Biological Valve Prostheses Research Articles

Dabigatran Versus Warfarin After Bioprosthesis Valve Replacement for the Management of Atrial Fibrillation Postoperatively: Protocol

BackgroundWarfarin and similar vitamin K antagonists have been the standard therapy for patients with mechanical or biological valve prosthesis and atrial fibrillation (AF). Even with the appropriate use of therapy, some studies have reported that there is a high incidence of thromboembolic events, 1%-4% per year. Furthermore, a bleeding risk is significant, ranging from 2% to 9% per year, according to some studies.ObjectiveThe objective of our study was to examine the effect of dabigatran etexilate versus dose-adjusted warfarin for the prevention of intracardiac thrombus in persistent or permanent AF at least 3 months after aortic and/or mitral bioprosthesis replacement.MethodsDabigatran versus warfarin after bioprosthesis valve replacement for the management of atrial fibrillation postoperatively (DAWA) is a phase 2, prospective, open label, randomized exploratory pilot study. The main variable to be observed in this study is intracardiac thrombus. From August 2013 to April 2015, 100 patients, at least 3 months after aortic and/or mitral bioprosthesis replacement and permanent or persistent AF postoperatively, who match eligibility criteria will be selected from Ana Nery Hospital in Salvador-Bahia with a follow-up of three months. Patients were randomly assigned in a 1:1 ratio to receive either dabigatran etexilate or warfarin.ResultsAlthough the present study has no statistic power to proof non-inferiority, it is expected that the dabigatran etexilate group will be protected as well as the warfarin group from intracardiac thrombus, without increasing the bleeding rates, since we are using safer doses (110 mg bid). The lack of necessity of monitoring INR is also another factor that contributes to a better adherence to the new drug and it can make all the difference in the manner of doing anticoagulation for patients with similar clinical characteristics.ConclusionsThe study is in the recruitment phase. It is possible that dabigatran etexilate is as effective as warfarin in preventing the emergence of intracardiac thrombus in patients with AF and mitral and/or aortic bioprosthesis.Trial RegistrationClinicaltrials.gov NCT01868243; http://clinicaltrials.gov/ct2/show/NCT01868243 (Archived by WebCite at http://www.webcitation/6OABiuasd).

Influence of Prosthesis Type on Long-Term Survival after Re-replacement of Aortic Valve Prosthesis

The purpose of this study is to examine the influence of the prosthesis type on early mortality and long-term survival after re-replacement of aortic valve prosthesis, especially in patients over 60 years old. Late outcome of 223 patients who underwent a reoperation on the aortic valve and received a mechanical (mechanical group) or biological (biological group) heart valve prosthesis at a single institution were analyzed for survival and major valve-related complications, including structural valve deterioration, thromboembolism, hemorrhage, further reoperation, and valve-related mortality. Preoperative New York Heart Association class IV (P = 0.001), emergency procedure (P = 0.002), and endocarditis (P = 0.025) were significant risk factors for 30-day mortality rates, which were 8.4 % and 12.5 %, respectively (mechanical versus biological group, P = 0.361). A subanalysis of elective patients revealed a low risk of 30-day mortality of 2.4 % and 1.8 %, respectively. Event-free survival was comparable at 5 years (73.9% ± 3.6% versus 70.5% ± 6.5%, mechanical versus biological group) and 10 year (49.7% ± 5.0% versus 35.3% ± 9.8%, mechanical versus biological group). In a propensity-matched subanalysis, survival and event-free survival were comparable at 5 and 10 years in both groups. The type of aortic valve prosthesis did not affect early outcome and late survival in patients who underwent valve replacement, and therefore, the current strategy favoring a biological aortic valve prosthesis for patients aged over 60 years in first-time operations could also be applied in re-replacement.

Pre-operative left atrial strain predicts post-operative atrial fibrillation in patients undergoing aortic valve replacement for aortic stenosis

Post-operative atrial fibrillation (AF) is a common and serious complication in patients undergoing aortic valve replacement (AVR). Speckle tracking echocardiography (STE) has recently enabled the quantification of longitudinal myocardial left atrial (LA) deformation dynamics. Our aim was to investigate LA preoperative mechanical function in patients undergoing AVR for aortic stenosis using STE and determine predictors of post-operative AF. 76 patients with aortic stenosis in sinus rhythm, undergoing AVR, were prospectively enrolled. Conventional echocardiographic parameters, and peak atrial longitudinal strain (PALS) were measured in all subjects the day before surgery. PALS values were obtained by averaging all segments in the 4- and 2-chamber views (global PALS). All patients received biological valve prostheses and a standard postoperative care. Postoperative AF occurred in 15 patients (19.7 %). On univariate analysis among all clinical and echocardiographic variables, global PALS showed the highest diagnostic accuracy (HR 6.55 p < 0.0001; AUC of 0.89) with a cut-off value <16.9 %, having sensitivity and specificity of 86 and 91 %, respectively, in predicting postoperative AF. LA volume indexed and E/e' ratio had lower diagnostic accuracy (AUC 0.76 and 0.51, respectively). On multivariate analysis global PALS remains a significant predictor of postoperative AF (p < 0.0001). STE analysis of LA myocardial deformation is considered a promising tool for the evaluation of LA subclinical dysfunction in patients undergoing AVR, giving a potentially better risk stratification for the occurrence of postoperative AF.

Long-term results after aortic root replacement using self-assembled valve composite grafts in patients with small aortic annulus

The study was aimed to evaluate operative and long-term results after complete root replacement using self-assembled valve composite grafts in patients with a small aortic annulus. Among 547 consecutive patients who received the Bentall procedure between 2000 and 2012, a total of 29 patients (61 ± 10; range 42-79 years) had an annulus of ≤20 mm (mean 19.0 ± 0.9). Patients with a native aortic valve (22) suffered from stenosis, insufficiency or mixed defect in 10, 10 and 2 cases, respectively. Among the remaining 7 patients with an artificial aortic valve, there were 3 symptomatic prosthesis-patient mismatches, 3 valve prosthesis deteriorations (1 structural and 2 none-structural) and 1 paravalvular leak. Indication for aortic root replacement was true or false aneurysm, porcelain aorta and intraoperative aortic wall injury in 17, 6 and 6 patients, respectively. The composite graft for complete aortic root replacement was assembled using a mechanical (26) or biological (3) valve prosthesis placed inside a vascular graft with a median size of 24 (range 22-26) mm. The margin of the tube beneath the valve was anastomosed to the aortic annulus, and coronary ostia were implanted in the usual manner. The mean transvalvular gradient at discharge was 10.8 ± 3.9 mmHg and remained virtually unchanged at the follow-up completed for all patients. Early mortality was 0. During the mean follow-up of 95.8 ± 43.7 months, 2 patients died (54 and 146 months after surgery) due to pulmonary embolism and myocardial infarction, respectively. In patients with a small aortic annulus who need complete aortic root replacement, an oversizing of the valve can be easily achieved using modified, self-assembled composite grafts. Offering excellent haemodynamic characteristics, these grafts lead to prevention of prosthesis-patient mismatch and result in very good and durable functional and clinical results.

Reconstructive surgery for aortic valve stenosis

Background The native aortic valve can be explained with rules of the equal side triangle, and as a part of the aortic root it is wedged between the heart and the ascending aorta. Beside different types of aortic valve replacements, reconstructive techniques are increasingly performed to restore normal aortic valve function. Reconstructive techniques themselves can be divided into isolated reconstruction of aortic valve/root structures and the isolated replacement of one or more structures. With this study we evaluated clinical results of reconstructive surgery of the aortic root with 3 leaflets pericardial patch. Methods We created this reconstructive technique using bovine/ equine pericardium, replacing valve cusps on aortic fibrous ring of patient. The leaflets are made from same pericardium from which other biologic valve prosthesis are done. The ring of patient’s aorta was used as guide for sizing this valve. Leaflets are implanted separately; using continuous sutures with 2 supported stitches at newly created commissure, without a stent or sowing ring. Main including criteria was stenosis of the aortic valve and patients with aortic annuli ring dilatation had been excluded. Intraoperative and postoperative TEE was performed for every created valve. Results

Long-term tricuspid valve prosthesis-related complications in patients with congenital heart disease

In patients with acquired valvar disease, morbidity and mortality rates after tricuspid valve replacement (TVR) are high. However, in adult patients with congenital heart disease, though data concerning outcome after TVR are scarce, even poorer results are suggested in patients with Ebstein anomaly. To investigate the applicability of these results to a broader array of congenital heart disease patients, we report the long-term follow-up of prosthesis-related complications, including re-replacement of patients with a tricuspid valve prosthesis and congenital heart disease. From the Dutch Congenital Corvitia (CONCOR) registry, we identified 20 patients with a biological or mechanical tricuspid valve prosthesis implanted between 1977 and 2012 (total of 31 prostheses). We analysed the tricuspid valve-related complications and mortality. Ten patients with a median age of 16.2 years at the time of surgery (interquartile range 13.2-28.2 years) received a bioprosthesis while 10 patients with a median age of 36.4 years (interquartile range 14.0-47.0) at the time of surgery received a mechanical prosthesis (P = 0.28). During a mean follow-up of 14 years, 50% needed a re-replacement because of valve-related complications (e.g. valve degeneration or valve thrombosis). The yearly percentage of patients with valve-related complications was 4.2% in patients with a bioprosthesis and 2.7% in those with a mechanical prosthesis. Within 20 years of implantation, the median duration of event-free survival was significantly shorter in 3 patients with a prosthesis-patient mismatch (PPM; 1.0 year; interquartile range 0.01-2.6), compared with 7 without mismatch (8.0 years; interquartile range 5.1-12.3; P = 0.02). Compared with previous literature on acquired valvar disease, we found a higher incidence of valve-related complications in patients with congenital heart disease that was unrelated to prosthesis material. Our data suggest that PPM may have a negative effect on the event-free interval.

Cardiac surgery in nonagenarians: not only feasible, but also reasonable?†

Changes in the age profile of the population in the western world and improvement in surgical techniques and postoperative care have contributed to a growing number of cardiosurgical patients aged over 90. In periods when transapical and transfemoral aortic valve replacement were done, we aimed at evaluating the outcome of nonagenarians after conventional aortic valve replacement and cardiac surgery in general, and determining perioperative parameters to predict a complicated postoperative course. Between 1995 and 2011, 49 nonagenarians (aged 91.2±3.1 years) underwent cardiac surgery. A subgroup of 30 patients received aortic valve replacement alone (63%; n=19), in combination with coronary artery bypass grafting (27%; n=8) or other surgical procedures (10%; n=3). Most of the patients suffered from combined aortic valve disease with a mean valve orifice area of 0.6±0.3 cm2 and a mean antegrade pressure gradient of 86±22 mmHg. Cardiac surgery in nonagenarians resulted in remarkable postoperative morbidity and an overall in-hospital mortality of 10% (n=5). In the AVR subgroup, biological valve prostheses were implanted in 29 patients. In this subgroup, the length of stay was 2.9±0.9 days in the intensive care unit and 17.0±5.5 days in the hospital. The in-hospital mortality amounted to 13% (n=4). Although several general preoperative risk factors of postoperative complications such as renal failure, low cardiac output syndrome and New York Heart Association Class IV were remarkably more frequent among the patients who died after the operation, the small cohort of non-surviving nonagenarians did not allow for significant differences. Cardiac surgery in the very elderly, particularly with regard to aortic valve replacement, carries a high risk of early morbidity and mortality. However, in selected nonagenarians, surgery can be performed with an acceptable outcome. The risk may even be reduced by an individual approach to the procedure. With regard to potential risk factors, the selection of these patients should be carried out very carefully.

Long-Term Safety and Effectiveness of Mechanical Versus Biologic Aortic Valve Prostheses in Older Patients

Background— There is a paucity of long-term data comparing biological versus mechanical aortic valve prostheses in older individuals. Methods and Results— We performed follow-up of patients aged 65 to 80 years undergoing aortic valve replacement with a biological (n=24 410) or mechanical (n=14 789) prosthesis from 1991 to 1999 at 605 centers within the Society of Thoracic Surgeons Adult Cardiac Surgery Database using Medicare inpatient claims (mean, 12.6 years; maximum, 17 years; minimum, 8 years), and outcomes were compared by propensity methods. Among Medicare-linked patients undergoing aortic valve replacement (mean age, 73 years), both reoperation (4.0%) and endocarditis (1.9%) were uncommon to 12 years; however, the risk for other adverse outcomes was high, including death (66.5%), stroke (14.1%), and bleeding (17.9%). Compared with those receiving a mechanical valve, patients given a bioprosthesis had a similar adjusted risk for death (hazard ratio, 1.04; 95% confidence interval, 1.01–1.07), higher risks for reoperation (hazard ratio, 2.55; 95% confidence interval, 2.14–3.03) and endocarditis (hazard ratio, 1.60; 95% confidence interval, 1.31–1.94), and lower risks for stroke (hazard ratio, 0.87; 95% confidence interval, 0.82–0.93) and bleeding (hazard ratio, 0.66; 95% confidence interval, 0.62–0.70). Although these results were generally consistent among patient subgroups, bioprosthesis patients aged 65 to 69 years had a substantially elevated 12-year absolute risk of reoperation (10.5%). Conclusions— Among patients undergoing aortic valve replacement, long-term mortality rates were similar for those who received bioprosthetic versus mechanical valves. Bioprostheses were associated with a higher long-term risk of reoperation and endocarditis but a lower risk of stroke and hemorrhage. These risks varied as a function of a patient’s age and comorbidities.

Homografts in aortic position: does blood group incompatibility have an impact on patient outcomes?†

Aortic homografts are an alternative to mechanical or biological valve prostheses. Homografts are generally not transplanted ABO-compatible while this policy is still under debate. The purpose of this study was to investigate whether ABO compatibility impacts on long-term outcomes or not. Between 1992 and 2009, 363 adult patients with a mean age of 52 years received homografts in aortic position. Donor and acceptor blood groups could be obtained for 335 patients. Sixty-three percent received blood group-compatible (n = 212) (Group iso) and 37% non-blood group-compatible allografts (n = 123) (Group non-iso). The overall event-free survival (freedom from death or reoperation) was 55.5% (n = 186). In the iso group, the event-free survival was 84.1% at 5 years and 63.3% at 10 years. In the non-iso group, the event-free survival was 79.4% at 5 years and 51.8% at 10 years. 28.5% of patients (n = 35) with ABO-incompatible and 25.5% (n = 54) with ABO-compatible grafts required reoperation. The mean time to reoperation in the iso group was 97.3 vs 90 months in the non-iso group. In 17 years of research, we have not yet found a statistical significant difference in blood group incompatibility regarding overall event-free survival. In our opinion, there is no need to use ABO-compatible homografts for aortic valve replacement in adults. Histological and immunohistochemical assays are mandatory to confirm our results.

Results after four years of experience with the new Trifecta™ biological aortic valve prosthesis

Objectives: The Trifecta™ aortic valve prosthesis has been used in clinical studies since 2007. After the market release in 2010 the implant numbers rose quickly. This might be due to the excellent hemodynamic results. However, long term results are missing so far. This study is to present the midterm clinical and echocardiographic results of all patients of a single center who received aortic valve replacement (AVR) with the Trifecta™ prosthesis ± any other concomitant surgery.

Left atrial endocarditis as a rare complication of mitral valve endocarditis: a clinical case

BackgroundInfective Endocarditis (IE) is considered as a multifaceted problem in every aspect from etiology and presentation to diagnosis and management. Early recognition of this disease and especially its complications, remain a critical task for the cardiologist. Atrial endocarditis is a rare and sometimes unrecognized complication of mitral valve endocarditis.Case presentationWe present a 48 year-old male patient who was admitted to our clinic because of recent onset of malaise, fever, jaundice and peripheral edema. Important physical findings were peripheral stigmata of IE in addition to holosystolic murmur over the left sternal border. Transthoracic and transesophageal echocardiophy revealed a severe eccentric MR due to a flailed posterior mitral valve caused by IE. The presence of atrial septal endocarditis caused by jet streaming was also observed. Blood culture was positive for streptococcus oralis and antibiotic therapy was immediately initiated. Considering the large burden of infective tissue, the patient was planned for an early surgical intervention. A minimally invasive resection of the atrial mass, direct closure of the defect, resection of the diseased portions of mitral leaflets and implantation of a biological mitral valve prosthesis was performed. Intra-operative and histological findings confirmed provisional diagnosis by echocardiography.ConclusionsTogether with comprehensive echocardiographic evaluation, attention should be placed on mural vegetations and excluded among all cases of mitral valve endocarditis, particularly those with severe eccentric regurgitant jets.

Use of transcatheter heart valves for a valve-in-valve implantation in patients with degenerated aortic bioprosthesis: Technical considerations and results

Transcatheter aortic valve implantation has been used to treat high-risk patients with bioprosthetic valve degeneration (valve-in-valve). We report our experience with transcatheter aortic valve implantation in the treatment of degenerated biologic aortic valve prostheses and discuss factors that can influence the outcome. From February 2009 to October 2011, 278 patients underwent transcatheter aortic valve implantation, of whom 23 underwent a valve-in-valve procedure with the Edwards Sapien valve to treat a failing bioprostheses in the aortic position. Eight of these valves were stentless bioprostheses. Thirteen patients had valve failure resulting predominantly from stenosis, and the remaining resulting from regurgitation. Mean age was 76.9 ± 14.4 years. The mean logistic EuroSCORE was 31.8% ± 20.3% and the Society of Thoracic Surgeons score was 7.6% ± 5.4%. All patients were New York Heart Association class III or IV. The majority of the operations (21/23) were performed via the transapical route. Procedural success was 100%, although 1 patient with a degenerated homograft needed immediate placement of a second valve because of low placement of the first. The reduction in the mean gradient was 31.2 ± 17.06 mm Hg to 9.13 ± 4.9 mm Hg. In those patients with predominant aortic regurgitation (9/23), reduction in aortic regurgitation was achieved in all. The median length of stay was 11.7 days (range, 3-44 days). In-hospital and/or 30-day mortality was 0%. Valve-in-valve is a safe and feasible alternative to treat high-risk patients with failing aortic bioprostheses. The early results are excellent, with improvement seen in hemodynamics.

A prospective, randomized comparison of 3 contemporary bioprosthetic aortic valves: Should hemodynamic performance influence device selection?

Latest generation biologic aortic valve prostheses were designed to improve hemodynamic performance. We sought to determine whether there are clinically important early differences among these devices. Three hundred adults with severe aortic valve stenosis undergoing aortic valve replacement were randomized to receive the Edwards Magna, Sorin Mitroflow, or St. Jude Epic bioprostheses (n=100, n=101, n=99, respectively). Early hemodynamic performance was studied by echocardiography. Mean patient age was 76 ± 8 years and there were 203 men (68%). There were no significant differences in baseline characteristics among implant groups. Early mortality was 1.7%, and there were no differences in early adverse events. Postoperative echocardiography showed small but statistically significant differences overall between the Magna, Mitroflow, and Epic valves in mean gradient (14.2 mm Hg, 16.3mm Hg, 16.5 mm Hg, respectively; P=.011), aortic valve area (2.05 cm(2), 1.88 cm(2), 1.86 cm(2), respectively; P=.012), and indexed aortic valve area (1.05 cm(2)/m(2), 0.97 cm(2)/m(2), 0.95 cm(2)/m(2), respectively; P=.012). Prosthetic performance was similar among all with a small (≤21 mm) aortic annulus. Patients who received the Magna device with a 23-mm annulus had slightly greater indexed aortic valve area; those with >23 mm had a slightly lower transprosthetic gradient. Analogous trends were found when data were stratified by either commercial implant size or echocardiography-determined aortic annulus size. Severe patient-prosthesis mismatch was infrequent overall and was similarly low among devices (P value not significant). This prospective, randomized comparison reveals that there are small but consistent early postoperative hemodynamic differences among current third-generation porcine and pericardial aortic valve prostheses. The 3 valves studied performed equally well in patients with a small (≤21 mm) aortic annulus. The Magna valve had a slightly lower mean gradient in those with larger annular size (>23 mm). Longitudinal follow-up of these randomized cohorts is essential to determine late clinical implications of these early postoperative findings.

A Novel Approach to an Anatomical Adapted Stent Design for the Percutaneous Therapy of Tricuspid Valve Diseases

Tricuspid valve regurgitation mostly occurs as result of dilation of the right ventricle, secondary to left heart valve diseases. Until recently, little attention has been given to the development of percutaneous therapeutic tools exclusively designed for tricuspid valve disease. A new approach to the interventional therapy of tricuspid regurgitation, in particular, the design of a conceptual new valve-bearing, self-expansible stent, is presented here. A three-dimensional computer model of a right porcine heart was developed to gain a realistic anatomical geometry. The new design consists of two tubular stent elements, one inside the superior vena cava and the other inside the tricuspid valve annulus after being eventually equipped with a biological valve prosthesis, which are connected by struts. Anchoring to the heart structure is provided primarily by the vena cava stent, strengthened by the struts. The stents are designed to be cut from a 10 mm tube and later expanded to their designated diameter. Simulation software analyzing the expansion process with respect to the intended geometrical design is used in an iterative process. A validation of the anatomical geometry and function of the stent design inside a silicone model within in vitro tests and a random porcine heart shows an accurate anatomical fitting.

A supra-annular malposition of the Perceval S sutureless aortic valve: the ‘χ-movement’ removal technique and subsequent reimplantation

The Perceval S sutureless valve prosthesis has recently been introduced as a new biological aortic valve prosthesis, but a specific learning curve is required, as for every cardiac surgical centre dealing with a new technique. After the removal of the stenotic valve, the prosthetic valve is correctly positioned within the mildly decalcified aortic annulus. When a supra-annular malposition occurs, due to an excessively rapid release of the prosthesis in the aorta or incomplete annular visualization, the Perceval S valve can safely be removed even after balloon dilation. The procedure performed is a 'χ-movement' with the aid of anatomical forceps. If the prosthesis does not show any malformation after the procedure, it can be reimplanted in the correct intra-annular position.

Implantation of a Melody® valve in triscuspid position

A transcatheter pulmonary valve (Melody) was implanted within a stenotic biological valve prosthesis in tricuspid position, as an alternative to the fourth major cardiac surgery in a 12-year-old girl. There were no complications. The postinterventional result was very good.

Associação entre doenças imunológicas e suas manifestações clínicas semelhantes

Trata-se de um caso de uma paciente de 30 anos do sexo feminino, com prótese biológica valvar mitral em razão de estenose mitral sintomática e antecedentes de infarto agudo do miocárdio, episódios de convulsões tônico-clônicas generalizadas, alucinações visuais, eventos tromboembólicos cerebrais, apresentando no momento coreia e cardite aguda. Foram diagnosticados na paciente febre reumática em atividade, lúpus eritematoso sistêmico e síndrome do anticorpo antifosfolipídeo. A combinação de três diagnósticos incomuns em um mesmo paciente torna esse caso único, modificando o tratamento e seu prognóstico.

Nanocoating with titanium reduces iC3b- and granulocyte-activating immune response against glutaraldehyde-fixed bovine pericardium: A new technique to improve biologic heart valve prosthesis durability?

An IgG and granulocyte-activating immune response with secondary dystrophic calcification might be the reason glutaraldehyde (GA)-fixed xenograft valves fail, especially in young patients, who are more immunocompetent than the elderly. Titanium nanocoating on GA-fixed bovine pericardium was tested for its ability to prevent major immunoreactions. The immune activity of platelets from GA-fixed bovine pericardium with different treatment procedures was evaluated using the blood from 5 human donors: group I (n = 5), GA fixed as the control; group 2 (n = 5), detoxified with 10% citric acid; group 3 (n = 5), 10% citric acid, aldehyde-dehydrogenase, and a physical plasma treatment; and group 4 (n = 5), treated the same as group 3, but with an additional titanium coat 30 nm in thickness. Titanium deposition was visualized using scanning electron microscopy. IgG deposits (iC3b) were shown by immunostaining and documented as colored pixels (red). The pixels were evaluated electronically. Attracted granulocytes (polymorphonuclear leukocytes) were counted in front of the titanium-coated surface. IC3b deposits and polymorphonuclear leukocytes within control group 1 were defined as 100%; in group 2, iC3b was 149% ± 34% and polymorphonuclear leukocytes were 89%, in group 3, IC3b was 102% ± 24% and polymorphonuclear leukocytes were 47%; and in group 4, IC3b had decreased to 38.49% ± 21% (P < .05) and polymorphonuclear leukocyte activation had decreased to 6.3% (P ≤ .01). Titanium coating significantly reduced the iC3b and granulocyte activating immune response of GA-fixed pericardium. Therefore, it might prevent relevant immunorejection and increase the durability of GA-fixed bioprosthetic heart valves.

Biological Mitral Valve Prosthesis in a Patient Supported With a Permanent Left Ventricle Assist Device

Mitral valve pathology, especially status postvalve replacement (biological or mechanical), remains challenging in patients suffering from end-stage heart failure and undergoing left ventricular assist device (LVAD) placement due to several factors (potential source for thromboembolic complications, risk for structural deterioration of the biological prosthesis leading to stenosis, and inadequate LVAD preload). We report a case of long-term LVAD support in a patient with a previously implanted biological mitral valve prosthesis. During LVAD insertion, the valve was left in place, and it functioned well until the death of the patient 3 years later. The patient remained free of any valve-related complications.

Pulmonary Homografts for Aortic Valve Replacement: Long-term Comparison with Aortic Grafts

The use of homografts for aortic valve replacement (AVR) is an alternative to mechanical or biological valve prostheses, especially in younger patients. This retrospective comparative study evaluated our single-center long-term results, with a focus on the different origins of the homografts. Since 1992, 366 adult patients have undergone AVR with homografts at our center. We compared 320 homografts of aortic origin and 46 homografts of pulmonary origin. The grafts were implanted via either a subcoronary technique or the root replacement technique. We performed a multivariate analysis to identify independent factors that influence survival. Freedom from reintervention and survival rates were calculated as cumulative events according to the Kaplan-Meier method, and differences were tested with the log-rank test. Overall mortality within 1 year was 6.5% (21/320) in the aortic graft group and 17.4% (8/46) in the pulmonary graft group. In the pulmonary graft group, 4 patients died from valve-related complications, 1 patient died after additional heterotopic heart transplantation, and 1 patient who entered with a primary higher risk died from a prosthesis infection. Two patients died from non-valve-related causes. During the long-term follow-up, the 15-year survival rate was 79.9% for patients in the aortic graft group and 68.7% for patients in the pulmonary graft group (P = .049). The rate of freedom from reoperation was 77.7% in the aortic graft group and 57.4% in the pulmonary graft group (P < .001). The reasons for homograft explantation were graft infections (aortic graft group, 5.0%; pulmonary graft group, 6.5%) and degeneration (aortic graft group, 7.5%; pulmonary graft group, 32.6%). Our study demonstrated superior rates of survival and freedom from reintervention after AVR with aortic homografts. Implantation with a pulmonary graft was associated with a higher risk of redo surgery, owing to earlier degenerative alterations.