Prosthesis size and long-term survival after aortic valve replacement

Association of Valve Size and Hemodynamic Performance With Clinical Outcomes in Aortic Valve Replacement - A Long-Term Follow-up in an Asian Population

BACKGROUND

Studies of the influence of smaller body type on the severity of prosthesis-patient mismatch (PPM) after small-sized surgical aortic valve replacement (SAVR) are few, but the issue is particularly relevant for Asian patients.Methods and Results: 695 patients who underwent SAVR with bioprosthetic valves had their hemodynamic valve performance analyzed at 3 months, 1 year, 3 years, and 5 years after operation, and clinical outcomes were assessed. The patients were stratified into 3 valve size groups: 19/21, 23, and 25/27 mm. A smaller valve was associated with higher mean pressure gradients at the 4 time points after operation (P trend <0.05). However, the 3 valve size groups demonstrated no significant differences in the risk of clinical events. At none of the time points did patients with projected PPM show increased mean pressure gradients (P>0.05), whereas patients with measured PPM did (P<0.05). Compared with patients with projected PPM, those with measured PPM demonstrated higher rates of infective endocarditis readmission (adjusted hazard ratio [aHR] 3.31, 95% confidence interval [CI] 1.06-10.39) and a higher risk of composite outcomes (aHR 1.45, 95% CI 0.95-2.22, P=0.087).

CONCLUSIONS

Relative to those receiving larger valves, patients receiving small bioprosthetic valves had poorer hemodynamic performance but did not demonstrate differences in clinical events in long-term follow-up.

Do postoperative hemodynamic parameters add prognostic value for mortality after surgical aortic valve replacement?

Background

Although various hemodynamic parameters to assess prosthetic performance are available, prosthesis-patient mismatch (PPM) is defined exclusively by effective orifice area (EOA) index thresholds. Adjusting for the Society of Thoracic Surgeons predicted risk of mortality (STS PROM), we aimed to explore the added value of postoperative hemodynamic parameters for the prediction of all-cause mortality at 5 years after aortic valve replacement.

Methods

Data were obtained from the Pericardial Surgical Aortic Valve Replacement (PERIGON) Pivotal Trial, a multicenter prospective cohort study examining the performance of the Avalus bioprosthesis. Candidate predictors were assessed at the first follow-up visit; patients who had no echocardiography data, withdrew consent, or died before this visit were excluded. Candidate predictors included peak jet velocity, mean pressure gradient, EOA, predicted and measured EOA index, Doppler velocity index, indexed internal prosthesis orifice area, and categories for PPM. The performance of Cox models was investigated using the c-statistic and net reclassification improvement (NRI), among other tools.

Results

A total of 1118 patients received the study valve, of whom 1022 were eligible for the present analysis. In univariable analysis, STS PROM was the sole significant predictor of all-cause mortality (hazard ratio, 1.40; 95% confidence interval, 1.26-1.55). When extending the STS PROM with single hemodynamic parameters, neither the c-statistics nor the NRIs demonstrated added prognostic value compared to a model with STS PROM alone. Similar findings were observed when multiple hemodynamic parameters were added.

Conclusions

The STS PROM was found to be the main predictor of patient prognosis. The additional prognostic value of postoperative hemodynamic parameters for the prediction of all-cause mortality was limited.

Valve-sparing aortic root replacement-for all patients?

BACKGROUND

Valve-sparing root replacement (VSRR) has been associated with good survival and low rates of valve-related complications (VRCs). Whether these advantages are present irrespective of patient comorbidity or age is unclear. The aim of this study was to analyze survival and frequency of VRCs in relation to patient comorbidity and age.

METHODS

Between October 1995 and December 2021, 1156 patients with a bicuspid or tricuspid aortic valve were treated by root remodeling. The mean patient age was 53.3 ± 14 years, and 973 (84%) were male. The mean duration of follow-up was 6.7 ± 5.5 years (median, 5.9 years), and follow-up was 95% complete (7746 patient-years). We analyzed the population according to comorbidity and age at surgery. A discriminating cutoff for the effect of age was determined using receiver operating characteristic curve (ROC) analysis.

RESULTS

Mean survival at 15 years was 74.7 ± 2.5%. Deceased patients were older (mean, 65.3 ± 12 years vs 51.6 ± 14.1 years; P < .001) at the time of surgery and had more comorbidities (coronary artery disease [CAD], 28.4% vs 9.8%; P < .001). The sole significant adjusted predictor was age (P < .001). By ROC analysis (area under the curve, 0.780), the optimal cutoff for age was 61 years. Survival was 87.1 ± 2.8% at 15 years in patients age <61 years, compared to 55.3 ± 4.3% in patients age >61 years (P < .0001). Using competing risk analysis, VRC-free survival at 15 years was 66.8% at 15 years, including 76.7% in patients age <61 years and 52.4% in those age >61 years (P < .0001).

CONCLUSIONS

VSRR is associated with a low incidence of VRC and excellent durability. Survival is decreased in the presence of comorbidities, mainly CAD, and patient age >61 years. Despite lower survival, freedom from VRC is good.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The prognostic impacts of frailty on clinical and patient-reported outcomes in patients undergoing coronary artery or valvular surgeries/procedures: A systematic review and meta-analysis

BACKGROUND

Frailty is emerging as an important prognostic indicator for patients undergoing cardiac surgeries/procedures. We sought to evaluate the prognostic and differential impacts of frailty on patients undergoing coronary artery or valvular surgical procedures of different levels of invasiveness, and to explore the differential predictability of various frailty measurement models.

METHODS

Eight databases were searched for prospective cohort studies that have adopted validated measure(s) of frailty and reported clinical, healthcare service utilization, or patient-reported outcomes in patients undergoing coronary artery or valvular surgeries/procedures.

RESULTS

Sixty-two articles were included (N = 16,679). Frailty significantly predicted mortality (short-term [≤ 30 days]: odds ratio [OR]: 2.33, 95% confidence interval [CI]: 1.28-4.26; midterm [6 months to 1 year]: OR: 3.93, 95%CI: 2.65-5.83; long-term [>1 year]: HR: 2.23, 95%CI: 1.60-3.11), postoperative complications (ORs: 2.54-3.57), discharge to care facilities (OR: 5.52, 95%CI: 3.84-7.94), hospital readmission (OR: 2.00, 95%CI: 1.15-3.50), and reduced health-related quality of life (HRQoL; standardized mean difference: -0.74, 95%CI: -1.30 to -0.18). Subgroup analyses showed that frailty exerted a greater impact on short-term mortality in patients undergoing open-heart surgeries than those receiving transcatheter procedures. Multidimensional and physical-aspect-focused frailty measurements performed equally in predicting mortality, but multidimensional measurements were more predictive of hospital readmission than physical-aspect-focused measurements.

CONCLUSION

Frailty was predictive of postoperative mortality, complications, increased healthcare service utilization, and reduced HRQoL. The impact of frailty on short-term mortality was more prominent in patients undergoing open-heart surgeries than those receiving transcatheter procedures. Multidimensional measures of frailty enhanced prognostic risk estimation, especially for hospital readmission.

Surgical versus transcatheter aortic valve replacement: Impact of patient-prosthesis mismatch on outcomes

BACKGROUND

The hemodynamics of most prosthetic valves are often inferior to that of the normal native valve, and a significant proportion of patients undergoing surgical (SAVR) or transcatheter aortic valve replacement (TAVR) have high residual transaortic pressure gradients due to prosthesis-patient mismatch (PPM). As the experience with TAVR has increased and long-term outcomes are reported, a close look at the PPM literature is required in light of new evidence.

METHODS

For this review, we searched the Embase, Medline, and Cochrane databases from 2000 to 2022. Articles reporting PPM as an outcome following aortic valve replacements were identified and reviewed.

RESULTS

The impact of PPM on clinical outcomes in aortic valve replacement has not been clear as multiple studies failed to report PPM incidence. However, the PPM outcomes after SAVR vary more widely than after TAVR, ranging from 8% to 80% in SAVR and from 24% to 35% in TAVR. Incidence of severe PPM following redo SAVR ranges from 2% to 9% and following valve-in-valve TAVR is from 14% to 33%, however, while PPM is higher in valve-in-valve TAVR, patients had better survival rates.

CONCLUSIONS

The gap between valve performance and clinical outcomes in SAVR and TAVR could be reduced by carefully selecting patients for either treatment option. Understanding predictors of PPM can add to the safety, effectiveness, and increased survival benefit of both SAVR and TAVR.

Females have an increased risk of short-term mortality after cardiac surgery compared to males: Insights from a national database

OBJECTIVES

Female sex is considered a risk factor for mortality and morbidity following cardiac surgery. This study is the first to review the UK adult cardiac surgery national database to compare outcomes following surgical coronary revascularisation and valvular procedures between females and males.

METHODS

Using data from National Adult Cardiac Surgery Audit, we identified all elective and urgent, isolated coronary artery by-pass grafting (CABG), aortic valve replacement (AVR) and mitral valve replacement/repair (MVR) procedures from 2010 to 2018. We compared baseline data, operative data and outcomes of mortality, stroke, renal failure, deep sternal wound infection, return to theater for bleeding, and length of hospital stay. Multivariable mixed-effect logistical/linear regression models were used to assess relationships between sex and outcomes, adjusting for baseline characteristics.

RESULTS

Females, compared to males, had greater odds of experiencing 30-day mortality (CABG odd ratio [OR] 1.76, confidence interval [CI] 1.47-2.09, p < .001; AVR OR 1.59, CI 1.27-1.99, p < .001; MVR OR 1.37, CI 1.09-1.71, p = .006). After CABG, females also had higher rates of postoperative dialysis (OR 1.31, CI 1.12-1.52, p < .001), deep sternal wound infections (OR 1.43, CI 1.11-1.83, p = .005) and longer length of hospital stay (β 1.2, CI 1.0-1.4, p < .001) compared to males. Female sex was protective against returning to theater for postoperative bleeding following CABG (OR 0.76, CI 0.65-0.87, p < .001) and AVR (OR 0.72, CI 0.61-0.84, p < .001).

CONCLUSION

Females in the United Kingdom have an increased risk of short-term mortality after cardiac surgery compared to males. This highlights the need to focus on the understanding of the causes behind these disparities and implementation of strategies to improve outcomes in females.

Construction and validation of a nomogram for predicting survival in elderly patients with cardiac surgery

Background

In recent years, the number of elderly patients undergoing cardiac surgery has rapidly increased and is associated with poor outcomes. However, there is still a lack of adequate models for predicting the risk of death after cardiac surgery in elderly patients. This study sought to identify independent risk factors for 1-year all-cause mortality in elderly patients after cardiac surgery and to develop a predictive model.

Methods

A total of 3,752 elderly patients with cardiac surgery were enrolled from the Medical Information Mart for Intensive Care III (MIMIC-III) dataset and randomly divided into training and validation sets. The primary outcome was the all-cause mortality at 1 year. The Least absolute shrinkage and selection operator (LASSO) regression was used to decrease data dimensionality and select features. Multivariate logistic regression was used to establish the prediction model. The concordance index (C-index), receiver operating characteristic curve (ROC), and decision curve analysis (DCA) were used to measure the predictive performance of the nomogram.

Results

Our results demonstrated that age, sex, Sequential Organ Failure Assessment (SOFA), respiratory rate (RR), creatinine, glucose, and RBC transfusion (red blood cell) were independent factors for elderly patient mortality after cardiac surgery. The C-index of the training and validation sets was 0.744 (95%CI: 0.707-0.781) and 0.751 (95%CI: 0.709-0.794), respectively. The area under the curve (AUC) and decision curve analysis (DCA) results substantiated that the nomogram yielded an excellent performance predicting the 1-year all-cause mortality after cardiac surgery.

Conclusions

We developed a novel nomogram model for predicting the 1-year all-cause mortality for elderly patients after cardiac surgery, which could be an effective and useful clinical tool for clinicians for tailored therapy and prognosis prediction.

Impact of sex on outcomes after cardiac surgery: A systematic review and meta-analysis

BACKGROUND

Despite advances in cardiac surgery, observational studies suggest that females have poorer post-operative outcomes than males. This study is the first to review sex related outcomes following both coronary artery bypass graft (CABG) and valve surgery with or without combined CABG.

METHODS

We identified 30 primary research articles reporting either short-term mortality (in-hospital/30 day), long-term mortality, and post-operative stroke, sternal wound infection and myocardial infarction (MI) in both sexes following CABG and valve surgery with or without combined CABG. Reported adjusted odds/hazard ratio were pooled using an inverse variance model.

RESULTS

Females undergoing CABG and combined valve and CABG surgery were at higher risk of short-term mortality (odds ratio (OR) 1.40; 95% confidence interval (CI) 1.32-1.49; I² = 79%) and post-operative stroke (OR 1.2; CI 1.07-1.34; I² = 90%) when compared to males. However, for isolated AVR, there was no difference found (OR 1.19; 95% CI 0.74-1.89). There was no increased risk in long-term mortality (OR 1.04; 95% CI: 0.93-1.16; I² = 82%), post-operative MI (OR 1.22; 95%CI: 0.89-1.67; I² = 60%) or deep sternal wound infection (OR 0.92; 95%CI: 0.65-1.03, I² = 87%). No evidence of publication bias or small study effect was found.

CONCLUSION

Females are at a greater risk of short-term mortality and post-operative stroke than males following CABG and valve surgery combined with CABG. However, there is no difference for Isolated AVR. Long-term mortality is equivalent in both sexes. PROSPERO Registration: CRD42021244603.

Sex Differences in the Utilization and Outcomes of Cardiac Valve Replacement Surgery for Infective Endocarditis: Insights From the National Inpatient Sample

Background

The data on the differential impact of sex on the utilization and outcomes of valve replacement surgery for infective endocarditis are limited to single‐center and small sample size patient population.

Methods and Results

We utilized the National Inpatient Sample database to identify patients with a discharge diagnosis of infective endocarditis from 2004 to 2015 to assess differences in the characteristics and clinical outcomes of patients hospitalized with infective endocarditis stratified by sex. We also evaluated trends in utilization of cardiac valve replacement and individual valve replacement surgeries in women versus men over a 12‐year period, and compared in‐hospital mortality after surgical treatment in women versus men. A total of 81 942 patients were hospitalized with a primary diagnosis of infective endocarditis from January 2004 to September 2015, of whom 44.31% were women. Women were less likely to undergo overall cardiac valve replacement (6.92% versus 12.12%), aortic valve replacement (3.32% versus 8.46%), mitral valve replacement (4.60% versus 5.57%), and combined aortic and mitral valve replacement (0.85% versus 1.81%) but had similar in‐hospital mortality rates. From 2004 to 2015, the overall rates of cardiac valve replacement increased from 11.76% to 13.96% in men and 6.34% to 9.26% in women and in‐hospital mortality declined in both men and women. Among the patients undergoing valve replacement surgery, in‐hospital mortality was higher in women (9.94% versus 6.99%, P<0.001).

Conclusions

Despite increased utilization of valve surgery for infective endocarditis in both men and women and improving trends in mortality, we showed that there exists a treatment bias with underutilization of valve surgeries for infective endocarditis in women and demonstrated that in‐hospital mortality was higher in women undergoing valve surgery in comparison to men.

Choosing Between Transcatheter Aortic Valve Replacement and Surgery in the Low-Risk Transcatheter Aortic Valve Replacement Era

The landmark results of the low surgical risk pivotal transcatheter aortic valve replacement (TAVR) trials fueled speculation that the role of surgical aortic valve replacement (SAVR) would be limited in the future. Instead, the field has pivoted away from reductive surgical risk stratification toward understanding the complex interplay of anatomy, timing, and surgical risk to optimize the lifetime management of aortic stenosis. In this review, we systematically explore the subtleties that influence the choice between TAVR and surgery in the low-risk TAVR era.

Outcomes Following Aortic Stenosis Treatment (Transcatheter vs Surgical Replacement) in Women vs Men (From a Nationwide Analysis)

Gender-differences in survival following transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) have been suggested. The objective of this study was to analyze outcomes following TAVR according to gender and to compare outcomes between TAVR and SAVR in women, at a nationwide level. Based on the French administrative hospital-discharge database, the study collected information for all consecutive patients treated with TAVR and SAVR between 2010 and 2019. Outcomes were analyzed according to gender and propensity score matching was used for the analysis of outcomes. In total 71,794 patients were identified in the database. After matching on baseline characteristics, we analyzed 12,336 women and 12,336 men treated with TAVR. In a second matched analysis, we compared 9,297 women treated with TAVR and 9,297 women treated with SAVR. Long term follow-up showed lower risk of all-cause death (12.7% vs 14.8%, hazard ratio (HR) 0.85, 95% CI 0.81 to 0.90) in women than men. Although the difference in cardiovascular death remained non-significant (5.8% vs 6.0%, HR 0.96, 95% CI 0.88 to 1.05), non-cardiovascular death was less frequent in women than in men following TAVR (6.9% vs 8.8% HR 0.78, 95%CI 0.72 to 0.84).When TAVR was compared with SAVR in women, long-term follow-up with TAVR showed higher rates of all-cause death (11.2% vs 6.5%, HR 1.91, 95%CI 1.78 to 2.05), cardiovascular death (5.0% vs 3.2%, HR 1.44, 95%CI 1.30 to 1.59), and non-cardiovascular death (6.2% vs 3.3%, HR 2.48, 95% CI 2.25 to 2.72). In conclusion, we observed that women undergoing TAVR have lower long-term all-cause mortality as compared with TAVR in men, driven by non-cardiovascular mortality. SAVR was associated with lower rates of long-term cardiovascular adverse events in women as compared with TAVR.

Mid-term outcomes of rapid deployment aortic prostheses in patients with small aortic annulus

OBJECTIVES

The Edwards Intuity valve is a rapid deployment aortic prosthesis that favours less invasive approaches. However, evidence about the clinical behaviour of their smaller sizes is scarce. Herein, we studied haemodynamic behaviours and clinical outcomes of small Intuity prostheses (19-21 mm) in comparison to larger Intuity prostheses (>21 mm).

METHODS

This is an observational study including patients implanted with an Edwards Intuity rapid deployment aortic prosthesis. Patients with prosthesis sizes 19-21 and >21 mm were included. Baseline and perioperative variables, as well as adverse events during the follow-up were recorded and compared between groups.

RESULTS

A total of 122 patients (37% female, mean age 75 ± 4.5 years) were included, of whom 54 (45%) were implanted with a small prosthesis and 68 (55%) with a prosthesis >21 mm. There were no significant differences between patients with small Intuity prostheses and patients with larger prostheses regarding in-hospital mortality (2% vs 4%, P = 0.43) or mortality during the follow-up (3.41 vs 2.45 per 100 patients-years; P = 0.58). Survival in the small Intuity valve group was 95% at 1 year and 83% at 6 years, whereas in the larger Intuity valve group was 96% at 1 year and 78% at 6 years. The presence of a small prosthesis did not influence mid-term survival (log-rank P-value = 0.62).

CONCLUSIONS

This study showed good clinical performance of Intuity aortic prostheses with appropriate mid-term survival in patients with the small aortic annulus. Thus, the Edwards Intuity rapid deployment aortic prosthesis may be considered as a potential option in patients with the small aortic annulus.

Valvular heart diseases in women

BACKGROUND

Valvular heart disease is a common health problem affecting both sexes and all age groups. Almost all guidelines are based on studies that mainly involved male patients.

MAIN BODY

The features of valvular heart diseases in women were essentially derived from small observational studies. These studies have shown that women differ from men in terms of the type of valve disease, pathology affecting the valve, perception of symptoms, parameters measured in echocardiography, response to drugs, surgical techniques, and postoperative outcomes. This review was conducted to demonstrate the uniqueness of valvular heart diseases in women and raise awareness about the need for sex-based randomized study designs to provide a piece of proper evidence to support suitable sex-based guidelines and recommendations. Moreover, it briefly describes the effects of pregnancy on women with valvular heart diseases and the impact of the latter on the course of pregnancy and the well-being of the mother and fetus.

CONCLUSION

Valvular heart diseases in women are different from those in men. Sex-based guidelines for managing valvular heart diseases are needed.

Patient-prosthesis mismatch and surgical aortic valve replacement outcomes: Retrospective analysis of single-center surgical data

BACKGROUND

Patient-prosthesis mismatch (PPM) has been identified as a risk factor for mortality and reoperation in patients undergoing surgical aortic valve replacement (SAVR). We present a retrospective analysis of risk factors for PPM and the effects of PPM on early postoperative outcomes after SAVR.

METHODS

Chart review was conducted for patients (N = 3003) undergoing SAVR. PPM was calculated from valve reference orifice areas and patient body surface area. Logistic regression was used to analyze risk factors for PPM and develop a risk score from these results. Regression was also conducted to identify associations between projected PPM status and postoperative outcomes.

RESULTS

Risk factors for PPM included female sex, higher body mass index (BMI), and use of the St. Jude Epic valve. Patients receiving St. Jude trifecta valves or mechanical valves were less likely to have predicted PPM. We developed a risk score using BMI, sex, and valve type, and retrospectively predicted PPM in our cohort. Mild PPM (odds ratio [OR] = 2.267), severe PPM (OR = 2.869), male sex (OR = 2.091), and younger age (OR = 0.940) were all predictors of SAVR reoperation, while aortic root replacement was associated with reduced reoperation rates (OR = 0.122). Severe PPM carried a risk of in-hospital mortality (OR = 3.599), and moderate PPM carried a smaller but significant risk (OR = 1.920). Other factors increasing postoperative morbidity and mortality included older age, renal failure, and diabetes.

CONCLUSION

PPM could be retrospectively predicted in our cohort using a risk calculation from sex, BMI and valve type. We conclude that all degrees of PPM carry risk for mortality and reoperation.

Sutureless versus conventional bioprostheses for aortic valve replacement in severe symptomatic aortic valve stenosis

OBJECTIVE

Sutureless aortic valves are a novel option for aortic valve replacement. We sought to demonstrate noninferiority of sutureless versus standard bioprostheses in severe symptomatic aortic stenosis.

METHODS

The Perceval Sutureless Implant Versus Standard-Aortic Valve Replacement is a prospective, randomized, adaptive, open-label trial. Patients were randomized (March 2016 to September 2018) to aortic valve replacement with a sutureless or stented valve using conventional or minimally invasive approach. Primary outcome was freedom from major adverse cerebral and cardiovascular events (composite of all-cause death, myocardial infarction, stroke, or valve reintervention) at 1 year.

RESULTS

At 47 centers (12 countries), 910 patients were randomized to sutureless (n = 453) or conventional stented (n = 457) valves; mean ages were 75.4 ± 5.6 and 75.0 ± 6.1 years, and 50.1% and 44.9% were female, respectively. Mean ± standard deviation Society of Thoracic Surgeons scores were 2.4 ± 1.7 and 2.1 ± 1.3, and a ministernotomy approach was used in 50.4% and 47.3%, respectively. Concomitant procedures were performed with similar rates in both groups. Noninferiority was demonstrated for major adverse cerebral and cardiovascular events at 1 year, whereas aortic valve hemodynamics improved equally in both groups. Use of sutureless valves significantly reduced surgical times (mean extracorporeal circulation times: 71.0 ± 34.1 minutes vs 87.8 ± 33.9 minutes; mean crossclamp times: 48.5 ± 24.7 vs 65.2 ± 23.6; both P < .0001), but resulted in a higher rate of pacemaker implantation (11.1% vs 3.6% at 1 year). Incidences of perivalvular and central leak were similar.

CONCLUSIONS

Sutureless valves were noninferior to stented valves with respect to major adverse cerebral and cardiovascular events at 1 year in patients undergoing aortic valve replacement (alone or with coronary artery bypass grafting). This suggests that sutureless valves should be considered as part of a comprehensive valve program.

Computed Tomography Annular Dimensions: A Novel Method to Compare Prosthetic Valve Hemodynamics

BACKGROUND

The Cardiac Surgical Societies Valve Labeling Task Force consensus document acknowledged inconsistent sizing and labeling of prosthetic heart valves. This study compared the labeled size, internal diameter, and hemodynamics of different surgical and transcatheter valve types implanted into the same size annulus, measured by preprocedural computed tomography (CT).

METHODS

Patients were retrospectively sorted into 3 CT annular diameter size groups: small (less than 23 mm), medium (23 to less than 26 mm), and large (26 mm or greater). Surgical valves were sorted into 4 categories based on tissue and design: (stentless porcine, standard stented bovine, wraparound stented bovine, and stented porcine). Comparisons were made within the surgical types and with a transcatheter valve. Echocardiograms were independently assessed and CTs were centrally measured.

RESULTS

We analyzed 726 surgical and 923 transcatheter valve paired data sets. Among the various valve types implanted into the same size CT annulus, there were significant differences regarding size, internal diameter, and hemodynamics within all 3 size groups. Root enlargement procedures occurred in 1.2% with no differences across valve types or size groups. Transcatheter valve hemodynamics were similar to stentless valves and were significantly better than all stented valves. There was no difference in hemodynamics between the 2 bovine stented valve types, and stented porcine valves were inferior to all valve types.

CONCLUSIONS

This study documents that prosthetic heart valve sizing and labeling inconsistencies exist. Use of preoperative CT annular dimensions is the most accurate method to compare size, internal diameter, and hemodynamics of bioprosthetic aortic valves because it compares values among various valve types implanted into the same size annulus.

Soft robotic in the construction of prosthetic heart valve: a novel approach

In this study, we describe the design, fabrication and computational testing of a new prosthetic device for aortic valve replacement. The device is an active stent composed of a silicone rubber during initial prototyping, with adaptation towards a hydrogel, poly-vinyl alcohol reinforced with bacterial cellulose nanofibres underway. The nature of the stent is soft robotic (SR), where an increase in internal pressure of the pneumatic network causes an increase in the internal diameter of the device. When working in tandem with the SR heart valve, described briefly, pulsations of the blood and the energy gained from ventricular pressure actuates the valve-and-stent combination. This increases the effective orifice area of the entire device and addresses an issue with small sized heart valves facing prosthesis-patient mismatch.

Gender-specific differences in valvular heart disease

The development of new devices and treatment options has greatly increased the interest in heart valve diseases. In this context, the consideration of gender differences in diagnosis, treatment success, and prognosis is of great importance. Available data show that women and men with heart valve disease have different risk profiles, which have a significant impact on treatment outcomes and prognosis.

It is the purpose of this review article to give an overview of gender-related differences in patients with valvular heart disease, regarding clinical presentation, treatment, and outcomes. In light of the emerging treatment possibilities, future research should emphasize the role of gender since both sexes benefit from tailored management.

Aortic Valve Replacement in Elderly Patients With Small Aortic Annulus: Results With Three Different Bioprostheses

Objectives

Aortic valve replacement (AVR) in patients with small aortic annulus (diameter ≤21 mm) is considered a challenging scenario because of technical aspects and the high risk of patient-prosthesis mismatch (PPM). The choice of the appropriate prosthesis is crucial, and at the moment, an ideal device has yet to be identified. We compare clinical and hemodynamic results after AVR with three bioprostheses with different design and characteristics.

Methods

We retrospectively evaluated 76 consecutive patients from two cardiac surgery centers who underwent AVR (Trifecta = 24; Edwards INTUITY Elite valve system = 26, and Perceval = 26) for severe aortic stenosis between 2013 and 2017. Patients selected were older than 75 years and with an annulus diameter ≤21 mm at preoperative echocardiogram. Reinterventions and combined procedures were excluded. Minimally invasive AVR was performed in 44 (57.8%) patients. Telephonic interview was obtained at 2.9 ± 0.5 years and echocardiographic follow-up at 2.2 ± 0.8 years.

Results

Clinical outcome was similar in the three groups. At follow-up, Trifecta patients presented significantly higher peak and mean transprosthetic pressure gradients ( P = 0.04 and 0.01). Effective orifice area and left ventricular mass regression were comparable, although an advantage was observed in Perceval patients without reaching the statistical significance. Incidence of moderate ( P = 0.2) and severe PPM ( P = 0.7) was comparable.

Conclusions

Despite higher postoperative pressure gradients observed with the Trifecta valve, all three prostheses (Trifecta, Edwards INTUITY Elite, and Perceval) have proven to be reliable when implanted in small aortic annuli, with good clinical outcome and favorable left ventricular mass regression.

Aortic root enlargement to mitigate patient-prosthesis mismatch: do early adverse events justify reluctance?†

OBJECTIVES:

Concomitant aortic root enlargement (ARE) at the time of surgical aortic valve replacement can be performed to avoid patient-prosthesis mismatch, an important predictor of adverse long-term outcome.

METHODS:

We performed a single-centre, retrospective analysis of 4120 patients receiving isolated aortic valve replacement, of whom 171 (4%) had concomitant ARE between January 2005 and December 2015. The analysis of postoperative outcome and early mortality was performed. Owing to inequality of the groups, patients were matched 1:1.

RESULTS:

The mean age of all 4120 patients was 68.8 ± 10.5 years, and comorbidities were equally balanced after matching. The mean aortic cross-clamp time, cardiopulmonary bypass time and total operative time were prolonged by 19, 20 and 27 min in the ARE group, respectively. Early mortality was not statistically significantly different with 1.4% in the surgical aortic valve replacement and 1.8% in the ARE group. Postoperative complications were <5% in all matched 338 patients: bleeding (3% vs 3%), pericardial effusion (3.0% vs 4.2%), sternal instability (1.8% vs 0%) and sternal wound infection (3.0% vs 1.2%). A significant higher number of patients had respiratory failure after ARE (unmatched: 17.1% vs 9.9%, P < 0.001; matched: 18.3% vs 9.5%, P = 0.028). Factors independently associated with overall mortality were age [hazard ratio (HR) 1.71], chronic obstructive pulmonary disease (HR 1.47), diabetes (HR 1.82), atrial fibrillation (HR 2.14) and postoperative respiratory failure (HR 2.84).

CONCLUSIONS:

ARE can be performed safely in experienced centres with no significant increase in the risk of early postoperative surgical complications and early mortality. However, the surgeon and the intensive care unit team should be aware of an increased risk for postoperative respiratory failure in ARE patients.

Clinical case: aortic valve replacement with aortic root reconstruction and coronary artery bypass grafting in 73-yo obese female patient

Aortic valve replacement is the second most common cardiac surgery procedure. Prosthesis-patient size mismatch can increase the incidence of adverse events postoperatively, it also leads to increased left ventricular load. Some studies describe the higher mortality in this group of patients. It is also proved that patients with severe aortic stenosis usually have impaired platelet aggregation and low von Willebrand factor causing bleeding disorders. We report a case of successful aortic valve replacement and aortic root enlargement (Nicks technique) combined with coronary artery bypass grafting (left internal mammary artery to the left anterior descending artery) and left atrial appendage resection in 73-y.o. obese female patient. Postoperative course was uneventful.

Stented versus Stentless Aortic Valve Replacement in Patients with Small Aortic Root

Objective

The aim of the study was to compare hemodynamic and perioperative outcomes of stented against stentless aortic valve replacement in patients with small aortic root (21 mm or less).

Methods

A comprehensive search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing stentless to stented bioprosthetic valves in small aortic root patients. Odds ratios, weighted mean differences, or standardized mean differences and their 95% confidence intervals were analyzed.

Results

A total of seven studies with a total of 965 patients fulfilled the inclusion criteria. There was no significant difference in preoperative baselines including mean age between both groups ( P = 0.08), peak aortic valve gradient ( P = 0.06), and effective orifice area ( P = 0.28), whereas higher mean aortic valve gradient in the stented group ( P = 0.007). No difference in cardiopulmonary bypass time ( P = 0.74), aortic cross-clamp times ( P = 0.88), intensive care unit stay ( P = 0.13), and stroke rate ( P = 0.56) were noted. However, stented group of patients showed higher rate of patient prosthesis mismatch ( P = 0.0001) and longer total hospital stay ( P = 0.002). Postoperatively, stentless group showed lower peak and mean aortic valve gradient ( P = 0.003 and P = 0.008, respectively) with a better effective orifice area ( P < 0.00001) at 6 months of follow-up. Mortality rates while in-hospital and at 1 year were similar in both groups ( P = 0.94 and P = 0.86, respectively).

Conclusions

Stentless aortic valves offer superior short-term hemodynamic outcomes in patients with small aortic root when compared with stented aortic valves. Although both groups have similar perioperative complications rates, stentless valves bring about a shorter hospital stay. A further large multicenter randomized controlled trial should address the longer-term benefit of stentless aortic valve over stented valve.

The Prognostic Significance of Patient-Prosthesis Mismatch after Aortic Valve Replacement

Patient-prosthesis mismatch (PPM) is a controversial issue in current clinical practice. PPM has been reported to have a negative impact on patients’ prognosis after aortic valve replacement in several studies, showing increased all-cause and cardiac mortality. Moreover, a close relationship has recently been described between PPM and structural valve deterioration in biological prostheses. In patients at risk for PPM, several issues should be considered, and in the current era of cardiac surgery, preoperative planning should consider the different types of valves available and the various surgical techniques that can be used to prevent PPM. The present paper analyses the state of the art of the PPM issue.

Mechanical Surface Area of Prosthetic Heart Valve: Adverse Clinical Impact of Large Mechanical Valve in Mitral Position

Although thromboembolic accidents are serious adverse events associated with mechanical mitral valves, there have been no studies on the clinical impact of the large mechanical surface areas (MSAs) of mechanical mitral prostheses. Between 1995 and 2010, 488 consecutive adult patients underwent isolated mechanical mitral valve replacement. We measured the MSA via three-dimensional computed tomography for each prosthesis. Mean patient age was 50.6 ± 11.1 years. The mean body surface area (BSA) and MSA index (MSAI, MSA/BSA) were 1.6 ± 0.17 m and 12.9 ± 1.7 cm/m, respectively. The patients were divided into two groups according to the median MSAI. Patients in the high MSAI group had higher indexed left ventricular end-diastolic dimensions and smaller BSAs. The multivariate analysis demonstrated that old age, New York Heart Association class III or IV, and high MSAI were independent predictors of death. With respect to thromboembolic complications, New York Heart Association class III or IV and high MSAI were identified as independent risk factors. There were 11 patients (3%) with mean pressure gradients across the mitral valve greater than 6 mm Hg 1 year after operation. A large MSA relative to patient size was identified as a predictor of poor clinical outcome after mechanical mitral valve replacement.

Moderate Patient-Prosthesis Mismatch Has No Negative Effect on Patients' Functional Status After Aortic Valve Replacement With CarboMedics Prosthesis

Background:

Patient-prosthesis mismatch (PPM) after aortic valve replacement (AVR) is the subject of continuing debate in the cardiac surgery field.

Objectives:

The aim of this study was to evaluate the frequency and severity of patient-prosthesis mismatch (PPM) and the functional status of patients undergoing aortic valve replacement (AVR) using a CarboMedics prosthesis in the mid-term follow up.

Patients and Methods:

We retrospectively studied 66 consecutive patients who were referred to AVR with a CarboMedics prosthesis at the Rajaie cardiovascular medical and research center, a university referral hospital in Tehran, Iran. The severity of PPM as well as clinical and echocardiographic parameters and the patients’ New York heat association (NYHA) functional classification status, operative data and postoperative complications, and mortality in a mid-term (4 - 5 months) follow up period was assessed. Severe PPM was defined as the effective orifice area (EOA) indexed to the patient’s body surface area (BSA) < 0.65 cm²/m² and moderate PPM was defined as the indexed effective orifice area (IEOA) between 0.65 and 0.85 cm²/m².

Results:

Of the 66 studied patients, 39 were male and 27 were female. The mean age of the patients was 43 ± 17 with a range of 6 - 76 years. Implanted sizes of the CarboMedics AV prosthesis in 22 patients were 19 and 21 mm, and in 44 patients were 23 and 25 mm. Eleven patients had moderate PPM (IEOA < 0.85 cm²/m²) and 55 of them did not have PPM (IEOA ≥ 0.85 cm²/m²). There were no statistically significant differences between the two groups in the echocardiographic trans-aortic pressure gradients (35.6 ± 19 vs. 23.2 ± 16 mmHg; P = 0.061) and the mean NYHA functional classification (1.10 ± 0.3 vs. 1.01 ± 0.10; P = 0.074) after AVR in the mid-term follow up.

Conclusions:

Moderate PPM has no negative effect on echocardiographic trans-aortic pressure gradients or the patients’ NYHA functional status after AVR with a CarboMedics prosthesis in the mid-term follow up.

Multicentre, propensity-matched study to evaluate long-term impact of implantation technique in isolated aortic valve replacement on mortality and incidence of redo surgery

OBJECTIVES

Studies suggest that the use of semicontinuous suture (SC) technique increases the risk of redo valve surgery after aortic valve replacement (AVR). The objective of this study was to identify 30-day mortality, rate of redo operation and long-term outcomes after AVR using either a semicontinuous suture or interrupted suture (IS) technique.

METHODS

A total of 1617 patients from 2 cardiothoracic centres, undergoing isolated AVR between April 2005 and August 2013 were included. AVR was performed using SC technique in 765 patients and IS technique in 852 patients. Data were collected prospectively and follow-up was obtained to date for all patients. We compared 30-day mortality, rate of redo operation and long-term mortality in SC and IS groups. One-to-one propensity-matching analysis was performed using IBM SPSS version 22 to evaluate outcomes.

RESULTS

Four hundred and eleven patients in the SC group were matched to 411 patients in the IS group (total of 822 patients) using propensity-score matching. The baseline characteristics were similar between SC and IS groups after matching. There were no statistically significant differences in 30-day mortality (3.9 vs 2.7%; P = 0.328), long-term mortality at 9-year follow-up (14.4 vs 15.3%; log-rank = 0.524) or rate of redo surgery (2.9 vs 2.0%; P = 0.320) between SC and IS, respectively. However, shorter cross-clamp time (51.9 ± 15.2 vs 60.9 ± 17.6 min; P < 0.001), bypass time (71.3 ± 23.0 vs 81.3 ± 37.8 min; P < 0.001) and the use of larger valve sizes (23.4 ± 2.1 vs 21.9 ± 2.2 mm; P < 0.001) were observed in SC patients compared with IS patients. Multivariate analysis did not show the suture technique as a significant determinant of redo valve surgery.

CONCLUSIONS

This multicentre study demonstrates that neither mortality nor the risk of redo surgery was influenced by the choice of implantation technique using semicontinuous vs interrupted suture techniques. The SC technique allowed shorter operations and larger size valves to be utilized.

Prosthesis-patient mismatch in aortic stenosis

BACKGROUND

The clinical impacts of prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) have been debated since Rahimtoola first reported PPM in 1978. Many reports discussing several aspects of PPM have been published to date, but the definitive clinical impacts of PPM have not yet been clarified.

PURPOSE

The purpose of this review is to evaluate recent articles regarding PPM and discuss the latest findings.

RESULTS

Moderate PPM (indexed effective orifice area ≤ 0.85 cm(2)/m(2)) did not affect the surgical outcomes in several papers, but severe PPM (indexed effective orifice area ≤ 0.65 cm(2)/m(2)) affected early and late mortality in almost of the all papers in which it was reported. PPM had a greater effect on younger patients and patients with left ventricular dysfunction than it did on elderly patients and patients with preserved left ventricular function.

CONCLUSION

Based on recent findings, it is difficult to define the impact of PPM after AVR. To some degree, PPM affects the clinical outcomes after AVR; therefore, it is important to avoid PPM, especially severe PPM.