Mitroflow LXA structural deterioration following aortic valve replacement: a single-center experience.

BACKGROUND: Concerns have been previously raised regarding the potential early degeneration of the Mitroflow (Sorin Group Italia, Saluggia, Vercelli, Italy) bioprostheses. We aimed to evaluate our clinical experience with the Mitroflow LXA prosthesis for aortic valve replacement. METHODS: We prospectively analyzed data from 227 consecutive patients (133 males, mean age 73.9±9.2 years) implanted with the Mitroflow LXA between February 2007 and October 2011. Follow-up data were obtained by contacting the referring cardiologists. Kaplan-Meier curves were constructed for all-cause mortality, valve related mortality and structural valve degeneration (SVD). Multivariable analysis was conducted to identify SVD predictors. RESULTS: Median follow-up time was 54.2±37.9 months and completeness of follow-up was 95%. Overall mortality in the entire series was at 31% (N.=71) and mortality from cardiac or unknown causes at 20% (N.=46). SVD occurred in 24 patients (10%) (median delay between implantation and diagnosis: 62.6 (36.5) months). Reintervention was required in 20 cases (13 redo surgery, 7 percutaneous transcatheter valve intervention). The 8 years actuarial global survival was 54.7±4.9%, freedom from valve related mortality 67.5±4.9% and freedom from SVD 72±8%. The estimated freedom from SVD was significantly (P=0.007) longer in larger prosthesis (diameter >21 mm, 77±11%) compared to the smaller devices (≤21 mm, 59±13%.). Multivariate analysis identified smaller prostheses and age at implantation as independent predictors of SVD. CONCLUSIONS: The Mitroflow LXA showed evidence of early SVD in this cohort. A close follow-up of these patients is strongly advised.

Long-term results of external aortic ring annuloplasty for aortic valve repair.

OBJECTIVES: An untreated dilated aortic annulus is a major risk factor for failure of aortic valve-sparing operations or repair of either bicuspid or tricuspid valve. Aortic annuloplasty efficiently reduces the annulus and increases the coaptation height, thus protecting the repair. This study analyses long-term results of 232 consecutive patients operated on with a standardized and physiological approach to aortic valve repair according to each phenotype of the dystrophic ascending aorta. Subvalvular aortic annuloplasty was systematically added using an external aortic ring to reduce annulus diameter when ≥25 mm. METHODS: Data were collected into the multicentric international AVIATOR registry (AorticValve repair InternATiOnal Registry): 149 patients with root aneurysm underwent remodelling with an external ring; 21 patients with tubular aortic aneurysm underwent supracoronary grafts with an external open ring and 62 patients with isolated aortic insufficiency (AI) underwent double sub- and/or supravalvular external open ring annuloplasty. Preoperative AI ≥ Grade III was present in 58.6% (133), and the valve was bicuspid in 37.9% (88). RESULTS: Cusp repair was performed in 75.4% (175) patients. The 30-day operative mortality rate was 1.4% (3). The mean follow-up was 40.1 ± 37.8 months (0-145.5). The actuarial survival rate at 7 years was 89.9%. The rate of freedom from reoperation at 7 years was similar among each phenotype, being 90.5% for root aneurysms, 100% for tubular aortic aneurysms and 97.5% for isolated AI with no difference between the bicuspid and tricuspid valve. The rates of freedom from AI ≥ Grade 2 and from AI ≥ Grade 3 at 7 years were, respectively, 76.0 and 93.1% for root aneurysms, 92.9 and 100% for tubular aortic aneurysms and 57.3 and 82.2% for isolated AI. Eye balling repair achieved suboptimal valve competency when compared with systematic cusp effective height assessment, which tended to improve the rate freedom from reoperation, respectively, from 85.8 ± 5.5% to 98.9 ± 1.1% and the rate of freedom from AI ≥ Grade 3 from 89.8 ± 4.9% to 100%. For isolated AI, an additional sinotubular junction ring (double sub- and supravalvular annuloplasty) tended to reduce recurrent AI when compared with single subvalvular annuloplasty. CONCLUSIONS: External aortic ring annuloplasty provides a reproducible technique for aortic valve repair with satisfactory long-term results for each ascending aorta phenotype with bicuspid or tricuspid valve. Longer follow-up is ongoing with the AVIATOR registry.

Surgical management of pulmonary atresia with ventricular septal defect in late adolescence and adulthood.

OBJECTIVE: In presence of adequate pulmonary blood flow, patients presenting with unoperated or palliated pulmonary atresia with ventricular septal defect (PA/VSD) can reach adult age. However, they remain symptomatic with a limited life expectancy. METHODS: Since 1993, 27 patients underwent surgery for unrepaired PA/VSD. Median age was 20 (range: 15-43) years. Nineteen patients had 33 previous palliative procedures while eight were unoperated survivors. Major aortopulmonary collateral artery (MAPCA) had been observed in all but 2 and were still patent in 23. All bronchopulmonary segments were connected to the native pulmonary arteries (NPA) in 4 (type A), to both NPA and MAPCA in 18 (type B) and only to MAPCA in 5 (type C). The biventricular repair was performed in 17 patients: 3 type A, 12 type B and 2 type C. Ten patients underwent palliative procedure: eight aortopulmonary shunt, with unifocalisation in two and one right ventricle to NPA restrictive conduit. RESULTS: One (4%) hospital death occurred following the failure of a palliative procedure. No clinical improvement was observed in seven patients including one repaired and six palliated survivors. Two late cardiac death occurred 1 and 7 years after repair. At last visit, 15 of 16 repaired survivors were in NYHA class I or II. Only one patient awaits septation, while eight other with subsequent palliation were considered not repairable. CONCLUSION: The outcome was encouraging in patients who were eligible for completed biventricular repair. Although considered as unique alternative to cardiopulmonary transplantation, the justification for palliative surgery to improve pulmonary blood flow remains to be established.