Absence of prosthesis-patient mismatch with the new generation of Edwards stented aortic bioprosthesis

A Controlled Trial Comparing One-Year Hemodynamics of Two Bovine Pericardial Valves

BACKGROUND

 This randomized controlled trial was designed to compare 1-year hemodynamic performances and clinical outcomes after aortic valve replacement (AVR) using a recently introduced (the AVALUS group) and worldwide used (the CEPME group) bovine pericardial bioprostheses.

METHODS

 Patients were screened to enroll 70 patients in each group based on a noninferiority design. The primary endpoint of the trial was the mean pressure gradient across the aortic valve (AVMPG) at 1 year after surgery. One-year echocardiographic data were obtained from 92.1% (129 of 140 patients) of the study patients.

RESULTS

 There were no differences in baseline characteristics, including sex and body surface area (1.64 ± 0.18 vs. 1.65 ± 0.15 m2) between the groups. The AVMPG on 1-year echocardiography was 14.0 ± 4.3 and 13.9 ± 5.1 mmHg in the AVALUS and CEPME groups, respectively (the p-value for noninferiority was 0.0004). In the subgroup analyses for the respective size of the prostheses, AVMPG of the 19-mm prostheses was significantly lower in the AVALUS group than in the CEPME group (14.0 ± 4.3 vs. 20.0 ± 4.7 mmHg, p = 0.012), whereas those of the other sizes were not significantly different between the two groups. There were no significant differences in the effective orifice area (1.49 ± 0.40 vs. 1.53 ± 0.38 cm2, p = 0.500) or effective orifice area index (0.91 ± 0.22 vs 0.93 ± 0.23 cm2/m2, p = 0.570) in all the patients, or in the subgroup analysis for the 19-mm prosthesis. There were no differences in the 1-year clinical outcomes between the two groups.

CONCLUSION

 The 1-year hemodynamic and clinical outcomes of the AVALUS group were noninferior to those of the CEPME group (NCT03796442).

Preliminary Report from a Randomized Controlled Trial Comparing Two Bovine Pericardial Valves

BACKGROUND

A randomized controlled trial was designed to compare 1-year hemodynamic profiles and clinical outcomes after bioprosthetic aortic valve replacement (AVR) using a recently introduced (study group) and world-widely used (control group) bovine pericardial bioprostheses. This study evaluated early postoperative outcomes as a preliminary analysis.

METHODS

The primary end point of the trial was the mean pressure gradient across the aortic valve (AVMPG) at 1 year after surgery. Patients were screened to enroll 70 patients in each group based on a noninferiority design. Early postoperative hemodynamic and clinical outcomes were compared between the two groups.

RESULTS

There were no differences in baseline characteristics, including sex and body surface area (1.64 ± 0.18 vs. 1.65 ± 0.15 m2) between the two groups. The AVMPG on early postoperative echocardiography was 15.2 ± 4.6 mm Hg and 16.5 ± 6.2 mm Hg in the study and control groups, respectively (p = 0.177). Although AVMPG of the 19 mm prostheses was lower in the study group than in the control group (17.0 ± 6.3 mm Hg vs. 22.8 ± 6.6 mm Hg, p = 0.039), there were no significant differences in the effective orifice area in all patients (1.57 ± 0.41 cm2 vs. 1.53 ± 0.34 cm2, p = 0.568), and each valve size. The effective orifice area index was also similar between the two groups in overall (p = 0.352), and in each valve size. There were no significant differences in clinical outcomes including operative mortality and postoperative complications between the two groups.

CONCLUSION

Early postoperative hemodynamic and clinical results after AVR using a recently introduced bovine pericardial valve were comparable with those using the control valve (NCT03796442).

Improved Early Outcomes in Women Undergoing Aortic Valve Interventions

Surgical aortic valve replacement (SAVR) in female patients has been associated with higher mortality (up to 3.3-8.9%) and postoperative complication rates when compared with their male counterparts. In recent years, TAVI has been shown to provide a greater benefit than SAVR in women. We sought to assess the early outcomes of the contemporary aortic valve intervention practice (surgical and transcatheter) in patients referred to our cardiac surgery unit. The data of consecutive patients who underwent isolated aortic valve intervention for aortic valve stenosis during the 2018-2022 period were retrieved from our internal database. Several preoperative, intraoperative, and postoperative variables were analyzed, including the predicted risk of a prosthesis-patient mismatch. Nine hundred and fifty-five consecutive patients-514 women and 441 men-were included. Among them, 480 patients-276 female and 204 male-received a transcatheter procedure, and 475-238 women and 237 men-had conventional SAVR. The women were older and had higher EuroSCORE II, while the male patients presented a higher incidence of cardiovascular comorbidities. There was no difference in mortality or major postoperative complication rates after either the surgical or transcatheter procedures between the female and male populations. The availability and targeted use of different techniques and technologies have enabled the safe and effective treatment of female patients treated for severe symptomatic aortic valve stenosis with similar results when compared with their male counterparts.

Two-Year Clinical Follow-Up Assessment of the Novel Cingular Surgical Bovine Pericardial Valve

Objectives: To evaluate the 2-year clinical safety and hemodynamic outcomes of the Cingular bovine pericardial bioprosthesis. Methods: A prospective, multicenter, single-arm trial was conducted in patients who required aortic or mitral valve replacement. From March 2016 to October 2017, 197 patients were implanted with the Cingular bovine pericardial valve at five sites in China. The clinical outcomes and hemodynamic performance were assessed through a 2-year follow-up. Clinical safety events were reviewed by an independent clinical events committee, and echocardiographic data were assessed by an independent core laboratory. Results: The mean age was 66.9 ± 4.9 years. The 2-year survival rate was 96.4%. A complete 2-year clinical follow-up was achieved in 189 of 190 survivors. No case of structural valve deterioration, major perivalvular leak, prosthetic valve endocarditis, or valve-related reoperation was seen. For the aortic valve, the mean pressure gradient observed was 12.5 ± 4.0 mm Hg, and the effective orifice area (EOA) was 2.0 ± 0.3 cm2. For the smaller size aortic valves, 19 mm and 21 mm, respective mean EOA values of 1.7 ± 0.2 cm2 and 1.8 ± 0.2 cm2 were found. The values for mean pressure gradient and mean EOA for mitral bioprostheses were 4.0 ± 1.4 mm Hg and 2.2 ± 0.3 cm2, respectively. There was no significant change between 1-year and 2-year hemodynamic performance. Conclusions: The Cingular bovine pericardial valve showed favorable clinical safety and hemodynamic outcomes over a 2-year follow-up. Further follow-up is required to validate the long-term durability.

Serial echocardiographic evaluation of the Perimount Magna Ease prosthesis

Background

The Carpentier-Edwards Perimount Magna Ease prosthesis (PME) represents the latest generation of stented bioprostheses used for surgical aortic valve replacement (SAVR). The aim of our study was to evaluate the long-term clinical outcome and hemodynamic performance of the prosthesis with a focus on the incidence and course of structural valve deterioration (SVD) by serial echocardiographic examinations.

Methods

SAVR with the PME was performed in 58 consecutive patients between 2007 and 2008. Transthoracic echocardiography was performed preoperatively, at discharge and annually during a 10-year follow-up at the German Heart Center Munich.

Results

Mean age at surgery was 62±14 years. At discharge (n=57), the overall mean pressure gradient (MPG) and effective orifice area (EOA) were 15.8±4.1 mmHg and 1.8±0.4 cm², respectively. Moderate patient-prosthesis mismatch (PPM) was present in 18 patients (32%) and severe PPM in 6 patients (11%) at discharge. Ten years following SAVR (n=33), the overall MPG was 16.6±7.3 mmHg and EOA was 1.3±0.4 cm².Thirty-day and late mortality was 2% (n=1) and 21% (n=12), respectively. Survival at 1, 5, and 10 years was 94.7%±3.3%, 91.1%±4.1%, and 77.3%±5.9%, respectively. Freedom from reoperation at 10 years was 88.8%±4.7%. Ten years after PME implantation the cumulative incidence of any SVD, severe SVD, and bioprosthetic valve failure (BVF) was 25%±6%, 14%±5%, and 16%±5%, respectively.

Conclusions

The PME shows an excellent hemodynamic performance over the course of 10 years with development of clinically relevant SVD as late as 6 years post implant, and a 10-year incidence of severe SVD of 14%.

Mid-term follow-up after aortic valve replacement with the Carpentier Edwards Magna Ease prosthesis

BACKGROUND

Approximately 250,000 heart valve operations are performed annually worldwide. An intensive research and development effort has led to progressively more advanced heart valve prostheses. The Carpentier-Edwards Perimount Magna Ease (CEPME) prosthesis represents the latest iteration of the Edwards Perimount series of aortic tissue valves. The current study aims to evaluate the midterm performance of this bioprosthesis.

METHODS

Five hundred and eighteen patients with aortic stenosis underwent aortic valve replacement with the CEPME valve at Papworth Hospital between August 2008 and November 2011. After a minimum of 3 years from the index operation, eligible patients were retrospectively and consecutively recruited to participate. Recruitment was closed after 100 eligible patients had completed all study assessments. Investigations at follow-up included echocardiography, and NYHA status. Primary endpoints included valve performance measures.

RESULTS

The mean age was 72 years, 64% were male and median follow-up was 5.1 years. NYHA status had improved in 66% of patients. The average postoperative peak and mean pressure gradients decreased by 51.2 mmHg (64.5%) and 31.8 mmHg (59.4%), with a significant improvement in NYHA status. The frequency of moderate aortic regurgitation was 3%. There was no evidence for structural valve deterioration.

CONCLUSIONS

The CEPME has excellent mid-term durability. Its use effectively improves haemodynamics and functional capacity.

One-year outcome with a bovine pericardial valve

Objectives

To evaluate the safety and effectiveness of a novel surgical bovine pericardial valve for aortic and mitral valve replacements.

Methods

Between March 2016 and October 2017, 197 patients (mean age, 66.9 ± 4.9 years; 40.6% were women) underwent aortic valve replacement and mitral valve replacement and were implanted with the Cingular bovine pericardial valve (Shanghai Cingular Biotech Corporation, Shanghai, China) in a prospective, multicenter, single-arm trial in China. A total of 161 aortic and 49 mitral prostheses were implanted. Patients were followed up to 1 year. The primary end point was the 1-year overall rate of valve-related complications, including thromboembolic event, valve thrombosis, major hemorrhage event, major perivalvular leak, and prosthetic valve endocarditis.

Results

The 1-year overall rate of valve-related complications was 0.5% (95% confidence interval, 0.1%-3.7%). The 1-year survival was 96.4%. The mean gradient and effective orifice area for aortic prostheses at 1 year postoperatively were 12.8 ± 4.4 mm Hg and 1.9 ± 0.3 cm², respectively. Particularly, the mean gradients and effective orifice area for 19 mm and 21 mm sizes of aortic prostheses at 1 year were 17.0 ± 3.8 mm Hg and 1.6 ± 0.2 cm², 13.1 ± 4.0 mm Hg and 1.8 ± 0.1 cm², respectively. Patient–prosthesis mismatch occurred in only 1.3% patients for aortic valve implantation at 1 month. No structural valve deterioration and no endocarditis occurred.

Conclusions

The Cingular bovine pericardial valve was safe and effective for surgical aortic and mitral valve replacement. The 1-year rate of valve-related complications was very low. Early hemodynamic performance was excellent even for the small aortic root.

Outcomes of a Rapid Deployment Aortic Valve versus its Conventional Counterpart

Objective

The aim of this study was to compare outcomes after rapid-deployment aortic valve replacement (RDAVR) and conventional aortic valve replacement (AVR) from two studies.

Methods

Patients who underwent RDAVR (INTUITY valve) in the prospective, 5-year, single-arm multicenter TRITON study, or conventional AVR (Perimount Magna Ease valve) in the prospective Perimount Magna Ease postmarket study, were propensity score matched and compared for procedural, hemodynamic, safety, and clinical outcomes.

Results

Matched RDAVR (n = 106) and conventional AVR (n = 106) patients had similar baseline characteristics (mean ± SD age, 72.8 ± 7.6 vs 72.5 ± 7.4 years; male 59.4% vs 61.3%) and procedures (concomitant procedures: 41.5% vs 50.9%). Mean ± SD aortic cross-clamp time was significantly shorter in RDAVR than AVR patients (51.8 ± 20.9 vs 73.9 ± 33.2 minutes; P < 0.001), as was mean cardiopulmonary bypass time (82.8 ± 34.2 vs 102.4 ± 41.7 minutes; P < 0.001). At 1 year, RDAVR patients showed significantly lower mean ± SD and peak aortic valve gradients (9.0 ± 3.4 and 17.0 ± 6.2 mm Hg, respectively) than conventional AVR patients (13.4 ± 5.5 and 24.2 ± 10.8 mm Hg, respectively; all P < 0.001). Patient-prosthesis mismatch was significantly less common with RDAVR than with AVR [overall: 16/66 (24.2%) vs 46/76 (60.5%); P = 0.007; severe: 2/66 (3.0%) vs 13/76 (17.1%)]. There were no significant differences between the RDAVR and AVR groups regarding 30-day safety endpoints. Survival rates in the RDAVR and conventional AVR groups were, respectively, 99.1% and 100.0% at 30 days, 97.1% and 95.1% at 1 year, and 93.3% and 94.1% at 3 years ( P = nonsignificant).

Conclusions

In this retrospective study with matched populations, the RDAVR with the INTUITY valve system provided superior procedural and hemodynamic outcomes than a standard bioprosthesis without compromising safety.

Outcomes of surgical aortic valve replacement using Carpentier-Edwards PERIMOUNT bioprosthesis series in elderly patients with severe aortic valve stenosis: a retrospective cohort study

OBJECTIVE

We sought to compare the outcomes of Carpentier-Edwards PERIMOUNT (CEP), Magna and Magna Ease valves in Japanese elderly patients with severe aortic valve stenosis (AS).

METHODS

We retrospectively identified 136 patients (mean age 76.61 ± 5.5 years old) who had undergone isolated surgical aortic valve replacement (SAVR) using CEP, Magna, and Magna Ease valves at a single institution, from January 2001 to December 2013. We compared the valves according to their survival rates, freedom from major adverse cardiovascular and cerebrovascular events (MACCE), and durability and hemodynamic performance by echocardiographic data.

RESULTS

The thirty-day mortality after isolated SAVR in all the valve groups was "zero". The differences among the three groups in terms of survival rates, freedom from MACCE at 2 years, durability and hemodynamic performance of the valves by echocardiographic data was not statistically significant.

CONCLUSION

All CEP, Magna and Magna Ease valves seemed to be similarly useful in Japanese elderly patients with severe AS. Our data did not clearly support the superiority of one valve over another. A longer follow-up period might be necessary to compare the durability and hemodynamic performance of these valves with more certainty.

Cuff leakage, not paravalvular leakage, in the Carpentier Edwards PERIMOUNT Magna Ease aortic bioprosthesis

Though the Carpentier Edwards PERIMOUNT Magna Ease valve is a bioprosthesis with documented excellent haemodynamics and easy implantability, this valve has a gap between the cobalt-chromium-nickel alloy stent and silicone sewing ring. This gap, which is widest just below each of the three commissural struts, lacks silicone and leaves the two-layer polytetrafluoroethylene fabric unsupported and unprotected. If the needle of a valve suture is placed in this structurally weak area of the sewing ring, the resultant fabric tear may result in a true cuff leakage, not the usual paravalvular leakage. We describe this pitfall in the context of a recent operation to alert surgeons everywhere that suture placement too close to the stent (missing the silicone sewing ring) can result in postoperative cuff leakage. We need to be very careful to include the silicone ring in each stitch to prevent injury to the valve cuff of this prosthesis and to avoid cuff leakage.

Current status and future perspectives of prosthetic valve selection for aortic valve replacement

Aortic valve abnormality is the most frequent form of valvular heart disease. Notably, aortic stenosis in the elderly population has been increasingly common. Aortic valve replacement (AVR) using prosthetic valve has been still believed as a gold standard surgical intervention for various types of diseased aortic valve. The numerous reports and studies evaluating the clinical outcomes and durability of prosthesis were revealed, however, prosthesis selection for AVR is still debated. In twenty-first century, paradigm shift of prosthesis preference might be emerged from mechanical valves to bioprosthesis due to the development of the technology. Moreover, transcatheter aortic valve implantation accelerated among the worldwide trends. It could be developed having the potential to reduce the mortality and morbidity associated with high-risk traditional AVR. After the current guidelines for the management of patients with valvular heart disease, we should consider the valve choice in various patients' profile setting. This review summarizes the current status of prosthesis selection and future perspectives of ideal aortic valve intervention, including minimal invasive care.

Early Doppler-echocardiography evaluation of Carpentier-Edwards Standard and Carpentier-Edwards Magna aortic prosthetic valve: comparison of hemodynamic performance

OBJECTIVES

This study was designed to describe Doppler-echocardiography values of Carpentier-Edwards Perimount Standard (CEPS) and Carpentier-Edwards Perimount Magna (CEPM) aortic prosthetic valves, evaluated by a single, experienced echo-laboratory, early in the postoperative phase.

METHODS

Three-hundred-seventy-seven consecutive patients, who had had a CEPS or a CEPM implanted in our Hospital due to aortic stenosis and/or insufficiency, underwent baseline Doppler echocardiography evaluation within 7 days after surgery. Hemodynamic performances of CEPS and CEPM were accurately described, evaluating flow-dependent (transprosthetic velocities and gradients) and flow-independent (effective orifice area, indexed effective orifice area and Doppler velocity index) Doppler-echocardiography parameters.

RESULTS

Out of the 377 patients 48.8% were men (n = 184), mean age was 74.63 ± 6.77 years, mean BSA was 1.78 ± 0.18 m2, mean ejection fraction was 57.78 ± 8%. Two-hundred and sixty two CEPS and 115 CEPM were implanted. Comparing size-by-size CEPS with CEPM, both prostheses showed a good hemodynamic profile, with fairly similar values of pressure gradients (PGmax and mean, in mmHg, = 37,18 ± 11.57 and 20.81 ± 7.44 in CEPS n°19 compared to 32,47 ± 7,76 and 17,67 ± 4.63 in CEPM n°19 and progressively lower in higher sized prostheses, having PGmax and mean 15 ± 3,16 and 9.15 ± 1,29 in CEPS n°29 compared to 15,67 ± 1,53 and 9 ± 1 in CEPM n°29) and EOAi (being 0,65 ± 0,33 cm²/m² in CEPS n°19 compared to 0,77 ± 0,29 cm²/m² in CEPM n°19 and progressively higher in higher sized prostheses, being 1,28 ± 0,59 cm²/m² in CEPS n°29 compared to 1,07 ± 0,18 cm²/m² in CEPM n°29), the latter resulting, however, basically less flow obstructive.

CONCLUSIONS

Our data confirm the good hemodynamic performance of both aortic bioprostheses and the more favourable hemodynamic profile of CEPM compared to CEPS, pointing out the need to perform routinely an accurate baseline Doppler-echocardiography evaluation early after surgery to allow an adequate interpretation of data at follow-up.