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Fard A, Mahmood Z, Nair S, Shaikhrezai K, Al-Attar N. Analysis of incidence and reasons for re-intervention after aortic valve replacement using the Trifecta aortic bioprosthesis. Curr Probl Cardiol 2022; 48:101125. [PMID: 35114295 DOI: 10.1016/j.cpcardiol.2022.101125] [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: 01/21/2022] [Accepted: 01/25/2022] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Trifecta bioprosthesis claims favourable haemodynamic performance. However, reports of structural valve deterioration (SVD) raise concerns of its long-term durability. We assessed outcomes with the Trifecta valve over a 10-year period. METHODS All patients receiving Trifecta bioprostheses between October 2011 and October 2020 were included. Perioperative and survival characteristics were prospectively collated in an independent database. Re-intervention was recorded as a surrogate for SVD. RESULTS 944 patients (mean age 72.82 years ± 8.13, 58% male) underwent aortic valve replacement with the Trifecta valve. At 10-years, 1.4% of patients required a redo operation, giving an overall freedom from re-intervention of 98.6%. The mean time to re-intervention was 48.87 months. Survival was 73.58% and 76.92% in patients who did not require re-intervention vs re-intervention group, respectively. CONCLUSIONS In a large, single-centre cohort, the Trifecta aortic bioprosthesis had a 1.4% all-cause re-intervention rate at 10-years, with insignificant impact on survival.
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Affiliation(s)
| | - Zahid Mahmood
- Golden Jubilee National Hospital, Clydebank, Scotland
| | | | | | - Nawwar Al-Attar
- University of Glasgow, Glasgow, UK; Golden Jubilee National Hospital, Clydebank, Scotland.
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2
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Porterie J, Salaun E, Ternacle J, Clavel MA, Dagenais F. Stress exercise haemodynamic performance and opening reserve of a stented bovine pericardial aortic valve bioprosthesis. J Card Surg 2022; 37:618-627. [PMID: 35020229 DOI: 10.1111/jocs.16220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Despite unusual high rates of patient-prosthesis mismatch (PPM), excellent midterm clinical outcomes have been reported after surgical aortic valve replacement (SAVR) with the Avalus™ bioprosthetic valve (Medtronic). To elucidate this "PPM conundrum," the Avalus valve haemodynamics were assessed during exercise testing. METHODS Of the 148 patients who had undergone SAVR with the Avalus valve at our institution, 30 were randomly selected among those in whom stress test was deemed feasible and underwent a resting transthoracic echocardiography immediately followed by exercise echocardiography. Severe PPM was defined as indexed effective orifice area (iEOA) ≤ 0.65 cm2 /m2 and moderate PPM as iEOA > 0.65 and ≤ 0.85 cm2 /m2 . Measured PPM was determined with the use of the measured iEOA at rest or stress, while the estimated PPM was based on the estimated iEOA, derived from the mean EOA reported for each valve size in the manufacturer chart. RESULTS Measured EOA significantly increased from rest to peak exercise in all PPM groups (p < .05) and the rates of moderate and severe measured PPM decreased from 40% and 20% to 27% and 0%, respectively. The patients with low-flow state (flow < 250 ml/s) had significantly lower measured rest EOA (p = .03). On the basis of the estimated iEOA, there was no severe PPM and 19 patients had moderate PPM (63.3%), with a significantly lower opening reserve than the patients without estimated PPM (p = .04). The estimated iEOA was more reliably correlated to the measured iEOA at maximal stress than the measured iEOA at rest, especially in patients with a low-flow state. CONCLUSIONS This study supports the concept of an opening reserve of the Avalus valve to explain the PPM conundrum and promotes the use of exercise Doppler-echocardiography to complete the assessment of mismatch, especially in patients with a low-flow state. Published estimated EOA seems reliable to predict the haemodynamic performance of the Avalus valve, whether the flow conditions at rest.
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Affiliation(s)
- Jean Porterie
- Department of Cardiac Surgery, Heart and Lung University Institute, Quebec City, Quebec, Canada
| | - Erwan Salaun
- Department of Clinical Research, Heart and Lung University Institute, Quebec City, Quebec, Canada.,Department of Medicine, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
| | - Julien Ternacle
- Department of Clinical Research, Heart and Lung University Institute, Quebec City, Quebec, Canada.,Department of Cardiology, Hôpital Cardiologique Haut-Lévêque, CHU de Bordeaux, France
| | - Marie-Annick Clavel
- Department of Clinical Research, Heart and Lung University Institute, Quebec City, Quebec, Canada.,Department of Medicine, Faculty of Medicine, Laval University, Quebec City, Quebec, Canada
| | - François Dagenais
- Department of Cardiac Surgery, Heart and Lung University Institute, Quebec City, Quebec, Canada
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Amirjamshidi H, Vidovich C, Goodman A, Knight PA. Early Outcomes of Isolated Aortic Valve Replacement Through Right Anterior Minithoracotomy Using the Latest-Generation Biological Prosthesis. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2020; 16:52-57. [PMID: 33337279 DOI: 10.1177/1556984520975889] [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: 10/22/2022]
Abstract
OBJECTIVE The aim of this study is to evaluate early and intermediate outcomes and hemodynamics of the latest-generation Trifecta valve implanted using right anterior minithoracotomy. METHODS We performed a single-center, retrospective, observational study including 175 individuals who underwent isolated minimally invasive aortic valve replacement with the latest-generation Trifecta valves through a right anterior minithoracotomy between January 2016 and January 2019. Exclusion criteria for follow-up echocardiographic study included concomitant procedures, conversion to median sternotomy, and nonsurvival during the index admission. Analyses addressed implantation safety, 30-day and intermediate-term survival and hemodynamic performance of the valves. RESULTS Overall, patients were followed with duration ranging from 0.5 to 3 years. Early (<30 days) mortality occurred in 2 patients (1.1%), and there were 9 (5.1%) late (>30 days) deaths. Early thromboembolic events and postoperative bleeding requiring reoperation occurred at a rate of 4.0% (n = 7) and 6.2% (n = 11), respectively. Overall in 175 patients who met inclusion criteria for the follow-up echocardiography study, mean gradients across all valve sizes were 41.3 ± 14.9 (standard deviation) mm Hg preoperatively and remained low at 7.2 ± 3.9 mm Hg with mean effective orifice area of 1.8 ± 0.5 cm2 on the last follow-up echo. There was 1 case of infective prosthetic endocarditis, which did not require valve explant. There were no reoperations due to valve-related problems during the study period. CONCLUSIONS This is the largest series reporting on outcomes of the latest-generation Trifecta valve implanted using right anterior minithoracotomy. Our results demonstrate that this valve can be safely implanted via a minimally invasive approach with excellent early and intermediate outcomes and hemodynamic performance.
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Affiliation(s)
- Hossein Amirjamshidi
- 6923 Division of Cardiac Surgery, University of Rochester Medical Center, NY, USA
| | - Courtney Vidovich
- 6923 Division of Cardiac Surgery, University of Rochester Medical Center, NY, USA
| | - Ariana Goodman
- 6923 Division of Cardiac Surgery, University of Rochester Medical Center, NY, USA
| | - Peter A Knight
- 6923 Division of Cardiac Surgery, University of Rochester Medical Center, NY, USA
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Boujemaa H, Yilmaz A, Robic B, Koppo K, Claessen G, Frederix I, Dendale P, Völler H, van Loon LJ, Hansen D. The effect of minimally invasive surgical aortic valve replacement on postoperative pulmonary and skeletal muscle function. Exp Physiol 2019; 104:855-865. [PMID: 30938881 DOI: 10.1113/ep087407] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Accepted: 04/01/2019] [Indexed: 01/02/2023]
Abstract
NEW FINDINGS What is the central question of this study? How does surgical aortic valve replacement affect cardiopulmonary and muscle function during exercise? What is the main finding and its importance? Early after the surgical replacement of the aortic valve a significant decline in pulmonary function was observed, which was followed by a decline in skeletal muscle function in the subsequent weeks of recovery. These date reiterate, despite restoration of aortic valve function, the need for a tailored rehabilitation programme for the respiratory and peripheral muscular system. ABSTRACT Suboptimal post-operative improvements in functional capacity are often observed after minimally invasive aortic valve replacement (mini-AVR). It remains to be studied how AVR affects the cardiopulmonary and skeletal muscle function during exercise to explain these clinical observations and to provide a basis for improved/tailored post-operative rehabilitation. Twenty-two patients with severe aortic stenosis (AS) (aortic valve area (AVA) <1.0 cm²) were pre-operatively compared to 22 healthy controls during submaximal constant-workload endurance-type exercise for oxygen uptake ( V ̇ O 2 ), carbon dioxide output ( V ̇ C O 2 ), respiratory gas exchange ratio, expiratory volume ( V ̇ E ), ventilatory equivalents for O2 ( V ̇ E / V ̇ O 2 ) and CO2 ( V ̇ E / V ̇ C O 2 ), respiratory rate (RR), tidal volume (Vt ), heart rate (HR), oxygen pulse ( V ̇ O 2 /HR), blood lactate, Borg ratings of perceived exertion (RPE) and exercise-onset V ̇ O 2 kinetics. These exercise tests were repeated at 5 and 21 days after AVR surgery (n = 14), along with echocardiographic examinations. Respiratory exchange ratio and ventilatory equivalents ( V ̇ E / V ̇ O 2 and V ̇ E / V ̇ C O 2 ) were significantly elevated, V ̇ O 2 and V ̇ O 2 /HR were significantly lowered, and exercise-onset V ̇ O 2 kinetics were significantly slower in AS patients vs. healthy controls (P < 0.05). Although the AVA was restored by mini-AVR in AS patients, V ̇ E / V ̇ O 2 and V ̇ E / V ̇ C O 2 further worsened significantly within 5 days after surgery, accompanied by elevations in Borg RPE, V ̇ E and RR, and lowered Vt . At 21 days after mini-AVR, exercise-onset V ̇ O 2 kinetics further slowed significantly (P < 0.05). A decline in pulmonary function was observed early after mini-AVR surgery, which was followed by a decline in skeletal muscle function in the subsequent weeks of recovery. Therefore, a tailored rehabilitation programme should include training modalities for the respiratory and peripheral muscular system.
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Affiliation(s)
- Hajar Boujemaa
- BIOMED - Biomedical Research Center, and REVAL - Rehabilitation Research Center, Faculty of Medicine and Life Sciences, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium
| | - Alaaddin Yilmaz
- Jessa Hospital, Department of Cardiothoracic Surgery, Hasselt, Belgium
| | - Boris Robic
- Jessa Hospital, Department of Cardiothoracic Surgery, Hasselt, Belgium
| | - Katrien Koppo
- Exercise Physiology Research Group, Department of Movement Sciences, KU Leuven, Leuven, Belgium
| | - Guido Claessen
- Jessa Hospital, Heart Centre Hasselt, Hasselt, Belgium.,University Hospitals Leuven, Leuven, Belgium
| | - Ines Frederix
- BIOMED - Biomedical Research Center, and REVAL - Rehabilitation Research Center, Faculty of Medicine and Life Sciences, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium.,Jessa Hospital, Heart Centre Hasselt, Hasselt, Belgium.,Faculty of Medicine and Health Sciences, Antwerp University, Antwerp, Belgium
| | - Paul Dendale
- BIOMED - Biomedical Research Center, and REVAL - Rehabilitation Research Center, Faculty of Medicine and Life Sciences, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium.,Jessa Hospital, Heart Centre Hasselt, Hasselt, Belgium
| | - Heinz Völler
- Humanwissenschaftliche Fakultät, Universität Potsdam, Potsdam, Germany
| | - Luc Jc van Loon
- Department of Human Biology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Dominique Hansen
- BIOMED - Biomedical Research Center, and REVAL - Rehabilitation Research Center, Faculty of Medicine and Life Sciences, Faculty of Rehabilitation Sciences, Hasselt University, Diepenbeek, Belgium.,Jessa Hospital, Heart Centre Hasselt, Hasselt, Belgium
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5
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Nardi P, Pisano C, Bertoldo F, Vacirca SR, Greci M, Bassano C, Scafuri A, Pellegrino A, Ruvolo G. Clinical outcome and hemodynamic performance of St. Jude Trifecta aortic prosthesis: short-term follow-up and risk factors analysis. J Thorac Dis 2019; 11:1465-1474. [PMID: 31179089 PMCID: PMC6531685 DOI: 10.21037/jtd.2019.03.41] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 02/25/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND We retrospectively analysed the short-term outcome of the third-generation St. Jude Trifecta aortic prosthesis. METHODS Between December 2014 and December 2017, 177 patients (mean age 75.1±6.8 years, 95 males, 82 females) underwent aortic valve replacement with a St. Jude Trifecta aortic prosthesis and were followed up to 27±9 months. Preoperatively 92 patients (52.0%) were in NYHA class III-IV, EuroSCORE II was 3.2%±2.1%. RESULTS Trifecta sizes implanted were 19 mm (n=46) (26%), 21 mm (n=69) (39%), 23 mm (n=46) (26%), 25 mm (n=16) (9%). Concomitant coronary artery bypass grafting was performed in 60 patients (34.0%). Operative mortality was 3.4% (1.7% for isolated aortic valve replacement versus 6.7% for combined aortic valve replacement and coronary artery bypass grafting) (P=0.084). The only independent predictor of mortality was the need for the mechanical ventilation greater than 24 hours (P=0.037); recently occurring myocardial infarction was risk factor for mortality at the univariate analysis only (P=0.013). Three-year survival was 84%±6%, freedom from cardiac death 98%±1%, freedom from prosthetic endocarditis 97%±1%. No thromboembolisms or structural valve degeneration were observed. Patient-prosthesis mismatch (PPM) was absent in 126 patients (71.2%), mild-to-moderate in 32 (18.1%), moderate in 19 (10.7%), severe in no any patient. Follow-up echocardiography showed an average mean and peak trans-aortic valve gradients reduction more than 70% in comparison with preoperative value (P<0.0001), and a significant regression of left ventricular hypertrophy (P<0.0001). Moderate PPM did not negatively affect survival. Concomitant severe coronary artery disease was found as an independent predictor of reduced survival (72%±12% versus 86%±6%) (P=0.015). CONCLUSIONS Trifecta aortic prosthesis seems to provide very favourable clinical outcome and hemodynamic performance. At three years, survival was negatively affected by severe coronary artery disease detected at the time of operation. During short-term follow-up, no early structural valve degeneration was been observed. Due to low incidence of PPM and low peak and mean trans-prosthetic aortic valve gradients, third generation Trifecta aortic prosthesis should be considered as one of the best options in the setting of the aortic valve replacement surgery. However, a long-term follow-up is mandatory to confirm the early promising data.
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Affiliation(s)
- Paolo Nardi
- Cardiac Surgery Division, Tor Vergata University Hospital, Rome, Italy
| | - Calogera Pisano
- Cardiac Surgery Division, Tor Vergata University Hospital, Rome, Italy
| | - Fabio Bertoldo
- Cardiac Surgery Division, Tor Vergata University Hospital, Rome, Italy
| | - Sara Rita Vacirca
- Cardiac Surgery Division, Tor Vergata University Hospital, Rome, Italy
| | - Monica Greci
- Cardiac Surgery Division, Tor Vergata University Hospital, Rome, Italy
| | - Carlo Bassano
- Cardiac Surgery Division, Tor Vergata University Hospital, Rome, Italy
| | - Antonio Scafuri
- Cardiac Surgery Division, Tor Vergata University Hospital, Rome, Italy
| | | | - Giovanni Ruvolo
- Cardiac Surgery Division, Tor Vergata University Hospital, Rome, Italy
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6
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Amorim PA, Diab M, Walther M, Färber G, Hagendorff A, Bonow RO, Doenst T. Limitations in the Assessment of Prosthesis-Patient Mismatch. Thorac Cardiovasc Surg 2019; 68:550-556. [DOI: 10.1055/s-0038-1676814] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Abstract
Background Prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) may affect survival but data are conflicting. It is assessed by relating effective orifice area (EOA) to body surface area (EOAi). EOA is patient-specific as the result of flow-velocity times area at the individual patient's outflow tract levels (LVOTA) divided by trans-prosthetic flow velocity. However, some studies use projected EOAs (i.e., valve size associated EOAs from other patient populations) to assess how PPM affects outcome.
Methods We analyzed 76 studies addressing hemodynamic outcome and/or mortality after bioprosthetic AVR.
Results In 48 studies, projected or measured EOA for calculation of EOAi and PPM assessment was used (of which 25 demonstrated an effect on survival). We identified 28 additional studies providing measured EOA values and the corresponding Bernoulli's pressure gradients after AVR. Despite EOA being a patient-specific parameter, 77% of studies assessing a PPM impact on survival used projected EOAs. The 28 studies are providing measured EOA values and the corresponding Bernoulli's pressure gradients in patients after AVR showed a highly significant, linear relationship between EOA and Bernoulli's gradient. Considering this relationship, it is surprising that relating EOA to body surface area (BSA) (EOAi) is standard but relating pressure gradients to BSA is not.
Conclusion We conclude that the majority of studies assessing PPM have used false assumptions because EOA is a patient-specific parameter and cannot be transferred to other patients. In addition, the use of EOAi to assess PPM may not be appropriate and could explain the inconsistent relation between PPM and survival in previous studies.
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Affiliation(s)
- Paulo A. Amorim
- Department of Cardiothoracic Surgery, Friedrich Schiller University Jena, Jena, Germany
| | - Mahmoud Diab
- Department of Cardiothoracic Surgery, Friedrich Schiller University Jena, Jena, Germany
| | - Mario Walther
- Department of Basic Sciences, University of Applied Sciences Jena, Jena, Germany
| | - Gloria Färber
- Department of Cardiothoracic Surgery, Friedrich Schiller University Jena, Jena, Germany
| | - Andreas Hagendorff
- Department of Internal Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Robert O. Bonow
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine Chicago, Chicago, Germany
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Friedrich Schiller University Jena, Jena, Germany
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7
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Magna Ease versus Trifecta Early Hemodynamics. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:267-272. [DOI: 10.1097/imi.0000000000000534] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective This meta-analysis compares the early echocardiographic outcomes of aortic valve replacement using the two most commonly implanted stented bioprostheses. Methods We searched MEDLINE and EMBASE databases until 2017 for studies comparing Magna or Magna Ease (Edwards Lifesciences, Irvine, CA USA) versus Trifecta (St Jude Medical, St. Paul, MN USA) aortic bioprosthetic valves. A random-effects meta-analysis was performed for the primary outcome of mean gradient on echocardiography and secondary outcomes of effective orifice area, indexed effective orifice area, and in-hospital mortality. Results There were two randomized controlled trial, three matched, and six unmatched retrospective observational studies with 2119 patients [median reported follow-up = 6 months (interquartile range = 6 to 12)]. The Magna/Magna Ease valve was associated with higher early mean gradient (mean difference = 4.09, 95% confidence interval = 3.48 to 4.69, P < 0.0001) and smaller effective orifice area (mean difference = 0.30, 95% confidence interval = −0.38 to −0.22, P < 0.0001). There were no differences in 30-day mortality between Magna/Magna Ease and Trifecta (relative risk = 1.01, 95% confidence interval = 0.41 to 2.50, P = 1.0). Conclusions Trifecta may offer a small hemodynamic advantage compared with the Magna/Magna Ease valve with no differences in early mortality. Long-term follow-up is required to determine whether these differences persist and translate into differences in clinical outcomes.
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Stock S, Lohmann I, Hanke T, Stierle U, Richardt D, Tsvelodub S, Sievers HH. Rest and exercise haemodynamics in patients with one of two stented bioprostheses and in healthy controls with small aortic annuli. Interact Cardiovasc Thorac Surg 2018; 26:425-430. [PMID: 29095979 DOI: 10.1093/icvts/ivx356] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/03/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Because bioprosthetic aortic valve replacement remains one of the most frequent cardiac surgical procedures, it is necessary to study patient haemodynamics in more detail. Until now, a few studies assessed haemodynamics during exercise, but none with special regard to small aortic annuli. We compared patients who had the differently designed bioprostheses, Trifecta and Perimount Magna Ease (PME), size ≤ 23 mm, and a healthy control group during rest and exercise. METHODS We determined the mean transvalvular gradient, the effective orifice area (EOA) and the EOA index during rest and exercise using transthoracic echocardiography in 35 patients with the Trifecta (mean age 71.4 years, follow-up 1 year, labelled valve size 21.7 mm), in 16 patients with the PME (mean age 66.2 years, follow-up 2.6 years, labelled valve size 21.6 mm) and in 25 healthy persons. The parameters derived were summarized in a simplified Valve Academic Research Consortium-2 classification to determine prosthetic valve dysfunction. RESULTS When we compared the Trifecta and the PME, a significant superiority of the Trifecta was seen at rest in mean transvalvular gradient (7.96 vs 12.19 mmHg) and EOA (1.57 vs 1.48 cm2), during exercise in all parameters (mean transvalvular gradient 11.06 vs 19.2 mmHg, EOA 1.77 vs 1.26 cm2, EOA index 0.96 vs 0.67 cm2/m2). The Trifecta showed a physiological increase in the EOA index during exercise. Exercise led to a shift to better simplified Valve Academic Research Consortium-2 categories in the Trifecta and to worse in the PME group. CONCLUSIONS This study reveals the haemodynamic superiority of the Trifecta to the PME. Especially in small aortic annuli, this difference might have some relevance for clinical and research issues.
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Affiliation(s)
- Sina Stock
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Inga Lohmann
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Thorsten Hanke
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Ulrich Stierle
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Doreen Richardt
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Stanislav Tsvelodub
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Hans-Hinrich Sievers
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
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9
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Lehmann S, Meyer A, Schroeter T, Uhlemann M, Fischer J, Leontyev S, Garbade J, Holzhey D, Misfeld M, Mohr FW. Midterm Durability and Hemodynamic Performance of a Third-Generation Bovine Pericardial Prosthetic Aortic Valve: The Leipzig Experience. Ann Thorac Surg 2017; 103:1933-1939. [DOI: 10.1016/j.athoracsur.2016.09.073] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 08/28/2016] [Accepted: 09/12/2016] [Indexed: 11/28/2022]
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10
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Anselmi A, Ruggieri VG, Lelong B, Flecher E, Corbineau H, Langanay T, Verhoye JP, Leguerrier A. Mid-term durability of the Trifecta bioprosthesis for aortic valve replacement. J Thorac Cardiovasc Surg 2017; 153:21-28.e1. [DOI: 10.1016/j.jtcvs.2016.07.080] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 07/09/2016] [Accepted: 07/30/2016] [Indexed: 10/21/2022]
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12
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Chambers JB, Parkin D, Roxburgh J, Bapat V, Young C. A comparison of two forms of the continuity equation in the Trifecta bovine pericardial aortic valve. Echo Res Pract 2016; 3:25-8. [PMID: 27249811 PMCID: PMC5329893 DOI: 10.1530/erp-16-0007] [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: 02/11/2016] [Accepted: 03/08/2016] [Indexed: 11/08/2022] Open
Abstract
AIM To compare the classical and simplified form of the continuity equation in small Trifecta valves. METHODS This is a retrospective analysis of post-operative echocardiograms performed for clinical reasons after implantation of Trifecta bioprosthetic valves. RESULTS There were 60 patients aged 74 (range 38-89) years. For the valves of size 19, 21 and 23mm, the mean gradient was 11.3, 10.7 and 9.7mmHg, respectively. The effective orifice areas by the classical form of the continuity equation were 1.4, 1.7 and 1.9cm(2), respectively. There was a good correlation between the two forms of the continuity equation, but they were significantly different using a t-test (P<0.00001). Results using the classical form were a mean 0.11 (s.d. 0.18)cm(2) larger than those using the simple formula. CONCLUSION Haemodynamic function of the Trifecta valve in the small aortic root is good. There are significant differences between the classical and simplified forms of the continuity equation.
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Affiliation(s)
- John B Chambers
- Cardiothoracic Centre, Guy's and St Thomas' Hospitals, London, UK
| | - Denise Parkin
- Cardiothoracic Centre, Guy's and St Thomas' Hospitals, London, UK
| | - James Roxburgh
- Cardiothoracic Centre, Guy's and St Thomas' Hospitals, London, UK
| | - Vinayak Bapat
- Cardiothoracic Centre, Guy's and St Thomas' Hospitals, London, UK
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13
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Bach DS, Patel HJ, Kolias TJ, Deeb GM. Randomized comparison of exercise haemodynamics of Freestyle, Magna Ease and Trifecta bioprostheses after aortic valve replacement for severe aortic stenosis. Eur J Cardiothorac Surg 2016; 50:361-7. [DOI: 10.1093/ejcts/ezv493] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 12/22/2015] [Indexed: 11/13/2022] Open
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Abstract
The specific flow pattern and imaging features of prosthetic heart valves poses major challenges for the Doppler echocardiographic assessment of prosthetic valve structure and function. A comprehensive approach that integrates several semi-quantitative and quantitative parameters obtained from multiple views is key to appropriately detect and quantitate prosthetic valve dysfunction and complications. In patients with prosthetic valves, and particularly in those with mitral prostheses, transesophageal echocardiography is often required to confirm and/or complement information obtained by transthoracic echocardiography. Three-dimensional echocardiography may provide incremental information for the identification of the underlying etiology of prosthetic valve stenosis or regurgitation. Transcatheter aortic valve implantation has rapidly expanded in the past 10 years and paravalvular regurgitation is frequent following this procedure. Given that paravalvular regurgitant jets are often multiple, irregular, and eccentric, the grading of this type of regurgitation is particularly challenging and requires an integrative multiwindow, multiplane, multiparametric approach.
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Affiliation(s)
- Haïfa Mahjoub
- Institut Universitaire de Cardiologie et de Pneumologie de Québec / Québec Heart and Lung Institute, Department of Medicine, Laval University, 2725 Chemin Sainte-Foy, Québec, Québec, Canada, G1V-4G5
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Fouquet O, Flecher E, Nzomvuama A, Remadi JP, Bière L, Donal E, Levy F, Dalmayrac E, Szymanski C, Leguerrier A, Tribouilloy C. Haemodynamic performance of the small supra-annular Trifecta bioprosthesis: results from a French multicentre study. Interact Cardiovasc Thorac Surg 2016; 22:439-44. [DOI: 10.1093/icvts/ivv363] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 11/17/2015] [Indexed: 11/12/2022] Open
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16
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Mariscalco G, Mariani S, Bichi S, Biondi A, Blasio A, Borsani P, Corti F, De Chiara B, Gherli R, Leva C, Russo CF, Tasca G, Vanelli P, Alfieri O, Antona C, Di Credico G, Esposito G, Gamba A, Martinelli L, Menicanti L, Paolini G, Beghi C. St. Jude Medical Trifecta aortic valve: results from a prospective regional multicentre registry. J Cardiothorac Surg 2015; 10:169. [PMID: 26589286 PMCID: PMC4654896 DOI: 10.1186/s13019-015-0379-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 11/12/2015] [Indexed: 12/04/2022] Open
Abstract
Background The Trifecta aortic bioprosthesis (St. Jude Medical, Inc., St. Paul, MN, USA) is a stented pericardial heart valve with excellent preliminary results. Aim of the study was to evaluate its early clinical and hemodynamic performances in a multicenter regional registry. Methods Between January 2011 and June 2012, 178 consecutive patients undergoing aortic valve replacement with the Trifecta bioprosthesis were prospectively enrolled at 9 Italian centers. Clinical and echocardiographic data were collectedat discharge, 6-months and at 1-year postoperatively. Results The average age was 75.4 ± 7.7 years,and 95 (53 %) were men. Indication for valve replacement included stenosis in 123 patients (69 %), mixed lesions in 25 (14 %), and regurgitation in 30 (17 %). Ninety-three (52 %) patients were in NYHA functional class III/ IV. Hospital mortality accounted for 5 (2.8 %) patients. No valve-related perioperative complications were encountered. Median follow-up was 20.5 months (range: 1-34). Early (≤6 months) complications included one thromboembolic event, one major bleeding, and 3 endocarditis (2 explants). Two late (>6 months) thromboembolic events and two endocarditis (1 explant) were registered. No valve thrombosis or structural deterioration were observed after discharge. At 30-months, freedom from all-cause mortality was 87 %, freedom from valve-related mortality 99.4 %, freedom from endocarditis 97.5 %, and freedom from valve explants 98 %. At 1-year, mean gradients ranged from 8 to 16 mmHg, and effective orifice area indexes from 1.0 to 1.2 cm2/m2 for valve sizes from 19 to27 mm, respectively. No patients had severe prosthesis-patient mismatch. Conclusions Trifecta bioprosthesis provided favourable clinical and hemodynamic results over time.
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Affiliation(s)
- Giovanni Mariscalco
- Department of Cardiovascular sciences, Clinical Science Wing, University of Leicester, Glenfield Hospital, Leicester, United Kingdom.
| | - Silvia Mariani
- Cardiac Surgery Clinic, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Samuele Bichi
- Section of Cardiac Surgery, Department of Cardiovascular Disease, Cliniche Humanitas Gavazzeni, Bergamo, Italy
| | - Andrea Biondi
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Andrea Blasio
- Department of Cardio-Thoracic and Vascular Surgery, Università Vita-Salute San Raffaele, Milan, Italy
| | - Paolo Borsani
- Department of Cardiovascular sciences, Clinical Science Wing, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
| | - Fabrizio Corti
- Cardiac Surgery Clinic, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Benedetta De Chiara
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, Niguarda Cà Granda Hospital, Milan, Italy
| | - Riccardo Gherli
- Department of Cardiovascular sciences, Clinical Science Wing, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
| | - Cristian Leva
- Department of Cardiac Surgery, Ospedale Civile di Legnano, Legnano, Italy
| | - Claudio Francesco Russo
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, Niguarda Cà Granda Hospital, Milan, Italy
| | - Giordano Tasca
- Cardiac Surgery Unit, Alessandro Manzoni Hospital of Lecco, Lecco, Italy
| | - Paolo Vanelli
- Cardio-Cerebro-Vascular Department, 'L. Sacco' University General Hospital, Milan, Italy
| | - Ottavio Alfieri
- Department of Cardio-Thoracic and Vascular Surgery, Università Vita-Salute San Raffaele, Milan, Italy
| | - Carlo Antona
- Cardio-Cerebro-Vascular Department, 'L. Sacco' University General Hospital, Milan, Italy
| | - Germano Di Credico
- Department of Cardiac Surgery, Ospedale Civile di Legnano, Legnano, Italy
| | - Giampiero Esposito
- Section of Cardiac Surgery, Department of Cardiovascular Disease, Cliniche Humanitas Gavazzeni, Bergamo, Italy
| | - Amando Gamba
- Cardiac Surgery Unit, Alessandro Manzoni Hospital of Lecco, Lecco, Italy
| | - Luigi Martinelli
- Cardiac Surgery Unit, Cardio-Thoraco-Vascular Department, Niguarda Cà Granda Hospital, Milan, Italy
| | - Lorenzo Menicanti
- Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Giovanni Paolini
- Cardiac Surgery Clinic, University of Milano-Bicocca, San Gerardo Hospital, Monza, Italy
| | - Cesare Beghi
- Department of Cardiovascular sciences, Clinical Science Wing, University of Leicester, Glenfield Hospital, Leicester, United Kingdom
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Ruggieri VG, Anselmi A, Chabanne C, Lelong B, Flecher E, Verhoye JP, Leguerrier A. Three-year haemodynamic performance of the St Jude Trifecta bioprosthesis. Eur J Cardiothorac Surg 2015; 49:972-7. [DOI: 10.1093/ejcts/ezv211] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2015] [Accepted: 05/04/2015] [Indexed: 11/14/2022] Open
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Permanyer E. Time, it needs time. J Thorac Cardiovasc Surg 2015; 149:1483-4. [PMID: 25869086 DOI: 10.1016/j.jtcvs.2015.03.029] [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: 03/13/2015] [Accepted: 03/14/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Eduard Permanyer
- Department of Cardiac Surgery, Vall d'Hebron Hospital, Barcelona, Spain.
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Colli A, Marchetto G, Salizzoni S, Rinaldi M, Di Marco L, Pacini D, Di Bartolomeo R, Nicolini F, Gherli T, Agrifoglio M, Borghetti V, Khoury G, De Paolis M, Zoffoli G, Mangino D, Amorim MJ, Manzan E, Zucchetta F, Balduzzi S, Gerosa G. The TRIBECA study: (TRI)fecta (B)ioprosthesis (E)valuation versus (C)arpentier Magna-Ease in (A)ortic position. Eur J Cardiothorac Surg 2015; 49:478-85. [PMID: 25769464 DOI: 10.1093/ejcts/ezv070] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 01/23/2015] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To determine whether the Trifecta bioprosthetic aortic valve produces postoperative haemodynamic results comparable with or better than those of the Magna Ease aortic valve bioprosthesis. METHODS We retrospectively reviewed the medical records of patients who had undergone aortic valve replacement with Trifecta or Magna Ease prostheses at eight European institutions between January 2011 and May 2013, and analysed early postoperative haemodynamic performance by means of echocardiography. RESULTS A total of 791 patients underwent aortic valve replacement (469 Magna Ease, 322 Trifecta). Haemodynamic variables were evaluated on discharge and during the follow-up (minimum 6 months, maximum 12 months). The mean gradient and the indexed effective orifice area (IEOA) were as follows: 10 mmHg [interquartile range (IQR): 8-13] and 1.10 cm(2)/m(2) (IQR: 0.95-1.27) for Trifecta; 16 mmHg (IQR: 11-22) and 0.96 cm(2)/m(2) (IQR: 0.77-1.13) for Magna Ease (P < 0.001). These significant differences were maintained across all valve sizes. Similar statistically significant differences were found when patients were matched and/or stratified for preoperative characteristics: body-surface area, ejection fraction, mean gradients and valve size. Severe prosthesis-patient mismatch (IEOA: <0.65 cm(2)/m(2)) was detected in 2 patients (0.6%) with Trifecta and 40 patients (8.5%) with Magna Ease (P < 0.001). CONCLUSIONS The haemodynamic performance of the Trifecta bioprosthesis was superior to that of the Magna Ease valve across all conventional prosthesis sizes, with almost no incidence of severe patient-prosthesis mismatch. The long-term follow-up is needed to determine whether these significant haemodynamic differences will persist, and influence clinical outcomes.
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Affiliation(s)
- Andrea Colli
- Department of Cardiology, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Giovanni Marchetto
- Division of Cardiac Surgery, San Giovanni Battista Hospital 'Molinette', University of Turin, Turin, Italy
| | - Stefano Salizzoni
- Division of Cardiac Surgery, San Giovanni Battista Hospital 'Molinette', University of Turin, Turin, Italy
| | - Mauro Rinaldi
- Division of Cardiac Surgery, San Giovanni Battista Hospital 'Molinette', University of Turin, Turin, Italy
| | - Luca Di Marco
- Cardiac Surgery Department, S.Orsola-Malpighi Hospital, University of Bologna, Parma, Italy
| | - Davide Pacini
- Cardiac Surgery Department, S.Orsola-Malpighi Hospital, University of Bologna, Parma, Italy
| | - Roberto Di Bartolomeo
- Cardiac Surgery Department, S.Orsola-Malpighi Hospital, University of Bologna, Parma, Italy
| | - Francesco Nicolini
- Department of Clinical and Experimental Medicine, Cardiac Surgery Unit, University of Parma, Parma, Italy
| | - Tiziano Gherli
- Department of Clinical and Experimental Medicine, Cardiac Surgery Unit, University of Parma, Parma, Italy
| | - Marco Agrifoglio
- Department of Clinical Sciences and Community Health, Cardiac Surgery, University of Milan, Centro Cardiologico Monzino Hospital, Milan, Italy
| | - Valentino Borghetti
- Cardio-Thoracic and Vascular Department, University Hospital of Terni, Terni, Italy
| | - Georgette Khoury
- Cardio-Thoracic and Vascular Department, University Hospital of Terni, Terni, Italy
| | - Marcella De Paolis
- Cardio-Thoracic and Vascular Department, University Hospital of Terni, Terni, Italy
| | - Giampaolo Zoffoli
- Department of Cardiac Surgery, Ospedale dell'Angelo, Venezia-Mestre, Italy
| | - Domenico Mangino
- Department of Cardiac Surgery, Ospedale dell'Angelo, Venezia-Mestre, Italy
| | | | - Erica Manzan
- Department of Cardiology, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Fabio Zucchetta
- Department of Cardiology, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
| | - Sara Balduzzi
- Department of Clinical and Diagnostic Medicine and Public Health, University of Modena and Reggio Emilia, Padua, Italy
| | - Gino Gerosa
- Department of Cardiology, Thoracic and Vascular Sciences, University of Padua, Padua, Italy
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Tasca G, Redaelli P, Riva B, De Carlini CC, Lobiati E, Gamba A. Hemodynamic comparison between Trifecta and freestyle aortic valve during exercise in patients with small aortic root. J Card Surg 2015; 30:400-4. [PMID: 25756936 DOI: 10.1111/jocs.12536] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Patients with a small aortic annulus, that is ≤ 23 mm, constitute a challenge for the surgeon, because they are at high risk of patient-prosthesis mismatch. Stentless valves provide better hemodynamic performance at rest and during exercise than stented valves, and are advocated in this group of patients. A new-generation stented valve, the Trifecta (St. Jude), has recently become available with improved hemodynamics. The aim of this study was to compare the hemodynamic performance of Freestyle (Medtronic) and Trifecta at rest and during exercise in patients with a small aortic annulus. METHODS From September 2012 to September 2014, 22 patients with a native aortic annulus ≤ 23 mm underwent ergometric stress testing one year after aortic valve replacement with either a Trifecta (12 patients) or a Freestyle (10 patients) bioprosthesis as part of a randomized study. RESULTS The mean gradient at rest was 6.0 ± 2.3 mmHg for Trifecta and 4.3 ± 3.5 for Freestyle (p = 0.213). The mean gradient at peak of exercise was 9.7 ± 3.4 mmHg for Trifecta and 7.4 ± 5 mmHg for Freestyle (p = 0.243). No significant differences were found between the two prostheses regarding other hemodynamic parameters: effective orifice area, velocity index, and performance indexes. CONCLUSION Both the stented Trifecta and stentless Freestyle prostheses provide excellent hemodynamic results during physical stress in patients with a small aortic annulus. Our study confirms that Trifecta implantation results in low gradients at rest and during exercise and that the performance of Trifecta is similar to that of a stentless valve.
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Affiliation(s)
- Giordano Tasca
- Department of Cardiovascular, Operative Unit of Cardiac Surgery, Ospedale "A. Manzoni" di Lecco, Lecco, Italy; Department of Electronic, Information and Bioengeering, Politecnico di Milano, Milan, Italy
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Early hemodynamic performance of the third generation St Jude Trifecta aortic prosthesis: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2015; 149:1567-75.e1-2. [PMID: 25802135 DOI: 10.1016/j.jtcvs.2015.01.043] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 01/05/2015] [Accepted: 01/29/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The Trifecta aortic prosthesis is a latest-generation trileaflet stented pericardial valve designed for supra-annular placement in the aortic position. Robust clinical evidence and long-term follow-up data for this new prosthesis are lacking; a systematic review was conducted to assess current evidence. METHODS A comprehensive search from 6 electronic databases was performed, with time period parameters dating from database inception to January 2014. Results utilizing Trifecta prosthesis for aortic valve replacement (AVR) were identified. RESULTS A total of 13 studies with 2549 patients undergoing AVR with this prosthesis were included in this review. The mean proportion of patients with aortic stenosis was 82.4%, with a mean gradient of 47.4 mm Hg, and a pooled effective orifice area (EOA) of 0.74 cm(2). Valve sizes of 21 mm and 23 mm were implanted in 71.3% of patients. The pooled rates of 30-day mortality, cerebrovascular accidents, and acute kidney injuries were 2.7%, 1.9%, and 2.6%, respectively. After implantation, the pooled mean gradient decreased to 9.2 mm Hg, whereas discharge EOA increased to 1.8 cm(2), compared with preoperative parameters. Among included studies with significant heterogeneity detected, most patients had satisfactory patient-prosthesis mismatch, with 2.7% having severe mismatch. CONCLUSIONS The present systematic review demonstrated that short-term AVR with this prosthesis provided excellent early safety and hemodynamic outcomes with acceptable mean gradients and EOA. Long-term follow-up and randomized controlled trials are warranted to confirm the early results.
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Kheradvar A, Groves EM, Goergen CJ, Alavi SH, Tranquillo R, Simmons CA, Dasi LP, Grande-Allen KJ, Mofrad MRK, Falahatpisheh A, Griffith B, Baaijens F, Little SH, Canic S. Emerging Trends in Heart Valve Engineering: Part II. Novel and Standard Technologies for Aortic Valve Replacement. Ann Biomed Eng 2014; 43:844-57. [DOI: 10.1007/s10439-014-1191-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 11/13/2014] [Indexed: 11/29/2022]
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Coisne A, Levy F, Malaquin D, Richardson M, Quéré JP, Montaigne D, Tribouilloy C. Feasibility of Doppler hemodynamic evaluation of primary and secondary mitral regurgitation during exercise echocardiography. Int J Cardiovasc Imaging 2014; 31:291-9. [DOI: 10.1007/s10554-014-0550-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Accepted: 10/07/2014] [Indexed: 11/25/2022]
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Dumesnil JG, Pibarot P. The Problem of Severe Valve Prosthesis-Patient Mismatch in Aortic Bioprostheses: Near Extinction? J Am Soc Echocardiogr 2014; 27:598-600. [DOI: 10.1016/j.echo.2014.04.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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