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Tong Q, Cai J, Wang Z, Sun Y, Liang X, Xu Q, Mahamoud OA, Qian Y, Qian Z. Recent Advances in the Modification and Improvement of Bioprosthetic Heart Valves. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2024; 20:e2309844. [PMID: 38279610 DOI: 10.1002/smll.202309844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/10/2023] [Indexed: 01/28/2024]
Abstract
Valvular heart disease (VHD) has become a burden and a growing public health problem in humans, causing significant morbidity and mortality worldwide. An increasing number of patients with severe VHD need to undergo heart valve replacement surgery, and artificial heart valves are in high demand. However, allogeneic valves from donors are lacking and cannot meet clinical practice needs. A mechanical heart valve can activate the coagulation pathway after contact with blood after implantation in the cardiovascular system, leading to thrombosis. Therefore, bioprosthetic heart valves (BHVs) are still a promising way to solve this problem. However, there are still challenges in the use of BHVs. For example, their longevity is still unsatisfactory due to the defects, such as thrombosis, structural valve degeneration, calcification, insufficient re-endothelialization, and the inflammatory response. Therefore, strategies and methods are needed to effectively improve the biocompatibility and longevity of BHVs. This review describes the recent research advances in BHVs and strategies to improve their biocompatibility and longevity.
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Affiliation(s)
- Qi Tong
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
| | - Jie Cai
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
| | - Zhengjie Wang
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
| | - Yiren Sun
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
| | - Xuyue Liang
- Department of Biotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
| | - Qiyue Xu
- School of Basic Medicine, Mudanjiang Medical University, Mudanjiang, Heilongjiang, 157011, P. R. China
| | - Oumar Abdel Mahamoud
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
| | - Yongjun Qian
- Department of Cardiovascular Surgery, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
| | - Zhiyong Qian
- Department of Biotherapy, Cancer Center and State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, #37 Guoxue Alley, Chengdu, Sichuan, 610041, P. R. China
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Braile-Sternieri MCVB, Goissis G, Giglioti ADF, Ramirez VDA, Pereira NP, de Vasconcellos A, Basso-Frazzato GG, Braile DM. In vivo evaluation of Vivere bovine pericardium valvular bioprosthesis with a new anti-calcifying treatment. Artif Organs 2020; 44:E482-E493. [PMID: 32364253 DOI: 10.1111/aor.13718] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 04/10/2020] [Accepted: 04/20/2020] [Indexed: 11/26/2022]
Abstract
The objective of this study was to evaluate the effect of chemical treatment with glutamic acid to avoid calcification of biological cardiac valves. The bovine pericardium (BP) tissues were fixed with 0.5% glutaraldehyde (BP/GA), followed by treatment with glutamic acid (BP/GA + Glu) for neutralization of the free aldehyde groups. Microscopic analysis showed that the wavy structure of collagen fibrils was preserved, but changes in elastin's integrity occurred. However, the treatment did not promote undesirable changes in the thermal and mechanical properties of the modified BPs. These samples were systematically studied in rat subcutaneous tissue: control (BP/GA) and anticalcificant (BP/GA + Glu). After 60 days, both groups induced similar inflammatory reactions. In terms of calcification, BP/GA + Glu remained more stable with a lower index (3.1 ± 0.2 μg Ca2+ /mg dry tissue), whereas for BP/GA it was 5.7 ± 1.3 μg Ca2+ /mg dry tissue. Bioprostheses made from BP/GA + Glu were implanted in the pulmonary position in sheep, and in vivo echocardiographic analyses revealed maintenance of valvar function after 180 days, with low gradients and minimal valve insufficiency. The explanted tissues of the BP/GA + Glu group had a lower average calcium content 3.8 ± 3.0 μg Ca2+ /mg dry tissue. The results indicated high anticalcification efficiency of BP/GA + Glu in both subcutaneous implant in rats and in the experimental sheep model, which is an advantage that should encourage the industrial application of these materials for the manufacture of bioprostheses.
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Affiliation(s)
| | | | | | | | | | | | | | - Domingo Marcolino Braile
- Braile Biomédica Ind. Com. e Repres. Ltda., São Paulo, Brazil.,Faculdade de Medicina de São José do Rio Preto (FAMERP), São José do Rio Preto, Brazil.,Universidade de Campinas (UNICAMP), Campinas, Brazil
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Christersson C, James SK, Lindhagen L, Ahlsson A, Friberg Ö, Jeppsson A, Ståhle E. Comparison of warfarin versus antiplatelet therapy after surgical bioprosthetic aortic valve replacement. Heart 2019; 106:838-844. [PMID: 31757813 PMCID: PMC7282554 DOI: 10.1136/heartjnl-2019-315453] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/19/2019] [Accepted: 10/25/2019] [Indexed: 11/13/2022] Open
Abstract
Objectives To compare effectiveness of warfarin and antiplatelet exposure regarding both thrombotic and bleeding events, following surgical aortic valve replacement with a biological prosthesis(bioSAVR). Methods The study included all patients in Sweden undergoing a bioSAVR during 2008–2014 who were alive at discharge from the index hospital stay. Exposure was analysed and defined as postdischarge dispension of any antithrombotic pharmaceutical, updated at each following dispensions and categorised as single antiplatelet (SAPT), warfarin, warfarin combined with SAPT, dual antiplatelet (DAPT) or no antithrombotic treatment. Exposure to SAPT was used as comparator. Outcome events were all-cause mortality, ischaemic stroke, haemorrhagic stroke, any thromboembolism and major bleedings. We continuously updated adjustments for comorbidities with any indication for antithrombotic treatment by Cox regression analysis. Results We identified 9539 patients with bioSAVR (36.8% women) at median age of 73 years with a mean follow-up of 3.13 years. As compared with SAPT, warfarin alone was associated with a lower incidence of ischaemic stroke (HR 0.49, 95% CI 0.35 to 0.70) and any thromboembolism (HR 0.75, 95% CI 0.60 to 0.94) but with no difference in mortality (HR 0.94, 95% CI 0.78 to 1.13). The incidence of haemorrhagic stroke (HR 1.94, 95% CI 1.07 to 3.51) and major bleeding (HR 1.67, 95% CI 1.30 to 2.15) was higher during warfarin exposure. As compared with SAPT, DAPT was not associated with any difference in ischaemic stroke or any thromboembolism. Risk-benefit analyses demonstrated that 2.7 (95% CI 1.0 to 11.9) of the ischaemic stroke cases could potentially be avoided per every haemorrhagic stroke caused by warfarin exposure instead of SAPT during the first year. Conclusion In patients discharged after bioSAVR, warfarin exposure as compared with SAPT exposure was associated with lower long-term risk of ischaemic stroke and thromboembolic events, and with a higher incidence of bleeding events but with similar mortality.
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Affiliation(s)
| | - Stefan K James
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Lars Lindhagen
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Anders Ahlsson
- Department of Thoracic and Cardiovascular Surgery, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular and Clinical Medicine, Institute of Medicine Sahlgrenska Academy, Gothenburg, Sweden
| | - Örjan Friberg
- Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden
| | - Anders Jeppsson
- Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elisabeth Ståhle
- Department of Surgical Sciences Thoracic Surgery, University Hospital Uppsala, Uppsala, Sweden
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Lee S, Kim DH, Youn YN, Joo HC, Yoo KJ, Lee SH. Rosuvastatin attenuates bioprosthetic heart valve calcification. J Thorac Cardiovasc Surg 2019; 158:731-741.e1. [PMID: 30738596 DOI: 10.1016/j.jtcvs.2018.12.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 11/27/2018] [Accepted: 12/10/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE There are pathophysiologic similarities between calcification and atherosclerosis because both are the product of an active inflammatory process. The aim of the study was to examine the effects of statin treatment on calcification in commercially available bioprosthetic heart valves. METHODS Twenty Sprague-Dawley rats were fed a high-fat diet to induce hypercholesterolemia during 4 weeks. They were randomly divided into 2 groups according to statin intake (control, n = 10: high-fat diet/statin; n = 10: high-fat diet with statin). Four commercially available tissue valve (Magna Perimount, Carpentier-Edwards, Irvine, Calif; Hancock, Medtronic, Minneapolis, Minn; Mitroflow, LivaNova, London, England; and Trifecta, St Jude Medical, St Paul, Minn) cusp samples (total 320) were implanted in rat dorsal subcutis at 4 weeks. After implantation, rosuvastatin was administered daily to the statin group. The cusps were explanted at 12 weeks, and calcium levels were determined by atomic absorption spectroscopy. Western blotting, histologic, and immunohistochemical analyses were conducted to identify the anticalcification mechanism of the statin. RESULTS The mean calcium level in the control group was significantly higher than in the statin group (P < .01) for all tissue valves (Magna Perimount: 2.67 ± 0.26 mg/g vs 1.31 ± 0.40 mg/g; Hancock: 2.70 ± 0.57 mg/g vs 1.53 ± 0.34 mg/g; Mitroflow: 2.39 ± 0.71 mg/g vs 1.26 ± 0.38 mg/g; Trifecta: 2.54 ± 0.42 mg/g vs 1.63 ± 0.72 mg/g). Inflammatory cell infiltration and interleukin-6 and bone morphogenetic protein 2 expressions were significantly reduced in the statin group. CONCLUSIONS Statin treatment significantly attenuated bioprosthetic heart valve calcification associated with decreasing the levels of interleukin-6 and bone morphogenetic protein 2. Thus, statin treatment might be helpful for the longevity of bioprosthetic heart valves.
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Affiliation(s)
- Sak Lee
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Dae-Hyun Kim
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Young-Nam Youn
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Hyun Chel Joo
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Kyung-Jong Yoo
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Republic of Korea
| | - Seung Hyun Lee
- Division of Cardiovascular Surgery, Department of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei University Health System, Seoul, Republic of Korea.
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1-Year Results in Patients Undergoing Transcatheter Aortic Valve Replacement With Failed Surgical Bioprostheses. JACC Cardiovasc Interv 2018; 10:1034-1044. [PMID: 28521921 DOI: 10.1016/j.jcin.2017.03.018] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 03/06/2017] [Accepted: 03/09/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study evaluated the safety and effectiveness of self-expanding transcatheter aortic valve replacement (TAVR) in patients with surgical valve failure (SVF). BACKGROUND Self-expanding TAVR is superior to medical therapy for patients with severe native aortic valve stenosis at increased surgical risk. METHODS The CoreValve U.S. Expanded Use Study was a prospective, nonrandomized study that enrolled 233 patients with symptomatic SVF who were deemed unsuitable for reoperation. Patients were treated with self-expanding TAVR and evaluated for 30-day and 1-year outcomes after the procedure. An independent core laboratory was used to evaluate serial echocardiograms for valve hemodynamics and aortic regurgitation. RESULTS SVF occurred through stenosis (56.4%), regurgitation (22.0%), or a combination (21.6%). A total of 227 patients underwent attempted TAVR and successful TAVR was achieved in 225 (99.1%) patients. Patients were elderly (76.7 ± 10.8 years), had a Society of Thoracic Surgeons Predicted Risk of Mortality score of 9.0 ± 6.7%, and were severely symptomatic (86.8% New York Heart Association functional class III or IV). The all-cause mortality rate was 2.2% at 30 days and 14.6% at 1 year; major stroke rate was 0.4% at 30 days and 1.8% at 1 year. Moderate aortic regurgitation occurred in 3.5% of patients at 30 days and 7.4% of patients at 1 year, with no severe aortic regurgitation. The rate of new permanent pacemaker implantation was 8.1% at 30 days and 11.0% at 1 year. The mean valve gradient was 17.0 ± 8.8 mm Hg at 30 days and 16.6 ± 8.9 mm Hg at 1 year. Factors significantly associated with higher discharge mean aortic gradients were surgical valve size, stenosis as modality of SVF, and presence of surgical valve prosthesis patient mismatch (all p < 0.001). CONCLUSIONS Self-expanding TAVR in patients with SVF at increased risk for surgery was associated with a low 1-year mortality and major stroke rate, significantly improved aortic valve hemodynamics, and low rates of moderate and no severe residual aortic regurgitation, with improved quality of life.
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Bioprosthetic Aortic Valve Durability: A Meta-Regression of Published Studies. Ann Thorac Surg 2017; 104:1080-1087. [DOI: 10.1016/j.athoracsur.2017.02.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Revised: 01/12/2017] [Accepted: 02/06/2017] [Indexed: 11/17/2022]
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Lee SH, Kim DH, Youn YN, Lee S, Joo HC, Chang BC, Yoo KJ. Effect of Rosuvastatin on Bovine Pericardial Aortic Tissue Valve Calcification in a Rat Subdermal Implantation Model. Korean Circ J 2017; 47:401-408. [PMID: 28567091 PMCID: PMC5449535 DOI: 10.4070/kcj.2016.0214] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2016] [Revised: 10/27/2016] [Accepted: 02/16/2017] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES There are pathophysiologic similarities between calcification and atherosclerosis because both are the product of an active inflammatory process. The aim of this study was to examine the effects of statin treatment on calcification in bovine pericardial tissue valves. MATERIALS AND METHODS Forty Sprague-Dawley rats were randomly divided into 4 groups according to hypercholesterolemia induction and statin intake (Group 1, n=10: normal diet without statin treatment, Group 2, n=10: normal diet with statin treatment, Group 3, n=10: high fat diet without statin treatment, Group 4, n=10: high fat diet with statin treatment). Serum lipid levels were measured just before the experiment and after 4 and 12 weeks. Bovine pericardial tissue valve cusps were surgically implanted in rat dorsal subcutis at 4 weeks. After the surgery, statin was administered daily to Groups 2 and 4. Serum interleukin-6 (IL-6) level was measured at 5 weeks. Cusps were explanted at 12 weeks and calcium levels were determined by atomic absorption spectroscopy. RESULTS Mean IL-6 was significantly higher in Group 3 at 5 weeks (7.14, 2.03, 31.70, and 6.90 pg/dL for each group, respectively). Mean calcium level in Group 3 was significantly higher among groups but Group 4 was significantly lower compared to Group 3 and was similar to Group 1, 2 (1.86, 1.92, 2.55, and 1.80 mg/g for each group, respectively, p<0.01). CONCLUSION Hypercholesterolemia may be a significant risk factor for bovine pericardial valve calcification. Statin treatment significantly attenuated calcification of bovine pericardial valve tissue in a rat subdermal implantation model and might prolong the durability of bioprostheses.
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Affiliation(s)
- Seung Hyun Lee
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Dae-Hyun Kim
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Nam Youn
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Sak Lee
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hyun Chel Joo
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Chul Chang
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Jong Yoo
- Division of Thoracic and Cardiovascular Surgery, Severance Cardiovascular Hospital, Yonsei Cardiovascular Research Institute, Yonsei University College of Medicine, Seoul, Korea
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Lee S, Levy RJ, Christian AJ, Hazen SL, Frick NE, Lai EK, Grau JB, Bavaria JE, Ferrari G. Calcification and Oxidative Modifications Are Associated With Progressive Bioprosthetic Heart Valve Dysfunction. J Am Heart Assoc 2017; 6:JAHA.117.005648. [PMID: 28483776 PMCID: PMC5524104 DOI: 10.1161/jaha.117.005648] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background Bioprosthetic heart valves (BHVs), fabricated from glutaraldehyde‐pretreated bovine pericardium or porcine aortic valves, are widely used for the surgical or interventional treatment of heart valve disease. Reoperation becomes increasingly necessary over time because of BHV dysfunction. Methods and Results Forty‐seven explanted BHV aortic valve replacements were retrieved at reoperation for clinically severe BHV dysfunction over the period 2010–2016. Clinical explant analyses of BHV leaflets for calcium (atomic absorption spectroscopy) and oxidized amino acids, per mass spectroscopy, were primary end points. Comorbidities for earlier BHV explant included diabetes mellitus and coronary artery bypass grafting. Mean calcium levels in BHV leaflets were significantly increased compared with unimplanted BHV (P<0.001); however, time to reoperation did not differ comparing calcified and noncalcified BHV. BHV dityrosine, an oxidized amino acid cross‐link, was significantly increased in the explants (227.55±33.27 μmol/mol [dityrosine/tyrosine]) but was undetectable in unimplanted leaflets (P<0.001). BHV regional analyses revealed that dityrosine, ranging from 57.5 to 227.8 μmol/mol (dityrosine/tyrosine), was detectable only in the midleaflet samples, indicating the site‐specific nature of dityrosine formation. 3‐Chlorotyrosine, an oxidized amino acid formed by myeloperoxidase‐catalyzed chlorinating oxidants, correlated with BHV calcium content in leaflet explant analyses from coronary artery bypass graft patients (r=0.62, P=0.01) but was not significantly correlated with calcification in non–coronary artery bypass graft explanted BHV. Conclusions Both increased BHV leaflet calcium levels and elevated oxidized amino acids were associated with bioprosthesis dysfunction necessitating reoperation; however, BHV calcium levels were not a determinant of implant duration, indicating a potentially important role for oxidized amino acid formation in BHV dysfunction.
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Affiliation(s)
| | | | | | | | | | - Eric K Lai
- University of Pennsylvania, Philadelphia, PA
| | - Juan B Grau
- Ottawa Heart Institute, Ottawa, Ontario, Canada
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Abstract
Transcatheter aortic valve replacement (TAVR) is a transformational and rapidly evolving treatment for patients with aortic stenosis who require valve replacement. Novel technological advancements have made this percutaneous minimally invasive therapy a first-line treatment for many patients at extreme risk for conventional cardiac surgery. New devices and improvements in existing devices have reduced procedural complications, and scientific trials are investigating the role of TAVR in lower-risk aortic stenosis populations, in patients with aortic regurgitation, and in patients with bicuspid aortic valve disease. Finally, there is intense interest in identifying patients in whom the risk-benefit ratio of TAVR is not favorable and should not be performed.
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Affiliation(s)
- Mackram F Eleid
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota 55905;
| | - David R Holmes
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine, Rochester, Minnesota 55905;
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Choudhary SK, Talwar S, Airan B. Choice of prosthetic heart valve in a developing country. HEART ASIA 2016; 8:65-72. [PMID: 27326237 PMCID: PMC4898620 DOI: 10.1136/heartasia-2015-010650] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 03/29/2016] [Accepted: 03/30/2016] [Indexed: 11/04/2022]
Abstract
Mechanical prostheses and stented xenografts (bioprosthesis) are most commonly used substitutes for aortic and mitral valve replacement. The mechanical valves have the advantage of durability but are accompanied with the risk of thromboembolism, problems of long-term anticoagulation, and associated risk of bleeding. In contrast, bioprosthetic valves do not require long-term anticoagulation, but carry the risk of structural valve degeneration and re-operation. A mechanical valve is favoured in young patients (<40 years) if reliable anticoagulation is ensured. In elderly patients (>60 years), a bioprosthesis is a suitable substitute. In middle-aged patients (40-60 years), risk of re-operation in a bioprosthesis is equal to that of bleeding in a mechanical valve. Traditionally, a bioprosthesis is opted in patients with limited life expectancy. Calculation of life expectancy, based solely upon chronological age, is erroneous. In developing countries, the calculated life expectancy is much lower than that of Western population, hence age related Western cut-offs are not valid in developing countries. Besides age, cardiac condition of the patient, systemic illnesses, socio-economic status, gender and geographical location also decide the life expectancy of the patients. Selection of the prosthetic valve substitute should be based on: aspiration of the patient, life expectancy, socio-economic and educational background, occupation of the patient, availability, cost, monitoring of anti-coagulation, monitoring of valve function and other valve related complications, and possibility of re-operation.
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Affiliation(s)
- Shiv Kumar Choudhary
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Sachin Talwar
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
| | - Balram Airan
- Cardiothoracic Centre, All India Institute of Medical Sciences , New Delhi , India
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EFFICACY OF CARPENTIER-EDWARDS PERICARDIAL PROSTHESES: A SYSTEMATIC REVIEW AND META-ANALYSIS. Int J Technol Assess Health Care 2015; 31:19-26. [DOI: 10.1017/s0266462315000148] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Objectives: The Carpentier-Edwards pericardial (CEP) prostheses are the type of bioprostheses most used worldwide. Although they were designed to minimize the rate of valve deterioration and reoperation, their clinical superiority over other prostheses models still lacks confirmation. The objective of this study was to evaluate its effectiveness.Methods: We performed a systematic review and meta-analysis in the PubMed, Embase, Cochrane, and Lilacs databases. Operative mortality, overall mortality and reoperation rates after heart valve surgery were compared between the use of CEP and other cardiac prostheses. Two independent reviewers screened studies for inclusion and extracted the data. Disagreements were resolved by consensus. The GRADE criterion was used to assess the evidence quality.Results: A total of twenty-eight studies were selected, including 19,615 individuals. The studies presented a high heterogeneity and low quality of evidence what limited the reliability of the results. The pooled data from the selected studies did not demonstrate significant differences between CEP and porcine, pericardial or stentless prostheses regarding operative mortality, overall mortality and reoperation rates. However, the pooled data from 3 observational trials pointed out a higher risk for reoperation after valve replacement using CEP prostheses against mechanical prostheses (OR 4.92 [95 percent confidence interval 2.43–9.96]).Conclusions: The current data present in the literature still does not support a clinical advantage for the use of CEP prostheses over other bioprostheses. The quality of the studies in the literature is limited and further studies are needed to address if CEP prostheses will have a clinical advantage over other prostheses.
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Mylotte D, Andalib A, Theriault-Lauzier P, Dorfmeister M, Girgis M, Alharbi W, Chetrit M, Galatas C, Mamane S, Sebag I, Buithieu J, Bilodeau L, de Varennes B, Lachapelle K, Lange R, Martucci G, Virmani R, Piazza N. Transcatheter heart valve failure: a systematic review. Eur Heart J 2014; 36:1306-27. [DOI: 10.1093/eurheartj/ehu388] [Citation(s) in RCA: 153] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 08/28/2014] [Indexed: 11/14/2022] Open
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Abstract
Degenerative, calcific valvular aortic stenosis (AS), caused by an active process of atherosclerosis, calcification and ossification, is the most common cause of AS in industrialized nations. The prevalence of calcific AS is age-dependent, and thus is expected to increase due to demographic aging of the global population. It is well recognized that severe AS carries a poor prognosis if left untreated. Despite this recognition, many patients are inappropriately denied surgery because of perceived risk. This article will examine the etiology, prevalence, and current trends in the treatment of degenerative AS focusing on indications for surgical aortic valve replacement.
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Affiliation(s)
- Jeremy J Thaden
- Division of Cardiovascular Disease and Internal Medicine, Mayo Clinic, Rochester, MN
| | - Vuyisile T Nkomo
- Division of Cardiovascular Disease and Internal Medicine, Mayo Clinic, Rochester, MN.
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Jainandunsing JS, Mahmood F, Matyal R, Shakil O, Hess PE, Lee J, Panzica PJ, Khabbaz KR. Impact of Three-Dimensional Echocardiography on Classification of the Severity of Aortic Stenosis. Ann Thorac Surg 2013; 96:1343-1348. [DOI: 10.1016/j.athoracsur.2013.05.018] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2013] [Revised: 05/03/2013] [Accepted: 05/10/2013] [Indexed: 11/26/2022]
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Vink R, Van Den Brink RBA, Levi M. Management of Anticoagulant Therapy for Patients with Prosthetic Heart Valves or Atrial Fibrillation. Hematology 2013; 9:1-9. [PMID: 14965863 DOI: 10.1080/10245330100016542464] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
There is a wide array of recommendations for the management of anticoagulant therapy in patients with mechanical heart valves. Especially the optimal intensity of vitamin K antagonists (VKA) is a ongoing matter of debate. On the basis of several studies, recommendations for daily clinical practice can be made. In this review, we discussed the studies and the different guidelines. Guidelines for the prevention of thromboembolic complications in patients with atrial fibrillation are more stringent. VKA with a target INR between 2.0 and 3.0 is more effective in the prevention of stroke than aspirin, especially in the presence of riskfactors for thromboembolism (age above 65, previous thromboembolism, history of hypertension and diabetes, enlarged left atrial diameter and left ventricular dysfunction). In the absence of clinical or echocardiographical riskfactors for thromboembolism, patients may be safely treated with aspirin.
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Affiliation(s)
- Roel Vink
- Department of Vascular Medicine, Academic Medical Center, University of Amsterdam, The Netherlands.
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Lange R, Piazza N. Transcatheter aortic valve-in-surgical aortic valve implantation: current status and future perspectives. Eur J Cardiothorac Surg 2013; 44:403-6. [DOI: 10.1093/ejcts/ezt373] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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A look at recent improvements in the durability of tissue valves. Gen Thorac Cardiovasc Surg 2013; 61:182-90. [DOI: 10.1007/s11748-013-0202-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Indexed: 10/27/2022]
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Piazza N, Bleiziffer S, Brockmann G, Hendrick R, Deutsch MA, Opitz A, Mazzitelli D, Tassani-Prell P, Schreiber C, Lange R. Transcatheter Aortic Valve Implantation for Failing Surgical Aortic Bioprosthetic Valve. JACC Cardiovasc Interv 2011; 4:721-32. [DOI: 10.1016/j.jcin.2011.03.016] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 03/24/2011] [Accepted: 03/31/2011] [Indexed: 10/18/2022]
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Moon D, Lee JW, Kim YS, Cho WC, Jung SH, Choo SJ, Chung CH. Midterm Results of Aortic Valve Replacement Using Tissue Valve. THE KOREAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2010. [DOI: 10.5090/kjtcs.2010.43.6.627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dukhwan Moon
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Jae-Won Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Yun Seok Kim
- Department of Thoracic and Cardiovascular Surgery, The Army Armed Forces Hampyung Hospital
| | - Won-Chul Cho
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Sung-Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Suk-Jung Choo
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
| | - Cheol-Hyun Chung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine
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Mahmood F, Swaminathan M. Stuck With a Decision: What Is the “True” Aortic Valve Area—Anatomic, Geometric, or Effective Orifice Area? J Cardiothorac Vasc Anesth 2010; 24:714-5. [DOI: 10.1053/j.jvca.2010.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2010] [Indexed: 11/11/2022]
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Mahmood F, Fritsch M, Maslow A. Unanticipated mild-to-moderate aortic stenosis during coronary artery bypass graft surgery: scope of the problem and its echocardiographic evaluation. J Cardiothorac Vasc Anesth 2009; 23:869-77. [PMID: 19589698 DOI: 10.1053/j.jvca.2009.03.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2008] [Indexed: 11/11/2022]
Affiliation(s)
- Feroze Mahmood
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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von Knobelsdorff-Brenkenhoff F, Rudolph A, Wassmuth R, Bohl S, Buschmann EE, Abdel-Aty H, Dietz R, Schulz-Menger J. Feasibility of cardiovascular magnetic resonance to assess the orifice area of aortic bioprostheses. Circ Cardiovasc Imaging 2009; 2:397-404, 2 p following 404. [PMID: 19808628 DOI: 10.1161/circimaging.108.840967] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Prosthetic orifice area, usually calculated by transthoracic echocardiography (TTE) or transesophageal echocardiography (TEE), provides important information regarding the hemodynamic performance of aortic bioprostheses. However, both TTE and TEE have limitations; therefore accurate and reproducible determination of the orifice area often remains a challenge. The present study aimed to investigate the feasibility of cardiovascular magnetic resonance (CMR) to assess the orifice areas of aortic bioprostheses. METHODS AND RESULTS CMR planimetry of the orifice area was performed in 65 patients (43/22 stented/stentless prostheses; mean time since implantation, 3.1+/-2.8 years; mean orifice area [TTE], 1.70+/-0.43 cm(2); 62 normally functioning prostheses, 2 severe stenoses, and 1 severe regurgitation) in an imaging plane perpendicular to the transprosthetic flow using steady-state free-precession cine imaging under breath-hold conditions on a 1.5-T MR system. CMR results were compared with TTE (continuity equation, n=65) and TEE (planimetry, n=31). CMR planimetry was readily feasible in 80.0%; feasible with limitation in 15.4% because of stent, flow, and sternal wire artifacts; and impossible in 4.6% because of flow artifacts. Correlations of the orifice areas by CMR with TTE (r=0.82) and CMR with TEE (r=0.92) were significant. The average difference between the methods was -0.02+/-0.24 cm(2) (TTE) and 0.05+/-0.15 cm(2) (TEE). Agreement was present for stented and stentless devices and independent of orifice size. Intraobserver and interobserver variabilities of CMR planimetry were 6.7+/-5.4% and 11.5+/-7.8%. CONCLUSIONS The assessment of aortic bioprostheses with normal orifice areas by CMR is technically feasible and provides orifice areas with a close correlation to echocardiography and low observer dependency.
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Nishimura RA, Carabello BA, Faxon DP, Freed MD, Lytle BW, O'Gara PT, O'Rourke RA, Shah PM. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 52:e1-142. [PMID: 18848134 DOI: 10.1016/j.jacc.2008.05.007] [Citation(s) in RCA: 1058] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS. 2008 Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e523-661. [PMID: 18820172 DOI: 10.1161/circulationaha.108.190748] [Citation(s) in RCA: 698] [Impact Index Per Article: 43.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Brown ML, Schaff HV, Lahr BD, Mullany CJ, Sundt TM, Dearani JA, McGregor CG, Orszulak TA. Aortic valve replacement in patients aged 50 to 70 years: Improved outcome with mechanical versus biologic prostheses. J Thorac Cardiovasc Surg 2008; 135:878-84; discussion 884. [DOI: 10.1016/j.jtcvs.2007.10.065] [Citation(s) in RCA: 117] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2007] [Revised: 10/15/2007] [Accepted: 10/26/2007] [Indexed: 11/27/2022]
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Affiliation(s)
- Reida El Oakley
- From the Department of Surgery, Prince Sultan Cardiac Centre, Riyad, Saudi Arabia (R.E.O.); Department of Surgery, Section of Cardiac Surgery, J.W. Goethe University, Frankfurt am Main, Germany (P.K.); and Department of Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (D.S.B.)
| | - Peter Kleine
- From the Department of Surgery, Prince Sultan Cardiac Centre, Riyad, Saudi Arabia (R.E.O.); Department of Surgery, Section of Cardiac Surgery, J.W. Goethe University, Frankfurt am Main, Germany (P.K.); and Department of Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (D.S.B.)
| | - David S. Bach
- From the Department of Surgery, Prince Sultan Cardiac Centre, Riyad, Saudi Arabia (R.E.O.); Department of Surgery, Section of Cardiac Surgery, J.W. Goethe University, Frankfurt am Main, Germany (P.K.); and Department of Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (D.S.B.)
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Vink R, Kamphuisen PW, van den Brink RB, Levi M. Challenges in managing anticoagulant therapy in patients with heart valve prostheses. Expert Rev Cardiovasc Ther 2007; 5:563-70. [PMID: 17489678 DOI: 10.1586/14779072.5.3.563] [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] [Indexed: 11/08/2022]
Abstract
There is a wide array of recommendations for the management of anticoagulant therapy in patients with mechanical heart valves. The optimal intensity of vitamin K antagonists, management of patients during noncardiac surgery and use of anticoagulants during pregnancy are all ongoing matters of debate. In this review, we discuss the various studies on these topics and the different guidelines. Based on these, literature recommendations for daily clinical practice are formulated.
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Affiliation(s)
- Roel Vink
- University of Amsterdam, Department of Internal Medicine, Academic Medical Center, Amsterdam, The Netherlands.
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Bonow RO, Carabello BA, Chatterjee K, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing Committee to Revise the 1998 guidelines for the management of patients with valvular heart disease) developed in collaboration with the Society of Cardiovascular Anesthesiologists endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. J Am Coll Cardiol 2006; 48:e1-148. [PMID: 16875962 DOI: 10.1016/j.jacc.2006.05.021] [Citation(s) in RCA: 1094] [Impact Index Per Article: 60.8] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bonow RO, Carabello BA, Kanu C, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (writing committee to revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation 2006; 114:e84-231. [PMID: 16880336 DOI: 10.1161/circulationaha.106.176857] [Citation(s) in RCA: 1391] [Impact Index Per Article: 77.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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ACC/AHA 2006 Practice Guidelines for the Management of Patients With Valvular Heart Disease: Executive Summary. J Am Coll Cardiol 2006. [DOI: 10.1016/j.jacc.2006.05.030] [Citation(s) in RCA: 131] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Lund O, Bland M. Risk-corrected impact of mechanical versus bioprosthetic valves on long-term mortality after aortic valve replacement. J Thorac Cardiovasc Surg 2006; 132:20-6. [PMID: 16798297 DOI: 10.1016/j.jtcvs.2006.01.043] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2005] [Revised: 01/10/2006] [Accepted: 01/13/2006] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Choice of a mechanical or biologic valve in aortic valve replacement remains controversial and rotates around different complications with different time-related incidence rates. Because serious complications will always "spill over" into mortality, our aim was to perform a meta-analysis on overall mortality after aortic valve replacement from series with a maximum follow-up of at least 10 years to determine the age- and risk factor-corrected impact of currently available mechanical versus stented bioprosthetic valves. METHODS Following a formal study protocol, we performed a dedicated literature search of publications during 1989 to 2004 and included articles on adult aortic valve replacement with a mechanical or stented bioprosthetic valve if age, mortality statistics, and prevalences of well-known risk factors could be extracted. We used standard and robust regression analyses of the case series data with valve type as a fixed variable. RESULTS We could include 32 articles with 15 mechanical and 23 biologic valve series totaling 17,439 patients and 101,819 patient-years. The mechanical and biologic valve series differed in regard to mean age (58 vs 69 years), mean follow-up (6.4 vs 5.3 years), coronary artery bypass grafting (16% vs 34%), endocarditis (7% vs 2%), and overall death rate (3.99 vs 6.33 %/patient-year). Mean age of the valve series was directly related to death rate with no interaction with valve type. Death rate corrected for age, New York Heart Association classes III and IV, aortic regurgitation, and coronary artery bypass grafting left valve type with no effect. Included articles that abided by current guidelines and compared a mechanical and biologic valve found no differences in rates of thromboembolism. CONCLUSION There was no difference in risk factor-corrected overall death rate between mechanical or bioprosthetic aortic valves irrespective of age. Choice of prosthetic valve should therefore not be rigorously based on age alone. Risk of bioprosthetic valve degeneration in young and middle-aged patients and in the elderly and old with a long life expectancy would be an important factor because risk of stroke may primarily be related to patient factors.
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Affiliation(s)
- Ole Lund
- Department of Health Sciences, University of York, York, United Kingdom.
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Huh J, Bakaeen F. Heart valve replacement: which valve for which patient? Curr Cardiol Rep 2006; 8:109-16. [PMID: 16524537 DOI: 10.1007/s11886-006-0021-2] [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] [Indexed: 10/23/2022]
Abstract
The ideal heart valve substitute would show no deterioration or thrombogenicity, offer no resistance to blood flow, and be easy to implant. However, such a valve does not exist and we must accept compromises in some of these qualities based on our patients' needs. In selection of cardiac valve prosthesis, valve-related factors such as durability, thrombogenicity, and fluid dynamics should be carefully matched to patient-related factors such as age, size, life expectancy, comorbidities, plans for pregnancy, and lifestyle. In addition, surgeon- or operation-related factors should be considered. Technical aspects of implantation, ease of reoperation, and operative mortalities may tip the risk and benefit balance in a particular direction. We review currently available heart valve prostheses and the clinical factors that are involved in selection of a heart valve substitute.
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Affiliation(s)
- Joseph Huh
- Michael E. DeBakey Veterans Affairs Medical Center (112), 2002 Holcombe Boulevard, Houston, TX 77030, USA.
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Puvimanasinghe JPA, Takkenberg JJM, Edwards MB, Eijkemans MJC, Steyerberg EW, Van Herwerden LA, Taylor KM, Grunkemeier GL, Habbema JDF, Bogers AJJC. Comparison of outcomes after aortic valve replacement with a mechanical valve or a bioprosthesis using microsimulation. Heart 2004; 90:1172-8. [PMID: 15367517 PMCID: PMC1768482 DOI: 10.1136/hrt.2003.013102] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Mechanical valves and bioprostheses are widely used for aortic valve replacement. Though previous randomised studies indicate that there is no important difference in outcome after implantation with either type of valve, knowledge of outcomes after aortic valve replacement is incomplete. OBJECTIVE To predict age and sex specific outcomes of patients after aortic valve replacement with bileaflet mechanical valves and stented porcine bioprostheses, and to provide evidence based support for the choice of prosthesis. METHODS Meta-analysis of published results of primary aortic valve replacement with bileaflet mechanical prostheses (nine reports, 4274 patients, and 25,726 patient-years) and stented porcine bioprostheses (13 reports, 9007 patients, and 54,151 patient-years) was used to estimate the annual risks of postoperative valve related events and their outcomes. These estimates were entered into a microsimulation model, which was employed to calculate age and sex specific outcomes after aortic valve replacement. RESULTS Life expectancy (LE) and event-free life expectancy (EFLE) for a 65 year old man after implantation with a mechanical valve or a bioprosthesis were 10.4 and 10.7 years and 7.7 and 8.4 years, respectively. The lifetime risk of at least one valve related event for a mechanical valve was 48%, and for a bioprosthesis, 44%. For LE and EFLE, the age crossover point between the two valve types was 59 and 60 years, respectively. CONCLUSIONS Meta-analysis based microsimulation provides insight into the long term outcome after aortic valve replacement and suggests that the currently recommended age threshold for implanting a bioprosthesis could be lowered further.
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Affiliation(s)
- J P A Puvimanasinghe
- Department of Cardiothoracic Surgery, Room Bd 162a, Erasmus MC, Rotterdam, Netherlands.
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Mistiaen W, Van Cauwelaert P, Muylaert P, Sys SU, Harrisson F, Bortier H. Thromboembolic events after aortic valve replacement in elderly patients with a Carpentier-Edwards Perimount pericardial bioprosthesis. J Thorac Cardiovasc Surg 2004; 127:1166-70. [PMID: 15052218 DOI: 10.1016/j.jtcvs.2003.11.010] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Thromboembolic events after aortic valve replacement with a bioprosthesis were the most frequently occurring complications in elderly patients. Whether this was valve related or dependent on other factors needed further exploration. METHODS Five hundred patients with a median age of 73 years were followed retrospectively after aortic valve replacement with a pericardial prosthesis for occurrence of thromboembolism. Of these, 348 also underwent coronary artery bypass grafting. Twenty-five factors were investigated for their potential effect by using univariate and multivariate analysis. RESULTS Univariate analysis revealed 6 significant factors: preoperative endocarditis (P =.0001), preoperative cerebrovascular accident (P =.002), use of postoperative warfarin sodium (Coumadin, DuPont Merck; P =.006), arterial hypertension (P =.023), size of valve prosthesis of 27 mm or larger (P =.023), and hospital thromboembolism (P =.040). There was a trend toward increased fatal thromboembolism in patients without medication. With a multivariate analysis, 4 factors remained significant: preoperative cerebrovascular accident (risk ratio, 4.8; P =.0016), warfarin sodium (risk ratio, 3.0; P =.0028), preoperative endocarditis (risk ratio, 5.6; P =.006), and hospital thromboembolism (risk ratio, 6.1; P =.016). Hypertension had a borderline effect. Age, sex, diabetes, 4 coronary artery factors, 3 other valvular factors, atrial fibrillation, and carotid artery disease had no significant effect. CONCLUSIONS Some emboli seemed triggered by the valve prosthesis. A proper anticoagulant protocol but also a treatment of hypertension is important in the prevention of thromboembolism after aortic valve replacement with a bioprosthesis. We did not find a significant role of atrial fibrillation and carotid artery disease.
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Affiliation(s)
- W Mistiaen
- Laboratory for Human Anatomy and Embryology, University of Antwerp, Belgium.
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Phillips SJ. Selecting the best heart valve for your patient: mechanical or tissue. THE AMERICAN HEART HOSPITAL JOURNAL 2004; 2:149-52. [PMID: 15805765 DOI: 10.1111/j.1541-9215.2004.03220.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
This review provides general guidance for heart valve selection. Mechanical heart valves exhibit excellent durability and hemodynamic performance but require anticoagulation to reduce thromboembolism, and therefore risk of anticoagulation-related hemorrhage is increased. Tissue valves were introduced to avoid anticoagulation, but in fact often do not, and lack durability. A literature review was performed to compare the complications of thromboembolism, anticoagulation-related hemorrhage, reoperation structural valve deterioration, and reoperative mortality associated with mechanical and tissue valves. The thromboembolism rates for mechanical and tissue valves are equivalent. During their lives, many recipients of tissue valves receive anticoagulation therapy due to comorbid conditions. The anticoagulation-related blood loss rates associated with mitral mechanical valves and mitral tissue valves are equivalent, whereas the blood loss rates associated with aortic tissue valves are less than those associated with aortic mechanical valves.
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Affiliation(s)
- Steven J Phillips
- National Library of Medicine, National Institutes of Health, Bethesda, MD, USA.
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Abstract
Intervention for valvular heart disease poses unique clinical challenges in cardiology because the diseases are of relatively low prevalence, the interventions do not lend themselves to randomized comparative trials, and important clinical end points are assessed only after decades of follow-up. In addition, continuing advances in prosthetic heart valve technology make follow-up a moving target because long-term data by definition are available only for older prostheses. Newer tissue and mechanical prostheses afford superior hemodynamics compared with their older counterparts, and data suggest that durability and patient mortality are superior with newer compared with older bioprostheses. Arbitrary cutoffs dictating valve choice based predominantly on patient age may not give appropriate weight to individual patient perspectives. In educating and counseling patients regarding choices in heart valve prostheses, the clinician should help the patient weigh the relative merits for the individual patient of projected mortality, valve durability, and requirement for anticoagulation, with associated freedom from re-operation, hemorrhagic and thromboembolic risk, and impact on lifestyle.
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Affiliation(s)
- David S Bach
- Department of Medicine, Division of Cardiology, University of Michigan, Ann Arbor, Michigan 48109-0273, USA.
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Farivar RS, Cohn LH. Hypercholesterolemia is a risk factor for bioprosthetic valve calcification and explantation. J Thorac Cardiovasc Surg 2003; 126:969-75. [PMID: 14566234 DOI: 10.1016/s0022-5223(03)00708-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE There are pathophysiologic similarities between calcification and atherosclerosis. We wished to determine whether risk factors for atherosclerosis were linked to bioprosthetic valve calcification and dysfunction. METHODS We performed a retrospective cohort study on 144 patients at a single institution who had bioprosthetic aortic or mitral valves removed, serum cholesterol levels recorded, and valve calcification assessed on the basis of hematoxylin and eosin staining and radiography of the valve. We also performed case-control analysis of a group of 66 patients whose tissue valves were explanted and compared them with an age- and position-matched group of 66 patients with similar duration of implantation. We also compared mean serum cholesterol levels. RESULTS In the retrospective cohort study cholesterol (P =.035), younger age at implantation (P =.014), and coronary artery disease (P =.017) were linked to calcification of the valve by means of univariate analysis. In stepwise multiple regression analysis only the mean serum cholesterol level was linked to calcification (P =.02). Sex, hypertension, smoking, diabetes, and implant position were not linked to calcification. In the case-control analysis the mean serum cholesterol level of the explanted valve group was significantly higher (189 vs 163 mg/dL, P <.0001) than that of the group whose valves did not require explantation. For those whose serum cholesterol levels were greater than 200 mg/dL, the odds ratio was 3.9 (95% confidence interval, 1.7-8.9) for valve explantation. CONCLUSIONS Increased serum cholesterol level may be a risk factor for bioprosthetic valve calcification requiring explantation.
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Affiliation(s)
- Robert Saeid Farivar
- Division of Cardiac Surgery, Department of Surgery, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Abstract
Bioprosthetic heart valves have evolved over the years into remarkably useful and predictable devices. During this process, a number of specific designs have come and gone, and a few have remained. Many design changes were successful, and many were not. This article will describe the successes and failures of the various bioprosthetic valve designs and will detail the specific reasons why a particular design change succeeded or failed to improve bioprosthetic valve performance.
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Affiliation(s)
- I Vesely
- Department of Biomedical Engineering/ND20, Lerner Research Institute, Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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Eslami M, Rahimtoola SH. Prophylactic aortic valve replacement in older patients for mild aortic stenosis during coronary bypass surgery. THE AMERICAN JOURNAL OF GERIATRIC CARDIOLOGY 2003; 12:197-200. [PMID: 12732816 DOI: 10.1111/j.1076-7460.2003.02068.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Coronary bypass surgery (CBS) is performed in many older patients who frequently also have mild calcific aortic stenosis. It is important that a correct assessment of the severity of aortic stenosis is done by calculating the aortic valve area. Mild aortic stenosis is aortic valve area >1.5 cm(2), >0.9 cm(2)/m(2); severe aortic stenosis is aortic valve area < or =1.0 cm(2), < or =0.6 cm(2)/m(2). Patients who have severe aortic stenosis should have aortic valve replacement (AVR) at the time of CBS. Patients with mild aortic stenosis should not have AVR simultaneously with CBS because: 1) patients having AVR+CBS have a higher operative and 10-year mortality; 2) prosthetic heart valves are associated with a complication rate of 2%-6% per year; and 3) only about 12% of patients with mild aortic stenosis will have developed severe aortic stenosis in 10 years. Performing AVR for mild aortic stenosis at the time of CBS will probably result in 91 unnecessary AVRs and 29 excess deaths in 10 years.
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Affiliation(s)
- Mahmoud Eslami
- Griffith Center, Division of Cardiology, Department of Medicine LAC+USC Medical Center and Keck School of Medicine,University of Southern California, Los Angeles, CA 90033, USA
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Butany J, Fayet C, Ahluwalia MS, Blit P, Ahn C, Munroe C, Israel N, Cusimano RJ, Leask RL. Biological replacement heart valves. Identification and evaluation. Cardiovasc Pathol 2003; 12:119-39. [PMID: 12763552 DOI: 10.1016/s1054-8807(03)00002-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Jagdish Butany
- Department of Pathology, Toronto General Hospital, Toronto, ON, Canada.
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Abstract
This review summarizes the major long-term (> or =10 to 15 years) patient outcomes after insertion of many Food and Drug Administration approved prosthetic heart valves (PHV). Mechanical PHV was associated with a better survival (p < 0.02) at 15 years after aortic valve replacement (AVR) than with a bioprosthesis in the Department of Veterans Affairs (DVA) trial. In both the DVA and the Edinburgh Heart Valve trials, bioprosthesis were associated with structural valve deterioration (SVD) (mitral valve replacement [MVR] > AVR) and, therefore, for replacement of the PHV. Thromboembolism and bleeding rate were higher with mechanical PHV. Mortality after AVR and MVR is high at 10 to 15 years because of the associated comorbid conditions and older age of patients. Outcomes with "new" good valves are similar to that with "older" good valves. Complication rates of thromboembolism, bleeding, endocarditis, and leak vary widely; the rates of these complications are not different among different mechanical PHV and among different bioprosthetic PHV. Structural valve deterioration is rare with mechanical PHV. Structural valve deterioration of bioprosthesis after MVR is higher than after AVR; after AVR, homografts and bioprosthesis have similar rates of SVD. The exact rate of SVD of the pulmonary autograft is uncertain. Valve prosthesis-patient mismatch is clinically important when it is severe and in selected patients when it is moderate. Bioprosthesis have a low rate of SVD in the older patient and, thus, are the PHV of choice for AVR in patients > or =60 to 65 years of age and for MVR in patients > or =65 to 70 years of age; in younger patients mechanical valves are the PHV of choice. In individual patients there may be exceptions to these general rules.
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Affiliation(s)
- Shahbudin H Rahimtoola
- Griffith Center, Division of Cardiovascular Medicine, Department of Medicine, LAC + USC Medical Center, Keck School of Medicine at the University of Southern California, 2025 Zonal Avenue, Los Angeles, CA 90033, USA
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Yoshida K, Matsumoto M, Sugita T, Nishizawa J, Matsuyama K, Tokuda Y, Matsuo T. Management of asymptomatic aortic stenosis in patients undergoing coronary artery bypass grafting. Circ J 2003; 67:199-202. [PMID: 12604866 DOI: 10.1253/circj.67.199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
This study compared the outcomes of combined coronary artery bypass grafting (CABG)/aortic valve replacement (AVR) and CABG alone in patients with moderate aortic stenosis and determined the possible indications for AVR at the time of CABG. Between December 1988 and January 2001, in Tenri Hospital, 41 patients with aortic stenosis underwent CABG: 26 patients underwent the combined procedure and 15 patients underwent CABG alone. The patients who underwent CABG alone were separated them into 2 groups on the basis of the results of annual echocardiography: the rapid progression group, defined by an increase of deltaP by >/=10 mmHg/year, and the slow progression group. Of the 15 patients who underwent CABG alone, the probability of survival at the end of the study in 2001 was 92% at 5 years and 74% at 10 years, and the respective event-free rates were 65% and 50%. Patients less than 70 years old and who were in the rapid progression group had a greater risk for re-operation. The study suggests that patients younger than 70 years old with risk factors for rapid progression should undergo CABG/AVR, and conversely, those older than 70 years old without the risk factors can undergo CABG only.
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Affiliation(s)
- Kazunori Yoshida
- Department of Cardiovascular Surgery, Tenri Hospital, Nara, Japan
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Affiliation(s)
- Marcos Murtra
- Cardiac Surgical Department, University Hospital Vall d'Hebron, Autonomic University of Barcelona, Spain.
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Corbineau H, De La Tour B, Verhoye JP, Langanay T, Lelong B, Leguerrier A. Carpentier-Edwards supraannular porcine bioprosthesis in aortic position: 16-year experience. Ann Thorac Surg 2001; 71:S228-31. [PMID: 11388192 DOI: 10.1016/s0003-4975(01)02545-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND The aim of the study was to evaluate the long-term results of aortic valve replacement with the Carpentier-Edwards supraannular porcine bioprosthesis. METHODS A total of 278 patients who underwent aortic valve replacement between January 1983 and December 1986 were reviewed. Mean age was 69.4+/-11.0 years (range 24 to 90 years). RESULTS The operative mortality was 8.6% (24 patients). The total follow-up was 2367.1 years (mean 9.3+/-4.3 years, maximum 15.5). The late mortality rate was 6.8%/patient-year (162 patients) and the overall survival at 15 years was 26.5%+/-3.6%. Structural valve deterioration (SVD) occurred in 19 patients (linearized rate 0.8%/ patient-year). The mean time to onset of deterioration was 10.9+/-2.9 years. This time was independent of the age at the time of implantation. The freedom from SVD at 10, 12, and 15 years for patients aged less than 60 was respectively 87.6%+/-6.8%, 77.8%+/-8.9%, and 44.2%+/-12.9% (linearized rate 3.3%/patient-year). For patients aged 61 to 70 years, freedom from SVD was, respectively, 100%, 97.3%+/-2.1%, and 80.8%+/-8.3% (linearized rate 0.63% patient-year). For patients older than 70 years, it was respectively 99.1%+/-0.9%, 95.6%+/-2.6%, and 93.3%+/-3.3% (linearized rate 0.31%/patient-year). No significant difference was observed below the age of 60 years (< or =50 vs 51 to 60 years) or in the older subgroups (61 to 70 years, vs >70 years). CONCLUSIONS The Carpentier-Edwards supraannular bioprosthesis in aortic position provides low rate of structural valve deterioration at 15 years in patients aged more than 60 years at the time of implantation. The mean time to onset of SVD is independent of the subject's age at the time of implantation. After 60 years, the risk of deterioration is low and does not present any significant variation. The Carpentier-Edwards supraannular bioprosthesis can reliably be used for aortic valve replacement in patients over the age of 60 years because, beyond this age, SVD is observed much more rarely.
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Affiliation(s)
- H Corbineau
- Department of Cardiovascular and Thoracic Surgery, University Hospital Center, Rennes, France.
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Puvimanasinghe JP, Steyerberg EW, Takkenberg JJ, Eijkemans MJ, van Herwerden LA, Bogers AJ, Habbema JD. Prognosis after aortic valve replacement with a bioprosthesis: predictions based on meta-analysis and microsimulation. Circulation 2001; 103:1535-41. [PMID: 11257081 DOI: 10.1161/01.cir.103.11.1535] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Bioprostheses are widely used as an aortic valve substitute, but knowledge about prognosis is still incomplete. The purpose of this study was to provide insight into the age-related life expectancy and actual risks of reoperation and valve-related events of patients after aortic valve replacement with a porcine bioprosthesis. METHODS AND RESULTS We conducted a meta-analysis of 9 selected reports on stented porcine bioprostheses, including 5837 patients with a total follow-up of 31 874 patient-years. The annual rates of valve thrombosis, thromboembolism, hemorrhage, and nonstructural dysfunction were 0.03%, 0.87%, 0.38%, and 0.38%, respectively. The annual rate of endocarditis was estimated at 0.68% for >6 months of implantation and was 5 times as high during the first 6 months. Structural valve deterioration was described with a Weibull model that incorporated lower risks for older patients. These estimates were used to parameterize, calibrate, and validate a mathematical microsimulation model. The model was used to predict life expectancy and actual risks of reoperation and valve-related events after implantation for patients of different ages. For a 65-year-old male, these figures were 11.3 years, 28%, and 47%, respectively. CONCLUSIONS The combination of meta-analysis with microsimulation enabled a detailed insight into the prognosis after aortic valve replacement with a bioprosthesis for patients of different ages. This information will be useful for patient counseling and clinical decision making. It also could serve as a baseline for the evaluation of newer valve types.
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Affiliation(s)
- J P Puvimanasinghe
- Center for Clinical Decision Sciences, Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
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Rahimtoola SH. Should patients with asymptomatic mild or moderate aortic stenosis undergoing coronary artery bypass surgery also have valve replacement for their aortic stenosis? Heart 2001; 85:337-41. [PMID: 11179280 PMCID: PMC1729639 DOI: 10.1136/heart.85.3.337] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- S H Rahimtoola
- Division of Cardiology, Department of Medicine, University of Southern California and LAC+USC Medical Center, Los Angeles, California 90033, USA
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48
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Abstract
Whether antithrombotic therapy in elderly patients differs from that in younger populations depends on whether the risk for such bleeding differs in the elderly. Regarding long-term therapy with warfarin derivatives, evidence shows that there is a difference. The anticoagulation response to warfarin is exaggerated with advancing age. This article discusses antithrombotic therapies for valvular heart disease, including bioprosthetic and mechanical prosthetic heart valves, aspirin and dipyridamole in combination with oral anticoagulant therapy, antiplatelet agents alone or in combination with very low dose warfarin, tilting disk valves, valve position, first-generation valves compared with modern valves, interruption of anticoagulant therapy, and miscellaneous indications for antithrombotic therapy.
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Affiliation(s)
- P D Stein
- St. Joseph Mercy-Oakland Hospital, Pontiac, Michigan, USA.
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Stein PD, Alpert JS, Bussey HI, Dalen JE, Turpie AG. Antithrombotic therapy in patients with mechanical and biological prosthetic heart valves. Chest 2001; 119:220S-227S. [PMID: 11157651 DOI: 10.1378/chest.119.1_suppl.220s] [Citation(s) in RCA: 181] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
1. Permanent therapy with oral anticoagulants offers the most consistent protection in patients with mechanical heart valves. 2. Antiplatelet agents alone do not consistently protect patients with mechanical prosthetic heart valves, including patients in sinus rhythm with St. Jude Medical valves in the aortic position. 3. Levels of oral anticoagulants that prolong the INR to 2.0 to 3.0 appear satisfactory for patients with St. Jude Medical bileaflet and Medtronic-Hall tilting disk mechanical valves in the aortic position, provided they are in sinus rhythm and the left atrium is not enlarged. Presumably, this is also true for the CarboMedics bileaflet valve, based on the observation of no clinically important difference in the rate of systemic embolism with this valve and the St. Jude Medical bileaflet valve. 4. Levels of oral anticoagulants that prolong the INR to 2.5 to 3.5 are satisfactory for tilting disk valves and bileaflet prosthetic valves in the mitral position. 5. Experience in patients with caged ball valves who had prothrombin time ratios reported in terms of the INR is sparse, because few such valves have been inserted in recent years. The number of surviving patients with caged ball valves continues to decrease. It has been suggested that the most advantageous level of the INR in patients with caged ball or caged disk valves should be as high as 4.0 to 4.9. However, others have shown a high rate of major hemorrhage with an INR that is even somewhat lower, 3.0-4.5. The problem is self-limited, however, because few such valves are being inserted. 6. In patients with mechanical heart valves, aspirin, in addition to oral anticoagulants, has been shown to diminish the frequency of thromboemboli. The risk of bleeding is somewhat increased if the INR is 2.0 to 3.0 or 2.5 to 3.5. However, if the INR is 3.0 to 4.5, the risk of bleeding becomes excessive with aspirin. There are no investigations in which aspirin 80 mg/d in combination with oral anticoagulants was evaluated. 7. Data are insufficient to recommend dipyridamole over low doses of aspirin in combination with warfarin. Whether dipyridamole plus aspirin is more effective than aspirin alone when used with warfarin is undetermined. 8. Patients with bioprosthetic valves in the mitral position as well as patients with bioprosthetic valves in the aortic position may be at risk for thromboemboli during the first 3 months after operation. 9. Among patients with bioprosthetic valves in the mitral position, oral anticoagulants at an INR of 2.0 to 2.3 were as effective as an INR of 2.5 to 4.0 and were associated with fewer bleeding complications during the first 3 months after operation.10. Aspirin may reduce the long-term frequency of thromboembolism in patients with bioprosthetic valves.
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Affiliation(s)
- P D Stein
- St Joseph Mercy-Oakland Hospital, Pointia, MI 48341-2964, USA.
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50
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Hammermeister K, Sethi GK, Henderson WG, Grover FL, Oprian C, Rahimtoola SH. Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial. J Am Coll Cardiol 2000; 36:1152-8. [PMID: 11028464 DOI: 10.1016/s0735-1097(00)00834-2] [Citation(s) in RCA: 716] [Impact Index Per Article: 29.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES The goal of this study was to compare long-term survival and valve-related complications between bioprosthetic and mechanical heart valves. BACKGROUND Different heart valves may have different patient outcomes. METHODS Five hundred seventy-five patients undergoing single aortic valve replacement (AVR) or mitral valve replacement (MVR) at 13 VA medical centers were randomized to receive a bioprosthetic or mechanical valve. RESULTS By survival analysis at 15 years, all-cause mortality after AVR was lower with the mechanical valve versus bioprosthesis (66% vs. 79%, p = 0.02) but not after MVR. Primary valve failure occurred mainly in patients <65 years of age (bioprosthesis vs. mechanical, 26% vs. 0%, p < 0.001 for AVR and 44% vs. 4%, p = 0.0001 for MVR), and in patients > or =65 years after AVR, primary valve failure in bioprosthesis versus mechanical valve was 9 +/- 6% versus 0%, p = 0.16. Reoperation was significantly higher for bioprosthetic AVR (p = 0.004). Bleeding occurred more frequently in patients with mechanical valve. There were no statistically significant differences for other complications, including thromboembolism and all valve-related complications between the two randomized groups. CONCLUSIONS At 15 years, patients undergoing AVR had a better survival with a mechanical valve than with a bioprosthetic valve, largely because primary valve failure was virtually absent with mechanical valve. Primary valve failure was greater with bioprosthesis, both for AVR and MVR, and occurred at a much higher rate in those aged <65 years; in those aged > or =65 years, primary valve failure after AVR was not significantly different between bioprosthesis and mechanical valve. Reoperation was more common for AVR with bioprosthesis. Thromboembolism rates were similar in the two valve prostheses, but bleeding was more common with a mechanical valve.
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Affiliation(s)
- K Hammermeister
- Denver VA Medical Center and University of Colorado Health Sciences Center, USA
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