Yankah / Bechtel / Weng Aortic Root Surgery

The Biological Solution
1. Auflage 2010
ISBN: 978-3-7985-1869-8
Verlag: Steinkopff
Format: PDF
Kopierschutz: 1 - PDF Watermark

E-Book, Englisch, 616 Seiten

The surgical treatment of the aortic valve and root disease, organic and ischemic mitral regurgitation, and endocarditis has made great strides. Still, there is the well-known dilemma: on the one hand the need for anticoagulation in patients with mechanical valves that otherwise guarantee long-term functioning and, on the other, the unpredictable durability of biological substitutes and of valve repair procedures which, per se, do not require anticoagulation. The choice of procedure is determined by factors such as patients` age, metabolic and bleeding disorders, and bleeding preconditions, as well as such critical issues as the desire to bear children in young women. In this book internationally renowned experts focus on current surgical approaches to and evolving trends in aortic valve repair, aortic root and valve replacement with pulmonary autograft, aortic allograft, stentless and stented bioprostheses. Further contributions deal with recent advances in catheter-based percutaneous and transapical techniques, ablation techniques for atrial fibrillation, tissue engineering of heart valves, multi-modality imaging, and anticoagulation.

Autoren/Hrsg.

Bechtel, Matthias

Beholz, Sven

Conradi, Lenard

Yankah, Charles Abraham

Weng, Yu-Guo

Hetzer, Roland

Inhaltsverzeichnis

1;Preface;6
2;Table of Contents ;9
3;Authors;16
4;Imagingof the aortic root;21
4.1;Perioperative imaging for assessing aortic and mitral valve diseases and surgical procedures;22
4.1.1;History;22
4.1.2;Application in cardiac surgery;23
4.1.3;Indications for iTEE;23
4.1.4;Why iTEE before cardiopulmonary bypass?;23
4.1.5;iTEE in patients undergoing mitral valve surgery;24
4.1.6;iTEE evaluation during transapical aortic valve replacement;26
4.1.7;The future;29
4.1.8;Conclusion;29
4.1.9;References;29
5;Innovations in aortic valve surgery;30
5.1;The aortic root;31
5.1.1;Introduction;31
5.1.2;The anatomic units of the aortic root;31
5.1.2.1;The aortic annulus;35
5.1.2.2;The semilunar leaflets;36
5.1.2.3;The aortic sinuses of Valsalva;36
5.1.2.4;The commissures;37
5.1.2.5;Interleaflet triangle (the trigonum);37
5.1.2.6;The sinotubular junction;37
5.1.2.7;The coronary arteries;37
5.1.3;Comments;38
5.1.3.1;Acknowledgment.;38
5.1.4;References;38
5.2;Percutaneous transluminal aortic valve replacement: The CoreValve prosthesis;40
5.2.1;History of percutaneous aortic valve replacement;40
5.2.2;Patient population;41
5.2.3;Device description and procedure;41
5.2.4;Medication;46
5.2.5;Outcomes following implantation;46
5.2.6;Conclusions;48
5.2.7;References;48
5.3;Transapical aortic valve implantation – a truly minimally invasive option for high-risk patients;50
5.3.1;Introduction;50
5.3.2;The concept of transcatheter aortic valve impIantation;50
5.3.2.1;Transcatheter aortic valve prostheses;51
5.3.3;Patient selection;52
5.3.3.1;Risk assessment;52
5.3.3.2;Anatomical considerations;52
5.3.3.3;Transapical or transfemoral AVI?;53
5.3.4;TA-AVI – setup;53
5.3.4.1;The OR;53
5.3.4.2;The team approach;54
5.3.5;TA-AVI – the procedure step by step;54
5.3.5.1;Anesthesia;54
5.3.5.2;The “safety net”;54
5.3.5.3;Sizing and valve preparation;55
5.3.5.4;Surgical access to the left ventricular apex;55
5.3.5.5;Positioning of the fluoroscopic system;55
5.3.5.6;Hemodynamic management;56
5.3.5.7;Valvuloplasty and valve deployment;56
5.3.6;How to achieve optimal outcome;59
5.3.7;Postoperative care;60
5.3.8;Current results;61
5.3.9;References;62
5.4;From minimally invasive to percutaneous aortic valve replacement;64
5.4.1;Introduction;64
5.4.2;Indications;65
5.4.3;Techniques of minimally invasive aortic valve surgery;65
5.4.4;Results after minimally invasive aortic valve surgery;66
5.4.5;Percutaneous aortic valve replacement;68
5.4.6;Results after percutaneous aortic valve replacement;70
5.4.7;Conclusions;71
5.4.8;References;72
5.5;Sutureless equine aortic valve replacement;75
5.5.1;Introduction;75
5.5.2;Operative technique;76
5.5.3;Clinical experience;79
5.5.4;Comments;79
5.5.5;References;80
6;The Ross operation: Aortic valve and root replacement with pulmonary autograft;82
6.1;Pulmonary autograft or aortic allograft for surgical treatment of activeinfective aortic valve endocarditis: a review of the literature;83
6.1.1;Results;84
6.1.1.1;The pulmonary autograft in the aortic position;84
6.1.1.2;Aortic allograft in the aortic position;85
6.1.1.3;Aortic root replacement;85
6.1.1.4;Freehand subcoronary aortic valve replacement;86
6.1.2;Comments;86
6.1.2.1;Acknowledgment.;88
6.1.3;References;88
6.2;The Ross operation: two decades of clinical experience;90
6.2.1;The German-Dutch Ross registry;92
6.2.2;Results;94
6.2.3;Discussion;97
6.2.4;Conclusions;99
6.2.5;References;100
7;Aortic valve repair and valve sparing root procedures;102
7.1;The bicuspid aortic valve;103
7.1.1;Etiology;103
7.1.2;Prevalence;104
7.1.3;Diagnosis;104
7.1.4;Classification;105
7.1.5;Complications and treatment;108
7.1.5.1;Valve-related complications;108
7.1.5.2;Aortic complications;111
7.1.6;Summary and outlook;112
7.1.7;References;112
7.2;From dynamic anatomy to conservative aortic valve surgery: the tale of the ring;116
7.2.1;Introduction;116
7.2.2;Anatomy of the aortic root;116
7.2.2.1;Descriptive anatomy;116
7.2.2.2;The aortic valve apparatus: a dynamic structure;118
7.2.2.3;Echocardiographic anatomy of the normal aortic root;120
7.2.2.4;Anatomy of dystrophic aortic roots;121
7.2.3;Surgical treatment for aortic root aneurysm;121
7.2.3.1;Composite valve and graft replacement;121
7.2.3.2;Aortic valve-sparing procedures;122
7.2.3.3;In vitro studies;123
7.2.3.4;In vivo studies;123
7.2.4;Repair of cusp prolapse and bicuspid valve;134
7.2.5;Lesional classification for aortic insufficiencies;136
7.2.6;Conservative aortic valve surgery versus valve replacement:what do we know?;136
7.2.7;Conclusions;140
7.2.8;References;140
7.3;Yacoub/David techniques for aortic root operation: success and failures;147
7.3.1;Techniques of valve-sparing aortic root replacement;147
7.3.2;Methods;148
7.3.3;Results;149
7.3.4;Discussion;152
7.3.5;Conclusions;156
7.3.6;References;156
7.4;Aortic annuloplasty;158
7.4.1;Introduction;158
7.4.2;The normal aortic annulus and root;158
7.4.3;The diseased aortic annulus and root;163
7.4.3.1;Aging;163
7.4.3.2;“Annuloaortic ectasia”/Marfan syndrome;164
7.4.3.3;Bicuspid aortic valve;165
7.4.4;Geometric mismatch without annuloplasty;166
7.4.5;Reduction aortic annuloplasty;168
7.4.5.1;Annuloplasty math;169
7.4.5.2;Suturing techniques;169
7.4.5.3;Subcommissural plication;170
7.4.5.4;Intertrigonal plication;171
7.4.5.5;Circumferential plication;172
7.4.5.6;Resection;175
7.4.5.7;External buttress;176
7.4.6;Augmentation annuloplasty;176
7.4.6.1;Aortic-mitral curtain enlargement procedures;177
7.4.6.2;Ventricular septum enlargement procedures (aortoventriculoplasty);180
7.4.7;Conclusion;184
7.4.8;References;184
7.5;Correction of aortic valve incompetence combined with ascending aortic aneurysm by relocation of the aortic valve plane through a short-length aortic graft replacement;192
7.5.1;Introduction;192
7.5.2;Pathophysiological considerations;192
7.5.3;Surgical technique;193
7.5.4;Routine investigations;195
7.5.5;Patients;195
7.5.6;Comments;196
7.5.7;References;198
7.6;Using BioGlue to achieve hemostasis in aortic root surgery;199
7.6.1;Rationale for using BioGlue;199
7.6.2;Balancing potential benefits with risks;199
7.6.3;Technical aspects of using BioGlue during aortic root repair;201
7.6.4;Summary;203
7.6.4.1;Acknowledgments.;203
7.6.5;References;203
8;Endocarditis;206
8.1;Challenges in the surgical management of infective endocarditis;207
8.1.1;Introduction;207
8.1.2;Appendix 1;208
8.1.3;Current challenges in infective endocarditis;209
8.1.3.1;Conceptual challenges;209
8.1.3.2;Timing;210
8.1.3.3;Special populations;211
8.1.3.4;Anatomical and technical issues;213
8.1.3.5;Risk stratification;215
8.1.4;Conclusions;216
8.1.5;References;216
8.2;Clinical results of the Shelhigh® stentless bioprosthesis in patients with active infective endocarditis:;222
8.2.1;Introduction;222
8.2.2;Patients and methods;223
8.2.2.1;Patient population;223
8.2.2.2;Indications for surgery and operations performed;225
8.2.2.3;Definition of active infective endocarditis;225
8.2.2.4;The Shelhigh® SuperStentless bioprosthesis;225
8.2.2.5;Statistical analysis;226
8.2.3;Results;227
8.2.3.1;Overall survival and survival in relation to surgical urgency;227
8.2.3.2;Survival in relation to valve position and comparison of single versus double valve replacement;228
8.2.3.3;Survival in relation to abscess formation;228
8.2.3.4;Reinfection after Shelhigh® implantation;229
8.2.4;Discussion;230
8.2.4.1;Survival and surgical urgency;230
8.2.4.2;Survival and abscess formation;231
8.2.4.3;Clinical results of Shelhigh® bioprostheses;231
8.2.4.4;Study limitations;232
8.2.5;Conclusions;232
8.2.5.1;Acknowledgments.;232
8.2.5.2;Conflict of interest.;232
8.2.6;References;232
8.3;Double valve endocarditis and evolving paraannular abscess formation;235
8.3.1;Introduction;235
8.3.2;Types of endocarditis;236
8.3.2.1;Native valve and prosthetic endocarditis;236
8.3.2.2;Prosthetic endocarditis;236
8.3.2.3;Simple and destructive forms of endocarditis;237
8.3.2.4;Paravalvular abscess as the main sign of the destructive form of endocarditis;238
8.3.2.5;Echocardiographic definition of abscess;239
8.3.2.6;Abscess classification according to stage of development;241
8.3.2.7;Extension of infection from the aortic area;241
8.3.2.8;Double valve disease;242
8.3.2.9;Asymptomatic destruction of the heart structures after successful medical treatment of AIE;243
8.3.2.10;Primary mitral valve endocarditis;244
8.3.2.11;Extension to the right side;245
8.3.3;Three-dimensional echocardiography;245
8.3.4;Conclusions;248
8.3.4.1;Acknowledgment.;249
8.3.5;References;249
8.4;Aortic root abscess: reconstruction of the left ventricular outflow tract and allograft aortic valve and root replacement;255
8.4.1;Introduction;255
8.4.2;Methods;256
8.4.2.1;The aortic root;259
8.4.2.2;Pre- and postoperative monitoring and diagnostics;259
8.4.2.3;Current indications for allograft valve and root replacement;261
8.4.2.4;Surgical techniques;261
8.4.2.5;Implantation techniques;263
8.4.2.6;Lower (proximal) suture line.;263
8.4.2.7;Distal suture line.;264
8.4.2.8;Freehand subcoronary aortic valve replacement;264
8.4.2.9;Data collection and postoperative follow-up;266
8.4.2.10;Statistical methods;266
8.4.3;Results;267
8.4.3.1;Hospital mortality;267
8.4.3.2;Late mortality;268
8.4.3.3;Early and late complications;269
8.4.4;Discussion;275
8.4.5;Inferences;280
8.4.6;Recommendations for cardiologists, surgeons, and patients;280
8.4.7;Conclusions;281
8.4.7.1;Acknowledgments.;281
8.4.8;References;281
8.5;Implantation techniques of freehand subcoronary aortic valve and root replacement with a cryopreserved allograft for aortic root abscess;286
8.5.1;Historical background;286
8.5.2;Surgical management of aortic root abscess;286
8.5.3;Debridement and local disinfection of the aortic root;287
8.5.4;Pericardial reconstruction of the left ventricular outflow tract;287
8.5.5;Aortic root replacement and reimplantation of the coronary arteries;290
8.5.6;Freehand subcoronary aortic valve replacement;292
8.5.7;Comments;294
8.5.8;References;298
9;Surgery for atrial fibrillation;300
9.1;Cryoablation for the treatment of atrial fibrillation in patients undergoing minimally invasive mitral valve surgery;301
9.1.1;Introduction;301
9.1.2;Surgical treatment options;301
9.1.3;Minimal invasive MV surgery and cryoablation: current methods and results at the Leipzig Heart Center;304
9.1.3.1;Surgical technique and perioperative management;304
9.1.3.2;Results – perioperative;306
9.1.3.3;Long-term results;307
9.1.3.4;Comment;308
9.1.4;References;310
9.2;Minimally invasive endoscopic ablation on the beating heart in patients with lone atrial fibrillation;312
9.2.1;Treatment of atrial fibrillation;313
9.2.2;Current surgical ablation practice;313
9.2.3;Totally endoscopic ablation;314
9.2.3.1;Surgical procedure;316
9.2.3.2;Ablation;317
9.2.4;Postoperative management;319
9.2.4.1;Follow-up;319
9.2.5;Future role of surgical ablation therapy for lone atrial fibrillation;320
9.2.6;References;320
10;Hemodynamice valuation of the bioprosthetic aortic valves;321
10.1;Evaluation of bioprosthetic valve performance as a function of geometric orifice area and space efficiency –;322
10.1.1;Introduction;322
10.1.2;The common approach to bioprosthetic valve evaluation;322
10.1.2.1;Effective orifice area;323
10.1.2.2;Patient-prosthesis mismatch and effective orifice area index;325
10.1.3;Geometric orifice area – a valid alternative;327
10.1.4;Comparison of seven commercially available bioprosthetic valves on the basis of geometric orifice area and space efficiency;328
10.1.4.1;Materials and methods;328
10.1.5;Results;332
10.1.5.1;Geometric orifice areas;332
10.1.5.2;Space efficiency;336
10.1.5.3;An additional observation – leaflet flutter;339
10.1.6;Discussion;341
10.1.7;Study limitations;344
10.1.8;Conclusions;345
10.1.9;References;345
11;Long-term results of biological valves;347
11.1;Stentless bioprostheses;348
11.2;Stented and stentless aortic bioprostheses: competitive or complimentary?;348
11.2.1;References;351
11.3;Edwards Prima Plus Stentless Bioprosthesis: long-term clinical and hemodynamic results;353
11.3.1;Introduction;353
11.3.2;Materials and methods;353
11.3.2.1;Clinical data – patients;353
11.3.2.2;Surgical technique and medical management;354
11.3.2.3;Follow-up;354
11.3.2.4;Statistical analysis;355
11.3.3;Results;356
11.3.3.1;Operative data;356
11.3.3.2;Survival;356
11.3.3.3;Late adverse events (Table 3);357
11.3.3.4;Embolic events.;358
11.3.3.5;Endocarditis.;358
11.3.3.6;Valve reoperation.;358
11.3.3.7;Late New York Heart Association functional classification.;358
11.3.3.8;Hemodynamic data.;359
11.3.4;Discussion;359
11.3.5;References;361
11.4;The Cryo-Life O’Brien stentless valve: 1991–2008;363
11.4.1;The study valve;363
11.4.1.1;Patients;363
11.4.1.2;Operative technique;364
11.4.1.3;Results with the original valve manufactured at the Cryo-Life facility;365
11.4.1.4;Patient survival;365
11.4.1.5;Late mortality;365
11.4.1.6;Valve-related complications (Table 3);366
11.4.1.7;Nonstructural dysfunction.;366
11.4.1.8;Valve thrombosis;367
11.4.1.9;Hemorrhagic and embolic complications.;367
11.4.1.10;Operated valvular endocarditis.;367
11.4.1.11;Structural valve deterioration.;367
11.4.1.12;Reoperations.;368
11.4.1.13;Hemodynamic data;368
11.4.2;Results with the second-generation valve manufactured at the Labcor facility in Brazil and sterilized at Cryo-Life;369
11.4.3;Comment;369
11.4.4;Conclusion;371
11.4.5;References;372
11.5;Medtronic stentless Freestyle® porcine aortic valve replacement;373
11.5.1;Introduction: stentless biological valves;373
11.5.2;The Freestyle® bioprosthesis: surgical technique;374
11.5.2.1;Subcoronary technique;374
11.5.2.2;Total root technique;375
11.5.3;The Freestyle® bioprosthesis: hemodynamic outcome;376
11.5.3.1;Decrease in gradients postoperatively;376
11.5.3.2;Valve prosthesis-patient mismatch;376
11.5.3.3;Technical issues of subcoronary technique and the impact of the surgeons on hemodynamic outcome;377
11.5.3.4;Subcoronary versus total root implantation technique *;382
11.5.4;The Freestyle® bioprosthesis: valve related morbidity and mortality *;385
11.5.5;The Freestyle® bioprosthesis: special indications;387
11.5.5.1;Concomitant replacement of the ascending aorta;387
11.5.5.2;Octogenarians;388
11.5.5.3;Young patients;389
11.5.6;References;389
11.6;The ATS 3 f Aortic Bioprosthesis;393
11.6.1;Introduction;393
11.6.2;Development and preclinical evaluation of the ATS 3 f Aortic Bioprosthesis;395
11.6.2.1;The choice of equine pericardium;395
11.6.2.2;Transvalvular flow dynamics;395
11.6.2.3;Stress distribution on the valve leaflets;396
11.6.2.4;In vitro hemodynamic performance;396
11.6.2.5;In vitro durability tests;398
11.6.3;Clinical performance and results;400
11.6.3.1;Clinical hemodynamic performance;400
11.6.3.2;Clinical flow dynamics and aortic root preservation;400
11.6.4;Summary;401
11.6.5;References;402
11.7;The Vascutek Elan stentless porcine prosthesis – the Glasgow experience;403
11.7.1;Introduction;403
11.7.2;Materials and methods;404
11.7.2.1;Study population;404
11.7.2.2;Echocardiography;404
11.7.2.3;Surgical technique;405
11.7.2.4;Statistical analysis;406
11.7.3;Results;406
11.7.4;Discussion;409
11.7.5;Limitations of the study;411
11.7.6;Conclusions;411
11.7.7;References;411
11.8;Sorin pericardial valves Operative technique and early results of biological valves;413
11.8.1;Introduction;413
11.8.2;Material and methods;414
11.8.2.1;Operative technique Freedom;415
11.8.2.2;Operative technique Solo;416
11.8.3;Results;419
11.8.4;Discussion;421
11.8.5;References;422
12;Stented bioprostheses;424
12.1;The changing role of pericardial tissue in biological valve surgery: 22 years’ experience with the Sorin Mitroflow stented pericardial valve;424
12.1.1;Background;424
12.1.2;Patients and methods;425
12.1.3;Aortic root disease and morphology;427
12.1.4;Design and characteristics of the Mitroflow pericardial bioprosthesis;427
12.1.5;Surgical procedure;428
12.1.6;Follow-up;429
12.1.7;Postoperative anticoagulation;431
12.1.8;Statistical analysis;433
12.1.9;Results;433
12.1.9.1;Early mortality;433
12.1.9.2;Long-term survival;433
12.1.9.3;Postoperative hemodynamic profile;435
12.1.9.4;Reoperation;436
12.1.9.5;Structural valve deterioration;436
12.1.9.6;Nonstructural valve deterioration;439
12.1.9.7;Prosthetic valve endocarditis;440
12.1.9.8;Hemorrhage;440
12.1.9.9;Thromboebolism;441
12.1.10;Discussion;441
12.1.10.1;Inferences;444
12.1.11;Conclusion;444
12.1.11.1;Acknowledgments.;444
12.1.12;References;444
12.2;20 years’ durability of Carpentier-Edwards Perimount stented pericardial aortic valve;448
12.2.1;Clinical material and methods;448
12.2.1.1;Patients;448
12.2.1.2;Surgical technique;449
12.2.1.3;Anticoagulation;449
12.2.1.4;Follow-up;449
12.2.1.5;Data analysis;450
12.2.2;Results;450
12.2.2.1;Follow-up;450
12.2.2.2;Patient survival;450
12.2.2.3;Clinical status;451
12.2.2.4;Valve-related complications;451
12.2.2.5;Valve-related death;451
12.2.2.6;Thromboembolism;452
12.2.2.7;Bleeding events;452
12.2.2.8;Endocarditis;452
12.2.2.9;Hemolysis;452
12.2.2.10;Reoperation;452
12.2.2.11;Structural valve deterioration;453
12.2.2.12;Hemodynamics;454
12.2.2.13;Discussion;454
12.2.3;References;457
12.3;Twenty-year experience with the St. Jude Medical Biocor bioprosthesis in the aortic position;459
12.3.1;Material and methods;459
12.3.1.1;Patients;459
12.3.1.2;Follow-up;459
12.3.1.3;Valve selection;460
12.3.1.4;Operative techniques;460
12.3.1.5;Anticoagulation management;460
12.3.1.6;Outcomes;460
12.3.1.7;Statistical analysis;460
12.3.2;Results;461
12.3.2.1;Patient population;461
12.3.2.2;Patient survival;461
12.3.2.3;Hemorrhage;462
12.3.2.4;Endocarditis;462
12.3.2.5;Structural valve deterioration;462
12.3.2.6;Nonstructural valve dysfunction;463
12.3.2.7;Reoperation;463
12.3.2.8;Thromboembolism;463
12.3.3;Comment;464
12.3.3.1;Survival;464
12.3.3.2;Valve-related mortality;465
12.3.3.3;Reoperation;465
12.3.3.4;Structural valve deterioration;465
12.3.3.5;Reoperations due to SVD;466
12.3.3.6;Hemorrhage;466
12.3.3.7;Other complications;466
12.3.3.8;Influence of patient age on outcome;467
12.3.3.9;Limitations of the study;467
12.3.4;Conclusion;467
12.3.4.1;Acknowledgments.;468
12.3.5;References;468
12.4;20-Year durability of bioprostheses in the aortic position;470
12.4.1;References;476
12.5;Clinical results including hemodynamic performance of the Medtronic Mosaic porcine bioprosthesis up to ten years *;477
12.5.1;Patients and methods;478
12.5.1.1;Patient population and study design;478
12.5.1.2;Surgical technique;480
12.5.1.3;Postoperative anticoagulation;480
12.5.1.4;Follow-up;480
12.5.1.5;Statistical analysis;480
12.5.2;Results;481
12.5.2.1;Echocadiography;481
12.5.2.2;Cardiac rhythm;482
12.5.2.3;Adverse events;483
12.5.2.4;Structural valve deterioration (SVD);485
12.5.2.5;Thrombosed valves;485
12.5.2.6;Thromboembolism;486
12.5.2.7;Bleeding;486
12.5.2.8;Paravalvular leak;487
12.5.2.9;Prosthesis mismatch;487
12.5.2.10;Endocarditis;487
12.5.2.11;Explants;487
12.5.2.12;Mortality;488
12.5.3;Discussion;489
12.5.4;Conclusion;491
12.5.5;References;492
12.6;Aortic root replacement with the BioValsalva prosthesis;494
12.6.1;Introduction;494
12.6.2;The BioValsalva conduit;494
12.6.3;Clinical experience;496
12.6.3.1;Patients’ characteristics;496
12.6.3.2;Operative technique;496
12.6.4;Results;498
12.6.4.1;Inhospital outcomes;498
12.6.4.2;Hemodynamic characteristics and follow-up;501
12.6.5;Discussion;501
12.6.6;Conclusions;503
12.6.6.1;Disclosures and freedom of investigation.;503
12.6.7;References;503
12.7;Valve replacement in renal dialysis patients: bioprostheses versus mechanical prostheses;505
12.7.1;References;509
12.8;Replacement of bioprostheses after structural valve deterioration;510
12.8.1;Introduction;510
12.8.2;Methods;511
12.8.3;Operation technique;514
12.8.3.1;Preoperative imaging;514
12.8.3.2;Reentry sternotomy;515
12.8.3.3;Statistical analysis;515
12.8.4;Results;516
12.8.4.1;Valve re-replacement with a second;516
12.8.4.2;Valve re-replacement with mechanical prosthesis after bioprosthetic structural valve deterioration;516
12.8.4.3;Hospital survival;517
12.8.4.4;Hospital mortality by period: 2002–2007.;517
12.8.4.5;Hospital mortality by period: 1986–2007.;517
12.8.4.6;Long-term survival;518
12.8.5;Comments;519
12.8.6;Conclusions;523
12.8.6.1;Acknowledgments.;524
12.8.7;References;524
13;Predictors of patient’s outcome;527
13.1;Predicted outcomes after aortic valve replacement in octogenarians with aortic stenosis;528
13.1.1;Introduction;528
13.1.2;Methods;528
13.1.2.1;Study patients;528
13.1.2.2;Statistics;529
13.1.3;Results;530
13.1.4;Discussion;532
13.1.5;Conclusion;533
13.1.6;References;534
13.2;Predicted patient outcome after bioprosthetic AVR and the Ross operation;535
13.2.1;Determinants of survival after AVR;535
13.2.2;Predicted patient outcome after AVR;537
13.2.2.1;Stented bioprostheses;538
13.2.2.2;Stentless bioprostheses;538
13.2.2.3;Allografts;539
13.2.3;Predicted patient outcome after the Ross operation in young adults;540
13.2.4;Summary and conclusions;541
13.2.5;References;542
14;Anticoagulation;544
14.1;Anticoagulation and self-management of INR: mid-term results;545
14.1.1;Anticoagulation and general complications;545
14.1.2;Patient autonomy;546
14.1.3;Self-management;547
14.1.4;Telemedical monitoring;548
14.1.5;Low-dose anticoagulation;549
14.1.6;Conclusion;552
14.1.7;References;552
15;Tissue engineering;553
15.1;Biomatrix-polymer hybrid material for heart valve tissue engineering;554
15.1.1;Heart valve tissue engineering;554
15.1.2;Hybrid tissue fabrication;555
15.1.2.1;Decellularization process;555
15.1.2.2;Polymer coating;556
15.1.3;In vitro testing of hybrid valve tissue;557
15.1.3.1;Toxicity and cell proliferation;557
15.1.3.2;Hemocompatibility;558
15.1.4;Mechanical tissue properties;558
15.1.4.1;Suture retention strength;559
15.1.4.2;Leaflet testing;559
15.1.4.3;Valve testing;560
15.1.5;In vivo biocompatibility testing;561
15.1.6;Large animal testing;562
15.1.7;Interpretation;563
15.1.8;References;564
15.2;Standards for the in vitro fabrication of heart valves using human umbilical cord cells;567
15.2.1;Background;567
15.2.2;Scaffold materials;568
15.2.2.1;Natural scaffolds;568
15.2.2.2;Biological scaffolds;568
15.2.2.3;Synthetic scaffolds;569
15.2.3;Cell sources;570
15.2.4;Cell seeding and in vitro conditioning;571
15.2.5;Conclusion and perspectives;573
15.2.6;References;574
15.3;Tissue engineering with a decellularized valve matrix;577
15.3.1;References;581
16;Regularatory issues on tissue valves;582
16.1;Human tissues for cardiovascular surgery: regulatory requirements;583
16.1.1;Introduction;583
16.1.2;United States;583
16.1.3;European Union;585
16.1.4;Decellularized cardiac tissues;587
16.1.5;References;588
16.2;Concluding remarks;590
16.2.1;Conclusion;591
16.2.2;Acknowledgments;592
17;Atlas of biological valves;593
18;Subject index;601