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Effect of valve orientation on flow development past aortic valve prostheses in a model human aorta.

The effect of valve orientation on flow development in a model human aorta was studied by means of a qualitative flow visualization technique. The model replicated the geometry of the human aorta and the experiment simulated a physiologically realistic pulsatile flow. The following valves were studied: Starr-Edwards Stellite, Starr-Edwards silicone, Björk-Shiley spherical disc, Björk-Shiley convexo-concave disc, and Hall-Kaster tilting disc. All the valves had a tissue anulus diameter of 27 mm. With the ball-in-cage valves, the flow in the ascending aorta was predominantly axial and uniform throughout systole, while vortex formation was observed downstream from the ball. With the tilting disc valves, the flow development in the aorta was a function of the orientation of the valves. With the major flow orifice directed toward the commissure between the right and noncoronary cusps, the fluid motion was predominantly in the axial direction through early systole. A vortex developed along the wall of lesser curvature of the aorta with the progression of systole. In early diastole, a well-defined flow reversal was observed along the lesser curvature of the aorta. With the major flow orifice directed toward the left coronary cusp, the fluid motion, although predominantly axial, was not uniform in the ascending aorta. Regions of relative stasis present near the wall of greater curvature subsequently developed into a trapped vortex throughout the cardiac cycle. With the major flow orifice directed more posteriorly, an improved fluid dynamic characteristic was observed, and there was no trapped vortex present near the wall of greater curvature. The flow visualization study in the model human aorta suggests that, from a fluid dynamic point of view, orientation of the major flow orifice of the tilting disc valve toward the wall of lesser curvature is not advisable.

Aortic Valve↗

Pressure field in the vicinity of mechanical valve occluders at the instant of valve closure: correlation with cavitation initiation.

In order to analyse cavitation dynamics during the closing phase of mechanical heart valve prostheses, an experimental study was performed to simulate a single closing event of the occluder with pressure measurements close to the occluder surface on the inflow side at the instant of valve closure. Cavitation bubble visualization was also performed using a stroboscopic lighting technique and photographic recording with tilting disc and bileaflet valve geometries. Large negative pressure transients were measured in the major orifice region of tilting disc valves and in the peripheral edges of bileaflet valves. The intensity of cavitation increased with increasing loading rate (transvalvular pressure rise rate) during the closing phase and with increasing valve size. The squeezing of fluid between the occluder and the seat stop or seating lip in the region where the occluder velocity at closure is at its maximum, and the resulting local flow dynamics are suggested as mechanisms for initiation of cavitation. The fluid forced through the clearance region due to the instantaneous large pressure difference across the occluder may be another source of large negative pressures and cavitation. The present in vitro study also suggests that cavitation may be the cause of platelet and red blood cell destruction, and ensuing thrombus formation associated with mechanical heart valves.

Blood Pressure↗

Porcine stentless aortic valve in re-replacements and acute aortic valve endocarditis.

Between June 1990 and June 1993, 135 patients received a porcine stentless aortic valve (PSAV) at our institution. In this group, there were 33 patients in whom the stentless valve was used to replace a previously inserted malfunctioning aortic valve prosthesis (n = 19) or to treat acute aortic valve endocarditis (n = 14, five native, nine prosthetic endocarditis). There was one hospital death caused by multiple organ failure in a patient with endocarditis and preoperative cerebral stroke. Two patients died after hospital discharge; one suffered sudden death following a pacemaker failure four month after surgery and the other died due to Candida albicans sepsis after a prolonged antibiotic treatment. There were two reoperations; one to correct a dehiscence of the proximal suture line and the other to replace a degenerated valve 3.5 years after implantation in a 14 year old boy. All operative survivors were followed clinically with serial color Doppler echocardiography. No recurrence of endocarditis was detected. Aortic root reconstruction was achieved even in the presence of multiple abscesses. All but one patients showed a normally functioning valve with none or minimal aortic insufficiency. In our opinion the PSAV is an excellent aortic valve substitute for patients with damaged aortic annulus, because it promotes aortic root remodeling, decreases the incidence of postoperative paravalvular leaks and helps to prevent endocarditis recurrence.

Acute Disease↗

Internal shear properties of fresh porcine aortic valve cusps: implications for normal valve function.

BACKGROUND AND AIMS OF THE STUDY: Several types of stress act on aortic heart valve tissue during the cardiac cycle. When closed the valve is subjected to primarily tensile stress due to the diastolic pressure, and upon opening bending stress occurs near the attachment with the aortic root and throughout the body of the cusps. Smooth bending requires internal tissue shearing. To measure the internal shear properties of the tissue a testing device was created which combined a high-precision linear actuator with a sensitive load cell. MATERIALS AND METHODS: Circular punch biopsy specimens from fresh porcine aortic valve cusps (n = 32) were examined. The shear stress versus shear strain characteristics were measured both in the circumferential (n = 17) and the radial (n = 13) direction, and the stress relaxation characteristics were also examined circumferentially (n = 15) and radially (n = 15). In addition seven specimens were tested repeatedly in both radial and circumferential directions for tissue isotropy. RESULTS: The results from the shear stress versus strain tests showed the tissue to behave non-linearly over the strain range between -0.9 and 0.9. The average moduli at the near zero strains were less than 300 Pa and increased to over 20 kPa at the extreme strains. The circumferential direction yielded slightly higher average moduli than the radial direction but this difference was not significant. The stress relaxation results indicated that valve tissue relaxation occurs in two distinct phases, an initial low slope region and a second high slope region with respective values of -7.5 log(s)-1 and -15 log(s)-1 and with no significant difference between test directions. CONCLUSIONS: Our results define and describe the pattern of internal shear properties of the aortic valve that are particularly important during the transition between the open and closed positions. This behavior pattern has particular application in the creation of accurate mathematical models of the valve tissue and may be important in understanding the mechanism of tissue failure in bioprosthetic valves.

Animals↗

[Aortic valve reconstruction in ectasia of the aortic root and valve insufficiency].

Aortic valve regurgitation in conjunction with ectasia of the proximal aorta is a common finding. The pathologic mechanism of valve insufficiency is mainly caused by dilatation of the aortic root at the level of the sino-tubular and the aorto-ventricular junction. Total replacement of the proximal aorta with resuspension of the aortic valve within the graft is a new alternative approach. Between July 1993 and March 1995, 17 patients were treated for root ectasia using this approach. The age ranged from 15 to 70 years. Aortic insufficiency (mean grade 3) was present in all patients. The operation consisted of total replacement of the proximal aorta with resuspension of the native valve within the graft. In five patients the aortic arch was replaced as well, one patient underwent mitral reconstruction for severe mitral regurgitation. There was no mortality; postoperative aortic regurgitation was reduced to a mean of 0.7. Aortic valve function has been stabled in 16 instances, in one patient a mild increase in regurgitation was seen. Aortic valve reconstruction in conjunction with total tubular graft replacement of the proximal aorta is a new alternative approach for patients with root ectasia. The disadvantages of mechanical heart valve replacement can be avoided.

Adolescent↗

Comparison of magnetic resonance imaging and Laser Doppler Anemometry velocity measurements downstream of replacement heart valves: implications for in vivo assessment of prosthetic valve function.

BACKGROUND AND AIM OF THE STUDY: The non-invasive, in-vivo assessment of prosthetic valve function is compromised by the lack of accurate measurements of the transvalvular flow fields or hemodynamics by current techniques. Short echo time magnetic resonance imaging (MRI) may provide a method for the non-invasive, in vivo assessment of prosthetic valve function by accurately measuring changes in the transvalvular flow fields associated with normal and dysfunctional prosthetic valves. The objectives of these in vitro experiments were to investigate the potential for using MRI as a tool to measure the complex flow fields distal to replacement heart valves, and to assess the accuracy of MRI velocity measurements by comparison with Laser Doppler Anemometry (LDA), a gold standard. METHODS: The velocity fields downstream of tilting disc, bileaflet, ball and cage, and pericardial tissue valves were measured using both three-component LDA and MRI phase velocity encoding under a steady flow rate of 22.8 l/min, simulating peak systolic flow. The valves were tested under normal and stenotic conditions to assess the MRI capabilities under a wide range of local flow conditions, velocities and turbulence levels. A new short echo time MRI technique (FAcE), which allowed velocity measurements in stenotic jets with high turbulence, was tested. RESULTS: Good overall agreement was obtained between the MRI velocity measurements and the LDA data. The MRI velocity measurements adequately reproduced the spatial structure of the flow fields. In most cases peak velocities were accurately measured to within 15%. CONCLUSIONS: The results indicate that the FAcE MRI method has the potential to be used as a diagnostic tool to assess prosthetic valve function.

Aortic Valve↗

[Aortic valve replacement with stentless porcine aortic valve].

The Toronto stentless porcine valve (TSPV) is a stentless porcine aortic valve, preserved with glutaraldehyde solution, which has been designed to maintain natural laminar blood flow and improve hemodynamic performance and enhance durability. Aortic valve replacement with TSPV was performed in seven patients. The reason for this indication was advanced age (65 years or more) in six patients and connective tissue disease in another patient. One patient required reoperation because of prosthetic valve endocarditis 4 months after implantation. There were no other valve-related complications. Echocardiographic examination of prosthetic valve function one month after surgery showed no aortic regurgitation in any patient. Transprosthetic gradient was 15.1 +/- 5.0 mmHg. Technical know-how is required for the implantation. The hemodynamic characteristics of the TSPV were excellent. Further follow-up is required to determine durability, but further extensive indication of this valve is expected as a bioprosthesis.

Adult↗

Clinical utility of cardiac valve Gram stain and culture in patients undergoing native valve replacement.

OBJECTIVES: To determine if routine cardiac valve culture is useful in diagnosing clinically unsuspected infective endocarditis in patients undergoing native valve replacement, to see if false-positive culture results have a deleterious effect on patient care, and to determine if microbiology and histopathology can be used to differentiate partially treated and untreated infective endocarditis from valve contamination. DESIGN: Case series. SETTING: Tertiary-care teaching hospital with 1125 beds. PATIENTS: Forty-eight patients with culture-positive cardiac valves after native valve replacement. RESULTS: A single unsuspected case of endocarditis was disclosed by microbiology over a 5-year period. Histopathology in this case was also positive, however, and the diagnosis should have been suspected clinically. Eighty-three percent of positive cultures were the result of contamination over an 18-month period; results were disregarded appropriately by clinicians. Clinical context or histopathology was required to categorize microorganisms correctly as pathogens or contaminants; only the presence of organisms on Gram stain had a good predictive value for endocarditis. CONCLUSION: Routine valve cultures in patients undergoing native valve replacement are not warranted. Although false-positive culture results had no deleterious effects on patient care in this study, misinterpretation of such results could lead to overtreatment. Microbiology results alone are not sufficient to distinguish endocarditis from contamination.

Adult↗

Amyloid deposits in aortic and mitral valves. A clinicopathological investigation of material from 100 consecutive heart valve operations.

The material from 100 consecutive aortic and mitral valve operations has been studied histologically with particular reference to the presence of amyloid deposits. Sixty seven per cent were positive (aortic 88%, mitral 45%). The simultaneous occurrence of calcification of the valves and amyloid degeneration as well as of calcification and hyalinization was significant. Similarly there was significantly more amyloid in the older age groups, as well as a significant correlation between the degree of hyalinization of the valve and amyloid. Thirty-two patients had previously suffered from rheumatic fever. The heart valves of these patients did not differ histologically from the others, whereas significantly more amyloid was observed in the stenotic mitral valves than in the mitral valves which were insufficient.

Adolescent↗

Mechanisms of severe mitral regurgitation in mitral valve prolapse determined from analysis of operatively excised valves.

Certain clinical and mitral valvular morphologic findings are described in 83 patients (age 26 to 79 years [mean, 60]; 26 women [31%] and 57 men [69%]) with mitral valve prolapse (MVP) and mitral regurgitation (MR) severe enough to warrant mitral valve replacement. All 83 operatively excised valves were examined by the same person, and all excised valves had been purely regurgitant (no element of stenosis). No patients had hemodynamic evidence of dysfunction of the aortic valve. In each valve a portion of the posterior mitral leaflet was elongated such that the distance from the distal margin to basal attachment of this leaflet was similar to the distance from the distal margin of the anterior leaflet to its basal attachment to the left atrial wall. Two major mechanisms for the severe MR were found: dilatation of the mitral anulus with or without rupture of chordae tendineae and rupture of chordae tendineae with or without dilatation of the mitral anulus. Of the 83 patients, 48 (58%) had both dilated anuli (greater than 11 cm in circumference) and ruptured chordae tendineae; 16 (19%) had dilated anuli without ruptured chordae, and 16 (19%) had ruptured chordae without significant anular dilatation. In three patients the anulus was not dilated, nor were chordae ruptured, and therefore the mechanism of the MR is uncertain. Mitral chordal rupture was nearly as frequent in the 64 patients with clearly dilated anular circumferences as in the 19 patients with normal or insignificantly dilated anular circumferences (less than or equal to 11 cm).

Adult↗

Four-year experience with the CarboMedics valve: the North American experience. North American team of clinical investigators for the CarboMedics prosthetic heart valve.

A multicenter prospective trial of the CarboMedics valve was initiated in July 1988. Twelve North American centers were included for the purpose of establishing the safety and efficacy of this new rotatable, bileaflet, pyrolytic-Carbon prosthesis. The study included 786 patients (using 891 valves) enrolled between July 1988 and August 1992. There were 447 male and 339 female patients from ages 2 to 83 years. Of the 618 primary replacement operations (including double valves), 393 were aortic and 292 were mitral valve replacements. Mean follow-up time was 16.1 months; 94.7% of patients had completed documentation up to and including one year. New York Heart Association functional class was III or IV for 84.4% of patients preoperatively, and I and II in over 96% of patients for the first three postoperative years. Survival for the entire group was 93% (622) at 1 month, 89% (504) at 1 year, 87% (213) at 2 years, and 85% (41) at 3 years. There were no significant survival differences between primary and repeat replacements or between aortic, mitral, and double-valve replacements. Primary replacement patients with concomitant procedures (n = 241) had slightly decreased survival rates compared with those who underwent isolated procedures (isolated survival rate, 92% [98]; concomitant procedure survival rate, 81% [59] at 2 years; p = 0.002). There was no valve failure. Linearized rates (events per 100 patient-years) in primary replacement patients after 30 days included the following: thrombosis, 0.39; thromboembolism, 0.92; hemolysis, 0.53; anticoagulant-related hemorrhage, 2.36; paravalvular leak, 0.92; endocarditis, 0.53; reoperation, 0.92; and explantation, 0.66.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗

Effect of the preservation of annulo-papillary continuity on left ventricular ejection fraction after mitral valve replacement. A clinical randomized study on patients affected by rheumatic valve disease.

This perspective study has been designed to evaluate the modifications induced on left ventricular contractility by the interruption of annulo-papillary continuity during mitral valve replacement in patients with rheumatic valve disease. Patients with associated cardiac diseases were not admitted to the study. Sixty-nine patients entered the trial, each patient was randomly assigned to mitral valve replacement either with preservation of the annulo-papillary continuity (PAPC) or with excision of all the chordae (EC). Patients with mitral stenosis (MS) and combined mitral disease (MS & R) were considered separately. The four groups were similar regarding preoperative characteristics including the radioisotopic left ventricular ejection fraction (LVEF). All the patients had the mitral valve replaced with a bileaflet prosthesis fixed by interrupted mattress sutures in the supra-annular position; the methods of anesthesia, cardiopulmonary bypass and myocardial preservation were similar in all patients. In the patients of the two EC groups a complete excision of the mitral valve was performed. In the patients of the PAPC groups a modified Miki's technique was used to preserve annulo-papillary continuity; in eight cases with heavy calcification of the subvalvular apparatus, after total excision of the mitral valve, PTFE sutures were used to reconnect the annulus to the papillary muscles. After 6 months' follow-up, 2D and Doppler echocardiography was completed in each patient to confirm the absence of any prosthetic leakage and left ventricular outflow tract obstruction. (LVOT).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗

Impact of valve prosthesis-patient mismatch on pulmonary arterial pressure after mitral valve replacement.

OBJECTIVES: We sought to determine the impact of valve prosthesis-patient mismatch (PPM) on pulmonary arterial (PA) pressure after mitral valve replacement (MVR). BACKGROUND: Pulmonary arterial hypertension is a serious complication of mitral valve disease, and it is a major risk factor for poor outcome after MVR. We hypothesized that valve PPM might be a determinant of PA hypertension after MVR. METHODS: Systolic PA pressure was measured by Doppler echocardiography in 56 patients with normally functioning mitral prosthetic valves. Mitral valve effective orifice area (EOA) was determined by the continuity equation and indexed for body surface area. RESULTS: Thirty patients (54%) had PA hypertension defined as systolic PA pressure >40 mm Hg, whereas 40 patients (71%) had PPM defined as an indexed EOA < or =1.2 cm(2)/m(2). There was a significant correlation (r = 0.64) between systolic PA pressure and indexed EOA. The average systolic PA pressure and prevalence of PA hypertension were 34 +/- 8 mm Hg and 19% in patients with no PPM versus 46 +/- 8 mm Hg and 68% in patients with PPM (p < 0.001). In multivariate analysis, the indexed EOA was by far the strongest predictor of systolic PA pressure. CONCLUSIONS: Persistent PA hypertension is frequent after MVR and strongly associated with the presence of PPM. The clinical implications of these findings are important given that PPM can largely be avoided by using a simple prospective strategy at the time of operation.

Aged↗

Intraatrial mitral valve insertion with native valve preservation in children.

Two patients underwent intraatrial mitral valve insertion for an unsuccessful valvotomy for severe mitral stenosis and left-sided atrioventricular valve insufficiency associated with corrected transposition utilizing a porcine valve from a valved conduit with preservation of the native valve. The valves were inserted using continuous suture distally at the mitral annulus and proximally at the pulled atrial wall distal to the pulmonary veins. Both patients had uneventful hospital course and are doing well at up to 6 months postoperatively. This approach provides a viable option for congenital mitral stenosis or insufficiency in children.

Bioprosthesis↗

Transcranial Doppler detection of microemboli in prosthetic heart valve patients: dependency upon valve type.

Transcranial Doppler ultrasound has revealed the existence of cerebrovascular microemboli in asymptomatic patients with prosthetic heart valves. We investigated the relation between the presence and number of emboli signals and valve type. Patients with six types of prosthetic valves (Björk-Shiley monostrut, Medtronic-Hall, Carbomedics, ATS, Carpentier-Edwards standard, Carpentier-Edwards supraannular) were examined using transcranial Doppler ultrasound in two centers. The monitoring time was 30 min over the right middle cerebral artery. All patients were stabilized on warfarin at the time of study. Microemboli signals were identified by their characteristic audiovisual signal and on subsequent spectral analysis, based on accepted criteria. A standard neurologic questionnaire was completed by all patients. The prevalence of microemboli signals varied between 49% (Medtronic Hall) and 97% (Björk-Shiley monostrut), while their number varied between 1 [0-3] (Carpentier-Edwards standard) and 187 [136-240] (Björk-Shiley monostrut) per hour (median and 95% CI). Both parameters were significantly higher in patients with Björk-Shiley monostrut valves compared to the other patient groups. There were no significant differences in the prevalence of neurologic complications among the groups examined (overall 16%), or in emboli numbers between symptomatic and asymptomatic patients. The prevalence and quantity of microemboli signals in patients with prosthetic heart valves, as detected by transcranial Doppler, is dependent upon valve type. The clinical significance of these microemboli signals remains to be further evaluated.

Aged↗

Determinants of hospital mortality after repeat mitral valve surgery for rheumatic mitral valve disease.

OBJECTIVE: The aim of this study is to detect the risk factors for hospital mortality in patients who underwent reoperative mitral valve replacement. METHODS: Rheumatic mitral valve patients who underwent primary mitral valve replacement (386 cases) and repeat mitral valve replacement (94 cases) were analysed retrospectively. The incremental effects of the reoperative procedure on hospital mortality were studied by comparing primary and reoperative procedures and analyzing a series of possible predisposing factors. RESULTS: Operative mortality for repeat procedures was found significantly higher than the first operations (respectively 12.8% versus 4.3%, p=0.022). Risc factors affecting the hospital mortality in reoperation group were determined as advanced age, diameter of left atrium, prolonged bypass time and development of postoperative low output state. The indication for surgery also had a significant role in patients' outcome. Mortality found significantly higher in cases operated due to endocarditis or mitral mechanical valve thrombosis compared to other reoperation groups. CONCLUSION: Patients over age of 70 years, with a left atrial diameter over 60 mm, reoperated due to endocarditis and mechanical valve thrombosis, should be reevaluated for risk assessment while giving the decision of optimal operation timing. Especially patients with left ventricular hypertrophy and decreased myocardial reservoirs, efficient myocardial protection during the operation had an important role.

Adult↗

Thirty years experience with heart valve surgery: isolated mitral valve replacement.

BACKGROUND: Thirty years have elapsed since the commencement of open-heart surgery in South Australia. A retrospective study was performed to evaluate mortality and complication rates and to identify factors associated with poor outcomes in all patients who underwent prosthetic mitral valve replacement during this period. METHODS: Questionnaires and personal contact have been used to generate a combined database of pre-operative and post-operative information and long-term follow-up on 938 patients who underwent isolated prosthetic mitral valve replacement at the Cardio-Thoracic Surgical Unit of the Royal Adelaide Hospital between 1963 and 1993. RESULTS: Complete survival follow-up data were obtained for 92% (865) of the patients. The Starr-Edwards valve was used in 95% (891) of the patients, a Bjork-Shiley prosthesis in 2.5% (23) of the patients, and only 24 (2.5%) other valves were inserted. The hospital mortality rate for the 30-year period was 4.7%. The mean age of the patients who underwent surgery was greater in each of the three successive decades. A long-term survival advantage was observed for patients with mitral stenosis, however, survival was significantly shorter for patients with higher New York Heart Association (NYHA) functional classifications and for patients in pre-operative atrial fibrillation. Pre-operative dyspnoea was significantly improved following mitral valve replacement. The rates of postoperative haemorrhagic and embolic complications were low by comparison with other published series. CONCLUSION: Mitral valve recipients do not regain a normalized life expectancy, but risk factors that determine long-term survival can be identified pre-operatively to aid appropriate patient selection.

Adolescent↗

Aortic valve replacement and mitral valve repair with allograft.

Techniques of repair of defects in the anterior leaflet of the mitral valve and replacement of the aortic valve using allograft are presented. The case history and operative procedure of a reconstructive operation that did not require anticoagulant therapy after surgery are described for three adult patients. Mitral valve defects were repaired using the anterior leaflet of the mitral valve of the allograft. The aortic valve or entire root was replaced with the aortic allograft. The aortic/mitral allograft should be considered as an alternative to replacement of the aortic and mitral valves with prostheses in selected patients.

Adult↗