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Fedorov D, Bauernschmitt R, Grunebaum JP, Bauer S, Sodian R, von Hodenberg E. Interventional versus Surgical Treatment of Degenerated Freestyle Prosthesis. Thorac Cardiovasc Surg 2024; 72:188-196. [PMID: 36858066 DOI: 10.1055/s-0043-1763286] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
Abstract
BACKGROUND Bioprosthetic stentless aortic valves may degenerate over time and will require replacement. This study aimed to evaluate early- and mid-term outcomes after isolated surgical redo aortic valve replacement (redo-SAVR) and transcatheter valve-in-valve implantation (TAVI-VIV) for degenerated stentless Freestyle bioprostheses. METHODS We reviewed records of 56 patients at a single center. Overall, 37 patients (66.1%) received TAVI-VIV and 19 (33.9%) received redo-SAVR. RESULTS Thirty-day survival was similar in both groups (100%). One-year survival was comparable between groups (97.3% in TAVI-VIV and 100% in redo-SAVR, p = 1.0). The difference in mid-term survival after adjusting for age and EuroScore II was not significant (p = 0.41). The incidence of pacemaker implantation after TAVI-VIV was higher than after redo-SAVR (19.4% vs. 0%, p = 0.08). CONCLUSION The 30-day and 1-year survival rates after both procedures were outstanding, irrespective of baseline characteristics. Isolated redo-SAVR should be favored in young patients, as the pacemaker implantation rate is lower. TAVI-VIV for degenerated Freestyle prosthesis can be a method of choice in elderly patients and those with high operative risk.
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Affiliation(s)
- Denis Fedorov
- Department of Cardiology, MediClin Herzzentrum Lahr/Baden, Lahr, Germany
| | - Robert Bauernschmitt
- Department of Cardiovascular Surgery, MediClin Herzzentrum Lahr/Baden, Lahr, Germany
- Department of Cardiovascular Surgery, UniversitätsSpital Zürich, Zurich, Switzerland
| | | | - Stefan Bauer
- Department of Cardiovascular Surgery, MediClin Herzzentrum Lahr/Baden, Lahr, Germany
| | - Ralf Sodian
- Department of Cardiovascular Surgery, MediClin Herzzentrum Lahr/Baden, Lahr, Germany
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Khazaal J, Ragagni M, Parker J, Timek T, Murphy E, Heiser J, Willekes C. Freestyle Aortic Bioprostheses in Patients 60 Years old and Younger. Semin Thorac Cardiovasc Surg 2021; 34:870-877. [PMID: 34380081 DOI: 10.1053/j.semtcvs.2021.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 08/02/2021] [Indexed: 11/11/2022]
Abstract
Evaluate outcomes of the Freestyle stentless aortic bioprosthesis in patients 60 years old and younger. All patients, 60 years old and younger, between January 1, 1998 to December 31, 2015 who underwent implantation of a Freestyle aortic valve at a single institution were reviewed. Medical records and telephone interviews were utilized for data collection. 515 patients were identified with an average age of 51.3 years. Mean follow up was 11.1 years. 225 full root replacements and 290 subcoronary implants were performed. Overall survival, including patients with concomitant procedures, at 15 years was 63.7% (95% CI 58.3-68.5). Isolated subcoronary implants (58%,167/290) had a 15-year survival of 71.6% (95% CI 62.6-78.7) vs 78.4% (95% CI 69.7, 84.9) for isolated root replacements (63%,141/225) which was not statistically significant (P = 0.397). No significant difference in operative SVD at 15 years occurred between full root replacements 37.6% (95% CI 27.2-50.2) vs subcoronary implants 39.4% (95% CI31.1, 49.0). 110 patients required reoperation solely for intrinsic SVD. 93% (102/110) failed due to aortic insufficiency. Of reoperative interventions for SVD, 37% (41/110) of patients required urgent reoperation and 4.5% (5/110) required emergent reoperation. Pseudoaneurysms developed in six of the full root replacements. Freestyle aortic valves have a high rate of acute failure requiring urgent or emergent reintervention in patients 60 years old and younger. This has led our group to shift practice away from their implantation.
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Affiliation(s)
- Jawad Khazaal
- College of Human Medicine, Michigan State University, Grand Rapids
| | - Mary Ragagni
- Department of Cardiovascular Research, Spectrum Health, Grand Rapids
| | - Jessica Parker
- Office of Research and Education, Spectrum Health, Grand Rapids
| | - Tomasz Timek
- Department of Cardiothoracic Surgery, Spectrum Health, Grand Rapids
| | - Edward Murphy
- Department of Cardiothoracic Surgery, Spectrum Health, Grand Rapids
| | - John Heiser
- Department of Cardiothoracic Surgery, Spectrum Health, Grand Rapids
| | - Charles Willekes
- Department of Cardiothoracic Surgery, Spectrum Health, Grand Rapids.
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3
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Dawidowska K, Siondalski P, Kołaczkowska M. In Vitro Study of a Stentless Aortic Bioprosthesis Made of Bacterial Cellulose. Cardiovasc Eng Technol 2020; 11:646-654. [PMID: 33205361 PMCID: PMC7782396 DOI: 10.1007/s13239-020-00500-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 11/05/2020] [Indexed: 12/02/2022]
Abstract
PURPOSE The paper present findings from an in vitro experimental study of a stentless human aortic bioprosthesis (HAB) made of bacterial cellulose (BC). Three variants of the basic model were designed and tested to identify the valve prosthesis with the best performance parameters. The modified models were made of BC, and the basic model of pericardium. METHODS Each model (named V1, V2 and V3) was implanted into a 90 mm porcine aorta. Effective Orifice Area (EOA), rapid valve opening time (RVOT) and rapid valve closing time (RVCT) were determined. The flow resistance of each bioprosthesis model during the simulated heart systole, i.e. for the mean differential pressure (ΔP) at the time of full valve opening was measured. All experimental specimens were exposed to a mean blood pressure (MBP) of 90.5 ± 2.3 mmHg. RESULTS The V3 model demonstrated the best performance. The index defining the maximum opening of the bioprosthesis during systole for models V1, V2 and V3 was 2.67 ± 0.59, 2.04 ± 0.23 and 2.85 ± 0.59 cm2, respectively. The mean flow rate through the V3 valve was 5.7 ± 1, 6.9 ± 0.7 and 8.9 ± 1.4 l/min for stroke volume (SV) of 65, 90 and 110 mL, respectively. The phase of immediate opening and closure for models V1, V2 and V3 was 8, 7 and 5% of the cycle duration, respectively. The mean flow resistance of the models was: 4.07 ± 2.1, 4.28 ± 2.51 and 5.6 ± 2.32 mmHg. CONCLUSIONS The V3 model of the aortic valve prosthesis is the most effective. In vivo tests using BC as a structural material for this model are recommended. The response time of the V3 model to changed work conditions is comparable to that of a healthy human heart. The model functions as an aortic valve prosthesis in in vitro conditions.
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Affiliation(s)
- Kinga Dawidowska
- Medical Engineering Division, Maritime Advanced Research Centre, Szczecińska 65, 80-392, Gdańsk, Poland.
| | - Piotr Siondalski
- Cardiac and Vascular Surgery Department, Medical University of Gdańsk, Dębinki 7, 80-211, Gdańsk, Poland
| | - Magdalena Kołaczkowska
- Cardiac and Vascular Surgery Department, Medical University of Gdańsk, Dębinki 7, 80-211, Gdańsk, Poland
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4
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Complementary Role of the Computed Biomodelling through Finite Element Analysis and Computed Tomography for Diagnosis of Transcatheter Heart Valve Thrombosis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:1346308. [PMID: 30426001 PMCID: PMC6217904 DOI: 10.1155/2018/1346308] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 09/04/2018] [Accepted: 10/02/2018] [Indexed: 11/24/2022]
Abstract
Introduction The TAVR procedure is associated with a substantial risk of thrombosis. Current guidelines recommend catheter-based aortic valve implantation for prohibitive-high-risk patients with severe aortic valve stenosis but acknowledge that the aetiology and mechanism of thrombosis are unclear. Methods From 2015 to 2018, 607 patients with severe aortic valve stenosis underwent either self-expandable or balloon-expandable catheter-based aortic valve implantation at our institute. A complementary study was designed to support computed tomography as a predictor of complications using an advanced biomodelling process through finite element analysis (FEA). The primary evaluation of study was the thrombosis of the valve at 12 months. Results At 12 months, 546 patients had normal valvular function. 61 patients had THVT while 6 showed thrombosis and dislodgement with deterioration to NYHA Class IV requiring rehospitalization. The FEA biomodelling revealed a strong link between solid uncrushed calcifications, delayed dislodgement of TAVR and late thrombosis. We observed an interesting phenomenon of fibrosis/calcification originating at the level of the misplaced valve, which was the primary cause of coronary obstruction. Conclusion The use of cardiac CT and predictive biomodelling should be integrated into routine practice for the selection of TAVR candidates and as a predictor of negative outcomes given the lack of accurate investigations available. This would assist in effective decision-making and diagnosis especially in a high-risk cohort of patients.
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5
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Takaya H, Masuda S, Naganuma M, Yoshioka I, Takahashi G, Akiyama M, Adachi O, Kumagai K, Sugita S, Saiki Y. Morphometrical and biomechanical analyses of a stentless bioprosthetic valve: an implication to avoid potential primary tissue failure. Gen Thorac Cardiovasc Surg 2018; 66:523-528. [PMID: 29956049 DOI: 10.1007/s11748-018-0959-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Stentless bioprosthetic valves provide hemodynamic advantages over stented valves as well as excellent durability. However, some primary tissue failures in bioprostheses have been reported. This study was conducted to evaluate the morphometrical and biomechanical properties of the stentless Medtronic Freestyle™ aortic root bioprosthesis, to identify any arising problem areas, and to speculate on a potential solution. METHODS The three-dimensional heterogeneity of the stentless bioprosthesis wall was investigated using computed tomography. The ascending aorta and the right, left, and non-coronary sinuses of Valsalva were resected and examined by an indentation test to evaluate their biomechanical properties. RESULTS The non-coronary sinus of Valsalva was significantly thinner than the right sinus of Valsalva (p < 0.01). Young's modulus, calculated as an indicator of elasticity, was significantly greater at the non-coronary sinus of Valsalva (430.7 ± 374.2 kPa) than at either the left (190.6 ± 70.6 kPa, p < 0.01) or right sinuses of Valsalva (240.0 ± 56.5 kPa, p < 0.05). CONCLUSIONS Based on the morphometrical and biomechanical analyses of the stentless bioprosthesis, we demonstrated that there are differences in wall thickness and elasticity between each sinus of Valsalva. These differences suggest that the non-coronary sinus of Valsalva is the most vulnerable and at greater risk of tissue failure. The exclusion of the non-coronary sinus of Valsalva may be beneficial to mitigate the long-term risks of tissue failure in the stentless bioprosthesis.
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Affiliation(s)
- Hiroki Takaya
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryocho, Aoba-ku, Sendai, Miyagi, 980-8575, Japan.
| | - Shinya Masuda
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryocho, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Masaaki Naganuma
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryocho, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Ichiro Yoshioka
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryocho, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Goro Takahashi
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryocho, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Masatoshi Akiyama
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryocho, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Osamu Adachi
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryocho, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
| | - Kiichiro Kumagai
- Research Division of Sciences for Aortic Disease, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Shukei Sugita
- Biomechanics Laboratory, Department of Mechanical Engineering, Graduate School of Engineering, Nagoya Institute of Technology, Nagoya, Japan
| | - Yoshikatsu Saiki
- Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryocho, Aoba-ku, Sendai, Miyagi, 980-8575, Japan
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Subramaniam K, Nazarnia S. Prosthesis-patient mismatch - what cardiac anesthesiologists need to know? Ann Card Anaesth 2017; 20:234-242. [PMID: 28393786 PMCID: PMC5408531 DOI: 10.4103/aca.aca_9_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Prosthesis-patient Mismatch (PPM) is not uncommon with an incidence reported up to 70% after aortic valve (AV) replacement. Severe forms of PPM are less common (up to 20%); PPM can lead to increased short- and long-term morbidity and mortality. It is important to discriminate PPM from other forms of prosthetic valve dysfunction. Sometimes, prosthetic valve degenerative disease may coexist with PPM. Echocardiography plays an important role in the prevention and diagnosis of PPM. Preemptive strategies to prevent PPM include insertion of newer generation prosthetic valves with better hemodynamic characteristics, stentless prosthesis, aortic root enlargement to insert a larger prosthesis, aortic homograft, and transcutaneous AV implantation. We present an illustrative case and review the literature on PPM pertinent to anesthesiologists.
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7
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Mohammadi S, Kalavrouziotis D, Voisine P, Dumont E, Doyle D, Perron J, Dagenais F. Bioprosthetic Valve Durability After Stentless Aortic Valve Replacement: The Effect of Implantation Technique. Ann Thorac Surg 2014; 97:2011-8. [DOI: 10.1016/j.athoracsur.2014.02.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2013] [Revised: 02/03/2014] [Accepted: 02/17/2014] [Indexed: 10/25/2022]
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8
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Long-Term Clinical Outcomes 15 Years After Aortic Valve Replacement With the Freestyle Stentless Aortic Bioprosthesis. Ann Thorac Surg 2014; 97:544-51. [DOI: 10.1016/j.athoracsur.2013.08.047] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 08/19/2013] [Accepted: 08/22/2013] [Indexed: 11/19/2022]
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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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10
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Mohammadi S, Tchana-Sato V, Kalavrouziotis D, Voisine P, Doyle D, Baillot R, Sponga S, Metras J, Perron J, Dagenais F. Long-Term Clinical and Echocardiographic Follow-Up of the Freestyle Stentless Aortic Bioprosthesis. Circulation 2012; 126:S198-204. [DOI: 10.1161/circulationaha.111.084806] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
Stentless aortic bioprostheses were designed to provide enhanced hemodynamic performance and potentially greater longevity. The present report describes the outcomes of patients with the Freestyle stentless bioprosthesis followed for ≤18 years.
Methods and Results—
Between 1993 and 2011, 430 patients underwent primary aortic valve replacement with a Freestyle bioprosthesis in the subcoronary position. Mean age was 68.2±8.2 years. All of the clinical and echocardiographic data were collected prospectively. Mean overall follow-up was 9.1±4.4 years and was complete in all of the patients. In-hospital mortality was 3.5% (n=15). Overall, 10- and 15-year survival were 60.7% and 35.0%, respectively. Fifty-one patients required reoperation during follow-up, including 27 for structural valve deterioration (SVD). Overall, freedom from reoperation was 91.0% and 75.0% at 10 and 15 years, whereas freedom from reoperation for SVD was 95.9% and 82.3%, respectively. At 10 and 15 years, freedom from reoperation for SVD was 94.0% and 62.6% for patients <60 years of age and 96.3% and 88.4% for patients ≥60 years of age (
P
=0.002). The median time to explant for SVD was 10.7 years. SVD presented mostly as acute, severe aortic insufficiency attributed to leaflet tear (77.8%). The independent risk factors for reoperation for SVD were age <60 years (
P
=0.001) and dyslipidemia (
P
=0.02).
Conclusions—
Aortic valve replacement with the Freestyle bioprosthesis in a subcoronary position provides good long-term clinical and echocardiographic outcomes for patients >60 years of age. Severe aortic insufficiency with leaflet tear is the major mode of SVD leading to reoperation in these patients.
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Affiliation(s)
- Siamak Mohammadi
- From the Division of Cardiac Surgery, Quebec Heart and Lung University Institute, Laval University, Quebec City, Quebec, Canada
| | - Vincent Tchana-Sato
- From the Division of Cardiac Surgery, Quebec Heart and Lung University Institute, Laval University, Quebec City, Quebec, Canada
| | - Dimitri Kalavrouziotis
- From the Division of Cardiac Surgery, Quebec Heart and Lung University Institute, Laval University, Quebec City, Quebec, Canada
| | - Pierre Voisine
- From the Division of Cardiac Surgery, Quebec Heart and Lung University Institute, Laval University, Quebec City, Quebec, Canada
| | - Daniel Doyle
- From the Division of Cardiac Surgery, Quebec Heart and Lung University Institute, Laval University, Quebec City, Quebec, Canada
| | - Richard Baillot
- From the Division of Cardiac Surgery, Quebec Heart and Lung University Institute, Laval University, Quebec City, Quebec, Canada
| | - Sandro Sponga
- From the Division of Cardiac Surgery, Quebec Heart and Lung University Institute, Laval University, Quebec City, Quebec, Canada
| | - Jacques Metras
- From the Division of Cardiac Surgery, Quebec Heart and Lung University Institute, Laval University, Quebec City, Quebec, Canada
| | - Jean Perron
- From the Division of Cardiac Surgery, Quebec Heart and Lung University Institute, Laval University, Quebec City, Quebec, Canada
| | - François Dagenais
- From the Division of Cardiac Surgery, Quebec Heart and Lung University Institute, Laval University, Quebec City, Quebec, Canada
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Torii R, Xu XY, El-Hamamsy I, Mohiaddin R, Yacoub MH. Computational biomechanics of the aortic root. ACTA ACUST UNITED AC 2011. [DOI: 10.5339/ahcsps.2011.16] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Ryo Torii
- 1Qatar Cardiovascular Research Center, Doha,
Qatar
- 2Harefield Heart Science Centre, Imperial College London, Harefield,
UK
- 5Department of Chemical Engineering,
Imperial College London, London, UK
| | - Xiao Yun Xu
- 5Department of Chemical Engineering,
Imperial College London, London, UK
| | - Ismail El-Hamamsy
- 4Department of Cardiac Surgery, Montreal
Heart Institute, Montreal, Canada
| | - Raad Mohiaddin
- 3Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital and
Imperial College London, London, UK
| | - Magdi H. Yacoub
- 1Qatar Cardiovascular Research Center, Doha,
Qatar
- 2Harefield Heart Science Centre, Imperial College London, Harefield,
UK
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12
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Funder JA. Current status on stentless aortic bioprosthesis: a clinical and experimental perspective. Eur J Cardiothorac Surg 2011; 41:790-9. [DOI: 10.1093/ejcts/ezr141] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Abstract
Prosthetic heart valve (PHV) dysfunction is a rare, but potentially life-threatening, complication. In clinical practice, PHV dysfunction poses a diagnostic dilemma. Echocardiography and fluoroscopy are the imaging techniques of choice and are routinely used in daily practice. However, these techniques sometimes fail to determine the specific cause of PHV dysfunction, which is crucial to the selection of the appropriate treatment strategy. Multidetector-row CT (MDCT) can be of additional value in diagnosing the specific cause of PHV dysfunction and provides valuable complimentary information for surgical planning in case of reoperation. Cardiac magnetic resonance imaging (CMR) has limited value in the evaluation of biological PHV dysfunction. In this Review, we discuss the use of established imaging modalities for the detection of left-sided mechanical and biological PHV dysfunction and discuss the complementary role of MDCT in this context.
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15
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Which Patients Benefit From Stentless Aortic Valve Replacement? Ann Thorac Surg 2009; 88:2061-8. [DOI: 10.1016/j.athoracsur.2009.06.060] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 06/15/2009] [Accepted: 06/01/2009] [Indexed: 11/19/2022]
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16
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Clavel MA, Webb JG, Pibarot P, Altwegg L, Dumont E, Thompson C, De Larochellière R, Doyle D, Masson JB, Bergeron S, Bertrand OF, Rodés-Cabau J. Comparison of the hemodynamic performance of percutaneous and surgical bioprostheses for the treatment of severe aortic stenosis. J Am Coll Cardiol 2009; 53:1883-91. [PMID: 19442889 DOI: 10.1016/j.jacc.2009.01.060] [Citation(s) in RCA: 298] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Revised: 01/06/2009] [Accepted: 01/25/2009] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This study was undertaken to compare the hemodynamic performance of a percutaneous bioprosthesis to that of surgically implanted (stented and stentless) bioprostheses for the treatment of severe aortic stenosis. METHODS Fifty patients who underwent percutaneous aortic valve implantation (PAVI) with the Cribier-Edwards or Edwards SAPIEN bioprosthetic valve (Edwards Lifesciences, Inc., Irvine, California) were matched 1:1 for sex, aortic annulus diameter, left ventricular ejection fraction, body surface area, and body mass index, with 2 groups of 50 patients who underwent surgical aortic valve replacement (SAVR) with a stented valve (Edwards Perimount Magna [SAVR-ST group]), or a stentless valve (Medtronic Freestyle, Medtronic, Minneapolis, Minnesota [SAVR-SL group]). Doppler echocardiographic data were prospectively obtained before the intervention, at discharge, and at 6- to 12-month follow-up. RESULTS Mean transprosthetic gradient at discharge was lower (p < 0.001) in the PAVI group (10 +/- 4 mm Hg) compared with the SAVR-ST (13 +/- 5 mm Hg) and SAVR-SL (14 +/- 6 mm Hg) groups. Aortic regurgitation (AR) occurred more frequently in the PAVI group (mild: 42%, moderate: 8%) compared with the SAVR-ST (mild: 10%, moderate: 0%) and SAVR-SL (mild: 12%, moderate: 0%) groups (p < 0.0001). At follow-up, the mean gradient in the PAVI group remained lower (p < 0.001) than that of the SAVR-ST group, but was similar to that of the SAVR-SL group. The incidence of severe prosthesis-patient mismatch was significantly lower (p = 0.007) in the PAVI group (6%) compared with the SAVR-ST (28%) and SAVR-SL (20%) groups. However, the incidence of AR remained higher (p < 0.0001) in the PAVI group compared with the 2 other groups. CONCLUSIONS PAVI provided superior hemodynamic performance compared with the surgical bioprostheses in terms of transprosthetic gradient and prevention of severe prosthesis-patient mismatch, but was associated with a higher incidence of AR.
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Affiliation(s)
- Marie-Annick Clavel
- Quebec Heart & Lung Institute/Laval Hospital, Laval University, Québec City, Québec, Canada
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Payne DM, Pavan Koka H, Karanicolas PJ, Chu MW, Dave Nagpal A, Briel M, Schünemann HJ, Lonn EM. Hemodynamic Performance of Stentless Versus Stented Valves: A Systematic Review and Meta-Analysis. J Card Surg 2008; 23:556-64. [DOI: 10.1111/j.1540-8191.2008.00705.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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18
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Lopez S, Mathieu P, Pibarot P, Mohammadi S, Dagenais F, Voisine P, Dumesnil J, Doyle D. Does the Use of Stentless Aortic Valves in a Subcoronary Position Prevent Patient-Prosthesis Mismatch for Small Aortic Annulus? J Card Surg 2008; 23:331-5. [DOI: 10.1111/j.1540-8191.2008.00631.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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19
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Delayed Improvement in Valve Hemodynamic Performance After Percutaneous Pulmonary Valve Implantation. Ann Thorac Surg 2008; 85:1787-8. [DOI: 10.1016/j.athoracsur.2007.11.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2007] [Revised: 10/10/2007] [Accepted: 11/05/2007] [Indexed: 11/17/2022]
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20
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Albert A, Florath I, Rosendahl U, Hassanein W, Hodenberg EV, Bauer S, Ennker I, Ennker J. Effect of surgeon on transprosthetic gradients after aortic valve replacement with Freestyle stentless bioprosthesis and its consequences: a follow-up study in 587 patients. J Cardiothorac Surg 2007; 2:40. [PMID: 17919325 PMCID: PMC2146998 DOI: 10.1186/1749-8090-2-40] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2007] [Accepted: 10/05/2007] [Indexed: 11/10/2022] Open
Abstract
Background The implantation of stentless valves is technically demanding and the outcome may depend on the performance of surgeons. We studied systematically the role of surgeons and other possible determinants for mid-term survival, postoperative gradients and Quality of Life (QoL) after aortic valve replacement (AVR) with Freestyle® stentless bioprostheses. Methods Between 1996 and 2003, 587 patients (mean 75 years) underwent AVR with stentless Medtronic Freestyle® bioprostheses. Follow-up was 99% complete. Determinants of morbidity, mortality, survival time and QoL were evaluated by multiple, time-related, regression analysis. Risk models were built for all sections of the Nottingham Health Profile (NHP): energy, pain, emotional reaction, sleep, social isolation and physical mobility Results Actuarial freedom from aortic valve re-operation, structural valve deterioration, non-structural valve dysfunction, prosthetic valve endocarditis and thromboembolic events at 6 years were 95.9 ± 2.1%, 100%, 98.7 ± 0.5%, 97.0 ± 1.5%, 79.6 ± 4.3%, respectively. The actuarial freedom from bleeding events at 6 years was 93.1 ± 1.9%. Estimated survival at 6 years was similar to the age-matched German population (61.4 ± 3.8 %). Predictors of survival time were: diabetes mellitus, atrial fibrillation, peripheral vascular disease, renal dysfunction, female gender > 80 years and patients < 165 cm with BMI < 24. Predictive models showed characteristic profiles and good discriminative powers (c-indexes > 0.7) for each of the 6 QoL sections. Early transvalvular gradients were identified as independent risk factors for impaired physical mobility (c-index 0.77, p < 0.002). A saturated propensity score identified besides patient related factors (e.g. preoperative gradients, ejection fraction, haematological factors) indexed geometric orifice area, subcoronary implantation technique and individual surgeons as predictors of high gradients. Conclusion In addition to the valve size (in relation to body size), subcoronary technique (versus total root) and various patient-related factors the risk of elevated gradients after stentless valve implantation depends, considerably on the individual surgeon. Although there was no effect on survival time and most aspects of QoL, higher postoperative transvalvular gradients affect physical mobility after AVR.
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Affiliation(s)
- Alexander Albert
- Department of cardiac surgery, Heart Institute Lahr/Baden, Hohbergweg 2, 77933 Lahr/Germany.
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Affiliation(s)
- Xu Yu Jin
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford Heart Centre, Headington, Oxford, OX3 9DU United Kingdom.
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Nakamura K, Asai T, Murakami M, Saitoh Y, Yamaguchi H. Early results of Bentall-type operations during the last 10 years: comparison of mechanical valves and stentless bioprostheses. Gen Thorac Cardiovasc Surg 2007; 55:6-11. [PMID: 17444165 DOI: 10.1007/s11748-006-0061-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
UNLABELLED OBJECTIVE. Various types of prostheses have been used for combined diseases of the aortic root and ascending aorta. METHODS All Bentall-type operations (n=64) between 1996 and 2005 were retrospectively studied, comparing different types of prosthesis in the aortic position. The patients were 29-87 years old (mean 59.5 +/- 14.0 years) and included 47 men and 17 women. Mechanical valves, stentless bioprostheses (Freestyle), stented bioprostheses, and a homograft were used in 31, 29, 3, and I patients, respectively. Early results, especially hemodynamics, were analyzed among two groups: mechanical valve group (M-group) and Freestyle group (F-group). RESULTS The average age was significantly higher in the F-group (62.8 +/- 12.7 years) than in the M-group (54.9 +/- 14.0 years) (P = 0.025). The implanted valve was significantly larger in the F-group (26.0 +/- 2.3 mm) than in the M-group (23.5 +/- 2.1mm) (P = 0.000). The estimated effective orifice area of the prosthesis was significantly larger in the F-group (2.23 +/- 0.38 cm2) than in the M-group (1.84 +/- 0.49 cm2) (P = 0.001). The pressure gradient across the prosthesis was significantly lower in the F-group (18.6 +/- 5.5 mmHg) than in the M-group (25.4 +/- 7.6 mmHg) (P = 0.001). CONCLUSION The Bentall-type procedure using the Freestyle valve has an advantage regarding hemodynamics compared to the procedure employing mechanical prostheses.
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Affiliation(s)
- Koki Nakamura
- Department of Cardiovascular Surgery, Shin-Tokyo Hospital, Nemoto 473-1, Matsudo, Chiba 271-0077, Japan.
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Bridges CR, O'Brien SM, Cleveland JC, Savage EB, Gammie JS, Edwards FH, Peterson ED, Grover FL. Association between indices of prosthesis internal orifice size and operative mortality after isolated aortic valve replacement. J Thorac Cardiovasc Surg 2007; 133:1012-21. [PMID: 17382644 DOI: 10.1016/j.jtcvs.2006.11.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2005] [Revised: 11/01/2006] [Accepted: 11/16/2006] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The appropriate index of prosthesis internal orifice size and its effect on operative mortality after aortic valve replacement are controversial. We examined the association between several relevant indices and patient size on operative mortality. Indices examined included projected in vivo effective orifice area and geometric orifice area, with patient size defined as body surface area. METHODS A review of the Society of Thoracic Surgeons National Cardiac Database (2000-2004) yielded 48,722 patients who had isolated aortic valve replacement. This analysis is based on the cohort of 42,310 patients with the 8 most prevalent valve types with manufacturer's labeled sizes 19 mm through 29 mm. Multivariable logistic regression models were employed to determine the effects of body surface area, effective orifice area, geometric orifice area, and selected derived indices (eg, effective orifice area/body surface area) on risk-adjusted operative mortality. RESULTS In separate multivariable models, effective orifice area and geometric orifice area were both inversely correlated with operative mortality. However, an unanticipated finding was that with either effective orifice area or geometric orifice area held constant, body surface area was significantly and inversely correlated with operative mortality. When patients were stratified by effective orifice area, geometric orifice area, or manufacturer's labeled valve size and type, elevations in body surface area were associated with a decrease rather than an increase in operative mortality. CONCLUSIONS Prostheses with small geometric orifice area or small effective orifice area are associated with increased operative mortality after isolated aortic valve replacement. Even for valves with small effective orifice area, however, mortality decreases as body surface area increases. With respect to operative mortality, therefore, our results do not support using arbitrary cutoff values of effective orifice area/body surface area to determine the valve to utilize in a given patient.
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Affiliation(s)
- Charles R Bridges
- Department of Surgery, the University of Pennsylvania Health System, Philadelphia, Pa, USA.
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de Kerchove L, Glineur D, El Khoury G, Noirhomme P. Stentless valves for aortic valve replacement: where do we stand? Curr Opin Cardiol 2007; 22:96-103. [PMID: 17284987 DOI: 10.1097/hco.0b013e328014670a] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Following more than a decade's experience with stentless valves and the development of better profiled stented valves, the article discusses the advantages of stentless valves regarding hemodynamic performance, left ventricular mass regression, durability and survival. RECENT FINDINGS Recent studies show that stentless valves remain hemodynamically superior compared with modern porcine stented valves. This superiority is, however, rarely reported in comparison with modern pericardial stented valves. In general, patient-prosthesis mismatch is less frequent in stentless vs. stented valves. Recent randomized trials comparing stentless valves and modern stented valves show equivalent left ventricular mass regression at 1 year. At 10 years, stentless valve durability is excellent and comparable with that of stented valves. Recent comparative studies do not confirm the previously reported midterm survival advantages of stentless valves. SUMMARY Improvement of stented valves has significantly reduced the hemodynamic differences between them and their stentless counterpart. Patients with small aortic annulus, however, should benefit from a stentless valve due to the better expected gradients and lower risk of patient-prosthesis mismatch. Midterm results suggest equivalent durability and survival for both prosthesis types but additional and longer-term trials are necessary to confirm these results.
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Affiliation(s)
- Laurent de Kerchove
- Department of Cardiology, Cardiothoracic and Vascular Surgery, Université Catholique de Louvain, Brussels, Belgium
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Mohammadi S, Baillot R, Voisine P, Mathieu P, Dagenais F. Structural deterioration of the Freestyle aortic valve: Mode of presentation and mechanisms. J Thorac Cardiovasc Surg 2006; 132:401-6. [PMID: 16872969 DOI: 10.1016/j.jtcvs.2006.03.056] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2005] [Revised: 03/17/2006] [Accepted: 03/23/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND Structural valve deterioration is the major cause of bioprosthetic valve failure. Because of the unique design features and anti-calcification treatment of the Freestyle (Medtronic Inc, Minneapolis, Minn) stentless bioprosthesis, development of structural valve deterioration may differ in comparison with other bioprosthetic valves. This study evaluates the mechanisms and clinical presentation of structural valve deterioration in the Freestyle stentless bioprosthesis. METHODS Between January 1993 and August 2005, 608 patients underwent aortic valve replacement with a Freestyle stentless bioprosthesis. The implantation technique was subcoronary in 475 patients and a root replacement in 133 patients. Mean overall follow-up was 5.6 +/- 3.4 years. Follow-up was complete in all patients. Clinical and echocardiographic follow-ups were conducted prospectively. RESULTS Freedom from structural valve deterioration was 95.8% at 10 years. Twelve patients showed evidence of structural valve deterioration and underwent reoperation for aortic regurgitation (n = 10) or aortic stenosis (n = 2). The mean age of patients with structural valve deterioration was significantly lower than patients without structural valve deterioration (62.6 +/- 8.2 years vs 68.6 +/- 8.3 years, P = .02). The median time between implantation and explantation was 8.7 years (range: 1.9-13.3 years). Eleven structural valve deteriorations occurred after subcoronary implantation, and 1 structural valve deterioration occurred after root implantation (P = .4). The mechanisms of structural valve deterioration were leaflet tears in 10 patients (6 in the left coronary cusp and 4 in the right coronary cusp), severe valve calcification in 1 patient, and cusp fibrosis in 1 patient. The interval between onset of symptoms and reoperation was acute or subacute in 10 patients. CONCLUSION At 10 years, the Freestyle stentless bioprosthesis shows excellent freedom from structural valve deterioration. Structural valve deterioration in the Freestyle stentless bioprosthesis relates to leaflet tear with minimal calcification in the majority of cases. Because of the fast onset of symptoms with leaflet tear, patients with a Freestyle stentless bioprosthesis should be informed of the preferential mode of failure and time-frame of symptoms.
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Affiliation(s)
- Siamak Mohammadi
- Department of Cardiac Surgery, Laval Hospital, Québec City, Québec, Canada
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Badano LP, Zamorano JL, Pavoni D, Tosoratti E, Baldassi M, Zakja E, Gianfagna P, Fioretti PM, Livi U. Clinical and hemodynamic implications of supra-annular implant of biological aortic valves. J Cardiovasc Med (Hagerstown) 2006; 7:524-32. [PMID: 16801814 DOI: 10.2459/01.jcm.0000234771.96324.28] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The use of stented bioprostheses in elderly patients with degenerative aortic stenosis, despite being desirable, raises concerns about the harmful effects of residual obstruction to left ventricular outflow. To overcome this limitation new stented and stentless bioprostheses have been designed for supra-annular implant. However, the actual hemodynamic advantage of supra-annular implant over the intra-annular one remains incompletely understood. This review focuses on the geometry of biological valve prostheses designed for supra-annular implant and its implications for the echocardiographic assessment of valve hemodynamics. Available data about the hemodynamic performance of these valves implanted in the supra-annular position in comparison with the usual intra-annular implant are also reviewed. Other issues related to biological heart valve performance, such as biomaterials, tissue mechanics, durability, and clinical outcome are not addressed in this review.
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Affiliation(s)
- Luigi P Badano
- Department of Cardiopulmonary Sciences, A.O. S Maria della Misericordia, Udine, Italy.
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Dumesnil JG, Pibarot P. Prosthesis–patient mismatch and clinical outcomes: The evidence continues to accumulate. J Thorac Cardiovasc Surg 2006; 131:952-5. [PMID: 16678574 DOI: 10.1016/j.jtcvs.2005.12.032] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Revised: 12/13/2005] [Accepted: 12/16/2005] [Indexed: 11/21/2022]
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Vánky FB, Håkanson E, Tamás E, Svedjeholm R. Risk Factors for Postoperative Heart Failure in Patients Operated on for Aortic Stenosis. Ann Thorac Surg 2006; 81:1297-304. [PMID: 16564261 DOI: 10.1016/j.athoracsur.2005.11.036] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2005] [Revised: 11/10/2005] [Accepted: 11/22/2005] [Indexed: 10/24/2022]
Abstract
BACKGROUND Risk factors for postoperative heart failure (PHF) have not been specifically studied in valve surgery although it has been acknowledged that patient variables may have a more profound influence on postoperative outcome than valve-related factors. METHODS All patients undergoing isolated aortic valve replacement for aortic stenosis from January 1995 to December 2000 in the southeast region of Sweden were studied (n = 398). Forty-five patients with aortic valve replacement required treatment for PHF. Univariate and multivariate logistic regression analysis was carried out to identify risk factors for PHF. RESULTS Thirty-day mortality was 6.7% versus 1.4% for patients with and without PHF, respectively (p = 0.05). With regard to clinical presentation of aortic stenosis, angina was associated with reduced risk, whereas history of congestive heart failure increased the risk for PHF. Five preoperative (hypertension, history of congestive heart failure, severe systolic left ventricular dysfunction, pulmonary hypertension, preoperative hemodynamic instability) and two intraoperative (aortic cross-clamp time, intraoperative myocardial infarction) variables were identified as independent risk factors for PHF. Patient-prosthesis mismatch did not influence the risk of PHF significantly. CONCLUSIONS Postoperative heart failure was associated with a marked increase in postoperative mortality and morbidity. Risk factors for PHF were variables indicating preexisting myocardial dysfunction, increased right or left ventricular afterload, and intraoperative myocardial injury. Our results highlight issues concerning cross-clamp time and myocardial protection, particularly for patients with preoperatively compromised myocardial function. Asymptomatic patients with significant aortic stenosis should be considered for surgery before substantial echocardiographic evidence of left ventricular dysfunction or increased pulmonary artery pressure develops.
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Affiliation(s)
- Farkas B Vánky
- Department of Cardiothoracic Surgery, University Hospital, Linköping, Sweden
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Moon MR, Pasque MK, Munfakh NA, Melby SJ, Lawton JS, Moazami N, Codd JE, Crabtree TD, Barner HB, Damiano RJ. Prosthesis-Patient Mismatch After Aortic Valve Replacement: Impact of Age and Body Size on Late Survival. Ann Thorac Surg 2006; 81:481-8; discussion 489. [PMID: 16427836 DOI: 10.1016/j.athoracsur.2005.07.084] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2005] [Revised: 07/25/2005] [Accepted: 07/26/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND The purpose of this study was to identify patient subgroups in which prosthesis-patient mismatch most influenced late survival. METHODS Over a 12-year period, 1,400 consecutive patients underwent bioprosthetic (933 patients) or mechanical (467) aortic valve replacement. Prosthesis-patient mismatch was defined as prosthetic effective orifice area/body surface area less than 0.75 cm2/m2 and was present with 11% mechanical and 51% bioprosthetic valves. RESULTS With bioprosthetic valves, prosthesis-patient mismatch was associated with impaired survival for patients less than 60 years old (10-year: 68% +/- 7% mismatch versus 75% +/- 7% no mismatch, p < 0.02) but not older patients (p = 0.47). Similarly, with mechanical valves, prosthesis-patient mismatch was associated with impaired survival for patients less than 60 years old (10-year: 62% +/- 11% versus 79% +/- 4%, p < 0.005) but not older patients (p = 0.26). For small patients (body surface area less than 1.7 m2), prosthesis-patient mismatch did not impact survival with bioprosthetic (p = 0.32) or mechanical (p = 0.71) valves. For average-size patients (body surface area 1.7 to 2.1 m2), prosthesis-patient mismatch was associated with impaired survival with both bioprosthetic (p < 0.05) and mechanical (p < 0.005) valves. For large patients (body surface area greater than 2.1 m2), prosthesis-patient mismatch was associated with impaired survival with mechanical (p < 0.04) but not bioprosthetic (p = 0.40) valves. CONCLUSIONS Prosthesis-patient mismatch had a negative impact on survival for young patients, but its impact on older patients was minimal. In addition, although prosthesis-patient mismatch was not important in small patients, prosthesis-patient mismatch negatively impacted survival for average-size patients and for large patients with mechanical valves.
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Affiliation(s)
- Marc R Moon
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
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Abstract
Prosthesis-patient mismatch (PPM) is present when the effective orifice area of the inserted prosthetic valve is too small in relation to body size. Its main haemodynamic consequence is to generate higher than expected gradients through normally functioning prosthetic valves. This review updates the present knowledge about the impact of PPM on clinical outcomes. PPM is common (20-70% of aortic valve replacements) and has been shown to be associated with worse haemodynamic function, less regression of left ventricular hypertrophy, more cardiac events, and lower survival. Moreover, as opposed to most other risk factors, PPM can largely be prevented by using a prospective strategy at the time of operation.
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Affiliation(s)
- P Pibarot
- Research Group in Valvular Heart Disease, Laval Hospital Research Centre/Quebec Heart Institute, Laval University, Sainte-Foy, Quebec, Canada.
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Bach DS, Kon ND, Dumesnil JG, Sintek CF, Doty DB. Eight-year results after aortic valve replacement with the freestyle stentless bioprosthesis. J Thorac Cardiovasc Surg 2004; 127:1657-63. [PMID: 15173720 DOI: 10.1016/j.jtcvs.2004.01.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
OBJECTIVES We sought to describe the hemodynamic and clinical outcomes for the Freestyle aortic root bioprosthesis (Medtronic, Inc, Minneapolis, Minn) in a large multicenter cohort prospectively followed for 8 years. METHODS A total of 700 patients (651 [93%] >60 years of age) at 8 centers in North America were followed prospectively after aortic valve replacement with the Freestyle stentless bioprosthesis; the implant technique was subcoronary in 500, total root in 162, and root inclusion in 38. Follow-up was 3395 patient-years (4.9 +/- 2.3 years per patient). Clinical and echocardiographic follow-up was prospectively obtained at yearly intervals. RESULTS For the subcoronary, total root, and root inclusion groups, actuarial freedom from valve-related death was 96.8% (SE 3.0%), 92.3% (SE 7.7%), and 90.9% (SE 11.2%), respectively, and freedom from structural deterioration was 98.6% (SE 2.0%), 100.0% (SE 0.0%), and 100.0% (SE 0.0%), respectively. Hemodynamics remained excellent at 6 years. Freedom from moderate or more aortic regurgitation was 86.0% (SE 5.1%), 98.7% (SE 3.9%), and 97.3% (SE 6.6%), respectively. Gradients were slightly lower (P =.0009), and the effective orifice area (P =.02) and freedom from aortic regurgitation were slightly higher (P =.03) with total root than subcoronary implantation. CONCLUSIONS The Freestyle stentless aortic root bioprosthesis is a versatile option for aortic valve replacement. Measures of clinical outcomes and prosthesis durability remain excellent in multicenter follow-up through 8 years in a population predominantly older than 60 years at the time of the operation.
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Affiliation(s)
- David S Bach
- Department of Medicine, Division of Cardiology, University of Michigan, Ann Arbor, 48109, USA.
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Soylu MO, Demir AD, Ozdemir O, Uzun Y, Kunt A, Korkmaz S, Taşdemir O. Comparison of changes in diastolic functions after aortic valve replacement with freestyle stentless porcine xenografts in patients with restrictive and nonrestrictive physiology. Angiology 2003; 54:655-9. [PMID: 14666953 DOI: 10.1177/000331970305400604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In this study, the effect of valve replacement on diastolic parameters was evaluated preoperatively and postoperatively at 3, 6, and 12 months by comparing diastolic parameters in patients after aortic valve replacement with freestyle stentless porcine xenografts for aortic stenosis. Depending on deceleration time (DT) and isovolumetric relaxation time (IVRT) with preoperative echocardiographic assessment, patients were divided into two groups: restrictive physiology (DT < or = 150 msec and IVRT < 100 msec, 20 patients), and nonrestrictive physiology (DT > 150 msec and IVRT > or = 100 msec, 27 patients). Although left ventricular mass index significantly decreased in both groups, improvement in DT, IVRT, and ejection fraction occurred only in patients with restrictive physiology. As a result, the patients with restrictive diastolic characteristics had more benefit than the patients with nonrestrictive physiology after aortic valve replacement.
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Pibarot P, Dumesnil JG. Is the hemodynamic performance of the carpentier-edwards perimount valve really equivalent to that of stentless valves? Ann Thorac Surg 2003; 76:656-7; author reply 657-8. [PMID: 12902139 DOI: 10.1016/s0003-4975(03)00269-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Gillinov AM, Blackstone EH, Rodriguez LL. Prosthesis-patient size: measurement and clinical implications. J Thorac Cardiovasc Surg 2003; 126:313-6. [PMID: 12928620 DOI: 10.1016/s0022-5223(02)73223-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
OBJECTIVE Small aortic valve replacement remains a challenging hemodynamic problem. A new bioprosthesis (3F Therapeutics, Lake Forest, Calif) was designed to further improve the hemodynamic performance currently achieved with stentless bioprostheses. This valve consists of a tubular structure assembled from 3 equal sections of equine pericardial material, with virtually no foreign material except for a thin polyester ring. Its hemodynamic performance was compared with that of a commercially available stentless prosthesis in a bovine model. PATIENTS AND METHODS Twelve calves (55 +/- 2.8 kg) received a 19-mm 3F valve (3F group, n = 6) or a 19-mm stentless control valve (control group, n = 6). The animals were fully equipped for hemodynamic monitoring and transvalvular gradient measurements. After implantation, dopamine was infused in increasing doses, and the hemodynamic values were recorded at each step of 100-microg/min increase. Linear regression analysis was applied for group comparison of each variable. RESULTS The mean transvalvular gradient at 4.5 L/min was 3.48 +/- 0.14 mm Hg (95% confidence interval) in the 3F group and 5.72 +/- 0.28 mm Hg in the control group (P <.0001) and at 6.5 L/min, 7.4 +/- 1.55 mm Hg, and 11.13 +/- 0.18 mm Hg, respectively (P <.0001). The effective orifice area at 4.5 L/min was 2.4 +/- 0.03 cm(2) in the 3F group and 1.86 +/- 0.02 cm(2) in the control group (P <.0001) and at 6.5 L/min, 2.41 +/- 0.04 cm(2), and 1.96 +/- 0.02 cm(2), respectively (P <.0001). CONCLUSIONS This new bioprosthesis without a stent and without a supporting wall that has its commissures fixed directly to the aorta outperforms in vivo standard stentless prostheses in the immediate postimplant period.
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Affiliation(s)
- Xavier M Mueller
- Department of Cardio-vascular Surgery, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Quebec, Canada.
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Akar AR, Szafranek A, Alexiou C, Janas R, Jasinski MJ, Swanevelder J, Sosnowski AW. Use of stentless xenografts in the aortic position: determinants of early and late outcome. Ann Thorac Surg 2002; 74:1450-7; discussion 1457-8. [PMID: 12440592 DOI: 10.1016/s0003-4975(02)03845-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Whether to perform a stentless aortic valve replacement (AVR) is not well established. Our aim was to determine the outcome after AVR with stentless xenograft valves. METHODS Between 1996 and 2001, a total of 404 patients (mean age 70.4 years) underwent a stentless AVR by one surgeon in our unit. Concomitant procedures were performed in 132 patients (33%). Twenty patients (6.4%) had undergone previous AVR. Eleven types of stentless xenograft valves were implanted: Medtronic Freestyle in 221 patients (55%), Shelhigh in 55 (14%), Shelhigh composite conduit in 33 (8%), Sorin in 26 (6%), Cryolife O'Brien in 25 (6%), Aortech-Elan in 17 (4%), Edwards Prima in 14 (4%), Toronto SPV in 7 (2%), and other valves in 6 (1%). A subcoronary implantation technique was used in 302 cases (76%), complete root replacement in 62 (15%), and a modified Bentall-De Bono procedure in 33 (8%). Mean follow-up was 19.4 months (range, 1.2 to 60.6 months). RESULTS Overall hospital mortality was 4.2%. This was 2.4% for isolated AVR, 3.6% for AVR and coronary artery bypass grafting, 5.5% for replacement of two or more valves, and 12% for the modified Bentall procedure. On multiple logistic regression redo cardiac operation (p = 0.0006), cardiogenic shock (p = 0.001), left ventricular ejection fraction less than 0.30 (p = 0.01), modified Bentall procedure (p = 0.03), and endocarditis (p = 0.04) were predictors of in-hospital death. Five-year freedom from thromboembolism, hemorrhage, prosthetic endocarditis, structural valve deterioration, and reoperation was 97%, 99%, 99%, 98%, and 96%, respectively. Kaplan-Meier survival at 5 years was 88%. On Cox regression, cardiogenic shock (p = 0.001) and older age (p = 0.03) were adverse predictors of survival. At echocardiographic examination within 6 months from the operation, mean aortic valve gradients were 15 +/- 6 mm Hg, 12.8 +/- 3 mm Hg, 10.8 +/- 4 mm Hg, 9.3 +/- 3 mm Hg, 9.1 +/- 4 mm Hg, and 8.2 +/- 3 mm Hg for valve sizes of 19, 21, 23, 25, 27, and 29 mm, respectively. CONCLUSIONS The availability of several stentless valve designs facilitates the surgical treatment of diverse aortic valve or root diseases with encouraging early and mid-term results. Patients requiring concomitant procedures may also benefit from the excellent hemodynamic characteristics of a stentless valve. We consider stentless AVR the treatment of choice for patients older than 60 years and those having small aortic roots.
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Affiliation(s)
- A Ruchan Akar
- Department of Cardiothoracic Surgery, University Hospitals of Leicester, Glenfield Hospital, United Kingdom
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Lau WC, Carroll JR, Deeb GM, Tait AR, Bach DS. Intraoperative transesophageal echocardiographic assessment of the effect of protamine on paraprosthetic aortic insufficiency immediately after stentless tissue aortic valve replacement. J Am Soc Echocardiogr 2002; 15:1175-80. [PMID: 12411902 DOI: 10.1067/mje.2002.123965] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Mild paravalvular aortic insufficiency (AI) is common immediately after stentless bioprosthetic aortic valve replacement. Although resolution of paraprosthetic jets with protamine has been described, the predictability of resolution has not been addressed. Intraoperative transesophageal echocardiography was performed before and after protamine administration among 2 groups. The first group (n = 20) was used to define the prevalence and severity of paravalvular AI after stentless tissue AVR, and define a threshold value for jet size associated with resolution with protamine. A second group (n = 18) was used to prospectively test the determined threshold. Paravalvular AI occurred in 13 of 20 (65%) patients. Using a threshold value of 0.3 cm or less jet width, prospective testing revealed positive and negative predictive values for AI resolution with protamine of 93% (14 of 15) and 100% (3 of 3), respectively. Protamine administration is associated with resolution of small AI jets immediately after implantation of a stentless aortic bioprosthesis, with a jet width 0.3 cm or less strongly predictive of resolution.
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Affiliation(s)
- Wei C Lau
- Department of Anesthesiology, University of Michigan, Ann Arbor 48109, USA.
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Eichinger WB, Botzenhardt F, Gunzinger R, Kemkes BM, Sosnowski A, Maïza D, Coto EO, Bleese N. European experience with the Mosaic bioprosthesis. J Thorac Cardiovasc Surg 2002; 124:333-9. [PMID: 12167794 DOI: 10.1067/mtc.2002.122552] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to prospectively evaluate the clinical and hemodynamic performance of the Mosaic bioprosthesis (Medtronic, Inc, Minneapolis, Minn). METHODS The stented porcine bioprosthesis combines the amino-oleic acid antimineralization treatment and the zero-pressure differential fixation technique for improved tissue durability. From February 1994 to May 1999, a total of 561 patients underwent valve replacement with the Mosaic bioprosthesis at 5 centers in Europe: 461 in the aortic and 100 in the mitral position. There were 261 women and 300 men; mean age at implantation was 70 years (range, 23-89 years). Mean follow-up was 2.9 years (range, 0-6.2 years), with a total follow-up of 1710.1 patient-years. RESULTS Postoperative mortality was 4.2% per patient-year, including a valve-related mortality of 0.4% per patient-year. The freedom from event rates in the aortic position at 5 years and in the mitral position at 4 years were, respectively, 96.6% +/- 1.1% and 94.9% +/- 3.3% for primary thromboembolism, 96.4% +/- 5.0% and 87.1% +/- 4.8% for antithromboembolic-related hemorrhage, 99.1% +/- 0.5% and 100% for thrombosed prosthesis, 98.8% +/- 1.2% and 100% for structural valve deterioration, 98.8% +/- 0.7% and 100% for nonstructural dysfunction, 98.4% +/- 0.6% and 94.4% +/- 3.8% for endocarditis, and 95.4% +/- 1.6% and 95.3% +/- 3.7% for explant and reoperation. Mean pressure gradient values at 5 years ranged from 7.5 to 15.9 mm Hg in the aortic position and at 4 years from 2.0 to 6.9 mm Hg in the mitral position across all valve sizes. CONCLUSIONS Clinical and hemodynamic performance of the Mosaic bioprosthesis were very satisfactory during the first 6 years after clinical introduction.
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Affiliation(s)
- Walter Benno Eichinger
- Department of Cardiovascular Surgery, Deutsches Herzzentrum Munich, Lazarettstrasse 36, D-80636 Munich, Germany.
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Mecozzi G, Milano AD, De Carlo M, Sorrentino F, Pratali S, Nardi C, Bortolotti U. Intravascular hemolysis in patients with new-generation prosthetic heart valves: a prospective study. J Thorac Cardiovasc Surg 2002; 123:550-6. [PMID: 11882830 DOI: 10.1067/mtc.2002.120337] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE A prospective clinical study was designed to assess the frequency and severity of intravascular hemolysis in patients with new-generation, normally functioning prosthetic heart valves. METHODS Hemolysis was evaluated in 172 patients with a mechanical prosthesis (53 CarboMedics and 119 Sorin Bicarbon) and in 106 patients with a bioprosthesis (15 St Jude Medical Toronto, 19 Baxter Perimount, and 72 Medtronic Mosaic) in the aortic position, mitral position, or both. Aortic valve replacement was performed in 206 patients, mitral valve replacement in 59 patients, and double valve replacement in 13 patients. The presence of hemolysis was assessed on the basis of the level of serum lactic dehydrogenase and serum haptoglobin and the presence and amount of reticulocytes and schistocytes in the peripheral blood. Severity of intravascular hemolysis was estimated on the basis of serum lactic dehydrogenase. Clinical, echocardiographic, and hematologic evaluations were performed 1, 6, and 12 months after discharge. RESULTS None of the 278 patients experienced decompensated anemia, whereas at 12 months, mild subclinical hemolysis was identified in 49 patients, 44 (26%) with a mechanical prosthesis and 5 (5%) with a bioprosthesis (P <.001). At multivariate analysis, independent predictors of the presence of subclinical hemolysis were mitral valve replacement (P <.001), use of a mechanical prosthesis (P =.002), and double valve replacement (P =.02). Frequency of hemolysis in patients with stented aortic bioprostheses was 3%, whereas it was absent in those with stentless valves. Among mechanical valve recipients, double versus single valve replacement (P =.04) and mitral versus aortic valve replacement (P =.05) were correlated with the presence of hemolysis; double valve recipients also showed a more severe degree of hemolysis (P =.03). In patients with a Sorin Bicarbon prosthesis, hemolysis was less frequent (22% vs 34%, P =.09) and severe (P <.001) than in those with a CarboMedics prosthesis. CONCLUSIONS In normally functioning prosthetic heart valves, subclinical hemolysis is a frequent finding. A low incidence of hemolysis is found in stented biologic prostheses, and it is absent in stentless aortic valves. Modifications of valve design may contribute to minimize the occurrence of hemolysis in mechanical prostheses.
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Affiliation(s)
- Gianclaudio Mecozzi
- Division of Cardiac Surgery, Cardio-Thoracic Department, University of Pisa Medical School, 56124 Pisa, Italy
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Carrier M, Pellerin M, Perrault LP, Hébert Y, Pagé P, Cartier R, Dyrda I, Pelletier LC. Experience with the 19-mm Carpentier-Edwards pericardial bioprosthesis in the elderly. Ann Thorac Surg 2001; 71:S249-52. [PMID: 11388197 DOI: 10.1016/s0003-4975(01)02508-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Valve replacement in small aortic root remains a surgical challenge. The objective of this study was to compare results of the 19-mm bioprosthesis with those of larger prostheses in the elderly. METHODS The 443 patients, 70 years of age and older, who underwent aortic valve replacement with Carpentier-Edwards pericardial bioprostheses were reviewed. RESULTS There were 93 patients with a mean age of 76+/-4 years with implantation of 19-mm prostheses and 350 patients with a mean age of 75+/-4 years with larger bioprostheses. Associated aortoplasty was performed in 10 patients (11%) with 19-mm bioprostheses and in 8 patients (2%) with larger bioprostheses (p = 0.001). There were 11 deaths (12%) within 30 days of surgery in patients with 19-mm prostheses and 22 deaths (6%) among those with larger prostheses (p = 0.1). The 7-year survival rate averaged 61%+/-7% in patients with 19-mm prostheses and 67%+/-4% in those with larger prostheses (p = 0.8). The 7-year freedom rates from all valve-related events averaged 96%+/-2% and 93%+/-2%, respectively (p = 0.6). CONCLUSIONS Aortic valve replacement with the 19-mm Carpentier-Edwards pericardial bioprosthesis offers excellent midterm results in the elderly.
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Affiliation(s)
- M Carrier
- Department of Surgery and Medicine, Montreal Heart Institute, and the University of Montreal, Quebec, Canada.
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Jamieson WR, Janusz MT, MacNab J, Henderson C. Hemodynamic comparison of second- and third-generation stented bioprostheses in aortic valve replacement. Ann Thorac Surg 2001; 71:S282-4. [PMID: 11388205 DOI: 10.1016/s0003-4975(01)02540-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The hemodynamic performance of aortic replacement prostheses is of extreme importance. There is renewed interest in hemodynamics because of the influence of prosthesis-patient mismatch on left ventricular mass regression and the potential influence on survival. METHODS The hemodynamic performance of the second-generation Carpentier-Edwards supraannular porcine and pericardial (Perimount) bioprostheses and the third-generation Medtronic Mosaic porcine bioprosthesis were compared for mean gradient and effective orifice area index. The effective orifice area index of at least 0.85 cm2/M2 was considered as lack of prosthesis-patient mismatch. The study group included included 53 patients with Carpentier-Edwards supraannular porcine, 48 with pericardial, and 98 with Medtronic Mosaic porcine bioprostheses. RESULTS The mean gradients were not different between the prostheses by prosthesis size. The Medtronic Mosaic was not provided in size 19. The mean gradients for the prostheses, except in the very large sizes, were all double-digit values. The effective orifice area index was not different between the prostheses but there was a trend toward prosthesis-patient mismatch in smaller size prostheses. CONCLUSIONS There was no apparent hemodynamic advantage between porcine and pericardial bioprostheses in the aortic position.
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Affiliation(s)
- W R Jamieson
- Department of Surgery, University of British Columbia, Vancouver, Canada.
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Kappetein AP, Braun J, Baur LH, Prat A, Peels K, Hazekamp MG, Schoof PH, Huysmans HA. Outcome and follow-up of aortic valve replacement with the freestyle stentless bioprosthesis. Ann Thorac Surg 2001; 71:601-7; discussion 607-8. [PMID: 11235714 DOI: 10.1016/s0003-4975(00)02519-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The aim of this study was to determine the morbidity, mortality, and hemodynamics after implantation of the Freestyle stentless bioprosthesis in the aortic position. METHODS A total of 280 patients were operated on from June 1993 to July 1999 as part of a multicenter investigation. Factors influencing hospital mortality and long-term survival were assessed by logistic regression and Cox proportional hazards analysis. Patients were evaluated postoperatively at discharge, at 3 to 6 months, and yearly by clinical examination and color flow Doppler echocardiography. RESULTS Hospital mortality in this group was relatively high (9.6%). Logistic regression analysis showed that cross-clamp time, age, myocardial infarction, diabetes, left ventricular hypertrophy, coronary artery disease, New York Heart Association class III or IV and female gender were the independent predictive factors. According to the Kaplan-Meier method, the 4-year survival for hospital survivors was 94%. In the multivariate Cox proportional hazard analysis, only coronary artery disease proved to be prognostic. During follow-up, 11 patients developed paravalvular leakage due to prosthetic dehiscence at the side of the noncoronary cusp. Performance of the prosthesis as assessed by echocardiography was excellent. Mean gradient decreased significantly between discharge and follow-up at 3 to 6 months. At 1-year follow-up trivial regurgitation was found in 6 patients (3%) and mild regurgitation in 4 (2%). Regurgitation did not increase with time. The effective orifice area increased significantly from discharge to follow-up at 3 to 6 months. CONCLUSIONS Hospital mortality after implantation of a stentless bioprosthesis was higher compared to conventional prosthesis. A high incidence of prosthesis dehiscence at the proximal suture line was found, which was probably due to technique. Hemodynamic performance up to 3 years showed low transvalvular gradients. There is echocardiographic evidence for reduction of left ventricular hypertrophy and improvement of left ventricular function.
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Affiliation(s)
- A P Kappetein
- Department of Thoracic Surgery, Leiden University Medical Center, The Netherlands.
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Abstract
Stentless tissue aortic valves are gaining in popularity because of advantages in hemodynamics and durability compared with stented bioprostheses. The absence of a rigid sewing ring and struts makes these valves pliable, and distortion at implantation can result in valve dysfunction. Because the anatomy and implantation techniques of stentless tissue valves are unlike those of mechanical and stented tissue valves, their echocardiographic appearance is unique on both intraoperative and subsequent transthoracic and transesophageal echocardiography. This report describes the echocardiographic appearance of normally functioning stentless tissue heterograft aortic valves as an aid to their intraoperative and subsequent echocardiographic assessment.
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Affiliation(s)
- D S Bach
- Department of Internal Medicine, Division of Cardiology, University of Michigan, Ann Arbor, 48109, USA.
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Pibarot P, Dumesnil JG. Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention. J Am Coll Cardiol 2000; 36:1131-41. [PMID: 11028462 DOI: 10.1016/s0735-1097(00)00859-7] [Citation(s) in RCA: 415] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Prosthesis-patient mismatch is present when the effective orifice area of the inserted prosthetic valve is less than that of a normal human valve. This is a frequent problem in patients undergoing aortic valve replacement, and its main hemodynamic consequence is the generation of high transvalvular gradients through normally functioning prosthetic valves. The purposes of this report are to present an update on the concept of aortic prosthesis-patient mismatch and to review the present knowledge with regard to its impact on hemodynamic status, functional capacity, morbidity and mortality. Also, we propose a simple approach for the prevention and clinical management of this phenomenon because it can be largely avoided if certain simple factors are taken into consideration before the operation.
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Affiliation(s)
- P Pibarot
- Quebec Heart Institute/Laval Hospital, Laval University, Sainte-Foy, Canada
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Riley RD, Hammon JW, Adair SM, Cordell AR, Kon ND. Stentless aortic valve replacement with Freestyle or Toronto SPV: an early comparison. Ann Thorac Surg 2000; 70:48-51; discussion 51-2. [PMID: 10921681 DOI: 10.1016/s0003-4975(00)01559-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Stentless aortic xenograft valves have been developed to overcome the disadvantages of conventional stented prostheses. We have implanted two new aortic bioprostheses: the Medtronic Freestyle and the St. Jude Toronto SPV. Early results are compared. METHODS Forty-four Freestyle valves were implanted using a freestanding total root technique. Fourteen subcoronary Toronto SPV bioprostheses were implanted. Sixty-four percent of both groups (28 of 44 Freestyle and 9 of 14 Toronto SPV) underwent concurrent procedures. RESULTS Ischemic time was 117 +/- 21 minutes for Freestyle and 124 +/- 19 minutes for Toronto SPV. There were no operative deaths or valve-related reoperations. Aortic valve area was 1.83 +/- 0.51 cm2 for Freestyle and 1.80 +/- 0.51 cm2 (p = 0.89) for Toronto SPV. Transvalvular gradient was 8.03 +/- 4.09 mm Hg for Freestyle and 12.4 +/- 1.82 mm Hg (p = 0.002) for the Toronto SPV. Aortic regurgitation was not experienced in any Freestyle patients, while Toronto SPV patients were graded as none to trace 79% (11 of 14), mild 14% (2 of 14), and moderate 7% (1 of 14). CONCLUSIONS Aortic valve replacement with the Freestyle and Toronto SPV required equal time for implantation and had equal effective orifice areas. Freestyle had lower transvalvular gradient and less aortic insufficiency without increasing morbidity or mortality.
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Affiliation(s)
- R D Riley
- Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA
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Kalangos A, Trigo-Trindade P, Vala D, Panos A, Faidutti B. Aortic valve replacement with the freestyle stentless bioprosthesis with respect to spacial orientation of patient coronary ostia. J Thorac Cardiovasc Surg 2000; 119:1185-93. [PMID: 10838537 DOI: 10.1067/mtc.2000.105642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study evaluates our results for safety and efficacy of aortic valve replacement using the Freestyle bioprosthesis (Medtronic, Inc, Minneapolis, Minn) with a new modified subcoronary implantation technique. This technique takes into account the spacial orientation of the stentless bioprosthesis in the aortic root with respect to the patient's coronary ostia rather than the native commissures. METHODS Fifty-two consecutive patients with predominant aortic valve stenosis underwent aortic valve replacement with a Freestyle bioprosthesis by means of the described modified subcoronary technique over a 15-month period. Fifty of them were followed up by means of echocardiography at discharge, 6 months, and 1 year. There were 19 men and 31 women, with a mean age of 76 +/- 7 years (range, 58-87 years). Valve size ranged from 21 to 27 mm. RESULTS Patients with bicuspid aortic valves had a significantly larger angle between both coronary ostia than patients with tricuspid aortic valves (P =.0001). The peak and mean systolic gradients decreased significantly during the first postoperative year for each valve size (P </=.001), and the effective valve areas increased significantly during this time interval for each valve size (P </=.01). Only 13 patients had aortic insufficiency at discharge, which was trivial in 9 and mild in 4 patients. The prevalence of trivial aortic insufficiency decreased during the first postoperative year, and that of mild aortic insufficiency remained unchanged. The sinotubular junction diameter was significantly greater than that of the aortic anulus for each valve size before operation (P <.001). The sinotubular junction diameter decreased significantly after aortic valve replacement and remained unchanged during the first postoperative year for each valve size (P <.001). CONCLUSIONS Aortic valve replacement with the Freestyle bioprosthesis using the modified subcoronary technique, which takes into account the spacial orientation of the patient's coronary ostia, has hemodynamic results similar to those of other series with different subcoronary implantation techniques. This technique is reproducible, safe at the coronary ostial level, and effective in accommodating variability in angles between human coronary ostia, ranging from 130 degrees to 170 degrees. Moreover, the great preoperative discrepancies between aortic anulus and sinotubular junction diameters are corrected immediately after operation.
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Affiliation(s)
- A Kalangos
- Clinic for Cardiovascular Surgery, Division of Cardiology, University Cantonal Hospital of Geneva, Switzerland.
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Pibarot P, Dumesnil JG, Leblanc MH, Cartier P, Métras J. Changes in left ventricular mass and function after aortic valve replacement: a comparison between stentless and stented bioprosthetic valves. J Am Soc Echocardiogr 1999; 12:981-7. [PMID: 10552360 DOI: 10.1016/s0894-7317(99)70152-5] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The objective of this study was to compare stentless bioprostheses with stented bioprostheses with regard to the postoperative changes in left ventricular (LV) mass and function. Forty patients with aortic stenosis undergoing valve replacement with a stentless (20 patients) or a stented (20 patients) bioprosthesis were evaluated early (baseline), 1 year, and 2 years after operation. Left ventricular mass index was calculated with the corrected American Society of Echocardiography formula. The relative changes between end-diastole and end-systole in LV mid-wall radius, length, and volume (ejection fraction) were determined with a previously validated model for dynamic geometry of the left ventricle. Overall, a significant decrease was found in LV mass index (from 155 +/- 30 to 112 +/- 23 g/m(2); P <.001) and a significant increase in longitudinal shortening (from 0.12 +/- 0.11 to 0.22 +/- 0.08; P <. 001), and ejection fractions (from 0.67 +/- 0.11 to 0.71 +/- 0.10; P =.017). No significant change was found in the mid-wall radius shortening fraction. Two years after surgery, the extent of LV mass regression was greater in stentless bioprostheses (-51 +/- 18 vs -35 +/- 17 g/m(2); P =.01), though the average mass index was similar in both groups (114 +/- 26 vs 110 +/- 20 g/m(2)). Also at 2 years, the longitudinal shortening fraction was greater in patients with a stentless bioprosthesis (0.25 +/- 0.07 vs 0.18 +/- 0.08; P =.03). In conclusion, this study suggests that the superior hemodynamic performance of stentless bioprostheses may have some benefits with regard to LV mass regression and function after aortic valve replacement. The significance of these benefits in terms of prognosis remains to be determined.
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Affiliation(s)
- P Pibarot
- Quebec Heart Institute/Laval Hospital, Department of Medicine, Laval University, Ste-Foy, Quebec, Canada.
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