The effect of balloon-expandable stent and self-expanding stent on changes in mitral annular motion after aortic valve replacement in patients with aortic stenosis.

OBJECTIVES: The purpose of this study was to evaluate the effect of decalcification and existence of stent at the aortic annulus on mitral annular motion after surgery. METHODS: Patients receiving Inspiris (Edwards, CA, USA, n = 117), Intuity (Edwards, n = 36), Perceval (Corcym, London, UK, n = 36), Evolut (Medtronics, MN, USA, n = 81) and Sapien 3 (Edwards, n = 250) were included in the study. Mitral annular motion was evaluated by E', using tissue doppler imaging. RESULTS: After surgery, a significant increase in E' was observed in patients receiving Inspiris (Before: 4.2 ± 1.21 cm/s vs. Discharge: 5.0 ± 1.23 cm/s, p < 0.001). Mid-term echocardiogram performed at 11.8 ± 2.2 months after the surgery, showed a significant increase in E' in patients receiving Inspiris (Before: 4.2 ± 1.21 cm/s vs. Mid-term: 5.2 ± 1.20 cm/s, p < 0.001) and Perceval (Before: 3.9 ± 1.34 cm/s vs. Mid-term: 4.5 ± 1.24 cm/s, p = 0.008). Univariable analysis showed a higher increase in E' in patients with decalcified annulus compared to those without decalcified annulus (Decalcification: 0.15 ± 1.321 cm/s vs. No Decalcification: 0.66 ± 1.420 cm/s, p < 0.001). Multivariable analysis showed that balloon-expandable stent (ß = - 0.6960, p < 0.001) and self-expanding stent (r = - 0.3592, p = 0.042) were independent limiting factors for an increase in E' at discharge. However, balloon-expandable stent (ß = - 0.8382, p < 0.001), and not self-expanding stent (ß = - 0.3682, p = 0.089), was a remaining independent factor associated with E' at mid-term follow-up. CONCLUSIONS: Decalcification was associated with improvement in E' after surgery. Balloon-expandable stent was an independent limiting factor for improvement in E' up to 1 year after the surgery, while self-expanding stent was not a significant factor after 1 year.

[Right Coronary Artery Stenosis Demonstrated a Few Hours After Surgical Aortic Valve Replacement: Report of a Case].

Some cases of coronary artery occlusion by prosthetic valves after surgical aortic valve replacement (SAVR) may be diagnosed and treated during operation if it is difficult to be separated from cardiopulmonary bypass. We present a case of a 74-year-old woman with symptomatic aortic stenosis due to bicuspid valve and a narrow aortic valve annulus. SAVR was considered to be feasible over transcatheter aortic valve implantation given her anatomy and frailty. A few hours after successful SAVR using a 19 mm bioprosthetic valve, she became hemodynamically unstable in the intensive care unit, and coronary angiography revealed severe stenosis at the right coronary artery orifice. Percutaneous coronary intervention was deemed technically demanding, and she subsequently underwent coronary artery bypass grafting. On the 35th postoperative day, the patient was transferred to another facility for rehabilitation. Two years after surgery, she has no chest symptoms and constantly visits the outpatient clinic by herself.

Peripheral VA-ECMO and pericardial drainage connected to the ECMO circuit for cardiac tamponade from blowout rupture: a case report.

BACKGROUND: Left ventricular free wall rupture, particularly the blowout type, is still one of the most lethal complications of myocardial infarction and can cause catastrophic cardiac tamponade. Extracorporeal membrane oxygenation (ECMO) is often used to treat haemodynamic instability due to cardiac tamponade. However, elevated pericardial pressure can cause collapse of the right atrium, resulting in inadequate ECMO inflow and preventing the stabilisation of the circulation. Further, it can interfere with the venous return from the superior vena cava (SVC), increasing the intracranial pressure and reducing cerebral perfusion levels. CASE PRESENTATION: A 65-year-old man was hospitalised for out-of-hospital cardiac arrest. We used ECMO for cardiopulmonary resuscitation. After the establishment of ECMO, transthoracic echocardiography and left ventriculography revealed massive pericardial effusion. The treatment was supplemented with pericardial drainage since ECMO flow was frequently hampered by suction events. However, the blowout rupture led to the requirement of constant drainage from the pericardial catheter. To tend to this leak, we connected the venous cannula of ECMO and the pericardial drainage catheter. The surgery was performed with stable circulation without suction failure of ECMO. During the course of the intensive care management, the neurological prognosis of the patient was revealed to be poor, and the patient was shifted to palliative care. Unfortunately, the patient died on day 10 of hospitalisation. CONCLUSION: We present a case wherein the combination of pericardial drainage and ECMO was used to maintain circulation in a patient with massive pericardial effusion due to cardiac rupture.

The effect of stent and decalcification on mitral annular motion after aortic valve replacement.

OBJECTIVE: The purpose of this study was to evaluate the changes in mitral annular motion after surgery in patients with aortic stenosis. METHODS: Patients receiving Edwards (Edwards) valves were included in the study. Echocardiographic findings were compared among the three treatments postoperatively, at discharge, and at 1 year after the surgery. Mitral annular motion was evaluated by e prime, using tissue doppler imaging. RESULTS: There were 111 patients receiving Inspiris, 30 patients receiving Intuity and 241 patients receiving Sapien 3. The patients receiving Sapien 3 were significantly older, (Inspiris: 71 ± 6.7 years vs. Intuity: 75 ± 5.2 years vs. Sapien 3: 84 ± 5.1 years, p < .001), and prevalence of hemodialysis were significantly higher in patients receiving Intuity (Inspiris: 11.7% vs. Intuity: 46.7% vs. Sapien 3: 0.0%, p < .001). There was a significant improvement in mean pressure gradient in all groups (Inspiris: 55 ± 21.2-13 ± 5.2 mmHg, p < .001; Intuity: 48 ± 17.6-12 ± 4.9 mmHg, p < .001, Sapien 3: 55 ± 16.6-14 ± 5.2 mmHg, p < .001). Decalcification was associated with increase in e prime after surgery (no decalcification: 0.10 ± 1.280 cm/s vs. decalcification: 0.68 ± 1.405 cm/s, p < .001) Further, existence of stent was associated with less increase in e prime after surgery (no stent: 0.83 ± 1.210 cm/s vs. stent: 0.10 ± 1.356; p < .001). Multivariate analysis showed that existence of stent but not decalcification of the aortic valve was independently associated with changes in e prime after surgery (ß: -.4679, 95% confidence interval: -0.93389 to -0.00200, p = .049). CONCLUSIONS: Although improvement in pressure gradient was achieved in all treatments, existence of stent inhibited mitral annular motion after surgery.

[Anomalous Aortic Origin of a Right Coronary Artery:Report of a Case].

An anomalous right coronary artery originating from the left Valsalva is rare, but sometimes causes sudden cardiac death in a healthy young to middle-aged patient. We present a case of 30-year-old male who was suggested from cardiopulmonary arrest, during playing basketball. He was resuscitated using automated external defibrillator, and was brought to the emergency department. Electrocardiogram showed no ST segment elevation. Coronary angiography and computed tomography revealed anomalous right coronary artery, which originated from the left sinus of Valsalva, and ran between the aorta and the pulmonary artery trunk. Coronary artery bypass grafting was performed using the right internal thoracic arterial graft, with proximal native coronary artery ligation. He was discharged on the nineth postoperative day and had no chest symptoms for seven months.

Long-Term Outcomes and Echocardiographic Data After Aortic Valve Replacement With a 17-mm Mechanical Valve.

BACKGROUND: We investigated the long-term clinical and hemodynamic outcomes after aortic valve replacement (AVR) with a 17-mm mechanical valve.Methods and Results:Between January 2005 and December 2011, 80 patients with aortic stenosis underwent AVR with the 17-mm St. Jude Medical Regent prosthetic valve. Echocardiography was performed preoperatively, at discharge, and at follow-up, which was performed at least 2 years postoperatively (median interval, 7.3 years). Prosthesis-patient mismatch (PPM) was defined as an indexed effective orifice area <0.85 cm2/m2at discharge and occurred in 25 patients (31%). The median follow-up period was 8.7 years (100% complete). Overall in-hospital mortality was 2.5% (2 patients) with 27 late deaths (34%). The 5- and 10-year survival rates were 78.7% and 63.0%, respectively. Peripheral arterial disease and concomitant mitral valve repair were independent predictors of late mortality. The 5- and 10-year freedom from major adverse valve-related events (MAVRE) rates were 91.6% and 83.5%, respectively. PPM at discharge did not affect long-term survival, freedom from MAVRE, or freedom from heart failure. Echocardiographic data at follow-up revealed a significant reduction in the mean left ventricular mass index (LVMI). LVMI reduction observed at follow-up was similar between patients with and without PPM. CONCLUSIONS: AVR with the 17-mm mechanical prosthesis had acceptable long-term clinical and hemodynamic outcomes. Significant reduction in LVMI was observed regardless of PPM.

Minimized perfusion circuit for acute type A aortic dissection surgery.

A minimized perfusion circuit (MPC) may reduce transfusion requirement and inflammatory response. Its use, however, has not been standardized for complicated cardiovascular surgery. We assessed outcomes of surgery for acute type A aortic dissection (ATAAD) performed with a MPC under circulatory arrest. The study involved 706 patients treated surgically for ATAAD (by hemiarch repair [n = 571] or total arch repair [n = 135]). Total arch repair was performed using selective antegrade cerebral perfusion. Our MPC, a semi-closed bypass system, incorporating a completely closed circuit and a level-sensing reservoir in the venous circuit, was used. Clinical variables, transfusion volume, and outcomes were investigated in patients who underwent hemiarch repair or total arch repair. The overall incidences of shock, organ ischemia, and coagulopathy (prothrombin time-international normalized ratio >1.5) were 26%, 35%, and 8%, respectively. Mean extracorporeal circulation (ECC) time was 149 minutes for the hemiarch repair group and 241 minutes for the total arch repair group, respectively. No patient required conversion to conventional ECC, and there were no complications related to the use of the MPC. The need for transfusion (98% vs. 91%, P = .017) and median transfusion volume (1970 vs. 1680 mL, P = .002) was increased in the total arch repair group. Neither in-hospital mortality (total arch; 12% vs. hemiarch; 7%, P = .11) nor 10-year survival (74.4% vs. 68.4%, P = .79) differed significantly. Outcomes of surgery for ATAAD performed with the MPC were acceptable. The possibility of transfusion and transfusion volume remains high during such surgery, despite the use of the MPC.

Dissected thoracoabdominal aortic aneurysm repair with modified parallel endografting.

A 67-year-old woman with a prior history of aortic dissection was admitted for enlarging the thoracoabdominal aortic aneurysm (TAAA). She has received multiple treatments including Bentall procedure, hemiarch replacement, and subsequent endovascular procedures for the closure of re-entry. Preoperative computed tomography revealed previously implanted thoracic endograft from distal arch to superior mesenteric artery with dissected TAAA measuring up to 70 mm in diameter. Re-entry was observed at bilateral common iliac arteries. The patient was successfully treated by endovascular treatment using a fenestrated stent graft to obtain a landing zone for parallel endograft technique to the iliac arteries for the closure of re-entry.

Etiology and impact on outcomes of polycystic kidney disease in abdominal aortic aneurysm.

PURPOSE: We investigated the etiology and impact on outcomes of polycystic kidney disease in patients with abdominal aortic aneurysm. METHODS: Eight-hundred patients who underwent open (n = 603) or endovascular aortic repair (n = 197) were divided into three groups: no cyst (n = 204), non-polycystic kidney (n = 503), and polycystic kidney (≥ 5 cysts in the bilateral kidneys, n = 93). The characteristics and outcomes were compared among the groups. RESULTS: In the polycystic kidney group, the age was increased and the proportions of patients with male sex, hypertension, and estimated glomerular filtration rate < 30 mL/min/1.73 m2 were greater. The overall hospital mortality rates were similar. The incidence of acute kidney injury after elective open aortic repair was increased in the polycystic kidney group (12%, 17%, and 29%, P = 0.020). In the polycystic kidney group, 80 patients did not have renal enlargement or a family history of renal disease, while 13 (corresponding to 1.6% [13/800] of the overall patients), had renal enlargement, suggesting the possibility of hereditary polycystic kidney disease. CONCLUSIONS: In our cohort, 1.6% of the patients with abdominal aortic aneurysm who underwent surgery were at risk of hereditary polycystic kidney disease. Polycystic kidney disease was associated with acute kidney injury after open aortic repair.

Perioperative factors associated with aneurysm sac size changes after endovascular aneurysm repair.

PURPOSE: To identify the perioperative factors associated with aneurysm size changes after endovascular aortic aneurysm repair (EVAR). METHODS: Between August, 2008 and December, 2014, 187 patients underwent EVAR treatment in our institution. The subjects of this study were 135 of these patients without peripheral artery disease, who were followed up with computed tomography (CT) for 3 years. Significant aneurysm size change was defined as sac size change of more than 5 mm from the baseline. RESULTS: Sac enlargement was identified in 25 patients (18.5%) and sac shrinkage was identified in 59 (43.7%) patients. The factors associated with sac enlargement were postoperative pulse wave velocity (OR: odds ratio 3.80, p = 0.047), prevalence of a type 2 endoleak 1 week after surgery (OR 4.26, p = 0.022), inner diameter (OR 1.10, p = 0.005), and distance from the lower renal artery to the terminal aorta (OR 1.05, p = 0.017). The factors associated with sac shrinkage were prevalence of a type 2 endoleak (OR 0.09, p < 0.001) and preoperative pulse wave velocity (OR 0.32, p = 0.022). The factors independently associated with type 2 endoleak were the use of an Excluder device (OR 3.99, p = 0.002) and the length of the aneurysm (OR 1.02, p = 0.027). CONCLUSION: Inner diameter, treatment length, perioperative pulse wave velocity, and type 2 endoleak were associated with sac size changes after EVAR.

Appetite Predicts Clinical Outcomes in High Risk Patients Undergoing Trans-Femoral TAVI.

Transcatheter aortic valve implantation (TAVI) has been recognized as a standard therapy for severe aortic valve stenosis. However, since some patients who receive TAVI have poor outcomes, the predictors of clinical outcomes after TAVI are important. The aim of this study was to investigate the association between appetite and long-term clinical outcomes.We screened consecutive cases who received TAVI at our medical center between July 2014 and October 2018. A total of 139 patients who received transfemoral TAVI were included as the final study population. They were divided into a good appetite group (n = 105) and a less appetite group (n = 34) according to their dietary intake rate (> 90%: good appetite group, ≤ 90%: less appetite group). We defined the intake rate as the average for breakfast, lunch, and dinner on the day just before discharge. We defined two-year major adverse cardiovascular and cerebrovascular events (MACCE) as a composite of cardiovascular death, myocardial infarction, any coronary revascularization, history of hospitalization due to heart failure, and disabling acute cerebral infarction. Kaplan-Meier analyses and multivariate Cox regression analysis were performed.The median duration of the follow-up period was 372 (189-720) days. Kaplan-Meier curves showed that the less appetite group got MACCE more frequently (event free rate of the less appetite group: 76.5% versus the good appetite group: 94.3%, Log Rank P = 0.01). In multivariate Cox regression analysis, having less appetite was a significant predictor of two-year MACCE (HR 5.26, 95%CI 1.66-16.71, P < 0.01).In conclusion, among the patients who received transfemoral TAVI, appetite status just before discharge was significantly associated with long-term outcome.

[Total Aortic Arch Replacement by Minimally Invasive Approach in a Patient with Permanent Tracheostomy;Report of a Case].

Standard full median sternotomy for total aortic arch replacement in patients with tracheostomy has higher risks for mediastinitis and graft infection. To avoid surgical site infection, it is necessary to keep a sufficient distance between the tracheostomy and the site of surgical skin incision. We herein report a case of a 74-year-old man with permanent tracheostomy after total laryngectomy, who underwent total aortic arch replacement for an aneurysm. Antero-lateral thoracotomy in the 2nd intercostal space with lower partial sternotomy( ALPS approach) provided an enough distance between the tracheostomy and the surgical field. It also provided a good view for surgical procedure and enabled the standard setup of cardiopulmonary bypass with ascending aortic cannulation, venous drainage from the right atrium and the left ventricular venting through the upper right pulmonary vein. The operation was completed in 345 minutes and the patient was discharged on the 11th postoperative day without any complications.

Nipro extra-corporeal left ventricular assist device fitting after left ventricular reconstruction with mitral valve plasty.

Both left ventricular assist device and left ventricular reconstruction are treatment choices for severe heart failure conditions. Our institution performed a left ventricular assist device installation following a left ventricular reconstruction procedure on a 42-year-old male patient who presented with dilated cardiomyopathy and low cardiac output syndrome. A mitral valve plasty was used to correct the acute mitral valve regurgitation and we performed a Nipro extra-corporeal left ventricular assist device installation on post-operative day 14. Due to the left ventricular reconstruction that the patient had in a previous operation, we needed to attach an apical cuff on posterior apex, insert the inflow cannula with a large curve, and shift the skin insertion site laterally to the left. We assessed the angle between the cardiac longitudinal axis and the inflow cannula using computed tomography. The patient did not complain of any subjective symptoms of heart failure. Although Nipro extra-corporeal left ventricular assist device installation after left ventricular reconstruction has several difficulties historically, we have experienced a successful case.

[Valve replacement after omentum flap for medicastinitis;report of a case].

A 71-year-old woman presented with heart failure due to aortic and mitral valve regurgitation. She had developed midiastinitis and graft infection, 15 months before, following replacement of the ascending aorta for acute aortic dissection. Omentum flap operation had been performed and the infection had been controlled. This time, she underwent re-thoracotomy, and replacement of ascending aorta, aortic valve replacement and mitral valve plasty were performed. The omenal tissue was exfoliated without any damage to the heart or the great vessels by using an ultrasonic scalpel. As the omental tissue was viable, it was placed back in the mediastinal space.

A Case of Popliteal Venous Aneurysm Diagnosed after Sudden Cardiac Arrest.

A popliteal venous aneurysm (PVA) is a rare vascular disorder. We report a case of PVA discovered through further evaluation of sudden cardiac arrest (CA) caused by a pulmonary embolism (PE). It is well-known that PVA causes PE; however, there are few reports of PVA causing CA. A tangential aneurysmectomy and lateral venorrhaphy were performed. The patient's postoperative course was uneventful. When contrast-enhanced computed tomography is performed to search for the cause of CA, PVA should be considered and thus, screening below the knee is recommended. At 1-year follow-up, there were no complications.

Reduction of mitral valve leaflet tethering by procedures targeting the subvalvular apparatus in addition to mitral annuloplasty.

BACKGROUND: Ischemic mitral regurgitation (IMR) with ischemic cardiomyopathy (ICM) was treated with surgical procedures, and mitral leaflet tethering was assessed. Twenty-two patients with both ICM (left ventricular ejection fraction <0.35) and IMR (>2) underwent coronary artery bypass grafting (CABG), mitral annuloplasty (MAP) with or without surgical ventricular restoration (SVR) and procedures targeting the subvalvular apparatus. METHODS AND RESULTS: Fourteen patients (group 1) underwent CABG and MAP, and the remaining 8 (group 2) underwent CABG, MAP, SVR, papillary muscle approximation (PMA), and papillary muscle suspension (PMS). PMA joined the entire papillary muscles with 3 mattress sutures. For PMS, 2 ePTFE sutures were placed between papillary muscle tips and fibrous annuli. Anterior and posterior mitral leaflet tethering angles (ALA and PLA) relative to the line connecting annuli, posterior and apical displacement of coaptation, and IMR grade were measured on echocardiography. Although preoperative ALA and PLA in group 2 were significantly larger than in group 1, there was no significant difference between groups at 1 month after surgery. At 1 year after surgery, however, the situation reversed: ALA and PLA in group 1 were significantly larger than in group 2. CONCLUSIONS: In addition to MAP, procedures targeting the subvalvular apparatus including PMA and PMS achieved persistent reduction of mitral valve leaflet tethering, which might lead to the improvement of long-term outcome.

Is the threshold for postoperative prosthesis-patient mismatch the same for all prostheses?

PURPOSE: The effective orifice area index (EOAI) is used to define the prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR). However, few studies have so far evaluated whether the cutoff value for PPM varies across prostheses. This study assessed the hemodynamics in patients given a mechanical valve and then re-evaluated the validity of the commonly accepted threshold. METHODS: The subjects included 329 patients that underwent AVR with a St. Jude Medical Regent valve. The transvalvular pressure gradient and EOAI were determined echocardiographically, and the commonly accepted threshold was analyzed in relation to survival. RESULTS: The mechanical valves very often yielded a postoperative transvalvular pressure gradient >10 mmHg, and thus, clinically significant residual pressure, regardless of the EOAI. The slope of the curve describing the relationship between the transvalvular pressure gradient and EOAI was gentler than that reported for bioprosthetic valves, for which the pressure gradient rises sharply at EOAI <0.85 cm(2)/m(2). The commonly defined PPM did not affect the long-term survival or regression of the left ventricular mass index. CONCLUSIONS: The relationship between the transvalvular pressure gradient and the EOAI in patients given a mechanical prosthesis differed from the reference standard. These data suggest the need to reconsider the appropriate cutoff value for PPM in relation to different prostheses.

[Brain protection during operation for aortic arch aneurysms].

Aortic arch replacement has been safely performed by moderate hypothermic circulatory arrest, and antegrade selective cerebral perfusion. To prevent permanent neurological deficit, it is important to precisely evaluate brain, neck vessels and atherosclerotic thoracic aorta by computed tomography(CT), magnetic resonance imaging (MRI)and intraoperative epiaortic echography, which can lead the safest cannulation site, careful manipulation of cerebral perfusion catheters. It is also important to make good exposure of surgical site, especially in distal anastomosis, and irrigate and flush atheromatous debris. Since 1991 to 2013, our consecutive 410 cases of total and hemi arch replacement of aorta, including 57 emergency cases, result in 22 cases( 5.4%) of mortality( 3.1% of elective, 19.3% of emergency) and 10 cases( 2.4%) of stroke( 2.3% of elective, 3.5% of emergency). Mortality and morbidities are more likely be occurred in emergency cases. It is possible to keep good operative results with reliable brain protection of selective antegrade cerebral perfusion which gives enough time for secure open distal anastomosis to every surgeon, but atheroemborism from shaggy aorta remains as a problem yet to be solved.

Mid-term outcomes after aortic valve replacement with the 17-mm St. Jude Medical Regent valve.

BACKGROUND: When aortic valve replacement (AVR) is performed in patients with a small aortic annulus, prosthesis-patient mismatch (PPM) is of concern. We investigated the mid-term outcomes of AVR with a 17-mm mechanical prosthesis. METHODS AND RESULTS: Seventy-eight patients with aortic stenosis underwent AVR with a 17-mm St. Jude Medical Regent prosthesis. Echocardiography was performed preoperatively, at discharge, and at follow-up (mean follow-up, 33 months). Patients were divided into 2 groups: with and without PPM at discharge. Between-group differences in postoperative variables, particularly survival, were analyzed. Overall hospital mortality was 2.6%. Actuarial 1- and 5-year survival rates were 95% and 79%, respectively. Diabetes and renal insufficiency were associated with long-term mortality. Freedom from major adverse valve-related cardiac events at 1 year and 5 years was 97.3% and 93.9%, respectively. Diabetes was shown to be an independent risk factor for major adverse valve-related cardiac events. Echocardiography 13 months after AVR showed a significant increase in mean effective orifice area index, decrease in mean left ventricular-aortic pressure gradient, and decrease in mean left ventricular mass index. PPM at discharge did not influence long-term survival or left ventricular mass regression. CONCLUSIONS: The 17-mm Regent prosthesis provided satisfactory clinical and hemodynamic results. It is a reliable choice for patients with a small aortic annulus.

Clinical outcomes and hemodynamics of the 19-mm Perimount Magna bioprosthesis in an aortic position: comparison with the 19-mm Medtronic Mosaic Ultra Valve.

BACKGROUND: When aortic valve replacement is performed in patients with a small aortic annulus, prosthesis-patient mismatch (PPM) is of concern because it can affect postoperative clinical outcomes. Although larger bioprosthetic valves have been well studied, the hemodynamics of 19-mm bioprostheses have been reported in only a small number of patients. The effectiveness as well as the impact of PPM on outcomes are thus still unclear. METHODS AND RESULTS: Postoperative clinical and hemodynamic variables were compared in 67 patients with a 19-mm Carpentier Edwards Perimount Magna bioprosthesis and in 10 patients with a 19-mm Medtronic Mosaic Ultra valve. Mean follow-up time was 13 months. There was no in-hospital mortality. Echocardiography 6.5±4.0 months after surgery showed significant decreases in the mean left ventricular (LV)-aortic pressure gradient, and decreases in the mean LV mass index. Reduction in LV mass index did not differ between the valve groups, despite a higher pressure gradient in the Mosaic group. Although PPM was detected in 21 patients in the Magna group, it did not affect regression of the LV mass index during the follow-up period. CONCLUSIONS: Use of the 19-mm Magna bioprosthesis appears to provide satisfactory clinical results. LV-aortic pressure gradient was lower in the Magna group. The present data suggest that PPM is not related to reduction in the LV mass index.