Acquired Valve Disease Research Articles

Diagnosis and Management of Pediatric Heart Failure.

Heart failure is a highly morbid syndrome, recognized as a major cause of adult mortality. Heart failure in pediatric patients, whether in the setting of congenital or acquired heart disease, is similarly associated with high mortality and resource utilization. Understanding the clinical presentation, diagnosis, and initial stabilization of pediatric heart failure is paramount for any acute care clinician as it may mimic common childhood ailments like viral respiratory or gastrointestinal illnesses. Pediatric heart failure occurs in patients with palliated or unpalliated congenital heart disease, familial or acquired cardiomyopathy, acquired valve disease, and myocarditis. This review will focus on heart failure in pediatric patients with structurally normal hearts and will summarize what is known about patterns of presentation, etiologies, diagnostic evaluation, and the acute and chronic management of this highly morbid syndrome.

Aortenklappe: wann konservativ, wann operativ, wann interventionell?

Aortic valve disease, especially aortic valve stenosis, is one of the most common acquired valve diseases and is associated with increased mortality and morbidity. Due to the rising age of the population, the prevalence of aortic valve stenosis has increased sharply in recent years. For many years, surgical aortic valve replacement was the only available therapy beside the conservative approach. With the implantation of the first catheter-based valve prosthesis in 2002, the era of transcatheter aortic valve implantation began. While this therapy was initially limited to inoperable and high-risk patients, the indication has been increasingly extended to younger patients with lower surgical risk over the past years. However, choosing the optimal therapy modality and determining the ideal timing of treatment can often be challenging in clinical practice. The aim of this article is to provide an overview of the different therapy modalities, the decision-making process and current therapy guidelines.

Prox1+ Endothelial Cells in Heart Valve Development and Homeostasis

Heart valve malformations are commonly found in congenital heart defects and acquired valve disease affects 2.5% of the U.S. population. As blood circulates through the heart, the valves are subjected to fluid forces that potentially dictate the gene expression profile of their surface endothelial cells with implications for valve development and disease. Recently, three distinct valve endothelial cell (VEC) subpopulations were found to be localized to regions of unique blood flow patterns. However, the role of these subpopulations in heart valve development and disease is largely unknown. Prox1, an oscillatory shear stress (OSS)-sensitive regulator of lymphatic valves, is highly expressed in a VEC subpopulation exposed to OSS. In mouse heart valves, Prox1 is restricted to VECs on the fibrosa side of the aortic valve leaflet starting at embryonic day (E)12.5 and is maintained in adults. However, in myxomatous valve disease, commonly characterized by enlarged mitral and aortic valves and abnormal blood flow, Prox1 expression is expanded to both sides of the valve leaflets. Therefore, we hypothesize that Prox1 regulates heart valve leaflet elongation and size in response to blood flow. To determine the role of Prox1 in heart valves, we are analyzing heart valve morphogenesis and homeostasis in mice with embryonic VEC-specific Prox1 loss-of-function (Prox1 cKO). Preliminary studies using 3D reconstructions of Prox1 cKO hearts suggests that embryonic loss of Prox1 results in abnormal valve leaflets postnatally which become myxomatous in adulthood. Together, these data indicate an important role for Prox1 in heart valve development and disease.

Italian Cardiological Guidelines (COCIS) for Competitive Sport Eligibility in athletes with heart disease: update 2020.

Since 1989, SIC Sport and a FMSI, in partnership with leading Italian Cardiological Scientific Associations (ANCE, ANMCO and SIC) have produced Cardiological Guidelines for Completive Sports Eligibility for athletes with heart disease (COCIS -- 1989, 1995, 2003, 2009 and 2017). The English version of the Italian Cardiological Guidelines for Competitive Sports Eligibility for athletes with heart disease was published in 2013 in this Journal. This publication is an update with respect to the document previously published in English in 2013. It includes the principal innovations that have emerged over recent years, and is divided into five main chapters: arrhythmias, ion channel disorders, congenital heart diseases, acquired valve diseases, cardiomyopathies, myocarditis and pericarditis and ischemic heart disease. Wherever no new data have been introduced with respect to the 2013 publication, please refer to the previous version. This document is intended to complement recent European and American guidelines but an important difference should be noted. The European and American guidelines indicate good practice for people engaging in physical activity at various levels, not only at the competitive level. In contrast, the COCIS guidelines refer specifically to competitive athletes in various sports including those with high cardiovascular stress. This explains why Italian guidelines are more restrictive than European and USA ones. COCIS guidelines address 'sports doctors' who, in Italy, must certify fitness to participate in competitive sports. In Italy, this certificate is essential for participating in any competition.

Ce qu'un réanimateur doit savoir des TAVI

Le rétrécissement aortique est la valvulopathie acquise la plus fréquente. Quand il devient serré et symptomatique, la mortalité à 2 ans est proche de 80% en l’absence de prise en charge. Le traitement repose sur le remplacement valvulaire, historiquement réalisé par voie chirurgicale. L’avènement des procédures percutanées par cathétérisme cardiaque TAVI (Trans-catheter Aortic Valve Implantation) a tout d’abord permis de traiterdes patients jugés inopérables, puis avec l’avancée des connaissances cette procédure s’est étendue aux populations à risque chirurgicale élevépuis intermédiaire, et a même été validée chez les patients à bas risque aux Etats-Unis suite à de grandes études multicentriques. Le principe consiste à implanter une bioprothèse aortique suturée sur un stent directement au sein de la valve native calcifiée, soit par un procédé de dilatation au ballonnet, soit par un procédé auto-expansé. Le TAVI présente l’avantage d’une procédure peu invasive, le plus souvent réalisée sous anesthésie locale et sédation, et une durée de séjour courte. La récupération fonctionnelle est plus rapide qu’après chirurgie cardiaque conventionnelle.Un autre avantage par rapport à la chirurgie cardiaque conventionnelle est un moindre taux de complications graves (choc cardiogénique, saignement majeure, accident vasculaire cérébrale, insuffisance rénale, décès toute cause). En revanche certaines complications sont plus spécifiques du TAVI comme l’apparition d’un trouble conduction de haut degré nécessitant la pose d’un pacemaker, et l’existence de complications vasculaires. La surveillance en soins intensifs en découlant est donc plus courte qu’après chirurgie et doit probablement être personnalisée selon le risque du patient.
 L’utilisation du TAVI chez les sujets à risque et/ou âgés semble parfaitement implanté en France. L’extension des indications à des sujets à bas risque et plus jeunes n’est pas encore autorisée en France et en Europe. L’étude de la durabilité des bioprothèses implantées par voie percutanée à long terme nécessite des investigations supplémentaires.

Katetrizační implantace aortální chlopně - co víme v roce 2020

stenosis is the most common acquired valve disease in adults and the prevalence of this disease is increasing with the aging population. Transcatheter aortic valve implantation (TAVI) became fully established method for treating this disease. The aim of this review is to present the current view of the performance technique, to summarize the data on the outcome of patients from recently published randomized studies and registries and to simply describe patient care after the procedure.

Mechanisms of heart valve development and disease.

The valves of the heart are crucial for ensuring that blood flows in one direction from the heart, through the lungs and back to the rest of the body. Heart valve development is regulated by complex interactions between different cardiac cell types and is subject to blood flow-driven forces. Recent work has begun to elucidate the important roles of developmental pathways, valve cell heterogeneity and hemodynamics in determining the structure and function of developing valves. Furthermore, this work has revealed that many key genetic pathways involved in cardiac valve development are also implicated in diseased valves. Here, we review recent discoveries that have furthered our understanding of the molecular, cellular and mechanosensitive mechanisms of valve development, and highlight new insights into congenital and acquired valve disease.

New developments in transcatheter therapy of mitral valve disease.

Mitral valve regurgitation (MR) belongs to one of the most common acquired valve diseases in western countries with increasing prevalence in older age. For patients with high perioperative risk and older age prohibitive for valve surgery, the development of transcatheter mitral valve therapies offers new options. Assessment of the severity and etiology of MR and thorough imaging of the mitral valve anatomy and pathology are necessary prerequisites for appropriate decision making in the field of transcatheter mitral valve therapies. Different transcatheter repair and replacement techniques are on the market, most of them mimicking surgical techniques. With some techniques (e.g., the MitraClip device), there is good clinical experience (>80,000 devices implanted worldwide), and evidence (three randomized studies), whereas for newer procedures, safety and efficacy data are still very limited. Transcatheter mitral repair and replacement techniques have to be considered as complementary treatment options for high-risk patients indicated by the Heart Teams. The different techniques and devices will be introduced and discussed in the following paper.

Partial anomalous pulmonary venous connection with acquired valve disease

We describe the rare case of a 76-year-old man with left partial anomalous pulmonary venous connection with intact atrial septum. He experienced dyspnea due to significant aortic stenosis and mitral regurgitation, and required valve repair. Preoperative computed tomography revealed connection of the left upper pulmonary vein to the innominate vein. Although right heart overload was not recognized, we repaired the left partial anomalous pulmonary venous connection with concomitant aortic valve replacement and mitral annuloplasty, because of the potential for unpredictable harmful effects of a residual left-to-right shunt. The patient recovered well with no signs of left upper lung congestion.

Etiology of valvular heart disease-genetic and developmental origins.

Valvular heart disease occurs as either a congenital or acquired condition and advances in medical care have resulted in valve disease becoming increasingly prevalent. Unfortunately, treatments remain inadequate because of our limited understanding of the genetic and molecular etiology of diseases affecting the heart valves. Therefore, surgical repair or replacement remains the most effective option, which comes with additional complications and no guarantee of life-long success. Over the past decade, there have been significant advances in our understanding of cardiac valve development and, not surprisingly, mutations in these developmental genes have been identified in humans with congenital valve malformations. Concurrently, there has been a greater realization that acquired valve disease is not simply a degenerative process. Molecular investigation of acquired valve disease has identified that numerous signaling pathways critical for normal valve development are re-expressed in diseased valves. This review will discuss recent advances in our understanding of the development of the heart valves, as well as the implications of these findings on the genetics of congenital and acquired valvular heart disease.

Transkatheteraortenklappenersatz (TAVI)

Aortic valve stenosis (AS) is the most common acquired valve disease in the industrialized countries. Most patients--especially young and low-risk patients--can be safely and effectively operated with aortic valve replacement. Due to increasing life expectancy, however, the number of elderly patients with AS and various concomitant diseases will increase in the coming decades. For those elderly high-risk patients, transfemoral or transapical aortic valve implantation (TAVI) has evolved as a valuable alternative to conventional surgery. The TAVI approach has been shown to be superior to standard medical treatment in these high-risk patients. All patients considered for TAVI should be discussed in a consensus conference consisting of cardiac surgeons and cardiologists (heart team). Furthermore, for successful treatment with transcatheter techniques, sophisticated pre-interventional imaging is required to screen patients. Available data on TAVI from randomized trials and large-scale registries demonstrate that this method is very promising.

Perioperative results of mechanical valve implantantation in patients with acquired valve disease

Methods 1500 patients underwent mechanical valve replacement. The analysis included 960 after aortic (AVR), 455 mitral (MVR) valve surgery. Mean age in AVR was 58.7 ± 13.0 years and 59.4 ± 9.0 years in MVR. Over 70 years of life in AVR was 22% and 13% in MVR. Results After mechanical aortic valve perioperative mortality was 1.95% (stenosis - 1.9%, insufficiency - 2.4%) and after mechanical mitral valve was 1.97% (stenosis - 1.6%, insufficiency- 2.75%). Mortality in the age groups 70 years amounted for mechanical aortic valve 1.6%, 1.0%, 1.7% and 3.2% and for mechanical mitral valve 1, 8%, 2.8%, 1.8% and 0% respectively. In patients with aortic stenosis greatest mortality was observed after 70 years (3.0%), similarly in aortic regurgitation (> 70 years - 8.3%). In patients with mitral stenosis greatest mortality was observed in the group <50 years (2.9%) and in the case of regurgitation greatest mortality was observed in group aged 5060 years (6.6%). Risk factor for mortality in patients undergoing implantation of a mechanical aortic valve was age, severity of symptoms (NYHA), and chronic lung disease, and mechanical mitral valve - symptoms (NYHA) and chronic heart failure. Conclusions Implantation of artificial aortic or mitral valve is associated with a low risk of perioperative death. In the case of the aortic valve mortality mainly grows with the age of the patient and in the case of the mitral valve depends on the development and severity of symptoms of cardiac failure.

Analysis of Osteopontin Levels for the Identification of Asymptomatic Patients With Calcific Aortic Valve Disease

Calcific aortic valve disease (CAVD) is the most common cause of acquired valve disease. Initial phases of CAVD include thickening of the cusps, whereas advanced stages are associated with biomineralization and reduction of the aortic valve area. These conditions are known as aortic valve sclerosis (AVSc) and aortic valve stenosis (AVS), respectively. Because of its asymptomatic presentation, little is known about the molecular determinants of AVSc. The aim of this study was to correlate plasma and tissue osteopontin (OPN) levels with echocardiographic evaluation for the identification of asymptomatic patients at risk for CAVD. In addition, our aim was to analyze the differential expression and biological function of OPN splicing variants as biomarkers of early and late stages of CAVD. From January 2010 to February 2011, 310 patients were enrolled in the study. Patients were divided into 3 groups based on transesophageal echocardiographic (TEE) evaluation: controls (56 patients), AVSc (90 patients), and AVS (164 patients). Plasma and tissue OPN levels were measured by immunohistochemical evaluation, enzyme-linked immunosorbent assay (ELISA), and real-time quantitative polymerase chain reaction (qPCR). Patients with AVSc and AVS have higher OPN levels compared with controls. OPN levels are elevated in asymptomatic patients with AVSc with no appearance of calcification during TEE evaluation. OPN splicing variants OPN-a, OPN-b, and OPN-c are differentially expressed during CAVD progression and are able to inhibit biomineralization in a cell-based biomineralization assay. The analysis of the differential expression of OPN splicing variants during CAVD may help in developing diagnostic and risk stratification tools to follow the progression of asymptomatic aortic valve degeneration.

Neuroprotection in cardiosurgery

Acute stroke is one of the most important complications of corоnary artery bypass grafting surgery (CABG) and valve replacement in the setting of assisted circulation. Therefore the cerebral protection becomes the crucial part of preoperative care. We performed prospective randomized controlled trial to estimate the efficacy of cytoflavin in 103 patients (94 men, 9 women) with ischemic heart disease (ICD) and acquired valve disease who undergone CABG and valve replacement surgery. The patients were divided into 4 groups. Group 1 (main) consisted of 32 patients with ICD (mean age 55.7±7.9 years) who underwent CABG and received 20 ml of cytoflavin i.v. in 3 consecutive days before and 3 days after surgery. Group 2 (control) included 40 patients with ICD (mean age 48.2±12.6 years) and CABG without cytoflavin. Thirteen patients with valve disease (mean age 53.1±8.4 years) were randomized in Group 3 (main); they underwent valve replacement and were treated with cytoflavin using the same regimen (20 ml i.v. in 3 days before and 3 days after surgery). Group 4 (control) was comprised of 18 patients with valve disease (mean age 48.2±12.0 years) and surgery without cerebral protection with cytoflavin. One month after the intervention significant improvement (p<0.05) was observed in Group 1 vs. Group 2 in the dynamic modality of cognitive performance, recent memory and long-term memory, and clear trend to improvement in the same variables in Group 3 vs. Group 4. Moreover, in Group 2 (CABG without treatment) significant deterioration was observed in long-term memory (p=0.028), along with the distinct trend towards worsening in Group 4 in recent and long-term memory. As an effective antioxidant, cytoflavin renders reliable neuroprotective effect in patients whо underwent CABG in the setting of assisted circulation and improves cognitive functioning and emotional well-being. Cytoflavin ameliorates absolute characteristics of long-term and recent memory in patients after valve replacement surgery. Cytoflavin improves absolute parameters of cognitive evoked potentials (P300) decreasing the latency and increasing the amplitude in patients after CABG and valve replacement. Cytoflavin is recommended for use in patients with ICD and acquired valve disease who underwent CABG and valve replacement in the setting of assisted circulation.

Operative Risk and Outcome of Surgery in Adults With Congenital Valve Disease

To define risk and outcome of surgery in adults with congenital valve disease (CVD), experience between 2002 and 2005 with 371 CVD operations (288 males, aged 56 +/- 9 years) was compared with 2102 for acquired valve disease (AVD) (69 +/- 22 years, p = 0.02). Diagnosis included: bicuspid aortic valve (BAV), 337, s/p ToF repair, 11; atrio-ventricular valve dysfunction, 10; other, 13. Associated lesions were present in 259 patients (70% vs. 17%, p = 0.001): ascending aorta, 205; right ventricular outflow tract obstruction, 40; coronary artery, 34; mitral/tricuspid valve, 27; septal defect, 17; subaortic stenosis, 4; aortic arch, 4; other, 3. Fifty-two patients (14% vs. 2.5% AVD, p = 0.001) had undergone 75 prior operations (1.4/patient) and 14 (3.8% vs. 1.9% AVD, p = 0.04) required urgent/emergent surgery (endocarditis, dissection). Valve repair was done in 36 (10% vs. 3% AVD, p = 0.02) and replacement in 335: stentless solution (native, autograft, xenograft) was offered to 101 (29%) patients. In BAV, partial root replacement was associated in 63, complete in 77 and ascending aorta in 92. Three (0.8%) hospital deaths occurred (vs. 1.9% AVD, p = 0.2) due to endocarditis. Twenty-six patients (7.0% vs. 10.8% AVD, p = 0.003) experienced complications (cardiac, 7; neurologic, 6; respiratory, 5; renal, 3; sepsis/multiple organ failure (MOF), 2; hemorrhage, 8). Urgent/emergent surgery predicted hospital mortality (p = 0.001). During 5-year follow-up (average 2.6 +/- 1.8 years), there was one late cardiac death and three reoperations (98% free). Despite higher prevalence of associated procedures, reoperation and emergent indication, operative risk in CVD is lower than in AVD, possibly because of younger age. Stentless valve surgery, allowing normal life-style (e.g., exercise, pregnancy), is increasingly preferred.

Aortic valve-sparing repair with autologous pericardial leaflet extension has a greater early re-operation rate in congenital versus acquired valve disease☆

We sought to establish whether there was a difference in outcome after aortic valve repair with autologous pericardial leaflet extension in acquired versus congenital valvular disease. One hundred and twenty-eight patients underwent reparative aortic valve surgery at our institution from 1997 through 2005 for acquired or congenital aortic valve disease. The acquired group (43/128) (34%) had a mean age of 56.4+/-20.3 years (range, 7.8-84.6 years) and the congenital group (85/128) (66%) had a mean age of 16.9+/-19.2 years (range, 0.3-82 years). The endpoints of the study were mortality and reoperation rates. Thirty-day mortality was 0/43 (0%) in the congenital group and 1/85 (1.1%) in the acquired group. Late mortality in the acquired group was 3/43 (7%) and 3/84 (3.5%) in the congenital group (neither early nor late proportion of mortality is significantly different between the two groups, according to the nonparametric Binomial test for proportions). There were 13 total reoperations among 11 patients: 1/43 (2.3%) in the acquired group and 10/85 (11.7%) in the congenital group (p=0.07). Two patients from the congenital group were reoperated on twice. The mean interval between original repair and reoperation was 3.6+/-5 years (range, 0-7 years) for acquired and 3.5+/-2.5 years (range, 0-7 years) for the congenital group (Wilcoxon 2-sample test, p=0.7). Total early reoperation rate (<30 days after first surgery) was 11/128 (8.5%); for the congenital group 9/85 (10.5%) and for the acquired group 2/43 (4.6%). Early reoperation rate was significantly higher among the congenital group (p=0.013). The remaining patients are well at mean follow-up of 2.8+/-2.4 years (range 0-7.9). In the acquired group, the mean postoperative aortic regurgitation and stenosis grade by echocardiography was 0.5+/-0.3 (scale, 0-4) and 0.3+/-0.1, respectively. In the congenital group, the follow-up, mean aortic regurgitation and stenosis were 0.9+/-0.8 and 0.5+/-0.3, respectively. There was no significant difference in early or late mortality and late reoperation rate between the two groups. Early reoperation rate was higher in the congenital versus the acquired aortic valvular disease group. This study supports the fact that the valve-sparing technique is safe and reproducible and repeatable in patients with acquired valve disease.

THE RELEVANCE OF BRAIN NATRIURETIC PEPTIDES INVESTIGATION IN VARIOUS CARDIOVASCULAR DISEASES

Brain natriuretic peptides are relevant markers of heart impairment. We investigated the relevance of investiging brain natriuretic peptides (NT-proBNP, BNP) in monitoring different types of cardiovascular disease (chronic heart failure due to coronary artery disease, cardiomyopathy, acquired valve disease, congenital heart diseases). The NT-proBNP assay (Roche) was performed on 280 patients (mean age 49 years; range 20-89 years) and 48 healthy controls (mean age 43 years; range 13-65 years) and BNP assay (Bayer Shionoria) was performed in a subgroup of 42 patients (mean age 50 years; range 20-79 years). Patients were divided into four groups characterized by severity of heart failure according to the New York Heart Association classification. NT-proBNP concentrations differed in patients with cardiovascular diseases from controls (median 371 ng/l versus 41.5 ng/l, p < 0.0001). The cut off value of NT-proBNP determined in 280 patients with cardiovascular diseases was at 130 ng/l (AUC-area under curve = 0.93; sensitivity 98 %; specificity 79 %). Comparison of NT-proBNP and BNP values in patients showed significant correlation (r = 0.93; p < 0.0001). NT-proBNP showed significant differences between groups. Measurement of brain natriuretic peptides is useful and relevant in various types of heart diseases including congenital.

NT-proBNP AND BNP VALUES IN CARDIAC PATIENTS WITH DIFFERENT DEGREE OF LEFT VENTRICULAR SYSTOLIC DYSFUNCTION

We investigated the performance of brain natriuretic peptides (BNP and NT-proBNP) in detecting various degrees of left ventricular systolic dysfunction. The NT-proBNP assay (Roche) and the BNP assay (Bayer Shionoria) were performed in 46 patients (mean age 50 years; range 20-79 years) with various types of heart disease (chronic heart failure due to coronary artery disease, cardiomyopathy, acquired valve disease, congenital heart diseases) and different impairment of left ventricular systolic dysfunction was assessed by echocardiography. Patients were divided into four groups according to the left ventricular ejection fraction (LVEF) correlated with clinical severity. Significant differences in medians of NT-proBNP and BNP values between all groups were determined (P= 0.0161 for NT-proBNP and P=0.0180 for BNP). For identifying patients with severe systolic dysfunction (LVEF<40%), receiver operating characteristic (ROC) analysis for both BNP and NT-proBNP was performed. The diagnostic performances expressed as areas under the curve were of 0.69 for NT-proBNP (cut off value 367 pg/ml) and 0.60 for BNP (cut off value 172 pg/ml). However, the BNP showed higher sensitivity (85 % vs. 63 %) and a higher positive predictive value (69 % vs 55 %) than the NT-proBNP. The negative predictive values of BNP and NT-proBNP were similar (70 % and 71 % respectively). Brain natriuretic peptides are promising markers for the diagnosis of severe left ventricular systolic dysfunction.

Avaliação inicial de homoenxertos em posição pulmonar em crianças e adolescentes

Objective: Heart valve homografts - fresh or cryopreserved - are a good valvular substitute in infants and teenagers as they need no anticoagulation, have a higher resistance to infection and present a good hemodynamic performance. The objective of this report was to evaluate the initial postoperative results on pediatric subjects after homograft implant in pulmonary position. Methods: Fourteen homografts were implanted in pulmonary position from September, 1995 to December, 1997. Four of them were fresh (28.6%) and ten were cryopreserved (71.4%). Subjects ranged in age from 10 months to 17 years with 9 (64%) males and 5 (36%) females . The subjects were divided into two groups, as follows: A - aortic valve disease (Ross operation) and B - congenital heart disease. The diameter of the homografts ranged from 16 to 26 mm. The cardiopulmonary-bypass time ranged from 74 to 303 minutes and the aortic-occlusion time between 49 to 160 minutos. Results: A hospital death occurred. All the survivors were clinically, radiologically, electrocardiographycally and echocardiographycally monitored. There were 13 NYHA I patients and one NYHA II patients. The most common complications were low output syndrome, pericardial effusion and EKG abnormalities. All these ocurred in two patient but with a favorable outcome. Stenosis of the right ventricular outflow track was observed early on in two subjects with gradients of 44 and 23 mmHg. One of the pulmonary homografts was submitted to a successful balloon valvuloplasty due to a severe stenosis. The rheumatic patients are still receiving antibiotic therapy and without recurrence of the disease. Conclusion: Evaluation of the hemodynamics of the homografts, in pulmonary position, was satisfactory. One of the subjects has presented marked stenosis but, after a balloon valvuloplasty, his gradient decreased. Another patient has kept his preoperative NYHA classification. We believe was not correlated with the homograft (coagulation disorder). It's our belief that fresh and cryopreserved homografts are a satisfactory solution for the correction of congenital or acquired valve disease in infants and adolescents.

Rhythm disturbances after mitral valve surgery: comparison between left atrial and extended trans-septal approach

This study was undertaken to determine the incidence of postoperative arrhythmias in mitral valve surgery through the left atrium as compared with the extended trans-septal approach. All patients undergoing mitral valve surgery for acquired valve disease between 1 January 1991 and 31 December 1993 were reviewed. Only patients with preoperative normal sinus rhythm were included in this study. End-points for analysis were: ‘any supraventricular arrhythmia’; ‘atrial fibrillation or flutter’; and ‘ectopic atrial or junctional rhythm’. All predictive factors with a P-value <0.10 in univariate analysis were entered into the multivariate proportional hazard model of Cox. Some 72 patients were included for analysis. No variables were independently predictive of ‘any supraventricular arrhythmia’. Age is an independent predictor of ‘atrial fibrillation or flutter’ and surgical approach of ‘ectopic atrial or junctional rhythm’. Copyright © 1996 The International Society for Cardiovascular Surgery.