Case Series of Early Structural Valve Deterioration of Trifecta Bioprosthesis - New Zealand Experience.

PURPOSE: Structural valve deterioration (SVD) remains a limitation on the use of bioprosthetic valves, with patient and valve-related factors contributing to early SVD. The Trifecta valve has been reported to have excellent hemodynamics but studies have highlighted early failure. We present a review and case series at a New Zealand tertiary hospital defining early SVD as failure within 3 years of implant. METHODS: A retrospective review from January 2015 to July 2019 included 525 patients undergoing surgical aortic valve replacement with 263 patients receiving an Abbott Trifecta or Trifecta Glide Technology (GT) valve. Our review found an acceptable safety profile for the valve with excellent hemodynamics, with a low mortality, stroke, and permanent pacemaker rate. RESULTS: Three patients out of 263 were identified from the study period as having early SVD requiring reintervention within 3 years of valve implantation leading to a 1.14% failure rate. One of the valves that had early SVD was a new generation Trifecta GT. An additional four patients were identified to have valves implanted prior to the study period and had valve failure at greater than 3 years post implantation. Five cases had cusp tears as their mechanism of failure, raising concerns about durability. CONCLUSION: The Trifecta valve has an acceptable safety profile and offers good hemodynamics due to the externally mounted leaflets. However, our experience of early SVD and failure is concerning for valve durability. Further comparison to other bioprosthetic valves and longer term follow-up are required to characterize the mechanism of failures.

Review of bioprosthetic structural valve deterioration: Patient or valve?

BACKGROUND: With guidelines progressively recommending bioprosthetic aortic valves in younger patients, a greater emphasis is placed on structural valve deterioration (SVD) as an important clinical endpoint for both transcatheter and surgically implanted valves. However, SVD of bioprosthetic valves is a complex entity with varying definitions in the literature and a multifaceted pathogenesis. AIM: This review first aims to establish the most updated definitions of SVD as per the literature. We then explore the patient- and valve-related factors that play the greatest roles in facilitating early SVD. METHODS: A PubMed literature review was conducted to identify the relevant research in this field within the past two decades. CONCLUSION: Increasing rates of obesity and metabolic syndrome pose a significant risk to the longevity of bioprosthetic valves. Additionally, externally mounted valves have proven to sacrifice durability for superior haemodynamics. Bioprosthetic SVD continues to be a multifactorial issue that will require various patient- and valve-related factors to be addressed.

Novel Use of Ex Vivo Uretero-Pyeloscopy in Autotransplantation: A Systematic Review and Case Report.

BACKGROUND: Autotransplant has been practiced for decades but is regaining popularity in the nephron-sparing era. Initially for benign disease, autotransplantation has a select role in malignant processes that warrants new techniques and ideas to ensure patient safety. We review the use of ex vivo uretero-pyeloscopy and frozen section to ensure kidneys may be utilized in a patient with suspected malignancy. CASE PRESENTATION: A systematic review (PRISMA standard) of ex vivo uretreo-pyeloscopy was undertaken. We then present the case of a 37-year-old Caucasian female who was suspected of having ureteral obstructing malignancy; she had previous treatment of the bladder with bacillus Calmette-Guerin (BCG) for recurrent urothelial malignancy. The lesion biopsies and cytology were suspicious but inconclusive, indicating nephroureterectomy was a likely course of management. RESULTS: On reviewing the literature, we found that the use of ex vivo uretero-pyeloscopy has been described for urolithiasis to remove stones before transplantation but not specifically to exclude malignancy. Ultimately, in this case, the patient underwent a renal autotransplantation for obstruction that was caused by a granuloma on the background of the previous BCG treatment. Intraoperatively, ex vivo uretero-pyeloscopy and frozen section were crucial in guiding this case by allowing for appropriate identification and resection of the ureteral lesion. In addition, the preservation of ureteral length allowed for autotransplantation, which remains effective at follow-up. CONCLUSION: Ex vivo urteroscopy has been used effectively in donor kidneys to treat urolithiasis with minimal complications. We believe that this is the first documented case of ex vivo uretero-pyeloscopy being used effectively in renal autotransplantation to exclude urothelial malignancy.