St Jude Research Articles

Issue Highlights

HomeCirculationVol. 113, No. 3Issue Highlights Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBIssue Highlights Originally published24 Jan 2006https://doi.org/10.1161/circ.113.3.329Circulation. 2006;113:329MORTALITY AND CARDIOVASCULAR RISK ACROSS THE ANKLE-ARM INDEX SPECTRUM: RESULTS FROM THE CARDIOVASCULAR HEALTH STUDY, by O’Hare et al.The ankle arm index (AAI; ratio of ankle and arm systolic blood pressures) has been used as an indicator of subclinical and clinical peripheral vascular disease, and values below 0.9 and above 1.4 have been reported to indicate an adverse vascular prognosis. In this issue of Circulation, O’Hare and colleagues evaluated the mortality and cardiovascular risks associated with a broad range of AAI (categories defined in 0.1 unit increments from 0.6 to 1.4) in a large elderly community-based sample. Compared to the referent group with an AAI between 1.10 and 1.20, values below 1.0 and above 1.4 were associated with higher all-cause and cardiovascular mortality. Specifically, an AAI in the range 0.9 to 1.0 (often regarded as normal) was associated with a 40% higher mortality risk compared to the referent group, whereas a value above 1.40 was associated with a 57% greater mortality hazard. The authors noted effect modification by age, with stronger associations of high and low AAI with mortality risk in people below age 75 years. Overall, these observational data emphasize the nonlinear relations of AAI and mortality risk and raise the possibility that the mortality risk associated with a low AAI may extend to values above the traditional cut point of 0.9 (ie, to the range 0.9 to 1.0). See p 388.IMPACT OF PROSTHESIS-PATIENT MISMATCH ON LONG-TERM SURVIVAL IN PATIENTS WITH SMALL ST JUDE MEDICAL MECHANICAL PROSTHESES IN THE AORTIC POSITION, by Mohty-Echahidi et al.The issue of prosthesis-patient mismatch continues to be an area of active clinical investigation. The article by Mohty-Echahidi et al focuses on long-term survival in a defined population of patients receiving an aortic valve with a small (19 or 21 mm) St Jude prosthesis. Three-hundred eighty-eight patients were studied and the degree of mismatch was measured by postoperative transesophageal echocardiography in each patient. The effective orifice area index is defined as the echo-derived prosthesis effective orifice area divided by the patient’s body surface area. The patients with severely mismatched effective orifice area index <0.6 cm2/m2 comprised 17% of the study patients. These patients were observed to have a significantly worse survival at 5 years (72%) and 8 years (41%) than those patients with moderate mismatch (0.6 cm2/m2 to 0.85 cm2/m2) or no significant mismatch (>0.85 cm2/m2). Severe mismatch was an independent predictor of mortality (hazard ratio=2.18, P=0.007) and congestive heart failure (hazard ratio=3.1, P= 0.009). The ability of a surgeon to predict potential mismatch should be part of current surgical practice. The effective orifice areas for specific valves are available in tables provided by the manufacturers. The surgeon can calculate the effective orifice area index and choose a hemodynamically superior prosthesis or perform an annular enlargement to avoid mismatch, thus improving outcomes in cardiac surgery. See p 420.EFFECT OF INTENSIVE VERSUS STANDARD LIPID-LOWERING TREATMENT WITH ATORVASTATIN ON THE PROGRESSION OF CALCIFIED CORONARY ATHEROSCLEROSIS OVER 12 MONTHS: A MULTICENTER, RANDOMIZED, DOUBLE-BLIND TRIAL, by Schmermund et al.Emerging clinical trials suggest that low-density lipoprotein (LDL) cholesterol lowering beyond previously defined targets improves clinical outcomes in patients with coronary artery disease and those with multiple cardiovascular risk factors. Quantification of coronary artery calcification by electron-beam computed tomography has been shown to provide prognostic information in patients with known or suspected coronary artery disease. In this issue of Circulation, Schmermund et al evaluate whether intensive LDL lowering using high-dose atorvastatin reduces the presence of coronary artery calcification as assessed by electron-beam computed tomography compared to treatment with low dose atorvastatin. In this randomized controlled trial of 471 patients, the mean LDL after 12 months of treatment was 87±33 mg/dL in the high-dose group and was 109±28 mg/dL in the low-dose group. However, the progression in calcium score did not differ between groups. This unexpected funding may have implications for the clinical utility of coronary calcium score as a surrogate marker for cardiovascular risk. See p 427.Visit http://www.circ.ahajournals.org:Images in Cardiovascular MedicineNot So Mural Thrombus. See p e38.Cardiomyopathy Resulting From Primary Hyperoxaluria Type II. See p e39.Role of Inflammation in Atherosclerosis: Immunohistochemical and Electron Microscopic Images of a Coronary Endarterectomy Specimen. See p e41. Download figureDownload PowerPointCorrespondenceSee p e44. Previous Back to top Next FiguresReferencesRelatedDetails January 24, 2006Vol 113, Issue 3 Advertisement Article InformationMetrics https://doi.org/10.1161/circ.113.3.329 Originally publishedJanuary 24, 2006 PDF download Advertisement

Obstruction of st jude medical valves in the aortic position: histology and immunohistochemistry of pannus

Objective This study aims to reveal the morphological, histological, and immunohistochemical mechanism of pannus formation using resected pannus tissue from patients with prosthetic valve dysfunction. Method Eleven patients with prosthetic valve (St Jude Medical valve) dysfunction in the aortic position who underwent reoperation were studied. We used specimens of resected pannus for histological staining (hematoxylin and eosin, Grocott’s, azan, elastica van Gieson) and immunohistochemical staining (transforming growth factor-beta, transforming growth factor-beta receptor 1, α-smooth muscle actin, desmin, epithelial membrane antigen, CD34, factor VIII, CD68KP1, matrix metalloproteinase-1, matrix metalloproteinase-3, and matrix metalloproteinase-9). Results Pannus without thrombus was observed at the periannulus of the left ventricular septal side; it extended into the pivot guard, interfering with the movement of the straight edge of the leaflet. The histological staining demonstrated that the specimens were mainly constituted with collagen and elastic fibrous tissue accompanied by endothelial cells, chronic inflammatory cells infiltration, and myofibroblasts. The immunohistochemical findings showed significant expression of transforming growth factor-beta, transforming growth factor-beta receptor 1, CD34, and factor VIII in the endothelial cells of the lumen layer; strong transforming growth factor-beta receptor 1, α-smooth muscle actin, desmin, and epithelial membrane antigen in the myofibroblasts of the media layer; and transforming growth factor-beta, transforming growth factor-beta receptor 1, and CD68KP1 in macrophages of the stump lesion. Conclusions Pannus appeared to originate in the neointima in the periannulus of the left ventricular septum. The structure of the pannus consisted of myofibroblasts and an extracellular matrix such as collagen fiber. The pannus formation after prosthetic valve replacement may be associated with a process of periannular tissue healing via the expression of transforming growth factor-beta.

Simultaneous doppler and catheter transvalvular pressure gradients across st jude bileaflet mitral valve prosthesis: In vivo study in a chronic animal model with pediatric valve sizes

A mixture of valve types has been used in previous in vivo studies to assess the accuracy of Doppler echocardiography compared with catheter-measured pressure gradients across prosthetic mitral valves. However, limited data exist regarding the most commonly used bileaflet mechanical valve. We studied 14 sheep with St Jude Medical mechanical mitral valves. Continuous wave Doppler data were obtained across each of the 3 valve orifices. Hemodynamic data were obtained simultaneously by direct measurements with catheters. Valve sizes commonly used in the pediatric population in the mitral position (23 mm, 25 mm, and 27 mm) were studied. Linear regression analyses of Doppler-predicted versus catheter-measured gradients provided correlation coefficients ranging from 0.75 to 0.91. Agreement analysis demonstrated a scatter of Doppler data about the regression line. Although a reasonably good correlation of Doppler-predicted peak and mean pressure gradients across bileaflet mechanical valves exists in the mitral position, caution is needed when this method is applied to patients. Doppler overestimation was greatest across the 23-mm valves. Analyses of the specific orifice interrogated demonstrated higher estimated pressure gradients across the central orifice compared with the side orifices.

Color Doppler regurgitant characteristics of normal mechanical mitral valve prostheses in vitro.

To evaluate normal regurgitant characteristics of St. Jude (SJ) and Medtronic-Hall (MH) mitral valves, four sizes (25-31 mm) of each were studied in a pulsatile flow model. Regurgitant flow was measured by flowmeter at left ventricular pressures of 80, 130, and 180 mm Hg. Peak regurgitant flow rates ranged from 6.2 to 12.7 cm3/sec in SJ valves and from 7.9 to 17.5 cm3/sec in MH valves. Regurgitant orifice areas calculated from the Doppler continuity equation ranged from 1.6 to 2.0 mm2 in SJ valves and from 2.2 to 2.9 mm2 in MH valves. Regurgitant volumes across the closed valve at a left ventricular pressure of 130 mm Hg were normalized to an ejection time of 280 msec and ranged from 1.5 to 1.9 cm3 in SJ valves and from 2.1 to 2.8 cm3 in MH valves. Jets were imaged by color Doppler in six rotational planes, and jet size and morphology were compared with those of regurgitant jets from circular orifices with sizes comparable to the calculated prosthetic valve regurgitant orifices (1.1-3.1 mm2). SJ valves showed two converging jets from the pivot points, one central jet, and a variable number of peripheral jets. The mean color jet area derived from the six image planes ranged from 1.6 to 5.3 cm2. Aliasing occurred only close to the valve (maximal distance 0.5-2.0 cm). MH valves showed a large central jet with a maximal length of aliased flow between 2.0 and 5.5 cm. Depending on valve size, driving pressure, and image plane, one or two small peripheral jets were found. These jets did not show aliasing in any case. The mean color jet area ranged from 5.1 to 11.0 cm2. Jets originating from circular orifices of comparable size showed jet areas from 5.5 to 13.9 cm2 and aliasing distances from 3.3 to 7.3 cm. At similar regurgitant orifice areas, driving pressures, and regurgitant flows, the measured color areas and aliasing distances were smallest in SJ valves, larger in MH valves, and largest in simple circular orifices. Large, complex regurgitant jets can be found in normal closed SJ and MH valves by color Doppler, although regurgitant flow volume is minimal. Jet size and velocity distribution differs markedly between SJ valves, MH valves, and circular orifices, even with comparable driving pressure, regurgitant orifice area, and regurgitant volume. The characteristic patterns of normal regurgitation must be recognized to avoid incorrect diagnoses of pathological regurgitation in SJ and MH prosthetic valves. MH valves should not be removed solely on the basis of a central regurgitant jet with a long aliasing distance. Peripheral jets in MH valves and all jets in SJ valves should be considered normal as long as no or only minimal aliasing is present. In contrast, peripheral jets with significant aliasing may represent strong evidence of pathological regurgitation.

An In Vitro Comparative Study of St. Jude Medical and Edwards-Duromedics Bileaflet Valves Using Laser Anemometry

An in vitro comparative study of St. Jude (SJ) and Edwards-Duromedics (DM) Bileaflet valves was performed under steady and physiological pulsatile flow conditions in an axisymmetric chamber using Laser Doppler Anemometry (LDA). LDA measurements were conducted in two different orientations; in the first orientation, the LDA traverse was perpendicular and, in the second orientation, parallel to the tilt axis of the leaflets. The axial velocities were measured in both orientations at two different locations distal to the valves. The velocity profiles at peak systole show the presence of stronger vortex in the sinus region for flow past SJ valve in the first orientation compared to the DM valve. Velocity profile distal to the SJ valve in second orientation was relatively flat where as for the DM valve, a jet-like flow was present. The differences found in the velocity profiles between the two valves can be attributed to the differences in geometry with thicker leaflets, smaller angle of leaflets opening and the presence of the leaflet curvature for the DM valve. The results obtained in this study do not show any fluid dynamic advantages due to the curved leaflet geometry of the DM valve.

Evaluation of normal prosthetic valve function by Doppler echocardiography

Previous investigations have suggested that Doppler echocardiography is useful in detecting dysfunction in aortic (AVR) and mitral prostheses (MVR). However, to diagnose abnormallties, the spectrum of normal velocities through these valves must be established. Therefore, we used Doppler echocardiography to study 100 patients with 105 prosthestic valves that had no clinical evidence of valve dysfunction 9 ± 8 days postoperatively. There were 66 Carpentler-Edwards (C-E), 23 St. Jude (S-J), and 16 lonescu-Shlley (I-S) valves. In 70 AVR, the peak instantaneous gradient was 26.4 ± 8.2 Hg, mean systolic gradient was 15.6 ± 5 mm Hg, and gradients varied inversely with valve size, although differences were significant only when comparing the smallest vs the largest valve sizes ( p≤0.03). Peak instantaneous gradients >36 mm Hg occurred only in AVR size 23 or smaller. There were no significant differences in gradients among C-E, S-J, and I-S AVR. In 35 MVR, mean gradient was 6.9 ± 2.3 mm Hg and valve area was 2.7 ± 0.8 cm 2; neither varied significantly with valve size. However, S-J MVR group had smaller mean gradients and larger effective valve area than C-E bioprosthetic MVR ( p = 0.01 and p = 0.05, respectively). Regurgitation was more common in AVR (26%) than in MVR (9%), p = 0.04, although all instances were mild and clinically silent. We conclude that normal AVR and MVR of a given size and type have a predictable range of Doppler echocardiographic parameters. Doppler evidence of mild regurgitation is a frequent finding in normal AVR and MVR. The inverse relationship between valve size and gradient should be taken into account when interpreting Doppler echocardiographic measurements in AVR.

THE EPISTLE OF ST JUDE AND THE MARCOSIAN HERESEY

Journal Article THE EPISTLE OF ST JUDE AND THE MARCOSIAN HERESEY Get access J. B. MAYOR J. B. MAYOR Search for other works by this author on: Oxford Academic Google Scholar The Journal of Theological Studies, Volume os-VI, Issue 24, July 1905, Pages 569–577, https://doi.org/10.1093/jts/os-VI.24.569 Published: 01 July 1905