Cineradiography has revealed the presence of the "non-fully-open" phenomenon in patients with the ATS valve. Preliminary in vitro investigations have identified two contributing factors: the expanding space at the outlet of the valve, and the local flow in the pivot area. This further study was performed with the aim of elucidating these factors with respect to different sizes of the ATS valve. Three bileafet valves, ATS, CarboMedics (CM), and St. Jude Medical (SJM), with tissue annulus diameters of 25 and 29mm, were studied. The hydrodynamic performance of the valves was tested at the mitral position of our own pulse duplicator. The opening angle was measured using a high-speed video camera. All the CM and SJM valves were able to open fully in these tests, whereas the 25-mm and 29-mm ATS valves opened to 75° and 82°, respectively, despite their design maximum of 85°. The ATS exhibited the smallest pressure drop of the 29-mm valves, and the SJM the smallest of the 25-mm valves. The incomplete opening of the ATS valve might be explained by the ability of its leaflets to align themselves with the divergent outlet flow, due to its unique open-pivot design. Such a feature would also exhibit a low pressure drop, as seen in the 29mm valve. The smaller opening angle in the 25-mm valve, however, could be caused by the additional pivot flow, which might cause greater deviation of the leaflets in the smaller valve, resulting in a higher relative pressure drop.
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