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De Kanter AJ, Daal MV, Gunn CJ, Bredenoord AL, Graeff ND, Jongsma KR. A value hierarchy for inclusive design of heart valve implants in regenerative medicine. Regen Med 2024; 19:289-301. [PMID: 39177570 PMCID: PMC11346526 DOI: 10.1080/17460751.2024.2357500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 05/16/2024] [Indexed: 08/24/2024] Open
Abstract
Aim: This paper investigates the conditions for inclusive design of regenerative medicine interventions from a bioethical perspective, taking regenerative valve implants as a showcase.Methods: A value hierarchy is construed to translate the value of justice into norms and design requirements for inclusive design of regenerative valve implants.Results: Three norms are proposed and translated into design requirements: regenerative valve implants should be designed to promote equal opportunity to good health for all potential users; equal respect for all potential users should be shown; and the implants should be designed to be accessible to everyone in need.Conclusion: The norms and design requirements help to design regenerative valve implants that are appropriate, respectful and available for everyone in need.
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Affiliation(s)
- Anne Johanna De Kanter
- Department of Bioethics & Health Humanities, Julius Center for Health Sciences & Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, 3508 GA, The Netherlands
| | - Manon Van Daal
- Department of Bioethics & Health Humanities, Julius Center for Health Sciences & Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, 3508 GA, The Netherlands
| | - Callum J Gunn
- Department of Bioethics & Health Humanities, Julius Center for Health Sciences & Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, 3508 GA, The Netherlands
| | - Annelien L Bredenoord
- Erasmus School of Philosophy, Erasmus University Rotterdam, Rotterdam, 3062 PA, The Netherlands
| | - Nienke De Graeff
- Department of Medical Ethics & Health Law, Leiden University Medical Center, Leiden University, Leiden, The Netherlands
| | - Karin R Jongsma
- Department of Bioethics & Health Humanities, Julius Center for Health Sciences & Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, 3508 GA, The Netherlands
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2
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Sengupta PP, Kluin J, Lee SP, Oh JK, Smits AIPM. The future of valvular heart disease assessment and therapy. Lancet 2024; 403:1590-1602. [PMID: 38554727 DOI: 10.1016/s0140-6736(23)02754-x] [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: 04/16/2023] [Revised: 08/15/2023] [Accepted: 12/06/2023] [Indexed: 04/02/2024]
Abstract
Valvular heart disease (VHD) is becoming more prevalent in an ageing population, leading to challenges in diagnosis and management. This two-part Series offers a comprehensive review of changing concepts in VHD, covering diagnosis, intervention timing, novel management strategies, and the current state of research. The first paper highlights the remarkable progress made in imaging and transcatheter techniques, effectively addressing the treatment paradox wherein populations at the highest risk of VHD often receive the least treatment. These advances have attracted the attention of clinicians, researchers, engineers, device manufacturers, and investors, leading to the exploration and proposal of treatment approaches grounded in pathophysiology and multidisciplinary strategies for VHD management. This Series paper focuses on innovations involving computational, pharmacological, and bioengineering approaches that are transforming the diagnosis and management of patients with VHD. Artificial intelligence and digital methods are enhancing screening, diagnosis, and planning procedures, and the integration of imaging and clinical data is improving the classification of VHD severity. The emergence of artificial intelligence techniques, including so-called digital twins-eg, computer-generated replicas of the heart-is aiding the development of new strategies for enhanced risk stratification, prognostication, and individualised therapeutic targeting. Various new molecular targets and novel pharmacological strategies are being developed, including multiomics-ie, analytical methods used to integrate complex biological big data to find novel pathways to halt the progression of VHD. In addition, efforts have been undertaken to engineer heart valve tissue and provide a living valve conduit capable of growth and biological integration. Overall, these advances emphasise the importance of early detection, personalised management, and cutting-edge interventions to optimise outcomes amid the evolving landscape of VHD. Although several challenges must be overcome, these breakthroughs represent opportunities to advance patient-centred investigations.
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Affiliation(s)
- Partho P Sengupta
- Division of Cardiovascular Diseases and Hypertension, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA; Cardiovascular Services, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA.
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Erasmus MC Rotterdam, Thorax Center, Rotterdam, Netherlands
| | - Seung-Pyo Lee
- Department of Internal Medicine, Seoul National University Hospital and Seoul National University College of Medicine, Seoul, South Korea
| | - Jae K Oh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anthal I P M Smits
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, Netherlands; Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, Netherlands
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3
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Notenboom ML, Rhellab R, Etnel JRG, Huygens SA, Hjortnaes J, Kluin J, Takkenberg JJM, Veen KM. How microsimulation translates outcome estimates to patient lifetime event occurrence in the setting of heart valve disease. Eur J Cardiothorac Surg 2024; 65:ezae087. [PMID: 38515198 DOI: 10.1093/ejcts/ezae087] [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: 11/17/2023] [Revised: 02/08/2024] [Accepted: 03/06/2024] [Indexed: 03/23/2024] Open
Abstract
Treatment decisions in healthcare often carry lifelong consequences that can be challenging to foresee. As such, tools that visualize and estimate outcome after different lifetime treatment strategies are lacking and urgently needed to support clinical decision-making in the setting of rapidly evolving healthcare systems, with increasingly numerous potential treatments. In this regard, microsimulation models may prove to be valuable additions to current risk-prediction models. Notable advantages of microsimulation encompass input from multiple data sources, the ability to move beyond time-to-first-event analysis, accounting for multiple types of events and generating projections of lifelong outcomes. This review aims to clarify the concept of microsimulation, also known as individualized state-transition models, and help clinicians better understand its potential in clinical decision-making. A practical example of a patient with heart valve disease is used to illustrate key components of microsimulation models, such as health states, transition probabilities, input parameters (e.g. evidence-based risks of events) and various aspects of mortality. Finally, this review focuses on future efforts needed in microsimulation to allow for increasing patient-tailoring of the models by extending the general structure with patient-specific prediction models and translating them to meaningful, user-friendly tools that may be used by both clinician and patient to support clinical decision-making.
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Affiliation(s)
- Maximiliaan L Notenboom
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Reda Rhellab
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jonathan R G Etnel
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Jesper Hjortnaes
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Rotterdam, Netherlands
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Kevin M Veen
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
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4
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Notenboom ML, Van Hoof L, Schuermans A, Takkenberg JJM, Rega FR, Taverne YJHJ. Aortic Valve Embryology, Mechanobiology, and Second Messenger Pathways: Implications for Clinical Practice. J Cardiovasc Dev Dis 2024; 11:49. [PMID: 38392263 PMCID: PMC10888685 DOI: 10.3390/jcdd11020049] [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: 12/24/2023] [Revised: 01/22/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
During the Renaissance, Leonardo Da Vinci was the first person to successfully detail the anatomy of the aortic root and its adjacent structures. Ever since, novel insights into morphology, function, and their interplay have accumulated, resulting in advanced knowledge on the complex functional characteristics of the aortic valve (AV) and root. This has shifted our vision from the AV as being a static structure towards that of a dynamic interconnected apparatus within the aortic root as a functional unit, exhibiting a complex interplay with adjacent structures via both humoral and mechanical stimuli. This paradigm shift has stimulated surgical treatment strategies of valvular disease that seek to recapitulate healthy AV function, whereby AV disease can no longer be seen as an isolated morphological pathology which needs to be replaced. As prostheses still cannot reproduce the complexity of human nature, treatment of diseased AVs, whether stenotic or insufficient, has tremendously evolved, with a similar shift towards treatments options that are more hemodynamically centered, such as the Ross procedure and valve-conserving surgery. Native AV and root components allow for an efficient Venturi effect over the valve to allow for optimal opening during the cardiac cycle, while also alleviating the left ventricle. Next to that, several receptors are present on native AV leaflets, enabling messenger pathways based on their interaction with blood and other shear-stress-related stimuli. Many of these physiological and hemodynamical processes are under-acknowledged but may hold important clues for innovative treatment strategies, or as potential novel targets for therapeutic agents that halt or reverse the process of valve degeneration. A structured overview of these pathways and their implications for cardiothoracic surgeons and cardiologists is lacking. As such, we provide an overview on embryology, hemodynamics, and messenger pathways of the healthy and diseased AV and its implications for clinical practice, by relating this knowledge to current treatment alternatives and clinical decision making.
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Affiliation(s)
- Maximiliaan L Notenboom
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Art Schuermans
- Department of Cardiac Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Filip R Rega
- Department of Cardiac Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
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Galzerano D, Kholaif N, Al Amro B, Al Admawi M, Eltayeb A, Alshammari A, Di Salvo G, Al-Halees ZY. The Ross Procedure: Imaging, Outcomes and Future Directions in Aortic Valve Replacement. J Clin Med 2024; 13:630. [PMID: 38276135 PMCID: PMC10816914 DOI: 10.3390/jcm13020630] [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: 11/02/2023] [Revised: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 01/27/2024] Open
Abstract
The Ross procedure is gaining recognition as a significant option for aortic valve replacement (AVR), and is particularly beneficial in specific patient groups. Although categorized as a class IIb recommendation in the 2020 American College of Cardiology (ACC)/American Heart Association (AHA), and the European Society of Cardiology (ESC) management guidelines on valvular heart disease, recent studies bolster its credibility. Research, including a propensity-matched study, underlines the Ross procedure's association with enhanced long-term survival and reduced adverse valve-related events compared to other AVR types. This positions the Ross procedure as a primary option for AVR in young and middle-aged adults within specialized centers, and potentially the only choice for children and infants requiring AVR. This review meticulously examines the Ross procedure, covering historical perspectives, surgical techniques, imaging, and outcomes, including hemodynamic performance and quality of life, especially focusing on pediatric and young adult patients. It explores contemporary techniques and innovations like minimally invasive approaches and tissue engineering, underscoring ongoing research and future directions. A summarization of comparative studies and meta-analyses reiterates the Ross procedure's superior long-term outcomes, valve durability, and preservation of the left ventricular function, accentuating the crucial role of patient selection and risk stratification, and pinpointing areas for future research.
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Affiliation(s)
- Domenico Galzerano
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Naji Kholaif
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Bandar Al Amro
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Mohammed Al Admawi
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
| | - Abdalla Eltayeb
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
| | - Amal Alshammari
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
| | - Giovanni Di Salvo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Medical School, University of Padua, 35122 Padua, Italy;
| | - Zohair Y. Al-Halees
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
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6
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Andreeva A, Coti I, Werner P, Scherzer S, Kocher A, Laufer G, Andreas M. Aortic Valve Replacement in Adult Patients with Decellularized Homografts: A Single-Center Experience. J Clin Med 2023; 12:6713. [PMID: 37959179 PMCID: PMC10650916 DOI: 10.3390/jcm12216713] [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: 09/01/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND decellularized aortic homografts (DAH) represent a promising alternative for aortic valve replacement in young adults due to their low immunogenicity and thrombogenicity. Herein, we report our midterm, single-center experience in adult patients with non-frozen DAH from corlife. METHODS safety, durability, and hemodynamic performance were evaluated according to current guidelines in all consecutive patients who had received a DAH at our center since 03/2016. RESULTS seventy-three (mean age 47 ± 11 years, 68.4% (n = 50) male) patients were enrolled. The mean diameter of the implanted DAH was 24 ± 2 mm. Mean follow-up was 36 ± 27 months, with a maximum follow-up of 85 months and cumulative follow-up of 215 years. No cases of stenosis were observed, in four (5.5%) cases moderate aortic regurgitation occurred, but no reintervention was required. No cases of early mortality, non-structural dysfunction, reoperation, valve endocarditis, or thrombosis were observed. Freedom from bleeding and thromboembolic events was 100%; freedom from re-intervention was 100%; survival was 98.6% (n = 72). CONCLUSIONS early and mid-term results showed low mortality and 100% freedom from reoperation, thromboembolic events, and bleeding at our center. However, in order for this novel approach to be established as a valid alternative to aortic valve replacement in young patients, long-term data are required.
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Affiliation(s)
- Alexandra Andreeva
- Department of Cardiac Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria; (I.C.); (P.W.); (S.S.); (A.K.); (G.L.); (M.A.)
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7
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Crago M, Winlaw DS, Farajikhah S, Dehghani F, Naficy S. Pediatric pulmonary valve replacements: Clinical challenges and emerging technologies. Bioeng Transl Med 2023; 8:e10501. [PMID: 37476058 PMCID: PMC10354783 DOI: 10.1002/btm2.10501] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 01/17/2023] [Accepted: 01/29/2023] [Indexed: 03/06/2023] Open
Abstract
Congenital heart diseases (CHDs) frequently impact the right ventricular outflow tract, resulting in a significant incidence of pulmonary valve replacement in the pediatric population. While contemporary pediatric pulmonary valve replacements (PPVRs) allow satisfactory patient survival, their biocompatibility and durability remain suboptimal and repeat operations are commonplace, especially for very young patients. This places enormous physical, financial, and psychological burdens on patients and their parents, highlighting an urgent clinical need for better PPVRs. An important reason for the clinical failure of PPVRs is biofouling, which instigates various adverse biological responses such as thrombosis and infection, promoting research into various antifouling chemistries that may find utility in PPVR materials. Another significant contributor is the inevitability of somatic growth in pediatric patients, causing structural discrepancies between the patient and PPVR, stimulating the development of various growth-accommodating heart valve prototypes. This review offers an interdisciplinary perspective on these challenges by exploring clinical experiences, physiological understandings, and bioengineering technologies that may contribute to device development. It thus aims to provide an insight into the design requirements of next-generation PPVRs to advance clinical outcomes and promote patient quality of life.
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Affiliation(s)
- Matthew Crago
- School of Chemical and Biomolecular EngineeringThe University of SydneySydneyAustralia
| | - David S. Winlaw
- Department of Cardiothoracic SurgeryHeart Institute, Cincinnati Children's HospitalCincinnatiOHUSA
| | - Syamak Farajikhah
- School of Chemical and Biomolecular EngineeringThe University of SydneySydneyAustralia
| | - Fariba Dehghani
- School of Chemical and Biomolecular EngineeringThe University of SydneySydneyAustralia
| | - Sina Naficy
- School of Chemical and Biomolecular EngineeringThe University of SydneySydneyAustralia
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Meyers B, Nyce J, Zhang J, Frank LH, Balaras E, Vlachos PP, Loke YH. Intracardiac Flow Analysis of the Right Ventricle in Pediatric Patients With Repaired Tetralogy of Fallot Using a Novel Color Doppler Velocity Reconstruction. J Am Soc Echocardiogr 2023; 36:644-653. [PMID: 36822439 PMCID: PMC10247486 DOI: 10.1016/j.echo.2023.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/08/2023] [Accepted: 02/10/2023] [Indexed: 02/25/2023]
Abstract
BACKGROUND Repaired tetralogy of Fallot (RTOF) patients will develop right ventricular (RV) dysfunction from chronic pulmonary regurgitation (PR). Cardiac magnetic resonance sequences such as four-dimensional flow can demonstrate altered vorticity and flow energy loss (FEL); however, they are not as available as conventional echocardiography (echo). The study determined whether a novel, vendor-independent Doppler velocity reconstruction (DoVeR) could measure RV intracardiac flow in conventional echo of RTOF patients. The primary hypothesis was that DoVeR could detect increased vorticity and diastolic FEL in RTOF patients. METHODS Repaired tetralogy of Fallot patients with echo were retrospectively paired with age-/size-matched controls. Doppler velocity reconstruction employed the stream function-vorticity equation to approximate intracardiac flow fields from color Doppler. A velocity field of the right ventricle was reconstructed from the apical 4-chamber view. Vortex strength (VS, area integral of vorticity) and FEL were derived from DoVeR. Cardiac magnetic resonance and exercise stress parameters (performed within 1 year of echo) were collected for analysis. RESULTS Twenty RTOF patients and age-matched controls were included in the study. Mean regurgitant fraction was 40.5% ± 7.6%, and indexed RV end-diastolic volume was 158 ± 36 mL/m2. Repaired tetralogy of Fallot patients had higher total, mean diastolic, and peak diastolic VS (P = .0013, P = .0012, P = .0032, respectively) and higher total, mean diastolic, and peak diastolic body surface area-indexed FEL (P = .0016, P = .0022, P < .001, respectively). Peak diastolic indexed FEL and peak diastolic VS had weak-to-moderate negative correlation with RV ejection fraction (r = -0.52 [P = .019] and r = -0.49 [P = .030], respectively) and left ventricular ejection fraction (r = -0.47 [P = .034] and r = -0.64 [P = .002], respectively). Mean diastolic indexed FEL and VS had moderate-to-strong negative correlation with percent predicted maximal oxygen consumption (r = -0.69 [P = .012] and r = -0.75 [P = .006], respectively). CONCLUSIONS DoVeR can detect alterations to intracardiac flow in RTOF patients from conventional color Doppler imaging. Echo-based measures of diastolic VS and FEL correlated with ventricular function. DoVeR has the potential to provide serial evaluation of abnormal flow dynamics in RTOF patients.
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Affiliation(s)
- Brett Meyers
- School of Mechanical Engineering, Purdue University, West Lafayette, Indiana
| | - Jonathan Nyce
- Department of Cardiology, Children's National Hospital, Washington, D.C
| | - Jiacheng Zhang
- School of Mechanical Engineering, Purdue University, West Lafayette, Indiana
| | - Lowell H Frank
- Department of Cardiology, Children's National Hospital, Washington, D.C
| | - Elias Balaras
- School of Engineering & Applied Science, George Washington University, Washington, D.C
| | - Pavlos P Vlachos
- School of Mechanical Engineering, Purdue University, West Lafayette, Indiana
| | - Yue-Hin Loke
- Department of Cardiology, Children's National Hospital, Washington, D.C..
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Boudewijns EA, Otten TM, Gobianidze M, Ramaekers BL, van Schayck OCP, Joore MA. Headroom Analysis for Early Economic Evaluation: A Systematic Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:195-204. [PMID: 36575333 DOI: 10.1007/s40258-022-00774-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 11/14/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVES The headroom analysis is an early economic evaluation that quantifies the highest price at which an intervention may still be cost effective. Currently, there is no comprehensive review on how it is applied. This study investigated the application of the headroom analysis, specifically (1) how the headroom analysis is framed (2) the analytical approach and sources of evidence used, and (3) how expert judgement is used and reported. METHODS A systematic search was conducted in PubMed, Embase, Web of Science, EconLit, and Google Scholar on 28 April 2022. Studies were eligible if they reported an application of the headroom analysis. Data were presented in tabular form and summarised descriptively. RESULTS We identified 42 relevant papers. The headroom analysis was applied to medicines (29%), diagnostic or screening tests (29%), procedures, programmes and systems (21%), medical devices (19%), and a combined test and device (2%). All studies used model-based analyses, with 40% using simple models and 60% using more comprehensive models. Thirty-three percent of the studies assumed perfect effectiveness of the health technology, while 67% adopted realistic assumptions. Ten percent of the studies calculated an effectiveness-seeking headroom instead of a cost-seeking headroom. Expert judgement was used in 71% of the studies; 23 studies (55%) used expert opinion, 6 studies (14%) used expert elicitation, and 1 study (2%) used both. CONCLUSIONS Because the application of the headroom analysis varies considerably, we recommend its appropriate use and clear reporting of analytical approaches, level of evidence available, and the use of expert judgement.
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Affiliation(s)
- Esther A Boudewijns
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | - Thomas M Otten
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre MUMC+/Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Mariam Gobianidze
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Bram L Ramaekers
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre MUMC+/Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Onno C P van Schayck
- Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Manuela A Joore
- Department of Clinical Epidemiology and Medical Technology Assessment (KEMTA), Maastricht University Medical Centre MUMC+/Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
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10
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Loerakker S, Humphrey JD. Computer Model-Driven Design in Cardiovascular Regenerative Medicine. Ann Biomed Eng 2023; 51:45-57. [PMID: 35974236 PMCID: PMC9832109 DOI: 10.1007/s10439-022-03037-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/20/2022] [Indexed: 01/28/2023]
Abstract
Continuing advances in genomics, molecular and cellular mechanobiology and immunobiology, including transcriptomics and proteomics, and biomechanics increasingly reveal the complexity underlying native tissue and organ structure and function. Identifying methods to repair, regenerate, or replace vital tissues and organs remains one of the greatest challenges of modern biomedical engineering, one that deserves our very best effort. Notwithstanding the continuing need for improving standard methods of investigation, including cell, organoid, and tissue culture, biomaterials development and fabrication, animal models, and clinical research, it is increasingly evident that modern computational methods should play increasingly greater roles in advancing the basic science, bioengineering, and clinical application of regenerative medicine. This brief review focuses on the development and application of computational models of tissue and organ mechanobiology and mechanics for purposes of designing tissue engineered constructs and understanding their development in vitro and in situ. Although the basic approaches are general, for illustrative purposes we describe two recent examples from cardiovascular medicine-tissue engineered heart valves (TEHVs) and tissue engineered vascular grafts (TEVGs)-to highlight current methods of approach as well as continuing needs.
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Affiliation(s)
- Sandra Loerakker
- Department of Biomedical Engineering and Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, Netherlands
| | - Jay D Humphrey
- Department of Biomedical Engineering and Vascular Biology & Therapeutics Program, Yale University and Yale School of Medicine, New Haven, CT, USA.
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11
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Browne IL, Zhang W, Sutton AJ. Exploring the approach to parameter uncertainty in early economic evaluations of surgical technology - a systematic review. Expert Rev Pharmacoecon Outcomes Res 2023; 23:29-41. [PMID: 36357336 DOI: 10.1080/14737167.2023.2145946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
INTRODUCTION The role of early economic evaluation (EEE) in the development of medical technology has been increasingly recognized; however, data on the use of EEE in surgical technology are sparse. The objective of this review was to explore the use of EEE in the development of surgical technologies, with emphasis on how uncertainty has been addressed. AREAS COVERED A systematic review was conducted, and original articles employing any form of EEE of surgical technology were selected for review, with 10 studies included in the analysis. These studies demonstrated significant variation in the approach to managing parameter uncertainty, specifically regarding the type of analysis used and the inclusion of effectiveness parameters in sensitivity analysis. The conclusions drawn did not appear to factor in uncertainty in the models. EXPERT OPINION Approaches to handling parameter uncertainty in previous EEEs of surgical technology have been limited, with some studies failing to address parameter uncertainty. In addition, EEEs do not appear to follow established guidelines with respect to the use of sensitivity analyses. It is important that EEEs of surgical technology address parameter uncertainty in order to draw more robust conclusions from the analysis and allow investors to consider this uncertainty when making investment decisions.
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Affiliation(s)
- Ikennah L Browne
- Department of Surgery, University of Calgary, Calgary, Alberta, Canada.,School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Wei Zhang
- School of Population and Public Health, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.,Centre for Health Evaluation and Outcome Sciences, St. Paul's Hospital, Vancouver, British Columbia, Canada
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12
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Aguilera-Cobos L, Rosario-Lozano MP, Ponce-Polo A, Blasco-Amaro JA, Epstein D. Barriers for the evaluation of advanced therapy medicines and their translation to clinical practice: Umbrella review. Health Policy 2022; 126:1248-1255. [DOI: 10.1016/j.healthpol.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 10/03/2022] [Accepted: 10/11/2022] [Indexed: 11/04/2022]
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13
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Bobylev D, Horke A, Boethig D, Hazekamp M, Meyns B, Rega F, Dave H, Schmiady M, Ciubotaru A, Cheptanaru E, Vida V, Padalino M, Tsang V, Jashari R, Laufer G, Andreas M, Andreeva A, Tudorache I, Cebotari S, Haverich A, Sarikouch S. 5-Year results from the prospective European multi-centre study on decellularized homografts for pulmonary valve replacement ESPOIR Trial and ESPOIR Registry data. Eur J Cardiothorac Surg 2022; 62:6568944. [PMID: 35425983 PMCID: PMC9615428 DOI: 10.1093/ejcts/ezac219] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/28/2022] [Accepted: 03/22/2022] [Indexed: 12/23/2022] Open
Affiliation(s)
- Dmitry Bobylev
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Alexander Horke
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dietmar Boethig
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Mark Hazekamp
- Department of Congenital Cardiac Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Bart Meyns
- Department of Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Hitendu Dave
- Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | - Martin Schmiady
- Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | - Anatol Ciubotaru
- Cardiac Surgery Center, State Medical and Pharmaceutical University, Chisinau, Moldova
| | - Eduard Cheptanaru
- Cardiac Surgery Center, State Medical and Pharmaceutical University, Chisinau, Moldova
| | - Vladimiro Vida
- Pediatric and Congenital Cardiac Surgery Unit, Azienda Ospedaliera di Padova, University of Padua Medical School, Padua, Italy
| | - Massimo Padalino
- Pediatric and Congenital Cardiac Surgery Unit, Azienda Ospedaliera di Padova, University of Padua Medical School, Padua, Italy
| | - Victor Tsang
- Department of Cardiothoracic Surgery, Great Ormond Street Hospital for Children, NHS Foundation Trust, London, UK
| | - Ramadan Jashari
- European Homograft Bank, Clinique Saint-Jean, Brussel, Belgium
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Alexandra Andreeva
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Igor Tudorache
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Serghei Cebotari
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Samir Sarikouch
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
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14
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Immuno-regenerative biomaterials for in situ cardiovascular tissue engineering - Do patient characteristics warrant precision engineering? Adv Drug Deliv Rev 2021; 178:113960. [PMID: 34481036 DOI: 10.1016/j.addr.2021.113960] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 08/20/2021] [Accepted: 08/30/2021] [Indexed: 02/07/2023]
Abstract
In situ tissue engineering using bioresorbable material implants - or scaffolds - that harness the patient's immune response while guiding neotissue formation at the site of implantation is emerging as a novel therapy to regenerate human tissues. For the cardiovascular system, the use of such implants, like blood vessels and heart valves, is gradually entering the stage of clinical translation. This opens up the question if and to what extent patient characteristics influence tissue outcomes, necessitating the precision engineering of scaffolds to guide patient-specific neo-tissue formation. Because of the current scarcity of human in vivo data, herein we review and evaluate in vitro and preclinical investigations to predict the potential role of patient-specific parameters like sex, age, ethnicity, hemodynamics, and a multifactorial disease profile, with special emphasis on their contribution to the inflammation-driven processes of in situ tissue engineering. We conclude that patient-specific conditions have a strong impact on key aspects of in situ cardiovascular tissue engineering, including inflammation, hemodynamic conditions, scaffold resorption, and tissue remodeling capacity, suggesting that a tailored approach may be required to engineer immuno-regenerative biomaterials for safe and predictive clinical applicability.
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15
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Movileanu I, Harpa M, Al Hussein H, Harceaga L, Chertes A, Al Hussein H, Lutter G, Puehler T, Preda T, Sircuta C, Cotoi O, Nistor D, Man A, Cordos B, Deac R, Suciu H, Brinzaniuc K, Casco M, Sierad L, Bruce M, Simionescu D, Simionescu A. Preclinical Testing of Living Tissue-Engineered Heart Valves for Pediatric Patients, Challenges and Opportunities. Front Cardiovasc Med 2021; 8:707892. [PMID: 34490371 PMCID: PMC8416773 DOI: 10.3389/fcvm.2021.707892] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/05/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: Pediatric patients with cardiac congenital diseases require heart valve implants that can grow with their natural somatic increase in size. Current artificial valves perform poorly in children and cannot grow; thus, living-tissue-engineered valves capable of sustaining matrix homeostasis could overcome the current drawbacks of artificial prostheses and minimize the need for repeat surgeries. Materials and Methods: To prepare living-tissue-engineered valves, we produced completely acellular ovine pulmonary valves by perfusion. We then collected autologous adipose tissue, isolated stem cells, and differentiated them into fibroblasts and separately into endothelial cells. We seeded the fibroblasts in the cusp interstitium and onto the root adventitia and the endothelial cells inside the lumen, conditioned the living valves in dedicated pulmonary heart valve bioreactors, and pursued orthotopic implantation of autologous cell-seeded valves with 6 months follow-up. Unseeded valves served as controls. Results: Perfusion decellularization yielded acellular pulmonary valves that were stable, no degradable in vivo, cell friendly and biocompatible, had excellent hemodynamics, were not immunogenic or inflammatory, non thrombogenic, did not calcify in juvenile sheep, and served as substrates for cell repopulation. Autologous adipose-derived stem cells were easy to isolate and differentiate into fibroblasts and endothelial-like cells. Cell-seeded valves exhibited preserved viability after progressive bioreactor conditioning and functioned well in vivo for 6 months. At explantation, the implants and anastomoses were intact, and the valve root was well integrated into host tissues; valve leaflets were unchanged in size, non fibrotic, supple, and functional. Numerous cells positive for a-smooth muscle cell actin were found mostly in the sinus, base, and the fibrosa of the leaflets, and most surfaces were covered by endothelial cells, indicating a strong potential for repopulation of the scaffold. Conclusions: Tissue-engineered living valves can be generated in vitro using the approach described here. The technology is not trivial and can provide numerous challenges and opportunities, which are discussed in detail in this paper. Overall, we concluded that cell seeding did not negatively affect tissue-engineered heart valve (TEHV) performance as they exhibited as good hemodynamic performance as acellular valves in this model. Further understanding of cell fate after implantation and the timeline of repopulation of acellular scaffolds will help us evaluate the translational potential of this technology.
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Affiliation(s)
- Ionela Movileanu
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
- Institute of Cardiovascular Diseases and Transplant, Târgu Mureş, Romania
| | - Marius Harpa
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
- Institute of Cardiovascular Diseases and Transplant, Târgu Mureş, Romania
| | - Hussam Al Hussein
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
- Institute of Cardiovascular Diseases and Transplant, Târgu Mureş, Romania
| | - Lucian Harceaga
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
| | - Alexandru Chertes
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
| | - Hamida Al Hussein
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
| | - Georg Lutter
- Department for Experimental Cardiac Surgery and Heart Valve Replacement, School of Medicine, University of Kiel, Kiel, Germany
| | - Thomas Puehler
- Department for Experimental Cardiac Surgery and Heart Valve Replacement, School of Medicine, University of Kiel, Kiel, Germany
| | - Terezia Preda
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
| | - Carmen Sircuta
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
| | - Ovidiu Cotoi
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
| | - Dan Nistor
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
- Institute of Cardiovascular Diseases and Transplant, Târgu Mureş, Romania
| | - Adrian Man
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
| | - Bogdan Cordos
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
| | - Radu Deac
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
| | - Horatiu Suciu
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
- Institute of Cardiovascular Diseases and Transplant, Târgu Mureş, Romania
| | - Klara Brinzaniuc
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
- Institute of Cardiovascular Diseases and Transplant, Târgu Mureş, Romania
| | - Megan Casco
- Biocompatibility and Tissue Regeneration Laboratory, Department of Bioengineering, Clemson University, Clemson, SC, United States
| | | | - Margarita Bruce
- Biocompatibility and Tissue Regeneration Laboratory, Department of Bioengineering, Clemson University, Clemson, SC, United States
| | - Dan Simionescu
- Regenerative Medicine Laboratory, University of Medicine, Pharmacy, Science and Technology “George Emil Palade”, Târgu Mureş, Romania
- Biocompatibility and Tissue Regeneration Laboratory, Department of Bioengineering, Clemson University, Clemson, SC, United States
| | - Agneta Simionescu
- Tissue Engineering Laboratory, Department of Bioengineering, Clemson University, Clemson, SC, United States
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16
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Horke A, Tudorache I, Laufer G, Andreas M, Pomar JL, Pereda D, Quintana E, Sitges M, Meyns B, Rega F, Hazekamp M, Hübler M, Schmiady M, Pepper J, Rosendahl U, Lichtenberg A, Akhyari P, Jashari R, Boethig D, Bobylev D, Avsar M, Cebotari S, Haverich A, Sarikouch S. Early results from a prospective, single-arm European trial on decellularized allografts for aortic valve replacement: the ARISE study and ARISE Registry data. Eur J Cardiothorac Surg 2021; 58:1045-1053. [PMID: 32386409 PMCID: PMC7577293 DOI: 10.1093/ejcts/ezaa100] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 02/20/2020] [Accepted: 02/24/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Decellularized aortic homografts (DAH) may provide an additional aortic valve replacement option for young patients due to their potential to overcome the high early failure rate of conventional allogenic and xenogenic aortic valve prostheses. METHODS A prospective, European Union-funded, single-arm, multicentre, safety study was conducted in 8 centres evaluating non-cryopreserved DAH for aortic valve replacement. RESULTS One hundred and forty-four patients (99 male) were prospectively enrolled between October 2015 and October 2018, mean age 33.6 ± 20.8 years; 45% had undergone previous cardiac operations. Mean implanted DAH diameter 22.6 ± 2.4 mm and mean durations for the operation, cardiopulmonary bypass and cross-clamp were 341 ± 140, 174 ± 80 and 126 ± 43 min, respectively. There were 2 early deaths (1 LCA thrombus on day 3 and 1 ventricular arrhythmia 5 h postop) and 1 late death due to endocarditis 4 months postoperatively, resulting in a total mortality of 2.08%. One pacemaker implantation was necessary and 1 DAH was successfully repaired after 6 weeks for early regurgitation following subcoronary implantation. All other DAH were implanted as a free-standing root. After a mean follow-up of 1.54 ± 0.81 years, the primary efficacy end points peak gradient (mean 11.8 ± 7.5 mmHg) and regurgitation (mean 0.42 ± 0.49, grade 0-3) were excellent. At 2.5 years, freedom from explantation/endocarditis/bleeding/stroke was 98.4 ± 1.1%/99.4 ± 0.6%/99.1 ± 0.9%/99.2 ± 0.8%, respectively, with results almost identical to those in an age-matched Ross operation cohort of 212 patients (mean age 34 years) despite DAH patients having undergone >2× more previous procedures. CONCLUSIONS The initial results of the prospective multicentre ARISE trial show DAH to be safe for aortic valve replacement with excellent haemodynamics in the short follow-up period.
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Affiliation(s)
- Alexander Horke
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Igor Tudorache
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Jose L Pomar
- Department of Cardiovascular Surgery, Hospital Clinico de Barcelona, Barcelona, Spain.,Department of Cardiology, Hospital Clinico de Barcelona, Barcelona, Spain
| | - Daniel Pereda
- Department of Cardiovascular Surgery, Hospital Clinico de Barcelona, Barcelona, Spain.,Department of Cardiology, Hospital Clinico de Barcelona, Barcelona, Spain
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinico de Barcelona, Barcelona, Spain.,Department of Cardiology, Hospital Clinico de Barcelona, Barcelona, Spain
| | - Marta Sitges
- Department of Cardiovascular Surgery, Hospital Clinico de Barcelona, Barcelona, Spain.,Department of Cardiology, Hospital Clinico de Barcelona, Barcelona, Spain
| | - Bart Meyns
- Department of Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Mark Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Michael Hübler
- Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | - Martin Schmiady
- Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | - John Pepper
- Department of Cardiovascular Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - U Rosendahl
- Department of Cardiovascular Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Artur Lichtenberg
- Department for Cardiovascular Surgery, Heinrich-Heine University, Düsseldorf, Germany
| | - Payam Akhyari
- Department for Cardiovascular Surgery, Heinrich-Heine University, Düsseldorf, Germany
| | - Ramadan Jashari
- European Homograft Bank, Clinique Saint-Jean, Brussels, Belgium
| | - Dietmar Boethig
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dmitry Bobylev
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Serghei Cebotari
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Samir Sarikouch
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
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17
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Hjortnaes J, Mokhles MM, Takkenberg JJM, Bouten CVC. Editorial: Heart Valve Tissue Engineering: Are We Ready for Clinical Translation? Front Cardiovasc Med 2021; 8:658719. [PMID: 34055937 PMCID: PMC8155343 DOI: 10.3389/fcvm.2021.658719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/29/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jesper Hjortnaes
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - M M Mokhles
- Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, Netherlands
| | - J J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, Netherlands
| | - C V C Bouten
- Department of Biomedical Engineering and Institute for Complex Molecular Systems, Eindhoven University of Technology, Eindhoven, Netherlands
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18
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Long-Term Outcomes of Patients Undergoing the Ross Procedure. J Am Coll Cardiol 2021; 77:1412-1422. [DOI: 10.1016/j.jacc.2021.01.034] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 11/19/2022]
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19
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Poulis N, Zaytseva P, Gähwiler EKN, Motta SE, Fioretta ES, Cesarovic N, Falk V, Hoerstrup SP, Emmert MY. Tissue engineered heart valves for transcatheter aortic valve implantation: current state, challenges, and future developments. Expert Rev Cardiovasc Ther 2020; 18:681-696. [DOI: 10.1080/14779072.2020.1792777] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Nikolaos Poulis
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland
| | - Polina Zaytseva
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland
| | - Eric K. N. Gähwiler
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland
| | - Sarah E. Motta
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland
- Wyss Translational Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
| | | | - Nikola Cesarovic
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Health Sciences and Technology, Swiss Federal Institute of Technology in Zurich, Zurich, Switzerland
| | - Volkmar Falk
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Health Sciences and Technology, Swiss Federal Institute of Technology in Zurich, Zurich, Switzerland
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
- German Center of Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Simon P. Hoerstrup
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland
- Wyss Translational Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
| | - Maximilian Y. Emmert
- Institute for Regenerative Medicine, University of Zurich, Zurich, Switzerland
- Wyss Translational Center Zurich, University of Zurich and ETH Zurich, Zurich, Switzerland
- Department of Cardiovascular Surgery, Charité Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
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20
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Zakko J, Blum KM, Drews JD, Wu YL, Hatoum H, Russell M, Gooden S, Heitkemper M, Conroy O, Kelly J, Carey S, Sacks M, Texter K, Ragsdale E, Strainic J, Bocks M, Wang Y, Dasi LP, Armstrong AK, Breuer C. Development of Tissue Engineered Heart Valves for Percutaneous Transcatheter Delivery in a Fetal Ovine Model. JACC Basic Transl Sci 2020; 5:815-828. [PMID: 32875171 PMCID: PMC7452327 DOI: 10.1016/j.jacbts.2020.06.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/10/2020] [Accepted: 06/10/2020] [Indexed: 02/06/2023]
Abstract
A fully biodegradable fetal valve was developed using a zinc-aluminum alloy stent and electrospun PCL leaflets. In vitro evaluation of the valve was performed with accelerated degradation, mechanical, and flow loop testing, and the valve showed trivial stenosis and trivial regurgitation. A large animal model was used for percutaneous delivery of the valve to the fetal pulmonary annulus. Following implantation, the valve had no stenosis or regurgitation by echocardiography, and the fetal sheep matured and was delivered at term with the tissue-engineered valve.
This multidisciplinary work shows the feasibility of replacing the fetal pulmonary valve with a percutaneous, transcatheter, fully biodegradable tissue-engineered heart valve (TEHV), which was studied in vitro through accelerated degradation, mechanical, and hemodynamic testing and in vivo by implantation into a fetal lamb. The TEHV exhibited only trivial stenosis and regurgitation in vitro and no stenosis in vivo by echocardiogram. Following implantation, the fetus matured and was delivered at term. Replacing a stenotic fetal valve with a functional TEHV has the potential to interrupt the development of single-ventricle heart disease by restoring proper flow through the heart.
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Key Words
- EOA, effective orifice area
- MPA, main pulmonary artery
- Mn, molecular size
- Mw, molecular weight
- NOI, normalized orientation index
- PCL, polycaprolactone
- PDI, polydispersity index
- PG, pressure gradient
- RF, regurgitant fraction
- RV, right ventricular/ventricle
- SEM, scanning electron microscopy
- TEHV, tissue-engineered heart valve
- congenital heart disease
- tissue-engineered heart valve
- transcatheter heart valve
- translational medicine
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Affiliation(s)
- Jason Zakko
- Center for Regenerative Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Kevin M Blum
- Center for Regenerative Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Biomedical Engineering, Ohio State University, Columbus, Ohio
| | - Joseph D Drews
- Center for Regenerative Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Yen-Lin Wu
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York
| | - Hoda Hatoum
- Coulter Department of Biomedical Engineering, Georgia Tech, Atlanta, Georgia
| | - Madeleine Russell
- Oden Institute for Computational and Engineering Sciences, University of Texas at Austin, Austin, Texas
| | - Shelley Gooden
- Coulter Department of Biomedical Engineering, Georgia Tech, Atlanta, Georgia
| | - Megan Heitkemper
- Center for Regenerative Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Biomedical Engineering, Ohio State University, Columbus, Ohio
| | - Olivia Conroy
- Oden Institute for Computational and Engineering Sciences, University of Texas at Austin, Austin, Texas
| | - John Kelly
- Center for Regenerative Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Stacey Carey
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Michael Sacks
- Oden Institute for Computational and Engineering Sciences, University of Texas at Austin, Austin, Texas
| | - Karen Texter
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Ellie Ragsdale
- Department of OB/GYN-Maternal Fetal Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - James Strainic
- Department of Pediatric Cardiology, University Hospitals Rainbow Babies and Children's Hospital, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Martin Bocks
- University Hospitals Rainbow Babies and Children's Hospital, School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Yadong Wang
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York
| | - Lakshmi Prasad Dasi
- Coulter Department of Biomedical Engineering, Georgia Tech, Atlanta, Georgia
| | | | - Christopher Breuer
- Center for Regenerative Medicine, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio.,Department of Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio
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21
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Huygens SA, Ramos IC, Bouten CVC, Kluin J, Chiu ST, Grunkemeier GL, Takkenberg JJM, Rutten-van Mölken MPMH. Early cost-utility analysis of tissue-engineered heart valves compared to bioprostheses in the aortic position in elderly patients. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:557-572. [PMID: 31982976 PMCID: PMC7214484 DOI: 10.1007/s10198-020-01159-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 01/07/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES Aortic valve disease is the most frequent indication for heart valve replacement with the highest prevalence in elderly. Tissue-engineered heart valves (TEHV) are foreseen to have important advantages over currently used bioprosthetic heart valve substitutes, most importantly reducing valve degeneration with subsequent reduction of re-intervention. We performed early Health Technology Assessment of hypothetical TEHV in elderly patients (≥ 70 years) requiring surgical (SAVR) or transcatheter aortic valve implantation (TAVI) to assess the potential of TEHV and to inform future development decisions. METHODS Using a patient-level simulation model, the potential cost-effectiveness of TEHV compared with bioprostheses was predicted from a societal perspective. Anticipated, but currently hypothetical improvements in performance of TEHV, divided in durability, thrombogenicity, and infection resistance, were explored in scenario analyses to estimate quality-adjusted life-year (QALY) gain, cost reduction, headroom, and budget impact. RESULTS Durability of TEHV had the highest impact on QALY gain and costs, followed by infection resistance. Improved TEHV performance (- 50% prosthetic valve-related events) resulted in lifetime QALY gains of 0.131 and 0.043, lifetime cost reductions of €639 and €368, translating to headrooms of €3255 and €2498 per hypothetical TEHV compared to SAVR and TAVI, respectively. National savings in the first decade after implementation varied between €2.8 and €11.2 million (SAVR) and €3.2-€12.8 million (TAVI) for TEHV substitution rates of 25-100%. CONCLUSIONS Despite the relatively short life expectancy of elderly patients undergoing SAVR/TAVI, hypothetical TEHV are predicted to be cost-effective compared to bioprostheses, commercially viable and result in national cost savings when biomedical engineers succeed in realising improved durability and/or infection resistance of TEHV.
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Affiliation(s)
- Simone A Huygens
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands.
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands.
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands.
| | - Isaac Corro Ramos
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands
| | - Carlijn V C Bouten
- Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Jolanda Kluin
- Department of Cardio-Thoracic Surgery, Academic Medical Centre, Amsterdam, The Netherlands
| | - Shih Ting Chiu
- Medical Data Research Centre, Providence Health and Service, Portland, OR, USA
| | - Gary L Grunkemeier
- Medical Data Research Centre, Providence Health and Service, Portland, OR, USA
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Maureen P M H Rutten-van Mölken
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
- Institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands
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22
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Durko AP, Yacoub MH, Kluin J. Tissue Engineered Materials in Cardiovascular Surgery: The Surgeon's Perspective. Front Cardiovasc Med 2020; 7:55. [PMID: 32351975 PMCID: PMC7174659 DOI: 10.3389/fcvm.2020.00055] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 03/20/2020] [Indexed: 12/13/2022] Open
Abstract
In cardiovascular surgery, reconstruction and replacement of cardiac and vascular structures are routinely performed. Prosthetic or biological materials traditionally used for this purpose cannot be considered ideal substitutes as they have limited durability and no growth or regeneration potential. Tissue engineering aims to create materials having normal tissue function including capacity for growth and self-repair. These advanced materials can potentially overcome the shortcomings of conventionally used materials, and, if successfully passing all phases of product development, they might provide a better option for both the pediatric and adult patient population requiring cardiovascular interventions. This short review article overviews the most important cardiovascular pathologies where tissue engineered materials could be used, briefly summarizes the main directions of development of these materials, and discusses the hurdles in their clinical translation. At its beginnings in the 1980s, tissue engineering (TE) was defined as “an interdisciplinary field that applies the principles of engineering and the life sciences toward the development of biological substitutes that restore, maintain, or improve tissue function” (1). Currently, the utility of TE products and materials are being investigated in several fields of human medicine, ranging from orthopedics to cardiovascular surgery (2–5). In cardiovascular surgery, reconstruction and replacement of cardiac and vascular structures are routinely performed. Considering the shortcomings of traditionally used materials, the need for advanced materials that can “restore, maintain or improve tissue function” are evident. Tissue engineered substitutes, having growth and regenerative capacity, could fundamentally change the specialty (6). This article overviews the most important cardiovascular pathologies where TE materials could be used, briefly summarizes the main directions of development of TE materials along with their advantages and shortcomings, and discusses the hurdles in their clinical translation.
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Affiliation(s)
- Andras P Durko
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Magdi H Yacoub
- Imperial College London, National Heart and Lung Institute, London, United Kingdom
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, Amsterdam, Netherlands
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23
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Bichell DP. Commentary: (1) Spare the valve; (2) sacrifice the valve; or (3) park valve rudiments in situ, as growable inventory, for future re-employment. J Thorac Cardiovasc Surg 2019; 159:2393-2394. [PMID: 31447134 DOI: 10.1016/j.jtcvs.2019.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 11/28/2022]
Affiliation(s)
- David P Bichell
- Department of Cardiac Surgery, Monroe Carell, Jr Children's Hospital, Vanderbilt University Medical Center, Nashville, Tenn.
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