A 20-year experience with mitral valve repair with artificial chordae in 608 patients.

OBJECTIVE: Mitral valve repair with artificial chordae for degenerative mitral regurgitation is widely adopted. We evaluated long-term results of mitral repair with expanded polytetrafluoroethylene sutures (GORE-TEX CV-5; W. L. Gore & Associates, Inc, Flagstaff, Ariz). METHODS: Between November 1986 and November 2006, 608 consecutive patients underwent mitral repair with artificial neochordae. Mean age was 55 +/- 11 years (15-85 years); 433 (71.2%) were male. Valve disease was purely degenerative in 555 patients (91.3%). Prolapse of anterior, posterior, or both leaflets was present in 47 (7.7%), 308 (50.7%), and 253 (41.6%), respectively. Atrial fibrillation was associated in 117 (19.2%). In 125 cases (20.5%), additional surgical procedures were performed. Follow-up was complete at a median of 5.7 years (interquartile range 2.2-9.8 years, range 0-19.4 years). RESULTS: In-hospital mortality was less than 1% (6 deaths). Overall and cardiac late mortalities were 6.6% and 3.9% (34 and 24 deaths). Kaplan-Meier survival at 15 years was 84% (95% confidence interval 75%-90%). Freedoms from endocarditis, thromboembolic events, reoperation, and recurrent mitral regurgitation at 15 years were 97% (95% confidence interval 93%-99%), 92% (87%-95%), 92% (88%-95%), and 85% (78%-91%), respectively. Sinus rhythm was restored in 75% (33 patients) after surgical atrial fibrillation correction. Calcification of GORE-TEX neochordae was never reported. CONCLUSION: Mitral valve repair with GORE-TEX artificial chordae is effective, safe, and associated with low operative mortality and low rates of valve-related complications at long-term follow-up. Artificial chordae showed excellent biologic adaptation, retaining flexibility and tension with time.

Clinical results of Hancock II versus Hancock Standard at long-term follow-up.

OBJECTIVE: We performed a multi-institutional study to compare the long-term structural valve deterioration of isolated Hancock Standard versus Hancock II bioprostheses. METHODS: From 1983 to 2002, 714 Hancock Standard and 1293 Hancock II bioprostheses were implanted at hospitals of the Venetian territory (Padova, Treviso, and Venice). Follow-up on January 1, 2003, included 14,749 patient-years with a median of 12 years and was 96% complete: 115 Hancock Standard and 53 Hancock II bioprostheses were at risk at 15 years. The 2 series were nonconcomitant, and many covariates differed (Table 1). Survival was analyzed with Cox analysis, and durability was analyzed with Weibull analysis. Balancing analysis with the logistic propensity score model was performed. RESULTS: Perioperative mortality was 6% in Hancock II and 12% in Hancock Standard operations. The overall unadjusted 15-year survival was identical (39.7% +/- 2.3% vs 39.9% +/- 2.4%, respectively), but age-adjusted survival at 15 years was 46% versus 25% (P < .001). Late survival was unrelated to the prosthetic model, whereas it was adversely affected by older age, previous operations, aortic regurgitation, male sex, higher New York Heart Association class, atrial fibrillation, and coronary artery bypass grafting. In Hancock II patients aged 65 years and older, the cumulative hazard of structural valve deterioration at 15 years was 6%, versus 17.5% in Hancock Standard patients. In younger patients, it was 18% and 37%, respectively. Analysis of 541 propensity-balanced patients showed a hazard ratio of the Hancock Standard prosthesis of 2 and a risk reduction of older age of approximately 10% every 10 years. CONCLUSION: After balancing risk factors and calibrating age effects, Hancock II propensity-matched bioprostheses showed similar survival but definitely increased durability.

Fifteen-year results with the Hancock II valve: a multicenter experience.

OBJECTIVES: The purpose of this multi-institutional study was to review the 15-year outcome of patients who received isolated aortic or mitral valve replacement with the Hancock II bioprosthesis. METHODS: From 1983 through 2002, 1274 patients underwent 1293 isolated valve replacements, 809 aortic valve replacements and 484 mitral valve replacements, at hospitals in the Venetian area (Padova, Treviso, and Venice). Mean age was 68 +/- 8 years in patients undergoing aortic valve replacement and 66 +/- 9 years in patients undergoing mitral valve replacement; 52% of patients undergoing aortic valve replacement and 63% of patients undergoing mitral valve replacement were in New York Heart Association class III or greater. Coronary artery disease was present in 32% of patients who had undergone aortic valve replacement and 18% of patients who had undergone mitral valve replacement. Follow-up included 8520 patient-years, with a median of 12 years, and was 97% complete. RESULTS: Overall 15-year survival was 39.7% +/- 2.4%, similar in both the aortic and mitral positions. Multivariable analysis of late survival showed the incremental risk of male sex, higher New York Heart Association class, coronary artery disease, and mitral position. Freedom from embolism was higher in the aortic position (81% +/- 2.9% in aortic vs 72% +/- 4.7% in mitral valve replacements). Freedom from endocarditis was similar in the aortic and mitral position (95% +/- 1.2% vs 94% +/- 1.7%). Freedom from reoperation (82% +/- 3.7% vs 71% +/- 5.0%) and from valve-related morbidity-mortality (52% +/- 3.6% vs 36% +/- 4.4%) was higher in patients who had undergone AVR. Actual freedom from structural valve deterioration for patients 60 years and older who had undergone aortic valve replacement was 96.5% +/- 1.3% versus 88% +/- 3.2% for patients who had undergone mitral valve replacement and 70% +/- 7.5% versus 77.5% +/- 5.3%, respectively, in younger patients. Multivariable Weibull analysis showed structural valve deterioration related to younger age and preoperative valve incompetence and inversely related to coronary artery disease. CONCLUSION: Optimal 15-year durability can be expected in male patients 60 years and older who have undergone aortic valve replacement and in male patients 65 years and older who have undergone mitral valve replacement, extending safely the age limits for the use of this valve.

Ten-year experience with cryopreserved aortic allografts in the surgical treatment of aortic valve pathologies.

BACKGROUND: The aim of this study was to evaluate the performance of cryopreserved aortic allografts (CAA) in the treatment of adult aortic valve pathologies. METHODS: Between May 1992 and October 2002, 122 CAA were implanted in 119 adult patients with pathologies of the aortic valve. The mean age of the patients was 38.03 +/- 13.6 years (range 17-78 years). Thirty had had previous cardiac surgery. The principal indication was endocarditis (n = 45). In 66 patients one or more associated pathologies were present including: an abscess of the left ventricular outflow tract (n = 32), an aneurysm of the ascending aorta (n = 22), mitral incompetence (n = 10), and coronary artery disease (n = 3). The indications for surgery were elective in 77 cases and urgent in 45. The CAA was implanted as a total root replacement in 46 patients and as a free-hand in 76. In 66 patients an associated procedure such as a left ventricular outflow tract reconstruction (in 27 cases) was performed. RESULTS: The in-hospital mortality was 5.73% (7/122). In one patient the CAA was replaced before discharge with another CAA because of a mediastinitis with endocarditis by Candida albicans. At the follow-up of the 114 patients discharged from the hospital (mean 50.11 months, range 1-126 months), 6 patients died and 6 were reoperated. The actuarial 10-year survival, reoperation-free, endocarditis-free, structural degeneration-free rates were respectively 83.88, 81.70, 86.30, and 92.80%. CONCLUSIONS: From our experience we conclude that CAA are good substitutes for aortic valve replacement and even in desperate situations exhibit an acceptable long-term performance.