Bioprosthetic Aortic Valve Replacement Research Articles

Hemodynamic outcomes of the Ross procedure versus other aortic valve replacement: a systematic review and meta-analysis.

Life expectancy in young adults undergoing mechanical or bioprosthetic aortic valve replacement (AVR) may be reduced by up to 20 years compared to age matched controls. The Ross procedure is a durable, anticoagulation-sparing alternative. We performed a systematic review and meta-analysis to compare the valve hemodynamics of the Ross procedure versus other AVR. We searched Cochrane CENTRAL, MEDLINE and EMBASE from inception to February 2017 for randomized controlled trials (RCTs) and observational studies (n≥10 Ross). Independently and in duplicate, we performed title and abstract screening, full-text eligibility assessment, and data collection. We evaluated the risk of bias with the Cochrane and CLARITY tools, and the quality of evidence with the GRADE framework. We identified 2 RCTs and 13 observational studies that met eligibility criteria (N.=1412). In observational studies, the Ross procedure was associated with a lower mean aortic gradient at discharge (MD -9 mmHg, 95% CI: -13 to -5, P<0.0001, I2=97%) and latest follow-up (MD -5 mmHg, 95% CI: -7 to -3, P<0.0001, I2=92%). There was no significant difference in the incidence of severe aortic regurgitation at latest follow-up (RR 1.3, 95% CI: 0.3 to 5.8, P=0.70, I2=30%). In RCTs, the Ross procedure was associated with a lower mean gradient at latest follow-up (MD -15 mmHg, 95% CI: -32 to 2, P=0.08, I2=99%). The mean pulmonic gradient for the Ross procedure was 18.0 mmHg (95% CI: 16 to 20, P<0.0001) at latest follow-up. The evidence for all outcomes from observational studies was deemed to be of very low quality, while the evidence from RCTs was downgraded for imprecision and moderately serious risk of bias. Compared to conventional AVR, the Ross procedure was associated with better aortic valve hemodynamics. Future studies should evaluate the impact of the Ross procedure on exercise capacity and quality of life.

Repair of Gerbode Defect Following Bioprosthetic Aortic Valve Replacement and Left Ventricular Outflow Myomectomy

Repair of Gerbode Defect Following Bioprosthetic Aortic Valve Replacement and Left Ventricular Outflow Myomectomy

Rest and exercise haemodynamics in patients with one of two stented bioprostheses and in healthy controls with small aortic annuli.

Because bioprosthetic aortic valve replacement remains one of the most frequent cardiac surgical procedures, it is necessary to study patient haemodynamics in more detail. Until now, a few studies assessed haemodynamics during exercise, but none with special regard to small aortic annuli. We compared patients who had the differently designed bioprostheses, Trifecta and Perimount Magna Ease (PME), size ≤ 23 mm, and a healthy control group during rest and exercise. We determined the mean transvalvular gradient, the effective orifice area (EOA) and the EOA index during rest and exercise using transthoracic echocardiography in 35 patients with the Trifecta (mean age 71.4 years, follow-up 1 year, labelled valve size 21.7 mm), in 16 patients with the PME (mean age 66.2 years, follow-up 2.6 years, labelled valve size 21.6 mm) and in 25 healthy persons. The parameters derived were summarized in a simplified Valve Academic Research Consortium-2 classification to determine prosthetic valve dysfunction. When we compared the Trifecta and the PME, a significant superiority of the Trifecta was seen at rest in mean transvalvular gradient (7.96 vs 12.19 mmHg) and EOA (1.57 vs 1.48 cm2), during exercise in all parameters (mean transvalvular gradient 11.06 vs 19.2 mmHg, EOA 1.77 vs 1.26 cm2, EOA index 0.96 vs 0.67 cm2/m2). The Trifecta showed a physiological increase in the EOA index during exercise. Exercise led to a shift to better simplified Valve Academic Research Consortium-2 categories in the Trifecta and to worse in the PME group. This study reveals the haemodynamic superiority of the Trifecta to the PME. Especially in small aortic annuli, this difference might have some relevance for clinical and research issues.

TCT-51 Impact of anticoagulation therapy on valve hemodynamics and clinical outcomes after bioprosthetic aortic valve replacement: A pooled analysis of the PARTNER2 trials

TCT-51 Impact of anticoagulation therapy on valve hemodynamics and clinical outcomes after bioprosthetic aortic valve replacement: A pooled analysis of the PARTNER2 trials

THE DIFFERENTIAL IMPACT AND LONG-TERM EFFECTS OF MECHANICAL OR BIOLOGICAL VALVE REPLACEMENTS IN MEDICARE PATIENTS ON HEMODIALYSIS

Hemodialysis patients have increased risk for valve replacement and have decreased long-term survival. Debate is ongoing regarding biologic versus mechanical valve replacements in hemodialysis patients. This study sought to investigate the differential impact of biological and mechanical valves on aortic valve replacement (AVR) and mitral valve replacement (MVR) Medicare patients on hemodialysis. Medicare Provider Analysis and Review (MEDPAR) Files were used to identify all hemodialysis patients undergoing aortic valve replacement (AVR) and mitral valve replacement (MVR) between January 2008 and December 2013. Patients were separated based on the use of either bioprosthetic or mechanical valves. Comorbidities present on implantation were assigned using ICD-9 codes and a modified Elixhauser comorbidity index. Propensity matching was used to analyze bioprosthetic and mechanical valves in AVR and MVR patients. Univariate and multivariate models were used to examine survival; all other analyses were conducted using pearson’s chi-square or independent-sample t tests. A total of 11,850 patients were initially included in the study (8775 AVR and 4298 MVR). In propensity matched samples, Kaplan Meier survival analysis indicates that survival was significantly higher in mechanical AVR patients compared to prosthetic AVR patients, although similar between mechanical and prosthetic MVR patients (Figure 1). Overall AVR mortality was significantly lower than MVR mortality (58% vs. 66%, p < 0.01). Bioprosthetic AVR patients were more likely to require redo operations compared to mechanical AVR (2% vs. 1%, p < 0.01). Multivariate logistic regression models indicate that mechanical valves do not provide a protective effect for 30 day mortality in either AVR or MVR patients. Cox proportional models indicate that mechanical valves may provide some protective effect in long-term mortality for AVR patients (HR 0.94 CI 0.88 - 1.02, p=0.05). These results indicate that there is no significant difference in survival or redo operation between bioprosthetic and mechanical valves in MVR patients. However, bioprosthetic AVR patients are significantly more at risk for death or redo operations. It is possible that mechanical AVR offers a long-term survival benefit to older patients on hemodialysis undergoing valve replacement surgery.

Bioprosthetic aortic valve replacement: Revisiting prosthesis choice in patients younger than 50 years old

ObjectiveAortic prosthesis choice is controversial in young adults because robust comparative outcome data are lacking. We therefore compared mortality and morbidity in young adults after bioprosthetic versus mechanical aortic valve replacement. MethodsThis was a retrospective analysis of 5111 patients aged 18 to 50 years undergoing primary aortic valve replacement in California and New York State from 1997 to 2006. Median follow-up time was 11.8 years (maximum 18.9 years). The primary endpoint was mortality; secondary endpoints were stroke, bleeding, and reoperation. Propensity score matching yielded 1175 patient pairs. ResultsBioprosthetic valves increased from 14% to 47% of aortic valve replacements between 1997 and 2014 (P < .001). There was no survival difference with bioprosthetic versus mechanical aortic valves in the propensity score-matched cohort: actuarial 15-year survival was 79.0% (95% confidence interval [CI], 75.8%-81.8%) versus 81.5% (95% CI, 78.5%-84.2%) respectively (hazard ratio [HR], 1.14; 95% CI, 0.93-1.40, P = .20). No interaction was found between age and prosthesis choice on survival (Pinteraction = 0.16). After bioprosthetic valve replacement, stroke rates were lower (5.4% [95% CI, 3.8%-7.2%] vs 8.1% [95% CI, 6.3%-10.2%], HR 0.62 [95% CI 0.43-0.91]), bleeding rates were lower (4.2% [95% CI, 3.0-5.6%] vs 8.4% [95% CI, 6.6-10.4%], HR 0.48 [95% CI, 0.33-0.69]), but reoperation rates were greater (24.5% [95% CI, 21.3%-27.8%] vs 9.3% [95% CI, 7.2%-11.7%], HR 5.9 [95% CI 3.2-11.0]) at 15 years versus mechanical valve replacement. ConclusionsAlthough lifetime risks are represented incompletely, these findings suggest that in adults aged 18-50 years, bioprostheses are a reasonable alternative to mechanical valves for aortic valve replacement.

P3271The impact of warfarin on the long term survivals of patients undergoing bioprosthetic aortic valve replacement

P3271The impact of warfarin on the long term survivals of patients undergoing bioprosthetic aortic valve replacement

P2997Prophylactic antiplatelet therapy is superior to anticoagulation after surgical bioprosthetic aortic valve replacement: a meta-analysis and meta-regression

P2997Prophylactic antiplatelet therapy is superior to anticoagulation after surgical bioprosthetic aortic valve replacement: a meta-analysis and meta-regression

Long-term follow-up of bioprosthetic aortic valve replacement in patients aged ≤60 years

ObjectiveTo address the long-term durability of bioprostheses used for aortic valve replacement (AVR) in adult patients aged ≤60 years at the time of surgery. MethodsThrough a retrospective review of a prospectively collected database, we identified 416 bioprosthetic AVRs performed between 1977 and 2013. A prospective follow-up of valve-related and non–valve-related events was performed. ResultsFollow-up was 98.5% complete (2423.1 patient-years; average, 6 ± 5.5 years). At 15 years, overall survival was 62.1 ± 4.4%; freedom from valve-related death was 97.1 ± 1.6%. There were 68 SVD events (11.9 ± 28.8 years after surgery). Freedom from SVD at 15 years was 48.7 ± 5.5% for Kaplan-Meier analysis and 61.4 ± 4.3% for competing-risks analysis. After stratification into age subgroups (<40 years, ≥40 and <50 years, and ≥50 and ≤60 years), we observed no significant difference in freedom from SVD (P = .50). The average delay to SVD was not statistically different among subgroups (P = .30). There were 57 reoperations for SVD (11.8 ± 5.2 years after implantation). The 15 year freedom from reoperation for SVD was 55.4 ± 5.6% by Kaplan-Meier analysis and 67.1 ± 4.2% by competing-risks analysis. After stratification by age, freedom from reoperation for SVD was comparable (P = .13). Freedom from any valve-related complication or death was 42 ± 5% by Kaplan-Meier analysis and 54.4 ± 4.1% by competing-risks analysis. ConclusionsThe lifetime risk of SVD is considerable in patients aged ≤60 years at the time of bioprosthesis implantation. Nonetheless, durability remains consistent during the first decade; additional data are required for the second decade. Patients' information is pivotal for valve choice (competing-risks method).

Incremental Prognostic Use of Left Ventricular Global Longitudinal Strain in Asymptomatic/Minimally Symptomatic Patients With Severe Bioprosthetic Aortic Stenosis Undergoing Redo Aortic Valve Replacement.

With improved survival of patients undergoing primary bioprosthetic aortic valve replacement (AVR), reoperation to relieve severe prosthetic aortic stenosis (PAS) is increasing. Timing of redo surgery in asymptomatic/minimally symptomatic patients remains controversial. Left ventricular (LV) global longitudinal strain (GLS) is a marker of subclinical LV dysfunction. In asymptomatic/minimally symptomatic patients with severe PAS undergoing redo AVR, we sought to determine whether LV-GLS provides incremental prognostic use. We studied 191 patients with severe bioprosthetic PAS (63±16 years, 58% men) who underwent redo AVR between 2000 and 2012 (excluding mechanical PAS, severe other valve disease transcatheter AVR, and LV ejection fraction <50%). Society of Thoracic Surgeons score was calculated. Standard echocardiography data were obtained. LV-GLS was measured on 2-, 3-, and 4-chamber views using velocity vector imaging. Severe PAS was defined as aortic valve area <0.8 cm2, mean aortic valve gradient ≥40 mm Hg, and dimensionless index <0.25. A composite outcome of death and congestive heart failure admission was recorded. At baseline, mean Society of Thoracic Surgeons score, LV ejection fraction, mean aortic valve gradients, and right ventricular systolic pressure were 7±6, 58±6%, 54±10 mm Hg and 40±14 mm Hg, whereas 50% had >2+ aortic regurgitation. Median LV-GLS was -14.2% (-11.4, -17.1%). At 4.2±3 years, 41 (22%) patients met the composite end point (2.5% deaths and 1% strokes at 30 days postoperatively). On multivariable Cox survival analysis, LV-GLS was independently associated with longer-term composite events (hazard ratio, 1.21; 95% confidence interval, 1.10-1.33), P<0.01. The C statistic for the clinical model (Society of Thoracic Surgeons score, degree of aortic regurgitation, and right ventricular systolic pressure) was 0.64 (95% confidence interval 0.54-0.79), P<0.001. Addition of LV-GLS to the clinical model increased the C statistic significantly to 0.71 (95% confidence interval 0.58-0.81), P<0.001. In asymptomatic/minimally symptomatic patients with severe bioprosthetic PAS undergoing redo AVR, baseline LV-GLS provides incremental prognostic use over established predictors and could potentially aid in surgical timing and risk stratification.

Helcococcus kunzii prosthetic valve endocarditis secondary to lower extremity cellulitis

An 88-year-old man with history of bioprosthetic aortic valve replacement was hospitalised with fever, chills, malaise and right lower extremity cellulitis. Laboratory investigations revealed leucocytosis and blood cultures grew Helcococcus...

Mechanical versus bioprosthetic aortic valve replacement.

Mechanical valves used for aortic valve replacement (AVR) continue to be associated with bleeding risks because of anticoagulation therapy, while bioprosthetic valves are at risk of structural valve deterioration requiring reoperation. This risk/benefit ratio of mechanical and bioprosthetic valves has led American and European guidelines on valvular heart disease to be consistent in recommending the use of mechanical prostheses in patients younger than 60 years of age. Despite these recommendations, the use of bioprosthetic valves has significantly increased over the last decades in all age groups. A systematic review of manuscripts applying propensity-matching or multivariable analysis to compare the usage of mechanical vs. bioprosthetic valves found either similar outcomes between the two types of valves or favourable outcomes with mechanical prostheses, particularly in younger patients. The risk/benefit ratio and choice of valves will be impacted by developments in valve designs, anticoagulation therapy, reducing the required international normalized ratio, and transcatheter and minimally invasive procedures. However, there is currently no evidence to support lowering the age threshold for implanting a bioprosthesis. Physicians in the Heart Team and patients should be cautious in pursuing more bioprosthetic valve use until its benefit is clearly proven in middle-aged patients.

Biyoprotez Aort Kapak Replasmanı Sonrası Görülebilen Trombositopeni ve İlişkili Komplikasyonların Değerlendirilmesi

Introduction: We aimed to determine whether thrombocytopaenia (TCP) is associated with postoperative complications in patients undergoing bioprosthetic aortic valve replacement. Patients and Methods: Clinical records of 39 consecutive patients undergoing bioprosthetic aortic valve replacement for aortic stenosis were reviewed. Patients were divided into 2 groups based on whether they had TCP or not within 7 days after the operation [TCP (+), 9 patients and TCP (-), 30 patients]. TCP was defined as a platelet count less than 50 × 109/L. Results: Both the groups were similar with regard to baseline clinical characteristics and operative variables. Stentless bioprosthesis was used in 16 patients (41.02%). The use of Sorin Pericarbon Freedom was significantly more common in the TCP (+) group. Postoperative complications such as the removal time of the drainage tube, intensive care unit (ICU) stay and acute renal failure were significantly higher in the TCP (+) group. Overall, 30-day mortality occurred in 3 (7.7%) patients, and the difference between the groups was not statistically significant. Conclusion: Postoperative TCP may be associated with a substantial threat for the postoperative status of patients undergoing bioprosthetic valve replacement. The issue is still subject to further research until the exact mechanism underlying its occurrence is elucidated.

Bioprosthetic surgical and transcatheter heart valve thrombosis

Excellent outcomes of transcatheter aortic valve replacement (TAVR) have been experienced by patients with aortic stenosis at high and intermediate risk of surgery. 1 Vahl TP Kodali SK Leon MB Transcatheter aortic valve replacement 2016: a modern-day “Through the Looking-Glass” adventure. J Am Coll Cardiol. 2016; 67: 1472-1487 Crossref PubMed Scopus (106) Google Scholar Findings from large randomised trials 1 Vahl TP Kodali SK Leon MB Transcatheter aortic valve replacement 2016: a modern-day “Through the Looking-Glass” adventure. J Am Coll Cardiol. 2016; 67: 1472-1487 Crossref PubMed Scopus (106) Google Scholar , 2 Dangas GD Weitz JL Giustino G Makkar R Mehran R Prosthetic heart valve thrombosis. J Am Coll Cardiol. 2016; 68: 2670-2689 Crossref PubMed Scopus (225) Google Scholar have shown survival with TAVR that is similar to or improved compared with bioprosthetic surgical aortic valve replacement (SAVR), and very low stroke rates have been observed with new-generation devices. Investigators of echocardiographic follow-up studies 3 Daubert MA Weissman NJ Hahn RT et al. Long-term valve performance of TAVR and SAVR: a report from the PARTNER I trial. JACC Cardiovasc Imaging. 2017; 10: 15-25 Crossref Scopus (73) Google Scholar have consistently reported low transvalvular gradients up to 5 years after TAVR and SAVR, with slightly greater aortic valve areas after TAVR than after SAVR. Against this background, the occurrence of subclinical valve leaflet thrombosis in patients, detected with CT after TAVR or SAVR, has been described. 4 Makkar RR Fontana G Jilaihawi H et al. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. N Engl J Med. 2015; 373: 2015-2024 Crossref PubMed Scopus (736) Google Scholar Subclinical leaflet thrombosis in surgical and transcatheter bioprosthetic aortic valves: an observational studySubclinical leaflet thrombosis occurred frequently in bioprosthetic aortic valves, more commonly in transcatheter than in surgical valves. Anticoagulation (both NOACs and warfarin), but not dual antiplatelet therapy, was effective in prevention or treatment of subclinical leaflet thrombosis. Subclinical leaflet thrombosis was associated with increased rates of TIAs and strokes or TIAs. Despite excellent outcomes after TAVR with the new-generation valves, prevention and treatment of subclinical leaflet thrombosis might offer a potential opportunity for further improvement in valve haemodynamics and clinical outcomes. Full-Text PDF

STATINS USE AND LONG TERM OUTCOME POST SURGICAL AORTIC VALVE REPLACEMENT

Background: Statins have been shown to be beneficial after coronary artery bypass grafting. However, the association between statin use and long term outcomes after surgical bioprosthetic aortic valve replacement are conflicting. Methods: Consecutive patients (n = 429) who underwent surgical

Long-Term Outcomes for Patients Receiving Consecutive Bioprosthetic Aortic Valve Replacement

Background: Worldwide there's increased use of bio-prosthetic valves in the aortic position. Part of this increase has been patient driven for quality of life reasons. More recently, bio-prosthetic valves are chosen by progressively younger patients with the strategy to perform a valve-in-valve TAVI if they should wear out. Therefore, we reviewed our experience with patients whose first two aortic valve replacements (AVR) were with bio-prosthetic valves. Methods: Patients receiving consecutive bio-prosthetic AVR performed by the Green Lane Cardiothoracic Surgical Unit were identified from a departmental database. Data was retrieved from prospective databases, electronic and archived clinical records. Outcomes of interest were overall survival and freedom from third or more AVR. Results: 267 patients met inclusion criteria with a mean follow-up of 22.3 years. Concurrent procedures (CABG etc.) were performed in 65.2% of patients that underwent two bio-prosthetic AVR and 79.8% of patients undergoing three or more bio-prosthetic AVR. Median survival of the cohort was 31.7 years. Age at operation was the best predictor of needing a third or more AVR. ROC analysis identifies that being younger than 45 at first operation and 56 at second operation as the optimal cut-off point for likelihood of needing a third or more aortic valve intervention. Conclusion: Overall survival for consecutive bio-prosthetic AVR is remarkably good. Data on consecutive bio-prosthetic AVR is of particular relevance to the evolution of TAVI and valve-in-valve TAVI. However, it must be noted that the majority of patients in this cohort required concurrent cardiac surgical procedures. This study provides encouraging data for consecutive bio-prosthetic AVR and data that may be applicable in the setting TAVI being performed in younger cohorts of patients.

Bioprosthetic Mitral Valve Leaflet Thrombosis, Novel Oral Anticoagulants a Potential Solution for a Sticky Problem

A 52-year-old female presented with NYHA class III dyspnoea on a background of a previous bioprosthetic mitral valve replacement. This was inserted five years previously for severe mitral regurgitation secondary to anthracycline cardiomyopathy. The patient had declined a mechanical valve prosthesis. Transoesophageal echocardiography demonstrated restricted leaflet motion, and confirmed severe stenosis of the bioprosthetic mitral valve with a mean gradient of 12 mmHg across the valve. Coronary angiogram did not reveal significant coronary disease and after heart team discussion the patient was referred for a re-do mechanical mitral valve replacement. Whilst awaiting surgery apixaban was prescribed for a deep vein thrombosis and co-existent paroxysmal atrial fibrillation. A repeat transoesophageal echocardiogram performed on table pre-sternotomy two months later revealed normal bioprosthetic valve function with appropriate leaflet excursion and a mean gradient of 3 mmHg across the valve. The patient's symptoms had improved during the anticoagulation period. Bioprosthetic valve leaflet thrombosis (BVLT) has been reported post transcatheter and surgical bioprosthetic aortic valve replacements. This clinical vignette highlights the importance of recognising BVLT in the months and years post implantation. The case also demonstrates a potential role for novel oral anticoagulants in treating this condition. Future studies are required to determine risk factors for BVLT and optimal treatment methods.

Antithrombotic therapy after bioprosthetic aortic valve implantation: Warfarin versus aspirin, a randomized controlled trial

BackgroundThe optimal medical strategy for prevention of thromboembolic events after surgical bioprosthetic aortic valve replacement (BAVR) is still debated. The objective of this study was to compare warfarin therapy (target INR of 2.0 to 3.0) with aspirin 150mg daily as antithrombotic therapy for the first three months after BAVR with or without concomitant coronary artery bypass grafting (CABG). The aim was to evaluate thromboembolic complications, major bleeding complications and death. Materials and methodsProspective, single-centre, open-label, randomized controlled trial. 370 patients were enrolled, 328 were available for data analysis. ResultsAt baseline the warfarin and aspirin groups were comparable. Thromboembolic events were comparable between groups 11 (6.6%) vs. 12 (7.5%), p=0.83. Major bleeding events occurred numerically more often in warfarin patients 9 (5.4%) vs. 3 (1.9%), p=0.14. Warfarin was in multivariate analysis significantly associated with major bleeding OR 5.18 (CI 1.06–25.43), p=0.043. 90-day mortality was comparable between groups 8 (4.7%) vs. 6 (3.7%), p=0.79. ConclusionsOur results suggest that aspirin might be equally effective as warfarin in preventing thromboembolic events after BAVR, but with less major bleedings. Although this is numerically the largest trial testing this hypothesis in a prospective randomized trial, further adequately powered studies are warranted.

Abstract 13161: Incremental Prognostic Utility of Left Ventricular Global Longitudinal Strain in Asymptomatic/minimally Symptomatic Patients With Severe Bioprosthetic Aortic Stenosis Undergoing Redo Aortic Valve Replacement

Introduction: With improved survival of patients undergoing primary bioprosthetic aortic valve replacement (AVR), reoperation to relieve severe prosthetic aortic stenosis (PAS) is increasing. Timing of redo surgery in asymptomatic/minimally symptomatic patients remains controversial. Left ventricular global longitudinal strain (LV-GLS) is a marker of subclinical LV dysfunction. In asymptomatic/minimally symptomatic patients with severe PAS undergoing redo AVR, we sought to determine if LV-GLS provides incremental prognostic utility. Methods: We studied 191 patients with severe bioprosthetic PAS (63±16 years, 58% men) who underwent redo-AVR between 2000-12 (excluding mechanical PAS, severe other valve disease transcatheter AVR, LV ejection fraction &lt;50%). Society of Thoracic Surgeons (STS) score was calculated. Standard echocardiography data was obtained. LV-GLS was measured on 2, 3 and 4-chamber views using Velocity Vector Imaging. Severe PAS was defined as AV area &lt;0.8 cm 2 , mean AV gradient ≥40 mm Hg and/or dimensionless index &lt;0.25. A composite outcome of death and congestive heart failure (CHF) admission was recorded. Results: At baseline, mean STS score, LV ejection fraction, mean AV gradients, right ventricular systolic pressure (RVSP) were 7±6, 58±6%, 54±10 mm Hg and 40±14 mm Hg, while 50% had &gt;II+ aortic regurgitation (AR). Median LV-GLS was -14.2% [-11.4, -17.1%]. At 4.2±3 years, 41 (22%) patients met the composite endpoint. The results of the multivariable Cox analysis are shown in Table 1. Kaplan-Meier survival curves separated based on median LV-GLS are shown in Figure 1. Incremental prognostic utility of LV-GLS over established predictors is shown in Figure 2. Conclusions: In asymptomatic/minimally symptomatic patients with severe bioprosthetic PAS undergoing redo AVR, baseline LV-GLS provides incremental prognostic utility over established predictors; and could potentially aid in surgical timing and risk stratification.

346 - Patients with Prosthetic Valves and Need for Left Ventricular Assist Device

Introduction: The use of left ventricular assist device (LVAD) in patients with prosthetic valves has been a subject of debate. The risk of thromboembolic (TE) events remains a concern especially if anticoagulation had to be interrupted in case bleeding occurs. Case Report: We report a case of a 63-year-old female with end-stage heart failure awaiting a heart transplant. She was admitted to the hospital for worsening chronic heart failure and was inotrope dependent. While awaiting heart transplant, a decision was made to implant a left ventricular assist device (LVAD) as a bridge to transplant. She had a mechanical mitral valve (mMVR) which was exchanged to a bioprosthetic valve at the time of LVAD implantation. Post-operative course was complicated by bleeding while she was on anticoagulation but she survived. Objectives and methods: We searched PubMed for case studies of patients with LVAD having bioprosthetic valves. We found retrospective studies and case reports from 1982 to 2010 on patients with LVAD and prosthetic valves. Only patients with permanent LVAD were analyzed (n = 37). These patients were further subgrouped into bioprosthetic mitral valve replacement (bMVR) and aortic valve replacement (bAVR); mechanical mitral valve replacement (mMVR) and aortic valve replacement (mAVR); and combined mechanical and bioprosthetic MVR and AVR. Moreover, we analyzed different eras of anticoagulation. Outcomes analyzed were TE events, bleeding and death. Results: Majority patients were bridged to warfarin as their anticoagulation regimen. Nine patients with mMVR had a mean LVAD support time of 168.2 days. Four patients with bMVR had a mean LVAD support time of 229.6 days. No clinical TE events or bleeds were reported in both these subgroups. Seven patients with mAVR had a mean LVAD support time of 47.57 days. Thrombus was found in one of the explanted heart, but no clinical TE events were reported. One patient had bleed. Eight patients with bAVR had a mean support time of 223.7 days. Thrombus was found underneath the aortic valve of the explanted heart of one patient. No bleeding or clinical TE events were noted. In the combination group, mean LVAD support time was 96.3 days. One patient had a bleeding complication. One patient had a TE event. Overall mortality was high in all subgroups ranging from 25% to 37.5% unrelated to TE event or bleed. Conclusion: Our analysis showed no significant TE events or bleeding complications in these patients. LVAD in patients with pre-existing prosthetic valves is worth consideration given the shortage of heart donors. We prefer exchanging the mechanical valve to a bMVR as it carries a lesser risk of TE events. However, one should be mindful of the overall high mortality rate in these patients. Larger studies need to be conducted to confirm these findings.