Outcomes of emergent cardiac surgery after transcatheter aortic valve implantation.

OBJECTIVE: The aim of this study was to evaluate the reasons for emergent cardiac surgery (ECS) after transcatheter aortic valve implantation (TAVI) and assess outcomes of these patients. METHODS: All patients undergoing ECS following a complicated TAVI procedure at a high-volume TAVI centre in the Netherlands from 1 January 2008 to 1 April 2022 were included. Baseline and procedural characteristics and outcome data (procedural, 30-day and 1­year mortality, in-hospital stroke, 30-day pacemaker implantation, 30-day vascular complications, 30-day deep sternal wound infections and 30-day re-exploration) were collected from patient files and analysed using descriptive statistics. RESULTS: During the study period, 16 of 1594 patients (1.0%) undergoing TAVI required ECS. The main reason for ECS was valve embolisation (n = 9; 56.3%), followed by perforation of the left/right ventricle with guide wire/pacemaker lead (n = 3; 18.8%) and annular rupture (n = 3; 18.8%). Procedural, 30-day and 1­year mortality was 0%, 18.8% (n = 3) and 31.3% (n = 5), respectively. In-hospital stroke occurred in 1 patient (6.3%), a pacemaker was implanted at 30 days in 2 patients (12.5%), and major vascular complications did not occur. CONCLUSION: ECS following complicated TAVI was performed in only a small number of cases. It had a high but acceptable perioperative and 30-day mortality, taking into account the otherwise lethal consequences. In case of valve embolisation, no periprocedural or 30-day mortality was observed for surgical aortic valve replacement (even in a redo setting), which supported the necessity to perform TAVI in centres with cardiac surgical backup on site.

Impact of Experience Corps® Participation on Children's Academic Achievement and School Behavior.

This article reports on the impact of the Experience Corps® (EC) Baltimore program, an intergenerational, school-based program aimed at improving academic achievement and reducing disruptive school behavior in urban, elementary school students in Kindergarten through third grade (K-3). Teams of adult volunteers aged 60 and older were placed in public schools, serving 15 h or more per week, to perform meaningful and important roles to improve the educational outcomes of children and the health and well-being of volunteers. Findings indicate no significant impact of the EC program on standardized reading or mathematical achievement test scores among children in grades 1-3 exposed to the program. K-1st grade students in EC schools had fewer principal office referrals compared to K-1st grade students in matched control schools during their second year in the EC program; second graders in EC schools had fewer suspensions and expulsions than second graders in non-EC schools during their first year in the EC program. In general, both boys and girls appeared to benefit from the EC program in school behavior. The results suggest that a volunteer engagement program for older adults can be modestly effective for improving selective aspects of classroom behavior among elementary school students in under-resourced, urban schools, but there were no significant improvements in academic achievement. More work is needed to identify individual- and school-level factors that may help account for these results.

Low-intensity daily walking activity is associated with hippocampal volume in older adults.

Hippocampal atrophy is associated with memory impairment and dementia and serves as a key biomarker in the preclinical stages of Alzheimer's disease. Physical activity, one of the most promising behavioral interventions to prevent or delay cognitive decline, has been shown to be associated with hippocampal volume; specifically increased aerobic activity and fitness may have a positive effect on the size of the hippocampus. The majority of older adults, however, are sedentary and have difficulty initiating and maintaining exercise programs. A modestly more active lifestyle may nonetheless be beneficial. This study explored whether greater objectively measured daily walking activity was associated with larger hippocampal volume. We additionally explored whether greater low-intensity walking activity, which may be related to leisure-time physical, functional, and social activities, was associated with larger hippocampal volume independent of exercise and higher-intensity walking activity. Segmentation of hippocampal volumes was performed using Functional Magnetic Resonance Imaging of the Brain's Software Library (FSL), and daily walking activity was assessed using a step activity monitor on 92, nondemented, older adult participants. After controlling for age, education, body mass index, cardiovascular disease risk factors, and the Mini Mental State Exam, we found that a greater amount, duration, and frequency of total daily walking activity were each associated with larger hippocampal volume among older women, but not among men. These relationships were specific to hippocampal volume, compared with the thalamus, used as a control brain region, and remained significant for low-intensity walking activity, independent of moderate- to vigorous-intensity activity and self-reported exercise. This is the first study, to our knowledge, to explore the relationship between objectively measured daily walking activity and hippocampal volume in an older adult population. Findings suggest the importance of examining whether increasing nonexercise, lifestyle physical activities may produce measurable cognitive benefits and affect hippocampal volume through molecular pathways unique to those related to moderate-intensity exercise.

Impact of Experience Corps(®) participation on school climate.

We examined the impact of the Experience Corps(®) (EC) program on school climate within Baltimore City public elementary schools. In this program, teams of older adult volunteers were placed in high intensity (>15 h per week), meaningful roles in public elementary schools, to improve the educational outcomes of children as well as the health and well-being of volunteers. During the first year of EC participation, school climate was perceived more favorably among staff and students in EC schools as compared to those in comparison schools. However, with a few notable exceptions, perceived school climate did not differ for staff or students in intervention and comparison schools during the second year of exposure to the EC program. These findings suggest that perceptions of school climate may be altered by introducing a new program into elementary schools; however, research examining how perceptions of school climate are impacted over a longer period is warranted.

Postoperative conduction disorders after implantation of the self-expandable sutureless Perceval S bioprosthesis.

BACKGROUND AND AIM OF THE STUDY: Minimally invasive techniques for aortic valve replacement (AVR) have been developed as an alternative to conventional AVR for patients with high operative risk. Yet, these techniques are still associated with an increased risk of postoperative conduction disorders. The study aim was to identify the incidence and fate of postoperative conduction disorders in patients undergoing sutureless (SU) AVR with the Perceval S bioprosthesis. METHODS: In this observational study, patients who underwent SU AVR with the Perceval S prosthesis at the Catharina Hospital, Eindhoven, were analyzed. Electrocardiograms (ECGs) recorded at baseline, within 24 h postoperatively, before hospital discharge and at follow up were collected by reviewing patients' records. The ECGs were analyzed by two independent investigators to record QRS-duration and conduction disorders. RESULTS: All patients (n = 31) who underwent implantation of the Perceval S bioprosthesis between September 2010 and September 2012 were included. At baseline, three patients (9.7%) had preexisting left bundle branch block (LBBB), and one patient (3.2%) had a permanent pacemaker (PPM). New-onset LBBB developed in 11 patients (39.3%), and was transient in three patients (10.7%). Postoperatively, four patients (13.3%) required PPM implantation because of total atrioventricular block; all of these patients had either pre-existing LBBB (n = 1) or new LBBB (n = 3). CONCLUSION: Sutureless AVR with the Perceval S bioprosthesis was frequently complicated by new LBBB, which was persistent in the majority of patients. A relatively high incidence of postoperative PPM implantation was also observed.

Lifestyle Activities in Sociodemographically at-risk Urban, Older Adults Prior to Participation in the Baltimore Experience Corps(®) Trial.

Experience Corps(®) places teams of trained volunteers in elementary school classrooms to promote academic achievement in children, and serve as a health promotion intervention for older adults. Prior to randomization, individuals reported participation in several activities of varying cognitive, physical, and social demands. Maintaining an active lifestyle, particularly in intellectually demanding activities, was associated with physical, mental, and cognitive health in adulthood. Establishing how individuals allocated their time before randomization to this program provides insight to prevalent health behaviors for at-risk older adults, and can provide the basis for examining intervention-related changes in lifestyle as a result of volunteer participation.

Randomized controlled trial between conventional versus sutureless bioprostheses for aortic valve replacement: Impact of mini and full sternotomy access at 1-year follow-up.

BACKGROUND: The present study is a sub-analysis of the multicenter, randomized PERSIST-AVR trial (PERceval Sutureless Implant versus Standard Aortic Valve Replacement) comparing the in-hospital and 1-year results of sutureless versus conventional stented bioprostheses in isolated surgical aortic valve replacement (SAVR) within two different surgical approaches: mini-sternotomy (MS) and full-sternotomy (FS). METHODS: A total of 819 patients (per-protocol population) underwent preoperative randomization to sutureless or stented biological valve at 47 centers worldwide. Sub-analysis on isolated SAVR was performed. Results were compared between sutureless and stented within the two different surgical approaches. RESULTS: 285 patients were implanted with Perceval (67% in MS) and 293 with stented valves (65% in MS). Sutureless group showed significantly reduced surgical times both in FS and MS. In-hospital results show no differences between Perceval and stented valves in FS, while a lower incidence of new-onset of atrial fibrillation (3.7% vs 10.8%) with Perceval in MS. After 1-year, use of sutureless valve showed a significant reduction of MACCE (5.2% vs 10.8%), stroke rate (1.0% vs 5.4%), new-onset of atrial fibrillation (4.2% vs 11.4%) and re-hospitalizations (21.8 days vs 47.6 days), compared to stented valves but presented higher rate of pacemaker implantation (11% vs 1.6%). CONCLUSIONS: Sutureless bioprosthesis showed significantly reduced procedural times during isolated SAVR in both surgical approaches. Patients with sutureless valves and MS access showed also better 1-year outcome regarding MACCEs, stroke, re-hospitalization and new-onset atrial fibrillation, but presented a higher rate of permanent pacemaker implantation compared to patients with stented bioprosthesis.

Hemodynamic Performance of Sutureless vs. Conventional Bioprostheses for Aortic Valve Replacement: The 1-Year Core-Lab Results of the Randomized PERSIST-AVR Trial.

OBJECTIVE: Sutureless aortic valves are an effective option for aortic valve replacement (AVR) showing non-inferiority to standard stented aortic valves for major cardiovascular and cerebral events at 1-year. We report the 1-year hemodynamic performance of the sutureless prostheses compared with standard aortic valves, assessed by a dedicated echocardiographic core lab. METHODS: Perceval Sutureless Implant vs. Standard Aortic Valve Replacement (PERSIST-AVR) is a prospective, randomized, adaptive, open-label trial. Patients undergoing AVR, as an isolated or combined procedure, were randomized to receive a sutureless [sutureless aortic valve replacement (Su-AVR)] (n = 407) or a stented sutured [surgical AVR (SAVR)] (n = 412) bioprostheses. Site-reported echocardiographic examinations were collected at 1 year. In addition, a subgroup of the trial population (Su-AVR n = 71, SAVR = 82) had a complete echocardiographic examination independently assessed by a Core Lab (MedStar Health Research Institute, Washington D.C., USA) for the evaluation of the hemodynamic performance. RESULTS: The site-reported hemodynamic data of stented valves and sutureless valves are stable and comparable during follow-up, showing stable reduction of mean and peak pressure gradients through one-year follow-up (mean: 12.1 ± 6.2 vs. 11.5 ± 4.6 mmHg; peak: 21.3 ± 11.4 vs. 22.0 ± 8.9 mmHg). These results at 1-year are confirmed in the subgroup by the core-lab assessed echocardiogram with an average mean and peak gradient of 12.8 ± 5.7 and 21.5 ± 9.1 mmHg for Su-AVR, and 13.4 ± 7.7 and 23.0 ± 13.0 mmHg for SAVR. The valve effective orifice area was 1.3 ± 0.4 and 1.4 ± 0.4 cm2 at 1-year for Su-AVR and SAVR. These improvements are observed across all valve sizes. At 1-year evaluation, 91.3% (n = 42) of patients in Su-AVR and 82.3% in SAVR (n = 51) groups were free from paravalvular leak (PVL). The rate of mild PVL was 4.3% (n = 2) in Su-AVR and 12.9% (n = 8) in the SAVR group. A similar trend is observed for central leak occurrence in both core-lab assessed echo groups. CONCLUSION: At 1-year of follow-up of a PERSIST-AVR patient sub-group, the study showed comparable hemodynamic performance in the sutureless and the stented-valve groups, confirmed by independent echo core lab. Perceval sutureless prosthesis provides optimal sealing at the annulus with equivalent PVL and central regurgitation extent rates compared to sutured valves. Sutureless valves are therefore a reliable and essential technology within the modern therapeutic possibilities to treat aortic valve disease.

Pacemaker implantation after sutureless or stented valve: results from a controlled randomized trial.

OBJECTIVES: Sutureless aortic valves demonstrated non-inferiority to standard stented valves for major cardiovascular and cerebral events at 1 year after aortic valve replacement. We aim to assess the factors correlating with permanent pacemaker implantation (PPI) in both cohorts. METHODS: PERSIST-AVR is a prospective, randomized, open-label trial. Patients undergoing aortic valve replacement were randomized to receive a sutureless aortic valve replacement (Su-AVR) or stented sutured bioprosthesis (SAVR). Multivariable analysis was performed to identify possible independent risk factors associated with PPI. A logistic regression analysis was performed to estimate the risk of PPI associated to different valve size. RESULTS: The 2 groups (Su-AVR; n = 450, SAVR n = 446) were well balanced in terms of preoperative risk factors. Early PPI rates were 10.4% in the Su-AVR group and 3.1% in the SAVR. PPI prevalence correlated with valve size XL (P = 0.0119) and preoperative conduction disturbances (P = 0.0079) in the Su-AVR group. No predictors were found in the SAVR cohort. Logistic regression analysis showed a significantly higher risk for PPI with size XL compared to each individual sutureless valve sizes [odds ratio (OR) 0.272 vs size S (95%confidence interval 0.07-0.95), 0.334 vs size M (95% CI 0,16-0; 68), 0.408 vs size L (95% CI 0,21-0.81)] but equivalent risk of PPI rates for all other combination of valve sizes. CONCLUSIONS: Su-AVR is associated with higher PPI rate as compared to SAVR. However, the increased PPI rate appears to be size-dependent with significant higher rate only for size XL. The combination of preoperative conduction disorder and a size XL can lead to a higher probability of early PPI in Su-AVR. CLINICAL TRIAL REGISTRATION NUMBER: NCT02673697.

Recovery of conduction disorders after sutureless aortic valve replacement.

OBJECTIVES: Conduction disorders and the need for permanent pacemaker (PPM) implantation after surgical aortic valve replacement are well-recognized complications. However, in the case of sutureless valve prostheses, it remains unknown whether pacemaker (PM) dependency and conduction disturbances resolve over time. Our aim was to evaluate whether conduction disorders after Perceval sutureless valve implantation recover during follow-up. METHODS: Patients undergoing isolated surgical aortic valve replacement or concomitant aortic valve replacement with coronary artery bypass surgery using the Perceval sutureless valve, between January 2010 and July 2018, were included. Postoperative electrocardiogram findings were analysed to determine the incidence of new-onset left bundle branch blocks (LBBBs) and the requirement for PPM implantation. During a postoperative period of 6-18 months, electrocardiogram findings during PM checks were analysed to determine PM dependency and LBBB persistence. RESULTS: Out of 184 patients who received a Perceval prosthesis during the study period, 39 (21.2%) patients developed new-onset LBBB and 10 patients (5.4%) received a PPM postoperatively. The occurrence of conduction disorders was not associated with valve size. Follow-up was completed in 176 (95.7%) patients. In patients with a new-onset LBBB, 35.9% recovered during follow-up (P = 0.001). Seven out of 10 (70%) patients remained PM dependent. CONCLUSIONS: After Perceval aortic valve implantation, new-onset LBBB recovers in more than one-third of patients during follow-up. In patients who needed a postoperative PPM, the majority remained PM dependent.

Marketing public health through older adult volunteering: Experience Corps as a social marketing intervention.

OBJECTIVES: We present a social marketing conceptual framework for Experience Corps Baltimore City (EC) in which the desired health outcome is not the promoted product or behavior. We also demonstrate the feasibility of a social marketing-based recruitment campaign for the first year of the Baltimore Experience Corps Trial (BECT), a randomized, controlled trial of the health benefits of EC participation for older adults. METHODS: We recruited older adults from the Baltimore, MD, area. Participants randomized to the intervention were placed in public schools in volunteer roles designed to increase healthy behaviors. We examined the effectiveness of a recruitment message that appealed to generativity (i.e., to make a difference for the next generation), rather than potential health benefits. RESULTS: Among the 155 participants recruited in the first year of the BECT, the average age was 69 years; 87% were women and 85% were African American. Participants reported primarily generative motives as their reason for interest in the BECT. CONCLUSIONS: Public health interventions embedded in civic engagement have the potential to engage older adults who might not respond to a direct appeal to improve their health.

Potential for intensive volunteering to promote the health of older adults in fair health.

Volunteer service opportunities for older adults may soon be expanded. Although volunteering is thought to provide health benefits for healthier older adults, it is not known whether older adults in less than very good health are suitable candidates for high-intensity volunteering and can derive health benefits. This manuscript presents a prospective analysis of 174 older adult volunteers serving in Experience Corps Baltimore, a high-intensity senior volunteer program in Baltimore, Maryland. Volunteers served > or =15 h per week, for a full school year, in elementary schools helping children with reading and other skills between 1999 and 2002. Volunteers were assessed with standardized questionnaires and performance-based testing including grip strength, walking speed, chair stand speed, and stair-climbing speed prior to school volunteering and at the end of the school year. Results were stratified by health status. Among 174 volunteers, 55% initially reported "good" and 12% "fair" or "poor" health status. At baseline, those in fair health reported higher frequencies of disease and disability than volunteers in excellent or very good health. After volunteering, a majority of volunteers in every baseline health status category described increased strength and energy. Those in fair health were significantly more likely to display improved stair-climbing speed than those in good or excellent/very good health (100.0% vs. 53.4% vs. 37.5%, p = 0.05), and many showed clinically significant increases in walking speed of >0.5 m/s. Satisfaction and retention rates were high for all health status groups. Clinicians should consider whether their patients in fair or good health, as well as those in better health, might benefit from high-intensity volunteer programs. Productive activity such as volunteering may be an effective community-based approach to health promotion for older adults.

Effects of Age Discrimination on Self-perceptions of Aging and Cancer Risk Behaviors.

BACKGROUND AND OBJECTIVES: Almost one-third of older adults report experiencing age discrimination. We hypothesized sequential links between older adults' everyday experiences of age discrimination and future health behaviors related to cancer risk through self-perceptions of aging (SPA). RESEARCH DESIGN AND METHODS: Participants were community-dwelling respondents (age: 51-96 years) from the 2008, 2012, and 2014 waves of the Health and Retirement Study (N = 4,467). Generalized path models estimated the immediate and enduring effects of age discrimination in 2008 on proximal SPA in 2012 and distal health behaviors in 2014. RESULTS: Age discrimination was associated with lower positive SPA and higher negative SPA in 2012. The effect of age discrimination on physical activity, smoking, and drinking in 2014 was mediated by positive and negative SPA in 2012. Through subsequent SPA, those who experienced age discrimination in 2008 were less likely to engage in regular moderate physical activity, more likely to smoke, and less likely to drink more than 3 times per week in 2014. Analysis of change in positive and negative SPA showed the effect of age discrimination on physical activity to be mediated by change in positive, but not negative, SPA. DISCUSSION AND IMPLICATIONS: The enduring effects of age discrimination were found through a reduction in positive SPA. Elevating positive SPA could be as important as reducing negative SPA for future health behaviors related to cancer risk.

Sutureless aortic valve replacement in a calcified homograft combined with mitral valve replacement.

BACKGROUND: Aortic valve replacement in a patient with an aortic homograft can be very challenging, especially when concomitant mitral valve surgery needs to be performed. CASE PRESENTATION: We report a case of implantation of a sutureless aortic valve bioprosthesis combined with mitral valve replacement in a patient with a severely calcified aortic homograft where conventional valve replacement was technically unfeasible. CONCLUSIONS: We believe that sutureless AVR is a viable option especially for young patients with a high surgical risk where conventional valve replacement cannot be achieved.

Positive Aging Expectations Are Associated With Physical Activity Among Urban-Dwelling Older Adults.

Purpose: Regular physical activity is a key component of healthy aging, but few older adults meet physical activity guidelines. Poor aging expectations can contribute to this lack of activity, since negative stereotypes about the aging process can be internalized and affect physical performance. Although prior cross-sectional studies have shown that physical activity and aging expectations are associated, less is known about this association longitudinally, particularly among traditionally underrepresented groups. It is also unclear whether different domains of aging expectations are differentially associated with physical activity. Design and Methods: The number of minutes/week of physical activity in which Baltimore Experience Corps Trial participants (N = 446; 92.6% African American) engaged were measured using the CHAMPS questionnaire, while their aging expectations were measured using the ERA-12 survey. Linear mixed effects models assessed the association between physical activity and aging expectations over 2 years, both in full and sex-stratified samples. Separate models were also fit for different ERA-12 domains. Results: We found that higher overall expectations regarding aging are associated with higher engagement in moderate- to high-intensity physical activity over a 2-year period of time for women only. When the ERA-12 domains were examined separately, only the physical domain was associated with physical activity, both in women and overall. Implications: Low expectations regarding physical aging may represent a barrier to physical activity for older adults. Given that most older adults do not meet recommended physical activity guidelines, identifying factors that improve aging expectations may be a way to increase physical activity levels in aging populations.

Effect of Community Volunteering on Physical Activity: A Randomized Controlled Trial.

INTRODUCTION: Older adults with a high number of chronic conditions and who live in environments that do not promote physical activity have great difficulty initiating and adhering to exercise programs. Novel lifestyle activity interventions that can effectively increase physical activity may address disparities in health in these populations. This study evaluates the effects of the Baltimore Experience Corps program, a community-based volunteer program, on walking activity in older adults. METHODS: The Baltimore Experience Corps Trial is a sex-stratified RCT that recruited participants from 2006 to 2009. Older adult participants aged ≥60 years (n=123) were from a nested objective physical activity trial within the larger Baltimore Experience Corps Trial. Participants randomized to the intervention group were placed as volunteers within the Baltimore public school system for 2 years. The primary study outcome was objectively measured total amount of walking activity measured in steps/day. Differences between intervention and control groups were measured at 12 and 24 months using linear mixed effects models. Data were analyzed in 2014. RESULTS: At 24 months, women, but not men, in the intervention group showed an increased amount of walking activity, averaging 1,500.3 (95% CI=77.6, 2,922.9) greater steps/day compared with the control group. Women in the control group showed a decline of 1,191.6 (95% CI=-2243.7, -139.5) steps/day at 24 months compared to baseline. CONCLUSIONS: A community-based volunteer intervention increased walking activity among older women, who were at elevated risk for both inactivity and adverse health outcomes. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT00380562.

A European Multicenter Study of 616 Patients Receiving the Freedom Solo Stentless Bioprosthesis.

BACKGROUND: The purpose of this study was to evaluate the safety and performance of the Freedom Solo valve in aortic valve replacement by clinical and hemodynamic outcomes. METHODS: Six hundred sixteen patients underwent aortic valve replacement in 18 European centers; mean age was 74.5 ± 5.9 years, 54.1% of the patients were male, and concomitant procedures were performed in 43.2% of the patients. The majority (69%) of the implanted sizes were 23 mm and 25 mm. RESULTS: At 1 year, overall survival was 94.0%, whereas freedom from valve-related death was 98.6%. There were 9 (1.5%) early (≤ 30 days) and 27 (4.4%) late (>30 days) deaths. Early and late valve-related mortality was 0.3% (n = 2) and 1.1% (n = 7), respectively. Freedom from explant was 97.6%; 10 valves were explanted for endocarditis and 4 for paravalvular leak. There were 10 (1.6%) early and 5 (0.8%) late strokes. Atrioventricular block requiring pacemaker implant occurred in 8 (1.3%) and 1 (0.2%) patients in the early and late postoperative period, respectively. Thrombocytopenia was seen in 27 cases (4.4%) in the early postoperative period. Preoperatively, 93.8% of patients were in New York Heart Association functional classes II through IV, whereas at 1 year 96.9% of patients were in New York Heart Association functional classes I and II. At 1-year follow-up, mean and peak pressure gradients were 7.2 and 14.6 mm Hg, respectively. Indexed left ventricular mass decreased by 12% from 138 g/m(2) at discharge to 122 g/m(2) at 1 year. CONCLUSIONS: At 1-year follow-up after Freedom Solo implantation, we found acceptable clinical results with low mortality and morbidity and good hemodynamic performance, confirming safety and effectiveness in this multicenter experience.

Clinical and haemodynamic outcomes in 804 patients receiving the Freedom SOLO stentless aortic valve: results from an international prospective multicentre study.

OBJECTIVES: The Freedom SOLO™ valve (Sorin Group, Italy) is a stentless aortic bioprosthesis designed for simplified implantation. The present multicentre study is the largest prospective evaluation of this prosthesis. Herein, we report on outcomes at 3-year follow-up. METHODS: From March 2009 to February 2013, a total of 804 consecutive patients (mean age 74.9 ± 6.3 years; 45.1% females) underwent aortic valve replacement with the Freedom SOLO™ valve at 33 centres. Concomitant procedures (70.2% coronary artery bypass grafting) were performed in 376 patients. The cumulative follow-up included 1100 patient-years (mean 16.5 ± 10.8 months; range: 0-40.5 months). RESULTS: Sixty-four patients died (14 early, 50 late); 12 deaths (1 early, 11 late) were valve-related. Operative mortality (30 days) was 1.7%. At 3 years, overall survival was 82.6% [95% confidence interval (CI) 75.5-87.8%] and freedom from valve-related death was 95.5% (95% CI 89.2-98.2%). Linearized late event rates were 0.82%/patient-years for non-structural valve dysfunction, 0.55%/patient-years for structural valve deterioration, 1.55%/patient-years for endocarditis, 3.64%/patient-years for thromboembolism and 3.18%/patient-years for bleeding. In total, there were 22 reinterventions [19 valve explants, 2 refixations, 1 transcatheter aortic valve intervention (TAVI)] for endocarditis (11), non-structural dysfunction (9) and structural valve deterioration (2). Freedom from reintervention was 95.2% (95% CI 91.2-97.4%) at 3 years. There were no instances of valve thrombosis or haemolysis. At 1, 2 and 3 years, 97.0, 95.5 and 91.4% of patients were in NYHA class I or II. Between discharge and 3 years after surgery, mean transvalvular gradients exhibited a non-significant increase (6.5 ± 4.3 vs 8.7 ± 6.5 mmHg), whereas effective orifice area index remained stable (0.9 ± 0.2 vs 0.8 ± 0.3 cm(2)/m(2)). At 3 years, no patient presented with more than mild aortic regurgitation. Left ventricular mass index decreased significantly between discharge and 1 year after surgery (139.4 ± 40.9 vs 122.4 ± 35.3 g/m(2), P < 0.001) and remained unchanged thereafter. Left ventricular size and function did not change over time. CONCLUSIONS: The Freedom SOLO™ valve is a unique stentless pericardial bioprosthesis whose design favours haemodynamic performance and thus facilitates left ventricular reverse remodelling. In terms of survival, morbidity and functional status, it is associated with beneficial outcomes up to 3 years after surgery. Ongoing follow-up will assess the valve at the long-term course.

Differences in mortality of black and white patients enrolled in the program of all-inclusive care for the elderly.

OBJECTIVES: To examine the relationship between race and mortality in frail community-dwelling older people with access to a program providing comprehensive access and coordination of services. DESIGN: A longitudinal cohort study. SETTING: Twelve nationwide demonstration sites of the Program of All-Inclusive Care for the Elderly (PACE) from 1990 to 1996. PACE provides comprehensive medical and long-term care services for nursing home-eligible older people who live in the community. PARTICIPANTS: Two thousand two white patients and 859 black patients. MEASUREMENTS: Patients were followed after enrollment until death or the end of the follow-up period. Time from enrollment to death was measured with adjustment of the Cox proportional hazards model for comorbid conditions, functional status, site, and other demographic characteristics. RESULTS: Black patients were younger than white patients (mean age 77 vs 80, P <.001) but had worse functional status (mean activity of daily living (ADL) score 6.5 vs 7.2, P <.001) on enrollment. Survival for black and white patients was 88% and 86% at 1 year, 67% and 61% at 3 years, and 51% and 42% at 5 years, respectively (unadjusted hazard ratio (HR) for black patients = 0.77; 95% confidence interval (CI) = 0.67-0.89). After adjustment for baseline comorbid conditions, functional status, site, and demographic characteristics, black patients still had a lower mortality rate (HR = 0.77; 95% CI =.65-0.93). The survival advantage for black patients did not emerge until about 1 year after PACE enrollment (HR for first year after enrollment = 0.97; 95% CI = 0.72-1.31; HR after first year = 0.67; 95% CI = 0.54-0.85, P-value for time interaction <.001). During the first year of enrollment, black patients were more likely to improve and less likely to decline in ADL function than white patients (P <.001). CONCLUSION: In PACE, a system providing access to and coordination of comprehensive medical and long-term care services for frail older people, black patients have a lower mortality rate than white patients. This survival advantage, which emerges approximately 1 year after PACE enrollment, may be related to the comprehensive access and coordination of services provided by the PACE program.