Background and aims of the study: In the production of porcine bioprostheses, the initial glutaraldehyde treatment is often followed by a short incubation in formaldehyde to ensure sterility of the valve. It is assumed that the glutaraldehyde cross links are stable and that the formaldehyde step does not alter the glutaraldehyde incorporated. The objective of this study was to determine whether the formaldehyde interacts with the tissue to cause changes in the glutaraldehyde composition.

Materials and methods: Two methods of tissue treatment were investigated: (i) fresh porcine leaflet tissue was treated with glutaraldehyde, followed by storage in formaldehyde, (ii) tissue processed in glutaraldehyde and transferred to formaldehyde for six hours was returned to glutaraldehyde for storage. The content of the two aldehydes was estimated by high performance liquid chromatography (HPLC), using an adaptation of the method developed by Hughes et al, which measures the acid labile Schiff bases formed between the collagen and the aldehyde.

Results: The initial content of glutaraldehyde in the tissue declined from 63 +/- 10 nmol/mg dry weight to 21 +/- 4 nmol/mg dry weight when the leaflets were placed in formaldehyde for 24 hours. The initial uptake of formaldehyde was 800 +/- 144 nmol/mg dry weight after 24 hours and this declined to 370 +/- 33 nmol/mg dry weight over a 16 week period of storage in formaldehyde. By this stage, the level of glutaraldehyde had decreased to 2.4 +/- 0.2 nmol/mg dry weight. There was a sharp decline in the glutaraldehyde concentration from 89 +/- 6 nmol/mg dry weight to 14 +/- 1 nmol/mg dry weight when the tissue was placed in 4% formaldehyde solution for six hours. The formaldehyde uptake was 770 +/- 54 nmol/mg dry weight. After return to 0.625% glutaraldehyde solution the formaldehyde concentration declined whilst the glutaraldehyde concentration initially increased.

Conclusions: These results show that the formaldehyde reacts with the epsilon amino groups of lysine which had not reacted with glutaraldehyde, probably for steric reasons; and that formaldehyde replaces some glutaraldehyde in the tissue by a mass action effect. The tissue concentration of both aldehydes subsequently declined over the study period.

How to cite: McClurg, W. M., Lawford, P. V., Hughes, H., & Rogers, S. (1996). Formaldehyde replaces glutaraldehyde in porcine bioprosthetic heart valves. The Journal of heart valve disease, 5(3), 343–347.

Background and aims of the study: Mechanical valves are the prosthesis of choice in valve replacement in children. However, the problem of somatic growth leading to patient-valve mismatch remains present, and the appropriate anticoagulation regimen remains controversial. We present our experience of valve replacement in a young population over 20 years.

Materials and methods: Between 1972 and 1992, 48 patients (34 males and 14 females), mean age 11.2 years (range 0.4-27.4 years), underwent mechanical valve replacement at our institution. Aortic valve replacement was performed in 28 patients (58.3%), mitral valve replacement in 13 (27.1%), tricuspid valve replacement in six (12.5%) and pulmonary valve replacement in one patient (2.1%). The prostheses used were: St. Jude Medical (n = 2), Björk-Shiley (n = 14), Medtronic Hall (n = 16), Duromedics (n = 2) and CarboMedics (n = 14). Early mortality was 14.3%, 10.7% for aortic valve replacement and 30.8% for mitral valve replacement. Mean follow up for all patients was 8.3 years (range 0-22 years), with a total of 398 patient-years.

Results: Seven patients died during the follow up (17.1%). Survival after 10 years, including operative mortality, was 81% for aortic valve replacement, 33% for mitral valve replacement, 83% for tricuspid valve replacement and 100% for pulmonary valve replacement. All patients were anticoagulated with warfarin. In eight patients (16.7%) an antiplatelet drug (aspirin or dipyridamole) was added. Major events included paravalvular leak in six patients (1.5%/pty), valve thrombosis in five (mitral position in two, tricuspid in three) (1.3%/pty) and endocarditis in one patient (0.3%/pty). Minor thromboembolic events occurred in three patients (0.8%/pty) and minor hemorrhagic events in three (0.8%/pty). No patients developed hemolytic anemia and there was no case of structural failure.

Conclusions: In our experience, mechanical prostheses in congenital heart disease were associated with significant morbidity and mortality, however long term survival after aortic valve replacement was good (81% at 10 years). Thromboembolic and hemorrhagic events were of minor significance. Atrio-ventricular valve replacement carried the highest risk of valve thrombosis and we now give warfarin and an antiplatelet drug to children undergoing mechanical valve implantation in this position.

How to cite: Fiane, A. E., Lindberg, H. L., Saatvedt, K., & Svennevig, J. L. (1996). Mechanical valve replacement in congenital heart disease. The Journal of heart valve disease, 5(3), 337–342.

Background and aims of the study: Preliminary reports have suggested hemodynamic disparities between single leaflet tilting disc prostheses. We tested the hypothesis that similarities in prosthetic design may not necessarily indicate hemodynamic equivalence.

Materials and methods: In a retrospective analysis, we compared the functional characteristics of two single tilting disc (Omniscience and Medtronic Hall) prostheses implanted in the aortic position in 30 patients matched for valve size and left ventricular systolic function.

Results: Echocardiographic and Doppler analysis blinded to patient and valve type indicated similar quantitative left ventricular ejection fractions (64% +/- 6% for both) and cardiac outputs (4.8 +/- 1.2 vs. 4.6 +/- 1.2 l/min, p = 0.65) in the Onmiscience and Medtronic Hall groups, respectively. Transprosthetic instantaneous peak gradients were greater for Omniscience than for Medtronic Hall valves (44 +/- 8 vs. 35 +/- 11 mmHg, p < or = 0.02), as were the mean values (24 +/- 6 vs. 18 +/- 6 mmHg, p = 0.01). Even when 21 and 23 mm prostheses were analyzed separately to allow for unequal sewing ring diameters in the smallest valve sizes (Omniscience = 19 mm, Medtronic Hall = 20 mm), higher gradients were noted in the Omniscience prostheses. Effective orifice areas were smaller in the Omniscience than Medtronic Hall prostheses whether data from all prostheses (0.92 +/- 0.11 cm2 vs. 1.09 +/- 0.18 cm2, p < or = 0.05), or only data from 21 and 23 mm valves (0.94 +/- 0.11 cm2 vs. 1.10 +/- 0.18 cm2, p < 0.05) were included. Similarly, the dimensionless obstructive index, a parameter independent of left ventricular flow and annular size, was reduced in the Omniscience valves, indicating greater obstruction, whether all valves (0.31 +/- 0.04 vs. 0.36 +/- 0.07, p < or = 0.01) or only 21 and 23 mm valves (0.31 +/- 0.04 vs. 0.36 +/- .04, p < 0.001) were analyzed.

Conclusion: Despite prosthetic design similarities, resting hemodynamic assessment indicates greater stenosis in Omniscience than Medtronic Hall valves when placed in the aortic position. The long term effects of these differences in terms of ventricular diastolic and systolic function and mass regression requires further evaluation.

How to cite: Plehn, J. F., Arbuckle, B. E., Southworth, J., Nugent, W., Plume, S., & Marrin, C. A. (1996). A hemodynamic comparison of Omniscience and Medtronic Hall aortic prostheses. The Journal of heart valve disease, 5(3), 328–336.

Background and aims of the study: The Liotta low profile porcine bioprosthesis (LBP) was designed in order to minimize complications due to excessive protrusion of the stent prongs in the left ventricle.

Materials and methods: From April 1984 to November 1993, 25 LBP surgical explants were available for pathology study, which included gross and X-ray evaluations. Reoperation was performed after a mean period of 95 +/- 25 months (range 46 to 143 months), in five males and 20 females (mean age at implantation 51.1 +/- 11.4 years).

Results: The cause of failure was stenosis due to cusp stiffness caused by dystrophic calcification in one and incompetence in 24 LBPs. In only one case was incompetence ascribable to endocarditis; in the remaining 23 the mechanism of regurgitation was due to commissural tearing (21 LBPs), commissural dehiscence (one LBP) and both tears and dehiscence (one LBP). Overall, 28 commissural tears were observed: 20 involved the right coronary cusp, eight the left coronary cusp, and none the non-coronary cusp. The anterior commissure was most frequently involved by tears (n = 17) followed by the right posterior (n = 9) and the left posterior (n = 2). Tears were calcium-related in all but two cases. Calcific deposits were observed in each explant, involving a total of 62 commissural attachments, 17 cusp bodies and five right muscular shelves.

Conclusion: In conclusion, valve regurgitation is the usual mode of LBP failure in the mitral position; commissural tearing of the right coronary cusp was the most common cause of valve regurgitation, and occurred even in the presence of pin-point calcification. These pathologic findings seem to confirm that low profile design, which implies bulging of the right coronary cusp, entails the risk of increased stress at the commissures, accelerated calcification and tearing.

How to cite: Ius, P., Thiene, G., Minarini, M., Valente, M., Bortolotti, U., Talenti, E., & Casarotto, D. (1996). Low-profile porcine bioprosthesis (Liotta): pathologic findings and mode of failure in the long-term. The Journal of heart valve disease, 5(3), 323–327.

Background and aims of the study: In an attempt to overcome the problem of calcification of bioprostheses, a novel bovine pericardial tissue valve preserved with a non-aldehyde, dye mediated photo-oxidation process (PhotoFixTM) developed by CarboMedics, Inc. The device was evaluated by implantation in the mitral position of juvenile sheep with a mean age of 3.5 months.

Materials and methods: Thirteen valves were evaluated; six experimental valves with photo-oxidized tissue, five identically designed valves with glutaraldehyde-fixed tissue, and two Carpentier-Edwards pericardial valves as controls.

Results: Four of the six animals in the photo-oxidized group were free of calcification when electively sacrificed at 152 days, 152 days, one year and 1.5 years respectively. One animal was electively sacrificed at 98 days. Pathologic findings indicated minimal calcification of the valve due to uneven stress distribution from two bent stent posts that most likely occurred during surgical implantation, but the device was still functional. The sixth animal with photo-oxidized tissue died at 131 days due to massive calcification of a single leaflet. There was no pathologic evidence of infection. Explants at five months from additional and still continuing sheep studies per FDA guidelines have not reproduced single leaflet calcification in over forty explanted valves with photo-oxidized tissue. The glutaraldehyde-fixed valves all exhibited some calcification at explant; two of these animals died early due to the mineralization. Both control animals with Carpentier-Edwards valves died early from mitral stenosis due to extensive device calcification.

Conclusions: The fact that four of six valves with photo-oxidized tissue remained free of any signs of calcification for up to 1.5 years, while none of the other valves did, suggests that photo-oxidation is a promising method of preserving and fixing tissue for use in bioprostheses. These results suggest that photo-oxidized bioprosthetic valves may be clinically valuable and warrant further study.

How to cite: Bianco, R. W., Phillips, R., Mrachek, J., & Witson, J. (1996). Feasibility evaluation of a new pericardial bioprosthesis with dye mediated photo-oxidized bovine pericardial tissue. The Journal of heart valve disease, 5(3), 317–322.

Background and aims of the study: The first generation of pericardial valves was withdrawn from the market because of an excessive rate of premature failure. With an original design, the Carpentier-Edwards pericardial valve promised improved results.

Materials and methods: From July 1984 to December 1993, 71 patients underwent double mitral and aortic valve replacement with the Carpentier-Edwards pericardial valve. Mean age was 63.4 years. 58% were male, mean clinical status was 2.9 with 71% of patients in NYHA class III or IV, 55% were in atrial fibrillation. All patients were followed for an average of 4.17 years after their operation, and total follow up was 296 patients years.

Results: Operative mortality was 7% (5/71). At this point of the study, 70% of patients are in clinical NYHA class I or II, 42% of patients are in atrial fibrillation and 66% receive anticoagulation treatment. We observed 19 late deaths with an actuarial survival of 58% +/- 14% at ten years. Valve-related complications include four endocarditis, four reoperations, seven anticoagulant-related hemorrhages, two structural failures, one thromboembolic episode, and one sudden death. Two patients died of valve-related causes. After 10 years, freedom from valve related death is 97% +/- 3%, from endocarditis 90% +/- 8%, from reoperation 87% +/- 10%, from thromboembolic complications 98% +/- 2%, from valve failure 93% +/- 7%, and freedom from all complications is 58% +/- 18%. No failure in patients older than 60 years was noted and no leaflet tear was observed.

Conclusions: The 10-year results of this pericardial bioprosthesis make this valve an outstanding choice when a bioprosthesis is required and in patients over 60 years old.

How to cite: Aupart, M. R., Babuty, D. G., Guesnier, L., Meurisse, Y. A., Sirinelli, A. L., & Marchand, M. A. (1996). Double valve replacement with the Carpentier-Edwards pericardial valve: 10-year results. The Journal of heart valve disease, 5(3), 312–316.

Background and aims of the study: It is commonly held that preservation of the annulo-ventricular continuity during mitral valve replacement has a beneficial effect on postoperative ventricular function. This paper presents our eight-year experience with this technique.

Materials and methods: From 1986 to December 1992, 120 patients with rheumatic valve disease underwent mitral valve replacement (MVR) combined with preservation of the posterior leaflet of the mitral valve. The mean age was 33.87 years (range 16 to 63). The preoperative New York Heart Association (NYHA) class was III in 64% of the patients and IV in 3%. The early (30 day) mortality rate was 2.5% (3/120). Follow up was 100% complete. The total cumulative follow up was 477 patient-years (pty) with a mean 3.94 years (range: 2-8 years).

Results: The actuarial survival rate (including hospital mortality) was 87.6% at eight years. Advanced age (p = 0.0457), increased preoperative functional capacity (p = 0.0251), increased preoperative end-systolic diameter (p = 0.0352) and combined tricuspid reconstruction (p = 0.0001) were found to be independent parameters for a lower actuarial survival rate. Six patients (1.25%/pty) developed thromboembolic complications. Two of these were cerebrovascular accidents (0.41%/pty) and four were caused by mechanical valve thrombosis (1.83%/pty). Freedom from thromboembolic complications (including mechanical valve thrombosis) was 89.8% +/- 7.9%. Fifteen patients (3.14%/pty) developed valve failure, four (0.83%/pty) mechanical valve thrombosis and nine (1.88%/pty) bioprosthetic valve failure. Freedom from reoperation was 60.7% +/- 16.1%. One patient with a St. Jude Medical valve (0.2%/pty) suffered from prosthetic valve endocarditis. Three patients (0.62%/pty) died during the follow up period, and, freedom from all valve related complications was 51.4% +/- 16.1% at eight years.

Conclusion: Preservation of the posterior leaflet during mitral valve replacement reduces the risk of early mortality and did not cause additional complications to the patients. Despite the beneficial effects of this technique in the long term this technique did not increase the long term survival in patients with associated impaired valvular and/or ventricular function.

How to cite: Katircioglu, F., Yamak, B., Battaloglu, B., Saritas, A., Kiziltepe, U., Kural, T., Tasdemir, O., & Bayazit, K. (1996). Long term results of mitral valve replacement with preservation of the posterior leaflet. The Journal of heart valve disease, 5(3), 302–306.

Background and aim of the study: Mitral valve repair is less stable in rheumatic than in degenerative disease. This failure rate is inversely related to the age of the patient. Based on our clinical experience, we selected the group of patients with the worst results for this study: (i) rheumatic, (ii) age 20 or under, (iii) pure mitral regurgitation (MR), and, (iv) no aortic disease.

Materials and methods: Between 1988 and 1995, 83 consecutive patients complied with these characteristics. No patient was excluded. Replacement (MVR) was performed in 26 and repair (MRp) in 57 (69%).

Results: There was one hospital death (1%) with an actuarial survival at 48 months of 74.8% +/- 19% for MVR and of 97.9% +/- 2.1% at 78 months for MRp. There were no thromboembolic events. Reoperation was required in one MVR (4%) and in 21 MRp (37%), within same admission in six, within three months in eight, under one year in three, and beyond in four cases. Severe MR appeared in five further cases. No statistical difference was found between the preoperative clinical data, operative findings and surgical maneuvers of those patients with successful and unsuccessful repair. The rate of failure was similar after Kay (14/29) and Duran (12/28) annuloplasty. All patients showed a rapid decrease in left ventricular dimensions. Early failures showed elongation of previously shortened chordae at reoperation, together with more reduction in systolic dimension than the other groups. Late failures were more related to progression of the rheumatic process. No clear relationship between rheumatic activity and failure rate was found.

Conclusion: Rheumatic mitral regurgitation in the young remains a serious problem. The treatment of this frequent pathology in the developing countries needs a new approach based on the knowledge that it starts at the annulus. Earlier surgery at this level might prevent its further progression, avoiding the problems of secondary chordal elongation.

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How to cite: Ghosh P. K. (1996). Mitral annuloplasty: a ring-side view. The Journal of heart valve disease, 5(3), 286–293.

We describe a patient with dysfunction of a Medtronic Hall prosthetic valve showing peculiar patterns of aortic regurgitation and carotid pulse caused by valvular thrombosis. The aortic regurgitation was considered to be caused by a significant delay in prosthetic valve closure, manifested by a peculiar regurgitation pattern limited to early diastole, in association with widely split closing clicks and an abnormally low dicrotic notch in the carotid pulse. At surgery, fibrin thrombi were noted just below the prosthetic ring in the minor outflow region which restricted disc movement. The fibrin thrombi were removed and the valve was rotated 90 degrees. Following reoperation, all abnormalities disappeared.

How to cite: Fukuda, N., Oki, T., Iuchi, A., Tabata, T., Manabe, K., Sasaki, M., Yamada, H., & Ito, S. (1996). Peculiar patterns of aortic regurgitation and carotid pulse due to dysfunction of a Medtronic Hall prosthetic valve: a case report. The Journal of heart valve disease, 5(3), 283–285.

Background and aims of the study: To determine whether warm blood cardioplegia (BCP) is superior to cold BCP in terms of myocardial protection, we compared warm (37 degrees C) and cold (4 degrees C) continuous retrograde administration of BCP in 40 patients undergoing aortic valve replacement (AVR) in a prospective, randomized study.

Materials and methods: The main subjects of investigation were the myocardial oxygen consumption and the maintenance of the ultrastructure of the tissue. In addition, we looked at intraoperative recordings of time, heart rhythm disturbances, CK/MB serum levels, and inotropic support.

Results: We found, that oxygen consumption is significantly higher during warm BCP (7.95-10.38 ml/min) than during cold BCP (2.11-3.47 ml/min). Mild, reversible myocardial damage occurs during cold and warm BCP. The intraoperative serum potassium level was significantly higher after warm (7.25 mmol/l) than after cold (6.55 mmol/l) BCP. There was no statistically significant difference in the duration of extracorporeal circulation and of cardiac arrest, the CK/MB serum level or the recorded right and left ventricular performance data in the two groups.

Conclusions: We conclude that continuous retrograde warm BCP is not superior to continuous retrograde cold BCP as far as myocardial protection is concerned. The administration of cold BCP prolongs the tolerated ischemic time of the myocardium and provides a higher safety margin.

How to cite: Boening, A., Sanuri, M., Buchwald, D., & Laczkovics, A. M. (1996). Aortic valve replacement: better myocardial protection by cold or warm retrograde blood cardioplegia?. The Journal of heart valve disease, 5(3), 273–280.

Background and aims of the study: Significant pulmonary hypertension in aortic stenosis is evidence of severe dysfunction of the left ventricle. It is also a predictor of a bad prognosis in the natural course of the disease. This study was performed to evaluate the changes in the hemodynamic parameters of pulmonary circulation at rest and effort in patients who had significant pulmonary hypertension preoperatively and underwent valve replacement.

Materials and methods: The study consists of 11 male patients with aortic stenosis with an average peak transvalvular gradient of 68 mmHg and impaired left ventricular function (mean ejection fraction 38%). Six patients were in NYHA functional class III, and five were in class IV. The patients underwent Swan-Ganz catheterization before urgent valve replacement.

Results: Significant pulmonary hypertension was found in all subjects, and a below normal cardiac index in eight. Urgent valve replacement was performed in all patients: two of them were operated on during pulmonary edema and cardiogenic shock which developed soon after diagnosis-one of them died. Patients were followed up six months after surgery, and all of them showed major clinical improvement (six in NYHA class I, four in class II). Mean pulmonary artery systolic pressure dropped from 77 mmHg preoperatively to 32 mmHg, and the pulmonary artery mean pressure from 47 mmHg to 17 mmHg, pulmonary wedge pressure from 32 mmHg to 9 mmHg, and pulmonary vascular resistance from 4.74 to 1.8 Wood units. The cardiac index came back to normal in all patients (2.18 vs. 3.0 l/min/m2). Swan-Ganz catheterization was also performed during exercise (work load; 50 Watts in three patients, 100 Watts in six patients). The reaction of the hemodynamic parameters on exercise in most patients was almost normal.

Conclusion: Our data indicate that in aortic stenosis, even with severe left heart failure, pulmonary hypertension can be fully reversible and a significant improvement in both rest and effort hemodynamic parameters can be expected.

How to Cite: Snopek, G., Pogorzelska, H., Zielinski, T., Rajecka, A., Korewicki, J., Biederman, A., & Kotlinski, Z. (1996). Valve replacement for aortic stenosis with severe congestive heart failure and pulmonary hypertension. The Journal of heart valve disease, 5(3), 268–272.

Background and aim of the study: The sequelae of early aortic valve replacement (AVR) for aortic stenosis (AS) are controversial, with an increasing body of opinion regarding the patient risk profile as having an influence on long term survival and prosthesis-related morbidity rates. We therefore undertook a comparison of the morbidity and mortality rates of the patients undergoing AVR at our institution over a 22 year period with those in the background population to establish whether early intervention leads to an increased incidence of either.

Methods: A multivariate risk analysis of 630 consecutive patients with AS who were alive 30 days after AVR performed between January 1965 and December 1986 was completed. The patients had a mean age of 59 years (range 14-78 years), 98% received a mechanical prosthetic valve, and 71% were in functional classes III or IV preoperatively.

Results: Relative to an age- and sex-matched background population, the patients suffered a slight excess mortality during the first postoperative year, and a significant excess mortality after the 12th year, which was primarily related to congestive heart failure (64% of deaths versus 25% during the first 12 years; p < 0.01). A multivariate Cox regression model allowed calculation of a prognostic index for each patient. The index divided the patients into three groups (from low to high index): group A (n = 195) had normal sex- and age-specific survival, group B (n = 165) had a slight late (> 12th year) excess mortality, while group C (n = 270) had significant excess mortality throughout the follow up. Multivariate risk analysis of thromboembolism (1.7%/pt-yr), anticoagulant related hemorrhage (1.5%/pt-yr), all prosthesis-related complications combined (4.2%/pt-yr), and sudden cardiac events (arrhythmia and myocardial infarct; 1.8%/pt-yr) identified variables underlying advanced preoperative heart disease, coronary artery disease and systemic hypertension as the decisive risk factors. The preoperative prevalence of these risk factors as well as the postoperative incidence of the complications differed significantly between the three patient groups; A < B < C. Incidence rates of stroke in the patients (95% confidence interval) and in sex- and age-matched background populations were: group A, 0.48 (0.13-0.83) and 0.34 %/pt-yr, respectively, group B, 1.07 (0.46-1.68) and 0.52%pt-yr, respectively, and group C, 2.28 (1.50-3.06) and 0.68%/pt-yr respectively. Similar results were obtained for incidence rates of myocardial infarct.

Conclusion: Operative intervention early in the course of AS, being equivalent to a favorable risk profile, may result in an age- and sex-specific normal long term survival, generally low rates of prosthesis-related complications and a normal incidence of the dominant thromboembolic and hemorrhagic events and of myocardial infarction.

How to cite: Lund, O., Magnussen, K., Knudsen, M., Pilegaard, H., Nielsen, T. T., & Albrechtsen, O. K. (1996). The potential for normal long term survival and morbidity rates after valve replacement for aortic stenosis. The Journal of heart valve disease, 5(3), 258–267.

Background and aims of the study: Long term survival after replacement of the aortic root is improving. The most common cause of late death is progression of disease in the remaining aorta (dissection or atherosclerosis). The purpose of this study was to review our clinical experience with composite graft replacement of the aortic root with special reference to long term results.

Materials and methods: One hundred twenty-six patients (mean age: 53 years) with different pathologies of the ascending aorta underwent aortic root replacement with a composite-graft prosthesis over a 12-year period. Twenty-three patients had previously undergone cardiovascular surgery. The surgical technique included resection of the ascending aorta with the aortic valve and end-to-side anastomosis between full-thickness buttons of the aortic wall with the coronary ostia and the graft. One or more associated cardiovascular procedures were performed in 24 cases. Long term follow up to July 1995 is complete. Uni- and multivariate analysis were performed to identify risk-factors for early and late mortality and reoperation.

Results: Twenty-three patients died during the first 30 days (18%). Sixteen of them had aortic dissection. The most common cause of early death was heart failure. Twenty-three patients died during the follow up time with heart failure, again, being the most common cause of death. Thirteen late reoperations on the composite-graft or the remaining aorta were performed in 12 patients, six of whom had Marfan's syndrome. The 30-day mortality at reoperation was 30%.

Conclusions: This surgical option offers good long term results with a five-year actuarial survival of 67% or 75% when the 30-day mortality is excluded. Careful follow up of patients with Marfan's syndrome and/or aortic dissection is mandatory to increase the long term survival.

How to cite: Lepore, V., Larsson, S., Bugge, M., Mantovani, V., & Karlsson, T. (1996). Replacement of the ascending aorta with composite valve grafts: long term results. The Journal of heart valve disease, 5(3), 240–246.

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How to cite: David T. E. (1996). Surgery for aortic root aneurysm with aortic insufficiency. The Journal of heart valve disease, 5(3), 238–239.