Valve Replacement In Young Patients Research Articles

Mitral valve replacement in young patients: review and current challenges.

Mitral valve repair is the ideal intervention for mitral valve disease with excellent long-term survival comparable to the age-matched general population. When the mitral valve is not repairable, mechanical prostheses may be associated with improved survival as compared with biological prostheses. Newer mechanical and biological valve prostheses have the potential to improve outcomes following mitral valve replacement in young patients. Patients presenting for mitral valve surgery after failed transcatheter mitral valve-in-valve have high rates of postoperative mortality and morbidity, exceeding those seen with reoperative mitral valve surgery, which poses issues in young patients who have a higher cumulative incidence of reintervention.

Mitral valve replacement in young patients: review and current challenges.

Mitral valve repair is the ideal intervention for mitral valve disease with excellent long-term survival comparable to the age-matched general population. When the mitral valve is not repairable, mechanical prostheses may be associated with improved survival as compared with biological prostheses. Newer mechanical and biological valve prostheses have the potential to improve outcomes following mitral valve replacement in young patients. Patients presenting for mitral valve surgery after failed transcatheter mitral valve-in-valve have high rates of postoperative mortality and morbidity, exceeding those seen with reoperative mitral valve surgery, which poses issues in young patients who have a higher cumulative incidence of reintervention.

Commentator Discussion: Long term durability of bioprosthetic aortic valve replacement in young patients with bicuspid aortic stenosis

Commentator Discussion: Long term durability of bioprosthetic aortic valve replacement in young patients with bicuspid aortic stenosis

Aortic Valve Replacement in Adult Patients with Decellularized Homografts: A Single-Center Experience.

decellularized aortic homografts (DAH) represent a promising alternative for aortic valve replacement in young adults due to their low immunogenicity and thrombogenicity. Herein, we report our midterm, single-center experience in adult patients with non-frozen DAH from corlife. safety, durability, and hemodynamic performance were evaluated according to current guidelines in all consecutive patients who had received a DAH at our center since 03/2016. seventy-three (mean age 47 ± 11 years, 68.4% (n = 50) male) patients were enrolled. The mean diameter of the implanted DAH was 24 ± 2 mm. Mean follow-up was 36 ± 27 months, with a maximum follow-up of 85 months and cumulative follow-up of 215 years. No cases of stenosis were observed, in four (5.5%) cases moderate aortic regurgitation occurred, but no reintervention was required. No cases of early mortality, non-structural dysfunction, reoperation, valve endocarditis, or thrombosis were observed. Freedom from bleeding and thromboembolic events was 100%; freedom from re-intervention was 100%; survival was 98.6% (n = 72). early and mid-term results showed low mortality and 100% freedom from reoperation, thromboembolic events, and bleeding at our center. However, in order for this novel approach to be established as a valid alternative to aortic valve replacement in young patients, long-term data are required.

Partial Heart Transplantation in Adult Cardiac Surgery.

Many young adults require heart valve replacements. Current options for valve replacement in adults include mechanical valves, bioprosthetic valves, or the Ross procedure. Of these, mechanical and bioprosthetic valves are the most common options, although mechanical valve usage predominates in younger adults due to durability, while bioprosthetic valve usage predominates in older adults. Partial heart transplantation is a new method of valvular replacement that can deliver durable and self-repairing valves and allow adult patients freedom from anticoagulation therapy. This procedure involves transplantation of donor heart valves only, permitting expanded utilization of donor hearts as compared with orthotopic heart transplantation. In this review, we discuss the potential benefits of this procedure in adults who elect against the anticoagulation regimen required of mechanical valve replacements, although it has not yet been clinically established. Partial heart transplantation is a promising new therapy for the treatment of pediatric valvular dysfunction. This is a novel technique in the adult population with potential utility for valve replacement in young patients for whom anticoagulation therapy is problematic, such as women who wish to become pregnant, patients with bleeding disorders, and patients with active lifestyles.

Lifetime Management of Aortic Stenosis: Transcatheter Versus Surgical Treatment for Young and Low-Risk Patients.

Transcatheter aortic valve replacement is now indicated across all risk categories of patients with symptomatic severe aortic stenosis and has been proposed as first line option for the majority of patients >74 years old. However, median age of patients enrolled in the transcatheter aortic valve replacement low-risk trials is 74 years and transcatheter aortic valve replacement has never been systematically investigated in young low risk patients. Although the long-term data in surgical aortic valve replacement in young patients (age <75) are well known, such data remain lacking in transcatheter aortic valve replacement. In the absence of clear guideline recommendations in patients with challenging anatomies (eg, hostile calcium, bicuspid), it is important to know the potential advantages and disadvantages of each treatment and to consider how they might integrate with each other in the lifetime management of such patients. In this review, we discuss current outstanding issues on the management of severe aortic stenosis from a lifetime management perspective, particularly in terms of initial intervention and future reinterventions.

The MITRIS RESILIA mitral valve is a safe and effective option for mitral valve replacement in young patients requiring mitral valve replacement.

We report the first successful implantation in the United States of a novel mitral valve (MITRIS RESILIA by Edwards Lifesciences) in a patient with history of mitral valve replacement at a young age. This new bioprosthetic valve offers a unique profile and innovative option for mitral valve replacement in patients who are at risk of left ventricular outflow tract obstruction.

The effect of decellularisation on the real time mechanical fatigue of porcine aortic heart valve roots.

Decellularised heart valve roots offer a promising option for heart valve replacement in young patients, having the potential to remodel and repair. Replacement heart valves have to undergo billions of opening and closing cycles throughout the patient’s lifetime. Therefore, understanding the effect of cyclic loading on decellularised heart valve roots is important prior to human implantation. The aim of this preliminary study was to investigate the influence of low concentration sodium dodecyl sulphate (SDS) decellularisation treatment on the in vitro real time mechanical fatigue of porcine aortic heart valve roots under physiological real time cyclic loading conditions. This required a specific real time in vitro method to be developed, since previous methods relied on accelerated testing, which is non-physiological, and not appropriate for valve replacement materials that exhibit time dependent characteristics. The effects of the real time fatigue on hydrodynamic function and mechanical properties of the heart valve roots were assessed. The mechanical fatigue of decellularised porcine aortic heart valve roots (n = 6) was assessed and compared to cellular porcine aortic heart valve roots (n = 6) in a modified Real time Wear Tester (RWT) at a physiological frequency and under cyclic pressure conditions for a maximum of 1.2 million cycles. Periodically, the heart valve roots were removed from the RWT to assess the influence of cyclic loading on valve competency (static leaflet closure). At the end of testing further hydrodynamic performance parameters were ascertained, along with determination of leaflet material properties. A real time mechanical fatigue assessment method was developed and applied; with two cellular and two decellularised porcine aortic leaflets in different heart valve roots showing tears in the belly region. The decellularised aortic heart valve roots exhibited comparative functionality to the cellular heart valve roots under in vitro static and pulsatile hydrodynamic conditions. However, the material properties of the decellularised aortic leaflets were significantly altered following cyclic fatigue assessment and showed increases in elastin and collagen phase slopes and ultimate tensile strength compared to the cellular porcine aortic leaflets in the circumferential direction. This preliminary study demonstrated that low concentration SDS decellularised porcine aortic heart valve roots can withstand physiological cyclic deformations up to 1.2 million cycles in a RWT whilst maintaining their overall hydrodynamic function and leaflet mechanical properties. This is the first full report of preclinical mechanical fatigue assessment of decellularised porcine aortic heart valve roots under physiological real time conditions.

Life expectancy after aortic valve replacement in young patients

Introduction and objectivesIn young patients with severe aortic stenosis, it is unknown whether their life expectancy restored after aortic valve replacement (AVR) is unknown. MethodsWe analyzed all patients aged between 50 and 65 years who underwent isolated AVR in 27 Spanish centers during an 18-year period. We compared observed and expected survival at 15 years of follow-up. We repeated all analyses for patients without complications in the postoperative period. ResultsA total of 5084 patients were analyzed. For the overall sample, observed survival at 10 and 15 years was 85.3% (95%CI, 84.1%-86.4%) and 73.7% (95%CI, 71.6%-75.6%), respectively. Expected survival was 90.1% and 82.1%. Cumulative relative survival for 1, 5, 10 and 15 years of follow-up was 97.4% (95%CI, 96.9%-97.9%), 96.5% (95%CI, 95.7%-97.3%), 94.7% (95%CI, 93.3%-95.9%), and 89.8% (95%CI, 87.3%-92.1%). For patients without complications, cumulative relative survival for 1, 5, 10 and 15 years was 100.3% (95%CI, 99.8%-100.5%), 98.9% (95%CI 97.6% -99.9%), 97.3% (95%CI, 94.9%-99.4%), and 91.9% (95%CI, 86.5%-96.8%). ConclusionsLife expectancy in young patients who have severe aortic stenosis and undergo AVR is lower than that of the general population. Life expectancy of individuals without complications during the postoperative period is also reduced. Therefore, baseline characteristics are likely the main factors that explain the reduction in life expectancy.

Echocardiographic Profiles and Reasons for Valve-Related Reoperation after Mechanical vs Bioprosthetic Mitral Valve Replacement in Young Patients: Two-Center Collaborative Experience

Echocardiographic Profiles and Reasons for Valve-Related Reoperation after Mechanical vs Bioprosthetic Mitral Valve Replacement in Young Patients: Two-Center Collaborative Experience

Corrigendum to 'The Ross procedure versus mechanical aortic valve replacement in young patients: a decision analysis' [Eur J Cardiothorac Surg 2019;55:1180--6

Corrigendum to 'The Ross procedure versus mechanical aortic valve replacement in young patients: a decision analysis' [Eur J Cardiothorac Surg 2019;55:1180--6

The Ross procedure versus mechanical aortic valve replacement in young patients: a decision analysis.

Our goal was to determine the range of perioperative mortality rates associated with the Ross procedure that results in a life expectancy similar to that seen with mechanical aortic valve replacement (mAVR) in young patients with aortic valve disease. A fully probabilistic Markov microsimulation model with 1000 outer loops and 10000 inner loops was constructed to compare gain in life expectancy and quality-adjusted life years between the index treatment with the Ross procedure versus mAVR for a theoretical cohort of young patients with aortic valve disease. Inputs for early deaths and late complications (death, stroke, bleeding, reoperation) were obtained from a single-centre study of 208 propensity score matched patients. In the primary analysis, the perioperative mortality rate for the Ross procedure was varied by increments of 0.5% to determine its impact on life expectancy and quality-adjusted life years. A 2-way sensitivity analysis was conducted to determine simultaneously the impact of the Ross reoperation rate and Ross reoperative mortality rate on life expectancy. Life expectancy was improved with the Ross procedure when the perioperative mortality rate with the Ross procedure was <2.5% and was equivalent to mAVR when the mortality rate was 2.5% to 5%. Similarly, when the perioperative mortality rate of the Ross procedure was between 4% and 5.5%, the quality-adjusted life years gained were similar between the Ross procedure and mAVR. Life expectancy was improved when the Ross procedure reoperative mortality rate was <7% at an incidence of Ross reoperations of 18% at 20 years. Improved life expectancy can be expected with the Ross procedure when the operative mortality rate is less than 2.5%.

Aortic valve replacement in young patients: should the biological prosthesis be recommended over the mechanical?

Schnittman and colleagues have recently published a very interesting observational study from the Mount Sinai group (1). It contributes with new and useful data on the controversial issue of the most adequate aortic valve type when performing an aortic valve replacement (AVR) in young patients (under 50 years old).

Comparison of the Ross Procedure in Patients with Endocarditis and Noninfective Valve Disease: Long-term Follow-up of 641 Patients

Objectives: Executed by an experienced surgeon, the Ross procedure is an excellent alternative to prosthetic aortic valve replacement in young patients and might be advantageous in the setting of infective endocarditis (IE), since no prosthetic material is implanted thus keeping the use of foreign material to a minimum. The aim of this study was to compare early and long-term outcome after the Ross procedure in patients with IE and non-infective aortic valve disease.

Mitral valve repair in rheumatics: Is it still worthwhile?

Prosthetic valve replacement in young patients carries increased morbidity and mortality, even with recent types and models of prostheses. Fortunately, rheumatic mitral regurgitation in this young population group is amenable to repair, although the results are less favourable than those observed with other types of mitral valve disease and in older populations. A better knowledge of the pathology and evolution of repair techniques has improved results. Hence mitral valve repair is still worthwhile, even in rheumatic pathology and, the percentage of valves repaired, increases with the experience and the will of the surgeon to preserve the valve. Mitral valve replacement can only be justified when good repair is not feasible. It is vital that the surgeon has adequate experience which can only be gained by exposure to enough patients with this condition. Most of these patients are in developing countries and hampered by socio-economic conditions – which means 1st World surgeons get limited required exposure.

Improved Results Using Decellularized Human Valves for Children with Congenital Heart Defects

Operative mortality of children with congenital heart defects has decreased substantially in the past decade, thereby leading to increasing reoperations and increased valve replacement need. Within this article we want to summarize the mid-term clinical results of nonseeded decellularized homografts, deriving from donated human heart valves. So far, the most common therapeutic options for valve replacement in children have been either a biological valve replacement, which undergoes degenerative processes, or a mechanical valve replacement, which requires lifelong anticoagulation. Decellularized pulmonary homografts showed superior results for both, freedom from explantation and infective endocarditis in a direct matched comparison to other available therapeutic options, such as bovine jugular vein conduits or conventional cryopreserved homografts. Decellularized homografts have been also used for aortic valve replacement in young patients and shown encouraging early results. Therefore decellularized homografts constitute a new therapeutic option for children and adults with congenital heart defects.

Are Bioprosthetic Valves Appropriate for Aortic Valve Replacement in Young Patients?

Selection of a prosthetic aortic valve for use in the young patient is complicated by a variety of important considerations. Age, growth potential, activity and life style expectations, child bearing, and social factors, in addition to anatomic considerations, are all important to the recommendation of a prosthetic valve choice. We review the clinical experience and expectations of currently available prosthetic aortic valves available for the young patient, and describe the advantages and disadvantages for each.

Ventricular Performance Assessed by 2-Dimensional Strain Analysis After Ross Operation Versus Aortic Valve Reconstruction

The Ross procedure is an established option for aortic valve replacement in young patients. It does, however, involve implantation of a valved conduit in the pulmonary position and dissection in the right ventricular (RV) myocardium with the possibility of RV impairment. Aortic valve reconstruction (AVr) may avoid the drawbacks of this method. To assess ventricular performance, 2-dimensional (2D) echocardiography and longitudinal strain analysis were performed in 19 patients after a Ross procedure and 19 patients after AVr and compared with 19 age-matched healthy controls. Left ventricular (LV) volumes were significantly increased in both patient groups compared with controls (p < 0.05). Right ventricular (RV) volumes were significantly elevated in the Ross group compared with the AVr group (p < 0.05) and controls (p < 0.01). Peak longitudinal LV strain was significantly reduced in the Ross group (-14.8% ± 4.7%) compared with the AVr group (-18.8% ± 2.5%; p = 0.003) and healthy controls (-20.2% ± 3.9%; p = 0.001). Peak longitudinal RV strain was also significantly reduced in the Ross group (-21.8% ± 4.8%) compared with the AVr group (-25.1% ± 2.5%; p = 0.02) and healthy controls (-26.5% ± 3.2%; p = 0.003). Reduced RV strain was associated with increased pressure gradients of the pulmonary substitute (r = 0.48; p = 0.04) but not with follow-up time, RV volumes, or RV ejection fraction (EF). Elevation of LV volumes can still be noticed in patients years after the Ross operation or AVr. Increased RV volumes and a reduced RV longitudinal strain are found after the Ross operation, indicating persistent systolic RV dysfunction even in patients with mild RV pressure overload.

Repair of regurgitant bicuspid aortic valves: A systematic approach

Patients with bicuspid aortic valves can present with aortic insufficiency caused by cusp disease or the aortic root pathology. We present our 13-year experience with a functional and systematic approach to bicuspid aortic valve repair. Between 1995 and 2008, 122 consecutive patients (mean age, 44 +/- 11 years) with bicuspid aortic valves underwent non-emergency valve repair for isolated aortic insufficiency (43%), aortic root dilatation (14%), or both (43%). Preoperative echocardiography identified aortic dilatation (n = 75), cusp prolapse (n = 96), and cusp restriction (n = 45) as mechanisms of aortic insufficiency. Raphé repair (n = 98) was performed by shaving (21%) or resection with primary closure (60%) or pericardial patch (18%). Functional aortic annuloplasty was performed using subcommissural annuloplasty (n = 51), ascending aortic replacement (n = 17), or aortic root replacement (n = 54) using a reimplantation (76%) or remodeling technique (24%). There was no operative mortality. Five patients underwent early aortic valve reoperation (3 re-repairs). At discharge, 93% of patients had aortic insufficiency grade 0/1 and 7% of patients had grade 2. Seven additional patients underwent aortic valve reoperation during follow-up (2 re-repairs). Overall survival was 97% +/- 3% at 8 years. At 5 and 8 years follow-up, freedom from aortic valve reoperation was 94% +/- 2% and 83% +/- 5%, respectively, and freedom from aortic valve replacement was 96% +/- 2% and 90% +/- 5%, respectively. Freedom from recurrent aortic insufficiency (>2+) was 94% +/- 3% at 5 years. Freedom from thromboembolism and bleeding was 96% +/- 2% at 8 years. A systematic approach to bicuspid aortic valve repair yields good early and midterm results. Repair of bicuspid valves for aortic insufficiency is a feasible and attractive alternative to mechanical valve replacement in young patients.

In young patients with rheumatic aortic regurgitation compared to non-rheumatics is a Ross operation associated with increased incidence of autograft failure?

A best evidence topic in cardiac surgery was written, according to a structured protocol. The question addressed was: in young patients with rheumatic aortic regurgitation compared to non-rheumatics is a Ross operation associated with increased incidence of autograft failure? The pulmonary autograft with its inherent advantages of viable autologous transplant, central laminar flow, freedom from prosthetic valve complications, side effects of anticoagulation, and growth potential is considered a well-accepted option for aortic valve replacement in young patients. However, the use of a pulmonary autograft in young patients with rheumatic aortic valve disease is controversial. We analyse existing evidence to determine the suitability of the pulmonary autograft as a substitute for the diseased aortic valve in patients with rheumatic disease. Altogether 901 papers were found using the reported search terms, from which eight represented the best evidence to answer the clinical question. In addition, a meta-analysis also superficially addressed this issue. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All eight publications were from two institutions with one reporting outcomes for a Ross operation vs. mechanical valve implantation and two compared results of the Ross operation in rheumatic vs. non-rheumatic aortic valve disease. We conclude that the current available evidence suggests that pulmonary autograft is susceptible to rheumatic involvement. Use of pulmonary autograft in young patients (<30 years) with rheumatic aortic regurgitation and concomitant mitral regurgitation requires a cautious approach as there is an impaired autograft durability in this subgroup of patients.