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How to cite: Antunes M. J. (1993). In response to: Gometza B, Kumar N, Prabhakar G, Galio R, Kandeel M, Duran CMG. The challenge of valve surgery in a developing population. The Journal of heart valve disease, 2(4), 487–489.

A 58 year old woman underwent re-replacement of a Cross-Jones caged-lens mitral prosthesis 23 years after the first operation. She represented one of the 38 patients who received 42 Cross-Jones prostheses two decades earlier. Continued adequate performance for more than two decades in five patients bears a surprising testimony to the longevity of this historic low profile prosthesis.

How to cite: Ghosh, P. K., Tager, S., Raanani, E., & Levy, M. J. (1993). Late outcome of valve replacement with the Cross-Jones caged-lens prosthesis. The Journal of heart valve disease, 2(4), 485–486.

Aortic valve endocarditis commonly leads to the formation of a root abscess, but fistulae are uncommon. The echocardiographic findings in a patient with Streptococcus viridans endocarditis of a prosthetic aortic valve associated with a fistula between the aorta and the left atrium are presented. The diagnosis was made by transthoracic echocardiography, although the transesophageal study gave higher resolution views and allowed a more confident exclusion of mitral valve involvement.

How to cite: Kelion, A. D., Chambers, J. B., & Deverall, P. B. (1993). Aorto-left atrial fistula in prosthetic aortic endocarditis. The Journal of heart valve disease, 2(4), 481–484.

A 68 year old male patient with corrected transposition of the great arteries in situs solitus (SLL) underwent successful repair of regurgitant tricuspid, mitral and pulmonary valves. An aneurysm of the pulmonary artery, found incidentally during surgery, was also repaired.

How to cite: Oswal, D., Ribeiro, V. G., & Antunes, M. J. (1993). Corrected transposition of the great arteries. Repair of regurgitant tricuspid, mitral and pulmonary valves. The Journal of heart valve disease, 2(4), 478–480.

The author's method for sternal re-entry in cases of extremely dense mediastinal adhesions is described. The anterior lamina and the spongiosa of the sternum is cut with an osteotome and the posterior lamina is divided using the Lebsche knife so as to leave the densely adhered patch of the posterior lamina on the underlying soft tissue. These bone fragments may be left in loco or, if the course of the operation requires it, they may be gently raised and peeled off. Removal of such a portion or portions of the posterior lamina does not appreciably weaken the sternum and safe sternal closure may be accomplished without difficulty.

How to cite: Robicsek F. (1993). The management of severe adherence of mediastinal structures to the sternum during cardiac reoperations. The Journal of heart valve disease, 2(4), 476–477.

Assessing the severity of aortic stenosis remains an important clinical problem. The turbulent pressure fluctuations generated by the jet downstream of the stenotic valve produce vibrations in the aortic wall. These vibrations are transmitted through the chest to the skin surface, where they can be recorded as systolic ejection murmurs. The purpose of the present study was to estimate the transvalvular aortic pressure difference by spectral analysis of heart murmurs (spectral vibrocardiography). Forty-four patients with clinical signs of aortic stenosis underwent cardiac catheterization to measure the transvalvular pressure difference. In a double blind prospective study, precordial vibrations were measured prior to catheterization using a dedicated heart sound analyzer (Vibrocard 2000) to calculate the spectral ratio of murmur energy between 100-500 Hz and 20-500 Hz. Three different weighting filters were used to compensate for individual differences in the transthoracic attenuation of murmurs. The square root of the murmur energy ratio correlated linearly with the mean transvalvular pressure difference (r = 0.80, SEE = 13 mmHg) and with the peak transvalvular pressure difference (r = 0.81, SEE = 16 mmHg). The use of individual compensation filters improved the correlation. This study shows that it is possible to estimate the transvalvular pressure difference in patients with aortic valve stenosis by spectral analysis of heart murmurs. It is a fast, simple and cost effective technique, which requires less skill than conventional methods.

How to cite: Nygaard, H., Thuesen, L., Terp, K., Hasenkam, J. M., & Paulsens, P. K. (1993). Assessing the severity of aortic valve stenosis by spectral analysis of cardiac murmurs (spectral vibrocardiography). Part II: Clinical aspects. The Journal of heart valve disease, 2(4), 468–475.

Assessing the severity of aortic stenosis remains an important clinical problem. The turbulent pressure fluctuations generated by the confined jet down-stream of the stenotic valve produce vibrations in the aortic wall. These vibrations are transmitted through the chest to the skin surface, where they can be measured as systolic ejection murmurs. The purpose of the present study was to find the relationship between the severity of aortic valve stenosis and the frequency content of the precordial systolic murmurs, and to evaluate the transthoracic attenuation of murmurs and its variation from patient to patient. Twenty-four patients with clinical signs of aortic stenosis underwent cardiac catheterization to measure the peak transvalvular pressure difference. The mean energy density spectrum of the measured systolic precordial murmurs was calculated and the murmur energy ratio between 100-500 Hz and 20-500 Hz was correlated to the transvalvular pressure difference. The inter-individual variability of the transthoracic attenuation was evaluated by calculating the transthoracic transfer function from simultaneous measurements of precordial vibrations at the second right intercostal space and intravascular recordings of high frequency pressure fluctuations in the ascending aorta. The transvalvular pressure difference and the square root of the murmur energy ratio correlated well (r = 0.81, SEE = 27 mmHg). In the frequency range from 10-500 Hz the transthoracic transfer function could be modelled by a low-pass filter function with a low frequency attenuation of 36 +/- 7.7 dB (mean +/- SD), a corner frequency of 26 +/- 12 Hz and an attenuation slope of -29 +/- 7.9 dB/decade. Spectral analysis of systolic murmurs might be an attractive non-invasive addition to the array of techniques already in use for assessing the severity of aortic stenosis. It is a simple and cost effective technique, and requires less skill and time for data analysis than conventional methods.

How to cite: Nygaard, H., Thuesen, L., Hasenkam, J. M., Pedersen, E. M., & Paulsen, P. K. (1993). Assessing the severity of aortic valve stenosis by spectral analysis of cardiac murmurs (spectral vibrocardiography). Part I: Technical aspects. The Journal of heart valve disease, 2(4), 454–467.

Non-destructive evaluation by hologram interferometry of seven mechanical and seven bioprosthetic valves was carried out. Irregular fringe patterns suspect of intrinsic valve anomaly which may lead to later dysfunction were detected in one mechanical and six bioprosthetic valves. Histologic examination of two bioprosthetic valves revealed focal degeneration, especially in the fibrosa, in those parts of the leaflets that had obvious anomalies on the holographic interferograms. It was shown that the flow turbulences caused by prosthetic valves can also be evaluated using hologram interferometry. The experimental results, obtained with six different types of prostheses (Lillehei-Kaster, Bjork-Shiley, Omnicarbon, St. Jude Medical, Carpentier-Edwards S.A.V. and Valcor), demonstrated the applicability of this technique to both mechanical and bioprosthetic valves. Carrying out non-destructive screening tests for heart valve prostheses may prevent the implantation of potentially dysfunctional devices.

How to cite: Geiger, A. W., Zarubin, A. M., Fahrenkamp, A., Konertz, W., von Bally, G., & Scheld, H. H. (1993). Non-destructive evaluation techniques for prosthetic heart valves based on hologram interferometry. Part II: Experimental results and clinical implications. The Journal of heart valve disease, 2(4), 448–453.

The development of a technique applying hologram interferometry, which is a non-destructive, non-contact, full-field, highly sensitive method is reported. The valve under investigation is placed in a test chamber which has windows providing optical access. Deformations of the valve leaflets due to pressure loading are recorded by hologram interferometry. The resulting interferogram clearly indicates the existence of any defects or structural anomalies which may be present in the valve material. Three modifications to this technique, intended for qualitative and quantitative non-destructive valve screening tests are described. The proposed technique is expected to become an effective means of detecting hidden defects of replacement heart valves; it is thus considered as a prospective tool for quality control, particularly in the manufacture of bioprosthetic valves, where initial sites of late calcification and degeneration might be identified. The application of holographic non-destructive testing may therefore substantially improve the quality and durability of heart valve substitutes.

How to cite: Zarubin, A. M., Geiger, A. W., von Bally, G., & Scheld, H. H. (1993). Non-destructive evaluation techniques for prosthetic heart valves based on hologram interferometry. Part I. The Journal of heart valve disease, 2(4), 440–447.

Between January 1978 and June 1992, 798 patients underwent isolated AVR for hemodynamically significant calcific aortic stenosis. Preoperative coronary angiography was performed in 687 patients, of whom 229 had coronary stenosis > 40% and were divided into three (I, IIa and IIb) groups. Group I consisted of 144 patients undergoing AVR plus coronary artery bypass grafts (CABG); 39 patients in Group IIa had AVR only in the presence of coronary stenoses < 60%, and 46 patients in Group IIb had AVR only in the presence of coronary stenoses > 60%. Group III consisted of 144 matched patients selected from the remaining 458 patients with no coronary disease, or stenoses less than 40%, according to five matching criteria (age, sex, functional status, ejection fraction and year of surgery) with patients in Group I. Early mortality was 10.4% in Group I, 7.7% in Group IIa, 13% in Group IIb and 4.9% in Group III. Although the differences in operative mortality are apparent, they did not reach statistical significance. A difference in long term survival could only be detected between Groups I and III (actuarial survival at nine years 66% and 78.9%, respectively, p < 0.01). Similarly, late coronary events were more frequent in Group I than in Group III (13.9% vs. 5.1%, p < 0.03). It is concluded that revascularization should be as complete as possible for severe coronary stenoses coexisting with significant calcific aortic stenosis. However, bypassing of moderate coronary lesions (stenoses in the order of 50%) in association with AVR does not appear justified on current evidence. Further studies on this important aspect are clearly required.

How to cite: Iung, B., Drissi, M. F., Michel, P. L., de Pamphilis, O., Tsezana, R., Cormier, B., Vahanian, A., & Acar, J. (1993). Prognosis of valve replacement for aortic stenosis with or without coexisting coronary heart disease: a comparative study. The Journal of heart valve disease, 2(4), 430–439.

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How to cite: Grunkemeier G. L. (1993). Will randomized trials detect random valve failure? Reflections on a recent FDA workshop. The Journal of heart valve disease, 2(4), 424–429.

A patient who underwent aortic valve replacement with a Lillehei-Kaster prosthesis developed an early duodenal ulcer requiring suspension of warfarin treatment. Subsequently he was managed without oral anticoagulants, receiving only antiplatelet agents, starting from the third postoperative year. Neither thromboembolic nor hemorrhagic complications occurred but at reoperation, performed almost 20 years later for prosthetic stenosis caused by a fibrous ring, and aneurysm of the ascending aorta, mild fresh thrombus was found on the prosthetic ring. Although the long term outcome of patients with a mechanical aortic prosthesis can occasionally be successful even without long term anticoagulation, such management appears to be justified only in highly selected cases.

How to cite: Mazzaro, E., Bortolotti, U., Milano, A., Thiene, G., & Casarotto, D. (1993). Long term survival without anticoagulation after aortic valve replacement with a Lillehei-Kaster prosthesis. A case report. The Journal of heart valve disease, 2(4), 420–423.

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How to cite: Horstkotte, D., Bergemann, R., Althaus, U., Babin-Ebell, J., Chares, M., Dahm, M., Eigel, P., Elert, O., Emmrich, K., & Geiger, A. W. (1993). German experience with low intensity anticoagulation (GELIA): protocol of a multi-center randomized, prospective study with the St. Jude Medical valve. The Journal of heart valve disease, 2(4), 411–419.

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How to cite: Gohlke-Bärwolf, C., Acar, J., Burckhardt, D., Oakley, C., Butchart, E., Krayenbühl, P., Hall, R., Bodnar, E., Krzeminska-Pakula, M., & Delahaye, J. P. (1993). Guidelines for prevention of thromboembolic events in valvular heart disease. Ad Hoc Committee of the Working Group on Valvular Heart Disease, European Society of Cardiology. The Journal of heart valve disease, 2(4), 398–410.

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How to cite: Acar J. (1993). Thromboembolic events in prosthetic valve recipients: what is the safe level of anticoagulation?. The Journal of heart valve disease, 2(4), 395–397.

The expanded use of autografts for aortic valve replacement has focused attention on developing an improved implantation technique with the aim of reducing the incidence of early insufficiency. While the technique for total root replacement with nonstented tissue valves is a proven and established method, it is, however, not generally accepted for use in all clinical circumstances. Through the use of a partial inclusion technique, we propose to modify the standard method of extended aortic root replacement and pedicle coronary implantation. This approach also has the advantage of leaving the recipient aortic root intact. Unlike traditional scalloped subcoronary homograft implantation, it does not enclose the transplanted valve totally within the recipient aorta. Thus, there is preservation of the patient's aorta without distortion of the transplanted valve which occurs when it is forced completely into the closed recipient aortic root. While this partial inclusion method is not as simple as total root replacement, preservation of the recipient root is generally more acceptable to implanting surgeons. Either perfection of this proposed method or the acceptance of a traditional extended aortic root replacement will result in correction of the persistent problem of early aortic insufficiency following the use of autograft valves. Decreasing valve incompetence will have the desired effect of increasing the indication for the use of autografts for aortic valve replacement in young patients.

How to cite: Angell, W. W., Pupello, D. F., Bessone, L. N., Hiro, S. P., Lopez-Cuenca, E., & Glatterer, M. S., Jr (1993). Partial inclusion aortic root replacement with the pulmonary autograft valve. The Journal of heart valve disease, 2(4), 388–394.

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How to cite: O'Brien M. F. (1993). Aortic valve implantation techniques--should they be any different for the pulmonary autograft and the aortic homograft?. The Journal of heart valve disease, 2(4), 385–387.

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How to cite: O'Brien M. F. (1993). Aortic valve implantation techniques--should they be any different for the pulmonary autograft and the aortic homograft?. The Journal of heart valve disease, 2(4), 385–387.

The excellent clinical results with homografts inserted for aortic endocarditis encouraged us to take this method one step further, believing that the placement of a pulmonary autograft which is totally viable and antibiotic-perfused would be an even better choice for valve replacement. We applied this technique in 13 consecutive patients with infective aortic endocarditis, achieving excellent early results. Our follow up extending to 30 months continues to show excellent results with 0% re-infection and 0% mortality. We conclude from our experience that this technique affords excellent results in curing the infection with the lowest chance of thromboembolism, the lack of need for anticoagulation and only a small chance of reoperation in the future.

How to cite: Oswalt, J. D., & Dewan, S. J. (1993). Aortic infective endocarditis managed by the Ross procedure. The Journal of heart valve disease, 2(4), 380–384.

The use of pulmonary autografts for aortic valve replacement is nearing its third decade. It is showing promise as a permanent aortic valve with its ability to grow with age. We report our experience of 45 patients with a mean age of 16.89 years over a three year period. Rheumatic heart disease was the cause of aortic valve dysfunction in 38 (84.4%) patients. Sixteen (35.5%) patients also underwent mitral valve repair. Echocardiographic examination revealed early reduction of aortic regurgitation and left ventricular dimensions, which remained stable in the short follow up period. There were no early or late deaths. One patient required reoperation for a regurgitant pulmonary autograft at two years. We conclude that pulmonary autograft transplantation to the aortic root seems to offer a near permanent solution in a young population affected by rheumatic valve disease.

How to cite: Kumar, N., Prabhakar, G., Gometza, B., al-Halees, Z., & Duran, C. M. (1993). The Ross procedure in a young rheumatic population: early clinical and echocardiographic profile. The Journal of heart valve disease, 2(4), 376–379.

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How to cite: Oury, J. H., Angell, W. W., Eddy, A. C., & Cleveland, J. C. (1993). Pulmonary autograft--past, present, and future. The Journal of heart valve disease, 2(4), 365–375.

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How to cite: Ross D. N. (1993). Reflections on the pulmonary autograft. The Journal of heart valve disease, 2(4), 363–364.