ◽

Group B

The aim of this study was to evaluate the incidence of thromboembolic events in patients with giant left atrium (> 6.5 cm) after mitral valve replacement. From January 2000 to September 2002, a total of 126 patients who had undergone mitral valve replacement were divided into two groups according to the presence or absence of giant left atrium. Group A comprised 34 patients with left atrium over 6.5 cm without compression symptoms and Group B comprised 92 patients. The preoperative variables did not distinguish the patients in each group, except for atrial fibrillation; Group A 85.2% and Group B 61.9% (p < 0.01). After mitral valve replacement, left atrium mean diameter was significantly decreased in Group A from 8.1 ± 1.3 mm to 6.2 ± 1.6 mm ( p < 0.01). There were no significant differences in thrombosis, hemorrhage and thromboembolism rates in both groups. Postoperative clinical and hemodynamic parameters demonstrated a positive clinical response to mitral valve replacement in patients with giant left atrium. During follow-up no direct relationship between thromboembolism and giant left atrium was evident.

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EARLY MORTALITY & MORBIDITY IN MITRAL VALVE REPLACEMENT WITH TOTAL SUB-VALVULAR APPARATUS PRESERVATION, PARTIAL PRESERVATION AND NO PRESERVATION - A COMPARATIVE STUDY

Pakistan Armed Forces Medical Journal ◽

10.51253/pafmj.v70isuppl-4.6006 ◽

2021 ◽

Vol 70 (Suppl-4) ◽

pp. S715-20

Author(s):

Muhammad Ashfaq ◽

Nasir Ali ◽

Asif Mahmood Janjua ◽

Naser Ali Khan ◽

Muhammad Imran Ashgar ◽

...

Keyword(s):

Mitral Valve ◽

Comparative Study ◽

Valve Replacement ◽

Mitral Valve Replacement ◽

Statistical Difference ◽

Armed Forces ◽

Cross Sectional ◽

Group A ◽

Group B ◽

Preservation Technique

Objective: To compare the early morbidity & mortality of total sub-valvular apparatus preservation technique vs partial preservation technique and no preservation technique in mitral valve replacement. Study Design: Cross-sectional comparative study. Place and Duration of Study: Department of Cardiac Surgery, Armed Forces Institute of Cardiology Rawalpindi, from Jan 2017 to Dec 2018. Methodology: One hundred fifty seven patients who underwent Mitral valve replacement were included in study. These patients were divided into three groups; group “A” comprised of those patients with total subvalvular apparatus preservation (n1=46), group “B” comprised of those patients with partial sub-valvular apparatus preservation (n2=70), group “C” comprised of those patients with no sub-valvular apparatus preservation(n3=41). Results: There were no statistical difference in the pre-operative data of the patients. No statistical difference noted in cross clamp & bypass time (p>0.05). The early morbidity in terms of ICU stay, Ventilation time, Inotropic supports, post-operative bleeding, Blood transfusion, postoperative rhythm abnormality & Re-exploration were statically significant (p<0.05). The mortality rate of patients with total sub-valvular apparatus preservation was 2.17% which is significantly less than those with partial preservation (2.85%) & no preservation (9.75%). Conclusions: Mitral valve replacement with total subvalvular apparatus preservation had low postoperative morbidity & mortality in comparison with partial and no preservation techniques.

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Posterior leaflet preservation during mitral valve replacement for rheumatic mitral stenosis

Acta chirurgica iugoslavica ◽

10.2298/aci0601013d ◽

2006 ◽

Vol 53 (1) ◽

pp. 13-17 ◽

Cited By ~ 1

Author(s):

P.L. Djukic ◽

B.B. Obrenovic-Kircanski ◽

M.R. Vranes ◽

M.J. Kocica ◽

A.Dj. Mikic ◽

...

Keyword(s):

Mitral Valve ◽

Valve Replacement ◽

Mitral Valve Replacement ◽

Mitral Stenosis ◽

Posterior Leaflet ◽

Rheumatic Mitral Stenosis ◽

Long Term Follow Up ◽

Group A ◽

Group B

Mitral valve replacement with posterior leaflet preservation was shown beneficial for postoperative left vetricular (LV) performance in patients with mitral regurgitation. Some authors find it beneficial even for the long term LV function. We investigated a long term effect of this technique in patients with rheumatic mitral stenosis. We studied 20 patents with mitral valve replacement due to rheumatic mitral stenosis, in the period from January 1988. to December 1989. In group A (10 patients) both leaflets and coresponding chordal excision was performed, while in group B (10 patients) the posterior leaflet was preserved. In all patients a Carbomedics valve was inserted. We compared clinical pre and postoperative status, as well as hemodynamic characteristics of the valve and left ventricle in both groups. Control echocardiographyc analysis included: maximal (PG) and mean (MG) gradients; effective valve area (AREA); telediastolic (TDV) and telesystolic (TSV) LV volume; stroke volume (SV); ejection fraction (EF); fractional shortening (FS) and segmental LV motion. The mean size of inserted valve was 26.6 in group A and 27.2 in group B. Hemodynamic data: PG (10.12 vs 11.1); MG (3.57 vs 3.87); AREA (2.35 vs 2.30); TDV 126.0 vs 114.5); TSV (42.2 vs 36.62); SV (83.7 vs 77.75); EF (63.66 vs 67.12); FS (32.66 vs 38.25) Diaphragmal segmental hypokinesis was evident in one patient from group A and in two patients from group B. In patients with rheumatic stenosis, posterior leaflet preservation did not have increased beneficial effect on left ventricular performance during long-term follow-up. An adequate posterior leaflet preservation does not change hemodynamic valvular characteristics even after long-term follow-up.

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Preservation of Posterior Mitral Leaflet in Mitral Valve Replacement: Effect on Left Ventricular Geometry with Immediate Outcome.

Cardiovascular Journal ◽

10.3329/cardio.v11i1.38240 ◽

2018 ◽

Vol 11 (1) ◽

pp. 39-41

Author(s):

AKM Manzurul Alam ◽

Monzil Ahmed ◽

Istiaq Ahmed ◽

Mamun Hossain ◽

Mohashin Reza ◽

...

Keyword(s):

Mitral Valve ◽

Ejection Fraction ◽

Valve Replacement ◽

Mitral Valve Replacement ◽

Left Ventricular ◽

Left Ventricular Geometry ◽

Posterior Mitral Leaflet ◽

Group A ◽

Group B

Bcakground: Preservation of the posterior mitral leaflet and subvalvular structures during mitral valve replacement (MVR) preserve left ventricular geometry and function. We evaluated the effect of preservation of subvalvular structures during mitral valve replacement on LV ejection fraction (LVEF).Methods: Total 60 patients were taken and then grouped into group A and group B. Group A include patients of MVR with preservation of posterior leaflet and subvalvular structure, Group B without preservation of subvalvular structures. All patients were evaluated before operation, at discharge, and at 3 months follow-up. Left ventricular function was assessed by ventricular ejection fraction (LVEF).Results: Preoperative LV ejection fraction was 58.3±11.0% and 56.6±8.4% in Group A and Group B respectively. Post-operative mean LVEF at discharge was found 44.2±5.1% in group A and 37.3±4.8% in group B. Observation at three months follow-up showed that mean LVEF was 49.0±4.7% in group A and 39.6±4.7% in group B.Conclusion: Left ventricular function is better maintained when MVR is done preserving posterior leaflet and subvalvular structure.Cardiovasc. j. 2018; 11(1): 39-41

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