Midterm, multicenter clinical and hemodynamic results for the Trifecta aortic pericardial valve

Five- Year Outcomes in Low-Risk Patients Undergoing Surgery in the PARTNER 3 Trial

BACKGROUND

Surgery remains an important treatment for low-risk patients with severe symptomatic aortic stenosis (AS). This study evaluated 5-year outcomes in low-risk patients undergoing isolated surgical aortic valve replacement (SAVR) or SAVR with concomitant procedures within the randomized Placement of Aortic Transcatheter Valves (PARTNER) 3 trial.

METHODS

In the PARTNER 3 trial, 454 patients underwent surgery for severe, symptomatic, trileaflet AS and were followed up for 5 years. Patients were stratified into those undergoing isolated SAVR (n = 334; 73.6%) vs concomitant SAVR (n = 120; 26.4%). Short- and long-term morbidity was adjudicated by a Clinical Events Committee. Hemodynamic valve performance was evaluated by an echocardiographic core laboratory. Patient-reported health status was measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ).

RESULTS

The mean age of participants was 73.6 ± 6.1 years; 71.1% of these patients were male. The median SAVR implant size was 23 mm overall. Five-year all-cause mortality (with vital status sweep) was 9.0% for all patients (8.5% isolated SAVR; 10.2% concomitant SAVR; P = .58), comparable to a recent analysis of low-risk isolated SAVR-treated patients in the STS database (overall mortality, 7.1%). The average 5-year mean gradient was 11.7 ± 5.6 mm Hg overall. Reintervention rates were low in both groups (isolated SAVR, 2.3% vs concomitant SAVR, 5.0%; P = .21), and most patients (isolated SAVR, 87.9%; concomitant SAVR, 86.1%) were alive with no evidence of bioprosthetic valve failure at 5 years.

CONCLUSIONS

SAVR in low-risk patients in the PARTNER 3 trial demonstrated excellent 5-year outcomes. Five-year mortality was similar in patients undergoing isolated SAVR vs concomitant SAVR. This result was comparable to recently published national SAVR outcomes, thus demonstrating the generalizability of these findings.

Real-world outcomes and management considerations following surgical aortic valve replacement with the Trifecta valve

BACKGROUND

Bioprosthetic surgical aortic valve replacement (SAVR) using the Trifecta valve was frequently chosen because of its large opening area and low transvalvular gradient. However, long-term follow-up revealed the potential for early structural valve deterioration. To further assess the long-term clinical outcomes and management considerations for patients implanted with the Trifecta valve, a real-world study using Medicare fee-for-service claims data was conducted with a focus on Trifecta valve reintervention.

METHODS

De-identified patients undergoing SAVR with the Trifecta™ valve (Abbott) in the U.S. between 1/1/2011-12/31/2021 were selected by ICD-9/10 procedure codes and then linked to a manufacturer device tracking database. All-cause mortality and freedom from Trifecta valve reintervention with repeat SAVR or valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) were evaluated at 10-years using the Kaplan Meier method. Independent predictors for reintervention and clinical outcomes following reintervention were assessed.

RESULTS

Among 242,160 Medicare beneficiaries undergoing SAVR during the study period, 23,197 were implanted with the Trifecta valve. Mean age was 75.2 ± 7.4 years. At 10-years survival was 32.3 % (95 % CI, 31.4 %-33.3 %) and the freedom from valve reintervention was 82.4 % (95 % CI, 81.1 %-83.5 %). Independent predictors for reintervention included younger age, female, obesity, and implants with a small valve size (19 mm, 21 mm). Reintervention with ViV-TAVI (N = 796) was associated with better operative survival (3.8 % vs. 12.5 %, p < 0.001) than repeat SAVR (N = 577).

CONCLUSION

This real-world nationwide study of Medicare beneficiaries receiving the Trifecta valve demonstrates >80 % freedom from all-cause valve reintervention at 10-years post-implant with reintervention using ViV-TAVI having improved operative survival compared to repeat SAVR.

Midterm outcomes of aortic valve replacement using a rapid-deployment valve for aortic stenosis: TRANSFORM trial

Background

The use of rapid-deployment valves (RDVs) has been shown to reduce the operative time for surgical aortic valve replacement (AVR). Long-term core laboratory-adjudicated data are scarce, however. Here we report final 7-year data on RDV use.

Methods

TRANSFORM was a prospective, nonrandomized, multicenter, single-arm trial implanting a stented bovine pericardial valve with an incorporated balloon-expandable sealing frame. A prior published 1-year analysis included 839 patients from 29 centers. An additional 46 patients were enrolled and implanted, for a total of 885 patients. Annual clinical and core laboratory-adjudicated echocardiographic outcomes were collected through 8 years. Primary endpoints were structural valve deterioration (SVD), all-cause reintervention, all-cause valve explantation, and all-cause mortality. Secondary endpoints included hemodynamic performance assessed by echocardiography. The mean duration of follow-up was 5.0 ± 2.0 years.

Results

The mean patient age was 73.3 ± 8.2 years. Isolated AVR was performed in 62.1% of the patients, and AVR with concomitant procedures was performed in 37.9%. Freedom from all-cause mortality at 7 years was 76.0% for isolated AVR and 68.2% for concomitant AVR. Freedom from SVD, all-cause reintervention, and valve explantation at 7 years was 97.5%, 95.7%, and 97.8%, respectively. The mean gradient and effective orifice area at 7 years were 11.1 ± 5.3 mm Hg and 1.6 ± 0.3 cm2, respectively. Paravalvular leak at 7 years was none/trace in 88.6% and mild in 11.4%. In patients undergoing isolated AVR, the cumulative probability of pacemaker implantation was 13.9% at 30 days, 15.5% at 1 year, and 21.8% at 7 years.

Conclusions

AVR for aortic stenosis using an RDV is associated with low rates of late adverse events. This surgical pericardial tissue platform provides excellent and stable hemodynamic performance through 7 years.

Rates and Predictors of Structural Valve Degeneration and Failure of Trifecta Bioprosthetic Valve Over a 5-year Follow-up Period: A Single-center Experience

Introduction

The Trifecta bioprosthetic valve has been commonly used for surgical aortic valve replacement (SAVR). Multiple studies have been done to define the rate of structural valve degeneration (SVD) and failure (SVF), but the outcomes are still debatable. Therefore, we aim to conduct this single-center study to estimate the rate and predictors of SVD/SVF.

Methodology

This retrospective observational cohort single-center study was conducted between 2014 and 2019 among Trifecta SAVR patients. Data were patient's characteristics collected from electronic medical records at baseline and follow-up (3-5 years). Statistical analysis was performed with a significance level of P ≤ 0.05.

Results

A total of 271 eligible patients were identified. Most of our sample were males (57.9%), with a mean age of 71.1 ± 10.6 years. The mean baseline preoperative ejection fraction (EF) was 53.0%, with no change (P = 0.88) in the immediate postoperative EF (53.6%). A most recent follow-up EF revealed a significant increase of EF (55.2%), P = 0.01. Furthermore, there was a significant increase from peak velocity to PVMRE (mean difference [MD] ± standard error of mean (SEM) [0.15 ± 0.04], P < 0.01), an increase in pressure gradient (PGIPE) to PGMRE (MD ± SEM [1.70 ± 0.49], P < 0.01), and a decrease in Doppler velocity index (DVIIPE) to DVIMRE (MD ± SEM [-0.037 ± 0.01], P = 0.01). Regarding the SVF rate, 13 (4.8%) patients had failed valves requiring replacement throughout the study period.

Conclusions

Over a 5-year follow-up period, 4.8% had SVF with an SVD of 23.2%, with the majority of SVD not being clinically significant except in six patients. These results corroborate with a previously published study suggesting a bad clinical outcome of Trifecta valve placement.

Case Series of Early Structural Valve Deterioration of Trifecta Bioprosthesis - New Zealand Experience

PURPOSE

Structural valve deterioration (SVD) remains a limitation on the use of bioprosthetic valves, with patient and valve-related factors contributing to early SVD. The Trifecta valve has been reported to have excellent hemodynamics but studies have highlighted early failure. We present a review and case series at a New Zealand tertiary hospital defining early SVD as failure within 3 years of implant.

METHODS

A retrospective review from January 2015 to July 2019 included 525 patients undergoing surgical aortic valve replacement with 263 patients receiving an Abbott Trifecta or Trifecta Glide Technology (GT) valve. Our review found an acceptable safety profile for the valve with excellent hemodynamics, with a low mortality, stroke, and permanent pacemaker rate.

RESULTS

Three patients out of 263 were identified from the study period as having early SVD requiring reintervention within 3 years of valve implantation leading to a 1.14% failure rate. One of the valves that had early SVD was a new generation Trifecta GT. An additional four patients were identified to have valves implanted prior to the study period and had valve failure at greater than 3 years post implantation. Five cases had cusp tears as their mechanism of failure, raising concerns about durability.

CONCLUSION

The Trifecta valve has an acceptable safety profile and offers good hemodynamics due to the externally mounted leaflets. However, our experience of early SVD and failure is concerning for valve durability. Further comparison to other bioprosthetic valves and longer term follow-up are required to characterize the mechanism of failures.

Structural valve degeneration of bioprosthetic aortic valves: A network meta-analysis

OBJECTIVE

To compare the rate of structural valve degeneration (SVD) following surgical aortic valve replacement associated with the Trifecta (TF) valve (St Jude Medical) versus other bioprosthetic valves.

METHODS

A systematic literature search was conducted for studies comparing durability of the TF prosthesis to other valve types, including Perimount (Edwards Lifesciences), Carpentier-Edwards Perimount Magna Ease (ME) (Edwards Lifesciences), and Mitroflow (LivaNova USA) after surgical aortic valve replacement. Random effect pairwise and network meta-analyses were performed to compare the incident rate ratio of the composite primary outcome of SVD or reintervention due to SVD.

RESULTS

Ten studies with 31,029 patients were included, of whom 6832 received TF, 19,023 received Perimount, 3514 received ME, and 713 received Mitroflow. When compared with TF, ME was associated with lower rates of SVD or reintervention for SVD (incident rate ratio, 0.13; 95% CI, 0.02-0.92; P = .04). Similarly, at network meta-analysis, when compared with TF, only ME was associated with significantly lower rates of SVD or reintervention for SVD (incident rate ratio, 0.13; 95% CI, 0.02-0.97). ME (incident rate ratio, 0.18; 95% CI, 0.07-0.47) and PM (incident rate ratio, 0.34; 95% CI, 0.12-0.98) were associated with significantly lower rate of all-cause reintervention when compared with TF. No differences in the other secondary outcomes were found.

CONCLUSIONS

The TF valve is associated with significantly higher rates of SVD or reintervention for SVD than the ME valve, but not the Mitroflow valve. The TF valve was also associated with higher rates of all-cause reintervention than ME and Perimount valves. The underlying mechanism(s) of these findings warrant further investigation.

Externally mounted versus internally mounted leaflet aortic bovine pericardial bioprosthesis: meta-analysis

BACKGROUND

Recent studies reported higher-than-expected rates of early structural valve degeneration (SVD) and/or reoperation of externally mounted leaflet aortic bioprosthesis compared with others. This meta-analysis aims to compare the outcomes of bioprostheses with externally versus internally mounted leaflet design in patients who underwent surgical aortic valve replacement (SAVR).

METHODS

MEDLINE and EMBASE were searched through November 2021 to identify comparative studies investigating outcomes following SAVR with either externally or internally mounted leaflet aortic bioprosthesis. Outcomes of interest were reoperation for SVD or any cause and all-cause mortality.

RESULTS

Our analysis included 15 observational studies that enrolled a total of 23,539 patients who underwent SAVR using externally mounted (n = 9338; 39.7%) or internally mounted leaflet (n = 14,201; 60.3%) bioprostheses. Externally mounted valves consisted of the Trifecta (Abbott, St Paul, MN) (n = 6146) and the Mitroflow (LivaNova, London, UK) (n = 3192), and all internally mounted valves were the Perimount (Edwards Lifesciences, Irvine, CA). Externally mounted valves compared with the Perimount were associated with higher reoperation rates for SVD [hazard ratio (HR) 3.55, 95% confidence interval (CI) 2.67-4.72; P < 0.001] and any cause (HR 9.36, 95% CI 3.70-23.67; P < 0.001). Furthermore, externally mounted valves demonstrated higher all-cause mortalities (HR 1.33, 95% CI 1.13-1.56; P < 0.001).

CONCLUSIONS

The present study summarizing updated evidence revealed higher reoperation rates and all-cause mortalities in patients with externally mounted leaflet aortic bioprostheses compared with those with internally mounted design. Choosing the right SAVR valve type is critical part of lifetime management of aortic valve disease.

Mid-Term Clinical Outcomes and Hemodynamic Performances of Trifecta and Perimount Bioprostheses following Aortic Valve Replacement

Aims of the Study: We evaluated the clinical outcome and the hemodynamic and freedom from structural valve degeneration of two standard aortic bioprostheses. Methods: Clinical results, echocardiographic findings and follow-up data of patients operated for isolated or combined aortic valve replacement with the Perimount or the Trifecta bioprosthesis were prospectively collected, retrospectively analysed and compared. We weighted all the analyses by the inverse of the propensity of choosing either valves. Results: Between April 2015 and December 2019, 168 consecutive patients (all comers) underwent aortic valve replacement with Trifecta (n = 86) or Perimount (n = 82) bioprostheses. Mean age was 70.8 ± 8.6 and 68.8 ± 8.6 years for the Trifecta and Perimount groups, respectively (p = 0.120). Perimount patients presented a greater body mass index (27.6 ± 4.5 vs. 26.0 ± 4.2; p = 0.022), and 23% of them suffered from angina functional class 2–3 (23.2% vs. 5.8%; p = 0.002). Mean ejection fraction was 53.7 ± 11.9% (Trifecta) and 54.5 ± 10.4% (Perimount) (p = 0.994), with mean gradients of 40.4 ± 15.9 mmHg (Trifecta) and 42.3 ± 20.6 mmHg (Perimount) (p = 0.710). Mean EuroSCORE-II was 7 ± 11% and 6 ± 9% for the Trifecta and Perimount group, respectively (p = 0.553). Trifecta patients more often underwent isolated aortic valve replacement (45.3% vs. 26.8%; p = 0.016) and annulus enlargement (10.5% vs. 2.4%; p = 0.058). All-cause mortality at 30 days was 3.5% (Trifecta) and 8.5% (Perimount), (p = 0.203) while new pacemaker implantation (1.2% vs. 2.5%; p = 0.609) and stroke rate (1.2% vs. 2.5%; p = 0.609) were similar. Acute MACCE were observed in 5% (Trifecta) and 9% (Perimount) of patients with an unweighted OR of 2.22 (95%CI 0.64–7.66; p = 0.196) and a weighted OR of 1.10 (95%CI: 0.44–2.76, p = 0.836). Cumulative survival at 24 months was 98% (95%CI: 0.91–0.99) and 96% (95%CI: 0.85–0.99) for Trifecta and Perimount groups, respectively (log-rank test; p = 0.555). The 2-year freedom from MACCE was 94% (95%CI: 0.65–0.99) for Trifecta and 96% (95%CI: 0.86–0.99) for Perimount (log-rank test; p = 0.759, HR 1.46 (95%CI: 0.13–16.48)) in the unweighted analysis (not estimable in the weighted analysis). During the follow-up (median time: 384 vs. 593 days; p = 0.0001) there were no re-operations for structural valve degeneration. Mean valve gradient at discharge was lower for Trifecta across all valve sizes (7.9 ± 3.2 vs. 12.1 ± 4.7 mmHg; p < 0.001), but the difference did not persist during follow-up (8.2 ± 3.7 mmHg for Trifecta, 8.9 ± 3.6 mmHg for Perimount; p = 0.224); Conclusions: Postoperative outcome and mid-term follow-up were similar. An early better hemodynamic performance was detected for the Trifecta valve but did not persist over time. No difference in the reoperation rate for structural valve degeneration was found.

Structural Valve Deterioration After Self-Expanding Transcatheter or Surgical Aortic Valve Implantation in Patients at Intermediate or High Risk

Importance

The frequency and clinical importance of structural valve deterioration (SVD) in patients undergoing self-expanding transcatheter aortic valve implantation (TAVI) or surgery is poorly understood.

Objective

To evaluate the 5-year incidence, clinical outcomes, and predictors of hemodynamic SVD in patients undergoing self-expanding TAVI or surgery.

Design, Setting, and Participants

This post hoc analysis pooled data from the CoreValve US High Risk Pivotal (n = 615) and SURTAVI (n = 1484) randomized clinical trials (RCTs); it was supplemented by the CoreValve Extreme Risk Pivotal trial (n = 485) and CoreValve Continued Access Study (n = 2178). Patients with severe aortic valve stenosis deemed to be at intermediate or increased risk of 30-day surgical mortality were included. Data were collected from December 2010 to June 2016, and data were analyzed from December 2021 to October 2022.

Interventions

Patients were randomized to self-expanding TAVI or surgery in the RCTs or underwent self-expanding TAVI for clinical indications in the nonrandomized studies.

Main Outcomes and Measures

The primary end point was the incidence of SVD through 5 years (from the RCTs). Factors associated with SVD and its association with clinical outcomes were evaluated for the pooled RCT and non-RCT population. SVD was defined as (1) an increase in mean gradient of 10 mm Hg or greater from discharge or at 30 days to last echocardiography with a final mean gradient of 20 mm Hg or greater or (2) new-onset moderate or severe intraprosthetic aortic regurgitation or an increase of 1 grade or more.

Results

Of 4762 included patients, 2605 (54.7%) were male, and the mean (SD) age was 82.1 (7.4) years. A total of 2099 RCT patients, including 1128 who received TAVI and 971 who received surgery, and 2663 non-RCT patients who received TAVI were included. The cumulative incidence of SVD treating death as a competing risk was lower in patients undergoing TAVI than surgery (TAVI, 2.20%; surgery, 4.38%; hazard ratio [HR], 0.46; 95% CI, 0.27-0.78; P = .004). This lower risk was most pronounced in patients with smaller annuli (23 mm diameter or smaller; TAVI, 1.32%; surgery, 5.84%; HR, 0.21; 95% CI, 0.06-0.73; P = .02). SVD was associated with increased 5-year all-cause mortality (HR, 2.03; 95% CI, 1.46-2.82; P < .001), cardiovascular mortality (HR, 1.86; 95% CI, 1.20-2.90; P = .006), and valve disease or worsening heart failure hospitalizations (HR, 2.17; 95% CI, 1.23-3.84; P = .008). Predictors of SVD were developed from multivariate analysis.

Conclusions and Relevance

This study found a lower rate of SVD in patients undergoing self-expanding TAVI vs surgery at 5 years. Doppler echocardiography was a valuable tool to detect SVD, which was associated with worse clinical outcomes.

Trial Registration

ClinicalTrials.gov Identifiers: NCT01240902, NCT01586910, and NCT01531374.

Eight-year outcomes of aortic valve replacement with the Carpentier-Edwards PERIMOUNT Magna Ease valve

INTRODUCTION

The Carpentier-Edwards PERIMOUNT Magna Ease valve is a third-generation bioprosthesis for aortic valve replacement (AVR). This is a postapproval study reporting on its 8-year outcomes.

METHODS

Adults undergoing AVR with the Magna Ease valve between October 2007 and December 2012 were enrolled for this prospective, nonrandomized, single-arm, and multicenter study. Assessments occurred preoperatively, at hospital discharge, 6 months, 1 year, and annually thereafter for up to 8 years. Outcomes included safety endpoints, hemodynamic performance, and New York Heart Association (NYHA) functional class.

RESULTS

Of the 258 study patients, 67.5% were in NYHA Class I or II, and 32.5% were in NYHA Class III or IV at baseline. Concomitant procedures were performed in 44.2%. Total follow-up was 1597.6 patient-years, and median follow-up was 7 years (interquartile range: 5.5-8.0 years). Eight years following AVR, the functional class remained improved from baseline with 93.9% in NYHA Class I/II and 6.1% in NYHA Class III; 38 deaths had occurred, 8 of which were valve related; freedom from all-cause mortality was 80.7% (95% confidence intervals: 74.9, 86.4); freedom from valve-related mortality was 95.8% (92.8, 98.8); freedom from reintervention, explant, major bleeding events, and structural valve deterioration was 89.8% (85.1, 94.6), 94.8% (91.7, 97.9), 85.1% (80.0, 90.1), and 90.1% (84.7, 95.4), respectively; effective orifice area was 1.5 ± 0.5 cm² , the mean gradient was 14.8 ± 8.3 mmHg, and 88.6% of patients had no or trivial aortic regurgitation.

CONCLUSIONS

This study demonstrated satisfactory safety and sustained hemodynamic and functional improvements at 8 years following AVR with the Magna Ease valve.

Review of bioprosthetic structural valve deterioration: Patient or valve?

BACKGROUND

With guidelines progressively recommending bioprosthetic aortic valves in younger patients, a greater emphasis is placed on structural valve deterioration (SVD) as an important clinical endpoint for both transcatheter and surgically implanted valves. However, SVD of bioprosthetic valves is a complex entity with varying definitions in the literature and a multifaceted pathogenesis.

AIM

This review first aims to establish the most updated definitions of SVD as per the literature. We then explore the patient- and valve-related factors that play the greatest roles in facilitating early SVD.

METHODS

A PubMed literature review was conducted to identify the relevant research in this field within the past two decades.

CONCLUSION

Increasing rates of obesity and metabolic syndrome pose a significant risk to the longevity of bioprosthetic valves. Additionally, externally mounted valves have proven to sacrifice durability for superior haemodynamics. Bioprosthetic SVD continues to be a multifactorial issue that will require various patient- and valve-related factors to be addressed.

Structural valve deterioration of bioprosthesis in the aortic position: A single-center experience

BACKGROUND

Aortic valve replacement (AVR) is one of the most common open-heart surgical procedures. The durability of the tissue valve in the aortic position is crucial in AVR and transcatheter AVR. We reviewed structural valve deterioration using echocardiographic follow-up in three types of surgical aortic tissue valves.

METHODS

A retrospective analysis was conducted where hemodynamic deterioration was evaluated and compared using transthoracic echocardiography, including pressure gradients and effective orifice area. Kaplan-Meier analyses were used to summarize the time to failure.

RESULTS

The study included 133 Trifecta, 156 Epic, and 321 Magna Ease valves. Seventy-six percent (1941/2551) of patients had to be excluded due to insufficient echo data. Through univariate analysis, 34% (216/610) of valves met deterioration criteria after 24 months. Unadjusted survival curves showed a significant difference between valves (p ≤ .001), with a longer mean time to deterioration for the Magna Ease versus Trifecta and Epic of 68.9 versus 50.1 and 38.2 months, respectively. A Cox proportional hazard analysis found worse hazard ratios of 1.69 (p ≤ .04) and 2.4 (p ≤ .01) for Trifecta versus Magna and Epic versus Trifecta, respectively.

CONCLUSION

All three valve types demonstrated structural valve deterioration on echocardiographic follow-up with significant differences in rate. The Magna Ease appeared to have the highest durability, and the Epic the lowest. Further investigation is warranted to confirm the results in a larger multicenter study.

Early Outcomes of Intuity Rapid Deployment Aortic Valve Replacement Compared With Conventional Biological Valves in Japanese Patients

BACKGROUND

This study aimed to elucidate the short-term surgical outcomes and hemodynamics of the Intuity valve compared to the standard bioprosthesis in Japanese patients.

METHODS AND RESULTS

Among the 307 consecutive patients who underwent aortic valve replacement (AVR) between February 2019 and March 2021, the Intuity valve was implanted in 95 patients (Intuity group) and a conventional stented bioprosthesis was implanted in 193 patients (conventional group). After propensity score matching, there was no significant difference in in-hospital mortality between the Intuity (n=2, 3%) and conventional groups (n=0, P=0.490). Operation, cardiopulmonary bypass, and aortic cross-clamping times were significantly shorter in the Intuity group. Although the effective orifice area index, trans-prosthetic mean pressure gradient, and peak velocity were similar between the 2 groups at 1 week postoperatively, the Intuity group showed a better mean pressure gradient and peak velocity at 1 year postoperatively. Complete atrioventricular block requiring permanent pacemaker implantation developed in 2 patients (3%) in the Intuity group and none in the conventional group (P=0.476). Mild or greater paravalvular leakage was present in 8 patients (13%) in the Intuity group and 2 patients (3%) in the conventional group (P=0.095).

CONCLUSIONS

AVR using the Intuity valve in Japanese patients is satisfactory, with a better valve performance and a low incidence of complete atrioventricular block at 1 year postoperatively.

Impact of postoperative patient-prosthesis mismatch as a risk factor for early structural valve deterioration after aortic valve replacement with Trifecta bioprosthesis

BACKGROUND

Several studies have reported high rates of structural valve deterioration (SVD) in the Trifecta valves. Herein, we analyzed the midterm results of the Trifecta valve and risk factors for early SVD.

METHODS

We retrospectively reviewed the records of 110 patients who had undergone Trifecta implantation between January 2012 and December 2017.

RESULTS

We encountered seven cases of Trifecta valve failure. We performed a redo aortic valve replacement in five patients and a transcatheter aortic valve replacement in two patients. The SVD rate was 4.8% at 5 years and 6.6% at 7 years. The mean pressure gradient and peak velocity on the first postoperative echocardiogram in patients with SVD were higher than those in patients without SVD. The SVD rates with and without patient-prosthesis mismatch (PPM) were 2.8% and 12.6% at 5 years and 2.8% and 20.0% at 7 years. PPM is a risk factor for SVD. Noncoronary cusp tears were observed in all patients who had undergone redo surgery.

CONCLUSIONS

The most common cause of SVD was noncoronary cusp tear. Patients with PPM are at high risk of developing SVD.

Surgical aortic valve replacement with a stented pericardial bioprosthesis: 5-year outcomes

OBJECTIVES

This analysis evaluated the safety, durability, and haemodynamic performance of a stented bovine pericardial valve through 5 years of follow-up in patients with an indication for surgical aortic valve replacement (SAVR).

METHODS

Kaplan-Meier analysis was used to estimate the incidence of survival and valve-related thromboembolism, major paravalvular leak (PVL), endocarditis, structural valve deterioration (SVD), and reintervention. Mean aortic gradient and New York Heart Association (NYHA) class were also evaluated.

RESULTS

1118 patients have received the Avalus valve (Medtronic); 564 have completed 5-year follow-up. Median follow-up was 4.85 years (4810 patient-years total follow-up). At baseline, mean age was 70.2 ± 9.0 years; 75.1% of patients were male. STS predicted risk of mortality was 2.0 ± 1.4%. Most patients were in NYHA class II (46.8%) or III (40.3%). At 5 years follow-up, the overall Kaplan-Meier survival rate was 88.1% (85.9-90.0%). The Kaplan-Meier event rates were 5.6% (4.3-7.2%) for thromboembolism, 4.4% (3.2-6.0%) for endocarditis, 0.2% (0.0-0.7%) for major PVL, and 3.2% (2.3-4.6%) for reintervention. There were no cases of SVD. Mean gradient decreased from 42.1 ± 17.1 mmHg at baseline, to 13.1 ± 4.7 mmHg at discharge, and remained stable at 12.5 ± 4.6 mmHg at 5 years. More than 95% of patients were in NYHA class I/II 5 years after surgery.

CONCLUSIONS

The findings of a high survival rate, excellent safety, no SVD, and stable haemodynamic performance and functional status through 5 years of follow-up are encouraging. Additional follow-up is needed to assess the long-term durability of this contemporary surgical bioprosthesis.

Biomechanics of Transcatheter Aortic Valve Implant

Transcatheter aortic valve implantation (TAVI) has grown exponentially within the cardiology and cardiac surgical spheres. It has now become a routine approach for treating aortic stenosis. Several concerns have been raised about TAVI in comparison to conventional surgical aortic valve replacement (SAVR). The primary concerns regard the longevity of the valves. Several factors have been identified which may predict poor outcomes following TAVI. To this end, the lesser-used finite element analysis (FEA) was used to quantify the properties of calcifications which affect TAVI valves. This method can also be used in conjunction with other integrated software to ascertain the functionality of these valves. Other imaging modalities such as multi-detector row computed tomography (MDCT) are now widely available, which can accurately size aortic valve annuli. This may help reduce the incidence of paravalvular leaks and regurgitation which may necessitate further intervention. Structural valve degeneration (SVD) remains a key factor, with varying results from current studies. The true incidence of SVD in TAVI compared to SAVR remains unclear due to the lack of long-term data. It is now widely accepted that both are part of the armamentarium and are not mutually exclusive. Decision making in terms of appropriate interventions should be undertaken via shared decision making involving heart teams.

Association of the Surgical Technique With the Structural Valve Deterioration of a Bioprosthesis: A Prospective Cohort Study

The Trifecta aortic valve is a prosthesis with externally mounted leaflets and a stent which may be deformed during implant. Our aim was to know if the use of the holder as a protection device during the knotting has an impact on the incidence of structural valve deterioration (SVD) or endocarditis. Prospective cohort study where all patients who underwent aortic valve replacement with a Trifecta aortic valve between 2013 and 2018 were included. The use of the holder as a protection device was collected in a database. Propensity-score matched methods were used and analyses were based on competing events. Death without SVD or prosthesis replacement not due to SVD was considered competing events. 782 patients were included, 352 pairs after the matching. Rates of SVD at 5 and 8 years were 5.8% (95% CI 3.5-8.7) and 13.6% (95% CI 9.2-18.9) in the group without holder and 2.3% (95% CI 1-4.5) and 7% (95% CI 4.2-10.8) in the group with holder; sHR = 0.49 (95% CI 0.27-0.86; P = 0.015). The risk of endocarditis at 8 years was 4.8% (95% CI 2.8-7.4) in the group without holder and 2.3% (95% CI 1.1-4.3) in the group with holder, sHR = 0.49 (95% CI 0.21-1.15, P = 0.1). The use of holder as a protection device during the knotting of the Trifecta aortic valve is associated with less risk of SVD.

Trifecta versus Perimount Magna Ease aortic valves: Failure mechanisms

Background

There are increasing reports of early externally mounted pericardial Trifecta bioprosthesis failure. We compared the hemodynamic performance of Trifecta and Carpentier–Edwards Perimount Magna Ease valves to determine the failure mechanism.

Methods

We retrospectively included 270 consecutive patients (age: 73.4 ± 8.2 years; 57.5% male; mean follow-up: 48.0 ± 20.3 months) who underwent aortic valve replacement from 2014 to 2021 at a single center and compared the Trifecta (N = 137) and Carpentier–Edwards Perimount Magna Ease valve (N = 133) patients.

Results

The prosthetic valve major aortic regurgitation incidence was higher for the Trifecta than that for the Carpentier–Edwards Perimount Magna Ease valve (6.3% vs. 0%, P < 0.009). Among the Trifecta failures, 33% developed structural valve deterioration, but all requiring redo aortic valve replacement developed major prosthetic valve aortic regurgitation. Freedom at 5 years from redo aortic valve replacement due to structural valve deterioration was significantly lower for Trifecta (89.4% vs. 100%, P = 0.003). The reoperation hazards were determined for Trifecta (vs. Carpentier–Edwards Perimount Magna Ease): 11.6 (1.47–90.9; P = 0.02), prosthetic valve aortic regurgitation: 2.38 (1.70–3.32; P < 0.01), structural valve deterioration: 20.82 (4.08–106.2; P < 0.01), 5-year mean transprosthetic pressure gradient: 1.14 per 1-point increase (1.03–1.24; P = 0.007), and urgent surgery: 10.1 (2.59–39.0; P = 0.001). The Cox regression analysis identified that prosthetic valve aortic regurgitation solely contributed to redo aortic valve replacement (hazard ratio: 2.38; confidence intervals: 1.70–3.32).

Conclusions

Significantly, more early failures occurred with the Trifecta valve than the Carpentier–Edwards Perimount Magna Ease valve but the Trifecta showed reasonable mean transprosthetic pressure gradient over time. Prosthetic valve aortic regurgitation and calcific structural valve deterioration synergistically contributed to Trifecta valve failure alternatively.

Aortic valve biologic protheses: A cohort comparison of premature valve failure

BACKGROUND

Recent reports suggest an increased rate of early structural valve degeneration (SVD) in the Trifecta bioprosthesis (Abbott Cardiovascular). We sought to compare the intermediate-term outcomes of the Magna (Edwards Life Sciences) and Trifecta valves.

METHODS

All surgical aortic valve replacements (SAVRs) with Trifecta or Magna/Magna Ease bioprostheses at an academic medical center were extracted from an institutional database. Patients who survived until after discharge (2011-2019) were included. The primary outcome was valve failure for any reason requiring reintervention or contributing to death, identified by reintervention or review of cause of death. Time to failure was estimated with Kaplan-Meier analysis and Cox Proportional Hazards Modeling.

RESULTS

Out of 1444 patients, 521 (36%) underwent Trifecta and 923 (64%) underwent Magna implantation with a median follow-up of 27.6 months. Trifecta patients had larger median valve size (25 vs. 23 mm, p < .001) and lower median gradient (8.0 vs. 10.9 mmHg, p < .001). Trifecta patients had higher 48-month estimated failure rates (20.2 ± 7.6% vs. 2.6 ± 0.7%, p < .0001), with failure rates of 21.4 versus 9.2 failures per 1000 person-years (p < .001). After risk-adjustment, Trifecta patients had a 5.3 times hazard of failure (95% confidence interval: 2.78-12.34, p < .001) compared to Magna patients. Only Trifecta valves failed due to sudden aortic regurgitation, 8 out of 521 (1.5%).

CONCLUSION

Despite lower postoperative mean gradients, the Trifecta bioprosthesis may have an increased risk of intermediate-term SVD. Further research is warranted to confirm the potential for sudden valve failure.

Analysis of incidence and reasons for re-intervention after aortic valve replacement using the Trifecta aortic bioprosthesis

INTRODUCTION

Trifecta bioprosthesis claims favourable haemodynamic performance. However, reports of structural valve deterioration (SVD) raise concerns of its long-term durability. We assessed outcomes with the Trifecta valve over a 10-year period.

METHODS

All patients receiving Trifecta bioprostheses between October 2011 and October 2020 were included. Perioperative and survival characteristics were prospectively collated in an independent database. Re-intervention was recorded as a surrogate for SVD.

RESULTS

944 patients (mean age 72.82 years ± 8.13, 58% male) underwent aortic valve replacement with the Trifecta valve. At 10-years, 1.4% of patients required a redo operation, giving an overall freedom from re-intervention of 98.6%. The mean time to re-intervention was 48.87 months. Survival was 73.58% and 76.92% in patients who did not require re-intervention vs re-intervention group, respectively.

CONCLUSIONS

In a large, single-centre cohort, the Trifecta aortic bioprosthesis had a 1.4% all-cause re-intervention rate at 10-years, with insignificant impact on survival.

Impact of valvuloarterial impedance on left ventricular reverse remodeling after aortic valve neocuspidization

Background

Aortic valve neocuspidization (AVNeo) has emerged as a promising aortic valve procedure, and is expected to have a larger effective orifice area (EOA) than commercially available bioprostheses. It is, however, unclear which indices could facilitate left ventricular (LV) reverse remodeling after AVNeo. The aim of this study is to verify the impact of global left ventricular afterload on the LV reverse remodeling following AVNeo.

Methods

Data-available consecutive 38 patients (median age, 77; interquartile range, 72.8–82.0) undergoing AVNeo for severe aortic stenosis were enrolled in this study. Preoperative and the last follow-up echocardiographic data were retrospectively analyzed including the valvuloarterial impedance (Zva), a marker of global LV afterload. Reduction in LV geometry index (LVGI) and relative wall thickness (RWT) were used as an indicator for LV reverse remodeling.

Results

The Zva reduced in 24 patients (63.2%) during the follow-up period (median, 12 months). Reduction in Zva significantly correlated to improvement of LV geometry (LVGI (r = 0.400, p = 0.013) and RWT (r = 0.627, p < 0.001)), whereas increase in EOA index did not significantly correlate to LVGI (r = 0.009, p = 0.957), or RWT (r = 0.105, p = 0.529)). The reduction in Zva was the multivariate predictor of LV reverse remodeling.

Conclusions

Low global LV afterload led to significant LV reverse remodeling even after AVNeo, which could achieve better valve performance than the conventional bioprostheses.

Mid-term clinical and haemodynamic results after aortic valve replacement with the Trifecta bioprosthesis

OBJECTIVES

The aim of this study was to evaluate the clinical and haemodynamic results after implantation of the Trifecta bioprosthesis.

METHODS

This study is a retrospective analysis of all patients undergoing Trifecta aortic valve replacement between 01 January 2012 and 31 December 2017 at the Ghent University Hospital. Univariable and multivariable analyses were performed to identify predictors of valve- and procedure-related complications and mortality. The haemodynamic performance was analysed by longitudinal Doppler echocardiography.

RESULTS

The mean age of the 182 patients was 77 [standard deviation (SD): 5.5] years; 54.9% were women. The mean follow-up was 39.8 (SD: 24.3) months. Overall survival at 1 and 5 years was 86% (SD: 3%) and 68% (SD: 4%), respectively, and overall freedom from structural valve deterioration was 100% and 98% at 1 and 5 years, respectively. There was no valve thrombosis nor early endocarditis. Urgent surgery was the only risk factor for early mortality in the multivariable analysis [P = 0.009, odds ratio 0.06, 95% confidence interval (CI) 0.01-0.5]. Preoperative atrial fibrillation was the most important predictor of late mortality (P = 0.001, hazard ratio 3.68, 95% CI 1.65-8.21). The average peak gradients were stable from discharge up to 1 and 5 years postoperatively [15 (SD: 6) and 17 (SD: 8) mmHg].

CONCLUSIONS

These results confirm the excellent clinical performance of the Trifecta valve, particularly in an elderly age group. Through the 7-year follow-up period, low transvalvular gradients persisted, and only a few patients needed reoperation. Although structural valve degeneration occurred rarely, it was unrelated to valve size or age at implantation; therefore, further long-term follow-up remains mandatory.

Long-term durability after surgical aortic valve replacement with the Trifecta and the Intuity valve-a comparative analysis

OBJECTIVES

Long-term durability of surgical bio-prostheses is a key factor, especially in the era of transcatheter aortic valve replacement. We compared the incidence of structural valve deterioration (SVD) between patients undergoing surgical aortic valve replacement (SAVR) with the Trifecta (Abbott Laboratories, Abbott Park, IL, USA) or the Intuity valve (Edwards Lifesciences, Irvine, CA, USA).

METHODS

Between April 2010 and May 2020, 1118 patients underwent SAVR with the Trifecta (n = 346) and the Intuity (n = 772) valve at a single centre. A total of 1070 patients (Trifecta n = 298, Intuity n = 772) were analysed after the exclusion of patients with pure regurgitation and endocarditis. Retro- and prospective echocardiographic and clinical follow-up was performed. Cox proportional hazards regression models were performed to identify prognostic factors for SVD, aortic re-interventions and mortality.

RESULTS

With 27 cases (Trifecta n = 23, Intuity n = 4) of SVD observed, cumulative incidence of SVD was significantly higher in the Trifecta cohort (P < 0.001). Implantation of a Trifecta valve [hazard ratio (HR) 11.20; 95% confidence interval 3.79-33.09], log-transformed preoperative creatinine (HR 2.47; 1.37-4.44) and sex (male HR 0.42; 0.19-0.92) emerged as prognostic factors of SVD. A significantly higher cumulative incidence of re-interventions was observed in the Trifecta cohort (P = 0.004) and valve type was an independent time-varying risk factor (HR at 12 months 2.78; 95% confidence interval 1.42-5.45). Overall, no significant differences in all-cause mortality were observed between the groups (log-rank test: P = 0.052).

CONCLUSIONS

SVD was significantly more frequent in patients receiving a Trifecta valve and its implantation was an independent risk factor for the occurrence of SVD and aortic valve re-interventions. This comparative analysis of 2 low-gradient bioprosthesis put the long-term durability of the Trifecta valve in question and need to be taken into consideration when performing bioprosthetic SAVR.

Trifecta versus perimount bioprosthesis for surgical aortic valve replacement; systematic review and meta-analysis

OBJECTIVE

Recent studies suggested higher rates of early structural valve degeneration or reintervention for the Trifecta valve compared to other valves. Thus, we conducted a systematic review and meta-analysis comparing the outcomes of the Trifecta valve and the Perimount valves in patients who underwent a surgical aortic valve replacement (SAVR).

METHODS

All randomized control trials and observational studies which investigated the outcomes of the Trifecta valve and Perimount valves were identified with PubMed and EMBASE. The endpoints were the rates of reintervention and all-cause mortality. Hazard ratios (HRs) for reintervention and all-cause mortality were combined with the random-effects model.

RESULTS

Our search identified 6 eligible observational studies which enrolled a total of 11,135 patients who underwent SAVR with either the Trifecta valve (n = 4932) or Perimount (n = 6203). Pooled analyses demonstrated that the reintervention rates were significantly higher with the Trifecta valve compared with Perimount valves (HR [95% confidence interval {CI}] = 3.16 [1.83-5.46]; p < .0001; I² = 40%). In contrast, all-cause mortality was not significantly different between the two groups (HR [95% CI] = 1.09 [0.75-1.58]; p = .32, I² = 12%).

CONCLUSION

Our analysis showed that AVR with the Trifecta valve was associated with higher rates of reintervention compared for that with the Perimount valve. Although further long-term randomized trials are warranted, surgeons need to be cautious when choosing a bioprosthetic valve for patients undergoing SAVR.

Aortic valve neocuspidization with autologous pericardium in adult patients: UK experience and meta-analytic comparison with other aortic valve substitutes

OBJECTIVES

We sought to provide further evidence on the safety and efficacy of aortic valve neocuspidization (AVNeo) using autologous pericardium in adult patients with aortic valve disease by reporting clinical and echocardiographic results from the first UK experience and performing a meta-analytic comparison with other biological valve substitutes.

METHODS

We reported clinical and echocardiographic outcomes of 55 patients (mean age 58 ± 15 years) undergoing AVNeo with autologous pericardium in 2 UK centres from 2018 to 2020. These results were included in a meta-analytic comparison between series on AVNeo (7 studies, 1205 patients, mean weighted follow-up 3.6 years) versus Trifecta (10 studies, 8705 patients, 3.8 years), Magna Ease (3 studies, 3137 patients, 4.1 years), Freedom Solo (4 studies, 1869 patients, 4.4 years), Freestyle (4 studies, 4307 patients, 7 years), Mitroflow (4 studies, 4760 patients, 4.1 years) and autograft aortic valve (7 papers, 3839 patients, 9.1 years).

RESULTS

In the present series no patients required intraoperative conversion. After mean follow-up of 12.5 ± 0.9 months, 3 patients presented with endocarditis and 1 required reintervention. The remaining patients had absent or mild aortic valve insufficiency with very low peak and mean transvalvular gradients (16 ± 3.7 and 9 ± 2.2 mmHg, respectively). Meta-analytic estimates showed non-significant difference between AVNeo and all but Magna Ease valves with regards to structural valve degeneration, reintervention and endocarditis. When compared Magna Ease valve, AVNeo and other valve substitutes showed an excess of valve-related events.

CONCLUSIONS

AVNeo is safe, associated with excellent haemodynamic profile. Its midterm risk of valve-related events is comparable to most biological valve substitutes. Magna Ease is potentially the best biological choice as far as risk of reintervention is concerned.

Structural valve deterioration after aortic valve replacement with the Trifecta valve

OBJECTIVES

Despite promising short- and mid-term results for durability of the Trifecta valve, contradictory reports of early structural valve deterioration (SVD) do exist. We investigated the incidence of SVD after surgical aortic valve replacement (SAVR) with the Trifecta in our single-centre experience.

METHODS

Data of 347 consecutive patients (mean age 71.6 ± 9.5 years, 63.4% male) undergoing SAVR with the Trifecta between 2011 and 2017 were analysed. Clinical and echocardiographic reports were obtained with a median follow-up of 41 months (1114 patient years).

RESULTS

Isolated SAVR was performed in 122 patients (35.2%), whereas 225 patients (64.8%) underwent concomitant procedures. The median EuroSCORE II was 4.0 (0.9; 7.1) and 30-day mortality was 3.7% (n = 13). Kaplan-Meier estimates for the freedom of overall mortality at 1, 5 and 7 years were 88.7 ± 1.7%, 73.7 ± 2.6% and 64.7 ± 4.2%, respectively. SVD was observed in 25 patients (7.2%) with a median time to first diagnosis of 73 months. Freedom of SVD was 92.5 ± 0.9% at 5 years and 65.5 ± 7.1% at 7 years. Thirteen patients underwent reintervention for SVD (6 re-SAVR, 7 valve-in-valve), resulting in a freedom of reintervention for the SVD of 98.5 ± 1.1% at 5 years and 76.9 ± 6.9% at 7 years.

CONCLUSIONS

We herein report one of the highest rates of SVD after SAVR with the Trifecta. These data indicate that the durability of the prosthesis decreases at intermediate to long-term follow-up, leading to considerable rates of reintervention due to SVD.

Leaflet stress quantification of porcine vs bovine surgical bioprostheses: an in vitro study

Calcified aortic stenoses are among the most prevalent form of cardiovascular diseases in the industrialized countries. This progressive disease, with no effective medical therapy, ultimately requires aortic valve replacement - either a surgical or very recently transcatheter aortic valve implantation. Increase leaflet mechanical stress is one of the main determinants of the structural deterioration of bioprosthetic aortic valves. We applied a coupled in vitro/in silico method to compare the timing, magnitude, and regional distribution of leaflet mechanical stress in porcine versus pericardial bioprostheses (Mosaic and Trifecta). A double activation simulator was used for in vitro testing of a bioprosthesis with externally mounted pericardium (Abbott, Trifecta) and a bioprosthesis with internally mounted porcine valve (Medtronic, Mosaic). A non-contact system based on stereophotogammetry and digital image correlation (DIC) with high spatial and temporal resolution (2000 img/s) was used to visualize the valve leaflet motion and perform the three-dimensional analysis. A finite element model of the valve was developed, and the leaflet deformation obtained from the DIC analysis was applied to the finite element model calculate local leaflet mechanical stress throughout the cardiac cycle. The maximum leaflet stress was higher with the pericardial versus the porcine bioprosthesis (2.03 vs. 1.30 MPa) For both bioprostheses the highest values of leaflet stress occurred during diastole and were primarily observed in the upper leaflet edge near the commissures and to a lesser extent in the mid-portion of the leaflet body. In conclusion, the coupled in vitro/in silico method described in this study shows that the highest levels of leaflet stress occur in the regions of the commissures and mid-portion of the leaflet body. This method may have important insight with regard to bioprosthetic valve durability. Our results suggest that, compared to porcine bioprostheses, those with externally mounted pericardium have higher leaflet mechanical stress, which may translate into shorter durability.

Percutaneous versus Surgical Intervention for Severe Aortic Valve Stenosis: A Systematic Review

Aortic stenosis is a disease that is increasing in prevalence and manifests as decreased cardiac output, which if left untreated can result in heart failure and ultimately death. It is primarily a disease of the elderly who often have multiple comorbidities. The advent of transcatheter aortic valve therapies has changed the way we treat these conditions. However, long-term results of these therapies remain uncertain. Recently, there has been an increasing number of studies examining the role of both surgical aortic valve replacement and transcatheter aortic valve replacement. We therefore performed a systematic review using Ovid MEDLINE, Ovid Embase, and the Cochrane Library. Two investigators searched papers published between January 1, 2007, and to date using the following terms: "aortic valve stenosis," "aortic valve operation," and "transcatheter aortic valve therapy." Both strategies in aortic stenosis treatment highlighted specific indications alongside the pitfalls such as structural valve degeneration and valve thrombosis which have a bearing on clinical outcomes. We propose some recommendations to help clinicians in the decision-making process as technological improvements make both surgical and transcatheter therapies viable options for patients with aortic stenosis. Finally, we assess the role of finite element analysis in patient selection for aortic valve replacement. THVT and AVR-S are both useful tools in the armamentarium against aortic stenosis. The decision between the two treatment strategies should be best guided by a strong robust evidence base, ideally with a long-term follow-up. This is best performed by the heart team with the patient as the center of the discussion.

Fifty years of the pericardial valve: Long-term results in the aortic position

It is now 50 years since the development of the first pericardial valve in 1971. In this time significant progress has been made in refining valve design aimed at improving the longevity of the prostheses. This article reviews the current literature regarding the longevity of pericardial heart valves in the aortic position. Side by side comparisons of freedom from structural valve degeneration are made for the valves most commonly used in clinical practice today, including stented, stentless, and sutureless valves. Strategies to reduce structural valve degeneration are also discussed including methods of tissue fixation and anti-calcification, ways to minimise mechanical stress on the valve, and the role of patient prosthesis mismatch.

A Retrospective Comparison of Hemodynamic and Clinical Outcomes between Two Differently Designed Aortic Bioprostheses for Small Aortic Annuli

The Trifecta valve has externally mounted leaflets; it differs from classic internally mounted valves (e.g., Carpentier-Edwards [C-E]). We evaluated post-implantation hemodynamics and clinical outcomes of these bioprostheses in small aortic annuli. From January 2015 to April 2019, 490 patients who underwent aortic valve replacement (AVR) were reviewed retrospectively. Altogether, 183 patients received 19 or 21 mm diameter C-E (n = 121) or Trifecta (n = 62) prostheses. To minimize confounding variables, we performed propensity-score matching analysis. The mean transvalvular pressure gradient (TVPG) was significantly lower in the Trifecta than in the C-E group at discharge (12.9 ± 4.8 vs. 15.0 ± 5.3 mmHg, p = 0.044). TVPG change over time was not significantly different between groups (p = 0.357). Left ventricular mass index decreased postoperatively (reduction: C-E, 28.1%; Trifecta, 30.1%, p = 0.879). No late mortality, severe patient–prosthesis mismatch, moderate-to-severe paravalvular leakage, structural valve degeneration, or valve thromboses were observed. Freedom from valve-related events at 3 years were similar for C-E (97.9% ± 2.1%) and Trifecta (97.7% ± 2.2%) patients (log-rank p = 0.993). Bioprosthesis design for small annuli significantly affected TVPG immediately after AVR. However, hemodynamics over time and clinical outcomes did not differ between the two designs.

Midterm outcomes with a sutureless aortic bioprosthesis in a prospective multicenter cohort study

OBJECTIVE

The objective of this study was to report midterm clinical outcomes with a self-expandable sutureless aortic valve.

METHODS

Between 2010 and 2013, 658 patients at 25 European institutions received the Perceval sutureless valve (LivaNova Plc, London, United Kingdom). Mean follow-up was 3.8 years; late cumulative follow-up was 2325.2 patient-years.

RESULTS

The mean age of the population was 78.3 ± 5.6 years and 40.0% (n = 263) were 80 years of age or older; mean Society of Thoracic Surgeons-Predicted Risk of Mortality score was 7.2 ± 7.4. Concomitant procedures were performed in 31.5% (n = 207) of patients. Overall duration of cardiopulmonary bypass time was 64.8 ± 25.2 minutes and aortic cross-clamping time was 40.7 ± 18.1 minutes. Thirty-day all-cause mortality was 3.7% (23 patients), with an observed:expected ratio of 0.51. Overall survival was 91.6% at 1 year, 88.5% at 2 years, and 72.7% at 5 years. Peak and mean gradients remained stable during follow-up, and were 17.8 ± 11.3 mm Hg and 9.0 ± 6.3 mm Hg, respectively, at 5 years. Preoperatively, 33.4% of those who received the Perceval valve (n = 210) were in New York Heart Association functional class I or II versus 93.1% (n = 242) at 5 years.

CONCLUSIONS

This series, representing, to our knowledge, the longest follow-up with sutureless technology in a prospective, multicenter study, shows that aortic replacement using sutureless valves is associated with low mortality and morbidity and good hemodynamic performance.

Early surgical aortic bioprosthesis failure caused by cusp tear: A word of caution

Cusp tear is an increasingly described mode of failure of the Trifecta aortic bioprosthesis. Acute aortic regurgitation after implantation of a Trifecta in absence of endocarditis should suggest a cusp tear and be promptly treated with redo surgery.

Early Outcomes of Isolated Aortic Valve Replacement Through Right Anterior Minithoracotomy Using the Latest-Generation Biological Prosthesis

OBJECTIVE

The aim of this study is to evaluate early and intermediate outcomes and hemodynamics of the latest-generation Trifecta valve implanted using right anterior minithoracotomy.

METHODS

We performed a single-center, retrospective, observational study including 175 individuals who underwent isolated minimally invasive aortic valve replacement with the latest-generation Trifecta valves through a right anterior minithoracotomy between January 2016 and January 2019. Exclusion criteria for follow-up echocardiographic study included concomitant procedures, conversion to median sternotomy, and nonsurvival during the index admission. Analyses addressed implantation safety, 30-day and intermediate-term survival and hemodynamic performance of the valves.

RESULTS

Overall, patients were followed with duration ranging from 0.5 to 3 years. Early (<30 days) mortality occurred in 2 patients (1.1%), and there were 9 (5.1%) late (>30 days) deaths. Early thromboembolic events and postoperative bleeding requiring reoperation occurred at a rate of 4.0% (n = 7) and 6.2% (n = 11), respectively. Overall in 175 patients who met inclusion criteria for the follow-up echocardiography study, mean gradients across all valve sizes were 41.3 ± 14.9 (standard deviation) mm Hg preoperatively and remained low at 7.2 ± 3.9 mm Hg with mean effective orifice area of 1.8 ± 0.5 cm² on the last follow-up echo. There was 1 case of infective prosthetic endocarditis, which did not require valve explant. There were no reoperations due to valve-related problems during the study period.

CONCLUSIONS

This is the largest series reporting on outcomes of the latest-generation Trifecta valve implanted using right anterior minithoracotomy. Our results demonstrate that this valve can be safely implanted via a minimally invasive approach with excellent early and intermediate outcomes and hemodynamic performance.

Premature Structural Failure of Trifecta Bioprosthesis in Midterm Follow-up: A Single-Center Study

BACKGROUND

A cluster of aortic bioprosthetic valve failures, most of which were Trifecta bioprostheses, was observed in Southampton General Hospital, Southampton, United Kingdom. This study was performed to assess whether the cluster represents a significant failure of this valve model or whether there is a selection bias that can explain the failure of these valves.

METHODS

This retrospective study evaluated all bioprosthetic aortic valve replacement operations performed between 2011 and 2016 inclusive in our center. The study compared the performance of the Trifecta valve (Abbott, Abbott Park, IL) with that of Perimount (Edwards Lifesciences, Irvine, CA), Perimount Magna Ease, and Mitroflow (LivaNova, London, United Kingdom) bioprostheses. In addition, the study analyzed patient-related and valve-related risk factors for early failure in the failed valves.

RESULTS

A total of 2807 bioprosthetic aortic valve replacements were performed. Of these, 836 were Trifecta valves, 1031 were Perimount, 449 were Perimount Magna Ease, and 351 were Mitroflow valves. A total of 24 Trifecta valves had premature structural failure, a number significantly higher than seen with Perimount or Perimount Magna Ease (no failure, P < .001 and P < .005, respectively) valves and the Mitroflow valve (1 failure, P < .05). There was no difference in the incidence of endocarditis or death. At the time of valve failure, 17 (71%) of the failed Trifecta valves had moderate or severe regurgitation, and the average peak gradient was 61 ± 29 mm Hg. The median failed prosthetic size was 23 mm. One failed valve had severe patient-prosthesis mismatch. The mean time to failure was 4.5 ± 1.7 years.

CONCLUSIONS

The Trifecta bioprosthesis has an increased incidence of early structural valve failure, which is significantly higher than that of Perimount, Perimount Magna Ease, or Mitroflow. No patient-related or valve-related cause for the failure could be identified.

Sutureless versus conventional bioprostheses for aortic valve replacement in severe symptomatic aortic valve stenosis

OBJECTIVE

Sutureless aortic valves are a novel option for aortic valve replacement. We sought to demonstrate noninferiority of sutureless versus standard bioprostheses in severe symptomatic aortic stenosis.

METHODS

The Perceval Sutureless Implant Versus Standard-Aortic Valve Replacement is a prospective, randomized, adaptive, open-label trial. Patients were randomized (March 2016 to September 2018) to aortic valve replacement with a sutureless or stented valve using conventional or minimally invasive approach. Primary outcome was freedom from major adverse cerebral and cardiovascular events (composite of all-cause death, myocardial infarction, stroke, or valve reintervention) at 1 year.

RESULTS

At 47 centers (12 countries), 910 patients were randomized to sutureless (n = 453) or conventional stented (n = 457) valves; mean ages were 75.4 ± 5.6 and 75.0 ± 6.1 years, and 50.1% and 44.9% were female, respectively. Mean ± standard deviation Society of Thoracic Surgeons scores were 2.4 ± 1.7 and 2.1 ± 1.3, and a ministernotomy approach was used in 50.4% and 47.3%, respectively. Concomitant procedures were performed with similar rates in both groups. Noninferiority was demonstrated for major adverse cerebral and cardiovascular events at 1 year, whereas aortic valve hemodynamics improved equally in both groups. Use of sutureless valves significantly reduced surgical times (mean extracorporeal circulation times: 71.0 ± 34.1 minutes vs 87.8 ± 33.9 minutes; mean crossclamp times: 48.5 ± 24.7 vs 65.2 ± 23.6; both P < .0001), but resulted in a higher rate of pacemaker implantation (11.1% vs 3.6% at 1 year). Incidences of perivalvular and central leak were similar.

CONCLUSIONS

Sutureless valves were noninferior to stented valves with respect to major adverse cerebral and cardiovascular events at 1 year in patients undergoing aortic valve replacement (alone or with coronary artery bypass grafting). This suggests that sutureless valves should be considered as part of a comprehensive valve program.

Early Midterm Results After Valve Replacement With Contemporary Pericardial Prostheses for Severe Aortic Stenosis

BACKGROUND

Clinical studies have demonstrated improved gradients after aortic valve replacement with the Trifecta (TR) valve (Abbott Cardiovascular, St Paul, MN) as compared with the Carpentier-Edwards Magna Ease (ME) valve (Edwards Lifesciences, Irvine, CA). Clinical benefits of this strategy have not been demonstrated.

METHODS

Patients undergoing aortic valve replacement for severe aortic stenosis with either valve were included. Patients were excluded if they underwent concomitant procedures other than coronary artery bypass grafting. Inverse proportion treatment weighting was used in the analysis. The primary outcome was a composite of cardiac mortality, need for reintervention, and freedom from first congestive heart failure (CHF). Secondary outcomes were all-cause mortality, the composite components, and cumulative CHF admission. Follow-up echocardiograms were assessed in a cohort of patients to assess structural valve degeneration.

RESULTS

There were 331 patients in the TR group and 360 patients in the ME group. The TR group had more women (48% vs 32%, P < .001) with smaller roots (left ventricular outflow tract diameter: TR, 2.11 cm; ME, 2.17 cm; P < .001). After weighting there was no significant difference in the composite measure between groups (P > .05). There was no difference in all-cause mortality (hazard ratio, 0.82; 95% confidence interval, 0.42-1.59; P = .56), and 5-year survival was 91.9% in the ME group and 93.4% in the TR group. There was no difference in cardiac death, reintervention, or first onset of CHF or incidence of structural valve degeneration between groups. There was no difference in the rate of admissions for CHF per 100 patients between the 2 valve types (P = .19).

CONCLUSIONS

Early hemodynamic benefits have not translated into differences in medium-term clinical outcomes between these 2 valves. Long-term follow-up is necessary.

An in vitro comparison of internally versus externally mounted leaflets in surgical aortic bioprostheses

OBJECTIVES

To improve haemodynamic performance, design modifications of prosthetic valves have been proposed with each new generation of valves. These different designs also impact the amount of mechanical wear, because mechanical stresses are distributed differently. Because long-term evidence for new prosthetic valves is lacking, this in vitro study compared hydrodynamic performance and durability among 3 currently available bioprosthetic valves with internally (IMLV) or externally mounted leaflets (EMLV).

METHODS

Prostheses of the internally mounted Medtronic Avalus and Carpentier-Edwards Perimount Magna Ease valves were compared to prostheses of the externally mounted Abbott Trifecta valve. For each labelled size (e.g. 19, 21 and 23) of the 3 types, 3 valves underwent accelerated wear testing for up to 600 million cycles, corresponding to ∼15 years of simulated wear. The valves underwent hydrodynamic testing and visual inspection.

RESULTS

EMLV had the largest effective orifice area and lowest pressure gradient for each labelled size at baseline and 600 million cycles; the effective orifice area and the pressure gradient were equivalent for the 2 types of IMLV. Five of 9 EMLVs had at least 1 hole or tear in the leaflet tissue around the stent posts, which resulted in severe regurgitation at 500 million cycles in 2 cases. All IMLVs were intact at 600 million cycles with minimal tissue wear.

CONCLUSIONS

EMLV showed superior hydrodynamic performance but inferior mechanical durability compared to IMLV after 600 million cycles of testing. The primary failures were because of significant mechanical abrasion in the commissural region, which may warrant close monitoring of EMLV during long-term follow-up.

Learning From Controversy: Contemporary Surgical Management of Aortic Valve Endocarditis

Aortic valve replacement is the commonest cardiac surgical operation performed worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are goals of the procedure. However, no detailed guidelines on prosthesis selection and surgical strategies guided by the comprehensive evaluation of the extension of the infection and its microbiological characteristics, clinical profile of the patient, and risk of infection recurrence are currently available. Conventional mechanical or stented xenografts are the preferred choice for localized aortic infection. However, in cases of complex IE with the involvement of the root or the aortomitral continuity, the use of homograft is suggested according to the surgeon and center experience. Homograft use should be counterbalanced against the risk of structural degeneration. Prosthetic bioroot or prosthetic valved conduit (mechanical and bioprosthetic) are also potentially suitable alternatives. Further development of preservation techniques enabling longer durability of allogenic substitutes is required. We evaluate the current evidence for the use of valve substitutes in aortic valve endocarditis and propose an evidence-based algorithm to guide the choice of therapy. We performed a systemic review to clarify the contemporary surgical management of aortic valve endocarditis.

Six-year follow-up of aortic valve reoperation rates: Carpentier-Edwards Perimount versus St. Jude Medical Trifecta

BACKGROUND

The Carpentier-Edwards Perimount valves have a proven track record in aortic valve replacement: good durability, hemodynamic performance, rates of survival, and low rates of valve-related complications and prosthesis-patient mismatch. The St. Jude Medical Trifecta is a newer valve that has shown comparable early and midterm outcomes. Studies show reoperation rates of Trifecta are comparable with Perimount valves, with a few recent studies bringing into focus early structural valve deterioration (SVD), and increased midterm SVD in younger patients. Given that midterm data for Trifecta is still sparse, we wanted to confirm the early low reoperation rates of Trifecta persist over time compared with Perimount.

METHODS

The Maritime Heart Centre Database was searched for AVR between 2011 and 2016, inclusive. The primary endpoint of the study was all-cause reoperation rate.

RESULTS

In total, 711 Perimount and 453 Trifecta implantations were included. The reoperation hazards were determined for age: 0.96 (0.92-0.99; p = .02), female (vs. male): 0.35 (0.08-1.53; p = .16), smoker (vs. nonsmoker): 2.44 (0.85-7.02; p = .1), and Trifecta (vs. Perimount): 2.68 (0.97-7.39; p = .06). Kaplan-Meier survival analysis in subgroups-age <60, age ≥60, male, female, smoker, and nonsmoker-showed Perimount having lower reoperation rates than Trifecta in patients younger than 60 (p = .02) and current smokers (p < .01).

CONCLUSIONS

The rates of reoperation of Perimount and Trifecta were comparable, with Trifecta showing higher rates in patients younger than 60 years, and current smokers. Continued diligence and further independent reporting of midterm reoperation and SVD rates of the Trifecta, including detailed echocardiographic follow-up, are needed to confirm these findings.

Revisiting the guidelines and choice the ideal substitute for aortic valve endocarditis

Aortic valve replacement is the most commonly performed cardiac surgical operation worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are the treatment goals. However, no detailed guidelines on prosthesis selection and surgical strategy are available. Management should be guided by a comprehensive evaluation of infection extension and its microbiological characteristics, the clinical profile of the patient and the risk of infection recurrence. We conducted a literature search of the PubMed database, EMBASE and Cochrane Library (through November 2019) for studies reporting to the use of biological substitutes in aortic valve endocarditis (AVE). Studies comparing long-term outcomes in the use of allogenic and autologous with conventional prostheses were investigated. Conventional mechanical or stented xenografts are the preferred choice for localized aortic infection. In cases of complex IE with the involvement of the root or the aorto-mitral continuity, the use of homografts are recommended, according to surgeon's and center experience. Homograft use needs to be balanced against the risk of structural degeneration. Prosthetic bioroot or prosthetic valved conduit with a mechanical or bioprosthetic valve are acceptable alternatives. The choice of aortic valves substitute and surgical strategy in IE is multifaceted. Principles guiding the selection of prosthesis and surgical approach rely on the long-term durability and the avoidance of infection relapse. A decisional algorithm considering the extension of the infection and its microbiological characteristics, the clinical profile of the patient and the risk of infection recurrence is provided. A multidisciplinary effort is required to achieve consistent outcomes.

Impact of Leaflet Laceration on Transcatheter Aortic Valve-in-Valve Washout: BASILICA to Solve Neosinus and Sinus Stasis

OBJECTIVES

The aim of this study was to evaluate any potential leaflet washout benefits after bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction during TAVR (BASILICA) in transcatheter valve-in-valve (ViV) in the context of leaflet thrombosis.

BACKGROUND

Leaflet thrombosis after transcatheter aortic valve replacement is secondary to flow stasis in both the sinus and neosinus. Strategies to improve washout and ameliorate neosinus and sinus flow velocities may have the potential to mitigate the occurrence of clinical and subclinical leaflet thrombosis.

METHODS

A 23-mm Edwards SAPIEN 3 and a 26-mm Medtronic Evolut were deployed in a 23-mm transparent surgical aortic valve model before and after leaflet laceration. The valves were placed in the aortic position of a pulse duplicator flow loop. Particle image velocimetry was performed to quantify sinus flow hemodynamic status. A tracing fluorescent dye was injected to evaluate the number of cycles to washout in both regions of interest.

RESULTS

The leaflet laceration procedure led to an increase in the velocities in the sinus and the neosinus by 50% for Evolut ViV and 61.9% for SAPIEN 3 ViV. In addition, leaflet laceration led to a reduction in overall cycles to washout in the neosinus by at least 56% with the Evolut and 54.5% with the SAPIEN 3 and in the sinus by at least 16.7% with the Evolut and 60.8% with the SAPIEN.

CONCLUSIONS

Leaflet laceration using a BASILICA-type approach may hold the potential to mitigate neosinus and sinus flow stasis. Controlled in vivo trials are necessary to establish the potential benefit of BASILICA to reduce the occurrence of leaflet thrombosis.

Trifecta Bioprosthesis Sudden-Onset Three-Leaflet Detachment

Acute bioprosthesis failure is an uncommon event that may require urgent surgery. This is even less frequent when it is not associated with endocarditis, thrombus formation, or structural valve deterioration. We describe an acute complete detachment of the 3 leaflets of a Trifecta tissue valve 6 years after implantation in a patient who suddenly experienced strong chest pain with severe dyspnea. In the operating room, total detachment of the 3 leaflets from the scalloped cuff and from 1 of the cusps was observed. No signs of endocarditis or leaflet calcifications were found.

Aortic root morphology can cause early bioprosthetic valve failure of externally mounted pericardial bioprosthesis

A 73-year-old woman with a narrow aortic root had undergone aortic valve replacement with a 19-mm Mitroflow valve. Aortic annular enlargement with Manouguian's technique was performed, and the bioprosthesis had been implanted on the tilt in a supra-annular position. Four years after the implantation, echocardiography showed a significant de novo aortic regurgitation, which had not been detected 1 year earlier. In the reoperation, the left coronary leaflet of the bioprosthesis had attached and fused to the wall of the sinus of Valsalva, causing deformation of the valve leaflet and a commissural gap between the left and right coronary leaflets, which appeared to have caused the de novo aortic regurgitation. We assessed the cause of early valve deterioration by focusing on the morphology of the aortic root. Preoperative understanding of the aortic root morphology would help to avoid early valve dysfunction for aortic valve replacement with an externally mounted bioprosthesis.