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Leviner DB, Abraham D, Ronai T, Sharoni E. Mechanical Valves: Past, Present, and Future-A Review. J Clin Med 2024; 13:3768. [PMID: 38999334 PMCID: PMC11242849 DOI: 10.3390/jcm13133768] [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: 04/18/2024] [Revised: 06/24/2024] [Accepted: 06/24/2024] [Indexed: 07/14/2024] Open
Abstract
The mechanical valve was first invented in the 1950s, and since then, a wide variety of prostheses have been developed. Although mechanical valves have outstanding durability, their use necessitates life-long treatment with anticoagulants, which increases the risk of bleeding and thromboembolic events. The current guidelines recommend a mechanical prosthetic valve in patients under 50-60 years; however, for patients aged 50-70 years, the data are conflicting and there is not a clear-cut recommendation. In recent decades, progress has been made in several areas. First, the On-X mechanical valve was introduced; this valve has a lower anticoagulant requirement in the aortic position. Second, a potential alternative to vitamin K-antagonist treatment, rivaroxaban, has shown encouraging results in small-scale trials and is currently being tested in a large randomized clinical trial. Lastly, an innovative mechanical valve that eliminates the need for anticoagulant therapy is under development. We attempted to review the current literature on the subject with special emphasis on the role of mechanical valves in the current era and discuss alternatives and future innovations.
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Affiliation(s)
- Dror B Leviner
- Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa 3436212, Israel
| | - Dana Abraham
- Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa 3436212, Israel
- The Ruth & Baruch Rappaport Faculty of Medicine, Technion, Haifa 3525433, Israel
| | - Tom Ronai
- Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa 3436212, Israel
- The Ruth & Baruch Rappaport Faculty of Medicine, Technion, Haifa 3525433, Israel
| | - Erez Sharoni
- Department of Cardiothoracic Surgery, Carmel Medical Center, Haifa 3436212, Israel
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Mylonas KS, Angouras DC. Bioprosthetic Valves for Lifetime Management of Aortic Stenosis: Pearls and Pitfalls. J Clin Med 2023; 12:7063. [PMID: 38002679 PMCID: PMC10672358 DOI: 10.3390/jcm12227063] [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: 09/10/2023] [Revised: 10/31/2023] [Accepted: 11/02/2023] [Indexed: 11/26/2023] Open
Abstract
This review explores the use of bioprosthetic valves for the lifetime management of patients with aortic stenosis, considering recent advancements in surgical (SAV) and transcatheter bioprostheses (TAV). We examine the strengths and challenges of each approach and their long-term implications. We highlight differences among surgical bioprostheses regarding durability and consider novel surgical valves such as the Inspiris Resilia, Intuity rapid deployment, and Perceval sutureless bioprostheses. The impact of hemodynamics on the performance and durability of these prostheses is discussed, as well as the benefits and considerations of aortic root enlargement during Surgical Aortic Valve Replacement (SAVR). Alternative surgical methods like the Ross procedure and the Ozaki technique are also considered. Addressing bioprosthesis failure, we compare TAV-in-SAV with redo SAVR. Challenges with TAVR, such as TAV explantation and considerations for coronary circulation, are outlined. Finally, we explore the potential challenges and limitations of several clinical strategies, including the TAVR-first approach, in the context of aortic stenosis lifetime management. This concise review provides a snapshot of the current landscape in aortic bioprostheses for physicians and surgeons.
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Affiliation(s)
| | - Dimitrios C. Angouras
- Department of Cardiac Surgery, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, 15772 Athens, Greece;
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Velho TR, Guerra N. The necessity of investigator-initiated trials in cardiothoracic surgery. Eur J Cardiothorac Surg 2023; 64:ezad292. [PMID: 37610357 DOI: 10.1093/ejcts/ezad292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/22/2023] [Indexed: 08/24/2023] Open
Affiliation(s)
- Tiago R Velho
- Department of Cardiothoracic Surgery, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisboa, Portugal
- Innate Immunity and Inflammation Laboratory, Instituto Gulbenkian de Ciência, Oeiras, Portugal
| | - Nuno Guerra
- Department of Cardiothoracic Surgery, Hospital de Santa Maria, Centro Hospitalar Universitário Lisboa Norte EPE, Lisboa, Portugal
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Montero Cruces L, Carnero Alcázar M, Pérez Camargo D, Cobiella Carnicer J, Campelos Fernández P, Reguillo Lacruz FJ, Maroto Castellanos LC. 5-Year haemodynamic performance of three aortic bioprostheses. A randomized clinical trial. Eur J Cardiothorac Surg 2023; 64:ezad261. [PMID: 37471587 DOI: 10.1093/ejcts/ezad261] [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: 09/07/2022] [Revised: 07/05/2023] [Accepted: 07/19/2023] [Indexed: 07/22/2023] Open
Abstract
OBJECTIVES The Carpentier Perimount (CP) Magna Ease, the Crown Phospholipid Reduction Treatment (PRT) and the Trifecta bovine pericardial valves have been widely used worldwide. The primary end point of this study was to compare the haemodynamic performance quantified by in vivo echocardiograms of these 3 aortic prostheses. METHODS The "BEST-VALVE" (comparison of 3 contemporary cardiac bioprostheses: mid-term valve haemodynamic performance) was a single-centre randomized clinical trial to compare the haemodynamic and clinical outcomes of the aforementioned bioprostheses. The 5-year results are assessed in this manuscript. RESULTS A total of 154 patients were included. The CP Magna Ease (n = 48, 31.2%), Crown PRT (n = 51, 32.1%) and Trifecta (n = 55, 35.7%) valves were compared. Significant differences were observed among the 3 bioprostheses 5 years after the procedure. The following haemodynamic differences were found between the CP Magna Ease and the Crown PRT bioprostheses [mean aortic gradient: 12.3 mmHg (interquartile range {IQR} 7.8-17.5) for the CP Magna Ease vs 15 mmHg (IQR 10.8-31.9) for the Crown PRT, P < 0.001] and between the CP Magna Ease and the Trifecta prostheses [mean aortic gradient: 12.3 mmHg (IQR 7.8-17.5) for the CP Magna Ease vs 14.7 mmHg (IQR 8.2-55) for the Trifecta, P < 0.001], with a better haemodynamic performance of the CP Magna Ease. The cumulative incidence of severe structural valve degeneration was 9.5% in the Trifecta group at 6 years of follow-up. The 1-, 3- and 5-year survival from all-cause mortality was 91.5%, 83.5% and 74.8%, respectively (log rank P = 0.440). Survival from the composite event at the 1-, 3- and 5-year follow-up was 92.8%, 74.6% and 59%, respectively (log rank P = 0.299). CONCLUSIONS We detected significant differences between the 3 bioprostheses; the CP Magna Ease had the best haemodynamic performance at the 5-year follow-up.
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Affiliation(s)
| | | | - Daniel Pérez Camargo
- Department of Cardiovascular Surgery, Clínico San Carlos Hospital, Madrid, Spain
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Sa YK, Hwang BH, Chung WB, Lee KY, Lee J, Kang D, Ko YG, Yu CW, Kim J, Choi SH, Bae JW, Chae IH, Choi YS, Park CS, Yoo KD, Jeon DS, Kim HS, Chung WS, Chang K. Real-World Comparison of Transcatheter Versus Surgical Aortic Valve Replacement in the Era of Current-Generation Devices. J Clin Med 2023; 12:jcm12020571. [PMID: 36675500 PMCID: PMC9864945 DOI: 10.3390/jcm12020571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 01/05/2023] [Accepted: 01/08/2023] [Indexed: 01/13/2023] Open
Abstract
Few studies have reported comparisons of out-of-hospital clinical outcomes after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis (AS) in the era of current-generation valves that reflect the real-world situation. Data on patients with severe AS aged 65 years or older who underwent TAVR or SAVR between 2015 and 2018 were obtained from the National Health Insurance Service in Korea and clinical event rate was analyzed. The primary endpoint was all-cause death at 1 year. The cohort included a total of 4623 patients over 65 years of age, of whom 1269 (27.4%) were treated with TAVR. After 1:1 propensity score matching, 2120 patients were included in the study. TAVR was associated with reduced 1-year mortality (hazard ratio (HR): 0.55; 95% confidence interval (CI): 0.42−0.70; p < 0.001). There was no difference between the groups in the incidence of ischemic stroke (HR: 0.72, 95% CI: 0.43−1.20; p = 0.21) and intracranial hemorrhage (HR: 1.10; p = 0.74). Permanent pacemaker insertion was observed more frequently in the TAVR cohort (9.4% vs. 2.5%, HR: 3.95, 95% CI: 2.57−6.09; p < 0.001), whereas repeat procedures were rare in both treatments (0.5% vs. 0.3%, p = 0.499). In the nation-wide real-world data analysis, TAVR with current-generation devices showed significantly lower 1-year mortality compared to SAVR in severe AS patients.
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Affiliation(s)
- Young Kyoung Sa
- Division of Cardiology, Department of Internal Medicine, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul 07345, Republic of Korea
| | - Byung-Hee Hwang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Woo-Baek Chung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Kwan Yong Lee
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Jungkuk Lee
- Data Science Team, Hanmi Pharm. Co., Ltd., Seoul 05545, Republic of Korea
| | - Dongwoo Kang
- Data Science Team, Hanmi Pharm. Co., Ltd., Seoul 05545, Republic of Korea
| | - Young-Guk Ko
- Division of Cardiology, Department of Internal Medicine, Severance Hospital, Yonsei University, Seoul 03722, Republic of Korea
| | - Cheol Woong Yu
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Korea University, Seoul 02841, Republic of Korea
| | - Juhan Kim
- Division of Cardiology, Department of Internal Medicine, Chonnam National University Hospital, Chonnam National University, Gwangju 61469, Republic of Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Internal Medicine, Samsung Medical Center, Sungkyunkwan University, Seoul 06351, Republic of Korea
| | - Jang-Whan Bae
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University, Cheongju 28644, Republic of Korea
| | - In-Ho Chae
- Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University, Seongnam 13620, Republic of Korea
| | - Yun-Seok Choi
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Chul Soo Park
- Division of Cardiology, Department of Internal Medicine, Yeouido St. Mary’s Hospital, The Catholic University of Korea, Seoul 07345, Republic of Korea
| | - Ki Dong Yoo
- Division of Cardiology, Department of Internal Medicine, St. Vincent Hospital, The Catholic University of Korea, Suwon 65091, Republic of Korea
| | - Doo Soo Jeon
- Division of Cardiology, Department of Internal Medicine, Incheon St. Mary’s Hospital, The Catholic University of Korea, Incheon 06591, Republic of Korea
| | - Hyo-Soo Kim
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital, Seoul National University, Seoul 03080, Republic of Korea
| | - Wook-Sung Chung
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul 06591, Republic of Korea
| | - Kiyuk Chang
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul 06591, Republic of Korea
- Correspondence:
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Yang R, Grober AF, Riojas R, Ponna V, Shunk KA, Zimmet JM, Gustafson J, Ge L, Tseng EE. Midterm Durability and Structural Valve Degeneration of Transcatheter Aortic Valve Replacement in a Federal Facility. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:382-391. [PMID: 36217736 PMCID: PMC9761483 DOI: 10.1177/15569845221123259] [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] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Transcatheter aortic valve replacement (TAVR), previously reserved for patients of intermediate to prohibitive surgical risk, has now been expanded to patients of any surgical risk with severe aortic stenosis. Bioprostheses are prone to structural valve degeneration (SVD), a progressive and multifactorial process that limits valve durability. As the population undergoing TAVR shifts toward a lower-risk and younger profile, long-term durability is a crucial determinant for patient outcomes. Our objective was to determine the incidence and risk factors of SVD at midterm follow-up in a veteran TAVR population. METHODS Patients undergoing TAVR at our federal facility were retrospectively evaluated for SVD and other endpoints with standardized consensus criteria. Multivariable Cox proportional hazards analysis was performed to evaluate risk factors for mortality and SVD. RESULTS From 2013 to 2020, 344 patients (median age, 78 years) underwent TAVR. Survival from all-cause mortality was 91.3% at 1 year, 75.1% at 3 years, and 61.7% at 5 years. Cumulative freedom from SVD was 98.2% at 1 year, 96.5% at 3 years, and 93.7% at 5 years. All 13 patients with SVD met hemodynamic criteria, and 1 required intervention. Median time to hemodynamic SVD was 1.04 years. Independent risk factors for SVD included age (hazard ratio [HR] = 0.92, 95% confidence interval [CI]: 0.86 to 0.99) and valve size (HR = 0.19, 95% CI: 0.04 to 0.89). CONCLUSIONS SVD was evident at a low but detectable rate at 5-year follow-up. Further understanding of TAVR biomechanics as well as continued longer-term follow-up will be essential for informing patient-specific risk of SVD.
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Affiliation(s)
- Rachel Yang
- Division of Cardiothoracic Surgery,
University of California San Francisco and San Francisco VA Medical Center, CA,
USA
| | - Aaron F. Grober
- Division of Cardiology, University of
California San Francisco and San Francisco VA Medical Center, CA, USA
| | - Ramon Riojas
- Division of Cardiothoracic Surgery,
University of California San Francisco and San Francisco VA Medical Center, CA,
USA
| | - Vimala Ponna
- Division of Cardiothoracic Surgery,
University of California San Francisco and San Francisco VA Medical Center, CA,
USA
| | - Kendrick A. Shunk
- Division of Cardiology, University of
California San Francisco and San Francisco VA Medical Center, CA, USA
| | - Jeffrey M. Zimmet
- Division of Cardiology, University of
California San Francisco and San Francisco VA Medical Center, CA, USA
| | - Joshua Gustafson
- Division of Cardiothoracic Surgery,
University of California San Francisco and San Francisco VA Medical Center, CA,
USA,Uniformed Services University of the
Health Sciences, Bethesda, MD, USA
| | - Liang Ge
- Division of Cardiothoracic Surgery,
University of California San Francisco and San Francisco VA Medical Center, CA,
USA
| | - Elaine E. Tseng
- Division of Cardiothoracic Surgery,
University of California San Francisco and San Francisco VA Medical Center, CA,
USA,Elaine E. Tseng, MD, Division of
Cardiothoracic Surgery, University of California San Francisco and San Francisco
VA Medical Center, 500 Parnassus Ave, Ste 405W, Box 0118, San Francisco, CA
94143, USA.
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Errico K, Hui DS. Commentary: Wagering on Trifecta. J Thorac Cardiovasc Surg 2022:S0022-5223(22)00105-2. [DOI: 10.1016/j.jtcvs.2022.01.030] [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: 01/24/2022] [Revised: 01/24/2022] [Accepted: 01/25/2022] [Indexed: 11/29/2022]
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