Mid-term outcomes and hemodynamic performance of the St Jude Medical Epic aortic bioprosthesis for severe aortic stenosis

The St. Jude Medical Epic Supra valve is a porcine bioprosthesis designed for complete supraannular implantation. No report has shown the hemodynamic performance and clinical outcomes of aortic valve replacement with the Epic Supra valve for severe aortic stenosis in a Japanese cohort. We retrospectively evaluated 65 patients who underwent aortic valve replacement using the Epic Supra valve for aortic stenosis at our department between May, 2011 and October, 2016. The mean follow-up period was 68.7 ± 32.7 months, and the follow-up rate was 89.2%. The mean age was 76.8 ± 5.3 years. The 1-, 5-, and 8-year survival rates were 96.9%, 79.4%, and 60.3%, respectively. The rates of freedom from valve-related events were 96.6% and 81.9% at 5 and 8 years, respectively. Four patients were diagnosed with structural valve deterioration (SVD), and reintervention was performed in two patients. The rates of freedom from SVD were 98.2% and 83.3% at 5 and 8 years, respectively, and the mean time to diagnosis of SVD was 72.5 ± 25.3 months. The mean pressure gradient (MPG) was 16.8 ± 6.0 mmHg postoperatively, 17.5 ± 9.4 mmHg at 5 years, and 21.2 ± 12.4 mmHg at 8 years (p = 0.08). The effective orifice area index (EOAI) was 0.95 ± 0.2 cm2/m2 immediately after surgery, 0.96 ± 0.27 cm2/m2 at 5 years, and 0.84 ± 0.2 cm2/m2 at 8 years (p = 0.10). An increase in MPG and decrease in EOAI were also observed, which may be associated with SVD. Follow-up after 5 years is important to determine if there is an increase.

Five-Year Transcatheter Aortic Valve Replacement Outcomes in Chronic Hemodialysis vs. Non-Hemodialysis Patients Using Balloon-Expandable Devices

BACKGROUND

Based on the results of a clinical trial in Japan, transcatheter aortic valve replacement (TAVR) for hemodialysis (HD) patients gained approval; however, mid-term TAVR outcomes and transcatheter aortic valve (TAV) durability in HD patients remain unexplored.Methods and Results: We analyzed background, procedural, in-hospital outcome, and follow-up data for 101 HD patients and 494 non-HD patients who underwent TAVR using balloon-expandable valves (SAPIEN XT or SAPIEN 3) retrieved from Osaka University Hospital TAVR database. Periprocedural mortality and TAVR-related complications were comparable between HD and non-HD patients. However, Kaplan-Meier analysis revealed that HD patients had significantly lower survival rates (log-rank test, P<0.001). In addition, HD patients had significantly higher rates of severe structural valve deterioration (SVD) than non-HD patients (Gray test, P=0.038).

CONCLUSIONS

TAVR in HD patients had comparable periprocedural mortality but inferior mid-term survival and TAV durability than in non-HD patients. Indications for TAVR in younger HD patients should be carefully determined, considering the possibility of a TAV-in-TAV procedure when early SVD occurs.

Valve-in-valve transcatheter aortic valve implantation: The issues behind crossing a bioprosthesis

Valve-in-valve transcatheter aortic valve implantation (ViV TAVI) is rapidly arising as a safe and effective alternative to redo-surgery in the treatment of bioprostheses deterioration. While scientific community is currently focusing its attention on the most common limitations related to this procedure, such as the risk of coronary obstruction and patient-prosthesis mismatch, data regarding the first step of a ViV TAVI, the crossing of a degenerated bioprosthesis, are still lacking. The aim of this review is to analyze the available information about bioprosthesis crossing, to show the inherent challenges encountered by interventional cardiologists during valve crossing and to describe the current strategies to perform a correct crossing.

Transcatheter aortic valve implantation for structural valve deterioration of homograft surgical aortic valve using SAPIEN3 Ultra RESILIA: a case report

Background

There are a few case reports regarding transcatheter aortic valve implantation (TAVI) for deteriorated surgical homograft.

Case summary

We present a case of severe structural valve deterioration (SVD) of homograft surgical aortic valve presenting severe aortic regurgitation in an 84-year-old man with decompensated heart failure. We performed TAVI in homograft valve using 23 mm SAPIEN3 Ultra RESILIA. The resulting grade of paravalvular regurgitation was trace, the post-operative effective orifice area (EOA) was 1.66 cm2 (index EOA: 1.19 cm2/m2), and device success was achieved.

Discussion

Stented bioprosthetic valves are more commonly implanted than mechanical and stentless bioprosthetic valves. In the 1980s and the early 1990s, homografts became particularly popular as alternatives to stented valves. There are several reports of TAVI for homograft SVD, but the paravalvular leakage grade is worse than that of redo-surgical aortic valve replacement, although the mortality rate is lower. However, the valves used in these reports were from older valves such as SAPIEN XT or SAPIEN3. There are no reports using SAPIEN3 Ultra RESILIA with a significant reduction in paravalvular leak due to an external textured polyethylene terephthalate skirt extending 40% higher above the valve inflow than the classical SAPIEN3, which is now available. Transcatheter aortic valve implantation using SAPIEN3 Ultra RESILIA showed good therapeutic efficacy.

Mid-term clinical and echocardiographic results of the INSPIRIS RESILIA aortic valve: a retrospective comparison to the Magna Ease

OBJECTIVES

The INSPIRIS aortic valve combines the RESILIA proprietary tissue preservation process and an expandable stent frame to benefit future transcatheter valve-in-valve procedures. As the INSPIRIS valve became commercially available in 2017, mid-term outcome reports are scarce. We aimed to evaluate mid-term safety and echocardiographic performance of the INSPIRIS valve in comparison to its predecessor, the Carpentier Edwards Perimount Magna Ease (ME).

METHODS

This study was a retrospective single-centre study. Clinical results included early postoperative outcomes, mid-term mortality and readmission for cardiovascular cause or stroke. Echocardiographic follow-up (FU) was performed at discharge and 1-3, 6, 12 and 24 months. Clinical end point analyses were accomplished with a propensity score matching analysis and FU echocardiographic data comparisons using pairwise analyses and linear mixed-effect models.

RESULTS

We included 953 patients who received an INSPIRIS (n = 488) or ME (n = 463) bioprosthesis between January 2018 and July 2021. In the matched population (n = 217 per group), no significant difference in short-term outcomes was observed, survival was similar at 30 months (INSPIRIS: 94% vs ME: 91%, P = 0.89), but freedom from readmission was higher in the INSPIRIS group (94% vs 86%, P = 0.014). INSPIRIS valves had a lower gradient at discharge (∼10 vs 14 mmHg, P < 0.001), 1-3 months (∼10 vs 12 mmHg, P < 0.001) and 24 months (∼11 vs 17 mmHg, P < 0.001) in paired analyses and significantly lower evolution of mean transvalvular gradients compared to ME.

CONCLUSIONS

This study represents the largest comparative evaluation of the INSPIRIS to the ME valves, which demonstrated safe clinical outcomes and favourable haemodynamic performance at 2 years. Long-term FU is underway.

Ten years' experience with the sutureless aortic valve replacement: incidence and predictors for survival and valve durability at follow-up

OBJECTIVES

Aortic valve replacement with a sutureless prosthesis [sutureless aortic valve replacement (Su-AVR)] is an option for patients with severe aortic valve stenosis. However, data regarding long-term outcomes and prosthesis durability are still lacking.

METHODS

All consecutive patients who successfully underwent Su-AVR with the Perceval valve in our centre between 2010 and 2020 were included in the analysis and followed prospectively with echocardiography. Risk factor analysis was performed to assess variables associated with worse survival and bioprosthetic valve failure.

RESULTS

Study population consisted of 547 patients: the mean age was 76.4 (5.2) years, 51% were female and the mean logistic EuroSCORE was 13% (11). The median survival was 7.76 years [95% confidence interval (CI) = 6.9-8.6]. Risk factor analysis identified age [hazard ratio (HR) 1.06, 95% CI 1.03-1.11; P < 0.001), EuroSCORE II (HR 1.08, 1.02-1.13; P < 0.001), baseline dialysis (HR 2.14, 95% CI 1.4-4.4; P = 0.038) and postoperative acute kidney injury ≥2 (HR 8.97, 95% CI 4.58-17.6; P < 0.001) as factors significantly correlated with worse survival. The reported HRs for age are per 1 year and for EuroSCORE II is 1 percentage point. Structural valve deterioration (SVD) was observed in 23 patients, of whom 19 underwent reintervention (median freedom from SVD 10.3 years). In multivariable Cox analysis, age (HR 0.89, 95% CI 0.82-0.95; P < 0.001) was found to be a significant predictor of SVD. Overall, 1.8% was referred for prosthetic valve endocarditis (confirmed or suspected) during follow-up. One patient showed moderate non-SVD and none developed prosthetic valve thrombosis.

CONCLUSIONS

The sutureless valve represents a reliable bioprosthesis for aortic valve replacement in patients with a 10-year life expectancy. Younger age at the time of implant is the only factor associated with the risk of long-term SVD.

Thromboembolic and hemorrhagic complications in patients with prosthetic heart valves cared for in a tertiary care center. What have we learned?

BACKGROUND

Heart valve replacement surgery with mechanical or biological prostheses entails a risk of thromboembolism and bleeding complications.

OBJECTIVE

To determine the complications related to complementary anticoagulation therapy and the probability of risk.

METHODS

One-hundred and sixty-three patients who underwent heart valve replacement between 2002 and 2016 with either mechanical or biological prostheses, and who received vitamin K antagonists after hospital discharge, were studied. Anticoagulation therapy was categorized into optimal and non-optimal according to INR values prior to the development of complications. Patients with comorbidities and other risk factors for thrombosis and/or bleeding were excluded.

RESULTS

In total, 68.7 % of patients received mechanical prostheses, and 31.3 %, biological prostheses (p ≤ 0.001); 25.2 % experienced the complications that motivated the study (p ≤ 0.001), which were hemorrhagic in 48.8 %, thromboembolic in 26.8 %, and of both types in 24.4 % (relative risk = 4.229). Among the patients with complications, 95.1 % received mechanical prostheses, and 4.9 %, biological (p = 0.005); non-optimal INR was identified in 49.7 % (p ≤ 0.001).

CONCLUSIONS

Given the high risk of thromboembolic and hemorrhagic complications, valve prostheses must be carefully chosen, and care priorities should include prevention and follow-up, especially in those patients who require anticoagulation therapy.

Is cell regeneration and infiltration a double edged sword for porcine aortic valve deterioration? A large cohort of histopathological analysis

BACKGROUND AND OBJECTIVE

Bioprostheses are the most common prostheses used for valve replacement in the Western medicine. The major flaw of bioprostheses is the occurrence of structural valve deterioration (SVD). This study aimed to assess the pathological features of porcine aortic valve (PAV)-SVD based on histomorphological and immunopathological characteristics of a large cohort of patients.

METHODS

Histopathological data of 109 cases with resected PAV were collected. The type and amount of infiltrated cells were evaluated in the different types of bioprosthetic SVD by immunohistochemical staining.

RESULTS

The most common cause of SVD was calcification, leaflet tear, and dehiscence (23.9%, 19.3%, and 18.3%, respectively). Immunohistochemical staining demonstrated that macrophages were infiltrated in the calcified, lacerated and dehiscence PAV, in which both M1 and M2 macrophages were existed in the calcified PAV. Importantly, the higher content of M1 macrophages and less content of M2 macrophages were found in the lacerated and dehiscence PAV, and MMP-1 expression was mainly found in the lacerated PAV. The endothelialization rate of leaflet dehiscence was higher than that of calcified and lacerated leaflets. A large number of CD31+/CD11b+ cells was aggregated in the spongy layer in the lacerated and dehiscence PAV.

CONCLUSION

Cell regeneration and infiltration is a double edged sword for the PAV deterioration. Macrophage infiltration is involved in the different types of SVD, while only MMP-1 expression is involved in lacerated leaflets. The macrophage subtype of circulating angiogenic cells in dehiscence and tear PAV could be identified, which could reserve macrophages in the PAV-SVD.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

Retrospective study

Background

Structural valve deterioration (SVD) remains the major determinant of bioprosthesis durability. The aim of this study was to investigate the SVD incidence, predictors and outcomes in patients aged 50 years and younger after bioprosthetic aortic valve replacement (bAVR).

Methods

We retrospectively analyzed 73 consecutive patients ≤50 years old who underwent bioprosthetic AVR at our center between 2005 and 2015. Median age at surgery was 44 (interquartile range [IQR]: 39-47) years. Follow-up was 93.2% complete at a median time of 7.2 (IQR: 5.5-9.5) years. Cumulative follow-up was 545.5 valve-years. Bioprosthesis SVD was determined by strict echocardiographic assessment.

Results

The overall survival-rate at 10/15 years and freedom from SVD at 10/12.5 years were 89.6 ± 5.2%/81.5 ± 9.1% and 73.5 ± 8.2%/41.9 ± 18.9%, respectively. SVD occurred at a median time of 8.2 (IQR: 6.0-9.9) years after bAVR. Age was not found as an independent predictor for SVD at the multivariable model, despite a higher rate of SVD in the age group ≤30 years. Freedom from reoperation due to SVD at 10/15 years was 71.3 ± 14.1%/13.6 ± 12.3%. Reoperation was performed at a median time of 10.0 (IQR: 8.9-11.9) years since first bAVR and was associated with a 100% 12-month survival.

Conclusions

In our study, the rate and time of SVD occurrence were comparable to those of other studies' older age groups. Strict echocardiographic monitoring of valve performance is mandatory to set the appropriate timing of eventual reoperation. This attitude can improve outcomes of bAVR in younger patients.

Long-Term Echocardiographic Follow-Up After Transcatheter Aortic Valve Implantation to Assess Structural Valve Deterioration and Bioprosthetic Valve Failure

BACKGROUND

Indications for transcatheter aortic valve implantation (TAVI) in aortic stenosis are expanding and the life expectancy of patients following TAVI is increasing. Determining the long-term durability of TAVI valves is therefore important. Rates of long-term (≥5 years) structural valve deterioration (SVD) vary widely and there are currently no comparable data from Australia. The aim herein was to determine the incidence of haemodynamic SVD and bioprosthetic valve failure (BVF) using recently standardised definitions in a Western Australian cohort after at least 5 years.

METHODS

This is a retrospective cohort study of consecutive patients undergoing TAVI at Royal Perth Hospital between January 2009 and January 2015. Of 211 patients, 55 survived ≥5 years and had echocardiographic data available for review. Median time to the echocardiogram was 5.9 years (max 7.8 years); 49% male, mean age 83 years.

RESULTS

Of the 55 survivors who had echocardiograms available ≥5 years after TAVI, four (9%) had moderate haemodynamic SVD and one (2%) had severe SVD and BVF.

CONCLUSIONS

Our results suggest excellent long-term durability of contemporary TAVI valves in an Australian cohort with very low incidence of SVD and BVF. These findings add confidence to the expanding applications of TAVI valves.

Modes of the bioprosthetic valve failure of the porcine and pericardial valves in the mitral position

OBJECTIVES

This study was conducted to examine the incidence and modes of the bioprosthetic valve failure of the porcine valve in the mitral position and compare them with those of the pericardial valve.

METHODS

This study included 240 patients (116 men [48.3%]; mean age, 74.87 ± 6.61 years) who underwent mitral valve replacement using the St. Jude Medical Epic bioprosthesis (Epic) (N = 125) or Carpentier-Edwards Perimount (CEP) pericardial valve (N = 115) from January 2000 to December 2020.

RESULTS

The median clinical follow-up durations in the Epic and CEP groups were 54.5 months (range, 0-111 months) and 81.5 months (range, 0-194 months), respectively. Structural valve degeneration (SVD) was observed in 9 patients (7.2%) in the Epic group and 11 patients (9.6%) in the CEP group. The rates of freedom from SVD at 3, 5 and 7 years were 97.7%, 90.5% and 75.5% in the Epic group and 100.0%, 96.1% and 90.0% in the CEP group, respectively. SVD reoperation was performed for 7 patients (5.6%) in the Epic group and 6 patients (5.2%) in the CEP group. The rates of freedom from SVD reoperation at 3, 5 and 7 years were 97.7%, 90.5% and 75.5% in the Epic group and 100%, 96.1% and 90.0% in the CEP group, respectively. Epic SVD was predominantly due to leaflet tearing, whereas CEP SVD was predominantly due to leaflet calcification and adhesion to the subvalvular apparatus.

CONCLUSIONS

SVD of the porcine valve was predominantly due to leaflet tearing. The rate of reoperation for SVD was slightly higher for the porcine valve in the mitral position than for the pericardial valve at adjusted survival analysis.

Strict control of phosphorus concentration of hemodialysis patients may decrease structural valve deterioration after aortic valve replacement

OBJECTIVES

The number of hemodialysis patients requiring aortic valve replacement (AVR) is increasing. Although bioprosthetic valves are increasingly popular, they are associated with a risk of structural valve deterioration (SVD). The aim of this study is to examine the outcomes of bioprosthetic valves in hemodialysis patients undergoing AVR and to identify treatment strategies that can decrease the risk of SVD.

METHODS

Between February 2010 and November 2019, 61 patients on hemodialysis underwent AVR using bioprosthetic valves at our hospital. Five patients died while still in the hospital. Kaplan-Meier estimates of overall survival and univariate Cox proportional hazards regression analyses were performed for the remaining 56 patients.

RESULTS

During follow-up, there were six SVD events (10.7%) related to the bioprosthetic valves. The survival rate was 67.9% at 3 years and 39.5% at 5 years. In all SVD cases, SVD was caused by aortic stenosis. The mean interval between AVR and the discovery of SVD was 41.5 months. The SVD-free rate was 88.6% at 3 years and 65.3% at 5 years. Preoperative phosphorus levels are associated with SVD risk. High preoperative phosphorus concentration is associated with elevated SVD risk.

CONCLUSIONS

In this study, we determined that the risk of SVD can be influenced by preoperative phosphorus level. Strict control of the phosphorus concentration of hemodialysis patients may decrease structural valve deterioration after aortic valve replacement.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Aortic and mitral bioprosthetic valve dysfunction: surgical or percutaneous solutions?

In the last years, there has been a trend to prefer biological prostheses, especially among young patients, with the aim to avoid anticoagulant treatment. Surgical tissue valves have so far demonstrated their solid long-term durability. However, younger age has been identified as one of the main risk factors for developing structural valve deterioration (SVD). As a consequence, the proportion of subjects at risk for valve dysfunction will constantly rise in the near future. However, while surgical reintervention has always been considered the gold standard for treatment of prosthesis deterioration, the introduction of transcatheter heart valves could offer new therapeutical options, particularly among high-risk patients, aiming a second less invasive chance. The recent standardization of valve durability definitions will soon allow a more comprehensive understanding of the mechanism underlying SVD and guide the choice of prosthesis for patients needing valve replacement.

Surgical explantation of a failed transcatheter aortic valve

With transcatheter aortic valve replacement being increasingly utilized in a younger and lower risk population, we can expect to see larger numbers of patients presenting with structural deterioration of aortic valves replaced by the transcatheter route that now require explantation and surgical replacement.   Surgical aortic valve replacement after transcatheter aortic valve replacement is associated with operative morbidity and mortality rates significantly higher than those seen in the setting of surgical replacement of the native valve, which had a 30-day mortality of 12-20% in recent series. Centers performing transcatheter aortic valve replacement in lower risk patients with longer expected lifespans and a higher probability of late structural deterioration of the transcatheter aortic valve replacement should carefully consider their choice of valve type (balloon-expandable versus self-expanding) and patient anatomy, including annulus and root diameter, at the time of the initial valve intervention. Further, one should not forget the mechanical surgical aortic valve replacement option in younger patients with risk factors for early structural valve deterioration such as obesity, metabolic syndrome, and chronic kidney disease. The objectives of this tutorial are to describe the preoperative workup for a patient with late structural valve deterioration after transcatheter aortic valve replacement, detail the explantation approach specific to self-expanding valves, and illustrate the key decisions and techniques needed for subsequent surgical aortic valve replacement.

Long-Term Outcomes of the Mosaic Mitral Porcine Bioprosthesis in Japan - Results From the Japan Mosaic Valve Long-Term Multicenter Study

BACKGROUND

This study retrospectively evaluated the long-term patient outcomes and durability of the Mosaic mitral porcine bioprosthesis in the Japan Mosaic valve long-term multicenter study.Methods and Results:The medical records of 390 patients who underwent mitral valve replacement with the Mosaic bioprosthesis at 10 centers in Japan (1999-2014) were reviewed. Patient data were collected using the Research Electronic Data Capture software. Patient survival was determined using the Kaplan-Meier method. Freedom from structural valve deterioration (SVD) and valve-related reoperation and death were determined using actuarial methods. The median (interquartile range [IQR]) age of the cohort was 73 (69-77) years. The median (IQR) follow-up period was 4.83 (1.84-8.26) years. The longest follow-up period was 15.8 years. The 30-day mortality rate was 5.4%. The 12-year actuarial survival rate was 54.1±4.5%, and the freedom from valve-related death was 85.3±3.4%. The freedom from reoperation at 12 years was 74.3±5.7%. The freedom from SVD at 12 years was 81.4±6.6% for patients aged ≥65 years and 71.6±11.1% for those aged <65 years. The median (IQR) mean pressure gradient was 4.1 (3.0-6.0) and 5.6 (4.0-6.7) mmHg at 1 and 10 years, respectively. The median (IQR) effective orifice area was 1.7 (1.4-2.0) and 1.4 (1.2-1.6) cm²at 1 and 10 years, respectively.

CONCLUSIONS

The Mosaic porcine bioprosthesis offered satisfactory long-term outcomes for up to 12 years.

Redo aortic valve replacement due to early structural valve deterioration in a trifecta valve: A case report

Introduction and importance

While the number of SAVR cases has been increasing for patients below their sixties due to the improvement of bioprosthetic valves, some early structural valve deterioration (SVD) in Trifecta valves has been reported.

Case presentation

We present a case of a female who presented with sudden shortness of breath. Ultrasonography diagnosed SVD. We performed redo aortic valve replacement due to SVD in Trifecta valve. With our surgical technique we could remove the bioprosthetic valve easily.

Clinical discussion

We could easily remove the mounted prosthetic valve along with the titanium band. These cases may emerge with acute heart failure due to sudden massive aortic regurgitation, not like the gradual progression of stenosis due to calcification.

Conclusion

The postoperative course in Trifecta recipients must be followed carefully.

•

Early structural valve deterioration with Trifecta valve

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Postoperative patients using Trifecta valve should be carefully followed up.

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Mounted Trifecta valve could easily be removed along with titanium band.

Longitudinal Hemodynamics of Aortic Bioprosthetic Valve in Hemodialysis Patients

We examined the hemodynamic profile of bioprosthetic aortic valves in patients on hemodialysis (HD), longitudinally, and assess the incidence of adverse changes detected by echocardiography. Of 1,146 consecutive patients with severe aortic stenosis who underwent bioprosthetic aortic valve replacement (AVR), 148 patients had end-stage renal disease requiring HD. Each patient on HD was matched one-to-one with a non-HD patient on the basis of propensity scores. The mean follow-up period was 3.3 years for the HD group and 5.9 years for the non-HD group. Follow-up information was available for 95.2%. Postoperative trends of valve hemodynamics derived from linear mixed-effect models showed significant group vs time interactions between the two groups. Stable hemodynamics was consistently observed in the non-HD group, whereas the HD group showed a decrease of -0.06 cm²/y (95% confidence interval (CI), -0.10 to -0.02) in effective orifice area, an increase of 0.8 mm Hg/year (95% CI, 0.4-1.1) in mean pressure gradient, and an increase of 0.08 m/s/year (95%CI, 0.02-0.13) in peak velocity. Cumulative incidence function of SVD more than stage 2 was significantly higher in the HD group (13.1% vs 3.1% at 5 years, Gray test p = 0.01). In a multivariable Fine-Gray analysis, diabetes was independently associated with SVD more than stage 2 in the HD group (subhazard ratio, 1.91; 95% CI, 1.25-2.89; p = 0.02). Survival free-from stenotic-type SVD was significantly lower in HD patients undergoing bioprosthetic AVR. Diabetes was independently associated with postoperative stenotic-type SVD in HD patients.

The pathology of early failure in Mitroflow pericardial valve bioprosthesis (12A/LX)

BACKGROUND

Limited mid-term durability of 12A/LX Mitroflow bioprosthesis has been reported. Aim of the study was to ascertain the pathologic substrates and possible mechanisms of structural valve deterioration in explants from animals and humans.

METHODS

Nine aortic 12A/LX Mitroflow bioprostheses preserved in hypotonic solution and three aortic 12A/LX bioprostheses, preserved in isotonic solution, were explanted from juvenile sheep, mean time from implant 95.66 ± 36.04 days and 132.33 ± 28.88 days from implant respectively. One stented unimplanted 12A/LX Mitroflow preserved in isotonic colution before glutaraldeyde fixation served as control. Ten aortic 12A/LX Mitroflow bioprostheses were explanted from humans because of severe dysfunction: five children, (3 females and 2 males, mean age 14.19 ± 4.77 years, range 11-21), 26 ± 8.24 months from implant and 5 adults (4 females and 1 male, mean age 57.4 ± 19.85 years, range 31-72), 64.4 ± 26.94 months from implant. X-ray, histology, and transmission electron microscopy were carried out as well as spectroscopy for calcium (Ca++) and phosphorus (P) content in human explants.

RESULTS

Explants, from both animals and humans, showed cusp folding and stiffness, with coarse calcific deposits at gross examination and X-ray. Severe collagen denaturation, plasma insudation and massive calcification, involving both collagen and cell debris, were observed microscopically. Mean Ca++ content of 183.27 ± 62.48 and P content of 94.35 ±33.76 mg/g dry weight was found in children and Ca++ content of 205.49 ± 2.23 and P content of 99.75 ± 0.11 mg/g dry weight in adults. Obstructive fibrous tissue overgrowth was detected in 6 human cases.

CONCLUSIONS

Collagen denaturation was observed in pericardial Mitroflow 12A/LX bioprosthesis with premature structural valve deterioration. Optimal collagen fixation and preservation as well as phospholipids reduction by removing cell debris, as employed in the novel CROWN PRT Mitroflow bioprosthesis, are expected to solve the flaw and achieve long-term durability.

Morphologic investigation on Perceval S, a sutureless pericardial valve prosthesis: collagen integrity after collapsing-ballooning and structural valve deterioration at distance

Perceval S is a self-expandable, stent-mounted bioprosthetic valve (BPV), with glutaraldehyde treated bovine pericardium, processed with homocysteic acid as an anti-calcification treatment. The stent is crimpable but the valve insertion is done surgically via a shorter procedure which does not require sutures. OBJECTIVES: MATERIAL AND METHODS: RESULTS: CONCLUSIONS: Collapsing and ballooning do not alter cusp collagen periodicity. Structural valve deterioration with stenosis, due to dystrophic calcification and fibrous tissue overgrowth, seldom occurred in the mid-term. Glutaraldehyde fixed pericardium has the potential to undergo structural valve deterioration with time, similar to well-known BPV failure. This supports the recommendation to pursue improvement of tissue valve treatment with enhanced durability.

Structural valve deterioration after aortic valve replacement with the Trifecta valve

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Early cusp tear of the second-generation Trifecta valve with Glide Technology

We herein report a case of early cusp tear of the second-generation Trifecta valve with Glide Technology. A 69-year-old woman underwent aortic valve replacement with a Trifecta valve with Glide Technology and partial arch replacement for severe aortic valve stenosis caused by a bicuspid valve and ascending aortic and aortic arch aneurysms 2 years previously. During follow-up, she suddenly developed dyspnoea and a heart murmur. Echocardiography revealed severe aortic valve regurgitation caused by structural valve deterioration. We performed re-aortic valve replacement with a mechanical valve through re-median sternotomy. Intraoperative examination revealed a bottom tear of the left coronary cusp without infection or pannus formation.

Impact of dialysis in patients undergoing bioprosthetic aortic valve replacement

OBJECTIVES

To determine the incidence of bioprosthetic structural valve deterioration in dialysis patients undergoing aortic valve replacement compared to that in patients without dialysis.

METHODS

This single-centre retrospective observational study included 1159 patients who underwent aortic valve replacement using bioprosthetic valves for aortic stenosis and/or regurgitation at our institution between 2007 and 2017 [patients with dialysis (group D, n = 134, 12%) or without dialysis (group N, n = 1025, 88%)]. To adjust for potential differences between groups in terms of initial preoperative characteristics or selection bias, a propensity score analysis was conducted. The final sample that was used in the comparison included 258 patients, as follows: 129 patients with dialysis (group D) and 129 patients without dialysis (group N). The cumulative incidences of all-cause death, cardiac death and moderate or severe structural valve deterioration were estimated using the Kaplan-Meier method.

RESULTS

Operative mortality was significantly higher in group D than group N (9% vs 0%, P = 0.001). Kaplan-Meier analysis revealed that in group D, the incidence was significantly higher for all-cause death (P < 0.001, 50% vs 18% at 5 years), cardiac death (P = 0.001, 18% vs 5% at 5 years) and moderate or severe structural valve deterioration (P < 0.001, 29% vs 5% at 5 years) compared with group N.

CONCLUSIONS

The incidence of structural valve deterioration in dialysis patients undergoing aortic valve replacement was higher than that in patients without dialysis. Bioprosthetic valves should be carefully selected in dialysis patients undergoing aortic valve replacement.

Balloon-expanding transcatheter aortic valve implantation for degenerated Mitroflow bioprostheses: clinical and echocardiographic long-term outcomes

OBJECTIVES

This study aims to analyse the risks associated with valve-in-valve procedures for treating structural valve deterioration in Mitroflow bioprostheses, as well as to determine the impact of the original Mitroflow size on the patients' long-term outcomes.

METHODS

Between January 2012 and September 2019, 21 patients (61.9% males; mean age 82.4 ± 5.4 years) were treated for Mitroflow deterioration with valve-in-valve procedures (12 transapical and 9 transfemoral).

RESULTS

Mean EuroSCORE I and EuroSCORE II were 28.2% ± 13.6% and 10.5% ± 6.1%, respectively. Six patients presented an indexed aortic root diameter <14 mm/m2 and 7 patients a diameter of sinus of Valsalva <30 mm. Implanted transcatheter valve sizes were 20 mm in 6 cases, 23 mm in 14 cases and 26 mm in 1 patient. A Valve Academic Research Consortium-2 complication occurred in 23.8% of cases, including 3 coronary occlusions. In-hospital mortality was 9.5%. The 20 mm transcatheter valves presented significantly higher postoperative peak and mean aortic gradients than other sizes (54.1 ± 11.3 mmHg vs 29.9 ± 9.6 mmHg, P = 0.003; and 29.3 ± 7.7 mmHg vs 17.4 ± 5.9 mmHg, P = 0.015, respectively). There were 12 cases of patient-prosthesis mismatch (57.1%) and 3 cases (14.3%) of severe patient-prosthesis mismatch. Cumulative survival was 85.7% ± 7.6% at 1 year, 74.3% ± 10% at 2 years and 37.1% ± 14.1% at 5 years.

CONCLUSIONS

Valve-in-valve procedures with balloon-expandable transcatheter valves associate a high risk of coronary occlusion in patients with indexed aortic root diameter <14 mm/m2 and low coronary ostia <12 mm. Valve-in valve procedures with 20 mm balloon-expandable transcatheter valves in ≤21 mm Mitroflow bioprosthesis leave significant residual transvalvular gradients that might obscure patients' long-term outcomes.

Magna ease bioprosthetic aortic valve: mid-term haemodynamic outcomes in 1126 patients

OBJECTIVES

The Magna Ease aortic valve (Edwards Lifesciences, Irvine, CA) is a third-generation bioprosthetic valve developed as a modification of the well-studied Perimount and Magna valve designs. This study's objective is to evaluate a large, single-centre experience with Magna Ease aortic valve replacement (AVR) focusing on clinical outcomes and haemodynamic performance.

METHODS

All patients undergoing AVR between 8/2010 and 10/2018 at our institution implanted with the Magna Ease valve were included except those undergoing ventricular assist device or congenital aortic surgery. Primary outcomes were overall survival and freedom from reoperation. Mean transprosthetic gradient (mTPG) and structural valve deterioration (SVD) served as secondary outcomes.

RESULTS

Totally 1126 consecutive implantations of Magna Ease valves were included. Concomitant procedures were performed in 56.5% (n = 636). No severe patient-prosthesis mismatch (PPM) was present at implantation. Overall survival at 30 days, 1 year, 5 years and 9 years was 97.2%, 95.0%, 86.1% and 78.2%, respectively, with improved survival for isolated AVR. Total of 2.4% (n = 27) of patients required reoperation with 0.3% (n = 4) for SVD. Echocardiographic follow-up data revealed low mTPG throughout the study period. SVD occurred in 28.7% of patients at a mean of 3.9 years post implantation.

CONCLUSIONS

Magna Ease AVR maintained low mean transprosthetic gradients throughout mid-term evaluation and was associated with excellent overall survival and freedom from reoperation at nine years post implantation.

Structural Valve Deterioration Is Linked to Increased Immune Infiltrate and Chemokine Expression

We aim to investigate whether structural valve deterioration (SVD) of bioprosthetic xenogenic tissue heart valves (XTHVs) is associated with increased immune cell infiltration and whether co-expression of several chemokines correlates with this increase in immune infiltrate. Explanted XTHVs from patients undergoing redo valve replacement for SVD were obtained. Immunohistochemical, microscopic, and gene expression analysis approaches were used. XTHVs (n = 37) were obtained from 32 patients (mean 67.7 years) after a mean time of 11.6 years post-implantation. Significantly increased immune cellular infiltration was observed in the explanted SVD valves for all immune cell types examined, including T cells, macrophages, B cells, neutrophils, and plasma cells, compared to non-SVD controls. Furthermore, a significantly increased chemokine gradient in explanted SVD valves accompanied immune cell infiltration. These data suggest the development of SVD is associated with a significantly increased burden of immune cellular infiltrate correlated to the induction of a chemokine gradient around the XHTV, representing chronic immune rejection.Graphical abstract Proposed interaction between innate and adaptive immunity leading to the development of structural valve deterioration in xenogenic tissue heart valves.

Late surgical explantation of a transcatheter heart valve in a patient with a porcelain aorta

Structural valve deterioration is a well-studied phenomenon in bioprosthetic heart valves. Conversely, structural valve deterioration after transcatheter aortic valve implantation is not as well-elucidated. Therefore, late surgical explantation after transcatheter aortic valve implantation is an infrequent procedure, and thus, surgical findings and management of such cases remain unclear, particularly in patients previously labelled as 'inoperable' or at 'high risk'. Herein, we report the case of a late surgical explantation of a transcatheter heart valve (THV) 7 years after its implantation in a patient with a porcelain aorta and periprosthetic regurgitation.

Durability of transcatheter aortic valve implantation: A translational review

Until recently, transcatheter aortic valve implantation was restricted to high-risk and inoperable patients. The updated 2017 European Society of Cardiology Guidelines has widened the indication to include intermediate-risk patients, based on two recently published trials (PARTNER 2 and SURTAVI). Moreover, two other recent trials (PARTNER 3 and EVOLUT LOW RISK) have demonstrated similar results with transcatheter aortic valve implantation in low-risk patients. Thus, extension of transcatheter aortic valve implantation to younger patients, who are currently treated by surgical aortic valve replacement, raises the crucial question of bioprosthesis durability. In this translational review, we propose to produce a state-of-the-art overview of the durability of transcatheter aortic valve implantation by integrating knowledge of the basic science of bioprosthesis degeneration (pathophysiology and biomarkers). After summarising the new definition of structural valve deterioration, we will present what is known about the pathophysiology of aortic stenosis and bioprosthesis degeneration. Next, we will consider how to identify a population at risk of early degeneration, and how basic science with the help of biomarkers could identify and predict structural valve deterioration. Finally, we will present data on the differences in durability of transcatheter aortic valve implantation compared with surgical aortic valve replacement.

Developments in transcatheter aortic bioprosthesis durability

Introduction: Valve durability represents a main concern, as the target population for transcatheter aortic valve implantation (TAVI) evolves to include lower risk and younger patients who are likely to survive for a number of years after the procedure.Areas covered: The purpose of this review article is to provide an overview of potential mechanisms and rates of structural valve deterioration (SVD) of transcatheter bioprostheses.Expert opinion: Recently the standardized definitions of SVD proposed by European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) have permitted for the first time, an objective evaluation of existing and novel TAVI prostheses, and to compare their longevity versus surgical bioprostheses. Although the results of midterm durability of the transcatheter bioprostheses are encouraging, our knowledge concerning the clinical outcomes of TAVI beyond 5 years is still limited. Evidence of longer-term durability is mandatory before replacing surgery with TAVI, particularly in younger and lower-risk patients.

Transcatheter Aortic Valve Replacement: Procedure and Outcomes

Initially, transcatheter aortic valve replacement (TAVR) was only used in patients with severe symptomatic aortic stenosis and prohibitive risk for surgical aortic valve replacement. Subsequently, TAVR was extended to patients with high and intermediate surgical risk. Recently, the results of randomized trials in low-surgical-risk patients showed superiority or noninferiority of TAVR versus surgical aortic valve replacement in this population. Procedural outcomes have been improved. Long-term durability of transcatheter heart valves remains to be confirmed. This article presents the evolution and current status of TAVR, with respect to the different types of devices and procedures as well as its outcomes.

Influence of Mitroflow bioprosthesis structural valve deterioration on cardiac morbidity

Background

This study investigated the extent and nature of cardiac morbidity and cause of mortality in patients with Mitroflow structural valve deterioration (SVD).

Methods

A retrospective study was performed examining the medical records of patients who had received Mitroflow bioprosthesis between February 2001 and April 2014 and died during this period. A total of 211 patients were identified and included in the analyses. To determine the cause of mortality, cases were divided into three predefined groups: cardiovascular death due to SVD (group 1), cardiovascular death with no SVD (group 2) and non-cardiovascular death without SVD (group 3).

Results

Overall mortality in this study was 7.6% at 1 year, 46.4% at 5 years and 97.2% at 10 years. In group 1, 53 patients (25%) died; in group 2, 59 patients (28%) died; and in group 3, 99 patients (47%) died. Hospitalisation for congestive heart failure was observed in 49.1% in the SVD group vs. 10.2 and 13.1% in the two other groups, p < 0.001. Hospitalisation for endocarditis was also significantly higher in the SVD group (11.3%) than in the two other groups (6.8 and 0%), p < 0.05. Hospitalisation due to myocardial infarction, cerebral stroke, arrhythmia or other cardiac-related diseases was not significantly different between groups.

Conclusion

Structural valve deterioration in Mitroflow bioprosthesis was associated with a high prevalence of hospital admissions due to congestive heart failure and endocarditis. Patients with Mitroflow bioprosthesis should be systematically and routinely followed with echocardiography, and reoperation should be considered if SVD has developed.

Bioprosthetic structural valve deterioration: How do TAVR and SAVR prostheses compare?

BACKGROUND

The durability of TAVR prostheses has come under major scrutiny since the move towards lower risk patients. We sought to compare the rate of structural valve deterioration (SVD) over time between transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR).

METHODS

We included all TAVR and SAVR patients (age ≥ 75 years) that were performed in our centre from 2005 until 2015. Applying the internationally "agreed on" definitions of SVD, we surveyed all available serial echocardiographic follow-ups.

RESULTS

We included 269 TAVR and 174 SAVR cases. Post-intervention, TAVR patients had lower mean and peak gradients but higher rate of mild aortic regurgitation. SAVR patients had longer follow-up (in months, SAVR: 53 (30, 85) Vs TAVR: 33.4 (23, 52)). SVD as per Valve Academic Research Consortium-2 (VARC-2) was similar between the two groups (TAVR 28% Vs SAVR 31%; P = 0.593) but moderate haemodynamic SVD (European Association of Percutaneous Cardiovascular Intervention (EAPCI) criteria) was more common among SAVR cases (TAVR 11.5% Vs SAVR 20.7%; P = 0.007). Using Kaplan-Meier estimates, the rate of SVD over time was not different between the two groups as per VARC-2 criteria but different when moderate haemodynamic SVD criteria were applied (Log Rank P = 0.022) in favour of TAVR. The mean gradient rose steadily over time but more so post-SAVR (β = 0.52 ± 0.24 in comparison to TAVR at every given time point; P = 0.032).

CONCLUSION

Structural valve deterioration is common on long-term follow-up post-TAVR. The rate is similar to post-SAVR cases according to VARC-2 criteria but less according to the moderate haemodynamic SVD criteria.

A case of aortic valve leaflet tear and perforations after neocuspidization

Although aortic valve (AV) replacement is a curative procedure for severe aortic stenosis, prosthetic heart valves have many disadvantages and cause serious complications. A new promising surgical procedure—aortic valve neocuspidization (AVNeo)—has recently been developed; it is an original method of AV reconstruction with autologous pericardium. It has been reported to yield excellent medium‐term results with respect to durability and complications. Herein, we encountered a first case of AV leaflet tear and perforations 27 months after AVNeo using autologous pericardium. AV leaflet tear or perforation is well recognized as a long‐term serious complication of pericardial xenografts. Interestingly, however, AVNeo caused early structural valve deterioration in the current case. In the present case, an eccentric aortic regurgitation jet observed on colour flow imaging led us to reach the correct diagnosis. Finally, the patient showed complete recovery with redo AV replacement. This case highlights the importance of understanding the potential pitfalls of this new surgical technique and that of colour Doppler echocardiography in reaching a definite diagnosis.

Structural valve deterioration in the Mitroflow biological heart valve prosthesis

OBJECTIVES

Concern has been raised regarding the long-term durability of the Mitroflow biological heart valve prosthesis. Our aim was to assess the incidence of structural valve degeneration (SVD) for the Mitroflow bioprosthesis in a nationwide study in Denmark including all patients alive in Denmark who had received a Mitroflow aortic bioprosthesis since 2000.

METHODS

Patients alive in Denmark with a Mitroflow bioprosthesis implanted since January 2000 were invited to participate in a nationwide cross-sectional study with a predefined definition of SVD. Of 1552 patients, 861 patients had died and 47 patients had been reoperated with 40 reoperations due to SVD. The remaining 644 patients were invited for evaluation; 574 patients accepted and were evaluated for SVD. The incidence of SVD was calculated using competing risk regression analysis with death as the competing event.

RESULTS

A total of 173 patients were diagnosed with SVD by echocardiography. Of these, 64 (11%) patients had severe SVD and 109 (19%) patients moderate SVD. Severe SVD was associated with the age of the prosthesis and small prosthesis size [Size 21: hazard ratio (95% confidence interval, CI) 2.72 (0.97-8.56), P = 0.06; Size 19: 6.26 (1.63-24.06), P = 0.008]. The cumulative incidences of reoperation or severe SVD at Year 9 were 12.5% for Size 19, 7.6% for Size 21 and 3.1 (1.2-6.4)% for Size 23. Median survival in patients with prosthesis Sizes 23-29 was 6.4 (95% CI 5.7-7.0) years, with Size 21 it was 6.5 (95% CI 5.9-7.1) years and with Size 19 it was 6.9 (95% CI 5.7-8.2) years (P = 0.78).

CONCLUSIONS

The incidence of undetected severe SVD was as high as the incidence of operated SVD. The overall risk for SVD is high for the Mitroflow bioprosthesis, especially if the prosthesis is small and older than 5 years.

Long-Term Clinical Outcomes of the Carpentier-Edwards Perimount Pericardial Bioprosthesis in Chinese Patients with Single or Multiple Valve Replacement in Aortic, Mitral, or Tricuspid Positions

OBJECTIVES

To report the safety and efficacy results of a 9- to 15-year follow-up investigation among patients who had received Carpentier-Edwards Perimount (CE-P) bovine pericardial bioprostheses (Edwards Lifesciences, Irvine, CA, USA) for valve replacement.

METHODS

This retrospective study investigated freedom from structural valve deterioration (SVD) as well as survival and reoperation among different age and etiology groups in patients who were implanted with a CE-P bioprosthesis at Guangdong General Hospital between 2001 and 2007. Kaplan-Meier survival analysis and multivariate Cox proportional hazards regression were performed.

RESULTS

The mean age of the patients (N = 225) was only 61.2 ± 11.5 years at valve replacement. More than half of the patients (55.1%) had rheumatic heart disease. The survival rates were 86.46, 81.58, and 74.42% at 5 years, 64.39, 66.19, and 55.85% at 10 years, and 48.37, 57.33, and 46.54% at 15 years for the groups with mitral valve replacement (MVR), aortic valve replacement (AVR), and double valve replacement (DVR), respectively. The median time to freedom from SVD was 12.5, 13.2, and 11.2 years, respectively, for patients with MVR, AVR, and DVR. A higher age at valve replacement was a significant risk factor for SVD in all patients (p < 0.01).

CONCLUSIONS

Good long-term clinical results of CE-P valves have been demonstrated in Chinese patients >60 years.

Real Structural Valve Deterioration of the Mitroflow Aortic Prosthesis: Competing Risk Analysis

INTRODUCTION AND OBJECTIVES

The Mitroflow aortic prosthesis is a bovine pericardial bioprosthesis specially designed to increase the valve area in relation to its size. There is controversy regarding the pattern of structural valve deterioration (SVD). Our aim was to determine the cumulative incidence of SVD, risk factors influencing its occurrence, and its impact on mortality.

METHODS

A total of 1028 patients were clinically and echocardiographically followed up. Because the study population was elderly and had heart disease, we used a competing risk analysis.

RESULTS

The percentage of patients with SVD at 5 years was 4.22% (95%CI, 2.96-5.81) and was 15.77% at 8 years (95%CI, 12.46-19.43). The incidence was higher for small valves (19mm and 21mm) reaching 6.43% at 5 years (95%CI, 4.48-8.84) and 20.06% at 8 years (95%CI, 15.53-25.01). Severe patient-prosthesis mismatch (PPM) influenced the incidence of SVD (_sHR, 3.53; 95%CI, 2.20-5.66; P < .001) but moderate PPM had no impact. The most powerful predictor of mortality was the presence of SVD (HR, 4.59; 95%CI, 2.91-7.22; P < .001).

CONCLUSIONS

This study used a definition based on the increase in the transprosthetic gradient and found a higher incidence of SVD of the Mitroflow prosthesis than that reported by other series, especially for sizes 19mm and 21mm and in patients with severe PPM. The incidence of SVD increased exponentially from the fifth year after implantation and its occurrence led to a 4.5-fold increase in the risk of death.

A case of an explanted 26-year-old Carpentier-Edwards supra-annular valve in the tricuspid position

Whether a mechanic or bioprosthetic valve is better for tricuspid valve replacement is still controversial. One problem of bioprostheses is structure valve deterioration. However, a bioprosthesis in the tricuspid position is more durable than that in the aortic and mitral positions. We report a case of an explanting Carpentier-Edwards supra-annular valve (CE-SAV) (Baxter Healthcare Corp., Irvine, CA, USA) in tricuspid position 26 years after tricuspid valve replacement. A 36-year-old female underwent total correction of tetralogy of Fallot at the age of five, and three years later she underwent tricuspid valve replacement for severe tricuspid regurgitation using a Björk-Shiley valve. Two years later, the mechanical valve was explanted due to thrombus formation, and a 29-mm CE-SAV was implanted in tricuspid position. Twenty-six years after implantation, we explanted the valve due to structural valve deterioration. The leaflets of the valve were hard and stiff, and calcifications were present on all the leaflets. A small tear existed in the part of most calcified leaflet. To the best of our knowledge, this is the longest durability of CE-SAV in tricuspid position. <Learning objective: Whether bioprosthetic or mechanical valve should be chosen for tricuspid valve replacement is still controversial. A bioprosthesis in the tricuspid position is more durable than that in the aortic or mitral position. We explanted the valve due to structural valve deterioration 26 years after implantation. The leaflets were hard and stiff, and calcifications were present on all the leaflets. A small tear existed in the part of most calcified leaflet.>.

Durability after aortic valve replacement with the Mitroflow versus the Perimount pericardial bioprosthesis: a single-centre experience in 2393 patients

OBJECTIVES

This study compares the durability and risk of reoperation in patients undergoing aortic valve replacement (AVR) with either a Mitroflow or a Carpentier-Edwards (CE) pericardial bioprosthesis. Since AVR with bioprosthetic valves has increased progressively in recent years as compared to mechanical valves, especially in patients aged 60-70 years, there has been renewed interest in the long-term durability of current pericardial bioprostheses.

METHODS

We compared 440 AVR with Mitroflow valves with 1953 AVR with CE pericardial valves implanted from 1999 to 2014 with regard to reoperation, reoperation for structural valve deterioration (SVD) and all-cause mortality.

RESULTS

Ten-year freedom from explant of any cause was higher for CE Perimount (98 ± 0.7%) than for Mitroflow (95 ± 1.4%, P < 0.01). Reasons for explant for CE Perimount were SVD (n = 2), endocarditis (n = 8) and paraprosthetic leak (n = 10). The reasons for explant for Mitroflow were SVD (n = 11), endocarditis (n = 3) SVD and pericarditis (n = 1) and paraprosthetic leak (n = 2). Ten-year freedom from explant due to SVD was higher for CE Perimount (100%) than for Mitroflow (96%) (P < 0.01). In small aortic annuli (bioprosthesis size 19-21 mm), freedom from SVD at 10 years for CE Perimount and Mitroflow was 100 versus 96%, respectively. By multivariate analysis, it was found that bioprosthesis size was not a risk factor for SVD. The choice of valve type could not be demonstrated to influence long-term survival.

CONCLUSIONS

The Mitroflow pericardial bioprosthesis provides less than optimal mid- and long-term durability compared with the CE Perimount pericardial valve, especially for small aortic diameter implants (19 and 21 mm). This study hereby confirms the existence of a real risk of valvular deterioration of the Mitroflow valve that might compromise the prognosis of the patients.

Impact of sinuses of Valsalva on prosthesis durability in patients undergoing ascending aorta and aortic valve replacement with Carpentier-Edwards bioprosthesis: a propensity score-based study

OBJECTIVES

The effect of sinuses of Valsalva on aortic bioprosthesis durability has not been investigated so far. The aim of this study was to compare durability of the Carpentier-Edwards aortic bioprosthesis in patients undergoing aortic valve and ascending aorta replacement as a composite bioconduit (Group A, case group) versus patients undergoing separate replacement of the aortic valve and ascending aorta, with preservation of the aortic root (Group B, control group), between January 2000 and January 2014.

METHODS

Records of Group A (n = 133) and Group B (n = 162) patients were retrospectively reviewed. End-points were evaluated among groups in three ways: before and after propensity score 1:1 matching (Group A, n = 94; Group B, n = 94 patients) and after patient stratification through quintiles of propensity scores.

RESULTS

There was no difference among groups regarding mean and maximal trans-prosthetic pressure gradients at discharge (P = 0.07 and 0.45, respectively). Maximal trans-prosthetic gradients were lower in Group A patients at last control (P = 0.03). Structural valve deterioration (SVD) was due to prosthesis regurgitation (Group A, n = 5; Group B, n = 1), stenosis (Group A, n = 2; Group B, n = 5) or combined (Group A, n = 4; Group B, n = 2). After a mean follow-up of 68 ± 42 months, there was no difference among groups, at 5 and 12 years, regarding mortality, freedom from SVD, from redo aortic valve replacement for SVD and cardiac redo of any type, before and after matching and after stratification according to quintiles of propensity scores.

CONCLUSIONS

Within the 12-year follow-up, the absence of the sinuses of Valsalva seems to have no influence on durability of Carpentier Edwards aortic bioprosthesis. Longer follow-up may be warranted.