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Differential flow improvements after valve replacements in bicuspid aortic valve disease: a cardiovascular magnetic resonance assessment

Differential flow improvements after valve replacements in bicuspid aortic valve disease: a cardiovascular magnetic resonance assessment

Patients with a BAV suffer from valve disease at a younger age than patients with trileaflet aortic valves and the majority of BAV patients will require aortic valve replacement (AVR) in their lifetime [7]. Given the likely pathophysiological effects of the abnormal helical flow on aortic dilation in BAV disease, examining the flow patterns in the proximal aorta after AVR may pro- vide novel insights. A recent pilot study examined these in mainly trileaflet aortic valve disease [8], and suggested that different AVR types may result in different flow pat- terns. To date however, no study has assessed the impact of AVR alone on the flow abnormalities in specifically BAV. We therefore hypothesized that AVR may favorably alter flow patterns in the ascending aorta in patients with a BAV. We also sought to examine in this pilot study the flow patterns after different AVR types (bioprosthetic versus mechanical) to determine if these differ.
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Degenerative mitral valve disease: Survival of dogs attending primary-care practice in england

Degenerative mitral valve disease: Survival of dogs attending primary-care practice in england

M.J. Mattin, A. Boswood, D.B. Church, P.D. McGreevy, D.G. O’Neill, P.C. Thomson, D.C. Brodbelt, Degenerative mitral valve disease: Survival of dogs attending primary-care practice in England, Preventive Veterinary Medicine, Available online 30 May 2015, ISSN 0167-5877, http://dx.doi.org/10.1016/j.prevetmed.2015.05.007.

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Cardiovascular magnetic resonance in the evaluation of heart valve disease

Cardiovascular magnetic resonance in the evaluation of heart valve disease

accurate and reproducible assessment of ventricular vol- umes and function in patients with left- or right-sided valve disease. The ability to image in unlimited planes is particularly important in patients with right-sided valve disease, which is poorly evaluated by echo. The quantifi- cation of regurgitant volumes/fraction with CMR is a particularly promising area, and one which is established for pulmonary regurgitation following surgical correc- tion of Fallot’s. However further prospective studies, and ideally randomised controlled trials comparing MR and echocardiography, are required before the assessment of left sided valve lesions can be considered the clinical routine. The limitations of CMR should be borne in mind and CMR can never replace echo for use at the bedside or in the critically ill patient. Despite these shortcomings CMR is an exciting non-invasive imaging modality in patients with VHD and improvements in techniques and technologies are likely to enhance its utility in clinical practice.
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Myxomatous mitral valve disease in dogs - an update and perspectives

Myxomatous mitral valve disease in dogs - an update and perspectives

Dyspnea can also be caused by pleural effusion or ascites due to right heart failure. Right heart failure in MMVD is a sign of progressive mitral valve disease and pulmonary hypertension that can be accompanied by tricuspid valve degeneration. Clinical signs may develop gradually and progress or they may come acutely due to sudden worsening of the disease. The owner may not have noticed the gradual declining of the dog’s physical activity, or acute disease may be caused by a rupture of chordae tendinae, the onset of arrhythmia (usually atrial fibrillation) or some kind of stress that puts the animal over the edge (separation from the owner, new environment, exertion). Hearing the typical murmur over the mitral area can determine the diagnosis of MMVD, and heart failure can be confirmed by thoracic radiography (Fig 3). Echocardiography further documents the individual chamber enlargement, the magnitude of regurgitant flow, the severity of mitral degeneration, valve prolapse, chordal rupture and pulmonary hypertension (Fig 6). Systolic function is difficult to assess in MMVD due to the enhanced sympathetic tone (24).
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Use of Conventional Ultrafiltration in Patients with Pulmonary Hypertensive Mitral Valve Disease Undergoing Valve Surgery

Use of Conventional Ultrafiltration in Patients with Pulmonary Hypertensive Mitral Valve Disease Undergoing Valve Surgery

Despite all the technological and methodological developments in cardiac surgery, use of CPB still has negative effects on organs such as increased myocardial edema, coronary vasoconstriction, perivascular and interstitial pulmonary edema, increased tendency for atelectasis, intraalveolar congestion, decreased renal perfusion, acute tubulary necrosis, confusion, agitation, delirium, prolonged sleepiness, transient parkinsonism, decreased insulin response, metabolic asidosis, intestinal malabsorbsionetc [18]. In case of mitral valve disease, patients with secondary pulmonary hypertension due to valvular disease, negative effects of CPB and additional factors such as general anesthesia, sternotomy, mechanical ventilation-induced acute lung injury, hypothermia, surgical trauma, medications and/or transfusion of blood products may contribute in pulmonary dysfunction [19, 20]. Use of ultrafiltration was thought to be an effective choice for improving the CP and gas exchange, which may successfully reduce the pulmonary dysfunction [12, 21-23].
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Management of Mild to Moderate Aortic Valve Disease undergoing Mitral Valve Surgery

Management of Mild to Moderate Aortic Valve Disease undergoing Mitral Valve Surgery

The optimal management strategy of patients undergoing mitral valve intervention for rheumatic heart disease and having mild to moderate aortic valve disease is controversial. The decision making in this clinical setting is difficult as there are no guidelines on the management of combined valvular diseases. Mild aortic stenosis has a propensity of rapid progression however does it warrant a concomitant aortic valve replacement at the time of mitral valve intervention is not clear. In 2014 AHA guidelines recomended concomitant aortic valve replacement in patients with moderate aortic stenosis undergoing cardiac surgery for other indications including mitral valve surgery (Level of Evidence: C). These guidelines also recommended concomitant aortic valve replacement for moderate aortic regurgitation in patients undergoing surgery for ascending aorta, coronary artery bypass grafting (CABG),or mitral valve surgery (Level of Evidence:C). [1] .
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Multimodality imaging in heart valve disease

Multimodality imaging in heart valve disease

Heart valve disease is common and a major indication for imaging in all cardiac centres. Imaging needs to assess: (1) valve morph- ology to determine the aetiology and suitability for invasive intervention; (2) haemodynamic severity; (3) remodelling of the left ventricle (LV) and right ventricle (RV); (4) involvement of the aorta and (5) the prediction of adverse cardiovascular events. Echocardiography will continue as the first-line technique for diagnosis and is likely to remain the mainstay for assessment and serial surveillance in most cases. However, other modalities, notably cardiac MRI (CMR) and CT, are used if echocardiographic imaging is suboptimal and can give comple- mentary information, particularly to aid risk assessment.
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3D printing for heart valve disease: a systematic review

3D printing for heart valve disease: a systematic review

Building on the experience of the early adopters, the use of 3D printing recently has enormously increased in a wide variety of medical applications. The field has demonstrated itself as an example of multidisciplinary cooperation where radiologists, surgeons, and mechan- ical/biomedical engineers all provide their specific ex- pertise in the different application areas [4]. These application areas vary from the printing of anatomical models for teaching and training [5] to models to inform the patient about treatment and from the preoperative evaluation of devices to the printing of guides and im- plants used during surgery. In recent years, cardiac anat- omy and especially congenital heart disease have become one of the focus areas of 3D printing to easily visualise and explore complex cardiovascular anatomy. However, other applications that could have a major im- pact on the field of cardiothoracic surgery, such as plan- ning of transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve replacement (TMVR), are also arising. 3D printing can be used to tackle some of the challenges in these interventions such as patient se- lection, prosthesis choice and sizing, and innovation in valve design. In this narrative review, we discuss the current state of the art in this area from a technical point of view by considering the constraints and possi- bilities of the 3D printing technique based on published work that specifically focuses on 3D printing in cardiac valve disease treatment. We will look at general topics such as data preparation, time requirements, printer possibilities, and material properties relating to this spe- cific application area. Possible clinical applications from the literature will also be introduced.
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A retrospective study of clinical signs and epidemiology of chronic valve disease in a group of 207 Dachshunds in Poland

A retrospective study of clinical signs and epidemiology of chronic valve disease in a group of 207 Dachshunds in Poland

The clinical symptom most frequently noted by ow- ners, regardless of ISACHC class, was coughing (Table 5). It was the only clinical symptom occurring in more than half of Class 2 patients (55.7%) and more than 75% of Class 3 patients and was the only symptom significantly related to chronic valve disease (p=0.0002). The increase in heart disease severity was accompanied by an increase in occurrence of exercise intolerance, dyspnea and tach- ypnea, which occurred in more than 50% of class 3 pa- tients (Table 5). There were 14 dogs in ISACHC class 2 that were asymptomatic according to the owners, how- ever after clinical examination and history evaluation, these dogs were classified as symptomatic. Dogs clas- sified as ISACHC 1a (24 dogs) or 1b (7 dogs) had un- specific clinical symptoms such as cough, exercise intolerance or tachypnea, however additional tests (radi- ography and echocardiography) showed that these symp- toms were in fact a result of chronic upper airway disease. Statistical analyses showed that clinical signs were noted by the owner more often with increasing se- verity of the heart disease when compared to asymp- tomatic or healthy dogs: tachypnoe (p<0.0001), exercise
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Should high risk patients with concomitant severe aortic stenosis and mitral valve disease undergo double valve surgery in the TAVR era?

Should high risk patients with concomitant severe aortic stenosis and mitral valve disease undergo double valve surgery in the TAVR era?

There are several limitations to this study. First, as an STS score is unable to be calculated for double valve surgery, we used the STS score for isolated AVR as the basis for expected mortality risk for risk stratification. Although this inevitably underestimates the surgical risk for double valve surgery, its use is justified for the pur- pose of this study as the same score would be used for the risk stratification of patients with concomitant mitral and aortic valve disease being considered for TAVR. Sec- ondly, as this study was limited to patients to high risk patients undergoing concomitant surgical aortic valve replacement and mitral valve surgery, the results of this study may not be applicable to intermediate and low risk patients undergoing similar surgeries. Lastly, as with all single center studies, the results of this study may not be generalizable to all institutions.
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Heart valve operations associated with reduced risk of death from mitral valve disease but other operations associated with increased risk of death: a national population-based case–control study

Heart valve operations associated with reduced risk of death from mitral valve disease but other operations associated with increased risk of death: a national population-based case–control study

This was the first national population-based study to evaluate the association between operations, including frequency and type thereof, and the mortality risk of mitral valve disease. We determined that patients with mitral valve disease had a higher rate of mortality than patients who underwent other operations, namely other CVD, respiratory condition, or urinary system opera- tions. Patients who underwent a heart valve operation had a higher mortality rate among patients with comor- bidity, namely diabetes, emphysema, and CKD. The mortality rate of patients with mitral valve disease who underwent the heart valve operations, including closed heart valvotomy, open heart valvuloplasty, replacement of heart valve, was lower than that of patients who did not. Finally, we purposed that patients with mitral valve disease who underwent more heart valve operations exhibited a lower rate of mortality, which contrasted Table 1 Basic characteristics of the study participants from 2002 to 2013
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Heart valve disease: investigation by cardiovascular magnetic resonance

Heart valve disease: investigation by cardiovascular magnetic resonance

CMR offers similar capabilities for the assessment of tri- cuspid regurgitation (TR) as for mitral regurgitation. SSFP cine sequences are used to visualise the anatomy and function of the leaflets. The horizontal long axis view provides a good overview, but multiple contiguous transverse images through the valve can often provide additional useful information, particularly for abnormal leaflet morphology such as in Ebstein’s anomaly. Visua- lising the jet is difficult on SSFP sequences due to the lower shear and turbulence, but qualitative assessment of the TR jet can be achieved with in-plane velocity mapping in a long axis RV view (Figure 14). Wider jets (especially > 7 mm at the vena contracta) suggest more severe tricuspid regurgitation. The regurgitant orifice can sometimes be assessed directly, in a similar fashion to mitral regurgitation, with a cine image through the leaflet tips in systole (Figure 15). Through-plane velocity mapping in this plane can also aid in visualising the size of the regurgitant orifice by visualising the flow jet in cross section. This allows assessment of the regurgitant orifice area, though thresholds for guiding severity grad- ing are not yet available. The ‘diameter’ of the
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Isolated Rheumatic Pulmonary Valve Disease—Case Reports

Isolated Rheumatic Pulmonary Valve Disease—Case Reports

Echocardiography revealed a thickened pulmonary valve as shown in Figure 1 with commissural fusion as shown in Figure 2, moderate to severe pulmonary stenosis as in Figure 3 and a modera[r]

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Bicuspid aortic valve disease: systematic review and meta-analysis of surgical aortic valve repair

Bicuspid aortic valve disease: systematic review and meta-analysis of surgical aortic valve repair

Our systematic review demonstrated that the clinical lit- erature on outcomes after aortic valve repair in BAVD patients is still limited to mostly case series including in some cases retrospective comparisons of repair techni- ques within individual centres. Methodologically rigor- ous controlled studies comparing outcomes after aortic valve repair with alternatives, speci fi cally aortic valve replacement, are needed. Aortic valve repair is still developing at individual centres, and its role in the treat- ment of BAVD is not yet fully understood. While mainly used in aortic valve insuf fi ciency, additional centre- speci fi c applications for the treatment of stenotic bicus- pid valves have been described. Synthesising the avail- able evidence from case series, we found that aortic valve repair in patients with BAVD appears to be asso- ciated with favourable survival. No systematic in fl uence Figure 5 Proportion of patients
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Case Report of Multiple Valve Disease Found in Triplets

Case Report of Multiple Valve Disease Found in Triplets

by two-dimensional echocardiography can be difficult, and sometimes a patient with an isolated cleft may remain un- diagnosed (Van Praagh et al., 2003). Wyss and coworkers (2009) reported that the prevalence of isolated cleft of the posterior mitral leaflet was 0.11% (n = 22 out of 19,320 two-dimensional transthoracic echocardiograms). In our case, two-dimensional transthoracic echocardiography did not reveal the mechanism of mitral regurgitation. Using the three-dimensional transesophageal echocardiography tech- nique enabled us to identify the cleft of the posterior mitral valve leaflet. Assessment of the mechanism and severity of mitral valve regurgitation is of paramount importance for therapeutic management. Three-dimensional echocardio- graphy has improved both morphological and functional assessment of valvular heart disease. It provides additional morphologic information of the components of mitral valve apparatus, which leads to better understanding of the mech- anism of mitral regurgitation (Cai & Ahmad, 2012; Lancel- lotti et al., 2010a).
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Relationship between incidentally detected calcification of the mitral valve on 64-row multidetector computed tomography and mitral valve disease on echocardiography

Relationship between incidentally detected calcification of the mitral valve on 64-row multidetector computed tomography and mitral valve disease on echocardiography

Mitral valve calcification was noted in 59 (7.7%) of 760 patients on multidetector CT. All of the cases detected were aged . 60 years. Five patients refused to take part in the study and four died before echocardiography could be performed due to the severity of their underlying disease. Baseline characteristics of the patients and controls are shown in Table 1. There were no differences in sex, age, and a preva- lence of hypertension, hyperlipidemia, and diabetes mellitus between the groups (Table 1). Of the remaining 50 patients with mitral valve calcification, 32 (64%) had mitral annular calcification, with 24 (48%) having calcification at the pos- terior annulus and eight (16%) at the anterior annulus. Nine patients (18%) had calcification of the posterior mitral valve leaflet and both mitral valve leaflet and annular calcification were detected in nine (18%) cases.
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Role Of Nitric Oxide In Embryonic Heart Development And Adult Aortic Valve Disease

Role Of Nitric Oxide In Embryonic Heart Development And Adult Aortic Valve Disease

The morphogenesis of the heart valves occurs concomitantly with changes in the cardiac morphology and in a complex process that includes initiation, cushion formation, elongation, valve remodeling and maturation. 7, 34 Valve development is initiated during cardiac looping when the primary myocardium secretes a hyaluronan-rich matrix called cardiac jelly that projects into the lumen at the atrioventricular junction and the outflow tract at E9.0 in mice. The underlining myocardial cells produced factors including bone morphogenetic protein-2 (BMP2), BMP4 and transforming growth factor (TGF)-, which activate the overlaying endocardium. At E10.5, the activated endocardial cells undergo EMT to become spindle shaped migratory cells (mesenchymal phenotype) and invade the cardiac jelly. Proliferation of the mesenchymal cells and matrix deposition extend the cushions into the cardiac lumen and form primordium of each distinct valve. This is then followed by elongation and remodeling/thinning of the valve primordial at E12.5, which leads to the gradual maturation of the valves that are rich in elastin, fibrillar collagen and proteoglycans. During valve remodeling, cell proliferation decreases, and subsequently there is little to no proliferation of valve interstitial cells in the adult. Formation of four distinct valves is a result of septation of the outflow tract into aorta and pulmonary trunk giving rise to aortic and pulmonary valves, and fusion of the atrioventricular canal endocardial cushions giving rise to mitral and tricuspid valves. 29
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Surgical Treatment of Mitral Valve Disease

Surgical Treatment of Mitral Valve Disease

The combined lesion of mitral stenosis and regurgitation is usually due to rheumatic heart disease and is treated like mitral regurgita- tion because most patients requi[r]

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Results of mitral valve repair in rheumatic valvular heart disease

Results of mitral valve repair in rheumatic valvular heart disease

The survival rate and freedom from re-operation at 71 months is 97% and 95% respectively in this study. The literature shows the survival rate and freedom from re-operation in the range of 80-90% and 75-80%. (Antunes et al., 1987; Duran et al., 1991; Bernal et al., 1993; Skoularigis et al., 1994; Chauvaud et al., 2001; Kumar et al., 2006) Survival rate and freedom from reoperation in this study was better as compared to other studies .This was due to comprehensive complete mitral valve repair techniques as described by Carpentier (Carpentier et al., 2010). Freedom from reoperations in this study was better or equivalent to other studies probably because of comprehensive reconstructive techniques especially avoidance of custom made indigenous annuloplasty rings. It suggest better durability of repair when complete mitral valve repair techniques are used. There are many factors which affects the long term durability of mitral valve repair in rheumatic etiology. Many studies have shown that the presence of acute rheumatic activity at the time of surgery is associated with high failure rate of repair. The presence of mixed lesion is also associated with high failure rate. (Antunes et al., 1987; Duran et al., 1991; Bernal et al., 1993; Skoularigis et al., 1994; Chauvaud et al., 2001; Kumar et al., 2006) Bernal et al and skoularigis et al have shown the high rate of freedom from reoperation than other studies (Bernal et al., 1993; Skoularigis et al., 1994). They considered that the important factors were the severity of mitral valve disease and the repair techniques used. The mitral valve leaflet mobility and subvalvular pathology are the most important factors for the success of mitral valve repair. The differences in results of various studies could be due to non uniformity of surgical techniques
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Indications for uses of Homografts in Cardiac Patients at Sri Jayadeva Institute of Cardiac Sciences & Research and Their Follow Up

Indications for uses of Homografts in Cardiac Patients at Sri Jayadeva Institute of Cardiac Sciences & Research and Their Follow Up

Patients with a medical contraindication to anticoagulation or want to avoid anticoagulation (female patient of child bearing age, etc.) may be candidates for a homograft valve rather than a mechanical prosthesis. Replacement with bioprosthetic valve also an alternative. Patients with periprosthetic insufficiency and evidence of dehiscence of the prosthetic aortic annulus and the native aortic annulus can be managed with aortic homograft root replacement of the prosthetic valve. Patients with ascending aortic aneurysm and associated aortic valve disease may require homobent all operation (replacement of ascending aorta and aortic valve with homograft root).The advantages of homograft use are: rare chances of thromboembolic events, hence no need for anticoagulation, absence of haemolysis, lack of ring/cuff of graft support (minimising the transvalvular gradient compared to the stented prosthetic valves) ,optimum haemodynamic performance (similar to that of stentless valves), higher resistance to endocarditis compared to all the other valves, etc. Use of homografts as a complete aortic root replacement in cases of complex aortic valve endocarditis, allows the resection or isolation from the circulatory system of all the infected tissues with radical elimination of the infection. The homografts can be used for the replacement of the aortic valve in three ways: a) Replacement of the valve with graft implantation
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