Mitral Aortic Valve Replacement Research Articles

Bloodless Operations in the Surgical Treatment of Mitral-Aortic Heart Disease in Conditions of Artificial Circulation

Traditional mitral and aortic valve replacement in conditions of artificial blood circulation (ABC) involves the use of blood products. Given various complications arising in perioperative period, the authors propose a technique for “bloodless operations” without the use of donor blood, without the use of columns, and the “sell-saver” method. From January 1, 2011 to December 31, 2018, mitral-aortic valve replacement was performed in 79 patients; in 42 of them blood products were used during surgery, and in 37 patients donor blood components were not used. The method of anaesthetic and infusion-perfusion measures for mitral-aortic valve replacement in conditions of ABC is given. The use of the blood-saving method has allowed to obtain good clinical effect without transfusion complications in perioperative period, which facilitated the use of bloodless methods for mitral-aortic valve replacement in the main group in conditions of ABC and reduce blood transfusions in perioperative period from 27.4 % to 10.3 % of the circulating blood volume (CBV), compared to the control group. In the variant of reservation of autoblood “A+B+C” and exfusion of 27.2% of the CBV, the most effective variants of the blood-saving) technology were observed during mitral-aortic valve repair in conditions of ABC.

P806 Cavitation phenomenon in mechanical valves: not only microbubbles

Abstract Introduction It is well described the presence of microbubbles (MBs) which are high-velocity, small, bright echoes presences that occur with the closing/opening of the mechanical double disk valve, more frequently in mitral position but less frequent growth of the cavitation bubbles are described. We considered the echo studies of patients with growth of cavitation bubbles and we evaluate the possible impact of the hemodynamic parameters of their formation and then misdiagnosis with endocarditis. Methods We analyzed retrospectively the echocardiographic studies of 49 patients with growth of cavitation bubbles and we went back to all studies until the date of surgery if available, to see in how many of those echos, this phenomenon was present. Patient"s blood pressure (BP) and heart rate (HR) measurement were available for each echo study. For the present analysis the last echo study with or without growth of cavitation bubbles were considered. The last echo study without growth of cavitation bubbles was considered as control group. Results Fourty nine patients (M26/F23) with mean age of 46.5 ± 13.6 years were identify as having growth of the cavitation bubbles and a total of 325 echo studies were reviewed. All patients had mitral valve replacement but 4, that had only aortic mechanical valve. 43% had mitral-aortic valve replacement and 5 had 3 or 4 valves replaced. The follow-up period was of 3697 ± 2481 days, 52%±31% of the echo studies reviewed had growth of the cavitation bubbles. At the time of the study systolic BP was 124 ± 12.5 vs 121.1 ± 16.4 mmHg, p = 0.1 (echo study with versus without growth cavitation respectively), diastolic 72.7 ± 10.1 vs 69.4 ± 14.9 mmHg, p= 0.2; HR 81.3 ± 19.4 vs 73.7 ± 14.1 bpm, p = 0.05. No statistical differences in trans mitral gradients were found between the two groups (peak 11.8 ± 3.9 vs 11.7 ± 4.3 mmHg, p = 0.7; mean 4.6 ± 1.9 vs 4.2 ± 1 mmHg.6p = 0.1). 33 TEE were performed and in 50% of cases because of suspecion of endocarditis. Only 2 TEE were positive for endocarditis and one positive for pannus and high gradients across the valve in addition to cavitation. Conclusion Cavitation phenomenon in mechanical valves, in particular mitral bi-leaflet valve is well known but growth of cavitation bubbles is seldom described. We found that this fenomenon is frequently present although not constant, is related with increased HR and can be responsible of misdiagnosis with endocarditis. Abstract P806 Figure.

Percutaneous endovascular treatment of an iatrogenic superior cava vein syndrome during the immediate post-operative period after mitral-aortic valve replacement

Superior vena cava syndrome (SVCS) results from superior vena cava obstruction, causing a decrease in venous return from the head, neck, and upper extremities. Although the most frequent cause is still malignant tumour processes, in recent years an increase has been observed in non-tumour causes, such as thrombosis of intravascular devices or iatrogenic causes during cardiac surgery. A case is presented of SVCS after cardiac surgery treated satisfactorily by an endovascular technique and systemic anticoagulation. El síndrome de vena cava superior (SVCS) resulta de la obstrucción de la vena cava superior, que origina una disminución del retorno venoso procedente de cabeza, cuello y extremidades superiores. Aunque la causa más frecuente siguen siendo procesos tumorales malignos, en los últimos años hemos visto un aumento de causas no tumorales, como trombosis de dispositivos intravasculares permanentes o causas iatrogénicas durante la cirugía cardiaca. Presentamos un caso de SVCS tras cirugía cardiaca tratado de forma satisfactoria mediante técnica endovascular y anticoagulación sistémica.

Flexible band made of autologous pericardium for functional tricuspid regurgitation repair

ABSTRACTIntroduction: Secondary (Functional) tricuspid regurgitation (TR) is a common problem in cardiac surgery that occurs secondary to left-sided valvular heart disease, more evident with mitral valve pathology, especially mitral stenosis. Right ventricular overload caused by pulmonary hypertension is the main leading factor causing right ventricular enlargement and tricuspid annular dilatation. Many techniques were developed for repair of tricuspid incompetence. Some techniques failed to show good results and even the regurgitation may recur with progression of disease. We studied the early results of tricuspid annuloplasty procedure using flexible band made of autologous pericardium.Methods: The study was conducted from September 2016 to July 2018. Thirty patients treated with tricuspid annuloplasty using flexible band made of autologous pericardium for functional TR. Concomitant procedures included mitral valve replacement in 24 patients and mitral-aortic valve replacement in 6 patients. Follow-ups both clinically to assess the functional status (NYHA class) and by echocardiography were used to judge on success of repair. During the study, another nine patients were treated with Devega repair due to surgeon preference. The results with this method were compared with a group collected from the records.Results: Thirty patients were operated using a flexible band of pericardium and followed up for at least 1 year. There was no mortality, neither in hospital nor during follow-up period. The severity of TR and the functional status improved with time. Twenty-eight patients (93.3%) were in NYHA class I at 1-year postoperative follow-up. Freedom from recurrent TR was 96.7% at 1 year. In comparison to the traditionally used Devega repair, there were no statistical differences neither in postoperative TR nor in functional status.Discussion: Tricuspid repair using flexible band of autologous pericardium is an option for functional TR. Further studies with a larger number of samples and a longer term of follow-up are necessary to confirm our findings.

Successful Thrombolytic Treatment of a Thrombosed Mechanical Mitral Valve in a Post-brain Surgery Patient- A Case Report and Literature Review

The first-line management of prosthetic valve thrombosis is not yet finalized; dealing with such cases remains a clinical challenge and requires prompt detection, timely diagnosis and individualized case management regardless of whether the case in question requires a surgical or medical therapeutic approach. We report a unique case of mechanical mitral valve thrombosis post Bentall procedure with a double aortic-mitral valve replacement in a patient who previously underwent brain surgery after experiencing a Road Traffic Accident (RTA). The patient was successfully treated by using a combined loading and infusion regimen of tissue-Plasminogen Activators (t-PA). A small loading dose of 15 mg followed by a low-dose slow infusion of t-PA has been shown to provide effective and safe thrombolysis in high-risk patients with prosthetic valve thrombosis.

Effect of large dose creatine phosphate on myocardial ischemia-reperfusion injury in patients undergoing cardiac valve replacement

Objective To investigate the effect of high-dose creatine phosphate (CP) on myocardial ischemia-reperfusion (I/R) injury in patients undergoing cardiac valve replacement. Methods Two hundred and forty-six ASA Ⅱ or Ⅲ patients aged 42-71 yr weighing 45-80 kg undergoing mitral-aortic valve replacement were randomly assigned into 2 groups: control group ( n = 122) and CP group ( n = 124). CP 10 g in 100 ml normal saline (NS) was infused over 60 min starting from the beginning of operation in group CP. In control group NS 100 ml was infused instead of CP. Blood samples were collected before anesthesia and on 1st and 5th postoperative day for determination of serum CK, CK-MB and LDH activity and cTnI concentration. The number of patients receiving dopamine and adrenaline at the time of return of spontaneous heart beat and 12, 24 and 48 h after operation was recorded. The incidence of arrhythmia (auricular fibrillation, ventricular arrhythmia), myocardial infarct and left ventricular ejection fraction (LVEF) were also compared between the 2 groups. Results Serum CK, CK-MB and LDH activity and cTnI concentration on 1st and 5th postoperative day, the doses of dopamine and adrenalin, the incidence of arrhythmia and myocardial infarct were significantly lower in group CP than in control group. The postoperative LVEF and the incidence of spontaneous recovery of spontaneous heart-beat were significantly higher in group CP than in control group. Conclusion Pretreatment with high dose CP can protect myocardium against I/R injury in patients undergoing cardiac valve replacement under CPB. Key words: Phosphocreatine; Heart valve prosthesis; Myocardial reperfusion injury

Heart valve surgery in patients with the antiphospholipid syndrome: analysis of a series of nine cases

Antiphospholipid syndrome (APS) is a rare coagulation disorder associated with recurrent arterial and venous thrombotic events. Heart valve abnormalities are commonly found in patients with APS. From March 1998 to March 2007, nine patients with APS underwent heart valve surgery using cardiopulmonary bypass. We retrospectively reviewed their clinical data, operative and postoperative courses and the long-term results. The mean age was 43.6+/-10.4 years, six were female and three male. Four patients underwent mitral valve replacement, three went through aortic valve replacement, one underwent combined mitral-aortic valve replacement and another aortic valve plasty. The syndrome was primary in seven patients and associated with systemic lupus erythematosus (SLE) in two. Follow-up was 8 days to 8 years (median 66 months). Two patients died in the early postoperative period: both due to an acute cerebrovascular accident. Four patients presented an uneventful late postoperative course. One patient experienced an ischaemic stroke 5 years after mitral valve replacement (MVR) and developed refractory congestive heart failure requiring heart transplantation three years postoperatively. Heart valve surgery in patients with antiphospholipid syndrome may carry considerable early and late mortality and morbidity. Thrombo-embolic complications are the most common complications. Mechanical prostheses have been used at our Institution in the previous years; however, today, after reviewing our historical results, we reconsider our general strategy and believe that tissue heart valve prostheses are the possible ideal substitutes, minimising the risks of morbidity and mortality due to the hypercoagulable state of APS.

Eight-Year Outcomes of Tricuspid Annuloplasty Using Autologous Pericardial Strip for Functional Tricuspid Regurgitation

Although several techniques of tricuspid annuloplasty have been used to treat tricuspid regurgitation (TR), TR can persist or recur with redilatation of the annulus or disease progression. We compared the long-term results of newly developed tricuspid annuloplasty procedure using autologous pericardial strip with that of conventional suture annuloplasty. From January 1997 to April 2006, 334 patients (mean age, 52.7 years) underwent tricuspid annuloplasty for functional TR. Concomitant procedures included mitral valve replacement in 261 patients and mitral-aortic valve replacement in 73. We performed conventional suture annuloplasty (De Vega or Kay) in 117 patients and autologous pericardial strip annuloplasty in 217 patients. There were 8 in-hospital deaths (mortality, 2.4%). Mean follow-up was 42.1 months, and total follow-up duration was 1,145 patient-years. Significant TR before discharge was noted in 34 patients (11.1%). The severity of TR improved with time in the autologous pericardial strip annuloplasty group; however, it became worse in conventional suture annuloplasty group (p = 0.05). Multivariate analysis demonstrated that preoperative severity of TR and conventional suture annuloplasty were significant predictors of recurrent TR. Overall survival was comparable between two groups (p = 0.742); however, recurrence-free survival was better for the autologous pericardial strip annuloplasty group than for the conventional suture annuloplasty group (86.8% versus 71.9%; p = 0.039). The long-term recurrence-free survival after autologous pericardial strip annuloplasty appeared to be better than that of conventional suture annuloplasty. Autologous pericardial strip annuloplasty appears to be a simple, easily reproducible, and valid option for surgical treatment of functional TR.

Impact of preoperative ejection fraction on long-term outcome after combined mitral-aortic valve replacement

Impact of preoperative ejection fraction on long-term outcome after combined mitral-aortic valve replacement

Bivalvular mechanical Mitral-Aortic valve replacement in 254 patients: Long-Term results—a 22-year follow-up

Background We have retrospectively studied 254 patients who underwent a bivalvular mechanical mitral-aortic replacement in the cardiovascular and thoracic surgery unit of Nantes from 1979 to 1989. The follow-up was 22 years (1979 to 2001). The last patient was operated on 12 years before the end of the follow-up. Methods All mitral prostheses were St. Jude Medical (SJM) bileaflet valves, and the aortic prostheses were 124 monodisc Björk-Shiley valves, 3 Sorin prostheses, and 127 St. Jude Medical bileaflet prostheses. The mean age was 56.8 ± 8.5 years with a sex ratio equal to 1. Rheumatism as the etiology predominated with 79.5%. Ninety-seven percent of the patients were followed for a total of 2,779 patient-years and a mean of 11.7 years. Results Operative mortality was 7.08%. Freedom from overall mortality and valve-related mortality at 22 years were 45.7% ± 3.6% and 73.1% ± 3%, respectively. The linearized rates of thromboembolic and hemorrhagic events were 1.07% and 0.9% per patient-year, respectively. Multivariate analysis showed age ( p < 0.002), sex ( p < 0.01), and degenerative etiology ( p = 0.04) as independent factors of late mortality, and age, sex, degenerative disease, and tricuspid pathology were related to valve-related mortality. Conclusions This study shows good results after mechanical mitral-aortic replacement in terms of survival rate and quality of life in surviving patients, and outlines the factors influencing long-term results as compared with isolated mitral valve replacement.

Mitral-aortic annular enlargement: modification of Manouguian's technique

We hereby present a technical modification for mitral-aortic annular enlargement. The mitral valve is replaced through the retro-septal approach, avoiding patches for left atrial roof closure. We report a mitral-aortic valve replacement in a patient whose original annuli would preclude adequate prostheses. The simultaneous annular enlargement may be necessary for avoiding patient-prosthesis mismatch and for reconstructing destroyed mitral and aortic annuli. The technique may minimize the risk of bleeding and of paravalvular leakage, using an approach well known to cardiac surgeons.

Late results of double-valve replacement with biologic or mechanical prostheses

Background. We previously showed that the risk of reoperation for structural degeneration of bioprostheses was higher in cases involving patients older than 65 years (p = 0.003) and double-valve replacement (p = 0.02). The purpose of this study was to compare late outcome of mitral-aortic valve replacement using bioprostheses or mechanical valves.Methods. The bioprosthesis group included all mainland France residents (n = 48) between 55 and 65 years old operated on between 1980 and 1995 for mitral-aortic valve replacement using bioprostheses. The mechanical valve group was obtained by matching each of these patients with a patient operated on using mechanical valves at approximately the same time during the study.Results. In the bioprosthesis group, 10-year survival was 45% ± 8% versus 62% ± 7% in the mechanical valve group (not significant). The linearized reoperation rate was 6.8 per patient-year versus 1.1 per patient-year (p = 0.001), and the linearized reoperative mortality rate was 1.8 per patient-year and 0.7 per patient-year (not significant), respectively.Conclusions. The reoperative mortality risk after mitral-aortic valve replacement using two bioprostheses does not significantly decrease overall survival after age 65 years.

Correction Of Functional Tricuspid Insufficiency By Means Of A Limited Posterior Crossed Suture Annuloplasty

J Thorac Cardiovasc Surg 1998;115:1378-81

Porcine valve durability: A comparison between Hancock standard and Hancock II bioprostheses

Two series of patients who received a Hancock standard (HS) (1970 to 1983) and a Hancock II (HII) (1983 to 1992) porcine bioprosthesis were reviewed to compare bioprosthetic durability. Patients with HS porcine bioprostheses (n = 769) differed from those with HII bioprostheses mostly in mean age at operation (47 +/- 12 versus 62 +/- 9 years; p < 0.001); the latter prosthesis was implanted mostly in patients older than 50 years. At 8 years after operation, actuarial survival was 57% +/- 4% after aortic, 61% +/- 3% after mitral, and 39% +/- 7% after mitral-aortic valve replacement with the HS bioprosthesis; actuarial survival was 51% +/- 9% after aortic, 66% +/- 6% after mitral, and 49% +/- 10% after mitral and aortic valve replacement with an HII bioprosthesis. No cases of structural deterioration of HII bioprostheses were observed at 8 years in any patients. Actuarial freedom from structural valve deterioration was 78% +/- 4% after aortic, 88% +/- 3% after mitral, and 79% +/- 7% after mitral-aortic valve replacement with an HS bioprosthesis at 8 years. In all patients greater than 50 years of age, actuarial freedom from structural valve deterioration at 8 years was 90% +/- 3% in patients with an HS bioprosthesis and 100% in those with an HII bioprosthesis (p = 0.08). A trend to an improved durability of the HII bioprosthesis compared with the HS was observed during the first 8 postoperative years. Because these results could be influenced partly by the age difference in the two series of patients, a longer follow-up is needed to confirm these data.

Hancock II porcine bioprosthesis: Excellent durability at intermediate-term follow-up

Objectives. This study aimed to assess the clinical performance and durability of a new generation of porcine valve, the Hancock II bioprosthesis, at intermediate-term follow-up.Background. Standard porcine bioprostheses undergo progressive structural deterioration, mainly due to cusp and commissural calcification, affecting durability and requiring reoperation. The Hancock II bioprosthesis, which is currently undergoing clinical investigation, is made from a porcine aortic valve treated with a calcium-retarding agent (sodium dodecyl sulfate [T6]), which should delay onset of calcification and increase durability.Methods. From May 1983 to December 1992, we used the Hancock II bioprosthesis in aortic (59 patients), mitral (101 patients) and mitral-aortic (25 patients) valve replacement procedures. Postoperative follow-up ranged from 0.1 to 8.7 years (mean [±SD] 4.5 ± 2.6 years) and was 100% complete. Freedom from major postoperative events was calculated at 7 years for patients with aortic valve replacement and at 8 years for those with mitral and mitral-aortic valve replacement.Results. The actuarial survival rate was 48 ± 10%, 76 ± 3% and 63 ± 6%; freedom from valve-related mortality was 91 ± 4%, 94 ± 2% and 89 ± 6%; freedom from thromboembolism was 80 ± 11%, 90 ± 2% and 79 ± 7%; and freedom from reoperation was 100%, 97 ± 1% and 89 ± 6% after aortic, mitral and mitral-aortic valve replacement, respectively. No structural valve deterioration occurred.Conclusions. At intermediate-term follow-up the Hancock II bioprosthesis showed excellent durability in all positions. However, the effectiveness of anticalcification treatment must be assessed with longer follow-up studies.

Annular enlargement during aortic valve replacement: preliminary results with a simplified technique.

A simplified technique has been used to enlarge the aortic annulus in a series of 13 patients undergoing aortic valve replacement. The procedure basically consists of extending the aortotomy incision into the aortic annulus by dividing the commissure between the left and noncoronary sinuses, without involving the anterior mitral leaflet. Wide opening of the commissure is obtained and the resulting defect is closed, preferably using a patch of bovine pericardium sutured to the mitral annulus and aortic wall. This technique is simple, reproducible, avoids opening of the left atrium (reducing the potential bleeding sites), allows insertion of a prosthesis at least two sizes larger than the original annulus, and is also applicable in cases of mitral-aortic valve replacement. Our preliminary results are satisfactory and seem to demonstrate that in many patients, even in the young age group, more complex procedures are often unnecessary when enlargement of the aortic annulus is required.

Influence of type of prosthesis on late results after combined mitral-aortic valve replacement

The influence of type of prosthesis on the late outcome of patients with combined mitral-aortic valve replacement was analyzed by comparing, at a 14-year follow-up, patients receiving two biological prostheses (group 1; n = 135), two mechanical prostheses (group 2; n = 221), or a mechanical prosthesis in the aortic position and a bioprosthesis in the mitral position (group 3; n = 97). No difference was found among the three groups in terms of actuarial survival and incidence of and freedom from valve-related deaths, thromboemboli, and hemorrhages. Patients with biological prostheses had a significantly greater incidence of structural valve deterioration, reoperations, and overall complications when compared with patients with only mechanical prostheses. The results of an extended follow-up of patients with combined mitralaortic valve replacement indicate that mechanical prostheses perform better in the long-term owing to their superior durability when compared with biological valves. The use of bioprostheses should be confined to old patients with limited life expectancy because of their cardiac disease, provided that anticoagulants are not used. Combination of mechanical and biological prostheses in the same patient should be avoided because the advantages of each type of prosthesis are lost.

Failure of Hancock pericardial xenografts: Is prophylactic bioprosthetic replacement justified?

The incidence of major valve-related complications was evaluated in a series of patients in whom the Hancock pericardial xenograft was used for aortic (AVR; n = 84), mitral (MVR; n = 17) and mitral-aortic (MAVR; n = 13) valve replacement. At 7 years actuarial survival is 66% ± 8% after AYR, 64% ± 13% after MVR, and 41% ± 15% after MAVR, whereas actuarial freedom from valve-related death is 79% ± 7% after AVR, 78% ± 13% after MVR, and 81% ± 12% after MAVR. Actuarial freedom from thromboemboli and anticoagulant-related hemorrhage at 7 years is 93% ± 4% and 98% ± 2% after AVR and 83% ± 10% and 88% ± 11% after MVR; no such complications occurred after MAVR. Structural valve deterioration determined at reoperation, at autopsy, or by clinical investigation was observed in 34 patients with AVR (10.0 ± 0.2%/patient-year), in 10 with MVR (10.6 ± 3.3% /patient-year), and in 9 with MAVR (16.6 ± 5.5%/ patient-year). After AVR, 19 patients underwent reoperation and 2 died before reoperation; 4 patients with MVR underwent reoperation, and 7 patients with MAVR underwent reoperation and 1 died before reoperation. Seventy-eight percent of the current survivors (13 patients with AVR, 7 with MVR, and 1 with MAVR) have clinical evidence of valve failure. At 7 years actuarial freedom from structural deterioration of the Hancock pericardial xenograft is 25% ± 7% after AVR, 29% ± 14% after MVR, and 0% after MAVR. The extremely poor durability of the Hancock pericardial xenograft, besides confirming the need for a closer noninvasive monitoring of Hancock pericardial xenograft recipients, justifies prophylactic replacement of this device in asymptomatic patients with clinical evidence of Hancock pericardial xenograft dys-function.

The Hancock II porcine bioprosthesis: A preliminary report

From May 1983 to July 1987 a total of 153 Hancock II porcine bioprostheses have been implanted in 130 patients with a mean age of 59 +/- 8 years (range 29 to 76 years). Mitral valve replacement was performed in 72 patients, aortic valve replacement in 35, and mitral-aortic valve replacement in 23. Cumulative follow-up of 121 survivors is 223 patient-years and 100% complete (range 0.4 to 4.5 years). The actuarial survival rate at 4 years is 88% +/- 8% for mitral, 86% +/- 7.8% for aortic, and 84% +/- 8% for mitral-aortic valve replacement. Minor thomboembolism occurred in two patients (0.9% +/- 0.6%/pt-yr) with an actuarial freedom from emboli at 4 years of 100% for mitral, 96% +/- 3.7% for aortic, and 91% +/- 8.6% for mitral-aortic valve replacement. Anticoagulant-related hemorrhage occurred in 10 patients (4.4% +/- 1.4%/pt-yr) with an actuarial freedom at 4 years of 90% +/- 4.8% for mitral, 89% +/- 5.8% for aortic, and 84% +/- 10.6% for mitral-aortic valve replacement. Failure of the porcine bioprosthesis was observed in three patients with an actuarial freedom at 4 years of 96% +/- 3.6% for aortic, 91% +/- 8% for mitral, and 91% +/- 8.6% for mitral-aortic valve replacement. Actuarial freedom from all porcine bioprosthesis-related complications at 4 years is 85.7% +/- 6.6% for aortic, 79% +/- 9% for mitral, and 70% +/- 13% for mitral-aortic valve replacement. No instances of primary tissue failure occurred.(ABSTRACT TRUNCATED AT 250 WORDS)

The standard Hancock porcine bioprosthesis: overall experience at the University of Padova.

All patients undergoing aortic (AVR, n = 196), mitral (MVR, n = 502), and mitral-aortic (MAVR, n = 71) valve replacement with a standard Hancock porcine bioprosthesis (HPB) from 1970 to 1983 were reviewed. A total of 665 patients discharged were followed for 5,099 patient-years with an actuarial survival at 15 years of 52% +/- 4.5%, for MVR, 37% +/- 14% for AVR, and at 12 years of 52 +/- 7.4% for MAVR. Embolic episodes occurred in 9 patients after AVR (0.7% +/- 0.2% pt-yr), in 61 after MVR (1.7% +/- 0.2% pt-yr), and in 6 after MAVR (1.7% +/- 0.7% pt-yr); actuarial freedom from emboli at 15 years is 91% +/- 3.5% after AVR, 79% +/- 14% after MVR, and at 12 years is 87% +/- 5% after MAVR. Reoperation because of primary tissue failure (PTF) was performed in 47 patients with AVR (3.9% +/- 0.5% pt-yr), 91 with MVR (2.6% +/- 0.3% pt-yr), and in 13 with MAVR (4.1% +/- 1.1% pt-yr); actuarial freedom from PTF at 15 years is 41% +/- 5.5% after MVR, 37% +/- 10% after AVR, and at 12 years is 49% +/- 13% after MAVR. After AVR and MVR, freedom from PTF is significantly better for patients over 50 years of age.(ABSTRACT TRUNCATED AT 250 WORDS)