A 22-year course of the Kay-Shiley disc valve with muscle guard at the mitral position

Almost 33 years have elapsed since the introduction of the Kay-Shiley disc valve in Japan. Following the developement of pyrolite carbon, the Kay-Shiley valve is no longer in clinical use. We report the case of a female patient who had had an isolated mitral valve replacement with the Kay-Shiley disc valve with single muscle guard 22 years previously. After numerous thromboembolic episodes with the Kay-Shiley disc valve, a successful reoperation was done with the CarboMedics valve. The explanted valve revealed that the grooved occluder disc had a loosely adherent clot The thromboembolism is a notorious complication associated with this valve. We recommend re-replacement of the Kay-Shiley valve whenever possible.     

A 22-year course of the Kay-Shiley disc valve with muscle guard at the mitral position.

Almost 33 years have elapsed since the introduction of the Kay-Shiley disc valve in Japan. Following the development of pyrolite carbon, the Kay-Shiley valve is no longer in clinical use. We report the case of a female patient who had had an isolated mitral valve replacement with the Kay-Shiley disc valve with single muscle guard 22 years previously. After numerous thromboembolic episodes with the Kay-Shiley disc valve, a successful reoperation was done with the CarboMedics valve. The explanted valve revealed that the grooved occluder disc had a loosely adherent clot. The thromboembolism is a notorious complication associated with this valve. We recommend re-replacement of the Kay-Shiley valve whenever possible.     

Twenty-year comparison of tissue and mechanical valve replacement

OBJECTIVE: We sought to compare outcomes with tissue and St Jude Medical mechanical valves over a 20-year period. METHODS: Valve-related events and overall survival were analyzed in 2533 patients 18 years of age or older undergoing initial aortic, mitral, or combined aortic and mitral (double) valve replacement with a tissue valve (Hancock, Carpentier-Edwards porcine, or Carpentier-Edwards pericardial) or a St Jude Medical mechanical valve. Total follow-up was 13,390 patient-years. There were 666 St Jude Medical aortic valve replacements, 723 tissue aortic valve replacements, 513 St Jude Medical mitral valve replacements, 402 tissue mitral valve replacements, 161 St Jude Medical double valve replacements, and 68 tissue double valve replacements. The mean age was 68 +/- 13.3 years (St Jude Medical valve, 64.5 +/- 12.9; tissue valve, 72.0 +/- 12.6). RESULTS: There were no overall differences in survival between tissue and mechanical valves. Multivariable analysis indicated that the type of valve did not affect survival. Analysis by age less than 65 years or 65 years or older and presence or absence of coronary disease revealed similar long-term survival in all subgroups. The risk of hemorrhage was lower in patients receiving tissue aortic valve replacements but was not significantly different in patients receiving mitral valve or double valve replacements. Thromboembolism rates were similar for tissue and mechanical valve recipients. However, reoperation rates were significantly higher in patients receiving both aortic and mitral tissue valves. The reoperation hazard increased progressively with time both in patients receiving aortic and in those receiving mitral tissue valves. Overall valve complications were initially higher with mechanical aortic valves but not with mechanical mitral valves. However, valve complication rates later crossed over, with higher rates in tissue valve recipients after 7 years in patients undergoing mitral valve replacement and 10 years in those undergoing aortic valve replacement. CONCLUSIONS: Tissue and mechanical valve recipients have similar survival over 20 years of follow-up. The primary tradeoff is an increased risk of hemorrhage in patients receiving mechanical aortic valve replacements and an increased risk of late reoperation in all patients receiving tissue valve replacements. The risk of tissue valve reoperation increases progressively with time.     

Mechanical valve thrombosis in the tricuspid position--reoperative management of 2 cases

Because valve thrombosis occurred after the tricuspid valve replacement with the mechanical valve, we performed replacement of the mechanical valve with the bovine pericardial valve in two cases. Case 1: The patient, at 13 years old, received open-heart surgery to correct infundibular stenosis. At 23 years of age, decortication and tricuspid valve replacement (TVR) with a phi 31 mm Bj?rk-Shiley valve were performed due to constrictive pericarditis and tricuspid regurgitation developed after the initial operation. Thrombosis of the mechanical valve occurred after the TVR. Treatment with urokinase for the thrombolytic therapy failed to improve the valve opening. Finally 12 years after the TVR, replacement of the mechanical valve with a phi 27 mm Carpentier-Edwards bovine pericardial valve was performed. Case 2: The patient, at 21 years old, received open-heart surgery to close an atrial septal defect. At 40 years of age, mitral and tricuspid valve replacements were performed because regurgitation developed in both valves. The mitral and tricuspid valves were replaced with phi 27 mm and 31 mm St. Jude Medical valves, respectively. Thrombosis of the mechanical valve used for the TVR occurred 2 months after the replacement. The mechanical valve was replaced with a phi 27 mm Carpentier-Edwards bovine pericardial valve. In both cases, subjective symptoms improved and prosthetic valve complications did not occur after re-replacement with the bovine pericardial valve. These cases suggested that for TVR a bovine pericardial valve of sufficient size would be better to select than a mechanical valve.     

Heart valve replacement with the Sorin tilting-disc prosthesis. A 10-year experience.

From 1978 to 1988, 697 patients with a mean age of 48 +/- 11 years (range 5 to 75 years) received a Sorin tilting-disc prosthesis; 358 had had aortic valve replacement, 247 mitral valve replacement, and 92 mitral and aortic valve replacement. Operative mortality rates were 7.8%, 11.3%, and 10.8%, respectively, in the three groups. Cumulative duration of follow-up is 1650 patient-years for aortic valve replacement (maximum follow-up 11.4 years), 963 patient-years for mitral valve replacement (maximum follow-up 9.9 years) and 328 patient-years for mitral and aortic valve replacement (maximum follow-up 9.4 years). Actuarial survival at 9 years is 72% +/- 4% after mitral valve replacement, 70% +/- 3% after aortic valve replacement, and 50% +/- 12% after mitral and aortic valve replacement, and actuarial freedom from valve-related deaths is 97% +/- 2% after mitral valve replacement, 92% +/- 2% after aortic valve replacement, and 62% +/- 15% after mitral and aortic valve replacement. Thromboembolic events occurred in 21 patients with aortic valve replacement (1.3% +/- 0.2%/pt-yr), in 12 with mitral valve replacement (1.2% +/- 0.3% pt-yr), and in seven with mitral and aortic valve replacement (2.1% +/- 0.8%), with one case of prosthetic thrombosis in each group; actuarial freedom from thromboembolism at 9 years is 92% +/- 3% after mitral valve replacement, 91% +/- 3% after aortic valve replacement, and 74% +/- 16% after mitral and aortic valve replacement. Anticoagulant-related hemorrhage was observed in 15 patients after aortic valve replacement (0.9% +/- 0.2%/pt-yr), in 9 after mitral valve replacement (0.9% +/- 0.3%/pt-yr), and in 6 with mitral and aortic valve replacement (0.9% +/- 0.5%/pt-yr); actuarial freedom from this complication at 9 years is 94% +/- 2% after aortic valve replacement, 91% +/- 4% after mitral valve replacement, and 68% +/- 16% after mitral and aortic valve replacement. Actuarial freedom from reoperation at 9 years is 97% +/- 2% after mitral and aortic valve replacement, 92% +/- 4% after mitral valve replacement, and 89% +/- 3% after aortic valve replacement, with no cases of mechanical fracture. The Sorin valve has shown a satisfactory long-term overall performance, comparable with other mechanical prostheses, and an excellent durability that renders it a reliable heart valve substitute for the mitral and aortic positions.     

Comparative analysis of long-term results with porcine-aortic, bovine pericardial and tilting disc valves

The three series with the first-generation valve prostheses were reviewed for long-term clinical evaluation in isolated aortic and mitral valve replacement. Hancock porcine xenograft was implanted in 71 patients from 1977 to 1979, ionescu-Shiley pericardial xenograft (standard model) in 271 patients from 1979 to 1983, and Bjork-Shiley tilting disc valve in 194 from 1978 to 1986. In aortic position, no any significant difference among three valve types could be demonstrated in the actuarial survival and freedom from thromboembolism and valve infection, while the actuarial freedom from valve dysfunction in lonescu-Shiley valve was significantly lower than that in other two valves. Bj?rk-Shiley valve in mitral position showed satisfactory clinical performance in terms of valve-related complications and survival in comparison with two types of bioprosthetic valves. In our conclusion at present time, Bj?rk-Shiley valve is suitable for the first choice of both aortic and mitral valve prostheses. In case of valve replacement with a bioprosthesis, however, porcine aortic valve is a better choice for aortic, and bovine pericardial valve likely for mitral replacement.     

Single‐session double valve replacement: TAVI+tricuspid valve‐in‐valve procedures

We describe a 70‐year‐old lady with rheumatic heart disease and a history of the mitral valve and tricuspid valve replacement, who underwent transcatheter aortic valve implantation and the tricuspid valve‐in‐valve procedure in a single session.     

A case of SAPIEN XT valve fallen into left ventricle during valve-in-valve transcatheter aortic valve implantation

Late transcatheter heart valve embolization is a rare but life-threatening complication of transcatheter aortic valve implantation. Surgical intervention is performed for most cases, but some cases were treated by valve-in-valve transcatheter aortic valve implantation. We describe a patient in whom a 29-mm Edwards SAPIEN XT valve migrated into the left ventricular outflow tract 41 days after the initial implantation. We tried to perform valve-in-valve transcatheter aortic valve implantation using a transfemoral approach. As soon as the second transcatheter heart valve touched the first implanted valve, it fell into the left ventricle. Immediate surgical intervention was required. The first valve was removed, and surgical aortic valve replacement was successfully performed. In conclusion, we should choose surgical aortic valve replacement for late transcatheter heart valve embolization. Even if we need to treat by catheter intervention, transapical approach may be better.     

Repair of traumatic rupture of the aortic valve.

Traumatic aortic valve rupture is a rare complication of nonpenetrating cardiac injury and can be caused by a tear or avulsion of the valve. The most common method of treatment has been valve replacement, although valve repair has been successful in a few cases of cusp tear or detachment. We report a case of aortic valve commissural avulsion in which a reparative technique was applied and the natural valve was preserved.     

Three‐Dimensional Computer‐Aided Design–Based Geometric Modeling of a New Trileaflet Aortic Valve

Our objective was to design a new trileaflet aortic valve using computer‐aided design (CAD). Quantification of aortic valve geometries is essential in understanding normal and pathological valvular function and eventually in the design of valves. We have designed a new tissue valve model to investigate its suitability in aortic valve replacement. Steps involved in three‐dimensional CAD‐based geometric modeling of a trileaflet aortic valve and the effects of different component dimensions on the mechanical behavior of valve are presented in this article. Conceptual designing of individual components was used to build the total geometric model. A new geometric model of a trileaflet aortic valve was designed. This may be of great interest to designers of new prosthetic heart valve models, as well as to surgeons involved in valve‐sparing surgery.     

Stentless porcine and pericardial valve in aortic position.

Fifty-seven patients underwent aortic valve replacement with a stentless glutaraldehyde-fixed bioprosthesis; 27 received a porcine aortic valve and 30 had a bovine pericardial valve. Two groups of 30 patients each who had aortic valve replacement with a tilting-disc mechanical valve or a stented porcine bioprosthesis served as controls. There were no differences in sex, body surface area, valve lesion, and valve size among the four groups. Results were assessed on a Doppler-based determination of maximum velocity across the valve, aortic valve area, and degree of valve regurgitation. Velocity across the valve was significantly less with stentless pericardial valves than with stentless porcine valves, stented bioprostheses, and mechanical valves. Stentless valves had a significantly larger aortic valve area when compared with stented valves. Mild central aortic insufficiency was detected more often with stentless pericardial than with stentless porcine bioprostheses (p = 0.04). Stentless valves showed a higher incidence of complete atrioventricular block when compared with stented valves (p = 0.04). Long-term studies are now warranted to assess the durability of both types of stentless valves.     

An evaluation study on the quietness of the ATS valve.

BACKGROUND: The closure sound of the ATS bileaflet mechanical valve is said to be quieter than that of the other mechanical valves. However, the reasons for this are still unknown. In this study, we investigated the reasons for the quietness of the ATS valve closure sound. PATIENTS AND METHODS: The valve closure sound was evaluated in 70 patients and in another 70 patients in whom the SJM valve had been used for single valve replacement, based on frequency analysis of the closure sound, measurement of the opening angle of the valve, cardiac function, and patient interviews. RESULTS: In the valve closure sound analysis, the mean peak frequency of the valve closure sound was 1.02 kHz for the ATS valve, and the mean pressure was 22.8+/-4.04 dB. The mean peak frequency of the closure sound of the SJM valve was1.02 kHz, with another intermittent peak at 3 to 9 kHz in the human audibility range. The mean sound pressure was 25.0+/-3.20 dB. The noise classification score was 2.07+/-1.95 points for the SJM valve, significantly higher as compared with that for the ATS valve which was 0.36+/-0.95 points. Multilateral examinations showed a significant difference in the mean opening angle between the ATS and the SJM valves: the angle was 76.6+/-4.67 degrees for the ATS valve and 82.3+/-2.05 degrees for the SJM valve. CONCLUSION: In view of the lower sound pressure in the human audibility range and lower patient awareness of the valve closure sound, the ATS valve would appear to be a superior mechanical valve when compared to the SJM valve from the point of view of the quality of life of the patients. The significant difference in the opening angle in patients with the ATS valve between those who were aware of the valve closure sound and those who were not suggested a possible association between the opening angle and the patient awareness of the valve closure sound.     

Repeat heart valve surgery: risk factors for operative mortality.

BACKGROUND: Patients undergoing repeat heart valve operations are a diverse population. We assessed risk factors for operative mortality in patients undergoing a first heart valve reoperation. METHODS: A retrospective review of hospital records was performed for 671 patients who underwent first repeat heart valve operations between 1969 and 1998. Univariable and multivariable analyses were performed. RESULTS: Operative mortality was 8.6%. Mortality fell each decade to 4.8% in the most recent period (adjusted chi(2) for linear trend P <.0005). Mortality increased from 3.0% for reoperation for a failed repair or reoperation at a new valve site to 10.6% for prosthetic valve dysfunction or periprosthetic leak and to 29.4% for endocarditis or valve thrombosis. Concomitant coronary artery bypass grafting was associated with a mortality of 15.4% compared with 8.2% when it was not required. Mortality for aortic valve replacement was 6.4%, mitral valve replacement 7.4%, aortic and mitral valve replacement 11.5%, tricuspid valve replacement 25.6%, periprosthetic leak repair 9.1%, and isolated valve repair 2.2%. Among 336 patients requiring replacement of prosthetic valves, mortality was 26.1% for replacement of a mechanical valve compared with 8.6% for replacement of a tissue valve (P <.0005). Multivariable analyses identified year of reoperation, age, coronary artery bypass grafting, indication, and replacement of a mechanical valve rather than a tissue valve as significant explanatory variables for operative mortality. CONCLUSIONS: Heart valve reoperations can be performed with an acceptable operative mortality. However, we have identified several categories of patients in whom reoperation carries an increased risk.     

Bacterial endocarditis of systemic atrioventricular valve (tricuspid valve) in corrected transposition and its surgical treatment.

We describe a case of congenitally corrected transposition of great arteries (CCTGA). Tricuspid valve replacement was performed due to valve dysfunction following bacterial endocarditis. After two weeks' antibiotic therapy haemodynamic stabilisation was obtained and the patient was operated in the third week. On cardiopulmonary bypass with 28 degrees C degree systemic hypothermia, the left atrium was approached transeptally. At exploration, the systemic atrioventricular valve was tricuspid valve and pulmonary atrioventricular valve was in shape of a mitral valve. The posterior leaflet of the tricuspid valve was ruptured and vegetations above it were observed. The valve was excised and a 29 mm St-Jude mechanical heart valve prosthesis implanted using a teflon reinforced separated suture technique. After operation the patient recovered rapidly and following six weeks' antibiotic therapy, the patient was discharged.     

Three-year clinical results with the Monostrut Bj?rk-Shiley prosthesis

Between November 1981 and June 1983, 351 patients underwent valve replacement with the Monostrut Bj?rk-Shiley prosthesis. There were 214 aortic valve replacements, 101 mitral valve replacements, and 31 double (aortic and mitral) valve replacements. Four patients had valve implanted in the tricuspid position, and one patient underwent exchange of a valved, extracardiac conduit. Mean age was 61 years (range 2 to 78) and 186 (53%) were male. Concomitant procedures were performed in 52 patients (15%) and 17 (5%) were emergency operations. Early mortality (4.3%) was related to New York Heart Association Functional Class IV, emergency operation, or the presence of a concomitant procedure. Follow-up was 100% and covered 870 patients-years (mean 2.6 years per operative survivor). Postmortem examination was performed in 38 (79%) of the 48 fatalities. Only one patient suffered a sudden, unexplained death. The 3 year survival rate (early mortality excluded) was 88.6% (aortic valve replacement 89.2%, mitral valve replacement 89.3%, and double valve replacement 82.5%). The 3 year freedom from thromboembolism in patients receiving anticoagulants was as follows: aortic valve replacement 97.5%, mitral valve replacement 92.8%, and double valve replacement 100%. There were no instances of valve thrombosis or fatal embolism. In contrast, there were two instances of aortic valve thrombosis among 34 patients having aortic valve replacement without anticoagulation. The 3 year freedom from valve failure (modified Stanford definition) was as follows: aortic valve replacement 96.0%, mitral valve replacement 93.9%, and double valve replacement 89.7%. There were no mechanical failures. In conclusion, the Monostrut Bj?rk-Shiley valve showed a low incidence of complications. There were no mechanical failures, no fatal emboli, and, when anticoagulants were administered, no valve thromboses.     

A case of aortic valve replacement with St. Jude Medical Regent valve (first implant in Japan).

The St. Jude Medical (SJM) Regent valve was developed as a new mechanical valve by improving the conventional SJM valve. The effective orifice area is wider than that of Hemodynamic Plus (HP) series. The efficacy of the new valve has been reported in Europe and the United States. On October 26, 2004, we first performed aortic valve replacement (AVR) with the SJM Regent valve for aortic valve stenosis in Japan. A 64-year-old female was admitted to our hospital with dyspnea on exertion. She was diagnosed with aortic valve stenosis. She underwent AVR with a 17 mm SJM Regent valve. According to the results of echocardiography conducted two months postoperatively, the peak pressure gradient of the prosthetic valve was 32.0 mmHg, the mean pressure gradient was 13.2 mmHg, and the effective orifice area index (EOAI) was 0.92 cm2/m2. Cinefluoroscopy showed the valve opening angle of 85 degrees indicating full opening. She was discharged 15 days after surgery without complications. As demonstrated by the present case, implantation of a 17 mm SJM Regent valve produced a satisfactory result reflected by lower pressure gradient and absence of patient-prosthetic mismatch. In the future, the new valve is expected to be the optimum mechanical valve for a narrow annulus.     

Long-term results of mechanical valves in aortic position and biological valves in mitral and tricuspid positions

The long-term results of patients undergoing aortic valve replacement (AVR) with a mechanical valve (AM), mitral valve replacement with a biological valve (MB), and tricuspid valve replacement (TVR) with a biological valve (TB) operated upon from 1977 to 1988 were retrospectively analysed. A total of 899 patients received 1117 valves (381 AM, 633 TB, 103 TB) with a follow-up 3778 patient-years and 4582 valve-years. A significant incidence of thromboembolism, hemorrhage, and endocarditis was not found among AVR, MVR, TVR, or multiple valve replacement. We found a significantly decreased incidence of survival rate in multiple valve replacement compared with AVR or MVR, and a significantly increased incidence of reoperation in MB compared with AM and TB. We use AM and TB in any adult patients as a first choice. However, we prefer a mechanical valve in the mitral position except in patients over 65 years old, who have a short life expectancy, in whom anticoagulation is thought to be difficult, and who desire a biological valve.     

Cardiac valve replacement with Wada-Cutter prosthesis

The Wada-Cutter cardiac valve prosthesis, a hingeless valve, was developed and used clinically in 106 patients in whom 42 aortic valve replacements, 48 mitral valve replacements, 5 tricuspid valve replacements, and 11 multiple valve replacements were done. A continuous knotless suture technique was invariably employed for fixation of the prosthesis regardless of the type of operation.     

Severe mitral regurgitation due to cardiac amyloidosis--a rare reason for ruptured chordae

Although cardiac amyloidosis is often associated with mitral valve disease due to amyloid deposits, severe mitral valve regurgitation in a patient with systemic amyloidosis is uncommon. We report a 38-year-old man with severe mitral valve regurgitation due to ruptured chordae. He underwent mitral valve repair and both leaflets of mitral valve appeared normal except for ruptured chordae. Postoperative histological results revealed the presence of the amyloid deposit in the mitral valve and ruptured chordae. The amyloid deposit might be a cause of ruptured chordae, which is a rare reason for mitral valve regurgitation in a patient with cardiac amyloidosis.     

How to perform a late explantation of a Sapien XT transcatheter aortic prosthesis

Starting as a therapeutically option for high-risk surgical patients with degenerative aortic valve stenosis, the transcatheter aortic valve implantation method is probably going to become the method of choice for this pathology also in younger and low-risk patients. As bioprosthesis are prone to degeneration, requiring a redo procedure, whenever a valve in valve procedure is contraindicated, a surgical valve replacement will become necessary. We describe a simple surgical method for explantation of a Sapien XT prosthesis that was implanted 7 years previously in a calcified aortic valve.