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:	REVERSIBLE SNARING TECHNIQUE FOR PROPER PROSTHETIC VALVE REPLACEMENT 

Mohamed A.K. Salama Ayyad
Assistant Professor. Cardiothoracic Surgery Department. 
Faculty of Medicine, Assiut University, Egypt.
Tel: +201002001932
Email:  HYPERLINK "mailto:ayyadclinic@gmail.com" ayyadclinic@gmail.com
            HYPERLINK "mailto:ayyad@aun.edu.eg" ayyad@aun.edu.eg
















Abstract:
The use of snaring technique to fit-into-annulus a prosthetic valve either in aortic or mitral valve replacement (MVR, AVR) surgery has been previously described. Using this technique from August 2014 until August 2016 I performed 83 prosthetic valve replacements in 68 patients (56 prosthetic MVR and 27 prosthetic AVR, 41 patients with single MVR, 12 single AVR and 15 double A, MVR) in Assiut University Hospitals.
The purpose of this article is to provide a benefit, modest, easy technique regardless the type, size and position of prosthetic heart valve for valve fitting during valve replacement surgery. In this technique we use 3 to 4 sutures from the valve sutures to be snared, the main stem of this technique is to visualize the pledgets in-place, and if this can be done then the given valve can certainly be adequately seated. Those snares wedge the prosthetic valve into position in a reversible manner, allowing the surgeon to make estimation whether it is certainly reasonable for that size valve to be settled in a given annulus or not. The snaring technique has major advantages; first, it allows for confirmation of the technical possibility of a given valve fitting into and functioning in a given orifice. Second, the reversibility of the technique permits for altering surgeon�s plan by placing a smaller valve, performing annular enlargement (in aortic valve), or excising obstructing subvalvular tissues (in mitral valve). Third, in cases of aortic valve replacement it allows for the visibility of the coronary ostia after valve fitting into position and make sure it�s not obstructed by valve body. Fourth, it maintains a snug fit of the valve while the remaining sutures are tied down making its easily to fit down the tied sutures into the valve. 
We recommend using this technique in all heart valve replacements prior to the final tightening of stitches.







Introduction:
     The use of snaring technique to fit-into-annulus a prosthetic valve either in aortic or mitral valve replacement (MVR,AVR) surgery has been previously described. ADDIN EN.CITE <EndNote><Cite><Author>Baumgartner</Author><Year>1998</Year><RecNum>40</RecNum><DisplayText>[1]</DisplayText><record><rec-number>40</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">40</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Baumgartner, Fritz J</author><author>Omari, Bassam O</author><author>Stuart, Lillia</author><author>Milliken, Jeffrey C</author><author>Nelson, Ronald J</author><author>Robertson, John M</author></authors></contributors><titles><title>Reversible snaring for proper prosthetic seating during valve replacement</title><secondary-title>The Annals of thoracic surgery</secondary-title></titles><periodical><full-title>The Annals of thoracic surgery</full-title></periodical><pages>957-958</pages><volume>66</volume><number>3</number><dates><year>1998</year></dates><isbn>0003-4975</isbn><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_1" \o "Baumgartner, 1998 #40" 1] The proper seating of a prosthetic valve in a small annulus, particularly in the aortic position, may pose substantial problems. Therefore, the full-root technique or annular enlargement is sometimes required in order to implant an adequate size of prosthesis into a small annulus ADDIN EN.CITE <EndNote><Cite><Author>Wendler</Author><Year>2001</Year><RecNum>39</RecNum><DisplayText>[2]</DisplayText><record><rec-number>39</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">39</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Wendler, O</author><author>Dzindzibadze, V</author><author>Langer, F</author><author>El Dsoki, S</author><author>Sch�fers, H-J</author></authors></contributors><titles><title>Aortic valve replacement with a stentless bioprosthesis using the full-root technique</title><secondary-title>The Thoracic and cardiovascular surgeon</secondary-title></titles><periodical><full-title>The Thoracic and cardiovascular surgeon</full-title></periodical><pages>361-364</pages><volume>49</volume><number>06</number><dates><year>2001</year></dates><isbn>0171-6425</isbn><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_2" \o "Wendler, 2001 #39" 2]. 
Patient Prosthetic Mismatch (PPM) in mitral position is independently associated with persisting pulmonary hypertension, increased incidence of congestive heart failure, and reduced survival after MVR. ADDIN EN.CITE <EndNote><Cite><Author>Lam</Author><Year>2007</Year><RecNum>22</RecNum><DisplayText>[3, 4]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lam, Buu-Khanh</author><author>Chan, Vincent</author><author>Hendry, Paul</author><author>Ruel, Marc</author><author>Masters, Roy</author><author>Bedard, Pierre</author><author>Goldstein, Bill</author><author>Rubens, Fraser</author><author>Mesana, Thierry</author></authors></contributors><titles><title>The impact of patient�prosthesis mismatch on late outcomes after mitral valve replacement</title><secondary-title>The Journal of thoracic and cardiovascular surgery</secondary-title></titles><pages>1464-1473. e3</pages><volume>133</volume><number>6</number><dates><year>2007</year></dates><isbn>0022-5223</isbn><urls></urls></record></Cite><Cite><Author>Magne</Author><Year>2007</Year><RecNum>21</RecNum><record><rec-number>21</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">21</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Magne, Julien</author><author>Mathieu, Patrick</author><author>Dumesnil, Jean G</author><author>Tann�, David</author><author>Dagenais, Fran�ois</author><author>Doyle, Daniel</author><author>Pibarot, Philippe</author></authors></contributors><titles><title>Impact of prosthesis-patient mismatch on survival after mitral valve replacement</title><secondary-title>Circulation</secondary-title></titles><pages>1417-1425</pages><volume>115</volume><number>11</number><dates><year>2007</year></dates><isbn>0009-7322</isbn><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_3" \o "Lam, 2007 #22" 3,  HYPERLINK \l "_ENREF_4" \o "Magne, 2007 #21" 4] 
Snaring technique could be used to fit proper valve size into annulus without enlargement. However, in mitral valve it was suggested that the snaring technique is useful to detect whether the retained subvalvular apparatus disturbs mechanical leaflet motion or not ADDIN EN.CITE <EndNote><Cite><Author>Baumgartner</Author><Year>1998</Year><RecNum>40</RecNum><DisplayText>[1]</DisplayText><record><rec-number>40</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">40</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Baumgartner, Fritz J</author><author>Omari, Bassam O</author><author>Stuart, Lillia</author><author>Milliken, Jeffrey C</author><author>Nelson, Ronald J</author><author>Robertson, John M</author></authors></contributors><titles><title>Reversible snaring for proper prosthetic seating during valve replacement</title><secondary-title>The Annals of thoracic surgery</secondary-title></titles><periodical><full-title>The Annals of thoracic surgery</full-title></periodical><pages>957-958</pages><volume>66</volume><number>3</number><dates><year>1998</year></dates><isbn>0003-4975</isbn><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_1" \o "Baumgartner, 1998 #40" 1]
The purpose of this article is to provide a multiple benefit, modest, easy technique regardless the type, size and position of prosthetic heart valve during valve implantation surgery. 
Patient and methods:
     From August 2014 until August 2016 I have performed a total number of 83 prosthetic valve replacements in 68 patients (56 prosthetic MVR and 27 prosthetic AVR, 41 patients with single MVR, 12 single AVR and 15 double A, MVR), all were done in Cardio-Thoracic surgery department, Faculty of Medicine Assiut University, Egypt.
Cardiopulmonary bypass is established with Aorto-bicaval cannulation for mitral replacement and two stage single venous cannulation for aortic valve replacement. After the valve is excised, the annulus is sized to get a plan for possible succeeding maneuvers. 
In case of aortic valve replacement, pledged 2-0 sutures are placed first at the three commissures; the remaining sutures are then placed. All sutures passed from the ventricular to the aortic direction in case of supra-annular position or from the aortic side to the ventricular side in intra-annular position of the valve. (Which I operated only in one case with Aortic valve sized 25)
Generally, we use a total of 12 sutures in the annulus. The orifice is resized, the prosthetic valve is chosen, and the sutures are placed through the sewing ring. The valve is seated and three of the sutures located at equal distances from each other (usually at the commissures) are chosen to be snugged. 
In the mitral position the needle passes from the atrial side to the ventricular side in all the 12-14 sutures. The orifice is resized, the prosthetic valve is chosen, and the sutures are placed through the sewing ring. The valve is seated, and we chose 4 sutures to be snugged two at the commissures and the other two at half way of each leaflet. 
In all prosthetic valves, snugly tightening these snares wedges the prosthesis into position in a reversible manner, letting the surgeon to make estimation whether it is certainly reasonable for that size valve to be settled in a given annulus.
The main stem of this method is to visualize the pledgets in-place, and if this can be done then the given valve can surely be adequately seated. Also we assess the sub-valvular apparatus in the mitral position as impingement on prosthetic leaflet excursion by the sub-valvular apparatus can be corrected if necessary before the valve is permanently fixed in place; we assess the visibility of the coronary ostia in aortic position. 
If everything is accepted, the sutures between the snares are then tied down, and finally the snared sutures are tied. 
We have found that stiffer snares are more useful in snugging down the valve than the more rubbery, softer snares. 
If the valve cannot be properly seated, or another problem the sutures can be withdrawn from the sewing ring and passed through the sewing ring of a smaller valve with a French-eye needle, or dealing with the excitant problem surgically.
Results:
     From August 2014 until August 2016 I have performed a total of 83 prosthetic valve replacements in 68 patients, with a 30-day operative mortality of 1.47%, redo-valve replacements were excluded from this study
The �valve reversible snaring technique� to evaluate and maintain proper valve seating was used in every case. The valve replacements have included 27 aortic, 56 mitral valve replacement. Post-operative transthoracic echocardiography was done in every case up to the 6th week post-operatively in some cases. There was no instance of perivalvular leak, with good valve mobility and accepted pressure gradient across the valve in all the cases. Valve pathologies mostly were rheumatic, in origin. 
The small aortic annulus poses a particular problem but placing the pledged sutures from the ventricular to the aortic side of the annulus results in supra-annular placement of the valve, which often allows placement of a larger valve than if placed intra-annularly with accepted pressure gradient across the valve.
We have found that the routine use of snares in fixing the aortic prosthesis is extremely valuable in making feasible the placement of the maximal allowable valve size avoiding the need of root enlargement in all the cases included in our study, although we use aortic size of 19mm �supra-annular� in 5 cases out of 27 but it was accepted with their BSA. 
Discussion:
Despite the marked improvements in prosthetic valve design and surgical techniques over the past years, valve replacement does not deliver an ultimate therapy to the patient. Instead, native valve disease is switched to �prosthetic valve disease,� and the outcome of patients undergoing valve replacement is affected by prosthetic valve hemodynamics, durability, and thrombogenicity. Nonetheless, many of the prosthesis-related complications can be prevented or their impact minimized through optimal prosthesis choice and careful medical and surgical management and follow-up after implantation. One of these complications is the term valve Patient Prosthetic Mismatch �PPM� which was first proposed in 1978 by Rahimtoola. ADDIN EN.CITE <EndNote><Cite><Author>Rahimtoola</Author><Year>1978</Year><RecNum>18</RecNum><DisplayText>[5]</DisplayText><record><rec-number>18</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">18</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Rahimtoola, Shahbudin H</author></authors></contributors><titles><title>The problem of valve prosthesis-patient mismatch</title><secondary-title>Circulation</secondary-title></titles><pages>20-24</pages><volume>58</volume><number>1</number><dates><year>1978</year></dates><isbn>0009-7322</isbn><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_5" \o "Rahimtoola, 1978 #18" 5]�
PPM occurs when the effective orifice area �EOA� of a normally functioning prosthesis is too small in relation to the patient�s body size resulting in abnormally high postoperative gradients across the valve. The most widely accepted and validated parameter for identifying PPM is the indexed EOA, ADDIN EN.CITE  ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_6" \o "Dumesnil, 1990 #29" 6-9] Moderate PPM may be quite frequent in both the aortic (20% to 70%) and mitral (30% to 70%) positions, whereas the prevalence of severe PPM ranges from 2% to 10% in both positions.  ADDIN EN.CITE  ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_3" \o "Lam, 2007 #22" 3,  HYPERLINK \l "_ENREF_4" \o "Magne, 2007 #21" 4,  HYPERLINK \l "_ENREF_8" \o "Pibarot, 2000 #17" 8,  HYPERLINK \l "_ENREF_9" \o "Pibarot, 2006 #19" 9] 

In light of data published in the literature, the surgeon should attempt to avoid severe PPM in every patient undergoing AVR or MVR. Likewise, every effort should be made to avoid moderate PPM in patients undergoing AVR and presenting with the following coexisting conditions: preexisting LV dysfunction and/or severe LV hypertrophy, age <65 to 70 years, and regular and/or intense physical activity. Although the surgeon try to do his best to implant a large prosthetic valve with accepted EOA  for the patient  ADDIN EN.CITE  ADDIN EN.CITE.DATA [ HYPERLINK \l "_ENREF_10" \o "Castro, 2002 #34" 10-12]  here comes the safety and efficacy of using the reversible snaring technique as it allows for confirmation of the technical feasibility of a given valve fitting into and functioning in a given orifice, while , the reversibility of the technique allows for altering one�s plan by placing a smaller valve if any other maneuvers can�t be done to implant the �corrected size valve according to measured EOA� .Recent studies have reported that this procedure can be performed safely for this purpose. The prevention of PPM in the mitral position represents a much greater challenge than in the aortic position because valve annulus enlargement or stentless valve implantation is not an option in this situation. ADDIN EN.CITE <EndNote><Cite><Author>Magne</Author><Year>2007</Year><RecNum>21</RecNum><DisplayText>[4, 9]</DisplayText><record><rec-number>21</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">21</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Magne, Julien</author><author>Mathieu, Patrick</author><author>Dumesnil, Jean G</author><author>Tann�, David</author><author>Dagenais, Fran�ois</author><author>Doyle, Daniel</author><author>Pibarot, Philippe</author></authors></contributors><titles><title>Impact of prosthesis-patient mismatch on survival after mitral valve replacement</title><secondary-title>Circulation</secondary-title></titles><pages>1417-1425</pages><volume>115</volume><number>11</number><dates><year>2007</year></dates><isbn>0009-7322</isbn><urls></urls></record></Cite><Cite><Author>Pibarot</Author><Year>2006</Year><RecNum>19</RecNum><record><rec-number>19</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">19</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pibarot, Philippe</author><author>Dumesnil, Jean G</author></authors></contributors><titles><title>Prosthesis-patient mismatch: definition, clinical impact, and prevention</title><secondary-title>Heart</secondary-title></titles><pages>1022-1029</pages><volume>92</volume><number>8</number><dates><year>2006</year></dates><isbn>1468-201X</isbn><urls></urls></record></Cite></EndNote>[ HYPERLINK \l "_ENREF_4" \o "Magne, 2007 #21" 4,  HYPERLINK \l "_ENREF_9" \o "Pibarot, 2006 #19" 9] 
In cases of aortic valve replacement, it allows for the visibility of the coronary ostia after valve fitting into position and make sure it�s not obstructed by valve body especially in cases of supra-annular implantation or uses of large valve size. 
The snaring technique has major advantages; 
First, it allows for confirmation of the technical possibility of a given valve fitting into and functioning in a given orifice. 
Second, the reversibility of the technique permits for altering surgeon�s plan by placing a smaller valve, performing annular enlargement (in aortic valve), or excising obstructing subvalvular tissues (in mitral valve). 
Third, in cases of aortic valve replacement it allows for the visibility of the coronary ostia after valve fitting into position and make sure it�s not obstructed by valve body. 
Fourth, it maintains a snug fit of the valve while the remaining sutures are tied down making its easily to fit down the tied sutures into the valve. 
We are able to increase the size of the prosthesis chosen with confidence for a given annulus with this simple maneuver. Suture reversible snaring technique is a useful, in valve replacement, and in instances of small annuli or bulky subvalvular structures.



Conclusion:
I could say that this maneuver has zero disadvantage despite the good advantages if it and I recommend using it in all heart valve surgery prior to tying down the stitches.






















References:

 ADDIN EN.REFLIST 1.	Baumgartner FJ, Omari BO, Stuart L et al. Reversible snaring for proper prosthetic seating during valve replacement. The Annals of thoracic surgery 1998; 66: 957-958.
2.	Wendler O, Dzindzibadze V, Langer F et al. Aortic valve replacement with a stentless bioprosthesis using the full-root technique. The Thoracic and cardiovascular surgeon 2001; 49: 361-364.
3.	Lam B-K, Chan V, Hendry P et al. The impact of patient�prosthesis mismatch on late outcomes after mitral valve replacement. The Journal of thoracic and cardiovascular surgery 2007; 133: 1464-1473. e1463.
4.	Magne J, Mathieu P, Dumesnil JG et al. Impact of prosthesis-patient mismatch on survival after mitral valve replacement. Circulation 2007; 115: 1417-1425.
5.	Rahimtoola SH. The problem of valve prosthesis-patient mismatch. Circulation 1978; 58: 20-24.
6.	Dumesnil JG, Honos GN, Lemieux M, Beauchemin J. Validation of applications of indexed aortic prosthetic valve areas calculated by Doppler echocardiography. Journal of the American College of Cardiology 1990; 16: 637-643.
7.	Dumesnil JG, Honos GN, Lemieux M, Beauchemin J. Validation and applications of mitral prosthetic valvular areas calculated by Doppler echocardiography. The American journal of cardiology 1990; 65: 1443-1448.
8.	Pibarot P, Dumesnil JG. Hemodynamic and clinical impact of prosthesis�patient mismatch in the aortic valve position and its prevention. Journal of the American College of Cardiology 2000; 36: 1131-1141.
9.	Pibarot P, Dumesnil JG. Prosthesis-patient mismatch: definition, clinical impact, and prevention. Heart 2006; 92: 1022-1029.
10.	Castro LJ, Arcidi JM, Fisher AL, Gaudiani VA. Routine enlargement of the small aortic root: a preventive strategy to minimize mismatch. The Annals of thoracic surgery 2002; 74: 31-36.
11.	Dhareshwar J, Sundt TM, Dearani JA et al. Aortic root enlargement: What are the operative risks? The Journal of thoracic and cardiovascular surgery 2007; 134: 916-924.
12.	Kulik A, Al-Saigh M, Chan V et al. Enlargement of the small aortic root during aortic valve replacement: is there a benefit? The Annals of thoracic surgery 2008; 85: 94-100.

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app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dumesnil, Jean G</author><author>Honos, George N</author><author>Lemieux, Michel</author><author>Beauchemin, Jocelyn</author></authors></contributors><titles><title>Validation and applications of mitral prosthetic valvular areas calculated by Doppler echocardiography</title><secondary-title>The American journal of cardiology</secondary-title></titles><pages>1443-1448</pages><volume>65</volume><number>22</number><dates><year>1990</year></dates><isbn>0002-9149</isbn><urls></urls></record></Cite><Cite><Author>Pibarot</Author><Year>2000</Year><RecNum>17</RecNum><record><rec-number>17</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">17</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pibarot, Philippe</author><author>Dumesnil, Jean G</author></authors></contributors><titles><title>Hemodynamic and clinical impact of prosthesis–patient mismatch in the aortic valve position and its prevention</title><secondary-title>Journal of the American College of Cardiology</secondary-title></titles><pages>1131-1141</pages><volume>36</volume><number>4</number><dates><year>2000</year></dates><isbn>0735-1097</isbn><urls></urls></record></Cite><Cite><Author>Pibarot</Author><Year>2006</Year><RecNum>19</RecNum><record><rec-number>19</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">19</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pibarot, Philippe</author><author>Dumesnil, Jean G</author></authors></contributors><titles><title>Prosthesis-patient mismatch: definition, clinical impact, and prevention</title><secondary-title>Heart</secondary-title></titles><pages>1022-1029</pages><volume>92</volume><number>8</number><dates><year>2006</year></dates><isbn>1468-201X</isbn><urls></urls></record></Cite></EndNote>�D<EndNote><Cite><Author>Dumesnil</Author><Year>1990</Year><RecNum>29</RecNum><DisplayText>[6-9]</DisplayText><record><rec-number>29</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">29</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dumesnil, Jean G</author><author>Honos, George N</author><author>Lemieux, Michel</author><author>Beauchemin, Jocelyn</author></authors></contributors><titles><title>Validation of applications of indexed aortic prosthetic valve areas calculated by Doppler echocardiography</title><secondary-title>Journal of the American College of Cardiology</secondary-title></titles><pages>637-643</pages><volume>16</volume><number>3</number><dates><year>1990</year></dates><isbn>0735-1097</isbn><urls></urls></record></Cite><Cite><Author>Dumesnil</Author><Year>1990</Year><RecNum>30</RecNum><record><rec-number>30</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">30</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dumesnil, Jean G</author><author>Honos, George N</author><author>Lemieux, Michel</author><author>Beauchemin, Jocelyn</author></authors></contributors><titles><title>Validation and applications of mitral prosthetic valvular areas calculated by Doppler echocardiography</title><secondary-title>The American journal of cardiology</secondary-title></titles><pages>1443-1448</pages><volume>65</volume><number>22</number><dates><year>1990</year></dates><isbn>0002-9149</isbn><urls></urls></record></Cite><Cite><Author>Pibarot</Author><Year>2000</Year><RecNum>17</RecNum><record><rec-number>17</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">17</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pibarot, Philippe</author><author>Dumesnil, Jean G</author></authors></contributors><titles><title>Hemodynamic and clinical impact of prosthesis–patient mismatch in the aortic valve position and its prevention</title><secondary-title>Journal of the American College of Cardiology</secondary-title></titles><pages>1131-1141</pages><volume>36</volume><number>4</number><dates><year>2000</year></dates><isbn>0735-1097</isbn><urls></urls></record></Cite><Cite><Author>Pibarot</Author><Year>2006</Year><RecNum>19</RecNum><record><rec-number>19</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">19</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pibarot, Philippe</author><author>Dumesnil, Jean G</author></authors></contributors><titles><title>Prosthesis-patient mismatch: definition, clinical impact, and prevention</title><secondary-title>Heart</secondary-title></titles><pages>1022-1029</pages><volume>92</volume><number>8</number><dates><year>2006</year></dates><isbn>1468-201X</isbn><urls></urls></record></Cite></EndNote>�D<EndNote><Cite><Author>Lam</Author><Year>2007</Year><RecNum>22</RecNum><DisplayText>[3, 4, 8, 9]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lam, Buu-Khanh</author><author>Chan, Vincent</author><author>Hendry, Paul</author><author>Ruel, Marc</author><author>Masters, Roy</author><author>Bedard, Pierre</author><author>Goldstein, Bill</author><author>Rubens, Fraser</author><author>Mesana, Thierry</author></authors></contributors><titles><title>The impact of patient–prosthesis mismatch on late outcomes after mitral valve replacement</title><secondary-title>The Journal of thoracic and cardiovascular surgery</secondary-title></titles><pages>1464-1473. e3</pages><volume>133</volume><number>6</number><dates><year>2007</year></dates><isbn>0022-5223</isbn><urls></urls></record></Cite><Cite><Author>Magne</Author><Year>2007</Year><RecNum>21</RecNum><record><rec-number>21</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">21</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Magne, Julien</author><author>Mathieu, Patrick</author><author>Dumesnil, Jean G</author><author>Tanné, David</author><author>Dagenais, François</author><author>Doyle, Daniel</author><author>Pibarot, Philippe</author></authors></contributors><titles><title>Impact of prosthesis-patient mismatch on survival after mitral valve replacement</title><secondary-title>Circulation</secondary-title></titles><pages>1417-1425</pages><volume>115</volume><number>11</number><dates><year>2007</year></dates><isbn>0009-7322</isbn><urls></urls></record></Cite><Cite><Author>Pibarot</Author><Year>2000</Year><RecNum>17</RecNum><record><rec-number>17</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">17</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pibarot, Philippe</author><author>Dumesnil, Jean G</author></authors></contributors><titles><title>Hemodynamic and clinical impact of prosthesis–patient mismatch in the aortic valve position and its prevention</title><secondary-title>Journal of the American College of Cardiology</secondary-title></titles><pages>1131-1141</pages><volume>36</volume><number>4</number><dates><year>2000</year></dates><isbn>0735-1097</isbn><urls></urls></record></Cite><Cite><Author>Pibarot</Author><Year>2006</Year><RecNum>19</RecNum><record><rec-number>19</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">19</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pibarot, Philippe</author><author>Dumesnil, Jean G</author></authors></contributors><titles><title>Prosthesis-patient mismatch: definition, clinical impact, and prevention</title><secondary-title>Heart</secondary-title></titles><pages>1022-1029</pages><volume>92</volume><number>8</number><dates><year>2006</year></dates><isbn>1468-201X</isbn><urls></urls></record></Cite></EndNote>�D<EndNote><Cite><Author>Lam</Author><Year>2007</Year><RecNum>22</RecNum><DisplayText>[3, 4, 8, 9]</DisplayText><record><rec-number>22</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">22</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Lam, Buu-Khanh</author><author>Chan, Vincent</author><author>Hendry, Paul</author><author>Ruel, Marc</author><author>Masters, Roy</author><author>Bedard, Pierre</author><author>Goldstein, Bill</author><author>Rubens, Fraser</author><author>Mesana, Thierry</author></authors></contributors><titles><title>The impact of patient–prosthesis mismatch on late outcomes after mitral valve replacement</title><secondary-title>The Journal of thoracic and cardiovascular surgery</secondary-title></titles><pages>1464-1473. e3</pages><volume>133</volume><number>6</number><dates><year>2007</year></dates><isbn>0022-5223</isbn><urls></urls></record></Cite><Cite><Author>Magne</Author><Year>2007</Year><RecNum>21</RecNum><record><rec-number>21</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">21</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Magne, Julien</author><author>Mathieu, Patrick</author><author>Dumesnil, Jean G</author><author>Tanné, David</author><author>Dagenais, François</author><author>Doyle, Daniel</author><author>Pibarot, Philippe</author></authors></contributors><titles><title>Impact of prosthesis-patient mismatch on survival after mitral valve replacement</title><secondary-title>Circulation</secondary-title></titles><pages>1417-1425</pages><volume>115</volume><number>11</number><dates><year>2007</year></dates><isbn>0009-7322</isbn><urls></urls></record></Cite><Cite><Author>Pibarot</Author><Year>2000</Year><RecNum>17</RecNum><record><rec-number>17</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">17</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pibarot, Philippe</author><author>Dumesnil, Jean G</author></authors></contributors><titles><title>Hemodynamic and clinical impact of prosthesis–patient mismatch in the aortic valve position and its prevention</title><secondary-title>Journal of the American College of Cardiology</secondary-title></titles><pages>1131-1141</pages><volume>36</volume><number>4</number><dates><year>2000</year></dates><isbn>0735-1097</isbn><urls></urls></record></Cite><Cite><Author>Pibarot</Author><Year>2006</Year><RecNum>19</RecNum><record><rec-number>19</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">19</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Pibarot, Philippe</author><author>Dumesnil, Jean G</author></authors></contributors><titles><title>Prosthesis-patient mismatch: definition, clinical impact, and prevention</title><secondary-title>Heart</secondary-title></titles><pages>1022-1029</pages><volume>92</volume><number>8</number><dates><year>2006</year></dates><isbn>1468-201X</isbn><urls></urls></record></Cite></EndNote>�
D<EndNote><Cite><Author>Castro</Author><Year>2002</Year><RecNum>34</RecNum><DisplayText>[10-12]</DisplayText><record><rec-number>34</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">34</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Castro, Luis J</author><author>Arcidi, Joseph M</author><author>Fisher, Audrey L</author><author>Gaudiani, Vincent A</author></authors></contributors><titles><title>Routine enlargement of the small aortic root: a preventive strategy to minimize mismatch</title><secondary-title>The Annals of thoracic surgery</secondary-title></titles><periodical><full-title>The Annals of thoracic surgery</full-title></periodical><pages>31-36</pages><volume>74</volume><number>1</number><dates><year>2002</year></dates><isbn>0003-4975</isbn><urls></urls></record></Cite><Cite><Author>Dhareshwar</Author><Year>2007</Year><RecNum>35</RecNum><record><rec-number>35</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">35</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dhareshwar, Jayesh</author><author>Sundt, Thoralf M</author><author>Dearani, Joseph A</author><author>Schaff, Hartzell V</author><author>Cook, David J</author><author>Orszulak, Thomas A</author></authors></contributors><titles><title>Aortic root enlargement: What are the operative risks?</title><secondary-title>The Journal of thoracic and cardiovascular surgery</secondary-title></titles><pages>916-924</pages><volume>134</volume><number>4</number><dates><year>2007</year></dates><isbn>0022-5223</isbn><urls></urls></record></Cite><Cite><Author>Kulik</Author><Year>2008</Year><RecNum>36</RecNum><record><rec-number>36</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">36</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kulik, Alexander</author><author>Al-Saigh, Manal</author><author>Chan, Vincent</author><author>Masters, Roy G</author><author>Bédard, Pierre</author><author>Lam, B-Khanh</author><author>Rubens, Fraser D</author><author>Hendry, Paul J</author><author>Mesana, Thierry G</author><author>Ruel, Marc</author></authors></contributors><titles><title>Enlargement of the small aortic root during aortic valve replacement: is there a benefit?</title><secondary-title>The Annals of thoracic surgery</secondary-title></titles><periodical><full-title>The Annals of thoracic surgery</full-title></periodical><pages>94-100</pages><volume>85</volume><number>1</number><dates><year>2008</year></dates><isbn>0003-4975</isbn><urls></urls></record></Cite></EndNote>�
D<EndNote><Cite><Author>Castro</Author><Year>2002</Year><RecNum>34</RecNum><DisplayText>[10-12]</DisplayText><record><rec-number>34</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">34</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Castro, Luis J</author><author>Arcidi, Joseph M</author><author>Fisher, Audrey L</author><author>Gaudiani, Vincent A</author></authors></contributors><titles><title>Routine enlargement of the small aortic root: a preventive strategy to minimize mismatch</title><secondary-title>The Annals of thoracic surgery</secondary-title></titles><periodical><full-title>The Annals of thoracic surgery</full-title></periodical><pages>31-36</pages><volume>74</volume><number>1</number><dates><year>2002</year></dates><isbn>0003-4975</isbn><urls></urls></record></Cite><Cite><Author>Dhareshwar</Author><Year>2007</Year><RecNum>35</RecNum><record><rec-number>35</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">35</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Dhareshwar, Jayesh</author><author>Sundt, Thoralf M</author><author>Dearani, Joseph A</author><author>Schaff, Hartzell V</author><author>Cook, David J</author><author>Orszulak, Thomas A</author></authors></contributors><titles><title>Aortic root enlargement: What are the operative risks?</title><secondary-title>The Journal of thoracic and cardiovascular surgery</secondary-title></titles><pages>916-924</pages><volume>134</volume><number>4</number><dates><year>2007</year></dates><isbn>0022-5223</isbn><urls></urls></record></Cite><Cite><Author>Kulik</Author><Year>2008</Year><RecNum>36</RecNum><record><rec-number>36</rec-number><foreign-keys><key app="EN" db-id="watasdrdpz525xewxpcv5a0updv0spw59rx0">36</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Kulik, Alexander</author><author>Al-Saigh, Manal</author><author>Chan, Vincent</author><author>Masters, Roy G</author><author>Bédard, Pierre</author><author>Lam, B-Khanh</author><author>Rubens, Fraser D</author><author>Hendry, Paul J</author><author>Mesana, Thierry G</author><author>Ruel, Marc</author></authors></contributors><titles><title>Enlargement of the small aortic root during aortic valve replacement: is there a benefit?</title><secondary-title>The Annals of thoracic surgery</secondary-title></titles><periodical><full-title>The Annals of thoracic surgery</full-title></periodical><pages>94-100</pages><volume>85</volume><number>1</number><dates><year>2008</year></dates><isbn>0003-4975</isbn><urls></urls></record></Cite></EndNote>w���������666666666vvvvvvvvv666666>666666666666666666666666666�6666666666�666666666666hH66666666666666666666666666666666666666666666666666666666666666666�62����&6FVfv������2(��&6FVfv������&6FVfv������&6FVfv������&6FVfv������&6FVfv������&6FVfv��8X�V~�������� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@�� 0@6666$OJPJQJ^J_HmH	nH	sH	tH	J`�JNormald��CJ_HaJmH	sH	tH	d"d�w��	Heading 2d��d�d@&[$\$5�CJ$OJPJQJ\�^JaJ$d2d�w��	Heading 3d��d�d@&[$\$5�CJOJPJQJ\�^JaJff
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