Ehlers-Danlos syndrome is associated with fatal cardiovascular complications and intraoperative death. The lack of literature on cardiac surgery in the syndrome makes it difficult for surgeons to assess the risk of an operation and to choose optimal treatment. We describe the case of a 63-year-old man with Ehlers-Danlos syndrome type I or II, mitral regurgitation and atrial fibrillation who was managed successfully with mitral valve repair and surgical cardioversion.

How to cite: Avlonitis, V. S., & Large, S. R. (1999). Ehlers-Danlos syndrome: surgical management of mitral regurgitation and atrial fibrillation. The Journal of heart valve disease, 8(4), 463–465.

Patients with valvular myxoma are usually candidates for surgery because of the high incidence of life-threatening embolism. In some cases, the tumor is sessile or presents with a large peduncle: complete excision may then lead to valve replacement. We report two cases of atrioventricular valve myxoma where replacement was avoided. In one patient, a mitral myxoma appended from the edge of the anterior leaflet close to the chordae insertion; safe excision implied destruction of the two chordae and a peritumoral section of the anterior leaflet. A chordal transposition technique was used to preserve valve competence. In a second patient, a tricuspid myxoma causing syncopal episodes was resected; this was characterized by a large stalk, located on the anterior tricuspid leaflet away from chordal attachment and the valvular annulus. Treatment was by resection and the leaflet reconstructed with a pericardial patch. Techniques for conservative treatment of degenerative valvular disease or endocarditis, when monitored peroperatively by transesophageal echocardiography, may be successful in the surgical resection of atrioventricular myxoma.

How to cite: Roques, F., Ulmer, B., Sanchez, B., Godreuil, J., Bernasconi, F., Smadja, D., & Bucher, B. (1999). Conservative surgery for atrioventricular valve myxoma. The Journal of heart valve disease, 8(4), 460–462.

A rare case of isolated tricuspid regurgitation (TR) in a 65-year-old man is presented. Echocardiography revealed enlargement of the right atrium, dilatation of the tricuspid valve annulus without thickening or prolapse of the leaflets, and an intact atrial septum. No downward displacement of the tricuspid septal leaflet was observed by echocardiography. Mild mitral regurgitation and severe TR were detected on color flow Doppler studies. Cardiac catheterization indicated elevated right atrial pressure, with a pronounced V-wave. No left-to-right shunt was detected at the right atrium. At surgery, severe annular dilatation of the tricuspid valve (without organically diseased or deformed tricuspid leaflets) was observed, and tricuspid annuloplasty with a prosthetic ring performed. Postoperative echocardiography and right ventriculography showed trivial TR.

How to cite: Aoyagi, S., Maruyama, H., Akasu, K., & Kawara, T. (1999). Isolated tricuspid valve regurgitation resulting from severe annular dilatation: case report. The Journal of heart valve disease, 8(4), 457–459.

A case is reported of chronic atrial fibrillation resulting from long-standing rheumatic mitral stenosis complicated by a massively thrombosed left atrium. In this patient, restoration of sinus rhythm and atrial transport function was performed using a Cox-maze III procedure with mitral valve replacement.

How to cite: Louagie, Y., Rombaut, E., & Marchandise, B. (1999). Successful Cox-maze III procedure combined with mitral valve replacement in a massively thrombosed left atrium. The Journal of heart valve disease, 8(4), 453–456.

It has been shown that inappropriate anterior mitral leaflet preservation during mitral valve replacement may cause left ventricular outflow tract (LVOT) obstruction, usually with dismal prognosis. In this report, we describe a patient with chronic asymptomatic LVOT obstruction after mitral valve replacement with leaflet preservation.

How to cite: Popovic, Z., Vukajlovic, D., & Popovic, A. D. (1999). Asymptomatic left ventricular outflow tract obstruction after mitral valve replacement with leaflet preservation. The Journal of heart valve disease, 8(4), 450–452.

Combined repair of the mitral and tricuspid valves involved with acute infective endocarditis was carried out in a 38-year-old drug addict. Mitral valve repair included vegetectomy, closure of posterior leaflet perforation, and posterior annuloplasty with a patch and a strip of glutaraldehyde-tanned autologous pericardium, respectively, while the tricuspid valve was reconstructed with the use of artificial chordae and valve bicuspidalization. At five months follow up the patient is asymptomatic, with echocardiographic evidence of only trivial mitral and tricuspid incompetence, and no signs of recurrent infection. This case report supports the use of valve reconstruction as a valuable option in patients in whom there is simultaneous involvement of the mitral and tricuspid valves with infective endocarditis.

How to cite: Pratali, S., Nardi, C., Di Gregorio, O., Becherini, F., Milano, A., & Bortolotti, U. (1999). Combined mitral and tricuspid valve repair in acute infective endocarditis. The Journal of heart valve disease, 8(4), 447–449.

Endogenous ochronosis, a rare inherited disease of tyrosine metabolism, is caused by a deficiency of the enzyme, homogentisic acid oxidase, and may lead to cardiovascular involvement seen most frequently as aortic valve stenosis. We report the case of a patient with generalized ochronosis who developed cardiovascular symptoms due to aortic valve stenosis and who underwent aortic valve replacement.

How to cite: Casselman, F., Herijgers, P., Meyns, B., & Daenen, W. (1999). Aortic stenosis in endogenous ochronosis. The Journal of heart valve disease, 8(4), 445–446.

Background and aim of the study: Mitral valve surgery requires optimal exposure of the valvular apparatus, particularly when a conservative procedure is used. Retrospectively, we compared surgical results in patients who underwent mitral valve surgery using the vertical transseptal approach (which has been adopted routinely in our institute) with those in patients undergoing conventional left atriotomy.

Methods: A total of 172 consecutive patients operated on for mitral procedures were allocated to either group A (those operated on through a longitudinal left atriotomy; n = 62), or group B (mitral valve exposure achieved through an extensive vertical transseptal approach; n = 110).

Results: In group A, there were 24 valvular reconstructions and 38 valvular replacements. Mean (+/- SD) cardiopulmonary bypass (CPB) time was 65.9 +/- 17 min and mean ischemia time 37.4 +/- 13 min. Total postoperative bleeding was 277 +/- 171 ml. There was no surgical re-exploration for bleeding. One patient in this group died (mortality rate 2%). Among 40 patients in atrial fibrillation preoperatively, four had one episode of temporary junctional rhythm, six had temporary sinus rhythm and two had stable sinus rhythm. Among patients with preoperative sinus rhythm, six (27%) had episodes of atrial fibrillation and two (9%) temporary atrioventricular block. In group B, 46 mitral reconstructions and 64 mitral replacements were performed. Mean CPB time was 67.9 +/- 20 min and mean ischemia time 48.1 +/- 17 min. Total postoperative bleeding was 400 +/- 189 ml. Three patients in this group died (mortality rate 2.7%). Among 60 patients with preoperative atrial fibrillation, six (10%) had one episode of temporary junctional rhythm, 14 (24%) had temporary sinus rhythm and two (3%) had conversion to stable sinus rhythm. Among those in sinus rhythm preoperatively, 16 (32%) had episodes of temporary junctional rhythm, two (4%) had temporary atrial fibrillations, and four (8%) had stable atrial fibrillation. In group B patients, the incidences of ischemia time and total postoperative bleeding (p = 0.004), and postoperative junctional arrhythmia in those with preoperative sinus rhythm (p < 0.001), were greater than in group A patients.

Conclusions: No technique-related deaths occurred; neither were causes of re-exploration for bleeding related to technique, and there was no evidence of residual interatrial shunt. In conclusion, transseptal extended atriotomy provides excellent exposure for mitral valve surgery. Disadvantages of minimally increased ischemia time and surgical bleeding are minor compared with the superior and more complete surgical reconstruction achieved. The advantages of the technique are undermined by the higher incidence of junctional arrhythmia which, even if temporary, requires strict postoperative monitoring.

How to cite: Masiello, P., Triumbari, F., Leone, R., Itri, F., Del Negro, G., & Di Benedetto, G. (1999). Extended vertical transseptal approach versus conventional left atriotomy for mitral valve surgery. The Journal of heart valve disease, 8(4), 440–444.

Background and aims of the study: The study aim was to examine the effects of balloon mitral valvotomy (BMV) on exercise-induced hyperkalemia, and on changes in the concentration of Na,K-pumps in skeletal muscle, as an exaggerated exercise-induced rise in potassium concentration ([K+]) may contribute to exertional fatigue and breathlessness.

Methods: Eight subjects were evaluated with mitral stenosis (mean age 34 +/- 5.2 years) before, and at two weeks and four months after BMV. Subjects underwent incremental exercise to exhaustion for exercise-induced rise in [K+] and vastus lateralis biopsy for concentration of Na,K-pumps.

Results: Mean (+/- SE) valve area increased from 0.89 +/- 0.03 cm2 before to 1.75 +/- 0.05 cm2 after BMV. There was a progressive increase in VO2,max (15.3 +/- 1.6, 17.2 +/- 1.4 and 19.9 +/- 1.9 l/kg/min) at baseline, early after and later after BMV, respectively (p < 0.01). The rise in [K+] with absolute workload fell progressively at early and late follow up post-BMV (p < 0.05), but was unchanged when plotted against percentage of VO2,max to match for relative workload. The concentration of Na,K-pumps was similar to baseline at early follow up (233 +/- 10 versus 228 +/- 15 pmol/g wet weight), but was significantly increased at late follow up after four months (265 +/- 17 pmol/g; p < 0.05). When the relationship between the concentration of Na,K-pumps and the exercise-induced rise in [K+] was studied, a negative correlation was found. However, correlation analysis for the effects of changes in Na,K-pumps on changes in exercise hyperkalemia after BMV was not significant.

Conclusions: The progressive reduction in exercise-induced rise in [K+] after BMV may contribute to the progressive improvement in exercise performance. The increased concentration of Na,K-pumps in skeletal muscle may assist in this improvement, and emphasizes the importance of peripheral adaptations in clinical improvement after BMV.

How to cite: Barlow, C. W., Long, J. E., Manga, P., Meyer, T. E., Paterson, D. J., & Robbins, P. A. (1999). Exercise-induced hyperkalemia and concentration of Na,K-pumps in skeletal muscle in mitral stenosis: effect of balloon mitral valvotomy. The Journal of heart valve disease, 8(4), 430–439.

Background and aim of the study: Rupture of congenital sinus of Valsalva aneurysm is a rare cardiac malformation that usually causes reduced cardiac performance.

Methods: Twenty patients (mean age 28.3 +/- 10.7 years; range: 14 to 55 years) with rupture of congenital sinus of Valsalva aneurysm were operated on at our institution between January 1985 and March 1999. The origin of the ruptured aneurysms was the right coronary sinus in 18 patients (90%) and the non-coronary sinus in two (10%). No ruptures were observed originating from the left coronary sinus. The aneurysms ruptured into the right ventricle in 14 patients (70%), into the right atrium in five (25%), and into the left ventricle in one patient (5%). Subarterial ventricular septal defect (VSD) was the most common associated defect (30%), and aortic insufficiency the second (20%). No correlation was found between subarterial VSDs and aortic insufficiency (p > 0.05). To achieve repair, the aorta and cavity into which the aneurysm had ruptured were opened. The aneurysmal sac was excised and the defect closed with a patch in 18 patients, and without patch in two.

Results: One patient died in hospital (mortality rate 5%); no late mortality was observed. Surviving patients were followed up for 4.4 +/- 3.3 years (range: 1 to 13 years). The actuarial survival rate was 95% at 12.35 years. Recurrence of fistula was observed in one patient (5%) in whom the ruptured aneurysm had been closed by primary suture without the use of a patch. At 12.35 years, the actuarial freedom from recurrence of fistula was 94.74% for all survivors, and 100% for patients with patch closure. No late complications have been observed.

Conclusions: Following diagnosis of ruptured sinus of Valsalva aneurysm, surgical repair is the treatment of choice. Surgery performed as rapidly as possible after diagnosis in general leads to an excellent outcome.

How to cite: Kirali, K., Güler, M., Daglar, B., Yakut, N., Mansuroglu, D., Balkanay, M., Berki, T., Gürbüz, A., Isik, O., & Yakut, C. (1999). Surgical repair in ruptured congenital sinus of Valsalva aneurysms: a 13-year experience. The Journal of heart valve disease, 8(4), 424–429.

Aortic stenosis is a common disorder, which affects an increasing number of elderly patients, and is responsible for considerable morbidity. Although some associations for this disorder have been described, factors driving its progression remain obscure. This review proposes the hypothesis that aortic stenosis is another manifestation of atherosclerotic disease, and that its progression can be explained by classical cardiovascular risk factors.

How to cite: Wierzbicki, A., & Shetty, C. (1999). Aortic stenosis: an atherosclerotic disease?. The Journal of heart valve disease, 8(4), 416–423.

Background and aims of the study: Growing interest in aortic root replacement with the use of stentless auto-, homo- and xenografts, and new developments in aortic valve conservation demand a deeper understanding of the normal aortic root anatomy.

Methods: Ten cryopreserved human aortic roots were pressurized, fixed and measured directly (leaflet free edge and attachment) and using three-dimensional computed tomography imaging software (sinus of Valsalva height and volume).

Results: The mean of the measurements of all four parameters yielded a pattern in which the non-coronary sinus (N) structures had the greatest dimensions followed by the right (R) and then the left (L). Non-parametric ANOVA on each of these parameters also showed significant differences among the sinuses yielding a pattern of N > R > L. This pattern determined an angle of tilt between the plane at the base (annulus) and the plane intersecting the sinotubular junction with a mean value of 11 degrees. Linear regression indicated that this angle did not depend on the size of the base (annulus).

Conclusions: The data showed a geometric pattern of the aortic root, with the structures of the non-coronary sinus being the largest followed by the right and then the left. The possible hemodynamic relevance and surgical implications of these findings need to be explored.

How to cite: Choo, S. J., McRae, G., Olomon, J. P., St George, G., Davis, W., Burleson-Bowles, C. L., Pang, D., Luo, H. H., Vavra, D., Cheung, D. T., Oury, J. H., & Duran, C. M. (1999). Aortic root geometry: pattern of differences between leaflets and sinuses of Valsalva. The Journal of heart valve disease, 8(4), 407–415.

Background and aim of the study: Thrombosis of a bileaflet mechanical heart valve is a life-threatening clinical event. Surgical thrombectomy of bileaflet mechanical prostheses remains an appropriate treatment in selected patients.

Methods: Between 1996 and 1998, five patients (three men, two women; average age 56 +/- 1 years; range: 56 to 66 years) with thrombosis of left-sided bileaflet mechanical valves were treated with videoassisted thrombectomy of the prosthesis. Four patients had thrombosis of a bileaflet mitral mechanical valve, and one patient had thrombosis of an aortic valve prosthesis. Preoperatively, patients were in either NYHA functional class IV (n = 4) or class I (n = 1). Surgery was performed through a right anterior thoracotomy or a median sternotomy. A rigid 30 degrees thoracoscope was inserted into the left atrium or aorta to visualize the thrombosed valve. The thrombus was extracted and the prosthesis under-surface examined and cleaned. Leaflet mobility, assessed with transesophageal echocardiography, was normal following surgical thrombectomy.

Results: Mean cardiopulmonary bypass time was 102 +/- 30 min; mean aortic cross-clamping time was 47 +/- 25 min. There was no hospital mortality; mean hospital stay was 9 +/- 1 days (range: 6 to 11 days). Anticoagulation with intravenous heparin was resumed 24 h after surgery. Three patients were discharged on coumarin treatment alone; two patients received aspirin plus coumarin. Mean postoperative follow up was 7 +/- 8 months (range: 1 to 21 months). One patient died 21 months after thrombectomy of a mitral prosthesis, with an unconfirmed diagnosis of recurrent mitral valve dysfunction. At 1-15 months after surgery, four patients are in NYHA class I, without evidence of prosthesis dysfunction.

Conclusion: Videoassisted thrombectomy of a bileaflet mechanical heart valve is a treatment option in patients with acute thrombosis of the prosthesis.

How to cite: Carrier, M., Pellerin, M., Dagenais, F., Perrault, L. P., Petitclerc, R., & Pelletier, L. C. (1999). Videoassisted thrombectomy of mechanical prosthetic heart valves. The Journal of heart valve disease, 8(4), 404–406.

Background and aim of the study: The study goal was to determine whether the visualization of single-leg separation (SLS) in cineangiographic sequences of Björk-Shiley convexo-concave heart valves could be correlated to the position of the occluder disk within the cardiac cycle.

Methods: Images from ten patient cases with SLS valves were reviewed by three experts, who identified the image frames within a cine sequence that appeared suspicious for SLS. The position of the occluder disk, the frame rate, and the length of the cardiac cycle were noted relative to these image frames.

Results: The probability of detecting a SLS was not significantly correlated to any of these factors.

Conclusions: Visualization of SLS in cineangiographic images is limited to a few frames within an imaging sequence. It appears that other features within the image play a larger role in a clinician's ability to detect a fracture than do the cardiac dynamics of the system.

How to cite: Powell, K. A., Obuchowski, N. A., Yeung, A. C., Kennedy, J. A., & Cornhill, J. F. (1999). Correlation of valve closing to visualization of single-leg separation in radiographic images of Björk-Shiley convexo-concave heart valves. The Journal of heart valve disease, 8(4), 399–403.

Background and aims of the study: The study aim was to determine the risk of thromboembolic and bleeding complications in patients with mechanical heart valve prostheses who underwent non-cardiac surgery under different regimens of perioperative anticoagulation. Data were analyzed on the basis of surgery type and underlying disease.

Methods: A series of 235 patients (mean age 63 +/- 4.5 years) with one or two mechanical heart valves underwent subsequent non-cardiac surgery comprising abdominal, vascular and thoracic, orthopedic, urologic, neurosurgery, ENT, plastic and reconstructive, and gynecologic operations. Mean interval between heart valve replacement and non-cardiac surgery was 3.9 +/- 3.3 years. Perioperative oral anticoagulation was managed by discontinuation of oral anticoagulation and intravenous heparin administration; or by discontinuation and early postoperative re-institution of oral anticoagulation without intravenous heparin; or by no withdrawal of oral anticoagulation. Patients with bioprostheses were excluded.

Results: Overall hospital mortality during non-cardiac surgery was 2.9%. Thromboembolic events included cerebral embolism with transient deficit (n = 3), residual defect (n = 1) and irreversible defect (n = 1), as well as peripheral embolism (n = 11). Hemorrhagic complications included wound hematoma (n = 10) and increased postoperative bleeding (n = 8) with re-exploration in five patients. Thromboembolic complications occurred most often in patients with prosthetic mitral valve and atrial fibrillation; the lowest risk was in patients with sinus rhythm after aortic valve replacement. Most complications occurred after discharge and in patients with surgery for malignancy, within 10 days of instituting oral anticoagulation, and despite a therapeutic INR value.

Conclusions: Minor surgical procedures can be performed safely without discontinuing anticoagulation. When major non-cardiac surgery is planned, discontinuing oral anticoagulation and starting perioperative intravenous heparin minimizes bleeding and thromboembolic risks. Thromboembolic complications may occur within one month of surgery, despite adequate oral anticoagulation, though permanent morbidity is low.

How to cite: Carrel, T. P., Klingenmann, W., Mohacsi, P. J., Berdat, P., & Althaus, U. (1999). Perioperative bleeding and thromboembolic risk during non-cardiac surgery in patients with mechanical prosthetic heart valves: an institutional review. The Journal of heart valve disease, 8(4), 392–398.

Current standards governing the evaluation of prosthetic heart valve designs have come under scrutiny. Generally, standards require measurements of pressure drops and regurgitant flow. While this information is important in the characterization of valve performance, these standards are both insufficient and ambiguous. Their insufficiency is due to the fact that they do not cover issues related to thrombosis and structural damage, and their ambiguity is demonstrated by the fact that different pulse duplicators will produce different results for nominally the same set of conditions. While the insufficiency of the current standards has recently been addressed, the ambiguity has not been addressed in a systematic way except for one particular study involving two pulse duplicator systems. This paper explores physical sources for disagreement in pressure and flow measurements between pulse duplicators, and suggests ways to account for them. By considering these physical phenomena, standards can be developed for testing chambers that improve similarity between systems. This should not compromise innovation in the design of new pulse duplicators, which may be necessary to address additional concerns besides the pressure and flow characteristics of the valve.

How to cite: VanAuker, M. D., & Strom, J. A. (1999). Inter-laboratory comparisons: approaching a new standard for prosthetic heart valve testing in vitro. The Journal of heart valve disease, 8(4), 384–391.

Background and aim of the study: The study aim was to analyze the results of reoperations for structural degeneration of bioprostheses, and to define a high-risk population for reoperative procedures.

Methods: A series of 524 consecutive patients who had undergone a first reoperative replacement for a failed bioprosthesis between 1978 and 1998 was reviewed retrospectively. The reoperative procedure comprised 363 single valve replacements, and 161 multiple valve replacements. During the original procedure, 648 bioprostheses had been implanted in the mitral (n = 403), aortic (n = 220) and tricuspid (n = 25) positions.

Results: The mean interval between the original procedure and reoperation was 8.8 +/- 3.3 years. Tissue valve failure was revealed by recurrence of cardiac insufficiency in 70% of cases. The overall early mortality rate was 8%, but early mortality rates for elective single mitral and aortic reoperative valve replacements were only 3.9% and 4%, respectively. Early mortality following reoperation for single and multiple valve replacement was 6.0% and 12.4% respectively (p = 0.02). Other significant multivariable predictors for early mortality were old age (p = 0.003), NYHA functional class (p = 0.007), presence of ascites (p = 0.02) and reoperation performed before 1988 (p = 0.013).

Conclusions: The risk of reoperation for structural degeneration of bioprostheses is acceptable for elective single reoperative valve replacement as opposed to multiple reoperative valve replacement. This may limit the use of bioprostheses during the original procedure when multiple valve replacement is required.

How to cite: Caus, T., Albertini, J. N., Chi, Y., Collart, F., Monties, J. R., & Mesana, T. (1999). Multiple valve replacement increases the risk of reoperation for structural degeneration of bioprostheses. The Journal of heart valve disease, 8(4), 376–383.

Background and aim of the study: The aim of the study was to compare the durability and risk of reoperation in patients undergoing isolated aortic valve replacement with either a porcine standard Carpentier Edwards or a Mitroflow pericardial valve.

Methods: Follow up evaluation was performed in 118 patients receiving a Mitroflow valve (M) and 94 patients receiving a standard Carpentier Edwards porcine valve (CE) between 1980 and 1987. The two groups were identical in terms of clinical characteristics; only prosthesis size differed, with small-sized valves used more frequently among the Mitroflow group.

Results: The risk of structural valve deterioration (SVD) was 2.3% per patient-year (pt-yr) in CE valves, and 5.4 per pt-yr in M valves. Freedom from SVD was 100%, 87 +/- 4% and 63 +/- 8% at 5, 10 and 15 years for CE valves, and 96 +/- 2%, 56 +/- 7% and 5 +/- 4% for M valves. Freedom of reoperation was 98 +/- 1%, 83 +/- 5% and 76 +/- 7% at 5, 10 and 15 years respectively for CE valves, and 94 +/- 2%, 55 +/- 7% and 11 +/- 9% for M valves. Despite the high number of valve-related reoperations, survival at 5, 10 and 15 years was not affected in M valve patients. Multivariate analysis (Cox model) showed that age and valve type were the two main risk factors for SVD and reoperation, though the latter factor had no impact on survival.

Conclusions: In younger patients (aged < 75 years), the CE valves offer superior results to the M counterpart in valve replacement. However, in patients aged > 75 years, pericardial and porcine bioprostheses demonstrate equivalent durability, despite post-implantation tissue changes in the former material.

How to cite: Houel, R., Le Besnerais, P., Soustelle, C., Kirsch, M., Hillion, M. L., & Loisance, D. (1999). Lack of durability of the Mitroflow valve does not affect survival. The Journal of heart valve disease, 8(4), 368–375.

Background and aim of the study: For long-term substitution of the mitral valve, mechanical prostheses require life-long anticoagulation which is impractical in developing countries, xenografts degenerate early in our young population, and mitral homografts have not yet been established as being suitable. We therefore returned to an original concept first reported by one of the authors (D.N.R.) in 1967.

Methods: Between July 1997 and November 1998, 22 patients (mean age 40.3 years; range: 28 to 57 years) with rheumatic mitral valve disease unsuitable for reconstruction were subjected to excision of their pulmonary valve in the standard fashion of the Ross procedure. The inverted autograft was incorporated in a 2.5 cm-long Dacron conduit, with a pericardial collar attached to its proximal end. The distal end of the autograft-conduit was sutured to the annulus of the excised mitral valve, and the proximal end incorporating the pericardial collar was attached to the adjacent atrial wall. In this way all prosthetic material was covered. The right ventricular outflow was reconstructed with a pulmonary homograft in 17 patients, with an aortic homograft in two, and with a porcine pulmonary xenograft in three.

Results: One patient developed a fatal cerebrovascular accident, probably related to an incorrectly placed pericardial collar with rough surface exposed to the blood flow. In a second patient the autograft had to be replaced six weeks after operation due to bacterial endocarditis contracted in the operating room. Echocardiography confirmed excellent function of the remaining autografts up to 16 months postoperatively (mean follow up 8.3 months).

Conclusions: We believe the pulmonary autograft to be a valid option for mitral valve replacement in our patients.

How to cite: Kabbani, S. S., Ross, D. N., Jamil, H., Hammoud, A., Nabhani, F., Hariri, R., & Kabbani, L. S. (1999). Mitral valve replacement with a pulmonary autograft: initial experience. The Journal of heart valve disease, 8(4), 359–367.

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How to cite: Schoen F. J. (1999). Future directions in tissue heart valves: impact of recent insights from biology and pathology. The Journal of heart valve disease, 8(4), 350–358.