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Frontiers in Cardiovascular Medicine 2018Heart valves are dynamic, highly organized structures required for unidirectional blood flow through the heart. Over an average lifetime, the valve leaflets or cusps... (Review)
Review
Heart valves are dynamic, highly organized structures required for unidirectional blood flow through the heart. Over an average lifetime, the valve leaflets or cusps open and close over a billion times, however in over 5 million Americans, leaflet function fails due to biomechanical insufficiency in response to wear-and-tear or pathological stimulus. Calcific aortic valve disease (CAVD) is the most common valve pathology and leads to stiffening of the cusp and narrowing of the aortic orifice leading to stenosis and insufficiency. At the cellular level, CAVD is characterized by valve endothelial cell dysfunction and osteoblast-like differentiation of valve interstitial cells. These processes are associated with dysregulation of several molecular pathways important for valve development including Notch, Sox9, Tgfβ, Bmp, Wnt, as well as additional epigenetic regulators. In this review, we discuss the multifactorial mechanisms that contribute to CAVD pathogenesis and the potential of targeting these for the development of novel, alternative therapeutics beyond surgical intervention.
PubMed: 30460247
DOI: 10.3389/fcvm.2018.00162 -
Vascular Health and Risk Management 2011Although porcine aortic valves or pericardial tissue mounted on a stent have made implantation techniques easier, these valves sacrifice orifice area and increase stress... (Review)
Review
Although porcine aortic valves or pericardial tissue mounted on a stent have made implantation techniques easier, these valves sacrifice orifice area and increase stress at the attachment of the stent, which causes primary tissue failure. Optimizing hemodynamics to prevent patient-prosthetic mismatch and improve durability, stentless bioprostheses use was revived in the early 1990s. The purpose of this review is to provide a current overview of stentless valves in the aortic position. Retrospective and prospective randomized controlled studies showed similar operative mortality and morbidity in stented and stentless aortic valve replacement (AVR), though stentless AVR required longer cross-clamp and cardiopulmonary bypass time. Several cohort studies showed improved survival after stentless AVR, probably due to better hemodynamic performance and earlier left ventricular (LV) mass regression compared with stented AVR. However, there was a bias of operation age and nonrandomization. A randomized trial supported an improved 8-year survival of patients with the Freestyle or Toronto valves compared with Carpentier-Edwards porcine valves. On the contrary, another randomized study did not show improved clinical outcomes up to 12 years. Freedom from reoperation at 12 years in Toronto stentless porcine valves ranged from 69% to 75%, which is much lower than for Carpentier-Edwards Perimount valves. Cusp tear with consequent aortic regurgitation was the most common cause of structural valve deterioration. Cryolife O'Brien valves also have shorter durability compared with stent valves. Actuarial freedom from reoperation was 44% at 10 years. Early prosthetic valve failure was also reported in patients who underwent root replacement with Shelhigh stentless composite grafts. There was no level I or IIa evidence of more effective orifice area, mean pressure gradient, LV mass regression, surgical risk, durability, and late outcomes in stentless bioprostheses. There is no general recommendation to prefer stentless bioprostheses in all patients. For new-generation pericardial stentless valves, follow-up over 15 years is necessary to compare the excellent results of stented valves such as the Carpentier-Edwards Perimount and Hancock II valves.
Topics: Aortic Valve; Bioprosthesis; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Hemodynamics; Humans; Patient Selection; Practice Guidelines as Topic; Prosthesis Design; Time Factors; Treatment Outcome
PubMed: 21731886
DOI: 10.2147/VHRM.S11253 -
Interactive Cardiovascular and Thoracic... Oct 2021We herein report a case of early cusp tear of the second-generation Trifecta valve with Glide Technology. A 69-year-old woman underwent aortic valve replacement with a...
We herein report a case of early cusp tear of the second-generation Trifecta valve with Glide Technology. A 69-year-old woman underwent aortic valve replacement with a Trifecta valve with Glide Technology and partial arch replacement for severe aortic valve stenosis caused by a bicuspid valve and ascending aortic and aortic arch aneurysms 2 years previously. During follow-up, she suddenly developed dyspnoea and a heart murmur. Echocardiography revealed severe aortic valve regurgitation caused by structural valve deterioration. We performed re-aortic valve replacement with a mechanical valve through re-median sternotomy. Intraoperative examination revealed a bottom tear of the left coronary cusp without infection or pannus formation.
Topics: Aged; Aortic Valve; Aortic Valve Insufficiency; Aortic Valve Stenosis; Bioprosthesis; Female; Heart Valve Prosthesis; Humans; Technology
PubMed: 34000015
DOI: 10.1093/icvts/ivab141 -
Journal of Thoracic Disease May 2021Porcine valves are used for mitral valve replacement, but the limited long-term durability has restricted the application in younger patients. Degenerated porcine mitral...
BACKGROUND
Porcine valves are used for mitral valve replacement, but the limited long-term durability has restricted the application in younger patients. Degenerated porcine mitral valves were explanted to analyze the failure modes and damage characteristics.
METHODS
Twelve porcine valves were explanted via secondary mitral valve replacement surgery. Microcomputed tomography scanning, morphological and pathological examinations were performed to classify the cusp tears, calcification, and pannus formation. The causes of valve deterioration were subsequently analyzed.
RESULTS
The mean age at first implantation was 45.42±19.58 years (range, 11-64 years). The mean duration of implantation was 9.39±4.14 years (range, 4.25-18.75 years). The indications for first surgery were rheumatic heart disease in 8 patients (66.67%), infective endocarditis in 2 patients (16.67%), degenerative valvular disease in one patient (8.33%), and congenital heart disease in one patient (8.33%). Type I cusp tears and commissural dehiscence that occurred near the stent post position were found in 6 (50%) and 5 (41.67%) valves, respectively. Calcification was detected in 6 (50%) cases, and pannus was found in most valves (91.67%).
CONCLUSIONS
Leaflet damage occurred near the stent posts area was the main failure mode of porcine mitral valves in this study. Patients who undergo the first surgery at younger age, the higher prevalence rate of rheumatic heart disease, the structure of bioprosthetic porcine valve, and left ventricular stresses could be considered as the main factors causing valve deterioration.
PubMed: 34164177
DOI: 10.21037/jtd-20-3578 -
The Journal of Thoracic and... Jun 2018We had previously reported the short-term results of the aortic valve neocuspidization (AVNeo) procedure. We have now evaluated the midterm results with the longest...
OBJECTIVE
We had previously reported the short-term results of the aortic valve neocuspidization (AVNeo) procedure. We have now evaluated the midterm results with the longest follow-up of 118 months.
METHODS
From April 2007 through December 2015, 850 patients were treated with AVNeo using autologous pericardium. Medical records of these patients were retrospectively reviewed. The procedure was on the basis of independent tricuspid replacement using autologous pericardium. The distances between the commissures were measured with an original sizing device, the pericardial cusp was trimmed using an original template, and then sutured to the annulus.
RESULTS
There were 534 patients with aortic stenosis, 254 with aortic regurgitation, 61 with aortic stenoregurgitation, 19 with infective endocarditis, and 5 with a previous aortic valve procedure. Besides 596 patients with tricuspid aortic valve, 224 patients had bicuspid valve, 28 had unicuspid valve, and 2 had quadricuspid valve. There were 444 male and 406 female patients. The median age was 71 (range, 13-90) years old. Preoperative echocardiography revealed a peak pressure gradient average of 68.9 ± 36.3 mm Hg with aortic stenosis. Surgical annular diameter was 20.9 ± 3.3 mm. There was no conversion to a prosthetic valve replacement. There were 16 in-hospital mortalities. Postoperative echocardiography revealed a peak pressure gradient average of 19.5 ± 10.3 mm Hg 1 week after surgery and 15.2 ± 6.3 mm Hg 8 years after surgery. Fifteen patients needed reoperation (13 infective endocarditis, 1 break of thread, and 1 tear of cusp case). The mean follow-up period was 53.7 ± 28.2 months. Actuarial freedom from death, cumulative incidence of reoperation, and that of recurrent moderate aortic regurgitation or greater was 85.9%, 4.2%, and 7.3%, respectively, with the longest follow-up of 118 months.
CONCLUSIONS
The midterm outcomes of AVNeo using autologous pericardium were satisfactory in 850 patients with various aortic valve diseases. However, further randomized, multicenter prospective studies are needed to confirm the results of the current study.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Animals; Aortic Valve; Cattle; Female; Glutaral; Heart Valve Diseases; Heart Valve Prosthesis Implantation; Heterografts; Horses; Humans; Kaplan-Meier Estimate; Male; Middle Aged; Pericardium; Retrospective Studies; Treatment Outcome; Young Adult
PubMed: 29567131
DOI: 10.1016/j.jtcvs.2018.01.087 -
Annals of Thoracic and Cardiovascular... Jun 2017Trifecta is a stented bioprosthetic heart valve with a bovine pericardial sheet externally mounted on a titanium stent. This valve is applied only for aortic valve... (Review)
Review
Trifecta is a stented bioprosthetic heart valve with a bovine pericardial sheet externally mounted on a titanium stent. This valve is applied only for aortic valve replacement (AVR), providing excellent hemodynamics and extremely low incidence of structural valve deterioration (SVD). A 76-year-old woman presented with dyspnea on effort 24 months after AVR with a 21-mm Trifecta valve. Echocardiography revealed severe aortic regurgitation with prolapse of a cusp of Trifecta valve, which suggested that she developed acute heart failure due to early SVD. In the operation, Trifecta valve had a cusp tear near the commissure with circumferential fibrous pannus ingrowth only at the inflow side. There was neither calcification nor infection. The Trifecta valve was successfully replaced with a new porcine bioprosthesis.
Topics: Aged; Aortic Valve; Aortic Valve Insufficiency; Bioprosthesis; Device Removal; Echocardiography, Doppler, Color; Female; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Prosthesis Design; Prosthesis Failure; Severity of Illness Index; Time Factors; Treatment Outcome
PubMed: 27980283
DOI: 10.5761/atcs.cr.16-00183 -
The Journal of Cardiovascular Surgery Oct 2004Pericardial valve bioprostheses were introduced in early 1970s and were widely used in the 1980s. The longterm results with the Ionescu-Shiley valve, the first... (Comparative Study)
Comparative Study Review
Pericardial valve bioprostheses were introduced in early 1970s and were widely used in the 1980s. The longterm results with the Ionescu-Shiley valve, the first commercially available pericardial valve, were disappointing because of high rate cusp tears during the first decade after implantation. The enthusiasm for this type of bioprosthetic valve was further hampered by the premature failure of the Hancock pericardial valve. The long-term results of aortic valve replacement with the Carpentier-Edwards pericardial valve, which was introduced in 1981, indicated that that valve was durable and the issue of cusp tears had been resolved by an appropriate design. This knowledge prompted surgeons to revisit the merits of pericardial valves for mitral valve replacement and several other pericardial valves are now commercially available. The largest data on long-term results are with the Carpentier-Edwards pericardial mitral valve. The reported freedom from structure valve failure ranged from 69% to 85% at 10 years in patient population with mean age of 60 to 70 years. Young age is a major determinant of valve failure, which is largely due to calcification. There are also long-term data, albeit more limited on the Sorin Pericarbon and Mitroflow valves used for mitral valve replacement. This paper review the published experience with various pericardial bioprosthetic valves used for mitral valve replacement during the past 3 decades.
Topics: Adult; Aged; Bioprosthesis; Echocardiography, Doppler; Female; Follow-Up Studies; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Male; Middle Aged; Mitral Valve Insufficiency; Mitral Valve Stenosis; Pericardium; Prosthesis Design; Prosthesis Failure; Risk Assessment; Severity of Illness Index; Time Factors; Treatment Outcome
PubMed: 15736567
DOI: No ID Found -
The Annals of Thoracic Surgery Aug 1995We studied the aortic root (wall, semilunar cusp, septal myocardium) in 37 patients (29 male and 8 female; mean age; 41 years) who died 2 to 4,380 days (mean, 398 days)...
We studied the aortic root (wall, semilunar cusp, septal myocardium) in 37 patients (29 male and 8 female; mean age; 41 years) who died 2 to 4,380 days (mean, 398 days) after heart (n = 34) and heart-lung (n = 3) transplantation. The aim of the study was to assess tissue viability, graft-host biological interaction, and cusp mineralization with time. Study methods included gross inspection and photos of each specimen, microradiography, histology and immunohistochemistry, scanning and transmission electron microscopy, and atomic absorption spectroscopy. There were no cases of valve dysfunction; in particular, cusp tears or perforations never occurred. Only 1 valve, in place for 12 years, had a pin-point calcification visible to the naked eye. Optimal preservation of the tissue components (endothelium, fibroblasts, collagen and elastic fibers, proteoglycans, intrinsic nervous ganglia) was observed at both short and long term. Concomitant acute rejection of valve leaflets and myocardium was seen in 7, mild valve thickening in 14, myxoid degeneration in 4, and graft aortic atherosclerosis in 26. Mineralization was negligible and was not progressive with time. No linear correlation was found between mineralization and number of acute rejections. In conclusion, we observed optimal cusp viability and integrity even at long term, concomitant valve and myocardium rejection with no valvular sequelae, and negligible, non-progressive cusp calcification. Donor-recipient blood group matching, heart-beating donor, and chronic immunosuppression are the reasonable explanations of the optimal durability of the aortic valve after heart transplantation.
Topics: Adult; Aorta; Aortic Valve; Female; Graft Rejection; Heart Transplantation; Heart-Lung Transplantation; Humans; Male; Radiography; Spectrophotometry, Atomic; Tissue Survival
PubMed: 7646145
DOI: 10.1016/0003-4975(95)00251-f -
Journal of Cardiothoracic Surgery Jul 2022Several studies have reported high rates of structural valve deterioration (SVD) in the Trifecta valves. Herein, we analyzed the midterm results of the Trifecta valve...
BACKGROUND
Several studies have reported high rates of structural valve deterioration (SVD) in the Trifecta valves. Herein, we analyzed the midterm results of the Trifecta valve and risk factors for early SVD.
METHODS
We retrospectively reviewed the records of 110 patients who had undergone Trifecta implantation between January 2012 and December 2017.
RESULTS
We encountered seven cases of Trifecta valve failure. We performed a redo aortic valve replacement in five patients and a transcatheter aortic valve replacement in two patients. The SVD rate was 4.8% at 5 years and 6.6% at 7 years. The mean pressure gradient and peak velocity on the first postoperative echocardiogram in patients with SVD were higher than those in patients without SVD. The SVD rates with and without patient-prosthesis mismatch (PPM) were 2.8% and 12.6% at 5 years and 2.8% and 20.0% at 7 years. PPM is a risk factor for SVD. Noncoronary cusp tears were observed in all patients who had undergone redo surgery.
CONCLUSIONS
The most common cause of SVD was noncoronary cusp tear. Patients with PPM are at high risk of developing SVD.
Topics: Aortic Valve; Aortic Valve Stenosis; Bioprosthesis; Heart Valve Diseases; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation; Humans; Prosthesis Design; Prosthesis Failure; Retrospective Studies; Risk Factors
PubMed: 35804395
DOI: 10.1186/s13019-022-01918-3 -
Case Reports in Cardiology 2015Left coronary cusp perforation is an extremely rare consequence of blunt chest trauma. A 22-year-old male presented after a motor vehicle accident with dyspnea....
Left coronary cusp perforation is an extremely rare consequence of blunt chest trauma. A 22-year-old male presented after a motor vehicle accident with dyspnea. Transthoracic echocardiogram (TTE) and transesophageal echocardiogram (TEE) showed moderate to severe aortic regurgitation with prolapsing right coronary cusp. In the operating room he was found to have a left coronary cusp tear near the annulus and an enlarged right cusp. The patient recovered well after successful aortic valve replacement with a mechanical valve. Traumatic aortic regurgitation with left cusp perforation is serious and surgical intervention may be lifesaving if performed timely.
PubMed: 25802765
DOI: 10.1155/2015/235629