Mean Valve Size Research Articles

Comparison of four aortic bioprostheses: Hancock II vs. St Jude Trifecta vs. Carpentier-Edwards Perimount Magna vs. Magna Ease-mid-term results (COMPARE SAVR study).

In the era of percutaneous aortic valve implantation, biological valves are the preferred prostheses implanted in patients undergoing surgical aortic valve replacement (sAVR). The aim was to present a real-life analysis of mid-term sAVR outcomes for the four aortic bioprostheses: the Hancock II, the Carpentier-Edwards Perimount Magna, the Carpentier-Edwards Perimount Magna Ease and the Trifecta valve. This is a retrospective study based on data from the Polish National Cardiac Surgery Database. The study population comprised of 1,589 consecutive patients, of whom 432 were in the Hancock II group, 356 in the Carpentier-Edwards Perimount Magna group, 427 in the Carpentier-Edwards Magna Ease group, and 374 in the Trifecta group. A comparison of the four groups was performed using analysis of variance (ANOVA) or Kruskal-Wallis test with appropriate post hoc tests (Tukey HSD or Steel-Dwass, respectively). Patients in the Hancock II group were older, had higher New York Heart Association (NYHA) and Canadian Cardiovascular Society (CCS) classes, had lower prevalence of hypertension and hyperlipidemia but higher prevalence of diabetes. The lowest mean valve size was observed in Trifecta group and the highest was in the Magna group (P<0.001). Survival analysis showed no significant differences in in-hospital mortality: 3.9% in Hancock II, 3.1% in Perimount, 3.3% in Magna and 2.1% in Trifecta group. Five-year mortality was significantly higher in Hancock II group (25.7%) compared to the other bioprostheses: 12.1% in Perimount, 9.1% in Magna and 10.70% in Trifecta group respectively. The 5-year mortality rate was significantly higher in the Hancock II group compared to the other bioprostheses. In contrast, Trifecta, Perimount Magna, and Magna Ease had similar 5-year mortality rates.

Long-term durability of bioprosthetic aortic valve replacement in young patients with bicuspid aortic stenosis

ObjectiveTo examine long-term surgical aortic valve replacement (SAVR) outcomes for young (ie, younger than age 65 years) patients with bicuspid aortic valve and aortic stenosis (AS) with or without concomitant aneurysm. BackgroundThere are few studies evaluating the early and late outcomes of SAVR in young patients (younger than age 65 years) with bicuspid aortic valve and AS. MethodsUsing institutional data from 2004 through 2022, 498 patients with bicuspid aortic valve younger than age 65 years underwent SAVR for AS with bioprosthetic valves. We examined operative outcomes, long-term valve durability, and reintervention. ResultsThe total cohort comprised 281 patients undergoing isolated SAVR and 217 with concomitant aneurysm repair (SAVR/aneurysm). The average age was 55 ± 8 years, with Society of Thoracic Surgeons predicted risk of mortality score of median 0.7 (IQR 0.5, 1.0) and mean valve size of 25 mm. Operative mortality (0.7% vs 1.4%; P = .77) was similar between SAVR and SAVR/aneurysm patients. Predischarge permanent pacemaker implantation occurred in 1.6% (8 out of 498) patients. During overall follow-up of 5.0 years (IQR 1.8-9.9; range, 0.2-18.2 years), the cumulative incidence of reintervention at 10 years for structural valve degeneration (n = 33), including valve-in-valve (n = 15) was 6.6% (8.1% SAVR vs 4.5% SAVR/aneurysm; P = .66). No mortality was observed for valve-in-valve or redo-SAVR. Moderate or greater aortic regurgitation and paravalvular leak were observed in 6.5% and 0.3%, respectively, at most recent follow-up. ConclusionsBicuspid AS is common in patients younger than 65 years and management includes consideration of future valve intervention. SAVR confers excellent operative and reoperative outcomes, 10-year durability, and valve function. These results may support initial SAVR when considering lifetime management of AS.

The Aortic Annulus Stabilization Technique Prevents Paravalvular Leaks after Rapid Deployment Aortic Valve Implantation.

Background: Surgical aortic valve replacement with rapid deployment bioprosthesis guarantees good hemodynamic results but carries the risk of paravalvular leaks. To address this issue, an annulus stabilization technique has been recently developed. Methods: Clinical and hemodynamic parameters from patients treated for aortic valve replacement with the rapid deployment bioprosthesis and a concomitant annulus stabilization technique were prospectively collected and retrospectively analyzed. Echocardiographic data at discharge and at 1-year follow-up were collected and analysed. Results: A total of 57 patients (mean age 74.3 ± 6.1 years) with symptomatic aortic valve stenosis underwent aortic valve replacement with the rapid deployment bioprosthesis and concomitant annulus stabilization technique (mean valve size: 23.8 ± 1.9 mm). Combined procedures accounted for 56.1%. Hospital mortality was 1.8% and a new pacemaker for conduction abnormalities was implanted in 10 patients. The pre-discharge echocardiographic control showed absence of paravalvular leaks of any degree in all patients with mean valve gradient of 9.6 ± 4.0 mmHg. The 1-year echocardiographic control confirmed the good valve hemodynamic (mean gradient of 8.0 ± 2.8 mmHg) and absence of leaks. Conclusion: In this preliminary clinical experience, the annulus stabilization technique prevents postoperative paravalvular leaks after rapid deployment aortic valve implantation, up to 1-year postoperatively. Studies on larger series are of paramount importance to confirm the long-term efficacy of this new surgical technique.

Extensive calcification of the mitral valve annulus in transcatheter aortic valve implants.

OBJECTIVESThis study sought to report the calcification pattern of the mitral valve annulus and its implications for procedural and safety outcomes in transcatheter aortic valve implantation.METHODSBetween November 2018 and September 2019, a total of 305 patients had transcatheter aortic valve implants at our institution. The extent of calcification of the mitral valve annulus was analysed, and the impact on safety outcomes was evaluated.RESULTSThe prevalence of mitral annular calcification (MAC) was 43%. Calcification of the mitral valve annulus was either less than or at least one-third of the posterior annulus (34% and 32%), the whole posterior annulus (28%) or the extension to the attachment of the anterior leaflets (7%). Severe circumferential MAC revealed moderate paravalvular leaks in 5/8 (63%) patients and was associated with right branch bundle block [odds ratio (OR) 2.01 (0.39–3.06); P = 0.098] and low cardiac output [OR 3.12 (1.39–7.04); P = 0.033]. Subannular calcification at the anterolateral trigonum represented a risk factor for left ventricular outflow tract injury [OR 3.54 (1.38–8.27); P = 0.001] in balloon-expandable valves, associated with relevant rhythm disorders [OR 2.26 (1.17–5.65); P = 0.014] and female gender (7/8, 88%). The 30-day all-cause mortality in circumferential MAC reaching into the anterior annulus (grade IV) compared to patients with less MAC (grade I–III) was 13% vs 2% with a mean valve size of 24.6 vs 25.7 mm.CONCLUSIONSExtensive MAC was associated with moderate paravalvular leaks, with implications for the prosthesis size and survival in transcatheter aortic valve implants. In severe MAC, we recommend implanting oversized self-expandable prostheses, the goal being to reduce the risk of right branch bundle block and paravalvular leaks.Subj collection122, 125

Environmental drivers of size changes in lower Jurassic Schizosphaerella spp

The Early Jurassic nannofossil Schizosphaerella has displayed major changes in its mean valve size through time. These variations are investigated in detail in the Sinemurian to lowermost Toarcian of the Sancerre-Couy core (Paris Basin), based on previously published measurements of 7050 specimens. Through multivariate morphon analysis and mixture analysis, we decipher three distinct overlapping varieties of Schizosphaerella (small, medium, large) and show that mean size changes of this taxon can be mostly related to variations in the relative abundance of these three varieties. Comparison to facies changes and to newly and previously acquired geochemical data (bulk carbonate C and O isotopes and organic C isotopes, %CaCO3 and TOC) suggest that, whilst sea-surface temperature was indeed an important driver of size changes in Schizosphaerella, it is insufficient on its own to explain the full variability of our dataset. Likewise, sea-level controlled proximal-distal variations and levels of nutrient supply were additional drivers of Schizosphaerella size changes. The small population of Schizosphaerella remains, however, a good indicator for warmer episodes.

Mini-sternotomy versus conventional sternotomy for aortic valve replacement: a randomised controlled trial

ObjectiveTo compare clinical and health economic outcomes after manubrium-limited mini-sternotomy (intervention) and conventional median sternotomy (usual care).DesignA single-blind, randomised controlled trial.SettingSingle centre UK National Health Service tertiary hospital.ParticipantsAdult patients undergoing...

Long-term outcomes after transcatheter aortic valve implantation. An analysis of 5-year survival and beyond

Abstract Background Transcatheter aortic valve implantation (TAVI) has seen an unprecedented rise in the past decade and has become the gold-standard therapy for inoperable, high- and intermediate-risk patients with aortic valve stenosis. Purpose To investigate the long-term clinical outcomes (5-year survival and beyond) of patients undergoing TAVI. Methods Consecutive patients who underwent TAVI with a self-expanding valve between 2012 - 2015 were included in the study. Patients with bicuspid valves and valve-in-valve procedures were excluded. Clinical follow-up was performed at specified time intervals (30-day post TAVI and yearly thereafter). The primary endpoint of this study was to evaluate survival rates in the long-term (≥5 years). Secondary endpoints were echocardiographic findings and clinical status at 5 years. All endpoints were considered as per the VARC-2 criteria and the latest consensus documents. Results In total, 267 patients were included in the study. Complete follow-up was complete in 189 (70%) patients. The mean age at implantation was 80.71±6.81 years, 129 (48%) were female, mean logistic EuroSCORE was 24.28±8.64% and 73% of patients were at NYHA Class III. The median follow-up was 4.0±1.5 years. Before the procedure, ejection fraction (EF) was 49.92±9.37%, mean gradient was 48.83±14.68mmHg, pulmonary artery systolic pressure (PASP) was 44.31±12.72mmHg and aortic valve area was 0.98±5.02cm2. All patients received the self-expanding valve (mean valve size was 27.60±2.12mm), with the majority of them undergoing transfemoral TAVI (71%). Predilation was performed in 77% of the population and post TAVI dilation was performed in 20%. Compared to pre TAVI values, EF was higher at 50.66±9.37% (p=0.041), mean gradient was lower at 9.41±4.65mmHg (p&amp;lt;0.001), PASP was lower at 41.55±9.93mmHg (p=0.005) and aortic valve area was higher at 1.69±0.81cm2 (p&amp;lt;0.001) post TAVI. At the end of the fifth year, 160 (60%) patients were alive. Mean survival post TAVI was 32 months (median: 32.2 months, range: 0–91.2 months) and the majority of deaths were non-cardiac in nature (78%). Also, 43% patients of patients were at NYHA Class I, 50% were at NYHA Class II and 7% were at NYHA Class III. At multivariate analysis, sole independent predictor of death at 5 years was baseline PASP levels (OR 1.027, 95% CI: 1–1.054, p=0.049). Conclusion Transcatheter aortic valve implantation offers a viable solution for aortic stenosis patients and long-term results beyond 5 years are reassuring. Further studies are necessary in order to shed a light for very long-term outcomes. Funding Acknowledgement Type of funding source: None

Hemodynamic performance and clinical outcome of pericardial Perimount Magna and Porcine Hancock-II valves in aortic position.

We investigated hospital and midterm outcome of patients operated for an aortic valve replacement (AVR) with a pericardial Perimount or a Porcine Hancock-II valve. We analyzed 353 patients with Perimount Magna (n = 189) or Hancock-II valves (n = 164). Echocardiographic data, hospital outcome, and follow-up were collected and compared. The role of the type of valve on perioperative and midterm outcome was investigated. Mean age was 75.3 ± 6.8 and 74.3 ± 7.1 years (P = .17) for Perimount and Hancock-II group, respectively. Fifty-four Perimount (28.6%) and 24 patients with Hancock-II (14.6%) required urgent procedures (P = .002), including six type-A dissections and five endocarditis. EuroSCORE-II was 3.1 ± 2.7% (Perimount) and 2.7 ± 2.2% (Hancock-II). Combined procedures were performed in 115 Perimount (60.8%) and 71 patients with Hancock (43.3%); redo procedures counted for 1% and 2.4%, respectively (P = .42). Mean valve size was 23.2 ± 1.8 mm for pericardial and 23.6 ± 1.9 mm for porcine valves (P = .08). Hospital mortality (6.3% vs 2.4%; P = .05), kidney failure (11.6% vs 9.8%; P = .73), and new pacemaker implantation rates (6.3% vs 3.0%; P = .21) were higher in the Perimount group reflecting the fact that more urgent, combined, and critical procedures were implanted with a Perimount Magna. Overall, 51 patients died over 60 months (34 Perimount, 17 Hancock), corresponding to a mortality of 5.3 per 100-persons year (95% confidence interval [CI]: 3.8-7.4) and 3.0 (95% CI: 1.8-4.8), respectively. Survival at 5 years was 76% (95% CI: 68-82) and 83% (95% CI: 74-89) in the Perimount and Hancock groups (log-rank test; P = .099). We confirm a good clinical outcome of patients with AVR with modern pericardial or a porcine bioprosthesis. Despite better hemodynamic, the Perimount does not improve the midterm clinical outcome compared with the porcine valve.

Mini-Sternotomy Versus Conventional Sternotomy for Aortic Valve Replacement: Results from the MAVRIC Randomised Controlled Trial

Background: While Aortic Valve Replacement (AVR) outcomes have improved, morbidity remains significant. Need for transfusion is a key indicator of quality; transfusions are linked to prolonged hospital stay and increased mortality. Over one third of patients undergoing AVR via conventional median sternotomy require post-operative red-cell transfusion. Methods: MAVRIC was a single centre, single blind, randomised controlled trial, comparing AVR via manubrium-limited mini-sternotomy (intervention) and conventional median sternotomy (usual care) to assess the impact on post-operative red-cell transfusion. Patients were stratified by baseline logistic EuroSCORE and haemoglobin and followed for 12 weeks. The primary outcome was proportion of patients receiving red-cell transfusion within 7 days of index surgery. Findings: 271 patients were randomised using a central computer system with concealed allocation; 270 received surgery and contributed to the intention to treat analysis. No difference between intervention and usual care in red-cell transfusion within 7 days was found; 23/135 patients in each arm received a transfusion, odds ratio 1·0 (95% CI: 0·5, 2·0) and risk difference 0·0 (95% CI: -0·1, 0·1). Intervention reduced chest drain losses (mean 181·6ml (SD 138·7) vs usual care mean 306·9ml (SD 348·6)); this did not reduce red-cell transfusions. Mean valve size and postoperative valve function were comparable between intervention and usual care; 23mm vs 24mm, and 6/134 moderate or severe aortic regurgitation vs 3/130, respectively. Mini-sternotomy resulted in longer bypass times (82·7 minutes (SD 23·5) vs 59·6 minutes (SD 15·1)) and cross clamp times (64·1 minutes (SD 17·1) vs 46·3 minutes (SD 10·7)). Conventional sternotomy was more cost-effective with only a 5·8% probability of ministernotomy being cost-effective at a willingness to pay of £20,000/QALY. Interpretation: AVR via manubrium-limited mini-sternotomy did not reduce red blood cell transfusion within 7 days following index surgery when compared to conventional sternotomy. Clinical Trial Number: International Standard Randomised Controlled Trial Number (ISRCTN) ISRCTN29567910. Registered on 3 February 2014. Funding Statement: The trial was funded by the NIHR Research for Patient Benefit Programme (grant number PB-PG-1112-29035). GJM is supported by the British Heart Foundation (CH/12/1/29419) and the NIHR Leicester Biomedical Research Centre. Declaration of Interests: The authors declare that they have no competing interests. Ethics Approval Statement: This protocol and all trial-related documents were originally approved by the National Research Ethics Service Committee, North East - Newcastle & North Tyneside 1 in March 2014 (IRAS Project 137295; REC Reference 14/NE/0005). Since initial approval, three amendments have been made and approved; thus, this is version 5 of the protocol. Written informed consent will be obtained from all participants. The trial will be run according to the principles of ICH-GCP and in accordance with relevant UK legislation and the protocol.

Clinical outcome and hemodynamic behavior of the Labcor Dokimos Plus aortic valve.

BackgroundThe Labcor Dokimos Plus (LDP) is a stented externally mounted pericardial aortic bioprosthesis, which was recently introduced in Europe. Aims of the study are evaluation of operative and postoperative results as well as hemodynamic performance.MethodsOne hundred consecutive patients with a mean age of 65.9 ± 10.7 years (range 35–87) and a mean EuroSCORE II of 3.1 ± 3.9 (range 0.67–24.5) underwent aortic valve replacement with the LDP. Mean valve-size was 25.2 ± 1.7 mm. Concomitant procedures were performed in 34% of the cases. Postoperative clinical data were analyzed and hemodynamic performance of the prostheses was evaluated by transthoracic echocardiography. Clinical follow-up was 100%, echocardiographic follow-up was 93% complete.ResultsIntraoperatively no peculiarities occurred. Mean cross clamp times for isolated and complex procedures were 74.5 ± 20.0 min and 103.7 ± 37.1 min, respectively. Patients were extubated after a mean of 9.4 ± 15.8 h. There were no perioperative strokes. Bleeding events occurred in 4 patients. 30-day-mortality was 2%. One case of early endocarditis occurred. Echocardiography showed maximum and mean pressure gradients of 18.1 ± 6.4 and 9.6 ± 3.7 mmHg, respectively. Correspondingly to valve sizes 21, 23, 25 and 27 mm, mean pressure gradients were 17.3, 9.5, 8.5 and 10.2 mmHg, effective orifice areas were 1.92, 1.79, 2.0, 2.16 cm2 and indexed effective orifice areas were 1.08, 0.95, 0.99 and 1.01 cm2/m2, respectively. No relevant regurgitations occurred.ConclusionsThe LDP showed operatively no peculiarities and a satisfactory clinical outcome with low perioperative morbidity and mortality. The hemodynamic performance of the implanted valve sizes was satisfactory.

Does implantation of larger bioprosthetic pulmonary valves in young patients guarantee durability in adults? Durability analysis of stented bioprosthetic valves in the pulmonary position in patients with Tetralogy of Fallot†.

In a previous study, we identified factors affecting the durability of bioprosthetic valves in the pulmonary position following total repair of Tetralogy of Fallot (TOF). In this study, we aimed to identify factors affecting the durability of the bioprosthetic valve with regard to patient age and implanted valve size in order to guide valve choice in adolescent patients. We enrolled and analysed 108 cases of pulmonary valve replacement (PVR) with stented bioprosthetic valves in TOF patients between January 1998 and February 2014. Valvular dysfunction was defined as at least a moderate amount of pulmonary regurgitation or a peak pressure gradient of ≥40 mmHg on the most recent echocardiography. We analysed the effect of patient age and valve size on the durability of the bioprosthetic valve in the pulmonary position. There were 2 early deaths; no late deaths were observed. The follow-up duration was 92.8 ± 44.5 months. The mean age at PVR was 19.3 ± 9.1 years. The mean valve size was 24.7 ± 1.8 mm. Whereas patients ≥20 years old showed no valvular dysfunction (i.e. 100% freedom from valvular dysfunction at 10 and 14 years), patients who were adolescents and children (<20 years) showed worse durability, regardless of the z-score of valve size (68.2% at 10 years and 24.7% at 14 years). Although a larger valve with a z-score of ≥2 was implanted, patients <20 years old did not exhibit good valvular durability. The results were particularly worse in patients <10 years old, with 66.7% freedom from valvular dysfunction at 6 years and 33.3% at 8 years, compared with patients within the age range of 10 to <20 years (75.1% at 10 years, and 20.5% at 14 years). The durability of bioprosthetic valves in the pulmonary position was acceptable in patients aged ≥20 years, regardless of the z-score of valve size. However, patients who were children and adolescents did not show optimal durability of the bioprosthetic valve, irrespective of the z-score of valve size.

Long term outcomes of an Australian TAVI program – better than PARTNER?

Introduction: Transcatheter valve programs are now well established in Australia as they are around the world. As the indications for transcatheter aortic valve implant (TAVI) begin to expand into a more traditional surgical cohort, it is important to review the long-term outcomes of this technique. It is also relevant to compare the outcomes of a highly integrated, team orientated TAVI program to those achieved in major trials published to date. Methods: All patients undergoing transfemoral TAVI at our institution from 2008 to 2013 were included. Patients were treated using the Edwards Sapien and Sapien XT devices and included both inoperable and high-risk patients. The inoperable group included those medically inoperable and those technically inoperable due to factors such as porcelain aorta. Data was collected prospectively and mortality crosschecked against multiple sources. The TAVI team included cardiac surgeons, interventional cardiologists, a vascular surgeon, an interventional radiologist, cardiac anaesthetists, and echocardiographic cardiologists. Results: A total of 114 patients underwent transfemoral TAVI at a mean age of 84 6years. Mean preoperative Logistic EuroSCOREwas 31 16. Mean preoperative LVEFwas 55 13% and 11.4% of patients had moderate or severe LV dysfunction. Successful deployment was achieved in 98.3% of patients planned for valve deployment, with a mean valve size of 24.9 mm, and 1 valve per patient implanted. Median ICU LOS was 26 hrs with 17.5% of patients requiring inotropic support. Thirty-day mortality was 1.8%. Other postoperative complications included stroke/TIA 2.6%, new dialysis 0% and transfusion 29.8%. Post-operative paravalvular regurgitation was a mean of 1.8 1.1. Combined latemortality at amean of 27 17monthswas 29.8%. The one-year mortality for all patients was 9.6% (11/ 114) compared favourably with PARTNER A at 24.2% (84/ 348) (p<0.01). Two-year mortality was 21.1% (16/76) compared with PARTNER A at 33.9% (116/348) (p=0.04). Three-year mortality was 33.9% (19/56) compared with PARTNER A at 44.2% (154/348). Discussion: The application of the term “heart team” should offer exactly that – a multidisciplinary and cohesive team with a common focus. Using this model we have been able to achieve excellent long-term outcomes in a cohort of high-risk and inoperable patients undergoing TAVI. These results compare favourably to the PARTNER cohort A.

Direct Aorta Ascending Approach in Transcatheter Aortic Valve Implantation

Direct aorta ascending approach [transaortic approach (TAo)] is a new access way for transcatheter aortic valve implantation (TAVI) to be used in patients with peripheral vascular disease and as an alternative to transapical approach. Both the Edwards SAPIEN and CoreValve systems were used. Depending on the position of the ascending aorta, the relation to the sternum, the brachiocephalic vein, vein grafts, and left and right internal mammary artery grafts from previous heart surgery, either right minithoracotomy or left ministernotomy was selected. Computed tomographic scan with reconstruction was applied for this decision making. A hybrid operating room was used with echocardiographic and fluoroscopy guidance. We have done 30 procedures via the aorta ascendens. The mean age of the patients was 80 years, and 18 were men. The mean Logistic EuroSCORE of 33 reflects the comorbidities. More than half of the patients had coronary vessel disease and had undergone coronary artery bypass graft; 20% had abdominal aortic aneurysm. The mean ejection fraction was 41%, and the patients were in New York Heart Association class III to IV. The mean gradient was 50 mm Hg, and the mean valve area was 0.7 cm. The mean valve size was 28 mm. The use of Edwards SAPIEN versus CoreValve was 50%/50%, and thoracotomy versus sternotomy was 9 versus 21. All procedures were done successfully, but one patient had a periprocedural valve-in-valve implantation. Twenty-two patients were extubated in the operation room. The patients stayed in the intensive care unit for one night. Six patients were reoperated on. One patient had a postoperative balloon aortic valvuloplasty. The overall survival was 81% (follow up, 1-18 months). Access design is an important issue in TAVI. When central approach is needed, TAVI-TAo is safe. For patients with low ejection fraction, the TAVI-TAo is preferred to the TAVI-transapical. The cannulation technique of the aorta is well known for cardiothoracic surgeons, and the method is feasible both for the Medtronic CoreValve and the Edwards SAPIEN valve, either via right minithoracotomy or ministernotomy to obtain the best coaxial alignment. It seems easier to position the bigger valves more precisely via this central approach.

Morphometric Reconstructions And Size Variability Analysis Of The Surf Clam, Atactodea (=Paphies) Striata From Muralag 8, Southwestern Torres Strait, Northern Australia

This paper describes (a) the methods and results of a morphometric reconstruction and (b) a size variability study of a heavily fragmented Atactodea (=Paphies) striata (surf clam) assemblage recovered from a small midden on the island of Muralag in the southwest Torres Strait, Queensland. Two intense but discrete pulses of late Holocene cultural activity at the site have been determined. Phase 1 is centred around 622 cal. BP (544–674 cal. BP) and Phase 2 is centred around 485 cal. BP (426–532 cal. BP). The results from our morphometric reconstruction reveal a statistically significant change (reduction) in the mean valve size of A. striata between occupational phases. Mean size and range of valve sizes are used as measures to determine when people were potentially exploiting the surf clam in Phases 1 and 2. While more data is required to determine an exact season of death, our findings reveal a relative signal of the seasonal exploitation of A. striata between these two phases.

Mid-term results of bioprosthetic pulmonary valve replacement in pulmonary regurgitation after tetralogy of Fallot repair

Pulmonary valve replacement (PVR) is performed to reduce right ventricular (RV) volume overload, resulting in improved ventricular function and clinical status. Significant pulmonary regurgitation (PR) after tetralogy of Fallot (TOF) repair could result in RV dysfunction, exercise intolerance, arrhythmia and sudden death. The present study was conducted to investigate the mid-term clinical outcomes of PVR after TOF repair. Between 2001 and 2010, we retrospectively reviewed the outcomes of 131 (89 males and 42 females) PVRs with PR or pulmonary steno-insufficiency after TOF repair. PVR was performed at a mean age of 14.8±6.7 years. The mean interval from total correction of TOF to PVR was 12.5±5.2 years. Surgical indications of PVR were more than moderate PR with/without pulmonary stenosis, right ventricle dilatation, right ventricle dysfunction and reduced exercise capacity. Hancock II (n=58), Carpentier-Edwards Perimount (n=49) and St Jude Biocor (n=35) bioprosthetic valves were used. The mean z-score at implantation was 1.1±0.8. The mean valve size implanted was 25.1±1.5 mm. There was no early or late mortality in this study. RV end-diastolic and end-systolic volume indices (from 111.3±34.7 to 64.6±23.6, P<0.01) (preoperative n=70, postoperative n=17) were markedly decreased PVR during the 13.2±16.1 months follow-up period. Eleven patients (male=10, female=1) required a repeat PVR operation due to prosthetic valve failure. The rate of freedom from reoperation at 10 years was 66.4±4.4%. Implanted valve type (Carpentier-Edwards bovine valve), young age, and large-sized valve implantation (z-score>2.0) were risk factors for a repeat PVR in the univariate analysis. There was no risk factor in the multivariable analysis. PVR reduced the RV volume and improved the RV function within the first postoperative year. The rate of freedom from reoperation during the 10-year follow-up period in our series was acceptable. However, a longer follow-up will be necessary to determine the long-term outcomes of bioprosthetic valves in PVR.

Aortic root enlargement does not increase the surgical risk and short-term patient outcome?☆

To analyze the short-term outcome of aortic root enlargement (ARE) using death and adverse events as end points. From January 1999 through December 2009, 3339 patients were subjected to aortic valve replacement (AVR). A total of 678 were considered to have small aortic roots (SARs) in which an aortic prosthesis size 21 mm or smaller was implanted. ARE using a bovine pericardial patch was performed in another 218 patients, who constitute the study population. This comprised 174 females (79.8%); the mean age was 69.4 ± 13.4 years (8-87, median 74 years), the body surface area (BSA) was 1.59 ± 0.15m² and the body mass index (BMI) 25.77 ± 3.16 k gm⁻², and 192 (88.5%) were in New York Heart Association (NYHA) II-III. Preoperative echocardiography revealed significant left ventricular (LV) dysfunction in 17 patients (8%), a mean aortic valve area of 0.57 ± 0.27 cm², and a mean gradient of 62.51 ± 21.25 mm Hg. A septal myectomy was performed in 129 subjects (59.2%), and other associated procedures, mostly coronary artery bypass grafting (CABG), in 60 (27.5%). Bioprostheses were implanted in 161 patients (73.9%). The mean valve size was 21.9 ± 1.0 (21-25). The mean extracorporeal circulation (ECC) and aortic clamping times were 82.8 ± 19.8 min and 56.8 ± 12.5 min, respectively. Hospital mortality was 0.9% (n=2) for ARE as compared with 0.6% (n=4) for the SAR group (p=0.8). Inotropic support was required in only 13 (5.9%) patients and the first 24-h chest drainage was 336.2 ± 202 ml. Other complications included pacemaker implantation (7.8%), acute renal failure (10.6%), respiratory (4.1%), and CVA/transient ischemic attack (CVA/TIA) (3.2%). Postoperative echocardiographic evaluation showed a significant decrease in peak and mean aortic gradients (23.7 ± 9.5 and 14 ± 6.2 mm Hg, respectively, p<0.0001). The mean indexed effective orifice area (iEOA) was 0.92 ± 0.01 cm² m⁻² (vs 0.84±0.07 cm² m⁻², in SAR, p<0.0001). Only 11% of patients (n=24) with ARE exhibited moderate patient-prosthesis mismatch (PPM) and none had severe PPM. Mean hospital stay was 9.7 ± 9.29 days (median 7 days). With the growing number of patients with degenerative aortic valve pathology, mainly an older population, sometimes with calcified and fragile aortic wall, the issue of dealing with an SAR poses the dilemma of whether to implant a smaller prosthesis and admit some degree of PPM, or to enlarge the aortic root. This study demonstrates that the latter can be done in a safe and reproducible manner.

Morphometric and taphonomic analysis of granular ark ( Anadara granosa) dominated shell deposits of Blue Mud Bay, northern Australia

Metrical analyses of complete mollusc shells have commonly been used to examine aspects of prehistoric mollusc demography, and by extension to investigate potential human exploitation of a variety of species. Recently it has been highlighted that several taphonomic processes, such as fragmentation, have the potential to introduce size bias into these archaeological samples, particularly towards smaller size classes, and thus the potential to significantly skew results of these metrical analyses. This is investigated here by deriving morphometric equations for the sand/mudflat bivalve Anadara granosa, a species prevalent in archaeological sites across northern Australia. A linear regression model based on a series of valve measurements, resulting in high coefficients of determination, demonstrates strong predictive power for size reconstruction. The effects of fragmentation on assemblages from two case study sites are then examined as a means of reviewing issues of differential size preservation, variation in mean valve size, and evaluating the strength of previous interpretations of intensive human exploitation in Blue Mud Bay. Based on these analyses it appears that A. granosa mean size is not significantly affected by fragmentation as other species described in the literature, and previous interpretations retain their validity.

TERATOLOGY IN EUNOTIA TAXA IN THE GREAT SMOKY MOUNTAINS NATIONAL PARK AND DESCRIPTION OF EUNOTIA MACROGLOSSA SP. NOV.

High altitude springs and headwater streams directly interact with atmospheric deposition and as a result may be useful first response bioindicators of changes in acid precipitation, i.e. from increased acid rain or mitigation efforts. We examined the diatom assemblages associated with bryophytes collected from high elevation springs and streams in the Great Smoky Mountains National Park, U.S.A. in 2005 and 2007. The high elevation areas were dominated by Eunotia taxa, primarily E. subarcuatoides Alles, Nörpel et Lange-Bert., and secondarily by E. exigua (Bréb. ex Kütz.) Rabh., E. muscicola var. tridentula Nörpel et Lange-Bert., and E. macroglossa sp. nov. The presence of valve malformations in four of the high elevation springs and two streams suggest that acid precipitation in the park may be interacting with local bedrock geology to release metals toxic to algal communities, especially under the low pH conditions of these high elevation areas. Sites with the greatest number of deformities showed higher levels of Al, Ba, and Mn relative to other sites. Internal and external diatom morphology of normal and abnormal E. subarcuatoides valves were explored and demonstrated the presence of valve aberrations across all size ranges, including shape distortions and unusual raphe development. No difference in mean valve length or size range was present between normal and abnormal valves. However, more data are necessary before any clear linkages between diatom deformities, metals, geology, and acid precipitation can be unequivocally established.

Hemodynamic performance of the Edwards Prima Plus stentless valve at 1 year

The Edwards Prima Plus stentless valve bioprosthesis (EPPSV) is a porcine aortic root cylinder with resected coronary ostia, fixed in glutaraldehyde at low pressure, and chemically treated to prevent calcification. Utilization of this valve was approved in January 2005 in Japan. The purpose of this study was to evaluate the early hemodynamic performance of EPPSVs in our experience. From April 2005 to January 2006, a total of 21 patients underwent aortic valve replacement with EPPSVs. The hemodynamic performance of EPPSVs was evaluated at the time of discharge (2 weeks) and at 1 year by transthoracic two-dimensional Doppler echocardiography. There was one non-valve-related early death and one non-valve-related late death. Hemodynamic data were available for comparison from the time of discharge and at 1 year postoperatively in 19 patients (mean valve size 22 +/- 1 mm). Hemodynamic follow-up showed a significant decrease in the peak and mean transvalvular pressure gradients at discharge (37 +/- 16 and 18 +/- 8 mmHg, respectively) and 1 year postoperatively (25 +/- 7 and 12 +/- 4 mmHg, respectively) (P < 0.01). The effective orifice area increased significantly between the time of discharge (1.31 +/- 0.31 cm2) and 1 year (1.57 +/- 0.37 cm2) (P < 0.05) postoperatively. The left ventricular mass index was significantly reduced from the time of discharge (167 +/- 49 g/m2) to 1 year postoperatively (126 +/- 47 g/m2) (P < 0.001). EPPSVs have been associated with high early transprosthetic gradients. Such gradients tend to regress, with significant improvement at 1 year and concomitant regression of left ventricular hypertrophy.

One year hemodynamic performance of the Perimount Magna pericardial xenograft and the Medtronic Mosaic bioprosthesis in the aortic position: a prospective randomized study

We compared the hemodynamic performance of the Edwards Perimount Magna (EPM) and the Medtronic Mosaic (MM) bioprostheses according to the patient aortic annulus diameter (AAD). Eighty-six patients undergoing aortic valve replacement were prospectively assigned to receive either an EPM-valve (n=43) or an MM-bioprosthesis (n=43). Randomization was performed after measuring the AAD and patients were grouped according to their AAD: <22 mm (n=12), 22-23 mm (n=31) and >23 mm (n=43). Echocardiographic assessment was performed one year postoperatively. The mean AAD (EPM 23.9+/-2.1 mm vs. MM 23.6+/-2.3 mm) and mean valve size implanted (EPM 22.6+/-2.1 mm vs. MM 23.3+/-2.1 mm) were comparable in both groups. The EPM-group showed significantly lower mean gradient (EPM 10.2+/-3.2 mmHg vs. MM 17.1+/-8.2 mmHg) and larger effective orifice area (EOA) (EPM 1.99+/-0.4 cm(2) vs. MM 1.69+/-0.4 cm(2), P<0.0001). The EPM-valve was superior with respect to mean pressure gradient and EOA in all AAD. This difference was statistically significant in AAD of 22-23 mm (EPM 9.6+/-3.0 mmHg vs. MM 18.2+/-8.6 mmHg; EPM 1.82+/-0.3 cm (2) vs. MM 1.51+/-0.2 cm (2)) and >23 mm (EPM 9.9+/-3.1 mmHg vs. MM 14.2+/-5.6 mmHg; EPM 2.18+/-0.4 cm(2) vs. MM 1.94+/-0.5 cm(2)). Patient-prosthesis mismatch was present in 26.8% (MM) vs. 6.9% (EPM) of the patients (P=0.01). When the same AAD is taken as a reference, the EPM-valve was hemodynamically superior to the MM-bioprosthesis. The EPM-prosthesis significantly reduced the incidence of PPM.