Hemodynamic Performance and Durability of Mosaic Bioprostheses for Aortic Valve Replacement, up to 13 Years.

BACKGROUND: This study evaluated the mid to long-term durability and hemodynamics of the small-size Mosaic bioprosthesis, a third-generation stented porcine bioprosthesis, for aortic valve replacement (AVR). METHODS AND RESULTS: From 2000 to 2012, 207 patients (117 women; age, 74±8 years; body surface area, 1.48±0.25 m(2)) underwent AVR with a Mosaic bioprosthesis. The mean follow-up period was 3.5±2.7 years (maximum, 12.4 years) and the follow-up rate was 93.7%. A 19-, 21-, 23-, 25-, and 27-mm prosthesis was used in 103, 53, 35, 13, and 3 patients, respectively. The measured effective orifice area was 1.17±0.25, 1.29±0.19, 1.39±0.24, and 1.69 cm(2)for the 19-25 mm prostheses, and the mean transvalvular pressure gradient was 19.4±6.0, 18.5±5.8, 16.5±7.3, and 13.2±2.9 mmHg, respectively. The left ventricular mass regression was significant (P<0.05) with rates of 74.6±18.8%, 75.5±30.2%, 68.1±30.5%, 55.9±12.9%, and 49.2%, respectively. The 30-day mortality rate was 1.9% and the 5- and 10-year actuarial survival rates were 86.0% and 73.7%, respectively. Valve-related comorbidities occurred in 3 patients (structural valve deterioration [SVD] in 1 after 7.2 years, and prosthetic valve endocarditis in 2). Freedom from SVD at 10-year was 96.7%. CONCLUSIONS: The mid to long-term performance of the small Mosaic bioprosthesis was satisfactory, with excellent hemodynamics and few valve-related adverse events.

Obesity is associated with higher long-term mortality after aortic valve replacement with small prosthesis.

OBJECTIVE: Although many studies have evaluated the impacts of obesity on various medical treatments, it is not known whether obesity is related to late mortality with implantation of small aortic prosthesis. This study evaluated the effect of obesity on late survival of patients after aortic valve replacement (AVR) with implantation of small aortic prosthesis (size ≤ 21 mm). METHODS: From January 1998 to December 2008, 536 patients in our institution who underwent primary AVR (307 patients with smaller prostheses) survived the 30 days after surgery. Patients were categorised as normal weight if body mass index (BMI) was ≤ 25 kg/m(2), as overweight if BMI 25-30 kg/m(2), and as obese if BMI ≥ 30 kg/m(2). Data were collected at the third-month (M), sixth-M, first-year (Y), third-Y, fifth-Y, and eighth-Y after operation. RESULTS: By multivariable analysis, obesity was a significant independent factor of late mortality (hazard ratio [HR]: 1.59; p=0.006). The obese and overweight groups of patients exhibited lower survival (p<0.001) and a higher proportion in NYHA class III/IV (p<0.01) compared with the normal group. Lower EOAI and higher left ventricular mass index were found in the obese and overweight groups, but we saw no significant variance in LVEF among the three groups. CONCLUSIONS: Obesity was associated with increased late mortality of patients after AVR with implantation of small aortic prosthesis. Being obese or and overweight may also affect the NYHA classification, even in the longer term.

Assessment and repair of aortic valve cusp prolapse: implications for valve-sparing procedures.

OBJECTIVES: Cusp prolapse causing aortic insufficiency is associated with unique echocardiographic, clinical, and surgical features. Recognition and appropriate surgical repair of this pathologic condition can not only treat affected patients but also improve results of aortic valve-sparing procedures, for which pre-existing or induced cusp prolapse is an important cause of failure. METHODS: Of 428 patients undergoing aortic valve repair, 195 (46%) were treated for cusp prolapse, and 111 (57%) of those had trileaflet aortic valve and make up this cohort. Cusp disease was the sole mechanism for aortic insufficiency (isolated group) in 50 patients whereas aortic dilatation was contributory in 61 (associated group). In total, 144 cusps were repaired in 111 patients. Preoperative echocardiograms, intraoperative findings, and clinical and echocardiographic outcomes were reviewed. RESULTS: On preoperative echocardiography, presence of an eccentric aortic insufficiency jet, regardless of severity, had 92% sensitivity and 96% specificity for the detection of single cusp prolapse. A transverse fibrous band was characteristically identified on the prolapsing cusp (sensitivity 57%; specificity 92%), correctly localizing a prolapsing cusp in all cases. Freedom from aortic valve reoperation at 8 years was 100% in the isolated group and 93% ± 5% in the associated group (p = 0.33). Freedom from recurrent aortic insufficiency (>2+) at 5 years was 90% ± 5% in the isolated and 85% ± 8% in the associated group (P = .54). The choice of surgical technique did not affect aortic insufficiency recurrence at follow-up (P = .6). CONCLUSIONS: Recognition and repair of isolated aortic cusp prolapse provides durable midterm outcome. An eccentric aortic insufficiency jet and a fibrous band can aid in the diagnosis and localization of cusp prolapse associated with ascending aortic disease and may help to improve results of aortic valve-sparing procedures.

Cusp prolapse repair in trileaflet aortic valves: free margin plication and free margin resuspension techniques.

BACKGROUND: Cusp prolapse management is important in aortic valve (AV) sparing and repair to achieve durable results. We analyzed the midterm outcomes of two different techniques for trileaflet AV prolapse repair. METHODS: Between 1996 and 2008, 376 patients underwent elective AV repair: 88 with trileaflet AV (23%) had cusp prolapse repair, plication technique was performed in 34 (39%), resuspension technique in 33 (37%) and plication plus resuspension in 21 (24%). One cusp was repaired in 55 (62%), 2 cusps in 18 (21%), and 3 cusps in 15 (17%). RESULTS: No hospital deaths occurred. Patients undergoing resuspension with or without plication had more preoperative aortic insufficiency (AI; p = 0.01) and multiple cusp prolapses (p = 0.01). During follow-up (median, 41 months), 4 deaths occurred and 2 were cardiac related. Overall survival at 5 years was 95% +/- 5%. Two patients needed AV reoperation because of recurrent AI or AI plus AV stenosis. Recurrent AI grade > or =3+ developed in 4 patients; 1 with moderate AV stenosis. Freedom from reoperation at 5 years was 100% for plication, 96% +/- 4% for resuspension, and 93% +/- 7% for plication plus resuspension (p = 0.6); respective freedom from AI > or =3+ at 3 years was 100%, 92% +/- 8%, and 89% +/- 11% (p = 0.8). CONCLUSIONS: Cusp plication or resuspension are efficient and durable techniques to correct cusp prolapse in the trileaflet AV. Plication is typically the first choice because of its ease of use and lower risk of overcorrection; however, free margin resuspension is useful in specific situations.

Natural aortic valve complications of ventricular septal defect: a prospective cohort study.

OBJECTIVE: To study the incidence and onset of aortic valve prolapse (AVP) and aortic regurgitation (AR) in the ventricular septal defect (VSD). STUDY DESIGN: A prospective cohort study POPULATION: The less than one-year-old children with diagnosis of isolated VSD were studied from October 2000 to September 2006 at Queen Sirikit National Institute of Child Health. Clinical follow-up and echocardiographic studies were scheduled every 2-3 months in the first year of age and then every 6 months to evaluate the size, location, flow across VSD, aortic valve morphology and aortic regurgitation. RESULTS: Three hundred and twenty-one cases of VSD were followed up. One was excluded due to associated hypoplastic RV An overall of 2,644 echocardiograms were performed. The percentage of perimembranous, subpulmonic, muscular inlet and multiple types were 70.3%, 19.4%, 5.6%, 3.1% and 1.6%, respectively. Size of the VSD was diagnosed to be small, moderate, and large VSD in 62.5%, 15.9% and 21.6% respectively. At the end of the study, the incidence of AVP in subpulmonic VSD was 87.1% compared to 16.4% in perimembranous VSD, with a relative risk of 5.30 and the incidence of AR in subpulmonic VSD was 37.1% compared to 5.3% in perimembranous VSD, with a relative risk of 6.95. From the survival analysis, the patient with subpulmonic VSD developed AVP at 46%, 77%, 90% and 94% compare to 8%, 13%, 20% and 23% of perimembranous VSD at 12, 24, 36 and 48 months of age respectively (p < 0.001). The patient with subpulmonic VSD developed AR at 8%, 17%, 35% and 38% compare to 2%, 4%, 5% and 7% of perimembranous VSD at 12, 24, 36 and 48 months of age respectively (p < 0.001). At the end of the study, ninety-six cases (30%) underwent cardiac operation with the indication of heart failure or the occurrence of AR. Sixty one cases (19.1%), including two cases of subpulmonic type had spontaneous closure of VSD. Seven cases (2.2%) had lost to follow up and five cases (1.6%) died during the follow up period. CONCLUSION: The incidence of AVP and AR are high in subpulmonic VSD being much higher than perimembranous VSD with a relative risk of 5.30 and 6.95 respectively. These complications are significantly from infancy period and are an indication for early cardiac surgery.

Impact of preoperative aortic cusp prolapse on long-term outcome after surgical closure of subarterial ventricular septal defect.

BACKGROUND: Previous reports on the long-term outcome of surgical closure of subarterial ventricular septal defect were based on a relatively small number of patients. METHODS: We reviewed the long-term outcome of 135 patients who underwent closure of their defect and, in light of the findings, assessed the impact of preoperative aortic cusp prolapse and surgical interventions on occurrence of aortic regurgitation (AR) in the long-term. The patients were categorized into three groups for comparison: group I consisted of 79 patients with no aortic cusp prolapse and underwent simple closure of ventricular septal defect, group II comprised 39 patients with mild to moderate cusp prolapse who similarly had only closure of the defect performed, whereas group III comprised 17 patients who had additional aortic valvoplasty for greater than moderate to severe cusp prolapse. RESULTS: Group I patients had significantly higher pulmonary arterial pressure (p < 0.001) and ratio of pulmonary blood flow to systemic blood flow (p < 0.001). None of these patients had AR before their operation, and none experienced AR afterward at a median follow-up of 6.1 years. Of the 39 group II patients, 30 (77%) had trivial or mild AR preoperatively. The AR improved in 15 patients, remained trivial or mild in 14 and absent in 7, but progressed to trivial or mild in 3 at a median follow-up of 3.1 years. None required further interventions. In contrast, 14 (82%) of the 17 group III patients had moderate to severe AR before operation. The regurgitation improved in 10, but remained moderate or severe in 4 and worsened further in 3 at a median follow-up of 4.6 years. The freedom from failure of aortic valvoplasty was (mean +/- standard error of the mean) 71%+/-11%, 64%+/-12%, and 43%+/-19% at 1, 5, and 10 years, respectively. An older age at latest follow-up was the only identifiable significant risk factor (p = 0.03). CONCLUSIONS: Our data do not support the need of aortic valvoplasty for mild to moderate aortic cusp prolapse. Close follow-up is warranted in those with greater than moderate to severe cusp prolapse despite valvoplasty as there is continued failure on follow-up. Nothing, however, is better than early closure of defects before development of aortic valve complications.

Aortic valve replacement with combined myocardial revascularisation.

Early and late outcome was studied in 630 patients who underwent aortic valve replacement between 1974 and 1982. Group 1 (506 patients) did not have important coronary artery disease, group 2 (69 patients) had coronary artery disease and underwent coronary artery bypass grafting, and group 3 (55 patients) had coronary artery disease but did not undergo myocardial revascularisation. Early mortality (within 30 days of operation) was significantly lower for group 1 (6%) than for group 2 (13%) and for group 3 (16%). Operative mortality in all three groups was lower in patients operated on more recently. The three year survival of patients in group 1 (83%) was significantly higher than that of patients in group 3 (62%) but not than that of patients in group 2 (76%). The findings of this study suggest that the presence of coronary artery disease increases the risk of aortic valve replacement whether or not coronary artery grafting is performed. Myocardial revascularisation, however, seems to return patients with aortic valve and coronary artery disease to a survival curve similar to that of patients with isolated aortic valve disease.