Biological Valve Research Articles

Polymorphic size of Lipoprotein (a) and structural bioprosthetic valve degeneration

Abstract Background The use of biological heart valves (BHV) is constantly growing for the treatment of patients with aortic stenosis and their durability arises as a main concern in the field. Structural valve deterioration (SVD) of the BHV occurs gradually post-implantation and seems to reiterate, at least in part, the pathophysiological processes described in native valve stenosis. Lipoprotein (a) [Lp(a)] is an important genetically determine cardiovascular risk factors, associated with native valve calcification. The shorter polymorphic sizes of Lp(a), defined as low of apolipoprotein (a) [apo(a)] Kringle-IV copy number, have been associated with more deleterious cardiovascular phenotype. However, the association of Lp(a) plasma levels and/or its polymorphic sizes with SVD remains unclear. Purpose To determine whether Lp(a) plasma levels and/or the Lp(a) polymorphic size were associated with SVD. Methods 332 patients who underwent aortic valve replacement (AVR) with BHV from the Translink trial were included in this study. Clinically significant SVD has been defined as Stage 3 SVD based on the VARC-3 definition. Lp(a) concentration was determine by immunoturbidimetry method and the apo(a) Kringle-IV copy number by liquid chromatography-tandem mass spectrometry. Univariable and multivariable models, adjusted for clinically relevant and statistically significant variables, were used to determine the independent association between Lp(a) concentrations or apo(a) Kringle-IV copy numbers with SVD. Results Among the 332 patients included in this study, the mean age was 78 ±8 years and 71% were males. 76 patients (23%) presented clinically significant SVD. Low apo(a) Kringle-IV copy number was associated with an increased risk of SVD (per log decrease: OR=2.71 [1.34-5.50], p=0.006), but not Lp(a) plasma concentration (OR=0.99 [0.84-1.15], p=0.85). This association remained significant after comprehensive multivariable adjustments, including Lp(a) concentration (OR=3.21 [1.31-7.84], p=0.01). The analysis of the transprosthetic mean gradient, as a surrogate marker of SVD, provided consistent results (all p≤0.03). Conclusion This cross-sectional study from the Translink trial demonstrates the association between Lp(a) polymorphic size and SVD, highlighting a potential therapeutic option to limit the occurrence of SVD in selected patients who underwent AVR with surgical or transcatheter BHV.

Prevalence and prognostic value of thrombocytopenia in aortic valve replacement surgery: bioprosthesis versus mechanical prosthesis

Abstract Background Thrombocytopenia is a frequent complication of valve surgery, and is associated with different postoperative outcomes. Concern has recently arisen about thrombocytopenia following aortic valve replacement (AVR), as some authors have reported increased postoperative thrombocytopenia with certain biological aortic valves. In adittion, it is unclear whether thrombocytopenia predicts mortality in this type of surgery. Purpose The aim of this study was to determine the prevalence and prognostic value of thrombocytopenia in biological and mechanical aortic valve replacement. Methods The study was an observational analysis of patients undergoing AVR with or without associated coronary artery bypass grafting (CABG) at a single center between October 2014 and October 2023. Cardiac Surgery database was computerized and prospectively completed. Preoperative and first 4 days postoperative platelet counts were analyzed. Thrombocytopenia was defined as platelet count < 100 × 10³/mm³. To obtain comparable populations, a propensity score matching analysis was performed. Results A total of 1,197 patients underwent AVR with (n = 494) or without CABG (n = 703). Patients received either a mechanical prosthesis (n = 320), or a biological prosthesis (n = 877). The mean population age was 68 years (SD 6), with the majority being male (68%). Univariate analysis of the baseline characteristics of both groups of patients showed that they were not comparable. A risk-adjusted subanalysis was performed according to a propensity score (n=278). The nadir of bioprostheses was on the third postoperative day with an average of 93.8 × 10³/mm³, while in mechanical prostheses was also on the same day but with an average of 114.7 × 10³/mm³ (p: 0.001). (Figure 1) Bioprosthesis implantation was significantly associated with a higher prevalence of thrombocytopenia (72.7% vs. 45.3%, p<0.001). The presence of postoperative thrombocytopenia has been associated with higher in-hospital mortality (6.7% vs. 0.9%, p=0.019); but not with other postoperative complications. (Figure 2) Conclusions Patients undergoing AVR with bioprostheses had a significantly higher prevalence of thrombocytopenia, and also lower platelet counts than mechanical prothesis within the first 4 postoperative days. Thrombocytopenia was associated with higher in-hospital mortality in a risk score-adjusted population.Platelet counts after AVROutcomes according to platelet count

Evolution and prognostic relevance of right ventricular morphofunctional parameters in patients undergoing isolated tricuspid valve surgery

Abstract Background Right ventricular (RV) function is key in evolution after isolated tricuspid valve surgery (ITVS). Right ventricular-pulmonary artery coupling (RV-PA coupling), determined with echocardiography as the ratio TAPSE/sPAP, has merged as a relevant functional parameter in many clinical scenarios. Purpose Our aim is to evaluate the prognostic relevance of RV-PA coupling in patients undergoing ITVS. Methods We carried out a retrospective study involving all the patients undergoing ITVS at our tertiary centre. Several RV function measurements were assessed from the baseline echocardiogram (TAPSE, fractional area change (FAC), systolic pulmonary artery pressure (sPAP), tricuspid annulus tissue Doppler velocity (RVS´) and free-wall global longitudinal strain (FW-GLS)) and RV-PA coupling was calculated. Association between RV morphofunctional variables and mortality during one year follow-up was determined. Results 45 patients were included (68 years-old, 51,1% female). The most common TR etiology was functional (51.1%) and 42.2% had previous left-sided valvular surgery. The median Tri-Score was 2 (1-4) points and the most frequent procedure was biological valve replacement (65%). Baseline echocardiographic parameters were as follows: basal 52 (48 – 53.5) mm, mid 40 (36-45.5) mm and longitudinal 73 (68-80) RV diameters, TAPSE 18.1 (15.5-20.7) mm, RVS´ 10.1 (9-12.5) cm/s, FAC 0.5 (0.43-0.57), sPAP 35 (31.5-37.5) mmHg, and FW-GLS - 21.1 (17.2-25) %. During the follow-up 8 (18%) patients died. Solely TAPSE (16 vs 19, p= 0.047) and RV-PA coupling (0.35 vs 0.5; p= 0.035) showed significant differences in mortality among RV echocardiographic parameters. An RV-PA coupling <0.375 mm/mmHg appeared to be the best mortality predictor (RR 1.45; p= 0.04) one year after the intervention (Figure). Conclusions In our series RV-PA coupling has proved to be the best echocardiographic prognostic factor in ITVS, so it could be considered a relevant parameter in risk stratification previous to this surgery. Figure. Kaplan Meier curves of mortality after ITVS by RV-PA coupling.Figure

Temporal trends in mitral valve surgery in Denmark: changes in patient characteristics and outcomes from 1996 to 2021

Abstract Background Mitral valve regurgitation (MR) is associated with increased morbidity and mortality. Mitral valve surgery (MVS) is recommended in severe MR, which is the second most common cause of heart valve surgery in the Western world. Data on national practice patterns are lacking and are essential for the continuous epidemiologic surveillance of the disease. Purpose To investigate temporal trends in patient characteristics, incidence and mortality in patients undergoing MVS for MR in Denmark from 1996 to 2021. Methods Using Danish nationwide registries, we identified all patients ≥18 years undergoing MVS for MR. Patients operated due to infective endocarditis were excluded. The study population was grouped into one 6-year and four 5-year calendar bands and type of MVS (mitral valve repair, mechanical or biological valve replacement and transcatheter-edge-to-edge repair (TEER)). Temporal trends in patient characteristics were computed. Annual incidence rates were calculated while considering the total Danish population ≥18 years at risk. For one-year postoperative mortality analysis, the reverse Kaplan-Meier estimator and a multivariable Cox proportional hazard analysis were used. Results We identified 7,813 patients (median age 67.3 years, 65.6% males) undergoing MVS. Over calendar time, burden of comorbidities decreased while median age increased, Table 1. From 1996 to 2021, a stepwise increase was seen in the overall incidence rate for MVS from 3.87 [95% CI 3.32-4.51] to 7.06 [95% CI 6.34-7.58] per 100,000 person-years (p<0.001). The incidence of mechanical valve replacement statistically significantly decreased (p<0.001), while the incidence of mitral valve repair (p=0.004), biological replacement (p≤0.001) and TEER statistically increased (p=0.015), Figure 1. For the overall study period, one-year mortality was 5.0% for mitral valve repair, 12.7% for mechanical valve replacement, 15.7% for biological valve replacement and 19.0% for TEER. Demographics and one-year mortality stratified by calendar period are shown in Table 1. In the mitral valve repair group, adjusted analysis showed a stepwise statistically significant decrease in one-year mortality with HR 0.30 (95% CI 0.17-0.53, p≤0.001) in 2017-2021 as compared to 1996-2001. In the remaining surgical groups, trends were towards decreasing one-year mortality over calendar periods but did not reach statistical significance. Conclusion(s) In this Danish nationwide cohort study, we observed an increase in the incidence of overall mitral valve surgery from 1996 to 2021. The incidence of mechanical valve replacement decreased, while the incidence of mitral valve repair, biological replacement and TEER increased. Mortality rates significantly improved for mitral valve repair patients over calendar time. Continuous epidemiological surveillance of this patient group is required in an era of development in treatment guidelines, surgical methods and patient demographics.Table 1Figure 1

Early structural valve deterioration following transcatheter aortic valve implantation in a patient with Scheie syndrome: a case report

BackgroundScheie syndrome, an attenuated subtype of mucopolysaccharidosis type I, is a rare storage disease that causes progressive glycosaminoglycans (GAGs) accumulation. Cardiovascular disorders determine the prognosis, and cardiac valve abnormalities are the most common cause. The patients are usually young so mechanical valve replacement is often performed, but because of the features of this disease, the surgical treatment is very risky. Recently, transcatheter aortic valve implantation (TAVI) has been reported as an alternative choice for aortic stenosis, but optimal choice is still unclear. Here, we introduce a patient that underwent TAVI and refer to the histological finding of a biological valve extracted in relation to GAGs accumulation.Case presentationA 54-year-old woman with Scheie syndrome underwent valve surgeries three times throughout her whole life. At age 41, she received a mitral valve replacement with a mechanical valve for mitral stenosis. She promptly developed severe diastolic dysfunction and low output syndrome after the release of aortic clamping, thus requiring temporary mechanical circulatory support4. At age 51, she suffered from heart failure due to severe aortic stenosis and underwent TAVI because conventional aortic valve replacement (AVR) was deemed too risky. Three years later, her heart failure relapsed, and an echocardiogram unexpectedly revealed thickened bioprosthetic valve leaflets and a significant pressure gradient across the valve, consistent with early structural valve deterioration. AVR was performed via median sternotomy with a mechanical valve. As with the first operation, she presented refractory heart failure requiring mechanical circulatory support and was meticulously managed. However, she steadily showed worsening of multiple organ systems and died 9 days after the operation. Pathological autopsy and histological examination revealed accumulation of tissue with GAGs on the leaflets of the bioprosthetic valve of TAVI, which may have been the cause of early structural valve deterioration.ConclusionFor patients with Scheie syndrome, a biological valve can be compromised by the accumulation of GAGs, thereby causing early SVD. These findings may support valve selection for these high-risk patients.

Lingual artery thrombosis as a presentation of infective endocarditis in a pregnant patient; a case report

Abstract Background Infective endocarditis during pregnancy is a rare condition that compromises the health of both the mother and the fetus, presenting high rates of morbidity and mortality. The clinical manifestations of this disease are varied, with embolic phenomena being a frequent presentation. Case summary We report the case of a 37-year-old patient, at 29 weeks of pregnancy, with no known cardiovascular history, who presented with 48 hours of sudden mandibular and lingual pain. The study showed acute thrombosis of the right lingual artery and the rest of the right external carotid artery. In this context, searching for the origin of the embolism, acute mitral valve endocarditis was diagnosed, which was effectively treated with antibiotic therapy and biological mitral valve replacement, as well as early cesarean delivery. Discussion We report the first case where lingual artery thrombosis was the key diagnostic feature of infective endocarditis.

Comparison of mid-to-long term outcomes between mitral valve repair and biological valve replacement in patients over 60 with rheumatic mitral valve disease based on a propensity score matching study

Objective: To compare and discuss the mid-to-long-term outcomes of mitral valve repair (MVP) versus biological mitral valve replacement (bMVR) in patients over 60 years old with rheumatic mitral valve disease. Methods: This is a retrospective cohort study. A total of 765 patients aged 60 years and older, diagnosed with rheumatic mitral valve disease and who underwent MVP or bMVR at Beijing Anzhen Hospital from January 2010 to January 2023, were retrospectively included. Among them, 186 were male and 579 were female, with an age of (66.1±4.5) years (range: 60 to 82 years). Patients were divided into two groups based on the surgical method: the mitral valve repair group (MVP group, n=256) and the bioprosthetic mitral valve replacement group (bMVR group, n=509). A 1∶1 propensity score matching was performed using a caliper value of 0.2 based on preoperative data. Paired sample t-tests, χ² tests, or Fisher's exact tests were used for intergroup comparisons. Kaplan-Meier method was employed to plot survival curves and valve-related reoperation rate curves for both groups before and after matching, and Log-rank tests were used to compare the mid-to long-term survival rates and valve-related reoperation rates between the two groups. Results: A total of 765 patients who completed follow-up were ultimately included, with a follow-up period (M(IQR)) of 5.1(5.0) years (range: 1.0 to 12.9 years). After matching, each group consisted of 256 patients. The incidence of early postoperative atrial fibrillation (39.1% vs. 49.2%, χ2=4.95, P=0.026) and early mortality rates (2.0% vs. 6.2%, χ2=4.97, P=0.026) were lower in the MVP group. Unadjusted Kaplan-Meier analysis showed significantly higher 5-year and 10-year survival rates for the MVP group (92.54% vs. 83.02%, 86.22% vs. 70.19%, Log-rank P=0.001). After adjustment with propensity scores, the Kaplan-Meier analysis still indicated higher 5-year and 10-year survival rates in the MVP group compared to the bMVR group (92.54% vs. 85.89%, 86.22% vs. 74.83%, Log-rank P=0.024). There were no significant differences in the rates of valve-related reoperation between the two groups before and after matching (5-year and 10-year reoperation rates pre-matching: 1.75% vs. 0.57%, 5.39% vs. 7.54%, Log-rank P=0.207; post-matching: 1.75% vs. 0%, 5.39% vs. 9.27%, Log-rank P=0.157). Conclusion: For patients over 60 with rheumatic mitral valve disease, mitral valve repair offers better mid-to-long-term survival compared to biological valve replacement.

4D-Flow MRI and Vector Ultrasound in the In-Vitro Evaluation of Surgical Aortic Heart Valves - a Pilot Study.

The aim of this study was the initial investigation of 4D-Flow MRI and Vector Ultrasound as novel imaging techniques in the in-vitro analysis of hemodynamics in anatomical models. Specifically, by looking at the hemodynamic performance of state-of-the-art surgical heart valves in a 3D-printed aortic arch. The mock circulatory loop simulated physiological, pulsatile flow. Two mechanical and three biological aortic valves prostheses were compared in a 3D-printed aortic arch. 4D magnetic resonance imaging and vector flow Doppler ultrasound served as imaging methods. Hemodynamic parameters such as wall shear stress, flow velocities and pressure gradients were analyzed. The flow analysis revealed characteristic flow-patterns in the 3D-printed aortic arch. The blood-flow in the arch presented complex patterns, including the formation of helixes and vortices. Higher proximal peak velocities and lower flow volumes were found for biological valves. The mock circulatory loop in combination with modern radiological imaging provides a sufficient basis for the hemodynamic comparison of aortic valves.

Effects of preoperative respiratory muscle training for improvement of postoperative health related quality of life in mitral valve replacement patients.

A patient's defective mitral valve is replaced as part of a treatment called mitral valve replacement (MVR) with a mechanical or biological (bioprosthetic) valve. To evaluate the effects of preoperative respiratory muscle training (RMT) on the improvement of postoperative Health related quality of life in MVR patients. A quasi-experimental study was conducted at Faisalabad Institute of Cardiology. A Sample of 40 adult patients aged 25-50years of both genders who underwent MVR was selected and divided into two groups Group 1 (Respiratory Muscle Training Group) was received RMT consisting of 10-15 repetitions a day for 5days; for 3weeks. Whereas Group 2 (Conventional Group) was receive breathing exercise consisting of 10-12 repetitions a day for 5days; for 3weeks. Modified Healthy Heart Questionnaire (HHQ-GP-1) was used as screening tool. In outcome measuring tools Health Related Quality of life Questionnaire (EuroQol), New York Heart Association, was used at baseline, 3rd week and postoperatively. Duration of Postoperative Mechanical Ventilation (hours) and Hospital Stay was also noted as outcome measures of this study. Results obtained indicate that level of Self-Care in EuroQol-5-D-5L has improved in group 1 3.35±1.03 to 1.35±0.48 showing significant improvement similarly in case of Hospital Length of Stay, Mechanical ventilation 4.05±0.68 to 5.05±0.51 and Pain 65.25±8.34 to 71.50±6.70 has improved. It was concluded that Respiratory Muscle Training and Conventional Muscle Training both are effective in MVR patients. But RMT is more effective in improving self-care, reducing pain, Hospital Length of Stay and Mechanical Ventilation in postoperative period as compared to Conventional Muscle Treatment.

Mechanical versus Biological Valve Prostheses for Infective Endocarditis Presenting with Stroke.

Objectives: This study aimed to compare the clinical outcomes of mechanical and biological valve prostheses in patients with infective endocarditis presenting with stroke. Methods: Ninety-five adults with infective endocarditis complicated by stroke at baseline who underwent aortic and/or mitral valve replacement were analyzed retrospectively. The primary outcome was a composite outcome of all-cause mortality, ischemic stroke, hemorrhagic stroke, and re-endocarditis. Secondary outcomes included the individual components of the composite outcome and modified Rankin scale deterioration during follow-up. Results: Among the study cohort, 34 patients (35.8%) received mechanical valve prostheses and 61 (64.2%) received biological valve prostheses. Implantation of a mechanical valve prosthesis seems to be associated with a decreased risk of attaining the composite outcome (adjusted HR 0.46, 95% CI 0.22-0.96, and p = 0.037). Analyses of the individual components of the composite outcome showed that implantation of a mechanical valve prosthesis might not be associated with an increased risk of ischemic stroke, hemorrhagic stroke, and all-cause mortality during the follow-up period. Further, the risk of re-endocarditis was significantly lower in recipients of a mechanical valve prosthesis (adjusted HR 0.15, 95% CI 0.06-0.77, p = 0.026). Notably, a trend toward decreased risk of modified Rankin scale deterioration throughout the follow-up period was observed in this group (adjusted odds ratio 0.22, 95% CI 0.05-1.02, p = 0.053). Conclusions: Implantation of mechanical valve prostheses in patients presenting with infective endocarditis complicated by stroke seems to be beneficial in terms of a reduced risk of experiencing a composite outcome. Analyses of larger cohorts are required to validate our findings.

Comparison of Hemodynamic Performance, Three-Dimensional Flow Fields, and Turbulence Levels for Three Different Heart Valves at Three Different Hemodynamic Conditions.

The hemodynamic performance of different prosthetic heart valves is difficult to compare among studies due to a variety of test conditions and experimental techniques. Existing studies are typically limited to one family of valves (biological or mechanical) and testing conditions of 5l/min and often lack sufficient spatial resolution. To address these limitations, a pulse duplicator with a multi-view imaging system (Tomo-PIV) was employed to investigate the three-dimensional flow field in the aortic root of three different valves: a tri-leaflet mechanical heart valve (TRIFLO, Novostia), a bi-leaflet mechanical heart valve (On-X, Artivion), and a biological heart valve (Perimount, Edwards Lifesciences). The valves were tested at low (3l/min), normal (5l/min), and elevated (7l/min) cardiac output under hypotensive (40/60mmHg), normotensive (80/120mmHg), and moderate hypertensive (105/170mmHg) pressure conditions, respectively. Compared to the Perimount, peak mean velocity was - 33%, - 24%, - 18% for the TRIFLO and - 32%, - 20%, - 11% for the On-X at low, moderate, and elevated , respectively. Corresponding peak values decreased by - 66%, - 57%, - 44% (TRIFLO) and - 60%, - 50%, - 36% (On-X). At low , was lower for Perimount (1.07cm2) than for TRIFLO (1.47cm2) and On-X (1.52cm2), while it increased for elevated to 2.75cm2 (TRIFLO) and 2.16cm2 (Perimount and On-X). For all valves, increasing led to increased flow velocities, higher and higher levels of turbulence, and the spatial influence of the valve on the flow field in the ascending aorta was extended. peaked closer to the STJ than for TRIFLO and Perimount.

Comparison of four aortic bioprostheses: Hancock II vs. St Jude Trifecta vs. Carpentier-Edwards Perimount Magna vs. Magna Ease-mid-term results (COMPARE SAVR study).

In the era of percutaneous aortic valve implantation, biological valves are the preferred prostheses implanted in patients undergoing surgical aortic valve replacement (sAVR). The aim was to present a real-life analysis of mid-term sAVR outcomes for the four aortic bioprostheses: the Hancock II, the Carpentier-Edwards Perimount Magna, the Carpentier-Edwards Perimount Magna Ease and the Trifecta valve. This is a retrospective study based on data from the Polish National Cardiac Surgery Database. The study population comprised of 1,589 consecutive patients, of whom 432 were in the Hancock II group, 356 in the Carpentier-Edwards Perimount Magna group, 427 in the Carpentier-Edwards Magna Ease group, and 374 in the Trifecta group. A comparison of the four groups was performed using analysis of variance (ANOVA) or Kruskal-Wallis test with appropriate post hoc tests (Tukey HSD or Steel-Dwass, respectively). Patients in the Hancock II group were older, had higher New York Heart Association (NYHA) and Canadian Cardiovascular Society (CCS) classes, had lower prevalence of hypertension and hyperlipidemia but higher prevalence of diabetes. The lowest mean valve size was observed in Trifecta group and the highest was in the Magna group (P<0.001). Survival analysis showed no significant differences in in-hospital mortality: 3.9% in Hancock II, 3.1% in Perimount, 3.3% in Magna and 2.1% in Trifecta group. Five-year mortality was significantly higher in Hancock II group (25.7%) compared to the other bioprostheses: 12.1% in Perimount, 9.1% in Magna and 10.70% in Trifecta group respectively. The 5-year mortality rate was significantly higher in the Hancock II group compared to the other bioprostheses. In contrast, Trifecta, Perimount Magna, and Magna Ease had similar 5-year mortality rates.

TREATMENT OF SEVERE AORTIC STENOSIS IN PATIENTS WITH LOW SURGICAL RISK

Following the first implantation of a percutaneous valve in 2002, two of the leading manufacturers of biological valve prostheses developed percutaneous aortic platforms, which have promoted transcatheter aortic valve implantation (TAVI) as an alternative to surgical aortic valve replacement (SAVR). In the last decade, both companies have funded six randomized studies grouping patients according to surgical risk and comparing the results between the two therapies. None of these studies has demonstrated the superiority of one technique over the other in terms of 5-year mortality. In general, patients who received percutaneous valves suffered a higher incidence of the need for pacemaker implantation, perivalvular leaks, and vascular complications, while surgical patients suffered more bleeding and atrial fibrillation. Following these results, the use of TAVI in young and low-risk patients has exponentially increased.

Fluid-Solid Interaction Analysis for Developing In-Situ Strain and Flow Sensors for Prosthetic Valve Monitoring.

Transcatheter aortic valve implantation (TAVI) was initially developed for adult patients, but there is a growing interest to expand this procedure to younger individuals with longer life expectancies. However, the gradual degradation of biological valve leaflets in transcatheter heart valves (THV) presents significant challenges for this extension. This study aimed to establish a multiphysics computational framework to analyze structural and flow measurements of TAVI and evaluate the integration of optical fiber and photoplethysmography (PPG) sensors for monitoring valve function. A two-way fluid-solid interaction (FSI) analysis was performed on an idealized aortic vessel before and after the virtual deployment of the SAPIEN 3 Ultra (S3) THV. Subsequently, an analytical analysis was conducted to estimate the PPG signal using computational flow predictions and to analyze the effect of different pressure gradients and distances between PPG sensors. Circumferential strain estimates from the embedded optical fiber in the FSI model were highest in the sinus of Valsalva; however, the optimal fiber positioning was found to be distal to the sino-tubular junction to minimize bending effects. The findings also demonstrated that positioning PPG sensors both upstream and downstream of the bioprosthesis can be used to effectively assess the pressure gradient across the valve. We concluded that computational modeling allows sensor design to quantify vessel wall strain and pressure gradients across valve leaflets, with the ultimate goal of developing low-cost monitoring systems for detecting valve deterioration.

Mitral valve replacement in young patients: review and current challenges.

Mitral valve repair is the ideal intervention for mitral valve disease with excellent long-term survival comparable to the age-matched general population. When the mitral valve is not repairable, mechanical prostheses may be associated with improved survival as compared with biological prostheses. Newer mechanical and biological valve prostheses have the potential to improve outcomes following mitral valve replacement in young patients. Patients presenting for mitral valve surgery after failed transcatheter mitral valve-in-valve have high rates of postoperative mortality and morbidity, exceeding those seen with reoperative mitral valve surgery, which poses issues in young patients who have a higher cumulative incidence of reintervention.

Mechanical versus biological mitral valve replacement: Insights from propensity score matching on survival and reoperation rates

ObjectivesPatients with symptomatic mitral valve disease unsuitable for repair can be sufficiently treated with surgical mitral valve replacement. The decision between biological and mechanical mitral valve replacement can be difficult, especially due to the question of the lesser of 2 evils: anticoagulation versus reoperation. MethodsThis single-center, retrospective study included all patients undergoing mitral valve replacement between 2001 and 2020. Thirty-day mortality and periprocedural complications were analyzed. Propensity score matching adjusted for age, gender, weight, height, endocarditis, diabetes, hypertension, peripheral arterial occlusive disease, atrial fibrillation, chronic kidney disease, cancer, and history of neurological disorders was performed. After propensity score matching, survival and cumulative incidence of reoperation at time of follow-up were analyzed. ResultsThe study included 2027 patients in 2 main groups: 1658 patients with biological mitral valve replacement and 369 patients with mechanical mitral valve replacement; 51.2% were male. Age at surgery was 65.9 ± 12.9 years. Median follow-up time was 6.83 years (interquartile range, 1.11-10.61 years). Concomitant procedures were performed in 1467 cases (72.4%). Propensity score matching yielded comparable groups of 339 pairs. Both groups showed comparable survival (P = .203). Survival after mechanical mitral valve replacement and biological mitral valve replacement was comparable for all analyzed time points over the course of 20 years. Patients with mechanical mitral valve replacement showed a significantly lower cumulative incidence for reoperation (20 years: 15% vs 59%, P < .001). ConclusionsFollow-up of 20 years at a high-volume center demonstrates comparable survival after mechanical or biological mitral valve replacement, whereas reoperation rates are significantly lower after mechanical mitral valve replacement.

Mechanical or biological prosthesis for aortic valve replacement in patients aged 45 to 74 years

ObjectiveThe selection of valve prostheses for patients undergoing surgical aortic valve replacement remains controversial. In this study, we compared the long-term outcomes of patients undergoing aortic valve replacement with biological or mechanical aortic valve prostheses. MethodsWe evaluated late results among 5762 patients aged 45 to 74 years who underwent biological or mechanical aortic valve replacement with or without concomitant coronary artery bypass from 1989 to 2019 at 4 medical centers. The Cox proportional hazards model was used to compare late survival; the age-dependent effect of prosthesis type on long-term survival was evaluated by an interaction term between age and prosthesis type. Incidences of stroke, major bleeding, and reoperation on the aortic valve after the index procedure were compared between prosthesis groups. ResultsOverall, 61% (n = 3508) of patients received a bioprosthesis. The 30-day mortality rate was 1.7% (n = 58) in the bioprosthesis group and 1.5% (n = 34) in the mechanical group (P = .75). During a mean follow-up of 9.0 years, the adjusted risk of mortality was higher in the bioprosthesis group (hazard ratio, 1.30, P < .001). The long-term survival benefit associated with mechanical prosthesis persisted until 70 years of age. Bioprosthesis (vs mechanical prosthesis) was associated with a similar risk of stroke (P = .20), lower risk of major bleeding (P < .001), and higher risk of reoperation (P < .001). ConclusionsCompared with bioprostheses, mechanical aortic valves are associated with a lower adjusted risk of long-term mortality in patients aged 70 years or less. Patients aged less than 70 years undergoing surgical aortic valve replacement should be informed of the potential survival benefit of mechanical valve substitutes.

Sex-specific aspects on prognosis after aortic valve replacement for aortic stenosis: a SWEDEHEART registry study

ObjectiveTo compare long-term cardiovascular (CV) outcomes between men and women with aortic stenosis (AS) undergoing aortic valve replacement (AVR) by the type of valve implant.MethodsThe study population consisted of 14...

Application of right ventricular to pulmonary valved conduit in the surgical treatment of congenital heart disease.

Pulmonary valve replacement and right ventricular outflow tract reconstruction with valved conduits have been the shortcomings of paediatric cardiac surgeons in the treatment of CHD. In recent decades, encouraging achievements have been made in right ventricular outflow tract technology. Since Klinner reported the first right ventricle-to-pulmonary artery connection using unvalved conduits made of autologous pericardium in 1964, various right ventricle-to-pulmonary artery conduits have gradually been used in the treatment of various complex CHD. Compared with other materials, valved homograft conduit (VHC) is more consistent with physiological characteristics, better haemodynamics, easy suture and good haemostasis, anti-calcification, anti-infection, and without the need for lifelong anticoagulation, which makes VHC the best material for reconstruction of right ventricular outflow tract. However, due to the shortage of donor sources, other alternative conduits such as polytetrafuoroethylene valved conduits have been developed, and the results are not inferior to VHC in clinical application. The emerging tissue engineering technology is expected to utilise recipient-derived endothelial cells for implantation onto the decellularized VHC or degradable synthetic materials in order to construct a recipient-specific tissue-engineered valved conduit. This advancement holds great potential as an ideal biological transplant material and valve replacement for CHD. It will completely solve the problems of immune rejection and the growth of the conduit that cannot adapt to the physical growth of children. This review provides a comprehensive review of the clinical indications for right ventricle-to-pulmonary artery conduits application, optimal timing for surgery, current practices in utilising various types of external conduits, and considerations for re-replacement.

Aortic valved homograft degeneration: surgical or transcatheter approach for repeat aortic valve replacement?

Aortic valved allografts (homografts) have been used alternatively to mechanical or biological valve prostheses in expectation of better durability; however, homograft valves do degenerate, and redo procedures have proven challenging due to heavy wall calcification. The aim of the study was to compare the outcome of open surgical (SAVR) and transcatheter aortic valve replacement (TAVR) in degenerated homografts. Between 1993 and 2022, 81 patients underwent repeat aortic valve procedures having previously received an aortic homograft. The redo had become necessary due to regurgitation in 85% and stenosis in 15%. Sixty-five percent underwent open surgery, 35% TAVR. Isolated SAVR was possible in 79%, and root procedures were necessary in 21%. TAVR was performed in 79% via transfemoral and 21% via transapical access. Median prosthetic valve size was 23 (22.3-23.2) mm in the SAVR and 26 (25.2-26.9) in the TAVR group. Thirty-day mortality was 0% in the TAVR and 7% in the SAVR group (P = n.s.). TAVR showed a significantly better outcome concerning prolonged ventilation (0 vs 21%, P = 0.013) as well as ICU (1 vs 2 days; P < 0.001) and in-hospital stay (10.5 vs 13 days; P = 0.028). Five-year survival was statistically comparable between groups, and no severe leakage was observed. SAVR following structural homograft degeneration shows acceptable results, but the perioperative risk remains substantial and poorly predictable. TAVR presents a reasonable and more easily accessible alternative and is associated with good short- and mid-term results. In the absence of relevant contraindications, TAVR is presently the preferred treatment option for these patients at our center.