Structural abnormalities after aortic root replacement with stentless xenograft

• Published in: The Journal of thoracic and cardiovascular surgery Vol. 165; no. 4; pp. 1285 - 1297.e6
• Main Authors: Dagnegård, Hanna Sofia Holmgren, Sigvardsen, Per Ejlstrup, Ihlemann, Nikolaj, Kofoed, Klaus Fuglsang, El-Hamamsy, Ismail, Bekke, Kirstine, Valentin, Jan Brink, Lefebvre, Laurence, Johnsen, Søren Paaske, Søndergaard, Lars, Lund, Jens Teglgaard, Smerup, Morten Holdgaard
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.04.2023
• Subjects: Aged; Animals; aortic root replacement; Aortic Valve - diagnostic imaging; Aortic Valve - surgery; Bioprosthesis; coronary ostial stenosis; Cross-Sectional Studies; Follow-Up Studies; Heart Valve Prosthesis; Heart Valve Prosthesis Implantation - adverse effects; Heterografts; Humans; leaflet abnormalities; Myocardial Infarction - surgery; Prosthesis Design; pseudoaneurysm; reimplanted coronaries; stentless Freestyle bioprosthesis; Swine; Treatment Outcome; TTE; CI; pseudoaneurysm; HR; IQR; aortic root replacement; coronary ostial stenosis; leaflet abnormalities; MHI; CT; stentless Freestyle bioprosthesis; RH; 4DCT; reimplanted coronaries
• ISSN: 0022-5223; 1097-685X
• DOI: 10.1016/j.jtcvs.2021.04.087

In complex and high-risk aortic root disease, the porcine Freestyle stentless bioprosthesis (Medtronic Inc, Minneapolis, Minn) is an important surgical treatment option. We aimed to determine prevalence and clinical effect of structural and functional abnormalities after full-root Freestyle implantation. Our cross-sectional 2-center study combined with clinical follow-up included 253 patients with full-root Freestyle bioprostheses implanted from 1999 to 2017. Patients underwent transthoracic echocardiography (TTE) and contrast-enhanced, electrocardiogram-gated 4-dimensional cardiac computed tomography (4DCT) at median age 70 (interquartile range, 62-75) years. After 4DCT, clinical follow-up continued throughout 2018. Median follow-up was 3.3 years before 4DCT and 1.4 years after. We identified abnormalities in 46% of patients, including pseudoaneurysms (n = 32; 13%), moderate or severe coronary ostial stenosis (n = 54; 21%), and moderate-severe leaflet thickening or reduced leaflet motion (n = 51; 20%). TTE only identified 1 patient with pseudoaneurysm. After 4DCT, the unadjusted hazard ratio for surgical reintervention among patients with abnormal 4DCT was 4.2 (95% confidence interval, 1.2-15.3), in all, 10% required a reintervention. 4DCT abnormalities were associated with a statistically nonsignificant increased risk of death, stroke, or myocardial infarction (hazard ratio obtained using Cox proportional hazards regression analysis, 2.4; 95% confidence interval, 0.7-7.6). In all, 4.0% died, 3.6% had a myocardial infarction, and 2.0% had a stroke. Structural and functional abnormalities of the aortic root are frequent after Freestyle implantation and TTE appears to be insufficient for follow-up. Abnormalities might be associated with increased risk of reintervention and potentially adverse clinical outcomes. Longer follow-up and larger study populations are needed to further clarify the clinical implications of abnormalities identified with 4DCT. This study comprised a cross-sectional analysis of 253 survivors after full root Freestyle (Medtronic Inc, Minneapolis, Minn) implantation in 2 institutions. Study participants were examined using contrast enhanced, electrocardiogram-gated 4-dimensional cardiac computed tomography (4DCT) with the purpose of identifying structural abnormalities. Pseudoaneurysms, significant ostial coronary stenoses, or leaflet abnormalities (hypoattenuated leaflet thickness or reduced leaflet motion) were found in 46% and were not seen on transthoracic echocardiography. The abnormalities might require reintervention, which is why the authors recommend serial follow-up after aortic root replacement with cardiac computed tomography (CT) or magnetic resonance imaging (MRI) in addition to echocardiography. PA, Pulmonary artery; LM, left main coronary artery; LVOT, left ventricular outflow tract; PV, pulmonary valve. [Display omitted]