We report a patient who was successfully reoperated because of almost complete thrombosis of a Björk-Shiley tilting disc mitral prosthesis. Considering the usually acute presentation and the frequently catastrophic consequences of most similar cases in the literature, the unusual feature of this case is that the patient survived until reoperation with minimal symptoms despite almost total prosthetic occlusion by a chronic thrombus.

How to cite: Levantino, M., Tartarini, G., Barzaghi, C., Grana, M., & Bortolotti, U. (1995). Survival despite almost complete occlusion by chronic thrombosis of a Björk-Shiley mitral prosthesis. The Journal of heart valve disease, 4(1), 103–105.

Two cases of severe aortic regurgitation due to non-traumatic rupture of the aortic valve commissures are reported. The cause of rupture was hypertension in one patient, but it could not be identified in the other, where microscopic examinations of the aortic wall and the aortic cusps showed no particular pathologic changes. M-mode echocardiography revealed enlargement of the left ventricle, diastolic flutter of the anterior mitral leaflet and diastolic separation of the closure line of the aortic cusps in both patients. Two-dimensional echocardiography showed a downward displacement of the prolapsing motion of the aortic valve cusp during diastole toward the left ventricular outflow tract in one patient, and eccentricity of the coaptation point of the aortic valve without thickening of the cusps in the other. In addition to clinical features of progressive heart failure and characteristic cardiac murmur, echocardiographic studies provided correct diagnosis of aortic valve prolapse resulting from rupture of the aortic valve commissures. Both patients underwent aortic valve replacement successfully.

How to cite: Aoyagi, S., Fukunaga, S., & Oishi, K. (1995). Aortic regurgitation due to non-traumatic rupture of the aortic valve commissures: report of two cases. The Journal of heart valve disease, 4(1), 99–102.

Grunkemeier, Johnson, and Naftel have given a method for computing sample size requirements for a clinical study of a new heart valve. This paper gives an implementation of the method on a computer spreadsheet. Moreover, it computes the sample size for the most powerful test with exactly the prescribed level of significance and power; all other tests will necessarily have smaller power and will need larger sample sizes. All graphs and tables are produced on the spreadsheet, and no use of special statistical functions is necessary.

How to cite: Anderson W. N., Jr (1995). Spreadsheet method for determining sample sizes for heart valve studies. The Journal of heart valve disease, 4(1), 95–98.

How to cite: Leeson-Dietrich, J., Boughner, D., & Vesely, I. (1995). Porcine pulmonary and aortic valves: a comparison of their tensile viscoelastic properties at physiological strain rates. The Journal of heart valve disease, 4(1), 88–94.

Atrioventricular valves were studied in pisces (shark), amphibians (frog), reptiles (turtle, snake and crocodile) and aves (duck, chicken and quail). Dog shark, Tiger shark and Hammerhead shark have a contractile common atrioventricular orifice with anterior and posterior bridging leaflets. Angel shark resembles the frog in having a contractile oval common atrioventricular orifice guarded by two lateral (right and left) and two central bridging (anterior and posterior) leaflets. In turtles and snakes the interatrial septation is complete. The common oval atrioventricular orifice is divided into two D-shaped orifices by the lower edge of the interatrial septum. Each orifice is guarded by a flap valve hanging down from the interatrial septum with rudimentary chordae tendinae, functionally corresponding to the septal leaflet of the human venous atrioventricular valve (VAVV) and the aortic leaflet of the human arterial atrioventricular valve (AAVV). There is no curved mural leaflet on either side related to curved contractile segments of the annuli. In crocodiles, the interventricular septation is complete. The VAVV is bicuspid with a prominent septal and diminutive mural component with no chordopapillary support. The AAVV is bicuspid with direct attachment of the fused commissural lines between the two leaflets to the ventricular musculature. In the aves, with four chambered hearts the VAVV has a curved mussular mural leaflet with a primitive muscular chorda and no septal leaflet. The AAVV resembles closely the human mitral valve. This study lends support to the view that VAVV and AAVV in man are similar in design and function with a D-shaped annulus and a skirt of leaflet tissue divisible into two functional units. The relatively straight part of the annuli suspend the straight leaflets; septal leafleft of the VAVV and aortic leaflet of the AAV. The curved annular components suspend the curved mural leaflets in both valves. Since this segment is contractile, the related mural leaflets of both valves need to have slits which split them into varying number of scallops to enable them to adapt themselves to the reduced systolic orifice and open widely during diastole. These scallops are best numbered as subsegments of the curved mural leaflet and not considered as separate leaflets. The curved leaflet of the VAVV needs to negotiate the acute border of the heart. Hence a major slit is usually present at this region which artificially divides it into an 'anterior' and 'posterior' portion resulting in assumption of a 'tricuspid' configuration.(ABSTRACT TRUNCATED AT 400 WORDS)

How to cite: Victor, S., Nayak, V. M., Raveen, R., & Gladstone, M. (1995). Bicuspid evolution of the arterial and venous atrioventricular valves. The Journal of heart valve disease, 4(1), 78–87.

The existing terminology for the various structures of the mitral valve are diverse and numerous. With the resurgence of interest in reparative procedures for mitral valve disease, it becomes imperative to have a unified terminology which would convey precise connotations in recording the pathology as well as the corrective procedures applied. In an effort to suggest a commonly acceptable nomenclature, we reviewed the available terminology and propose a simple system which will fulfil the needs of recording the intraoperative observations of the pathology of each valve and the manouveres carried out to correct them by the surgeon. This involves designating all structures anterior to the intercommissural line as "anterior" or "A" and those posterior as "posterior" or "P". The structures, as observed by the surgeon through a standard left atriotomy, to the left of the line dropped perpendicular to the middle of the aortic curtain will be designated by the numeral "1" and those to the right "2". The chords will be termed in groups based on their point of insertion, irrespective of whether they are inserted to the free edge or the ventricular surface of the leaflet. The anterior leaflet chords will further be subdivided based on their relation to the stay chords. We hope that this system of naming the structures would provide a unified method of reporting intraoperative findings of mitral valve disease.

How to cite: Kumar, N., Kumar, M., & Duran, C. M. (1995). A revised terminology for recording surgical findings of the mitral valve. The Journal of heart valve disease, 4(1), 70–77.

One hundred and thirty-seven consecutive patients had mitral valve replacement between January 1983 and January 1993 with Bicor porcine bioprosthesis. Concomitant cardiac procedures were performed in 37% (51/137). Mean age was 63 years. Follow up was 98% complete at a mean of 53 months. Early mortality was 13% (18/137). Within the 10-year follow up another 34 patients died, 21 due to cardiac and three to valve related causes. Overall survival at 10 years as 54.7 +/- 4.9%, and freedom from valve related mortality 94.9 +/- 2.8%. Functional class improved in all surviving patients with 84% being in NYHA class I or II at the end of the tenth year. There were 10 reoperations, three for structural valve deterioration (SVD), three for non-structural valve dysfunction (non-SVD) and four because of prosthetic valve endocarditis (PVE). Actuarial freedom from reoperation for all causes was 78.9 +/- 9.2%. None of the patients were on long term anticoagulation at hospital discharge but 57% received chronic anticoagulant treatment at the end of the 10-year follow up. Embolism occurred in 13 patients (2.5%/pty, fatal 0.4%/pty). Three patients had anticoagulant related hemorrhage (0.6%/pty, fatal 0.2%/pty). Doppler echocardiography was carried out in 52% within the last three years of follow up. Actuarial freedom from SVD (confirmed at reoperation or by echocardiography) was 80.3 +/- 9.8%. At 10 years 93.2 +/- 2.8% were free from PVE. The incidence of total mortality and morbidity was 5.9%/pty (fatal 0.8%/pty) with an actuarial freedom of 59.6 +/- 8.8% from all valve related complications.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Myken, P. S., Caidahl, K., Larsson, S., & Berggren, H. E. (1995). 10-year experience with the Biocor porcine bioprosthesis in the mitral position. The Journal of heart valve disease, 4(1), 63–69.

A multi-center, international, prospective trial of the CarboMedics valve was initiated in September 1987. Twenty-five centers were included for the purpose of demonstrating the clinical effectiveness of this new rotatable bileaflet Pyrolite carbon prosthesis. The study included 1228 patients (1372 valves) enrolled between September 1987 and September 1993. There were 674 males and 554 females from ages two to 84 years. There were 603 aortic, 476 mitral and 144 double valve implants. Mean follow up time was 30.2 months; 96.3% of patients had completed documentation up to and including one year. Functional class was III or IV for 87.1% of patients preoperatively, and I or II in over 96% of patients for the first five post-operative years. Survival for the entire group was 89% (n = 902) at one year, 84% (n = 463) at three years, and 81% (n = 92) at five years. There were no significant survival differences between the aortic and mitral valve replacement groups. Statistically significant differences in survival (p < or = 0.1) for all patients (primary and non-primary) were found to be associated with female gender (p = .0097), increasing age (p = 0.0001), increasing preoperative NYHA classification (p = 0.0001), concomitant procedures performed during surgery (p = .0001), double valve replacement (p = 0.0622), and presence of preoperative endocarditis (p = .0829). Late deaths totaled 88 with 46 of those classified as valve-related. There was no valve failure.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Copeland J. G., 3rd (1995). An international experience with the CarboMedics prosthetic heart valve. The Journal of heart valve disease, 4(1), 56–62.

Published durability results of porcine and pericardial bioprostheses in the aortic position have been reviewed for the purpose of a qualitative comparison between these valve types, and also with previously reviewed series of homograft valves. Porcine bioprostheses exhibit a wide range of failure curves, with a characteristic Weibull-shaped pattern. Patient characteristics must account for the majority of differences seen among the series. Newer series generally contain older patients and have better results. A second generation pericardial valve has distinctly better durability than a previously discontinued pericardial model, and appears to be as durable as that of the best porcine valve series. Homograft valves using cold antibiotic storage have durability results approximately equal to porcine valves, but with younger patients on the average. The results with cryopreserved valves may be comparable, but insufficient long term information is available. To make these qualitative comparisons quantitative would require a formal analysis which takes age and other patient-related characteristics into account.

How to cite: Grunkemeier, G. L., & Bodnar, E. (1995). Comparative assessment of bioprosthesis durability in the aortic position. The Journal of heart valve disease, 4(1), 49–55.

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How to cite: Bernal, J. M., & Revuelta, J. M. (1995). Mitral valve homografts. The Journal of heart valve disease, 4(1), 47–48.

An eighteen-year-old male with rheumatic mitral and aortic regurgitation, and mixed tricuspid disease underwent surgery at our institution. Ross procedure, mitral homograft insertion and tricuspid valve repair was performed. We believe that this option is ideal for young patients with multivalvular disease.

How to cite: Kumar, A. S., Chander, H., & Trehan, H. (1995). Surgical technique of multiple valve replacement with biological valves: a new option. The Journal of heart valve disease, 4(1), 45–46.

Three patients aged 43, 64 and 54 years (two females and one male) underwent allograft mitral valve replacement including the subvalvular apparatus in 1984 at the Department of Cardiovascular Surgery, University of Kiel. Transpapillary epicardial suture technique was used to support the graft-native papillary muscle union site. Early postoperative course was uneventful in all three patients. There was no early or late postoperative death. Trivial mitral regurgitation was recorded by color Doppler echocardiography but it was not progressive. The regurgitant volume measured at the postoperative catheterization by videodensitometry was less than 10% of the total stroke volume. Two patients were in NYHA class II, nine and 44 months and the third patient was in class III two months after the operation before they suddenly developed severe mitral incompetence which led to emergency reoperations and explantation of their grafts. The early graft failures (two and nine months after insertion) were due to chordal rupture caused by technical error in one and endocarditis in the other, while the late graft failure (44 months after operation) was due to rupture of the scarred graft papillary muscle. No postoperative anticoagulation was given while the homograft mitral valves were in place, and thromboembolic episodes were not observed during that period. All the three patients are alive with prosthetic valves. Although the stentless mitral allograft reinstituted the functional unit of the native mitral valve after replacement and was non-thrombogenic, the graft failure was sudden and unpredictable.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Yankah, A. C., Sievers, H. H., Lange, P. E., & Bernhard, A. (1995). Clinical report on stentless mitral allografts. The Journal of heart valve disease, 4(1), 40–44.

he in vivo echocardiographic behavior of a new mitral allograft design that incorporates ePTFE patches and chordae to enhance durability has been evaluated in sheep. A strip of pericardium was sewn around the anulus margin and an ePTFE patch of 0.4 mm thickness placed over the truncated papillary muscle tip. In four out of ten cases, 5/0 ePTFE sutures were used additionally to reinforce the native chordae of the anterior leaflet. The allografts were cold-stored at 4 degrees C after antibiotic treatment and implanted in weanling sheep. Valvular function was first examined intraoperatively by transesophageal echocardiography and again after a mean follow up of 153 +/- 8 days by epicardial echo. In all six long term survivors, valve motion was unimpaired and similar to that of the natural mitral valve. There was sufficient coaptation and concentric opening action of the leaflets. Ventricular contraction was enhanced by maintaining the annulo-ventricular connection of the native valve. Color and pulsed Doppler revealed a physiologic biphasic flow pattern and only minor regurgitation in one case. Mean transvalvular pressure gradient was 3.3 +/- 2.1 mmHg on average which correlates well with values obtained from subsequent cardiac catheterization. In conclusion, this new design of a mitral allograft shows excellent in vivo echocardiographic behavior after five months of implantation. Therefore, human allografts of this type could be recommended for clinical application.

How to cite: Vetter, H. O., Dagge, A., Liao, K., Erhorn, A., Chryssagis, K., Strenkert, C., & Reichart, B. (1995). Mitral allograft with chordal support: echocardiographic evaluation in sheep. The Journal of heart valve disease, 4(1), 35–39.

In this paper, we have reviewed previous experiences in the technique of homograft replacement of the mitral valve. Following laboratory studies, we have initiated a clinical program of partial and total homograft replacement of the mitral valve and present our early results in the first 32 patients.

How to cite: Acar, C., Gaer, J., Chauvaud, S., & Carpentier, A. (1995). Technique of homograft replacement of the mitral valve. The Journal of heart valve disease, 4(1), 31–34.

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How to cite: Duran C. M. (1995). Mitral valve allografts. An opportunity. The Journal of heart valve disease, 4(1), 29–30.

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How to cite: Fehske W. (1995). In response to: The echocardiographic assessment of replacement heart valves: high time for a consensus by Chambers JB. The Journal of heart valve disease, 4(1), 26–28.

The purpose of this study was to determine the relationship between effective orifice areas of mechanical valves in the aortic position assessed by Doppler echocardiography, and published data from in vitro studies. Eighty-six patients with a normally functioning Standard St. Jude Medical (n = 56) or Björk-Shiley (n = 30) prosthesis in the aortic position were studied. Valve sizes varied between 19 and 27 mm. Pressure gradient was calculated by the Bernoulli, and effective orifice area by the continuity equation. Published data on prosthetic orifice areas from in vitro pulsatile flow experiments using the Gorlin formula were used for comparison. A weak correlation was present between Doppler derived pressure gradient and in vitro estimated effective orifice area, which significantly decreased with increasing valve size (R = -0.61; p < 0.0001). There was only a moderate correlation between Doppler derived and in vitro estimated effective orifice areas whether sewing ring diameter or left ventricular outflow tract diameter was used in the Doppler studies (R = 0.75 and R = 0.71, p < 0.0001, respectively). The difference between in vitro measured and Doppler derived areas was greater with Standard St. Jude Medical than with Björk-Shiley valves, both using the sewing ring diameter (1.04 +/- 0.61 cm2 vs. 0.53 +/- 0.39 cm2, p < 0.0003) and the outflow tract diameter (1.20 +/- 0.68 vs. 0.68 +/- 0.46 cm2, p < 0.006). The presence of atrial fibrillation, concomitant mitral valve replacement, small prosthesis size (19 to 23 mm) or a postoperative interval of less than one year did not change the uniform underestimation of prosthetic orifice areas by Doppler echocardiography. These findings are attributable to pressure recovery and localized transprosthetic velocities, and should be taken into account in the case of a suspected prosthesis malfunction.

How to cite: Henneke, K. H., Pongratz, G., & Bachmann, K. (1995). Limitations of Doppler echocardiography in the assessment of prosthetic valve hemodynamics. The Journal of heart valve disease, 4(1), 18–25.

Echocardiography may allow preoperative selection of appropriately sized aortic homograft valves. This study compared measurement of aortic annulus diameter from the preoperative transthoracic two-dimensional echocardiogram with prosthetic valve annulus diameter in 178 consecutive patients under-going primary aortic valve replacement. Aortic annulus diameter was measured independently from the two-dimensional parasternal long axis view by two experienced observers blinded to the size of valve implanted. Mean annulus diameter from three end-diastolic frames was recorded. Of the 178 patients, 124 (70%) of Observer 1 measurements and 102 (57%) of Observer 2 measurements were within 2mm of valve annulus diameter (p < 0.0001 for both observers). Six percent of Observer 1 measurements and 12% of Observer 2 measurements were more than 4mm away from valve annulus diameter. The echocardiographic prediction of valve size corresponded to actual prosthetic valve annulus diameter in 69 patients (39%) for Observer 1 and 60 patients (34%) for Observer 2. The percentages of echocardiographic measurements within two millimeter of valve annulus diameter were significantly different for the two observers (p < 0.05). The percentages of echocardiographic measurements within two millimeter of valve annulus diameter in 39 patients without significant aortic valve calcification were not significantly different from the remaining 139 patients with calcified valves. The interobserver coefficient of variation was 6.2% and the intraobserver coefficient of variation was 4.3%. Although preoperative measurement of aortic annulus diameter from transthoracic echocardiography approximates prosthetic valve annulus diameter in the majority of patients undergoing primary aortic valve replacement, a significant minority of estimates may be inaccurate, even in the absence of heavy calcification.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Greaves, S. C., Reimold, S. C., Lee, R. T., Cooke, K. A., & Aranki, S. F. (1995). Preoperative prediction of prosthetic aortic valve annulus diameter by two-dimensional echocardiography. The Journal of heart valve disease, 4(1), 14–17.

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How to cite: Chambers, J., & Shah, P. M. (1995). Recommendations for the echocardiographic assessment of replacement heart values. The Journal of heart valve disease, 4(1), 9–13.

To assess the association of possible risk factors with ischemic cerebrovascular events after aortic valve replacement (AVR), 619 consecutive patients undergoing AVR with a Medtronic Hall valve between the beginning of December 1979 and the end of December 1992 and surviving the immediate postoperative period were analyzed. Possible risk factors examined were valve lesion, prosthesis size, postoperative functional status, systemic hypertension, cigarette smoking, diabetes, coronary artery disease and atrial fibrillation. There were 53 ischemic cerebrovascular events in 38 patients during 3,174 follow up years, yielding a linearized event rate of 1.7%/patient-year. Significant risk factors in terms of odds ratios (OR) were postoperative hypertension (OR 8.0), postoperative NYHA class III or IV (OR 5.5), postoperative smoking (OR 4.0), diabetes (OR 3.5), preoperative hypertension (OR 2.7) and preoperative smoking (OR 1.8). There was highly significant interaction between postoperative hypertension and postoperative smoking (OR 54.0). Eighty-one percent of patients who suffered events were hypertensive or smoking postoperatively or both. These findings have important implications for postoperative management and for the reporting of ischemic cerebrovascular events after valve replacement.

How to cite: Butchart, E. G., Moreno de la Santa, P., Rooney, S. J., & Lewis, P. A. (1995). Arterial risk factors and ischemic cerebrovascular events after aortic valve replacement. The Journal of heart valve disease, 4(1), 1–8.