Heart Valve Replacement Surgery Research Articles

Recent Advances in the Modification and Improvement of Bioprosthetic Heart Valves.

Valvular heart disease (VHD) has become a burden and a growing public health problem in humans, causing significant morbidity and mortality worldwide. An increasing number of patients with severe VHD need to undergo heart valve replacement surgery, and artificial heart valves are in high demand. However, allogeneic valves from donors are lacking and cannot meet clinical practice needs. A mechanical heart valve can activate the coagulation pathway after contact with blood after implantation in the cardiovascular system, leading to thrombosis. Therefore, bioprosthetic heart valves (BHVs) are still a promising way to solve this problem. However, there are still challenges in the use of BHVs. For example, their longevity is still unsatisfactory due to the defects, such as thrombosis, structural valve degeneration, calcification, insufficient re-endothelialization, and the inflammatory response. Therefore, strategies and methods are needed to effectively improve the biocompatibility and longevity of BHVs. This review describes the recent research advances in BHVs and strategies to improve their biocompatibility andlongevity.

Preoperative continuation of aspirin before isolated heart valve surgery and postoperative bleeding and transfusion: a single-center retrospective study

Background The risks and benefits of preoperative aspirin continuation in patients undergoing isolated heart valve replacement surgery are unclear. We investigated the effect of aspirin continuation on the risk of bleeding and transfusion in these patients. Methods In this single center, retrospective study, among 474 adult patients who underwent isolated heart valve surgery between April 2013 and June 2018, 269 continued aspirin within 5 days before surgery (aspirin group) and 205 patients did not take or stopped aspirin no later than 5 days before surgery (non-aspirin group). The chi-square test, the Mann-Whitney U-test, and the Student’s T-test were used to compare data between the groups. Univariate and Multivariate logistic regressions were used to assess crude and adjusted relationships between outcome and exposure. Results The primary outcome, red blood cell (RBC) transfusion, occurred in 59 patients (22%) of the aspirin group and in 24 patients (12%) of the non-aspirin group (p = 0.004). After adjustment for confounding factors, continuation of aspirin was no longer associated with RBC transfusion (aOR1.8;95%CI,0.98–3.2;p = 0.06). The amount of allogenic blood products, the incidence of surgical re-exploration for bleeding, the volume of re-transfused cell-saved blood, and the cumulative chest tube drainage during the first 24 postoperative hours were similar between groups. Conclusion Preoperative continuation of aspirin in patients undergoing isolated heart valve surgery is neither associated with a higher incidence of RBC transfusion, nor with larger perioperative blood loss, or more frequent surgical revision for bleeding. Trial registration Clinicaltrials.gov (NCT05151796)

Recent progress in functional modification and crosslinking of bioprosthetic heart valves.

Valvular heart disease (VHD), clinically manifested as stenosis and regurgitation of native heart valve, is one of the most prevalent cardiovascular diseases with high mortality. Heart valve replacement surgery has been recognized as golden standard for the treatment of VHD. Owing to the clinical application of transcatheter heart valve replacement technic and the excellent hemodynamic performance of bioprosthetic heart valves (BHVs), implantation of BHVs has been increasing over recent years and gradually became the preferred choice for the treatment of VHD. However, BHVs might fail within 10-15 years due to structural valvular degeneration (SVD), which was greatly associated with drawbacks of glutaraldehyde crosslinked BHVs, including cytotoxicity, calcification, component degradation, mechanical failure, thrombosis and immune response. To prolong the service life of BHVs, much effort has been devoted to overcoming the drawbacks of BHVs and reducing the risk of SVD. In this review, we summarized and analyzed the research and progress on: (i) modification strategies based on glutaraldehyde crosslinked BHVs and (ii) nonglutaraldehyde crosslinking strategies for BHVs.

Thromboembolic and hemorrhagic complications in patients with prosthetic heart valves cared for in a tertiary care center. What have we learned?

Heart valve replacement surgery with mechanical or biological prostheses entails a risk of thromboembolism and bleeding complications. To determine the complications related to complementary anticoagulation therapy and the probability of risk. One-hundred and sixty-three patients who underwent heart valve replacement between 2002 and 2016 with either mechanical or biological prostheses, and who received vitamin K antagonists after hospital discharge, were studied. Anticoagulation therapy was categorized into optimal and non-optimal according to INR values prior to the development of complications. Patients with comorbidities and other risk factors for thrombosis and/or bleeding were excluded. In total, 68.7 % of patients received mechanical prostheses, and 31.3 %, biological prostheses (p ≤ 0.001); 25.2 % experienced the complications that motivated the study (p ≤ 0.001), which were hemorrhagic in 48.8 %, thromboembolic in 26.8 %, and of both types in 24.4 % (relative risk = 4.229). Among the patients with complications, 95.1 % received mechanical prostheses, and 4.9 %, biological (p = 0.005); non-optimal INR was identified in 49.7 % (p ≤ 0.001). Given the high risk of thromboembolic and hemorrhagic complications, valve prostheses must be carefully chosen, and care priorities should include prevention and follow-up, especially in those patients who require anticoagulation therapy.

Analysis of Risk Factors and Intervention Strategies for Acute Kidney Injury After Cardiac Valve Replacement.

To investigate the risk factors and intervention strategies for the development of acute kidney injury (AKI) after cardiac valve replacement with extracorporeal circulation. Retrospective analysis of the clinical data of a total of 106 patients diagnosed with heart valve disease and undergoing extracorporeal circulation heart valve replacement surgery from January 2021 to December 2021 in the Department of Cardiac and Major Vascular Surgery of our hospital. The two groups were divided into AKI and non-AKI groups according to whether acute kidney injury occurred after surgery, and the preoperative, intraoperative and postoperative clinical data were compared. Single-factor analysis and multi-factor logistic regression analysis were used to explore the risk factors for acute kidney injury after extracorporeal heart valve replacement, and to improve the prognosis by giving kidney function protection strategies as early as possible. Univariate analysis showed that age, preoperative blood creatinine >130umol/L, LVEF <45%, presence of subacute infective endocarditis (SIE), concurrent coronary artery bypass grafting (CABG), time to extracorporeal circulation, time to surgery, MAP <70mmHg, urine output <0.5mL/(kg-h), pulmonary infection, low cardiac output, and bacteraemia were risk factors for postoperative AKI. Multi-factor regression analysis showed that preoperative blood creatinine >130umol/l, LVEF <45%, combined infective endocarditis, extracorporeal circulation time >2h, intraoperative and postoperative hypotension, low cardiac output, and postoperative bacteremia were independent risk factors for postoperative AKI. Active intervention strategies in the perioperative period can reduce the occurrence of postoperative AKI and improve patient prognosis.

µAVR: Endoscopic Microinvasive Aortic Valve Surgery With Automated Suturing Technology for Enhanced Patient Outcomes.

Modern heart surgery should strive toward the most durable therapeutic results and enhanced patient recoveries. Novel customized technology is available to advance the evolution of less invasive heart valve replacement surgery and ultimately facilitate "microinvasive" techniques utilizing very small bone-sparing incisions and endoscopy. In this article, we present our approach to aortic valve replacement, including the use of automated suturing devices to improve the surgical ergonomics and reliability of these procedures. This patient-centered approach can be safely performed by surgeons interested in offering the benefits of truly minimally invasive cardiac surgery to improve patient outcomes. We believe that each patient should be offered personalized surgery to provide the optimized procedure and aortic valve replacement to suit their individual needs and preferences.

Impact of 1-week preoperative auto-CPAP treatment on postoperative outcomes in patients undergoing heart valve replacement surgery: a prospective randomized controlled trial.

Whether preoperative continuous positive airway pressure (CPAP) treatment improves postoperative outcomes in patients undergoing cardiac valve replacement (CVR) remains unknown. This study was to evaluate the effects of 1-week perioperative auto-continuous positive airway pressure (CPAP) treatment on postoperative heart and pulmonary outcomes in patients with obstructive sleep apnea (OSA) and valvular heart disease. Thirty-two patients with OSA and valvular heart disease were randomly assigned to 1-week CPAP (n = 15) group and non-CPAP treatments (n = 17) group. After the treatment, all patients underwent CVR surgery. The length of ICU and hospital stays, postoperative cardiac and respiratory complications were assessed and compared between the 2 groups. The results showed there was no significant difference in the baseline characteristics between the CPAP and non-CPAP treatment groups. The length of postoperative ICU and hospital stays, as well as the duration of mechanical ventilation were significantly reduced in the CPAP treatment group compared to the non-CPAP treatment group; however, there were no significant differences in cardiac complications (postoperative arrhythmias, pacemaker use, first dose of dopamine in the ICU, and first dose of dobutamine in the ICU), and respiratory complications (reintubation and pneumonia). We concluded that in patients underwent CVR, preoperative use of auto-CPAP for OSA significantly decreased the duration of mechanical ventilation, and postoperative stays in the ICU and hospital.Clinical Trial Registration: https://ClinicalTrials.gov, identifier NCT03398733.

Assessment of Machine Learning Approaches to Predict in-Hospital Mortality in Patients Underwent Prosthetic Heart Valve Replacement Surgery

Assessment of Machine Learning Approaches to Predict in-Hospital Mortality in Patients Underwent Prosthetic Heart Valve Replacement Surgery

Effect of multicomponent rehabilitation on independence and functioning in elderly patients with common age-associated diseases: protocol for a scoping review (REHOLD)

IntroductionElderly patients after hospitalisation for acute events on account of age-related diseases (eg, joint or heart valve replacement surgery) are often characterised by a remarkably reduced functional health. Multicomponent rehabilitation...

Technical Features of the Experimental Target Device for Denervation of the Pulmonary Arteries

Objectives: Creation of a device that allows additionally performing a procedure to correct high pulmonary hypertension during heart valve replacement surgery. Methods: In laboratory conditions, a number of parameters of the pulmonary vessels were measured - the wall thickness in various areas, the diameter of the pulmonary trunk in the initial state (without squeezing it) and the transverse size of the pulmonary trunk when squeezing until its inner walls were completely closed.

Antioxidant activity in off and on-pump coronary artery bypass grafting and valve replacement surgery.

Cardiac surgeries initiate oxidative stress, increasing organ dysfunction development and mortality. The present study investigated the superoxide dismutase (SOD) activity, as an antioxidant enzyme, in patients undergoing coronary artery bypass (CABG) and heart valve replacement surgeries. A prospective study was performed on patients with proven coronary artery disease (CAD) or valvular heart disease (VHD) candidates for on- or off-pump CABG andvalve replacement surgery. Serum SOD activity was measured preoperatively, at 24h postoperatively, and at thetime of discharge. In addition, echocardiography was performed before surgery and at discharge. A total of 48, 51, and 47 patients were enrolled in theon-pump, off-pump CABG, and valve replacement groups, respectively. Baseline serum SOD activity showed no significant association with BMI, age, and blood pressure in either CAD or VHD patients. The SOD values decreased at the 24h postoperative time and then increased at the time of discharge in all groups, except for a slight decrease in the on-pump group. The changes in serum SOD values were not significantly different for the three surgical groups. The serum SOD activities fell significantly after CABG and valve replacement surgery. Further investigation is emphasized for the role of SOD in oxidative stress after cardiac surgery.

Temperature management of intraoperative cardiopulmonary bypass in valve replacement surgery: a retrospective analysis of the impact on postoperative organ function.

This study aimed to systematically analyze the effects of cardiopulmonary bypass (CPB) at different temperatures on the function of different organs in patients after heart valve replacement and to investigate its safety and feasibility. The data of 275 heart valve replacement surgery patients who underwent static suction compound anesthesia under CPB between February 2018 and October 2019 were retrospectively analyzed and divided into normothermic CPB anesthesia group (group 0), shallow hypothermic CPB anesthesia group (group 1), medium hypothermic CPB anesthesia group (group 2), and deep hypothermic CPB anesthesia group (group 3) according to the different intraoperative CPB temperatures. The basic preoperative conditions, cardiac resuscitation, number of defibrillations, postoperative ICU stay, postoperative hospital stay, and postoperative evaluation of different organ functions, such as heart, lung, and kidney functions, were analyzed and studied in each group. The comparison of preoperative and postoperative pulmonary artery pressure and left ventricular internal diameter (LVD) was statistically significant in each group (p < 0.05), and the postoperative pulmonary function pressure was statistically significant in group 0 compared with groups 1 and 2 (p < 0.05). The preoperative glomerular filtration rate (eGFR) and the eGFR on the first postoperative day were statistically significant in all the groups (p < 0.05), and the eGFR on the first postoperative day in groups 1 and 2 were statistically significant (p < 0.05). The control of appropriate temperature during CPB was associated with the recovery of organ function in patients after valve replacement. Intravenous compound general anesthesia with superficial hypothermic CPB might be more beneficial in recovering cardiac, pulmonary, and renal functions.

Effect of Education Based on the Health Belief Model on Treatment Adherence in Patients With Heart Valve Replacement Surgery

Background: Adherence to the treatment regimen reduces complications of surgery after heart valve replacement. Educating the patient can improve treatment adherence. This study thus aimed to evaluate the effect of education based on the health belief model (HBM) on treatment adherence in patients with heart valve replacement surgery. Methods: In this quasi-experimental research, a total of 90 patients undergoing valve replacement surgery were studied. The subjects were selected randomly and then divided into an intervention and a control group using the permutation blocks method. The data were collected using a demographic questionnaire, an HBM- based questionnaire, and a treatment adherence questionnaire during two stages before and one month after the education. Three 60-minute sessions on HBM- based education were held based on a need assessment for the intervention group. The collected data were analyzed using the chi-square test, paired t test, independent t test, and linear regression in SPSS software version 16.0. Results: Most of the patients in the two groups were male, married, and employed, had reading and writing literacy and lived in an urban area. Both groups were similar in terms of demographic data except for marital status, disease history, and familial disease history. The mean scores of knowledge, HBM constructs (e.g., perceived susceptibility, perceived severity, perceived benefits, perceived barriers, perceived self-efficacy, and cues to action), and treatment adherence were greater in the control group than in the intervention group pre-intervention. However, the mean scores of all variables improved in the intervention group, and there were significant differences in the knowledge, all HBM constructs (except for perceived susceptibility and perceived self-efficacy), and medical adherence between the two groups post-intervention (P&lt;0.05). Conclusion: Considering the positive effect of HBM-based educational intervention on the patients’ treatment adherence, HBM-based education could be suggested for patients with heart valve replacement surgery.

Evaluation of the effect of crocin on prevention of atrial fibrillation after coronary artery bypass grafting or heart valve replacement: A double-blind, randomized, placebo-controlled trial.

The aim of this study was to evaluate the effect of crocin on the prevention of atrial fibrillation after coronary artery bypass grafting (CABG) and heart valve replacement. 100 patients who were scheduled for CABG or heart valve replacement surgeries were randomly assigned into two groups of treatment and placebo. In the treatment group, patients received crocin tablets from three days prior to surgery and on the first three postoperative days (for a total of six days). During the first three days after surgery, postoperative atrial fibrillation (POAF) was assessed by electrocardiogram monitoring. Prooxidant-antioxidant balance (PAB) and c-reactive protein (CRP) levels were also assessed. POAF developed in 7 patients in the treatment group versus 18 patients in the control (p=0.02). PAB levels were significantly lower in the crocin group (p<0.001), while differences in CRP levels were insignificant (p=0.39). It seems that prophylactic use of crocin is effective in reducing the incidence of POAF in patients undergoing heart surgeries.

Monocyte to Lymphocyte Ratio, A Novel Predictor of Acute Kidney Injury After Cardiac Valve Surgery.

Although inflammation contributes to the development of acute kidney injury (AKI), the role of monocyte to lymphocyte ratio (MLR) in predicting the risk of postoperative AKI in patients underwent cardiac surgery is not completely clear yet. This study aimed to investigate whether elevated MLR predicts postoperative AKI. In this retrospective study, a total of 331 adult patients who underwent heart valve replacement were included. These patients are not distinguished between single valve replacement or double valve replacement. AKI was diagnosed, according to the KDIGO classification criteria. The associations between monocyte to lymphocyte ratio (MLR), neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR) and the occurrence of AKI were investigated. Postoperative AKI was detected in 37 (11.2%) patients. In the early period after surgery, the patients who developed AKI had a significant higher preoperative MLR than those who did not (0.38(0.33-0.44) vs. 0.26(0.20-0.34), = 0.02). The receiver operating characteristics (ROC) curve showed that the area under the curve (AUC) of the MLR for predicting AKI was 0.772 (P = 0.01), and the cut-off value was 0.47. Multivariate logistic regression analysis suggested that the higher preoperative MLR (≥0.47) was independent predictor of AKI (OR: 2.951, 95% CI: 1.412-6.167, P = 0.004). According to the cut-off value group verification, patients in the higher preoperative MLR group are more likely to have low cardiac output syndrome (LCOS), renal replacement therapy, and hospital death after surgery. These results showed that MLR could be used as a cost-effective predictor of postoperative AKI in patients who undergo heart valve replacement surgery.

The association between preoperative blood calcium and postoperative blood loss in patients undergoing heart valve replacement surgery.

Bleeding after heart valve surgery is a serious clinical challenge. Hypocalcemia has been associated with the extent of bleeding in patients with spontaneous intracerebral hemorrhage. However, the association between blood calcium levels and bleeding extent in heart valve replacement patients has not been clearly established. This study aimed at determining the association between blood calcium levels and perioperative hemorrhage after heart valve replacement therapy. Based on preoperative blood calcium levels, patients were grouped into the hypocalcemia group and normocalcemia group. Postoperative bleeding, blood product use, and complications were monitored during hospitalization. The association between blood calcium levels and major bleeding was determined by multivariable logistic regression models. In the first 12h after surgery, bleeding in hypocalcemia group was significantly larger than that of the normocalcemia group (338 ± 234mL vs 232 ± 96mL; p = .024). The outcome was the same when the overall chest tube output was considered (950 ± 447mL vs 738 ± 220mL; p = .038). The incidence of major bleeding was 65.91% in the hypocalcemia group and 18.97% in the normocalcemia group (p = .001). Postoperative complications in the two groups were similar. After adjusting for multiple covariates, the adjusted odds ratios (OR) for participants in hypocalcemia group was 10.01 (95% CI 3.35-34.82), compared with that in normocalcemia group (p < .001). In patients undergoing heart valve surgery, preoperative blood concentrations of calcium are associated with postoperative blood loss. Hypocalcemia before operation may increase the risk of postoperative bleeding. When patients with valvular heart disease present with hypocalcemia before surgery, prompt intervention may lead to better control of postoperative bleeding.

High-dose ulinastatin reduces postoperative bleeding and provides platelet-protective effects in patients undergoing heart valve replacement surgery

The aim of this prospective study was to investigate the effect of a high dose of ulinastatin on platelets and coagulation in patients undergoing mitral valve and/or aortic valve replacement with cardiopulmonary bypass (CPB). 273 patients were enrolled in this open-label study. According to patients' willingness, 243 patients were assigned to the ulinastatin group and 30 to the control group. In the ulinastatin group, ulinastatin (300,000 U) was given after the induction of anesthesia, ulinastatin (400,000 U) was added to the CPB pump prime, and then ulinastatin (300,000 U) was administered after weaning from CPB. Complete blood count and coagulation function test were conducted 1 day before surgery and on the first postoperative day. Bleeding and other safety events were recorded during hospitalization. Less postoperative major bleeding occurred in the ulinastatin group (0.4 vs. 6.7%, p=0.03). Moreover, 1 day after CPB, platelet count in the ulinastatin group increased significantly compared to that in the control group (157.7±71.0 vs. 132.1±59.6, p=0.03). Interestingly and contrary to what was expected, activated partial thromboplastin time (APTT) and prothrombin time (PT) did not differ significantly between the two groups. Ulinastatin application did not cause significant increase in total costs (p=0.89). In heart valve replacement surgery with CPB, high-dose ulinastatin could reduce postoperative bleeding and promote platelet recovery with no significant additional medical cost.

Hybrid heart valves with VEGF-loaded zwitterionic hydrogel coating for improved anti-calcification and re-endothelialization.

With the aging of the population in worldwide, valvular heart disease has become one of the most prominent life-threatening diseases in human health, and heart valve replacement surgery is one of the therapeutic methods for valvular heart disease. Currently, commercial bioprosthetic heart valves (BHVs) for clinical application are prepared with xenograft heart valves or pericardium crosslinked by glutaraldehyde. Due to the residual cell toxicity from glutaraldehyde, heterologous antigens, and immune response, there are still some drawbacks related to the limited lifespan of bioprosthetic heart valves, such as thrombosis, calcification, degeneration, and defectiveness of re-endothelialization. Therefore, the problems of calcification, defectiveness of re-endothelialization, and poor biocompatibility from the use of bioprosthetic heart valve need to be solved. In this study, hydrogel hybrid heart valves with improved anti-calcification and re-endothelialization were prepared by taking decellularized porcine heart valves as scaffolds following grafting with double bonds. Then, the anti-biofouling zwitterionic monomers 2-methacryloyloxyethyl phosphorylcholine (MPC) and vascular endothelial growth factor (VEGF) were utilized to obtain a hydrogel-coated hybrid heart valve (PEGDA-MPC-DHVs@VEGF). The results showed that fewer platelets and thrombi were observed on the surface of the PEGDA-MPC-DHVs@VEGF. Additionally, the PEGDA-MPC-DHVs@VEGF exhibited excellent collagen stability, biocompatibility and re-endothelialization potential. Moreover, less calcification deposition and a lower immune response were observed in the PEGDA-MPC-DHVs@VEGF compared to the glutaraldehyde-crosslinked DHVs (Glu-DHVs) after subcutaneous implantation in rats for 30 days. These studies demonstrated that the strategy of zwitterionic hydrogels loaded with VEGF may be an effective approach to improving the biocompatibility, anti-calcification and re-endothelialization of bioprosthetic heart valves.

Changes in serum zinc and copper concentrations in patients with cardiovascular disease following cardiac surgery.

The trace elements copper (Cu) and zinc (Zn) are essential for maintaining oxidative balance, and cardiac surgery is known to provoke an increase in oxidative stress. We investigated the variations in serum Zn and Cu concentrations before and after surgery in patients undergoing on‐ and off‐pump CABG and heart valve replacement. We performed a prospective study on patients undergoing on‐ or off‐pump CABG, or heart valve replacement surgery (48, 51, and 47 patients, respectively). Venous blood samples were obtained, and serum Cu and Zn concentrations were measured preoperatively, 24 h postoperatively, and the time of discharge. In addition, echocardiography was carried out on all patients before surgery and again on the day of discharge. We found the temporal changes in Cu, Zn, and Zn/Cu ratio were significantly different in all three groups of surgery (p < 0.05). In each group, Cu and Zn values and Zn/Cu ratio decreased at the 24‐h postoperative time and rose at the discharge time. There were no significant differences between surgery groups in the changes induced in Zn or Cu values (p > 0.05). In conclusion, the concentrations of Cu and Zn were markedly reduced after on‐ and off‐pump CABG and valve replacement surgery. This may suggest that supplementary Zn and Cu administration could be beneficial during open‐heart surgeries. However, more long‐term studies with more patients are needed to confirm this hypothesis.

The effect of progressive muscle relaxation on sleep quality and postoperative pain in patients undergoing heart valve replacement surgery

Background and aims: To investigate the effect of progressive muscle relaxation on sleep quality and postoperative pain in patients undergoing heart valve replacement surgery. Methods: In this quasi-experimental study, 60 patients undergoing surgery that enter were randomly divided into the muscle relaxation (n=30) or control group (n=30). Data were collected by Pittsburgh Sleep Quality Index and McGill Pain Questionnaire before and after the intervention. Patients in the control group received routine care, but patients in the muscle relaxation group performed a progressive relaxation technique twice a week for one month. Results: Most of the male participants in both groups had diplomas. There is no significant difference between the two groups of relaxation and control regarding age, gender, occupation, and education levels. The mean sleep quality score in the control group was not significantly reduced after the intervention. However, the mean sleep quality in the relaxation group before 13.90±2.23 and after the intervention was 8.03±2.01 significantly decreased (P&lt;0.001). Also, the pain score was significantly reduced after the progressive relaxation group in the intervention group (P&lt;0.001). Although the two groups were the same in all the dimensions of sleep quality before the intervention, significant differences were observed between groups after the intervention in all the dimensions. Conclusion: Progressive muscle relaxation has an influential role in the pain decrease and sleep quality of patients undergoing heart valve replacement surgery and can be used as a safe and cost-free method for patients.