Aortic valve replacement with cryopreserved aortic allograft: ten-year experience

OBJECTIVE: Cryopreserved aortic allograft can be used for aortic valve replacement in congenital, rheumatic, degenerative, and infected native valve conditions, as well as failed prosthetic valves. This study was conducted to determine the long-term results of aortic valve replacement with cryopreserved aortic allografts. METHODS: Aortic valve replacement with cryopreserved aortic allografts was performed in 117 patients from July 1985 until August 1996. All patients requiring aortic valve replacement regardless of valve disease were considered for allograft replacement; the valve was preferentially used in patients under age 55 years and in the setting of bacterial endocarditis. Four operative techniques involving cryopreserved aortic allografts were used: freehand aortic valve replacement with 120-degree rotation, freehand aortic valve replacement with intact noncoronary sinus, aortic root enlargement with intact noncoronary sinus, and total aortic root replacement. Valve function was assessed by echocardiography during the operation in 78 patients (66%) and after the operation in 77 patients (65%). RESULTS: One-hundred eighteen aortic valve replacements with cryopreserved aortic allografts were performed on 117 patients; mean age was 45.6 years (range 15 to 83 years) and mean follow-up was 4.6 years (range up to 11 years). Intraoperative echocardiography disclosed no significant aortic valve incompetence. There were four operative deaths (3%) and seven late deaths; freedom from valve-related mortality at 10 years was 9:3% +/- 4.55%. New York Heart Association functional status at latest follow-up was normal in 98 (94%) patients. On postoperative echocardiography, 90% had no or trivial aortic valve incompetence. Freedom from thromboembolism at 10 years was 100% and from endocarditis, 98% +/- 2.47%. Seven (6%) patients required valve explantation, four for structural deterioration. At 10 years, freedom from reoperation for allograft-related causes was 92% +/- 3.47%. CONCLUSIONS: Aortic valve replacement with cryopreserved aortic allografts can be performed with low perioperative and long-term mortality. Most patients have excellent functional status, and reoperation for valve-related causes is unusual. Aortic valve replacement with cryopreserved aortic allografts demonstrates excellent freedom from thromboembolism, endocarditis, and progressive valve incompetence.     

Sternomental distance as the sole predictor of difficult laryngoscopy in obstetric anaesthesia

BACKGROUND AND AIMS OF THE STUDY: The first generation of pericardial valves was withdrawn from the market because of an excessive rate of premature failure. With an original design, the Carpentier-Edwards pericardial valve promised improved results. MATERIALS AND METHODS: From July 1984 to December 1993, 71 patients underwent double mitral and aortic valve replacement with the Carpentier-Edwards pericardial valve. Mean age was 63.4 years. 58% were male, mean clinical status was 2.9 with 71% of patients in NYHA class III or IV, 55% were in atrial fibrillation. All patients were followed for an average of 4.17 years after their operation, and total follow up was 296 patients years. RESULTS: Operative mortality was 7% (5/71). At this point of the study, 70% of patients are in clinical NYHA class I or II, 42% of patients are in atrial fibrillation and 66% receive anticoagulation treatment. We observed 19 late deaths with an actuarial survival of 58% +/- 14% at ten years. Valve-related complications include four endocarditis, four reoperations, seven anticoagulant-related hemorrhages, two structural failures, one thromboembolic episode, and one sudden death. Two patients died of valve-related causes. After 10 years, freedom from valve related death is 97% +/- 3%, from endocarditis 90% +/- 8%, from reoperation 87% +/- 10%, from thromboembolic complications 98% +/- 2%, from valve failure 93% +/- 7%, and freedom from all complications is 58% +/- 18%. No failure in patients older than 60 years was noted and no leaflet tear was observed. CONCLUSIONS: The 10-year results of this pericardial bioprosthesis make this valve an outstanding choice when a bioprosthesis is required and in patients over 60 years old.     

Determinants of reoperation after 960 valve replacements with Carpentier-Edwards prostheses

During the period of 1977 to 1990, 960 Carpentier-Edwards standard prostheses (Baxter Healthcare Corp., Santa Ana, Calif.) were placed in 875 operations. Freedom from reoperation at 10 years was 57% +/- 4%, 76% +/- 3%, and 95% +/- 5% for mitral, aortic, and tricuspid valve replacement, respectively. Age was the only independent determinant of reoperation for both aortic and mitral valves. Likelihood of reoperation decreased with age, with freedom from reoperation after 10 years in patients aged less than 60 years versus 60 or more years being 65% +/- 5% versus 90% +/- 4% after aortic valve replacement and 48% +/- 5% versus 75% +/- 6% after mitral valve replacement. For mitral valve replacement, larger valve size made reoperation more likely, with freedom from reoperation at 10 years being 71% +/- 6% for sizes median less than 31 mm and 57% +/- 5% for sizes 31 mm or larger. For aortic valve replacement, prior median sternotomy reduced freedom from reoperation at 10 years from 80% +/- 3% to 25% +/- 5%. The low prevalence of reoperation affirms the suitability of the Carpentier-Edwards prosthesis for selected elderly patients and for tricuspid valve replacement. Because of their influence on the probability of reoperation, valve size and prior cardiac procedures also merit consideration in the choice of valvular prosthesis.     

A novel sodium channel mutation causing a hyperkalemic paralytic and paramyotonic syndrome with variable clinical expressivity

BACKGROUND: The CarboMedics valve is a relatively new, low-profile, bileaflet, mechanical prosthesis. The results of a prospective follow-up study after valve replacement with this prosthesis in a university hospital are presented. METHODS: We implanted 640 CarboMedics prostheses in 583 patients in the aortic (n = 359), mitral (n = 167), or aortic and mitral positions (double valve replacement; n = 57). Patient ages ranged from 11 to 81 years (mean age, 58 +/- 12.3 years). RESULTS: Overall hospital mortality was 9.0%; however, when high-risk urgent cases were removed from the calculation, the operative mortality fell to 4.5%. Follow-up was 98% complete, comprising 2,027 patient-years for a mean follow-up of 44 months (range, 6 to 72 months). Actuarial freedom from complications (linearized rates in parentheses) was as follows: late mortality, 85% +/- 2.0% (2.3%/patient-year); thromboembolism, 92% +/- 1.1% (1.6%/patient-year); anticoagulation-related hemorrhage, 87% +/- 1.2% (2.8%/patient-year); prosthetic valve endocarditis, 98% +/- 0.5% (0.1%/patient-year); and overall valve-related morbidity and mortality, 76% +/- 2.1% (4.3%/ patient-year). CONCLUSIONS: The CarboMedics valve shows a low rate of valve-related complications comparable with other new mechanical heart valve prostheses.     

Long-term results of heart valve replacement with the Edwards Duromedics bileaflet prosthesis: a prospective ten-year clinical follow-up

OBJECTIVE: The Edwards Duromedics valve (Baxter Healthcare Corp., Edwards Division, Santa Ana, Calif.) was designed with a self-irrigating hinge mechanism to reduce thromboembolic complications. After good initial clinical results, distribution was suspended in 1988 after reports of valve fracture after 20,000 valves had been implanted. The manufacturer conducted extensive studies to improve the Edwards Duromedics and reintroduced a modified version, which is available as Edwards Tekna. The purpose of the study was the evaluation of long-term results of the original Edwards Duromedics that might be important for the current version, the Edwards Tekna valve. METHODS: A prospective clinical 10-year follow-up was performed of 508 patients who underwent valve replacement with the Edwards Duromedics valve in the aortic (n = 268), mitral (n = 183), and aortic and mitral (n = 56) position. RESULTS: The perioperative mortality rate was 6.9%; follow-up was 98% complete, comprising 3648 patient-years for a mean follow-up of 86 months (range: 33 to 144 months). The actuarial freedom from complications at the 10-year follow-up and the incidence rate (percent per patient-year) were as follows: late mortality rate, 69.2% +/- 2.4% (3.5% per patient-year); thromboembolism, 90.7% +/- 1.6% (0.96% per patient-year); anticoagulation-related hemorrhage, 87.7% +/- 1.7% (1.34% per patient-year); prosthetic valve endocarditis, 96.7% +/- 0.09% (0.38% per patient-year); valve-related mortality rate, 89.3% +/- 1.6% (1.21% per patient-year); valve failure, 86.2% +/- 1.85% (1.54% per patient-year); and valve-related morbidity and mortality rate, 71.1% +/- 2.3% (3.2% per patient-year). Three leaflet escapes were observed (one lethal, two successful reoperations; 99.1% +/- 0.05% freedom, 0.08% per patient-year). All patients functionally improved (86% in New York Heart Association classes I and II), and incidence of anemia was insignificant. CONCLUSIONS: These results confirm that the Edwards Duromedics valve shows excellent performance concerning thromboembolism, hemolysis, and functional improvement and will serve as a reference for the last version, the Edwards Tekna valve, where comparable long-term data are currently not available.     

Should a bicuspid aortic valve be replaced in the presence of subvalvar or supravalvar aortic stenosis?

BACKGROUND: A bicuspid aortic valve is commonly associated with other levels of left ventricular outflow tract obstruction. Providing the bicuspid aortic valve is competent and nonobstructive, repair of subvalvar or supravalvar stenosis usually focuses on the obstructive lesions, leaving the valve in situ. The aim of this report was to examine the impact of a bicuspid aortic valve on the risk of reoperation for patients undergoing operation for subvalvar or supravalvar aortic stenosis. METHODS: Since 1976, 47 patients with supravalvar or subvalvar aortic stenosis have undergone repair. The median follow-up is 5.1 years (range, 2 months to 20.1 years). Sixteen patients (34%) had a bicuspid aortic valve that was competent and nonobstructive, and 31 (66%) had a tricuspid aortic valve. RESULTS: Reoperation was required in 9 patients (56%) with a bicuspid aortic valve, in each involving aortic valve replacement with an autograft (3), homograft (2), or prosthesis (4). Six patients (19%) with a tricuspid aortic valve required reoperation, yet only 1 required aortic valve replacement. The freedom from valve replacement was 43% (70% confidence interval, 31% to 55%) in the bicuspid aortic valve group versus 100% (70% confidence interval, 94% to 99.5%) in the tricuspid group at 5 years (p = 0.0001). The freedom from any reoperation at 5 years was 43% (70% confidence interval, 31% to 55%) in patients with a bicuspid aortic valve versus 86% (70% confidence interval, 80% to 93%) in the tricuspid group (p = 0.02). CONCLUSIONS: The data suggest that patients with subvalvar or supravalvar aortic stenosis and a bicuspid valve may be better palliated with a more definitive operation such as the Ross or Ross-Konno procedure.     

Tyrosine phosphorylation of platelet derived growth factor beta receptors in coronary artery lesions: implications for vascular remodelling after directional coronary atherectomy and unstable angina pectoris

BACKGROUND AND AIMS OF THE STUDY: The aim of this study was to evaluate the long-term follow up of the Pericarbon pericardial bioprosthesis implanted in the mitral position. METHODS: Between January 1985 and January 1991, 78 patients (26 males, 52 females; mean age 56.9 +/- 7.8 years) underwent isolated mitral valve replacement with a Pericarbon valve. All bioprostheses were size 29 mm and implanted by the same surgeon. RESULTS: Total follow up was 663.2 pt-years and it was 97% complete. Early mortality was 1.3% (1/78); two minor cerebral embolisms were observed as early complications. At 12 years the overall survival rate was 85.0 +/- and valve-related survival 93.1 +/- 3.0%; freedom from embolic events was 83.0 +/- 4.5% and from endocarditis 98.7 +/- 1.3%. Freedom from primary tissue failure was 56.8 +/- 6.6%; it was 86.3 +/- 7.5% in patients aged > 60 years and 36.8 +/- 8.2% in younger patients. There were 27 reoperations, 26 for primary tissue failure, one for endocarditis. Comparison between basal and follow up echocardiographic studies showed a significant stenotic deterioration of the bioprosthesis and a negligible incidence of regurgitation. Morphological findings of explanted bioprostheses were characterized by stenotic and diffuse microcalcification, but no tissue tear was observed. CONCLUSIONS: These results confirm that the Pericarbon bioprosthesis is structurally safe and free from the fatigue problems which afflicted the first and second generation of pericardial valves. As with other tissue valves, the rate of calcification is age-dependent, suggesting preferential use of the Pericarbon prosthesis in elderly people.     

Outcome analysis of 245 CarboMedics and St. Jude valves implanted at the same institution

BACKGROUND: Thromboembolism and valve-related death are major complications associated with prosthetic valve implants, but it is difficult to evaluate the relative incidence of these complications based on studies in which the implantation of only one valve is reported from any given institution. We therefore report the outcome of patients implanted at our institution during the same time period with either the recently released CarboMedics (CM) or the St. Jude Medical (SJ) valve prostheses. METHODS: Between October 1994 and January 1996, 245 consecutive patients received either SJ (116 patients) or CM (129 patients) valves at our institution. Follow up of these patients was 99.6% complete, for a total of 318.5 cumulative patient-years (median follow-up, 1.4 years). RESULTS: The 30-day mortality rates for SJ and CM implants were 3.4% and 3.1%, respectively. Actuarial survival and freedom from valve related mortality rates at 1.5 years for SJ and CM valves were 94%+/-2% versus 86%+/-3% (p = 0.03) and 100% versus 94%+/-2% (p = 0.005), respectively. There was no structural valve failure for either implant, but there were five thrombosed valves in the CM group and none in the SJ group (p = 0.04). All thrombosed valves were mitral (four mitral valve replacement, one aortic and mitral valve replacement). Two of the thrombosed valves were successfully explanted, whereas the three remaining patients died. Freedom from a thromboembolic event in the mitral position at 1.5 years, including thrombosed valves was 97%+/-3% and 83%+/-5% for SJ and CM valves, respectively (p = 0.04). CONCLUSIONS: The results of this study suggest that further evaluation of thromboembolic outcomes after CM compared with SJ valve implantation is warranted.     

Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures

OBJECTIVE: This study was carried out to evaluate the long-term results of mitral valve repair for mitral regurgitation caused by myxomatous disease of the mitral valve and the late effects of chordal replacement with expanded polytetrafluoroethylene sutures in this operation. METHODS: A total of 324 patients with mitral regurgitation caused by myxomatous disease underwent mitral valve repair from 1981 to 1995; the group comprised 241 men and 83 women whose mean age was 58 +/- 14 years. Chordal replacement with expanded polytetrafluoroethylene sutures has been performed in 165 patients since 1985. Most of the patients who had chordal replacement with expanded polytetrafluoroethylene sutures had prolapse of the anterior leaflet or prolapse of both leaflets, whereas most patients who had mitral valve repair without chordal replacement had prolapse of the posterior leaflet. Patients were followed up at annual intervals and had a Doppler echocardiographic study. The follow-up was complete and extended from 6 to 156 months (mean 36 +/- 30 months). RESULTS: Two operative and 21 late deaths occurred (14 cardiac and 7 noncardiac). At 10 years the actuarial survival was 75% +/- 5%, the freedom from stroke was 94% +/- 2%, the freedom from transient ischemic attacks was 92% +/- 4%, the freedom from endocarditis was 99% +/- 1%, the freedom from mitral valve reoperation was 96% +/- 1%, and the freedom from severe mitral regurgitation was 93% +/- 3%. Chordal replacement with expanded polytetrafluoroethylene sutures had no effect on any of these end points. CONCLUSIONS: Mitral valve repair was feasible in most patients with mitral regurgitation caused by myxomatous disease and it was associated with low rates of valve-related complications. Chordal replacement with expanded polytetrafluoroethylene had no adverse effect on the late outcome and was believed to have increased the probability of mitral valve repair.     

St. Jude Medical valve prosthesis: an analysis of long-term outcome and prognostic factors

Between 1979 and 1984, 321 patients received 354 St. Jude Medical prostheses (194 aortic, 94 mitral, 1 tricuspid, and 32 multiple valve replacements). Follow-up was 96% complete (2967 patient-years; mean 9.5 years per patient). Actuarial event-free rates at 10 years and linearized rates (in parentheses) of late complications were as follows: embolism, 85.0% +/- 2.3% (2.3% per patient-year); anticoagulant-related hemorrhage, 74.8% +/- 2.7% (3.3% per patient-year); cerebrovascular accident, 81.8% +/- 2.5% (2.6% per patient-year); prosthesis thrombosis, 98.5% +/- 0.7% (0.1% per patient-year); endocarditis, 97.2% +/- 1.1% (0.4% per patient-year); prosthesis dysfunction, 97.1% +/- 1.0% (0.4% per patient-year); hemolytic anemia, 98.5% +/- 0.7% (0.1% per patient-year); reoperation, 97.4% +/- 1.0% (0.4% per patient-year); overall mortality, 63.3% +/- 2.7% (4.2% per patient-year); and valve-related death (including sudden death), 84.7% +/- 2.2% (1.4% per patient-year). Independent preoperative risk factors were as follows: (1) for embolism, cardiac failure as indication for operation and history of prior systemic embolism; (2) for cerebrovascular accidents, the same two factors and age; (3) for endocarditis, diabetes, chronic alcoholism, and aortic valve replacement; (4) for overall mortality, age, ejection fraction (or cardiac index or cardiothoracic index), chronic alcoholism, and history of systemic embolism; and (5) for valve-related death, chronic alcoholism, degenerative cause of valve disease, and prosthetic diameter 23 mm or smaller. Ninety percent of survivors were in New York Heart Association functional class I or II at the end of follow-up. In conclusion, this study confirms the excellent durability of the St. Jude Medical valve and the remarkable functional benefit for the majority of the patients. However, prosthesis-related complications are still common, particularly for small-diameter prostheses. Outcome is strongly related to the patient's preoperative cardiac condition and to the adequacy of anticoagulation control.     

Aortic valve replacement with patch enlargement of the aortic annulus

BACKGROUND: Aortic annulus enlargement has long been advocated for the placement of valve prostheses larger than otherwise would have been possible. Little information exists, however, on the short- and long-term outcome of this surgical procedure. METHODS: We performed a retrospective review of 530 patients enrolled in a registry for patients who underwent aortic valve replacement using the Hancock II bioprosthesis and were followed up prospectively over the course of 11 years at a single institution. In an effort to avoid prosthetic valve-patient mismatch, the aortic annulus was enlarged in 98 patients (18%). Short- and long-term outcome was analyzed. RESULTS: Enlargement of the aortic annulus during aortic valve replacement increased the operative mortality rate from 3.5% to 7.1%, but this difference did not reach statistical significance (p = 0.10). The long-term survival of patients who had annulus enlargement was similar to that of patients who did not. Because there were differences in the clinical profile of patients who had annulus enlargement and those who did not, a case-control study was carried out. This study showed similar long-term survival, freedom from valve-related and cardiac death, and combined end points in the two groups of patients. CONCLUSION: Aortic annulus enlargement increased the operative mortality of aortic valve replacement. However, patients who underwent enlargement of a small aortic annulus had long-term survival and freedom from cardiac and valve-related death comparable to those of patients who received larger aortic prostheses.     

Relationship between hamstring strains and leg muscle strength. A follow-up study of collegiate track and field athletes

Between August 1988 and October 1992, 1,052 patients underwent 1,522 valve procedures in our institution. Their mean age was 32.69 years (range 1-90). The etiology was rheumatic in 724 (68.8%), congenital in 120 (11.4%), degenerative in 99 (9.4%), infective in 58 (5.5%) and ischemic in 17 (1.6%). The mean preoperative functional class (NYHA) was 2.95 and 780 (74.1%) were in sinus rhythm. Repair was possible in 885 (58.1%) valves. The rate of repair versus replacement was 94.5% for the tricuspid, 56.2% for the mitral and 43.6% for the aortic valve. The total hospital mortality was 4.18%. For isolated mitral surgery it was 2.94%, for isolated aortic 4.12% and for isolated tricuspid 15%. Double valve surgery carried a mortality of 3% and triple valve surgery 13%. Hospital mortality for isolated mitral and isolated aortic surgery was lower for repair than for replacement (1.5% vs. 5% and 0 vs. 6.8%). The follow-up was 94.65% complete. The total incidence of embolic events was 2.93% with an actuarial freedom at 48 months of 92.71 +/- 5.35% for repair, 88.22 +/- 6.26% for replacement and 90.31 +/- 5.65% for patients with repair and replacement. Late mortality was 4.5%. The actuarial survival excluding hospital deaths was 94.89 +/- 2.10% for repair, 86.84 +/- 2.84% for replacement and 91.33 +/- 2.73% for the mixed group. The reoperation rate was higher for repair (13%) than for replacement (0.1%). This rate was highest for the rheumatic mitral patients with an age below 20 years (25.2%).(ABSTRACT TRUNCATED AT 250 WORDS)     

Congenital aortic valve disease. Improved survival and quality of life

OBJECTIVE: The purpose of the study was to assess the effect of recent trends in surgical management, including use of the Ross Operation, on improved survival and quality of life in patients treated surgically for aortic valve (AV) disease at Oklahoma Children's Hospital. BACKGROUND: Surgical treatment of congenital AV disease has proved to be palliative, but newer procedures may be improving outcomes. METHODS: A retrospective review of 301 patients, age 1 day to 26 years (median, 5 years), having a surgical AV procedure or aortic balloon valvuloplasty at Children's Hospital of Oklahoma between 1960 and February 1996, was conducted. Information was collected on all prior and subsequent operations, and follow-up within 1 year was 96% complete. RESULTS: Survival for all patients was 90% +/- 2% at age 10 years and 73% +/- 8% at age 25. By age 5, 52% +/- 4% had required an AV procedure, 89% +/- 3% by age 15. Patient survival was affected adversely by the diagnosis of valvar aortic stenosis, 79% +/- 6% at age 25 compared to 95% +/- 4% for subvalvar aortic stenosis or aortic insufficiency (p = 0.01). The AV morphology did not affect survival, but patients with a bicuspid or unicuspid valve required operative intervention at an earlier age. Survival after autograft replacement of the AV (Ross Operation) was significantly better than for other types of valve replacement (p = 0.0043). Quality of life as assessed by need for reoperation favors the use of the Ross Operation, with freedom from reoperation at 9 years of 87% +/- 7% compared to 55% +/- 5% in all patients after first AV surgery (p = 0.003). CONCLUSIONS: The Ross Operation appears to have a significant advantage in survival and quality of life in children requiring a valve replacement as a first operation or after a prior AV procedure.     

Early clinical and hemodynamic evaluation of the aortic intact porcine bioprosthesis

Between October 1990 and June 1992, 89 patients underwent aortic valve replacement using the Intact porcine bioprosthesis. Their mean age (+/- SD) was 74.6 +/- 7.8 years (range 48 to 92). Seventy-five percent were in NYHA Class III-IV, 79 (89%) had AS or AS/AI, 10 (11%) had had previous cardiac surgery and 25 (32%) had an EF < 0.50. Associated procedures included CABG 45 (51%), septal myectomy 13 (15%), annular enlargement eight (9%), LV aneurysmectomy one, ascending aortic replacement one, and arch replacement one. Hospital mortality was four (4.5%). Hemodynamics were assessed with 2D echo with Doppler at seven days, six weeks and 12 months, and compared with 130 standard Carpentier-Edwards (C-E) porcine bioprostheses. At follow up, two patients have 2/4 perivalvular AI. The transvalvular gradients for the Intact valve were as follows: 21 mm-16.9 +/- 7.4 mmHg; 23 mm-18.9 +/- 6.2 mmHg; 25 mm-17.1 +/- 5.4 mmHg; 27 mm-15.0 +/- 3.7 mmHg; and 29 mm-15.0 +/- 2.1 mmHg. When compared to the standard Carpentier-Edwards porcine bioprostheses, the 21 mm Intact valve had the same gradient as the C-E prosthesis. However, the transvalvular gradients were slightly higher for the Intact valve for sizes 23-29 mm when compared to the corresponding C-E valve. The effective orifice area and effective orifice area index was no different between the two valves. Satisfactory hemodynamics are seen in the smaller prostheses when valves are matched for BSA and when aortic annular enlargement is performed when necessary.     

Long-term clinical performance of Sorin tilting-disc mechanical prostheses in the mitral and aortic position

OBJECTIVE: Analyzing the long term performance of sorin tilting-disc mechanical prostheses. EXPERIMENTAL DESIGN: Retrospective patient-oriented study. The total follow-up was 460.2 patient-years. Follow-up data was obtained from the patients themselves or from their relatives. SETTING: Department of Cardiovascular Surgery in a general community hospital. PATIENTS: Seventy four patients undergoing valve replacement with Sorin tilting-disc mechanical prostheses between May, 1982 and July 1991. INTERVENTIONS: Thirty one of those patients underwent isolated mitral valve replacement (MVR) and 43 isolated aortic valve replacement (AVR). MEASURES: The incidence of the different complications is expressed as linearized rates. Actuarial analysis was performed with the Kaplan-Meier method. RESULTS: Linearized rates for MVR and AVR for the different complications (events per 100 patient-years) were, respectively: Late mortality: 4.5 +/- 1.6 and 1.8 +/- 0.8; Thromboembolism: 3.4 +/- 1.4 and 1.1 +/- 0.6; Anticoagulant-related hemorrhage: 2.8 +/- 1.3 and 0.3 +/- 0.3; Prosthetic endocarditis: 1.1 +/- 0.8 and 0.7 +/- 0.5; Non-structural dysfunction: 0.5 +/- 0.5 and 1.1 +/- 0.6; Reoperation: 1.1 +/- 0.8 and 0.3 +/- 0.3. Actuarial probabilities of freedom from the different complications were, respectively, at 13 years follow-up for MVR and 12 years follow-up for AVR, the following: Late mortality: 45.7 +/- 12.4% and 70.3 +/- 7.9%; Thromboembolism: 74.6 +/- 10.8% and 90.7 +/- 5.1%; Anticoagulant-related hemorrhage: 79.4 +/- 11.6% and 97.3 +/- 2.7%; Prosthetic endocarditis: 92.7 +/- 4.9% and 91.2 +/- 6.4%; Non-structural dysfunction: 95.6 +/- 4.3% and 88.2 +/- 6.6%; Reoperation: 83.6 +/- 11.8% and 97.3 +/- 2.7%. All valve-related mortality and morbidity: 42.2 +/- 11.0% and 56.7 +/- 8.6%. There was no instances of prosthetic structural failure. CONCLUSIONS: The Sorin mechanical prosthesis presents a good durability and its performance in the long term is comparable to other tilting-disc devices of the same generation.     

Aortic root replacement: twenty years of experience

BACKGROUND: Aortic root replacement is a complex surgical procedure which has undergone major technical modifications with time. In order to assess the early and long-term outcome after aortic root replacement with this procedure, our entire experience of a two decade period was reviewed. METHODS: Between January 1979 and March 1997, 156 aortic root replacement operations were performed. One hundred and twenty five patients (80%) were male and 31 female; their mean age was 50 +/- 16 years. Diagnosis was annuloaortic ectasia in 79 patients, aortic dissection in 51 (acute 22, chronic 29), isolated aortic valve pathology in 24 and aneurysm of sinus of Valsalva in 5. Thirty nine patients had aortic root replacement using the standard "Bentall" technique, 73 using the "modified Bentall" technique, 15 using the Cabrol technique. Biologic substitutes of the aortic root were used in 29 patients (19 autografts, 4 homografts, 6 xenografts). Mean follow-up time was 41 +/- 40 months (range 1 month-18 years). RESULTS: There were 12 (7.6%) hospital deaths. Hospital mortality in elective cases was 5% (7/134) and 22% (5/22) in emergent (p = 0.01). A trend toward reduced early mortality was demonstrated in recent years. Mortality was 5% for the "modified Bentall" group, 3% for the "Biologic root" group, 10% for the "Bentall" group and 20% for the "Cabrol" group. Hospital mortality was significant higher in "Cabrol" group than in "modified Bentall" group (p = 0.04). The overall long-term survival rate was 78 +/- 4% at 5 years, 71 +/- 6% at 10 years and 51 +/- 13% at 15 years. No significant difference in survival rate nor freedom from complications was observed among patient groups. Need for reoperation and valve-related adverse events become prevalent after 10 years of follow-up. CONCLUSION: The decrease in early mortality and the satisfying late results demonstrate that aortic root replacement is a low risk surgical procedure and an effective and durable treatment. The availability of biologic substitutes for the aortic root has allowed the extension of this operation to all patient age group, with results comparable to these obtained with composite grafts.     

Valve repair versus replacement for mitral insufficiency: when is a mechanical valve still indicated?

OBJECTIVES: Although many advantages of mitral valve reconstruction have been demonstrated, whether specific subgroups of patients exist in whom mechanical valve replacement offers advantages over mitral reconstruction remains undetermined. METHODS: This study examined the late results of mitral valve surgery in patients with mitral insufficiency who received either a St. Jude Medical valve (n = 514) or a mitral valve reconstruction with ring annuloplasty (n = 725) between 1980 and 1996. RESULTS: Overall operative mortality was 7.2% in the patients receiving a St. Jude Medical mitral valve and 5.4% in those undergoing mitral valve reconstruction (no significant difference); isolated mortality was 2.5% in the St. Jude Medical group and 2.2% in the valve reconstruction group (no significant difference). The follow-up interval was more than 5 years for 340 patients with a mean of 39.8 months (98.5% complete). Overall 8-year freedom from late cardiac death, reoperation, and all valve-related complications was 72.8% for the St. Jude Medical group and 64.8% for valve reconstruction group (no significant difference). For patients with isolated, nonrheumatic mitral valve disease, 8-year freedom from late cardiac death and reoperation was better in the mitral valve reconstruction group (88.3%) than in the St. Jude Medical valve group (86.0%; p = 0.05). Furthermore, Cox proportional hazards regression revealed that mitral valve reconstruction was independently associated with a lesser incidence of late cardiac death (p = 0.04), irrespective of preoperative New York Heart Association class. However, the St. Jude Medical valve offered better 8-year freedom from late cardiac death, reoperation, and all valve-related complications than did mitral valve reconstruction in patients with multiple valve disease (77.0% vs 45.3%; p < 0.01). CONCLUSIONS: Therefore, mitral valve reconstruction appears to be the procedure of choice for isolated, nonrheumatic disease, whereas insertion of a St. Jude Medical valve should be preferred for patients with multiple valve disease.     

Variance in male mating success and female choice for persuasive courtship displays

BACKGROUND: The aim of the study was to evaluate our clinical experience with the CarboMedics Heart Valve Prosthesis. METHODS: Nine hundred ninety-seven consecutive patients underwent mechanical valve implantation (aortic, 771; mitral, 169; double, 52; tricuspid, 5) with this prosthesis from September 1987 through December 1993. The mean age was 62.3+/-13.7 years (range, 0.4 to 84 years); 56.6% (564 patients) were men. Four hundred seventy patients (47.1%) underwent additional surgical procedures. Mean follow-up was 4.1+/-2.2 years (range, 0 to 8.3 years) with a total of 4,040 patient-years. RESULTS: Early mortality was 5.0% (50/997; aortic, 4.4%; mitral, 6.4%; double, 9.6%). Late mortality was 14.8% (140/947). Survival at 7 years was 75.9%+/-1.8% (aortic, 78.4%+/-2%; mitral, 70.7%+/-4.5%; double, 60.8%+/-7.4%). When matched for sex and age and compared with the normal Norwegian population, our patients had an increased standard mortality ratio in both men (1.9+/-0.4) and women (2.9+/-0.6). The linearized rate of major thromboembolism was 0.9% per patient-year, valve thrombosis 0.2% per patient-year, major bleeding event 0.6% per patient-year, paravalvular leak needing reoperation 0.5% per patient-year, prosthetic valve endocarditis 0.1% per patient-year, and of all reoperations 0.6% per patient-year. CONCLUSIONS: The CarboMedics Heart Valve Prosthesis has incidences of morbid events comparable with or better than reported for other mechanical valves.     

Heparin coating of extracorporeal circuits inhibits contact activation during cardiac operations

OBJECTIVE: The choice of a valve substitute remains a challenge in young patients, with numerous reports of early degeneration and calcification of biological valves in this age group. Therefore an assessment of the long-term results after mechanical aortic valve replacement in children was initiated. METHODS: A retrospective study was conducted in 54 consecutive patients aged 1.1 to 17 years (mean 12.8 +/- 4 years) operated on between 1975 and 1993. Aetiology was congenital in 34 patients, rheumatic in 13, infectious in 5, and dystrophic in 2. Concomitant surgery included mitral valve replacement (10), aortic annulus enlargement (9), correction of truncus arteriosus (7), Bentall operation (2), coarctation repair (2), tricuspid valvuloplasty (2), correction of double outlet right ventricle (1), and replacement of a right ventricle to pulmonary artery conduit (1). A Bjork-Shiley valve was implanted in 14 patients, and a St Jude Medical valve in 40. All patients were given Warfarin with a monthly INR control. Follow-up was completed through questionnaires mailed to referring physicians and direct clinical examination. RESULTS: Overall early mortality was 13% (7 cases), and 6% (2 cases) in the 32 patients operated on after 1984. Follow-up was complete in 45 survivors (2 lost to follow-up), with a total follow-up of 261 patient-years. There were 6 late deaths, 4 being cardiac and due to persistent LV dysfunction, and 2 valve-related, due respectively to major gastro-intestinal bleeding and massive thromboembolism. Linearized rates of valve thrombosis and anticoagulant-related hemorrhage were both 0.3% per patient-year. Actuarial survival rate was respectively 84.5% at 5 years and 70.2% at 10 years. Reoperation was necessary in 3 patients for recurrent LV outflow tract obstruction. One patient with severe LV dysfunction is awaiting a heart transplant. CONCLUSION: We conclude that the longterm outcome after mechanical aortic valve replacement in children and adolescents is satisfactory and comparable to currently available reports on biological substitutes. The mandatory anticoagulant therapy is well tolerated in this age group.     

Results of Biocor stentless valve replacement for infective endocarditis of the native aortic valve

The mid-term results in a selected group of 9 patients with native aortic valve endocarditis managed by aortic valve replacement (with or without complex annular reconstruction) using a totally biological stentless valve are outlined. At a mean follow-up of 48 months, there are currently 7 survivors (2 late noncardiac deaths) with 100% freedom from reoperation, valve-related complication, and endocarditis.