Background and aim of the study: The new Sorin Freedom SOLO pericardial stentless valve is designed for supra-annular implantation, and requires only one running suture. It can be implanted with a short cross-clamp time, and is designed to offer the same hemodynamic advantages of other stentless valves. The study aim was to evaluate the prospective postoperative and two-month follow up hemodynamic performance of this bioprosthesis.

Methods: Thirty patients (13 males, 17 females; mean age 75.6 +/- 6.21 years) with severe aortic stenosis underwent valve replacement with the Sorin Freedom SOLO stentless valve. All patients underwent transthoracic echocardiography before surgery, before hospital discharge, and at two months' follow up. The peak and mean transprosthetic gradients, telediastolic and telesystolic diameters, septal and posterior wall thicknesses, total and indexed ventricular mass volume and left ventricular ejection fraction were evaluated.

Results: Both, the transprosthetic peak gradient and mean gradient decreased significantly during the first two months (p < 0.05 and p < 0.001, respectively). The telediastolic diameter was significantly reduced between preoperative evaluation and follow up (p < 0.05). The interventricular septum thickness was decreased significantly after two months (p <0.001), as was the posterior wall thickness, albeit to a lesser degree (p < 0.05). Both, total and indexed ventricular mass volume showed a significant regression at the two months follow up (p < 0.001).

Conclusion: The Sorin Freedom SOLO stentless valve shows good hemodynamic performance, with an early and highly progressive left ventricular remod eling. If these data are confirmed in future studies, the SOLO prosthesis might represent a safe alternative to the use of conventional stentless valves.

How to cite: Da Col, U., Di Bella, I., Bardelli, G., Ramoni, E., Affronti, A., Vidili, A., & Ragni, T. (2007). Short-term hemodynamic performance of the Sorin Freedom SOLO stentless valve. The Journal of heart valve disease, 16(5), 546–550.

Background and aim of the study: The preferred choice of annuloplasty ring in mitral surgery has not yet been determined. The study aim was to compare the effects of using two ring types, the Duran and the Carpentier-Edwards, for degenerative mitral valve repair.

Methods: The follow up data were reviewed from 294 patients who underwent mitral valvuloplasty for degenerative mitral regurgitation (MR) with either a Carpentier-Edwards ring (n = 153) or a Duran ring (n = 141), between 1994 and 2004. The long-term clinical and echocardiographic outcomes were compared.

Results: There were no inter-group preoperative demographic differences. The preoperative left ventricular (LV) ejection fraction (EF) and MR grade were similar in both groups, but the left atrial (LA) size, LV mass and LV dimension were significantly greater in the CE group. Rates of overall survival, reoperation-free survival and MR (> or = 3)-free survival were similar in the two groups (five-year MR-free survival 75.1 +/- 4.6% for CE and 82.4 +/- 4.5% for Duran; p = 0.83). The CE group showed an overall superior five-year mitral stenosis (MS)-free survival. Significantly more Duran patients had a mean transmitral pressure gradient (MPG) of > or = 10 mmHg (five-year MS (MPG > or = 10 mmHg)-free survival rate: 91.2 +/- 2.8% in for CE and 65.1 +/- 10.7% for Duran group; p = 0.011). The LV EF did not change over time in either group. In contrast, the LV mass and LV dimension decreased significantly after surgery in both groups, but no significant inter-group difference was seen for either index.

Conclusion: Although the Duran and Carpentier-Edwards rings showed comparable long-term outcomes in terms of LV function, MR recurrence, survival and reoperation, a greater tendency towards MS development was observed with the Duran ring, this being most likely due to late pannus formation.

How to cite: Chung, C. H., Kim, J. B., Choo, S. J., Kim, K. S., Song, H., Song, M. G., Song, J. K., Kang, D. H., & Lee, J. W. (2007). Long-term outcomes after mitral ring annuloplasty for degenerative mitral regurgitation: Duran ring versus Carpentier-Edwards ring. The Journal of heart valve disease, 16(5), 536–545.

Echocardiography is the technique of choice for the assessment of replacement aortic valves. Hemodynamic function depends on the design and size of the valve. This review summarizes the published information available to the end of 2005. The most obstructive valve was the caged-ball, followed by the stented porcine and single tilting-disc valves. The stented bovine pericardial valves were slightly less obstructive than these, and similar to the intra-annular bileaflet mechanical valves. Stentless valves appeared slightly less obstructive still, and similar to reduced-cuff mechanical bileaflet valves. Homografts were the least obstructive. Approximate guide thresholds suggesting obstruction were derived.

How to cite: Rajani, R., Mukherjee, D., & Chambers, J. B. (2007). Doppler echocardiography in normally functioning replacement aortic valves: a review of 129 studies. The Journal of heart valve disease, 16(5), 519–535.

Background and aim of the study: In a previous sono-metric study, changes were described that occurred in the normal tricuspid valve during the cardiac cycle. However, the wealth of data available suggested the need for reporting further findings that should contribute to a better understanding of the dynamics of the tricuspid valve.

Methods: Thirteen sonomicrometry transducers were placed in the hearts of each of seven sheep. Six transducers were placed in the tricuspid annulus (TA), at the base of each leaflet, and at each commissure; three at the tips of the papillary muscles (PMs); three in the free edges of the leaflets; and one transducer was placed at the apex. Distances between transducers, pulmonary and right ventricular pressures, and pulmonary flow were recorded simultaneously.

Results: The TA area underwent two major contractions and expansions during the cardiac cycle, reaching its maximum during isovolumic relaxation and its minimum in diastole. The TA height-to-width ratio changed from 8.4 +/- 1.9% to 15.3 +/- 4.2%. The leaflets began to open before end-systole. By the end of isovolumic relaxation, the leaflets had completed 54.1 +/- 13.4% of their opening. The PM and TA planes were not parallel, but were offset by 11.5 +/- 1.9 degrees to 17.8 +/- 2.1 degrees. The PM rotated 6.9 +/- 0.9 degrees with respect to the TA, with 3.1 +/- 1.1 degrees of the rotation occurring during ejection.

Conclusion: The tricuspid valve is not a passive structure but rather forms a dynamic part of the right ventricle. Its orifice area changes not only due to the contraction and expansion of its perimeter but also to changes in its saddle shape. Leaflet opening and closure is not simply a response to pressure. The PMs rotate in relation to the TA. These data should impact upon the diagnosis and surgery of functional tricuspid regurgitation.

How to cite: Jouan, J., Pagel, M. R., Hiro, M. E., Lim, K. H., Lansac, E., & Duran, C. M. (2007). Further information from a sonometric study of the normal tricuspid valve annulus in sheep: geometric changes during the cardiac cycle. The Journal of heart valve disease, 16(5), 511–518.

Background and aim of the study: Duplication of an atrioventricular valve is a rare congenital anomaly, with only single cases of double-orifice tricuspid valves (DOTV) having been identified. Because of its rarity, the clinical spectrum of this entity remains obscure.

Methods: A literature search was conducted using databases and search engines. In addition, the reference sections of all relevant articles were searched to identify additional cases. All cases reported until March 2006 were included.

Results: In total, 22 cases of DOTV were identified. The mean patient age was 21 years, and there was a male predominance. Autopsy was the leading mode of detection, followed by surgery and echocardiography. In cases where the functional status of the DOTV was specifically mentioned, pure regurgitation was found in 62.5%, and combined stenosis and regurgitation in 25%. In 12.5% of cases the valve function was normal. Additional congenital malformations were present in (72.7%) of cases (n = 16).

Conclusion: The DOTV is a very rare congenital heart defect. The isolated occurrence of this condition seems extremely rare, and in most cases it is associated with other congenital cardiac malformations that determine patient outcome.

How to cite: Tutarel, O., & Westhoff-Bleck, M. (2007). The double-orifice tricuspid valve: a review. The Journal of heart valve disease, 16(5), 508–510.

Aortic stenosis (AS) can develop in a congenitally bicuspid aortic valve, or as the result of an age-related calcific degenerative disease process. Although sudden death occurs in about 20% of patients dying of AS, the mechanisms involved are not well documented. The case is reported of a 67-year-old man who experienced progressive dyspnea and persistent chest tightness for over 60 min after mountain climbing. Cardiac catheterization revealed patent coronary arteries; however, the man had severe AS. On the third day after hospital admission, he experienced a sudden loss of consciousness at the same time that torsade de pointes was recorded on the electrocardiogram. The patient was defibrillated and his vital signs restored. The corrected QT interval (QTc) prolongation seen on admission decreased toward normal after aortic valve replacement. Although the mechanism of sudden cardiac death in severe AS patients remains unclear, ventricular arrhythmia-related syncope may play a role.

How to cite:  Tsai, J. P., Lee, P. Y., Wang, K. T., & Hou, C. J. (2007). Torsade de pointes in severe aortic stenosis: case report. The Journal of heart valve disease, 16(5), 504–507.

Background and aim of the study: Activation of the angiotensin II type 2 receptor (AT2R) gene lowers blood pressure, inhibits endothelial and smooth muscle proliferation, and modifies left ventricular hypertrophy (LVH) and fibrosis. Recently, several studies on the presence and importance of AT2R polymorphism for cardiovascular pathology have been reported. The study aim was to investigate any relationship between +1675 G/A AT2R polymorphism and the degree of LVH in patients with aortic stenosis (AS).

Methods: The influence of +1675 G/A AT2R gene polymorphism on AS severity, degree of LVH and systolic function was analyzed in 308 patients (185 men, 123 women; mean age 61.5 +/- 10 years) with significant AS.

Results: Due to chromosome X localization of the AT2R gene, the analysis was performed separately in males and females. The prevalence of genotypes was 32.8% for AA, 40.8% for AG, and 26.4% for GG in females; and 52.9% and 47.1% for the A and G alleles, respectively, in males. No correlation was found between +1675 G/A AT2R polymorphism and LVH. The only significant difference was a lower left ventricular ejection fraction (LVEF) and a greater end-systolic LV dimension in males carrying the A allele as compared to allele G carriers. The A allele was more frequently observed in patients with LVEF < 40%. In the multivariate analysis, presence of the A allele was significantly related to LVEF (adjusted for age, hypertension, coronary artery disease), although the impact was of borderline statistical significance (p = 0.04) and explained only 2% of LVEF variance.

Conclusion: The study results indicate that the +1675 G/A AT2R gene polymorphism cannot be considered as a marker of LVH in patients with AS, but its negative influence on LVEF in A allele carriers may be considered as a marker of premature left ventricular decompensation in males.

How to cite: Orlowska-Baranowska, E., Placha, G., Baranowski, R., Michalek, P., Gora, J., Gaciong, Z., & Stepinska, J. (2007). Can angiotensin II +1675 G/A type 2 receptor gene polymorphism be a marker of left ventricular hypertrophy in patients with aortic stenosis?. The Journal of heart valve disease, 16(5), 495–503.

Background and aim of the study: Pressure recovery is a source of discrepancy between Doppler-derived and catheter aortic valve pressure drops. Pressure recovery occurs where the stenotic jet reattaches to the aortic wall. An equation to predict the jet reattachment location has been developed based on the density and viscosity of blood, the velocity in the stenotic jet, and the aortic root and valve areas. The study aim was to define the conditions where this equation is valid and could be accurately applied to Doppler echocardiographic data.

Methods: In a pulse duplicator, mean flow rates were varied between 2 and 5 l/min, and anatomic orifice areas between 0.32 and 2.85 cm2, to produce values of the ratio of anatomic valve area to the aortic root area (E) of 0.04 to 0.36. For each hemodynamic state, continuous-wave, pulsed-wave Doppler and color Doppler flow maps were recorded. Instantaneous flow rates and pressures proximal and distal to the valve were recorded. Calculated reattachment lengths were compared to measurements from color Doppler echocardiography.

Results: Except for the smallest E value, there was a correlation between the predicted and measured jet reattachment lengths. The equation was good for predicted attachment lengths of less than 5 cm. Overestimation was seen for the smallest E value, representing a critically stenotic valve.

Conclusion: Except for the most severe stenoses, pressure drops for aortic valves are best measured with the aortic sensor placed approximately 5 cm above the aortic valve. For moderate stenoses, where pressure recovery is relevant, the site of fully recovered pressure can be predicted.

How to cite: Rhodes, K. D., Stroml, J. A., Rahman, M. M., & VanAuker, M. D. (2007). Prediction of pressure recovery location in aortic valve stenosis: an in-vitro validation study. The Journal of heart valve disease, 16(5), 489–494.

Background and aim of the study: Cardiovascular risk factors have been associated with aortic valve stenosis, which is considered as an atherosclerosis-like process. The study aim was to assess the effect of cardiovascular risk factors on early and late outcome after valve replacement with a bioprosthesis for aortic stenosis (AS), and the impact of these factors on the outcome of the bioprosthesis.

Methods: Preoperative clinical, biological and echocardiographic data were recorded in 222 patients (110 males, 112 females; mean age 73 +/- 8 years) who underwent surgery for severe AS between 1989 and 1993. The mean follow up was 7.3 +/- 4.7 years; total follow up was 1,621 patient-years (pt-yr).

Results: Overall 12-year actuarial survival rate was 36.1%. Independent predictors of mortality were age (hazards ratio (HR) 1.11; 95% CI: 1.08-1.14, p < 0.0001), diabetes mellitus (DM) (HR 2.53; 95% CI: 1.65-3.88, p < 0.0001), male gender (HR 2.17; 95% CI: 1.53-3.12, p < 0.0001), and NYHA class (HR 1.66; 95% CI: 1.17-2.34, p = 0.004). Other cardiovascular risk factors had no significant effect on survival. DM and NYHA class were also independent predictive factors for valve-related death and overall valve-related complications. The 12-year actuarial survival was 13% in DM patients compared to 38% in non-diabetic patients (p = 0.003), with a significant increase in cardiovascular death (p = 0.0028), and a non-significant increase in thromboembolic events (p = 0.08) in DM patients. The only independent predictive risk factor of structural valve failure in multivariate analysis was renal failure (HR 1.1, 95% CI: 1.03-1.16, p = 0.047). Cardiovascular risk factors such as hypercholesterolemia, DM, hypertension, tobacco smoking and obesity had no effect on the outcome of the bioprosthesis.

Conclusion: Age, male gender, DM and NYHA class were the main predictors for long-term mortality after bioprosthesis implantation for AS. DM significantly impaired survival, with an excess of cardiovascular deaths and thromboembolic events. Other cardiovascular risk factors had no significant effect on either survival or bioprosthesis durability.

How to cite: Le Tourneau, T., Marechaux, S., Vincentelli, A., Ennezat, P. V., Modine, T., Polge, A. S., Fayad, G., Prat, A., Warembourg, H., & Deklunder, G. (2007). Cardiovascular risk factors as predictors of early and late survival after bioprosthetic valve replacement for aortic stenosis. The Journal of heart valve disease, 16(5), 483–488.

Background and aim of the study: The study aim was to analyze the relationship between patient-prosthesis mismatch (PPM) and in-hospital complications and mortality after aortic valve replacement (AVR).

Methods: AVR was performed in 1,819 patients between January 1996 and July 2006. Follow up investigations were performed after a mean of 4.3 years (range: 0 days to 10.6 years). Univariate and multivariate analysis were used to evaluate risk factors for in-hospital complications and mortality in patients with prosthesis mismatch. Actuarial statistics were used to calculate survival rates.

Results: Multivariate analysis showed that PPM (defined as indexed effective orifice area < or = 0.85 cm2/m2) was associated with an increased risk of postoperative neurological events (OR 2.26, 95% CI 1.05-4.83, p = 0.037). There were no significant differences in 30-day mortality between the PPM and non-PPM groups. Neither was any significant difference found between the two groups regarding long-term survival adjusted for significant risk factors for death after AVR.

Conclusion: The results suggest PPM to be an independent predictor of postoperative neurological complications in patients undergoing AVR. However, PPM did not negatively influence either short- or long-term survival. PPM may play an important role in selected categories of patients, and should be considered in order to avoid postoperative neurological complications.

How to cite: Nozohoor, S., Nilsson, J., Lührs, C., Roijer, A., & Sjögren, J. (2007). The influence of patient-prosthesis mismatch on in-hospital complications and early mortality after aortic valve replacement. The Journal of heart valve disease, 16(5), 475–482.

Background and aim of the study: Atrial fibrillation (AF) is the most common arrhythmia in patients with rheumatic mitral stenosis (MS), with an increased risk of mortality and morbidity. Although recent data have suggested that the inflammatory process is associated with non-valvular AF, the relationship between inflammation and AF occurrence in MS patients remains unknown. The study aim was to determine whether plasma levels of high-sensitivity C-reactive protein (hs-CRP), as a marker of inflammation, are elevated in patients with isolated rheumatic MS and AF compared to patients with MS but without AF.

Methods: The study population comprised 89 patients with isolated rheumatic MS (57 patients in sinus rhythm and 32 in AF) and 35 healthy controls. Patients with MS were categorized into subgroups in terms of their mitral valve area (MVA). Mean transmitral diastolic gradients and pulmonary artery pressure were monitored, and morphologic features of the mitral valve classified using an echocardiographic scoring system. Plasma levels of hs-CRP were monitored in all patients and control subjects, using a commercially available analytical kit.

Results: Patients with AF were shown to have significantly higher plasma levels of hs-CRP compared to those in sinus rhythm and controls (p < 0.001). In general, patients with AF were older (p < 0.001) and had a larger left atrial diameter (LAD) (p < 0.001). Plasma levels of hs-CRP were associated with LAD only in the AF group (rho = 0.437; p = 0.012). Multivariate logistic regression analysis revealed a significant independent relationship between AF and hs-CRP plasma level (odds ratio (OR) 3.57; 95% confidence interval (CI) 1.2-10.5; p = 0.021), age (OR 1.08; 95% CI 1.03-1.14; p = 0.003), and LAD (OR 1.2; 95% CI 1.02-1.4; p = 0.023).

Conclusion: The study results indicated that hs-CRP plasma levels are associated with the presence of AF in patients with MS. This finding may have important implications for the development of new therapeutic and preventive approaches of AF in the setting of MS.

How to cite: Selcuk, M. T., Selcuk, H., Maden, O., Temizhan, A., Aksu, T., Dogan, M., & Sasmaz, A. (2007). Relationship between inflammation and atrial fibrillation in patients with isolated rheumatic mitral stenosis. The Journal of heart valve disease, 16(5), 468–474.

Background and aim of the study: Autoimmunity plays an essential role in the pathogenesis of rheumatic heart disease. Although the ongoing rheumatic process has been demonstrated with high levels of inflammatory markers, the cellular mechanism(s) of autoimmunity have not yet been investigated. The study aim was to examine levels of circulating CD4+CD25+ T cells in patients with rheumatic mitral stenosis, and to evaluate the relationship between regulatory CD4+CD25+ T-cell count and clinical and echocardiographic measures.

Methods: A total of 42 patients with mitral stenosis was enrolled into the study, and 27 normal age- and gender-matched healthy subjects served as controls. All patients and controls underwent clinical, electrocardiographic, echocardiographic and laboratory evaluation. T-cell levels were determined with flow cytometry using monoclonal fluorescein isothiocyanate-labeled anti-CD4 and phycoerythrin-labeled anti-CD25 antibodies.

Results: The circulating CD4+CD25+ T-cell count was significantly lower in patients with mitral stenosis than in controls (231 +/- 120 versus 372 +/- 180 per mm3; p = 0.001). The percentage ratio of CD4+CD25+ T cells to total leukocytes and lymphocytes was significantly lower in patients with mitral stenosis than in controls (2.9 +/- 1.5 versus 5.2 +/- 2.1; p < 0.001, and 11.2 +/- 5.6 versus 14.8 +/- 5.6; p = 0.011, respectively). In addition, a significant negative correlation was identified between the erythrocyte sedimentation rate and circulating CD4+CD25+ T-cell count (Spearman rho = -0.414; p = 0.006). No correlation was found between CD4+CD25+ T-cell count and clinical and echocardiographic parameters in patients with mitral stenosis.

Conclusion: A decrease in CD4+CD25+ T cell numbers in mitral stenosis patients might suggest a role for cellular autoimmunity in a smoldering rheumatic process.

How to cite: Yildiz, A., Ozeke, O., Aras, D., Balci, M., Deveci, B., Ergun, K., Topaloglu, S., Dogan, M., Ozcan, F., Sokmen, Y., Sasmaz, A., & Korkmaz, S. (2007). Circulating CD4+CD25+ T cells in rheumatic mitral stenosis. The Journal of heart valve disease, 16(5), 461–467.