ATS
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Juan A. Crestanello
Christopher G. A. McGregor
Gordon K. Danielson
Richard C. Daly
Joseph A. Dearani
Thomas A. Orszulak
Charles J. Mullany
Francisco J. Puga
Kenton J. Zehr
Hartzell V. Schaff
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Crestanello, J. A.
Right arrow Articles by Schaff, H. V.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Crestanello, J. A.
Right arrow Articles by Schaff, H. V.
Related Collections
Right arrow Valve disease

Ann Thorac Surg 2004;78:826-831
© 2004 The Society of Thoracic Surgeons

Original article: Cardiovascular

Mitral and tricuspid valve repair in patients with previous mediastinal radiation therapy

Juan A. Crestanello, MDa, Christopher G. A. McGregor, MDa,*, Gordon K. Danielson, MDa, Richard C. Daly, MDa, Joseph A. Dearani, MDa, Thomas A. Orszulak, MDa, Charles J. Mullany, MDa, Francisco J. Puga, MDa, Kenton J. Zehr, MDa, Cathy Schleck, BSb, Hartzell V. Schaff, MDa

a Division of Cardiovascular Surgery, Mayo Clinic and Mayo Foundation, Rochester, MN, USA
b Division of Biostatistics, Mayo Clinic and Mayo Foundation, Rochester, Minnesota, USA

Accepted for publication April 1, 2004.

* Address reprint requests to Dr McGregor, Mayo Clinic, 200 First St SW, Rochester, MN 55906, USA
mcgregor.christopher{at}mayo.edu

Presented at the Fiftieth Annual Meeting of the Southern Thoracic Surgical Association, Bonita Springs, FL, Nov 13–15, 2003.


   Abstract
Top
 Abstract
Introduction
 Patients and methods
 Results
 Comment
 Discussion
 References
 
BACKGROUND: The purpose of this study was to evaluate outcomes of mitral and tricuspid valve repair after mediastinal radiation therapy.

METHODS: From 1976 to 2001, 22 patients (mean age 61 ± 14 years) underwent mitral (n = 14), tricuspid (n = 6), or both (n = 2) valve repairs 15 ± 9 years after mediastinal radiation therapy. Concomitant procedures included coronary artery bypass graft, 11 patients; valve replacement, 6 patients (4 aortic, 3 mitral, 1 tricuspid, and 1 pulmonary); and pericardiectomy, 4 patients.

RESULTS: Total follow-up was 82.5 patient-years (mean 3.7 ± 3.3 years). Early mortality was 3 patients. There were 7 late deaths, 4 of which were of cardiovascular origin. Of the 19 early survivors, 2 required subsequent valve replacements, and 1 required cardiac transplantation 3.4 ± 2.8 years after valve repair. One patient died after reoperation. In 4 patients who did not undergo reoperation, echocardiographic examinations showed progressive deterioration of their repaired valve function. Overall survival, freedom from cardiac death, and freedom from valve reoperation or cardiac transplantation at 5 years for early survivors was 66%, 85%, and 88%, respectively. New York Heart Association functional class at follow-up was I or II in 8 of the 12 late survivors.

CONCLUSIONS: Functional status was good in two-thirds of late survivors. However, severe dysfunction of the repaired valve developed in 32% of early survivors and 16% required further surgery. Valve repair is technically feasible in selected patients after mediastinal radiation therapy; however, the limited durability of repairs after mediastinal radiation in this series suggests that valve replacement might be preferable.


   Introduction
Top
 Abstract
 Introduction
Patients and methods
 Results
 Comment
 Discussion
 References
 
Mediastinal radiation therapy is associated with significant cardiac morbidity. The effect of mediastinal radiation therapy on the heart includes pericardial disease, conduction disturbances, myocardial fibrosis, coronary artery disease, and cardiac valve disease [1–5]. Cardiac valve disease associated with mediastinal radiation therapy is characterized by valve fibrosis and calcification, often with progression to heart failure and death [2, 5].

In patients with cardiac valve disease and no previous radiation therapy, preservation of the native valve by surgical repair has clear advantages over valve replacement [6–10]. Valve repair is associated with a better outcome in long-term survival, preservation of ventricular function, and freedom from reoperation, thromboembolism, and anticoagulant-associated morbidity [6–10]. It is unknown whether these advantages of valve repair are maintained in patients with radiation-associated cardiac valve disease.

In this study we examine the results of mitral and tricuspid valve repair in patients with previous mediastinal radiation therapy over a 25-year period at a single institution.


   Patients and methods
Top
 Abstract
 Introduction
 Patients and methods
Results
 Comment
 Discussion
 References
 
Databases of patients who had mitral or tricuspid valve repairs at the Mayo Clinic, Rochester, MN, from January 1976 to December 2001 were matched with databases of patients with malignant neoplasms that had been treated by mediastinal radiation therapy. Those malignant neoplasms were breast cancer, lymphoma, lung cancer, esophageal cancer, thymic tumors, and germ cell tumors of the mediastinum.

Twenty-two patients were identified who had mitral or tricuspid valve repairs after mediastinal radiation therapy. For this study, operative notes, anesthesia records, clinical case histories, radiation oncology records, and laboratory investigations including electrocardiogram, echocardiogram, and cardiac catheterization data were retrospectively reviewed. Follow-up data were collected from clinic records of inpatient and outpatient visits and correspondence with patients and referring physicians, focusing on functional status, results of echocardiography, and the status of the patient's malignant disease. A total of 264 clinical, hemodynamic, electrocardiographic, and echocardiographic variables were entered into a computerized database and analyzed.

This study was approved by the Mayo Foundation Institutional Review Board, and patients gave written informed consent.

Preoperative demographic and cardiac data in the 22 patients of this study are detailed in Table 1. Preoperative patient comorbidities associated with radiation therapy are detailed in Table 2.


View this table:
[in this window]
[in a new window]
  		Table 1. Preoperative Patient Characteristics

 

View this table:
[in this window]
[in a new window]
  		Table 2. Preoperative Patient Comorbidities Associated With Mediastinal Radiation Therapy

 
Indications for mediastinal radiation therapy were breast cancer (n = 10), Hodgkin lymphoma (n = 8), and non-Hodgkin lymphoma (n = 4). Total radiation dose was available in 7 patients. The mean dose of radiation was 61 Gy (range of 35 to 126 Gy). The source of radiation is known in only 2 patients (4 MeV and cobalt 16 in 1 patient each). The mean interval between the end of radiation therapy and valve repair was 14.9 ± 9.2 years (range from 40 days to 31 years). Nine patients had undergone concomitant chemotherapy for the treatment of their malignancy.

Valve operations performed and concomitant cardiac procedures are detailed in Table 3. Five patients had a single procedure, 11 had 2, 3 had 3, 2 had 4, and 1 had 5 procedures. Notably, 50% of patients (n = 11) had concomitant coronary artery bypass grafts (CABG).


View this table:
[in this window]
[in a new window]
  		Table 3. Surgical Proceduresa

 
Operative findings in the 16 repaired mitral valves included prolapsed posterior leaflet (n = 10), dilated mitral annulus (n = 9), prolapsed anterior leaflet (n = 4), thickened leaflet tissue (n = 4), rupture of posterior leaflet chordae tendineae (n = 3), elongation of posterior leaflet chordae (n = 2), restricted motion of posterior leaflet (n = 1), annulus calcification (n = 1), posterior leaflet cleft (n = 1), and leaflet perforation (n = 1). It was not possible to differentiate which findings were directly related to radiation damage; to annular dilatation secondary to radiation-induced cardiomyopathy, coronary artery disease, or chronic mitral regurgitation; or to other causes. The 3 patients who had mitral valve replacement had marked thickening and retraction of the leaflet tissue. Tricuspid annular dilatation was the primary pathology in all of the repaired tricuspid valves. Eleven patients had moderate-to-severe mediastinal or pericardial adhesions, or both.

Mitral valve repairs included ring annuloplasty (n = 15), partial resection and plication of the posterior leaflet (n = 10), plication of the anterior leaflet (n = 3), Alfieri repair (n = 3) [11], artificial neochordae insertion (n = 1), and commisural plication (n = 1). Tricuspid valve repairs consisted of annuloplasty ring (n = 5), DeVega annuloplasty (n = 2) [12], and Kay annuloplasty (n = 1) [13].

The surgeon's decision regarding valve repair versus replacement was guided by the concept that all valves should be repaired if technically feasible. In the later cases, valve repair was accepted only if satisfactory valve function was confirmed by intraoperative transesophageal echocardiography.

Statistical methods
Early mortality was defined as death occurring within 30 days of operation or at any time during the operative hospitalization. Late mortality was defined as mortality occurring any time thereafter. The probability of survival was estimated by the Kaplan-Meier method. Survival curves of the patients were compared with the expected curves of persons of the same age and sex, as derived from vital statistics for the west north central region of the United States. Observed versus expected survival and freedom from reoperation were assessed with a one-sample log-rank test. The association of continuous variables with survival and freedom from reoperation and the association of combinations of variables with survival and freedom from reoperation were evaluated with Cox proportional hazards models. Statistical significance was defined as p less than 0.05.


   Results
Top
 Abstract
 Introduction
 Patients and methods
 Results
Comment
 Discussion
 References
 
Early mortality from left ventricular failure occurred in 3 patients (14%), all of whom had concomitant cardiac procedures. One patient had a mitral valve repair and aortic valve replacement; the second patient had a tricuspid valve repair, CABG, and pericardiectomy; and the third patient had a mitral valve repair and CABG.

For the 19 early survivors, the mean duration of stay in the intensive care unit was 4 ± 7 days. The mean duration of hospital stay was 14 ± 14 days (range 6 to 65 days). Early morbidity included prolonged ventilator support (> 72 hours) in 3 patients, all of whom required tracheostomy. Exploration for bleeding was required in 2 patients. No patient had delayed wound healing or sternal wound infection.

In addition to the patient who had received a previous permanent pacemaker, 3 additional patients required permanent pacemakers in the early postoperative period. Late pacemaker insertion was required in 2 additional patients.

Follow-up was complete in all patients. Total follow-up was 82.5 patient-years with a mean of 3.7 ± 3.3 years and a range of 0.8 to 13.2 years. Seven late deaths occurred. Causes of late death were stroke (n = 2), congestive heart failure (n = 1), tricuspid valve thrombosis (n = 1), respiratory failure (n = 1), a new cancer (n = 1), and unknown (n = 1). None of the patients with a known cause of death died from their primary malignancy. No preoperative factor was significantly associated with increased risk of late death. Factors analyzed included preoperative New York Heart Association (NYHA) class IV (p = 0.06), constrictive pericarditis as defined by the need for pericardiectomy (p = 0.06), left ventricular ejection fraction less than 50% (p = 0.14), and concomitant or previous CABG (p = 0.74). Patients who required pericardiectomy had an increased early (1 of 4) and late mortality (2 of 3 early survivors).

Other malignancies developed in 7 patients that were different from the primary malignancy for which radiotherapy was initially done (lymphoma in 2, leukemia in 1, and lung, skin, thyroid, and metastatic squamous cell cancer in 1 patient each).

One-year and 5-year estimated survival of the 19 early survivors was 95% (CI: 80,100) and 66% (CI: 44, 98), respectively (Fig 1). One-year and 5-year expected survival for an age and sex matched population was 98% and 91%. Freedom from cardiac death at 5 years was 85% (CI: 64,100) (Fig 1).



View larger version (15K):
[in this window]
[in a new window]
  		Fig 1. Survival analysis at 5 years (excluding early mortality): expected survival (line A), freedom from reoperation (line B), freedom from cardiac death (line C), and freedom from all causes of death (line D). Numbers in parenthesis are the population at risk for all causes of death. See text for confidence intervals.

 
Three patients required cardiac reoperations. The mean interval to reoperation was 3.4 ± 2.8 years (range 1.3 to 6.6 years). One patient required mitral and tricuspid valve replacement 2.4 years after mitral valve repair. A second patient required mitral and tricuspid valve replacement 6.6 years after mitral and tricuspid valve repair and aortic valve replacement. That patient died from thrombosis of a mechanical tricuspid prosthesis in the early postoperative period. The previously repaired mitral valve leaflets were prominently scarred and retracted in both patients. A third patient had cardiac transplantation for left ventricular failure 1.3 years after mitral valve replacement and tricuspid valve repair. The replaced mitral valve prothesis was intact and mild residual tricuspid regurgitation was noted at the time of heart transplant. Failure of mitral valve repairs was not significantly different between patients with (n = 2 of 7) or without (n = 3 of 7) severe coronary artery disease. Freedom from valve reoperation or cardiac transplantation at 1 year and 5 years was 100% and 88% (CI: 66,100) (Fig 1).

Preoperative factors significantly associated with increased risk of reoperation or cardiac transplantation by univariate analysis were NYHA class IV (p = 0.04) and a left ventricular ejection fraction of less than 50% (p = 0.01). Other factors analyzed included preoperative atrial fibrillation (p = 0.33), time from radiation therapy to surgery (p = 0.46), and concomitant CABG (p = 0.64).

NYHA functional class at the most recent follow-up was available in the 12 late survivors and was class I (n = 7), class II (n = 1), class III (n = 3), and class IV (n = 1). Therefore, 67% of late survivors were in either NYHA functional class I or II at their most recent follow-up.

Echocardiographic data were available in 11 of the 12 late survivors (mean time from surgery 3.8 ± 2.4 years (range 0.5 to 8.2 years). Of the 14 early survivors who had mitral valve repair, 2 had reoperation (1 died) and 12 had no reoperation (3 died). Echocardiographic follow-up of the repaired valve in 8 of the 9 late survivors showed that mitral regurgitation was absent in 1 patient, mild in 4, moderate in 2, and severe in 1.

Of the 7 early survivors who had tricuspid valve repair, 2 required reoperation (1 died) and 5 had no reoperation (3 died). Late echocardiographic follow-up of the repaired valve in the 2 late survivors showed mild tricuspid regurgitation in 1 and severe regurgitation in 1.

The estimated survival, freedom from cardiac death, and freedom from reoperation at 1 and 5 years were not significantly different from those of patients with valve replacements after mediastinal radiation therapy [14] (Table 4). However, late survivors were in different NYHA classes. In the present series, 67% (8 of 12) were in class I or II compared with 93% (25 of 27) of late survivors after valve replacement (p = 0.06, Fischer exact test) [14].


View this table:
[in this window]
[in a new window]
  		Table 4. Comparison of Survivals Between Patients With Cardiac Valve Repairs and Replacements at 1 and 5 Years

 

   Comment
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
Discussion
 References
 
Advances in oncologic therapies have resulted not only in an increased number of long-term cancer survivors, but also in an increased number of patients with long-term adverse effects of those therapies [1, 3, 15, 16]. During radiation therapy for thoracic and chest wall malignancies, normal cardiac and mediastinal tissues are irradiated, which may result in radiation-mediated injury to those structures [3]. Chronic radiation injury is characterized by progressive tissue fibrosis, necrosis, atrophy, and vascular damage that develop over the course of several years after the exposure [17]. The spectrum of mediastinal injury is broad, extending from minor fibrosis to heavy scarring and fusion of mediastinal structures with extensive cardiac and great vessel damage [18].

Radiation-associated cardiac valve disease is present in up to 60% of patients after mediastinal radiation. It is a progressive condition with its prevalence and severity increasing with time after radiation [2]. Most patients are asymptomatic, with valve regurgitation being more prevalent than valve stenosis [2].

Cardiac valve disease from other etiologies may develop in patients who have undergone mediastinal radiation. However, even if the primary pathology for which a patient is operated on is not radiation-induced, the deleterious long-term, progressive effects of radiation are present and will continue to act on the repaired valve. Also, the risks of reoperation on a previously irradiated mediastinum should be considered. In this review, the reoperative mortality was 1 in 3 patients. Measures should be taken to minimize the chances of reoperation. The surgeon should consider all these factors at the time the decision is made on valve repair versus replacement.

Radiation-associated comorbidities in this group of patients were similar to those of patients in our previous study who underwent valve replacements after mediastinal radiation [14]. Coronary artery disease in the present series was found in 55% of the patients in spite of their relatively young age and a high preponderance of women. Constrictive pericarditis was also prevalent in this series. Constrictive pericarditis in the setting of mediastinal radiation is a marker for greater radiation injury to the heart, and it is usually associated with ventricular diastolic dysfunction and high mortality [14]. In this review, patients who required pericardiectomy had an increased early and late mortality, which is consistent with data from previous reports [14, 19, 20].

Radiation damage to the conduction system was also prevalent, with 27% of the patients requiring pacemaker placement. In spite of the known poor healing capabilities of irradiated tissues, no delayed wound healing or incidence of sternal wound infection was observed in this series.

Carcinogenesis is a known long-term complication of radiotherapy and has been associated with almost all types of cancers. Breast, thyroid, and bone marrow are the organs most susceptible to radiation-induced carcinogenesis [17, 21, 22]. In a large series of patients who received radiation therapy for Hodgkin lymphoma, a second primary solid tumor developed in 10%, non-Hodgkin lymphoma and lung cancer being the most common [21]. In the present series, the incidence of second primary cancers (7 of 19 early survivors) was high. Surprisingly, only 1 patient died of a new malignancy. The risk of a second primary cancer after radiotherapy emphasizes the need for lifelong follow-up of patients receiving such treatment.

The main causes of early and late death in this series were cardiovascular. Because of the small sample size, we were not able to identify any factor as a predictor of increased mortality. However, preoperative left ventricular dysfunction, advanced NYHA class, and atrial fibrillation are known to be predictors of early and late mortality in larger series of patients with organic mitral regurgitation undergoing mitral valve repair [6–10] and in patients undergoing mitral valve replacement after mediastinal radiation therapy [14]. Therefore, for all patients with radiation-associated valvular heart disease, early operation is recommend before left ventricular dysfunction, congestive heart failure, or atrial fibrillation develops.

The mitral valve was more commonly repaired than the tricuspid valve. Mitral valve repair is the procedure of choice to treat mitral valve regurgitation of multiple etiologies [6–10]. In general, mitral valve repair provides a lower operative mortality, a better long-term survival, better preservation of left ventricular function, and improved freedom from endocarditis and anticoagulant-related complications than mitral valve replacement, [6–10]. However, these advantages of repair over replacement were not substantiated in this review of patients who had previous mediastinal radiation therapy; survival and freedom from reoperation were similar to those of patients who had undergone mitral valve replacement after previous mediastinal radiation therapy. In addition, of the 9 patients who had no reoperations, 3 had recurrent moderate-to-severe mitral regurgitation.

With the possible exception of tricuspid regurgitation associated with pulmonary hypertension, most surgeons prefer to treat tricuspid regurgitation with valve repair rather than replacement [23]. However, in the current series of patients with radiation-associated tricuspid regurgitation, tricuspid valve repair was associated with poor early and late results. Early and late mortality was high, 2 of 7 early survivors required reoperation, and severe regurgitation recurred in 1 of the 2 late survivors.

Although no significant difference was evident between the estimated survival, freedom from cardiac death, and freedom from reoperation at 1 and 5 years in this series compared with patients with valve replacement after mediastinal radiation therapy, there was an important difference in NYHA functional class I and II for late survivors. The smaller percentage of patients in class I or II in this series may be explained in part by the high incidence of late valve failure (4 of 10) in the repaired valves of patients who did not undergo reoperation.

The choice of valve prosthesis should be made after consideration of the usual patient and prosthesis characteristics. As late survival is limited for many patients after reoperation for radiation-associated cardiac valve disease, a bioprosthesis may have advantages over a mechanical valve for some patients.

The present study is observational with a relatively small number of patients and a relatively small number of adverse events. These characteristics limit the power of this study to detect differences and risk factors associated with adverse outcomes. However, these results on the outcome of mitral and tricuspid valve repair after mediastinal radiation therapy are important, because with the increasing number of long-term cancer survivors and the aging of the population, this will be an increasingly common situation. This study spans a long period of time (25 years) over which the techniques of valve repair were developed and perfected. Increased experience and feasibility in repair procedures may change the conclusions of this study in the future.

In conclusion, valve repair after mediastinal radiation therapy was associated with good functional status in two-thirds of late survivors. However, the durability of valve repair was limited, as severe dysfunction of the repaired valve developed in 6 of 19 early survivors (32%) and 3 of 19 (16%) required further surgery. Progressive deterioration of irradiated valve function was not necessarily halted with surgical repair. Progression of coronary artery disease and myocardial and valve fibrosis can result in progressive deterioration of cardiac valve function irrespective of a successful initial repair [14, 17]. Valve repair is technically feasible in selected patients after mediastinal radiation therapy. However, the limited durability of repairs after mediastinal radiation in this series suggests that valve replacement might be preferable.


   Discussion
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Discussion
References
 
DR STEVEN BOLLING (Ann Arbor, MI): A very nice paper on a very difficult group of patients. We have an overall number of about 32 patients like this, of which in 22 we felt the anterior leaflet was too short to make the repair. The deciding process for us was the ability to have that anterior leaflet cover the disk size of the appropriately selected ring for the repair. If not, we put an anterior patch in, and we made that patch basically as big as possible so that it would billow and go up. So we have 10 patients who are out there where the repair, without a patch, was satisfactory.

What decision-making process did you see in these patients whether you could repair or replace and, what was the pathology of the underlying process?

You had a number of redos come back. Was it continued retraction of these leaflets? Our fear is both in the radiation patients and in these young rheumatic patients, that there is a continued pathologic process that retracts the leaflets. That is why we went to an anterior repair in almost all of them. So what do you use as your deciding factor? Is it the length of the leaflets, as we do? It can't cover the disk? Very nice paper. Thank you.

DR CRESTANELLO: Thank you for your questions, Dr Bolling. The surgeon's decision regarding valve repair versus valve replacement was guided by the concept that all valves should be repaired if technically feasible. In the later cases in this series, valve repair was accepted only if satisfactory valve function was confirmed by intraoperative transesophageal echocardiography. There was a wide spectrum of valve pathology including prolapsed posterior and/or anterior mitral leaflets, dilated mitral and/or tricuspid annuli, thickened leaflets, and ruptured chordae tendineae.

As you said in your question, this is a progressive disease, so the radiation-induced changes in the valvular apparatus may continue in spite of surgical repair. Reoperations in this group of patients are difficult and are associated with high mortality.

In the patients who came back for reoperation after mitral valve repair, marked thickening and retraction of the leaflet tissue and annular dilatation were the most common findings. Radiation not only involves the valves, but it also involves the coronary arteries, the myocardium, the conduction system, and the pericardium. As the whole heart is involved in radiation-associated cardiac disease, it seems less likely that valve repairs will be as durable as they are for degenerative valves, and this is what the results of our study suggest.


   References
Top
 Abstract
 Introduction
 Patients and methods
 Results
 Comment
 Discussion
 References
 

  1. Adams MJ, Hardenbergh PH, Constine LS, Lipshultz SE. Radiation-associated cardiovascular disease. Crit Rev Oncol Hematol. 2003;45:55–75[Medline]
  2. Heidenreich PA, Hancock SL, Lee BK, Mariscal CS, Schnittger I. Asymptomatic cardiac disease following mediastinal irradiation. J Am Coll Cardiol. 2003;42:743–749[Abstract/Free Full Text]
  3. Gyenes G, Rutqvist LE, Liedberg A, Fornander T. Long-term cardiac morbidity and mortality in a randomized trial of pre- and postoperative radiation therapy versus surgery alone in primary breast cancer. Radiother Oncol. 1998;48:185–190[Medline]
  4. Lederman GS, Sheldon TA, Chaffey JT, Herman TS, Gelman RS, Coleman CN. Cardiac disease after mediastinal irradiation for seminoma. Cancer. 1987;60:772–776[Medline]
  5. Veinot JP, Edwards WD. Pathology of radiation-induced heart disease: A surgical and autopsy study of 27 cases. Hum Pathol. 1996;27:766–773[Medline]
  6. Mohty D, Orszulak TA, Schaff HV, Avierinos JF, Tajik JA, Enriquez-Sarano M. Very long-term survival and durability of mitral valve repair for mitral valve prolapse. Circulation. 2001;104(Suppl 1):I1–I7
  7. Ling LH, Enriquez-Sarano M, Seward JB, et al. Early surgery in patients with mitral regurgitation due to flail leaflets: a long-term outcome study. Circulation. 1997;96:1819–1825[Abstract/Free Full Text]
  8. Enriquez-Sarano M, Schaff HV, Orszulak TA, Tajik AJ, Bailey KR, Frye RL. Valve repair improves the outcome of surgery for mitral regurgitation. Circulation. 1995;91:1264–1265[Free Full Text]
  9. Tribouilloy CM, Enriquez-Sarano M, Schaff HV, et al. Impact of preoperative symptoms on survival after surgical correction of organic mitral regurgitation: rationale for optimizing surgical indications. Circulation. 1999;99(3):400–405[Abstract/Free Full Text]
  10. Braunberger E, Deloche A, Berrebi A, et al. Very long-term results (more than 20 years) of valve repair with Carpentier's techniques in nonrheumatic mitral valve insufficiency. Circulation. 2001;104(suppl I):I8–11
  11. Maisano F, Torracca L, Oppizzi M, et al. The edge-to-edge technique: a simplified method to correct mitral insufficiency. Eur J Cardiothorac Surg. 1998;13:240–246[Abstract/Free Full Text]
  12. DeVega N. La anuloplastia selectiva regulable y permanente. Una técnica original para el tratamiento de la insuficiencia tricuspidea. Rev Esp Cardiol. 1972;25:555–560[Medline]
  13. Kay JH, Maselli-Campagna G, Tsuji HK. Surgical treatment of tricuspid insufficiency. Ann Surg. 1965;162:53–58[Medline]
  14. Handa N, McGregor CG, Danielson GK, et al. Valvular heart operation in patients with previous mediastinal radiation therapy. Ann Thorac Surg. 2001;71(6):1880–1884[Abstract/Free Full Text]
  15. Reinders JG, Heijmen BJ, Olofsen-van Acht MJ, van Putten WL, Levendag PC. Ischemic heart disease after mantlefield irradiation for Hodgkin's disease in long-term follow-up. Radiother Oncol. 1999;51:35–42[Medline]
  16. Vallis KA, Pintilie M, Chong N, et al. Assessment of coronary heart disease morbidity and mortality after radiation therapy for early breast cancer. J Clin Oncol. 2002;20:1036–1042[Abstract/Free Full Text]
  17. Stone HB, Coleman NC, Anscher MS, McBride WH. Effect of radiation on normal tissue: consequences and mechanisms. Lancet Oncol. 2003;4:529–536[Medline]
  18. Hancock SL, Tucker MA, Hoppe RT. Factors affecting late mortality from heart disease after treatment of Hodgkin's disease. JAMA. 1993;270:1949–1955[Abstract/Free Full Text]
  19. Ling LH, Oh JK, Schaff HV, et al. Constrictive pericarditis in the modern era. Evolving clinical spectrum and impact on outcome after pericardiectomy. Circulation. 1999;100:1380–1386[Abstract/Free Full Text]
  20. Handa N, McGregor CGA, Daly RC, et al. Heart transplantation for radiation-associated end-stage heart failure. Transpl Int. 2000;13:162–165[Medline]
  21. Vlachaki MT, Ha CS, Hagemister FB, et al. Long-term outcome of treatment for Ann Arbor stage 1 Hodgkin's disease: patterns of failure, toxicity and second malignancies. Int J Rad Onc Biol Physics. 1997;39:609–616
  22. Holm LE. Cancer occurring after radiotherapy and chemotherapy. Int J Rad Onc Biol Physics. 1990;19:1303–1308
  23. Schaff HV, Marsh DH. Multiple valve disease. Cohn L, Edmunds LH Jr. Cardiac Surgery in the Adult. New York, NY: McGraw-Hill; 2003. p. 1017–1045



This article has been cited by other articles:


Home page
 J. Thorac. Cardiovasc. Surg.Home page
A. S.Y. Chang, N. G. Smedira, C. L. Chang, M. M. Benavides, U. Myhre, J. Feng, E. H. Blackstone, and B. W. Lytle
Cardiac surgery after mediastinal radiation: Extent of exposure influences outcome
J. Thorac. Cardiovasc. Surg., February 1, 2007; 133(2): 404 - 413.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Juan A. Crestanello
Christopher G. A. McGregor
Gordon K. Danielson
Richard C. Daly
Joseph A. Dearani
Thomas A. Orszulak
Charles J. Mullany
Francisco J. Puga
Kenton J. Zehr
Hartzell V. Schaff
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Crestanello, J. A.
Right arrow Articles by Schaff, H. V.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Crestanello, J. A.
Right arrow Articles by Schaff, H. V.
Related Collections
Right arrow Valve disease

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS