Differences in accumulation of elements in human cardiac valves

To elucidate changes of human cardiac valves with aging, the authors determined age-related changes of element contents in the four human cardiac valves by inductively coupled plasma-atomic emission spectrometry and attempted to examine the relationships in the element contents among the four cardiac valves. The subjects consisted of 10 men and 15 women, ranging in age from 65 to 102 yr. The accumulation of calcium and phosphorus was the highest in the aortic valve, and decreased in the order mitral, pulmonary, and tricuspid valves. The contents of calcium and phosphorus in the aortic valves corresponded to about 12 and 19 times the amounts of those in the tricuspid valves, in which the contents were very low. The contents of calcium and phosphorus in the aortic valves were about 2.5-fold the amounts of those in the mitral valves. An examination was attempted to determine whether or not there were relationships in element contents among the four cardiac valves. As for the aortic and mitral valves, there were no relationships in the contents of calcium and phosphorus between them, but there were relationships in the contents of sulfur and magnesium between them. Three out of 24 cases contained high contents of calcium and phosphorus in both the mitral and aortic valves, whereas 16 out of 24 cases contained high contents of calcium and phosphorus in the aortic valves alone, without the high contents in the mitral valves. Likewise, there were no relationships in the element contents, such as calcium, phosphorus, sulfur, and magnesium, between the mitral and pulmonary valves or between the mitral and tricuspid valves. It is suggested that the accumulation of calcium and phosphorus in the cardiac valve occurs independent of the other cardiac valves.     

Earlier accumulation of calcium, phosphorus, and magnesium in the coronary artery in comparison with the ascending aorta, aortic valve, and mitral valve

To explore reasons for a high accumulation of Ca and P occurring in the coronary artery of Thai with aging, the authors investigated age-related changes of elements in the coronary artery, ascending aorta near the heart, and cardiac valves in single individuals, and the relationships in the elements between the coronary artery and either the ascending aorta or cardiac valves. After an ordinary dissection by medical students at Chiang Mai University was finished, the anterior descending arteries of the left coronary artery, ascending aortas, mitral valves, and aortic valves were resected from the subjects. The subjects consisted of 17 men and 9 women, ranging in age from 46 to 76 yr. The element content was analyzed by inductively coupled plasma-atomic emission spectrometry. The average content of Ca and P was the highest in the coronary artery and decreased in the order aortic valve, ascending aorta, and mitral valve. The Ca, P, and Mg content increased in the coronary artery in the fifties and in the ascending aorta, aortic valve, and mitral valve in the sixties. It should be noted that the accumulation of Ca, P, and Mg occurred earlier in the coronary artery than in the ascending aorta, aortic valve, and mitral valve. It was found that with respect to the Ca, P, Mg, and Na contents, the coronary artery correlated well with both the aortic valve and ascending aorta, especially with the aortic valve, but it did not correlate with the mitral valves. This finding suggests that the accumulation of Ca, P, Mg, and Na occurs in the coronary artery together with the aortic valve and ascending aorta, but not together with the mitral valve. Because regarding the accumulation of Ca, P, and Mg, the ascending aorta and aortic valve are preceded by the coronary artery, it is unlikely that the accumulation of Ca, P, and Mg spreads from the ascending aorta or aortic valve to the coronary artery.     

Age-related changes of element contents in human mitral and tricuspid valves

To examine age-related changes of human cardiac valves, mitral and tricuspid valves were analyzed by inductively coupled plasma-atomic emission spectrometry. The subjects for mitral valves consisted of 12 men and 8 women, ranging in age from 52 to 96 yr. The subjects for tricuspid valves consisted of 11 men and 6 women, ranging in age from 52 to 93 yr. Furthermore, 16 of the samples of the cardiac valves were derived from the same subjects. The contents of calcium, phosphorus, and magnesium in the mitral valves increased progressively with advancing age and reached maximum in the 80s in regard to calcium and phosphorus and maximum in the 90s in regard to magnesium. The maximum average amounts corresponded to about three times the average contents in the 60s. In contrast, the content of sulfur in the mitral valves remained constant between the 50s and 90s. Regarding tricuspid valve, the contents of calcium, phosphorus, and magnesium scarcely increased with advancing age, except for one subject who died of chronic renal failure. Histological observations of the mitral valves revealed that deposits of calcium were present in both the elastic fibers and its degenerative tissues of the mitral valve. The present study indicates that the accumulation of calcium, phosphorus, and magnesium occurs progressively in the mitral valve with aging, but does not occur in the tricuspid valve.     

Cardiac hemolytic anemia resolving after second mitral annuloplasty.

Following an episode of rheumatic carditis, severe mitral incompetence developed in a 9-year-old girl. A mitral annuloplasty succeeded for a short time in ameliorating her symptoms of cardiac failure. However, mitral incompetence recurred and was accompanied by severe anemia and hemosiderinuria. Distortion of erythrocytes was evident on a peripheral blood smear. A second mitral annuloplasty resulted in resolution of the hemolytic anemia.     

Local serotonin mediates cyclic strain-induced phenotype transformation, matrix degradation, and glycosaminoglycan synthesis in cultured sheep mitral valves

This study addressed the following questions: 1) Does cyclic tensile strain induce protein expression patterns consistent with myxomatous degeneration in mitral valves? 2) Does cyclic strain induce local serotonin synthesis in mitral valves? 3) Are cyclic strain-induced myxomatous protein expression patterns in mitral valves dependent on local serotonin? Cultured sheep mitral valve leaflets were subjected to 0, 10, 20, and 30% cyclic strain for 24 and 72 h. Protein levels of activated myofibroblast phenotype markers, α-smooth muscle actin (α-SMA) and nonmuscle embryonic myosin (SMemb); matrix catabolic enzymes, matrix metalloprotease (MMP) 1 and 13, and cathepsin K; and sulfated glycosaminoglycan (GAG) content in mitral valves increased with increased cyclic strain. Serotonin was present in the serum-free media of cultured mitral valves and concentrations increased with cyclic strain. Expression of the serotonin synthetic enzyme tryptophan hydroxylase 1 (TPH1) increased in strained mitral valves. Pharmacologic inhibition of the serotonin 2B/2C receptor or TPH1 diminished expression of phenotype markers (α-SMA and SMemb) and matrix catabolic enzyme (MMP1, MMP13, and cathepsin K) expression in 10- and 30%-strained mitral valves. These results provide first evidence that mitral valves synthesize serotonin locally. The results further demonstrate that tensile loading modulates local serotonin synthesis, expression of effector proteins associated with mitral valve degeneration, and GAG synthesis. Inhibition of serotonin diminishes strain-mediated protein expression patterns. These findings implicate serotonin and tensile loading in mitral degeneration, functionally link the pathogeneses of serotoninergic (carcinoid, drug-induced) and degenerative mitral valve disease, and have therapeutic implications.     

Velocity and turbulence measurements past mitral valve prostheses in a model left ventricle

Thrombogenesis and hemolysis have both been linked to the flow dynamics past heart valve prostheses. To learn more about the particular flow dynamics past mitral valve prostheses in the left ventricle under controlled experimental conditions, an in vitro study was performed. The experimental methods included velocity and turbulent shear stress measurements past caged-ball, tilting disc, bileaflet, and polyurethane trileaflet mitral valves in an acrylic rigid model of the left ventricle using laser Doppler anemometry. The results indicate that all four prosthetic heart valves studied create at least mildly disturbed flow fields. The effect of the left ventricular geometry on the flow development is to produce a stabilizing vortex which engulfs the entire left ventricular cavity, depending on the orientation of the valve. The measured turbulent shear stress magnitudes for all four valves did not exceed the reported value for hemolytic damage. However, the measured turbulent shear stresses were near or exceeded the critical shear stress reported in the literature for platelet lysis, a known precursor to thrombus formation.     

Defect in oxidative phosphorylation in LV papillary muscle mitochondria of patients undergoing mitral valve replacement

Mitochondria play a pivotal role in cellular metabolism, especially in energy production. Myocardial function depends on adenosine triphosphate (ATP) supplied by oxidation of several substrates. In the adult heart, this energy is obtained primarily from fatty acid oxidation through oxidative phosphorylation (OXPHOS). With this in view, we studied OXPHOS, Total-ATPase and cytochrome content in the mitochondria of the left ventricular (LV) papillary muscles in excised mitral valves of patients who underwent mitral valve replacement (MVR). The mitochondrial OXPHOS, cytochrome content and ATPase activity were studied in 70 patients (ranging from 22 to 40 years) operated on for mitral valve disease. Control study includes 25 normal mitral valves removed at necropsy from patients who died of extracardiac causes. In the presence of glutamate and succinate as substrates, the rate of mitochondrial oxygen consumption was significantly lower in LV papillary muscles of pathological mitral valves (P<0.001) by using with and without addition of ADP. The ADP/O ratio indices for glutamate and succinate were not significantly affected. Using glutamate as substrate, respiratory control index was significantly raised (P<0.05) as compared with control. A significant reduction of total cytochrome content and ATPase activity (P<0.001) was noted in LV papillary muscles of patients operated for mitral valve disease. Our results showed that OXPHOS, cytochromes 'a', 'b', 'c+c(1)' and ATP activity are significantly impaired in LV papillary muscles in patients with pathological mitral valve. Cardiac mitochondrial oxygen consumption is a very valuable tool to investigate the regulation of cardiac mitochondrial energy metabolism. There is increasing evidence that mitochondrial diseases, such as mitochondrial cardiomyopathy, valvular disease and some myopathies, can be responsive to treatment with metabolic intermediates such as coenzyme Q(10), thiamine, prednisone, and vitamin therapy.     

The use of autologous fascia lata for cardiac valve replacement: Preliminary results

Since November 1969, 53 patients have been operated on at the Toronto General Hospital for cardiac valve replacement with valves fashioned from autologous fascia lata. Sixty-three such valves have been inserted, including single aortic and mitral, double and triple valve replacements. The preliminary results indicate that operative mortality, considering the status of the patient submitted to the procedure, is comparable to that of plastic prosthetic valve replacement at this centre. Early follow-up confirms that anticoagulation is unnecessary and thromboembolism can be avoided with this form of valve substitution.     

LOW PROFILE BIOPROSTHESIS FOR CARDIAC VALVE REPLACEMENT: EARLY CLINICAL RESULTS

Between May 1976 and April 1977, 100 patients underwent cardiac valve replacement with a unique low profile glutaraldehyde-treated porcine aortic xenograft. These patients were classified in four groups: Group I, 43 patients who underwent isolated mitral valve replacement (MVR); Group II, 27 patients who had isolated aortic valve replacement (AVR); Group III, 10 patients who had MVR and AVR; and Group IV, 20 patients who had MVR or AVR associated with other cardiac procedures. The operative mortality for Group I was 2.3% (1 of 43) and 15% (3 of 20) in Group IV. The total operative mortality was 4% (4 of 100) and the late mortality was 1.02% (1 of 96 survivors), who died apparently secondary to a cardiac arrhythmia. During a follow-up period extending for 16 months, thromboembolic complications occurred early in the postoperative period in 3% (3 of 100), one patient with neurological residual, and two patients with transient symptoms only. The embolic complications occurred only in Group I. Considering all patients in whom the mitral valves were replaced, the incidence of emboli was 4.9% (3 of 61). The 96 patients did not receive anticoagulant therapy. Reoperation was necessary in one patient because of periprosthetic leak. The incidence of endocarditis was 1.02% (1 of 96 survivors). We recommend anticoagulant therapy for eight to twelve weeks postoperatively in MVR patients after bioprosthetic insertion.     

Tomographic PIV in a model of the left ventricle: 3D flow past biological and mechanical heart valves

Left ventricular flow is intrinsically complex, three-dimensional and unsteady. Its features are susceptible to cardiovascular pathology and treatment, in particular to surgical interventions involving the valves (mitral valve replacement). To improve our understanding of intraventricular fluid mechanics and the impact of various types of prosthetic valves thereon, we have developed a custom-designed versatile left ventricular phantom with anatomically realistic moving left ventricular membrane. A biological, a tilting disc and a bileaflet valve (in two different orientations) were mounted in the mitral position and tested under the same settings. To investigate 3D flow within the phantom, a four-view tomographic particle image velocimetry setup has been implemented. The results compare side-by-side the evolution of the 3D flow topology, vortical structures and kinetic energy in the left ventricle domain during the cardiac cycle. Except for the tilting disc valve, all tested prosthetic valves induced a crossed flow path, where the outflow crosses the inflow path, passing under the mitral valve. The biological valve shows a strong jet with a peak velocity about twice as high compared to all mechanical heart valves, which makes it easier to penetrate deeply into the cavity. Accordingly, the peak kinetic energy in the left ventricle in case of the biological valve is about four times higher than the mechanical heart valves. We conclude that the tomographic particle imaging velocimetry setup provides a useful ground truth measurement of flow features and allows a comparison of the effects of different valve types on left ventricular flow patterns.     

Biochemical characterization of individual normal, floppy and rheumatic human mitral valves.

Human mitral valves (32 floppy and 17 rheumatic) obtained at surgery were analysed and compared with 35 normal (autopsy) valves. Total amounts of collagen, proteoglycan and elastin were increased approx. 3-fold in floppy and rheumatic valves. The water content of rheumatic cusps was lower than normal. The most significant changes in floppy valves were the 59% increase in mean value of the proteoglycan content, a large increase in the ease of extractability of proteoglycans from 26.7 to 57.2% of the total and a 62% increase in mean value of the elastin content in the anterior cusps. Normal human mitral valve cusps contained a mean proportion of 29.3 (and chordae 26.6) type III collagen (as % of total types III + I collagen), the values increasing significantly to 33.2 and 36.3% respectively in chronic rheumatic disease. The ratio observed in floppy valves depended on the extent of secondary surface fibrosis, which could be demonstrated histologically; in valve cusps with considerable secondary fibrosis, the percentage of type III increased significantly (to 34.4%), whereas it decreased significantly (to 25.2%) when fibrosis was negligible. It is concluded that the ratio of collagen types in floppy valves reflects the extent of secondary fibrosis rather than the pathogenesis of the disrupted collagen in the central core of the valve.     

Telocytes in human heart valves

Valve interstitial cells (VICs) are responsible for maintaining the structural integrity and dynamic behaviour of the valve. Telocytes (TCs), a peculiar type of interstitial cells, have been recently identified by Popescu's group in epicardium, myocardium and endocardium (visit www.telocytes.com ). The presence of TCs has been identified in atria, ventricles and many other tissues and organ, but not yet in heart valves. We used transmission electron microscopy and immunofluorescence methods (double labelling for CD34 and c‐kit, or vimentin, or PDGF Receptor‐β) to provide evidence for the existence of TCs in human heart valves, including mitral valve, tricuspid valve and aortic valve. TCs are found in both apex and base of heart valves, with a similar density of 27–28 cells/mm² in mitral valve, tricuspid valve and aortic valve. Since TCs are known for the participation in regeneration or repair biological processes, it remains to be determined how TCs contributes to the valve attempts to re‐establish normal structure and function following injury, especially a complex junction was found between TCs and a putative stem (progenitor) cell.     

Prevalence of Valvular Heart Disease in A Cohort of Patients Taking Cabergoline for Management of Hyperprolactinemia

ObjectiveTo determine the prevalence of valvular heart disease in a cohort of patients taking cabergoline for the management of hyperprolactinemia.MethodsA retrospective review of medical records identified patients with hyperprolactinemia who underwent evaluation at Vanderbilt University Medical Center between January and June 2007. The medical records of those patients who were prescribed cabergoline and who underwent elective echocardiography were reviewed for details pertaining to cardiac valvular abnormalities and cabergoline use.ResultsForty-five patients (mean age, 41 ± 10 years [SD]) taking 0.91 ± 0.96 mg of cabergoline per week for a mean duration of 39 ± 29 months underwent echocardiography. Abnormalities of the cardiac valves were present in 3 patients (7%): 1 patient exhibited mild mitral regurgitation, 1 patient had focal aortic valve thickening, and 1 patient demonstrated mitral valve thickening. We found no significant difference in either the cumulative dose of cabergoline (P = .800) or the duration of cabergoline therapy (P = .745) between those patients with and those without these echocardiographic abnormalities.ConclusionWe found echocardiographic valve abnormalities in 3 of 45 patients (7 %) who had been prescribed cabergoline for the management of hyperprolactinemia. This prevalence of valvular heart disease after approximately 3 years of cabergoline treatment is no different from that previously reported in normal populations as determined by echocardiography. (Endocr Pract. 2008;14:672-677)     

Accumulation of elements in the arteries and cardiac valves of Thai with aging

To elucidate whether the extent of element accumulation in the arteries and cardiac valves with aging was different between different races, the authors investigated the accumulation of elements in the arteries and cardiac valves of the Thai with aging and the relationships among elements in the cardiac valves. After ordinary dissection at Chiang Mai University was finished, 16 arteries and 4 cardiac valves were resected and element contents were determined by inductively coupled plasma-atomic emission spectrometry. In the 16 arteries, the average content of calcium was the highest in the site of the abdominal aorta ramifying into the common iliac arteries, and it decreased in the order internal iliac, coronary, abdominal aorta, common iliac, external iliac, superior mesenteric, inferior mesenteric, thoracic aorta, brachial, radial, common carotid, subclavian, ulnar, axillary, renal, and internal thoracic arteries. The average contents of phosphorus and magnesium in respective arteries were parallel with the average contents of calcium, except for the coronary artery. In comparison with the arteries of the Japanese, the trend of calcium accumulation in the arteries of the Thai was almost similar to that in the arteries of the Japanese, except for the coronary artery and thoracic aorta. The calcium accumulation in the coronary artery was much higher in the Thai than in the Japanese, whereas that in the thoracic aorta was lower in the Thai than in the Japanese. Regarding elements in the cardiac valves, the calcium content increased remarkably in the seventies in the aortic valve and in the nineties in the pulmonary valve, but it hardly increased in both the mitral and tricuspid valves with aging. The average content of calcium was the highest in the aortic valve, and it decreased in the order pulmonary, tricuspid, and mitral valves. Regarding the relationship among elements in the aortic valves, it was found that there were extremely significant direct correlations among the contents of calcium, phosphorus, and magnesium, whereas there were significant direct correlations between zinc and either calcium or phosphorus contents. Although significant correlations were found between sulfur and the other element contents in the aortic valves of the Japanese, no significant correlations were found between them in the aortic valves of the Thai. In the mitral valves, extremely or very significant direct correlations were found among the contents of calcium, phosphorus, magnesium, and sulfur, with some exceptions that there were no significant correlations between phosphorus and either magnesium or sulfur contents. In addition, no significant correlation was found in the calcium content between the aortic valve and coronary artery in the same individuals.     

Ionescu-Shiley pericardial xenograft valve: Hemodynamic evaluation and early clinical follow-up of 326 patients

Dissatisfaction with the hemodynamic characteristics of available porcine valves prompted a clinical trial of the Ionescu-Shiley percardial xenograft (ISPX) valve. Three hundred fifty-six ISPX valves were implanted consecutively in 326 patients. Operative mortality was 2.6% (2/75) for aortic valve replacement alone and 7.7% (12/155) for aortic valve replacements that included reoperations and combined procedures such as mitral commissurotomy, annuloplasty, and coronary artery bypass. Operative mortality for all patients who underwent mitral valve replacement was 9.5% (14/147). The mean peak systolic gradient pressure in the aortic position was 5.4 mm Hg overall and 4.27 mm Hg with the size 19 mm valve. There were no embolic episodes in patients who received the ISPX valve in the aortic position. The available data indicate that the rate of peripheral embolism with the ISPX valve compares favorably with that of porcine valves. Considering its hemodynamic advantage, if the longterm durability of the full-orifice Ionescu-Shiley pericardial xenograft valve continues to be confirmed by follow-up studies, it is our opinion that it is the biologic valve of choice.     

Multi-Scale Biomechanical Remodeling in Aging and Genetic Mutant Murine Mitral Valve Leaflets: Insights into Marfan Syndrome

Mitral valve degeneration is a key component of the pathophysiology of Marfan syndrome. The biomechanical consequences of aging and genetic mutation in mitral valves are poorly understood because of limited tools to study this in mouse models. Our aim was to determine the global biomechanical and local cell-matrix deformation relationships in the aging and Marfan related Fbn1 mutated murine mitral valve. To conduct this investigation, a novel stretching apparatus and gripping method was implemented to directly quantify both global tissue biomechanics and local cellular deformation and matrix fiber realignment in murine mitral valves. Excised mitral valve leaflets from wild-type and Fbn1 mutant mice from 2 weeks to 10 months in age were tested in circumferential orientation under continuous laser optical imaging. Mouse mitral valves stiffen with age, correlating with increases in collagen fraction and matrix fiber alignment. Fbn1 mutation resulted in significantly more compliant valves (modulus 1.34±0.12 vs. 2.51±0.31 MPa, respectively, P<.01) at 4 months, corresponding with an increase in proportion of GAGs and decrease in elastin fraction. Local cellular deformation and fiber alignment change linearly with global tissue stretch, and these slopes become more extreme with aging. In comparison, Fbn1 mutated valves have decoupled cellular deformation and fiber alignment with tissue stretch. Taken together, quantitative understanding of multi-scale murine planar tissue biomechanics is essential for establishing consequences of aging and genetic mutations. Decoupling of local cell-matrix deformation kinematics with global tissue stretch may be an important mechanism of normal and pathological biomechanical remodeling in valves.     

AORTIC STENOSIS—Surgical Treatment Under Direct Vision,Using the Heart-Lung Machine

Cardiac operation with the operative field under direct vision and the patient''s oxygenation maintained by a heart-lung machine affords an excellent means of treating aortic stenosis, for it allows unlimited time in which to repair aortic stenosis no matter how involved the cusps are with calcium. The valves can be sculptured and the commissures cut at their place of fusion. Concomitant aortic insufficiency can also be taken care of at the same time, as can associated mitral valve stenosis and insufficiency.This method was used in ten patients. Two died. Eight were considerably improved.     

Replacement of the Aortic and Mitral Valves Using the Starr-Edwards Ball-Valve Prosthesis: A Report of 50 Cases

The aortic and mitral valves were replaced in 50 patients at the University of Alberta Hospital using the Starr-Edwards ball-valve prosthesis. The basis of the selection of 20 patients for isolated aortic valve replacement and 27 for mitral valve replacement using this type of prosthesis is presented, and the techniques of insertion of the aortic and mitral valve are described in detail. Of the 27 patients in whom the mitral valve was replaced by the Starr-Edwards prosthesis six died within 30 days of surgery and two after discharge from hospital at two and a half and four months, respectively. Left atrial thrombosis was the cause of death in four of these patients. In 20 patients in whom the aortic valve was replaced, four died in hospital and two died more than 30 days after returning home. Three of these six patients died from bleeding—the result of the use of anticoagulants. The difficulty in assessing whether or not anticoagulants are needed following replacement by a Starr-Edwards prosthesis is considered. It is felt, in our present state of knowledge, that anticoagulants should be used following mitral valve replacement but are probably not essential following replacement of the aortic valve. Two patients survived replacement of both aortic and mitral valves and have been followed up 18 months and seven months, respectively.     

Disc erosion in Models 103 and 104 of Beall mitral valve prostheses

Three cases of severe disc variance and erosion of the Teflon-disc Beall mitral valve prosthesis (Models 103 and 104) are reported. In two patients, the Beall mitral valves were excised and replaced with two Bj?rk-Shiley mitral valves. The remaining patient did not survive, and at autopsy, the lens was found at the aortic bifurcation level. Because of this potentially lethal complication, careful follow-up of patients with Beall mitral valve prostheses (Models 103 and 104) is recommended.     

Results of a comparative in vitro study of Duromedics and Björk-Shiley monostrut mitral heart valve prostheses

Two different mechanical heart valves with annulus diameters 21–29 mm, (five Björk-Shiley monostrut tilting disc valves and five Duromedics bileaflet valves) have been tested in pulsatile flow in the mitral position of a mock circulation. Reflux, pressure, and orifice area have been measured while cardiac output was varied between 2 and 6 1 min⁻¹. Insufficiency, mean orifice area, discharge coefficient, and performance and efficiency indices have been calculated. Mean values of insufficiency for the Björk-Shiley monostrut valves varied between 4.8 and 17.2% while the corresponding values for the Duromedics valves were in the range 6.1–17.3%. Mean values for orifice areas of the Björk-Shiley monostrut valves increased with the larger valve sizes from 101.1 to 210.2 mm²; for the Duromedics valves the area range was 134.5–262.9 mm². Because of the larger orifice areas the values of discharge coefficient and performance index for the Duromedic valves were higher than those for the Björk-Shiley monostrut valves. As the insufficiency of the two mechanical valves was similar, and the orifice area of the bileaflet valves was greater than that of the tilting disc valves, Duromedics valves gave higher values for the efficiency index, which varied between 0.31 and 0.39; for Björk-Shiley monostrut valves the index varied between 0.24 and 0.28 under the same test conditions. This hydrodynamic in vitro comparison of mechanical heart valves showed that the Duromedics bileaflet valves were superior to the Björk-Shiley tilting disc valves.