Pericardial Xenograft Research Articles

Partial Inferior Vena Cava Reconstruction with Cryopreserved Aortic Homograft Following Resection for Malignancy.

Malignant invasion of the inferior vena cava (IVC) often necessitates complete tumor thrombectomy and IVC reconstruction. Bovine pericardial xenografts and prosthetic grafts are frequently used for partial or entire IVC reconstruction with adequate subsequent patency and freedom from thrombosis. Cryopreserved aortic homografts represent an alternative conduit for vena cava replacement with resistance to infection in contaminated fields or following extensive retroperitoneal dissection. Specific reports of aortic homograft use for IVC reconstruction are scarce. Described are 2 cases of cryopreserved aortoiliac artery allograft use for long segment cava patch repair while avoiding extensive caval reconstruction, mobilization and the need for renal vein and hepatic vein re-implantation.

Simulating the time evolving geometry, mechanical properties, and fibrous structure of bioprosthetic heart valve leaflets under cyclic loading

Currently, the most common replacement heart valve design is the ‘bioprosthetic’ heart valve (BHV), which has important advantages in that it does not require permanent anti-coagulation therapy, operates noiselessly, and has blood flow characteristics similar to the native valve. BHVs are typically fabricated from glutaraldehyde-crosslinked pericardial xenograft tissue biomaterials (XTBs) attached to a rigid, semi-flexible, or fully collapsible stent in the case of the increasingly popular transcutaneous aortic valve replacement (TAVR). While current TAVR assessments are positive, clinical results to date are generally limited to <2 years. Since TAVR leaflets are constructed using thinner XTBs, their mechanical demands are substantially greater than surgical BHV due to the increased stresses during in vivo operation, potentially resulting in decreased durability. Given the functional complexity of heart valve operation, in-silico predictive simulations clearly have potential to greatly improve the TAVR development process. As such simulations must start with accurate material models, we have developed a novel time-evolving constitutive model for pericardial xenograft tissue biomaterials (XTB) utilized in BHV (doi: 10.1016/j.jmbbm.2017.07.013). This model was able to simulate the observed tissue plasticity effects that occur in approximately in the first two years of in vivo function (50 million cycles). In the present work, we implemented this model into a complete simulation pipeline to predict the BHV time evolving geometry to 50 million cycles. The pipeline was implemented within an isogeometric finite element formulation that directly integrated our established BHV NURBS-based geometry (doi: 10.1007/s00466-015-1166-x). Simulations of successive loading cycles indicated continual changes in leaflet shape, as indicated by spatially varying increases in leaflet curvature. While the simulation model assumed an initial uniform fiber orientation distribution, anisotropic regional changes in leaflet tissue plastic strain induced a complex changes in regional fiber orientation. We have previously noted in our time-evolving constitutive model that the increases in collagen fiber recruitment with cyclic loading placed an upper bound on plastic strain levels. This effect was manifested by restricting further changes in leaflet geometry past 50 million cycles. Such phenomena was accurately captured in the valve-level simulations due to the use of a tissue-level structural-based modeling approach. Changes in basic leaflet dimensions agreed well with extant experimental studies. As a whole, the results of the present study indicate the complexity of BHV responses to cyclic loading, including changes in leaflet shape and internal fibrous structure. It should be noted that the later effect also influences changes in local mechanical behavior (i.e. changes in leaflet anisotropic tissue stress-strain relationship) due to internal fibrous structure resulting from plastic strains. Such mechanism-based simulations can help pave the way towards the application of sophisticated simulation technologies in the development of replacement heart valve technology.

Allografts and xenografts for right ventricular outflow tract reconstruction in Ross patients

Pulmonary allografts (AG) are the gold standard for right ventricular outflow tract (RVOT) reconstruction during the Ross procedure. However, there is limited availability of AG in some countries, and the use of alternative grafts for RVOT reconstruction remains controversial. This study aimed to compare the rates of freedom from RVOT graft dysfunction for AG and diepoxide-treated pericardial xenografts (DPXG). Between 1998 and 2015, 793 adult patients underwent the Ross procedure in our centre. Using propensity score matching, the clinical outcomes and echocardiographic results of AG and DPXG were compared. Propensity score matching resulted in 2 groups (AG and DPXG) of 122 patients each. No difference was found in early mortality (2.5%) in both groups. The freedom from RVOT graft dysfunction curves were comparable between the AG and DPXG groups (P = 0.186) and the 8-year rates of freedom from graft dysfunction were 91.8% and 82.2%, respectively. The survival rates at 8 years were 90.5% and 90.1%, and the rates of freedom from RVOT reintervention at 8 years were 100% and 96.8% for the AG and DPXG groups, respectively. At discharge and follow-up, transprosthetic gradients were significantly higher in the DPXG group. The rate of the RVOT gradient progression was also higher in the DPXG group than in the AG group (1.80 ± 0.06 vs 1.39 ± 0.04 mmHg/year, P < 0.001). There was no difference in freedom from RVOT graft dysfunction by 8 years when using AG and DPXG in adult Ross patients, nor in survival and freedom from RVOT conduit reintervention. Long-term results need further evaluation.

Nonglutaraldehyde Fixation for off the Shelf Decellularized Bovine Pericardium in Anticalcification Cardiac Valve Applications.

In valvular replacement surgery, especially in the construction of bioprosthetic valves with decellularized pericardial xenograft, glutaraldehyde (GA) is routinely utilized as the golden standard reagent to fix bovine or porcine pericardial tissues. However, the apparent defects of GA, including cytotoxicity and calcification, increase the probability of leaflet failure and motivate the exploration for alternatives. Thus, the aim of this study is to develop nonglutaraldehyde combined-cross-linking reagents composed of alginate-EDC/NHS (Alg) or oxidized alginate-EDC/NHS (Alg-CHO) as substitute for GA, which is confirmed to be less toxic and more biocompatible. Evaluations of the fixed acellular bovine pericardial tissues included mechanical performance, thermodynamics/enzymatic/in vivo stability tests, blood compatibility assay, cytocompatibility assay, in vitro anticalcification, and in vivo anticalcification assay by subcutaneous implantation in juvenile Wistar rats. The data revealed that the tissues fixed with the combined cross-linking reagents were superior to GA control and commercially available Sino product in terms of better in vitro hemocompatibility and cytocompatibility, lower calcification levels, better thermodynamics stability, and better regenerative capacity in subcutaneous implants, while the mechanical strength and in vivo stability were comparable. Considering all above performances, it indicated that both Alg and Alg-CHO are appropriate to replace GA as the cross-linkers for biological tissue, particularly as a nonglutaraldehyde fixation for off the shelf decellularized bovine pericardial tissue in the anticalcification cardiac valve applications. Nevertheless, studies on the long-term durability and calcification-resistance capacity in large animal model are further needed.

Duraplasty Type as a Predictor of Meningitis and Shunting After Chiari I Decompression

Expansile duraplasty is frequently performed during Chiari I decompression. Aseptic and bacterial meningitis are possible complications of this procedure. We sought to compare the rates of meningitis and subsequent need for cerebrospinal fluid (CSF) diversion with duraplasty using bovine pericardial (BPC) xenograft and allograft. We conducted a retrospective review of 112 patients who underwent Chiari I decompression. All patients underwent duraplasty with either allograft or BPC. Occurrence of postoperative lumbar punctures and associated data were recorded to determine rates of meningitis. Rates of subsequent shunting were also recorded. Overall, 112 patients were included in the study: 30 underwent duraplasty with allograft (27%) and 82 received BPC (73%). A total of 26 patients developed postoperative meningitis (23 cases of chemical meningitis and 3 of bacterial meningitis). Rates of meningitis were higher in patients who received BPC than patients who received allograft (28% vs. 10%, respectively; P= 0.047). The rate of shunting was greater in patients with meningitis compared with patients without meningitis (56.5% vs. 5.75%, respectively; P < 0.0001). Moreover, 13 of the 15 patients (87%) in the BPC cohort who were shunted were found to have meningitis compared with 0 of the 3 shunted patients (0%) in the allograft cohort (P= 0.044). We found that rates of total meningitis were greater in patients who underwent Chiari I decompression and duraplasty with BPC compared with an allograft. The rate of shunting was significantly higher for patients who developed meningitis after decompression compared with patients without meningitis.

RIGHT VENTRICULAR OUTFLOW TRACT RECONSTRUCTION DURING THE ROSS PROCEDURE: COMPARISON OF PULMONARY ALLOGRAFTS AND PERICARDIAL XENOGRAFTS

Aim The aim of this study was to compare the results of right ventricular outflow tract reconstruction during the Ross procedure with pulmonary allografts versus diepoxide-treated pericardial xenografts. Methods Between 1998 and 2015, 793 adult patients underwent the Ross procedure. The right ventricular outflow tract reconstruction was performed with pulmonary allografts in 185 patients, diepoxide-treated pericardial xenografts in 402 patients. Two groups of patients (122 patients in each group) were allocated using «propensity score matching»: the allograft group (pulmonary allograft) and the xenograft group (xenograft). Surgical results in two groups were assessed. Results The overall early mortality rate in both groups was 2.5%. The mean follow-up was 5,1±2,6 years in the allograft group and 5,2±2,8 years in xenograft group (p = 0,692). The 5-year survival rate did not differ between the study groups (93,7±2,6% in the allograft group versus 94,02±2,4% in the xenograft group, p = 0.748). The peak pressure gradients across the right ventricular outflow tract in early and mid-term follow-up were significantly higher in the xenograft group. Two patients in the xenograft group underwent redo surgeries due to the graft failure. There were no reoperations in the allograft group (p = 0,176). The freedom from right ventricular outflow tract reoperations was 96,3±2,7% for the xenograft group. Conclusion The diepoxide-treated pericardial xenografts demonstrates acceptable haemodynamic results at the mid-term follow-up and could be considered as an alternative to allografts for right ventricular outflow tract reconstruction during the Ross procedure in adults. Further study focused on the assessment of the longterm results are required.

One Year Clinical Outcome and Biomarker Levels after Randomized Comparison of Two Supraannular Pericardial Aortic Xenografts

One Year Clinical Outcome and Biomarker Levels after Randomized Comparison of Two Supraannular Pericardial Aortic Xenografts

Results of the Ross procedure in adults: a single-centre experience of 741 operations.

Although the Ross procedure provides excellent long-term survival and a high quality of life, only a limited number of centres perform it as an alternative to the standard aortic valve replacement in adults. In the present study, we evaluated our 16-year results of using the Ross procedure in adult patients. Between 1998 and 2014, 741 adult patients underwent the Ross procedure. The mean patient age was 47.4 ± 12.8 years (range, 18-67 years). The total root replacement technique was used in all patients. Right ventricular outflow tract (RVOT) reconstruction was performed with pulmonary allograft in 175 (23.6%) patients, with different types of xenografts in 561 (75.7%) and with polytetrafluoroethylene conduits in 5 (0.7%) patients. The early mortality rate was 3.0%. The mean follow-up duration was 5.8 ± 2.2 years. The survival rate at 10 years was 90.7% and was comparable with survival of an age- and sex-matched general population. The rate of freedom from autograft reoperations was 94.1 and 88.3% at 5 and 10 years, respectively. The aortic annulus dilatation was the only independent predictor of autograft failure. The 10-year freedom rates from reoperations for allograft, diepoxide- and glutaraldehyde-treated pericardial xenografts as well as porcine aortic root grafts were 100, 94.4, 82.7 and 80.6%, respectively. The use of xenografts and young patient age were associated with increased risk of RVOT conduit failure. The Ross operation provides long-term survival rates that are comparable with an age- and gender-matched general population. The dilated aortic annulus is a risk factor for late autograft valve insufficiency. A cryopreserved pulmonary homograft is the best option for RVOT reconstruction. Diepoxide-treated pericardial xenografts can be an alternative to allografts in elderly patients when an allograft is not available.

Right Ventricular Outflow Tract Replacement With Xenografts in Ross Patients Older Than 60 Years

Because of the limited availability of pulmonary allografts, stentless pericardial xenografts have been proposed as an alternative for right ventricular outflow tract (RVOT) reconstruction during the Ross procedure. However, the durability of the bioprostheses for RVOT reconstruction in older patients isunknown. Inthe present study, we evaluated the use of pericardial xenografts for RVOT reconstruction during the Ross procedure in patients aged more than 60years. Between 1998 and 2014, 710 consecutive adult patients underwent the Ross procedure. We analyzed the results of the operation in 102 patients aged more than 60 years. The mean patient age was 63.4± 2.8 years (range, 60 to 68). The total root replacement technique was used in all patients. The RVOT reconstruction was performed with stentless pericardial xenografts. The mean size of the xenografts was 26.8 ± 1.3 mm. Xenograft calcification was assessed by computed tomography in 39 patients. At the time of discharge, the RVOT peak gradient was 10.3 ± 3.5 mm Hg. The mean follow-up duration was 52.3 ± 23.6 months. None of the cases required reoperation for xenograft dysfunction. At the final follow-up, the RVOT peak gradient was 17.9 ± 4.3 mm Hg. Computed tomography scan analyses showed that calcification was localized mainly at the graft wall, and that the valve was relatively free of calcium. Stentless diepoxide-treated pericardial xenografts are an acceptable alternative to pulmonary allografts for RVOT reconstruction with the Ross procedure in patients aged more than 60 years, and yield good midterm results.

Çıkan Aortadan Anormal Kaynaklanan Sağ Pulmoner Arter, Aortopulmoner Pencere ve Kesintili Arkus Aorta Birlikteliği: Tek 3D Yama ile Başarılı Cerrahi Düzeltme

Anomalous origin of the right pulmonary artery from the ascending aorta (AORPA) is a rare congenital heart defect and generally associated with other cardiac anomalies. Patients with AORPA have high pulmonary fl ow results in congestive heart failure and unilateral pulmonary hypertension. Thus, it is frequently a fatal malformation in the neonatal or early infancy periods if early surgical repair is not performed. Herein, we report a 1.5 month-old girl who was diagnosed with AORPA associated with aortopulmonary window and interrupted aortic arch and successfully operated using a single pericardial xenograft 3D patch.

Transapical Aortic Valve Implantation in Patients With Previous Cardiac Surgery

This study compared surgical outcomes of patients with previous cardiac surgery undergoing transapical transcatheter aortic valve implantation (PCS-TA-TAVI) with those of patients undergoing transapical transcatheter aortic valve implantation as an initial procedure (initial TA-TAVI) by using propensity analysis. From January 2005 through January 2013, 267 consecutive high-risk patients underwent transapical transcatheter aortic valve implantation using a pericardial xenograft fixed within a stainless steel, balloon-expandable stent (Edwards SAPIEN). Of these, 59 patients underwent PCS-TA-TAVI (coronary artery bypass grafting: n = 31; valve surgery: n = 28), and the remaining 208 had an initial TA-TAVI procedure. Logistic regression analysis was used to identify covariates among 10 baseline patient variables. Using the significant regression coefficients, each patient's propensity score was calculated, allowing selectively matched subgroups of 45 patients in the two groups. Operative outcomes were analyzed for differences. Follow-up was 4 ± 2 years and 100% complete. There was no significant difference between PCS-TA-TAVI and initial TA-TAVI patients in operative time, postoperative bleeding, 30-day survival (91% versus 93%), and survival at late follow-up (63% versus 68%; p ≥ 0.28). Overall incidence of early stroke was low with 0% for the PCS-TA-TAVI and 4% for initial TA-TAVI group (p = 0.56). Transapical transcatheter aortic valve implantation was successfully performed in all but 1 patient from the initial TA-TAVI group who required conversion to sternotomy. Transapical transcatheter aortic valve implantation has simplified surgical treatment of high-risk patients with previous cardiac surgery and severe aortic valve stenosis and is associated with minimal risk of stroke. Furthermore, current data suggest that the presence of previous cardiac surgery does not impair outcomes after transapical transcatheter aortic valve implantation, making this subset of patients particularly applicable for this evolving approach.

Technique of managing periprosthetic leakage due to mitral prosthetic valve endocarditis: report of a case

A patient with multiple leaks caused by active mitral prosthetic valve endocarditis with an annular abscess underwent repeat mitral valve replacement. To secure the new mitral prosthesis, sutures were placed through the healthy interatrial septal wall from right to left at the posteromedial region and then to the new prosthetic valve sewing cuff. In the anterolateral region, sutures were placed through the reconstructed annulus after debridement of the abscess and then reinforced with a pericardial xenograft patch. Postoperatively, the perivalvular leakage stopped and the patient recovered uneventfully.

Onchocerca armillata contamination of a bovine pericardial xenograft in a human patient with repaired tetralogy of Fallot

Bovine pericardial patches are used for many purposes, including facilitating right ventricular outflow tract reconstruction in patients with congenital heart disease. Here we present a case of parasitic contamination of a bovine pericardium used as a transannular patch during repair of tetralogy of Fallot 28 years prior at a hospital in China. The patient presented to the University of Washington Medical Center for congestive heart failure and pulmonic regurgitation, and heart tissues including the xenograft pericardial patch were submitted to the Pathology Department and subsequently to the Comparative Pathology Program. The pericardial parasitic nodules with intralesional adult nematodes and microfilaria in the bovine tissues were preserved at harvest by (presumed) glutaraldehyde fixation. Onchocerca armillata parasitic pericardiopathy was diagnosed in the xenograft tissue based on the characteristic nematode morphology and the presumed geographic location of the donor bovine. This resulted in O. armillata contamination of the pericardial xenograft in a human patient with repaired tetralogy of Fallot.

Transcatheter Aortic Valve Implantation after Previous Mechanical Mitral Valve Replacement: Expanding Indications?

Cardiac operation for severe aortic stenosis after previous mitral valve replacement is a surgical challenge in older patients with multiple morbidities. Transcatheter aortic valve implantation (TAVI) after previous mechanical mitral valve replacement has been considered a high-risk procedure, owing to possible interference with the mitral valve prosthesis. Since August 2008, 5 female high-risk patients with severe aortic stenosis and previous mitral valve replacement (mean ± SD age, 80 ± 5.1 years; logistic EuroSCORE, 39.3% ± 20.5%) underwent TAVI with a pericardial xenograft valve that was fixed with a stainless steel, balloon-expandable stent (Edwards Lifesciences SAPIEN). We used a transapical approach in 4 patients and a transfemoral approach in 1 patient. Transesophageal echocardiography and multidetector computed tomography were used for preoperative planning and assessment of operation feasibility. The mean distance between the aortic annulus and the mitral valve prosthesis was 10 ± 1 mm (range, 9-11 mm). TAVI was performed successfully in all 5 patients. There was no direct or functional interference with the mechanical mitral valve prostheses. Echocardiography revealed good valve function with no more than mild paravalvular incompetence early in the postoperative period and during routine follow-up. There were no neurologic events. After an initially uneventful course with good aortic valve function at the most recent echocardiography evaluation, however, 2 of the patients died from fulminant pneumonia on postoperative days 4 and 48. TAVI is technically feasible in high-risk patients after previous mechanical mitral valve replacement; however, careful patient selection is mandatory with respect to preoperative clinical status and anatomic dimensions regarding the distance between aortic annulus and mitral valve prosthesis.

Transcatheter aortic valve implantation – TAVI: early results from the transapical approach in a multimorbid, elderly, high-risk population*

BACKGROUND: Report of our single centre experiences with transcatheter aortic valve implantation (TAVI) in a group of high-risk patients without extracorporeal circulation. METHODS: TAVI was performed via a left-sided small anterolateral minithoracotomy on the beating heart. A pericardial xenograft fixed within a stainless steel, balloon expandable stent (Edwards SAPIEN THV, Edwards Lifesciences) was implanted. RESULTS: Twenty-two consecutive patients (80.3 a) were operated on from 11/09 until 12/10 using fluoroscopic and echocardiographic visualization. Average EuroSCORE and STS-score predicted risk for mortality was 24.8 ± 6.5 and 14.3 ± 4.5, respectively. Transapical valve positioning was performed successful in 22 patients, two required immediate conversion to sternotomy, because of coronary artery obstruction and severe aortic regurgitation. Echocardiography revealed minor paravalvular or central leakage in 8 patients. One patient died in-hospital on day 40. Actuarial survival was 95.5% at a follow-up interval of 223 days (range 19–391 days). Conclusions: TAVI can be performed safely with good results in selected high-risk patients. Long-term valve performance will need to be evaluated.

Transcatheter aortic valve implantation after previous mechanical mitral valve replacement: Expanding indications?

Background: Cardiac operation for severe aortic stenosis after previous mitral valve replacement is a surgical challenge in older patients with multiple morbidities. Transcatheter aortic valve implantation (TAVI) after previous mechanical mitral valve replacement has been considered a high-risk procedure, owing to possible interference with the mitral valve prosthesis.Methods: Since August 2008, 5 female high-risk patients with severe aortic stenosis and previous mitral valve replacement (mean ± SD age, 80 ± 5.1 years; logistic EuroSCORE, 39.3% ± 20.5%) underwent TAVI with a pericardial xenograft valve that was fixed with a stainless steel, balloon-expandable stent (Edwards Lifesciences SAPIEN). We used a transapical approach in 4 patients and a transfemoral approach in 1 patient. Transesophageal echocardiography and multidetector computed tomography were used for preoperative planning and assessment of operation feasibility. The mean distance between the aortic annulus and the mitral valve prosthesis was 10 ± 1 mm (range, 9-11 mm).Results: TAVI was performed successfully in all 5 patients. There was no direct or functional interference with the mechanical mitral valve prostheses. Echocardiography revealed good valve function with no more than mild paravalvular incompetence early in the postoperative period and during routine follow-up. There were no neurologic events. After an initially uneventful course with good aortic valve function at the most recent echocardiography evaluation, however, 2 of the patients died from fulminant pneumonia on postoperative days 4 and 48.Conclusion: TAVI is technically feasible in high-risk patients after previous mechanical mitral valve replacement; however, careful patient selection is mandatory with respect to preoperative clinical status and anatomic dimensions regarding the distance between aortic annulus and mitral valve prosthesis.

Transapical aortic valve implantation in 100 consecutive patients: comparison to propensity-matched conventional aortic valve replacement

To evaluate the outcome of transapical aortic valve implantation (TA-AVI) in comparison to conventional surgery. One hundred consecutive high-risk patients with symptomatic aortic valve stenosis received TA-AVI using the Edwards SAPIEN pericardial xenograft between February 2006 and January 2008. Patient age was 82.7 +/- 5 years, 77 were females, logistic EuroSCORE predicted risk of mortality was 29.4 +/- 13% and Society Thoracic Surgeons score risk for mortality was 15.2 +/- 8.3%. Propensity score analysis was used to identify a control group of patients that underwent conventional aortic valve replacement (C-AVR). Transapical aortic valve implantation was performed successfully in 97 patients, whereas three patients required early conversion. There were no new onset neurological events in the TA-AVI group and early extubation was performed in 82 patients. Echocardiography revealed good valve function with low transvalvular gradients in all patients. Thirty-day survival was 90 +/- 3 vs. 85 +/- 4% for TA-AVI vs. C-AVR, and 1-year survival was 73 +/- 4 vs. 69 +/- 5% (P = 0.55). Transapical aortic valve implantation is a safe, minimally invasive, and off-pump technique to treat high-risk patients with aortic stenosis. Results of the initial 100 patients are good and compare favourably to conventional surgery.

Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler Ultrasound: A Report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, Developed in Conjunction With the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the

Recommendations for Evaluation of Prosthetic Valves With Echocardiography and Doppler Ultrasound: A Report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, Developed in Conjunction With the American College of Cardiology Cardiovascular Imaging Committee, Cardiac Imaging Committee of the American Heart Association, the European Association of Echocardiography, a registered branch of the

Transapical aortic valve implantation in patients requiring redo surgery☆

To evaluate the results of minimally invasive transapical aortic valve implantation (TA-AVI) in patients requiring redo surgery. Twenty-five high risk patients with symptomatic aortic valve stenosis and previous cardiac surgical interventions received TA-AVI using a pericardial xenograft fixed within a stainless steel, balloon-expandable stent (Edwards SAPIEN) since February 2006. All valves were implanted in a hybrid operative theater. Patient age was 78 years, 60% were female, logistic EuroSCORE and STS score risk for mortality were 39% and 17%, respectively. Previous cardiac surgery was CABG in 17, valve surgery in 5 and other in 3 patients. TA-AVI was performed successfully in 24 (96%) of the patients. One patient required early conversion to sternotomy and one patient required temporary ECMO support. A total of 21 patients (84%) were treated completely off-pump, one early patient was treated on-pump by intention and three patients required secondary cardiopulmonary bypass support. Echocardiography revealed good valve function in all but the converted patient, with trivial to mild (1 degrees) paravalvular incompetence in 40%. Three patients died within 30 days of the procedure and during follow-up four patients died, all with good valve function at most recent echo. Thirty-day survival was 88% and one-year survival was 72%. There were no new-onset neurological events. TA-AVI can be performed with excellent results and minimal stroke risk in high risk patients requiring redo cardiac surgery. TA-AVI represents an important alternative to conventional surgery in elderly high risk patients requiring reoperative procedures.

Human Minimally Invasive Off-Pump Valve-in-a-Valve Implantation

Reoperative heart valve replacement for degenerated xenografts is associated with an increased surgical risk. We used our experience with transcatheter transapical aortic valve implantation to perform a transapical off-pump aortic valve-in-a-valve implantation. Hemodynamic function was excellent and the patient had a fast and uneventful recovery.