[Heart valve replacement (Hancock's valve) and annuloplasty in tricuspid valve insufficiency].
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Adult↗
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Evaluation of valve sound and its effects on ATS prosthetic valves in patients' quality of life.
BACKGROUND: We interviewed patients and carried out frequency analyses to compare the closing sounds of ATS and St. Jude Medical (SJM) prosthetic valves. METHODS: Forty-five patients undergoing valve replacements using ATS valves were investigated. We interviewed patients at 1 month and 1 year after the operation, and carried out frequency analysis to investigate the prosthetic valve's closing sound. RESULTS: According to the results of the interviews, 84.4% of patients with ATS valves were not aware of the valve sounds. ATS valves scored significantly lower than SJM valves on audibility of the valve sound, disturbance during daytime, sleep disturbance, request for replacement with a soundless prosthetic valve, audibility to others, and noise index. According to the frequency analysis on the prosthetic valve's closing sound, the sound peak of the ATS valves was around 1.2 kHz, and the sound pressure of the ATS valves was significantly lower than that of the SJM valves. CONCLUSIONS: Though a further long-term observation on thromboembolism and hemolysis is needed for evaluation of prosthetic valves, the ATS valve is presently considered to impart a better quality of life.
Adult↗
Serial Doppler echocardiographic evaluation of Carpentier-Edwards pericardial valve dysfunction: comparison with Ionescu-Shiley valve.
BACKGROUND: Doppler echocardiography is a valuable noninvasive method for evaluating of the occurrence and degree of either prosthetic valve stenosis or regurgitation. By using serial Doppler echocardiographic examination, we evaluated the incidence and the mode of the Carpentier-Edwards pericardial valve (CEPX) dysfunction compared with that of the Ionescu-Shiley valve (IS). METHODS AND RESULTS: After aortic and/or mitral valve replacement, 80 patients with CEPX and 111 with IS underwent Doppler echocardiography at intervals of at least 2 years after surgery. The average durations of follow-up were 6.1 +/- 2.9 years for patients with CEPX and 7.2 +/- 3.0 years for those with IS. Bioprosthetic valve stenosis was defined as reduced excursion of the bioprosthetic valve leaflets and peak gradient > or =60 mm Hg after aortic valve replacement and mean gradient > or =7 mm Hg after mitral valve replacement. Bioprosthetic valve regurgitation caused by bioprosthetic valve dysfunction was defined as grade > or =3 transvalvular regurgitation. In the aortic position, although there was no significant difference in the actuarial rate of freedom from bioprosthetic valve stenosis between patients with IS and those with CEPX (10 years after surgery, 88% +/- 7% vs 90%, NS), bioprosthetic regurgitation caused by bioprosthetic valve dysfunction occurred less frequently in patients with CEPX than in those with IS (10 years after surgery, 86% vs 54% +/- 9%, p < 0.05). In the mitral position, bioprosthetic valve stenosis occurred more frequently in patients with CEPX than in those with IS (10 years after surgery, 54% +/- 11% vs 72% +/- 8%, p < 0.01). Although grade > or =3 transvalvular bioprosthetic regurgitation occurred later in patients with CEPX than in those with IS, there was no significant difference in the actuarial rate of freedom from that regurgitation between patients with CEPX and those with IS (10 years after surgery, 63% +/- 10% vs 54% +/- 7%, NS). CONCLUSIONS: For aortic valve replacement, CEPX has good long-term durability because of the low incidence of bioprosthetic regurgitation. For mitral valve replacement, long-term durability of CEPX is poor, although medium-term durability is satisfactory.
Aortic Valve↗
New insights in minimally invasive valve replacement: description of a cooperative approach for the off-pump replacement of mitral valves.
AIMS: The aim of the present study was to evaluate whether off-pump mini-invasive mitral valve replacement is possible after prior bioprosthetic mitral valve replacement in animals. METHODS AND RESULTS: To validate this concept for off-pump redo mitral valve insertion, we first replaced surgically mitral valves of six sheep under extracorporeal circulation using a Mosaïc valve. Prior to its insertion, we added a radio-opaque ring on its base to enhance its visualization under fluoroscopy. A bovine jugular valve mounted into a stent was then inserted off-pump through an opening of the atrial wall. Mitral valves were replaced successfully in all animals. Following the surgical valve insertion, mean left atrium and left ventricular end-diastolic pressures were 38 (22-42) and 18.8 mmHg (13-22), respectively. Angiography showed perfectly functioning valves, no subaortic valve obstruction, and a mild paravalvular leak in one animal. In one animal, we were unable to control the bleeding from the atrial opening. In this case, trans-atrial valvulation was not attempted. The off-pump valvular implantation was successful in the other five sheep. Haemodynamic data did not change after the insertion of valved stents. Implanted valves were all competent. The animal with the better haemodynamics was kept alive and is still alive 3 months after implantation. CONCLUSION: Surgically implanted bioprosthetic valves provide excellent support for off-pump insertion of a valved stent. Further experiments are necessary, in particular with appropriate valve size, before considering this approach for percutaneous mitral valvular replacement in patients with a dysfunctional bioprosthesis.
Animals↗
Tissue engineering of pulmonary heart valves on allogenic acellular matrix conduits: in vivo restoration of valve tissue.
BACKGROUND: Tissue engineering using in vitro-cultivated autologous vascular wall cells is a new approach to biological heart valve replacement. In the present study, we analyzed a new concept to process allogenic acellular matrix scaffolds of pulmonary heart valves after in vitro seeding with the use of autologous cells in a sheep model. METHODS AND RESULTS: Allogenic heart valve conduits were acellularized by a 48-hour trypsin/EDTA incubation to extract endothelial cells and myofibroblasts. The acellularization procedure resulted in an almost complete removal of cells. After that procedure, a static reseeding of the upper surface of the valve was performed sequentially with autologous myofibroblasts for 6 days and endothelial cells for 2 days, resulting in a patchy cellular restitution on the valve surface. The in vivo function was tested in a sheep model of orthotopic pulmonary valve conduit transplantation. Three of 4 unseeded control valves and 5 of 6 tissue-engineered valves showed normal function up to 3 months. Unseeded allogenic acellular control valves showed partial degeneration (2 of 4 valves) and no interstitial valve tissue reconstitution. Tissue-engineered valves showed complete histological restitution of valve tissue and confluent endothelial surface coverage in all cases. Immunohistological analysis revealed cellular reconstitution of endothelial cells (von Willebrand factor), myofibroblasts (alpha-actin), and matrix synthesis (procollagen I). There were histological signs of inflammatory reactions to subvalvar muscle leading to calcifications, but these were not found in valve and pulmonary artery tissue. CONCLUSIONS: The in vitro tissue-engineering approach using acellular matrix conduits leads to the in vivo reconstitution of viable heart valve tissue.
Animals↗
Clinical and hemodynamic performance of the Ionescu-Shiley valve in the small aortic root. Results in 117 patients with 17 and 19 mm valves.
The Ionescu-Shiley pericardial valve was our bioprosthetic valve of choice between 1981 and 1985 for patients in whom the aortic anulus could not accept a valve larger than 19 mm in outer diameter or in whom the avoidance of warfarin sodium (Coumadin) was important. A series of 117 consecutive patients who received 17 or 19 mm valves for isolated aortic valve replacement or aortic valve replacement combined with coronary artery bypass grafting or other valvular procedures was analyzed. Overall, 74% of the patients were female, with a mean age of 70.9 years and a body surface area of 1.67 +/- 0.19 m2; 92.3% were in New York Heart Association class III-IV, and the operation was urgent or emergent in 46%. The operative mortality rate was 7.7%, with no deaths in patients undergoing isolated elective first-time aortic valve replacement. Mean follow-up for survivors was 2.5 years (10 to 62 months). There were 20 late deaths, of which three were valve related, three were due to sudden death or arrhythmias, and two were due to persistent heart failure. The actuarial survival rate at 5 years was 68%. Clinical follow-up revealed a low incidence of valve-related complications, and 96.4% of survivors were in class I-II. Postoperative echocardiography before hospital discharge revealed a maximum instantaneous gradient of 18.4 +/- 3.0 mm Hg in five patients having a 17 mm valve and 31.3 +/- 12.7 mm Hg in 20 patients having a 19 mm valve. Doppler echocardiography was performed in 22 patients at a mean follow-up of 39.3 +/- 11.7 months. The maximum instantaneous gradient was 25 +/- 17.2 mm Hg for 17 mm and 17.41 +/- 5.4 mm Hg for 19 mm valves at late follow-up. The effective orifice area was 0.85 +/- 0.1 cm2 for 17 mm and 1.21 +/- 0.21 cm2 for 19 mm valves. This study defines the normal range of Doppler echocardiographic transprosthetic gradients for the Ionescu-Shiley valve and confirms that low operative mortality and excellent clinical improvement can result from the use of small Ionescu-Shiley valves in elderly patients despite moderate postoperative transvalvular gradients.
Adult↗
Mechanism of venous valve closure and role of the valve in circulation: a new concept.
PURPOSE: The purpose of this study was to investigate the blood flow changes and venous wall movements that occur in the perivalvular area during venous flow, to learn how these physiologic events influence the movements of the valve cusps, and to learn how the movements of the valve cusps influence the venous flow. MATERIALS AND METHODS: Twenty healthy volunteers (10 male, 10 female, age 18 to 52) were subjects of this study. Each volunteer was examined in semi-recumbent and standing positions at rest and during active foot movements. Ultrasound examinations were performed in the B-flow mode supplemented by B-mode and pulsed-wave Doppler scanning. RESULTS: Four phases of the valve cycle are described. During the opening phase (0.27 +/- 0.05 s), the cusps move from the closed position toward the sinus wall. After reaching a certain point, the valves cease opening and enter the equilibrium phase. During this phase (0.65 +/- 0.08 s), the leading edges remain suspended in the flowing stream and undergo self-excited oscillations with an amplitude of 0.01 to 0.16 cm. During the closing phase (0.41 +/- 0.07 sec), the leaflets move synchronously toward the center of the vein. The subsequent closed phase has a duration of 0.45 +/- 0.05 seconds when the cusps remain closed. During the equilibrium phase, flow separation occurs at the leading edge of the cusp with reattachment at the wall of sinus. At this point, flow splits into two streams at each valve cusp. Part of the flow is directed into the sinus pocket behind the valve cusp, forming a vortex along the valve cusp before re-emerging in the main stream in the vein. When the valve is maximally open, the two cusps create a narrowing of the lumen about 35% smaller than the vein distal to the valve. In this narrowed area flow accelerates, forming a proximally directed jet. CONCLUSIONS: The valve cusps undergo the four phases constituting the valve cycle. The local hemodynamic events, such as flow separation and reattachment, and vortical flow in the sinus play important roles in the valve operation. In addition to prevention of retrograde flow, the valve acts as a venous flow modulator. The vortical stream behind the valve cusps participates in the operation of the valve, and prevents stasis inside the valve pocket. The central jet possibly facilitates outflow.
Adolescent↗
A randomized, controlled study of a programmable shunt valve versus a conventional valve for patients with hydrocephalus. Hakim-Medos Investigator Group.
OBJECTIVE: A multicenter prospective randomized controlled study was performed to assess the safety and efficacy of a Codman Hakim programmable shunt valve (Codman/Johnson & Johnson, Raynham, MA) versus a conventional valve system of the surgeon's choice for the treatment of patients with hydrocephalus. METHODS: Enrollment was stratified on the basis of whether the patient was undergoing initial shunt insertion or revision of an existing valve system at study entry. Study end points were: 1) valve explantation, and 2) shunt failure (surgical intervention for any component of the shunt). A total of 377 patients were enrolled onto the study, with 235 undergoing first shunt insertion (119 experimental, 116 control) and 142 undergoing revisions (75 experimental, 67 control). RESULTS: During a follow-up interval of 104 weeks after the first implantation on-study, explantation of the valve was required in 62 (32%) of 194 experimental valves, compared with 71 (39%) of 183 control valves. Two-year survival rates of the original shunt without revision of any component were 52% (62 of 119) and 50% (58 of 116) in experimental and control patients, respectively, who underwent initial shunt insertion, and 43% (32 of 75) and 43% (29 of 67) in experimental and control patients, respectively, who underwent replacement of an existing valve. No statistically significant difference was observed between experimental and control patients in the survival of either the valve or the overall shunt system. Control of hydrocephalus as assessed symptomatically and by imaging was comparable in the two treatment groups. Although problems related to inability to achieve the desired pressure setting were reported in 22 experimental valves, in all but four instances no additional programming was attempted because the patients were functioning well clinically. The most common reasons cited for valve explantation and shunt revision were infection (9.8% frequency in the overall cohort) and proximal shunt malfunction, which occurred with comparable frequency in the experimental and control groups. CONCLUSION: Safety and efficacy of the Codman Hakim programmable shunt valve is comparable to conventional valves in the overall population of patients with hydrocephalus. However, the current study was not designed to assess the efficacy of programmable versus conventional valves in the management of individual hydrocephalus problems, and it had insufficient statistical power to support such comparisons. This study provides a rationale for examining whether the theoretical advantages of a programmable valve for managing challenging hydrocephalus problems can translate into meaningful improvements in shunt and valve survival.
Adolescent↗
Aortic valve debridement by ultrasonic surgical aspirator in degenerative, aortic valve stenosis: follow-up with Doppler echocardiography.
OBJECTIVE: Recently there has been an emphasis on reconstructing diseases native valves as an alternative to prosthetic valve replacement. Whereas; the surgical repair of aortic valve stenosis has been always problematic. This study was performed to estimate the clinical results after aortic valve debridement using ultrasonic energy. METHODS: Between 1990-1994 26 patients underwent ultrasonic aortic valve decalcification. There were 15 females and 11 males, the age was in average 74 years. As a concomitant diagnosis 88% patients (23) had mostly mild, aortic valve insufficiency, 16 (61%) had coronary artery disease and 11 (42%) had mild mitral valve incompetence. All of the patients were operated with cardiopulmonary bypass using moderate hypothermia, cardioplegical arrest and topical cooling for myocardial protection. The calcifications were removed tangentially using Cavitron Ultrasonic Surgical Aspirator. (CUSA), CAVITRON, USA. Leaflet perforation and/or unsatisfactory valve closure have been indications for aortic valve replacement. RESULTS: Two operative death (8%) have occurred and six patients have died in the further course (follow-up mean 17 months ranging from 4 to 61 months). Postoperative Doppler-Echocardiography results taken directly after surgery and then again 17 months later (n = 18) showed a decrease of peak and mean gradients across the aortic valve three and two times respectively (p < 0.001). 17 months after debridement we observed a mild rise in both gradients (by peak gradient p < 0.05). Directly postoperative, the aortic valve area increased doubly and decreased 17 months later slight, but it was still statistically significant in comparison with our preoperative data (p < 0.001). Follow-up echocardiography demonstrated late onset of moderate aortic valve insufficiency in 6 patients. The classification of New York Heart Association was improved in 13 (72%) survivors after 17 months. CONCLUSIONS: Ultrasonic debridement of aortic valve stenosis allows precise and energy-controlled removal of calcium, increased doubly the valve area and decreased of peak and mean gradients statistically significant. The advantages of preserving the native aortic valve in elderly patients are relative good arguments; although a longer follow-up is necessary to establish this procedure.
Aged↗
Long-term results of the viable cryopreserved allograft aortic valve: continuing evidence for superior valve durability.
From December 1969 to May 1975, 124 patients underwent aortic valve replacement with an allograft aortic valve sterilized by incubation in a low dose antibiotic solution and stored by refrigeration at 4 degrees C (4 degrees C stored valve group). From June 1975 to December 1987, 231 patients received an allograft aortic valve, sterilized by the same low dose antibiotic solution, but stored by cryopreservation in liquid nitrogen at -196 degrees C (cryopreserved valve group). The 4 degrees C stored valves were essentially nonviable, whereas the cryopreserved valves were viable at implantation. Of the 355 aortic valve replacements, associated procedures were performed in 127 patients. The 30-day mortality was 8.9% (confidence limits [C.L.] 6.2% ... 12.3%) (4 degrees C stored) and 4.8% (C.L. 3.3% ... 6.7%) (cryopreserved). Actuarial survival was similar in both groups, being 71% and 67% at 10 years in the 4 degrees C stored and cryopreserved valve groups, respectively (P = .18). The probability of a thromboembolic event was low, but appeared higher in the 4 degrees C stored valve group (actuarial freedom at 10 years, 90%) than the cryopreserved valve group (actuarial freedom at 10 years, 98%) (P = .01) probably related to associated mitral valve surgery. The actuarial freedom from allograft valve endocarditis at 10 years was 94% and 95% for the 4 degrees C stored and cryopreserved valve groups, respectively (P = .23). Reoperation was undertaken in 34 patients in the 4 degrees C stored group and 12 patients in the cryopreserved valve group for leaflet degeneration, endocarditis, or technical reasons.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Comparison of aortic valve gradient during exercise after aortic valve reconstruction.
PURPOSE: Aortic valve preservation is a promising alternative to conventional composite replacement of aortic valve and ascending aorta. This approach may have a physiologic benefit compared with valve replacement similar to that seen in mitral valve reconstruction. We investigated aortic valve gradients at rest and during exercise in patients who had undergone valve-preserving aortic replacement and compared them with composite replacement of valve and aorta. METHODS: Four groups were studied: nine patients underwent composite valve replacement (group A: valve diameter, 23 to 27 mm), eight patients underwent remodeling of the aortic root (group B), and another nine patients had reimplantation of the aortic valve (group C). Healthy volunteers were studied as a control group (group D). Using continuous-wave Doppler echocardiography, all patients were examined on a bicycle ergometer for aortic valve gradients (0 to 75 W). RESULTS: There were no differences among the groups with respect to age, body surface, left ventricular end-diastolic diameter, fractional shortening, or left ventricular mass. Maximum resting gradients were significantly elevated in group A compared with groups B, C, and D (group A: 21.3 +/- 7.1 mm Hg; group B: 9.0 +/- 4.5 mm Hg; group C: 8.6 +/- 3.7 mm Hg; group D: 4.9 +/- 1.6 mm Hg; p < 0.05). At 75 W, group A exhibited significantly higher gradients than all other groups (group A: 31.3 +/- 7.5 mm Hg; group B: 13.9 +/- 6.6 mm Hg; group C: 12.8 +/- 3.5 mm Hg; group D: 9. 2 +/- 1.9 mm Hg; p < 0.05). There was no significant difference among the other groups. Both valve-preserving groups had only insignificantly higher gradients than the control group. CONCLUSION: Our data strongly support the suggestion that preserving the aortic valve restores nearly normal hemodynamic function of the aortic valve. Long-term observations will have to prove the clinical relevance of restoring physiologic aortic valve hemodynamics.
Adult↗
In-vitro comparison of aortic valve hemodynamics between aortic root remodeling and aortic valve reimplantation.
BACKGROUND AND AIM OF THE STUDY: Valve-preserving aortic replacement has become an accepted option for patients with aortic valve regurgitation and aortic dilatation. The relative role of root remodeling versus valve reimplantation inside a vascular graft has been discussed, albeit controversially. In the present study, an in-vitro model was used to investigate the aortic valve hemodynamics of root remodeling and valve reimplantation; roots with supracommissural aortic replacement served as controls. METHODS: Aortic roots with aortoventricular diameter 21 mm were obtained from pigs. Root remodeling was performed using a 22-mm graft (group I, n = 6), or valve reimplantation with a 24-mm graft (group II, n = 7). Control roots were treated by supracommissural aortic replacement (22-mm graft; group III, n = 7). Using an electrohydraulic, computer-controlled pulse duplicator, the valves were tested at flows of 2, 4, 5, 7, and 9 I/min at a heart rate of 70 /min and a mean arterial pressure of 100 mmHg. Parameters assessed included: mean pressure gradient, effective orifice area, valve closure and regurgitant volume, and energy loss due to ejection, valve closure and regurgitation. Data were compared using ANOVA. RESULTS: There were no differences between the three groups in terms of regurgitant volume, energy loss due to valve regurgitation, or valve closure. The aortic valve orifice area was largest and systolic gradient lowest in group I at all flow rates (p < 0.001). Ejection energy loss was lowest in group I at all flow rates (9 l/min: group I, 128 +/- 21 mJ; group II, 399 +/- 46 mJ; group III, 312 +/- 27 mJ; p < 0.001). Valve closure volumes were similar in groups I and III, but significantly lower in group II at all flow rates (p = 0.047). CONCLUSION: In this standardized experimental setting, root remodeling--but not valve reimplantation--resulted in physiologic hemodynamic performance of the aortic valve with regard to orifice area, pressure gradient, and systolic energy loss.
Animals↗
[Status of aortic valve reconstruction and Ross operation in aortic valve diseases].
BACKGROUND: At first glance the aortic valve is a relative simple valve mechanism connecting the left ventricle and the ascending aorta. Detailed analysis of the different components of the aortic valve including the leaflets and sinuses revealed a complex motion of each part leading to a perfect durable valve mechanism at rest and during exercise. Theoretically, the reconstruction or imitation of these structures in patients with aortic valve disease should lead to optimal results. Prerequisite is the exact knowledge of the important functional characteristics of the aortic valve. The dynamic behavior of the aortic root closely harmonizing with the leaflets not only warrants stress minimizing and valve durability, but also optimizes coronary flow, left ventricular function and aortic impedance. The newly discovered contractile capacity of the leaflets and the root components are important for tuning the dynamics. AORTIC VALVE RECONSTRUCTION: Isolated reconstruction of the aortic valve such as decalcification, commissurotomy, plication of ring or leaflets of a tricuspid aortic valve and cusp extension are seldom indicated in contrast to the reconstruction of the bicuspid insufficient valve. Proper indication and skilled techniques lead to excellent hemodynamic and clinical intermediate-term result up to 7 years after reconstruction. Latest follow-up revealed a mean aortic insufficiency of 0.7, maximal pressure gradient of 11.4 +/- 8.5 mm Hg with zero hospital or late mortality, reoperation or thromboembolic events in 22 patients. The reconstructive techniques for aortic root aneurysm and/or type A dissection according to David or Yacoub have become routine procedures in the last 10 years. The hemodynamic and clinical results are excellent with low reoperation rate and very low risk of thromboembolism. Generally, a maximal diameter of the root of 5 cm is indicative for performing the operation. In patients with Marfan's syndrome the reconstruction should be advanced even with smaller diameters especially if these are progressive and combined with aortic insufficiency. ROSS-OPERATION: The Ross-Operation includes the replacement of the diseased aortic valve with the pulmonary autograft and reconstruction of the right ventricular outflow tract using a homograft. The hemodynamic results are excellent regarding the autograft and also the clinical results with very low thromboembolic risk and acceptable reoperation rate. This method is especially indicated for active young patients, women, who desire children, athletes and patients in general, who like to avoid long-term anticoagulation. In some cases the homograft may develop a dysfunction predominantly a pulmonary stenosis requiring reoperation. In the author's series of 245 Ross-operations in 12 years the homograft had to be replaced in 4 cases without letality. Innovative, decellularized homografts with the potential to repopulate with autologeous cells show promising results after 1 year of clinical implantation without signs of antibody development. Probably these tissue-engineered modification may improve the homograft results. The reconstructive techniques of the aortic valve and the Ross-operation have a certain risk of reoperation that must be weighed against the advantages of very low hospital and late valve related death, excellent hemodynamics, very low risk of macro- and microembolism as well as bleeding, lack of long-term anticoagulation and unrestricted life-style.
Adult↗
Ten years' experience of aortic valve replacement with the Omnicarbon valve prosthesis.
BACKGROUND: There are few clinical studies on late follow-up of the Omnicarbon monoleaflet valve. We report our 10-year experience with this valve in the aortic position and also compare late hemodynamic performance of this valve with that of the CarboMedics valve in the aortic position. METHODS: From January 1985 to June 1995, 117 consecutive patients underwent aortic valve replacement (AVR) with the Omnicarbon valve. There were 66 men and 51 women aged 13 to 69 years (mean age, 50 +/- 12 years). They were divided into three groups: group 1 (43 patients) had isolated AVR, group 2 (36) had AVR and concomitant operations, and group 3 (38) had combined AVR and mitral valve replacement. Follow-up was 96.6% complete and consisted of 882.7 patient-years (range, 2.5 to 10.6 years; mean follow-up, 7.5 +/- 2.7 years). RESULTS: There were three early deaths (2.6%) and 18 late deaths (2.0%/patient-year) ten of which were due to valve-related causes and eight, non-valve-related causes. Survival rates at 10 years in groups 1, 2, and 3 were 77.6%, 82.4%, and 78.6%, respectively. The overall rates of freedom from valve-related complications in groups 1, 2, and 3 at 10 years were 77.4%, 100%, and 80.9%, respectively. The rates of freedom from the following complications in groups 1, 2, and 3 at 10 years were as follows: thromboembolism--94.8%, 100%, and 89.4%, respectively; valvar thrombosis--95.0%, 100%, and 100%; anticoagulant-related hemorrhage--93.6%, 100%, and 93.4%; prosthetic valve endocarditis--93.0%, 100%, and 97.2%; and reoperation--90.6%, 100%, and 97.2%. There were no significant differences between groups. All survivors showed marked improvement in New York Heart Association functional class, from 86% in classes III and IV preoperatively to 96% in classes I and II postoperatively. The Omnicarbon valve exhibited no significant difference in hemodynamic performance after isolated AVR compared with the CarboMedics bileaflet valve at the same follow-up periods. CONCLUSIONS: This 10-year study confirms that the Omnicarbon valve is a durable prosthesis and provides excellent functional improvement with low rates of thromboembolism and valvar thrombosis in the aortic position.
Adolescent↗
Immediate and long-term results of valve replacement for native and prosthetic valve endocarditis.
BACKGROUND: The objective of the present study was to compare current results of prosthetic valve replacement following acute infective native valve endocarditis (NVE) with that of prosthetic valve endocarditis (PVE). Prosthetic valve replacement is often necessary for acute infective endocarditis. Although valve repair and homografts have been associated with excellent outcome, homograft availability and the importance of valvular destruction often dictate prosthetic valve replacement in patients with acute bacterial endocarditis. METHODS: A retrospective analysis of the experience with prosthetic valve replacement following acute NVE and PVE between 1988 and 1998 was performed at the Montreal Heart Institute. RESULTS: Seventy-seven patients (57 men and 20 women, mean age 48 +/- 16 years) with acute infective endocarditis underwent valve replacement. Fifty patients had NVE and 27 had PVE. Four patients (8%) with NVE died within 30 days of operation and there were no hospital deaths in patients with PVE. Survival at 1, 5, and 7 years averaged 80% +/- 6%, 76% +/- 6%, and 76% +/- 6% for NVE and 70% +/- 9%, 59% +/- 10%, and 55% +/- 10% for PVE, respectively (p = 0.15). Reoperation-free survival at 1, 5, and 7 years averaged 80% +/- 6%, 76% +/- 6%, and 76% +/- 6% for NVE and 45% +/- 10%, 40% +/- 10%, and 36% +/- 9% for PVE (p = 0.003). Five-year survival for NVE averaged 75% +/- 9% following aortic valve replacement and 79% +/- 9% following mitral valve replacement. Five-year survival for PVE averaged 66% +/- 12% following aortic valve replacement and 43% +/- 19% following mitral valve replacement (p = 0.75). Nine patients underwent reoperation during follow-up: indications were prosthesis infection in 4 patients (3 mitral, 1 aortic), dehiscence of mitral prosthesis in 3, and dehiscence of aortic prosthesis in 2. CONCLUSIONS: Prosthetic valve replacement for NVE resulted in good long-term patient survival with a minimal risk of reoperation compared with patients who underwent valve replacement for PVE. In patients with PVE, those who needed reoperation had recurrent endocarditis or noninfectious periprosthetic dehiscence.
Adult↗
Comparison of outcomes after aortic valve replacement with a mechanical valve or a bioprosthesis using microsimulation.
BACKGROUND: Mechanical valves and bioprostheses are widely used for aortic valve replacement. Though previous randomised studies indicate that there is no important difference in outcome after implantation with either type of valve, knowledge of outcomes after aortic valve replacement is incomplete. OBJECTIVE: To predict age and sex specific outcomes of patients after aortic valve replacement with bileaflet mechanical valves and stented porcine bioprostheses, and to provide evidence based support for the choice of prosthesis. METHODS: Meta-analysis of published results of primary aortic valve replacement with bileaflet mechanical prostheses (nine reports, 4274 patients, and 25,726 patient-years) and stented porcine bioprostheses (13 reports, 9007 patients, and 54,151 patient-years) was used to estimate the annual risks of postoperative valve related events and their outcomes. These estimates were entered into a microsimulation model, which was employed to calculate age and sex specific outcomes after aortic valve replacement. RESULTS: Life expectancy (LE) and event-free life expectancy (EFLE) for a 65 year old man after implantation with a mechanical valve or a bioprosthesis were 10.4 and 10.7 years and 7.7 and 8.4 years, respectively. The lifetime risk of at least one valve related event for a mechanical valve was 48%, and for a bioprosthesis, 44%. For LE and EFLE, the age crossover point between the two valve types was 59 and 60 years, respectively. CONCLUSIONS: Meta-analysis based microsimulation provides insight into the long term outcome after aortic valve replacement and suggests that the currently recommended age threshold for implanting a bioprosthesis could be lowered further.
Aged↗
Mitral valve replacement with total preservation of native valve and subvalvular apparatus.
BACKGROUND AND AIMS OF THE STUDY: Preservation of the mitral valve and subvalvular apparatus was introduced clinically in the early 1960s, but for two decades the technique for mitral valve replacement included excision of both leaflets and their attached chordae tendineae. Lately, emphasis has been replaced on retaining the mitral subvalvular apparatus during valve replacement because of its role in left ventricular function. Hence, during the past six years, when performing mitral valve replacement we have, when possible, preserved the valvular and sub-valvular mitral apparatus. METHODS: Between January 1990 and November 1996, complete retention of all mitral tissue in connection with mitral valve replacement was performed in 58 patients (23 women and 35 men). Mean age was 63 years (range: 23 years to 77 years). Coronary bypass was a concomitant procedure in 19 patients; both the mitral and aortic valve was replaced in four cases. Calcified and/or stenotic valves were not a contraindication for the procedure; calcified plaques were removed. Adhesion between anterior and posterior leaflets was treated with sharp dissection. Valve and subvalvular tissue were preserved. The leaflets were reefed within the valve-sutures and compressed between the sewing ring and the native annulus when implanting the valve prosthesis. Chordal tension on the ventricle is thus maintained and the chordae pulled away from the valve effluent. RESULTS: Six patients died in the postoperative period and three had transient neurological symptoms. In no patient was death or transient neurological symptoms a consequence of the retention of mitral leaflets with subvalvular apparatus. CONCLUSIONS: We find the described technique to be useful not only in valve insufficiency but also in valve stenosis when preserving the mitral leaflets with sub-valvular apparatus during valve replacement. The technique is without procedure-related complications and prevents obstruction of left ventricular outflow tract.
Adult↗
[Relative valve area stenosis after replacement of a Starr-Edwards mitral valve (model 6520) for corrected TGA (S, L, L): report of a case].
The patient was a 38-year-old man who had undergone mitral valve replacement with a Starr-Edwards disc valve (model 6520, 3 M, phi 30 mm, functional valve area: 2.85 cm2) at the age of 15 years for TR combined with corrected TGA. He developed dyspnea on exertion and palpitations at the age of 30 years, and paroxysmal supraventricular tachycardia appeared at the age of 35 years. Cardiac catheterization revealed that the PCWP was 30 mmHg and the TVA was 1.1 cm2, and a diagnosis of stenosis of the prosthetic valve was made. Thus, replacement of the Starr-Edwards disc valve using a BICARBON double leaflet valve (phi 27 mm, functional valve area: 2.85 cm2) was performed. The operative findings of the Starr-Edwards disc valve revealed a normal appearance and no pannus growth. Postoperative echocardiography and cardiac catheterization found that the TVA was 3.7 cm2 and the PCWP was 13 mmHg. The actual valve area of the disc valve sewn on the ventrical, which was anatomically RV construction might have been smaller than the ideal area; however, the double leaflet valve proved efficient in our patient. This case report serves to demonstrate that because of the postoperative difference in measurement between the actual valve area and the prostheticin ball or disc valve, patients undergoing mitral valve replacement must be followed up carefully.
Adult↗