Considerations for prostheses choice in multiple valve surgery.

OBJECTIVES: The prosthesis type for multiple valve surgery (replacement of two or more diseased native or prosthetic valves, replacement of two diseased valves with repair/reconstruction of a third, or replacement of a single diseased valve with repair/reconstruction of a second valve) remains inadequately evaluated. The clinical performance of multiple valve surgery with bioprostheses (BP) and mechanical prostheses (MP) was assessed to compare patient survival and composites of valve-related complications. METHODS: Between 1975 and 2000, 1245 patients had multiple valve surgery (BP 785, mean age 62.0 ± 14.7 years; and MP 460, mean age 56.9 ± 12.9 years). There were 1712 procedures performed [BP 969(56.6%) and MP 743(43.4%). Concomitant coronary artery bypass (conCABG) was BP 206(21.3%) and MP 105(14.1%) (p = 0.0002). The cumulative follow-up was BP 5131 years and MP 3364 years. Independent predictors were determined for mortality, valve-related complications and composites of complications. RESULTS: Unadjusted patient survival at 12 years was BP 52.1 ± 2.1% and MP 54.8 ± 4.6% (p = 0.1127), while the age adjusted survival was BP 48.7 ± 2.3% and MP 54.4 ± 5.0%. The predictors of overall mortality were age [Hazard Ratio (HR) 1.051, p < 0.0001], previous valve (HR 1.366, p = 0.028) and conCABG (HR 1.27, p = 0.021). The actual freedom from valve-related mortality at 12 years was BP 85.6 ± 1.6% and MP 91.0 ± 1.6% (actuarial p = 0.0167). The predictors of valve-related mortality were valve type (BP > MP) (2.61, p = 0.001), age (HR 1.032, p = 0.0005) and previous valve (HR 12.61, p < 0.0001). The actual freedom from valve-related reoperation at 12 years was BP 60.8 ± 1.9% and MP85.6 ± 2.1% (actuarial p < 0.001). The predictors of valve-related reoperation were valve type (MP > BP) (HR 0.32, p < 0.0001), age (HR 0.99, p = 0.0001) and previous valve (HR 1.38, p = 0.008) CONCLUSIONS: Overall survival (age adjusted) is differentiated by valve type over 10 and 12 years and valve-related mortality and valve-related reoperation favours the use of mechanical prostheses, overall for multiple valve surgery.

Longest follow-up of in situ working Bjork Shiley valve: 42-year follow-up.

The Bjork Shiley valve (BSV) is considered as the pioneer among modern disc valves, and eventually evolved into a reliable prosthesis after considerable research and multiple modifications. Various case reports have been published with follow-up of different types of BSV. We are reporting the longest follow-up ever published of a plano-convex type of BSV. Our patient's valve was implanted in 1973 due to a congenital bicuspid aortic valve with concomitant severe, symptomatic aortic stenosis, discovered at the age of 27. She presented with exertional dyspnoea, syncope and chest pain; however, her cardiovascular status remained stable and these symptoms abated after successful valve replacement at the age of 34. She is now 77 years old with no limitations in her activities and is able to walk a few miles most days of the week. Her echocardiograms throughout the decades have shown acceptable gradients across the aortic prosthesis without evidence of haemolysis. Our case report includes a summary of the patient with a discussion of the evidence that supports the durability of the original plano-convex BSV.

Mitral valve reconstruction: experience related to early and late mortality and reoperation.

BACKGROUND AND AIM OF THE STUDY: The present authors' experience with mitral valve reconstruction was reviewed to determine the influence of anatomical and functional abnormalities on mortality and reoperation. METHODS: Between 1991 and 2001, a total of 397 patients (mean age 59.0 +/- 13.4 years) underwent mitral valve reconstruction at the authors' institution. Patients were grouped according to the Carpentier functional classification as follows: type I, n = 88 (mean age 57.4 years; range: 24-81 years); type II, n = 169 (mean age 59.8 years; range: 16-81 years); type IIIa, n = 44 (mean age 52.8 years; range: 22-78 years); type IIIb, n = 85 (mean age 65.1 years; range: 33-82 years); and congenital (C), n = 11 (mean age 36.2 years; range: 18-65 years). RESULTS: The total follow up was 1,485.8 patient-years (pt-yr). Early mortality was: type I, 3.4% (n = 3); type II, 0; type IIIa; 2.3% (n = 1); type IIIb, 9.4% (n = 8); and C, 0 (p = 0.0028, IIIb > II and C). The late mortality was: type I, 2.1%/pt-yr (n = 6); type II, 1.1%/pt-yr (n = 7); type IIIa, 1.8%/pt-yr (n = 4); type IIIb, 4.3%/pt-yr (n = 12); and C, 1.7%/pt-yr (n = 1) (p = 0.0035 IIIb > II). The overall survival at 10 years was 79.6 +/- 4.2% (p <0.001, II > IIIb; p = 0.029, I > IIIb; p = 0.046, II > I). The reoperations were: type I, 1.4%/pt-yr (n = 4); type II, 1.9%/pt-yr (n = 12); type IIIa, 0.9%/pt-yr (n = 2); type IIIb, 0.4%/pt-yr (n = 1); and C, 0 (p = 0.0435 II > IIIb). Among the 19 reoperations there were 17 replacements, one re-repair, and one annuloplasty. The failures were predominantly type II, posterior (n = 5) and anterior (n = 5), or a combination (n = 2). The overall freedom from reoperation was 92.0 +/- 2.2% (p = NS between groups). CONCLUSION: Mitral valve reconstruction can be performed in all four functional categories with generally satisfactory results, except possibly for functional ischemic disease. The results of surgery for degenerative disease afford the opportunity for early surgical management, if proven techniques are adhered to in order to minimize the risk of reoperation. The repair of ischemic disease due primarily to ventricular dysfunction is in a state of evolution.

Carpentier-Edwards supra-annular aortic porcine bioprosthesis: clinical performance over 20 years.

OBJECTIVE: Experience with the Carpentier-Edwards supra-annular porcine bioprosthesis (Edwards Lifesciences, Irvine, Calif) has been evaluated longitudinally over 20 years. Clinical performance was evaluated by actuarial and actual analysis. Hemodynamic performance was evaluated by echocardiographic/Doppler assessment. Morphology of structural failure was evaluated from pathologic examinations. METHODS: From 1981 through 1999, 1823 patients (mean age, 68.9 +/- 10.9 years; range, 19-89 years) underwent 1847 procedures. Concomitant coronary artery bypass was performed in 788 (42.7%) patients. Previous valve procedures were performed in 107 (5.8%) patients, and other cardiac procedures were performed in 87 (4.7%) patients. RESULTS: The overall valve-related complication rate was 4.36% per patient-year (630 patients), with a fatality rate of 0.96% per patient-year (139 patients). Patient survival at 18 years was 15.8% +/- 1.6%. Overall late mortality rate was 6.3% per patient-year. Overall actual cumulative freedom at 18 years from reoperation was 85.0% +/- 1.2%, valve-related mortality was 88.7% +/- 1.1%, and valve-related residual morbidity was 96.3% +/- 5.0%. Actual freedom from structural valve deterioration at 18 years was 86.4% +/- 1.2% overall, 90.5% +/- 1.8% for age 61 to 70 years, and 98.2% +/- 0.6% for age greater than 70 years. Structural valve deterioration presented with pathologic evidence consistent with stenosis in 27.6% and insufficiency in 72.4%. Hemodynamic performance at 1 year revealed normal effective orifice area indexes for sizes 23 to 27 mm and mild-to-moderate reduction for size 21 mm. CONCLUSIONS: The Carpentier-Edwards supra-annular aortic porcine bioprosthesis continues to provide excellent freedom from structural valve deterioration and overall freedom from valve-related residual morbidity, mortality, and reoperation up to 18 years. Hemodynamic performance is satisfactory. The prosthesis remains recommended for patients older than 70 years and for patients 61 to 70 years of age, especially when comorbid risk factors are not anticipated to provide extended survival.

Performance of the Carpentier-Edwards SAV and Hancock-II porcine bioprostheses in aortic valve replacement.

BACKGROUND AND AIMS OF THE STUDY: Extended experiences of the Carpentier-Edwards Supra-Annular Valve (CE-SAV) and the Hancock II (H II) porcine bioprostheses were evaluated to determine the freedom from structural valve deterioration (SVD) by reoperation in the aortic position. METHODS: Between 1981 and 1994, 1,524 procedures (mean patient age 67.6+/-11.2 years) with the CE-SAV, and 670 procedures (mean patient age 65.2+/-12.1 years) with the H II were conducted at the University of British Columbia and University of Toronto, respectively. The patient populations were differentiated by mean age, gender and valve size, but not by concomitant coronary artery bypass. The analyses included actuarial and actual freedom from SVD and evaluation of predictors of SVD. RESULTS: Actuarial freedom from SVD at 15 years for patients aged > or =65 years was 91.5+/-2.9% for CE-SAV, and 100% for H II (p = NS), while the actual freedom was 96.4+/-1.0% and 100%, respectively. For the patient population aged 66-70 years, the actuarial freedom from SVD was 87.0+/-6.0% for CE-SAV and 100% for H II (p = NS), while the actual rates were 93.6+/-2.3% and 100%, respectively. For the population aged >70 years, the actuarial freedom from SVD was 96.9+/-1.5% for CE-SAV, and 100% for H II (p = NS), while the actual freedom was 98.8+/-0.5% and 100%, respectively. In the patient population aged <65 years, the actuarial freedom from SVD at 15 years favored the H II (p = 0.04), and the actual freedom showed the same outcome. The valve type was not predictive of SVD for age groups < or =60 years, >60 years, 61-70 years and >70 years, but was predictive for the overall population (p = 0.03), as was age and previous valve replacement. CONCLUSION: The CE-SAV and Hancock II both provide satisfactory clinical performances, with a low incidence of SVD, and no significant difference in SVD was shown in patients aged > or =65, 66-70, or >70 years. There is a trend to less SVD by actual analysis for the Hancock II in patients aged <65 years. This evaluation must be considered as work-in-progress because of the limited number of patients at risk at 15 years, especially with the Hancock II prosthesis.