Background and aim of the study: The Sorin Perceval S (SP) sutureless bioprosthesis was developed as an advancement of conventional biological aortic valve replacement (AVR) with stented bioprostheses, and perhaps also as an alternative to the transcatheter aortic valve implantation (TAVI) procedure, especially for high-risk patients. Herein are described the authors' early results with SP valve replacement, compared to AVR with Carpentier-Edwards Perimount (EP) stented valves.

Methods: Between September 2012 and February 2013, a total of 14 patients was enrolled in a single-center SP study group, and their data were analyzed in a prospective manner. For comparison, 14 patients who received an EP valve replacement during the same period were matched with the SP group, in a retrospective manner. Hemodynamic parameters and clinical outcome were monitored until discharge of the patients in order to analyze the early results of the two groups.

Results: The cardiopulmonary bypass (CPB) and aortic cross-clamp (ACC) times needed for AVR with SP valves were significantly shorter than with EP valves. The mean CPB time for SP valve replacement without concomitant procedures was 58.4 +/- 11.0 min, compared to 71.8 +/- 11.3 min in the EP group (p = 0.015), while the mean ACC times were 37.3 +/- 6.8 and 49.1 +/- 11.2 min, respectively (p = 0.006). Permanent pacemaker implantation was required in four patients after SP valve replacement, but in only one patient after EP valve replacement (p = 0.326). The mean transprosthetic peak and mean gradients were 24.8 +/- 5.2 mmHg and 13.3 +/- 3.3 mmHg, respectively, in the SP group, and 19.0 +/- 6.5 mmHg and 10.4 +/- 3.0 mmHg, respectively, in the EP group (p = 0.024 and p = 0.087). The mean valve size was 23.8 +/- 1.3 mm and 23.3 +/- 1.5 mm in the SP and EP groups, respectively. The fall in platelet count after SP valve replacement was 180.4 +/- 79.4 x 10(3)/microl on the first postoperative day (POD), and 114.1 +/- 51.2 x 10(3)/microl with a minimum of 42 x 10(3)/microl and a maximum of 230 x 10(3)/microl at the nadir on POD 2.6 +/- 4.0. The mean minimum values at the nadir corresponded to 40% of the initial preoperative value.

Conclusion: The sutureless SP bioprosthesis seems to represent a good alternative to conventional stented bioprostheses, especially in older patients with a high-risk profile, and particularly if concomitant surgical procedures are planned.

How to cite: König, K. C., Wahlers, T., Scherner, M., & Wippermann, J. (2014). Sutureless Perceval aortic valve in comparison with the stented Carpentier-Edwards Perimount aortic valve. The Journal of heart valve disease, 23(2), 253–258.

Background and aim of the study: The symptoms of Parkinson's disease are alleviated by dopamine D2 agonists, which are classified as ergot dopamine D2 agonists and non-ergot D2 agonists. Among the former, pergolide has been associated with valvular heart disease, since it has both potent D2 receptor and serotonin 5-HT(2B) receptor agonistic properties. Among the latter, pramipexole has few incidences of heart valve disease onset, since it has an absence of 5-HT(2B) receptor agonism.

Method: A [3H]thymidine incorporation assay was performed to monitor function, and microarray global analysis to monitor gene expression, on porcine heart valve interstitial cells (VICs) treated with pergolide or pramipexole.

Results: The 5-HT(2B) receptor was abundantly expressed in porcine VICs. The 5-HT(2B) receptor agonist pergolide induced an increase in [3H]thymidine incorporation, accompanied by a decrease in 5-HT(2B) receptor mRNA expression. [3H]thymidine incorporation was blocked by lisuride, a 5-HT(2B) receptor antagonist, and also by LY-294002, a specific inhibitor of PI3K and Akt. Moreover, type 2 iodothyronine deiodinase (Dio2) expression in porcine VICs treated with pergolide was shown, by a global analysis of mRNA, to be markedly increased compared to that induced by pramipexole. Such changes in VICs may correlate with the mechanism of heart valve disease pathogenesis.

Conclusion: There were substantial differences (increased [3H]thymidine incorporation, and Dio2 expression) between pergolide and pramipexole, which might correlate with the mechanism of heart valve disease onset.

How to cite: Oana, F., Onozuka, H., Tsuchioka, A., Suzuki, T., Tanaka, N., Kaidoh, K., Hoyano, Y., Hiratochi, M., Kikuchi, S., Takehana, Y., & Shibata, N. (2014). Function and expression differences between ergot and non-ergot dopamine D2 agonists on heart valve interstitial cells. The Journal of heart valve disease, 23(2), 246–252.

Background and aim of the study: Triple-valve surgery is a challenging and complex procedure with significant risk, even at centers experienced at performing such operations. The study aim was to investigate the early and late outcomes of this surgery, performed at a single center for the past 11 years.

Methods: A total of 45 consecutive patients (19 males, 26 females; mean age 69.42 +/- 12.72 years) underwent triple-valve surgery at the authors' institution between 2000 and 2011. The mean logistic EuroSCORE was 22.46 +/- 12.8%. The most common aortic valve pathology was calcific degeneration (40%), while the mitral valves were mostly rheumatic (31%) or degenerative (26%). The tricuspid valve pathology was functional regurgitation in 64% of patients. The aortic valve procedures were all replacements, while the mitral valves were either repaired (n = 20) or replaced (n = 25). The tricuspid valves were almost exclusively repaired (n = 43). Univariate and multivariate analyses were performed to highlight predictors of mortality. A Kaplan-Meier analysis was also performed.

Results: The operative mortality was 8.9% (n = 4). Survival at one, three, and five years was 91%, 85.5% and 66.4%, respectively. Morbidity was not particularly high: the incidence of all postoperative neurological complications was 13%, that of transient renal impairment was 18%, and pacemaker implantation 8.9%.

Conclusion: The results of triple-valve surgery were considerably improved compared to historical reports. Early mortality was close to that occurring after less complex procedures, while late survival was comparable to that after single-valve surgery. It is believed that the best results are achieved by centers experienced in valve procedures. Compared to older studies, rheumatic disease was not the most frequent requirement for of triple-valve surgery among the present patients.

How to cite: Nikolaidis, N., Roubelakis, A., Karangelis, D., Hanratty, M., Barlow, C. W., Tsang, G. M., Livesey, S. A., & Ohri, S. K. (2014). The outcomes of triple-valve surgery: eleven years' experience from a single center. The Journal of heart valve disease, 23(2), 240–245.

Background and aim of the study: In developing countries rheumatic heart disease (RHD) is still the most common acquired cardiovascular disease affecting children and young adults. The study aim was to investigate, via an echocardiographic screening, the prevalence of subclinical RHD in high-school students in Eritrea.

Methods: A total of 684 students (314 females, 370 males; mean age 16.7 years) was randomly selected from nine secondary high schools in different regions of Eritrea to assess, via clinical and echocardiographic examinations, the presence of subclinical RHD. The term 'subclinical' was used to define the disease at its early stage, when it could not be detected by clinical examination only.

Results: Evidence of RHD was found in 28 students (4%), and of suspected RHD in 23 students (3.3%). Only 26 students (51%) with RHD (both evident or suspected) had a murmur at cardiac auscultation, and only 25 (49%) had a history of previous sore throat and tonsillitis. No student had clinical symptoms. All students with evident or suspected RHD were sent to secondary prophylaxis.

Conclusion: Despite involving only a limited population sample, the present study confirmed that, in Eritrea, there is a high prevalence (4%) of RHD among high-school-aged students. The data acquired demonstrated the importance of a clinical and echocardiographic surveillance, and the need to start a preventive campaign for rheumatic fever and RHD in this country. This has now been commenced in Eritrean primary schools, with the collaboration of local teachers.

How to cite: Rossi, E., Felici, A. R., & Banteyrga, L. (2014). Subclinical rheumatic heart disease in an Eritrean high-school population, detected by echocardiography. The Journal of heart valve disease, 23(2), 235–239.

Background and aim of the study: Very few data exist regarding the clinical outcome of redo valvular surgery in patients aged > 75 years.

Methods: A retrospective analysis was conducted of 42 consecutive patients (mean age 78.3 years) who had undergone redo valvular surgery between January 1991 and December 2010, and who had been followed up for a mean of 2.5 years. Factors associated with early outcomes were analyzed using logistic regression analysis, while predictors of late death and valve-related events were identified using Cox regression analysis.

Results: The overall hospital mortality rate of redo procedures was 17%. Multivariate logistic regression analysis showed that prolonged ventilator support (OR 1.007; 95% CI: 1.000-1.014; p < 0.0464) was an independent risk factor for hospital mortality. Overall survival rates at one and three years were 78.3 +/- 6.8% and 67.1 +/- 8.6%, respectively. Multivariate Cox regression analysis of survival revealed that age (HR 1.399; 95% CI: 1.044-1.875; p < 0.0238) and prolonged ventilator support (HR 1.004; 95% CI: 1.001-1.006; p < 0.0051) were negative predictors of mid-term survival. Rates of freedom for valve-related events at one and three years were 77.4 +/- 7.5% and 60.2 +/- 9.6%, respectively. An absence of peripheral artery disease protected against valve-related events (HR 0.045; 95% CI: 0.004-0.44; p < 0.0080).

Conclusion: Early and late outcomes for elderly patients who had undergone redo valvular surgery were relatively poor and satisfactory, respectively. Hence, an optimal referral for redo surgery is important to achieve better outcomes.

How to cite: Fukunaga, N., Okada, Y., Konishi, Y., Murashita, T., Kanemitsu, H., & Koyama, T. (2014). Redo valvular surgery in elderly patients aged > 75 years. The Journal of heart valve disease, 23(2), 228–234.

Background and aim of the study: The evaluation of prosthetic valve thrombosis (PVT) is crucial due to higher mortality and morbidity rates. The study aim was to assess the value of fibrinogen in the diagnosis of PVT, an important and a common cause of prosthetic valve failure.

Methods: Between December 2007 and April 2012, 154 patients with PVT and 116 control subjects with a normally functioning prosthesis were enrolled in the study. PVT was diagnosed using transesophageal echocardiography, and fibrinogen levels were measured at presentation. The patients and controls had similar demographic features.

Results: NYHA functional class, ineffective anticoagulation, presence of symptoms and moderate to severe left atrial spontaneous echo contrast (LASEC) were significantly different between the groups. The fibrinogen level was significantly higher in patients with PVT compared to controls (393.46 +/- 127.87 versus 276.93 +/- 69.22 mg/dl, p < 0.001). Ineffective anticoagulation, the presence of symptoms, a poor NYHA functional class, the presence of moderate to severe LASEC and elevated fibrinogen levels were independent predictors of PVT on multivariate regression analysis (p < 0.001, odds ratio (OR) 38.811, 95% confidence interval (CI): 13.319-113.091; p < 0.001, OR 6.745, CI: 2.777-16.386; p = 0.031, OR 3.557, CI: 1.126-11.239; p = 0.026, OR 3.203, CI: 1.146-8.955, and p < 0.001, OR 1.011, CI: 1.007-1.016 respectively).

Conclusion: Besides known indicators of PVT, including ineffective anticoagulation, the presence of LASEC and decreased NYHA functional capacity, elevated fibrinogen levels may be a valuable marker for the assessment of PVT.

How to cite: Aykan, A. C., Gökdeniz, T., Gündüz, S., Astarcioğlu, M. A., Gürsoy, O. M., Ertürk, E., Oğuz, A. E., Bayram, Z., Karakoyun, S., Kalçik, M., & Ozkan, M. (2014). Value of serum fibrinogen levels in the assessment of mechanical prosthetic valve thrombosis. The Journal of heart valve disease, 23(2), 222–227.

The case is described of a frail patient who developed prosthetic valve endocarditis due to methicillin-resistant Staphylococcus aureus (MRSA). Conventional antimicrobial treatments either failed or were contraindicated, and the patient was judged unsuitable for a further valve replacement. A salvage therapy with high doses of a new cephalosporin, ceftaroline, given three times daily was undertaken; subsequently, the patient had not relapsed at two months after completing a six-week course of ceftaroline. Ceftaroline deserves major attention as an alternative choice in difficult-to-treat MRSA endocarditis.

How to cite: Pagani, L., Bonnin, P., Janssen, C., Desjoyaux, E., Vitrat, V., & Bru, J. P. (2014). Ceftaroline for the treatment of prosthetic valve endocarditis due to methicillin-resistant Staphylococcus aureus. The Journal of heart valve disease, 23(2), 219–221.

Transcatheter aortic valve implantation (TAVI) is sometimes associated with severe complications due to the unpredictability of such closed-chest procedures. Reported complications include atrioventricular blocks, vascular complications, aortic root rupture, aorto-right ventricular fistulas, and aortic dissections. Herein is presented the case of an 88-year-old female with a late atrioventricular septal defect that developed after TAVI.

How to cite: Salizzoni, S., Marra, W. G., Moretti, C., D'Amico, M., La Torre, M. W., & Rinaldi, M. (2014). An iatrogenic atrioventricular septal defect that developed following transfemoral TAVI. The Journal of heart valve disease, 23(2), 216–218.

Background and aim of the study: Tricuspid valve replacement (TVR) is considered a high-risk operation. The study aim was to analyze the authors' eight-year experience with TVR and to characterize the specific risk factors for this operation.

Methods: Between January 2005 and August 2012, a total of 67 patients (46 females, 21 males; mean age 58 +/- 14 years; range: 25-86 years) underwent TVR at the authors' center. Re-do operations were performed in 48 patients (72%), including 37 patients (55%) who had at least two previous surgeries. Isolated TVR was performed in 28 patients (42%). The follow up (mean 28 months) included echocardiography and survival analysis.

Results: The overall operative mortality was 17.9% (n = 12, all female). In the latter half of the study period, mortality declined to 11.4% (p = NS). Major postoperative morbidity included prolonged mechanical ventilation (28.4%), low cardiac output (29.8%), and acute renal failure requiring hemodialysis (10.4%). Univariate analysis revealed that female gender (p = 0.007), NYHA class (p = 0.038), serum bilirubin level (p = 0.02) and number of previous cardiac surgeries (p = 0.05) were associated with increased operative mortality. Multivariable analysis demonstrated that reoperation (OR 6.06, p = 0.036) was an independent risk factor for operative mortality or complications. Echocardiography at follow up showed that 92.6% of all patients had tricuspid regurgitation grade < 2. The overall five-year survival rates for males and females were 82% and 53%, respectively (p = 0.03), but five-year survival for operative survivors was similar in males and females (82% versus 73%, p = 0.5). Cox regression analysis showed that age (OR 1.07, p = 0.028) and reoperation (OR 6.1, p = 0.038) were independent risk factors for late mortality.

Conclusion: TVR remains a high-risk operation, particularly for advanced age and previously operated patients; however, the long-term survival is satisfactory. Typically, women undergo TVR at an older age with a higher mortality rate than men. However, the long-term mortality rate of patients who survived surgery was not associated with gender.

How to cite: Leviner, D. B., Medalion, B., Baruch, I., Sagie, A., Sharoni, E., Fuks, A., Aravot, D., & Sharony, R. (2014). Tricuspid valve replacement: the effect of gender on operative results. The Journal of heart valve disease, 23(2), 209–215.

Background and aim of the study: The study aim was to evaluate whether, in patients with severe mitral regurgitation (MR), tricuspid valve remodeling was independent of the degree of functional tricuspid regurgitation (FTR) present. Whether any differences in the analysis remodeling, as assessed by two-dimensional (2D) and three-dimensional (3D) echocardiography, can be demonstrated was also addressed.

Methods: A total of 188 patients (mean age 63.5 +/- 16.0 years) with severe organic or functional MR with or without associated FTR, and 30 normal controls (mean age 59.2 +/- 15 years) were enrolled in the study. Subsequently, both 2D and 3D transthoracic anatomic and functional parameters of the tricuspid valve were analyzed.

Results: Patients and controls differed in all 2D and 3D parameters of tricuspid valve remodeling, except for the 2D end-diastolic annular diameter and circularity indices. The patients were then allocated to either group A (trivial/mild FTR) or group B (moderate/severe FTR). Significant differences were identified between groups A and B compared to controls in all tricuspid valve remodeling indices, except for the diastolic 2D annular diameter and circularity indices. Groups A and B had similar 2D and 3D parameters of tricuspid valve remodeling. The right ventricular end-diastolic diameter (RVEDD) (beta = 0.24, 95% CI: 0.11 to 0.22, p = 0.02) and fractional area change (beta = -0.48, 95% CI: -0.24 to 0.09, p = 0.0001, R2 = 0.22) were independent predictors of the tenting area, whereas the RVEDD was the only independent predictor of the diastolic 3D tricuspid annular area (beta = 0.53, 95% CI: 1.2 to 2.7, p = 0.0001, R2 = 0.28).

Conclusion: In patients with severe MR, tricuspid valve remodeling was also demonstrated in those with trivial/mild FTR, but was better characterized by 3D echocardiography. Tricuspid valve remodeling and right ventricular dilation were the main determinants of tricuspid valve regurgitation.

How to cite: Agricola, E., Ingallina, G., Slavich, M., Tufaro, V., Badano, L., Oppizzi, M., Fisicaro, A., & Margonato, A. (2014). Evidence of tricuspid valve remodeling in patients with severe mitral regurgitation independently of degree of functional tricuspid regurgitation: a two- and three-dimensional echocardiographic study. The Journal of heart valve disease, 23(2), 200–208.

Background and aim of the study: Three-dimensional (3D) transesophageal echocardiography (TEE) is useful for the quantification of mitral valve structures. The study aim was to investigate, in quantitative manner, any differences in mitral valve anatomy among patients with mitral valve prolapse (MVP) or functional mitral regurgitation (FMR), compared to normal control subjects.

Methods: 3D-TEE was performed in 20 MVP patients, 10 FMR patients and in 15 control subjects. Analyses of the full-volume 3D mitral valve data sets were performed offline, using Q-Lab software.

Results: Distinctive patterns were identified in annular geometric changes in normal subjects compared to patients with MVP or FMR. Patients with FMR showed significant annular anterior to posterior dilatation (34.6 +/- 8.3 mm versus 28.4 +/- 2.9 mm, p < 0.04: FMR versus control), whereas in patients with MVP dilatation in the anterolateral to posteromedial diameter was more prominent (41.0 +/- 5.9 mm versus 36.6 +/- 2.4 mm, p < 0.03; MVP versus control).

Conclusion: 3D-TEE represents a useful method for the evaluation of mitral valve geometry.

How to cite: Tani, T., Kawai, J., Kitai, T., Kim, K., Okada, Y., Kita, T., & Furukawa, Y. (2014). Mitral annular morphology in mitral valve disease with three-dimensional transesophageal echocardiography. The Journal of heart valve disease, 23(2), 193–199.

Background and aim of the study: Knowledge of the anatomy of the coronary venous system and its relationship with the mitral valve annulus (MVA) and coronary arteries is a key element to successful percutaneous transvenous mitral annuloplasty (PTMA) device implantation for treating patients with severe mitral regurgitation.

Methods: The spatial relationship of the coronary sinus-great cardiac vein (CS-GCV) with the MVA, left circumflex coronary artery (LCx) and its branches was examined in 120 formalin-fixed adult human cadaveric hearts.

Results: During the initial part of its journey, the CS-GCV was seen to course along and parallel to the plane of the MVA in 109 cases (90.8%), and to cross the MVA obliquely in 11 cases (9.2%). The LCx crossed deep or superficial to the CS-GCV at a discrete point in 98 cases (81.6%) and in eight cases (6.6%), respectively. In two cases (1.6%), the LCx was overlapped by the CS-GCV for an average length of 3.5 +/- 0.7 cm, and in five cases (4.1%) it lay superficial to the CS-GCV for an average length of 3.1 +/- 1.0 cm. In the remaining seven cases (5.8%), the artery did not accompany the CS-GCV along the MVA. Obtuse marginal arteries and the ramus intermedius were seen coursing deep to the CS-GCV in 40 cases (33.3%) and 33 cases (27.5%), respectively.

Conclusion: The study results showed that the CS-GCV crosses the annulus obliquely in 9.2% of cases, and hence might affect the efficiency of PTMA. Similarly, positioning of the annuloplasty device in the CS-GCV in cases where the LCx and its branches lay deep to the vein may result in an impingement of the arteries, leading to ischemia.

How to cite: Sahni, D., Randhawa, A., Aggarwal, A., & Rohit, M. K. (2014). Spatial relationship of coronary sinus-great cardiac vein with adjoining anatomic structures: a key element in predicting the success of percutaneous transvenous mitral annuloplasty. The Journal of heart valve disease, 23(2), 184–192.

Background and aim of the study: The appropriate management of patients with mitral regurgitation (MR) and left ventricular dysfunction (LVD) is controversial. The study aim was to determine whether the presence of contractile reserve (CR) assessed by dobutamine stress echocardiography (DSE) was associated with improved outcomes.

Methods: Death and heart transplantation were analyzed as the primary outcomes associated with the presence of CR. A total of 125 consecutive patients (96 males, 29 females; mean age 60 +/- 12 years) with left ventricular ejection fraction (LVEF) < or = 35% and hemodynamically significant MR underwent DSE between 1999 and 2005. CR was defined as an increase in LVEF of > or = 10% during dobutamine infusion.

Results: Among 125 patients, 55 (43.0%) showed evidence of CR. Within five years after DSE, 24 patients (34.3%) in the CR- group and seven (12.7%) in the CR+ group had died or required heart transplantation (p < 0.01, log rank). After adjusting for age, baseline LVEF, NYHA class and moderate/severe tricuspid regurgitation (TR), CR remained an independent predictor of time to death or heart transplantation (HR 0.34; 95% CI: 0.15-0.76, p < 0.01). Improvement in the degree of MR was present at one year in 85.0% of CR+ patients, and in 62.5% of CR- patients (p = 0.03). An improvement of 5% in LVEF was noted in the CR+ group, compared to 0% in the CR- group (p = 0.04).

Conclusion: In patients with advanced LVD and severe MR, CR detected by DSE was associated with significant reductions in the risk of death and heart transplantation.

How to cite: Moss, R. R., Bar, S. L., Chandavimol, M., Munt, B., Thompson, C. R., Abel, J. G., Humphries, K., & Ignaszewski, A. P. (2014). Contractile reserve induced with dobutamine echocardiography predicts outcome in patients with left ventricular dysfunction and mitral regurgitation. The Journal of heart valve disease, 23(2), 177–183.

Background and aim of the study: Anterior leaflet flail resulting from elongated or ruptured marginal chordae is frequently diagnosed among adults, and is amenable to surgical repair. The study aim was to investigate the efficacy of three surgical techniques, namely neochordoplasty, limited triangular resection and edge-to-edge repair, to correct anterior leaflet flail in an in-vitro experimental model.

Methods: Seven porcine mitral valves were evaluated in a pulsatile heart simulator before surgical manipulation, after anterior marginal chordae transection, and with each surgical repair. Marginal chordal transection induced leaflet flail with moderate mitral regurgitation (MR). Following the confirmation of MR via direct flow measurements, it was corrected by three repairs: neochordoplasty with ePTFE sutures, limited triangular resection, and edge-to-edge repair. The post-repair valve hemodynamics were quantified under pulsatile conditions of 120 mmHg peak transmitral pressure and 5 l/min cardiac output at 70 beats/min. Hemodynamic, geometric and echocardiographic indices were also measured.

Results: Transecting the marginal chordae induced A2 prolapse and produced the regurgitant fraction to 18.7 +/- 10.2%. Surgical repair effectively reduced the regurgitant fraction to 6.9 +/- 6.3% (p = 0.019 to prolapse, p = 0.0117 to baseline) with neochordae, to 5.8 +/- 7.0% (p = 0.03 to prolapse, p = 0.0378 to baseline) with triangular resection, and to 13.3 +/- 10.2% (p = 0.2091 to prolapse, p = 0.0045 to baseline) with edge-to-edge repair. Remnant regurgitation was largest with edge-to-edge repair compared to limited leaflet resection and neochordoplasty, though central leaflet coaptation was restored equally by the three repairs, with mild systolic leaflet restriction after repair.

Conclusion: Anterior leaflet repair and a reduction in MR is achievable with the three techniques, although neochordoplasty and triangular resection proved superior to edge-to-edge repair in eliminating MR.

How to cite: Padala, M., Sweet, M., Hooson, S., Thourani, V. H., & Yoganathan, A. P. (2014). Hemodynamic comparison of mitral valve repair: techniques for a flail anterior leaflet. The Journal of heart valve disease, 23(2), 171–176.

Hypereosinophilic syndrome (HES) is defined as a prolonged, unexplained peripheral eosinophilia. Endomyocardial fibrosis and mural thrombus formation are common occurrences such that patients are exposed to lethal thromboembolic complications. The valvular damage described is mainly related to iterative valve thromboses that are amenable to surgery. Here, the case is reported of a 39-year-old woman suffering from HES with mitral valve thrombosis and mechanical prosthetic mitral valve replacement, in whom a new thrombosis of the inserted prosthesis occurred one month postoperatively, concomitant with severe hypereosinophilia and despite adequate anticoagulation. The patient had received a new bioprosthetic mitral valve replacement, and her eosinophil count had been normalized after treatment with corticosteroids. Oral anticoagulation with warfarin was maintained. Subsequently, no recurrent thromboembolic events were reported, and echocardiography performed at the one-year follow up showed the bioprosthesis to have a normal hemodynamic profile.

How to cite: Zakhama, L., Slama, I., Boussabah, E., Harbegue, B., Mimouni, M., Abdelaali, N., Sioua, S., Thameur, M., & Benyoussef, S. (2014). Recurrent native and prosthetic mitral valve thrombosis in idiopathic hypereosinophilic syndrome. The Journal of heart valve disease, 23(2), 168–170.

Background and aim of the study: The impact of a minimally invasive approach on patient-prosthesis mismatch (PPM) in patients undergoing aortic valve replacement (AVR) remains unknown. The study aim was to identify the impact of a minimally invasive approach for AVR on the incidence of PPM.

Methods: The results of a single-center experience in 506 patients who underwent isolated AVR through a minimally invasive or conventional sternotomy were analyzed. Postoperative PPM was defined as an effective orifice area index < 0.85 cm2/m2, and was correlated with surgical approach, mortality and cardiac events after surgery.

Results: Overall, postoperative PPM was present in 26.0% of the patients. The ratio of PPM was 24.1% in minimal access patients and 27.7% in conventional AVR patients (p = 0.35). Hospital mortality was similar in both groups (3.8% versus 3.4%, p = 0.62). The body mass index (BMI) was higher in patients with PPM (28.5 +/- 4.4 versus 25.3 +/- 3.6 kg/m2; p = 0.0001), but obesity was significantly associated with PPM (36.3% versus 9.4%; p = 0.0001). The PPM group included more patients with a left ventricular ejection fraction (LVEF) < 0.50 (12.8% versus 5.3%; p = 0.004). The independent risk factors for PPM were increased BMI (p = 0.0001), LVEF < 0.50 (p = 0.007) and preoperative aortic stenosis (p = 0.029). A LVEF < 0.50 increased the risk for PPM by 3.77-fold (95% CI: 1.4-9.9), while a high BMI increased the risk by 1.42-fold (95% CI: 1.3-1.5). Preoperative aortic insufficiency was associated with PPM, but did not significantly increase the risk.

Conclusion: A minimally invasive approach for AVR did not lead to an increased incidence of PPM and associated adverse events following surgery.

How to cite: Bakir, I., Casselman, F. P., Onan, B., Van Praet, F., Vermeulen, Y., & Degrieck, I. (2014). Does a minimally invasive approach increase the incidence of patient-prosthesis mismatch in aortic valve replacement?. The Journal of heart valve disease, 23(2), 161–167.

Congenital atresia of the LMCA is an extremely rare anomaly which is often clinically complicated by silent angina, myocardial infarction, failure to thrive, or sudden cardiac death. Moreover, the atretic and ectopic origin of the LMCA associated with aortic valve anomalies is an even rarer condition. Herein, the case is described of a patient with a very rare association between the ectopic and atretic left main coronary artery (LMCA) and severe aortic valve regurgitation.

How to cite: Nicolini, F., Corradi, D., Agostinelli, A., Borrello, B., & Gherli, T. (2014). Aortic valve regurgitation secondary to ectopia and atresia of the left main coronary artery. The Journal of heart valve disease, 23(2), 158–160.

Background and aim of the study: The aim of this retrospective single-center study was to assess the authors' results in mitral-aortic double valve replacement (DVR), with attention focused on the risk factors of in-hospital mortality (HM). As the initial results showed a strong relationship between HM and aortic prosthesis-patient mismatch (PPM), this led to an assessment of the impact of PPM on the early results of DVR.

Methods: Data from 196 consecutive patients (mean age 60 +/- 10 years) who had undergone DVR between January 1996 and December 2011 at the authors' institution were analyzed. A statistical comparison was made of groups defined by the presence/absence of in-hospital death, postoperative complications, and aortic PPM. A logistic regression analysis of the factors associated with HM and their postoperative evolution was also conducted.

Results: Surgery was mostly performed on an elective basis (89.3%), using mainly bileaflet mechanical valves (93.9%). The rate of associated coronary bypass (CABG) was 11.2%. Aortic PPM (i.e., an effective orifice area index (EOAI) < or = 0.85 cm2/m2) was noted in 28.1% of patients. HM (6.63%) was significantly related to PPM (p < 0.002), greater age (p < 0.003), a smaller EOAI (p = 0.005), associated CABG (p < 0.008), and a longer aortic cross-clamp time (p < 0.03). Patients with aortic PPM had a significantly worse early outcome, with higher overall (p < 0.0007) and cardiac (p < 0.05) complication rates, a longer intensive care unit stay (p < 0.03), and an almost six-fold higher rate of HM (16.4% versus 2.8%; p < 0.002). PPM and age as risk factors were included in a predictive model of HM based on logistic regression; a similar model for postoperative complications highlighted PPM, age and cardiopulmonary bypass time as significant risk factors.

Conclusion: Aortic PPM greatly affects the postoperative outcome of DVR, as it is related to an increased complication rate and a higher in-hospital mortality. A strategy of avoiding PPM but without taking additional risks might improve the early results of DVR.

How to cite: Iosifescu, A. G., Moldovan, H., & Iliescu, V. A. (2014). Aortic prosthesis-patient mismatch strongly affects early results of double valve replacement. The Journal of heart valve disease, 23(2), 149–157.

Background and aim of the study: Synthetic materials used for pulmonary autograft (PA) reinforcement in the Ross procedure fail to match the demand for structural growth, have only a limited longevity, and do not guarantee adequate vascular compliance in high-pressure load systems. The study aim was to develop a resorbable reinforcement of a PA, tailored to provide structural support and to guide the process of wall structure modification for the preservation of graft viability.

Methods: An experimental model of translocation of the pulmonary trunk as an autograft in the aortic position was developed and performed under cardiopulmonary bypass in young lambs. The PA was left without reinforcement, reinforced with standard commercially available mesh, or reinforced with resorbable mesh of polyglactin and polydioxanone.

Results: Based on vessel diameter measurements by transesophageal echography at day 0 and at six months postoperatively, only the PA with resorbable reinforcement showed a behavior similar to that of the normal aorta in a growing lamb. With the non-resorbable reinforcement, transmural migration of the mesh was observed, accompanied by a conspicuous inflammatory infiltrate and fibrosis.

Conclusion: The resorbable mesh allowed for histological wall modification, characterized by the presence of highly organized smooth muscle cells and elastic lamellae in the media. The mechanical and histological features of this resorbable mesh-reinforced PA may be crucial to the clinical long-term success of the Ross procedure.

How to cite: Nappi, F., Spadaccio, C., Castaldo, C., Di Meglio, F., Nurzynska, D., Montagnani, S., Chello, M., & Acar, C. (2014). Reinforcement of the pulmonary artery autograft with a polyglactin and polydioxanone mesh in the Ross operation: experimental study in growing lamb. The Journal of heart valve disease, 23(2), 145–148.