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PubMed2006

Surgical management of functional tricuspid regurgitation with a new remodeling annuloplasty ring.

BACKGROUND: Moderate-to-severe functional tricuspid regurgitation (TR) should be corrected in patients undergoing surgery for left-sided valvular diseases, to improve long-term outcomes. Several techniques of surgical repair (suture annuloplasty or prosthetic annuloplasty) to correct this condition have been described. Multiple clinical studies have shown the superiority of prosthetic remodeling annuloplasty over the other surgical approaches. Despite this, suture-based annuloplasty remains the most commonly used technique for tricuspid valve repair. A new 3-dimensional remodeling prosthesis has been developed to address the issue of residual TR. We report our early experience with this new 3-dimensional prosthetic remodeling ring, the Edwards MC 3 system. MATERIAL: From August 2002 to March 2004, 51 patients (24 male, 27 female, mean age 64 +/- 15, ejection fraction 49 +/- 15, median NYHA III [II-IV]) underwent tricuspid valve repair for functional TR due to annular dilatation, with the Edwards MC 3 system. Etiology of left-sided valvular disease was: rheumatic (n = 19), degenerative (n = 16), ischemic cardiomyopathy (n = 1), and endocarditis (n = 5). Twenty (50%) patients underwent redo operations. Concomitant procedures included: mitral valve surgery (repair n = 34, replacement n = 14), aortic valve replacement (n = 5), coronary artery bypass graft (n = 8) and left arterial maze (n = 16). Median EuroSCORE was 12% (1-74%) in this patient population. RESULTS: Operative and late mortality were 3.8% (n = 2) and 13.7% (n = 7), respectively. Echocardiography at discharge showed a mean TR decrease from 3.1 +/- 0.9 to 0.3 +/- 0.4 (p < 0.001) and mean mitral regurgitation (MR) decrease from 3.2 +/- 1 to 0.1 +/- 0.1 (p < 0.001), while ejection fraction increased to 53% (p = 0.047), and at 6-month follow-up, mean TR and MR remained unchanged. CONCLUSION: Concomitant tricuspid valve repair for functional TR with left-sided valve surgery carries a low operative mortality. The Edwards MC 3 annuloplasty system is relatively simple to implant and corrects TR effectively (without significant residual TR), while providing excellent short-term clinical results. The 3-dimensional saddle shape of this ring may further optimize the fixation of the annulus in systolic position, and improve long-term results. Larger clinical series with longer-term follow-up are necessary to confirm these early promising results.

Aged↗
PubMed2003

Early and late stroke after mitral valve replacement with a mechanical prosthesis: risk factor analysis of a 24-year experience.

OBJECTIVE: We evaluated risk factors for mortality and stroke after mechanical mitral valve replacement between May 1977 and December 2001. METHODS: Early and late mortality and stroke were assessed. Potential predictors of mortality and stroke were entered into a Cox proportional hazards model. Actuarial survival and freedom from stroke were determined by a log-rank test. RESULTS: Mitral valve replacement was performed in 812 patients. Concomitant procedures included left atrial appendage closure in 493 (61%) patients, tricuspid annuloplasty-replacement in 348 (43%) patients, maze procedure in 185 (23%) patients, plication of the left atrium in 148 (18%) patients, and other procedures in 151 (19%) patients. Five-year actuarial survival was 91.1% +/- 2.3%. Freedom from stroke at 8 years was significantly better in patients with sinus rhythm versus atrial fibrillation (P <.001). Ninety-nine percent of patients with mitral valve replacement combined with a maze procedure were free from stroke, whereas only 89% of patients with mitral valve replacement alone were free from stroke at 8 years after surgical intervention. Seventy-two patients had late stroke; sixty-five patients (90%) were in atrial fibrillation, and 47 (65%) patients had the left atrial appendage closed. Multivariate analysis showed that late atrial fibrillation (odds ratio, 3.39; 95% confidence interval, 1.72-6.67; P =.0001) and omission of the maze procedure (odds ratio, 3.40; 95% confidence interval, 1.14-10.14; P =.003) were the significant risk factors for late stroke. CONCLUSIONS: Persistent atrial fibrillation was the most significant risk factor for late stroke after mechanical mitral valve replacement. Restoration of sinus rhythm with a maze procedure nearly eliminated the risk of late stroke, whereas neither closure of the left atrial appendage nor therapeutic anticoagulation prevented this complication.

Adolescent↗
PubMed2000

Mid-term clinical and echocardiographic follow up of patients with CarboMedics valves in the tricuspid position.

BACKGROUND AND AIM OF THE STUDY: Debate continues regarding tricuspid valve replacement (TVR) with a mechanical prosthesis. Experience with bileaflet prostheses is limited; hence the study aim was to explore early and mid-term outcome and hemodynamic data in patients with bileaflet CarboMedics prosthetic valves in the tricuspid position. METHODS: The study population included 25 patients (21 females, four males; mean age 50.5 +/- 13.4 years) who underwent TVR with a CarboMedics valve over a six-year period. Routine clinical examinations and details of transthoracic echocardiography (TTE) were reviewed. Additional TTE, transesophageal echocardiography (TEE) and fluoroscopy were performed as indicated. The number of previous cardiac operations was zero, one and two in 36%, 32% and 32% of patients, respectively. Previous tricuspid surgery was performed in eight cases (32%); concurrent mitral valve replacement was performed in 17 (68%). The hospital mortality rate was 24% and late mortality rate 12%. Seventeen early survivors (13 females, four males) were followed up for 46 +/- 28 months (range: 4-96 months). RESULTS: Among early survivors, the mean and peak transvalvular gradients were 4.0 +/- 1.7 and 7.9 +/- 3.3 mmHg, respectively. Commonly observed INR levels were >2.5 in seven patients (41%), and >3.0 in only three (18%). Five patients (29% of mid-term survivors) experienced a total of 13 episodes of obstructive valve thrombosis, mostly with inappropriate anticoagulation. One patient required emergency re-do surgery; the others responded initially to thrombolysis or intensified antithrombotic treatment, but experienced at least two additional relapses. Aside from thrombotic episodes, all patients but two were in NYHA functional class II-III, and all but four required diuretics. CONCLUSION: TVR with bileaflet mechanical valves carries a high perioperative mortality and mid-term morbidity. Among patients with poor or fair anticoagulation, these valves were associated with a high incidence of obstructive valve thrombosis. If poor patient compliance is anticipated, insertion of a bioprosthesis should be encouraged.

Echocardiography↗
PubMed2006

Root replacement using stentless valves in the small aortic root: a propensity score analysis.

BACKGROUND: Root replacement using a stentless bioprosthesis may be the optimal approach to avoid patient-prosthesis mismatch in patients with a small aortic root. Primary root replacement, however, is considered to be associated with increased surgical risk. We compared early outcome of full root replacement with a stentless bioprosthesis with that of aortic valve replacement with a stented bioprosthesis using propensity score-matching analysis. METHODS: Of 231 patients undergoing elective, first-time aortic valve replacement with a small root (< or = 22 mm), 120 patients were selected using propensity score-matching analysis. They underwent either root replacement using a 23-mm stentless bioprosthesis (stentless group, n = 60) or supra-annular aortic valve replacement using a 21-mm stented bioprosthesis (stented group, n = 60). Preoperative characteristics and frequency of concomitant operations were identical. RESULTS: Duration of operation (196 +/- 54 versus 174 +/- 49 minutes), cardiopulmonary bypass (112 +/- 36 versus 91 +/- 33 minutes), and aortic cross-clamping (76 +/- 21 versus 61 +/- 21 minutes) were significantly longer in the stentless group. However, the need for perioperative transfusion and the incidence of postoperative reexploration for bleeding (3% versus 8%) was lower, and ventilation time was shorter. Mean duration of intensive care and hospital stay were also significantly shorter (2.3 +/- 1.7 versus 4.0 +/- 3.9 days, 8.9 +/- 3.1 versus 12.4 +/- 5.7 days). In-hospital mortality was identical (5% each). No independent predictor for in-hospital mortality was identified. CONCLUSIONS: Full root replacement using a stentless bioprosthesis does not increase postoperative morbidity or mortality of aortic valve replacement and may be advantageous in patients with a small aortic root.

Aged↗
PubMed2005

Three years' experience with the on-x conform-X bileaflet prosthesis for 'atrialized' mitral valve replacement: a preliminary report.

BACKGROUND AND AIM OF THE STUDY: Positioning of a mechanical prosthesis outside the native annulus facilitates mitral valve replacement, especially when the annulus is small and calcified, and preservation of the posterior leaflet (PML) is desired. Herein is described the authors' initial experience with a new mechanical bileaflet prosthesis comprising a sheltered leaflet housing and a novel, modified asymmetrical sewing ring for an 'atrialized' implantation technique. METHODS: Forty-seven patients (24 males, 23 females; mean age 65.8 +/- 10.9 years) were operated on for isolated mitral regurgitation or combined stenosis and insufficiency. Ten of the patients underwent valve replacement due to active endocarditis. Preoperative cardiac insufficiency was reflected by a mean NYHA class of 2.6 +/- 0.7. The On-X Conform-X bileaflet mitral valve prosthesis (25/33 mm) was implanted in either an epiannular (43 patients) or intra-annular (four patients) fashion, and the PML and its chordae tendineae were preservable in 33 patients (70.2%). All patients were monitored intraoperatively by transesophageal echocardiography (TEE) and post-operatively by transthoracic echocardiography (TTE). RESULTS: TEE and TTE exhibited excellent function with low mean transvalvular gradients early after surgery (4.9 +/- 2.7 mmHg) and after three months (4.8 +/- 1.4 mmHg). Paravalvular leakage was not detected. Initial postoperative left ventricular (LV) function was almost identical to preoperative findings (ejection fraction: preop. 55.1 +/- 13.7%, early postop. 53.7 +/- 13.6%) and improved slightly after three months (60.1 +/- 6.4%). Clinically significant hemolysis was not apparent (LDH at postoperative day 7: 5.3 +/- 0.8 micromol/l x s). Two patients died from multiorgan failure (4.2%) and four are currently in a reduced condition requiring long-term hospitalization (morbidity 8.5%). After three months all other patients were in an excellent clinical state (mean NYHA class 1.5 +/- 0.6) and being followed up as outpatients. CONCLUSION: Current designs of mechanical bileaflet valves require redundant space in the LV cavity for undisturbed leaflet movement. A small annulus, marked fibrosis and calcification of the valvular apparatus can lead to an impedance of prosthetic leaflet motion. Consequently, the native leaflets are often removed. The cylindrical housing of the On-X valve shelters almost the entire motion of the leaflets, allowing an undisturbed function and improved transvalvular flow pattern. The newly developed asymmetrical sewing ring facilitates anchoring of the ring in an 'atrialized' fashion, while the flexibility of the cuff adapts to all native ring diameters larger than 25 mm.

Aged↗
PubMed1998

Minimally invasive aortic valve replacement without sternotomy. Experience with the first 50 cases.

OBJECTIVE: The method of replacing the aortic valve via a mini-thoracotomy has been reported in the recent literature. Although this strategy has clear advantages, further refinements of the process make the procedure even less invasive. METHODS: Aortic valve replacement was performed in 50 patients whose age ranged between 49 and 82 years, averaging 68+/-8.3 years. As access route, a right parasternal mini-thoracotomy of about 8 cm, without rib resection was used. Cardiopulmonary bypass was connected through the same access. Standard surgical techniques and equipment were employed. In all patients a mechanical prosthesis was implanted. RESULTS: There were neither intraoperative complications nor hospital death. All patients could be discharged home at an average of 10+/-3 days postoperatively. Cardiopulmonary bypass time, aortic cross-clamp time, total operation time averaged 118+/-32, 70+/-21, 180+/-45 min, respectively. Four patients could be extubated in the operative theater, the others on the intensive care units at an average of 12+/-6 h, postoperatively. One patient with a very thin aortic wall sustained a severe bleeding from the aortic cannulation site during an hypertensive crisis, just after extubation. He had to be re-entered immediately via a median sternotomy. A second patient, who was initially operated on because of a floride aortitis, had a limited periprosthetic leak 2 months postoperatively. The leak was repaired via a median sternotomy. Drainage lost and blood substitution averaged 751+/-400 and 274+/-390, respectively. CONCLUSIONS: The advantages of the present method include further reduction of hospital trauma, preservation of chest wall integrity, early mobilization and rehabilitation of the patient. Surgical technical improvements include avoidance of groin cannulation, simpler equipment, and an easy access in case of reoperation.

Aged↗
PubMed1998

Mitroflow pericardial bioprosthesis experience in aortic valve replacement > or =60 years of age.

BACKGROUND: The Mitroflow pericardial bioprosthesis (model 11), a second-generation pericardial prosthesis, has clinical performance assessment to 10 years. The authors previously recommended the prosthesis for aortic valve replacement in patients 70 years or older. The purpose of the current assessment is to report on performance in patients 60 years or older undergoing aortic valve replacement. METHODS: This bioprosthesis was implanted in 161 patients (mean age, 69.5+/-6.3 years; range, 60 to 94 years) with aortic valve replacement from 1982 to 1992. There were 84 patients 60 to 69 years (mean, 64.5+/-3.1 years) and 77 patients 70 years or older (mean, 74.8+/-4.3 years). Of the total population, concomitant procedures were performed in 63 patients (39.1%); of these, coronary artery bypass grafting was performed in 39 (24.2%). RESULTS: The early mortality was 4.8% (4 patients) for the 60 to 69-year age group and 10.4% (8) for those 70 years or older (not significant). The late mortality was 4.4%/patient-year (27) for those 60 to 69 years and 6.9%/ patient-year (35) for those 70 years or older (not significant). The patient survival for those 60 to 69 years was 58.0%+/-6.3% and for those 70 years or older, 45.3%+/-5.9% at 10 years (p < 0.05). The valve-related mortality for those 60 to 69 years was 0.82%/patient-year (5) and for those 70 years or older, 1.58%/patient-year (8) (not significant). The reoperation rate for those 60 to 69 years was 3.29%/patient-year (20) and for those 70 years or older, 1.0%/patient-year (5) (p < 0.05). The structural valve deterioration rate for those 60 to 69 years was 3.13%/ patient-year (19) and for those 70 years or older, 1.2%/ patient-year (6) (p < 0.05). CONCLUSIONS: The Mitroflow pericardial bioprosthesis remains recommended for aortic valve replacement in patients 70 years and older.

Age Factors↗
PubMed2005

Valve opening and closing dynamics after different aortic valve-sparing operations.

BACKGROUND AND AIM OF THE STUDY: Aortic valve resuspension for ascending aortic aneurysm repair is associated with removal of the sinus of Valsalva. This may cause changes in leaflet motion and thus impact on long-term durability. The opening and closing characteristics of the aortic valve leaflets after reimplantation were studied using a published technique and a modification to create a 'neosinus', and the results compared to those of an age-matched control group. METHODS: Between September 1995 and March 2002, 25 patients underwent normal aortic root reconstruction (group A), while in a further 21 patients the modified neosinus technique was used (group B). In both groups, the native valve was preserved and suspended inside a tubular prosthesis, with reimplantation of the coronary arteries. Transthoracic and transesophageal studies of aortic valve dynamics were performed intraoperatively, before hospital discharge, and at one year after surgery in all patients; the data were compared with those from a separate group of 25 matched control individuals (group C). RESULTS: The valve opening velocity was 61.3+/-20.1, 46.3+/-8 and 29.2+/-9.8 cm/s in groups A, B and C, respectively (group A versus B, p = 0.003; A versus C, p <0.0001; B versus C, p <0.0001). Closing velocity was increased to 57.5+/-23 and 43.8+/-7 cm/s in groups A and B, compared to 23.6+/-7 cm/s in group C (A versus B, p = 0.012; A versus C, p <0.0001; B versus C, p = 0.0002). In seven group A patients, the leaflets touched the prosthetic wall during systole. Slow systolic closing displacement (SCD) amounted to 7.3+/-6 % of maximal opening in group A and 12.6+/-5 % in group B (p = 0.05), compared to 21.1+/-8.3% in group C (group A versus group C, p <0.0001; B versus C, p = 0.002). CONCLUSION: Reimplantation of the natural aortic valve in a prosthetic graft causes abnormally high opening and closing speeds, with possibly increased stress. The study results showed lower valve opening and closure dynamics after the creation of a sinus bulge compared to the conventional reimplantation technique. However, mid-term clinical observations showed favorable valve competence for both types of repair. Further long-term follow up is necessary to prove whether more physiological leaflet dynamics lead to improved durability.

Adolescent↗
PubMed1998

Valve-related complications in elderly patients with biological and mechanical aortic valves.

BACKGROUND: Controversy still exists about the choice of aortic prosthesis in elderly patients. This study investigates valve- and anticoagulant-related morbidity and mortality in elderly patients after aortic valve replacement (AVR) with a biologic (BP) or mechanical prosthesis (MP). METHODS: Between 1981 and 1995, 355 consecutive patients aged 70 years or older (mean, 74+/-4 years; range, 70 to 87 years) underwent isolated AVR. There were 222 (63%) replacements with an MP and 133 (37%) with a BP. Mean follow-up was 3.7+/-2.8 years (range, 3 months to 15 years), with a total follow-up of 1,214 patient-years. RESULTS: Hospital mortality was 7.6% (27 of 355), decreasing to 4.6% in the last 3 years. There were 55 late deaths, 33 in patients with MP and 22 in those with BP. At 10 years there was no significant difference between MP and BP recipients in the actuarial estimates of survival (51%+/-8% versus 33%+/-13%), freedom from valve-related death (82%+/-7% versus 72%+/-12%), and freedom from thromboembolism (84%+/-7% versus 94%+/-3%). In contrast, 10-year freedom from anticoagulant-related hemorrhages was 74%+/-8% for MP and 99%+/-1% for BP (p = 0.02). Only 1 structural deterioration occurred, in a patient with BP. CONCLUSIONS: Satisfactory early results can be obtained in elderly patients after AVR with both MP and BP. The comparable low late survival in the two groups was predominantly influenced by non-valve-related deaths. A higher incidence of anticoagulant-related hemorrhages limits the use of MP in elderly patients. Thus, in this population, BP should be preferred not just on the basis of their expected longer durability, but mainly to avoid the risk of anticoagulant-related hemorrhages.

Actuarial Analysis↗
PubMed1998

Medtronic mosaic porcine bioprosthesis satisfactory early clinical performance.

BACKGROUND: The Medtronic (Minneapolis, MN) Mosaic porcine bioprosthesis is an investigational prosthesis which incorporates zero-pressure fixation, aortic root predilation, low profile stent, and alpha oleic acid antimineralization treatment. METHODS: From September 1994 to August 1996, 289 patients (mean age 70 years, range, 28 to 88 years) had 227 (78.5%) aortic valve replacements and 62 (21.5%) mitral valve replacements. Concomitant procedures were performed in 61.2% (139) of aortic valve replacements and 54.8% (34) of mitral valve replacements. Of the aortic valve replacement group 70 (30.8%) were in the 61 to 70 age group and 134 (59.0%) were 71 years or older. Of the mitral valve replacements, 23 (37.1%) were 61 to 70 years and 30 (48.4%) 71 years or older. RESULTS: The early mortality, overall, was 4.2% (12 of 289); for aortic valve replacement it was 4.0% (9) and for mitral valve replacement it was 4.8% (3). The late mortality for aortic valve replacement was 2.6% per patient-year (3 events, 1.3% of total) and for mitral valve replacement it was 3.3% per patient-year (one event, 1.6% of total). The reoperative rate for aortic valve replacement was 3.0% per patient-year (4), while there were no mitral valve replacement reoperations. The freedom from major thromboembolism was 97.3%+/-1.6% for aortic valve replacement and 94.7%+/-3.0% for mitral valve replacement at 1 to 1.5 years. The freedom from reoperation was 96.7%+/-1.7% for aortic valve replacement; there was no reoperation for mitral valve replacement. There were no cases of structural valve deterioration. In the aortic position the mean systolic gradient was low, approximately 11 mm Hg, across all sizes (range 8 to 12 mm Hg at 3 months and 10 to 13 mm Hg at 12 months). In the mitral position the mean diastolic gradient was approximately 5 mm Hg (range, 2 to 6 mm Hg) for all sizes 25 to 31 mm at the early and 1 year follow-up echocardiographic assessment. CONCLUSIONS: The early clinical performance and in vivo hemodynamics are encouraging.

Adult↗
PubMed2000

Mitroflow pericardial valve prosthesis in the aortic position: an analysis of long-term outcome and prognostic factors.

BACKGROUND AND AIM OF THE STUDY: Pericardial valves combine optimal hemodynamic properties with limited durability. To describe the long-term performance of Mitroflow pericardial valves in the aortic position, outcome and risk factors up to 12 years after implantation were analyzed. METHODS: A retrospective study, based on follow up of 1,029 patients who received 1,044 Mitroflow pericardial valves in the aortic position between February 1985 and December 1996, was performed. Follow up was 98.2% complete. Average follow up was 3.79 years. Mean patient age was 75.2+/-6.5 years (range: 27.9-90.9 years). At surgery, 86.3% of patients were aged over 70 years. Among patients, 482 (46.8%) had concomitant operations. RESULTS: Results (+/- SE) are given for evident and possible (in parentheses) valve-related events; the latter included all reported postoperative strokes and sudden deaths. Actuarial event-free rates after 5 and 10 years respectively were: structural valve deterioration: 99.2+/-0.5% and 77.6+/-4.4%; non-structural valve deterioration: 99.7+/-0.2% and 99.7+/-1.2%; valve-related complications: 95.7+/-0.9% and 73.5+/-4.0% (5 years 90.1+/-1.2%, 10 years 57.0+/-4.3%); endocarditis: 96.6+/-0.8% and 92.6+/-1.6%; explantation: 98.6+/-0.5% and 80.1+/-3.9%; cerebrovascular accident 95.2+/-0.9% and 82.5+/-3.5%; embolism 99.9+/-0.1% and 99.9+/-0.5%; bleeding 99.8+/-0.2% and 99.8+/-1.3%; overall mortality 69.9+/-1.8% and 35.3+/-3.0%; valve-related death 97.5 +/-1.1% and 95.1+/-4.2% (5 years 91.9+/-1.4%, 10 years 76.1+/-3.2%). The 30-day mortality rate was 4.1%. Patients aged 70 years or more with valve diameters of < or =23 mm showed 10-year freedom rates of 85.8+/-4.6% for structural valve degeneration and 95.1+/-1.2% for evident valve-related death. The detailed risk factor analysis showed results that were in accordance with clinical experience. CONCLUSION: Long-term results with Mitroflow pericardial valves in the aortic position compare well with those for other widely used bioprostheses, especially in patients aged > or =70 years and with small aortic root diameters (< or =23 mm).

Adult↗
PubMed2006

Patient prosthesis mismatch affects short- and long-term outcomes after aortic valve replacement.

OBJECTIVE: The aim of this study was to evaluate the impact of patient prosthesis mismatch (PPM) and additional risk factors on outcome after aortic valve replacement (AVR). METHODS: Four thousand one hundred and thirty-one patients who were operated between May 1996 and April 2004 were evaluated. One thousand eight hundred and fifty-six patients received bileaflet mechanical AVR and 2275 stented xenograft AVR. PPM was defined as severe if manufacturers effective orifice area (EOA) divided by body surface area (BSA) was <0.65 cm(2)/m(2) and as moderate in the range of 0.65-0.85 cm(2)/m(2). PPM, age, gender, EOA index, emergency indication for surgery (within 24h), EuroSCORE as well as requirement for additional procedures were tested. Univariate (Fisher's exact test) and multivariate logistic regression analysis as well as survival analysis (Kaplan-Meier) were performed. RESULTS: Severe PPM was present in 97 (2.4%) and moderate PPM in 1103 (26.7%) patients. PPM occurs more frequently with xenograft AVR. In-hospital mortality was 5.2% for severe, 10.6% for moderate and 6.9% with no PPM (p=0.018, OR 1.4). Moderate PPM was independently predictive for short- and long-term mortality. Further analysis revealed patient age >70 years (n=1589, p=0.002, OR 1.85), emergency indication (n=374, p<0.001, OR 4.4), EuroSCORE >10 (n=494, p<0.001, OR 4.7) and additional cardiac procedures (n=2049, p<0.001, OR 2.0) as predictors for adverse outcome after AVR. CONCLUSION: Severe PPM is rare; moderate PPM is present in a quarter of patients. PPM has a significant impact on short- and long-term mortality after AVR.

Aged↗
PubMed2004

Cardiac valve replacement with mechanical prostheses in patients aged 65 years and over.

BACKGROUND AND AIM OF THE STUDY: Recent data regarding the performance of mechanical prostheses in patients aged > or =65 years are scant. Hence, the outcome of mechanical prosthesis implantation in this age group has been retrospectively evaluated. METHODS: Between January 1990 and October 2002, 253 patients (163 males, 90 females) aged > or =65 years (mean age 68.2 years) underwent aortic valve replacement (AVR) and/or mitral valve replacement (MVR) at the authors' institution. RESULTS: Among the patients, 94 (37.2%) had MVR, 137 (54.1%) had AVR, and 22 (8.7%) had MVR+AVR. In total, 99 patients (39.1%) had concomitant coronary artery bypass grafting (CABG). The early mortality rate was 11.1%; that for patients aged > or =70 years was greater than that for patients aged 65-69 years (14.5% versus 9.6%, p <0.001). The overall actuarial survival was 91.3 +/- 2.4% at 5 years, 81.1 +/- 4.1% at 8 years, and 73.8 +/- 6.3% at 10 years. Actuarial survival for patients with isolated AVR and MVR at 10 years was 84.7 +/- 6.0% and 61.4 +/- 18.8%, respectively. Actuarial survival at 10 years for patients with isolated valve replacement was 76.1 +/- 8.1%, and 68.7 +/- 10.2% for patients with concomitant CABG (p = 0.680). Actuarial survival at 10 years was 81.3 +/- 6.9% for patients aged 65-69 years, and 50.3 +/- 11.0% for patients aged > or =70 years (p = 0.001). Freedom from a major thromboembolic event was 99.4 +/- 0.7% at five years and 86.3 +/- 6.0% at 10 years, while freedom from hemorrhage was 90.4 +/- 2.6% and 70.3 +/- 6.8%, respectively. CONCLUSION: Mechanical prostheses can be used in patients aged > or =65 years, with favorable results. However, on the basis of the present findings, patients aged > or =70 years have a reduced early and late survival.

Aged↗
PubMed2005

Prospective evaluation of aortic valve replacement in young adults and middle-aged patients: mechanical prosthesis versus pulmonary autograft.

BACKGROUND AND AIM OF THE STUDY: The best option for aortic valve replacement (AVR) in young adults and middle-aged patients remains controversial. A longitudinal comparison between the Ross procedure (RP) and mechanical prosthesis (MP) was conducted in this group of patients. METHODS: Between January 1997 and January 2003, 125 consecutive patients (age range: 20-50 years) were submitted for AVR; 62 patients (mean age 37.73+/-7.28 years) were included in the MP group, and 63 (mean age 35.33+/-7.63 years) in the RP group. Gender, etiology, NYHA functional class and other preoperative data were comparable between the two groups. RESULTS: The operative mortality was four (6.5%) in the MP group, and one (1.6%) in the RP group (p = NS). The postoperative complication rate was similar in both groups. Two RO patients required early autograft replacement due to severe regurgitation. There were no late deaths during the follow up period. In the MP group, three patients (4.8%) suffered major bleeding, three (4.8%) were diagnosed with prosthetic endocarditis (one required reoperation), and three (4.8%) suffered valve- or coumarin-related thromboembolic complications. All RP patients were free from bleeding, thromboembolic, or infectious complications, but three suffered severe pulmonary homograft stenosis (one re-replacement, one Palmaz stent, and one under clinical surveillance). The combined freedom from death or major complications was 64.72+/-4.3% in the MP group, and 87.92+/-9.65% in the RP group (p = 0.068). CONCLUSION: Intraoperative and early postoperative morbidity and mortality rates were similar among RP and MP patients, despite a steep learning curve during the early RP cases. Although the follow up was limited, and homograft-related morbidity was seen in the RP group, the overall five-year major complication rate supported use of the pulmonary autograft for AVR in patients aged between 20 and 50 years.

Adult↗
PubMed1999

Carpentier-Edwards standard and supraannular porcine bioprostheses: comparison of technology.

BACKGROUND: Performance with regard to structural valve deterioration (SVD) with the Carpentier-Edwards standard (CE-S) and supraannular (CE-SAV) (Baxter Healthcare Corp, Irvine, CA) porcine bioprostheses was evaluated to determine whether progress in reduction of structural failure has been achieved with technological changes. METHODS: The CE-S was implanted during 567 aortic valve replacement (AVR) and 486 mitral valve replacement (MVR) procedures, and the CE-SAV was implanted during 1,670 AVR and 1,096 MVR procedures. The failure mode of early stent dehiscence with the CE-SAV prosthesis, thought to be controlled by manufacturing changes in 1986 and 1987, supported comparison of the CE-SAV with censored cases of stent dehiscence. Stent dehiscence accounted for only 1.2% (1 of 81) and 14.1% (29 of 205) of AVR and MVR CE-SAV failures, respectively. RESULTS: The only difference for AVR for freedom from SVD occurred in the 21- to 40-year age group at 15 years and was 68% for the CE-SAV and 31% for the CE-S (p<0.05). In the 61- to 70-year age group, freedom from SVD at 15 years was 76% for the CE-S and 84% for the CE-SAV; for the 71-year or higher age group, freedom from SVD was 89% and 95%, respectively (p = NS). For MVR freedom from SVD was different only in the 71-year or higher age group and was 90% for the CE-S and 59% for the CE-SAV (p<0.05). Freedom from SVD was reduced but was similar (p = NS) for the other age groups. For AVR the actual freedom from SVD at 15 years for the CE-S and CE-SAV was, respectively, 79% and 72% for the 51- to 60-year age group, 86% and 91% for the 61- to 70-year age group, and 98% and 98% for the 71-year or higher age group. For MVR, these rates were, respectively, 69% and 75% for the 61- to 70-year age group and 96% and 89% for the 71-year and higher age group. CONCLUSIONS: The technologic advancements made in the second-generation CE-SAV bioprosthesis to reduce the incidence of structural failure have not uniformly been successful. The actual freedom from SVD provides evidence for implantation of porcine bioprostheses for AVR in age groups 61 to 70 years and 71 years or higher and for MVR in the age group 71 years or higher.

Adult↗
PubMed2000

Management of a patient with a mechanical aortic valve and antibodies to both thrombin and factor V after repeat exposure to fibrin sealant.

We describe a patient who developed a markedly prolonged PT, PTT, and thrombin time 13 days after repeat exposure to fibrin sealant during coronary artery bypass grafting and aortic valve replacement. Evaluation revealed an inhibitor to bovine thrombin that cross-reacted with human thrombin. In addition an inhibitor to human coagulation factor V was identified. Despite coagulation abnormalities there was no evidence of bleeding. Nevertheless, effective anticoagulation was required to minimize the thrombotic complications associated with the patient's prosthetic valve. We elected to take a conservative approach and not utilize pharmacologic anticoagulation until there was diminution in the effect of the acquired inhibitors. We report on our patient's course and review the available literature addressing the management of patients demonstrating inhibitors to blood coagulation factors after repeat exposure to fibrin sealants.

Aged↗