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How to cite: Bokros J. (1997). The On-X. The Journal of heart valve disease, 6(1), 101.

Background and aims of the study: In vitro evaluation and animal testing are fundamental steps in the assessment of prosthetic heart valves before their use in clinical practice. Valve testing under pulsatile conditions is the best in vitro simulation of cardiac valve function, and the ensuing results should support the surgeon's decision concerning the time of valve replacement. However, limits in hydraulic reproduction of cardiac function and differences in protocol implementation of in vitro testing lead to difficulties in obtaining reliable and comparable results. Debate among researchers and standardizing bodies about discrepancies in results becomes critical in light of the European CE certification of implantable medical devices. An interlaboratory environment has been created at the Biomedical Engineering unit of the Istituto Superiore di Sanita in Rome, which uses differing test apparatus to evaluate prosthetic heart valves in vitro, in order to define significant measurement parameters and procedures that produce comparative data.

Methods: Two prosthetic valves-a tilting disc and a bileaflet valve-each sized 29 mm, were tested in the aortic position on two different pulse duplicators (PDs), namely the Dynatek MP1 and a system developed at the University of Sheffield. The common protocol adopted was the FDA Interlaboratory Comparison Testing Protocol. Original software was used to manage all test phases, thus minimizing operator-dependent variability in both systems and imposing strict control of experimental conditions. Statistical analysis performed on the data followed two approaches: (i) separate fitting of the two regression equations of pressure drop-flow rate relationship obtained for each valve on both PDs, and (ii) application of a multiple regression model, to fit a single regression equation of pressure drop-flow rate relationship, using data obtained from both PDs for each valve. In addition, an additional independent (dummy) variable was introduced.

Results and conclusions: Using this approach, the valve parameter range was obtained and, by imposing strict control of the experimental set-up, the coincidence of the two valve power laws, estimated by each of the two PDs, was studied.

How to cite: Barbaro, V., Grigioni, M., Daniele, C., & Boccanera, G. (1997). A statistical approach to the quantitative comparison of pulsatile flow in vitro data of prosthetic heart valve testing. The Journal of heart valve disease, 6(1), 93–100.

Background and aims of the study: While the hemostatic effect of aprotinin for patients undergoing reoperative coronary bypass is well established, it remains unclear whether these effects extend to patients undergoing reoperative valvular surgery.

Methods: We examined our experience with 85 consecutive patients undergoing isolated reoperative valvular surgery with and without use of perioperative aprotinin in order to investigate differences in perioperative blood use, blood loss, bleeding complications, mortality and incidence of myocardial injury.

Results: Aprotinin recipients benefited from a significant reduction in bleeding complications, and a decrease in perioperative and in-hospital mortalities as compared with untreated patients. Anaphylactic reactions and clinically significant thromboembolic events were not observed. There was no difference in the incidence of renal dysfunction or myocardial injury among aprotinin-treated and untreated groups.

Conclusions: Our results indicate that aprotinin therapy can be safely administered to patients undergoing reoperative valvular surgery. No increased incidence of anaphylactic reactions, renal dysfunction or perioperative myocardial injury was noted. The observed reductions in bleeding complications and perioperative and in-hospital mortality strongly warrant the evaluation of aprotinin for reoperative valvular surgery in a prospective fashion.

How to cite: Goldstein, D. J., DeRosa, C. M., Seldomridge, J. A., Weinberg, A. D., Oz, M. C., & Smith, C. R. (1997). Is aprotinin indicated for reoperative valvular surgery?. The Journal of heart valve disease, 6(1), 88–92.

Reoperation after a surgical procedure for prosthetic valve endocarditis (PVE) is often required due to the existence of either septic recurrence or sterile para-prosthetic leak (PL). The aim of this study was to assess the risk to patients of undergoing a second operation after PVE. Thirty-six patients underwent operation for active PVE at our institution. The operative mortality rate was 11.2%. Among the 32 patients discharged, six underwent a second operation (in two cases due to persisting sepsis) and two underwent a third procedure. Multivariate analysis demonstrated increased probability of further operation for: inability to identify the infecting organism (p = 0.005); drug addiction (p = 0.007); existence of annular abscess (p = 0.016); and early occurrence of PVE (p = 0.018). In the case of mechanical prostheses, PVE was not an independent risk factor (p = 0.206). Nonetheless, 58.3% of patients with mechanical prostheses compared with 5.3% of those with bioprostheses showed annular abscesses, while 41.7% of the former versus 5.6% of the latter suffered one or more recurrences.

How to cite: Pansini, S., di Summa, M., Patane, F., Forsennati, P. G., Serra, M., & Del Ponte, S. (1997). Risk of recurrence after reoperation for prosthetic valve endocarditis. The Journal of heart valve disease, 6(1), 84–87.

Background and aims of the study: The optimal aortic valve substitute in cases of active native valve endocarditis (NVE) remains controversial. This report summarizes our experience with the surgical treatment of active aortic NVE using only mechanical prostheses.

Methods: Between January 1988 and January 1996, 20 patients underwent aortic valve replacement for active NVE. There were 17 men and three women. Mean age was 46.5 years (range eight to 63 years). Thirteen patients were in NYHA class IV and seven in class V. Streptococci were isolated in eight cases, while no causative micro-organism could be identified in seven patients. All operations were performed on urgent (n = 13) or emergency (n = 7) bases. A mechanical valve was implanted in all cases and radical resection of the infected tissues performed using different techniques. All patients were followed up at our institution. Two-dimensional color Doppler studies were performed one month after surgery and at six-month intervals after the first year. Transesophageal echocardiography (TEE) was performed at discharge, six months after surgery and yearly thereafter.

Results: No patient died in hospital. Mean follow up was 30.5 months, during which time three patients died, though none from endocarditis-related causes. Endocarditis recurred only one (5%). TEE demonstrated a normally functioning aortic prosthesis in 15 cases and trivial paravalvular leakage in two.

Conclusions: Mechanical prostheses represent a safe aortic valve substitute in cases of acute native valve endocarditis. When radical resection of all the infected areas is performed, the incidence of endocarditis recurrence is acceptable. The concept that homografts are the valve substitute of choice in endocarditis cases cannot be supported by this study.

How to cite: Gaudino, M., De Filippo, C., Pennestri, F., & Possati, G. (1997). The use of mechanical prostheses in native aortic valve endocarditis. The Journal of heart valve disease, 6(1), 79–83.

We report the case of a 65-year-old woman with rheumatoid arthritis who was admitted with a stroke. Echocardiographic examination revealed a multilobule, highly mobile tumor on the posterior leaflet of the mitral valve. Surgical exploration showed a tumor infiltrating the valve, the annulus, and the adjacent left ventricular wall, which required complete valve resection. Histologic study demonstrated typical characteristics of a rheumatoid nodule.

How to cite: Mounet, F. S., Soula, P., Concina, P., & Cerene, A. (1997). A rare case of embolizing cardiac tumor: rheumatoid nodule of the mitral valve. The Journal of heart valve disease, 6(1), 77–78.

We report the case of a 51-year-old woman who underwent percutaneous mitral valvotomy using single balloon technique for restenosis after a previous surgical closed commissurotomy. After the procedure, she presented with severe mitral regurgitation and was referred to our center for mitral valve replacement. At surgery, the underlying cause of the mitral regurgitation was shown to be a tear at the commissural site which extended into the annulus. The mitral valve was successfully replaced and the post-operative course was uneventful. One year later the patient is in good clinical condition.

How to cite: Ressia, L., Depieri, G., Grande, A. M., & Vigano, M. (1997). Rupture of mitral valve annulus after mitral balloon valvotomy: a case report. The Journal of heart valve disease, 6(1), 74–76.

In this report, we discuss the feasibility of percutaneous mitral valvulotomy in the presence of mitral stenosis and concomitant atrial septal aneurysm. Our data suggest that percutaneous mitral valvulotomy can be safely performed if the atrial septal aneurysm does not involve the entire interatrial septum.

How to cite: Sarikamis, C., Bozat, T., & Koca, V. (1997). Percutaneous mitral valvulotomy in the presence of atrial septal aneurysm. The Journal of heart valve disease, 6(1), 71–73.

Hemolytic anemia is a well-recognized complication of mechanical heart valve prosthesis but, as yet, has not been reported after mitral valve repair with chordal replacement. We report a case of severe hemolytic anemia after mitral valve repair with chordal replacement and Carpentier-Edwards annuloplasty ring insertion. Progressive prolapse of the anterior leaflet due to the artificial chordae being too long caused recurrent regurgitation which was responsible for the hemolysis. The patient also had idiopathic thrombocytopenic purpura, but successful second mitral valve repair was performed after high-dose gamma-globulin therapy.

How to cite: Kihara, S., Kasegawa, H., Kobayashi, N., Saiki, Y., Abe, H., Mannouji, E., Ida, T., & Kawase, M. (1997). Severe hemolysis due to artificial chordae displacement. The Journal of heart valve disease, 6(1), 69–70.

A case of mitral regurgitation (MR) caused by mitral paraannular cyst is reported. A 37-year-old woman on maintenance hemodialysis was admitted to Akita University Hospital because of congestive heart failure. Echocardiography revealed mitral paraannular cyst, which caused coaptation failure of the mitral leaflets and significant MR. She underwent decapsulation of the cyst followed by mitral valve replacement. Postoperative echocardiography showed no recurrence of the cyst three years after surgery. Although mitral annular calcification has been described as a cause of MR in patients with uremia, a report of a solitary intracardiac cyst which causes significant MR is quite rare.

How to cite: Sekine, S., Abe, T., Kuribayashi, R., Aida, H., Seki, K., & Shibata, Y. (1997). Mitral regurgitation caused by mitral paraannular cyst. The Journal of heart valve disease, 6(1), 67–68.

A case of parachute mitral valve (PMV) associated with multiple muscular ventricular septal defects (VSDs) is reported in a 16-year-old girl who presented with dyspnea and a cardiac murmur. In addition, there were deformities of the right ear lobe and kyphoscoliosis of the thoracolumbar spine since birth. A preoperative diagnosis was made using two-dimensional and Doppler echocardiography, cardiac catheterization and angiocardiography. PMV was found to be stenotic and mildly regurgitant. At surgery, mitral valvuloplasty, preservation of the native valve apparatus and Dacron patch closure of multiple muscular VSDs was achieved. The latest available case reports in the literature pertaining to PMV and associated deformities have been reviewed.

How to cite: Suri, R. K., Jha, N. K., & Sarwal, V. (1997). Repair of parachute mitral valve with multiple ventricular septal defects: a case report and literature review. The Journal of heart valve disease, 6(1), 63–66.

The mechanism of obstruction of the left ventricular outflow tract (LVOT) in hypertrophic obstructive cardiomyopathy (HOCM) is mainly due to dynamic systolic anterior motion (SAM) of the mitral valve. We report a case of HOCM with mitral regurgitation (MR) associated with complicated abnormalities of the mitral apparatus which contributed to a high pressure gradient through the LVOT. A small, 53-year-old woman was admitted for chest pain and palpitation. Examinations revealed asymmetric septal hypertrophy of the left ventricle, MR, SAM of the mitral valve and a high pressure gradient (108 mmHg) through the LVOT. Operative findings revealed an abnormally hypertrophied interventricular septum, an extensively thickened and enlarged anterior mitral leaflet (AML), malposition of the origin of the anterior papillary muscle arising closer to the aortic annulus than normal, and its direct insertion into the AML without any distinguishable chordae tendineae. The hypertrophied septum and the large and protruding AML appeared to obstruct the LVOT, resulting in a loss of subaortic clearance that was recovered after mitral valve replacement and myectomy. Pathology of the papillary muscle was characteristic of HOCM, showing disorganization and disarray of myocardial fibers, bizarre-shaped nuclei, and intercellular fibrosis, while those of the mitral leaflets negated both rheumatic changes and endocarditis.

How to cite: Ohkado, A., Kitamura, M., Hachida, M., Nishinaka, T., Hanayama, N., Sato, W., & Koyanagi, H. (1997). Hypertrophic obstructive cardiomyopathy with abnormalities of the mitral valve complex. The Journal of heart valve disease, 6(1), 60–62.

Background and aims of the study: Mitral valve prolapse due to floppy mitral valve (MVP/FMV) is a common valvular abnormality with a variable clinical course. Flail mitral valve leaflet resulting in severe mitral regurgitation is a complication of MVP/FMV.

Methods: In order to understand the structural correlates of flail mitral valve leaflet in MVP, we reviewed the morphologic characteristics of the mitral valve by transesophageal echocardiography (TEE) in 72 patients (24 normal; 26 mitral valve prolapse; 22 flail mitral valve leaflet).

Results: Compared with the normal group, the mitral valve prolapse group had greater anterior and posterior mitral valve leaflet thickness and anterior mitral valve leaflet length. Patients with flail mitral valve leaflets as a complication of FMV had greater anterior and posterior mitral valve leaflet length and posterior mitral valve leaflet thickness compared with MVP patients without flail mitral valve leaflets. Posterior mitral valve leaflet length was the only echocardiographic independent predictor of flail mitral valve leaflet. Older FMV patients with increased mitral valve leaflet length and thickness are predisposed to flail mitral valve leaflets and severe mitral regurgitation.

Conclusions: TEE may identify patients with MVP/FMV with the greatest structural abnormalities who are at risk for complications such as flail mitral valve leaflet(s).

How to cite: Malkowski, M. J., Guo, R., Orsinelli, D. A., Wooley, C. F., Tice, F. D., Pearson, A. C., & Boudoulas, H. (1997). The morphologic characteristics of flail mitral leaflets by transesophageal echocardiography. The Journal of heart valve disease, 6(1), 54–59.

Background and aims of the study: Mitral annuloplasty has long been considered as the basic procedure for mitral regurgitation (MR). However, it is increasingly advisable to avoid foreign material and to use a method that provides greater adjustment for control of annular size. In this study, the semicircular suture annuloplasty (Paneth-Burr method) was evaluated for its efficacy and durability; the optimum size of the mitral annulus was also assessed.

Methods: The Paneth-Burr method was modified using Gore-Tex suture, a crossing suture technique, and obturator for temporary annulus size adjustment. Between 1992 and 1994, 21 patients with an average age of 45 years (range: 8 months to 67 years) underwent such annuloplasty combined with various valvuloplasties and chordal reconstruction. The etiologies were degenerative in 11 patients, congenital in five, ischemic in three and endocarditis in two.

Results: Mean MR grades (0-4) decreased from 3.3 +/- 0.6 to 0.2 +/- 0.4 after surgery. At an average 24 months follow up (range: 12 to 41 months), 16 patients showed no increase in MR, but five showed increased MR grades (all grade 3 or less: three grade 3 and two grade 2). Only one patient with ischemic MR required reoperation. Patients with increased MR grade during follow up had a larger intraoperative annular size (> 90% of normal), while those with < 90% of normal mitral annular size showed no increase in MR beyond grade 2, except one with ischemic etiology.

Conclusions: A measured semicircular suture annuloplasty appears to be useful for MR, with acceptable efficacy and durability. In addition, the annular size to be adjusted at surgery is proposed to be < or = 90% of normal mitral annular diameter.

How to cite: Matsuda, H., Shintani, H., Taniguchi, K., Mitsuno, M., Miyamoto, Y., Kadoba, K., & Shimazaki, Y. (1997). Semicircular suture annuloplasty for mitral regurgitation: appraisal of the Paneth-Burr method. The Journal of heart valve disease, 6(1), 48–53.

Background and aims of the study: Three-dimensional (3D) echocardiography permits the objective analysis of structures and of pathologic conditions of complex geometry. Multiplane transesophageal echocardiography (TEE) permits 3D image sets of the heart to be produced from multiple 2D images by rotating the transducer, without changing its position. The purpose of this study was to clarify the capability of 3D echocardiography to evaluate the configuration and dynamics of the mitral annulus in patients fitted with an annuloplasty ring.

Methods: Twenty patients who underwent mitral valve repair for pure mitral regurgitation (10 with a flexible Duran ring and 10 with a rigid Carpentier ring) were studied. Using a multiplane transesophageal probe, sequential tomographic images were obtained by rotating the transducer at 2 degrees angular intervals around a 180 degrees arc. 3D reconstructions were performed to produce dynamic 3D images of the mitral annulus in a manner that simulated visualization from the left atrium. Mitral annular configuration was assessed from volume-rendered display and extractive 3D imaging. Mitral annular area change was evaluated from selected long-axis cut planes.

Results: The configuration and dynamics of the mitral annulus were visualized by 3D displays. In patients with a Duran ring, the mitral annulus had a non-planar configuration and mitral annular area changed during cardiac cycle (increased in diastole; reduced in atrial and ventricular systole; percentage reduction 25 +/- 2%). In patients with a Carpentier ring, the mitral annulus had a planar configuration and mitral annular area was effectively unchanged during the cardiac cycle.

Conclusions: 3D echocardiography using a multiplane transesophageal probe is useful in evaluating the configuration and dynamics of the mitral annulus in patients fitted with an annuloplasty ring.

How to cite: Yamaura, Y., Yoshida, K., Hozumi, T., Akasaka, T., Okada, Y., & Yoshikawa, J. (1997). Three-dimensional echocardiographic evaluation of configuration and dynamics of the mitral annulus in patients fitted with an annuloplasty ring. The Journal of heart valve disease, 6(1), 43–47.

Background and aims of the study: Although many studies have found that preservation of the continuity between the mitral annulus and the papillary muscles during mitral valve replacement improves postoperative left ventricular performance in patients with mitral regurgitation, much less research has been done in this respect in patients with mitral stenosis. We reviewed our experience with mitral valve replacement combined with chordae tendineae replacement in 29 patients with mitral disease, 26 of whom had mitral stenosis.

Methods: During mitral valve replacement, continuity between the papillary muscle and annulus was restored with expanded polytetrafluoroethylene (ePTFE) mattress sutures, which were threaded into the compact portion of each papillary muscle and placed at the 2, 4, 8 and 10 o'clock positions in the mitral annulus. Postoperatively, the patients were followed by echocardiographic assessment and exercise (stress) radionuclide angiography testing. The stress test results were compared with those in patients who had undergone traditional mitral valve replacement, and also those in normal people.

Results: There were no hospital deaths, complications, or cardiac deaths or events during a median follow up of two-and-a-half years. Echocardiography showed no postoperative cardiac dilatation. The stress tests found no significant differences between the ejection fraction in mitral stenosis patients who underwent conventional mitral valve replacement and in those who had valve replacement combined with ePTFE chordae tendineae replacement.

Conclusions: A direct advantage of chordae-preserving mitral valve replacement over conventional replacement with respect to postoperative global left ventricular performance in patients with mitral valve stenosis has not been demonstrated. However, postoperative regional left ventricular contraction in patients with mitral stenosis has been observed to be better among those who have undergone the chordae-preserving procedure. Additional investigations are needed to elucidate the effects of this procedure in mitral stenosis, but we believe that the technique improves left ventricular performance and may decrease the risk of left ventricular rupture.

How to cite: Okita, Y., Miki, S., Ueda, Y., Tahata, T., Ogino, H., Sakai, T., Morioka, K., Matsubayashi, K., & Nomoto, T. (1997). Mid-term results of mitral valve replacement combined with chordae tendineae replacement in patients with mitral stenosis. The Journal of heart valve disease, 6(1), 37–42.

Background and aims of the study: Combined aortic and mitral valve replacement continues to result in significant morbidity and mortality. Although mitral repair has improved the results of mitral valve surgery, its influence on combined aortic valve replacement has not been assessed.

Methods: We reviewed 38 consecutive patients who underwent aortic valve replacement (AVR) and mitral repair (MR) between 1985 and 1995. The average age was 57 years; 20 were men and 18 women. Nineteen patients were considered high risk: six had previous cardiac surgery, three were on chronic dialysis, two required emergency surgery for low output syndrome, one had a chronic tracheotomy for chronic lung disease, and seven had left ventricular ejection fraction < 30%. MR consisted of ring application alone in 28 patients, chordal shortening in nine, posterior leaflet transfer in six and posterior leaflet resection in four. AVR was accomplished with 21 bioprostheses, 14 mechanical and three allograft valves. The mean (+/-SD) cross-clamp time was 133 +/- 41 min. Additional procedures included coronary bypass in six patients and tricuspid procedures in three.

Results: There were no operative deaths. Six patients died between 4 and 73 months postoperatively. Patient survival was 75% five and 67% 10 years after surgery. The causes of death were heart failure (two cases), and respiratory failure, drug overdose, electrolyte imbalance and unknown (one each). Logistic risk analysis was significant for females and rheumatic valve disease, bacterial endocarditis, and degenerated valve patients. During follow up there were no valve failures or endocarditis, but three embolic episodes occurred without permanent sequel.

Conclusions: With increased surgical expertise, improved myocardial protection of MR combined with AVR offers excellent short- and long-term results, optimal chordal preservation, no valve failure and no endocarditis; it is the ideal choice where anti-coagulation is contraindicated. The prolonged cross-clamp time was well tolerated.

How to cite: Szentpetery, S., Rich, J. B., Azar, H., Newton, J. R., & Tenzer, M. M. (1997). Mitral valve repair combined with aortic valve replacement. The Journal of heart valve disease, 6(1), 32–36.

Background and aims of the study: Previous studies have shown that outcome from mitral valve surgery is poorer in the elderly. However, such studies did not distinguish between age itself, age-associated factors and interactions between age and other factors. We aimed to examine the relative influences of age and these other factors on outcome.

Methods: We compared outcomes from mitral valve repair or replacement in 190 elderly (> or = 70 years) and 424 younger (< 70 years) consecutive adult patients.

Results: At baseline, the elderly had more (p > 0.05) degenerative mitral regurgitation, coronary artery disease, left ventricular impairment, New York Heart Association (NYHA) class III or IV symptoms, bioprosthetic replacement and mitral valve repair. Operative mortality rate was low both in elderly (7/190 patients, 3.7%) and younger patients (15/424 patients, 3.5%, NS). Seven-year survival was poorer in the elderly with respect to overall survival, (49 +/- 6% vs. 72 +/- 3%, p = 0.0001), freedom from complications-related death (57 +/- 7% vs. 79 +/- 3%, p = 0.001), from death due to myocardial failure (66 +/- 6% vs. 86 +/- 3%, p < 0.0001) and from overt myocardial failure (44 +/- 7% vs. 74 +/- 3%, p = 0.0001). Multivariate analysis showed better survival with younger age, mitral valve repair, better preoperative NYHA class and better left ventricular function. However, 7-year freedom from complications-related death was excellent and similar in both elderly (90 +/- 7%) and younger (93 +/- 3%, NS) patients who underwent surgery early while in NYHA class I or II with left ventricular ejection fraction > 40%.

Conclusions: Late surgery contributes far more than age itself to poor outcome from mitral valve surgery in the elderly. If surgery is performed early and repair preferred to replacement whenever feasible, medium-term results are excellent in both young and old.

How to cite: Lee, E. M., Porter, J. N., Shapiro, L. M., & Wells, F. C. (1997). Mitral valve surgery in the elderly. The Journal of heart valve disease, 6(1), 22–31.

Background and aims of the study: The incidence and impact of congestive heart failure and coronary artery disease on late survival after surgical correction of mitral regurgitation are poorly defined. In addition to the uncertainty about the frequency of this complication, the mechanisms of heart failure have not been fully analyzed.

Methods: To determine survival and the incidence and mechanisms of congestive heart failure after mitral valve surgery for mitral regurgitation, we analyzed the long-term outcome of 576 consecutive postoperative survivors.

Results: The analysis demonstrated that preserved preoperative left ventricular function (ejection fraction > or = 60%) was associated with improved survival (adjusted risk ratio 0.49; 95% C.I. 0.36-0.661) and reduced incidence of congestive heart failure (adjusted risk ratio 0.30; 95% C.I. 0.20-0.441), while concomitant coronary artery disease was associated with an excess mortality (adjusted risk ratio 1.80; 95% C.I. 1.34-2.41) and incidence of congestive heart failure (adjusted risk ratio 2.12; 95% C.I. 1.48-3.031).

Conclusions: These results suggest that left ventricular dysfunction and coronary artery disease are major determinants of mortality and morbidity after surgical correction of mitral regurgitation. For the prevention of postoperative congestive heart failure, early surgical correction of mitral regurgitation should be considered before left ventricular dysfunction occurs.

How to cite: Dujardin, K. S., Seward, J. B., Orszulak, T. A., Schaff, H. V., Bailey, K. R., Tajik, A. J., & Enriquez-Sarano, M. (1997). Outcome after surgery for mitral regurgitation. Determinants of postoperative morbidity and mortality. The Journal of heart valve disease, 6(1), 17–21.

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How to cite: Butchart E. G. (1997). Fibrinogen and leukocyte activation-the keys to understanding prosthetic valve thrombosis?. The Journal of heart valve disease, 6(1), 9–16.

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Ho wto cite: Levy R. J. (1997). Strategies to mitigate mineralization in the bioprosthetic or homograft cusp and aortic wall. The Journal of heart valve disease, 6(1), 7–8.

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How to cite: Schoen F. J. (1997). Aortic valve structure-function correlations: role of elastic fibers no longer a stretch of the imagination. The Journal of heart valve disease, 6(1), 1–6.