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Ann Thorac Surg 2002;74:1482-1487
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Reoperative mitral valve replacement: importance of preservation of the subvalvular apparatus

^a Division of Cardiovascular Surgery, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
^b Department of Surgery, University of Toronto, Toronto, Ontario, Canada

Accepted for publication June 26, 2002.

* Address reprint requests to Dr Borger, Toronto General Hospital, Room CN13-222, 200 Elizabeth St, Toronto, Ontario, Canada M5G 2C4.
e-mail: michael.borger{at}utoronto.ca

	Abstract

Top Abstract Introduction Material and methods Results Comment Appendix. Variables assessed as... References

 
BACKGROUND: Preservation of the subvalvular apparatus has been demonstrated to be beneficial during first-time mitral valve replacement (MVR), but has not been fully examined in reoperative (redo) MVR. The purpose of this study was to analyze outcomes in a large cohort of redo MVR patients, focusing on the effect of subvalvular preservation on mortality.

METHODS: We undertook a review of prospectively gathered data on patients undergoing MVR, with or without concomitant cardiac procedures, at our institution from 1990 to 1999. Predictors of mortality were determined by stepwise logistic regression.

RESULTS: A total of 1,521 consecutive MVR patients were analyzed, of which, 513 (34%) had undergone one or more previous MV procedures. In-hospital mortality occurred in 6.9% of first-time MVR patients versus 9.0% in redo patients (p = 0.13). The number of prior MV operations ranged from one to five in redo MVR patients, with 115 patients (22% of redos) having two or more. In redo MVR patients, preservation of the native posterior subvalvular apparatus was performed in 103 patients (21%), whereas native anterior and posterior preservation was performed in 31 patients (6%). Gore-Tex neochordal construction was performed in 135 redo MVR patients (26%). Perioperative mortality occurred in 3.6% of redo MVR patients with a preserved subvalvular apparatus (native tissue and/or Gore-Tex reconstruction) versus 13.3% of redo patients without preservation (p < 0.001). Independent predictors of mortality in redo MVR patients were (in decreasing order of magnitude) failure to preserve the subvalvular apparatus, preoperative renal failure, previous stroke/transient ischemic attack, left ventricular dysfunction (left ventricular ejection fraction <40%), and urgent timing.

CONCLUSIONS: Redo MVR can be performed with an acceptable risk of mortality. Although preservation of the subvalvular apparatus may increase operative complexity, we recommend subvalvular preservation in order to decrease the risk of early mortality.

	Introduction

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This article has been selected for the open discussion forum on the CTSNet Web site:http://www.ctsnet.org/discuss

 

It has been well demonstrated that preservation of the subvalvular apparatus during first-time mitral valve replacement (MVR) is associated with improved clinical outcomes. We have previously shown that preserved annular-papillary continuity results in improved left ventricular function in the early [1–3] and late [1] postoperative period, as well as improved short-term [4] and long-term [4, 5] survival post-MVR. Other investigators have confirmed the beneficial effects of subvalvular preservation on left ventricular function [6–8], symptomatology [6], and survival [7, 9] after MVR.

Reoperative (redo) mitral valve surgery is a common clinical problem. Bioprosthetic valves, in particular, commonly require re-replacement because of their predisposition to structural deterioration [10]. As long-term survival improves after mitral valve surgery, the incidence of redo MVR may be increasing over time. Relatively few studies have examined the results of reoperative MVR, consisting mostly of single-institution retrospective case series [10–12]. The effect of subvalvular preservation during redo MVR has not been fully assessed.

The purpose of this study was to examine outcomes during reoperative MVR in a large contemporary cohort of patients, with a focus on the effects of preservation of the subvalvular apparatus on perioperative mortality.

	Material and methods

Top Abstract Introduction Material and methods Results Comment Appendix. Variables assessed as... References

 
We performed a review of prospectively gathered data on all patients undergoing MVR surgery at our institution from 1990 to 1999. Patients undergoing mitral valve repair were excluded. We included MVR patients undergoing concomitant cardiac procedures (eg, aortic or tricuspid valve surgery, coronary bypass grafting). A total of 1,521 consecutive MVR patients were identified, of which, 513 (34%) had undergone one or more previous MV operations.

Perioperative management for redo MVR
A median sternotomy was performed with an oscillating saw in nearly all patients, with a right thoracotomy approach used rarely. Cardiopulmonary bypass (CPB) was established via ascending aortic cannulation and bicaval venous cannulation. Cannulation of the femoral vessels before sternotomy was not routinely performed. The hematocrit was maintained between 20% and 25%, pump flow rates between 2.0 and 2.5 L/min/m², and mean arterial pressures between 50 and 70 mm Hg during CPB. Myocardial protection consisted of cold antegrade blood cardioplegia in the vast majority of patients, with some receiving warm antegrade cardioplegia. Retrograde cardioplegia was used only in patients with diseased coronary bypass grafts [13]. Mild systemic hypothermia (30°C to 35°C) was employed during CPB in the majority of patients, with some operations being performed during moderate hypothermia (20°C to 29°C).

The mitral valve was approached through an incision in the left atrium, just posterior to the interatrial groove, in nearly all patients. A superior transeptal approach was used only in patients with a small left atrium or difficult surgical exposure. The decision of whether or not to preserve the subvalvular apparatus was made intraoperatively and was at the discretion of the attending surgeon. Our method of subvalvular preservation has been previously described in detail [14, 15], but the following is a brief summary.

In those patients in whom a decision was made to perform subvalvular preservation, we attempted to retain native subvalvular tissue whenever possible. Redundant valvular leaflet tissue was imbricated between the annulus and prosthetic sewing ring, or excised if necessary. If native leaflets and chordae were extensively scarred and fibrosed, such as in rheumatic disease or advanced myxomatous disease, then they were excised and annular-papillary continuity was restored with neochordae. Our method of neochordae construction involved placing 4-0 polytetrafluoroethylene sutures (Gore-Tex; W.L. Gore & Assoc; Flagstaff, AZ) through the fibrous heads of both papillary muscles, then attaching these sutures at 2, 4, 8, and 10 o’clock on the mitral annulus [14, 16]. The appropriate length of Gore-Tex suture was determined by measuring the distance between the papillary heads and the mitral annulus. We used this same technique (ie, Gore-Tex neochordal construction) in patients who had undergone removal of the subvalvular apparatus during their first MVR operation. Pledgeted 2-0 braided sutures were used to secure the sewing ring to the mitral annulus in all patients, placing the pledgets on the ventricular side of the mitral apparatus for all redo operations. In those patients in whom neochordal construction was performed, the Gore-Tex sutures were placed through the ring of the mitral prosthesis and securely tied after the prosthesis was in place. The mitral prosthesis was routinely inspected before atrial closure to ensure that retained subvalvular tissue did not interfere with prosthetic function. Transesophageal echocardiography was frequently employed post-CPB to assess prosthetic function.

Mitral valve replacement was performed before aortic or tricuspid valve procedures in patients requiring multivalvular operations. In those patients requiring concomitant coronary bypass grafting, distal anastomoses were performed before MVR and proximal anastomoses were performed last.

Statistical analysis
Categorical data are expressed as percentages and continuous data as means ± standard deviation throughout the manuscript. SAS version 8.01 (SAS Institute, Cary, NC) was used for all statistical analyses. Categorical data were analyzed univariately by ² or Fisher’s exact test, and continuous data were analyzed by Student’s unpaired t tests or Wilcoxon rank-sum tests where appropriate. Stepwise multivariable logistic regression analysis was used to calculate risk-adjusted odds ratios and to determine the independent predictors of perioperative mortality, defined as death during the same hospitalization. All variables suggested by the univariate analysis (p < 0.25) or those judged to be clinically important were entered into the logistic regression model. Model discrimination was evaluated by the area under the receiver operating characteristic (ROC) curve, and model precision was evaluated by the Hosmer-Lemeshow goodness-of-fit statistic, as previously described [17].

	Results

Top Abstract Introduction Material and methods Results Comment Appendix. Variables assessed as... References

 
First-time versus redo MVR patients
A total of 1,521 patients underwent MVR at our institution from 1990 to 1999, of which, 513 (34%) had one or more previous mitral valve operations. The prevalence of perioperative mortality was 6.9% in first-time MVR patients versus 9.0% in redo patients (p = 0.13). There were no statistically significant differences between first-time and redo MVR patients for ventilation time (34 ± 60 vs 31 ± 54 hours, respectively, p = 0.30), intensive care unit (ICU) length of stay (3.2 ± 5.9 vs 3.4 ± 5.8 days, p = 0.38), or hospital length of stay (13.7 ± 12.8 vs 13.9 ± 10.8 days, p = 0.77).

Table 1 displays the prevalence of risk factors in first-time and reoperative MVR patients. The redo population had a significantly higher prevalence of female gender, New York Heart Association (NYHA) class IV symptoms, urgent or emergent timing, previous stroke or transient ischemic attack (TIA), and atrial fibrillation. In addition, redo MVR patients were less likely to receive subvalvular preservation of the mitral valve, had more concomitant aortic and tricuspid valve procedures, and had longer CPB times. In contrast, first-time MVR patients were more likely to be older and more likely to have left ventricular (LV) dysfunction, a preoperative myocardial infarction (MI), unstable angina, diabetes, and hypertension. First-time MVR patients were also more likely to undergo concomitant coronary bypass grafting.

A total of 13 surgeons performed redo MVR surgery over the 10-year time period of this study. The percent of redo MVR patients who received some form of subvalvular preservation ranged from 4% to 60% for different surgeons. Figure 1 displays the method of subvalvular preservation used for redo MVR patients. The subvalvular apparatus was preserved (by retaining the native posterior valve leaflet, retaining both valve leaflets, and/or neochordal construction with Gore-Tex) in 44% of all redo MVR patients. No method of subvalvular preservation was performed in 56% of patients. As can be seen in Figure 2, the proportion of patients who received subvalvular preservation was relatively stable over the time period of the study.

View larger version (21K): [in this window] [in a new window]   Fig 1. Technique of subvalvular preservation employed in redo mitral valve replacement patients. Note that proportions do not total 100% because methods of subvalvular preservation (ie, native leaflet preservation and/or Gore-Tex neochordal construction) were not mutually exclusive. (Ant = anterior; Post = posterior.)

View larger version (26K): [in this window] [in a new window]   Fig 2. Proportion of redo mitral valve replacement patients who received some form of subvalvular preservation over the time period of the study.

View larger version (20K): [in this window] [in a new window]   Fig 3. Perioperative mortality in redo mitral valve replacement patients with and without preservation of the subvalvular apparatus.

Logistic regression analysis was performed to determine the risk-adjusted predictors of mortality. As can be seen in Table 2, the independent predictors of mortality were (in decreasing order of magnitude) failure to preserve the subvalvular apparatus, prior history of stroke or TIA, LV dysfunction, and urgent timing. Although previous mitral valve replacement (vs repair) was a significant univariate predictor of mortality, it did not achieve significance in the multivariable model.

	Comment

Top Abstract Introduction Material and methods Results Comment Appendix. Variables assessed as... References

In the current study, the risk of mortality was not significantly higher for reoperative (redo) MVR surgery when compared with first-time MVR. It should be noted, however, that we excluded all mitral valve repair patients in the current study. Exclusion of these low-risk patients resulted in a relatively high prevalence (6.9%) of operative mortality in first-time MVR patients. We feel our operative mortality rate of 9.0% in redo patients compared favorably with the 6.9% for first-time patients, as well as with reports from other centers of mortality during redo MVR [10–12]. The relatively low prevalence of mortality in redo MVR patients was particularly encouraging given the high-risk profile of these patients. That is, redo MVR patients were more likely to be in NYHA class IV heart failure and more likely to be undergoing urgent or emergent surgery than first-time MVR patients. In addition, redo MVR patients were more likely to undergo multiple valvular procedures, although concomitant coronary bypass was more prevalent in first-time patients.

It has been well demonstrated, in both clinical and laboratory studies, that preservation of the subvalvular apparatus during first-time MVR is associated with improved outcomes. We have previously demonstrated in canine [18] and porcine [19] models that LV dimensions and function post-MVR are better with subvalvular preservation than with complete excision of native valve tissue. Similarly, the Stanford group has used large animal models to demonstrate that preserved annular-papillary continuity results in improved LV function [20] and decreased LV strain [21] post-MVR when compared with native valve excision.

Several investigators have demonstrated the beneficial effects of subvalvular preservation on clinical outcomes after first-time MVR. We performed a randomized trial in 16 patients undergoing MVR for chronic mitral regurgitation, and found that subvalvular preservation resulted in improved LV ejection fraction and preload recruitable stroke work 3 months and 5 years postoperatively [1]. We also examined a group of high-risk patients undergoing MVR after a recent myocardial infarction [4]. We found that failure to preserve annular-papillary continuity was an independent predictor of early and late mortality. Similarly, Lee and associates examined 612 consecutive MV surgery patients and found that failure to preserve the subvalvular apparatus was an independent predictor of early and late mortality [9]. Wasir and associates recently demonstrated in a prospective study that subvalvular preservation is associated with improved LV function and exercise capacity post-MVR [6]. Wu and associates randomized 68 patients with rheumatic mitral disease to receive subvalvular preservation or complete excision of the native valve during MVR, and found improved early survival and LV function in the preservation group [7]. In addition to the beneficial effects of subvalvular preservation on LV performance post-MVR, this technique likely decreases the risk of myocardial rupture, an uncommon but disastrous complication of MVR [22].

Preservation of the native subvalvular apparatus can be achieved by retaining both the anterior and posterior leaflets, or by retaining the posterior leaflet only. There is some evidence that preservation of both leaflets results in better LV function post-MVR than preservation of the posterior leaflet alone [23]. In those patients requiring excision of native leaflets secondary to extensive fibrosis and scarring (ie, advanced rheumatic or myxomatous disease), preservation of annular-papillary continuity can be performed via neochordal construction with Gore-Tex sutures. In the current study, the results achieved with neochordal construction were similar to those achieved with native tissue preservation and were superior to patients who received no subvalvular preservation. We therefore believe that neochordal construction is the procedure of choice in patients with advanced rheumatic or myxomatous disease. Gore-Tex can also be used to shorten elongated native chordae, while retaining native valve tissue. We have previously demonstrated that neochordal construction with Gore-Tex is a safe and durable technique, with excellent function up to 10 years postoperatively [24]. Although Gore-Tex neochordal construction is more commonly used for mitral valve repair, it is also eminently feasible and efficacious for MVR surgery, particularly in patients with extensive scarring of the subvalvular apparatus.

We have previously examined the feasibility of represervation of chordae tendinae during redo MVR [16]. We analyzed 54 reoperative patients who underwent chordal preservation/reconstruction at the time of their first MV operation. The papillary muscles and Gore-Tex neochordae were intact in all patients up to 22 years after the first operation. All preserved chordae were in excellent condition and freely mobile, except in 1 patient. A preserved posterior chord was adherent to the bioprosthetic stent in this patient, requiring careful dissection for represervation. Operative times in patients undergoing chordal represervation were similar to patients who did not undergo subvalvular preservation. We concluded that chordal represervation was safe and feasible during redo MVR [16].

In the current study, we examined a much larger group of reoperative MVR patients who underwent surgery over a 10-year time period. Subvalvular preservation, by native leaflet preservation or neochordal construction, was performed in almost one-half of the 513 patients. Preservation of the subvalvular apparatus was associated with a significantly decreased risk of perioperative mortality. Failure to preserve mitral annular-papillary continuity was the biggest independent predictor of mortality. Furthermore, it was the only risk factor identified that cardiac surgeons are able to influence. We therefore strongly recommend preservation of the subvalvular apparatus during redo MVR in order to lower the risk of mortality.

It is noteworthy that over one-half of patients in the current study did not receive any form of subvalvular preservation during redo MVR. There are two probable explanations for this finding. First, the beneficial effects of subvalvular preservation were still controversial during the time period of the current study, particularly in the earlier years. Second, preservation of the subvalvular apparatus may increase operative time and complexity, which may have caused some surgeons to avoid this technique in redo patients. It should be restated that the decision of whether or not to preserve the subvalvular apparatus was at the discretion of the operating surgeon in the current study. Some surgeons were undoubtedly more willing to perform this procedure than others, a finding reflected by the significant variation in preservation rates between surgeons. Therefore, some of our results may have been "surgeon specific," and this is one of the main limitations of our study. However, the trend in outcomes was consistent for all surgeons: operative mortality was lower in patients who received preservation of the subvalvular apparatus than for those without preservation for every surgeon. We therefore believe that subvalvular preservation during redo MVR is feasible and reproducible, particularly for surgeons who routinely use this technique in first-time MVR. It is now our policy to perform preservation of the subvalvular apparatus, via native leaflet preservation or Gore-Tex neochordal construction, whenever possible in first-time and redo MVR patients.

In summary, reoperative MVR can be performed with an acceptable risk of mortality, despite the relatively increased risk profile of redo patients. Preservation of the subvalvular apparatus is associated with a decreased risk of mortality during redo MVR. Although subvalvular preservation may increase operative complexity, we strongly recommend the use of this technique in first-time and redo MVR surgery.

	Appendix. Variables assessed as univariate predictors of mortality in reoperative mitral valve patients (asignificant at p < 0.05 level)

Top Abstract Introduction Material and methods Results Comment Appendix. Variables assessed as... References

 

Age Gender Year of redo surgery Number of years between operations Left ventricular dysfunctiona Left ventricular ejection fraction <40%, as assessed by angiography or echocardiography New York Heart Association heart failure class Canadian Cardiovascular Society angina class Urgent timinga Operation during same hospitalization, including emergency procedures Acute endocarditisa Hypertension Patient taking antihypertensive medication preoperatively Recent myocardial infarction Myocardial infarction within 30 days of surgery Renal failurea Serum creatinine >200 mmol/L or history of renal failure Diabetes mellitus History of diabetes treated with diet, oral hypoglycemics, or insulin Smoking history Previous or present Peripheral vascular diseasea History of peripheral or carotid vascular disease Previous stroke or transient ischemic attacka Congestive heart failurea History of hospital admission for heart failure Atrial fibrillation History of preoperative atrial fibrillation Coronary artery disease As documented by coronary angiography Number of previous mitral valve proceduresa Type of previous mitral valve procedurea Repair or replacement Mitral valve pathology Type of mitral prosthesis Bioprosthetic or mechanical Size of mitral prosthesis Subvalvular preservationa Preservation of the native posterior leaflet, native anterior and posterior leaflet, or Gore-Tex chordal reconstruction Concomitant proceduresa Aortic valve surgery, tricuspid valve surgery, and coronary artery bypass grafting Cardiopulmonary bypass temperature Normothermia, mild hypothermia, moderate hypothermia, or deep hypothermia as measured by nasopharyngeal probe Cardioplegia temperature Cold, tepid, or warm blood cardioplegia Retrograde cardioplegia Cardiopulmonary bypass timea Aortic cross-clamp timea

	References

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1. Komeda M., David T.E., Rao V., Sun Z., Weisel R.D., Burns R.J. Late hemodynamic effects of the preserved papillary muscles during mitral valve replacement. Circulation 1994;90:II190-II194.
2. David T.E., Burns R.J., Bacchus C.M., Druck M.N. Mitral valve replacement for mitral regurgitation with and without preservation of chordae tendineae. J Thorac Cardiovasc Surg 1984;88:718-725.[Abstract]
3. David T.E., Uden D.E., Strauss H.D. The importance of the mitral apparatus in left ventricular function after correction of mitral regurgitation. Circulation 1983;68:II76-II82.
4. David T.E., Ho W.C. The effect of preservation of chordae tendineae on mitral valve replacement for postinfarction mitral regurgitation. Circulation 1986;74:I116-I120.
5. David T.E., Armstrong S., Sun Z. Left ventricular function after mitral valve surgery. J Heart Valve Dis 1995;4(Suppl 2):S175-S180.
6. Wasir H., Choudhary S.K., Airan B., Srivastava S., Kumar A.S. Mitral valve replacement with chordal preservation in a rheumatic population. J Heart Valve Dis 2001;10:84-89.[Medline]
7. Wu Z.K., Sun P.W., Zhang X., Zhong F.T., Tong C.W., Lu K. Superiority of mitral valve replacement with preservation of subvalvular structure to conventional replacement in severe rheumatic mitral valve disease: a modified technique and results of one-year follow up. J Heart Valve Dis 2000;9:616-622.[Medline]
8. Straub U., Feindt P., Huwer H., et al. Postoperative assessment of chordal preservation and changes in cardiac geometry following mitral valve replacement. Eur J Cardiothorac Surg 1996;10:734-740.[Abstract]
9. Lee E.M., Shapiro L.M., Wells F.C. Importance of subvalvular preservation and early operation in mitral valve surgery. Circulation 1996;94:2117-2123.[Abstract/Free Full Text]
10. Akins C.W., Buckley M.J., Daggett W.M., et al. Risk of reoperative valve replacement for failed mitral and aortic bioprostheses. Ann Thorac Surg 1998;65:1545-1551.[Abstract/Free Full Text]
11. Bortolotti U., Milano A., Mossuto E., Mazzaro E., Thiene G., Casarotto D. Early and late outcome after reoperation for prosthetic valve dysfunction: analysis of 549 patients during a 26-year period. J Heart Valve Dis 1994;3:81-87.[Medline]
12. Cohn L.H., Aranki S.F., Rizzo R.J., et al. Decrease in operative risk of reoperative valve surgery. Ann Thorac Surg 1993;56:15-20.[Abstract]
13. Borger M.A., Rao V., Weisel R.D., et al. Reoperative coronary bypass surgery: effect of patent grafts and retrograde cardioplegia. J Thorac Cardiovasc Surg 2001;121:83-90.
14. Reardon M.J., David T.E. Mitral valve replacement with preservation of the subvalvular apparatus. Curr Opin Cardiol 1999;14:104-110.[Medline]
15. David T.E. Mitral valve replacement with preservation of chordae tendinae: rationale and technical considerations. Ann Thorac Surg 1986;41:680-682.[Abstract]
16. Rao V., Komeda M., Weisel R.D., et al. Results of represervation of the chordae tendineae during redo mitral valve replacement. Ann Thorac Surg 1996;62:179-183.[Abstract/Free Full Text]
17. Borger M.A., Ivanov J., Weisel R.D., et al. Decreasing incidence of stroke during valvular surgery. Circulation 1998;98:II137-II143.
18. David T.E., Strauss H.D., Mesher E., Anderson M.J., Macdonald I.L., Buda A.J. Is it important to preserve the chordae tendinae and papillary muscles during mitral valve replacement?. Can J Surg 1981;24:236-239.[Medline]
19. Spence P.A., Peniston C.M., David T.E., et al. Toward a better understanding of the etiology of left ventricular dysfunction after mitral valve replacement: an experimental study with possible clinical implications. Ann Thorac Surg 1986;41:363-371.[Abstract]
20. DeAnda A.J., Komeda M., Nikolic S.D., Daughters G.T., Ingels N.B., Miller D.C. Left ventricular function, twist, and recoil after mitral valve replacement. Circulation 1995;92:II458-II466.
21. Moon M.R., DeAnda A.J., Daughters G.T., Ingels N.B.J., Miller D.C. Effects of mitral valve replacement on regional left ventricular systolic strain. Ann Thorac Surg 1999;68:894-902.[Abstract/Free Full Text]
22. Heath B.J., Warren E.T., Nickels B. Mitral valve replacement: techniques to eliminate myocardial rupture and prevent valvular disruption. Ann Thorac Surg 1991;52:839-841.[Abstract]
23. Yun K.L., Sintek C.F., Miller D.C., et al. Randomized trial of partial versus complete chordal preservation methods of mitral valve replacement: a preliminary report. Circulation 1999;100:II90-II94.
24. David T.E., Omran A., Armstrong S., Sun Z., Ivanov J. Long-term results of mitral valve repair for myxomatous disease with and without chordal replacement with expanded polytetrafluoroethylene sutures. J Thorac Cardiovasc Surg 1998;115:1279-1285.[Abstract/Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Michael A. Borger Terrence M. Yau Vivek Rao Hugh E. Scully Tirone E. David Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Borger, M. A. Articles by David, T. E. Search for Related Content PubMed PubMed Citation Articles by Borger, M. A. Articles by David, T. E. Related Collections Valve disease