Comparison of mid-term haemodynamic performance between the BioValsalva and the BioIntegral valved conduits after aortic root replacement

The Sutureless Biological Bentall Procedure: A New Technique to Create a Modular Valve-Conduit Construct

The Perceval sutureless valve (Corcym, Saluggia, Italy) has been effectively adopted by surgeons for the treatment of degenerative aortic valve stenosis. Its simplified true sutureless implantation technique has proven useful for minimally invasive cases, but the use of Perceval as part of more complex root replacement has not previously been described. We present a novel technical modification to the manufactured biologic Bentall, called the sutureless biological Bentall. This technique allows for a true modular valve-conduit construction that will simplify future reintervention.

Aortic Root Replacement Surgery—A Center Experience with Biological Valve Prostheses

Objective: Outcomes after surgical aortic root replacement using different valved conduits are rarely reported. The present study shows the experience of a single center with the use of the partially biological LABCOR (LC) conduit and the fully biological BioIntegral (BI) conduit. Special attention was paid to preoperative endocarditis. Methods: All 266 patients who underwent aortic root replacement by an LC conduit (n = 193) or a BI conduit (n = 73) between 01/01/2014 and 31/12/2020 were studied retrospectively. Dependency on an extracorporeal life support system preoperatively and congenital heart disease were exclusion criteria. For patients with (n = 67) and without (n = 199) preoperative endocarditis subanalyses were made. Results: Patients treated with a BI conduit were more likely to have diabetes mellitus (21.9 vs. 6.7%, p < 0.001), previous cardiac surgery (86.3 vs. 16.6%; p < 0.001), permanent pacemaker (21.9 vs. 2.1%; p < 0.001), and had a higher EuroSCORE II (14.9 vs. 4.1%; p < 0.001). The BI conduit was used more frequently for prosthetic endocarditis (75.3 vs. 3.6%; <0.001), and the LC conduit was used predominantly for ascending aortic aneurysms (80.3 vs. 41.1%; <0.001) and Stanford type A aortic dissections (24.9 vs. 9.6%; p = 0.006). The LC conduit was used more often for elective (61.7 vs. 47.9%; p = 0.043) and emergency (27.5 vs. 15.1%; p = 0–035) surgeries, and the BI conduit for urgent surgeries (37.0 vs. 10.9%; p < 0.001). Conduit sizes did not differ significantly, with a median of 25 mm in each case. Surgical times were longer in the BI group. In the LC group, coronary artery bypass grafting and proximal or total replacement of the aortic arch were combined more frequently, whereas in the BI group, partial replacement of the aortic arch were combined. In the BI group, ICU length of stay and duration of ventilation were longer, and rates of tracheostomy and atrioventricular block, pacemaker dependence, dialysis, and 30-day mortality were higher. Atrial fibrillation occurred more frequently in the LC group. Follow-up time was longer and rates of stroke and cardiac death were less frequent in the LC group. Postoperative echocardiographic findings at follow-up were not significantly different between conduits. Survival of LC patients was better than that of BI patients. In the subanalysis of patients with preoperative endocarditis, significant differences between the used conduits were found with respect to previous cardiac surgery, EuroSCORE II, aortic valve and prosthesis endocarditis, elective operation, duration of operation, and proximal aortic arch replacement. For patients without preoperative endocarditis, significant differences were observed concerning previous cardiac surgery, pacemaker implantation history, duration of procedure, and bypass time. The Kaplan–Meier curves for the subanalyses showed no significant differences between the used conduits. Conclusions: Both biological conduits studied here are equally suitable in principle for complete replacement of the aortic root in all aortic root pathologies. The BI conduit is often used in bail-out situations, especially in severe endocarditis, without being able to show a clinical advantage over the LC conduit in this context.

Early and midterm outcomes of a bentall operation using an all-biological valved BioConduit™

OBJECTIVES

To analyze the midterm results of aortic root replacement using the valved, all biological, No React®, BioConduit™.

METHODS

From 2017 to 2020, we prospectively followed 91 consecutive patients who underwent a Bentall procedure with a BioConduit™ valved graft in our institution. The primary outcomes were aortic bioprosthetic valve dysfunction and mortality according to Valve Academic Research Consortium 3 (VARC3).

RESULTS

Mean age was 70 ± 10 years and 67 patients (74%) were men. Ascending aortic aneurysm (72%), aortic valve regurgitation (51%) or stenosis (20%) and acute endocarditis (14%) were the main indications for surgery. Seventy-four patients (81.3%) were followed up at 1 year. The perioperative mortality was 8% (n = 8), the early, 1 year, mortality was 2% (n = 2) and the midterm mortality, at 4 years of follow up, was 4% (n = 3). Ten patients fulfilled the criteria for hemodynamic valve deterioration at 1 year (13%) and 14 for a bioprosthetic valve failure during the entire follow-up (17%).

CONCLUSIONS

We are reporting early and midterm results of Bentall procedures with the all-biological, valved, No-React® BioConduit™. To our knowledge, this is the first study reporting an early and midterm unexpectedly high rate of non-structural prosthetic hemodynamic deterioration. The rate of endocarditis and atrioventricular disconnections remain similar to previous studies.

High incidence of fever in patients after biointegral pulmonic valved conduit implantation

OBJECTIVE

To describe our short- and medium-term outcomes using the BioIntegral pulmonic conduit.

METHODS

Between August 2018 and September 2019, the BioIntegral pulmonic valved conduit was used for right ventricular outflow tract reconstruction in 48 patients. The data were retrospectively retrieved from the patient charts.

RESULTS

The median age at surgery was 36 months (interquartile range [IQR] = 18-62 months). The diagnoses were pulmonary atresia-ventricular septal defect in 28 patients, absent pulmonary valve in four patients, truncus arteriosus in six patients, TGA-VSD-PS in five patients, conduit stenosis in three patients, and left venticular outflow tract obstruction requiring a Ross operation in two patients. In the postoperative short-term follow-up, 15 patients out of 48 had a high fever. Of these, 12 patients had concomitantly elevated C-reactive protein levels. There were no patients with blood culture positivity. The median postoperative length of hospital stay was 14 days (IQR = 8-21 days). The overall mortality was 4% in two patients, one died of right ventricular failure and multiple organ failure and one died of pulmonary embolism. The two patients who died were not among the 15 patients with fever. However, four patients with fever underwent balloon angioplasty for conduit restenosis in their medium-term follow-up.

CONCLUSION

There was a high incidence of fever and adverse outcomes in the short-term postoperative follow-up of patients in whom the BioIntegral pulmonic valved conduit was implanted. Caution is advisable in using these conduits until there is convincing evidence about the sterilization and storage standards of these grafts.

Mid-term single-center outcomes of BioIntegral compared to Freestyle aortic conduit implantation

BACKGROUND

Full aortic root replacement with biological conduit has limited options. This non-randomized cohort study aims to compare mid-term clinical and hemodynamic results of the BioIntegral (BI) composite biological versus the stentless Freestyle (FS) conduits in patients undergoing full aortic root replacement.

METHODS

From February 2013 to July 2017, 265 patients underwent aortic root replacement at a single institution (202 BI, 65 FS). Preoperative, intraoperative and postoperative parameters, complications including stroke, myocardial infarction (MI), endocarditis and reoperation were studied. Hemodynamic performance of both conduits was analyzed by echocardiography. Target endpoints were 30-day mortality, two-year survival, two-year freedom from major adverse valve-related and cardiovascular events.

RESULTS

Wider BI conduits were used (BI 27±2 vs. FS 25±2 mm, P<0.0001). The BI group had shorter cardiopulmonary bypass (BI 165±67 vs. FS 200±78 min, P<0.0001) and cross-clamp (BI 102±36 vs. FS 122±40 min, P=0.001) times. Thirty-day mortality was similar in both groups. There were fewer conduit-related reoperations in the BI group (BI 0% vs. FS 3%, P=0.012) but higher postoperative atrial fibrillation (BI 31% vs. FS 17%, P=0.025). No significant differences were observed for stroke (BI 5% vs. FS 10%, P=0.947), MI (BI 3% vs. FS 4%, P=0.583), or infective endocarditis (BI 0% vs. FS 2%, P=0.077). No significant hemodynamic differences were evident on follow-up echocardiography while an improved overall survival trend was seen in the BI group (P=0.062).

CONCLUSIONS

FS and BI provide comparable clinical mid-term results and hemodynamic parameters. Simplified implantation technique providing shorter cardiopulmonary bypass and operation times are advantageous for BI.

An Alternative Approach to Build a "Biologic Bentall" From a Pericardial Tube and a Sutureless Valve

This report describes a technique to create a biologic Bentall from a pericardial tube and a rapid deployment valve. This technique facilitates reimplantation of the coronary arteries because the proximal anastomosis is sewn before valve implantation and allows suturing of the coronary ostia from inside and outside, given that there is no interference with the implanted valve. Indications for this technique include complex redo cases and patients with contraindications to a conventional Bentall procedure. This technique has been used in 2 patients with good results.