Background and aim of the study: A number of sutureless bioprosthetic aortic valves have been recently introduced in clinical practice, their main advantage being a reduction in the aortic cross-clamp time (AXCT). The study aim was to investigate if AXCT was a determinant of cardiovascular morbidity in patients undergoing surgical aortic valve replacement (AVR) to treat aortic valve stenosis, and to identify any subset of patients who might benefit from a reduction in AXCT.

Methods: A retrospective analysis was conducted of 979 consecutive patients with aortic valve stenosis who underwent surgical AVR. The AXCT was analyzed as an independent predictor of severe cardiovascular morbidity, defined as the presence of a low cardiac output, stroke, acute kidney injury, or operative mortality. Subgroups of patients who benefited more from a reduction in AXCT were investigated.

Results: The AXCT was an independent predictor of severe cardiovascular morbidity, with an increased risk of 1.4% per 1 min increase. Patients with a left ventricular ejection fraction < or = 40%, and also diabetic patients, showed the most relevant clinical benefits induced by a reduction in AXCT.

Conclusion: In selected patient populations at high risk of systolic dysfunction, the use of sutureless aortic valve bioprostheses may be considered. However, the routine use of such bioprostheses should be pondered within a cost-benefit analysis.

Background and aim of the study: Severe aortic regurgitation (AR) is a contraindication for balloon aortic valvuloplasty (BAV). As the effects of mild and moderate AR are unknown, the study aim was to determine the effects of BAV in patients with mild and moderate AR.

Methods: A total of 263 consecutive patients with symptomatic severe aortic stenosis (AS) who underwent BAV was included in the study. The patients were stratified into three groups according to their pre-procedural degree of AR, as assessed echocardiographically.

Results: The study groups included pre-BAV with no AR (n = 76; 28.9%), mild AR (n = 180; 68.4%), and moderate AR (n = 7; 2.7%). There were no differences in the baseline characteristics of the groups, with a mean age of 81.9 +/- 9.0 years and a Society of Thoracic Surgeons score of 12.9 +/- 6.0. Among patients with no AR pre-BAV, 48.7% developed mild AR post-BAV, while 4.5% of those with mild AR pre-BAV developed moderate AR (p < 0.001). The majority of patients (93%) had mild AR both pre- and post-BAV. Only two patients developed severe AR post-BAV. A good agreement existed between the categories of AR pre- and post-BAV (weighted kappa = 0.54, 95% CI, 0.43-0.65). The degree of AR post-BAV did not impact on the mortality rates of mild AR (41.1%), moderate AR (46.9%), or severe AR (63.6%) (p = 0.31).

Conclusion: It is safe to perform BAV in patients with mild and moderate AR. About half of all patients with no AR may develop mild AR, the majority will remain in mild AR, and a small percentage will develop moderate or severe AR.

Background and aim of the study: The study aim was to compare the hydrodynamics of the Carpentier-Edwards Magna 21 (CEM) and St. Jude Medical Biocor-Epic-Supra 21 (SJME) valves at increasing stroke volume and pulse rate in two different aortic conduits, namely straight and with sinuses of Valsalva present.

Methods: Both valve types were tested in the aortic chamber of the Sheffield pulse duplicator, at rates of 70, 80 and 90 beats/min, and stroke volumes of 50 and 60 ml. The systolic and diastolic performances were each recorded. The leaflet coaptation time, ventricle isovolumetric time and maximum instantaneous flow rate were also recorded.

Results: Regardless of the aortic conduit, CEM valves showed a significantly lower gradient than SJME valves (p < 0.05), and a significantly larger effective orifice area (EOA) (p < 0.05); the latter parameter was unaffected for both valves, at an increasing pulse rate (p > 0.05). The maximum transvalvular flow velocity was significantly higher in the straight conduit for both valves (p < 0.05). With regards to diastole, the SJME valve showed the lowest regurgitant volume (p < 0.05). The leaflet coaptation time was significantly shorter for the SJME valve than for the CEM valve (p < 0.05), but when tested in a straight conduit it was shortened significantly for both valves (p < 0.05).

Conclusion: An absence of the sinuses of Valsalva may modify the diastolic and systolic behaviors of the tissue valve leaflets by reducing the time required for leaflet coaptation, and increasing the valve closing volume and maximum transvalvular flow velocity. It is speculated that these hydrodynamic changes may increase the working stress on the valve tissue, leading to possible premature structural valve deterioration.

Background and aim of the study: Spontaneous intracranial hypotension, an important but frequently misdiagnosed cause of headache, is often associated with the presence of an underlying systemic connective tissue disorder. Bicuspid aortic valve (BAV) is a relatively common systemic connective tissue disorder that has been associated with other causes of headache, such as intracranial aneurysm and cervico-cephalic arterial dissection. The study aim was to assess the frequency of BAV among patients with spontaneous intracranial hypotension.

Methods: The medical records of a consecutive group of patients with spontaneous intracranial hypotension were reviewed for the presence of BAV. The control population consisted of a group of patients evaluated for face pain or headache not due to spontaneous intracranial hypotension.

Results: The presence of a BAV was confirmed in three of 273 patients (1.1%) with spontaneous intracranial hypotension, but in none of 506 controls (p = 0.04).

Conclusion: Patients with BAV may be at an increased risk of spontaneous intracranial hypotension. The aortic valvular cusps, as well as the spinal dura, are derived from cells that originate in the neural crest; hence, a disorder of neural crest cell migration could explain the findings of BAV and spontaneous intracranial hypotension in the presently reported patients.

Background and aim of the study: Severe symptomatic aortic stenosis (AS) portends a poor prognosis, and there is growing evidence that even mild disease carries significant morbidity. Systematic echocardiographic monitoring of asymptomatic disease is therefore essential to optimize the effectiveness of interventions. Inconsistencies exist, however, between different guidelines, and this may lead to inefficient resource utilization or, conversely, to inadequate monitoring. The study aim was to assess the appropriateness of AS surveillance echocardiography at the authors' institution. An additional aim was to document AS progression patterns in a contemporary British population, for which few data currently exist.

Methods: British, European, and North American guidelines relating to echocardiographic surveillance of asymptomatic AS were examined. A retrospective analysis of practice at the authors' institution was conducted, with timing of surveillance compared to guidelines. Progression was documented by monitoring the effective orifice area (EOA) and peak pressure gradient (PPG).

Results: Mean progression rates were consistent with published data (deltaEOA = -0.15 +/- 0.49 cm2/year; deltaPPG = +6.67 +/- 24.76 mmHg/year), with wide variation, and poor correlation between surveillance interval and disease progression. Progression of mild AS was significantly faster than severe AS (deltaEOA = -0.33 +/- 0.53 versus +0.04 +/- 0.41 cm2/year, respectively; p < 0.001). Of 169 echocardiograms evaluated, 60.9% were appropriately timed, 33.1% were early, and 6.0% were late. Surveillance of mild AS was less often appropriate than that of moderate or severe AS (12.0% versus 78.3% versus 84.7% appropriate, respectively; p < 0.001). On extrapolating these results nationally, an excess expenditure of pound 4.6 million (US$ 6.0 million) per year was estimated for this indication alone.

Conclusion: Echocardiographic surveillance of asymptomatic AS is often non-compliant with published guidance, which may be attributable to ambiguities and conflicts between different guidelines. The variable natural history of AS necessitates systematic surveillance at all stages of the disease spectrum, which in turn requires unambiguous, standardized guidelines to minimize variation in quality of care, while providing a clear framework to maximize the impact of investigations.

Background and aim of the study: The safety and durability of intra-atrial placement of mitral valve prostheses in patients with severe mitral annular calcification (MAC) were evaluated.

Methods: A retrospective analysis was conducted of all patients with severe MAC who underwent intra-atrial placement of a mitral valve prosthesis between September 2008 and August 2011, by placement of an 8 mm Dacron graft sutured circumferentially around the sewing cuff. Both, intraoperative and postoperative echocardiography were performed to evaluate the adequacy of prosthesis placement and to assess the presence of mitral regurgitation (MR).

Results: A total of six patients (three males, three females; mean age 78 +/- 9.7 years) was identified. The median EuroSCORE risk calculation was 14.5 (IQR 13-18), and three patients had a history of previous cardiac surgery. Three operations were performed via a minimally invasive approach. Three patients underwent concomitant coronary artery bypass graft surgery; one of these patients also underwent aortic valve replacement. All prostheses were placed successfully and no paravalvular leaks were observed postoperatively. There was one in-hospital mortality. The median aortic cross-clamp time was 176 min (IQR 156-190 min) and the median cardiopulmonary bypass time 178 min (IQR 156-218 min). The median preoperative versus postoperative MR grade was 3 (IQR 3-4) versus 0 (IQR 0-0). Follow up echocardiography was performed on two patients on postoperative days 20 and 70, respectively, but there was no evidence of MR. The median total length of hospital of stay was 11 days (IQR 4-19 days).

Conclusion: In patients requiring mitral valve replacement in which severe annular calcification prohibits standard valve surgery, the intra-atrial placement of a mitral valve prosthesis is a feasible option.

Background and aim of the study: Intraoperative real-time three-dimensional transesophageal echocardiography (RT-3D TEE) was used to examine the geometric changes that occur in the mitral annulus immediately after aortic valve replacement (AVR).

Methods: A total of 35 patients undergoing elective surgical AVR under cardiopulmonary bypass was enrolled in the study. Intraoperative RT-3D TEE was used prospectively to acquire volumetric echocardiographic datasets immediately before and after AVR. The 3D echocardiographic data were analyzed offline using TomTec Mitral Valve Assessment software to assess changes in specific mitral annular geometric parameters.

Results: Datasets were successfully acquired and analyzed for all patients. A significant reduction was noted in the mitral annular area (-16.3%, p < 0.001), circumference (-8.9%, p < 0.001) and the anteroposterior (-6.3%, p = 0.019) and anterolateral-posteromedial (-10.5%, p < 0.001) diameters. A greater reduction was noted in the anterior annulus length compared to the posterior annulus length (10.5% versus 6.2%, p < 0.05) after AVR. No significant change was seen in the non-planarity angle, coaptation depth, and closure line length. During the period of data acquisition before and after AVR, no significant change was noted in the central venous pressure or left ventricular end-diastolic diameter.

Conclusion: The mitral annulus undergoes significant geometric changes immediately after AVR. Notably, a 16.3% reduction was observed in the mitral annular area. The anterior annulus underwent a greater reduction in length compared to the posterior annulus, which suggested the existence of a mechanical compression by the prosthetic valve.

ackground and aim of the study: The current trends in the surgical technique of mitral valve repair (MVR) among North American medical centers participating in the Sorin Valve Repair Registry are described.

Methods: A total of 2,314 MVR procedures was performed and documented between 2003 and 2009 at 89 North American medical centers. Surgical procedure characteristics on all mitral valve annuloplasty and valve reconstructions were collected by participating surgeons, and documented in the registry.

Results: Early in the reporting period (between 2003 and 2007), posterior leaflet resection comprised 60% of all MVR procedures, but the percentage declined systematically through the years 2008 (56.1%) and 2009 (50.4%). A decrease over time was also observed in the frequency of sliding valvuloplasty procedures (from -30% in 2003 to 4.0% in 2009). Proportions of chordal repair techniques tended to increase towards the end of the reporting period, from a low of 15% in 2003 to a peak of 32% in 2008.

Conclusion: This report documents important trends in current MVR techniques among a representative cohort of surgical centers across North America. The data obtained were consistent with a practical shift from the conventional surgical MVR techniques to methods that allow a greater leaflet preservation--and thus less resection--over the latter half of the reporting period.