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How to cite: Frater R. W. (1993). Ischemic mitral regurgitation. The Journal of heart valve disease, 2(6), 706.

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How to cite: Smith, J. A., Mitchell, R. S., & Miller, D. C. (1993). Which patients will require two or more reoperations for structural valve deterioration of porcine bioprostheses?. The Journal of heart valve disease, 2(6), 705.

Homograft heart valves are usually sterilized by exposure to multiple-antibiotic solutions at 4 degrees C for 24 hours. Several combinations of antibiotics have been proposed and discussed in the literature, but their toxicity to cusp endothelium has not been investigated yet. We studied the endothelial cell viability of porcine aortic valves by measuring their in vitro prostacyclin (PGI2) production after being exposed to different antibiotics solutions. Porcine aortic valves were immersed for 24 hours at 4 degrees C in RPMI medium to which antibiotics (Gentamycin 80 micrograms/ml, Azlocillin 500 micrograms/ml, Cloxacillin 25 micrograms/ml, Metronidazole 100 micrograms/ml, Amphotericin B 50 micrograms/ml, GACMA) were added separately or in combination. The basal and bradykinin (10 microM) stimulated PGI2 release of these valves in the medium were measured during consecutive incubation lasting 15 minutes at 37 degrees C, using a radioimmunoassay for 6-oxo-PGF1 alpha. Valves treated with the combination of all five antibiotics produced significantly less PGI2 in basal and stimulated conditions (1.64 +/- 0.63--7.25 +/- 1.73 ng/ml x cm2, p < 0.05) than the controls (4.66 +/- 0.66--30.55 +/- 3.84 ng/ml x cm2, p < 0.001). Although all antibiotics, when studied separately at the above mentioned concentrations, tended to reduce the biosynthesis of PGI2, amphotericin B was responsible for the most pronounced decrease in its production. The toxic effect of amphotericin B was dose dependent; at a low concentration (5 micrograms/ml), which is usually enough for antifungal action, toxicity was undetectable. At 50 micrograms/ml PGI2 production was half of that found at 5 micrograms/ml, although concentrations as high as 100 micrograms/ml have been used clinically to disinfect homografts. Scanning electron microscopy (SEM) also confirmed the extensive loss of endothelium after exposure to high concentrations of amphotericin B. Our study suggests that the other four antibiotics used in the concentrations described above do not damage endothelial function; amphotericin B is also harmless if used at a concentration of 5 micrograms/ml.

How to cite: Feng, X. J., van Hove, C. E., Mohan, R., Walter, P. J., & Herman, A. G. (1993). Effects of different antibiotics on the endothelium of the porcine aortic valve. The Journal of heart valve disease, 2(6), 694–704.

Inflammatory and immune reactions are thought to mediate both calcification and biodegradation of bioprosthetic cardiac valve implants. To investigate the mechanisms of implant degeneration, we evaluated the role of inflammatory and immune reactions and the effects of tissue preservative treatment in three series of experiments. In the first experiment, three kinds of implants, i.e. glutaraldehyde-treated autograft Sprague-Dawley (SD) rat skin, xenograft Swiss-Webster (SW) mouse skin, and saline-treated autograft (control) were subcutaneously implanted in ten weanling SD rats, and retrieved after 70 days. There was no significant difference in the level of calcification in the autograft (113.13 +/- 27.09 micrograms/mg dry weight) and xenograft (78.27 +/- 31.53 micrograms/mg dry weight) (p > 0.05), but both differed significantly from the control specimens (1.55 +/- 0.87 micrograms/mg dry weight). In the second experiment, the immunological response to glutaraldehyde-treated bovine pericardium (glut tBP) and glycerol treated bovine pericardium (glyc tBP) implants were tested in vivo and in vitro. A Gore-Tex implant was used as a control. Sections of these materials were implanted to the abdominal muscle wall of Lewis rats, with each group composed of twelve animals. Lymphocytes and sera from the animals were isolated, and histological examination was performed at two or four weeks post-implantation. Collagen type 1 (calf skin) was used as antigen. Tritiated thymidine incorporation was used to measure lymphocyte response to antigen collagen type 1 (calf skin), and an Enzyme Linked Immunosorbent Assay (ELISA) was used to test antibodies. The results showed that lymphocytes from both the glut tBP and the glyc tBP groups responded to collagen type 1. The ELISA results showed that the glyc tBP group produced more antibodies than did the glut tBP group, with the difference being significant at a level of p < 0.02. Histology revealed that the glyc tBP had greater inflammatory changes and collagen degeneration than did the glut tBP. In the third experiment, sections of glut tBP and glyc tBP were implanted subcutaneously in two groups of ten weanling SD rats, and retrieved after 70 days. The results showed that glut tBP caused more calcification (197.04 +/- 83.56 micrograms/mg dry weight) than did the glyc tBP (6.74 +/- 0.55 microgram/mg dry weight), with the difference being significant at a level of p < 0.05. From these investigations it is concluded that tissue treatment prior to implantation was very important in determining the tendency of tissue to calcify, and that there was no obvious relationship between bioprosthetic calcification and immunogenicity.

How to cite: Gong, G., Seifter, E., Lyman, W. D., Factor, S. M., Blau, S., & Frater, R. W. (1993). Bioprosthetic cardiac valve degeneration: role of inflammatory and immune reactions. The Journal of heart valve disease, 2(6), 684–693.

The case of a 27-year-old male heroin addict suffering from mitral and aortic prosthetic valve endocarditis is presented. Double valve re-replacement was performed using cryopreserved aortic homografts. Aortic root replacement with coronary re-implantation and intra-atrial valve implantation for mitral valve replacement were the techniques used. Despite the fatal outcome of this case, it clearly illustrates the possibilities of expanding the indications for combined complex replacement of heart valves by using fully biological tissue of human origin.

How to cite: Mestres, C. A., Ginel, A., Cartana, R., & Pomar, J. L. (1993). Cryopreserved homografts in aortic and mitral prosthetic endocarditis: expanding the use of biological tissues in complex cardiac infections. The Journal of heart valve disease, 2(6), 679–683.

One hundred and twenty-one patients who received 145 Cross-Jones prostheses between 1967 and 1973 were followed for over 20 years. Thirty-six patients had undergone single aortic valve replacement, receiving an uncovered prosthesis (Group A), while 83 of the 85 patients in Group B undergoing isolated mitral or combined mitral and aortic and/or tricuspid replacements received a cloth-covered prosthesis in the mitral and/or tricuspid position. There were no mechanical failures in Group A, and three patients are alive 24 years after their operations. The seat was smooth in all prostheses inspected at autopsy and the disc was not worn even 15-18 years after surgery. The overall incidence of thromboembolism in this group was 3.56%/pty, of which 2.13%/pty were fatal. All operative offvivors with cloth-covered valves developed mechanical dysfunction leading to death or requiring reoperation within ten years. The cloth cover was invariably disrupted and the disc hitting this rough surface had become worn, with significant diminution in their diameters in all valves recovered during reoperation or at autopsy. In seven patients, the disc escaped from a mitral prosthesis causing immediate death, while one patient survived a tricuspid disc escape for over one month and was then successfully reoperated. The overall incidence of thromboembolism in Group B was 23.4%/pty, of which 11.7%/pty were fatal.

How to cite: Kovacs, G. S., Felkai, B., & Toszegi, A. M. (1993). Lessons from the past: twenty-five years experience with the Cross-Jones caged disc prosthesis. The Journal of heart valve disease, 2(6), 671–678.

In order to define normal flow characteristics at mid-term follow up, prospective Doppler echocardiographic studies were performed in 145 patients (mean age 49.3 years) with Duromedics-Edwards bileaflet valve prostheses (76 aortic, 55 mitral and 14 double aortic and mitral) at a mean interval of 5.2 years following operation. All patients had clinically normal prosthetic valve function and no clinical or radiographic signs of heart failure. None of the patients had severely impaired left ventricular function as assessed by cross sectional 2D echocardiography. Mean peak velocity across prostheses in the aortic position was 2.8 +/- 0.5 m/sec, corresponding to a calculated instantaneous peak pressure gradient of 31.4 +/- 10.2 mmHg. Gradients varied inversely to valve size, although differences were significant only when comparing the 19mm and 21mm versus the 27mm valve (p < 0.05). In the mitral position the mean of peak velocity was 1.8 +/- 0.3 m/sec and pressure half time was 102 +/- 14 msec, representing a calculated mean orifice size of 2.2 +/- 0.5 cm2, with no significant difference between valves of different sizes. Paravalvular regurgitation was more common in the aortic than in mitral position (39% vs. 4%, p < 0.05), although in all cases it was mild (range less than one centimeter from prosthesis ring) and clinically insignificant. We conclude that normally functioning DE valve prostheses have a predictable range of Doppler echocardiographic parameters, although the individual variability of pressure gradients and effective valve area (in mitral valves) has to be emphasized. Nevertheless, the Duromedics Edwards valve shows good hemodynamic properties at mid-term follow up.

How to cite: Globits, S., Rödler, S., Moritz, A., Schreiner, W., Pacher, R., Glogar, D., & Wolner, E. (1993). Doppler sonographic evaluation of the Duromedics-Edwards bileaflet valve at five-year follow up. The Journal of heart valve disease, 2(6), 665–670.

Papillary fibroelastomas are rare, primary cardiac tumors most often diagnosed incidentally at autopsy. These tumors have been associated with embolism, neurologic injury, coronary ischemia and sudden death. We report a case of clinical detection of an asymptomatic aortic valve papillary fibroelastoma by transesophageal echocardiography. The mass was an incidental finding during routine coronary artery bypass surgery. This finding dictated a change in the operative approach to include resection of the aortic valve mass in addition to coronary revascularization.

How to cite: Autz, L., Krieger, K. H., & Yao, F. S. (1993). Transesophageal echocardiographic localization of an aortic valve papillary fibroelastoma during routine coronary artery bypass surgery. The Journal of heart valve disease, 2(6), 662–664.

The leaflets of the aortic valve move extremely rapidly during opening and closing. To analyse this movement, radiopaque markers were placed on the aortic valves of four dogs during cardiopulmonary bypass. One to five months later the dogs were studied using x-ray, and the marker motion was recorded on cine-film at 500 frames/second. Simultaneous aortic pressure varied from 70/30 to 188/152 mmHg and heart rate from 33 to 150 bpm. Analysis of 19 systolic periods and 2500 cine-frames indicated that leaflet motion occurred in four phases: 1--rapid movement during initial opening, 2--a little movement near maximal excursion, 3--a slow movement during early closing and 4--a rapid movement to complete closure. Phases 1 and 4 averaged 17.6 and 16.5 msec respectively, and were independent of heart rate, whereas the length of phases 2 and 3 varied with heart rate. The leaflets moved 82% of their maximum excursion during rapid opening and 53% during rapid closure. Leaflet curvature reversed in both the radial and the circumferential directions during opening. The leaflet profile in the radial direction changed as follows: during rapid opening, the belly of the leaflet moved outward, first causing the leaflet to straighten and then to conform to the profile of blood flow. During closure the belly of the leaflet moved centrally, causing the leaflet to curve toward the ventricle. The leaflet profile in the circumferential direction indicated that during opening the midpoint of the leaflet leads the motion towards the aortic wall.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Thubrikar, M. J., Heckman, J. L., & Nolan, S. P. (1993). High speed cine-radiographic study of aortic valve leaflet motion. The Journal of heart valve disease, 2(6), 653–661.

Seven patients with a mean age of 65 years (range 50-76 years) who had minor aortic valve gradients (less than 25 mmHg) at preoperative cardiac catheterization underwent coronary artery bypass surgery without aortic valve surgery, but required a second operation for aortic valve replacement between five and nine years later because of symptomatic aortic valve stenosis with a valve gradient which had increased to between 60 and 100 mmHg. Serial hemodynamic observations in patients with aortic stenosis have demonstrated that the rate at which stenosis progresses is widely variable. However, replacement of aortic valves at the time of initial coronary artery surgery may subject the patients to an increased risk of operative mortality and prosthetic valve-related complications. On the other hand, the patient may miss the opportunity to obtain maximum benefit from valve replacement before deterioration of left ventricular function, particularly in the presence of coronary artery disease, and there are also the risks of resternotomy. We are currently inclined to replace the aortic valve in coronary patients with asymptomatic aortic stenosis, but our experience is not sufficient to draw final conclusions and the relevant literature does not provide a clear guidance. The aim of this publication is to expose this dilemma.

How to cite: Wong, P. S., Davies, S. W., Youhana, A., Wright, J. E., & Magee, P. G. (1993). Coronary artery bypass surgery and minor aortic stenosis--to replace or not to replace?. The Journal of heart valve disease, 2(6), 649–652.

Our experience with 221 patients undergoing a first reoperation for bioprosthesis failure in the mitral position is reviewed. Most, (196, 89%) were reoperated because of structural valve deterioration, 16 (7%) had periprosthetic leak and nine (4%) had prosthetic endocarditis. Operative mortality (23 patients overall, 10.4%) was significantly higher in those patients who were in NYHA functional class IV or had impaired left ventricular function, in those reoperated because of prosthetic endocarditis and those undergoing emergency reoperation. Those patients who had structural valve deterioration, good left ventricular function and who were reoperated electively had the lowest operative risk. With increasing experience and the use of standardized surgical techniques, the results of reoperation for bioprosthetic failure have improved considerably in recent years. A further reduction in operative risk can be expected with better patient selection, obtained through more careful non-invasive assessment of valve performance to detect the initial signs of bioprosthetic failure.

How to cite: Mazzucco, A., Milano, A., Mazzaro, E., & Bortolotti, U. (1993). Reoperation in patients with a bioprosthesis in the mitral position: indications and early results. The Journal of heart valve disease, 2(6), 646–648.

The importance of the subvalvular mitral apparatus for left ventricular performance was studied in eight anesthetized dogs. During extracorporeal circulation St. Jude Medical mitral valve prostheses were implanted preserving the chordae tendineae. Flexible wires were slung around the chordae tendineae and brought to the outside through the left ventricular wall to cut the chordae tendineae by electrocautery in the closed beating heart. The left ventricular diameters were measured by sonomicrometry, left ventricular stroke volume and enddiastolic volume by dye dilution, and left ventricular pressure by catheter tip manometer. Data were collected at different preloads achieved by volume loading with blood before and after the chordae tendineae were cut. The results showed that after the chordae tendineae had been cut left ventricular systolic pressure, heart rate, diastolic and systolic diameters of the left ventricle along the minor axis were not different from the pre-cut values at any left ventricular enddiastolic pressure. However, significant differences were observed for maximum dp/dt (-15%), major axis diastolic diameter (+10%) and systolic shortening (-40%), enddiastolic volume (+18%) at any left ventricular enddiastolic pressure, and stroke volume (-24%) at any enddiastolic volume level. The data demonstrate that the subvalvular apparatus not only maintains physiologic valve function, but contributes significantly to left ventricular performance. The impairment of left ventricular function following removal of the subvalvular apparatus might be aggravated in pre-injured hearts in mitral valve disease. Consequently, the subvalvular apparatus should be preserved in mitral valve replacement whenever possible.

How to cite: Gams, E., Schad, H., Heimisch, W., Hagl, S., Mendler, N., & Sebening, F. (1993). Importance of the left ventricular subvalvular apparatus for cardiac performance. The Journal of heart valve disease, 2(6), 642–645.

Of 127 consecutive patients who underwent surgical repair of degenerative mitral valve incompetence between 1986 and 1992, 55 received posterior annuloplasty reinforced by an autologous pericardial tube. All patients had echocardiographic assessment before surgery and at discharge from hospital. There was one hospital death (0.78%) and one patient (0.79%) required early reoperation because of suture dehiscence. Postoperative fluoroscopy and echocardiography ascertained excellent relieve of the mitral regurgitation without any distortion of the annulus. It is concluded that early results with autologous pericardial annuloplasty are very promising, and a prospective follow up study is underway to assess mid to long term results.

How to cite: Salati, M., Scrofani, R., & Santoli, C. (1993). Annular remodelling with pericardial reinforcement: surgical technique and early results. The Journal of heart valve disease, 2(6), 639–641.

One hundred and twenty-nine patients underwent posterior mitral annuloplasty with a Gore-Tex tube for mitral regurgitation between January 1982 and June 1991. The hospital mortality was 1.5% (CL = 0.5%-2.5%). The overall survival of hospital survivors was 96.5% +/- 2.7% at five and 86.2% +/- 7.6% at nine years, freedom from cardiac death was 99.1% +/- 0.9% and 95.2% +/- 3.9%, respectively. The actuarial freedom from embolism was 96.1% +/- 2.3% at five and 88.5% +/- 5.5% at nine years. The freedom from endocarditis (one patient) was 100% and 92.6 +/- 7.1%, respectively. Reoperation was necessary in six cases between one and 72 months after the operation (mean 38.5 +/- 30.5 months). The etiology of the valvular insufficiency was rheumatic in all reoperated cases. The freedom from reoperation was 94.1% +/- 3.2% at five and 87.2% +/- 5.6% at nine years. There was no mortality at reoperation. Of the 117 patients alive at the end of follow up and not requiring reintervention, 113 (96.6%) showed good functional improvement and were in NYHA functional class I or II. We conclude that both the immediate and long-term results of reconstructive surgery using the technique of inserting a half-ring on the posterior mitral annulus compare favorably with those obtained using other annuloplasty methods.

How to cite: Pellegrini, A., Quaini, E., Colombo, T., Lanfranchi, M., Russo, C., & Vitali, E. (1993). Posterior annuloplasty in the surgical treatment of mitral insufficiency. The Journal of heart valve disease, 2(6), 633–638.

M-mode and two-dimensional echocardiographic images were obtained using the planimeter method in the short axis view and calculated by Doppler-derived pressure half-time in 24 patients with mitral stenosis before and after surgical commissurotomy and posterior annuloplasty. The diameter of the mitral valve annulus was measured in the standard long axis view and in the apical four-chamber view using two-dimensional echocardiography. Preoperatively, the mitral annulus was dilated in all patients as a consequence of left atrial dilation. This could be one of the factors causing residual regurgitation after surgical mitral commissurotomy. However, more data are needed to demonstrate that annuloplasty can prevent the development of mitral regurgitation after surgery.

how to cite: Morea, M., Di Summa, M., Pansini, S., Pecchio, F., & Mangiardi, L. (1993). Mitral annulus size in isolated mitral stenosis. The Journal of heart valve disease, 2(6), 630–632.

The aim of the present study was to determine the effect of sinus conversion after mitral commissurotomy on the exercise performance of patients with mitral stenosis (MS) and atrial fibrillation (Af). Electric cardioversion was attempted 10 days after successful balloon mitral commissurotomy in 32 patients with MS and Af. Both symptom-limited exercise tests with respiratory gas analysis and constant workload exercise tests with echo-Doppler examinations were performed before, five days and three months after mitral commissurotomy, and five days after successful sinus conversion. The balloon commissurotomy attenuated the increase in transmitral pressure gradient during exercise. However, no significant increase either in peak oxygen uptake (PVO2) or stroke volume were observed even three months after commissurotomy in patients with persistent Af. Sinus conversion was successful in 17 patients and PVO2 increased from 21.4 +/- 4.1 to 23.4 +/- 4.0 ml/min/kg (p < 0.01). The extent of the increase in PVO2 was related to the atrial contribution in transmitral flow (R2 = 0.39, y = 0.81x + 1.2). Sinus rhythm was maintained for three months in 14 of 17 patients. Increased PVO2 was also preserved in these patients. These results suggest that the sinus conversion after mitral commissurotomy has an effect on the exercise performance of patients with MS and Af.

How to cite: Tamai, J., Yoshioka, T., Yasuda, S., Takaki, H., Okano, Y., Ishikura, F., Nagata, S., Miyatake, K., & Shimomura, K. (1993). Increase in peak oxygen uptake by restoration of atrial contraction in patients after percutaneous transvenous mitral commissurotomy. The Journal of heart valve disease, 2(6), 623–628.

Non-invasive assessment of the stenotic mitral valve area is often difficult when the mitral stenosis is associated with atrial fibrillation. In this study, 16 patients with mitral stenosis and atrial fibrillation were evaluated by transthoracic Doppler echocardiography. The mitral valve area calculated by the pressure half-time method was 1.65 +/- 0.73 cm2. The enddiastolic mitral gradient was obtained from the enddiastolic forward mitral flow velocity by application of the simplified Bernoulli equation. For each patient there was a linear relationship between the enddiastolic mitral gradient and the corresponding RR interval. The slope and intercept of this relationship were significantly correlated with the mitral valve area. From the regression equations describing these correlations we established a nomogram ascertaining mitral valve area from enddiastolic mitral gradient and corresponding heart rate. This nomogram was helpful in the non-invasive assessment of stenotic mitral valve area in the presence of atrial fibrillation.

How to cite: Christiaens, L., Coisne, D., Allal, J., Mergy, J., & Barraine, R. (1993). Nomogram for Doppler echocardiographic assessment of mitral stenosis in atrial fibrillation. The Journal of heart valve disease, 2(6), 618–622.

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How to cite: Shah P. M. (1993). Evaluating the severity of mitral stenosis. The Journal of heart valve disease, 2(6), 616–617.