Mechanical Prosthesis Research Articles

A Rare 10-Year Outcome Inverted Replacement of the Mitral Valve with a Mechanical Aortic Valve Prosthesis in an Achondroplastic Dwarfism

A Rare 10-Year Outcome Inverted Replacement of the Mitral Valve with a Mechanical Aortic Valve Prosthesis in an Achondroplastic Dwarfism

P21 INFECTIVE ENDOCARDITIS COMPLICATED BY BLOCKED ATRIAL FIBRILLATION AND AORTIC VALVE RUPTURE: A CASE REPORT

Abstract A 63–year–old male patient with a mechanical mitral prosthesis and permanent atrial fibrillation in TAO was hospitalized for heart failure during a SARS CoV–2 infection in April 2022; the transthoracic echocardiogram performed during the hospitalization showed an ejection fraction of 38% The patient was rehospitalized in September 2022 due to worsening general conditions during suspected pneumonia. The hospitalization was complicated by brady AF with heart rate < 30 b.p.m. symptomatic for asthenia and dyspnoea despite the suspension of beta–blocker and digitalis therapy. Therefore, we decided on the implantation of a temporary pacemaker in urgency and subsequently a definitive pacemaker (Essentio MRI – Boston Scientific). During the hospitalization, the clinical conditions continued to be precarious; a transthoracic echocardiogram revealed suspicious formation of endocardic nature at the aortic valve with consensual severe regurgitation. This datum was confirmed with the TEE echo. At this point, in the suspicion of infective endocarditis, antibiotic therapy was set up and the patient was taken to our reference cardiac surgery where he underwent aortic valve replacement with a mechanical prosthesis, reconstruction of the coronary sinus and of the outflow tract of the left ventricle with heterologous pericardial patch. Currently, the patient performs regular clinical follow up at our Center and is in good general condition.

P272 ROLE OF 3D TRANSESOPHAGEAL ECHOCARDIOGRAPHY IN DIANOSIS OF DYSFUNCTION OF MECHANICAL PROSTHESES

Abstract Infections with endocardial vegetation or the exuberant growth of neoendothelialization tissue (cloth –tissue overgrowth) in heart valve prostheses lead, among other complications, to the malfunction of the prostheses themselves due to obstruction. Among the diagnostic methods available to us, to achieve the diagnosis of prosthetic dysfunction, in recent years three–dimensional transesophageal echocardiography (3D TTE) has become increasingly imposed. We present two clinical cases of patients admitted to our Cardiology department Case 1: Patient of 62 years old, hospitalized for established congestive heart failure. In 2006 he underwent ascending aorta replacement with Dacron 28 prosthesis and aortic valve replacement with mechanical prosthesis (Sorin 25) for aortic bicuspid and ascending aortic aneurysm. During the last follow–up was observed a slight increase in the value of intraprosthetic gradients, as well as a variability in INR values. Physical examination showed signs of heart failure (NT–ProBNP >1000 pg/ml); normal inflammation indices (PCR <2.9 mg/l); ECG: sinus rhythm at 85 bpm with left ventricular overload; trans–thoracic echocardiography showed severe intraprosthetic aortic gradient (Gmax 132mmHg–Gmed 72mmHg), doubtful for cloth adhered to prosthetic discs; 3D TTE shoved hyperechoreflective image adhered to the posterior mobile element (5x9mm) which was fixed in semi–closure. Subsequently, the patient underwent prosthetic replacement surgery with biological prosthesis. Case 2: Patient of 67 years old, heavy smoker, hypertensive, with aortic mechanical prosthesis, a few weeks before hospitalized for Corynebacterium Jeikeium infection. Hospitalized again for fever with increased inflammation indices (CRP 202mg/l). A first TTE concluded for suspected endocarditis of the prosthesis; this doubt was also dissolved by 3D TTE which showed a soft protruding image of the posterior mobile element, preventing the opening and determining severe stenosis (Gmax 160mmHg–Gmed of 80 mmHg), so this patients was transferred to the cardiac surgery department. Conclusions 3D TTE is a method of rapid and safe execution that can be exploited not only pre– or intraoperatively but also to settle diagnostic suspicions not clarified by traditional 2d methods, even managing to distinguish cloth deposits from vegetation / abscesses.

P136 “THERE’S NO TWO WITHOUT THREE”: A STRANGE CASE OF RECURRENT CORONARY EMBOLISM

Abstract Background A 68 year–old woman with rheumatic heart disease underwent surgery replacement of aortic and mitral valves with mechanical prostheses 20 years ago, and since then has been in VKAs therapy. One year after the operation, she was hospitalized for ischemic stroke without relics. For detection of 2:1 block on the ECG Holter/24h a PM was implanted. After 4 years, she had an acute coronary syndrome (ACS) with VF (treated with DC–Shock). Coronary angiography (CA) showed no coronary stenosis. It was replaced PM to ICD. In 2017, she had a TIA and a mitral prosthesis dysfunction was detected from EET with hemidisk thrombosis. After CA, mitral valve replacement was performed but on the 2nd day after surgery she had an anterior STEMI caused by the occlusion of LAD. PTCA and stenting were performed. In October u.s. the patient was referred to the Emergency room for typical angina. An inferior–posterior STEMI was revealed to ECG. CA highlighted embolic occlusion of Cx and good result of prior LAD’s stenting. After multiple and ineffective attempts, invasive recanalization’s procedure was interrupted considering both patient’s high bleeding risk and embolic aetiology. Excluded prosthetic thrombosis and thrombophilic anomalies, patient was discharged in clinical stability with SAPT+ VKAs therapies. Discussion Coronary embolism (CE) represents 3% of ACS because the coronary arteries are protected from embolism thanks to their acute’s angle origin from the aorta. Embolism origin is various and it can originate from left (LAA, LVx, valvular, prosthetic structures) or right heart sections (paradoxical embolism in the case of PFO),generally during AF. In our case, prosthetic origin is the most probable embolic source as demonstrated by cerebral ischemic (TIA/stroke) and coronary events (first anterior then inferior–posterior STEMI) after valves surgery. Treatment consists of restoring antegrade flow without DES implantation, using if possible intracoronary thrombolysis or thromboaspiration. In secondary prevention, embolism sources removal and anticoagulant therapy are mandatory. In our case we recommended SAPT+VKAs with strict INR’s control (range 3.5–4). Conclusions Although CE is a rare and potentially fatal phenomenon it should be suspected in the absence of coronary atherosclerosis and in the presence of predisposing conditions such as those mentioned above. This case demonstrates that CE can occur in absence of prosthetic thrombosis with suboptimal INR control.

C35 A RARE CASE OF NON–BACTERIAL THROMBOTIC ENDOCARDITIS IN YOUNG WOMAN AFFECTED BY ADVANCED UTERINE CANCER

Abstract A 37–year–old woman affected by uterine HPV–related adenocarcinoma complicated by paraneoplastic pulmonary thromboembolism, came to the emergency department for recurrent episodes of dysarthria and blurred vision with spontaneous resolution. Home medications: Enoxaparin 5000 UI b.i.d, levofloxacin 500 mg/die, deltacortene 25 mg/die and omeprazole 20 mg/die. Blood analysis: normocytic anemia (Hb 9 gr/dl),elevated D–dimer (22.5 mcg/ml) and elevated C–reactive protein (18.3 mg/dl). Procalcitonin and blood cultures resulted negative. Brain CT scan: ischemic brain lesions of embolic nature in the right precentral gyrus and in the left post central gyrus. EKG: sinus rhythm, T–wave inversion in inferior leads. In the suspect of cardioembolic stroke a transthoracic (TTE) and subsequent transesophageal (TOE) echocardiography was performed: TTE: isoechoic oval–shaped thickening of the aortic valve cusp tips, producing aortic regurgitation with double jet regurgitation. TOE: evidence of multiple isoechoic masses involving all the aortic cusps, without perivalvular aortic extension, producing significant aortic regurgitation due to coaptation– gap (Figure 1). The diagnosis of non–bacterial thrombotic endocarditis (NBTE) was made up. Although the standard medical therapy (anticoagulation and chemotherapy) was promptly started, it wasn’t effective with progression of the disease leading to surgical indications of valve intervention. The patient underwent aortic valve replacement with bioprosthesis avoiding mechanical prosthesis, despite the young age, in anticipation of major surgery for the uterine cancer. Surgical specimen turned negative for microorganism growth confirming the diagnosis of marantic endocarditis. No further episodes of ischemic stroke appeared after the replacement of the valve and the patient had no neurological sequelae. NBTE is a rare condition of non–infective endocarditis characterized by the formation of aggregates of platelets and fibrin that affects usually undamaged heart valves in the absence of bacteremia and mostly occurs in patients with a predisposing state like hypercoagulability. Surgical indications of valve intervention are not well encoded but in most cases they follow the raccomandations for infective endocarditis. Our experience highlights the need of a prompt intervention in order to reduce the damage of systemic embolization and preserve patient’s hemodynamics with a strict checking of disease progression.

P255 A GOOD PERSPECTIVE NEEDS TWO POINT OF VIEW: TRANSVENOUS CRT–D LEAD EXTRACTION COMPLICATED BY INTRAOSSEUS COURSE OF THE CORONARY SINUS LEAD

Abstract A 66 year old woman with dilated cardiomyopathy, carrier of CRT–D device in secondary prevention since 2013 and a mitralic mechanical prosthesis, suffered of CIED infection, confirmed by PET imaging exam. She was scheduled in our Hospital Unit for transvenous lead extraction. The procedure was performed by the subclavian approach, and the transvenous lead extraction was staged using mechanical telescopic sheats. After the extraction of the atrial and ventricular leads, the advance of the sheats was hampered by tenacious adherences along the site of vascular subclavian access of the coronary sinus lead. Firstly the portion of the lead running inside the coronary sinus was retracted with a pigtail by femoral vein approach. The inability to pass over the tenacious adherences at the point of the subclavian vein access were overcome expanding the surgical field with the help of the Vascular Surgeon, finding out that the adherence was determined by the presence of an osteophyte embracing the lead to the clavicle. The osteophyte was then surgically removed and the lead was finally extracted by jugular vein access. In this case the CIED leads were implanted using a intrathoracic subclavian venous access, where the vein lies behind the medial region of the clavicle. This approach could rarely lead to a periosteal penetration during needle advance that can generate osteophytes between the lead and the bone. In those circumstances the transvenous lead extraction could become extremely complicated, whatever technique is used.

An Intelligent Medical Platform for PCG Signal Preprocessing For Patients with Mechanical Double-Winged Prostheses Valve

An Intelligent Medical Platform for PCG Signal Preprocessing For Patients with Mechanical Double-Winged Prostheses Valve

Aortic valve replacement for aortic stenosis in patients under 65-years-old

Aortic valve stenosis is the most common valve disease in the world, with particularly poor prognosis if left untreated. Its management in young patients is based on surgical aortic valve replacement (bioprosthesis or mechanical prosthesis, and Ross or Ozaki technique), and rarely percutaneous (TAVR). In this population, the choice of the technique used is of primary importance in terms of hemodynamic performance and durability. The objective of this work is to compare 5 different techniques used in the management of aortic stenosis in patients under 65 years old at CHRU of Tours. We conducted a retrospective, single-center, observational study at the CHRU of Tours. Five cohorts (mechanical prosthesis, INSPIRIS bioprosthesis, Ross, Ozaki and TAVR) were compared in terms of pre-, per- and postoperative, clinical and hemodynamic parameters. We included 163 patients under 65-years-old with aortic stenosis operated at the CHRU of Tours between January 2015 and October 2021. Hemodynamically, after stratification on the prosthetic caliber, the best results were found with the Ozaki and Ross techniques, followed by TAVR, the INSPIRIS bioprosthesis and finally the mechanical prosthesis. A severe prosthesis-patient mismatch rate of 10% was found in all patients, with no significant difference between the different techniques (P = 0.1827). Clinically, there was no significant difference between the groups in terms of mortality or re-intervention related to the aortic valve after a mean follow-up of 19.2 months (P = 0.6545). However, pacemaker implantation was significantly higher in the TAVR group (P = 0.0178). Each surgical and percutaneous technique has its specific advantages and complications. The excellent short-term hemodynamic parameters of the Ross and Ozaki techniques seem to encourage the use of these techniques in the management of aortic stenosis in young patients. More powerful studies with a longer follow-up time would allow to confirm these preliminary results.

Pregnancy outcomes in women with a mitral valve prosthesis: A systematic review and meta-analysis

ObjectivesTo evaluate the ongoing debate concerning the choice of valve prosthesis for women requiring mitral valve replacement (MVR) and who wish to conceive. Bioprostheses are associated with risk of early structural valve deterioration. Mechanical prostheses require lifelong anticoagulation and carry maternal and fetal risks. Also, the optimal anticoagulation regimen during pregnancy after MVR remains unclear. MethodsA systematic review and meta-analysis was conducted of studies reporting on pregnancy after MVR. Valve- and anticoagulation-related maternal and fetal risks during pregnancy and 30 days’ postpartum were analyzed. ResultsFifteen studies reporting 722 pregnancies were included. In total, 87.2% of pregnant women had a mechanical prosthesis and 12.5% a bioprosthesis. Maternal mortality risk was 1.33% (95% confidence interval [CI], 0.69-2.56), any hemorrhage risk 6.90% (95% CI, 3.70-12.88). Valve thrombosis risk was 4.71% (95% CI, 3.06-7.26) in patients with mechanical prostheses. 3.23% (95% CI, 1.34-7.75) of the patients with bioprostheses experienced early structural valve deterioration. Of these, the mortality was 40%. Pregnancy loss risk was 29.29% (95% CI, 19.74-43.47) with mechanical prostheses versus 13.50% (95% CI, 4.31-42.30) for bioprostheses. Switching to heparin during the first trimester demonstrated a bleeding risk of 7.78% (95% CI, 3.71-16.31) versus 4.08% (95% CI, 1.17-14.28) for women on oral anticoagulants throughout pregnancy and a valve thrombosis risk of 6.99% (95% CI, 2.08-23.51) versus 2.89% (95% CI, 1.40-5.94). Administration of anticoagulant dosages greater than 5 mg resulted in a risk of fetal adverse events of 74.24% (95% CI, 56.11-98.23) versus 8.85% (95% CI, 2.70-28.99) in ≤5 mg. ConclusionsA bioprosthesis seems the best option for women of childbearing age who are interested in future pregnancy after MVR. If mechanical valve replacement is preferred, the favorable anticoagulation regimen is continuous low-dose oral anticoagulants. Shared decision-making remains priority when choosing a prosthetic valve for young women.

Follow-up of the aortic valve replacement surgery in a national reference hospital in Lima, Peru, period 2016-2019

Objective: To describe the perioperative characteristics of patients undergoing aortic valve replacement; as well as complications, mortality, follow-up and survival.
 Materials and methods: A retrospective study of patients operated between 2016 and 2019 was carried out. Pre, intra, and postoperative characteristics were determined, as well as clinical and echocardiographic follow-up. Student's t test was used to compare means. Overall survival and cardiovascular event-free survival were analyzed using the Kaplan-Meier method.
 Results:110 patients were included (59.1% male), the mean age was 65.2 ± 11.3 years, the majority with arterial hypertension (47.3%). The most frequent etiology was degenerative (47.3%). A mechanical prosthesis was implanted in 59.1%. In the postoperative period, a median mechanical ventilation time of 8 hours was observed, with an average stay in the ICU of 5.8 ± 6.7 days. The most frequent complications were atelectasis (21.8%), atrial fibrillation (19.1%), low output syndrome, pneumonia, and acute kidney injury (7.3% each). Hospital mortality was 5.5% (cardiogenic shock as the frequent cause). During follow-up at one year, there was an improvement from NYHA II-III functional class (pre-surgical) to NYHA I-II (p <0.001), prosthesis dysfunction was found in 13.3% (the majority due to paravalvular leak). Overall survival at 1, 3, and 5 years was 88,2 ± 3,1, 83.4 ± 3.6% y 74.3 ± 5.0%, respectively.
 Conclusions: Aortic valve replacement surgery in our setting implies an improvement in quality of life with good functional results, complication rate, and morbidity and mortality comparable with the world literature.

Mechanical prosthetic mitral valve thrombosis during dabigatran treatment

Dabigatran has been approved for prevention of thromboembolic complications in non-valvular atrial fibrillation. We present a case of a mechanical prosthetic mitral valve thrombosis during anticoagulation with dabigatran, switched in the last three months after 10 years treatment with warfarin. The patient presented with acute respiratory failure and decompensated heart failure. She was initially treated with unfractioned heparin and then was sent for emergency surgery for cardiogenic shock. As emerging from contemporary evidence and as recommended by guidelines, dabigatran, as well as the other direct oral anticoagulants, should be avoided in patients with mechanical valve prosthesis. Echocardiography is indicated if dyspnoea develops in such patients.

Valve-sparing root replacement versus composite valve graft root replacement: Analysis of more than 1500 patients from 2 aortic centers

ObjectivesThe long-term outcomes comparing valve-sparing root replacement, composite valve graft with bioprosthesis, and mechanical prosthesis have yet to be explored. We investigated the long-term survival and reintervention rates after 1 of 3 major aortic root replacements in patients with tricuspid aortic valves and patients with bicuspid aortic valves. MethodsA total of 1507 patients underwent valve-sparing root replacement (n = 700), composite valve graft with bioprosthesis (n = 703), or composite valve graft with mechanical prosthesis (n = 104) between 2004 and 2021 in 2 aortic centers, excluding those with dissection, endocarditis, stenosis, or prior aortic valve surgery. End points included mortality over time and cumulative incidence of aortic valve/proximal aorta reintervention. Multivariable Cox regression compared adjusted 12-year survival. Fine and Gray competing risk regression compared the risk and cumulative incidence of reintervention. Propensity score–matched subgroup analysis balanced the 2 major groups (composite valve graft with bioprosthesis and valve-sparing root replacement), and landmark analysis isolated outcomes beginning 4 years postoperatively. ResultsOn multivariable analysis, both composite valve graft with bioprosthesis (hazard ratio, 1.91, P = .001) and composite valve graft with mechanical prosthesis (hazard ratio, 2.62, P = .005) showed increased 12-year mortality risk versus valve-sparing root replacement. After propensity score matching, valve-sparing root replacement displayed improved 12-year survival versus composite valve graft with bioprosthesis (87.9% vs 78.8%, P = .033). Adjusted 12-year reintervention risk in patients receiving composite valve graft with bioprosthesis or composite valve graft with mechanical prosthesis versus valve-sparing root replacement was similar (composite valve graft with bioprosthesis subdistribution hazard ratio, 1.49, P = .170) (composite valve graft with mechanical prosthesis subdistribution hazard ratio, 0.28, P = .110), with a cumulative incidence of 7% in valve-sparing root replacement, 17% in composite valve graft with bioprosthesis, and 2% in composite valve graft with mechanical prosthesis (P = .420). Landmark analysis at 4 years showed an increased incidence of late reintervention in composite valve graft with bioprosthesis versus valve-sparing root replacement (P = .008). ConclusionsValve-sparing root replacement, composite valve graft with mechanical prosthesis, and composite valve graft with bioprosthesis demonstrated excellent 12-year survival, with valve-sparing root replacement associated with better survival. All 3 groups have low incidence of reintervention, with valve-sparing root replacement showing decreased late postoperative need for reintervention compared with composite valve graft with bioprosthesis.

Monocyte to HDL ratio may predict thrombosis in patients with mechanical mitral and aortic valve prosthesis.

Increased inflammatory biomarkers have been reported in prosthetic heart valve thrombosis (PHVT). Monocyte to HDL ratio (MHR) and albumin to CRP levels (CAR) are two biomarkers used widely for systemic inflammation but there is a lack of data on prosthetic heart valves. This study aimed to find out the potential predictive value of MHR and CAR for PHVT. Patients who had the diagnosis of mechanical mitral/aortic PHVT and normally functioning prosthesis were retrospectively analyzed. Laboratory data including complete blood count and biochemistry were recorded. Transesophageal echocardiography was performed to diagnose PHVT. The study included 118 patients with mechanical PHVT and 120 patients with normally functioning prosthesis. White blood count, monocyte levels, C-reactive protein, MHR and CAR were significantly higher whereas the lymphocyte, HDL and INR levels on admission were lower in patients with PHVT. Multivariate analysis showed that as well as inadequate anticoagulation, MHR, but not CAR, was found to be an independent predictor of thrombosis in patients with PHVT. Receiver operating characteristic curve analysis was performed to detect the best cut-off value of MHR in the prediction of thrombosis in patients with prosthetic valves. MHR level of > 12.8 measured on admission, yielded an AUC value of 0.791 [(CI 95% 0.733-0.848 p < 0.001) sensitivity 71%, specificity 70%]. Inadequate anticoagulation is the primary cause that leads to thrombosis in mechanical prosthetic valves. Increased MHR, but not CAR, was also shown to be an independent predictor of thrombosis in patients with mechanical mitral and aortic prosthetic valves.

Starr–Edwards ball caged mechanical heart valves’ reverberations – Need for a Phoenix of analysis with a critical mindset

The mechanical heart valve prosthesis with a caged ball has been around for 60 years. It has since experienced changes and adjustments. The Starr–Edwards (SE) valve was a pioneer and was taken out of clinical use in the late 2000s. SE is reportedly close to or has reached the age of 50, according to numerous sources from around the globe. The author’s observations and review of the literature about thrombogenicity, pannus formation, left ventricular outflow tract obstructions, and infective endocarditis in the SE valves, which were reportedly higher before its clinical ending, were only an overestimation and were not supported by scientific data. However, it was less discussed in the article, along with potential benefits. The main reasons for its demise were its obtrusive size and unattractive shape. There have been several successful implantations of these valves in Asian nations and reports of fewer primary failures and unexpected cardiac fatalities. Therefore, there is a need for extensive data gathering, documentation, and more recent studies on these valves to prepare for a prospective revival of use with newer research, mainly when long-term durability is considered.

Simultaneous pulmonary vein isolation and ablation of the substrate of biatrial flutter in a patient with a mechanical mitral valve prosthesis: a case report

Catheter radiofrequency ablation of the atrial fibrillation substrate may be difficult in patients after open heart surgery. Difficulties may arise in the presence of a mitral valve prosthesis, atrial arrhythmias of several morphologies (more often left atrial atypical flutter), including incisional ones. These cases require a thorough and scrupulous approach to achieve complete isolation of all available arrhythmia substrates. A distinctive feature of this observation is the successful simultaneous pulmonary vein isolation and two atrial arrhythmias in a patient with a mechanical mitral prosthesis.

NEWLY DETECTED SEVERE RHEUMATIC HEART DISEASE IN ELDERLY AND THE CHALLENGES IN ITS MANAGEMENT—A CASE REPORT

A 60-year-old man with a history of frequent lower respiratory tract infections presented with symptoms of face pufness, swelling of bilateral limbs, palpitation, and shortness, but subsequent diagnostic testing at the hospital revealed rheumatic heart disease with poorly managed atrial brillation, severely enlarged left atrium, and mitral valve area 1.1 cm2. It was determined that replacing the patient's mitral valve with a mechanical prosthesis would be the best course of action. Our choice was inuenced by the fact that the patient will require chronic anticoagulation for atrial brillation anyway, despite the common trend of employing bio prosthesis in the elderly. Our case presentation demonstrates a late-presenting example of RHD with unexpected connections and the difculties in selecting the most effective treatment.

Is It Possible to Place a Pacemaker Lead Through a Bileaflet Mechanical Prosthesis?

We present a 64-year-old woman who underwent mitral, aortic, and tricuspid valve (TV) replacement with mechanical prostheses. Two months after TV surgery, she presented third-degree atrioventricular block. After attempting to place a pacemaker lead through the coronary sinus, it was placed through the mechanical valve in the tricuspid position as the last option. At 1 year of follow-up, the device shows no signs of dysfunction, and the prosthesis has moderate regurgitation.

Comparative Morphological and Morphometrical Analysis of Atrio-Ventricular Valves of Human and Porcine

There is increased incidence of valvular heart diseases in recent years due to life style modifications. The mortality rates in valvular diseases are kept in pace using various modalities of treatments. One such lifesaving treatment is valve replacement surgeries. These are done by using mechanical valve prosthesis or tissue grafts. The tissue valves prosthesis, harvested from porcine heart are called as xenograft and are increasingly used in valve repair and replacement surgeries. In the present scenario, there is a smaller number of systematically analysed literatures available on the comparative anatomy of human and porcine heart valves. Hence this study was carried out to acquire knowledge and to put forth some points to future research works on heart valves. In this study, 20 formalin fixed porcine and human hearts were procured from slaughter house and cadavers respectively. The morphology and morphometry of tricuspid valve and mitral valve was observed and analysed using spss software 20 version. All the dependent variables were compared using student t test and independent sample test. The results were tabulated and compared. It was observed that the tricuspid and the mitral valve of the porcine resembles the corresponding human heart valves in morphology and morphometry and their values were coinciding to their maximum. The porcine valve resembles human heart valves in morphology and it can be used in designing valve substitutes in replacement surgeries. Porcine valve can also be used as bio-prosthesis by matching the morphometry and by reducing the geometrical difference to their minimum by using any interventional radiology. KEY WORDS: Tissue Graft, Porcine, Tricuspid Valve, Mitral Valve, Morphology And Morphometry.

Mechanical versus Bioprosthetic Aortic Valve Replacement in Middle-Aged Adults: A Systematic Review and Meta-Analysis.

Mechanical prostheses and bioprosthetic prostheses have their own advantages and disadvantages. Mechanical ones are recommended for younger patients (<50 years old), and bioprosthetic ones are recommended for older patients (>70 years old). There is still debate regarding which kind of prosthesis is better for middle-aged patients (50 to 70 years old) receiving aortic valve replacement (AVR). To solve this problem, we conducted this meta-analysis. Given that only one randomized controlled trial (RCT) study was included, we conducted a subgroup analysis of RCT and propensity score matching (PSM) retrospective studies to reduce the bias. We systematically searched articles related to clinical outcomes of mechanical and bioprosthetic prostheses in middle-aged patients receiving AVR in the PubMed, Cochrane Library, and China National Knowledge Infrastructure (CNKI) databases. The published date was up to 1 October 2022. Studies were excluded if not only middle-aged patients were included, or if they lacked direct comparisons between mechanical and bioprosthetic prostheses. In total, 22 studies with 32,298 patients were included in the final analysis. The results show that patients aged between 50 and 70 receiving AVR with mechanical prostheses achieved better long-term survival and fewer reoperations and valve-related events but suffered more with bleeding events. No significant difference could be found in terms of early mortality and long-term cardiac death. The same results could be observed in the subgroup analysis of RCT and PSM retrospective studies. Both mechanical and bioprosthetic prostheses are beneficial to middle-aged patients undertaking AVR procedures. However, mechanical prostheses show better clinical outcomes in long-term survival and comorbidities. Individual recommendation is still necessary.

Oral Anticoagulation in Patients with Chronic Liver Disease.

The administration of an anticoagulant in patients with liver disease (nonalcoholic steatohepatitis-NASH, nonalcoholic fatty liver disease-NAFLD, chronic hepatitis, or cirrhosis) who have an indication (atrial fibrillation, venous thrombosis, or pulmonary embolism) is challenging because there is an imbalance between thrombosis and bleeding. There is a need to focus our attention on preventing risk factors because diabetes, obesity, dyslipidemia, smoking, and sedentary behavior are risk factors for both NASH/NAFLD and AF, and these patients require anticoagulant treatment. Patients with advanced liver disease (Child-Pugh C) were excluded from studies, so vitamin K antagonists (VKAs) are still recommended. Currently, VKAs are recommended for other conditions (antiphospholipid syndrome, mitral valve stenosis, and mechanical valve prosthesis). Amongst the patients under chronic anticoagulant treatment, especially for the elderly, bleeding as a result of the improper use of warfarin is one of the important causes of emergency admissions due to adverse reactions. DOACs are considered to be efficient and safe, with apixaban offering superior protection against stroke and a good safety profile as far as major bleeding is concerned compared to warfarin. DOACs are safe in the Child-Pugh A and B classes (except rivaroxaban), and in the Child-Pugh C class are contraindicated. Given that there are certain and reliable data for chronic kidney disease regarding the recommendations, in liver function impairment more randomized studies must be carried out, as the current data are still uncertain. In particular, DOACs have a simple administration, minimal medication interactions, a high safety and effectiveness profile, and now a reversal agent is available (for dabigatran and idarucizumab). Patients are also statistically more compliant and do not require INR monitoring.