Mitral valve repair in the young rheumatic patient carries a high reoperation rate due to progression of the disease. In an attempt to halt or at least slow down this process, the possibility of fixing in situ the valve tissues with glutaraldehyde was explored. Six weanling sheep underwent tanning of their anterior mitral leaflet for two minutes with 0.5% buffered glutaraldehyde. The non-treated posterior mitral leaflet served as control. The animals were sacrificed at varying intervals between 2.5 and 6 months. At sacrifice, Doppler echocardiography and hemodynamic studies were done. The leaflets were subjected to histopathologic examination and calcium and glutaraldehyde contents were estimated. Glutaraldehyde treatment of the anterior leaflet caused thickening of the cusp and chordae associated with partial devitalization of its core tissue, partial loss of endothelium and intense fibrocellular reaction with abundant elastic fibers without altering its functional integrity. It did not induce calcification. There were no detectable levels of glutaraldehyde at explantation. The posterior mitral leaflets were normal. Although the absence of calcification and partial viability of the tissue are encouraging, it does not necessarily follow that this treatment would arrest progression of the underlying disease. This process may have clinical application in the future, but it is not yet recommended.

How to cite: Kumar, S. P., Ali, M. L., Prabhakar, G., Becker, A., & Duran, C. M. (1995). In situ mitral valve stabilization with glutaraldehyde. The Journal of heart valve disease, 4(4), 439–443.

Hypertrophic cardiomyopathy, or HCM, is a relatively common disease which results in the hospitalization of more than 13,000 patients every year. It is characterized by a thickening of the interventricular septum and by systolic anterior motion, or SAM, of the mitral valve, which occurs when the distal tip of the mitral leaflets contacts the hypertrophied septum during systole and obstructs the left ventricular outflow tract. Using an in vitro pulsatile flow model of the left ventricle, the objective of the study was to investigate the relationship between the ventricular flow field and the mechanism of SAM and to specifically address the hypothesis that papillary muscle displacement can alter left ventricular flow patterns and create drag forces that can initiate SAM. Flow visualization revealed the presence in the ventricle of a large organized recirculation region throughout diastole. Besides maintaining the mitral leaflets close to the posterior wall, normally positioned papillary muscles also caused the diastolic vortex to help the mitral valve close near the posterior wall while simultaneously prepositioning the upcoming systolic outflow stream close to the septum, thereby minimizing the flow forces acting on the mitral valve. In contrast, the anterior displacement of the papillary muscles moves the entire mitral apparatus into the outflow tract. It also reverses the direction of the recirculating diastolic flows: The diastolic vortex now promotes the initiation of SAM by displacing the closing mitral leaflets anteriorly and by positioning the systolic outflow stream close to the posterior wall. These events lead to the creation of form drag forces as the systolic flow impacts the posterior side of the mitral leaflets, initiating SAM.

How to cite: Lefebvre, X. P., He, S., Levine, R. A., & Yoganathan, A. P. (1995). Systolic anterior motion of the mitral valve in hypertrophic cardiomyopathy: an in vitro pulsatile flow study. The Journal of heart valve disease, 4(4), 422–438.

The application of transcranial Doppler (TCD) ultrasonography to asymptomatic prosthetic heart valve patients can result in detection of localized bursts of high intensity signals, similar to those caused by the passage of emboli. The origin of these signals is not known. In order to investigate this phenomenon in a simplified, more controllable environment, a TCD machine was used to record flow downstream from mechanical prosthetic heart valves in a mock circulatory loop. The model, which uses a saline solution seeded with silk particles (< 15 micrometers) as the circulatory fluid, recreates the principal hydrodynamic characteristics of the left heart and systemic circulation. Reproducibility of the system was established through repeated testing of a Monostrut valve. Three different mechanical valve types, (Monostrut, Medtronic Hall, St. Jude Medical) were tested over a range of simulated cardiac outputs, and the effect of valve size was investigated with four Omniscience tilting disc valves (21, 23, 25 and 29 mm). Average energy of the reflected Doppler signal was used to quantify the amount of high intensity Doppler signal, QTCD. TCD signals recorded in vitro were visually and aurally similar to those found in prosthetic heart valve patients. All valve types generated exponentially more QTCD with increasing simulated cardiac output. Differences amongst valve types were only significant at higher flow outputs, with the Monostrut valve producing the greatest QTCD. Larger valves consistently generated greater QTCD than smaller valves. In conclusion, TCD signals found in prosthetic heart valve patients can be reproduced, at least qualitatively, using a mock circulatory loop which does not incorporate the formed elements of blood.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Mackay, T. G., Georgiadis, D., Grosset, D. G., Kelman, A. W., Lees, K. R., & Wheatley, D. J. (1995). Transcranial Doppler ultrasound signals associated with prosthetic heart valves: an in vitro study. The Journal of heart valve disease, 4(4), 414–419.

From 1983 to 1992, 366 patients received 407 Mitroflow pericardial bioprostheses at our institution. Mean age was 62 +/- 14 years (range: 15-86 years). There were 229 isolated aortic valve replacements (AVR), 96 isolated mitral valve replacements (MVR), 39 double mitral and aortic valve replacements (DVR) and four tricuspid replacements. Mean follow up was 6 +/- 2.33 years ranging from 1.67 to 10.9 years. Total follow up was 1791 patient-years. Overall survival was 77.2 +/- 2.2% at five and 56.2 +/- 6.4% at 10 years. It was 74 +/- 3% and 56.2 +/- 5.3% after AVR, 78.3 +/- 4.4% and 55.7 +/- 8.8% after MVR, 81 +/- 6.4% and 36.6 +/- 16.5% after DVR at five and 10 years, respectively. Freedom from structural valve deterioration (SVD) was 95 +/- 1.2% and 36.7 +/- 8.1% at five and 10 years for all valves, 96.9 +/- 1.3% and 39.2 +/- 9.8% for AVR, 91.7 +/- 3.2% and 36.4 +/- 10% for MVR. There was no difference in freedom from SVD between AVR and MVR. The freedom from SVD in patients older than 70 years of age was 100% and 93.9 +/- 5.8% at five and 10 years, respectively. Freedom from reoperation was 94.7 +/- 1.37% and 28.36 +/- 7.5% at five and 10 years for all valves, 96.2 +/- 1.5% and 38.6 +/- 9.7% for AVR, 91.7 +/- 3.2% and 36.4 +/- 10% for MVR. The denaturation process did not lead to acute hemodynamic deterioration. Pathologic findings were cuspal tears (one or more) associated with structural tissue changes.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Mazzucotelli, J. P., Bertrand, P. C., & Loisance, D. Y. (1995). The Mitroflow pericardial valve: clinical performance to 10 years. The Journal of heart valve disease, 4(4), 407–413.

From October 1993 through August 1994, 21 patients underwent Ross procedures. In the first 12 patients bleeding and/or sequelae resulted in three deaths. In the subsequent nine patients, we modified the technique to prevent bleeding from the raw area of the right ventricular outflow tract (RVOT) without further mortality. This is described in detail.

How to cite: Kumar, A. S., Rao, P. N., & Trehan, H. (1995). A technique to prevent bleeding after Ross procedure. The Journal of heart valve disease, 4(4), 405–406.

From January 1991 to October 1994, 20 Ross procedures were performed. Mean age was 39.70 +/- 7.72 years, range 26 to 56 years. Male/female ratio was 14/6. Nineteen operations were elective, one was semiurgent. Predominant valvular lesion was stenosis in seven patients, aortic regurgitation in four, mixed disease in eight and prosthetic dysfunction in one patient. Twelve pulmonary autografts were implanted in the subcoronary (SC) position, eight as an intraaortic cylinder (inclusion technique (INCL)). Early mortality (< 30 days postoperative) was one (5.0%), there was no late mortality. Reoperation for valve failure occurred in two patients (10.0%). Additional CABG was performed in two patients (10.0%) for technical reasons. Major ECG changes were detected in five patients (three RBBB, two ischemia). No thromboembolic events were reported. Mean follow up was 21.2 months. Aortic insufficiency (AI) at one year was similar in the SC and INCL group. AI grade I in SC: 60%, in INCL: 60%; AI grade II in SC 10%, in INCL: 20%. At two years AI grade I occurred in 100% of the SC group. At three years AI grade I occurred in 75% of the SC group and AI grade II in 25%. No patients of the INCL group had two- or three-year follow up. At discharge slight pulmonary regurgitation was traced in only three patients and it remained stable during the follow up.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Dossche, K., & Vanermen, H. (1995). Three years surgical and clinical experience with the Ross procedure in adults. The Journal of heart valve disease, 4(4), 401–404.

Between July 1994 and March 1995, seven patients (six male) with a mean age of 27 years (range 18 to 34 years) were selected for aortic valve replacement with a pulmonary autograft (Ross operation). The aortic valve disease was isolated insufficiency in four cases, stenosis in one and mixed lesion in two. Three patients had a bicuspid aortic valve. Previous cardiac surgical procedures had been performed in two cases (coarctation repair and valvuloplasty in one; isolated aortic valvuloplasty in one). Two patients were in NYHA class II and five in class III. In two cases the autograft was inserted as a scalloped subcoronary implant. Four patients had total aortic root replacement with re-implantation of the coronary ostia. The RVOT was reconstructed with a cryopreserved homograft (five pulmonary two aortic). The aortic cross-clamp time was 150 +/- 10 minutes with a total bypass time of 212 +/- 14 minutes. There was neither operative nor late mortality. Postoperative echocardiography revealed trivial autograft insufficiency in one case with a mean transvalvular gradient of 15.8 mmHg. All patients improved symptomatically (100% in NYHA class I). Freedom from reoperation, valve related complications and endocarditis is 100% at a mean follow up of 5.6 months (range 1-9 months). This preliminary experience supports the concept of pulmonary autograft implantation in selected patients.

How to cite: Mazzucco, A., Santini, F., Fabbri, A., Dan, M., Campanile, F., & Faggian, G. (1995). Preliminary experience with pulmonary autografts. The Journal of heart valve disease, 4(4), 398–400.

Cryopreserved homografts have been used at the German Heart Institute Berlin since October 1986. Until 31st May 1994, cryopreserved aortic (AA) or pulmonary (PA) homografts were implanted in the pulmonary position and followed up in 104 patients. The mean age at operation was 5.5 years. The patients were treated with 3-5 mg/kg aspirin daily after the operation for three months. They all had routine echocardiographic evaluation of their homografts, 47 patients were studied by heart catheterization. Excellent functional results of the homograft valves were found in 92 patients (88.5%). Early degeneration of the homograft conduit leading to reoperation was observed in 12 patients. Freedom from wall calcification was 18% in aortic and 78% in pulmonary homografts while freedom from valve dysfunction in aortic and pulmonary homografts at 60 months was 60% and 67%, respectively. Freedom from reoperation was 81% overall, 78% and 84% in patients with aortic and pulmonary homografts respectively (p < 0.05). In conclusion, pulmonary homograft has proved to be more durable than the aortic homograft in the pulmonary position, hence it is the preferential valve for RVOT reconstruction in children.

How to cite: Yankah, A. C., Alexi-Meskhishvili, V., Weng, Y., Berger, F., Lange, P., & Hetzer, R. (1995). Performance of aortic and pulmonary homografts in the right ventricular outflow tract in children. The Journal of heart valve disease, 4(4), 392–395.

Infants who have undergone pulmonary valve allograft reconstruction of the right ventricular outflow tract experience an increased incidence of allograft fibrocalcification and valvar insufficiency compared to older allograft recipients. Since April 1985, 186 cryopreserved pulmonary valve allografts have been used for right ventricular outflow tract reconstruction in pediatric patients at The Children's Hospital and the University of Colorado Health Sciences Center in Denver. One hundred and forty-six patients were one to 18.4 years of age (mean age: 5.0 years) and 40 children were younger than one year of age at operation (mean age: 4.4 months). In the older patient group, there were 15 hospital deaths (10%) and one child with dilated cardiomyopathy and cardiac failure underwent cardiac transplantation two days postoperatively. One hundred and thirty operative survivors have been followed clinically for a mean of 4.6 years. One child was lost to follow up and one patient with myocardial dysfunction required cardiac transplant 3.8 years postoperatively. There have been five late deaths (4%), one of which resulted from accidental trauma. Five children (4%) have undergone reoperation to replace their valve allograft at 1.3 to 9.8 years after the initial allograft procedure. In the infant group, there were nine hospital deaths (23%). During follow up averaging 3.0 years, there have been nine late deaths (29%) and five children (16%) have undergone valve allograft explant 2.0 months to 3.5 years following implantation. Allografts are technically desirable in small children for whom surgical repair alternatives are limited.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Clarke, D. R., & Bishop, D. A. (1995). Ten year experience with pulmonary allografts in children. The Journal of heart valve disease, 4(4), 384–391.

From March 1992 through March 1995 we have performed 45 Ross procedures for total aortic root replacement in our institution. There were 32 males and 13 females with a mean age of 31 years (range: 3-49 years). Indications for surgery were: aortic stenosis (n = 20), aortic regurgitation (n = 16), native valve endocarditis (n = 6), replacement of prosthetic valve (n = 3). Of these 45 patients 13 (28%) had at least one prior repair. Additional procedures were Dacron graft extension of the autograft (n = 7), enlargement of aortic annulus (n = 3), mitral valve repair (n = 2), CABG (n = 1), closure of VSD (n = 1). The mean cross-clamp time was 132 minutes (76-187 minutes) and the mean bypass time 156 minutes (106-240 minutes). There were two postoperative cardiac deaths, not valve-related, and five non-lethal postoperative complications: right ventricular failure (n = 1), low cardiac output (n = 1), sternal re-entry for bleeding (n = 3). The follow up is complete (1.5-37 months) for the 43 survivors. There was one non-cardiac late death (acute fulminating hepatitis) in an eight years old boy eight months post-operatively. Discharge echo-Doppler studies showed normal autograft and homograft valve function except in one patient who had a grade two aortic regurgitation. Serial echo-Doppler studies showed no significant progression of aortic regurgitation, no significant pulmonary gradients, no dilatation of the autografts during the follow up. It is suggested in conclusion that aortic root replacement with a pulmonary autograft is a safe procedure in selected patients.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Prat, A. G., Doisy, V. C., Savoye, C., Moreau, D. C., Monier, E. J., & Stankowiak, C. (1995). Total aortic root replacement with pulmonary autografts: short term results in 45 consecutive patients. The Journal of heart valve disease, 4(4), 368–373.

During the past 2.5 years, 50 Ross operations have been performed at Rigshospitalet in Copenhagen in a broad range of patients with aortic valve disease including children and adults from 6 weeks to 71 years of age. Many patients had complicating conditions including endocarditis (n = 13, eight native, five prosthetic valve), prosthetic valve dysfunction (n = 4), subvalvular obstruction (n = 3) treated by septal myectomy (n = 1) or modified Konno operation (n = 2), ascending aortic aneurysm (n = 2), ventricular septum defect (n = 1), mitral valve disease (n = 6), rheumatic heart disease (n = 4), coronary artery disease (n = 1), and extreme obesity (n = 1). All operations were performed as free-standing total aortic root replacements. The results have been encouraging with low mortality (2%) and no major morbidity. One patient has been reoperated because of autograft insufficiency due to left coronary cusp prolapse and two additional patients have grade 2 autograft insufficiency and are being followed closely. Two patients have developed early pulmonary homograft stenosis, which has required pulmonary homograft replacement. Despite these problems, we are enthusiastic about this operation and believe it may emerge as operation of choice for most patients under 60-65 years of age with aortic valve disease and for patients with prosthetic or advanced native aortic valve endocarditis. With increasing frequency, our choice has been to proceed with a Ross operation, and currently, our only absolute contraindication is Marfan's syndrome. Based on reported recurrent disease in patients with rheumatic valve disease, the autograft should be used with caution for this indication.(ABSTRACT TRUNCATED AT 250 WORDS)

How to cite: Joyce, F., Tingleff, J., & Pettersson, G. (1995). Expanding indications for the Ross operation. The Journal of heart valve disease, 4(4), 352–363.