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Tong Q, Cai J, Wang Z, Sun Y, Liang X, Xu Q, Mahamoud OA, Qian Y, Qian Z. Recent Advances in the Modification and Improvement of Bioprosthetic Heart Valves. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2024; 20:e2309844. [PMID: 38279610 DOI: 10.1002/smll.202309844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/10/2023] [Indexed: 01/28/2024]
Abstract
Valvular heart disease (VHD) has become a burden and a growing public health problem in humans, causing significant morbidity and mortality worldwide. An increasing number of patients with severe VHD need to undergo heart valve replacement surgery, and artificial heart valves are in high demand. However, allogeneic valves from donors are lacking and cannot meet clinical practice needs. A mechanical heart valve can activate the coagulation pathway after contact with blood after implantation in the cardiovascular system, leading to thrombosis. Therefore, bioprosthetic heart valves (BHVs) are still a promising way to solve this problem. However, there are still challenges in the use of BHVs. For example, their longevity is still unsatisfactory due to the defects, such as thrombosis, structural valve degeneration, calcification, insufficient re-endothelialization, and the inflammatory response. Therefore, strategies and methods are needed to effectively improve the biocompatibility and longevity of BHVs. This review describes the recent research advances in BHVs and strategies to improve their biocompatibility and longevity.
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Affiliation(s)
- Qi Tong
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
| | - Jie Cai
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
| | - Zhengjie Wang
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
| | - Yiren Sun
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
| | - Xuyue Liang
- Department of Biotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
| | - Qiyue Xu
- School of Basic Medicine, Mudanjiang Medical University, Mudanjiang, Heilongjiang, 157011, P. R. China
| | - Oumar Abdel Mahamoud
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
| | - Yongjun Qian
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
| | - Zhiyong Qian
- Department of Biotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
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Bouhout I, Singh S, Nguyen S, Vinogradsky A, Barrett C, Kalfa D, Bacha E, Goldstone A. Influence of preoperative aortic regurgitation on long-term autograft durability and dilatation in children and adolescents undergoing the Ross procedure. J Thorac Cardiovasc Surg 2024; 167:1123-1131.e2. [PMID: 37385527 PMCID: PMC10751386 DOI: 10.1016/j.jtcvs.2023.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 06/03/2023] [Accepted: 06/19/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE Primary aortic insufficiency (AI) is a risk factor for autograft reintervention in adults undergoing the Ross procedure. We sought to examine the influence of preoperative AI on autograft durability in children and adolescents. METHODS From 1993 to 2020, 125 consecutive patients between ages 1 and 18 underwent a Ross procedure. The autograft was implanted using a full-root technique in 123 (98.4%) and included in a polyethelene terephthalate graft in 2 (1.6%). Patients with aortic stenosis (aortic stenosis group) (n = 85) were retrospectively compared with those with AI or mixed disease (AI group) (n = 40). Median length of follow-up was 8.2 years (interquartile range, 3.3-15.4 years). The primary end point was the incidence of severe AI or autograft reintervention. Secondary end points included changes in autograft dimensions analyzed using mixed-effect models. RESULTS The incidence of severe AI or autograft reintervention was 39.0% ± 13.0% in the AI group and 8.8% ± 4.4% in the aortic stenosis group at 15 years (P = .02). Annulus z scores increased in both aortic stenosis and AI groups over time (P < .001). However, the annulus dilated at a faster rate in the AI group (absolute difference, 3.8 ± 2.0 vs 2.5 ± 1.7; P = .03). Sinus of Valsalva z scores increased in both groups as well (P < .001), but at similar rates over time (P = .11). CONCLUSIONS Children and adolescents with AI undergoing the Ross procedure have higher rates of autograft failure. Patients with preoperative AI have more pronounced dilatation at the annulus. Akin to adults, a surgical aortic annulus stabilization technique that modulates growth is needed in children.
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Affiliation(s)
- Ismail Bouhout
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| | - Sameer Singh
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| | - Stephanie Nguyen
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| | - Alice Vinogradsky
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| | - Connor Barrett
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| | - David Kalfa
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| | - Emile Bacha
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY
| | - Andrew Goldstone
- Section of Pediatric and Congenital and Cardiac Surgery, Division of Cardiac, Thoracic, and Vascular Surgery, Department of Surgery, Morgan Stanley Children Hospital-New York Presbyterian, Columbia University College of Physicians and Surgeons, New York, NY.
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Ram E, Lau C, Dimagli A, Gaudino M, Girardi LN. Valve Sparing vs Composite Valve Graft Root Replacement: Propensity Score-Matched Analysis. Ann Thorac Surg 2024; 117:69-76. [PMID: 37541560 DOI: 10.1016/j.athoracsur.2023.05.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 04/25/2023] [Accepted: 05/30/2023] [Indexed: 08/06/2023]
Abstract
BACKGROUND Both valve-sparing root replacement and composite valve graft (CVG) are acceptable options in aortic root replacement. We compare outcomes of these 2 approaches and durability of the aortic valve. METHODS A consecutive 1635 patients without acute dissection underwent primary aortic root replacement from 1997 to 2022; 473 (29%) underwent valve-sparing root replacement, and 1162 (71%) received CVG. Propensity score matching was used to reduce baseline differences. RESULTS The CVG group was older (59 ± 14 years vs 49 ± 14 years; P < .001) with more comorbidities, such as hypertension (88.4% vs 66.4%; P < .001), diabetes (7% vs 1.7%; P < .001), ischemic heart disease (5.1% vs 1.3%; P = .001), pulmonary disease (6.6% vs 1.3%; P < .001), renal impairment (8.6% vs 1.3%; P < .001), class III-IV heart failure (35% vs 9.2%; P < .001), bicuspid aortic valves (44.8% vs 24.1%; P < .001), and severe aortic insufficiency (50.2% vs 13.2%; P < .001). Operative mortality was 0.4% (0% in valve sparing); incidence of major postoperative complications was 2.9% (3.6% vs 1.1%; P = .009). Ten-year survival was 93.1% (91.2% vs 97.7%; hazard ratio [HR], 1.7; 95% CI, 0.9-3.3; P = .120). Mean follow-up was 65 ± 60 months; aortic valve reoperations were similar (5.8% vs 5.7%; HR, 0.8; 95% CI, 0.4-1.4; P = .401). Recurrent moderate-severe aortic insufficiency was less prevalent in CVG (6.1% vs 11.1%; HR, 0.14; 95% CI, 0.07-0.27; P < .001). Propensity score matching identified 225 pairs. There was no difference in 10-year survival or reoperations. Recurrent moderate-severe aortic insufficiency was higher with valve sparing. CONCLUSIONS Both valve-sparing operations and CVG provide excellent early and late outcomes out to 10 years. Valve sparing is associated with a higher risk for development of aortic insufficiency but no difference in reoperations.
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Affiliation(s)
- Eilon Ram
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York; Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Christopher Lau
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Arnaldo Dimagli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York
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Nappi F, Schoell T, Spadaccio C, Acar C, da Costa FDA. A Literature Review on the Use of Aortic Allografts in Modern Cardiac Surgery for the Treatment of Infective Endocarditis: Is There Clear Evidence or Is It Merely a Perception? Life (Basel) 2023; 13:1980. [PMID: 37895362 PMCID: PMC10608498 DOI: 10.3390/life13101980] [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: 08/21/2023] [Revised: 09/18/2023] [Accepted: 09/25/2023] [Indexed: 10/29/2023] Open
Abstract
Infective valve endocarditis is caused by different pathogens and 60% of those involve the aortic valve with valve failure. Although S. aureus is recognized as the most frequently isolated causative bacterium associated with IE in high-income countries, Gram-positive cocci nevertheless play a crucial role in promoting infection in relation to their adhesive matrix molecules. The presence of pili on the surface of Gram-positive bacteria such as in different strains of Enterococcus faecalis and Streptococcus spp., grants these causative pathogens a great offensive capacity due to the formation of biofilms and resistance to antibiotics. The indications and timing of surgery in endocarditis are debated as well as the choice of the ideal valve substitute to replace the diseased valve(s) when repair is not possible. We reviewed the literature and elaborated a systematic approach to endocarditis management based on clinical, microbiological, and anatomopathological variables known to affect postoperative outcomes with the aim to stratify the patients and orient decision making. From this review emerges significant findings on the risk of infection in the allograft used in patients with endocarditis and no endocarditis etiology suggesting that the use of allografts has proved safety and effectiveness in patients with both pathologies.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France;
| | - Thibaut Schoell
- Department of Cardiac Surgery, Centre Cardiologique du Nord, 93200 Saint-Denis, France;
| | - Cristiano Spadaccio
- Cardiothoracic Surgery, Lancashire Cardiac Center, Blackpool Victoria Hospital, Blackpool FY3 8NP, UK;
| | - Christophe Acar
- Department of Cardiothoracic Surgery, Hôpital Pitié-Salpêtrière, Boulevard de Hôpital 47-83, 75013 Paris, France;
| | - Francisco Diniz Affonso da Costa
- Department of Cardiovascular Surgery, Instituto de Neurologia e Cardiologia de Curitiba—INC Cardio, Curitiba 81210-310, Parana, Brazil;
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Kiaii BB, Moront MG, Patel HJ, Ruel M, Bensari FN, Kress DC, Liu F, Klautz RJM, Sabik JF. Outcomes of Surgical Bioprosthetic Aortic Valve Replacement in Patients Aged ≤65 and >65 Years. Ann Thorac Surg 2023; 116:483-490. [PMID: 35065064 DOI: 10.1016/j.athoracsur.2021.12.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 11/17/2021] [Accepted: 12/14/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Implantation of a bioprosthetic valve is a reasonable choice for patients aged > 65 years. For middle-aged patients there is less certainty about whether a mechanical or bioprosthetic valve is best. METHODS The Pericardial Surgical Aortic Valve Replacement (PERIGON) Pivotal Trial is evaluating the safety and efficacy of the Avalus bioprosthesis (Medtronic). We evaluated clinical and echocardiographic outcomes through 5 years of follow-up, stratified by age ≤ 65 and >65 years. RESULTS Two hundred seventy-one patients (24.2%) were ≤65 years old and 847 (75.8%) >65 years old. Most patients in both groups were men (217 [80.1%] vs 623 [73.6%], respectively; P = .031). Younger patients had a lower Society of Thoracic Surgeons risk of mortality (1.1% ± 0.9% vs 2.2% ± 1.4%, P < .001), better baseline New York Heart Association class (P = .004), and fewer comorbidities than older patients. At 5 years mortality was lower among younger than older patients (5.3% vs 14.0%, P < .001) and no cases of structural valve deterioration occurred in either group. Effective orifice area was similar between age groups (P = .11), and mean gradient was 13.9 ± 5.4 vs 12.0 ± 4.1 mm Hg (P < .001). Multivariable linear regression identified several parameters associated with mean aortic gradient at 5 years, including baseline age and mean aortic gradient, discharge stroke volume index and EOA, and implanted valve size. Ninety-five percent of patients were in New York Heart Association class I/II through 5 years in both age groups (P = .85). CONCLUSIONS Findings from this analysis demonstrate satisfactory safety, hemodynamic performance, and durability of the Avalus bioprosthesis through a 5-year follow-up in patients aged ≤ 65 and >65 years.
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Affiliation(s)
- Bob B Kiaii
- Department of Cardiac Surgery, London Health Sciences Centre, London, Ontario, Canada.
| | | | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Hospitals, Ann Arbor, Michigan
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - David C Kress
- Department of Cardiothoracic Surgery, Aurora St Luke's Medical Center, Milwaukee, Wisconsin
| | - Fang Liu
- Department of Biostatistics, Medtronic, Mounds View, Minnesota
| | - Robert J M Klautz
- Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Joseph F Sabik
- University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
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Halder V, Mishra A, Ghosh S, Singh H, Barwad P, Thingnam SK, Dutta ARS, Harunal M. Effectiveness and Safety of the Ozaki Procedure for Aortic Valve Disease in Pediatric Patients: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e45269. [PMID: 37846270 PMCID: PMC10576845 DOI: 10.7759/cureus.45269] [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] [Accepted: 09/14/2023] [Indexed: 10/18/2023] Open
Abstract
The surgical treatment options for pediatric aortic valve disease are limited and have debatable long-term durability. In the current situation, the Ross procedure is considered in children for aortic valve disease(s). It is a complex surgical procedure with the risk of neo-aortic dilatation, converting a single valve disease into double valve disease, and associated with future re-interventions. Conversely, the Ozaki procedure has shown promising results in adults. Thus, the present study aimed to provide comparative evidence on the effectiveness and safety of the Ozaki versus Ross procedure for pediatric patients by performing a meta-analytic comparison of reporting outcomes. A total of 15 relevant articles were downloaded and among them, seven articles (one prospective study, five retrospective studies, and one case series) were used in the analysis. Primary outcomes such as physiological laminar flow pattern and hemodynamic parameters, and secondary outcomes such as hospital stays, adverse effects, mortality, and numbers of re-intervention(s) were measured in the meta-analysis. There were no significant differences in the age of patients between children who underwent the Ozaki procedure and those who underwent the Ross procedure at the time of surgeries. The Ozaki procedure is a good solution to an aortic problem(s) similar to the Ross procedure. Unlike the Ross procedure, the Ozaki procedure has restored a physiological laminar flow pattern in the short-term follow-up without the bi-valvular disease. Mean hospital stays (p = 0.048), mean follow-up (p = 0.02), adverse effects (p = 0.02), death, and numbers of re-intervention(s) of children who underwent the Ozaki procedure were fewer than those who underwent the Ross procedure. The time required for re-intervention(s) is higher for children who underwent the Ozaki procedure than those who underwent the Ross procedure. None of the procedures, including the Ozaki procedure for aortic valve disease(s), has significant effects on hemodynamic parameters and the frequent death rate of children after surgeries. Based on our analysis, we may suggest the Ozaki procedure for aortic valve disease surgery in children.
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Affiliation(s)
- Vikram Halder
- Department of Cardiothoracic Surgery, U. N. Mehta Institute of Cardiology & Research Centre, Gujarat, IND
| | - Amit Mishra
- Department of Cardiothoracic Surgery, U. N. Mehta Institute of Cardiology & Research Centre, Ahmedabad, IND
| | - Soumitra Ghosh
- Department of Cardiology, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Harkant Singh
- Department of Cardiothoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Parag Barwad
- Department of Cardiothoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Shyam K Thingnam
- Department of Cardiothoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Aduri Raja S Dutta
- Department of Cardiothoracic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, IND
| | - Maruti Harunal
- Department of Cardiothoracic Surgery/Congenital Heart Disease, U. N. Mehta Institute of Cardiology & Research Centre, Ahmedabad, IND
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Sánchez-Ceña J, Asmarats L, Li CHP, Millán X, Fernández-Peregrina E, Menduiña I, Massó van Roessel A, Arzamendi D. Redo transcatheter aortic valve replacement in degenerated transcatheter bioprosthesis (TAV-in-TAV). Expert Rev Cardiovasc Ther 2023; 21:703-712. [PMID: 37815845 DOI: 10.1080/14779072.2023.2266368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/29/2023] [Indexed: 10/11/2023]
Abstract
INTRODUCTION With the expanding indications of transcatheter aortic valve replacement (TAVR) to younger and low-risk patients, the life expectancy of patients currently undergoing TAVR will likely outlive the durability of transcatheter bioprosthesis. Consequently, the number of failed transcatheter bioprosthesis requiring surgical valve explant or redo TAVR is expected to increase. AREAS COVERED The aim of this review is to provide an updated overview of redo TAVR for treating degenerated transcatheter bioprosthesis, focusing on pre-procedural planning, potential challenges of coronary reaccess during TAVR-in-TAVR and main outcomes of TAVR explant and redo TAVR. EXPERT OPINION Patient-tailored device selection and individualized implantation height should be carefully assessed during the index TAVR procedure (weighting between pacemaker avoidance and the potential risk of coronary occlusion in future TAVR-in-TAVR). Future prospective studies comparing safety and clinical outcomes between redo TAVR vs TAVR explant are eagerly awaited.
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Affiliation(s)
- Juan Sánchez-Ceña
- Hospital Santa Creu i Sant Pau, Biomedical Research Institute IIB-Sant Pau, Barcelona, Spain
| | - Lluis Asmarats
- Hospital Santa Creu i Sant Pau, Biomedical Research Institute IIB-Sant Pau, Barcelona, Spain
| | - Chi Hion Pedro Li
- Hospital Santa Creu i Sant Pau, Biomedical Research Institute IIB-Sant Pau, Barcelona, Spain
| | - Xavier Millán
- Hospital Santa Creu i Sant Pau, Biomedical Research Institute IIB-Sant Pau, Barcelona, Spain
| | | | - Irene Menduiña
- Hospital Santa Creu i Sant Pau, Biomedical Research Institute IIB-Sant Pau, Barcelona, Spain
| | | | - Dabit Arzamendi
- Hospital Santa Creu i Sant Pau, Biomedical Research Institute IIB-Sant Pau, Barcelona, Spain
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Xue Y, Kossar AP, Abramov A, Frasca A, Sun M, Zyablitskaya M, Paik D, Kalfa D, Della Barbera M, Thiene G, Kozaki S, Kawashima T, Gorman JH, Gorman RC, Gillespie MJ, Carreon CK, Sanders SP, Levy RJ, Ferrari G. Age-related enhanced degeneration of bioprosthetic valves due to leaflet calcification, tissue crosslinking, and structural changes. Cardiovasc Res 2023; 119:302-315. [PMID: 35020813 PMCID: PMC10022861 DOI: 10.1093/cvr/cvac002] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/03/2021] [Accepted: 01/06/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Bioprosthetic heart valves (BHVs), made from glutaraldehyde-fixed heterograft materials, are subject to more rapid structural valve degeneration (SVD) in paediatric and young adult patients. Differences in blood biochemistries and propensity for disease accelerate SVD in these patients, which results in multiple re-operations with compounding risks. The goal of this study is to investigate the mechanisms of BHV biomaterial degeneration and present models for studying SVD in young patients and juvenile animal models. METHODS AND RESULTS We studied SVD in clinical BHV explants from paediatric and young adult patients, juvenile sheep implantation model, rat subcutaneous implants, and an ex vivo serum incubation model. BHV biomaterials were analysed for calcification, collagen microstructure (alignment and crimp), and crosslinking density. Serum markers of calcification and tissue crosslinking were compared between young and adult subjects. We demonstrated that immature subjects were more susceptible to calcification, microstructural changes, and advanced glycation end products formation. In vivo and ex vivo studies comparing immature and mature subjects mirrored SVD in clinical observations. The interaction between host serum and BHV biomaterials leads to significant structural and biochemical changes which impact their functions. CONCLUSIONS There is an increased risk for accelerated SVD in younger subjects, both experimental animals and patients. Increased calcification, altered collagen microstructure with loss of alignment and increased crimp periods, and increased crosslinking are three main characteristics in BHV explants from young subjects leading to SVD. Together, our studies establish a basis for assessing the increased susceptibility of BHV biomaterials to accelerated SVD in young patients.
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Affiliation(s)
- Yingfei Xue
- Department of Surgery, Columbia University, New York, NY, USA
| | | | - Alexey Abramov
- Department of Surgery, Columbia University, New York, NY, USA
| | - Antonio Frasca
- Department of Surgery, Columbia University, New York, NY, USA
| | - Mingze Sun
- Department of Surgery, Columbia University, New York, NY, USA
| | | | - David Paik
- Department of Ophthalmology, Columbia University, New York, NY, USA
| | - David Kalfa
- Division of Cardiac, Thoracic and Vascular Surgery, Section of Pediatric and Congenital Cardiac Surgery, Department of Surgery, New-York Presbyterian—Morgan Stanley Children’s Hospital, Columbia University Medical Center, New York, NY, USA
| | - Mila Della Barbera
- Department of Cardiac, Thoracic, Vascular Science and Public Health, University of Padua, Medical School, Padua, Italy
| | - Gaetano Thiene
- Department of Cardiac, Thoracic, Vascular Science and Public Health, University of Padua, Medical School, Padua, Italy
| | - Satoshi Kozaki
- Gorman Cardiovascular Research Group, Department of Surgery, Smilow Center for Translational Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Takayuki Kawashima
- Gorman Cardiovascular Research Group, Department of Surgery, Smilow Center for Translational Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, Department of Surgery, Smilow Center for Translational Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, Department of Surgery, Smilow Center for Translational Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew J Gillespie
- Gorman Cardiovascular Research Group, Department of Surgery, Smilow Center for Translational Research, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Chrystalle Katte Carreon
- The Cardiac Registry, Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA
- The Cardiac Registry, Department of Pathology, Boston Children’s Hospital, Boston, MA, USA
- The Cardiac Registry, Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA, USA
- Department of Pathology, Boston Children’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Stephen P Sanders
- The Cardiac Registry, Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA
- The Cardiac Registry, Department of Pathology, Boston Children’s Hospital, Boston, MA, USA
- The Cardiac Registry, Department of Cardiac Surgery, Boston Children’s Hospital, Boston, MA, USA
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Robert J Levy
- The Pediatric Heart Valve Center & Division of Cardiology, Department of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, PA, USA
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Tamer S, Mastrobuoni S, Vancraeynest D, Lemaire G, Navarra E, Khoury GE, de Kerchove L. Late results of aortic valve repair for isolated severe aortic regurgitation. J Thorac Cardiovasc Surg 2023; 165:995-1006.e3. [PMID: 34049711 DOI: 10.1016/j.jtcvs.2021.04.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 03/09/2021] [Accepted: 04/05/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVES The objectives were to analyze the long-term outcomes of tricuspid aortic valve repair for isolated severe aortic regurgitation and the impact of different annuloplasty techniques. METHODS The study cohort consists of 127 consecutive patients who received aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve between 1996 and 2019 in our institution. Exclusion criteria were aorta dilatation (≥45 mm), connective tissue disease, active endocarditis, type A dissection, and rheumatic disease. Mean age of patients was 55.6 ± 16 years, and 80% were male. Median follow-up was 6.4 years. Time-to-event analysis was performed, as well as risk of death, reoperation, and aortic regurgitation recurrence. RESULTS Cusp repair was performed in 117 patients (92%), and annuloplasty was performed in 126 patients (99%) with Cabrol stitch (73%), reimplantation technique (19.7%), or ring annuloplasty (6.3%). There was no hospital mortality. At 10 and 14 years, overall survival was 81% ± 5% and 71% ± 6%, respectively, and freedom from reoperation was 80% ± 5% and 73% ± 6%, respectively. Age and left coronary cusp repair were independent predictors of reoperation. Freedom from recurrent severe aortic regurgitation (>2+) was 73% ± 5% and 66% ± 7% at 10 and 12 years, respectively. Age, left ventricular end-diastolic diameter, and patch repair were independent predictors of recurrent aortic regurgitation. Type of annuloplasty had no impact on survival or reoperation. CONCLUSIONS Aortic valve repair for isolated severe aortic regurgitation in the tricuspid aortic valve is a safe procedure, and durability at 14 years is acceptable. In this study, the annuloplasty technique did not influence repair durability as was found in bicuspid aortic valve repair or aortic valve-sparing surgery. Severity of cusp pathology seems to be the main determinant of repair durability.
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Affiliation(s)
- Saadallah Tamer
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Stefano Mastrobuoni
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - David Vancraeynest
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Guillaume Lemaire
- Division of Anesthesiology, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Emiliano Navarra
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Gebrine El Khoury
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Laurent de Kerchove
- Pôle de Recherche Cardiovasculaire, Institut de Recherche Expérimentale et Clinique, Université Catholique de Louvain and Division of Cardiothoracic and Vascular Surgery, Cliniques Universitaires Saint-Luc, Brussels, Belgium.
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Abstract
The clinical outcome of severe aortic regurgitation (AR) remains suboptimal, but surgery has been shown to have survival benefit over medical therapy. Postoperative survival is inferior in patients with reduced left ventricular function, and therefore early surgical intervention is recommended. Aortic valvuloplasty (AVP) is an attractive option to avoid the major drawbacks of prosthetic valves but has not been widely adopted. The etiology of AR is classified functionally into three groups: normal leaflet motion (type I), cusp prolapse (type II), and restriction (type III). Type I with dilatation of the sinus of Valsalva (type Ib) can be repaired by aortic valve reimplantation or aortic root remodeling with similar valve stability. Type I with dilatation of the aortic annulus (type Ic) can be managed by annuloplasty. Type II can be corrected by plication or resuspension techniques. Pericardial patch is necessary in AVP for type Id (perforation/fenestration) and type III but is associated with risk of recurrence. Bicuspid aortic valve is classified according to commissure angle: symmetrical, asymmetrical, and very asymmetrical. Tricuspidization is recommended for repair of very asymmetrical valves to avoid postoperative stenosis. Recent progress has achieved similar reoperation rates between bicuspid and tricuspid aortic valve repair. For Marfan syndrome, valve-sparing root replacement is advantageous compared to Bentall operation regarding late survival, thromboembolic and hemorrhagic events, and endocarditis. Similar findings have been reported in acute aortic dissection. Both remodeling and reimplantation procedures provide similar favorable outcomes in these settings. Recent advances in AVP are summarized by quantitative assessment of cusp configuration (effective height and geometric height), graft size decision, use of template to cut the graft, and videoscopic assessment of post-repair cusp configuration. Due to these advances, AVP shows superior results to replacement surgery. Further concrete evidence with larger case volumes and longer observation periods are necessary to popularize AVP.
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11
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Desai PV, Goel SS, Kleiman NS, Reardon MJ. Transcatheter Aortic Valve Implantation: Long-Term Outcomes and Durability. Methodist Debakey Cardiovasc J 2023; 19:15-25. [PMID: 37213878 PMCID: PMC10198228 DOI: 10.14797/mdcvj.1201] [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: 03/24/2023] [Accepted: 04/27/2023] [Indexed: 05/23/2023] Open
Abstract
Transcatheter aortic valve implantation (TAVI) has become the standard of care in symptomatic older patients with severe aortic stenosis regardless of surgical risk. With the development of newer generation transcatheter bioprostheses, improved delivery systems, better preprocedure planning with imaging guidance, increased operator experience, shorter hospital length of stay, and low short- and mid-term complication rates, TAVI is gaining popularity among younger patients at low or intermediate surgical risk. Long-term outcomes and durability of transcatheter heart valves have become substantially important for this younger population due to their longer life expectancy. The lack of standardized definitions of bioprosthetic valve dysfunction and disagreement about how to account for the competing risks made comparison of transcatheter heart valves with surgical bioprostheses challenging until recently. In this review, the authors discuss the mid- to long-term (≥ 5 years) clinical outcomes observed in the landmark TAVI trials and analyze the available long-term durability data emphasizing the importance of using standardized definitions of bioprosthetic valve dysfunction.
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Affiliation(s)
| | - Sachin S. Goel
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Neal S. Kleiman
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Michael J. Reardon
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
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12
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Keuffel EL, Reifenberger M, Marfo G, Nguyen TC. Long-run savings associated with surgical aortic valve replacement using a RESILIA tissue bioprosthetic valve versus a mechanical valve. J Med Econ 2023; 26:120-127. [PMID: 36524536 DOI: 10.1080/13696998.2022.2159662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Prior economic analyses demonstrate that legacy tissue valves are associated with substantial financial savings over the long run after a surgical aortic valve replacement (SAVR). Bioprostheses with RESILIA tissue reduce calcification, the primary cause of structural valve deterioration (SVD), and have demonstrated promising pre-clinical and 5-year clinical results. This economic evaluation quantifies the expected long-run savings of bioprosthetic valves with RESILIA tissue relative to mechanical valves given 5-year clinical results and expected performance through year 15. METHODS Simulation models estimated disease progression across two hypothetical SAVR cohorts (tissue vs. mechanical) of 10,000 patients in the US over 15 years. One comparison evaluated RESILIA tissue valves relative to mechanical valves. The other compared legacy SAVR tissue and mechanical valves. Health outcome probabilities and costs were based on literature and expert opinion. Incidence rates of health outcomes associated with mechanical valve were calculated using relative risks of expected outcomes in tissue valve versus mechanical valve patients. The comparisons also accounted for anti-coagulation monitoring in both cohorts. Savings estimates are based on US healthcare costs and do not yet account for the premium associated use of RESILIA relative to a standard tissue valve. RESULTS Relative to mechanical SAVR, the median net discounted savings for a patient receiving SAVR with a RESILIA tissue valve is $20,744 ($US, 2020; 95% CI = $15,835-$26,655) over a 15-year horizon. While 30-day and 1-year savings were not significant, expected savings after 5 years are $9,110 (95% CI = $6,634-$11,969). Net savings for RESILIA SAVR valves were approximately 30-50% larger than savings anticipated using legacy tissue SAVR valves. CONCLUSION RESILIA tissue valves are associated with lower health expenditures relative to mechanical valves.
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Affiliation(s)
- Eric L Keuffel
- Health Economics, Health Finance & Access Initiative, Ardmore, PA, USA
| | | | - Godfred Marfo
- Health Economics, Edwards Life Sciences, Irvine, CA, USA
| | - Tom C Nguyen
- Department of Cardiothoracic Surgery, University of California San Francisco, San Francisco, CA, USA
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13
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Baman JR, Medhekar AN, Malaisrie SC, McCarthy P, Davidson CJ, Bonow RO. Management Challenges in Patients Younger Than 65 Years With Severe Aortic Valve Disease. JAMA Cardiol 2022; 8:281-289. [PMID: 36542365 DOI: 10.1001/jamacardio.2022.4770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
ImportanceThe management of aortic valve disease, including aortic stenosis and aortic regurgitation (AR), in younger adult patients (age &lt;65 years) is complex, and the optimal strategy is often unclear, contingent on multiple anatomic and holistic factors.ObservationsTraditional surgical approaches carry significant considerations, including compulsory lifelong anticoagulation for patients who receive a mechanical aortic valve replacement (AVR) and the risk of structural valvular deterioration and need for subsequent valve intervention in those who receive a bioprosthetic AVR. These factors are magnified in young adults who are considering pregnancy, for whom issues of anticoagulation and valve longevity are heightened. The Ross procedure has emerged as a promising alternative; however, its adoption is limited to highly specialized centers. Valve repair is an option for selected patients with AR. These treatment options offer varying degrees of durability and are associated with different risks and complications, especially for younger adult patients. Patient-centered care from a multidisciplinary valve team allows for discussion of the optimal timing of intervention and the advantages and disadvantages of the various treatment options.Conclusions and RelevanceThe management of severe aortic valve disease in adults younger than 65 years is complex, and there are numerous considerations with each management decision. While mechanical AVR and bioprosthetic AVR have historically been the standards of care, other options are emerging for selected patients but are not yet generalizable beyond specialized surgical centers. A detailed discussion by members of the multidisciplinary heart team and the patient is an integral part of the shared decision-making process.
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Affiliation(s)
- Jayson R. Baman
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Ankit N. Medhekar
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - S. Chris Malaisrie
- Department of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Patrick McCarthy
- Department of Cardiac Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Charles J. Davidson
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Robert O. Bonow
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Editor, JAMA Cardiology
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Kittayarak C, Reifenberger M, Chan S, Keuffel EL. Reimbursement Savings Associated With Tissue Versus Mechanical Surgical Aortic Valve Replacement in Thailand. Value Health Reg Issues 2022; 32:23-30. [PMID: 35964437 DOI: 10.1016/j.vhri.2022.06.003] [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: 01/11/2022] [Revised: 05/06/2022] [Accepted: 06/09/2022] [Indexed: 10/15/2022]
Abstract
OBJECTIVES Surgical aortic valve replacement (SAVR) is an indicated treatment for severe aortic stenosis. Although mechanical valves are typically more durable, tissue SAVR valves do not require lifetime anticoagulation monitoring and may have lower rates of expensive sequelae. This economic evaluation estimates payer costs to the 3 largest Thai health insurance mechanisms for tissue versus mechanical SAVR. METHODS A deterministic and Monte Carlo simulation model based on literature and expert opinion estimated total payer costs for tissue and mechanical valves over a 25-year duration for 3 separate age cohorts (45, 55, and 65 years). Reimbursements levels for hospitalization services were from the Thai Diagnosis Related Groups. Separate models are generated for the 3 main Thai health insurance mechanisms. RESULTS The discounted expected 25-year reduction in payer savings associated with tissue SAVR are $2540, $2529, and $2311 per surgery for patients aged 45, 55, and 65 years, respectively, for the largest Thai insurer. Expected cost reductions associated with tissue SAVR are larger for each of the other schemes and generally decrease with patient age. Most savings accrue within 10 years of surgery. Reoperation costs are larger with tissue valves, but reductions in complications and anticoagulation monitoring more than offset these expenditures. Results are robust to multiple sensitivity and scenario analyses. CONCLUSIONS Coverage and reimbursement of tissue valves can financially benefit Thai insurers and reduce expenditures in the Thai health system compared with mechanical valves. As tissue valve technology evolves and reoperation rates decline, the financial benefit associated with tissue valves will increase.
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Affiliation(s)
- Chanapong Kittayarak
- Department of Cardiac Surgery, King Chulalongkorn Memorial Hospital, Chulalongkorn University, Bangkok, Thailand
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15
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Corona S, Manganiello S, Pepi M, Tamborini G, Muratori M, Ali SG, Capra N, Naliato M, Alamanni F, Zanobini M. Bioprosthetic aortic valve replacement in patients aged 50 years old and younger: Structural valve deterioration at long-term follow-up. Retrospective study. Ann Med Surg (Lond) 2022; 77:103624. [PMID: 35637981 PMCID: PMC9142659 DOI: 10.1016/j.amsu.2022.103624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 04/10/2022] [Accepted: 04/10/2022] [Indexed: 11/27/2022] Open
Abstract
Background Structural valve deterioration (SVD) remains the major determinant of bioprosthesis durability. The aim of this study was to investigate the SVD incidence, predictors and outcomes in patients aged 50 years and younger after bioprosthetic aortic valve replacement (bAVR). Methods We retrospectively analyzed 73 consecutive patients ≤50 years old who underwent bioprosthetic AVR at our center between 2005 and 2015. Median age at surgery was 44 (interquartile range [IQR]: 39-47) years. Follow-up was 93.2% complete at a median time of 7.2 (IQR: 5.5-9.5) years. Cumulative follow-up was 545.5 valve-years. Bioprosthesis SVD was determined by strict echocardiographic assessment. Results The overall survival-rate at 10/15 years and freedom from SVD at 10/12.5 years were 89.6 ± 5.2%/81.5 ± 9.1% and 73.5 ± 8.2%/41.9 ± 18.9%, respectively. SVD occurred at a median time of 8.2 (IQR: 6.0-9.9) years after bAVR. Age was not found as an independent predictor for SVD at the multivariable model, despite a higher rate of SVD in the age group ≤30 years. Freedom from reoperation due to SVD at 10/15 years was 71.3 ± 14.1%/13.6 ± 12.3%. Reoperation was performed at a median time of 10.0 (IQR: 8.9-11.9) years since first bAVR and was associated with a 100% 12-month survival. Conclusions In our study, the rate and time of SVD occurrence were comparable to those of other studies' older age groups. Strict echocardiographic monitoring of valve performance is mandatory to set the appropriate timing of eventual reoperation. This attitude can improve outcomes of bAVR in younger patients.
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Key Words
- AVR, Aortic Valve Replacement
- Aortic valve replacement
- Bioprosthesis
- EF, Ejection Fraction
- LV, Left Ventricle
- NYHA, New York Heart Association
- PASP, Pulmonary Artery Systolic Pressure
- PPM, Prosthesis-Patient Mismatch
- Reoperation
- SVD, Structural Valve Deterioration
- Structural valve deterioration
- TAVR, Transcatheter Aortic Valve Replacement
- TTE, Transthoracic Echocardiography
- bAVR, bioprosthetic Aortic Valve Replacement
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Affiliation(s)
- Silvia Corona
- Department of Cardiac Surgery, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Sabrina Manganiello
- Department of Cardiac Surgery, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Mauro Pepi
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Gloria Tamborini
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Manuela Muratori
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Sarah Ghulam Ali
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Nicolò Capra
- Department of Biostatistics, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Moreno Naliato
- Department of Cardiac Surgery, Centro Cardiologico Monzino, IRCCS, Milan, Italy
| | - Francesco Alamanni
- Department of Cardiac Surgery, Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Marco Zanobini
- Department of Cardiac Surgery, Centro Cardiologico Monzino, IRCCS, Milan, Italy
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16
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Mazine A, David TE, Stoklosa K, Chung J, Lafreniere-Roula M, Ouzounian M. Improved Outcomes Following the Ross Procedure Compared With Bioprosthetic Aortic Valve Replacement. J Am Coll Cardiol 2022; 79:993-1005. [PMID: 35272805 DOI: 10.1016/j.jacc.2021.12.026] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Revised: 11/15/2021] [Accepted: 12/08/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND The ideal aortic valve substitute for young and middle-aged adults remains elusive. OBJECTIVES This study sought to compare the long-term outcomes of patients undergoing the Ross procedure and those receiving bioprosthetic aortic valve replacements (AVRs). METHODS Consecutive patients aged 16-60 years who underwent a Ross procedure or surgical bioprosthetic AVR at the Toronto General Hospital between 1990 and 2014 were identified. Propensity score matching was used to account for differences in baseline characteristics. The primary outcome was all-cause mortality. Secondary outcomes included valve reintervention, valve deterioration, endocarditis, thromboembolic events, and permanent pacemaker implantation. RESULTS Propensity score matching yielded 108 pairs of patients. The median age was 41 years (IQR: 34-47 years). Baseline characteristics were similar between the matched groups. There was no operative mortality in either group. Mean follow-up was 14.5 ± 7.2 years. All-cause mortality was lower following the Ross procedure (HR: 0.35; 95% CI: 0.14-0.90; P = 0.028). Using death as a competing risk, the Ross procedure was associated with lower rates of reintervention (HR: 0.21; 95% CI: 0.10-0.41; P < 0.001), valve deterioration (HR: 0.25; 95% CI: 0.14-0.45; P < 0.001), thromboembolic events (HR: 0.15; 95% CI: 0.05-0.50; P = 0.002), and permanent pacemaker implantation (HR: 0.22; 95% CI: 0.07-0.64; P = 0.006). CONCLUSIONS In this propensity-matched study, the Ross procedure was associated with better long-term survival and freedom from adverse valve-related events compared with bioprosthetic AVR. In specialized centers with sufficient expertise, the Ross procedure should be considered the primary option for young and middle-aged adults undergoing AVR.
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Affiliation(s)
- Amine Mazine
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Tirone E David
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Klaudiusz Stoklosa
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Chung
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Myriam Lafreniere-Roula
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada.
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Tanaka D, Mazine A, Ouzounian M, El-Hamamsy I. Supporting the Ross procedure: preserving root physiology while mitigating autograft dilatation. Curr Opin Cardiol 2022; 37:180-190. [PMID: 35081548 DOI: 10.1097/hco.0000000000000949] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this article is to describe the optimized approach to nonrepairable aortic valve disease in young adults with a Ross procedure, while preserving the dynamic physiology of the aortic root. RECENT FINDINGS As the techniques for supporting pulmonary autografts continue to be refined, and the applicability of the Ross procedure continues to expand, an assessment of the various techniques based on aortic root physiology is warranted. Semi-resorbable scaffolds show promise in ovine models for improving the Ross procedure. Recent long-term outcomes for the Dacron inclusion technique in comparison to more physiologic methods of support emphasize the importance of balancing the prevention of early dilatation with the preservation of root haemodynamics. As this review will synthesize, the dynamic physiology of the root may be preserved even in patients at a higher risk of autograft dilatation. SUMMARY The favourable long-term outcomes of the Ross procedure can be partly attributed to the ability of the autograft to restore dynamism to the neoaortic root. Patient-specific modifications that respect root physiology can tailor the Ross procedure to address each patient's risk factors for early dilatation and late failure. As such, the Ross procedure should be recognized as an increasingly favourable solution for a wide spectrum of nonpreservable aortic valve disease in young adults.
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Affiliation(s)
| | | | - Maral Ouzounian
- Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6564539. [DOI: 10.1093/ejcts/ezac193] [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: 09/30/2021] [Revised: 02/16/2022] [Accepted: 03/15/2022] [Indexed: 11/12/2022] Open
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Piperata A, Fiocco A, Cavicchiolo A, Ponzoni M, Pesce R, Gemelli M, Evangelista G, Gastino E, Michelotti S, Mazzaro E, Garufi L, DePaulis R, Zanella L, Nadali M, Mangino D, Lorenzoni G, Gregori D, Jorgji V, Gerosa G, Bottio T. Carpentier-Edwards Magna Ease bioprosthesis: a multicentre clinical experience and 12-year durability. Eur J Cardiothorac Surg 2021; 61:888-896. [PMID: 34962258 DOI: 10.1093/ejcts/ezab552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 10/19/2021] [Accepted: 11/01/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The goal of this multicentre retrospective study was to compare long-term clinical and haemodynamic outcomes of the Carpentier-Edwards Magna Ease (CEME) bioprosthesis by patient age. METHODS We included consecutive patients who underwent isolated and combined surgical aortic valve replacement (AVR) with CEME valve between January 2008 and March 2020 at 4 cardiac surgery centres in Italy. Survival distribution was evaluated at follow-up according to age and surgery type (combined or isolated AVR), together with freedom from structural valve deterioration (SVD), reoperation and combined events, i.e. SVD, reoperation, endocarditis and thromboembolic events. RESULTS A total of 1027 isolated and 1121 combined AVR were included; 776 patients were younger than 65 years whereas 1372 were 65 years or older. The 30-day Valve-Academic-Research-Consortium mortality was 2% (<65 years) and 6% (≥ 65 years) (P < 0.001), whereas it was 3% for isolated AVR and 7% for combined AVR (P < 0.001). The 12-year survival was 81% for those younger than 65 years vs 45% for those equal to or older than 65 years (P < 0.001), whereas they were 61% vs 49% for isolated and combined AVR (P = 0.10). The 12-year freedom from combined events, excluding death, was 79% for those younger than 65 years vs 87% for those equal to or older than (P = 0.51), whereas they were 83% for isolated and 86% for combined AVR (P = 0.10). The 12-year freedom from SVD was 93% and 93% in patients younger than 65 and those equal to or older than 65 years (P = 0.63), and the results were comparable even in cases with isolated and combined AVR (92% vs 94%, P = 0.21). A multivariable Cox analysis including gender, presence of patient-prosthesis mismatch, isolated AVR and age showed that only the age was an independent risk factor for the incidence of SVD (P = 0.029). CONCLUSIONS Outcomes from this large multicentre analysis demonstrated that a CEME bioprosthesis provides good clinical results and long-term durability even in patients younger than 65 years. Furthermore, the hazard for SVD has been shown to be lower for older age. CLINICAL TRIAL REGISTRATION NUMBER 105n/AO/21.
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Affiliation(s)
- Antonio Piperata
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Alessandro Fiocco
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Andrea Cavicchiolo
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Matteo Ponzoni
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Rita Pesce
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Marco Gemelli
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Giuseppe Evangelista
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Elisa Gastino
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Sara Michelotti
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Enzo Mazzaro
- Cardiac Surgery Unit, Azienda Integrata Isontina, Trieste Hospital, Trieste, Italy
| | - Luigi Garufi
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Ruggero DePaulis
- Cardiac Surgery Unit, European Hospital, Unicamillus, International Medical University, Rome, Italy
| | - Luca Zanella
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Matteo Nadali
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | | | - Giulia Lorenzoni
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Dario Gregori
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Vjola Jorgji
- Hacohen Lab, Massachusetts General Hospital, Boston, MA, USA
| | - Gino Gerosa
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
| | - Tomaso Bottio
- Department of Cardiac-Thoracic-Vascular Sciences and Public Health, University of Padua, Padova, Italy
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20
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Johnston DR, Griffith BP, Puskas JD, Bavaria JE, Svensson LG, Blackstone EH, Gammie JS, Heimansohn DA, Sadowski J, Bartus K, Rozanski J, Bilewskai A, Rosengart T, Girardi LN, Klodell CT, Mumtaz MA, Takayama H, Halkos M, Starnes V, Boateng P, Timek TA, Ryan W, Omer S, Smith CR. Intermediate-term outcomes of aortic valve replacement using a bioprosthesis with a novel tissue. J Thorac Cardiovasc Surg 2021; 162:1478-1485. [DOI: 10.1016/j.jtcvs.2020.01.095] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 12/30/2019] [Accepted: 01/17/2020] [Indexed: 01/28/2023]
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21
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Okutucu S, Niazi AK, Oliveira D, Fatihoglu SG, Oto A. A systematic review on durability and structural valve deterioration in TAVR and surgical AVR. Acta Cardiol 2021; 76:921-932. [PMID: 33302806 DOI: 10.1080/00015385.2020.1858250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Mechanical valves and bioprosthetic heart valves are widely used for aortic valve replacement (AVR). Mechanical valves are associated with risk of bleeding because of oral anticoagulation, while the durability and structural valve deterioration (SVD) represent the main limitation of the bioprosthetic heart valves. The implantation of bioprosthetic heart valves is increasing precipitously due aging population, and the widespread use of transcatheter aortic valve replacement (TAVR). TAVR has become the standard treatment for intermediate or high surgical risk patients and a reasonable alternative to surgery for low risk patients with symptomatic severe aortic stenosis. Moreover, TAVR is increasingly being used for younger and lower-risk patients with longer life expectancy; therefore it is important to ensure the valve durability for long-term transcatheter aortic valves. Although the results of mid-term durability of the transcatheter heart valves are encouraging, their long-term durability remains largely unknown. This review summarises the definitions, mechanisms, risk factors and assessment of SVD; overviews available data on surgical bioprosthetic and transcatheter heart valves durability.
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Affiliation(s)
- Sercan Okutucu
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
| | - Attaullah Khan Niazi
- Department of Cardiovascular Surgery, Shalamar Medical & Dental College, Lahore, Pakistan
| | - Dinaldo Oliveira
- Department of Cardiology, Federal University of Pernambuco, Recife, Brazil
| | | | - Ali Oto
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
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22
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Van Hoof L, Rega F, Golesworthy T, Verbrugghe P, Austin C, Takkenberg JJM, Pepper JR, Treasure T. Personalised external aortic root support for elective treatment of aortic root dilation in 200 patients. Heart 2021; 107:1790-1795. [PMID: 34326135 DOI: 10.1136/heartjnl-2021-319300] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/05/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In personalised external aortic root support (PEARS), a custom-made, macroporous mesh is used to stabilise a dilated aortic root and prevent dissection, primarily in patients with genetically driven aortopathies. Data are needed on the safety and postoperative incidence of aortic events. METHODS We present a multicentre cohort study evaluating the first 200 consecutive patients (median age 33 years) undergoing surgery with an intention to perform PEARS for aortic root dilatation in 23 centres between 2004 and 2019. Perioperative outcomes were collected prospectively while clinical follow-up was retrieved retrospectively. Median follow-up was 21.2 months. RESULTS The main indication was Marfan syndrome (73.5%) and the most frequent concomitant procedure was mitral valve repair (10%). An intervention for myocardial ischaemia or coronary injury was needed in 11 patients, 1 case resulting in perioperative death. No ascending aortic dissections were observed in 596 documented postoperative patient years. Late reoperation was performed in 3 patients for operator failure to achieve complete mesh coverage. Among patients with at least mild aortic regurgitation (AR) preoperatively, 68% had no or trivial AR at follow-up. CONCLUSIONS This study represents the clinical history of the first 200 patients to undergo PEARS. To date, aortic dissection has not been observed in the restrained part of the aorta, yet long-term follow-up is needed to confirm the potential of PEARS to prevent dissection. While operative mortality is low, the reported coronary complications reflect the learning curve of aortic root surgery in patients with connective tissue disease. PEARS may stabilise or reduce aortic regurgitation.
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Affiliation(s)
- Lucas Van Hoof
- Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Filip Rega
- Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Conal Austin
- Department of Paediatric Cardiology and Cardiothoracic Surgery, St Thomas' Hospital, London, UK
| | - Johanna J M Takkenberg
- Department of Cardio-Thoracic Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - John R Pepper
- Cardiothoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Tom Treasure
- Clinical Operational Research Unit, University College London, London, UK
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23
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Ohri S, Luthra S. 50 th anniversary of Ionescu's pericardial heart valve concept. THE BRITISH JOURNAL OF CARDIOLOGY 2021; 28:28. [PMID: 35747704 PMCID: PMC8988801 DOI: 10.5837/bjc.2021.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
| | - Suvitesh Luthra
- Locum Cardiac Surgeon University Hospital Southampton, Tremona Road, Southampton, SO16 6YD
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24
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Mitrev Z, Risteski P, Todorovska M, Pavlovik M, Sá MPBO, Rosalia R. Aortic valve neocuspidisation using xenologous pericardium versus bioprosthetic valve replacement. Ann Thorac Surg 2021; 113:1192-1199. [PMID: 34048758 DOI: 10.1016/j.athoracsur.2021.04.099] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Revised: 04/25/2021] [Accepted: 04/30/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Surgical aortic valve replacement (SAVR) for aortic valve stenosis (AS) patients with small aortic root is associated with a higher rate of prosthesis-patient mismatch and suboptimal clinical outcomes. Aortic valve neocuspidisation using xenologous pericardium (xAVNeo) has shown favorable hemodynamic performance. The aim was to compare 6-year clinical outcomes of xAVNeo with SAVR. METHODS Between 2003-2018, 412 patients with severe AS and small aortic root received either xAVNeo (N=114) or bioprosthesis (N=298). After propensity matching, the cohort included 222 patients. The primary endpoints were early-, 6-year mortality and freedom from reoperation. Mean follow-up averaged 3.4±3.1 years and was 95% complete. RESULTS Early mortality was 8.1% for the SAVR group vs 9.9% for the xAVNeo group, OR 1.25 [CI95% 0.51-2.89]. The estimated survival probabilities at 6 years for the SAVR and xAVNeo cohorts were 89.9% and 88.8%, respectively, OR 1.07 [0.49-2.34]. Progressive degeneration of the neo-cusps resulted in mean gradients increase from 6.1±2.3 mmHg to 22.7±11.5 mmHg ( p<0.0001 ); cusp sclerosis was the most common indication for reoperation in the xAVNeo group with a linearised rate of 1.92% vs. 0.26% per patient-year, rate ratio = 7.41 [CI95% 0.95-333.7]. The freedom from reoperation was 84.8% at 6 years, inferior to that of the SAVR group (100%). CONCLUSIONS Early clinical outcome and 6-year survival following xAVNeo and SAVR was comparable. However, xAVNeo using bovine pericardium was associated with a higher rate of structural valve deterioration and inferior freedom from reoperation when compared to SAVR.
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Affiliation(s)
- Zan Mitrev
- Department of Cardiovascular Surgery, Zan Mitrev Clinic, Skopje, Republic of North Macedonia
| | - Petar Risteski
- Department of Cardiovascular Surgery, Zan Mitrev Clinic, Skopje, Republic of North Macedonia; Department of Thoracic and Cardiovascular Surgery, University Hospital Tuebingen, Tübingen, Germany.
| | - Marija Todorovska
- Department of Cardiovascular Surgery, Zan Mitrev Clinic, Skopje, Republic of North Macedonia
| | - Monika Pavlovik
- Department of Cardiovascular Surgery, Zan Mitrev Clinic, Skopje, Republic of North Macedonia
| | - Michel Pompeu B O Sá
- Division of Cardiovascular Surgery, Pronto Socorro Cardiológico de Pernambuco - PROCAPE, Recife, Brazil; University of Pernambuco - UPE, Recife, Brazil
| | - Rodney Rosalia
- Department of Cardiovascular Surgery, Zan Mitrev Clinic, Skopje, Republic of North Macedonia
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25
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2020 ACC/AHA guideline for the management of patients with valvular heart disease: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Thorac Cardiovasc Surg 2021; 162:e183-e353. [PMID: 33972115 DOI: 10.1016/j.jtcvs.2021.04.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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26
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The First 100 Cases of Two Innovations Combined: Video-Assisted Minimally Invasive Aortic Valve Replacement Through Right Anterior Mini-Thoracotomy Using a Novel Aortic Prosthesis. Adv Ther 2021; 38:2435-2446. [PMID: 33788152 PMCID: PMC8010499 DOI: 10.1007/s12325-021-01705-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 03/10/2021] [Indexed: 11/25/2022]
Abstract
Introduction Aortic valve replacement (AVR) via right anterior mini-thoracotomy (RAMT) is less traumatic than via other surgical routes; using a novel aortic valve may confer long-term resistance against valve deterioration, and thus be useful in younger, more active patients. Here we aim to validate using the INSPIRIS RESILIA valve with minimally invasive RAMT. Methods Between April 2017 and June 2019, 100 patients underwent video-assisted minimally invasive AVR by RAMT, using the INSPIRIS RESILIA aortic valve. Cannulation for cardiopulmonary bypass (CPB) was through femoral vessels. Clinical data were prospectively entered into our institutional database. Results Cardiopulmonary bypass (CPB) and cross-clamping times were 79 ± 38 and 41 ± 17 min. Surgical access was successful in 100% of cases. There were no cases of intraoperative mortality, 30-day mortality, cerebrovascular events, rethoracotomy for bleeding, valve-related reoperation, right internal mammary artery injury, or conversion to sternotomy. Intensive care and hospital stays were 2 ± 1 and 6 ± 3 days, respectively. One patient had a pacemaker fitted. Postoperative dialysis was necessary in one patient. Trace to mild aortic valve regurgitation occurred in two patients. No structural valve deterioration (SVD) and paravalvular leak were seen. At 1-year follow-up mean effective orifice area (EOA) was 1.8 ± 0.1 cm2, peak gradient was 22.1 ± 3.1 mmHg, and mean gradient was 11.5 ± 2.3 mmHg. Conclusion Our preliminary experience suggests that RAMT for AVR using the INSPIRIS RESILIA aortic valve is safe, effective, and reproducible. Larger studies are needed to evaluate the long-term efficacy and durability of this new valve.
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Abstract
Aortic stenosis is the most common valvular disease requiring valve replacement. Valve replacement therapies have undergone progressive evolution since the 1960s. Over the last 20 years, transcatheter aortic valve replacement has radically transformed the care of aortic stenosis, such that it is now the treatment of choice for many, particularly elderly, patients. This review provides an overview of the pathophysiology, presentation, diagnosis, indications for intervention, and current therapeutic options for aortic stenosis.
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Affiliation(s)
- Marko T Boskovski
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Thomas G Gleason
- Division of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
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28
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2021; 143:e72-e227. [PMID: 33332150 DOI: 10.1161/cir.0000000000000923] [Citation(s) in RCA: 517] [Impact Index Per Article: 172.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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29
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Otto CM, Nishimura RA, Bonow RO, Carabello BA, Erwin JP, Gentile F, Jneid H, Krieger EV, Mack M, McLeod C, O'Gara PT, Rigolin VH, Sundt TM, Thompson A, Toly C. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 77:e25-e197. [PMID: 33342586 DOI: 10.1016/j.jacc.2020.11.018] [Citation(s) in RCA: 716] [Impact Index Per Article: 238.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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30
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Nguyen TC, Walker T, Gunnarsson C, Moore M, Keuffel EL. Long-term Healthcare Expenditures Over Time for Tissue and Mechanical Aortic Valve Replacement. Ann Thorac Surg 2020; 112:526-531. [PMID: 33144108 DOI: 10.1016/j.athoracsur.2020.07.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 06/07/2020] [Accepted: 07/30/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Guidelines currently indicate the use of surgical aortic valve replacement (SAVR) to treat severe cases of aortic stenosis, particularly for low- to medium-risk patients. Although several studies have compared health outcomes of tissue and mechanical SAVR, this economic simulation model estimates the difference in long-term healthcare costs associated with tissue relative to mechanical SAVR. METHODS The deterministic and Monte Carlo simulation models used literature-based epidemiologic and cost inputs to calculate annual expenditures related to SAVR for up to 25 years after initial surgery. A series of 3 cohort studies across different age groups provided the health outcome probabilities for tissue valve patients. Outcome probabilities for mechanical valve patients were based on relative risks reported in comparative meta-analyses or large cohort studies. RESULTS Relative to mechanical SAVR the expected net discounted savings for a patient receiving tissue SAVR at ages 45, 55, and 65 years were $12,266, $15,462, and $16,008, respectively (based on 2018 US dollars) over a 25-year horizon (95% confidence intervals exceed $0). For a 45-year-old tissue SAVR patient, the estimated per-patient cost difference (relative to mechanical SAVR) of reoperation over 25 years ($16,201) were offset by expected savings on anticoagulation monitoring ($26,257) over the same period. In a sensitivity analysis in which mortality risk was assumed equal, significant long-term savings associated with tissue SAVR still accrued in each of the 3 age cohorts. CONCLUSIONS Payers, providers, and the healthcare system may financially benefit from the use of tissue valves because significant savings were associated with the use of tissue valves relative to mechanical valves for SAVR.
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Affiliation(s)
- Tom C Nguyen
- Memorial Hermann Medical Center, University of Texas, Houston, Texas.
| | | | | | - Matt Moore
- Edwards Lifesciences, Irvine, California
| | - Eric L Keuffel
- Health Finance & Access Initiative, Bryn Mawr, Pennsylvania
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31
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Nappi F, Avtaar Singh SS, Timofeeva I. Learning From Controversy: Contemporary Surgical Management of Aortic Valve Endocarditis. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820960729. [PMID: 33088184 PMCID: PMC7545763 DOI: 10.1177/1179546820960729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 08/30/2020] [Indexed: 12/27/2022]
Abstract
Aortic valve replacement is the commonest cardiac surgical operation performed worldwide for infective endocarditis (IE). Long-term durability and avoidance of infection relapse are goals of the procedure. However, no detailed guidelines on prosthesis selection and surgical strategies guided by the comprehensive evaluation of the extension of the infection and its microbiological characteristics, clinical profile of the patient, and risk of infection recurrence are currently available. Conventional mechanical or stented xenografts are the preferred choice for localized aortic infection. However, in cases of complex IE with the involvement of the root or the aortomitral continuity, the use of homograft is suggested according to the surgeon and center experience. Homograft use should be counterbalanced against the risk of structural degeneration. Prosthetic bioroot or prosthetic valved conduit (mechanical and bioprosthetic) are also potentially suitable alternatives. Further development of preservation techniques enabling longer durability of allogenic substitutes is required. We evaluate the current evidence for the use of valve substitutes in aortic valve endocarditis and propose an evidence-based algorithm to guide the choice of therapy. We performed a systemic review to clarify the contemporary surgical management of aortic valve endocarditis.
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Affiliation(s)
- Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord de Saint-Denis, Paris, France
| | - Sanjeet Singh Avtaar Singh
- Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Irina Timofeeva
- Department of Imaging, Centre Cardiologique du Nord de Saint-Denis, Paris, France
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32
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Percy ED, Harloff M, Hirji S, Malarczyk A, Cherkasky O, Yazdchi F, McGurk S, Shekar P, Kaneko T. Subclinical Structural Valve Degeneration in Young Patients With Bioprosthetic Aortic Valves. Ann Thorac Surg 2020; 111:1486-1493. [PMID: 32979371 DOI: 10.1016/j.athoracsur.2020.07.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 06/21/2020] [Accepted: 07/10/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Bioprosthetic structural valve degeneration (SVD) has previously been a clinical diagnosis, but subclinical changes have been increasingly recognized in transcatheter valves. The significance of subclinical SVD after surgical aortic valve replacement (SAVR), however, is not well understood. The purpose of this study was to characterize the incidence and outcomes of subclinical SVD in young patients after SAVR. METHODS Patients aged ≤65 years who underwent bioprosthetic SAVR between January 2002 and June 2018 at a single institution were included. Endocarditis cases and those with in-hospital mortality were excluded. All available longitudinal postoperative echocardiograms were reviewed. Subclinical SVD was defined as an increase in mean transvalvular gradient of at least 10 mm Hg and/or new onset of mild intraprosthetic regurgitation or increase by at least 1 grade, compared with baseline postoperative echocardiogram. RESULTS Overall, 822 unique SAVR cases were included. Over the study period, 356 (43.3%) patients developed subclinical SVD. Only 21.5% of those with subclinical SVD progressed to clinical SVD or to repeat aortic valve procedures. In those with progression, the first signs of SVD occurred significantly earlier than in those whose changes remained stable (11 months vs 23 months; P = .036). Anticoagulation did not impact the development or progression of subclinical SVD. There was no difference in long-term survival for those who did or did not develop subclinical SVD. CONCLUSIONS Subclinical SVD occurred in a large proportion of young patients undergoing bioprosthetic SAVR. Despite its high prevalence, subclinical SVD was not associated with decreased survival or repeat procedures.
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Affiliation(s)
- Edward D Percy
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Morgan Harloff
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alexandra Malarczyk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Olena Cherkasky
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Farhang Yazdchi
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Siobhan McGurk
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Prem Shekar
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Tsuyoshi Kaneko
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
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33
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Trifecta Versus Perimount Magna Ease Aortic Valve Prostheses. Ann Thorac Surg 2020; 110:879-888. [DOI: 10.1016/j.athoracsur.2019.12.071] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 12/10/2019] [Accepted: 12/23/2019] [Indexed: 12/13/2022]
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Jawad K, Lehmann S, Koziarz A, Dieterlen M, Feder S, Misfeld M, Garbade J, Rao V, Borger M. Midterm results after St Jude Medical Epic porcine xenograft for aortic, mitral, and double valve replacement. J Card Surg 2020; 35:1769-1777. [PMID: 32598528 DOI: 10.1111/jocs.14554] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The aim of this study was to evaluate the results after stented porcine xenograft implantation (Epic, SJM, St Paul, MN) with Linx anticalcification treatment in elderly patients at our high-volume tertiary care center. METHODS A total of 3825 patients undergoing aortic (AVR = 2441), mitral (MVR = 892), or double valve (DVR = 492) replacement between 11/2001 and 12/2017 with Epic xenografts were evaluated. Outcomes were assessed by reviewing the prospectively acquired hospital database results, and regular annual follow-up information was acquired from questionnaires or telephone interviews. RESULTS For patients undergoing AVR, MVR, DVR, age at surgery were 76.4 ± 6, 71.2 ± 9, 72.9 ± 8 years; active endocarditis was an indication for valve surgery in 4.5%, 20.7%, 19.7%; and the predicted median (interquartile range [IQR]) mortality risk (EuroSCORE II) was 5.2% (3.1%-9.4%), 7.5% (3.9%-16.2%), 9.9% (6.0%-19.6%), respectively. Median follow-up was 3.04 (IQR: 0.18-5.21). Thirty-day survival was 91.2% ± 0.6%, 87.6% ± 0.1.1%, 84.7% ± 1.6%; and 10-year survival was 56.7% ± 1.0%, 59.4% ± 2.5%, 50.45% ± 3.1%, respectively. Patients who underwent MVR versus AVR were at significant increased risk for reoperation for endocarditis (adjusted odds ratio; 2.2, 95% confidence interval; 1.29-3.7; P = .003). There was no significant difference in all-cause mortality at midterm in AVR vs MVR in the matched cohort (P = .85). CONCLUSIONS Implantation of the Epic stented porcine xenograft is associated with acceptable survival and freedom from valve-related complications or reoperation due to structural valve disease at midterm follow-up.
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Affiliation(s)
- Khalil Jawad
- Department of Cardiac Surgery, Heart Center, Leipzig University, Leipzig, Germany.,Department of Cardiac Surgery, Peter Munk Cardiac Center, Toronto, Canada
| | - Sven Lehmann
- Department of Cardiac Surgery, Heart Center, Leipzig University, Leipzig, Germany
| | | | - Maja Dieterlen
- Department of Cardiac Surgery, Heart Center, Leipzig University, Leipzig, Germany
| | - Stefan Feder
- Department of Cardiac Surgery, Heart Center, Leipzig University, Leipzig, Germany
| | - Martin Misfeld
- Department of Cardiac Surgery, Heart Center, Leipzig University, Leipzig, Germany
| | - Jens Garbade
- Department of Cardiac Surgery, Heart Center, Leipzig University, Leipzig, Germany
| | - Vivek Rao
- Department of Cardiac Surgery, Peter Munk Cardiac Center, Toronto, Canada
| | - Michael Borger
- Department of Cardiac Surgery, Heart Center, Leipzig University, Leipzig, Germany
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Bruno AG, Santona L, Palmerini T, Taglieri N, Marrozzini C, Ghetti G, Orzalkiewicz M, Galiè N, Saia F. Predicting and improving outcomes of transcatheter aortic valve replacement in older adults and the elderly. Expert Rev Cardiovasc Ther 2020; 18:663-680. [DOI: 10.1080/14779072.2020.1778465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Antonio Giulio Bruno
- Cardiology Unit, Cardio-Thorax-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Laura Santona
- Cardiology Unit, Cardio-Thorax-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Tullio Palmerini
- Cardiology Unit, Cardio-Thorax-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Nevio Taglieri
- Cardiology Unit, Cardio-Thorax-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Cinzia Marrozzini
- Cardiology Unit, Cardio-Thorax-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Gabriele Ghetti
- Cardiology Unit, Cardio-Thorax-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Mateusz Orzalkiewicz
- Cardiology Unit, Cardio-Thorax-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Nazzareno Galiè
- Cardiology Unit, Cardio-Thorax-Vascular Department, University Hospital of Bologna, Bologna, Italy
| | - Francesco Saia
- Cardiology Unit, Cardio-Thorax-Vascular Department, University Hospital of Bologna, Bologna, Italy
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Yamauchi T, Takano H, Miyata H, Motomura N, Takamoto S. Risk Factors for Mortality and Morbidity of Surgical Aortic Valve Replacement for Aortic Stenosis - Risk Model From a Japan Cardiovascular Surgery Database. Circ Rep 2020; 1:131-136. [PMID: 33693127 PMCID: PMC7890290 DOI: 10.1253/circrep.cr-19-0010] [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] [Indexed: 11/13/2022] Open
Abstract
Background:
The aim of this study was to determine adequate indication for transcatheter aortic valve replacement (TAVR). We analyzed risk factors of surgical aortic valve replacement (SAVR) not only for mortality, but also for morbidity, including long hospital stay (≥90 days) and patient activity at discharge, in patients who underwent SAVR for aortic stenosis (AS). Methods and Results:
Using the Japan Adult Cardiovascular Surgery Database (JCVSD), 13,961 patients with or without coronary artery bypass grafting who underwent elective SAVR for AS were identified from January 2008 to December 2012. The hospital mortality rate was 3.1%. The percentage of patients who had long hospital stay (≥90 days) and who had moderately or severely decompressed activity at discharge (modified Rankin scale ≥4) was 2.9% and 6.5%, respectively. Eleven and 20 preoperative predictors of hospital mortality and morbidity, respectively, including long hospital stay and compromised status at discharge, were identified. Based on these risk factors, the risk model predicted hospital mortality (area under the curve [AUC], 0.732) and morbidity (AUC, 0.694). Conclusions:
Using JCVSD, a risk model of SAVR was developed for AS. This model can identify patients at high risk not only for mortality, but also for mortality and morbidity, including long hospital stay and status at discharge.
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Affiliation(s)
- Takashi Yamauchi
- Department of Cardiovascular Surgery, Dokkyo Medical University Saitama Medical Center Koshigaya Japan
| | - Hiroshi Takano
- Department of Cardiovascular Surgery, Dokkyo Medical University Saitama Medical Center Koshigaya Japan
| | - Hiroaki Miyata
- Department of Healthcare Quality Assessment, The University of Tokyo Tokyo Japan
| | - Noboru Motomura
- Department of Cardiovascular Surgery, Toho University, Sakura Medical Center Sakura Japan
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Abstract
Introduction: Valve durability represents a main concern, as the target population for transcatheter aortic valve implantation (TAVI) evolves to include lower risk and younger patients who are likely to survive for a number of years after the procedure.Areas covered: The purpose of this review article is to provide an overview of potential mechanisms and rates of structural valve deterioration (SVD) of transcatheter bioprostheses.Expert opinion: Recently the standardized definitions of SVD proposed by European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) have permitted for the first time, an objective evaluation of existing and novel TAVI prostheses, and to compare their longevity versus surgical bioprostheses. Although the results of midterm durability of the transcatheter bioprostheses are encouraging, our knowledge concerning the clinical outcomes of TAVI beyond 5 years is still limited. Evidence of longer-term durability is mandatory before replacing surgery with TAVI, particularly in younger and lower-risk patients.
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Affiliation(s)
- Anna Sonia Petronio
- Cardio Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
| | - Cristina Giannini
- Cardio Thoracic and Vascular Department, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy
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Bidar E, Folliguet T, Kluin J, Muneretto C, Parolari A, Barili F, Suwalski P, Bonaros N, Punjabi P, Sadaba R, De Bonis M, Al-Attar N, Obadia JF, Czerny M, Shrestha M, Zegdi R, Natour E, Lorusso R. Postimplant biological aortic prosthesis degeneration: challenges in transcatheter valve implants. Eur J Cardiothorac Surg 2019; 55:191-200. [PMID: 30541101 DOI: 10.1093/ejcts/ezy391] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 10/15/2018] [Indexed: 12/29/2022] Open
Abstract
Surgical aortic valve replacement (SAVR) is highly effective and can be achieved with relatively low risk in patients with severe aortic stenosis. Bioprostheses have been used most frequently during the past 60 years. However, the function of biological valves usually declines after 10-15 years from implant when structural valve degeneration occurs often mandating a reoperation once valve dysfunction becomes haemodynamically significant. Known for many years by surgeons and cardiologists taking care of patients with SAVR, the issue of postimplant structural valve degeneration has been recently highlighted also in patients with transcatheter aortic valve implant (TAVI). There is growing concern that TAVI valves exhibit structural valve degeneration due to inherent challenges of the deployment mode. The impact on postimplant degeneration of TAVI valves compared to SAVR has still to be understood and defined. Based on the ongoing process of expanding TAVI indications, several potential shortcomings and caveats, learned during the last 60 years of SAVR experience, should be taken into consideration to refine this technique.
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Affiliation(s)
- Elham Bidar
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Thierry Folliguet
- Centre Hospitalo-Universitaire Brabois ILCV, Hôpital Henri Mondor, Division of Cardio Thoracic Surgery and Transplantation, Université Paris 12 UPEC, France
| | - Jolanda Kluin
- Department of Cardio-Thoracic Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Claudio Muneretto
- Cardiac Surgery Unit, University of Brescia Medical School, Brescia, Italy
| | - Alessandro Parolari
- Cardiac Surgery and Translational Research Units, IRCCS, Policlinico S. Donato, University of Milan, Milan, Italy
| | - Fabio Barili
- Department of Cardiac Surgery, S. Croce Hospital, Cuneo, Italy
| | - Piotr Suwalski
- Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Nikolaos Bonaros
- Department of Cardiac Surgery, Innsbruck Medical University, Innsbruck, Austria
| | - Prakash Punjabi
- Department of Cardio-Thoracic Surgery, Imperial College Healthcare NHS Trust, Imperial College School of Medicine, London, UK
| | - Rafa Sadaba
- Department of Cardiac Surgery, Hospital de Navarra, Pamplona, Spain
| | - Michele De Bonis
- Department of Cardiac Surgery, S. Raffaele University Hospital, Milan, Italy
| | - Nawwar Al-Attar
- Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, UK
| | - Jean Francois Obadia
- Department of Cardio-Thoracic Surgery, Hôpital Cardiothoracique Louis Pradel, Lyon, France
| | - Martin Czerny
- Department of Cardio-Vascular Surgery, University Hospital Freiburg, Freiburg, Germany
| | - Malakh Shrestha
- Department of Cardio-Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Rachid Zegdi
- Hôpital Européen Georges Pompidou, Paris, France
| | - Ehsan Natour
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
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Chivers SC, Pavy C, Vaja R, Quarto C, Ghez O, Daubeney PEF. The Ozaki Procedure With CardioCel Patch for Children and Young Adults With Aortic Valve Disease: Preliminary Experience – a Word of Caution. World J Pediatr Congenit Heart Surg 2019; 10:724-730. [DOI: 10.1177/2150135119878108] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Background: The Ozaki procedure is a surgical technique for patients with significant aortic stenosis or regurgitation or both where valve repair cannot be performed. Individual cusps are cut from glutaraldehyde-treated autologous pericardium or bovine pericardium and implanted into the aortic valve position. Encouraging results have been reported within the adult population. There are limited published data on success of this procedure in younger patients. Methods: We present a series of five children and young adults who underwent the Ozaki procedure with neoaortic valve cusps made from CardioCel, a decellularized bovine pericardial patch treated with a monomeric glutaraldehyde. Results: There were no complications in the initial postoperative period and short inpatient stay. At a mean follow-up of 29.6 months (range: 22-36 months), 4 patients had no evidence of stenosis and 3 patients had trivial or no regurgitation from the neoaortic valve. Overall, two patients had complications related to the valve and underwent reintervention during the follow-up period with a Ross procedure. One of these patients who was not taking long-term anticoagulation experienced a transient ischemic attack. Conclusions: Our experience demonstrates that the Ozaki procedure with CardioCel in pediatric and young adult patients should be approached with caution. Further research with larger groups of pediatric patients, comparison of different graft materials, and longer follow-up is required to ascertain long-term success in children.
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Affiliation(s)
- Sian C. Chivers
- Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Carine Pavy
- Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Ricky Vaja
- Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Cesare Quarto
- Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Olivier Ghez
- Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Piers E. F. Daubeney
- Royal Brompton Hospital, London, United Kingdom
- National Heart and Lung Institute, Imperial College, London, United Kingdom
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Attias D, Nejjari M, Nappi F, Dreyfus J, Eleid MF, Rihal CS. How to treat severe symptomatic structural valve deterioration of aortic surgical bioprosthesis: transcatheter valve-in-valve implantation or redo valve surgery? Eur J Cardiothorac Surg 2019; 54:977-985. [PMID: 29868728 DOI: 10.1093/ejcts/ezy204] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 04/22/2018] [Indexed: 11/12/2022] Open
Abstract
The optimal management of aortic surgical bioprosthesis presenting with severe symptomatic structural valve deterioration is currently a matter of debate. Over the past 20 years, the number of implanted bioprostheses worldwide has been rapidly increasing at the expense of mechanical prostheses. A large proportion of patients, however, will require intervention for bioprosthesis structural valve deterioration. Current options for older patients who often have severe comorbidities include either transcatheter valve-in-valve (TVIV) implantation or redo valve surgery. The emergence of TVIV implantation, which is perceived to be less invasive than redo valve surgery, offers an effective alternative to surgery for these patients with proven safety and efficacy in high-risk patient groups including elderly and frail patients. A potential caveat to this strategy is that results of long-term follow-up after TVIV implantation are limited. Redo surgery is sometimes preferable, especially for young patients with a smaller-sized aortic bioprosthesis. With the emergence of TVIV implantation and the long experience of redo valve surgery, we currently have 2 complementary treatment modalities, allowing a tailor-made and patient-orientated intervention. In the heart team, the decision-making should be based on several factors including type of bioprosthesis failure, age, comorbidities, operative risk, anatomical factors, anticipated risks and benefits of each alternative, patient's choice and local experience. The aim of this review is to provide a framework for individualized optimal treatment strategies in patients with failed aortic surgical bioprosthesis.
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Affiliation(s)
- David Attias
- Department of Cardiology, Centre Cardiologique du Nord, Saint Denis, France
| | - Mohammed Nejjari
- Department of Cardiology, Centre Cardiologique du Nord, Saint Denis, France
| | - Francesco Nappi
- Department of Cardiac Surgery, Centre Cardiologique du Nord, Saint Denis, France
| | - Julien Dreyfus
- Department of Cardiology, Centre Cardiologique du Nord, Saint Denis, France
| | - Mackram F Eleid
- Department of Cardiovascular Diseases and Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Charanjit S Rihal
- Department of Cardiovascular Diseases and Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
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Lansac E, Youssefi P, de Heer F, Bavaria J, De Kerchove L, El-Hamamsy I, Elkhoury G, Enriquez-Sarano M, Jondeau LDG, Kluin J, Pibarot P, Schäfers HJ, Vanoverschelde JL, Takkenberg JJM. Aortic Valve Surgery in Nonelderly Patients: Insights Gained From AVIATOR. Semin Thorac Cardiovasc Surg 2019; 31:643-649. [PMID: 31229691 DOI: 10.1053/j.semtcvs.2019.05.033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 05/02/2019] [Indexed: 11/11/2022]
Abstract
Aortic valve surgery in non-elderly patients represents a very challenging patient population. The younger the patient is at the point of aortic valve intervention, the longer their anticipated life expectancy will be, with longer exposure to valve-related complications and risk for re-operation. Although the latest international guidelines recommend aortic valve repair in patients with aortic valve insufficiency, what we see in the real world is that the vast majority of these aortic valves are replaced. However, current prosthetic valves has now been shown to lead to significant loss of life expectancy for non-elderly patients up to 50% for patients in their 40s undergoing mechanical aortic valve replacement. Bioprostheses carry an even worse long-term survival, with higher rates of re-intervention. The promise of trans-catheter valve-in-valve technology is accentuating the trend of bioprosthetic implantation in younger patients, without yet the appropriate evidence. In contrast, aortic valve repair has shown excellent outcomes in terms of quality of life, freedom from re-operation and freedom from major adverse valve-related events with similar life expectancy to general population as it is also found for the Ross procedure, the only available living valve substitute. We are at a time when the paradigm of aortic valve surgery needs to change for the better. To better serve our patients, we must acquire high quality real-world evidence from multiple centers globally - this is the vision of the AVIATOR registry and our common responsibility.
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Affiliation(s)
- Emmanuel Lansac
- Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France.
| | - Pouya Youssefi
- Department of Cardiac Surgery, Institut Mutualiste Montsouris, Paris, France
| | - Frederiek de Heer
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Joseph Bavaria
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laurent De Kerchove
- Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | - Ismail El-Hamamsy
- Department of Cardiac Surgery, Montreal Heart Institute, Montréal, Canada
| | - Gebrine Elkhoury
- Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
| | | | | | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Philippe Pibarot
- Department of Cardiology, Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Jean-Louis Vanoverschelde
- Department of Cardiovascular and Thoracic Surgery, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium
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Costa G, Criscione E, Todaro D, Tamburino C, Barbanti M. Long-term Transcatheter Aortic Valve Durability. ACTA ACUST UNITED AC 2019; 14:62-69. [PMID: 31178931 PMCID: PMC6545973 DOI: 10.15420/icr.2019.4.2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 04/29/2019] [Indexed: 12/26/2022]
Abstract
Transcatheter aortic valve implantation (TAVI) has become the standard of care for high-risk and inoperable surgical patients and a valid alternative to surgery for low- and intermediate-risk patients with severe, symptomatic aortic stenosis. It is increasingly being used for younger, lower-risk patients, so it is important to ensure the durability for long-term transcatheter aortic valves. The lack of standard definitions of structural valve degeneration (SVD) had made comparison among studies on prosthetic valve durability problematic. The 2017 standardised definitions of SVD by the European Association of Percutaneous Cardiovascular Intervention), the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery, and the 2018 definitions by the Valve In Valve International Data group, has generated an increased uniformity in evaluations. This article examines the potential mechanisms and rates of SVD of transcatheter bioprostheses and the role of redo TAVI as a treatment option.
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Affiliation(s)
- Giuliano Costa
- Vittorio Emanuele Hospital, University of Catania Catania, Italy
| | - Enrico Criscione
- Vittorio Emanuele Hospital, University of Catania Catania, Italy
| | - Denise Todaro
- Vittorio Emanuele Hospital, University of Catania Catania, Italy
| | | | - Marco Barbanti
- Vittorio Emanuele Hospital, University of Catania Catania, Italy
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Gennari M, Agrifoglio M, Polvani G. Favorable early outcomes of composite grafts with the Edwards resilia valve in young patients. J Card Surg 2019; 34:649-650. [PMID: 31099430 DOI: 10.1111/jocs.14076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2019] [Revised: 04/02/2019] [Accepted: 04/17/2019] [Indexed: 11/29/2022]
Affiliation(s)
| | - Marco Agrifoglio
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Cardiovascular Sciences and Community Health, University of Milan, Milan, Italy
| | - Gianluca Polvani
- Centro Cardiologico Monzino, IRCCS, Milan, Italy.,Department of Cardiovascular Sciences and Community Health, University of Milan, Milan, Italy
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44
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Abdi S, Nazeri I, Mandegar MH, Geraiely B, Mortazavi SH. Single-session double valve replacement: TAVI+tricuspid valve-in-valve procedures. J Card Surg 2019; 34:518-521. [PMID: 31017333 DOI: 10.1111/jocs.14061] [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: 01/20/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 11/30/2022]
Abstract
We describe a 70-year-old lady with rheumatic heart disease and a history of the mitral valve and tricuspid valve replacement, who underwent transcatheter aortic valve implantation and the tricuspid valve-in-valve procedure in a single session.
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Affiliation(s)
- Seifollah Abdi
- Rajaie Cardiovascular, Medical, and Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Iraj Nazeri
- Department of Cardiology, Day General Hospital, Tehran, Iran
| | | | - Babak Geraiely
- Tehran Heart Center, Tehran University of Medical Sciences, Tehran, Iran
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Kwak YJ, Ahn H, Choi JW, Kim KH. Long-Term Results of the Leaflet Extension Technique for Rheumatic Aortic Regurgitation: A 20-Year Follow-up. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2019; 52:9-15. [PMID: 30834212 PMCID: PMC6383856 DOI: 10.5090/kjtcs.2019.52.1.9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 11/07/2018] [Accepted: 11/07/2018] [Indexed: 11/16/2022]
Abstract
Background Although aortic valve repair can reduce prosthesis-related complications, rheumatic aortic regurgitation (AR) caused by leaflet restriction is a significant risk factor for recurrent AR. In this study, we evaluated the long-term results of the leaflet extension technique for rheumatic AR. Methods Between 1995 and 2016, 33 patients underwent aortic valve repair using the leaflet extension technique with autologous pericardium for rheumatic pure AR. Twenty patients had severe AR and 9 had combined moderate or greater mitral regurgitation. Their mean age was 32.2±13.9 years. The mean follow-up duration was 18.3±5.8 years. Results There were no cases of operative mortality, but postoperative complications occurred in 5 patients. Overall survival at 10 and 20 years was 93.5% and 87.1%, respectively. There were no thromboembolic cerebrovascular events, but 4 late deaths occurred, as well as a bleeding event in 1 patient who was taking warfarin. Twelve patients underwent aortic valve reoperation. The mean interval to reoperation was 13.1±6.1 years. Freedom from reoperation at 10 and 20 years was 96.7% and 66.6%, respectively. Conclusion The long-term results of the leaflet extension technique showed acceptable durability and a low incidence of thromboembolic events and bleeding. The leaflet extension technique may be a good option for young patients with rheumatic AR.
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Affiliation(s)
- Yu-Jin Kwak
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine
| | - Hyuk Ahn
- Department of Thoracic and Cardiovascular Surgery, Bundang Jesaeng Hospital
| | - Jae Woong Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine
| | - Kyung-Hwan Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine
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46
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Bavaria JE, Tommaso CL, Brindis RG, Carroll JD, Deeb GM, Feldman TE, Gleason TG, Horlick EM, Kavinsky CJ, Kumbhani DJ, Miller DC, Seals AA, Shahian DM, Shemin RJ, Sundt TM, Thourani VH. 2018 AATS/ACC/SCAI/STS Expert Consensus Systems of Care Document: Operator and institutional recommendations and requirements for transcatheter aortic valve replacement. J Thorac Cardiovasc Surg 2019; 157:e77-e111. [DOI: 10.1016/j.jtcvs.2018.07.001] [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] [Indexed: 10/28/2022]
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Karciauskas D, Mizariene V, Jakuska P, Ereminiene E, Orda P, Ordiene R, Vaskelyte JJ, Nedzelskiene I, Kinduris S, Benetis R. Early and long-term results of aortic valve sparing aortic root reimplantation surgery for bicuspid and tricuspid aortic valves. Perfusion 2019; 34:482-489. [DOI: 10.1177/0267659119831926] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: To evaluate early and long-term clinical outcomes following aortic valve sparing aortic root reimplantation surgery in patients with leaking bicuspid and tricuspid aortic valves. Methods: The study consisted of 92 consecutive adult patients (tricuspid aortic valve group = 63 and bicuspid aortic valve group = 29) who underwent aortic valve sparing aortic root reimplantation surgery with or without aortic cusp repair for dilatation of the aortic root and/or aortic valve regurgitation at our institution from April 2004 to October 2016. Clinical outcomes were investigated using Kaplan–Meier and log-rank tests between groups. Results: The follow-up was 100% complete with a mean time of 5.3 ± 3.3 years. The 30-day in-hospital mortality was 3.1% in tricuspid aortic valve group and 3.4% in bicuspid aortic valve group patients. The overall survival rates at 10 years did not differ between bicuspid aortic valve and tricuspid aortic valve patient groups (96.6 ± 3.3% vs. 90.3 ± 4.2%, p = 0.3). Freedom from recurrent aortic valve regurgitation (>2+) at 10 years was 90.5 ± 4.1% in tricuspid aortic valve group and 75.7 ± 8.7% in bicuspid aortic valve group (p = 0.06). Freedom from aortic valve reoperation at 10 years was 100% in tricuspid aortic valve group and 83.9 ± 7.4% in bicuspid aortic valve group (p = 0.002). Conclusion: Aortic valve sparing aortic root reimplantation surgery is a safe and efficient technique, providing acceptable long-term survival with low rates of valve-related complications in both tricuspid aortic valve and bicuspid aortic valve patient groups. However, aortic valve reoperation rates at 10 years follow-up were higher in bicuspid aortic valve group patients compared to tricuspid aortic valve group patients.
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Affiliation(s)
- Dainius Karciauskas
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Vaida Mizariene
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Povilas Jakuska
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Egle Ereminiene
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Paulius Orda
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rasa Ordiene
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Jolanta Justina Vaskelyte
- Department of Cardiology, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Irena Nedzelskiene
- Department of Dental and Oral Diseases, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Sarunas Kinduris
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Rimantas Benetis
- Department of Cardiac, Thoracic and Vascular Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, Medical Academy, Lithuanian University of Health Sciences, Kaunas, Lithuania
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Etnel JR, Huygens SA, Grashuis P, Pekbay B, Papageorgiou G, Roos Hesselink JW, Bogers AJ, Takkenberg JJ. Bioprosthetic Aortic Valve Replacement in Nonelderly Adults. Circ Cardiovasc Qual Outcomes 2019; 12:e005481. [DOI: 10.1161/circoutcomes.118.005481] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jonathan R.G. Etnel
- Department of Cardiothoracic Surgery (J.R.G.E., S.A.H., P.G., B.P., G.P., A.J.J.C.B., J.J.M.T.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Simone A. Huygens
- Department of Cardiothoracic Surgery (J.R.G.E., S.A.H., P.G., B.P., G.P., A.J.J.C.B., J.J.M.T.), Erasmus University Medical Center, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands (S.A.H.)
| | - Pepijn Grashuis
- Department of Cardiothoracic Surgery (J.R.G.E., S.A.H., P.G., B.P., G.P., A.J.J.C.B., J.J.M.T.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Begüm. Pekbay
- Department of Cardiothoracic Surgery (J.R.G.E., S.A.H., P.G., B.P., G.P., A.J.J.C.B., J.J.M.T.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Grigorios Papageorgiou
- Department of Cardiothoracic Surgery (J.R.G.E., S.A.H., P.G., B.P., G.P., A.J.J.C.B., J.J.M.T.), Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Biostatistics (G.P.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jolien W. Roos Hesselink
- Department of Cardiology (J.W.R.H.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Ad J.J.C. Bogers
- Department of Cardiothoracic Surgery (J.R.G.E., S.A.H., P.G., B.P., G.P., A.J.J.C.B., J.J.M.T.), Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Johanna J.M. Takkenberg
- Department of Cardiothoracic Surgery (J.R.G.E., S.A.H., P.G., B.P., G.P., A.J.J.C.B., J.J.M.T.), Erasmus University Medical Center, Rotterdam, The Netherlands
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Heinisch PP, Carrel T. Commentary: Tissue valves in younger patients: Hazardous developments on the horizon. J Thorac Cardiovasc Surg 2019; 158:46-47. [PMID: 30685169 DOI: 10.1016/j.jtcvs.2018.12.038] [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: 12/13/2018] [Accepted: 12/14/2018] [Indexed: 11/17/2022]
Affiliation(s)
- Paul Philipp Heinisch
- Department of Cardiovascular Surgery, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Thierry Carrel
- Department of Cardiovascular Surgery, Inselspital, University Hospital, University of Bern, Bern, Switzerland.
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50
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Bavaria JE, Tommaso CL, Brindis RG, Carroll JD, Michael Deeb G, Feldman TE, Gleason TG, Horlick EM, Kavinsky CJ, Kumbhani DJ, Craig Miller D, Allen Seals A, Shahian DM, Shemin RJ, Sundt TM, Thourani VH. 2018 AATS/ACC/SCAI/STS expert consensus systems of care document: Operator and institutional recommendations and requirements for transcatheter aortic valve replacement. Catheter Cardiovasc Interv 2019; 93:E153-E184. [DOI: 10.1002/ccd.27811] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 06/10/2018] [Indexed: 11/10/2022]
Affiliation(s)
| | - Carl L. Tommaso
- Society for Cardiovascular Angiography and Interventions Representative
| | | | | | | | - Ted E. Feldman
- Society for Cardiovascular Angiography and Interventions Representative
| | | | - Eric M. Horlick
- Society for Cardiovascular Angiography and Interventions Representative
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