Stentless Versus Stented Aortic Valve Replacement for Aortic Stenosis

BACKGROUND

The differences in long-term outcomes of aortic valve replacement for aortic stenosis between stentless and stented bioprostheses are controversial.

METHODS

Between 2007 and 2018, 1173 patients underwent aortic valve replacement for aortic stenosis, including 559 treated with a stentless valve and 614 with a stented valve. A propensity score matched cohort with 348 pairs was generated by matching for age, sex, body surface area, bicuspid aortic valve, chronic lung disease, previous cardiac surgery, coronary artery disease, renal failure on dialysis, valve size, concomitant procedures, and surgeon. The primary endpoints of the study were long-term survival and incidence of reoperation.

RESULTS

Immediate postoperative outcomes were similar between the stentless and stented groups with an overall operative mortality of 2.9% (P = .19). Kaplan-Meier estimation for long-term survival was comparable between the stentless and stented valves in both the whole cohort and the propensity score matched cohort (10-year survival 59% vs 55%, P = .20). The hazard ratio of stentless vs stented valve for risk of long-term mortality was 1.12 (P = .33). The 10-year cumulative incidence of reoperation due to valve degeneration was 5.5% in the stentless group and 4.7% in the stented group (P = .25). The transvalvular pressure gradient at 5-year follow-up was significantly lower in the stentless group (7 vs 11 mm Hg, P < .001).

CONCLUSIONS

Both stented and stentless valves could be used in aortic valve replacement for aortic stenosis. We recommend stented valves for aortic valve replacement in patients with aortic stenosis for their simplicity of implantation.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Clinical outcome and hemodynamic performance of St. Jude Trifecta aortic prosthesis: short-term follow-up and risk factors analysis

BACKGROUND

We retrospectively analysed the short-term outcome of the third-generation St. Jude Trifecta aortic prosthesis.

METHODS

Between December 2014 and December 2017, 177 patients (mean age 75.1±6.8 years, 95 males, 82 females) underwent aortic valve replacement with a St. Jude Trifecta aortic prosthesis and were followed up to 27±9 months. Preoperatively 92 patients (52.0%) were in NYHA class III-IV, EuroSCORE II was 3.2%±2.1%.

RESULTS

Trifecta sizes implanted were 19 mm (n=46) (26%), 21 mm (n=69) (39%), 23 mm (n=46) (26%), 25 mm (n=16) (9%). Concomitant coronary artery bypass grafting was performed in 60 patients (34.0%). Operative mortality was 3.4% (1.7% for isolated aortic valve replacement versus 6.7% for combined aortic valve replacement and coronary artery bypass grafting) (P=0.084). The only independent predictor of mortality was the need for the mechanical ventilation greater than 24 hours (P=0.037); recently occurring myocardial infarction was risk factor for mortality at the univariate analysis only (P=0.013). Three-year survival was 84%±6%, freedom from cardiac death 98%±1%, freedom from prosthetic endocarditis 97%±1%. No thromboembolisms or structural valve degeneration were observed. Patient-prosthesis mismatch (PPM) was absent in 126 patients (71.2%), mild-to-moderate in 32 (18.1%), moderate in 19 (10.7%), severe in no any patient. Follow-up echocardiography showed an average mean and peak trans-aortic valve gradients reduction more than 70% in comparison with preoperative value (P<0.0001), and a significant regression of left ventricular hypertrophy (P<0.0001). Moderate PPM did not negatively affect survival. Concomitant severe coronary artery disease was found as an independent predictor of reduced survival (72%±12% versus 86%±6%) (P=0.015).

CONCLUSIONS

Trifecta aortic prosthesis seems to provide very favourable clinical outcome and hemodynamic performance. At three years, survival was negatively affected by severe coronary artery disease detected at the time of operation. During short-term follow-up, no early structural valve degeneration was been observed. Due to low incidence of PPM and low peak and mean trans-prosthetic aortic valve gradients, third generation Trifecta aortic prosthesis should be considered as one of the best options in the setting of the aortic valve replacement surgery. However, a long-term follow-up is mandatory to confirm the early promising data.