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Aortic root replacement with stentless xenografts in patients with aortic stenosis. J Thorac Cardiovasc Surg 2019; 158:1021-1027. [DOI: 10.1016/j.jtcvs.2018.11.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 10/24/2018] [Accepted: 11/04/2018] [Indexed: 11/18/2022]
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Ennker J, Meilwes M, Pons-Kuehnemann J, Niemann B, Grieshaber P, Ennker IC, Boening A. Freestyle stentless bioprosthesis for aortic valve therapy: 17-year clinical results. Asian Cardiovasc Thorac Ann 2016; 24:868-874. [PMID: 27926465 DOI: 10.1177/0218492316675244] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic valve replacement with stentless bioprostheses has been shown to produce lower aortic gradients than stented bioprostheses, thus facilitating left ventricular mass regression and preventing heart failure. We sought to determine the long-term results of stentless biological aortic valve replacement over a 17-year follow-up. METHODS Between 1996 and 2012, 2551 patients underwent isolated aortic valve replacement with a stentless prosthesis (Medtronic Freestyle) at a single center. The mean patient age was 72 ± 10 years, 55% were male, 24.1% were in New York Heart Association class I and II, 9.6% had undergone previous surgery, 18.1% had coronary artery disease, and 23.1% had diabetes. For the long-term follow-up, patients were contacted in writing and by telephone; follow-up was 96.3% complete, resulting in 11,546 patient-years. RESULTS At 30 days, mortality (5.4%), renal failure (3.9%), myocardial infarction (0.7%), and stroke (1.4%) rates were acceptable. During long-term follow-up of 1-17 years, the bleeding rate (2.9%) was higher than the thromboembolic event rate (0.7%) despite 18.1% of patients being on oral anticoagulants. New pacemaker implantation (4.5%; 0.87 events/100 patient-years), neurological disorders (5%; 0.52 events/100 patient-years), valve insufficiency (0.7%; 0.16 events/100 patient-years), paravalvular leakage (0.4%; 0.09 events/100 patient-years) and reoperation due to valvular complications (0.7%; 0.38 events/100 patient-years) were rare. Long-term survival was 41.8% ± 1.6 after 10 years, 21.3% ± 2.3 after 15 years, and 12.1% ± 3.9 after 17 years. CONCLUSION Long-term results after aortic valve replacement with stentless biological prostheses compare favorably with those obtained with stented bioprostheses.
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Affiliation(s)
- Juergen Ennker
- Heart Center, Helios Hospital Siegburg Germany.,Faculty of Medicine, Witten-Herdecke University, Witten, Germany
| | - Markus Meilwes
- Institute of Medical Statistics, Justus-Liebig University Giessen, Giessen, Germany.,Department of Cardiovascular Surgery, Justus-Liebig University Giessen, Giessen, Germany
| | | | - Bernd Niemann
- Department of Cardiovascular Surgery, Justus-Liebig University Giessen, Giessen, Germany
| | - Philippe Grieshaber
- Department of Cardiovascular Surgery, Justus-Liebig University Giessen, Giessen, Germany
| | - Ina C Ennker
- Hannover Medical School, Department of Plastic and Reconstructive Surgery, Hannover, Germany
| | - Andreas Boening
- Department of Cardiovascular Surgery, Justus-Liebig University Giessen, Giessen, Germany
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Di Eusanio M, Murana G, Cefarelli M, Mazzola A, Di Bartolomeo R. The Bentall procedure with a biological valved conduit: substitute options and techniques. Multimed Man Cardiothorac Surg 2014; 2014:mmu010. [PMID: 24925908 DOI: 10.1093/mmcts/mmu010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
As originally described by Bentall and De Bono, aortic root replacement with reimplantation of the coronary arteries using a composite valved conduit represents the gold standard intervention in patients with aneurysmal disease or dissection involving the aortic root. Over the last decade, the number of Bentall procedures performed using biological valved conduit has dramatically expanded mainly due to the increased incidence of aortic disease in the aging population. Here, we sought to describe the commercially available biological composite grafts and the techniques that, to the best of our knowledge, are most frequently used in this setting.
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Affiliation(s)
- Marco Di Eusanio
- Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy
| | - Giacomo Murana
- Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy
| | - Mariano Cefarelli
- Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy
| | - Alessandro Mazzola
- Division of Cardiothoracic Surgery, Research Hospital Foundation San Matteo, Pavia, Italy
| | - Roberto Di Bartolomeo
- Cardiovascular Surgery Department, Sant'Orsola-Malpighi Hospital, Bologna University, Bologna, Italy
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Abstract
Stentless aortic xenografts were introduced into clinical practice as aortic valve substitutes over a decade ago. Stentless prosthetic valves were expected to provide enhanced durability and more physiologic hemodynamic behavior when compared with stented bioprostheses. Whilst the former expectation has not been fulfilled, partly due to concomitantly improved durability of second-generation stented bioprostheses, the latter has consistently been satisfied in early and late clinical observation. Evidence is accumulating suggesting improved long-term survival due to more timely and thorough regression of ventricular hypertrophy. In addition, stentless xenografts have shown extreme versatility when adopted in a variety of complex clinical conditions associated with aortic valve disease, including small aortic anulus, ascending aortic aneurysm, endocarditis and left ventricular dysfunction. Future research in the form of prospective, multicenter, randomized trials must address the issues of very long-term durability and survival, while simplification in valve design is required to promote wider use of stentless valves.
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Vohra HA, Whistance RN, De Kerchove L, Punjabi P, El Khoury G. Valve-preserving surgery on the bicuspid aortic valve. Eur J Cardiothorac Surg 2013; 43:888-98. [DOI: 10.1093/ejcts/ezs664] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Xiong FL, Goetz WA, Chong CK, Chua YL, Pfeifer S, Wintermantel E, Yeo JH. Finite Element Investigation of Stentless Pericardial Aortic Valves: Relevance of Leaflet Geometry. Ann Biomed Eng 2010; 38:1908-18. [DOI: 10.1007/s10439-010-9940-6] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 01/18/2010] [Indexed: 11/29/2022]
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Stewart AS, Takayama H, Smith CR. Modified Bentall Operation With a Novel Biologic Valved Conduit. Ann Thorac Surg 2010; 89:938-41. [DOI: 10.1016/j.athoracsur.2009.11.043] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2009] [Revised: 11/08/2009] [Accepted: 11/11/2009] [Indexed: 11/17/2022]
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LeMaire SA, Green SY, Sharma K, Cheung CK, Sameri A, Tsai PI, Adams G, Coselli JS. Aortic Root Replacement With Stentless Porcine Xenografts: Early and Late Outcomes in 132 Patients. Ann Thorac Surg 2009; 87:503-12; discussion 512-3. [DOI: 10.1016/j.athoracsur.2008.11.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2007] [Revised: 11/08/2008] [Accepted: 11/12/2008] [Indexed: 10/21/2022]
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Li W, Price S, O'Sullivan CA, Kumar P, Jin XY, Henein MY, Pepper JR. Medium-term outcome of Toronto aortic valve replacement: single center experience. Int J Cardiol 2008; 129:210-5. [PMID: 17904666 DOI: 10.1016/j.ijcard.2006.03.098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2005] [Revised: 03/22/2006] [Accepted: 03/25/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIMS Long-term competence of any aortic prosthesis is critical to its clinical durability. Bioprosthetic valves, and in particular the stentless type have been proposed to offer superior haemodynamic profiles with consequent potential for superior left-ventricular mass regression. These benefits however are balanced by the potential longevity of the implanted valve. The aims of this study were to assess medium-term Toronto aortic valve function and its effect on left-ventricular function. METHODS Between 1992 and 1996 86 patients underwent Toronto aortic valve replacement for aortic valve disease and were followed up annually. Prospectively collected data was analyzed for all patients where detailed echocardiographic follow-up was available. Echocardiographic studies were analyzed at 2+/-0.6 and 6+/-1.4 years after valve replacement. Data collected included left-ventricular systolic and diastolic dimensions, fractional shortening and left-ventricular mass. In addition, data on aortic valve and root morphology, peak aortic velocities, time velocity integral, stroke volume and the mechanism of valve failure where relevant, were also collected. RESULTS Complete echocardiographic data were available for eighty-four patients, age 69+/-9 years, 62 male. Additional coronary artery bypass grafting was performed in 38% of patients. Twelve (14%) valves had failed during follow-up, 7 (8%) requiring re-operation. Valve failure was associated with morphologically bicuspid native aortic valve (9/12), and progressive dilatation of the aortic sinuses, sino-tubular junction and ascending aorta (11/12). Left-ventricular mass index remained high (184+/-75 g/m(2)) and did not continue to regress between early and medium-term follow-up (175.8+/-77 g/m(2)). CONCLUSIONS Although more than 90% of implanted Toronto aortic valves remained haemodynamically stable with low gradient at medium-term follow-up, young age and larger aortic dimensions in patients with valve failure suggest better outcome if used in the elderly with normal aortic root geometry.
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Affiliation(s)
- Wei Li
- Department of Cardiology, Royal Brompton and Harefield NHS Trust, Sydney Street, London, SW3 6NP UK
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Bochenek-Klimczyk K, Lau KKW, Galiñanes M, Sosnowski AW. Preassembled stentless valved-conduit for the replacement of the ascending aorta and aortic root. Interact Cardiovasc Thorac Surg 2008; 7:964-8. [PMID: 18713779 DOI: 10.1510/icvts.2008.184457] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Here we report the early clinical results of a new preassembled stentless valved-conduit incorporating artificial sinuses of Valsalva (BioValsalva). This new composite conduit incorporates a stentless porcine aortic valve (Elan, Vascutek Terumo, UK) suspended within a triple-layered vascular conduit (Triplex, Vascutek Terumo, UK) constructed with sinuses of Valsalva. Between December 2006 and January 2008, 17 patients with the mean age of 65 years underwent aortic valve, root and ascending aorta replacement with the BioValsalva valved-conduit. There was no perioperative mortality. There were no myocardial infarctions, cardiac failure or cerebrovascular events. Mean cardiopulmonary bypass time was 156+/-56 min and ischemic time was 112+/-33 min. Eight patients required deep hypothermic circulatory arrest for additional distal ascending aorta replacement. Mean mediastinal drainage was 499+/-262 ml. Postoperative transthoracic echocardiography and CT-scans of the aorta in all patients before discharge demonstrated well-functioning prosthetic aortic valves with small residual mean gradients, no regurgitation, and the presence of sinuses of Valsalva. In conclusion, the novel prefabricated, composite stentless valved-conduit BioValsalva possesses excellent hemodynamic performance and can be implanted with low morbidity. In addition, the conduit material has good hemostatic properties which reduced bleeding, and is easy to implant with a variety of surgical techniques.
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Replacement of the Ascending Aorta, Aortic Root, and Valve with a Novel Stentless Valved Conduit. Ann Thorac Surg 2008; 86:278-81. [DOI: 10.1016/j.athoracsur.2008.01.058] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2007] [Revised: 01/17/2008] [Accepted: 01/18/2008] [Indexed: 11/20/2022]
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Deleterious outcome of No-React–treated stentless valved conduits after aortic root replacement: Why were Warnings ignored? J Thorac Cardiovasc Surg 2008; 136:52-7. [DOI: 10.1016/j.jtcvs.2007.09.047] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Accepted: 09/11/2007] [Indexed: 11/23/2022]
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Pavoni D, Badano LP, Ius F, Mazzaro E, Frassani R, Gelsomino S, Livi U. Limited long-term durability of the Cryolife O'Brien stentless porcine xenograft valve. Circulation 2007; 116:I307-13. [PMID: 17846322 DOI: 10.1161/circulationaha.107.688564] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Despite the fact that early and midterm hemodynamic and clinical results of the Cryolife O'Brien (CLOB) stentless valve have been reported to be favorable, the long-term durability and clinical results of this valve are largely unknown. Accordingly, we analyzed 10-year outcomes after aortic valve replacement with this valve. METHODS AND RESULTS From January 1994 to September 2004, 185 patients (67, 73, and 75 years, 25th, 50th, and 75th quartiles, respectively; 38% older than 75 years; 56% females) underwent aortic valve replacement with the CLOB valve. Sixty-eight percent of patients were in NYHA class 3 to 4. Standard EuroSCORE was 7.1+/-2.7. Pure aortic stenosis accounted for 42% (n=79), and pure insufficiency for 12% of cases (n=22). Concomitant surgery: 28% coronary artery bypass (n=51), 11% mitral valve replacement/annuloplasty (n=21), and 2% ascending aorta replacement (n=3). Sixty-one percent of patients received a 23-mm valve or smaller size. Follow-up was 100% completed, and cumulative follow-up was 65 months/patient. The 30-day mortality was 5.4% (none were valve related). Actuarial survival at 5 and 10 years were 68% and 40%, respectively. Actuarial freedom from structural valve deterioration was 91% at 5 years and dropped to 44% at 10 years. Actuarial freedom from reoperation was 94% at 5 years and declined to 57% at 10 years. CONCLUSIONS In a population with a high prevalence of elderly females with small aortic root, the CLOB valve demonstrated satisfactory clinical results till 8-years. Afterward, a significant increase in hazard for structural valve deterioration and reoperation occurred in late follow-up.
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Affiliation(s)
- Daisy Pavoni
- Department of Cardiopulmonary Sciences, Azienda Ospedaliero-Universitaria Santa Maria della Misericordia, P.le S Maria della Misericordia 15, 33100 Udine, Italy.
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Musci M, Siniawski H, Knosalla C, Grauhan O, Weng Y, Pasic M, Meyer R, Hetzer R. Early and mid–term results of the Shelhigh stentless bioprosthesis in patients with active infective endocarditis. Clin Res Cardiol 2006; 95:247-53. [PMID: 16598398 DOI: 10.1007/s00392-006-0370-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2005] [Accepted: 01/18/2006] [Indexed: 11/24/2022]
Abstract
AIMS This study investigated the early and mid-term results following valve replacement with the new Shelhigh stentless bioprosthesis made entirely of biological material in patients with active infective endocarditis (AIE). MATERIAL AND METHODS Between 02/2000 and 12/2004, 164 patients (n = 122 men, mean age 59, 18-85 years) received implantation of an AIE Shelhigh stentless bioprosthesis in the aortic, mitral, tricuspid or pulmonary position. A total of 119 patients (72.6%) had native AIE and 45 (27.4%) prosthetic AIE. A large proportion of the patients reached the operating room in a condition of cardiac decompensation: 37 (22.6%) patients were intubated, 40 (24.4%) had protracted septic shock and 41 (25.0%) required intensive catecholamine treatment. Surgery was regarded as urgent in 94 patients (57.4%) and was performed as an emergency procedure in 70 (42.6%). The mean follow-up time is 1.5 +/- 0.11 years (range, 5 months to 5.2 years). Echocardiographic follow-up examinations were performed early postoperatively and after 12 months. RESULTS In terms of the operative indication, we found a highly significant difference in the survival rate between patients who were operated on urgently vs in an emergency. In patients who died within 30 days, the main cause of death was septic multiorgan failure (67.6%). Only three patients required reoperation due to reinfection of the Shelhigh bioprostheses; this represents a reinfection rate of 1.8% in relation to the whole cohort. The postoperative echocardiographic examinations showed the Shelhigh valves to have very good hemodynamics without relevant pressure gradients. CONCLUSION Our experience in the use of Shelhigh bioprostheses in patients with native and prosthetic endocarditis show the early and mid-term results, in particular the low reinfection rate and the good hemodynamics, to be comparable with the results achieved using homografts. Since these prostheses are readily available and their implantation straightforward, they are increasingly being used in patients with endocarditis. These promising results need to verified in the long term.
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Affiliation(s)
- Michele Musci
- Deutsches Herzzentrum Berlin, Abt. für Herz-, Thorax und Gefässchirurgie, Augustenburger Platz 1, 13353, Berlin, Germany.
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Frühe und mittelfristige Ergebnisse der „Shelhigh“-Stentless-Bioprothese bei Patienten mit aktiver, infektiöser Endokarditis. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2006. [DOI: 10.1007/s00398-006-0526-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Totaro P, Degno N, Zaidi A, Youhana A, Argano V. Carpentier-Edwards PERIMOUNT Magna bioprosthesis: A stented valve with stentless performance? J Thorac Cardiovasc Surg 2005; 130:1668-74. [PMID: 16308014 DOI: 10.1016/j.jtcvs.2005.07.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2005] [Revised: 06/10/2005] [Accepted: 07/07/2005] [Indexed: 11/21/2022]
Abstract
OBJECTIVE We designed this study to evaluate the early hemodynamic performance of the recently introduced Carpentier-Edwards PERIMOUNT Magna bioprosthesis (Edwards Lifesciences, Irvine, Calif) and compare it with those of the conventional Carpentier-Edwards PERIMOUNT stented bioprosthesis (Edwards Lifesciences) and Edwards Prima Plus porcine stentless bioprosthesis (Edwards Lifesciences). METHODS Sixty-three patients (>70 years old) were enrolled in this prospective, randomized study. At operation, once the annulus had been measured, the best size suitable was assessed for each of the three valves before random assignment. Transthoracic echocardiography was performed before discharge to evaluate early postoperative hemodynamic performances of the different valves implanted. RESULTS The best size suitable of Edwards Prima Plus (24.3 +/- 1.7 mm) was significantly superior to those of both the Carpentier-Edwards PERIMOUNT Magna (23.4 +/- 2.1 mm) and Carpentier-Edwards PERIMOUNT (22.4 +/- 1.8 mm). The best size suitable of the Carpentier-Edwards PERIMOUNT Magna, however, was significantly superior to that of the Carpentier-Edwards PERIMOUNT. Furthermore the best size suitable of the Carpentier-Edwards PERIMOUNT Magna was equal to the measured annulus in 55% of patients, as opposed to 25% for the Carpentier-Edwards PERIMOUNT (P < .001). Mean implanted labeled size of the Edwards Prima Plus was significantly higher than those of both the Carpentier-Edwards PERIMOUNT Magna and the Carpentier-Edwards PERIMOUNT (24.6 +/- 1.9 mm, 23.1 +/- 1.9 mm, and 22.5 +/- 1.8 mm, respectively). Early postoperative hemodynamic performance of the Carpentier-Edwards PERIMOUNT Magna, however, was superior to those of both the Edwards Prima Plus and the Carpentier-Edwards PERIMOUNT in both effective orifice area index (1.07 +/- 0.4 cm2/m2, 0.87 +/- 0.3 cm2/m2, and 0.80 +/- 0.2 cm2/m2, respectively) and mean peak gradient (20 +/- 6 mm Hg, 27 +/- 8 mm Hg, and 28 +/- 12 mm Hg, respectively). CONCLUSION The improved design of the recently introduced third-generation stented bioprosthesis Carpentier-Edwards PERIMOUNT Magna allows implantation of a significantly bigger valve than with the old generation. Furthermore, the improved hemodynamic performance of the Carpentier-Edwards PERIMOUNT Magna compares favorably with both the Carpentier-Edwards PERIMOUNT and the Edwards Prima Plus.
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Affiliation(s)
- Pasquale Totaro
- Cardiac Surgery Division, Regional Cardiac Centre, Morriston Hospital, Swansea, United Kingdom.
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Carr JA, Savage EB. Aortic valve repair for aortic insufficiency in adults: a contemporary review and comparison with replacement techniques. Eur J Cardiothorac Surg 2004; 25:6-15. [PMID: 14690726 DOI: 10.1016/j.ejcts.2003.09.018] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
In evaluating the goal of aortic valve preservation, there have been 11 reports of large series of aortic valve repair for aortic insufficiency in adults published in recent years. We sought to analyze the validity of these methods and compare them to published results for bioprosthetic valves, pulmonary autografts, and aortic homografts. From 1990 to 2002, 761 adult aortic valve repairs were reported. Perioperative morbidity ranged from 3.6 to 23% (mean 14%), early mortality 0-8% (mean 3.6%), and late mortality 0-8% (mean 2.8%). The 5- and 10-year freedom from reoperation rates for repair were 89 and 64%. Although early results are good, long-term analysis suggests that, as a group, the durability of repair is unclear. Patients with rheumatic valvular disease appear to have an increased incidence of recurrence and repair failure. Although suture line dehiscence continues to be both an early and late complication with repair, the long-term morbidity and mortality is low and valve repair may be an option in carefully selected patients. However, the inability to break down the results by techniques does not allow for a definitive conclusion. Further subanalysis is necessary as larger series are reported. Proponents must attempt to separate successful from unsuccessful techniques. Aortic valve repair is a technique in evolution.
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Affiliation(s)
- John Alfred Carr
- Department of Cardiovascular-Thoracic Surgery, Rush-Presbyterian-St. Luke's Medical Center, Rush Medical College, 1653 West Congress Parkway, Chicago, IL 60612, USA
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