Aortic Valve Conduit Research Articles

Benign Intravalvular Strut Leak After Placement of the Inspiris Resilia Valve

ObjectivesWhat is the incidence of intravalvular leak after aortic valve replacement with the Inspiris Resilia valve? DesignThis is a retrospective chart review. SettingThis study used data from a single, tertiary care academic center. Participants81 patient charts and echo images were reviewed. InterventionsAll patients received an aortic valve replacement using the Inspiris Resilia valve. Pediatric patients or patients receiving an aortic valve conduit were excluded. Measurements and Main ResultsTransesophageal echo images were reviewed independently by two echocardiographers for incidence and severity of intravalvular leak after Inspiris Resilia valve placement. Outpatient follow-up imaging was then compared to intraoperative findings. Valve size and mean gradients were also documented.Of the 81 TEEs that were reviewed, 56 (69.1%) were found to have a strut leak at the time of implantation. Of these 56 patients, 30 were classified as trace regurgitation, 21 as mild and 5 as moderate. Only one case required a return to bypass due to persistent intravalvular leak. Follow up TTE reports were available for 50 of the patients with no persistent leaks. ConclusionsThis pattern of intravalvular leak is unique to the Inspiris Resilia valve and is commonly found in the intraoperative period. While many hypotheses exist for the origin of this leak, the exact mechanism is unclear. Given the high frequency of this post-procedural finding, it is essential that intraoperative echocardiographers be able to distinguish this clinically insignificant leak based on its origin, severity and direction and provide appropriate recommendations to our surgical colleagues.

Valvular and ascending aortic hemodynamics of the On-X aortic valved conduit by same-day echocardiography and 4D flow MRI.

This study aims to assess whether the On-X aortic valved conduit better restores normal valvular and ascending aortic hemodynamics than other commonly used bileaflet mechanical valved conduit prostheses from St. Jude Medical and Carbomedics by using same-day transthoracic echocardiography (TTE) and 4D flow magnetic resonance imaging (MRI) examinations. TTE and 4D flow MRI were performed back-to-back in 10 patients with On-X, six patients with St. Jude (two) and Carbomedics (four) prostheses, and 36 healthy volunteers. TTE evaluated valvular hemodynamic parameters: transvalvular peak velocity (TPV), mean and peak transvalvular pressure gradient (TPG), and effective orifice area (EOA). 4D flow MRI evaluated the peak systolic 3D viscous energy loss rate (VELR) density and mean vorticity magnitude in the ascending aorta (AAo). While higher TPV and mean and peak TPG were recorded in all patients compared to healthy subjects, the values in On-X patients were closer to those in healthy subjects (TPV 1.9 ± 0.3 vs. 2.2 ± 0.3 vs. 1.2 ± 0.2 m/s, mean TPG 7.4 ± 1.9 vs. 9.2 ± 2.3 vs. 3.1 ± 0.9 mmHg, peak TPG 15.3 ± 5.2 vs. 18.9 ± 5.2 vs. 6.1 ± 1.8 mmHg, p < 0.001). Likewise, while higher VELR density and mean vorticity magnitude were recorded in all patients than in healthy subjects, the values in On-X patients were closer to those in healthy subjects (VELR: 50.6 ± 20.1 vs. 89.8 ± 35.2 vs. 21.4 ± 9.2 W/m3, p < 0.001) and vorticity (147.6 ± 30.0 vs. 191.2 ± 26.0 vs. 84.6 ± 20.5 s-1, p < 0.001). This study demonstrates that the On-X aortic valved conduit may produce less aberrant hemodynamics in the AAo while maintaining similar valvular hemodynamics to St. Jude Medical and Carbomedics alternatives.

P343 WHAT IS HIDING BEHIND A ‘STEMI‘?

Abstract Introduction Stanford type A aortic dissection associated with ST–segment elevation myocardial infarction (STEMI) is a rare event with a high mortality rate. Emergency coronary angiography and antithrombotic therapy expose to a greater risk of complications and mortality. Case presentation: A 57–year–old heavy smoker gentleman with no previous medical history was admitted to the emergency department due to the sudden onset of severe oppressive chest pain. The ECG was suggestive of inferior STEMI and thus he was brought to the cath lab. During coronary angiography, there was spontaneous regression of the ST–segment alterations with persistence, however, of chest pain. The coronary angiography was unremarkable, but the cannulation of the right coronary artery was unexpectedly difficult. In light of the clinic and the suspicious fluoroscopic images (dilated aorta and severe valvular calcifications), an aortography was performed showing a type A aortic dissection. CT angiography confirmed the presence of dissection confined to the ascending aorta with origin of the right coronary artery from the false lumen. The supra–aortic trunks were not involved by the dissection. A bicuspid aortic valve and a bovine trunk were also found. The patient therefore underwent emergency cardiac surgery: a composite aortic valve conduit (Bentall procedure) was implanted and double aorto–coronary bypass surgery was performed, due to intraoperative evidence of complete detachment of the right coronary ostium and partial detachment of the left. The operation was successful and the following hospitalization was uneventful. Conclusions This case report exemplifies an important alternative diagnosis in patients referred for STEMI, particularly if with an inferior localization (the right coronary artery is the most frequently involved by the dissection). It is necessary to pay attention to the possible clues coming from the clinical findings and from the radioscopic and angiographic images obtained in the cath lab in order not to miss the diagnosis of a pathology on whose recognition and timely treatment the patient‘s life depends.

Impact of PPAR-gamma activation on the durability of biological heart valve prostheses in hypercholesterolaemic rats.

Hypercholesterolaemia and obesity are risk factors for the development of calcified aortic valve disease and common comorbidities in respective patients. Peroxisome proliferator-activated receptor gamma activation has been shown to reduce the progression of native aortic valve sclerosis, while its effect on bioprosthetic valve degeneration is yet unknown. This project aims to analyse the impact of pioglitazone, a peroxisome proliferator-activated receptor gamma agonist, on the degeneration of biological aortic valve conduits in an implantation model in obese and hypercholesterolaemic rats. Cryopreserved allogenic rat aortic valve conduits (n = 40) were infrarenally implanted into Wistar rats on high-fat (34.6%) diet. One cohort was treated with pioglitazone (75 mg/kg chow; n = 20, group PIO) and compared to untreated rats (n = 20, group control). After 4 or 12 weeks, conduits were explanted and analysed by (immuno-)histology and real-time polymerase chain reaction. A significantly decreased intima hyperplasia occurred in group PIO compared to control after 4 (P = 0.014) and 12 weeks (P = 0.045). Calcification of the intima was significantly decreased in PIO versus control at 12 weeks (P = 0.0001). No significant inter-group differences were shown for media calcification after 4 and 12 weeks. Echocardiographically, significantly lower regurgitation through the implanted aortic valve conduit was observed in PIO compared to control after 4 (P = 0.018) and 12 weeks (P = 0.0004). Inflammatory activity was comparable between both groups. Systemic peroxisome proliferator-activated receptor gamma activation decreases intima hyperplasia and subsequent intima calcification of cryopreserved allografts in obese, hypercholesterolaemic recipients. Additionally, it seems to inhibit functional impairment of the implanted aortic valve. Further preclinical studies are required to determine the long-term impact of peroxisome proliferator-activated receptor gamma agonists on graft durability.

Aortic root replacement in the setting of a mildly dilated nonsyndromic ascending aorta

ObjectiveThere is controversy on how to address mild aortic root dilation during concomitant aortic valve replacement: composite aortic valve conduit replacement or separate ascending aorta and aortic valve replacement. We reviewed our experience to address the issue. MethodsWe retrospectively reviewed 778 adult nonsyndromic patients with aortic root diameter 55 mm or less who received replacement of the ascending aorta and aortic valve from January 1994 to June 2017. Patients were divided into 2 groups based on the type of aortic root intervention: composite aortic valve conduit replacement in 406 patients (52%) and separate ascending aorta and aortic valve replacement in 372 patients (48%). Propensity matching was used to mitigate differences in baseline patient characteristics and produced 188 matched pairs. ResultsSinus of Valsalva diameter was 43 mm (39-47). Operative mortality occurred in 3 patients (2%) in the composite aortic valve conduit replacement group and in 5 patients (3%) in the separate ascending aorta and aortic valve replacement group (P = .470). Median follow-up was 9.6 years (8.4-10.1). Long-term mortality was similar in the 2 groups (P = .083). Repeat operation was performed in 13 patients (7%) in the composite aortic valve conduit replacement group and in 19 patients (10%) in the separate ascending aorta and aortic valve replacement group (P = .365). Sinus of Valsalva diameter decreased 2 mm (−4-0; median follow-up 41 months) in the propensity-matched separate ascending aorta and aortic valve replacement group. ConclusionsIn patients with mild aortic root dilation, separate ascending aorta and aortic valve replacement results in a similar risk of repeat operation and mortality in comparison with composite aortic valve replacement. Separate ascending aorta and aortic valve replacement is not associated with subsequent aortic root dilation on medium-term echocardiography follow-up.

Homograft Versus Valves and Valved Conduits for Extensive Aortic Valve Endocarditis with Aortic Root Involvement/Destruction: A Systematic Review and Meta-Analysis.

Aortic valve infective endocarditis is a life-threatening condition. Patients frequently present profoundly unwell and extensive surgery may be required to correct the underlying anatomical deficits and control sepsis. Periannular involvement occurs in more than 10% of patients with aortic valve endocarditis. Complex aortic valve endocarditis has a mortality rate of 10 to 40%. Longstanding surgical dogma suggests homografts represent the optimal replacement option in complex aortic valve endocarditis; however, there is a paucity of evidence and lack of consensus on the optimal replacement choice. A systematic review and meta-analysis was performed utilizing EMBASE, PubMed, and the Cochrane databases to review articles describing homografts versus aortic valve replacement and/or valved conduit graft implantation for complex aortic valve endocarditis. The outcomes of interest were mortality, reinfection, and reoperation. Eleven studies were included in this meta-analysis, contributing 810 episodes of complex aortic valve endocarditis. All included reports were cohort studies. There was no statistically significant difference in overall mortality (risk ratio [RR] 0.99; 95% confidence interval [CI], 0.61–1.59; p = 0.95), reinfection (RR 0.89; 95% CI, 0.45–1.78; p = 0.74), or reoperation (RR 0.91; 95% CI, 0.38–2.14; p = 0.87) between the homograft and valve replacement/valved conduit graft groups. Overall, there was no difference in mortality, reinfection, or reoperation rates between homografts and other valve or valved conduits in management of complex aortic endocarditis. However, there is a paucity of high-quality evidence in the area, and comparison of valve types warrants further investigation.

A Role for Peroxisome Proliferator-Activated Receptor Gamma Agonists in Counteracting the Degeneration of Cardiovascular Grafts.

Aortic valve replacement for severe stenosis is a standard procedure in cardiovascular medicine. However, the use of biological prostheses has limitations especially in young patients because of calcifying degeneration, resulting in implant failure. Pioglitazone, a peroxisome proliferator-activated receptor gamma (PPAR-gamma) agonist, was shown to decrease the degeneration of native aortic valves. In this study, we aim to examine the impact of pioglitazone on inflammation and calcification of aortic valve conduits (AoC) in a rat model. Cryopreserved AoC (n = 40) were infrarenally implanted into Wistar rats treated with pioglitazone (75 mg/kg chow; n = 20, PIO) or untreated (n = 20, controls). After 4 or 12 weeks, AoC were explanted and analyzed by histology, immunohistology, and polymerase chain reaction. Pioglitazone significantly decreased the expression of inflammatory markers and reduced the macrophage-mediated inflammation in PIO compared with controls after 4 (P = 0.03) and 12 weeks (P = 0.012). Chondrogenic transformation was significantly decreased in PIO after 12 weeks (P = 0.001). Calcification of the intima and media was significantly reduced after 12 weeks in PIO versus controls (intima: P = 0.008; media: P = 0.025). Moreover, echocardiography revealed significantly better functional outcome of the AoC in PIO after 12 weeks compared with control. Interestingly, significantly increased intima hyperplasia could be observed in PIO compared with controls after 12 weeks (P = 0.017). Systemic PPAR-gamma activation prevents inflammation as well as intima and media calcification in AoC and seems to inhibit functional impairment of the implanted aortic valve. To further elucidate the therapeutic role of PPAR-gamma regulation for graft durability, translational studies and long-term follow-up data should be striven for.

Unchanged gait biomechanics following an 8-week home-based exercise program targeting excessive anterior pelvic tilt in patients with symptomatic hip dysplasia

We report Aspergillus delacroxii (formerly Aspergillus nidulans var. echinulatus) causing recurrent prosthetic valve endocarditis. The fungus was the sole agent detected during replacement of a mechanical aortic valve conduit due to abscess formation. Despite extensive surgery and anti-fungal treatment, the patient had a cerebral hemorrhage 4 months post-surgery prompting a diagnosis of recurrent prosthetic valve endocarditis and fungemia.

3D direct printing of mechanical and biocompatible hydrogel meta-structures

Direct Ink Writing (DIW) has demonstrated great potential as a versatile method to 3D print multifunctional structures. In this work, we report the implementation of hydrogel meta-structures using DIW at room temperature, which seamlessly integrate large specific surface areas, interconnected porous characteristics, mechanical toughness, biocompatibility, and water absorption and retention capabilities. Robust but hydrophobic polymers and weakly crosslinked nature-origin hydrogels form a balance in the self-supporting ink, allowing us to directly print complex meta-structures without sacrificial materials and heating extrusion. Mechanically, the mixed bending or stretching of symmetrical re-entrant cellular lattices and the unique curvature patterns are combined to provide little lateral expansion and large compressive energy absorbance when external forces are applied on the printed meta-structures. In addition, we have successfully demonstrated ear, aortic valve conduits and hierarchical architectures. We anticipate that the reported 3D meta-structured hydrogel would offer a new strategy to develop functional biomaterials for tissue engineering applications in the future.

Abstract 14789: Multimodality Imaging in Mycobacterium Chimaera Cardiovascular Infections

Introduction: Mycobacterium Chimaera (MC) infections following cardiovascular surgery are challenging to diagnose given their insidious presentation. We therefore reviewed the various imaging modalities used to diagnose these infections at Mayo Clinic. Methods: Cases from 01/01/2010-06/01/2020 were identified using electronic medical records. Demographics and clinical history were collected. Imaging studies, including transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE), positron emission tomography / computed tomography (PET/CT), cardiac CT (CCT), and cardiac magnetic resonance (CMR) were reviewed. Results: A total of 7 patients (85.7% male) were found. 6 underwent aortic valve replacement and 1 received an aortic composite valve conduit. Surgical dates ranged from 01/2010-12/2018. Mean age at presentation was 63.3 years. Mean time from surgery to symptom onset was 28.0 months. All patients underwent TTE and TEE; prosthetic valve endocarditis was identified in 6 cases between both, while CMR established the diagnosis in 1 case. TTE showed prosthetic valve obstruction in 2 cases and an anterior pseudoaneurysm in 1 case. TEE findings included thickened prosthesis and/or vegetations (n=5), thickened posterior root (n=4), and root abscess (n=3). Among the 3 patients who underwent PET/CT, 2 demonstrated increased fluorodeoxyglucose (FDG) uptake around the aortic prosthesis; in addition, 1 had elevated FDG uptake in the myocardium suggesting myocarditis. 1 patient did not have aortic prosthesis FDG uptake. In the 2 patients who had CCT, 1 showed a pseudoaneurysm that prompted suspicion for endocarditis, and the other revealed a fluid collection adjacent to the aortic valve conduit. 2 patients underwent CMR; 1 had aortic prosthesis thickening and patchy areas of myocardial delayed enhancement suspicious for myocarditis, whereas the other showed vegetation and an aortic root abscess. Conclusion: TTE plus TEE successfully identified MC prosthetic valve endocarditis in most cases with TEE having higher specificity. Advanced imaging techniques are helpful to support the diagnosis and assess for myocardial and/or aortic involvement. Combining these modalities is therefore crucial in unveiling this elusive organism.

Implantability of a novel, pre-assembled aortic valved conduit with RESILIA™ tissue.

Currently, the only commercial pre-assembled aortic valved conduits employ mechanical valves, requiring lifelong anticoagulation. Tissue-valved conduits that require assembly on the operating table are less standardized, require extensive experience for satisfactory results, and are limited in their longevity. The KONECT RESILIA™ Aortic Valved Conduit is a new tissue valved conduit that consists of a Carpentier-Edwards PERIMOUNT™ Magna Ease™ aortic valve stent, the novel RESILIA™ tissue leaflets, and a new DualFit sewing ring pre-assembled to a Terumo GelWeave Valsalva Graft™. RESILIA tissue is a bovine pericardial tissue that may offer superior anti-calcification properties compared to contemporary tissue valves; furthermore, it may be stored dry. We tested the handling and implantability of this new aortic valved conduit in 8 human cadaver hearts, as well as the valve removal potential without detaching the coronary ostia. The KONECT RESILIA aortic valved conduit's handling and implantability was uniformly satisfactory. The valve inside the conduit could be easily surgically extracted, leaving the conduit and coronary ostia intact. We found this first evaluation of the KONECT RESILIA Aortic Valved Conduit to be that it handled well and was easily implantable and extractable in a human cadaver model.

In vitro evaluation of a new aortic valved conduit

BackgroundThis study examined whether the presence of a sinus of Valsalva equivalent in the KONECT RESILIA aortic valved conduit (Edwards Lifesciences, Irvine, Calif) improves valve hemodynamics, kinematics, and performance. MethodsA 28-mm KONECT RESILIA aortic valved conduit was used to create an in vitro flow test model, and the same aortic valved conduit model without a sinus section was used as a control. Particle image velocimetry and hydrodynamic characterization experiments were conducted in the vicinity of the valves in a validated left-heart simulator at 3 cardiac output levels. In addition, leaflet kinematics of the valves were determined through en face high-speed imaging. ResultsThe KONECT RESILIA aortic valved conduit model exhibited lower mean and peak transvalvular pressure gradients than the control model at all 3 cardiac outputs. In addition, its leaflets opened more fully than did those of the valved conduit without the sinuses, yielding greater effective and geometric orifice areas. It was found that the presence of the sinuses not only facilitated the development of larger and more stable vortices at the initial stages of the cardiac cycle but also helped to maintain these vortices during the late stages of the cardiac cycle, leading to smoother valve closure. ConclusionsThe KONECT RESILIA aortic valved conduit reproduces the bulged section of the aortic root corresponding to the sinuses of Valsalva. With this Valsalva-type conduit, larger orifice areas were observed, improving valve hemodynamics that may enhance performance.

Bentall procedure after previous aortic valve or complete root replacement: Usefulness of self-assembled aortic valve conduit

ObjectivesThe aim of this study was to evaluate surgical results of complete aortic root replacement using self-assembled valve composite graft in the setting of destroyed aortic annulus after previous valve replacement. MethodsAortic root pathology being addressed by complete root replacement was combined with partial or complete absence of annular tissue in 112 consecutive patients. Eighty-eight had undergone a previous replacement of the aortic valve and 24 had undergone root replacement with a valved conduit. Altogether, 31 patients (27.7%) presented with acute endocarditis, which was the indication for surgery in 75% of patients with prior root replacement. In all patients, the root replacement or re-replacement was performed with a self-assembled valved conduit using mechanical (n = 74) or, in patients with an advanced age, biological (n = 38) valve prostheses. ResultsIn-hospital mortality was 11.6%, including a 30-day mortality of 6.3%. Resternotomy for bleeding was necessary in 5.4% of patients and about one-quarter did not need any blood transfusion. Estimated survival at 1, 5, and 10 years was 84.8% ± 3.4%, 75.7% ± 4.3%, and 57.1% ± 6.5%, respectively. Freedom from any valve-related events at 10 years was 86.2% ± 4.1%. During the follow-up time (mean, 63 ± 47 months), there was only 1 reoperation necessary 9 years after surgery (replacement of deteriorated biological valve prosthesis within the vascular tube leaving the conduit untouched). ConclusionsA self-assembled composite graft allows safe proximal fixation of the conduit in patients with destroyed aortic annulus, resulting in sufficient proximal anastomosis and a very low incidence of aorta-related reoperations.

Decellularization of human donor aortic and pulmonary valved conduits using low concentration sodium dodecyl sulfate.

The clinical use of decellularized cardiac valve allografts is increasing. Long‐term data will be required to determine whether they outperform conventional cryopreserved allografts. Valves decellularized using different processes may show varied long‐term outcomes. It is therefore important to understand the effects of specific decellularization technologies on the characteristics of donor heart valves. Human cryopreserved aortic and pulmonary valved conduits were decellularized using hypotonic buffer, 0.1% (w/v) sodium dodecyl sulfate and nuclease digestion. The decellularized tissues were compared to cellular cryopreserved valve tissues using histology, immunohistochemistry, quantitation of total deoxyribose nucleic acid, collagen and glycosaminoglycan content, in vitro cytotoxicity assays, uniaxial tensile testing and subcutaneous implantation in mice. The decellularized tissues showed no histological evidence of cells or cell remnants and >97% deoxyribose nucleic acid removal in all regions (arterial wall, muscle, leaflet and junction). The decellularized tissues retained collagen IV and von Willebrand factor staining with some loss of fibronectin, laminin and chondroitin sulfate staining. There was an absence of major histocompatibility complex Class I staining in decellularized pulmonary valve tissues, with only residual staining in isolated areas of decellularized aortic valve tissues. The collagen content of the tissues was not decreased following decellularization however the glycosaminoglycan content was reduced. Only moderate changes in the maximum load to failure of the tissues were recorded postdecellularization. The decellularized tissues were noncytotoxic in vitro, and were biocompatible in vivo in a mouse subcutaneous implant model. The decellularization process will now be translated into a good manufacturing practices‐compatible process for donor cryopreserved valves with a view to future clinical use. Copyright © 2016 The Authors Tissue Engineering and Regenerative Medicine published by John Wiley & Sons, Ltd.

Decellularized aortic conduits: could their cryopreservation affect post-implantation outcomes? A morpho-functional study on porcine homografts.

Decellularized porcine aortic valve conduits (AVCs) implanted in a Vietnamese Pig (VP) experimental animal model were matched against decellularized and then cryopreserved AVCs to assess the effect of cryopreservation on graft hemodynamic performance and propensity to in vivo repopulation by host's cells. VPs (n=12) underwent right ventricular outflow tract substitution using AVC allografts and were studied for 15-month follow-up. VPs were randomized into two groups, receiving AVCs treated with decellularization alone (D; n=6) or decellularization/cryopreservation (DC; n=6), respectively. Serial echocardiography was carried out to follow up hemodynamic function. All explanted AVCs were processed for light and electron microscopy. No signs of dilatation, progressive stenosis, regurgitation, and macroscopic calcification were echocardiographically observed in both D and DC groups. Explanted D grafts exhibited near-normal features, whereas the presence of calcification, inflammatory infiltrates, and disarray of elastic lamellae occurred in some DC grafts. In the unaltered regions of AVCs from both groups, almost complete re-endothelialization was observed for both valve cusps and aorta walls. In addition, side-by-side repopulation by recipient's fibroblasts, myofibroblasts, and smooth muscle cells was paralleled by ongoing tissue remodeling, as revealed by the ultrastructural identification of typical canals of collagen fibrillogenesis and elastogenesis-related features. Incipient neo-vascularization and re-innervation of medial and adventitial tunicae of grafted aortic walls were also detected for both D and DC groups. Cryopreservation did not affect post-implantation AVC hemodynamic behavior and was topically propensive to cell repopulation and tissue renewal, although graft deterioration including calcification was present in several areas. Thus, these preliminary data provide essential information on feasibility of decellularization and cryopreservation coupling in the perspective of treatment optimization and subsequent clinical trials using similarly treated human allografts as innovative heart valve substitutes.

Comparison of mid-term haemodynamic performance between the BioValsalva and the BioIntegral valved conduits after aortic root replacement

We retrospectively compared the haemodynamic performance of the BioValsalva (BV) and BioIntegral (BI) biological aortic-valved conduits in the aortic root position. Between July 2008 and June 2014, a total of 55 patients underwent aortic root replacement using the BV conduit (n = 27) or the BI conduit (n = 28). The primary study endpoints were haemodynamic performance during follow-up, including mean pressure gradients (MPGs) and effective orifice areas (EOAs). Secondary study endpoints were early postoperative outcomes within 30 days and survival. Both groups did not differ in regard to demographics (BV: median age 71 years, 70.4% female; BI: median age 66 years, 85.7% female, P = 0.15 and P = 0.17) and risk profile (median EuroSCORE-II BV: 3.8 vs 5.3% for BI, P = 0.38). A total of 20% of the total patients (BV 5/27, 18.5% vs BI 6/28, 21.4%) presented with acute type-A aortic dissection. During follow-up, both groups showed no difference in MPGs for all valve sizes [BV, 11.0 mmHg (8.3-14.8 mmHg) vs BI, 11.5 mmHg (9.0-13.0), P = 0.82]. Similar results were achieved for EOAs for all valve sizes [BV, 1.85 cm(2) (1.55-2.21) vs BI, 1.80 cm(2) (1.64-1.83), P = 0.24]. Moreover, there was no statistically significant difference in aortic regurgitation (AR) with none/trace AR in (21/23) 91.3% in BV patients versus (16/21) 76.2% in BI patients (P = 0.23) at follow-up. Both groups showed a high rate of concomitant procedures (BV: 59.3% vs BI: 71.4%, P = 0.40) and emergency indication (BV: 18.5% vs BI: 21.4%, P = 0.79), resulting in an overall 30-day mortality rate of 7.3% (4/55 patients). The present small single-centre study is one of the first to evaluate and compare the BioValsalva and BioIntegral biological aortic-valved conduit in the aortic root position. Both conduits showed optimal haemodynamic results with a low incidence of aortic regurgitation.

Aortic valve conduit implantation in the descending thoracic aorta in a sheep model: The outcomes of pre-seeded scaffold

BackgroundWe evaluated the outcomes of implanting pre-seeded decellularized aortic valve conduit (AVC) with bone marrow-derived mesenchymal stem cells (MSCs) in a sheep model. MethodsEight sheep AVCs were obtained under sterile conditions and decellularized by using detergent-based methods. Decellularized AVCs were seeded with autologous bone marrow-derived MSCs in a dynamic bioreactor system. Pre-seeded AVCs were implanted in the descending thoracic aorta in a sheep model. In all sheep, a decellularized pericardial patch was also anastomosed to the proximal part in order to reduce the incidence of rupture. Pathological evaluations, echocardiography, multislice computed tomography (CT), and CT angiography were performed for the evaluation of implanted AVCs. ResultsThe longest survival period was 19 months in pre-seeded animals with complete recellularization at the long-term follow-up. Immunohistochemical staining for desmin, smooth muscle actin, and cytokeratin was significantly positive in the pre-seeded samples and reached near normal ranges. CT angiography revealed no intimal tearing after 18 months of follow-up. ConclusionPre-seeded AVCs with bone marrow-derived MSCs may have satisfactory results in postoperative cell seeding capabilities with promising functional potentiality. This modality may be beneficial and may provide a new era of biological grafts in cardiovascular surgery.

Concomitant bentall-de bono procedure plus total arch replacement and coronary artery bypass grafting in acute aortic dissection

We report the images of a case of a 31-year-old male presented with acute Type A aortic dissection with severe aortic regurgitation involving the arch vessels. He was taken up for surgery on cardiopulmonary bypass (femoro-axillary-bicaval). Bentall-De Bono procedure with mechanical aortic valved conduit and total arch replacement with woven polyester branched graft under hypothermic circulatory arrest plus selective antegrade cerebral perfusion was performed. Reversed saphenous venous graft to proximal right coronary artery grafting was also performed.

Management of Pregnant Woman with Marfan Syndrome and Mechanical Aortic Valved Conduit

Management of Pregnant Woman with Marfan Syndrome and Mechanical Aortic Valved Conduit

Long-term follow-up after implantation of the Shelhigh® No-React® complete biological aortic valved conduit

Long-term follow-up reports after implantation of the Shelhigh® (Shelhigh, Inc., NJ, USA) No-React® aortic valved conduit used for aortic root replacement do not exist. Between November 1998 and December 2007, the Shelhigh® No-React® aortic valved conduit was implanted in 291 consecutive patients with a mean age of 69.6 ± 9.1 years, and 33.7% were female (n = 98). Indications were annulo-aortic ectasia (n = 202), aortic valve stenosis combined with ascending aortic aneurysm (n = 67), acute type A aortic dissection (n = 29), endocarditis (n = 26) and other related pathologies (n = 48) including 62 patients with previous cardiac surgery. Data from two cardiac institutions were analysed retrospectively using SPSS (SPSS Software IBM, Inc., 2014, NY, USA). Operative mortality was 10% (n = 29). Main cause of death was cardiac failure in 15 patients (51.8%), neurological events in 6 patients (20.7%), respiratory failure in 4 patients (13.8%), bleeding complications in 2 patients (6.9%) and gastrointestinal ischaemia in 2 cases (6.9%). There were 262 hospital survivors and all were entered in the follow-up study (100% complete). During the long-term follow-up (mean 70.3 ± 53.1 in months), a total of 126/262 patients (44.3%) died. Main causes of death in patients after discharge were cardiac (n = 37, 14.1%), neurological (n = 15, 5.7%) respiratory (n = 12, 4.6%), endocarditis (n = 12, 4.6%) and peripheral vascular disease (n = 5, 1.9%). In 29 (11.1%) patients, the cause of death could not be determined. Reoperation was required in 25 (8.6%) patients due to infection of the conduit (n = 9), aortoventricular disconnection (n = 4), pseudoaneurysm formation (n = 4) and structural valve degeneration (n = 8). Reoperations were performed 5.0 ± 3.8 (range 0.1-11.7) years after index surgery. The Shelhigh® No-React® aortic valved conduit showed satisfactory short-term operative results. However, the long-term follow-up revealed a relatively high rate of deaths, which may be explained by the epidemiology of the patient group, but a substantial proportion of deaths could not be clarified. The overall rate of reoperation (8.6%) during the mid-term follow-up is worrisome and the failures due to aortoventricular disconnection, endocarditis and pseudoaneurysm formation remain unexplained. The redo-procedures were technically demanding. We recommend close follow-up of patients with the Shelhigh® No-React® aortic valved conduit, because besides classical structural valve degeneration, unexpected findings may be observed.