Mechanical versus biological valve prosthesis: a ten-year comparison regarding function and quality of life

One-year postprocedural quality of life following mitral valve surgery: data from The Netherlands heart registration

OBJECTIVES

The aim of surgical treatment of mitral valve disease is to reverse heart failure and to restore life expectancy and quality of life (QoL). In mitral valve surgery, QoL has not been studied extensively, especially regarding the surgical approach. The current study aimed to evaluate QoL after mitral valve surgery through full sternotomy and a minimally invasive approach (MIMVS).

METHODS

All patients undergoing mitral valve surgery between 2013-2018 through sternotomy or a MIMVS approach (right anterolateral mini-thoracotomy, sternal-sparing), with or without concomitant tricuspid valve surgery, surgical ablation, or atrial septal defect closure were eligible for inclusion in this multicentre nationwide registry in the Netherlands. Quality of life was measured using the 12- and 36-item short form surveys, before surgery and postoperatively at 1 year. Independent predictors for loss of QoL were evaluated.

RESULTS

485 patients were included (full sternotomy: n = 276, and MIMVS: n = 209). Overall, patients experienced a significant increase in physical component score (56 [42-75] vs 74 [57-88], p < 0.001) and mental component score at 1-year (63 [52-74] vs 70 [59-86], p < 0.001). Baseline QoL scores and new onset of atrial arrhythmia were independently associated with a clinically relevant reduction in physical and mental QoL.

CONCLUSIONS

Mitral valve surgery is associated with significant improvement in physical and mental QoL. Baseline QoL scores and new onset of atrial arrhythmia are associated with a clinically relevant reduction in postoperative QoL.

Age-stratified outcomes of bioprosthetic and mechanical aortic valve replacements in an Australian cohort of 13 377 patients

OBJECTIVES

To quantify age-stratified outcomes of bioprosthetic valve (BV) and mechanical valve (MV) surgical aortic valve replacement (AVR) in Australian patients.

DESIGN

Retrospective cohort study using population-based linked hospital morbidity and mortality data.

SETTING

Public and private hospitals.

PARTICIPANTS

Patients aged 18 years and over undergoing AVR from 2001 to 2013, stratified by age (18-64 years; 65+ years).

MAIN OUTCOME MEASURES

Age-standardized index AVR rates; rates and multivariable-adjusted (age, sex, Charlson Comorbidity Index) incidence rate ratios (IRRs) for reoperation, incident cardiovascular events (hospitalization or death for acute myocardial infarction (AMI), stroke, major hemorrhage or thromboembolism) and mortality (cardiovascular and all-cause).

RESULTS

Our cohort comprised 13 377 patients, of whom 3464 (26%) were aged 18-64 years. Annual age-standardized AVR rates increased by 2.7% with BV implants increasing in both age groups. After 5 years of follow-up, patients implanted with BV had lower rates of stroke (IRR: 0.40, 95% CI 0.27 to 0.60) and hemorrhage (IRR: 0.36, 95% CI 0.26 to 0.50). Among patients 65+ years, those implanted with BV had lower rates of AMI, hemorrhage, and cardiovascular and all-cause mortality than those implanted with MV (IRR: 0.71, 95% CI 0.53 to 0.96; IRR: 0.77, 95% CI 0.62 to 0.95; IRR: 0.80, 95% CI 0.69 to 0.92 and IRR: 0.85, 95% CI 0.74 to 0.97, respectively). After 6-10 years of follow-up, reoperation rates among patients 18-64 years were markedly higher in those implanted with BV compared with MV (IRR: 5.48, 95% CI 2.38 to 12.62) and rates of AMI were lower among patients implanted with BV compared with MV (IRR: 0.49, 95% CI 0.26 to 0.94). Among patients 65+ years rates of cardiovascular and all-cause mortality remained significantly lower for patients implanted with BV compared with MV.

CONCLUSIONS

This study provides real-world evidence of AVR use and outcomes. Use of BV implants is increasing irrespective of age. Valve choice in younger patients requires thorough evaluation of patient factors influencing both short-term outcomes and longer-term risks of reoperation, stroke and hemorrhage.

Incidence and factors associated with infective endocarditis in patients undergoing left-sided heart valve replacement

Aims

Patients with left-sided heart valve replacement are considered at high-risk of infective endocarditis (IE). However, data on the incidence and risk factors associated with IE are sparse.

Methods and results

Through Danish administrative registries, we identified patients who underwent left-sided heart valve replacement from January 1996 to December 2015. Patients were categorized in mitral and aortic valve replacement (MVR and AVR) and followed until: 12 years after valve surgery, end of study, death, emigration, or hospitalization due to IE, whichever came first. Multivariable adjusted Cox proportional hazard analysis was used to investigate which baseline characteristics were associated with IE. A total of 18 041 patients were included. The cumulative IE risk at 10 years follow-up was 5.2% in both MVR and AVR patients. In patients with MVR, male sex [hazard ratio (HR) = 1.68, 95% confidence interval (95% CI) 1.06-2.68], bioprosthetic valve (HR = 1.91, 95% CI 1.08-3.37), and heart failure (HR = 1.69, 95% CI 1.06-2.68) were among factors associated with an increased risk of IE. In AVR patients, male sex (HR = 1.59, 95% CI 1.33-1.89), bioprosthetic valve (HR = 1.70, 95% CI 1.35-2.15), and cardiac implantable electronic device (CIED) (HR = 1.57, 95% CI 1.19-2.06) were among factors associated with an increased risk of IE.

Conclusion

Infective endocarditis after left-sided heart valve replacement is not uncommon and occurs in about 1/20 over 10 years. Male, bioprosthetic valve, and heart failure were among factors associated with IE in MVR patients while male, bioprosthetic valve, and CIED were among factors associated with IE in AVR patients.

Health-related quality of life after adverse bleeding events associated with antithrombotic drug therapy - A systematic review

Little is known about the health-related quality of life (HRQOL) following adverse bleeding events associated with antithrombotic drug therapy. This systematic review assesses the HRQOL of patients who suffered a bleeding event related to antithrombotic drug use. A literature search was performed using PubMed, EMBASE, and the Cochrane Library from inception through June 16, 2017. Studies measuring HRQOL after a bleeding event related to antithrombotic drug therapy for primary or secondary prevention of a thromboembolic event were included. Four studies with a total of 13,209 patients met the inclusion criteria, and of them, 3,649 patients developed a bleeding event. Patients who were included received antithrombotic drugs because of acute myocardial infarction or atrial fibrillation. EQ-5D, SF-36, and GHP MOS-13 were used to measure HRQOL. The follow-up time ranged from 6 to 29 months. Patients who suffered a bleeding event reported worse HRQOL compared to those who did not (EQ-5D - average increase on all domains of 0.09, p-values ranging from <0.001 to 0.003; SF-36 - average decrease on all domains of 21.4, p < 0.001; and GHP MOS-13 score - decrease of 11.9 points, p < 0.05) and an increased health concern (13.4-point increase; p < 0.05). In conclusion, adverse bleeding events occurring because of the use of antithrombotic agents are associated with a clinically relevant lower HRQOL and hence deserve more attention as part of the shared decision-making process between patients and providers. These data should be valuable for facilitating more substantive care and risk discussions regarding potential changes in outcome and rehabilitation.

Mitral Valve Replacement Using Carpentier-Edwards Pericardial Bioprosthesis in Patients With Rheumatic Heart Disease Aged Below 40 Years: 17-Year Results

BACKGROUND

This study was designed to evaluate patients aged less than 40 years implanted with tissue heart valves with respect to survival, thromboembolism, structural degeneration and quality of life.

METHODS

Between January, 2000 and December, 2016, 132 patients (51 males) with rheumatic heart disease underwent mitral valve replacement using Carpentier-Edwards, perimount, pericardial bioprostheses. The patients' ages ranged between 12 and 39 years (mean±SD 30.12±5.51 years).

RESULTS

The hospital and late mortality were 1.5% and 1.5% respectively. The total cumulative follow-up period was 1330.98 patient-years with a mean of 124.78±50.3 months (range, 1-204 months). The actuarial survival and actuarial event-free survival at 204 months was 96.9% (±0.01%) and 93.4%(±0.03%) respectively. There was one episode of thromboembolism (0.32 events per 100 patient years). Six (4.7%) patients underwent redo mitral valve replacement for severe bioprosthetic degeneration with stiffening and calcification using a Medtronic mechanical prosthesis (Medtronic Open Pivot, MN, USA).

CONCLUSIONS

We conclude that Carpentier-Edwards perimount pericardial prosthesis provides satisfactory clinical performance in a young population with a low risk of degeneration and other valve-related events.

Performance by Age Groups in Biological and Mechanical Cardiac Valve Replacement

A group of 1195 patients who received biological valve prostheses (mean age 57.3 years, range 8 to 85 years) and a group of 1345 patients who received mechanical heart valves (mean age 56.1 years, range 13 to 91 years) were analyzed for complications by age group (less than or equal to 54 years, 55 to 65 years, and over 65 years). The freedom from thromboembolism and anticoagulant-related hemorrhage at 8 years after aortic valve replacement was significantly higher in patients who received a biological prosthesis in all age groups. The freedom from thromboembolism and anticoagulant-related hemorrhage at 8 years after mitral valve replacement was significantly higher in patients who received a biological prosthesis in the age groups less than or equal to 54 years and over 65 years. The freedom from all valve-related complications at 5 and 8 years after aortic or mitral valve replacement showed the same trend of greater freedom from complications in biological prostheses patients compared with mechanical prostheses in most age groups. However, freedom from valve-related reoperation, mortality, and residual morbidity for aortic and mitral valve replacement for all age groups was not significantly different. These results show that biological prostheses can be considered for patients aged 55 years and older. The prostheses by age group or position at 8 years were not differentiated by valve-related reoperation, mortality, and residual morbidity. t 8 years there is a demonstrated price to pay for a presumed increase in longevity for patients with mechanical valves in the aortic position, reflected by an increase in thromboembolism and anticoagulant-related hemorrhage in all age groups.

Comparison of Quality of Life Perceived by Patients with Bioprosthetic versus Mechanical Valves after Composite Aortic Root Replacement

Objective: To assess whether postoperative quality of life (QOL) for composite aortic root replacement patients differs according to whether it is based on the use of mechanical valves or bioprosthetic valves. Methods: The study included 146 consecutive patients who underwent composite aortic root replacement at our institution from January 2010 to April 2014 with bioprosthetic (34.9%, n = 51) and mechanical (65.1%, n = 95) valves. Patient-perceived QOL was measured by administering the Short Form (SF)-36v2 Health Survey and a series of supplemental questions to further evaluate valve-specific differences. Final survey participation (n = 121) included 82.9% of the qualifying patients, and involved 76.5% (39/51) of those with bioprosthetic valves and 86.3% (82/95) of those with mechanical valves. Reasons for not completing the survey included 5 expired patients (3.4%), 1 lost due to a language barrier (0.7%), 6 who refused to participate (4.1%) and 13 who were lost to follow-up (8.9%). The mean follow-up time was 32 months (range 4-56 months). Results: Patients in the bioprosthetic valve group were older (mean age 67.5 ± 13.6 years) and included more females (25.6% or 10/39) than those in the mechanical valve group (mean age 56.6 ± 12.0 years; 11.0% or 9/82 were female). No significant differences were found between the bioprosthetic and mechanical valve groups for any QOL aspects scored by the SF-36v2 survey. All 8 domains and 2 summary scales comprising the QOL evaluation were above national norms calculated using gender- and age-matched, norm-based scoring for a standard national average of 50. The supplemental questions indicated satisfaction with each valve type despite characteristics that were of concern to patients. In the mechanical valve group, 90.2% (74/82) reported that the audible valve click was not troublesome, 85.4% (70/82) that taking a blood thinner regularly did not affect daily life and 81.7% (67/82) that blood testing for anticoagulation therapy was not troublesome. Conclusions: Receiving a tissue or a mechanical valve does not directly affect postoperative QOL. Answers to supplemental questions suggest that prior concerns with mechanical valves do not affect patients in the commonly anticipated negative manner. The preconception of a heavy QOL burden for mechanical composite grafts is contradicted by this study.

A single-center experience with the ross procedure over 20 years

BACKGROUND

The Ross procedure offers several potential advantages in a young patient population. The widespread use of the procedure is still limited due to the technical challenge. Pulmonary homograft stenosis and autograft dilatation remain a matter of concern. We present the long-term outcome in a single center with special emphasis on mortality and need for valvular reintervention.

METHODS

All patients who received a Ross procedure as freestanding root replacement (modified Yacoub technique) at our institution between 1991 and 2011 were followed. Descriptive statistical methods and Kaplan-Meier analyses were performed.

RESULTS

A total of 246 patients (191 males, 55 females) underwent the Ross procedure during the study period. There were 176 adults and 70 pediatric patients with an average age of 36 ± 10 and 10 ± 5 years, respectively. The median follow-up was 10 years. Twelve (4.9%) subjects were lost to follow-up. Early mortality was 1.6%. Overall mortality was comparable with an age and sex matched population for adult patients. The linearized risk for reoperation per patient-year was 0.6% for the autograft and 0.6% for the right ventricular outflow tract, with a mean time to surgery of 6.4 ± 4.9 years. Overall freedom from reintervention was 95% at 5 years, 88% at 10 years, and 81% at 15 years.

CONCLUSIONS

The Ross procedure provides good early results and an excellent long-term survival. It represents an excellent method of aortic valve replacement in children and young adults. Root reinforcement techniques and aortic reduction plasty may be beneficial, especially in adult patients with native aortic valve regurgitation.

Update on mitral valve surgery

Recently, the outcome for patients with mitral valve disease has significantly improved. This may be due to concomitant advances in many fields. In particular, the development of surgical techniques has contributed to this improvement, and many surgical techniques and topics are introduced in this article. After the evaluation of results in mitral valve surgery and exploration of the relationship between the mitral valve and the mitral subvalvular apparatus, it is currently accepted that mitral valve repair is superior to replacement and that replacement with preservation of the mitral subvalvular apparatus is preferable to replacement alone. Another current topic is mitral repair in dilated cardiomyopathy. Mitral regurgitation is a known complication of end-stage cardiomyopathy and is associated with a poor prognosis because of progressive mitral annular dilatation. Recently, to solve this problem, undersized mitral annuloplasty or cardiomyoplasty has been advocated. In the future, mitral valve surgery may be performed off-pump or by a percutaneous approach. Several groups are investigating the use of new devices and new techniques that avoid cardiopulmonary bypass in experimental studies. In this article, we review current topics and discuss our experiences in mitral valve surgery.

Performance of bioprostheses and mechanical prostheses assessed by composites of valve-related complications to 15 years after mitral valve replacement

OBJECTIVE

Predominant concerns of patients undergoing valve replacement surgery are risks of death, stroke, antithrombotic bleeding, and reoperation related to the replacement prosthesis. The purpose of this study was to compare valve-related reoperation, morbidity (permanent impairment), and mortality between bioprostheses and mechanical prostheses for mitral valve replacement.

METHODS

Between 1982 and 1998, a total of 959 bioprostheses were implanted in 943 patients, and a total of 961 mechanical prostheses were implanted in 839 patients. Total follow-ups were 5730 years for bioprostheses and 5271 years for mechanical prostheses. Eight variables were considered as predictors of risk for the composites of valve-related complications.

RESULTS

The linearized occurrence rates for valve-related reoperation were 3.7 events/100 patient-years for bioprostheses and 0.5 events/100 patient-years for mechanical prostheses ( P < .001), with all age groups differentiated except older than 70 years. Valve-related morbidity was undifferentiated for bioprostheses and mechanical prostheses. Valve-related mortalities were 1.7 events/100 patient-years for bioprostheses and 0.7 events/100 patient-years for mechanical prostheses ( P < .001). Predictors of valve-related reoperation were age and valve type. The only predictor of valve-related morbidity was age, whereas age and valve type were predictors for valve-related mortality. Actual freedom from valve-related reoperation favored mechanical prostheses in all age groups except older than 70 years (91.7% +/- 2.0% for bioprostheses at 15 years and 96.7% +/- 1.5% at 12 years for mechanical prostheses). Actual freedom from valve-related morbidity was not different between bioprostheses and mechanical prostheses. Actual freedom from valve-related mortality favored mechanical prostheses in all groups except older than 70 years.

CONCLUSION

Comparative evaluation gives high priority in mitral valve replacement for mechanical prostheses relative to bioprostheses for freedom from valve-related reoperation and valve-related mortality but not valve-related morbidity. Freedom from valve-related reoperation and valve-related mortality favors mechanical prostheses for all age groups except older than 70 years. Valve-related morbidity, due to neurologic or functional impairments, does not differentiate between bioprostheses and mechanical prostheses.

Quality of life before and after heart valve surgery is influenced by gender and type of valve

BACKGROUND

Quality of life (QoL) in valvular surgery may differ according to the underlying pathology and surgical technique used.

METHOD

82 adults undergoing their first elective surgery for valve repair (VP; n = 9) or valve replacement (VR) with a mechanical valve (MVR; n = 57) or bioprosthesis (BVR; n = 16) were assessed before surgery and three months afterwards.

DEPENDENT VARIABLES

delta scores (postoperative-preoperative) on QoL measures (Quality of Life Systemic Inventory (QLSI) and SF-36).

ANALYSES

Paired t tests and ANCOVAs with age and preoperative QoL scores as covariates.

RESULTS

QoL improves after surgery according to most subscales. According to group comparisons, patients with an MVR improve more than those with a BVR on the mental health subscale. In physical roles, patients with an MVR improve while those with a BVR deteriorate. In emotional roles, patients with a VR improve while those with a VP deteriorate. However, they are similar on all other subscales. Women improve more than men on leisure, affectivity and social functioning while the opposite holds true for mental health.

CONCLUSION

QoL improves after surgery. However, significant differences between groups are small because of a lack of statistical power.

"Our complication rates are lower than theirs": statistical critique of heart valve comparisons

OBJECTIVES

From the widely differing complication rates published for every heart valve, is it possible to determine a true rate for each valve and to compare the rates of two different valves? We investigated this question for the two most popular bileaflet valves.

METHODS

Aortic valve data were abstracted from 14 St Jude Medical (St Jude Medical Inc, Minneapolis, Minn; 33,125 patient-y) and 11 Carbomedics (Sulzer Carbomedics Inc, Austin, Tex; 19,141 patient-y) series, and mitral valve data were abstracted from 11 St Jude Medical (21,553 patient-y) and 8 Carbomedics (8368 patient-y) series. Regression analysis was used to accommodate heterogeneity among rates with the same valve model, to estimate hazard ratios and 95% confidence intervals for the valve model effect, and to incorporate other series-level risk factors.

RESULTS

Most of the complication rates with both valve models exhibited significant heterogeneity. For thromboembolism and bleeding, the relative risks for valve model were not significantly different from unity. Valve thrombosis rates exhibited less heterogeneity: the Carbomedics valve had a lower rate in the aortic position (hazard ratio 0.2, 95% confidence interval 0.1-0.6) and a higher rate in the mitral position (hazard ratio 1.9, 95% confidence interval 1.0-3.8).

CONCLUSIONS

Unlike simple weighted averages of valve complication rates, regression methods can incorporate heterogeneity related to center effects and allow for inclusion of other risk factors. Thromboembolism and bleeding rates were not significantly different with St Jude Medical and Carbomedics valves. Valve thrombosis appeared to differ between the two valves, but the absolute differences in rates were small. Because of the variability among rates with the same valve, statistical comparisons must be interpreted cautiously.

Fifteen-year clinical experience with the biocor porcine bioprostheses in the mitral position

BACKGROUND

Bioprosthetic valve use represents a crucial improvement in surgical treatment of mitral valve disease. The aim of this study is to determine the long-term durability of the Biocor porcine bioprosthetic mitral valve.

METHODS

Between 1985 and 1989, a total of 158 Biocor porcine bioprosthetic valves were placed in the mitral position, and long-term results of these patients were investigated retrospectively in 1999.

RESULTS

Thirty-day mortality was 4.4% (7 patients). Total follow-up was 1,499 patient-years. Actuarial survival was 83.66% +/- 3% at 5 years, 77.78% +/- 3.36% at 13 years (1.8% patient-year). Multivariate analysis demonstrated younger age, duration of implantation, congestive heart failure, and functional class to be significant predictors of late mortality. Actuarial freedom from valve-related mortality was 98.58% +/- 1% at 15 years (0.13% patient-year). Actuarial freedom from structural valve deterioration was 95.49% +/- 1.8% at 5 years, 70.2% +/- 4.12% at 10 years, and 64.82% +/- 5.34% at 13 years (2.6% patient-year). Actuarial freedom from structural valve deterioration-related reoperation was 98.43% +/- 1.1% at 5 years, 89.15% +/- 2.85% at 10 years, and 76.82% +/- 7.91% at 14 years. Multivariate analysis showed younger age and duration of implantation to be significant predictors of structural valve deterioration and its related reoperation.

CONCLUSIONS

By studying a 15-year time period, it is seen that this new generation porcine bioprosthetic valve should be considered an alternative for mechanical valves in selected patients.

Prosthetic valve type for patients undergoing aortic valve replacement: a decision analysis

BACKGROUND

In two large, randomized, clinical trials long-term survival after aortic valve replacement (AVR) was similar for patients receiving tissue and mechanical aortic heart valve prostheses. Higher bleeding rates among patients with mechanical valves, who must receive permanent oral anticoagulation to prevent thromboembolism, were offset by higher reoperation rates for valve degeneration among patients with tissue valves. Because the average age of patients undergoing AVR and clinical practices have changed considerably since the randomized clinical trials were conducted, we performed a decision analysis to reassess the optimal valve type for patients undergoing AVR.

METHODS

We used a Markov state-transition model to simulate the occurrence of valve-related events and life expectancy for patients undergoing AVR. Probabilities of clinical events and mortality were derived from the randomized clinical trials and large follow-up studies.

RESULTS

Although the two valve types were associated with similar life expectancy in 60-year-old patients (mean age of patients in the randomized clinical trials), tissue valves were associated with greater life expectancy than mechanical valves (10.7 versus 11.1 years) in 70-year-old patients (currently mean age of AVR patients). For 70-year-old patients, the effects of major bleeding complications (24%) with mechanical valves substantially outweighed those of reoperation for valve failure (12%) with tissue valves at 12 years. Of the clinical practice changes assessed, the recommended valve type was most sensitive to changes in bleeding rates with anticoagulation. However, bleeding rates would have to be 68% lower than those reported in the European randomized clinical trial to affect the recommended valve type for 70-year-old patients. Reoperation rates would have to be five times higher, and mortality rates at reoperation would have to be four times higher to affect the recommended valve type for 70-year-old patients.

CONCLUSIONS

Although mechanical valves are preferred for AVR patients less than 60 years old, most patients currently undergoing AVR are elderly and would benefit more from tissue valves.

Replacement of the aortic valve and ascending aorta with a valved stentless composite graft: technical considerations and early clinical results

BACKGROUND

Replacement of the aortic valve and the ascending aorta with a conduit consisting of a mechanical valve and a Dacron tube has become a fairly common procedure. Commercially available conduits employing xenografts are rarely used for the same purpose, because if a reoperation becomes necessary due to degeneration of the valve prosthesis, usually the entire conduit must be replaced. A composite graft with a stentless valve, such as we describe in this article, avoids this problem, because in case of reoperation only the valve cusps need to be resected and the tube graft may be left in place.

METHODS

Surgical technique of replacement of the aortic valve and the ascending aorta with a stentless composite graft and early results of the procedure are presented.

RESULTS

Hemodynamics of the graft soon after surgery were excellent, with an average systolic gradient of 8 mm Hg and no regurgitation across the valve. There were two reoperations for bleeding in the early postoperative period.

CONCLUSIONS

The stentless composite graft we describe provides excellent hemodynamics, has no need for anticoagulation, and is expected to offer a benefit in case of reoperation.

Reoperative surgery for degenerated aortic bioprostheses: predictors for emergency surgery and reoperative mortality

OBJECTIVE

The long-term outcome of patients with aortic bioprosthetic valves could be improved by decreasing the reoperative mortality rate.

METHODS

Predictors of emergency reoperation and reoperative mortality were identified retrospectively in 172 patients who had the first bioprosthetic aortic valve replacement between 1975 and 1988 (mean age 46+/-13 years) and were subjected to replacement of the degenerated bioprostheses between 1978 and 1997 (mean age 56+/-14 years). Emergency reoperation had to be performed in 31 patients (18%).

RESULTS

The operative mortality was 5.2% (9/172), 22.6% for emergency (odds ratio 11.17; 95%-confidence limit 4.33-28.85) and 1.4% for elective replacement of the degenerated aortic bioprosthesis (P<0.0001; OR=20.3). Patients who died at reoperation had higher transvalvular gradients before the primary aortic valve replacement (P=0.007), received smaller bioprostheses at the first operation (P=0.03), had later recurrence of symptoms after the first aortic valve replacement (P=0.04), a higher pre-reoperative New York Heart Association (NYHA) class (P=0.02), and a higher incidence of coronary artery disease (P=0.001) and pulmonary artery hypertension (P=0.009). Endocarditis before the primary aortic valve replacement (P=0.004), postoperative pneumonia at the first operation (P=0.005), pulmonary hypertension (P=0.0004) acquired during the interval, later recurrence of symptoms (P=0.04) after the first operation, a lower ejection fraction at the time of reoperation (P=0.03) and acute onset of bioprosthetic regurgitation (P=0.00002) were predictors for emergency surgery. Higher transvalvular gradients at the primary aortic valve replacement (P=0. 006), coronary artery disease (P=0.003) acquired during the interval, the need for concomitant coronary artery revascularization (P=0. 001), sex (P=0.02) and size (P=0.05) and type of the bioprostheses used (P=0.007) were incremental predictors for reoperative mortality which were independent of emergency surgery.

CONCLUSIONS

Elective replacement of failed aortic bioprostheses is safe. Patients undergoing emergency reoperation have a considerably higher mortality. They can be identified by a history of native aortic valve endocarditis, higher transvalvular gradients at primary aortic valve replacement, smaller bioprostheses, and pulmonary hypertension or coronary artery disease acquired during the interval. A failing bioprosthesis must be replaced at its first sign of dysfunction.

Replacement of the ascending aorta and aortic valve with a valved stentless composite graft

A technique of total aortic root replacement with a stentless porcine composite graft is described. This graft is assembled during surgery using a woven polyester vascular prosthesis and a stentless aortic bioprosthesis.

Long-term outcome after biologic versus mechanical aortic valve replacement in 841 patients

OBJECTIVE

The purpose of this study was to optimize selection criteria of biologic versus mechanical valve prostheses for aortic valve replacement.

METHODS

Retrospective analysis was performed for 841 patients undergoing isolated, first-time aortic valve replacement with Carpentier-Edwards (n = 429) or St Jude Medical (n = 412) prostheses.

RESULTS

Patients with Carpentier-Edwards and St Jude Medical valves had similar characteristics. Ten-year survival was similar in each group (Carpentier-Edwards 54% 3% versus St Jude Medical 50% 6%; P =.4). Independent predictors of worse survival were older age, renal or lung disease, ejection fraction less than 40%, diabetes, and coronary disease. Carpentier-Edwards versus St Jude Medical prostheses did not affect survival (P =.4). Independent predictors of aortic valve reoperation were younger age and Carpentier-Edwards prosthesis. The linearized rates of thromboembolism were similar, but the linearized rate of hemorrhage was lower with Carpentier-Edwards prostheses (P <.01). Perivalvular leak within 6 months of operation was more likely with St Jude Medical than with Carpentier-Edwards prostheses (P =.02). Estimated 10-year survival free from valve-related morbidity was better for the St Jude Medical valve in patients aged less than 65 years and was better for the Carpentier-Edwards valve in patients aged more than 65 years. Patients with renal disease, lung disease (in patients more than age 60 years), ejection fraction less than 40%, or coronary disease had a life expectancy of less than 10 years.

CONCLUSIONS

For first-time, isolated aortic valve replacement, mechanical prostheses should be considered in patients under age 65 years with a life expectancy of at least 10 years. Bioprostheses should be considered in patients over age 65 years or with lung disease (in patients over age 60 years), renal disease, coronary disease, ejection fraction less than 40%, or a life expectancy less than 10 years.

Choosing a prosthetic heart valve

Although most of the available prosthetic heart valves function remarkably well, the variety of available choices attests to the inability of any single one to fulfill the requirements of the ideal valve substitute. The mechanical prostheses include the caged-ball, tilting-disc, and bileaflet valves. Tissue valves available in the United States are the Carpentier-Edwards and Hancock porcine heterograft valves and the Carpentier-Edwards pericardial valve. Review of several large comparative studies on valve performance reveals that the overall results with tissue and mechanical valves are about equal at the end of 10 years. The characteristics of each type of valve substitute dictate the selection of one prosthesis in preference to others for a particular patient. Mechanical prostheses are recommended for patients without contraindications for anticoagulants. Tissue valves are reserved for patients over 65 years of age or for patients in whom anticoagulation is contraindicated. Multiple other patient-related factors need to be considered in selecting the appropriate valve, including the psychosocial situation and patient preference.

Mechanical versus biological isolated aortic valvular replacement after the age of 70: equivalent long-term results

OBJECTIVE

In order to evaluate the long-term outcome of valvular substitutes in the elderly, we retrospectively analyzed two comparative groups of patients consecutively operated on by the same team for an isolated valvular aortic replacement using either a mechanical or a pericardial prosthesis.

METHODS

From 1982 to 1996, 206 patients over 70 years (mean 76.5+/-4.4) underwent an isolated aortic valvular replacement using either a St. Jude Medical (Group I, n = 93) or a Mitroflow (Group II, n= 113) prosthesis depending on the surgeon's preference at the time of surgery. Both groups matched for the following pre-operative variables: sex ratio, type of aortic valve disease, NYHA status, cardiac rhythm, mean pulmonary arterial pressure, left ventricular end-diastolic pressure, LV-AO gradient, cardiac index and ejection fraction.

RESULTS

Given an early mortality rate of 6.4% in Group I and 4.4% in Group II (NS), follow-up (mean 4.4+/-3.7 years in Group I and 5.3+/-3.1 years in Group II) was 100% complete. Actuarial survival was 69.9+/-6 and 70.2+/-4.6% at 5 years for Group I and Group II, respectively, and 49.6+/-7.7 vs. 51.4+/-6.3% at 10 years (NS). Freedom from valve-related death was 86.5+/-4.8% in Group I vs. 82.7+/-4% in Group II at 5 years (NS) and 66.7+/-8.7 vs. 66.3+/-7% at 10 years (NS). There were no anticoagulant-related deaths or severe accidents in Group 1. A secondary valvular replacement was necessary in 4 patients in Group II vs. none in Group I.

CONCLUSION

The study shows a similar late survival in both groups, with a strikingly low incidence of anticoagulant-related deaths in this population. Given a higher rate of reoperation after biological valve replacement, the use of mechanical valve in this aging population seems to be a valid option.