This article is closed access and to view this content please login: https://www.icr-heart.com/author/login/ and request for the access.

How to cite: Sierra-Quiroga, J., Rubio-Alvarez, J., Duran-Munoz, D., & Garcia-Bengochea, J. B. (1999). Katarcioglu SF, Yamak B, Ulus AT, Tasdemir O, Bayazit K. Mitral valve replacement with St. Jude Medical prosthesis and low-dose anticoagulation in patients aged over 50 years. J. Heart Valve Dis 1998;7:455-459. The Journal of heart valve disease, 8(2), 232–233.

This article is closed access and to view this content please login: https://www.icr-heart.com/author/login/ and request for the access.

How to cite: Garon, C. F., Oury, J. H., & Duran, C. M. (1999). Virus-like particles in the mitral and tricuspid valves explanted from a patient treated with Fenfluramine-Phentermine. The Journal of heart valve disease, 8(2), 232.

Background and aim of the study: Multiple reports of convexo-concave valve outlet strut fractures have focused on the welds, often implicating putative defects of uncertain character and significance. This study differs from all others in that it systematically assesses a large number (n = 60) of intact and fractured valves and clearly differentiates findings on the critical, tensile-stressed, inflow side of the outlet strut leg from those on the outflow side, which are subject only to compression.

Methods: Each valve was examined by scanning electron microscopy and subjected to multiple metallographic sectioning of each strut-flange interface. All fractures and selected intact valves were further analyzed with X-ray dispersive spectroscopy.

Results: Fatigue striations were seen in all fractured valves, and their orientation indicated that every fracture initiated in an area on the inflow side, spreading out progressively towards the outflow side. Data indicated that 22% of the first-to-fail leg separations and 17% of all fractures initiated outside of the weld. Element segregation areas were seen in 40% of welds, significantly more commonly in intact valves, invariably located on the outflow side, and typically (85%) apart from the fracture path. Microporosity was identified in 15% of welds, usually near the outflow side, and in the same proportion of intact and fractured valves. One fracture surface had a 38 microns, inflow-side void that might have been a factor in crack initiation in this valve, which was highly stressed.

Conclusions: With this singular exception, no metallurgical feature of any weld was found that appeared to have contributed, even in a minor way, to the process of outlet fracture.

How to cite: Wenzel, T. C., Manning, C. R., Chandler, J. G., & Williams, D. F. (1999). Welding metallurgy's putative influence on Björk-Shiley convexo-concave valve outlet strut failures. The Journal of heart valve disease, 8(2), 218–231.

Investigations of convexo-concave (C/C) valve outlet strut fractures (OSFs) were initially confounded by knowledge that the strut was subject to bending forces in arresting the opening disc. Pulse duplicator studies subsequently showed that closing loads were all born by the inlet strut, along with an understandable focus on the nature of the welds, where most fractures occurred. As observations of explanted valves accumulated, certain features pointed to unusual closing loads that might be contributory factors, but these hypothetical forces could not be verified. Epidemiological extrapolations and case-matched control studies have shown that certain valve and patient characteristics were each associated independently with increased OSF risk, leading to clinically valuable risk stratification, but little additional understanding of why OSFs continued to occur. Detection of the causative, highly transient (< 0.5 ms), outlet-strut-tip impacts due to closing disc over-rotation that have almost ten times the force of disc opening, and the capability of inducing leg-base bending stresses beyond the strut wire's fatigue endurance limit had to await the development of computer-controlled pulse duplicators and strut-leg strain gaging. Exercised young animals easily achieved such strut loading, but most human patients would probably have more difficulty. The actual OSF mechanism is a long-term, valve-patient interaction that requires the concurrence of susceptible valve geometry and sufficient ventricular contractility potential to develop the isovolumic, high dP/dt needed for forceful disc over-rotation. Critical strut tip loading must then occur often enough to fatigue fracture both strut legs within the patient's lifetime with the valve.

How to cite: Wieting, D. W., Eberhardt, A. C., Reul, H., Breznock, E. M., Schreck, S. G., & Chandler, J. G. (1999). Strut fracture mechanisms of the Björk-Shiley convexo-concave heart valve. The Journal of heart valve disease, 8(2), 206–217.

Background and aim of the study: Recent clinical thrombotic experiences with the Medtronic Parallel (MP) bileaflet heart valve have highlighted the need for new methods to assess preclinical valve hinge flow. The aim of the current study was to investigate hinge pivot flow fields in bileaflet mechanical heart valves using flow visualization in scaled x5 magnification transparent polymer models and computational fluid dynamic (CFD) analysis using CFD 2000 STORM code.

Methods: Polymeric x5 flow models of the On-X, St. Jude Medical (SJM) and MP bileaflet heart valves were constructed using laser stereolithography to replicate the interior geometry while maintaining realistic manufacturing tolerances. Each hinge flow experiment was carried out by installing the transparent x5 model in a pulsatile flow loop, which was designed according to Womersley number similitude requirements. Motions of suspended microparticles in the valve hinge area, recorded by laser imaging techniques, were used to visualize hinge flow. Experimentally measured parameters were used as input for CFD analysis. CFD simulations were made by solving the Navier-Stokes equation using a finite volume method with the pressure-based algorithm for continuity, and a pressure-implicit with splitting of operators (PISO) algorithm for pressure-velocity coupling. Moving grid methodology was employed to simulate periodic motion of the valve leaflets. CFD hinge flow results were visualized on four parallel planes at different depths in the hinge socket. The hinge flow patterns of the three types of bileaflet heart valve design are discussed.

Results: Prominent vortex formation and stagnant flow areas were noticed in the pivot region of the MP valve. Vortices persisted throughout both the forward- and reverse-flow phases. These flow structures were not observed in the hinge areas of the SJM and On-X valves.

Conclusions: Vortex formation observed in the MP valve may contribute to the high thrombogenic potential of this valve. The absence of such vortices and areas of stagnant flow in the On-X and SJM valves indicate that hinge flow conditions in these valves do not favor mechanically induced thrombogenesis or thromboembolic events.

How to cite: Gao, Z. B., Hosein, N., Dai, F. F., & Hwang, N. H. (1999). Pressure and flow fields in the hinge region of bileaflet mechanical heart valves. The Journal of heart valve disease, 8(2), 197–205.

Background and aim of the study: Recent clinical research using transcranial Doppler ultrasonography has shown the presence of emboli in the cranial circulation of some mechanical heart valve patients. Due to the high-intensity signals produced by these emboli, it has been suggested that they are small gas bubbles. Meanwhile, transesophageal echocardiography of mechanical heart valve patients has shown images of bright, mobile particles (also considered to be gas bubbles) near the valve. Motivated by these reports, a series of in vitro studies was performed to investigate the relationship between dissolved gas concentration and the incidence of bubble formation after valve closure.

Methods: A mock circulatory loop was used to study a Medtronic Hall tilting disc valve in the mitral position of the Penn State Electrical Ventricular Assist Device (EVAD). The valve was videotaped as it operated in saline with various levels of dissolved CO2. A Doppler ultrasound probe served as a bubble detector on the outflow side of the EVAD. Measurements of vaporous cavitation intensity with a high-fidelity pressure transducer were also made. Similar experiments were then performed in porcine blood, using an imaging ultrasound transducer to detect bubbles.

Results: Bubbles were seen moving off the valve in the retrograde direction just after closure. The ultrasound probe detected these bubbles downstream, indicating a bubble lifetime on the order of seconds. It was observed with high-speed video that bubble formation and cavitation are separate events and occur at different times during valve closure. Bubbles were more likely to be observed when CO2 levels were higher. Experiments in blood provided images of bubbles near the valve, predominantly at higher CO2 levels and high valve loading conditions.

Conclusions: These results show that stable gas bubbles can form during mechanical heart valve operation. The bubbles likely form from the combined effects of gaseous nuclei formed by cavitation, low-pressure regions associated with regurgitant flow, and the presence of CO2, a highly soluble gas.

How to cite: 

Background and aims of the study: Although bioprosthetic valves currently in use have low thrombogenicity, durability remains very unsatisfactory. Valve failure occurs early from calcification, and later from tissue wear. Stentless design lessens the latter, and anticalcification treatments the former. Recently, a stentless chordally supported quadrileaflet mitral valve (QMV) bioprosthesis made of selected tanned bovine pericardium, treated to minimize calcification, has become available for clinical study. The aim of this study was to report the early results relating to valve performance, and patient outcome.

Methods: Since December 1996, the QMV has been implanted in 23 patients (mean age 38 +/- 12 years) requiring isolated mitral valve replacement for valve lesions not suited for repair. All patients were symptomatic (three in NYHA functional class II, 16 in class III, four in class IV). Preoperatively, all underwent full clinical and echocardiographic assessment, and intraoperative transesophageal evaluation immediately after valve implantation. Blood tests for hemolysis were performed preoperatively and at 3 months after surgery.

Results: After a mean follow up of 8.3 months (range: 1 to 18 months), 22 patients were alive and symptomatically improved (NYHA class I or II). One patient died of sternal sepsis soon after surgery. There have been no reoperations, nor cases of infective endocarditis or thromboembolism. Subclinical hemolysis was shown pre- and postoperatively in 35% and 32% of cases, respectively. Intraoperative transesophageal echocardiography post valve implantation demonstrated mitral regurgitation which was trivial in 15 patients (78%) and mild in five (22%).

Conclusions: The QMV can be implanted safely, and the early clinical results relating to patient outcome and valve performance are encouraging.

How to cite: Middlemost, S. J., Sussman, M., Patel, A., & Manga, P. (1999). The stentless quadrileaflet bovine pericardial mitral valve: early clinical results. The Journal of heart valve disease, 8(2), 174–179.

Background and aim of the study: Non-obstructive prosthetic valve thrombosis (PVT) is a unique subset that features clinical presentation without heart failure, and may be asymptomatic. Thrombolysis has been accepted for obstructive PVT, but treatment strategies of non-obstructive PVT are controversial. This study compared the efficacy and safety of thrombolysis and heparin treatment in these patients.

Methods: Between 1993 and 1998, 20 consecutive patients were found by multiplane transesophageal echocardiography (TEE) to have non-obstructive PVT. TEE was performed for peripheral embolism in two patients, stroke or transient ischemic attack in six, stroke and fever in two, fever in one patient, as a routine postoperative examination in two patients, and for other reasons in seven. Patients were allocated to two groups: group I (n = 8) received streptokinase-mediated fibrinolysis; group II (n = 12) received intravenous heparin by infusion. Treatment was monitored using TEE.

Results: There was no difference between patient groups with regard to sex, age, type of prosthesis and time since operation, though anticoagulant status was more often inadequate in group II. By TEE, valve motion was normal in all patients. In group I, all thrombi were mobile and 5-13 mm in diameter; in group II, all thrombi but three were mobile and 3-18 mm in diameter. In group I, thrombolysis was successful in all patients, without complications, within 6-72 h. In group II, heparin treatment was successful in six patients in 3-32 days. In one patient, seven days' of unsuccessful heparin was followed by two months' successful coumarin therapy. Among five unsuccessful cases, the thrombus size increased in four (three became obstructive in 7-35 days); all four patients were switched to fibrinolysis, which was successful without complications in 12-60 h. The fifth patient developed a stroke after nine days of heparin treatment and was subsequently operated on.

Conclusions: Non-obstructive PVT may be asymptomatic in one-third of patients. Thrombolysis is an efficient and safe treatment, and may be first-line therapy if there is no contraindication. Heparin treatment was successful in about one-half of our cases in the presence of sessile or small thrombi and inadequate anticoagulant status. In unsuccessful cases, thrombi became obstructive or caused stroke during heparin therapy, the adequate duration of which remains unclear.

How to cite: Lengyel, M., Vegh, G., & Vandor, L. (1999). Thrombolysis is superior to heparin for non-obstructive mitral mechanical valve thrombosis. The Journal of heart valve disease, 8(2), 167–173.

Background and aim of the study: Increasing numbers of elderly (aged > 80 years) patients are being referred for cardiac surgery, and results for coronary artery bypass grafting (CABG) are generally better than for combined CABG and valve replacement.

Methods: During the past 55 months, 77 octogenarians underwent cardiac intervention in our institution. Forty-five patients (mean age 82.5 years) underwent CABG alone; surgery was elective in 33% of patients and 2.7 +/- 1.0 grafts per patient were performed. Thirty-two patients (mean age 82.4 years) underwent combined CABG and valve surgery (28 aortic, four mitral); 2.1 +/- 0.8 grafts per patient were performed and 65% of cases were emergencies.

Results: In patients undergoing CABG alone, the operative mortality rate was 2% and rose to 4% (n = 2) at the end of follow up. Mean NYHA functional class improved significantly from 3.5 +/- 0.5 to 1.4 +/- 0.3 after surgery (p < 0.05) and most patients reported marked improvement in their quality of life. In CABG + valve surgery patients, the operative mortality rate was 6% (n = 2) and reached 18% by the end of follow up. In these patients the complication rate was 24% and mean hospitalization stay 11.0 +/- 2.9 days, while mean NYHA functional class improved from 3.4 +/- 0.6 to 1.2 +/- 0.5. Data analysis revealed that mitral regurgitation combined with coronary artery disease (p < 0.03) and prolonged cross-clamping time (p < 0.01) were the most important independent factors for mortality.

Conclusion: This study confirms that, in selected elderly patients, combined CABG and cardiac surgery can achieve good postoperative results.

How to cite: Sahar, G., Abramov, D., Erez, E., Sagie, A., Barak, J., Raanani, E., Sulkes, J., & Vidne, B. A. (1999). Outcome and risk factors in octogenarians undergoing open-heart surgery. The Journal of heart valve disease, 8(2), 162–166.

This article is closed access and to view this content please login: https://www.icr-heart.com/author/login/ and request for the access

How to cite: Acar J. (1999). Detecting coronary artery stenosis before surgery in patients with valvular heart disease. The Journal of heart valve disease, 8(2), 160–161.

Spontaneous thrombosis of a native aortic valve is an uncommon event that usually follows local trauma, such as cardiac surgery or left heart catheterization, or occurs as a complication of bacterial endocarditis. We report the case of a 65-year-old woman with a history of retinal artery occlusion and severe aortic valve stenosis, in whom transesophageal echocardiography revealed a mobile mass attached to the ventricular surface of the aortic valve. There was no evidence of any hypercoagulable state or infection process. Surgery was performed and a severely stenotic valve resected; a partially organized and firmly adherent free-floating thrombotic mass was observed on the ventricular surface of the aortic valve. Histologic examination demonstrated an organized thrombus. Eleven months after surgery the patient is doing well.

How to cite: Massetti, M., Babatasi, G., Saloux, E., Bhoyroo, S., Grollier, G., & Khayat, A. (1999). Spontaneous native aortic valve thrombosis. The Journal of heart valve disease, 8(2), 157–159.

Background and aim of the study: The effect of aging on aortic valve and root function was examined using a three-dimensional finite element model of the aortic root and valve.

Methods: Three models representing normal (< 35 years), middle (35-55 years) and older (> 55 years) age groups, were created by assigning tissue thickness and stiffness that increased with age (using ANSYS software). Diastolic pressure was applied; stresses and strains were then evaluated for the valve and root, and percent leaflet coaptation was calculated.

Results: Leaflet stresses were increased with aging, whereas leaflet strain and coaptation were decreased with aging. Specifically, leaflet stresses were increased by 6-14% in the middle-age model, and by 2-11% in the older-age model, as compared with normal in specified leaflet regions. Conversely, leaflet strains were decreased by 27-41% and 42-50% in the middle-age and older-age models, respectively. This reduced strain resulted in markedly decreased coaptation (9% and 30% reduction for middle- and older-age models). In the root, stress remained fairly constant with age, but strain in the root was progressively reduced with age (11% and 35% reduction for the middle and older-age models, respectively).

Conclusions: In these models, increased stiffness and thickness due to aging reduces leaflet deformation and restricts coaptation. Clinically, valvular regurgitation may result due to leaflet thickening and stiffening with normal aging. Our model can now be utilized to evaluate the root-valve relationship in the presence of bioprosthetic valves or root replacements.

How to cite: Grande, K. J., Cochran, R. P., Reinhall, P. G., & Kunzelman, K. S. (1999). Mechanisms of aortic valve incompetence in aging: a finite element model. The Journal of heart valve disease, 8(2), 149–156.

Background and aim of the study: Autonomic dysfunction may be a risk factor for the generation of arrhythmias and sudden death in patients with severe aortic stenosis; thus, patients with this condition were studied to assess cardiac autonomic function.

Methods: Twelve patients (five males, seven females; mean age 63 +/- 13 years) with severe symptomatic aortic stenosis before and after aortic valve replacement, were compared with a control group matched by age and sex. In the study group, mean fractional shortening was 36.5 +/- 5% and maximal aortic gradient 94.7 +/- 12 mmHg, assessed echocardiographically. Autonomic dysfunction was evaluated by following heart rate variability in both time and frequency domains. Spectral analysis was assessed at very low frequency (VLF: 0.017-0.05 Hz), low frequency (LF: 0.05-0.15 Hz) and high frequency (HF: 0.15-0.50 Hz). Heart rate variability was analyzed during three intervals, between 6:00-8:00 am (morning), 14:00-16:00 (afternoon) and 02:00-04:00 (night), and re-evaluated at 8-10 months after aortic valve replacement.

Results: Compared with controls, patients with aortic stenosis presented a significantly lower heart rate variability in the morning and afternoon, analyzed either by time or frequency domain: 50 +/- 22 versus 132 +/- 52 ms (p < 0.05); VLF 5.0 +/- 1.5 versus 7.9 +/- 1.4 ln (ms)2 (p < 0.05); LF 4.9 +/- 1.7 versus 7.5 +/- 1.8 ln (ms)2 (p < 0.05); HF 5.3 +/- 1.4 versus 7.5 +/- 1.8 ln (ms)2 (p < 0.05). Results at night showed a similar tendency, but were not statistically significantly different. At 8-10 months after aortic valve replacement, heart rate variability was increased significantly during the morning, from 50 +/- 22 to 79.5 +/- 22 ms (p < 0.05); VLF from 5.0 +/- 1.5 to 6.7 +/- 0.8 ln (ms)2 (p < 0.05); LF from 4.9 +/- 1.7 to 6.2 +/- 1.3 ln (ms)2 (p < 0.05). HF values tended to increase, though not significantly so. During the remainder of the day there was also a non-statistically significant increment in all values of heart rate variability.

Conclusions: The study results suggest that patients with severe symptomatic aortic stenosis present with autonomic dysfunction that tends to normalize within the first year of valve replacement.

How to cite: Vukasovic, J. L., Florenzano, F., Adriazola, P., & Escobar, E. (1999). Heart rate variability in severe aortic stenosis. The Journal of heart valve disease, 8(2), 143–148.

Background and aim of the study: Autonomic dysfunction may be a risk factor for the generation of arrhythmias and sudden death in patients with severe aortic stenosis; thus, patients with this condition were studied to assess cardiac autonomic function.

Methods: Twelve patients (five males, seven females; mean age 63 +/- 13 years) with severe symptomatic aortic stenosis before and after aortic valve replacement, were compared with a control group matched by age and sex. In the study group, mean fractional shortening was 36.5 +/- 5% and maximal aortic gradient 94.7 +/- 12 mmHg, assessed echocardiographically. Autonomic dysfunction was evaluated by following heart rate variability in both time and frequency domains. Spectral analysis was assessed at very low frequency (VLF: 0.017-0.05 Hz), low frequency (LF: 0.05-0.15 Hz) and high frequency (HF: 0.15-0.50 Hz). Heart rate variability was analyzed during three intervals, between 6:00-8:00 am (morning), 14:00-16:00 (afternoon) and 02:00-04:00 (night), and re-evaluated at 8-10 months after aortic valve replacement.

Results: Compared with controls, patients with aortic stenosis presented a significantly lower heart rate variability in the morning and afternoon, analyzed either by time or frequency domain: 50 +/- 22 versus 132 +/- 52 ms (p < 0.05); VLF 5.0 +/- 1.5 versus 7.9 +/- 1.4 ln (ms)2 (p < 0.05); LF 4.9 +/- 1.7 versus 7.5 +/- 1.8 ln (ms)2 (p < 0.05); HF 5.3 +/- 1.4 versus 7.5 +/- 1.8 ln (ms)2 (p < 0.05). Results at night showed a similar tendency, but were not statistically significantly different. At 8-10 months after aortic valve replacement, heart rate variability was increased significantly during the morning, from 50 +/- 22 to 79.5 +/- 22 ms (p < 0.05); VLF from 5.0 +/- 1.5 to 6.7 +/- 0.8 ln (ms)2 (p < 0.05); LF from 4.9 +/- 1.7 to 6.2 +/- 1.3 ln (ms)2 (p < 0.05). HF values tended to increase, though not significantly so. During the remainder of the day there was also a non-statistically significant increment in all values of heart rate variability.

Conclusions: The study results suggest that patients with severe symptomatic aortic stenosis present with autonomic dysfunction that tends to normalize within the first year of valve replacement.

How to cite: Vukasovic, J. L., Florenzano, F., Adriazola, P., & Escobar, E. (1999). Heart rate variability in severe aortic stenosis. The Journal of heart valve disease, 8(2), 143–148.

Background and aim of the study: In order to prevent prosthetic valve endocarditis (PVE), the implantation of a new silver-coated sewing ring has been introduced to provide peri- and postoperative protection against microbial infection.

Methods: A 56-year-old woman with aortic stenosis had elective replacement with a St. Jude Medical mechanical valve fitted with a silver-coated sewing ring (Silzone). The patient developed early PVE, which necessitated reoperation after one month. Despite a second Silzone prosthesis being implanted, the endocarditis recurred. During a third operation an aortic homograft was implanted, and after six months a fourth operation was performed for a pseudoaneurysm at the base of the homograft, in proximity to the anterior mitral valve leaflet.

Results: The diagnosis of PVE was confirmed by the presence of continuous fever, transesophageal echocardiography and growth of penicillin-resistant Staphylococcus epidermidis from the valve prosthesis.

Conclusion: The implantation of all prosthetic valves is encumbered with a risk of endocarditis. Although silver has bacteriostatic actions, the advantages of silver-coated prostheses in the treatment of this condition have yet to be assessed in clinical trials.

How to cite: Kjaergard, H. K., Tingleff, J., Abildgaard, U., & Pettersson, G. (1999). Recurrent endocarditis in silver-coated heart valve prosthesis. The Journal of heart valve disease, 8(2), 140–142.

Cardiac papillary fibroelastoma (CPF) located on mitral and aortic valves are known to produce systemic embolism mainly represented by strokes, whereas myocardial infarction and sudden death usually result from specific locations around LVOT. Coronary artery embolic occlusion originating from a mitral location has not yet been reported. The case is reported of a 42-year-old man referred for surgical treatment of a mitral valve papillary fibroelastoma disclosed after transitory and completely regressive left hemicorporeal deficiency and previous myocardial infarct. Due to the left chamber location, surgery was scheduled and complete removal of the mass achieved. These findings emphasize the potential life-threatening complications of CPF and, independent of risk factors, the need to perform systematic coronary angiography before surgical excision is considered.

How to cite: Grandmougin D, Delolme MC, Robin C, Vola M, Barral X. Incidental disclosure of asymptomatic coronary embolic occlusion related to mitral valve papillary fibroelastoma: an unusual finding and a review of the literature. J Heart Valve Dis. 2006 Jan;15(1):136-9. PMID: 16480026.

Background and aim of the study: This article presents the protocol of the Artificial Valve Endocarditis Reduction Trial (AVERT), a multicenter, international randomized trial to assess the efficacy of the SilzoneTM coating of St. Jude Medical Masters Series mechanical heart valves in the prevention of prosthetic heart valve endocarditis (PVE). A total of 4,400 eligible patients will be randomized within three years of study commencement at 17 participating clinical centers in North America and Europe, with study completion within four years.

Eligibility criteria: Eligible patients are candidates for St. Jude mechanical valves with either the Silzone or conventional cuff, in the mitral and/or aortic position, who give informed written consent to participate. Major exclusion criteria are the presence of prosthetic valves that do not require replacement, and the need for tricuspid valve replacement. Bypass surgery and valve repair are allowed during the implant operation. Patients will be randomized using an envelope-based intraoperative randomization scheme, stratified by clinical center and by the presence of endocarditis at the time of surgery.

Follow up: Patients will be contacted at discharge, three months, and each anniversary of the implant procedure. A brief follow up survey, administered via clinic interview, telephone or mail, will elicit events associated with possible endocarditis (unexplained fever, worsening angina, hospitalization) that will initiate contact with the patient's following physician.

Outcome analysis: The primary PVE endpoint will be based upon a published algorithm, with two infectious disease specialists making the final determination of cases classified as possible endocarditis. Study data will be periodically reviewed by a Data Safety Monitoring Board. The primary analysis will be an intention-to-treat comparison of freedom from PVE curves between the Silzone and conventional cuff treatment groups.

Conclusions: AVERT will provide much-needed information on the effectiveness of Silzone in preventing PVE, as well as practice patterns and outcomes of valve replacement.

How to cite: Schaff, H., Carrel, T., Steckelberg, J. M., Grunkemeier, G. L., & Holubkov, R. (1999). Artificial Valve Endocarditis Reduction Trial (AVERT): protocol of a multicenter randomized trial. The Journal of heart valve disease, 8(2), 131–139.

Background and aim of the study: In order to achieve better operative results, myocardial protection for cardiac valve re-replacement must be further improved. The aim of this study was to compare the efficacy of continuous warm blood cardioplegia (CWBC) with that of intermittent cold potassium cardioplegia (ICPC) in cardiac valve re-replacement.

Methods: A total of 49 consecutive patients underwent elective cardiac valve re-replacement via sternal re-entry; 27 patients received CWBC and 22 ICPC. During surgery, a narrower dissection of the heart was used in the CWBC group. The myocardial protective effects and operative outcome were analyzed in the two groups.

Results: Two ICPC patients died in hospital, one from cerebral bleeding and one from low output syndrome. The rate of spontaneous recovery of the heart-beat after aortic declamping was significantly higher in CWBC patients than in the ICPC group (92.3% versus 13.6%, p < 0.001). Postoperatively, maximum serum creatine kinase-MB levels were significantly lower in CWBC patients than in ICPC patients (25.5 +/- 6.0 versus 81.1 +/- 26.0 IU/l, p < 0.02). Left ventricular stroke work index in the CWBC group showed significantly better recovery in the early postoperative period compared with that in the ICPC group. Extraction of myocardial oxygen (range: 0.33 to 0.35) and lactate (range: -0.02 to 0.14) in CWBC patients was maintained within the normal range immediately after aortic declamping and in the early postoperative period. In contrast, in ICPC patients extraction of myocardial oxygen (range: 0.18 to 0.23) and lactate (range: -0.27 to -0.17) was impaired during the same period. Postoperative (24-h) blood loss was significantly less in CWBC patients than in ICPC patients (p < 0.02).

Conclusion: In cardiac valve re-replacement surgery through sternal re-entry, and without wide exposure of the heart, continuous warm blood cardioplegia provides much greater myocardial protection than does intermittent cold potassium cardioplegia.

How to cite: Nagaoka, H., Hirooka, K., Ohnuki, M., & Fujiwara, N. (1999). Effectiveness of continuous warm blood cardioplegia in cardiac valve re-replacement. The Journal of heart valve disease, 8(2), 124–130.

Background and aims of the study: The use of retrograde cardioplegia is controversial, mainly due to differences in theoretic and methodologic aspects. The aim of this study was to identify an optimal position for the cardioplegia catheter within the coronary sinus.

Methods: Thirteen cadaver hearts was used, and three different catheter positions in the coronary sinus were compared, using a radio-opaque dye which had a viscosity similar to that of blood. The distribution of dye at different segments of the heart was examined.

Results: Dye distribution, indicative of cardiac perfusion, was found to be related to the position of the catheter in the coronary sinus and the quantity of dye injected.

Conclusions: This study demonstrated the efficiency of retrograde cardioplegia, and also that optimal positioning of the catheter and the use of high-volume cardioplegia are required concomitantly for successful perfusion.

How to cite: Tosson, R., Kuschkowitz, F., Dasbach, G., & Laczkovics, A. (1999). Relationship between position of the coronary sinus catheter and distribution of cardioplegia. The Journal of heart valve disease, 8(2), 120–123.

This article is closed access and to view this content please login: https://www.icr-heart.com/author/login/ and request for the access.

How to cite: Frater R. W. (1999). Retrograde cardioplegia. The Journal of heart valve disease, 8(2), 118–119.