Long-term Doppler echocardiographic results of aortic or mitral valve replacement with Biocor porcine bioprosthesis

OBJECTIVES: Our objectives were to evaluate the long-term bioprosthetic and cardiac functional outcome after insertion (over a 10-year period) of a new-generation porcine zero pressure-fixed Biocor bioprosthesis, as well as to determine the echocardiographic accuracy for selection of patients requiring reoperation. The long-term systematic Doppler echocardiographic assessment after valve replacement with this bioprosthesis is lacking. METHODS: Between January 1983 and January 1993, we inserted 756 Biocor prostheses in the aortic (619) or mitral (137) positions. All 51 patients who had a reoperation during the follow-up time were evaluated echocardiographically before reoperation. Additionally, 263 of 446 patients (59%) with aortic bioprostheses and 42 of 74 patients (57%) with mitral bioprostheses who were alive in January 1993 had long-term echocardiographic follow-up. RESULTS: Group A: Normally functioning bioprostheses were found in the aortic position in 242 of 263 patients and in the mitral position in 33 of 42 patients. Group B: Thirty patients had abnormal bioprosthetic function. Eleven patients had regurgitation, 3 had a combined lesion, and signs of calcification appeared in 16 patients with aortic valves, all with a peak gradient of above 60 mm Hg. Group C: Patients who had a reoperation (41 aortic and 10 mitral) within the follow-up period were followed up echocardiographically from the detection of a possible valve dysfunction until reoperation, and the findings accorded well with those at operation in 49 of 51 patients. CONCLUSIONS: These findings suggest that, during a long-term follow-up, most bioprostheses function normally, facilitating improved heart function. Abnormalities in a bioprosthesis usually develop gradually, enabling their detection by Doppler echocardiographic evaluations performed regularly or in case of any symptomatic deterioration.     

Echocardiography after mitral valve replacement and criteria of paraprosthetic regurgitation

19 patients with Bj?rk-Shiley mitral tilting disc valve prostheses were studied by echocardiography before the valve replacement operation and postoperatively every three months up to one year. In 14 patients with normal prosthetic function the left atrial diameter decreased markedly after operation (p less than 0.001), but echocardiographic dimensional indices of left ventricular performance remained unchanged. Paradoxical or markedly hypokinetic motion of the interventricular septum was observed within 3 months of operation in 46% of the patients, but in only 28% in studies performed 9 - 12 months after the replacement. The ampliture of the disc was on average 11 +/- 2 mm. In 5 patients with paraprosthetic regurgitation the left atrial diameter increased with the development of regurgitation and decreased again after successful reoperation. In these patients the left ventricular end diastolic and stroke volumes were great (p less than o.01) than in patients with normal prostheses. The septal motion was in the normal direction in all these 5 patients and the septal amplitudes were greater (p less than 0.01) than in the patients with normal prostheses. The amplitudes of the disc were normal, but abnormal anterior movement of the disc at the beginning of the diastole was observed. These data demonstrate that echocardiography is useful in the diagnosis of paraprosthetic mitral valve regurgitation.     

Reoperation for mitral regurgitation 13 years after aortic valve replacement and manouguian's anulus enlargement: report of a case

The patient was 22-year-old female. She had undergone aortic valve replacement and Manouguian's anulus enlargement with low porosity woven Dacron patch for congenital aortic stenosis 13 years ago, and developed mitral regurgitation 9 years after that operation. Two regurgitant flow were observed. One was originated from the orifice due to mitral prolapse. The other was from a tear in the anterior leaflet. It was around the tip of the prosthetic patch, approximately 7 mm in size, and was repaired easily. But the mitral valve itself was found to be malformed and prolapsed, requiring mitral valve replacement. Her postoperative course was uneventful.     

Effects of valve replacement on ventricular mechanics in mitral regurgitation and aortic stenosis

BACKGROUND: This study in humans assessed changes in left ventricular function early and late after correction of mitral regurgitation (MR) (n = 9) or aortic stenosis (AS) (n = 10). METHODS: Ventricular function was measured with radionuclide and micromanometer-derived pressure-volume loops during preload manipulation, thermodilution cardiac outputs, and echocardiograms. Late radionuclide and echocardiographic data were acquired at 24 hours and 20 months. RESULTS: Perioperative left ventricular performance (stroke work-end-diastolic volume relationship) did not change for patients with MR or AS. Significant changes in afterload occurred: ejection fraction (MR, 0.49 to 0.37; AS, 0.54 to 0.60; both, p = 0.013), mean left ventricular ejection pressure (MR, 73 to 91 mm Hg; AS, 138 to 93 mm Hg; both, p < 0.01), and end-systolic wall stress (MR, 26 to 42 x 10(3) dynes/cm2; AS, 37 to 22 x 10(3) dynes/cm2; both, p < 0.01). Ejection efficiency improved for MR patients (0.69 +/- 0.26 to 1.0 +/- 0.15; p < 0.05). The 20-month data showed improved New York Heart Association functional class, normal resting ejection fraction, and normal exercise response for both groups. CONCLUSIONS: Early after operation, a significant change in left ventricular load was seen with correction of MR and AS. Data obtained late after operation showed improvement consistent with ventricular remodeling.     

Successful pregnancy in a patient with heart failure secondary to aortic and mitral regurgitation

The transmembrane nature of the receptor-like protein tyrosine phosphatases (PTPases) suggests that they transduce as yet unidentified extracellular signals to intracellular events via a phosphotyrosyl-protein dephosphorylation step, although little is known of their regulation and cellular activities. Structure/function studies of PTP alpha demonstrate that both catalytic domains are required for full enzymatic efficiency and that interdomain interactions may modulate PTP alpha activity and specificity. Overexpression of PTP alpha results in cell transformation and tumorigenesis, likely as a consequence of the ability of PTP alpha to dephosphorylate and activate the c-src tyrosine kinase. This suggests a role for PTP alpha in normal cell proliferation. PTP alpha is so far unique among the PTPases in terms of its oncogenic potential, and overexpression or deregulation of PTP alpha may be involved in the genesis, progression or maintenance of certain tumor states.     

Non-inflammatory aortic root disease and floppy aortic valve as cause of isolated regurgitation: a clinico-morphologic study

Fermented milk was used as therapy in infantile diarrhoea due to post-gastroenteritis syndrome. This treatment eliminated the disease in 4.0 days (mean value, SD = 2.8; n = 13) and allowed patients to return to free feeding according to their age. The weight percentile variation during treatment with fermented milk (15 days) was higher in the patients showing 3rd degree malnutrition than in other children. Bacteriotherapy can restore faecal flora which has been lowered by diarrhoea. Our results showed that levels higher than 10(6) UFC lactobacilli/g of faeces correlated with a healthy status of the children. Clinical applications of fermented milk with a mixture of Lactobacillus casei and Lactobacillus acidophilus in the prevention of gastrointestinal disorders are possible.     

Normal echocardiographic characteristics of the Sorin Bicarbon bileaflet prosthetic heart valve in the mitral and aortic positions

Doppler echocardiographic characteristics of normally functioning Sorin Bicarbon prostheses were prospectively assessed in 226 consecutive patients (135 male and 91 female patients, mean age 61 +/- 10 years) with 233 valves in the mitral (n = 67) and aortic (n = 166) positions whose function was considered normal by clinical and echocardiographic evaluation. Patterns of "normal" transprosthetic leakage were assessed with transthoracic echocardiography in all valves and with transesophageal echocardiography in six selected mitral valve prostheses. For the mitral valve prostheses, we found that peak and mean gradient, as well as pressure half-time, were not significantly different in either the 25 or the 31 mm valves (median values from 15 to 10 mm Hg, from 4 to 4 mm Hg, and from 70 to 83 ms; p = Not significant for all). On transthoracic study, 12 patients (17%) with a Sorin Bicarbon valve in the mitral position showed minimal transprosthetic leakage. On transesophageal study, all patients showed a transprosthetic leakage whose spatial distribution had a complex pattern: in planes orthogonal to the leaflet axis, two to four jets arising from the hinge points and converging toward the center of the valve plane could be visualized; in planes parallel to the leaflet axis, there were three jets, the two lateral ones diverging and the central one perpendicular to the valve plane. For the aortic valve prostheses, there was a significant decrease in transprosthetic gradients and an increase in effective orifice areas as prosthesis size increased. Peak and mean gradients decreased from a median value of 25 and 13 mm Hg in the 19 mm valves to 9 and 5 mm Hg in the 29 mm valves, respectively. Effective prosthetic valve area calculated with the continuity equation increased from a median value of 0.97 cm2 for the 19 mm size valves to 3.45 cm2 for the 29 mm size. With analysis of variance, effective prosthetic aortic valve area differentiated various valve sizes (F = 40.9, p < 0.0001) better than peak (F = 10.3, p < 0.0001) or mean (F = 8.04, p < 0.0001) gradients alone did. Furthermore, effective prosthetic aortic valve area correlated better than peak and mean gradients with prosthetic size (r = 0.76, r = -0.45, and r = -0.39, respectively). On transthoracic study, 109 patients (66%) showed minimal transprosthetic leakage. These normal values, obtained in a large number of patients with normofunctioning mitral and aortic Sorin Bicarbon valves, may help to identify Sorin Bicarbon prosthesis dysfunction.     

Successful surgical treatment for type B aortic dissection with Marfan's syndrome after aortic root and mitral valve replacement: report of a case

A 30-year-old female with Marfan's syndrome underwent aortic root replacement for annuloaortic ectasia and mitral valve replacement for mitral regurgitation. She remained well until 16 months postoperatively when she had sudden onset of pain. Preoperative angiogram showed Stanford B aortic dissection. Thoracoabdominal aortic replacement was performed successfully under deep hypothermic bypass.     

Bentall operation, total aortic replacement and mitral valve replacement for a young adult with Marfan syndrome: a case of three-staged operation

BACKGROUND: Early postpartum discharge of babies was gradually introduced in Sweden in the 1980s on ideological grounds, based on the premise that maternity wards were unnatural settings for mothers and babies and hampered breastfeeding. From about 1990, early discharge was used as a means to reduce costs. The purpose of this study was to examine if mandated early discharge at Central Hospital of Karlstad, Sweden, influenced subsequent breastfeeding. METHOD: Breastfeeding outcomes of infants up to six months of age of all births in 1993 (n = 3231) were compared with the outcome of newborns in 1990 (n = 1462). RESULTS: Breastfeeding at six months postpartum continued to increase during the early 1990s for both healthy and sick infants, irrespective of whether or not they were discharged early. In infants born in 1995 the breastfeeding rate at six months was 64 percent for healthy newborns and 53 percent for sick newborns. CONCLUSION: Factors other than the time of discharge, most likely a positive change of attitude in society and vigorous introduction of the Baby Friendly Hospital Initiative, seem to have been more important for successful breastfeeding.     

Left ventricular volume reduction for end-stage heart failure: intrapapillary or extrapapillary resection, mitral valve repair or replacement?

We report on two patients with end-stage dilated cardiomyopathy and functional mitral valve insufficiency who underwent left ventricular volume reduction. Intrapapillary resection and correction of the mitral valve regurgitation produced inadequate reduction of the ventricular cavity and resulted in inability to wean the patients from cardiopulmonary bypass. Following extension of the resection to include the papillary muscles and mitral valve replacement, there was a significant improvement in cardiac function. Both patients survived surgery; subsequent echocardiography provided evidence of improved myocardial function and NYHA functional class.     

Comparative study of in vitro flow characteristics between a human aortic valve and a designed aortic valve and six corresponding types of prosthetic heart valves

A model of a pulsatile cardiovascular system is described including an electronic control, a hydraulic driving unit, a volume storage, a peripheral resistance and measuring equipment. Six different artificial heart valves, a designed aortic valve (Aachen pockett valve II) and a human aortic valve have been tested in the outflow position of the pump. Three of them are presently being used in clinical applications. Measurements of pressure and volume flow have been obtained for different frequencies n, pump volumes Vp and time ratios between pressure and suction phase. From the experimental results a comparative evaluation was deducted for different working conditions. In comparison to natural human aortic valve (NK) large volume flow is verified by the Aachen pocket valve II (AT), the Gott-Dagget value (GD), the Starr-Edwards valve (SE) and the Lillehei-Kaster valve (LK). The Gott-Daggett valve has the smallest back flow volume. The Smeloff-Cutter and in particular the Wada-Cutter valve have the largest regurgitation. This is to be expected since the Cutter valves are purposely so designed that they do not close tightly in order to avoid blood sedimentation. The human aortic valve, the Gott-Daggett valve and the Aachen pocket valve demonstrate the most favourable opening-closing characteristics. The human aortic valve achieves a negligible pressure loss, followed by the Bj?rk-Shiley and the Lillehei-Kaster valve.     

Kyphosis secondary to tuberculosis osteomyelitis as a cause of ventilatory failure. Clinical features, mechanisms, and management

STUDY OBJECTIVES: To investigate the relationship of thoracic kyphosis following tuberculosis to the development of ventilatory failure and to assess the efficacy on nocturnal noninvasive ventilatory support. DESIGN: Retrospective consecutive case series with crossover from a phase without noninvasive ventilatory support to a phase with this treatment. SETTING: The Respiratory Support and Sleep Centre, Papworth, Hospital, Cambridge, England. PATIENTS: Seven patients with thoracic kyphosis following tuberculous osteomyelitis which had been contracted by the age of 4 years were studied. Their mean age was 53 (SD 7.1) years and the mean angle of kyphosis was 113.60. All patients were in ventilatory failure. INTERVENTIONS: The patients were treated with nocturnal noninvasive ventilation with either an individually constructed cuirass shell and a negative pressure pump or nasal intermittent positive pressure ventilation using a volume preset ventilator. MEASUREMENT AND RESULTS: Each patient underwent an initial clinical assessment along with radiologic studies of the spine, pulmonary function tests, daytime arterial blood gas tensions, and overnight recordings of arterial saturation, and transcutaneous carbon dioxide tension. They were reassessed in detail at a mean of 5 years after starting ventilatory support. Symptoms, vital capacity, daytime carbon dioxide tension, and overnight oximetry had all improved following treatment. Temporary withdrawal of ventilatory support led to severe sleep fragmentation in four patients and the appearance of central apneas and hypopneas in the other three. Six of the 7 patients were alive at a mean of 5.7 years after starting nocturnal ventilation. CONCLUSION: These results show that ventilatory failure may develop, after an interval of many years, in patients with a severe thoracic kyphosis due to tuberculosis in childhood. Noninvasive nocturnal ventilatory support can control the symptoms of ventilatory failure, improve the physiologic abnormalities, and is associated with prolonged survival.     

Successful surgical treatment of a pseudoaneurysm after composite graft replacement of the aortic valve and ascending aorta: report of two cases

Composite graft replacement of the ascending aorta and aortic valve has now become a safe surgical procedure; however, early and late complications still frequently occur. Anastomotic dehiscence after a composite graft replacement is one potentially lethal complication. We herein report two cases of a pseudoaneurysm caused by dehiscence of the right coronary anastomosis, and the proximal aortic anastomosis. A follow-up with an echocardiogram and computed tomography scan was found to be very useful and accurate. We thus successfully treated two cases of pseudoaneurysm using either Bentall's or Carbrol's procedures.     

Myocardial structure as a determinant of pre- and postoperative ventricular function and long-term prognosis after valve replacement for aortic stenosis

BACKGROUND: Long-term results after aortic value replacement for aortic stenosis can be correlated to a cardiac-related pre-operative risk profile. This predictability indicates that there is a common basis in subtle or overt structural abnormalities of left ventricular myocardium. METHODS AND RESULTS: Forty-nine patients aged 24-82 (mean 61) years, with aortic stenosis had a full wall thickness transmural biopsy of the left ventricular antero-lateral free wall during aortic valve replacement. Echocardiography and radionuclide ventriculography were performed prior to, and 18 months (n = 41) after, the operation. Postoperative follow-up to a maximum of 7.7 years was 100% complete. Pre-operatively, all patients had an increase in both the left ventricular mass index (202 +/- 67 g.m-2) and the muscle cell diameter (41 +/- 8 microns); other morphological data included a muscle cell nucleus volume of 752 +/- 192 microns3, a muscle cell mass index of 163 +/- 54.m-2, and a fibrous tissue mass index of 39 +/- 16 g.m-2. Patients with a pre-operative episode of clinical left ventricular failure (n = 19) had significantly greater morphological variables than those without. Pre-operative ejection fraction and other measures of systolic function correlated inversely with the morphological data, except for the fibrous tissue mass index; diastolic function indices correlated inversely with all the morphological variables. At the 18-month re-study, the same general picture was noted, but with an underlying strengthening, especially of the muscle cell mass index. Overall, the mass index dropped to 152 +/- 51 g.m-2 (P < 0.0001), but in 17% of the patients it became normal; the mass index at 18 months was directly correlated to morphological variables. A high muscle cell nucleus volume was identified as an independent predictor of early and late mortality. CONCLUSIONS: Abnormalities of the hypertrophied left ventricular muscle cell and the degree of muscle hypertrophy are, to some degree, underlying determinants of pre-operative symptomatology, pre- and postoperative ventricular function, and early and late mortality after valve replacement for aortic stenosis. Incomplete hypertrophy impaired results, was related to pre-operative myocardial structural abnormalities.     

Results of heart valve replacement: especially on the selection criteria for valve prostheses and on a new anticoagulation regimen

Since March 1981 till the end of 1987, a total of 76 artificial heart valves were implanted in 72 patients. Heart valve prostheses were selected individually according to the patient's needs rather than assigning a single model to every patient. Postoperatively patients were placed on an anticoagulation therapy regimen consisting of reduced-dose warfarin (prothrombin time maintained at 30% of the control) and a small dose (81 mg/day) aspirin. During this period no bioprosthesis was implanted. For aortic valves, Starr-Edwards caged-ball valves were used in 53.1% and St. Jude Medical (SJM) valves in 37.5%. For mitral valves, SJM valves were used in 68%. No mechanical valve failure and no thrombosed valve was encountered. There was one patient-prosthesis missmatch. The incidence of thromboembolism for the entire series was 5/181.2 patient-years. There was 1-2/181.2 patient-years incidence of hemorrhagic complications. These figures were comparable to the ones with conventional warfarin therapy. No intracranial hemorrhage was encountered. Our selection criteria for artificial heart valves and our method of anticoagulation were discussed in detail. We conclude that at present there is no single prosthesis which satisfies all the varying needs of every patient, and the prosthesis which is best suited to that particular patient should be selected. We are generally happy with our current method of postoperative anticoagulation and will continue with this regimen.     

Transesophageal Doppler echocardiography assessment of mitral valve insufficiency: Comparison of jet area, pulmonary venous flow profile, proximal jet diameter, maximal regurgitation flow rate and regurgitation orifice area with angiography

In transesophageal echocardiography several methods have been used to grade mitral regurgitation. For a direct comparison of these techniques, 36 patients (60 +/- 13 years) with native mitral regurgitation underwent multiplane transesophageal echocardiography and angiography within 5 days. We compared the following measurements: 1) The maximal color jet area of mitral regurgitation, 2) the ratio of maximal systolic to diastolic pulmonary venous flow velocity in the left upper pulmonary vein, 3) the proximal jet width of mitral regurgitation, 4) the maximal regurgitant flow rate Qmax, measured by the proximal convergence method, 5) the regurgitant office area Areg, calculated by dividing Qmax by maximal regurgitant velocity obtained by continuous wave Doppler. RESULTS: The correlation between color jet area (r = 0.4; p < 0.05) or pulmonary venous flow (r = -0.3; p = n.s.) with angiographic severity of mitral regurgitation is low. The sensitivity of the retrospective best cut-off values is 69% (color jet area) and 83% (pulmonary venous flow). Using retrospective best cut-off values all patients with mitral regurgitation Sellers grade III and IV are correctly identified by a proximal jet width > or = 0.7 cm, Qmax > or = 300 ml/s or a Areg > or = 0.5 cm2 (sensitivity and specificity of 83-100%). Spearman's rank coefficient demonstrated a high correlation (r = 0.75-0.77; p < 0.001) between proximal jet width, Qmax and Areg and with angiographic severity. CONCLUSION: Multiplane transesophageal echocardiographic grading of mitral regurgitation by proximal jet width or proximal convergence zone shows comparably good results and is clearly superior to grading by color jet area or pulmonary venous flow, if adequate image quality is achieved.     

Fever, negative blood culture findings and absence of response to antibiotic therapy in a patient after a second aortic valve prosthesis

HISTORY AND CLINICAL FINDINGS: A 53-year-old patient had a prosthetic valve (St. Jude Medical 25) 9 years ago because of a Staphylococcus aureus endocarditis with severe aortic regurgitation. An initially mild, progressively more severe, aortic regurgitation then developed as a result of an empty paravalvular abscess cavity, requiring another valve replacement. Fever started on the 3rd postoperative day and persisted despite combined treatment with beta-lactam antibiotics and aminoglycoside. INVESTIGATIONS: At first no infectious focus could be identified radiologically or by echocardiography. But transoesophageal echocardiography revealed vegetations in the old abscess cavity. Several blood cultures were negative, while serological tests gave markedly raised antibody titers against Coxiella burnetii. DIAGNOSIS, TREATMENT AND COURSE: Assuming Coxiella burnetii endocarditis the patient was given doxycycline, 2 x 100 mg daily and cotrimoxazole, 1 x 960 mg daily. The fever subsided and the vegetations had disappeared after four weeks. Because of the high risk of recurrence the antibiotic treatment was to be continued for two years. CONCLUSION: Coxiella burnetii should be considered as a possible cause of fever of unknown origin, especially in patients with existing or operated cardiac valvar defects, when endocarditic vegetations have been demonstrated and several blood cultures have been negative.     

Basic fibroblast growth factor in a porcine model of chronic myocardial ischemia: a comparison of angiographic, echocardiographic and coronary flow parameters

Recently, a number of growth factors including basic fibroblast growth factor (bFGF) have been shown to promote angiogenesis in vivo. In this study, we evaluated dose-dependent effect of bFGF administration in the setting of chronic myocardial ischemia. A total of 18 Yorkshire pigs subjected to ameroid occluder placement on the left circumflex artery were randomized to treatment with 10 (n = 6) or 100 microg (n = 5) of bFGF incorporated into heparin-alginate microspheres or inactive control pellets (n = 7). Eight weeks later, all animals underwent angiographic evaluation of collateral development as well as studies of coronary flow and global and regional left ventricular function. Both bFGF groups had significantly higher angiographic collateral index, TIMI flow scores and coronary flow in the ameroid-compromised territory compared with controls. Left ventricular function studies demonstrated improved global and regional function in both fibroblast growth factor groups with significantly better preservation of regional wall motion in high dose (100 microg) bFGF animals. We conclude that local perivascular delivery of bFGF results in significant improvement in myocardial function in the setting of chronic myocardial ischemia.     

Atrial septal defect with tricuspid valve regurgitation and heart failure in early childhood: report of a case with successful surgical management consisting of special patch closure technique and use of polydioxanone suture for the tricuspid annuloplasty

A management of surgery for infant having a small left ventricular cavity associated with atrial septal defect and tricuspid valve regurgitation was presented. A right upper part of the defect was remained in open during a patch closure of ASD and this portion was temporarily sutured by prolene stayed extracardialy through Waterston's groove. During 20 minutes after weaning from the cardiopulmonary bypass, left heart failure did not appear and then it was completely closed. DeVega's method was employed for the tricuspid valve regurgitation using a absorbale Polydioxanone suture, because of a growth of the sutured annulus. Postoperative course was uneventful and trivial tricuspid valve regurgitation was recognized in angiocardiographic studies performed in 2 weeks and 6 months after operation.