Suture technique does not affect hemodynamic performance of the small supra-annular Trifecta bioprosthesis

Continuous or interrupted pledgeted suture technique in stented bioprosthetic aortic valve replacement: a comparison of in-hospital outcomes

BACKGROUND

There is ambiguity in the literature regarding the continuous suture technique (CST) for aortic valve replacement (AVR). At our center, there has been a gradual shift towards CST over the interrupted pledgeted technique (IPT). This study aims at comparing outcomes for both techniques.

METHODS

We performed a retrospective analysis of a single-center study of patients undergoing AVR between January 2011 and July 2020. Patients were divided into two groups: Continuous suture technique and interrupted pledget-reinforced sutures. The pre-operative and In-hospital clinical characteristics and echocardiographic hemodynamics (i.e. transvalvular gradients and paravalvular leakage) were compared between CST and IPT.

RESULTS

We compared 791 patients with CST to 568 patients with IPT (median age: 73 and 74 years, respectively, p = 0.02). In CST there were 35% concomitant procedure vs. 31% in IPT (p = 0.16). Early mortality was 3.2% in CST versus 4.8% in IPT (p = 0.15), and a second cross-clamp due to a paravalvular-leak in 0.5% vs. 1.2%, respectively (p = 0.22). The CST was not associated with new-onset conduction-blocks mandating pacemaker implants(OR 1.07, 95% CI 0.54-2.14; P = 0.85). The postoperative gradients on echocardiography were lower in CST compared to IPT, especially in smaller annuli (peak gradients: 15.7mmHg vs. 20.5mmHg, in valve size < 23 mm, p < 0.001).

CONCLUSIONS

The continuous suture technique was associated with lower postoperative gradients and shorter cross-clamp time compared to interrupted pledgeted technique. Differences in paravalvular leaks were non-significant, although slightly less in the continuous suture technique. There were no further differences in valve-related complications. Hence, continues suture technique is safe, with better hemodynamics compared to the interrupted pledgeted technique. This may be of clinical importance, especially in smaller size annular size.

Figure of eight suture technique in aortic valve replacement decreases prosthesis-patient mismatch

BACKGROUND

While the pledget suture technique has been the standard for surgical aortic. valve replacement (AVR), discussion continues regarding the possibility of the nonpledget suture technique to produce superior structural and hemodynamic parameters. This study aims to assess the effectiveness of the figure-of-eight suture technique in AVR, as determined by the incidence of prosthesis-patient mismatch (PPM).

METHODS

We reviewed records of patients (N = 629) who underwent a surgical AVR procedure between January 2011 and July 2018 at a single institution. Indexed effective orifice area values and PPM incidence were calculated from implanted valve size and patient body surface area. Incidence of none, moderate, and severe PPM was compared across AVR suture techniques.

RESULTS

A total of 570 pledget and 59 figure-of-eight patients were compared for incidence of PPM. Patients who received AVR with the pledget suture technique had significantly lower echocardiographic measurements of baseline ejection fraction than patients who had received AVR with the figure-of-eight suture technique (p = 0.003). Patients who received the figure-of eight suture had a 14% decrease in moderate PPM compared to patients who received the pledget suture (p = 0.022). Patients who received the figure-of-eight suture also had a significantly higher rate of no PPM (p = 0.044).

CONCLUSIONS

The use of the figure-of-eight suture technique in AVR can reduce the incidence of moderate PPM. While the pledget suture is the standard technique in AVR, the figure-of-eight suture technique may offer better structural and hemodynamic outcomes, especially for patients with a smaller aortic annulus.

Pledgeted versus nonpledgeted sutures in aortic valve replacement: Insights from a prospective multicenter trial

Objective

The objective of this study was to compare short- and midterm clinical and echocardiographic outcomes according to the use of pledgeted sutures during aortic valve replacement.

Methods

Patients with aortic stenosis or regurgitation requiring aortic valve replacement were enrolled in a prospective cohort study to evaluate the safety of a new stented bioprosthesis. Outcomes were analyzed according to the use of pledgets (pledgeted group) or no pledgets (nonpledgeted group). The primary outcome was a composite of thromboembolism, endocarditis, and major paravalvular leak at 5 years of follow-up. Secondary outcomes included multiple clinical endpoints and hemodynamic outcomes. Propensity score matching was performed to adjust for prognostic factors, and subanalyses with small valve sizes (<23 mm) and suturing techniques were performed.

Results

The pledgeted group comprised 640 patients (59%), and the nonpledgeted group 442 (41%), with baseline discrepancies in demographic characteristics, comorbidities, and stenosis severity. There were no differences between groups in any outcome. After propensity score matching, the primary outcome occurred in 41 (11.7%) patients in the pledgeted and 36 (9.8%) in the nonpledgeted group (P = .51). The effective orifice area was smaller in the pledgeted group (P = .045), whereas no difference was observed for the mean or peak pressure gradient. Separate subanalyses with small valve sizes and suturing techniques did not show relevant differences.

Conclusions

In this large propensity score-matched cohort, comprehensive clinical outcomes were comparable between patients who underwent aortic valve replacement with pledgeted and nonpledgeted sutures up to 5 years of follow-up, but pledgets might lead to a slightly smaller effective orifice area in the long run.

In vitro comparison of everting vs. non-everting suture techniques for the implantation of a supra-annular biological heart valve

Background

The aim of this study was to evaluate the hemodynamic effect of different suturing techniques for aortic valve replacement (AVR) in vitro. Whether or not the applied suturing technique impacts the outflow tract diameter by narrowing the annulus diameter was examined.

Methods

The commonly applied non-everting pledget forced suture technique (NE, n=13) was compared with an everting pledget forced suture (ET, n=13) for AVR using the 25 mm St. Jude Trifecta aortic valve. Hemodynamic parameters were obtained in a pulsatile flow simulator. A high speed camera captured the visual aspects of the suturing technique.

Results

Despite some kind of left ventricular outflow narrowing due to protruding pledgets using the NE suture technique, mean pressure gradients of both techniques were nearly similar (NE 5.88±2.7 mmHg, ET 5.23±1.31 mmHg, P=0.44). Closing volume (NE 3.16±0.48 mL; ET 3.51±0.68 mL; P=0.14) and the leakage volume (NE: 8.09±2.53 mL; ET: 8.35±3.65 mL; P=0.83) also showed no differences.

Conclusions

AVR using either suturing techniques leads to a similar hemodynamic performance in vitro. The impact of the suturing technique may be higher in a smaller annulus. Therefore, further studies using smaller prostheses are necessary.

Mitroflow LXA structural deterioration following aortic valve replacement: a single-center experience

BACKGROUND

Concerns have been previously raised regarding the potential early degeneration of the Mitroflow (Sorin Group Italia, Saluggia, Vercelli, Italy) bioprostheses. We aimed to evaluate our clinical experience with the Mitroflow LXA prosthesis for aortic valve replacement.

METHODS

We prospectively analyzed data from 227 consecutive patients (133 males, mean age 73.9±9.2 years) implanted with the Mitroflow LXA between February 2007 and October 2011. Follow-up data were obtained by contacting the referring cardiologists. Kaplan-Meier curves were constructed for all-cause mortality, valve related mortality and structural valve degeneration (SVD). Multivariable analysis was conducted to identify SVD predictors.

RESULTS

Median follow-up time was 54.2±37.9 months and completeness of follow-up was 95%. Overall mortality in the entire series was at 31% (N.=71) and mortality from cardiac or unknown causes at 20% (N.=46). SVD occurred in 24 patients (10%) (median delay between implantation and diagnosis: 62.6 (36.5) months). Reintervention was required in 20 cases (13 redo surgery, 7 percutaneous transcatheter valve intervention). The 8 years actuarial global survival was 54.7±4.9%, freedom from valve related mortality 67.5±4.9% and freedom from SVD 72±8%. The estimated freedom from SVD was significantly (P=0.007) longer in larger prosthesis (diameter >21 mm, 77±11%) compared to the smaller devices (≤21 mm, 59±13%.). Multivariate analysis identified smaller prostheses and age at implantation as independent predictors of SVD.

CONCLUSIONS

The Mitroflow LXA showed evidence of early SVD in this cohort. A close follow-up of these patients is strongly advised.

Pledget-Armed Sutures Affect the Haemodynamic Performance of Biologic Aortic Valve Substitutes: A Preliminary Experimental and Computational Study

Surgical aortic valve replacement is the most common procedure of choice for the treatment of severe aortic stenosis. Bioprosthetic valves are traditionally sewed-in the aortic root by means of pledget-armed sutures during open-heart surgery. Recently, novel bioprostheses which include a stent-based anchoring system have been introduced to allow rapid implantation, therefore reducing the duration and invasiveness of the intervention. Different effects on the hemodynamics were clinically reported associated with the two technologies. The aim of this study was therefore to investigate whether the differences in hemodynamic performances are an effect of different anchoring systems. Two commercially available bio-prosthetic aortic valves, one sewed-in with pledget-armed sutures and one rapid-deployment, were thus tested in this study by means of a combined approach of experimental and computational tools. In vitro experiments were performed to evaluate the overall hydrodynamic performance under identical standard conditions; computational fluid dynamics analyses were set-up to explore local flow variations due to different design of the anchoring system. The results showed how the performance of cardiac valve substitutes is negatively affected by the presence of pledget-armed sutures. These are causing flow disturbances, which in turn increase the mean pressure gradient and decrease the effective orifice area. The combined approach of experiments and numerical simulations can be effectively used to quantify the detailed relationship between local fluid-dynamics and overall performances associated with different valve technologies.

A comparison of two forms of the continuity equation in the Trifecta bovine pericardial aortic valve

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.

St. Jude Medical Trifecta aortic valve: results from a prospective regional multicentre registry

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.

Early hemodynamic performance of the third generation St Jude Trifecta aortic prosthesis: A systematic review and meta-analysis

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.