Background and aims of the study: The application of the flexible Duran mitral annuloplasty ring in the treatment of various mitral valvular diseases is a physiologically appealing method of surgical repair. However, accurate identification of the trigonal structures, which is crucial in selecting the proper ring size, cannot always be made with certainty. A method is proposed to calculate the intertrigonal distance (ITD) from the aortic diameter.

Methods: Using digital calipers, the linear intertrigonal distance was measured in human homograft (n = 10) and sheep (n = 10) aortic root specimens. The aortic diameter was obtained from the circumference of the pressurized aortic root. A conversion factor was acquired for each specimen by dividing the aortic diameter with the measured ITD. A single constant conversion factor, which closely approximated the mean of the conversion factors in both groups, was then applied broadly to derive the ITD by calculation from the aortic diameter, which is known. The validity of using this constant conversion factor was tested by comparing the degree of variation of the calculated ITD from the direct measurements of the ITD.

Results: The mean of the conversion factors was 0.79 and 0.80 in the human and the sheep roots, respectively. The value 0.80 was used as the constant conversion factor in both groups for calculating the ITD. A paired comparison t-test in each group showed the difference between the calculated intertrigonal distance and the direct measurements of the ITD to be insignificant, validating the use of 0.80 as a constant conversion factor.

Conclusions: The results of the study suggest that the conversion factor of 0.80 can be reliably used to obtain a calculated value of the intertrigonal distance; this method has the potential to aid the surgeon in determining the intertrigonal distance and the proper ring size.

How to cite: Choo, S. J., Olomon, J., Bowles, C., Luo, H. H., Pang, D., Oury, J. H., & Duran, C. M. (1998). An in vitro study of the correlation between aortic valve diameter and mitral intertrigonal distance: a simple method to select the correct mitral annuloplasty ring size. The Journal of heart valve disease, 7(5), 593–597.

Complete papillary muscle rupture is a catastrophic complication of acute myocardial infarction which usually leads to acute severe mitral regurgitation requiring urgent or emergent surgery. A case in which this complication occurred after chordal sparing mitral valve replacement is described. The severed papillary muscle was removed surgically. The incidence and natural history of papillary muscle rupture occurring after chordal sparing mitral valve replacement for ischemic mitral insufficiency is not known.

How to cite: Goldenberg, M. R., Rozanski, L. T., Degeratu, F. T., & Berger, B. C. (1998). Papillary muscle rupture after chordal sparing mitral valve replacement. The Journal of heart valve disease, 7(5), 590–592.

Background and aims of the study: The study was performed to establish the frequency of significant coronary artery stenosis (SCS) in patients with valvular heart disease (VHD), and in particular its correlation with the incidence of angina pectoris and presence of coronary risk factors. The need for coronary arteriography to be performed in all patients with VHD before surgery was also investigated.

Methods: Retrospective examinations were performed in 1292 patients with VHD (mean age 51 years) who underwent selective coronary angiography before surgery between 1982 and 1990. In each patient the presence of angina pectoris and the following risk factors were noted: cigarette smoking, systemic hypertension, family history of ischemic heart disease, elevated fasting serum lipids, history of diabetes mellitus and overweight.

Results: The incidence of SCS was 13%, was higher in patients with angina, and correlated significantly with coronary risk factors of smoking, hypertension, history of ischemic heart disease, elevated lipids and diabetes, but not with overweight. The incidence of SCS increased progressively with the number of coronary risk factors, from 2% in patients without risk factors, to 6% with one risk factor, and to 21% with two or more risk factors. SCS was not found in patients without coronary risk factors and without angina pectoris below 55 years of age.

Conclusions: A statistically significant correlation was found between increasing numbers of coronary risk factors and significant coronary artery disease. These results suggest that coronary angiography may not be an obligatory diagnostic step before valve replacement in patients aged < 55 years who have neither risk factors nor angina pectoris.

How to cite: Orlowska-Baranowska, E., & Rawczynska-Englert, I. (1998). Risk factors for coronary artery stenosis in valvular heart disease. The Journal of heart valve disease, 7(5), 586–589.

Background and aims of the study: It is now well recognized that regurgitation through a common atrioventricular valve can compromise the clinical course both before and after surgical interventions in patients with visceral heterotaxy. This may reflect the anatomic structure of the valve. This study aimed to determine whether the structure of the common atrioventricular valve found in the setting of hearts with isomeric atrial appendages and double inlet ventricle differs from that of the valve guarding a common junction in hearts with biventricular atrioventricular connections.

Methods: Sixty-three autopsied hearts with double inlet ventricle and isomeric atrial appendages were studied, in addition to 79 with isomerism and biventricular atrioventricular connections, all having a common valve guarding the atrioventricular junctions.

Results: A valve with three or four leaflets was seen more frequently in hearts with double inlet ventricle than in those with biventricular atrioventricular connections (p = 0.016, chi-squared test). Complicated multiple orifices within the valvular curtain, including abnormal accessory orifices within a leaflet, were found in seven cases with double inlet to a dominant morphologically left or right ventricle. The presence of four papillary muscles was the most common pattern in hearts with double inlet ventricle. Straddling of the papillary muscles to a rudimentary and incomplete ventricle was seen in 23% of cases. Direct attachment of tendinous cords to the ventricular septum or parietal wall was seen 81% of hearts with double inlet.

Conclusions: These features of the common valve found with double inlet atrioventricular connection seem less suited to function as the inlet valve supporting the systemic circulation. The recognized abnormal features should be identified preoperatively so as to plan more effective valvular plasty, or alternatively to establish different surgical strategies.

How to cite: Uemura, H., Ho, S. Y., Anderson, R. H., & Yagihara, T. (1998). The structure of the common atrioventricular valve in hearts having isomeric atrial appendages and double inlet ventricle. The Journal of heart valve disease, 7(5), 580–585.

Background and aims of the study: In patients in sinus rhythm following aortic valve replacement (AVR) with bioprosthetic valves, aspirin prophylaxis generally keeps bleeding complications to a minimum without increasing the risks of thromboembolic events. To study the efficacy of aspirin prophylaxis in patients receiving the recently introduced Tissuemed porcine bioprosthetic implant in the aortic position we reviewed our database of 145 patients who underwent AVR between 1991 and 1996.

Methods: Mean patient age was 73.5 years (range: 56 to 94 years); 85 were males and 60 females. Preoperatively, 70% of the patients were in NYHA functional class III or IV. Concomitant procedures were performed in 26% of patients. Following AVR, low-dose aspirin prophylaxis (75 mg/day) was commenced in all patients in sinus rhythm. The bioprosthesis was evaluated using standard Society of Thoracic Surgery guidelines.

Results: Follow up was 100% complete (total cumulative follow up 253.7 patient-years (pt-yr)). There were three minor thromboembolic episodes, all occurring at least one year after surgery; there were no major thromboembolic complications and bleeding events. Valve-related complication rates (expressed as %/pt-yr and number of events) were thromboembolism 0.7%/yr (three episodes), hemorrhage 0.4%/yr (one) and bacterial endocarditis 0.4%/yr (one). The reoperation rate was 0.4%/yr (one). At five years, actuarial freedom from thromboembolism was 95 +/- 3.6% (SE); hemorrhage 99.2 +/- 0.75%; endocarditis 98.4 +/- 1.5); non-structural valve failure 100%; structural valve dysfunction 100% and reoperation 98.4 +/- 1.5%. The 30-day mortality rate in this elderly population, influenced by clinical status (NYHA class III and IV; p = 0.005), was 9.6% (95% CI, 4.8 to 14.4), with no early valve-related deaths. Patient survival at five years was 78.5 +/- 3.7%. At follow up, 94.8% of the patients were in NYHA functional class I or II.

Conclusions: Early clinical evaluation showed that, following AVR, bleeding complications were minimal with no increase in thromboembolic events in the first three months and on long-term follow up, when low-dose aspirin prophylaxis was started in patients in sinus rhythm. There was overall improvement in patient symptoms while valve-related complications were minimal with no episode of structural deterioration or non-structural failure.

How to cite: Goldsmith, I., Lip, G. Y., Mukundan, S., & Rosin, M. D. (1998). Experience with low-dose aspirin as thromboprophylaxis for the Tissuemed porcine aortic bioprosthesis: a survey of five years' experience. The Journal of heart valve disease, 7(5), 574–579.

Background and aims of the study: This study aimed to investigate the early postoperative Doppler-derived hemodynamic results from the first patients receiving the On-XR prosthetic heart valve, a new bileaflet, pyrolytic carbon valve.

Methods: Data were derived from 111 patients included in a 10-center international trial between September 1996 and December 1997.

Results: The effective orifice area (EOA) for the valve, when implanted in the aortic position, ranged from 1.5 to 2.7 cm2 in 19 mm to 25 mm valves. The corresponding mean pressure gradients ranged from 11.8 to 7.6 mmHg. Mitral EOA was 2.3 cm2 for all sizes, these values being combined because the housing was identical for all mitral valves used in this study. The mitral mean gradient was 4.7 mmHg.

Conclusions: Early results of the study show the good hemodynamic performance of the On-X valve when implanted in the aortic or mitral positions.

How to cite: Chambers, J., & Ely, J. L. (1998). Early postoperative echocardiographic hemodynamic performance of the On-X prosthetic heart valve: a multicenter study. The Journal of heart valve disease, 7(5), 569–573.

Background and aims of the study: In order to optimize the length-to-diameter ratio, a series of circular aluminum rings with flared inlet and varying ring lengths, with internal diameters corresponding to that of 19 mm replacement prosthetic heart valve orifices, were tested in a steady-flow hydraulic system. The study aim was to determine the ring length-to-internal diameter ratio that produces the best hydraulic efficiency (i.e. lowest pressure gradient) within the physiologic flow rate range.

Methods: Each ring was tested at flow rates of 10, 15, 20, 25 and 30 l/min and length-to-diameter ratio effect on hydraulic efficiency determined experimentally. The hydraulic effect was most significant for a ratio of about 0.6, with an increase to 1.2 providing little additional benefit. Thus, a ratio of about 0.6 was considered optimum in terms of hydraulic efficiency and incorporated into the design of the On-X bileaflet mechanical heart valve (BHV) series. An in vitro hydrodynamic study of the smallest (19 mm) and largest (25 mm) clinical On-X aortic valves was performed at two independent laboratories. Standard St. Jude Medical BHVs were used as the study controls.

Results: Steady-flow experiments showed that the pressure gradient in the On-X valve was about 50% less than that of the comparable size control. The pulsatile flow study demonstrated a similar pressure gradient advantage. Laser Doppler anemometer velocity profiles taken downstream of the On-X valve at the aortic root showed typical characteristics of bileaflet valves, with three velocity peaks. The peak velocity reached 1.6 m/s for the On-X and 1.75 m/s for the control valve. A recirculating vortex was seen in the sinus cavity during the ejection period. This vortex, found in most aortic valves (including bioprostheses), is believed to provide a beneficial wash-out of the valve region and assist in valve closure.

Conclusions: These two independent studies clearly demonstrated that the elongated valve body and comparably larger flow area helped to improve the valve hydrodynamic performance, which is especially beneficial in the smallest (19 mm) size valve.

How to cite: Hwang, N. H., Reul, H., & Reinhard, P. (1998). In vitro evaluation of the long-body On-X bileaflet heart valve. The Journal of heart valve disease, 7(5), 561–568.

Background and aims of the study: Cloth-covered Starr-Edwards ball valves were the first choice in prosthetic substitution at the authors' institution between June 1968 and March 1977. This study investigated, retrospectively, macroscopic aspects of the prostheses at reoperation.

Methods: Among 59 survivors who underwent isolated aortic or mitral valve replacement, 12 required reoperation for valve dysfunction (five aortic valve replacements, seven mitral valve replacements). Reoperation was necessitated by valvular endocarditis, paravalvular leak, hemolysis, thromboembolism, orifice stenosis attributable to pannus, and inappropriate sizing related to growth and thrombus. The mean time to reoperation was 11.7 +/- 6.2 years after initial surgery (range: 2 years 4 months to 21 years 8 months).

Results: Marked cloth wear was observed in all aortic prostheses, but only slight wear in mitral valves. Pannus formation was observed around the orifice in both aortic and mitral prostheses, but strut cloth was not extensively covered by autologous tissue. In mitral valves, strut cloth was only slightly worn and less loose than that of the aortic valve. These changes notably affected prosthetic valve function, the most significant problem in mitral prostheses being thrombus (four of seven valves).

Conclusions: Pannus formation and thrombus caused by the reaction of the patient's tissues remain major problems in the use of artificial valves, and require further work for their improvement.

How to cite: Tsukamoto, S., Shiono, M., Orime, Y., Hata, H., Yagi, S., Okumura, H., Inoue, T., Kimura, S., Sezai, A., & Sezai, Y. (1998). Macroscopic aspects of cloth-covered Starr-Edwards prostheses at reoperation: what the precursory valve teaches us. The Journal of heart valve disease, 7(5), 556–560.

Background and aims of the study: Turbulences downstream of mechanical aortic valves are known to contribute to most valve-related complications such as thrombosis, embolization or damage to blood components. In vitro studies have demonstrated the impact of the orientation of prostheses on transvalvular energy loss. This study evaluates the influence of valve orientation on turbulences in the supravalvular aorta in pigs.

Methods: A rotation device which could carry a Medtronic Hall (MH) or St. Jude Medical (SJM) aortic valve prosthesis (23 mm) was constructed and implanted into four healthy pigs. Turbulence measurements using pulsed Doppler ultrasonography were carried out 3 cm downstream of the valve, while the prostheses were rotated in 45 degrees steps. Reynold's normal stress values (RNS) were calculated as key markers for turbulent stresses.

Results: Turbulences downstream of MH and SJM valves demonstrated a significant change with rotation. The MH valve showed minimum RNSmean values with orientation of the large orifice to the right posterior aortic wall, which is the area of highest velocities during ejection. With this orientation, aortic flow almost complied with physiologic conditions. Increase of turbulence was observed with any other position. The SJM valve revealed significant turbulent flow at any orientation. Minimum RNSmean values were also measured with one orifice facing the right posterior wall of the aorta.

Conclusion: With optimum orientation (major orifice facing the right posterior aortic wall) the MH valve matches the aortic flow pattern to near-normal physiology. The flow patterns of the SJM valve are less susceptible to rotation, but cannot attain the optimum RNS values of the MH prosthesis.

How to cite: Kleine, P., Perthel, M., Nygaard, H., Hansen, S. B., Paulsen, P. K., Riis, C., & Laas, J. (1998). Medtronic Hall versus St. Jude Medical mechanical aortic valve: downstream turbulences with respect to rotation in pigs. The Journal of heart valve disease, 7(5), 548–555.

Background and aims of the study: This study reports mortality and morbidity rates observed with the Omniscience valve prosthesis. Complication rates were calculated from a prospective, long-term follow up study of patients with the Omniscience valve prosthesis in the aortic, mitral, or both aortic and mitral positions.

Methods: The Omniscience heart valve was implanted into 200 consecutive patients (42.5% aortic valve replacement (AVR); 51.5% mitral valve replacement (MVR); 6% AVR/MVR), with an average age of 57 +/- 12 years, at the author's institution. Patients were checked regularly at a clinic which specialized in prosthetic valve follow up. Only one patient was lost to follow up during this 13-year period (99.5% completeness of follow up).

Results: The total follow up was 1475 patient-years (pt-yr); mean follow up 8.0 +/- 2.9 years. Survival probability at 12 years, including freedom from both early and late mortalities, was 67.1 +/- 6.7% for AVR and 62.8 +/- 6.0% for MVR patients. There were no structural valve failures. Twelve-year freedom from thromboembolism was 85.5 +/- 5.0% and 85.2 +/- 6.5% for AVR and MVR, respectively. For thromboembolism + anticoagulation-related hemorrhage, the 12-year freedom rates were 79.4 +/- 5.3% for AVR and 77.3 +/- 6.7% for MVR patients.

Conclusions: The Omniscience valve demonstrated a low risk of late complications, comparable with that of other modern mechanical valves. Omniscience valve patients also exhibited excellent hematology values and good functional improvement during this long-term prospective follow up. It is concluded that the Omniscience valve has satisfactory long-term clinical performance in both the aortic and mitral positions.

How to cite: Teijeira F. J. (1998). Long-term experience with the omniscience cardiac valve. The Journal of heart valve disease, 7(5), 540–547.

Background and aims of the study: In patients with small aortic annuli, the choice of prosthesis should be based on hemodynamics and valve durability. The Carpentier-Edwards pericardial valve offers good hemodynamic performance and long-term valve durability. We reviewed our 12-year experience with 121 patients who received a 19 mm prosthesis.

Methods: A total of 121 patients (97 females, 24 males; mean age 73.2 +/- 9.4 years) underwent isolated aortic valve replacement with a 19 mm Carpentier-Edwards pericardial bioprosthesis in our institution between July 1984 and December 1995. Patients were followed up for an average of 4.84 years after surgery; total follow up was 581 patient-years (pt-yr).

Results: The operative mortality rate was 3.3% (4/121). At the present time, 77 patients (86%) are in NYHA class I or II with a mean gradient of 18.0 +/- 6.9 mmHg and mean effective orifice area 1.1 +/- 0.23 cm2. There were 25 late deaths. After 12 years the actuarial survival rate was 42 +/- 26%. Eight patients died of valve-related cause (one endocarditis, one structural failure, two thromboembolisms, one anticoagulant-related hemorrhage, three sudden deaths). At 12 years, the actuarial rate of freedom from valve-related death was 61 +/- 37% and from non-sudden valve-related death 88 +/- 11%. Valve-related complications included six thromboembolic episodes (1.0%/pt-yr), one endocarditis (0.17%/pt-yr), two reoperations (0.34%/pt-yr) and two structural valve failures (0.34%/pt-yr). After 12 years, freedom from reoperation was 89 +/- 11%, from valve failure 92 +/- 8%, from thromboembolic episodes 82 +/- 16% and from endocarditis 99 +/- 1%.

Conclusion: With a low rate of structural valve failure at 12 years and a good clinical performance, the Carpentier-Edwards prosthesis is a reliable alternative for small aortic annuli.

How to cite: Nakajima, H., Aupart, M. R., Neville, P. H., Sirinelli, A. L., Meurisse, Y. A., & Marchand, M. A. (1998). Twelve-year experience with the 19 mm Carpentier-Edwards pericardial aortic valve. The Journal of heart valve disease, 7(5), 534–539.

Despite progress in the area of antimicrobial treatment and the surgical use of homografts, prosthetic valve endocarditis (PVE) remains one of the most dangerous complications following heart valve replacement. We present the case of a patient treated for acute endocarditis which affected the mitral valve and who developed recurrent PVE and native aortic valve endocarditis. After multiple valve surgery, the infection was controlled following aortic and mitral valve replacement using silver-coated prostheses. The St. Jude Medical (SJM) mechanical heart valve Masters Series with Silzone coating is intended to protect heart valve patients against microbial infection. The Silzone coating is formed by an ion beam-assisted deposition process that incorporates silver into the sewing cuff of the SJM heart valve. It has also been suggested that silver treatment may improve the healing characteristics of the heart valve sewing cuff. This technology may be a valuable option to prevent or cure PVE, in addition to homografts. Although the present patient is an isolated case, it was encouraging to find not only a well-healed mitral valve silver-coated prosthesis but also no persistent or recurrent infection during a nine-month follow up.

How to cite: Carrel, T., Nguyen, T., Kipfer, B., & Althaus, U. (1998). Definitive cure of recurrent prosthetic endocarditis using silver-coated St. Jude Medical heart valves: a preliminary case report. The Journal of heart valve disease, 7(5), 531–533.

Background and aims of the study: Prosthetic valve endocarditis (PVE) is an infrequent but serious complication of cardiac valve replacement. PVE is a foreign body infection predominantly based in the sewing cuff of a prosthetic heart valve leading to thromboembolism, ring abscess, paravalvular leakage, and eventual invasion of the myocardium. Mortality rates as high as 75% have been reported. A silver-coated sewing cuff is now available (St. Jude Medical mechanical heart valve SJMR Masters Series with Silzone coating) intended to inhibit the colonization and attachment to the sewing cuff of those microorganisms commonly associated with PVE. Silzone is a dense layer of metallic silver deposited on individual fiber surfaces of the valve cuff. Previously, Silzone coating was shown in vitro to decrease attachment and colonization of microorganisms with no adverse affect on biocompatibility. The present study was designed to assess the efficacy of Silzone-coated polyester fabric in vivo in a direct-contamination model. The organism chosen was a pathogenic strain of Staphylococcus epidermidis capable of producing biofilm.

Methods: Infection resistance of uncoated polyester and Silzone-coated polyester fabric was assessed by the acute inflammatory response in a guinea pig subdermal model. Fabric samples were implanted sterile or inoculated with S. epidermidis. The ability of the strain to produce biofilm was verified in vitro. Samples were explanted at one and two days postoperatively. Verification of the infecting bacteria was by colony morphology and Gram-staining properties of bacteria from the explanted samples. Inflammation was assessed histopathologically. Percent necrotic tissue within the fabric was determined by computer-assisted image analysis.

Results: Histopathology and image analysis of necrotic tissue showed significantly less inflammation within the Silzone-coated fabric than within uncoated polyester fabric.

Conclusions: The Silzone coating reduced inflammation in this direct-contamination model using a strain of S. epidermidis that is capable of producing biofilm. This indicates a concentration of silver ions sufficient for bacteriostatic or bactericidal activity within the fabric in vivo.

How to cite: Illingworth, B. L., Tweden, K., Schroeder, R. F., & Cameron, J. D. (1998). In vivo efficacy of silver-coated (Silzone) infection-resistant polyester fabric against a biofilm-producing bacteria, Staphylococcus epidermidis. The Journal of heart valve disease, 7(5), 524–530.

A very rare case of Marfan syndrome associated with acute aortic regurgitation due to rupture of a fibrous strand of a fenestrated aortic valve is presented. Although an aortic valve fenestration usually has no pathologic significance, its association with aortic annular dilatation plays an important role. Rupture of a myxomatously degenerated fibrous strand loaded with high tension from annular dilatation reducing the coaptation area of each cusp during diastole was the suspected cause of acute massive regurgitation by complete retroversion of the right coronary cusp. Rupture of a fibrous strand of a fenestrated aortic valve with a dilated annulus could result in acute massive aortic regurgitation, for which prompt surgical repair is mandatory.

How to cite: Akiyama, K., Ohsawa, S., Hirota, J., & Takiguchi, M. (1998). Massive aortic regurgitation by spontaneous rupture of a fibrous strand in a fenestrated aortic valve. The Journal of heart valve disease, 7(5), 521–523.

Coagulase-negative staphylococci have been implicated in certain human infections but are generally considered to be contaminants. Although their clinical significance has been questioned, rare species of coagulase-negative staphylococci such as Staphylococcus capitis and Staphylococcus ludgunensis have recently emerged which cause endocarditis with high morbidity and mortality rates. We report a case of severe aortic valve endocarditis with conduction delays due to S. capitis infection which was treated successfully with antibiotics.

How to cite: al-Rashdan, A., Bashir, R., & Khan, F. A. (1998). Staphylococcus capitis causing aortic valve endocarditis. The Journal of heart valve disease, 7(5), 518–520.

Quadricuspid aortic valve is an uncommon cause of aortic regurgitation. We report two patients who underwent aortic valve replacement because of severe aortic incompetence; the presence of a quadricuspid aortic valve was an accidental surgical finding. In one patient the aortic valve comprised two equal-sized larger cusps and two equal-sized smaller cusps, while in the other it comprised three cusps of similar size and a small accessory cusp between the right and non-coronary cusps. This report confirms the rarity of the disease and the fact that patients with quadricuspid aortic valves characterized by cusps of different sizes are more prone to develop progressive aortic incompetence because of unequal distribution of stresses on the valve. Therefore, such patients should undergo periodic, life-time echocardiographic assessment once this malformation is detected.

How to cite: Bortolotti, U., Scioti, G., Levantino, M., Milano, A., Nardi, C., & Tartarini, G. (1998). Aortic valve replacement for quadricuspid aortic valve incompetence. The Journal of heart valve disease, 7(5), 515–517.

Aortic insufficiency is a well known but uncommon valvular dysfunction in patients with osteogenesis imperfecta. In such cases, aortic valve surgery has rarely been performed, and carries a high risk of perioperative complications. We report two patients with osteogenesis imperfecta, who underwent elective successful aortic valve replacement. The surgical problems encountered in this connective tissue disorder are also reviewed.

How to cite: Zegdi, R., D'Attellis, N., Fornes, P., Fuzellier, J. F., Carteaux, J. P., Fabiani, J. N., & Carpentier, A. (1998). Aortic valve surgery in osteogenesis imperfecta: report of two cases and review of the literature. The Journal of heart valve disease, 7(5), 510–514.

Background and aims of the study: Postoperative aortic complications of aortic dissection or enlargement of the ascending aortic develop in patients with aortic valve replacement (AVR) and dilated ascending aorta. This clinical study aimed to demonstrate the incidence of aortic complications after AVR in patients with dilated ascending aorta, and to clarify the surgical indication and approach for dilated ascending aorta and aortic regurgitation.

Methods: A total of 82 patients who underwent AVR between 1985 and 1997 were allocated to two groups according to the preoperative diameter of the ascending aorta. A dilated ascending aorta with diameter > or = 40 mm was seen in 38 patients (group I), and a small ascending aorta with diameter < 39 mm in 44 patients (group II). Group I patients were further allocated to two subgroups: 12 patients underwent aortoplasty (group IA) and 26 did not (group IB). Event-free rates of aortic complications and survival rate were compared between groups I and II.

Results: Postoperative aortic dissection during the follow up period occurred in four hypertensive patients in group I (one in group IA, three in group IB); no aortic dissection was seen in group II. Freedom from all aortic complications at 10 years after surgery was 75 +/- 10% in group I and 100% in group II (p < 0.05). The cumulative survival rate at 10 years was 59 +/- 11% in group I (group IA: 71 +/- 18%, group IB: 51 +/- 14%) and 95 +/- 4% in group II (p < 0.05).

Conclusions: Patients with a dilated ascending aorta (> or = 40 mm diameter) were more likely to encounter complications of the aortic dissection or enlargement after AVR than those with a small ascending aorta. Surgery to prevent aortic dissection or enlargement must be selected in patients with mildly dilated ascending aorta and hypertension.

How to cite: Natsuaki, M., Itoh, T., Rikitake, K., Okazaki, Y., & Naitoh, K. (1998). Aortic complications after aortic valve replacement in patients with dilated ascending aorta and aortic regurgitation. The Journal of heart valve disease, 7(5), 504–509.

Background and aims of the study: This study reports the clinicopathologic characteristics of congenital bicuspid aortic valves necessitating surgical intervention.

Methods: Among 374 aortic valve procedures during the past 15 years, 63 cases of bicuspid aortic valve were encountered. Patients included 45 males and 18 females; mean age was 53 years (range: 14 to 76 years).

Results: Thirty-two patients demonstrated aortic stenosis (AS), 27 aortic regurgitation (AR), and four had both conditions. Patients with AR were significantly younger than those with AS (45 +/- 13 versus 60 +/- 11 years; p < 0.01). Histologic study of the excised valve disclosed severe myxoid degeneration in 16 of 27 patients with AR. These patients underwent surgery at a younger age than the other 11 with calcification and endocarditis (40 +/- 13 versus 52 +/- 10 years; p = 0.01). Based on the macroscopic appearance, the lesions were divided into those with (n = 38) and without (n = 25) raphe. Twenty-one patients (55%) in the former group demonstrated AR, whereas 19 (76%) in the latter group demonstrated AS. Patients with raphe were significantly younger at the time of surgery than those without raphe (50 +/- 15 versus 57 +/- 11 years; p = 0.02). As a complication, ascending aortic aneurysm was observed in six patients.

Conclusions: In a bicuspid aortic valve, calcification with stenosis commonly occurs in most older patients. However, in some young adult patients with raphe, AR may result from myxoid degeneration. The presence of raphe in the bicuspid valve appears to have a significant influence on valve hemodynamics.

How to cite: Yotsumoto, G., Moriyama, Y., Toyohira, H., Shimokawa, S., Iguro, Y., Watanabe, S., Masuda, H., Hisatomi, K., & Taira, A. (1998). Congenital bicuspid aortic valve: analysis of 63 surgical cases. The Journal of heart valve disease, 7(5), 500–503.

The effects of both single and long-term oral captopril or nifedipine treatment on cardiac parameters at rest and during exercise in patients with moderate to severe aortic regurgitation was investigated.

Methods: Thirty-one asymptomatic patients with chronic, isolated, previously untreated, moderate to severe aortic regurgitation (AR) of mean grade 3.1 +/- 0.6, had left ventricular end-diastolic diameter (LVEDD) 64 +/- 5 mm, left ventricular end-systolic diameter (LVESD) 41 +/- 5 mm, ejection fraction (EF) 66 +/- 6% and fractional shortening (FS) 37 +/- 5% measured by echo-Doppler. Bedside Swan-Ganz measurements at rest and at peak exercise (75 W) were conducted before (baseline) and at 75-90 min after oral administration of 20 mg nifedipine. Repeat testing was performed 24 h later, at 75-90 min after oral administration of 25 mg captopril.

Results: At rest, nifedipine significantly reduced systemic vascular resistance (SVR) compared with baseline (704 +/- 152 versus 880 +/- 216 dynes.s.cm-5; p < 0.0001) and captopril treatment (800 +/- 176 dynes.s.cm-5; p < 0.0001). Despite significant improvement of effective left ventricular (LV) stroke volume (LVSVef) after both nifedipine and captopril over baseline (103 +/- 20 ml), LVSVef did not differ between nifedipine and captopril (110 +/- 17 versus 110 +/- 22 ml; NS). Nifedipine significantly increased effective cardiac output (COef) from baseline (6.7 +/- 1.3 l/min) to 8.2 +/- 1.5 l/min; p < 0.0001, but this was due to an increase in heart rate (HR) (66 +/- 10 versus 75 +/- 1 beats/min; p < 0.0001). In contrast, captopril affected neither COef nor HR. In addition, captopril reduced pulmonary capillary wedge pressure (PCWP) more than nifedipine (8.7 +/- 2.5 versus 11 +/- 2.9 mmHg; p < 0.0001). At exercise, both drugs caused similar reductions in blood pressure and systemic vascular resistance (SVR). By comparison with exercise baseline, LVSVef was increased by captopril (139 +/- 24 versus 147 +/- 27 ml; p < 0.01) but was unchanged after nifedipine. Compared with baseline, nifedipine increased COef (from 14.4 +/- 2.0 to 15.5 +/- 2.1 l/min; p < 0.0001) due to a significantly higher HR, while COef and HR were unchanged after captopril. A smaller increase in PCWP was also seen after captopril than nifedipine and baseline (both p < 0.0001). After long-term therapy (33 +/- 12; range: 12 to 53 months) with captopril (75 mg/day, n = 13) or nifedipine (40 mg/day; n = 12) there was no change in LVESD, and in left ventricular EF and FS in either groups. None of the patients became symptomatic. Compared with baseline, captopril significantly reduced AR grade by 0.9 +/- 0.6 (p < 0.01), but not significantly so versus nifedipine. LVEDD was reduced in captopril patients by 4.0 +/- 2.6 mm (p < 0.0002), but not significantly so in nifedipine patients. LVEDD was normalized in five captopril patients, and in four treated with nifedipine.

Conclusions: Single captopril treatment caused a greater hemodynamic improvement than nifedipine, notably during exercise; these findings were confirmed by long-term therapy with both drugs. Therefore, captopril may delay the development of left ventricular dysfunction and thus the time for corrective surgery.

How to cite: Banaszewski, M., Rydlewska-Sadowska, W., & Rubkiewicz, S. (1998). Captopril or nifedipine? Comparison of rest and exercise acute effects and long-term therapy in chronic isolated asymptomatic moderate to severe aortic regurgitation. The Journal of heart valve disease, 7(5), 488–499.

We report on two patients with end-stage dilated cardiomyopathy and functional mitral valve insufficiency who underwent left ventricular volume reduction. Intrapapillary resection and correction of the mitral valve regurgitation produced inadequate reduction of the ventricular cavity and resulted in inability to wean the patients from cardiopulmonary bypass. Following extension of the resection to include the papillary muscles and mitral valve replacement, there was a significant improvement in cardiac function. Both patients survived surgery; subsequent echocardiography provided evidence of improved myocardial function and NYHA functional class.

How to cite: Lim, K. H., Callaway, M., & Angelini, G. D. (1998). Left ventricular volume reduction for end-stage heart failure: intrapapillary or extrapapillary resection, mitral valve repair or replacement?. The Journal of heart valve disease, 7(5), 484–487.

Background and aims of the study: Partial left ventriculectomy (PLV, the "Batista procedure") has received recent attention as a surgical treatment for patients with dilated cardiomyopathy and end-stage congestive heart failure; however, the mechanisms responsible for the purported short-term improvement in left ventricular (LV) function are poorly characterized. This study examined the effects of PLV on three-dimensional (3-D) LV geometry, wall stress and passive LV mechanics in excised porcine hearts.

Methods: Thirty-three radio-opaque tantalum markers were placed into the LV wall of nine freshly excised, porcine hearts (arrested with cold crystalloid cardioplegia) to measure three dimensional LV geometry and volume. Simultaneous biplane video-fluoroscopic marker images and LV pressure (LVP) were obtained over a wide range of LV volumes generated with an intracavitary LV balloon. Measurements were repeated after excision of a diamond-shaped wedge of the lateral LV wall between the papillary muscles (mean: 8 x 3 x 2 cm; 10 +/- 2% of LV mass).

Results: Following PLV, the ventricle assumed a more elliptical shape (LV eccentricity rose from 0.71 +/- 0.15 to 0.81 +/- 0.09, p < 0.01). Circumferential radius of curvature fell in the anterior, lateral and posterior regions at the equatorial level (p < 0.01), while the posterior wall longitudinal radius of curvature increased at the basal, equatorial and apical levels (p < 0.01). No change in the longitudinal radius of curvature was observed in the other walls. These changes were associated with a fall in average equatorial LV wall stress from 176 +/- 34 to 159 +/- 30 kdyne/cm2 (p < 0.02). Myocardial stiffness (slope of the LV stress-strain relation) fell from 12.4 +/- 4.0 to 10.0 +/- 3.4 (p < 0.004), indicating lower global LV wall stress at any given LV size.

Conclusions: In flaccid porcine hearts, the left ventricle became more elliptical and chamber size decreased after PLV, which resulted in lower regional LV wall stress and myocardial stiffness. LV ellipticalization may improve systolic LV performance by decreasing regional LV afterload (e.g., systolic wall stress), which would thereby lower myocardial oxygen consumption and improve LV pump efficiency.

How to cite: Green, G. R., Moon, M. R., DeAnda, A., Jr, Daughters, G. T., 2nd, Glasson, J. R., & Miller, D. C. (1998). Effects of partial left ventriculectomy on left ventricular geometry and wall stress in excised porcine hearts. The Journal of heart valve disease, 7(5), 474–483.