Colonization of Staphylococcus aureus is commonly observed in skin lesions of atopic dermatitis (AD) patients, and scratching of the pruritic lesions may lead to reiterative bacteremia. It is possible that acute native valve endocarditis may develop in a patient with uncontrolled AD; the latter condition may be a risk factor for the former. We report two cases of acute aortic and/or mitral valve endocarditis complicated with recurrent cutaneous infections caused by severe AD. The patients underwent successful surgical treatment of the heart lesions, plus intensive postoperative antibiotics and skin treatment for AD.

How to cite: Onoda, K., Mizutan, H., Komada, T., Kanemitsu, S., Shimono, T., Shimpo, H., & Yada, I. (2000). Atopic dermatitis as a risk factor for acute native valve endocarditis. The Journal of heart valve disease, 9(3), 469–471.

We describe a patient who developed the rare hemodynamic phenomenon of intermittent electromechanical dissociation during normal sinus rhythm at about four months after mitral valve replacement with a Medtronic Hall prosthesis, along with resuspension of the papillary muscles using Gore-Tex sutures. Echocardiographic examination confirmed the presence of a filamentous structure that could be either suture material, tissue tag or thrombus, and was entangling intermittently in the prosthesis. The patient recovered spontaneously after a three-week symptomatic period, with no subsequent evidence of either electromechanical dissociation or the filamentous structure; normal prosthetic valve function was restored. During a subsequent three-month follow up period, the patient was asymptomatic, with normal prosthetic valve function. The diagnostic and hemodynamic aspects of this case are discussed.

How to cite: Garg, N. K., Kapoor, A., & Sinha, N. (2000). Intermittent electromechanical dissociation due to mechanical prosthetic valve dysfunction. The Journal of heart valve disease, 9(3), 466–468.

Background and aim of the study: The vasoactive agent 5-hydroxytryptamine (5-HT) has been implicated in valve disease due to possible trophic effects on valve interstitial cells (IC). The present study was aimed at characterizing the responses of cultured human heart valve IC to 5-HT in terms of intracellular calcium concentration ([Ca2+]i), mitogenesis and collagen synthesis. The effects of angiotensin II (Ang II) were also studied in parallel.

Methods: IC were obtained by collagenase digestion of valve leaflets isolated from transplant recipient hearts. Changes in [Ca2+]i were measured from fluorescence of the ratiometric calcium dye, fura 2. Mitogenic and collagen synthetic responses of valve IC were measured by 3H-thymidine incorporation (DNA synthesis) and 3H-proline incorporation assays respectively, in quiescent cells.

Results: Human valve IC responded to 5-HT and Ang II with mean maximal increases in [Ca2+]i of 249 +/- 47 nM and 397 +/- 159 nM, respectively. 5-HT stimulated DNA synthesis in quiescent IC, although to varying degrees among different isolations, with a maximum 43.4 +/- 20.1% increase by 10(-7) M 5-HT (p <0.05). Ang II did not stimulate IC DNA synthesis. Valve IC also responded to 5-HT with a maximum increase in collagen synthesis of 15.7 +/- 2.0% by 10(-6) M 5-HT (p <0.05). Ang II provoked a more powerful collagen synthesis response (maximum 50.5 +/- 15.1% increase by 10(-5) M Ang II; p <0.05).

Conclusion: We have shown that 5-HT and Ang II promote the prolonged processes of growth and collagen synthesis in cultured human valve IC. Thus, these vasoactive agents may play a role in the development of heart valve disease.

How to cite: Hafizi, S., Taylor, P. M., Chester, A. H., Allen, S. P., & Yacoub, M. H. (2000). Mitogenic and secretory responses of human valve interstitial cells to vasoactive agents. The Journal of heart valve disease, 9(3), 454–458.

Background and aim of the study: The vasoactive agent 5-hydroxytryptamine (5-HT) has been implicated in valve disease due to possible trophic effects on valve interstitial cells (IC). The present study was aimed at characterizing the responses of cultured human heart valve IC to 5-HT in terms of intracellular calcium concentration ([Ca2+]i), mitogenesis and collagen synthesis. The effects of angiotensin II (Ang II) were also studied in parallel.

Methods: IC were obtained by collagenase digestion of valve leaflets isolated from transplant recipient hearts. Changes in [Ca2+]i were measured from fluorescence of the ratiometric calcium dye, fura 2. Mitogenic and collagen synthetic responses of valve IC were measured by 3H-thymidine incorporation (DNA synthesis) and 3H-proline incorporation assays respectively, in quiescent cells.

Results: Human valve IC responded to 5-HT and Ang II with mean maximal increases in [Ca2+]i of 249 +/- 47 nM and 397 +/- 159 nM, respectively. 5-HT stimulated DNA synthesis in quiescent IC, although to varying degrees among different isolations, with a maximum 43.4 +/- 20.1% increase by 10(-7) M 5-HT (p <0.05). Ang II did not stimulate IC DNA synthesis. Valve IC also responded to 5-HT with a maximum increase in collagen synthesis of 15.7 +/- 2.0% by 10(-6) M 5-HT (p <0.05). Ang II provoked a more powerful collagen synthesis response (maximum 50.5 +/- 15.1% increase by 10(-5) M Ang II; p <0.05).

Conclusion: We have shown that 5-HT and Ang II promote the prolonged processes of growth and collagen synthesis in cultured human valve IC. Thus, these vasoactive agents may play a role in the development of heart valve disease.

How to cite: Hafizi, S., Taylor, P. M., Chester, A. H., Allen, S. P., & Yacoub, M. H. (2000). Mitogenic and secretory responses of human valve interstitial cells to vasoactive agents. The Journal of heart valve disease, 9(3), 454–458.

Background and aims of the study: Previous studies have suggested that elastin in porcine aortic valve cusps is responsible for restoring collagen fibers to their original configuration between loading-unloading cycles.

Methods: Biaxial loading tests were performed on intact aortic valves before and after elastase treatment to further investigate the role of elastin.

Results: Degradation of elastin caused an increase in the radial dimensions of the cusps (mean increase in gauge length, 29%), which corresponded to a significant decrease in radial extensibility (mean decrease, 61%) and a threefold increase in radial stiffness. Changes in circumferential extensibility and stiffness were smaller and, for most cusps, were not statistically significant. Control experiments, in which the valves were treated with buffer only, resulted in the opposite changes in radial dimensions and extensibility (7% decrease in gauge length and doubling of extensibility).

Conclusion: Changes in the mechanical properties of the aortic valve cusps following incubation in elastase were due to elastin damage, and not incidental to soaking in buffer. As many explanted bioprosthetic valves have mechanical characteristics similar to those of the elastase-treated valves, elastin damage may be a factor in the progressive degeneration and ultimate failure of bioprosthetic heart valves.

How to cite: Adamczyk, M. M., Lee, T. C., & Vesely, I. (2000). Biaxial strain properties of elastase-digested porcine aortic valves. The Journal of heart valve disease, 9(3), 445–453.

Background and aim of the study: We and others have demonstrated an immune response to homograft valve endothelial cells both in vivo and in vitro. Clinically, this is particularly manifest in children. In an attempt to address this problem we have explored a strategy of inducing specific immune tolerance by genetic manipulation of valve endothelial cells. FasL is an inducer of apoptosis; it binds Fas and results in programmed cell death (apoptosis) of Fas-bearing cells such as T lymphocytes. FasL has been shown to be important in the protection of tissue grafts (testis, cornea, kidney and pancreatic islet) from rejection. The ultimate aim of this work is to determine whether the transfection of FasL into human heart valve endothelial cells can hinder immune rejection by induction of apoptosis in T cells.

Methods: The full-length human FasL cDNA was cloned into a mammalian expression vector containing the neomycin resistance marker. The endothelial cell line HMEC-1 was transfected with the plasmid and selected with antibiotic G418. Cultures from positive clones were analyzed by semi-quantitative polymerase chain reaction (PCR) to determine approximate copy numbers of FasL. Reverse transcription (RT)-PCR was carried out to examine the production of mRNA from the construct. Western blot analysis was performed to detect the protein expression. Cytotoxic assays were subsequently performed to detect the FasL function in those transfected cells.

Results: High copy number transfected cell lines were produced, and mRNA and protein expression were confirmed. Preliminary results from cytotoxic assays show that transfected cells have enhanced cytotoxicity in comparison with their parent cell line.

Conclusion: FasL can be overexpressed in endothelial cells and appears to modify the cells' immunological behavior. These findings could have important implications for enhancing homograft valve durability.

How to cite: Li, Y., McCormack, A. M., Brand, N. J., & Yacoub, M. H. (2000). A strategy for inducing immune tolerance to valve endothelial cells through gene transfer. The Journal of heart valve disease, 9(3), 439–444.

Background and aim of the study: There is renewed interest in the pericardial heart valve as an alternative to the porcine bioprosthesis. The long-term results of a randomized trial comparing a second-generation pericardial valve against a well-tested porcine bioprosthesis are presented. Seven-year follow up has been reported previously. Production of the Bioflo pericardial prosthesis used in this trial was discontinued due to fears related to bovine spongiform encephalopathy.

Methods: Between February 1987 and March 1990, 170 patients undergoing aortic (AVR) or mitral (MVR) valve replacement were assigned randomly to receive either the Bioflo pericardial bioprosthesis or the Carpentier-Edwards (CE) supra-annular porcine bioprosthesis. Eighty-five patients received 93 Bioflo valves (46 AVR, 31 MVR, eight AVR+MVR), and the remaining 85 received 99 CE valves (48 AVR, 23 MVR, 14 AVR+MVR). Mean patient age was 61.0 years (range: 38-77 years) for the Bioflo group and 62.1 years (range: 41-77 years) for the CE group. Current follow up is 100% complete and totals 1,391 patient-years; mean +/- SD follow up was 8.2 +/- 3.4 years (maximum 12.2 years).

Results: The operative mortality rate was 4.12%. There were 70 patients still at risk at 11 years (31 Bioflo, 39 CE); of these, 91.4% were in NYHA classes I/II. No significant difference in survival or valve-related complications was seen between the groups. Mean (+/- SEM) survival at 11 years was 41.4 +/- 6.8% in the Bioflo group and 55.3 +/- 6.8% in the CE group (p = 0.15). There were 16 valve-related deaths (nine in the Bioflo group, seven in the CE group). At 11 years, freedom from valve-related mortality was 89.5 +/- 3.9% for the Bioflo group and 91.0 +/- 3.5% for the CE group (p = 0.4). Valve position had no impact on survival. At 11 years, freedom from structural valve deterioration was 83.9 +/- 5.4% and 87.5 +/- 4.2% in the Bioflo and CE groups, respectively (p = 0.9).

Conclusion: Over the 11-year period of follow up, clinical performance of the Bioflo pericardial valve was comparable with that of the Carpentier-Edwards supra-annular porcine bioprosthesis. No difference was apparent between the two valve types when implanted in either the aortic or the mitral position.

How to cite: Chaudhry, M. A., Raco, L., Muriithi, E. W., Bernacca, G. M., Tolland, M. M., & Wheatley, D. J. (2000). Porcine versus pericardial bioprostheses: eleven-year follow up of a prospective randomized trial. The Journal of heart valve disease, 9(3), 429–438.

Background and aim of the study: The study aim was to evaluate 10 years' results obtained with the Pericarbon pericardial bioprosthesis.

Methods: Between September 1988 and December 1997, 277 patients (mean age 75.8 +/- 8.5 years) received a total of 287 Pericarbon pericardial valves. Of these patients, 224 (80.8%) underwent single aortic valve replacement (AVR) and 39 single mitral valve replacement (MVR); one patient had a tricuspid valve replacement (TVR), three patients had a pulmonary valve replacement (PVR) and 10 had both aortic and mitral valve replacement (DVR). Associated cardiac procedures were performed in 86 patients (31.0%), mainly coronary artery bypass graft (n = 71). Mean patient follow up was 4.9 +/- 2.6 years; total cumulative follow up was 1,221.4 patient-years.

Results: The overall hospital mortality rate was 10.1%. There were 50 late deaths (20.1%), four (1.6%) being valve-related. The patient survival rate at 10.8 years was 60.0 +/- 4.5% for AVR and 46.5 +/- 11.9% for MVR. Freedom from valve-related death at 10.8 years was 97.6 +/- 1.1% for AVR and 100% for MVR. Freedom from structural valve deterioration was 96.1 +/- 2.7% for AVR and 100% for MVR. Freedom from embolic events was 96.0 +/- 1.5% for AVR and 100% for MVR. In total, 16 patients needed reoperation, three for stenosis due to dystrophic calcification, six for endocarditis and seven for paravalvular leak. Freedom from reoperation was 89.9 +/- 4.2% for AVR and 80.6 +/- 7.3% for MVR.

Conclusion: These results show that, over a period of up to 10 years, the Pericarbon pericardial bioprosthesis constitutes an excellent and safe replacement valve.

How to cite: Folliguet, T. A., Dibie, A., Czitrom, D., Le Bret, E., & Laborde, F. (2000). Ten-years' clinical experience with the Sorin Pericarbon valve. The Journal of heart valve disease, 9(3), 423–428.

Background and aim of study: The study aim was to review the 15-year results of aortic (AVR) and mitral (MVR) valve replacement with the St. Jude Medical Biocor porcine prosthesis, in order to investigate long-term survival and valve-related complications.

Methods: Between January 1983 and January 1998, a total of 1,187 patients underwent either AVR (n = 1,029; mean age 69 years) or MVR (n = 158; mean age 63 years). Follow up (99.7% complete) was monitored in 1998, and all data were analyzed with regard to actuarial valve failure rates. Long-term echocardiographic data were obtained.

Results: Cumulative follow up time was 5,049 patient-years (pt-yr) for AVR patients, and 845 pt-yr for MVR patients. Actuarial survival rate at 15 years was 41 +/- 3%, and freedom from valve-related death was 94 +/- 1% for the AVR group; corresponding values for the MVR group were 25 +/- 11% and 84 +/- 6%. The occurrence of structural valve deterioration (SVD) varied with age; older patients were less affected. Freedom from SVD was 76 +/- 7% and 92 +/- 4% for AVR and MVR patients, respectively. Thromboembolism (TE) occurred mainly among the oldest patients, and was most prevalent among those with MVR. Actuarial freedom from TE was 82 +/- 5% after AVR and 75 +/- 7% after MVR. Prosthetic valve endocarditis (PVE) was rare, but caused the only reoperative mortality. Freedom from PVE was 95 +/- 2% after AVR and 93 +/- 3% after MVR.

Conclusion: Although the optimal valve substitute remains to be found, this long-term study of a third-generation bioprosthesis showed a low incidence of valve-related complications, especially of valve deterioration. This type of bioprosthesis appears to be more durable than valves of previous generations.

How to cite: Mykén, P., Bech-Hanssen, O., Phipps, B., & Caidahl, K. (2000). Fifteen years follow up with the St. Jude Medical Biocor porcine bioprosthesis. The Journal of heart valve disease, 9(3), 415–422.

Background and aim of the study: We have reported clinical findings that normally functioning open pivot ATS valves did not open completely. In order to analyze features of the ATS valve motion more precisely, in vitro tests were conducted.

Methods: Opening angles and pressure gradients of the ATS valve were measured and compared with those of the St. Jude Medical (SJM) valve under steady flow, but with various outlet configurations. Second, opening angles of the two valves were measured under pulsatile conditions in two different outflow configurations: (i) a 'straight outlet' where the leaflets did not extend into the tapering outflow chamber, and (ii) an 'abrupt enlargement outlet' where the leaflets extended directly into the enlarged outflow space. Third, flow visualization studies were made under steady flow conditions in the straight and abrupt enlargement outlet conduits, respectively.

Results: Under steady flow conditions, opening of the ATS valve was restricted in most outflow configurations; only when the outlet angle was 0 degrees did the valve open fully. The SJM valve opened completely in all downstream configurations. Despite restricted opening in the ATS valve, the pressure gradient was similar in both valves. Under pulsatile conditions, both valves opened fully in the straight outlet; however, in the abrupt enlargement outlet the ATS valve opened incompletely and the SJM valve completely. Substantial turbulent flow was observed at the outside of the leaflet and corners of the conduit, notably with the ATS valve.

Conclusion: This study showed that the ATS valve did not open fully except when the outflow was straight, and the leaflet did not extend into an enlarged downstream chamber. Structural features of the ATS, such as its axis being located close to the straight edge and its leaflets extending further downstream from the ring orifice, may cause this unique valve behavior.

How to cite: Tayama, E., Feng, Z., Oda, T., Tomoeda, H., Hayashida, N., Fukunaga, S., Umezu, M., & Aoyagi, S. (2000). ATS prosthetic valve motion: an in vitro analysis. The Journal of heart valve disease, 9(3), 408–414.

Background and aim of the study: The study aim was to evaluate the hemodynamic function after aortic valve replacement (AVR) using the On-X valve, in comparison with St. Jude Medical (SJM) HP bileaflet valves.

Methods: Patients received either the On-X (n = 20) or SJM HP prosthesis (n = 20) for AVR. The control (SJM HP) group was computer-matched with the On-X group for age, gender, aortic stenosis as underlying disease, body surface area, NYHA functional class, left ventricular size, mass and function, transvalvular pressure gradients and cardiac index. Mean implanted valve size was 23.5 mm (three 21 mm, ten 23 mm, six 25 mm, one 27 mm) in both groups. All patients underwent postoperative, and six- and 12-month follow up echocardiography.

Results: The intra- and postoperative course was uneventful in all patients. There were no significant differences in cross-clamp and cardiopulmonary bypass times, intensive care unit stay, in-hospital stay and postoperative NYHA functional class. Two patients (both On-X) had paravalvular leakage postoperatively and at follow up. Five patients in the control group had additional myocardial revascularization. Transvalvular flow velocities were 2.38 +/- 0.3 versus 2.38 +/- 0.4 m/s (p = NS) postoperatively, and 2.08 +/- 0.2 versus 2.22 +/- 0.3 m/s (p = NS) at one year follow up for On-X and SJM HP valves, respectively. Maximum pressure gradients were 16.9 +/- 6.0 versus 18.5 +/- 8.0 mmHg (p = NS) postoperatively and 14.0 +/- 3.7 versus 16.5 +/- 5.7 mmHg (p = NS) at one year for the two valve types, respectively. A relatively pronounced transvalvular reflux was diagnosed for On-X valves.

Conclusion: At one year after implantation, the On-X bileaflet prosthesis is equally suited for AVR in comparison with the 'standard' therapy (SJM HP). Exact sizing requires some experience. There were no significant differences between the two prostheses with regard to hemodynamic parameters either postoperatively or at one-year follow up. Long-term prospective randomized studies yet have to be carried out.

How to cite: Walther, T., Falk, V., Tigges, R., Krüger, M., Langebartels, G., Diegeler, A., Autschbach, R., & Mohr, F. W. (2000). Comparison of On-X and SJM HP bileaflet aortic valves. The Journal of heart valve disease, 9(3), 403–407.

Background and aim of the study: Debate continues regarding tricuspid valve replacement (TVR) with a mechanical prosthesis. Experience with bileaflet prostheses is limited; hence the study aim was to explore early and mid-term outcome and hemodynamic data in patients with bileaflet CarboMedics prosthetic valves in the tricuspid position.

Methods: The study population included 25 patients (21 females, four males; mean age 50.5 +/- 13.4 years) who underwent TVR with a CarboMedics valve over a six-year period. Routine clinical examinations and details of transthoracic echocardiography (TTE) were reviewed. Additional TTE, transesophageal echocardiography (TEE) and fluoroscopy were performed as indicated. The number of previous cardiac operations was zero, one and two in 36%, 32% and 32% of patients, respectively. Previous tricuspid surgery was performed in eight cases (32%); concurrent mitral valve replacement was performed in 17 (68%). The hospital mortality rate was 24% and late mortality rate 12%. Seventeen early survivors (13 females, four males) were followed up for 46 +/- 28 months (range: 4-96 months).

Results: Among early survivors, the mean and peak transvalvular gradients were 4.0 +/- 1.7 and 7.9 +/- 3.3 mmHg, respectively. Commonly observed INR levels were >2.5 in seven patients (41%), and >3.0 in only three (18%). Five patients (29% of mid-term survivors) experienced a total of 13 episodes of obstructive valve thrombosis, mostly with inappropriate anticoagulation. One patient required emergency re-do surgery; the others responded initially to thrombolysis or intensified antithrombotic treatment, but experienced at least two additional relapses. Aside from thrombotic episodes, all patients but two were in NYHA functional class II-III, and all but four required diuretics.

Conclusion: TVR with bileaflet mechanical valves carries a high perioperative mortality and mid-term morbidity. Among patients with poor or fair anticoagulation, these valves were associated with a high incidence of obstructive valve thrombosis. If poor patient compliance is anticipated, insertion of a bioprosthesis should be encouraged.

How to cite: Shapira, Y., Nili, M., Hirsch, R., Vaturi, M., Vidne, B., & Sagie, A. (2000). Mid-term clinical and echocardiographic follow up of patients with CarboMedics valves in the tricuspid position. The Journal of heart valve disease, 9(3), 396–402.

Background and aim of the study: The CarboMedics bileaflet prosthetic heart valve was introduced in 1986, and first implanted by the authors in March 1991. The aim of this study was to analyze the authors' clinical experience with this valve.

Methods: Between March 1991 and October 1998, 1,503 valves were implanted in 1,350 patients (758 males, 592 female; mean age 62 +/- 13 years). Follow up was 99% complete and totaled 4,342 patient-years (pt-yr).

Results: The hospital mortality rate was 4.3% (59/1,350). Preoperative NYHA class (p = 0.012), emergency surgery (p = 0.03) and cardiopulmonary bypass time (p = 0.01) were significantly associated with increased risk of operative death (multiple logistic regression). Mean (+/- SEM) survival rates at one and five years were 92.0 +/- 0.7% (n = 1,109) and 80.0 +/- 1.3% (n = 335). Freedom from valve-related complications (linearized rate 5.6%/pt-yr) at one and five years was 89.5 +/- 0.8% (n = 1,031) and 76.3 +/- 1.4% (n = 284). Linearized rates for bleeding events were 2.19%/pt-yr, thromboembolic events 2%/pt-yr, operated valvular endocarditis 0.18%/pt-yr, valve thrombosis 0.14%/pt-yr and non-structural dysfunction 1.22%/pt-yr. Freedom from reoperation at one and five years was 98.5 +/- 0.3% (n = 1,107) and 97.3 +/- 0.5% (n = 334).

Conclusion: Mid-term results demonstrate that the CarboMedics prosthetic heart valve exhibits a low incidence of valve-related complications.

How to cite: Dalrymple-Hay, M. J., Pearce, R. K., Dawkins, S., Alexiou, C., Haw, M. P., Livesey, S. A., & Monro, J. L. (2000). Mid-term results with 1,503 CarboMedics mechanical valve implants. The Journal of heart valve disease, 9(3), 389–395.

Background and aim of the study: Thrombosis and thromboembolism remain the main problems associated with mechanical heart valves. We have devised a milk-based clotting technique to simulate in-vitro clinical incidence of thrombosis. Early results with the technique revealed good correlation between milk clot deposition and clinical thrombosis, but were limited in their ability to predict the course of clot deposition, as deposition could only be measured upon dismantling the apparatus.

Methods: Clot deposition was observed ultrasonically for both steady and pulsatile flows of a milk preparation through a cylindrical test chamber containing axisymmetric test bodies similar in shape to those used in earlier studies of thrombosis. Echo ultrasound images were recorded at regular time intervals, depicting the interface between clot deposits and flowing milk. From these images, the thickness of the clot deposit could be determined as a function of time.

Results: Milk clot deposition on the test bodies, while observed, could not be measured accurately due to faint reflections arising from significant differences between the angle of incidence and the angle of reflection of the ultrasound beam. However, measurement was possible at the wall of the test chamber where deposition rates revealed steady growth of clot, following an initial 'lag', with growth continuing until a maximum thickness is reached. In some experiments shedding of parts of the deposit was observed. In pulsatile flow, wall clot deposition rates and final clot thickness attained were significantly lower than in steady flow.

Conclusion: Ultrasonic measurement of clot deposition rates is possible in our thrombogenicity assessment apparatus on surfaces perpendicular to the line of incidence of the ultrasound beam. With suitably designed viewing windows in an artificial heart, such measurements should enable the time course of clot deposition on artificial valves to be determined, with a view to identifying initial deposition sites and the dynamics of clot growth. Observations of the growth of clot on the test chamber wall in this study suggest that both the rate of deposition and nature of deposit formed are strongly influenced by fluid mechanical properties such as shear and mass transfer rates. In particular, our results appear to suggest a different structure of deposit, whose rate of deposition is relatively slow, under conditions of high shear.

How to cite: Christy, J. R., & Marosek, K. W. (2000). Ultrasonic determination of clot deposition rates in a milk-based, in-vitro procedure for thrombogenicity assessment. The Journal of heart valve disease, 9(3), 379–388.

Three cases of aortic valve replacement with porcine bioprostheses are reported in liver transplant recipients at two to six years after transplantation. Indications for aortic valve replacement (AVR) were aortic stenosis (n = 2) and aortic regurgitation (n = 1). The use of bioprostheses was recommended because of patient age, the need for multiple liver biopsies, and contraindication to the use of anticoagulation therapy. The patient who underwent AVR because of aortic regurgitation developed structural valve deterioration (SVD) during the next five years after surgery, and thus replacement of the bioprosthetic valve was required. Recipients of liver transplant who undergo valve replacement with tissue valves should be carefully followed up because of the risk of early SVD. AVR may be performed safely after liver transplantation.

How to cite: Segura, I., Herrero, J. I., Martín, A., Saénz de Buruaga, J. D., Quiroga, J., Latorre, G., Fernandez, E., López-Coronado, J. L., & Sangro, B. (2000). Aortic valve replacement with bioprostheses in liver transplant recipients. The Journal of heart valve disease, 9(3), 370–373.

Background and aim of the study: Abnormal calcium homeostasis in patients with end-stage renal failure results in dystrophic calcification; this limits the use of heterograft tissue valve prostheses in patients on chronic dialysis. Mitral valve reconstruction offers advantages over mitral replacement in many patients without renal failure, and offers theoretical advantages in patients requiring dialysis. This study was performed to determine the outcome of mitral valve reconstruction in patients with renal failure requiring chronic dialysis.

Methods: Ten patients with end-stage renal failure and on chronic dialysis who underwent mitral valve repair were identified retrospectively and followed for clinical and echocardiographic outcome. All patients had good results immediately following surgical valve mitral repair, with no more than mild mitral regurgitation and low transmitral gradients on intraoperative transesophageal echocardiography.

Results: Clinical and echocardiographic follow up was available for eight patients at an average of 2.3 +/- 1.4 years after surgery. Despite there being no significant valve calcification at the time of surgery, visible mitral leaflet calcification was evident in seven of these patients, and the transmitral gradient for the group was significantly increased (from 4.8 +/- 1.7 mmHg to 8.3 +/- 3.9 mmHg, p = 0.04). Two patients required reoperation for failed mitral repair; one at six months due to chordal rupture, and one at 15 months due to mitral calcification with stenosis.

Conclusion: Despite good early surgical results, there was accelerated calcification of the repaired mitral valve, a rapid increase in postoperative mitral gradients, and a high incidence of failure of the reconstruction. Additional prospective studies are required to evaluate the optimal intervention for patients with end-stage renal failure who require mitral valve surgery.

How to cite: Lewandowski, T. J., Armstrong, W. F., Bolling, S. F., & Bach, D. S. (2000). Calcification and degeneration following mitral valve reconstruction in patients requiring chronic dialysis. The Journal of heart valve disease, 9(3), 364–369.

Four males aged 20-37 years (three drug addicts and one with a congenital mixed pulmonary valve lesion) were diagnosed in 1989, 1991 and 1993 with pulmonary valve endocarditis without tricuspid infection. Three patients were positive for hepatitis B, C or both, and one patient was HIV-positive. The predominant organism in blood cultures was Staphylococcus aureus. Antibiotic treatment of pulmonary valve endocarditis had failed; thus partial or total valvectomies were performed. Postoperatively, all patients were cured of infection and initial recovery was good. At mid-term follow up (5-10 years) there were no recurrences, and tolerance of the resultant pulmonary insufficiency was good. Slight to severe tricuspid valve insufficiency developed, together with right ventricular dilatation, in all cases. Hepatomegaly was apparent in two cases and peripheral edema in one. Despite treatment, the latter patient remained in moderate right ventricular failure, and may require homograft valve replacement. The other three patients remained in good clinical condition. Eradication of the infection was achieved in all patients. It is concluded that pulmonary valve resection is the treatment of choice for pulmonary valve endocarditis when antibiotic treatment has failed. Complete resection of all affected tissue should be performed in these cases. Analysis of preoperative data did not permit differentiation of those patients likely to develop right heart failure.

How to cite: Llosa, J. C., Gosalbez, F., Cofiño, J. L., Naya, J. L., & Valle, J. M. (2000). Pulmonary valve endocarditis: mid-term follow up of pulmonary valvectomies. The Journal of heart valve disease, 9(3), 359–363.

Background and aim of the study: In 1967, following the replacement of infected tricuspid valves in drug addicts with incurable endocarditis, all patients died. The study aim was to determine if tricuspid valve removal, rather than replacement, might offer these patients an improved outcome.

Methods: Since July 1970, we have operated on 55 patients with intractable right-sided endocarditis. Before surgery, all had a history of intravenous drug abuse (IVDA) (duration range: 2-20 years; 5 years in 38 cases). In 53 patients the tricuspid valve was excised without replacement; the pulmonary valve was also removed in two cases.

Results: Six (11%) patients died within six weeks of surgery, and 11 died between six months and 24.5 years. Ten of the late deaths were related to IVDA. Among 49 patients who survived surgery for six months to 29 years, 24 (50%) returned to the use of illicit drugs. Only six patients eventually required insertion of a heart valve prosthesis; of these, four died, two due to repeat IVDA. Of 38 long-term survivors (range: 9-29 years), two have a non-functioning bioprosthesis in the tricuspid position, 35 have a trivalvular heart, and one has a bivalvular heart. Only three patients required diuretics and digitalis.

Conclusion: IVDA patients with intractable right-sided infective endocarditis have the best chance of cure and long-term survival by undergoing tricuspid or tricuspid and pulmonary valve excision(s), without prosthetic replacement. No published evidence or long-term follow up data indicate better surgical treatment for this patient group. In this day and age of cost containment, these operations are economical. Operations that work well in non-addicted patients become costly and invariably are associated with a second endocarditis and death in inveterate IVDA cases.

How to cite: Arbulu A. (2000). Trivalvular/bivalvular heart: a philosophical, scientific and therapeutic concept. The Journal of heart valve disease, 9(3), 353–358.

Background and aim of the study: Coverage of large commissural defects may present a surgical challenge in mitral valve repair, for which the transfer of posterior tricuspid valve leaflet tissue is an attractive approach.

Methods: Five patients aged between 35 and 55 years underwent this procedure. After wide excision of the diseased mitral commissures, the posterior leaflet of the tricuspid valve was carefully checked, removed with its subvalvular apparatus, and transferred to the commissural area of the mitral valve. The stress on the papillary muscle suture was relieved by reinforcement of the free edge of the transferred leaflet by natural or artificial chordae. The tricuspid valve was repaired using either a sliding plasty or an annuloplasty.

Results: One patient who had no reinforcement of the subvalvular apparatus had a papillary muscle rupture and required mitral valve replacement during the early postoperative period. The four remaining patients remained asymptomatic and had no or trivial mitral regurgitation after a median of 13 months (range: 3-18 months), with excellent result at transesophageal echocardiography.

Conclusion: We conclude that transfer of the tricuspid valve leaflet allows coverage of large commissural defect, and deserves a place among the surgeon's arsenal of reconstructive techniques for mitral valve repair.

How to cite: Khoury, G. E., d'Udekem, Y., Noirhomme, P., Verhelst, R., Rubay, J., & Dion, R. (2000). Transfer of the posterior leaflet of the tricuspid valve to the mitral valve. The Journal of heart valve disease, 9(3), 350–352.

Background and aim of the study: The study aim was to evaluate the feasibility of intraoperative three-dimensional (3D) transesophageal echocardiography (TEE) in patients referred for mitral valve prolapse (MVP) repair and to compare two-dimensional (2D) TEE and 3D TEE and surgical findings.

Methods: Forty-six patients (mean age 67 +/- 11 years) underwent 3D TEE intraoperatively. Measurements were made of the posterior part of mitral annulus circumference (PMAC), and the width of mitral valve surgical resection on the mitral annulus (WMVR). Using 3D TEE, MVP topography was described, and PMAC in diastole and the width of implantation of MVP on the mitral annulus (WMVP) in systole were measured.

Results: 3D TEE was successful in 42 patients (91%). 2D and 3DTEE correctly predicted MVP localization in 38 (90%) and 36 (86%) patients, respectively (p = NS). 3D TEE and surgical PMAC were 89 +/- 13 and 93 +/- 21 mm, respectively (p = 0.01, R = 0.42). WMVR and WMVP were 28 +/- 11 mm and 26 +/- 11 mm, respectively (p <0.0001, R = 0.82). WMVR/anatomic PMAC (0.29 +/- 0.11) and WMVP/3D echo PMAC (0.32 +/- 0.11) were correlated (p <0.0001, R= 0.69).

Conclusion: Intraoperative 3D TEE evaluation of MVP is feasible. MVP width and its ratio to the mitral annulus were assessed, and found to correlate with surgical findings. These 3D data may be of value to the surgeon when performing mitral valve repair.

How to cite: Chauvel, C., Bogino, E., Clerc, P., Fernandez, G., Vernhet, J. C., Becat, A., & Dehant, P. (2000). Usefulness of three-dimensional echocardiography for the evaluation of mitral valve prolapse: an intraoperative study. The Journal of heart valve disease, 9(3), 341–349.

Background and aim of the study: Mitral valve reconstruction in patients with acute endocarditis (AE) is a challenging operation which prompts the surgeon into immediate action. This report summarizes the mid-term results of 22 patients who required mitral valve reconstruction due to AE.

Methods: Mean patient age was 46 years (range: 20-79 years); mean follow up was 46 months (range: 1-90 months). Preoperatively, >70% of patients had severe mitral regurgitation and were in NYHA functional class III. Surgical techniques used were annuloplasty (n = 16; 10 with Carpentier ring, five Wooler-Kay and one Frater); suture closure of the perforation (n = 1), patch closure of the perforation (n = 5), leaflet resection with primary closure (n = 2), leaflet resection with patch closure (n = 8), and chordal transfer (n = 3). Additional surgery included CABG (n = 3) and De Vega plasty (n = 4). Aortic valve replacement or reconstruction (n = 9) included one mechanical valve, one bioprosthesis, one reconstruction and six homografts. Patients were followed up annually in our outpatient department and/or by questionnaires.

Results: Two patients died perioperatively due to either low output syndrome or uncontrolled sepsis. There were three reoperations; two of these were successful, and one patient subsequently died. In addition, one patient died six years after operation due to prostatic cancer, and one seven years later due to progressive heart failure. At the last follow up, 15 patients were in NYHA class I (68%) and five in class II (23%); no or only mild mitral insufficiency was seen on transthoracic echocardiography (91%). The estimated survival rate at 60 months was 87 +/- 12.7%, and 12 patients were followed up for >60 months. No incidence of recurrent valve infection occurred.

Conclusion: Mitral valve reconstruction in patients with AE shows a low incidence of valve-related complications with promising postoperative functional results and mid-term survival. On this basis, mitral valve reconstruction for mitral insufficiency secondary to AE may be recommended as a valve salvage treatment, when it is technically possible.

How to cite: Podesser, B. K., Rödler, S., Hahn, R., Eigenbauer, E., Vodrazka, M., Moritz, A., Laufer, G., Simon, P., & Wolner, E. (2000). Mid-term follow up of mitral valve reconstruction due to active infective endocarditis. The Journal of heart valve disease, 9(3), 335–340.

Background and aims of the study: The study aim was to review our experience in surgical treatment of infective mitral valve endocarditis, and to identify predictors of early and late outcome.

Methods: Ninety-one consecutive patients (52 males, 39 females, mean age 55.6 years) underwent surgery between 1973 and 1997 for endocarditis of isolated mitral (n = 65, 71%), mitral and aortic (n = 25, 28%) and mitral, aortic and tricuspid valves (n = 1, 1%). Native valve endocarditis (NVE) was present in 60 patients (66%) and prosthetic valve endocarditis (PVE) in 31 (34%). The main indications for surgery were heart failure in 32 patients, valve dysfunction in 23, vegetations in 21, and persistent sepsis in 11. Eighty-six patients (95%) were in NYHA classes III-IV, and 58 (64%) had active culture-positive endocarditis at surgery. Mechanical valves were implanted in 73 patients and bioprosthetic valves in 13; valves were repaired in five patients. The impact of 46 parameters on early and late outcome was defined by means of univariate and multivariate statistical analysis. Follow up was complete (mean 5.5 years; range: 0-23.1 years; total 507.3 patient-years).

Results: Operative mortality rate was 11% (n = 10). Recurrent infection was recorded in five patients (6%), and reoperation was required in eight (9%). Freedom from recurrent infection and reoperation at 10 years was 89.1% and 87.8% respectively. There were 22 late deaths, 15 from cardiac causes. Actuarial survival rates for all patients at 5, 10 and 15 years were 73.0%, 62.7% and 58.7% (for hospital survivors, the corresponding rates were 81.9%, 69.7% and 66.0%). On multiple logistic regression and Cox proportional hazards models, the following were independent predictors: preoperative pulmonary edema (p = 0.01) for operative mortality; PVE (p = 0.02) for recurrence; younger age (p = 0.02) and PVE (p = 0.02) for reoperation; male gender (p = 0.004) and longer ITU stay for survival (if all patients were included); male gender (p = 0.01) and myocardial invasion by infection (p = 0.02) for survival (if only the hospital survivors were analyzed).

Conclusion: Surgery for infective mitral valve endocarditis carries a relatively high, though acceptable, risk but provides satisfactory freedom from recurrent infection, reoperation and improved long-term survival. Analysis of these data demonstrated that the preoperative hemodynamic status was the major predictor of in-hospital outcome, PVE increased the risk for recurrent infection and reoperation, whereas male gender and myocardial invasion by the infective process critically reduced the probability of long-term survival. The type of offending pathogen, the activity of infection and the involvement of more than one valve did not appear to influence early and/or late outcome.

How to cite: Alexiou, C., Langley, S. M., Stafford, H., Haw, M. P., Livesey, S. A., & Monro, J. L. (2000). Surgical treatment of infective mitral valve endocarditis: predictors of early and late outcome. The Journal of heart valve disease, 9(3), 327–334.

Background and aim of the study: Mitral valve repair (MVR) is the treatment of choice in patients with degenerative valve disease. However, controversy persists as to whether mitral valve annuloplasty should always be included as part of the reconstructive procedure.

Methods: The records of 62 consecutive patients undergoing MVR for degenerative disease between January 1994 and December 1996 were reviewed. Four different annuloplasty techniques were associated with various MVR procedures: local posterior annuloplasty (group 1, n = 10), rigid Carpentier ring (group 2, n = 20), Duran ring (group 3, n = 17), and posterior annular plication with autologous pericardium (group 4, n = 15). The four patient groups were similar in terms of preoperative clinical and echocardiographic characteristics. Serial clinical and echocardiographic follow up was performed to assess functional status and stability of repair.

Results: There were no early or late deaths. Mean follow up in the entire patient series was 31 +/- 12 months. One patient in group 2 required reoperation 14 months after MVR. In all groups there was a significant improvement in NYHA functional class (from 2.7 +/- 0.6 to 0.9 +/- 0.5, p <0.001), with a reduction of left ventricular end-diastolic and end-systolic volumes (154 +/- 50 ml to 105 +/- 33 ml, p <0.001; and 64 +/- 23 ml to 52 +/- 22 ml, p <0.001). In patients of groups 2, 3 and 4, residual mitral incompetence at follow up (0.8 +/- 0.9 in group 2, 0.8 +/- 0.7 in group 3, and 0.2 +/- 0.6 in group 4) was not significantly different from discharge. However, in group 1, a higher degree of residual mitral regurgitation was present at discharge (0.9 +/- 0.6) with a trend to progress at follow up (1.6 +/- 0.5).

Conclusion: In patients with degenerative mitral valve disease, MVR provides clinical and functional improvement. Techniques of stabilization of the entire posterior mitral annulus achieve better early and medium-term results, and should be always considered as part of MVR. Autologous pericardium appears to be an excellent annuloplasty material, though its apparent superiority over synthetic rings must be confirmed at longer follow up.

How to cite: Milano, A., Codecasa, R., De Carlo, M., Nardi, C., Tartarini, G., Verunelli, F., & Bortolotti, U. (2000). Mitral valve annuloplasty for degenerative disease: assessment of four different techniques. The Journal of heart valve disease, 9(3), 321–326.

Background and aim of the study: Mitral valve repair has been associated with better preservation of left ventricular (LV) function, especially in the setting of degenerative regurgitation. The goal of this study was to evaluate the impact of mitral valve repair on postoperative LV ejection fraction (LVEF) and LV remodeling as determined by LV end-systolic and diastolic diameters.

Methods: A prospective echocardiographic and clinical evaluation of 91 patients undergoing mitral valve repair for degenerative regurgitation between 1993 and 1998 was performed. Patients with normal preoperative LVEF (> or = 50%; group 1, n = 71) were compared with patients with decreased preoperative LVEF (< 50%; group 2, n = 20) one year after mitral valve repair.

Results: In group 1 patients, the LVEF was preserved at one year, while the LV end-systolic diameter was significantly reduced from 36 +/- 7 mm to 32 +/- 8 mm (p <0.05). There was a significant improvement in LVEF in group 2 patients (38 +/- 6% preoperative versus 50 +/- 12% at one year, p <0.05). The preoperative LV end-systolic diameter was significantly larger in group 2 patients (47 +/- 9 mm) than in group 1 patients (36 +/- 7 mm) (p <0.001), but decreased to normal values at one year after repair (38 +/- 7 mm, p <0.05).

Conclusion: There was good preservation of LV function after mitral valve repair in group 1 patients. The LVEF significantly increased towards normal in patients with depressed LV function before repair. The LV systolic diameter was restored to normal within one year of repair, even in patients with poor LV function. Decreased preoperative LV function should not be a contraindication to mitral valve repair in patients with degenerative regurgitation.

How to cite: de Varennes, B., & Haichin, R. (2000). Impact of preoperative left ventricular ejection fraction on postoperative left ventricular remodeling after mitral valve repair for degenerative disease. The Journal of heart valve disease, 9(3), 313–320.