Use Of Biological Prostheses Research Articles

Trend in mitral valve prostheses of choice and early outcomes in the United Kingdom

ObjectiveDespite the superiority of mitral valve repair, surgical mitral valve replacement (SMVR) remains an important intervention for patients with valve stenosis, infective endocarditis and complex mitral valve degeneration.There has been an increasing popularity in the worldwide use of biological valves due to the avoidance of long-term anti-coagulation and recent advancements in transcatheter techniques. We aim to evaluate the trend, early clinical outcomes and the choice of prostheses use in isolated SMVR over a 23 years period in the United Kingdom. MethodsAll patients (n = 13,147) who underwent elective or urgent isolated SMVR from March 1996 to April 2019 were identified from the National Adult Cardiac Surgery Audit database.Trends in clinical outcomes, predicted/observed mortality of patients and the utilization of biological prostheses across 5 different age groups: <50, 50–59, 60–69, 70–79 and ≥80 years old were investigated. Early clinical outcomes associated with the use of mechanical and biological mitral valve prostheses in patients between the age of 60–70 years old were analysed. ResultsThe number of isolated SMVR performed has remained stable with approximately 600 cases annually since 2010. The in-hospital/30-day mortality rate has decreased from 7.41% (1996) to 3.92% (2018), despite the EuroScore II increasing from 1.42% in 1996 to 2.43% in 2018.Biological prostheses usage increased across all age group, and particularly in the 60–69 and 70–79 group, from 17.86% and 53.85% in 1996 to 48.85% and 82.38% in 2018, respectively. The use of mechanical prostheses was reduced in patients between the age of 50–59 from 100% in 1996 to 80.65% in 2018. There were no differences in short term outcomes among patients aged 60–70 years who received either a biological or mechanical prostheses. ConclusionThere has been a significant reduction in surgical mitral valve replacement early in-hospital mortality, despite an observed increase in the risk profile of patients over 23 years. A shifting trend in valve replacement choices was observed with a rise in the use of biological prostheses, particularly within the 60–69 and 70–79 age group. Early in hospital outcomes for patients aged 60–70 were not determined by the implanted valve type.

Role of hypercholesterolemia and PSCK9 in bioprosthetic aortic valve degeneration

Calcific aortic valve stenosis (CAVS) is one of the most frequent cardiovascular diseases affecting more than 10% of the population over 70 years old. There is currently no pharmacological treatment to stop this process, and the only solution remains to replace the diseased valve with a prosthesis. A shift toward the use of biological prosthesis occurred in the last 10 years, as these protheses presented better hemodynamic profile without lifelong anticoagulation treatment. However, the main disadvantage of the bioprostheses is their limited durability overtime, with the development of a gradual structural bioprosthetic degeneration (SVD) in the following years post intervention. Our objective is to test the role of hypercholesterolemia and/or PCSK9, a well-know modulator of the cholesterol metabolism, on the early process leading to SVD. As the currently gold standard technic to test calcification potential of biological tissue from bioprosthetic valve, we implanted subcutaneously 5 mm punches of biological matrix from bovine pericardium, in 3 groups of mice: PCSK9 KO, WT and overexpressing hepatic PCSK9 (with AAV injection). After 28 days, punches werehandled and analyzed. Histology and molecular screening were performed. As compared to WT, KO PCSK9 mice presented a 25% to 50% reduction in cholesterol, and mice overexpressing hepatic PCSK9 a 2-time higher circulating cholesterol over the course of the protocol (all P < 0.003). PCSK9 circulating level was not detectable in KO and was significantly increased in mice overexpressing hepatic PCSK9 (fold change > 10 vs. WT; all P < 0.001). Preliminary histological analysis of explanted punches after 28 days revealed an important infiltration of mononuclear cells into the pericardial matrix, consistent over the 3 groups of mice. However, the quantity and degree of infiltration of these cells appeared to be exacerbated in mice overexpressing hepatic PCSK9. Further molecular screening is ongoing. We successfully developed an animal model allowing us the investigation of PCSK9 and hypercholesterolemia roles in SVD. Preliminary analyses suggest that high PCSK9 and/or cholesterol can potentiate cell infiltration post-implantation of bovine pericardial matrix. Further molecular analyses will provide key elements to decipher the mechanisms related to PCSK9 and cholesterol in the development of SVD.

Trend and early outcomes in isolated surgical aortic valve replacement in the United Kingdom.

Surgical aortic valve replacement (SAVR) is traditionally the gold-standard treatment in patients with aortic valve disease. The advancement of transcatheter aortic valve replacement (TAVR) provides an alternative treatment to patients with high surgical risks and those who had previous cardiac surgery. We aim to evaluate the trend, early clinical outcomes, and the choice of prosthesis use in isolated SAVR in the United Kingdom. All patients (n = 79,173) who underwent elective or urgent isolated surgical aortic valve replacement (SAVR) from 1996 to 2018 were extracted from the National Adult Cardiac Surgery Audit database. Patients who underwent additional procedures and emergency or salvage SAVR were excluded from the study. Trend and clinical outcomes were investigated in the whole cohort. Patients who had previous cardiac surgery, high-risk groups (EuroSCORE II >4%), and predicted/observed mortality were evaluated. Furthermore, the use of biological prostheses in five different age groups, that are <50, 50-59, 60-69, 70-79, and >80, was investigated. Clinical outcomes between the use of mechanical and biological aortic valve prostheses in patients <65 years old were analyzed. The number of isolated SAVR increased across the study period with an average of 4,661 cases performed annually after 2010. The in-hospital/30-day mortality rate decreased from 5.28% (1996) to 1.06% (2018), despite an increasing trend in EuroSCORE II. The number of isolated SAVR performed in octogenarians increased from 596 to 2007 (the first year when TAVR was introduced in the UK) to 872 in 2015 and then progressively decreased to 681 in 2018. Biological prosthesis usage increased across all age groups, particularly in the 60-69 group, from 24.59% (1996) to 81.87% (2018). There were no differences in short-term outcomes in patients <65 years old who received biological or mechanical prostheses. Surgical aortic valve replacement remains an effective treatment for patients with isolated aortic valve disease with a low in-hospital/30-day mortality rate. The number of patients with high-risk and octogenarians who underwent isolated SAVR and those requiring redo surgery has reduced since 2016, likely due to the advancement in TAVR. The use of biological aortic prostheses has increased significantly in recent years in all age groups.

Effect of nHA-Coated Femoral Stem Prosthesis Combined with Platelet-Rich Plasma in Hemi Hip Replacement of Femoral Neck Fracture in the Elderly.

Purpose This study investigated the efficacy of nanohydroxyapatite- (nHA-) coated biological prosthesis combined with platelet-rich plasma (PRP) in hemi hip replacement of femoral neck fracture (FNF) in the elderly. Methods From September 2018 to September 2021, 102 elderly patients with FNF treated in our hospital were chosen and divided into two groups according to different intervention methods. Fifty-one patients in the bone cement group were treated with bone cement prosthesis, and the rest 51 patients in the observation group were treated with nHA biological prosthesis combined with PRP in hemi hip replacement. In order to explore the osteogenic effect of nHA and PRP, osteoblasts were cultured. Results It was found that nHA and PRP could both effectively promote the proliferation of osteoblasts and improve their mineralization ability, especially when used in combination. In the course of clinical therapy, we found that the use of biological prosthesis combined with PRP could effectively reduce the level of serum procollagen type I carboxy terminal peptide (PICP) and better improve the levels of bone alkaline phosphatase (BALP) and bone Gla protein (BGP), so as to reduce the bone conversion rate and promote the formation of new bone around the prosthesis. In addition, no significant difference was found in intraoperative bleeding, operation time, hospital stay, 48 h drainage volume, partial weight-bearing time, and complete weight-bearing time between two groups. Otherwise, the use of biological prosthesis could effectively avoid the occurrence of adverse reactions such as bone cement crisis and fracture around femoral prosthesis, so as to better restore the hip function and improve patients' life quality. Conclusions Therefore, in hemi hip replacement of FNF in the elderly, nHA biological prosthesis combined with PRP can effectively promote the formation of new bone around the prosthesis stem, so as to obtain good initial stability, enable patients to carry out early weight-bearing exercise, and effectively avoid adverse reactions caused by bone cement prosthesis, thus improving patients' hip function and life quality.

Three-year results of Ozaki surgery in patients aged ≥65 years: a multicentre study

Background. Currently, aortic valve stenosis is the most common disease of the native valve, which affects 5% of the elderly population. In symptomatic patients, aortic valve replacement is the ‘gold standard’. For patients aged ≥65 years, the use of biological prostheses is recommended. The Ozaki operation is an alternative to bioprostheses.Aim. The aim of this study was to evaluate the immediate and 3-year results of Ozaki surgery in patients aged ≥65 years.Methods. This was a prospective multicentre study conducted on 107 patients aged ≥65 years, who underwent the Ozaki procedure at three centres during 2016–2019. There were 46 (43%) men. The median age of the patients was 69 [67–74] years. Severe aortic stenosis was the major cause of aortic valve dysfunction (106 patients [99.1%]). Chronic heart failure III–IV functional class according to NYHA was diagnosed in 47 (43.9%) patients. The following complications were also registered: atrial fibrillation in 30 (28%) patients, a history of diabetes mellitus in 16 (15%) patients, chronic obstructive pulmonary disease in 14 (13.1%) patients and coronary artery disease in 42 (39.2%) patients. Bicuspid aortic valve was detected in 36 (34.6%) patients. There were 72 (67.2%) patients with a small annulus (≤21 mm) and 59 (55.14%) patients with a left ventricular ejection fraction of 64%. The median follow-up period was 23 [18–33] months. This study included all patients who underwent Ozaki surgery from 2016 to 2019.Results. No patient had any conversions. A total of 45 (42.1%) patients underwent combined interventions. The operation duration was 240 [214–300] min, cardiopulmonary bypass duration was 104 [93–120] min and aortic cross-clamp duration was 82 [72–95] min. The rate of hospital mortality was 1.9%, and the incidence rates of acute renal failure requiring haemodialysis, stroke, pacemaker implantation, sepsis and reoperation for bleeding were 1.9%, 0.9%, 1.9%, 0.9% and 0.9%, respectively. The hospitalisation duration was 14 [11–16] days. The gradients of peak and mean pressure on the aortic valve after surgery were 9 [7–13] and 4 [3–6] mmHg, respectively, and the effective valve opening area was 2.6 [2.3–2.9] cm2. None of the patients had moderate and severe aortic regurgitation. The 3-year overall survival and freedom from reoperation were 88.6% and 97%, respectively.Conclusion. The Ozaki operation in patients aged ≥65 years has good immediate results, with a hospital mortality rate of 1.9%, excellent haemodynamic parameters with an average pressure gradient across the aortic valve of 4 [3–6] mmHg and a valve opening area of 2.6 [2.3–2.9] cm2. The 3-year overall survival and freedom from reoperation were 88.6% and 97%, respectively. Further monitoring of these patients is required to evaluate long-term results, and there is also a need for randomised clinical trials comparing Ozaki operation with bioprostheses. Received 4 February 2021. Revised 21 June 2021. Accepted 23 June 2021. Funding: The study did not have sponsorship. Conflict of interest: Authors declare no conflict of interest. Contribution of the authorsConception and study design: I.I. Chernov, R.N. Komarov, D.G. Tarasov, Yu.S. Sinelnikov, A.V. Marchenko, V.B. Arutyunayan, K.Yu. ZhigalovData collection and analysis: B.K. Kadyraliev, A.M. Ismailbaev, B.M. Tlisov, D.A. Zorin, M.I. TcheglovStatistical analysis: S.T. EnginoevDrafting the article: I.I. Chernov, S.T. EnginoevCritical revision of the article: I.I. Chernov, R.N. Komarov, D.G. Tarasov, Yu.S. Sinelnikov, A.V. Marchenko, V.B. Arutyunayan, K.Yu. ZhigalovFinal approval of the version to be published: I.I. Chernov, S.T. Enginoev, R.N. Komarov, D.G. Tarasov, Yu.S. Sinelnikov, A.V. Marchenko, V.B. Arutyunayan, B.K. Kadyraliev, A.M. Ismailbaev, B.M. Tlisov, D.A. Zorin, M.I. Tcheglov, K.Yu. Zhigalov

O34 AUTOLOGOUS FENESTRATED CUTIS GRAFTS FOR VENTRAL HERNIA REPAIR IN PATIENTS WITH OBESITY

Abstract Aim Traditional approaches to ventral hernia repair involve implantation of synthetic mesh (SM), primary suture (PS) repair, and the use of biologic prostheses (BP). A body mass index (BMI) &amp;gt; 30 increases recurrence rates and complications for such repairs. We have begun to use Autologous Fenestrated Cutis Grafts (CG) as an alternative hernia repair. We investigated the impact of obesity on the recurrence and complication rates of CG compared to traditional repairs. Material and Methods A five-surgeon, retrospective study included all ventral/incisional, epigastric and umbilical hernia repairs (SM, PS, and BP from 2015-2020; CG repairs from 2018-2020). Patients with a BMI ≥ 30 were stratified according to surgical approach. Outcomes included recurrence and complication rates. Descriptive statistics for demographics and outcomes were compared and logistic regression performed with p &amp;lt; 0.05 considered significant. Results A total of 301 hernia repairs were performed (173 CGs, 54 SM, 59 PS, 15 BS). The groups had similar recurrence rates. A significant difference in complications rates did exist (37% CGs, 48.1% SMs, 15.3% PS, 66.7% BP, p &amp;lt; 0.001). Logistic regression revealed PS had fewer total complications than all other repairs. Compared to SM, CG had fewer seromas. Compared to BP, CG had fewer wound infections, systemic infections, renal complications, and additional procedures. Conclusions CG for abdominal wall hernia repair in patients with BMI ≥ 30 is an acceptable hernia repair in obese patients with similar recurrence rates and an acceptable complication profile compared to traditional repairs.

A Role for Peroxisome Proliferator-Activated Receptor Gamma Agonists in Counteracting the Degeneration of Cardiovascular Grafts.

Aortic valve replacement for severe stenosis is a standard procedure in cardiovascular medicine. However, the use of biological prostheses has limitations especially in young patients because of calcifying degeneration, resulting in implant failure. Pioglitazone, a peroxisome proliferator-activated receptor gamma (PPAR-gamma) agonist, was shown to decrease the degeneration of native aortic valves. In this study, we aim to examine the impact of pioglitazone on inflammation and calcification of aortic valve conduits (AoC) in a rat model. Cryopreserved AoC (n = 40) were infrarenally implanted into Wistar rats treated with pioglitazone (75 mg/kg chow; n = 20, PIO) or untreated (n = 20, controls). After 4 or 12 weeks, AoC were explanted and analyzed by histology, immunohistology, and polymerase chain reaction. Pioglitazone significantly decreased the expression of inflammatory markers and reduced the macrophage-mediated inflammation in PIO compared with controls after 4 (P = 0.03) and 12 weeks (P = 0.012). Chondrogenic transformation was significantly decreased in PIO after 12 weeks (P = 0.001). Calcification of the intima and media was significantly reduced after 12 weeks in PIO versus controls (intima: P = 0.008; media: P = 0.025). Moreover, echocardiography revealed significantly better functional outcome of the AoC in PIO after 12 weeks compared with control. Interestingly, significantly increased intima hyperplasia could be observed in PIO compared with controls after 12 weeks (P = 0.017). Systemic PPAR-gamma activation prevents inflammation as well as intima and media calcification in AoC and seems to inhibit functional impairment of the implanted aortic valve. To further elucidate the therapeutic role of PPAR-gamma regulation for graft durability, translational studies and long-term follow-up data should be striven for.

Mechanical Versus Biologic Prostheses for Surgical Aortic Valve Replacement in Patients Aged 50 to 70

The use of biologic prosthesis is increasing in surgical aortic valve replacement (SAVR). Recent US guidelines recommend either biologic or mechanical prosthesis for SAVR in patients aged 50 to 70 years. We set out to study long-term outcomes of mechanical versus biologic prosthetic valves in this patient group. All patients (excluding infective endocarditis and concomitant surgery other than coronary artery bypass grafting) aged 50 to 70 with first-time SAVR in Finland between 2004 and 2014 were retrospectively studied (N= 2928). Propensity score matching (1:1) was used to identify patients with comparable baseline features (n= 1152). Outcomes were 10-year all-cause mortality, aortic valve reoperation, major bleeding, ischemic stroke, and infective endocarditis. Mean follow-up was 6.7 years. Ten-year all-cause mortality was 18.6% with mechanical valves and 27.6% with biologic valves (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.54-0.97; P= .028). Prosthetic valve reoperation was performed in 1.4% with mechanical valves and in 8.5% with bioprosthetic valves (HR, 0.30; 95% CI, 0.12-0.74; P= .009). Major bleeding occurred in 21.5% with mechanical valves and in 16.9% with biologic prostheses (HR, 1.19; P= .402). Rates of intracranial bleeding were also comparable. Ischemic stroke rates within 10 years were 12.7% with mechanical valves and 9.3% with biologic valves (HR, 1.29; P= .316). Infective endocarditis occurred in 3.7% of mechanical valves and in 7.3% of biologic valves (HR, 0.46; 95% CI, 0.24-0.88; P= .018). Mechanical valve prostheses were associated with lower mortality, lower rates of reoperation, and lower occurrence of infective endocarditis compared with bioprostheses within 10 years after SAVR in matched patients aged 50 to 70 years. Our results do not support the routine use of biologic valve prostheses in this patient group.

“Valve-On-Valve” — an alternative method of surgical treatment of tissue valve dysfunctions

Every year, the frequency of use of biological prostheses for treatment of valvular heart disease increases.The implantation of a biological prosthesis allows avoiding lifelong anticoagulant therapy, but at the same time it may require further replacement due to the dysfunction development.Traditional reoperation is associated with a certain risk of trauma to various structures and cardiac chambers during explantation of non-functioning valve.Transcatheter replacement of the prosthesis (“valve-in-valve”) is not always realizable due to lack of routes for the delivery system and small diameter of the initial valve.“Valve-in-valve” is not always demanded because it does not provide an option to choose mechanical or biological prosthesis.Valve-on-valve implantation technique implies that the new prosthesis is implanted in the carcass of the previous valve. It allows avoiding severe intraoperative complications, reducing the duration of the main stage of the surgery and adverse events in the early postoperative period, and provide an option to choose implantable device.In this review, the authors attempted to comprehensively evaluate the world experience in applying the “valve-on-valve” technique.

Emergency repair of complicated abdominal wall hernias: WSES guidelines.

In July 2013, the World Society of Emergency Surgery (WSES) held the first Consensus Conference on emergency repair of abdominal wall hernias in adult patients with the intention of producing evidence-based guidelines to assist surgeons in the management of complicated abdominal wall hernias. Guidelines were updated in 2017 in keeping with varying clinical practice: benefits resulting from the increased use of biological prosthesis in the emergency setting were highlighted, as previously published in the World Journal of Emergency Surgery. This executive summary is intended to consolidate knowledge on the emergency management of complicated hernias by providing the broad readership with a practical and concise version of the original guidelines. This executive manuscript summarizes the WSES guidelines reporting on the emergency management of complicated abdominal wall hernias; statements are highlighted focusing the readers' attention on the main concepts presented in the original guidelines. Emergency repair of complicated abdominal hernias remains one of the most common and challenging surgical emergencies worldwide. WSES aims to provide an essential version of the evidence-based guidelines focusing on the timing of intervention, laparoscopic approach, surgical repair following the Centers for Disease Control and Prevention (CDC) wound classification, antimicrobial prophylaxis and anesthesia in the emergency setting.

Mid-term outcomes after biologic mesh use: Does their performance meet our expectations?

The indications for use of biological mesh prostheses are very limited because of their high cost, but include parietal repair in a contaminated setting. Their efficacy has been questioned by several recent studies. We therefore studied the results of all of our patients who received a biological prosthesis, including hernia recurrence and infectious complications. We retrospectively reviewed the outcomes of 68 patients who underwent biological prosthesis placement from 2009 to 2015 in a single center. The site of implantation was on the anterior abdominal wall in 49 (72%) of cases, in the pelvis in 19 (28%). The median follow-up was 19 months. In the early post-operative period, 22 (32.3%) of patients presented with wall abscess; eight (11.7%) underwent surgical revision and seven (10.2%) underwent interventional radiological drainage. In the medium term, 41/56 (73%) had a late complication; 32 (57%) of the patients developed recurrent herniation and 15 (26.7%) of them were re-operated. In addition, nine (16%) of patients developed a late surgical site infection and eight (14.2%) a chronic residual infection. In multivariate analysis, the risk factors for recurrence were parastomal hernia (P=0.007) and a history of recurrent hernia (P=0.002). A majority of patients developed recurrent incisional herniation in the medium term. This puts the use of biological prostheses into question. These results need to be compared to those of semi-absorbable prostheses.

Mechanical or Biologic Prostheses for Aortic-Valve and Mitral-Valve Replacement

BackgroundIn patients undergoing aortic-valve or mitral-valve replacement, either a mechanical or biologic prosthesis is used. Biologic prostheses have been increasingly favored despite limited evidence supporting this practice.MethodsWe compared long-term mortality and rates of reoperation, stroke, and bleeding between inverse-probability-weighted cohorts of patients who underwent primary aortic-valve replacement or mitral-valve replacement with a mechanical or biologic prosthesis in California in the period from 1996 through 2013. Patients were stratified into different age groups on the basis of valve position (aortic vs. mitral valve).ResultsFrom 1996 through 2013, the use of biologic prostheses increased substantially for aortic-valve and mitral-valve replacement, from 11.5% to 51.6% for aortic-valve replacement and from 16.8% to 53.7% for mitral-valve replacement. Among patients who underwent aortic-valve replacement, receipt of a biologic prosthesis was associated with significantly higher 15-year mortality than receipt of a mechanical prosthesis among patients 45 to 54 years of age (30.6% vs. 26.4% at 15 years; hazard ratio, 1.23; 95% confidence interval [CI], 1.02 to 1.48; P=0.03) but not among patients 55 to 64 years of age. Among patients who underwent mitral-valve replacement, receipt of a biologic prosthesis was associated with significantly higher mortality than receipt of a mechanical prosthesis among patients 40 to 49 years of age (44.1% vs. 27.1%; hazard ratio, 1.88; 95% CI, 1.35 to 2.63; P<0.001) and among those 50 to 69 years of age (50.0% vs. 45.3%; hazard ratio, 1.16; 95% CI, 1.04 to 1.30; P=0.01). The incidence of reoperation was significantly higher among recipients of a biologic prosthesis than among recipients of a mechanical prosthesis. Patients who received mechanical valves had a higher cumulative incidence of bleeding and, in some age groups, stroke than did recipients of a biologic prosthesis.ConclusionsThe long-term mortality benefit that was associated with a mechanical prosthesis, as compared with a biologic prosthesis, persisted until 70 years of age among patients undergoing mitral-valve replacement and until 55 years of age among those undergoing aortic-valve replacement. (Funded by the National Institutes of Health and the Agency for Healthcare Research and Quality.)

Effectiveness and versatility of biological prosthesis in transplanted patients.

AIMTo emphasize the effectiveness and versatility of prosthesis, and good tolerance by patients with incisional hernia (IH).METHODSFrom December 2001 to February 2016, 270 liver transplantations were performed at San Camillo Hospital. IH occurred in 78 patients (28.8%). IH usually appeared early within the first year post-orthotopic liver transplantation. In the first era, fascial defect was repaired by primary closure for defects smaller than 2.5 cm or with synthetic mesh for greater defects. Recently, we started using biological mesh (Permacol™, Covidien). We present a series of five transplanted patients submitted to surgery for abdominal wall defect correction repaired with biological mesh (Permacol™, Covidien).RESULTSIn our cases, the use of biological prosthesis (Permacol™, Covidien) have proven to be effective and versatile in repairing hernia defects of different kinds; patients did not suffer infections of the prosthesis and no recurrence was observed. Furthermore, the prosthesis remains intact even in the years after surgery.CONCLUSIONThe cases that we presented show that the use of biological mesh (Permacol™, Covidien) in transplanted patients may be safe and effective, being careful in the management of perioperative immunosuppression and renal and graft function, although the cost of the product itself has been the main limiting factor and there is need for prospective studies for further evaluations.

Incisional Hernia Repair in Contaminated Surgical fields (I.H.R.C.S.) study using biological prostheses in emergency surgery setting with contaminated hernias: a multicenter prospective observational study

There are still difficulties to find appropriate indication for prosthetic implant in hernia surgery in contaminated surgical fields. Biologic prosthetic materials have been developed and proposed for the clinical use in contaminated surgical fields with interesting outcomes. The aim of this study is to analyze data from nine Italian Emergency Surgery Units concerning patients consecutively admitted with diagnosis of strangulated incisional hernia (IH), submitted to surgery in emergency and treated with biological prostheses. This is a prospective observational study. Subjects submitted to singlestaged IH repair in a contaminated surgical field, with the use of biologic mesh, were prospectively studied over a 1-year time period. All patients enrolled in this study were submitted to bowel/intestinal resection at the same operative time for perforation. Primary end points of our study were wound complication and hernia recurrence. Seventy-one patients were enrolled (F=21, M=50); the mean age was 69.2±11.1 standard deviation (SD) years and the mean American Society of Anesthesiologist (ASA) score was 3.1±0.8 SD. Twenty-one patients (29.57%) had a wound complication, associated with high ASA score, diabetes, smoking, chronic immunosuppression, number of previous hernia repairs, dirty surgical field, sublay extra peritoneal mesh placement and no anterior fascia closure. After a mean follow up time of 27.2 months, hernia recurrence occurred in 19 patients (26.76%). Predictors of hernia recurrence included wound complications, high ASA score, diabetes, chronic immunosuppression, dirty surgical field and sublay extra peritoneal mesh placement. Use of biological prostheses in contaminated fields is safe with favorable medium term recurrence rate (26.76% in our experience). Surgical technique performed is important to decrease hernia recurrence rate.

Effectiveness and properties of the biological prosthesis Permacol™ in pediatric surgery: A large single center experience.

IntroductionThe use of prosthetic patches of non-absorbable materials represents a valid tool in the treatment of abdominal wall and diaphragmatic defects in pediatric age. In recent years research has developed biological dermal scaffolds made from a sheet of acellular matrix that can provide the desired support and reduce the occurrence of complications from non-absorbable implant. We present our experience and a systematic review to evaluate the use of biologic prosthesis for abdominal wall closure in pediatric patients.MethodsThe study from January 2009 to January 2015 involved 20 patients treated with Permacol™ implant. We observed postoperative complications only in patients treated for abdominal wall closure, which is the major indication for the use of Permacol™. We conducted a systematic review and meta-analysis (according to PRISMA) on PubMed/Medline, Scopus and EMBASE regarding the use of biological prosthesis in pediatric population considering the incidence of complications as the primary outcome.Results3/20 patients experienced complications: 2 patients with skin necrosis healed conservatively and 1 of them developed laparocele. Thus only 1 patient with incisional hernia had significant surgery complication. In patients who were permanently implanted with Permacol™ it has not determined adverse reactions with optimal functional outcome.ConclusionsIn accordance with the few data (case reports and case series) reported in literature about pediatric patients, our experience in different pathologies and applications has shown the effectiveness of Permacol™, in particular for the non-occurrence of infections, that often affect the use of prosthesis.

Early Postoperative Eventration: Surgical Treatment with Use of Biological Prosthesis

Purpose: Eventration is a rare complication after laparotomy and its treatment is actually not standardized. We retrospectively analyzed 12 patients with early postoperative eventration; 8 of 12 were treated with use of biological mesh (non-cross-linked porcine derma). Materials and Methods: We observed, from January 2009 to January 2014, 12 patients with eventration. In 4/12 patients we performed a direct abdominal wall closure and these patients were excluded from the study; remaining 8 patients encountered inclusion criteria and were enrolled on study. Study population was composed by 8 patients (6 male, 2 female). Mean age was 53 years (range 35-70). Direct abdominal wall closure was not performed because of the risk of “abdominal compartment syndrome” (ACS). In six of eight patients early post-operative eventration occurred after urgent surgery Surgical technique: in 4 patients we performed direct wall closure with biological prosthesis (porcine derma) (one-step procedure). In 2 patients wall closure with similar technique was delayed after 9 and 12 days of intra-abdominal VAC (vacuum assisted closure) Therapy (two-step procedure). In 2 cases, because of large skin defect, we applied biological prosthesis and a surface VAC Therapy system on the prosthesis after intra-abdominal VAC Therapy (three-step procedure). Results: We observed immediate complications in four cases (seroma). No patients underwent re-eventration. One year after surgery one patient manifested laparocele. Conclusions: In our opinion, in these cases biological prosthesis can be used as valid device. However, our study is limited by number of patients and other studies are needed to draw definitive conclusions.

Minimally invasive reoperative aortic valve replacement: a systematic review and meta-analysis.

With prolonged life expectancy and more frequent use of biological prostheses, an increasingly higher proportion of patients are undergoing aortic valve replacement (AVR) after previous sternotomy. We critically appraised the quantity and quality of evidence to demonstrate the efficacy and safety of the minimally invasive (MIrAVR) versus conventional (CrAVR) approaches for reoperative AVR. Electronic searches were performed using six databases from their inception to April 2014. Relevant studies utilizing a MIrAVR were identified. Data were extracted and analyzed according to predefined clinical endpoints. Four single-arm and seven comparative observational studies including a total of 441 MIrAVR patients were included for quality assessment, data extraction and analysis. In-hospital mortality ranged from 0-9.5%, and was similar between the MIrAVR and CrAVR groups (RR, 0.77; 95% CI, 0.39-1.54; P=0.46). Stroke rates ranged from 2.6-8% and were also similar between the two cohorts. The rates of pacemaker implantation, renal failure and reoperation for bleeding were not significantly different between the two groups. There were no reports of myocardial infarctions in the included studies. No significant difference in hospital stay was observed for the MIrAVR versus CrAVR group. The current literature suggests that MIrAVR has similar efficacy and mortality outcomes compared to CrAVR without compromise to myocardial protection or hospitalization duration. It appears to be a valid alternative option for patients requiring reoperative AVR.

Use of a Bioprosthetic Mesh in Complex Hernia Repair

Implantation of synthetic meshes for reinforcement of abdominal wall hernias can be complicated by mesh infection, which often requires mesh explantation. The risk of mesh infection is increased in a contaminated environment or in patients who have comorbidities such as diabetes or smoking. The use of biological prostheses has been advocated because of their ability to resist infection. Initial results, however, have shown high hernia recurrence rates and wound occurrences. The objective of the present study is to evaluate early and mid-term outcomes in the largest French series that included 43 consecutive complex abdominal hernias repaired with biological prostheses. Retrospective observational study of a prospective collected data bank. Patient demographics, history of previous repairs, intraoperative findings and degree of contamination, associated procedures, postoperative prosthetic-related complications, and long-term results were retrospectively reviewed. There were 25 (58%) incisional, 14 parastomal, and 4 midline hernia repairs. Hernias were considered "clean" (n = 5), "clean-contaminated" (n = 19), "contaminated" (n = 12), or "dirty" (n = 7). Wound-related morbidity occurred in 17 patients; 4 patients needed reoperation for cutaneous necrosis or abscess. Smoking was the only risk factor associated with wound complication (P = .022). No postoperative wound events required removal of the prosthesis. There were 4 hernia recurrences (9%). A previous attempt at repair (P = .018) and no complete fascia closure (P = .033) were associated with hernia recurrence. This study demonstrated that the use of bioprothesis in complex hernia repair allowed successful single-stage reconstruction. Wound-related complications were frequent. Cost-benefit analyses are important to establish the validity of these findings.

Left cardiac chambers after implantation of mitral valve prostheses “MIX”, “MEDINGE-2”, “KemCor”, and “PeriCor”

Aim. To compare ultrasound parameters of left cardiac chambers after the implantation of mitral valve prostheses “MIX”, “MEDINGE-2”, “KemCor”, and “PeriCor”, using the 10-year follow-up data. Material and methods. We analysed 2,543 echocardiography protocols of patients with mitral valve disease, who in 1995–2008 underwent the implantation of mitral valve prostheses “MIX” (n=122), “MEDINGE-2” (n=67), and biological prostheses “KemCor” or “PeriCor” (n=306). The exclusion criteria were aortal valve prosthesis, prosthesis dysfunction, and age under 18 years. Results and conclusion. In the early post-intervention period, left ventricular (LV) ejection fraction tended to decrease (p&gt;0,10); however, by the end of the first year, it was normalised. The use of biological prostheses resulted in a significant (p

Parastomal Hernia Repair

Parastomal hernias remain a daunting challenge to general and colorectal surgeons. Their unique anatomy and alteration of abdominal wall mechanics contribute to a significant recurrence rate and associated morbidity in repair. Recent advances in synthetic and biologic meshes, as well as refinement of laparoscopic surgical techniques, may offer potential improvements in outcome for these patients. We conducted a review of the literature for parastomal hernia repair, including manuscripts specifically addressing the use of synthetic and biologic prostheses. We then chose selected references from these studies to include in this review. Results are summarized to reflect current evidence for use of prostheses and other techniques in the repair of parastomal hernias. Repair of parastomal hernias remains plagued by significant recurrence rates. Recurrence may be higher when other abdominal wall hernias are addressed simultaneously. Synthetic mesh repair appears to reduce recurrence compared with primary suture repair. The use of biologic prostheses may reduce recurrence rate and eliminate the potential for mesh infection. The laparoscopic approach should be individualized to both patient and surgeon factors.