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How to cite: Carroll, J. D., & Hellman, K. E. (1993). In response to: Nygaard H, Thuesen L, Hasenkam JM, Pedersen EM. Assessing the severity of aortic valve stenosis by spectral analysis of cardiac murmurs (spectral vibrocardiography) Part I and Part II. The Journal of heart valve disease, 2(5), 612–615.

The Medtronic Intact valve is the only porcine valve which is fixed in glutaraldehyde at zero pressure. This preserves near normal extensibility of the leaflet collagen, enabling full leaflet opening without kinking, which in turn should improve durability compared with low and high pressure fixed valves. From 1983 to 1991, 265 patients had 276 Intact valves inserted (125 aortic, 129 mitral, 22 tricuspid). The mean age was 53 years (10-81), with 24% below 40 years. The 100% follow up represents 911 patient years and averaged 50 months (3-106) in survivors. The actuarial survival was 54% +/- 9% at eight years, compared with a matched general population of 82%. The mean NYHA class was 3.2 preoperatively and 1.2 at follow up. At eight years, freedom from infective endocarditis was 97% +/- 1%, from thromboembolism 89% +/- 3%, and from non-structural dysfunction 96% +/- 2%. Reoperation was required in three patients for infective endocarditis, in six for non-structural dysfunction and in seven for structural valve deterioration (SVD). Freedom from SVD in the aortic position (mean age 59 years) was 100%, in the tricuspid position (mean age 48 years) 80% +/- 7%. In the mitral position, freedom from SVD was 86% +/- 10% in patients aged 60 years or more (n = 39, two events), 96% +/- 4% in those aged 40-59 years (n = 23, one event in a patient with renal failure), 67% +/- 16% in those aged 20-39 years (n = 31, three events in two following pregnancy) and 38% +/- 28% in those under 20 years (n = 9, two events).(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Barratt-Boyes, B. G., Jaffe, W. M., Ko, P. H., & Whitlock, R. M. (1993). The zero pressure fixed medtronic intact porcine valve: an 8.5 year review. The Journal of heart valve disease, 2(5), 604–611.

Transthoracic two-dimensional echocardiography has been considered the method of choice for the non-invasive assessment of bioprosthetic valves. Recently, transesophageal echocardiography has provided a better imaging window for detecting valve abnormalities not identified otherwise, but pathologic confirmation is essential to establish the role of new diagnostic techniques in clinical practice. Therefore, the purpose of this study was to evaluate the usefulness of transesophageal echocardiography in determining the etiology of bioprosthetic valve dysfunction. Transthoracic and transesophageal two-dimensional and color-flow Doppler echocardiography were performed on 44 consecutive patients with suspected bioprosthetic dysfunction who underwent surgical intervention. At surgery a total of 63 abnormalities in 44 bioprostheses were identified: 31 (49.2%) flail cusps, 14 (22.2%) vegetations, four (6.3%) abscesses, four (6.3%) dehiscences, and 10 (15.9%) stenoses. Transesophageal echocardiography was superior to its transthoracic counterpart for the detection of flail cusps (96.7% vs. 54.8%, p < 0.01), vegetations (85.7% vs. 42.8%, p < 0.01), abscesses (100% vs. 25.0%, p < 0.05), and dehiscences (100% vs. 25.0%, p < 0.05). All patients with flail cusps had severe regurgitation as evaluated by color-flow Doppler. In bioprosthetic mitral stenosis, both methods provided accurate estimates of valve area, while in bioprosthetic aortic stenosis, transthoracic Doppler velocity measurements allowed calculation of valve area in four of six patients. In two patients with high flow velocities, the valve area was not estimated because of an inability to measure the left ventricular outflow tract dimension. Conversely, the transesophageal approach provided measurement of the outflow tract in all six patients, but Doppler velocities were not obtained in any of them.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Zabalgoitia, M., Herrera, C. J., Chaudhry, F. A., Calhoon, J. H., Mehlman, D. J., & O'Rourke, R. A. (1993). Improvement in the diagnosis of bioprosthetic valve dysfunction by transesophageal echocardiography. The Journal of heart valve disease, 2(5), 595–603.

The reflux of aortic regurgitation causes an increased and longer diastolic reverse flow in the aorta and its branching vessels as compared to the normal flow contour. The changes of the aortic flow are related to the severity of aortic regurgitation and can be demonstrated by Doppler ultrasound. As Doppler examinations are often restricted in the aorta, a prospective study was designed to determine the feasibility and accuracy of Doppler measurements in the subclavian artery for the identification of severe forms of aortic regurgitation. Fifty-five patients with and 40 patients without aortic regurgitation were examined both by aortography and pulsed Doppler flow analysis of the subclavian artery. Two age groups were differentiated: patients below and those over 60 years of age, respectively. A high quality Doppler signal was recorded in all patients. In patients below 60 years, the best predictors of severe aortic regurgitation proved to be a pandiastolic reverse flow and an increased regurgitant fraction (77%) with a sensitivity of 100% and specificity of 75% and 92%, respectively. Since a pandiastolic reverse flow was detected in most patients in the control group over 60 years, it was not indicative of aortic regurgitation in these cases. However, an increased maximal diastolic velocity (> -37 cm/s) identified severe forms of aortic regurgitation in this age group with a sensitivity of 89% and a specificity of 100%. Therefore, severe forms of aortic regurgitation may be reliably identified by analysing the subclavian artery Doppler spectrum. In conclusion, the method is a useful adjunctive technique to other Doppler echocardiographic methods to assess the severity of aortic regurgitation.

How to cite: Omran, H., Fehske, W., & Lüderitz, B. (1993). Semiquantitation of aortic regurgitation by pulsed Doppler examination of the subclavian artery velocity contour. The Journal of heart valve disease, 2(5), 585–594.

The aim of this study was to evaluate the clinical consequences of the poor correlations between Doppler and hemodynamic measurements before and after balloon mitral commissurotomy (BMC). From March 1987 to December 1991, 317 patients with symptomatic mitral stenosis were selected for BMC at the Montreal Heart Institute. Despite the low correlation coefficients between Doppler and hemodynamic measurements before BMC (transmitral gradient: r = 0.57, mitral valve area: r = 0.35, mitral regurgitation: r = 0.33), the positive predictive value of Doppler echocardiography to select patients for BMC was 96%. Hemodynamic success, defined as a final mitral valve area greater than 1.5 cm2 and an increase in mitral valve area of more than 25% was obtained in 204 (80%) of the 253 patients who completed the procedure without complications. Doppler and hemodynamic mitral valve area increase were poorly correlated (r = 0.2) but the sensitivity and specificity of Doppler in the diagnosis of hemodynamic success were 86% and 63% respectively. A prospective six month echocardiography and hemodynamic re-examination was performed in our 50 patients first treated by BMC. Hemodynamic restenosis, defined as a loss of more than 50% of the gain achieved in mitral valve area and a mitral valve area of less than 1.5cm2 were diagnosed in 12 (26%) of the 46 patients with initially successful BMC. Despite a low correlation between Doppler and hemodynamic mitral valve area measurements (r = 0.28), the sensitivity and specificity of echocardiography in the diagnosis of hemodynamic restenosis were 66% and 88% respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Le Feuvre, C., Lachuriè, M. L., Mercier, L. A., Lespèrance, J., Dyrda, I., Crèpeau, J., & Bonan, R. (1993). Clinical relevance of the low correlations between Doppler and hemodynamic measurements before and after balloon mitral commissurotomy. The Journal of heart valve disease, 2(5), 578–584.

The Hatle orifice area formula was derived in patients with significant mitral stenosis and was not intended for use in other situations. Comparisons between it and other methods of estimating orifice area have shown variability in the slope of the regression lines with wide dispersal of data points. There is no relationship in prosthetic valves between pressure half-time and annulus diameter. Pressure half-time is determined by a number of factors other than orifice area, notably left ventricular compliance, the square root of the peak transmitral pressure drop at the start of diastole, and stroke volume. In normal prosthetic valves, therefore, pressure half-time reflects non-prosthetic factors more accurately than orifice area, and other formulae, such as the continuity equation, should be used to assess the latter. A pressure half-time prolonged beyond 200 ms remains a useful indication of obstruction, especially when the peak transmitral velocity is high.

How to cite: Chambers J. B. (1993). Mitral pressure half-time: is it a valid measure of orifice area in artificial heart valves?. The Journal of heart valve disease, 2(5), 571–577.

We report on a patient who developed tricuspid valve endocarditis on a permanent endocardial pacemaker lead. At operation the endocardial lead was removed and accurate debridement of the tricuspid tissue was performed. Tricuspid valve reconstruction included commissural plication and the construction of artificial polytetrafluoroethylene chordae from the anterior leaflet to the anterior papillary muscle to obtain valve competence.

How to cite: Bortolotti, U., Tursi, V., Fasoli, G., Milano, A., Frigato, N., & Casarotto, D. (1993). Tricuspid valve endocarditis: repair with the use of artificial chordae. The Journal of heart valve disease, 2(5), 567–570.

The paucity of reports on the incidence and management of organic involvement of the tricuspid valve in rheumatic disease led us to carry out this retrospective study. Over a four and a half year period, of the 1052 patients undergoing valve surgery at our institution, 253 (24.05%) required tricuspid surgery. Organic involvement was noted in 115 (45.45%) of these patients. Definitive preoperative diagnosis was feasible by echocardiogram in only 48 (41.73%). Tricuspid regurgitation was present in all patients while detectable stenosis was present in 48 (41.7%). Annular dilatation was seen in 52 (45.2%). Primary repair was possible in 107 patients (93.0%). The reduction in tricuspid regurgitation remained stable at the last follow up in all but seven patients. Nine patients underwent reoperation in this study for failure of left-sided valve repairs, of which five needed reoperation on the tricuspid valve. All the five reoperated tricuspid valves had had dilated annuli at primary surgery. The presence or absence of annular dilatation did not cause any significant difference in early or late mortality. The presence of annular dilatation in the presence of left-sided valve lesions superimposed on organically involved tricuspid valves evokes the possibility of the presence of an organo-functional disease.

How to cite: Prabhakar, G., Kumar, N., Gometza, B., al-Halees, Z., & Duran, C. M. (1993). Surgery for organic rheumatic disease of the tricuspid valve. The Journal of heart valve disease, 2(5), 561–566.

Infection with group G streptococcus is an unusual but virulent cause of endocarditis. Aortitis and abscess formation due to this organism have been described in one previous report, but only at necropsy. We present here a patient with group G streptococcal endocarditis and aortic annular abscess diagnosed during life by transesophageal echocardiography, leading to successful surgical intervention.

How to cite: Pollack, B. D., Belkin, R. N., Rubin, D. A., & Moggio, R. A. (1993). Aortic annular abscess complicating prosthetic valve endocarditis with group G streptococcus: detection during life with transesophageal echocardiography. The Journal of heart valve disease, 2(5), 558–560.

Aortic valve replacement is an established mode of therapy that enhances and prolongs life in patients with significant aortic valve disease. This is true for the elderly, but with a higher reported mortality and morbidity than in younger patients. One hundred and eighty-three elderly patients aged 70 years and over were considered suitable candidates for isolated aortic valve replacement (n = 97) or aortic valve replacement combined with coronary artery bypass surgery (n = 86) in the decade 1980-89. The mean age at surgery was 73.2 years (70-80). The hospital mortality and morbidity of this group were compared to 340 consecutive patients aged 60-69 who underwent similar surgery over the same period. There was no significant difference in hospital mortality: 4.4% for elderly patients and 4.1% for those aged 60-69. Measures of hospital morbidity were similar except for the perioperative stroke rate, which was 4.4% in the elderly patients and 1.5% in the younger group (p < 0.05). Detailed long term follow up was obtained in 75 of the 76 elderly patients who underwent aortic valve replacement or aortic valve replacement combined with coronary artery bypass surgery in the first five year period. Hospital survival was 99% (one hospital death). The overall five year actuarial survival was 81% and greater than the age and sexmatched general population (73%). Of the 44 patients alive at the time of review, 35 (80%) were free of angina and 32 (73%) had no significant symptoms of heart failure. Additionally, these patients were questioned about their quality of life.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Ruygrok, P. N., Barratt-Boyes, B. G., Agnew, T. M., Coverdale, H. A., Kerr, A. R., & Whitlock, R. M. (1993). Aortic valve replacement in the elderly. The Journal of heart valve disease, 2(5), 550–557.

Patients with mitral valve prolapse may present with chest pain and dyspnea. Left ventricular hemodynamics as a cause for these symptoms have not been completely evaluated in these patients. The present study was undertaken to investigate left ventricular hemodynamics in symptomatic patients with mitral valve prolapse. One hundred and three patients with mitral valve prolapse (female 72, male 31, age 56 +/- 11 years) had diagnostic cardiac catheterization for evaluation of chest pain (n = 44), dyspnea (n = 10) and for chest pain plus dyspnea (n = 49). All patients had diagnostic auscultatory findings and angiographic documentation of mitral valve prolapse. Patients with coronary artery disease and mitral regurgitation greater than mild were excluded from the study. Left ventricular end diastolic pressures before (chest pain 9.3 +/- 3.7 mmHg; dyspnea 8.2 +/- 4.2 mmHg; chest pain plus dyspnea 9.3 +/- 4.1 mmHg) and after left ventriculography (chest pain 11.6 +/- 5.5 mmHg; dyspnea 10.2 +/- 2.3 mmHg; chest pain plus dyspnea 11.7 +/- 5.6 mmHg) were normal in the majority of patients and similar in all three groups. Likewise, the left ventricular end diastolic volume index (chest pain 72.0 +/- 16 cm3, dyspnea 69.1 +/- 20 cm3, chest pain plus dyspnea 70.0 +/- 16 cm3) and ejection fraction (chest pain 64.0 +/- 8.4%, dyspnea 64.1 +/- 6.1%, chest pain plus dyspnea 64.3 +/- 6.1%) were normal in the majority of patients and similar in the three groups. Symptomatic patients with mitral valve prolapse without significant mitral regurgitation had normal left ventricular hemodynamics, and their symptoms cannot be explained on the basis of hemodynamic abnormalities alone.

How to cite: Vavuranakis, M., Kolibash, A. J., Wooley, C. F., & Boudoulas, H. (1993). Mitral valve prolapse: left ventricular hemodynamics in patients with chest pain, dyspnea or both. The Journal of heart valve disease, 2(5), 544–549.

True and significant ischemic mitral regurgitation affects on average 4% of the patients undergoing coronary bypass surgery. It not corrected, it profoundly influences the hospital mortality and the five year survival, even in the case of satisfactory myocardial revascularization. It is found predominantly in cases of right coronary and/or circumflex disease, and results mostly from restricted leaflet motion rather than from prolapse. Mitral annulus dilatation is present in all cases, and is the only mechanism of regurgitation in 50% of the patients. The indication for a valve procedure usually rests on findings at heart catheterization (i.e. the ratio of regurgitant/forward stroke volume, LV end-systolic volume index), but may be refined by pre- and perioperative transesophageal echocardiography; the LV volume loading test is very helpful in taking the decision in case of moderate or intermittent regurgitation. Mitral valve annuloplasty will easily and expeditiously correct or decrease the regurgitation in the majority of cases. If the mitral valve has to be replaced, the surgeon should always try to keep the papillary muscle-annulus continuity, at least posteriorly.

How to cite: Dion R. (1993). Ischemic mitral regurgitation: when and how should it be corrected?. The Journal of heart valve disease, 2(5), 536–543.

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How to cite: Rankin J. S. (1993). Improving surgical strategies for ischemic mitral regurgitation. The Journal of heart valve disease, 2(5), 533–535.

A case of a 61 year old male with lateral myocardial infarction, congestive heart failure and fever of days is presented. The exact etiology of this patient's heart failure was established with the application of transesophageal echocardiography. The transthoracic two-dimensional and Doppler echo showed a mobile echogenic density attached to the tip of the anterior mitral leaflet accompanied by moderate mitral regurgitation. Transesophageal echocardiography attributed this echogenic density to a ruptured head of the anterolateral papillary muscle, resulting in severe mitral regurgitation. Cardiac catheterization confirmed the severe mitral regurgitation and uncovered significant stenotic lesions of the coronary arteries. The resultant surgical treatment for the replacement of the mitral valve and coronary artery by-pass confirmed the rupture of the head of the anterolateral papillary muscle. It is suggested that transesophageal echocardiography is particularly capable of providing a definitive and prompt diagnosis of papillary muscle rupture.

How to cite: Kranidis, A., Koulouris, S., Filippatos, G., Sideris, A., & Anthopoulos, L. (1993). Mitral regurgitation from papillary muscle rupture: role of transesophageal echocardiography. The Journal of heart valve disease, 2(5), 529–532.

Of 263 consecutive patients undergoing mitral balloon valvulotomy at the Cardiac Catheterization Unit of Padua University Hospital, six (2.3%) required surgical treatment within 24 hours. The indication for surgery was unstable hemodynamic status due to acute mitral insufficiency caused by the percutaneous balloon valvulotomy. The purpose of this study was to evaluate whether the failure of percutaneous mitral balloon valvulotomy, in this subset of patients, was related to technical problems or was the direct consequence of unfavourable pathologic conditions. Additionally, we evaluated the operative results and clinical outcome of these six patients. The patients were all female with a mean age of 55.7 +/- 14 years (range 38-75 years). Previous surgical commissurotomy was performed in three. The anatomical lesions responsible for the massive regurgitation were tear of the anterior leaflet in two patients and tear of the posterior leaflet in four; rupture of the papillary muscle and/or chordae tendineae were present in five. All patients underwent mitral valve replacement. The elapsed time between the onset of mitral regurgitation and surgery ranged from two to 24 hours (mean 10 +/- 11 hours). There were two hospital deaths (33.3 +/- 21.1%): all surviving patients are alive and clinically well. In conclusion, massive mitral regurgitation following percutaneous mitral dilatation appears to be related to unfavourable pathology of the mitral valve rather than to technical errors. Therefore, careful patient selection is mandatory in order to achieve optimal results. In our experience, adequate and aggressive medical therapy provided sufficient time to prepare for the surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Gerosa, G., Fracasso, A., Guzzi, G., Muneretto, C., Thiene, G., & Casarotto, D. (1993). Emergency surgical treatment of ruptured incompetent mitral valve after percutaneous valvuloplasty. The Journal of heart valve disease, 2(5), 523–528.

Forty-two consecutive patients received emergency treatment for acute mitral insufficiency causing pulmonary edema between 1984 and 1992. The underlying diagnoses were acute myocardial infarction (n = 21), acute bacterial endocarditis on the native mitral valve (n = 9), prosthetic endocarditis in the mitral position (n = 4), acute failure of a replacement valve (n = 5), blunt chest trauma (n = 1) and chordal rupture in Marfan's syndrome (n = 2). Dysfunction of the subvalvular apparatus was present in 24 patients, verified by transthoracic echocardiography in 18 (75%) and by transoesophageal echocardiography in all patients in whom this technique was used. There were four cases of outflow strut fracture of a Björk-Shiley mitral prosthesis; a reliable diagnosis was made by fluoroscopy in all patients. Bedside hemodynamic monitoring was found to be unreliable both for differential diagnosis and for the quantitative assessment of the degree of mitral insufficiency. The right ventricular filling pressure was normal in 32/39 patients (82%), and the pulmonary artery and pulmonary capillary pressures elevated in 37/39 (95%). Diagnostically important, high pulmonary capillary v-waves were documented in 13 patients (33%). The left ventricular impedance could be influenced with sodium nitroprussid combined in some cases with dobutamin, and the resultant decrease of the peripheral vascular resistance from 1480 +/- 222 to 702 +/- 86 dyn x sec x cm-5 was followed by a proportionate reduction in the transmitral regurgitant fraction. Three patients died prior to the intended emergency surgical intervention. Emergency surgery was completed in 21 patients with an early mortality of 23.8% (n = 5). Ten patients underwent elective surgery within, and another three later than one year from the onset of the acute symptoms with an early mortality of 7.7% (n = 1). Four patients are alive and clinically well with medical treatment alone.

How to cite: Horstkotte, D., Schulte, H. D., Niehues, R., Klein, R. M., Piper, C., & Strauer, B. E. (1993). Diagnostic and therapeutic considerations in acute, severe mitral regurgitation: experience in 42 consecutive patients entering the intensive care unit with pulmonary edema. The Journal of heart valve disease, 2(5), 512–522.

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How to cite: Cohn L. H. (1993). Acute mitral regurgitation. The Journal of heart valve disease, 2(5), 509–511.

A novel approach to the prediction of valve-related complications in patients with implanted artificial heart valves is discussed. Adaptive artificial neural networks were used to identify patients at high risk of valve-related events based on preoperative data. Data from a clinical trial on 789 subjects with Carpentier-Edwards pericardial bioprostheses were used. Patients' records were divided into two groups, one of which was used for training the neural network and the other for testing the trained network and determining error rates. Patient information such as age, sex, NYHA class and anticoagulation therapy, as well as valve information such as size and the date of implant, were used as the network inputs. The neural net had a single output variable indicating the risk that an individual patient would develop a valve-related complication resulting in death. The results show that a trained neural network was able to predict valve-related deaths in the specified time interval of 1981-1991 with a high degree of accuracy. The neural network was also successful in classifying patients into high and low risk categories.

How to cite: Katz, A. S., Katz, S., Wickham, E., & Quijano, R. C. (1993). Prediction of valve-related complications for artificial heart valves using adaptive neural networks: a preliminary study. The Journal of heart valve disease, 2(5), 504–508.

Heart valve manufacturers possess the most complete inventory of world-wide mechanical valve failures, but to convert failures to time-related risks requires estimates of patient follow up. Since manufacturers did not actively track patients, they needed a model that incorporates an assumed death rate to decrease the numbers of patients at risk. We present a method for using a manufacturer's implant card database to estimate time-related complication rates for patient subsets, and illustrate its use by examining the risk of outlet strut fracture (OSF) with the Björk-Shiley 60 degrees Convexo-Concave valve (CC60). We developed a parametric model for valve patient survival based on actively followed valve patients from three centers using only variables typically available from implant cards. Using this survival model, a simulated lifetime was produced for each valve in the CC60 implant database for which the required covariates were known. These lifetimes were then used to analyze OSF as if they were true follow up times. This allowed the use of conventional methods of univariate and multivariate analysis for OSF, including parametric statistical models. According to the approximate linearity of the cumulative hazard functions, OSF risk over time appeared to be fairly constant. Several risk factors were identified, including valve size, patient age at implant and valve position. Using parametric models for both patient survival and OSF permits the estimation of the probability of OSF before death for an individual patient (as opposed to the usual actuarial probability of OSF given that the patient does not die). Because the patient may die before his valve would have failed, this cumulative incidence of OSF is always less than the actuarial risk. For all but the very highest risk patients, the cumulative incidence over their relatively short remaining lifetimes is very small.

How to cite: Grunkemeier, G. L., Chandler, J. G., Miller, D. C., Jamieson, W. R., & Starr, A. (1993). Utilization of manufacturers' implant card data to estimate heart valve failure. The Journal of heart valve disease, 2(5), 493–503.

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How to cite: Bodnar E. (1993). Prediction of valve failure: statistical modelling and pattern recognition. The Journal of heart valve disease, 2(5), 490–492.