Table Of ContentGuide to
Prosthetic Cardiac Valves
Guide to
Prosthetic Cardiac Valves
Edited by
Dryden Morse, Robert M. Steiner,
and Javier Fernandez
With Contributions by
V.O. Bjork J.M. Dunn J. Fernandez
S. Flicker W.S. Frankl S. Gabbay
L. Gonzalez-Lavin M.N. Kotler J .Y. Kresh
S.G. Meister G.S. Mintz D. Morse
LP. Panidis F.J. Schoen R.M. Steiner
N.M. Wolf
With 204 halftone illustrations in 301 parts and 78 line illustrations
Springer-V erl ag
New York Berlin Heidelberg Tokyo
Dryden Morse, M.D., Deborah Heart and Lung Center, Browns Mills,
New Jersey, 08015, U.S.A.
Robert M. Steiner, M.D., Professor of Radiology, Department of Radiology,
Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
19107, U.S.A.
Javier Fernandez, M.D., Deborah Heart and Lung Center, Browns Mills,
New Jersey 08015, U.s.A.
Library of Congress Cataloging in Publication Data
Main entry under title:
Guide to prosthetic cardiac valves.
Includes bibliographies and index.
1. Heart valve prosthesis. I. Morse, Dryden P.
(Dryden Phelps), 1924- II. Steiner, Robert M.
III. Fernandez, Javier.
[DNLM: 1. Heart Valve Prosthesis-instrumentation.
2. Pacemaker, Artificial-instrumentation. WG 26 G946]
RD598.G79 1985 617' .412 85-9952
@ 1985 by Springer-Verlag New York Inc.
Sofcover reprint of the hardcover I st edition 1985
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Typeset by Kingsport Press, Kingsport, Tennessee
9 8 7 6 5 432 1
ISBN-13: 978-1-4612-9562-4 e-ISBN-13: 978-1-4612-5096-8
DOl: 10.1007/978-1-4612-5096-8
.
Foreword: Recent Improvements In
Tissue Valves
The field of valvular heart replacement has evolved during the last two
decades to a level where valve substitutes are highly reliable. From the
outset this field divided sharply into two main approaches: mechanical
prostheses and biological tissue valves. Both methods have taken signifi
cant steps forward toward the ultimate goal of the "ideal valve substi
tute." However, each still falls short of that goal.
Mechanical prostheses, although available in all shapes and materials,
continue to have gradients in small valve sizes and the perennial problem
of thromboembolism. Anticoagulants are mandatory for the rest of the
patient's life when using any of these prostheses, which introduces the
inherent risk of anticoagulant-related hemorrhage. Durability is sup
posed to be their "forte," and in general this has been true, regarding
the device itself. But all of us involved in this field have seen patients
die from complications of thromboembolism or anticoagulant-related
hemorrhage with a perfectly intact and functional prosthesis.
Biological tissue valves have diverged in several directions, with re
spect to the tissue used and to the supporting apparatus, while retaining
the common characteristic of simulating the native (aortic) valve. The
original method of implanting a "free-hand" homograft aortic valve (1,2)
continues to be very reliable in the aortic position, although there are
some shortcomings as to availability and durability. The initial uncertain
ties have dissipated to some extent, as long-term follow-up studies have
repeatedly shown excellent hemodynamics without valve gradients and
no thromboembolism, even without anticoagulant therapy (3,4). Homo
graft valve preparation, namely sterilization and storage, has signifi
cantly influenced durability (5,6). Fresh antibiotic-sterilized homograft
valves show less degenerative changes, hence, greater durability (6). Due
to the cumbersome process of valve procurement, deep-freezing tech
niques to -90°C have been developed; the long-term superiority of this
method over antibiotic-sterilized valves preserved in nutrient medium
at 4°C for 4-8 weeks is yet to be determined.
Due to the problems of supply of homograft valves and the strong
belief in the advantages of biological tissue for heart valve replacement,
xenograft valves were the logical step forward (7) after a short trial
with autologous fascia lata.
Availability and reliability have established the porcine (8,9) xenobio
prosthesis as the most commonly used tissue valve. By attaching the
vi Foreword: Recent Improvements in Tissue Valves
valve to a frame (a necessary step due to the inherent anatomical features
of the porcine valve) a hybrid type of device was produced. This has
shown advantages, namely, commercial availability and good hemody
namic function in the larger sizes. Disadvantages, however, include a
significant incidence of thromboembolic complications (10). This finding
is even more conspicuous when compared with the free-hand homograft
aortic valve and other xenobioprostheses (11). They have also shown a
significant incidence of degenerative changes, namely, late calcification
recognized 6-8 years after implantation (12).
An alternative device, the man-made bovine pericardial valve has im
proved some of the features of the porcine xenobioprostheses (13). The
larger effective orifice allows for better hemodynamics and a signifi
cantly lower incidence of thromboembolism (11). The durability of this
xenobio prosthesis is being evaluated after an 8-year experience in this
country (14) and a 15-year experience in the United Kingdom (15).
The most important factors in the overall performance of the hybrid
(porcine and bovine pericardial) valves are: valve design, type of valve
tissue, and process of preparation. Valve design dictates the hydraulic
and hemodynamic function and, to a degree, determines the thrombogen
icity of a given valve. The tissue utilized and the pressure applied to it
during fabrication dictates, to a certain extent, the durability of each
device, as does the methods of sterilization and stabilization. Along these
lines, several modifications have taken place with porcine valves in the
past few years. Improvements in the type of frame and mounting tech
niques, as well as in the methods of preparation, appear promising for
the newer Carpentier-Edwards and the Tascon porcine valves. The bovine
pericardial valve has been modified to have a lower profile. A different
approach to its construction is being developed to avoid the well-known
"abrasion lesion" which has been identified as the initial step for calcifica
tion and tissue disruption. The addition of surfactants and other chemi
cal methods to decrease the incidence of calcification is being tested
with several of the xenobioprostheses. With these modifications one can
expect an improved valve substitute with a lower incidence of thrombo
embolism and better hemodynamic features as well as increased dura
bility.
For the homograft valve, the methods of procurement and sterilization
will playa major role in future durability. The application of surfactants
during sterilization and/or the addition of immunosuppressive drugs ei
ther to the valve per se or to the recipient should improve long-term
function.
One other approach in the field of biological tissue valves that should
be considered (again) is the use of autologous pulmonary valves for aortic
valve replacement. This method, originally devised by D. N. Ross (16),
has proven to be reliable with excellent valve durability (17). The au
thor has had experience with this approach and the long-term follow
up results corroborate the experience reported by D. N. Ross and associ
ates (18).
In summary, recent improvements in the quality of the available tissue
valves leads to hope for further steps forward in the development of
"the ideal valve substitute."
References vii
References
1. Ross DN: Homograft replacement of the aortic valve. Lancet 2:487,1962.
2. Barrett-Boyes B: Homograft aortic valve replacement in aortic incompetence
and stenosis. Thorax 19:131, 1964.
3. Thompson R, Yacoub M: The use of "fresh" unstented homograft valves
for replacement of the aortic valve: analysis of 8 years' experience. J Thorac
Cardiovasc Surg 79:896, 1980.
4. Penta A, Qureshi S, Radley-Smith R, Yacoub M: Patient status 10 or more
years after fresh homograft replacement of aortic valves. Circulation (Part
II) 70:1-182, 1984.
5. Gonzalez-Lavin L, Al-Janabi N, Lockey E, Ross DN: Fibroblast viability in
antibiotic treated valves. N Z Med J 77:36, 1973.
6. Gonzalez-Lavin L, O'Connell T: Mitral valve replacement with viable aortic
homograft valves. Ann Thorac Surg 6:592, 1973.
7. Binet JP, Duran CG, Carpentier A, Langlois J: Heterologous aortic valve
transplantation. Lancet 2:1275, 1965.
8. Davila JC, Magilligan DJ Jr, Lewis JW Jr: Is the Hancock porcine valve
the best cardiac valve substitute today? Ann Thorac Surg 26:303, 1978.
9. Oyer PE, Miller DC, Stinson EB, Shumway NE: Clinical durability of the
Hancock porcine bioprosthetic valve. J Thorac Cardiovasc Surg, 80:824, 1980.
10. Gonzalez-Lavin L, Chi S, Blair TC, Lewis B, Daughters G: Thromboembolism
and bleeding after mitral valve replacement with porcine valves: Influence
of thromboembolic risk factors. J Surg Res 36:508, 1984.
11. Gonzalez-Lavin L, Tandon AP, Chi S, Blair TC, McFadden PM, Lewis B,
Daughters G: The risk of thromboembolism and hemorrhage following mitral
valve replacement: A comparative analysis between the porcine xenograft
valve and the Ionescu-Shiley bovine pericardial valve. J Thorac Cardiovasc
Surg 87:340, 1984.
12. Magilligan DJ Jr, Lewis JW Jr, Jara FM: Spontaneous degeneration of por
cine bioprosthetic valves, Annals of Thoracic Surgery, 30:259, 1980.
13. Ionescu MI, Tandon AP, Mary DAS, Adid A: Heart valve replacement with
the Ionescu-Shiley pericardial xenograft. J Thorac Cardiovasc Surg 73:31,
1977.
14. Gonzalez-Lavin L, Chi S, Johnson D, Lewis B: Eight-year experience with
the standard Ionescu Shiley pericardial valve in the aortic position. Interna
tional Symposium on Cardiac Bioprosthesis, London, 21-23 May, 1985.
15. Ionescu MI, Silverton NP: Long term durability of the pericardial valve.
International Symposium on Cardiac Bioprosthesis, London, 21-23 May,
1985.
16. Ross DN: Replacement of aortic and mitral valves with pulmonary autografts.
Lancet 2:956, 1967.
17. Gonzalez-Lavin L, Geens M, Somerville J, Ross DN: Autologous pulmonary
valve replacement of the diseased aortic valve. Circulation 42:781, 1970.
18. Robles A, Vaughn M, Lau JK, Bodnar E, Ross DN: Long term assessment
of aortic valve replacement with autologous pulmonary valves. Ann Thorac
Surg 39:238, 1985.
Browns Mills, New Jersey Lorenzo Gonzalez-Lavin, M.D.
April,1985
Preface
Weare entering an especially prolific era in reporting and publishing
clinical experiences with cardiac valve replacement. A voluminous litera
ture on this subject is already in existence, emanating from clinicians,
surgeons, bioengineers, and other scientists. Additionally, information
presented at heart valve symposia in the form of bound collections
reaches the shelves of the medical book stores every year. This activity
reflects the dynamic state of cardiac valve technology, highlighted by
the introduction each year of new valve designs that often utilize new
materials.
As a result, the authors recognized the need to update their book The
Pacemaker and Valve Identification Guide, separating the contents into
two volumes dealing with pacemakers* and cardiac valve technology.
For this Guide to Prosthetic Cardiac Valves, we have gathered a group
of recognized authorities in the field, all of whom have contributed in
depth analysis in their areas of expertise. New material dealing with
the preoperative and postoperative care ofthe heart valve patient, pathol
ogy of cardiac valves, bioengineering problems of cardiac valve technol
ogy, and separate chapters on valve implantation in children and ultra
sonography have been added. Chapter 3, "The Radiology of Prosthetic
Heart Valves," we feel will be particularly helpful to the physician in
identifying a prosthetic valve and revealing the most likely complica
tions. Chapter 10 is an atlas with descriptions to supply the reader with
the essential features of the various prostheses when he or she is faced
with a new patient bearing an implanted cardiac valve. (This situation
arises frequently because of the mobility of our population.) When a
late complication such as stroke affects a patient with an artificial heart
valve, the attending physician must try to determine the cause of the
complication and decide whether it is valve related or due to some other
cause, so that appropriate medical or surgical therapeutic measures may
be taken.
The chapter describing the various surgical techniques of cardiac valve
replacement is designed to give important background information on
postoperative complications that may have their inception in the operat
ing room. Material related to valves that have not been fully approved
by the Food and Drug Administration and that are classified as investiga-
• A Guide to Cardiac Pacemakers, F. A. Davis Company, Philadelphia, Pennsylvania, 1983.
x Preface
tional devices and bioengineering data on heart valves are included to
make the book more "durable," since many ofthese devices are promising
and may soon be introduced from trial series into general clinical prac
tice.
The purpose of this book is to be a useful and practical reference
source for cardiologists, internists, radiologists, surgeons, emergency
room physicians, and others who deal with patients suffering from valvu
lar heart disease.
We would like to acknowledge the generous cooperation and assistance
of valve manufacturers who have supplied us with photographs, dia
grams, and other printed information about their valves. We wish partic
ularly to thank Dr. Jerry Stone of Springer-Verlag New York Inc. for
his editorial help and patience.
Contents
Foreword Lorenzo Gonzalez-Lavin v
Preface ix
Contributors xv
1 The Development of Artificial Heart Valves:
Introduction and Historical Perspective 1
Viking 0. Bjork
2 The Evaluation of Patients for Prosthetic Valve
Implantation 5
William S. Frankl
Mitral Stenosis 5
Rheumatic Mitral Regurgitation 12
Nonrheumatic Mitral Regurgitation 17
Combined Mitral Stenosis and Regurgitation 21
Aortic Stenosis 23
Aortic Regurgitation 28
Combined Aortic Stenosis and Regurgitation 35
Combined Mitral and Aortic Valve Disease 36
Tricuspid Valve Disease 37
Pulmonic Valve Disease 40
Summary 41
References 41
3 The Radiology of Prosthetic Heart Valves 53
Robert M. Steiner and Stephanie Flicker
Preoperative Patient Selection 53
Postoperative Evaluation 54
Radiographic Identification of Prosthetic Valves 55
Radiographic Evaluation Following Valve Replacement 55
Complications of Prosthetic Valves 65
Magnetic Resonance Imaging 75
Summary 75
References 75
xii Contents
4 Ultrasonography of Cardiac Valves 79
Gary S. Mintz, Morris N. Kotler, and Ioannis P. Panidis
Noninvasive Techniques 79
Mechanical Prostheses 81
Bioprostheses 95
Left Ventricular Dysfunction 97
References 99
5 Surgical Aspects of Valve Implantation 101
Javier Fernandez
Types of Artificial Heart Valves 103
Complications of Valve Substitutes 152
Technical Principles of Valve Replacement 158
References 171
6 Postoperative Management of Patients with Implanted Valvular
Prostheses 179
Steven G. Meister and Nelson M. Wolf
Early Postoperative Management 179
Long-Term Management of Patients with Valvular
Prostheses 185
References 188
7 Prosthetic Cardiac Valves in Children 191
Jeffrey M. Dunn
The Mitral Valve in Children 191
The Aortic Valve in Children 193
The Pulmonary Valve in Children 199
The Tricuspid Valve in Children 201
The Choice of Prosthetic Valves for Children 202
Prosthetic Valves in Children-An Overview 207
Acknowledgment 207
Bibliography 207
8 Pathology of Cardiac Valve Replacement 209
Frederick J. Schoen
Early Postoperative Pathology 209
Late Pathologic Features 211
Prosthesis-Associated Complications 212
Analysis of Explanted Specimens 230
Acknowledgment 232
References 232
9 Bioengineering of Mechanical and Biological Heart Valve
Substitutes 239
Shlomo Gabbay and J. Yasha Kresh
Dynamic Valve Motion Analysis 239
In Vitro Hydrodynamic Characteristics 244
Results 247
Discussion 251
