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root is severely dilated as well (> 55 cm), then the valve may be housed in a Dacron sheath (Bentall procedure) and the root replaced as well Alternatively, a human homograft root and valve replacement may be used In the elderly, bioprosthetic (either porcine or bovine pericardial) valves with a life expectancy of about 10 15 years are routinely used to avoid need for anticoagulation Recent data favor the bovine over the porcine pericardial valve If the aortic annulus is small, a bioprosthetic valve with a short sheath can be sewn to the aortic wall (the stentless AVR) rather than sewing the prosthetic annulus to the aortic annulus Anticoagulation is required with the use of mechanical valves, and the international normalized ratio (INR) should be maintained between 20 and 25 Mechanical aortic valves are less subject to thrombosis than mechanical mitral valves There is growing interest in developing a percutaneous approach to AVR Both a retrograde approach (from the aorta) and an antegrade approach (from the ventricles by way of a transseptal catheter across the atrial septum) are being investigated The devices being tested use either a stent with a trileaflet bovine pericardial valve constructed in it, or a stent with a large valve from a cow s jugular vein mounted inside Preliminary data are encouraging

Carabello B Clinical practice Aortic stenosis N Engl J Med 2002 Feb 28;346(9):677 82 [PMID: 11870246] Otto C Valvular aortic stenosis: disease severity and timing of intervention J Am Coll Cardiol 2006 Jun 6;47(11):2141 51 [PMID: 16750677] Pereira JJ et al Survival after aortic valve replacement for severe aortic stenosis with low transvalvular gradients and severe left ventricular dysfunction J Am Coll Cardiol 2002 Apr 17;39 (8):1356 63 [PMID: 11955855]

AORTIC REGURGITATION (CHRONIC REGURGITATION)

Usually asymptomatic until middle age; presents with left-sided failure or chest pain Wide pulse pressure Echocardiography/Doppler is diagnostic Afterload reduction is beneficial if the LV is dilated (LV end-diastolic dimension > 50 cm) Surgery indicated for symptoms, EF < 55%, or LV end-systolic dimension > 50 cm

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Rheumatic aortic regurgitation has become much less common than in the preantibiotic era, and nonrheumatic causes now predominate These include congenitally bicuspid valves, infective endocarditis, and hypertension Many patients have aortic regurgitation secondary to aortic root diseases such as cystic medial necrosis, Marfan syndrome, or aortic dissection Rarely, inflammatory dis-

By referring to Figure 3-7 you may see the settings that affect the requested delivery date: Lead time in days is the requested delivery date in the sales order It is recommended this be left as a zero in most instances The propose delivery date checkbox is checked to propose the current date as the delivery date Date type allows the user to set the format of the delivery schedule line date for internal system use for example, date, week, month, etc Proposal for pricing date allows you to specify the valid-from date for the pricing of the reference document, or the requested delivery date, or the current date Propose valid-from date allows you to determine when the valid-from date for pricing should be This is used, for example, in quotations Propose PO date proposes the current date as purchase order date Figure 3-8 is the final portion of the configuration settings of the sales document It refers to the contract and availability check: Pricing procedure conditions at header level refers to contract conditions (Refer to contracts in 4) Pricing procedure conditions at item level refers to contract conditions (Refer to contracts in 4) Contract profile is a default setting that will propose default data such as validity dates into the contract you are creating (Refer to Contract profiles in 4) Billing request is also associated with contracts (Refer to contracts in 4) Group reference procedure is used for master contracts to determine which data is to be copied or proposed into lower-level contracts The referencing procedures are configured with master contracts later in this chapter

primarily as pulmonary edema, may develop rapidly; surgery is urgently required in such cases Patients with acute aortic regurgitation do not have the dilated LV of chronic aortic regurgitation and the extra volume is handled poorly For the same reason, the diastolic murmur is shorter and may be minimal in intensity, and the pulse pressure may not be widened, making clinical diagnosis difficult The mitral valve may close prematurely before systole has been initiated (pre-closure) due to the rapid rise in the LV diastolic pressure and the first heart sound is thus diminished or inaudible

eases, such as ankylosing spondylitis or Reiter s syndrome, may be causative Chronic aortic regurgitation presents both an increased preload and an increased afterload to the LV The response to these effects is to hypertrophy by laying sarcomeres end to end, increasing the LV chamber size greater than the wall thickness (eccentric hypertrophy) The amount of LVH in chronic aortic regurgitation is substantial and greater than that seen in aortic stenosis or mitral regurgitation

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