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PubMed1990

Ten-year experience with the St. Jude Medical valve for primary valve replacement.

The St. Jude Medical valve is a bileaflet prosthesis with excellent hemodynamic characteristics, but the long-term surgical experience with this valve, its durability, and its biocompatibility are unknown. During a 10-year period from March 1978 to 1988, 690 prostheses (290 aortic, 252 mitral, and 74 double aortic-mitral) were inserted as the initial valve replacement substitute in 616 patients (mean age 63 years). Coronary atherosclerosis was present in 58%. Follow-up totaled 2031 patient-years (mean 3.3 years) and was 95% complete (32 lost). Early (30-day) mortality rates were 5.2%, 11.9%, and 8.1% after aortic, mitral, and double valve replacement; 5- and 9-year actuarial survival rates were 71% +/- 3% and 51% +/- 8%, 59% +/- 4% and 41% +/- 6%, and 69% +/- 6% and 47% +/- 15%, respectively. Deaths were associated with extensive coronary atherosclerosis (p less than 0.001), older age (p less than 0.001), advanced preoperative New York Heart Association functional class (p less than 0.05), and malignant ventricular arrhythmias (p less than 0.05). No structural failures have been observed. Embolism (40 events) occurred at a rate of 2.0%/pt-yr (2.3% aortic, 1.6% mitral, 2.0% double). There were six cases of valve thrombosis (0.3%/pt-yr; one fatal). Hemorrhage was the most frequent complication (2.6%/pt-yr); 13 (25%) of 52 events were fatal, accounting for 62% of all valve-related deaths. After the target prothrombin time ratio was lowered, the rate of hemorrhage decreased by 44% (2.7% to 1.5%/pt-yr), while the combined rate of embolism and valve thrombosis increased slightly (2.2% to 2.5%/pt-yr, a 14% change). In summary, the St. Jude Medical valve remains a durable valve substitute. Survival was strongly related to the presence of associated coronary atherosclerosis. The most common complication has been hemorrhage; a less intensive warfarin regimen may reduce hemorrhagic risk while maintaining thromboembolic protection.

Adolescent↗
PubMed1982

Early clinical evaluation after aortic valve replacement with the St. Jude Medical valve in patients with a small aortic root.

Forty-three patients, nine men and 34 women, mean age 60 years (range 23-81 years), who had small aortic roots underwent aortic valve replacement with a St. Jude Medical valve. Preoperatively, five patients were in New York Heart Association (NYHA) class I, 19 were in class II, 15 were in class III and four were in class IV. In 30 of 36 patients with aortic stenosis, the mean gradient was 102 mm Hg (range 52-175 mm Hg; in six patients with aortic stenosis, the gradient was not measured. Seven patients underwent surgery for aortic regurgitation. Ten patients received a 19-mm valve, 29 a 21-mm valve and nine a 23-mm valve. Two patients (4.6%) died in the hospital, one immediately postoperatively and the other from low cardiac output 9 days postoperatively. There are 670 patient-months of follow-up (mean 17 months). Thirty-six patients are NYHA class I and two patients are in class II. There have been no thromboembolic episodes in 605 months of follow-up for patients maintained on warfarin. There was one partial valve thrombosis among eight patients being managed without warfarin. No mechanical valve failures have occurred. The St. Jude Medical valve provides a satisfactory early result when used to replace the aortic valve of patients who have a small aortic root.

Adult↗
PubMed2002

Hemodynamic stability of valve area, valve resistance, and stroke work loss in aortic stenosis: a comparative analysis.

BACKGROUND: Although aortic valve area (AVA) has provided the standard index for assessing aortic stenosis severity, valve resistance and percent left ventricular stroke work (%LVSW) loss have been proposed as alternative flow independent indices of stenosis severity that may provide a more stable measure under diverse hemodynamic conditions. In 30 patients with moderate or severe aortic stenosis (AVA < or = 1.2 cm(2)), Doppler echocardiography indices of AVA, valve resistance, and %LVSW loss were measured at multiple transvalvular flow rates during dobutamine infusions (0-10 microg/kg/min) to compare their hemodynamic stability. RESULTS: From baseline to maximum dobutamine dose in the 30 patients, transvalvular flow rate increased 43% and resulted in a 42% increase in mean transvalvular pressure gradient, a 15% increase in Doppler AVA, and a 26% increase in %LVSW loss. Group mean valve resistance did not change for the total cohort. For individual patients, AVA and %LVSW loss demonstrated a linear relationship with transvalvular flow (median r = 0.74 and 0.84, respectively). In contrast, both flow-mediated increases and decreases in valve resistance were observed in individual patients, resulting in the apparent stability of the group mean valve resistance in the total cohort. For individual patients, Doppler AVA and valve resistance demonstrated comparable stability in response to changes in hemodynamic conditions and were significantly more stable than mean transvalvular pressure gradient and %LVSW loss. CONCLUSION: Doppler AVA and valve resistance provide stenotic indices of equivalent hemodynamic stability. However, transvalvular flow has a predictable directional effect on AVA and an unpredictable directional effect on valve resistance, potentially limiting valve resistance as a measure of hemodynamic severity.

Adult↗
PubMed2006

Characterization of an artificial valve flow using the numerical dye washout visualization technique: application to the monoleaflet valve with purged flow.

Until today, no ideal heart valve prosthesis for the replacement of a diseased natural valve or for use in ventricular assist devices exists. Valves still cause thromboembolic complications originating from thrombus formations in the valve's stagnant zones. Optimization of valve design involves avoiding stagnation zones and zones of high shear stresses. This requires detailed flow field investigations. Usually, the regions which are more prone to thrombus formation can be estimated using a dye washout experiment. The method allows an assessment of regions with a high or low residence time that may in turn predict regions with a corresponding thrombus risk. This successful experimental method was simulated using numerical methods with a combination of the computational fluid dynamics program FLUENT (Fluent Inc., Lebanon, NH, USA) and of the visualization tool AMIRA (TGS Inc., San Diego, CA, USA). The numerical dye washout visualization was applied to four monoleaflet valves with varying valve housing geometries. The results show a significant difference in the washout processes of the examined valves. The dye washout was characterized by a time course of the gray value averaged over a defined region of interest. Finally, these curves were quantified by a half dye time. The half dye time in the best optimized valve was only 0.2753 s. The same time in the original valve was 0.6834 s. This study shows that the proposed numerical method of dye washout visualization can be used as an additional tool of the flow characterization in artificial organs.

Dye Dilution Technique↗
PubMed2005

Staphylococcus lugdunensis infective endocarditis: description of 10 cases and analysis of native valve, prosthetic valve, and pacemaker lead endocarditis clinical profiles.

OBJECTIVE: To evaluate the incidence and the clinical and echocardiographic features of infective endocarditis (IE) caused by Staphylococcus lugdunensis and to identify the prognostic factors of surgery and mortality in this disease. DESIGN: Prospective cohort study. SETTING: Study at two centres (a tertiary care centre and a community hospital). PATIENTS: 10 patients with IE caused by S lugdunensis in 912 consecutive patients with IE between 1990 and 2003. METHODS: Prospective study of consecutive patients carried out by the multidisciplinary team for diagnosis and treatment of IE from the study institutions. English, French, and Spanish literature was searched by computer under the terms "endocarditis" and "Staphylococcus lugdunensis" published between 1989 and December 2003. MAIN OUTCOME MEASURES: Patient characteristics, echocardiographic findings, required surgery, and prognostic factors of mortality in left sided cases of IE. RESULTS: 10 cases of IE caused by S lugdunensis were identified at our institutions, representing 0.8% (four of 467), 1.5% (two of 135), and 7.8% (four of 51) of cases of native valve, prosthetic valve, and pacemaker lead endocarditis in the non-drug misusers. Native valve IE was present in four patients (two aortic, one mitral, and one pulmonary), prosthetic valve aortic IE in two patients, and pacemaker lead IE in the other four patients. All patients with left sided IE had serious complications (heart failure, periannular abscess formation, or shock) requiring surgery in 60% (three of five patients) of cases with an overall mortality rate of 80% (four of five patients). All patients with pacemaker IE underwent combined medical treatment and surgery, and mortality was 25% (one patient). In total 59 cases of IE caused by S lugdunensis were identified in a review of the literature. The combined analysis of these 69 cases showed that native valve IE (53 patients, 77%) is characterised by mitral valve involvement and frequent complications such as heart failure, abscess formation, and embolism. Surgery was needed in 51% of cases and mortality was 42%. Prosthetic valve endocarditis (nine of 60, 13%) predominated in the aortic position and was associated with abscess formation, required surgery, and high mortality (78%). Pacemaker lead IE (seven of 69, 10%) is associated with a better prognosis when antibiotic treatment is combined with surgery. CONCLUSIONS: S lugdunensis IE is an uncommon cause of IE, involving mainly native left sided valves, and it is characterised by an aggressive clinical course. Mortality in left sided native valve IE is high but the prognosis has improved in recent years. Surgery has improved survival in left sided IE and, therefore, early surgery should always be considered. Prosthetic valve S lugdunensis IE carries an ominous prognosis.

Adult↗
PubMed2005

Tissue engineering of heart valves: decellularized porcine and human valve scaffolds differ importantly in residual potential to attract monocytic cells.

BACKGROUND: Tissue-engineered or decellularized heart valves have already been implanted in humans or are currently approaching the clinical setting. The aim of this study was to examine the migratory response of human monocytic cells toward decellularized porcine and human heart valves, a pivotal step in the early immunologic reaction. METHODS AND RESULTS: Porcine and human pulmonary valve conduits were decellularized, and migration of U-937 monocytic cells toward extracted heart valve proteins was examined in a transmigration chamber in vitro. Homogenized tissue specimens were size fractionated by SDS-PAGE. The decellularization procedure effectively reduced the migration of human monocytes toward all heart valve tissue. However, only the antigen reduction of human pulmonary valves abolished the monocytic response (wall, 0.88+/-0.19% versus 30.20+/-3.93% migrated cells [mean+/-SEM]; cusps, 0.10+/-0.06% versus 10.24+/-1.83%) and was significantly lower (P<0.05) than that of the decellularized porcine equivalent (wall, 5.03+/-0.14% versus 24.31+/-2.38%; cusps, 3.18+/-0.38% versus 10.24+/-1.83%). SDS-PAGE of the pulmonary heart valve tissue revealed that considerable amounts of proteins with different molecular weights that were not detected in the human equivalent remain in the decellularized porcine heart valve. CONCLUSIONS: We describe for the first time that the remaining potential of decellularized pulmonary heart valves to attract monocytic cells depends strongly on whether porcine or human scaffolds were used. These findings will have an important impact on further investigations in the field of heart valve tissue engineering.

Animals↗
PubMed1989

Reconstruction of right ventricular outflow tract by autologous pericardial tri-semilunar valve with sinus of Valsalva: report of a case with absent pulmonary valve.

The choice of a valved conduit or a valve in the right ventricular outflow tract remains a problem. We propose to reconstruct the pulmonary valve inside the patient's own pulmonary trunk by autologous pericardium in tri-semilunar fashion with concomitant formation of the sinus of Valsalva and commissure. This operation was carried out on a 7-year-old girl suffering from Fallot's tetralogy with an absent pulmonary valve. The ventricular septal defect was repaired and the pulmonary valve reconstructed as above. The postoperative cross-sectional echocardiogram, color Doppler echocardiogram and angiogram showed a pliable tri-semilunar valve across the pulmonary outflow tract without regurgitation. It is concluded that firstly, the sinus of Valsalva is indispensable for a stentless semilunar valve to be competent; secondly, reconstruction of the semilunar valve inside the pulmonary trunk by autologous pericardium is recommended for the absent pulmonary valve syndrome, but the long-term fate of this pericardial valve awaits further evaluation.

Child↗
PubMed2005

Impact of the improvement of valve area achieved with aortic valve replacement on the regression of left ventricular hypertrophy in patients with pure aortic stenosis.

BACKGROUND: Previous studies have reported that patient-prosthesis mismatch may be associated with lesser regression of left ventricular hypertrophy. However, among the patients with mismatch, the extent of left ventricular mass regression varied markedly from one patient to another, and we hypothesized that it could be related to the magnitude of the increase in valve area achieved with aortic valve replacement. Our aim was to examine the relationship between the improvement in valve effective orifice area obtained with aortic valve replacement and the extent of postoperative left ventricular mass regression in patients with patient-prosthesis mismatch. METHODS: Preoperative and postoperative measurements of valve effective orifice area, transvalvular pressure gradient, and left ventricular mass were obtained by Doppler echocardiography in 111 patients with pure aortic stenosis who were found to have patient-prosthesis mismatch based on an indexed effective orifice area of 0.8 cm2/m2 or less after operation. RESULTS: On average, the valve effective orifice area increased by 0.45 +/- 0.24 cm2/m2 with operation, and mean transvalvular pressure gradients decreased by -31.6 +/- 13.5 mm Hg. The absolute and relative differences between preoperative and postoperative left ventricular mass were -28 +/- 30 g and -17% +/- 18%, respectively. In multivariate analysis, higher preoperative left ventricular mass (p < 0.0001) and larger increase in indexed valve effective orifice area with operation (p = 0.019) were independently associated with greater left ventricular mass regression. CONCLUSIONS: This study shows that in patients with patient-prosthesis mismatch, the degree of left ventricular mass regression is influenced by the increase in valve effective orifice area achieved by aortic valve replacement.

Aged↗
PubMed2002

Are stentless valves hemodynamically superior to stented valves? A prospective randomized trial.

BACKGROUND: Although stentless aortic bioprostheses are believed to offer improved outcomes, hemodynamic benefits remain unsubstantiated. METHODS: Fifty-three patients were randomized to receive the stented C-E pericardial valve (CE) and 46 patients the Toronto Stentless Porcine valve (SPV). Annuli were sized for the optimal insertion of both valve types, such that surgeons were required to commit to specific valve sizes before randomization. Echocardiographic measurements and functional status (Duke Activity Status Index) were assessed at 3 and 12 months postoperatively. RESULTS: Although cardiopulmonary bypass times (CE: 118.6+/-36.3 minutes; SPV: 148.5+/-30.9 minutes; p = 0.0001) and aortic cross-clamp times (CE: 95.4+/-28.6 minutes; SPV: 123.6+/-24.1 minutes; p = 0.0001) were significantly prolonged in the SPV group, perioperative morbidity and mortality was similar between groups. Neither valve offered a superior internal diameter for any given annular diameter (mean decrease in left ventricular outflow tract diameter after valvular implantation: SPV: 3.4+/-1.11 mm versus CE: 3.7+/-1.33 mm; p = 0.25). Although labeled mean valve size was significantly larger in the SPV group, the actual mean valve size based on internal valvular diameter was no different between groups (CE: 21.9+/-2.0 mm; SPV: 22.3+/-2.0 mm; p = 0.286). Although effective orifice areas increased, and mean and peak transvalvular gradients decreased in both groups over time, no differences were demonstrated between groups at 12 months. Similarly, although significant regression of left ventricular mass was accomplished in both groups over time, no differences were demonstrated between groups. Finally, Duke Activity Status Index scores of functional status improved in both groups over time; however, no differences were noted between groups at 12 months postoperatively. CONCLUSIONS: Although offering excellent outcomes, stentless valves did not demonstrate superior hemodynamic indices in comparison to stented valves up to 12 months after implantation.

Aged↗
PubMed1983

Nine years' experience with the Björk-Shiley prosthetic valve: early and late results of 932 valve replacements.

Between November, 1970, and December, 1977, 932 consecutive patients received the standard Björk-Shiley prosthesis. Operative mortality was 4.6% for aortic valve replacement (AVR; N = 364), 5.1% for mitral valve replacement (MVR; N = 313); 11.3% for multiple valve replacement (N = 194), and 13.7% for valve replacement combined with coronary artery bypass grafting (CABG; N = 51). Factors influencing hospital mortality included type of valve replacement, age at operation, whether the valve replacement was done as an emergency, and year of implantation. Complete follow-up (mean, 3.7 years) was achieved in 95% of the survivors. Actuarial survival was 82% for AVR patients at 8 years, 83% for MVR patients at 7 years, 72% for multiple valve replacement patients at 7 years, and 76% for those who had valve replacement with CABG at 3 years. No significant difference in late survival was found between patients with mitral insufficiency alone (p greater than 0.2) or aortic insufficiency alone (p greater than 0.9) and those with stenotic lesions only. Thromboembolic complications occurred at an incidence of 1.17% per patient-year, and Dicumarol-induced hemorrhages occurred at an incidence of 2.11% per patient-year. Twelve out of 13 patients survived operation for prosthetic valve thrombosis, indicating that this complication is not as catastrophic as many believe. The incidence of reoperation in anticoagulated patients was 0.63% per patient-year. All of these results are compared with data from the recent literature.

Aged↗
PubMed1985

Long-term assessment of aortic valve replacement with autologous pulmonary valve.

Two hundred two autologous pulmonary valves were transplanted into the aortic position between 1967 and 1982 at the National Heart Hospital in London. The indication for operation was congenital or acquired aortic valve disease, and the patients were followed for periods from 1 to 4 years. The patients were not anti-coagulated, but the entire series has been completely free from thromboembolism or bleeding. The actuarial prediction of freedom from valve-related deaths was 82 +/- 6% at the end of the fourteenth year after operation; deaths were due to reoperations for technical failure and to infective endocarditis. Event-free survival of the autologous pulmonary valve in the aortic position was 73 +/- 6% after 14 years at risk. Valve failure resulted mainly from technical problems encountered during the early years of surgical experience. There was no macroscopic or histological evidence of calcification in any of the failed valves. The right ventricular outflow was reconstructed with an aortic homograft in the majority of patients; 81 +/- 5% of these homografts demonstrated event-free performance over a 12-year follow-up period. It is concluded that the long-term performance of a pulmonary autograft inserted for aortic valve disease is superior to that of any other valve substitute and that the operation offers an almost ideal means of aortic valve replacement in appropriate patients.

Adolescent↗
PubMed1998

Aortic valve replacement in the elderly: bioprosthesis or mechanical valve?

BACKGROUND: With increased life expectancy, valve operations are more and more common in elderly patients. The choice of valve substitute-mechanical valve or bioprosthesis-remains debated. METHODS: Two groups of patients of the same age (69, 70, and 71 years) with isolated aortic valve replacement (mechanical 240, bioprostheses 289) were compared for mortality, morbidity, and valve-related complications. RESULTS: No significant difference was found in survival, valve-related mortality, valve endocarditis, and thromboembolism. Mechanical valve had more bleeding events; bioprostheses had more structural deterioration, reoperation, and valve-related morbidity and mortality. CONCLUSIONS: To avoid reoperations in octogenarians, the 10-year durability of current bioprostheses should be matched with the life expectancy of the particular patient. Bioprostheses should be used after 74 years in men and 78 years in women.

Age Factors↗
PubMed2003

Minimally invasive mitral valve repair suggests earlier operations for mitral valve disease.

OBJECTIVE: We began minimally invasive mitral valve surgery in August, 1996, to reduce hospital costs, to improve patient recovery, cosmetic appearance, and to decrease trauma, yet maintain the same quality of surgery. To validate this approach we reviewed our entire experience through May 2002. METHODS: From August 1996 to May 2002, we performed 413 minimally invasive mitral valve operations including 51 mitral valve replacements and 362 mitral valve repairs. Excluding 4 robotically assisted repairs, we evaluated 358 patients, using the mitral valve repairs as the basis for this retrospective survey. These operations were performed through a 6- to 8-cm minimally invasive incision, beginning with parasternal and, most recently, lower ministernotomy (181 patients). The mitral valve reparative techniques include repair of 94 prolapsed anterior leaflets, posterior leaflet resection, leaflet advancement, commissuroplasty, Polytetrafluoroethylene (PTFE; Gore-Tex, W. L. Gore & Associates, Inc, Flagstaff, Ariz) chordal placement, and ring annuloplasty. Cannulation sites varied but primarily utilized a miniaturized system of 24F catheters in both the inferior and superior venae cavae with assisted venous suction. The Cosgrove ring was used in 95% of the patients undergoing this procedure. RESULTS: The operative mortality was 0/358. Perioperative morbidity included a 26% incidence of new atrial fibrillation, 2% incidence of pacemaker implantation, 0.5% incidence of deep sternal wound infection, and 1.9% incidence of stroke after an operation. There were 10 arterial and 3 venous complications. The mean length of stay was 6 days and 208 patients stayed < or =5 days. Only 25% of the patients underwent homologous blood transfusion. The mean follow-up was 36 months with 1.4% lost to follow-up. There were 12 late deaths and a survival at 5 years of 95%. There were 21 valves requiring reoperation for structural valve failure of 5.8%. The probability of freedom from reoperation at 5 years was 92%. CONCLUSION: This study documents the safety of minimally invasive mitral valve repair surgery in 358 patients. It also documents a low incidence of homologous blood use, requirement for post-hospital rehabilitation, and general morbidity.

Adolescent↗
PubMed1999

Primary aortic valve replacement with allografts over twenty-five years: valve-related and procedure-related determinants of outcome.

OBJECTIVES: Allografts offer many advantages over prosthetic valves, but allograft durability varies considerably. METHODS: From 1969 through 1993, 618 patients aged 15 to 84 years underwent their first aortic valve replacement with an aortic allograft. Concomitant surgery included aortic root tailoring (n = 58), replacement or tailoring of the ascending aorta (n = 56), and coronary artery bypass grafting (n = 87). Allograft implantation was done by means of a "freehand" subcoronary technique (n = 551) or total root replacement (n = 67). The allografts were antibiotic sterilized (n = 479), cryopreserved (n = 12), or viable (unprocessed, harvested from brain-dead multiorgan donors or heart transplant recipients, n = 127). Maximum follow-up was 27.1 years. RESULTS: Thirty-day mortality was 5.0%, and crude survival was 67% and 35% at 10 and 20 years. Ten- and 20-year rates of freedom from complications were as follows: endocarditis, 93% and 89%; primary tissue failure, 62% and 18%; and redo aortic valve replacement, 81% and 35%. Multivariable Cox analyses identified several valve- and procedure-related determinants: rising allograft donor age and antibiotic-sterilized allograft for mortality; donor more than 10 years older than patient for endocarditis; rising donor age minus patient age, rising implantation time (from harvest to aortic valve replacement), and donor age more than 65 years for tissue failure; and rising donor age minus patient age, young patient age, rising implantation time, and subcoronary implantation preceded by aortic root tailoring for redo aortic valve replacement. Estimated 10- and 20-year rates of freedom from tissue failure for a 70-year-old patient with a viable valve from a 30-year-old donor and no other risk factors were 91% and 64%; the figures were 71% and 20% if the donor age was 65 years. The rates of freedom from tissue failure for a 30-year-old patient with a 30-year-old donor were 82% and 39%; the figures were 49% and 3% with a 65-year-old donor. Beneficial influences of a viable valve were largely covered by short harvest time (no delay for allografts from brain dead organ donors or heart transplant recipients) and short implantation time. CONCLUSIONS: Primary allograft aortic valve replacement can give acceptable results for up to 25 years. The late results can be improved by the use of a viable allograft, by matching patient and donor age, and by more liberal use of free root replacement with re-implantation of the coronary arteries rather than tailoring the root to accommodate a subcoronary implantation.

Aged↗
PubMed2002

Etiology of aortic valve disease and recent changes in Japan:a study of 600 valve replacement cases.

BACKGROUND: Recent studies on the etiology of aortic valve disease in the US showed a decrease in rheumatic valve disease and an increase in age-related degenerative disease. The purpose of this study was to describe the etiology of aortic valve disease and its temporal changes in Japan, based on a large number of cases. METHODS: The medical charts of all patients who underwent aortic valve replacement at our institute between 1977 and 1999 were reviewed. Among the 600 patients analyzed, 213 (36%) had pure aortic stenosis, 265 (44%) had pure aortic regurgitation, and 122 (20%) had combined stenosis and regurgitation. RESULTS: The causes were rheumatic change (49%), degenerative change (19%), bicuspid valves (18%), infective endocarditis (5%) and others (9%). Rheumatic disease continued to be the most common cause of aortic stenosis, but its frequency decreased from 100% in 1977-1979 to 37% in 1995-1999. In contrast, the frequency of degenerative change among stenotic valves increased recently from 11% in 1990-1994 to 30% in 1995-1999. Similarly, rheumatic disease remained to be the leading cause of aortic regurgitation, with a decline in frequency from 46% in 1985-1989 to 27% in 1995-1999. The percentage of degenerative change among regurgitant valves did not change appreciably. CONCLUSIONS: There was a shift in the causes of aortic valve disease, with a decrease in rheumatic disease and an increase in degenerative disease. This trend was similar to that observed in the US. These findings suggest the increasing importance of aortic valve disease due to degenerative change.

Adult↗
PubMed2001

Composite stentless valve with graft extension for combined replacement of the aortic valve, root and ascending aorta.

OBJECTIVE: The composite mechanical valve conduit has been most commonly used for patients who require combined aortic valve, root, and ascending aorta replacement, but is limited, especially in the elderly, because of the need for long-term anticoagulation. We report the first consecutive series of patients in whom a composite stentless valve with graft extension, which does not require long-term anticoagulation, was performed. METHODS: Between April 1998 and July 2000, eight patients with severe aortic root and ascending aortic pathology underwent a combined aortic valve, root, and ascending aorta replacement with a Freestyle stentless porcine valve with a Hemashield graft extension. Mean age was 74 (range 56--82), three were males. Concomitant procedures included coronary artery bypass graft (CABG) alone (n=2), mitral valve replacement with atrial septal defect repair (n=1) and CABG with septal myomectomy (n=1). RESULTS: Operative mortality was zero. Median aortic cross-clamp and cardiopulmonary bypass times were 150 and 203 min, respectively. Two patients returned to the operating room for bleeding. Median blood transfusions and hospital length of stay were 4 units and 11 days, respectively. CONCLUSIONS: The composite stentless valve with graft extension is a reasonable alternative to a mechanical valve conduit for patients who require a combined aortic valve, root, and ascending aorta replacement, in whom anticoagulation is not desirable or contraindicated.

Aged↗
PubMedDate not supplied

Mechanical valve replacement of the systemic atrioventricular valve in children.

In children with systemic atrioventricular valve disease (SAVVD), reconstructive surgery is the primary goal. However, in cases with severely dysplastic valves or failed repair, valve replacement is the only option. The purpose of this study was to assess the early and late outcome following mechanical valve replacement in SAVVD. Between 1989 and 2003, 31 children underwent mechanical valve replacement (19 St. Jude Medical, 12 Carbomedics) in SAVVD (27 mitral, 3 tricuspid in corrected transposition of the great arteries, 1 common in an univentricular heart) at our institution. The ages ranged from 3 months to 15 years (mean 4 years) and body weight varied between 4.2 and 57 kg (mean 13.3 kg). The size of prostheses ranged between 16 and 31 mm (mean 23.9 mm). The main indication for valve replacement was severe insufficiency of left atrioventricular valve (84%); 84% of the patients had had a previous cardiac operation. The overall hospital mortality was 6.5% The mean follow up was 7.7 years (range 2-13 years). Ninety percent of children represent sinus rhythm, 87% are in NYHA class I. All patients were placed on a regimen of Phenprocoumon aiming to maintain the international normalized ratio (INR) between 3.0 and 4.0. Since 1994, INR self-management of oral anticoagulation was performed either by the patient or his or her parents. There was no anticoagulation-related complication in this patient group. Mechanical valve replacement in left atrioventricular valve disease carries a low operative risk across the spectrum of pediatric age despite previous operations in most cases. Long-term survival and quality of life are good in nearly all cases. The rate of anticoagulation-related complications is very low, especially when INR self management is performed.

Adolescent↗
PubMed2006

Long-term survivors after valve replacement with a Starr-Edwards mitral disk valve prosthesis.

We report four long-term survivors after valve replacement with a Starr-Edwards (S-E) mitral caged-disk valve. A model 6520 disk valve, size 3M, had been used in all of the four patients. Of the four patients, three underwent replacement of the disk valves 23, 24, and 26 years after mitral valve replacement (MVR), respectively. A pacemaker was implanted in the remaining patient 33 years after MVR. The S-E disk valves were considered hemodynamically slightly stenotic compared with modern bileaflet valves. No disk wear was detected in any of the three explanted valves, and in the remaining patient, a noninvasive evaluation of the disk showed that it was functioning normally. These results suggest the favorable long-term durability of the S-E disk valve.

Aged↗