Failure of Hancock xenograft valve: importance of valve position (4- to 9-year follow-up)

To evaluate long-term durability of Hancock valves, we reviewed our results in 107 hospital survivors (120 valves) who were operated on during 1974 through mid-1979. Mitral valve replacement was done in 63 patients, aortic valve replacement in 20, and mitral valve replacement combined with other procedures in 24. The 7-year survival was 84 +/- 4% (standard error of the mean) for 91 patients and 97 valves. During a follow-up of 590 patient-years, 15 (12 mitral and 3 aortic) of 120 valves at risk (87 mitral, 32 aortic, 1 tricuspid) were removed from 14 patients. Six valves (3 mitral and 3 aortic) were removed because of bacterial endocarditis. One mitral valve was removed because of thromboembolism. Eight mitral valves were removed because of valve structural failure, which occurred at a mean follow-up of 42 months. These valves showed extensive calcification, leaflet perforation, or cusp tear. Structural failure was unrelated to valve size, year of implantation, or valve shelf-life. Structural failure was not seen after aortic valve replacement. Results show that structural failure of the Hancock xenograft valve in the mitral position is related primarily to valve position. After aortic valve replacement, valve failure is predominantly due to endocarditis. Although medium-term (mean, 6-year) durability of this xenograft valve compares satisfactorily with prosthetic valves, its high failure rate in the mitral position indicates the necessity for improvement in valve mounting, design, and preservation.     

Late results after Starr-Edwards valve replacement in children

Selection of types of prosthetic heart valves for children remains controversial. The case histories of 50 children surviving valve replacement with Starr-Edwards prostheses between 1963 and 1978 were reviewed to evaluate the long-term performance of mechanical valves. The 31 boys and 19 girls ranged from 6 months to 18 years in age (mean 10.4 years); 19 patients had had aortic valve replacement, 24 patients had had mitral valve replacement, and one patient had had both. Among the six patients who had had tricuspid valve replacement, four had corrected transposition, so that the tricuspid valve was the systemic atrioventricular valve. Mean (+/- standard deviation) follow-up interval was 7.9 +/- 4.9 years (maximum 17 years). For all patients, the 5 year survival rate was 86% +/- 6%. At 10 years postoperatively, the survival rate (+/- standard error) was 90% +/- 7% after aortic valve replacement and 76% +/- 8% after systemic atrioventricular valve replacement. At follow-up, 39 patients were alive, and 38 were in New York Heart Association Class I or II. Of the 11 deaths, four were valve-related. Seven patients had major (requiring hospitalization) thromboembolic events, and five patients had minor transient neurological symptoms suggesting thromboembolism; 50% of these patients were not taking warfarin (Coumadin) at the time of the thromboembolic event. The incidence of late (greater than 30 days) thromboembolism was 5.3 per 100 patient-years after aortic and 2.0 per 100 patient-years after systemic atrioventricular valve replacement. At 10 years postoperatively, 66% +/- 15% of patients who had had aortic valve replacement and 91% +/- 6% of those who had had systemic atrioventricular valve replacement were free of thromboembolism. The excellent long-term survival, absence of mechanical failure, and relatively low rate of thromboembolism with this prosthesis contrast with our experience with biological valves, in which 41% of children required reoperation in 5 years. Currently, mechanical valves, such as the Starr-Edwards prostheses, are our preferred valves for pediatric patients.     

Twenty-year comparison of tissue and mechanical valve replacement

OBJECTIVE: We sought to compare outcomes with tissue and St Jude Medical mechanical valves over a 20-year period. METHODS: Valve-related events and overall survival were analyzed in 2533 patients 18 years of age or older undergoing initial aortic, mitral, or combined aortic and mitral (double) valve replacement with a tissue valve (Hancock, Carpentier-Edwards porcine, or Carpentier-Edwards pericardial) or a St Jude Medical mechanical valve. Total follow-up was 13,390 patient-years. There were 666 St Jude Medical aortic valve replacements, 723 tissue aortic valve replacements, 513 St Jude Medical mitral valve replacements, 402 tissue mitral valve replacements, 161 St Jude Medical double valve replacements, and 68 tissue double valve replacements. The mean age was 68 +/- 13.3 years (St Jude Medical valve, 64.5 +/- 12.9; tissue valve, 72.0 +/- 12.6). RESULTS: There were no overall differences in survival between tissue and mechanical valves. Multivariable analysis indicated that the type of valve did not affect survival. Analysis by age less than 65 years or 65 years or older and presence or absence of coronary disease revealed similar long-term survival in all subgroups. The risk of hemorrhage was lower in patients receiving tissue aortic valve replacements but was not significantly different in patients receiving mitral valve or double valve replacements. Thromboembolism rates were similar for tissue and mechanical valve recipients. However, reoperation rates were significantly higher in patients receiving both aortic and mitral tissue valves. The reoperation hazard increased progressively with time both in patients receiving aortic and in those receiving mitral tissue valves. Overall valve complications were initially higher with mechanical aortic valves but not with mechanical mitral valves. However, valve complication rates later crossed over, with higher rates in tissue valve recipients after 7 years in patients undergoing mitral valve replacement and 10 years in those undergoing aortic valve replacement. CONCLUSIONS: Tissue and mechanical valve recipients have similar survival over 20 years of follow-up. The primary tradeoff is an increased risk of hemorrhage in patients receiving mechanical aortic valve replacements and an increased risk of late reoperation in all patients receiving tissue valve replacements. The risk of tissue valve reoperation increases progressively with time.     

Long-term assessment of aortic valve replacement with autologous pulmonary valve

Two hundred two autologous pulmonary valves were transplanted into the aortic position between 1967 and 1982 at the National Heart Hospital in London. The indication for operation was congenital or acquired aortic valve disease, and the patients were followed for periods from 1 to 4 years. The patients were not anti-coagulated, but the entire series has been completely free from thromboembolism or bleeding. The actuarial prediction of freedom from valve-related deaths was 82 +/- 6% at the end of the fourteenth year after operation; deaths were due to reoperations for technical failure and to infective endocarditis. Event-free survival of the autologous pulmonary valve in the aortic position was 73 +/- 6% after 14 years at risk. Valve failure resulted mainly from technical problems encountered during the early years of surgical experience. There was no macroscopic or histological evidence of calcification in any of the failed valves. The right ventricular outflow was reconstructed with an aortic homograft in the majority of patients; 81 +/- 5% of these homografts demonstrated event-free performance over a 12-year follow-up period. It is concluded that the long-term performance of a pulmonary autograft inserted for aortic valve disease is superior to that of any other valve substitute and that the operation offers an almost ideal means of aortic valve replacement in appropriate patients.     

Clinical experience with omniscience and omnicarbon prosthetic heart valves

Omniscience valves were implanted in sixty-two patients. Twenty-eight of these patients underwent aortic valve replacement (AVR), 15 had mitral valve replacement (MVR) and 8 had aortic and mitral valve replacement (DVR). Post-operative events occurred in nine (5.9%/patient year) of the AVR group, in three (1.7%/patient year) of the MVR group and in three (5.4%/patient year) of the DVR group. The actuarial freedom from all events at five years in the AVR, MVR and DVR was 74 +/- 8%, 88 +/- 6%, 67 +/- 16%, respectively. Cardiac death occurred in four (2.5%/patient year) of the AVR, one (0.6%/patient year) of the MVR and two (3.6%/patient year) of the DVR. The freedom at five years in the AVR, MVR and DVR was 88 +/- 6%, 96 +/- 4%, and 77 +/- 14%, respectively. Valve-related complications were noted in four patients. Post-operative cerebral hemorrhage was seen in three of the AVR. Maximum opening angle of the Omniscience valve was 39.1 +/- 4.5 degrees at the aortic position and 44.6 +/- 9.7 degrees at the mitral position. Omnicarbon valves implanted in ninety-five patients, fifty-eight of these patients underwent AVR, 24 had MVR and 13 had DVR. Events occurred post-operatively in four (2.6%/patient year) of the AVR group, in three (12.2%/patient year) of the MVR group, but in none of the DVR group. The freedom at five years was 89 +/- 6% in the AVR and 84 +/- 8% at three years in the MVR. Post-operative cardiac death occurred in one (0.7%/patient year) of the AVR and in two (8.1%/patient year) of the MVR.(ABSTRACT TRUNCATED AT 250 WORDS)     

Aortic valve replacement with the freestyle stentless bioprosthesis with respect to spacial orientation of patient coronary ostia

OBJECTIVE: This study evaluates our results for safety and efficacy of aortic valve replacement using the Freestyle bioprosthesis (Medtronic, Inc, Minneapolis, Minn) with a new modified subcoronary implantation technique. This technique takes into account the spacial orientation of the stentless bioprosthesis in the aortic root with respect to the patient's coronary ostia rather than the native commissures. METHODS: Fifty-two consecutive patients with predominant aortic valve stenosis underwent aortic valve replacement with a Freestyle bioprosthesis by means of the described modified subcoronary technique over a 15-month period. Fifty of them were followed up by means of echocardiography at discharge, 6 months, and 1 year. There were 19 men and 31 women, with a mean age of 76 +/- 7 years (range, 58-87 years). Valve size ranged from 21 to 27 mm. RESULTS: Patients with bicuspid aortic valves had a significantly larger angle between both coronary ostia than patients with tricuspid aortic valves (P =.0001). The peak and mean systolic gradients decreased significantly during the first postoperative year for each valve size (P 相似文献   

Evaluation of kangaroo aortic valved conduits in a juvenile sheep model: preliminary findings

BACKGROUND: Biological heart valve substitutes, manufactured from either porcine or bovine tissue, have been in use for more than 30 years. Despite low thrombogenicity and excellent performance, bioprosthetic heart valves tend to degenerate and calcify early in young patients because of patient and valve related factors. The aim of this study was to examine the calcification behavior of glutaraldehyde-preserved kangaroo heart valves in a juvenile sheep model. METHODS: Porcine (n = 10) and kangaroo (n = 10) valved conduits were implanted in the descending aortic position of juvenile sheep and retrieved after 6, 8, and 12 months. Retrieved valved conduits were examined for morphological changes and calcification of the valve tissue, using Von Kossa's stain technique and atomic absorption spectrophotometry. RESULTS: Structural valve deterioration, characterized by increased stiffness and severe calcification, occurred in 100% of the porcine conduits within 4 months. Kangaroo valve leaflets were significantly (p < 0.001) less calcified at 6 months (3.39+/-1.80 microg/mg), 8 months (5.86+/-4.57 microg/mg), and at 12 months (14.38+/-6.72 microg/mg), compared to porcine valves at 3 months (176.45+/-42.88 microg/mg ) and at 4 months (154.67+/-52.67 microg/mg ). Porcine aortic wall tissue was more calcified (118.24+/-42.86 microg/mg) than kangaroo aortic wall tissue (79.55+/-26.40 microg/mg). CONCLUSIONS: Kangaroo heart valves calcify less than porcine heart valves. These findings suggest that a different donor valve tissue has a lower calcification potential probably due to a difference in the morphological ultrastructure. This could result in improved long-term durability of kangaroo heart valves.     

Comparison of long-term results of Carpentier-Edwards and Hancock bioprosthetic valves

The long-term survival following valve replacement with Carpentier-Edwards or Hancock bioprostheses was compared between the two valve models and between the two groups totaling 407 patients who were discharged after valve replacement beginning in 1974. The two groups of patients were treated in a nonrandomized fashion. The actuarial survival for 299 patients with Carpentier-Edwards valves was 94 +/- 1.5% (+/- standard error) and 93 +/- 1.7% after 5 and 8 years of follow-up, respectively. Comparable figures for 108 patients undergoing valve replacement with Hancock valves were 89 +/- 3.0% and 83 +/- 3.7%, respectively (p = not significant [NS]). The probability of freedom from death and valve removal after 5 and 8 years of follow-up was 91 +/- 1.8% and 79 +/- 4.6%, respectively, with the Carpentier-Edwards valve and 84 +/- 3.5% and 75 +/- 4.3%, respectively, with the Hancock valve (p = NS). An accelerated rate of attrition for both valves was observed in the mitral position. There were no significant differences in actuarial survival between the two valves in the mitral or the aortic position or in the incidence of major valve-related complications.     

Three-dimensional in vivo characterization of calcification in native valves and in Freestyle versus homograft aortic valves

OBJECTIVE: This article describes a novel interactive method for quantitative evaluation of calcium deposits in the aortic valve by means of electron beam tomography data fusion technique. METHODS: The technique relied on the use of hierarchic 3-dimensional free-form volume registration with fast global optimization between normally acquired and contrast-enhanced electron beam tomographic volume. A total of 66 contrast-enhanced electron beam tomographic scans of the aortic root were performed in 27 patients, 10 with native aortic valve disease (group A) and 17 from a prospective randomized trial of aortic root replacement (group B, 9 Freestyle grafts [Medtronic, Inc, Minneapolis, Minn] and 8 homografts). To validate the in vivo electron beam tomographic measurements, 5 patients from group A underwent electron beam tomographic scans before the operation and then had their own valves, explanted at the time of surgery, analyzed for calcium quantification by ex vivo electron beam tomography. RESULTS: In group A, the mean (+/- SE) calcification score was 6560 +/- 2388, which correlated with peak gradients measured at echocardiography ( r = 0.93, P = .02). In group B, the mean (+/- SE) calcification score was 168 +/- 27, showing a tendency toward a lower calcification for Freestyle valves than for homografts at 2 years after implantation ( P = .052). A mean variability of 6% was found between in vivo electron beam tomographic scores of calcification and those measured on valve specimens after explantation. CONCLUSION: We describe a novel method to characterize the degree and location of calcification in both native valves and postoperative valve implants. The technique may be useful in the management of patients with aortic valve disease and has potential as a screening tool for high-risk patients to diagnose early valve calcification and possibly institute corrective measures.     

Kangaroo versus freestyle stentless bioprostheses in a juvenile sheep model: hemodynamic performance and calcification behavior

BACKGROUND: Glutaraldehyde-preserved bioprosthetic heart valve substitutes have limited performance and longevity due to tissue degeneration and calcification. The Freestyle valve (Medtronic Heart Valves, Inc, Minneapolis, MN) combines zero fixation pressure and proportional, variant-amino oleic acid (AOA) as antidegeneration and antimineralization measures. The aim of this study was to compare the calcification behavior of glutaraldehyde-preserved kangaroo aortic valves with Freestyle stentless bioprostheses in a juvenile sheep model. METHODS: Pulmonary artery and valve replacements were performed in juvenile sheep with Freestyle stentless aortic valves (n = 4) or glutaraldehyde-preserved kangaroo stentless aortic valves with no antimineralization measures (n = 6), and explanted at 200 postoperative days. RESULTS: Freestyle stentless valves and stentless kangaroo aortic valves showed normal valve function immediately postoperatively and up to 120 days. Valve leaflets of all valves were macroscopically free of visible calcification with normal histology. Valve leaflet calcification (microg Ca/mg tissue) was less in kangaroo than Freestyle (1.27 +/- 0.43 versus 2.38 +/- 1.37, p = 0.856). Aortic wall tissue calcification was severe in kangaroo and Freestyle (127.93 +/- 12.22 versus 122.19 +/- 11.99, p = 0.596). CONCLUSIONS: We conclude that glutaraldehyde-preserved kangaroo aortic valve leaflets are equal to AOA-treated Freestyle stentless valve leaflets with regard to calcification in juvenile sheep. Both bioprostheses are prone to aortic wall calcification. The low calcification features of the kangaroo aortic valve leaflets without antimineralization treatment may benefit the longevity of the valve.     

Long-term performance of the Hancock porcine bioprosthesis in the tricuspid position. A review of forty-five patients with fourteen-year follow-up

Because little information is available regarding the clinical performance of the Hancock porcine bioprosthesis (Johnson & Johnson Cardiovascular, King of Prussia, Pa.) implanted in the tricuspid position, we reviewed the long-term follow-up of patients who had tricuspid valve replacement with this device. From March 1970 to December 1983, 45 patients had tricuspid valve replacement, either isolated (seven patients) or combined with replacement of other valves (38 patients) by means of a standard, glutaraldehyde-preserved Hancock porcine bioprosthesis. Follow-up ranged from 0.2 to 14.7 years (mean, 7.6 +/- 3.6 years) and was complete. The late mortality rate was 6.6% +/- 1.6%/pt-yr and the actuarial survival rate at 14 years was 23% +/- 9%. Reoperation because of structural deterioration of the tricuspid, the mitral, or both bioprostheses was performed in nine patients (3.7% +/- 1.2%/pt-yr) from 40 to 177 months (mean, 112 +/- 43 months) and resulted in no deaths. Actuarial freedom from structural deterioration of a Hancock tricuspid porcine bioprosthesis at 14 years is 68% +/- 13%. Morphologic examination of explanted porcine bioprostheses showed that those implanted in the tricuspid position had lower degrees of calcification and less severe structural changes than those simultaneously explanted from the mitral position. We conclude that the Hancock porcine bioprosthesis has an acceptable long-term durability and satisfactory performance after tricuspid valve replacement, and we continue to favor its use in the tricuspid position even in association with mechanical prostheses in the left side of the heart.     

A five-year appraisal and hemodynamic evaluation of the Bj?rk-Shiley Monostrut valve

Two hundred forty-four Bj?rk-Shiley Monostrut valves were implanted in 225 consecutive patients from October 1983 to December 1988. Aortic valve replacement was performed in 90 patients, mitral valve replacement in 118, and double valve replacement in 16 patients. One patient had tricuspid valve replacement. There were 100 female patients and 125 male patients with a mean age of 54 years (range 2 to 71 years). Present data were completely available for all patients. The cumulative follow-up was 541 patient-years with a mean of 2 years, 5 months. The closing date for follow-up was July 1989, and the closing interval was 2 months. The early mortality rate was 3.1%, and the late mortality rate, 3.1%. The 5-year survival rate was 88% +/- 2.0%: 87% +/- 3.0% for aortic valve replacement, 91% +/- 3.3% for mitral valve replacement, and 75% +/- 9.6% for double valve replacement. The actuarial rates of freedom from thromboembolism at 5 years were 93% +/- 3.2% for aortic, 96% +/- 1.4% for mitral, and 94% +/- 6.1% for double valve replacement. There were no instances of structural valve deterioration. Actuarial rate of freedom from valve-related morbidity and mortality was 86% +/- 2.0% at 5 years: 86% +/- 9.5% for aortic, 87% +/- 3.3% for mitral, and 75% +/- 7.3% for double valve replacement. Effective valve areas (average) of 12 mitral and 12 aortic valve prostheses were calculated at rest and during bicycle exercise: 2.4 cm2 at rest and 2.8 cm2 during exercise in 27 mm aortic valves, 2.4 cm2 at rest and 3.0 cm2 during exercise in 25 mm aortic valves, 2.0 cm2 at rest and 2.4 cm2 during exercise in 27 mm mitral valves, and 2.6 cm2 at rest and 2.5 cm2 during exercise in 29 mm mitral valve. On the basis of our follow-up period of 5 years, we have judged the Bj?rk-Shiley Monostrut valve reliable, with a low incidence of valve-related morbidity and with acceptably satisfactory hemodynamic characteristics at rest and during exercise.     

Porcine versus pericardial bioprostheses: a comparison of late results in 1,593 patients

From 1976 to 1988, 1,593 patients underwent valve replacement with a porcine (878 patients) or a pericardial bioprosthesis (715 patients). There were 701 aortic, 678 mitral, and 214 multiple-valve replacements. Follow-up was obtained for 1,559 patients (98%). Early mortality was 9% (79 patients) in the porcine valve group and 5% (37 patients) among patients with a pericardial valve (p less than 0.01). Late survival after replacement with porcine valves was 80% +/- 1% and 62% +/- 3% at 5 and 10 years, respectively. With pericardial valves, 5-year survival was 79% +/- 2%. Among valve-related complications, rates of freedom from thromboembolism, endocarditis, and hemorrhage after 6 years were similar for both valve groups. Freedom from reoperation at 6 years was also similar after aortic (96% versus 91%) or multiple-valve replacement (95% versus 88%). However, for mitral valve replacement, freedom from reoperation was significantly better with porcine valves than with pericardial valves at 6 years (92% versus 68%; p less than 0.001). This difference was mainly due to the Ionescu-Shiley valve, which accounted for 83% of primary tissue failures among pericardial bioprostheses implanted in the mitral position (10/12 patients). After 6 years, freedom from primary tissue failure of mitral valves was 92% +/- 2% with porcine and 70% +/- 11% with pericardial bioprostheses (p less than 0.0001). The degree of clinical improvement among survivors was similar with both valve types. Thus, in the aortic position, pericardial valves compare with porcine valves up to 6 years, whereas in the mitral position, the durability of the former is significantly less, mainly because of the suboptimal performance of the Ionescu-Shiley pericardial bioprosthesis.     

Congenital quadricuspid aortic valve: report of nine surgical cases.

We report the clinicopathologic characteristics of the congenital quadricuspid aortic valve necessitating surgery. Among 616 patients for whom we performed an aortic valve operation over the past 20 years, nine patients (1.46%) (five men and four women, mean age 60 years) with quadricuspid aortic valve were encountered. All had aortic regurgitation (AR) except one with aortic stenosis and mild regurgitation (ASr). All were free of cardiac anomaly including that of the coronary arterial system. Macroscopically, severe calcification of the valve was seen in the one case of ASr. Fenestration of the cusp was seen in five cases of AR. Infective endocarditis was not seen. Histological study disclosed fibrous thickening and myxoid degeneration in the AR cases. In accordance with the Hurwitz and Roberts classification, four valves were type b (three equal-sized cusps and one smaller cusp), two valves were type a (four equal-sized cusps), two valves were type d (one large, two intermediate, and one small cusp), and one valve was type g (four unequal-sized cusps). Valve repair failed in one patient and was converted to valve replacement during the operation. All patients underwent successful aortic valve replacement (AVR).     

More than ten years' follow-up of the Hancock porcine bioprosthesis in Japan.

From February 1975 through October 1981, 256 Hancock porcine bioprostheses (Johnson & Johnson Cardiovascular, King of Prussia, Pa.) (60 aortic, 169 mitral, and 27 pulmonary/tricuspid position) were implanted in 220 patients (104 male and 116 female, aged 9 to 67 years; mean 43.3) at Kyushu University Hospital in Japan. The procedures include 41 aortic valve replacements, 121 mitral valve replacements, 4 pulmonary valve replacements, 6 tricuspid valve replacements, and 48 combined valve replacements (31 aortic plus mitral, 13 mitral plus tricuspid, and 4 aortic plus mitral plus tricuspid). Hospital mortality was 6.4%. Follow-up was 98% during 8 to 14 (mean 10.5) years. Cumulative follow-up was 1836 patient-years and 2078 valve-years. At 10 years the overall actuarial survival rate, including hospital morality, was 70% +/- 3%, and freedom from valve-related mortality with sudden death was 87% +/- 3%. More than half of the current survivors required no anticoagulant therapy. Freedom from thromboembolism or anticoagulant-related hemorrhage (or both) and prosthetic valve endocarditis was common. Freedom from structural valve failure and reoperation declined more than 9 years after replacement of left-sided heart valves but not after replacement of right-sided heart valves. Sixty-seven patients underwent 68 repeat operations, and there were four deaths (5.9%). The rate of freedom from overall valve-related complications at 10 years was 62% +/- 8% for aortic valve replacement, 53% +/- 5% for mitral valve replacement, 80% +/- 13% for pulmonary/tricuspid valve replacement, and 42% +/- 9% for combined valve replacement. There was a significant difference between pulmonary/tricuspid valve replacement and combined valve replacement (p less than 0.05). The Hancock bioprosthesis is suitable for the replacement of valves in the right side of the heart but not for combined valve replacement.     

Should the ascending aorta be replaced more frequently in patients with bicuspid aortic valve disease?

OBJECTIVE: The optimal diameter at which replacement of the ascending aorta should be performed in patients with bicuspid aortic valve disease is not known. METHODS: We reviewed all patients with bicuspid aortic valves undergoing aortic valve replacement at our institution from 1979 through 1993 (n = 201). Patients undergoing concomitant replacement of the ascending aorta were excluded. RESULTS: Follow-up was obtained on 98% of patients and was 10.3 +/- 3.8 (mean +/- SD) years. The average patient age was 56 +/- 15 years, and 76% were male. The ascending aorta was normal (<4.0 cm) in 115 (57%) patients, mildly dilated (4.0-4.4 cm) in 64 (32%) patients, and moderately dilated (4.5-4.9 cm) in 22 (11%) patients. All patients with bicuspid aortic valves with marked dilation (>5.0 cm) underwent replacement of the ascending aorta and were therefore excluded. Fifteen-year survival was 67%. During follow-up, 44 patients required reoperation, predominantly for aortic valve prosthesis failure. Twenty-two patients had long-term complications related to the ascending aorta: 18 required an operative procedure to replace the ascending aorta (for aortic aneurysm), 1 had aortic dissection, and 3 experienced sudden cardiac death. Fifteen-year freedom from ascending aorta-related complications was 86%, 81%, and 43% in patients with an aortic diameter of less than 4.0 cm, 4.0 to 4.4 cm, and 4.5 to 4.9 cm, respectively ( P < .001). CONCLUSIONS: Patients undergoing operations for bicuspid aortic valve disease should be considered for concomitant replacement of the ascending aorta if the diameter is 4.5 cm or greater.     

Valve-related complications with the Hancock I porcine bioprosthesis. A twelve- to fourteen-year follow-up study

Valve-related morbidity and mortality after heart valve replacement with the Hancock I porcine bioprosthesis has been retrospectively analyzed. From June 1974 through December 1976, 253 Hancock I bioprostheses (150 mitral and 103 aortic) were inserted in 220 selected patients who survived the operation and had follow-up until June 1989 (mean follow-up 13.5 years, with an accumulative follow-up of 2956.4 patient-years). One hundred seventeen patients had mitral valve replacement, 70 had aortic valve replacement, and 33 had combined mitral and aortic valve replacement. There were 27 thromboembolic events. The probability of being free from thromboembolism at 14 years was 81.0% +/- 7.4% for the mitral valve replacement group, 85.4% +/- 6.7% for the aortic group, and 67.1% +/- 18.4% for the mitral-aortic group. Fifteen episodes of prosthetic valve endocarditis occurred. There were 10 instances of nonstructural dysfunction (paravalvular leaks) in seven mitral valves (4.6%) and in three aortic valves (2.9%). One hundred twenty-two bioprostheses in 106 patients resulted in structural deterioration. The probability of freedom from structural deterioration at 14 years was 37.2% +/- 3.9% for the mitral group, 43.9% +/- 7.1% for the aortic group, and 30.1% +/- 8.9% for the mitral-aortic group. The logistic regression analysis between age at the time of operation and bioprosthetic life (structural deterioration-free period) demonstrates a linear regression curve (r = 0.53). There were 56 late deaths (27 patients died at reoperation). The actuarial survival rate (including hospital mortality) at 14 years was 57.2% +/- 5.4% for the entire series, with no statistically significant difference between groups. The probability of remaining free from valve-related morbidity and mortality at 14 years was 16.7% +/- 4.8% for the mitral group, 20.8% +/- 6.2% for the aortic group, and 14.0% +/- 7.0% for the mitral-aortic group. The long-term results of this series show that the clinical performance of the Hancock I porcine valve appears satisfactory during the first 6 years. The behavior of this bioprosthesis at 14 years' follow-up changes drastically, because only a minor group of patients is free from valve-related complications, justifying the restriction of its use for selected patients.     

Relation of calcification to torn leaflets of spontaneously degenerated porcine bioprosthetic valves

The gross appearance of 54 spontaneously degenerated porcine bioprosthetic valves was evaluated to determine the relation of calcium deposition to cusp disruption. Tears or perforations were shown in 89% (48) of the degenerated valves. The most common site of tears or perforations was near the commissural attachment (60% of all tears). Grossly visible deposits of calcium salts that ruptured to the surface of the cusps or caused changes in the topography were observed in 70% (38) of the 54 valves. Calcification was adjacent to tears or perforations in 56% (27) of the 48 valves with torn cusps. Among the valves that showed calcification, the deposits of calcium salts were adjacent to tears or perforations in 71% (27 of 38). The location of deposits of calcium did not relate to the age or sex of the patient or to the position of the valve, but valves with calcium were inserted longer than valves with no calcium (87 +/- 4 versus 58 +/- 7 months; p less than 0.001). The outflow surfaces showed more calcification than the inflow surfaces, irrespective of whether the valves were in the aortic or mitral position. Among the 38 valves with calcification, 92% (35) showed calcification at the commissural attachments, 53% (20) showed calcification in the body of 1 or more cusps, 11% (4) near the base, and 8% (3) near the free edge. In conclusion, most patients with spontaneous porcine valve degeneration showed calcification. The calcification was associated with tears or perforations of the cusps in 50% of all degenerated valves, in 56% of valves with torn cusps, and in 71% of valves that showed gross calcification.     

Neurocognitive deficit following aortic valve replacement with biological/mechanical prosthesis.

OBJECTIVE: The aim of this study was to objectively measure neurocognitive deficit following aortic valve replacement with a mechanical or biological prosthesis. MATERIALS AND METHODS: In this prospective, contemporary study we followed 82 consecutive patients undergoing isolated aortic valve replacement with either a mechanical (n=29, mean age=52+/-7 years) or a biological (n=53, mean age=68+/-10 years) valve prosthesis. Neurocognitive function was measured by means of objective P300 auditory evoked potentials (peak latencies, ms) and two standard psychometric tests (Trailmaking Test A, Mini Mental State Examination) before the operation, 7 days and 4 months after the operation, respectively. RESULTS: Since P300 peak latencies increase with age, preoperative P300 measures are lower in patients receiving mechanical valves (360+/-35 ms, mean 52 years) as compared to patients receiving biological valves (381+/-34 ms, 68 years, P=0.0001). Seven days after surgery, P300 peak latencies were prolonged (-worsened) in both groups as compared to preoperative values (mechanical valves: 384+/-36 ms; P=0.0001 and biological valves: 409+/-39 ms; P=0.0001). Although on a different level (-age-related), this development was comparable within both groups (P=0.800). Four months after surgery, P300 peak latencies normalized in the mechanical valve group (372+/-27 ms, P=0.857 versus preoperative), while in contrast in the biological valve group they remained prolonged (417+/-37 ms, P=0.0001). We found no difference within patients receiving different types of biological or mechanical aortic valves. CONCLUSION: Postoperative neurocognitive damage is not reversible in (-elderly) patients with biological aortic valve replacement, while in contrast postoperative neurocognitive damage is reversible in (-younger) patients with mechanical valve replacement. For this contrary development, age seems to be most important, whereas damage related to type of valve prosthesis may be overestimated.     

Cardiac valve replacement in the elderly]

From January 1980 through December 1990, seventy one consecutive patients over 60 years of age (mean age 64 +/- 4 years) and 231 patients younger than 60 years underwent cardiac valve replacement procedures. In the elderly group, aortic valve replacement was performed in nineteen patients, mitral valve replacement in thirty-three patients both aortic and mitral valve replacement in sixteen patients, and both mitral and tricuspid valve replacement in three patients. Aortocoronary bypass was performed in four and tricuspid annuloplasty in 19 patients simultaneously. Two patients were operated on emergency. As for preoperative status, 63 patients (88.7%) were in New York Heart Association (NYHA) Functional Class III or IV. Mechanical valves were implanted in all aortic position and 16 mitral position. Bioprosthetic valves were placed in 34 mitral position and 3 tricuspid position. Mean follow-up period was 42 +/- 33 months. The early mortality rate was 11% (8 patients) and the actuarial survival rate was 88 +/- 5% at five years and 74 +/- 10% at ten years. Postoperative functional improvement was excellent in 85.7% of the survivors. In the younger age group, 77.9% belonged to NYHA class III or IV preoperatively. The early mortality was 3.0% (7 patients) and the actuarial survival rate was 95 +/- 2% at five years and 86 +/- 2% at ten years. And postoperatively 91.3% were in NYHA class I or II. In conclusion, cardiac valve replacement in the elderly can be performed with an acceptable mortality and excellent functional improvement.