[Congenital mitral valve insufficiency--congenital mitral valve diseases and cleft mitral valve].
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Adult↗
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Aortic valve replacement with homograft and autograft valves. Performance of 615 valves over 15 years.
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Aortic Valve↗
[A report of successful re-mitral valve replacement for prosthetic valve endocarditis (PVE : Hancock valve) (author's transl)].
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Adult↗
[Mitral valve disease, mitral valve prolapse syndrome, ruptured chordae tendineae of the mitral valve].
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Chordae Tendineae↗
Factors affecting mitral valve reoperation in 317 survivors after mitral valve reconstruction.
From a very heterogeneous group of 340 patients undergoing mitral valve reconstruction from 1969 through 1988, 313 hospital survivors were analyzed for factors affecting the occurrence of reoperative mitral valve procedures related to native mitral valve dysfunction. Follow-up was 100% and extended from 1 year to 20 years (mean follow-up, 7.2 years). Sixty-three patients (18.5% of the 340) required mitral valve reoperation at a mean postoperative interval of 6 years (range, 1 to 15 years). Incremental risk factors analyzed for the event late mitral valve failure included age, sex, preoperative New York Heart Association class, cause of valvular disease, pathophysiology of the mitral valve, previous mitral valve operation, mitral valve pathology, and estimation of mitral valve function at operation after repair. Mitral valve pathophysiology affected the actuarial freedom from mitral valve replacement (p = 0.023 [log-rank]). Actuarial freedom from mitral valve reoperation was 90% at 5 years and 80% at 8 years in patients who had either pure mitral regurgitation or isolated mitral stenosis compared with 80% and 72% at 5 and 10 years, respectively, in patients who had mixed mitral stenosis and regurgitation (p = 0.023). Patients undergoing late reoperation were younger (51.7 +/- 1.56 years [+/- the standard error of the mean]) than those not having reoperation (p less than 0.0003). Durability of the repair was less in patients with rheumatic heart disease (p less than 0.025) and greater in patients with ischemic heart disease (p less than 0.004). Seventy-three percent of patients undergoing reoperation had concomitant operations compared with 68% of those not having reoperation (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Echocardiographic assessment of mitral valve size in obstructive hypertrophic cardiomyopathy. Anatomic validation from mitral valve specimen.
BACKGROUND: In patients with hypertrophic cardiomyopathy, obstruction to left ventricular outflow is produced by systolic anterior motion of the mitral valve. In many of these patients, the mitral leaflets are elongated and increased in overall size. Mitral valve size may be responsible, in part, for the presence and magnitude of the outflow gradient and the pattern of systolic anterior motion of the leaflets. It may also influence the effectiveness of ventricular septal myotomy-myectomy in relieving subaortic obstruction. Therefore, the present study was undertaken to determine whether mitral valve dimensions could be assessed in quantitative terms from the echocardiogram in patients with hypertrophic cardiomyopathy. METHODS AND RESULTS: A group of 37 patients with hypertrophic cardiomyopathy was selected for this study by virtue of having a high-quality transthoracic or intraoperative echocardiogram suitable for certain quantitative measurements from stop-frame images as well as a morphologically intact mitral valve specimen (removed during surgery). Seven measurements of mitral valve dimensions were obtained from the two-dimensional and M-mode echocardiograms. A univariate regression analysis identified the mitral valve opening area as the best single predictor of actual mitral leaflet area measured from the specimen (r2 = .75; r = .87). The linear relation between mitral valve opening area as assessed by two-dimensional echocardiography and actual mitral leaflet area measured from the mitral valve specimen accounted for approximately 75% of the variability in mitral leaflet area. With such statistical models, it was possible to reliably identify from the echocardiogram enlarged mitral valves (> or = 12.0 cm2) in 16 of 19 patients (84%) and normal-sized valves in 15 of 18 patients (83%). CONCLUSIONS: In a selected group of patients with obstructive hypertrophic cardiomyopathy, a model derived from a regression analysis of quantitative echocardiographic measurements permitted (with good precision) estimation of actual mitral leaflet area and consequently overall mitral valve size and the discrimination of enlarged from normal-sized mitral valves.
Adolescent↗
Preoperative left ventricular wall stress, ejection fraction, and aortic valve gradient as prognostic indicators in aortic valve stenosis.
Patients with aortic valve stenosis (AS) and left ventricular (LV) dysfunction may dramatically improve after aortic valve replacement, but operative risk is high. In an earlier study, all patients with low preoperative wall stress and low ejection fraction, or with low aortic valve gradient, died or had persistent heart failure after operation. Because wall stress is difficult to calculate, we reassessed its effect and the effect of other preoperative characteristics on outcome in 66 consecutive catheterization patients with predominant aortic stenosis referred for valve replacement. Despite ejection fraction that was inordinately low compared with afterloading wall stress in nine patients, seven patients improved with surgery. All three patients with ejection fraction less than 20% improved after surgery. Two of three patients with mean aortic valve gradients of less than 30 mm Hg improved. Mortality was 33% in patients with mean gradient less than 30 mm Hg and 19% with mean gradient less than 50 mm Hg. In the 54 patients with calculated aortic valve areas of less than or equal to 0.8 cm2, 1 (2%) had continuing heart failure, while 6 of 12 (50%, P less than .01) patients with aortic valve areas of 0.9-1.2 cm2 had continued symptoms of or died of heart failure. Patients who died or failed to improve after operation were older (71 +/- 9 years) than those who improved (65 +/- 9 years, P = .02). We conclude that wall stress calculations do not predict which patients with aortic stenosis will benefit from aortic valve replacement and that poor left ventricular function and low mean aortic valve gradient do not absolutely preclude operation. On the other hand, low gradient, non-critical valve area, and advanced age are all relative contraindications to aortic valve replacement in aortic stenosis.
Aged↗
Mid-term surgical results after valve replacement with the CarboMedics valve prosthesis.
We present herein a review of 95 patients who underwent valve replacement with the CarboMedics (CM) valve prosthesis between April 1990 and December 1992. The operative mortality for the entire group was 4.2%: 0% following aortic valve replacement (AVR), 2.7% following double valve replacement (DVR). All patients were prescribed warfarin and bucolome for anticoagulation, and were followed up for a mean period of 29.9 months. Late mortality was 8.4%; 3.1% following AVR, 10.8% following MVR, and 12.5% following DVR. There were no cases of mechanical prosthetic valve failure, significant hemolysis, infective prosthetic valve endocarditis, or bleeding complications. After 44 months of follow-up, the actuarial freedom from complications was calculated as: thromboembolism, 97.8 +/- 1.6%; valve thrombosis, 97.8 +/- 1.1%; paravalvular leak, 96.7 +/- 1.9%; and reoperation, 98.9 +/- 1.1%. The overall survival rate was 84.3 +/- 6.3% and all survivors showed a significant improvement in NYHA functional class, from 81% in classes III and IV preoperatively to 99% in classes I and II postoperatively. The CM valve exhibited no significant differences in hemolytic parameters or hemodynamic performance after isolated AVR or MVR compared with the similar type of St. Jude Medical bileaflet valve. The evidence provided by the present study therefore suggests that the CM valve prosthesis can achieve excellent mid-term clinical results and hemodynamic performance with a low incidence of thromboembolism and valve thrombosis.
Adolescent↗
Prosthetic valve endocarditis: clinicopathologic analysis of 22 necropsy patients with comparison observations in 74 necropsy patients with active infective endocarditis involving natural left-sided cardiac valves.
Clinical and morphologic features are described in 22 necropsy patients with endocarditis involving rigid-framed prosthetic valves: aortic in 15 patients and mitral in 7. The interval from valve replacement to onset of symptoms of prosthetic valve endocarditis was less than 2 months in 8 patients and longer than 2 months in 14 patients. The most frequent infecting organism was the Staphylococcus (13 patients). In each of the 22 patients the infection was located behind the site of attachment of the prosthesis to the valve ring, and the infection spread to adjacent structures in 13 patients, 11 of whom had aortic prostheses. Prosthetic detachment causing severe regurgitation occurred in 12 of the 15 patients with an infected aortic valve prosthesis, and in 2 of the 7 with an infected mitral valve prosthesis. Prosthetic obstruction by vegetative material occurred in 5 of 7 patients with prosthetic mitral infection and in only 1 of 15 with prosthetic aortic infection. High degrees of conduction defects developed in seven patients with aortic prosthetic valve endocarditis: complete heart block in five, and complete left bundle branch block in two. Comparison of observations in the 22 patients with prosthetic valve endocarditis with those in 74 patients with active infective endocarditis involving natural left-sided cardiac valves revealed significant (P less than 0.05) differences in the percent with ring abscess, hemodynamic consequences of the endocarditis (valve stenosis), frequency of Staphylococcus as the causative organism and percent with complete heart block or left bundle branch block. No significant differences were observed between the two groups when comparing age, sex, type of underlying valve disease or frequency of organ infarcts of splenomegaly.
Abscess↗
Determinants of survival and valve failure after mitral valve replacement.
A prospective evaluation of 333 consecutive patients undergoing isolated mitral valve replacement between 1982 and 1985 was performed to identify the predictors of survival and valve failure. Follow-up between 2 and 6 years postoperatively (mean, 32 +/- 17 months) was 98% complete. Four prostheses were inserted to permit a prospective evaluation of alternative valves: Björk-Shiley mechanical (n = 118), Ionescu-Shiley pericardial (n = 146), Carpentier-Edwards porcine (n = 38), and Hancock pericardial (n = 31). Hospital mortality was 6%, and actuarial survival at 5 years was 74% +/- 5%. Multivariate Cox regression analysis identified advancing age (less than 40 years, 88% +/- 7%; greater than 70 years, 50% +/- 14%) and poor left ventricular function (ejection fraction less than 0.20, 62% +/- 17%; ejection fraction greater than 0.60, 80% +/- 7%) as independent predictors of postoperative survival. Freedom from structural valve dysfunction, prosthetic valve endocarditis, reoperation, and valve-related mortality and morbidity were 86% +/- 4%, 91% +/- 4%, 81% +/- 4%, and 72% +/- 5%, respectively, at 5 years. The actuarial incidence of valve failure was inordinately high with the Hancock pericardial valve (p less than 0.05). Freedom from thromboembolic events (78% +/- 8% at 5 years) was significantly lower in patients with poor ventricular function (ejection fraction (less than 0.20, 54% +/- 20%; ejection fraction greater than 0.60, 73% +/- 11%; p less than 0.05). Survival after mitral valve replacement was determined by age and left ventricular function. Premature failure of the Hancock pericardial valve resulted in an unacceptable rate of valve-related complications.
Adult↗
Tricuspid valve replacement with bioprostheses: long-term results and causes of valve dysfunction.
BACKGROUND: Although the clinical performance of bioprostheses after valve replacement in the aortic and mitral position has been reported, little is known of the performance of tricuspid bioprostheses. The mechanism of bioprosthetic valve dysfunction after tricuspid valve replacement (TVR) is not clear. METHODS: We reviewed 98 cases of TVR with bioprostheses. To clarify the causes of valve dysfunction, pathologic examination of the explanted valve at the reoperation was performed. RESULTS: Actuarial survival at 18 years was 68.7% +/- 5.8%. There were 12 redo TVRs. In six of the 12 cases, isolated redo TVR was performed. In the other cases, concomitant cardiac procedures were performed. The causes of prosthetic valve dysfunction were pannus formation on the cusps of the right ventricle side (four cases), native valve attachment (two cases), pannus formation + native valve attachment (two cases), sclerotic change (one case), pannus formation + sclerotic change (one case), and native valve attachment + valve infection (one case). Freedom from reoperation, structural valve deterioration, and nonstructural dysfunction at 18 years was 62.7% +/- 10.7%, 96.0% +/- 2.9%, and 76.7% +/- 8.3%, respectively. CONCLUSIONS: In our 18 years of experience, although the survival after TVR with bioprostheses is acceptable, the reoperation free rate is not satisfactory. Pannus formation on the cusps of the ventricular side seems to be a serious problem that causes bioprosthetic dysfunction in the tricuspid position.
Adolescent↗
Left ventricular mass reduction after aortic valve replacement: homografts, stentless and stented valves.
BACKGROUND: We studied the effect of four different types of prosthetic aortic valves on time course and extent of regression of left ventricular hypertrophy after aortic valve replacement for aortic stenosis. METHODS: Four groups of 10 patients each were randomly assigned to receive: (1) aortic homograft preserved in antibiotic solution at 4 degrees C, (2) Toronto stentless porcine valve, (3) Medtronic Freestyle stentless valve, or (4) Medtronic Intact aortic valve. The left ventricular mass index, effective orifice area index, and peak and mean transaortic gradients were measured by Doppler echocardiography before the operation and 8 months postoperatively. RESULTS: The hemodynamic performance indices were much better for the homograft and stentless valves than for the stented one. The absolute left ventricular mass index reduction was greater in the homograft group compared with the Intact (p = 0.0004) and Toronto (p = 0.007) groups. The extent of percent left ventricular mass index reduction was greater only in the homograft group versus Intact group (p = 0.005). The multilinear regression analysis showed that the only predictors of a larger percentage of left ventricular mass index reduction were the homograft type, a higher valve size index, and a higher preoperative left ventricular mass index. CONCLUSIONS: When a stentless or homograft aortic valve was used instead of a stented valve to replace a stenotic aortic valve there was more complete or at least faster regression of left ventricular hypertrophy. The hemodynamic performance of stentless porcine valves was similar to that of aortic homografts, nevertheless the aortic homografts preserved in antibiotic solution offered a faster regression of left ventricular hypertrophy during the same period of time.
Aged↗
A comparison of macroscopic lipid content within porcine pulmonary and aortic valves. Implications for bioprosthetic valves.
Lipid droplets have been demonstrated within both explanted porcine bioprostheses and normal porcine aortic valves. Because of the increasing interest in pulmonary valves as an allograft or xenograft aortic valve substitute, we examined the incidence and distribution of such lipid deposits in 50 porcine aortic valves and 50 matched porcine pulmonary valves. All 300 cusps were removed with surgical scissors and, under a dissecting microscope, the ventricularis layer was removed to expose the spongiosal layer. Macroscopic extracellular lipid droplets analyzed by means of a dissecting microscope with an eyepiece grid and stereology point-counting techniques to provide an area-density average spatial probability map for each cusp. Only 8% of porcine aortic valves were free of lipid, with the distribution of the lipids being 52% +/- 14% right coronary cusp, 90% +/- 8% left coronary cusp, and 68% +/- 13% noncoronary cusp. Of the pulmonary valves, 60% were free of lipid, with the incidence of lipids being 26% +/- 12% left cusp, 6% +/- 7% right cusp, and 12% +/- 9% anterior cusp. Subsequently, lipid cluster samples underwent thin-layer chromatography, which showed them to be phospholipids, oleic acid (fatty acid), triglycerides, and unesterified cholesterol. One primary mode of bioprosthetic valve failure is leaflet calcification. The similarity of distribution within the spongiosal layer between leaflet calcification and intrinsic cusp lipids suggests that the observed lipids might act as a nucleation site for calcification. The substantially lower incidence of lipid in pulmonary valves therefore may represent a potential benefit when these valves are considered for use as aortic valve replacements.
Animals↗
Variable effects of changes in flow rate through the aortic, pulmonary and mitral valves on valve area and flow velocity: impact on quantitative Doppler flow calculations.
Doppler echocardiographic methods for measuring volumetric flow through the aortic, pulmonary and mitral valves provide the cardiologist with several potentially interchangeable noninvasive methods for determining cardiac output. In addition, comparison of flow differences through individual valves offers the potential to quantitate shunt flow and regurgitant volumes. To date, however, no study has compared the relative accuracies of each of these flow measurements in a controlled experimental setting. Therefore, in this study, Doppler echocardiography was used to measure aortic, pulmonary and mitral valve flows in seven open chest dogs on right atrial bypass where forward cardiac output was precisely controlled with a roller pump. Correlations with roller pump output were better for Doppler measurements of aortic (r = 0.98, SD = 0.3) and mitral (r = 0.97, SD = 0.3) than for pulmonary (r = 0.93, SD = 0.5) valve flow. Interobserver reproducibility was also better for aortic (r = 0.94) and mitral (r = 0.97) than for pulmonary (r = 0.88) valve flow measurements. All valves showed flow-related increases in cross-sectional area, but the slope of this response was variable: 0.05, 0.16 and 0.21 for the aortic, the pulmonary and the mitral valve, respectively. Increased forward flow through the aortic valve, therefore, was manifested primarily by an increase in velocity, whereas increasing flow through the pulmonary and mitral valves produced more significant area changes with correspondingly smaller increases in the velocity component. Recalculation of Doppler-determined outputs, assuming a fixed valve area for the entire range of flows, resulted in a decreased correlation with roller pump output. Both velocity and valve area should be measured at each flow rate for greatest accuracy in volumetric flow calculations.
Animals↗
Aortic root replacement with human tissue valves in aortic valve endocarditis.
OBJECTIVE: Aortic allograft and pulmonary autograft aortic root replacement in native and prosthetic aortic valve endocarditis are evaluated and risk factors for hospital death are assessed by univariate risk factor analysis. METHODS: From April 1989 to May 1996, 59 patients with aortic valve endocarditis (27 native; 32 prosthetic) underwent aortic root replacement with a human tissue valve. Mean age was 53.4 +/- 12.3 years; 46 patients (78%) were male. The mean preoperative NYHA functional class was 3.4. The predominant infective organisms were streptococci (30%) in the native valve group and staphylococci (30%) in the prosthetic valve group. In native valve endocarditis, valve destruction (32%) was the predominant finding. Abscesses, either annular (29%) or subannular (36%) and valve dehiscence (36%) were the most common findings in patients with prosthetic valve endocarditis. Partial or total ventriculo-aortic discontinuity (20%) and aortico-mitral discontinuity (27%) were other important operative observations. A cryopreserved allograft was used in 53 patients (89.5%), the pulmonary autograft (Ross procedure) in 5 patients (8.5%), and a fresh antibiotic sterilized allograft root in one patient (2%). Mean aortic cross-clamp time was 131 +/- 32 min. In active native and prosthetic valve endocarditis, intravenous antibiotics were continued for at least 6 weeks, monitored by serial CRP measurements. RESULTS: Hospital mortality was 8.5% (n = 5; 70% CL: 4.9-12.1%). Univariate risk factors for hospital mortality were age (P = 0.001), preoperative New York Heart Association functional class (P = 0.001), pre- (P = 0.001) and postoperative (P = 0.001) renal insufficiency. Major complications were allograft failure (n = 1; 2%), technical failure (n = 1; 2%) and false aneurysm formation at the proximal suture line (n = 1; 2%). Follow-up was complete, mean 33.1 +/- 20.1 months. Two late deaths occurred. Actuarial five year survival was 88.8% (70% CL: 80.0-97.5%); actuarial five year freedom from recurrent endocarditis was 98.1% (70% CL: 94.5-100%). CONCLUSION: Allograft aortic root replacement is a valuable technique in the life threatening situations both of native and prosthetic aortic valve endocarditis with involvement of the annular and peri-annular region.
Adult↗
Downstream turbulence and high intensity transient signals (HITS) following aortic valve replacement with Medtronic Hall or St. Jude Medical valve substitutes.
OBJECTIVE: High intensity transient signals (HITS) representing microembolization to the brain have been found to contribute to cognitive impairment and psychoneurological dysfunction in patients carrying a mechanical aortic valve. It is unknown, whether HITS represent gaseous or solid emboli. This animal study evaluates the impact of valve orientation on HITS for two different mechanical valves with both valves implanted in their best and worst orientation, which has been defined in previous studies with respect to downstream turbulence. METHODS: In four pigs a rotation device carrying either a Medtronic Hall (MH) or St. Jude Medical (SJM) valve size 23 mm was implanted. The device allowed rotation of the implanted valves without reopening of the aorta. Approximately 30 min after weaning from extracorporeal circulation, a Doppler probe was placed on both common carotid arteries. In different orientations of the implanted valves (best and worst position), HITS were detected by the Doppler probe and recorded for ten min by a transcranial Doppler sonography device (Medilab Inc., Estenfeld, Germany). RESULTS: HITS showed significant change with rotation for both valve designs. With the major orifice of the MH oriented towards the non-coronary leaflet (optimum position) very low HITS-counts (0.8-1.7/min) were observed. In the worst orientation HITS rose to 43-66/min. For the SJM the HITS count in the optimum position was 23.4-24/min and in the worst orientation 38-48/min. CONCLUSIONS: Valve orientation has an important impact on microembolization to the brain. In the optimum orientation (large orifice facing the non-coronary leaflet) the Medtronic Hall valve showed negligible incidence of HITS. The St. Jude Medical bileaflet valve showed less variation but demonstrated significant HITS counts at any orientation. As the MH in the worst position shows significantly higher turbulent stresses than the SJM but no higher incidence of HITS, a strong correlation between turbulence and HITS was not demonstrated by this study.
Animals↗
Hospital volume and selection of valve type in older patients undergoing aortic valve replacement surgery in the United States.
BACKGROUND: Hospital volume has been linked to quality of care. The relation between hospital volume and recommended use of bioprosthetic valves in older patients undergoing aortic valve replacement (AVR) is unknown. METHODS AND RESULTS: We identified 80,470 patients aged > or =65 years undergoing isolated AVR (with or without bypass surgery) in 1045 US hospitals during 1999-2001 from Medicare Part A files. International Classification of Diseases, Ninth Revision, Clinical Modification codes were used to identify patients undergoing bioprosthetic valve (35.21) or mechanical valve (35.22) AVR. The sample was categorized into deciles on the basis of the valve surgery volume of the hospital. Generalized estimating equations determined the relative risk of receiving a bioprosthetic valve in different volume deciles, with adjustment for age, gender, race, comorbidity, and other factors. Bioprosthetic valve use increased (P<0.001) from 44% in 1999 to 52% in 2001 and with age (from 36% in patients aged 65 to 69 years to 60% in patients aged > or =90 years). Rates were directly related (P<0.001) to volume, rising from 28% in the 1st decile to 68% in the 10th decile. With the use of generalized estimating equations, the relative risk of bioprosthetic valve use, relative to the 1st decile, progressively increased from 1.2 (95% CI, 1.1 to 1.4) in the 2nd decile to 2.3 (95% CI, 1.9 to 2.7) in the 10th decile. CONCLUSIONS: Hospital volume was a strong predictor of bioprosthetic valve use in older patients undergoing AVR. The lower use of bioprosthetic valves in low-volume hospitals is at odds with recent guidelines recommending bioprosthetic valves in patients aged > or =65 years. These findings further support the use of volume as a marker of hospital quality.
Age Factors↗
Effect of prosthetic valve malfunction on the Doppler-catheter gradient relation for bileaflet aortic valve prostheses.
BACKGROUND: Considerable discrepancies between Doppler and catheter gradients caused by localized gradients and pressure recovery have been reported for normal bileaflet aortic valve prostheses. METHODS AND RESULTS: To examine whether this Doppler-catheter gradient relation is affected by prosthetic valve malfunction, a 19-mm CarboMedics aortic valve was simultaneously studied with continuous-wave Doppler and catheter technique in normal function and in various states of malfunction ranging from slightly restricted opening to total occlusion of one leaflet. For each functional status, peak and mean gradients were measured at eight different flow rates (cardiac output, 2.0-6.0 L/min). Excellent correlation between Doppler and catheter gradients was found regardless of the valve function (r = 0.99, SEE = 1.0-3.3 mm Hg). However, the relation between Doppler and catheter gradient was highly dependent on the function of the valve as shown by a variation of slopes from 1.08 to 2.08. For the normally functioning valve (angle between flow axis and leaflet 5 degrees), peak and mean Doppler gradients were approximately twice the catheter gradients (slope, 2.08 and 2.03 for peak and mean gradients, respectively). Slightly restricted opening of one leaflet (22 degrees) significantly altered the Doppler-catheter gradient relation, and slopes decreased to 1.69 (p < 0.01) and 1.52 (p < 0.001) for peak and mean gradients, respectively. The differences between Doppler and catheter gradients significantly decreased with further restriction of valve opening, and slopes ranged from 1.25 to 1.41 for angles between 34 degrees and 52 degrees. When one leaflet was totally occluded, the slope finally dropped to 1.08 for both peak and mean gradients, and Doppler gradients were only slightly greater than catheter gradients. Gradients increased with malfunction of the valve caused by reduction of the effective orifice area. However, the increase of Doppler gradients was considerably smaller than the increase of simultaneous catheter gradients. CONCLUSIONS: The discrepancies between Doppler and catheter gradients that have been reported for normally functioning bileaflet aortic valve prostheses may be reduced or even disappear in patients with malfunctioning valves. Furthermore, the increase of Doppler gradients caused by malfunction of the valve may underestimate the true hemodynamic changes.
Aortic Valve↗