Aortic Position Research Articles

Our new tornado-compatible aortic valve prosthesis: notable results of hydrodynamic testing and experimental trials

Standard hydrodynamic tests of the new prosthetic valve have been carried out for comparing with the other existing valve designs. A new method for the heart valve prosthesis testing in a tornado-like flow has been developed. The valve function has been verified in a swine excluding the anticoagulation treatment during the period of time exceeding six months. Results The significant advantage of the new prosthesis in the standard hydrodynamic tests has been demonstrated. The tests in the tornado-like flow have shown that only this prosthesis allows maintaining the pattern, the head and flow rate characteristics of the tornado-like jet. Upon implanting the new prosthesis in the aortic position in a swine, the good performance of the valve without anticoagulation therapy has been confirmed in the course of more than six months. Conclusion Obtained has been the evidence of the merits of the new mechanical aortic valve owing to the due consideration of the hydrodynamic peculiarities of the aortic blood flow and the creation of the design providing the proper hydrodynamic compatibility.

Use of balloon expandable transcatheter valves for valve-in-valve implantation in patients with degenerative stentless aortic bioprostheses: Technical considerations and results

Transcatheter valve-in-valve is an accepted treatment in high-risk patients with degenerative stented bioprostheses in the aortic position. Experience in treating stentless valves is, however, limited. Our aim was to determine the feasibility and single-center outcome of balloon expandable SAPIEN valve placement in degenerated stentless aortic valve bioprostheses. From February 2010 to January 2014, 10 patients with failing stentless bioprostheses underwent transcatheter aortic valve implantation using the Edwards SAPIEN transcatheter heart valve (SAPIEN, SAPIEN XT, and SAPIEN 3) at our institution. Seven patients had valve failure due to regurgitation and three to stenosis. The mean age was 73.3 ± 15.0 years. The mean logistic EuroSCORE was 31.8 ± 20.3, and the Society of Thoracic Surgeons score was 7.6 ± 5.4. Technical success was achieved in 9 of 10 patients. One patient required immediate placement of a second valve owing to low placement of the first. Two intraoperative complications developed that needed additional procedures. One patient underwent immediate repair of a right ventricular perforation from a pacing lead, the other, reexploration for epicardial bleeding. No deaths occurred. The median length of stay was 8.5 days (range, 3-44). The mean follow-up was 8.1 months (range, 1-21). No late reoperations or reinterventions were required. Transcatheter aortic valve implantation after previous stentless aortic valve replacement is technically demanding but a safe and feasible approach. The early results were excellent, with consistent improvement in hemodynamics. Prospective long-term follow-up in larger series is needed to evaluate this technique further.

Angiographic Catheter Entrapped in a Mitral Valve Prosthesis

The patient was a man with a Bjork-Shiley mitral valve prosthesis. During a hemodynamic study, the angiographic catheter inserted into the left ventricle inadvertently passed into the atrium through the minor orifice of the prosthesis, which immobilized the disc (Figure 1). On trying to withdraw it, we noted resistance. All attempts to withdraw it failed. We were able to advance it once again, forming a loop in the atrium, but when we tried to draw it back, it again became entrapped. The patient developed acute pulmonary edema and shock. He was intubated and transferred to the operating room. When we learned from his medical records that he had not undergone left atrial appendage ligation, we decided to perform left thoracotomy with the idea of a rapid approach and of the possibility of removing the catheter without cardiopulmonary bypass. Once a tourniquet had been applied to the atrial appendage, the surgeon inserted his index finger into the atrium to grasp the catheter, and removed it in the retrograde direction after the distal Luer connector had been detached (Figure 2). The patient’s circulatory status normalized and the outcome of the intervention was good. Follow-up examinations demonstrated that the prosthesis was functioning normally. The catheter was retained when it was passed through the minor orifice of the prosthesis in the retrograde direction and an attempt was made to withdraw it in the anterograde direction. The probe remained wedged between the disc and the ring by a ‘‘trapdoor’’ mechanism. The entrapment became more resistant when we attempted to pull the device out and yielded when it was reinserted; thus, it was easy to release the probe from the atrium by opening the ‘‘trapdoor’’ mechanism in the right direction. This complication is fatal unless resolved within minutes, and can occur with any single disc valve, either in the mitral or aortic position. Figure 1. Figure 2.

Misconceptions, diagnostic challenges and treatment opportunities in bioprosthetic valve thrombosis: lessons from a case series.

Bioprosthetic valve thrombosis (BPVT) is a rare but potentially life-threatening complication. Current guidelines favour surgery or thrombolysis as initial treatment. We set forth to characterize timing, diagnostic criteria and treatment strategies in BPVT. A free-text search tool was used to identify patients diagnosed with BPVT at Mayo Clinic between 1997 and 2013. We compared patients treated initially with vitamin K antagonists (VKA group; N = 15) versus surgery/thrombolysis (non-VKA group; N = 17). Peak incidence of BPVT was 13-24 months after implantation in both groups. VKA and surgery/thrombolysis decreased prosthetic mean gradients to a similar extent (VKA group: 13 ± 5 to 6 ± 2 mmHg in mitral position, 9 ± 3 to 5 ± 1 mmHg in tricuspid position and 39 ± 3 to 24 ± 7 mmHg in aortic/pulmonary position; non-VKA group: 16 ± 12 to 5 ± 1 mmHg in mitral, 10 ± 5 to 4 ± 1 mmHg in tricuspid and 57 ± 9 to 18 ± 6 mmHg in aortic position; P = 0.59 for group effect). NYHA class improved in 11 of 15 patients in the VKA group and 10 of 17 patients in the non-VKA group (P = 0.39). There were no deaths, strokes or recognized embolic events; 1 patient in each group experienced gastrointestinal bleeding requiring transfusion. Index transthoracic echocardiogram formally identified BPVT in a minority of patients. BPVT may occur late after surgical implantation. VKA therapy resulted in haemodynamic and clinical improvement with minimal risk, and should be considered the first-line therapy in haemodynamically stable patients. Echocardiographic criteria for improving BPVT diagnosis are proposed.

Prognosis of patients with carcinoid heart disease after valvular surgery.

A best evidence topic in cardiac surgery was written according to a structured protocol. We addressed the following question: in patients who are diagnosed with carcinoid heart disease (CHD), do valvular surgeries improve their prognosis? Fifty percent of the patients with clinically diagnosed carcinoid syndrome had cardiac involvement which was present either as valvular dysfunction or as cardiac metastases. These patients often require surgery due to their heightened risk of cardiac disease. Altogether 217 relevant papers were identified as a result of the below-mentioned search, of which 10 papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. Of the patients who were identified to have carcinoid heart disease in different studies, 193 patients had valve procedure, mainly replacements at tricuspid, mitral and aortic valve positions and either valvuloplasty or replacement at pulmonary valve. Tricuspid and pulmonary valves represented the majority of the excised valves among patients undergoing valvular surgery for CHD. The pathology of carcinoid valve was attributed to the presence of plaque, causing thickening and retraction. Pure regurgitation was the most common finding in all the valves except pulmonary valve which had both stenosis and insufficiency. Thirty-day mortality was 17% (range 1-63%) and long-term survivors were reported to be alive at an average of 58 months (28-80 months) after the valve surgery. The evidence demonstrates that surgical intervention can lead to improved prognosis and reduce the symptoms of heart failure. Postoperative mortality was mainly due to the carcinoid disease itself and not as a complication of the surgery. Therefore, surgery could be considered for symptomatic palliation in carefully selected individuals.

Early hemodynamics results of aortic valve replacement with the new St Jude Trifecta bioprosthesis

Aortic stenosis is the most frequent acquired heart valve lesion in the Western countries. The aim of this prospective study was to evaluate the early clinical results and hemodynamic performance of the new St Jude Medical Trifecta stented bioprosthesis. One hundred consecutive patients were prospectively included in this study from April 2011 to December 2012. They underwent aortic valve replacement (AVR) with the St Jude Bioprosthesis Trifecta in our institution. The Trifecta valve is a tri-leaflet stented pericardial valve designed for supra-annular placement in the aortic position. A single cardiac surgeon operated on all the patients. Echocardiograms were performed pre-operatively and post-operatively, between 7 and 10 days to assess the hemodynamic performance of the prosthesis. The effective orifice area (EOA) of the aortic valve was calculated by the continuity equation and the mean transvalvular gradient at rest was derived from the simplified Bernoulli equation accounting for the flow velocity across the left ventricular outflow tract. A follow-up was performed at one year (100% complete). An informed consent form was signed by the patients before the intervention to allow data processing. Mean age at implantationwas 75.2 ± 7.5 ans (from 34.2 to 83.6 ans, median 71.7 ans). The sex ratio was 1.32 (Table 1). Fifty-five (55%) patients were octogenarians. The main AVR indication was aortic stenosis (n = 79). Preoperative New York Heart Association (NYHA) functional class was: I for 2 patients, II for 61 pts, III for 34 pts, and IV for 3 patients (Table 1). The preoperative cardiac rhythm was sinus for 94 patients, atrial fibrillation for 5 patients and one patient had a pacemaker. This study included 1 redo procedure. Ten patients (10%) had a poor left ventricular ejection fraction (LVEF b 35%). All prostheses were implanted in supra annular position using a continuous suture of polypropylene 2/0. The operation was elective in 98 patients and urgent in 2 patients. Forty one patients underwent a concomitant procedure, including 36 coronary artery bypass grafting (CABG) with an average of 1.16 grafts performed and the left internal thoracic artery was used for all patients. The prosthesis diameters were mainly 21 and 23 mm (Fig. 1). Operation times were for isolated AVR: 31 ± 20.2 mn for aortic cross-clamp and 45.5 ± 20.7 mn for cardiopulmonary bypass (Table 2). A de novo atrioventricular (AV) block occurred in 8 patients with only one pacemaker implantation. Acute atrial fibrillation was the most frequent post-operative complication (42%). Operativemortality (b30 days after the surgery ormore if the patient was not discharged) was 2%. One patient died after a redo procedure due to endocarditis and one because of respiratory failure. Therewere no valve related post-operative complications. Baseline mean pre-operative and post-operative LVEF were 60 ± 15% and 58± 18% respectively (ns). Themean transvalvular gradient improves significantly from 52.8 ± 15.4 mmHg pre-operatively to 10.4 ± 3.5 mmHg postoperatively (p= 0.001) (Table 3). The mean gradient was low for all bioprosthesis sizes (Fig. 2). The indexed effective orifice area (EOA) was for all diameters greater than 0.65 cm/m (Fig. 3). Only 3 trivial paravalvular leaks were observed. A trans-thoracic echocardiography was performed for fifty patients between 4 and 6 months and showed that mean gradients were stable (10.2 ± 2.5 mmHg). At one year, one non valve related death occurred. During this short follow-up, therewere novalve related complications.Ninetyninepercentof thepatientswere in NYHA class I (70%) or class II (29%). In Western countries, AVR has increased because of the increasing rate of octogenarians operated on. During this period the bioprosthesis has become the prosthesis most commonly used with almost 70% of the implantation rate compared to mechanical prostheses. This evolution could be explained by the aging population and the good bioprostheses durability [1,2]. Hemodynamic performance and long term durability are both crucial to get an ideal bioprosthesis. The Carpentier Edwards valve is the oldest bioprosthesis, implanted since 1969, and remains the “gold standard bioprosthesis” because of the extended durability studied in literature for more than 20 years [1–3]. Freedom from structural deterioration at 18 years for the porcine Carpentier–Edwards valve was 86.4% ± 1.2% and respectively 98.2% ± 0.6% for patients aged between 61 et 70 years and 90.5% ± 1.8% for patients older than

The long-term follow-up of large-diameter Dacron® vascular grafts in surgical practice: a review.

Synthetic grafts have been widely used in cardiac and vascular surgery since the mid-1970s. Considering the relative lack of randomized clinical trials or systematic analyses in the field of prosthetic large vessel diameter replacement, we reviewed the literature on the long-term performance and surgical management of complications of Dacron® grafts in both thoracic and abdominal aorta reconstruction and in the pediatric population. MedLine, Embase and Cochrane Library databases were searched for meta-analyses, reviews, clinical trials, and case reports pertinent to the study object. Aortic replacement with Dacron® prostheses is widely performed with acceptable outcome and a relatively low rate of graft-related and postimplantation complications, such as rupture, infection and fistulization. However, progressive dilation and mechanical failure of the grafts represent the most worrisome complication in all the districts analyzed. The emerging concept of the mismatch in the biomechanical properties between the prosthetic material and native aorta is thought to be at the root of these complications leading to even more daunting consequences when the ascending aorta is involved. Indeed introduction of a non-compliant prosthesis in place of the native ascending aorta can exert detrimental effects not only at the level of the anastomosis, leading to pseudoaneurysm, but also can influence the optimal performance of the aortic root complex with consequent valve dysfunction and ventricular hypertrophy. Albeit confirming their overall successful performance, this review launches a warning on the current liberal use of non-compliant grafts in aortic position, remarking the need for alternative vascular conduits mimicking the native artery compliance.

Cardiac Magnetic Resonance for Paravalvular Leaks in Post-Transcatheter Aortic Valve Replacement

An 80-year–old man with known coronary artery disease presented with progressively worsening shortness of breath over the past few weeks. On transthoracic echocardiography (TTE) examination he was found to have severe aortic stenosis with an aortic valve area of 0.8 cm2. Maximum aortic valve velocity was 4.25 m/s, peak gradient was 72.2 mm Hg with a mean gradient of 43.0 mm Hg, and mild aortic valve insufficiency was noted. He was deemed a surgical candidate and was randomly assigned to transcatheter aortic valve replacement (TAVR) as part of the Placement of Aortic Transcatheter Valve Trial II trial. An Edwards Sapien 29-mm XT bioprosthetic valve was placed through left-sided transfemoral access uneventfully. Within a day of the procedure, the patient reported worsening dyspnea. A postprocedural TTE revealed mild anterior and posterior paravalvular leak (PVL) by color Doppler (Figure 1 and Movie I in the online-only Data Supplement). Given the clinical and imaging findings, a higher-grade PVL was suspected, prompting further evaluation with cardiac magnetic resonance (CMR) imaging. Figure 1. Post-transcatheter aortic valve replacement transthoracic echocardiogram showing paravalvular defect and leak. A , B-mode parasternal long axis view showing 29-mm Sapien valve in the aortic position (yellow arrows). B …

Prótesis valvular en el tracto de salida del ventrículo izquierdo en niños

A systematic review will be done in this chapter about valvular prosthesis in aortic position as the last therapeutic option for children who other reparative options have failed. Different prosthesis are described and surgical techniques to open the aortic annulus. Finally, particular attention to mitral position is also reviewed.

Joint modeling of two longitudinal outcomes and competing risk data

Aortic gradient and aortic regurgitation are echocardiographic markers of aortic valve function. Both are biomarkers repeatedly measured in patients with valve abnormalities, and thus, it is expected that they are biologically interrelated. Loss of follow-up could be caused by multiple reasons, including valve progression related, such as an intervention or even the death of the patient. In that case, it would be of interest and appropriate to analyze these outcomes jointly. Joint models have recently received much attention because they cover a wide range of clinical applications and have promising results. We propose a joint model consisting of two longitudinal outcomes, one continuous (aortic gradient) and one ordinal (aortic regurgitation), and two time-to-events (death and reoperation). Moreover, we allow for more flexibility for the average evolution and the subject-specific profiles of the continuous repeated outcome by using B-splines. A disadvantage, however, is that when adopting a non-linear structure for the model, we may have difficulties when interpreting the results. To overcome this problem, we propose a graphical approach. In this paper, we apply the proposed joint models under the Bayesian framework, using a data set including serial echocardiographic measurements of aortic gradient and aortic regurgitation and measurements of the occurrence of death and reoperation in patients who received a human tissue valve in the aortic position. The interpretation of the results will be discussed.

TexMi: development of tissue-engineered textile-reinforced mitral valve prosthesis.

Mitral valve regurgitation together with aortic stenosis is the most common valvular heart disease in Europe and North America. Mechanical and biological prostheses available for mitral valve replacement have significant limitations such as the need of a long-term anticoagulation therapy and failure by calcifications. Both types are unable to remodel, self-repair, and adapt to the changing hemodynamic conditions. Moreover, they are mostly designed for the aortic position and do not reproduce the native annular-ventricular continuity, resulting in suboptimal hemodynamics, limited durability, and gradually decreasing ventricular pumping efficiency. A tissue-engineered heart valve specifically designed for the mitral position has the potential to overcome the limitations of the commercially available substitutes. For this purpose, we developed the TexMi, a living textile-reinforced mitral valve, which recapitulates the key elements of the native one: annulus, asymmetric leaflets (anterior and posterior), and chordae tendineae to maintain the native annular-ventricular continuity. The tissue-engineered valve is based on a composite scaffold consisting of the fibrin gel as a cell carrier and a textile tubular structure with the twofold task of defining the gross three-dimensional (3D) geometry of the valve and conferring mechanical stability. The TexMi valves were molded with ovine umbilical vein cells and stimulated under dynamic conditions for 21 days in a custom-made bioreactor. Histological and immunohistological stainings showed remarkable tissue development with abundant aligned collagen fibers and elastin deposition. No cell-mediated tissue contraction occurred. This study presents the proof-of-principle for the realization of a tissue-engineered mitral valve with a simple and reliable injection molding process readily adaptable to the patient's anatomy and pathological situation by producing a patient-specific rapid prototyped mold.

Clinical and hemodynamic study of tilting disc heart valve: Single-center study

The TTK Chitra heart valve has been developed and widely used in India. This study aimed to evaluate its hemodynamics, complications, and event-free survival in comparison with other commonly used prosthetic valves. The role of color Doppler echocardiography in the follow-up of patients with prosthetic valves was also studied. Two hundred patients underwent 249 valve replacements (122 mitral, 29 aortic, 49 both). Total follow-up was 451 patient-years. There were 18 late deaths (3.98% ± 0.92% per patient-year). One mitral valve replacement patient (0.36% ± 0.36% per patient-year) developed valve thrombosis. Two aortic valve replacement patients (2.74% ± 1.91% per patient-year), 2 double-valve replacement patients (1.95% ± 1.36% per patient-year) and 3 mitral valve replacement patients (1.08% ± 0.62% per patient-year) developed embolic complications. Freedom from all valve related mortality and morbidity at 4 years was 86% ± 4% for mitral valve replacement, 56% ± 10% for double-valve replacement, and 89% ± 6% for aortic valve replacement. The average peak gradient, mean gradient, and average peak velocity for the aortic and mitral positions were found to be comparable to those of other commonly used valves. The performance of this valve in terms of hemodynamic complications, mortality, and morbidity is comparable to other valves in common use. Hemodynamic gradients are more reproducible than effective orifice area, hence more beneficial for follow-up.

Long-term results of Freestyle stentless bioprosthesis in the aortic position: A single-center prospective cohort of 500 patients

Stentless xenograft bioprostheses may be the future valve of choice for aortic valve replacement. The study aim was to investigate the long-term clinical outcome after aortic valve replacement with the Medtronic Freestyle bioprosthesis (Medtronic Inc, Minneapolis, Minn). Between April 1997 and November 2004, a total of 500 patients (mean age, 74.5±9.6 years; 52% were male) underwent aortic valve replacement with a Freestyle bioprosthesis, without population selection. The surgical procedure used a modified subcoronary technique in 479 patients and a complete root replacement in 21 patients, conducted with mini-extracorporeal circulation. Concomitant procedures included coronary artery bypass grafting in 122 patients (24%) and mitral valve repair/replacement in 11 patients. The mean cardiopulmonary bypass time was 98±26 minutes, and total aortic crossclamp time was 77±19 minutes. Operative mortality was 5.2%. The median follow-up time was 104.8±5.7 months. During this period, there were 224 deaths (n=122 cardiovascular and n=102 noncardiovascular deaths). The actuarial survivals from cardiovascular and valve-related mortality were 67%±3% and 70%±4%, respectively, at 10 years. Freedom from structural valve deterioration at 10 years was 94%±2%. The linearized structural valve deterioration incidence was 0.6% per patient/year. Multivariate Cox regression analysis revealed that older age, impaired renal function, and coronary artery disease were independent predictors of cardiovascular death. In the subgroup of patients aged less than 65 years at implantation (n=45), the actuarial cardiovascular survival was 83%±8% and freedom from structural valve deterioration was 89%±6% at 10 years. The use of the Freestyle bioprosthesis for aortic valve replacement resulted in good long-term cardiovascular survival and freedom from structural valve deterioration in this cohort regardless of age at implantation.

Percutaneous Closure of a Traumatic Ventricular Septal Defect After Transcatheter Aortic Valve Implantation

An 89-year-old patient underwent successful transcatheter implantation of a 26-mm Edwards Sapien valve in the aortic position. Clinical improvement was initially observed, but after 6 months the patient's condition deteriorated, leading to a novel evaluation. A 6-mm acquired perimembranous ventricular septal defect (VSD) was diagnosed, with a significant shunt (Qp/Qs ratio = 2 at right heart catheterization) (A).

Twenty-seven-year experience with the St. Jude Medical Biocor™ bioprosthesis in the aortic position

Twenty-seven-year experience with the St. Jude Medical Biocor™ bioprosthesis in the aortic position

The Medtronic Mosaic prothesis in aortic and mitral position: Clinical perfomance in 1540 patients up to 13 years

The Medtronic Mosaic prothesis in aortic and mitral position: Clinical perfomance in 1540 patients up to 13 years

Twenty-year durability of the aortic Hancock II bioprosthesis in young patients: is it durable enough?†

There is a current trend towards the use of bioprosthetic aortic valves in the aortic position in young patients, but there is limited information on durability beyond the first decade. The Hancock II bioprosthesis has been reported to have excellent durability in patients ≥ 60 years of age. This study examines the long-term durability of the Hancock II bioprosthesis in the aortic position in patients <60 years of age. From 1982 to 2008, 304 patients aged 59 years or less underwent aortic valve replacement (AVR) with a Hancock II bioprosthesis at two centres. The mean age was 49.2 ± 9.0 years, and 79% of the patients were male. Valve function was serially assessed by echocardiography. The median follow-up was 14.6 years (maximum 27.5 years). Survival and freedom from adverse events were calculated by using a Kaplan-Meier method. Independent predictors of those events were assessed by using Cox proportional hazards analyses. Survival and freedom from repeat AVR (re-AVR) at 20 years were 57.0 ± 6.1 and 25.4 ± 4.7%, respectively. During the follow-up, 100 patients (33%) underwent re-AVR: 78 for structural valve deterioration (SVD), 11 for endocarditis, 4 for non-structural valve dysfunction and 7 for other reasons. The overall 10-, 15- and 20-year freedom from re-AVR due to SVD were 91.4 ± 2.1, 64.7 ± 4.3 and 29.1 ± 5.3%, respectively. By age group, the 20-year freedom from re-AVR due to SVD amounted to 14.1 ± 8.7% in patients younger than 40 years of age, 21.5 ± 8.5% in patients aged 40-49 and 41.4 ± 8.2% in patients between 50 and 59 (P = 0.04). The independent predictors of re-AVR due to SVD were age [odds ratio (OR): 0.72 per 10 years; 95% confidence interval (CI): 0.58, 0.90; P < 0.01] and prosthesis-patient mismatch (PPM) (effective orifice area index <0.80 cm(2)/m(2)) (OR: 1.63; 95% CI: 1.01, 2.63; P = 0.045). The Hancock II bioprosthesis for AVR in patients <60 years of age is associated with excellent durability during the first decade. However, SVD increases dramatically during the second decade and by 20 years, especially in patients aged <50 and/or with PPM. These findings may assist prosthesis selection for patients and their surgeons.

Seventeen-millimeter St. Jude Medical Regent valve in patients with small aortic annulus: dose moderate prosthesis-patient mismatch matter?

BackgroundThe study was designed to evaluate the effects of moderate prosthesis-patient mismatch (defined as 0.65 cm2/m2 < indexed effective orifice area ≤ 0.85 cm2/m2) on midterm outcomes after isolated aortic valve replacement with a 17-mm St. Jude Medical Regent valve in a large series of patients, and to determine if these effects are influenced by patient confounding variables.MethodsOne-hundred and six patients with and without moderate prosthesis-patient mismatch early after implantation of a 17-mm Regent valve at aortic position were included. Both clinical and echocardiographic assessments were performed preoperatively, at discharge and during follow-up period (mean follow-up time 52.6 ± 11.9 months).ResultsThe prevalence of moderate prosthesis-patient mismatch was documented in 46 patients (43.4%) at discharge. During the follow-up period, no difference in the regression of left ventricular mass, decrease of transvalvular pressure gradients, mortality and prosthesis-related complications was observed between patients with and without moderate prosthesis-patient mismatch. After adjustment for several risk factors, moderate prosthesis-patient mismatch was associated with increased midterm mortality in patients with baseline left ventricular ejection fraction < 50% (HR: 1.80, p = 0.02), but with normal prognosis in those with preserved LV function. Younger age (cut off value = 65 years) was not an independent predictor of increased midterm mortality and valve-related complications in patients with moderate prosthesis-patient mismatch.ConclusionsModerate prosthesis-patient mismatch after aortic valve replacement with a small mechanical prosthesis is associated with increased mortality and adverse events in patients with pre-existing left ventricular dysfunction. Selected patients with small aortic annulus can experience satisfactory clinical improvements and midterm survival after aortic valve replacement with a 17-mm Regent valve.

Late outcomes comparison of nonelderly patients with stented bioprosthetic and mechanical valves in the aortic position: A propensity-matched analysis

Our study compares late mortality and valve-related morbidities between nonelderly patients (aged <65 years) undergoing stented bioprosthetic or mechanical valve replacement in the aortic position. We identified 1701 consecutive patients aged <65 years who underwent aortic valve replacement between 1992 and 2011. A stented bioprosthetic valve was used in 769 patients (45%) and a mechanical valve was used in 932 patients (55%). A stepwise logistic regression propensity score identified a subset of 361 evenly matched patient-pairs. Late outcomes of death, reoperation, major bleeding, and stroke were assessed. Follow-up was 99% complete. The mean age in the matched cohort was 53.9 years (bioprosthetic valve) and 53.2 years (mechanical valve) (P=.30). Fifteen additional measurable variables were statistically similar for the matched cohort. Thirty-day mortality was 1.9% (bioprosthetic valve) and 1.4% (mechanical valve) (P=.77). Survival at 5, 10, 15, and 18 years was 89%, 78%, 65%, and 60% for patients with bioprosthetic valves versus 88%, 79%, 75%, and 51% for patients with mechanical valves (P=.75). At 18 years, freedom from reoperation was 95% for patients with mechanical valves and 55% for patients with bioprosthetic valves (P=.002), whereas freedom from a major bleeding event favored patients with bioprosthetic valves (98%) versus mechanical valves (78%; P=.002). There was no difference in stroke between the 2 matched groups. In patients aged <65 years, despite an increase in the rate of reoperation with stented bioprosthetic valves and an increase in major bleeding events with mechanical valves, there is no significant difference in mortality at late follow-up.

Evaluation of advancing the standard valve dysfunction by multidetector-row CT

We evaluated the diagnostic usefulness of electrocardiographically gated multidetector-row computed tomography (MDCT) for prosthetic valve dysfunction (PVD) of an ATS valve. Twenty-four patients underwent MDCT following echocardiography and cineradiography. Echocardiography and cineradiography showed normal valve function in 17 patients and PVD in 7. PVD included aortic prosthetic valve obstruction in 4 patients, an aortic annular aneurysm with paraprosthetic regurgitation in one, and a blocked leaflet in the mitral position in 2. Among the 7 patients, 5 received reoperation after MDCT. MDCT revealed a subprosthetic mass in all 5 patients with PVD and in 4 patients with normal valve function in the aortic position. In addition to a subprosthetic mass, an annular aneurysm was found in one. Valvular masses were detected in 2 patients with mitral PVD. At reoperation, subprosthetic pannus in the aortic position was detected in 2 patients, subprosthetic pannus and annular aneurysm with paraprosthetic leaks in one, and mitral valve thrombosis in 2. These findings confirmed at reoperation matched to the findings observed on MDCT. The mean CT attenuation of the subprosthetic mass in 6 patients was 152±12HU and that of the subprosthetic pannus in 3 patients was 163±17HU. CT attenuation of the thrombus in the mitral valve in the 2 patients was 60 and 99HU. Our study demonstrates that MDCT is a valuable and reliable diagnostic technique for PVD in an ATS valve and that MDCT may identify an abnormality causing PVD.