Expanded PTFE (ePTFE) sutures have been used widely as a mitral chordal substitute. We present a structural analysis of ePTFE sutures implanted as artificial chordae for 7.5 years and 8.6 years in patients with mitral regurgitation. No calcification was found either macroscopically or microscopically, and the ePTFE suture retained its normal flexibility. The suture was totally encapsulated with host tissues composed of dense fibrous tissue covered with endothelial cells.

How to cite: Minatoya, K., Kobayashi, J., Sasako, Y., Ishibashi-Ueda, H., Yutani, C., & Kitamura, S. (2001). Long-term pathological changes of expanded polytetrafluoroethylene (ePTFE) suture in the human heart. The Journal of heart valve disease, 10(1), 139–142.

Fracture of the occluder disc of a low-profile Starr-Edwards prosthesis is a hitherto unrecognized complication. We describe a patient who presented with right heart failure and severe pulmonary hypertension 27 years after mitral valve replacement with a model 6520 caged-disc prosthesis. At surgery, there was a longitudinal split in the occluder disc, and organized thrombus was lodged between the split segments. This case offers a unique opportunity to study the long-term effects of wear on the polyethylene poppet and Stellite cage.

How to cite: Malouf, J. F., Hannoush, H. M., & Odell, J. A. (2001). Fractured occluder disc: a previously unrecognized complication of the Starr-Edwards disc prosthesis. The Journal of heart valve disease, 10(1), 136–138.

Background and aim of the study: Intraoperative swabs of heart valves are obtained regularly from patients undergoing heart valve surgery for infective endocarditis (IE) in order to confirm the preoperative diagnosis and to adjust the antibiotic regimen. The study aim was to assess the diagnostic value of intraoperative swabs of heart valves in IE.

Methods: A total of 83 patients was referred for surgical treatment of active IE between October 1994 and May 1999. Preoperatively, microorganisms were isolated using a minimum of two positive blood cultures; results were compared with those obtained from intraoperative heart valve swab cultures.

Results: Preoperatively, 73 patients (88%) had a positive blood culture, and 10 (12%) had culture-negative endocarditis. The intraoperative swab confirmed the preoperative diagnosis in 31 cases (37%). Bacteria were isolated in three of the ten patients with preoperative culture-negative IE. Despite positive histopathological findings in seven patients, no microorganisms were cultured either pre- or intraoperatively. Among the remaining 42 patients (51%) with active IE, 25 valve cultures were sterile and 17 valve swabs were presumed to be contaminated.

Conclusion: In patients with active IE in whom the causative agent could be isolated and identified before surgery, intraoperative valve swabs did not contribute further to patient management. In isolating contaminants, the risk of inappropriate modification of the antibiotic regimen is imminent. The diagnostic validity in culture-negative IE appears negligible.

How to cite: Thiele, H., Hambrecht, R., Lauer, B., Weinert, M., Mohr, F. W., & Schuler, G. (2001). Diagnostic value of intraoperative swabs of heart valves in infective endocarditis. The Journal of heart valve disease, 10(1), 129–135.

Background and aim of the study: In order to provide valved xenografts with reduced immunity, yet durability comparable with that of homografts, a method for endothelial cell removal was developed.

Methods: Adult porcine valved pulmonary conduits were isolated, washed and incubated in trypsin-EDTA solution. The endothelial cells were flushed free with a stream of culture medium, and the xenografts cryopreserved. Grafts were thawed after three months, and evaluated structurally.

Results: Macroscopic inspection of the grafts revealed no cracks or other morphological damage. Light microscopy revealed mildly edematous changes, and the elastic layers appeared to be preserved. Incubation with trypsin-EDTA solution consistently removed the entire endothelial layer, without obvious damage to the underlying tissues.

Conclusion: With care and appropriate timing, the xenograft endothelium can be selectively removed, leaving the underlying tissue intact. This process may allow further structural manipulations to improve the durability of these grafts.

How to cite: Erez, E., Sandbank, J., Stamler, A., Raanani, E., Sharoni, E., Vidne, B. A., & Barak, J. (2001). Structural modification and cryopreservation of porcine heart valves for xenotransplantation with reduced immunity. The Journal of heart valve disease, 10(1), 125–128.

Background and aim of the study: Recent developments suggest that stentless bioprosthetic mitral valve heterografts should be considered in order to optimize valve hydrodynamics. The fixation process alters the mechanical properties of tissue. This study investigates the changes in mitral valve morphology and hemodynamic performance following fixation.

Methods: Porcine mitral valves were excised and attached to a physiological annular ring. Mitral valve function was studied in vitro with a rigid transparent left heart model, allowing transverse and sagittal views. Initial experiments were performed with fresh valves under physiological conditions. Three different papillary muscle positions were used, and each was recorded. After glutaraldehyde fixation, genipin fixation, and cryopreservation, the valves were re-studied while maintaining cardiac output. Performance characteristics before and after fixation were obtained from hydrodynamic pressure and flow data, high-speed video camera, digital video, Doppler ultrasound, and three-dimensional papillary muscle force measurements. Morphology changes were detected by detailed anatomic measurements of the valves before and after fixation.

Results: Valve length was reduced by 18.5% after fixation with genipin (p <0.001), but not with glutaraldehyde. Cryopreserved valves showed no statistically significant changes in morphology or hydrodynamic performance after preservation. The forward flow opening area was reduced by 12.2% (p <0.001) after glutaraldehyde fixation, and by 32.3% (p = 0.004) after genipin fixation. Thus, maximal forward flow velocity was increased by 33.3% (p = 0.008) after glutaraldehyde fixation and by 52.8% (p = 0.001) after genipin fixation. The flow acceleration was consistent with a funnel shape of the fixed valves causing important flow contraction beyond the orifice (vena contracta). The papillary muscle force increased with apically posterior papillary muscle displacement by 20.4% (p = 0.001) and 101.5% (p <0.001) after glutaraldehyde and genipin fixation, respectively, and total regurgitant volume was increased by 91.6% (p <0.001) and 117.3% (p <0.001), respectively. The work required by the heart simulator to maintain a constant cardiac output at constant vascular resistance increased by 24.2% (p = 0.003) and 34.2% (p = 0.004) after glutaraldehyde and genipin fixation, respectively.

Conclusion: The present study shows that chemical fixation of porcine mitral valves adversely affects the hemodynamics of the valves, increasing overall workload. The effects were more severe after fixation with genipin than with glutaraldehyde. This suggests the need to explore other fixation agents to optimize valvular cardiac function. Cryopreservation had no detrimental effects on valvular hemodynamic performance.

How to cite: Jensen, M. O., Lemmon, J. D., Gessaghi, V. C., Conrad, C. P., Levine, R. A., & Yoganathan, A. P. (2001). Harvested porcine mitral xenograft fixation: impact on fluid dynamic performance. The Journal of heart valve disease, 10(1), 111–124.

Background and aim of the study: The synthetic flexible tri-leaflet heart valve offers considerable potential for improvement in both hydrodynamic and biomechanical performance of replacement heart valves. To date, success with the synthetic leaflet heart valve has been limited, partly due to limitations in the biostability of the polyurethanes used. With the synthesis of new biostable polyurethanes, the integration of advancing technology, and better knowledge of the functional and biomechanical design requirements necessary to increase the long-term durability of the polyurethane heart valve, novel clinical solutions are now in sight.

Methods: This study describes the design characteristics, hydrodynamic and biomechanical performance of a new design of polyurethane heart valve. The function and durability characteristics of this novel design of heart valve, manufactured using a proven durable non-biostable polyurethane, was compared with that of a single AorTech porcine bioprosthetic heart valve and a single tilting disc mechanical heart valve, the Björk-Shiley Monostrut valve (BSM), of similar size.

Results: For equivalent sizes of valve, the new polyurethane heart valve design had significantly lower pressure gradients compared with the porcine valve at all flow rates and to the BSM valve at the higher flow rates. The effective orifice area of the polyurethane valve was greater than the other two valves studied; regurgitation and total energy loss were less. The new polyurethane valve design reached over 360 million cycles in an accelerated durability tester, without failure.

Conclusion: This new design of polyurethane heart valve showed improved hydrodynamic function in comparison with either the porcine bioprosthetic or the BSM mechanical heart valve. The pulsatile flow results showed a lower total energy loss associated with this valve, indicating improved potential patient benefit. The durability of this new design of polyurethane heart valve was demonstrated when manufactured using a medical-grade polyurethane.

How to cite: Butterfield, M., Wheatley, D. J., Williams, D. F., & Fisher, J. (2001). A new design for polyurethane heart valves. The Journal of heart valve disease, 10(1), 105–110.

Background and aim of the study: The Medtronic Mosaic bioprosthesis (MMB) is a newly developed tissue valve which incorporates several features such as a low-profile semi-flexible stent, zero-pressure tissue fixation, and anti-mineralization pretreatment with alpha-amino oleic acid aimed to improve hemodynamics and prevent structural deterioration.

Methods: Between November 1995 to June 1999, 62 patients underwent aortic valve replacement (AVR) with the MMB; 41 of these who reached the one-year follow up interval and who had isolated AVR without any concomitant procedure with size 23 mm and 25 mm MMB were evaluated by serial echocardiography after three, six and 12 months.

Results: For size 23 mm valves, mean and peak gradients were 12+/-3 and 21+/-6 mmHg at 3 months, 12+/-3 and 20+/-5 mmHg at 6 months, and 12+/-4 and 20+/-6 mmHg at 12 months. For size 25 mm valves, mean and peak gradients were 13+/-2 and 22+/-4 mmHg at 3 months, 12+/-3 and 21+/-5 mmHg at 6 months, and 12+/-4 and 22+/-6 mmHg at 12 months. In patients with 23 mm MMB, left ventricular mass index (LVMi) was reduced from 181+/-34 g/m2 before surgery to 158+/-32, 150+/-28 and 140+/-25 g/m2 at 3, 6 and 12 months after AVR (p <0.001); in patients with 25 mm MMB, LVMi was reduced from 182+/-28 g/m2 before surgery to 165+/-25, 156+/-24 and 146+/-19 g/m2 at 3, 6 and 12 months after AVR (p <0.001).

Conclusion: Our results indicate that MMB is associated with low mean and peak gradients and significant reduction in LVMi throughout the postoperative period. Thus, the MMB appears to be an excellent cardiac valve substitute in elderly subjects who require AVR.

How to cite: Nardi, C., Scioti, G., Milano, A. D., De Carlo, M., & Bortolotti, U. (2001). Hemodynamic assessment of the Medtronic Mosaic bioprosthesis in the aortic position. The Journal of heart valve disease, 10(1), 100–104.

Background and aim of the study: The study was designed to investigate the clinical performance of the On-X prosthetic heart valve in a multicenter experience.

Methods: Between September 1996 and September 1999, 301 patients (56% males) underwent isolated On-X valve replacement (184 isolated aortic (AVR), 117 isolated mitral (MVR)) at 11 European centers under a standardized protocol. Average age at implant was 60.2 years. Office or hospital follow up was required by the protocol; average follow up on all patients was 11 months.

Results: Thirty-day mortality in the study was 2.2% for AVR and 6.0% for MVR, with valve-related mortality of 0.5% for AVR. There were eight late deaths (0.7%/pt-yr AVR and 2.3%/pt-yr MVR). Two of these deaths were sudden, and thus possibly valve-related (one AVR, one MVR). Early total valve-related morbidity was 3.5% for AVR and 2.6% for MVR. In total, 13 thromboembolic events occurred; one early event in AVR resulted in death (0.5%), and one transient early event occurred in MVR (0.9%). There were 11 late events (seven AVR (1.7%/pt-yr) and four MVR (1.8%/pt-yr)), for a two-year freedom from thromboembolism of 96.6% after AVR and 97.1% after MVR. Three late bleeding events occurred, all after AVR (0.7%/pt-yr and 98.9% free at two years). Major paravalvular leaks requiring reoperation occurred on two occasions early (one AVR (0.5%), one MVR (0.8%)) and once late in MVR (0.5%/pt-yr). Late minor, untreated paravalvular leaks occurred in three AVR patients (0.7%/pt-yr) and in one MVR patient (0.5%/pt-yr). Prosthetic endocarditis occurred four times (two AVR (0.5%/pt-yr), two MVR (0.9%/pt-yr)), all within the first 12 months of surgery. Actuarial freedom from all valve-related events at two years was 88.7% for AVR and 88.1% for MVR. NYHA class was improved in 75.8% of AVR patients and 70.6% of MVR patients at two years after surgery.

Conclusion: These early results indicate that the On-X valve provides satisfactory clinical outcome in the immediate postoperative period, and that the valve is both safe and effective.

How to cite: Laczkovics, A., Heidt, M., Oelert, H., Laufer, G., Greve, H., Pomar, J. L., Mohr, F. W., Haverich, A., Birnbaum, D., Regensburger, D., Palatianos, G., & Wolner, E. (2001). Early clinical experience with the On-X prosthetic heart valve. The Journal of heart valve disease, 10(1), 94–99.

Rupture mechanics of mitral valve chordae have been difficult to elucidate because most surgical repairs and pathological examinations are performed after the rupture. In an excised anterior leaflet from a fibrotic mitral valve, chordae were observed in an initial phase of rupture. Microscopic sections showed that thinned, nearly ruptured chordal segments were actually chordal cores, containing highly aligned collagen fibers. The outer sheath of elastic fibers, disorganized circumferentially oriented collagen fibers, and endothelial cells that normally surrounds the collagen core apparently had retracted to the extreme ends of the thinned segment, resulting in a bulbous shape, as noted in the chordal rupture literature. In conclusion, these new observations lead us to propose that the rupture of mitral valve chordae is not spontaneous, but may occur over time. The failure of the outer sheath may represent the first phase in a slow, two-part process leading to eventual chordal rupture.

How to cite: Grande-Allen, K. J., Ratliff, N. B., Griffin, B. P., Cosgrove, D. M., 3rd, & Vesely, I. (2001). Case report: outer sheath rupture may precede complete chordal rupture in fibrotic mitral valve disease. The Journal of heart valve disease, 10(1), 90–93.

Background and aim of the study: Mitral valve replacement (MVR) with preservation of the subvalvular apparatus may maintain postoperative left ventricular (LV) function better than conventional MVR. A prospective study was undertaken to assess the advantages of chordal preservation in rheumatic patients undergoing isolated MVR.

Methods: Between January 1996 and January 1999, 240 patients with rheumatic etiology and normal LV ejection fraction (>50%) underwent isolated MVR using a St. Jude Medical prosthesis. Patients were allocated to two groups: in group I (n = 168), both the anterior and posterior chordae were preserved; in group II (n = 72), the entire native mitral valve apparatus was excised. Patients from both groups were evaluated postoperatively (mean 12.5 months) by echocardiography and treadmill testing.

Results: Demographic and clinical profiles were comparable in both groups. There were three early deaths in group I, and one in group II. There were no late deaths. One patient in group I required reoperation for a stuck mitral prosthesis. LV function (ejection fraction >50%) was better in group I (94%) than in group II (82%) (p <0.05). No patient in either group had LV outflow tract obstruction on echocardiography. Patients in group I showed better exercise performance on treadmill (Bruce protocol): 92% of group I patients versus 88% of group II patients (p >0.05) completed stage I; 16% of group I patients, but no group II patients, were able to complete stage IV (p <0.05).

Conclusion: Mitral valve replacement with preservation of the subvalvular apparatus maintains LV function, and does not cause LV outflow tract obstruction.

How to cite: Wasir, H., Choudhary, S. K., Airan, B., Srivastava, S., & Kumar, A. S. (2001). Mitral valve replacement with chordal preservation in a rheumatic population. The Journal of heart valve disease, 10(1), 84–89.

Background and aim of the study: During the past 30 years, the development of mechanical and biological valves has led to major improvements in patient survival. Here, we present long-term results obtained with both types of prosthesis.

Methods: At our institution, between 1985 and 1989, 158 patients received a Biocor porcine bioprosthesis, and 100 patients a St. Jude Medical (SJM) mechanical valve. Preoperatively, mean age, male:female ratio, NYHA functional class and pathology of mitral valve disease were similar in both groups.

Results: The 30-day mortality was 4.4% in the Biocor group and 4% in the SJM group, the major cause being congestive heart failure. Late mortality was 17.9% and 15.6% respectively in the two groups, but valve-related mortality was very low in both (1.3% versus 4.2%). Ten-year survival was similar in each group (77.8+/-3.4% versus 81.0+/-3.9%; p = 0.538). Ten-year freedom from anticoagulant-related hemorrhage was higher with Biocor prostheses (99.3+/-0.7% versus 90.9+/-3.1%; p = 0.007). Valve thrombosis was seen only in the SJM group, and structural valve degeneration (SVD) only in the Biocor group. Ten-year freedom from reoperation was lower in the Biocor group (84.9+/-3.2% versus 92.2+/-2.8%; p = 0.206). The significant causes of reoperation were SVD in the Biocor group and valve thrombosis in the SJM group. Freedom from prosthetic valve endocarditis was similar in both groups (96.3+/-1.6% versus 95.5+/-2.2%).

Conclusion: As no difference was seen in survival and reoperation rates between patients receiving either bioprostheses or mechanical valves, the valve used will depend on the surgeon's choice and the type of patient, notably elderly patients who are intolerant of anticoagulation, and young women wishing to have children.

How to cite: Demirag, M., Kirali, K., Omeroglu, S. N., Mansuroglu, D., Akinci, E., Ipek, G., Berki, T., Gürbüz, A., Isik, O., & Yakut, C. (2001). Mechanical versus biological valve prosthesis in the mitral position: a 10-year follow up of St. Jude Medical and Biocor valves. The Journal of heart valve disease, 10(1), 78–83.

Background and aim of the study: Limited data are available regarding the efficacy of mitral valve repair in patients affected by active, acute infective endocarditis. In addition, the predictivity of transesophageal echocardiography (TEE) for guiding the surgical decision-making process in these patients has not yet been reported. The study aim was to evaluate the long-term results of mitral valve repair and role of TEE in active, acute infective endocarditis.

Methods: The study population consisted of patients affected by infective endocarditis of the mitral valve who underwent surgery. TEE was performed intraoperatively to guide the best surgical approach. All patients were followed up (mean 73+/-8 months) after surgery.

Results: Twenty-eight patients underwent surgery for infective endocarditis; of these, 13 had mitral valve repair for active, acute infective endocarditis and formed the basis of the study. Sensitivity, specificity, positive predictive value, negative predictive value of TEE in detecting the mechanism of mitral regurgitation were 87%, 100%, 100% and 92%, respectively. The predictivity test of TEE in guiding surgical strategy was 94%. All patients were alive at the time of follow up; 10 (77%) were in NYHA class I and three in class II (23%). Mitral regurgitation was severe in one patient (8%), moderate in three (23%), mild in four (31%), and absent in five (38%). No relapses of active infective endocarditis were observed during the follow up period.

Conclusion: Mitral valve repair appears to be an effective treatment for active, acute infective endocarditis with mitral regurgitation and should be considered as a therapeutic strategy when surgery is contemplated. TEE has a fundamental role in the surgical decision-making process in these patients.

How to cite: Senni, M., Merlo, M., Sangiorgi, G., Gamba, A., Procopio, A., Glauber, M., & Ferrazzi, P. (2001). Mitral valve repair and transesophageal echocardiographic findings in a high-risk subgroup of patients with active, acute infective endocarditis. The Journal of heart valve disease, 10(1), 72–77.

Background and aim of the study: Mitral valve repair has recently emerged as the treatment of choice in patients presenting with insufficiency due to valve prolapse. The study aims were to evaluate: (i) the clinical presentation in a consecutive series of patients with mitral valve prolapse undergoing surgical repair; (ii) the correlation between pre- and intraoperative echocardiographic features and surgical findings in these patients; and (iii) whether clinical and echocardiographic data may predict surgical outcome.

Methods: Between March 1997 and May 2000, 152 patients (110 men, 42 women; mean age 59+/-13 years) were recruited into the study. All patients had myxomatous mitral valve disease causing severe regurgitation and underwent systematic examination by transesophageal echocardiography (TEE) for clear delineation of the three scallops of the posterior leaflet and juxtaposed segments of the anterior leaflet.

Results: In 119 patients (78%) a flail valve was documented by TEE and confirmed on surgical inspection; an anterior leaflet chordal rupture was not visualized by TEE in one case. In 15 cases (10%) there was flail of the anterior leaflet, and in 105 cases (69%) flail of the posterior leaflet. A bileaflet complex prolapse without chordal rupture was found in 32 cases. On the basis of TEE evaluation, mitral valve replacement was performed electively in 10 patients (7%); the other 142 (93%) underwent mitral valve repair. Adequate repair was obtained in 93% of cases; residual mitral regurgitation (eight cases; grade 3+) and mitral stenosis (one case) were documented by intraoperative TEE, and nine patients (6%) underwent valve replacement.

Conclusion: The majority of patients with myxomatous mitral valve prolapse and severe regurgitation undergoing valve repair have chordal rupture of the posterior mitral leaflet, a condition in which results of valve repair are excellent. TEE provides a powerful means to define the mechanisms of mitral regurgitation and to identify the suitability of patients for valvuloplasty.

How to cite: Muratori, M., Berti, M., Doria, E., Antona, C., Alamanni, F., Sisillo, E., Salvi, L., & Pepi, M. (2001). Transesophageal echocardiography as predictor of mitral valve repair. The Journal of heart valve disease, 10(1), 65–71.

Background and aim of the study: Mitral valve replacement (MVR) with chordal preservation in patients with chronic mitral regurgitation (MR) has been reported to maintain systolic function of the left ventricle. However, the benefits of MVR with chordal preservation are not always predictable. The study aim was to ascertain the influence that papillary muscle (PM) size has on cardiac function after MVR with chordal preservation.

Methods: Postoperative regional shortening and its relationship with PM size were investigated by two-dimensional echocardiography in 18 patients who underwent MVR with chordal preservation, and nine patients without chordal preservation between 1986 and 1998 at Tenri Hospital. The PM cross-sectional area was measured in each patient, as well as postoperative fractional shortening (FS) of the septolateral, anteroposterior and vertical dimensions of the left ventricle. The technique of preserving all chordae tendineae involved reattaching the anterior leaflet chordae to the mitral annulus near each commissure.

Results: Postoperative FS of the septolateral and anteroposterior dimensions was better in patients with chordal preservation than in those without. In the former subgroup, a larger PM was associated with better FS of the left ventricle in the septolateral dimension (anterior PM, p <0.001, r = 0.78; posterior PM, p = 0.0010, r = 0.69), but not in the anteroposterior or vertical dimensions. This discrepancy in the relationship between PM size and functional benefits among the three dimensions may be related to the direction in which the PMs are suspended in our technique, or its effect on regional left ventricular function.

Conclusion: The present study indicated that PM size may be used as a factor to better predict the outcome of MVR with chordal preservation.

How to cite: Izumi, C., Himura, Y., Iga, K., Gen, H., Komeda, M., Ueda, Y., & Konishi, T. (2001). Relationship between papillary muscle size and benefit to cardiac function in mitral valve replacement with chordal preservation. The Journal of heart valve disease, 10(1), 57–64.

Background and aim of the study: The non-invasive evaluation of mitral valve area is often used in the assessment of patients with mitral stenosis. The pressure half-time method is commonly used to calculate valve area, but is inaccurate in many clinical scenarios. We sought to quantify the effects of changing cardiac output on the accuracy of mitral valve area determination.

Methods: Thirteen patients with mitral stenosis underwent routine stress echocardiography with resting and peak exercise results compared. A previously described and clinically validated mathematical model of the cardiovascular system was used to validate the clinical results. Seven different loading conditions for each of four different stenotic valve areas were modeled.

Results: In patients, with increasing cardiac output, pressure half-time decreased (-30.6+/-35.3 ms/l/min) and calculated valve area increased by 0.25+/-0.30 cm2/l/min. By continuity, it appeared that approximately half of this increase was due to actual valve orifice stretching, the remainder reflecting fundamental changes in the relationship between half-time and valve area. Mathematical modeling resulted in similar changes in pressure half-time and calculated valve area (0.06 to 0.12 cm2/l/min, p = 0.20 versus clinical results).

Conclusion: Changes in cardiac output result in predictable changes in pressure half-time, and should be considered when performing serial examinations in patients with mitral stenosis.

How to cite: Firstenberg, M. S., Prior, D. L., Greenberg, N. L., Wahi, S., Pasquet, A., Garcia, M. J., & Thomas, J. D. (2001). Effect of cardiac output on mitral valve area in patients with mitral stenosis: validation and pitfalls of the pressure half-time method. The Journal of heart valve disease, 10(1), 49–56.

Background and aim of the study: Aortic valve replacement (AVR) with a pulmonary autograft is an alternative treatment for young patients with aortic valve disease. Superior hemodynamic performance of the pulmonary autograft, and impact on parameters of left ventricular function were analyzed.

Methods: Thirty patients (21 males, nine females; mean age 29.97+/-12.29 years; range: 6-54 years) underwent a Ross procedure between November 1997 and November 1999. Seven patients (23%) were children (aged <15 years). In total, 22 patients were analyzed; each had at least three months follow up. Eleven patients had predominant aortic stenosis (AS), and 11 had aortic insufficiency (AI).

Results: There were no operative deaths. Two patients developed severe insufficiency, and the autograft was replaced with a mechanical valve. Pre- and postoperative echocardiograms were reviewed. The mean neoaortic maximal gradient was 7.85+/-5.59 mmHg (range: 3-29 mmHg). AS patients showed reduced interventricular septal (IVS) thickness at one month (from 13.27+/-3.69 to 11.60+/-2.44 mm; p = 0.0165) and 18 months after surgery (p = 0.0104). Left ventricular posterior wall (LVPW) thickness was reduced from 12.04+/-3.75 to 9.48+/-2.47 mm (p = 0.0338) at one month and 18 months (p= 0.0128) after surgery. The left ventricular end-diastolic internal dimension (LVIDd) decreased from 50.71+/-10.20 to 44.98+/-7.29 mm (p = 0.0491) at one month after surgery. In AI patients, LVPW and IVS thicknesses showed no significant variation, and LVIDd was decreased at one month (from 68.50+/-8.39 to 59.04+/-9.21 mm; p = 0.0017) and 18 months (p = 0.0229) after surgery. Left ventricular end-systolic internal dimension (LVIDs) decreased from 44.06+/-6.39 to 39.03+/-7.99 mm (p = 0.0081) at three months after surgery. Left ventricular mass index (LVMI) in the AS group decreased from 179.01+/-62.26 to 115.74+/-37.62 g/m2 (p = 0.0021) at one month after surgery, and at 18 months was normal, with a decrease from 208.77+/-32.89 to 95.89+/-28.82 g/m2 (p= 0.0003) (n = 5). In the AI group, LVMI decreased from 186.25+/-85.21 to 140.58+/-62.02 g/m2 (p = 0.0011) at one month after surgery, and at 18 months from 217.70+/-98.02 to 146.73+/-84.55 g/m2 (p= 0.0131) (n = 5).

Conclusion: The pulmonary autograft procedure can be used safely to replace the aortic valve, and allows optimal hemodynamic performance, with no significant aortic regurgitation. The Ross procedure results in normalization of left ventricular dimensions and improvement of left ventricular function early in the postoperative period.

How to cite: Legarra, J. J., Concha, M., Casares, J., Merino, C., Muñoz, I., & Alados, P. (2001). Left ventricular remodeling after pulmonary autograft replacement of the aortic valve (Ross operation). The Journal of heart valve disease, 10(1), 43–48.

Background and aim of the study: The Ross procedure (aortic valve replacement (AVR) with pulmonary autograft and pulmonary homograft replacement of pulmonary valve) was developed as a durable aortic valve substitute that avoids the need for anticoagulation and provides young patients with a long-lasting aortic valve substitute. Our seven-year follow up echocardiography data are reviewed.

Methods: Between May 1993 and March 2000, 40 adult patients (28 males, 12 females; mean age 33.3 years) underwent the Ross procedure at the Brigham and Women's Hospital for congenital aortic stenosis (n = 6), aortic insufficiency (n = 17) and mixed disease (n = 17). All patients had aortic root replacement with the pulmonary autograft and had no regurgitation after operation. Postoperative evaluation was conducted by transthoracic echocardiography, office visit and/or telephone interview. NYHA functional class, aortic and pulmonary valve function and aortic root dimensions were evaluated.

Results: One patient died postoperatively as a result of a low output state related to global left ventricular dysfunction. Four patients (10%) developed pulmonary homograft stenosis with a peak gradient >40mmHg; and six developed mild pulmonary stenosis. One patient had aortic insufficiency seven years postoperatively that required valve replacement. Eight patients developed mild dilatation (>37 mm) of the neoaortic root, and five of these had aortic insufficiency. One patient required transplantation at 40 months for restrictive cardiomyopathy.

Conclusion: The Ross procedure is an effective means of AVR that can be accomplished with low perioperative morbidity and mortality if certain technical modifications are carried out. In this series of 40 patients with mid-term follow up, a significant number developed moderate pulmonary trunk stenosis, though echo characterization demonstrated good valve function.

How to cite: Linden, P. A., & Cohn, L. H. (2001). Medium-term follow up of pulmonary autograft aortic valve replacement: technical advances and echocardiographic follow up. The Journal of heart valve disease, 10(1), 35–42.

Background and aim of the study: Intraoperative transesophageal echocardiography (TEE) is commonly used during aortic valve surgery. In aortic valve replacement (AVR), this permits measurement of the aortic annulus, study of the anatomy of aortic valve components, and prediction of prosthesis valve size. After cardiopulmonary bypass (CPB), echocardiography is valuable in checking prosthesis function. In this study, we evaluated the impact of intraoperative TEE on the decision-making process of aortic Toronto stentless prosthetic valve (TSPV) implantation.

Methods: Fifty-two consecutive patients undergoing elective AVR were collected prospectively. Multiplane TEE was performed before CPB to determine diameters of the aortic valve annulus and sinotubular junction. This was to evaluate the feasibility of TSPV implantation in the aortic position and to predict prosthesis size. Further TEE evaluation was carried out after CPB to assess prosthetic valve function.

Results: TEE allowed measurement of the aortic annulus and sinotubular junction, and enabled correct prediction of prosthesis size. Ultrasonic evaluation also revealed contraindications to TSPV implantation in five patients. In one case, color-Doppler examination led to immediate successful surgical correction of prosthetic incompetence.

Conclusion: Intraoperative multiplane TEE examination is useful in the decision-making process in AVR with the TSPV by selecting patients suitable for the stentless valve, predicting prosthesis size, and checking prosthesis function.

How to cite: Guarracino, F., Zussa, C., Polesel, E., Rigo, F., Penzo, D., & De Cosmo, D. (2001). Influence of transesophageal echocardiography on intraoperative decision making for toronto stentless prosthetic valve implantation. The Journal of heart valve disease, 10(1), 31–34.

Background and aim of the study: The natural history of patients with Marfan syndrome is depressing, but surgical intervention on the aorta can improve the prognosis. Study results were analyzed with reference to long-term survival, morbidity and function.

Methods: Seventy-four Marfan patients (51 males, 23 females; mean age 41+/-14 years), underwent first-time aortic surgery between 1977 and 1998. Follow up information regarding mortality, morbidity and functional status was obtained from patient records and by questionnaire. The mean follow up was 5 years (range: 0-19 years). Forty-seven patients (64%) had a dissection, 27 (36%) an aneurysm, and 45 (61%) patients underwent emergency operations (<4 h from arrival at hospital). In 72 patients (97%) the disease affected the ascending aorta, and implantation of a composite graft was the most frequent operation.

Results: Overall 30-day mortality was 12% (3% in elective cases, 18% in emergency cases, p <0.05). Emergency operations and surgery extended to the aortic arch were risk factors for early mortality. Overall actuarial survival was 63.4+/-8% at 10 years. Age was the only risk factor for late mortality. Seventeen patients were reoperated on due to pathologies of the remaining aorta (n = 12), pseudoaneurysms (n = 4) and aortic valve endocarditis (n = 1). A total of five patients had endocarditis; one patient with a homograft required surgery, and medical treatment was successful in the other four patients. Five patients had neurological thromboembolic episodes without permanent damage, and six had minor bleeding complications. Freedom from early and late mortality, reoperation on the aorta and major cardiovascular events (endocarditis episodes, thromboembolic/hemorrhagic strokes and other major bleeding/embolic episodes) was 33.3 +/- 8.1% at 10 years. At follow up, 98% of patients were in NYHA functional class I or II, and 80% were working.

Conclusion: Elective aortic surgery in Marfan patients can be performed with good results. Close follow up of patients undergoing surgery is important. The long-term functional status of surviving patients is satisfactory.

How to cite: Marfan syndrome, aortic surgery, composite graft, morbidity, functional status

Background and aim of the study: Hyperlipidemia is a risk factor for the progression of coronary artery disease, and possibly also valvular aortic stenosis. Thus, patients with aortic stenosis, coronary disease (or both) might be expected to have more abnormal lipid profiles than those without these two conditions.

Methods: The lipid profiles of patient subsets undergoing aortic valve replacement (AVR) with or without concomitant coronary artery bypass grafting (CABG), as well as those undergoing isolated CABG, between 1987 and 1997 were analyzed retrospectively. Four surgical groups were identified: AVR for aortic regurgitation (n = 370); AVR for predominant aortic stenosis (n = 1,072); AVR for aortic stenosis (AS) with CABG (n = 914); and isolated CABG (n = 11,156). The complete fasting lipid profiles of patients were collected, analyzed by group, and compared.

Results: Analysis by Spearman's correlation showed that total cholesterol levels, triglycerides and low-density lipoproteins (LDL-C) were modestly, yet significantly, increased in each successive group, while high-density lipoproteins were decreased. AS patients undergoing isolated AVR had significantly higher total cholesterol (215 versus 201 mg/dl; p <0.0001), triglycerides (125 versus 104 mg/dl; p <0.0001) and LDL-C (139 versus 132 mg/dl; p = 0.003) than those undergoing AVR for aortic regurgitation. Total cholesterol >200 mg/dl was significantly associated with AS, even after adjusting for differences in age, sex, diabetes mellitus and hypertension, with an odds ratio of 1.5 (95% confidence interval, 1.2-2.0; p = 0.001).

Conclusion: Progressively abnormal lipid profiles are associated with AS and coronary disease in patients undergoing AVR. This evidence helps to extend the link between dyslipidemia and AS in a large consecutive series of patients.

How to cite: Novaro, G. M., Pearce, G. L., Sprecher, D. L., & Griffin, B. P. (2001). Comparison of cardiovascular risk and lipid profiles in patients undergoing aortic valve surgery versus those undergoing coronary artery bypass grafting. The Journal of heart valve disease, 10(1), 19–24.

Recurrent aortic insufficiency presents in as many as 20% of patients late after repair of acute type A aortic dissection. This underscores the need for life-long follow up and appropriate management of patients after such surgery. The prevalence of, and risk factors for, recurrent aortic regurgitation, and the indications for and results of medical and surgical treatment are discussed.

How to cite: Luciani, G. B., & Mazzucco, A. (2001). Aortic insufficiency after surgical repair of acute type a aortic dissection: incidence, indications for reoperation and medical management. The Journal of heart valve disease, 10(1), 12–18.

Background and aim of the study: In some patients with dilated aortic root, attempts have been made to replace the aorta and preserve the anatomically normal leaflets. The tubular Dacron graft used in the valve-sparing procedure does not have the sinuses of Valsalva, and therefore might adversely affect the valve. The effect of the presence or absence of the sinuses was investigated on stresses in the leaflets.

Methods: Finite element models of the tubular aortic root and the root with the sinuses were constructed. The model dimensions were: aorta radius 13 mm; valve height 18 mm; leaflet thickness 0.5 mm; aorta and sinus wall thickness 1.3 mm. In the root with the sinuses, each leaflet-sinus unit formed a cylindrical geometry. The model was loaded with an internal pressure of 80 mmHg (0.01 N/mm2) and the stress determined.

Results: The stress in the leaflet belly was 0.26 N/mm2, and not affected by the geometry and stiffness of the root. In the tubular root there was a stress concentration along the leaflet attachment, and the stress reached 0.65 N/mm2; in contrast, in the sinus root there was no stress concentration and maximum stress was only 0.3 N/mm2. Under pressure, the leaflet-sinus assembly expanded in a uniform manner, whereas in a tubular root large deformations occurred along the leaflet attachment.

Conclusion: The sinuses of Valsalva play a very important role in minimizing stress in the leaflets; thus, use of the sinus graft is expected to enhance the longevity of the spared valve.

How to cite: Beck, A., Thubrikar, M. J., & Robicsek, F. (2001). Stress analysis of the aortic valve with and without the sinuses of valsalva. The Journal of heart valve disease, 10(1), 1–11.