Carpentier-Edwards Pericardial Valve Research Articles

Performance of Novel Polymer Heart Valve in Ovine Mitral Model

Objective: Evaluate the performance, hemocompatibility and histopathological consequences of a novel polymer mitral valve implant compared to Carpentier-Edwards bovine pericardial valve in an ovine model. This polymer valve (silicone polyurethan urea) was previously compared to bovine pericardial valve in the aortic position and found to be equivalent. Methods: Four sheep underwent thoracotomy open heart surgery on cardiopulmonary bypass in which both anterior and posterior mitral leaflets were excised and a patented polymer heart valve was implanted. The control group had implant of a bovine pericardial valve. Post-operative transthoracic echocardiograms were performed to evaluate valve function on post-op days 7-14, 30, 60 and pre-termination at 90 days. Blood samples for hematologic and chemistry measurements were obtained on the same schedule. Gross and histological examination of the valves was done after excision on POD 90. Histological exam of the heart, brain, kidneys and liver were done to identify potential embolic injury. Enoxaparin was given from POD 4 to POD 42. Results: Serial echocardiographic measurements showed comparable values between pre-operative and post-operative studies. There were no significant changes in blood test results in either group. The polymer valve leaflets were free of pannus, calcium-mineralization, shrinkage, endothelium or reduction in pliability. There was appropriate endothelialization and fibrosis at each tissue/frame interface. The bovine pericardial valve results were similar with the exception of fibrous pannus extending onto leaflet surface. Conclusions: The novel polymer mitral valve has a functional and safety profile that is similar to a bovine pericardial valve. However, the polymer valve has no cellular or thrombotic debris on its leaflets. It appears to be safe for human implants.

Late clinical outcomes of aortic valve replacement with Carpentier-Edwards pericardial valves.

The present study aimed to compare the long-term clinical and hemodynamic outcomes of aortic valve replacement using Carpentier-Edwards Perimount (Perimount) or Perimount Magna (Magna) valves. We enrolled 430 patients who underwent aortic valve replacements with Perimount (n=58) or Magna (n=372) valves [1998-2013]. Multivariable and inverse probability of treatment weight (IPTW) analyses were performed. Before IPTW analysis, the overall 8-year survival rate differed significantly between the groups [Perimount 90%±4% vs. Magna 76%±4%; P=0.02; hazard ratio (HR): 0.37 for the Perimount group; 95% confidence interval (CI): 0.17-0.83]. Multivariable analysis of the overall survival identified Perimount valve use as a protective factor (P=0.009; HR: 0.32; 95% CI: 0.14-0.75). Independent risk factors of overall survival were older age, male sex, higher preoperative left ventricular mass index, lower ejection fraction, lower aortic valve pressure gradient, and lower haemoglobin. After applying IPTW, overall survival was again found to be significantly longer in the Perimount group (P=0.04; HR: 0.43; 95% CI: 0.20-0.93). Event-free survival was also better in the Perimount group (P=0.006; HR: 0.38; 95% CI: 0.19-0.75). However, the Magna group had significantly lower aortic valve pressure gradients at one year and five years postoperative. Although Magna use led to decreased aortic valve pressure gradients at follow-up, overall and event-free survival rates were significantly better with use of the Perimount valve. Additional and larger studies are needed to confirm these results.

The Perimount Valve in the Aortic Position: Twenty-Year Experience With Patients Under 60 Years Old

With improved durability of contemporary bioprostheses, surgeons are now recommending biologic valves in younger patients. However, long-term outcomes of patients younger than 60 years old undergoing biologic aortic valve implantation are not well known. From November 1991 to March 2011, 144 patients less than 60 years old underwent aortic valve replacement (AVR) with Carpentier-Edwards pericardial valves (Edwards Lifesciences, Irvine, CA). Mean follow-up was 10±4 years. Outcomes were reported according to published guidelines. Seventy-five percent of patients were male, with a mean age of 51±9 years. Actuarial survival rates including early deaths were 89%±3%, 79%±4%, and 57%±6% after 5, 10, and 15 years of follow-up, respectively. Survival of patients was comparatively lower than a gender- and age-matched general population at all time points. The freedom from major adverse cardiac events (myocardial infarction, heart failure, hemorrhage, thromboembolic event, and endocarditis) was 89%±3%, 87%±3%, and 75%±6% at 5, 10, and 15 years after surgery. The freedom rate from prosthetic valve dysfunction was 97%±2%, 84%±4%, and 57%±6% at 5, 10, and 15 years after surgery. Patients with a diagnosis of structural valve deterioration (29 of 37, 78%) underwent reoperation 11±5 years after the initial valve replacement with no perioperative mortality. In patients younger than 60 years undergoing AVR, the Carpentier-Edwards Perimount bioprosthesis provided satisfactory clinical outcomes. However, late survival was inferior to an age- and gender-matched population. Structural valve deterioration and the need for reintervention were common late after implantation, but reoperation for prosthetic valve dysfunction was associated with a very low risk of mortality.

Long-Term Outcome of the Carpentier-Edwards Pericardial Valve in the Aortic Position in Japanese Patients

According to the Japanese Circulation Society guidelines, a bioprosthesis is recommended for aortic valve replacement (AVR) in patients aged ≥65 years who have no risk factors for thromboembolism. There are few data, however, regarding the actual durability of bioprosthetic valves in Japanese patients. The purpose of this study was to assess the long-term durability of Carpentier-Edwards pericardial (CEP) valves in Japanese AVR patients, and to assess the risk factors for reoperation due to structural valve deterioration (SVD). From 1986 to 2001, a total of 591 patients underwent AVR with CEP valves in 9 hospitals. Of these, 574 patients (mean age, 71.9±8.5 years) were analyzed in this study. There were 26 in-hospital deaths (4.5%). The 10-year follow-up rate was 82.6% and the median follow-up time was 9.2 years. Freedom from reoperation due to SVD was 99.5%, 96.7%, and 87.5% at 5, 10, and 15 years, respectively. Factors that raised the risk of reoperation due to SVD included younger age at operation and history of prior operation. In patients aged ≥65 years, freedom from reoperation due to SVD was 94.4% at 15 years. The durability of CEP valves in patients with AVR was excellent, especially in elderly patients. Thus, it seems appropriate to follow the current Japanese Circulation Society recommendations for the use of bioprosthetic valves.

Carpentier-Edwards Pericardial Valve in the Aortic Position: 25-Years Experience

The Carpentier-Edwards pericardial valve was designed to minimize structural valve deterioration. Excellent durability and low incidence of valve-related complications have been reported. The objective of the present study was to analyze clinical results after 25 years of experience with this valve implanted in the aortic position. The effect of patient age at the time of surgery was also evaluated. This is a retrospective cohort study of 2,405 patients from November 1981 to March 2011. Primary outcomes of interest were survival and freedom from major adverse effects such as thromboembolic, endocarditis, and reoperation. Sixty percent were male, with a mean age of 71 ± 9 years old. Actuarial survival rates including early deaths averaged 78% ± 2%, 55% ± 2%, and 16 % ± 2% after 5, 10, and 20 years of follow-up, respectively. The freedom rate of valve reoperation for prosthesis dysfunction and all other causes averaged 98 % ± 0.2%, 96% ± 1%, and 67% ± 4% at 5, 10, and 20 years. Patients younger than 60 years of age had a 15-year survival averaging 54% ± 5% compared with patients aged between 60 and 70 years of age averaging 46% ± 3% and with patients older than 70 years of age averaging 28% ± 3% (p = 0.001). Survival at 5, 10, and 20 years for patients who had concomitant CABG [coronary artery bypass grafting] were 78% ± 1%, 55% ± 2%, and 9% ± 3% compared with no concomitant CABG (84% ± 1%, 62% ± 2%, and 22% ± 3% (p < 0.001)). Carpentier-Edwards pericardial valve implantation in the aortic position is secure and durable. The effects of age influence reoperation rate and survival as well as a concomitant coronary artery bypass procedure.

EComment. A novel lower age threshold for use of biological valves

The publication by Niclauss et al. [1] highlights a subject with conflicting results in the literature: the determination of a lower age limit for bioprosthetic valves in the aortic position. They concluded that biological aortic valve replacement could be an alternative treatment option for patients between 56 and 60 years old at the time of surgery. Nevertheless, biological aortic valves in patients younger than 60 years old is still a matter of ongoing debates, and the debate has gained renewed impetus with the advent of transcatheter aortic valve implantation and the feasibility of valve-in-valve procedures [2]. Moreover, valve-related complications in this patient population have not been clearly investigated. It is noteworthy that in two recently published studies, mechanical valves among younger patients were shown to have more superior clinical outcomes compared to bioprostheses. Badhwar et al. [3], who conducted a prospective study on 172 propensity-matched patients, demonstrated a significantly lower mortality rate in patients with mechanical prostheses after 4 years of follow-up. Of note, patients with bileaflet mechanical prostheses enrolled in the above-mentioned study were monitored at low international normalized ratio thresholds using point-of-care home monitoring. The merits of mechanical aortic valve have been reiterated by the study of Weber et al. [4]. They selected a cohort of 103 patients younger than 60 years old with the Perimount Carpentier-Edwards pericardial tissue valve and compared them with a propensity matched group of 103 patients with mechanical bileaflet aortic valve over a period of 10 years. Surprisingly, valve-related event rates were similar in both groups; however, survival was significantly reduced in patients with bioprostheses (90% vs 98%). One possible explanation speculated by the authors was the protective role of oral anticoagulation in patients with mechanical valves. The current guidelines from major international cardiovascular societies propose that both valve types are acceptable in patients aged between 60 and 65 years at the time of surgery. However, there is still insufficient evidence to recommend biological valves for patients younger than 60 years, other than in patients who have major medical contraindications to anticoagulant therapy. Conflict of interest: none declared.

EComment. The current bioprosthesis of choice for aortic valve replacements

I read with great interest the paper by Yap et al. regarding the best valve substitute for aortic valve replacement [1]. In their results, they included six randomized controlled trials and nine cohort studies yielding a total of 9880 patients from 1974 to 2006. However, we found two additional relevant articles investigating the long-term durability of pericardial and porcine valves. Brown et al. from the Mayo clinic recently published an interesting article assessing the incidence of early thrombosis in patients with biological valves [2]. The paper was in favour of bovine valves because all patients with early valve thrombosis requiring reoperation were implanted with porcine valves. The calculated incidence of valve thrombosis was 1.26% for the Biocor valve, 0.84% for the Hancock valve and 0.37% for the Mosaic valve. There were no patients with valve thrombosis in the pericardial valve cohort. One possible explanation of this discrepancy is related to the design of the porcine valve stent, which promotes blood stasis between the rail of the stent and the belly of the leaflet. Based on their findings, they recommended the implantation of a mechanical or a pericardial valve, in case of early thrombosis of a porcine valve. Grunkemeier et al. reviewed the long-term durability of the Carpentier-Edwards pericardial and bovine aortic valves in 2955 patients [3]. The likelihood of explantation by 15 years was similar for both valves (7% for the porcine valve and 8% for the pericardial valve). However, the modes of failure were different: structural valve deterioration was seen mainly in the form of a leaflet tear for porcine valves and calcification and fibrosis for pericardial valves. According to the available literature, we concur with the conclusion of Yap et al. that the bovine valve is superior in its haemodynamic profiles and has a lower rate of complications. Another advantage of the pericardial valve is the very low rate of valve thrombosis with only one case report of early bioprosthesis thrombosis in the aortic position [4]. Conflict of interest: none declared

740 The Carpentier-Edwards Pericardial Valve: 30-Year Experience at the Montréal Heart Institute

The Carpentier-Edwards pericardial valve (Edwards Lifesciences, Irvine, CA, USA) has been in clinical use since 1980 in Canada. It was designed to minimize structural valve deterioration. Several studies have published clinical results with this pericardial valve to up to 20 years. Excellent durability especially in the aortic position in elderly patients and low incidence of valve-related complications has been reported. The objective of the present study is to analyse clinical results after 30 years of experience with this valve implanted in aortic position.

Ten-year comparison of pericardial tissue valves versus mechanical prostheses for aortic valve replacement in patients younger than 60 years of age

Aortic valve replacement using a tissue valve is controversial for patients younger than 60 years old. The long-term survival in this age group, the expected event rates during long-term follow-up, and valve-related complications are not clearly determined. From January 2000 to December 2009, overall survival, valve-related events, and echocardiographic outcomes were analyzed in all patients younger than 60 years of age, who underwent biologic aortic valve replacement. Patients who received a Perimount Carpentier-Edwards pericardial tissue valve (n = 103) were selected and compared with a propensity matched group of 103 patients who received aortic valve replacement using a mechanical bileaflet valve. The mean follow-up was 33 ± 24 months (range, 2-120), and the mean age at implantation was 50.6 ± 8.8 years (bioprosthesis, 55 ± 8.9 years; mechanical valve, 50 ± 8.6 years; P = .03). Survival was significantly reduced in patients after biologic aortic valve replacement (90.3% vs 98%; P = .038). Freedom from all valve-related complications (bioprosthesis, 54.5%; mechanical valve, 51.6%; P = NS) and freedom from reoperation (bioprostheses, 100%; mechanical valve, 98%; P = NS) were comparable in both groups. The average transvalvular mean (11.2 ± 4.2 mm Hg vs 10.5 ± 6.0 mm Hg, P = .05) and peak (19.9 ± 6.7 mm Hg vs 16.7 ± 8.0 mm Hg, P = .03) gradients were greater after biologic aortic valve replacement. Regression of the left ventricular mass index was more pronounced after mechanical valve replacement (118.5 ± 24.9 g/m(2) vs 126.5 ± 38.5 g/m(2); P = NS). The echocardiographic patient-prosthesis mismatch was greater at follow-up after biological aortic valve replacement (0.876 ± 0.2 cm(2)/m(2) vs 1.11 ± 0.4 cm(2)/m(2); P = .01). Oral anticoagulation was a protective factor for survival among the bioprosthetic valve patients (P = .024). In the present limited cohort of patients younger than 60 years old, biologic aortic valve replacement was associated with reduced mid-term survival compared with survival after mechanical aortic valve replacement. Despite similar valve-related event rates in both groups, the better hemodynamic performance of the mechanical valves and/or protective effect of oral anticoagulation seemed to improve the outcome. The transcatheter valve-in-valve intervention as potential treatment of tissue valve degeneration should not be considered the sole bailout strategy for younger patients because no evidence is available that this would improve the outcome.

Long-term Results after Carpentier-Edwards Pericardial Aortic Valve Implantation, with Attention to the Impact of Age

The purpose of this study was to determine long-term patient survival and valve durability for Carpentier-Edwards pericardial valves (Edwards Lifesciences) implanted in the aortic position, with specific attention to the impact of patient age. We performed a retrospective cohort study of 2168 patients who underwent implantation of a Carpentier-Edwards pericardial aortic valve between 1991 and 2008. The mean follow-up time was 4.5 years. Primary outcomes of interest were mortality and valve explantation. Survival curves and event-free curves were obtained with the Kaplan-Meier method and compared with the log-rank test. Survival was 92% at 1 year, 73% at 5 years, 38% at 10 years, and 18% at 15 years. Although the mortality rate of younger patients was worse than in the general population, older patients had significantly better survival than their contemporaries. Age was the independent variable most significantly associated with explantation. There was an early hazard phase for patients between 21 and 49 years of age, such that the freedom from explantation was 89% at 3 years. By 10 years, the freedom from explantation was 58% for patients 21 to 49 years of age, compared with 68% for patients 50 to 64 years, 93% for patients 65 to 74 years, and 99% for patients 75 years of age and older. We found good long-term survival and durability. Older patients had excellent freedom from explantation, whereas younger patients fared worse. As our population ages, this information becomes increasingly important. Assessing the durability of this pericardial aortic valve may aid in predicting the durability of the transcatheter aortic valves that share the same leaflets.

Twelve-year experience with the Carpentier–Edwards pericardial aortic valve at a single Japanese center

Our aim was to evaluate the long-term results of implantation of the Carpentier-Edwards pericardial (CEP) valve in the aortic position. Between January 1996 and December 2007, 244 patients who underwent aortic valve replacement using the CEP valve were enrolled in this study. A 19-mm valve was used in 39 patients, a 21-mm valve in 94 patients, a 23-mm valve in 81 patients, and a 25-mm valve in 30 patients. The early and the late results were evaluated. Furthermore, echocardiographic examination was performed at follow-up. There were 5 early deaths, with an early mortality rate of 2.0%. Follow-up was performed in 95.4% of the survivors of the operation for a mean period of 4.1years. Actuarial survival rates at 5, 10, and 12years were 85.3±2.8, 80.0±3.7 and 70.0±9.8%, respectively. Thromboembolism was observed in 6 patients, endocarditis in 2 patients, reoperation in 4 patients, and structural valve deterioration in 2 patients. Actuarial freedoms from thromboembolism, endocarditis, and reoperation at 10years were 96.9±0.14, 97.7±0.16, and 97.0±0.16%, respectively. Echocardiographic examination revealed that the pressure gradients across the valve prosthesis for valves of each size were acceptable. Left ventricular mass index decreased significantly in all valve sizes. The long-term results of implantation of the CEP bioprosthesis in the aortic position were satisfactory. The CEP bioprosthesis maintained its hemodynamic performance even as late as 10years after implantation.

Late Outcomes for Aortic Valve Replacement With the Carpentier-Edwards Pericardial Bioprosthesis: Up to 17-Year Follow-Up in 1,000 Patients

This study reviews a single institution experience with the Carpentier-Edwards pericardial aortic valve bioprosthesis, concentrating on late outcomes. From December 1991 to June 2002, 1,000 patients underwent aortic valve replacement with the Carpentier-Edwards pericardial valve (mean follow-up 6.01 +/- 3.56 years). The institutional database was reviewed. Follow-up data were acquired through telephone interviews and mail-in questionnaires. Time-to-event analyses were performed by the Kaplan-Meier method. Mean age was 74.1 years; 545 patients (54.5%) were male. Mean preoperative ejection fraction was 52.5%. Isolated aortic valve replacement occurred in 372 cases (37.2%). Combined aortic valve replacement with coronary artery bypass grafting occurred in 443 cases (44.3%). The remaining 185 patients (18.5%) underwent complex procedures with concomitant mitral, tricuspid, or arch repair. One hundred forty patients (14.0%) had prior aortic valve surgery. Follow-up was 99.4% complete. Overall operative mortality was 7.2% (72 of 1,000). There were 503 late deaths (50.3%). Age-stratified survival at 15 years was 43.7% for patients less than 65 years of age; 18.2% for patients aged 65 to 75; and 9.4% for patients aged more than 75 years. There were 26 failed bioprostheses (2.6%) requiring reoperation. Structural valve deterioration was the cause in 13 of 26 cases (50%), endocarditis in 11 of 26 (42%), and perivalvular leak in 2 of 26 (7.6%). Age-stratified freedom from reoperation due to structural valve deterioration at 15 years was 34.7% for patients less than 65 years of age; 89.4% for patients aged 65 to 75; and 99.5% for patients aged more than 75 years. The Carpentier-Edwards pericardial bioprosthesis shows long-term durability with low rates of structural failure.

Are stentless valves hemodynamically superior to stented valves? Long-term follow-up of a randomized trial comparing Carpentier–Edwards pericardial valve with the Toronto Stentless Porcine Valve

The benefit of stentless valves remains in question. In 1999, a randomized trial comparing stentless and stented valves was unable to demonstrate any hemodynamic or clinical benefits at 1 year after implantation. This study reviews long-term outcomes of patients randomized in the aforementioned trial. Between 1996 and 1999, 99 patients undergoing aortic valve replacement were randomized to receive either a stented Carpentier-Edwards pericardial valve (CE) (Edwards Lifesciences, Irvine, Calif) or a Toronto Stentless Porcine Valve (SPV) (St Jude Medical, Minneapolis, Minn). Among these, 38 patients were available for late echocardiographic follow-up (CE, n = 17; SPV, n = 21). Echocardiographic analysis was undertaken both at rest and with dobutamine stress, and functional status (Duke Activity Status Index) was compared at a mean of 9.3 years postoperatively (range, 7.5-11.1 years). Clinical follow-up was 82% complete at a mean of 10.3 years postoperatively (range, 7.5-12.2 years). Preoperative characteristics were similar between groups. Effective orifice areas increased in both groups over time. Although there were no differences in effective orifice areas at 1 year, at 9 years, effective orifice areas were significantly greater in the SPV group (CE, 1.49 +/- 0.59 cm(2); SPV, 2.00 +/- 0.53 cm(2); P = .011). Similarly, mean and peak gradients decreased in both groups over time; however, at 9 years, gradients were lower in the SPV group (mean: CE, 10.8 +/- 3.8 mm Hg; SPV, 7.8 +/- 4.8 mm Hg; P = .011; peak: CE, 20.4 +/- 6.5 mm Hg; SPV, 14.6 +/- 7.1 mm Hg; P = .022). Such differences were magnified with dobutamine stress (mean: CE, 22.7 +/- 6.1 mm Hg; SPV, 15.3 +/- 8.4 mm Hg; P = .008; peak: CE, 48.1 +/- 11.8 mm Hg; SPV, 30.8 +/- 17.7 mm Hg; P = .001). Ventricular mass regression occurred in both groups; however, no differences were demonstrated between groups either on echocardiographic, magnetic resonance imaging, or biochemical (plasma B-type [brain] natriuretic peptide) assessment (P = .74). Similarly, Duke Activity Status Index scores of functional status improved in both groups over time; however, no differences were noted between groups (CE, 27.5 +/- 19.1; SPV, 19.9 +/- 12.0; P = .69). Freedom from reoperation at 12 years was 92% +/- 5% in patients with CEs and 75% +/- 5% in patients with SPVs (P = .65). Freedom from valve-related morbidity at 12 years was 82% +/- 7% in patients with CEs and 55% +/- 7% in patients with SPVs (P = .05). Finally, 12-year actuarial survival was 35% +/- 7% in patients with CEs and 52% +/- 7% in patients with SPVs (P = .37). Although offering improved hemodynamic outcomes, the SPV did not afford superior mass regression or improved clinical outcomes up to 12 years after implantation.

Bidirectional Glenn with Existing Transvenous Cardioverter-Defibrillator Leads

The population of patients with adult congenital heart disease is increasing. A significant number of these patients already have or will require placement of either a transvenous pacemaker or implantable cardioverter defibrillator. In addition to this, some with right ventricular dysfunction might benefit from volume unloading of the right ventricle by the construction of a superior cavopulmonary anastomosis. The usual technique for the bidirectional Glenn anastomosis precludes the presence of upper extremity transvenous hardware. We present a modified technique for the superior cavopulmonary anastomosis when pacing or cardioverter defibrillator leads are present.

Impact of Energy Loss Coefficient on Left Ventricular Mass Regression in Patients Undergoing Aortic Valve Replacement: Preliminary Observation

The purpose of this study was to evaluate the impact of Doppler-derived energy loss coefficient (ELCo) on the regression of left ventricular (LV) hypertrophy after aortic valve replacement (AVR) in patients with severe aortic stenosis. Twenty-four patients with severe aortic stenosis who underwent AVR with Carpentier-Edwards pericardial bioprosthetic valves (valve size 19 mm, n = 16; valve size 21 mm, n = 8) were examined. Within 12 months after AVR, follow-up echocardiography and Doppler measurements were performed. The effect of AVR was quantified on the basis of absolute and relative LV mass regression. There were significant correlations between indexed ELCo and absolute (r = 0.50, P = .013) and relative (r = 0.48, P = .018) LV mass regression. The mean value of relative LV mass regression was 25%, and a cutoff value of 0.9 cm2/m2 for indexed ELCo could detect patients with relative LV mass regression > 25% after AVR with sensitivity of 71% and specificity of 100%. ELCo, which can be calculated noninvasively from echocardiography, might be an important value to relate to LV mass regression in patients after AVR.

Pannus overgrowth after mitral valve replacement with a Carpentier-Edwards pericardial bioprosthesis

A Carpentier-Edwards pericardial (CEP) bioprosthesis was explanted from an 81-year-old woman due to nonstructural dysfunction 9 years after mitral valve replacement. The nonstructural dysfunction produced severe regurgitation in the mitral position. During the surgery, excessive pannus overgrowth was seen on the left ventricular side of the CEP bioprosthesis. Pannus overgrowth was prominent on one leaflet. That leaflet was stiff and shortened due to the excessive overgrowth of pannus. In this patient, the distortion of one leaflet was the main reason for transvalvular leakage of the CEP bioprosthesis in the mitral position. A new CEP bioprosthesis was implanted in the mitral position. Pathological analysis revealed fibrotic pannus with a small amount of cellular material over the leaflets of the resected CEP valve. This change was marked on the distorted leaflet.

Which valve and which size should we use in the valve-on-valve technique for re-do mitral valve surgery?

The valve-on-valve (VOV) technique is that a mechanical valve is implanted on the sewing cuff of the previous bioprosthesis after removing degenerated leaflets. We conducted an in vitro study to determine the size-match of the valves for VOV technique. The Carpentier-Edwards pericardial (CEP) valve and Mosaic valve were used. We measured the inner diameter of the bioprosthesis after removing the leaflets. We investigated five mechanical mitral valves and two mechanical aortic valves (inverted use). The mitral valves used in this study were the ATS valve (ATS), the CarboMedics standard valve (CMS), the CarboMedics OptiForm valve (CMO), the On-X valve, and the St Jude valve (SJM). Two aortic mechanical valves, CarboMedics and St Jude Regent valves, were investigated for inverted use. After removing the tissue leaflets, the inner diameter of the Mosaic valve was 3 mm smaller than that of the CEP valve even in the same catalogue labeling size. The outer diameters of the housing of the ATS, CMS, CMO, On-X, and SJM valves of the same catalogue size (25 mm) were 25.7, 25.8, 22.0, 25.0, and 23.2 mm, respectively. SJM and CMO valves are the favorite mechanical valve for the VOV technique in terms of the profile and size-match.

Reconstruction of the Bicuspid Aortic Valve

Abicuspid aortic valve (BAV) occurs in 2% of the population and is a common reason for significant aortic regurgitation, particularly in the third and fourth decades of life.1 In these young patients, the choice of valve substitute is difficult. With a mechanical valve, the linearized risk of thromboembolic complications and anticoagulation-related hemorrhage is low,2 but the cumulative risk may be substantial due to a long life expectancy. Many young individuals do not wish a coumadin-based anticoagulation for lifestyle reasons. A biologic prosthesis, on the other hand, is associated with suboptimal durability in younger patients.3 Thus, for patients with a regurgitant bicuspid aortic valve, repair appears an attractive alternative to replacement. Bicuspid aortic valve anatomy is also associated with aortic dilation in more than 50% of individuals.4 Aortic dilation may induce or aggravate aortic valve regurgitation, and there is increasing evidence that a diameter of more than 4.5 cm may be associated with impaired long-term prognosis.5 Elimination of a dilated ascending aorta may also serve the purpose of stabilizing a valve repair procedure.6 Thus, any reconstructive procedure on a bicuspid aortic valve should address aortic pathology, if present. We have developed a differentiated approach to these procedures that has worked well in more than 180 patients operated over an 11-year period. Department of Thoracic and Cardiovascular Surgery, University Hospital of Saarland, Homburg/Saar, Germany. Address reprint requests to H.-J. Schafers, MD, Dept. of Thoracic and Cardiovascular Surgery, University Hospitals of Saarland, 66421 Homburg/ Saar, Germany. E-mail: h-j.schaefers@uniklinikum-saarland.de

Does the type of biological valve affect patient outcome?

Patient background mortality and excess mortality related to aortic valve disease may play a greater role than implanted valve type in explaining the observed survival differences after aortic valve replacement. This study attempts to identify the differences between the performance of selected biological valves, given similar patient characteristics and excess mortality. Four biological valve types, the Carpentier-Edwards pericardial and supra-annular valve, Medtronic Freestyle valve and allografts were used for this analysis. Primary data calculated observed patient-survival and median time to structural valvular deterioration. We then used a microsimulation model to calculate age-specific patient survival and reoperation- and event-free life expectancies. The model incorporated the US population mortality and a uniform excess mortality, while the hazards of valve-related events after implantation of the four valve types were estimated from corresponding meta-analysis and primary data. Observed 10-year survival (60-69)-year age group survival and median time to SVD for the different valve types did not differ. Microsimulation calculated, for a 65-year-old male for example, a 10-year survival of 51%, 51%, 53% and 56% for Carpentier-Edwards pericardial and Supra-annular valve, Freestyle and allografts, respectively. Patient life expectancy was 10.8, 10.8, 11.0 and 11.4 years, respectively. Assuming uniform patient characteristics and excess mortality, the observed difference in performance between the four biological valve types is less marked. Patient selection and the timing of operation may explain most of the observed differences in prognosis after aortic valve replacement with biological prostheses.

Fungal prosthetic mitral valve endocarditis caused by Scopulariopsis species: Case report and review of the literature

Clinical Summary A 67-year-old woman with a past medical history significant for rheumatic fever, gout, pulmonary hypertension, atrial fibrillation, congestive heart failure, and 3 prior valve operations presented with fever and right leg pain. One year before presentation she underwent replacement of her aortic and mitral valves with a 19-mm Carpentier-Edwards Magna pericardial valve and a 25-mm Carpentier-Edwards pericardial valve (Baxter Healthcare Corp, Edwards Lifesciences, Irvine, Calif), respectively. Her social history was significant for pet finches. Her temperature was 101°F, she had a systolic murmur at the left sternal border, and her right foot was cold with diminished pulses. She had no evidence of onychomycosis or peripheral emboli. Abdominal computed tomography demonstrated a nonocclusive clot in the right ileac artery. Hematologic parameters and chemistries were normal. Blood cultures, including fungal isolator blood cultures incubated over 4 weeks, were negative. After the patient’s left leg became cold and pulseless, she urgently underwent thromboendarterectomy of an acutely occluded femoral artery. Pathology from the embolectomized specimen demonstrated septated hyphal elements. Subsequently on day 5, fungal cultures grew a mold morphologically identified as a Scopulariopsis species (Figure 1). She underwent a transesophageal echocardiogram revealing a larger than 12-mm vegetation on the mitral valve with moderate mitral regurgitation. Confirmatory identification and susceptibility testing performed at Focus Diagnostics (Cyprus, Calif) identified the organism as S brevicaulis and demonstrated mean inhibitory concentrations of 4 g/mL to amphotericin B, 1 g/mL to terbinafine, 8 g/mL to voriconazole, and greater than 8 g/mL to itraconazole. The patient underwent excision of the senescent infected mitral valve pericardial prosthesis, extensive debridement of the associated fungal vegetation, and a mitral valve replacement with a Carpentier-Edwards pericardial valve. She was treated preoperatively and postoperatively with amphotericin B and voriconazole. The amphotericin was continued for 3 weeks postoperatively, and the voriconazole was arbitrarily continued for 11 weeks until the patient could not tolerate it because of debilitating nausea. She had a complicated respiratory course postoperatively and was discharged to a rehabilitation facility. She was subsequently readmitted with dyspnea and died 5 months after initial presentation without signs of recurrent infection. Culture of her pet finch’s feathers grew Aspergillus species and not Scopulariopsis species, despite the mold’s propensity to grow in bird feathers.