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How to cite: Fundaro, P., Marchetto, G., Moneta, A., Donatelli, F., & Grossi, A. (2000). Chordal shortening: a technique to be set aside?. The Journal of heart valve disease, 9(5), 738–739.

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How to cite: Légaré, J. F., & Ross, D. B. (2000). The aortic valve blood supply. The Journal of heart valve disease, 9(5), 736–738.

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How to cite: Rabago G. (2000). Eighteen-year follow-up after Hancock II bioprosthesis insertion. The Journal of heart valve disease, 9(5), 736.

Acquired left ventricle-to-right atrium communications are a known complication of valvular heart surgery. Previous reports have described the clinical features and diagnosis using cardiac catheterization. We report two cases of acquired left ventricle-to-right atrium fistula following mitral valve replacement. Particular emphasis is placed on the diagnosis using transthoracic and transesophageal echocardiography, obviating the need for cardiac catheterization before repair.

How to cite: Benisty, J., Roller, M., Sahar, G., Paz, R., Vidne, B., & Sagie, A. (2000). Iatrogenic left ventricular-right atrial fistula following mitral valve replacement and tricuspid annuloplasty: diagnosis by transthoracic and transesophageal echocardiography. The Journal of heart valve disease, 9(5), 732–735.

Background and aim of the study: Our previous studies of bileaflet mechanical heart valves (MHV) explanted from sheep revealed patterns of localized platelet aggregation on valve surfaces, which may have clinical relevance. Since flow phenomena may promote localized platelet aggregation, an evaluation of flow within a valve lumen was conducted.

Methods: Phase-locked particle image velocimetry (PIV) measurements were obtained within the lumen of a 'mitral' model bileaflet MHV with transparent acrylic leaflets and housing, in a pulsatile flow loop. Instantaneous, two-dimensional flow maps of a central plane, perpendicular to the flow and leaflet pivot axes, were obtained at discrete times during the simulated cardiac cycle. Flow conditions were cardiac output, 3.5 l/min; rate, 72 beats/min; and systolic duration, 300 ms, using blood analog fluid refractive index-matched to acrylic. Leaflet closing velocities and angles were found using double-exposure imagery, and maximum leaflet closing velocity was extrapolated from regression analysis.

Results: During full opening, flow within the three lumenal orifices formed a three-peak axial velocity profile. Vorticity was concentrated in shear layers adjacent to downstream leaflet surfaces and in downstream wakes. Forward flow peak velocity was 90 cm/s, with a steep velocity gradient in the central orifice. During closing, the central-gap regurgitant flow formed a jet (peak velocity, 144 cm/s). High vorticity occurred near leaflet leading and trailing edges. During full closure, first a transient (<3 ms) 'stopping vortex' developed near the leaflet trailing edge, followed by a wall jet which formed at the leaflet-housing junction. Maximum leaflet closing velocity was 1.4 m/s.

Conclusion: Localized jets, steep velocity gradients, high vorticity and vortex recirculation have been observed in vitro near model MHV surfaces. In vivo, each of these flow phenomena, when occurring near valve surfaces, may promote localized platelet aggregation. For the acrylic leaflets, maximum velocity was comparable with results reported for pyrolytic carbon leaflets. PIV of fully transparent models is a promising method for evaluating lumenal flows.

How to cite: Subramanian, A., Mu, H., Kadambi, J. R., Wernet, M. P., Brendzel, A. M., & Harasaki, H. (2000). Particle image velocimetry investigation of intravalvular flow fields of a bileaflet mechanical heart valve in a pulsatile flow. The Journal of heart valve disease, 9(5), 721–731.

Background and aim of the study: The current standard of in vitro and in vivo preclinical heart valve testing has recently been questioned because of its failure to reveal the thrombogenic potential of the Medtronic Parallel prosthetic valve. The aim of this study was to develop a swine model for the in vivo preclinical evaluation of mechanical heart valves, and to assess the ability of this model to identify mechanical heart valve design features that result in valve-related thrombosis.

Methods: Twenty-two swine underwent mitral valve replacement (MVR) using three different bileaflet mechanical valve designs (St Jude Medical, CarboMedics, Medtronic Parallel). Each animal was placed in an anticoagulation protocol (group I, INR 3.0-3.5; group II, INR 2.0-2.5; group III, no anticoagulation) and followed for up to 20 weeks. Terminal studies were performed on all animals surviving for more than 30 days.

Results: Twenty-one animals survived the immediate postoperative period. Four of six group I animals died from hemorrhagic (large wound hematoma; hemopericardium) complications early in the study. In the two long-term (61 and 89 days) survivors, INRs of 3.0 to 3.5 were never achieved (61-day survivor, mean INR 2.0 +/- 1.03; range: 0.8-5.4; 89-day survivor, mean INR 1.92 +/- 1.34; range: 1.0-7.9). Pathological analysis of explants from group I survivors revealed minimally obstructive fibrous sheathing on the inflow orifice without restriction of bileaflet motion (61 and 89 days), and two large perivalvular defects (61 days). Six of seven group II animals died from early hemorrhagic complications (hemopericardium) (mean INR 2.32 +/- 1.84; range: 0.8-8.2). Vegetations resulting in obstruction of both sides of the valve orifice and restriction of bileaflet motion were observed in a group II survivor (mean INR 2.33 +/- 1.58; range: 0.9-7.0). Group III animals (n = 8) survived for a mean of 106 +/- 60 days (range: 1-177 days). In group III, fibrous sheathing was present on all explanted valves and organized thrombi in six valves; orifice obstruction (seven valves) and restriction of bileaflet motion (three valves) were also observed.

Conclusion: The use of MVR in swine as a preclinical model to evaluate the safety and performance of mechanical heart valves is limited by: (i) difficulty in maintaining safe levels of anticoagulation with warfarin, resulting in a high incidence of hemorrhagic complications; (ii) marked fibrous sheath formation and associated thrombosis; and (iii) an increased incidence of perivalvular defects, believed to result from normal somatic growth occurring in young swine.

How to cite: Grehan, J. F., Hilbert, S. L., Ferrans, V. J., Droel, J. S., Salerno, C. T., & Bianco, R. W. (2000). Development and evaluation of a swine model to assess the preclinical safety of mechanical heart valves. The Journal of heart valve disease, 9(5), 710–720.

Background and aim of the study: Early diagnosis of infective endocarditis is important for clinical outcome, as mortality increases if diagnosis is delayed. Diagnosis is based on clinical features, echocardiography and blood culture findings, but negative blood cultures have been reported in 5-15% of proven cases. The study aim was to investigate serum cytokine levels in patients with infective endocarditis, and the possible use of these data in diagnosis and monitoring of the disease.

Methods: The study group comprised 40 patients with acquired rheumatic valvular heart disease and ongoing infective endocarditis. A diagnosis of infective endocarditis was established by clinical examination, echocardiography, laboratory investigations (inflammatory parameters) and positive blood cultures (n = 34). Two control groups included patients with acquired rheumatic valvular heart disease: 15 without infective endocarditis, and 15 with active urinary tract infection with significant bacteriuria. Serum interleukin-1alpha (IL-1alpha), interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha) levels were measured on three occasions during antimicrobial treatment (mean period 14 +/- 7 days).

Results: Serum IL-1alpha and TNF-alpha levels were not elevated in the study group, or in controls (IL-1alpha <3.9 pg/ml; TNF-alpha <10 pg/ml). Serum IL-6 levels were elevated on all occasions in patients with infective endocarditis (first measurement: 37.0 +/- 44.3 pg/ml; second 18.7 +/- 16.4; third 8.5 +/- 5.2) with a significant tendency to decrease during treatment (p <0.01, ANOVA). In all controls without infection the serum IL-6 concentrations were below calibration range (<3.2 pg/ml). In the control group with active urinary tract infection, IL-6 concentrations were slightly (but not significantly) elevated (4.49 +/- 1.82 pg/ml, p = NS).

Conclusion: Elevated serum IL-6 levels may suggest ongoing infective endocarditis and might be used to aid in diagnosis and monitoring of treatment of the disease. Serum IL-1alpha and TNF-alpha levels were not affected. A further understanding of the role of serum cytokine concentrations in the diagnosis, prognosis and monitoring of infective endocarditis might be valuable in clinically uncertain diagnoses, especially when blood cultures are negative.

How to cite: Rawczynska-Englert, I., Hryniewiecki, T., & Dzierzanowska, D. (2000). Evaluation of serum cytokine concentrations in patients with infective endocarditis. The Journal of heart valve disease, 9(5), 705–709.

Background and aim of the study: The study aim was to determine risk factors for operative mortality, recurrent infection, reoperation and long-term survival following aortic valve replacement (AVR) for infective endocarditis.

Methods: Between 1973 and 1997, 109 patients (91 male, 18 female, mean age 52.6 years) underwent isolated AVR for infective endocarditis in our unit. Native valve endocarditis was present in 89 (81.6%) and prosthetic valve endocarditis in 20 (18.4%). Active culture-positive endocarditis was present in 53 (48.6%). Preoperatively, 99 patients (90.8%) were in NYHA classes III and IV. Indications for surgery included cardiac failure in 41 patients, valvular dysfunction in 38, vegetations in 18, sepsis in seven, abscess in six and embolism in four. Mechanical valves were implanted in 69 patients (63.3%) and bioprostheses in 40 (36.7%), including a homograft in 19 (17.4%). Follow up was complete (mean 5.8 years; range: 0-23.8 years; total 633.5 patient-years).

Results: The operative mortality was 10.1% (11 deaths). At ten years, freedom from recurrent infection was 94.2%, and freedom from reoperation 83.6%. Biological valve and younger age were significant adverse parameters for freedom from reoperation (p = 0.01 and p = 0.01). There have been 21 late deaths, 15 due to cardiac causes. Kaplan-Meier survival, including operative mortality, at five and ten years was 77.4% and 68.0%, respectively. On Cox proportional hazards regression, Staphylococcus aureus infection (p = 0.008) and older age (p = 0.04) were independent adverse predictors of survival.

Conclusion: AVR for endocarditis carries a relatively high operative mortality, but can result in a satisfactory freedom from recurrent infection, reoperation and long-term survival. Analysis of our series demonstrates that implantation of a biological valve limits the freedom from reoperation and that infection by Staph. aureus reduces the probability of long-term survival.

How to cite: Langley, S. M., Alexiou, C., Stafford, H. M., Dalrymple-Hay, M. J., Haw, M. P., Livesey, S. A., & Monro, J. L. (2000). Aortic valve replacement for endocarditis: determinants of early and late outcome. The Journal of heart valve disease, 9(5), 697–704.

Background and aim of the study: The CarboMedics 'Top-Hat' aortic valve prosthesis has been specifically designed for supra-annular implantation. The aim of this study was to assess the safety of implantation of this prosthesis by reporting the short-term results of follow up.

Methods: Between May 1993 and May 1998, 128 patients (mean age 62.5 +/- 9.8 years; range: 22-76 years) received a CarboMedics 'Top-Hat' prosthesis at our institution. Among patients, 55% were in NYHA functional classes III or IV, and 54.7% had an isolated aortic valve replacement. Associated procedures were: coronary artery bypass grafting (25.7%), double valve replacement (17.1%), treatment of ascending aortic aneurysm (4.7%) and miscellaneous (5.5%). Follow up was 100% complete; total cumulative follow up was 265 patient-years (pt-yr) (range: 2-60 months).

Results: The overall mortality rate was 1.5% (two deaths). The operative mortality rate was 0.8% (one death); this patient died from neurological complications after operation for aortic dissection. The other patient died on postoperative day 40 from a massive cerebral hemorrhage. Four patients presented thromboembolic events; in all cases these were reversible ischemic neurologic deficits. One patient had a nonstructural deterioration (endocarditis) and required reoperation. Freedom from mortality was 98.3% at five years (linearized rate of 0.75%/pt-yr). Freedom from thromboembolism was 63.1% at five years (linearized rate 1.5%/pt-yr).

Conclusion: Short-term results with the CarboMedics 'Top-Hat' prosthesis were satisfactory, with low rates of morbidity and mortality. As this prosthesis has demonstrated a good reliability to date, we have continued its implantation in our institution, and long-term follow up will be necessary to confirm these good early results.

How to cite: Binuani, P., Baufreton, C., Subayi, J. B., & de Brux, J. L. (2000). The CarboMedics 'Top-Hat' aortic valve prosthesis: short-term results. The Journal of heart valve disease, 9(5), 693–696.

Background and aim of the study: The Ultracor valve is a recent introduction in the evolution of the tilting disc valve. This report summarizes a single surgeon's experience with the valve in the aortic position over a nine-year period.

Methods: Between 1990 and 1999, 94 patients received an Ultracor heart valve prosthesis in the aortic position. Forty-five patients (48%) had associated procedures, of which 32 (34%) were coronary artery grafts. Mean follow up was 2.6 years; total follow up was 229 patient-years. Follow up was 100% complete.

Results: The actuarial survival rate, including operative mortality rate, at five years was 82%. Actuarial freedom from valve-related death was 96% at five years. The linearized complication rate was 1.7%/year for late valve-related mortality, 1.7%/year for thromboembolism, 2.2%/year for anticoagulant-related hemorrhage (ACH), 1.3%/year for prosthetic valve endocarditis (PVE), and 1.7%/year for reoperation. The estimates of actuarial freedom from complications at five years were thromboembolism 89%, ACH 90%, PVE 96% and reoperation 96%. No structural failure or valve thrombosis was observed.

Conclusion: Our experience over nine years showed the Ultracor heart valve prosthesis in the aortic position to be comparable with other currently evaluated mechanical heart valves in terms of durability and clinical results. Further study in this area should concentrate on the impact of valve type on left ventricular recovery post-implantation to provide additional information to the surgeon when selecting a valve from the plethora of choices available.

How to cite: Sin, Y. K., Campbell, K., & Pillai, R. (2000). The Ultracor tilting disc heart valve prosthesis in the aortic position: mid-term follow up. The Journal of heart valve disease, 9(5), 688–692.

Background and aim of the study: The bileaflet St. Jude Medical mechanical prosthesis has been implanted for over 20 years. The purpose of this study was to evaluate the clinical performance of the bileaflet CarboMedics (CM) prosthesis, which was introduced in 1986.

Methods: The CM prosthesis was implanted in 1,258 patients (709 males, 549 females; mean age 60.9 +/- 12.3 years) between 1989 and 1997. The prosthesis distribution was aortic valve replacement (AVR) 613; mitral valve replacement (MVR) 447; and multiple replacement (MR) 231. Coronary artery bypass (CAB) was performed in 334 (26.6%) patients; previous procedures had been performed in 346 (27.5%). The age distribution was <60 years (n = 527), 61-70 years (n = 424) and >70 years (n = 307). Risk factors assessed were age or age groups, gender, CAB, previous surgery, rhythm, valve position, status and NYHA functional class. The total follow up was 4,765.0 patient-years (pt-yr), and was 98.4% complete.

Results: The early mortality rate was 5.6% (AVR 4.8%, MVR 3.7%, MR 11.5%). The late mortality rate was 3.7%/pt-yr (n = 174), and valve-related mortality 1.1%/pt-yr (n = 50). The total thromboembolism (TE) rate was 4.1%/pt-yr (n = 195) (p = NS by valve position); the major TE rate was 1.9%/pt-yr and fatal TE rate 0.31%/pt-yr (n = 15). The valve thrombosis rate was 0.31%/pt-yr (n = 15; 11 MVR, four MR). The fatal thrombosis rate was 0.06%/pt-yr (n = 3; two MVR, one MR). The hemorrhage rate was 2.7%/pt-yr (n = 128) and fatal hemorrhage rate 0.4%/pt-yr (n = 20). The reoperation rate was 1.0%/pt-yr (n = 46), fatal 0.1%/pt-yr (n = 5). The actuarial freedom from overall TE at eight years was 77.3 +/- 2.8%; major TE 88.5 +/- 1.6%, and hemorrhage 76.4 +/- 3.2% (all p = NS by valve position). There were no independent predictors of overall TE and TE exclusion of early events. The only predictor for TE major was status (emergency > urgent > elective). The actuarial freedom from valve-related mortality at eight years was 91.4 +/- 1.8% (p = NS by position) (actual freedom 93.0 +/- 1.3%). The actuarial freedom from valve-related reoperation was 91.1 +/- 2.4% (p <0.05; AVR > MVR and MR, MVR > MR) (actual freedom 92.2 +/- 2.7%). Overall survival rate at eight years was 68.2 +/- 2.3% (p <0.05; AVR > MVR and MR, MVR > MR).

Conclusion: The clinical performance of the CarboMedics mechanical prosthesis is satisfactory when implanted in the mitral, aortic and multiple positions.

How to cite: Jamieson, W. R., Fradet, G. J., Miyagishima, R. T., Henderson, C., Brownlee, R. T., Zhang, J., & Germann, E. (2000). CarboMedics mechanical prosthesis: performance at eight years. The Journal of heart valve disease, 9(5), 678–687.

Background and aim of the study: The optimum material for heart valves bioprostheses remains in dispute. We have created a biological valve made from hepatic Glisson's capsule and named 'Bioglis'. Experimental studies have shown the major characteristics of the 'Bioglis' valve to be equivalent to, and in some cases superior to, those of traditional valves made from xenopericardial tissue. We present the first experience of the 'Bioglis' valve use in surgical treatment of Ebstein's anomaly.

Methods: Twelve consecutive patients (age range: 7-48 years) with Ebstein's anomaly who underwent surgery between 1997 and 1999 were reviewed. A 'Bioglis' valve was implanted in all cases; two patients underwent repeat surgery because of incompetence of a previously implanted xenopericardial valve. The 'Bioglis' valve was formed, using a flexible frame, from the hepatic Glisson's capsule of bull calves. Short-term results at between two and 10 weeks after surgery were analyzed. Valvular function of the implanted 'Bioglis' valve was monitored by echocardiography.

Results: The implanted 'Bioglis' valve diameter ranged from 31 to 33 mm. There were no in-hospital deaths or complications. Echocardiography showed good function of the bioprostheses. Consequent peak and mean pressure gradients across the biological valve ranged from 3 to 7 mmHg and from 1.2 to 2.3 mmHg, respectively. Valve insufficiency occurred in one patient, but was minimal.

Conclusion: Preliminary results with the 'Bioglis' support our recommendation of this new biological valve for clinical use.

How to cite: Bockeria, L. A., Kagramanov, I. I., Kokshenev, I. V., Chiaureli, M. R., Gadzhiev, A. A., Mitina, I. N., Zaets, S. B., & Ruzmetov, M. S.h (2000). Immediate results of the 'Bioglis' valve use in the surgical treatment of Ebstein's anomaly. The Journal of heart valve disease, 9(5), 674–677.

Background and aims of the study: Currently available bioprosthetic mitral valves do not provide sufficient durability. A new stentless pericardial prosthesis was designed for better hemodynamic performance and reduction of stress load compared with current stented bioprostheses.

Methods: Between September 1997 and August 1999, the Quadrileaflet mitral valve (QMV) was implanted in 17 patients at our institution. Four patients had minimally invasive mitral valve replacement. Mean patient age was 62.2 +/- 16.3 years; preoperative NYHA class was 3.06 +/- 0.2; ejection fraction was 64.1 +/- 14.7%. Echocardiography was performed pre-, intra- and postoperatively, and at 3-6, 12 and 24 months follow up.

Results: Fifteen patients had an uneventful intra- and postoperative course. Two patients died, one from acute left heart failure at 6 h after surgery, and one on the first postoperative day after resuscitation for ventricular fibrillation. A small-sized prosthesis was implanted in four patients, medium-sized in eight and large-sized in five. The mean duration of cardiopulmonary bypass was 138.3 +/- 37.0 min; mean cross-clamp time was 91.3 +/- 26.3 min. Postoperative control echocardiography showed a mean valve orifice area of 2.5 +/- 0.4 cm2, transvalvular velocity (Vmax) was 1.6 +/- 0.4 m/s, and mean pressure gradient 3.6 +/- 2.0 mmHg. Echocardiographic evaluation after 3, 6 and 12 months showed no significant difference compared with the intraoperative data. Three patients had a minor mitral regurgitation (grade I-II). At 12 months all patients were in NYHA class I or II.

Conclusion: The implantation technique of the QMV is more demanding, but the prosthesis is a promising alternative to conventional biological mitral valve replacement. Further follow up is needed to confirm these favorable mid-term results.

How tto cite: Aybek, T., Simon, A., Dogan, S., Greinecker, G. W., & Moritz, A. (2000). Two years' clinical experience with a quadrileaflet stentless bioprosthesis in the mitral position. The Journal of heart valve disease, 9(5), 667–673.

Background and aim of the study: The Synergy ST (previously Labcor) valve is constructed from three separate porcine aortic cusps mounted on a scalloped, flexible, acetal copolymer stent. To date, no hemodynamic data describing this valve have been published. The aim of this study was to describe the echocardiographic findings in a population of unselected patients.

Methods: One investigator, who was blinded to valve size, studied 84 patients (31 females, 53 males; mean age 58 years; range: 19-83 years) at four centers in Brazil. The valves were studied at a mean of 31 months after implantation (range: 1-116 months). Mean gradient was calculated using the long modified Bernoulli equation, effective orifice area (EOA) using the classical from of the continuity equation, and resistance as mean gradient/flow.

Results: There were no significant differences in peak transaortic velocity and mean gradient between valves of different annulus size. However, EOA was directly related (p = 0.0075) and resistance indirectly related to valve size (p = 0.021, ANOVA). Trivial or mild regurgitation was seen in 31 patients (37%), moderate in three (4%) and severe in two (2%). The regurgitation was solely paraprosthetic in five patients, solely through the valve in 23, and both in seven. Regurgitation through the valve usually occurred adjacent to the commissures.

Conclusion: The Synergy ST porcine valve has hemodynamics of forward flow similar to that of other stented porcine valves.

How to cite: Chambers, J., Dolman, W., Jawetz, J., Ramos, A., Collaco, J., & Barros-Pena, J. (2000). An echocardiographic description of the Sulzer Carbomedics Synergy ST (Labcor) porcine valve in the aortic position. The Journal of heart valve disease, 9(5), 661–666.

Background and aim of the study: The study aim was to collect intermediate-term data on the Mosaic bioprosthesis implanted in the aortic position. The device has been in clinical use since February 1994.

Methods: The Mosaic bioprosthesis is a stented porcine aortic valve, which combines a zero pressure differential fixation technique and anti-mineralization treatment with amino oleic acid for improved tissue durability. Between February 1994 and May 1999, 100 patients (49 females, 51 males; mean age at implant 73.4 +/- 7.3 years (range: 31-87 years) underwent aortic valve replacement with the Mosaic prosthesis in our department. Concomitant procedures were performed in 40% of cases. Patients were followed up prospectively at annual intervals; the mean follow up was 2.7 years (total 273.7 patient-years (pt-yr)) and was 100% complete.

Results: Total early mortality (within 30 days) was 3.0%; the late mortality rate was 4.4%/pt-yr and included a valve-related mortality rate of 0.7%/pt-yr. The freedom from event rates at five years were 97.3 +/- 1.9% for permanent neurological, 99.0 +/- 1.0% for transient neurological, 95.9 +/- 3.2 for thrombosed prosthesis, 95.6 +/- 2.2% for anti-thromboembolic-related hemorrhage, 100% for primary valvular leak, 96.9 +/- 3.0% for non-structural dysfunction, 100% for endocarditis, and 92.0 +/- 4.9% for explant. The mean systolic gradients were 15.2, 13.1 and 10.1 mmHg for the 21, 23 and 25 mm valve sizes, respectively.

Conclusion: The clinical and hemodynamic performance of the Mosaic prosthesis was highly satisfactory during the first five years after clinical introduction. Further data will be necessary to confirm long-term durability.

How to cite: Eichinger, W., Günzinger, R., Botzenhardt, F., Simmerl, D., Gansera, B., & Kemkes, B. M. (2000). The Mosaic bioprosthesis in the aortic position at five years. The Journal of heart valve disease, 9(5), 653–660.

Background and aim of the study: By providing a superior hemodynamic profile, the stentless valve design allows ventricular remodeling and may improve patient survival after aortic valve replacement (AVR). Compared with stent-mounted prostheses, implantation is more complex and requires a longer ischemic time; this may adversely affect surgical risk, especially if patients are elderly or require a concomitant procedure. The mid-term clinical and hemodynamic performance of the Toronto SPV bioprosthesis in a predominantly elderly patient group was analyzed.

Methods: A total of 123 patients (median age 72 years) underwent AVR with the Toronto SPV. Concomitant procedures (mainly coronary artery bypass grafting, CABG), were performed in 60 patients (49%). Clinical details were recorded, with 100% follow up (total 317 patient-years). Hemodynamic evaluation, by serial echocardiography, was performed at four and 18 months after implantation.

Results: The early mortality rate was low (0.8%). Mean (+/- SD) actuarial survival at 53 months was 78 +/- 5.9%, with most patients (91%) in NYHA classes I and II. Freedom from valve-related complications were: endocarditis 93.8 +/- 2.3%, thromboembolism 90.3 +/- 3.7% and bleeding 95.8 +/- 1.8%; there were no structural failures. The valve hemodynamic profile was excellent for all sizes: peak gradient 8.8 +/- 4.3 mmHg, effective orifice area 1.9 +/- 0.54 cm2 with significant improvement in left ventricular fractional shortening.

Conclusion: In this patient population the Toronto SPV was a suitable choice. Advanced age, a requirement for concomitant procedures and increased ischemic times did not adversely affect surgical risk. AVR with the Toronto SPV provided an excellent hemodynamic profile, and improved both left ventricular function and NYHA functional class.

How to cite: Danton, M. H., Sarsam, M. A., Byrne, J. G., Campbell, N. S., Jones, J. M., & Campalani, G. (2000). Clinical and hemodynamic performance of the Toronto SPV bioprosthesis. The Journal of heart valve disease, 9(5), 644–652.

We report a case of edge-to-edge (Alfieri's technique) repair of congenital familiar tricuspid regurgitation in a 49-year-old woman, who had severe tricuspid regurgitation, atrial septal defect with left-to-right shunt, and two stenoses in peripheral branches of the left pulmonary artery, of no clinical relevance. The repair was performed through a longitudinal inferior partial sternotomy. The atrial septal defect was closed by direct suture; the anterior and posterior leaflets of the tricuspid valve were sutured together. The chordae to the prolapsing medial part of the anterior leaflet were shortened by direct suture to the leaflet free edge. Annuloplasty was performed by means of a Carpentier ring. The final step was edge-to-edge approximation of the septal leaflet to the new antero-posterior position with two interrupted stitches. The hemodynamic result was excellent, and the patient eventually returned to full active life.

How to cite: Mantovani, V., Grossi, C., Ferrarese, S., & Sala, A. (2000). Edge-to-edge repair of congenital familiar tricuspid regurgitation: case report. The Journal of heart valve disease, 9(5), 641–643.

Background and aim of the study: When replacing the regurgitant tricuspid valve in children, the decision to use either a bioprosthesis or a mechanical valve remains controversial.

Methods: The atrioventricular valve for the pulmonary circulation was replaced in 11 young patients aged between 8 months and 13 years. Complications of congenital cardiac malformation were present in seven patients, and Ebstein's anomaly in three; tricuspid valvular regurgitation was an isolated lesion in one patient. A bioprosthesis was implanted on seven occasions, and a bileaflet mechanical valve on eight, including re-replacement of the valve in four patients.

Results: One patient died two years after implantation due to respiratory problems. Tricuspid stenosis due to valve calcification occurred in four bioprostheses at between four and nine years after initial replacement (57%). In three of these cases the native valve leaflets had not been removed. Thrombosis occurred in one patient with a mechanical valve; rereplacement was successful. Anticoagulant-related hemorrhage occurred in another patient. Among patients receiving a mechanical valve, 83% of valves were dysfunction-free after five and ten years.

Conclusion: When replacing an atrioventricular valve for the pulmonary circulation in children, we prefer to use a low-profile mechanical valve, especially when extensive repair of intracardiac malformation has been carried out, but ventricular function is good. In children with poor cardiac performance, a bioprosthesis is preferred, with total resection of the native valve leaflets.

How to cite: Kawahira, Y., Yagihara, T., Uemura, H., Yoshizumi, K., Yoshikawa, Y., & Kitamura, S. (2000). Replacement of the tricuspid valve in children with congenital cardiac malformations. The Journal of heart valve disease, 9(5), 636–640.

Wegener's disease is an inflammatory disease of unknown etiology, characterized by a granulomatous-necrotizing general vasculitis. Cardiac involvement in the form of aortic pathology is not frequent. We report a case of Wegener's granulomatosis which required prosthetic aortic valve replacement for aortic valve insufficiency. Microscopic examination of the valve demonstrated histopathology typical of Wegener's disease.

How to cite: Bruno, P., Le Hello, C., Massetti, M., Babatasi, G., Saloux, E., Galateau, F., & Khayat, A. (2000). Necrotizing granulomata of the aortic valve in Wegener's disease. The Journal of heart valve disease, 9(5), 633–635.

Background and aim of the study: The study aim was to determine the incidence and clinical significance of late cardiac conduction defects (CD) after aortic valve replacement (AVR).

Methods: An analysis was made of 100 consecutive cases after AVR in a prospective outpatient evaluation program.

Results: The perioperative (30-day) mortality rate was 5%, and incidence of perioperative pacemaker implantation 3%. Among patients, 19% had CDs before surgery; a normal ECG was present during all periods in 45% of patients. The most frequent perioperative CD was left anterior hemiblock (LAHB; n = 8), and the most frequent late CD was left bundle branch block (LBBB; n = 8). Overall, 13.7% of operative survivors with normal preoperative and perioperative ECGs developed late CDs; one patient (1%) required pacemaker implantation 82 months after AVR. A further three patients (3%) had worsening of pre-existent CDs. Late CDs occurred over a wide time range (3 to 102 months) after surgery.

Conclusion: There is an important incidence of CDs that occur late after AVR, even if the perioperative ECGs are normal; however, a need for late pacemaker implantation is rare. As CDs may occur at any time after surgery, regular follow up with precise evaluation of ECGs is called for.

How to cite: Habicht, J. M., Scherr, P., Zerkowski, H. R., & Hoffmann, A. (2000). Late conduction defects following aortic valve replacement. The Journal of heart valve disease, 9(5), 629–632.

Background and aim of the study: The aim of the study was to report on the long-term results of aortic valve balloon dilatation (AVBD) for congenital valvular aortic stenosis in children and young adults.

Methods: The records of 74 patients (age range: 1-20 years) who underwent AVBD at a single center were analyzed retrospectively. Special attention was paid to factors that might influence long-term outcome.

Results: The procedure was successful in 71 patients (96%). The mean (+/- SD) reduction in peak-to-peak systolic gradient (PSG) was 68.7 +/- 13.5%. No patient required immediate surgical intervention. Survival after dilatation was 100% at 12 years. At follow up (mean 5.5 +/- 2.9 years; range: 2-12 years), 20% of patients had restenosis and 21% had significant aortic regurgitation (AR) (grade > or = 3). Reintervention was performed in 14% of patients. Severity of AR and high residual stenosis immediately after AVBD were associated with the late event rates. The actuarial intervention-free rates at five, seven and 12 years were 92.9%, 84.4% and 60%, respectively.

Conclusion: AVBD is a useful, albeit palliative, procedure for children and young adults with significant congenital valvular aortic stenosis.

How to cite: Jindal, R. C., Saxena, A., Juneja, R., Kothari, S. S., & Shrivastava, S. (2000). Long-term results of balloon aortic valvulotomy for congenital aortic stenosis in children and adolescents. The Journal of heart valve disease, 9(5), 623–628.

Background and aim of the study: Mitral valve replacement with preservation of the subvalvular apparatus (MRVP) has been proven superior to conventional mitral valve replacement (MVR). We devised a simple modified MVRP method in this prospective, randomized study to investigate the clinical effects and one-year follow up echocardiographic results of MVRP compared with MVR in patients with severe rheumatic mitral insufficiency (MI).

Methods: Sixty-eight patients with severe rheumatic MI with or without stenosis were randomized to MVRP (n = 35) and MVR (n = 33) groups. In MVRP patients, the preserved tissue was pulled back posteriorly to the posterior wall of the left ventricle, then plicated and reaffixed to one-fourth of the annular circumference in the posterior annulus, in order to prevent left ventricular outflow tract (LVOT) obstruction. Clinical data including cumulative ventricular arrhythmias and use of inotropes were collected. Echocardiography examination was performed before surgery, and at five days, three months and one year thereafter.

Results: There were no preoperative differences patient data. The cross-clamp time was 2.2 min longer in MVRP patients. The one-month mortality rate after surgery was lower in MVRP patients (2.9% versus 15.2%, p = 0.074). Mechanical ventilation and ICU times were shorter in the MVRP group (17.6 versus 24.8 and 52.5 versus 70.6 h, p = 0.001 and 0.1, respectively). There were fewer ventricular arrhythmias and less need for inotropic support in this group. One year follow up echocardiography data showed better preserved left ventricular ejection fraction (LVEF) and better recovery of heart size after MRVP. There was no indication that preserved valvular tissue interfered with mechanical valve function, or caused LVOT obstruction.

Conclusion: This modified MVRP technique is simple, effective and without risk of LVOT obstruction. In severe rheumatic MI patients the outcome of MVRP is superior to that of conventional MVR in term's of mortality, postoperative care needs, left ventricular function and heart dimensions.

How to cite: Wu, Z. K., Sun, P. W., Zhang, X., Zhong, F. T., Tong, C. W., & Lu, K. (2000). Superiority of mitral valve replacement with preservation of subvalvular structure to conventional replacement in severe rheumatic mitral valve disease: a modified technique and results of one-year follow up. The Journal of heart valve disease, 9(5), 616–622.

Background and aims of the study: Despite advances in surgical techniques, mitral valve surgery in patients with severe pulmonary arterial hypertension (PAH) causes considerable mortality and morbidity. Balloon mitral valvotomy (BMV) is an established alternative to treat high-risk surgical patients with mitral stenosis (MS). The study aims were to evaluate immediate and long-term efficacy of BMV in patients with MS and severe PAH, compared to those with mild/moderate PAH.

Methods: Among 1,125 patients who underwent Inoue BMV, 315 had severe PAH (mean pulmonary artery (PA) pressure > or = 50 mmHg (group I; 79 of these patients had suprasystemic PAH). Results from this group were compared with those of patients with mild/moderate PAH (group II).

Results: Group I patients were younger and more symptomatic (mean PA pressure 62 +/- 10.6 mmHg versus 32.6 +/- 8.2 mmHg in group II). Before BMV, mean transmitral gradient (17.8 +/- 6.5 versus 14.4 +/- 5.4 mmHg) and pulmonary capillary wedge pressure (PCWP) (31.6 +/- 6.1 versus 22.8 +/- 6.2 mmHg) were significantly higher, while mitral valve area (MVA) (0.66 +/- 0.2 versus 0.85 +/- 0.2 cm2) was significantly lower in group I. After BMV, PA mean pressure was significantly reduced (34.8 +/- 11.2 and 21.1 +/- 8.4 mmHg), transmitral gradient (8.0 +/- 3.9 and 6.9 +/- 3.2 mmHg) and mean PCWP (12.8 +/- 5.8 and 11.0 +/- 5.1 mmHg) in groups I and II, respectively, with a comparable increase in MVA (1.77 +/- 0.4 and 1.84 +/- 0.5 cm2). Group I patients had worse baseline hemodynamic parameters than group II, but the former had a higher absolute gain in hemodynamic parameters. Residual severe PAH after BMV was seen in 9.8% of patients, with PA pressures normalized in 9.5%. Among 79 patients with suprasystemic PA pressure (mean PA systolic pressure 116.6 +/- 28.2 mmHg), 16.5% normalized their PA pressures and 25.3% had residual severe PAH. At mean follow up of 33 months, 80.4% were in NYHA class I. Mean PA systolic pressure in 161 patients was 39.0 +/- 14.2 mmHg compared with a post-BMV value of 55.0 +/- 16.9 mmHg; thus, a sustained fall in pressure was demonstrated at follow up.

Conclusion: Inoue BMV is safe and effective in patients with MS and severe PAH. Although these patients have worse clinical and hemodynamic parameters before BMV, they achieve a greater absolute gain in terms of improvement in all hemodynamic parameters.

How to cite: Umesan, C. V., Kapoor, A., Sinha, N., Kumar, A. S., & Goel, P. K. (2000). Effect of Inoue balloon mitral valvotomy on severe pulmonary arterial hypertension in 315 patients with rheumatic mitral stenosis: immediate and long-term results. The Journal of heart valve disease, 9(5), 609–615.

The results of treatment of heart valve disease have improved steadily during the past 20 years. In aortic stenosis, although postoperative survival rates approximated those of age-matched controls, the outcome of surgery to treat ischemic and non-ischemic mitral regurgitation was grave. The reasons for this were two-fold: first, patients were referred for surgery late in the course of their disease, when irreversible left ventricular (LV) dysfunction prevented postoperative restoration of contractile function. Second, the value of the mitral valve apparatus in facilitating LV contraction was unrecognized, and this structure was often removed at surgery, in turn worsening pre-existent LV dysfunction. Consequently, patients with LV dysfunction due to mitral regurgitation underwent surgery that caused further damage to the left ventricle. Not surprisingly, postoperative LV function was poor, congestive heart failure persistent, and lifespan shortened. More recently, however, substantial insight has been gained into the value of the mitral valve apparatus, the causes of LV dysfunction in mitral regurgitation, and into the objective markers of LV function that permit the clinician to recommend surgery before muscle dysfunction has become severe and irreversible.

How to cite: Carabello B. A. (2000). The pathophysiology of mitral regurgitation. The Journal of heart valve disease, 9(5), 600–608.