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Objective: The aim of this study was to determine the occurrence of patient-prosthesis mismatch (P-PM) after aortic valve replacement (AVR) with a small-size Cryolife O'Brien (CLOB) bioprosthesis and to evaluate its clinical and hemodynamic implications., Methods: Sixty-two patients (mean age 70.9 +/- 5.2 years, 77.8% females), receiving a labeled 21-23 mm CLOB between 1993 and 2000, were retrospectively studied. Effective orifice area (EOA) was calculated by the continuity equation and then indexed to the patient's body surface area (BSA) to obtain the indexed EOA (EOAI). Based on previous observations a mismatch was defined as EOAI or= 0.8 cm/m2 showed an earlier concentric remodeling up to 1 year; no difference was demonstrated at later studies between groups. Survival and clinical status results were not affected by an EOAI

Study Objectives: The aim of this study was to evaluate the early and long-term outcomes in patients undergoing aortic root replacement (ARR) with the Bentall procedure., Design: Retrospective study., Setting: Cardiothoracic surgery unit., Patients and Methods: Between January 1986 and January 2002, 72 patients (mean age 58.3 +/- 12.4 years, 81.9% males) underwent ARR by means of a Bentall operation. Annuloaortic ectasia was the most frequent cause of aortic disease in this series of patients (31 patients; 43.1%), followed by type A dissection (19 patients; 26.3%), atherosclerotic aneurysm (18 patients; 25.1%), and poststenotic dilatation (4 patients; 5.5%). Nine patients (12.5%) had Marfan syndrome, and 10 patients (13.8%) underwent a concomitant replacement of the aortic arch. Follow-up ranged from 2 to 192 months (mean [+/- SD], 86.6 +/- 23.8 months)., Results: The mean 30-day mortality rate was 5.5 +/- 2%. The mean early mortality rate was 21 +/- 4% and 0% (p < 0.001), respectively, in patients with and without dissecting aortic aneurysms. There were two late deaths that were due to a pulmonary neoplasm and a cerebrovascular accident. The mean 16-year survival rate was 91.7 +/- 3.2%. The mean hazard of freedom from death was constant beyond 3 years (8.5 +/- 3.5%). No patient required reoperation. Furthermore, the long-term clinical follow-up was marked by a complete absence of endocarditis, anticoagulant-related hemorrhage, valve thrombosis, and prosthesis failure. Finally, patients showed a significant improvement in mean New York Heart Association functional status (1.3 +/- 0.1; p < 0.001 [postoperatively vs preoperatively])., Conclusions: In our experience, the late results of the Bentall operation were satisfactory. Our findings confirm that this technique still represents the procedure of choice for ARR with coronary reimplantation.

Objective: The purpose of this study was to assess the usefulness of transesophageal echocardiography to detect complications after a Cabrol procedure., Methods: A total of 28 unselected patients (mean age 52.2 +/- 13.3 years; 86% male) who survived a Cabrol procedure were examined with transesophageal echocardiography at a mean of 64 +/- 32 postoperative months. Underlying diagnosis was Stanford type A dissection in 11% of the patients and nondissecting aneurysm in 89%., Results: Periprosthetic jet as a result of a valve leakage was demonstrated in 3 patients (11%). In 1 patient (4%) with infected aortic graft, a fistula between the periprosthetic space and the right ventricle was detected, requiring reoperation. One patient (4%) showed a complete occlusion of the graft limb of the right coronary artery but did not need reoperation. An aneurysm of the periprosthetic space with perivalvular leakage and persistence of periprosthetic right atrial fistula was visualized in 3 patients (11%)., Conclusions: Our findings encourage the use of transesophageal echocardiography for the follow-up of patients undergoing a Cabrol operation.

Background: The St Jude Medical Regent is a new-generation mechanical heart valve that represents a design evolution of the St Jude Hemodynamic Plus Series (HP). The purpose of this study was to evaluate early "in vivo" hemodynamic performance of the Regent valve in patients with aortic stenosis., Methods: Between March 2000 and December 2001, 32 patients (mean age 59.9 +/- 5.9,56.3% male) with pure aortic stenosis received a Regent mechanical prosthesis in the aortic position. Hemodynamic performance was assessed by Doppler echocardiography at discharge, two months, six months, and one year by calculating peak transprosthetic velocity (Vmax), mean (MG) and peak (PG) transprosthetic gradients, effective orifice area index (EOAI), left ventricular mass index (LVMI), and degree of aortic regurgitation., Results: A significant reduction in mean and peak transaortic gradients (p < 0.001) and a significant increase in EOAI (p < 0.001) over time followed valve replacement, and a bivariate analysis of variance (ANOVA) failed to demonstrate statistical differences by valve size over time (p = ns). A significant reduction in left ventricular hypertrophy occurred over time (p < 0.001) in all valve sizes (p = ns between groups): baseline LVMI was 221 +/- 57 g/cm2; it decreased by 30 g/cm2 (p < 0.001) at discharge. LVMI decreased from 191 +/- 54 g/cm2 to 161 +/- 41 g/cm2 (p < 0.001) from discharge to two months. Further reductions were not significant. At the six-month follow-up no patient in our cohort exhibited moderate or severe aortic regurgitation at Doppler echocardiography., Conclusions: Early results with the St Jude Medical Regent valve have been satisfactory. Further assessments are necessary to confirm these results.

Background: The aim of this study was to assess the utility of intraoperative transesophageal echocardiography (TEE) in the evaluation of patients undergoing aortic valve replacement with the CryoLife-O'Brien (CLOB) Stentless Porcine Aortic Bioprosthesis., Methods: Between May 1994 and March 1995, 26 patients (15 men, mean age 68.4+/-10.78 years) had a CLOB valve in the aortic position. Transprosthetic gradients and valve regurgitation were detected by intraoperative TEE. Prosthetic regurgitation and transvalvular gradients were evaluated at six-month intervals using transthoracic echo-Doppler (TTE)., Results: The majority of implants resulted in low gradients (83.7%), with only four patients exhibiting a moderate gradient (15.3%). Color flow Doppler imaging showed central aortic regurgitation in only four of 25 patients (trivial, n=4; mild, n=1). There was one paravalvular leak (trivial, n=1). At follow-up examination (mean 37+/-12 months), 24 of 25 patients exhibited low mean gradients (7.25+/-2.81 mmHg). At follow-up one patient who had low velocities in the LVOT at perioperative evaluation exibited a moderate gradient (45 mmHg) with an effective orifice area of 0.8-0.9 cm(2)., Conclusions: Intraoperative TEE was effective in assessing prosthetic stentless valve function.

Objectives: This study evaluated the occurrence of prosthesis-patient mismatch (PPM) after Cryolife O'Brien (CLOB) suprannular stentless valve replacement in patients with a small aortic root and its repercussions on the patient's hemodynamic status and left ventricular mass regression., Background: The correct management of the small aortic annulus is still controversial. Small aortic prostheses can lead to a PPM, which results in high gradients with important repercussions on the hemodynamic status., Methods: Seventy-two patients (mean age: 72.5 +/- 6.2 years, 73.6% women) with a small aortic root (< or =21 mm intraoperatively measured aortic annulus) had a CLOB valve implanted in the aortic position between November 1993 and July 2001 at our institution. Mean prosthesis size was 22.0 +/- 0.8 mm. Patients underwent echocardiography preoperatively, at discharge, six months, one year and yearly thereafter., Results: The incidence of PPM at discharge was 22.2% (16/72); 18.7% were severe (effective orifice area index [EOAI] < or =0.65 cm/m(2)), 43.7% were moderate (EOAI = 0.66 to 0.75 cm/m(2)) and 37.6% were mild (0.76 to 0.85 cm/m(2)). At multivariable analysis, gender (p < 0.001), age (p = 0.015), body surface area (p < 0.001) and patient's annulus index (p < 0.001) were significant factors influencing the occurrence of "transient" PPM. At one year the incidence of PPM was 0%. CONCLUSIONS; Suprannular CLOB valve yielded excellent hemodynamic results in patients with small aortic roots. This study demonstrates that PPM can be completely avoided when using the CLOB valve. The superior hemodynamics of this stentless valve are likely to be related to its suprannular design.

Background: The St. Jude Medical Regent is a new generation mechanical aortic valve., Methods: Between March 2000 and July 2001, this valve was implanted in the aortic position in 40 patients (21 men; mean age 59.1 +/- 9.0 years). Preoperatively, 24 patients (60%) were in New York Heart Association functional class III or IV. Eighteen patients (45%) underwent associated procedures. Mean valve size was 21.4 +/- 2.4 mm. The mean duration of follow-up was 8.5 +/- 4.5 months (range, 1 to 16 months)., Results: There were no operative deaths. Early complications included one reoperation for bleeding and one transient low output syndrome. Valve replacement was followed by a significant reduction in mean and peak transaortic gradients over time (p < 0.001) and analysis of variance failed to demonstrate statistical differences between valve size over time (p = not significant). A significant reduction in left ventricular hypertrophy occurred over time (p = 0.01) in all valve sizes (p = not significant between groups): baseline left ventricular mass index was 194 g/cm2; it reduced by 22 g/cm2 (p = 0.006) at discharge. Left ventricular mass index decreased from 172 +/- 55 g/cm2 to 156 +/- 44 g/cm2 (p = 0.03) from discharge to 2 months. Further reductions were not significant. Relative wall thickness decreased from 0.57 +/- 0.13 preoperatively to 0.42 +/- 0.06 at discharge (p = 0.001), and again at 2 months (-0.2; p = not significant), and at 1 year (-0.02; p = not significant)., Conclusions: The early experience with the St. Jude Medical Regent valve has been satisfactory.

Objective: Seven-year clinical and hemodynamic results of the Cryolife O'Brien (CLOB) stentless bioprosthesis in elderly patients are reported., Methods: From 1993 to 2000, 36 patients aged >75 years had a CLOB implanted in the aortic position. Eighteen (50%) were male. All patients were monitored with serial echocardiograms performed preoperatively, at discharge, six months, one year and yearly thereafter., Results: The 30-day mortality was 2.4% (1/36). Actuarial survival at one, five and seven years were 96.7+/-1.5, 94.8+/-2.0 and 94.8+/-2.0%, respectively. Peak and mean gradients (PG and MG) reduced and effective orifice area index (EOAI) increased over time (P<0.001). Left ventricular mass index (LVMI) reduced by 32 g/m2 at discharge (P<0.001) and by 33 g/m2 at six months (P<0.001) without further significant changes., Conclusions: In our series CLOB xenograft resulted to be a satisfactory valve substitute in elderly patients.

Objective: The aim of this study was to evaluate early recovery of systolic function after stentless aortic valve replacement (AVR) versus stented AVR., Methods: Fifty-four consecutive patients with pure aortic stenosis and impaired left ventricular function (LVEF < or = 35%) were studied retrospectively. Aortic regurgitation, concomitant valvular or coronary artery surgery, atrial fibrillation, and a previous AVR were exclusion criteria. Twenty-two patients (mean age, 70.0 +/- 6.5 years) received a stentless bioprosthesis and 32 (mean age, 58.9 +/- 6.2 years, P =.031 between groups) a mechanical or stented biologic valve. Patients underwent echocardiography preoperatively, at discharge, at 6 months, and at 1 year after surgery., Results: At 6 months, analysis of variance demonstrated significant differences between groups in fractional shortening measured at the endocardium and midwall fractional shortening (<0.001), velocity of circumferential shortening (P <.001) ejection fraction (P =.02), left ventricular mass index (P <.001), systolic meridional wall stress, and circumferential wall stress (P <.001), One-year studies confirmed these findings., Conclusion: LV function showed, after a stentless AVR, an early recovery greater than in patients receiving a stented valve., (Copyright 2001 by W.B. Saunders Company)

Background: Stentless aortic valves are associated with a significant decrease in left ventricular hypertrophy. This study examined the time course and factors affecting left ventricular mass regression (LVMR) after aortic valve replacement (AVR) with Cryolife O'Brien (CLOB) (Cryolife International, Atlanta, Ga) stentless valves., Methods: Between 1993 and 2000, 130 consecutive patients underwent AVR with CLOB. Mean age was 71.3 +/- 6.3 years. Sixty-four (49.2%) were male. Mean body surface area (BSA) was 1.7 +/- 0.2 m(2). Mean valve size implanted was 23.6 +/- 2.0 mm. All patients were monitored with serial echocardiograms; the first study was performed preoperatively, and subsequent controls were at 6 months, 1, 2, 3, 4, 5, 6, and 7 years, respectively. Left ventricular mass was calculated by the Devereux formula and indexed by BSA., Results: Analysis of variance showed a significant reduction in the left ventricular mass index (LVMI) over time (P < .001). Most LVMRs occurred within the first 6 months, and after 1 year LVMI had decreased by 37.5% with further, but not statistically significant, reductions at later examinations. We found that baseline BSA > 1.75 m(2), male sex, arterial blood pressure > or = 150 mm Hg, left ventricular ejection fraction < or = 35%, New York Heart Association functional class > or = III, non-sinus rhythm, and prevalent aortic incompetence to be factors influencing LVMR. LVMR was not related to postoperative effective orifice area < or = 0.85 cm/m(2) and prosthetic size., Conclusions: AVR with a CLOB valve is followed by a significant LVMR that occurs soon after surgery. It is influenced by several patient-related factors: most of them can be predicted preoperatively.

Background: The Cryolife O'Brien (CLOB) is a composite stentless bioprosthesis constructed from noncoronary leaflets of three porcine aortic valves. This study aimed to investigate early and midterm results after aortic valve replacement with CLOB xenograft., Methods: Between 1993 and 2000, the CLOB was implanted in 125 patients (62 men; mean age 71.3+/-6.4 years). Mean prosthesis size was 23.6+/-2 mm. Mean follow-up time was 37.0+/-12.1 months. Patients underwent echocardiographic studies preoperatively, at discharge, at 6 and 12 months postoperatively, and yearly thereafter., Results: Early (30-day) mortality rate was 2.4% (3 of 125 patients). Of the four late deaths, none was valve related. Actuarial 7-year survival was 93.6%+/-3%. Seven-year freedom from primary valve failure was 98.1%+/-1.8%. All patients showed an improvement of functional status (p < 0.001). ANOVA revealed a significant reduction over time in peak and mean systolic gradients (p < 0.001). Effective orifice area index increased (p < 0.001) and left ventricular mass index significantly reduced in all valve sizes (p < 0.001) during this time interval., Conclusions: Because the early and midterm results with CLOB xenograft have been satisfactory, we encourage its use as a valve substitute, particularly in patients with small aortic roots.

Background: Mortality, morbidity, complication rates, and echo hemodynamic results using the Cryolife O'Brien stentless aortic bioprosthesis over a 5-year period are reported., Methods: The stentless valve was implanted in 97 conscecutive patients, 54 male and 43 female, mean age 70.9 +/- 6.5 years. All patients underwent preoperative, discharge (early study), 6-month (intermediate study), and late (18.3 +/- 10.4 months) echocardiography., Results: The actuarial 5-year survival rate was 93.9% +/- 3%. Aortic regurgitation was absent in 95.5%, mild in 3.4%, and moderate in 1.1%. Peak and mean systolic gradients were significantly lower at discharge (p < 0.001) and at the 6-month follow-up (p < 0.001) but did not significantly fall further at the late study (p = NS). The effective orifice area index at discharge (p < 0.001) and at 6 months (p < 0.001) differed significantly from preoperative values, but variations at late study were not significant (p = NS). Left ventricular mass index decreased early postoperatively (p < 0.001) and at 6-month assessment (p < 0.001) with a further significant reduction at late echocardiography (p = 0.04)., Conclusions: The 5-year results of this stentless valve showed a low rate of valve-related complications with excellent hemodynamic performance in all valve sizes.

Objectives: The usefulness of transesophageal echocardiography (TEE) in assessing the postoperative results of aortic root replacement (Cabrol's procedure) was evaluated., Methods: Between 1986 and 1993, 31 patients underwent replacement of the aortic valve and ascending aorta by a composite graft using the Cabrol procedure. Twenty-six patients had annuloaortic ectasia, two type I DeBakey dissection and four type II dissection. Hospital mortality was 9.7%. Studies were performed in 18 patients, two to 70 months (mean 27.5 months) after composite graft replacement. The following features were examined: prosthetic aortic valve function, coronary graft morphology and function, tubular graft and aneurysm wrapped around morphology and dimensions, presence of intimal flap, false lumen and thrombus in the false lumen and persistence of right atrial fistula., Results: Periprosthetic leakage with significant regurgitation was detected by TEE in 3 (16.6%) of 18 patients. In one patient with infected aortic graft a fistula between the periprosthetic space and the right ventricle was detected (confirmed at reoperation). In another patient occlusion of the graft for left coronary artery was noted. In three patients (16.6%) an aneurysm of the periprosthetic space with perivalvular leakage and persistence of the fistula with the right atrium was visualized. In the two patients operated for DeBakey type I dissection an intimal flap persisted distal to the graft and in one patient flow was detected in the false lumen, while it was totally obliterated in the other., Conclusions: 1) Complications after Cabrol's procedure are not infrequent; although the real importance of some of them (periprosthetic aneurysm, persistence of dissection) is uncertain, a careful follow-up may be essential to improve the long term survival. 2) TEE is a useful and well-tolerated procedure for postoperative follow-up of patients who underwent aortic root replacement with Cabrol's procedure.