1
|
Fringand T, Mace L, Cheylan I, Lenoir M, Favier J. Analysis of Fluid-Structure Interaction Mechanisms for a Native Aortic Valve, Patient-Specific Ozaki Procedure, and a Bioprosthetic Valve. Ann Biomed Eng 2024:10.1007/s10439-024-03566-1. [PMID: 39225853 DOI: 10.1007/s10439-024-03566-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Accepted: 06/08/2024] [Indexed: 09/04/2024]
Abstract
The Ozaki procedure is a surgical technique which avoids to implant foreign aortic valve prostheses in human heart, using the patient's own pericardium. Although this approach has well-identified benefits, it is still a topic of debate in the cardiac surgical community, which prevents its larger use to treat valve pathologies. This is linked to the actual lack of knowledge regarding the dynamics of tissue deformations and surrounding blood flow for this autograft pericardial valve. So far, there is no numerical study examining the coupling between the blood flow characteristics and the Ozaki leaflets dynamics. To fill this gap, we propose here a comprehensive comparison of various performance criteria between a healthy native valve, its pericardium-based counterpart, and a bioprosthetic solution, this is done using a three-dimensional fluid-structure interaction solver. Our findings reveal similar physiological dynamics between the valves but with the emergence of fluttering for the Ozaki leaflets and higher velocity and wall shear stress for the bioprosthetic heart valve.
Collapse
Affiliation(s)
- Tom Fringand
- Aix Marseille Univ, CNRS, Centrale Med, M2P2, Marseille, France.
| | - Loic Mace
- Aix Marseille Univ, CNRS, Centrale Med, M2P2, Marseille, France
- Department of Cardiac Surgery, La Timone Hospital, APHM, Aix Marseille Univ, Marseille, France
| | | | - Marien Lenoir
- Aix Marseille Univ, CNRS, Centrale Med, M2P2, Marseille, France
- Department of Cardiac Surgery, La Timone Hospital, APHM, Aix Marseille Univ, Marseille, France
| | - Julien Favier
- Aix Marseille Univ, CNRS, Centrale Med, M2P2, Marseille, France
| |
Collapse
|
2
|
Frankel WC, Robinson JA, Roselli EE, Unai S, Tretter JT, Fuller S, Nelson JS, Ghobrial J, Svensson LG, Pettersson GB, Najm HK, Karamlou T. Lifetime Management of Adolescents and Young Adults with Congenital Aortic Valve Disease. Ann Thorac Surg 2024:S0003-4975(24)00461-2. [PMID: 38871162 DOI: 10.1016/j.athoracsur.2024.04.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/26/2024] [Accepted: 04/24/2024] [Indexed: 06/15/2024]
Abstract
In this invited expert review, we focus on evolving lifetime management strategies for adolescents and young adults with congenital aortic valve disease, acknowledging that these patients often require multiple interventions during their lifetime. Our goal is to preserve the native aortic valve when feasible. Leveraging advanced multimodality imaging, a detailed assessment of the aortic valve and root complex can be obtained, and a surgically approach tailored to an individual patient's anatomy and pathology can be used. In turn, aortic valve repair and reconstruction can be offered to a greater number of patients, either as a definitive strategy or as a component of a staged strategy to delay the need for aortic valve replacement until later in life when more options are available.
Collapse
Affiliation(s)
- William C Frankel
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Justin A Robinson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Justin T Tretter
- Department of Pediatric Cardiology, Heart, Vascular and Thoracic Institute, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Stephanie Fuller
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jennifer S Nelson
- Division of Cardiovascular Surgery, Department of Cardiovascular Services, Nemours Children's Hospital, Orlando, Florida
| | - Joanna Ghobrial
- Department of Pediatric Cardiology, Heart, Vascular and Thoracic Institute, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Heart, Vascular and Thoracic Institute, Cleveland Clinic Children's Hospital, Cleveland, Ohio.
| |
Collapse
|
3
|
Notenboom ML, Rhellab R, Etnel JRG, Huygens SA, Hjortnaes J, Kluin J, Takkenberg JJM, Veen KM. How microsimulation translates outcome estimates to patient lifetime event occurrence in the setting of heart valve disease. Eur J Cardiothorac Surg 2024; 65:ezae087. [PMID: 38515198 DOI: 10.1093/ejcts/ezae087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 02/08/2024] [Accepted: 03/06/2024] [Indexed: 03/23/2024] Open
Abstract
Treatment decisions in healthcare often carry lifelong consequences that can be challenging to foresee. As such, tools that visualize and estimate outcome after different lifetime treatment strategies are lacking and urgently needed to support clinical decision-making in the setting of rapidly evolving healthcare systems, with increasingly numerous potential treatments. In this regard, microsimulation models may prove to be valuable additions to current risk-prediction models. Notable advantages of microsimulation encompass input from multiple data sources, the ability to move beyond time-to-first-event analysis, accounting for multiple types of events and generating projections of lifelong outcomes. This review aims to clarify the concept of microsimulation, also known as individualized state-transition models, and help clinicians better understand its potential in clinical decision-making. A practical example of a patient with heart valve disease is used to illustrate key components of microsimulation models, such as health states, transition probabilities, input parameters (e.g. evidence-based risks of events) and various aspects of mortality. Finally, this review focuses on future efforts needed in microsimulation to allow for increasing patient-tailoring of the models by extending the general structure with patient-specific prediction models and translating them to meaningful, user-friendly tools that may be used by both clinician and patient to support clinical decision-making.
Collapse
Affiliation(s)
- Maximiliaan L Notenboom
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Reda Rhellab
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Jonathan R G Etnel
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | | | - Jesper Hjortnaes
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Rotterdam, Netherlands
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Kevin M Veen
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| |
Collapse
|
4
|
Notenboom ML, Van Hoof L, Schuermans A, Takkenberg JJM, Rega FR, Taverne YJHJ. Aortic Valve Embryology, Mechanobiology, and Second Messenger Pathways: Implications for Clinical Practice. J Cardiovasc Dev Dis 2024; 11:49. [PMID: 38392263 PMCID: PMC10888685 DOI: 10.3390/jcdd11020049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 01/22/2024] [Accepted: 01/29/2024] [Indexed: 02/24/2024] Open
Abstract
During the Renaissance, Leonardo Da Vinci was the first person to successfully detail the anatomy of the aortic root and its adjacent structures. Ever since, novel insights into morphology, function, and their interplay have accumulated, resulting in advanced knowledge on the complex functional characteristics of the aortic valve (AV) and root. This has shifted our vision from the AV as being a static structure towards that of a dynamic interconnected apparatus within the aortic root as a functional unit, exhibiting a complex interplay with adjacent structures via both humoral and mechanical stimuli. This paradigm shift has stimulated surgical treatment strategies of valvular disease that seek to recapitulate healthy AV function, whereby AV disease can no longer be seen as an isolated morphological pathology which needs to be replaced. As prostheses still cannot reproduce the complexity of human nature, treatment of diseased AVs, whether stenotic or insufficient, has tremendously evolved, with a similar shift towards treatments options that are more hemodynamically centered, such as the Ross procedure and valve-conserving surgery. Native AV and root components allow for an efficient Venturi effect over the valve to allow for optimal opening during the cardiac cycle, while also alleviating the left ventricle. Next to that, several receptors are present on native AV leaflets, enabling messenger pathways based on their interaction with blood and other shear-stress-related stimuli. Many of these physiological and hemodynamical processes are under-acknowledged but may hold important clues for innovative treatment strategies, or as potential novel targets for therapeutic agents that halt or reverse the process of valve degeneration. A structured overview of these pathways and their implications for cardiothoracic surgeons and cardiologists is lacking. As such, we provide an overview on embryology, hemodynamics, and messenger pathways of the healthy and diseased AV and its implications for clinical practice, by relating this knowledge to current treatment alternatives and clinical decision making.
Collapse
Affiliation(s)
- Maximiliaan L Notenboom
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Art Schuermans
- Department of Cardiac Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| | - Filip R Rega
- Department of Cardiac Surgery, University Hospitals Leuven, 3000 Leuven, Belgium
| | - Yannick J H J Taverne
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, 3000 CA Rotterdam, The Netherlands
| |
Collapse
|
5
|
Galzerano D, Kholaif N, Al Amro B, Al Admawi M, Eltayeb A, Alshammari A, Di Salvo G, Al-Halees ZY. The Ross Procedure: Imaging, Outcomes and Future Directions in Aortic Valve Replacement. J Clin Med 2024; 13:630. [PMID: 38276135 PMCID: PMC10816914 DOI: 10.3390/jcm13020630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 11/30/2023] [Accepted: 12/05/2023] [Indexed: 01/27/2024] Open
Abstract
The Ross procedure is gaining recognition as a significant option for aortic valve replacement (AVR), and is particularly beneficial in specific patient groups. Although categorized as a class IIb recommendation in the 2020 American College of Cardiology (ACC)/American Heart Association (AHA), and the European Society of Cardiology (ESC) management guidelines on valvular heart disease, recent studies bolster its credibility. Research, including a propensity-matched study, underlines the Ross procedure's association with enhanced long-term survival and reduced adverse valve-related events compared to other AVR types. This positions the Ross procedure as a primary option for AVR in young and middle-aged adults within specialized centers, and potentially the only choice for children and infants requiring AVR. This review meticulously examines the Ross procedure, covering historical perspectives, surgical techniques, imaging, and outcomes, including hemodynamic performance and quality of life, especially focusing on pediatric and young adult patients. It explores contemporary techniques and innovations like minimally invasive approaches and tissue engineering, underscoring ongoing research and future directions. A summarization of comparative studies and meta-analyses reiterates the Ross procedure's superior long-term outcomes, valve durability, and preservation of the left ventricular function, accentuating the crucial role of patient selection and risk stratification, and pinpointing areas for future research.
Collapse
Affiliation(s)
- Domenico Galzerano
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Naji Kholaif
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Bandar Al Amro
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia
| | - Mohammed Al Admawi
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
| | - Abdalla Eltayeb
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
| | - Amal Alshammari
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
| | - Giovanni Di Salvo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Medical School, University of Padua, 35122 Padua, Italy;
| | - Zohair Y. Al-Halees
- Heart Center Department, King Faisal Specialist Hospital and Research Center, Riyadh 11564, Saudi Arabia; (D.G.); (B.A.A.); (M.A.A.); (A.E.); (A.A.); (Z.Y.A.-H.)
| |
Collapse
|
6
|
Meccanici F, Notenboom ML, Meijssen J, Smit V, van de Woestijne PC, van den Bosch AE, Helbing WA, Bogers AJJC, Takkenberg JJM, Roos-Hesselink JW. Long-term surgical outcomes of congenital supravalvular aortic stenosis: a systematic review, meta-analysis and microsimulation study. Eur J Cardiothorac Surg 2024; 65:ezad360. [PMID: 37889257 PMCID: PMC10782899 DOI: 10.1093/ejcts/ezad360] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 10/10/2023] [Accepted: 10/26/2023] [Indexed: 10/28/2023] Open
Abstract
OBJECTIVES Congenital supravalvular aortic stenosis (SVAS) is a rare form of congenital outflow tract obstruction and long-term outcomes are scarcely reported. This study aims to provide an overview of outcomes after surgical repair for congenital SVAS. METHODS A systematic review of published literature was conducted, including observational studies reporting long-term clinical outcome (>2 years) after SVAS repair in children or adults considering >20 patients. Early risks, late event rates and time-to-event data were pooled and entered into a microsimulation model to estimate 30-year outcomes. Life expectancy was compared to the age-, sex- and origin-matched general population. RESULTS Twenty-three publications were included, encompassing a total of 1472 patients (13 125 patient-years; pooled mean follow-up: 9.0 (6.2) years; median follow-up: 6.3 years). Pooled mean age at surgical repair was 4.7 (5.8) years and the most commonly used surgical technique was the single-patch repair (43.6%). Pooled early mortality was 4.2% (95% confidence interval: 3.2-5.5%) and late mortality was 0.61% (95% CI: 0.45-0.83) per patient-year. Based on microsimulation, over a 30-year time horizon, it was estimated that an average patient with SVAS repair (mean age: 4.7 years) had an observed life expectancy that was 90.7% (95% credible interval: 90.0-91.6%) of expected life expectancy in the matched general population. The microsimulation-based 30-year risk of myocardial infarction was 8.1% (95% credible interval: 7.3-9.9%) and reintervention 31.3% (95% credible interval: 29.6-33.4%), of which 27.2% (95% credible interval: 25.8-29.1) due to repair dysfunction. CONCLUSIONS After surgical repair for SVAS, 30-year survival is lower than the matched-general-population survival and the lifetime risk of reintervention is considerable. Therefore, lifelong monitoring of the cardiovascular system and in particular residual stenosis and coronary obstruction is recommended.
Collapse
Affiliation(s)
- Frederike Meccanici
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Maximiliaan L Notenboom
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre Rotterdam, Netherlands
| | - Jade Meijssen
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Vernon Smit
- Department of Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | | | | | - Willem A Helbing
- Department of Paediatrics, Division of Paediatric Cardiology, Erasmus University Medical Centre, Rotterdam, Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre Rotterdam, Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre Rotterdam, Netherlands
| | | |
Collapse
|
7
|
Santarpino G, Di Mauro M, De Feo M, Menicanti L, Paparella D, Mastroroberto P, Speziale G, Pollari F, Mauro M, Torella M, Coscioni E, Barili F, Parolari A. Mechanical heart valves and oral anticoagulation: a survey of the Italian Society of Cardiac Surgery. J Cardiovasc Med (Hagerstown) 2024; 25:38-43. [PMID: 38051658 DOI: 10.2459/jcm.0000000000001525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2023]
Abstract
In the latest European guidelines for the management of valvular heart disease, mechanical valve prostheses maintain a strategic role, particularly for certain patient subsets and age groups. Despite the high number of devices implanted in clinical practice, particularly in non-European and North American regions, current scientific literature and debate seem to suggest a limited use of mechanical heart valves. The cardiac surgery community seems to be highly interested in biological and transcatheter valve prostheses but less interested in mechanical heart valves, including possible strategies for self-management of anticoagulation therapy. In this respect, the Italian Society of Cardiac Surgery (SICCH), in particular the Italian Group of Research for Outcome in Cardiac Surgery (GIROC), has promoted a survey among its members to stimulate the interest in this topic and express their opinion on this issue that, due to the prevalence of the affected population and the new treatment options for improving patients' quality of life, should be more appraised and debated in the cardiac surgery community. The recorded results, obtained on the answers to 111 questionnaires, seem to divide the specialists into 'pros' and 'contras' on a useful tool for the entire cardiac surgery community. For this reason, SICCH proposes in conclusion to declare its unified and institutional opinion on this topic.
Collapse
Affiliation(s)
- Giuseppe Santarpino
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, Catanzaro
- Department of Cardiac Surgery, Città di Lecce Hospital, GVM Care and Research, Lecce, Italy
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Michele Di Mauro
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Marisa De Feo
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Napoli
| | - Lorenzo Menicanti
- Department of Cardiac Surgery, IRCCS, Policlinico San Donato, San Donato Milanese
| | - Domenico Paparella
- Department of Medical and Surgical Sciences, Division of Cardiac Surgery, University of Foggia, Foggia
- Division of Cardiac Surgery, Santa Maria Hospital, GVM Care & Research, Bari
| | - Pasquale Mastroroberto
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, Catanzaro
| | - Giuseppe Speziale
- Division of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari
| | - Francesco Pollari
- Department of Cardiac Surgery, Klinikum Nürnberg, Paracelsus Medical University Nuremberg, Nuremberg, Germany
| | - Marianna Mauro
- Department of Experimental and Clinical Medicine, Magna Graecia University of Catanzaro, Catanzaro
| | - Michele Torella
- Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", Napoli
| | - Enrico Coscioni
- Division of Cardiac Surgery, AOU San Giovanni di Dio e Ruggi d'Aragona, Salerno
| | - Fabio Barili
- Department of Cardiac Surgery, Santa Croce Hospital, Cuneo
| | - Alessandro Parolari
- University Department of Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| |
Collapse
|
8
|
Notenboom ML, Melina G, Veen KM, De Robertis F, Coppola G, De Siena P, Navarra EM, Gaer J, Ibrahim MEK, El-Hamamsy I, Takkenberg JJM, Yacoub MH. Long-Term Clinical and Echocardiographic Outcomes Following the Ross Procedure: A Post Hoc Analysis of a Randomized Clinical Trial. JAMA Cardiol 2024; 9:6-14. [PMID: 37938855 PMCID: PMC10633393 DOI: 10.1001/jamacardio.2023.4090] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/24/2023] [Indexed: 11/10/2023]
Abstract
Importance The Ross procedure as treatment for adults with aortic valve disease (AVD) has been the subject of renewed interest. Objective To evaluate the long-term clinical and echocardiographic outcomes following the Ross procedure for the treatment of adults with AVD. Design, Setting, and Participants This post hoc analysis of a randomized clinical trial included adult patients (age <69 years) who underwent a Ross procedure for the treatment of AVD, including those with active endocarditis, rheumatic AVD, decreased ejection fraction, and previous cardiac surgery. The trial, conducted from September 1, 1994, to May 31, 2001, compared homograft root replacement with the Ross procedure at a single center. Data after 2010 were collected retrospectively in November and December 2022. Exposure Ross procedure. Main Outcomes and Measures The primary end point was long-term survival among patients who underwent the Ross procedure compared with that in the age-, country of origin- and sex-matched general population. Secondary end points were freedom from any reintervention, autograft reintervention, or homograft reintervention and time-related valve function, autograft diameter, and functional status. Results This study included 108 adults (92 [85%] male) with a median age of 38 years (range, 19-66 years). Median duration of clinical follow-up was 24.1 years (IQR, 22.6-26.1 years; 2488 patient-years), with 98% follow-up completeness. Of these patients, 9 (8%) had active endocarditis and 45 (42%) underwent reoperations. The main hemodynamic lesion was stenosis in 30 (28%) and regurgitation in 49 (45%). There was 1 perioperative death (0.9%). Twenty-five year survival was 83.0% (95% CI, 75.5%-91.2%), representing a relative survival of 99.1% (95% CI, 91.8%-100%) compared with the general population (83.7%). At 25 years, freedom from any reintervention was 71.1% (95% CI, 61.6%-82.0%); from autograft reintervention, 80.3% (95% CI, 71.9%-89.6%); and from homograft reintervention, 86.3% (95% CI, 79.0%-94.3%). Thirty-day mortality after the first Ross-related reintervention was 0% and after all Ross-related reinterventions was 3.8% (n = 1); 10-year survival after reoperation was 96.2% (95% CI, 89.0%-100%). Conclusions and Relevance This study found that the Ross procedure provided excellent survival into the third decade postoperatively that was comparable to that in the general population. Long-term freedom from reintervention demonstrated that the Ross procedure may be a durable substitute into late adulthood, showing a delayed but progressive functional decline. Trial Registration isrctn.org Identifier: ISRCTN03530985.
Collapse
Affiliation(s)
- Maximiliaan L. Notenboom
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Giovanni Melina
- Department of Cardiac Surgery, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Kevin M. Veen
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Fabio De Robertis
- Department of Cardiothoracic Surgery and Transplantation, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Giuditta Coppola
- Department of Cardiothoracic Surgery and Transplantation, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Paolo De Siena
- Department of Cardiothoracic Surgery and Transplantation, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Emiliano M. Navarra
- Department of Cardiac Surgery, Sant’Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Jullien Gaer
- Department of Cardiothoracic Surgery and Transplantation, Royal Brompton & Harefield Hospitals, Guy’s and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | | | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, The Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Johanna J. M. Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Magdi H. Yacoub
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Cardiac Surgery Department, Aswan Heart Centre, Magdi Yacoub Foundation, Aswan, Egypt
| |
Collapse
|
9
|
Andreeva A, Coti I, Werner P, Scherzer S, Kocher A, Laufer G, Andreas M. Aortic Valve Replacement in Adult Patients with Decellularized Homografts: A Single-Center Experience. J Clin Med 2023; 12:6713. [PMID: 37959179 PMCID: PMC10650916 DOI: 10.3390/jcm12216713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 10/16/2023] [Accepted: 10/17/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND decellularized aortic homografts (DAH) represent a promising alternative for aortic valve replacement in young adults due to their low immunogenicity and thrombogenicity. Herein, we report our midterm, single-center experience in adult patients with non-frozen DAH from corlife. METHODS safety, durability, and hemodynamic performance were evaluated according to current guidelines in all consecutive patients who had received a DAH at our center since 03/2016. RESULTS seventy-three (mean age 47 ± 11 years, 68.4% (n = 50) male) patients were enrolled. The mean diameter of the implanted DAH was 24 ± 2 mm. Mean follow-up was 36 ± 27 months, with a maximum follow-up of 85 months and cumulative follow-up of 215 years. No cases of stenosis were observed, in four (5.5%) cases moderate aortic regurgitation occurred, but no reintervention was required. No cases of early mortality, non-structural dysfunction, reoperation, valve endocarditis, or thrombosis were observed. Freedom from bleeding and thromboembolic events was 100%; freedom from re-intervention was 100%; survival was 98.6% (n = 72). CONCLUSIONS early and mid-term results showed low mortality and 100% freedom from reoperation, thromboembolic events, and bleeding at our center. However, in order for this novel approach to be established as a valid alternative to aortic valve replacement in young patients, long-term data are required.
Collapse
Affiliation(s)
- Alexandra Andreeva
- Department of Cardiac Surgery, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria; (I.C.); (P.W.); (S.S.); (A.K.); (G.L.); (M.A.)
| | | | | | | | | | | | | |
Collapse
|
10
|
Carrel T, Vogt PR, Obrist D, Schaff H. Evolving technology: the TRIFLO tri-leaflet mechanical valve without oral anticoagulation: a potential major innovation in valve surgery. Front Cardiovasc Med 2023; 10:1220633. [PMID: 37840955 PMCID: PMC10570810 DOI: 10.3389/fcvm.2023.1220633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/08/2023] [Indexed: 10/17/2023] Open
Abstract
The aortic valve is the most frequently diseased valve and aortic stenosis (AS) is the most prevalent valvular heart disease in developed countries. The diseased native aortic valve can be replaced by either a biological or mechanical valve prosthesis. The main concerns relate to durability, the need for oral anticoagulants and the incidence of complications related to this medication. Experimental, computational and biomolecular blood flow studies have demonstrated that the systolic forward flow but also the reverse flow phase at the end of the systole and leakage during the diastolic phase is mainly responsible for platelet activation and thrombosis. Better design of mechanical prosthetic heart valves must ensure smooth closing during flow deceleration and must eliminate high-shear hinge flow during diastole to prevent life-threatening thrombosis. A novel tri-leaflet valve should combine the favorable hemodynamics and the durability of existing mechanical heart valves and eliminate the less favorable characteristics, including the extremely rapid closing. In this paper, we discuss some issues of current mechanical heart valve prostheses and present a new valve design with the potential for significant innovation in the field. The TRIFLO Heart Valve, is a rigid, three-leaflet central flow heart valve prosthesis consisting of an alloyed titanium housing, and three rigid polymer (PEEK) cusps. This valve has a physiological operating mode. During the forward flow phase, the intraventricular pressure opens the leaflets so that blood can freely flow through with little obstruction, and with the deceleration of the blood flow, the leaflets close early and smoothly, minimizing blood flow regurgitation, blood cell damage, and activation of the coagulation cascade. Pre-clinical studies have shown pretty favorable results and a first-in-man study should start very soon.
Collapse
Affiliation(s)
- Thierry Carrel
- Department of Cardiac Surgery, University Hospital Basel, Switzerland
| | | | - Dominique Obrist
- ARTORG Center for Biomedical Research, University of Bern, Bern, Switzerland
| | | |
Collapse
|
11
|
Notenboom ML, Schuermans A, Etnel JRG, Veen KM, van de Woestijne PC, Rega FR, Helbing WA, Bogers AJJC, Takkenberg JJM. Paediatric aortic valve replacement: a meta-analysis and microsimulation study. Eur Heart J 2023; 44:3231-3246. [PMID: 37366156 PMCID: PMC10482570 DOI: 10.1093/eurheartj/ehad370] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 04/21/2023] [Accepted: 05/24/2023] [Indexed: 06/28/2023] Open
Abstract
AIMS To support decision-making in children undergoing aortic valve replacement (AVR), by providing a comprehensive overview of published outcomes after paediatric AVR, and microsimulation-based age-specific estimates of outcome with different valve substitutes. METHODS AND RESULTS A systematic review of published literature reporting clinical outcome after paediatric AVR (mean age <18 years) published between 1/1/1990 and 11/08/2021 was conducted. Publications reporting outcome after paediatric Ross procedure, mechanical AVR (mAVR), homograft AVR (hAVR), and/or bioprosthetic AVR were considered for inclusion. Early risks (<30d), late event rates (>30d) and time-to-event data were pooled and entered into a microsimulation model. Sixty-eight studies, of which one prospective and 67 retrospective cohort studies, were included, encompassing a total of 5259 patients (37 435 patient-years; median follow-up: 5.9 years; range 1-21 years). Pooled mean age for the Ross procedure, mAVR, and hAVR was 9.2 ± 5.6, 13.0 ± 3.4, and 8.4 ± 5.4 years, respectively. Pooled early mortality for the Ross procedure, mAVR, and hAVR was 3.7% (95% CI, 3.0%-4.7%), 7.0% (5.1%-9.6%), and 10.6% (6.6%-17.0%), respectively, and late mortality rate was 0.5%/year (0.4%-0.7%/year), 1.0%/year (0.6%-1.5%/year), and 1.4%/year (0.8%-2.5%/year), respectively. Microsimulation-based mean life-expectancy in the first 20 years was 18.9 years (18.6-19.1 years) after Ross (relative life-expectancy: 94.8%) and 17.0 years (16.5-17.6 years) after mAVR (relative life-expectancy: 86.3%). Microsimulation-based 20-year risk of aortic valve reintervention was 42.0% (95% CI: 39.6%-44.6%) after Ross and 17.8% (95% CI: 17.0%-19.4%) after mAVR. CONCLUSION Results of paediatric AVR are currently suboptimal with substantial mortality especially in the very young with considerable reintervention hazards for all valve substitutes, but the Ross procedure provides a survival benefit over mAVR. Pros and cons of substitutes should be carefully weighed during paediatric valve selection.
Collapse
Affiliation(s)
- Maximiliaan L Notenboom
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Zuid-Holland, The Netherlands
| | - Art Schuermans
- Department of Cardiac Surgery, University Hospitals Leuven, UZ Leuven Gasthuisberg, Herestraat 49, 3000, Leuven, Flanders, Belgium
- Cardiovascular Research Center, Massachusetts General Hospital, 149 13th Street, 4th floor, Boston, MA 02129, USA
- Program in Medical and Population Genetics and the Cardiovascular Disease Initiative, Broad Institute of Harvard and MIT, Merkin Building, 415 Main St., Cambridge, MA 02142, USA
| | - Jonathan R G Etnel
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Zuid-Holland, The Netherlands
| | - Kevin M Veen
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Zuid-Holland, The Netherlands
| | - Pieter C van de Woestijne
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Zuid-Holland, The Netherlands
| | - Filip R Rega
- Department of Cardiac Surgery, University Hospitals Leuven, UZ Leuven Gasthuisberg, Herestraat 49, 3000, Leuven, Flanders, Belgium
| | - Willem A Helbing
- Department of Paediatrics, Division of Paediatric Cardiology, Erasmus MC-Sophia Children's Hospital, Wytemaweg 80, 3015 CN, Rotterdam, Zuid-Holland, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Zuid-Holland, The Netherlands
| | - Johanna J M Takkenberg
- Department of Cardiothoracic Surgery, Erasmus University Medical Centre, Erasmus MC, Doctor Molewaterplein 40, 3015 GD, Rotterdam, Zuid-Holland, The Netherlands
| |
Collapse
|
12
|
Kiaii BB, Moront MG, Patel HJ, Ruel M, Bensari FN, Kress DC, Liu F, Klautz RJM, Sabik JF. Outcomes of Surgical Bioprosthetic Aortic Valve Replacement in Patients Aged ≤65 and >65 Years. Ann Thorac Surg 2023; 116:483-490. [PMID: 35065064 DOI: 10.1016/j.athoracsur.2021.12.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 11/17/2021] [Accepted: 12/14/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Implantation of a bioprosthetic valve is a reasonable choice for patients aged > 65 years. For middle-aged patients there is less certainty about whether a mechanical or bioprosthetic valve is best. METHODS The Pericardial Surgical Aortic Valve Replacement (PERIGON) Pivotal Trial is evaluating the safety and efficacy of the Avalus bioprosthesis (Medtronic). We evaluated clinical and echocardiographic outcomes through 5 years of follow-up, stratified by age ≤ 65 and >65 years. RESULTS Two hundred seventy-one patients (24.2%) were ≤65 years old and 847 (75.8%) >65 years old. Most patients in both groups were men (217 [80.1%] vs 623 [73.6%], respectively; P = .031). Younger patients had a lower Society of Thoracic Surgeons risk of mortality (1.1% ± 0.9% vs 2.2% ± 1.4%, P < .001), better baseline New York Heart Association class (P = .004), and fewer comorbidities than older patients. At 5 years mortality was lower among younger than older patients (5.3% vs 14.0%, P < .001) and no cases of structural valve deterioration occurred in either group. Effective orifice area was similar between age groups (P = .11), and mean gradient was 13.9 ± 5.4 vs 12.0 ± 4.1 mm Hg (P < .001). Multivariable linear regression identified several parameters associated with mean aortic gradient at 5 years, including baseline age and mean aortic gradient, discharge stroke volume index and EOA, and implanted valve size. Ninety-five percent of patients were in New York Heart Association class I/II through 5 years in both age groups (P = .85). CONCLUSIONS Findings from this analysis demonstrate satisfactory safety, hemodynamic performance, and durability of the Avalus bioprosthesis through a 5-year follow-up in patients aged ≤ 65 and >65 years.
Collapse
Affiliation(s)
- Bob B Kiaii
- Department of Cardiac Surgery, London Health Sciences Centre, London, Ontario, Canada.
| | | | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan Hospitals, Ann Arbor, Michigan
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | | | - David C Kress
- Department of Cardiothoracic Surgery, Aurora St Luke's Medical Center, Milwaukee, Wisconsin
| | - Fang Liu
- Department of Biostatistics, Medtronic, Mounds View, Minnesota
| | - Robert J M Klautz
- Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Joseph F Sabik
- University Hospitals Cleveland Medical Center and Case Western Reserve University School of Medicine, Cleveland, Ohio
| |
Collapse
|
13
|
Lausberg HF, Schäfers HJ. Recent innovations in aortic valve surgery: True progress? TURK GOGUS KALP DAMAR CERRAHISI DERGISI 2023; 31:155-160. [PMID: 37484648 PMCID: PMC10357859 DOI: 10.5606/tgkdc.dergisi.2023.98551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/16/2023] [Indexed: 07/25/2023]
Affiliation(s)
- Henning F. Lausberg
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg, Germany
| |
Collapse
|
14
|
Sherard C, Bisbee C, Konsek H, Kang L, Turek JW, Rajab TK. Partial Heart Transplantation in Adult Cardiac Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:126-131. [PMID: 36872577 DOI: 10.1177/15569845231156921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Many young adults require heart valve replacements. Current options for valve replacement in adults include mechanical valves, bioprosthetic valves, or the Ross procedure. Of these, mechanical and bioprosthetic valves are the most common options, although mechanical valve usage predominates in younger adults due to durability, while bioprosthetic valve usage predominates in older adults. Partial heart transplantation is a new method of valvular replacement that can deliver durable and self-repairing valves and allow adult patients freedom from anticoagulation therapy. This procedure involves transplantation of donor heart valves only, permitting expanded utilization of donor hearts as compared with orthotopic heart transplantation. In this review, we discuss the potential benefits of this procedure in adults who elect against the anticoagulation regimen required of mechanical valve replacements, although it has not yet been clinically established. Partial heart transplantation is a promising new therapy for the treatment of pediatric valvular dysfunction. This is a novel technique in the adult population with potential utility for valve replacement in young patients for whom anticoagulation therapy is problematic, such as women who wish to become pregnant, patients with bleeding disorders, and patients with active lifestyles.
Collapse
Affiliation(s)
- Curry Sherard
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Cora Bisbee
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Haley Konsek
- College of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Lillian Kang
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Joseph W Turek
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Taufiek K Rajab
- Section of Pediatric Cardiothoracic Surgery, Department of Surgery, Medical University of South Carolina, Charleston, SC, USA
| |
Collapse
|
15
|
Gofus J, Fila P, Vobornik M, Ondrasek J, Nemec P, Sterba J, Cermakova E, Tuna M, Vojacek J. Unicuspid Aortic Valve in Patients Undergoing the Ross Procedure. Ann Thorac Surg 2023; 115:626-631. [PMID: 35430219 DOI: 10.1016/j.athoracsur.2022.03.061] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/28/2022] [Accepted: 03/22/2022] [Indexed: 11/01/2022]
Abstract
BACKGROUND The prevalence and outcomes of the unicuspid aortic valve (UAV) in patients undergoing the Ross procedure have been strongly underreported in the current literature. We sought to evaluate this in comparison with bicuspid (BAV) and tricuspid valve (TAV) in our Ross cohort. METHODS This was a retrospective observational study of patients undergoing the Ross procedure at 2 dedicated centers between 2009 and 2020. Primary end points were the risks of midterm autograft reoperation and the onset of at least moderate aortic regurgitation during follow-up. The secondary end point was to compare the perioperative outcomes between the groups. RESULTS Included in the analysis were 286 patients, of those 39% with UAV, 52% with BAV, and 9% with TAV. UAV patients were operated on at the youngest age (P < .001) and more often for a combined hemodynamic aortic valve pathology (P = .02). They had the largest aortic root dimensions: annulus (P = .01), Valsalva sinuses (P = .11), sinotubular junction (P = .001), and ascending aorta (P < .0001). The risks of reoperation (P = .86) and the onset of aortic regurgitation (P = .75) were comparable among the groups over the follow-up of 4.1 years. There was no difference in perioperative outcomes. CONCLUSIONS UAV is a separate unit characterized by a distinct hemodynamic pathology and generated aortopathy. It is not associated with a higher risk of reoperation or new onset of aortic regurgitation after the Ross procedure in the midterm postoperatively. At the current state, UAV remains acceptable for the Ross procedure.
Collapse
Affiliation(s)
- Jan Gofus
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Petr Fila
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic; Department of Cardiovascular Surgery and Transplantation Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Martin Vobornik
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jiri Ondrasek
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Petr Nemec
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic; Department of Cardiovascular Surgery and Transplantation Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Jan Sterba
- Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic; Department of Cardiovascular Surgery and Transplantation Brno, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Eva Cermakova
- Department of Medical Biophysics, Charles University Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Martin Tuna
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jan Vojacek
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| |
Collapse
|
16
|
El Sherif N, Dearani JA, Connolly HM, Bagameri G, Pochettino A, Stulak JM, Stephens EH. Complexity and Outcome of Reoperations After the Ross Procedure in the Current Era. Ann Thorac Surg 2023; 115:633-639. [PMID: 35644264 DOI: 10.1016/j.athoracsur.2022.05.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 04/04/2022] [Accepted: 05/09/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Ross procedure has several advantages, but the need for reintervention is inevitable. The aim of this study was to examine the complexity and outcomes of reoperation after the Ross procedure. METHODS Retrospective chart review was performed of patients with a prior Ross procedure who underwent reoperation at our institution from September 1991 to January 2021. Demographic, echocardiographic, surgical, and perioperative data were collected. Descriptive statistical and regression analyses were performed. RESULTS A total of 105 patients underwent a reoperation at Mayo Clinic after the initial Ross procedure performed at our institution (n = 16; 16.2%) or elsewhere (n = 83; 83.8%). Mean age at the Ross procedure was 27 ± 17 years, and mean age at reoperation at our institution was 37 ± 19 years. Indications for surgical procedure varied, but 64% had autograft regurgitation as 1 of their indications for reoperation. Autograft interventions were performed in 78 patients (74.2%). Pulmonary valve or conduit replacement was performed in 56 patients (53.3%). Double root replacement was performed in 11 patients (10.5%). Aortic reconstruction was performed in 37 patients (38.4%). There were 5 early deaths (5%). During a median follow-up of 6.25 years (3 months-24 years), late deaths occurred in 14 patients (13.1%). Patients with ejection fraction <30% on preoperative echocardiography had shorter duration between the Ross procedure and subsequent reoperation (P = .03). CONCLUSIONS Reoperations after the Ross procedure are performed for a wide range of indications, with most due to autograft dysfunction. The number of early deaths is not low. Reoperation after the Ross procedure should be advised before left ventricular systolic dysfunction.
Collapse
Affiliation(s)
- Nibras El Sherif
- Division of Pediatric Cardiology, Mayo Clinic, Rochester, Minnesota
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Gabor Bagameri
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - John M Stulak
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
17
|
Stoica S, Beard C, Takkenberg JJM, Mokhles MM, Turner M, Pepper J, Hopewell-Kelly N, Benedetto U, Nashef SAM, El-Hamamsy I, Skillington P, Glauber M, De Paulis R, Tseng E, Meuris B, Sitges M, Delgado V, Krane M, Kostolny M, Pufulete M. Formal consensus study on surgery to replace the aortic valve in adults aged 18-60 years. Heart 2023; 109:857-865. [PMID: 36849232 DOI: 10.1136/heartjnl-2022-321740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/12/2022] [Indexed: 03/01/2023] Open
Abstract
OBJECTIVE There is uncertainty about surgical procedures for adult patients aged 18-60 years undergoing aortic valve replacement (AVR). Options include conventional AVR (mechanical, mAVR; tissue, tAVR), the pulmonary autograft (Ross) and aortic valve neocuspidisation (Ozaki). Transcatheter treatment may be an option for selected patients. We used formal consensus methodology to make recommendations about the suitability of each procedure. METHODS A working group, supported by a patient advisory group, developed a list of clinical scenarios across seven domains (anatomy, presentation, cardiac/non-cardiac comorbidities, concurrent treatments, lifestyle, preferences). A consensus group of 12 clinicians rated the appropriateness of each surgical procedure for each scenario on a 9-point Likert scale on two separate occasions (before and after a 1-day meeting). RESULTS There was a consensus that each procedure was appropriate (A) or inappropriate (I) for all clinical scenarios as follows: mAVR: total 76% (57% A, 19% I); tAVR: total 68% (68% A, 0% I); Ross: total 66% (39% A, 27% I); Ozaki: total 31% (3% A, 28% I). The remainder of percentages to 100% reflects the degree of uncertainty. There was a consensus that transcatheter aortic valve implantation is appropriate for 5 of 68 (7%) of all clinical scenarios (including frailty, prohibitive surgical risk and very limited life span). CONCLUSIONS Evidence-based expert opinion emerging from a formal consensus process indicates that besides conventional AVR options, there is a high degree of certainty about the suitability of the Ross procedure in patients aged 18-60 years. Future clinical guidelines should include the option of the Ross procedure in aortic prosthetic valve selection.
Collapse
Affiliation(s)
- Serban Stoica
- Cardiothoracic Surgery, Bristol Heart Institute, Bristol, UK
| | - Chloe Beard
- Cardiothoracic Surgery, Bristol Heart Institute, Bristol, UK
| | | | - Mostafa M Mokhles
- Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mark Turner
- Department of Cardiology, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - John Pepper
- Surgery, Royal Brompton Hospital, London, UK
| | - Noreen Hopewell-Kelly
- Health and Social Sciences, University of the West of England-Frenchay Campus, Bristol, UK
| | | | - Samer A M Nashef
- Cardiac Surgery, Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | | | | | | | | | - Elaine Tseng
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Bart Meuris
- Cardiac Surgery, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Marta Sitges
- Cardiology, Hospital Clinic de Barcelona, Barcelona, Spain
| | | | - Markus Krane
- Yale School of Medicine, New Haven, Connecticut, USA
| | - Martin Kostolny
- Cardiothoracic Unit, Great Ormond Street Hospital and Institute of Cardiovascular Science, University College London, London, UK
| | - Maria Pufulete
- Bristol Heart Institute, Bristol Medical School, University of Bristol, Bristol, UK
| |
Collapse
|
18
|
Abstract
The clinical outcome of severe aortic regurgitation (AR) remains suboptimal, but surgery has been shown to have survival benefit over medical therapy. Postoperative survival is inferior in patients with reduced left ventricular function, and therefore early surgical intervention is recommended. Aortic valvuloplasty (AVP) is an attractive option to avoid the major drawbacks of prosthetic valves but has not been widely adopted. The etiology of AR is classified functionally into three groups: normal leaflet motion (type I), cusp prolapse (type II), and restriction (type III). Type I with dilatation of the sinus of Valsalva (type Ib) can be repaired by aortic valve reimplantation or aortic root remodeling with similar valve stability. Type I with dilatation of the aortic annulus (type Ic) can be managed by annuloplasty. Type II can be corrected by plication or resuspension techniques. Pericardial patch is necessary in AVP for type Id (perforation/fenestration) and type III but is associated with risk of recurrence. Bicuspid aortic valve is classified according to commissure angle: symmetrical, asymmetrical, and very asymmetrical. Tricuspidization is recommended for repair of very asymmetrical valves to avoid postoperative stenosis. Recent progress has achieved similar reoperation rates between bicuspid and tricuspid aortic valve repair. For Marfan syndrome, valve-sparing root replacement is advantageous compared to Bentall operation regarding late survival, thromboembolic and hemorrhagic events, and endocarditis. Similar findings have been reported in acute aortic dissection. Both remodeling and reimplantation procedures provide similar favorable outcomes in these settings. Recent advances in AVP are summarized by quantitative assessment of cusp configuration (effective height and geometric height), graft size decision, use of template to cut the graft, and videoscopic assessment of post-repair cusp configuration. Due to these advances, AVP shows superior results to replacement surgery. Further concrete evidence with larger case volumes and longer observation periods are necessary to popularize AVP.
Collapse
|
19
|
Fujita B, Ensminger S. In-vitro Evaluierung der Neokuspidalisierung nach Ozaki. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2023. [DOI: 10.1007/s00398-022-00553-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
|
20
|
Yokoyama Y, Kuno T, Toyoda N, Fujisaki T, Takagi H, Itagaki S, Ibrahim M, Ouzounian M, El‐Hamamsy I, Fukuhara S. Ross Procedure Versus Mechanical Versus Bioprosthetic Aortic Valve Replacement: A Network Meta-Analysis. J Am Heart Assoc 2022; 12:e8066. [PMID: 36565200 PMCID: PMC9973571 DOI: 10.1161/jaha.122.027715] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background The Ross operation appears to restore normal survival in young and middle-aged adults with aortic valve disease. However, there are limited data comparing it with conventional aortic valve replacement. Herein, we compared outcomes of the Ross procedure with mechanical and bioprosthetic aortic valve replacement (M-AVR and B-AVR, respectively). Methods and Results MEDLINE and EMBASE were searched through March 2022 to identify randomized controlled trials and propensity score-matched studies that investigated outcomes of patients aged ≥16 years undergoing the Ross procedure, M-AVR, or B-AVR. The systematic literature search identified 2 randomized controlled trials and 8 propensity score-matched studies involving a total of 4812 patients (Ross: n=1991; M-AVR: n=2019; and B-AVR: n=802). All-cause mortality was significantly lower in the Ross procedure group compared with M-AVR (hazard ratio [HR] [95% CI], 0.58 [0.35-0.97]; P=0.035) and B-AVR (HR [95% CI], 0.32 [0.18-0.59]; P<0.001) groups. The reintervention rate was lower after the Ross procedure and M-AVR compared with B-AVR, whereas it was higher after the Ross procedure compared with M-AVR. Major bleeding rate was lower after the Ross procedure compared with M-AVR. Long-term stroke rate was lower following the Ross procedure compared with M-AVR and B-AVR. The rate of endocarditis was also lower after the Ross procedure compared with B-AVR. Conclusions Improved long-term outcomes of the Ross procedure are demonstrated compared with conventional M-AVR and B-AVR options. These results highlight a need to enhance the recognition of the Ross procedure and revisit current guidelines on the optimal valve substitute for young and middle-aged patients.
Collapse
Affiliation(s)
- Yujiro Yokoyama
- Department of SurgerySt. Luke’s University Health NetworkBethlehemPA
| | - Toshiki Kuno
- Department of Cardiology, Montefiore Medical CenterAlbert Einstein College of MedicineNew YorkNY
| | - Nana Toyoda
- Department of Cardiovascular SurgeryIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Tomohiro Fujisaki
- Department of MedicineIcahn School of Medicine at Mount Sinai, Mount Sinai Morningside and WestNew YorkNY
| | - Hisato Takagi
- Department of Cardiovascular SurgeryShizuoka Medical CenterShizuokaJapan
| | - Shinobu Itagaki
- Department of Cardiovascular SurgeryIcahn School of Medicine at Mount SinaiNew YorkNY
| | - Michael Ibrahim
- Division of Cardiovascular SurgeryHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Maral Ouzounian
- Division of Cardiovascular SurgeryPeter Munk Cardiac Centre, Toronto General Hospital and the University of Toronto, TorontoOntarioCanada
| | - Ismail El‐Hamamsy
- Department of Cardiovascular SurgeryIcahn School of Medicine at Mount SinaiNew YorkNY
| | | |
Collapse
|
21
|
Saisho H, Scharfschwerdt M, Schaller T, Sadat N, Aboud A, Ensminger S, Fujita B. Ex vivo evaluation of the Ozaki procedure in comparison with the native aortic valve and prosthetic valves. Interact Cardiovasc Thorac Surg 2022; 35:6650697. [PMID: 35895002 PMCID: PMC9443990 DOI: 10.1093/icvts/ivac199] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 07/14/2022] [Accepted: 07/26/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Hiroyuki Saisho
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig Holstein , Lübeck, Germany
- University of Lübeck , Lübeck, Germany
| | - Michael Scharfschwerdt
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig Holstein , Lübeck, Germany
- University of Lübeck , Lübeck, Germany
| | - Tim Schaller
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig Holstein , Lübeck, Germany
- University of Lübeck , Lübeck, Germany
| | - Najla Sadat
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig Holstein , Lübeck, Germany
- University of Lübeck , Lübeck, Germany
- DZHK (German Centre for Cardiovascular Research—Partner Site Hamburg/Kiel/Lübeck) , Germany
| | - Anas Aboud
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig Holstein , Lübeck, Germany
- University of Lübeck , Lübeck, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig Holstein , Lübeck, Germany
- University of Lübeck , Lübeck, Germany
- DZHK (German Centre for Cardiovascular Research—Partner Site Hamburg/Kiel/Lübeck) , Germany
| | - Buntaro Fujita
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig Holstein , Lübeck, Germany
- University of Lübeck , Lübeck, Germany
- DZHK (German Centre for Cardiovascular Research—Partner Site Hamburg/Kiel/Lübeck) , Germany
| |
Collapse
|
22
|
Li S, Zhang Y. Do Oral Factor Xa Inhibitors have a Role in Patients with Mechanical Heart Valves? Am J Cardiovasc Drugs 2022; 22:595-600. [DOI: 10.1007/s40256-022-00544-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/30/2022] [Indexed: 11/01/2022]
|
23
|
Dalén M, Persson M, Glaser N, Sartipy U. Socioeconomic Status and Risk of Bleeding After Mechanical Aortic Valve Replacement. J Am Coll Cardiol 2022; 79:2502-2513. [PMID: 35738711 DOI: 10.1016/j.jacc.2022.04.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 03/08/2022] [Accepted: 04/01/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Whether low socioeconomic status (SES) is associated with increased risk of anticoagulation-related adverse events in patients with mechanical heart valves is unknown. OBJECTIVES This study sought to investigate the impact of patients' SES on the risk of bleeding after mechanical aortic valve replacement (AVR). METHODS This nationwide population-based cohort study included all patients aged 18-70 years who underwent mechanical AVR in Sweden from 1997 to 2018. Data were obtained from the SWEDEHEART register and other national health data registers. The exposure was quartiles of household disposable income. The primary outcome was hospitalization for a bleeding event. RESULTS Among 5974 patients, the absolute risk for bleeding after 20 years of follow-up was 20% (95% CI: 17%-24%) in the lowest income quartile (Q1) and 16% (95% CI: 13%-20%) in the highest quartile (Q4). The risk of bleeding decreased with increasing income level and was significantly lower in patients in income level Q3 (HR: 0.77; 95% CI: 0.60-0.99) and Q4 (HR: 0.68; 95% CI: 0.50-0.92) than Q1. The risk of death from intracranial hemorrhage was five times higher in the lowest income quartile than the age- and sex-matched general Swedish population (standardized mortality ratio: 5.0; 95% CI: 3.3-7.4). CONCLUSIONS We observed a strong association between SES and risk of bleeding among patients who underwent mechanical AVR. These findings suggest suboptimal anticoagulation treatment in patients with lower SES and the need for strategies to optimize anticoagulation treatment in patients with a mechanical heart valve. (Health-Data Register Studies of Risk and Outcomes in Cardiac Surgery [HARTROCS]; NCT02276950).
Collapse
Affiliation(s)
- Magnus Dalén
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.
| | - Michael Persson
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Natalie Glaser
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Stockholm South General Hospital, Stockholm, Sweden
| | - Ulrik Sartipy
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden; Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
24
|
Lansac E, Di Centa I, Danial P, Bouchot O, Arnaud Crozat E, Hacini R, Doguet F, Demaria R, Verhoye JP, Jouan J, Chatel D, Lopez S, Folliguet T, Leprince P, Langanay T, Latremouille C, Fayad G, Fleury JP, Monin JL, Mankoubi L, Noghin M, Berrebi A, Pousset S, Laubriet-Jazayeri A, Lafourcade A, Marcault E, Kindo M, Payot L, Bergoend E, Jourdain Hoffart C, Debauchez M, Tubach F. Aortic valve repair versus mechanical valve replacement for root aneurysm: The CAVIAAR Multicentric Study. Eur J Cardiothorac Surg 2022; 62:6588078. [PMID: 35583290 DOI: 10.1093/ejcts/ezac283] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 04/11/2022] [Accepted: 05/16/2022] [Indexed: 11/14/2022] Open
Abstract
AIMS Despite growing evidence that aortic valve repair improves long-term patient outcomes and quality of life, aortic valves are mostly replaced. We evaluate the effect of aortic valve repair versus replacement in patients with dystrophic aortic root aneurysm up to 4 years. METHODS The multicentric CAVIAAR prospective cohort study enrolled 261 patients: 130 underwent standardized aortic valve repair (REPAIR) consisting of remodelling root repair with expansible aortic ring annuloplasty, and 131 received mechanical composite valve and graft replacement (REPLACE). Primary outcome was a composite criterion of mortality, reoperation, thromboembolic or major bleeding events, endocarditis or operating site infections, pacemaker implantation and heart failure, analyzed with propensity score-weighted Cox model analysis. Secondary outcomes included Major Adverse Valve Related Events (MAVRE) and components of primary outcome. RESULTS Mean age was 56.1 years, valve was bicuspid in 115 patients (44.7%). Up to 4 years, REPAIR did not significantly differ from REPLACE in terms of primary outcome (HR 0.66 [0.39; 1.12]), but showed significantly less valve-related deaths (HR 0.09 [0.02; 0.34]) and major bleeding events (HR 0.37 [0.16; 0.85]) without an increased risk of valve-related reoperation (HR 2.10 [0.64; 6.96]). When accounting for occurrence of multiple events in a single patient, REPAIR group had half the occurrence of MAVRE (RR 0.51 [0.31; 0.86]). CONCLUSION Although primary outcome did not significantly differ between REPAIR and REPLACE group, the trend is in favour of REPAIR by a significant reduction of valve-related deaths and major bleeding events. Long-term follow-up beyond 4 years is needed to confirm these findings.
Collapse
Affiliation(s)
- Emmanuel Lansac
- Department of Cardiac Surgery, CHU Pitié Salpetriere, Paris, France
| | | | - Pichoy Danial
- Department of Cardiac Surgery, CHU Pitié Salpetriere, Paris, France
| | | | | | - Rachid Hacini
- Department of Cardiac Surgery, CHU A. Michallon, La Tronche, France
| | - Fabien Doguet
- Department of Cardiac Surgery, C.H.U Charles Nicolle, Rouen, France
| | - Roland Demaria
- Department of Cardiac Surgery, CHU A. De Villeneuve, Montpellier, France
| | | | - Jerome Jouan
- Department of Cardiac Surgery, CHU Limoges, France
| | - Didier Chatel
- Department of Cardiac Surgery, Clinique Saint Gatien, Tours, France
| | - Stephane Lopez
- Department of Cardiac Surgery, Institut Arnault Tzanck, Saint Laurent Du Var, France
| | | | - Pascal Leprince
- Department of Cardiac Surgery, CHU Pitié Salpetriere, Paris, France
| | | | | | - Georges Fayad
- Department of Cardiac Surgery, Centre Hospitalier Régional Universitaire de Lille, Lille, France
| | | | - Jean Luc Monin
- Department of Cardiac Surgery, Institut Mutualiste Montouris, Paris, France
| | - Leila Mankoubi
- Department of Cardiac Surgery, Institut Mutualiste Montouris, Paris, France
| | - Milena Noghin
- Department of Cardiac Surgery, Institut Mutualiste Montouris, Paris, France
| | - Alain Berrebi
- Department of Cardiac Surgery, Institut Mutualiste Montouris, Paris, France
| | - Sarah Pousset
- Department of Cardiac Surgery, Institut Mutualiste Montouris, Paris, France
| | | | - Alexandre Lafourcade
- AP-HP.Sorbonne Université, Hôpital Pitié Salpêtrière, Centre de Pharmacoépidémiologie (Cephepi), INSERM, CIC-1422, F75013, Paris, France
| | - Estelle Marcault
- APHP, Hôpital Bichat, Département d'Epidémiologie et Recherche Clinique, F-75018 Paris INSERM CIC-EC 1425, F-75018, Paris
| | - Michel Kindo
- Department of Cardiac Surgery, CHU de Strasbourg, Strasbourg, France
| | - Laurent Payot
- Cardiology, Saint Brieuc Hospital, Saint Brieuc, France
| | - Eric Bergoend
- Department of Cardiac Surgery, CHU Mondor, Créteil, France
| | - Cecile Jourdain Hoffart
- APHP, Département de la Recherche Clinique et du Développement (DRCD) Groupement Interrégional de Recherche Clinique et d'Innovation-GIRCI Ile-de-France Hôpital Saint Louis
| | | | - Florence Tubach
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP.Sorbonne Université, Hôpital Pitié Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), CIC-1422, F75013, Paris, France
| |
Collapse
|
25
|
Turner E, Piccinini F. Tratamiento moderno de la estenosis aórtica: reemplazo valvular aórtico 2022. REVISTA MÉDICA CLÍNICA LAS CONDES 2022. [DOI: 10.1016/j.rmclc.2022.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
|
26
|
Wang Z, Dasi LP, Hatoum H. Controlling the Flow Separation in Heart Valves Using Vortex Generators. Ann Biomed Eng 2022; 50:914-928. [PMID: 35415767 DOI: 10.1007/s10439-022-02966-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 04/06/2022] [Indexed: 11/25/2022]
Abstract
A comprehensive computational study is performed to investigate the effectiveness of vortex generators (VGs) applied to mechanical bi-leaflet heart valves. Co-rotating and counter-rotating VG configurations are compared to a control valve without VGs. Detailed flow fields are obtained and used to elucidate the underlying flow physics. It was found that VGs reduce flow separation over the leaflets and hence reduce the Reynolds shear stress (RSS) in the vicinity regions of heart valve. The co-rotating VG configuration demonstrates a better performance compared with the counter-rotating configuration in terms of the RSS, turbulent kinetic energy production and velocity distributions, especially in the peripheral jet flows. The fraction of blood damage in the co-rotating configuration shows a 4.7% reduction in comparison to the control case, while a 3.7% increase is observed in the counter-rotating configuration. The passive flow control technique of applying co-rotating VG illustrates a great potential to help mitigate the hemodynamic factors leading to potential blood damage risk.
Collapse
Affiliation(s)
- Zhenyu Wang
- Simulation Innovation and Modeling Center (SIMCenter), The Ohio State University, Columbus, OH, USA.,Department of Mechanical and Aerospace Engineering, The Ohio State University, Columbus, OH, USA
| | - Lakshmi Prasad Dasi
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Hoda Hatoum
- Department of Biomedical Engineering, Michigan Technological University, Houghton, MI, USA. .,Health Research Institute, Center of Biocomputing and Digital Health and Institute of Computing and Cybernetics, Michigan Technological University, Houghton, MI, USA.
| |
Collapse
|
27
|
Galian-Gay L, Evangelista A. Menor supervivencia de los jóvenes con estenosis aórtica tras el recambio valvular. Rev Esp Cardiol 2022. [DOI: 10.1016/j.recesp.2021.09.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
|
28
|
Galian-Gay L, Evangelista A. Reduced survival of young people with aortic stenosis after valve replacement. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2022; 75:286-287. [PMID: 34893455 DOI: 10.1016/j.rec.2021.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 09/28/2021] [Indexed: 06/14/2023]
Affiliation(s)
- Laura Galian-Gay
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Artur Evangelista
- Servicio de Cardiología, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| |
Collapse
|
29
|
Gofus J, Fila P, Drabkova S, Zacek P, Ondrasek J, Nemec P, Sterba J, Tuna M, Jarkovsky J, Vojacek J. Ross procedure provides survival benefit over mechanical valve in adults: a propensity-matched nationwide analysis. Eur J Cardiothorac Surg 2022; 61:1357-1365. [PMID: 35150238 DOI: 10.1093/ejcts/ezac013] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 11/15/2021] [Accepted: 01/05/2022] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES The choice of optimal surgical treatment for young and middle-aged adults with aortic valve disease remains a challenge. Mechanical aortic valve replacement (mAVR) is generally preferred despite promising recent outcomes of the Ross procedure. Our goal was to compare the strategies at a nationwide level. METHODS This study was a retrospective analysis of prospectively recorded data from the National Registry of Cardiac Surgery of the Czech Republic. Using propensity score matching, we compared the outcomes of patients undergoing the Ross procedure in 2 dedicated centres with all mAVRs performed in country between 2009 and 2020. RESULTS Throughout the study period, 296 adults underwent the Ross procedure and 5120 had an mAVR. We found and compared 291 matched pairs. There were no in-hospital deaths, and the risk of perioperative complications was similar in both groups. Over the average follow-up period of 4.1 vs 6.1 years, the Ross group had a lower all-cause mortality (0.7 vs 6.5%; P = 0.015). This result remained significant even when accounting for cardiac- and valve-related deaths only (P = 0.048). Unlike the Ross group, the mAVR group had a significantly lower relative survival compared with the age- and sex-matched general population. There was no difference in the risk of reoperation (4.5 vs 5.5%; P = 0.66). CONCLUSIONS The Ross procedure offers a significant midterm survival benefit over mAVR. The procedures have a comparable risk of perioperative complications. Patients after mAVR have reduced survival. Thus, the Ross procedure should be the preferred treatment option for young and middle-aged adults with aortic valve disease in dedicated centres.
Collapse
Affiliation(s)
- Jan Gofus
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Petr Fila
- Department of Cardiac Surgery, Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Svetlana Drabkova
- Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Pavel Zacek
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jiri Ondrasek
- Department of Cardiac Surgery, Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Petr Nemec
- Department of Cardiac Surgery, Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Jan Sterba
- Department of Cardiac Surgery, Centre of Cardiovascular Surgery and Transplantation, Brno, Czech Republic
| | - Martin Tuna
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Jiri Jarkovsky
- Institute of Health Information and Statistics of the Czech Republic, Prague, Czech Republic
| | - Jan Vojacek
- Department of Cardiac Surgery, Charles University, Faculty of Medicine and University Hospital in Hradec Kralove, Hradec Kralove, Czech Republic
| |
Collapse
|
30
|
Van Hoof L, Truyers I, Van Hauwermeiren H, Nachtergaele B, Langenaeken T, Jacquemin M, Rega F, Verhamme P, Meuris B. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6543570. [PMID: 35253872 PMCID: PMC9297512 DOI: 10.1093/icvts/ivac070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/21/2022] [Accepted: 02/23/2022] [Indexed: 11/20/2022] Open
Affiliation(s)
- Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | | | | | - Tom Langenaeken
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Marc Jacquemin
- Department of Hemostasis in Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Vascular Medicine and Hemostasis, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meuris
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
- Corresponding author. Department of Cardiac Surgery, University Hospitals Leuven, Herestraat 49, Leuven 3000, Belgium. Tel: +32-16-344260; fax: +32-16-344616; e-mail: (B. Meuris)
| |
Collapse
|
31
|
OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6570590. [DOI: 10.1093/ejcts/ezac263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 03/29/2022] [Accepted: 04/14/2022] [Indexed: 11/13/2022] Open
|
32
|
Surgical Aortic Valve Replacement-Age-Dependent Choice of Prosthesis Type. J Clin Med 2021; 10:jcm10235554. [PMID: 34884256 PMCID: PMC8658378 DOI: 10.3390/jcm10235554] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/23/2021] [Accepted: 11/24/2021] [Indexed: 11/26/2022] Open
Abstract
Background: Recently, the use of surgically implanted aortic bioprostheses has been favoured in younger patients. We aimed to analyse the long-term survival and postoperative MACCE (Major Adverse Cardiovascular and Cerebral Event) rates in patients after isolated aortic valve replacement. Methods: We conducted a single-centre observational retrospective study, including all consecutive patients with isolated aortic valve replacement. 1:1 propensity score matching of the preoperative baseline characteristics was performed. Results: A total of 2172 patients were enrolled in the study. After propensity score matching the study included 428 patients: 214 biological vs. 214 mechanical prostheses, divided into two subgroups: group A < 60 years and group B > 60 years. The mean follow-up time was 7.6 ± 3.9 years. Estimated survival was 97 ± 1.9% and 89 ± 3.4% at 10 years for biological and mechanical prosthesis, respectively in group A (p = 0.06). In group B the survival at 10 years was 79.1 ± 5.8% and 69.8 ± 4.4% for biological and mechanical prosthesis, respectively (p = 0.83). In group A, patients with a bioprosthesis exhibited a tendency for higher cumulative incidence MACCE rates compared to patients with a mechanical prosthesis, p = 0.83 (bio 7.3 ± 5.3% vs. mech 4.6 ± 2.2% at 10 years). In group B, patients with a mechanical prosthesis showed a tendency for higher cumulative incidence MACCE rates compared to patients with bioprosthesis, p = 0.86 (bio 4.3 ± 3.1% vs. mech 9.1 ± 3.1% at 10 years). Conclusions: Long-term survival after surgical aortic valve replacement is similar in patients with a biological and mechanical prosthesis, independent of the patients’ age. Moreover, younger patients (<60 years) with bioprosthesis showed a survival benefit, compared to patients with mechanical prosthesis in this age group.
Collapse
|
33
|
Dalén M, Persson M, Glaser N, Sartipy U. Permanent pacemaker implantation after On-X surgical aortic valve replacement: SWEDEHEART observational study. BMJ Open 2021; 11:e047962. [PMID: 34794986 PMCID: PMC8603281 DOI: 10.1136/bmjopen-2020-047962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Bioprosthetic aortic valves with an extended subannular component, such as transcatheter valves, exert increased compression on the cardiac conduction system and increase the risk for permanent pacemaker implantation. It is unknown if the On-X mechanical prosthetic valve, which has an elongated subannular valve housing, increases the risk of permanent pacemaker implantation following aortic valve replacement. DESIGN Observational nationwide cohort study. SETTING Swedish population-based study. PARTICIPANTS All patients aged 18-65 years who underwent primary mechanical aortic valve replacement in Sweden between 2005 and 2018. We used the Swedish Web system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies register and other Swedish national health-data registers. EXPOSURE Patients implanted with an On-X valve versus patients implanted with other bileaflet mechanical valves. PRIMARY AND SECONDARY OUTCOME MEASURES Primary outcome measure was permanent pacemaker implantation within 30 days of surgery. RESULTS A total of 2602 patients were included, and 581 patients received an On-X valve and 2021 patients received a St Jude Masters/Regent (n=945) or Carbomedics Reduced valve (n=1076). In the total study population, 115 (4.4%) permanent pacemaker implantations were performed within 30 days after aortic valve replacement. In the propensity score matched population, there was no significant difference in the rate of permanent pacemaker implantation in the On-X group compared with the control group: 3.6% (95% CI: 2.4% to 5.5%) vs 4.0% (95% CI: 2.7% to 5.9%), p=0.877. CONCLUSIONS The On-X prosthetic heart valve was associated with a similarly low risk for permanent pacemaker implantation after aortic valve replacement compared with other conventional bileaflet mechanical valves. The On-X elongated subannular valve housing does not interfere with the cardiac conduction system.
Collapse
Affiliation(s)
- Magnus Dalén
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Michael Persson
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Natalie Glaser
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Stockholm South General Hospital, Stockholm, Sweden
| | - Ulrik Sartipy
- Department of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
34
|
Whitlock R, Belley-Cote E, Rega F, Chu MWA, McClure GR, Hronyecz H, Verbrugghe P, Devereaux PJ, Bangdiwala S, Eikelboom J, Brady K, Sharifulin R, Bogachev-Prokophiev A, Stoica S. Ross for Valve replacement In AduLts (REVIVAL) pilot trial: rationale and design of a randomised controlled trial. BMJ Open 2021; 11:e046198. [PMID: 34531204 PMCID: PMC8449981 DOI: 10.1136/bmjopen-2020-046198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION In non-elderly adults, aortic valve replacement (AVR) with conventional prostheses yield poor long-term outcomes. Recent publications suggest a benefit of the Ross procedure over conventional AVR and highlight the need for high-quality randomised controlled trial (RCTs) on the optimal AVR. We have initiated a pilot trial assess two feasibility criteria and one assumption: (1) evaluate the capacity to enrol six patients per centre per year in at least five international centre, (2) validate greater than 90% compliance with allocation and (3) to validate the proportion of mechanical (≥65%) vs biological (≤35%) valves in the conventional arm. METHODS AND ANALYSIS Ross for Valve replacement In AduLts (REVIVAL) is a multinational, expertise-based RCT in adults aged 18-60 years undergoing AVR, comparing the Ross procedure versus one of the alternative approaches (mechanical vs stented or stentless bioprosthesis). The feasibility objectives will be assessed after randomising 60 patients; we will then make a decision regarding whether to expand the trial with the current protocol. We will ultimately examine the impact of the Ross procedure as compared with conventional AVR in non-elderly adults on survival free of valve-related life-threatening complications (major bleeding, systemic thromboembolism, valve thrombosis and valve reoperation) over the duration of follow-up. The objectives of the pilot trial will be analysed using descriptive statistics. In the full trial, the intention-to-treat principle will guide all primary analyses. A time-to-event analysis will be performed and Kaplan-Meier survival curves with comparison between groups using a log rank test will be presented. ETHICS AND DISSEMINATION REVIVAL will answer whether non-elderly adults benefit from the Ross procedure over conventional valve replacement. The final results at major meetings, journals, regional seminars, hospital rounds and via the Reducing Global Perioperative Risk Multimedia Resource Centre. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT03798782 PROTOCOL VERSION: January 29, 2019 (Final Version 1.0).
Collapse
Affiliation(s)
- Richard Whitlock
- Surgery, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Emilie Belley-Cote
- Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Filip Rega
- Department of Cardiac Surgery, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Michael W A Chu
- Cardiac Surgery, University of Western Ontario Faculty of Health Sciences, London, Ontario, Canada
| | - Graham R McClure
- Surgery, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | | | - Peter Verbrugghe
- Department of Cardiac Surgery, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - P J Devereaux
- Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | | | - John Eikelboom
- Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Katheryn Brady
- Population Health Research Institute, Hamilton, Ontario, Canada
| | - Ravil Sharifulin
- FSBI National Medical Research Center named after E N Meshalkin, Novosibirsk, Novosibirskaâ, Russian Federation
| | | | - Serban Stoica
- Cardiac Surgery, Bristol Royal Hospital for Children, Bristol, UK
| |
Collapse
|
35
|
Flynn CD, De Bono JH, Muston B, Rattan N, Tian DH, Larobina M, O'Keefe M, Skillington P. Systematic review and meta-analysis of long-term outcomes in adults undergoing the Ross procedure. Ann Cardiothorac Surg 2021; 10:411-419. [PMID: 34422553 DOI: 10.21037/acs-2021-rp-30] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 06/18/2021] [Indexed: 12/15/2022]
Abstract
Background The management of aortic valve disease is becoming increasingly complicated with the evolution of treatment options available to cardiac surgeons and cardiologist. Pulmonary autograft replacement of the aortic valve, commonly known as the Ross procedure, involves excision of the pulmonary valve from the right ventricular outflow tract and implantation in the aortic position. This systematic review aims to evaluate the long-term outcomes, following the Ross procedure. Methods An electronic search strategy queried five online medical referencing databases from inception to 21 August 2020. All studies detailing the long-term outcomes of adults undergoing the Ross procedure were included. A random effects model was used to determine pooled continuous data. Enhanced secondary survival analysis was performed on reconstructed individual patient data. Results Twenty-three studies were included in the qualitative synthesis, including a total of 6,278 patients with a mean follow-up duration of 6.0±2.8 years. Long-term survival was 95.6%, 91.8%, 86.3% and 80.5% at five, ten, fifteen and twenty years, respectively. Freedom from autograft reoperation was 95.7%, 91.2%, 84.9% and 76.1% at five, ten, fifteen and twenty years, respectively. Conclusions When performed in experienced centres and for appropriately selected patients, the Ross procedure represents a durable replacement of the aortic valve with excellent long-term survival.
Collapse
Affiliation(s)
- Campbell D Flynn
- Department of Cardiothoracic Surgery, Epworth Hospital, Richmond, Victoria, Australia
| | - Joshua H De Bono
- Department of Cardiothoracic Surgery, Epworth Hospital, Richmond, Victoria, Australia
| | - Benjamin Muston
- Collaborative Research Group, Sydney, Australia.,Faculty of Medicine, University of New South Wales, Sydney, Australia
| | | | - David H Tian
- Department of Anaesthesia and Perioperative Medicine, Westmead Hospital, Sydney, Australia
| | - Marco Larobina
- Department of Cardiothoracic Surgery, Epworth Hospital, Richmond, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery and Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Michael O'Keefe
- Department of Cardiothoracic Surgery, Epworth Hospital, Richmond, Victoria, Australia.,Department of Cardiothoracic Surgery and Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Peter Skillington
- Department of Cardiothoracic Surgery, Epworth Hospital, Richmond, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia.,Department of Cardiothoracic Surgery and Cardiology, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| |
Collapse
|
36
|
Hage A, Hage F, Valdis M, Guo L, Chu MWA. The Ross procedure is the optimal solution for young adults with unrepairable aortic valve disease. Ann Cardiothorac Surg 2021; 10:454-462. [PMID: 34422557 DOI: 10.21037/acs-2021-rp-26] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/05/2021] [Indexed: 11/06/2022]
Abstract
While aortic valve repair remains the ideal intervention to restore normal valvular function, the optimal aortic valve substitute for patients with a non-repairable aortic valve remains an ongoing subject for debate. In particular, younger patients with a non-repairable valve represent a unique challenge because of their active lifestyle and long life expectancy, which carries a higher cumulative risk of prosthesis-related complications. The Ross procedure, unlike prosthetic or homograft aortic valve replacement (AVR), provides an expected survival equivalent to that of the age and gender-matched general population. Contemporary data has shown that the Ross procedure can be performed safely in centers with expertise, and is associated with improved valvular durability, hemodynamics and quality of life.
Collapse
Affiliation(s)
- Ali Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Fadi Hage
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Matthew Valdis
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Linrui Guo
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| | - Michael W A Chu
- Division of Cardiac Surgery, Department of Surgery, Western University, London Health Sciences Centre, London, ON, Canada
| |
Collapse
|
37
|
Verstraete A, Herregods MC, Verbrugghe P, Lamberigts M, Vanassche T, Meyns B, Oosterlinck W, Rega F, Adriaenssens T, Van Hoof L, Keuleers S, Vandenbriele C, Sinnaeve P, Janssens S, Dubois C, Meuris B, Verhamme P. Antithrombotic Treatment After Surgical and Transcatheter Heart Valve Repair and Replacement. Front Cardiovasc Med 2021; 8:702780. [PMID: 34422930 PMCID: PMC8375148 DOI: 10.3389/fcvm.2021.702780] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Accepted: 07/05/2021] [Indexed: 12/14/2022] Open
Abstract
New antithrombotic drugs have been developed, new valve types have been designed and minimally invasive transcatheter techniques have emerged, making the choice of antithrombotic therapy after surgical or transcatheter heart valve repair and replacement increasingly complex. Moreover, due to a lack of large randomized controlled trials many recommendations for antithrombotic therapy are based on expert opinion, reflected by divergent recommendations in current guidelines. Therefore, decision-making in clinical practice regarding antithrombotic therapy for prosthetic heart valves is difficult, potentially resulting in sub-optimal patient treatment. This article compares the 2017 ESC/EACTS and 2020 ACC/AHA guidelines on the management of valvular heart disease and summarizes the available evidence. Finally, we established a convenient consensus on antithrombotic therapy after valve interventions based on over 800 annual cases of surgical and transcatheter heart valve repair and replacement and a multidisciplinary team discussion between the department of cardiovascular diseases and cardiac surgery of the University Hospitals Leuven, Belgium.
Collapse
Affiliation(s)
- Andreas Verstraete
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | | | - Peter Verbrugghe
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Marie Lamberigts
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Thomas Vanassche
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Wouter Oosterlinck
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tom Adriaenssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Lucas Van Hoof
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Siegmund Keuleers
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | | | - Peter Sinnaeve
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Stefan Janssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Christophe Dubois
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Bart Meuris
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Peter Verhamme
- Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
38
|
Van Hoof L, Rega F, Golesworthy T, Verbrugghe P, Austin C, Takkenberg JJM, Pepper JR, Treasure T. Personalised external aortic root support for elective treatment of aortic root dilation in 200 patients. Heart 2021; 107:1790-1795. [PMID: 34326135 DOI: 10.1136/heartjnl-2021-319300] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 07/05/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES In personalised external aortic root support (PEARS), a custom-made, macroporous mesh is used to stabilise a dilated aortic root and prevent dissection, primarily in patients with genetically driven aortopathies. Data are needed on the safety and postoperative incidence of aortic events. METHODS We present a multicentre cohort study evaluating the first 200 consecutive patients (median age 33 years) undergoing surgery with an intention to perform PEARS for aortic root dilatation in 23 centres between 2004 and 2019. Perioperative outcomes were collected prospectively while clinical follow-up was retrieved retrospectively. Median follow-up was 21.2 months. RESULTS The main indication was Marfan syndrome (73.5%) and the most frequent concomitant procedure was mitral valve repair (10%). An intervention for myocardial ischaemia or coronary injury was needed in 11 patients, 1 case resulting in perioperative death. No ascending aortic dissections were observed in 596 documented postoperative patient years. Late reoperation was performed in 3 patients for operator failure to achieve complete mesh coverage. Among patients with at least mild aortic regurgitation (AR) preoperatively, 68% had no or trivial AR at follow-up. CONCLUSIONS This study represents the clinical history of the first 200 patients to undergo PEARS. To date, aortic dissection has not been observed in the restrained part of the aorta, yet long-term follow-up is needed to confirm the potential of PEARS to prevent dissection. While operative mortality is low, the reported coronary complications reflect the learning curve of aortic root surgery in patients with connective tissue disease. PEARS may stabilise or reduce aortic regurgitation.
Collapse
Affiliation(s)
- Lucas Van Hoof
- Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Filip Rega
- Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | | | | | - Conal Austin
- Department of Paediatric Cardiology and Cardiothoracic Surgery, St Thomas' Hospital, London, UK
| | - Johanna J M Takkenberg
- Department of Cardio-Thoracic Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
| | - John R Pepper
- Cardiothoracic Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Tom Treasure
- Clinical Operational Research Unit, University College London, London, UK
| |
Collapse
|
39
|
Horke A, Tudorache I, Laufer G, Andreas M, Pomar JL, Pereda D, Quintana E, Sitges M, Meyns B, Rega F, Hazekamp M, Hübler M, Schmiady M, Pepper J, Rosendahl U, Lichtenberg A, Akhyari P, Jashari R, Boethig D, Bobylev D, Avsar M, Cebotari S, Haverich A, Sarikouch S. Early results from a prospective, single-arm European trial on decellularized allografts for aortic valve replacement: the ARISE study and ARISE Registry data. Eur J Cardiothorac Surg 2021; 58:1045-1053. [PMID: 32386409 PMCID: PMC7577293 DOI: 10.1093/ejcts/ezaa100] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Revised: 02/20/2020] [Accepted: 02/24/2020] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES Decellularized aortic homografts (DAH) may provide an additional aortic valve replacement option for young patients due to their potential to overcome the high early failure rate of conventional allogenic and xenogenic aortic valve prostheses. METHODS A prospective, European Union-funded, single-arm, multicentre, safety study was conducted in 8 centres evaluating non-cryopreserved DAH for aortic valve replacement. RESULTS One hundred and forty-four patients (99 male) were prospectively enrolled between October 2015 and October 2018, mean age 33.6 ± 20.8 years; 45% had undergone previous cardiac operations. Mean implanted DAH diameter 22.6 ± 2.4 mm and mean durations for the operation, cardiopulmonary bypass and cross-clamp were 341 ± 140, 174 ± 80 and 126 ± 43 min, respectively. There were 2 early deaths (1 LCA thrombus on day 3 and 1 ventricular arrhythmia 5 h postop) and 1 late death due to endocarditis 4 months postoperatively, resulting in a total mortality of 2.08%. One pacemaker implantation was necessary and 1 DAH was successfully repaired after 6 weeks for early regurgitation following subcoronary implantation. All other DAH were implanted as a free-standing root. After a mean follow-up of 1.54 ± 0.81 years, the primary efficacy end points peak gradient (mean 11.8 ± 7.5 mmHg) and regurgitation (mean 0.42 ± 0.49, grade 0-3) were excellent. At 2.5 years, freedom from explantation/endocarditis/bleeding/stroke was 98.4 ± 1.1%/99.4 ± 0.6%/99.1 ± 0.9%/99.2 ± 0.8%, respectively, with results almost identical to those in an age-matched Ross operation cohort of 212 patients (mean age 34 years) despite DAH patients having undergone >2× more previous procedures. CONCLUSIONS The initial results of the prospective multicentre ARISE trial show DAH to be safe for aortic valve replacement with excellent haemodynamics in the short follow-up period.
Collapse
Affiliation(s)
- Alexander Horke
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Igor Tudorache
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Jose L Pomar
- Department of Cardiovascular Surgery, Hospital Clinico de Barcelona, Barcelona, Spain.,Department of Cardiology, Hospital Clinico de Barcelona, Barcelona, Spain
| | - Daniel Pereda
- Department of Cardiovascular Surgery, Hospital Clinico de Barcelona, Barcelona, Spain.,Department of Cardiology, Hospital Clinico de Barcelona, Barcelona, Spain
| | - Eduard Quintana
- Department of Cardiovascular Surgery, Hospital Clinico de Barcelona, Barcelona, Spain.,Department of Cardiology, Hospital Clinico de Barcelona, Barcelona, Spain
| | - Marta Sitges
- Department of Cardiovascular Surgery, Hospital Clinico de Barcelona, Barcelona, Spain.,Department of Cardiology, Hospital Clinico de Barcelona, Barcelona, Spain
| | - Bart Meyns
- Department of Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Mark Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Michael Hübler
- Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | - Martin Schmiady
- Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | - John Pepper
- Department of Cardiovascular Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - U Rosendahl
- Department of Cardiovascular Surgery, Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Artur Lichtenberg
- Department for Cardiovascular Surgery, Heinrich-Heine University, Düsseldorf, Germany
| | - Payam Akhyari
- Department for Cardiovascular Surgery, Heinrich-Heine University, Düsseldorf, Germany
| | - Ramadan Jashari
- European Homograft Bank, Clinique Saint-Jean, Brussels, Belgium
| | - Dietmar Boethig
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dmitry Bobylev
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Serghei Cebotari
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Samir Sarikouch
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| |
Collapse
|
40
|
Horke A, Bobylev D, Avsar M, Meyns B, Rega F, Hazekamp M, Huebler M, Schmiady M, Tzanavaros I, Cesnjevar R, Ciubotaru A, Laufer G, Zimpfer D, Jashari R, Boethig D, Cebotari S, Beerbaum P, Tudorache I, Haverich A, Sarikouch S. Paediatric aortic valve replacement using decellularized allografts. Eur J Cardiothorac Surg 2021; 58:817-824. [PMID: 32443152 PMCID: PMC7890932 DOI: 10.1093/ejcts/ezaa119] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Revised: 03/04/2020] [Accepted: 03/10/2020] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES Options for paediatric aortic valve replacement (AVR) are limited if valve repair is not feasible. Results of paediatric Ross procedures are inferior to adult Ross results, and mechanical AVR imposes constant anticoagulation with the inherent risks. METHODS The study design was a prospective, multicentre follow-up of all paediatric patients receiving decellularized aortic homografts (DAHs) for AVR in 8 European centres. RESULTS A total of 106 children (77 boys) were operated (mean age 10.1 ± 4.8 years, DAH diameter 20.5 ± 3.8 mm). A total of 60 (57%) had undergone previous surgical interventions: 34 with 1, 15 with 2 and 11 with ≥3. There was one early death in a 12-year-old girl, who underwent her fourth aortic valve operation, due to intracerebral haemorrhage on extracorporeal membrane oxygenation after coronary reimplantation problems following 3-sinus reconstruction 1 year earlier. One 2-year-old patient died due to sepsis 2 months postoperatively with no evidence for endocarditis. In addition, a single pacemaker implantation was necessary and a 2.5-year-old girl underwent successful HTx due to chronic myocardial failure despite an intact DAH. After a mean follow-up of 3.30 ± 2.45 years, primary efficacy end points mean peak gradient (18.1 ± 20.9 mmHg) and regurgitation (mean 0.61 ± 0.63, grade 0-3) were very good. Freedom from death/explantation/endocarditis/bleeding/stroke at 5 years was 97.8 ± 1.6/85.0 ± 7.4/100/100/100% respectively. Calculated expected adverse events were lower for DAH compared to cryopreserved homograft patients (mean age 8.9 years), lower than in Ross patients (9.4 years) and in the same range as mechanical AVR (12.8 years). CONCLUSIONS Even though the overall number of paediatric DAH patients and the follow-up time span are still limited, our data suggest that DAHs may present a promising additional option for paediatric AVR.
Collapse
Affiliation(s)
- Alexander Horke
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Dmitry Bobylev
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Murat Avsar
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Bart Meyns
- Department of Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Filip Rega
- Department of Cardiac Surgery, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Mark Hazekamp
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, Netherlands
| | - Michael Huebler
- Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | - Martin Schmiady
- Division of Congenital Cardiovascular Surgery, University Children's Hospital, Zurich, Switzerland
| | | | - Robert Cesnjevar
- Division of Pediatric Cardiac Surgery, University of Erlangen, Erlangen, Germany
| | - Anatol Ciubotaru
- Cardiac Surgery Center, State Medical and Pharmaceutical University, Chisinau, Moldova
| | - Günther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Ramadan Jashari
- European Homograft Bank, Clinique Saint-Jean, Brussels, Belgium
| | - Dietmar Boethig
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany.,Department for Pediatric Cardiology and Intensive Care, Hannover Medical School, Hannover, Germany
| | - Serghei Cebotari
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Philipp Beerbaum
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany.,Department for Pediatric Cardiology and Intensive Care, Hannover Medical School, Hannover, Germany
| | - Igor Tudorache
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Samir Sarikouch
- Department for Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| |
Collapse
|
41
|
Youssefi P, Pepper J. A new age of aortic valve repair. Eur J Cardiothorac Surg 2021; 60:1062-1063. [PMID: 34008012 DOI: 10.1093/ejcts/ezab258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Pouya Youssefi
- Department of Cardiac Surgery, Royal Brompton & Harefield Hospital, London, UK
| | - John Pepper
- National Heart & Lung Institute, Imperial College London, London, UK.,NIHR Imperial Biomedical Research Centre, London, UK
| |
Collapse
|
42
|
Romeo JLR, Papageorgiou G, da Costa FFD, Sievers HH, Bogers AJJC, El-Hamamsy I, Skillington PD, Wynne R, Mastrobuoni S, El Khoury G, Takkenberg JJM, Mokhles MM. Long-term Clinical and Echocardiographic Outcomes in Young and Middle-aged Adults Undergoing the Ross Procedure. JAMA Cardiol 2021; 6:539-548. [PMID: 33656518 DOI: 10.1001/jamacardio.2020.7434] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance There is no ideal valve substitute for young adults requiring aortic valve replacement. Multicenter data supporting use of the Ross procedure with respect to long-term postoperative valve-related mortality and reintervention, as well as function of the autograft and pulmonary homograft, are needed. Objective To determine the long-term clinical and echocardiographic outcomes in young and middle-aged patients undergoing the Ross procedure. Design, Setting, and Participants A retrospective multicenter international cohort study with a median follow-up period of 9.2 years was conducted in 5 experienced centers regularly performing the Ross procedure. Consecutive patients aged 18 to 65 years were included by each center between 1991 and 2018. Main Outcomes and Measures Survival and autograft-related and homograft-related reintervention. Serial echocardiographic measurements of valve function were analyzed using mixed-effects modeling. Results During the study period, 1431 patients (74.3% men; n = 1063) were operated on at a median age of 48.5 years (mean [SD], 47.7 [9.5]; range, 18.1-65; interquartile range, 42.7-54.0). Implantation techniques were root inclusion in 355 (24.9%), root replacement in 485 (34.0%), and subcoronary implantation in 587 (41.1%). Right ventricular outflow tract reconstruction was performed with homografts in 98.6% (n = 1189) and bioprostheses in 1.4% (n = 17). Ten patients (0.7%) died before discharge. Median follow-up was 9.2 years (13 015 total patient-years). Survival after 10 and 15 years was 95.1% (95% CI, 93.8%-96.5%) and 88.5% (95% CI, 85.9%-91.1%), respectively. Freedom from autograft and homograft reintervention after 15 years was 92.0% and 97.2%, respectively. Late events were autograft endocarditis in 14 patients (0.11% per patient-year), homograft endocarditis in 11 patients (0.08% per patient-year), and stroke in 37 patients (0.3% per patient-year). Conclusions and Relevance Given its excellent short-term and long-term outcome in young and middle-aged adults in this study, the Ross procedure should be considered in young and middle-aged adults who require aortic valve replacement. Patients should be referred to an experienced center with a program dedicated to the Ross procedure.
Collapse
Affiliation(s)
- Jamie L R Romeo
- Department of Cardio-Thoracic Surgery Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Grigorios Papageorgiou
- Department of Cardio-Thoracic Surgery Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Francisco F D da Costa
- Department of Cardiac Surgery, Santa Casa de Curitiba, Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, Brazil
| | - Hans H Sievers
- Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck, Lübeck, Germany
| | - Ad J J C Bogers
- Department of Cardio-Thoracic Surgery Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Ismail El-Hamamsy
- Department of Cardiovascular Surgery, CHU Sainte Justine, Montreal, Canada, Montreal, Quebec, Canada
| | - Peter D Skillington
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rochelle Wynne
- Department of Cardiothoracic Surgery, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Western Sydney Local Health District, Blacktown Clinical School, Western Sydney University, Penrith, New South Wales, Australia
| | - Stefano Mastrobuoni
- Department of Cardiovascular and Thoracic Surgery, St Luc University Clinic, Brussels, Belgium
| | - Gebrine El Khoury
- Department of Cardiovascular and Thoracic Surgery, St Luc University Clinic, Brussels, Belgium
| | - Johanna J M Takkenberg
- Department of Cardio-Thoracic Surgery Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Mostafa M Mokhles
- Department of Cardio-Thoracic Surgery Erasmus Medical Centre, Rotterdam, the Netherlands.,Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, the Netherlands
| |
Collapse
|
43
|
Long-Term Outcomes of Patients Undergoing the Ross Procedure. J Am Coll Cardiol 2021; 77:1412-1422. [DOI: 10.1016/j.jacc.2021.01.034] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 11/19/2022]
|
44
|
Mechanical Versus Bioprosthetic Valve Replacement in the Tricuspid Valve Position: A Systematic Review and Meta-Analysis. Heart Lung Circ 2021; 30:362-371. [DOI: 10.1016/j.hlc.2020.03.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 02/19/2020] [Accepted: 03/11/2020] [Indexed: 11/18/2022]
|
45
|
Clinical Outcome of Reoperation for Mechanical Prosthesis at Aortic Position. Heart Lung Circ 2021; 30:1084-1090. [PMID: 33589402 DOI: 10.1016/j.hlc.2021.01.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 12/19/2020] [Accepted: 01/01/2021] [Indexed: 11/22/2022]
Abstract
AIM Redo aortic valve surgery is usually associated with a high risk of mortality and complications. The aim of this study was to investigate the perioperative and long-term outcomes of reoperation after prior mechanical prosthesis implantation at the aortic position. METHOD The clinical data of 146 consecutive patients who underwent reoperation at the aortic position between 2003 and 2019 were analysed. RESULTS Mean age was 51.5±12.7 years and 69 (47.3%) were female. The median interval from prior surgery to redo aortic valve surgery was 6 years. The aetiologies were pannus formation with prosthetic aortic stenosis in 62 cases (42.5%), prosthetic valve endocarditis (PVE) in five (3.4%), PVE with perivalvular leakage (PVL) in 16 (11.0%), PVL in 45 (30.8%), thrombosis in seven (4.8%), and aortic disease in 11 (7.5%). As for surgical procedure, aortic valve replacement was performed in 81 cases (55.5%), Bentall in 34 (23.3%), PVL repair in six (4.1%), and pannus debridement in 25 (17.1%). Fourteen (14) (9.6%) patients expired perioperatively. Prolonged ventilation time and postoperative renal failure were proved to be significant independent predictors of mortality according to multivariate analysis. Overall survival was 87.8%±7.4% and 76.4%±15.1% at 5 and 10 years, respectively. Survival was 87.7%±13.7% and 84.2%±15.6% in the pannus group, and 84.5%±12.6% and 74.6%±19.4% in the non-pannus group at 5 and 10 years, respectively (p=0.951). Survival was 87.5%±14.2% and 75.8%±22.7% in the PVL group and 84.7%±11.9% and 81.6%±13.5% in the non-PVL group at 5 and 10 years, respectively (p=0.365). CONCLUSIONS Pannus formation and PVL are two major indications for reoperation of mechanical prosthesis at the aortic position. Redo aortic valve surgery has a satisfactory outcome but with a high risk of complications. Long-term survival of patients seems not to be related to the aetiology. Final decision-making of redo aortic valve surgery should be based on aetiology.
Collapse
|
46
|
Milleron O, Arnoult F, Delorme G, Detaint D, Pellenc Q, Raffoul R, Tchitchinadze M, Langeois M, Guien C, Beroud C, Ropers J, Hanna N, Arnaud P, Gouya L, Boileau C, Jondeau G. Pathogenic FBN1 Genetic Variation and Aortic Dissection in Patients With Marfan Syndrome. J Am Coll Cardiol 2020; 75:843-853. [PMID: 32130918 DOI: 10.1016/j.jacc.2019.12.043] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 11/21/2019] [Accepted: 12/21/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND Aortic risk has not been evaluated in patients with Marfan syndrome and documented pathogenic variants in the FBN1 gene. OBJECTIVES This study sought to describe aortic risk in a population with Marfan syndrome with pathogenic variants in the FBN1 gene as a function of aortic root diameter. METHODS Patients carrying an FBN1 pathogenic variant who visited our reference center at least twice were included, provided they had not undergone aortic surgery or had an aortic dissection before their first visit. Aortic events (aortic surgery or aortic dissection) and deaths were evaluated during the 2 years following each patient visit. The risk was calculated as the number of events divided by the number of years of follow-up. RESULTS A total of 954 patients were included (54% women; mean age 23 years). During follow-up (9.1 years), 142 patients underwent prophylactic aortic root surgery, 5 experienced type A aortic dissection, and 12 died (noncardiovascular causes in 3, unknown etiology in 3, post-operative in 6). When aortic root diameter was <50 mm, risk for proven type A dissection (0.4 events/1,000 patient-years) and risk for possible aortic dissection (proven aortic dissection plus death of unknown cause, 0.7 events/1,000 patients-years) remained low in this population that was treated according to guidelines. Three type A aortic dissections occurred in this population during the 8,594 years of follow-up, including 1 in a patient with a tubular aortic diameter of 50 mm, but none in patients with a family history of aortic dissection. The risk for type B aortic dissection in the same population was 0.5 events/1,000 patient-years. CONCLUSIONS In patients with FBN1 pathogenic variants who receive beta-blocker therapy and who limit strenuous exercise, aortic risk remains low when maximal aortic diameter is <50 mm. The risk of type B aortic dissection is close to the remaining risk of type A aortic dissection in this population, which underlines the global aortic risk.
Collapse
Affiliation(s)
- Olivier Milleron
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France
| | - Florence Arnoult
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France; Service des explorations fonctionnelles AP-HP, Hôpital Bichat, Paris, France
| | - Gabriel Delorme
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France
| | - Delphine Detaint
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France
| | - Quentin Pellenc
- Service de chirurgie vasculaire AP-HP, Hôpital Bichat, Paris, France
| | - Richard Raffoul
- Service de chirurgie cardiaque AP-HP, Hôpital Bichat, Paris, France
| | - Maria Tchitchinadze
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France
| | - Maud Langeois
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France
| | - Celine Guien
- Aix Marseille Université, INSERM, MMG, Bioinformatics & Genetics, Marseille, France
| | - Christophe Beroud
- Aix Marseille Université, INSERM, MMG, Bioinformatics & Genetics, Marseille, France
| | - Jacques Ropers
- Unité De Recherche Clinique, AP-HP, Pitié Salpêtrière-Charles Foix, Paris, France
| | - Nadine Hanna
- Département de génétique moléculaire AP-HP, Hôpital Bichat, Paris, France; INSERM U1148, LVTS, Hôpital Bichat, Paris, France
| | - Pauline Arnaud
- Département de génétique moléculaire AP-HP, Hôpital Bichat, Paris, France; INSERM U1148, LVTS, Hôpital Bichat, Paris, France; Université de Paris, Paris, France
| | - Laurent Gouya
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France; Université de Paris, Paris, France
| | - Catherine Boileau
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France; Département de génétique moléculaire AP-HP, Hôpital Bichat, Paris, France; INSERM U1148, LVTS, Hôpital Bichat, Paris, France; Université de Paris, Paris, France
| | - Guillaume Jondeau
- Centre de référence pour le syndrome de Marfan et apparentés, VASCERN HTAD European Reference Center, AP-HP, Hôpital Bichat, Paris, France; INSERM U1148, LVTS, Hôpital Bichat, Paris, France; Université de Paris, Paris, France.
| |
Collapse
|
47
|
Schneider U, Hofmann C, Schöpe J, Niewald AK, Giebels C, Karliova I, Schäfers HJ. Long-term Results of Differentiated Anatomic Reconstruction of Bicuspid Aortic Valves. JAMA Cardiol 2020; 5:1366-1373. [PMID: 32936224 DOI: 10.1001/jamacardio.2020.3749] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance Bicuspid aortic valve (BAV) repair has been used in limited cohorts, but its long-term results in a large population are unknown. Objectives To analyze the long-term stability of BAV repair for survival and the factors associated with repair failure and to evaluate whether a differentiated anatomic repair approach may improve repair stability. Design, Setting, and Participants In this case series, 1024 patients underwent BAV repair for aortic regurgitation or aneurysm between October 1995 and June 2018, with a mean (SD) follow-up time of 56 (49) months and maximum follow-up of 271 months. Systematic modifications in technique based on anatomic principles were introduced in 2009 and applied for the last 727 patients. Data were acquired prospectively and analyzed retrospectively. Exposures Repair of BAV with or without concomitant aortic replacement, as well as postoperative clinical and echocardiographic follow-up. Main Outcomes and Measures Survival and incidence of reoperation or recurrent aortic regurgitation, as well as factors associated with valve repair failure. Results Among the 1024 patients in the study (920 male [89.8%]; mean [SD] age, 47 [13] years [range, 15-86 years]), the survival rate at 15 years was 82.1%. The cumulative incidence of reoperation was 30.7% (95% CI, 22.7%-38.7%) at 15 years. Cusp calcification (subdistribution hazard ratio, 1.78; 95% CI, 1.14-2.77; P = .01), asymmetric commissural orientation (subdistribution hazard ratio, 1.95; 95% CI, 1.02-3.72; P = .04), and use of a pericardial patch for cusp repair (subdistribution hazard ratio, 5.25; 95% CI, 3.52-7.82; P < .001) were associated with time to reoperation. At 10 years, the incidence of reoperation was significantly reduced among patients who received the anatomic repair concept compared with those who had undergone surgery in the earlier period (8.8% vs 24.6%; P < .001). Conclusions and Relevance This study suggests that survival after BAV repair is excellent and that a large proportion of BAV repairs will remain stable. Repair stability can be markedly improved by an anatomic repair concept. Cusp calcification and the need for cusp repair using a patch remain the factors most strongly associated with valve failure. In those instances, valve replacement should be preferred.
Collapse
Affiliation(s)
- Ulrich Schneider
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Christopher Hofmann
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Jakob Schöpe
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg/Saar, Germany
| | - Ann-Kristin Niewald
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg/Saar, Germany
| | - Christian Giebels
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Irem Karliova
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| |
Collapse
|
48
|
Chan N, Sobieraj-Teague M, Eikelboom JW. Direct oral anticoagulants: evidence and unresolved issues. Lancet 2020; 396:1767-1776. [PMID: 33248499 DOI: 10.1016/s0140-6736(20)32439-9] [Citation(s) in RCA: 92] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Revised: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 12/12/2022]
Abstract
Currently licenced direct oral anticoagulants selectively target thrombin (eg, dabigatran) or coagulation factor Xa (eg, apixaban, betrixaban, edoxaban, and rivaroxaban). Designed to be given in fixed doses without routine monitoring, direct oral anticoagulants have a lower propensity for food and drug interactions than do vitamin K antagonists, and in randomised controlled trials involving around 250 000 patients, they were at least as effective for prevention and treatment of thrombosis and were associated with a lower risk of life-threatening bleeding. The absolute benefits of direct oral anticoagulants over vitamin K antagonists are modest; however, guidelines recommend them in preference to vitamin K antagonists for most indications because of their ease of use and superior safety. The greatest benefits of direct oral anticoagulants are likely to be in patients who were previously deemed unsuitable for vitamin K antagonist therapy. The emergence of generic preparations is expected to further increase the uptake of direct oral anticoagulants, particularly in countries where they are currently not widely used because of cost. Direct oral anticoagulants are contraindicated in patients with mechanical heart valves and should be used with caution or avoided in patients with advanced kidney or liver disease. In this Therapeutics paper, we review the pharmacology of direct oral anticoagulants, summarise the evidence that led to their approval and incorporation into treatment guidelines, and explore key unresolved issues. We also briefly discuss future perspectives for the development of oral anticoagulants.
Collapse
Affiliation(s)
- Noel Chan
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Hamilton General Hospital and McMaster University, Hamilton, ON, Canada.
| | | | - John W Eikelboom
- Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada; Hamilton General Hospital and McMaster University, Hamilton, ON, Canada
| |
Collapse
|
49
|
Patel PM, Wei JW, McPherson L, Binongo J, Leshnower BG, Chen EP. Bicuspid aortic valve sparing root replacement. J Card Surg 2020; 36:118-123. [PMID: 33225511 DOI: 10.1111/jocs.15210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND AIM OF STUDY Mid and long-term data regarding the durability of bicuspid aortic valve sparing root replacement is not completely understood. In this study, our institutional experience is reviewed regarding this procedure with special attention to the operative technique. METHODS From 2004 to 2019, 1241 patients underwent aortic root replacement and of these 79 patients underwent bicuspid aortic valve sparing root replacement. Early and late outcomes along with echocardiographic data were reviewed. Univariate analysis was used to identify risk factors for mortality. RESULTS Median age at operation was 43 (inner quartile range: 34.5-50.5) years, with 17% (14) being female. Median follow up time was 4 (inner quartile range: 1-8) years with 359 years of total follow up. Early mortality was 2.5% (2). Overall 10-year freedom from aortic valve intervention was 95.6%. Risk factor analysis did not demonstrate preoperative root diameter, aortic diameter, or aortic insufficiency to be risk factors for mortality. CONCLUSION Bicuspid aortic valve sparing root replacement can be performed safely in the setting of aortic root pathology and valve insufficiency. With appropriate selection and excellent surgical technique, long-term durable valve function is observed without the need for repeat valve intervention.
Collapse
Affiliation(s)
- Parth M Patel
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jane W Wei
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - LaRonica McPherson
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Jose Binongo
- Department of Biostatistics and Bioinformatics, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| |
Collapse
|
50
|
Uiterwijk M, Vis A, de Brouwer I, van Urk D, Kluin J. A systematic evaluation on reporting quality of modern studies on pulmonary heart valve implantation in large animals. Interact Cardiovasc Thorac Surg 2020; 31:437-445. [PMID: 32888025 DOI: 10.1093/icvts/ivaa132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 06/05/2020] [Accepted: 06/16/2020] [Indexed: 12/09/2022] Open
Abstract
OBJECTIVES Before new heart valves can be implanted safely in humans, animal experiments have to be performed. These animal experiments have to be clearly designed, analysed and reported to assess the accuracy and importance of the findings. We aimed to provide an overview of the reporting and methodological quality of preclinical heart valve research. METHODS We conducted a systematic literature search on biological and mechanical pulmonary valve implantations in large animals. We used the Animals in Research: Reporting In Vivo Experiments (ARRIVE) guidelines to score the quality of reporting in each article. We compared the scores before and after the introduction of the ARRIVE guidelines (2010). RESULTS We screened 348 articles, of which 31 articles were included. The included articles reported a mean of 54.7% adequately scored ARRIVE items (95% confidence interval 52.2-57.3%). We did not identify a difference in reporting quality (54.7% vs 54.8%) between articles published before and after 2010. We found an unclear (lack of description) risk of selection bias, performance bias and detection bias. CONCLUSIONS The reporting quality of studies that implanted bioprosthetic or mechanical valves in the pulmonary position in the large animal model is not on the desired level. The introduction of the ARRIVE guidelines in 2010 did not improve the reporting quality in this field of research. Hereby, we want to emphasize the importance of clearly describing the methods and transparently reporting the results in animal experiments. This is of great importance for the safe translation of new heart valves to the clinic. CLINICAL TRIAL REGISTRATION NUMBER PROSPERO (CRD42019147895).
Collapse
Affiliation(s)
- Marcelle Uiterwijk
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, University of Amsterdam, Heart Center, Amsterdam, Netherlands
| | - Annemijn Vis
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, University of Amsterdam, Heart Center, Amsterdam, Netherlands
| | - Iris de Brouwer
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, University of Amsterdam, Heart Center, Amsterdam, Netherlands
| | - Debora van Urk
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, University of Amsterdam, Heart Center, Amsterdam, Netherlands
| | - Jolanda Kluin
- Department of Cardiothoracic Surgery, Amsterdam University Medical Center, University of Amsterdam, Heart Center, Amsterdam, Netherlands
| |
Collapse
|