Background and aims of the study: The biocompatibility of a silver-coated polyethylene terephthlate (PET, polyester) fabric for the inhibition of prosthetic valve endocarditis (PVE) associated with mechanical heart valves (MHVs) was assessed. The infrequency of PVE is outweighed by mortality rates commonly exceeding 50%. These high mortality rates have been attributed to the poor effect of antibiotic therapy on colonized valves and infected myocardial tissue. Silver has been used as an antimicrobial for centuries due to its general effectiveness and relative lack of toxicity. Our previous work has shown PET polyester fabric coated with metallic silver by an ion beam-assisted deposition (IBAD) process to: (i) be effective in vitro in the inhibition of microbial attachment and colonization; (ii) be tightly adherent and low leaching; and (iii) promote tissue ingrowth and the organization of tissue pannus in a short-duration (five weeks) sheep mitral mechanical heart valve model.

Methods: This paper addresses additional biocompatibility assessment consisting of a cell compatibility assay in which serum extracts of silver-coated fabric were exposed to fibroblasts for 48 hours, after which cell viability and function were measured. The amount of silver in the extract was measured using elemental analysis techniques.

Results: No signs of toxicity were seen in the cells until the extract concentration reached 1200 p.p.m. Ten-week duration mechanical valve replacement studies in sheep with uncoated or coated polyester sewing cuffs showed comparable tissue ingrowth and mature pannus with a suggestion of a thinner pannus on the silver-coated fabric. Additional antimicrobial testing confirmed the effectiveness of this coating in inhibiting colonization of polyester fabric.

Conclusions: These current results, together with the earlier data, suggest that IBAD silver coating on polyester facilitates healing and may provide protection against PVE.

How to cite: Tweden, K. S., Cameron, J. D., Razzouk, A. J., Holmberg, W. R., & Kelly, S. J. (1997). Biocompatibility of silver-modified polyester for antimicrobial protection of prosthetic valves. The Journal of heart valve disease, 6(5), 553–561.

Two cases of acute staphylococcal mitral annular abscesses resulting in transannular left ventriculoatrial fistulation are reported. Mitral annular abscess debridement and repair of the annulus, obliteration of the fistulation, and preservation of the native valve were successful in both cases.

How to cite: Baumgartner, F., Omari, B., & Milliken, J. (1997). Repair of left ventriculo-atrial fistulas due to posterior mitral annular abscesses. The Journal of heart valve disease, 6(5), 550–552.

Before the development of standard aortic valve replacement, Hufnagel treated aortic insufficiency by implanting a ball-valve prosthesis in the descending thoracic aorta. In a patient who, after four major thoracic procedures, ultimately received two mechanical bileaflet valves in series (one in the ascending and one in the descending aorta), the downstream prosthesis became progressively immobilized, with total blockage of the leaflets in the open position due to insufficient transvalvular negative pressure gradient. After evaluation of this particular situation in an experimental model, we predicted blockage of the downstream prosthesis, once the ascending valve had regained normal function, and easily cleared the blockage of the distal valve by removing the two leaflets using balloon inflation. Normal circulation was clinically restored in three separate steps. (a) Normal function was re-established surgically in the ascending aorta position. (b) A second thoracotomy was avoided by endovascular dislocation of both blocked descending thoracic leaflets through endovascular balloon inflation. (c) Both leaflets embolized to the level of the left common iliac artery, where the nearly intact leaflets were removed surgically, finally creating a near-normal circulatory situation.

How to cite: Van Nooten, G. J., Taeymans, Y., & Verdonck, P. (1997). Hufnagel procedure reconverted by endovascular leaflet dislocation and extirpation. The Journal of heart valve disease, 6(5), 546–549.

Despite previous unsatisfactory results with inverted pulmonary homografts in mitral valve replacement, we have rekindled our interest in this technique by the use of a pulmonary autograft with the fully flexible 'top hat' type of mounting. The surgical technique and the clinical feasibility of the operation are presented.

How to cite: Ross, D. N., & Kabbani, S. (1997). Mitral valve replacement with a pulmonary autograft: the mitral top hat. The Journal of heart valve disease, 6(5), 542–545.

Background and aims of the study: Aortic valve replacement in the small aortic root results in a heart-prosthesis mismatch in a significant number of patients. The new Masters series of St. Jude Medical (SJM) valves represents the company's most recent innovation, combining the beneficial Hemodynamic Plus (HP) characteristics with rotatability. Thus, this valve allows for a larger valve orifice area with an equivalent tissue annulus diameter and reduces the potential interferences of subannular tissue with leaflet mobility.

Methods: We compared prospectively the hemodynamic characteristics and the early clinical results in four groups of 25 patients each who received either the 21 Masters-HP, the 21 Standard, the 21 HP or the 23 Standard SJM valves. Patients were selected from our database and matched rigorously for age, gender, body surface area, NYHA functional class, underlying lesion, native valve opening area and left ventricular function, as well as preoperative peak and mean valve gradients. Postoperative evaluation included clinical examination and echocardiographic studies before hospital discharge and at six months.

Results: Short-term clinical follow up was marked by a complete absence of valve-related complications in all groups. Doppler-derived mean and maximal pressure gradients were significantly lower in the 21 HP (8.7 +/- 3.1 mmHg and 15.1 +/- 4.0 mmHg, respectively) and 21 Masters-HP groups (8.9 +/- 2.6 mm +/- Hg and 14.5 +/- 3.8 mmHg) than those in the 21 Standard group (15.1 +/- 3.2 mmHg and 22.5 +/- 6.1 mmHg; p = 0.002 and p = 0.004, respectively). These results confirm that the superior hemodynamic performance of the HP series is maintained in the Masters-HP valve, despite the introduction of a new cuff design allowing rotatability. Pressure gradients did not differ significantly between the 21 HP, the 21 Masters-HP and the 23 Standard groups.

Conclusions: The hemodynamic performance of the 21 Masters-HP SJM valve corresponds closely with that of the 21 HP and 23 Standard valves and is substantially better than that of the 21 Standard valve. The Masters-HP valve will continue to reduce cardiac-prosthesis mismatch in normal-sized patients with a narrowed aortic root; its performance index is equal to that of the 21 HP valve and significantly higher than that of the 21 Standard valves. The valve will also further reduce the need for aortic annulus enlargement.

How to cite: Zingg, U., Aeschbacher, B., Seiler, C., Althaus, U., & Carrel, T. (1997). Early experience with the new Masters series of St. Jude Medical heart valve: in vivo hemodynamic and clinical results in patients with narrowed aortic annulus. The Journal of heart valve disease, 6(5), 535–541.

Background and aims of the study: Mean and peak Doppler gradients remain the most frequently used parameters for follow up of prosthetic aortic valves. Gradients that deviate from baseline recordings can lead to uncertainty among physician and patient, especially if symptoms have not completely subsided after surgery, or have recurred. This study aimed to document long-term evolution of mean and peak gradients in patients with stationary clinical symptoms and signs.

Methods: Seventy-six patients (48 men, 28 women), of mean age 56.1 +/- 14.5 years (range: 23 to 82 years) who underwent St. Jude Medical bileaflet prosthesis implantation were followed up for a mean of 3.9 years (range: 1 to 7 years), both clinically and echocardiographically. Evolution of mean and peak gradients, left ventricular function, other valvular lesions and rhythm as well as adequacy of anticoagulation were examined.

Results: Mean gradient increased from 12.3 +/- 5.5 to 14 +/- 5.7 mmHg (p = 0.002). Mean gradient increased in 47 patients, decreased in 17 and was unchanged in 12. There was no correlation between left ventricular function, appropriate anticoagulation, left ventricular hypertrophy, age or gender with change in mean or peak gradient. Change in peak gradient correlated excellently (r2 = 0.82) with that in mean gradient.

Conclusions: The range of evolution of Doppler gradients in normally functioning St. Jude Medical prostheses has been defined in this study. Slight long-term increases in mean and peak pressure gradients are normal findings and do not warrant a change in management strategy if unaccompanied by deterioration of symptoms and/or clinical signs. Although we recommend routine determination of baseline flow measurements within three months of prosthesis implantation, mean and peak gradients are adequate follow up parameters. Peak gradient correlated well with mean gradient and may be a useful adjunct for follow up in clinical practice.

How to cite: Zimmerli, M., Kipfer, B., & Wagdi, P. (1997). Long-term Doppler echocardiographic follow up in normally functioning aortic St. Jude Medical prosthesis. The Journal of heart valve disease, 6(5), 531–534.

Background and aims of the study: This study was performed to evaluate the time course of intracranial high-intensity transient signals (HITS) in patients undergoing elective heart valve replacement.

Methods: Thirty-three patients were enrolled in this study. The examination protocol included serial (before and at one, five, 90 and 180 days after surgery) monitoring sessions with transcranial Doppler and detailed neurological examination. Monitoring was performed bilaterally over the middle cerebral arteries for one hour per session using 2 MHz probes. Microembolic signals were recognized according to standard criteria and stored on a computer for later evaluation.

Results: HITS prevalence increased from 3% preoperatively to 41% on the first postoperative day and remained unchanged during the postoperative period. No influence of the intensity of anticoagulation or valve type on HITS counts was evident. Unilateral monitoring provided adequate results in 83.9% of cases.

Conclusions: The causative role of the valve implant in the pathogenesis of HITS appears certain, since their prevalence dramatically increases following valve implantation. Valve type, duration of valve implant or intensity of anticoagulation did not influence HITS counts. Bilateral monitoring is warranted for accurate evaluation of HITS counts in this patient group.

How to cite: Lindner, A., Georgiadis, D., Lühmann, A., Stephan, M., Preiss, M., Zerkowski, H. R., & Zierz, S. (1997). Time course of high-intensity transient signals in patients undergoing elective heart valve replacement: a prospective study. The Journal of heart valve disease, 6(5), 527–530.

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How to cite: Moore M. A. (1997). Pericardial tissue stabilized by dye-mediated photooxidation: a review article. The Journal of heart valve disease, 6(5), 521–526.

Background and aims of the study: Due to its superb crosslinking activity, glutaraldehyde (GA) is still the most widely used fixative for bioprosthetic heart valves. At the same time, however, GA is also believed to be partly responsible for tissue calcification and the lack of surface re-endothelialization, both of which may contribute to valve degeneration. Although excess GA has previously been extracted from thin leaflet tissue, this treatment proved insufficient for the detoxification of thick aortic wall tissue of stentless valves or root prostheses.

Methods: In order to establish a detoxification procedure which thoroughly extracts biologically active GA from aortic wall tissue, we used a highly sensitive bioassay where endothelial cells were seeded onto glutaraldehyde-fixed aortic wall discs following various detoxification procedures. Absolute cell numbers and morphologic shape were correlated with shrinkage temperature and shrinkage extent of the tissue to determine the potential of the treatments to reverse crosslinks. To optimize treatment conditions, pH (3.2 versus 4.5), temperature (22 degrees C versus 37 degrees C) and incubation time (48 h versus one week) were varied. In order to identify an optimal detoxification agent, 12 different amino-reagents from four chemical groups were compared: low pKa aromatic amines, amino acids, low pKa N-heterocyclic compounds and amino sugars.

Results: Amino-reagent treatment required warm temperature (37 degrees C), prolonged reaction time (one week) and a pH of 4.5 to achieve long-term cell growth on glutaraldehyde-fixed aortic wall. All 12 amino-reagents were able to detoxify aortic tissue satisfactorily; and all mildly reversed crosslinks, although there were differences between candidates. When summarized data were ranked correlating cell growth and quality with shrinkage temperature and shrinkage extent, seven reagents had a rank sum above the overall mean value, and five below with statistically significant differences between candidates. The additional stabilization of the detoxification reaction through borohydride-reduction had no further effect on tissue biocompatibility and crosslinks.

Conclusions: Efficient detoxification of thick aortic wall tissue is possible if a one-week incubation in an acetic acid buffer-based amino-reagent is carried out at 37 degrees C.

How to cite: Zilla, P., Fullard, L., Trescony, P., Meinhart, J., Bezuidenhout, D., Gorlitzer, M., Human, P., & von Oppell, U. (1997). Glutaraldehyde detoxification of aortic wall tissue: a promising perspective for emerging bioprosthetic valve concepts. The Journal of heart valve disease, 6(5), 510–520.

Background and aims of the study: This study was performed in order to: (i) determine whether a similar reduction of tissue calcification as seen after prolonged storage can be achieved through higher concentrations of glutaraldehyde (GA); and (ii) verify that well-preserved tissue integrity can suppress calcification.

Methods: Before fixation in 0.2% GA (PBS, 4 degrees C, seven days) porcine aortas were kept on ice for 48 h. Alternatively, tissue was immediately fixed at the abattoir in 0.2%, 1.0% or 3% glutaraldehyde (PBS, 4 degrees C, seven days). A second group of immediately fixed tissue (0.2%, 1.0%, 3.0% GA) (PBS, 4 degrees C, two days) had an interim step of L-lysine treatment (0.1M, 37 degrees C, acetic acid buffer, two days) in order to enhance cross-linking followed by warm-temperature fixation (PBS, 37 degrees C, five days). Two animal models were compared: subcutaneous implantation in rats (12 weeks) and vascular implantation in non-human primates, Chacma baboons (six weeks).

Results: In both animal models the highest level of calcification was found in the group with delayed fixation in 0.2% GA. In the rat model there was an inverse correlation between tissue calcification and the GA concentration used, with 3% GA-fixed tissue showing the lowest level of tissue calcium. Overall, increasing GA concentration had a significant benefit on calcification (p < 0.0001; two-factor analysis of variance). Enhancement of cross-linking with L-lysine further abrogated tissue calcium levels at all GA concentrations (p < 0.0001; two- factor analysis of variance). Although the short-term baboon model showed lower tissue calcium levels, the trend seen in the rat model was confirmed.

Conclusions: Our results demonstrate the detrimental effect of delayed fixation and further suggest that, against previous beliefs, fixation at higher glutaraldehyde concentrations reduces the calcification tendency of cross-linked aortic tissue.

How to cite: Zilla, P., Weissenstein, C., Bracher, M., Zhang, Y., Koen, W., Human, P., & von Oppell, U. (1997). High glutaraldehyde concentrations reduce rather than increase the calcification of aortic wall tissue. The Journal of heart valve disease, 6(5), 502–509.

Background and aims of the study: Poor ultrastructural tissue preservation of bioprosthetic heart valves is associated with a higher propensity for calcification. In spite of this realization, commercial valve fixation remains suboptimal.

Methods: In an attempt to maintain tissue integrity through improved cross-linking procedures, transmission electron microscopy and a 21-point damage score were applied to assess the ultrastructural preservation of aortic wall tissue-the main component of contemporary aortic valve bioprostheses. An ideal glutaraldehyde (GA) concentration was assessed by immediate tissue fixation at 4 degrees C comparing 0.2%, 0.5%, 0.65%, 1.0%, 2.0%, 3.0% and 4.0% GA in phosphate-buffered saline (PBS). Subsequently, an optimal concentration of 3.0% GA was used to determine the effect of fixation temperature (4 degrees, 22 degrees and 37 degrees C). Finally, the superior glutaraldehyde concentration (3.0%) and cross-linking temperature (4 degrees C) were used to assess tolerance towards delayed fixation.

Results: When different GA concentrations were used almost identical damage scores of 6.3 and 5.8 were found for 0.2% and 0.65% fixation. The first significant improvement was found at a concentration of 1.0% (score 3.3; p < 0.01) followed by a further improvement at 3.0% (score 2.6; p = 0.05). The optimal fixation temperature was 4 degrees C (3.7) with the worst results obtained at room temperature (score 9.2; p < 0.03). When fixation was delayed, the most significant damage occurred during the initial 30 min after slaughter (from 2.3 to 7.4; p < 0.02) followed by another significant deterioration between 4 and 16 h (from 5.6 to 9.7; p < 0.02).

Conclusions: In summary, the prerequisites for an ideal ultrastructural preservation of bioprosthetic aortic wall tissue are immediate fixation (within 30 min), high GA concentrations (> 1.0%) and cold-temperature fixation (4 degrees C).

How to cite: Zilla, P., Zhang, Y., Human, P., Koen, W., & von Oppell, U. (1997). Improved ultrastructural preservation of bioprosthetic tissue. The Journal of heart valve disease, 6(5), 492–501.

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How to cite: Frater R. W. (1997). Tanning revisited for leaflets and the aortic wall. The Journal of heart valve disease, 6(5), 490–491.

Background and aims of the study: During stentless bioprosthetic aortic valve replacement, ischemic time may be decreased by the non-invasive prediction of bioprosthesis size, allowing earlier commencement of prosthesis preparation. In this study we examine whether the addition of transesophageal echocardiography (TEE) to transthoracic echocardiography (TTE) aids in the prediction of stentless bioprosthesis aortic valve size. We also report our preliminary experience with the use of magnetic resonance imaging (MRI) in bioprosthetic valve size prediction.

Methods: Eight patients in whom elective aortic valve replacement with a Toronto SPV valve was planned underwent preoperative TTE and MRI, and intraoperative TEE.

Results: In all cases the combination of TTE and TEE correctly predicted the size of Toronto SPV valve inserted. In three cases, TEE led to a revision of the TTE-based prediction. The need for sinotubuloplasty in two patients was correctly predicted by both TTE and TEE. MRI of the aortic annulus correctly predicted valve size in three of four cases, but could not reliably identify the sinotubular junction.

Conclusions: In aortic valve replacement the accuracy of prediction of stentless bioprosthesis size is improved by the addition of TEE to TTE.

How to cite: Bridgman, P. G., Bloomfield, P., Reid, J. H., & Mankad, P. S. (1997). Prediction of stentless aortic bioprosthesis size with transesophageal echocardiography and magnetic resonance imaging. The Journal of heart valve disease, 6(5), 487–489.

Background and aims of the study: The aims of this study were to evaluate symptomatic improvement and event-free/overall survival after balloon aortic valvulotomy in patients with significant sclerotic aortic valve stenosis.

Methods: Sixty-four patients with calcified aortic stenosis, in NYHA class III-IV, and of mean age 79.0 years, underwent a total of 75 scheduled attempts at balloon aortic valvulotomy, with single balloon catheters between December 1987 and June 1993. Patients were either considered as poor surgical candidates or themselves preferred such valvulotomy.

Results: Periprocedural major complications, including death in 6%, occurred in association with 16% of the procedures. Among 57 patients in whom initial dilatation was successful, the average period of symptom relief was 9.4 months (median 7.0, range: 0 to 47 months). Independent predictors for longer duration of symptom relief and survival were systolic arterial pressure > 115 mmHg and female gender; ejection fraction > or = 30% was only predictive of survival. Actuarial survival rates at one, two and three years were 77, 48 and 36% respectively.

Conclusions: Balloon aortic valvulotomy is followed by a short period of symptomatic relief and carries a low periprocedural mortality, but considerable morbidity. By comparison, aortic valve replacement patients aged over 70 and with serious physical limitations (NYHA class IIIB-IV) showed much better overall survival. As contraindications to surgery are in most cases relative, aortic valve replacement should always be considered as the only choice in the surgical decision-making.

How to cite: Kvidal, P. D., Stahle, E., Nygren, A., Landelius, J., Thuren, J., & Enghoff, E. (1997). Long-term follow up study on 64 elderly patients after balloon aortic valvuloplasty. The Journal of heart valve disease, 6(5), 480–486.

Background and aims of the study: Valve repair, where suitable, is the preferred option in patients who require mitral surgery. A number of studies have shown excellent long-term results, but most were undertaken in tertiary referral centers with a high throughput of patients.

Methods: We present our experience in 60 patients, aged 60 +/- 14 years, undergoing repair between 1984 and 1993. Most patients (83%) were in New York Heart Association (NYHA) class II or III at the time of surgery; 27% had concomitant ischemic heart disease. Almost all (98%) had posterior leaflet repair and 18% had anterior leaflet repair. Eight surgeons each performed a mean of 7.5 operations during this period.

Results: The 30-day mortality rate was 3.3%. There were seven late deaths. Five patients underwent reoperation for mitral regurgitation (two early, three late). At six years, 60% of patients were alive, or free of stroke or reoperation. Late follow up was obtained in 45 of 47 surviving patients: 95% were in NYHA class I or II; one-third were on anticoagulants for atrial fibrillation; 90% had mild (or less) mitral regurgitation on echocardiography.

Conclusions: These data show that most patients have a very good outcome from valve repair surgery and encourage the trend towards operating earlier in the course of the disease. Adverse outcomes occurred mainly in patients who were highly symptomatic at the time of surgery. The high proportion of patients on postoperative anticoagulants underscores the importance of operating before atrial fibrillation becomes permanent.

Hoew to cite: O'Meeghan, T. J., Jaffe, W. M., & Raudkivi, P. J. (1997). Green Lane Hospital experience with mitral valve repair for prolapse: adverse outcomes for highly symptomatic patients. The Journal of heart valve disease, 6(5), 475–479.

Background and aims of the study: Mitral valvuloplasty (MVP) for the prolapse of the anterior mitral leaflet (AML) is more difficult than that for the posterior mitral leaflet. The introduction of artificial chordae (November, 1986) and the concomitant maze operation (November, 1992) were surgical 'turning points' in our 17 years' experience.

Methods: In total, 163 surgical cases of AML prolapse based on the above turning points, and carried out between 1979 and 1996, were reviewed. These included 110 MVP and 53 mitral valve replacements. MVP was performed in only 46% (29/63) of patients before October 1986 (Group I); in 72% (42/58) of patients between November 1986 and October 1992 (Group II); and in 93% (39/42) of patients after November 1992 (Group III).

Results: Reoperation was required in nine patients. The reoperation-free rate after MVP was 79% at 17 years in all cases, 82% at 17 years in Group I, 86% at 10 years in Group II and 97% at four years in Group III. Besides reoperation cases, grade 3/4 mitral regurgitation (MR), assessed by color Doppler echocardiography, was detected in seven patients. The event-free (reoperation, MR, thromboembolism) rate was 69% at 17 years in all cases, 78% at 17 years in Group I, 71% at 10 years in Group II and 92% at 4 years in Group III. A concomitant maze operation was performed in 19 of 20 current patients with atrial fibrillation. The percentage of sinus rhythm after operation in Group I, II and III was 53%, 60% and 84%, respectively.

Conclusions: During 17 years' experience, mortality and morbidity after MVP for AML prolapse were satisfactory. With the use of artificial chordae, we have been able to perform MVP in more than 90% of current patients with AML prolapse. Further, a concomitant maze procedure could provide a higher incidence of postoperative sinus rhythm.

How to cite: Nakano, K., Eishi, K., Kobayashi, J., Sasako, Y., & Kosakai, Y. (1997). Surgical treatment for prolapse of the anterior mitral leaflet. The Journal of heart valve disease, 6(5), 470–474.

Background and aims of the study: Comparisons of mitral valve (MV) replacement and reconstruction have demonstrated lower overall complication rates, better left ventricular (LV) function, and inferred overall lower cost for the latter procedure compared with the former. However, assessment of economic differences between the two procedures in routine cases, without complications, has not been reported. This study retrospectively evaluates the economic impact of uncomplicated MV repair versus replacement.

Methods: As this study seeks only to evaluate economic comparisons between routine cases of mitral repair versus replacement, those patients having concomitant procedures performed (coronary revascularization or other valve procedure) or postoperative complications (i.e. pulmonary failure, wound infections, new-onset atrial fibrillation, return for bleeding, or neurologic sequelae) were excluded from the study. Among patients who underwent uncomplicated MV procedures, 30 were selected at random and reviewed.

Results: Variables for MV replacement versus reconstruction included aortic cross-clamp time (112 +/- 54 versus 92 +/- 20 min; p = NS), cardiopulmonary bypass (CPB) time (189 +/- 70 versus 128 +/- 18 min; p < 0.05), total hospital stay (8.3 +/- 1.6 versus 5.6 +/- 1.6 days; p < 0.0001), and total hospital charges ($44,697 +/- 4903 versus $31,337 +/- 4484; p < 0.0001), respectively.

Conclusions: These data suggest that, beyond the recognized benefits of MV reconstruction, namely preservation of LV function and avoidance of long-term anticoagulation, there is an economic advantage to MV reconstruction for patients and payors, even in uncomplicated cases. These differences may become more apparent with longer follow-up and in patients having poor function or combined procedures. This finding reinforces the idea that MV reconstruction is the option of choice for patients with mitral regurgitation.

How to cite: Pagani, F. D., Benedict, M. B., Marshall, B. L., & Bolling, S. F. (1997). The economics of uncomplicated mitral valve surgery. The Journal of heart valve disease, 6(5), 466–469.

Prosthetic valve endocarditis (PVE) emerged approximately 37 years ago when the first human heart valve replacements were performed. PVE can be classified as 'early' or 'late' with the pathophysiology and etiologic organisms varying between the two subgroups. The incidence of PVE ranges up to 0.5% per patient-year for mechanical mitral valves and up to 1.0% per patient-year for other valves. The clinical presentation is similar to that of native valve endocarditis, with fever being the most prevalent sign. Diagnosis is based on a constellation of clinical signs and symptoms as well as echocardiographic evaluation of the valve and perivalvular tissues. An algorithm is set forth for diagnosis and management of patients with suspected PVE based on our personal experience and the published literature. Indications for surgery, the surgical approach and methods of PVE prophylaxis and prevention are discussed.

How to cite: Vlessis, A. A., Khaki, A., Grunkemeier, G. L., Li, H. H., & Starr, A. (1997). Risk, diagnosis and management of prosthetic valve endocarditis: a review. The Journal of heart valve disease, 6(5), 443–465.