Alain Mirza

Very Long-Term Outcomes of the Carpentier-Edwards Perimount Valve in Aortic Position

BACKGROUND The Carpentier-Edwards Perimount pericardial bioprosthesis (Edwards Lifesciences, Irvine, CA) has demonstrated good long-term outcomes, but its durability remains unclear depending on age at implantation. We report our 20-year experience with the Perimount valve implanted in the aortic position, with particular attention to the probability and time to reoperation required due to bioprosthesis deterioration. METHODS From 1984 to 2008 at our center, 2,659 patients (mean age, 70.7 ± 10.4 years) underwent aortic valve replacement using the Perimount pericardial bioprostheses. Patients were prospectively followed on an annual basis (mean 6.7 ± 4.8 years, range 0 to 24.6 years) with an echocardiogram at the time of follow-up. Cumulative follow-up was 18,404 valve-years. Bioprosthesis structural valve deterioration was determined by strict echocardiographic assessment. RESULTS Overall operative mortality was 2.8%. Actuarial survival rates including early deaths averaged 52.4% ± 1.2%, 31.1% ± 1.4%, and 14.4% ± 1.7% after 10, 15, and 20 years of follow-up, respectively. Age-stratified freedom from reoperation due to structural valve deterioration at 15 and 20 years was 70.8% ± 4.1% and 38.1% ± 5.6%, respectively, for the group aged 60 years or less, 82.7% ± 2.9% and 59.6% ± 7.6% for those 60 to 70 years, and 98.1% ± 0.8% at 15 years and above for the oldest group. Expected valve durability is 19.7 years for the entire cohort. CONCLUSIONS With a low rate of valve-related events at 20 years, and particularly a low rate of structural valve deterioration, the Carpentier-Edwards Perimount pericardial bioprosthesis remains a reliable choice for a tissue valve in the aortic position, especially in patients over 60 years of age.

Undifferentiated mesenchymal stem cells seeded on a vascular prosthesis contribute to the restoration of a physiologic vascular wall

BACKGROUND We evaluated the possibility of restoring a physiologic vascular wall using undifferentiated mesenchymal stem cells (MSCs) seeded on a polyurethane vascular prosthesis. METHODS Undifferentiated MSCs were seeded on a vascular prosthesis and implanted into Wistar male rats (weight, 350 g) to investigate differentiation into smooth muscle cells and to determine graft endothelialization in vivo. RESULTS Seeded or nonseeded grafts were surgically implanted. Undifferentiated MSCs were first labelled for green fluorescent protein. After 2 weeks in vivo, MSC that were initially self-expanded on the graft in a monolayer were organized in a multicellular layer mimicking media of aortic adjacent wall. They coexpressed green fluorescent protein and smooth muscle proteins that were not present before the in vivo engraftment, indicating that in vivo conditions induced smooth muscle protein maturation. Undifferentiated MSC showed an electrophysiologic profile quite different than mature smooth muscle cells. In both in vitro- and in vivo-differentiated MSCs, adenosine triphosphate, an IP(3)-dependent agonist, induced an increase in calcium similar to that which occurred in mature smooth muscle cells. However, MSCs failed to respond to caffeine, a ryanodine receptor activator, indicating the absence of mature calcium signaling, and finally, contraction was absent. Endothelialization attested by immunohistology and scanning electron microscopy was greater in MSC-seeded grafts that prevent thrombosis. CONCLUSION Only partial smooth muscle cell differentiation of MSCs resulted when seeded on vascular grafts, but MSCs spontaneously restore a media-like thick wall. Mesenchymal stem cells have a positive impact on in vivo endothelialization in rats that supports their potential for use in vascular surgery. CLINICAL RELEVANCE Thrombosis of vascular prostheses is a major complication of surgery. We showed on rat aorta that mesenchymal stem cells seeded on polyurethane patch restore endothelium. It also induced incomplete smooth muscle differentiation. In the future, stem cell could prevent thrombosis of vascular prostheses.

Very late outcomes for mitral valve replacement with the Carpentier-Edwards pericardial bioprosthesis: 25-year follow-up of 450 implantations.

OBJECTIVE The aim of the present study was to evaluate the very-long-term results of the Carpentier-Edwards pericardial bioprosthesis in the mitral position. METHODS From 1984 to 2011, 450 Carpentier-Edwards PERIMOUNT pericardial mitral bioprostheses were implanted in 404 consecutive patients (mean age, 68 years; 53% female). Patients undergoing multiple valve replacements were excluded. The clinical, operative, and follow-up data were prospectively recorded. The mean follow-up was 7.2±5.1 years, for a total of 3258 valve-years. The follow-up data were 97.8% complete. RESULTS The operative mortality rate was 3.3%. A total of 188 late deaths occurred, for a linearized rate of 5.8%/valve-year. At 20 years, the overall actuarial survival rate was 16.9%±3.9%. Age at implantation, preoperative New York Heart Association class III or IV, and redo procedure were significant risk factors affecting late survival. The actuarial freedom from complications at 20 years was thromboembolism, 83.9%±7.6%; hemorrhage, 80.2%±10.8%; endocarditis, 94.8%±1.4%; structural valve deterioration, 23.7%±6.9%; and explantation owing to structural valve deterioration, 40.5%±8.0%. The competing risk analysis demonstrated an actual risk of explantation owing to structural valve deterioration at 20 years of 25.5%±2.9%. The expected valve durability was 16.6 years for the entire cohort (11.4, 16.6, and 19.4 years for patients aged <60, 60 to 70, and >70 years, respectively). CONCLUSIONS With a low rate of valve-related events at 20 years and, in particular, a low rate of structural valve deterioration, the Carpentier-Edwards PERIMOUNT pericardial bioprosthesis remains a reliable choice for a mitral tissue valve, especially in patients >60 years old.

Prognostic value of CHA2DS2-VASc score in patients with ‘non-valvular atrial fibrillation’ and valvular heart disease: the Loire Valley Atrial Fibrillation Project

AIMS The CHA2DS2VASc score is a clinical risk stratification tool which estimates the risk of stroke and thromboembolism in non-valvular atrial fibrillation (AF). We aimed to establish the value of this score for risk evaluation in patients with non-valvular AF and valvular heart disease. METHODS AND RESULTS Among 8053 patients with non-valvular AF (ESC guidelines definition), patients were categorized into Group 1 (no valve disease, n = 6851; 85%) and Group 2 (valve disease with neither rheumatic mitral stenosis nor valve prothesis, n = 1202; 15%). After follow-up of 868 ± 1043 days, 627 stroke/ thromboembolic (TE) events were recorded. Group 2 was significantly older, had a higher CHA2DS2VASc score and had a higher risk of thromboembolic events [hazard ratio (HR) 1.39; 95% CI 1.14-1.69, P = 0.001] compared with Group 1. Severe valve disease was not associated with worse prognosis for stroke/TE events. In the two groups, stroke/TE risk increased with a higher CHA2DS2VASc score. Factors independently associated with increased risk of stroke/TE events were older age (HR 1.25, 95% CI 1.14-1.36 per 10-year increase, P < 0.0001) and higher CHA2DS2VASc score (HR 1.33, 95% CI 1.23-1.45, P < 0.0001). The predictive value (c-statistic) of the CHA2DS2VASc score was similar in the two groups. CONCLUSION In patients with non-valvular AF, left-sided valvular heart disease (excluding mitral stenosis and protheses) was associated with an increased risk of stroke/TE events. A higher CHA2DS2VASc score in these patients is likely to explain these results.

Very long-term outcomes of the Carpentier-Edwards Perimount aortic valve in patients aged 50–65 years

OBJECTIVES Aortic valve replacement (AVR) using a bioprosthesis remains controversial for patients aged 50-65 years. This cohort study reports the very long-term outcomes of AVR using Carpentier-Edwards Perimount pericardial bioprosthesis in this age group. METHODS From 1984 to 2008, 522 Carpentier-Edwards Perimount pericardial aortic bioprostheses were implanted in 516 patients aged 50-65 years (mean age, 60 ± 4 years; 19% female). Multiple valve replacements were excluded fro m our cohort. Baseline demographic, perioperative and follow-up data were recorded prospectively. Mean follow-up was 9 ± 6 years, for a total of 4428 valve-years. Follow-up was complete for 97% of patients included. RESULTS Operative mortality rate was 2%. One hundred and forty-six late deaths occurred for a linearized rate of 3%/valve-year. Actuarial survival rates averaged 73 ± 2, 59 ± 3 and 35 ± 5% after 10, 15 and 20 years of follow-up, respectively. Mortality rate associated with reoperation was 2%. Actuarial freedom from reoperation rates due to structural valve deterioration (SVD) at 10, 15 and 20 years was respectively of 91 ± 2, 76 ± 3 and 50 ± 6%. Competing risk analysis demonstrated an actual risk of explantation secondary to SVD at 20 years of 30 ± 3%. Expected valve durability was 19 years for this age group. Age was not a significant risk factor for SVD in this middle-aged population. CONCLUSIONS In patients aged 50-65 years undergoing AVR with the Carpentier-Edwards Perimount bioprosthesis, the expected valve durability was 19 years. Age was not a significant risk factor for SVD within this age group. Patient selection and attention to timing of reintervention may be determinants of long-term outcomes.

A 25-year experience with Carpentier-Edwards Perimount in the mitral position.

Data of 401 patients who underwent mitral valve replacement with the Carpentier-Edwards Perimount bioprosthesis between 1984 and 2009 were evaluated. Their mean age was 68.1 ± 10.4 years (range, 22–90 years) and 54.9% were female. The most common etiology was degenerative disease (33.2%) and 62.1% of patients had mitral insufficiency. Follow-up was 3,178 patient-years, and 96.8% complete; the mean follow-up was 8.9 ± 3.1 years. Overall survival at 25 years was 10.2% ± 3%. Late mortality was 2.48% per patient-year, and valve-related deaths occurred at 1.62% per patient-year. The actuarial freedom from reoperation due to structural valve deterioration at 20 years was 24.3% ± 2% for degenerative disease and 15% ± 1.4% for non-degenerative disease. For degenerative valve disease, the freedom from structural valve deterioration at 18-years was 39% ± 1% for recipients <60-years old and 66% ± 2% for those ≥60-years old. Our data confirm the excellent durability and low mortality associated with the Carpentier-Edwards Perimount for mitral valve replacement. The rate of calcification of the valve was unrelated to degenerative valve disease, but our findings suggest that this prothesis gives better results in recipients ≥60-years old than in younger patients.

CHA2DS2-VASc Score for Predicting Stroke and Thromboembolism in Patients With AF and Biological Valve Prosthesis.

Patients with valvular atrial fibrillation (AF), as defined in the 2012 European Society of Cardiology guidelines (those with a valvular prosthesis or rheumatic mitral disease) should receive anticoagulation regardless of the CHA2DS2-VASc score, with vitamin K antagonist being recommended [(1–3)][

Left retropectoral axillary implantation of defibrillators in young women.

We propose a complete surgical approach by left retropectoral transaxillary implantation with no vein puncture to improve the aesthetic and psychological tolerance of the implantable cardioverter defibrillator and avoid the pneumothorax and the subclavian crush syndrome.

0189: Identification of risk factors for embolic events in left-sided infective endocarditis

Embolic complications (EC) occur in about 30% to 40% of left-sided infective endocarditis (LSIE) and are associated with a poor prognosis. We analysed risk factors for embolic events in the systematic analysis of a large cohort of consecutive patients treated for infective endocarditis (IE). Methods 533 consecutive patients admitted for definite or probable LSIE were included in this study. Results Mean age was 64 and 26% had a prosthetic valve. The location of IE was aortic in 68%. Causative microorganisms were Streptococcaceae in 40% and Staphylococcaceae in 27%. Rate of valve surgery and mortality during the initial hospital stay were 26% and 11%, respectively. The mean follow up was 5±6 years. Embolic events occur in 164 patients (30%). In multivariate analysis, presence of vegetation was an independent risk factor for embolic event (hazard ratio HR=1.96, p Conclusions Patients with LSIE and streptococcal infection have a lower risk of embolic events than others. The presence of vegetations was independently associated with an increased risk of embolic events.

LONG-TERM OUTCOME OF A REAL LIFE POPULATION-BASED COHORT WITH INFECTIVE ENDOCARDITIS

Infective endocarditis (IE) remains a severe disease. The short-term prognosis of IE is relatively well known, but data on long term prognosis are scarce, most analysis coming from declaratives registries. There are no data on long-term prognosis of IE in real life population-based studies. We