TREATMENT OF AORTO-ILIAC AND INFRA-INGUINAL VASCULAR INFECTIONS WITH A PREFABRICATED BOVINE PERICARDIAL GRAFT

OBJECTIVE

The use of biological grafts provides acceptable mid- and long-term results in native or prosthetic vascular infections. Several reports describe the successful use of bovine pericardium in case of vascular infections, mainly as a large patch to be sutured as a tubular graft. Recently, a novel prefabricated bovine pericardium graft (Biointegral Surgical No-React® Inc, Mississauga, ON, Canada) has been introduced in clinical practice with promising results. In this study, we report our preliminary experience utilizing Biointegral Surgical graft in case of native and or prosthetic aorto-iliac and infra-inguinal infection.

METHODS

We retrospectively analyzed data from 20 patients with native or prosthetic aorto-iliac and infra-inguinal infection who underwent in situ reconstruction with a Biointegral Surgical No-React bovine pericardium prosthesis between October 2020 and February 2023 at the Vascular Surgery Unit of the Fondazione Policlinico Universitario Gemelli - IRCCS in Rome, Italy. All patients followed a standardized protocol including postoperative anticoagulation and long-term intravenous antibiotics.

RESULTS

The indication for surgery was: mycotic aortic aneurysm in four patients (20%), graft infection after abdominal aortic repair in 11 patients (55%), peripheral graft infection in five patients (25%). Complete excision of the infected aorta or prosthetic graft, surgical debridement and in situ reconstruction were performed in all patients. Hospital mortality rate was 5% (n=1) and graft-related mortality of 0%. During follow-up (median 13 months, range 6-34 months), reinfection was 5.2% and primary graft patency 94.7%.

CONCLUSIONS

The use of prefabricated bovine pericardial grafts represent a promising option for the treatment of native and prosthetic aorto-iliac and infra-inguinal infections. The application of this biological graft with a standardized post-operative protocol has been associated with a satisfactory patency and reinfection rate without increased bleeding complications.

Mechanical versus Bioprosthetic Aortic Valve Replacement in Patients Aged 50 to 70 Years

Background

This study compared the outcomes of surgical aortic valve replacement (AVR) in patients aged 50 to 70 years based on the type of prosthetic valve used.

Methods

We compared patients who underwent mechanical AVR to those who underwent bioprosthetic AVR at our institution between January 2000 and March 2019. Competing risk analysis and the inverse probability of treatment weighting (IPTW) method based on propensity score were employed for comparisons.

Results

A total of 1,580 patients (984 patients with mechanical AVR; 596 patients with bioprosthetic AVR) were enrolled. There was no significant difference in early mortality between the mechanical AVR and bioprosthetic AVR groups (0.9% vs. 1.7%, p=0.177). After IPTW adjustment, the risk of all-cause mortality was significantly higher in the bioprosthetic AVR group than in the mechanical AVR group (hazard ratio [HR], 1.39; 95% confidence interval [CI], 1.07-1.80; p=0.014). Competing risk analysis revealed lower risks of stroke (sub-distributional hazard ratio [sHR], 0.44; 95% CI, 0.28-0.67; p<0.001) and anticoagulation-related bleeding (sHR, 0.35; 95% CI, 0.23-0.53; p<0.001) in the bioprosthetic AVR group. Conversely, the risk of aortic valve (AV) reintervention was higher in the bioprosthetic AVR group (sHR, 6.14; 95% CI, 3.17-11.93; p<0.001).

Conclusion

Among patients aged 50 to 70 years who underwent surgical AVR, those receiving mechanical valves showed better survival than those with bioprosthetic valves. The mechanical AVR group exhibited a higher risk of stroke and anticoagulation-related bleeding, while the bioprosthetic AVR group showed a higher risk of AV reintervention.

Aortic valve neocuspidization and bioprosthetic valves: Evaluating turbulence haemodynamics

Aortic valve disease is often treated with bioprosthetic valves. An alternative treatment is aortic valve neocuspidization which is a relatively new reparative procedure whereby the three aortic cusps are replaced with patient pericardium or bovine tissues. Recent research indicates that aortic blood flow is disturbed, and turbulence effects have yet to be evaluated in either bioprosthetic or aortic valve neocuspidization valve types in patient-specific settings. The aim of this study is to better understand turbulence production in the aorta and evaluate its effects on laminar and turbulent wall shear stress. Four patients with aortic valve disease were treated with either bioprosthetic valves (n=2) or aortic valve neocuspidization valvular repair (n=2). Aortic geometries were segmented from magnetic resonance images (MRI), and 4D flow MRI was used to derive physiological inlet and outlet boundary conditions. Pulsatile large-eddy simulations were performed to capture the full range of laminar, transitional and turbulence characteristics in the aorta. Turbulence was produced in all aortas with highest levels occurring during systolic deceleration. In the ascending aorta, turbulence production is attributed to a combination of valvular skew, valvular eccentricity, and ascending aortic dilation. In the proximal descending thoracic aorta, turbulence production is dependent on the type of arch-descending aorta connection (e.g., a narrowing or sharp bend) which induces flow separation. Laminar and turbulent wall shear stresses are of similar magnitude throughout late systolic deceleration and diastole, although turbulent wall shear stress magnitudes exceed laminar wall shear stresses between 27.3% and 61.1% of the cardiac cycle. This emphasises the significance of including turbulent wall shear stress to improve our comprehension of progressive arterial wall diseases. The findings of this study recommend that aortic valve treatments should prioritise minimising valvular eccentricity and skew in order to mitigate turbulence generation.

Early and mid-term outcomes after aortic valve replacement using a novel tissue bioprosthesis: a systematic review

OBJECTIVES

While current data show a clear trend towards the use of bioprosthetic valves during aortic valve replacement (AVR), durability of bioprosthetic valves remains the most important concern. We conducted a 1st systematic review of all available evidence that analysed early and mid-term outcomes after AVR using the Inspiris RESILIA™ bioprosthesis.

METHODS

A systematic literature search was performed to identify all relevant studies evaluating early and mid-term outcomes after AVR using the Inspiris RESILIA bioprosthesis and including at least 20 patients with no restriction on the publication date. Subgroup meta-analysis was performed to compare Inspiris RESILIA and PERIMOUNT Magna Ease bioprosthesis and to pool the early postoperative mortality and stroke rates.

RESULTS

A total of 416 studies were identified, of which 15 studies met the eligibility criteria. The studies included a total of 3202 patients with an average follow-up of up to 5.3 years. The average age of patients across the studies was 52.2-75.1 years. Isolated AVR was performed in 39.0-86.4% of patients. In-hospital or 30-day postoperative mortality was 0-2.8%. At the mid-term follow-up, freedom from all-cause mortality was up to 85.4%. Among studies with mid-term follow-up, trace/mild paravalvular leak was detected in 0-3.0%, while major paravalvular leak was found only in up to 2.0% of patients. No statistically significant differences in terms of mortality (P = 0.98, odds ratio 1.02, 95% confidence interval 0.36-2.83) and stroke (P = 0.98, odds ratio 1.01, 95% confidence interval 0.38-2.73) between the Inspiris RESILIA bioprosthesis and PERIMOUNT Magna Ease bioprosthesis were observed in the subgroup meta-analysis.

CONCLUSIONS

Mid-term data on the safety and haemodynamic performance of the novel aortic bioprosthesis are encouraging. Further comparative studies with other bioprostheses and longer follow-up are still required to endorse durability and safety of the novel bioprosthesis.

Revisiting aortic valve prosthesis choice in patients younger than 50 years: 10 years results of the AUTHEARTVISIT study

OBJECTIVES

This population-based cohort study investigated mid-term outcome after surgical aortic valve replacement with a bioprosthetic or mechanical valve prosthesis in patients aged <50 years in a European social welfare state.

METHODS

We analysed patient data from the main social insurance carriers in Austria (2010-2020). Subsequent patient-level record linkage with national health data provided patient characteristics and clinical outcome. Survival, reoperation, myocardial infarction, heart failure, embolic stroke or intracerebral haemorrhage, bleeding other than intracerebral haemorrhage and major adverse cardiac events were evaluated as outcomes.

RESULTS

A total of 991 patients were analysed. Regarding demographics, no major differences between groups were observed. Multivariable Cox regression revealed no significant difference in overall survival (P = 0.352) with a median follow-up time of 6.2 years. Reoperation-free survival was decreased (hazard ratio = 1.560 [95% CI: 1.076-2.262], P = 0.019) and the risk for reoperation was increased (hazard ratio = 2.770 [95% CI: 1.402-5.472], P = 0.003) in patients who received bioprostheses. Estimated probability of death after reoperation was 0.23 (CL: 0.08-0.35) after 2 years and 0.34 (CL: 0.06-0.53) after 10 years over both groups. Regarding further outcomes, no significant differences between the two groups were observed.

CONCLUSIONS

In patients below 50 years of age receiving aortic valve replacement, implantation of bioprostheses when compared to mechanical heart valve prostheses was associated with a significantly higher rate of reoperations and reduced reoperation-free survival. Nevertheless, we could not observe a difference in overall survival. However, long-term follow-up has to evaluate that a significantly lower rate of reoperations may translate in consistently improved long-term survival.

Systematic review of first-in-human and early phase clinical trials for surgically implantable biological mitral valve substitutes

BACKGROUND

The aim of this review was the creation of uniform protocols to carry out and disclose First-In-Human and preliminary clinical trials of biological mitral valve replacement. The need for consistent methodology in these early trials was highlighted by the observation of significant variability in the methods and protocols used across different research.

METHODS

An extensive search through six major databases was carried out to retrieve First-In-Human (FIH) clinical studies evaluating surgically implanted bio-prostheses in the mitral position.

RESULTS

Following the PRISMA guideline, a systematic search identified 2082 published articles until March 2023. After removing duplicates (189), 1862 citations were screened, resulting in 22 eligible studies with 3332 patients for analysis. The mitral valve prostheses in these studies ranged from 21 to 37 mm, with the 29 mm size being most prevalent. Patient numbers varied, with the FIH subgroup including 31 patients and the older subgroup including 163 patients. Average study durations differed: the older subgroup lasted 4.57 years, the FIH subgroup 2.85 years, and the early phase studies spanned 8.05 years on average.

CONCLUSION

FIH clinical report is essential to assess the significance of clinical data required for a "de novo" surgical implant. In addition, understanding the performance of the device, and recognizing the difficulties associated with the innovation constitute important lessons. These insights could be beneficial for the development of bioprosthetic heart valves and formulating a protocol for an FIH clinical trial.

Prognostic Impact of Residual Moderate Mitral Regurgitation Following Valve-in-Valve Transcatheter Aortic Valve Implantation

INTRODUCTION

The impact of mitral regurgitation (MR) on valve-in-valve transcatheter aortic valve implantation (VIV-TAVI) in patients with failed bioprostheses remains unclear. The purpose of this study was to assess the prognostic impact of residual moderate MR following VIV-TAVI.

METHODS

We retrospectively analyzed 127 patients who underwent VIV-TAVI between March 2010 and November 2021. At least moderate MR was observed in 51.2% of patients before the procedure, and MR improved in 42.1% of all patients. Patients with postoperative severe MR, previous mitral valve intervention, and patients who died before postoperative echocardiography were excluded from further analyses. The remaining 114 subjects were divided into two groups according to the degree of postprocedural MR: none-mild MR (73.7%) or moderate MR (26.3%). Propensity score matching yielded 23 pairs for final comparison.

RESULTS

No significant differences were found between groups before and after matching in early results. In the matched cohort, survival probabilities at one, three, and five years were 95.7% vs. 87.0%, 85.0% vs. 64.5%, and 85.0% vs. 29.0% in the none-mild MR group vs. moderate MR-group, respectively (log-rank P=0.035). Among survivors, patients with moderate MR had worse functional status according to New York Heart Association (NYHA) class at follow-up (P=0.006).

CONCLUSION

MR is common in patients with failed aortic bioprostheses, and improvement in MR-status was observed in over 40% of patients following VIV-TAVI. Residual moderate MR after VIV-TAVI is not associated with worse early outcomes, however, it was associated with increased mortality at five years of follow-up and worse NYHA class among survivors.

Endothelial Microparticles: Markers of Inflammatory Response After Sutureless Valve Implantation

INTRODUCTION

Systemic inflammatory response syndrome (SIRS) is related to increased circulating endothelial microparticles (EMP).

OBJECTIVE

The aim of this study was to compare the plasma concentration of EMP between patients undergoing aortic valve replacement with conventional bioprosthesis implantation and Perceval™ S (LivaNova) and to evaluate its impact on the inflammatory response in the short-term follow-up.

METHODS

This is a randomized clinical trial with 24 patients submitted to isolated aortic valve replacement divided into two groups: Perceval™ S (Group P) and conventional bioprostheses (Group C). Incidence of severe SIRS (three or more criteria) in the first 48 hours postoperatively, EMP release profile, interleukins (IL) 6 and 8, C-reactive protein, and procalcitonin were analyzed preand postoperatively at 24 hours and three months.

RESULTS

There were 24 patients (12 in each group), mean age was 69.92±5.17 years, 83.33% were female, the incidence of severe SIRS was 66.7% and 50% in groups C and P, respectively (P=0.68), and EMP showed a significant increase in the 24-hour postoperative period (P≤0.001) and subsequent decrease in the three-month postoperative period (P≤0.001), returning to baseline levels. For IL-6 and IL-8, there was a greater increase in group C at 24 hours postoperatively (P=.0.02 and P<0.001).

CONCLUSION

The incidence of severe SIRS was similar in both groups, with significantly higher levels of IL-6 and IL-8, at the 24-hour postoperative period, in group C, however with higher levels of EMP in group P, and subsequent return to baseline levels at the three-month postoperative period in both groups.

Safety, Effectiveness, and Hemodynamic Performance of the Bovine Pericardium Organic Valvular Bioprosthesis

OBJECTIVE

To assess actual data on the safety, effectiveness, and hemodynamic performance of Bovine Pericardium Organic Valvular Bioprosthesis (BVP).

METHODS

The BIOPRO Trial is an observational, retrospective, non-comparative, non-randomized, and multicenter study. We collected data from 903 patients with symptomatic, moderate, or severe valve disease who underwent BVP implants in the timeframe from 2013 to 2020 at three Brazilian institutions. Death, valve-related adverse events (AEs), functional recovery, and hemodynamic performance were evaluated at the hospital, at discharge, and six months and one year later. Primary analysis compared late (> 30 days after implant) linearized rates of valve-related AEs, such as thromboembolism, valve thrombosis, major hemorrhage, major paravalvular leak, and endocarditis, following objective performance criteria (OPC). Analysis was performed to include at least 400 valve-years for each valve position (aortic and mitral) for complete comparisons to OPC. Kaplan-Meier survival and major adverse cardiovascular and cerebrovascular event analyses were also performed.

RESULTS

This retrospective study analyzed follow-up data collected from 903 patients (834.2 late patient-years) who have undergone surgery for 455 isolated aortic valve replacement (50.4%), 382 isolated mitral valve replacement (42.3%), and 66 combined valve replacement or other intervention (7.3%). The linearized rates of valve-related AEs were < 2 × OPC. One-year survival rates were 95.1% and 92.7% for aortic and mitral valve replacement, respectively. This study demonstrated an improvement in the New York Heart Association classification from baseline and hemodynamic performance within an expected range.

CONCLUSION

According to this analysis, BVP meets world standards for safety and clinical efficacy.

DOAC versus VKA in patients with atrial fibrillation and bioprosthetic valves: a systematic review and meta-analysis

INTRODUCTION AND OBJECTIVES

Direct oral anticoagulant (DOAC) therapy has been shown to be safe and effective in patients with atrial fibrillation (AF). However, outcomes in AF patients with bioprosthetic valves are unclear, as this population has been underrepresented in clinical trials. The aim of this study was to assess the safety and efficacy of DOACs in this population based on the existing published literature.

METHODS

A systematic search and review were conducted to identify randomized clinical trials and comparative observational studies published from 2017 to January 2022 that compared DOACs and vitamin K antagonists (VKAs) in AF patients with bioprosthetic valves. Hazard ratios (HR) were collected to compare the 2 treatments in terms of cardiovascular and all-cause mortality, stroke/systemic embolism, and major bleeding. A meta-analysis combining the results was performed.

RESULTS

We included 12 studies (30 283 patients). DOACs and VKAs were compared based on HRs at the 95% confidence interval. DOAC therapy was associated with a significant 9% reduction in all-cause mortality (HR, 0.91; 95%CI, 0.85-0.97; P=.0068; I2=8%), with no significant differences in the risk of stroke/systemic embolism (HR, 0.87; 95%CI, 0.67-1.14; P=.29; I2=45%) or major bleeding (HR, 0.82; 95%CI, 0.67-1.00; P=.054; I2=48.7%).

CONCLUSIONS

DOAC therapy in AF patients with bioprosthetic valves may be associated with a significant reduction in all-cause mortality, with no reduction in the efficacy of stroke/systemic embolism prevention or increase in major bleeding risk.

Developing Hemodynamic Valve Deterioration and Mortality in Aortic Valve Replacement

BACKGROUND

As life span increases, in patients having a bioprosthetic valve, the development of hemodynamic valve deterioration (HVD) is an important concern. We evaluated the association of developing HVD to survival in patients undergoing surgical aortic valve replacement (SAVR).

METHODS

The individuals undergoing isolated SAVR and serial echocardiography exams (interval >30 d) were included in this study. HVD was defined as mean pressure gradient ≥ 20 mmHg, mean pressure gradient ≥10 mmHg higher than in the baseline exam, or more than moderate regurgitation on Doppler echocardiography (moderate and severe grade). A time-dependent Cox proportional hazard model was used for this study.

RESULTS

A total of 631 patients were included. The mean age was 71.8 ± 6.1 y old (female: 53.6%). HVD was found in 259 patients (41%) during echocardiographic follow-up (mean 3.3 ± 3.0 y). Patient-prosthetic mismatch was found in 174 patients. One hundred and twenty-six patients died during follow-up (median 62.1 mo, interquartile range 31.1-96.8). The development of HVD was an independent risk factor for death during follow-up (P = 0.038, hazard ratio 1.46, 95% confidential interval: 1.02-2.08).

CONCLUSIONS

HVD was common after bioprosthetic SAVR during mid-term follow-up. Developing HVD, including moderate and severe grades, was associated with a poor survival rate compared with patients without HVD.

Ten years' experience with the sutureless aortic valve replacement: incidence and predictors for survival and valve durability at follow-up

OBJECTIVES

Aortic valve replacement with a sutureless prosthesis [sutureless aortic valve replacement (Su-AVR)] is an option for patients with severe aortic valve stenosis. However, data regarding long-term outcomes and prosthesis durability are still lacking.

METHODS

All consecutive patients who successfully underwent Su-AVR with the Perceval valve in our centre between 2010 and 2020 were included in the analysis and followed prospectively with echocardiography. Risk factor analysis was performed to assess variables associated with worse survival and bioprosthetic valve failure.

RESULTS

Study population consisted of 547 patients: the mean age was 76.4 (5.2) years, 51% were female and the mean logistic EuroSCORE was 13% (11). The median survival was 7.76 years [95% confidence interval (CI) = 6.9-8.6]. Risk factor analysis identified age [hazard ratio (HR) 1.06, 95% CI 1.03-1.11; P < 0.001), EuroSCORE II (HR 1.08, 1.02-1.13; P < 0.001), baseline dialysis (HR 2.14, 95% CI 1.4-4.4; P = 0.038) and postoperative acute kidney injury ≥2 (HR 8.97, 95% CI 4.58-17.6; P < 0.001) as factors significantly correlated with worse survival. The reported HRs for age are per 1 year and for EuroSCORE II is 1 percentage point. Structural valve deterioration (SVD) was observed in 23 patients, of whom 19 underwent reintervention (median freedom from SVD 10.3 years). In multivariable Cox analysis, age (HR 0.89, 95% CI 0.82-0.95; P < 0.001) was found to be a significant predictor of SVD. Overall, 1.8% was referred for prosthetic valve endocarditis (confirmed or suspected) during follow-up. One patient showed moderate non-SVD and none developed prosthetic valve thrombosis.

CONCLUSIONS

The sutureless valve represents a reliable bioprosthesis for aortic valve replacement in patients with a 10-year life expectancy. Younger age at the time of implant is the only factor associated with the risk of long-term SVD.

Preclinical Large Animal In-Vivo Experiments for Surgically Implanted Atrioventricular Valve: Reappraisal and Systematic Review

BACKGROUND

The development of atrioventricular bioprosthesis has witnessed an increasing drive toward clinical translation over the last few decades. A significant challenge in the clinical translation of an atrioventricular bioprosthesis from bench to bedside is the appropriate choice of a large animal model to test the safety and effectiveness of the device.

METHODS

We conducted a systematic review of pre-clinical in vivo studies that would enable us to synthesize a recommended framework. PRISMA (Preferred Reporting Items for Systematic Reviews and MetaAnalyses) guidelines were followed to identify and extract relevant articles.

RESULTS

Sheep was the most common choice of animal, with nine out of the 12 included studies being conducted on sheep. There were acute and chronic studies based on our search criteria. An average of ~20 and 5 animals were used for chronic and acute studies. One out of three acute studies and eight out of nine chronic studies were on stented heart valve bioprosthesis. All analyses were conducted on the implantation of atrioventricular valves with trileaflet, except for one chronic study on unileaflet valves and one chronic and acute study on bileaflet valves.

CONCLUSION

Understanding the variance in past pre-clinical study designs may increase the appropriate utilization of large animal models. This synthesized evidence provides a pre-clinical in vivo studies framework for future research on an atrioventricular bioprosthesis.

Transcatheter Aortic Valve Implantation for Bioprosthetic Valve Failure: Placement of Aortic Transcatheter Valves 3 Aortic Valve-in-Valve Study

Background

Transcatheter aortic valve implantation is safe and effective for high-risk patients with bioprosthetic valve failure (BVF) but has not been studied in low- and intermediate-risk patients. One year outcomes of the PARTNER 3 Aortic Valve-in-valve (AViV) Study were evaluated.

Methods

This prospective, single-arm, multicenter study enrolled 100 patients from 29 sites with surgical BVF. The primary endpoint was a composite of all-cause mortality and stroke at 1 year. The key secondary outcomes included mean gradient, functional capacity, and rehospitalization (valve-related, procedure-related, or heart failure related).

Results

A total of 97 patients underwent AViV with a balloon-expandable valve from 2017 to 2019. Patients were 79.4% male with a mean age of 67.1 years and Society of Thoracic Surgeons score of 2.9%. The primary endpoint occurred in 2 patients (2.1%) who had strokes; there was no mortality at 1 year. Five patients (5.2%) had valve thrombosis events, and 9 patients (9.3%) had rehospitalizations, including 2 (2.1%) for strokes, 1 (1.0%) for heart failure, and 6 (6.2%) for aortic valve reinterventions (3 explants, 3 balloon dilations, and 1 percutaneous paravalvular regurgitation closure). From baseline to 1 year, New York Heart Association class III/IV decreased from 43.3% to 4.5%, mean gradient from 39.1 ± 18.2 mm Hg to 19.7 ± 7.6 mm Hg, and ≥moderate aortic regurgitation from 41.1% to 1.1%.

Conclusions

AViV with a balloon-expandable valve improved hemodynamic and functional status at 1 year and can provide an additional therapeutic option in selected low- or intermediate-risk patients with surgical BVF, although longer term follow-up is necessary.

Mid to Long-Term Echocardiographic Follow-up of Patients Undergoing Transcatheter Tricuspid Valve-in-Valve Replacement for Degenerated Bioprosthetic Valves: First Single-Center Report from Iran

Background

Transcatheter tricuspid valve-in-valve (TTViV) replacement has become an alternative treatment in high-risk patients with bioprosthetic valve degeneration. This is the first report on the mid to long-term echocardiographic findings of patients who underwent TTViV replacement in a cardiac referral center in Iran.

Methods

Data of 12 patients, consisting of 11 women and 1 man, who underwent TTViV replacement between 2015 and 2021 were reviewed retrospectively. The patients underwent echocardiography before the procedure and at a mean follow-up time of 3.17±1.75 years.

Results

All the patients had New York Heart Association (NYHA) function class III/IV before TTViV. Six patients had tricuspid regurgitation, 1 had tricuspid stenosis, and 5 had both. All the patients had successful TTViV. The mean time from the initial valve surgery to TTViV was 6.25±2.45 years. At follow-up, 2 patients had died: 1 due to COVID-19 pneumonia and 1 without a known cause. The remaining 10 patients experienced improvements in the NYHA functional class. Echocardiographic measures showed significant improvements. Transvalvular mean gradient pressure decreased from 7.08±1.98 mm Hg to 5.29±1.63 mm Hg (P=0.028), tricuspid valve pressure half time decreased from 245.00±49.46 ms to 158.64±57.41 ms (P=0.011), tricuspid regurgitation gradient decreased from 39.91±7.31 mm Hg to 26.72±8.99 mm Hg, and left ventricular ejection fraction increased from 47.71±4.70% to 49.79±4.58% (P=0.046). There was no significant paravalvular or transvalvular leakage at follow-up.

Conclusion

This is a single-center report on the mid and long-term echocardiographic follow-up of patients after TTViV replacement. Our study showed that TTViV was a safe and efficient method in treating high-risk patients with degenerated bioprosthetic tricuspid valves and had favorable echocardiographic and clinical results.

Are NOACs as safe and efficient as VKA regarding thromboembolic prophylaxis and major bleeding in patients with surgical bioprosthesis and atrial fibrillation within 3 months of surgery?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: ‘Are NOACs as safe and efficient as vitamin K antagonist regarding thromboembolic prophylaxis and major bleeding in patients with surgical bioprosthesis and atrial fibrillation within 3 months of surgery?’ Altogether more than 324 papers were found using the reported search, of which 6 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The RIVER and ENAVLE trials showed non-inferiority of rivaroxaban (regarding mean time free from composite of death, major cardiovascular events or major bleeding at 12 months) and edoxaban (composite of death, clinical thromboembolic events or asymptomatic intracardiac thrombosis; and major bleeding) when compared with vitamin K antagonist. These studies include a low number of patients within 3 months of index surgery and overall low statistical power regarding this particular subgroup of patients. Data derived from lower evidence studies are compatible with the aforementioned findings. The available evidence suggests that non-vitamin K antagonist anticoagulants are as safe and as efficient as vitamin K antagonist regarding thromboembolic prophylaxis and bleeding event rates in patients with surgical bioprosthesis and atrial fibrillation within 3 months of bioprosthesis implantation. However, this evidence is derived from a limited number of studies with important methodological limitations. Expanding non-vitamin K antagonist anticoagulant recommendation to the early postoperative period warrants more confirmatory research.

Bioprosthetic aortic valve replacement in patients aged 50 years old and younger: Structural valve deterioration at long-term follow-up. Retrospective study

Background

Structural valve deterioration (SVD) remains the major determinant of bioprosthesis durability. The aim of this study was to investigate the SVD incidence, predictors and outcomes in patients aged 50 years and younger after bioprosthetic aortic valve replacement (bAVR).

Methods

We retrospectively analyzed 73 consecutive patients ≤50 years old who underwent bioprosthetic AVR at our center between 2005 and 2015. Median age at surgery was 44 (interquartile range [IQR]: 39-47) years. Follow-up was 93.2% complete at a median time of 7.2 (IQR: 5.5-9.5) years. Cumulative follow-up was 545.5 valve-years. Bioprosthesis SVD was determined by strict echocardiographic assessment.

Results

The overall survival-rate at 10/15 years and freedom from SVD at 10/12.5 years were 89.6 ± 5.2%/81.5 ± 9.1% and 73.5 ± 8.2%/41.9 ± 18.9%, respectively. SVD occurred at a median time of 8.2 (IQR: 6.0-9.9) years after bAVR. Age was not found as an independent predictor for SVD at the multivariable model, despite a higher rate of SVD in the age group ≤30 years. Freedom from reoperation due to SVD at 10/15 years was 71.3 ± 14.1%/13.6 ± 12.3%. Reoperation was performed at a median time of 10.0 (IQR: 8.9-11.9) years since first bAVR and was associated with a 100% 12-month survival.

Conclusions

In our study, the rate and time of SVD occurrence were comparable to those of other studies' older age groups. Strict echocardiographic monitoring of valve performance is mandatory to set the appropriate timing of eventual reoperation. This attitude can improve outcomes of bAVR in younger patients.

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 haemodynamic results after aortic valve replacement with the Trifecta bioprosthesis

OBJECTIVES

The aim of this study was to evaluate the clinical and haemodynamic results after implantation of the Trifecta bioprosthesis.

METHODS

This study is a retrospective analysis of all patients undergoing Trifecta aortic valve replacement between 01 January 2012 and 31 December 2017 at the Ghent University Hospital. Univariable and multivariable analyses were performed to identify predictors of valve- and procedure-related complications and mortality. The haemodynamic performance was analysed by longitudinal Doppler echocardiography.

RESULTS

The mean age of the 182 patients was 77 [standard deviation (SD): 5.5] years; 54.9% were women. The mean follow-up was 39.8 (SD: 24.3) months. Overall survival at 1 and 5 years was 86% (SD: 3%) and 68% (SD: 4%), respectively, and overall freedom from structural valve deterioration was 100% and 98% at 1 and 5 years, respectively. There was no valve thrombosis nor early endocarditis. Urgent surgery was the only risk factor for early mortality in the multivariable analysis [P = 0.009, odds ratio 0.06, 95% confidence interval (CI) 0.01-0.5]. Preoperative atrial fibrillation was the most important predictor of late mortality (P = 0.001, hazard ratio 3.68, 95% CI 1.65-8.21). The average peak gradients were stable from discharge up to 1 and 5 years postoperatively [15 (SD: 6) and 17 (SD: 8) mmHg].

CONCLUSIONS

These results confirm the excellent clinical performance of the Trifecta valve, particularly in an elderly age group. Through the 7-year follow-up period, low transvalvular gradients persisted, and only a few patients needed reoperation. Although structural valve degeneration occurred rarely, it was unrelated to valve size or age at implantation; therefore, further long-term follow-up remains mandatory.

Carpentier-Edwards Magna Ease bioprosthesis: a multicentre clinical experience and 12-year durability

OBJECTIVES

The goal of this multicentre retrospective study was to compare long-term clinical and haemodynamic outcomes of the Carpentier-Edwards Magna Ease (CEME) bioprosthesis by patient age.

METHODS

We included consecutive patients who underwent isolated and combined surgical aortic valve replacement (AVR) with CEME valve between January 2008 and March 2020 at 4 cardiac surgery centres in Italy. Survival distribution was evaluated at follow-up according to age and surgery type (combined or isolated AVR), together with freedom from structural valve deterioration (SVD), reoperation and combined events, i.e. SVD, reoperation, endocarditis and thromboembolic events.

RESULTS

A total of 1027 isolated and 1121 combined AVR were included; 776 patients were younger than 65 years whereas 1372 were 65 years or older. The 30-day Valve-Academic-Research-Consortium mortality was 2% (<65 years) and 6% (≥ 65 years) (P < 0.001), whereas it was 3% for isolated AVR and 7% for combined AVR (P < 0.001). The 12-year survival was 81% for those younger than 65 years vs 45% for those equal to or older than 65 years (P < 0.001), whereas they were 61% vs 49% for isolated and combined AVR (P = 0.10). The 12-year freedom from combined events, excluding death, was 79% for those younger than 65 years vs 87% for those equal to or older than (P = 0.51), whereas they were 83% for isolated and 86% for combined AVR (P = 0.10). The 12-year freedom from SVD was 93% and 93% in patients younger than 65 and those equal to or older than 65 years (P = 0.63), and the results were comparable even in cases with isolated and combined AVR (92% vs 94%, P = 0.21). A multivariable Cox analysis including gender, presence of patient-prosthesis mismatch, isolated AVR and age showed that only the age was an independent risk factor for the incidence of SVD (P = 0.029).

CONCLUSIONS

Outcomes from this large multicentre analysis demonstrated that a CEME bioprosthesis provides good clinical results and long-term durability even in patients younger than 65 years. Furthermore, the hazard for SVD has been shown to be lower for older age.

CLINICAL TRIAL REGISTRATION NUMBER

105n/AO/21.

Pericardial Versus Porcine Valves for Surgical Aortic Valve Replacement

Two prototypes of material to constitute surgical bioprosthetic aortic valve (AV) are bovine pericardium and porcine valves. Earlier studies have consistently shown superior hemodynamic profiles in bovine pericardial valves, however, it is not clear whether such superior hemodynamic profiles can be translated into improved clinical outcomes. In patients undergoing isolated bioprosthetic surgical aortic valve replacement (AVR) (636 patients between January 2000 and May 2016), the use of bovine pericardial valves was associated with superior hemodynamic profiles and improved late survival as compared with porcine valves. Freedom from adverse valve-related complication rates were not significantly different between the 2 groups.

Background and Objectives

There still are controversies on which type between bovine pericardial and porcine valves is superior in the setting of aortic valve replacement (AVR). This study aims to compare clinical outcomes of AVR using between pericardial or porcine valves.

Methods

The study involved consecutive 636 patients underwent isolated AVR using stented bioprosthetic valves between January 2000 and May 2016. Of these, pericardial and porcine valves were implanted in 410 (pericardial group) and 226 patients (porcine group), respectively. Clinical outcomes including survival, structural valve deterioration (SVD) and trans-valvular pressure gradient were compared between the groups. To adjust for potential selection bias, inverse probability treatment weighting (IPTW) was conducted.

Results

The mean follow-up duration was 60.1±50.2 months. There were no significant differences in the rates of early mortality (3.1% vs. 3.1%; p=0.81) and SVD (0.3%/patient-year [PY] vs. 0.5%/PY; p=0.33) between groups. After adjustment using IPTW, however, landmark mortality analyses showed a significantly lower late (>8 years) mortality risk in pericardial group over porcine group (hazard ratio [HR], 0.61; 95% confidence interval, [CI] 0.41–0.90; p=0.01) while the risks of SVD were not significantly difference between groups (HR, 0.45; 95% CI, 0.12–1.70; p=0.24). Mean pressure gradient across prosthetic AV was lower in the Pericardial group than the Porcine group at both immediate postoperative point and latest follow-up (p values <0.001).

Conclusions

In patients undergoing bioprosthetic surgical AVR, bovine pericardial valves showed superior results in terms of postoperative hemodynamic profiles and late survival rates over porcine valves.

Antithrombotic Therapy for Patients With Atrial Fibrillation and Bioprosthetic Valves - Real-World Data From the Multicenter, Prospective, Observational BPV-AF Registry

BACKGROUND

Although bioprosthetic valve (BPV) replacements are becoming more common within our aging society, there are limited prospective data on the appropriate antithrombotic therapy for East Asian patients with atrial fibrillation (AF) and BPV replacement. Antithrombotic therapy and thrombotic and hemorrhagic event rates in Japanese patients with AF and BPV replacement are investigated.Methods and Results:This multicenter, prospective, observational study enrolled patients with BPV replacement and AF. The primary efficacy outcome was stroke or systemic embolism, and the primary safety outcome was major bleeding. Of the 894 patients analyzed, 54.7%, 29.4%, and 9.6%, were treated with warfarin-based therapy, direct oral anticoagulant (DOAC)-based therapy, or antiplatelet therapy without anticoagulants, respectively; 6.3% did not receive any antithrombotic drugs. The mean observation period was 15.3±4.0 months. The event rates for stroke or systemic embolism and major bleeding were 1.95%/year and 1.86%/year, respectively. The multivariate adjusted hazard ratios for DOAC vs. warfarin were 1.02 (95% confidence intervals [CI], 0.30-3.41 [P=0.979]) for systemic embolic events and 0.96 (95% CI, 0.29-3.16 [P=0.945]) for major bleeding.

CONCLUSIONS

Approximately 30% of patients with AF and BPV replacement were treated with DOAC. The risks of major bleeding and stroke or systemic embolism were similar between warfarin- and DOAC-treated patients with AF who had BPV replacement. Treatment with DOACs could be an alternative to warfarin in this population.

Bioprosthetic Aortic Valve Degeneration: a Review from a Basic Science Perspective

Introduction

The increase in the prevalence of aortic stenosis due to an aging population has led to an increasing number of surgical aortic valve replacements. Over the past 20 years, there has been a major shift in preference from mechanical to bioprosthetic valves. However, despite efforts, there is still no "ideal" bioprosthesis. It is crucial to understand the structure, biology, and function of native heart valves to design more intelligent, strong, durable, and physiological heart valve tissues.

Methods

A comprehensive review of the literature was performed to identify articles reporting the basic mechanisms of bioprosthetic valve dysfunction and the biology of native valve cells. Searches were run in PubMed, MEDLINE® (the Medical Literature Analysis and Retrieval System Online), and Google Scholar. Terms for subject heading and keywords search included “biological heart valve dysfunction”, “bioprosthesis dysfunction”, “bioprosthesis degeneration”, and “tissue heart valves”.

Results

All the relevant findings are summarized in the appropriate subsections. Structural dysfunction is a logical and expected consequence of the chemical, mechanical, and immunological processes that occur during fixation, manufacture, and implantation.

Conclusion

Biological prosthesis valve dysfunction is a clinically significant process. It has become a major issue considering the growing rate of bioprosthesis implantation and improved long-term patient survival. Understanding bioprosthetic aortic valve degeneration from a basic science perspective is a key point to improve technologic advances and specifications that lead to a new generation of bioprostheses.

High Residual Gradient Following a Self-Expandable Transcatheter Aortic Valve-in-Valve Implantation - Risk Factor Analysis, Outcomes, and Survival

INTRODUCTION

Transcatheter aortic valve-in-valve implantation (TAVI-ViV) can be associated with unfavorable hemodynamic outcomes. This study aimed to estimate the prevalence, identify the risk factors, and evaluate the outcomes and survival of patients with high residual gradients after TAVI-ViV.

METHODS

A total of 85 patients were included in the study. The cohort was divided into group A, with postprocedural mean pressure gradient (PG) ≥ 20 mmHg, and group B, with mean PG < 20 mmHg.

RESULTS

Postprocedural PG ≥ 20 mmHg was observed in 24.7% of the patients. In a univariate analysis, preoperative gradient, pre-existing patient-prosthesis mismatch (PPM), deep valve implantation, small degenerated valves, and an older generation of transcatheter aortic valves were found to be risk factors for high residual gradient. Multivariate analysis showed that preexisting maxPG > 60 mmHg, implantation level of 4 mm below neo-annulus, and degenerated valve size ≤ 23 mm were independent predictors of high residual gradient. There were no differences in early morbidity (myocardial infarction, pacemaker implantation, stroke, acute renal insufficiency) between groups. Kaplan-Meier estimated that the survival rate was comparable at one and five years regardless of postoperative gradient. Survivors with high residual mean gradient were significantly affected by a high New York Heart Association (NYHA) class.

CONCLUSION

High residual transvalvular gradient after TAVI-ViV is not rare, but it does not significantly affect mortality. High residual mean gradient has a negative impact on NYHA functional class improvement after the procedure. High preoperative gradient, implantation level, and small failed bioprosthesis may predispose to increased residual gradient.

Surgical pericardial heart valves: 50 Years of evolution

Valve disease carries a huge burden globally and the number of heart valve procedures are projected to increase from the current 300 000 to 800 000 annually by 2050. Since its genesis 50 years ago, pericardial heart valve has moved leaps and bounds to ever more ingenious designs and manufacturing methods with parallel developments in cardiology and cardiovascular surgical treatments. This feat has only been possible through close collaboration of many scientific disciplines in the fields of engineering, material sciences, basic tissue biology, medicine and surgery. As the pace of change continues to accelerate, we ask the readers to go back with us in time to understand developments in design and function of pericardial heart valves. This descriptive review seeks to focus on the qualities of pericardial heart valves, the advantages, successes and failures encapsulating the evolution of surgically implanted pericardial heart valves over the past five decades. We present the data on comparison of the pericardial heart valves to porcine valves, discuss structural valve deterioration and the future of heart valve treatments.

Long-Term Outcomes of the Mosaic Mitral Porcine Bioprosthesis in Japan - Results From the Japan Mosaic Valve Long-Term Multicenter Study

BACKGROUND

This study retrospectively evaluated the long-term patient outcomes and durability of the Mosaic mitral porcine bioprosthesis in the Japan Mosaic valve long-term multicenter study.Methods and Results:The medical records of 390 patients who underwent mitral valve replacement with the Mosaic bioprosthesis at 10 centers in Japan (1999-2014) were reviewed. Patient data were collected using the Research Electronic Data Capture software. Patient survival was determined using the Kaplan-Meier method. Freedom from structural valve deterioration (SVD) and valve-related reoperation and death were determined using actuarial methods. The median (interquartile range [IQR]) age of the cohort was 73 (69-77) years. The median (IQR) follow-up period was 4.83 (1.84-8.26) years. The longest follow-up period was 15.8 years. The 30-day mortality rate was 5.4%. The 12-year actuarial survival rate was 54.1±4.5%, and the freedom from valve-related death was 85.3±3.4%. The freedom from reoperation at 12 years was 74.3±5.7%. The freedom from SVD at 12 years was 81.4±6.6% for patients aged ≥65 years and 71.6±11.1% for those aged <65 years. The median (IQR) mean pressure gradient was 4.1 (3.0-6.0) and 5.6 (4.0-6.7) mmHg at 1 and 10 years, respectively. The median (IQR) effective orifice area was 1.7 (1.4-2.0) and 1.4 (1.2-1.6) cm²at 1 and 10 years, respectively.

CONCLUSIONS

The Mosaic porcine bioprosthesis offered satisfactory long-term outcomes for up to 12 years.

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.

Longitudinal Hemodynamics of Aortic Bioprosthetic Valve in Hemodialysis Patients

We examined the hemodynamic profile of bioprosthetic aortic valves in patients on hemodialysis (HD), longitudinally, and assess the incidence of adverse changes detected by echocardiography. Of 1,146 consecutive patients with severe aortic stenosis who underwent bioprosthetic aortic valve replacement (AVR), 148 patients had end-stage renal disease requiring HD. Each patient on HD was matched one-to-one with a non-HD patient on the basis of propensity scores. The mean follow-up period was 3.3 years for the HD group and 5.9 years for the non-HD group. Follow-up information was available for 95.2%. Postoperative trends of valve hemodynamics derived from linear mixed-effect models showed significant group vs time interactions between the two groups. Stable hemodynamics was consistently observed in the non-HD group, whereas the HD group showed a decrease of -0.06 cm²/y (95% confidence interval (CI), -0.10 to -0.02) in effective orifice area, an increase of 0.8 mm Hg/year (95% CI, 0.4-1.1) in mean pressure gradient, and an increase of 0.08 m/s/year (95%CI, 0.02-0.13) in peak velocity. Cumulative incidence function of SVD more than stage 2 was significantly higher in the HD group (13.1% vs 3.1% at 5 years, Gray test p = 0.01). In a multivariable Fine-Gray analysis, diabetes was independently associated with SVD more than stage 2 in the HD group (subhazard ratio, 1.91; 95% CI, 1.25-2.89; p = 0.02). Survival free-from stenotic-type SVD was significantly lower in HD patients undergoing bioprosthetic AVR. Diabetes was independently associated with postoperative stenotic-type SVD in HD patients.

Comparison of Postoperative Outcomes of Sutureless versus Stented Bioprosthetic Aortic Valve Replacement

OBJECTIVE

Sutureless aortic valve replacement (Su-AVR) offers an alternative to supra-annular stented biological aortic prostheses. This single-center study aimed to compare early outcomes after aortic valve replacement with sutureless and conventional stented bioprostheses.

METHODS

In this retrospective study, we analyzed 52 patients who underwent aortic valve replacement with sutureless and stented bioprostheses between January 2013 and October 2017. Sorin Perceval S sutureless valves were implanted in group 1 and Sorin Mitroflow stented bioprosthetic valves were used in group 2. Postoperative outcomes, including demographics, cardiopulmonary bypass (CPB) times, cross-clamp times, morbidity and mortality, as well as echocardiography in the first month, were compared.

RESULTS

Mortality occurred in 1 (3.6%) patient in group 1, and in 2 (8.3%) patients in group 2 (P=0.186). Group 1 had significantly shorter CPB (61.6±26.1 min vs. 106.3±32.7 min, P=0.001) and crossclamp (30.9±13.6 min vs. 73.3±17.3 min, P=0.001) times. The length of stay in the intensive care unit (1.9±1.3 days vs. 2.4±4.9 days, P=0.598) and hospital stay (7.6±2.7 days vs. 7.3±2.6 days, P=0.66) were similar. Postoperatively, there was no statistically significant difference between the two groups in echocardiography results, and morbidities. The mean aortic valve gradient was 13.5±5.8 mmHg in group 1 and 14.5±8.0 mmHg in group 2 (P=0.634). Paravalvular regurgitation was diagnosed in 3 (10.7%) patients in group 1 and in 1 (4.2%) patient in group 2 (P=0.220).

CONCLUSIONS

Su-AVR resulted in shorter cross-clamp and CPB times. However, early mortality, postoperative morbidity, and echocardiography results were similar between groups.

Aortic Valve Reconstruction with Ozaki Technique

Modern bioprostheses offer a complete and definitive solution to elderly patients who need aortic valve surgery. Nonetheless, the scenario is more demanding when dealing with younger and less fragile patients. In this setting, any prosthetic aortic valve replacement can provide only a suboptimal solution and its related issues have not been fixed yet. The answer to the needs of this special population is the enhancement and refinement of the surgical technique. The Ozaki technique relies on custom-tailored autologous aortic cusps individually sutured in the aortic position. This approach has been showing optimal results if performed after a dedicated training period.

In patients with AF and a bioprosthetic mitral valve, rivaroxaban was noninferior to warfarin for time to clinical events

Guimarães HP, Lopes RD, de Barros E Silva PG, et al. Rivaroxaban in patients with atrial fibrillation and a bioprosthetic mitral valve. N Engl J Med. 2020;383:2117-26. 33196155.

Risk Factors for Postoperative Pacemaker Implantation After Rapid Deployment Aortic Valve Replacement: Results from the RADAR Registry

INTRODUCTION

Rapid deployment aortic valve replacement has been recently introduced in clinical practice. Different studies have reported a significant reduction in surgical times with excellent hemodynamic profiles and short-term results. However, an increase in permanent pacemaker requirements compared with conventional aortic valve replacement has been described. Nevertheless, risk factors for postoperative pacemaker implantation are not well known. The aim of this study is to report our early outcomes with rapid deployment aortic valve replacement within the RADAR Registry, especially focusing on risk factors for postoperative pacemaker implantation.

METHODS

Between April 2012 and January 2016, 164 patients undergoing isolated or combined aortic valve replacement with Edwards INTUITY Elite (Edwards Lifesciences, Irvine, CA, USA) were included in the RADAR Registry. Pre-, intra- and postoperative clinical data results and complications were recorded, especially focusing on risk factors for the development of postoperative complete or high-grade AV block requiring pacemaker implantation. Patients were followed up for up to 1 year with evaluation of clinical and echocardiographic outcomes.

RESULTS

A total of 164 consecutive patients were included in this study, where 128 patients (78.05%) had an isolated aortic valve replacement (group 1) and 36 (21.95%) a concomitant procedure (group 2). The surgical approach was ministernotomy in 61 patients (37.20%) and median sternotomy in 100 patients (60.98%). Complications with valve implantation were observed in three patients. Postoperative complete or high-degree AV block requiring a permanent pacemaker implantation developed in ten patients (6.9%). Seven patients died in-hospital (4.27%). No significant differences between groups were found in terms of stroke, postoperative infection, mortality, atrial fibrillation and postoperative atrioventricular block. Seven patients presented acute renal impairment (5.51%) in group 1 versus seven patients (20%) in group 2 (p = 0.007). In multivariate analysis, low weight and preoperative arrhythmia (atrial fibrillation, bifascicular block, left bundle branch block) emerged as risk factors for postoperative AV block requiring a pacer. In median follow-up of 1 year, seven (4.27%) patients died, and no cases of structural valve deterioration or endocarditis were observed. Significant patient-prosthesis mismatch was found in seven (4.27%) patients.

CONCLUSION

Initial experience with rapid deployment aortic valve replacement in the RADAR Registry demonstrates low rates of implantation complications and good perioperative and 1-year clinical and echocardiographic outcomes. Incidence of postoperative AV block requiring a pacer correlated with low weight and preoperative arrythmias (atrial fibrillation, bifascicular block and left bundle branch block). Avoidance of oversizing and careful consideration of implantation of this technology in patients with pre-existing arrythmias could minimize the risk for postoperative pacemaker implantation.

Balloon-expanding transcatheter aortic valve implantation for degenerated Mitroflow bioprostheses: clinical and echocardiographic long-term outcomes

OBJECTIVES

This study aims to analyse the risks associated with valve-in-valve procedures for treating structural valve deterioration in Mitroflow bioprostheses, as well as to determine the impact of the original Mitroflow size on the patients' long-term outcomes.

METHODS

Between January 2012 and September 2019, 21 patients (61.9% males; mean age 82.4 ± 5.4 years) were treated for Mitroflow deterioration with valve-in-valve procedures (12 transapical and 9 transfemoral).

RESULTS

Mean EuroSCORE I and EuroSCORE II were 28.2% ± 13.6% and 10.5% ± 6.1%, respectively. Six patients presented an indexed aortic root diameter <14 mm/m2 and 7 patients a diameter of sinus of Valsalva <30 mm. Implanted transcatheter valve sizes were 20 mm in 6 cases, 23 mm in 14 cases and 26 mm in 1 patient. A Valve Academic Research Consortium-2 complication occurred in 23.8% of cases, including 3 coronary occlusions. In-hospital mortality was 9.5%. The 20 mm transcatheter valves presented significantly higher postoperative peak and mean aortic gradients than other sizes (54.1 ± 11.3 mmHg vs 29.9 ± 9.6 mmHg, P = 0.003; and 29.3 ± 7.7 mmHg vs 17.4 ± 5.9 mmHg, P = 0.015, respectively). There were 12 cases of patient-prosthesis mismatch (57.1%) and 3 cases (14.3%) of severe patient-prosthesis mismatch. Cumulative survival was 85.7% ± 7.6% at 1 year, 74.3% ± 10% at 2 years and 37.1% ± 14.1% at 5 years.

CONCLUSIONS

Valve-in-valve procedures with balloon-expandable transcatheter valves associate a high risk of coronary occlusion in patients with indexed aortic root diameter <14 mm/m2 and low coronary ostia <12 mm. Valve-in valve procedures with 20 mm balloon-expandable transcatheter valves in ≤21 mm Mitroflow bioprosthesis leave significant residual transvalvular gradients that might obscure patients' long-term outcomes.

NEW ORAL ANTICOAGULANTS VERSUS WARFARIN IN ATRIAL FIBRILLATION AFTER EARLY POST-OPERATIVE PERIOD IN PATIENTS WITH BIOPROSTHETIC AORTIC VALVE

BACKGROUND

The efficacy of novel non-vitamin K antagonist oral anticoagulants (NOACs) in nonvalvular atrial fibrillation (AF) to prevent stroke is well assessed but the use in AF occurred after bioprosthetic aortic valve replacement (AVR) is not endorsed. This retrospective real-world study evaluated the efficacy and safety of NOACs prescribed no earlier than 4 months after AVR as alternative to warfarin in patient with AF.

METHODS

We pooled 1032 patients from databases of five centres. Ischemic/embolic events and major bleeding rates were compared between 340 patients assuming NOACs and 692 warfarin. Propensity score matching was performed to avoid the bias between groups.

RESULTS

NOACs vs warfarin embolic/ischemic rate was 13.5% (46/340) vs 22.7% (157/692) (HR 0.5; 95% CI, 0.37-0.75; p<0.001); incidence rates 3.7% vs 6.9% patients/year; log rank test p=0.009. Major bleeding rates was 7.3% (25/340) vs 13% (90/692) (HR 0.5; 95% CI, 0.33-0.84; p=0.007); incidence rates 2% vs 4% patients/year; log rank test p=0.002. After Propensity score matching, NOACs vs warfarin embolic/ischemic rate was 13.1% (42/321) vs 21.8% (70/321) (HR 0.6; 95% CI, 0.4-0.9; p=0.02); incidence rates 4.1% vs 6.7% patients/year; log rank test p=0.01. Major bleeding rates was 7.8% (25/321) vs 13.7% (44/321) (HR 0.5; 95% CI, 0.31-0.86; p=0.01), incidence rates 2.4% vs 4.2% patients/year; log-rank p=0.01.

CONCLUSIONS

In real-word, NOACs use overcomes the indications provided by guidelines. This study evidenced that NOACs use in patients who developed AF after bioprosthetic AVR was more effective in prevention of thromboembolism and safe in reduction of major bleeding events compared to warfarin.

Late results after mitral valve replacement with Mosaic bioprosthesis in patients aged 65 years or younger

OBJECTIVES

Although in younger patients indications for biological prosthesis implantation in mitral valve replacement remain controversial, recently bioprostheses use increased considerably. We present late results obtained with the Medtronic Mosaic bioprosthesis in patients aged 65 years or younger.

METHODS

Between 2007 and 2017, 67 mitral Mosaic bioprostheses were implanted in patients aged 65 years or younger (58.5 ± 6.4 years). Follow-up extended up to 13 years. Survival, freedom from structural valve degeneration, endocarditis, thromboembolic events and reoperation were considered as main clinical end points evaluated at 1, 5 and 10 years.

RESULTS

The mean follow-up was 4.7 ± 2.8 years. Overall mortality rate was 12%. At 1, 5 and 10 years, survival was 94 ± 3%, 89 ± 4% and 77 ± 9%, respectively. Freedom from structural valve degeneration was 100%, 94 ± 4% and 71 ± 21%. Freedom from endocarditis was 95 ± 3%, 90 ± 6% and 84 ± 8%. Freedom from thromboembolic events was 94 ± 3%, 90 ± 5% and 90 ± 5%. Freedom from reoperation was 94 ± 3%, 87 ± 5% and 65 ± 19%.

CONCLUSIONS

Mosaic bioprosthesis appears a valid mitral valve substitute even when employed in ≤65-year-old patients.

Pulmonary valve replacement following repair of tetralogy of Fallot: comparison of outcomes between bio- and mechanical prostheses

OBJECTIVES

The aims of this study were to evaluate and compare the outcomes after pulmonary valve replacement (PVR) with a mechanical prosthesis (MP) and a bioprosthesis (BP).

METHODS

From 2004 through 2017, a total of 131 patients, who had already been repaired for tetralogy or Fallot or its variants, underwent their first PVR with an MP or a BP. Outcomes of interests were prosthesis failure (stenosis >3.5 m/s, regurgitation >mild or infective endocarditis) and reintervention.

RESULTS

The median age at PVR was 19 years. BP and MP were used in 88 (67.2%) and 43 (32.8%) patients, respectively. The median follow-up duration was 7.4 years, and the 10-year survival rate was 96.4%. Risk factors for prosthesis failure were smaller body surface area [hazard ratio (HR) 0.23 per 1 m2, P = 0.047] and smaller prosthesis size (HR 0.73 per 1 mm, P = 0.039). Risk factors for prosthesis reintervention were smaller body surface area (HR 0.11 per 1 m2, P = 0.011) and prosthesis size (HR 0.67 per 1 mm, P = 0.044). Probability of prosthesis failure and reintervention at 10 years were 24.6% (19.5% in BP vs 34.8% in MP, P = 0.34) and 7.8% (5.6% in BP vs 11.9% in MP, P = 0.079), respectively. Anticoagulation-related major thromboembolic events were observed in 4 patients receiving an MP.

CONCLUSIONS

MP might not be superior to BP in terms of prosthesis failure or reintervention. MP should be carefully considered for highly selected patients in the era of transcatheter PVR.

Outcomes Following Supracoronary Ascending Aortic Replacement with Aortic Valve Resuspension versus Modified Bentall's Operation for Acute Type A Aortic Dissection

Introduction

Type A acute aortic dissection (AAD) remains a challenging cardiac emergency despite the availability of various management strategies. This study compared the outcomes of supracoronary ascending aortic replacement (SCAAR) with aortic valve (AV) resuspension with those of modified Bentall's operation for type A AAD and the progression of aortic regurgitation (AR), long-term dilatation of aortic root and proximal arch, and long-term mortality in SCAAR patients.

Methods

Sixty patients underwent surgery for type A AAD (January 2005 to December 2015). Forty-three patients underwent SCAAR with AV resuspension and 17 underwent modified Bentall's operation. All patients were followed up.

Results

Upon follow-up of SCAAR patients (n=40), there was significant reduction in aortic root size (preoperative 39.3 mm [9.4] vs. postoperative 33.1 mm [9.1]; P<0.001). Three of these patients worsened to severe AR while others had similar or lesser degree of AR. On comparison between preoperative and postoperative dimensions of all patients (n=53), there was no significant difference in distal ascending aorta size (35.7 mm [8.1] vs. 34.4 mm [8.9]; P=0.52). However, an increase in descending thoracic aorta size (28.8 mm [7.8] vs. 33.7 mm [9.9]; P<0.001) was observed. In-hospital and late mortalities for SCAAR vs. modified Bentall's procedure were 11.7% (seven patients) (7% [3] vs. 23.5% [4]) and 28% (15 patients) (15% [6] vs. 69% [9]), respectively.

Conclusion

SCAAR with AV resuspension is a safe surgical option for type A AAD. Preservation of AV is associated with better long-term outcomes and reduced mortality. Modified Bentall's operation may be associated with long-term mortality.

Melody valve to replace the mitral valve in small children: Lessons learned

Objective:

Infants requiring mitral valve replacement have few viable options. Recently, stented bovine jugular vein graft (Melody) has been surgically implanted in such cases. Herein, we report our experience, elaborating on evolution of implantation technique, pitfalls, as well as long-term outcome (including late dilatability).

Methods:

Seven Melody valves were implanted (2013–2019). The median patient age and weight were 6.7 (1.8–30.5) months and 5.8 (4.6–9.5) kg, respectively. The indications for implantation were mitral stenosis and/or regurgitation postatrioventricular septal defect (AVSD) repair (5), congenital mitral valve dysplasia (1), and Shone's complex (1). Operative technique involved shortening the valve and creating a neo-sewing ring at 2/3 (atrial)–1/3 (ventricular) junction. Implantation was followed by intraoperative balloon dilatation.

Results:

Five out of seven patients survived the perioperative period (one death due to technical failure and the other due to acute respiratory distress syndrome postcardiopulmonary bypass). Two out of five medium-term survivors got transplanted (1) or died due to acute myeloid leukemia (1). No valves were replaced. The mean echo gradient at discharge was a median 4 (2–6) mmHg. None of the patients showed left ventricular outflow tract or pulmonary venous obstruction. Two Melody valves were dilated late (5 months and 3 years postoperatively), resulting in decreasing mean gradients from 6 to 1 and from 17 to 4 mmHg. At last follow-up, surviving Melody had a mean gradient of 4 (1–9) mmHg.

Conclusions:

Mitral valve replacement with a Melody valve is feasible in infants, is reproducible, shows good immediate results, and offers the possibility of later dilatation. This technique offers a better solution compared to the existing alternatives for infants requiring a prosthetic mitral valve.

Novel prefabricated bovine pericardial grafts as alternate conduit for septic aortoiliac reconstruction

OBJECTIVE

Infection of prosthetic aortic grafts represents a serious complication with high morbidity and mortality. Replacement with autologous material is recommended; however, in its absence, biological material should be favored. In the present retrospective cohort study, we evaluated the short- and midterm results with the use of commercially available prefabricated bovine pericardium grafts (BPGs) used for the management of aortic graft infection or aortic reconstructive surgery in the presence of systemic infection.

METHODS

We performed a retrospective analysis of patients in whom BPGs had been used for aortic reconstruction at two vascular centers. Prefabricated vascular pericardium grafts were preferred over other biological reconstruction techniques for selected cases. Comorbidities, procedure-related details, perioperative morbidity, clinical outcomes, and mortality were analyzed.

RESULTS

From 2014 to 2019, 21 patients had received BPGs at two Austrian vascular centers. Their median age was 63 years (interquartile range [IQR], 55-71 years), the patients were predominantly male (76%), and the median body mass index was 25.3 kg/m² (IQR, 21.7-27.3 kg/m²). The major comorbidities included arterial hypertension, peripheral artery disease, smoking, and chronic pulmonary disease. The indications for surgery were vascular graft or endograft infection in 62% and aortic reconstruction in the presence of systemic infection in 38%. Three patients (14%) had aortoenteric fistulas. Surgery was technically successful in all cases. The median follow-up was 21.6 months (IQR, 6.0-34.6 months). The 30-day mortality was 9.5%. The 1- and 2-year overall survival was 84% and 75%, respectively. Of the 21 patients, 89% had remained free of recurrent infection. One of the two reinfections had resolved after treatment of the underlying focus. At 2 years, the primary and assisted primary patency rates were 86% and 94%, respectively. No limbs were lost during follow-up.

CONCLUSIONS

Prefabricated BPGs represent a promising alternative for the management of aortic graft infections and aortoiliac reconstruction in the presence of systemic infection.

The use of cardiac valve procedures for rheumatic heart disease in Australia; a cross-sectional study 2002-2017

Background

Australia, although a high income economy, carries a significant burden of rheumatic heart disease (RHD). Acute rheumatic fever (ARF) and RHD are endemic in the Indigenous population. Immigrants from low/lower-income countries (‘non-Indigenous high-risk’) are also at increased risk compared with ‘non-Indigenous low-risk’ Australians. This study describes the utilisation of surgical and percutaneous procedures for RHD-related valve disease among patients aged less than 50 years, from 2002 to 2017.

Methods

A descriptive study using data from the ‘End RHD in Australia: Study of Epidemiology (ERASE) Project’ linking RHD Registers and hospital inpatient data from five states/territories, and two surgical databases. Trends across three-year periods were determined and post-procedural all-cause 30-day mortality calculated.

Results

A total of 3900 valves interventions were undertaken in 3028 procedural episodes among 2487 patients. Over 50% of patients were in the 35–49 years group, and 64% were female. Over 60% of procedures for 3-24 year-olds were for Indigenous patients. There were few significant changes across the study period other than downward trends in the number and proportion of procedures for young Indigenous patients (3–24 years) and ‘non-Indigenous/low risk’ patients aged ≥35 years. Mitral valve procedures predominated, and multi-valve interventions increased, including on the tricuspid valve. The majority of replacement prostheses were mechanical, although bioprosthetic valve use increased overall, being highest among females <35 years and Indigenous Australians. All-cause mortality (n = 42) at 30-days was 1.4% overall (range 1.1–1.7), but 2.0% for Indigenous patients.

Conclusions

The frequency of cardiac valve procedures, and 30-day mortality remained steady across 15 years. Some changes in the distribution of procedures in population groups were evident. Replacement procedures, the use of bioprosthetic valves, and multiple-valve interventions increased. The challenge for Australian public health officials is to reduce the incidence, and improve the early detection and management of ARF/RHD in high-risk populations within Australia.

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Epidemic RHD in Indigenous Australians drives RHD-related cardiac valve procedures.

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30-day mortality post-procedural is low in those under 50 years.

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Bioprosthetic valve replacements higher in young women, and increasing in older patients.

Final 5-year outcomes following aortic valve replacement with a RESILIA™ tissue bioprosthesis

OBJECTIVES

Long-term durability of bioprosthetic valves is predominantly limited by structural valve deterioration. RESILIA™ tissue has exhibited reduced calcification in pre-clinical and early clinical studies. This study evaluated the 5-year clinical and haemodynamic outcomes of an aortic valve with this tissue.

METHODS

This was a prospective, non-randomized, single-arm study of 133 patients implanted with a RESILIA aortic bioprosthesis between July 2011 and February 2013 at 2 sites in Poland. Clinical outcomes and haemodynamic performance were assessed annually for 5 years post-implant. Safety events were adjudicated by a Clinical Events Committee and echocardiographic data were assessed by an independent core laboratory.

RESULTS

Mean patient age was 65.3 ± 13.5 years, with 34 patients (25.6%) ≤60. The mean follow-up was 4.2 ± 1.5 years. Early (≤30 days) and late (>30 days) all-cause mortality were 2.3% (N = 3) and 3.2%/late patients-years (N = 18) respectively. Early events included thromboembolism in 3 patients (2.3%). Late valve-related events included endocarditis in 1 patient, which led to explant, and valve thrombosis in another patient. There were no events of structural valve deterioration throughout the study. At 5 years, mean gradient was 14.8 ± 7.6 mmHg and effective orifice area was 1.4 ± 0.5 cm2, a marked improvement over baseline values. All New York Heart Association class III patients and most class II patients at baseline had improved classifications at 5 years.

CONCLUSIONS

The bioprosthesis with RESILIA tissue demonstrated a good safety profile with excellent haemodynamic performance over 5 years of follow-up. These encouraging outcomes warrant additional investigation of this novel tissue.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01651052.

Hemodynamic Performance of Pericardial Bioprostheses in the Aortic Position

Background

This study was conducted to evaluate the hemodynamic performance and the incidence of prosthesis-patient mismatch (PPM) after aortic valve replacement (AVR) using bovine pericardial valves (Carpentier-Edwards Perimount Magana and Magna Ease).

Methods

In total, 216 patients (mean age, 70.0±10.5 years) who underwent AVR using stented bovine pericardial valves and had follow-up echocardiography between 3 months and 2 years (mean, 12.0±6.6 months) after surgery were enrolled. The implanted valve sizes were 19, 21, 23, and 25 mm in 32, 56, 99, and 29 patients, respectively.

Results

On follow-up echocardiography, the mean transvalvular pressure gradients for the 19-mm, 21-mm, 23-mm, and 25-mm valves were 13.3±4.4, 12.6±4.2, 10.5±3.9, and 10.2± 3.7 mm Hg, respectively. The effective orifice area (EOA) was 1.25±0.26, 1.54±0.31, 1.81±0.41, and 1.87±0.33 cm², respectively. These values were smaller than those suggested by the manufacturer for the corresponding sizes. No patients had PPM, when based on the reference EOA. However, moderate (EOA index ≤0.85 cm²/m²) and severe (EOA index ≤0.65 cm²/m²) PPM was present in 56 patients (11.8%) and 9 patients (1.9%), respectively, when using the measured values.

Conclusion

Carpentier-Edwards Perimount Magna and Magna Ease bovine pericardial valves showed satisfactory hemodynamic performance with low rates of PPM, although the reference EOA could overestimate the true EOA for individual patients.

Long-term results after the Ross procedure with the decellularized AutoTissue Matrix P® bioprosthesis used for pulmonary valve replacement

OBJECTIVES

Since 1967, the Ross procedure has been performed to treat aortic valve disease using homografts for pulmonary valve replacement. The decellularized Matrix P® prosthesis was developed to overcome (some) limitations of homografts. Until now, the long-term outcome data have been unavailable.

METHODS

Between 2002 and 2010, the Ross procedures using the Matrix P prosthesis were performed in 492 adult patients (mean age 57.2 ± 10.6 years, range 21-73 years) at our institution. Patient data were prospectively collected and analysed (3617.3 patient-years, mean follow-up 7.7  ±  4.3 years). Completeness of follow-up at 1, 5 and 10 years was 98.4%, 94.5% and 91.0%, respectively.

RESULTS

Hospital mortality was 3.9% (n  = 19). During follow-up, 121 patients died resulting in a survival rate at 5, 10 and 12.5 years of 82.8  ±  1.7%, 70.4  ±  2.3% and 62.4  ±  2.9%, respectively. Echocardiography revealed a high incidence of relevant dysfunction of the Matrix P prosthesis and subsequent right ventricular failure. Primary reoperation/reintervention was necessary for 150 Matrix P and 48 autografts. Freedom from pulmonary valve reoperation at 5, 10 and 12.5 years was 76.2  ±  2.1%, 58.6  ±  2.9% and 53.4  ±  3.4%, respectively. The autograft function and the left ventricular function showed similar results as previously reported with a freedom from autograft reoperation at 5, 10 and 12.5 years of 91.8  ±  1.4%, 86.1  ±  2.0% and 86.1  ±  2.0%, respectively.

CONCLUSIONS

The Matrix P prosthesis used for the right ventricular outflow tract reconstruction in the Ross procedure showed unfavourable long-term echocardiographic results with a high rate of reoperation/reintervention for structural pulmonary valve failure. As a consequence, long-term survival of this patient cohort was impaired. Based on these findings, the use of the Matrix P prosthesis for pulmonary valve replacement for Ross procedures in adults should not be recommended.

A review of the use of biological mesh products in modern UK surgical practice: a religious and cultural perspective

INTRODUCTION

The UK is an increasingly multicultural society. This change coincides with an increasing use of animal products in medicine and surgery and a change in the UK law of consent. The refusal of Jehovah's Witnesses to accept blood products is well known, but the use of animal products in surgery is a neglected topic. As society becomes more diverse and medicine becomes ever more advanced, there is increasing potential for a mismatch between what is medically possible and what is acceptable from a religious perspective.

METHODS

Surgical products were identified by searching the literature and contacting manufacturing companies. Literature was identified by using PubMed and OVID (MEDLINE). Religious views were established by contacting national bodies for each group.

FINDINGS

The views of common UK religious groups and the constituent parts of biological meshes are summarised in tables intended to be used as a reference during clinical practice. On an elective basis, the Islamic, Hindu. Sikh and Jain leaders contacted had strong views on avoiding animal derived products. The Christian and Jewish leaders contacted did not. All religious leaders contacted accepted the use of mesh derived from human tissue. All products, including those of porcine and bovine origin, were acceptable to all leaders contacted if the procedure was performed to save life. The highlighting of this issue should prompt earlier consideration and discussion in the surgical planning and the consenting process with all final decisions taken by both the surgeon and the individual patient.

Reduced Permanent Pacemaker Implantation in Patients With Stentless Freedom SOLO Compared With Stented Perimount Magna Aortic Bioprostheses: A Propensity Score Weighted Analysis

OBJECTIVES

Postoperative permanent pacemaker implantation (PPI) after conventional aortic valve replacement (AVR), due to new-onset severe conduction system disorders, is required in approximately 7% of patients. This study investigated the need for PPI after AVR with conventional stented Perimount Magna compared with the Freedom SOLO (FS) stentless valve (Sorin Group, Saluggia, Italy), now LivaNova plc (London, UK) that uses a strictly supra-annular, subcoronary running suture implantation technique, sparing the vulnerable interleaflet triangles in the region of the septum membranaceum.

METHODS

A total of 413 consecutive patients (71.4±9.2 yrs, 178 [43.1%] female) underwent isolated AVR using the stented Perimount Magna (n=264) or the stentless FS (n=149) bioprosthesis. Propensity score weighted analysis was used to account for patient-specific and procedural-specific variables, and to identify the prosthesis-specific need for early postoperative PPI within 30 days of AVR.

RESULTS

Twenty (20) patients required PPI, which was associated with longer intensive care unit (2.1±1.7 vs 1.5±3.0 days, p<0.001) and overall hospital stays (13.8±5.2 vs 10.7±5.3 days, p<0.001) compared with no PPI. Propensity weighted logistic regression including cross-clamp times identified that use of the stented Perimount Magna was associated with increased need for PPI, as compared with the FS, with an odds ratio 5.8 (95% CI, 1.09-30.76; p=0.039).

CONCLUSIONS

After corrections for all plausible confounders, AVR with the stented Perimount valve was associated with an odds ratio of almost 6 for an increased early postoperative need for pacemaker implantation compared with the FS stentless valve. This finding can be explained by the conventional implantation technique, which is potentially associated with mechanical trauma to the conducting system.