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Gallegos RP, Gersak B. The Sutureless Biological Bentall Procedure: A New Technique to Create a Modular Valve-Conduit Construct. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:320-325. [PMID: 37458235 DOI: 10.1177/15569845231185797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
The Perceval sutureless valve (Corcym, Saluggia, Italy) has been effectively adopted by surgeons for the treatment of degenerative aortic valve stenosis. Its simplified true sutureless implantation technique has proven useful for minimally invasive cases, but the use of Perceval as part of more complex root replacement has not previously been described. We present a novel technical modification to the manufactured biologic Bentall, called the sutureless biological Bentall. This technique allows for a true modular valve-conduit construction that will simplify future reintervention.
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Affiliation(s)
| | - Borut Gersak
- University of Ljubljana School of Medicine, Slovenia
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Brown JA, Serna-Gallegos D, Kilic A, Dai Y, Chu D, Navid F, Dunn-Lewis C, Sultan I. Midterm Outcomes of Stented Versus Stentless Bioprosthetic Valves After Aortic Root Replacement. Semin Thorac Cardiovasc Surg 2021; 34:1147-1155. [PMID: 34520838 DOI: 10.1053/j.semtcvs.2021.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 09/07/2021] [Indexed: 11/11/2022]
Abstract
To determine the impact of aortic root replacement (ARR) with a stentless bioprosthetic valve on midterm outcomes compared to a stented bioprosthetic valve-graft conduit. This was an observational study of aortic root operations from 2010 to 2018. All patients with a complete ARR for nonendocarditis reasons were included, while patients undergoing valve-sparing root replacements or primary aortic valve replacement or repair were excluded. Of the patients with a complete ARR, bioprosthetic valve implants were included, while mechanical valve implants were excluded. Patients were dichotomized into the stented ARR group and the stentless ARR group. A total of 1:1 nearest neighbor propensity matching was employed to assess the association of stentless valves with short-term and midterm outcomes. A total of 455 patients underwent a complete ARR with a bioprosthetic valve implant for nonendocarditis reasons, of which 212 (46.6%) received a stented valve, while 243 (53.4%) received a stentless valve. After matching, postoperative outcomes were similar across each group (P > 0.05), including operative mortality and adverse neurologic events. Median follow-up for the entire cohort was 4.41 years (95% CI: 4.01, 4.95). At 1 year follow-up, aortic regurgitation ≥ 2+ and ejection fraction were similar across each group (P > 0.05); however, the stentless valve group had lower aortic valve velocity and transvalvular pressure gradient. Finally, reoperations and survival were similar for each group over the study's follow-up (P > 0.05). Stentless valves may provide hemodynamic benefits after ARR; however, the clinical impact of those benefits for survival and reoperation may not yet be evident in the midterm.
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Affiliation(s)
- James A Brown
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Derek Serna-Gallegos
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Arman Kilic
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Yancheng Dai
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Danny Chu
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Forozan Navid
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Courtenay Dunn-Lewis
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ibrahim Sultan
- Division of Cardiac Surgery, Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA; Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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Della Barbera M, Pettenazzo E, Livi U, Mangino D, Gerosa G, Bottio T, Basso C, Valente M, Thiene G. Structural valve deterioration and mode of failure of stentless bioprosthetic valves. Cardiovasc Pathol 2020; 51:107301. [PMID: 33130282 DOI: 10.1016/j.carpath.2020.107301] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/22/2020] [Accepted: 10/22/2020] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Aortic stentless bioprosthetic valve (SLBPV), either porcine or pericardial, minimizes transvalvular gradient and favors regression of left ventricular hypertrophy. The drawback consists of longer time for suturing. While structural valve deterioration (SVD) in stented porcine and pericardial BPVs has been extensively investigated, less information is available on SLBPVs. MATERIAL AND METHODS We studied 82 SLBPVs explants, either porcine (Toronto SPV, [St. Jude Medical, MN, USA], CryolifeO'Brien Model 300 and CryoLife-O'Brien [Cryolife International, GA, USA], BioCor PVS [St. Jude Medical, MN, USA] Prima and Prima Plus [Edwards Lifesciences Corp. One Edwards Way, CA, formerly Baxter Inc, CA, USA]) or pericardial ([Pericarbon Freedom and Freedom Solo [Sorin-Biomedica, S.p.A., Saluggia, Italy]). RESULTS By excluding cases with leak and endocarditis, we focused the investigation on 46 SLBPVs, which failed because of SVD. Gender was male in 29 (63%). Mean age of patients at time of implant was 59.8 years. Postoperative time of SVD was 115.0 months for porcine and 79.0 months for pericardial SLBPVs. Dysfunction requiring reoperation was mainly incompetence for porcine and stenosis for pericardial SLBPVs. Even pinpoint mineralization at the commissures resulted in sudden cusp tearing and incompetence. Cuspal atheromasia accounted for cusp tearing even in the absence of calcification. Mineralization showed progression with time in pericardial but not in porcine SLBPVs. CONCLUSIONS Tissue mineralization remains the nightmare also of SLBPVs, with the peculiar features of pinpoint calcific deposits at commissures, tearing and abrupt incompetence in porcine SLBPVs and of massive cuspal mineralization and stenosis in pericardial SLBPVs.
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Affiliation(s)
- Mila Della Barbera
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy
| | - Elena Pettenazzo
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy
| | - Ugolino Livi
- Department of Cardiopulmonary Sciences, University of Udine, Italy
| | | | - Gino Gerosa
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy
| | - Tomaso Bottio
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy
| | - Cristina Basso
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy
| | - Marialuisa Valente
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy
| | - Gaetano Thiene
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Italy.
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Une D, Karkhanis R, David TE, Machida D, Masuda M, Goldman BS. Long-term clinical outcomes of the Toronto stentless porcine valve: 15-year results from dual centers. J Card Surg 2020; 35:2279-2285. [PMID: 32720369 DOI: 10.1111/jocs.14837] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY The purpose of this study is to examine the long-term durability of the Toronto stentless porcine valve (SPV) in the aortic position (St Jude Medical, Minneapolis, MN). METHODS We assessed the long-term clinical outcomes of 515 patients with aortic valve replacement (AVR) with the Toronto SPV from 1987 to 2001 at two centers, excluding early (<30 days) death. Median follow-up was 11.5 years (maximum 19.0 years). RESULTS Average age was 64.2 ± 10.8 years, and females were 34% (173/515). The incidence of prosthesis-patient mismatch was low, 10.9%. Overall survival was 90.7 ± 1.3%, 75.4 ± 2.0%, and 56.8 ± 3.2% at 5, 10, and 15 years, respectively after surgery. Over the follow-up duration, 116 patients (23%) underwent repeated AVR: 90 for structural valve deterioration (SVD), 12 for endocarditis, 10 nonstructural valve dysfunction (10 aortic regurgitation due to aorta dilatation), and four for other reasons. The cumulative incidence of repeated AVR with death as a competing risk was 1.4% (95% confidence interval [CI], 0.6-2.7), 11.1% (95% CI, 8.4-14.2), and 34.4% (95% CI, 28.8-40.2) at 5, 10, and 15 years, respectively. Reoperative mortality was 5.2% (6/116). In SVD, the regurgitation type was dominant (82%). CONCLUSIONS The Toronto SPV is associated with excellent survival and durability during the first decade of follow-up. However, regurgitation type of SVD increases from 10 years after operation with acceptable reoperative mortality. These findings may assist with prosthesis selection and reintervention strategy for failing stentless bioprosthesis.
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Affiliation(s)
- Dai Une
- Division of Cardiac Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada.,Department of Surgery, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Reena Karkhanis
- Division of Cardiac Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Tirone E David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and University of Toronto, Toronto, Canada
| | - Daisuke Machida
- Department of Surgery, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Munetaka Masuda
- Department of Surgery, Yokohama City University, Yokohama, Kanagawa, Japan
| | - Bernard S Goldman
- Division of Cardiac Surgery, Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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Stefanelli G, Pirro F, Macchione A, Bellisario A, Weltert L. Long-term follow-up after Bentall operation using a stentless Shelhigh NR-2000 bio-conduit. J Card Surg 2020; 35:988-995. [PMID: 32176376 DOI: 10.1111/jocs.14510] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND To analyze the long-term results after Bentall operation using the stentless Shelhigh No-React (NR)-2000 bio-root prosthesis. MATERIAL From 2004 to 2008, 26 consecutive, nonselected patients (mean age at surgery: 67 ± 9 years) underwent a Bentall operation using a stentless Shelhigh valved conduit at our institution. Mean preoperative Logistic-EuroSCORE was 17.1 ± 12.9. The mean size of the aortic root was 53.2 ± 5 mm. The mean preoperative ejection fraction was 55 ± 7.4%. Three patients had a bicuspid valve. One patient with acute endocarditis and one patient with type A aortic dissection were operated on an emergency. Three patients (11.54%) had a previous cardiac operation. The Button-Bentall technique was used in all cases. Seven patients (26.92%) received an associated procedure. The mean size of the implanted prosthesis was 26.1 ± 2.2. Follow-up ranged between 6 and 174 months (mean 93.4 ± 59.1 months). Primary endpoints consisted of early and late mortality, freedom from acute endocarditis, freedom from structural valve deterioration, and freedom from valve-related-reoperation. RESULTS Two patients died in hospital, while 10 patients died during follow-up time, of which three for cardiac causes (12.5%). Overall survival probability was 52.9% at 15 years. Freedom from acute endocarditis was 95.7% at 5 and 15 years. Freedom from severe aortic incompetence due to structural deterioration was 100% at 5 and 10 years, 90.9% at 15 years. The mean aortic gradient at follow-up was 11.4 ± 5 mm Hg. Freedom from valve-related reoperation was 100% at 5 and 10 years, 90.9% at 15 years. CONCLUSIONS In our experience, Bentall's operation using the Shelhigh NR-2000 stentless bio-conduit provided satisfactory early and long-term results. However, our findings are not consistent with unfavorable long-term outcomes following the implantation of this device reported by other authors.
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Affiliation(s)
| | - Fabrizio Pirro
- Department of Cardiac Surgery, Hesperia Hospital, Modena, Italy
| | | | | | - Luca Weltert
- Department of Cardiac Surgery, European Hospital, Rome, Italy
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Easo J, Weymann A, Hölzl P, Horst M, Eichstaedt H, Mashhour A, Zhigalov K, Szczechowicz M, Thomas RP, Sabashnikov A, Dapunt OE. Hospital Results of a Single Center Database for Stentless Xenograft Use in a Full Root Technique in Over 970 Patients. Sci Rep 2019; 9:4371. [PMID: 30867492 PMCID: PMC6416277 DOI: 10.1038/s41598-019-40772-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 02/19/2019] [Indexed: 12/01/2022] Open
Abstract
Our aim was to analyse the hospital outcome for the worldwide largest series of stentless bioroot xenografts (Medtronic Freestyle) as full root replacement in a single centre over a period of 18 years. Retrospective data analysis was performed for the entire cohort of patients undergoing aortic root surgery with the Medtronic Freestyle valve prosthesis. Logistic regression analysis was performed to analyse predictors of in-hospital mortality. 971 patients underwent aortic full root replacement with the Medtronic Freestyle valve in the period from 1999–2017, with an average age of 68.8 ± 10.3y and gender distribution of 608:363 (male:female). Concomitant surgery was performed in 693 patients (71.4%). In-hospital all-comers mortality was 9.8% (95 patients), with the respective highest risk profiles including dissections (6.4%), endocarditis (5.6%) and re-do procedures (12.5%). In-hospital mortality for elective patients was 7.6% while isolated aortic root replacement demonstrated a mortality of 3.6%. Logistic regression analysis demonstrated age (OR 1.05, p = 0.005), dissection (OR 5.78, p < 0.001) and concomitant bypass surgery (OR 2.68, p < 0.001) as preoperative risk factors for the entire cohort. Postoperative analysis demonstrated myocardial infarction (OR 48.6, p < 0.001) and acute kidney injury (OR 20.2, p < 0.001) to be independent risk factors influencing mortality. This analysis presents a work-through of all patients with stentless bioroot treatment without positive selection in a high-volume clinical center with the largest experience world-wide for this form of complex surgery. Isolated aortic root replacement could be performed at acceptable operative risk for this technically-challenging procedure.
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Affiliation(s)
- Jerry Easo
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg-Groningen, Rahel-Straus Str 10, 26133, Oldenburg, Germany.
| | - Alexander Weymann
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg-Groningen, Rahel-Straus Str 10, 26133, Oldenburg, Germany
| | - Philipp Hölzl
- Department of Cardiac and Thoracic Surgery HELIOS Hospital Siegburg, Ring Str. 49, 53721, Siegburg, Germany
| | - Michael Horst
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg-Groningen, Rahel-Straus Str 10, 26133, Oldenburg, Germany
| | - Harald Eichstaedt
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg-Groningen, Rahel-Straus Str 10, 26133, Oldenburg, Germany
| | - Ahmed Mashhour
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg-Groningen, Rahel-Straus Str 10, 26133, Oldenburg, Germany
| | - Konstantin Zhigalov
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg-Groningen, Rahel-Straus Str 10, 26133, Oldenburg, Germany
| | - Marcin Szczechowicz
- Department of Cardiac Surgery, University Clinic Oldenburg, European Medical School Oldenburg-Groningen, Rahel-Straus Str 10, 26133, Oldenburg, Germany
| | - Rohit Philip Thomas
- Department of Diagnostic and Interventional Radiology, University Clinic Oldenburg, European Medical School Oldenburg-Groningen, Rahel-Straus Str 10, 26133, Oldenburg, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Center, University of Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - Otto E Dapunt
- Division of Cardiac Surgery, Medical University of Graz, Auenbrugger Platz 29, 8036, Graz, Austria
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Commentary: Porcine bioprosthetic root replacement for aortic stenosis: Farcical or sensible? J Thorac Cardiovasc Surg 2019; 158:1030-1031. [PMID: 30598276 DOI: 10.1016/j.jtcvs.2018.11.065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 11/19/2018] [Indexed: 11/20/2022]
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Stented versus Stentless Aortic Valve Replacement in Patients with Small Aortic Root. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:404-416. [DOI: 10.1097/imi.0000000000000569] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objective The aim of the study was to compare hemodynamic and perioperative outcomes of stented against stentless aortic valve replacement in patients with small aortic root (21 mm or less). Methods A comprehensive search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing stentless to stented bioprosthetic valves in small aortic root patients. Odds ratios, weighted mean differences, or standardized mean differences and their 95% confidence intervals were analyzed. Results A total of seven studies with a total of 965 patients fulfilled the inclusion criteria. There was no significant difference in preoperative baselines including mean age between both groups ( P = 0.08), peak aortic valve gradient ( P = 0.06), and effective orifice area ( P = 0.28), whereas higher mean aortic valve gradient in the stented group ( P = 0.007). No difference in cardiopulmonary bypass time ( P = 0.74), aortic cross-clamp times ( P = 0.88), intensive care unit stay ( P = 0.13), and stroke rate ( P = 0.56) were noted. However, stented group of patients showed higher rate of patient prosthesis mismatch ( P = 0.0001) and longer total hospital stay ( P = 0.002). Postoperatively, stentless group showed lower peak and mean aortic valve gradient ( P = 0.003 and P = 0.008, respectively) with a better effective orifice area ( P < 0.00001) at 6 months of follow-up. Mortality rates while in-hospital and at 1 year were similar in both groups ( P = 0.94 and P = 0.86, respectively). Conclusions Stentless aortic valves offer superior short-term hemodynamic outcomes in patients with small aortic root when compared with stented aortic valves. Although both groups have similar perioperative complications rates, stentless valves bring about a shorter hospital stay. A further large multicenter randomized controlled trial should address the longer-term benefit of stentless aortic valve over stented valve.
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Philippart R, Brunet-Bernard A, Clementy N, Bourguignon T, Mirza A, Angoulvant D, Babuty D, Lip GYH, Fauchier L. Oral anticoagulation, stroke and thromboembolism in patients with atrial fibrillation and valve bioprosthesis. Thromb Haemost 2017; 115:1056-63. [DOI: 10.1160/th16-01-0007] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Accepted: 01/11/2016] [Indexed: 12/16/2022]
Abstract
SummaryVitamin K antagonists are currently recommended in patients with ‘valvular’ atrial fibrillation (AF), e. g. those having mitral stenosis or artificial heart valves. We compared thromboembolic risk in patients with ‘non valvular’ AF and in those with AF and biological valve replacement (valve bioprosthesis). Among 8962 AF patients seen between 2000 and 2010, a diagnosis of ‘non-valvular AF’ was found in 8053 (94 %). Among patients with ‘valvular’ AF, 549 (6 %) had a biological prosthesis. The patients with bioprosthesis were older and had a higher CHA2DS2-VASc score than those with non valvular AF. After a follow-up of 876 é 1048 days (median 400 days, interquartile range 12–1483), the occurrence of thromboembolic events was similar in AF patients with bioprosthesis compared to those with ‘non valvular’ AF (hazard ratio [HR] 1.10 95 % confidence interval [CI] 0.83–1.45, p=0.52, adjusted HR 0.93, 95 %CI 0.68–1.25, p=0.61). Factors independently associated with increased risk of stroke/TE events were older age (HR 1.25, 95 %CI 1.16–1.34 per 10-year increase, p> 0.0001) and higher CHA2DS2-VASc score (HR 1.35, 95 %CI 1.24–1.46, p> 0.0001) whilst female gender (HR 0.75, 95 %CI 0.62–0.90, p=0.002), use of vitamin K antagonist (HR 0.83, 95 %CI 0.71–0.98, p=0.03) were independently associated with a lower risk of stroke/TE. Neither the presence of bioprosthesis nor the location of bioprosthesis was independent predictor for TE events. In conclusion, AF patients with bioprosthesis had a non-significantly higher risk of stroke/TE events compared to patients with non-valvular AF. Second, the CHA2DS2-VASc score was independently associated with an increased risk of TE events, and was a valuable determinant of TE risk both in AF patients with non-valvular AF as well as those with bioprosthesis, whether treated or not treated with OAC.Note: The review process for this paper was fully handled by Christian Weber, Editor in Chief.
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David TE. Tirone on Tirone David operation and types. Gen Thorac Cardiovasc Surg 2017; 67:66-69. [PMID: 28849328 DOI: 10.1007/s11748-017-0819-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/12/2017] [Indexed: 11/26/2022]
Affiliation(s)
- Tirone E David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, 200 Elizabeth St. 4N453, Toronto, ON, M5G 2C4, Canada.
- University of Toronto, Toronto, ON, Canada.
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Lee MM, Alvarez J, Rao V. History of Cardiovascular Surgery at Toronto General Hospital. Semin Thorac Cardiovasc Surg 2017; 28:700-704. [PMID: 28285676 DOI: 10.1053/j.semtcvs.2016.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/05/2016] [Indexed: 11/11/2022]
Abstract
The Division of Cardiovascular Surgery at Toronto General Hospital has enjoyed an enviable history of academic achievement and clinical success. The foundations of this success are innovation, creativity and excellence in patient care, which continue to influence the current members of the division.
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Affiliation(s)
- Myunghyun M Lee
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Juglans Alvarez
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
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Sponga S, Barbera MD, Pavoni D, Lechiancole A, Mazzaro E, Valente M, Nucifora G, Thiene G, Livi U. Ten-year results of the Freedom Solo stentless heart valve: excellent haemodynamics but progressive valve dysfunction in the long term. Interact Cardiovasc Thorac Surg 2017; 24:663-669. [DOI: 10.1093/icvts/ivw391] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 10/10/2016] [Indexed: 11/14/2022] Open
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13
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Rao V, David CM. Historical perspectives of The American Association for Thoracic Surgery: Tirone E. David. J Thorac Cardiovasc Surg 2016; 153:741-743. [PMID: 27923489 DOI: 10.1016/j.jtcvs.2016.10.054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2016] [Accepted: 10/31/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Vivek Rao
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada.
| | - Carolyn M David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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Tamim M, Bové T, Van Belleghem Y, Caes F, François K, Van Nooten GJ. Aortic Valve Replacement with Toronto SPV in Elderly Patients: 10-Year Results. Asian Cardiovasc Thorac Ann 2016; 13:143-8. [PMID: 15905343 DOI: 10.1177/021849230501300210] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A retrospective assessment of clinical and echocardiographic variables was performed in 145 patients who received a Toronto SPV aortic valve replacement. The majority (90%) of these elderly patients (mean age, 75.5 ± 7.4 years) were preoperatively in New York Heart Association class III–IV. Operative mortality was 4.8%. Follow-up was complete up to 10 years and revealed few valve-related complications: thromboembolism (7), bleeding (4), and prosthesis dysfunction necessitating reoperation (3). Late mortality was cardiac-related in 11.7% and noncardiac-related in 17.2%. Actuarial survival was 83% at 5 years and 63% at 8 years. Echocardiography showed low transvalvular gradients (peak, 17.5 ± 7.5 mm Hg; mean, 9.2 ± 4.2 mm Hg) resulting in a significant reduction in left ventricular mass index during the first 3 years. Independent of the transprosthetic gradient, left ventricular mass index tended to increase again beyond the 5th year, which correlated positively with the presence of arterial hypertension in this older population. The Toronto SPV bioprosthesis offers an aortic valve substitute with excellent long-term hemodynamics, resulting in significant early left ventricular mass regression. Considering the limitations of this selected elderly population, the clinical outcome and survival up to 10 years are encouraging, with few observed valve-related events.
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Affiliation(s)
- Muhammed Tamim
- Heart Center, University Hospital of Ghent, Ghent, Belgium
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Fauchier L, Philippart R, Clementy N, Bourguignon T, Angoulvant D, Ivanes F, Babuty D, Bernard A. How to define valvular atrial fibrillation? Arch Cardiovasc Dis 2015; 108:530-9. [PMID: 26184867 DOI: 10.1016/j.acvd.2015.06.002] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 06/08/2015] [Indexed: 12/21/2022]
Abstract
Atrial fibrillation (AF) confers a substantial risk of stroke. Recent trials comparing vitamin K antagonists (VKAs) with non-vitamin K antagonist oral anticoagulants (NOACs) in AF were performed among patients with so-called "non-valvular" AF. The distinction between "valvular" and "non-valvular" AF remains a matter of debate. Currently, "valvular AF" refers to patients with mitral stenosis or artificial heart valves (and valve repair in North American guidelines only), and should be treated with VKAs. Valvular heart diseases, such as mitral regurgitation, aortic stenosis (AS) and aortic insufficiency, do not result in conditions of low flow in the left atrium, and do not apparently increase the risk of thromboembolism brought by AF. Post-hoc analyses suggest that these conditions probably do not make the thromboembolic risk less responsive to NOACs compared with most forms of "non-valvular" AF. The pathogenesis of thrombosis is probably different for blood coming into contact with a mechanical prosthetic valve compared with what occurs in most other forms of AF. This may explain the results of the only trial performed with a NOAC in patients with a mechanical prosthetic valve (only a few of whom had AF), where warfarin was more effective and safer than dabigatran. By contrast, AF in the presence of a bioprosthetic heart valve or after valve repair appears to have a risk of thromboembolism that is not markedly different from other forms of "non-valvular" AF. Obviously, we should no longer consider the classification of AF as "valvular" (or not) for the purpose of defining the aetiology of the arrhythmia, but for the determination of a different risk of thromboembolic events and the need for a specific antithrombotic strategy. As long as there is no better new term or widely accepted definition, "valvular AF" refers to patients with mitral stenosis or artificial heart valves. Patients with "non-valvular AF" may have other types of valvular heart disease. One should emphasize that "non-valvular AF" does not exclude patients with some types of valvular heart disease from therapy with NOACs.
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Affiliation(s)
- Laurent Fauchier
- Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France.
| | - Raphael Philippart
- Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France
| | - Nicolas Clementy
- Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France
| | - Thierry Bourguignon
- Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France
| | - Denis Angoulvant
- Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France
| | - Fabrice Ivanes
- Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France
| | - Dominique Babuty
- Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France
| | - Anne Bernard
- Service de cardiologie, faculté de médecine, université François-Rabelais, CHU Trousseau, Tours, France
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Aortic Root Replacement With Biological Valved Conduits. Ann Thorac Surg 2015; 100:337-53. [DOI: 10.1016/j.athoracsur.2015.02.057] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 02/06/2015] [Accepted: 02/12/2015] [Indexed: 11/24/2022]
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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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A look at recent improvements in the durability of tissue valves. Gen Thorac Cardiovasc Surg 2013; 61:182-90. [DOI: 10.1007/s11748-013-0202-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Indexed: 10/27/2022]
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The Sorin Freedom Stentless Pericardial Valve: Clinical and Echocardiographic Performance at 10 years. Int J Artif Organs 2012; 35:481-8. [DOI: 10.5301/ijao.5000103] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/17/2012] [Indexed: 11/20/2022]
Abstract
Objective: The Sorin Pericarbon Freedom (SPF) is a stentless valve made of pericardium clinically available in 1990. We report the clinical and hemodynamic performance of the SPF at 10 years. Methods: From April 2000 to December 2005, 85 patients with a mean age of 75 ± 6 years (range 57–86), underwent aortic valve replacement (AVR) with an SPF. Mean left ventricular ejection fraction was 58 ± 10% (range 29–86%) and mean peak transvalvular gradient (PG) 86 ± 24 mm Hg. Clinical evaluation was performed at 3, 6, 12 months, and yearly thereafter. Results: There were 2 operative deaths (2.4%). Follow-up ranged from 2 to 135 months (mean 78 ± 32 months) and was 99% complete. There were 35 late deaths, 7 of which were valve-related, with an actuarial survival of 45 ± 8% at 10 years. Structural SPF deterioration occurred in 2 patients, with an actuarial freedom of 96 ± 3%. A total of 4 patients were re-operated, 2 because of structural deterioration, 1 because of endocarditis, and 1 because of sinotubular junction dilatation; freedom from reoperation was 93 ± 4% at 10 years. At last clinical control, 41 patients (89%) were in NYHA class I or II. Mean SPF effective orifice area varied from 1.55 ± 0.66 cm2 for size 21 mm to 2.33 ± 0.86 cm2 for size 27 mm; PG varied from 19 ± 10 mm Hg for size 21 mm to 11 ± 6 mm Hg for size 27 mm. Left ventricular mass index decreased from 213 ± 51 gm/m2 to 157 ± 436 gm/m2 (p<0.001). Conclusions: The SPF has demonstrated overall good results in terms of valve durability and freedom from valve-related complications up to 10 years, with excellent hemodynamic performance.
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Nakamura H, Yamaguchi H, Nakao T, Oshima Y, Tokunaga N, Murakami M, Mitsuyama S. Reoperation for mid-term failure of a freestyle bioprosthesis using a full root technique --a surgical case--. Ann Thorac Cardiovasc Surg 2011; 17:287-9. [PMID: 21697792 DOI: 10.5761/atcs.cr.09.01532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2009] [Accepted: 03/10/2010] [Indexed: 11/16/2022] Open
Abstract
The aortic root of a 30-year-old man was replaced with a Freestyle stentless aortic bioprosthesis for aortic regurgitation associated with annuloaortic ectasia. His clinical course was uneventful, and he was discharged without complications. Three years and six months after surgery, he presented with a high fever. Four years after surgery, transthoracic echocardiography revealed severe aortic regurgitation. We performed exploratory surgery and discovered a torn left coronary cusp of the Freestyle bioprosthesis. Organized vegetation was adherent to the left coronary cusp leaflet. The non-coronary cusp and the right coronary cusp were normal. The diagnosis was aortic regurgitation due to valve failure related to infective endocarditis. Consequently, we reconstructed the aortic root with a composite graft (26-mm Valsalva graft and a 21-mm ON-X mechanical valve).
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Affiliation(s)
- Hiromasa Nakamura
- Department of Cardiovascular Surgery, Shin Tokyo Hospital, Matsudo, Chiba, Japan.
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Murtuza B, Pepper JR, Jones C, Nihoyannopoulos P, Darzi A, Athanasiou T. Does stentless aortic valve implantation increase perioperative risk? A critical appraisal of the literature and risk of bias analysis. Eur J Cardiothorac Surg 2010; 39:643-52. [PMID: 20850984 DOI: 10.1016/j.ejcts.2010.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 07/25/2010] [Accepted: 08/05/2010] [Indexed: 11/27/2022] Open
Abstract
Stentless aortic valve replacement has potential benefits in terms of valve hemodynamics and clinical outcomes, although these may be offset by greater technical complexity of implantation with longer cardiopulmonary bypass and cross-clamp times compared with stented valves. Meta-analyses of the small number of published randomized trials have been limited by their lack of critical synthesis of the literature, including evaluation of the Risk of Bias. Our objective was to determine whether stentless aortic valves increase perioperative risk of mortality. We also examined secondary clinical outcomes of neurological, renal and respiratory complications as well as hemodynamic changes reported by studies following implantation of the two types of aortic prosthesis. The methodology used to answer this question was a rigorous meta-analysis of randomized controlled trials, using bias-assessment techniques designed to address limitations of conventional meta-analysis. Our findings show that many of the existing randomized trials have a high or uncertain risk of bias. Analysis of studies with low risk of bias reveals that stentless valves do not increase perioperative risk in terms of 30-day mortality and morbidity though neither do they exhibit benefits in hemodynamics or clinical outcomes compared with stented valves. Larger, more stringent randomized studies would be required to identify any robust clinical difference.
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Affiliation(s)
- Bari Murtuza
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, Faculty of Medicine, Imperial College, UK.
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Cohen G, Zagorski B, Christakis GT, Joyner CD, Vincent J, Sever J, Harbi S, Feder-Elituv R, Moussa F, Goldman BS, Fremes SE. Are stentless valves hemodynamically superior to stented valves? Long-term follow-up of a randomized trial comparing Carpentier–Edwards pericardial valve with the Toronto Stentless Porcine Valve. J Thorac Cardiovasc Surg 2010; 139:848-59. [DOI: 10.1016/j.jtcvs.2009.04.067] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2008] [Revised: 03/08/2009] [Accepted: 04/27/2009] [Indexed: 12/14/2022]
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Mittal CM, Talwar S, Devagourou V, Kothari SS, Sampath Kumar A. Early results of aortic valve reconstruction with stentless glutaraldehyde treated autologous pericardial valve. Indian J Thorac Cardiovasc Surg 2010. [DOI: 10.1007/s12055-009-0055-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Tanaka K, Kinoshita T, Fujinaga K, Kanemitsu S, Tanaka J, Suzuki H, Tokui T. Hemodynamic performance of the Edwards Prima Plus stentless valve at 1 year. Gen Thorac Cardiovasc Surg 2008; 56:441-5. [PMID: 18791668 DOI: 10.1007/s11748-008-0286-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Accepted: 05/25/2008] [Indexed: 11/29/2022]
Abstract
PURPOSE The Edwards Prima Plus stentless valve bioprosthesis (EPPSV) is a porcine aortic root cylinder with resected coronary ostia, fixed in glutaraldehyde at low pressure, and chemically treated to prevent calcification. Utilization of this valve was approved in January 2005 in Japan. The purpose of this study was to evaluate the early hemodynamic performance of EPPSVs in our experience. MATERIALS AND METHODS From April 2005 to January 2006, a total of 21 patients underwent aortic valve replacement with EPPSVs. The hemodynamic performance of EPPSVs was evaluated at the time of discharge (2 weeks) and at 1 year by transthoracic two-dimensional Doppler echocardiography. RESULTS There was one non-valve-related early death and one non-valve-related late death. Hemodynamic data were available for comparison from the time of discharge and at 1 year postoperatively in 19 patients (mean valve size 22 +/- 1 mm). Hemodynamic follow-up showed a significant decrease in the peak and mean transvalvular pressure gradients at discharge (37 +/- 16 and 18 +/- 8 mmHg, respectively) and 1 year postoperatively (25 +/- 7 and 12 +/- 4 mmHg, respectively) (P < 0.01). The effective orifice area increased significantly between the time of discharge (1.31 +/- 0.31 cm2) and 1 year (1.57 +/- 0.37 cm2) (P < 0.05) postoperatively. The left ventricular mass index was significantly reduced from the time of discharge (167 +/- 49 g/m2) to 1 year postoperatively (126 +/- 47 g/m2) (P < 0.001). CONCLUSION EPPSVs have been associated with high early transprosthetic gradients. Such gradients tend to regress, with significant improvement at 1 year and concomitant regression of left ventricular hypertrophy.
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Affiliation(s)
- Keizo Tanaka
- Department of Thoracic and Cardiovascular Surgery, Anjo Kosei Hospital, 28 Higashihirokute Anjo-cho, Anjo, Aichi 446-8602, Japan.
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Luciani GB, Viscardi F, Cresce GD, Faggian G, Mazzucco A. Seven-Year Performance of the Edwards Prima Plus Stentless Valve with the Intact Non-Coronary Sinus Technique. J Card Surg 2008; 23:221-6. [DOI: 10.1111/j.1540-8191.2008.00592.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Aortic valve replacement with Toronto SPV bioprosthesis: Optimal patient survival but suboptimal valve durability. J Thorac Cardiovasc Surg 2008; 135:19-24. [DOI: 10.1016/j.jtcvs.2007.04.068] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2007] [Revised: 03/21/2007] [Accepted: 04/12/2007] [Indexed: 11/21/2022]
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D'Onofrio A, Auriemma S, Magagna P, Favaro A, Cannarella A, Piccin C, Bilotta M, Abbiate N, Lamascese N, Fabbri A. Aortic valve replacement with the Sorin Pericarbon Freedom stentless prosthesis: 7 years' experience in 130 patients. J Thorac Cardiovasc Surg 2007; 134:491-5. [PMID: 17662795 DOI: 10.1016/j.jtcvs.2007.04.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2007] [Revised: 03/21/2007] [Accepted: 04/11/2007] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Aortic stentless pericardial valves were introduced into clinical practice to combine properties of both stentless and pericardial prostheses. The aim of this single-center retrospective study was to assess midterm clinical and hemodynamic results of aortic valve replacement with the Sorin Pericarbon Freedom stentless bioprosthesis. METHODS From July 1999 through November 2005, 130 consecutive patients (73 [56.1%] male patients) underwent aortic valve replacement with the Sorin Pericarbon Freedom bioprosthesis at our institution. Mean age was 76 +/- 5 years (range, 42-86 years), and associated procedures were performed in 50 (38.4%) patients; of these, 41 were coronary artery bypass grafts. Surgical intervention under urgent/emergency conditions and reoperations were performed in 18 (13.8%) and 7 (5.3%) patients, respectively. Mean crossclamp and cardiopulmonary bypass times were 82 +/- 24 and 125 +/- 40 minutes, respectively. All patients underwent clinical and echocardiographic follow-up (100% complete), and the total cumulative follow-up was 324 patient/years (mean, 2.5 +/- 1.8; range, 6 months-7 years). RESULTS Overall hospital mortality was 8.4%. Overall patient survival was 63% +/- 6% and 50% +/- 10% at 5 and 7 years, respectively. Late deaths occurred in 23 patients, and 6 of them were valve related (1.8% patient/years). Freedom from valve-related death and reoperation was 91% +/- 4% and 94% +/- 4%, respectively, at 7 years. No structural valve deterioration was observed. Endocarditis, thromboembolism, and hemorrhagic complications occurred in 2 (0.6% patient/years), 1 (0.3% patient/years), and 1 (0.3% patient/years) patients, respectively. Mean transprosthetic gradients for valve sizes 23, 25, and 27 were 12.1 +/- 3.8, 10.8 +/- 3.8, and 9 +/- 3.1 mm Hg, respectively. CONCLUSIONS The Sorin Pericarbon Freedom stentless bioprosthesis provides good early and midterm results in terms of hemodynamic performance, survival, and freedom from valve-related complications.
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Borger MA, Prasongsukarn K, Armstrong S, Feindel CM, David TE. Stentless Aortic Valve Reoperations: A Surgical Challenge. Ann Thorac Surg 2007; 84:737-43; discussion 743-4. [PMID: 17720369 DOI: 10.1016/j.athoracsur.2007.04.061] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2007] [Revised: 04/10/2007] [Accepted: 04/16/2007] [Indexed: 11/24/2022]
Abstract
BACKGROUND Stentless aortic valve reoperations may become more common as these bioprostheses reach the limits of their durability. Relatively few studies have examined stentless valve reoperation, and we therefore reviewed our results for these procedures. METHODS All patients with stentless valves undergoing redo aortic valve replacement (AVR) at our institution were examined (n = 57). Ten patients had a prior Freestyle valve (Medtronic, Minneapolis, MN), and 47 patients had a Toronto stentless porcine valve (SPV; St. Jude Medical St Paul, MN). RESULTS Redo AVR was performed 8.4 +/- 3.7 years (range, 0.1 to 16.5 years) after stentless valve implantation. Reoperations were elective in 27 patients (49%), and 30 (51%) underwent urgent or emergency procedures. The indication for redo AVR was structural valve dysfunction in 48 patients (84%), acute endocarditis in 7 (12%), and other in 2 (4%). Aortic insufficiency was present in 47 patients (82%). A total of 36 aortic root replacement operations (63% of patients) were required, of which 19 were secondary to severe adhesions between the stentless valve and the native aortic root. Operative mortality was 11% (n = 6) for the entire group. Mortality was higher in patients undergoing redo AVR less than 1 year after stentless valve implantation versus more than 1 year (67% versus 7%, p = 0.03). Long-term survival at 5 years postoperatively was 79% +/- 7% in all patients, and 81% of survivors were in New York Heart Association class I or II. CONCLUSIONS Reoperation after stentless AVR is a challenging procedure that frequently requires aortic root replacement. Stentless valve reoperation is associated with an increased risk of death, particularly in patients operated on within 1 year of implantation.
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Affiliation(s)
- Michael A Borger
- Division of Cardiovascular Surgery, Toronto General Hospital, and Department of Surgery, University of Toronto, Toronto, Ontario, Canada
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Chambers JB, Rimington HM, Rajani R, Hodson F, Shabbo F. A randomized comparison of the Cryolife O'Brien and Toronto stentless replacement aortic valves. J Thorac Cardiovasc Surg 2007; 133:1045-50. [PMID: 17382651 DOI: 10.1016/j.jtcvs.2006.10.071] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2006] [Revised: 10/13/2006] [Accepted: 10/23/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE A composite stentless valve might be less obstructive than a preparation incorporating the porcine right coronary muscle bar. The aim of this study was to compare early hemodynamic function in a prospective series of 78 patients randomized to receive either a Toronto or Cryolife O'Brien stentless valve. METHODS Echocardiography was performed early after surgery, between 3 and 6 months, and at 1 year after surgery. RESULTS The groups were matched demographically. The Cryolife O'Brien valve was significantly less obstructive in terms of effective orifice area (1.81 vs 1.30 cm2; P < .0001), mean pressure difference (7.1 vs 11.7 mm Hg; P < .0001), and peak velocity (1.7 vs 2.2 m/s) assessed at 1 year (P = .001). Bypass time was 91 (SD 22) minutes for the Cryolife O'Brien compared with 125 (SD 22) minutes (P < .0001) for the Toronto. There was a higher incidence of paraprosthetic regurgitation in the Cryolife O'Brien valve (16.7% vs 3.2%). Mortality and clinical events were similar. CONCLUSION The composite valve was less obstructive than the porcine valve, suggesting that stentless valves cannot be considered as a homogeneous class.
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Nowell J, Wilton E, Markus H, Jahangiri M. Antithrombotic therapy following bioprosthetic aortic valve replacement. Eur J Cardiothorac Surg 2007; 31:578-85. [PMID: 17267235 DOI: 10.1016/j.ejcts.2006.12.017] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Revised: 12/06/2006] [Accepted: 12/14/2006] [Indexed: 11/23/2022] Open
Abstract
The life expectancy of the general population is increasing. This has meant that more elderly patients are requiring aortic valve replacement (AVR). The choice of valve replacement and its durability are important. Bioprosthetic (tissue) heart valves were introduced into clinical use in the 1960s and were developed primarily to reduce the complications associated with thromboembolism (TE) and the need for lifelong oral anticoagulation, due to their low thrombogenicity compared to mechanical prostheses. This makes them suitable for use in elderly patients (aged>65 years) and in others where the risks of anticoagulation are higher or anticoagulation is contraindicated. There is thought to be a higher risk of TE for up to 90 days following bioprosthetic AVR. Guidelines for the management of patients with valvular heart disease published by the American College of Cardiology (ACC)/American Heart Association (AHA), the American College of Chest Physicians (ACCP) and the European Society of Cardiology (ESC) all recommend the use of an anticoagulation regimen for the first 3 months following bioprosthetic AVR. However, there is division of opinion and practice, despite these recommendations, and more recent studies have not supported the evidence for these guidelines. In this article, we review the literature on the use of anticoagulation in the first 90 days following bioprosthetic AVR.
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Affiliation(s)
- Justin Nowell
- Department of Cardiothoracic Surgery and Neurosciences, St George's Hospital, University of London, UK
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Luciani GB, Santini F, Mazzucco A. Autografts, homografts, and xenografts: overview on stentless aortic valve surgery. J Cardiovasc Med (Hagerstown) 2007; 8:91-6. [PMID: 17299289 DOI: 10.2459/01.jcm.0000260208.98246.10] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Stentless valves, either human (autografts, homografts) or animal (porcine xenografts), were historically among the first substitutes to be used to replace the diseased aortic valve. Forty years after those pioneering days and 15 years after revival of such valves, stentless grafts have become a mainstay in aortic surgery. Although limitations associated with the use of autografts, homografts and xenografts remain, stentless valves have profoundly improved quality of life after aortic valve/root replacement. In addition, stentless surgery has greatly advanced the understanding of aortic root anatomy, physiology and pathology among surgeons.
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Kunihara T, Schmidt K, Glombitza P, Dzindzibadze V, Lausberg H, Schäfers HJ. Root Replacement Using Stentless Valves in the Small Aortic Root: A Propensity Score Analysis. Ann Thorac Surg 2006; 82:1379-84. [PMID: 16996937 DOI: 10.1016/j.athoracsur.2006.05.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2006] [Revised: 05/03/2006] [Accepted: 05/05/2006] [Indexed: 11/21/2022]
Abstract
BACKGROUND Root replacement using a stentless bioprosthesis may be the optimal approach to avoid patient-prosthesis mismatch in patients with a small aortic root. Primary root replacement, however, is considered to be associated with increased surgical risk. We compared early outcome of full root replacement with a stentless bioprosthesis with that of aortic valve replacement with a stented bioprosthesis using propensity score-matching analysis. METHODS Of 231 patients undergoing elective, first-time aortic valve replacement with a small root (< or = 22 mm), 120 patients were selected using propensity score-matching analysis. They underwent either root replacement using a 23-mm stentless bioprosthesis (stentless group, n = 60) or supra-annular aortic valve replacement using a 21-mm stented bioprosthesis (stented group, n = 60). Preoperative characteristics and frequency of concomitant operations were identical. RESULTS Duration of operation (196 +/- 54 versus 174 +/- 49 minutes), cardiopulmonary bypass (112 +/- 36 versus 91 +/- 33 minutes), and aortic cross-clamping (76 +/- 21 versus 61 +/- 21 minutes) were significantly longer in the stentless group. However, the need for perioperative transfusion and the incidence of postoperative reexploration for bleeding (3% versus 8%) was lower, and ventilation time was shorter. Mean duration of intensive care and hospital stay were also significantly shorter (2.3 +/- 1.7 versus 4.0 +/- 3.9 days, 8.9 +/- 3.1 versus 12.4 +/- 5.7 days). In-hospital mortality was identical (5% each). No independent predictor for in-hospital mortality was identified. CONCLUSIONS Full root replacement using a stentless bioprosthesis does not increase postoperative morbidity or mortality of aortic valve replacement and may be advantageous in patients with a small aortic root.
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Affiliation(s)
- Takashi Kunihara
- Department of Thoracic and Cardiovascular Surgery, University Hospital Homburg, Homburg, Germany
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Raja SG, Macarthur KJ, Pollock JC. Impact of Stentless Aortic Valves on Left Ventricular Function and Hypertrophy: Current Best Available Evidence. J Card Surg 2006; 21:313-9. [PMID: 16684073 DOI: 10.1111/j.1540-8191.2006.00240.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Past four decades have seen a gradual evolution in aortic valve replacement surgery. The ideal valve substitute should combine central flow, low transvalvular gradient, low thrombogenicity, durability, easy availability, resistance to infection, freedom from anticoagulation, and easy implantability. Although there are several types of valves available to replace the diseased aortic valve-autograft, allograft, xenograft, mechanical, and bioprosthetic valves-none is ideal. On one end of the spectrum is the pulmonary autograft, which comes closest to achieving these goals, but creates a double valve procedure for single valve disease, while on the other end are the mechanical valves and stented tissue valves, which allow easy "off the shelf" availability as well as easy implantability but are limited by the potential drawback of causing intrinsic obstruction to some extent because of the space occupied by the stent and sewing ring. Stentless xenograft aortic valves have been developed as a compromise between these ends of the valve spectrum. Stentless aortic valves have been reported to provide more physiologic hemodynamic behavior and cause more timely and thorough regression of ventricular hypertrophy. This review article attempts to evaluate current best available evidence from randomized controlled trials to assess the impact of stentless aortic valves on left ventricular function and hypertrophy.
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Affiliation(s)
- Shahzad G Raja
- Department of Cardiac Surgery, Royal Hospital for Sick Children, Glasgow, UK.
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Chambers JB, Rimington HM, Hodson F, Rajani R, Blauth CI. The subcoronary Toronto stentless versus supra-annular Perimount stented replacement aortic valve: Early clinical and hemodynamic results of a randomized comparison in 160 patients. J Thorac Cardiovasc Surg 2006; 131:878-2. [PMID: 16580447 DOI: 10.1016/j.jtcvs.2005.11.021] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2005] [Revised: 11/14/2005] [Accepted: 11/18/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND A stentless valve is expected to be hemodynamically superior to a stented valve. The aim of this study was to compare early postoperative hemodynamic function and clinical events in a randomized, prospective series of 160 stentless and stented biological replacement aortic valves. METHODS We randomized 160 consecutive patients on 1 surgeon's list to receive either a Toronto stentless porcine valve (St Jude Medical, Inc, St Paul, Minn) or a Perimount stented bovine pericardial valve (Edwards Lifesciences, Irvine, Calif). Echocardiography was performed at discharge, between 3 and 6 months, and at 1 year after surgery. Statistical analysis was performed by both intention to treat and actual valves implanted. RESULTS The mean labeled size of both designs of valve was 24.7. There were no statistically significant differences in results at any time interval or whether analysis was performed by actual valves implanted or intention to treat. At 3 to 6 months for the Toronto versus the Perimount valve, the effective orifice area was 1.58 versus 1.66 cm2, the mean pressure difference was 7.54 versus 7.42 mm Hg, and the peak velocity was 2.07 versus 2.0.1 m/s. There was no difference in mortality, regression of left ventricular hypertrophy, or complications other than paraprosthetic regurgitation at 12 months or on follow-up for a proportion of the sample to 8 years. The incidence of regurgitation through the valves was similar for Toronto (10%) and Perimount (13.8%) at 1 year, but mild paraprosthetic regurgitation was found in 5 patients with the Perimount valve and none with Toronto valves. CONCLUSIONS There were no significant differences in hemodynamic function or clinical events between the stented and stentless biological valves chosen for comparison in the early postoperative period or in preliminary follow-up to 5 years.
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Affiliation(s)
- John B Chambers
- Valve Study Group, St Thomas Hospital, London, United Kingdom.
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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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Shah PJ, Buxton BF, Matalanis G. Factors influencing the mean postoperative gradients across stentless porcine valves. Heart Lung Circ 2005; 14:19-24. [PMID: 16352247 DOI: 10.1016/j.hlc.2004.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2004] [Revised: 10/19/2004] [Accepted: 11/10/2004] [Indexed: 11/24/2022]
Abstract
BACKGROUND To study the preoperative and intraoperative variables influencing the mean post-operative transvalvular gradient across stentless porcine valves. METHODS From 1995 to 2002, 84 patients underwent stentless valve insertion. The mean age was 73 years, and 63% were male. The valve pathology was aortic stenosis (AS) in 79%, aortic regurgitation (AR) in 12%, and mixed in 9%. Valve sizes ranged from 21 to 29 with size 27 being most frequent. 54% of patients had concomitant procedures. Patients had at least yearly clinical and echocardiographic follow-up. RESULTS There was no operative mortality. 9.5% of the patients had significant postoperative complications. The average echo interval was 18.6 months (range 1-88). The overall mean transvalvular gradient was 9.88+/-5.67 (SD) mmHg. Variables associated with significantly reduced gradients were: larger valve sizes (p=0.002), younger age (p=0.05), pre-op AR (p=0.008), and increasing post-operative interval (p=0.05). The mean gradients decreased by 0.28 mmHg for each post-operative year. The method of implantation did not significantly affect gradients (p=0.26). CONCLUSIONS Excellent mean transvalvular gradients were achieved with stentless valves studied, with a low operative risk. The gradients did not appear to be related to intra-operative factors, suggesting that insertion techniques can be tailored to suit patient conditions and surgeon preferences.
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Affiliation(s)
- Pallav J Shah
- Department of Cardiac Surgery, Austin Hospital, Studley Road, Melbourne, Vic. 3084, Australia
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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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Martinovic I, Everlien M, Farah I, Wittlinger T, Knez I, Greve H, Vogt P. Midterm Results After Aortic Valve Replacement With a Stentless Bioprosthesis Aortic Valve. Ann Thorac Surg 2005; 80:198-203. [PMID: 15975367 DOI: 10.1016/j.athoracsur.2005.01.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2004] [Revised: 01/04/2005] [Accepted: 01/07/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND It is suggested that a simplified implant model Cryolife-O'Brien (CryoLife International, Kennesaw, GA) offers less satisfactory outcome compared with standard stentless models. This study was conducted to prospectively evaluate the midterm results after aortic valve replacement with the Cryolife-O'Brien stentless bioprosthesis. METHODS In 1996, a prospective clinical trial using different stentless valves was initiated. From September 1996 through September 2002, 156 consecutive patients with a mean age of 74.5 years underwent aortic valve replacement with the Cryolife-O'Brien porcine stentless bioprosthesis. The predominant aortic valve lesion was stenosis in 128 and insufficiency in 28 cases. Patients have been followed from 2 to 72 months (mean, 42 months). Echocardiography was performed by one echocardiographer preoperatively, intraoperatively, postoperatively at discharge, 2 to 6 months later, and annually thereafter. RESULTS Sixty percent of patients received a valve 25 mm in diameter or larger; 39% had concomittant coronary bypass grafting. The 30-day operative mortality rate was 6.4%. Ten late nonvalve-related deaths have occurred. Severe aortic insufficiency caused by oversizing leads to early reoperation in 3 patients. The peak and mean systolic gradients decreased significantly during the first 12 months after implantation, p < 0.001, and the effective valve areas increased significantly during this time interval p < 0.001. At 5 years, ten patients have moderate aortic insufficiency. The actuarial survival at 5 years was 88 +/- 3%. The rate for freedom from endocarditis was 100% and for freedom from thromboembolic events was 94%. CONCLUSIONS Midterm results after aortic valve replacement with the Cryolife-O'Brien stentless bioprosthesis are encouraging. Good hemodynamics have been coupled with low rate of valve-related complications, thus representing a very good alternative to conventional stented bioprostheses.
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Affiliation(s)
- Ivo Martinovic
- Department of Cardiothoracic Surgery, Klinikum Krefeld, Krefeld, Germany.
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O'Brien MF, Gardner MAH, Garlick B, Jalali H, Gordon JA, Whitehouse SL, Strugnell WE, Slaughter R. CryoLife-O'Brien Stentless Valve: 10-Year Results of 402 Implants. Ann Thorac Surg 2005; 79:757-66. [PMID: 15734372 DOI: 10.1016/j.athoracsur.2004.08.057] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/23/2004] [Indexed: 11/15/2022]
Abstract
BACKGROUND This truly stentless porcine valve is composite, without Dacron, and implanted supra-annularly. Ten-year analysis with magnetic resonance imaging is presented. METHODS From 1992 to 2002, 402 patients (mean 73.5 years) had aortic valve replacement. Associated procedures were required in 252 patients (63%). Serial echoes provided 1340 studies. Clinical follow-up was 100%. Magnetic resonance imaging focused on aortic annulus extensibility. RESULTS The 30-day mortality was 0.99% (4 deaths). Morbidity comprised thromboembolism (40 patients including 18 patients with permanent strokes); endocarditis (9 patients); and reoperation (9 patients [periprosthetic leak, 2; endocarditis, 5; technical needle damage, 1; and structural degeneration, 1]). Of 402 valves more than 10 years, five valves were explanted, one only for structural failure. Except for endocarditis (2 patients), no late deaths (69 patients, 1.5 months to 5.7 years) were valve related. Echocardiography demonstrated low gradients with good orifice areas, excellent ventricular regression (p = 0.0001 preoperative and postoperative comparisons) and late incompetence (mild in 45 patients and moderate in 9 patients). No living patient has severe incompetence. Magnetic resonance imaging demonstrated the annulus 'expanding and relaxing' throughout the cardiac cycle, the mean increase in cross-sectional area being 37%, resembling normal aortic root dynamics. CONCLUSIONS Elderly patients received this hemodynamically acceptable valve with its simple, supra-annular implantation and satisfactory mid-term morbid-free lifestyle to 10 years maximum follow-up. With only one structural failure, restoration of valve annular extensibility may have a favorable influence on long-term durability.
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Chambers JB, Oo L, Narracott A, Lawford PM, Blauth CI. Nominal size in six bileaflet mechanical aortic valves: a comparison of orifice size and biologic equivalence. J Thorac Cardiovasc Surg 2003; 125:1388-93. [PMID: 12830058 DOI: 10.1016/s0022-5223(03)00039-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVES Nominal size remains the standard by which valves are compared, but its relationship with orifice area and the patient tissue annulus diameter may differ according to valve design. The aims of this study were to measure the orifice size and compare biologic equivalence in six bileaflet mechanical heart valve designs. METHODS The inflow aspect of each of 29 valves was photographed then digitized, and the maximum internal diameter and orifice area were calculated. Biologic equivalence was assessed with a series of machined polypropylene blocks. RESULTS The orifice area ranged between 159 and 222 mm(2) for the six size 19 valves. The internal diameter ranged from 1.6 to 4.6 mm less than the manufacturer's nominal size. Biologic equivalence assessed from an estimate of tissue annulus diameter with machined blocks ranged from 1.0 and 3.5 mm larger than nominal size for the intra-annular valves. This diameter ranged from 3.5 mm smaller to 1.5 mm larger than nominal size for the supra-annular valves. CONCLUSION There are major differences between nominal size and biologic equivalence. This may lead to confusion when attempting to make comparisons between different valve designs with the same nominal size. A clearer sizing nomenclature is required and could be based on in vitro assessment of tissue annulus diameter or an alphanumeric code.
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Affiliation(s)
- John B Chambers
- Cardiothoracic Centre, Guy's and St Thomas' Hospitals, London, United Kingdom.
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Meuris B, Phillips R, Moore MA, Flameng W. Porcine stentless bioprostheses: prevention of aortic wall calcification by dye-mediated photo-oxidation. Artif Organs 2003; 27:537-43. [PMID: 12780508 DOI: 10.1046/j.1525-1594.2003.07108.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE Aortic wall calcification is problematic in stentless porcine valves. We evaluated the possible anticalcification effect of photo-oxidation on the aortic wall portion of porcine stentless bioprostheses. A comparison with glutaraldehyde-fixed tissue was made. METHODS Six Photofix and six Freestyle valves were implanted in juvenile sheep in pulmonary position. Valves were explanted after 3 or 6 months and examined macroscopically, by x-ray, light, and transmission electron microscopy. Calcium content was determined by atomic absorption spectrometry. RESULTS The aortic wall portion of all Photofix valves remained free from calcification, while the wall portion of glutaraldehyde-fixed valves calcified strongly, both after 3 and 6 months. Calcium content of the aortic wall portion was: 0.71 +/- 1.27 in the Photofix valves versus 10.78 +/- 77.22 in the Freestyle valves (P < 0.05). CONCLUSION Photo-oxidation of a porcine stentless valve prevents calcification not only in the cusps but also in the aortic wall portion.
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Affiliation(s)
- Bart Meuris
- Department of Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium; and Sulzer Carbomedics, Austin, Texas, USA
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Affiliation(s)
- John R Doty
- Division of Cardiac Surgery, The Johns Hopkins Hospital, Baltimore, MD 21287, USA.
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Bendre SC, Fessler CL, Starr A. Aortic valve repair with pericardial leaflet extension for aortic valve insufficiency. Indian J Thorac Cardiovasc Surg 2002. [DOI: 10.1007/s12055-002-0027-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Kon ND, Riley RD, Adair SM, Kitzman DW, Cordell AR. Eight-year results of aortic root replacement with the freestyle stentless porcine aortic root bioprosthesis. Ann Thorac Surg 2002; 73:1817-21; discussion 1821. [PMID: 12078775 DOI: 10.1016/s0003-4975(02)03575-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stentless porcine aortic valves offer several advantages over traditional valves. Among these are superior hemodynamics, laminar flow patterns, lack of need for anticoagulation, and perhaps improved durability. METHODS One hundred four patients were operated on from September 17, 1992, to October 31, 1997, as part of a multicenter worldwide investigation of the Medtronic Freestyle stentless porcine bioprosthesis. All patients received a total aortic root replacement. The patients were evaluated postoperatively at discharge, at 3 to 6 months, and yearly by clinical examination and color flow Doppler echocardiography. RESULTS Operative mortality was 3.9%. No patient experienced structural valve deterioration, nonstructural deterioration, perivalvular leak, or unacceptable hemodynamic performance. At 8 years, survival was 59.8%. Freedom from thromboembolic complications was 83.3%. Freedom from postoperative endocarditis was 96.9%. Freedom from reoperation was 100%. Mean systolic gradients did not change over the time period studied. They were 6.4 +/- 3.8 mm Hg at 1 year and 6.7 +/- 2.6 mm Hg at 8 years. Correspondingly, effective orifice area was 1.9 +/- 0.7 cm2 at 1 year and 1.8 +/- 0.8 cm2 at 8 years. The incidence of any aortic insufficiency also did not change over the length of follow-up. At 1 year, 98% of patients had no or trivial aortic insufficiency and 2% had mild aortic insufficiency. At 8 years, 100% of patients evaluated were free of any aortic insufficiency. CONCLUSIONS The Medtronic Freestyle aortic root bioprosthesis can be used safely to replace the aortic root or aortic valve for aortic valve and aortic root pathology. Total root replacement allows optimal hemodynamic performance with no significant aortic regurgitation. Results up to 8 years show excellent survival and no signs of degeneration. Further follow-up is still needed to determine valve durability.
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Affiliation(s)
- Neal D Kon
- Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1096, USA.
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Cohen G, Christakis GT, Joyner CD, Morgan CD, Tamariz M, Hanayama N, Mallidi H, Szalai JP, Katic M, Rao V, Fremes SE, Goldman BS. Are stentless valves hemodynamically superior to stented valves? A prospective randomized trial. Ann Thorac Surg 2002; 73:767-75; discussion 775-8. [PMID: 11899180 DOI: 10.1016/s0003-4975(01)03338-0] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although stentless aortic bioprostheses are believed to offer improved outcomes, hemodynamic benefits remain unsubstantiated. METHODS Fifty-three patients were randomized to receive the stented C-E pericardial valve (CE) and 46 patients the Toronto Stentless Porcine valve (SPV). Annuli were sized for the optimal insertion of both valve types, such that surgeons were required to commit to specific valve sizes before randomization. Echocardiographic measurements and functional status (Duke Activity Status Index) were assessed at 3 and 12 months postoperatively. RESULTS Although cardiopulmonary bypass times (CE: 118.6+/-36.3 minutes; SPV: 148.5+/-30.9 minutes; p = 0.0001) and aortic cross-clamp times (CE: 95.4+/-28.6 minutes; SPV: 123.6+/-24.1 minutes; p = 0.0001) were significantly prolonged in the SPV group, perioperative morbidity and mortality was similar between groups. Neither valve offered a superior internal diameter for any given annular diameter (mean decrease in left ventricular outflow tract diameter after valvular implantation: SPV: 3.4+/-1.11 mm versus CE: 3.7+/-1.33 mm; p = 0.25). Although labeled mean valve size was significantly larger in the SPV group, the actual mean valve size based on internal valvular diameter was no different between groups (CE: 21.9+/-2.0 mm; SPV: 22.3+/-2.0 mm; p = 0.286). Although effective orifice areas increased, and mean and peak transvalvular gradients decreased in both groups over time, no differences were demonstrated between groups at 12 months. Similarly, although significant regression of left ventricular mass was accomplished in both groups over time, no differences were demonstrated between groups. Finally, Duke Activity Status Index scores of functional status improved in both groups over time; however, no differences were noted between groups at 12 months postoperatively. CONCLUSIONS Although offering excellent outcomes, stentless valves did not demonstrate superior hemodynamic indices in comparison to stented valves up to 12 months after implantation.
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Affiliation(s)
- Gideon Cohen
- Division of Cardiovascular Surgery, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Ontario, Canada
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Affiliation(s)
- Marcos Murtra
- Cardiac Surgical Department, University Hospital Vall d'Hebron, Autonomic University of Barcelona, Spain.
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