A. D. Ferreira

The Early and Midterm Function of Decellularized Aortic Valve Allografts

BACKGROUND This study evaluates the early and midterm results of decellularized aortic valve allografts (DAVA) as an aortic valve replacement. METHODS Between October 2005 and February 2010, 41 patients, 28 of whom were male, with a median age of 34 years (range, 0.1 to 71), had aortic valve replacement with DAVA. Decellularization was obtained with a 0.1% sodium dodecyl sulfate solution. Postoperative evaluation was performed with serial echocardiograms, magnetic resonance imaging, and multislice computed tomography studies to evaluate valve hemodynamics, allograft conduit dimensions, and calcification scores. RESULTS There were 3 early deaths and 1 late death, with a mean follow-up of 19 months (range, 1 to 53). There was 1 reoperation due to a failed mitral valve repair. By echocardiography in all patients, the median immediate postoperative peak gradient was 7 mm Hg (range, 1 to 26 mm Hg), and at last follow-up it was 4 mm Hg (range, 1 to 16 mm Hg); valvular regurgitation was graded as none or trivial in all but 1 patient, who had a regurgitation graded as mild to moderate. By magnetic resonance imaging (n = 4), mean root dimensions were stable at the annulus (24 mm), sinus of Valsalva (33 mm), and sinotubular junction (28 mm). By computed tomography (n = 22), there was only discrete conduit calcification (median calcium score 63 Hounsfield units [HU]; range, 0 to 894 HU) to 3 years of follow-up. Conduit biopsy in the patient who underwent reoperation demonstrated well-preserved wall structure, absence of calcification, and limited in vivo host repopulation. CONCLUSIONS The early and midterm results with DAVA demonstrated stable structural integrity, low rate of calcification, and adequate hemodynamics. Although longer periods of observation are necessary, DAVA appears to be a promising alternative for aortic valve replacement in selected patients.

Long-term results of the Ross operation: An 18-year single institutional experience

OBJECTIVES The purpose of the study was to assess the 18-year outcome of the Ross operation (RO), with emphasis on survival, reoperations, and late function of the pulmonary autografts (PAs) and the right-sided pulmonary allografts. METHODS Between May 1995 to July 2013, 414 patients with a mean age (mean ± standard deviation) of 30.8 ± 13.1 years were submitted to an RO with the root replacement (n = 356) or the inclusion (n = 58) technique. The most prevalent aetiology was bicuspid valve (n = 206, 49.8%). Patients were divided in four groups depending on the type of allograft used on the right side. The mean follow-up was 8.2 ± 5.2 years and was 97.7% complete. In addition to longitudinal outcomes determined by means of the Kaplan-Meier analysis, log-rank test and Cox regression analysis were used to identify predictors of valve failure. RESULTS The early mortality rate was 2.7% and the late survival rate was 89.3% at 15 years, similar to an age- and sex-matched population. There were 22 reoperations on the PA (90.7% freedom at 15 years) and 15 on the pulmonary allografts (92.5% freedom at 15 years). The freedom rate from more than mild aortic insufficiency (AI) was 73.1% at 15 years. Thirty-three patients presented with a late root diameter >45 mm, corresponding to a freedom rate of 72.4% at 15 years. Patients with AI and a dilated annulus, especially males, are at greater risk for these complications. Among the right-sided allografts, fresh decellularized allografts showed significantly superior freedom from structural valve dysfunction. CONCLUSIONS The RO was associated with excellent long-term survival and low incidence of reoperations up to 15 years. Male patients with AI and dilated annulus are at increased risk for late insufficiency and root dilatation. Fresh decellularized allografts presented the best results for reconstruction of the right ventricular outflow tract.

20 years experience with the Ross operation in middle-aged patients: the autologous principle is still alive

Objectives Review our long-term results with the Ross operation in middle-aged patients. Methods Between 1995 and 2016, 129 consecutive patients (106 males); mean age (47.2 ± 5.2 years) underwent a Ross operation. Right ventricular outflow tract (RVOT) reconstruction was performed with cryopreserved (n = 45) or decellularized allografts (n = 84). Mean follow-up was 8.4 ± 5.3 years (0.1 20.5 years). We analyzed early and late mortality, as well as valve related events and the need for reoperations. Results Early mortality was 1.6% and late survival was 87.6% at 16 years. There were 4 reoperations on the pulmonary autograft (96% freedom at 16 years) and 2 on the pulmonary allografts (99% freedom at 16 years). The 16-year freedom from more than mild aortic insufficiency (AI) and a late root diameter >45 mm was 64% and 71%, respectively. Patients with the preoperative diagnosis of AI are at greater risk for these complications. Among the allografts, decellularized allografts showed superior freedom from structural valve dysfunction. Conclusions The Ross operation in this cohort was associated with long-term survival similar to the general population and low incidence of reoperations. Patients with the preoperative diagnosis of AI are at increased risk for late autograft insufficiency and root dilatation. Decellularized allografts presented the best results for reconstruction of the RVOT. These results support the conclusion that the Ross operation has an important role in the treatment of middle-aged patients with aortic valve disease, especially those with pure aortic stenosis.

Aortic valve replacement with the Cardioprotese Premium bovine pericardium bioprosthesis: four-year clinical results

OBJECTIVES This study reports the initial clinical and echocardiographic results of the Premium bioprosthetic aortic valve up to 4 years of follow-up. METHODS Between October 2007 and July 2011, 121 consecutive patients were submitted for aortic valve replacement with the Premium bioprosthetic valve. The mean age was 68 ± 9 years and 64 patients were males. The patients were periodically evaluated by clinical and echocardiographic examinations. The mean follow-up was 21 months (min = 2, max = 48), yielding 217 patients/year for the analysis. RESULTS The hospital mortality was 8%. Late survival at 3 years was 89% (95% CI: 81.9-93.3%), and 80% of the patients were in NYHA functional class I/II. The rates of valve-related complications were low, with a linearized incidence of 0.9%/100 patients/year for thromboembolic complications, 0% for haemorrhagic events and 0.9%/100 patients/year of bacterial endocarditis. There was no case of primary structural valve dysfunction. The mean effective orifice area was 1.61 ± 0.45 cm(2); mean gradient 13 ± 5 mmHg and peak gradient 22 ± 9 mmHg. Significant patient-prosthesis mismatch was found in only 11% of the cases. CONCLUSIONS The Premium bioprosthetic aortic valve demonstrated very satisfactory clinical and echocardiographic results up to 4 years, similar to other commercially available, third-generation bioprosthetic valves.

Dez anos de experiência com a substituição da valva aórtica com homoenxertos valvares aórticos implantados pela técnica da substituição total da raiz

OBJETIVO: Avaliar os resultados imediatos e tardios de 10 anos da substituicao da valva aortica por homoenxertos valvares aorticos implantados pela tecnica de substituicao total da raiz, e identificar eventuais fatores de risco correlacionados com a degeneracao tecidual primaria dos enxertos. METODO: Entre maio/1995 e janeiro/2006, 282 pacientes com media de idade de 52,8±16,6 anos foram submetidos a substituicao da valva aortica com homoenxertos valvares. As etiologias prevalentes foram a valva aortica bicuspide calcificada e a degeneracao senil em 49% dos casos. Quarenta e sete pacientes eram reoperacoes e 26 tinham endocardite bacteriana aguda. Procedimentos associados foram realizados em 113 pacientes. O homoenxerto valvar foi implantado pela tecnica de substituicao total da raiz em todos os casos. O tempo de seguimento pos-operatorio variou de 1 a 129 meses (media = 41±25 meses). RESULTADOS: A mortalidade imediata foi de 7%, sendo de apenas 2,6% nos casos de operacao eletiva para a substituicao isolada da valva aortica. Dos 262 que receberam alta hospitalar, foi possivel obter avaliacao clinica e/ou ecocardiograma em 209 deles, sendo 51 (20%) perdidos durante o seguimento. Houve 17 obitos tardios, entre o 2o e 81o meses de pos-operatorio, o que resultou em curva atuarial de sobrevida global de 90% e 80,1% aos 5 e 10 anos de evolucao, respectivamente. Foram observados apenas oito episodios tromboembolicos (quatro imediatos e quatro tardios), durante a evolucao para uma incidencia linearizada de 0,3%/100 pacientes/ano. Endocardite bacteriana ocorreu em tres ocasioes (0,4%/100 pacientes/ano). Nove pacientes foram reoperados, dos quais apenas tres por problemas no homoenxerto (uma degeneracao tecidual e dois casos de endocardite), o que resultou numa probabilidade de 94% livres dessa complicacao aos 10 anos de seguimento. A analise do ecocardiograma tardio demonstrou gradiente maximo variando entre 3 a 47 mmHg (media de 14,5 mmHg), sendo que apenas dois pacientes apresentavam gradiente superior a 40mmHg. Insuficiencia valvar moderada foi encontrada em quatro pacientes. CONCLUSOES: Os resultados imediatos e tardios com a substituicao da valva aortica por homoenxerto valvar criopreservado foram excelentes, com boa capacidade funcional e baixa morbi-mortalidade tardia. O unico fator de risco para a degeneracao tecidual primaria foi a idade do paciente menor que 20 anos. Homoenxertos aorticos representam uma excelente opcao para pacientes com idade acima de 40-50 anos, especialmente naqueles com contra-indicacao ou que nao desejem fazer o uso de anticoagulantes.

Long-Term Results of Mitral Valve Repair

Introduction Current guidelines state that patients with severe mitral regurgitation should be treated in reference centers with a high reparability rate, low mortality rate, and durable results. Objective To analyze our global experience with the treatment of organic mitral regurgitation from various etiologies operated in a single center. Methods We evaluated all surgically treated patients with organic mitral regurgitation from 2004-2017. Patients were evaluated clinically and by echocardiography every year. We determined early and late survival rates, valve related events and freedom from recurrent mitral regurgitation and tricuspid regurgitation. Valve failure was defined as any mitral regurgitation ≥ moderate degree or the need for reoperation for any reason. Results Out of 133 patients with organic mitral regurgitation, 125 (93.9%) were submitted to valve repair. Mean age was 57±15 years and 52 patients were males. The most common etiologies were degenerative disease (73 patients) and rheumatic disease (34 patients). Early mortality was 2.4% and late survival was 84.3% at 10 years, which are similar to the age- and gender-matched general population. Only two patients developed severe mitral regurgitation, and both were reoperated (95.6% at 10 years). Freedom from mitral valve failure was 84.5% at 10 years, with no difference between degenerative and rheumatic valves. Overall, late ≥ moderate tricuspid regurgitation was present in 34% of the patients, being more common in the rheumatic ones. The use of tricuspid annuloplasty abolished this complication. Conclusion We have demonstrated that mitral regurgitation due to organic mitral valve disease from various etiologies can be surgically treated with a high repair rate, low early mortality and long-term survival that are comparable to the matched general population. Concomitant treatment of atrial fibrillation and tricuspid valve may be important adjuncts to optimize long-term results.