The management of multivalvular heart disease during pregnancy is difficult, as no guidelines currently exist. Herein is reported the first case of percutaneous triple-valve balloon valvulotomy guided by intracardiac echocardiography (ICE) in a pregnant woman with multivalvular rheumatic heart disease. ICE provided excellent imaging and guidance, which resulted in a low radiation exposure to the mother and fetus.

How to cite: Yap, S. C., de Jaegere, P. P., Ligthart, J. M., Serruys, P. W., & Roos-Hesselink, J. W. (2006). Percutaneous triple-valve balloon valvulotomy in a pregnant woman using intracardiac echocardiography: case report. The Journal of heart valve disease, 15(3), 459–464.

Background and aim of the study: Mechanical valves are used in dialysis patients due to the presumed rapid degeneration of tissue valves. The study aim was to compare the results of mechanical and tissue valves placed in renal dialysis patients.

Methods: Information obtained from a computer-based valve replacement database, telephone interviews and patient charts was reviewed for follow up data.

Results: Between 1991 and 2004, 50 dialysis patients underwent left-sided valve replacement. Of these patients, 17 received 21 St. Jude Medical mechanical valves (12 aortic, nine mitral), and 33 received 39 tissue valves (19 aortic, 20 mitral). The mean follow up for the mechanical and tissue valve groups was 19.4 +/- 21.3 and 21.4 +/- 18.7 months, respectively. Mortality at four years was 65% (11/17) for the mechanical valve group, and 42% (14/33) for the tissue valve group (p = 0.15). Freedom from reoperation was not significantly different. The tissue valve group had significantly higher Kaplan-Meier freedom from thromboembolism (100% versus 75 +/- 15%, p = 0.01), hemorrhage (97 +/- 3% versus 44 +/- 17%, p = 0.002), valve-related morbidity (74 +/- 9% versus 42 +/- 16%, p = 0.043), and valve-related morbidity and mortality (69 +/- 9% versus 37 +/- 14%, p = 0.037) at three years. Linearized rates of hemorrhage (21 versus 2%/pt-yr; p = 0.005), valve-related morbidity (36 versus 12%/pt-yr; p = 0.02) and valve-related morbidity and mortality (50 versus 17%/pt-yr; p = 0.008) were all significantly higher in the mechanical valve group.

Conclusion: Dialysis patients had poor survival; prosthetic valve degeneration was negligible. Incidences of thromboembolism, bleeding and valve-related morbidity and mortality were higher with mechanical valves. Linearized, as opposed to actuarial, analysis further accentuated the unacceptably high rates of complications and death with mechanical valves.

How to cite: Toole, J. M., Stroud, M. R., Kratz, J. M., Crumbley, A. J., 3rd, Crawford, F. A., Jr, & Ikonomidis, J. S. (2006). Valve surgery in renal dialysis patients. The Journal of heart valve disease, 15(3), 453–458.

Background and aim of the study: The study aim was to evaluate the durability of the new Mitroflow 12A pericardial bioprosthesis and to assess ventricular mass regression after aortic valve replacement (AVR) in patients with small valves.

Methods: A total of 326 Mitroflow 12A pericardial bioprostheses was implanted without any other associated valve procedure. The mean patient age was 73.5 +/- 6.1 years; 252 patients (78.0%) were in NYHA class III/IV. Small valves (19 and 21 mm) were implanted in 212 patients (65.6%). The total follow up period was 837.1 patient-years (pt-yr). A subset of 61 patients with preoperative stenosis was selected and submitted to conventional echo-Doppler assessment at a mean period of 11.1 months after surgery.

Results: Hospital mortality was 8.6%. At eight years of follow up, survival was 57.1%. Freedom from structural valve deterioration (SVD) was 86.5% per pt-yr. Mean gradients were significantly reduced postoperatively for each valve size (to 18 +/- 8 mmHg for 19-mm valves and 12 +/- 4 mmHg for 25-mm valves). The effective orifice area (EOA) was also increased significantly for all valve sizes (to 1.1 +/- 0.1 cm2 for 19-mm valves and 1.8 +/- 0.2 cm2 for 25-mm valves). The left ventricular mass index (LVMI) decreased significantly, from 177 +/- 29 to 136 +/- 22 g/m2 for the 19-mm valve, and from 200 +/- 42 to 132 +/- 22 g/m2 for the 25-mm valve. The EOA index (EOAI) showed mismatch for the 19- and 21-mm valves (0.74 and 0.82 cm2/m2, respectively). The diagrammatic calculation between LVMI and relative wall thickness after surgery showed that 29.7% of patients achieved a normal pattern of remodeling (including 19- and 21-mm valves), despite various degrees of mismatch.

Conclusion: The new Mitroflow 12A pericardial bioprosthesis showed an absence of mechanical failure after an eight-year follow up, with a satisfactory rate of SVD. Significant reductions in LVMI and improved ventricular geometry were observed, despite the small valve sizes implanted.

How to cite: García-Bengochea, J., Sierra, J., González-Juanatey, J. R., Rubio, J., Vega, M., Fernández, A. L., & Sánchez, D. (2006). Left ventricular mass regression after aortic valve replacement with the new Mitroflow 12A pericardial bioprosthesis. The Journal of heart valve disease, 15(3), 446–452.

Background and aim of the study: The study aim was to compare prospectively the clinical performance and long-term durability of the Medtronic Mosaic and Carpentier-Edwards porcine (CE-SAV) bioprostheses in the aortic position over 10 years.

Methods: Between January 2001 and July 2003, a total of 242 patients undergoing bioprosthetic aortic valve replacement (AVR) were prospectively randomized to receive either Medtronic Mosaic (n = 126) or CE-SAV (n = 116) valves, and followed up annually.

Results: The mean follow up period was 1.7 +/- 0.8 years; total follow up was 411 patient-years. Early mortality and 40-month actuarial survival were 5.5% and 93 +/- 1% for the Mosaic valve, and 2.6% and 90 +/- 1% for the CE-SAV. Among patients, 78% showed symptomatic improvement in their NYHA functional class after AVR. To date there have been no structural failures, and one patient required reoperation for prosthetic valve (Mosaic) endocarditis. Early thromboembolic events occurred in 2.9% of patients (two Mosaic, five CE-SAV). Echocardiographic evaluations between the two valves demonstrated comparable hemodynamic performance for a given size at one year after surgery.

Conclusion: At this stage of the study there were no differences in clinical or hemodynamic outcome in patients undergoing AVR using either the Mosaic or CE-SAV porcine xenograft.

How to cite: John, A., Khan, Z., Kuo, J., Allen, S. M., Marchbank, A. J., Dalrymple-Hay, M. J., Lewis, C. T., Twine, G., Edwards, M., & Unsworth-White, J. (2006). A prospective randomized comparison of Medtronic Mosaic and Carpentier-Edwards-SAV in the aortic position: an interim report. The Journal of heart valve disease, 15(3), 441–445.

Background and aim of the study: A variety of stentless heterograft conduits has been developed as alternatives for pulmonary outflow reconstruction. Herein are reported the authors' results with four different types of stentless heterograft conduit implanted during the past nine years.

Methods: Between January 1996 and March 2005, stentless heterograft conduits were used in 54 patients (mean age 9.9 +/- 7.5 years; median age 7 years; range: 1-32 years) to reconstruct the pulmonary outflow tract. The main pathologies were tetralogy of Fallot, transposition of the great arteries and aortic valve disease (Ross operation). A Baxter-Edwards Prima valve (EP) was used in three patients, a Medtronic Freestyle bioprosthesis (MF) in 27, a Cryolife Ross pulmonic heterograft (CR) in 14, and a Medtronic Contegra bovine jugular vein conduit (MC) in 10. The mean conduit diameter was 20.4 +/- 1.7 mm (range: 16-23 mm).

Results: Early mortality was 5.5%. Mean intensive care unit and hospital stays were 4.3 +/- 4.8 days and 11.7 +/- 7.2 days, respectively. Clinical follow up was complete for 92.1% of patients; the mean follow up period was 45.6 +/- 20 months. Excluding early deaths, the probability of patient survival (Kaplan-Meier) was 97.9% and 74.6% at one and five years, respectively. Transconduit gradients increased significantly in all conduit types during follow up. Conduit failure occurred in 15 patients (two EP, nine MF, three CR, one MC) at a median duration of 70 +/- 7 months (range: 56-84 months). To date, nine patients have undergone conduit re-replacement, without mortality and major morbidity. The probability of freedom from conduit failure was 91.6%, 66.4% and 27.9% at three, five and seven years, respectively.

Conclusion: Stentless heterograft conduits are suitable alternatives to homografts, with acceptable early and mid-term results. However, they do not offer any significant advantage over homografts or other conventional Dacron or pericardial conduits.

How to cite: Erek, E., Yalcinbas, Y. K., Salihoglu, E., Colakoglu, A., Sarioglu, A., & Sarioglu, T. (2006). Stentless heterograft conduits for pulmonic ventricle to pulmonary artery connection: is it the right option?. The Journal of heart valve disease, 15(3), 433–440.

Background and aim of the study: Stentless aortic valve prostheses usually require two separate suture lines. The Freedom Solo valve (Sorin Group, Saluggia, Italy), by using a minimized implantation technique, requires only a single running suture line of 4-0 polypropylene. Herein are reported the surgical experience and early hemodynamic results obtained with this new valve.

Methods: Following annular decalcification, the Freedom Solo prosthesis was implanted in the supraannular aortic position in the sinuses of Valsalva of 82 patients (52 females, 30 males; mean age 76.6 +/- 7.0 years). Echocardiography was performed to monitor gradients and regurgitation.

Results: The logistic EuroSCORE was 12.8 +/- 9.9. Isolated aortic valve replacement was performed in 48 patients; concomitant procedures included coronary artery bypass grafting, mitral procedures, subvalvular myectomy, and atrial ablation. The mean valve size implanted was 26.4 +/- 2.1 mm, and cross-clamp time was 39.0 +/- 7.0 min in primary isolated valve replacement. Non-valve-related 30-day mortality was 3.6%. At discharge, hemodynamic parameters were favorable, with low peak (16.2 +/- 8.0 mmHg) and mean (8.3 +/- 4.5 mmHg) gradients, and without paravalvular leakage and only minimal regurgitation (grade < I degrees) in 10 patients.

Conclusion: Supraannular implantation of the Freedom Solo stentless valve is safe and reliable, using a single suture line. The valve provides excellent hemodynamics at hospital discharge, without paravalvular leakage. The reduced cross-clamp time represents an attractive surgical alternative in elderly patients.

How to cite: Beholz, S., Claus, B., Dushe, S., & Konertz, W. (2006). Operative technique and early hemodynamic results with the Freedom Solo valve. The Journal of heart valve disease, 15(3), 429–432.

Background and aim of the study: Modes of failure of the Perimount bioprostheses have not been characterized. Thus, the study aim was to classify their failure modes, to compare their rates of occurrence, and to relate these to patient age.

Methods: Between September 1981 and July 1985, a total of 478 patients received Carpentier-Edwards Perimount aortic valve prostheses as part of a premarket approval cohort. During yearly follow up over 19 years, 95 prostheses were explanted, 70 (74%) for reasons of structural valve deterioration (SVD). Preoperative diagnostic studies, echocardiograms, operative notes and pathology reports were reviewed to classify the primary modes of failure. Hazard function methodology established mode-specific occurrence rates and how these were modulated by patient age at implant.

Results: The pathophysiology of SVD was pure regurgitation in 23 cases, pure stenosis in 18, mixed in 20, and uncertain in nine. Primary modes of failure were calcification (n = 27; 39%), non-calcific degeneration (n = 21; 30%), fibrosis (n = 5; 7.1%), dehiscence (n = 4; 5.7%), a combination of these (n = 10; 14%), or unknown (n = 3; 4.3%). The failure rate for each mode accelerated with time, was highest and almost equal for calcification and degeneration, and was slower and almost equal for fibrosis and dehiscence. Except for dehiscence, failure modes were age-dependent (p < 0.05), and this was most prominent for degeneration and calcification.

Conclusion: Perimount bioprostheses rarely fail from design-related causes; rather, they fail at almost equal rates from calcific and non-calcific degeneration, both of which occur late and are age-dependent. Further investigation into improved methods for fixation and anti-calcification in preparing these valves is warranted.

How to cite: Roselli, E. E., Smedira, N. G., & Blackstone, E. H. (2006). Failure modes of the Carpentier-Edwards pericardial bioprosthesis in the aortic position. The Journal of heart valve disease, 15(3), 421–428.

Background and aim of the study: The study aim was to update the authors' experience with the CarboMedics bileaflet mechanical prosthesis in terms of early and long-term outcomes.

Methods: Between July 1994 and April 2005, a total of 774 CarboMedics valves was implanted at two Providence Health System hospitals in Portland Service Area. Of these valves, 406 (59%) were aortic valve replacements (AVR), 196 (28.5%) were mitral valve replacements (MVR), and 86 pairs (12.5%) were double valve replacements (DVR).

Results: The mean and maximum follow up was 4.6 and 10.2 years, respectively; total follow up was 3,150 patient-years (pt-yr) (total 3,503 valve-years). Operative mortality was 5.7% (4.4% for AVR, 7.7% for MVR, 7.0% for DVR). Five- and 10-year survivals respectively were 79 +/- 2% and 55 +/- 10% for AVR, 74 +/- 3% and 57 +/- 8% for MVR, and 64 +/- 6% and 39 +/- 11% for DVR (p = 0.009). Freedom from valve explant at five and 10 years respectively was 98 +/- 1% and 97 +/- 10% for AVR, 98 +/- 1% and 86 +/- 12% for MVR, and 96 +/- 3% and 96 +/- 3% for DVR (p = 0.950). Freedom from thromboembolism at five and 10 years respectively was 93 +/- 1% and 91 +/- 2% for AVR, 97 +/- 1% and 95 +/- 2% for MVR, and 90 +/- 4% and 90 4% for DVR (p = 0.226). Freedom from bleeding at five and 10 years respectively was 98 +/- 1% and 97 +/- 1% for AVR, 97 +/- 1% and 96 +/- 2% for MVR, and 91 +/- 4% and 91 +/- 4% for DVR (p = 0.006). Freedom from endocarditis at five and 10 years respectively was 99 +/- 1% and 99 +/- 1% for AVR, 98 +/- 1% and 98 +/- 1% for MVR, and 95 +/- 3% and 91 +/- 4% for DVR (p = 0.030). There were nine perivalvular leaks (six after AVR, three after MVR), and three valve thromboses (two after MVR, one after DVR). Freedom from overall valve-related events at five and 10 years respectively was 80 +/- 2% and 74 +/- 3% for AVR, 82 +/- 3% and 57 +/- 11% for MVR, and 69 +/- 6% and 66 +/- 6% for DVR (p = 0.074).

Conclusion: Long-term experience with the CarboMedics valve shows the clinical performance of the valve to be very good, with results comparable to those obtained with other mechanical valves.

How to cite: Wu, Y., Gao, G., Mody, S., Grunkemeier, G. L., & Ahmad, A. (2006). Update of the Providence Health System experience with the CarboMedics prosthesis. The Journal of heart valve disease, 15(3), 414–420.

Background and aim of the study: A total of 639 patients (479 men, 160 women; mean age 60 +/- 10 years) underwent isolated aortic valve replacement (AVR) between 25 November 1999 and 20 October 2003, using the Medtronic ADVANTAGE bileaflet mechanical heart valve. The study aim was to quantify the clinical performance of a valve with two design modifications: (i) an enlarged central orifice intended to improve blood flow characteristics; and (ii) an asymmetric butterfly pivot recess with expanded outflow component designed to enhance the washing of blood flow through the pivot region.

Methods: Patients were enrolled at 21 centers located in Europe, Canada, Australia, and the USA. The study was conducted under the authority of regional ethics committees, as well as the respective national regulatory agencies. All centers adhered to a common protocol.

Results: The total follow up was 1,215.9 patient-years. The average systolic mean pressure gradient across the prosthesis was < 10 mmHg. The mean left ventricular mass index decreased by 22.87 g/m2 (13% reduction) over 12 months. The numbers of valve-related intraoperative, early (< or = 30 days or prior to discharge) and late (> or = 31 days) deaths were 0, 10 and 19, respectively. After one year and four years of follow up, 99.3% (n = 560) and 100% of patients (n = 37), respectively, were in NYHA class I or II.

Conclusion: The evolutionary bileaflet design of the ADVANTAGE valve achieved the desired clinical functionality and performance.

How to cite: Körfer, R., Svennevig, J. L., Mohr, F. W., Leguerrier, A., Menicanti, L., Olsen, P. S., Karevold, A., Lange, R. S., Seifert, D., & Investigators of the ADVANTAGE Prosthetic Heart Valve (2006). The worldwide mid-term experience with the Medtronic ADVANTAGE bileaflet mechanical heart valve. The Journal of heart valve disease, 15(3), 404–413.

Background and aim of the study: Prosthetic valve thrombosis (PVT) is a rare, but serious, complication of heart valve replacement with a mechanical substitute. Herein is presented the authors' surgical experience of 18 patients with PVT.

Methods: A total of 1,584 heart valve operations was performed in 1,365 patients at the authors' institution between June 1995 and September 2005. Surgical reports of prosthetic valve reoperations over the same period were screened. Preoperative, operative and postoperative data were collected from the patient cohorts.

Results: Since July 1997, 18 patients (12 females, six males; mean age 35.9 +/- 11.3 years; range: 22-60 years) presented with PVT. The subtherapeutic anticoagulation level was the major etiologic factor involved in the pathogenesis of PVT. Thrombosis occurred in the mitral position in 14 patients (78%), and in the aortic position in four (22%). All mechanical valves implanted were bileaflet (1,097 St. Jude Medical, 324 CarboMedics, and 163 Sorin). The mean duration from valve replacement to PVT was 48.3 +/- 15.4 months. The majority of patients presented with poor functional status (56% in NYHA class IV) and poor anticoagulation (INR < or = 2 in 72% of cases). Valve re-replacement was performed for all patients. The 30-day mortality was 16.7%.

Conclusion: PVT is a potentially fatal complication of heart valve replacement. These acceptable results suggest that early surgical intervention might be a safe and effective treatment of choice in patients with PVT. Patients with mechanical valve prostheses should be informed adequately about the need for, and the importance of, an effective anticoagulation regimen.

How to cite: Lafci, B., Ozsöyler, I., Kestelli, M., Yilik, L., Göktogan, T., Karahan, N., Ozbek, C., & Gürbüz, A. (2006). Surgical treatment of prosthetic valve thrombosis: ten years' experience. The Journal of heart valve disease, 15(3), 400–403.

Background and aim of the study: Postoperative thromboembolic complications associated with mechanical valve prosthesis implantation can be reduced with either antiplatelet agents or warfarin. Warfarin been shown to be more effective in adults, but the data are less clear in the pediatric population.

Methods: Seventy-two children and adolescents who survived mechanical valve implantation on the left side of the heart at the authors' institution were followed prospectively from August 1979 until December 2003. All patients underwent surgery before the age of 20 years, and follow up was included up to the age of 20 years. Initially, 53 patients received warfarin alone; mean follow up was 5.9 years, and total follow up 312 patient-years (pt-yr). Likewise, 19 patients received antiplatelet agents; mean follow up was 5.2 years, and total follow up 99 pt-yr. Results were examined using intent-to-treat analyses.

Results: Age, gender, race, valve size and position, mean time of follow up and crossover rates were not different between groups. No differences were detected in survival or freedom from thromboembolic and hemorrhagic events. Complications associated with warfarin use were substantially more severe than those associated with antiplatelet agents.

Conclusion: The study results were inconclusive due to the small numbers of patient-years of follow up, but suggest that antiplatelet agents may be associated with less severe complications than warfarin. Moreover, warfarin and antiplatelet agents may be equally effective for clotting prophylaxis in children after valve replacement with St. Jude Medical prostheses.

How to cite: Khitin, L. M., Sade, R. M., Bradley, S. M., Crawford, F. A., Jr, Widener, C. E., & Stroud, M. R. (2006). Prevention of thrombosis and embolism in children and adolescents with mechanical valve prostheses: warfarin versus antiplatelet agents. The Journal of heart valve disease, 15(3), 394–399.

Herein is reported the long-term repair of a cryopreserved mitral homograft in the tricuspid position. A 34-year-old HIV-infected patient underwent tricuspid valve replacement in 1991 with a cryopreserved mitral homograft because of infective endocarditis. Chronic tricuspid regurgitation secondary to repeated endocarditis led to reoperation 13 years later. Mitral valve repair was performed with a rigid ring as there was annular dilatation; the valve tissue was intact. One year later, transthoracic echocardiography showed no tricuspid regurgitation. The cryopreserved mitral homograft is a potentially repairable valve in the long-term.

How to cite: Mestres, C. A., Castellá, M., Moreno, A., Paré, J. C., del Rio, A., Azqueta, M., Fernández, C., Miró, J. M., Pomar, J. L., & Hospital Clínico Endocarditis Study Group (2006). Cryopreserved mitral homograft in the tricuspid position for infective endocarditis: a valve that can be repaired in the long-term (13 years). The Journal of heart valve disease, 15(3), 389–391.

Background and aim of the study: Advances in echocardiography have awoken new interest in the tricuspid valve, which otherwise has been largely ignored by cardiologists and surgeons. These advances demand a precise terminology for the description of the tricuspid valve's different anatomic structures in health and disease. While simple nomenclatures have been developed for the mitral valve, no such system has been described for the tricuspid valve.

Methods: In order to develop a tricuspid valve terminology similar to the existing mitral valve nomenclature, a study of 50 porcine hearts was conducted. The study was designed not as a strict anatomical description but rather as a search for common parameters between both valves. The findings were based on the traditional understanding that the tricuspid valve has three main leaflets and three papillary muscles. The leaflets were defined according to their heights (free edge to base) and their chordal insertions. The papillary muscles were grouped according to the distribution of their chords to a commissure and its contiguous main leaflets.

Results: In all hearts, three main leaflets were found: septal (S), anterior (A), and posterior (P), associated with a variable number of commissural leaflets (C). Three groups of papillary muscles could be identified: anteroseptal with a mean of 1.78 muscles (range: 1-4), anteroposterior with 1.08 muscles (range: 1-4), and posteroseptal with 2.42 muscles (range: 1-5). Each group was identified (counterclockwise) with the numerals 1 (anteroseptal), 2 (posteroseptal), and 3 (anteroposterior). Each half of the leaflets and their corresponding commissures were identified by the initial letter of their classic name (S, A, P, or C) and their supporting papillary muscle group (1, 2, or 3).

Conclusion: This system provides a method for reporting echocardiographic and surgical findings for the tricuspid valve. The system parallels previously described mitral valve nomenclature. This unified terminology should facilitate the precise recording of echocardiographic and surgical data.

How to cite: Joudinaud, T. M., Flecher, E. M., & Duran, C. M. (2006). Functional terminology for the tricuspid valve. The Journal of heart valve disease, 15(3), 382–388.

Background and aim of the study: The study aim was to compare mitral valve repair techniques in vitro. Rupture or elongation of the mitral valve chordae tendineae is a known cause of mitral regurgitation, and can be corrected by edge-to-edge repair, chordal replacement, or chordal transposition.

Methods: A test apparatus was used to apply pressure to porcine mitral valves. Mitral valve specimens were tested intact (n = 50), after they had been experimentally damaged, and after repair. Each test was repeated ten times. Experimental damage consisted of severing either the anterior leaflet strut, and attached marginal chordae (n = 30) or posterior leaflet chordae (n = 20). Valves with damaged anterior leaflets were repaired by either: (i) edge-to-edge repair; (ii) chordal replacement; or (iii) chordal transposition. Valves with damaged posterior leaflets were repaired by the first two techniques. Each repair method was repeated on ten specimens.

Results: Mitral valves repaired using the edge-to-edge repair (p = 0.002) and chordal replacement (p = 0.038), after rupture to anterior leaflet chordae, recovered significantly better than specimens repaired by chordal transposition. There was no statistical difference in recovery between edge-to-edge repair and chordal replacement (p > 0.05). There was no statistical difference (p > 0.05) in the recovery of the pressure withstood by valves repaired by edge-to-edge repair and chordal replacement, after rupture of posterior leaflet chordae.

Conclusion: These results showed that edge-to-edge repair and chordal replacement are well suited for the repair of both the anterior and posterior leaflets.

How to cite: Espino, D. M., Hukins, D. W., Shepherd, D. E., & Buchan, K. G. (2006). Mitral valve repair: an in-vitro comparison of the effect of surgical repair on the pressure required to cause mitral valve regurgitation. The Journal of heart valve disease, 15(3), 375–381.

Background and aim of the study: Inflammation may play a central role in the progression of stenotic valvular heart disease. Serum levels of matrix metalloproteinases (MMPs), markers of extracellular matrix (ECM) turnover and potential markers of active inflammation, have been recently demonstrated in several inflammatory processes. The present study was designed to examine whether systemic evidence of ECM turnover was present in advanced stenotic mitral valve disease.

Methods: Serum levels of MMP-1, -3 and -9 were measured in 114 patients with mitral stenosis referred for percutaneous balloon mitral valve commissurotomy, and compared to those in 48 healthy, age- and gender-matched controls.

Results: Serum levels of MMP-1, -3 and -9 did not vary according to hemodynamic profile or heart failure class at the time of blood sampling. Levels of MMP-1 and -3 were not significantly different between those patients with mitral stenosis and controls. The level of MMP-9 was significantly higher in patients with mitral stenosis than in controls, and did not appear to be altered by commissurotomy.

Conclusion: Serum levels of MMP-9 were elevated in patients with mitral stenosis, providing further evidence that inflammation and ECM remodeling plays an important role in the pathophysiology of valvular heart disease.

How to cite: Garr, R. J., Krasuski, R. A., Eckart, R. E., Wang, A., Pierce, C., Kisslo, K. B., Harrison, J. K., & Bashore, T. M. (2006). Peripheral blood levels of matrix metalloproteinases in patients referred for percutaneous balloon mitral valve commissurotomy. The Journal of heart valve disease, 15(3), 369–374.

Background and aim of the study: Restoration of sinus rhythm with a maze procedure after concomitant mitral valve (MV) surgery has been shown to reduce the rate of stroke and improve cardiac function and quality of life compared to MV surgery alone. Unlike the classical Cox-Maze III operation, a simplified left-sided maze procedure can be performed without any significant increase in operative complexity.

Methods: Outcomes were compared retrospectively between radiofrequency (RF) and cryothermy as an energy source and analyzed predictors of outcome in 73 consecutive patients undergoing MV surgery with a concomitant simplified left-sided maze procedure. Clinical characteristics as well as rhythm and complication rate at follow up were assessed by review of medical records and patient and physician interview.

Results: There were no complications associated directly with the maze procedure. At an average follow up of 342 days, 69% of patients were in normal sinus rhythm. Of the remainder, 30% had recurrent atrial fibrillation (AF) and 1% atrial flutter. In addition, 7% of patients required cardioversion and 14% required anti-arrhythmic therapy to maintain sinus rhythm. Patients with recurrent AF were more likely to have an enlarged right atrium or Carpentier Type IIIa mitral regurgitation on preoperative echocardiography, and more likely to have undergone concomitant aortic or tricuspid valve surgery. There was no difference in outcome between RF and cryothermy as an energy source in unadjusted or adjusted analyses.

Conclusion: The results of the study helped to establish RF- or cryothermy-simplified left-sided maze procedure as being efficacious and without associated complications in patients having MV surgery and a history of AF. Further investigations are warranted to better define the clinical predictors of recurrent AF to improve patient selection and potentially to modify current maze techniques.

How to cite: Gehi, A. K., Adams, D. H., Salzberg, S. P., & Filsoufi, F. (2006). Outcomes and predictors of success of a radiofrequency- or cryothermy-simplified left-sided maze procedure in patients undergoing mitral valve surgery. The Journal of heart valve disease, 15(3), 360–368.

Background and aim of the study: Commissural lesions in the context of native mitral valve endocarditis are a technically challenging condition for conservative surgery. Herein are reported the authors' 10-year results for mitral valve repair (MVRep) or partial homograft replacement (PHR) performed in this setting.

Methods: Data were reviewed from 19 consecutive patients who underwent MVRep using either Carpentier's technique (n = 14) or PHR (n = 5) for endocarditis at the authors' institution between 1989 and 1994.

Results: There was one operative death (5%; 95% CI 0-15.5%). Two reoperations were performed in each subgroup for recurrence of endocarditis (n = 2) and mitral valve failure (n = 2). The 10-year survival rate and freedom from mitral valve reoperation were 95% (95% CI 84-100%) and 78% (95% CI 59-97%), respectively. At 10 years, 13 (93%) surviving and non-reoperated patients were in good functional status (NYHA class I-II), and 14 (100%) were in sinus rhythm. Although echocardiographic results were excellent in the MVRep group, all PHR patients had moderate or severe mitral valve dysfunction.

Conclusion: Commissural reconstruction using Carpentier's techniques demonstrated excellent long-term results in patients with native mitral valve endocarditis. In contrast, the results for PHR were rather disappointing.

How to cite: Zegdi, R., Khabbaz, Z., Flecher, E., Latrémouille, C., Noghin, M., Chauvaud, S., Gerota, J., Deloche, A., Carpentier, A., & Fabiani, J. N. (2006). Management of commissural lesions in native mitral valve endocarditis: long-term results of valve repair and partial homograft replacement. The Journal of heart valve disease, 15(3), 356–359.

Elastin is an extracellular matrix protein that is the primary component of elastic fibers, and is expressed in the great vessels as well as the semilunar and atrioventricular valves. Elastin haploinsufficiency, resulting from mutation or deletion of the elastin gene, is an important clinical problem that is typically characterized by arteriopathy. Herein is described a patient with elastin haploinsufficiency due to partial deletion of the Williams-Beuren syndrome region, resulting in bilateral semilunar valve disease and arteriopathy. Histochemical analysis of the aortic valve revealed decreased and disorganized elastin with loss of the normal trilaminar cusp organization. These findings suggest that elastin has a role in the pathogenesis of semilunar valve disease.

How to cite: Hinton, R. B., Jr, Deutsch, G. H., Pearl, J. M., Hobart, H. H., Morris, C. A., & Benson, D. W. (2006). Bilateral semilunar valve disease in a child with partial deletion of the Williams-Beuren syndrome region is associated with elastin haploinsufficiency. The Journal of heart valve disease, 15(3), 352–355.

Background and aim of the study: Aortic valve regurgitation (AR) can result in heart failure from chronic overloading of the left ventricle. As little is known of gender-specific responses of the left ventricle to this condition, the study aim was to compare left ventricular (LV) remodeling in male and female rats with severe AR. In order to assess the impact of estrogens on LV remodeling in AR, the effect of ovariectomy (OVX) was also evaluated.

Methods: AR was created in adult Wistar rats (females (control or OVX) and males). Animals were followed for 26 weeks and compared to sham-operated groups. Heart function was evaluated in vivo using echocardiography, and the hearts were subsequently harvested for tissue analysis.

Results: The LV ejection fraction was decreased similarly in both sexes. Despite similar echocardiographic AR severity, females had higher indexed cardiac output and the largest increase in LV weight, cardiomyocyte hypertrophy and eccentric remodeling. No differences were observed between control and OVX females. Ovariectomy had no significant impact on any of the parameters monitored.

Conclusion: Female rats developed more LV remodeling in response to chronic AR than males. AR appears to impose a greater LV workload on females due to their smaller body and heart size. Hormonal status did not have any impact on LV remodeling in this experimental model.

How to cite: Drolet, M. C., Lachance, D., Plante, E., Roussel, E., Couet, J., & Arsenault, M. (2006). Gender-related differences in left ventricular remodeling in chronic severe aortic valve regurgitation in rats. The Journal of heart valve disease, 15(3), 345–351.

Background and aim of the study: In recent studies, the impact of a low or high body mass index (BMI) on outcome after cardiac surgery has been the subject of controversy. A retrospective study was conducted to determine the influence of BMI on 30-day and six-month mortality after aortic valve replacement (AVR).

Methods: A multivariable logistic regression was performed on data from 1,241 consecutive patients (mean age 69 +/- 11 years) who underwent AVR either with (n = 514; 41%) or without coronary artery bypass grafting CABG between 2000 and 2003. A wide spectrum of periprocedural variables was collected, including laboratory data as markers for nutritional status and comorbidity. Patients were followed up for six months after AVR (99% complete).

Results: Mortality rates after 30 days and after six months were 3.9% (n = 49) and 7.6% (n = 94), respectively. A low BMI was identified as an independent risk factor for 30-day (OR (odds ratio) 0.87; CI (confidence interval) 0.8-0.94) and six-month mortality (OR 0.91; CI 0.86-0.96). The relationship between the logit function and BMI was linear; however, a BMI value of 24 was considered an appropriate cut-off point. Both models containing the BMI linearly or dichotomic were equivalent. As patients with a lower BMI differ in their preoperative risk profile compared to those with a higher BMI, a saturated propensity score estimating the propensity towards having a BMI < 24 was calculated. The propensity score was not significant in the final models for 30-day and six-month mortality (0.24 and 0.73, respectively), and the OR for BMI remained largely unaltered (0.89 and 0.91, respectively).

Conclusion: A BMI < 24 is predictive of an increased risk of mortality after AVR, independently of malnutrition, advanced heart disease, or valve size. Further studies are required to investigate the role of adipose tissue in extreme situations and chronic disease. It is mandatory to include BMI in outcome studies after AVR.

How to cite: Florath, I., Albert, A. A., Rosendahl, U. P., Hassanein, W. M., Bauer, S., Ennker, I. C., & Ennker, J. C. (2006). Body mass index: a risk factor for 30-day or six-month mortality in patients undergoing aortic valve replacement?. The Journal of heart valve disease, 15(3), 336–344.

Background and aim of the study: Valve-preserving aortic replacement has become an accepted option for patients with aortic valve regurgitation and aortic dilatation. The relative role of root remodeling versus valve reimplantation inside a vascular graft has been discussed, albeit controversially. In the present study, an in-vitro model was used to investigate the aortic valve hemodynamics of root remodeling and valve reimplantation; roots with supracommissural aortic replacement served as controls.

Methods: Aortic roots with aortoventricular diameter 21 mm were obtained from pigs. Root remodeling was performed using a 22-mm graft (group I, n = 6), or valve reimplantation with a 24-mm graft (group II, n = 7). Control roots were treated by supracommissural aortic replacement (22-mm graft; group III, n = 7). Using an electrohydraulic, computer-controlled pulse duplicator, the valves were tested at flows of 2, 4, 5, 7, and 9 I/min at a heart rate of 70 /min and a mean arterial pressure of 100 mmHg. Parameters assessed included: mean pressure gradient, effective orifice area, valve closure and regurgitant volume, and energy loss due to ejection, valve closure and regurgitation. Data were compared using ANOVA.

Results: There were no differences between the three groups in terms of regurgitant volume, energy loss due to valve regurgitation, or valve closure. The aortic valve orifice area was largest and systolic gradient lowest in group I at all flow rates (p < 0.001). Ejection energy loss was lowest in group I at all flow rates (9 l/min: group I, 128 +/- 21 mJ; group II, 399 +/- 46 mJ; group III, 312 +/- 27 mJ; p < 0.001). Valve closure volumes were similar in groups I and III, but significantly lower in group II at all flow rates (p = 0.047).

Conclusion: In this standardized experimental setting, root remodeling--but not valve reimplantation--resulted in physiologic hemodynamic performance of the aortic valve with regard to orifice area, pressure gradient, and systolic energy loss.

How to cite: Graeter, T. P., Fries, R., Aicher, D., Reul, H., Schmitz, C., & Schäfers, H. J. (2006). In-vitro comparison of aortic valve hemodynamics between aortic root remodeling and aortic valve reimplantation. The Journal of heart valve disease, 15(3), 329–335.

Background and aim of the study: Aortic stenosis (AS) is a common clinical problem which frequently necessitates aortic valve replacement (AVR). The traditional view of progressive AS is a 1:1 inverse relationship between valve calcium content and aortic valve area (AVA). However, this assumption has been based on subjective estimates of calcification on chest X-radiographic images. The study aim was to evaluate the relationship between AVA as measured with echocardiography compared to calcium quantification using electron beam computed tomography (EBT).

Methods: Sixty-one patients with an AVA between 0.7 and 2.0 cm2 underwent an EBT scan to evaluate the aortic valve calcium content.

Results: The mean (+/- SD) aortic valve Agatston calcium score was 1,458.4 +/- 1,362.2, and for the aortic valve volume score was 1,178.8 +/- 1,066.0. The aortic valve Agatston score did not correlate strongly with AVA (r = -0.34, 95% CI -0.54, -0.09; p = 0.007). The data pattern appeared curvilinear, with the poorest correlation noted for those patients with moderate and severe aortic valve calcification.

Conclusion: The study findings support the hypothesis that the aortic valve orifice area decreases not only due to calcium accumulation but also to sclerotic processes.

How to cite: Mohler, E. R., 3rd, Medenilla, E., Wang, H., & Scott, C. (2006). Aortic valve calcium content does not predict aortic valve area. The Journal of heart valve disease, 15(3), 322–328.

Background and aim of the study: Aortic stenosis (AS) remains the most common valvular disease of the elderly in the United States. Though valve replacement has proven effective among older adults, decision-making regarding surgery is difficult for these patients and their physicians. Herein, the clinical outcomes and decision-making process for elderly patients with severe symptomatic AS was assessed.

Methods: A retrospective cohort study of patients aged > or = 60 years with severe AS was conducted at two large urban teaching hospitals. Severe AS was defined by a mean valve gradient > or = 50 mmHg or valve area < 0.8 cm2 by echocardiogram, and associated symptoms (angina, congestive heart failure, dyspnea, fatigue, or exercise intolerance). Demographic and clinical data and information about decision-making were obtained from inpatient and outpatient medical records.

Results: Of the 124 patients studied, 49 (39.5%) had aortic valve replacement (AVR) surgery. In a logistic regression analysis adjusting for gender, comorbidity and baseline functional status, those patients aged < 80 years were significantly more likely to have surgery than older patients. Surgery was associated with a large reduction in mortality in all age groups. At one-year follow up, 87.8% of all patients (87.5% of those aged > or = 80 years) who had undergone surgery were alive, while only 54.7% (49.1% of those aged > or = 80 years) who did not receive surgery were alive. Postoperative complications were similar among older and younger elderly patients. Comorbidity and age were the most common reasons for not offering elderly patients valve replacement.

Conclusion: The results of the present study showed that AVR surgery improves the survival of elderly patients with severe AS, and patients aged > 80 years experience benefits similar to younger patients. Nevertheless, these findings suggest that surgery may not always be offered to elderly patients who might benefit from it.

How to cite: Charlson, E., Legedza, A. T., & Hamel, M. B. (2006). Decision-making and outcomes in severe symptomatic aortic stenosis. The Journal of heart valve disease, 15(3), 312–321.

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How to cite: Piper, C., Kleikamp, G., Hort, W., & Horstkotte, D. (2006). Intracardiac fibroelastomas in echocardiography. The Journal of heart valve disease, 15(3), 308–311.

Atrioventricular valve repair with artificial chordal replacement has been widely used for congenital and acquired mitral valve abnormalities, but not for tricuspid valve abnormalities. A case is presented of dysplastic tricuspid valve that was successfully repaired using artificial chordae. A 2-year-old female presented with poor weight gain. Echocardiography revealed severe tricuspid regurgitation due to dysplastic tricuspid valve, poor coaptation by prolapse of the anterior leaflet, and tethering of the septal leaflet by short chordae. The prolapsed anterior leaflet was repaired with three pairs of 6-0 expanded polytetrafluoroethylene sutures. The short chordae of the septal leaflet were detached, and the septal and posterior leaflets were sutured together. Trivial tricuspid regurgitation was noted postoperatively. There was no tricuspid regurgitation during the follow up period of three years. The present case provides further evidence that artificial chordal replacement is a useful technique even for small children with congenitally abnormal tricuspid valves.

How to cite: Honjo, O., Ishino, K., Yoshizumi, K., Kawada, M., Ohtsuki, S., Akagi, T., & Sano, S. (2006). Repair of a dysplastic tricuspid valve using artificial chordae: case report. The Journal of heart valve disease, 15(3), 392–393.