Long-Term Clinical Outcomes of the Carpentier-Edwards Perimount Pericardial Bioprosthesis in Chinese Patients with Single or Multiple Valve Replacement in Aortic, Mitral, or Tricuspid Positions

Procedural selection strategy and clinical outcomes in mitral valve surgery with concomitant aortic valve replacement in elderly patients

Introduction

In the context of double-valve surgery for elderly high-risk patients involving both the aortic and mitral valves, a clinically significant problem has been that no clear criteria or surgical strategies have been reported for the selection of mitral valve plasty (MVP) or mitral valve replacement (MVR) for mitral valve disease management during surgical aortic valve replacement (SAVR) to achieve better clinical outcomes. This study investigated valve durability and survival using our surgical strategy for mitral valve disease with concomitant SAVR in elderly patients.

Methods

Eighty-six patients aged > 65 years (mean 75 years) who underwent a double-valve procedure for mitral valve surgery with concomitant SAVR from 2010 to 2022 were reviewed. Our surgical strategy for mitral valve disease with concomitant SAVR for the elderly patients was as follows: MVP was selected for patients in whom mitral valve disease was expected to be controlled with simple surgical procedures (n = 47), otherwise MVR was selected (n = 39).

Results

The hospital mortality rate was 8% (n = 7). The mean follow-up was 4.9 (0-12.3) years. And the 10-year survival rate was 62%. The 10-year freedom from aortic valve reoperation rate was 95%. No mitral valve reintervention was performed during follow-up. Echocardiographic follow-up demonstrated freedom from at least moderate mitral regurgitation in 86% of cases at 10 years.

Conclusion

In double-valve surgery for elderly high-risk patients, appropriate selection of the mitral valve procedure with concomitant SAVR provided better early and long-term survival and valve durability. This surgical strategy may be beneficial in elderly patients with combined aortic and mitral valve disease.

Medium long-term follow-up outcomes of BalMedic® bovine pericardial bioprosthetic valve in the mitral position

Background

In China, where Rheumatic heart disease is still prevalent, two thirds of valve replacements are in mitral position. Before a valve replacement operation is conducted, most patients have reached Class III/IV heart function under the New York Heart Association (NYHA) classification system. As the background to this disease is quite different to that of degenerated cases, which are more prevalent in Western countries, the development of an artificial heart valve that is suitable for local patients is very significant for China. In this medium long-term clinical follow-up study, a data analysis was conducted of domestic heart valve production for mitral replacement.

Methods

A total of 288 patients who underwent mitral valve replacements from 2005 to 2015 at 2 cardiac surgery centres (i.e., The Affiliated Hospital of Qingdao University, and The First People’s Hospital of Yulin) were evaluated. All implanted bioprostheses were BalMedic^® bovine pericardial bioprosthetic valves, which had been granted marketing approval by the China Food and Drug Administration (CFDA) in 2003. Double valve cases that involved both aortic and mitral replacements were not included in the study. On average, patients were aged 54.5±10.8 (range, 11 to 77 years) before the procedure. The mean follow-up period was 7.2±2.6 years. The study examined the overall survival (OS) curve, and different age group results. To gain further insights into the functions of the valves, the OS curve and the age group results for the reoperation-free and structural valve deterioration (SVD)-free rates are also presented.

Results

The 10-year OS rate was 65.6%, the 10-year reoperation-free rate was 76.3%, and the 10-year SVD-free rate was 58.0%. In relation to the age group results, younger patients had higher survival rates, while older patients had higher reoperation-free rates and SVD-free rates.

Conclusions

In relation to the medium long-term clinical follow-up results, the durability performance of the BalMedic^® bovine pericardial valve in the mitral position was satisfactory, especially among patients whose heart function was worse than that of Western sufferers. Survival rate, reoperation-free rate and SVD-free rate were used for the comprehensive analysis.

Long-term survival after Carpentier-Edwards Perimount aortic valve replacement in Western Denmark: a multi-centre observational study

Background

This study describes the long-term survival, risk of reoperation and clinical outcomes of patients undergoing solitary surgical aortic valve replacement (SAVR) with a Carpentier-Edwards Perimount (CE-P) bioprosthetic in Western Denmark. The renewed interest in SAVR is based on the questioning regarding the long-term survival since new aortic replacement technique such as transcatheter aortic-valve replacement (TAVR) probably have shorter durability, why assessment of long-term survival could be a key issue for patients.

Methods

From November 1999 to November 2013 a cohort of a total of 1604 patients with a median age of 73 years (IQR: 69–78) undergoing solitary SAVR with CE-P in Western Denmark was obtained November 2018 from the Western Danish Heart Registry (WDHR). The primary endpoint was long-term survival from all-cause mortality. Secondary endpoints were survival free from major adverse cardiovascular and cerebral events (MACCE), risk of reoperation, cause of late death, patient-prothesis mismatch, risk of AMI, stroke, pacemaker or ICD implantation and postoperative atrial fibrillation (POAF). Time-to-event analysis was performed with Kaplan-Meier curve, cumulative incidence function was performed with Nelson-Aalen cumulative hazard estimates. Cox regression was applied to detect risk factors for death and reoperation.

Results

In-hospital mortality was 2.7% and 30-day mortality at 3.4%. The 5-, 10- and 15-year survival from all-cause mortality was 77, 52 and 24%, respectively. Survival without MACCE was 80% after 10 years. Significant risk factors of mortality were small valves, smoking and EuroSCORE II ≥4%. The risk of reoperation was < 5% after 7.5 years and significant risk factors were valve prosthesis-patient mismatch and EuroSCORE II ≥4%.

Conclusions

Patients undergoing aortic valve replacement with a Carpentier-Edwards Perimount valve shows a very satisfying long-term survival. Future research should aim to investigate biological valves long-term durability for comparison of different SAVR to different TAVR in long perspective.

A single-center 14-year follow-up study of the BalMedic® bovine pericardial bioprosthetic valve

Background

The causes of valvular disease in China are complex, with a broad age distribution. For patients with early mechanical valve replacement, the quality of life is affected by postoperative anticoagulation-related complications. Since 2005, we have used bioprosthetic valves to provide more options for patients. In this study, we retrospectively analyzed the 14-year follow-up data of patients undergoing BalMedic bovine pericardial bioprosthetic valve replacement (manufacturer: Beijing Balance Medical Tech Co., Ltd.) to evaluate its intermediate- to long-term clinical effectiveness.

Methods

From 2005 to 2014, 336 BalMedic pericardial bioprosthesis valves were implanted in 299 patients (mean age 53.5 years, 59.86% female) at The First People’s Hospital of Yulin. Among followed up 290 discharged patients, 284 underwent aortic valve replacement and mitral valve replacement (AVR group, MVR group) for further grouping analysis, 6 underwent tricuspid valve replacement (TVR). The mean follow-up was 7.7±2.5 years (5 to 14), for a total of 2,196 valve-years, 98.28% of the patients completed follow-up.

Results

The perioperative mortality was 3% (9/299). After discharge, 68 patients (23.4%, 68/290) died, and 36 (12.4% 36/290) underwent the second valve replacement. The overall 5- and 10-year survival rates were 89.95% and 72.53%, respectively. For patients undergoing AVR alone, the overall 10-year survival rates were 80.64%, the reoperation-free rates were 92.94%, and the SVD-free rates were 90.95%. For patients undergoing MVR and double valve replacement (DVR group), the 10-year survival rates were 67.21% and 82.90%, the reoperation-free rates were 72.26% and 73.33%, the SVD-free rates were 58.90% and 53.80%, respectively. Subgroup analysis by age showed no significant intergroup difference in overall survival but a significant intergroup difference in reoperation-free and SVD-free rates (P<0.05).

Conclusions

With a similar 10-year overall survival rate as its foreign counterparts, BalMedic bovine pericardial bioprosthesis is reliable choice for both aortic valve and mitral valve. In patients undergoing AVR, the BalMedic valve is superior to the similar foreign counterparts in overall survival, reoperation-free survival, and SVD-free rates. While in MVR or DVR, Chinese patients are younger because of different etiology, postoperative outcomes show non-inferior to those from the foreign counterparts.

Late clinical outcomes of aortic valve replacement with Carpentier-Edwards pericardial valves

Background

The present study aimed to compare the long-term clinical and hemodynamic outcomes of aortic valve replacement using Carpentier-Edwards Perimount (Perimount) or Perimount Magna (Magna) valves.

Methods

We enrolled 430 patients who underwent aortic valve replacements with Perimount (n=58) or Magna (n=372) valves [1998-2013]. Multivariable and inverse probability of treatment weight (IPTW) analyses were performed.

Results

Before IPTW analysis, the overall 8-year survival rate differed significantly between the groups [Perimount 90%±4% vs. Magna 76%±4%; P=0.02; hazard ratio (HR): 0.37 for the Perimount group; 95% confidence interval (CI): 0.17-0.83]. Multivariable analysis of the overall survival identified Perimount valve use as a protective factor (P=0.009; HR: 0.32; 95% CI: 0.14-0.75). Independent risk factors of overall survival were older age, male sex, higher preoperative left ventricular mass index, lower ejection fraction, lower aortic valve pressure gradient, and lower haemoglobin. After applying IPTW, overall survival was again found to be significantly longer in the Perimount group (P=0.04; HR: 0.43; 95% CI: 0.20-0.93). Event-free survival was also better in the Perimount group (P=0.006; HR: 0.38; 95% CI: 0.19-0.75). However, the Magna group had significantly lower aortic valve pressure gradients at one year and five years postoperative.

Conclusions

Although Magna use led to decreased aortic valve pressure gradients at follow-up, overall and event-free survival rates were significantly better with use of the Perimount valve. Additional and larger studies are needed to confirm these results.

Transprosthetic Cuff Leakage of a Bovine Pericardial Aortic Bioprosthesis

The Carpentier-Edwards PERIMOUNT Magna aortic heart valve is the most frequently implanted bioprosthesis. However, the existence of transvalvular cuff leakage necessitating a second cross clamp has been recently reported. The aim of this study is to seek the mechanism, occurrence rate, and influence of cuff leakage on the clinical course. Between September 2012 and August 2018, 754 consecutive patients underwent aortic valve replacement using a Magna aortic prosthesis at a single cardiovascular center. The overall mean patient age was 75 (69-80) years, and the percentage of female gender was 45.5% (343/754). The etiology included aortic stenosis in 506 patients (67.1%) and aortic insufficiency in 248 patients (32.9%). The implanted valve size was 19 mm, 21 mm, 23 mm, 25 mm, and 27 mm in 125 (16.6%), 243 (32.2%), 228 (30.2%), 130 (17.2%), and 28 (3.7%) patients, respectively. The incidence of cuff leakage was 1.59% (12/754). The origin was left-right commissure in all cases, and the jet passed toward the anterior mitral leaflet. In 9 patients (75%), cuff leakage faded completely within 3 months after surgery. Additionally, residual leak was not associated with hemolysis and cardiac events in all cases. Transvalvular cuff leakage should be perceived as a benign leakage. Nonperivalvular oblique jet from the left-right commissure toward the anterior mitral leaflet in transgastric long-axis view is likely to be cuff leakage, and follow-up with protamine administration for mild leak is suggested as the first-line choice of treatment rather than a second aortic clamp.

The Fluid Dynamical Performance of the Carpentier-Edwards PERIMOUNT Magna Ease Prosthesis

The aim of the present in vitro study was the evaluation of the fluid dynamical performance of the Carpentier-Edwards PERIMOUNT Magna Ease depending on the prosthetic size (21, 23, and 25 mm) and the cardiac output (3.6–6.4 L/min). A self-constructed flow channel in combination with particle image velocimetry (PIV) enabled precise results with high reproducibility, focus on maximal and local peek velocities, strain, and velocity gradients. These flow parameters allow insights into the generation of forces that act on blood cells and the aortic wall. The results showed that the 21 and 23 mm valves have a quite similar performance. Maximal velocities were 3.03 ± 0.1 and 2.87 ± 0.13 m/s; maximal strain E_xx, 913.81 ± 173.25 and 896.15 ± 88.16 1/s; maximal velocity gradient E_yx, 1203.14 ± 221.84 1/s and 1200.81 ± 61.83 1/s. The 25 mm size revealed significantly lower values: maximal velocity, 2.47 ± 0.15 m/s; maximal strain E_xx, 592.98 ± 155.80 1/s; maximal velocity gradient E_yx, 823.71 ± 38.64 1/s. In summary, the 25 mm Magna Ease was able to create a wider, more homogenous flow with lower peak velocities especially for higher flow rates. Despite the wider flow, the velocity values close to the aortic walls did not exceed the level of the smaller valves.

Mitral valve replacement with the novel TRIBIO and an established stented bioprosthesis in a sheep model

OBJECTIVES

Heart valve replacement with a bioprosthesis is one of the most frequently performed procedures in cardiac surgery and represents a highly effective therapy to relieve diseased heart valves. Nevertheless, as postoperatively elevated transvalvular gradients and prosthesis-patient mismatch are reported as shortcomings of the procedure or of the currently used devices, there is a need for novel bioprostheses with improved haemodynamics. This study presents preclinical haemodynamic results after mitral valve replacement with the novel TRIBIO bioprosthesis (TRIBIO) compared with an established bioprosthesis in a sheep model.

METHODS

Six female sheep had their mitral valves replaced with the TRIBIO and 3 with the Carpentier-Edwards Perimount, both sized 19 mm. The TRIBIO consists of a flexible valve-bearing crown, a force-decoupled interface and an intra-annular base ring. Mean and peak transvalvular gradients as well as an effective orifice area were monitored in both groups using transthoracic echocardiography over the course of the 90-day study.

RESULTS

In both groups, haemodynamic performance diminished over time. The TRIBIO demonstrated overall superior haemodynamics, i.e. lower transvalvular gradients and a larger effective orifice area, although the results were not statistically significant. On Day 90, the mean values for the mean and peak transvalvular gradients and the effective orifice area were 6 mmHg, 10.2 mmHg and 1.2 cm2 for the TRIBIO and 10 mmHg, 15.8 mmHg and 0.8 cm2 for the Carpentier-Edwards Perimount, respectively.

CONCLUSIONS

This study demonstrates a trend towards improved preclinical haemodynamic performance following mitral valve replacement with the TRIBIO compared to that with an established bioprosthesis in a sheep model.