Redo Valve Research Articles

Use of transesophageal echocardiography for transcatheter valve-in-valve implantation for patients with prior bioprosthetic surgical aortic, mitral, tricuspid, and pulmonic valves.

Valve-in-valve (ViV) transcatheter procedures are the preferred option for redo valve replacement in patients who otherwise would be high risk for surgery. Transesophageal echocardiography (TEE) is an integral imaging modality for both peri-procedural and intra-procedural guidance during transcatheter ViV replacement. When intentional leaflet laceration is needed, such as with the BASILICA (Bioprosthetic or native Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstructions during TAVR) or LAMPOON (Laceration of the Anterior Mitral valve leaflet to Prevent left ventricular Outlet ObstructioN) procedures, TEE is critical to proper guidewire positioning and achieving a successful laceration. In this paper we detail the role of TEE in ViV transcatheter valve replacement in patients with prior surgical aortic, mitral, tricuspid, and pulmonic valves.

Mini-thoracotomy in redo mitral valve surgery: safety and efficacy of a standardized procedure.

BackgroundRe-operative mitral valve surgery is sometimes burdened by a greater technical difficulty and a higher complications rate than the first operation. Minimally invasive cardiac surgery has become routine, and it could significantly reduce the surgical risk in redo surgery. The objective of our retrospective observational study is to assess the results of cardiac reoperations in patients with mitral valve disease approached trough a 5–7 cm right mini-thoracotomy.MethodsFrom February 2017 to December 2019, 65 patients underwent re-operative mitral valve surgery in our institution. Cardiopulmonary bypass (CPB) was started by cannulation of the femoral and jugular vein and femoral artery or alternatively right axillary artery. Patients enrolled had a mean age of 66.6±11.5 years. Patients were divided into three groups based on the procedure adopted: external aortic cross-clamp (EAC), EndoAortic balloon occlusion (EABO) and ventricular fibrillation (VF). Major complications were evaluated and compared with a propensity matched population of patients undergoing elective isolated mitral valve surgery via right minithoracotomy (MVS).ResultsThe average time between last operation and reoperation was 7.1±3.4 years. Fourteen patients (21%) underwent mitral valve repair and 51 patients (78%) underwent mitral valve replacement; 9 patients (14%) received tricuspid valve surgery. There was no statistically significant difference in CPB time between the groups. Seven patients (11%) had a postoperative renal failure, 5 patients (8%) underwent surgical reopening for bleeding; incidence of post-operative stroke and pace-maker implantation was 3% for both. No deaths were registered during in-hospital stay and at 30-days echocardiographic control all patients respect the criterions of device success according with MVARC. Propensity matched patients of group redo had a longer CPB time (100.8±42.7 versus 72.8±16.7 min, P<0.001) and cross-clamp time (71.9±30.7 versus 59±10.7 min, P<0.001) respect to first operation mitral valve surgery patients.ConclusionsMinimally invasive mitral valve redo surgery is a safe procedure. Less invasive techniques in redo surgery could minimize morbidity and mortality without prolonging the duration of CPB.

David procedure for aortic root aneurysm in the background of Marfan syndrome patient with severe kyphoscoliosis and previous mitral valve replacement

Cardiac complication is one of the diseases that usually develop in Marfan syndrome patient such as mitral valve regurgitation and aortic root aneurysm. Apart from that, other congenital anomalies also tend to occur in this group of patients such as pectus excavatum and scoliosis. We report a case of successful high-risk surgery involving a Marfan syndrome patient who had underlying severe kyphoscoliosis and previous mitral valve replacement that underwent redo sternotomy and valve sparing aortic root repair (David procedure). The surgery was challenging due to the need to perform redo-sternotomy on severe pectus patient, performing valve sparing aortic root repair, and complicated with injury to right coronary artery require modified Cabrol modification for implantation of the coronary artery. The available literature about redo sternotomy on severe pectus excavatum for aortic root repair is limited, hence this paper aims to highlight the successful of performing the procedure, and the complication that might occur during the procedure.

Rheumatic mitral regurgitation: is repair justified by the long-term results?

The best treatment for rheumatic mitral regurgitation is still under debate. Our goal was to assess the long-term results of mitral repair for rheumatic mitral regurgitation performed in 2 referral centres for mitral repair. Patients who underwent mitral valve repair between 1999 and 2009 were selected. Preoperative and postoperative data were prospectively entered into a dedicated database and retrospectively reviewed. Kaplan-Meier estimates were used to analyse long-term survival. Competing risk analysis was performed by calculating the cumulative incidence function for time to recurrence of mitral regurgitation ≥3+, mitral regurgitation ≥2+, mitral reoperation and the combined end point of repair failure (mitral regurgitation ≥ 3+ and/or mean gradient ≥ 10 mmHg and/or mitral valve REDO) with death as a competing risk. A total of 72 patients were included. Mitral calcifications were present in 25 patients (34.7%). Most of the patients (65/72, 90.3%) underwent annuloplasty, and mixes of reparative techniques were used in 21 patients (29.2%). In-hospital mortality was 2.8%. Mean follow-up was 11.6 ± 5.16 (max 19.1 years), 98.6% completed. Survival at 14 years was 70 ± 6.27%. At 14 years, the cumulative incidence function of repair failure was 36.7 ± 6.52%. The presence of severe mitral annulus calcification was an independent predictor of repair failure. Mitral repair for rheumatic mitral regurgitation is characterized by a high rate of failure in the long term (14 years), particularly in patients with severe annular calcifications. These results call for a very selective approach when considering a repair strategy in this setting, especially in case of unfavourable anatomical conditions.

Redo tricuspid valve replacement with mechanical prosthesis for repeated early bioprosthetic valve failure

Tricuspid leaflet lesion following infective endocarditis is a severe condition requiring surgical treatment in most cases. Currently, tricuspid valve replacement with mechanical prosthesis is still essential in the treatment of patients ineligible for reconstructive surgery or bioprosthesis implantation. The authors describe redo tricuspid valve replacement with mechanical prosthesis for repeated early bioprosthetic valve failure.

Structural Valve Deterioration Is Linked to Increased Immune Infiltrate and Chemokine Expression.

We aim to investigate whether structural valve deterioration (SVD) of bioprosthetic xenogenic tissue heart valves (XTHVs) is associated with increased immune cell infiltration and whether co-expression of several chemokines correlates with this increase in immune infiltrate. Explanted XTHVs from patients undergoing redo valve replacement for SVD were obtained. Immunohistochemical, microscopic, and gene expression analysis approaches were used. XTHVs (n = 37) were obtained from 32 patients (mean 67.7years) after a mean time of 11.6years post-implantation. Significantly increased immune cellular infiltration was observed in the explanted SVD valves for all immune cell types examined, including T cells, macrophages, B cells, neutrophils, and plasma cells, compared to non-SVD controls. Furthermore, a significantly increased chemokine gradient in explanted SVD valves accompanied immune cell infiltration. These data suggest the development of SVD is associated with a significantly increased burden of immune cellular infiltrate correlated to the induction of a chemokine gradient around the XHTV, representing chronic immune rejection.Graphical abstract Proposed interaction between innate and adaptive immunity leading to the development of structural valve deterioration in xenogenic tissue heart valves.

Surgical treatment of prosthetic mechanical valve thrombosis with the aid of high-flow CO2.

The surgical treatment of prosthetic mechanical valve thrombosis involves redo valve replacement and removal of the thrombi layers. The hinges and near-hinge areas of the bi-leaflet mechanical valve are a 'stagnation area' where blood flow is typically unsteady and can give rise to thrombi; however, these zones are not easily accessed with surgical instruments. Here, we present a case in which high-flow CO2 was used to facilitate the removal of microthrombi in the stagnation area around a prosthetic mechanical valve.

Minimally Invasive Isolated Tricuspid Valve Redo Surgery Has Better Clinical Outcome: A Single-Center Experience.

Reoperation for isolated tricuspid valve (TV) surgery is considered a high-risk procedure. The optimal surgical approach is controversial. We analyzed our experience with isolated TV redo surgery performed either through thoracoscopic approach (thoracoscopic group), right thoracotomy (thoracotomy group), or median sternotomy (sternotomy group). We retrospectively analyzed all patients with previous cardiac surgery who underwent redo-TV procedure through thoracoscopic approach (n = 33), right lateral thoracotomy approach (n = 14), or sternotomy (n = 72). All patients successfully underwent elective surgery, with no intraoperative conversion or death occurring. 69% and 31% of patients received valve replacement and valvuloplasty, respectively. After operation, one patient in the sternotomy group received reoperation for bleeding, while another patient received valve replacement surgery 2 weeks after operation due to heart failure caused by valvuloplasty failure. No obvious complications occurred in the minimally invasive groups. The overall success rate of valve repair during 1-year follow-up was 99.2%. Minimally invasive, isolated TV surgery as reoperation can be safe and may improve clinical outcome.

The Evolving Burden of Drug Use Associated Infective Endocarditis in the United States

The rise in the number of valve operations performed for infective endocarditis (IE) due to drug use is an important manifestation of the opioid epidemic. This study characterized national trends and outcomes of valve surgery for drug use-associated IE (DU-IE). Adults undergoing valve surgery for active IE in The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database between July 2011 and June 2018 were stratified as DU-IE and non-DU-IE. Trends and clinical profiles were analyzed. Early outcomes were assessed. The association of DU-IE with outcomes was analyzed with multivariable regression, adjusting for STS Valve Risk model covariates. There were 34,905 valve operations performed for IE, of which 33.7% were for DU-IE. DU-IE operations increased 2.7-fold during the study period. There was considerable regional variability in DU-IE operations, ranging from 28% to 58% of all IE surgeries in 2018, with highest rates observed in East South Central and South Atlantic regions. DU-IE patients were younger and had fewer cardiovascular comorbidities. Risk-adjusted major morbidity and in-hospital mortality were significantly higher in the DU-IE group. Redo valve procedures in DU-IE patients were associated with worse outcomes, compared with those receiving a first valve operation. Operations for DU-IE have increased sharply in the United States during the last several years, exhibiting substantial regional variability. DU-IE patients have unique clinical profiles, and worse risk-adjusted outcomes. This demonstrates the significant impact of the opioid epidemic on endocarditis surgeries and punctuates the urgent need for multidisciplinary regional and national efforts to reverse this trend.

SAT-115 PROLONGED ICU STAY IN POST CABG CKD PATIENTS AND POST-OPERATIVE QUALITY OF LIFE (QOL) AT 6 MONTHS

Intensive Care Unit(ICU) is associated with costly and limited resources in third world countries. Prolonged ICU stay not only increases hospital cost but it also prevents hospital equipment to be used by other patients who need them. Conflicting results have been found regarding risk factors that prolong ICU stay after cardiac surgery in Chronic Kidney Disease(CKD) patients. The aim of this study was to identify factors that impact the duration of ICU stay in post CABG CKD patients and to assess how CKD and prolonged ICU stay affect their QOL 6 months after Cardiac Surgery. Knowing these factors can help timely management and resource planning. We analysed medical records of 191 post CABG patients at our Cardiac Surgery ICU. CABG patients, above 18 years with and without CKD were included. However, those with redo CABG and valve surgery were excluded. Patients were categorized as normal ICU stay (less than 48 hours) and prolonged ICU stay (more than 48 hours). The effect of different patient variables and peri operative risk factors on prolonged ICU stay were analysed using Pearson Chi square test. QOL was assessed at 6 months follow up using SF36 QOL questionnaire: categorised as poor, good and excellent. Mean age of the patients was 57.83 years (± 9.862 SD). 32(16.8%) were females and 159(83.2%) were males.145 patients (75.9%) were hypertensive and 110(57.6%) were diabetic and all had dyslipidemias(Table 1). 72/191 (37.6%) patients had CKD 3-5 : 66- CKD 3, 4-CKD 4, 2-CKD 5). 56/191 patients (29.3%) had prolonged ICU stay. Patients who had Diabetes Mellitus and Chronic kidney disease(stage 3-5) had prolonged ICU stay(p value of 0.003 and 0.027 respectively). Patients who had a recent Myocardial Infarction (MI) (less than 90 days prior to CABG), diastolic dysfunction, and LV EF (Left Ventricular Ejection Fraction)less than 35% also had prolonged ICU stay (p value of 0.072, 0.06 and 0.003). Within the ICU, patients with post CABG arrhythmias(Atrial fibrillation, Supraventricular tachycardia, Ventricular tachycardia) and Cardiogenic shock had prolonged ICU stay(p value of 0.001 and 0.029). Patients with AKI and those who had dialysis post CABG had prolonged ICU stay (p value 0.02 and 0.02 respectively), as shown in Table 2. Out of 72 CKD patients,24 patients had prolonged ICU stay. Among CKD cohort, prolonged ICU stay was observed in diabetics (p : 0.05), patients who needed dialysis (p:0.04), patients with post op arrhythmias (p :0.001) and in those with LV EF <35% (p:0.002) (Table 3). Further analysis revealed a strong correlation of on pump surgeries with prolonged ICU stay (p value :0.04) and 50% of the CKD patients on pump had prolonged ICU stay. Out of 191 patients, 129 were available for follow up of QOL at 6 months. Only one patient in Stage 3 CKD had poor QOL. 34 patients in CKD 3 and 4 had good QOL. 14 patients with CKD 3 and 4 had excellent QOL (Table 4). There was no mortality at 6 months follow up. Significant correlation of the following risk factors was found with prolonged ICU stay: Diabetes mellitus, CKD, AKI, Dialysis, MI less than 90 days pre CABG, Post op arrhythmias, Shock, Diastolic dysfunction and LV EF<35%. However in CKD cohort, prolonged ICU stay was seen with AKI, dialysis, diabetics, post op arrhythmias and LV EF<35%.

Coming undone: a case of annuloplasty ring suture degeneration post mitral valve repair leading to recurrent severe MR

SummaryMitral valve repair is the gold standard treatment for degenerative mitral valve disease with superior perioperative and long-term morbidity and mortality outcomes vs mitral valve replacement. The 10 year survival freedom from redo valve repair varies from 72 to 90%. Often, failure of valve repair necessitating redo surgery is directly related to disease progression; however, rarely it can be attributed to technical complications such as annuloplasty dehiscence, leaflet suture rupture, incorrect artificial chord length or incorrect annuloplasty position. We report one such case of severe mitral regurgitation secondary to a degenerative annuloplasty ring suture occurring 1 year post valve repair.

Redo heart valve surgery in a patient with rheumatic heart disease

<h3></h3> Представлено клиническое наблюдение пациента с хронической ревматической болезнью сердца после ранее перенесенного протезирования аортального клапана биологическим бескаркасным протезом, аннулопластики митрального и трикуспидального клапанов.

Outcomes following bioprosthetic valve replacement in prior non-cardiac transplant recipients.

We report on overall survival and valve-related outcomes after bioprosthetic valve replacement in prior transplant recipients. From January 2004 to December 2018, 20 consecutive patients (mean age 65.7-years, 90% male) with prior non-cardiac transplantation underwent bioprosthetic aortic (n=18) or combined aortic and mitral (n=2) valve replacement. Patients consisted of kidney (n=14), lung (n=2), liver (n=3), and bone-marrow (n=2) transplants with the most common indication for valve replacement being calcific degeneration (n=12). Outcomes were measured over a 12-year span, with a median follow-up duration of 3.9years. Overall survival at 30days was 100% and at median follow-up was 60%. Acute kidney injury occurred in 50% (n=10) with temporary dialysis required in 5% (n=1) and 15% (n=3) suffered respiratory failure. No patients experienced major bleeding, heart failure, or sternal wound infection. No patients required redo valve replacement during the study period. Our results provide contemporary data demonstrating that patients with prior transplant can undergo bioprosthetic valve replacement with acceptable inhospital mortality rates and long-term survival, with a low rate of major morbidity. Furthermore, bioprosthetic valve replacement is a viable option in this group of patients with no redo valve replacement and acceptable long-term hemodynamic valvular function.

Surgical outcomes of obstructive mechanical valve thrombosis, risk factors, and comorbidity analysis

Background Obstructive mechanical valves thrombosis is a life-threatening complication associated with high morbidity and mortality. Although thrombolytic therapy has gained a lot of popularity in recent years, yet the treatment of choice is still controversial. Objective The aim of this study was to evaluate the outcomes of patients who underwent redo valve surgery for obstructive mechanical valve thrombosis. Patients and methods Outcomes of 380 patients who underwent emergency redo surgery for obstructive mechanical valve thrombosis at our institute during a 5-year period (January 2012 to December 2017) were reviewed retrospectively. Clinical symptoms and transthoracic echocardiography were the mainstay in diagnosis. Fluoroscopy was used in the presence of dilemma regarding diagnosis. All patients were treated on an emergency basis. Postoperative outcomes were analyzed to determine risk factors and comorbidities affecting mortality rates in this high-risk group of patients. Results Number of patients was 380, with prevalence of female sex being 268 (70.52%). Mean age was 32.65 ± 10.70 years. Associated comorbidities were hypertension in 96 (25.26%), diabetes mellitus in 32 (8.42%), elevated liver enzymes in 32 (8.42%), elevated creatinine in 44 (11.57%), and preoperative cardiac arrest in eight (2.10%). Overall mortality was seen in 52 (13.68%) patients. Risk factors influencing mortality rates were preoperative hemodynamic instability, increased NYHA class, renal dysfunction, low left ventricular ejection fraction, and right ventricle dysfunction. Moreover, mortality was significantly affected by repetition of redo surgery, long bypass and cross-clamp time, high postoperative cardiac support, duration of mechanical ventilation, and ICU stay. Conclusion Prosthetic valve thrombosis is a life-threatening situation associated with substantial risk regardless of treatment modality. Late presentation with hemodynamic instability, increased NYHA class, low left ventricular ejection fraction, and severe right ventricle dysfunction carry worst prognosis in surgically treated patients.

Risk of reoperative valve surgery for endocarditis associated with drug use

BackgroundWe aimed to quantify incidence and operative risks associated with reoperative valve surgeries (RVS) in patients with drug-associated infective endocarditis in a multi-center setting. MethodsWe formed a registry of patients with drug-associated infective endocarditis who underwent valve surgeries at 8 US centers between 2011 and 2017. Outcomes of first-time valve surgery (FVS) and RVS were compared. Multivariable logistic regression models related RVS to 30-day mortality. Poisson regression models were fitted to evaluate temporal trends in overall case volume and proportions of patients undergoing RVS. ResultsThe cohort consisted of 925 patients with drug-associated infective endocarditis who underwent a valve surgery, of which 652 were FVS and 273 were RVS. Patients undergoing FVS had fewer comorbidities than those undergoing RVS. Overall case volume increased from 108 in 2012 to 229 cases in 2017 (P < .001). The proportion of redo valve cases increased from 19% in 2012 to 28% in 2017 (P < .001). The 30-day mortality in RVS was higher compared with FVS (8.1% vs 4.8%; P = .049). An increase in unadjusted mortality rates were observed as the number of prior cardiac surgeries increased, from 4.8% in FVS to 11.8% in ≥3 RVS. Multivariable model demonstrated that RVS was associated with an increased risk of 30-day mortality (odds ratio, 2.22; 95% confidence interval, 1.22-4.06; P = .010). ConclusionsAn increasing proportion of valve surgery for drug-associated infective endocarditis is for RVS. Despite being young and harboring few comorbidities, the RVS cohort is still susceptible to increased risk of 30-day mortality compared with those undergoing FVS.

Fluorescence in situ hybridization for identification and visualization of microorganisms in infected heart valve tissue as addition to standard diagnostic tests improves diagnosis of endocarditis.

In infective endocarditis (IE), identification of the causative organism and consecutive treatment are crucial for patient survival. Although the macroscopic aspect resembles infected tissue, standard diagnostic tests often fail to allow one to identify bacteria. Fluorescence in situ hybridization (FISH) is a molecular, culture-independent technique that allows one to identify and visualize microorganisms within tissue and to recognize their morphology, number and activity. We analysed the diagnostic benefit of FISH/polymerase chain reaction (PCR) by comparing its results to those of standard diagnostic tests. From September 2015 to April 2018, 128 patients underwent first-time or redo valve surgery to treat IE. Patients were designated according to the modified Duke criteria as definite (n = 61), possible (n = 34) or rejected (n = 33) IE. Tissue specimens obtained intraoperatively were analysed using FISH/PCR in addition to undergoing standard diagnostic testing and PCR alone. We used blood cultures to detect microorganisms in 67/128 patients; valve cultures, in 34/128; PCR, in 67/128; histopathological diagnosis showed IE in 72/128 cases. We were able to detect microorganisms in 103/128 cases using FISH/PCR, with 55/61 in definite IE. Furthermore, we were able to identify 26 cases of bacterial biofilm using FISH/PCR, despite antibiotic treatment of 61 in the definite, 13 in the possible and 1 in the rejected group, including 8/33 patients in the rejected group with active bacteria. In all cases, the patient's therapy was altered. FISH/PCR was used to identify microorganisms in cases in which standard diagnostic tests failed to provide sufficient results for various reasons. Furthermore, FISH/PCR enabled us to identify bacterial biofilms and to differentiate between active versus degraded bacteria, thus indicating the impact of treatment. Therefore, we suggest FISH/PCR as an additional diagnostic tool in IE alongside standard diagnostic tests.

VD01 A CASE OF “VERY” SIMULTANEOUS TRANSAPICAL TRANSCATHETER AORTIC AND MITRAL VALVE IMPLANTATION

Abstract The ever widening diffusion of biological prostheses and the achievement of higher mean age have focused attention on new possible scenario: off-label use of transcatheter valve implantation (TAVI) via a valve-in-valve procedure as an alternative strategy to standard surgery redo valve replacement. We report the first simultaneous Transapical Transcatheter Aortic and Mitral Valve Implantation performed after contemporary wires positioning in aortic and mitral size. After apical puncture, soft and subsequent stiff guidewires were inserted trans-apically through the 2 prosthesis. The first wire was advanced through the aortic prosthesis and placed in femoral artery. The second one was inserted through the mitral prosthesis and placed in right superior pulmonary vein. The aortic prosthesis was introduced through a trans-apically placed sheath, positioned, and then deployed into the degenerated aortic bioprosthesis under fluoroscopic guidance. The same procedure was used for mitral prosthesis using the previous positioned wire.

Outcomes of Redo Valve Surgery in Indigenous Australians

Rheumatic heart disease often leads to valve surgery at a young age in our Indigenous population. Anticoagulation can be problematic and therefore repeat surgery to replace degenerated bioprosthetic valves is common. We sought to examine outcomes following redo valve surgery in this population. Data from our institutional database was reviewed from 1992 to 2017. During this period, 82 redo valve surgeries were performed in 73 patients identifying as Aboriginal and Torres Strait Islander. We compared this study group to Indigenous patients undergoing primary valve surgery (n=389) and non-Indigenous patients undergoing redo valve surgery (n=154). Redo patients had a median age of 29.5 years (IQR 24, 44), 59% were female, and they had significant comorbidities. The 30-day mortality in this cohort was 6% (EuroSCORE II 3.57), and they had significant morbidity. The median time to repeat surgery in those who had previous mitral valve surgery was 6.3 years, with no difference between mitral valve repair or replacement at the index procedure. Compared to non-Indigenous patients undergoing redo valve surgery, the Indigenous patients were significantly younger with higher left ventricular function but a greater proportion of pulmonary hypertension. There were no significant differences in short-term outcomes. Compared to Indigenous patients undergoing primary valve surgery, the Indigenous redo patients were significantly younger with more co-morbidities. There was no difference in 30-day mortality, but the redo patients did have significantly greater resource utilisation (increased hospital and intensive care unit (ICU) lengths of stay, ventilation and blood transfusion) and poorer long-term survival. Indigenous patients presenting for redo valve surgery represent a complex and comorbid group of patients, with outcomes worse than expected in a young population, albeit comparable within study groups. Time from original surgery was short at 6 years, and thus a strategy must be in place in terms of planning future surgeries in this cohort of predominantly young rheumatic heart disease patients.

Propensity Score Matched Analysis of Mechanical vs. Bioprosthetic Valve Replacement in Patients With Previous Stroke.

This study compared the long-term outcomes of prosthetic heart valve replacement with mechanical or bioprosthetic valves in patients with prior stroke.Methods and Results:In total, 1,984 patients with previous stroke who had received valve replacement between 2000 and 2011 were identified using the Taiwan National Health Insurance Research Database. Propensity score matching analysis was used. Ultimately, 547 patients were extracted from each group and were eligible for analysis. On survival analysis, the risks of all-cause mortality and recurrence of stroke were similar. The incidence of major bleeding was greater in the mechanical valve group than in the bioprosthetic valve group (P=0.040), whereas no difference was observed in re-do valve surgery. On subgroup analysis, the bioprosthetic valve was favored for older age (≥60 years) and previous gastrointestinal (GI) bleeding patients. The mechanical valve, however, was favored for younger patients (<60 years). In patients with previous stroke, bioprosthetic valves had a lower incidence of complications connected to major bleeding than did the mechanical valves. Survival and stroke recurrence rates, however, did not differ between the 2 groups. We recommend bioprosthetic valves for patients >60 years or who have a history of GI bleeding.

Mid-term result of atrioventricular valve replacement in patients with a single ventricle.

Atrioventricular valve replacement is the last option to treat the atrioventricular valve regurgitation in single ventricle. This study investigates the mid-term outcomes of the atrioventricular valve replacement based on the Japan Cardiovascular Surgery Database registry. From 2008 to 2014, 56 patients [34 males (61%) and 22 females (39%)] with a single ventricular circulation, underwent atrioventricular valve replacement. Questionnaires were collected to review operative data, mid-term mortality, morbidity and redo replacement. Risk factor analysis was performed by the Cox regression model for death and redo replacement. Heterotaxy, a right systemic ventricle and a common atrioventricular valve was present in 46% (26/56), 64% and 57% of patients, respectively. The most common timings for atrioventricular valve replacement were the interstage between the second and third palliations (34%) and after the Fontan operation (34%). Twenty died during the 3.7 ± 2.6-year follow-up. Eleven received redo atrioventricular replacement. The cumulative incidences of redo atrioventricular valve replacement and survival at 3 years were 20% [95% confidence interval (CI) 9-30] and 66% (95% CI 55-80), respectively. Univariable Cox regression analysis revealed that a tricuspid valve was a risk factor for redo valve replacement [hazard ratio (HR) 6.76, 95% CI 1.79-25.6; P = 0.005] and that young age was a risk factor for death (HR 0.77, 95% CI 0.62-0.96; P = 0.019). Fourteen patients required a pacemaker implantation. Valve replacement for uncontrollable atrioventricular valve regurgitation in single ventricular circulation was associated with a moderately high risk of death, redo replacement and pacemaker implantation, whereas valve replacement at a later period and with a larger prosthetic valve size was associated with low mortality.