We report a patient who experienced thrombotic obstruction of an Omniscience prosthesis three years after mitral valve replacement. At reoperation another Omniscience prosthesis was inserted which became thrombosed after eight months. Recurrent thrombosis of the same prosthesis in the same patient is unusual and raises the problem of which device to use when replacing a thrombosed valve. In our patient another mechanical prosthesis was inserted at second reoperation because of her young age and in the hope of reducing the risk of further thrombosis by using a valve with better flow characteristics such as a bileaflet prosthesis.

How to cite: Bortolotti, U., Bonato, R., Milano, A., Russo, R., Schivazappa, L., & Casarotto, D. (1995). Recurrent thrombosis of Omniscience prostheses in the mitral position: a case report. The Journal of heart valve disease, 4(2), 211–213.

Increased exertional dypsnea developed in a 25-year-old female with a long standing history of a myxomatous mitral valve. Transesophageal echocardiography demonstrated left atrial and ventricular dilatation and no significant functional impairment. In addition, there was prolapse of a voluminous anterior mitral valve leaflet as well as prolapse of the posterior leaflet. To avoid the risks of long term anticoagulation therapy including fetal teratogenicity, efforts were made to repair rather than replace this degenerated valve. Here we report a new technique of anterior or mitral valvuloplasty complementing a quadrangular resection of the mural leaflet and a ring annuloplasty. The elliptoid excision of the redundant anterior leaflet resulted in a competent valve apparatus without any significant gradient. This technique would not apply, however, when the chordae tendinae to the anterior leaflet were significantly stretched as a result of the myxomatous process. In that situation the valve would be replaced with a prosthesis.

How to cite: Quigley, R. L., & Stagl, R. D. (1995). Alternative approach to the repair of a floppy anterior mitral valve leaflet. The Journal of heart valve disease, 4(2), 208–210.

Valvulitis in systemic lupus erythematosus has been observed for many years. Fourteen cases of mitral valve replacement have been reported so far in the literature. In the light of all previously reported experiences, prosthetic valve related morbidity and mortality remain high in patients with systemic lupus erythematosus. We describe the first true instance of reconstructive approach in a patient who presented with severe mitral incompetence due to lupus valvulitis. The patient was clinically well with good valve function one year after surgery. Reconstructive mitral valve surgery may be preferable for the surgical management of mitral regurgitation in active lupus valvulitis since it eliminates the need for anticoagulation and avoids the disadvantages of different types of prostheses in these young patients who are under prolonged steroid therapy and have usually associated renal failure.

How to cite: Kalangos, A., Panos, A., & Sezerman, O. (1995). Mitral valve repair in lupus valvulitis--report of a case and review of the literature. The Journal of heart valve disease, 4(2), 202–207.

Valvular tumors are uncommon and usually benign lesions, discovered accidentally or when neurological or cardiological complications occur. We report a case of mitral valve papillary fibroelastoma measuring less than 1 cm and revealed by stroke. Transesophageal echocardiography was the best method to establish the diagnosis as it provided higher discriminative power than the transthoracic echocardiography or nuclear magnetic resonance. The embolic risks justify the surgical treatment of these lesions while anticoagulation therapy can be suggested as a substitute to surgery for the high risk patients.

How to cite: Pinelli, G., Carteaux, J. P., Mertes, P. M., Civit, T., Trinh, A., & Villemot, J. P. (1995). Mitral valve tumor revealed by stroke. The Journal of heart valve disease, 4(2), 199–201.

A case of cardiac myxoma arising from the mitral valve is reported. A 50-year-old woman presented with history of shortness of breath and angina. Two-dimensional echocardiography showed a left atrial mass. At surgery, the tumor was found to be arising from the anterior leaflet of the mitral valve. The tumor was excised and a defect in the anterior leaflet of the mitral valve was repaired by direct suture.

How to cite: Kulshrestha, P., Rousou, J. A., & Tighe, D. A. (1995). Mitral valve myxoma: a case report and brief review of the literature. The Journal of heart valve disease, 4(2), 196–198.

A surgical technique for reducing the size of large diameter homografts in order to make them suitable for right ventricular outflow reconstruction in infants was clinically introduced by us at the Department of Cardiac Surgery, University of Padova in 1990. The method consists of two longitudinal incisions along the oversized homograft root removing one cusp with the relevant part of the aortic annulus and aortic wall. The remaining, flat "bicuspid" homograft is closed into a tube again around a mandrel of appropriate size. Preliminary experiences with the first three patients were excellent and have already been reported. The current study includes five additional patients (two male, three female) ranging in age from 20 days to 11 months (mean 8.3 months) and in weight from 3.2 to 7.4 kg (mean 6.2 kg) who underwent right ventricular outflow tract reconstruction with this surgical technique. There were no operative deaths and no instances of valve related complications at a mean follow up of 18 months. Serial echocardiography showed mild homograft stenosis in one patient (15 mmHg) and mild regurgitation in another. Although a longer follow up is necessary to determine whether the durability of these surgically modified "bicuspid homografts" can match that of the intact valves, we believe that our technique represents a valuable therapeutic alternative at least in the short term to the use of synthetic grafts in infants when an appropriately small homograft is not available.

How to cite: Santini, F., Prioli, A., Pessotto, R., & Mazzucco, A. (1995). Use of oversized homografts for right ventricular outflow tract reconstruction in infants. The Journal of heart valve disease, 4(2), 192–195.

Eight pulmonary valve replacements (PVR) have been performed from January 1992 to October 1994. Three patients (mean age 7.7 years, range two to 16 years) had absent pulmonary valve with tetralogy of Fallot and underwent primary PVR at the time of surgical correction. Five other patients, who had correction of tetralogy of Fallot (four cases) and of double outlet right ventricle with ventricular septal defect and pulmonary stenosis (one case), were reoperated for pulmonary regurgitation with progressive right ventricular dysfunction. Mean age at the time of reoperation was 18 years (range seven to 34 years). There was no early death. Early postoperative recovery was satisfactory in all of them. The follow up ranges from six to 35 months (mean 19 months). Seven patients were in functional class I and one in functional class II when they were last evaluated in the out-patient department and five of them were off diuretics and vasodilator. In the presence of right ventricular dysfunction pulmonary regurgitation is poorly tolerated. A competent and non-obstructive pulmonary valve is often life saving in these critically ill patients.

How to cite: Saha, K., Iyer, K. S., Sharma, R., Bhan, A., Airan, B., & Venugopal, P. (1995). Orthotopic pulmonary valve replacement with a homograft. The Journal of heart valve disease, 4(2), 187–191.

Although the results of intracardiac repair for pulmonary stenosis or atresia are generally good, some patients develop symptoms due to to pulmonary regurgitation and right ventricular dilatation. Implantation of a pulmonary homograft may have a beneficial effect on these symptoms. Twenty-seven patients with symptoms due to pulmonary regurgitation and right ventricular dilatation were reoperated. The indication for surgery was dyspnea in 19, arrhythmia in five and both symptoms in three patients. The arrhythmia was supra-ventricular in four, ventricular in two and both supra-ventricular and ventricular in another two patients. A cryopreserved pulmonary homograft was implanted in the right ventricular outflow tract. Mean interval between intracardiac repair and homograft implantation was 15.6 years. Mean age at homograft implantation was 23.0 years. Concomitant procedures were performed in 18 patients. There were two early deaths (7%). Replacement of the homograft was necessary in one patient, 21 months after insertion. This patient had residual pulmonary stenosis immediately after surgery. On mid-term follow up (mean 36 months) all patients with dyspnea as indication for operation improved, except one with right and left ventricular dysfunction. Only two of eight patients with arrhythmia improved. On echocardiography, pulmonary regurgitation decreased in all patients. Right ventricular dilatation decreased in only 14 patients (52%). We conclude that pulmonary regurgitation after transannular patching can be treated with implantation of a cryopreserved pulmonary homograft with acceptable mortality and low morbidity. Clinical improvement results from reduction of the right ventricular volume overload rather than from decline in right ventricular dilatation. Arrhythmia as the only indication for operation is controversial.

How to cite: Hokken, R. B., Bogers, A. J., Spitaels, S. E., Hess, J., & Bos, E. (1995). Pulmonary homograft insertion after repair of pulmonary stenosis. The Journal of heart valve disease, 4(2), 182–186.

Although additional aortopulmonary anastomosis established by creating double outlet from the systemic ventricle and anastomosing the pulmonary trunk to the ascending aorta can undoubtedly provide an unobstructed outlet for the systemic ventricle, postoperative regurgitation of the morphologically pulmonary valve, if it occurs, may spoil the efficacy. To determine whether the pulmonary valve can be regurgitant, 11 patients undergoing this surgical option, six accompanying a Fontan-type operation and five associated with biventricular repair, were reviewed. Postoperative regurgitation was observed echocardiographically in five patients. One patient with severe pathologic changes of the valve showed progressive regurgitation, necessitating valve replacement two months after the aortopulmonary anastomosis. The other four patients, including one with slight thickening of the pulmonary leaflets, had previously undergone banding of the pulmonary trunk. Slight regurgitation in these cases appeared between one month and two years after the procedure, but then neither progressed nor regressed. Pathologic changes of the pulmonary valve, and previous banding, therefore, can be recognized as risk factors for postoperative regurgitation. The morphologically pulmonary valve, nonetheless, proved to be feasible for this surgical option unless it possessed severe organic changes.

How to cite: Uemura, H., Yagihara, T., Kawashima, Y., & Kamiya, T. (1995). Regurgitation through the morphologically pulmonary valve after additional aortopulmonary anastomosis. The Journal of heart valve disease, 4(2), 176–181.

Between June 1990 and June 1993, 135 patients received a porcine stentless aortic valve (PSAV) at our institution. In this group, there were 33 patients in whom the stentless valve was used to replace a previously inserted malfunctioning aortic valve prosthesis (n = 19) or to treat acute aortic valve endocarditis (n = 14, five native, nine prosthetic endocarditis). There was one hospital death caused by multiple organ failure in a patient with endocarditis and preoperative cerebral stroke. Two patients died after hospital discharge; one suffered sudden death following a pacemaker failure four month after surgery and the other died due to Candida albicans sepsis after a prolonged antibiotic treatment. There were two reoperations; one to correct a dehiscence of the proximal suture line and the other to replace a degenerated valve 3.5 years after implantation in a 14 year old boy. All operative survivors were followed clinically with serial color Doppler echocardiography. No recurrence of endocarditis was detected. Aortic root reconstruction was achieved even in the presence of multiple abscesses. All but one patients showed a normally functioning valve with none or minimal aortic insufficiency. In our opinion the PSAV is an excellent aortic valve substitute for patients with damaged aortic annulus, because it promotes aortic root remodeling, decreases the incidence of postoperative paravalvular leaks and helps to prevent endocarditis recurrence.

How to cite: Gontijo, B. F., Vrandecic, M., Fantini, F. A., Oliveira, M. H., & Avelar, S. O. (1995). Porcine stentless aortic valve in re-replacements and acute aortic valve endocarditis. The Journal of heart valve disease, 4(2), 171–175.

Paraprosthetic leaks in aortic prostheses may cause significant aortic regurgitation. Color flow Doppler echocardiography is the method of choice for detecting paraprosthetic leaks, but quantitation of regurgitation is limited by this method. This study investigated the value of pulsed Doppler of the left subclavian artery flow for assessing the hemodynamic significance of paraprosthetic regurgitation in aortic prostheses in 32 patients with, and in 77 control subjects without paraprosthetic leaks. Paraprosthetic leaks were either detected by transthoracic or transesophageal color flow echocardiography. The hemodynamic significance of paraprosthetic regurgitation was determined by means of a dichotomous angiographic classification - significant versus insignificant regurgitation. Pulsed Doppler was performed to measure the maximal diastolic and systolic velocities, and diastolic and systolic velocity-time-integrals (VTI) and their ratios in the subclavian artery flow. The accuracy of these parameters for differentiating significant versus insignificant regurgitation was assessed. Angiography revealed 13 significant and 19 insignificant forms of aortic regurgitation. In all patients, examination of the subclavian artery was feasible by pulsed Doppler. The highest correlation between Doppler derived parameters and regurgitation was calculated for the ratios of diastolic and systolic VTI (r = 0.84), diastolic VTI (r = 0.82) and ratio of diastolic and systolic velocities (r = 0.80). An increase of the ratio of diastolic and systolic VTI (> 45%) and ratio of diastolic to systolic velocity (> 0.4), and increased diastolic VTI (> 60 cm) in the subclavian artery velocity profile identified significant paraprosthetic regurgitation with a sensitivity of 94%, 75% and 87%, and specificity of 87%, 80% and 87%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Omran, H., Fehske, W., Hagendorff, A., Pizzulli, L., & Luderitz, B. (1995). Paraprosthetic regurgitation in aortic prostheses: determination of the hemodynamic significance by pulsed Doppler examination of the subclavian artery flow. The Journal of heart valve disease, 4(2), 166–170.

Periprosthetic leakage occurs in 1 to 3.5% of patients after aortic valve replacement. Antecedent or active infection increases the risk of perivalvular leakage. Other factors predisposing to perivalvular leakage have not been clearly identified. To determine whether clinical and/or early transthoracic echocardiographic features can identify patients who require reoperation for periprosthetic leakage, we reviewed 1,743 consecutive patients who underwent aortic valve replacement from 1983 through 1991. Thirty patients (1.7%) subsequently required repeat operation for correction of periprosthetic leakage, at a median of 18.0 months (range 0.5-81.0) after aortic valve replacement. Comparison of these 30 patients with periprosthetic leakage to those undergoing primary aortic valve replacement showed no differences in patient age, gender, native valve disease type or etiology, prosthetic valve type, or prosthetic valve size (all p = NS). Of the 30 patients with periprosthetic leaks, 20 had early postoperative transthoracic echocardiography, at a median 5.3 months (range 0.3 - 40.0) after aortic valve replacement. In this early postoperative study, 14 patients (70.0%) had no periprosthetic leak detectable by echocardiography; two patients had trivial leaks, and only four patients had significant periprosthetic leakage by echocardiography. During subsequent operation, aortic valve re-replacement was performed in 26 patients (86.7%), and the periprosthetic leak was repaired in the remaining four patients. Thirty-day and 5-year survival probabilities were 0.90 (70% CI, 0.84-0.96) and 0.73 (70% CI, 0.65-0.82), respectively. It is concluded that in this study, there were no clinical features that distinguished patients undergoing aortic valve replacement who later developed severe perivalvular leakage.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Miller, D. L., Morris, J. J., Schaff, H. V., Mullany, C. J., Nishimura, R. A., & Orszulak, T. A. (1995). Reoperation for aortic valve periprosthetic leakage: identification of patients at risk and results of operation. The Journal of heart valve disease, 4(2), 160–165.

In order to clarify the role of thrombolytic therapy for the treatment of left sided prosthetic valve thrombosis, a composite analysis of 158 cases reported in the English literature was undertaken. Complete success of therapy was achieved in 68.4% of patients, and the results were better in patients with aortic compared to mitral valve prostheses (p < 0.01), in those presenting in lower NYHA class (p < 0.01), and with acute rather than chronic symptoms (p < 0.05). A successful outcome was seen more frequently with tilting disc than bileaflet valves (p < 0.001). Overall mortality during therapy was 7%. Cerebral embolic events were observed in 9.5% of patients, and irreversible neurological injury occurred in 4.4%. The rethrombosis rate was 17% and the incidence of late death was 6.3%. Thrombolysis may be a useful therapeutic alternative for left sided prosthetic valve thrombosis in patients with a perceived contraindication to surgery. The risks of systemic clot embolization along with incomplete resolution of valve leaflet motion or rethrombosis limits any recommendation for more widespread use.

How to cite: Birdi, I., Angelini, G. D., & Bryan, A. J. (1995). Thrombolytic therapy for left sided prosthetic heart valve thrombosis. The Journal of heart valve disease, 4(2), 154–159.

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How to cite: Horstkotte, D., & Burckhardt, D. (1995). Prosthetic valve thrombosis. The Journal of heart valve disease, 4(2), 141–153.

In comparison to a control group of 47 healthy, non-anticoagulated persons, 164 patients under stable oral anticoagulation therapy showed significant reduction in the plasma level of the prothrombin fragment F1+2 (p < 0.0005). Even with low intensity anticoagulation (INR < 2.0), F1+2 levels were reduced to within the normal range (0.32 - 1.2 nM/l) in all patients. The reduction in the plasma level of prothrombin fragment F1+2 is directly dependent on the intensity of oral anticoagulation therapy and provides a means of monitoring the anticoagulation effect achieved. Clinical studies are required to assess the practicality of using F1+2 for monitoring anticoagulation and in particular to assess the usefulness of low levels in predicting bleeding risk and high levels in predicting thrombotic risk during treatment.

How to cite: Bruhn, H. D., & Zurborn, K. H. (1995). The use of prothrombin fragment F1+2 to monitor the effect of oral anticoagulation. The Journal of heart valve disease, 4(2), 138–140.

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How to cite: Piper, C., Schulte, H. D., & Horstkotte, D. (1995). Optimization of oral anticoagulation for patients with mechanical heart valve prostheses. The Journal of heart valve disease, 4(2), 127–137.

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How to cite: Hennerici M. G. (1995). Cardioembolism as a source of cerebrovascular events. The Journal of heart valve disease, 4(2), 121–126.

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How to cite: Horstkotte, D., Scharf, R. E., & Schultheiss, H. P. (1995). Intracardiac thrombosis: patient-related and device-related factors. The Journal of heart valve disease, 4(2), 114–120.

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How to cite: Butchart E. G. (1995). Rationalizing antithrombotic management for patients with prosthetic heart valves. The Journal of heart valve disease, 4(2), 106–113.