Invited Commentary

Abstract

The Trifecta aortic valve (Abbott, St Paul, MN) consists of an external single sheet of bovine pericardium mounted around a titanium stent. Favorable hemodynamic characteristics and midterm clinical outcomes after Trifecta valve implantation in the aortic position have been reported.1Goldman S. Cheung A. Bavaria J.E. Petracek M.R. Groh M.A. Schaff H.V. Midterm, multicenter clinical and hemodynamic results for the Trifecta aortic pericardial valve.J Thorac Cardiovasc Surg. 2017; 153: 561-562Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar However, there are reports of early Trifecta structural valve deterioration (SVD).2Hamamoto M. Kobayashi T. Ozawa M. et al.Pure cusp tear of Trifecta bioprosthesis 2 years after aortic valve replacement.Ann Thorac Cardiovasc Surg. 2017; 23: 157-160Crossref PubMed Scopus (24) Google Scholar, 3Kaneyuki D. Nakajima H. Asakura T. et al.Early first-generation Trifecta valve failure: a case series and a review of the literature.Ann Thorac Surg. 2020; 109: 86-93Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar Kaneyuki and colleagues3Kaneyuki D. Nakajima H. Asakura T. et al.Early first-generation Trifecta valve failure: a case series and a review of the literature.Ann Thorac Surg. 2020; 109: 86-93Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar reviewed the timing, mode, and reason for early prosthesis failure in 7 of 107 patients (6.5 %) with Trifecta valve implantation in a single center. The mean duration of durability was 51 ± 16 months.3Kaneyuki D. Nakajima H. Asakura T. et al.Early first-generation Trifecta valve failure: a case series and a review of the literature.Ann Thorac Surg. 2020; 109: 86-93Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar End-stage renal failure and prosthesis-patient mismatch were independent predictors of early SVD. The main cause of early SVD is leaflet tear, which occurred in 59% of patients in this study; calcification and pannus ingrowth are also reported. Tensile and bending stresses at the leaflet near the commissure have been proposed as a mechanism of Trifecta leaflet tear.2Hamamoto M. Kobayashi T. Ozawa M. et al.Pure cusp tear of Trifecta bioprosthesis 2 years after aortic valve replacement.Ann Thorac Cardiovasc Surg. 2017; 23: 157-160Crossref PubMed Scopus (24) Google Scholar Early SVD with leaflet tear in Mitroflow valves (LivaNova Group, Inc, Vancouver, Canada), which have an external mounting leaflet design similar to that of the Trifecta valve, has also been reported.4Butany J. Feng T. Luk A. Law K. Suri R. Nair V. Modes of failure in explanted Mitroflow pericardial valves.Ann Thorac Surg. 2011; 92: 1621-1627Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar We note that the results of this study differ substantially from those of other large series of the Trifecta valve that include follow-up up to 6 years.1Goldman S. Cheung A. Bavaria J.E. Petracek M.R. Groh M.A. Schaff H.V. Midterm, multicenter clinical and hemodynamic results for the Trifecta aortic pericardial valve.J Thorac Cardiovasc Surg. 2017; 153: 561-562Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar The valve sizes used in these studies were substantially larger than those described by Kaneyuki and colleagues,3Kaneyuki D. Nakajima H. Asakura T. et al.Early first-generation Trifecta valve failure: a case series and a review of the literature.Ann Thorac Surg. 2020; 109: 86-93Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar who reported that 84 of 107 patients had a 19- or 21-mm valve. We acknowledge that the populations are different (and the indexed effective orifice areas were not dissimilar), but this may contribute to the heterogenous results. Valve-in-valve transcatheter aortic valve replacement is emerging as a treatment for bioprosthetic valve failure; the external leaflet mounting of the Trifecta makes it more prone to coronary obstruction, and the titanium frame may not allow fracturing.5Edelman J.J. Khan J.M. Rogers T. et al.Valve-in-valve TAVR: state-of-the-art review.Innovations (Phila). 2019; 14: 299-310Crossref PubMed Scopus (30) Google Scholar Surgeons implanting this valve should consider these issues in young patients in whom reintervention is likely. More data and careful follow-up of the Trifecta valve are required. Early First-Generation Trifecta Valve Failure: A Case Series and a Review of the LiteratureThe Annals of Thoracic SurgeryVol. 109Issue 1PreviewThe Trifecta valve (Abbott, St Paul, MN) has excellent hemodynamic performance with acceptable rates of freedom from structural valve degeneration. However, some recent studies have reported early Trifecta valve failure. Here, we report a case series of seven Trifecta valve failures with a review of the literature. Full-Text PDF