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PubMed1986

Long-term management of patients with cardiac valve prostheses.

Marked improvements have been achieved in the results of valve replacement due to recent developments in cardiac valve prostheses, surgical procedures, myocardial protection methods, and supportive techniques. Since 1974, the aortic valve has been replaced with mechanical valves and the mitral valve with biological valves at our institution. During a cumulative follow-up of 1024 patient-years after 306 valve replacements (126 AVR, 148 MVR and 32 AVR + MVR), the 10-year survival rates were 88% for AVR, 72.6% for MVR and 77.5% for AVR + MVR. The cardiac function of 90% of the survivors was evaluated as Class I or II according to NYHA Functional Classification. As for valve-related postoperative complications, thromboembolism was observed in 2.3%/pt-yr, hemorrhage in 0.5%/pt-yr, prosthetic valve endocarditis in 1.3%/pt-yr, perivalvular regurgitation in 1.3%/pt-yr and valve malfunction in 1.1%/pt-yr. Of the causes of late deaths, 62.5% were related to valve complications. Re-replacement of the prosthesis was necessary in 17 patients due to valve-related complications, and early death occurred in 1 (5.9%) of these 17. While cardiac valve replacement contributes to improvements in the quality of the patients' long-term postoperative life, currently employed artificial valves are still not ideal with regard to their materials and design, and re-replacement may become necessary in the late postoperative period. Therefore, in addition to selection of the appropriate valve prosthesis for different disorders and optimal prevention of valve-related complications, early diagnosis by non-invasive techniques and early treatment of these complications if they have occurred are of particular importance for the long-term management of patients following cardiac valve replacement.

Activities of Daily Living↗
PubMed1983

Cardiac valve replacement in systemic lupus erythematosus. A review.

Three cases of cardiac valve replacement for Libman-Sacks endocarditis and their long-term follow-up are described. From the review of the literature, an additional nine patients who required cardiac valve replacement are studied. Steroids probably increase the incidence of valve incompetence, but most patients presumably die of other associated organ involvement before undergoing a cardiac operation. Operation is indicated because of change in the intensity or character of the murmur, and a new murmur with resultant, resistant congestive cardiac failure. Both the aortic and mitral valves should be explored. Valve reconstruction in these young patients, with the expectation of avoiding prosthetic valve dysfunction and repeat operation, is not possible. Bioprosthetic valve replacement may be preferable, since it eliminates the need for anticoagulation during steroid treatment. Overall mortality was 25%.

Adolescent↗
PubMed2005

Depression predicts mortality following cardiac valve surgery.

BACKGROUND: Depression is associated with mortality in several cardiovascular populations, but has not been evaluated in patients undergoing cardiac valve surgery. Because identifying nonsurgical mediators of survival is important for accurate risk adjustment and the development of interventions to improve outcomes of care, we evaluated the hypothesis that depression predicts mortality following cardiac valve surgery. METHODS: This prospective cohort study enrolled 648 patients undergoing valve surgery at 14 Veteran Administration hospitals. A preoperative mental health inventory (MHI) depression screen was performed in all patients and patients were classified as depressed or not depressed using the standard MHI cutoff score of less than or equal to 52. Multivariable logistic regression was used to evaluate the association between depression and 6-month all-cause mortality, adjusting for other clinical risk variables. RESULTS: Overall, 29.2% (189/648) of the patients were depressed at baseline. Depressed patients were younger, more frequently had New York Heart Association class III/IV symptoms, and more likely required emergent surgery, preoperative intravenous nitroglycerin, or intraaortic balloon pump. Unadjusted 6-month mortality was 13.2% for depressed patients compared with 7.6% for nondepressed patients (p = 0.03). In multivariable analyses, depression remained significantly associated with mortality (odds ratio 1.90; 95% confidence interval 1.07 to 3.40, p = 0.03). These findings were consistent across subgroups of patients undergoing aortic valve replacement, mitral valve replacement and valve replacement without coronary artery bypass graft. CONCLUSIONS: Preoperative depression is an independent risk factor for mortality following cardiac valve surgery. Depression screening should be incorporated into preoperative risk stratification, and future studies are warranted to determine if preoperative or postoperative interventions to treat depression can improve outcomes.

Adult↗
PubMedDate not supplied

Effect of cryopreservation and HLA-DR matching on the cellular immunogenicity of human cardiac valve allografts.

The cellular immunogenicity of fresh and cryopreserved human cardiac valve leaflets was measured in a lymphocyte proliferation assay. One fresh leaflet and a cryopreserved leaflet derived from the same valve were cut into 2 mm diameter pieces and incubated with responder peripheral blood mononuclear cells, matched or mismatched for HLA-DR. The tritiated thymidine incorporation into the lymphocytes measured after 7 days, was expressed as stimulation index. Fresh, HLA-mismatched valve pieces induced high stimulation index in all cases (median 9, range 4 to 117). The cryopreservation procedure resulted in a significantly lower stimulation index (p = 0.002, Wilcoxon), with a median stimulation index of 2 (range 0 to 9). In the instances where HLA-DR matched combinations were studied, cryopreservation was also associated with lower stimulation index. HLA matching itself was able to reduce the stimulation index both with cryopreserved and fresh valve pieces as stimulator, resulting in a median stimulation index of 4 (range 2 to 117) for the HLA-DR-mismatched and 1 (range 0 to 5) for the matched lymphocytes (p = 0.006, Wilcoxon). In conclusion, human cardiac valves are able to stimulate immune competent cells in vitro, even after cryopreservation. The cellular allogeneic response in vitro could be an explanation for valve allograft degeneration observed in the clinic. Matching for HLA-DR may reduce these effects.

Cryopreservation↗
PubMed1998

Evidence for rejection of homograft cardiac valves in infants.

OBJECTIVE: Concern about the durability of small homograft cardiac valves has been expressed by surgeons, and evidence has been found that homograft valves evoke a recipient immune response. We reviewed our experience with homograft valves for evidence of rejection. METHODS: A search of our files revealed 11 homograft cardiac valves removed at reoperation and one at autopsy. Six valves were from adults, five were from infants, and one was from a 13-year-old child. Immunohistochemical studies with antibodies against smooth muscle actin, CD20, CD43, CD34, and CD68 were performed on the homografts containing inflammatory infiltrates. These valves happened to be the valves from the five infants. These five valves were also stained with Gram and Gomori's methenamine silver stains. RESULTS: The failed homografts from the adults and 13-year-old child showed leaflet calcification, fibrosis, and degeneration, but no inflammation. The valves from the infants all failed in less than 8 months. The valve leaflets were thickened, and the valve leaflets and aortic sleeves contained a hyperplastic intimal layer with numerous spindle cells positive for smooth muscle actin embedded in a glycosaminoglycan matrix. The homografts contained multiple foci of inflammation consisting of T lymphocytes (in all five infant valves) and B lymphocytes (in three of the five infant valves). Special stains for organisms were negative. CONCLUSIONS: Rapid failure plus lymphocytic infiltration in valve leaflets and aortic sleeves is consistent with rejection. The hyperplastic intima is similar to coronary arteries in transplant-associated vascular disease. Our observations are consistent with other reports of rapid failure of homograft valves in this age group.

Actins↗
PubMed1978

Pregnancy and its complications following cardiac valve prostheses.

Approximately 100 cases of pregnancy in women with cardiac valve prostheses have been reported in the world's medical literature. In most instances, the need for continuous anticoagulation therapy constituted a major concern in the obstetric management of these high-risk pregnancies, particularly since coumarin has been implicated as causing an increased frequency of fetal wastage or birth defects (or both). Of all women who received cardiac valve prostheses at the Mayo Clinic between 1965 and 1975, 23 conceived 40 times after the procedure. Fetal wastage was more than doubled in women receiving coumarin therapy at conception and during the first trimester, as compared with that in women not receiving coumarin therapy. Fetal wastage exceeded 80% in women with multiple-valve prostheses who received coumarin therapy throughout early pregnancy. There were no serious maternal sequelae in any of the women. One infant of a mother receiving anticoagulation therapy had mild nasal hypoplasia, but there were no other congenital anomalies in which coumarin had been previously implicated.

Abnormalities, Drug-Induced↗
PubMedDate not supplied

Management of a parturient with cardiac valve prosthesis.

The parturient with a cardiac valve prosthesis presents a twofold problem of management: (1) that of a rising cardiac workload in the presence of serious heart disease, and (2) that of chronic anticoagulant therapy. Pain relief, a shortened 2nd stage of labor, and avoidance of bearing-down efforts reduce stress. Vaginal delivery is preferred to cesarean section, and segmental lumbar extradural block is the optimal anesthetic method. Oxytocics must be used with caution and heparin is preferred to longacting oral anticoagulants.

Adult↗
PubMedDate not supplied

Cardiac valve assessment with MR imaging and 64-section multi-detector row CT.

A variety of noninvasive techniques are available to assess cardiac valve morphologic features and function, with echocardiography currently being the most widely used modality for this purpose. Technical advances in electrocardiographically gated multi-detector row computed tomography (CT) and magnetic resonance (MR) imaging allow the noninvasive visualization of the cardiac valves. At present, 64-section multi-detector row CT and MR imaging are commonly being used for comprehensive examination of the heart. Information about the cardiac valves is routinely provided by MR imaging of cardiac function or coronary CT angiography. Thus, the interpreting physician may have additional information available that can aid in making the diagnosis. Supplemental movie clips are available at http://radiographics.rsnajnls.org/cgi/content/full/26/6/1769/DC1.

Heart Valve Diseases↗
PubMed1999

Absence of cardiac valve dysfunction in obese patients treated with sibutramine.

OBJECTIVE: Serotonin-releasing agents prescribed as weight-loss medications have been implicated as a cause of acquired aortic and mitral valve abnormalities. Sibutramine hydrochloride (MERIDIA) is a serotonin and norepinephrine reuptake inhibitor with proven efficacy of weight reduction. The purpose of this study was to determine the incidence of cardiac valve disease in sibutraminetreated patients. RESEARCH METHODS AND PROCEDURES: Obese patients with type 2 diabetes mellitus enrolled in an ongoing double-blind, placebo-controlled, parallel-arm, 12-month study of sibutramine (followed by a 12-month open label extension) underwent transthoracic echocardiographic imaging and color Doppler interrogation for assessment of cardiac valve anatomy and function. RESULTS: A total of 210 patients were evaluated. Of these, 133 were receiving sibutramine (72 in the double-blind period), and 77 were receiving placebo. The mean+/-Standard Deviation age was 54+/-9 years, and the mean duration of treatment was 229+/-117 days (approximately 7.6 months). The prevalence of left-sided cardiac valve dysfunction was low and similar for the two treatment groups (sibutramine 3/133, or 2.3%; placebo 2/77, or 2.6%). All five cases were cases of aortic insufficiency; four were mild, one was severe (in a placebo patient). All three sibutramine cases were patients over age 50; two had a history of systemic hypertension. CONCLUSION: The prevalence of left-sided cardiac valve dysfunction was not higher than background in obese patients treated with sibutramine for an average of 7.6 months.

Adult↗
PubMed1993

Frequency and severity of intravascular hemolysis after left-sided cardiac valve replacement with Medtronic Hall and St. Jude Medical prostheses, and influence of prosthetic type, position, size and number.

Intravascular hemolysis occurs often in patients with mechanical heart valve prostheses, but in most cases is of mild degree and subclinical. The severity of hemolysis is reported to be related to the type, position and size of prostheses used, as well as the presence of valve malfunction. Hemolysis was evaluated in 170 patients with St. Jude Medical (SJM) and 80 patients with Medtronic Hall (MH) prostheses, with normal mechanical function. The presence and severity of hemolysis was assessed on the basis of serum lactic dehydrogenase, serum haptoglobin, blood hemoglobin and reticulocyte levels as well as the presence of schistocytes. Overall, patients with SJM prostheses had greater frequency (51.2 vs 18.7%, p < 0.005) and severity (p < 0.005) of hemolysis than patients with MH prostheses, irrespective of position and size. No patient had decompensated anemia. The frequency of hemolysis was similar in both groups with double-valve replacement, whereas severity was greater with SJM than MH prostheses (p < 0.001). The number and position of the prostheses were correlated with severity of hemolysis: Double-valve replacement and mitral position were correlated with greater hemolysis than single-valve replacement (p < 0.01) and aortic position (p < 0.01). Valve size, cardiac rhythm and time from operation did not correlate either with frequency or severity of hemolysis. It is concluded that in normally functioning SJM and MH prostheses: (1) hemolysis is frequent but never severe; (2) SJM demonstrates greater frequency and severity when compared with MH valve; and (3) number, position, but not size, significantly affect the severity of hemolysis.

Adult↗
PubMed2006

Quantitative evaluation of sphingolipids using delayed extraction matrix-assisted laser desorption ionization time-of-flight mass spectrometry with sphingosylphosphorylcholine as an internal standard. Practical application to cardiac valves from a patient with Fabry disease.

Fabry disease is a glycolipid storage disorder caused by a defect of alpha-galactosidase A, and characterized by the systemic deposition of glycosphingolipids with terminal alpha-galactosyl moieties, mainly globotriaosylceramide, in tissues. Using delayed extraction matrix-assisted laser desorption ionization time-of-flight mass spectrometry (DE MALDI-TOF-MS), we analyzed the sphingolipids in the cardiac valves from a 49-year-old male patient with Fabry disease who suffered from congestive cardiac failure. Crude lipids were extracted from the cardiac valves with chloroform and methanol. After mild alkaline treatment of the crude lipids, a sphingolipid fraction was prepared and analyzed by DE MALDI-TOF-MS. The results were as follows: (a) ion peaks with m/z values corresponding to different ceramide trihexoside (CTH) species were detected; (b) with sphingosylphosphorylcholine (SPC) as the internal standard for semi-quantification of CTH, the relative peak height of CTH was calculated and plotted versus its amount loaded on the sample plate for MALDI-TOF-MS. The relative peak height of CTH with fatty acid C16:0 showed linearity between 0 and 50 ng CTH (regression coefficient, r>0.95); (c) semi-quantitative analysis revealed striking accumulation of CTH in the cardiac valves from the patient with Fabry disease. It was indicated that the accumulation of CTH in cardiac valves from Fabry disease patients can be detected with the DE MALDI-TOF-MS method. SPC is commercially available, and this semi-quantitative method involving MALDI-TOF-MS was found to be convenient, reliable and useful for CTH. It is expected to be applied to the quantification of CTH in small amounts of body fluids or other tissues and to clinical examination. It is also expected to be applicable to the quantification of other glycosphingolipids.

Chromatography, Thin Layer↗
PubMed1998

Cardiac valve endothelial cells: relevance in the long-term function of biologic valve prostheses.

OBJECTIVE: For reasons that are still unclear, biologic heart valve prostheses undergo degeneration after implantation. We studied the possible role of the immune system in this process. METHODS: We examined the expression of immunologically relevant molecules by human cardiac valve endothelium in situ and in vitro and studied re-endothelialization of implanted allogeneic and xenogeneic valvular surfaces using explanted bioprostheses and valves obtained from donor hearts at cardiac retransplantation. RESULTS: We demonstrate that human cardiac valve endothelial cells express molecules capable of initiating immune responses and might therefore play a role in the degeneration of viable cardiac valve prostheses. Also, we show evidence of re-endothelialization on the surfaces of xenografts and allografts but not on valves obtained from previously transplanted hearts. CONCLUSION: Inasmuch as valves from previously transplanted hearts seem to be free from degeneration, we conclude that reduction of the immunogenicity of allograft valve prostheses by HLA matching or immunosuppressive treatment might further improve long-term results after allograft valve replacement.

Antigens, CD↗
PubMed1979

Cardiac valve replacement (1963-1979).

A 15-year experience (from 1963-1978) in cardiac valve replacements with mechanical prosthetic valves (caged ball or tilting disc types) and with bioprostheses (porcine xenografts) is reported. The actuarial survival rates for patients who received the caged ball type prostheses (Starr-Edwards) were 42% and 36% respectively for mitral valve-replacements at 12 and 14 years. The actuarial survival rate for patients who received the tilting disc type prostheses (Björk-Shiley type and later the Lillehei-Kaster type) was 74% at six to seven years. The actuarial survival rate for patients who had aortic valve replacement with a caged ball valve was 43% at 14 years, and for those who had a tilting disc valve it was 80% at six to seven years. Multiple valve replacements were carried out with combinations of prostheses. The actuarial survival rate for patients was 65% for triple valves, and 57% for double valves at 13 years. Bioprostheses are now our first choice as cardiac valve replacements. In 121 implants performed since 1977, there have been two operative deaths, but no late deaths. Bioprostheses, although less thrombogenic than mechanical valve prostheses, are less durable and some risk of thromboembolism remains.

Adolescent↗