Background and aims of the study: The ATS Medical valve was first implanted in 1992. The purpose of this report was to establish the normal range of each hemodynamic parameter, measured by Doppler echocardiography, in small aortic ATS Medical valves.

Methods: Twenty-five patients with small aortic ATS Medical valves, operated on over six months, and with no cardiac or prosthetic dysfunction, in sinus rhythm, on adequate oral anticoagulant therapy, and no other valve prosthesis or significant valvulopathy, were reviewed on the basis of physical examination and transthoracic Doppler echocardiography.

Results: For the aortic 21 Standard ATS Medical valve (n = 10), the following values were registered: peak velocity 2.40 +/- 0.39 m/s; peak gradient 23.7 +/- 6.8 mmHg; mean gradient 12.6 +/- 4.0 mmHg; valve effective orifice area 1.73 +/- 0.41 cm2; Doppler velocity index 0.47 +/- 0.11. For the aortic 19 Standard ATS Medical valve (n = 9), these values were: 3.41 +/- 0.43 m/s; 47.0 +/- 12.6 mmHg; 26.2 +/- 7.9 mmHg; 0.96 +/- 0.18 cm2; and 0.32 +/- 0.06, respectively. For the aortic 16 AP ATS Medical valve (n = 6), these parameters were 3.44 +/- 0.47 m/s; 47.7 +/- 12.0 mmHg; 27.0 +/- 7.3 mmHg; 0.61 +/- 0.09 cm2; and 0.30 +/- 0.04, respectively.

Conclusions: Using Doppler echocardiography, the present study establishes the normal range of parameters which define the hemodynamic performance of the aortic 21 and 19 Standard and 16 AP ATS Medical valves, and demonstrates satisfactory hemodynamic performance of the aortic 21 and 19 Standard ATS Medical valves. It should be noted that the valve effective orifice area determined for the aortic 16 AP ATS Medical valve was smaller than that for the aortic 19 Standard ATS Medical valve, though these two prostheses have the same physical orifice area.

How to cite: Kirzner, C. F., Vinals, B., Moya, J., Puente, J. G., Rabago, R., Artiz, V., Martinelli, J., & Fraile-Chief, J. (1997). Hemodynamic performance evaluation of small aortic ATS Medical valves by Doppler echocardiography. The Journal of heart valve disease, 6(6), 661–665.

Background and aims of the study: Aortic valve surgery in patients with a narrow aortic root remains a clinical problem. The Extended Biocor Stentless porcine bioprosthesis was specifically designed to allow widening of the aortic annulus in patients with narrow aortic roots. The aim of this prospective study was to evaluate the hemodynamic performance of this prosthesis.

Methods: Serial Doppler echocardiography was used in 50 patients (mean age 77 years, range: 60 to 87 years) during a 15-month follow up after aortic valve replacement. Valve hemodynamics were also assessed in 30 patients at 15 months after surgery, during increased flow rates induced by a supine bicycle exercise test.

Results: Of these patients, 60% received valves sized 23 mm or smaller. The mean pressure difference before hospital discharge was 13.8 +/- 5.8 mmHg and this decreased by 40% during the first six months. During the same period there was a significant increase in effective orifice area and a decrease in left ventricular mass. Symptom-limited supine exercise increased cardiac output by 65% while the mean pressure difference increased only slightly (from 8.1 +/- 3.2 to 11.9 +/- 3.6 mmHg). Trivial aortic regurgitation (grade 1+) was detected in 12% of patients at 15 months follow up. All patients who were in NYHA functional class III or IV before surgery were in class I or II after surgery.

Conclusions: We conclude that the Extended Biocor Stentless prosthesis shows low Doppler-derived transvalvular pressure gradients both at rest and during exercise, and also when small-sized valves are employed. Doppler echocardiography, showing low incidence of aortic regurgitation and early regression of left ventricular hypertrophy, demonstrate the beneficial hemodynamic performance of this valve.

How to cite: Eriksson, M. J., Brodin, L. A., Dellgren, G. N., & Rådegran, K. (1997). Rest and exercise hemodynamics of an extended stentless aortic bioprosthesis. The Journal of heart valve disease, 6(6), 653–660.

A 70-year-old woman who had fatiguability due to right heart failure seven years after receiving blunt chest trauma in a road traffic accident presented to our hospital. Preoperative echocardiography revealed severe tricuspid regurgitation resulting from prolapse of the anterior leaflet. The valve was repaired by chordal replacement with expanded polytetrafluoroethylene sutures and DeVega annuloplasty. At three months after surgery, the patient is in good clinical condition, and repeat echocardiography revealed only mild tricuspid regurgitation.

How to cite: Sugita, T., Watarida, S., Katsuyama, K., Nakajima, Y., Yamamoto, R., & Mori, A. (1997). Valve repair with chordal replacement for traumatic tricuspid regurgitation. The Journal of heart valve disease, 6(6), 651–652.

There is general agreement that left-sided elastomas must be removed to avoid systemic complications. Right-sided localization is less risky and surgical treatment is not agreed upon. We report a case of surgical resected fibroelastoma of the tricuspid valve and discuss the indications to surgery by reviewing the literature on the few reported cases. We feel that, if surgery is timely, the tumor can be resected, thus preserving the native valve. This provides an opportunity to prevent possible right-sided complications due to increasing tumor size and embolization.

How to cite: Scalia, D., Basso, C., Rizzoli, G., Lupia, M., Budano, S., Thiene, G., & Venturini, A. (1997). Should right-sided fibroelastomas be operated upon?. The Journal of heart valve disease, 6(6), 647–650.

A very unusual case of traumatic tricuspid regurgitation is reported, with severe symptoms of right ventricular failure, extreme dilatation of the right heart, echocardiographic and angiographic criteria of major tricuspid regurgitation, and severe right ventricular systolic dysfunction. The patient was referred for heart transplantation, on the assumption that conventional surgery was not possible. After careful evaluation, as the patient had normal pulmonary artery pressure and resistance, a tricuspid valve was replaced with good surgical outcome.

How to cite: Almeida, M., Canada, M., Neves, J., Gouveia, R., Rebocho, M. J., Melo, J., & Seabra-Gomes, R. (1997). Longstanding traumatic tricuspid regurgitation with severe right ventricular failure. The Journal of heart valve disease, 6(6), 642–646.

Background and aims of the study: Tricuspid valve endocarditis traditionally has been treated with either valve resection or valve replacement. To avoid implantation of foreign material in an infected area and to circumvent anticoagulation, tricuspid valve repair was applied and the results assessed.

Methods: Tricuspid valve repair was performed in five patients with right-sided endocarditis. All patients had tricuspid regurgitation grade 3-4 on preoperative transesophageal echocardiography, and developed progressive deterioration associated with heart failure. The indications for surgery were congestive heart failure, persistent sepsis, recurrent emboli, concomitant left-sided endocarditis, and fungal infection. Surgical procedures included cusp resection, annular plication and annuloplasty, pericardial patch replacement, and construction of artificial chordae.

Results: There were no hospital deaths and major associated morbidity. Follow up is complete at a mean of 20.4 months. There were no reoperations or cases of recurrent infections. All patients are in NYHA class I-II. Postoperative echocardiography revealed no signs of major valvular dysfunction.

Conclusions: Valve repair in right-sided endocarditis is a relatively new application for repair techniques, but may become an attractive alternative to tricuspid valve excision or prosthetic valve replacement.

How to cite: Sons, H., Dausch, W., & Kuh, J. H. (1997). Tricuspid valve repair in right-sided endocarditis. The Journal of heart valve disease, 6(6), 636–641.

Background and aims of the study: Surgical treatment of functional tricuspid regurgitation associated with advanced valvular disease remains controversial, mainly due to the difficulty in choosing between valve replacement or reconstructive surgery. Failure to correct tricuspid regurgitation during valvular surgery carries a poor prognosis, as reoperation may represent a significant risk to the patient. Thus correct tricuspid valve surgery is vital to achieve improved early and long-term clinical results.

Methods: A total of 142 patients underwent concomitant tricuspid annuloplasty with mitral valve replacement and their clinical outcome was assessed.

Results: Overall hospital mortality rate was 11.3%. Seven patients died during follow up. The overall actuarial survival rate for 10 years was 74.1 +/- 14.2%. Postoperatively, 75.8% of the patients had no residual tricuspid insufficiency, while 24.2% had first- or second-degree tricuspid insufficiency and were treated medically. All patients were in NHYA functional class I or II postoperatively.

Conclusion: Clinically, it is important to assess the severity of functional tricuspid insufficiency before and/or during the operation. Bicuspidalization annuloplasty for functional tricuspid insufficiency has provided good results, with a low incidence of reoperation and significant clinical improvement. The technique could be used in most patients with functional tricuspid regurgitation.

How to cite: Katircioglu, S. F., Yamak, B., Ulus, A. T., Ozsöyler, I., Yildiz, U., Mavitas, B., Birincioglu, L., & Tasdemir, O. (1997). Treatment of functional tricuspid regurgitation by bicuspidalization annuloplasty during mitral valve surgery. The Journal of heart valve disease, 6(6), 631–635.

Background and aims of the study: Carcinoid syndrome originates from carcinoid tumors localized in the gastrointestinal system, pancreas, biliary vessels, bronchi, ovaries and testes. The condition is characterized by flushing, telangiectasias, diarrhea, bronchoconstriction and cardiac involvement, while cardiac lesions may occur in 50% of patients. This study aimed to investigate-non-invasively-the frequency, severity and evolution of carcinoid heart involvement.

Methods and results: Among 87 patients with carcinoid syndrome undergoing routine echocardiography, 39 (45%) had cardiac involvement; 36 of these had thickened, shortened, immobile tricuspid leaflets. Tricuspid regurgitation was present in all 36, it was moderate or severe in 22. Pressure half-time rose to 117 +/- 35 ms, implying mild tricuspid stenosis. The pulmonary valve was also thickened, retracted and immobile with stenotic appearance in 19 patients; regurgitation was present in 16, and mild in 11. Nine patients had pericardial effusion. Of 39 patients with cardiac lesions, 18 had at least one follow up study within 16 +/- 7 months; in 15 cases the valve lesions deteriorated. Tricuspid regurgitation became more severe in six and pressure half-time rose from 107 +/- 46 to 132 +/- 50 ms. Pulmonary regurgitation deteriorated in two, while three patients had new pulmonary valve involvement. The peak gradient across the pulmonary valve increased from 18 +/- 7 to 25 +/- 9 mmHg. Twenty-two patients without heart involvement in the first examination had a follow up study (19 +/- 5 months) during which seven developed valvular lesions, with four moderate and three mild tricuspid regurgitation; mild stenosis was present in all cases. Two patients with mild tricuspid regurgitation had mild mixed pulmonary valve involvement, while of those with moderate tricuspid regurgitation, one also had moderate pulmonary stenosis with mild regurgitation. Five patients with both tricuspid and pulmonary valve diseases had interventional treatment: three underwent balloon valvuloplasty on both valves simultaneously due to stenotic lesions but later relapsed; the other two underwent double valve replacement with biological prostheses but in both cases the pulmonary valve developed severe destruction leading to one death. The other four patients survived for 36, 41, 25 and 16 months, respectively.

Conclusions: Right valvular heart disease occurs frequently in patients with carcinoid syndrome. Evolution of lesions is rapid, leading to right heart failure, though death usually occurs from progressive systemic disease and rarely from pulmonary stenosis. Surgery is the most effective treatment and balloon valvulotomy is only palliative. However, therapy of the systemic condition is predominantly the treatment of choice.

How to cite: Moyssakis, I. E., Rallidis, L. S., Guida, G. F., & Nihoyannopoulos, P. I. (1997). Incidence and evolution of carcinoid syndrome in the heart. The Journal of heart valve disease, 6(6), 625–630.

We report a rare case of occult myocardial abscess due to group B Streptococcus that arose several weeks following streptococcal pneumonia. Hemopericardium was the initial presentation. Visualization of the abscess cavity was not possible with transthoracic echocardiography. A definitive diagnosis was made by left ventricular imaging during coronary arteriography. Rupture of the left ventricular free wall occurred during induction of anesthesia for operative exploration and debridement. Patch repair of the left ventricle was ultimately unsuccessful. Post-mortem examination revealed staphylococcal endocarditis of the mitral valve, valve ring abscess and multiple abscess cavities of the left ventricular free wall. A review of the clinical, diagnostic and therapeutic aspects of myocardial abscess is also presented.

How to cite: Terry, S. M., & Ryan, P. E., Jr (1997). Penetrating mitral valve annular abscess. The Journal of heart valve disease, 6(6), 621–624.

Background and aims of the study: Most studies on mitral regurgitation have focused on evaluating the regurgitant volume. The effects of mitral regurgitation and its associated cardiac workload on left ventricular function and mechanics may be equally important both in assessing the impact of regurgitation as well as in planning and evaluating therapy. The present study was undertaken to investigate the interrelationships of the regurgitant volume, hemodynamics and left ventricular work in an experimental animal model of chronic mitral regurgitation in which the regurgitant volume could be measured directly with electromagnetic flow probes.

Methods: A total of 21 hemodynamic states were studied in six sheep with surgically created mitral regurgitation. Regurgitant flow rates were obtained from electromagnetic flow meters. Left ventricular and atrial pressures were recorded using high-fidelity catheters. Regurgitant jet velocity was recorded by continuous wave Doppler. Left ventricular stroke work and energy losses due to the regurgitation were calculated.

Results: There was a close correlation between left ventricular stroke work and both jet energy and left atrial systolic pressure rise (r = 0.81, p = 0.0001 and r = 0.92, p = 0.0001, respectively). A moderate correlation to the regurgitant volume was found (r = 0.52, p = 0.01).

Conclusions: The regurgitant volume itself is only one of the determinants of left ventricular stroke work in mitral regurgitation. Other factors such as left atrial mechanical properties and the regurgitant kinetic jet energy are at least as important for assessing cardiac work in patients with mitral regurgitation.

How to cite: Teien, D. E., Jones, M., Shiota, T., Yamada, I., Frithiof, D., & Sahn, D. J. (1997). Left ventricular stroke work in mitral regurgitation: an animal experimental study. The Journal of heart valve disease, 6(6), 613–620.

Background and aims of the study: Patients with chronic mitral regurgitation (MR) are often referred for surgery only after irreversible left ventricular (LV) dysfunction has developed. Our aim was to determine whether plasma brain natriuretic peptide (BNP) concentrations could serve as a marker for early LV dysfunction in this condition.

Methods: Twenty-two patients with isolated chronic MR and echocardiographic evidence of at least moderate regurgitation were studied.

Results: Plasma BNP concentrations were significantly higher in patients than in normal volunteers (20.85 +/- 16.9 versus 3.37 +/- 0.9 pmol/l; p = 0.007). Concentrations increased with increasing severity of symptoms and were highest in those in NYHA class IV, but did not correlate with LV dimensions, fractional shortening or left atrial size. Of note, two asymptomatic patients with high BNP concentrations were referred for surgery within the 12-month follow up period due to symptom progression.

Conclusions: Plasma BNP concentrations are elevated in most patients with isolated chronic MR, including those who are asymptomatic with normal LV dimensions. The significance of these findings is uncertain, but they suggest that changes in ventricular physiology occur early in the disease process and before they can be detected echocardiographically. Longitudinal studies are required to determine if patients with high BNP levels have an adverse prognosis and if this can be altered by earlier surgical intervention.

How to cite: Brookes, C. I., Kemp, M. W., Hooper, J., Oldershaw, P. J., & Moat, N. E. (1997). Plasma brain natriuretic peptide concentrations in patients with chronic mitral regurgitation. The Journal of heart valve disease, 6(6), 608–612.

Background and aims of the study: The Carpentier-Edwards (CE) ring was developed to restore the normal 3:4 ratio between the anteroposterior and transverse diameters of the mitral valve orifice during systole. It is difficult to use in patients in whom the ratio is more than 3:4. To overcome this problem, we developed an adjustable obturator, the ratio of which may be changed by sliding apart its two components.

Methods: Remodeling annuloplasty was performed using part of a flexible Duran ring or autologous pericardium and the adjustable obturator in 17 patients with severe MR, including two with high anterior leaflet.

Results: Physiologic remodeling annuloplasty was easily accomplished in all cases. Intraoperative echocardiography was performed in 14 patients, and it showed no regurgitant jet in 11 cases and only trivial jet in three.

Conclusion: Physiologic remodeling annuloplasty to retain the natural shape of the anterior leaflet by using an adjustable obturator is a very useful technique that enables annuloplasty to be performed in all cases, irrespective of the shape of the anterior leaflet.

How to cite: Kasegawa, H., Kamata, S., Ida, T., Kawase, M., Fujimoto, T., & Umezu, M. (1997). Physiologic remodeling annuloplasty to retain the shape of the anterior leaflet: a new concept in mitral valve repair. The Journal of heart valve disease, 6(6), 604–607.

Background and aims of the study: Juvenile rheumatic mitral stenosis (MS) with severe pulmonary venous and arterial hypertension (PAH) is a relatively common occurrence in developing countries. The study objectives were to evaluate the safety, efficacy and follow up of Inoue balloon mitral valvotomy (IBMV) in juveniles with rheumatic MS.

Methods: A total of 193 patients with juvenile rheumatic MS were analyzed and compared with adults, with specific reference to the effect of IBMV on hemodynamics and pulmonary vasculature in patients with severe PAH.

Results: Mitral valve areas were smaller (0.76 +/- 0.22 versus 0.81 +/- 0.22 cm2), while mean pulmonary arterial pressure (MPAP) (44.5 +/- 16.5 versus 38.4 +/- 15.1 mmHg) and pulmonary vascular resistance (PVR) (5.5 +/- 4.6 versus 4.41 +/- 4.04 Wood units) were greater in juvenile patients when compared with adults. There was a 99% procedural success. Juvenile patients showed an overall greater fall in MPAP and PVR when compared with adults. The incidence of severe PAH was much higher (32%) among juveniles than adults (16%). Only 5% of patients with juvenile MS with severe PAH had residual severe PAH immediately after IBMV, compared with 17% in older patients. Hemodynamic benefits (echocardiographic mean transvalvular gradient and mitral valve area) were sustained at a mean follow up of 29 months, and there was no documented case of restenosis after successful IBMV.

Conclusions: We conclude that IBMV is safe and effective in juvenile rheumatic MS and provides greater hemodynamic benefit compared with adults; such benefit is sustained during a mean follow up of 29 months.

How to cite: Sinha, N., Kapoor, A., Kumar, A. S., Shahi, M., Radhakrishnan, S., Shrivastava, S., & Goel, P. K. (1997). Immediate and follow up results of Inoue balloon mitral valvotomy in juvenile rheumatic mitral stenosis. The Journal of heart valve disease, 6(6), 599–603.

Background and aims of the study: In terms of valve-related complication and ventricular function, mitral valve repair (MVR) is superior to valve replacement. To date, chordae shortening and transposition have been used for diffuse prolapses. We have used artificial chordae implantation for MVR since 1986, and here review our long-term results.

Methods: Pericardial strips were used in nine patients, and e-PTFE (Gore-Tex) sutures in 58. A degenerative lesion was present in 69% of cases, endocarditis in 16% and rheumatic valvulitis in 7%. Implantation of artificial chordae was indicated for treatment of diffuse prolapse. Annuloplasty was performed in patients with or without prosthetic ring.

Results: Actuarial survival rate was 78% for the pericardial chordae group at nine years, and 94% for the Gore-Tex chordae group at eight years. Thromboembolic events occurred in two pericardial chordae patients, and three Gore-Tex chordae patients required reoperation. Freedom from reoperation was 100% for pericardial chordae after nine years and 96% for Gore-Tex chordae after eight years. Quality of life among survivors is good: 83% are in NYHA class I, 89% are free from anticoagulation, and 60% require no medication. Mitral valve orifice area, estimated echocardiographically, was similar in both groups at discharge and at follow up.

Conclusions: MVR with artificial chordae provided satisfactory valve function for up to nine years. Gore-Tex chordae are less prone to deterioration than pericardial chordae. Follow up observations support the use e-PTFE chordae to correct diffuse leaflet prolapse.

How to cite: Eishi, K., Kawazoe, K., Nakano, K., Kosakai, Y., Sasako, Y., & Kobayashi, J. (1997). Long-term results of artificial chordae implantation in patients with mitral valve prolapse. The Journal of heart valve disease, 6(6), 594–598.

Between January 1988 and June 1996, a total of 531 patients underwent reconstruction of the mitral valve for mitral regurgitation (MR) with or without mitral stenosis (MS). Of these patients, 423 (79.7%) were aged under 30 years. The cause of mitral regurgitation was rheumatic in 471 patients (88.7%). Combined lesion (MR + MS) was present in 296 cases (55.7%). Operative mortality rate was 5.1% (27 patients) and there were 11 late deaths. Ten patients have been reoperated on for residual MR. All surviving patients were followed up by physical examination and echocardiography; follow up was 93% complete. The actuarial survival rate at 84 months was 93.1% and event-free survival rate was 87.3%. We conclude that mitral valve repair in the young rheumatic population is feasible, the probability of reoperation is low, and the symptomatic relief is gratifying.

How to cite: Kumar, A. S., Rao, P. N., & Saxena, A. (1997). Mitral valve reconstruction: eight years' experience in 531 patients. The Journal of heart valve disease, 6(6), 591–593.

We report a case of meralgia paresthetica, a rare neurological complication, following aortic valvuloplasty. Although this complication was previously described after coronary artery bypass surgery, we believe this is the first case described after a valve procedure and hypothesize on its etiology.

How to cite: Antunes, P. E., & Antunes, M. J. (1997). Meralgia paresthetica after aortic valve surgery. The Journal of heart valve disease, 6(6), 589–590.

A case of early autograft endocarditis occurring three weeks after a Ross operation is described. The origin of the infection appeared to be the proximal suture line of the autograft and the pathology included subvalvular destruction of the autograft, a pseudoaneurysm between the autograft and the left atrium, and a fistula to and a vegetation in the roof of the left atrium. The valve cusps were unaffected and there was only slight autograft insufficiency (grade I-II). The autograft was removed and successfully replaced with a homograft.

How to cite: Tingleff, J., Lindblom, D., Brolin, A., Joyce, F., & Pettersson, G. (1997). Early autograft endocarditis after Ross operation: a case history. The Journal of heart valve disease, 6(6), 587–588.

Background and aims of the study: The aortic regurgitant jet is frequently eccentric, and Doppler color flow mapping techniques of the distal jet is influenced by this eccentricity. The aim of the present study was to determine whether the effective regurgitant orifice area (EROA), determined by the proximal isovelocity surface area (PISA) method using multiplane transesophageal echocardiography (m-TEE), could be used to evaluate the severity of aortic regurgitation (AR) in patients with an eccentric jet.

Methods: Forty-eight patients with eccentric AR were studied. Values of EROA determined by the PISA method were compared with results from cross-sectional area (CSA), vena contracta (VC) width, aortic angiography, and regurgitant fraction.

Results: Values of EROA correlated well with results from CSA (r = 0.73, p < 0.001), VC (r = 0.74, p < 0.001), angiographic grade (rs = 0.90 p < 0.001), and regurgitant fraction (r = 0.84, p < 0.001) in patients with eccentric aortic regurgitation. Values of EROA > 0.27 cm2 were always associated with a regurgitant fraction > 0.4, while EROA values < 0.27 cm2 were always associated with a regurgitant fraction < 0.4.

Conclusions: We conclude that, in patients with an eccentric jet, measurement of EROA values by the PISA method using m-TEE is a reliable method of assessing the severity of AR.

How to site: Sato, Y., Kawazoe, K., Kamata, J., Izumoto, H., Kitahara, H., Tasai, K., Eishi, K., Nakai, K., Nasu, M., & Hiramori, K. (1997). Clinical usefulness of the effective regurgitant orifice area determined by transesophageal echocardiography in patients with eccentric aortic regurgitation. The Journal of heart valve disease, 6(6), 580–586.

Aortic valve replacement in patients with aortic stenosis or aortic regurgitation who have severe left ventricular (LV) systolic dysfunction continues to be associated with a high mortality risk despite surgical, cardiological and anesthetic improvements over time. As a result of earlier surgical referral, however, fewer patients with aortic regurgitation (AR) and advanced LV failure present for operation today. Favorable operative and long-term results, and data demonstrating recovery of LV systolic function if patients are referred prior to the onset of systolic dysfunction have largely solved this problem in the context of AR. On the other hand, patients with critical aortic stenosis (AS) and severe LV systolic dysfunction constitute a more heterogeneous and even more challenging group. On one side of the continuum, patients with truly critical AS and low ejection fraction due to LV 'afterload mismatch' (depressed ejection performance resulting from excessively high systolic LV wall stress secondary to a very tight valve) generally respond well to aortic valve replacement, which immediately normalizes LV afterload. Conversely, patients with 'critical' aortic stenosis and advanced LV systolic dysfunction who present with a low transvalvular gradient and cardiac output constitute a subgroup at high operative risk, which also has a suboptimal prognosis after aortic valve replacement. This clinical situation has been termed the 'Gorlin Conundrum', and is punctuated by a low mean transvalvular gradient and low flow. The reason for the low transvalvular gradient is not always known, but can be secondary to some type of coexistent cardiomyopathy. Patients with only mild pathologic aortic valve sclerosis/stenosis and markedly depressed LV systolic function are frequently judged to have 'critical' aortic stenosis (AVA < 0.8 cm2 or AVAI < 0.4 cm2/m2) due to inherent flaws in the Gorlin equation and limitations of the Doppler continuity equation. Although alternative diagnostic techniques have been proposed, e.g. aortic valve resistance, stroke work loss, none has yet proven to be totally reliable. The suboptimal results of aortic valve replacement in low-gradient AS patients underscore our difficulty in currently predicting which patients will benefit from valve replacement. Newer diagnostic techniques, including dobutamine echocardiography, and novel new findings regarding the basic molecular mechanisms responsible for contractile dysfunction in pressure overload hypertrophy may ultimately improve the results of surgical treatment in these patients.

How to cite: Green, G. R., & Miller, D. C. (1997). Continuing dilemmas concerning aortic valve replacement in patients with advanced left ventricular systolic dysfunction. The Journal of heart valve disease, 6(6), 562–579.