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Abstract

We thank Kattach and Ohri for their commentary1Kattach H. Ohri S.K. Trifecta bioprosthesis midterm results (letter).Ann Thorac Surg. 2020; 109: 615Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar on our article.2Kilic A. Sultan I. Navid F. et al.Trifecta aortic bioprosthesis: midterm results in 1,953 patients from a single center.Ann Thorac Surg. 2019; 107: 1356-1363Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar Most patients (n = 3) who developed at least moderate prosthetic valve regurgitation by 1 year were patients with endocarditis and intravenous drug use history and who reused drugs and reinfected their valves. Another patient underwent aortic valve replacement with coronary bypass grafting and developed moderate central prosthetic aortic insufficiency with progressive heart failure and then underwent redo valve replacement. Two patients had small paravalvular leaks at the conclusions of their aortic valve replacements that progressed to moderate with follow-up, but both were managed medically and ultimately improved to mild leaks. Both of these patients were octogenarians. The last patient (85 years old) underwent aortic valve replacement with coronary bypass grafting and developed a periannular abscess with moderate insufficiency, but the patient’s family allowed comfort measures only and the patient died. As highlighted above, the majority of these cases was a substrate of the patient’s disease process, such as prosthetic endocarditis from recurrent drug use, or potentially the result of implant technique. The current cadre of surgeons in our division are aggressive regarding paravalvular leaks during the index operation, and they will reapply an aortic cross-clamp to address these with a nearly zero intraoperative paravalvular leak rate. In addition, the 7 cases discussed here were performed during the earlier phase of the study period and not performed by the 2 senior surgeons (T.G. and F.N.), both of whom currently use a continuous running suture technique for aortic valve replacement, which has not been associated with any structural valve deterioration in our series. We are confident that with appropriate surgical technique, the structural valve deterioration rates of the Trifecta valve can be minimized with no appreciable increase compared with other contemporary bioprosthetic valves. Regarding mortality rates, it is difficult to compare outcomes between institutions without considering the baseline characteristics of the study population. In our current series, 62% of patients had concomitant operations, with 15% of the overall cohort having prior open-heart surgery and 7% having infective endocarditis. Only 31% of operations were elective isolated aortic valve replacements. In addition, 33% of our patients had baseline moderate or severe aortic valve insufficiency. In comparison, the commentators’ institution who reported on 400 Trifecta implants with 52% having concomitant procedures, 7.5% having prior open-heart operations, 2.5% having infective endocarditis, and 6.5% having aortic insufficiency as the predominant aortic valve lesion.3Modi A. Budra M. Miskolczi S. et al.Hemodynamic performance of Trifecta: a single-center experience of 400 patients.Asian Cardiovasc Thorac Ann. 2015; 23: 140-145Crossref PubMed Scopus (17) Google Scholar In our opinion, these study populations are not sufficiently similar to compare survival. Patient–prosthesis mismatch was defined using the manufacturer’s provided effective orifice area for the particular valve size and the patient’s body surface area. The 1 patient who underwent reoperation for patient–prosthesis mismatch had moderate mismatch with an effective orifice area index of 0.82 and structural valve deterioration with a transprosthetic mean gradient of 45 mm Hg 3.5 years after the index operation. During the study period, none of the patients underwent reintervention with transcatheter valve-in-valve replacement. Our surgical group is aggressive with redo surgical valve replacement, particularly in younger patients with preserved life expectancy. Trifecta Bioprosthesis Midterm ResultsThe Annals of Thoracic SurgeryVol. 109Issue 2PreviewKilic and colleagues1 claimed good outcomes with the Trifecta bioprosthesis (St Jude Medical, St Paul, MN) in midterm follow-up. However, their paper contains significant concerns that make us question the validity of their conclusion. Full-Text PDF