1
|
Miller M, Snyder M, Horne BD, Harkness JR, Doty JR, Miner EC, Jones KW, O’Neal KR, Reid BB, Caine WT, Clayson SE, Lindley E, Gardner B, Connors RC, Bowles BJ, Whisenant BK. Transcatheter Aortic Valve-in-Valve Replacement for Degenerated Stentless Bioprosthetic Aortic Valves. JACC Cardiovasc Interv 2019; 12:1217-1226. [DOI: 10.1016/j.jcin.2019.05.022] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 10/26/2022]
|
2
|
Biological aortic valve replacement: advantages and optimal indications of stentless compared to stented valve substitutes. A review. Gen Thorac Cardiovasc Surg 2018; 66:247-256. [PMID: 29322433 DOI: 10.1007/s11748-018-0884-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 12/29/2017] [Indexed: 10/18/2022]
Abstract
Controversy still surrounds the optimal biological valve substitute for aortic valve replacement. In light of the current literature, we review advantages and optimal indications of stentless compared to stented aortic bio-prostheses. Recent meta-analyses, prospective randomized controlled trials and retrospective studies comparing the most frequently used stentless and stented aortic bio-prostheses were analyzed. In the present review, the types and implantation techniques of the bio-prosthesis that are seldom taken into account by most studies and reviews were integrated in the interpretation of the relevant reports. For stentless aortic root bio-prostheses, full-root vs. sub-coronary implantation offered better early transvalvular gradients, effective orifice area and left ventricular mass regression as well as late freedom from structural valve deterioration in retrospective studies. Early mortality and morbidity did not differ between the stentless and stented aortic bio-prostheses. Early transvalvular gradients, effective orifice area and regression of left ventricular hypertrophy were significantly better for stentless, especially as full-root, compared to stented bio-prostheses. The long-term valve-related survival for stentless aortic root and Toronto SPV bio-prosthesis was as good as that for stented pericardial aortic bio-prostheses. For full-root configuration this survival advantage was statistically significant. There seems to be not one but different ideal biological valve substitutes for different subgroups of patients. In patients with small aortic root or exposed to prosthesis-patient mismatch full-root implantation of stentless bio-prostheses may better meet functional needs of individual patients. Longer follow-ups on newer generation of stented bio-prostheses are needed for comparison of their hemodynamic performance with stentless counterparts especially in full-root configuration.
Collapse
|
3
|
John A, Glauner C, Manoutcheri MA, Ziaukas V, Mahesh GM, Warnecke H. Aortic Valve Replacement with the Medtronic Freestyle Stentless Bioprosthesis. Asian Cardiovasc Thorac Ann 2016; 12:213-7. [PMID: 15353458 DOI: 10.1177/021849230401200307] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
During a five-year period from 1996 to 2000, the Medtronic Freestyle stentless bioprosthesis was implanted in 310 patients of advanced age. Age at operation ranged from 60 to 90 years (mean, 76 ± 4 years). 191 patients were female and 119 male. All implants were done by the modified subcoronary method using our own modification which enabled an improved adaptation of the porcine aortic root to the human anatomy. Two sinuses were scalloped and the third left intact. Additional coronary bypass grafts were necessary in 129 (39%) patients and mitral valve procedures in 23 (7%). Mean perfusion time was 109 ± 12 minutes and crossclamp time 87 ± 8 minutes. 16 (5%) patients died perioperatively. Another 17 (5.7%) patients died during a 1 to 5.6 year follow-up (mean, 2.9 years). There was only one valve related death due to infection of the valve. In spite of the advanced age, 95% of the survivors were free from cardiac symptoms and continued to live an active and fruitful life. The biological nature of the valve and the low gradients are perhaps reasons for the good results. The long-term results are expected to be good.
Collapse
Affiliation(s)
- Alexander John
- Department of Heart Surgery, Schuechtermann Klinik, Bad Rothenfelde, Germany.
| | | | | | | | | | | |
Collapse
|
4
|
Becerra V, Labbé J, Cataldo A, Becerra E. Long-term survival with a stentless free-hand Batista pericardial aortic valve prosthesis: A case report. Int J Surg Case Rep 2014; 6C:46-7. [PMID: 25524300 PMCID: PMC4337914 DOI: 10.1016/j.ijscr.2014.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 11/12/2014] [Accepted: 11/12/2014] [Indexed: 11/17/2022] Open
Abstract
Aortic stenosis and small annulus in older patients is a major issue in cardiac surgery. Stentless bovine pericardial valve using the Batista technique is a good solution. We report 15 years follow-up of such a valve showing good performance.
INTRODUCTION Stented bovine pericardial prosthetic valves are a good option for older patients, except when there is a fragile small aortic annulus, when, if there is no contraindication to anticoagulation, a mechanical prosthesis may be indicated. PRESENTATION OF CASE We report a 72 year-old man who underwent coronary bypass grafting and aortic valve replacement with a stentless valve fashioned from bovine pericardium using the Batista technique. Despite early sternal infection and dehiscence, and renal and respiratory failure during 15 years follow-up, he remains alive and self-sufficient. Echocardiography demonstrates a well-functioning aortic valve. DISCUSSION When Batista reported his first 60 patients, concerns were raised about the surgical feasibility of constructing the valve and its long-term durability. Our case perhaps addresses both concerns. CONCLUSION Replacement of the aortic valve with a free-hand Batista pericardial valve is a feasible option in a suitable and carefully selected patient.
Collapse
Affiliation(s)
| | - Javier Labbé
- Hospital Clínico Regional de Antofagasta, Antofagasta, Chile
| | - Anthony Cataldo
- Hospital Clínico Regional de Antofagasta, Antofagasta, Chile
| | | |
Collapse
|
5
|
Freestyle root replacement for complex destructive aortic valve endocarditis. J Thorac Cardiovasc Surg 2013; 147:1265-70. [PMID: 23849892 DOI: 10.1016/j.jtcvs.2013.05.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2013] [Revised: 04/14/2013] [Accepted: 05/02/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVES In destructive aortic valve endocarditis with abscess formation in the root, homografts are used more often than xenografts. Because we had reliable perioperative results with Freestyle (Medtronic Inc, Minneapolis, Minn) xenograft root replacement in these complex patients, we analyzed the long-term outcome in this high-risk indication. METHODS Of 126 consecutive patients with aortic valve endocarditis treated by surgery from 1997 to 2012, 32 (25.4%) received a Freestyle aortic root replacement for severe, destructive valve endocarditis and were studied retrospectively with approval of the local ethical committee. Perioperative complications, recurrence of endocarditis, and long-term morbidity and mortality were analyzed. The follow-up period was 3 months to 11.5 years. RESULTS Indication for surgery was native (n = 9) and prosthetic valve endocarditis (n = 23). In 18 patients, concomitant procedures were performed: coronary bypass (n = 9), additional valve surgery (n = 6), and ascending aortic surgery (n = 7). Thirty-day mortality was 19.4% (n = 6). There were no instances of technical failure requiring modification of the surgical strategy or reoperation for anastomotic bleeding. Actuarial survival at 5 and 10 years was 61.9% and 54.2%, respectively. Freedom from death, reoperation for prostheses dysfunction, and recurrence of endocarditis as the composite end point at 5 and 10 years was 56.3% and 53.1%, respectively. CONCLUSIONS The Freestyle root was used successfully with no technical complications in all patients with most severe destructive aortic root endocarditis. In view of this complex patient population, short- and long-term results make this conduit a reliable choice for treatment of this condition.
Collapse
|
6
|
Smith CR, Stamou SC, Hooker RL, Willekes CC, Heiser JC, Patzelt LH, Murphy ET. Stentless root bioprosthesis for repair of acute type A aortic dissection. J Thorac Cardiovasc Surg 2013; 145:1540-4. [DOI: 10.1016/j.jtcvs.2012.05.029] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2012] [Revised: 04/03/2012] [Accepted: 05/15/2012] [Indexed: 10/28/2022]
|
7
|
Mazzola A, Di Mauro M, Pellone F, Faragalli F, Villani C, Di Eusanio M, Gizzi G, Lemme E, Gregorini R, Romano S, Penco M. Freestyle Aortic Root Bioprosthesis Is a Suitable Alternative for Aortic Root Replacement in Elderly Patients: A Propensity Score Study. Ann Thorac Surg 2012; 94:1185-90. [DOI: 10.1016/j.athoracsur.2012.05.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2012] [Revised: 04/27/2012] [Accepted: 05/02/2012] [Indexed: 11/24/2022]
|
8
|
Robb JD, Wendler O. Stentless aortic bioprostheses: their role in the treatment of aortic endocarditis should not be underestimated. Eur J Cardiothorac Surg 2012; 43:453-4. [PMID: 22822107 DOI: 10.1093/ejcts/ezs431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
|
9
|
Abstract
Although porcine aortic valves or pericardial tissue mounted on a stent have made implantation techniques easier, these valves sacrifice orifice area and increase stress at the attachment of the stent, which causes primary tissue failure. Optimizing hemodynamics to prevent patient–prosthetic mismatch and improve durability, stentless bioprostheses use was revived in the early 1990s. The purpose of this review is to provide a current overview of stentless valves in the aortic position. Retrospective and prospective randomized controlled studies showed similar operative mortality and morbidity in stented and stentless aortic valve replacement (AVR), though stentless AVR required longer cross-clamp and cardiopulmonary bypass time. Several cohort studies showed improved survival after stentless AVR, probably due to better hemodynamic performance and earlier left ventricular (LV) mass regression compared with stented AVR. However, there was a bias of operation age and nonrandomization. A randomized trial supported an improved 8-year survival of patients with the Freestyle or Toronto valves compared with Carpentier–Edwards porcine valves. On the contrary, another randomized study did not show improved clinical outcomes up to 12 years. Freedom from reoperation at 12 years in Toronto stentless porcine valves ranged from 69% to 75%, which is much lower than for Carpentier–Edwards Perimount valves. Cusp tear with consequent aortic regurgitation was the most common cause of structural valve deterioration. Cryolife O’Brien valves also have shorter durability compared with stent valves. Actuarial freedom from reoperation was 44% at 10 years. Early prosthetic valve failure was also reported in patients who underwent root replacement with Shelhigh stentless composite grafts. There was no level I or IIa evidence of more effective orifice area, mean pressure gradient, LV mass regression, surgical risk, durability, and late outcomes in stentless bioprostheses. There is no general recommendation to prefer stentless bioprostheses in all patients. For new-generation pericardial stentless valves, follow-up over 15 years is necessary to compare the excellent results of stented valves such as the Carpentier–Edwards Perimount and Hancock II valves.
Collapse
Affiliation(s)
- Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
| |
Collapse
|
10
|
Okamura H, Yamaguchi A, Noguchi K, Naito K, Yuri K, Adachi H. Hemodynamics and Outcomes of Aortic Valve Replacement with a 17- or 19-mm Valve. Asian Cardiovasc Thorac Ann 2010; 18:450-5. [DOI: 10.1177/0218492310381174] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
When aortic valve replacement is performed in patients with a small aortic annulus, prosthesis-patient mismatch is of concern because it may affect postoperative clinical status. We conducted a retrospective study of outcomes in 65 patients with aortic stenosis requiring valve replacement. Fifty were given a 17-mm or 19-mm St. Jude Regent mechanical valve, and 15 were given a 19-mm Medtronic Mosaic bioprosthesis. Echocardiography was carried out preoperatively, at discharge, and at follow-up. There was 1 (2%) operative death in the Regent group and none in the Mosaic group. There was no valve-related event. Follow-up echocardiography in both groups revealed a significant increase in the mean effective orifice area index, a decrease in the mean left ventricular-aortic pressure gradient, and a decrease in the mean left ventricular mass index. Prosthesis-patient mismatch (effective orifice area index <0.85 cm2 · m−2) existed in 13 (26%) patients in the Regent group and 11 (73%) in the Mosaic group at discharge. All patients improved to New York Heart Association functional class II or better. A small-sized prosthesis may provide satisfactory clinical and hemodynamic results in patients with a small aortic annulus.
Collapse
Affiliation(s)
- Homare Okamura
- Department of Cardiovascular Surgery Saitama Medical Center, Jichi Medical University Saitama-shi, Saitama, Japan
| | - Atsushi Yamaguchi
- Department of Cardiovascular Surgery Saitama Medical Center, Jichi Medical University Saitama-shi, Saitama, Japan
| | - Kenichiro Noguchi
- Department of Cardiovascular Surgery Saitama Medical Center, Jichi Medical University Saitama-shi, Saitama, Japan
| | - Kazuhiro Naito
- Department of Cardiovascular Surgery Saitama Medical Center, Jichi Medical University Saitama-shi, Saitama, Japan
| | - Koichi Yuri
- Department of Cardiovascular Surgery Saitama Medical Center, Jichi Medical University Saitama-shi, Saitama, Japan
| | - Hideo Adachi
- Department of Cardiovascular Surgery Saitama Medical Center, Jichi Medical University Saitama-shi, Saitama, Japan
| |
Collapse
|
11
|
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.
Collapse
Affiliation(s)
- Bari Murtuza
- Department of Cardiothoracic Surgery, Royal Brompton Hospital, Faculty of Medicine, Imperial College, UK.
| | | | | | | | | | | |
Collapse
|
12
|
Aortenklappenersatz mit gerüstlosen Bioprothesen. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2010. [DOI: 10.1007/s00398-010-0774-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
13
|
Okamura H, Yamaguchi A, Tanaka M, Naito K, Kimura N, Kimura C, Kobinata T, Ino T, Adachi H. The 17-mm St. Jude Medical Regent valve is a valid option for patients with a small aortic annulus. Ann Thorac Surg 2009; 87:90-4. [PMID: 19101276 DOI: 10.1016/j.athoracsur.2008.09.051] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2008] [Revised: 09/22/2008] [Accepted: 09/23/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND When aortic valve replacement is performed in patients with a small aortic annulus, prosthesis-patient mismatch is of concern. Such prosthesis-patient mismatch may affect postoperative clinical status and survival. We investigated the outcomes of isolated aortic valve replacement performed with a 17-mm mechanical prosthesis in patients with aortic stenosis. METHODS Twenty-three patients with aortic stenosis (mean age, 74.6 +/- 6.3 years) underwent isolated aortic valve replacement with a 17-mm St. Jude Medical Regent prosthesis. Mean body surface area was 1.41 +/- 0.13 m(2). Preoperative echocardiography yielded a mean aortic valve area of 0.36 +/- 0.10 cm(2)/m(2), a mean left ventricular-aortic pressure gradient of 68.4 +/- 25.3 mm Hg, and a mean left ventricular mass index of 200 +/- 69 g/m(2). RESULTS There was no operative mortality, and there were no valve-related events. Echocardiography at 14.0 +/- 10.0 months after aortic valve replacement showed a significant increase in the mean effective orifice area index (0.95 +/- 0.24 cm(2)/m(2)), decrease in the mean left ventricular-aortic pressure gradient (17.4 +/- 8.2 mm Hg), and decrease in the mean left ventricular mass index (124 +/- 37 cm(2)/m(2)). Prosthesis-patient mismatch (effective orifice area index < 0.85 cm(2)/m(2)) was present in 8 patients at discharge. In these patients as well as in those without prosthesis-patient mismatch, the left ventricular mass index decreased remarkably during follow-up. CONCLUSIONS Aortic valve replacement with a 17-mm Regent prosthesis appears to provide satisfactory clinical and hemodynamic results in patients with a small aortic annulus. Remarkable left ventricular mass regression during follow-up was achieved irrespective of the effective orifice area index at discharge.
Collapse
Affiliation(s)
- Homare Okamura
- Department of Cardiovascular Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan.
| | | | | | | | | | | | | | | | | |
Collapse
|
14
|
Ten-Year Experience With Stentless Aortic Valves: Full-Root Versus Subcoronary Implantation. Ann Thorac Surg 2008; 85:445-52; discussion 452-3. [DOI: 10.1016/j.athoracsur.2007.10.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2007] [Revised: 10/01/2007] [Accepted: 10/02/2007] [Indexed: 11/18/2022]
|
15
|
Albert A, Florath I, Rosendahl U, Hassanein W, Hodenberg EV, Bauer S, Ennker I, Ennker J. Effect of surgeon on transprosthetic gradients after aortic valve replacement with Freestyle stentless bioprosthesis and its consequences: a follow-up study in 587 patients. J Cardiothorac Surg 2007; 2:40. [PMID: 17919325 PMCID: PMC2146998 DOI: 10.1186/1749-8090-2-40] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2007] [Accepted: 10/05/2007] [Indexed: 11/10/2022] Open
Abstract
Background The implantation of stentless valves is technically demanding and the outcome may depend on the performance of surgeons. We studied systematically the role of surgeons and other possible determinants for mid-term survival, postoperative gradients and Quality of Life (QoL) after aortic valve replacement (AVR) with Freestyle® stentless bioprostheses. Methods Between 1996 and 2003, 587 patients (mean 75 years) underwent AVR with stentless Medtronic Freestyle® bioprostheses. Follow-up was 99% complete. Determinants of morbidity, mortality, survival time and QoL were evaluated by multiple, time-related, regression analysis. Risk models were built for all sections of the Nottingham Health Profile (NHP): energy, pain, emotional reaction, sleep, social isolation and physical mobility Results Actuarial freedom from aortic valve re-operation, structural valve deterioration, non-structural valve dysfunction, prosthetic valve endocarditis and thromboembolic events at 6 years were 95.9 ± 2.1%, 100%, 98.7 ± 0.5%, 97.0 ± 1.5%, 79.6 ± 4.3%, respectively. The actuarial freedom from bleeding events at 6 years was 93.1 ± 1.9%. Estimated survival at 6 years was similar to the age-matched German population (61.4 ± 3.8 %). Predictors of survival time were: diabetes mellitus, atrial fibrillation, peripheral vascular disease, renal dysfunction, female gender > 80 years and patients < 165 cm with BMI < 24. Predictive models showed characteristic profiles and good discriminative powers (c-indexes > 0.7) for each of the 6 QoL sections. Early transvalvular gradients were identified as independent risk factors for impaired physical mobility (c-index 0.77, p < 0.002). A saturated propensity score identified besides patient related factors (e.g. preoperative gradients, ejection fraction, haematological factors) indexed geometric orifice area, subcoronary implantation technique and individual surgeons as predictors of high gradients. Conclusion In addition to the valve size (in relation to body size), subcoronary technique (versus total root) and various patient-related factors the risk of elevated gradients after stentless valve implantation depends, considerably on the individual surgeon. Although there was no effect on survival time and most aspects of QoL, higher postoperative transvalvular gradients affect physical mobility after AVR.
Collapse
Affiliation(s)
- Alexander Albert
- Department of cardiac surgery, Heart Institute Lahr/Baden, Hohbergweg 2, 77933 Lahr/Germany.
| | | | | | | | | | | | | | | |
Collapse
|
16
|
Takami Y, Masumoto H, Fyfe-Kirschner B. Late Disruption of a Freestyle Stentless Bioprosthesis Used for Repair of Sinus of Valsalva Aneurysm of Noncoronary Cusp. Ann Thorac Surg 2007; 83:2210-3. [PMID: 17532431 DOI: 10.1016/j.athoracsur.2007.01.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2006] [Revised: 01/04/2007] [Accepted: 01/08/2007] [Indexed: 11/30/2022]
Abstract
We present a case of disruption of the porcine aortic wall of the 27-mm Freestyle stentless bioprosthesis 5 years after the subcoronary implantation to exclude the sinus of Valsalva aneurysm of the noncoronary cusp. At the urgent reoperation, the inflow suture line was found to be intact, and therefore a new stented valve was sutured with the inflow Dacron cuff after removal of ruptured valve. The subcoronary implantation technique creates a cavity between the prosthetic and native aortic walls filled with hematoma. The outflow suture line dehiscence caused blood flow into the cavity, porcine aortic wall rupture, and leaflet destruction.
Collapse
Affiliation(s)
- Yoshiyuki Takami
- Department of Cardiovascular Surgery, Nagoya Daini Red Cross Hospital, Nagoya, Japan.
| | | | | |
Collapse
|
17
|
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.
Collapse
Affiliation(s)
- Justin Nowell
- Department of Cardiothoracic Surgery and Neurosciences, St George's Hospital, University of London, UK
| | | | | | | |
Collapse
|
18
|
Shiono N, Watanabe Y, Kawasaki M, Yokomuro H, Fujii T, Koyama N. Evaluation of bioprosthetic valve for small aortic root in elderly patients. Asian Cardiovasc Thorac Ann 2007; 15:102-5. [PMID: 17387190 DOI: 10.1177/021849230701500205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The hemodynamics of stentless bioprostheses are superior to those of mechanical valves, especially for patients with a small aortic root. Between March 1999 and July 2001, we implanted 18 Freestyle stentless porcine valves using our technique of repeated division of the space by halving the distance. Seven patients received 19-21-mm valves and 11 received 23-25-mm valves. Clinical data and early and midterm outcomes of both groups were compared. The mean preoperative echocardiography gradient of the small valve group was 84.7 mm Hg, and when discharged from hospital, the mean gradient was 14.8 mm Hg. One operative death was encountered due to arrhythmia. This stentless porcine prosthesis has excellent hemodynamics and can be implanted safely and easily, even in elderly patients with a small aortic root, using our suture technique.
Collapse
Affiliation(s)
- Noritsugu Shiono
- Division of Cardiovascular Surgery, Department of Surgery (Omori), School of Medicine, Faculty of Medicine, Toho University, Tokyo, Japan.
| | | | | | | | | | | |
Collapse
|
19
|
Perez de Arenaza D, Lees B, Flather M, Nugara F, Husebye T, Jasinski M, Cisowski M, Khan M, Henein M, Gaer J, Guvendik L, Bochenek A, Wos S, Lie M, Van Nooten G, Pennell D, Pepper J. Randomized Comparison of Stentless Versus Stented Valves for Aortic Stenosis. Circulation 2005; 112:2696-702. [PMID: 16230487 DOI: 10.1161/circulationaha.104.521161] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic valve replacement (AVR) is the established treatment for severe aortic stenosis. In response to the long-term results of aortic homografts, stentless porcine valves were introduced as an alternative low-resistance valve. We conducted a randomized trial comparing a stentless with a stented porcine valve in adults with severe aortic stenosis. METHODS AND RESULTS The primary outcome was change in left ventricular mass index (LVMI) measured by transthoracic echocardiography and, in a subset, by cardiovascular MR. Measurements were taken before valve replacement and at 6 and 12 months. Patients undergoing AVR with an aortic annulus < or =25 mm in diameter were randomly allocated to a stentless (n=93) or a stented supra-annular (n=97) valve. There were no significant differences in mean LVMI between the stentless versus stented groups at baseline (176+/-62 and 182+/-63 g/m2, respectively) or at 6 months (142+/-49 and 131+/-45 g/m2, respectively), although within-group changes from baseline to 6 months were highly significant. Changes in LVMI measured by cardiovascular MR (n=38) were consistent with the echo findings. There was a greater reduction in peak aortic velocity (P<0.001) and a greater increase in indexed effective orifice area (P<0.001) in the stentless group than in the stented group. There were no differences in clinical outcomes between the 2 valve groups. CONCLUSIONS Despite significant differences in indexed effective orifice area and peak flow velocity in favor of the stentless valve, there were similar reductions in left ventricular mass at 6 months with both stented and stentless valves, which persisted at 12 months.
Collapse
|
20
|
Florath I, Albert A, Rosendahl U, Alexander T, Ennker IC, Ennker J. Mid term outcome and quality of life after aortic valve replacement in elderly people: mechanical versus stentless biological valves. Heart 2005; 91:1023-9. [PMID: 16020589 PMCID: PMC1769036 DOI: 10.1136/hrt.2004.036178] [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] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess the benefit for patients older than 65 years of aortic valve replacement with stentless biological heart valves in comparison with mechanical valves. DESIGN Multiple regression analysis of a retrospective follow up study. SETTING Single cardiothoracic centre. PATIENTS Between 1996 and 2001, 392 patients with a mean age of 74 years underwent aortic valve replacement with stentless Freestyle bioprostheses or mechanical St Jude Medical prostheses. MAIN OUTCOME MEASURE Operative mortality and morbidity, postoperative morbid events, mid term survival, and New York Heart Association (NYHA) class improvement, and quality of life. RESULTS No significant differences were found between patients receiving stentless biological valves and patients receiving mechanical prostheses. However, analysis of subgroups showed that patients older than 75 years with mechanical valves had an increased risk of major bleeding events (p = 0.007). Patients requiring anticoagulation by means of coumarin had a twofold increased risk of an impaired emotional reaction (p = 0.052). However, for patients who received a mechanical valve for severe combined aortic valve disease a survival advantage (p = 0.045) and a decreased risk of prolonged ventilation (p = 0.001) was observed. On the other hand, patients receiving a stentless bioprosthesis had an increased risk of a prolonged stay in intensive care (p = 0.04) and stroke (p = 0.01) if they had severely reduced cardiac function (NYHA class IV). CONCLUSIONS Elderly people receiving stentless bioprostheses benefit emotionally because of the avoidance of coumarin. However, in patients with severe hypertrophied ventricles and extraordinary calcifications, stentless bioprostheses should be chosen with caution.
Collapse
Affiliation(s)
- I Florath
- Herzzentrum Lahr/Baden, Lahr, Germany.
| | | | | | | | | | | |
Collapse
|
21
|
Jasinski MJ, Ulbrych P, Kolowca M, Szafranek A, Baron J, Wos S. Early Regional Assessment of LV Mass Regression and Function after Stentless Valve Replacement: Comparative Randomized Study. Heart Surg Forum 2004; 7:E462-5; discussion E462-5. [PMID: 15799926 DOI: 10.1532/hsf98.20041096] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Early regional performance and hypertrophy regression after stentless aortic valve replacement are still incompletely characterized. We compared early postoperative changes of segmental thickness and function after stentless and stented aortic valve replacement as assessed by cardiac magnetic resonance (CMR). In 16 patients randomly assigned to stented (Mosaic, 8 patients) and stentless (Freestyle, 8 patients) groups, 4 parallel short-axis images at the level of the apex (slice 4), midventricle (slices 2-3), and mitral valve (slice 1) were obtained with a 1.5 T CMR scanner (Magnetom Sonata, Siemens) before and 1 month after surgery. Cine images were obtained using an echo gradient sequence. Left ventricle mass was calculated as the difference between the left ventricular end-diastolic volume at the epicardial and endocardial borders multiplied by a myocardium density factor (1.05). Each slice was divided into 8 segments (octants) from anterior (octant I-II) to septal (octant V-VIII). A total of 32 segments encompassed the entire heart. From each of these elements end diastolic thickness and systolic function (fractional thickening) were calculated. In stentless valves significant reduction of septal octant thickness on the midventricular slice was noted. There was no difference in regional systolic function-segment thickening. In stented valves no segmental thickness changes were observed. In stentless valves there was early postoperative thickness reduction of septal segments at the midventricular level. However, this finding did not coincide with changes in segmental function.
Collapse
Affiliation(s)
- M J Jasinski
- 2nd Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland.
| | | | | | | | | | | |
Collapse
|
22
|
Uchida T, Shimazaki Y, Uesho K, Koshika M, Takeda F, Inui K, Watanabe T. Aortic root replacement with stentless xenograft for aortic dissection. Artif Organs 2002; 26:1052-5. [PMID: 12460384 DOI: 10.1046/j.1525-1594.2002.07005_2.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This paper reviewed aortic root replacement with a stentless xenograft for Stanford Type A aortic dissection. Total aortic arch replacement plus aortic root reconstruction with a stentless xenograft was conducted in 2 patients with acute aortic dissection. In another 2 patients, aortic root replacement with a bioprosthesis was performed for chronic redissection of the aortic root which might be associated with the previous use of gelatin-resorcin-formalin glue. Full root replacement using this device is safe, reliable, reproducible, and technically less demanding. This device also provides a radical option for acute aortic dissection even in patients requiring concomitant aortic arch and root replacement.
Collapse
Affiliation(s)
- Tetsuro Uchida
- Second Department of Surgery, Yamagata University School of Medicine, Japan
| | | | | | | | | | | | | |
Collapse
|
23
|
Hata H, Iida M, Kashiwazaki S, Eda K, Hirose H, Shiono M, Negeshi N, Sezai Y. Replacement of the aortic root and ascending aorta using a freestyle valve and woven Dacron graft. Artif Organs 2002; 26:862-7. [PMID: 12296926 DOI: 10.1046/j.1525-1594.2002.06959.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
We contrived a surgical technique for the purpose of improving recent results. From April 1998 to June 2001, 24 patients (aged 60 to 81 years, mean age 71.0 +/- 4.8 years; 11 men, 13 women) underwent replacement of the aortic root and the ascending aorta electively using a Freestyle stentless valve with woven Dacron graft at our institution. The aortic root was replaced first, the distal side of the Dacron graft was then anastomosed, and finally, the proximal side was anastomosed with the outflow of the Freestyle valve. Cardiopulmonary bypass time and cardioplegic time were 297 +/- 83 min and 210 +/- 51 min, respectively. The geometry of the ascending aorta and the diameter mismatch between the dilated ascending aorta and the outflow of the Freestyle valve were fully corrected. There were two early deaths and three late deaths; none valve-related. Postoperative aortogram showed an excellent shape. The mortality, morbidity, and clinical events after the procedure were acceptable.
Collapse
Affiliation(s)
- Hiroaki Hata
- Department of Cardiovascular Surgery, Okata Enrei Hospital, Nagano, Japan
| | | | | | | | | | | | | | | |
Collapse
|
24
|
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.
Collapse
Affiliation(s)
- Neal D Kon
- Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157-1096, USA.
| | | | | | | | | |
Collapse
|
25
|
Takami Y, Ina H. Resolution of perivalvular hematoma of the Freestyle stentless aortic root bioprosthesis implanted with a subcoronary technique. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2001; 49:675-8. [PMID: 11757342 DOI: 10.1007/bf02912479] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The modified subcoronary technique is frequently used to implant the Freestyle aortic root bioprosthesis because of its ease. This technique is primarily associated with hematoma in the potential space between the prosthetic and native aortic walls. We report a case of resolution of perivalvular hematoma around the Freestyle valve 6 months after implantation in a patient with aneurysm of the noncoronary sinus of Valsalva. During follow-up, the patient underwent no significant changes in pressure gradient or degree of regurgitation. Although long-term results are not yet known, the subcoronary technique may be a feasible alternative for patients with aneurysms in the sinus of Valsalva to exclude it, unless the sinotubular junction and aortic annulus are intact.
Collapse
Affiliation(s)
- Y Takami
- Division of Cardiovascular Surgery, Kasugai Municipal Hospital, 1-1-1 Takagicho, Kasugai City, Aichi 486-8510, Japan
| | | |
Collapse
|
26
|
Abstract
INTRODUCTION The availability of aortic homografts is steadily decreasing. In the meantime, stentless xenografts convey similar flow characteristics, and tissue preservation methods are improving durability. Initially, these valves were contraindicated in aortic roots with discrepancy between annulus and sinotubular junction or with extensive calcification or sepsis. With increasing experience stentless xenografts are now applied in a wide spectrum of aortic root disease. METHODS I reviewed our own experience with stentless aortic bioprosthesis for aortic valve replacement (AVR) and more taxing root problems. I used these valves in aortic aneurysm repair, acute Type A dissection, and for endocarditis with abcess formation. I studied valve hemodynamics, regression of left ventricular hypertrophy, and comparative survival with stented bioprostheses. RESULTS Stentless bioprostheses convey hemodynamic and possibly survival benefit through a low incidence of valve-related complications. They provide a useful alternative to aortic homografts in endocarditis, Type A dissection, and aortic aneurysm surgery. CONCLUSIONS Stentless bioprostheses are no longer confined to AVR alone. Experience supports the use of stentless bioprostheses where aortic homografts were previously applied. With availability in a wide range of sizes.
Collapse
Affiliation(s)
- S Westaby
- Oxford Heart Centre, the John Radcliffe Hospital, Headington, Oxford, UK
| |
Collapse
|
27
|
Takahashi T, Shimazaki Y, Watanabe T, Minowa T, Uchida T, Toyama S. Concomitant aortic arch and root replacement using a stentless xenograft for acute type A dissection. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2001; 49:365-7. [PMID: 11481839 DOI: 10.1007/bf02913151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
A 78-year-old woman with an aortic root aneurysm and aortic regurgitation developing acute type A dissection successfully underwent aortic root replacement using a stentless xenograft during core cooling, followed by total aortic arch replacement under selective cerebral perfusion with deep hypothermia. This bioprosthesis can be used in the same way as a free-hand homograft and potentially provides an aggressive, safe option for acute aortic dissection requiring aortic root reconstruction in elderly patients.
Collapse
Affiliation(s)
- T Takahashi
- Second Department of Surgery, Yamagata University Medical School, Yamagata, Japan
| | | | | | | | | | | |
Collapse
|
28
|
Kirsch M, Vermes E, Houel R, Loisance D. The freestyle stentless aortic bioprosthesis: more about the subcoronary technique. Eur J Cardiothorac Surg 2001; 19:369-71. [PMID: 11251284 DOI: 10.1016/s1010-7940(00)00657-6] [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] [Indexed: 11/30/2022] Open
Abstract
Two years after aortic valve replacement with a Freestyle stentless aortic xenograft using the partial scallop inclusion technique, late prosthetic valve endocarditis developed with abscess formation in the space between the porcine and native human aortic wall. The presence of such a periprosthetic dead space exposes the patient to increased postoperative pressure gradients and the risk of superinfection.
Collapse
Affiliation(s)
- M Kirsch
- Department of Cardiothoracic Surgery, Hôpital Henri Mondor, 51 Avenue du Maréchal de Lattre de Tassigny, 94 010, Créteil Cédex, France.
| | | | | | | |
Collapse
|
29
|
Riley RD, Hammon JW, Adair SM, Cordell AR, Kon ND. Stentless aortic valve replacement with Freestyle or Toronto SPV: an early comparison. Ann Thorac Surg 2000; 70:48-51; discussion 51-2. [PMID: 10921681 DOI: 10.1016/s0003-4975(00)01559-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Stentless aortic xenograft valves have been developed to overcome the disadvantages of conventional stented prostheses. We have implanted two new aortic bioprostheses: the Medtronic Freestyle and the St. Jude Toronto SPV. Early results are compared. METHODS Forty-four Freestyle valves were implanted using a freestanding total root technique. Fourteen subcoronary Toronto SPV bioprostheses were implanted. Sixty-four percent of both groups (28 of 44 Freestyle and 9 of 14 Toronto SPV) underwent concurrent procedures. RESULTS Ischemic time was 117 +/- 21 minutes for Freestyle and 124 +/- 19 minutes for Toronto SPV. There were no operative deaths or valve-related reoperations. Aortic valve area was 1.83 +/- 0.51 cm2 for Freestyle and 1.80 +/- 0.51 cm2 (p = 0.89) for Toronto SPV. Transvalvular gradient was 8.03 +/- 4.09 mm Hg for Freestyle and 12.4 +/- 1.82 mm Hg (p = 0.002) for the Toronto SPV. Aortic regurgitation was not experienced in any Freestyle patients, while Toronto SPV patients were graded as none to trace 79% (11 of 14), mild 14% (2 of 14), and moderate 7% (1 of 14). CONCLUSIONS Aortic valve replacement with the Freestyle and Toronto SPV required equal time for implantation and had equal effective orifice areas. Freestyle had lower transvalvular gradient and less aortic insufficiency without increasing morbidity or mortality.
Collapse
Affiliation(s)
- R D Riley
- Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA
| | | | | | | | | |
Collapse
|
30
|
Kalangos A, Trigo-Trindade P, Vala D, Panos A, Faidutti B. Aortic valve replacement with the freestyle stentless bioprosthesis with respect to spacial orientation of patient coronary ostia. J Thorac Cardiovasc Surg 2000; 119:1185-93. [PMID: 10838537 DOI: 10.1067/mtc.2000.105642] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This study evaluates our results for safety and efficacy of aortic valve replacement using the Freestyle bioprosthesis (Medtronic, Inc, Minneapolis, Minn) with a new modified subcoronary implantation technique. This technique takes into account the spacial orientation of the stentless bioprosthesis in the aortic root with respect to the patient's coronary ostia rather than the native commissures. METHODS Fifty-two consecutive patients with predominant aortic valve stenosis underwent aortic valve replacement with a Freestyle bioprosthesis by means of the described modified subcoronary technique over a 15-month period. Fifty of them were followed up by means of echocardiography at discharge, 6 months, and 1 year. There were 19 men and 31 women, with a mean age of 76 +/- 7 years (range, 58-87 years). Valve size ranged from 21 to 27 mm. RESULTS Patients with bicuspid aortic valves had a significantly larger angle between both coronary ostia than patients with tricuspid aortic valves (P =.0001). The peak and mean systolic gradients decreased significantly during the first postoperative year for each valve size (P </=.001), and the effective valve areas increased significantly during this time interval for each valve size (P </=.01). Only 13 patients had aortic insufficiency at discharge, which was trivial in 9 and mild in 4 patients. The prevalence of trivial aortic insufficiency decreased during the first postoperative year, and that of mild aortic insufficiency remained unchanged. The sinotubular junction diameter was significantly greater than that of the aortic anulus for each valve size before operation (P <.001). The sinotubular junction diameter decreased significantly after aortic valve replacement and remained unchanged during the first postoperative year for each valve size (P <.001). CONCLUSIONS Aortic valve replacement with the Freestyle bioprosthesis using the modified subcoronary technique, which takes into account the spacial orientation of the patient's coronary ostia, has hemodynamic results similar to those of other series with different subcoronary implantation techniques. This technique is reproducible, safe at the coronary ostial level, and effective in accommodating variability in angles between human coronary ostia, ranging from 130 degrees to 170 degrees. Moreover, the great preoperative discrepancies between aortic anulus and sinotubular junction diameters are corrected immediately after operation.
Collapse
Affiliation(s)
- A Kalangos
- Clinic for Cardiovascular Surgery, Division of Cardiology, University Cantonal Hospital of Geneva, Switzerland.
| | | | | | | | | |
Collapse
|
31
|
Nagy ZL, Fisher J, Walker PG, Watterson KG. The effect of sizing on the hydrodynamic parameters of the Medtronic freestyle valve in vitro. Ann Thorac Surg 2000; 69:1408-13. [PMID: 10881814 DOI: 10.1016/s0003-4975(00)01239-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND An in vitro model has been established to investigate the effect of sizing on the hydrodynamic characteristics and leaflet motion of the Medtronic Freestyle valve. METHODS The valves were tested in fresh porcine aortic roots. Two or three different sizes of valves were implanted in the same aortic root one after the other. The compliance of the fresh aortic and the composite roots was measured in the pressure range of 0 to 120 mm Hg, and the composite roots were then tested in a pulsatile flow simulator. The transvalvular gradient and degree of regurgitation were measured and the effective orifice area and performance index were calculated. Leaflet motion was recorded on video. RESULTS The fresh aortic roots dilated by average 39.4% as the hydrostatic pressure rose from 0 to 120 mm Hg. Implantation of the Medtronic Freestyle valve did not change the distensibility of the aortic root significantly. The sizing protocol did not affect significantly the hydrodynamic performance. However, a significantly lower open leaflet bending deformation was found in the undersized valves. Regurgitation was found only at 2-mm undersized valves. CONCLUSIONS Leaflet motion of the Medtronic Freestyle valve in vitro was best if 1 mm undersized, and this may be beneficial to long-term durability.
Collapse
Affiliation(s)
- Z L Nagy
- Yorkshire Heart Centre, Leeds, England
| | | | | | | |
Collapse
|
32
|
Ohtake S, Sawa Y, Sakaguchi T, Nishimura M, Satoh H, Matsumiya G, Hayashi Y, Matsuda H. Early experience of aortic valve replacement with the Freestyle stentless aortic bioprosthesis in elderly patients. THE JAPANESE JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY : OFFICIAL PUBLICATION OF THE JAPANESE ASSOCIATION FOR THORACIC SURGERY = NIHON KYOBU GEKA GAKKAI ZASSHI 2000; 48:222-8. [PMID: 10824474 DOI: 10.1007/bf03218126] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/14/2023]
Abstract
OBJECTIVES Stentless bioprostheses have been gaining popularity in recent years as hemodynamically superior alternatives to conventional stented bioprostheses. METHODS Between July 1996 and November 1998, 13 patients with aortic valve disease, 7 males and 6 females with a mean age (+/- SD) of 68 +/- 5 years, underwent an aortic valve replacement using the Medtronic Freestyle aortic bioprosthesis. The predominant lesions were stenosis in 8 patients and regurgitation in 5, while 2 patients had endocarditis. The operation was performed by a subcoronary technique in 9, root-inclusion technique in 3, and full root technique in 1 patient. RESULTS Throughout the follow-up periods (with average follow-up period of 20.6 months), there was no hospital mortality, though there was one late death of unknown cause. The New York Heart Association class improved in all patients. The peak transvalvular gradient decreased from 18.4 +/- 9.8 to 12.6 +/- 9.6 mmHg, and the effective valve orifice area increased from 2.30 +/- 0.96 to 2.59 +/- 1.05 cm2 between the 1-month and the 6-month follow-up examinations. In patients with aortic regurgitation, the left ventricular end-diastolic/end-systolic volume index significantly decreased from 147 +/- 36/62 +/- 19 to 73 +/- 26/33 +/- 14 ml/m2 at 1 month after the operation. The left ventricular mass index also significantly decreased from 189 +/- 26 to 143 +/- 30 g/m2 in patients with aortic regurgitation and from 171 +/- 28 to 144 +/- 30 g/m2 in those with aortic stenosis. CONCLUSIONS Although long-term follow-up is required for further evaluation, the early results appeared to indicate that the Freestyle aortic bioprosthesis was suitable for elderly patients requiring aortic valve replacement.
Collapse
Affiliation(s)
- S Ohtake
- Department of Surgery, Osaka University Graduate School of Medicine, Japan
| | | | | | | | | | | | | | | |
Collapse
|
33
|
Affiliation(s)
- M Zabalgoitia
- Echocardiography Laboratories, University of Texas Health Science Center, San Antonio, USA
| |
Collapse
|
34
|
Fries R, Wendler O, Schieffer H, Schäfers HJ. Comparative rest and exercise hemodynamics of 23-mm stentless versus 23-mm stented aortic bioprostheses. Ann Thorac Surg 2000; 69:817-22. [PMID: 10750766 DOI: 10.1016/s0003-4975(99)01409-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The hemodynamic superiority of stentless valves at rest has been generally accepted, but there is a lack of studies on exercise hemodynamics. METHODS We assessed aortic valve hemodynamics at rest and during exercise in 10 patients with a 23-mm stentless aortic bioprosthesis (Medtronic Freestyle; Medtronic Europe SA/NV, St. Stevens Woluwe, Belgium), in 10 patients with a 23-mm stented aortic bioprosthesis (Carpentier-Edwards, SAV, model 2650; Baxter Edwards AG, Horw, Switzerland), and in 10 healthy volunteers (control group) by means of Doppler echocardiography. RESULTS Gradients at rest and gradients on comparable maximum exercise levels were significantly lower in patients with stentless valves compared to those with stented valves (rest: 6 +/- 2/11 +/- 4 mm Hg [mean/peak] versus 12 +/- 3/21 +/- 10 mm Hg; exercise: 9 +/- 3/18 +/- 6 mm Hg [mean/peak] versus 22 +/- 8/40 +/- 11 mm Hg). Patients with stentless valves revealed, in comparison to healthy young men, significantly higher gradients, but the small gradient difference of 3/7 mm Hg (mean/peak) at rest remained nearly unchanged throughout the exercise protocol (4/8 mm Hg [mean/peak] at 25 W, 4/9 mm Hg at 50 W and 4/9 mm Hg at 75 W). In contrast, the gradient difference between patients with stented and stentless valves increased significantly from one exercise level to the next (6/12 mm Hg [mean/peak] at rest, 8/14 mm Hg at 25 W, 12/17 mm Hg at 50 W, and 15/25 mm Hg at 75 W). CONCLUSIONS A stentless aortic bioprosthesis seems to be an appropriate aortic valve substitute, especially in patients who perform regular physical exercise.
Collapse
Affiliation(s)
- R Fries
- Department of Cardiology and Angiology, University Hospitals Homburg, Homburg/Saar, Germany.
| | | | | | | |
Collapse
|
35
|
Abstract
After replacement of a bicuspid aortic valve with a Freestyle stentless xenograft, right coronary leaflet dysfunction and an elevated pressure gradient developed. Attempts to match the right and left ostia of the prosthesis, which were located at an angle of less than 120 degrees, to the native right and left ostia, which were located at 180 degrees, may have resulted in the leaflet distension. This is a suggestive finding about its implantation technique.
Collapse
Affiliation(s)
- K Uemura
- First Department of Surgery, School of Medicine, Kumamoto University, Japan
| | | | | | | | | |
Collapse
|
36
|
Kon ND, Cordell AR, Adair SM, Dobbins JE, Kitzman DW. Aortic root replacement with the freestyle stentless porcine aortic root bioprosthesis. Ann Thorac Surg 1999; 67:1609-15; discussion 1615-6. [PMID: 10391263 DOI: 10.1016/s0003-4975(99)00370-7] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Stentless porcine prosthetic 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 and twelve patients were operated on from September 17, 1992 to April 13, 1998 as part of a multi-center worldwide investigation. All patients received a total aortic root replacement. Patients were evaluated postoperatively at discharge, 3 to 6 months, and yearly by clinical exam and color flow Doppler echocardiography. RESULTS There were 4 deaths either in the hospital or within 30 days after surgery for an operative mortality of 3.6%. No patients experienced structural valve deterioration, non-structural valve deterioration, paravalvular leak, unacceptable hemodynamic performance, or postoperative endocarditis. The linearized rates for survival and thromboembolic complications at 5 years were 82.8% and 90.5% respectively. Excellent hemodynamic function is demonstrated by very low gradients, large EOA, and an exceedingly low incidence of any aortic regurgitation. CONCLUSIONS The Medtronic Freestyle aortic root bioprosthesis can be used safely to replace the aortic root for aortic valve and aortic root pathology. Root replacement allows optimal hemodynamic performance with no significant aortic regurgitation. Early and intermediate results are encouraging, but further follow-up is needed to determine valve durability.
Collapse
Affiliation(s)
- N D Kon
- Department of Cardiothoracic Surgery, Wake Forest University School of Medicine/Baptist Medical Center, Winston-Salem, North Carolina 27157-1096, USA.
| | | | | | | | | |
Collapse
|
37
|
Mediratta N, Sosnowski AW, Galiñanes M. Posterior aortoventricular bleeding after supra-annular stentless aortic valve replacement. J Thorac Cardiovasc Surg 1999; 117:1031-2. [PMID: 10220705 DOI: 10.1016/s0022-5223(99)70391-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- N Mediratta
- Division of Cardiac Surgery, Department of Surgery, University of Leicester, Glenfield Hospital NHS Trust, Leicester, United Kingdom
| | | | | |
Collapse
|
38
|
Abstract
Replacement of the diseased aortic valve represents one of the triumphs of cardiac surgery; however, the perfect valve substitute continues to elude surgeons after almost four decades of clinical experience. The characteristics of the ideal valve substitute include the following: central flow capacity, low transvalvular gradient, low thrombogenicity, durability, easy availability, resistance to infection, non-immunogenicity, and easy implantability. The pulmonary autograft first performed by Ross (Lancet 1967, 2:956-958) came closest to achieving these goals, but creates a double valve procedure for single valve disease. Aortic valve replacement (AVR) with homograft aortic valve was introduced by Ross in 1962 (Lancet 1962, 2:487) and Barratt-Boyes in 1964 (Thorax 1964, 19:131-150). Like the pulmonary autograft, homograft AVR results in an excellent hemodynamic outcome but suffers from limitations of graft availability, lack of durability, and difficulty with implantation. Mechanical valves and stented tissue valves allow "off the shelf" easy availability as well as easy implantability. These valves are unfortunately intrinsically obstructed to some extent because of the space occupied by the stent and sewing ring. Stent mounted tissue valves also continue to exhibit limited durability. Stentless xenograft aortic valves have been developed as a compromise between these ends of the valve spectrum to allow excellent hemodynamics and hopefully improved durability while allowing "off the shelf" availability in a variety of standard sizes. We examine the rationale for use of the stentless xenograft aortic valve, the clinical development of this valve, and the surgical techniques of implantation.
Collapse
Affiliation(s)
- M J Reardon
- Division of Cardiothoracic Surgery, Baylor College of Medicine, Houston, TX 77030, USA
| | | |
Collapse
|
39
|
Abstract
BACKGROUND A variety of surgical techniques are used to manage a disintegrated aortic annulus in patients with endocarditis and excavating aortic root sepsis. Homograft root replacement is preferable in this setting but suitable homografts are restricted in availability and excision of the aortic root carries the risk of postoperative bleeding. As an alternative we used a stentless porcine xenograft root (Medtronic Freestyle valve) to manage this problem. METHODS Three male patients with active endocarditis presented with aortic root abscess and partial or complete aorto-left ventricular discontinuity. One had prosthetic valve endocarditis, and the abscess cavity entered the right atrium in another. The porcine aortic root was successfully implanted using the modified subcoronary technique providing a repair within the aortic root with proximal and distal suture lines that excluded the disintegrating tissues from the blood stream. All patients were treated with intravenous antibiotics for 6 weeks postoperatively and none suffered recurrent infection (follow-up > 6 months). CONCLUSION The stentless porcine aortic root implanted within the human aorta provides an additional surgical option for excavating aortic root sepsis.
Collapse
Affiliation(s)
- T Katsumata
- Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, Headington, United Kingdom.
| | | | | |
Collapse
|
40
|
Lee CH, Vyavahare N, Zand R, Kruth H, Schoen FJ, Bianco R, Levy RJ. Inhibition of aortic wall calcification in bioprosthetic heart valves by ethanol pretreatment: biochemical and biophysical mechanisms. JOURNAL OF BIOMEDICAL MATERIALS RESEARCH 1998; 42:30-7. [PMID: 9740004 DOI: 10.1002/(sici)1097-4636(199810)42:1<30::aid-jbm5>3.0.co;2-p] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The effectiveness of ethanol pretreatment on preventing calcification of glutaraldehyde-fixed porcine aortic bioprosthetic heart valve (BPHV) cusps was previously demonstrated, and the mechanism of action of ethanol was attributed in part to both lipid removal and a specific collagen conformational change. In the present work, the effect of ethanol pretreatment on BPHV aortic wall calcification was investigated using both rat subdermal and sheep circulatory implants. Ethanol pretreatment significantly inhibited calcification of BPHV aortic wall, but with less than complete inhibition. The maximum inhibition of calcification of BPHV aortic wall was achieved using an 80% ethanol pretreatment; calcium levels were 71.80+/-8.45 microg/mg with 80% ethanol pretreatment compared to the control calcium level of 129.90+/-7.24 microg/mg (p = 0.001). Increasing the duration of ethanol exposure did not significantly improve the inhibitory effect of ethanol on aortic wall calcification. In the sheep circulatory implants, ethanol pretreatment partly prevented BPHV aortic wall calcification with a calcium level of 28.02+/-4.42 microg/mg compared to the control calcium level of 56.35+/-6.14 microg/mg (p = 0.004). Infrared spectroscopy (ATR-FTIR) studies of ethanol-pretreated BPHV aortic wall (vs. control) demonstrated a significant change in protein structure due to ethanol pretreatment. The water content of the aortic wall tissue and the spin-lattice relaxation times (T1) as assessed by proton nuclear magnetic resonance spectroscopy did not change significantly owing to ethanol pretreatment. The optimum condition of 80% ethanol pretreatment almost completely extracted both phospholipids and cholesterol from the aortic wall; despite this, significant calcification occurred. In conclusion, these results clearly demonstrate that ethanol pretreatment is significantly but only partially effective for inhibition of calcification of BPHV aortic wall and this effect may be due in part to lipid extraction and protein structure changes caused by ethanol. It is hypothesized that ethanol pretreatment may be of benefit for preventing bioprosthetic aortic wall calcification only in synergistic combination with another agent.
Collapse
Affiliation(s)
- C H Lee
- Department of Pediatrics and Communicable Diseases, The University of Michigan, Ann Arbor 48109, USA
| | | | | | | | | | | | | |
Collapse
|
41
|
Doty DB, Cafferty A, Kon ND, Huysmans HA, Krause AH, Westaby S. Medtronic Freestyle aortic root bioprosthesis: Implant techniques. J Card Surg 1998; 13:369-75. [PMID: 10440652 DOI: 10.1111/j.1540-8191.1998.tb01099.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND The Medtronic Freestyle aortic root bioprosthesis is a complete porcine aortic root to allow implantation (1) as a subcoronary valve replacement by removing graft sinus aorta, (2) as a cylinder with the sinotubular junction intact within the aorta (root inclusion), or (3) as a complete aortic root replacement. The choice among the three implant techniques depends on surgeon preference or upon the pathology encountered. The advantages and differences among the three implant techniques are examined. METHODS The Medtronic Freestyle bioprosthesis was implanted in 1163 patients in a Food and Drug administration (FDA) clinical trial between August 1992 and October 1997. There were 21 centers in the international trial using a single data repository. Clinical data was collected prior to and at operation, at 3 to 6 months and annually. The data were compiled and statistical analysis performed at the data center. RESULTS Patients having subcoronary valve implants were older (80% > 65 years) and aortic occlusion time was about 20 minutes less than the other methods. Patients having aortic root replacement presented with more aortic valve insufficiency (20%). Pathology of the aortic root and ascending aorta requiring repair was 26%, and larger (27 mm) valves were used in 40% of patients. Risk of operation was lowest (5.0%) with subcoronary valve implants and highest (11.7%) with root replacement technique. Thromboembolism was higher, early and late, with root inclusion (3.0, 3.9%/patient per year) and root replacement (3.2, 3.0%/patient per year) than for subcoronary implants (1.8, 1.6%/patient per year). There were more patients taking warfarin at the 4-year point with root inclusion (20%) or root replacement techniques (24%) than among patients having subcoronary implants (14%). Explants of the valve occurred in 2% of patients, none of whom had aortic root replacement. CONCLUSIONS The Medtronic Freestyle bioprosthesis is an effective and versatile device for replacement of the aortic valve. It offers implant techniques that can treat the aortic root pathology encountered at surgery and allows the operation to proceed according to surgeon preference.
Collapse
Affiliation(s)
- D B Doty
- The Medtronic Freestyle Multicenter Clinical Trial Centers.
| | | | | | | | | | | |
Collapse
|
42
|
Westaby S, Jin XY, Katsumata T, Arifi A, Braidley P. Valve replacement with a stentless bioprosthesis: versatility of the porcine aortic root. J Thorac Cardiovasc Surg 1998; 116:477-84. [PMID: 9731790 DOI: 10.1016/s0022-5223(98)70014-5] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Stentless valves convey important hemodynamic benefits but are used selectively depending on aortic root structure. The Freestyle valve (Medtronic, Inc, Minneapolis, Minn) is a versatile device that can be implanted by different methods depending on operating conditions. We aimed to demonstrate that a stentless valve could be used in every patient without increased risk of morbidity or mortality. We documented the effects of this valve on clinical outcome and left ventricular mechanics. METHODS The Freestyle valve was implanted by the modified subcoronary method into 200 consecutive unselected patients who received a tissue valve in the aortic position and by root replacement in 2. Forty-three percent were older than 75 years. Forty percent underwent coronary bypass. Detailed clinical and echocardiographic follow-up (Food and Drug Administration protocol) was used out to 3 years. RESULTS Mean ischemic time was 43+/-6 minutes for isolated aortic valve replacement and 63+/-14 minutes with concomitant procedures. Thirty-day mortality was 6%, none of the deaths being valve related. Hemodynamic function improved progressively with falling valve gradients and increased effective orifice areas. Left ventricular mass fell within normal limits over 2 years, but at 3 years there was a non-valve-related upswing. No instances of valve thrombosis, hemolysis, or paravalvular leak were noted. Less than 5% had mild to moderate aortic regurgitation. CONCLUSIONS The Freestyle valve can be used in virtually every patient with aortic valve disease and provides superlative hemodynamic outcome. Hospital mortality and morbidity are similar to those reported for stented valves in an elderly population.
Collapse
Affiliation(s)
- S Westaby
- Department of Cardiac Surgery, Oxford Heart Centre, The John Radcliffe Hospital, United Kingdom
| | | | | | | | | |
Collapse
|
43
|
Del Rizzo DF, Abdoh A. Clinical and hemodynamic comparison of the Medtronic Freestyle and Toronto SPV stentless valves. J Card Surg 1998; 13:398-407. [PMID: 10440656 DOI: 10.1111/j.1540-8191.1998.tb01103.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The excellent hemodynamics of stentless valves have been observed by numerous investigators. With the recent release of the Toronto SPV (stentless porcine valve) and the Medtronic Freestyle stentless valves in North America, it is appropriate to now compare the clinical and hemodynamic performance of these devices. We analyzed the results of 995 patients who underwent aortic valve replacement (AVR) with either of the two valves; in all cases a subcoronary implant technique was used. There were important differences in the preoperative characteristics for the two groups: Medtronic Freestyle patients were notably older than the Toronto SPV patients (70.7+/-8.6 vs 61.8+/-11.1 years, p < 0.001) and were markedly more symptomatic (p < 0.0001). In the Toronto SPV group, most patients had New York Heart Association (NYHA) Class II (41.5%) or Class III (44.7%) symptoms preoperatively, while in the Freestyle group, 61.5% were in Class III and 12.5% were in Class IV. There were no notable differences in mortality or morbidity for the two groups. Both devices demonstrated a meaningful decrease in mean gradient and a corresponding increase in effective orifice area (EOA). Furthermore, the indexed EOA (EOA/body surface area [BSA]) was > 1cm2/m2 for all valves indicating there was no patient-prosthetic mismatch. There was a meaningful decrease in left ventricular (LV) mass as well as LV mass index (LVMI) for both devices up to 3 years postoperatively. Our data indicate that there were no differences in clinical outcome or hemodynamic performance of these two valves. Both devices offer excellent results with normalization of LV function.
Collapse
Affiliation(s)
- D F Del Rizzo
- Department of Surgery, University of Manitoba, Winnipeg, Canada.
| | | |
Collapse
|
44
|
Doty JR, Flores JH, Millar RC, Doty DB. Aortic valve replacement with medtronic freestyle bioprosthesis: operative technique and results. J Card Surg 1998; 13:208-17. [PMID: 10193992 DOI: 10.1111/j.1540-8191.1998.tb01264.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study evaluates the initial results for safety and efficacy of aortic valve replacement (AVR) using the Medtronic Freestyle Bioprosthesis. METHODS One hundred three patients underwent AVR with the Medtronic Freestyle Bioprosthesis over a 40-month period. There were 59 male and 44 female patients with a mean age of 74 years (range 36 to 88 years). Valve size ranged from 19 to 27 mm, and all valves were implanted using a freehand subcoronary technique. Anticoagulation with coumadin was only used for atrial fibrillation. Aspirin was given to patients with associated coronary artery disease. Echocardiography to assess transvalvular pressure gradient and effective valve orifice area was performed at discharge, 3 to 6 months, 1 year, and then annually. RESULTS There were 4 (3.9%) deaths within 30 days of operation and 5 (4.9%) late deaths. Two (1.9%) deaths were valve-related, one from commissural dehiscence and one from bacterial endocarditis. Three (2.9%) deaths, two early and one late, were from other cardiac causes. The remaining deaths were from noncardiac causes. Five (4.9%) patients suffered a thromboembolic event, two had permanent neurological deficits, two had transient neurological events, and one had coronary artery occlusion. Mean transvalvular gradient assessed by echocardiography was low at all time intervals: discharge (12.8 mmHg), 3 to 6 months (11.3 mmHg), 1 year (12.0 mmHg), and 2 years (11.6 mmHg). Mean effective valve orifice area was good at all time intervals: discharge (1.4 cm2), 3 to 6 months (1.5 cm2), 1 year (1.6 cm2), and 2 years (1.6 cm2). Of the 38 patients assessed by echocardiography at 1 year, 33 (87%) had no or trivial valve incompetence and the remainder had mild valve incompetence. CONCLUSIONS Aortic valve replacement with the Medtronic Freestyle Bioprosthesis has a low incidence of early valve-related mortality and thromboembolism. The bioprosthesis demonstrates good hemodynamic performance even in small diameters and is particularly well suited for older patients and the small aortic root.
Collapse
Affiliation(s)
- J R Doty
- The Department of Surgery, LDS Hospital, Salt Lake City, Utah 84103, USA.
| | | | | | | |
Collapse
|
45
|
Westaby S, Huysmans HA, David TE. Stentless aortic bioprostheses: compelling data from the Second International Symposium. Ann Thorac Surg 1998; 65:235-40. [PMID: 9456124 DOI: 10.1016/s0003-4975(97)01290-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Stentless aortic xenografts are an important addition to the range of prosthetic valves. So far their use has been restricted to a limited number of study centers. This report summarizes the principal findings from the Second International Symposium on Stentless Bioprostheses. Attention is focused on the Toronto SPV and Freestyle valves recently approved by the United States Food and Drug Administration. METHODS Stentless xenografts are used predominantly in elderly patients with aortic stenosis. Implant techniques are more complex than for stented valves, as reflected by longer ischemic and cardiopulmonary bypass times. The valves have been subjected to detailed serial echocardiographic assessment and clinical follow-up. RESULTS The hemodynamic characteristics resemble those of the aortic homograft. There is a progressive increase in effective orifice area and decrease in transvalvular pressure gradients with time. Left ventricular mass index and wall thickness normalize between 6 and 12 months postoperatively. Left ventricular remodeling is accompanied by improved symptomatic status and a low incidence of valve-related complications. Limited comparative studies suggest important benefits over stented xenografts. Improved hemodynamics may translate into better bioprosthetic durability. CONCLUSIONS Reproducible and reliable implant methods should be taught carefully, but the hemodynamic advantages are substantial. Stentless xenografts are ideal for the elderly patient with aortic stenosis.
Collapse
Affiliation(s)
- S Westaby
- Oxford Heart Centre, John Radcliffe Hospital, United Kingdom
| | | | | |
Collapse
|
46
|
Abstract
Nonstented porcine bioprostheses offer the surgeon a larger implant option with better hemodynamics than stented counterparts by eliminating the space occupied by the frame. A secondary benefit may be improved durability related to reduction of leaflet stresses created by the frame. The Medtronic Freestyle stentless porcine aortic root can be implanted as a root replacement, as a miniroot cylinder within the aorta, or as a partially or completely scalloped valve replacement. This report describes an easy, reliable, and reproducible technique of completely scalloped valve replacement performed in a population of 75 patients with Freestyle implants and uses the anatomy of the Freestyle and human aortic roots to facilitate the implant technique.
Collapse
Affiliation(s)
- A H Krause
- Department of Cardiac Surgery, Legacy Portland Hospitals, Oregon, USA
| |
Collapse
|
47
|
Garlick RB, O'Brien MF. The CryoLife-O'Brien composite stentless porcine aortic xenograft valve in 118 patients. JAPANESE CIRCULATION JOURNAL 1997; 61:682-6. [PMID: 9276773 DOI: 10.1253/jcj.61.682] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The CryoLife-O'Brien stentless valve is a composite trileaflet porcine aortic valve. It is assembled from 3 non-coronary leaflets and has no foreign material support. It is therefore truly stentless. From December 1992 to January 1996, 118 patients with aortic valve replacement had a CryoLife-O'Brien stentless valve inserted at the Prince Charles Hospital, Brisbane. The mean age was 73 years (range 59-89) and 54% were men. Most patients had aortic stenosis secondary to a calcific degenerative valve. Follow-up is 100% with hematological and echocardiographic studies before discharge, at 6 months, and at 12-18 months. Five deaths (2 early and 3 late) have occurred and morbidity includes 3 strokes, 1 peripheral embolism, 3 perivalvular leaks, and 1 patient with late endocarditis. Valve performance has been good, with low transvalvular gradients and only a trace or no regurgitation in over 95% of patients after 18 months. No structural deterioration or hemolysis has occurred. Echocardiographic surveillance confirms a very effective central orifice. Short-term results show that the overall performance of the CryoLife-O'Brien stentless valve has been very satisfactory, with low mortality and morbidity in this elderly group of patients. The benefits include the absence of prosthetic material, wide leaflet coaptation, and a quick and easy insertion. Long-term anticoagulation is not necessary. It is particularly suitable for elderly patients with a symmetrical aortic root.
Collapse
Affiliation(s)
- R B Garlick
- Department of Cardiac Surgery, Prince Charles Hospital, Brisbane, Australia
| | | |
Collapse
|
48
|
Bhatnagar G, Christakis GT, Murphy PM, Oxorn D, Goldman BS. Technique for reconstruction of the sinotubular junction. Ann Thorac Surg 1997; 63:559-60. [PMID: 9033347 DOI: 10.1016/s0003-4975(96)01036-3] [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] [Indexed: 02/03/2023]
Abstract
Correct geometric relationships between the annulus and sinotubular junction during stentless valve implantation are critical to minimize the development of insufficiency. Some patients with aortic valve disease have dilatation of the sinotubular junction and are unable to have a stentless valve placed by standard techniques. We recently encountered such a patient and reconstructed the sinotubular junction by aortic crenation. Multiple interrupted plicating sutures were used to reduce the aorta from a diameter of 42 mm to 28 mm. This method allows tailoring of the aorta to appropriate size by varying the number of crenating sutures.
Collapse
Affiliation(s)
- G Bhatnagar
- Division of Cardiovascular Surgery, Sunnybrook Health Science Centre, University of Toronto, Ontario, Canada
| | | | | | | | | |
Collapse
|
49
|
Del Rizzo DF, Goldman BS, Christakis GT, David TE. Hemodynamic benefits of the Toronto Stentless Valve. J Thorac Cardiovasc Surg 1996; 112:1431-45; discussion 1445-6. [PMID: 8975834 DOI: 10.1016/s0022-5223(96)70001-6] [Citation(s) in RCA: 82] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We report on 254 consecutive patients (170 male, 84 female) undergoing aortic valve replacement with the Toronto SPV Stentless Valve (St. Jude Medical, Inc., St. Paul, Minn.). Mean age (+/- standard deviation) was 62.1 +/- 11.6 years. Three patients (1%) received sizes 21 or 22 mm, 24 (9%) received size 23 mm, and 227 patients (89%) received sizes 25, 27, or 29 mm. Serial echocardiography was used to assess valve performance during a 3-year follow-up. Mean gradient decreased by 35.8% (p < 0.0001; 95% confidence interval -39.6%, -31.7%) from postoperative values to the 3- to 6-month follow-up and by 6.1% (p = 0.004; 95% confidence interval -10.1%, -2%) at each subsequent interval; effective orifice area increased by 17.2% (p = 0.0001; 95% confidence interval 12.0%, 22.6%) initially and by 4.4% (p < 0.001; 95% confidence interval 1.8%, 7.0%) thereafter. At 2 years of follow-up, mean gradient was 3.3 +/- 2.1 mm Hg and mean effective orifice area was 2.2 +/- 0.8 cm2. Studies on left ventricular mass were carried out on 84 patients. Left ventricular mass decreased by 14.3% (37.8 +/- 57.9 gm; p < 0.0001; 95% confidence interval -53.7, -21.9 gm) and left ventricular mass index decreased by 15.2% (21.1 +/- 30.5 gm/m2; p < 0.0001; 95% confidence interval -29.5, -12.7 gm/m2) from postoperative values to the 3- to 6-month follow-up interval. The reduction in residual gradient and potential regression in left ventricular hypertrophy may have a beneficial prognostic implication. We believe that the unique stentless design of the Toronto SPV Stentless Valve allows this to occur.
Collapse
Affiliation(s)
- D F Del Rizzo
- Sunnybrook Health Science Centre, University of Toronto, Canada
| | | | | | | |
Collapse
|
50
|
Westaby S, Amarasena N, Long V, Prothero A, Amarasena GA, Banning AP, Pillai R, Ormerod O. Time-related hemodynamic changes after aortic replacement with the freestyle stentless xenograft. Ann Thorac Surg 1995; 60:1633-8; discussion 1639. [PMID: 8787456 DOI: 10.1016/0003-4975(95)00639-7] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The Freestyle valve is a porcine aortic root fixed with net zero pressure across the cusps and treated with the anticalcification agent alpha-aminooleic acid. We evaluated the hemodynamic function of this stentless valve. METHODS We implanted the valve into 80 consecutive patients scheduled to receive a bioprosthesis. Sixty-nine patients were more than 70 years old and 14 had calcified aortic sinuses. The "cylinder within a cylinder" implantation technique was used. Twenty-seven patients received coronary grafts, and 3 had mitral repair. All patients were studied echocardiographically during week 1 and 41 were studied at 6 months. RESULTS Median ischemic time for isolated aortic valve replacement was 44 minutes. There were four hospital deaths, none valve related. No patient had more than trivial aortic regurgitation. Mean systolic gradients for valve sizes 21 to 25 mm fell significantly with time (p < or = 0.05) due to remodeling of the porcine root and early regression of left ventricular hypertrophy. Late hemodynamic function was equivalent to an aortic homograft. CONCLUSIONS The Freestyle valve is easily implanted and has excellent hemodynamics. Transvalvular gradients decrease progressively.
Collapse
Affiliation(s)
- S Westaby
- Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, England
| | | | | | | | | | | | | | | |
Collapse
|