Freestyle Aortic Root Bioprosthesis Is a Suitable Alternative for Aortic Root Replacement in Elderly Patients: A Propensity Score Study

Influence of Age on Longevity of a Stentless Aortic Valve

BACKGROUND

The longevity of a stentless valve in a younger population (20-60 years old) is unknown.

METHODS

From 1992 to 2015, 1947 patients underwent aortic valve/root replacement for aortic stenosis, insufficiency, root aneurysm, or aortic dissection with stentless bioprostheses (median size, 26 mm). At operation 105 patients were <40 years old, 528 were 40 to 59, 860 were 60 to 74, and 454 were ≥75 years. The data were obtained through chart review, administered surveys, and the National Death Index.

RESULTS

The 30-day mortality rate was 2.6%. During follow-up 807 patients (41%) died before reoperation, 993 (51%) were alive without reoperations because of deterioration, and 113 patients (5.8%) underwent reoperation for structural valve deterioration. After adjusting death and reoperation for non-structural valve deterioration causes as competing risks, the cumulative incidence of reoperation was significantly different between the younger groups (<40, 40-59) and the older groups (60-74, ≥75; P < .0001) but not inside the younger (<40 vs 40-59) or older (60-74 vs ≥75) group. The significant hazard ratio of reoperation for <40 versus ≥75 years of age was 12, <40 versus 60 to 74 was 4, 40 to 59 versus 60 to 74 was 3, and 40 to 59 versus ≥75 was 9 (P ≤ .01). The 10- and 15-year survival in the entire cohort was 53% and 29%, respectively.

CONCLUSIONS

The stentless aortic valve provides satisfactory durability as a conduit for aortic valve/root replacement for patients who prefer a bioprosthesis. However it should be judiciously considered for patients younger than 60 years because of an increased incidence of reoperation for structural valve deterioration.

Pseudoaneurysm formation after medtronic freestyle porcine aortic bioprosthesis implantation: a word of caution

BACKGROUND

A growing literature describes aneurysmal deterioration after implantation of the stentless porcine aortic Medtronic Freestyle bioprosthesis (MFB; Medtronic Inc, Minneapolis, MN), with some suggesting inadequate tissue fixation with immune response as a cause. However, disjointed reports make the significance of these findings difficult to interpret. We address this concern by aggregating available data.

METHODS

We reviewed institutional data, the Food and Drug Administration's Manufacturer and User Facility Device Experience registry, and the medical literature for mention of aneurysm or pseudoaneurysm after MFB. Case details were aggregated, and the rate of aneurysmal deterioration was estimated. Immunohistopathologic examination of institutional explanted specimens was performed to elucidate a cause.

RESULTS

We found 42 cases of aneurysmal deterioration with adequate detail for analysis; all occurred with full root replacement and valve sizes ranging from 23 to 29 mm. The rate of aneurysmal deterioration considering all data sources was 1.1% (9 of 851; 95% confidence interval, 0.5% to 2.0%) vs 4.7% (4 of 86; 95% confidence interval, 1.3% to 11.5%) at our institution, where yearly surveillance imaging is performed. Rate of aneurysmal deterioration appeared constant until 5 years after the operation; however, events are reported out to 10 years. Consistent with previous reports, histopathology demonstrated an immune cell infiltrate in areas of MFB wall breakdown.

CONCLUSIONS

Aneurysmal deterioration is an increasingly described complication of MFB implantation as a full root, with an incidence as high as 4.7%. Given the observed immune reaction and lack of occurrence in smaller (19-mm and 21-mm) valve sizes, inadequate pressure fixation of larger valves is a potential etiology. Patients with MFB require annual surveillance imaging, and consideration of this complication should factor into preoperative decision making because treatment mandates redo root replacement, which may not be feasible in high-risk patients.

The Bentall procedure with a biological valved conduit: substitute options and techniques

As originally described by Bentall and De Bono, aortic root replacement with reimplantation of the coronary arteries using a composite valved conduit represents the gold standard intervention in patients with aneurysmal disease or dissection involving the aortic root. Over the last decade, the number of Bentall procedures performed using biological valved conduit has dramatically expanded mainly due to the increased incidence of aortic disease in the aging population. Here, we sought to describe the commercially available biological composite grafts and the techniques that, to the best of our knowledge, are most frequently used in this setting.

Reoperation for failure of freestyle bioprosthesis using an Edwards intuity valve

We report the first case of a successful implantation of the new Edwards Intuity rapid-deployment bioprosthesis in a 50-year-old man with acute failure of a Freestyle Medtronic root with severe aortic regurgitation and massive calcification of the root and both coronary buttons.