Table A1. Mean Cardiac Valve Diameters (mm) Normalized to Body Surface Area.
Mitral Valve Tricuspid Valve Aortic Valve Pulmonary Valve
BSA RRLa GOSb RRL GOS RRL GOS RRL GOS
0.25 11.2 16.0 13.4 19.2 7.2 10.3 8.4 12.0
0.30 12.6 18.0 14.9 21.3 8.1 11.6 9.3 13.3
0.35 13.6 19.4 16.2 23.2 8.9 12.7 10.1 14.4
0.40 14.4 20.6 17.3 24.7 9.5 13.6 10.7 15.3
0.45 15.2 21.7 18.2 26.0 10.1 14.4 11.3 16.2
0.50 15.8 22.6 19.2 27.5 10.7 15.3 11.9 17.0
0.60 16.9 24.2 20.7 29.6 11.5 16.4 12.8 18.3
0.70 17.9 25.6 21.9 31.3 12.3 17.6 13.5 19.3
0.80 18.8 26.9 23.0 32.9 13.0 18.6 14.2 20.3
0.90 19.7 28.2 24.0 34.3 13.4 19.2 14.8 21.2
1.0 20.2 28.9 24.9 35.6 14.0 20.0 15.3 21.9
1.2 21.4 30.6 26.2 37.5 14.8 21.2 16.2 23.2
1.4 22.3 31.9 27.7 39.6 15.5 22.2 17.0 24.3
1.5 23.1 33.0 28.9 41.3 16.1 23.0 17.6 25.2
1.8 23.8 34.0 29.1 41.6 16.6 23.6 18.0 25.7
2.0 24.2 34.6 30.0 42.9 17.2 24.6 18.2 26.0
Standard Deviations
Mitral Valve BSA < 0.3 = ±1.9 To convert to approximate predicted manufactured rigid BSA> 0.3 = ±1.6 prosthetic valve sizes, add 3–4 mm to measurement.
Tricuspid Valve BSA < 1.0 = ±1.7 BSA> 1.0 = ±1.5 Aortic Valve All BSA ± 1.0
Pulmonary Valve All BSA ± 1.2 BSA = m2
a RRL: data derived from Rowlatt and associates.b GOS= Great Ormond Street “normalized” diameters. Adapted from de Leval.
Appendix: Valve Diameters
621 Table A1 lists mean “normal valve diameters:
the first column for each valve comes from the data measured by Rowlatt and associates. The Great Ormond Street (GOS) group have found that these valve measurements tend to under- estimate the true in vivo sizes. The data from
Rowlatt and coworkers (RRL data) were derived from a large series of normal hearts examined at autopsy. The Great Ormond Street group noted that there was a shrinkage factor due to formalin. Their angiographic estimates were correlated to fresh autopsy material and
suggested that the atrioventricular valves were certainly under-estimated by the earlier tech- niques. The London (GOS) workers suggested that the RRL measurements should be multi- plied by a factor of 1.43 to equal their fresh measurements (C. Bull, personal communica- tion). Thus this table includes both the original data of Rowlatt and coworkers and the larger estimates of “normal.”
The way we use this table relative to ventric- ular outflow valves is to consider the RRL valve diameters as the minimun acceptable diameter for a given body surface area and the GOS diameters as the mean to upper limits of achiev- able valve transplants. From a practical stand- point it means that we would try to place, for an “adult” sized freehand aortic valve implant, an allograft of 20 mm (internal diameter) for an individual with a body surface area (BSA) of 1 m2and a valve as large as 24.6 mm for a 2 m2 individual. Once a patient reaches approxi- mately 20 kg in weight, an aortic valve of 17 mm or larger is usually implantable in the aortic position with the techniques described in the foregoing chapters, which is within the accept- able range.
The pulmonary outflow tract is optimally reconstructed with a 22 mm pulmonary valve for a 1 m2individual and could be as large as a 26 mm for a 2 m2 individual adult. In most patients a valve between the upper and lower sizes is almost always achievable. On the right ventricular outflow tract side, a 14 mm (internal diameter) aortic valve can usually be place in a 5 kg child; once the child weighs more than 10 kg, a right ventricular allograft conduit of 16 mm or larger is implantable; and in children above 20 kg, it is almost always possible to place a 20 mm or larger conduit in the right ventricu- lar outflow tract position. Mercer has argued that a more than 50% reduction in pulmonary valve orifice size is required before significant gradients occur. However, right-sided conduits have length as well as diameter, thus sizes below the RRL values are not recommended.
With use, we have found that this table has been best at predicting the aortic and pulmonary valve diameters. It is important to remember that the diameters in these tables refer to the internal diameters, not the external diameters.
The aortic and pulmonary valve columns are immediately translatable to homograft sizes which are also measured in internal diameter.
For manufactured valves, at least 2–4 mm needs to be added to correlate with the external sewing ring diameter as usually listed for rigid stented valves.Thus, a mechanical mitral valve choice for a 2.0 m2BSA individual, would be preferably a size 27.For the aortic position,the smallest aortic prosthesis one would ever consider for a 2.0 m2 individual would be 17.2 plus 4.0 mm which equals a 21, but the GOS value gives the pre- ferred size of 25.
Manufactured valve sizes do not necessarily reflect either the predicted internal diameter of a natural valve for the patient or, in fact, even the measured external diameter of the pros- thesis, but in fact are an approximation of those two values based upon manufacturing require- ments. The mean diameters listed in Table I are actual internal diameters as would be measured by echocardiography from the hinge point of the base of the leaflets across the orifice of each valve. Thus they reflect the target values for reconstructions. They do not directly represent the prosthetic sewing ring valve size as is nor- mally tabulated for manufactured valves. The mitral and tricuspid valve measurements have been correlated with empiric use of valve ring diameters used in reconstructions for patients between 1.0 and 2.0 BSA. These are listed in Table A2.
These “ring” estimates are target values based on BSA normalized valve measurements. They must be modified by specific measurements at surgery of available leaflet tissue for orifice cov- erage and the specific type and configuration of ring being used. We do not use rigid rings in smaller children to allow for growth.
Table A2. AV Valve Ring Diameter for Reconstruction.
Mitral Valve Tricuspid Valve
BSA (m2) (mm) (mm)
1.0 26 32
1.2 28 34
1.4 29 36
1.5 30 37
1.8 31 38
A
AATB. See American Association of Tissue Banks (AATB) ABO blood group antigen
compatibility, 124–126, 128 relationship with allograft
heart valve rejection, 126 role in fibroblast calcification,
186
Abscess, of aortic root, 85 aortic vs. allograft
implementation in, 99 total-root replacements in, 351,
352
Abscess cavities, in endocarditis antibiotic/fibrin glue filling of,
90
debridement of, as annular defect cause, 90, 91 involving aortic annulus and
mitral valve, 92 patch closure of, 87–88 Acellularization technology, 153 Acid-base homeostasis, during
ischemia, 139
Acid glycosaminoglycans, heart valve content of, 135–136 Acid mucopolysaccharides,
diffusion from tissues, 252–253
Actin, co-localization with myosin, 115
Actinomyces, as myocarditis and endocarditis cause, 249 Activated partial thromboplastin
time (aPTT), 406
Adenine nucleotide metabolism, effect of preimplantation processing on, 214
Adenosine deaminase, inhibition of, 138
Adenosine diphosphate (ADP), effect of preimplantation processing on, 166, 167, 167, 167t, 168, 168, 169, 170, 171t, 172
Adenosine monophosphate (AMP), effect of preimplantation processing on, 166, 167, 167, 167t, 168, 168, 169, 170, 171t, 172
Adenosine triphosphate (ATP) effect of preimplantation
processing on, 120, 165–167, 166, 167, 167t, 168, 168, 169, 170, 171t, 172
in hypothermia, 137
Albumin, as cryoprotectant, 251 Aldehyde-formaldehyde
mixtures, as allograft sterilants, 196
Allergic reactions, to aprotinin, 402, 405–406
AlloFlow™cryoprotectant removal system, 151, 152, 265, 266
Allogeneic valves, immunological response in, 125–126 Allograft, definition of, 193 Allograft heart valves. See also
Cryopreserved allograft heart valves
advantages of, 596 antigenicity and
immunogenicity of, 31, 123–130, 186, 231–232
ABO blood group antigen compatibility, 124–126, 128, 186
animal studies of, 123–124 complement 3C, 125 effect of cryopreservation
on, 152–153
effect of immunosuppressant therapy on, 127
effect of viable donor cells on, 175
endothelial, 125, 138, 185 HLA, 153, 186
HLA-A, 110 HLA-B, 110 HLA-C, 110
HLA class I antigens, 125 HLA class II antigens, 125 HLA-DP, 110
HLA-DQ, 110
HLA-DR, 110, 127, 128 human studies of, 124–125 major histocompatibility
complex (MHC) antigens, 124, 125
modulation of, 126–127 role in pediatric allograft
heart valve failure, 152–153
classification of, 245, 247 Class II, 237, 599, 600 Class III, 237, 597–598
“implantable with some imperfections,” 247
“perfect,” 247
“unacceptable for clinical use,” 247
comparison with mechanical valves, 6
complement 3C, 110–111
Index
623
Allograft heart valves (cont.):
durability of, role of matrix and chemical properties in, 186–187
examination of, 245–247, 246 failure of
early, 123
immunologic factors in, 126, 152–153
in pediatric patients, 152–153 in younger patients, 123 fresh, wet-stored, 77, 196
fibroblast viability in, 6 ideal, 100
labeling of, 262–263 morphology of, 200–209
of aortic and pulmonary valves, 200–206, 207 cellular components,
201–204, 202, 203, 204, 205 extracellular matrix,
204–206, 207 general morphologic
features, 200–201 of mitral valves, 207–208 overview of, 193–212 quality assessment of, 247 repeat transplants of, 128 size criteria for, 240 sizing of, 245–247, 246 very low gradient, 5–6 Alpha-stat regulation, 139 American Association of Tissue
Banks (AATB), 266 role of, 596
Standards for Tissue Banking, 237, 596
for allograft evaluation and examination, 247–248 for cold and warm ischemia,
240
for cryopreservation, 136, 237, 251, 596
for heart valve dissection, 244, 245
for heart valve donors, 239–240
for heart valve donor screening, 239–240 for labeling of allograft
heart valves, 262–263 for sterilization and
disinfection of allograft heart valves, 247–248
voluntary compliance with, 595 American Red Cross, 598 Amicar
as aprotinin alternative, 402 comparison with aprotinin, 403 Amino acid incorporation test,
for cellular viability assessment, 162t Aminocaproic acid
as aprotinin alternative, 402 comparison with aprotinin, 403 Amphotericin B
contraindication as allograft heart valve disinfectant, 248–249
toxicity of, 140
Anaphylactic reactions, to aprotinin, 402, 405 Anastomosis. See also Distal
anastomosis; Proximal anastomosis
coronary, in inclusion- root/intra-aortic cylinder techniques, 340, 343 Damus/Kaye/Stanzel, 568, 575,
577, 578, 578, 579–580 inferior cavopulmonary
anastomosis, in Fontan operation, 588, 588–589 ventricular, pledgetted
techniques in, 463, 466 Anencephalic infants, as heart
valve donors, 239 Aneurysm, aortic
aortic root
as aortic valve allograft contraindication, 7–8 imaging of, 396
ascending aortic, total-root replacements in, 351 pulmonary autograft
implementation in, 502 Angiography, for aortic root
sizing, 272 Annuloplasty
with augmentation aortoplasty, 310, 311, 312, 390–311 for 180° coronary ostia
rotation, 314–315, 315 Antibiotic cold solutions, for allograft storage, 196 Antibiotic sterilization, of allo-
graft heart valves, 3, 139–140, 139t, 196, 247–248
American Association of Tissue Banks Standards for, 247–248
antibiotics used in, 248–249, 249t
effect on allograft heart valve survival rate, 6
effect on cellular viability, 175 gentle, 9
harsh, 9
sterility control procedures in, 250
temperature of, 138 Anticoagulation
contraindications to, 78, 455 in right ventricular outflow
reconstruction, 605 in elderly patients, 605, 608 with mechanical heart valves,
338, 602
in aortic positions, 608–609 monitoring of, 406
as mortality cause, 6 Antifreeze proteins, natural,
145–146, 145t
Antigens/antigenicity, 31, 123 ABO blood group antigen
compatibility, 124–126, 128 relationship with allograft
heart valve rejection, 126 role in fibroblast
calcification, 186 animal studies of, 123–124 effect of viable donor cells on,
175
endothelial cells in, 185 HLA
donor-specific, in recipients of cryopreserved heart valves, 153
in pediatric allograft heart valve recipients, 186 HLA-A, endothelial
expression of, 110
HLA-B, endothelial expression of, 110
HLA-C, endothelial expression of, 110
HLA class I antigens, 125 HLA class II antigens, 125 HLA-DP, endothelial
expression of, 110 HLA-DQ, endothelial expression of, 110
HLA-DR
endothelial expression of, 110
matching for, 127, 128 human studies of, 124–125 major histocompatibility
complex (MHC) antigens, 125
donor-recipient matching of, 124
modulation of, 126–127 Anti-HLA class I antibodies, 125 Aorta, dissection of, 241, 244, 245
aprotinin use in, 404 pulmonary autograft
implementation in, 502 Aortic allografts. See also
Cryopreserved aortic allografts
in aortic root replacement, 318–326, 327–337 coronary buttons in, 319,
322, 324, 328, 329, 332, 334–335
indications for, 318–319 Konno procedure in, 327,
328
Manouguian-type maneuver in, 319
myomectomy in, 319, 322 postoperative management
in, 333, 337 sizing, 319
surgical techniques, 319–326, 320–325, 327–333, 328, 329–332, 334–336
Teflon felt strips in, 319, 322, 323, 325
in aortic valve replacement actuarial durability curves
of, 97, 97
comparison with stented pericardial bioprostheses, 97
comparison with stented porcine bioprostheses, 97 cross clamp time in, 97 infrequent use of, 30 reoperation rate, 5 scalloped subcoronary
versus root implantation, 30–39
subcoronary implantation, 26–27, 30–31, 38, 97
as total percentage of aortic valve replacements, 30
in aortoventriculoplasty, 327–337
postoperative management, 333, 337
surgical techniques, 327–333, 328, 329–332, 334–336 calcification of, 81, 124, 226 comparison with
stented pericardial bioprostheses, 98–99 stented porcine
bioprostheses, 99 contraindications against, 7–8,
271
cross clamp time with, 271 Denver Series, in pediatric
patients, 50, 52–53, 52t, 61, 61t
DNA in situ hybridization for Y chromosomes in, 180, 181
donors of, 7, 43 age, 26–27
double tilting disc, 605 durability of, factors affecting,
9
endocarditis as indication for use of, 99, 608, 609 explant pathology of
aortic wall calcification, 217–218, 218, 224, 226 apoptosis, 218–220, 221, 222 clinical studies, 222–229 collagen elongation,
217–218, 219
cuspal acellularity, 224, 225 cuspal calcification, 224, 226 endothelial cell nonviability,
224
in infants, 231–232
intracuspal hematoma, 224, 225
in non-cryopreserved cells, 222
in orthotopic animal models, 216
in orthotopic heart transplants, 223, 227–228, 228, 229t
preclinical studies (ovine models), 216–221
pyknotic endothelial cells, 222
in unimplanted vs.
implanted allografts, 223–224, 225 in extended “divide and
reapproximate”
implantation technique, 496–500
aortic allograft division, 496, 497
distal anastomosis, 497, 498, 499
distal positioning of valve allografts, 499, 500 mitral valve anterior leaflet
plane in, 496, 497 proximal anastomosis, 498,
499 failure of
competing risk factor analysis of, 27–28 interrelated risk factors for,
26–27
technical factors in, 7 first clinical use of, 3 first insertion in orthotopic
position, 3
freehand insertion of, 78 subcoronary, 97, 339,
350–351
fresh, wet-stored, 4–5 advantages of, 9
aortic wall calcification in, 8 durability of, 8
hemodynamics of, 102, 102t historical perspective on,
4–5, 6–8
New Zealand Series, 7–8 resistance to calcification, 9 resistance to endocarditis, 9 resistance to
thromboembolism, 9 frozen irradiated, failure rate
of, 4
hemodynamics of, 338 comparison with
bioprosthetic heart valves, 272
comparison with mechanical heart valves, 272
echocardiographic measurement of, 272, 272–273
Aortic allografts (cont.):
historical perspective on, 3–13 in inclusion-root/intra-aortic
cylinder techniques, 339–352
advantages and
disadvantages of, 346–347 allograft size, 339
allograft trimming, 339–340, 340
coronary anastomoses, 340, 343
postoperative aortic insufficiency associated with, 351, 351t
surgical techniques, 339–352 suture techniques, 340, 341,
342–344
transverse aortotomy, 340, 341
indications for, 7, 271 London Series, 6–7
mechanical heart valves versus, 338
in “miniroot” replacement techniques, 338–353 definition of, 339
inclusion-root/intra-aortic cylinder techniques, 339–352
preparation for insertion, 273, 273
in pulmonary valve replacement, 468–470, 469–470
in right ventricular outflow tract anomaly repair, 527
in right ventricular outflow tract reconstruction, 50, 456
aortic replacement following, 53 calcification of, 81 conduit size, 81
Denver Series, in pediatric patients, 50, 52–53, 52t, 61, 61t
early postoperative mortality, 52t, 53 patient population, 52–53 rationale for valve choice in,
605, 608–609 results, 52t, 53, 54t
in right ventricular outflow tract reconstruction, with ventricle-to-pulmonary artery conduits, 458–467 allograft trimming, 459 conduit length adjustment,
459–460
distal anastomosis, 459, 460, 461, 463
end-to-end anastomosis, 461, 462
pledget placement, 463, 466 polytetrafluoroethylene
hood extension, 458, 461–462, 464 principles of, 458–459 proximal anastomosis,
460–462, 462, 463, 465 with pulmonary annulus,
462, 463 pulmonary artery
reconstruction, 459 resection of hypertrophic
ventricular muscle, 462–463, 465
retention of membranous septal remnant, 462, 465 sizing, 458
suturing techniques, 458, 460, 461, 462, 463 in truncus arteriosus, 463 ventriculotomy, 458,
459–460, 461–462, 464 without pulmonary annulus,
462, 464
stented xenografts versus, 338 subcoronary insertion of, 97,
339, 350–351
as aortic insufficiency risk factor, 417
scalloped, 30–31, 38
as thromboembolism cause, 98 as mortality cause, 6 Aortic annulus
in endocarditis, 92 hypoplastic/small, 408, 413
with aortic valvular stenosis, 318
as indication for use of aortic valve allografts, 271 surgical enlargement of,
300–305, 301–304, 327, 382, 608
measurement of, 32
reduction of, 32, 34, 382 relationship with body surface
area (BSA), 300 surgical anatomy of, 32 surgical enlargement of,
300–305, 301–304, 382 with Konno-type procedure,
327
for mechanical valve implantation, 608 Aortic arches
hypoplastic augmentation in
Damus/Kaye/Stanzel anastomosis, 575, 575, 578, 579, 579–580
in left heart syndrome, 564–567, 565, 566–568 in L-transposition of the
great arteries with outflow chamber, 568, 569–71 transverse, with or without
coarctation, 572, 575, 576–577
interrupted anatomy of, 532
surgical repair of, 571–572, 572, 573–575
transposition of the great arteries-associated, 444, 571
truncus arteriosus- associated, 532, 536–538, 538, 539 540–541, 571, 572
ventricular septal defect- associated, 571, 572 Aortic insufficiency
aortic allograft-related, 8 Aortic outflow, hypoplastic, double outlet right ventricle repair of, 444, 445–447
Aortic outflow tract
reconstruction. See also Left ventricular outflow tract reconstruction; Right ventricular outflow tract reconstruction
valve choice for, 608 Aortic regurgitation
in aortic valve allograft failure, 24, 26
severity assessment of, 399, 401
transesophageal echocardiographic detection of, 399
Aortic regurgitation jet, in aortic valve infection, 86 Aortic regurgitation jet
velocity, as aortic regurgitation severity indicator, 399, 401, color plate IV
Aortic regurgitation jet width, relative to left ventricular outflow tract width, 399, 400, color plate IV Aortic root
abscess of, 85 aortic vs. allograft
implementation in, 99 total-root replacements in,
351, 352 aneurysm of
as aortic allograft contraindication, 7–8 imaging of, 396 aortoplastic reduction of,
306–309
diameter of, 245, 246, 246–247 dilatation of
as aortic allograft failure cause, 26
as aortic valve
contraindication, 7–8 proximal, 318
ectasia of, as allograft heart valve contraindication, 271
in endocarditis, 33–34, 82, 90, 92, 93, 93
enlargement of in aortic stenosis, 6 with augmentation
aortoplasty, 310, 311, 312, 390–311
with concomitant annulus enlargement, 310–311, 311, 312
infections of, pathology of, 85–87
with problematic geometry, 306–317
asymmetric placement of coronary ostia within native sinuses, 313–314, 313–314
augmentation aortoplasty, 309–310, 310
augmentation aortoplasty with concomitant annulus enlargement, 310–311, 311, 312
contraindications for correction of, 306
indications for correction of, 306
management of complicating coronary anatomy, 311, 313
reduction aortoplasty for, 306–309, 307–309
rotational geometry alterations of, with aortic root enlargement, 300 size relationship with
pulmonary valve root, 247 sizing of, 272, 272–273, 273 small
aortoventriculoplasty of, 82 rationale for valve
replacement in, 609 total-root replacements of,
351
translocation, with arterial switch, 433–434, 434, 435–436
Aortic root replacement with aortic allografts, 318–326,
327–337
coronary buttons in, 319, 322, 324, 328, 329, 332, 334–335
indications for, 318–319 Konno procedure in, 327,
328
Manouguian-type maneuver in, 319
myomectomy in, 319, 322 postoperative management
in, 333, 337 sizing in, 319
surgical techniques, 319–326, 320–325, 327–333, 328, 329–332, 334–336
Teflon felt strips in, 319, 322, 323, 325
as aortic valve insufficiency risk factor, 416, 417 in endocarditis, 82, 90, 92, 93,
93
with modified (valve cylinder) technique, 33–34
freestanding total-root replacement, 347, 347, 348–349, 349–352 disadvantages of, 349 repeat operations, 350 results of, 350t, 351–352 surgical techniques, 347, 347,
348–349
inclusion-root/intra-aortic cylinder techniques, 339–352
allograft size, 339
allograft trimming, 339–340, 340
coronary anastomoses, 340, 343
postoperative aortic insufficiency associated with, 351, 351t
surgical technique, 339–352
suture techniques, 340, 341, 342–344
transverse aortotomy, 340, 341
modified (valve cylinder) technique, 33–39 advantages of, 33 allograft orientation, 34 allograft preparation, 34–35,
36
aortotomy, 34, 35, 36 coronary ostia identification,
34
coronary ostial attachment, 36
distal allograft/aortic anastomosis, 36–37 in endocarditis, 33–34 general operative approach,
34
intra-operative assessment of valvular
hemodynamics, 38 left coronary ostial
anastomosis, 37 measurement/sizing in, 32 right coronary ostial
implantation, 37 Ross procedure with, 33 suture line inspection, 35
Aortic root replacement (cont.):
testing of anastomosis and valvular mechanisms, 37–38
partial-inclusion techniques, 344, 344–346, 345–346 in pediatric patients, 318, 413 as pulmonary autograft
procedure alternative, 508
pulmonary autografts in, 502 with reimplantation of
coronary ostia, 318 versus scalloped subcoronary
technique, 30–31 with stentless porcine
xenograft valves, 361, 362–364, 364–365, 365–369, 369 Aortic valve
bicuspid, with 180° coronary ostia, 314–315, 315 donor criteria for, 206 function of, 200
gender-related anatomic changes in, 206 infected, homograft valve
reconstruction of, 85–94 surgical technique, 90–93,
90–93
internal diameters normalized to body surface area, 621t, 622
mineralization of, 135 morphology of, 200–209
cellular components, 201–204, 202, 203, 204, 205
extracellular matrix, 204–206, 207 general morphologic
features, 200–201 outflow surface of, 203–204 Aortic valve cusps, anatomy and
function of, 200, 201 Aortic valve insufficiency
explant studies of, 231, 232 fresh, wet-stored aortic
allograft-related, 7 intra-aortic cylinder technique-
related, 351t with proximal aortic root
dilatation, 318
Ross procedure-related, 396, 398, 415–416, 416
aortic root replacement- related, 416, 417 incidence of, 415–416 inclusion technique-related,
416, 417
with pulmonary autograft dilatation, 417
as reoperation cause, 416, 416, 417
risk factors for, 417 subcoronary implantation-
related, 415, 416, 417 techniques for minimization
of, 417–422, 418, 419–421, 422, 423–424
scalloped, subcoronary allograft replacement- related, 344
survival rate in, 338 testing for, 273
total aortic root replacement- related, 350–351
Aortic valve replacement in animal models
non-orthotopic, 216–221 orthotopic, 216
with aortic allografts, 95 actuarial durability curves,
97, 97
comparison with stented pericardial bioprostheses, 97
comparison with stented porcine bioprostheses, 97
cross clamp time in, 97 infrequent use of, 30 reoperation rate, 5 scalloped subcoronary
versus root implantation of, 30–39
subcoronary implantation, 97
as total percentage of aortic valve replacements, 30 cardiopulmonary bypass
management in, 274 for endocarditis treatment,
87–93
as recurrent endocarditis risk factor, 87–88, 89, 90, 90
surgical technique, 87–88, 90, 91–93, 93
freehand, definition of, 271
freehand, with aortic allograft valve transplant
aortotomy, 275–299 classic technique, 290,
291–292
distal suture line in, 279, 281–285, 285, 287, 288, 288, 289, 295
modified scallop technique, 293, 294–297, 297–298, 298
proximal suture line in, 275, 276–277, 278–279, 278–279, 280, 286, 295 reverse “lazy” S incision in,
275, 276 London Series, 6–7 New Zealand Series, 7–8 in pediatric patients, difficulties
associated with, 6 prosthetic valve endocarditis
and, 85–86
scalloped subcoronary versus aortic root replacement in, 30–31
with stented pericardial bioprostheses, 95, 96, 97 with stented porcine
bioprostheses, 95
subcoronary insertion of aortic allografts, 97, 339, 350–351 as aortic insufficiency risk
factor, 417
as geometric distortion cause, 26, 27 scalloped, 30–31, 38 thromboembolism associated
with, 6 Aortic valve stenosis
aortic root enlargement in, 6 bicuspid, 180° coronary ostia
in, 318
coronary arterial anatomy in, 378, 379, 380
with hypoplastic annulus, as aortic root replacement indication, 318
multilevel, 327
complex, as aortic root replacement indication, 318
prosthetic, 300
Ross-Konno procedure for, 408–414
advantages of, 412–413
alternative approaches in, 413
patient selection for, 408–409
surgical technique, 409, 409–410, 410, 412 University of California at
San Francisco experience with, 410–412
Ross procedure for, 408 as Ross procedure-related
aortic insufficiency risk factor, 417
survival rate in, 338 valvotomy for, 408 Aortic wall, calcification of
in aortic allografts, 224, 226 in cryopreserved aortic valve
allografts, 220 in fresh, wet-stored aortic
allografts, 8
in ovine aortic allograft model, 217–218, 218
Aortography, for aortic root sizing, 272
Aortoplastic techniques
in aortic root replacement with stentless xenografts, 364–365
augmentation aortoplasty, 309–310, 310
after aortic annulus enlargement, 303 with concomitant annulus
enlargement, 310–311, 311, 312
in problematic aortic root geometry management, 306–317
asymmetric placement of coronary ostia within native sinuses, 313–314, 313–314
augmentation aortoplasty, 309–310, 310
augmentation aortoplasty with concomitant annulus enlargement, 310–311, 311, 312
bicuspid aortic valve with 180° coronary ostia, 314–315, 315
both coronaries arising from a single sinus, 314, 314 contraindications to, 306
coronary ostia arising high in the sinuses, 315, 316 coronary ostia arising low in
the sinuses, 315, 315–316 indications for, 306
management of complicating coronary anatomy, 311, 313
reduction aortoplasty, 306–309, 307–309 Aortopulmonary collateral
arteries (MAPCAs), with pulmonary atresia, 552–557
central pulmonary artery reconstruction, 553, 554–555, 555
peripheral neo-pulmonary artery reconstruction, 553 right ventricular outflow tract
reconstruction, 555–556, 556
staged approach to, 552 surgical exposure and
collateral mobilization, 552–553
University of California at San Francisco experiences with, 556
Aortopulmonary window, 530 Aortotomy
in aortic annulus enlargement, 300, 301–302, 303–304, 303–304
in aortic root-Konno
reconstruction procedure, 327–328, 328
in aortic root replacement with modified (valve
cylinder) technique, 34, 35, 36
with stentless xenografts, 364–365, 367, 368, 369, 369 in freehand aortic valve
replacement, 275–299 classic technique, 290,
291–292
distal suture line in, 279, 281–285, 285, 287, 288, 288, 289, 295
modified scallop technique, 293, 294–297, 297–298, 298 proximal suture line in, 275,
276–277, 278–279, 278–279, 280, 286, 295
reverse “lazy” S incision in, 275, 276
“hockey stick,” 367 in stentless xenograft valve
insertion, 355–356, 356, 357
transverse
in inclusion-root/intra-aortic cylinder techniques, 340, 341
in Ross procedure, 381 T-shaped, in partial-inclusion
techniques, 344, 344–346 Aortoventriculoplasty, 82
with aortic allografts, 271, 327–337
postoperative management in, 333, 337
surgical techniques, 327–333, 328, 329–332, 334–336 with prosthetic valves, 413 as pulmonary autograft
procedure alternative, 508
Apoptosis, 172, 173
cellular viability and, 184, 185–186, 219
in cryopreserved allograft heart valves, 184, 185–186, 232
current theories of, 185–186 definition of, 218
in explanted allograft heart valves, 231
during harvesting and processing of allografts, 185
as leaflet acellularity cause, 173, 184, 219
metabolic stunning and, 185 in ovine aortic valve allograft
model, 184, 218–229, 221, 222
in transplanted allograft heart valve cells, 184, 185–186 Aprotinin
alternatives to, 402 cost, 403–404 dosage, 403
“high-dose”/
“Hammersmith” regimen, 403, 406
efficacy, 403–405 monitoring of, 406 pharmacology, 402
Aprotinin (cont.):
safety and toxicity, 402, 404, 405–406
use with Ross procedure, 381, 402–407
Arrhythmias, extracardiac Fontan operation-related, 591
Arterialis, 203 Arteriosclerosis, heart
transplantation-related, 227
Aseptic techniques
for heart valve dissection, 244 for packaging of allograft
heart valves, 250 Aspergillus, as infective
endocarditis cause, 249 Atrial arrhythmias, extracardiac
Fontan operation-related, 591
Atrial fibrillation, 605
Atrial fibrillation, as mechanical valve indication, 605 Atriotomy, in corrected
transposition anomaly, 475, 477
Atrioventricular block, Raselli’s operation-related, 433 Atrioventricular concordance,
496. See also Corrected transposition anomly Atrioventricular discordance,
474. See also Corrected transposition anomaly, 496 Atrioventricular junction,
surgical anatomy of, in Ross procedure, 376 Atrioventricular valves, anatomy
and function of, 612 Auricularis, of mitral valve, 207 Autograft heart valves. See also
Pulmonary autografts durability of, 7, 78
Autologous tissue valves, 195 Autopsy, heart procurement
during, 241
Autopsy reports, of heart donors, 239
Auto-replacement, of heart valves, 602
Axlocillin, contraindication as heart valve allograft disinfectant, 248
B
BacTAlert™automated microbial detection system, 250 Bacterial contamination, of
donor heart valves, 248, 249–250
Barratt-Boyes, Brian, 3, 6, 7–8 Barr bodies, 175
Basic fibroblast growth factor, effect on leaflet interstitial cell growth, 118
Bernoulli equation, 101 Beta-propiolactone, as allograft
sterilant, 4, 196 Biological heart valves, 193,
602–611, 602–611. See also Allograft heart valves;
Bioprosthetic heart valves; Xenograft heart valves
choice of, 602 failure of, 193–194
in vitro hydraulic performance of, 604–605
types of, 602
Bioprosthetic heart valves. See also Allograft heart valves; Xenograft heart valves
advantages and disadvantages of, 602
adverse effects of, 193, 194 durability of, 602
failure of, 193–194 fibrous sheathing in, 232 reoperation rate with, 194 in right ventricular outflow
tract reconstruction, 81 stentless, 195
worldwide usage rate, 194 Björk-Shiley valve, 5, 603 Blood transfusion requirements,
effect of aprotinin on, 402, 403–404
Body surface area (BSA) relationship with aortic annulus size, 300 relationship with heart valve
hemodynamics, 100 Bovine pericardial valves,
leaflet tears associated with, 194
Bovine pericardium, as artificial pericardial barrier, 559
Breast feeding, in pediatric tissue donors, 239
Brisbane group, 77–78 Buffers
pH, 139
phosphate, contraindication in cryopreservation, 141
C
Calcification
as allograft heart valve contraindication, 271 in aortic allografts, 124, 226,
color plate III
in right ventricular outflow tract reconstruction, 81 aortic allografts’ resistance to,
9 of aortic wall
in aortic allografts, 224, 226 in cryopreserved aortic
allografts, 220
in fresh, wet-stored aortic allografts, 8
in ovine aortic allograft models, 217–218, 218 of cryopreserved tissue, 135 cuspal, 193, 194, 224, 232
in aortic allografts, 224, 226 in cryopreserved aortic
allografts, 224
glutaraldehyde-related, 232 in porcine bioprosthetic
valves, 224
effect of allograft processing on, 222
effect of donor age on, 240 of fibroblasts, role of ABO immunogenicity in, 186 fresh-wet-stored allograft heart
valves’ resistance to, 9 glutaraldehyde-related, 224 of leaflets, 26, 195, 195
in right ventricle-to-pulmonary artery conduits, 226 of xenografts, 8
in pediatric patients, 6 Caliper measurement, of
allograft heart valves, 246–247
Candida, as infective
endocarditis cause, 249 Cannulation, 273, 274
Carbomedics mechanical valves
internal and external diameters, 606t mean gradients, 606t open and closed angles, 606t postoperative complications associated with, 603, 604t Reduced, 606t
Standard, 606t
TopHat Supra-Annular, 606t Cardiac output, across mechanical
heart valves, 100
Cardiectomy, sterile, 241–242. See also Dissection
Cardioplegia, in aortic valve replacement, 274 Cardiopulmonary bypass
management, in aortic valve replacement, 274 Cardiopulmonary resuscitation,
prolonged, in heart valve donors, 240
Carpentier-Edwards Porcine valves, 603–604 Denver Series, in pediatric
patients, 50–51, 51t, 52t internal and external
diameters, 607t mean gradients, 607t Model 2700 Perimount, 607t Model 2800 Perimount, 607t open and closed angles, 607t pericardial valves, 95, 602, 604,
605t, 607t
postoperative complications associated with, 604 Cavopulmonary shunts,
bidirectional superior, 585
Cefoxitin, as allograft heart valve disinfectant, 213, 248 Celite, 406
Cell death, programmed. See Apoptosis
Cell seeding, in vitro, of tissue- engineered heart valve scaffolds, 617–618 Cervical dilators, 246–247
Hegar, 246–247, 273, 381, 418, 421
Children. See Pediatric patients Chloramphenicol,
contraindication as allograft heart valve disinfectant, 248
Chondroitin-4 sulfate, heart valve content of, 135–136 Chondroitin-6 sulfate, heart
valve content of, 135–136 Chromosome banding, of
fibroblasts, 175
Classification, of allograft heart valves, 245, 247
Class II, 237, 599, 600 Class III, 237, 597–598
“implantable with some imperfections,” 247
“perfect,” 247
“unacceptable for clinical use,”
247
Coarctation, with diffusely hypoplastic transverse aortic arches, 572, 575, 576–577
Cold ischemia, in heart valve procurement, 240–241 American Association of
Tissue Banks Standards for, 240
“Cold pans,” 244
Colistimethate, contraindication as heart valve allograft disinfectant, 248 Collagen
in aortic allografts, 227 in cryopreserved allografts, 125 fibrillar structure of, 205–206 leaflet calcification of, 195 leaflet interstitial cell post-
transitional modification of, 115
in ovine aortic valve allografts, 217–218, 219
type I, 205
valve leaflet content, 135 type II, valve leaflet content,
135
type III, 163, 205 type V, 205
Collagen crimp, 205, 224, 227, 232 effect of warm ischemia on,
214, 214
in extracellular matrix scaffolded allografts, 615 loss in long-term allografts, 232 in ovine aortic allograft
models, 219 pressure-related loss of,
203–204, 204
Columbia Presbyterian Medical Center, 404–405
Complement 3C, 125 Conduit surgery, 8
Congenital heart defects. See also Infants; Pediatric patients;
specific congenital heart defects
with absent connection from ventricle to pulmonary artery, 63, 64t
factors affecting patient survival, 66, 66–67 factors affecting valve
survival, 67 natural history of, 63 Connective tissue, 204–205 Coronary artery anomalies,
truncus arteriosus- associated, 531–532, 540–541
Coronary artery bypass graft patients, aprotinin use in, 403–404, 405
Coronary ostia
arising from single sinus, 314, 314
arising high in the coronary sinuses, 315, 316 arising low in the coronary
sinuses, 315, 315–316 asymmetric placement within
native sinuses, 313–314, 313–314
180°, 313, 313–314
with bicuspid aortic valve, 314–315
rotation of, with annuloplasty, 314–315, 315
in porcine vs. human aortic roots, 364, 366
Coronary ostia buttons in aortic root replacement,
332, 334–335 with aortic allograft
conduits, 319, 322, 324
with aortic allografts, 328, 329, 332, 334–335 in Ross procedures
excision of, 384, 386 placement of, 387, 388, 389,
391, 391
Coronary sinuses, asymmetric placement of coronary ostia within, 313–314, 313–314
Corpora arantia, 30, 31
Corrected transposition anomaly atriotomy in, 475
cannulation in, 474, 475 distal anastomosis in, 477, 477,
479
proximal anastomosis in, 478, 479
pulmonary ventricle-to- pulmonary artery continuity in, 496
ventriculotomy in, 474, 476, 477 Cross clamp time, with aortic
allografts, 271 Cross-matching, for repeat
allograft transplants, 128 Cross-shippers, 262
CryoMed CMD-20 bulk dry- shipper, 262
CryoMed CMS-328 freezer, 261 Cryopreservation, 119–120,
133–160, 196. See also Cryoprotectants; Storage allograft heart valve failure
rate in, 152–153 allograft heart valve
preparation for, 138–139 allograft pouches in, during
thawing and dilution, 260–261, 266
American Association of Tissue Banks Standards for, 136, 237, 251, 596 antifreeze proteins and,
145–146, 145t
biological consequences of, 133–134
cold shock and, 133 cooling protocol/rates,
140–143, 142, 143, 213, 251–252, 253, 254, 255 effect of allograft
volume/surface ratio on, 256–257
rapid, 140–141 slow, 141
surrogate pack use in, 251–252, 252, 253 effect on adhesion molecule
expression, 110–111
effect on allograft heart valve antigenicity, 126–127 effect on allograft heart valve
function, 125
effect on cell viability, 161–162, 166, 167, 169, 170, 196, 255, 259
assessment of, 134–135, 260 effect on heart valve quality,
134–135, 134t effect on immunogenicity,
152–153
effect on leaflet interstitial cells (LICs), 120 extracellular ice formation
during, 141, 144, 145, 259 freezing “windows” in, 141–142 hemodynamic effects of,
101–102, 102t
historical background of, 133 intracellular ice formation
during, 140–141, 145 pH buffers in, 139
racking systems, 147–148, 148 recrystallization in, 149, 264 repeat, 253
technical variables affecting, 255–257
techniques, 250–257 thawing of allograft heart
valves, 135, 149–150, 260–261, 264–266 tissue storage and
transportation conditions, 146–148, 147, 148, 148t, 149
of vascular endothelium, 111–112
Cryopreserved allograft heart valves
comparison of implantation techniques for, 78–79 in complex right outflow tract
reconstruction, 78 durability of, 78
long-term, 195
in pediatric patients, 186 failure of, in pediatric patients,
152–153
historical perspective on, 338–339
HLA donor-specificity of, 153 hydraulic function of, 78 initial experiences with, 77–84
liquid nitrogen-related damage to, 260–261
long-term durability of, 195, 196
in pediatric patients
decreased durability of, 186 failure of, 152–153
limitations to, 612 racking systems for, 261 in right-sided ventricular
outflow tract positions, 608
thawing of, 135, 264–266 transportation of, 261–264 worldwide usage rate, 194 Cryopreserved aortic allografts
hemodynamics of, 101–102, 102t
Mayo Clinic Series, 17–22 operative technique, 18 patient population, 17 reoperations, 18–19, 19t, 21 results, 18–20
reoperation with, 78 resistance to endocarditis in,
78
in right ventricular outflow tract reconstruction, 79, 527
University of Alabama at Birmingham Series, 23–29 allograft durability, 24, 25,
26, 26–27
allograft failure, 27, 27–28 endocarditis associated with,
24, 25, 26, 26, 28 infracoronary insertion
technique, 23, 24 patient population, 23 patient survival, 23–24, 29 reoperations, 23, 27–28, 28 thromboembolism
associated with, 28 Cryopreserved mitral valve
allografts, 195–196 Cryopreserved tissue
calcification of, 135 thawing of, 149–150
Cryoprotectant removal system (AlloFlow™), 151, 152, 265, 266
Cryoprotectants, 143–146, 144t, 145t, 250–251
dilution of, 265–266
