Carpentier-Edwards Bioprosthesis Research Articles

26 Procedural planning and tip-to-base lampoon to succeed in a complex valve-in-valve TMVR procedure

Abstract Aims Left ventricle outflow tract (LVOT) obstruction is a feared complication of transcatheter mitral valve replacement (TMVR) procedures. Multimodal imaging evaluation is the key to identify at-risk patient and select the best management. Methods and results An 83-year-old woman with a history of mitral valve replacement with a 27-mm Carpentier-Edwards bioprosthesis (Edwards Lifesciences, Irvine, CA) for rheumatic heart disease was admitted to our department complaining worsening effort dyspnoea. Clinical evaluation revealed a grade 3/6 holosystolic murmur. She underwent combined transthoracic and transesophageal echocardiography (TEE) which demonstrated mitral bioprosthesis degeneration leading to severe stenosis (mean gradient = 13 mmHg, PHT-derived area = 0.9 cm2) and moderate regurgitation, with preserved biventricular function, and severe pulmonary hypertension (pulmonary artery systolic pression = 65 mmHg). The patient presented a high estimated risk for redo-surgery (Society of Thoracic Surgeons score estimated mortality: 6%) due to her complex medical history, including advanced chronic kidney disease and permanent atrial fibrillation; therefore, she underwent evaluation for valve-in-valve TMVR. Cardiac computed tomography (CT) revealed bioprosthetic anterior leaflet in tight contact with the septum in systole; predicted neo-LVOT using virtual 26-mm Sapien S3 (Edwards Lifesciences, Irvine, CA) valve was 150 mm2, conferring a high risk of fixed LVOTO. A 26-mm Sapien S3 valve was selected based on CT derived surgical valve ID of 24 mm. After Heart Team discussion, we performed a modified LAMPOON technique to achieve tip-to-base laceration of the bioprosthetic leaflet beside the LVOT, in order to prevent LVOT obstruction. Briefly, after transseptal puncture through right femoral vein access (16 Fr), we crossed the mitral prosthesis using a balloon wedge end-hole catheter, through which we advanced a 300 cm 0.014-inch wire into the ascending aorta, where it was snared from left arterial femoral access (8 Fr) and covered by a micro-catheter. The wire was previously kinked mid-shaft to form a ‘flying-V’ that was focally denuded and positioned at the target bioprosthetic leaflet’s tip using TEE and fluoroscopy. The guidewire was pulled toward the valve ring and electrified at 70 W with continuous 5% dextrose flush until adequate tip-to-base leaflet laceration. Thereafter, we successfully implant a 26-mm Sapien S3 valve. Maximal LVOT gradient post implant was 5 mmHg. The patient was discharged on post-operative day two and she recovered well, reporting functional and symptomatic improvement at 6-month follow-up. Conclusions our case highlights the importance of multimodality imaging and careful procedural planning to succeed even in complex valve-in-valve TMVR procedures. Transcatheter electrosurgery is an emerging tool for percutaneous structural heart interventions.

Percutaneous tricuspid valve-in-valve implantation in Ebstein's anomaly: One-year follow-up of valve function

A 39-year-old lady with Ebstein's anomaly presented with progressive exertional breathlessness (New York Heart Association functional class III). She was obese (body mass index 42kg/m2) and had undergone previous mechanical tricuspid valve replacement, followed by re-replacement at the age of 24years with a 31mm Carpentier-Edwards bioprosthesis. Cardiac catheterisation and echocardiography revealed restricted prosthetic leaflet excursion with moderate stenosis (mean pressure gradient 7mmHg), moderate-to-severe regurgitation, and mildly reduced right ventricular systolic function (peak tricuspid annulus systolic velocity by Doppler tissue imaging 0.08ms−1).

Failed valve-in-valve transcatheter mitral valve implantation

A 73-year old man underwent trans-septal anterograde implantation of a 26-mm Sapien-XT valve (Edwards Lifesciences, CA, USA) to treat a degenerated 27-mm Carpentier-Edwards bioprosthesis. During the follow-up, the patient experienced severe haemolysis with moderate-to-severe inter-valvular leak, and fluoroscopy revealed possible incomplete apposition of the Sapien-XT (Fig. 1). Reoperation was preferred and a mechanical 25 mm prosthesis implanted.

Balloon Valvuloplasty for Bioprosthetic Tricuspid Valve Stenosis

A 73-year-old woman was admitted to our hospital for a scheduled percutaneous transcatheter balloon valvuloplasty of a stenotic tricuspid bioprosthesis. The patient had a history consistent with exertional dyspnea, abdominal distension, and edema of the lower extremities resistant to diuretic treatment over the previous few months. Forty-three years prior, she underwent aortic valve replacement with a Starr-Edwards mechanical prosthetic valve, with a mean pressure gradient of 25 mm Hg, for aortic stenosis of rheumatic etiology (Fig. 1, white arrow). Furthermore, three years after aortic valve replacement the patient underwent mitral valve replacement with a bileaflet mechanical valve for mitral stenosis which had a stenotic portion (mean pressure gradient 10 mm Hg) (Fig. 1, black arrow), and tricuspid valve replacement with a Carpentier-Edwards bioprosthesis for tricuspid stenosis (Fig. 1, yellow arrow). On admission, the patient was on atrial fibrillation and physical examination was compatible with right heart failure. Echocardiography demonstrated severe tricuspid stenosis and a mild regurgitation. The mean diastolic gradient across the tricuspid valve was 15.4 mm Hg (Fig. 2A and B). Therefore, we proceeded to percutaneous valvuloplasty of the tricuspid valve using fluoroscopy, under regional anesthesia and sedation, inflating a 15×40-mm Inoue balloon up to a pressure of 15 atm (Fig. 1B).1),2) According to hemodynamic measurements, the gradient across the bioprosthetic tricuspid valve dropped from 13.0 mm Hg before to 6.0 mm Hg after dilation (Fig. 3), and on repeat echocardiography the mean diastolic gradient was decreased to 7.2 mm Hg without worsening of the regurgitation (Fig. 2C and D). The patient's symptoms soon improved; however, two months later she experienced a massive pulmonary hemorrhage while on heparin and acenocoumarol within therapeutic range, and died after a long hospitalization in the intensive care unit. Fig. 1 Fig. 2 Fig. 3

Systemic lupus erythrematosus; its implication in cardiac surgery: Institutional case report

Introduction Systemic lupus erythematosus (SLE) is an autoimmune disease that primarily affects young women. According to the literature, the prevalence of cardiovascular involvement in patients with systemic lupus erythematosus (SLE) has been estimated to be more than 50%. Valvular involvement is the most frequent cardiac manifestation in SLE. Functionally, valvular regurgitation hasbeen reported to occur in up to 74% of patients. Meanwhile valvular endocarditis is a frequent manifestation of SLE, and the mitral valve is most frequently affected. However, any valve or multivalvular affection may occur. Valvular lesions resulting from lupus can cause severe mitral regurgitation (MR). The most classic cardiac valvular abnormality in patientswith SLE is known as Libman–Sacks endocarditis, which consists of noninfective, verrucousvegetations(marantic endocarditis). They occur most frequently onthe mitral valve. Most of the valves that have vegetations are usually associated with diffuse thickeningor regurgitation. However, although cardiac involvement in patients with SLE has been recognized since the early 20th, But cardiac surgery was infrequently performed in patients with SLE, and its clinical outcome was reported only in small series. Also the impact of SLE on provision of anesthesia has never beeninvestigated, and the lack of evidence combined with theheterogeneity of disease manifestations makes it difficult toestablish definitive management protocols. That’s why, We herein describe a 22 years old female patient with SLE,with end stage renal diseaserequiring peritoneal dialysis. presented to our hospital (Al-Demerdash, Ain Shams University Hospital), with signsof congestiveheart failure such as dyspnea on exertion andorthopnea, paroxysmal nocturnal dyspnea, and fatigue, refractory to medical management.Her therapy for SLE required longterm prednisolonand hydroxychloroquine. Physical examination revealed no facial malar rash or generalized discoid rashes. The breath sounds were diminished at the lower lung zones. Cardiac auscultation showed regular heart beat with a heart rate of 102 beats/min, a grade III/VI systolic murmur at the left lower sternal border and the apex, and a pericardial friction rub. Palpation of the abdomen showed hepatomegaly. The extremities were notable for mild pitting edema. There was no clubbing, cyanosis or deformity of joints. Preoperative data Complete blood count revealed Hg 9.9 g/dl, WBC 11.100/ul, Platelet 247,000/ul. Bleeding Profile showed PT 16.4 sec, INR 1.45, PTT 44 sec. biochemistry work-up showed, Glucose 75 mg/dl, Creat 2.9 mg/dl with hemodialysis session, ALT 15U/l, AST 20U/l. Preoperative transesophageal Echocardiography showed: A large mass is attached to the atrial surface of the anterior mitral leaflet measuring 6 × 7 mm. the mass perforates the leaflet causing severe mitral regurgitation. And, another large mass measuring 6 × 9 mm attached to the non-coronary aortic valve cusp with 2 small masses attached to each of the other two leaflets causing severe aortic regurgitation.EF 60%,RVSP 50 mmHg. So the patient was scheduled for double valve replacement. Although valve repair and bioprosthetic valve replacement are not the best solution, since accelerated native valve and bioprosthetic valve calcification tend to occur because of the high calcium turnover. Also Porcine valves have become affected by valvulitiswith perforation of valve cusps. But, our cardiac surgical team decided to replace mitral and aortic valve with bioprothetic valve, as they believe that Anticoagulation may present higher risks in our young patient who require prolonged steroid use and who have end stage renal failure, the resultant dependence on dialysis. Also previous reports described patients with SLE who underwent mitral valve replacement, had a number of complications, and died secondary to anticoagulation. Also, because ofsuccessful placement of the porcine Carpentier-Edwards bioprosthesis in patients with SLE has been reported before. Finally weaning from cardiopulmonary bypass was uneventful (adrenaline 50 n/kg/min). The patient’s recovery from surgery was uncomplicated, and she was discharged on the 6th postoperative day. In conclusion, although the postoperative complication is common, cardiac operation could be performed in patients with SLE.

Transfemoral and Transseptal Valve-in-Valve Implantation Into a Failing Mitral Xenograft With a Balloon-Expandable Biological Valve

Valve-in-valve implantation for degenerated surgical bioprosthetic valves is becoming an increasingly accepted approach in selected high-risk patients. In the past, valve-in-valve implantations have been mainly performed in aortic position and only rarely in mitral position. We describe the case of an 81-year-old female patient with severe mitral regurgitation of a degenerated Carpentier-Edwards biological prosthesis treated by transfemoral and transseptal implantation of a SAPIEN-XT valve.

First Experience With Transcatheter Valve-In-Valve Implantation for a Stenotic Mitral Prosthesis Within the United States

A 72-year-old woman with coronary artery bypass graft surgery (CABG) with mitral valve replacement (MVR) using a 27-mm Carpentier-Edwards bioprosthesis (Edwards Lifesciences, Irvine, California) 6 years earlier was referred to our institution with severe, symptomatic prosthetic valve mitral stenosis

Energy Loss Due to Paravalvular Leak With Transcatheter Aortic Valve Implantation

Mild to moderate paravalvular leaks commonly occur after transcatheter aortic valve (TAV) implantation. Current TAVs match and may exceed hemodynamic performance of surgically implanted bioprostheses based on pressure gradient and effective orifice area. However, these hemodynamic criteria do not account for paravalvular leaks. We recently demonstrated that TAV implantation within 23 mm Perimount bioprostheses (Edwards Lifesciences, Irvine, CA) yields similar hemodynamics to the 23 mm Perimount valve. However, mild paravalvular leakage was seen after TAV implantation. The present study quantifies energy loss during the entire cardiac cycle to assess the impact of TAV paravalvular leaks on the ventricle. Four TAVs designed to mimic the 23 mm SAPIEN valve (Edwards Lifesciences) were created. Transvalvular energy loss of 19, 21, and 23 mm Carpentier-Edwards bioprostheses were obtained in vitro within a pulse duplicator as a hemodynamic baseline (n = 4). The 23 mm TAVs were subsequently implanted within the 23 mm bioprostheses to assess energy loss due to paravalvular leak. The 23 mm bioprosthesis demonstrated the least energy loss (213.25 +/- 31.35 mJ) compared with the 19 mm (330.00 +/- 36.97 mJ, p = 0.003) and 21 mm bioprostheses (298.00 +/- 37.25 mJ, p = 0.008). The TAV controls had similar energy loss (241.00 +/- 30.55 mJ, p = 0.17) as the 23 mm bioprostheses. However, after TAV implantation, total energy loss increased to 365.33 +/- 8.02 mJ significantly exceeding the energy loss of the 23 mm bioprosthesis (p < 0.001). Due to mild TAV paravalvular leakage, 39% of energy loss occurred during diastole. Substantial energy loss during diastole occurs due to TAV paravalvular leakage. In the presence of mild paravalvular leakage, TAV implantation imposes a significantly higher workload on the left ventricle than an equivalently sized surgically implanted bioprosthesis.

‘Valve-in-valve’ implantation in a patient with degenerated aortic bioprosthesis and severe regurgitation

A 70-year-old man was admitted due to dyspnoea (NYHA class III). In 1989, he underwent an aortic valve replacement using a Carpentier–Edwards bioprosthesis no. 21 and a left internal mammary artery–left anterior descending coronary bypass. In 2003, a laryngectomy and post-operative radiotherapy were performed because of laryngeal cancer. He then decided to stop smoking. …

Young Adult With Congenital Heart Disease Presenting With Anasarca

A 28-year-old man, diagnosed at birth with Ebstein’s anomaly, was admitted because of generalized edema. He had a history of successive tricuspid valve replacements. One year previously, a degenerated Carpentier-Edwards bioprosthesis had been replaced by a Bicarbon mechanical valve (Sorin Biomedica, Saluggia, Italy). Metallic heart sounds were absent. In addition to manifest peripheral edema, he had hepatomegaly and prominent jugular veins. He had severe hypoproteinemia (2.8 g/dL, normal 6.3–8.6 g/dL) and hypoalbuminemia (1.3 g/dL, normal 3.7–5.6 g/dL). Thorax radiograph demonstrated an enlarged right atrium, a hump-shaped infundibulum, and epicardial …

Aortic valve replacement in patients aged 50 to 70 years: Improved outcome with mechanical versus biologic prostheses

Improved durability of bioprostheses has led some surgeons to recommend biologic rather than mechanical prostheses for patients younger than 65 years. We compared late results of contemporary bioprostheses and bileaflet mechanical prostheses in patients who underwent aortic valve replacement between 50 and 70 years old. In this retrospective study, patients received either St Jude bileaflet valves or Carpentier-Edwards bioprostheses. Operations were performed between January 1991 and December 2000, and groups were matched one-to-one according to age, sex, need for coronary artery bypass grafting, and valve size. Four hundred forty patients were matched, and follow-up was 92% complete, with median durations of 9.1 years for patients who received mechanical valves and 6.2 years for patients who received bioprostheses. The 5- and 10-year unadjusted survivals were 87% and 68% for mechanical valves and 72% and 50% for bioprostheses, respectively (P < .01). Freedoms from reoperation at 10 years were 98% for mechanical valves and 91% for bioprostheses (P = .06). Rates of late stroke or other embolic events and of endocarditis were similar between groups. Hemorrhagic complications necessitating hospitalization occurred in 15% of patients with mechanical valves and 7% of patients with bioprostheses (P = .01). Notably, 19% of patients with bioprostheses were receiving warfarin sodium at last follow-up. After adjustment for unmatched variables, including diabetes, renal failure, lung disease, New York Heart Association functional class, ejection fraction, and stroke, the use of a mechanical valve was protective against late mortality (hazard ratio 0.46, P < .01). In this study, patients aged 50 to 70 years who underwent aortic valve replacement with mechanical valves had a survival advantage relative to matched patients who received bioprostheses. These findings question recommendations of bioprostheses for younger patients and suggest that a randomized trial may be warranted.

Percutaneous Transcatheter Balloon Valvuloplasty for Bioprosthetic Tricuspid Valve Stenosis

A 59-year-old woman was admitted to our hospital because of exertional dyspnea, abdominal distension, and leg edema over the past 2 weeks. She had a history of rheumatic fever at the age of 12 years. In 1983, at the age of 37, she had undergone tricuspid valve replacement with a Carpentier-Edwards bioprosthesis for tricuspid stenosis and mitral valve replacement with a mechanical valve for mitral stenosis. The physical examination on admission revealed marked edema in both legs. There was also presystolic pulsation of the liver, which was palpable 4 cm below the right costal margin. A Levine grade III/VI, rough, diastolic rumble at the lower left sternal border was accentuated during inspiration. Echocardiography revealed severe tricuspid stenosis and a large amount of ascites. The leaflets were thickened, …

15-Year Comparison of Supra-Annular Porcine and PERIMOUNT Aortic Bioprostheses

The second-generation Carpentier-Edwards bioprostheses, the supra-annular porcine valve and the PERIMOUNT pericardial valve, have been evaluated longitudinally for several years. This study compared clinical performance over 15 years. Aortic valve replacement was performed with a supra-annular porcine valve in 1,823 patients (group 1) aged 19-89 years (mean, 68.9 +/- 10.9 years) and with a PERIMOUNT pericardial bioprosthesis in 1,430 patients (group 2) aged 16-90 years (mean, 69.5 +/- 10.4 years). The groups were similar except for concomitant coronary artery bypass in 43% of group 1 and 18% of group 2 ( p < 0.001). Overall survival at 15 years was 29.3% +/- 1.5% for group 1 and 35.2% +/- 3.1% for group 2 ( p = 0.0009). The actual freedom from valve-related mortality was 88.5% +/- 0.9% for group 1 and 84.9% +/- 1.7% for group 2. The actual freedom from structural valve deterioration at 15 years was similar overall, and for patients aged > 60 years, between the groups, but was dissimilar (group 2 > group 1) for age </= 60 years. The predictors of structural valve deterioration were valve type (group 1 > group 2), sex (male > female), age, and concomitant coronary artery bypass. Both bioprostheses provided satisfactory clinical performance at 15 years after aortic valve replacement.

Percutaneous Closure of a Left Ventricular Free-Wall Rupture Site

An 86-year-old woman who lived independently was referred for consideration of percutaneous closure of a left ventricular free wall rupture site. Ten years earlier, she had undergone aortic valve replacement with a Carpentier-Edwards bioprosthesis (Edwards Lifesciences, Irvine, Calif) and received a single saphenous vein graft to the right coronary artery. Five years later, at the age of 81, she had an inferolateral myocardial infarction and an acute rupture of the left ventricular free wall. The resultant false …

Midterm results of aortic valve replacement with Carpentier-Edwards porcine bioprosthesis

Since 1987 we have been using Carpentier-Edwards porcine bioprostheses for aortic valve replacements in patients of advanced age and those with a contraindication for anticoagulation therapy. The purpose of this study was to provide insight into the midterm results of our series of patients with Carpentier-Edwards porcine bioprostheses in the aortic position. From September 1987 through June 1999, 31 patients underwent aortic valve replacement with Capentier-Edwards porcine bioprostheses. The age of the patients ranged from 21 to 89 (average, 71 ± 11 years old), and 21 patients (67.7%) were 70 years old or older. There were no operative deaths. Three hospital deaths (9.7%) and one nonhospital death (3.2%) took place. The actuarial survival rate of 31 patients was 90.3% at 5 years and 81.3% at 7 years. Valve-related complications were seen in six patients (19.4%). The postoperative Doppler peak gradient of aortic prostheses was less than 30 mm Hg in all groups, irrespective of valve size. In conclusion, the Carpentier-Edwards porcine bioprosthesis affords good durability with a low rate of valve-related complications and reoperation. Furthermore, the postoperative function of the prosthesis was reasonable in the Doppler echo studies.

An Unusual Complication Associated with the Carpentier-Edwards Porcine Bioprosthesis

Primary tissue failure of bioprosthetic heart valves refers primarily to calcification of the leaflets of the bioprosthesis. A 75 year old patient underwent reoperation 15 years after mitral valve replacement with a Carpentier-Edwards porcine bioprosthesis. The extracted bioprosthetic valve was found to have one prolapsed leaflet and a small amount of calcification on all three leaflets without tear or perforation. The two commissures suspending the prolapsed leaflet were detached, causing mitral valve regurgitation.

Comparison of durability of bioprostheses in tricuspid and mitral positions

Background. Few reports have assessed differences in the durability of mitral and tricuspid bioprostheses after simultaneous implantation of the same bioprosthesis in both positions. We investigated the long-term outcome after simultaneous mitral valve replacement (MVR) and tricuspid valve supraannular implantation (TVSI) with the Carpentier-Edwards bioprostheses in patients with severe tricuspid regurgitation and advanced mitral valve disease.Methods. Between 1982 and 1998, 37 patients in our hospital underwent MVR and TVSI with Carpentier-Edwards bioprostheses. The mean age of the patients was 55 ± 11 years. The average postoperative follow-up was 7.9 ± 4.5 years after surgery (range 0 to 14.6 years, 315.1 patient-years). The follow-up rate was 100%. We evaluated the actuarial survival rate, the actuarial freedom from structural valve deterioration (SVD) and reoperation, and postoperative complications.Results. The overall actuarial survival rate at 13 years after the operation was 69% ± 31%. The actuarial freedom from SVD and reoperation in the mitral and tricuspid positions were 78 ± 22 and 100% and 70 ± 30 and 90% ± 10% (p = 0.03), respectively. No patient had systemic or pulmonary thromboembolism, or complications associated with fatal arrhythmia.Conclusions. These results suggest that the bioprostheses in the tricuspid position yield significantly better long-term results than those in the mitral position after simultaneous MVR and TVSI.

An unexpected flow abnormality

A 71-YEAR-OLD woman with a recent history of dyspnea and ascites presented for surgical correction of Ebstein’s anomaly of the tricuspid valve. Diagnostic cardiac catheterization before surgery showed severe tricuspid regurgitation with a dilated hypokinetic right ventricle and moderate pulmonary hypertension. There was no evidence of an intracardiac shunt, and the left ventricle was normal in structure and function. Surgical findings were consistent with Ebstein’s anomaly, and tricuspid valve repair was attempted. Transesophageal echocardiography (TEE) examination after trial separation from cardiopulmonary bypass revealed persistent severe tricuspid regurgitation, however, and tricuspid valve replacement with a Carpentier-Edwards bioprosthesis was subsequently performed. Although separation from cardiopulmonary bypass was uneventful, intraoperative TEE revealed a Doppler color-flow abnormality below the prosthetic tricuspid valve (Fig 1). What is the origin of this color-flow jet?

Aortic Carpentier-Edwards supraannular porcine bioprosthesis: a 12-year experience

Background. After 35 years of cardiac valve replacement, the ideal substitute remains to be found. Homografts are considered best but, due to their scarcity, cannot meet the need of valve replacement. Artificial valves (mechanical or biological) remain the most commonly used but controversy is still present as to the better choice. We tested the Carpentier-Edwards bioprosthesis for its efficacy in valve replacement operations. Methods. From 1983 to 1995, 1,108 consecutive patients had an isolated aortic valve replacement with a porcine Carpentier-Edwards bioprosthesis, model 2650 supra-annular valve. Mean age was 73.8 ± 8.3 years. Aortic stenosis was the most common lesion (1,049 patients, 94.7%). The follow-up of 980 operative survivors was 96% complete and represented a total of 4,735 patient-years (maximum, 13.8 years; mean, 4 years and 10 months). Results. Actuarial survival including operative mortality (128 patients, 11.6%) was 43.6% ± 2.3% at 10 years and 27.3% ± 3.3% at 12 years and, at that time, was not statistically different from those of the normal French population matched for age and sex. Structural deterioration of the valve was observed in 27 patients, an actuarial freedom of 94.2% ± 1.5% at 10 years and 83.8% ± 4.5% at 12 years. Hazard function revealed a stable and low risk of structural deterioration until 10 years and significantly increased risk after that. Young age was found to be an increasing risk factor of deterioration. Reoperation for valve-related complications was necessary in 30 patients, an actuarial freedom of 94.5% ± 1.4% at 10 years. Conclusions. The Carpentier-Edwards porcine supra-annular valve affords a good durability up to 10 years, with a low rate of reoperation. The risk of structural deterioration decreases with older age. It is our valve of choice in elderly patients.

Determinants of 15-year outcome with 1,119 standard Carpentier-Edwards porcine valves

Background. The determinants of long-term outcome 15 years or more after porcine valve replacement are poorly documented. Methods. A retrospective review was performed of patients undergoing valve replacement with standard Carpentier-Edwards aortic (n = 531), mitral (n = 492), and tricuspid (n = 96) valves. Results. Patient survival was 26% ± 3%, 23% ± 2%, and 31% ± 8% 15 years after aortic, mitral, and tricuspid valve replacements, respectively. Independent determinants of impaired long-term survival for aortic or mitral valve replacement were multiple valve replacement, older age, renal disease, lung disease, or coronary disease. Actual (versus actuarial) freedom from reoperation at 15 years was 86% ± 2%, 76% ± 2%, and 95% ± 2% after aortic, mitral, and tricuspid valve replacement, respectively. Risk factors for reoperation were young age for aortic or mitral valve replacement, previous operation for aortic valve replacement, and large valve size for mitral valve replacement. Freedom from thromboembolism was 77% ± 4%, 62% ± 9%, and 80% ± 5%; from hemorrhage, 95% ± 5%, 87% ± 4%, and 82% ± 6%; and from endocarditis, 94% ± 1%, 96% ± 1%, and 89% ± 5% 15 years after aortic, mitral, and tricuspid valve replacement, respectively. Risk factors for thromboembolism or hemorrhage were multiple valve replacement and age. Conclusions. The standard Carpentier-Edwards bioprosthesis continues to provide relatively low complication rates at 15 years, especially in the aortic and tricuspid positions, and especially in patients older than 60 years or with significant comorbdity.