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    1. Least resistance to transvalvular blood flow during diastole for valves in the mitral position is provided by a large ratio of orifice to total annular area.
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    1. This fixative stabilized collagen bonding in the valve cusps and led to increased durability.
    1. These individuals may avoid anticoagulation with little risk of reoperation.
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    1. At the present time, percutaneous mitral balloon valve dilation is used in most cases of symptomatic noncalcified, fibrotic mitral stenosis.
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    1. Albert Starr, a cardiac surgeon in Portland, and Lowell Edwards, a mechanical engineer in southern California.
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    1. This was a mitral valvulotomy that he had worked on for two years in the laboratory with Samuel Levine, a Boston cardiologist.
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    1. Blood turbulence flowing across mitral valve devices results from impedance to forward or reverse flow.
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    1. Silastic ball in a Stellite alloy cage that projects into the left ventricle.
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    1. Patients in any age group in sinus rhythm who wish to avoid anticoagulation may prefer a bioprosthetic valve.
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    1. Many patients with chronic mitral stenosis now require valve replacement because the valve has developed significant dystrophic changes, including marked thickening and shortening of all chordae, obliteration of the subvalvular.
    1. The first successful prosthetic mitral valve was a device implanted by Nina Braunwald at the National Institutes of Health in 1959.
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    1. Nevertheless, there are still indications for mitral porcine bioprosthetic valves in young patients.
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    1. Indications for Bioprosthetic Valve Replacement.
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    1. Table 431 shows hemodynamic assessments of each of the FDAapproved mitral valve prostheses for the most commonly used mitral valve sizes.
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    1. The valves that are discussed are those that are currently (2006) approved by the FDA.
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    1. However, good results with reconstructive surgery in this patient group have been reported.
    1. Hemodynamics of Mitral Valve Prostheses.
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    1. The design must cause minimal turbulence and stasis in vivo during physiologic flow conditions.
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    1. Under age 40, echocardiographic findings of the mitral valve suffice in most symptomatic patients for the definition of mitral valve pathology unless there is a history of chest pain or coronary artery disease.
    1. The durability of porcine valves is less with mitral bioprostheses than with aortic bioprostheses.
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    1. INDICATIONS FOR MITRAL VALVE REPLACEMENT.
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    1. The degree of pulmonary artery pressure elevation secondary to mitral stenosis continues to be an area of concern for the mitral valve surgeon.
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    1. The designs of mechanical and bioprosthetic heart valves have evolved over the last five decades in an effort to.
    1. Southeast Asia and Latin America.
    1. Stenosis usually develops one or two decades after the acute illness of rheumatic fever with no or slow onset of symptoms until the stenosis becomes more severe.
    1. Hancock in the United States (1970) and Carpentier in Paris (1976), was the first commercially available bioprosthetic valve.
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    1. For the first time, devices were available that could effectively replace a diseased, nonreparable mitral valve with relative ease of implantation and assurance that the hemodynamic abnormalities from either mitral stenosis or mitral regurgitation were corrected and maintained indefinitely.
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    1. In ischemic mitral regurgitation, pathology that precludes satisfactory repair includes restrictive valve motion from shortened, scarred papillary muscles, an acutely infarcted papillary muscle, and rupture of chordae associated with extensive calcification of valve leaflets.
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    1. But recurrence of the stenosis still was a major problem, even after the development of cardiopulmonary bypass in the early 1950s, which enabled more complete open valvulotomy.
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    1. In some African and Asian countries, especially India, mitral stenosis is still very common.
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    1. Jude valve but still with a small but definite risk of hemorrhage related to anticoagulant therapy and thromboembolism.
    1. The disk occluder was allowed to slide out of the housing at the end of the closing cycle to provide a gap through which blood could flow to minimize stasis at the contact surfaces.
    1. The prosthetic valve is transplanted, donor papillary muscles are reattached to recipient papillary muscles, and the annulus is sutured circumferentially.
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    1. Although repair of the valve and avoidance of prosthetic material are very desirable in septic situations, the extent of the destruction may preclude repair.
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    1. The opening angle originally was increased to 78 degrees to decrease resistance to forward flow and later narrowed to 70 degrees when in vitro studies revealed an unacceptable regurgitant volume.
    1. Left ventricular angiography can be helpful but is otherwise indicated for evaluating the coronary arteries preoperatively in patients older than 40 years.
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    1. Limitation of exercise tolerance usually is the first symptom, followed by dyspnea that can progress to pulmonary edema.
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    1. The FDAapproved bioprosthetic valve devices are shown in Fig.
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    1. In a woman who desires to become pregnant, a bioprosthesis may be used to avoid warfarin anticoagulation and fetal damage during pregnancy.
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    1. It is important to stress that depressed ejection fraction is a poor indicator of left ventricular function in patients with mitral regurgitation.
    1. This technique has been shown to be safe and reproducible, but it does not always provide durable results and therefore should not be used in young patients.
    1. Thus, in regurgitation from degenerative prolapsing myxomatous valves that have a high probability of reconstruction, mitral valve repair is indicated if the prolapse is generalized, and local findings that decrease the probability of a successful repair are absent.
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    1. Indications to choose one prosthetic or another vary primarily by surgeon preference and occasionally depending on the state of the annulus and whether or not there have been multiple previous operations.
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    1. The pathologic changes in rheumatic valvulitis are mainly fusion of the valve leaflets at the commissures, shortening and fusion of the cordae tendinae, and thickening of.
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    1. Chapter 43 Mitral Valve Replacement.
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    1. Closure time is influenced by the difference between the opening and closing angles of the occluder and valve ring.
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    1. As the first, second, and third generations of prosthetic valves were developed, biologic or tissue replacement devices.
    1. Dynamic regurgitation is a feature of all prosthetic valves and is the sum of the closing volume during occluder closure and the leakage volume that passes through the valve while it is closed.
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    1. The diagnostic workup of the symptomatic patient with mitral stenosis should include a complete cardiac catheterization, including coronary angiography in any patient over the age of 40.
    1. CHOICE OF VALVE TYPE Indications for Mechanical Valve Replacement.
    1. The reason for this is not known.
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    1. In general, operation is prescribed.
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    1. In endocarditis, mitral valve replacement may be required because of destruction of the valve leaflets and subvalvular mechanisms and annular abscess formation.
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    1. It took two more decades until Dwight Harken and Charles Bailey independently continued the development of digital valvulotomy for rheumatic mitral stenosis.
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