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Zakkar M, Bruno VD, Visan AC, Curtis S, Angelini G, Lansac E, Stoica S. Surgery for Young Adults With Aortic Valve Disease not Amenable to Repair. Front Surg 2018; 5:18. [PMID: 29564333 PMCID: PMC5850822 DOI: 10.3389/fsurg.2018.00018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Accepted: 02/12/2018] [Indexed: 11/27/2022] Open
Abstract
Aortic valve replacement is the gold standard for the management of patients with severe aortic stenosis or mixed pathology that is not amenable to repair according to currently available guidelines. Such a simplified approach may be suitable for many patients, but it is far from ideal for young adults considering emerging evidence demonstrating that conventional valve replacement in this cohort of patients is associated with inferior long-term survival when compared to the general population. Moreover; the utilisation of mechanical and bioprosthetic valves can significantly impact on quality and is linked to increased rates of morbidities. Other available options such as stentless valve, homografts, valve reconstruction and Ross operation can be an appealing alternative to conventional valve replacement. Young patients should be fully informed about all the options available - shared decision making is now part of modern informed consent. This can be achieved when referring physicians have a better understanding of the short and long term outcomes associated with every intervention, in terms of survival and quality of life. This review presents up to date evidence for available surgical options for young adults with aortic stenosis and mixed disease not amenable to repair.
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Affiliation(s)
- Mustafa Zakkar
- Departments of Cardiology and Cardiothoracic Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom.,Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Vito Domanico Bruno
- Departments of Cardiology and Cardiothoracic Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Alexandru Ciprian Visan
- Departments of Cardiology and Cardiothoracic Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Stephanie Curtis
- Departments of Cardiology and Cardiothoracic Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Gianni Angelini
- Departments of Cardiology and Cardiothoracic Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Emmanuel Lansac
- Department of Cardiac Surgery, L'Institut Mutualiste Montsouris, Paris, France
| | - Serban Stoica
- Departments of Cardiology and Cardiothoracic Surgery, Bristol Heart Institute, Bristol Royal Infirmary, Bristol, United Kingdom
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Fouquet O, Baufreton C, Tassin A, Pinaud F, Binuani JP, DangVan S, Prunier F, Rouleau F, Willoteaux S, De Brux JL, Furber A. Influence of stentless versus stented valves on ventricular remodeling assessed at 6 months by magnetic resonance imaging and long-term follow-up. J Cardiol 2017; 69:264-271. [DOI: 10.1016/j.jjcc.2016.04.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 03/25/2016] [Accepted: 04/19/2016] [Indexed: 10/21/2022]
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Ennker J, Meilwes M, Pons-Kuehnemann J, Niemann B, Grieshaber P, Ennker IC, Boening A. Freestyle stentless bioprosthesis for aortic valve therapy: 17-year clinical results. Asian Cardiovasc Thorac Ann 2016; 24:868-874. [PMID: 27926465 DOI: 10.1177/0218492316675244] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic valve replacement with stentless bioprostheses has been shown to produce lower aortic gradients than stented bioprostheses, thus facilitating left ventricular mass regression and preventing heart failure. We sought to determine the long-term results of stentless biological aortic valve replacement over a 17-year follow-up. METHODS Between 1996 and 2012, 2551 patients underwent isolated aortic valve replacement with a stentless prosthesis (Medtronic Freestyle) at a single center. The mean patient age was 72 ± 10 years, 55% were male, 24.1% were in New York Heart Association class I and II, 9.6% had undergone previous surgery, 18.1% had coronary artery disease, and 23.1% had diabetes. For the long-term follow-up, patients were contacted in writing and by telephone; follow-up was 96.3% complete, resulting in 11,546 patient-years. RESULTS At 30 days, mortality (5.4%), renal failure (3.9%), myocardial infarction (0.7%), and stroke (1.4%) rates were acceptable. During long-term follow-up of 1-17 years, the bleeding rate (2.9%) was higher than the thromboembolic event rate (0.7%) despite 18.1% of patients being on oral anticoagulants. New pacemaker implantation (4.5%; 0.87 events/100 patient-years), neurological disorders (5%; 0.52 events/100 patient-years), valve insufficiency (0.7%; 0.16 events/100 patient-years), paravalvular leakage (0.4%; 0.09 events/100 patient-years) and reoperation due to valvular complications (0.7%; 0.38 events/100 patient-years) were rare. Long-term survival was 41.8% ± 1.6 after 10 years, 21.3% ± 2.3 after 15 years, and 12.1% ± 3.9 after 17 years. CONCLUSION Long-term results after aortic valve replacement with stentless biological prostheses compare favorably with those obtained with stented bioprostheses.
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Affiliation(s)
- Juergen Ennker
- Heart Center, Helios Hospital Siegburg Germany.,Faculty of Medicine, Witten-Herdecke University, Witten, Germany
| | - Markus Meilwes
- Institute of Medical Statistics, Justus-Liebig University Giessen, Giessen, Germany.,Department of Cardiovascular Surgery, Justus-Liebig University Giessen, Giessen, Germany
| | | | - Bernd Niemann
- Department of Cardiovascular Surgery, Justus-Liebig University Giessen, Giessen, Germany
| | - Philippe Grieshaber
- Department of Cardiovascular Surgery, Justus-Liebig University Giessen, Giessen, Germany
| | - Ina C Ennker
- Hannover Medical School, Department of Plastic and Reconstructive Surgery, Hannover, Germany
| | - Andreas Boening
- Department of Cardiovascular Surgery, Justus-Liebig University Giessen, Giessen, Germany
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Thalmann M, Kaiblinger J, Krausler R, Pisarik H, Veit F, Taheri N, Kornigg K, Dinges C, Grabenwöger M, Stanger O. Clinical Experience With the Freedom SOLO Stentless Aortic Valve in 277 Consecutive Patients. Ann Thorac Surg 2014; 98:1301-7. [DOI: 10.1016/j.athoracsur.2014.05.089] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2014] [Revised: 05/27/2014] [Accepted: 05/29/2014] [Indexed: 10/24/2022]
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5
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Amorim P, Diab M, Färber G, Kirov H, Gonzales-Lopes D, Doenst T. Hämodynamische Ergebnisse nach Aortenklappenersatz. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2014. [DOI: 10.1007/s00398-014-1109-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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6
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Kim SJ, Samad Z, Bloomfield GS, Douglas PS. A critical review of hemodynamic changes and left ventricular remodeling after surgical aortic valve replacement and percutaneous aortic valve replacement. Am Heart J 2014; 168:150-9.e1-7. [PMID: 25066553 DOI: 10.1016/j.ahj.2014.04.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 04/15/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED The introduction of transcatheter aortic valve replacement (TAVR) in clinical practice has widened options for symptomatic patients at high surgical risk; however, it is not known whether TAVR has equivalent or prolonged benefits in terms of left ventricular (LV) remodeling. METHODS To explore the relative hemodynamic benefits and postoperative LV remodeling associated with TAVR and surgical aortic valve replacement (SAVR), we performed a critical review of the available literature. A total of 67 studies were included in this systematic review. RESULTS There is at least equivalent if not slightly superior hemodynamic performance of TAVR over SAVR, and TAVR showed lower prosthesis-patient mismatch compared with SAVR. However, LV mass appears to regress to a greater degree after SAVR compared with TAVR. Aortic regurgitation, paravalvular in particular, is more common after TAVR than SAVR, although it is rarely more than moderate in severity. Improvements in diastolic function and mitral regurgitation are reported in only a handful of studies each and could not be compared across prosthesis types. CONCLUSIONS The published data support the hemodynamic comparability of SAVR and TAVR, with the higher incidence of prosthesis-patient mismatch in SAVR offset by higher incidence of paravalvular leak in TAVR. These results highlight the need for further studies focusing on hemodynamic changes after valve therapy.
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Iliopoulos DC, Deveja AR, Androutsopoulou V, Filias V, Kastelanos E, Satratzemis V, Khalpey Z, Koudoumas D. Single-center experience using the Freedom SOLO aortic bioprosthesis. J Thorac Cardiovasc Surg 2013; 146:96-102. [DOI: 10.1016/j.jtcvs.2012.06.041] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2011] [Revised: 05/07/2012] [Accepted: 06/15/2012] [Indexed: 11/16/2022]
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Rodriguez-Caulo EA, Garcia-Borbolla M, Velázquez CJ, Castro A, Miranda N, Ramírez B, Garcia-Borbolla R, Gutiérrez MA, Perez-Duarte E, Téllez JC, Araji O, Barquero JM. Sustitución valvular aórtica con prótesis biológicas en pacientes con estenosis aórtica severa. ¿Válvulas soportadas o no soportadas? CIRUGIA CARDIOVASCULAR 2013. [DOI: 10.1016/s1134-0096(13)70006-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
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9
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Funder JA. Current status on stentless aortic bioprosthesis: a clinical and experimental perspective. Eur J Cardiothorac Surg 2011; 41:790-9. [DOI: 10.1093/ejcts/ezr141] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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10
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Abstract
Although porcine aortic valves or pericardial tissue mounted on a stent have made implantation techniques easier, these valves sacrifice orifice area and increase stress at the attachment of the stent, which causes primary tissue failure. Optimizing hemodynamics to prevent patient–prosthetic mismatch and improve durability, stentless bioprostheses use was revived in the early 1990s. The purpose of this review is to provide a current overview of stentless valves in the aortic position. Retrospective and prospective randomized controlled studies showed similar operative mortality and morbidity in stented and stentless aortic valve replacement (AVR), though stentless AVR required longer cross-clamp and cardiopulmonary bypass time. Several cohort studies showed improved survival after stentless AVR, probably due to better hemodynamic performance and earlier left ventricular (LV) mass regression compared with stented AVR. However, there was a bias of operation age and nonrandomization. A randomized trial supported an improved 8-year survival of patients with the Freestyle or Toronto valves compared with Carpentier–Edwards porcine valves. On the contrary, another randomized study did not show improved clinical outcomes up to 12 years. Freedom from reoperation at 12 years in Toronto stentless porcine valves ranged from 69% to 75%, which is much lower than for Carpentier–Edwards Perimount valves. Cusp tear with consequent aortic regurgitation was the most common cause of structural valve deterioration. Cryolife O’Brien valves also have shorter durability compared with stent valves. Actuarial freedom from reoperation was 44% at 10 years. Early prosthetic valve failure was also reported in patients who underwent root replacement with Shelhigh stentless composite grafts. There was no level I or IIa evidence of more effective orifice area, mean pressure gradient, LV mass regression, surgical risk, durability, and late outcomes in stentless bioprostheses. There is no general recommendation to prefer stentless bioprostheses in all patients. For new-generation pericardial stentless valves, follow-up over 15 years is necessary to compare the excellent results of stented valves such as the Carpentier–Edwards Perimount and Hancock II valves.
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Affiliation(s)
- Junjiro Kobayashi
- Department of Cardiovascular Surgery, National Cerebral and Cardiovascular Center, Osaka, Japan.
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11
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Bech-Hanssen O, Aljassim O, Houltz E, Svensson G. The relative contribution of prosthetic gradients, systemic arterial pressure, and pulse pressure to the left ventricular pressure in patients with aortic prosthetic valves. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2010; 12:37-45. [DOI: 10.1093/ejechocard/jeq101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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12
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Which Patients Benefit From Stentless Aortic Valve Replacement? Ann Thorac Surg 2009; 88:2061-8. [DOI: 10.1016/j.athoracsur.2009.06.060] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Revised: 06/15/2009] [Accepted: 06/01/2009] [Indexed: 11/19/2022]
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13
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Risteski PS, Martens S, Rouhollahpour A, Wimmer-Greinecker G, Moritz A, Doss M. Prospective randomized evaluation of stentless vs. stented aortic biologic prosthetic valves in the elderly at five years. Interact Cardiovasc Thorac Surg 2009; 8:449-53. [DOI: 10.1510/icvts.2008.181362] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Toggweiler S, Zuber M, Gerber K, Schläpfer R, Erne P, Stulz P. Left ventricular mass regression following implantation of MIRA bileaflet valves in patients with severe aortic stenosis. Heart Vessels 2009; 24:37-40. [PMID: 19165567 DOI: 10.1007/s00380-008-1068-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2007] [Accepted: 04/30/2008] [Indexed: 11/30/2022]
Abstract
The aim of this study was to evaluate the factors that determine the course of left ventricular mass regression in a homogeneous group of patients following aortic valve replacement by use of the mechanical Edwards MIRA bileaflet prosthesis. Furthermore, we examined if the 19-mm valve leads to an equally good outcome when compared with larger 21- and 23-mm valves. We included 79 patients (49 men) with a mean age of 65+/-9 years operated on for isolated aortic valve replacement with the MIRA valve prosthesis. The analyses included preoperative and postoperative echocardiograms during a follow-up of at least 18 months (995+/-439 days) after valve surgery. Indication for valve replacement was aortic stenosis in 59 and combined disease (aortic stenosis and regurgitation) in 20 patients. Concomitant coronary artery bypass grafting was performed in 28 patients. Left ventricular mass index declined from 155.6+/-47 g/m(2) to 128.8+/-35 g/m(2) (P<0.001) at final visit and normalized in 49% of the patients. Female sex and a preoperatively highly elevated left ventricular mass index were identified as risk factors for residual hypertrophy. However, age and valve size did not have a predictive value for completeness of left ventricular mass regression. This study supports the evidence that an extensive preoperative left ventricular hypertrophy results in an incomplete postoperative mass regression in patients with aortic bileaflet valves. It shows that the slightly elevated pressure gradient in MIRA 19-mm valves does not affect left ventricular mass regression.
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Affiliation(s)
- Stefan Toggweiler
- Division of Cardiology, Kantonsspital Luzern, CH-6000 Luzern 16, Switzerland
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15
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Butany J, Zhou T, Leong SW, Cunningham KS, Thangaroopan M, Jegatheeswaran A, Jeggatheeswaran A, Feindel C, David TE. Inflammation and infection in nine surgically explanted Medtronic Freestyle® stentless aortic valves. Cardiovasc Pathol 2007; 16:258-67. [PMID: 17868876 DOI: 10.1016/j.carpath.2007.01.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2006] [Revised: 01/02/2007] [Accepted: 01/29/2007] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND The Medtronic Freestyle valve is fixed in glutaraldehyde at zero pressure on the cusps and treated with alpha-amino oleic acid. This valve reportedly has excellent clinical and hemodynamic results, but little has been reported about its long-term pathology. METHODS AND RESULTS Nine Freestyle valves explanted between 2003 and 2005 were reviewed to assess the reasons for bioprosthesis failure (six implanted at our institution). All valves were examined in detail, using histochemistry and immunohistochemistry to identify the cellular response. One Freestyle valve, explanted for mitral valve endocarditis on the fifth postoperative day, was excluded from analysis. Average implant duration was 52.8+/-35.5 months. Four valves were explanted for infective endocarditis, three for aortic insufficiency, two for aortic stenosis with cusp calcification seen in five valves, pannus and thrombus in all valves and a chronic inflammatory reaction involving the xenograft arterial wall seen in eight of nine valves. This was associated with significant damage to the porcine aortic wall in seven cases, and cusp myocardial shelf damage in six cases. CONCLUSIONS In this series of valves, we found (1) infective endocarditis; (2) pannus, thrombus, and calcification; and (3) unusual and significant inflammatory reaction and aortic tissue damage, which could by itself lead to aortic incompetence.
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Affiliation(s)
- Jagdish Butany
- Department of Pathology, Toronto General Hospital/University Health Network, Toronto, Canada.
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16
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Becker M, Kramann R, Dohmen G, Lückhoff A, Autschbach R, Kelm M, Hoffmann R. Impact of Left Ventricular Loading Conditions on Myocardial Deformation Parameters: Analysis of Early and Late Changes of Myocardial Deformation Parameters after Aortic Valve Replacement. J Am Soc Echocardiogr 2007; 20:681-9. [PMID: 17543737 DOI: 10.1016/j.echo.2006.11.003] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2006] [Indexed: 11/22/2022]
Abstract
Myocardial deformation imaging is used to assess regional left ventricular (LV) function. We sought to define the impact of changes in LV loading conditions on myocardial deformation parameters. Aortic valve replacement in patients with different aortic valve pathologies was used as a model to assess the impact of preload and afterload changes. In 53 patients scheduled for aortic valve replacement serial echocardiographic studies were performed preoperatively and postoperatively (within 7 days and at 6 months). Parasternal short-axis views were acquired. Using novel computer software radial and circumferential strain and strain rate were determined as parameters of myocardial deformation for each segment of the LV and were subsequently averaged. Immediately postoperatively there was a relative increase of radial strain by 4.5 +/- 1.8% after valve replacement for aortic stenosis (AS) (P < .001), a relative decrease of 9.4 +/- 7.7% after valve replacement for aortic regurgitation (aortic insufficiency [AI]) (P < .001), and unchanged radial strain after valve replacement for AS and aortic regurgitation. During the subsequent 6 months of follow-up, there was additional relative increase of radial strain by 5.2 +/- 3.1% in the AS group (P < .001), by 12.0 +/- 13.7% in the AI group (P < .01), and by 5.6 +/- 3.4% in the AS and AI group (P < .001). Similar changes were observed for the other strain and strain rate parameters. In conclusion, myocardial deformation parameters change significantly immediately after aortic valve replacement for AS or AI indicating a dependency of determined myocardial deformation parameters on LV preload and afterload.
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Affiliation(s)
- Michael Becker
- Medical Clinic I, University Hospital RWTH, Aachen, Germany
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Kincaid EH, Cordell AR, Hammon JW, Adair SM, Kon ND. Coronary Insufficiency After Stentless Aortic Root Replacement: Risk Factors and Solutions. Ann Thorac Surg 2007; 83:964-8; discussion 968. [PMID: 17307442 DOI: 10.1016/j.athoracsur.2006.09.021] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Revised: 08/31/2006] [Accepted: 09/01/2006] [Indexed: 11/20/2022]
Abstract
BACKGROUND Coronary insufficiency is a dreaded complication of total aortic root replacement (ARR) with few defined risk factors. This study describes the incidence, risk factors, management options, and outcomes of this condition after ARR with stentless porcine valves. METHODS The study consisted of a retrospective analysis of 503 patients (mean age, 68.9 +/- 10.2 years) undergoing stentless porcine total ARR (Medtronic Freestyle and St. Jude Toronto) between the years 1993 and 2005 at a single institution. Coronary insufficiency was defined as the need for unplanned bypass grafting during, or after removal from cardiopulmonary bypass to correct wall motion abnormalities, arrhythmias, or right ventricular failure in the absence of known obstructive coronary disease. RESULTS A total of 13 cases of right coronary artery and no cases of left coronary insufficiency were identified (overall incidence 13 of 503, 2.6%). All were treated with aortocoronary bypass grafting to the right coronary artery using saphenous vein. Compared with patients who did not have coronary insufficiency, patients with this complication were more likely to be female (11 of 13, 85%, versus 201 of 490, 41%; p = 0.006), had higher mean body mass index (34.6 +/- 12.0 kg/m2 versus 28.3 +/- 3.8 kg/m2, p = 0.04), and were implanted with smaller prostheses (23.9 +/- 2.1 mm versus 25.6 +/- 2.4 mm, p = 0.026), a finding not explained by the preponderance of female sex. Mean age, ejection fraction, and other demographic variables were similar. Despite longer cardiopulmonary bypass times (238 +/- 61 minutes versus 180 +/- 35 minutes, p = 0.005), operative mortality was not significantly different (1 of 13, 7.7%, versus 29 of 490, 5.9%; p = not significant). CONCLUSIONS Coronary artery insufficiency is uncommon after stentless aortic root replacement and more often affects the right coronary artery. Risk factors appear to be female sex, higher body mass index, and small aortic root. Preventive measures include recognition of coronary orientation, routine valve rotation, and adequate coronary button mobilization. When this complication occurs, good outcomes can still be obtained with early recognition and prompt bypass grafting.
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Affiliation(s)
- Edward H Kincaid
- Department of Cardiothoracic Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina 27157, USA.
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18
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Perez de Arenaza D, Lees B, Flather M, Nugara F, Husebye T, Jasinski M, Cisowski M, Khan M, Henein M, Gaer J, Guvendik L, Bochenek A, Wos S, Lie M, Van Nooten G, Pennell D, Pepper J. Randomized Comparison of Stentless Versus Stented Valves for Aortic Stenosis. Circulation 2005; 112:2696-702. [PMID: 16230487 DOI: 10.1161/circulationaha.104.521161] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Aortic valve replacement (AVR) is the established treatment for severe aortic stenosis. In response to the long-term results of aortic homografts, stentless porcine valves were introduced as an alternative low-resistance valve. We conducted a randomized trial comparing a stentless with a stented porcine valve in adults with severe aortic stenosis. METHODS AND RESULTS The primary outcome was change in left ventricular mass index (LVMI) measured by transthoracic echocardiography and, in a subset, by cardiovascular MR. Measurements were taken before valve replacement and at 6 and 12 months. Patients undergoing AVR with an aortic annulus < or =25 mm in diameter were randomly allocated to a stentless (n=93) or a stented supra-annular (n=97) valve. There were no significant differences in mean LVMI between the stentless versus stented groups at baseline (176+/-62 and 182+/-63 g/m2, respectively) or at 6 months (142+/-49 and 131+/-45 g/m2, respectively), although within-group changes from baseline to 6 months were highly significant. Changes in LVMI measured by cardiovascular MR (n=38) were consistent with the echo findings. There was a greater reduction in peak aortic velocity (P<0.001) and a greater increase in indexed effective orifice area (P<0.001) in the stentless group than in the stented group. There were no differences in clinical outcomes between the 2 valve groups. CONCLUSIONS Despite significant differences in indexed effective orifice area and peak flow velocity in favor of the stentless valve, there were similar reductions in left ventricular mass at 6 months with both stented and stentless valves, which persisted at 12 months.
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O'Brien MF, Gardner MAH, Garlick B, Jalali H, Gordon JA, Whitehouse SL, Strugnell WE, Slaughter R. CryoLife-O'Brien Stentless Valve: 10-Year Results of 402 Implants. Ann Thorac Surg 2005; 79:757-66. [PMID: 15734372 DOI: 10.1016/j.athoracsur.2004.08.057] [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] [Accepted: 08/23/2004] [Indexed: 11/15/2022]
Abstract
BACKGROUND This truly stentless porcine valve is composite, without Dacron, and implanted supra-annularly. Ten-year analysis with magnetic resonance imaging is presented. METHODS From 1992 to 2002, 402 patients (mean 73.5 years) had aortic valve replacement. Associated procedures were required in 252 patients (63%). Serial echoes provided 1340 studies. Clinical follow-up was 100%. Magnetic resonance imaging focused on aortic annulus extensibility. RESULTS The 30-day mortality was 0.99% (4 deaths). Morbidity comprised thromboembolism (40 patients including 18 patients with permanent strokes); endocarditis (9 patients); and reoperation (9 patients [periprosthetic leak, 2; endocarditis, 5; technical needle damage, 1; and structural degeneration, 1]). Of 402 valves more than 10 years, five valves were explanted, one only for structural failure. Except for endocarditis (2 patients), no late deaths (69 patients, 1.5 months to 5.7 years) were valve related. Echocardiography demonstrated low gradients with good orifice areas, excellent ventricular regression (p = 0.0001 preoperative and postoperative comparisons) and late incompetence (mild in 45 patients and moderate in 9 patients). No living patient has severe incompetence. Magnetic resonance imaging demonstrated the annulus 'expanding and relaxing' throughout the cardiac cycle, the mean increase in cross-sectional area being 37%, resembling normal aortic root dynamics. CONCLUSIONS Elderly patients received this hemodynamically acceptable valve with its simple, supra-annular implantation and satisfactory mid-term morbid-free lifestyle to 10 years maximum follow-up. With only one structural failure, restoration of valve annular extensibility may have a favorable influence on long-term durability.
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Jasinski MJ, Ulbrych P, Kolowca M, Szafranek A, Baron J, Wos S. Early Regional Assessment of LV Mass Regression and Function after Stentless Valve Replacement: Comparative Randomized Study. Heart Surg Forum 2004; 7:E462-5; discussion E462-5. [PMID: 15799926 DOI: 10.1532/hsf98.20041096] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Early regional performance and hypertrophy regression after stentless aortic valve replacement are still incompletely characterized. We compared early postoperative changes of segmental thickness and function after stentless and stented aortic valve replacement as assessed by cardiac magnetic resonance (CMR). In 16 patients randomly assigned to stented (Mosaic, 8 patients) and stentless (Freestyle, 8 patients) groups, 4 parallel short-axis images at the level of the apex (slice 4), midventricle (slices 2-3), and mitral valve (slice 1) were obtained with a 1.5 T CMR scanner (Magnetom Sonata, Siemens) before and 1 month after surgery. Cine images were obtained using an echo gradient sequence. Left ventricle mass was calculated as the difference between the left ventricular end-diastolic volume at the epicardial and endocardial borders multiplied by a myocardium density factor (1.05). Each slice was divided into 8 segments (octants) from anterior (octant I-II) to septal (octant V-VIII). A total of 32 segments encompassed the entire heart. From each of these elements end diastolic thickness and systolic function (fractional thickening) were calculated. In stentless valves significant reduction of septal octant thickness on the midventricular slice was noted. There was no difference in regional systolic function-segment thickening. In stented valves no segmental thickness changes were observed. In stentless valves there was early postoperative thickness reduction of septal segments at the midventricular level. However, this finding did not coincide with changes in segmental function.
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Affiliation(s)
- M J Jasinski
- 2nd Department of Cardiac Surgery, Medical University of Silesia, Katowice, Poland.
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21
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Langer F, Aicher D, Kissinger A, Wendler O, Lausberg H, Fries R, Schäfers HJ. Aortic Valve Repair Using a Differentiated Surgical Strategy. Circulation 2004; 110:II67-73. [PMID: 15364841 DOI: 10.1161/01.cir.0000138383.01283.b8] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Reconstruction of the aortic valve for aortic regurgitation (AR) remains challenging, in part because of not only cusp or root pathology but also a combination of both can be responsible for this valve dysfunction. We have systematically tailored the repair to the individual pathology of cusps and root. METHODS Between October 1995 and August 2003, aortic valve repair was performed in 282 of 493 patients undergoing surgery for AR and concomitant disease. Root dilatation was corrected by subcommissural plication (n=59), supracommissural aortic replacement (n=27), root remodeling (n=175), or valve reimplantation within a graft (n=24). Cusp prolapse was corrected by plication of the free margin (n=157) or triangular resection (n =36), cusp defects were closed with a pericardial patch (n=16). Additional procedures were arch replacement (n=114), coronary artery bypass graft (n=60) or mitral repair (n=24). All patients were followed-up (follow-up 99.6% complete), and cumulative follow-up was 8425 patient-months (mean, 33+/-27 months).Results- Eleven patients died in hospital (3.9%). Nine patients underwent reoperation for recurrent AR (3.3%). Actuarial freedom from AR grade > or =II at 5 years was 81% for isolated valve repair, 84% for isolated root replacement, and 94% for combination of both; actuarial freedom from reoperation at 5 years was 93%, 95%, and 98%, respectively. No thromboembolic events occurred, and there was 1 episode of endocarditis 4.5 years postoperatively. CONCLUSIONS Aortic valve repair is feasible even for complex mechanisms of AR with a systematic and individually tailored approach. Operative mortality is low and mid-term durability is encouraging. The incidence of valve-related morbidity is low compared with valve replacement.
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Affiliation(s)
- Frank Langer
- Department of Thoracic and Cardiovascular Surgery, University Hospitals Homburg, Homburg, Germany
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22
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Gleason TG, David TE, Coselli JS, Hammon JW, Bavaria JE. St. Jude Medical Toronto biologic aortic root prosthesis: Early FDA phase II IDE study results. Ann Thorac Surg 2004; 78:786-93. [PMID: 15336992 DOI: 10.1016/j.athoracsur.2004.02.077] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/17/2004] [Indexed: 11/18/2022]
Abstract
BACKGROUND Several biological aortic root replacement techniques have distinct advantages over mechanical composite root replacement including better valvular hemodynamic characteristics and the lack of need for anticoagulation. Current biological root replacement options lack proven long-term durability or are limited by technical or practical concerns. We report the early results from a phase II multicenter clinical trial of the porcine St. Jude Toronto Bioprosthesis with BiLinx (Toronto root). METHODS 176 Toronto roots were implanted as total aortic root replacement from August 2001 through August 2003. Concomitant cardiac procedures including coronary artery bypass grafting (31%) and ascending aortic replacement (55%) were performed in 74%. Patients were followed clinically and were examined with an echocardiogram at discharge, 6 months, 12 months, and yearly thereafter. Root sizes implanted included 29 mm in 38%, 27 mm in 30%, 25 mm in 20%, 23 mm in 10%, and 21 mm in 2.2%. RESULTS There are 205 patient years of follow-up through October 2003. Operative mortality was 3.9% (none were valve related) and late mortality was 4%. Operative stroke rate was 1.1% and late stroke rate was 0.6%. Endocarditis developed in 1 patient. Freedom from aortic regurgitation is to date 100% at discharge, 6 months, and 1 year postimplant. Reoperation of the aortic valve/root was not required in any patient. Six-month mean transvalvular gradients for 21-29 mm valves were 12.8, 8.8, 5.3, 4.9, and 4.7 mm Hg, respectively. CONCLUSIONS Aortic root replacement with the Toronto root is safe and provides superb transvalvular hemodynamics with freedom from anticoagulation. The Toronto root seems widely applicable for all types of aortic root pathology and these early data offer very encouraging results. Long-term follow-up is required.
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Affiliation(s)
- Thomas G Gleason
- Division of Cardiothoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
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23
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Sharma UC, Barenbrug P, Pokharel S, Dassen WRM, Pinto YM, Maessen JG. Systematic review of the outcome of aortic valve replacement in patients with aortic stenosis. Ann Thorac Surg 2004; 78:90-5. [PMID: 15223410 DOI: 10.1016/j.athoracsur.2004.02.020] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2004] [Indexed: 11/26/2022]
Abstract
BACKGROUND After the establishment of aortic valve replacement procedure for aortic stenosis, there are heterogeneous studies and varying reports on outcome. An analysis that compares individual studies to summarize the overall effect is still lacking. This study systematically analyzes the change in left ventricular (LV) mass index and ejection fraction after aortic valve replacement in adult patients. METHODS We performed MEDLINE and bibliographic searches and included 27 articles published between 1980 and 2003 about the outcome of valve replacement in 1546 aortic stenosis patients. To allow comparisons, we stratified the patients into early (0-6 months), intermediate (7-24 months), and late (25-120 months) follow-up groups for the analysis of both LV mass regression and ejection fraction. We separately analyzed five articles that reported groups of patients with low preoperative ejection fraction. RESULTS Increase in ejection fraction after surgery is more pronounced in the patients that have low preoperative ejection fraction (28% +/- 4.3%(preop) vs 40% +/- 9.4%(6-41 months) follow-up). Patients with normal or high preoperative ejection fraction have variable outcomes. However, regression of LV mass is uniformly achieved regardless of age, sex, time of operation, or types of valve substitute. Furthermore, LV mass regresses predominantly within the first 6 months after surgery (g/m2, 181 +/- 25.8(preop) vs 124 +/- 27(6 months), 117 +/- 15(24 months), and 113 +/- 14(120 months) follow-up). CONCLUSIONS This systematic review supports the concept that aortic stenosis patients with LV dysfunction show a clear functional improvement after aortic valve replacement. Ventricles regress rapidly and reach their approximate final size within the first 6 months of surgery.
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Affiliation(s)
- Umesh C Sharma
- Department of Cardiothoracic Surgery, Cardiovascular Research Institute Maastricht, University Hospital Maastricht, The Netherlands
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24
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Sensky PR, Loubani M, Keal RP, Samani NJ, Sosnowski AW, Galiñanes M. Does the type of prosthesis influence early left ventricular mass regression after aortic valve replacement? Assessment with magnetic resonance imaging. Am Heart J 2003; 146:E13. [PMID: 14564336 DOI: 10.1016/s0002-8703(03)00253-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Debate exists regarding selection of the prosthesis type most likely to maximize early left ventricular (LV) mass regression after aortic valve replacement (AVR) for stenotic valvular disease. The aim of this study was to compare the degree of LV mass regression measured by MRI 6 months after prospectively randomized valve implantation for two biological prostheses, stented and stentless, and for two mechanical valves, tilting disc and bileaflet. METHODS Thirty-nine consecutive patients with predominant aortic stenosis accepted for elective AVR were studied. Twenty patients requiring a tissue prosthesis were randomly assigned to receive either a Freestyle or Mosaic valve. The remaining 19 patients in whom mechanical prosthesis was indicated were randomly assigned to receive either an Ultracor or an ATS valve. RESULTS There was no difference in valve size implanted between the compared groups. LV mass measurements were performed with MRI (1.5-T Vision, Siemens, Germany) immediately before and 6 months after surgery. All valve types produced significant postoperative reduction in LV mass compared with preoperative values (P <.01). Percent change in LV mass regression was similar between the two porcine valve types, Mosaic (24.4% +/- 11.1%) and Freestyle (21.1% +/- 16.7%), and between the two mechanical valve designs, Ultracor (19.3% +/- 9.5%) and ATS (26.3% +/- 10.8%), respectively. CONCLUSIONS Significant LV remodeling occurs early after AVR for aortic stenosis. The degree of regression in LV mass is independent of prosthesis type implanted.
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Affiliation(s)
- Penelope R Sensky
- Division of Cardiology, University of Leicester, Leicester, United Kingdom
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25
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Cohen G. Reply. Ann Thorac Surg 2003. [DOI: 10.1016/s0003-4975(03)00270-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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26
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Fukui T, Suehiro S, Shibata T, Hattori K, Hirai H, Aoyama T. Aortic root replacement with Freestyle stentless valve for complex aortic root infection. J Thorac Cardiovasc Surg 2003; 125:200-3. [PMID: 12539008 DOI: 10.1067/mtc.2003.117] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Toshihiro Fukui
- Department of Cardiovascular Surgery, Osaka City University Medical School, Osaka, Japan.
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Kühl HP, Franke A, Puschmann D, Schöndube FA, Hoffmann R, Hanrath P. Regression of left ventricular mass one year after aortic valve replacement for pure severe aortic stenosis. Am J Cardiol 2002; 89:408-13. [PMID: 11835921 DOI: 10.1016/s0002-9149(01)02262-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The aim of the study was to quantify a 1-year change in left ventricular (LV) mass index (MI) and systolic LV function in 30 patients with pure severe aortic stenosis by means of serial 3-dimensional (3-D) echocardiography. To assess the completeness of LVMI regression after 1 year, we compared the postoperative mass of patients with mass values of 30 normotensive control subjects without a history of cardiac disease. Ejection fraction increased from 64 +/- 14% before surgery to 69 +/- 8% at follow-up (p = 0.067), and functional class improved from 2.9 +/- 0.5 to 1.4 +/- 0.5 (p <0.05), with improvement in each patient. During the same period, LVMI regressed by 23.4% (p <0.001). Postoperative LVMI was related to preoperative LVMI (r = 0.82; p <0.001) and baseline ejection fraction (r = -0.5; p = 0.009). LVMI regressed into the normal range in 64% of patients at follow-up. Patients achieving normal mass values did not differ with respect to patient gender, valve type, or valve size. Patients with reduced preoperative LV function had larger volumes (p <0.01), larger mass values (p <0.01), and a trend toward more mass regression (p = 0.062) than patients with normal preoperative function. Although ejection fraction improved after 1 year in all of these patients (p <0.03), they were less likely to achieve normal mass values at follow-up (p = 0.01). Regression of LVMI in patients with pure aortic stenosis is a positive event that occurs in each patient and that is associated with improvement in functional status. LVMI regressed into the normal range in most patients with normal preoperative function. Preoperative LV function, but not patient gender, valve type, or size, was related to normalization of LVMI at follow-up in this selected study population.
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Silberman S, Shaheen J, Merin O, Fink D, Shapira N, Liviatan-Strauss N, Bitran D. Exercise hemodynamics of aortic prostheses: comparison between stentless bioprostheses and mechanical valves. Ann Thorac Surg 2001; 72:1217-21. [PMID: 11603439 DOI: 10.1016/s0003-4975(01)03064-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Nonstented bioprostheses have been associated with lower resting gradients than stented bioprostheses or mechanical valves. We compared the hemodynamic performance of nonstented bioprostheses and mechanical valves with normal native aortic valves at rest and exercise. METHODS Dobutamine echocardiography was used to assess gradients and effective orifice area index at rest and exercise in patients with the Toronto stentless porcine valve (TSPV; n = 13; mean implant size 25.7 mm), Medtronic Freestyle (FR; n = 11; mean implant size 23.9 mm), Sorin Bicarbon (SOR; n = 11; mean implant size 24.5 mm), St. Jude Medical (SJM; n = 10; mean implant size 21.3 mm), and normal native aortic valves (NOR; n = 10). RESULTS All groups demonstrated a major rise in cardiac output at maximal dobutamine infusion. At rest and exercise, respectively, mean gradients were 5.48 +/- 1.1 mm Hg and 5.83 +/- 0.9 mm Hg for TSPV, 5.68 +/- 1.2 mm Hg and 7.50 +/- 1.7 mm Hg for FR, 10.29 +/- 1.4 mm Hg and 20.78 +/- 2.7 mm Hg for SJM, 5.26 +/- 0.8 mm Hg and 11.1 +/- 1.8 mm Hg for SOR, and 1.54 +/- 0.4 mm Hg and 2.18 +/- 0.7 mm Hg for NOR. In comparison with normal valves, both stentless groups showed no change in mean gradient at exercise, whereas both mechanical groups showed an increase in gradient at exercise (p < 0.04). CONCLUSIONS Stentless valves behave similarly to normal aortic valves in that there is almost no increase in gradient at exercise. Both mechanical valve groups showed increased gradients at exercise, suggesting that these valves obstruct blood flow. Our data add further evidence that stentless valves are hemodynamically superior to mechanical valves in the aortic position.
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Affiliation(s)
- S Silberman
- Department of Cardiac Surgery, Shaare Zedek Medical Center, Jerusalem, Israel.
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29
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Langer F, Graeter T, Nikoloudakis N, Aicher D, Wendler O, Schäfers HJ. Valve-preserving aortic replacement: does the additional repair of leaflet prolapse adversely affect the results? J Thorac Cardiovasc Surg 2001; 122:270-7. [PMID: 11479499 DOI: 10.1067/mtc.2001.114635] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Valve-preserving aortic replacement has evolved into an accepted therapeutic option for aortic ectasia with morphologically intact leaflets. Some patients, however, exhibit additional leaflet prolapse. We compared the results of established valve-preserving techniques with those of the combination of valve-preserving aortic surgery and additional repair of leaflet prolapse. METHODS Between October 1995 and March 2000, 99 patients underwent valve-preserving root replacement by means of root remodeling or valve reimplantation for acute dissection (n = 25), chronic dissection (n = 4), or aneurysm (n = 70). In group A (63 patients) either root remodeling (n = 49) or valve reimplantation (n = 14) was performed with a standard technique. In group B (36 patients) valvepreserving aortic replacement (remodeling, n = 31; reimplantation, n = 5) was combined with repair of leaflet prolapse in the presence of bicuspid (n = 24) or tricuspid (n = 12) valve anatomy. Additional replacement of the aortic arch was required more frequently in group A (group A, n = 43; group B, n = 14; P =.006); otherwise, the groups were comparable. RESULTS Cardiopulmonary bypass (group A, 133 +/- 31 minutes; group B, 117 +/- 30 minutes; P =.006) and myocardial ischemia times (group A, 96 +/- 25 minutes; group B, 88 +/- 20 minutes; P =.05) were significantly longer in group A. Mortality was not significantly different between groups (group A, 4.8%; group B, 0%). One patient in each group underwent secondary valve replacement, and all other patients had stable valve function. Freedom from aortic regurgitation of grade 2 or greater after 48 months was 93.0% in both groups. CONCLUSION Repair of leaflet prolapse in conjunction with valve-preserving root replacement leads to midterm results that are equal to those of valve-preserving root replacement for morphologically intact leaflets.
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Affiliation(s)
- F Langer
- Department of Thoracic and Cardiovascular Surgery, University Hospital Homburg, Germany
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Affiliation(s)
- L H Edmunds
- Hospital of the University of Pennsylvania, Philadelphia, PA 19104-4283, USA.
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Renzulli A, De Feo M, De Santo L, Corte AD, Dialetto G, Cotrufo M. Standard 19mm St Jude aortic valves in patients with body surface less than 1.7m 2. Int J Artif Organs 2001. [DOI: 10.1177/039139880102400411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although new models of bileaflet valves with improved orifice have been devised, aortic valve replacement with 19mm prostheses still raises concerns about long term effects of residual transprosthetic gradient. We reviewed our experience with 19 mm standard model St Jude prostheses in 68 patients operated on between January 1983 and December 1995. Clinical late assessment was performed to evaluate the incidence of valve related complications. Postoperative echocardiography was performed to evaluate hemodynamic performance of the prostheses. Mean body surface area was 1.66±0.14m2. Late postoperative peak gradient was 53.85±7.16 mmHg; mean gradient was 34.80±5.55 mm Hg; effective orifice area was 1.93±0.05 cm2. Thirteen-year actuarial survival has been 90.89 ± 0.6%; thirteen-year freedom from embolism 89.41 ± 0.7% and freedom from hemorrhage 98.25 ± 0.02%. No case of prosthetic endocarditis, thrombosis, or reoperation was observed during follow-up.
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Affiliation(s)
- A. Renzulli
- Department of Cardio-Thoracic and Respiratory Sciences, V. Monaldi Hospital, Second University of Naples, Naples - Italy
| | - M. De Feo
- Department of Cardio-Thoracic and Respiratory Sciences, V. Monaldi Hospital, Second University of Naples, Naples - Italy
| | - L.S. De Santo
- Department of Cardio-Thoracic and Respiratory Sciences, V. Monaldi Hospital, Second University of Naples, Naples - Italy
| | - A. Della Corte
- Department of Cardio-Thoracic and Respiratory Sciences, V. Monaldi Hospital, Second University of Naples, Naples - Italy
| | - G. Dialetto
- Department of Cardio-Thoracic and Respiratory Sciences, V. Monaldi Hospital, Second University of Naples, Naples - Italy
| | - M. Cotrufo
- Department of Cardio-Thoracic and Respiratory Sciences, V. Monaldi Hospital, Second University of Naples, Naples - Italy
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Ismeno G, Renzulli A, De Feo M, Della Corte A, Covino FE, Cotrufo M. Standard versus hemodynamic plus 19-mm St Jude Medical aortic valves. J Thorac Cardiovasc Surg 2001; 121:723-8. [PMID: 11279414 DOI: 10.1067/mtc.2001.113023] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We reviewed our experience with aortic valve replacement using 19-mm St Jude Medical prostheses (St Jude Medical, Inc, St Paul, Minn) in 119 patients, among which 68 (group A) had a Standard model and 51 (group B) had a Hemodynamic Plus model. METHODS Comparison between the 2 models included analysis of early and late mortality and all valve-related complications. Postoperative echocardiography was performed to evaluate the hemodynamic performance of both prosthetic models. Laboratory tests were performed to evaluate the amount of red blood cell damage caused by the transprosthetic turbulent flow. RESULTS Average body surface area was 1.66 +/- 0.14 m(2) in group A and 1.65 +/- 0.16 m(2) in group B (P =.72). There was no statistically significant difference between the 2 groups in terms of preoperative variables (sex, cardiac rhythm, body surface area, preoperative gradients, and New York Heart Association class). Five-year follow-up was 100% complete. Although group A patients had significantly higher postoperative peak and mean gradients (P =.0001) and a lower effective orifice area (P =.0001), no statistical differences were found in terms of late (5-year) survival (P =.6) and postoperative complications (P =.09). Moreover, postoperative left ventricular mass was found to be similar in the 2 groups (P =.18). Hematologic evaluation did not show any significant difference between the 2 groups as to incidence of hemolysis. CONCLUSIONS Aortic valve replacement with 19-mm aortic prostheses in patients with a body surface area of less than 1.7 m(2) allows good results. Although Hemodynamic Plus models have better hemodynamic results, no significant difference was found in terms of clinical results and clinical hemolysis.
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Affiliation(s)
- G Ismeno
- Department of Cardio-Thoracic and Respiratory Sciences, V. Monaldi Hospital, Second University of Naples, Italy
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O'Brien MF, Gardner MA, Garlick B, Jalali H, Harrocks S, McLoughlin L. The stentless xenograft aortic valve: The wheel turns around. Heart Lung Circ 2000; 9:61-73. [PMID: 16351997 DOI: 10.1046/j.1444-2892.2000.00032.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND A brief overview of the historical pathways of both stented and stentless porcine xenografts is presented in order to understand the return to and continuing clinical use of stentless devices. In addition, 7-11 years of durability with various models of stentless porcine valves has now accumulated and is beginning to be of relevance in determining the future place of this xenograft. Stentlessness and anticalcium agents, coupled with the poor results of stented xenografts in certain patient groups, have led to a resurgence of the clinical use of stentless xenograft valves for aortic valve replacement. An overview of the present state and future of stentless valves is given. METHODS At both The Prince Charles Hospital and St Andrew's War Memorial Hospital, Queensland, Australia, 307 patients have received the Model 300 CryoLife-O'Brien stentless composite aortic xenograft from December 1992 to February 2000. Associated procedures were required in 56% of patients (mostly coronary artery bypass, mean 2.4 grafts, in 144 patients (47%) and left ventricular myomectomy in 34 patients (11%)). RESULTS The hospital mortality (four early deaths) has been 1.3 +/- 1% (CL 95%) and the follow-up 100% for this analysis. The mean patient age was 73 years (range 57-89 years with 16% being 80 years and over). Morbid events have included six perivalvar leaks: four trivial and identified only on echo Doppler (no clinical murmurs) and two patients requiring reoperation at 10 days and 12 weeks with simple successful repair verified on subsequent echocardiograms. Of the 307 patients over the 7 year period, three valves only have been explanted, two for endocarditis at 1.5 and 3.5 years and one for possible technically induced structural failure at 15 months (probable needle damage). With this exception, there has been as yet no other intrinsic leaflet failure. Four early thromboembolic events (4 days-5 weeks) in patients with atrial fibrillation (no anticoagulants used postoperatively with the first 80 patients) constituted the important early morbid events. Late mortality of this elderly patient cohort has occurred in 27 patients over 7 years of maximum follow-up. One death (endocarditis) has been valve related at 5 years. Serial echocardiography (some 700 echoes in the study of this valve) has demonstrated a mean gradient of 7-9 mmHg with a very low incidence of trivial incompetence (96%) on Doppler examination with implant valve sizes ranging from 21 to 29 mm. One patient had significant regurgitation requiring reoperation. There has been no progression of either incompetence or stenosis of the remaining patients in this follow-up, now into the eighth postoperative year. CONCLUSION The early and intermediate results appear excellent in this elderly patient cohort. Nevertheless, important surveillance is obviously required to determine the durability at 10-12 years, a crucial time when stented porcine xenografts began to show an obvious failure rate from structural deterioration, in the middle and elderly aged patient cohort. An attempt is made to outline the future of this type of stentless xenograft and to justify that its cautious use should probably be extended down to the over 50 year age patient cohort.
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Affiliation(s)
- M F O'Brien
- The Prince Charles Hospital and St Andrew's War Memorial Hospital, Brisbane, Queensland, Australia.
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Westaby S, Horton M, Jin XY, Katsumata T, Ahmed O, Saito S, Li HH, Grunkemeier GL. Survival advantage of stentless aortic bioprostheses. Ann Thorac Surg 2000; 70:785-90; discussion 790-1. [PMID: 11016310 DOI: 10.1016/s0003-4975(00)01736-7] [Citation(s) in RCA: 68] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bioprostheses (BPs) are used to avoid anticoagulation after aortic valve replacement (AVR) in patients over 65 years of age. Stentless BPs offer established hemodynamic benefits. We sought to determine whether these advantages translate into improved survival. METHODS Between 1993 and 1997, follow-up data (for Food and Drug Administration submission) were collected prospectively for 160 consecutive, unselected hospital survivors who received the Freestyle valve (FS). Equivalent data were collected for 247 Carpentier-Edwards (CE) porcine xenograft patients. Detailed comparative statistical analysis was used to compare events and survival between the groups. Follow-up was 100% complete for the FS (5.2 years maximum; mean 3.2+/-1.0 years) group and 98% (7.2 years maximum; mean 3.8+/-2.0 years) for CE. RESULTS The groups were well matched in age (FS, 73+/-6 years; CE, 74+/-6 years), gender (FS, 58% male; CE, 62% male), ventricular function, and number of patients requiring coronary grafts (FS, 41%; CE, 37%). Actuarial survival at 5 years was 84% for FS versus 69% for CE (p = 0.023 Kaplan Meier, p = 0.009 Cox). Annual mortality rates were 3.6% for FS versus 7.1% for CE (p = 0.001). Thromboembolic rate was 0.8% per year for FS and 2.4% for CE (p = 0.024) without a difference in cardiac rhythm. Incidence of nonstructural dysfunction (paravalvular leak) was 0.2% for FS versus 1.3% for CE (p = 0.020). CONCLUSIONS By 5 years, the stentless valve patients had improved survival and reduced adverse events. Though differences in durability are yet to be proved, our findings support the use of stentless bioprostheses in this age group.
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Affiliation(s)
- S Westaby
- Department of Cardiac Surgery, Oxford Heart Centre, John Radcliffe Hospital, Headington, United Kingdom.
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35
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Affiliation(s)
- T E David
- Division of Cardiovascular Surgery, Toronto General Hospital, University of Toronto, Ontario, Canada
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36
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O'Brien MF, Gardner MA, Garlick RB, Davison MB, Thomson HL, Burstow DJ. The Cryolife-O'Brien stentless aortic porcine xenograft valve. J Card Surg 1998; 13:376-85. [PMID: 10440653 DOI: 10.1111/j.1540-8191.1998.tb01100.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The advantageous design of the Cryolife-O'Brien stentless porcine aortic valve permits specific quick, easy, supravalvular implantation using single layer continuous 3-0 polypropylene suture. The advantages, contraindications, and implantation errors to avoid are detailed. The use of this valve for aortic valve replacement in the elderly population has been directed to proving its efficacy and establishing its grounds for durability while maintaining all of the advantages of a stentless tissue valve. METHODS From December 1992 to September 1998, this valve was used in 240 patients (mean age 73 years: 15% > 80 years), 45% receiving associated coronary artery grafting (2.4 grafts per patient). Left ventricular (LV) myomectomy was necessary in 12% of patients. Detailed postoperative follow-up (100%) analysis included 650 serial echocardiographic studies. RESULTS The 30-day mortality was low at 1.2% (3 deaths of 240 elderly patients). Ten patients had late mortality (1.5 months to 5 years), all nonvalve related. No structural failure and one only explant for endocarditis have occurred. Echocardiographic analyses have shown low mean transvalvular gradients in relationship to time (8.18 mmHg at 18 months) and to valve size (8.52 mmHg for a 23-mm host aortic annulus). Incompetence has been zero or a trace in 97% of the patients at 21/2 years. No patient over the 6 years shows valve deterioration. CONCLUSION Six years of experience with this stentless valve in 240 elderly patients has revealed the many advantages of this safe, composite, and truly stentless device that is assembled without the need for Dacron support. Excellent sustained hemodynamics with low gradients, minimal regurgitation, and a good effective orifice have been coupled with low immediate mortality, no intrinsic valve failure, and one explant for endocarditis. Marked LV regression and minimal late valve-related complications confirm the safety and advantages of this stentless valve.
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Affiliation(s)
- M F O'Brien
- The Department of Cardiac Surgery, The Prince Charles Hospital, Brisbane, Australia.
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