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How to cite: Bassano, C., Creazzo, V., & Rabitti, G. (1998). Reliability of short-term follow-up for assessing bioprosthetic heart valve performance. The Journal of heart valve disease, 7(1), 121–122.

Background and aims of the study: Although pulmonary valve stenosis may be treated by percutaneous balloon valvulotomy, surgery is preferred in adult patients with dysplastic valves.

Methods: Recently a 50-year-old man with isolated, calcific pulmonary stenosis and concomitant coronary artery disease was referred for surgery. Preoperatively, he suffered from dyspnea (NYHA class I-II) and angina pectoris (CCS class I-II). During catheterization a peak-to-peak gradient of 120 mmHg was measured across the pulmonary valve, while angiography revealed two-vessel coronary artery disease.

Results: During surgery, after opening the main pulmonary artery, an unsuspected small ventricular septal defect (VSD) and a severely calcified, altered pulmonary valve were detected. The VSD was closed and the valve replaced with a stentless bioprosthesis; concomitant double coronary artery bypass grafting was performed. The postoperative course was uneventful.

Conclusions: Adult patients with pulmonary valve stenosis and concomitant coronary artery disease can be treated simultaneously by surgery with excellent results. Replacement devices may be homografts, or as in this patient, a stentless xenograft.

How to cite: Zytowski, M., Sidiropoulos, A., Liu, J., & Konertz, W. (1998). Concomitant pulmonary valve replacement, VSD closure and coronary artery bypass surgery. The Journal of heart valve disease, 7(1), 117–120.

Background and aims of the study: The study objective was to compare coaptation, and leaflet and chordal stresses in normal and dilated mitral valves (18% annular dilatation) versus valves with flexible (Duran) and rigid (Carpentier-Edwards classic) ring annuloplasty, using a computer model. We have developed a 3D finite element model which allows us to evaluate valvular function in terms of coaptation and stresses in both leaflets and individual chordae.

Methods: The mitral valve was simulated using ANSYS 4.4A software. Normal model geometry, collagen fiber orientation, tissue thickness and material properties were determined from fresh porcine valves. For annular dilatation, the annular circumference was increased by 18% versus normal. For annuloplasty, a simulated flexible ring was attached to the annulus, and a simulated rigid ring then attached. Valves were evaluated during systolic pressure loading, after which timing of coaptation and leaflet and chordal stresses were determined.

Results: In the normal valve, the anterior leaflet was subject to higher tensile stresses than the posterior leaflet which was under compression. With annular dilatation, all stresses were increased, particularly in the posterior leaflet. The flexible ring returned leaflet and chordal stresses closer to normal than did the rigid ring. Leaflet coaptation began at 5 ms in the normal state, was delayed by dilatation, and returned towards normal with both rings. The flexible ring returned coaptation and stresses closer to normal than did the rigid ring.

Conclusions: Ring annuloplasty reduces the stresses and improves coaptation relative to annular dilatation. The success of mitral annuloplasty is likely due to the re-establishment of posterior leaflet compressive stresses and near-normal coaptation.

How to cite: Kunzelman, K. S., Reimink, M. S., & Cochran, R. P. (1998). Flexible versus rigid ring annuloplasty for mitral valve annular dilatation: a finite element model. The Journal of heart valve disease, 7(1), 108–116.

Background and aims of the study: Although non-invasive assessment of the severity of aortic regurgitation (AR) is important, quantitative evaluation of AR can be difficult in clinical settings. Most Doppler echocardiographic methods have been compared with angiographic grading of AR severity. However, while aortic angiography is used widely for grading AR severity, the method is only semi-quantitative. A computed semi-automatic digital color Doppler method has recently been described for calculating stroke volume and cardiac output. The study aim was to develop a method of evaluating AR severity by using a digital automated color Doppler method (ACM) along with continuous wave (CW) Doppler for estimating aortic regurgitant effective orifice area.

Methods: A total of 22 different hemodynamic conditions were studied in six sheep. Regurgitant volumes (RV) were determined by electromagnetic flowmetry (EM) and by ACM. AR effective orifice areas (EOAs) were determined by dividing each of the RVs by the time integrals of the AR continuous wave velocities. AR EOAs by ACM were compared with those obtained by EM and with other EM indices of regurgitant severity. ACM was accurate for quantifying AR EOAs (r = 0.96).

Results and conclusions: Calculated AR EOA correlated well with peak AR flow and regurgitant fraction by EM. The combined ACM/CW Doppler method can be useful for estimating non-invasively the aortic regurgitant EOA and for evaluating the severity of AR.

How to cite: Chikada, M., Shiota, T., Aida, S., Yamada, I., Sahn, D. J., & Jones, M. (1998). A method for estimating aortic regurgitant effective orifice area by digital Doppler color flow mapping. The Journal of heart valve disease, 7(1), 102–107.

Background and aims of the study: Current techniques for assessment of aortic regurgitation (AR) are mainly qualitative. Magnetic resonance phase velocity mapping (PVM) provides accurate measurements of arterial blood blow. In AR, the aortic regurgitant volume (ARV) can be quantified with a single imaging slice measurement in the ascending aorta. The aim was to use PVM to: (i) quantify the regurgitant volume in patients with AR using an in vitro validated technique; and (ii) confirm in vivo our previous in vitro findings of the importance of measurement location.

Methods: Four healthy volunteers and 19 patients with AR, varying from mild to severe, were examined in a 1.5 Tesla MRI scanner. In 13 patients, the slice was placed: (i) between the aortic valve and the coronary ostia; (ii) at the sinotubular junction (SJ); and (iii) 2 cm above the SJ. In six patients, one measurement was taken as close as technically possible to the aortic valve. PVM measurements of the ARV were compared with angiographic/echocardiographic AR grading.

Results: No ARV was measured in healthy subjects. In patients, PVM results correlated well with angiographic/echocardiographic data. Repeatability of the PVM results was excellent and interobserver variability very small. The measured ARV decreased as the slice distance from the aortic valve increased, due to aortic compliance, in agreement to previous in vitro results. Close to the valve, acceleration did not affect the accuracy of velocity measurements.

Conclusions: PVM has great potential to measure AR in a purely quantitative manner. Measurement location is important and results suggest that the closer the measurement to the valve the more accurate the ARV quantification.

How to cite: Chatzimavroudis, G. P., Oshinski, J. N., Franch, R. H., Pettigrew, R. I., Walker, P. G., & Yoganathan, A. P. (1998). Quantification of the aortic regurgitant volume with magnetic resonance phase velocity mapping: a clinical investigation of the importance of imaging slice location. The Journal of heart valve disease, 7(1), 94–101.

Background and aims of the study: Cardiac function after aortic valve replacement (AVR) for patients with small aortic annulus and increased left ventricular (LV) wall thickness has not been clearly defined. The study aim was to examine a potential relationship between postoperative catheterization data (or radionuclide LV cardiac function) and the size of the aortic valve ring of a small St. Jude Medical prosthesis.

Methods: Sixty-one patients with small prosthesis (< or = 23 mm) were allocated to three groups based on the diameter of the native aortic annulus or aortic valve ring of the prosthesis (group I, 19 mm; group II, 21 mm; group III, 23 mm). Pre- and postoperative cardiac function was evaluated from catheterization data and radioisotope (RI) ventriculography.

Results: There were no significant inter-group differences in preoperative pulmonary artery pressures (PAPs), total pulmonary resistance (TPR), LV ejection fraction, peak ejection rate (PER) and peak filling rate (PFR). The mean postoperative PAPs and TPR of group I were significantly elevated in ICU compared with those of groups II or III (PAP: group I, 20+/-5; group II, 17+/-4; group III, 14+/-4 mmHg; p <0.01. TPR: group I, 505+/-268; group II, 316+/-134; group III, 276+/-125 dynes.s.cm-5; p <0.05). Postoperative PAPs and TPR of group I at one month after surgery were decreased, and no significant difference was found between the three groups. Cardiac function by RI study showed that postoperative PER and PFR improved in all three groups compared with the preoperative values.

Conclusions: Postoperative reversibility of PAPs and improvement of PER and PFR in patients with a prosthesis of 19 mm or 21 mm showed that a small-sized aortic SJM valve had hemodynamic advantages. However, careful postoperative management in the ICU must be applied to patients with a small aortic annulus of 19 mm and severe concentric hypertrophy.

How to cite: Natsuaki, M., Itoh, T., Tomita, S., & Naitoh, K. (1998). Hemodynamics after aortic valve replacement with St. Jude Medical valve for patients with small aortic annulus and severe left ventricular hypertrophy. The Journal of heart valve disease, 7(1), 86–93.

Background and aims of the study: The surgical management of patients with aortic valve disease associated with ascending aortic dilatation is a controversial issue. Structural abnormalities of the aortic wall predispose to further aortic enlargement and possibly to ascending aortic dissection (AAD). Indications to concomitant replacement of aortic valve and ascending aorta have not yet been clearly defined.

Methods: We reviewed eight consecutive patients (seven males and one female) among 2202 patients who underwent aortic valve replacement (AVR) between 1982 and 1996. These eight were subsequently reoperated on because of AAD, between November 1987 and November 1996. Indications for initial AVR were aortic regurgitation due to annular ectasia in five patients, combined aortic stenosis and regurgitation in two, and isolated aortic stenosis in one patient.

Results: The interval between AVR and AAD ranged from four months to 10.5 years. Five patients presented with acute AAD, and three with chronic AAD. Retrospectively, four patients showed progressive increase in ascending aortic diameter after AVR, with a mean diameter of 72+/-9 mm at reoperation. Histological examination showed cystic medial necrosis in three patients, atherosclerotic degeneration in one patient, and normal aortic wall structure in one. There was one operative death due to low cardiac output; the hospital mortality rate was 13%. There were no late deaths and no major adverse events during a mean follow up of 5+/-3 years (range: 8 months to 10 years).

Conclusions: In patients with ascending aortic dilatation (> or = 55 mm diameter), AVR alone may not prevent progression of aortic root enlargement. In these patients, the ascending aorta should be concomitantly replaced. Following AVR, all patients with mildly or moderately dilated aortic root should be periodically controlled to detect signs of progression of aortic dilatation.

How to cite: Milano, A., Pratali, S., De Carlo, M., Borzoni, G., Tartarini, G., & Bortolotti, U. (1998). Ascending aorta dissection after aortic valve replacement. The Journal of heart valve disease, 7(1), 75–80.

Background and aims of the study: Although small lacerations of the myocardium may be repaired easily using conventional methods, larger tears or ruptures, especially if they occur in infarcted myocardial tissue, may create formidable technical challenges. Described is a method for applying sutureless pericardial patches for control of hemorrhage.

Methods: A sutureless pericardial patch was glued to the myocardium with commercially available household cyanoacrylate (Krazy Glue) in seven patients.

Results: No patient in this series developed any evidence of mediastinal infection as a result of this technique. Six patients were discharged home without any long-term sequelae noted. One patient developed reinfarction and died of arrhythmia two weeks following surgery. Autopsy revealed that the laceration had healed and that the patch was closely adherent. Bacteriology studies revealed that different brands of cyanoacrylate are not only bacterium-free but also exhibit a bactericidal effect.

Conclusions: Sutureless pericardial patches fastened to the myocardium with cyanoacrylate glue to control hemorrhage under critical situations were easy to apply, safe and effective in this series of patients.

How to cite: Eastman, D. P., & Robicsek, F. (1998). Application of cyanoacrylate adhesive (Krazy Glue) in critical cardiac injuries. The Journal of heart valve disease, 7(1), 72–74.

Background and aims of the study: A precise annuloplasty is difficult to perform with pericardium as the ring material because unwanted plication of the pericardium itself typically occurs when the sutures are tied. A novel annuloplasty system has been developed which should allow a predictably precise measured plication of the annulus without plication of the pericardium itself. A feasibility study was designed to evaluate this new concept.

Methods: Three juvenile sheep underwent implantation of a new annuloplasty system into the posterior mitral annulus without tissue annulus plication. Small rigid titanium suture-platforms 7 x 3 x 1 mm with two-suture holes 3 mm apart were individually affixed to the posterior mitral tissue annulus each with a single horizontal mattress suture. A longitudinal strip of untreated autologous pericardium, corresponding to the perimeter dimension of the free edge of the anterior leaflet, was sutured to the posterior annulus including both fibrous trigones, covering the suture-platforms with the mesothelial surface up, using two different suture techniques. No postoperative anticoagulation was utilized. Serial transthoracic echocardiograms and necropsy at five to six weeks post implant were performed.

Results: When the pericardium was affixed to the annulus with a continuous suture exposing only the mesothelial surface to the blood, completely covering the suture-platforms and their suture knots or folded in upon itself as a tube above the suture-platforms, it appeared to maintain all of its original implant dimensions and flexibility. There was no functional or anatomical distortion of any part of the mitral apparatus; fibrotic reaction was minimal and there was no thrombus formation with this suture technique.

Conclusions: This annuloplasty system, combining rigid and flexible elements, 'melts' into the tissue annulus with a low profile, providing overall annular flexibility with no shrinkage of the overlying untreated autologous pericardium, no distortion of any part of the mitral apparatus, minimal fibrous reaction and no thrombus formation.

How to cite: Northrup, W. F., 3rd, Mrachek, J. P., McClay, C., & Feeny, D. A. (1998). A novel annuloplasty system with rigid and flexible elements: initial experimental results in sheep and the case for untreated autologous pericardium. The Journal of heart valve disease, 7(1), 62–71.

Background and aims of the study: This study aimed to determine the clinical performance of bovine pericardial aldehyde-treated material alone or in combination with aortic leaflets of porcine origin. These were the porcine aortic stentless pulmonary valved bovine pericardial conduit (PSPVC), and porcine aortic monocusp attached to pericardial patch (PAMC), used to correct right-sided heart lesions.

Methods: Between November 1985 and October 1995, 33 patients underwent corrective congenital surgery with PSPVC. Mean patient age was 5.7+/-4.3 years (range: 15 days to 18 years). Pulmonary atresia with ventricular septal defect (VSD) was the most frequent disease (16/33, 48%). For PAMC, 45 patients with various congenital heart malformations underwent implantation between June 1989 and April 1996. Mean patient age was 4.8+/-4.7 years (range: 2 weeks to 18 years).

Results: With PSPVC, hospital mortality rate was 18.2% and related to poor preoperative clinical condition in six cases. Four patients were lost to follow up; 23 (85%) were followed for 3 months to 10 years (mean 4.8+/-3.0 years). Distal anastomotic scarring in four patients was probably due to retraction of the pericardial tissue. With PAMC, hospital mortality rate was 11% and related to patients' preoperative clinical condition. Three patients were lost to follow up; 37 survivors have been followed for 6 to 88 months (mean 38.5+/-19.0 months). There were no late deaths. Two patients underwent reoperation; intra-operative observation showed well-preserved monocusps with no signs of tissue degeneration. The remaining 35 patients remain asymptomatic by clinical examination and Doppler echocardiography. The monocusps remained mobile in every case.

Conclusion: PSPVCs have shown excellent performance and durability in young patients with a low mean age (5 years). The monocusp graft has remained functional with good leaflet motion for up to seven years.

How to cite: Vrandecic, M., Filho, B. G., Fantini, F., Barbosa, J., Martins, I., Cesar de Oliveira, O., Martins, C., Max, R., Drumond, L., Oliveira, C., Ferrufino, A., Alcocer, E., Silva, J. A., & Vrandecic, E. (1998). The use of bovine pericardium for pulmonary valve reconstruction or conduit replacement: long-term clinical follow up. The Journal of heart valve disease, 7(1), 54–61.

Background and aims of the study: The study aim was to examine the long-term durability of the aortic Carpentier-Edwards Perimount pericardial bioprosthesis using actuarial and actual analyses.

Methods: A total of 267 patients were implanted at four centers between September 1981 and December 1983. Of these patients, 171 (64%) were males and 96 (36%) females; mean age at implant was 64.9+/-11.8 years (range: 21 to 86 years). Patients have been followed for 9.1+/-4.2 years (total 2335.7 patient-years). Long-term echocardiography data are presented.

Results: The total operative (<30 days postoperative) mortality rate was 4.9%; of this, 0.4% was valve-related. The total late (> or = 30 days postoperative) mortality rate was 6.2%/pt-yr and included a valve-related mortality rate of 1.6%/pt-yr. Complications of thromboembolism, thrombosis and bleeding showed linearized rates of 1.6%/pt-yr and 0.4%/pt-yr, respectively. Valve dysfunction resulted in an explant rate of 0.9%/pt-yr and an associated mortality rate of 0.1%/pt-yr. At 14 years post implant, actuarial freedom from overall and valve-related death was 39.3% and 78.8%, respectively. Actuarial and actual freedom from valve dysfunction was 70.4% and 81.7%. Actuarial freedom from valve explant as a result of dysfunction was 85.1% in all patients; explant in patients aged < or = 65 years at implant was less (76.1%) than in patients aged >65 years (96.3%).

Conclusion: The high actuarial and actual freedom from explant due to structural valve dysfunction supports the long-term durability of this pericardial bioprosthesis and justifies its clinical use in patients older than 65 years at implant.

How to cite: Frater, R. W., Furlong, P., Cosgrove, D. M., Okies, J. E., Colburn, L. Q., Katz, A. S., Lowe, N. L., & Ryba, E. A. (1998). Long-term durability and patient functional status of the Carpentier-Edwards Perimount pericardial bioprosthesis in the aortic position. The Journal of heart valve disease, 7(1), 48–53.

Background and aims of the study: Previous methods for reconstructing semilunar valves have been characterized by lack of precision and reproducibility and, with one exception, the use of unsuitable biomaterial. A new method combines precision with simplicity to reconstruct aortic and pulmonary valves with lightly tanned autologous tissue supported by the annulus of the native valve. Essential components include sizing based on distance between adjacent commissures, cutting a seamless, size-specific trefoil-shaped pattern of tissue with a tricuspid orifice, temporary mounting of the pattern on disposable formers, and suturing with continuous or interrupted monofilament suture to join the autologous tissue pattern with the valve annulus.

Methods: The tissue pattern is cut and mounted on forming devices that enable the implanting surgeon to visualize the orientation clearly, and perform repair accurately and rapidly. One, two or three leaflets can be reconstructed. The forming and cutting devices are discarded when reconstruction is complete. Diseased valves can be reconstructed in no more time than is required for replacement with a prosthesis of any type. Advantages of the method include preservation of full effective orifice area, lack of need for any foreign body other than the sutures used for reconstruction, and the use of non-immunogenic autologous tissue known to be durable and resistant to calcific degeneration. Contraindications include heavily calcified annulus that cannot be satisfactorily debrided, bicuspid anatomy, or a significantly asymmetric annulus.

Results: Pulmonary valve reconstructions have been performed in four juvenile sheep by this method. Three animals survived five months; there was one operative death due to non-valve related causes.

Conclusions: Semilunar valve reconstruction with autologous tissue can be simple, precise, and reproducible.

How to cite: Love J. W. (1998). Autologous pericardial reconstruction of semilunar valves. The Journal of heart valve disease, 7(1), 40–47.

Background and aims of the study: Compressive buckling at sites of sharp leaflet flexure has been implicated as a mechanism of failure in porcine xenografts. The potential for such buckling to cause damage in new-generation pericardial valves, however, has not been examined.

Methods: Clinical-grade bovine pericardium fixed in 0.625% glutaraldehyde was cut into 5 mm-wide strips. Fresh porcine aortic valve leaflets were fixed flat in 0.625% glutaraldehyde and 5 mm-wide circumferential strips were cut. These tissues were bent to various curvatures, held bent with sutures, histologically processed, and sectioned and stained with hematoxylin and eosin. Images of the specimens were acquired by computer and the depth of compressive buckling, thickness of the specimen, and local curvature were measured.

Results: Porcine tissue showed a progressive increase in depth of buckling as both thickness and curvature increased, while bovine pericardium had minimal buckling at all curvatures. Porcine tissues buckled to a mean (+/- SEM) fractional depth of 0.23+/-0.012 while bovine pericardium buckled to only 0.09+/-0.006.

Conclusions: These data suggest that the internal fibrous structure of bovine pericardium may tolerate high bending curvatures better than porcine aortic valve leaflets when stiffened and cross-linked with glutaraldehyde. This may explain the apparently good durability of current generation pericardial valves.

How to cite: Vesely, I., & Mako, W. J. (1998). Comparison of the compressive buckling of porcine aortic valve cusps and bovine pericardium. The Journal of heart valve disease, 7(1), 34–39.

Background and aims of the study: The risk of reoperation due to calcific degeneration is the most important drawback of biological heart valves compared with mechanical prostheses. Concepts to mitigate calcification have been tested experimentally and clinically, but none has proven completely to prevent degeneration.

Methods: Renewed interest has involved the use of autologous pericardium for intraoperative construction of autologous aortic valves (ATCV).

Results: Of 10 ATCV implanted between 1994 and 1996, one was removed from an 84-year-old female 27 months after implantation because of severe valvular insufficiency. Eight months earlier, a broken spring of the stent system was detected radiographically, with normal valvular competence at echocardiography. Valve dysfunction was due to shrinkage of one leaflet. Measurement of tissue calcium by atomic absorption spectroscopy showed high levels in the shrunken leaflet compared with two intact leaflets (42.82 versus 0.51 and 2.42 mg Ca2+/g). Histology and immunohistology demonstrated extensive fiber degeneration without inflammation or immune reactions in the destroyed leaflet, and moderate fiber degeneration in intact leaflets. Scanning electron microscopy showed smooth surfaces in the normal leaflet and exposure of collagen in the degenerated leaflet in association with calcium deposition.

Conclusions: In contrast to the outcome in animal studies, intraoperative tanning did not prevent tissue shrinkage in this case. Leaflet malfunction was associated with calcification. At present, the clinical use of valves constructed from autologous pericardium can not be recommended.

How to cite: Dahm, M., Prüfer, D., Mayer, E., Groh, E., Choi, Y. H., & Oelert, H. (1998). Early failure of an autologous pericardium aortic heart valve (ATCV) prosthesis. The Journal of heart valve disease, 7(1), 30–33.

Background and aims of the study: The use of human pericardium pretreated for 10 min with 0.625% glutaraldehyde (GLUT) in valvular repair or intracardiac reconstruction has produced good results. However, to date, no investigations have been made to determine the mechanical changes that occur in the tissue following such pretreatment.

Methods: Human pericardial samples were harvested from 25 patients and immersed in GLUT for increasing times (5, 10, 30, 60 min and 6 months). Either untreated human pericardium or bovine pericardium treated for six months with GLUT served as controls. Tensile tests were performed with a uniaxial load machine and a pulsative bench. Fatigue testing was for 14 days; each sample was tested at 1,200 cycles/min at a controlled pressure of 90-120 mmHg.

Results: Untreated tissue thickness was 0.44+/-0.16 mm, but after six months GLUT treatment it was 0.53+/-0.15 mm (p<0.001). There was a 13.7% shrinkage of tissue after six months immersion. Strain was significantly greater in treated tissue than in untreated tissue, while stiffness decreased with the duration of GLUT immersion. Young's modulus was significantly lower after six months GLUT treatment (0.26+/-0.06 MPa) compared with untreated, and 5-, 10- and 30-min GLUT treatment (0.32+/-0.15, 0.35+/-0.09, 0.32+/-0.09 and 0.36+/-0.10 MPa (p<0.05)), respectively. Creep was greater after six months GLUT treatment (0.5+/-0.03%) than in untreated and 10-, 30- and 60-min treatments (0.3+/-0.50, 0.27+/-0.01, 0.27+/-0.02, 0.3+/-0.01% (p<0.05)), respectively. Ultimate tensile stress (UTS) was greater in 10-min treated pericardium than in untreated tissue: 38.46+/-11.75 versus 22.17+/-8.30 MPa (p<0.05) respectively. Strain at rupture was greater in the 6-month group (30.62+/-2.54%) than for untreated and 10-, 30- and 60-min GLUT immersion 16.3+/-0.73, 21.85+/-0.75, 20.12+/-1.04 and 18.87+/-0.86% (p<0.05), respectively. Fatigue testing showed an increased length after five and 10 min, and six months, with a lengthening of 14.66, 12.53, 7.66%, respectively compared with 3.5% for untreated tissue (p<0.05). There were three failures in the untreated group (n = 5), none in the 5- and 10-min groups, and one in the 6-month group (p<0.05).

Conclusion: Brief immersion of human pericardial tissue in 0.625% glutaraldehyde reduces the tissue's stiffness and improves its durability for use in cardiac surgery.

How to cite: Vincentelli, A., Zegdi, R., Prat, A., Lajos, P., Latrémouille, C., LeBret, E., De Boisbaudry, G., Carpentier, A., & Fabiani, J. N. (1998). Mechanical modifications to human pericardium after a brief immersion in 0.625% glutaraldehyde. The Journal of heart valve disease, 7(1), 24–29.

Background and aims of the study: Short-term glutaraldehyde-fixed autologous pericardium is widely used in cardiac valve repair or in autologous pericardial bioprosthesis construction. The thinner the tissue, the better the fixation. The aim of this study was to determine thickness and useful surface area of pericardium in relation to harvesting site using a digital thickness counter (0.01 mm precision).

Methods: Parietal pericardium fragments were obtained from the pericardial sac of six fresh cadavers (group I). In the other groups, pericardial strips (80 x 30 mm) were obtained from patients undergoing surgery: group II patients (n = 5 females) and group III (n = 10 males) were non-cardiomegalic (cardiothoracic ratio (CTR)<0.5), while group IV patients (n = 5) were all cardiomegalic (CTR >0.5).

Results: Results were reported on a coloric scale according to measurement position. In group I, mean surface area was 93+/-18 cm2, and thickness gradually increased from 0.1 to 0.6 mm, maximally on the diaphragm, along the left heart side. In other groups, a gradual increase in thickness was identified towards the diaphragmatic zone. Significant differences in tissue thickness appear as a result of cardiomegaly, but are not related to the sex of the patients.

Conclusions: Pericardium taken from the right anterior aspect of the pericardial sac in patients without cardiomegaly is the most appropriate tissue for valve reconstructive surgery, due to its thin nature and hence better fixation properties.

How to cite: Latremouille, C. P., Vincentelli, A., Zegdi, R., D'Attellis, N., Chachques, J. C., Lassau, J. P., Fabiani, J. N., & Carpentier, A. (1998). Autologous pericardial patch harvesting site for cardiac valve repair: anatomic and morphometric considerations. The Journal of heart valve disease, 7(1), 19–23.

Pericardium is an excellent material for reconstruction of the heart during the surgical management of certain acquired heart defects. This review details our experience with pericardium as a patch material for various parts of the left ventricle. MITRAL ANNULUS: Extensive calcification of the mitral annulus, abscess, multiple previous mitral valve replacements and rupture of the posterior wall of the left ventricle are challenging surgical problems that can be satisfactorily managed by reconstructing the mitral annulus with either fresh autologous or glutaraldehyde-fixed bovine pericardium. The mitral valve prosthesis is secured to the newly reconstructed mitral annulus. This procedure has proven to be durable and has provided very good long-term results. LEFT VENTRICULAR OUTFLOW TRACT: We have used bovine pericardium to enlarge the aortic annulus in patients with small aortic annulus undergoing aortic valve replacement with bioprosthetic valves. Patch enlargement of the aortic annulus probably increases the operative mortality of aortic valve replacement but it may favorably effect the clinical outcome and late survival. Another problem in the aortic root that frequently requires reconstruction with pericardium is aortic root abscess. We believe that radical resection of the abscess is the single most important component to eradicate infection in these patients. Pericardium is an excellent material to reconstruct all parts of the left ventricular outflow tract and the results have been excellent. RECONSTRUCTION OF THE LEFT VENTRICULAR WALL: We have also used pericardium to repair the left ventricle in patients with postinfarction ventricular septal defect. We have used a technique of infarct exclusion by suturing a properly tailored bovine pericardium to the endocardium of the left ventricle all around the infarct, excluding the left ventricular cavity from the infarcted wall. This technique has improved the outcome of surgery for this mechanical complication of myocardial infarction, particularly in patients with posterior interventricular septal rupture.

How to cite: David T. E. (1998). The use of pericardium in acquired heart disease: a review article. The Journal of heart valve disease, 7(1), 13–18.

Background and aims of the study: Several different biological, bioprosthetic and mechanical devices are available for heart valve replacement. We present a quantitative methodology to estimate the (event-free) life-expectancy and lifetime risk of valve-related events for individual patients after implantation of any one of these valve types.

Methods: We modelled the age-dependent prognosis of a patient after aortic valve replacement with a discrete-time Markov model and Monte-Carlo simulation to estimate (event-free) life-expectancy and life-time risk of valve-related events, respectively. Quantitative estimates to parameterize these models used hypothetical devices and presumed data were based on a limited review of published literature.

Results: This decision-analytical approach allowed an estimation of the overall and event-free life-expectancy as well as the lifetime risk of valve-related events after implantation of different types of prosthetic heart valve in the aortic position. In the current, hypothetical model, one valve type excelled for all age groups in terms of life expectancy and life-time risk of valve-related events. The choice of the second-best alternative varied according to patient age and comorbidity. Sensitivity analyses showed results to be especially dependent on the durability of the replacement valve and surgical risk.

Conclusions: This methodological approach is very flexible, and its quantitative results may guide decision making, if increasing quantitative information on heart valve prosthesis performance becomes available in future. Markov models and Monte Carlo simulation may be used to obtain a better understanding of the effect that different types of prosthetic heart valves have on patient prognosis, while quantitative results may help cardiologists and cardiac surgeons to choose a specific valve type for an individual patient.

How to cite: de Kruyk, A. R., van der Meulen, J. H., van Herwerden, L. A., Bekkers, J. A., Steyerberg, E. W., Dekker, R., & Habbema, J. D. (1998). Use of Markov series and Monte Carlo simulation in predicting replacement valve performances. The Journal of heart valve disease, 7(1), 4–12.

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How to cite: Blackstone E. H. (1998). The choice of a prosthetic heart valve: how shall patient-specific recommendations be made?. The Journal of heart valve disease, 7(1), 1–3.