Excellent Durability of the Mosaic Porcine Aortic Bioprosthesis at Extended Follow Up.

BACKGROUND: Biological prostheses are widely employed for aortic valve replacement (AVR). The study aim was to evaluate the performance of the Mosaic porcine bioprosthesis in the aortic position over two decades. METHODS: Between November 1995 and December 2016, a total of 254 patients (194 males, 60 females; mean age 74 ± 9 years) underwent AVR with a Mosaic bioprosthesis at the authors' institution. Among the patients, 14% were aged ≥80 years and 86% had pure or prevalent calcific aortic stenosis. Preoperatively, the mean NYHA functional class was 2.5 ± 1.0. RESULTS: Overall hospital mortality was 5%. A total of 107 late deaths occurred, but only 15 were valve-related (0.72 ± 0.19% per patient-year). Actuarial survival at 15 years was 34 ± 7%. Fourteen embolic episodes occurred, with no cases of bioprosthetic thrombosis; freedom from thromboemboli was 88 ± 4% at 15 years. Eight cases of endocarditis occurred, with a freedom of 95 ± 2% at 15 years. Structural valve deterioration (SVD) was observed in four patients, all of whom were successfully reoperated. Freedom from SVD was 97 ± 2% at 15 years and 96 ± 2% at 20 years. At the last follow up, 23 mm and 25 mm prostheses showed mean gradients of 17 ± 6 mmHg and 15 ± 4 mmHg, respectively. A significant reduction in left ventricular mass was noted in patients with aortic stenosis. CONCLUSIONS: The Mosaic bioprosthesis has shown excellent durability over two decades of clinical use, with a negligible incidence of valve degeneration and need for reoperation. Thus, it may be considered a valid option for AVR, especially in elderly patients.

Micro-RNA-21 (biomarker) and global longitudinal strain (functional marker) in detection of myocardial fibrotic burden in severe aortic valve stenosis: a pilot study.

AIMS: Myocardial fibrosis (MF) is a deleterious consequence of aortic valve stenosis (AVS). Global longitudinal strain (GLS) is a novel left ventricular (LV) functional parameter potentially useful to non-invasively estimate MF. MicroRNAs (miRNAs) are non-coding small ribonucleic acids (RNA) modulating genes function, mainly through RNA degradation. miRNA-21 is a biomarker associated with MF in pressure overload. The aim of the present study was to find an integrated algorithm for detection of MF using a combined approach with both bio- and functional markers. METHODS: Thirty-six patients (75.2 ± 8 y.o.; 63 % Female) with severe AVS and preserved LV ejection fraction (EF), candidate to surgical aortic valve replacement (sAVR) were enrolled. Clinical, bio-humoral evaluation (including plasmatic miRNA-21 collected using specific tubes, PAXgene, for stabilization of peripheral RNA) and a complete echocardiographic study, including GLS and septal strain, were performed before sAVR. Twenty-eight of those patients underwent sAVR and, in 23 of them, an inter-ventricular septum biopsy was performed. Tissues were fixed in formalin and embedded in paraffin. Sections were stained with Hematoxylin and Eosin for histological evaluation and with histochemical Masson trichrome for collagen fibers. The different components were calculated and expressed as micrometers(2). To evaluate tissue miRNA components, sections 2-µm thick were cut using a microtome blade for each slide. Regression analysis was performed to test association between dependent variable and various predictors included in the model. RESULTS: Despite a preserved EF (66 ± 11 %), patients presented altered myocardial deformation parameters (GLS -14,02 ± 3.8 %; septal longitudinal strain, SSL -9.63 ± 2.9 %; septal longitudinal strain rate, SL-Sr -0.58 ± 0.17 1/s; Septal Longitudinal early-diastolic strain rate, SL-SrE 0.62 ± 0.32 1/s). The extent of MF showed an inverse association with both GLS and septal longitudinal deformation indices (GLS: R(2) = 0.30; p = 0.02; SSL: R(2) = 0.36; p = 0.01; SL-Sr: R(2) = 0.39; p < 0.001; SL-SrE: R(2) = 0.35; p = 0.001). miRNA-21 was mainly expressed in fibrous tissue (p < 0.0001). A significant association between MF and plasmatic miRNA-21, alone and weighted for measures of structural (LVMi R(2) = 0.50; p = 0.0005) and functional (SSL R(2) = 0.35; p = 0.006) remodeling, was found. CONCLUSIONS: In AVS, MF is associated with alterations of regional and global strain. Plasmatic miRNA-21 is directly related to MF and associated with LV structural and functional impairment.

The Modified Bentall Procedure: A Single-Institution Experience in 249 Patients with a Maximum Follow Up of 21.5 Years.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the long-term clinical outcomes of the modified Bentall procedure (MBP) with a mechanical conduit. METHODS: Between 1993 and 2014, a total of 249 patients (mean age 62 ± 12 years; range: 25-87 years) underwent a MBP at the authors' institution. The main indication was annuloaortic ectasia in 102 patients (41%), followed by acute aortic dissection in 82 patients (33%); moderate to severe aortic regurgitation was present in 79% of cases. A bicuspid aortic valve was found in 17% of patients, and Marfan syndrome in 7%. The mean NYHA functional class was 2.5 ± 1.1. Concomitant procedures were performed in 36 patients (14%). The mean follow up was 8.7 ± 5.0 years (range: 0.3-21.5 years) and was 99% complete. The total follow up was 6.475 patient-years (pt-yr). RESULTS: Operative mortality was 3% in elective cases. Age, prolonged cardiopulmonary bypass times and mechanical ventilation >96 h were independent risk factors for early mortality. Actuarial survival at 15 and 20 years was 62% and 60%, respectively. Risk factors for late mortality were age and emergency operation. Actuarial freedom from thromboembolism (linearized incidence 0.93%/pt-yr) was 82% at 15 years, and 74% at 20 years. Seven patients required reoperation (0.38%/pt-yr), with an actuarial freedom from reoperation of 91% at 15 years and 87% at 20 years. The incidence of overall valve-related complications was 0.32%/pt-yr, with actuarial freedoms of 94% at 15 and 20 years. CONCLUSIONS: The MBP has shown excellent long-term results with a low incidence of procedure-related complications up to 20 years postoperatively. For this reason, it is considered to be a valid option for the treatment of aortic root disease, whenever valvesparing procedures are not indicated.

Recurrent mitral regurgitation due to ruptured artificial chordae: case report and review of the literature.

The use of expanded polytetrafluoroethylene (ePTFE) sutures has become an established method to correct mitral regurgitation due to elongated or ruptured mitral chordae. Mitral valve repair using artificial chordae has demonstrated excellent long-term results, particularly as ePTFE retains its flexibility with time and is highly resistant to mechanical stress. On conducting a literature review, four cases were found of recurrent mitral regurgitation due to the late (6-14 years postoperatively) rupture of ePTFE chordae. Herein, the case is described of artificial chordal rupture that required reoperation at 11 years after the initial mitral valve repair. In all previously reported cases, chordal rupture was related to the calcification of ePTFE, whereas in the present case only minimal calcification was observed at histology, and chordal rupture was most likely due to ePTFE fatigue-induced lesion. Although rare, rupture of the artificial chordae may cause recurrent mitral regurgitation; hence, the continuous monitoring of these patients, especially when the follow up extends beyond 10 years, appears mandatory.

Reduction in platelet count after aortic valve replacement: comparison of three bioprostheses.

BACKGROUND AND AIM OF THE STUDY: Concerns have recently been raised regarding postoperative decreases in platelet count (PC) after aortic valve replacement (AVR) with the Sorin Freedom Solo (SFS) stentless bioprosthesis. In order to assess the relevance and the clinical impact of this phenomenon, variations in PC were monitored in patients with SFS valves, and compared to changes of PC in patients after AVR with two other bioprostheses, the Medtronic Mosaic (MOS) porcine valve and the Sorin Mitroflow (MIT) pericardial valve. METHODS: Three groups of patients (25 in each group) who had undergone AVR with a biological prosthesis were compared. The patients were similar in terms of their preoperative characteristics, including mean age, NYHA functional class, risk factors, EuroSCORE, and mean PC. The PC was monitored on postoperative days 1, 3, and 5, and again at discharge. Thrombocytopenia was considered to be 'present' when the PC was < 150,000/microl, and 'severe' when the PC was < 30,000/microl. RESULTS: No significant inter-group differences were observed in the duration of extracorporeal circulation or cross-clamp times. The mean postoperative PCs for MOS valves were 154,000 +/- 56,000/microl, 154,000 +/- 54,000/microl, 161,000 +/- 85,000/microl, and 228,000 +/- 95,000/microl at days 1,3, and 5, and at discharge, respectively. For MIT valves, these values were 126,000 +/- 37,000/microl, 113,000 +/- 38,000/microl, 130,000 +/- 46,000/microl, and 170,000 +/- 50,000/microl, respectively. For SFS valves, the values were 99,000 +/- 27,000/microl, 67,000 +/- 9000/microl, 78,000 +/- 54,000/microl, and 96,000 +/- 32,000/microl, respectively. Severe thrombocytopenia was never observed in any patient. A significant decrease in PC occurred with SFS when compared to MOS valves (on days 1, 3, 5, and at discharge, p < 0.001) and to MIT valves (on days 3, 5, and at discharge, p < 0.005). Multivariate analysis showed older age (p = 0.001) and the SFS valve (p = 0.0002) to be incremental risk factors for developing severe or moderate thrombocytopenia after AVR. CONCLUSION: A reduction in PC occurred with all bioprostheses on postoperative day 1, while a significant reduction in PC was continued for SFS valves on postoperative days 3 and 5, when compared to MOS and MIT valves. A normalization of PC at discharge was observed only with MOS valves. Thrombocytopenia after AVR with biological prostheses was not associated with any major postoperative complication.

Lipid insudation as a cause of structural failure of a stentless pericardial bioprosthesis.

The Sorin Pericarbon Freedom (SPF) valve is a stentless bioprosthesis made from bovine pericardium, with a peculiar design aimed at preventing the mechanical failures observed with old models of stented pericardial bioprostheses. Herein, the case is described of a patient who presented with severe regurgitation of a SPF six years after aortic valve replacement, caused by commissural dehiscence. Both, microradiographic and histologic investigations, revealed mild calcific deposits and massive lipid infiltration, thus confirming that a patient-related mechanism such as 'atheromasia' can account for structural valve deterioration also in recipients of pericardial bioprostheses.

Replacement of a Calcified Aortic Valve in a Porcine Aortic Root with the Perceval Sutureless Bioprosthesis.

We report a 79-year-old patient who had aortic valve replacement (AVR) using a porcine aortic root. Due to degeneration of the porcine aortic valve, he required reoperation during which a heavily calcified porcine root and aortic annulus prevented insertion of any traditional bioprosthesis. AVR was achieved using a sutureless bioprosthesis, combined with mitral valve replacement. The present case confirms the feasibility and advantages of using sutureless valve implantation in complex and high-risk redo procedures.

Unusual complication after aortic valve replacement with the Freedom Solo stentless bioprosthesis.

The case is presented of an unusual complication after aortic valve replacement with a Freedom Solo bioprosthesis. Excision of the aortic valve created a discontinuity of the aortic annulus that was missed intraoperatively and left uncorrected after supra-annular placement of the bioprosthesis; this created a pseudoaneurysm with direct communication to the pericardial cavity. When implanting the Freedom Solo bioprosthesis, care must be taken to exclude the presence of any aortic annular discontinuity. Implantation of the Freedom Solo bioprosthesis is not precluded by this possible complication, provided that any annular disruption is promptly recognized and adequately closed before placement of the supra-annular sutures.

Aortic valve-sparing procedure-a durable choice in liver transplantation recipient.

A 44-year old man with aortic regurgitation and aneurysm of the ascending aorta underwent an aortic valve-sparing procedure as a durable treatment before liver transplantation. Since patients with chronic liver failure are at high risk of hemorrhagic complications at time of major surgery, while management of warfarin administration may still represent a concern, the choice of a cardiac procedure which avoids any anticoagulant treatment appeared justified.

Intraoperative displacement of a Perceval sutureless prosthesis.

We describe a patient with mitral incompetence and aortic stenosis who underwent mitral valve repair and aortic valve replacement using a Perceval sutureless bioprosthesis. After weaning from cardiopulmonary bypass, repeated mitral valve repair was required due to residual mitral regurgitation. During this procedure, the aortic prosthesis was displaced, most likely by undue inadvertent traction on the atrial retractor, requiring its removal and reinsertion. When employing a sutureless valve gentle manipulation of the heart is mandatory to avoid possible adverse events as that herein described. Should this happen, the Perceval valve can be easily removed and repositioned.

Early aortic dissection after aortic valve replacement with a Perceval sutureless bioprosthesis.

We report a patient who developed ascending aorta dissection after aortic valve replacement with a Perceval sutureless pericardial bioprosthesis, a previously not reported complication with this device. At reoperation, the intimal tear was located at the aortotomy suture line; the tips of the nitinol stent were far from the aortic lesion which therefore was not attributable to the presence of this specific prosthetic model. Nevertheless, a previous report of aortic dissection due to erosion of the aortic wall by the strut of a transcatheter prosthesis may raise the suspicion that such complication could also occur with sutureless prostheses of similar design.

Transthyretin-related amyloid in a saphenous vein. Histological diagnosis in a patient undergoing coronary artery bypass surgery.

Amyloidosis is an underdiagnosed and challenging disease with clinical and etiologic heterogenicity, requiring amyloid subtyping because of the distinctive prognostic and therapeutic impact. Transthyretin amyloidosis is more common in elderly patients, and in such population undergoing cardiovascular surgery, it could be worthy to be investigated. We herein describe an unusual case of transthyretin-related vascular amyloidosis in an 81-year-old man undergoing coronary artery bypass surgery. Diagnosis done after histology showed an intimal eccentric thickening in a remnant segment of the right saphenous vein that was harvested for grafting. Transthyretin-related amyloidosis was demonstrated by histochemical Congo Red staining under polarized light and by immunohistochemistry, corresponding to the intimal thickening. The thorough histological analysis was crucial for the diagnosis of a previously unknown transthyretin-related vascular amyloidosis.

Repair of a giant left ventricular pseudoaneurysm with rupture of the interventricular septum.

Presence of two combined mechanical complications of acute myocardial infarction is extremely rare and still associated with a high-operative mortality. We describe a 73-year-old male patient who presented with a giant left ventricular pseudoaneurysm associated with rupture of the interventricular septum. Surgical repair of both lesions was successfully accomplished.

Incidence of Aortitis in Surgical Specimens of the Ascending Aorta Clinical Implications at Follow-Up.

The objectives of this study are to evaluate the incidence of aortitis on a surgical population, establish any relationship with systemic diseases, verify early and late surgical results and provide clinical and radiological follow-up to determine factors potentially predicting progression of the disease and influencing late outcome. From 2009 to 2017, 237 patients underwent elective operations on the ascending aorta. Segments of the excised tissues were routinely sent for histologic evaluation, providing adequate data in 178 (75%) for a clinical and pathologic correlation. Patients with aortitis (Group 1) (n = 26) were compared with 152 with atherosclerotic or degenerative disease (Group 2). Incidence of aortitis was 15%, being clinically isolated in 73%. In 24 patients (92%), a giant cell aortitis was found. Actuarial survival at 3 years is 88% in Group 1 and 98% in Group 2 and 74% and 98% at 5 years, respectively (P = 0.016). A control angio-computed tomography revealed an increased descending aorta diameter in 2 out of 14 late survivors. A positron emission tomography showed presence of arteritis in other vascular segments in 3 patients. Clinically isolated aortitis is extremely frequent in patients with inflammatory aortic disease. The diagnosis is often difficult and may be supported by routine pathologic evaluation of surgical explants and by multimodality imaging. The latter should be employed to allow adequate patient follow-up and to disclose potential recurrences in untreated aortic segments.

Syphilitic Aortic Aneurysm in the Third Millennium.

A 69-year-old man presented with precordial pain and a dilated ascending aorta with the suspicion of an intramural hematoma. At emergency operation, the aorta appeared grossly thickened with diffuse intimal scarring. Retrospectively, the patient tested positive to serologic screening for syphilis with histologic findings also compatible with a syphilitic aortitis.

Surgical Treatment of Annuloaortic Ectasia - Replace or Repair?

BACKGROUND: Patients with annuloaortic ectasia may be surgically treated with modified Bentall or David I valve-sparing procedures. Here, we compared the long-term results of these procedures. METHODS: A total of 181 patients with annuloaortic ectasia underwent modified Bentall (102 patients, Group 1) or David I (79 patients, Group 2) procedures from 1994 to 2015. Mean age was 62 ± 11 years in Group 1 and 64 ± 16 years in Group 2. Group 1 patients were in poorer health, with a lower ejection fraction and higher functional class. RESULTS: Early mortality was 3% in Group 1 and 2.5% in Group 2. Patients undergoing a modified Bentall procedure had a higher incidence of thromboembolism and hemorrhage, whereas those undergoing a David I procedure had a higher incidence of endocarditis. Actuarial survival was 70 ± 6% at 15 years in Group 1 and 84 ± 7% at 10 years in Group 2. Actuarial freedom from reoperation was 97 ± 2% at 15 years in Group 1 and 84 ± 7% at 10 years in Group 2. In Group 2, freedom from procedure-related reoperations was 98 ± 2% at 10 years. At last follow-up, no cases of moderate or severe aortic regurgitation were observed. CONCLUSIONS: The modified Bentall and David I procedures showed excellent early and late results. The modified Bentall procedure with a mechanical conduit was associated with thromboembolic and hemorrhagic complications, whereas the David I procedure was associated with unexplained occurrences of endocarditis. Thus, the David I procedure appears to be safe, reproducible, and capable of achieving stable aortic valve repair and is therefore our currently preferred solution for patients with annuloaortic ectasia. However, the much shorter follow-up for David I patients limits the strength of our comparison between the two techniques.

The Mosaic Mitral Valve Bioprosthesis: A Long-Term Clinical and Hemodynamic Follow-Up.

We reviewed the cases of 100 patients (mean age, 73 ± 10 yr; 64 men) who had mitral valve replacement with a Medtronic Mosaic porcine bioprosthesis from 1995 through 2011. The mean New York Heart Association (NYHA) class was 3 ± 0.7, and 52 patients were in atrial fibrillation. Prosthetic sizes were chiefly 27 mm (50 patients) and 29 mm (40 patients). Follow-up ended in December 2012 and is 97% complete, with a cumulative duration of 611 patient-years (mean duration, 6 ± 4.6 yr; maximum, 17.7 yr). The early mortality rate was 10% (6% in elective patients); late deaths occurred in 31 patients (5 valve-related). Actuarial survival rates at 5, 10, and 15 years were 74% ± 5%, 50% ± 6%, and 37% ± 8%. The mean NYHA class in survivors was 1.4 ± 0.6 (P <0.0001). Thromboembolic episodes occurred in 4 patients, with an actuarial freedom at 15 years of 91% ± 5%. No cases of endocarditis were observed. Four patients needed reoperation, 2 for structural failure, and 1 each for perivalvular leakage and valve thrombosis. Actuarial freedom from structural failure and from reoperation, respectively, was 93% ± 5% and 91% ± 5% at 15 years. Echocardiographic follow-up in 24 patients with 27-mm prostheses showed a mean gradient of 5 ± 1.7 mmHg and an effective orifice area of 1.57 ± 0.3 cm(2); in 16 patients with 29-mm prostheses, the mean gradient was 4.5 ± 1.9 mmHg, and the effective orifice area, 1.63 ± 0.4 cm(2). During nearly 17 years of follow-up, the Mosaic bioprosthesis has shown good overall clinical and hemodynamic performance after mitral valve replacement.

Splenectomy and Valve Replacement in Patients With Infective Endocarditis and Splenic Abscesses.

In patients with infective endocarditis (IE), splenic involvement is a rare but well-known adverse event. The treatment of patients with IE and splenic abscesses is still challenging and controversial. We report 3 patients with IE and splenic abscesses who underwent successful valve replacement and splenectomy. Our experience confirms that in such a patient, a valve operation combined with splenectomy can be performed with excellent results during the same hospitalization. The timing of splenectomy and the type of surgical approach should be based mainly on the stability of a patient's hemodynamic condition.

Aortic valve replacement in systemic sclerosis.

Systemic sclerosis (scleroderma) is a chronic systemic autoimmune disease of the connective tissue, which can involve the cardiac valves, the mitral valve being more frequently affected, although involvement of the aortic valve has been rarely described. We report a patient with aortic stenosis and systemic sclerosis who required aortic valve replacement. Awareness of this rare association may help to provide adequate management of such patients and prevent complications related to the underlying disease.