St. Jude Medical Trifecta™ aortic valve perioperative performance in 200 patients

In Vitro Comparison of a Closed and Semi-closed Leaflet Design for Adult and Pediatric Transcatheter Heart Valves

Transcatheter heart valve replacements (TVR) are mostly designed in a closed position (c) with leaflets coaptating. However, recent literature suggests fabricating valves in semi-closed (sc) position to minimize pinwheeling. With about 100,000 children in need of a new pulmonary valve each year worldwide, this study evaluates both geometrical approaches in adult as well as pediatric size and condition. Three valves of each geometry were fabricated in adult (30 mm) and pediatric (15 mm) size, using porcine pericardium. To evaluate performance, the mean transvalvular pressure gradient (TPG), effective orifice area (EOA), and regurgitation fraction (RF) were determined in three different annulus geometries (circular, elliptic, and tilted). For both adult-sized valve geometries, the TPG (TPGC = 2.326 ± 0.115 mmHg; TPGSC = 1.848 ± 0.175 mmHg)* and EOA (EOAC = 3.69 ± 0.255 cm2; EOASC = 3.565 ± 0.025 cm2)* showed no significant difference. Yet the RF as well as its fluctuation was significantly higher for valves with the closed geometry (RFC = 12.657 ± 7.669 %; RFSC = 8.72 ± 0.977 %)*. Recordings showed that the increased backflow was caused by pinwheeling due to a surplus of tissue material. Hydrodynamic testing of pediatric TVRs verified the semi-closed geometry being favourable. Despite the RF (RFC = 7.721 ± 0.348 cm2; RFSC = 5.172 ± 0.679 cm2), these valves also showed an improved opening behaviour ((TPGC = 20.929 ± 0.497 cm2; TPGSC = 15.972 ± 1.158 cm2); (EOAC = 0.629 ± 0.017 cm2; EOASC = 0.731 ± 0.026 cm2)). Both adult and pediatric TVR with semi-closed geometry show better fluiddynamic functionality compared to valves with a closed design due to less pinwheeling. Besides improved short-term functionality, less pinwheeling potentially prevents early valve degeneration and improves durability. *Results are representatively shown for a circular annulus geometry.

Rates and Predictors of Structural Valve Degeneration and Failure of Trifecta Bioprosthetic Valve Over a 5-year Follow-up Period: A Single-center Experience

Introduction

The Trifecta bioprosthetic valve has been commonly used for surgical aortic valve replacement (SAVR). Multiple studies have been done to define the rate of structural valve degeneration (SVD) and failure (SVF), but the outcomes are still debatable. Therefore, we aim to conduct this single-center study to estimate the rate and predictors of SVD/SVF.

Methodology

This retrospective observational cohort single-center study was conducted between 2014 and 2019 among Trifecta SAVR patients. Data were patient's characteristics collected from electronic medical records at baseline and follow-up (3-5 years). Statistical analysis was performed with a significance level of P ≤ 0.05.

Results

A total of 271 eligible patients were identified. Most of our sample were males (57.9%), with a mean age of 71.1 ± 10.6 years. The mean baseline preoperative ejection fraction (EF) was 53.0%, with no change (P = 0.88) in the immediate postoperative EF (53.6%). A most recent follow-up EF revealed a significant increase of EF (55.2%), P = 0.01. Furthermore, there was a significant increase from peak velocity to PVMRE (mean difference [MD] ± standard error of mean (SEM) [0.15 ± 0.04], P < 0.01), an increase in pressure gradient (PGIPE) to PGMRE (MD ± SEM [1.70 ± 0.49], P < 0.01), and a decrease in Doppler velocity index (DVIIPE) to DVIMRE (MD ± SEM [-0.037 ± 0.01], P = 0.01). Regarding the SVF rate, 13 (4.8%) patients had failed valves requiring replacement throughout the study period.

Conclusions

Over a 5-year follow-up period, 4.8% had SVF with an SVD of 23.2%, with the majority of SVD not being clinically significant except in six patients. These results corroborate with a previously published study suggesting a bad clinical outcome of Trifecta valve placement.

Case Series of Early Structural Valve Deterioration of Trifecta Bioprosthesis - New Zealand Experience

PURPOSE

Structural valve deterioration (SVD) remains a limitation on the use of bioprosthetic valves, with patient and valve-related factors contributing to early SVD. The Trifecta valve has been reported to have excellent hemodynamics but studies have highlighted early failure. We present a review and case series at a New Zealand tertiary hospital defining early SVD as failure within 3 years of implant.

METHODS

A retrospective review from January 2015 to July 2019 included 525 patients undergoing surgical aortic valve replacement with 263 patients receiving an Abbott Trifecta or Trifecta Glide Technology (GT) valve. Our review found an acceptable safety profile for the valve with excellent hemodynamics, with a low mortality, stroke, and permanent pacemaker rate.

RESULTS

Three patients out of 263 were identified from the study period as having early SVD requiring reintervention within 3 years of valve implantation leading to a 1.14% failure rate. One of the valves that had early SVD was a new generation Trifecta GT. An additional four patients were identified to have valves implanted prior to the study period and had valve failure at greater than 3 years post implantation. Five cases had cusp tears as their mechanism of failure, raising concerns about durability.

CONCLUSION

The Trifecta valve has an acceptable safety profile and offers good hemodynamics due to the externally mounted leaflets. However, our experience of early SVD and failure is concerning for valve durability. Further comparison to other bioprosthetic valves and longer term follow-up are required to characterize the mechanism of failures.

Review of bioprosthetic structural valve deterioration: Patient or valve?

BACKGROUND

With guidelines progressively recommending bioprosthetic aortic valves in younger patients, a greater emphasis is placed on structural valve deterioration (SVD) as an important clinical endpoint for both transcatheter and surgically implanted valves. However, SVD of bioprosthetic valves is a complex entity with varying definitions in the literature and a multifaceted pathogenesis.

AIM

This review first aims to establish the most updated definitions of SVD as per the literature. We then explore the patient- and valve-related factors that play the greatest roles in facilitating early SVD.

METHODS

A PubMed literature review was conducted to identify the relevant research in this field within the past two decades.

CONCLUSION

Increasing rates of obesity and metabolic syndrome pose a significant risk to the longevity of bioprosthetic valves. Additionally, externally mounted valves have proven to sacrifice durability for superior haemodynamics. Bioprosthetic SVD continues to be a multifactorial issue that will require various patient- and valve-related factors to be addressed.

Analysis of incidence and reasons for re-intervention after aortic valve replacement using the Trifecta aortic bioprosthesis

INTRODUCTION

Trifecta bioprosthesis claims favourable haemodynamic performance. However, reports of structural valve deterioration (SVD) raise concerns of its long-term durability. We assessed outcomes with the Trifecta valve over a 10-year period.

METHODS

All patients receiving Trifecta bioprostheses between October 2011 and October 2020 were included. Perioperative and survival characteristics were prospectively collated in an independent database. Re-intervention was recorded as a surrogate for SVD.

RESULTS

944 patients (mean age 72.82 years ± 8.13, 58% male) underwent aortic valve replacement with the Trifecta valve. At 10-years, 1.4% of patients required a redo operation, giving an overall freedom from re-intervention of 98.6%. The mean time to re-intervention was 48.87 months. Survival was 73.58% and 76.92% in patients who did not require re-intervention vs re-intervention group, respectively.

CONCLUSIONS

In a large, single-centre cohort, the Trifecta aortic bioprosthesis had a 1.4% all-cause re-intervention rate at 10-years, with insignificant impact on survival.

Mid-term clinical and health-related quality of life outcomes for the Trifecta bioprosthesis

Background

The Trifecta valve has been reported to have excellent hemodynamics. Controversy exists on occurrence of patient-prosthesis mismatch (PPM) and data on mid-term outcome is sparse. Health-related quality of life (HRQoL) assessment for the Trifecta valve has not been reported before. The aim of this study was to report the mid-term clinical and HRQoL outcomes in patients undergoing Trifecta valve implantation at our institution.

Methods

In this prospective, observational study, patients undergoing an aortic valve replacement (AVR) using the Trifecta valve were included. Data collection was retrospective from prospectively collected institutional database. Clinical and echocardiographic data were collected prospectively during follow-up. Quality of life was assessed using the Short Form-36 (SF-36) questionnaire.

Results

Forty-seven patients were included in the study of which 9 (19%) were women. Isolated AVR was carried out in 33 (70%) patients. In-hospital mortality and 30-day mortality were 1 (2.1%) and 2 (4.2%), respectively. With a mean indexed effective orifice area (iEOA) 0.96 ± 0.1, none of the patients had severe PPM. Moderate PPM was seen in 19%. The mean follow-up was 3 ± 1.7 years. The 5-year survival estimate was 83.2% in the overall cohort, 81.4% in the isolated and 87.5% in the concomitant procedure group. Freedom from re-operation and structural valve degeneration at 5 years was 95.7% and 97.8%. The mean physical health composite was 69.24 ± 2 and the mean mental health composite was 69.7 ± 25, indicating excellent mental and physical well-being among patients.

Conclusion

The Trifecta valve provides satisfactory hemodynamics, survival and freedom from re-operation and excellent HRQoL at mid-term follow-up.

Leaflet stress quantification of porcine vs bovine surgical bioprostheses: an in vitro study

Calcified aortic stenoses are among the most prevalent form of cardiovascular diseases in the industrialized countries. This progressive disease, with no effective medical therapy, ultimately requires aortic valve replacement - either a surgical or very recently transcatheter aortic valve implantation. Increase leaflet mechanical stress is one of the main determinants of the structural deterioration of bioprosthetic aortic valves. We applied a coupled in vitro/in silico method to compare the timing, magnitude, and regional distribution of leaflet mechanical stress in porcine versus pericardial bioprostheses (Mosaic and Trifecta). A double activation simulator was used for in vitro testing of a bioprosthesis with externally mounted pericardium (Abbott, Trifecta) and a bioprosthesis with internally mounted porcine valve (Medtronic, Mosaic). A non-contact system based on stereophotogammetry and digital image correlation (DIC) with high spatial and temporal resolution (2000 img/s) was used to visualize the valve leaflet motion and perform the three-dimensional analysis. A finite element model of the valve was developed, and the leaflet deformation obtained from the DIC analysis was applied to the finite element model calculate local leaflet mechanical stress throughout the cardiac cycle. The maximum leaflet stress was higher with the pericardial versus the porcine bioprosthesis (2.03 vs. 1.30 MPa) For both bioprostheses the highest values of leaflet stress occurred during diastole and were primarily observed in the upper leaflet edge near the commissures and to a lesser extent in the mid-portion of the leaflet body. In conclusion, the coupled in vitro/in silico method described in this study shows that the highest levels of leaflet stress occur in the regions of the commissures and mid-portion of the leaflet body. This method may have important insight with regard to bioprosthetic valve durability. Our results suggest that, compared to porcine bioprostheses, those with externally mounted pericardium have higher leaflet mechanical stress, which may translate into shorter durability.

Impact of the Trifecta bioprosthetic valve in patients with low-flow severe aortic stenosis

Aortic stenosis (AS) is the most common valve disorder in advanced age. Previous reports have shown that low-flow status of the left ventricle is an independent predictor of cardiovascular mortality after surgery. The Trifecta bioprosthesis has recently shown favorable hemodynamic performance. This study aimed to evaluate the effect of the Trifecta bioprosthesis, which has a large effective orifice area, in patients with low-flow severe AS who have a poor prognosis. We retrospectively evaluated 94 consecutive patients with severe AS who underwent aortic valve replacement (AVR). Patients were divided into two groups according to the stroke volume index (SVI): low-flow (LF) group (SVI < 35 ml/m², n = 22) and normal-flow (NF) group (SVI ≥ 35 ml/m², n = 72). Patients’ characteristics and early and mid-term results were compared between the two groups. There were no differences in patients’ characteristics, except for systolic blood pressure (LF:NF = 120:138 mmHg, p < 0.01) and the rate of atrial fibrillation between the groups. A preoperative echocardiogram showed that the pressure gradient was higher in the NF group than in the LF group, but aortic valve area was similar. The Trifecta bioprosthesis size was similar in both groups. The operative outcomes were not different between the groups. Severe patient–prosthesis mismatch (PPM) (< 0.65 cm²/m²) was not observed in either of the groups. There were no significant differences in mid-term results between the two groups. The favorable hemodynamic performance of the Trifecta bioprosthesis appears to have the similar outcomes in the LF and NF groups. AVR with the Trifecta bioprosthesis should be considered for avoidance of PPM, particularly in AS patients with LV dysfunction.

Intraoperative Trifecta Valve Malfunction

The Trifecta valve has been reported to have valve dysfunction months to years after operation. However there were no reports of intraoperative valve dysfunction. A 73-year-old man with aortic stenosis underwent aortic valve replacement using a 21-mm Trifecta valve with Glide Technology (Trifecta GT; Abbot). Hemodynamics were collapsed after aortic declamp because of severe regurgitation, and we replaced it with another biologic valve. We noticed that the removed valve's mount post was open outwardly more than usual. Despite the progress of the biologic valve, dysfunction like this case can occur during operation, and it is important to reoperate immediately even if there is no obvious tear or deformity.

Incidence and influence of prosthesis-patient mismatch after reoperative aortic valve replacement: a retrospective single-center study

Background

Reoperative aortic valve replacement (AVR) is associated with increased mortality compared with initial surgery, and a smaller valve might be implanted during repeat AVR (re-AVR; AVR after prior AVR). We describe the clinical outcomes and incidence of prosthesis-patient mismatches (PPM) after reoperative AVR.

Methods

Among 113 patients who underwent reoperative AVR between 2007 and 2018, 44 underwent re-AVR and 69 underwent a first replacement of a diseased natural valve after any cardiac surgery except AVR (primary AVR). We then compared early and late outcomes, the impact of re-AVR on the effective orifice areas (EOA), and the incidence and influence of PPM on reoperative AVR.

Results

Hospital mortality was 2.7%, and the overall 1-, 3-, and 5-year survival rates were 95, 91 and 86%, respectively. The reference EOA of the newly implanted valve was smaller than that of the previous valve (1.4 ± 0.3 vs. 1.6 ± 0.3 cm², p < 0.01). The mean pressure gradient was greater (15.2 ± 6.4 vs. 12.7 ± 6.2 mmHg, p = 0.04) and indexed EOA was smaller (0.92 ± 0.26 vs. 1.06 ± 0.36 cm²/m², p = 0.04) during re-AVR than primary AVR, whereas the incidence of PPM was similar (38.7% vs. 34.8%, p = 0.87) between the groups.

Conclusions

The clinical outcomes of reoperative AVR were acceptable. Although the reference EOA of new implanted valves was smaller than that of previous valves, re-AVR did not increase the incidence of PPM. These findings might serve as a guide for future decisions regarding the surgical approach to treating degenerated prosthetic valves.

Reintervention After Aortic Valve Replacement: Comparison of 3 Aortic Bioprostheses

BACKGROUND

The decision to implant a biological valve prosthesis is influenced by the issue of durability. We investigated the rate and the cause of reintervention in 3 different aortic valve bioprostheses.

METHODS

The study included all patients who underwent aortic valve replacement with a biological valve prosthesis between October 2009 and December 2018. Three different bioprostheses were compared: Carpentier-Edwards (CE) Magna Ease (Edwards Lifesciences, Irvine, CA), Trifecta (St. Jude Medical, St Paul, MN), and Mitroflow (LivaNova, London, United Kingdom). The primary end point was the rate of explantation. The degree of event-free survival and possible predictors for reintervention were also analyzed using Cox regression analysis.

RESULTS

In total, 2004 biological aortic valves were implanted, including 923 CE, 719 Trifecta, and 362 Mitroflow bioprostheses. The CE group had a significantly higher degree of event-free survival (917 [99.3%]) compared with the Trifecta (685 [95.3%]) and Mitroflow (340 [93.9%]) groups (P < .0001). The only cause of reintervention in the CE group was prosthetic valve endocarditis (6 [100%]), whereas structural valve deterioration was the most common cause of reintervention in the Trifecta (14 [41.2%]) and Mitroflow (14 [63.6%]) groups. Cox regression analysis revealed that age (hazard ratio [HR] 0.9; 95% confidence interval [CI], 0.9-0.9; P < .0001) and type of prosthesis (Trifecta: HR, 6.3; 95% CI, 2.6-15.2; P < .0001; Mitroflow: HR, 6.0, 95% CI, 2.4-15.1; P < .0001) were associated with lower event-free survival.

CONCLUSIONS

The freedom from reintervention after implantation of the CE bioprosthesis is significantly greater than that of the Trifecta and Mitroflow bioprostheses. Further investigations with larger patient populations and long-term follow-up are required to establish their durability and long-term efficacy.

Clinical outcome and hemodynamic performance of St. Jude Trifecta aortic prosthesis: short-term follow-up and risk factors analysis

BACKGROUND

We retrospectively analysed the short-term outcome of the third-generation St. Jude Trifecta aortic prosthesis.

METHODS

Between December 2014 and December 2017, 177 patients (mean age 75.1±6.8 years, 95 males, 82 females) underwent aortic valve replacement with a St. Jude Trifecta aortic prosthesis and were followed up to 27±9 months. Preoperatively 92 patients (52.0%) were in NYHA class III-IV, EuroSCORE II was 3.2%±2.1%.

RESULTS

Trifecta sizes implanted were 19 mm (n=46) (26%), 21 mm (n=69) (39%), 23 mm (n=46) (26%), 25 mm (n=16) (9%). Concomitant coronary artery bypass grafting was performed in 60 patients (34.0%). Operative mortality was 3.4% (1.7% for isolated aortic valve replacement versus 6.7% for combined aortic valve replacement and coronary artery bypass grafting) (P=0.084). The only independent predictor of mortality was the need for the mechanical ventilation greater than 24 hours (P=0.037); recently occurring myocardial infarction was risk factor for mortality at the univariate analysis only (P=0.013). Three-year survival was 84%±6%, freedom from cardiac death 98%±1%, freedom from prosthetic endocarditis 97%±1%. No thromboembolisms or structural valve degeneration were observed. Patient-prosthesis mismatch (PPM) was absent in 126 patients (71.2%), mild-to-moderate in 32 (18.1%), moderate in 19 (10.7%), severe in no any patient. Follow-up echocardiography showed an average mean and peak trans-aortic valve gradients reduction more than 70% in comparison with preoperative value (P<0.0001), and a significant regression of left ventricular hypertrophy (P<0.0001). Moderate PPM did not negatively affect survival. Concomitant severe coronary artery disease was found as an independent predictor of reduced survival (72%±12% versus 86%±6%) (P=0.015).

CONCLUSIONS

Trifecta aortic prosthesis seems to provide very favourable clinical outcome and hemodynamic performance. At three years, survival was negatively affected by severe coronary artery disease detected at the time of operation. During short-term follow-up, no early structural valve degeneration was been observed. Due to low incidence of PPM and low peak and mean trans-prosthetic aortic valve gradients, third generation Trifecta aortic prosthesis should be considered as one of the best options in the setting of the aortic valve replacement surgery. However, a long-term follow-up is mandatory to confirm the early promising data.

Numerical and in-vitro experimental assessment of the performance of a novel designed expanded-polytetrafluoroethylene stentless bi-leaflet valve for aortic valve replacement

The expanded polytetrafluoroethylene (ePTFE) heart valve can serve as a viable option for prosthetic aortic valve. In this study, an ePTFE bi-leaflet valve design for aortic valve replacement (AVR) is presented, and the performance of the proposed valve was assessed numerically and experimentally. The valve was designed using CAE software. The dynamic behavior of the newly designed bi-leaflet valve under time-varying physiological pressure loading was first investigated by using commercial finite element code. Then, in-vitro tests were performed to validate the simulation and to assess the hemodynamic performance of the proposed design. A tri-leaflet ePTFE valve was tested in-vitro under the same conditions as a reference. The maximum leaflet coaptation area of the bi-leaflet valve during diastole was 216.3 mm2. When fully closed, no leakage gap was observed and the free edges of the molded valve formed S-shaped lines. The maximum Von Mises stress during a full cardiac cycle was 4.20 MPa. The dynamic performance of the bi-leaflet valve was validated by the in-vitro test under physiological aortic pressure pulse. The effective orifice area (EOA), mean pressure gradient, regurgitant volume, leakage volume and energy loss of the proposed valve were 3.14 cm2, 8.74 mmHg, 5.93 ml/beat, 1.55 ml/beat and 98.99 mJ, respectively. This study reports a novel bi-leaflet valve design for AVR. The performance of the proposed valve was numerically and experimentally assessed. Compared with the reference valve, the proposed design exhibited better structural and hemodynamic performances, which improved valve competency. Moreover, the performance of the bi-leaflet design is comparable to commercialized valves available on the market. The results of the present study provide a viable option for the future clinical applications.

Limitations in the Assessment of Prosthesis-Patient Mismatch

Background Prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) may affect survival but data are conflicting. It is assessed by relating effective orifice area (EOA) to body surface area (EOAi). EOA is patient-specific as the result of flow-velocity times area at the individual patient's outflow tract levels (LVOTA) divided by trans-prosthetic flow velocity. However, some studies use projected EOAs (i.e., valve size associated EOAs from other patient populations) to assess how PPM affects outcome.

Methods We analyzed 76 studies addressing hemodynamic outcome and/or mortality after bioprosthetic AVR.

Results In 48 studies, projected or measured EOA for calculation of EOAi and PPM assessment was used (of which 25 demonstrated an effect on survival). We identified 28 additional studies providing measured EOA values and the corresponding Bernoulli's pressure gradients after AVR. Despite EOA being a patient-specific parameter, 77% of studies assessing a PPM impact on survival used projected EOAs. The 28 studies are providing measured EOA values and the corresponding Bernoulli's pressure gradients in patients after AVR showed a highly significant, linear relationship between EOA and Bernoulli's gradient. Considering this relationship, it is surprising that relating EOA to body surface area (BSA) (EOAi) is standard but relating pressure gradients to BSA is not.

Conclusion We conclude that the majority of studies assessing PPM have used false assumptions because EOA is a patient-specific parameter and cannot be transferred to other patients. In addition, the use of EOAi to assess PPM may not be appropriate and could explain the inconsistent relation between PPM and survival in previous studies.

Early and mid-term haemodynamic performance and clinical outcomes of St. Jude Medical Trifecta™ valve

Background

New models of aortic bioprostheses have proven excellent early haemodynamic profile, but their mid and long-term performance warrants further systematic assessment. The aim of this study is to report clinical and haemodynamic performance of St. Jude Medical Trifecta bioprosthesis during 5 years of implantation.

Methods

We performed a single centre, retrospective, observational and descriptive study including all 556 individuals who underwent aortic valve replacement (AVR) with the Trifecta bioprosthesis (between July of 2011 and June of 2016). Survival and re-intervention were censored in February 2017. Postoperative ambulatory echocardiographic data was available for 490 patients. A complete clinical follow-up was available in 463 individuals (mean follow-up time, 27±17 months).

Results

In our sample the mean age was 73±9 years, 57.6% were male and median European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was 2.9 (interquartile range, 1.6-5.8). There were 301 (54.1%) combined procedures, mostly coronary artery bypass grafting in 170 (30.6%). Overall 30-days mortality was 5.4% (n=30) and cumulative survival at 5-years was 72.3%. There were 23 (4.3%) permanent pacemaker implantations. During follow-up, 5 (0.9%) patients presented non-structural valve dysfunction (NSVD) and 4 (0.8%) underwent reoperation due to prosthesis endocarditis. At the first ambulatory evaluation transvalvular mean gradient and effective orifice area (EOA) were 10.9±4.1 mmHg and 2.0±0.5 cm², respectively. Severe patient-prosthesis mismatch (PPM) was observed in 5 (1.1%) individuals and moderate in 52 (11.3%).

Conclusions

In a "real-world" clinical setting, our findings support the good overall mid-term haemodynamic and safety profile of the Trifecta bioprosthesis.

Trifecta St. Jude medical® aortic valve in pulmonary position

Introduction: To evaluate an aortic pericardial valve for pulmonary valve (PV) regurgitation after repair of congenital heart defects.

Methods: From July 2012 to June 2016 71 patients, mean age 24 ± 13 years (four to years) underwent PV implantation of aortic pericardial valve, mean interval after previous repair = 21 ± 10 years (two to 47 years). Previous surgery at mean age 3.2 ± 7.2 years (one day to 49 years): tetralogy of Fallot repair in 83% (59/71), pulmonary valvotomy in 11% (8/71), relief of right ventricular outflow tract (RVOT) obstruction in 6% (4/71). Pre-operative echocardiography and MRI showed severe PV regurgitation in 97% (69/71), moderate in 3% (2/71) with associated RVOT obstruction. MRI and knowledge-based reconstruction 3D volumetry (KBR-3D-volumetry) showed mean PV regurgitation = 42 ± 9% (20–58%), mean indexed RV end-diastolic volume = 169 ± 33 (130–265) ml m^–2 BSA and mean ejection fraction (EF) = 46 ± 8% (33–61%). Cardio-pulmonary exercise showed mean peak O₂/uptake = 24 ± 8 ml kg^–1 min^–1 (14–45 ml kg^–1 min^–1), predicted max O₂/uptake 66 ± 17% (26–97%). Pre-operative NYHA class was I in 17% (12/71) patients, II in 70% (50/71) and III in 13% (9/71).

Results: Mean cardio-pulmonary bypass duration was 95 ± 30ʹ (38–190ʹ), mean aortic cross-clamp in 23% (16/71) 46 ± 31ʹ (8–95ʹ), with 77% (55/71) implantations without aortic cross-clamp. Size of implanted PV: 21 mm in seven patients, 23 mm in 33, 25 mm in 23, and 27 mm in eight. The z-score of the implanted PV was −0.16 ± 0.80 (−1.6 to 2.5), effective orifice area indexed (for BSA) of native PV was 1.5 ± 0.2 (1.2 to –2.1) vs. implanted PV 1.2 ± 0.3 (0.76 to –2.5) (p = ns). In 76% (54/71) patients surgical RV modelling was associated. Mean duration of mechanical ventilation was 6 ± 5 h (0–26 h), mean ICU stay 21 ± 11 h (12–64 h), mean hospital stay 6 ± 3 days (three to 19 days). In mean follow-up = 25 ± 14 months (six to 53 months) there were no early/late deaths, no need for cardiac intervention/re-operation, no valve-related complications, thrombosis or endocarditis. Last echocardiography showed absent PV regurgitation in 87.3% (62/71) patients, trivial/mild degree in 11.3% (8/71), moderate degree in 1.45% (1/71), mean max peak velocity through RVOT 1.6 ± 0.4 (1.0–2.4) m s^–1. Mean indexed RV end-diastolic volume at MRI/KBR-3D-volumetry was 96 ± 20 (63–151) ml m^–2 BSA, lower than pre-operatively (p < 0.001), and mean EF = 55 ± 4% (49–61%), higher than pre-operatively (p < 0.05). Almost all patients (99% = 70/71) remain in NYHA class I, 1.45% = 1/71 in class II.

Conclusion: (a) Aortic pericardial valve is implantable in PV position with an easy and reproducible surgical technique; (b) valve size adequate for patient BSA can be implanted with simultaneous RV remodelling; (c) medium-term outcomes are good with maintained PV function, RV dimensions significantly reduced and EF significantly improved; (d) adequate valve size will allow later percutaneous valve-in-valve implantation.

Pure Cusp Tear of Trifecta Bioprosthesis 2 Years after Aortic Valve Replacement

Trifecta is a stented bioprosthetic heart valve with a bovine pericardial sheet externally mounted on a titanium stent. This valve is applied only for aortic valve replacement (AVR), providing excellent hemodynamics and extremely low incidence of structural valve deterioration (SVD). A 76-year-old woman presented with dyspnea on effort 24 months after AVR with a 21-mm Trifecta valve. Echocardiography revealed severe aortic regurgitation with prolapse of a cusp of Trifecta valve, which suggested that she developed acute heart failure due to early SVD. In the operation, Trifecta valve had a cusp tear near the commissure with circumferential fibrous pannus ingrowth only at the inflow side. There was neither calcification nor infection. The Trifecta valve was successfully replaced with a new porcine bioprosthesis.

Pulmonary Valve Replacement With a Trifecta Valve Is Associated With Reduced Transvalvular Gradient

BACKGROUND

Outcomes after surgical pulmonary valve replacement (PVR) in patients with congenital cardiac disease are limited by long-term valve deterioration, which may be hastened by turbulent flow. The use of the Trifecta valve (St. Jude Medical, Little Canada, MN) at our institution (Duke University Medical Center, Durham, NC) appears to result in low postimplantation transvalvular gradients. This study was performed to compare the early transvalvular gradient associated with the Trifecta valve with that associated with two other valves commonly used for PVR.

METHODS

We performed a single institution review of patients undergoing PVR with the Perimount valve (Edwards Lifesciences, Irvine, CA), the Biocor valve (St. Jude Medical), or the Trifecta valve between November 1993 and January 2014. Multivariable linear regression modeling was used to determine the adjusted association between valve type and transvalvular gradient as determined by early postoperative echocardiography.

RESULTS

A total of 186 patients met study criteria; 54 (29%) received a Biocor valve, 87 (47%) received a Perimount valve, and 45 (24%) received a Trifecta valve. There were no baseline differences among the groups, but the peak transvalvular gradient was significantly decreased among patients with the Trifecta valve. After adjustment for age, valve size, patients' weight, and time to the assessment, as compared with the Trifecta valve, the Biocor valve was associated with a 57% higher peak valve gradient (p < 0.01), whereas the Perimount valve was associated with a 26% higher peak valve gradient (p = 0.04).

CONCLUSIONS

PVR for congenital heart disease with the Trifecta bioprosthetic valve is associated with a reduced early transvalvular gradient. This finding may be associated with reduced valve deterioration over time.

A comparison of two forms of the continuity equation in the Trifecta bovine pericardial aortic valve

AIM

To compare the classical and simplified form of the continuity equation in small Trifecta valves.

METHODS

This is a retrospective analysis of post-operative echocardiograms performed for clinical reasons after implantation of Trifecta bioprosthetic valves.

RESULTS

There were 60 patients aged 74 (range 38-89) years. For the valves of size 19, 21 and 23mm, the mean gradient was 11.3, 10.7 and 9.7mmHg, respectively. The effective orifice areas by the classical form of the continuity equation were 1.4, 1.7 and 1.9cm(2), respectively. There was a good correlation between the two forms of the continuity equation, but they were significantly different using a t-test (P<0.00001). Results using the classical form were a mean 0.11 (s.d. 0.18)cm(2) larger than those using the simple formula.

CONCLUSION

Haemodynamic function of the Trifecta valve in the small aortic root is good. There are significant differences between the classical and simplified forms of the continuity equation.

St. Jude Medical Trifecta aortic valve: results from a prospective regional multicentre registry

Background

The Trifecta aortic bioprosthesis (St. Jude Medical, Inc., St. Paul, MN, USA) is a stented pericardial heart valve with excellent preliminary results. Aim of the study was to evaluate its early clinical and hemodynamic performances in a multicenter regional registry.

Methods

Between January 2011 and June 2012, 178 consecutive patients undergoing aortic valve replacement with the Trifecta bioprosthesis were prospectively enrolled at 9 Italian centers. Clinical and echocardiographic data were collectedat discharge, 6-months and at 1-year postoperatively.

Results

The average age was 75.4 ± 7.7 years,and 95 (53 %) were men. Indication for valve replacement included stenosis in 123 patients (69 %), mixed lesions in 25 (14 %), and regurgitation in 30 (17 %). Ninety-three (52 %) patients were in NYHA functional class III/ IV. Hospital mortality accounted for 5 (2.8 %) patients. No valve-related perioperative complications were encountered. Median follow-up was 20.5 months (range: 1-34). Early (≤6 months) complications included one thromboembolic event, one major bleeding, and 3 endocarditis (2 explants). Two late (>6 months) thromboembolic events and two endocarditis (1 explant) were registered. No valve thrombosis or structural deterioration were observed after discharge. At 30-months, freedom from all-cause mortality was 87 %, freedom from valve-related mortality 99.4 %, freedom from endocarditis 97.5 %, and freedom from valve explants 98 %. At 1-year, mean gradients ranged from 8 to 16 mmHg, and effective orifice area indexes from 1.0 to 1.2 cm²/m² for valve sizes from 19 to27 mm, respectively. No patients had severe prosthesis-patient mismatch.

Conclusions

Trifecta bioprosthesis provided favourable clinical and hemodynamic results over time.

A European Multicenter Study of 616 Patients Receiving the Freedom Solo Stentless Bioprosthesis

BACKGROUND

The purpose of this study was to evaluate the safety and performance of the Freedom Solo valve in aortic valve replacement by clinical and hemodynamic outcomes.

METHODS

Six hundred sixteen patients underwent aortic valve replacement in 18 European centers; mean age was 74.5 ± 5.9 years, 54.1% of the patients were male, and concomitant procedures were performed in 43.2% of the patients. The majority (69%) of the implanted sizes were 23 mm and 25 mm.

RESULTS

At 1 year, overall survival was 94.0%, whereas freedom from valve-related death was 98.6%. There were 9 (1.5%) early (≤ 30 days) and 27 (4.4%) late (>30 days) deaths. Early and late valve-related mortality was 0.3% (n = 2) and 1.1% (n = 7), respectively. Freedom from explant was 97.6%; 10 valves were explanted for endocarditis and 4 for paravalvular leak. There were 10 (1.6%) early and 5 (0.8%) late strokes. Atrioventricular block requiring pacemaker implant occurred in 8 (1.3%) and 1 (0.2%) patients in the early and late postoperative period, respectively. Thrombocytopenia was seen in 27 cases (4.4%) in the early postoperative period. Preoperatively, 93.8% of patients were in New York Heart Association functional classes II through IV, whereas at 1 year 96.9% of patients were in New York Heart Association functional classes I and II. At 1-year follow-up, mean and peak pressure gradients were 7.2 and 14.6 mm Hg, respectively. Indexed left ventricular mass decreased by 12% from 138 g/m(2) at discharge to 122 g/m(2) at 1 year.

CONCLUSIONS

At 1-year follow-up after Freedom Solo implantation, we found acceptable clinical results with low mortality and morbidity and good hemodynamic performance, confirming safety and effectiveness in this multicenter experience.

The TRIBECA study: (TRI)fecta (B)ioprosthesis (E)valuation versus (C)arpentier Magna-Ease in (A)ortic position

OBJECTIVE

To determine whether the Trifecta bioprosthetic aortic valve produces postoperative haemodynamic results comparable with or better than those of the Magna Ease aortic valve bioprosthesis.

METHODS

We retrospectively reviewed the medical records of patients who had undergone aortic valve replacement with Trifecta or Magna Ease prostheses at eight European institutions between January 2011 and May 2013, and analysed early postoperative haemodynamic performance by means of echocardiography.

RESULTS

A total of 791 patients underwent aortic valve replacement (469 Magna Ease, 322 Trifecta). Haemodynamic variables were evaluated on discharge and during the follow-up (minimum 6 months, maximum 12 months). The mean gradient and the indexed effective orifice area (IEOA) were as follows: 10 mmHg [interquartile range (IQR): 8-13] and 1.10 cm(2)/m(2) (IQR: 0.95-1.27) for Trifecta; 16 mmHg (IQR: 11-22) and 0.96 cm(2)/m(2) (IQR: 0.77-1.13) for Magna Ease (P < 0.001). These significant differences were maintained across all valve sizes. Similar statistically significant differences were found when patients were matched and/or stratified for preoperative characteristics: body-surface area, ejection fraction, mean gradients and valve size. Severe prosthesis-patient mismatch (IEOA: <0.65 cm(2)/m(2)) was detected in 2 patients (0.6%) with Trifecta and 40 patients (8.5%) with Magna Ease (P < 0.001).

CONCLUSIONS

The haemodynamic performance of the Trifecta bioprosthesis was superior to that of the Magna Ease valve across all conventional prosthesis sizes, with almost no incidence of severe patient-prosthesis mismatch. The long-term follow-up is needed to determine whether these significant haemodynamic differences will persist, and influence clinical outcomes.

Early hemodynamic performance of the third generation St Jude Trifecta aortic prosthesis: A systematic review and meta-analysis

OBJECTIVE

The Trifecta aortic prosthesis is a latest-generation trileaflet stented pericardial valve designed for supra-annular placement in the aortic position. Robust clinical evidence and long-term follow-up data for this new prosthesis are lacking; a systematic review was conducted to assess current evidence.

METHODS

A comprehensive search from 6 electronic databases was performed, with time period parameters dating from database inception to January 2014. Results utilizing Trifecta prosthesis for aortic valve replacement (AVR) were identified.

RESULTS

A total of 13 studies with 2549 patients undergoing AVR with this prosthesis were included in this review. The mean proportion of patients with aortic stenosis was 82.4%, with a mean gradient of 47.4 mm Hg, and a pooled effective orifice area (EOA) of 0.74 cm(2). Valve sizes of 21 mm and 23 mm were implanted in 71.3% of patients. The pooled rates of 30-day mortality, cerebrovascular accidents, and acute kidney injuries were 2.7%, 1.9%, and 2.6%, respectively. After implantation, the pooled mean gradient decreased to 9.2 mm Hg, whereas discharge EOA increased to 1.8 cm(2), compared with preoperative parameters. Among included studies with significant heterogeneity detected, most patients had satisfactory patient-prosthesis mismatch, with 2.7% having severe mismatch.

CONCLUSIONS

The present systematic review demonstrated that short-term AVR with this prosthesis provided excellent early safety and hemodynamic outcomes with acceptable mean gradients and EOA. Long-term follow-up and randomized controlled trials are warranted to confirm the early results.

Hemodynamic performance of Trifecta: single-center experience of 400 patients

OBJECTIVE

To evaluate postoperative hemodynamic gradients and early outcomes of aortic valve replacement with the Trifecta bioprosthesis.

METHODS

Between 2011 and 2013, 400 patients underwent aortic valve replacement with a Trifecta bioprosthesis. Gradients were calculated by transthoracic echocardiography before discharge. Data were collected retrospectively; patients with postoperative severe left ventricular dysfunction or > mild mitral regurgitation were excluded.

RESULTS

The mean age was 75.9 ± 8.5 years, 197 (49.25%) patients were male, and 140 (35%) were >80-years old. Concomitant procedures were performed in 207 (51.75%) patients, and 30 (7.5%) had redo procedures. Supraannular aortoplasty with bovine pericardium was necessary in 25 (6.25%) cases. Hospital mortality was 2.75% (11 patients). Postoperative peak and mean gradients were 21.7 ± 9.3 and 11.1 ± 4.3 mm Hg for 19-mm valves (n = 29); 19.5 ± 7 and 9.7 ± 3.6 mm Hg for 21-mm valves (n = 158); 17.3 ± 6.6 and 8.7 ± 3.2 mm Hg for 23-mm valves (n = 134); 15.1 ± 6.1 and 7.8 ± 3.3 mm Hg for 25-mm valves (n = 56); 13.2 ± 3.7 and 6.9 ± 2.6 mm Hg for 27-mm valves (n = 11). Nine patients had trivial and one had mild transvalvular regurgitation. Mean follow-up was 1 ± 0.62 years; no patient required reoperation. Kaplan-Meier survival at 1 and 2 years was 94.3% ± 1.3% and 93.7% ± 1.4%.

CONCLUSION

Early postoperative gradients are low after Trifecta implantation. Significant transvalvular regurgitation was not observed, but the incidence of supraannular aortoplasty may be increased.

Early hemodynamic performance of the trifecta bioprosthetic valve in patients with aortic valve disease

BACKGROUND

The Trifecta valve (St Jude Medical) is a novel supra-annular aortic bioprosthesis designed to improve hemodynamic performance. We hypothesized that the Trifecta may offer better hemodynamic performance in Japanese patients, in whom the annulus is smaller, compared with Western populations. We compared the early results of hemodynamic performance between the Trifecta and the Magna (Edwards Lifescience) valves at our institution.

METHODS AND RESULTS

The Trifecta was implanted in 33 patients and the Magna was implanted in 41 patients who had aortic valve disease. Postoperative echocardiography was performed just before discharge, and the mean pressure gradient (MPG), effective orifice area (EOA) index and energy loss coefficient (ELCo) index were compared between the 2 groups. The average prosthesis size was similar between the 2 groups (21.1 vs. 21.3mm). The Trifecta group had a significantly lower MPG (P=0.001) and larger EOA index and ELCo index than the Magna group (P<0.001 for both). On multivariate linear regression analysis, use of the Trifecta was the strongest independent determinant of postoperative MPG, EOA and ELCo index.

CONCLUSIONS

The Trifecta valve provides excellent early postoperative hemodynamic performance in Japanese patients. Patients with a small annulus size relative to body size may benefit more from the Trifecta in terms of postoperative hemodynamic performance.