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PubMedDate not supplied

Aortic valve replacement for aortic stenosis with a small mechanical prosthetic valve.

BACKGROUND: Although aortic valve replacement (AVR) is the only effective treatment for patients with aortic stenosis (AS), it is recognized that the use of small prosthetic valves due to a small aortic root often affects postoperative course after AVR. The aim of this study was to determine whether the use of small prosthetic valves was a risk factor of AVR for AS. METHODS: We compared various perioperative factors and operative outcomes between patients with a small mechanical prosthetic valve (small group) and patients with a large mechanical prosthetic valve (large group). RESULTS: Early mortality was 0% in each group and the 5-year mortality was 25% in the small group and 10% in the large group. There were no significant differences in perioperative factors between the two groups. The small group patients were significantly older and smaller compared to the large group patients. The valve size was significantly correlated with age and BSA. CONCLUSIONS: The use of small mechanical prostheses was not a risk factor of AVR for AS when it was proportionate to the BSA even for elderly patients. AVR using a small mechanical prosthetic valve may be performed with good results in the short- and long-term.

Age Factors↗
PubMed1997

Cardiac valve calcification: characteristics of patients with calcification of the mitral annulus or aortic valve.

AIMS: To determine whether mitral annular calcification and aortic valve calcification, with or without stenosis, are expressions of atherosclerotic disease. METHODS: The incidence of atherosclerotic risk factors was analysed in patients with mitral annular calcification and aortic valve calcification and in control patients from a prospective echocardiographic database of 8160 consecutive patients; 657 patients (8%) were identified with mitral annular calcification and 815 (9%) with a calcified aortic valve, of whom 515 (6.3%) had stenosis with a minimal aortic valve gradient of 16 mm Hg. In these patients, cardiac and vascular risk factors were compared with 568 control patients using multiple logistic regression analysis. RESULTS: Age (odds ratio (OR) varying from 5.78 to 104, depending on age class), female sex (OR 1.75), hypertension (OR 2.38), diabetes mellitus (OR 2.85), and hypercholesterolaemia (OR 2.95) were strongly and significantly associated with aortic valve calcification without stenosis, as were age (OR varying from 8.82 to 67, depending on age class), female sex (OR 2.22), hypertension (OR 2.72), diabetes mellitus (OR 2.49), and hypercholesterolaemia (OR 2.86) with mitral annular calcification. Age (OR varying from 1.11 to 7.7), hypertension (OR 1.91), and hypercholesterolaemia (OR 2.55) were strongly and significantly associated with stenotic aortic valve calcification. CONCLUSIONS: Mitral annular calcification and stenotic or non-stenotic aortic valve calcification have a high incidence of atherosclerotic risk factors, suggesting they should be considered as manifestations of generalised atherosclerosis.

Adult↗
PubMed1992

Hypertension in aortic valve disease and its response to valve replacement.

We have investigated the prevalence of hypertension and the response of blood pressure to operation in 87 patients with lone aortic valve disease who underwent aortic valve replacement. In patients with aortic stenosis alone 26% were hypertensive pre-operatively (age and sex adjusted blood pressure greater than 160 systolic and or greater than 95 mmHg diastolic) and 24% were hypertensive post-operatively. In those with aortic regurgitation alone, hypertension was present in 65% before and 57% after valve replacement using the same criterion. For combined stenosis and regurgitation, the prevalence was 54% and 62%, respectively. The post-operative increase in systolic pressure in patients with aortic stenosis occurred mainly in those with a history of left ventricular failure. In those with aortic regurgitation or combined stenosis with regurgitation, diastolic pressure rose after valve replacement resulting in a prevalence of diastolic hypertension of 44% and 35%, respectively. Blood pressure changes were not predicted by the type of valve inserted nor its size. Our data show that despite severe symptomatic aortic valve disease, systolic hypertension was common in aortic stenosis and diastolic hypertension was found in aortic regurgitation. This underlines the importance of blood pressure monitoring in patients following aortic valve replacement.

Adult↗
PubMed1997

Circulating microemboli in patients after aortic valve replacement with pulmonary autografts and mechanical valve prostheses.

BACKGROUND: The pulmonary autograft procedure (Ross) is now considered the gold standard for aortic valve replacement. One of its advantages is the freedom from macroemboli without anticoagulation. Whether this holds true for circulating microemboli, detectable as high-intensity transient Doppler signals (HITS), has not yet been verified. METHODS AND RESULTS: We investigated 8 patients (2 women, 6 men; mean age, 50.6+/-17.9 years) after the Ross procedure, 9 patients (3 women, 6 men; mean age, 67.2+/-9.46 years) after aortic valve replacement with a mechanical valve prosthesis, and 12 young healthy volunteers by unilateral 1-hour recording of the middle cerebral artery on digital audio tape. Patients with extracranial carotid artery disease were excluded by color duplex sonography. During the off-line evaluation, the investigator was not aware of any patient details. No HITS were detected in healthy volunteers (95% confidence interval [CI], 0% to 26.46%). After the Ross procedure, 1 patient had 11 and 1 patient had 1 HITS (95% CI, 3.19% to 65.09%). All recipients of mechanical valves had HITS, ranging from 2 to 84 per hour (95% CI, 66.7% to 100%). Significantly more recipients of mechanical valves exhibited HITS than recipients of pulmonary autografts (P<.05) or control subjects (P<.05). CONCLUSIONS: In contrast to mechanical valves, pulmonary autografts are seldom the source of microemboli, confirming the pulmonary autograft as the superior substitute for aortic valve replacement.

Adult↗
PubMed1998

[Selection criteria for aortic valve prostheses: mechanical, stented, or stentless valve or homograft?].

A bioprosthesis is recommended for aortic valve replacement in patients 70 years (recently, 72 or 73 years) of age or older. The bovine pericardial valve is better suited in patients with a small aortic annulus less than 23 mm in diameter, and the porcine stented-bioprosthesis should be used in patients with an annulus larger than 25 mm. A mechanical valve is recommended in patients younger than 70 years of age with chronic atrial fibrillation or a history of thromboembolism. Moreover, a mechanical valve is selected in patients in whom it is necessary to enlarge the aortic root or annulus. When mitral valve replacement or coronary artery bypass grafting in performed concomitantly, the valve prosthesis is selected according to the age of the patient. A homograft is indicated in patients with active valve endocarditis having an abscess at the aortic annulus or root. When a patient with poor ventricular performance resulting from valvular disease is expected to undergo implantation of a ventricular assist device in the near future, a bioprosthesis is preferable.

Aged↗
PubMed1975

Homologous dura mater cardiac valves. Structural aspects of eight implanted valves.

We studied eight homologous dura mater valves removed 1 to 35 months after implantation. Five dura mater valves were placed in the mitral position and three in the aortic position. Two of the valves were obtained after deaths not related to the valve itself and six after reoperations due to immediate or late incompetence. In 2 cases the dura mater valves were entirely normal, both macroscopically and microscopically. In 2 other cases the leaflets were caught by stitches related to the struts, a technical error that caused laceration of the leaflets. Not withstanding this fact, the dura mater was normal on histologic examination. In 3 cases, and probably in 1 other, one or two leaflets were detached partially from the suture line, probably because of a technical error in the manufacture of the valve. These studies demonstrated satisfactory evolution of the homologous dura mater valves until 35 months after implantation. No signs of rejection or degeneration of the dura mater were observed in the present series.

Adolescent↗
PubMed2003

[Long-term results of prosthetic mitral valve replacement with home-made tilting disc valve: a report of 125 cases].

OBJECTIVE: To analyze the early and long-term results after mitral valve replacement for rheumatic valvular disease by using home-made tilting disc valve, and the determinant factors involved and subsequent therapies. METHODS: One hundred and five patients, including 31 patients with rheumatic mitral stenosis, 92 patients with mixed mitral stenosis and regurgitation, and 2 patients with bacterial endocarditis, underwent prosthetic mitral valve replacement with home-made tilting disc valve from September 1978 to June 1982. Three patients had a history of mitral commissurotomy, and 5 patients had concomitant functional tricuspid regurgitation. All patients were operated on under cardiopulmonary bypass with implantation of 25 - 29 mm size home-made tilting disc valve prosthesis. The associated functional tricuspid lesions were treated at the same time with modified DeVega's valvuloplasty or Kays bicuspidate valvuloplasty. RESULTS: Eleven patients died during the hospital stay with an early operative mortality of 8.8%. The major causes of the early death were low cardiac output syndrome (4 patients), respiratory failure (2), acute renal failure (2), extrinsic prosthesis dysfunction (1), ventricular arrhythmia (1), and left ventricular rupture (1). Ninety-eight survivors were followed up (total 1,162.2 years) for mean duration of 12.8 years. Eighty-nine patients (78%) survived over 10 years after operation, 58 (51%) over 15 years, and 55 (48%) over 20 years. There were 16 late deaths due to heart failure, anticoagulation related bleeding, thromboembolism and recurrence of rheumatic fever. The survival rates at 10 and 20 years were 82.3% and 51.1% respectively. Among the patients who survived over 20 years, 37 patients had the cardiac functional status returned to Class II, 13 Class III, and Class IV. CONCLUSIONS: Severe post-rheumatic valve deformity may occur in younger patients in China. Long-acting penicillin regimen given for 3 - 5 years for the prevention of rheumatic fever relapse is advocated. A low intensity anticoagulant regimen after mitral valve replacement is advisable in lowering the incidence of anticoagulant related bleeding, while optimizing sufficient protection against thromboembolic complication. Proper operative timing (e.g. when the patient is in sinus rhythm and in NYHA functional class II) is of great importance in achieving satisfied long-term results.

Adolescent↗
PubMed2005

Aortic valve replacement with new-generation stentless pericardial valves: short-term clinical and hemodynamic results.

BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement (AVR) with stentless bioprostheses offers superior hemodynamics. In order to overcome the disadvantages of older, stentless valves, a new generation of pericardial stentless prostheses has been developed. Herein, the hemodynamic and clinical results of these substitutes have been evaluated. METHODS: Between March 2002 and May 2004, 85 patients (59 females, 26 males; mean age 73.6 +/- 6.1 years) who underwent AVR received either a bovine (Sorin Pericarbon Freedom; SPF; n = 50) or an equine (3F Aortic Bioprosthesis; 3F; n = 35) pericardial stentless valve. Patients were followed up prospectively at six months after surgery by clinical and echocardiographic examination. The mean follow up period was 5.6 +/- 0.8 months, and was 96.4% complete. RESULTS: Mortality was 2.4% at 30 days (two SPF patients; one died at reoperation for suspected valve thrombosis and one was a non-valve-related death) and 2.5% at follow up (two SPF patients; both nonvalve-related). Neither structural valve failure nor endocarditis were observed. Preoperatively, there were no differences in baseline data, functional status and hemodynamics between SPF and 3F patients. The aortic cross-clamp time was similar in both groups (51.7 +/- 11.2 min for SPF; 51.6 +/- 8.2 min for 3F). NYHA functional status improvement was similar in each group (1.8 +/- 0.5 for SPF; 1.7 +/- 0.6 for 3F). The mean transaortic pressure gradient (deltapmean) was reduced in all patients during follow up. With SPF, a lower deltapmean was found for smaller aortic roots (indexed annular diameter (IAD) < 14 mm/m2) as well as in larger (IAD > 14 mm/m2) aortic roots: 8.0 +/- 4.5 mmHg versus 13.2 +/- 7.2 mmHg (p < 0.05) and 6.8 +/- 3.0 mmHg versus 12.8 +/- 4.8 mmHg (p < 0.05), respectively. CONCLUSION: New-generation pericardial stentless aortic valves are very pliable, which facilitates their implantation. Clinical and hemodynamic results with these prostheses are promising. The SPF prosthesis demonstrates excellent performance, and may be superior when implanted in small aortic roots.

Aged↗
PubMed2006

Detachment of the mitral valve anterior leaflet as a complication of aortic valve replacement.

Mitral regurgitation after aortic valve replacement is generally reported as a complication of a Manouguian's procedure for annulus enlargement. However, even if no annular enlargement procedure is performed, this complication may be encountered after isolated aortic valve replacement because of either extensive decalcification of the aortic annulus or progressive tension on the anterior leaflet of the mitral valve, caused by aortic valve sutures placed adjacent to firm or heavily calcified valve tissue. Routine transthoracic echocardiography may be inadequate for diagnosis of this condition; transesophageal echocardiography should be used both for preoperative diagnosis and for intraoperative management. We report the case of a patient who had severe mitral regurgitation that occurred after aortic valve replacement with a mechanical valve.

Aortic Valve↗
PubMed1991

The Ross procedure: aortic valve replacement using autologous pulmonary valve.

The use of pulmonary autologous valve in aortic valve replacement pioneered by Dr. Donald Ross in 1967 has been employed in young patients for more than two decades with impressive results. This procedure is recommended for young patients with isolated aortic disease who are expected to have a longer life span. Because of its lack of tissue degenerative changes, the autologous pulmonary valve has the potential to function longer than other biologic valves and mechanical valves while exhibiting the same inherent hemodynamic advantages. The assessment of the long-term performance of the pulmonary autograft in the aortic position suggests that the pulmonary autologous valve is the best choice for isolated aortic valve replacement in young patients.

Aortic Valve Insufficiency↗
PubMed1989

[A case of mitral valve replacement with autologous pulmonic valve in congenital mitral stenosis].

A one-year-old infant with congenital mitral stenosis and pulmonary hypertension underwent by mitral valve replacement with his pulmonic valve autograft and pulmonary tract reconstruction with heterogeneous pericardial conduit. His postoperative hemodynamics data showed that left atrial pressure decreased and pulmonary hypertension continued. Echocardiography showed that the implanted autograft functioned properly. On the seventh postoperative day, he died of pulmonary hypertension. In case with congenital mitral stenosis with the small mitral annulus and the small left ventricular cavity, it is difficult to perform mitral valve replacement by commercially available mechanical or tissue valves. Because these valves are not suitable for the small mitral annulus. The mitral valve replacement with pulmonic valve autograft is recommended in such a case with the congenital mitral stenosis.

Female↗
PubMed1988

A clinical comparison of mitral valve repair versus valve replacement in ischemic mitral regurgitation.

Severe mitral regurgitation caused by acute myocardial infarction has been a particularly difficult management problem with disappointing clinical results. Over a 75-month period, ending March 31, 1987, 611 patients underwent mitral valve operations at Duke University Medical Center. Within this group, 55 patients had clearly defined ischemic mitral regurgitation, and 37 of these required emergency operations. Thirty-one of the 55 patients had isolated posterior papillary muscle dysfunction, nine had papillary muscle rupture, and 15 had severe ventricular dysfunction and generalized annular dilatation. Thirty-two patients were treated with primary mitral valve replacement, and 23 had mitral valve repair. In 18, repair was accomplished by a transventricular approach, combining the techniques of commissural annuloplasty, papillary muscle shortening or reimplantation, and infarct exclusion. Transventricular mitral valve repair proved to be safe, expeditious, and effective in restoring valve competence. Although the repair and replacement groups were similar with respect to all relevant baseline characteristics, improved operative survival was observed after valve repair, as compared to replacement, both for the overall group (p = 0.03) and for acute papillary muscle dysfunction (p = 0.05). These data suggest that a policy of predominant mitral valve repair, when appropriately applied in patients with ischemic mitral regurgitation, offers the potential for improving therapeutic results.

Cardiopulmonary Bypass↗
PubMed1988

Surgical bypass of the systemic atrioventricular valve in children by means of a valved conduit.

The surgical approach to relief of mitral stenosis in children is still a controversial problem. We describe our experience with four severely symptomatic children in whom a valved conduit from the left atrium to the left ventricle was successfully used to bypass a hypoplastic systemic atrioventricular valve. A left atrial-left ventricular extracardiac conduit was implanted in these patients with a hypoplastic mitral anulus and an adequate left ventricular chamber. There were no early or late deaths. Postoperative cardiac catheterization performed in all patients 1 month after the operation showed reduced size of the left atrium, a reduction of the left atrial-left ventricular gradient from a mean of 14 mm Hg to a mean of 5 mm Hg, and an increase of the left atrial outlet from a mean diameter of 10.7 mm to 28.7 mm (including the diameter of the native mitral valve plus the internal diameter of the valved conduit). The application of this unconventional operation in children with congenital or acquired stenosis of the systemic atrioventricular valve should be considered when the mitral valve obstruction cannot be relieved by conventional valve repair or replacement. Furthermore, the left atrial-left ventricular conduit does not preclude future alternative surgical options.

Aorta↗
PubMedDate not supplied

Valve repair versus replacement in the surgical management of ruptured chordae. A post-operative echocardiographic assessment of mitral valve function.

Between January 1971 and December 1978, 74 patients (pts) underwent surgery for ruptured chordae (RC) of the mitral valve. Thirty-eight patients underwent mitral valve replacement and 36 patients underwent repair. The hospital mortality was 8.3% after repair and 7.9% after replacement. Repair was performed by trapezoidal excision of redundant leaflet, re-approximation of the leaflet edges and annuloplasty. At six years the incidence of re-operation after repair was 3% (1/33) and after mitral valve replacement was 14.7% (5/35). The five years survival was 68 +/- 8% after mitral valve replacement and 100% after repair. The incidence of major thrombo-embolic episodes was 0.67 per 100 patient years, without anticoagulation, after repair and 5.7 per 100 patient years, with anticoagulation, following mitral valve replacement. The peak rate of dimension change (PRDC) of the transverse dimension of the left ventricle was determined by echocardiography in 17 patients after repair. The PRDC was within normal range (10/20 cms/sec) in 15 patients, in the stenotic range (10 cms/sec) in 1 patient, and in the regurgitant range (20 cms/sec) in 1 patient. Mitral valve replacement invariably produces PRDC values in the stenotic range. Valve repair is the procedure of choice in ruptured chordae of the posterior leaflet.

Bioprosthesis↗
PubMed1980

The use of "fresh" unstented homograft valves for replacement of the aortic valve. Analysis of 8 years' experience.

Between August, 1969 and May 1978, 679 patients underwent homograft replacement of the aortic valve. Isolated elective valve replacement was performed in 411 patients. Thirty-four patients had total aortic root replacement with reimplantation of the coronary arteries. There were 16 early deaths (3.9%) and 43 late deaths (10.5%) during a follow-up between 3 and 102 months (mean 47 months). Actuarial analysis showed 87% survival at 5 years and 81% at 8 years. Valve failure occurred in 24 patients (5.9%) owing to prolapse of one cusp in eight patients (2.0%), infective endocarditis in seven patients (1.7%), and degeneration of the valve in nine patients (2.2%). Degenerative valve failure was encountered after the fourth year with an incidence of 4.8% of patients at risk and occurred only in grafts from donors over the age of 65 years. Diastolic murmurs were present in 28% of patients followed beyond 1 month and increased very slightly with time. Systemic embolism was not recorded in any patient despite the fact that anticoagulants were not used. The clinical results were judged to be good or excellent in 89% of patients. It is concluded that homograft replacement of the aortic valve gives satisfactory results with a low incidence of late valve failure.

Adolescent↗
PubMed1994

Tricuspid valve replacement with the bileaflet St. Jude Medical valve prosthesis.

Case histories of 39 patients who underwent tricuspid valve replacement with the St. Jude Medical prosthesis between June 1979 and August 1992 were reviewed in March 1993. The average patient age at the time of the operation was 46 +/- 11 years (range from 17 to 68 years). Concomitant mitral and/or aortic valve replacements were performed in 30 patients. All patients were given warfarin to maintain thrombotest between 10% to 25%. This number was between 2.8 to 1.6 times the control value in the International Normalized Ratio of prothrombin time. Three operative deaths occurred (7.7%). Among six late deaths, two patients died suddenly of unknown causes, and the remaining patient deaths were not valve-related. The actuarial survival rate at 14 years was 54.7%. Valve thrombosis occurred in one patient and was successfully treated with intravenous urokinase. This was the only valve-related complication (0.67%/patient-year). No reoperations were necessary in the tricuspid position. In conclusion, the St. Jude Medical valve is our choice of prosthesis for tricuspid valve replacement in adult patients who can receive proper anticoagulation therapy.

Adolescent↗
PubMed1993

An analysis of risk factors for death and mode-specific death after aortic valve replacement with allograft, xenograft, and mechanical valves.

From September 1967 to January 1990, a total of 2100 patients underwent 2366 aortic valve replacements with a variety of allograft, xenograft, and mechanical valves. Concomitant procedures were performed in 764 patients. Actuarial survival at 12 years was 59.6% (70% confidence limits 57.8% to 61.4%). Hazard function for death was highest immediately after operation, falling to merge with a slowly rising phase of risk at approximately 3 months. Actuarial freedom from sudden death at 12 years was 88.0% (70% confidence limits 86.7% to 89.3%). The shape of the hazard function for sudden death was similar to that for death. Actuarial freedom from death with cardiac failure at 12 years was 87.9% (70% confidence limits 86.5% to 89.2%). The shape of the hazard function for death with cardiac failure was also similar to that for death. Risk factor analysis revealed the important deleterious impact on long-term survival resulting from impaired left ventricular structure and function because of aortic valve disease. No current-era valve used in this study (allograft, xenograft, or mechanical) was a risk factor for death. Both aortic wall disease and endocarditis necessitating aortic valve replacement substantially decreased long-term patient survival. Aortic valve replacement is advisable much earlier in the natural history of aortic valve disease before secondary left ventricular damage occurs.

Actuarial Analysis↗
PubMed1993

[Aortic valve re-replacement with a SJM valve by aortic ring re-enlargement with Nick's method--report of a successful case].

An 11-year-old girl had undergone an aortic valve replacement for congenital aortic stenosis with #17 Björk-Shiley valve and aortic ring enlargement by Nick's method eight years later, the pressure gradient across the prosthetic valve increased up to 100 mmHg. Re-aortic valve replacement was successfully performed with #21 St. Jude Medical valve, when aortic valve ring increased to accommodate #21 SJM valve.

Aortic Valve↗