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How to cite: Vrandecic, M., Gontijo, B., & Fantini, F. (1995). The Biocor stentless mitral bioprosthesis. The Journal of heart valve disease, 4(3), 323–325.

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How to cite: Akins C. W. (1995). An international experience with the CarboMedics prosthetic heart valve. The Journal of heart valve disease, 4(3), 321–323.

Approximately 50% of all patients who require replacement of the aortic valve (AVR) also require coronary artery bypass grafting (CABG) for concomitant coronary artery disease. Internal mammary artery (IMA) pedicle grafts are being used with increasing frequency for this purpose. Since the ostia of the IMA are considerably downstream from the sinus of Valsalva we hypothesized the CABG would change the local coronary flow dynamics and possibly alter the timing of both natural and prosthetic valve opening and closing dynamics. Both IMA'S were dissected as pedicle grafts in five pigs and the animals were put on cardiopulmonary bypass. Anastomotic sites were the proximal 1/3 of the left anterior descending and proximal 1/5 of the right coronary arteries. Aortic root, left ventricular and right ventricular pressures were measured and flowmeter transducers were placed on the aortic root, the left main coronary artery, the right coronary artery, the left IMA and the right IMA for measuring flows. Echocardiographic images of the aortic valve, in the longitudinal view, were recorded with a simultaneous ECG. Time points were defined during each cardiac cycle based upon characteristic points in the native coronary hemodynamics. These were identified at 8, 14 and 22% of the cycle (valve opening) and 38, 45 and 55% of the cycle (valve closing). Calculations were made based upon each cycle being initiated with the ECG R wave peak. Significant alterations in flow patterns were identified and quantitated between native coronary and IMA grafts. Only minor changes in valve positioning were identified. These differences in natural valve leaflet position occurred at 22% and 45% of the cycle.

How to cite: Gross, D. R., Salley, R. K., Maley, R. H., Arden, W. A., & Nammalwar, P. (1995). Effects of internal mammary artery pedicle coronary artery bypass grafting on aortic valve leaflet positioning. The Journal of heart valve disease, 4(3), 313–320.

The goal of this study was to test the hypothesis whether a small balloon placed within the mitral orifice and pulsed in a synchronous manner could reduce the degree of acute mitral regurgitation. Previous experimental studies had shown that a similar balloon within the aortic orifice relieved satisfactorily aortic regurgitation. Acute mitral regurgitation was created in 14 dogs, and a catheter with a small polyurethane balloon on its distal end was introduced to the mitral ring through the left ventricular apex. The balloon was connected to a Datascope pump for intermittent, synchronous pulsation. Left atrial, left ventricular and aortic pressures were monitored. In three animals transesophageal echocardiography was used in addition to monitor the regurgitant transmitral flow with color Doppler image. Intermittent inflation of the balloon during systole decreased the maximum left atrial pressure from 31.83 mmHg +/- 3.48 mmHg to 23.16 +/- 3.3 mmHg (p < 0.001) and the mean left atrial pressure from 21.66 +/- 2.8 mmHg to 17.25 +/- 2.76 mmHg (p < 0.001). The systolic gradient across the mitral valve increased from 59 +/- 14.53 mmHg to 77.11 +/- 12.44 mmHg (p < 0.01). Transesophageal echocardiography showed an almost 50% decrease of the transmitral regurgitant flow. It is concluded that intermittent, systolic, synchronous balloon pulsation within the mitral orifice reduces the degree of experimental, acute mitral regurgitation.

The aim of this study was to compare different (long/short echo time, whole body/small bore scanner) magnetic resonance velocity measurement techniques and their applicability to the measurement of blood velocity downstream of prosthetic heart valves. In-vitro magnetic resonance velocity measurements were performed downstream of four normal and stenotic prosthetic heart valves (St. Jude Medical bileaflet, Monostrut tilting disc, Ionescu-Shiley Pericardial and Starr-Edwards caged-ball) under steady flow conditions in an aortic test chamber. Cross-sectional and longitudinal velocity images were obtained downstreamed of the valves. Magnetic resonance was able to measure all three components of fluid velocity downstream of the valves under normal and stenotic conditions except in regions of turbulence. The velocity was measured across the tube cross-section in 10-15 minutes producing a good visualization of the axial velocity profile. High velocity regions, shear layers and reversed/stagnant regions were identified. The flow rate calculated by integration of the magnetic resonance velocity across the cross-section of the tube was accurate to 5-6% in normal cases and slightly less accurate for stenotic valves. Although signal loss on the modulus image was adverse to the velocity images, it was found that these regions could be used to identify areas of flow disturbance. The high magnetic field, small bore scanner was able to produce images with a resolution of 0.2 x 0.2 x 1.0 mm and was less affected by turbulence producing more detailed flow images. Magnetic resonances has been shown to be a useful new tool in the measurement of the velocity downstream of prosthetic heart valves. In particular it's short data acquisition time and the possibilities to reproduce the same measurements in-vivo make it an attractive alternative to traditional methods.

How to cite: Walker, P. G., Pedersen, E. M., Oyre, S., Flepp, L., Ringgaard, S., Heinrich, R. S., Walton, S. P., Hasenkam, J. M., Jorgensen, H. S., & Yoganathan, A. P. (1995). Magnetic resonance velocity imaging: a new method for prosthetic heart valve study. The Journal of heart valve disease, 4(3), 296–307.

A 22-year-old male patient with penetrating cardiac injury was admitted to general surgery, where he underwent an immediate, life saving operation. Subsequent cardiological evaluation established the presence of a well tolerated mitral regurgitation without the need for urgent cardiac surgical intervention. One month later the patient was re-admitted in cardiac failure. Transesophageal echocardiography suggested the detachment of the posterior leaflet, which was not previously demonstrated by transthoracic echocardiography. Emergency surgery confirmed the diagnosis and the mitral valve was successfully repaired. The postoperative course was uneventful. This case history suggests that transesophageal echocardiography is mandatory after penetrating cardiac injury even in the case of good clinical condition and negative transthoracic echocardiographic findings. In the presence of valvular injury, early surgical intervention is recommended.

How to cite: Rywik, T., Sitkowski, W., Cichocki, J., Rajecka, A., & Suwalski, K. (1995). Acute mitral regurgitation caused by penetrating chest injury. The Journal of heart valve disease, 4(3), 293–295.

In 1988 we quantified the adherence of two Staphylococcus epidermidis strains to glutaraldehyde-fixed bovine pericardium and teflon. The pericardium was used with and without prior rinsing to remove the preservative formaldehyde. Bacterial adherence was not detected on non-rinsed pericardium, and it was significantly less on rinsed pericardium than on teflon (p < 0.001). In view of these results, we have since then implanted 31 pericardial bioprostheses without rinsing them in 29 patients with active bacterial endocarditis. Valve infection reoccurred in two patients (6.7%) and two patients developed early periprosthetic leaks in the absence of re-infection. No adverse clinical or biochemical findings attributable to residual aldehydes have been observed.

How to cite: Garcia-Bengoechea, J. B., Gonzalez-Juanatey, J. R., Rubio Alvarez, J., Sierra Quiroga, J., Duran Munoz, D., & Beiras, A. (1995). Experimental and clinical evaluation of formalin containing pericardial bioprostheses for replacement of infected valves. The Journal of heart valve disease, 4(3), 284–287.

Despite improving surgical techniques, treatment of heart valve disease in children remains controversial. Growth of the child and adequate anticoagulation level are the main concerns when valve replacement is performed in the pediatric age. We reviewed the case histories of 29 children who underwent valve replacement with mechanical prosthesis from 1979 to 1994 in order to evaluate the performance of mechanical valves in this age group. Age ranged from two years to 12 years (mean 8.97 +/- 3.7 years). A total of 31 valves were implanted; 17 children had atrioventricular (Av) valve replacement (15 mitral, one common Av (heterotaxia), one tricuspid (systemic ventricle)), 11 children had aortic valve replacement (one redo), and one child had double mitral and aortic valves implanted. The etiology of valvular disease was congenital in 34.5%, degenerative in 17.2%, rheumatic in 24%, infective in 13.8%, and prosthetic dysfunction in 10.3%. Of the 29 patients, eight had undergone previous procedures and eight required simultaneous repair of associated lesions. There were three hospital deaths (10.3%). The mean follow up was 5.79 +/- 5.36 years. There were four late deaths (2.66%/patient-year) at a mean of 37 months from surgery. All operative survivors received oral anticoagulation with sodium warfarin. No thromboembolic event or bleeding occurred, no endocarditis developed in any patient; one reoperation was performed for patient/prosthesis mismatch. Mechanical valves offer excellent hemodynamic performances and a low rate of thromboembolism and/or bleeding in our experience, and are our first choice for heart valve replacement in children when reparative surgery is not feasible.

How to cite: Vosa, C., Renzulli, A., Lombardi, P. F., & Damiani, G. (1995). Mechanical valve replacement under 12 years of age: 15 years of experience. The Journal of heart valve disease, 4(3), 279–283.

Between September 1986 and January 1994, 129 St. Jude Medical prostheses were implanted in 113 patients who were 18-year-old or younger at the Cardiovascular Surgery Clinic of Turkiye Yuksek Ihtisas Hospital. Thirty-seven patients underwent aortic, 60 patients mitral and the remaining 16 patients double valve replacement. Overall hospital mortality was 7.9% (9/113). All patients received 2.5 mg/day warfarin from the first postoperative day, in addition 225 mg/day dipyridamole and 100 mg/day aspirin was given following the removal of mediastinal tubes. This regimen was continued indefinitely thereafter. Follow up period ranged between 2-94 months. Total follow up experience was 276.4 patient-years. There were five late deaths; the cause of death was prosthetic valve thrombosis in two patients, intracerebral hemorrhage in one, cardiomyopathy in one, and sudden death in one. Other late complications included one endocarditis, a further anticoagulant related bleeding and one paravalvular leak. There was no case of cerebral or peripheral embolism reported. Seven-year actuarial survival was 92.4 +/- 6.8% for the entire group, 84.6 +/- 13.8% after mitral and 100% after aortic or double valve replacement. In conclusion, low dose oral anticoagulation after heart valve replacement with St. Jude Medical prosthesis in this age group showed satisfactory clinical results.

How to cite: Yamak, B., Sener, E., Kiziltepes, U., Gol, K., Tarcan, O., Mavitas, B., Tasdemir, O., & Bayazit, K. (1995). Low dose anticoagulation after St. Jude Medical prosthesis implantation in patients under 18 years of age. The Journal of heart valve disease, 4(3), 274–278.

From January 1989 to October 1992, 208 consecutive patients underwent isolated aortic valve replacement for calcified aortic stenosis in our department. Since the mean age of this patient population was 70 +/- 9 years, a retrospective clinical study was completed to assess the potential influence of advanced age on the independent predictors of early and late mortality. Hospital mortality was 6.2% (13 patients). Total follow up was 422.5 patient-years with a mean of 26 months. Nineteen patients died during the follow up period, equivalent to 4.5% per patient-year late mortality rate. Survival including hospital death was 88 +/- 2%, 86 +/- 2% and 79 +/- 4% at one, two and three years respectively. Eighteen variables as potential predictors of early and late mortality were studied. Predictors of hospital mortality were determined by logistic regression analysis, and those of late mortality by Cox proportional hazard model. Results were expressed as odds ratio (OR) or relative risk (RR). Age greater than 70 years (OR = 9.8, 95% CI = 1.2 to 80) and emergency surgery (OR = 8, 95% CI = 2.1 to 31) appeared as independent predictors of hospital mortality in multivariate analysis. Age above 75 years (RR = 3, 95% CI = 1.1 to 8.3), preoperative acute pulmonary edema (RR = 2.9, 95% CI = 1.1 to 7.7) and emergency surgery (RR = 4.2, 95% CI = 1.2 to 15) were independently associated with decreased late survival. Advanced functional class (NYHA III-IV) was shown to be an independent predictor of early or late mortality only in univariate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Seventy-two operative survivors of acute type A dissection between 1973 and 1993 had a complete follow up with a 16 years actuarial survival of 57% and a reoperation free actuarial survival of 34%. Follow up was 100% complete and covered a total of 500.6 patients-years with a median of seven years. Distal tear location (proximal, medium or distal aortic arch) with retrograde dissection toward the aortic valve was the single most important predictor of late mortality with a relative risk of 4.4 (70%CL 2.4-8.2) (p = 0.016). Mortality rate of patients with an aortic valve prosthesis was 6.2%/patient-year vs. 1.7/patient-year without aortic valve prosthesis, with a relative risk of 3.4 (70%CL 2.0-5.8) (p = 0.02). This finding could be due to confounding of variables related both to death and need of aortic valve replacement. Therefore a multivariate proportional hazard analysis, with mandatory inclusion of possible confounders, was done. It showed that patients with aortic valvular prosthesis had eight times higher risk (70% CL 2.7-24.2); prosthetic aortic valves and conservative aortic root procedures had an unconfounded relative risk of 14 times higher (70%CL 3.4-58.7) (P = 0.06), whereas patients with a composite conduit had a six times higher risk (70%CL 2.0-19.9) (p = 0.11). These findings support the attitude favoring a selective approach to aortic root repair and oppose standardized use of aortic valve prosthesis or composite conduit in acute type A dissection.

How to cite: Rizzoli, G., Tiso, E., Scalia, D., Fracasso, A., & Casarotto, D. (1995). Aortic valve prosthesis and late survival of successfully repaired type A dissection. The Journal of heart valve disease, 4(3), 260–267.

Although aortic valve replacement for aortic regurgitation relieves left ventricular volume overload, ventricular size often remains abnormal after operation, particularly in the setting of marked or prolonged preoperative left ventricular dysfunction. The aim of this study is to assess the relationship between the grade of ventricular arrhythmias before operation and the recovery of left ventricular function after aortic valve replacement. Between January 1980 and August 1993, 229 patients with pure aortic regurgitation underwent aortic valve replacement at our institution. In this group, 50 patients (21.8%) who showed left ventricular end-systolic volume index (LVESVI) of 150 ml/m2 or greater received 24-hour ambulatory electrocardiographic recordings before and after operation. According to the preoperative grade of ventricular arrhythmias, the patients were divided into three groups. Group A included 20 patients with severe and frequent ventricular premature beats (VPBs). Group B included nine patients with severe and non-frequent ventricular premature beats (VPBs). Group C included 21 patients with non-severe and non-frequent VPBs. Left ventricular end-systolic dimension (LVDs), end-diastolic dimension (LVDd) and fractional shortening (LVFS) were measured in each echocardiogram before, and one year and five years after operation. LVDd significantly decreased at one year after operation in all three groups. At one year after operation, LVDs significantly decreased in group B (42.0 +/- 7.6 mm) and group C (42.6 +/- 8.6 mm), while LVDs showed no significant change in Group A (55.4 +/- 11.1 mm). After five postoperative years, further significant decrease of LVDs was found in group C (32.4 +/- 7.1 mm).(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Noji, S., Kitamura, M., Hachida, M., Endo, M., Hashimoto, A., & Koyanagi, H. (1995). Different functional recovery of the left ventricle after valve replacement for aortic regurgitation: correlation between grade of ventricular arrhythmia and long-term mortality. The Journal of heart valve disease, 4(3), 254–259.

From July 1992 through February 1994, 34 patients have undergone a leaflet thinning procedure during reconstruction of the mitral valve. In this procedure a fibrous layer is separated from the atrial and/or ventricular surface of the anterior and posterior mitral leaflets. This reduces the thickness of the mitral leaflets and improves pliability and mobility. To our knowledge this procedure has not been reported previously.

How to cite: Kumar, A. S., & Rao, P. N. (1995). Restoration of pliability to the mitral leaflets during reconstruction. The Journal of heart valve disease, 4(3), 251–253.

Pulmonary capillary wedge pressure, currently accepted as an approximation of left atrial pressure, leads to underestimation of mitral valve area calculated with the Gorlin formula. Wave delay has been pointed out as a major source of the underestimation. The aim of this study was to increase the accuracy of pulmonary artery wedge pressure-based measurements through a correction for time delay. Electrocardiogram, pulmonary capillary wedge, left atrial and left ventricular pressures were recorded simultaneously at high paper speed in 18 patients with mitral stenosis who underwent transseptal left atrial catheterization prior to mitral valvulotomy. Heart rate and wedge pressure wave delay were closely correlated (r = 0.78, p < 0.001). Linear regression equation (y = 1.1x + 8) was then applied in order to adjust the pulmonary capillary wedge pressure for time delay in every complex. Relative to mitral area measured with left atrial pressure, areas calculated using wedge pressure with and without correction were, respectively, 5 +/- 6% and 16 +/- 7% (p < 0.001) lower. Both methods showed a close correlation (r > 0.95) with measurements obtained using left atrial pressure; plotting the standard deviation against the mean, the correction of capillary wedge pressure significantly (p < 0.001) increased the accuracy of area measurement. In conclusion, pulmonary wedge pressure, properly obtained and adjusted for time delay, allows a more reliable measurement of the mitral area.

How to cite: Marzocchi, A., Piovaccari, G., Zimarino, M., Branzi, A., & Magnani, B. (1995). Adjustment of pulmonary capillary wedge pressure for wave delay increases the accuracy of mitral valve area measurement. The Journal of heart valve disease, 4(3), 242–246.

Previous studies have shown that symptom complex in patients with mitral valve prolapse syndrome (MVPS) may result from various forms of autonomic dysfunction. However, the interaction between adrenergic activity and renin release has not been studied. The purpose of this investigation was to assess changes in plasma renin activity (PRA) and plasma aldosterone in response to prolonged orthostatic stimulation in 19 young men with MVPS when compared to age- and sex-matched 20 control subjects. Heart rate was measured, and blood samples for PRA and aldosterone were obtained in the supine position and 90 min after assuming an upright position and slow walk. With posture the heart rate increase was greater in patients with MVPS in comparison with control subjects (19 +/- 9 vs. 12 +/- 8 beats per min, p < 0.05). Also an increase of PRA during upright activity was significantly greater in patients with MVPS (control 1.0 +/- 0.5 ng angiotensin I/mlxh, MVPS 1.8 +/- 1.7 ng angiotensin I/mlxh; p < 0.05). A significant correlation (r = 0.52, p < 0.05) was found between a rise of heart rate and PRA in patients with MVPS, but not in the control subjects. During prolonged upright activity aldosterone increased significantly in control subjects (at rest 74 +/- 41 pg/ml, with posture 98 +/- 68 pg/ml, p < 0.05) but did not change in patients with MVPS (at rest 64 +/- 29 pg/ml, with posture 67 +/- 26 pg/ml, NS).(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Zdrojewski, T. R., Wyrzykowski, B., & Krupa-Wojciechowska, B. (1995). Renin-aldosterone regulation during upright posture in young men with mitral valve prolapse syndrome. The Journal of heart valve disease, 4(3), 236–241.

Cardiac valve replacement is a rare but not exceptional eventuality in patients with relapsing polychondritis. One case requiring aortic and mitral valve replacement and its follow up is described. From the review of the literature an additional twenty patients who required cardiac valve replacement are analyzed. The mean delay between the first onset of relapsing polychondritis and operation was 6.51 years and the mean age at operation was 38.8 years. There was a preponderance of male patients (73.7%). Aortic and mitral valves were replaced in 100% and 28.5% of patients, respectively. During the four first postoperative years 23.8% of them were reoperated for periprosthetic leak or aortic aneurysm, and during the same period 52.6% died of a cardiovascular cause. Immunosuppressive agents should be employed in patients with relapsing polychondritis and cardiovascular involvement because they seem to be more effective than steroids in severe forms of the disease. Therefore, we recommend close and prolonged follow up: firstly because there can be early paravalvular prosthetic leakage due to the friability of the tissue to which it has been anchored; secondly because aortic aneurysms occur frequently in relapsing polychondritis, may be multiple, may involve all parts of the aorta and result in fatal rupture even in asymptomatic patients; and thirdly because there can be a fatal outcome due to other organ involvement, like airway obstruction, acute glomerulonephritis, or systemic vasculitis. Prophylactic composite graft replacement of the ascending aorta associated with replacement of the aortic valve and re-implantation of the coronary arteries could avoid the need for reoperation in these high risk patients.

How to cite: Lang-Lazdunski, L., Hvass, U., Paillole, C., Pansard, Y., & Langlois, J. (1995). Cardiac valve replacement in relapsing polychondritis. A review. The Journal of heart valve disease, 4(3), 227–235.

Cardiac valve tumors are rare, but may have significant clinical manifestations. We report three cases of mitral valve tumor successfully treated by surgical excision. Two out of three patients presented with neurologic symptoms, and by utilizing echocardiography the valvular lesions were discovered. Surgical removal with preservation of normal valve tissue and function was accomplished without difficulty in all cases. A literature review was performed which comprises case reports of one hundred and twenty-eight patients. Most were asymptomatic, but when symptoms did occur, they could be disabling, such as stroke, myocardial infarction and sudden death. Transthoracic and transesophageal echocardiography has greatly enhanced the ability to make this diagnosis in a timely fashion. Papillary fibroelastoma is by far the most common lesion and is amenable to simple surgical excision with minimal morbidity and mortality. Recurrence has not been reported.

How to cite: Ryan, P. E., Jr, Obeid, A. I., & Parker, F. B., Jr (1995). Primary cardiac valve tumors. The Journal of heart valve disease, 4(3), 222–226.

We proposed that a similar mechanism for calcification exists for poly(ether)urethanes and glutaraldehyde stabilized tissue. The mechanism is based on the propensity of the polyether component of the materials to complex calcium and provide initiating sites for ultimate formation of calcific deposits. Data evaluating the role ether containing materials have on calcification demonstrate that the rate of mineralization of either tissue valves or polymer valves can be controlled by paying attention to the basic chemical mechanism of complexation occurring at the surface and within the bulk of the implant devices. The molecular models described above, point out that the driving force for complexation with either the polyethers of the polyurethane or the polyether of glutaraldehyde is very strong, therefore, controlling the driving force may lead to medical devices with longer term durability.

How to cite: Thoma, R. J., & Phillips, R. E. (1995). The role of material surface chemistry in implant device calcification: a hypothesis. The Journal of heart valve disease, 4(3), 214–221.

A case of delayed papillary muscle rupture is reported, which developed 24 hours following a mild chest trauma. Transthoracic echocardiography established the diagnosis; immediate mitral valve replacement was carried out. The postoperative course was uneventful.

How to cite: Larrea, J. L., Silvestre, J., Oliver, J., Calvo, L., Mate, I., Moreno, I., Cerron, F., Mesa, J. M., Baset, F., & Centeno, J. (1995). Delayed papillary muscle rupture following mild chest trauma. The Journal of heart valve disease, 4(3), 291–292.