A generalized formulation of the Gorlin formula for calculating the area of the stenotic mitral valve and other stenotic cardiac valves.
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Acceleration↗
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Lymphocytotoxic antibody production following calf aortic valve xenografts in human cardiac valve replacement.
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Animals↗
The tissue valve as a superior cardiac valve replacement.
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Animals↗
Surgical treatment of late tricuspid regurgitation after left cardiac valve replacement.
BACKGROUND: The development of late tricuspid regurgitation (TR) following left cardiac valve replacement is an important complication, as it is associated with a severe impairment of exercise capacity and a poor symptomatic outcome. The pathogenesis of this condition remains poorly defined. It is still a challenge in terms of its prevention, treatment and indications for surgical correction. AIMS: To investigate the possible pathogenesis and report the surgical results of the late TR after left cardiac valve replacement. METHODS: There were 56 patients with moderate to severe TR after left cardiac valve replacement, divided into normal prosthesis group (10 patients with normal prosthetic valve function) and dysfunctional prosthesis group (46 patients with prosthetic valve dysfunction). In the normal prosthesis group, 4 patients underwent mitral valve replacement (MVR) and 6 patients underwent combined mitral and aortic valve replacement (DVR). Patients in the dysfunctional prosthesis group included MVR in 36, aortic valve replacement (AVR) in 4 and DVR in 6, with bioprosthetic valve dysfunction occurring in 18, mechanical prosthetic valve obstruction in 22 and periprosthetic valve leakage in 6 patients. At the initial operation, 10 patients underwent DeVega's tricuspid annuloplasty and 46 patients' tricuspid valves were normal. At the second operation, the surgical treatment of TR included tricuspid valve replacement (TVR) in 9 and tricuspid annuloplasty in 47. RESULTS: Two patients died postoperatively giving a 3.6% hospital mortality. The 54 survivors were followed up for 6-132 months (mean of 79.4 months). Heart function improved significantly in 8 with TVR and in 40 with tricuspid annuloplasty. Echocardiography showed moderate TR in 5 and severe TR in 1 patient with tricuspid annuloplasty who need a further surgical treatment. CONCLUSION: Pulmonary hypertension, myocardial dysfunction, and atrial fibrillation might be responsible for the development of late TR after left cardiac valve replacement. Tricuspid annuloplasty, as the surgical method of first choice, resulted in improvement in 87% of patients with late TR after left cardiac valve replacement. TVR can also be safely applied to repair organic disease and the extremely dilated tricuspid valve annulus. If the TR area is more than 25cm(2), the TVR is recommended.
Journal Article↗
Blunt cardiac injury associated with cardiac valve insufficiency: trauma links to chronic disease?
CONTEXT: Cardiac injury has been well recognised as a complication of blunt chest trauma. Its clinical spectrum ranges from blunt cardiac injury (BCI) to complete rupture of cardiac tissues, with cardiac valvular injury often being overlooked. OBJECTIVE: To determine whether hospitalised BCI is associated with increased risk of cardiac valve insufficiency in a large multi-state hospitalised population. METHODS: Cases with BCI and cardiac valve insufficiency were identified based on discharge diagnoses in 1997 statewide hospital discharge data from 19 states. Four valvular outcomes were studied: (1) mitral valve insufficiency, incompetence, regurgitation (MVIIR); (2) aortic valve insufficiency, incompetence, regurgitation, stenosis (AVIIRS); (3) tricuspid valve insufficiency, incompetence, regurgitation, stenosis (TVIIRS); and (4) pulmonary valve insufficiency, incompetence, regurgitation, stenosis (PVIIRS). RESULTS: Among 1,051,081 injury discharges, 2709 (0.26%) people had BCI; 13,087 (1.25%) had MVIIR; 9811 (0.93%) had AVIIRS; 1338 (0.13%) had TVIIRS; 178 (0.02%) had PVIIRS. Independent of potential confounding factors, discharge for BCI was associated with a 12-fold increased risk for TVIIRS and a 3.4-fold increased risk for AVIIRS. CONCLUSION: Cardiac valve insufficiency has been well recognised as an important risk factor for congestive heart failure. With the findings that BCI is associated with an increased risk of specific valvular disorders, it is possible that trauma may play an important and heretofore largely unrecognised role in a portion of the burden of cardiovascular morbidity and mortality.
Age Factors↗
Cine MR Fourier velocimetry of blood flow through cardiac valves: comparison with Doppler echocardiography.
Noninvasive measurement of blood flow velocity through the cardiac valves has important clinical applications. A wide variety of MR methods are available for flow measurement. The aim of this study was to investigate the ability of cine MR Fourier velocimetry to measure flow through healthy cardiac valves and to compare MR and Doppler peak velocity measurements. Ten healthy volunteers (age mean +/- SD, 24 +/- 4 years) without history of valvular disease were studied. Four of the subjects were females. In each subject, aortic, pulmonary, mitral, and tricuspid valves were evaluated with MR and Doppler imaging. A whole-body mobile MR machine was used, operating at .5-T with actively shielded magnetic field gradient coils on all three axes capable of 20 mT/m at a slew rate of 60 mT/ m/msec. The heart rate during MR and Doppler studies was not significantly different. The mean difference between the two studies was 2 beats/min, with a 95% confidence interval of -22 beats/min, +25 beats/ min. Peak systolic flow velocity in the aortic and pulmonary valves and peak diastolic flow velocity in the mitral and tricuspid valves measured with MRI and Doppler echocardiography correlated well. The mean difference between the two measurements (MR-Doppler) was 63 mm/sec, with a 95% confidence interval of -180 mm/sec, +310 mm/sec. The agreement between two observers interpreting the same MR velocity maps was close. The mean difference between their two measurements was 23 mm/sec, with a 95% confidence interval of -20 mm/sec, +60 mm/sec. There was no significant difference between MR and Doppler imaging or between the two MR observers. MR Fourier velocimetry has the necessary ease, reliability, and speed to measure blood flow through the cardiac valves, although measurement of late diastolic flow in the atrioventricular valves is limited. Measurement of peak blood velocity through the cardiac valves by this method showed satisfactory agreement with Doppler, but its clinical application for assessing diseased cardiac valves must be established.
Adult↗
Identification of Staphylococcus aureus binding proteins on isolated porcine cardiac valve cells.
Infective endocarditis caused by Staphylococcus aureus may be initiated by bacterial binding to cardiac valve cells. We investigated binding of whole S. aureus organisms to preparations of isolated porcine cardiac valve proteins. Cultured endothelial and subendothelial cells were surface labeled with iodine 125. After preabsorption with Escherichia coli, an organism that only rarely causes infective endocarditis, binding of surface proteins to S. aureus was assessed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis and subsequent autoradiography. The results showed that cardiac valve endothelial cells expressed a major S. aureus-binding protein with an approximate apparent molecular weight of 120,000. In contrast, cardiac valve subendothelial cells expressed on their surface a single species of binding protein with an approximate apparent molecular weight of 220,000; immunoblot analysis suggested that this protein was fibronectin. We also used radiolabeled S. aureus to probe cellular proteins transferred to nitrocellulose membranes. This technique identified a 125,000 molecular weight protein that bound S. aureus in endothelial cell extracts. We conclude that specific S. aureus binding to cardiac valve cells is mediated by different receptors for endothelial and subendothelial cells.
Animals↗
A new bioprosthetic cardiac valve with reduced calcification.
A bioprosthetic cardiac valve cross-linked with a glycerol polyglycidyl ether polyepoxy compound (PC) was developed in order to reduce calcification and degeneration, which often occurs in bioprosthetic cardiac valves. Aortic valves harvested from dogs were treated with PC (PC valve). Right ventricle (RV)-pulmonary artery (PA) bypasses were placed in 12 dogs with PC-valved conduits, and the main PA was ligated. X-ray right ventriculography at 36 days (1 dog) and 37 days (1 dog) revealed an excellent open/close performance of the PC valve, and there was no visible thrombus in the valve. In our basic study, PC treated collagen gel disks implanted in the subcutaneous layer of growing rats showed remarkably less calcium deposition than did those treated with glutaraldehyde (GA). Biologic materials cross-linked with PC maintain their pliability, and become more hydrophilic and more hydrated than those cross-linked with GA. The hydrophilicity and hydration provide sufficient antithrombogenicity and a suitable environment for metabolism in the tissue fluid which contains oxygen, nutritive substances, and electrolytes, leading to inhibition of material degeneration. Therefore, PC valves are expected to show good valve function, sufficient antithrombogenicity, and excellent durability with less calcification, when compared to GA treated valves.
Animals↗
High energy phosphate depletion in leaflet matrix cells during processing of cryopreserved cardiac valves.
Preimplantation preparation of cardiac valves includes three major steps: (1) harvesting with accompanying ischemia (warm time from cessation of donor heart beat), (2) antibiotic disinfection, and (3) controlled-rate cryopreservation. To define the interdependent injury effects of these manipulations on leaflet matrix cells and specifically the potential for prolonged harvest-related ischemia to predispose greater injury by the subsequent steps, 96 semilunar valves were harvested from pigs in a manner analogous to human heart valve retrievals and randomly allocated to study groups as follows: 48 control valves were exposed to increasing harvested-related ischemic times, (2, 6, 12, 24 hr) and immersed in liquid nitrogen to arrest metabolic activity (i.e., prior to cryopreservation) and conclude the ischemia; another 48 were similarly harvested, subjected to identical ischemic times, then disinfected in 4 degrees C RPMI medium with standard antibiotics for 24 hr and dimethylsulfoxide cryopreserved at -1 degrees C/min to -170 degrees C (i.e., formal cryopreservation protocol). At thawing, each valve was extracted in 12% trichloroacetic acid and assayed by high performance liquid chromatography for components of the adenine nucleotide pool including ATP, lower energy nucleotides (total adenine nucleotides, [TAN] = [ATP] + [ADP] + [AMP]), adenosine, and the diffusible purines. Results are reported as nanomoles metabolite/milligram of leaflet cell protein (Lowry) and reflect a maintenance of total high energy phosphates in the control groups (5.41 +/- 0.29 nmole TAN at 2 hr; 8.34 +/- 0.67 nmole TAN at 24 hr), which fell significantly in all cryopreserved groups (1.27 +/- 0.33 nmole TAN at 2 hr; 0.34 +/- 0.22 nmole TAN at 24 hr).(ABSTRACT TRUNCATED AT 250 WORDS)
Adenine Nucleotides↗
UDP-glucose dehydrogenase required for cardiac valve formation in zebrafish.
Cardiac valve formation is a complex process that involves cell signaling events between the myocardial and endocardial layers of the heart across an elaborate extracellular matrix. These signals lead to marked morphogenetic movements and transdifferentiation of the endocardial cells at chamber boundaries. Here we identify the genetic defect in zebrafish jekyll mutants, which are deficient in the initiation of heart valve formation. The jekyll mutation disrupts a homolog of Drosophila Sugarless, a uridine 5'-diphosphate (UDP)-glucose dehydrogenase required for heparan sulfate, chondroitin sulfate, and hyaluronic acid production. The atrioventricular border cells do not differentiate from their neighbors in jekyll mutants, suggesting that Jekyll is required in a cell signaling event that establishes a boundary between the atrium and ventricle.
Amino Acid Sequence↗
Dysfunction and thromboembolism associated with cardiac valve xenografts in adults.
Cardiac valve xenografts often fail relatively early in children. We analyzed the incidence of valve dysfunction and thromboembolism in 253 consecutive adult survivors who received 294 porcine xenograft valves (150 aortic, 125 mitral and 19 tricuspid) from June 1974 to December 1979 (41% of all adult valve replacements). Mean follow-up was 25.6 months (range 9-75 months). Valve dysfunction occurred in four of 294 xenografts (three in mitral position and one in tricuspid position), all four caused by recurrent endocarditis; these four patients survived reoperation and are doing well. Thromboembolism occurred in six of 294 xenografts, none in aortic or tricuspid positions of rhythm or anticoagulation. Four of the six mitral xenografts associated with thromboembolism were in the 16 patients who had atrial fibrillation and received aspirin and dipyridamole but no warfarin (12% per patient-year), and two were in the 14 patients who were in sinus rhythm and were not taking medication, one of whom had recurrent Candida endocarditis. No thromboembolism occurred in mitral xenografts with sinus rhythm and antiplatelet agents. Thromboembolism did not occur in patients who were in atrial fibrillation and receiving warfarin anticoagulation. Late death (30 of 253) was unrelated to valve dysfunction, and only one death resulted from thromboembolism. This study showed excellent xenograft performance for as long as 75 months. Valve dysfunction occurred only with recurrent endocarditis, and thromboembolism occurred after mitral replacement, especially in patients who were in atrial fibrillation and were not receiving anticoagulants.
Adult↗
Inhibition of adenosine deaminase and nucleoside transport. Utility in a model of homograft cardiac valve preimplantation processing.
Human cardiac valves are increasingly used in the reconstruction of ventricular outflow tracts and offer performance advantages over porcine and mechanical prostheses; the durability of these replacements has been associated with leaflet interstitial cell viability and a presumed sustained function after implantation. Preimplantation tissue preparation entails sequential steps that are potentially cytotoxic and may therefore affect functional cell survival at thaw. We defined the metabolic consequences of each interval using semilunar cusps from 118 porcine valves to model a homograft preparation with 40 minutes of fixed cadaveric (harvest) ischemia. Fifty-eight valves served as controls and were first processed according to standard cryopreservation protocol; nucleosides were extracted at the end of each step to differentiate independent contributions to high-energy phosphate depletion. Sixty simultaneously harvested leaflets were administered the nucleoside transport inhibitor p-nitrobenzy-thionosine (NBMPR) and the adenosine deaminase inhibitor erythro-9-(2-hydroxy-3-nonyl) adenine (EHNA) at procurement, to attempt adenosine salvage and restitution of processing-incurred adenine nucleotide losses. High-performance liquid chromatography was used to compare adenosine triphosphate, diphosphate, and monophosphate and diffusible nucleopurines of the control and EHNA/NBMPR-treated groups. Control results indicate that disruption of the adenosine triphosphate-diphosphate cycle occurs independently with antibiotic disinfection and cryopreservation. However, throughout all preparation steps, adenine nucleotides were maintained at harvest (baseline) concentrations in the EHNA/NBMPR valves. This suggests that salvage therapy may protect a significant number of cells from net high-energy phosphate catabolism. If, with further study, the durability of transplanted valves is concluded to benefit from retained leaflet interstitial cell viability, such enhancement of metabolic tolerance to the obligatory processing may facilitate functional recovery.
Adenine↗
Accumulation of elements in the arteries and cardiac valves of Thai with aging.
To elucidate whether the extent of element accumulation in the arteries and cardiac valves with aging was different between different races, the authors investigated the accumulation of elements in the arteries and cardiac valves of the Thai with aging and the relationships among elements in the cardiac valves. After ordinary dissection at Chiang Mai University was finished, 16 arteries and 4 cardiac valves were resected and element contents were determined by inductively coupled plasma-atomic emission spectrometry. In the 16 arteries, the average content of calcium was the highest in the site of the abdominal aorta ramifying into the common iliac arteries, and it decreased in the order internal iliac, coronary, abdominal aorta, common iliac, external iliac, superior mesenteric, inferior mesenteric, thoracic aorta, brachial, radial, common carotid, subclavian, ulnar, axillary, renal, and internal thoracic arteries. The average contents of phosphorus and magnesium in respective arteries were parallel with the average contents of calcium, except for the coronary artery. In comparison with the arteries of the Japanese, the trend of calcium accumulation in the arteries of the Thai was almost similar to that in the arteries of the Japanese, except for the coronary artery and thoracic aorta. The calcium accumulation in the coronary artery was much higher in the Thai than in the Japanese, whereas that in the thoracic aorta was lower in the Thai than in the Japanese. Regarding elements in the cardiac valves, the calcium content increased remarkably in the seventies in the aortic valve and in the nineties in the pulmonary valve, but it hardly increased in both the mitral and tricuspid valves with aging. The average content of calcium was the highest in the aortic valve, and it decreased in the order pulmonary, tricuspid, and mitral valves. Regarding the relationship among elements in the aortic valves, it was found that there were extremely significant direct correlations among the contents of calcium, phosphorus, and magnesium, whereas there were significant direct correlations between zinc and either calcium or phosphorus contents. Although significant correlations were found between sulfur and the other element contents in the aortic valves fo the Japanese, no significant correlations were found between them in the aortic valves of the Thai. In the mitral valves, extremely or very significant direct correlations were found among the contents of calcium, phosphorus, magnesium, and sulfur, with some exceptions that there were no significant correlations between phosphorus and either magnesium or sulfur contents. in addition, no significant correlation was found in the calcium content between the aortic valve and coronary artery in the same individuals.
Adult↗
St. Jude Medical cardiac valve prosthesis: in vitro studies.
The St. Jude Medical cardiac valve prosthesis is an all-pyrolitic carbon, bileaflet, low profile, central flow device. Prior to clinical use on intensive program of in vitro and in vivo testing was undertaken. Simulated radiographic studies determined that the tungsten impregnation needed to make the valve leaflets radiopaque was 0.013 inch. Steady-state flow and pulse duplicator studies demonstrated a high ratio of flow orifice to tissue anulus diameter with low transvalvular pressure gradients. Regurgitation was found to be acceptable. Flow visualization revealed central flow through all three flow orifices with minimal turbulence and vorticeal current formation. In vitro comparison with other available cardiac valve devices of various sizes demonstrated superior hemodynamic performance of the St. Jude Medical cardiac valve.
Aortic Valve↗
Surface structure of the human cardiac valve. A comparative study of normal and diseased valves.
This article reports the surface structure of the endothelial cells covering the cardiac valves and their changes in chronic inactive rheumatic valvulitis and bacterial endocarditis. The endocardial surface of the normal cardiac valve was covered by a layer of endothelial cells, each of which was recognized because of the presence of centrally located nuclear bulge and marginal folds at the cell boundaries. In the cardiac valves affected by chronic rheumatic valvulitis, the endothelial layer denuded extensively, even in the regions where only slight thickening was noticed in the intravalvular tissues. As compared to the inflow side of the valve, denudation of the endothelial layer was more conspicuous on the outflow side. There was no morphological difference between the two hemodynamically different conditions, i.e. stenosis and regurgitation. In the cardiac valves affected by bacterial endocarditis, in contrast, the destruction of the endothelial layer was preferentially observed along the closing margins of the valve, and in the region of calcification and vegetation. These findings are compatible to the interpretation that differences in morphological changes of the endothelial layer in these two acquired valvular diseases may reflect the differences of their pathogeneses. The present study thus suggest an importance of endothelial cell in elucidating the pathogenesis of acquired valvular diseases.
Aortic Valve↗
[Clinicopathologic studies of 11 cases of primary cardiac valve tumors].
OBJECTIVE: To study the clinicopathologic features of primary cardiac valve tumors. METHODS: Eleven cases of primary valve tumors collected from Fuwai Hospital during the period from 1983 to 2005 were enrolled into the study. The tumors were stained with hematoxylin and eosin and Weigert-Van Gieson stain. Immunohistochemistry was also carried out in selected examples. RESULTS: Primary cardiac valve tumors were uncommon and accounted for only 3% (11/426) of all primary cardiac tumors. Most of them (10/11) were benign and malignancy was rarely encountered (1/11). The tumor subtypes included papillary fibroelastoma (4/11), cavernous hemangioma (4/11), glomus tumor (1/11), angiosarcoma (1/11) and hamartoma (1/11). Of the 11 tumors studied, 4 involved the tricuspid valve, 4 involved the mitral valve, 2 involved the pulmonary valve and 1 involved the aortic valve. The diagnosis was established by preoperative echocardiography in 7 patients. The remaining 4 cases were either misdiagnosed or undiagnosed. CONCLUSIONS: Preoperative diagnosis of primary cardiac valve tumors can be difficult due to lack of detailed information related to this group of lesions. Although benign cardiac valve tumors carry a good prognosis, the clinical outcome may be disastrous as a result of hemodynamic disturbances. Intraoperative frozen section examination is advisable for guiding proper surgical management.
Adolescent↗
Cardiac valve surgery in octogenarians: improving quality of life and functional status.
BACKGROUND: Although cardiac valve procedures are being performed more frequently in the elderly, long-term functional outcomes have not been well characterized. OBJECTIVE: To evaluate changes in quality of life and functional status in octogenarians after cardiac valve surgery. DESIGN: Retrospective medical record review and patient telephone interview. Median follow-up 30 months (range, 6-95 months). SETTING: Tertiary care university hospital. PATIENTS: Octogenarians undergoing cardiac valve surgery (N = 61; mean age, 83.5 years; range, 80-89 years). INTERVENTIONS: Forty-seven patients had aortic valve replacement, 14 had mitral valve replacement and/or repair, and 27 had a combined procedure with coronary artery bypass grafting. OUTCOMES: Actuarial survival, morbidity, length of hospital stay, and discharge disposition were evaluated. Functional status, using the New York Heart Association classification, and Karnofsky performance status were evaluated preoperatively and postoperatively at 1 and 3 months after hospital discharge. RESULTS: Operative (<30 days) mortality occurred in 7 (11.4%) of 61 patients. Preoperative intensive care unit stay (P < .001) and New York Heart Association class 4 (P < .02) were independent predictors of early death by multivariable analysis. Among hospital survivors, there were no major complications in 34 patients (63%), and this group had a mean (+/- SD) postoperative hospital stay of 12.2 +/- 5.5 days. Twenty patients (37%) incurred significant complications, the most common of which were bleeding, pneumonia, and renal insufficiency. The mean (+/- SD) postoperative hospital stay in this group was 25 +/- 17 days. Although significant complications were associated with an increased postoperative stay, this was not predictive of disposition to a skilled nursing facility or the final score on the postoperative Karnofsky performance scale. Actuarial survival was 85% at 1 year and 66% at 5 years. Patients with perioperative complications had significantly decreased actuarial survival by the Cox proportional hazards regression model (P < .001). Among hospital survivors, the score on the Karnofsky performance scale 1 month after discharge had improved 50% from a preoperative median score of 30% (severely disabled, requiring special care) to a postoperative median score of 80% (being able to perform normal activity with only moderate symptoms). The New York Heart Association classification improved a median of 2 classes in this group. These benefits were sustained at the 3-month follow-up. CONCLUSION: Although greater resource expenditure is required for the initial perioperative convalescence, octogenarians can be expected to have an excellent functional outcome and long-term performance status after cardiac valve surgery.
Aged↗
Cholelithiasis: a complication of cardiac valve surgery in children.
Gallstone formation complicating cardiac valve replacement has been amply documented in adults. Two children who developed gallstones shortly after cardiac valve surgery are reported.
Child, Preschool↗