Biological Valve Prostheses Research Articles

Operative outcome of patients at low, intermediate, high and 'very high' surgical risk undergoing isolated aortic valve replacement with sutureless and rapid deployment prostheses: results of the SURD-IR registry.

The ideal strategy for the treatment of severe aortic valve stenosis in patients of varying risk categories has become a debated topic in the last years: should the transcatheter or surgical approach be adopted? The aim of this study was to evaluate the outcomes of low-, intermediate-, high- and very high-risk patients undergoing sutureless, rapid deployment aortic valve replacement. From 2007 to 2017, data on a total of 3651 patients were collected from the Sutureless and Rapid Deployment Aortic Valve Replacement International Registry (SURD-IR). Of these, 2057 patients who underwent primary isolated aortic valve replacement were considered for this analysis and classified as being at low (EuroSCORE <5; n = 500), intermediate (EuroSCORE 5-10; n = 901), high (EuroSCORE 11-20; n = 500) and very high (EuroSCORE >20; n = 156) preoperative risk. Overall, a less invasive approach was used in 74.1% of patients and represented the most frequent (>50%) approach in all risk categories. The Perceval prosthesis was used more frequently than other devices, especially in patients at high and very high risk. Hospital mortality was 1.6%, 0.8%, 1.9% and 2.7% in low-, intermediate-, high- and very high-risk patients, respectively, with no significant differences among subgroups. Similarly, postoperative complication rates were similar across the different risk categories. Surgical aortic valve replacement using sutureless, rapid deployment biological valve prostheses is associated with excellent results and represents a safe and effective treatment option for patients with severe aortic valve stenosis. This seems to be particularly true in patients with a higher risk profile.

Trends and Predictors of Oral Anticoagulation in Patients with Atrial Fibrillation: A Serial Cross-Sectional Study from 2011 to 2016

Abstract Background: Despite the efficacy of vitamin K antagonists against stroke in patients with atrial fibrillation (AF), the underuse of this therapy is well documented. Objectives: To evaluate trends and predictors of oral anticoagulants utilization in patients with AF. Methods: Observational, retrospective, serial cross-sectional study between 2011-2016. Comparisons between groups were performed using the Student t, Mann-Whitney and Chi-square tests. Logistic regression was used to identify independent predictors of anticoagulation. A p value < 0.05 was considered significant. Results: A total of 377 patients were analyzed. The mean age was 70 ± 15 years; 52% were male and 75% were anticoagulated (20% with VKA and 55% with DOAC). Over 5 years, the overall frequency of anticoagulation increased by 22.4%. The use of DOACs increased from 29% to 70%, whereas the use of VKA decreased from 36% to 17%. The use of antiplatelet agents alone also fell from 21% to 6%. The predictors of anticoagulation were previous episodes of AF (OR 3.1, p < 0.001), hypertension (OR 3.0, p < 0.001) and HASBLED score (OR 0.5, p < 0.001). The predictors of DOAC use were serum creatinine (OR 0.2, p = 0.002), left atrial size (OR 0.9, p = 0.003) and biological valve prosthesis (OR 0.1, p = 0.007). Of the 208 patients using DOACs, 63 (30%) received inadequate prescriptions: 5 with severe drug interactions and 58 with incorrect dosing. Conclusions: Between 2011 and 2016, DOACs were rapidly incorporated into clinical practice, replacing AVKs and antiplatelets, and contributing to greater use of anticoagulation in patients with AF.

ОТДАЛЕННЫЕ РЕЗУЛЬТАТЫ ИСПОЛЬЗОВАНИЯ БИОЛОГИЧЕСКИХ ПРОТЕЗОВ У ПАЦИЕНТОВ C ПОРОКАМИ АОРТАЛЬНОГО КЛАПАНА

Background: This article presents hospital and long-term (1 year after the intervention) results of aortic valve replacement with biological valves of different size in patients with critical aortic valve stenosis. Objective: To evaluate hemodynamic parameters on the implanted biological aortic valve prostheses depending on the size, as well as to study left ventricular (LV) remodeling after surgery for aortic valve stenosis in the early and late periods. Material and methods: The study included 171 patients who were performed isolated or combined with the correction of concomitant pathology (coronary bypass surgery, mitral valve plasty, tricuspid valve plasty) aortic valve replacement with biological prostheses with landing sizes of 19-25 mm. Carprotier-Edwards PERIMOUNT, Carpentier-Edwards PERIMOUNT MAGNA, Medtronic Mosaic, St.Jude Medical Epic and TLPB Labcor bioprostheses were used for prosthetics. Results: The prosthesis-patient mismatch (PPM) phenomenon of a moderate (effective hole area index (iEHA) less than 0.85 cm2/m2) and severe degree (iEHA less than 0.65 cm2/m2) was observed in patients with implanted bioprostheses size 19 and 21. When PPM occurred, the peak and average transprosthetic gradients were lower than on the affected valve prior to surgery. The occurrence of PPM did not lead to complete remodeling of the left ventricle in the long-term period. Conclusions: In patients with implanted biological prostheses size 23 and 25 the prosthesis-patient mismatch phenomenon was not observed in the hospital and long-term period; a reverse left ventricular remodeling was detected in the long-term. The analysis showed that when using biological prostheses of standard sizes 19 and 21 iEHA in most cases was less than 0.85 cm2/m2. In these groups, it can be argued about the presence of a patient-prosthesis mismatch of varying severity.

Long-term outcomes of mechanical versus biological aortic valve prosthesis: Systematic review and meta-analysis

BackgroundIn recent years, the use of surgically implanted biological aortic valves has been favored over mechanical prosthesis in patients between 50 and 70 years of age. However, outcomes on long-term survival are contradictory. The objective of this study was to determine if patients with mechanical valves have worse long-term survival than patients with biological prostheses. MethodsWe systematically searched published studies that: (1) were propensity score-matched or randomized controlled trials; (2) provided survival data with a minimum follow-up of 5 years; and (3) included patients older than 50 and younger than 70 years of age. Review articles, case reports, and editorials were excluded. We conducted a meta-analysis on the basis of 2 types of analysis. A reconstruction of the database of each study to simulate a patient-level meta-analysis was performed. Log rank test of Kaplan–Meier curves was recalculated. Hazard ratio (HR) was calculated using a univariate Cox regression. In addition, we calculated a pooled HR using the fixed-effect inverse variance method. ResultsFour propensity score-matched studies and 1 randomized controlled trial met the inclusion criteria. Data of 4686 patients were analyzed. Survival rates for mechanical versus biological valves at 10 and 15 years of follow-up were: 76.78% (95% confidence interval [CI], 74.72%-78.69%) versus 74.09% (95% CI, 71.96%-76.08%), and 61.58% (95% CI, 58.29%-64.69%) versus 58.04% (95% CI, 54.57%-61.35%). Log rank test was statistically significant (P = .012) and the pooled HR was 0.86 (95% CI, 0.76-0.97; P = .01). ConclusionsCompared with biological aortic valves, mechanical valves are associated with a long-term survival benefit for patients between 50 and 70 years.

Hyponatremia after anticoagulant treatment: a rare cause of adrenal failure

SummaryA 69-year-old male was admitted for severe hyponatremia disclosed after an accidental fall. He was anticoagulated from 2 months after the implantation of a biologic aortic valve prosthesis. The work-up disclosed adrenal failure and MRI showed bilateral adrenal hemorrhage. Clinical picture and lab parameters normalized quickly after the appropriate replacement treatment. Anticoagulation excess should be added to the list of drugs potentially causing hyponatremia.Learning points:Hyponatremia requires a complete and timely workup in order to start an appropriate treatment for the improvement of clinical conditions.History is crucial: a detailed list of drugs potentially causing hyponatremia should be collected. Anticoagulants should be added to the list, mostly in the event of excessive anticoagulation.Intra-adrenal hemorrhage is a rare cause of hyponatremia and adrenal failure.The ACTH test is still the gold standard for the diagnosis of hypoadrenalism.

Outcomes and Long-term Effects of Pregnancy in Women With Biologic and Mechanical Valve Prostheses

The optimal choice of prosthetic heart valve for women of child-bearing age is not well established. We conducted this retrospective cohort study to compare pregnancy outcomes and maternal mortality and morbidity, including long-term valve reoperation, between women with biologic and mechanical valve replacements. Women ≤50 years of age with prosthetic heart valve implantation and subsequent pregnancy in California, New Jersey, and New York State between 1990 to 2015 were identified using mandatory state inpatient databases. Average follow-up time was 9.4 years (SD 6.7 years). Of 11,930 women who underwent 14,017 valve replacements, pregnancies in 417 women with 241 biologic valves, and 217 mechanical valves were identified. Women with mechanical prostheses experienced significantly higher rates of pregnancy loss, with almost 2/3 of pregnancies ending in either spontaneous or induced abortion, and hemorrhage and thromboembolic events during delivery. Delivery was a significant risk factor for reoperation for both biologic (hazard ratio 2.5, 95% confidence interval 1.6 to 3.8 after time-dependent propensity matching) and mechanical (hazard ratio 2.3, 95% confidence interval 1.3 to 4.1 after time-dependent propensity matching) prostheses. Half of reoperations in women with mechanical valves who experienced pregnancy occurred within 1 year after delivery, and most were associated with mitral valve thrombosis. In conclusion, pregnancy accelerates time to reoperation for both biologic and mechanical prostheses. Mechanical valves are at particular risk for near-term valve failure after delivery, and compared with bioprostheses, are associated with higher rates of adverse events during pregnancy.

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.

Severe aortic regurgitation after implantation of a sutureless valve prosthesis using an automatic knot fastener device

We report the case of severe aortic regurgitation 8 months after implantation of a 25-mm sutureless pericardial aortic valve prosthesis. On echocardiography, the regurgitation was suspected to be paravalvular. The sutureless prosthesis had been implanted using an automatic knot fastener device, which renders the suture tails less pliable because of the metal clip that is crimped around the suture. The patient was reoperated, a paravalvular leak was not observed. The sutureless prosthesis was explanted and a conventional biologic valve prosthesis was implanted instead. On examination of the explanted valve prosthesis, a perforation was observed in one of the leaflets. The leaflet perforation was in alignment with one of the knots produced by the automatic knot fastener. Obviously, the leaflet had hit the knot repeatedly which had caused the perforation. We conclude that knots produced by an automatic fastener device have the potential to cause leaflet perforation.

Transvenous Implantation of a Stent Valve in Patients With Degenerated Mitral Prostheses and Native Mitral Stenosis

The purpose of this study was to report the use of a transvenous transseptal approach using a stent valve in patients with degenerated biological mitral valve prostheses, regurgitation after mitral repair, and native mitral stenosis. Ten patients (median age, 74 years; range, 20-89 years; 5 men and 5 women) with degenerated mitral bioprosthetic valves (n= 7), failed mitral repair (n= 1), or calcified native stenotic valves (n= 2) underwent transvenous implantation of a stent valve. The procedure was initially successful in all patients. Predilation was performed for balloon sizing only in the 2 patients with native mitral stenosis. The stent valve was deployed during 1 period of rapid pacing. A guidewire, as a loop from the right femoral vein andthrough the left ventricular apex, facilitated a good angle and secure positioning of the stent valve. An ultrasonographically guided puncture of the apex was carried out in 6 patients, and in the other 4 we performed a minithoracotomy before apical puncture. All valves were implanted in a good position with improved function and without significant paravalvular leakage (PVL). There were no periprocedural deaths. The 30-day survival was 80% (8 of 10 patients), and 60% (6 of 10) of patients were still alive a median time of 290 days after the procedure. Transvenous transseptal implantation of a stent valve was performed in 10 patients with mitral valve disease, with good early functional results. These high-risk patients must be carefully selected by a multidisciplinary team because the procedure carries a high mortality.

Cardiac surgery for infective endocarditis in patients with intravenous drug use

Intravenous drug users have a high risk of infective endocarditis and reduced survival. Cardiac surgery may be recommended for these patients, but redo surgery is controversial. This study describes the characteristics and outcomes of intravenous drug users accepted for surgery during a 12-year period. This retrospective study included 29 injecting drug users treated with valve surgery for endocarditis between January 2001 and December 2013 at a tertiary academic centre. Survival was assessed by Kaplan-Meier analysis. The median patient age was 36 (24-63) years and 27 patients (93%) were male. Staphylococcus aureus (52%) and Enterococcus faecalis (17%) were the most common microorganisms. Common illicit drugs were opioids (69%), amphetamines (52%) and benzodiazepines (24%). Mixed abuse was reported in 66% of patients. Seven patients (24%) had prior intracardial implants or native valve pathology. Twenty-five patients (86%) were positive for hepatitis C virus antibody, but none carried the human immunodeficiency virus. Twelve (41%) were homeless and 15 (52%) had poor dental hygiene. Three patients (10%) received medication-assisted rehabilitation before surgery. The main indications for surgery were regurgitation and secondary heart failure (86%), embolization (41%) and uncontrolled infection (24%). Aortic valve replacement was performed in 24 patients (83%), either as part of univalvular or multiple valve surgery. Seven patients (24%) had multivalvular endocarditis. All but 3 patients received biological valve prostheses. The 30-day mortality was 7% after first time surgery. During follow-up, 15 patients (52%) presented with reinfection: 10 (35%) were offered a second and 2 (7%) a third operation. Thirty-day mortality was 10% after redo surgery. Thirteen patients (45%) died within a median of 22 (0-84) months. Continued intravenous drug use was reported in 70 and 44% of patients after the first and second operation, respectively. Cardiac surgery for infective endocarditis has acceptable early postoperative results among intravenous drug users. The 2- and 5-year survival were 79 and 59%, respectively. The number of reinfections was high within 2 years, as continued drug use seems to be a major challenge for this group.

0444: Risk stratification for thromboembolic events in patients with atrial fibrillation and biological valve prosthesis

Current ESC guidelines require anticoagulation with VKA in patients with “valvular atrial fibrillation (AF)”, which includes all types of prosthetic valve. We evaluated the value of the CHA 2 DS 2 -VASc score for thromboembolism risk assessment in AF patients with biological valve replacement. Among 8962 patients with AF seen between 2000 and 2010, 8053 (90%) had "non-valvular AF” and 909 (10%) had valvular AF. Patients with valvular AF had a biological prosthesis in 59% (n=549), among which 77% (n=426) had a single aortic prosthesis and 64% (n=309) received a VKA. Patients with aortic bioprosthesis were older and had a higher CHA 2 DS 2 -VASc score than those with a mitral prosthesis or a double valve replacement. During a follow up of 876±1048 days, 681 stroke/thromboembolic events were recorded. The occurrence of events were similar in patients with bioprosthesis compared to the patients without prosthesis: (hazard ratio HR 1.10, 95% CI 0.83-1.45, p=0.52). Patients with aortic bioprosthesis tended to have a higher risk of embolic events vs other AF patients with bioprosthesis (HR 1.73, 95% CI 0.87-3.45), p=0.12). In multivariate analysis, older age and higher CHA 2 DS 2- VASC score were the only predictors of embolic events whilst the presence of a bioprosthesis was not an independent predictor of events. The CHA 2 DS 2 -VASC score predicted the embolism risk in AF patients with a bioprosthesis (c-statistic 0.55 95% CI 0.47-0.63) but was less efficient than in “non-valvular” AF patient (c-statistic 0.66, 95% CI 0.64-0.67). This “real world” results support the use of oral anticoagulation in AF patients who have bioprosthetic heart valves. It also supports the use of CHA 2 DS 2 -VASc scoring for the risk evaluation of AF patients with bioprostheses, albeit with reduced reliability. Patients with aortic bioprosthesis had a non significant higher risk of embolic events. A higher CHA2DS2-VASc score in these patients is likely to explain these results.

Incidence, treatment, and outcome of acute aortic valve regurgitation complicating percutaneous balloon aortic valvuloplasty.

To evaluate the incidence, treatment, and outcomes of acute aortic regurgitation (ARR) complicating BAV. In the transcatheter aortic valve implantation (TAVI) era, there is an increase of percutaneous balloon aortic valvuloplasty (BAV) procedures with different indications. From the prospective BAV registry of the University of Bologna, which has enrolled patients between the year 2000 and the present, we selected those who suffered intraprocedural AAR with overt hemodynamic instability. Worsening of baseline aortic insufficiency without hemodynamic collapse, treatment of degenerated biological valve prosthesis, and BAV performed within a planned TAVI procedure were excluded. The main endpoints were in-hospital and 30-day mortality. Out of 1517 BAVs, we identified 26 cases of AAR (1.7%). This complication occurred in 80.8% of cases after one or two balloon inflations. Mean transaortic gradient decreased from 50.6±19.3 to 26.0±14.4 mmHg (p<0.01). In 8(30.8%) patients, AAR spontaneously resolved within few minutes; in 18 cases, the operators had to perform a rescue maneuver to reposition a valve leaflet got stuck in the opening position (this maneuver was successful in 13/18 of the cases, 72.2%). Out of 5 persistent AAR, 3 were managed with emergency TAVI or surgery, while 2 were unresolved. In-hospital mortality was 15.4% (n=4), whereas no more deaths occurred up to 30 days. AAR is a fearsome complication of BAV and portends a grim prognosis. In some cases, it can be resolved with appropriate technical maneuvers; in others, a rescue TAVI or surgical valve replacement may be necessary. © 2015 Wiley Periodicals, Inc.

TCT-685 Results After Transcatheter Valve-in-Valve Implantation And Redo Aortic Valve Surgery For Failed Aortic Bioprostheses

Redo surgery for degeneration of biological aortic valve prostheses can be a high-risk procedure. Transcatheter aortic valve-in-valve implantation poses a less-invasive treatment alternative for these patients. We aim to present our clinical outcomes of consecutive patients after a valve-in-valve

Unexpected early obstruction of a biological aortic valve prosthesis

A 64 years old male was submitted to the surgical substitution of a deteriorated biological aortic valve prosthesis with a new Hancock II biological prosthesis. The implantation was not followed by an anticoagulation or antiaggregation therapy. Two months later he was checked at our Institution because he complained symptoms and developed echocardiographic indexes suggestive of an aortic prosthesis obstruction by a clot. Both symptoms and the echocardiographic indexes of prosthesis obstruction faded away after giving warfarin; they arose again when the anticoagulation therapy was stopped and was replaced by aspirin. The following permanent use of warfarin normalized both clinic and echocardiographic aspects. The present case report underlines the utility of early controls after a biological prosthesis, yet aortic, implantation, when it is not followed by an anticoagulant therapy, also in subjects free from thrombosis high risk factors.

Predictors of Survival and Modes of Failure After Mitroflow Aortic Valve Replacement in 1,003 Adults

Midterm outcomes are unknown for patients undergoing aortic valve replacement (AVR) with a Mitroflow bovine pericardial prosthesis (Sorin Group, Inc) and without anticalcification treatment. Recent reports warn of early senescence in younger adults. From January 2004 through December 2011, 1,003 adults underwent Mitroflow AVR. The mean follow-up time was 25.0 (standard deviation [20.6]) months (total, 2,060 patient-years; maximum, 9 years). The patients were stratified for analysis according to age at implantation: group A, <60 years (n= 63, 6.3%); group B, 60-69 years (n= 173, 17.2%); group C, 70-79 years (n= 432, 43.1%); and group D, 80 years or older (n= 335, 33.4%). The mean age was 74.8 years (SD 9.8), and 609 patients (60.7%) were men. Aortic valve stenosis was present in 912 patients (90.9%), and 113 (11.3%) had severe aortic regurgitation. There were 27 (2.7%) early deaths, 15 of 431 (3.5%) underwent concomitant coronaryartery bypass grafting while 12 of 572 (2.1%) did not(p= 0.18), and 151 patients (15.1%) died during follow-up. Nineteen AVRs (1.9%) required re-replacement through August 2013; 12 (63.2%) were associated with structural valve deterioration. The overall rates of freedom from valve-related reoperation at 3 and 5 years were 98.3% and 93.8%, respectively. Group A had the greatest number of reoperations (6/63; p < 0.001). The overall survival rates at 1 and 5 years were 91.2% and 67.3%, respectively. Independent predictors of mortality were poorer New York Heart Association functional class (hazard ratio [HR], 2.1; p < 0.001), atrial fibrillation (HR, 1.8; p= 0.002), and prior cardiac operation (HR, 1.8; p= 0.003). Midterm follow-up shows acceptable hemodynamic performance of the Mitroflow biologic aortic valve prosthesis in selected patients 60 years old and older. Ongoing follow-up will be necessary to understand long-term performance and outcomes.

Biologic and Mechanical Mitral Valve Prostheses: Outcomes in 50- to 69-Year-Olds

Patients undergoing mitral valve replacement (MVR) need to balance the long-term risk of structural deterioration of biologic prostheses with the

Percutaneous tricuspid valve implantation: two-center experience with midterm results.

Severe tricuspid valve (TV) dysfunction may lead to surgical TV replacement with a biological valve prosthesis in patients with congenital heart disease. To expand the lifetime of this valve and reduce the number of surgeries, percutaneous TV implantation (PTVI) may be an effective alternative to repeated surgery. We report on our 2-center experience with PTVI. Between 2008 and 2014, 17 percutaneous valves were implanted in 16 patients with TV bioprosthesis dysfunction (9 females) from 2 centers. Median age and weight were 31.3 years (5-77.2) and 65.2 kg (17.7-107); 14 patients had congenital heart disease (univentricular heart with a right atrial to right ventricle bioprosthesis in 3, Ebstein's anomaly of the TV in 5, and other in 6), and 2 had acquired TV dysfunction. All procedures were successful (Melody n=7, Sapien 26 mm valve n=4, Sapien XT 29 mm valve n=6). One valve showed early dysfunction. It was replaced surgically and shortly after that a repeated PTVI was performed. The median duration of follow-up was 2.1 years (3 days to 6.3 years). The percutaneous valve was performing well in 15 of 16 patients. PTVI was safe and effectively improved TV function in all but 1 patient at midterm follow-up. We think that PTVI is a good alternative to repeated surgical TV replacements and that it may reduce the total number of open heart surgeries in these patients.

Strategy of sinus rhythm restoration after single stage correction of mitral valve defect and maze procedure for improvement of efficacy and safety of anticoagulant therapy

We analyzed clinical efficacy of a strategy of sinus rhythm (SR) restoration after single stage correction of mitral valve defect and failed radiofrequency maze procedure elaborated and realized in the Research Institute for Complex Issues of Cardiovascular Diseases, and assessed its value for increase of efficacy and safety of anticoagulant therapy. First stage of this strategy--cardiosurgical treatment with maze procedure--resulted in restoration of SR in 61.8% of cases. In case of persistence of tachyarrhythmia external elelectro-impulse therapy was used in 1-1.5 months after cardiac surgery as a second stage of our strategy. Third stage--catheter radiofrequency ablation--was applied to patients with implanted biological cardiac valves. Second and third stages facilitated restoration of SR in 84.8 and 93.2% of patients, respectively, and provided 100% SR restoration in patients with biological valve prostheses. The suggested strategy allowed to withdraw anticoagulant therapy in patients with biological valves and to reduce level of hypocoagulation to lower limit of target range in patients with mechanical prostheses.

Early degenerated bioprosthetic mitral valve

Mitral valve prolapse (MVP) is fairly common in children, often being randomly found in asymptomatic, as well as in symptomatic patients with conjunctive tissue diseases (CTD). The authors report the case of an 11-yearold girl, diagnosed at the age of 6 with MVP and severe mitral regurgitation (MR). She had surgery at the age of seven, when the mitral valve replacement with a biological valve prosthesis was performed. Four years later, the girl was admitted for sudden onset of dyspnoea with orthopnoea, haemoptysis and generalized cyanosis. The diagnosis of acute pulmonary oedema and degenerated biological valvular prosthesis correlated with severe mitral stenosis was evoked by means of clinical and echocardiographic examinations. The evolution was favourable after the replacement of the bioprosthesis with a mechanical prosthesis.

Bio-Bentall procedure versus isolated biological aortic valve replacement: a case-match study.

The aim of the study was to evaluate whether a complete aortic root replacement using a composite graft with biological valve prosthesis carries a higher early or late postoperative risk than isolated valve replacement. Between 1998 and 2008, 182 consecutive patients underwent complete aortic root and ascending aorta replacement using a self-assembled composite graft with a biological valve prosthesis located within the vascular tube (modified Bentall procedure). In the same period, 1959 patients received an isolated aortic valve replacement using a biological valve prosthesis. After matching the patients using five variables (sex, age-by 5-year increments, aortic valve defect, concomitant coronary surgery and the year of surgery), 79 perfectly matched pairs were found. Regarding other clinically essential but unmatched preoperative characteristics, there were no relevant differences between the groups. There was no statistically significant difference in the early postoperative mortality (30-day and/or in-hospital), which was 5.1% (4 patients) in the Root Group (RG) and 3.8% (3 patients) in the Valve Group (VG). The follow-up was complete for all patients and contained 499 patient-years in the RG versus 488 in the VG. In total, there were 23 deaths in each group during the follow-up time, which was 6.2 ± 2.8 years for the RG and 6.2 ± 3.2 years for the VG. Hence, the linearized death rate and actuarial survival at 10 years were almost identical. They were 4.66%/year and 63.2 ± 8.3%, respectively, in the RG; compared with 4.71%/year and 58.5 ± 9.3% in the VG. Also the rates of valve-related morbidities were similar except for the tendency of a lower rate of cerebral embolism in the RG. Complete aortic root replacement with a biological composite graft can be performed by experienced surgeons with an operative risk similar to that of an isolated biological aortic valve replacement. Starting with comparable operative outcomes, both procedures offer almost identical long-term survival. The rates of valve-related events after complete aortic root replacement and isolated valve replacement are also comparable, apart from cerebral embolism, which seems to be less frequent after aortic root replacement.