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Siontis GCM, Coles B, Häner JD, McGovern L, Bartkowiak J, Coughlan JJ, Spirito A, Galea R, Haeberlin A, Praz F, Tomii D, Melvin T, Frenk A, Byrne RA, Fraser AG, Windecker S. Quality and transparency of evidence for implantable cardiovascular medical devices assessed by the CORE-MD consortium. Eur Heart J 2024; 45:161-177. [PMID: 37638967 DOI: 10.1093/eurheartj/ehad567] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 08/15/2023] [Accepted: 08/21/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND AND AIMS The European Union Medical Device Regulation 2017/745 challenges key stakeholders to follow transparent and rigorous approaches to the clinical evaluation of medical devices. The purpose of this study is a systematic evaluation of published clinical evidence underlying selected high-risk cardiovascular medical devices before and after market access in the European Union (CE-marking) between 2000 and 2021. METHODS Pre-specified strategies were applied to identify published studies of prospective design evaluating 71 high-risk cardiovascular devices in seven different classes (bioresorbable coronary scaffolds, left atrial appendage occlusion devices, transcatheter aortic valve implantation systems, transcatheter mitral valve repair/replacement systems, surgical aortic and mitral heart valves, leadless pacemakers, subcutaneous implantable cardioverter-defibrillator). The search time span covered 20 years (2000-21). Details of study design, patient population, intervention(s), and primary outcome(s) were summarized and assessed with respect to timing of the corresponding CE-mark approval. RESULTS At least one prospective clinical trial was identified for 70% (50/71) of the pre-specified devices. Overall, 473 reports of 308 prospectively designed studies (enrolling 97 886 individuals) were deemed eligible, including 81% (251/308) prospective non-randomized clinical trials (66 186 individuals) and 19% (57/308) randomized clinical trials (31 700 individuals). Pre-registration of the study protocol was available in 49% (150/308) studies, and 16% (48/308) had a peer-reviewed publicly available protocol. Device-related adverse events were evaluated in 82% (253/308) of studies. An outcome adjudication process was reported in 39% (120/308) of the studies. Sample size was larger for randomized in comparison to non-randomized trials (median of 304 vs. 100 individuals, P < .001). No randomized clinical trial published before CE-mark approval for any of the devices was identified. Non-randomized clinical trials were predominantly published after the corresponding CE-mark approval of the device under evaluation (89%, 224/251). Sample sizes were smaller for studies published before (median of 31 individuals) than after (median of 135 individuals) CE-mark approval (P < .001). Clinical trials with larger sample sizes (>50 individuals) and those with longer recruitment periods were more likely to be published after CE-mark approval, and were more frequent during the period 2016-21. CONCLUSIONS The quantity and quality of publicly available data from prospective clinical investigations across selected categories of cardiovascular devices, before and after CE approval during the period 2000-21, were deemed insufficient. The majority of studies was non-randomized, with increased risk of bias, and performed in small populations without provision of power calculations, and none of the reviewed devices had randomized trial results published prior to CE-mark certification.
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Affiliation(s)
- George C M Siontis
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Bernadette Coles
- Velindre University NHS Trust Library and Knowledge Service, Cardiff, UK
| | - Jonas D Häner
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Laurna McGovern
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, Dublin, Ireland
| | - Joanna Bartkowiak
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - J J Coughlan
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, Dublin, Ireland
- School of Pharmacy and Biomolecular Sciences, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Alessandro Spirito
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Roberto Galea
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Andreas Haeberlin
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Fabien Praz
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Daijiro Tomii
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Tom Melvin
- School of Medicine, Trinity College Dublin, Ireland
| | - André Frenk
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
| | - Robert A Byrne
- Department of Cardiology and Cardiovascular Research Institute (CVRI) Dublin, Mater Private Network, Dublin, Ireland
| | - Alan G Fraser
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Stephan Windecker
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern, Freiburgstrasse 18, CH-3010 Bern, Switzerland
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Chen J, Lv M, Fu J, He C, Guo Y, Tao L, Zhou X, Gu T, Bartus K, Wei L, Hong T, Wang C. Five-year outcomes of surgical aortic valve replacement with a novel bovine pericardial bioprosthesis. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2024; 38:ivad209. [PMID: 38180879 PMCID: PMC10781661 DOI: 10.1093/icvts/ivad209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/03/2024] [Indexed: 01/07/2024]
Abstract
OBJECTIVES The short-term performance of the Cingular bovine pericardial aortic valve was proven. This study evaluated its 5-year safety and haemodynamic outcomes. METHODS It enrolled 148 patients who underwent surgical aortic valve replacement with the Cingular bovine pericardial aortic valve between March 2016 and October 2017 in 5 clinical centres in China. Safety and haemodynamic outcomes were followed up to 5 years. The incidence of all-cause mortality, structural valve deterioration and reintervention was estimated by Kaplan-Meier analysis. RESULTS The mean age of patients was 67.7 [standard deviation (SD) 5.1] years, and 36.5% of patients were female. The mean follow-up was 5.3 (SD 1.2) years. Five-year freedom from all-cause mortality, structural valve deterioration and all-cause reintervention were 91.2%, 100% and 99.3%, respectively. At 5 years, the mean gradient and effective orifice area of all sizes combined were 14.0 (SD 5.5) mmHg and 1.9 (SD 0.3) cm2, respectively. For 19- and 21-mm sizes of aortic prostheses, the mean gradients and effective orifice area at 5 years were 17.5 (SD 7.0) mmHg and 1.6 (SD 0.2) cm2 and 13.7 (SD 6.7) mmHg and 1.8 (SD 0.3) cm2, respectively. The incidence of moderate or severe patient-prosthesis mismatch was 4.1% and 0.0% patients at 5 years, respectively. CONCLUSIONS The 5-year safety and haemodynamic outcomes of Cingular bovine pericardial aortic valve are encouraging. Longer-term follow-up is warranted to assess its true durability.
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Affiliation(s)
- Jinmiao Chen
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Minzhi Lv
- Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiahui Fu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chen He
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yingqiang Guo
- Department of Cardiovascular Surgery, West China Hospital, Sichuan University, Sichuan, China
| | - Liang Tao
- Department of Cardiovascular Surgery, Wuhan Asia Heart Hospital, Hubei, China
| | - Xinmin Zhou
- Department of Cardiovascular Surgery, The Second Xiangya Hospital of Central South University, Hunan, China
| | - Tianxiang Gu
- Department of Cardiovascular Surgery, The First Hospital of China Medical University, Liaoning, China
| | - Krzysztof Bartus
- Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, John Paul II Hospital, Krakow, Poland
| | - Lai Wei
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Hong
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chunsheng Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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3
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Duan H, Shi L, Shao C, Wang Y, Wang Z, Ni Y, Zhao J, Sun J, Tong L, Lei J, Jiang T, Liu Z, Yan X. A multicenter, single-arm, open study of neoadjuvant or conversion atezolizumab in combination with chemotherapy in resectable small cell lung cancer (Cohort Study). Int J Surg 2023; 109:2641-2649. [PMID: 37428211 PMCID: PMC10498862 DOI: 10.1097/js9.0000000000000501] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/10/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND This study aimed to investigate the prospects of using chemotherapy in combination with atezolizumab in the neoadjuvant or conversion treatment of small cell lung cancer (SCLC). METHODS Prior to surgery, untreated patients with limited-stage SCLC received three cycles of neoadjuvant or conversion atezolizumab combined with chemotherapy of etoposide and platinum. The primary endpoint of the trial was pathological complete response (pCR) in the per-protocol (PP) cohort. In addition, safety was assessed based on treatment-related adverse events (AEs) and postoperative complications. RESULTS Overall, 13 of 17 patients (including 14 males and 3 females) underwent surgery. In the PP cohort, pCR and major pathological response were observed in 8 (8/13, 61.5%) and 12 (12/13, 92.3%) patients, respectively. According to the intention-to-treat (ITT) analysis, the pCR and major pathological response in the ITT cohort were 47.1% (8/17) and 70.6% (12/17), respectively. In addition, an overall response rate of 100% was recorded in the PP cohort. Moreover, 15 (15/17, 88.2%) patients and 1 (1/17, 5.9%) in the ITT cohort attained partial remission (PR), and complete remission, respectively, with an overall response rate of 94.1%. The median overall survival of the patients of pCR and the median event-free survival of the patients on surgery had not achieved. However, the median overall survival of the patients of non-pCR was 18.2 months and the median event-free survival of the nonsurgical patients was 9.5 months. During the neoadjuvant treatment, the incidence of grade 3 or higher AEs was 58.8% (10/17). Additionally, three patients (17.6%) developed immune-related adverse event (grades 1-2). CONCLUSION In patients with SCLC, neoadjuvant or conversion atezolizumab combined with chemotherapy significantly improved pCR with manageable AEs. Therefore, this regimen may be considered a safe and effective treatment for SCLC.
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Affiliation(s)
- Hongtao Duan
- Department of Thoracic Surgery at Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi
| | - Liang Shi
- Department of Oncology at Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Changjian Shao
- Department of Thoracic Surgery at Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi
| | - Yuanyong Wang
- Department of Thoracic Surgery at Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi
| | - Zhaoyang Wang
- Department of Thoracic Surgery at Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi
| | - Yunfeng Ni
- Department of Thoracic Surgery at Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi
| | - Jinbo Zhao
- Department of Thoracic Surgery at Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi
| | - Jianyong Sun
- Department of Thoracic Surgery at Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi
| | - Liping Tong
- Department of Thoracic Surgery at Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi
| | - Jie Lei
- Department of Thoracic Surgery at Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi
| | - Tao Jiang
- Department of Thoracic Surgery at Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi
| | - Zhe Liu
- Department of Oncology at Beijing Chest Hospital, Capital Medical University, Beijing, China
| | - Xiaolong Yan
- Department of Thoracic Surgery at Tangdu Hospital, Air Force Medical University, Xi’an, Shaanxi
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Langenaeken T, Vanoppen A, Janssens F, Tanghe L, Verbrugghe P, Rega F, Meuris B. DOACs in the Anticoagulation of Mechanical Valves: A Systematic Review and Future Perspectives. J Clin Med 2023; 12:4984. [PMID: 37568386 PMCID: PMC10419922 DOI: 10.3390/jcm12154984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/25/2023] [Accepted: 07/26/2023] [Indexed: 08/13/2023] Open
Abstract
Valvular heart disease is a common disease often necessitating valve replacement. Mechanical heart valves (MHVs) are often used in younger patients because of their longer durability. Their main disadvantage is the need for lifelong anticoagulation. Warfarin is considered a standard treatment, but it is far from perfect. Direct oral anticoagulants (DOACs) are a new and more patient-friendly alternative to warfarin when anticoagulation is required, but have not yet been approved for the indication of mechanical valves. EVIDENCE ACQUISITION A literature search of Pubmed, Embase, Web of Science (Core Collection), and Cochrane Library (from inception to May 2023) was performed using a search string that was well defined and not modified during the study. An extensive overview of the search terms used in each database can be found in the Appendix. Only prospective clinical trials were included in this review. A total of 10 publications were included in this review. RELEVANCE TO CLINICAL PRACTICE This systematic review summarizes the different types of DOACs and their possible use in the anticoagulation of mechanical valves. We aim to propose future directions in anticoagulation research for mechanical valves. CONCLUSIONS DOAC use in MHVs has been halted due to the failure of both dabigatran and apixaban in two major clinical trials. However, rivaroxaban was successful in two small clinical trials. Ample research is still needed to explore new valve designs as well as new anticoagulation targets.
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Affiliation(s)
- Tom Langenaeken
- Department of Cardiac Surgery, University Hospitals Leuven, Herestraat 49, 3000 Leuven, Belgium (B.M.)
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Wang TY, Svensson LG, Wen J, Vekstein A, Gerdisch M, Rao VU, Moront M, Johnston D, Lopes RD, Chavez A, Ruel M, Blackstone EH, Becker RC, Thourani V, Puskas J, Al-Khalidi HR, Cable DG, Elefteriades JA, Pochettino A, Wolfe JA, Graeve A, Sultan I, Sabe AA, Michelena HI, Alexander JH. Apixaban or Warfarin in Patients with an On-X Mechanical Aortic Valve. NEJM EVIDENCE 2023; 2:EVIDoa2300067. [PMID: 38320162 DOI: 10.1056/evidoa2300067] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
BACKGROUND: Vitamin K antagonists are the only oral anticoagulants approved to prevent valve thrombosis and valve-related thromboembolism in patients with mechanical heart valves. Whether patients with an On-X mechanical aortic valve can be safely anticoagulated with apixaban is unknown. METHODS: Patients with an On-X aortic valve implanted at least 3 months before enrollment were randomly assigned to receive apixaban 5 mg twice daily or warfarin (target international normalized ratio 2.0 to 3.0). The primary efficacy end point was the composite of valve thrombosis or valve-related thromboembolism with coprimary analyses comparing apixaban with warfarin for noninferiority and comparing the apixaban event rate with an objective performance criterion (OPC). RESULTS: The trial was stopped after 863 participants were enrolled owing to an excess of thromboembolic events in the apixaban group. Most (94%) participants took aspirin. A total of 26 primary end-point events occurred, 20 (in 16 participants) in the apixaban group (4.2%/patient-year; 95% confidence interval [CI], 2.3 to 6.0) and 6 (in 6 participants) in the warfarin group (1.3%/patient-year; 95% CI, 0.3 to 2.3). The difference in primary end-point rates between the apixaban and warfarin groups was 2.9 (95% CI, 0.8 to 5.0); noninferiority and OPC success criteria were not met. Major bleeding rates were 3.6%/patient-year with apixaban and 4.5%/patient-year with warfarin. CONCLUSIONS: Apixaban did not demonstrate noninferiority to warfarin and is less effective than warfarin for the prevention of valve thrombosis or thromboembolism in patients with an On-X mechanical aortic valve. (Funded by Artivion; ClinicalTrials.gov number, NCT04142658.)
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Affiliation(s)
- Tracy Y Wang
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Jun Wen
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Andrew Vekstein
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | | | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Alma Chavez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, ON
| | | | | | | | | | - Hussein R Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - David G Cable
- OSF HealthCare Cardiovascular Institute, Rockford, IL
| | | | | | - J Alan Wolfe
- Northeast Georgia Medical Center, Gainesville, GA
| | - Allen Graeve
- MultiCare Institute for Research and Innovation, Tacoma, WA
| | | | - Ashraf A Sabe
- Brigham and Women's Hospital, Harvard Medical School, Boston
| | | | - John H Alexander
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
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Varma PK, Vijayakumar M, Bhuvaneshwar GS, Kumar AS, Krishna N. Long-term evaluation of TTK Chitra™ heart valve prosthesis - a retrospective-prospective cohort study. Indian J Thorac Cardiovasc Surg 2023; 39:14-26. [PMID: 36531667 PMCID: PMC9735205 DOI: 10.1007/s12055-022-01437-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/25/2022] [Accepted: 10/28/2022] [Indexed: 12/04/2022] Open
Abstract
Purpose The TTK Chitra™ heart valve has more than 1,40,000 implantations so far, but no long-term data has been published. This study aims to provide long-term results of the valve. Methodology A cohort of 476 patients with implantations from January 2006 to December 2018 were followed up prospectively consisting of 104 aortic valve replacement (AVR), 87 double valve replacement (DVR), and 285 mitral valve replacement (MVR) patients. Total follow-up was 4079 patient-years (py) (AVR = 983, MVR = 2392, DVR = 704), being 96% complete. Results The results showed that actuarial survival at 15 years was 82.3% for AVR, 60.7% for MVR, and 52.2% for DVR. Freedom from all valve-related mortality and morbidity at 15 years was 73.8%, 64.8%, and 61.9% for AVR, MVR, and DVR, respectively. There was one instance of structural failure of valve disc leading to severe valvar regurgitation. Valve thrombosis incidence was 1 in AVR (0.1%/py), 6 in MVR (0.25%/py), and 1 in DVR (0.14%/py). Thrombo-embolic episodes occurred in 50 patients (AVR = 7 patients at 0.7%/py; MVR = 36 patients at 1.5%/py; DVR = 7 patients at 0.99%/py) and major hemorrhage (bleeding) in 24 patients (AVR = 0.61%/py; MVR = 0.5%/py; and DVR = 0.85%/py). The linearized rates of adverse events in this study were found to be lower than earlier published results. Conclusion The results highlight the continued safety and performance of the TTK Chitra™ heart valve (TTKCHV) in the long term at 15 years. Supplementary Information The online version contains supplementary material available at 10.1007/s12055-022-01437-9.
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Affiliation(s)
- Praveen Kerala Varma
- Department of Cardiovascular and Thoracic Surgery, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, India
| | - Maniyal Vijayakumar
- Department of Cardiology, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, India
| | | | - Adarsh Syla Kumar
- Department of Cardiovascular and Thoracic Surgery, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, India
| | - Neethu Krishna
- Department of Cardiovascular and Thoracic Surgery, Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham (Amrita University), Kochi, India
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Butany J, Schoen FJ. Cardiac valve replacement and related interventions. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00010-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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8
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Chen J, Lv M, Lu Y, Fu J, Guo Y, Tao L, Zhou X, Gu T, Wei L, Hong T, Wang C. Two-Year Clinical Follow-Up Assessment of the Novel Cingular Surgical Bovine Pericardial Valve. Front Cardiovasc Med 2021; 8:736877. [PMID: 34966792 PMCID: PMC8711235 DOI: 10.3389/fcvm.2021.736877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 10/25/2021] [Indexed: 02/05/2023] Open
Abstract
Objectives: To evaluate the 2-year clinical safety and hemodynamic outcomes of the Cingular bovine pericardial bioprosthesis. Methods: A prospective, multicenter, single-arm trial was conducted in patients who required aortic or mitral valve replacement. From March 2016 to October 2017, 197 patients were implanted with the Cingular bovine pericardial valve at five sites in China. The clinical outcomes and hemodynamic performance were assessed through a 2-year follow-up. Clinical safety events were reviewed by an independent clinical events committee, and echocardiographic data were assessed by an independent core laboratory. Results: The mean age was 66.9 ± 4.9 years. The 2-year survival rate was 96.4%. A complete 2-year clinical follow-up was achieved in 189 of 190 survivors. No case of structural valve deterioration, major perivalvular leak, prosthetic valve endocarditis, or valve-related reoperation was seen. For the aortic valve, the mean pressure gradient observed was 12.5 ± 4.0 mm Hg, and the effective orifice area (EOA) was 2.0 ± 0.3 cm2. For the smaller size aortic valves, 19 mm and 21 mm, respective mean EOA values of 1.7 ± 0.2 cm2 and 1.8 ± 0.2 cm2 were found. The values for mean pressure gradient and mean EOA for mitral bioprostheses were 4.0 ± 1.4 mm Hg and 2.2 ± 0.3 cm2, respectively. There was no significant change between 1-year and 2-year hemodynamic performance. Conclusions: The Cingular bovine pericardial valve showed favorable clinical safety and hemodynamic outcomes over a 2-year follow-up. Further follow-up is required to validate the long-term durability.
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Affiliation(s)
- Jinmiao Chen
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Minzhi Lv
- Department of Biostatistics, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yuntao Lu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiahui Fu
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yingqiang Guo
- Department of Cardiac Surgery, West China Hospital of Sichuan University, Chengdu, China
| | - Liang Tao
- Department of Cardiac Surgery, Wuhan Asia Heart Hospital, Wuhan, China
| | - Xinmin Zhou
- Department of Cardiac Surgery, The Second Xiangya Hospital of Central South University, Changsha, China
| | - Tianxiang Gu
- Department of Cardiac Surgery, The First Hospital of China Medical University, Changchun, China
| | - Lai Wei
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Tao Hong
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chunsheng Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
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Fraser AG, Nelissen RG, Kjærsgaard-Andersen P, Szymański P, Melvin T, Piscoi P. Improved clinical investigation and evaluation of high-risk medical devices: the rationale and objectives of CORE-MD (Coordinating Research and Evidence for Medical Devices). EFORT Open Rev 2021; 6:839-849. [PMID: 34760284 PMCID: PMC8559562 DOI: 10.1302/2058-5241.6.210081] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
In the European Union (EU), the delivery of health services is a national responsibility but there are concerted actions between member states to protect public health. Approval of pharmaceutical products is the responsibility of the European Medicines Agency, while authorising the placing on the market of medical devices is decentralised to independent 'conformity assessment' organisations called notified bodies. The first legal basis for an EU system of evaluating medical devices and approving their market access was the Medical Device Directive, from the 1990s. Uncertainties about clinical evidence requirements, among other reasons, led to the EU Medical Device Regulation (2017/745) that has applied since May 2021. It provides general principles for clinical investigations but few methodological details - which challenges responsible authorities to set appropriate balances between regulation and innovation, pre- and post-market studies, and clinical trials and real-world evidence. Scientific experts should advise on methods and standards for assessing and approving new high-risk devices, and safety, efficacy, and transparency of evidence should be paramount. The European Commission recently awarded a Horizon 2020 grant to a consortium led by the European Society of Cardiology and the European Federation of National Associations of Orthopaedics and Traumatology, that will review methodologies of clinical investigations, advise on study designs, and develop recommendations for aggregating clinical data from registries and other real-world sources. The CORE-MD project (Coordinating Research and Evidence for Medical Devices) will run until March 2024. Here, we describe how it may contribute to the development of regulatory science in Europe. Cite this article: EFORT Open Rev 2021;6:839-849. DOI: 10.1302/2058-5241.6.210081.
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Affiliation(s)
- Alan G. Fraser
- Department of Cardiology, University Hospital of Wales, Cardiff, UK
| | - Rob G.H.H. Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, Netherlands
| | | | - Piotr Szymański
- Centre of Postgraduate Medical Education, MSWiA Central Clinical Hospital, Warsaw, Poland
| | - Tom Melvin
- Healthcare Products Regulatory Authority, Earlsfort Terrace, Dublin 2, Ireland
| | - Paul Piscoi
- Health Technology Unit B6, Directorate General for Health (DG SANTE), European Commission, Brussels, Belgium
| | - On behalf of the CORE–MD Investigators (see Appendix)
- Alan Fraser, Piotr Szymański, Chris Gale, Aldo Maggioni, Elisabetta Zanon, Christina Dimopoulou, Cinzia Ceccarelli, Polyxeni Vairami, Anett Ruszanov, Per Kjærsgaard-Andersen, Rob Nelissen, Adrian Ott, Elizabeth Macintyre, Loredana Simulescu, Marieke Meijer, Berthold Koletzko, Sarah Wieczorek, Adamos Hadjipanayis, Stefano Del Torso, Perla Marang-van de Mheen, Lotje Hoogervorst, Ewout W. Steyerberg, Bas Penning De Vries, Peter McCulloch, Martin Landray, Daniel Prieto Alhambra, James Smith, Anne Lubbeke-Wolf, Stefan James, Sergio Buccheri, Robert Byrne, Laurna McGovern, Stephan Windecker, Andre Frenk, Georgios Siontis, Christoph Stettler, Arjola Bano, Lia Bally, Frank E. Rademakers, Jan D‘hooge, Anton Vedder, Elisabetta Biasin, Erik Kamenjasevic, Petra Schnell-Inderst, Felicitas Kühne, Ola Rolfson, Joel Jakobsson, Amanda Tornsö, Enrico G. Caiani, Lorenzo Gianquintieri, Cinzia Cappiello, Maristella Matera, Tom Melvin, Niall MacAleenan, Ria Mahon, Michèle Meagher, Gearóid McGauran, Thomas Wejs Møller, Ann-Sofie Sonne Holm-Schou, Jan Szulc, Robert E. Geertsma, Jantine W.P.M. van Baal, Joëlle M. Hoebert, Susana L.F. Cabaço, Paola Laricchiuta, Marina Torre, Filippo Boniforti, Eugenio Carrani, Stefania Ceccarelli, Claudia Wild, Sabine Ettinger, Juan Antonio Blasco Amaro, Juan Carlos Rejón Parrilla, Agnieszka Dobrzynska, David Epstein, Valentina Strammiello, Hannes Jarke, Kaisa Immonen, Françoise Schlemmer, Sabina Hoekstra, Marianna Mastroroberto, Christoph Ziskoven, Michael Hahn, Erman Melikyan, Richard Holborow, Suzanne Halliday, Alexey Shiryaev, Gero Viola, Harry van Vugt
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10
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Fraser AG, Nelissen RGHH, Kjærsgaard-Andersen P, Szymański P, Melvin T, Piscoi P. Improved clinical investigation and evaluation of high-risk medical devices: the rationale and objectives of CORE-MD (Coordinating Research and Evidence for Medical Devices). EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:249-258. [PMID: 34448829 PMCID: PMC9071523 DOI: 10.1093/ehjqcco/qcab059] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 08/23/2021] [Indexed: 11/13/2022]
Abstract
In the European Union (EU) the delivery of health services is a national responsibility but there are concerted actions between member states to protect public health. Approval of pharmaceutical products is the responsibility of the European Medicines Agency, while authorising the placing on the market of medical devices is decentralised to independent 'conformity asssessment' organisations called notified bodies. The first legal basis for an EU system of evaluating medical devices and approving their market access was the medical device directives, from the 1990s. Uncertainties about clinical evidence requirements, among other reasons, led to the EU Medical Device Regulation (2017/745) that has applied since May 2021. It provides general principles for clinical investigations but few methodological details ‒ which challenges responsible authorities to set appropriate balances between regulation and innovation, pre- and post-market studies, and clinical trials and real-world evidence. Scientific experts should advise on methods and standards for assessing and approving new high-risk devices, and safety, efficacy, and transparency of evidence should be paramount. The European Commission recently awarded a Horizon 2020 grant to a consortium led by the European Society of Cardiology and the European Federation of National Associations of Orthopaedics and Traumatology, that will review methodologies of clinical investigations, advise on study designs, and develop recommendations for aggregating clinical data from registries and other real-world sources. The CORE‒MD project (Coordination of Research and Evidence for Medical Devices) will run until March 2024; here we describe how it may contribute to the development of regulatory science in Europe.
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Affiliation(s)
- A G Fraser
- Department of Cardiology, University Hospital of Wales, Heath Park, Cardiff CF14 4XW, UK
| | - R G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands
| | - P Kjærsgaard-Andersen
- Department of Orthopaedics, Vejle Hospital, South Danish University, DK-7100 Vejle, Denmark
| | - P Szymański
- Centre of Postgraduate Medical Education, MSWiA Central Clinical Hospital, ul. Woloska 137, 02-507 Warsaw, Poland
| | - T Melvin
- Healthcare Products Regulatory Authority, Earlsfort Terrace, Dublin 2, Ireland
| | - P Piscoi
- Health Technology Unit B6, Directorate General for Health (DG SANTE), European Commission, Brussels, Belgium
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11
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Bando K. Commentary: Is a novel bioprosthetic valve durable? Time will tell. JTCVS OPEN 2021; 5:46-47. [PMID: 36003176 PMCID: PMC9390494 DOI: 10.1016/j.xjon.2020.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 10/06/2020] [Accepted: 10/09/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Ko Bando
- Address for reprints: Ko Bando, MD, PhD, Department of Cardiac Surgery, The Jikei University School of Medicine, 3-25-8, Nishi-Shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
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12
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Bartus K, Litwinowicz R, Bilewska A, Stapor M, Bochenek M, Rozanski J, Sadowski J, Filip G, Kusmierczyk M, Kapelak B. Final 5-year outcomes following aortic valve replacement with a RESILIA™ tissue bioprosthesis. Eur J Cardiothorac Surg 2020; 59:434-441. [PMID: 33141188 PMCID: PMC7850021 DOI: 10.1093/ejcts/ezaa311] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/15/2020] [Accepted: 07/23/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Long-term durability of bioprosthetic valves is predominantly limited by structural valve deterioration. RESILIA™ tissue has exhibited reduced calcification in pre-clinical and early clinical studies. This study evaluated the 5-year clinical and haemodynamic outcomes of an aortic valve with this tissue. METHODS This was a prospective, non-randomized, single-arm study of 133 patients implanted with a RESILIA aortic bioprosthesis between July 2011 and February 2013 at 2 sites in Poland. Clinical outcomes and haemodynamic performance were assessed annually for 5 years post-implant. Safety events were adjudicated by a Clinical Events Committee and echocardiographic data were assessed by an independent core laboratory. RESULTS Mean patient age was 65.3 ± 13.5 years, with 34 patients (25.6%) ≤60. The mean follow-up was 4.2 ± 1.5 years. Early (≤30 days) and late (>30 days) all-cause mortality were 2.3% (N = 3) and 3.2%/late patients-years (N = 18) respectively. Early events included thromboembolism in 3 patients (2.3%). Late valve-related events included endocarditis in 1 patient, which led to explant, and valve thrombosis in another patient. There were no events of structural valve deterioration throughout the study. At 5 years, mean gradient was 14.8 ± 7.6 mmHg and effective orifice area was 1.4 ± 0.5 cm2, a marked improvement over baseline values. All New York Heart Association class III patients and most class II patients at baseline had improved classifications at 5 years. CONCLUSIONS The bioprosthesis with RESILIA tissue demonstrated a good safety profile with excellent haemodynamic performance over 5 years of follow-up. These encouraging outcomes warrant additional investigation of this novel tissue. CLINICAL TRIAL REGISTRATION NUMBER NCT01651052.
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Affiliation(s)
- Krzysztof Bartus
- John Paul II Hospital, Krakow, Poland,Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, Krakow, Poland
| | - Radoslaw Litwinowicz
- John Paul II Hospital, Krakow, Poland,Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, Krakow, Poland,Corresponding author. Department of Cardiovascular Surgery and Transplantology, John Paul II Hospital, Jagiellonian University, Pradnicka 80, 31-202 Krakow, Poland. Tel: +48-126-143075; e-mail: (R. Litwinowicz)
| | - Agata Bilewska
- Department of Cardiac Surgery and Transplantology, Cardinal Wyszynski National Institute of Cardiology, Warsaw, Poland
| | | | - Maciej Bochenek
- John Paul II Hospital, Krakow, Poland,Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, Krakow, Poland,Department of Heart Transplantation and Mechanical Circulatory Support, Centre for Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Jacek Rozanski
- Department of Cardiac Surgery and Transplantology, Cardinal Wyszynski National Institute of Cardiology, Warsaw, Poland
| | - Jerzy Sadowski
- John Paul II Hospital, Krakow, Poland,Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, Krakow, Poland
| | - Grzegorz Filip
- John Paul II Hospital, Krakow, Poland,Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, Krakow, Poland
| | - Mariusz Kusmierczyk
- Department of Cardiac Surgery and Transplantology, Cardinal Wyszynski National Institute of Cardiology, Warsaw, Poland
| | - Boguslaw Kapelak
- John Paul II Hospital, Krakow, Poland,Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, Krakow, Poland
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13
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Jawitz OK, Wang TY, Lopes RD, Chavez A, Boyer B, Kim H, Anstrom KJ, Becker RC, Blackstone E, Ruel M, Thourani VH, Puskas JD, Gerdisch MW, Johnston D, Capps S, Alexander JH, Svensson LG. Rationale and design of PROACT Xa: A randomized, multicenter, open-label, clinical trial to evaluate the efficacy and safety of apixaban versus warfarin in patients with a mechanical On-X Aortic Heart Valve. Am Heart J 2020; 227:91-99. [PMID: 32693197 DOI: 10.1016/j.ahj.2020.06.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/16/2020] [Indexed: 12/16/2022]
Abstract
Vitamin K antagonists are the only approved oral anticoagulants for long-term prophylaxis against valve thrombosis and thromboembolism in patients with a mechanical heart valve. Despite the proven efficacy and safety of anticoagulation with the oral direct factor Xa inhibitor apixaban compared with warfarin in high-risk populations including subjects with atrial fibrillation or with venous thromboembolism, it remains unknown whether patients with a mechanical heart valve can be safely managed with apixaban. The On-X Aortic Heart Valve and On-X Ascending Aortic Prosthesis with the Vascutek Gelweave Valsalva Graft may have lower rates of valve thrombosis and thromboembolism than conventional bileaflet and tilting disc valves due its unique pyrolytic carbon composition and flared inlet design. DESIGN: PROACT Xa is a randomized, multicenter, open-label, active-controlled trial comparing apixaban with warfarin in patients with an On-X Aortic Heart Valve or On-X Ascending Aortic Prosthesis with the Vascutek Gelweave Valsalva Graft. The study will randomize approximately 1,000 patients from approximately 60 sites in North America who underwent aortic valve replacement at least 3 months prior. Patients will be randomized 1:1 to receiving apixaban 5 mg twice daily or warfarin with a target international normalized ratio of 2.0-3.0. The last randomized participant will be followed for at least 2 years. The primary efficacy outcome is the composite of valve thrombosis and valve-related thromboembolism, and the primary safety outcome is major bleeding. Assuming the primary outcome occurs in warfarin-anticoagulated patients at a rate of 1.75%/patient-year, the study has more than 90% power to assess noninferiority of apixaban treatment with an absolute noninferiority margin of 1.75%/patient-year. A second co-primary analysis is to compare the hazard rate for the apixaban arm to twice the objective performance criterion for thromboembolism and valve thrombosis, that is, 3.4%/patient-year. SUMMARY: PROACT Xa will determine whether patients with an On-X Aortic Heart Valve can be anticoagulated with apixaban as an alternative to warfarin.
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14
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Commentary: It looks good, but will it last? JTCVS OPEN 2020; 2:12-13. [PMID: 36003679 PMCID: PMC9390140 DOI: 10.1016/j.xjon.2020.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 04/15/2020] [Accepted: 04/16/2020] [Indexed: 11/17/2022]
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15
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Chen J, He C, Lv M, Guo Y, Tao L, Hong T, Wang C, Zhou X, Gu T, Wei L, Fu J, Wang Y, Shi Y. One-year outcome with a bovine pericardial valve. JTCVS OPEN 2020; 2:1-11. [PMID: 36003682 PMCID: PMC9390642 DOI: 10.1016/j.xjon.2020.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 03/24/2020] [Accepted: 04/07/2020] [Indexed: 11/18/2022]
Abstract
Objectives To evaluate the safety and effectiveness of a novel surgical bovine pericardial valve for aortic and mitral valve replacements. Methods Between March 2016 and October 2017, 197 patients (mean age, 66.9 ± 4.9 years; 40.6% were women) underwent aortic valve replacement and mitral valve replacement and were implanted with the Cingular bovine pericardial valve (Shanghai Cingular Biotech Corporation, Shanghai, China) in a prospective, multicenter, single-arm trial in China. A total of 161 aortic and 49 mitral prostheses were implanted. Patients were followed up to 1 year. The primary end point was the 1-year overall rate of valve-related complications, including thromboembolic event, valve thrombosis, major hemorrhage event, major perivalvular leak, and prosthetic valve endocarditis. Results The 1-year overall rate of valve-related complications was 0.5% (95% confidence interval, 0.1%-3.7%). The 1-year survival was 96.4%. The mean gradient and effective orifice area for aortic prostheses at 1 year postoperatively were 12.8 ± 4.4 mm Hg and 1.9 ± 0.3 cm2, respectively. Particularly, the mean gradients and effective orifice area for 19 mm and 21 mm sizes of aortic prostheses at 1 year were 17.0 ± 3.8 mm Hg and 1.6 ± 0.2 cm2, 13.1 ± 4.0 mm Hg and 1.8 ± 0.1 cm2, respectively. Patient–prosthesis mismatch occurred in only 1.3% patients for aortic valve implantation at 1 month. No structural valve deterioration and no endocarditis occurred. Conclusions The Cingular bovine pericardial valve was safe and effective for surgical aortic and mitral valve replacement. The 1-year rate of valve-related complications was very low. Early hemodynamic performance was excellent even for the small aortic root.
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16
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Klautz RJM, Vriesendorp MD, Dagenais F, Labrousse L, Bapat V, Moront MG, Misfeld M, Gearhart E, Kappetein AP, Sabik JF. Antithrombotic therapy and bleeding events after aortic valve replacement with a novel bioprosthesis. J Thorac Cardiovasc Surg 2019; 161:66-75.e4. [PMID: 31864696 DOI: 10.1016/j.jtcvs.2019.10.095] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Several recent-generation surgical tissue valves have been found to have bleeding rates exceeding rates recommended by regulatory bodies. We explored bleeding events using data from the Pericardial Surgical Aortic Valve Replacement (PERIGON) Pivotal Trial for the Avalus valve (Medtronic, Minneapolis, Minn) to examine whether this end point remains relevant for the evaluation of bioprostheses. METHODS Patients (n = 1115) underwent aortic valve replacement. Bleeding and thromboembolic event episodes in patients within 3 years postimplant were analyzed for frequency, timing, and severity, focusing on patients taking antiplatelet/anticoagulant medications at the time of the event. Clinical and hemodynamic outcomes are also reported. RESULTS At 3 years, the Kaplan-Meier cumulative probability estimate of all-cause death was 7.2% (cardiac, 3.6%; valve-related, 1.1%). The Kaplan-Meier cumulative probability estimates of all and major hemorrhage were 8.7% and 5.2%, respectively. Ninety-nine bleeding events occurred in 86 patients: most occurred >30 days postsurgery. Among the 51 late major bleeds, in 5 cases the patients were taking anticoagulant/antiplatelet medication for prophylaxis after surgical aortic valve replacement at the time of the event, whereas the remaining patients were taking medications for other reasons. Age (hazard ratio, 1.035; 95% confidence interval, 1.004-1.068), peripheral vascular disease (hazard ratio, 2.135; 95% confidence interval, 1.106-4.122), renal dysfunction (hazard ratio, 1.920; 95% confidence interval, 1.055-3.494), and antithrombotic medication use at the time of the event (hazard ratio, 1.417; 95% confidence interval, 1.048-1.915) were associated with late bleeds (major and minor). CONCLUSIONS Overall clinical outcomes demonstrated low mortality and few complications except for major bleeding. Most bleeding events occurred >30 days after surgery and in patients taking antiplatelet and/or anticoagulation for indications other than postimplant prophylaxis.
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Affiliation(s)
- Robert J M Klautz
- Department of Cardio-Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands.
| | - Michiel D Vriesendorp
- Department of Cardio-Thoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Francois Dagenais
- Cardiac Surgery Service, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Louis Labrousse
- Cardiac and Vascular Surgery Service, University Hospital of Bordeaux, Bordeaux, France
| | - Vinayak Bapat
- Department of Cardiothoracic Surgery, Columbia University Medical Center, New York, NY
| | - Michael G Moront
- Department of Cardiothoracic Surgery, ProMedica Toledo Hospital, Toledo, Ohio
| | - Martin Misfeld
- University Clinic for Cardiac Surgery, Leipzig Heart Center, Leipzig, Germany
| | - Elizabeth Gearhart
- Department of Biostatistics, Coronary and Structural Heart, Medtronic, Mounds View, Minn
| | - A Pieter Kappetein
- Thorax Center, Erasmus University Medical Center, and Office of Medical Affairs, Medtronic, Rotterdam, The Netherlands
| | - Joseph F Sabik
- Department of Surgery, University Hospitals, Case Western Reserve University School of Medicine, Cleveland, Ohio
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17
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Durko AP, Head SJ, Pibarot P, Atluri P, Bapat V, Cameron DE, Casselman FP, Chen EP, Dahle G, Ebels T, Elefteriades JA, Lancellotti P, Prager RL, Rosenhek R, Speir A, Stijnen M, Tasca G, Yoganathan A, Walther T, De Paulis R. Characteristics of surgical prosthetic heart valves and problems around labeling: A document from the European Association for Cardio-Thoracic Surgery (EACTS)—The Society of Thoracic Surgeons (STS)—American Association for Thoracic Surgery (AATS) Valve Labelling Task Force. J Thorac Cardiovasc Surg 2019; 158:1041-1054. [DOI: 10.1016/j.jtcvs.2019.04.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/08/2019] [Accepted: 01/17/2019] [Indexed: 12/26/2022]
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18
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Durko AP, Head SJ, Pibarot P, Atluri P, Bapat V, Cameron DE, Casselman FP, Chen EP, Dahle G, Ebels T, Elefteriades JA, Lancellotti P, Prager RL, Rosenhek R, Speir A, Stijnen M, Tasca G, Yoganathan A, Walther T, De Paulis R. Characteristics of Surgical Prosthetic Heart Valves and Problems Around Labelling: A Document From the European Association for Cardio-Thoracic Surgery (EACTS)–The Society of Thoracic Surgeons (STS)–American Association for Thoracic Surgery (AATS) Valve Labelling Task Force. Ann Thorac Surg 2019; 108:292-303. [DOI: 10.1016/j.athoracsur.2019.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 03/26/2019] [Indexed: 11/24/2022]
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19
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Bartus K, Litwinowicz R, Bilewska A, Stapor M, Bochenek M, Rozanski J, Sadowski J, Filip G, Kapelak B, Kusmierczyk M. Intermediate-term outcomes after aortic valve replacement with a novel RESILIA TM tissue bioprosthesis. J Thorac Dis 2019; 11:3039-3046. [PMID: 31463133 DOI: 10.21037/jtd.2019.07.33] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background The durability of bioprosthetic heart valves is limited by structural valve deterioration (SVD) due to long-term calcification. A novel bioprosthetic tissue (RESILIATM) has been developed which, in preclinical studies, has shown reduced calcification. The purpose of this study was to evaluate the intermediate-term clinical outcomes and hemodynamic performance of this tissue. Methods A prospective, single-arm, observational trial was conducted in patients who required surgical aortic valve replacement (AVR). Between July 2011 and February 2013, 133 patients were implanted at two sites in Poland. Hemodynamic performance and clinical outcomes were assessed annually through 4 years of follow-up. All safety events were adjudicated by an independent Clinical Events Committee, and echocardiographic data were evaluated by a core laboratory. Results Patients were 65.3±13.5 years old and 26% were ≤60 years old. The average follow-up was 3.8±1.1 (median: 4.1; IQR, 4.0-4.3) years. Early (≤30 day) and late (>30 day) all-cause mortality rates were 2.3% (n=3) and 3.2% late patient-years (n=16), respectively. There were no cases of early or late SVD. There was one early case of major paravalvular leak (0.8%), and no late cases. At 4 years, the mean gradient was 14.5±7.4 mmHg and the effective orifice area was 1.6±0.4 cm2, both markedly improved from baseline. At 4 years, the New York Heart Association functional class had improved from baseline in 54.5% of patients. Conclusions The aortic bioprosthesis with novel RESILIATM tissue demonstrated excellent hemodynamic performance and safety outcomes over 4 years. Longer follow-up will be important to confirm the durability of this bioprosthesis.
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Affiliation(s)
- Krzysztof Bartus
- John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, Krakow, Poland
| | - Radoslaw Litwinowicz
- John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, Krakow, Poland
| | - Agata Bilewska
- Department of Cardiac Surgery and Transplantology, Cardinal Wyszynski National Institute of Cardiology, Warsaw, Poland
| | | | - Maciej Bochenek
- John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, Krakow, Poland
| | - Jacek Rozanski
- Department of Cardiac Surgery and Transplantology, Cardinal Wyszynski National Institute of Cardiology, Warsaw, Poland
| | - Jerzy Sadowski
- John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, Krakow, Poland
| | - Grzegorz Filip
- John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, Krakow, Poland
| | - Boguslaw Kapelak
- John Paul II Hospital, Krakow, Poland.,Department of Cardiovascular Surgery and Transplantology, Jagiellonian University Medical College, Krakow, Poland
| | - Mariusz Kusmierczyk
- Department of Cardiac Surgery and Transplantology, Cardinal Wyszynski National Institute of Cardiology, Warsaw, Poland
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20
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Durko AP, Head SJ, Pibarot P, Atluri P, Bapat V, Cameron DE, Casselman FPA, Chen EP, Dahle G, Ebels T, Elefteriades JA, Lancellotti P, Prager RL, Rosenhek R, Speir A, Stijnen M, Tasca G, Yoganathan A, Walther T, De Paulis R. Characteristics of surgical prosthetic heart valves and problems around labelling: a document from the European Association for Cardio-Thoracic Surgery (EACTS)—The Society of Thoracic Surgeons (STS)—American Association for Thoracic Surgery (AATS) Valve Labelling Task Force. Eur J Cardiothorac Surg 2019; 55:1025-1036. [DOI: 10.1093/ejcts/ezz034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 01/08/2019] [Accepted: 01/17/2019] [Indexed: 01/08/2023] Open
Affiliation(s)
- Andras P Durko
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
- Department of Cardiac Surgery, Medical and Health Science Centre, University of Debrecen, Debrecen, Hungary
| | - Stuart J Head
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Philippe Pibarot
- Québec Heart and Lung Institute, Laval University, Quebec City, QC, Canada
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Vinayak Bapat
- Department of Cardiovascular Surgery, New York-Presbyterian/Columbia University Medical Center, New York, NY, USA
| | - Duke E Cameron
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Filip P A Casselman
- Department of Cardiovascular and Thoracic Surgery, OLV Clinic, Aalst, Belgium
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Gry Dahle
- Department of Cardiothoracic and Vascular Surgery, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Tjark Ebels
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, Netherlands
| | - John A Elefteriades
- Department of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Patrizio Lancellotti
- Department of Cardiology, GIGA Cardiovascular Sciences, University of Liège Hospital, Liège, Belgium
| | - Richard L Prager
- Department of Cardiac Surgery, University of Michigan Hospital, Ann Arbor, MI, USA
| | - Raphael Rosenhek
- Department of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Alan Speir
- Department of Cardiac Surgery, Inova Heart and Vascular Institute, Falls Church, VA, USA
| | | | - Giordano Tasca
- Cardiovascular Department, Operative Unit of Cardiac Surgery, Hospital A. Manzoni, Lecco, Italy
| | - Ajit Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology/Emory School of Medicine, Atlanta, GA, USA
| | - Thomas Walther
- Department of Thoracic and Cardiovascular Surgery, University Hospital Frankfurt, Johann Wolfgang Goethe University Frankfurt, Frankfurt, Germany
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21
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Li HF, Wu Y, Wang M, Grunkemeier GL. A Stopping Guideline for Pulmonary Heart Valve Premarket Approval Studies. Semin Thorac Cardiovasc Surg 2017; 30:81-84. [PMID: 28987280 DOI: 10.1053/j.semtcvs.2017.09.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Hsin-Fang Li
- Medical Data Research Center, Providence Health and Service, Portland, Oregon.
| | - YingXing Wu
- Medical Data Research Center, Providence Health and Service, Portland, Oregon
| | - Mansen Wang
- Medical Data Research Center, Providence Health and Service, Portland, Oregon
| | - Gary L Grunkemeier
- Medical Data Research Center, Providence Health and Service, Portland, Oregon
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Head SJ, Mylotte D, Mack MJ, Piazza N, van Mieghem NM, Leon MB, Kappetein AP, Holmes DR. Considerations and Recommendations for the Introduction of Objective Performance Criteria for Transcatheter Aortic Heart Valve Device Approval. Circulation 2016; 133:2086-93. [DOI: 10.1161/circulationaha.115.020493] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the United States, new surgical heart valves can be approved on the basis of objective performance criteria (OPC). In contrast, the US Food and Drug Administration traditionally requires stricter criteria for transcatheter heart valve (THV) approval, including randomized, clinical trials. Recent US Food and Drug Administration approval of new-generation THVs based on single-arm studies has generated interest in alternative study approaches for THV device approval. This review evaluates whether THV device approval could follow a pathway analogous to that of surgical heart valves by incorporating OPC and provides several considerations and recommendations. Factors to be taken into account in the construction of OPC include the maturity of THV technology, variability in transcatheter aortic valve replacement practice, end points included as OPC, follow-up terms for specific OPC, patient populations to which these OPC apply, and (statistical) methods for OPC development. We recommend that approval of THV devices in the United States for low- and intermediate-risk patients or for new indications should provisionally rely on data from randomized, clinical trials. However, it is recommended that formal OPC be applied for approval of new-generation THVs for use in high- and extreme-risk patient populations.
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Affiliation(s)
- Stuart J. Head
- From Cardiothoracic Surgery (S.J.H., A.P.K.) and Cardiology (N.M.v.M.), Erasmus MC, Rotterdam, The Netherlands; Cardiology, University Hospital Galway, Ireland (D.M.); Baylor Health Care System, The Heart Hospital, Plano, TX (M.J.M.); Interventional Cardiology, McGill University Health Centre, Montreal, QC, Canada (N.P.); Cardiac Surgery, German Heart Centre Munich, Munich (N.P.); Interventional Vascular Therapy, Columbia University Medical Center, New York Presbyterian Hospital, New York (M.B.L.)
| | - Darren Mylotte
- From Cardiothoracic Surgery (S.J.H., A.P.K.) and Cardiology (N.M.v.M.), Erasmus MC, Rotterdam, The Netherlands; Cardiology, University Hospital Galway, Ireland (D.M.); Baylor Health Care System, The Heart Hospital, Plano, TX (M.J.M.); Interventional Cardiology, McGill University Health Centre, Montreal, QC, Canada (N.P.); Cardiac Surgery, German Heart Centre Munich, Munich (N.P.); Interventional Vascular Therapy, Columbia University Medical Center, New York Presbyterian Hospital, New York (M.B.L.)
| | - Michael J. Mack
- From Cardiothoracic Surgery (S.J.H., A.P.K.) and Cardiology (N.M.v.M.), Erasmus MC, Rotterdam, The Netherlands; Cardiology, University Hospital Galway, Ireland (D.M.); Baylor Health Care System, The Heart Hospital, Plano, TX (M.J.M.); Interventional Cardiology, McGill University Health Centre, Montreal, QC, Canada (N.P.); Cardiac Surgery, German Heart Centre Munich, Munich (N.P.); Interventional Vascular Therapy, Columbia University Medical Center, New York Presbyterian Hospital, New York (M.B.L.)
| | - Nicolo Piazza
- From Cardiothoracic Surgery (S.J.H., A.P.K.) and Cardiology (N.M.v.M.), Erasmus MC, Rotterdam, The Netherlands; Cardiology, University Hospital Galway, Ireland (D.M.); Baylor Health Care System, The Heart Hospital, Plano, TX (M.J.M.); Interventional Cardiology, McGill University Health Centre, Montreal, QC, Canada (N.P.); Cardiac Surgery, German Heart Centre Munich, Munich (N.P.); Interventional Vascular Therapy, Columbia University Medical Center, New York Presbyterian Hospital, New York (M.B.L.)
| | - Nicolas M. van Mieghem
- From Cardiothoracic Surgery (S.J.H., A.P.K.) and Cardiology (N.M.v.M.), Erasmus MC, Rotterdam, The Netherlands; Cardiology, University Hospital Galway, Ireland (D.M.); Baylor Health Care System, The Heart Hospital, Plano, TX (M.J.M.); Interventional Cardiology, McGill University Health Centre, Montreal, QC, Canada (N.P.); Cardiac Surgery, German Heart Centre Munich, Munich (N.P.); Interventional Vascular Therapy, Columbia University Medical Center, New York Presbyterian Hospital, New York (M.B.L.)
| | - Martin B. Leon
- From Cardiothoracic Surgery (S.J.H., A.P.K.) and Cardiology (N.M.v.M.), Erasmus MC, Rotterdam, The Netherlands; Cardiology, University Hospital Galway, Ireland (D.M.); Baylor Health Care System, The Heart Hospital, Plano, TX (M.J.M.); Interventional Cardiology, McGill University Health Centre, Montreal, QC, Canada (N.P.); Cardiac Surgery, German Heart Centre Munich, Munich (N.P.); Interventional Vascular Therapy, Columbia University Medical Center, New York Presbyterian Hospital, New York (M.B.L.)
| | - A. Pieter Kappetein
- From Cardiothoracic Surgery (S.J.H., A.P.K.) and Cardiology (N.M.v.M.), Erasmus MC, Rotterdam, The Netherlands; Cardiology, University Hospital Galway, Ireland (D.M.); Baylor Health Care System, The Heart Hospital, Plano, TX (M.J.M.); Interventional Cardiology, McGill University Health Centre, Montreal, QC, Canada (N.P.); Cardiac Surgery, German Heart Centre Munich, Munich (N.P.); Interventional Vascular Therapy, Columbia University Medical Center, New York Presbyterian Hospital, New York (M.B.L.)
| | - David R. Holmes
- From Cardiothoracic Surgery (S.J.H., A.P.K.) and Cardiology (N.M.v.M.), Erasmus MC, Rotterdam, The Netherlands; Cardiology, University Hospital Galway, Ireland (D.M.); Baylor Health Care System, The Heart Hospital, Plano, TX (M.J.M.); Interventional Cardiology, McGill University Health Centre, Montreal, QC, Canada (N.P.); Cardiac Surgery, German Heart Centre Munich, Munich (N.P.); Interventional Vascular Therapy, Columbia University Medical Center, New York Presbyterian Hospital, New York (M.B.L.)
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23
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Pierce EL, Siefert AW, Paul DM, Wells SK, Bloodworth CH, Takebayashi S, Aoki C, Jensen MO, Gillespie MJ, Gorman RC, Gorman JH, Yoganathan AP. How Local Annular Force and Collagen Density Govern Mitral Annuloplasty Ring Dehiscence Risk. Ann Thorac Surg 2016; 102:518-26. [PMID: 27133454 DOI: 10.1016/j.athoracsur.2016.01.107] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Revised: 11/28/2015] [Accepted: 01/28/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Annuloplasty ring dehiscence is a well described mode of mitral valve repair failure. Defining the mechanisms underlying dehiscence may facilitate its prevention. METHODS Factors that govern suture dehiscence were examined with an ovine model. After undersized ring annuloplasty in live animals (n = 5), cyclic force (FC) that acts on sutures during cardiac contraction was measured with custom transducers. FC was measured at ten suture positions, throughout cardiac cycles with peak left ventricular pressure (LVPmax) of 100, 125, and 150 mm Hg. Suture pullout testing was conducted on explanted mitral annuli (n = 12) to determine suture holding strength at each position. Finally, relative collagen density differences at suture sites around the annulus were assessed by two-photon excitation fluoroscopy. RESULTS Anterior FC exceeded posterior FC at each LVPmax (eg, 2.8 ± 1.3 N versus 1.8 ± 1.2 N at LVPmax = 125 mm Hg, p < 0.01). Anterior holding strength exceeded posterior holding strength (6.4 ± 3.6 N versus 3.9 ± 1.6 N, p < 0.0001). On the basis of FC at LVPmax of 150 mm Hg, margin of safety before suture pullout was vastly higher between the trigones (exclusive) versus elsewhere (4.8 ± 0.9 N versus 1.9 ± 0.5 N, p < 0.001). Margin of safety exhibited strong correlation to collagen density (R(2) = 0.947). CONCLUSIONS Despite lower cyclic loading on posterior sutures, the weaker posterior mitral annular tissue creates higher risk of dehiscence, apparently because of reduced collagen content. Sutures placed atop the trigones are less secure than predicted, because of a combination of reduced collagen and higher overall rigidity in this region. These findings highlight the inter-trigonal tissue as the superior anchor and have implications on the design and implantation techniques for next-generation mitral prostheses.
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Affiliation(s)
- Eric L Pierce
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Andrew W Siefert
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Deborah M Paul
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Sarah K Wells
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Charles H Bloodworth
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Satoshi Takebayashi
- Gorman Cardiovascular Research Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Chikashi Aoki
- Gorman Cardiovascular Research Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Morten O Jensen
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Matthew J Gillespie
- Gorman Cardiovascular Research Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ajit P Yoganathan
- The Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia.
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24
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Wu C, Kurtzman SB, Laschinger J, Johnson T, Aguel F. United States Food and Drug Administration perspectives on the update to the objective performance criteria for surgically implanted heart valve prostheses. Ann Thorac Surg 2014; 98:1890-1. [PMID: 25441824 DOI: 10.1016/j.athoracsur.2014.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 08/29/2014] [Accepted: 09/09/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Changfu Wu
- Division of Cardiovascular Devices, Office of Device Evaluation, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD 20993.
| | - Steven B Kurtzman
- Division of Cardiovascular Devices, Office of Device Evaluation, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD 20993
| | - John Laschinger
- Division of Cardiovascular Devices, Office of Device Evaluation, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD 20993
| | - Terri Johnson
- Division of Biostatistics, Office of Surveillance and Biometrics, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD 20993
| | - Fernando Aguel
- Division of Cardiovascular Devices, Office of Device Evaluation, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, MD 20993
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