We present a case study of a 54-year-old patient with a perforated aneurysm of the anterior mitral valve leaflet, diagnosed 13 years after an episode of bacterial endocarditis by transesophageal echocardiography. This report illustrates the superiority of transesophageal echocardiography in the diagnosis and management of valvular endocarditis.

How to cite: Christiaens, L., Coisne, D., Allal, J., Mergy, J., & Barraine, R. (1992). Perforated aneurysm of the anterior mitral leaflet: late assessment with transesophageal echocardiography. The Journal of heart valve disease, 1(2), 260–261.

The use of a totally anatomical mitral valve heterograft as a mitral valve substitute has been proven to be technically feasible. A new stentless mitral porcine heart valve substitute was therefore developed to match the physiology and flow characteristics of the left ventricle and mitral valve complex, and tested in non-survival animal experiments. Having sought the approval of the Hospital Ethics Committee and the consent of each individual patient, this valve was implanted into 18 patients with diseased mitral valves. The duration of the procedure is approximately the same as for standard mitral valve replacement. The sizing of the valve and the anchoring of the sutures to the papillary muscle, although very straightforward, do require adherence to a protocol. The immediate clinical results are encouraging, although the first patient required a reoperation because of a patient/valve mismatch. All patients, including the patient reoperated, are in functional class I after four to 26 weeks of follow up. The patients will be followed by monthly clinical and Doppler echocardiographic examinations, as they have been so far, for the next 12 months, and annually thereafter.

How to cite: Vrandecic, M., Gontijo, B. F., Fantini, F. A., Gutierrez, C., Silva, J. A., Barbosa, J. T., & Andrade, C. A. (1992). Anatomically complete heterograft mitral valve substitute: surgical technique and immediate results. The Journal of heart valve disease, 1(2), 254–253.

Between 15th June 1991 and 15th August 1992, 40 patients underwent aortic valve replacement with the newly designed Edwards stentless aortic bioprosthesis 2500. The patients' ages ranged from 24 years to 80 years (mean 60.3 years). Preoperatively, 17 patients presented with pure aortic stenosis, three with aortic regurgitation and 20 with mixed lesion. The operations were performed with normothermic extracorporeal cardiopulmonary bypass and cold cardioplegic arrest. The implanted valves ranged in diameter from 21 mm to 27 mm. Ten patients received a subcoronary implantation, with the lower row of sutures being interrupted and the upper being continuous. The so-called miniroot technique was used in the other 30, also involving lower interrupted and running upper sutures after adaptation of the coronary ostia to the preformed openings in the graft. The aortic cross-clamp time ranged from 51 minutes to 94 minutes (mean 71 minutes). There was no operative mortality but three patients died early after the operation due to cardiac tamponade, sepsis and pneumonia. There was no late mortality or morbidity in the surviving patients up to 16 months postoperatively. Echocardiography, performed at discharge and twice a year thereafter showed no signs of significant valve incompetence in any patient, and continuous wave Doppler measurements indicated that resting pressure gradients across the aortic valve were low or absent. Our preliminary experience with the stentless aortic xenograft shows improved hemodynamic function as compared to stent mounted xenografts or mechanical prostheses. Further studies are needed, however, to establish the long-term performance of this device.

How to cite: Konertz, W., Hamann, P., Schwammenthal, E., Breithardt, G., & Scheld, H. H. (1992). Aortic valve replacement with stentless xenografts. The Journal of heart valve disease, 1(2), 249–252.

The Toronto SPV is a Dacron covered stentless porcine aortic prosthesis used for aortic valve replacement (AVR). We implanted this valve in 53 patients with a mean age of 58 years. The predominant valve lesion was aortic stenosis in 39 patients, insufficiency in 13 and a failed bioprosthesis in one. Six patients also had mitral valve disease and 18 had coronary artery disease. There was one operative death. Patients have been followed for four to 58 months, mean 27 months. There have been two late deaths but neither one was valve related. The actuarial survival at four years was 92% +/- 5%. Two patients required reoperation for reasons other than failure of the stentless aortic valve. There have been no thromboembolic complications. No patient had had infective endocarditis. Doppler echocardiographic assessment of the stentless valve revealed excellent effective valve areas and low transvalvular gradients. A few patients developed mild aortic insufficiency after implantation of the valve, but this problem has been practically eradicated by correct sizing of the prosthesis. AVR with the Toronto SPV provides excellent functional and hemodynamic results. This bioprosthesis seems to be associated with an extremely low rate of valve related complications. These findings justify its continued use, but further follow up is needed to determine its durability.

How to cite: David, T. E., Bos, J., & Rakowski, H. (1992). Aortic valve replacement with the Toronto SPV bioprosthesis. The Journal of heart valve disease, 1(2), 244–248.

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How to cite: Parker J. (1992). Stentless aortic valve xenografts--a real advance?. The Journal of heart valve disease, 1(2), 242–243.

The goal of the autologous tissue heart valve (ATHV) prosthesis project has been the development of a non-antigenic, non-calcifying bioprosthesis of greater durability than heterograft or homograft bioprostheses. It is made in the operating room, at a sterile work bench, during surgery for heart valve replacement. Autologous pericardium is used for valve construction after a five minute immersion in 0.6 per cent glutaraldehyde buffered to pH 7.4 with phosphate. The stent-mounted trileaflet prosthesis can be made in five minutes with a semi-automated method that uses two concentric mating stents that substitute clamping for sewing of the tissue. In vitro testing, to include pulse duplicator, accelerated wear tester, static testing for leakage and tensile strength testing, has been performed with ATHVs made with glutaraldehyde-tanned bovine and ovine pericardium. Transvalvular pressure gradients were measured at 3.3-7.3 mmHg at flow rates of 4-5 l/min. Six valves have been tested beyond 800,000,000 cycles with full opening and closing at differential closing pressures of 125 mmHg. One of the valves developed a 2mm leaflet tear after 26,000,000 cycles but the remaining five survived intact. No fractures were seen in the Dacron covered Delrin stents. Six ATHVs were implanted in juvenile sheep for five months. One animal died after five months of infective endocarditis secondary to an unrecognized deep wound infection and the other five were electively sacrificed at the same time interval. Four valves were fully competent at terminal elective cardiac catheterization and one showed minimal insufficiency attributed to a paravalvular leak. The leaflet tissue was free of generalized calcification in all instances. There was no evidence of leaflet tissue thickening or shrinkage. The mean calcium content at necropsy of the 15 leaflets from the five valves was 8.357 mg/g of tissue. There is experimental evidence that an ATHV made of pericardium treated briefly with glutaraldehyde may achieve the goal of a non-calcifying, more durable bioprosthesis.

How to cite: Love, J. W., Schoen, F. J., Breznock, E. M., Shermer, S. P., & Love, C. S. (1992). Experimental evaluation of an autologous tissue heart valve. The Journal of heart valve disease, 1(2), 232–241.

A consecutive series of 188 Mitroflow pericardial bioprostheses were inserted in 166 patients between 1st January 1983 and 31st December 1985. Twenty-two valves had to be removed from 16 patients after a mean follow up period of 78 months (range 58-92 months) for aortic, 73 months (65-79 months) for mitral and 78 months (48-103 months) for double valve replacements. All but one reoperations for primary tissue failure were carried out as elective surgical procedures. The most important cause of failure was collagen degeneration, seen in all explanted valves. The areas of degeneration were the major sites of origin of calcification, which was seen in 11 valves (50%). Ten valves (45%) showed features suggestive of lipid infiltration, extensive fatty acid deposition being identified in one and a typical atheromatous reaction in another. In contrast to the Ionescu-Shiley valve, the mode of failure was tear originating at the top of the commissure, associated with major structural changes in the tissue. Excessive pannus ingrowth was observed in 11 valves (50%). The universal presence of tissue degeneration in the glutaraldehyde treated pericardial leaflets of the Mitroflow bioprostheses explanted and examined in this study questions the adequacy of the methods employed in the harvesting and/or processing and/or preservation of this valve. We have, therefore, discontinued using the Mitroflow bioprosthesis. However, the slow deterioration of the Mitroflow bioprosthesis permits elective reoperation; preventive removal of functioning valves is therefore not indicated.

How to cite: Leandri, J., Bertrand, P., Mazzucotelli, J. P., & Loisance, D. (1992). Mode of failure of the Mitroflow pericardial valve. The Journal of heart valve disease, 1(2), 225–231.

Bovine pericardium has been widely employed as a xenograft tissue for the manufacture of bioprosthetic valve substitutes. Early three-leaflet valve models showed poor tissue preservation and shortcomings in valve design, which accounted for tissue wear and prosthesis failure due to cuspal tear. Reducing the number of cusps in the unicusp pericardial valve has proved unsuccessful due to stretching of the single pericardial leaflet with consequent valvular incompetence. The new generation of pericardial xenografts present basic changes in valve design and optimal tissue preservation after industrial processing, with no evidence of leaflet tear at medium term follow up. However, clinical experience is limited and, similarly to porcine xenografts, dystrophic calcification still appears to be a major problem.

How to cite: Valente, M., Minarini, M., Ius, P., Talenti, E., Bortolotti, U., Milano, A., & Thiene, G. (1992). Durability of glutaraldehyde-fixed pericardial valve prostheses: clinical and animal experimental studies. The Journal of heart valve disease, 1(2), 216–224.

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How to cite: Frater, R. W., & Bodnar, E. (1992). Towards understanding the pericardium as valve substitute. The Journal of heart valve disease, 1(2), 213–215.

Percutaneous mitral commissurotomy using the Inoue balloon was performed in seven pregnant women between May 1990 and November 1991. The mean age of the group was 31.5 years (range 28-35 years). The mean gestation time was 29 weeks (range 20-38 weeks). All patients presented with severe symptoms; two had a recent history of pulmonary oedema, the rest exhibited marked shortness of breath, and mild exercise and paroxysmal nocturnal dyspnea. All were in sinus rhythm. Two patients had previously undergone closed mitral valvulotomy five and 14 years before their recent hospitalization. Echocardiographic examination revealed severe mitral stenosis, with the mitral valve area being less than 1.2 cm2 in all but one patient. None of the patients had left atrial thrombi or mitral regurgitation as seen on two-dimensional and Doppler echocardiography. Four patients (two with restenosis) had severe lesions of the subvalvular apparatus with thickening and marked shortening of the chordae, as assessed by echocardiography. Successful percutaneous mitral valvulotomy was completed in all seven patients using 25-28 mm Inoue balloons. There was one, transient maternal complications. Fetal complication did not occur. It is concluded that percutaneous, transseptal, mitral balloon valvulotomy during pregnancy with the Inoue balloon is a safe procedure, which can be recommended for suitable clinical cases.

How to cite: Ruzyllo, W., Dabrowski, M., Woroszylska, M., & Rydlewska-Sadowska, W. (1992). Percutaneous mitral commissurotomy with the Inoue balloon for severe mitral stenosis during pregnancy. The Journal of heart valve disease, 1(2), 209–212.

Based on our experience and the experience of others, the following classification of patients with mitral valve prolapse has been proposed. Mitral valve prolapse - Anatomic includes patients with a wide spectrum of mitral valve abnormalities from mild to severe. Symptoms, physical findings and laboratory abnormalities in these patients are directly related to mitral valve dysfunction and progressive mitral regurgitation. Complications related to abnormal mitral valve include infective endocarditis, thromboembolic events, cardiac arrhythmias, progressive mitral regurgitation, rupture of chordae tendineae and congestive heart failure. Individuals with thick mitral leaflets and mitral systolic murmur are at higher risk of developing complications. The term mitral valve prolapse syndrome refers to the occurrence of symptoms such as palpitation, chest pain, fatigue, poor exercise tolerance, dyspnea, orthostatic phenomena and syncope or presyncope in patients with mitral valve prolapse which cannot be explained on the basis of mitral valve abnormality alone. The pathogenesis of these symptoms in patients with mitral valve prolapse syndrome appears to be related to metabolic neuroendocrine abnormalities. Preventing infective endocarditis is a major consideration in patients with mitral valve prolapse. Significant mitral regurgitation with the development of congestive heart failure often requires mitral valve surgery. The most important therapeutic approach in patients with mitral valve prolapse syndrome is to explain the mechanisms of symptoms and to reassure the patient.

How to cite: Boudoulas H. (1992). Mitral valve prolapse: etiology, clinical presentation and neuroendocrine function. The Journal of heart valve disease, 1(2), 175–188.

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How to cite: Barlow J. B. (1992). Idiopathic (degenerative) and rheumatic mitral valve prolapse: historical aspects and an overview. The Journal of heart valve disease, 1(2), 163–174.

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How to cite: Barlow J. B. (1992). Idiopathic (degenerative) and rheumatic mitral valve prolapse: historical aspects and an overview. The Journal of heart valve disease, 1(2), 163–174.

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How to cite: Shah P. M. (1992). Mitral valve prolapse--the elusive definitions and differing criteria of diagnosis. The Journal of heart valve disease, 1(2), 160–162.

The United Kingdom Heart Valve Registry project began in 1986 following discussions between the Department of Health (DOH) and the Society of Cardiothoracic Surgeons of the United Kingdom and Ireland. The intention was to establish a computerized database for valve replacement operations carried out in the UK Health Service cardiac units. This paper describes the experience gained over the first five years of this project. Around 30,000 patients were entered in the registry between 1986 and 1990. All Uk Health Service cardiac surgical units contribute their data, which is processed by the central Registry Office. The accuracy of the mortality data is ensured by tracking the registered patients through the Office of Population Census and Surveys (OPCS). The pattern of valve replacement surgery over the period 1986-90 revealed several interesting trends. Although the number of procedures remained static at around 5,000 valve transplants per year, the number of aortic replacements increased and the number of mitrals decreased. The use of prosthetic valves increased from 54% in 1986 to over 70% in 1990. The mean age of the patients increased from 58.31 years in 1986 to 60.97 years in 1990, with over 22% of the valve replacement operations in 1990 being performed on patients over 70 years of age. The five year survival rate for patients over 70 years at the time of the valve implant is significantly lower than for patients under 70 years (p < 0.005).

How to cite: Taylor, K. M., Gray, S. A., Livingstone, S., & Brannan, J. J. (1992). The United Kingdom Heart Valve Registry. The Journal of heart valve disease, 1(2), 152–159.

The purpose of randomization is to provide unbiased estimates of treatment effects and valid probability statements for hypothesis tests in comparative studies. Difficulties with randomized allocation of patients in surgical studies include: patient selection--due to protocol limitations, possible changes in referral patterns, the need for patient consent, and physician co-operation; disruption of the patient-physician relationship; static protocol not responsive to changes as surgical skill evolves and experience regarding patient selection is acquired; the larger number of patients required causes a longer study and more patients receiving what may be a worse therapy. Moreover, for evaluating a new heart valve, the primary purpose should be estimation rather than comparison with a current device. This can be accomplished faster, in a more generalizable way and with more concern for patient care by using non-randomized comparison groups.

How to cite: Grunkemeier, G. L., & Starr, A. (1992). Alternatives to randomization in surgical studies. The Journal of heart valve disease, 1(2), 142–151.