Exploiting the anti-fibrotic effects of statins on thoracic aortic aneurysm progression: results from a meta-analysis and experimental data.

Aims: Thoracic aortic aneurysm (TAA) that progress to acute aortic dissection is often fatal and there is no pharmacological treatment that can reduce TAA progression. We aim to evaluate statins' effects on TAA growth rate and outcomes using a meta-analysis approach. Methods and results: A detailed search related to the effects of statins on TAA was conducted according to PRISMA guidelines. The analyses of statins' effects on TAA growth rate were performed on 4 studies (n = 1850), while the impact on outcomes was evaluated on 3 studies (n = 2,867). Patients under statin treatment showed a reduced TAA growth rate (difference in means = -0.36 cm/year; 95%CI: -0.64, -0.08; p = 0.013) when compared to controls, patients not taking statins. Regarding the outcomes (death, dissection, or rupture of the aorta, and the need for operative repair), statins exhibited a protective effect reducing the number of events (log odds ratio = -0.56; 95%CI: -1.06, -0.05; p = 0.030). In vitro, the anti-fibrotic effect of atorvastatin was tested on vascular smooth muscle cells (VMSC) isolated from patients with TAA. Our results highlighted that, in transforming growth factor beta 1 (TGF-ß1) pro-fibrotic condition, VSMC expressed a significant lower amount of collagen type I alpha 1 chain (COL1A1) when treated with atorvastatin (untreated = +2.66 ± 0.23 fold-change vs. treated = +1.63 ± 0.09 fold-change; p = 0.014). Conclusion: Statins show a protective effect on TAA growth rate and adverse outcomes in patients with TAA, possibly via their anti-fibrotic properties on VSMC. Given the current lack of effective drug treatments for TAA, we believe our findings highlight the need for more in-depth research to explore the potential benefits of statins in this context.

Geodesic motion in Euclidean Schwarzschild geometry.

This paper performs a systematic investigation of geodesic motion in Euclidean Schwarzschild geometry, which is studied in the equatorial plane. The explicit form of geodesic motion is obtained in terms of incomplete elliptic integrals of first, second and third kind. No elliptic-like orbits exist in Euclidean Schwarzschild geometry, unlike the corresponding Lorentzian pattern. Among unbounded orbits, only unbounded first-kind orbits are allowed, unlike general relativity where unbounded second-kind orbits are always allowed.

Looking Back to Look Forward: What to Expect in a Redo Surgery for a Bioprosthesis Replacement.

Redo surgeries are becoming more common because of an increased rate of bioprosthesis implantation. We performed a retrospective study on patients who underwent redo replacement of an aortic and/or mitral bioprosthesis between 2005 and 2018 to evaluate intra-hospital mortality and morbidity. Univariate analysis was performed on the propensity score variables to determine predictors of mortality. A total of 180 patients were enrolled in the study: Group A (replacement of aortic bioprosthesis) with 136 patients (75.56%) and group B (replacement of mitral bioprosthesis ± aortic bioprosthesis) with 44 patients (24.44%). NYHA class ≥ 3 and female sex were significantly more common in group B. Cardiopulmonary-bypass time and aortic cross-clamping time in group A and group B were, respectively, 154.95 ± 74.35 and 190.25 ± 77.44 (p = 0.0005) and 115.99 ± 53.54 and 144.91 ± 52.53 (p = 0.0004). Overall mortality was 8.89%. After propensity score adjustment, Group B was confirmed to have an increased risk of death (OR 3.32 CI 95% 1.02−10.88 p < 0.0001), gastrointestinal complications (OR 7.784 CI 95% 1.005−60.282 p < 0.0002) and pulmonary complications (OR 2.381 CI 95% 1.038−5.46 p < 0.0001). At the univariate analysis, endocarditis, cardiopulmonary-bypass and aortic cross clamping time, NYHA class ≥ 3 and urgency setting were significantly associated to death. Intra-hospital outcomes were acceptable regarding mortality and complications. Patients who need redo surgery on mitral bioprosthesis have an increased risk of post-operative pulmonary and gastrointestinal complications and mortality. Therefore the choice of mitral bioprosthesis at time of first surgery should be carefully evaluated.

Successful Transvaginal Microwave Ablation of a Heterotopic Cervical Pregnancy. A Case Report.

Heterotopic cervical pregnancy is a rare and potentially dangerous condition where the challenge is the removal of the ectopic pregnancy while preserving the intrauterine one. We present the case of an otherwise healthy 36-year-old woman with heterotopic cervical pregnancy after an IVF cycle for tubal infertility. At 6.5 weeks after a consultation with gynecologists and interventional radiologists, the patient agreed to undergo microwave ablation of the cervical pregnancy. Monthly ultrasound examination showed the persistence of non homogeneous and vascularized tissue in the cervix. Intrauterine pregnancy continued without complications until 37 weeks when a cesarean section was performed for sudden and profuse bleeding, in the presence of uterine contractions. A healthy baby girl was delivered, and the postoperative course was otherwise uncomplicated. Heterotopic cervical pregnancies are rare, and no consolidated and risk-free treatments are available at the moment. Here, we present a case of heterotopic cervical pregnancy treated successfully and without complications with microwave ablation.

Minimally Invasive Aortic Arch Repair: Technical Considerations and Mid-Term Outcomes.

BACKGROUND: Reports of minimal invasive aortic arch surgery are scarce. We reviewed our experience with minimal access aortic arch surgery performed through an upper mini-sternotomy, with emphasis on details of operative technique and early and mid-term outcomes. METHODS: The medical records of 123 adult patients (mean age 66 ± 12 years), who underwent primary elective minimal access aortic arch surgery in two aortic referral centers, were reviewed. The most common indication was degenerative aortic arch aneurysm in 92 (75%) patients. Standard operative and organ protection techniques used in all patients were upper mini-sternotomy, uninterrupted antegrade cerebral perfusion, and moderate systemic hypothermia (27.4 ± 1°C). RESULTS: Sixty-eight (55%) patients received partial aortic arch replacement; the remaining 55 (45%) patients received total arch replacement, further extended with either a frozen elephant trunk in 43 (35%) patients or a conventional elephant trunk procedure in nine (7%) patients. No conversion to full sternotomy was required. New permanent renal failure occurred in one (0.8%) patient, stroke in two (1.6%), and spinal cord injury in four (3.3%) patients. Early mortality was observed in four (3.3%) patients. At five years, survival was 80 ± 6% and freedom from reoperation was 96 ± 3%. CONCLUSION: Minimal invasive aortic arch repair through an upper mini-sternotomy can be safely performed, with early and mid-term outcomes well comparable to series performed through a standard median sternotomy.

Stand-Alone Thoracoscopic Left Atrial Appendage Closure in Nonvalvular Atrial Fibrillation Patients at High Bleeding Risk.

OBJECTIVE: In nonvalvular atrial fibrillation (AF) patients at high bleeding risk, oral anticoagulants (OAC) may be contraindicated, and percutaneous left atrial appendage (LAA) closure has been advocated. However, following percutaneous procedure, either OAC or dual antiplatelet treatment is required. In this study, we present our experience in treating nonvalvular AF patients at high bleeding risk with thoracoscopic LAA closure with no subsequent antithrombotic therapy. METHODS: From April 2019 to January 2020, 20 consecutive AF patients, mean age 75.1 years, 16 (80%) males, underwent thoracoscopic LAA closure as a stand-alone procedure, using an epicardial clip device. OAC and antiplatelet therapy were contraindicated. Mean CHA2DS2-VASc score was 3.61, and the mean HAS-BLED score was 4.42. Successful LAA closure was assessed by transesophageal echocardiography. Primary endpoints were complete LAA closure (no residual LAA flow), operative complications, and all-cause mortality; secondary endpoints were 30-day and 6-month complications (death, ischemic stroke, hemorrhagic stroke, transient ischemic attack, any bleeding). Mean follow-up was 6 ± 4 months. RESULTS: Complete LAA closure was achieved in all patients. No operative clip-related complications or deaths occurred. At follow-up, freedom from postoperative complications was 95% and from any cerebrovascular events was 100%. Overall survival rate was 100%. CONCLUSIONS: In nonvalvular AF patients at high bleeding risk (HAS-BLED score >3), thoracoscopic LAA closure appears to be a valid alternative to percutaneous techniques not requiring dual antiplatelet or OAC treatment. Apparently, external LAA clipping minimizes the risk of thromboembolic events as compared with percutaneous procedures.

Zone 1 Debranching for Frozen Elephant Trunk and Whole-Body Perfusion.

A 65-year-old man with chronic type A aortic dissection underwent zone 1 debranching and frozen elephant trunk with whole-body perfusion. This approach has the potential to improve technical feasibility of the frozen elephant trunk procedure and reduce its ischemic complications.

Hybrid three-stage repair of mega-aortic syndrome with the Lupiae technique: 10-year results.

BACKGROUND: Mega-aortic syndrome (MAS) is a rare disease carrying a poor prognosis if treated conservatively. Open repairs of these aneurysms are invasive, while totally endovascular repairs are associated with higher rates of late reintervention due to endoleaks, compromising long-term prognosis. We describe the 10-year results of a hybrid three-stage approach to MAS using the Lupiae technique. METHODS: Between 2006 and 2016, 27 patients with MAS extending from the ascending aorta to the iliac arteries (MAS type III) underwent: (I) a surgical aortic arch debranching, using the Vascutek Lupiae™ multibranched graft to create a proximal Dacron landing zone; (II) an abdominal aorta debranching to create a distal Dacron landing zone and (III) the implantation of multiple endovascular stents to exclude any residual aneurysm between the two landing zones. RESULTS: One patient died following the first stage, and another following the second stage of the repair (overall mortality 7.4%). The interval between the first and the second stage was 58.3±16.1 days. The interval between the second and the third stage was 47.7±13.1 days. Four-year survival was 88.6%±6.2% while 10-year survival was 51.7%±17.9%. One patient had a type III endoleak after the third stage that self-resolved within 6 months without intervention. No patient had type I or II endoleaks and none underwent redo procedures. Mean follow-up was 5.9±3.6 years and completeness was 100%. CONCLUSIONS: Three-stage hybrid repairs using the Lupiae technique can be safely performed in MAS type III patients. Short intervals between the stages should mitigate the risk of rupture during the waiting periods and may enhance patient compliance, but to achieve this, the burden and the complexity of the first stage must be carefully weighted. Our strategy improves the long-term survival of these patients compared to their natural history and is less invasive than an open repair. The adoption of Dacron landing zones appears to be associated with very low rates of reintervention due to endoleaks.

Hybrid three-stage repair of mega aorta with Lupiae technique: tips and tricks.

Mega aorta syndrome (MAS) poses a complex clinical challenge: the involvement of the ascending aorta, aortic arch, descending thoracic and abdominal aorta with extension below the origin of renal arteries requires almost total replacement of the aorta. The modality of treatment remains still controversial. Different aortic debranching techniques have been developed to re-route the origin of epiaortic and visceral vessels and achieve an optimal landing zone for implantation of subsequent endovascular grafts. We illustrate the Lupiae technique as a further evolution of the aortic debranching and hybrid repair of a mega aorta. It was developed with the purpose to exclude a very long segment of diseased aorta by implanting two or more endoprostheses between two surgically-generated landing zones. We describe a series of 27 patients treated by this hybrid three-stage mega-aorta repair; the tips and tricks discussed here facilitate a safe and effective procedure, enable treatment of frail patients and help to avoid life-threatening complications.

Early and Mid-term Outcome of the St. Jude Medical Regent 19-mm Aortic Valve Mechanical Prosthesis. Functional and Haemodynamic Evaluation.

BACKGROUND AND OBJECTIVES: The aim of the present study is to report the early and mid-term clinical and haemodynamic results of the St Jude Medical Regent 19-mm aortic mechanical prothesis (SJMR-19). MATERIALS AND METHODS: Between January 2002 and January 2012, 265 patients with aortic valve disease underwent AVR (Aortic Valve Replacement) with a SJMR-19 (St Jude Medical Regent Nr.19). There were 51 males. Mean age was 67.5±12.72years and mean body surface area (BSA) was 1.67±0.14m2. Thirty-six patients required annulus enlargement. The mean follow-up was 34.5±18.8months (range 6-60 months). All patients underwent echocardiographic examination at discharge and within 1 year after surgery. RESULTS: There were 14 (5.3%) hospital deaths. Six of the hospital deaths were identified in patients undergoing reoperation, significantly higher than patients undergoing first time operation (p=0.0001). Also the postoperative mortality was significantly higher in patients undergoing annulus enlargement versus patients not requiring annulus enlargement (p=0.02). The mean transprosthesis gradient at discharge was 19±9mmHg. At 6 months follow-up the mean NYHA FC class was 1.6±0.5 significantly lower than preoperatively 2.4±0.75 (p <0.0001). The M-TPG was 15.2±6.5mmHg within 1 year after surgery. Left ventricular mass (LVM) and indexed left ventricular mass (LVMi) were significantly lower than preoperatively The actuarial survival and cumulative freedom from reoperation at 1, 2 and 3 years follow-up were 99.5%, 97.5%, 96.7% and 99.2%, 96.5%, 94.5% respectively. The cumulative actuarial free-events survival at 4 years was 92%. The Cox model identified age (p=0.015), LVEF≤35% (p=0.043), reoperation (p=0.031), combined surgery (p=0.00002), and annulus enlargement (p=0.015) as strong predictors for poor actuarial free-major events survival. CONCLUSIONS: The SJMR-19 offers excellent postoperative clinical, haemodynamic outcome and LVMi reduction in patients with small aortic annulus. These data demonstrate that the modern St Jude small mechanical protheses do not influence the intermediate free-reoperation survival.

Aortic events and reoperations after elective arch surgery: incidence, surgical strategies and outcomes.

OBJECTIVES: The true incidence of aortic events (AEs) and reoperations (REDO) following elective total aortic arch replacement remains unknown. The aim of this study was to review the incidence of AEs and surgical REDO, and its respective outcomes after 1232 elective arch repairs at 11 European aortic centres. METHODS: Retrospective chart review (in the absence of prospective data collection) was performed for statistical analysis. Follow-up was conducted during routine clinical examination or in a telephone interview with patients and/or their respective physicians. RESULTS: One hundred fifty-five (12.6%) patients were identified (median follow-up time 48.7 months). The recorded AEs comprised aortic dilatation (62.6%), rupture (15.5%), endoleak (11%), false aneurysm (3.9%), dissection (3.2%), infection (2.6%) and others (1.3%). REDO (open/endovascular) were performed in 85.8% of patients (n = 133). Intraoperative and in-hospital mortality in the REDO patients were 7.5% and 17.3%, respectively. Postoperative neurological complications comprised paraplegia (6.0%) and stroke (1.5%). Survival rates after REDO at 1, 3 and 5 years were 81.2%, 79.0% and 76.7%, respectively. Univariate analysis identified 'rupture' and 'diameter progression', 'older age at REDO' and the REDO strategies 'frozen elephant trunk' and 'no elephant trunk' as predictors of increased in-hospital mortality. Multivariate analysis identified 'older age at REDO' (P = 0.008) as the only independent risk factor for in-hospital mortality. CONCLUSIONS: AEs after elective arch surgery are not irrelevant and mostly involve the distal aspects of the adjoining aorta. In accordance with the underlying pathology, open or endovascular REDO may be performed with an acceptable outcome. Preparation of an adequate proximal landing zone at the time of primary arch surgery is advisable.

Whole body perfusion in patients undergoing frozen elephant trunk for type A acute aortic dissections.

The Frozen Elephant Trunk (FET) can be adopted in selected type A acute aortic dissections (TAAAD). During FET, a prolonged distal circulatory arrest exposes the spine and visceral organs to potential ischemic injuries. Antegrade distal aortic perfusion (ADAP) could minimize this risk: we describe the technical aspects of the simultaneous use of antegrade cerebral perfusion (ACP) and ADAP achieving a "Whole Body Perfusion" (WBP) during FET.

Hybrid approach to thoracic aortic aneurysm: The Lupiae technique.

Aortic diseases, especially when the entire aorta is involved, are often challenging to treat since they frequently require invasive interventions. Minimally invasive hybrid treatment of such pathologies is proving to be a valid option for complex cases (for example, dilation involving the entire aorta) and is improving postoperative outcomes. It consists of a minimally invasive opening stage, where ascending aorta and aortic arch replacement and epiaortic vessel rerouting is performed using a multibranched graft equipped with a radiopaque marker. This is followed by an endovascular stage, where the remaining diseased aorta is covered with an endoprosthesis. This procedure has been described as Lupiae technique and the results seem encouraging.  In this tutorial, we give a practical overview of this technique, describing the treatment of a particular condition called mega-aorta syndrome type 1, which is the dilation of the aorta up to celiac trunk.

Results of surgical aortic valve replacement and transapical transcatheter aortic valve replacement in patients with previous coronary artery bypass grafting.

OBJECTIVES: To evaluate the results of aortic valve replacement through sternotomic approach in redo scenarios (RAVR) vs transapical transcatheter aortic valve replacement (TAVR), in patients in the eighth decade of life or older already undergone previous coronary artery bypass grafting (CABG). METHODS: One hundred and twenty-six patients undergoing RAVR were compared with 113 patients undergoing TaTAVR in terms of 30-day mortality and Valve Academic Research Consortium-2 outcomes. The two groups were also analysed after propensity-matching. RESULTS: TaTAVR patients demonstrated a higher incidence of 30-day mortality (P = 0.03), stroke (P = 0.04), major bleeding (P = 0.03), worse 'early safety' (P = 0.04) and lower permanent pacemaker implantation (P = 0.03). TaTAVR had higher follow-up hazard in all-cause mortality [hazard ratio (HR) 3.15, 95% confidence interval (CI) 1.28-6.62; P < 0.01] and cardiovascular mortality (HR 1.66, 95% CI 1.02-4.88; P = 0.04). Propensity-matched patients showed comparable 30-day outcome in terms of survival, major morbidity and early safety, with only a lower incidence of transfusions after TaTAVR (10.7% vs RAVR: 57.1%; P < 0.01). A trend towards lower Acute Kidney Injury Network Classification 2/3 (3.6% vs RAVR 21.4%; P = 0.05) and towards a lower freedom from all-cause mortality at follow-up (TaTAVR: 44.3 ± 21.3% vs RAVR: 86.6 ± 9.3%; P = .08) was demonstrated after TaTAVR, although cardiovascular mortality was comparable (TaTAVR: 86.5 ± 9.7% vs RAVR: 95.2 ± 4.6%; P = 0.52). Follow-up freedom from stroke, acute heart failure, reintervention on AVR and thrombo-embolisms were comparable (P = NS). EuroSCORE II (P = 0.02), perioperative stroke (P = 0.01) and length of hospitalization (P = 0.02) were the determinants of all-cause mortality at follow-up, whereas perioperative stroke (P = 0.03) and length of hospitalization (P = 0.04) impacted cardiovascular mortality at follow-up. CONCLUSIONS: Reported differences in mortality and morbidity after TaTAVR and RAVR reflect differences in baseline risk profiles. Given the lower trend for renal complications, patients at higher perioperative renal risk might be better served by TaTAVR.

Multicentre analysis of current strategies and outcomes in open aortic arch surgery: heterogeneity is still an issue.

OBJECTIVES: The study was conducted to evaluate, on the basis of a multicentre analysis, current results of elective open aortic arch surgery performed during the last decade. METHODS: Data of 1232 consecutive patients who underwent aortic arch repair with reimplantation of at least one supra-aortic artery between 2004 and 2013 were collected from 11 European cardiovascular centres, and retrospective statistical examination was performed using uni- and multi-variable analyses to identify predictors for 30-day mortality. Acute aortic dissections and arch surgeries not involving the supra-aortic arteries were not included. RESULTS: Arch repair involving all 3 arch arteries (total), 2 arch arteries (subtotal) or 1 arch artery (partial) was performed in 956 (77.6%), 155 (12.6%) and 121 (9.8%) patients, respectively. The patients' characteristics as well as the surgical techniques, including the method of cannulation, perfusion and protection, varied considerably between the clinics participating in the study. The in-hospital and 30-day mortality rates were 11.4 and 8.8% for the entire cohort, respectively, ranging between 1.7 and 19.0% in the surgical centres. Multivariable logistic regression analysis identified surgical centre, patient's age, number of previous surgeries with sternotomy and concomitant surgeries as independent risk factors of 30-day mortality. The follow-up of the study group was 96.5% complete with an overall follow-up duration of 3.3 ± 2.9 years, resulting in 4020 patient-years. After hospital discharge, 176 (14.3%) patients died, yielding an overall mortality rate of 25.6%. The actuarial survival after 5 and 8 years was 72.0 ± 1.5% and 64.0 ± 2.0, respectively. CONCLUSIONS: The surgical risk in elective aortic arch surgery has remained high during the last decade despite the advance in surgical techniques. However, the patients' characteristics, numbers of surgeries, the techniques and the results varied considerably among the centres. The incompleteness of data gathered retrospectively was not effective enough to determine advantages of particular cannulation, perfusion, protection or surgical techniques; and therefore, we strongly recommend further prospective multicentre studies, preferably registries, in which all relevant data have to be clearly defined and collected.

St. Jude Medical Trifecta aortic valve: results from a prospective regional multicentre registry.

BACKGROUND: The Trifecta aortic bioprosthesis (St. Jude Medical, Inc., St. Paul, MN, USA) is a stented pericardial heart valve with excellent preliminary results. Aim of the study was to evaluate its early clinical and hemodynamic performances in a multicenter regional registry. METHODS: Between January 2011 and June 2012, 178 consecutive patients undergoing aortic valve replacement with the Trifecta bioprosthesis were prospectively enrolled at 9 Italian centers. Clinical and echocardiographic data were collectedat discharge, 6-months and at 1-year postoperatively. RESULTS: The average age was 75.4 ± 7.7 years,and 95 (53 %) were men. Indication for valve replacement included stenosis in 123 patients (69 %), mixed lesions in 25 (14 %), and regurgitation in 30 (17 %). Ninety-three (52 %) patients were in NYHA functional class III/ IV. Hospital mortality accounted for 5 (2.8 %) patients. No valve-related perioperative complications were encountered. Median follow-up was 20.5 months (range: 1-34). Early (≤6 months) complications included one thromboembolic event, one major bleeding, and 3 endocarditis (2 explants). Two late (>6 months) thromboembolic events and two endocarditis (1 explant) were registered. No valve thrombosis or structural deterioration were observed after discharge. At 30-months, freedom from all-cause mortality was 87 %, freedom from valve-related mortality 99.4 %, freedom from endocarditis 97.5 %, and freedom from valve explants 98 %. At 1-year, mean gradients ranged from 8 to 16 mmHg, and effective orifice area indexes from 1.0 to 1.2 cm(2)/m(2) for valve sizes from 19 to 27 mm, respectively. No patients had severe prosthesis-patient mismatch. CONCLUSIONS: Trifecta bioprosthesis provided favourable clinical and hemodynamic results over time.

Early and mid-term outcome in terms of functional and hemodynamic performance of the st. Jude regent 19-mm aortic mechanical prosthesis versus 19-mm carpentier edwards aortic biological prosthesis.

BACKGROUND: The aim of the present study is to compare the early and mid-term clinical and hemodynamic results of the aortic valve replacement (AVR) with a St Jude Medical Regent 19-mm prosthesis (SJMR-19) versus Carpentied-Edwars bovine pericardial 19-mm valve (CE-19). METHODS: Between January 2002 and January 2012, 265 patients (Group I) and 58 patients (Group II) with underwent AVR with a SJMR-19 and CE-19 respectively. There were no significant differences between groups regarding the demographic and preoperative echocardiographic data. Thirty-six patients in Group I and 4 in Group II required annulus enlargement in association or not with septal myectomy. The mean follow-up was 34 ± 18.5 months (range 5-60 months). RESULTS: There were 14 (5.3 %) hospital deaths in Group I versus 4 (6.8 %) in Group II (p = 0.86). The multivariate logistic regression analysis identified the LVEF ≤ 35 % (p = 0.001), combined operation (p = 0.0005), CPB (p = 0.033), age (p = 0.011), annulus enlargement (p = 0.0009), reoperation (p = 0.039) and chronic renal failure (p = 0.011) as strong predictors for early postoperative death. Within 1 year after surgery peak pulmonary artery pressure, interventricular septal and left ventricular posterior wall thickness decreased significantly in both groups. The M-TPG was 15.7 ± 6.5 mmHg in Group I versus 17 ± 7 mmHg in Group II (p = 0.19). The multivariate regression analysis revealed the annulus enlargement (p = 0.018), small EOAi (p = 0.00004), postoperative LVMi (p = 0.0001) and BSA (p = 0.019) as strong predictors for higher M-TPG. The postoperative LVMi was 119 ± 22.5 gm/m(2) in Group I and 122 ± 22 gm/m(2) in Group II (p = 0.37), significantly lower than the respective preoperative values 162.5 ± 34 gm/m(2) (Group I) and 168 ± 30 gm/m(2) (Group II). The actuarial survival and cumulative free-reoperation actuarial survival at 5 years follow-up were 96.7 and 94.5 % respectively in Group I and 97 and 91 % in Group II.. There were non significant differences between groups regarding the actuarial survival and cumulative free-reoperation survival. The Cox model identified the older age (p = 0.022), LVEF ≤ 35 % (p = 0.009), reoperation (p = 0.018), combined surgery (p = 0.00075) and annulus enlargement (p = 0.033) as strong predictors for poor actuarial free-reoperation survival. CONCLUSIONS: Both the SJMR-19 and CE-19 offers excellent postoperative clinical and hemodynamic outcome in patients with small aortic annulus. The LV hypertrophy and transvalvular gradients are reduced significantly indenpendently of the employed SJMR-19 or CE-19 prosthesis. Our data support recent suggestions that small valve size does not influence intermediate free-reoperation survival. The CE-19 is an excellent alternative to SJMR-19 in old patients.

Does the St. Jude Regent 17-mm Offer Better Outcomes Than the Hemodynamic Plus 17-mm Aortic Valve Mechanical Prothesis?

OBJECTIVE: The aim of the present study is to report the early and mid-term clinical and hemodynamic results of a prospective trial investigating the clinical performance of the St. Jude Medical Regent 17 mm (SJMR-17) versus St. Jude Medical Hemodynamic Plus 17 mm (SJMHP-17). MATERIALS AND METHODS: Between January 2000 and August 2013, 20 patients (Group I) with aortic valve (AV) stenosis underwent first time AV replacement with a SJMR-17 and nine patients (Group II) underwent AV replacement with a SJMHP-17. The mean follow-up was 58 ± 31 months. RESULTS: There was one death in Group I. The end-diastolic IVS thickness and end-systolic posterior left ventricle (LV) wall thickness was reduced significantly in boths groups (p = 0.001 and p = 0.006 in Group I and p = 0.007 and p = 0.011 in Group II). The peak and mean transprosthesis gradients (P-TPG and M-TPG) were 29 ± 6.8 mmHg and 17.5 ± 4.5 mmHg in Group I, significantly lower than in Group II (55.2 ± 19.7 mmHg and 28.8 ± 7.7 mmHg). The postoperative left ventricular mass (LVM) and indexed left ventricular mass (LVMi) were reduced significantly in both groups versus the preoperative values. The postoperative LVMi was 114.5 ± 10.6 g/m(2) in Group I versus 127 ± 8 g/m(2) in Group II (p = 0.01). With dobutamine, heart rate, left ventricular ejection fraction, cardiac output, transprosthesis peak, and mean gradients increased significantly in both groups, however, the P-TPG and M-TPG were significantly higher in Group II (p = 0.026 and p = 0.022) despite a non-significant increase of the indexed effective orifice area. CONCLUSIONS: The SJMR-17 can be employed with satisfactory postoperative clinical and hemodynamic outcomes in patients with small aortic annulus, especially in elderly patients offering better outcome than SJMHP-17.