A case is reported of aneurysm of both the ascending aorta and pulmonary artery, associated with massive pulmonary valve insufficiency. Pulmonary artery aneurysm is a rare condition of unknown natural history; therapeutic management has not yet been established. Pulmonary valve insufficiency is also rare, with reported etiologies comprising mainly pulmonary valve anomalies. A comparative review of the literature relating to the diagnosis and therapeutic management of the condition is provided.

How to cite: Naja G, Fayad G, Modine T, Decoene C, Azzaoui R, Larrue B, Warembourg H. Massive pulmonary valve insufficiency associated with double pulmonary artery and ascending aorta aneurysm. J Heart Valve Dis. 2006 Jan;15(1):146-8. PMID: 16480029.

The case presented is of prosthetic aortic valve endocarditis in a 23-year-old male patient, complicated by an inflammatory periprosthetic valvular leak, and fistula formation between the aorta and the right atrium. The fistulous tract was diagnosed intraoperatively. Closure of the fistula was performed successfully in concordance with re-replacement of the aortic valve.

How to cite: Darwazah A, Kiswani M, Ismail H, Hawari M, Awad S. Aorto-right atrial fistula: a complication of prosthetic aortic valve endocarditis. A case report. J Heart Valve Dis. 2006 Jan;15(1):142-5. PMID: 16480028.

During the past two decades, percutaneous mitral balloon valvulotomy (PMBV) has been frequently used, with high success and low complication rates, in the treatment of patients with moderate to severe rheumatic mitral stenosis. The case is reported of a patient with severe rheumatic mitral stenosis who developed acute pericarditis two days after successful PMBV. To the best of the authors' knowledge, this is the first such case to be reported.

How to cite: Turhan H, Basar N, Yasar AS, Erbay AR, Atak R. Acute pericarditis as a complication of percutaneous mitral balloon valvulotomy. J Heart Valve Dis. 2006 Jan;15(1):140-1. PMID: 16480027.

Background and aim of the study: Quadrangular resections for posterior mitral leaflet prolapse create a defect that requires readaptation of the annulus as well as the leaflet cut edges. A variety of techniques has been described to narrow the posterior mitral annulus. Herein is described a simple compression stitch that allows compensation of annular size reduction even for large resections of the mural leaflet.

Methods: The annular compression stitch consists of four bites: the first stitch is placed from the atrium into the ventricle; the second takes a piece of ventricular myocardium parallel to the mitral ring; the third returns the needle into the atrium some millimeters outside the opposite cut edge of the mitral leaflet; and the fourth stitch grabs atrial myocardium parallel to the previous ventricular stitch. Tying the knots compresses the annulus to an extent that allows reanastomosis of the two leaflet cut edges.

Results: This new technique was used in 212 patients undergoing mitral valve repair. Intraoperative outcome was excellent, and after a mean follow up period of 2.5 years no reoperation was needed due to failure of the annular compression stitch.

Conclusion: The new compression stitch simplifies the repair, avoids the creation of a trench, and allows readaptation of the two mural leaflet edges without tension, even in large posterior resections.

How to cite: Dzemali O, Kleine P, Moritz A. Annular compression stitch for quadrangular resections in mitral valve repair. J Heart Valve Dis. 2006 Jan;15(1):132-5. PMID: 16480025.

Background and aim of the study: Few data exist on infective endocarditis (IE) in intravenous drug abuse (IVDA) patients. In particular, clinical features, site of involvement and bacteriologic findings are controversial. Little is also known on the results of surgical treatment and on the long-term prognosis.

Methods: The clinical and microbiological characteristics of IE in a series of 39 IVDA patients were retrospectively assessed and compared to those in 85 non-IVDA patients with a likely similar life expectancy. The total follow up of patients was 717.6 patient-years (119.9 pt-yr for IVDA, 597.7 pt-yr for non-IVDA).

Results: Although tricuspid involvement was significantly more frequent in IVDA cases than in non-IVDA cases (p = 0.001), left-sided endocarditis prevailed in both groups. In addition to Staphylococcus aureus (51.3%), Staph. epidermidis (15.4%) and streptococcal spp. (23.1%) were emerging pathogens in IVDA cases. A worse cardiac function (p < 0.002) and a higher rate of embolism (p = 0.04) characterized the preoperative status of IVDA patients. No difference was observed as to indications, emergency procedures and pathologic findings. Hospital and long-term survival did not significantly differ between the two groups. The rate of recurrence was higher in IVDA cases; this difference was mostly accounted for by early postoperative events.

Conclusion: A new pattern of IE in IVDA is emerging, characterized by more frequent left heart involvement (61.5%), a severe clinical course, and a need for surgery in the active phase. Staph. epidermidis and streptococci are emerging pathogens. Drug abuse does not affect postoperative prognosis when an aggressive surgical attitude is combined with prolonged medical therapy. Higher rates of early recurrence are expected during the follow up period.

How to cite: Carozza A, De Santo LS, Romano G, Della Corte A, Ursomando F, Scardone M, Caianiello G, Cotrufo M. Infective endocarditis in intravenous drug abusers: patterns of presentation and long-term outcomes of surgical treatment. J Heart Valve Dis. 2006 Jan;15(1):125-31. PMID: 16480024.

Background and aim of the study: Few data exist on infective endocarditis (IE) in intravenous drug abuse (IVDA) patients. In particular, clinical features, site of involvement and bacteriologic findings are controversial. Little is also known on the results of surgical treatment and on the long-term prognosis.

Methods: The clinical and microbiological characteristics of IE in a series of 39 IVDA patients were retrospectively assessed and compared to those in 85 non-IVDA patients with a likely similar life expectancy. The total follow up of patients was 717.6 patient-years (119.9 pt-yr for IVDA, 597.7 pt-yr for non-IVDA).

Results: Although tricuspid involvement was significantly more frequent in IVDA cases than in non-IVDA cases (p = 0.001), left-sided endocarditis prevailed in both groups. In addition to Staphylococcus aureus (51.3%), Staph. epidermidis (15.4%) and streptococcal spp. (23.1%) were emerging pathogens in IVDA cases. A worse cardiac function (p < 0.002) and a higher rate of embolism (p = 0.04) characterized the preoperative status of IVDA patients. No difference was observed as to indications, emergency procedures and pathologic findings. Hospital and long-term survival did not significantly differ between the two groups. The rate of recurrence was higher in IVDA cases; this difference was mostly accounted for by early postoperative events.

Conclusion: A new pattern of IE in IVDA is emerging, characterized by more frequent left heart involvement (61.5%), a severe clinical course, and a need for surgery in the active phase. Staph. epidermidis and streptococci are emerging pathogens. Drug abuse does not affect postoperative prognosis when an aggressive surgical attitude is combined with prolonged medical therapy. Higher rates of early recurrence are expected during the follow up period.

How to cite: Carozza A, De Santo LS, Romano G, Della Corte A, Ursomando F, Scardone M, Caianiello G, Cotrufo M. Infective endocarditis in intravenous drug abusers: patterns of presentation and long-term outcomes of surgical treatment. J Heart Valve Dis. 2006 Jan;15(1):125-31. PMID: 16480024.

Background and aim of the study: Removal of the entire infected system is the traditionally indicated management of pacemaker lead endocarditis (PLE), based on expert recommendations. Herein is described the present authors' experience with this condition.

Methods: Between 1987 and 2004, all consecutive patients with PLE treated at a tertiary referral university hospital and a community hospital were prospectively selected. Clinical features, management and outcome were analyzed.

Results: Thirteen cases of PLE were diagnosed. Surgery was performed in 10 cases, and medical treatment alone in three (due to advanced age in two cases and because of terminal colon cancer in one case). Four subjects died before discharge: three deaths occurred after surgery (one patient died due to refractory ventricular arrhythmia and two from persistent sepsis), and one unoperated patient died from sepsis and severe renal failure. No deaths or late surgeries were observed after a mean follow up period of 37 +/- 14 months. Both patients who survived hospitalization and underwent only medical treatment were free from late complications after 30 and 60 months follow up, respectively.

Conclusion: Some patients with PLE present a good evolution without surgery, suggesting that surgical treatment is not mandatory in this situation. However, an indication for surgery may be similar to that for other cases of infective endocarditis.

How to cite: Ruiz M, Anguita M, Castillo JC, Delgado M, Romo E, Torres F, Mesa D, Franco M, Vallés F. Pacemaker-related endocarditis: clinical features and treatment. J Heart Valve Dis. 2006 Jan;15(1):122-4. PMID: 16480023

Background and aim of the study: Although retrospective reviews evaluating the surgical management of infective endocarditis (IE) have been conducted in Europe and in the USA, few data exist regarding management of the condition in Canada. The study aim was to evaluate the surgical management of individuals with culture-positive active IE at a Canadian tertiary care university hospital.

Methods: A retrospective analysis was performed of 74 patients (53 males, 21 females; mean age 56 +/- 14 years) with a preoperative diagnosis of acute IE between 1995 and 2003 at the Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia. Preoperative clinical variables evaluated included the Duke criteria for endocarditis, correlation between preoperative echocardiographic imaging and intraoperative findings, and postoperative morbidity and mortality.

Results: Native valve endocarditis (NVE) was present in 60 patients, and prosthetic valve endocarditis (PVE) in 14. All patients met the Duke criteria for endocarditis. Correlation between preoperative transesophageal echocardiography (TEE) and surgical findings (vegetations 63%, abscesses 96%, leaflet perforation 100%) was superior when compared with preoperative transthoracic echocardiography (vegetations 43%, abscesses 75%, leaflet perforation 89%). There were low rates of postoperative morbidity (reoperation 8%, stroke 5%). Overall in-hospital mortality was 14% (seven NVE, 12%; three PVE, 21%).

Conclusion: Herein is presented the largest and most current case series of patients treated surgically for active IE. The results demonstrate excellent agreement between preoperative TEE and intraoperative surgical findings in the current era of surgical management of this condition.

How to cite: Jassal DS, Hassan A, Buth KJ, Neilan TG, Koilpillai C, Hirsch GM. Surgical management of infective endocarditis. J Heart Valve Dis. 2006 Jan;15(1):115-21. PMID: 16480022. 

Background and aim of the study: The Ross procedure employs an autologous pulmonary valve to replace the aortic valve, but requires pulmonary homograft replacement. Concerns regarding long-term homograft function may limit the adoption of this technique. Herein, the incidence of, and factors leading to, stenosis of the homograft were examined.

Methods: Data were collected from 131 patients (32 females, 99 males) who underwent a Ross procedure between July 1994 and December 2003. Complete follow up data were collected from 113 of 125 (90.4%) living patients. Donor valve information, including storage time, was supplied by the graft manufacturers. Data were analyzed using chi-square tests, t-test and logistic regression.

Results: The mean patient follow up was 703 +/- 574 days (median 599 days; range: 2 to 2,408 days). Echocardiographic stenosis had occurred in 14 patients (12.4%). Four patients (3.2%) required homograft replacement, and two required balloon valvuloplasty. There was no significant difference in graft vendor, recipient, donor age or blood type match between stenotic and non-stenotic recipients. Donor valve size was appropriate for the recipients, and greater than predicted by recipient body surface area (BSA). Donor valves that developed stenosis had a shorter storage time after processing (160 +/- 100 versus 249 +/- 223 days; p = 0.03). Male donor valves became stenotic in 9.9% (7/71) of male recipients, but in none of 20 females. Female donor valves became stenotic in 27.3% (3/11) of male recipients, and in 28.6% (2/7) females. Logistic regression showed donor gender to be a significant predictor for stenosis (p = 0.007; odds ratio 14.1 for female/male donors; 95% CI 2.1-96.4).

Conclusion: Donor valves which developed stenosis had a shorter mean cryopreservation time than those that did not develop stenosis. In addition, female donor homografts appeared to develop stenosis at a greater rate, independent of patient age, graft size to BSA match, and blood type.

How to cite: Ryan WH, Herbert MA, Dewey TM, Agarwal S, Ryan AL, Prince SL, Mack MJ. The occurrence of postoperative pulmonary homograft stenosis in adult patients undergoing the Ross procedure. J Heart Valve Dis. 2006 Jan;15(1):108-13; discussion 113-4. PMID: 16480021.

Background and aim of the study: Concern exists regarding progressive root dilatation after the modified Ross procedure. The present prospective echocardiographic study aimed to provide further insight into neo-aortic regurgitation (nAR) and neoaortic root dimensions over time in adult Rotterdam Ross root patients, and to study potential risk factors for nAR and dilatation.

Methods: All Rotterdam Ross patients aged > or = 16 years at surgery were subjected to a prospective biennial standardized echocardiographic protocol. Analysis over time of nAR according to the jet length and jet diameter method, autograft annulus and sinotubular junction (STJ) diameters was carried out using a multilevel linear model in 90 patients who had two or more echocardiographic measurements (mean 5; range 2-9; total 458) up to 14 years (mean 7 years) after surgery.

Results: The mean (+/- SE) initial postoperative jet length nAR was grade 0.9 +/- 0.09, and the annual increase 0.1 +/- 0.02 (p < 0.001). Initial annulus and STJ diameters were 25 +/- 0.5 mm and 36 +/- 0.6 mm, while annual increases were 0.4 +/- 0.07 mm and 0.5 +/- 0.09 mm, respectively (p < 0.001). Patients who eventually underwent an autograft reoperation (n = 10) had significantly greater initial nAR and greater progression of nAR, and a greater initial annulus diameter. The annual annulus and STJ diameter increase was greater in patients who underwent autograft reoperation. Compared to freestanding root replacement, patients with inclusion cylinder aortic root replacement had smaller initial annulus and STJ diameters that did not increase over time. Female gender was associated with a greater initial jet length and jet diameter nAR and a greater increase over time in jet diameter nAR. Preoperative aortic regurgitation or combined aortic stenosis and regurgitation were associated with greater initial annulus and STJ diameters. Neither bicuspid valve disease, patient age, preoperative ascending aorta aneurysm, prior aortic valve surgery nor hypertension had an effect on initial or progression of nAR, annulus, and STJ diameter.

Conclusion: The annual increase in nAR and root dimensions is small, but persistent, after autograft aortic root replacement in adults, and further reoperations should be anticipated. Use of the inclusion cylinder root replacement technique seems to prevent neo-aortic dilatation.

How to cite: Takkenberg JJ, van Herwerden LA, Galema TW, Bekkers JA, Kleyburg-Linkers VE, Eijkemans MJ, Bogers AJ. Serial echocardiographic assessment of neo-aortic regurgitation and root dimensions after the modified Ross procedure. J Heart Valve Dis. 2006 Jan;15(1):100-6; discussion 106-7. PMID: 16480020.

The case is reported of a 26-year-old male patient who died eight years after the replacement of an aortic valve with a bileaflet mechanical valve (TEKNA; Edwards, USA). Following prosthesis implantation, the patient had been in a good state of health, and his death occurred unexpectedly. Forensic autopsy revealed a leaflet escape, with two fragments of the leaflet being found bilaterally in the common iliac arteries. Death occurred due to an acute cardiac insufficiency. Immunohistochemical investigations revealed fresh myocardial fiber necroses. Stereomicroscopic and scanning electron microscopic investigations demonstrated surface erosions of the leaflet. Although the valve was withdrawn from the market in June 2000, it had previously been implanted in over 18,000 patients. Thus, from a clinical viewpoint, the question of using a prophylactic replacement in affected patients must be discussed.

How to cite: Pfeiffer H, Bertolini J, Scheld HH, Brinkmann B. Fatal leaflet escape in an Edwards TEKNA aortic prosthesis. J Heart Valve Dis. 2006 Jan;15(1):97-9. PMID: 16480019.

Background and aim of the study: A variety of valve substitutes are used for right ventricular outflow tract (RVOT) reconstruction in children and young adults after previous RVOT surgery that has led to significant pulmonary insufficiency and/or stenosis. Herein, the authors' experience with pulmonary valve replacement (PVR) using a porcine valved conduit late after previous RVOT surgery was reviewed.

Methods: Between August 2002 and April 2005, 31 patients (mean age 14.5 +/- 9.5 years; range: 1.2-33.1 years) underwent PVR using the Medtronic Freestyle porcine aortic root. These patients averaged two prior operations (range: 1-5) for the following diagnoses: tetralogy of Fallot +/- pulmonary atresia (n = 21); persistent truncus arteriosus (n = 5); aortic stenosis (Ross-Konno procedure) (n = 2); pulmonary atresia with intact ventricular septum; (n = 1); congenital pulmonary stenosis (n = 1); and transposition of the great arteries (n = 1). Of these patients, 29 (93.5%) underwent additional procedures at the time of pulmonary valve insertion including: branch pulmonary artery reconstruction (n = 21), atrial septal defect closure (n = 5), ascending aorta replacement (n = 4), pacemaker or defibrillator placement (n = 3), tricuspid valve repair (n = 2), ventricular septal defect closure (n = 2), and other procedures (n = 2).

Results: There were no early or late deaths. The mean hospital stay was 8.3 +/- 5.9 days (range: 4-25 days). One patient had a subarachnoid hemorrhage with transient left hemiparesis, and two patients had acute tubular necrosis with temporary dialysis treatment. All patients were well at a mean follow up of 13 +/- 9.3 months (range: 0.5-31 months). Echocardiography showed trivial or no pulmonary insufficiency in 30 patients (96.7%). The calculated mean peak systolic RVOT gradient by echocardiography was 23.4 +/- 7.6 mmHg.

Conclusion: The Medtronic Freestyle bioprostheses demonstrated excellent short-term results for repeat RVOT reconstruction. This valve's hemodynamic characteristics are comparable to those of homografts, and it is an attractive alternative given the limited availability of homograft valves. A lack of availability in sizes smaller than 19 mm limits use of this valve in pediatric patients, and long-term results remain to be determined.

How to cite: Erez E, Tam VK, Doublin NA, Stakes J. Repeat right ventricular outflow tract reconstruction using the Medtronic Freestyle porcine aortic root. J Heart Valve Dis. 2006 Jan;15(1):92-6. PMID: 16480018.

Background and aim of the study: The study aim was to compare the effects of dobutamine stress and exercise on prosthetic mitral valve hemodynamics.

Methods: Twenty-three patients who had recently (3 +/- 1 months) undergone mechanical mitral valve implantation were studied. Hemodynamic variables, two-dimensional echocardiographic and Doppler mitral/aortic flows were recorded at rest, and then repeated during exercise and dobutamine stress. The investigations were randomized place to determine which stress would be performed first.

Results: Heart rates and pressure drops rose significantly from resting values. At maximum stress, exercise produced maximum and mean pressure drops which were statistically greater than with dobutamine (19.4 +/- 6.0 versus 12.8 +/- 4.7 mmHg (p < 0.001) and 10.2 +/- 3.5 versus 6.8 +/- 2.8 (p < 0.01), respectively). Exercise was associated with statistically shorter diastolic filling times and higher transvalvular diastolic flow rates. Dobutamine produced a greater augmentation in mitral effective orifice area (EOA) (p < 0.05). The slopes of pressure drop/cardiac flow were calculated for stress type and shown to be significantly lower during dobutamine administration (p = 0.03).

Conclusion: Normally functioning mitral prostheses can generate significant increases in valvular pressure drops under high flow conditions. Physiological differences exist between dobutamine stress and exercise when assessing diastolic filling. At a given flow rate, dobutamine produces a greater augmentation in the mitral EOA and a smaller drop in transvalvular pressure.

How to cite: Hobson NA, Wilkinson GA, Cooper GJ, Wheeldon NM, Lynch J. Hemodynamic assessment of mitral mechanical prostheses under high flow conditions: comparison between dynamic exercise and dobutamine stress. J Heart Valve Dis. 2006 Jan;15(1):87-91. PMID: 16480017.

Background and aim of the study: The study aim was to evaluate the clinical performance of the On-X heart valve in a socioeconomically disadvantaged population. Most patients were from an indigenous, poorly educated and geographically dispersed segment of the population where anticoagulation therapy was generally erratic.

Methods: Between 1999 and 2004, a total of 530 valves (242 mitral valves, 104 aortic valves, 92 double valves) was implanted in 438 patients (average age 33 years; range: 3-78 years). The most common reason for surgery was rheumatic valve disease (57%), followed by degenerative valve disease (11%) and infective endocarditis (9%). Follow up was 95% complete for a total of 746 patient-years (pt-yr). Among the patient population, 40% were either not anticoagulated or were unsatisfactorily anticoagulated.

Results: Hospital mortality was 2.3%, and none of the hospital deaths was valve-related. Mean (+/- SE) actuarial survival (including hospital deaths) at four years was: AVR 73.8 +/- 8.1%, MVR 83.4 +/- 5.7% and DVR 60.9 +/- 10.3%. Linearized rates (for AVR, MVR and DVR, respectively) for late complications (%/ pt-yr) were: bleeding events 0.6, 1.0, and 2.3; thrombosis 0.0, 0.2, and 0.0; endocarditis 0.6, 1.0, and 2.3; paravalvular leak 0.6, 0.2, and 0.0; systemic embolism 1.1, 1.5, and 3.5. Most systemic emboli were related to infective endocarditis. Among patients there were seven uncomplicated, full-term pregnancies.

Conclusion: Bearing in mind the erratic anticoagulation coverage and high incidence of infective endocarditis, the results of this study may be regarded as encouraging. The low incidence of valve thrombosis (one case) was noteworthy. These data also suggest that the On-X valve may be implanted with relative safety in women wishing to have children.

How to cite: Williams MA, van Riet S. The On-X heart valve: mid-term results in a poorly anticoagulated population. J Heart Valve Dis. 2006 Jan;15(1):80-6. PMID: 16480016.

Background and aim of the study: This ongoing, longitudinal, multi-center, North American study was designed to evaluate the safety and effectiveness of the On-X valve.

Methods: The On-X valve was implanted in isolated aortic (AVR) and mitral (MVR) valve replacement patients at nine North American centers. Follow up was 98.6% complete. Anticoagulation compliance was evaluated by collection of international normalized ratio (INR) results in all patients throughout their postoperative follow up. Adverse events were recorded according to the AATS/STS guidance criteria. Hematologic studies were conducted postoperatively to evaluate hemodynamics and hemolysis.

Results: In total, 142 AVR and 142 MVR implants were performed; the mean follow up was 4.5 years; total follow up was 1,273 patient-years (pt-yr). At implant, the mean patient age was 59.2 years (range: 28 to 85 years); 71.8% of patients who underwent AVR and 33.1% who underwent MVR were males. Preoperatively, 89.4% of AVR patients and 56.3% of MVR patients were in sinus rhythm. The cardiac disease etiology was primarily stenotic, calcific degeneration in AVR and rheumatic or degenerative regurgitation in MVR. Hemolysis represented by postoperative elevation of serum lactate dehydrogenase was very low (median 217 IU after AVR and 251 IU after MVR at one year (82% AVR and 98% MVR of upper normal). Late adverse event rates were low, most notably thromboembolism (0.9%/pt-yr after AVR; 1.6%/pt-yr after MVR) and thrombosis. Kaplan-Meier event-free rates at five years were correspondingly high. Anticoagulation compliance analysis showed only about 40% of INR readings to be within target ranges postoperatively; thus, the control range achieved was much greater than the desired target, as might generally be expected for clinic-controlled INR.

Conclusion: The On-X valve performed well in this study, confirming the original design intent of minimal hemolysis and low adverse event rates.

How to cite: McNicholas KW, Ivey TD, Metras J, Szentpetery S, Marra SW, Masters RG, Dilling EW, Slaughter MS, Mack MJ. North American multicenter experience with the On-X prosthetic heart valve. J Heart Valve Dis. 2006 Jan;15(1):73-8; discussion 79. PMID: 16480015.

Background and aim of the study: Mechanical prostheses are used in young patients, the CarboMedics valve having been the mechanical valve of choice of the present authors during the past 15 years. The study aim was to analyze long-term clinical and echocardiographic results obtained with CarboMedics mechanical valves.

Methods: A total of 2,953 patients underwent valve replacement with the CarboMedics valve between 1988 and 2004 at the Montreal Heart Institute. Patients were prospectively followed at the outpatient valve clinic. Subsequently, 1,004 patients underwent echocardiographic examinations during follow up.

Results: In total, 1,597 patients (mean age 57 +/- 12 years) underwent isolated aortic valve replacement (AVR), 1,043 patients (mean age 59 +/- 10 years) underwent isolated mitral valve replacement (MVR), and 313 patients (mean age 58 +/- 11 years) underwent AVR+MVR. The mean five-, 10- and 15-year actuarial survival rates were 83 +/- 1%, 70 +/- 2% and 62 +/- 3% in AVR patients, 76 +/- 1%, 59 +/- 2% and 40 +/- 14% in MVR patients, and 68 +/- 3%, 51 +/- 4% and 33 +/- 9% in AVR+MVR patients. The mean 15-year freedom from cerebral embolism, hemorrhage and reoperation was 95 +/- 1%, 97 +/- 1% and 95 +/- 1% in AVR patients, 92 +/- 1%, 97 +/- 1% and 93 +/- 1% in MVR patients, and 94 +/- 2%, 93 +/- 2% and 91 +/- 4% in AVR+MVR patients. AVR patients had a mean aortic gradient of 29 +/- 14, 20 +/- 8, 18 +/- 7, 16 +/- 7, 12 +/- 5 and 11 +/- 5 mmHg with 19, 21, 23, 25, 27 and 29 mm prostheses, respectively (p = 0.001). MVR patients had a mean mitral gradient of 5.3 +/- 3, 4.9 +/- 2.2, 4.6 +/- 2, 4.4 +/- 2.9 and 4.9 +/- 1.8 mmHg with 25, 27, 29, 31 and 33 mm prostheses, respectively (p = 0.63).

Conclusion: Patient survival and valve-related complications were satisfactory at 15 years after valve replacement with the CarboMedics valve. Mean aortic gradients were high with the 19-mm aortic prostheses, but all other valve sizes showed good hemodynamic performance, as measured using transthoracic echocardiography.

How to cite: Carrier M, Pellerin M, Basmadjian A, Bouchard D, Perrault LP, Cartier R, Pagé P, Demers P, Hébert Y. Fifteen years of clinical and echocardiographic follow up with the carbomedics heart valve. J Heart Valve Dis. 2006 Jan;15(1):67-72; discussion 72. PMID: 16480014.

Background and aim of the study: The selection of a suitable valve substitute in patients requiring valvular heart surgery is an important element in the preoperative decision-making process between cardiologist, surgeon, and patient. Controversy persists regarding the use of mechanical valves in the elderly. With the population living longer, reoperative risk becomes of paramount importance. Quality of life (QOL) considerations are often as important to the patient as longevity. The influence of mechanical valve replacement on QOL in elderly patients has not been well documented.

Methods: Between June 1981 and December 1999, a total of 1,125 consecutive patients aged > or = 65 years (582 men, 543 women; mean age 71.4 +/- 4.9 years) underwent valve replacement with at least one St. Jude Medical (SJM) mechanical valve. Preoperatively, 138 patients (12.3%) were in NYHA class II, 775 (68.9%) in class III, and 212 (18.8%) in class IV. In 535 patients (47.6%), coronary artery disease required surgical intervention. Survivors were administered the Short Form (SF)-36 QOL Survey at follow up, which was 96.1% complete.

Results: Hospital mortality was 7.6% (85/1,125). Mean follow up was 5.9 years (range: 9 months to 18.4 years). Mean (+/- SEM) actuarial survival was 70.6 +/- 1.4% at five years, and 40.6 +/- 2.0% at 10 years. Male patients scored significantly higher on the SF-36 than controls in physical (p = 0.012) and mental health (p = 0.004). Comparing female patients with controls revealed no significant difference in physical health; however, they scored higher in mental health than controls (p = 0.001).

Conclusion: The study results clearly demonstrate that heart surgery in the elderly with the SJM mechanical valve can be accomplished with acceptable hospital mortality, morbidity, and excellent long-term results. Moreover, long-term QOL in elderly patients with a SJM valve can be expected to meet or exceed that of age- and gender-matched controls.

How to cite: Accola KD, Scott ML, Spector SD, Thompson PA, Palmer GJ, Sand ME, Suarez-Cavalier JE, Ebra G. Is the St. Jude Medical mechanical valve an appropriate choice for elderly patients?: A long-term retrospective study measuring quality of life. J Heart Valve Dis. 2006 Jan;15(1):57-66; discussion 66. PMID: 16480013.

Background and aim of the study: The Hancock II bioprosthesis (HII) has several design features designed to increase its durability. The study aim was to determine very long-term outcomes for the HII valve in a large patient population.

Methods: Long-term follow up was obtained by mail and/or telephone questionnaire of patients undergoing HII valve replacement surgery between 1982 and 2001 (n = 1,569). Follow up was complete on 1,568 patients (99.9%), and ranged from 0 to 250 months.

Results: Isolated aortic valve replacement (AVR) was performed in 1,010 patients and mitral valve replacement (MVR) in 559. The average (+/- SD) age of patients was 67 +/- 11 years, and 65% were males. Long-term death occurred in 445 AVR patients and 275 MVR patients, of which 11% and 17%, respectively, were valve-related. Twenty-year freedom from thromboembolism (all results actuarial) was 79 +/- 3% after AVR and 83 +/- 3% after MVR; freedom from endocarditis was 91 +/- 5% and 85 +/- 5%, respectively. Twenty-year freedom from structural valve deterioration (SVD) was 73 +/- 16% and 39 +/- 9% in AVR patients aged > or = 65 years and < 65 years, respectively. Similarly, 20-year freedom from SVD was 59 +/- 11% and 27 +/- 9% in MVR patients aged > or = 65 years and < 65 years, respectively. When actual statistical techniques were applied (cumulative incidence), 20-year actual risk of SVD was 18 +/- 3% in all AVR patients and 23 +/- 3% in all MVR patients. Reoperation was required in 72 AVR patients, and was valve-related in 60. A total of 49 MVR patients underwent reoperation; 48 of these were valve-related.

Conclusion: The Hancock II bioprosthesis continues to show very good long-term results and durability, particularly in patients aged over 65 years.

How to cite: Borger MA, Ivanov J, Armstrong S, Christie-Hrybinsky D, Feindel CM, David TE. Twenty-year results of the Hancock II bioprosthesis. J Heart Valve Dis. 2006 Jan;15(1):49-55; discussion 55-6. PMID: 16480012.

Background and aim of the study: Calcification in aortic valves is the most common valvular lesion in western populations. This event is correlated with cellular degeneration in the valvular cusps, although there is no exact evidence how these cells die: this requires further exploration.

Methods: Twelve human severely calcified aortic valves obtained during cardiac surgery were studied by semi-quantitative analysis, and results compared with data from 12 human control aortic valves obtained during autopsy. Tissue analysis was by hematoxylin and eosin and Alcian blue staining. Detection of neurons was by immunohistochemical staining of PGP9.5 and neurofilament. In order to detect autophagy, an immunohistochemical staining for ubiquitin was used. The TUNEL technique was used to detect apoptosis. Co-localization of Alizarin red with ubiquitin labeling was performed on non-decalcified aortic valves.

Results: Hematoxylin and eosin staining showed moderate to severe mineralization in 10 of 12 patients in the surgical group, but in only one of 12 in the autopsy group. No significant observations were made with regard to PGP9.5 and neurofilament staining. Moderate to severe ubiquitin labeling was found initially in the majority of the surgical resection group (9/12) compared to a minority in the autopsy group (1/12). TUNEL-positive labeling was very rare and found mostly at the endothelial layer of the valvular cusps.

Conclusion: Immunohistochemical methods showed the main cell death mechanism involved in the calcification of aortic leaflets to be autophagy rather than apoptosis. These findings suggest that autophagic cell death might play a role in the release of matrix vesicles in early degenerative aortic valves, thereby attracting inflammatory cells, and this could eventually lead to mineralization.

How to cite: Somers P, Knaapen M, Kockx M, van Cauwelaert P, Bortier H, Mistiaen W. Histological evaluation of autophagic cell death in calcified aortic valve stenosis. J Heart Valve Dis. 2006 Jan;15(1):43-7; discussion 48. PMID: 16480011.

Background and aim of the study: Cardiovascular risk factors are believed to play a role in the pathogenesis of aortic valve disease. In the present study the hypothesis was proposed that elevated pressure would cause a change in the expression of prototypical pro-inflammatory genes. Hence, the expression of MCP-1, osteopontin (OPN), VCAM-1, GM-CSF and PAI-1 was examined using semi-quantitative real-time RT-PCR.

Methods: Porcine aortic valve interstitial cells at passage 1 were exposed to constant pressures of 100, 140, or 170 mmHg or cyclic pressures of 80-120, 120-160, or 150-190 mmHg for 2 h. Static cultures at atmospheric pressure served as controls. Total RNA from pooled experiments was isolated for analysis of gene expression. Single tube primer-mediated RT-PCR was performed directly on the RNA.

Results: Cells responded differently to constant and cyclic pressure. The most notable response was the expression of OPN, which was significantly up-regulated under steady conditions but down-regulated under cyclic conditions. The opposite was true in VCAM-1 expression, which was significantly down-regulated at 170 mmHg static pressure, but up-regulated at 140 and 170 mmHg mean cyclic pressure. There was no clear proportional correlation between pressure magnitude and expression of MCP-1, GM-CSF, or PAI-1. However, elevated cyclic pressure caused a proportional increase in VCAM-1 expression and a proportional decrease in OPN expression.

Conclusion: Elevated cyclic pressure is a potent stimulus for the up-regulation of VCAM-1 expression and the down-regulation of OPN expression. This demonstrates an association between hypertension and aortic valve stenosis and calcification. The regulation of the chemotactic genes MCP-1 and GM-CSF is not correlated to a change in compressive forces.

How to cite: Warnock JN, Burgess SC, Shack A, Yoganathan AP. Differential immediate-early gene responses to elevated pressure in porcine aortic valve interstitial cells. J Heart Valve Dis. 2006 Jan;15(1):34-41; discussion 42. PMID: 16480010.

Background and aim of the study: Patients with aortic stenosis (AS) exhibit increased platelet aggregability, and thrombus formation has been documented on calcific and severely stenosed valves. Isolated porcine and canine aortic valves (AV) release nitric oxide (NO) and prostacyclin, which exert local antithrombotic effects; to date, this has not been studied in humans. In the present study the possible interaction of AV tissue with platelet aggregation was examined, using fragments of AV obtained from patients with AS and aortic regurgitation (AR).

Methods: Fragments of AV tissue, excised from patients undergoing AV replacement, were co-incubated with blood samples obtained from normal subjects. The direct effects of valve tissue from patients with AS (n = 14) or with predominant AR (n = 13) on ADP-induced platelet aggregation and intraplatelet cGMP and cAMP content were compared.

Results: In whole blood, non-calcified AV fragments from AR patients inhibited platelet aggregation by 57 +/- 6% (p < 0.01); in platelet-rich plasma results were analogous. In order to determine whether this anti-aggregatory effect could be attributed to the valvular release of NO or prostacyclin, intraplatelet cGMP and cAMP formation was assessed, respectively. While there were no significant changes in cGMP content, cAMP increased by 26 +/- 4% (p < 0.02). Both, anti-aggregatory and cAMP-stimulating effects were similar to those produced by 10 nM prostaglandin E1, a prostacyclin mimetic. Fragments from stenotic valves did not inhibit aggregation and did not affect cGMP or cAMP. Furthermore, fragments from heavily calcified regions potentiated aggregation and, in some cases, induced spontaneous aggregation.

Conclusion: Minimally calcified aortic valves (i.e., AR) and, therefore, presumably also normal valves, exert anti-aggregatory effects, most likely via prostacyclin release. AS is associated with a loss of this effect, thus potentially contributing to thrombotic risk.

How to cite: Chirkov YY, Mishra K, Chandy S, Holmes AS, Kanna R, Horowitz JD. Loss of anti-aggregatory effects of aortic valve tissue in patients with aortic stenosis. J Heart Valve Dis. 2006 Jan;15(1):28-33. PMID: 16480009.

Background and aim of the study: Aortic wall stress has been shown to increase locally at the convex aspect of the ascending tract when axial root motion is increased, as occurs in aortic valve regurgitation. The study aim was to assess the expression of extracellular matrix (ECM) proteins involved in stress-induced vascular remodeling in the convexity and the concavity of dilated ascending aortas with aortic valve regurgitation.

Methods: Aortic wall specimens, harvested at the convexity and concavity of eight dilated ascending aortas with severe aortic valve regurgitation underwent morphometry, Western blot, RT-PCR and confocal immunohistochemistry. Five patients (group A) had congenital bicuspid aortic valve (BAV), and three (group B) had Marfan's syndrome. Specimens from the aorta of three multi-organ donors served as controls.

Results: At morphometry, medial degeneration was more severe in the convexity than in the concavity, especially in group A. Western blot, RT-PCR and immunohistochemistry disclosed an asymmetric pattern in the expression of some ECM proteins (laminin, tenascin, fibronectin). Fibronectin was increased in the convexity of both groups compared to controls at Western blot. Immunohistochemistry confirmed this pattern only in BAV. Higher levels of tenascin were found in the convexity in group A. The laminin content was greater in the concavity than in the convexity of both groups, but in group B the type of laminin was different, with the beta2 chain particularly expressed, and almost absent in non-Marfan patients. Type I and type III collagens were more markedly reduced in the convexity than in the concavity in BAV. In group B, type I collagen was decreased and type III increased, but without any significant difference between the two aspects of the aorta.

Conclusion: A tissue remodeling response to valve disease-related wall stress may underlie aortic dilatation with BAV regurgitation. Although morphometry showed similar changes in Marfan aortas, molecular investigations differentiated this condition, qualitatively, from BAV.

How to cite: Della Corte A, De Santo LS, Montagnani S, Quarto C, Romano G, Amarelli C, Scardone M, De Feo M, Cotrufo M, Caianiello G. Spatial patterns of matrix protein expression in dilated ascending aorta with aortic regurgitation: congenital bicuspid valve versus Marfan's syndrome. J Heart Valve Dis. 2006 Jan;15(1):20-7; discussion 27. PMID: 16480008.

Background and aim of the study: Concomitant aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) is an established risk factor for diminished postoperative survival. Results from a VA population were reviewed in order to determine factors influencing early and late survival.

Methods: Between 1993 and 2003, a total of 401 patients underwent AVR at the authors' institution. Of these patients, 249 (62%; mean age 70.6 years) had combined AVR and CABG. Surgical indications were primarily aortic valve pathology (group A: n = 168; 68%), primarily coronary artery disease (CAD) (group B: n = 55; 22%), and both severe aortic and coronary disease (group C: n = 26; 10%). In total, 177 patients (71%) received a bioprosthesis, and 72 (29%) received a mechanical valve. Short- and long-term outcomes were explored using univariate and multivariable hazard analyses.

Results: Overall operative mortality was 6.4%; mortality for groups A, B and C was 4.8%, 9.1% and 11.5%, respectively. On multivariable analysis, significant factors associated with early-phase mortality were NYHA class IV, diabetes, bioprosthetic valve and combined severe aortic and coronary disease. Survival at one and five years was 86% and 62%, respectively. Five-year survival for groups A, B and C was 71%, 63% and 54%, respectively. Significant associated factors for late-phase mortality were the presence of preoperative peripheral vascular disease (PVD) and cerebrovascular disease (CVD). Factors such as age, prior cardiac surgery, number of grafted coronary arteries, and/or effective orifice area index (EOAI) had no significant effect on outcome.

Conclusion: Combined AVR/CABG is a marker for decreased survival. Pre-existing factors such as diabetes, PVD and CVD, as well as poor preoperative NYHA functional status, affected survival. Further investigation is needed to assess the influence of the severity of CAD and EOAI on survival. Thoughtful consideration of all these factors is essential for an accurate prediction of survival, and to determine the appropriate type of aortic prosthesis to be used.

How to cite: Alsoufi B, Karamlou T, Slater M, Shen I, Ungerleider R, Ravichandran P. Results of concomitant aortic valve replacement and coronary artery bypass grafting in the VA population. J Heart Valve Dis. 2006 Jan;15(1):12-8; discussion 18-9. PMID: 16480007.

Background and aim of the study: Coronary perfusion is impaired in patients with aortic stenosis (AS). Aortic valve replacement (AVR) leads to improvement, but not complete restoration, of coronary flow. Previous studies have shown that postoperative coronary flow rate and coronary reserve in mechanical valves is dependent on valve design and orientation. The study aim was to investigate acute changes in coronary perfusion in patients undergoing mechanical or biological valve replacement in a prospective, randomized clinical study.

Methods: Forty patients undergoing AVR for AS underwent MRI scanning to measure coronary flow preoperatively and at five days after surgery. Patients scheduled for mechanical AVR (n = 20) were randomized to a tilting disc (Medtronic Hall) or bileaflet (Medtronic ADVANTAGE) prosthesis; the biological-valve group (n = 20) received a stented (Medtronic Mosaic) or stentless (Medtronic Freestyle) valve. Valve sizes were comparable in all groups. Patients also underwent echocardiography both preoperatively and postoperatively to measure transvalvular pressure gradients. The rate-pressure product (RPP) was calculated as a marker of myocardial oxygen demand and cardiac workload.

Results: The mean preoperative coronary flow rate was 90 +/- 32 ml/min, and this increased after AVR in all patients. The rise in the mechanical-valve groups was comparable for the two tested valves, whereas in the biological-valve groups a significantly higher increase for stentless valves was present (p < 0.05). Mean pressure gradients for the Hall and ADVANTAGE valves were equal; for biological valves, the Mosaic demonstrated a higher mean gradient (19 +/- 6 mmHg) than the Freestyle (10 +/- 4 mmHg) (p < 0.05). The RPP was lower for ADVANTAGE (mechanical group) and for Freestyle valves (biological group).

Conclusion: Coronary artery flow was increased following AVR in all valve groups. The rise was significantly more distinct for Medtronic Freestyle stentless valves compared to the three other valve substitutes. As the stentless design also demonstrated superior hemodynamics and a lower myocardial oxygen demand with lower pressure gradients and lower RPP, this may have a positive impact on the clinical long-term outcome of this valve.

How to cite: Bakhtiary F, Abolmaali N, Dzemali O, Wittlinger T, Doss M, Moritz A, Kleine P. Impact of mechanical and biological aortic valve replacement on coronary perfusion: a prospective, randomized study. J Heart Valve Dis. 2006 Jan;15(1):5-11; discussion 11. PMID: 16480006.

Background and aim of the study: An increased gradient in congenital valvular aortic stenosis (AS) during follow up remains the subject of controversy, and may determine a need for treatment in pediatric patients. It is hypothesized that a valvular gradient < 40 mmHg indicates a stable tendency at follow up for congenital valvular AS.

Methods: Twenty-five cases with valvular AS, isolated but not treated, were followed for eight years (range: 0.14-18.8 years). Clinical and complementary tests (electrocardiography, X-radiography) were undertaken. The gradient anatomy and function were measured using M-mode, two-dimensional, and Doppler echocardiography.

Results: No significant changes were noted in symptoms or at physical examination. Signs of cardiac enlargement were decreased (p < 0.001), and the functional status and gradient remained stable during the follow up period (mean difference 2.38 mmHg; p = 0.74). The relationship between gradient and age showed a slowly increasing trend (r = 0.20).

Conclusion: The trend in gradient confirmed the stable nature of mild AS. Patients in whom gradients were < 40 mmHg at the time of diagnosis remained stable and required no treatment. Subsequent follow up control and clinical management of these patients may be performed at intervals of two years, or more.

How to cite: Ardura J, Gonzalez C, Andres J. Does mild valvular aortic stenosis progress during childhood? J Heart Valve Dis. 2006 Jan;15(1):1-4. PMID: 16480005.