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How to cite: Walley, V. M., & Keon, W. (1994). Failure of Hancock pericardial bioprostheses. The Journal of heart valve disease, 3(5), 585.

We present an unusual sequence of events leading to massive cerebral air embolism and death in a patient who underwent mitral valve re-replacement for failure of the previously inserted bioprosthetic valve. An iatrogenic communication was created inadvertently between the adherent lung parenchyma and the left atrium. It caused a massive influx of air from the lung into the left atrium and systemic circulation causing fatal cerebral embolization. Retroperfusion was not Retroperfusion.

How to cite: Kole, S. D., Saksena, D. S., & Oswal, D. H. (1994). Fatal cerebral air embolism during open heart surgery caused by lung parenchyma to left atrial communication. The Journal of heart valve disease, 3(5), 583–584.

The case of a 50-year-old man is presented who underwent reoperation for a malfunctioning Björk-Shiley spherical valve which had been inserted 14 years previously. The patient made a satisfactory recovery after surgery. Examination of the explanted valve revealed that a segment of the pyrolytic carbon disc was missing. There was no evidence of embolization.

How to cite: Van Sabben, C., Griffin, S. C., & Venn, G. E. (1994). Disc failure in a Björk-Shiley mitral prosthesis. The Journal of heart valve disease, 3(5), 581–582.

The Freestyle Aortic Root Bioprosthesis is comprised of a porcine aortic root preserved in buffered 0.2% glutaraldehyde solution. It is fixed at a pressure sufficient to distend the aortic wall, but the leaflets are fixed with no transvalvular gradient. The bioprosthesis is treated with alpha-amino-oleic acid (AOA) to reduce the potential for leaflet calcification. In order to conduct in-vitro performance studies, a simulated aorta test chamber was developed. The test chamber material formulation can be altered to produce a wide range of desired compliances, while maintaining repeatable dimensional specifications. The test chamber design also allows for performance testing simulating a variety of implant techniques. Both Freestyle and the stented control valves (Hancock Standard Model 242) were mounted within the simulated aortas for these studies. Steady state and pulsatile flow pressure drop studies demonstrated a significantly lower gradient across the Freestyle valve when compared to stented Hancock Standard controls. In addition, the smaller size (19,21,23 mm) Freestyle valves had superior EOA's compared to the Standard St. Jude bileaflet mechanical and Hancock modified orifice (MO) porcine valve designs. The regurgitant volumes were equivalent to the control (Hancock Standard model 242) valves when compared to the Freestyle valves with equivalent flow areas. Additional studies were conducted in order to determine the effects of sizing and configuration on hydrodynamic performance. These studies were performed in four configurations: total root, inclusion, partially scalloped (two sinuses) and fully scalloped valve. These studies demonstrated that both pressure drop and regurgitation are significantly affected by valve sizing and implant technique. Accelerated wear studies were performed on three of each size and six of the largest Freestyle valves. Stented Hancock Standard valves and non-AOA treated Freestyle valves were used as controls. Hydrodynamic performance tests were conducted at intervals throughout the study. No evidence was found to indicate a difference in wear or hydrodynamic performance between the AOA treated and untreated Freestyle valves.

How to cite: Yoganathan, A. P., Eberhardt, C. E., & Walker, P. G. (1994). Hydrodynamic performance of the Medtronic Freestyle Aortic Root Bioprosthesis. The Journal of heart valve disease, 3(5), 571–580.

The in vitro function of the CarboMedics, Medtronic Hall, Omniscience, Starr-Edwards, St. Jude and Sorin (formerly Shiley) Monostrut heart valves have been compared using a pulsatile flow model left heart and load system. A wide range of flows and heart rates were used. The above valves in all sizes and in both aortic and mitral positions were tested. Results for transvalvular pressure, regurgitation and effective orifice area are presented. The small size St. Jude valves showed the least transvalvular pressure and largest effective orifice area. For large valves, the least regurgitation was exhibited by the Starr-Edwards valve. The data provides a reference for the range of normal performance that can be expected of mechanical prosthetic heart valves.

How to cite: Walker, D. K., & Scotten, L. N. (1994). A database obtained from in vitro function testing of mechanical heart valves. The Journal of heart valve disease, 3(5), 561–570.

Aortic homograft valves are accepted as excellent valve substitutes in the aortic position. Compared to stented bioprostheses, they are considered to have better hemodynamics and a zero or negligible thrombogenicity. Their perceived major single shortcoming is limited durability, but there is apparent broad variation within published data in this respect. Study of the relevant literature reveals important differences between procurement, sterilization and preservation of the individual series refuting any attempt at making a scientifically valid comparison of overall performances. Surgical method and patient selection are further sources of variation among reported long term results. Nevertheless, it appears that (a) cryopreservation produces results at least as good as those of other preservation methods, and (b) the worst results are those of series with the longest follow up. However, the good results with cryopreserved valves are reported in series with limited length of follow up. Because of the many variable factors associated with the use of homograft valves, a comprehensive set of definitions should be introduced, accepted and adhered to in reporting results.

How to cite: Grunkemeier, G. L., & Bodnar, E. (1994). Comparison of structural valve failure among different 'models' of homograft valves. The Journal of heart valve disease, 3(5), 556–560.

Echocardiography was performed in 94 patients with a total of 99 normally functioning Labcor-Santiago bioprostheses, 62 in the aortic and 37 in the mitral position. The following variables were measured: peak and mean transvalvular velocities, peak and mean instantaneous pressure gradients as calculated from the modified Bernoulli equation, pressure half-time, cardiac index, stroke volume and effective orifice area (using continuity and Hatle equations). Regurgitation patterns were sought by transthoracic echocardiography (all valves) and, for selected mitral bioprostheses, by transesophageal echocardiography. Calculated mean aortic pressure gradient ranged from six to 10 mmHg and calculated effective aortic orifice area increased with ring diameter, with means of 1.27 cm2 for the 19 mm valve and 2.58 cm2 for the 27 mm valve. For mitral bioprostheses, mean pressure gradient ranged from 3.0 to 4.5 mmHg and calculated effective orifice area from 2.27 to 2.73 cm2. Only central regurgitation was observed. The Labcor-Santiago pericardial bioprostheses created little resistance to forward flow. In the small aortic root their hemodynamic performance was as good or better than that of other currently available devices. It is hoped that this new design will contribute increased in vivo mechanical durability.

How to cite: Gonzalez-Juanatey, J. R., Garcia-Bengoechea, J. B., Vega, M., Rubio, J., Sierra, J., Duran, D., Amaro, A., & Gil, M. (1994). Echocardiographic features of the normofunctional Labcor-Santiago pericardial bioprosthesis. The Journal of heart valve disease, 3(5), 548–555.

The Jyros valve is a new bileaflet valve with the unusual feature that the hinge is expected to rotate continuously inside the housing. Nine isolated Jyros mitral prostheses were implanted from July to October 1993. All patients survived the surgical procedure and during the follow up underwent transthoracic (TTE) and transesophageal echocardiograms (TEE) for the evaluation of hinge rotation. Neither TTE nor TEE were able to show hinge rotation in any patient at any time. Five patients had prosthetic thrombosis. In the successfully treated with thrombolysis. In the remaining patient thrombolysis was contraindicated. Eight patients are alive; one died of gastro-intestinal bleeding a few months after discharge. The absence of hinge rotation may be the triggering mechanism of valve thrombosis although no explanted prostheses were available for examination. Further studies are necessary to understand the mechanism of valve thrombosis with the Jyros bileaflet prosthesis.

How to cite: Renzulli, A., Vitale, N., Caruso, A., Covino, F., De Vivo, F., Piazza, L., & Cotrufo, M. (1994). Early experience with the Jyros bileaflet valve in the mitral position: high incidence of valve thrombosis. The Journal of heart valve disease, 3(5), 543–547.

Comparison of long term clinical results after aortic valve replacement with 19 mm or 21 mm vs. 23 mm or larger bileaflet prostheses has not yet been reported. Between December 1979 and September 1993, 80 consecutive patients who underwent isolated aortic valve replacement at Niigata University using a standard St. Jude Medical valve were assigned to small size group (19 mm and 21 mm, n = 34) or to large size group (23 mm or larger, n = 46). In the small size group, patient's age was older, body surface area smaller, female patients and calcified aortic stenosis were dominant (all p < 0.01). The left ventricular systolic dimension was shorter (p < 0.001), while the cardiothoracic ratio was similar to that of the large size group. All patients received warfarin treatment, and target thrombotest level was 15 to 25% (equivalent to INR 1.6 to 2.1). Actuarial survival rates including hospital death in the small size group (94% at fifth postoperative year) were comparable to those in the large size group. Cerebrovascular event occurred in two patients with the small size prosthesis (1.3%/pty) and three with larger prosthesis (0.9%/pty). Major hemorrhagic complication was not observed in either group. No significant difference was noticed in the proportion free from valve-related morbidity. In the patients with aortic stenosis (n = 41), the left ventricular posterior wall thickness decreased from 15 mm preoperatively to 11 mm late post surgery in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Hayashi, J., Nakazawa, S., Okazaki, H., Ohzeki, H., Saito, A., Moro, H., Yamamoto, K., & Eguchi, S. (1994). Long term clinical results with 19 mm or 21 mm standard aortic St. Jude Medical prosthesis. The Journal of heart valve disease, 3(5), 537–542.

Records of 144 patients who received size 19 or 21 mm (Group A) aortic Standard St. Jude Medical (SSJM) prostheses were retrospectively reviewed and compared to 219 patients who received size 25 mm SSJM valves (Group B). Group A patients were older (70 +/- 9 years vs. 62 +/- 13 years) and had smaller body surface area (BSA) (1.65 m2 vs. 1.9 m2 p < 0.05). Operative mortality (5% vs. 2%) and postoperative unadjusted Doppler mean gradient (31 mmHg vs. 22 mmHg) were higher in Group A (p < 0.05). Total follow up was 1255 patient-years (450.6 Group A/804.4 Group B). There were no perivalvular leaks, valve thrombosis, or endocarditis in either group. Freedom from thromboembolism and anticoagulant-related hemorrhage was 89% and 95% in Group A and 93% and 98% in Group B, respectively. The major causes of late death were older age and progressive cardiac disease. The five-year actuarial analysis revealed a survival rate of 74% in Group A and 83% in Group B (p < 0.05). Of those who were alive, more than 70% were in functional class I and II. These patients not only enjoy a complication-free living but are able to perform daily routine activity despite being older. 19 mm and 21 mm SSJM aortic valve prostheses had higher transprosthetic gradient, but provided satisfactory performance in adult patients with a BSA of less than 1.7 m2. This valve can be used in the small aortic annulus with a valve size index of at least 12 mm/m2 as an alternative to an annular enlargement procedure.

How to cite: Arom, K. V., Goldenberg, I. F., & Emery, R. W. (1994). Long-term clinical outcome with small size Standard St Jude Medical valves implanted in the aortic position. The Journal of heart valve disease, 3(5), 531–536.

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How to cite: Zingone B. (1994). Coronary artery bypass surgery and minor aortic stenosis--the need for tailored solutions. The Journal of heart valve disease, 3(5), 527–530.

The many changes in classification of cardiovascular disease during the twentieth century reflect changing etiology of diseases, clinical comprehension and technological advances. In particular, the etiology of valvular heart disease has changed dramatically in the last five decades. The significant reduction of acute rheumatic fever and its sequelae, and the recognition of non-rheumatic causes of valvular disease are responsible for the metamorphosis in the etiology of valvular disorders. Valvular heart disease can be classified as follows: 1) Heritable-congenital causes of valvular heart disease e.g., floppy mitral valve with mitral valve prolapse, bicuspid aortic valve, and the Marfan syndrome; 2) Inflammatory-immunologic causes such as rheumatic fever, acquired immune deficiency syndrome, endocardial proliferative disorders, and antiphospolipid syndrome; 3) Myocardial dysfunction-ischemic cardiomyopathy, dilated or hypertrophic cardiomyopathy-resulting in valvular heart disease; 4) Diseases and disorders of other organs as causes of valvular heart disease, e.g., chronic renal failure and carcinoid heart disease; 5) Valvular heart disease related to aging: calcific aortic stenosis and mitral annular calcification; 6) Valvular disease following interventions such as valvuloplasty, valve reconstructive surgery and valve replacement; and 7) Valvular disease related to drugs and physical agents, such as chronic ergotamine use, radiation therapy and trauma. In clinical practice the most common causes of mitral regurgitation are floppy mitral valve with mitral valve prolapse, ischemic heart disease, dilated cardiomyopathy and mitral annular calcification, while the most common cause of mitral stenosis is rheumatic fever. The most common causes of isolated aortic regurgitation are bicuspid aortic valve and floppy aortic valve, while the most common causes of isolated aortic stenosis are related to the bicuspid aortic valve and the development of calcific senile aortic stenosis. The most common causes of tricuspid regurgitation are dilated cardiomyopathy, ischemic cardiomyopathy, floppy tricuspid valve with tricuspid valve prolapse and infectious endocarditis. Combined mitral and tricuspid regurgitation occur with heritable connective tissue disorders, dilated or ischemic cardiomyopathy, while the most common cause of mitral stenosis plus aortic regurgitation is rheumatic fever. Statistics obtained from cardiac surgery and necropsy may underestimate the true incidence of certain valvular diseases by selection bias. This is particularly so with valvular disease associated with significant ventricular dysfunction, or in the elderly who may not be surgical candidates, or in cases where the valvular disease is not severe enough to require surgical intervention. Recent advances in hemodynamic and imaging technology allow clinicians to define valvular structure and function and to accurately classify valvular heart disease in clinical practice.

How to cite: Boudoulas, H., Vavuranakis, M., & Wooley, C. F. (1994). Valvular heart disease: the influence of changing etiology on nosology. The Journal of heart valve disease, 3(5), 516–526.

Dipyridamole is a potent vasodilator used in pharmacologic stress testing. Patients with severe aortic stenosis are not suitable for exercise, and are usually not subjected to testing with vasodilator substances. The aim of the present study was to investigate hemodynamic changes during dipyridamole stress test in patients with aortic stenosis and to see if these changes where reversible by theophylline, an aminophylline derivative. Ten patients with aortic stenosis underwent right and left heart catheterization. Simultaneous recordings of cardiac output, left ventricular and aortic pressures were performed at baseline, after intravenous dipyridamole infusion (0.56 mg/kg dissolved in 250 ml of saline given over four minutes), and after intravenous theophylline injection (115 mg). There was an increase in heart rate, stroke volume and flow, and a decrease in systolic and diastolic blood pressure and in systemic vascular resistance after dipyridamole infusion. Left ventricular stroke work index and pressure time per minute increased after dipyridamole infusion suggesting an increase in myocardial oxygen demand, but there was no significant change compared to baseline after theophylline administration. Less than one third of left ventricular work was due to the resistance of the aortic valve. The aortic valve area changed with changes in flow. It is concluded that cardiac output, left ventricular work and myocardial oxygen demand after dipyridamole infusion increased in patients with aortic stenosis. The systemic vascular resistance seems to be more important determinant of cardiac output than the aortic valve obstruction. The calculated valve area appears to be flow-dependent.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Rask, L. P., Karp, K. H., & Teien, D. E. (1994). Hemodynamic changes during dipyridamole stress in patients with aortic stenosis. The Journal of heart valve disease, 3(5), 510–515.

This study was performed to assess the effects of one year of ACE inhibition with quinapril on left ventricular performance and morphology in asymptomatic patients with chronic aortic regurgitation. Pre- and afterload reduction is known to have beneficial effects in patients with chronic aortic regurgitation. To date, no controlled study has been reported analyzing long term influence of ACE inhibitor treatment on asymptomatic patients with chronic aortic regurgitation. Twelve asymptomatic patients with isolated moderate to severe chronic aortic regurgitation, no coronary disease on coronary angiography and no previous vasodilator treatment were studied under control conditions and after three and 12 months of quinapril therapy (10-20 mg/day) using echocardiography and simultaneous right heart catheterization and radionuclide ventriculography at rest and during supine bicycle exercise. After one year quinapril therapy regurgitant fraction fell by 17% compared to control before therapy (p = 0.001), left ventricular enddiastolic volume at rest was reduced from 150 +/- 33 to 128 +/- 30 ml/m2 (p = 0.0003) and endsystolic volume decreased from 55 +/- 27 to 44 +/- 28 ml/m2 (p = 0.0005). Left ventricular ejection fraction at rest averaged 0.64 +/- 0.11 at control and increased after one year therapy to 0.67 +/- 0.11 (p = 0.05). With maximum exercise (100 W), ejection fraction failed to rise at control; after one year therapy with quinapril it increased to 0.70 +/- 0.15 (p = 0.019). Moreover, after one year quinapril therapy there was a significant reduction of 35% in left ventricular mass compared to control.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Schön, H. R., Dorn, R., Barthel, P., & Schömig, A. (1994). Effects of 12 months quinapril therapy in asymptomatic patients with chronic aortic regurgitation. The Journal of heart valve disease, 3(5), 500–509.

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How to cite: Cheitlin M. D. (1994). Afterload reduction in chronic aortic regurgitation: going in the right direction?. The Journal of heart valve disease, 3(5), 497–499.

The increasing popularity of mitral valve repair and current interest in replacement with a mitral homograft or heterograft warrant a new look at the normal functional anatomy of the system. We conducted a detailed review of the anatomic structure of both the intact and excised mitral apparatus of porcine and human species. The following intact structural dimensions were measured: total annular length, anterior and posterior annular length. Excised measurements included: total annular length, anterior and posterior annular lengths, leaflet edge lengths, leaflet heights, and anterolateral and posteromedial commissural heights. Leaflet area was calculated from planimetric measurements. Chordal lengths were measured and distribution recorded. The majority of leaflet measurements were not statistically different between groups. For both groups, the measured annular length increased significantly upon valve excision. In both groups, the posterior leaflet area was significantly larger than the anterior leaflet area, and the area of each leaflet alone was significantly greater than the calculated orifice area. Chordal length was not significantly different between groups, however, distribution varied slightly with the ratio of origins to insertions being 8:1 (porcine) and 5:1 (human). The results are consistent with previous studies of the human mitral valve. This study showed little difference between human and porcine data, and the porcine valve was identified as an appropriate model for further investigation of the mitral valve system.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Kunzelman, K. S., Cochran, R. P., Verrier, E. D., & Eberhart, R. C. (1994). Anatomic basis for mitral valve modelling. The Journal of heart valve disease, 3(5), 491–496.

We developed a surgical technique for mitral valve reconstruction without a prosthetic ring. This procedure may have two advantages. One is avoidance of the potential thrombogenicity of the prosthetic ring, and the other is that this procedure may maintain the normal function of mitral annulus. To clarify the latter advantage, we defined a method for 3D assessment of the heart, especially for the dynamic changes of the mitral annulus. 3D images of the heart, including both mitral and tricuspid annuli in eight phases during the cardiac cycle, were reconstructed from magnetic resonance images of seven normal subjects, and used for this study. To depict the changes in the annular shape, we determined the following parameters of the annular function: (a) annular excursion, (b) direction of motion (direction cosine) and (c) orientation of the annulus (direction cosine) for the annular motion, (d) annular area and (e) displacement of the anterior portion from the approximated plane of the annulus. The data for the systolic annular motion indicate that the mitral annulus moves towards the apex with slight caudal deviation, with the excursion of 12.1 mm. The change in annular orientation indicates that the mitral annulus shows translational motion during systole. The mitral area was reduced by 25.6% (n = 5) from mid-diastole to mid-or late systole. Displacement at the anterior portion of the annulus did not change markedly during systole. The results demonstrate the physiologic function of the mitral annulus in normal subjects. This method will be applied to the clinical study of mitral valve reconstruction surgery. Based on the differences in annular length in intact and excised states, we describe the intact state of the posterior leaflet as "natural redundancy." Restoration of this natural redundancy has been a hallmark of successful mitral repair for over 20 years.

How to cite: Komoda, T., Hetzer, R., Uyama, C., Siniawski, H., Maeta, H., Rosendahl, U. P., & Ozaki, K. (1994). Mitral annular function assessed by 3D imaging for mitral valve surgery. The Journal of heart valve disease, 3(5), 483–490.

Chordal preservation during mitral valve replacement is thought to greatly preserve left ventricular function. Recently a stentless mitral valve (Biocor) became available for clinical use. It is a porcine mitral valve with the entire chordal apparatus, the sewing ring being reinforced by a bovine pericardial ring and the chordae being sutured together onto two pericardial patches. During a six months period, seven patients undergoing mitral valve replacement for mitral insufficiency (four cases), mitral stenosis (two cases) or mixed lesions (one case) received a stentless mitral valve. Their mean age was 66.3 +/- 4.8. The valve was implanted by suturing the pericardial patches onto the papillary muscles and the sewing ring onto the mitral annulus. Echocardiography control immediately after surgery showed good valve function. Three valves failed after a period of seven days, seven and 12 months respectively. The valve lesions were similar and consistent with an excessive tension on the chordae and on the valvular tissue. There were tears along the posterior annulus and at the level of the commissures, often accompanied by chordal rupture. Histology and scanning electron microscopy showed good integration of the prosthesis with the patients own tissues. There were areas of overgrowing tissue without endothelial cells especially in the area of papillary muscle -pericardial patch interaction. The remaining four patients continue to do well after a mean follow up of two years. The apparent excessive tension on the valve tissues leading to the premature failure of the prosthesis could be due to the variability in the distance between mitral annulus and papillary muscles.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Morea, M., De Paulis, R., Galloni, M., Gastaldi, L., & di Summa, M. (1994). Mitral valve replacement with the Biocor stentless mitral valve: early results. The Journal of heart valve disease, 3(5), 476–482.

This case report describes a 25-year-old patient with calcific rheumatic mitral restenosis who underwent mitral valve replacement using a fresh, antibiotic preserved mitral homograft. The technical details of the implantation are described.

How to cite: Kumar, A. S., & Trehan, H. (1994). Homograft mitral valve replacement--a case report. The Journal of heart valve disease, 3(5), 473–475.

A young patient suffering from acute bacterial endocarditis underwent reconstructive surgery of the mitral and tricuspid valves. One year later a recurrent endocarditis occurred that could not be controlled with antibiotic therapy. Two separate mitral homografts were used to replace both the mitral and the tricuspid valves. The homografts' papillary muscles were sutured side to side to the recipient's and a circumferential suture of the leaflet tissue was accomplished. Homograft implantation was associated with Carpentier ring annuloplasty of the atrioventricular valves. In the right sided position, the mitral homograft was oriented in an anti-anatomical manner and an inverted semi-rigid prosthetic ring of the mitral type was inserted. Clinical and echocardiographic follow up at four months was excellent.

How to cite: Acar, C., Iung, B., Cormier, B., Grare, P., Berrebi, A., D'Attellis, N., Acar, J., & Carpentier, A. (1994). Double mitral homograft for recurrent bacterial endocarditis of the mitral and tricuspid valves. The Journal of heart valve disease, 3(5), 470–472.

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How to cite: Bodnar E. (1994). Clinical use of homologous and heterologous mitral valves. The Journal of heart valve disease, 3(5), 468–469.

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How to cite: Lespinasse, F., Grimaud, E., & Piwnica, A. (1994). Regulatory, bioengineering and clinical requirements for cardiac valves: a new approach for a unique market. The Journal of heart valve disease, 3(5), 461–467.