Absence of prosthesis-patient mismatch with the new generation of Edwards stented aortic bioprosthesis (original) (raw)
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Transcatheter aortic valve implantation in failed bioprosthetic surgical valves
JAMA, 2014
IMPORTANCE Owing to a considerable shift toward bioprosthesis implantation rather than mechanical valves, it is expected that patients will increasingly present with degenerated bioprostheses in the next few years. Transcatheter aortic valve-in-valve implantation is a less invasive approach for patients with structural valve deterioration; however, a comprehensive evaluation of survival after the procedure has not yet been performed. OBJECTIVE To determine the survival of patients after transcatheter valve-in-valve implantation inside failed surgical bioprosthetic valves. DESIGN, SETTING, AND PARTICIPANTS Correlates for survival were evaluated using a multinational valve-in-valve registry that included 459 patients with degenerated bioprosthetic valves undergoing valve-in-valve implantation between 2007 and May 2013 in 55 centers (mean age, 77.6 [SD, 9.8] years; 56% men; median Society of Thoracic Surgeons mortality prediction score, 9.8% [interquartile range, 7.7%-16%]). Surgical valves were classified as small (Յ21 mm; 29.7%), intermediate (>21 and <25 mm; 39.3%), and large (Ն25 mm; 31%). Implanted devices included both balloon-and self-expandable valves. MAIN OUTCOMES AND MEASURES Survival, stroke, and New York Heart Association functional class. RESULTS Modes of bioprosthesis failure were stenosis (n = 181 [39.4%]), regurgitation (n = 139 [30.3%]), and combined (n = 139 [30.3%]). The stenosis group had a higher percentage of small valves (37% vs 20.9% and 26.6% in the regurgitation and combined groups, respectively; P = .005). Within 1 month following valve-in-valve implantation, 35 (7.6%) patients died, 8 (1.7%) had major stroke, and 313 (92.6%) of surviving patients had good functional status (New York Heart Association class I/II). The overall 1-year Kaplan-Meier survival rate was 83.2% (95% CI, 80.8%-84.7%; 62 death events; 228 survivors). Patients in the stenosis group had worse 1-year survival (76.6%; 95% CI, 68.9%-83.1%; 34 deaths; 86 survivors) in comparison with the regurgitation group (91.2%; 95% CI, 85.7%-96.7%; 10 deaths; 76 survivors) and the combined group (83.9%; 95% CI, 76.8%-91%; 18 deaths; 66 survivors) (P = .01). Similarly, patients with small valves had worse 1-year survival (74.8% [95% CI, 66.2%-83.4%]; 27 deaths; 57 survivors) vs with intermediate-sized valves (81.8%; 95% CI, 75.3%-88.3%; 26 deaths; 92 survivors) and with large valves (93.3%; 95% CI, 85.7%-96.7%; 7
Transcatheter Valve Unable to Cure Patient–Prosthesis Mismatch of Mosaic Bioprosthesis
The Thoracic and Cardiovascular Surgeon Reports, 2016
A 73-year-old man (80 kg, 171 cm, body surface area (BSA) 1.97 m 2) underwent conventional aortic valve replacement (CAVR) and bypass surgery in October 2008. A 23-mm Medtronic Mosaic bioprosthesis (Medtronic, Minneapolis, Minnesota, United States) was used to replace the stenotic native aortic valve. The intermediate branch was also revascularized. In January 2009, the perioperative echocardiography showed a mean gradient 38 mm Hg. Two years later, the patient was admitted to our unit with severe signs of left heart failure. An echocardiogram showed malfunctioning aortic bioprosthesis with calcified leaflets and relevant stenosis (mean gradient 34 mm Hg). Next to his deteriorated cardiac condition, he presented several comorbidities such as arterial hypertension, chronic renal insufficiency, and peripheral arterial disease. The calculated logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 16.6%. After discussion of the case in "heart team", the patient was planned for a transapical transcatheter aortic valve implantation (TAVI)-valve-in-valve implantation (VinV) procedure. The operation was done in general anesthesia.
Prosthetic aortic heart valves
2018
Background Aortic valve replacement (AVR) can be performed with different types of valve prostheses. There is no perfect aortic valve prosthesis, and the prosthetic choice for each patient requires careful consideration. This thesis evaluates mortality, morbidity, and prosthetic valve function after AVR with different aortic valve prostheses. Methods and Results Study I We studied all-cause mortality and postoperative outcomes in all 1219 patients who underwent AVR at Karolinska University Hospital between 2002 and 2010 and received either Perimount (n=864; Edwards Lifesciences, Irvine, CA) or Mosaic (n=355; Medtronic, Inc., Minneapolis, MN) bioprostheses. There was no difference in all-cause mortality (adjusted hazard ratio (HR) 0.85, 95% confidence interval (CI) 0.65-1.11) or rate of aortic valve reoperation between the two groups. Severe prosthesis-patient mismatch (PPM) was more common in the Mosaic group than in the Perimount group (15% vs. 6%, p<0.001). Study II We studied hemodynamic function and postoperative outcomes in all 355 patients who underwent AVR at Karolinska University Hospital between 2002 and 2008 and received a Mosaic bioprosthesis. The mean pressure gradient was 21.2 mmHg and 22.5 mmHg during early and late echocardiography, respectively. Moderate or severe PPM was found in 299 (84%) patients, and 46 patients had moderate or severe aortic stenosis at late echocardiography, but neither was associated with increased mortality. Study III We studied all-cause mortality and postoperative outcomes in all 4545 patients aged 50-69 years who underwent primary, isolated AVR with biological (n=1832) or mechanical (n=2713) prostheses in Sweden between 1997 and 2013. The study population was obtained from the SWEDEHEART register. In a propensity score-matched analysis, patients with mechanical valve prostheses had better survival than patients with bioprostheses (HR 1.34, 95% CI 1.09-1.66, p=0.006). There was no difference in the rate of stroke, but patients with mechanical valves had a higher risk of major bleeding events and a lower risk of aortic valve reoperation than patients with bioprostheses. Study IV We studied all-cause mortality and postoperative outcomes in all 13 102 patients with moderately reduced (n=3266), or normal (n=9836) kidney function who underwent primary AVR in Sweden between 1997 and 2013. The study population was obtained from the SWEDEHEART register. Patients with normal kidney function had better survival than patients with moderately reduced kidney function (adjusted HR 1.28, 95% CI 1.18-1.38). Patients with moderately reduced kidney function had a slightly higher risk of major bleeding events and a lower risk of aortic valve reoperation than patients with normal kidney function. Study V We studied the incidence of prosthetic valve endocarditis (PVE) in all 26 580 patients who underwent AVR with biological (n=16 426) or mechanical (n=10 154) prostheses in Sweden between 1995 and 2012. The study population was obtained from the SWEDEHEART register. The incidence rate of PVE was 0.57% (95% CI 0.54-0.61) per person-year. The incidence of PVE was highest during the first year after surgery and remained stable thereafter for up to 18 years of follow-up. The risk of PVE was higher in patients with bioprostheses than in patients with mechanical valve prostheses (adjusted HR 1.54, 95% CI 1.29-1.83, p<0.001). Study VI We performed a systematic review and meta-analysis evaluating all-cause mortality after AVR in 49 190 patients who received bovine (n=32 235) versus porcine (n=16 955) bioprostheses. In total, seven articles met the inclusion criteria. The random-effects model was used to obtain pooled HR and 95% CI. The metaanalysis revealed no difference in survival between the groups (pooled HR 1.00, 95% CI 0.92-1.09). Conclusions [1] Both the Perimount and Mosaic bioprostheses are acceptable valve alternatives for AVR. [2] In patients aged 50-69 years, survival after AVR was better for those who received mechanical valve prostheses rather than bioprostheses. [3] After AVR, patients with moderately reduced kidney function have higher mortality than patients with normal kidney function. [4] After AVR, the yearly rate of PVE was 0.57%. Patients with bioprostheses had a higher risk of PVE than that of patients with mechanical valves. [5] Both bovine and porcine bioprostheses are acceptable valve choices for AVR. LIST OF SCIENTIFIC PAPERS I. Glaser N, Franco-Cereceda A, Sartipy U. Late survival after aortic valve replacement with the Perimount versus the Mosaic bioprosthesis.
2020
TURUN YLIOPISTO Lääketieteellinen tiedekunta ALVAJÄRVI, ARVI Patient-prosthesis mismatch in the context of surgical aortic valve replacement with the Trifecta bioprosthesis Syventävien opintojen kirjallinen työ, 10 s. Kirurgia Marraskuu 2020 ________________________________________________________________________________ Surgical aortic valve replacement (SAVR) is widely used for the treatment of aortic valve diseases. Each valve prosthesis has individual hemodynamic characteristics, which may have implications in the clinical outcome of patients. This review considers the hemodynamic performance of the St. Jude Medical Trifecta biological aortic valve prosthesis early after surgery. An essential method to determine hemodynamic parameters after SAVR is transthoracic echocardiography (TTE) that can be used to measure transvalvular flow velocities and pressure gradients. Patient-prosthesis mismatch (PPM) occurs when the orifice of the implanted prosthesis is too narrow relative to the patient's body surface area. Postoperative PPM is thought to have a negative effect on the outcome after SAVR. The aim of this review is to summarise the current hemodynamic data of the Trifecta biological prosthesis in the aortic position. A systematic review of the literature was conducted through Pubmed, Scopus, Science Direct and Google Scholar with terms ''effective orifice area", "hemodynamic", "gradient" combined with "Trifecta" or "Perimount". This yielded 276 articles, 18 of which were included into a recently conducted meta-analysis. Out of those studies, ten evaluated the hemodynamics and outcome of more than 100 patients with the Trifecta prosthesis. Each of the studies showed excellent early hemodynamic results with relatively small incidence of PPM for the aortic bioprosthesis Trifecta. Moreover, the hemodynamic parameters of the Trifecta bioprosthesis seemed favourable when compared to other widely used biological valves.