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Ann Thorac Surg 2003;76:659
© 2003 The Society of Thoracic Surgeons
a Université de Sherbrooke, CHUS, Sherbrooke, Quebec J1H 5N4 Canada
e-mail: javier.teijeira{at}usherbrooke.ca
To the Editor:
Our favorable long-term (13-year) experience with the Omniscience valve [1] was contrasted by results published by Edwards and associates [2]. Unusually high rates of valve thrombosis, thromboembolism, and hemorrhage (1.30, 2.90, and 4.67 %/patient-year, respectively) were reported by those authors for patients with mitral valve replacement. In contrast, our results (University of Sherbrooke, two surgeons) were strikingly lower (0.4, 0.7, and 1.0 %/patient-year, respectively). In addition to references cited by Edwards and associates [2], Damle and colleagues [3] reported similarly favorable results in a 6-year study from four Canadian centers. Our low thromboembolism and hemorrhage rates may primarily result from careful patient management (0.5% lost). Our heart valve clinic methodically educates each patient and, being a university hospital in a smaller city, patients are followed-up regularly by our cardiologists, their family physicians, and us.
Edwards and associates [2] also reported a large number of cases (17) of limited disc excursion (with no apparent interference) and observed the disc to "stick at angles of less than 50 degrees." We did not observe such disc sticking; however, we observed two cases with unusually high Doppler echocardiography pressure gradients that were unexplainable at reoperation (valves removed). Later, a study by Vandervoort and coworkers [4] revealed the potential of gradient overestimation in mechanical prostheses by Doppler echocardiography. Also, less than maximal opening of the Omniscience valve has been attributed to atrial fibrillation and short strokes [5]. Under those conditions, or from heart failure unrelated to the valves, it is reasonable to expect partial opening in mechanical prostheses.
Although we currently preserve the posterior leaflet apparatus, this was not done in our Omniscience valve series (implanted between 1982 and 1989). Our technique at that time included complete mitral valve excision and annular debridement. Omniscience mitral prostheses were oriented with the larger orifice toward the posterior wall. Care was taken to choose the smaller size whenever possible to guard against oversizing. This technique could have contributed to fewer complications in patients with mitral valve replacement. The preferences of Edwards and associates [2] regarding preservation of the posterior leaflet, valve orientation, and sizing were not clear.
Those authors reported that 73% of Omniscience patients were New York Heart Association class I or II postoperatively, compared with 94% in our group. There is subjectiveness of New York Heart Association classification; however, their patient population included a remarkably higher percentage (19.4%) of repeat valve replacements in the mitral valve replacement group (compared with 9.7% in our patients). Those patients usually have advanced heart disease. Our patient group, now 20 years since the first implantation, continues to enjoy good quality of life.
References
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