==================================CMR04================================== 4. Tertiary mitral valve obstruction. Mitral valve stenosis of a mechanical mitral prothesis. Ventricle/valve mismatch of a prosthetic mitral valve from decreased left ventricular cavity size. 1 UI - 87075134 AU - Lytle BW ; Cosgrove DM ; Taylor PC ; Gill CC ; Goormastic M ; Golding LR ; Stewart RW ; Loop FD TI - Reoperations for valve surgery: perioperative mortality and determinants of risk for 1,000 patients, 1958-1984. AB - One thousand consecutive cardiac reoperations for valve surgery in 897 patients were reviewed to determine in-hospital mortality and indicators of risk. Subgroups based on the number of previous cardiac procedures and the valve or valves replaced or repaired at reoperation (aortic valve, mitral valve, tricuspid valve, or multiple valves and mortality [deaths/number of procedures (% mortality)]) for those subgroups are as follows: (Table: see text) Predictors of increased risk for a first aortic valve reoperation were advanced age (p = .0002), endocarditis (p = .0018), female sex (p = .014), impaired left ventricular function (p = .039), and number of coronary vessels obstructed by 70% or more (p = .055). For a first mitral valve reoperation, the predictors were advanced age (p less than .0001), preoperative shock or cardiac arrest (p = .01), previous aortic or tricuspid valve operations (p = .02), type of mitral valve procedure (risk for repair of periprosthetic leak was greater than mitral valve replacement which was greater than mitral valve-conserving operation [p = .05]), and impaired left ventricular function (p = .059). For a first multiple valve reoperation, the predictors were diabetes (p = .04) and ascites (p = .02), whereas patients undergoing mitral valve replacement and tricuspid valve operations were at decreased risk (p = .01). Comparison of second reoperations with first reoperations indicates risk increases for multiple operations (p = .01) but not for aortic or mitral valve procedures. Rereplacement of a prosthesis (p = .007), coronary bypass grafting at reoperation (p = .006), and advanced age (p = .06) increased the risk for second reoperations. Age is the most consistent predictor of risk for patients undergoing valve reoperations. MH - Aortic Valve/SURGERY ; Aortocoronary Bypass ; Comparative Study ; Heart Valve Diseases/MORTALITY/*SURGERY ; Heart Valve Prosthesis/ *ADVERSE EFFECTS ; Human ; Methods ; Mitral Valve/SURGERY ; Prognosis ; Prosthesis Failure ; Reoperation/MORTALITY ; Risk ; Tricuspid Valve/SURGERY SO - Ann Thorac Surg 1986 Dec;42(6):632-43 2 UI - 87045857 AU - Roberts WC ; Sullivan MF TI - Clinical and necropsy observations early after simultaneous replacement of the mitral and aortic valves. AB - Clinical and necropsy findings are described in 54 patients, aged 25 to 83 years (mean 53), who died within 60 days of simultaneous replacements of both mitral and aortic valves. The patients were separated into 4 groups on the basis of the presence of stenosis (with or without associated regurgitation) or pure regurgitation of each valve: 30 patients (56%) had combined mitral and aortic valve stenosis; 12 patients (22%) had mitral stenosis and pure aortic regurgitation; 8 patients (15%) had pure regurgitation of both valves; and 4 patients (7%) had pure aortic regurgitation and mitral stenosis. Necropsy examination in the 54 patients disclosed a high frequency (48%) of anatomic evidence of interference to poppet or disc movement in either the mitral or aortic valve position or both. Anatomic evidence of interference to movement of a poppet or disc in the aortic valve position was twice as common as anatomic evidence of interference to poppet or disc movement in the mitral position. Interference to poppet movement is attributable to the prosthesis's being too large for the ascending aorta or left ventricular cavity in which it resided. The ascending aorta is infrequently enlarged in patients with combined mitral and aortic valve dysfunction irrespective of whether the aortic valve is stenotic or purely regurgitant. Likewise, the left ventricular cavity is usually not dilated in patients with combined mitral and aortic valve stenosis, the most common indication for replacement of both left-sided cardiac valves. Of the 54 patients, 12 (22%) had 1 mechanical and 1 bioprosthesis inserted. It is recommended that both substitute valves should be mechanical prostheses or both should be bioprostheses. MH - Adult ; Aged ; Aortic Valve Insufficiency/*SURGERY ; Aortic Valve Stenosis/*SURGERY ; Coronary Arteriosclerosis/PATHOLOGY ; Female ; Heart Enlargement/ETIOLOGY ; Heart Rupture/ETIOLOGY ; *Heart Valve Prosthesis ; Human ; Male ; Middle Age ; Mitral Valve Insufficiency/*SURGERY ; Mitral Valve Stenosis/*SURGERY ; Myocardium/*PATHOLOGY ; Necrosis ; Postoperative Complications/ MORTALITY ; Prosthesis Failure SO - Am J Cardiol 1986 Nov 15;58(11):1067-84 3 UI - 87026376 AU - Morais P ; Westaby S ; Hallidie-Smith KA TI - Left ventricular outflow tract obstruction due to anomalous mitral valve: successful mitral valve replacement in a four month old infant. AB - A four month old infant was investigated for heart failure was found to have mitral incompetence and severe subvalvar aortic stenosis. The left ventricular outflow tract obstruction was found to be due to an anatomically anomalous mitral valve. The obstruction could only be relieved by removal of the mitral valve and its replacement with a St Jude's prosthesis. Two years after operation the child is fit and active. There have been no difficulties with anticoagulant treatment. MH - Aortic Subvalvular Stenosis/COMPLICATIONS/*THERAPY ; Cardiomyopathy, Hypertrophic/*THERAPY ; Case Report ; Cineangiography ; Coronary Circulation ; *Heart Valve Prosthesis ; Human ; Infant ; Male ; Mitral Valve Insufficiency/ COMPLICATIONS/*THERAPY SO - Br Heart J 1986 Oct;56(4):385-7 4 UI - 87022794 AU - Sullivan MF ; Roberts WC TI - Mitral valve stenosis and pure tricuspid valve regurgitation: comparison of necropsy patients having simultaneous mitral and tricuspid valve replacements with necropsy patients having simultaneous mitral valve replacement and tricuspid valve anuloplasty. AB - Clinical and morphologic observations are described in 30 patients (23 [77%] of whom were in functional class III or IV) who underwent replacement of the mitral valve for mitral stenosis and either simultaneous replacement (13 patients, group I) or anuloplasty (17 patients, group II) of the tricuspid valve for pure tricuspid valve regurgitation. Comparison of the 13 patients in group I with the 17 patients in group II disclosed similar mean ages (55 vs 58 years), similar average preoperative right ventricular systolic pressures (64 vs 61 mm Hg), similar average right atrial mean pressures (10 vs 9 mm Hg), similar average left ventricular systolic pressures (126 vs 120 mm Hg), similar average pulmonary artery wedge-left ventricular mean diastolic pressures (16 vs 18 mm Hg), similar cardiac indexes (2.1 vs 2.0 liters/min/m2), similar mean heart weights (507 vs 535 g), and similar percents with grossly visible foci of left ventricular necrosis (15% vs 12%) and fibrosis (23% vs 12%). Of the 13 patients in group I, 10 (77%) died early (less than or equal to 60 days of tricuspid valve replacement) and 3 (23%) died late (29, 37 and 120 months); of the 17 patients in group II, 14 (82%) died early and 3 (18%) died late (4, 9 and 98 months). The causes of early death in the 2 groups were different: of the 10 patients in group I who died early, the cause was excessive bleeding in 5, low cardiac output of undetermined etiology in 3, dysfunction of both prostheses in 1 and cerebral insult in 1; of the 14 patients in group II who died early, none died from excessive bleeding, 4 from decreased cardiac output of uncertain cause, 5 from left ventricular inflow obstruction (produced by a Starr-Edwards ball-valve prosthesis in 4 and from a Starr-Edwards disc prosthesis in 1), 1 from left ventricular outflow obstruction (by a porcine bioprosthesis), 2 from technical mishaps (incision into left ventricular free wall with rupture in 1 and ligation of the left circumflex coronary artery with resulting acute myocardial infarction in 1) and 2 died suddenly for reasons not determined. Of the 6 patients dying greater than 60 days after operation, 4 died from chronic congestive cardiac failure, 1 from a cerebral embolus and 1 from prosthetic valve endocarditis. MH - Adult ; Aged ; Female ; *Heart Valve Prosthesis ; Heart Ventricle/ PATHOLOGY ; Human ; Male ; Middle Age ; Mitral Valve Stenosis/ *PATHOLOGY ; Mitral Valve/SURGERY ; Tricuspid Valve Insufficiency/ *PATHOLOGY ; Tricuspid Valve/SURGERY SO - Am J Cardiol 1986 Oct 1;58(9):768-80 5 UI - 86322169 AU - Jett GK ; Jett MD ; Bosco P ; van Rijk-Swikker GL ; Clark RE TI - Left ventricular outflow tract obstruction following mitral valve replacement: effect of strut height and orientation. AB - The influence of strut position and strut height of Ionescu-Shiley bovine pericardial valves on the degree of left ventricular outflow tract (LVOT) obstruction was studied following mitral valve replacement (MVR) in hypertrophied left ventricles. Left ventricular hypertrophy was created in 6 lambs by constrictive banding of the descending thoracic aorta at 2 weeks of age. MVR was accomplished seven months later utilizing cardiopulmonary bypass and hypothermic cardioplegic arrest. Each animal underwent three consecutive valve replacements with 25-mm bovine pericardial valves randomly inserted in each of the following manners: (1) standard-profile valve with orientation of the struts out of the LVOT; (2) standard-profile valve with a strut oriented into the LVOT; and (3) low-strut profile investigational valve with a strut oriented into the LVOT. Gradients across the LVOT were measured after MVR and then following administration of isoproterenol hydrochloride (0.05 micrograms per kilogram of body weight per minute). No gradient was created with the struts oriented out of the LVOT with or without isoproterenol administration. When a strut was oriented into the LVOT without isoproterenol, the gradients were comparable with the standard- and low-profile valves (7 +/- 2 mm Hg versus 6 +/- 4 mm Hg, respectively). With isoproterenol, however, a significant difference in gradients between the standard- and low-profile valves (65 +/- 20 mm Hg versus 22 +/- 14 mm Hg, respectively) was observed when a strut was oriented into the LVOT. The results show that LVOT obstruction following MVR was related to the orientation of the strut of the bioprosthetic valve, and this obstruction was diminished with a decreased strut height of the Ionescu-Shiley prosthesis. MH - Animal ; Bioprosthesis ; *Cardiac Output/DRUG EFFECTS ; Equipment Design ; Heart Enlargement/PHYSIOPATHOLOGY ; *Heart Rate/DRUG EFFECTS ; Heart Valve Prosthesis/*ADVERSE EFFECTS ; Isoproterenol/ PHARMACODYNAMICS ; Mitral Valve/*SURGERY ; Sheep SO - Ann Thorac Surg 1986 Sep;42(3):299-303 6 UI - 86254656 AU - Kazama S ; Nishiguchi K ; Sonoda K ; Nakajima H ; Kawai Y ; Imai H ; Asari H ; Ishihara A TI - Postoperative left ventricular function in patients with mitral stenosis. The effect of commissurotomy and valve replacement on left ventricular systolic function. AB - Preoperative and postoperative left ventricular cineangiograms of 26 patients with mitral stenosis (MS) were analyzed to calculate left ventricular end-diastolic volume (EDV), end-systolic volume (ESV), stroke volume (SV), ejection fraction (EF) and systolic regional wall motion. Nine patients underwent commissurotomy (OMC group) and 17 patients underwent mitral valve replacement (MVR group). In both groups, postoperative EDV, SV and EF tended to increase, while ESV remained unchanged. In the OMC group, systolic wall motion of the left ventricle was found to be improved postoperatively, whereas systolic wall motion in the MVR group was found to be impaired postoperatively. The latter finding was assumed to be due to excision of the papillary muscles and chordae tendineae. Preservation of these structures is likely to be important for better postoperative functional recovery of the left ventricle. MH - Adult ; *Heart Valve Prosthesis ; Heart Ventricle/PHYSIOPATHOLOGY ; Human ; Middle Age ; Mitral Valve/SURGERY ; Mitral Valve Stenosis/*PHYSIOPATHOLOGY/SURGERY ; *Myocardial Contraction ; Postoperative Period ; Stroke Volume ; *Systole SO - Jpn Heart J 1986 Jan;27(1):35-42 7 UI - 86208051 AU - Harjula A ; Mattila S ; Maamies T ; Mattila I ; Mattila P ; Skytt:a J ; Tala P TI - Long-term follow-up of Bj:ork-Shiley mitral valve replacement. 10 years' experience. AB - Retrospective analysis was made of 176 patients who received a Bj:ork-Shiley mitral valve replacement in the period 1973 through 1982. Actuarial cumulative curves showed the 10-year and 5-year survival rates to be 79 +/- 3.4%. The functional status at follow-up was better than preoperatively in 77.1% of the patients. The hospital mortality was 9.1% and the late mortality was 3.6/100 patient years. Early complications included disc entrapment against the ventricular wall in three cases, wedging of chorda between disc and valve rim in two and posterior perforation of the left ventricle in three patients. There was no structural valve damage. Calculated per 100 patient years, the incidence of thromboembolism was 2.5, endocarditis 1.4 and prosthetic leak 1.8. One thrombosed valve was successfully replaced by a new prosthesis 11 years after the initial implantation. Jamming of the disc by tissue over-growth necessitated a new valve implantation in one case. The incidence of early valve-related complications was high, but the long-term results were comparable with those from other mechanical valves. One early complication--disc entrapment against the ventricular wall--may be avoided by use of a sufficiently small valve if the ventricle is small and thickened. MH - Actuarial Analysis ; Endocarditis, Bacterial/OCCURRENCE ; Female ; Follow-Up Studies ; *Heart Valve Prosthesis/MORTALITY ; Human ; Male ; Middle Age ; Mitral Valve ; Mitral Valve Insufficiency/ *SURGERY ; Mitral Valve Stenosis/*SURGERY ; Postoperative Complications/*OCCURRENCE ; Prosthesis Design ; Prosthesis Failure ; Retrospective Studies ; Thromboembolism/OCCURRENCE ; Time Factors SO - Scand J Thorac Cardiovasc Surg 1986;20(1):79-84 8 UI - 86134314 AU - Okamura K ; Fukuda I ; Maeta H ; Mitsui T ; Hori M TI - Two-dimensional echocardiographic evaluation of the severity of mitral stenosis with reference to the prediction for mitral valve commissurotomy or replacement. AB - Thirty patients with mitral stenosis were classified into three grades of severity reflected by anterior mitral leaflet and subvalvular apparatus using two-dimensional echocardiography in order to study the possibility of predicting the type of surgery indicated, and were evaluated pre- and postoperatively for systolic and diastolic volumes; left heart function using left ventricular posterior wall movement (LVPWVSmax, LVPWVdmax) and posterior wall excursion (PWE) and newly devised left atrial empty volume ratio (LAEVR). The LVPWVSmax was increased from 57 +/- 7 to 74 +/- 7 mm/s (p less than 0.001) in grade I, from 48 +/- 13 to 63 +/- 9 mm/s (p less than 0.02) in grade II, and from 44 +/- 6 to 64 +/- 7 mm/s (p less than 0.001) in grade III. The LVPWVdmax showed an increase from 68 +/- 15 to 91 +/- 15 mm/s (p less than 0.001) in grade I, from 57 +/- 17 to 86 +/- 18 mm/s (p less than 0.01) in grade II, and from 55 +/- 11 to 83 +/- 6 mm/s (p less than 0.01) in grade III. In the PWE, there was an improvement from 12.4 +/- 1.6 to 15.5 +/- 2.1 mm (p less than 0.01) in grade I; from 10.5 +/- 2.0 to 12.5 +/- 1.5 mm (p less than 0.02) in grade II; and from 9.4 +/- 1.5 to 14.4 +/- 1.5 mm (p less than 0.001) in grade III. In the LAEVR, there was also an improvement from 65 +/- 12 to 39 +/- 21% (p less than 0.01) in grade I.(ABSTRACT TRUNCATED AT 250 WORDS) MH - Adult ; Echocardiography/*METHODS ; Female ; *Heart Valve Prosthesis ; Human ; Male ; Middle Age ; Mitral Valve Stenosis/ *PATHOLOGY/SURGERY ; Prognosis ; Severity of Illness Index SO - Clin Cardiol 1986 Mar;9(3):99-105 9 UI - 86102320 AU - Jett GK ; Jett MD ; Barnhart GR ; van Rijk-Swikker GL ; Jones M ; Clark RE TI - Left ventricular outflow tract obstruction with mitral valve replacement in small ventricular cavities. AB - The inference that mitral valve replacement (MVR) may produce left ventricular outflow tract (LVOT) obstruction has been made, but no comparative hemodynamic studies with various types of prostheses have been done. The purpose of the present study was to compare the gradients created across the LVOT with MVR in young sheep with small left ventricular cavities. Mitral valve replacement was accomplished using cardiopulmonary bypass and hypothermic cardioplegic arrest. Five animals were used for each of the following valves studied: 25-mm Ionescu-Shiley bovine pericardial valve, 25-mm Hancock porcine aortic valve, 2M-6120 28-mm Starr-Edwards ball-valve prosthesis, 25-mm Bj:ork-Shiley 60-degree flat tilting-disc prosthesis, and 25-mm St. Jude Medical hemidisc valve. Gradients across the LVOT were measured after MVR and then during infusion of isoproterenol hydrochloride (0.05 micrograms/kg/min). Following MVR, only the Starr-Edwards valve produced an LVOT gradient (32 +/- 23 mm Hg). Substantial gradients after MVR were seen, however, with isoproterenol administration with the Ionescu-Shiley (47 +/- 4 mm Hg), Hancock (13 +/- 8 mm Hg), and Starr-Edwards (65 +/- 30 mm Hg) valves but not with the low-profile valves (Bj:ork-Shiley and St. Jude Medical). The results of the present study demonstrate that MVR can produce LVOT obstruction. The greatest degree of obstruction was with the high-profile mechanical and bioprosthetic valves. MH - Animal ; Bioprosthesis/ADVERSE EFFECTS ; Comparative Study ; Heart Valve Prosthesis/*ADVERSE EFFECTS ; Heart Ventricle/ *ANATOMY & HISTOLOGY/PHYSIOPATHOLOGY ; *Hemodynamics ; Mitral Valve/*PHYSIOPATHOLOGY/SURGERY ; Sheep ; Stroke Volume SO - Ann Thorac Surg 1986 Jan;41(1):70-4 16 UI - 86112954 AU - Czer LS ; Gray RJ ; Bateman TM ; DeRobertis MA ; Resser K ; Chaux A ; Matloff JM TI - Hemodynamic differentiation of pathologic and physiologic stenosis in mitral porcine bioprostheses. AB - Porcine bioprostheses are physiologically stenotic valves. Degenerative calcification leading to pathologic stenosis is an increasingly recognized serious late complication of mitral valve replacement with a porcine bioprosthesis. Hemodynamic differentiation of pathologic from physiologic stenosis is important for identification of porcine bioprosthetic valve dysfunction. In 42 patients with a normal Hancock porcine bioprosthesis (standard model, sizes 27 to 33 mm), mean diastolic flow (65 to 461 ml/s), mean gradient (2.0 to 13.4 mm Hg) and effective orifice area (1.1 to 4.4 cm2) were determined at rest, during epicardial pacing (90, 110 and 130/min) and with isoproterenol infusion. A statistically significant increase in mean gradient occurred with increases in flow and decreases in valve size (p less than 0.05). Effective orifice area increased significantly as flow rate increased and as valve size increased (p less than 0.05). These measurements were compared with those in 16 patients with pathologically confirmed porcine bioprosthetic valve stenosis: 8 patients with reoperation (1.1% per patient-year) 3 to 8.5 years after mitral valve replacement and 8 previously reported abnormal cases. Stenotic failure rate was inversely related to valve size (2.1, 1.4, 0.5 and 0% per patient-year for sizes 27 to 33 mm). Stenotic and normal bioprostheses were not accurately differentiated on the basis of a single value for gradient or effective orifice area. A mathematical model that related flow to the square root of the mean gradient allowed complete separation of stenotic from normal prosthetic valve function, after valve size was accounted for and normal confidence limits were established (r = 0.74 to 0.94, sizes 27 to 33, p less than 0.0001). The effective orifice area-flow relation did not provide accurate differentiation of abnormal from normal function. Thus, normal mitral bioprostheses have significant transvalvular gradients whose magnitude depends on flow. Risk of stenotic failure is increased in the smaller valves, which have a larger gradient at implantation. Differentiation of pathologic from physiologic stenosis cannot be made on the basis of a single value for gradient or effective orifice area. Accurate hemodynamic differentiation is achieved by relating mean gradient to mean diastolic flow rate and valve size. MH - *Bioprosthesis ; Comparative Study ; Diagnosis, Differential ; Diastole ; Heart Catheterization ; *Heart Valve Prosthesis ; *Hemodynamics ; Human ; Isoproterenol/PHARMACODYNAMICS ; Mitral Valve ; Mitral Valve Stenosis/ *DIAGNOSIS/ETIOLOGY ; Prospective Studies ; Prosthesis Failure ; Support, Non-U.S. Gov't ; Support, U.S. Gov't, P.H.S. SO - J Am Coll Cardiol 1986 Feb;7(2):284-94