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We performed a nationwide population-based cohort study to investigate sex differences in the rate of permanent pacemaker implantation after surgical aortic valve replacement (AVR).This study included all adult patients who underwent primary AVR in Sweden between 2005 and 2018. Study data were obtained from the Swedish Web system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies (SWEDEHEART) registry and other Swedish national health-data registers. The rate of permanent pacemaker implantation within 30 days of surgery AVR was compared between men and women. We estimated propensity scores that were used for inverse probability of treatment weighting to account for sex differences in patient characteristics.A total of 18 131 patients were included, 11 657 men (64%) and 6474 women (36%). The rate of permanent pacemaker implantation did not differ between women (3.8%; 95% CI, 3.2%-4.3%) and men (3.7%; 95% CI, 3.3%-4.1%; P = .831). In patients aged60 years, the rate of permanent pacemaker implantation was significantly higher in women (6.2%; 95% CI, 4.3%-8.0%) than in men (3.6%; 95% CI, 2.8%-4.4%; P = .006). The odds of pacemaker implantation in patients aged60 years was significantly higher in women (odds ratio, 1.76; 95% CI, 1.17-2.63; P = .006). In patients aged 60 to 79 years and ≥80 years, the rate of pacemaker implantation did not differ between men and women.The rate of permanent pacemaker implantation after surgical AVR in patients aged60 years was higher in women than in men. The susceptibility to conduction disturbances requiring permanent pacemaker implantation in women aged60 years warrants further investigation and should be recognized as transcatheter aortic valve replacement expands into younger patients.

Objectives This study was performed to investigate long-term, clinically important outcomes in patients who underwent permanent pacemaker implantation after transcatheter aortic valve repl...

BACKGROUND Few studies have analyzed outcomes after surgery for endocarditis in intravenous drug users (IVDUs). The aim of this study was to compare survival after surgery for endocarditis in IVDUs versus non-IVDUs. Secondary outcomes were the rates of reoperation, reinfection, and relapse to drug use. METHODS This population-based, observational cohort study included all patients who had undergone surgery for endocarditis at Karolinska University Hospital between 2002 and 2019. Patient data were collected from the institutional surgical database and medical charts. We used multivariable Cox regression to analyze associations between intravenous drug use and long-term survival. RESULTS Of the 510 study patients, 55 were IVDUs (11%) and 455 were not (89%). During a mean follow-up of 5.3 years (maximum, 17.1 years), 30 IVDUs (55%) and 133 non-IVDUs (29%) died. The 30-day mortality was 10.9% and 8.5%, respectively, for IVDUs and non-IVDUs (P = .53). Survival in IVDUs versus non-IVDUs at 1, 5, and 8 years was 76% versus 86%, 49% versus 76%, and 35% versus 68%, respectively (adjusted hazard ratio = 4.12; 95% confidence interval, 2.54-6.68; P < .001). The risk for reoperation was higher in IVDUs (adjusted hazard ratio = 3.47; 95% confidence interval, 1.74-6.89; P < .001). Forty-two IVDUs died or were reinfected (76%) and 49 died or returned to drug use (89%). CONCLUSIONS After surgery for endocarditis, IVDUs had substantially higher mortality and reoperation rates than did non-IVDUs. However, postoperative survival was comparable between groups, indicating that IVDUs manage surgery well. Prevention of relapse to drug use is of utmost importance in these patients.

ObjectivesThe objective of this cohort study was to analyse long-term relative survival in patients with bicuspid aortic valve (BAV) who underwent aortic valve surgery.MethodsWe studied 865 patients with BAVs who participated in three prospective cohort studies of elective, open-heart, aortic valve surgery at the Karolinska University Hospital, Stockholm, Sweden, between 2007 and 2020. The expected survival for the age, sex and calendar year-matched general Swedish population was obtained from the Human Mortality Database. The Ederer II method was used to calculate relative survival, which was used as an estimate of cause-specific survival.ResultsNo differences were found in the observed versus expected survival at 1, 5, 10 or 12 years: 99%, 94%, 83% and 76% vs 99%, 93%, 84% and 80%, respectively. The relative survival at 1, 5, 10 and 12 years was 100% (95% CI 99% to 100%), 101% (95% CI 99% to 103%), 99% (95% CI 95% to 103%) and 95% (95% CI 87% to 102%), respectively. The relative survival at the end of follow-up tended to be lower for women than men (86% vs 95%). The mean follow-up was 6.3 years (maximum 13.3 years).ConclusionsThe survival of patients with BAV following aortic valve surgery was excellent and similar to that of the general population. Our results suggest that the timing of surgery according to current guidelines is correct and provide robust long-term survival rates, as well as important information about the natural history of BAV in patients following aortic valve surgery.

The objective of this study is to investigate clinical outcomes in patients with bicuspid aortic valves (BAV) after surgical treatment for endocarditis.This was a population-based, observational cohort study, conducted on all patients who received aortic valve surgery for native or prosthetic valve endocarditis at Karolinska University Hospital between 2002-2020. Baseline characteristics and postoperative complications were collected from the institutional surgical database and patient medical charts. The primary endpoint was all-cause mortality. We used unadjusted and adjusted Cox regression to determine the association between valve morphology and long-term mortality.Of the 338 patients, 122 (36%) had a BAV and 216 (64%) had a tricuspid aortic valve (TAV). The mean follow-up was 5.8 years (maximum 18.4 years). Survival rates at one, five, ten and 14 years were 88%, 81%, 78% and 76% versus 85%, 69%, 58% and 43%, in BAV and TAV patients, respectively [adjusted hazard ratio (HR) 0.64; 95% confidence interval (CI): 0.39-1.05]. In patients with native valve endocarditis, those with BAV had lower all-cause mortality compared to those with TAV (adjusted HR 0.44; 95% CI: 0.22-0.89), despite having a higher prevalence of perivalvular abscess (40% versus 22%, respectively, in BAV and TAV patients). In patients with prosthetic valve endocarditis, original valve morphology did not affect all-cause mortality (adjusted HR 1.94; 95% CI: 0.64-5.87).In patients with native valve endocarditis, a BAV was associated with improved survival after surgical treatment. In patients with prosthetic valve endocarditis, survival was not affected by the original valve morphology of the patient.

Background Prior studies showed that life expectancy in patients who underwent surgical aortic valve replacement (AVR) was lower than in the general population. Explanations for this shorter life expectancy are unknown. The aim of this nationwide, observational cohort study was to investigate the cause‐specific death following surgical AVR. Methods and Results We included 33 018 patients who underwent primary surgical AVR in Sweden between 1997 and 2018, with or without coronary artery bypass grafting. The SWEDEHEART (Swedish Web‐System for Enhancement and Development of Evidence‐Based Care in Heart Disease Evaluated According to Recommended Therapies) register and other national health‐data registers were used to obtain and characterize the study cohort and to identify causes of death, categorized as cardiovascular mortality, cancer mortality, or other causes of death. The relative risks for cause‐specific mortality in patients who underwent AVR compared with the general population are presented as standardized mortality ratios. During a mean follow‐up period of 7.3 years (maximum 22.0 years), 14 237 (43%) patients died. The cumulative incidence of death from cardiovascular, cancer‐related, or other causes was 23.5%, 8.3%, and 11.6%, respectively, at 10 years, and 42.8%, 12.8%, and 23.8%, respectively, at 20 years. Standardized mortality ratios for cardiovascular, cancer‐related, and other causes of death were 1.79 (95% CI, 1.75–1.83), 1.00 (95% CI, 0.97–1.04), and 1.08 (95% CI, 1.05–1.12), respectively. Conclusions We found that life expectancy following AVR was lower than in the general population. Lower survival after AVR was explained by an increased relative risk of cardiovascular death. Future studies should focus on the role of earlier surgery in patients with asymptomatic aortic stenosis and on optimizing treatment and follow‐up after AVR. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02276950.

Objectives Our objective was to examine intermediate-term survival and reinterventions in unselected patients, stratified by indication, who received a Freestyle® bioprosthesis as a full aortic root replacement. Methods Data from medical records were retrospectively collected for patients who had aortic root replacement using Freestyle® bioprostheses between 1999 and 2018 at six North-Atlantic centers. Survival status was extracted from national registries and results stratified for indication for surgery. Results We included 1030 implantations in 1008 patients with elective indications for surgery: aneurysm (39.8%), small root (8.3%) and other (13.8%), and urgent/emergent indications: endocarditis (26.7%) and Stanford type A aortic dissection (11.4%). Across indications, 46.3% were non-elective cases and 34.0% were reoperations. Median age was 66.0 years (IQR 58.0-71.8) and median follow-up was 5.0 years (IQR 2.6-7.9). Thirty-day mortality varied from 2.9% to 27.4% depending on indication. Intermediate survival for 90-day survivors with elective indications were not different from the general population standardized by age and sex (p-values 0.95, 0.83 and 0.16 for aneurysms, small roots and other, respectively). In contrast, patients with endocarditis and type A dissection had excess mortality (p-values Objectives: Our objective was to examine intermediate-term survival and reinterventions in unselected patients, stratified according to indication, who received a Freestyle (Medtronic Inc, Minneapolis, Minn) bioprosthesis as a full aortic root replacement. Methods: Data from medical records were retrospectively collected for patients who had aortic root replacement using Freestyle bioprostheses between 1999 and 2018 at 6 North-Atlantic centers. Survival status was extracted from national registries and results stratified according to indication for surgery. Results: We included 1030 implantations in 1008 patients with elective indications for surgery: aneurysm (39.8%), small root (8.3%), and other (13.8%), and urgent/emergent indications: endocarditis (26.7%) and Stanford type A aortic dissection (11.4%). Across indications, 46.3% were nonelective cases and 34.0% were reoperations. Median age was 66.0 (interquartile range, 58.0-71.8) years and median follow-up was 5.0 (interquartile range, 2.6-7.9) years. Thirty-day mortality varied from 2.9% to 27.4% depending on indication. Intermediate survival for 90-day survivors with elective indications were not different from the general population standardized for age and sex (P = .95, 83, and .16 for aneurysms, small roots, and other, respectively). In contrast, patients with endocarditis and type A dissection had excess mortality (P < .001). Freedom from valve reinterventions was 95.0% and 94.4% at 5 and 8 years, respectively. In all, 52 patients (5.2%) underwent reinterventions, most because of endocarditis. Conclusions: At intermediate term follow-up this retrospective study provides further support for the use of the Freestyle bioprosthesis in the real-world setting of diverse, complex, and often high-risk aortic root replacement and suggests that outcome is determined by patient and disease, rather than by prosthesis, characteristics.

Background Contemporary data on loss in life expectancy after aortic valve replacement (AVR) are scarce, particularly in younger patients. Objectives The purpose of this national, observational cohort study was to analyze long-term relative survival and estimated loss in life expectancy after AVR. Methods The study included 23,528 patients who underwent primary surgical AVR with or without concomitant coronary artery bypass grafting in Sweden between 1995 and 2013 from the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) register. Individual level linking with other national health-data registers was performed to obtain baseline characteristics and vital status. The expected survival from the general Swedish population matched by age, sex, and year of surgery was obtained from the Human Mortality Database. The relative survival was used as an estimate of cause-specific mortality. Flexible parametric models based on relative survival were used to estimate the loss in life expectancy. Results The mean follow-up was 6.8 years. The 19-year observed, expected, and relative survival was 21%, 34%, and 63% (95% confidence interval [CI]: 59% to 67%), respectively. The loss in life expectancy was 1.9 years (95% CI: 1.2 to 2.6 years) in the total study population. The estimated loss in life expectancy increased with younger age: 0.4 years (95% CI: 0.3 to 0.5 years) versus 4.4 years (95% CI: 1.5 to 7.2 years) in patients ≥80 and Conclusions This study found a shorter life expectancy in patients after AVR compared with the general population. The estimated loss in life expectancy was substantial, and increased with younger age. These results provide important information to quantify disease burden after AVR, and are relevant for clinicians counseling patients before and after AVR. (HeAlth-data Register sTudies of Risk and Outcomes in Cardiac Surgery [HARTROCS]; NCT02276950)

This study was performed to investigate long-term, clinically important outcomes in patients who underwent permanent pacemaker implantation after transcatheter aortic valve replacement (TAVR).The impact of permanent pacemaker implantation after TAVR is unknown, and prior studies have produced conflicting results.In this nationwide, population-based cohort study, the study included all patients who underwent transfemoral TAVR in Sweden from 2008 to 2018 from the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) register. Additional baseline characteristics and information about outcomes were obtained by individual crosslinking with other national health data registers. Unadjusted and multivariable-adjusted analyses were performed using Cox proportional hazards regression.Of 3,420 patients, 481 (14.1%) underwent permanent pacemaker implantation within 30 days after TAVR. The survival rate at 1, 5, and 10 years was 90.0%, 52.7%, and 10.9% in the pacemaker group and 92.7%, 53.8%, and 15.3% in the nonpacemaker group, respectively (HR: 1.03; 95% CI: 0.88-1.22; P = 0.692). The median follow-up was 2.7 years (interquartile range: 2.5, and maximum 11.8 years). There was no difference in the risk of cardiovascular death (HR: 0.91; 95% CI: 0.71-1.18; P = 0.611), heart failure (HR: 1.23; 95% CI: 0.92-1.63; P = 0.157), or endocarditis (HR: 0.90; 95% CI: 0.47-1.69; P = 0.734) between the groups.The study found no difference in long-term survival between patients who did and did not undergo permanent pacemaker implantation after TAVR. As the use of TAVR expands to include younger and low-risk patients with a long life expectancy, it will become increasingly important to understand the impact of permanent pacemaker implantation after TAVR.

BackgroundSmall femoral arteries have been associated with a higher risk of vascular complications in transfemoral transcatheter aortic valve replacement (TAVR). We investigated the feasibility and safety of TAVR in patients with small femoral arteries.MethodsIn this observational study, we included 82 patients who underwent transfemoral TAVR with the ACURATE neo system using the expandable 14F iSleeve sheath between 2018 and 2019 at Karolinska University Hospital, Sweden. Of these, 41 patients had a minimal femoral artery diameter of ≥5.5 mm (mean 6.5, range 5.5–9.2), and 41 patients had a minimal femoral artery diameter ResultsThere was no significant difference in major vascular and bleeding complications between the small femoral artery group (7%) and the normal femoral artery group (2%) (p=0.62). The total of major and minor vascular complications did not differ significantly according to femoral artery size (17% vs 5%) (p=0.16). The iSleeve sheath was not correlated with any of the complications. The use of the iSleeve sheath was unsuccessful in four patients (5%), of which one patient had a small femoral artery diameter.ConclusionTransfemoral TAVR with the ACURATE neo system using the iSleeve sheath is a promising method for patients with small femoral arteries even though we found a trend towards higher rates of complications in these patients. The use of expandable sheaths may expand the spectrum of patients that can be treated with transfemoral TAVR, and thus may improve the prognosis in patients with severe aortic valve stenosis.

Background Previous studies have reported superior hemodynamic performance with bovine bioprosthetic aortic valves compared with porcine valves. However, conflicting results mean the long-term effect on survival is not well known. The aim of this study was to examine long-term survival, rate of aortic valve reoperations, and heart failure hospitalizations after surgical aortic valve replacement (AVR) with porcine vs bovine bioprosthetic valves. Methods This was a population-based cohort study including all patients who had undergone AVR in Sweden from 1995 to 2012, with or without concomitant coronary artery bypass grafting. Patients were identified through the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) registry. Baseline and outcome data were gathered from national registries. Propensity scores and inverse probability of treatment weighting were used to control for intergroup differences. Analyses accounted for competing risk of death when appropriate. Results A total of 12,845 patients underwent AVR with porcine (n = 4198) or bovine (n = 8647) prostheses. We found a small but significant difference in mortality favoring porcine prostheses: 78% vs 76%, 47% vs 43%, and 17% vs 15% at 5, 10, and 15 years, respectively (hazard ratio, 0.90; 95% confidence interval, 0.85-0.96). Porcine prostheses were associated with an increased risk of reoperation (hazard ratio, 1.48; 95% confidence interval, 1.11-1.98), but no difference in the risk of heart failure hospitalization. Results were similar in patients who underwent isolated AVR. Conclusions Consistent with previous reports, we found that patients receiving porcine prostheses had a higher rate of reoperation compared with bovine prostheses. However, porcine prostheses were associated with improved long-term survival compared with bovine prostheses.

The performance of bioprosthetic aortic valves is usually assessed in single valve models or head-to-head comparisons. National databases or registries offer the opportunity to investigate all available valve models in the population and allows for a comparative assessment of their performance.To analyze the long-term rates of reintervention, all-cause mortality, and heart failure hospitalization associated with commonly used bioprosthetic aortic valves and to identify valve model groups with deviation in clinical performance.This population-based, nationwide cohort study included all adult patients who underwent surgical aortic valve replacement (with or without concomitant coronary artery bypass surgery or ascending aortic surgery) in Sweden between January 1, 2003, and December 31, 2018. Patients were identified from the SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) registry. Patients with concomitant valve surgery, previous cardiac surgery, and previous transcatheter valve replacement were excluded. Follow-up was complete for all participants. Data were analyzed from March 9, 2020, to October 12, 2021.Primary surgical aortic valve replacement with the Perimount, Mosaic/Hancock, Biocor/Epic, Mitroflow/Crown, Soprano, and Trifecta valve models.The primary outcome was cumulative incidence of reintervention, defined as a subsequent aortic valve operation or transcatheter valve replacement. Secondary outcomes were all-cause mortality and heart failure hospitalization. Regression standardization and flexible parametric survival models were used to account for intergroup differences. Mean follow-up time was 7.1 years, and maximum follow-up time was 16.0 years.A total of 16 983 patients (mean [SD] age, 72.6 [8.5] years; 10 685 men [62.9%]) were included in the analysis. The Perimount valve model group had the lowest and the Mitroflow/Crown valve model group had the highest cumulative incidence of reintervention. The estimated cumulative incidence of reintervention at 10 years was 3.6% (95% CI, 3.1%-4.2%) in the Perimount valve model group and 12.2% (95% CI, 9.8%-15.1%) in the Mitroflow/Crown valve model group. The estimated incidence of reintervention at 10 years was 9.3% (95% CI, 7.3%-11.3%) in the Soprano valve model group.Results of this study showed that the Perimount valve was the most commonly used and had the lowest incidence of reintervention, all-cause mortality, and heart failure hospitalization, whereas the Mitroflow/Crown valve had the highest rates. These findings highlight the need for clinical vigilance in patients who receive either a Soprano or Mitroflow/Crown aortic bioprosthesis.

This cohort study investigates the association of long-term adverse clinical outcomes, including mortality, with permanent pacemaker implantation after surgical aortic valve replacement., Key Points Question Is permanent pacemaker implantation after aortic valve replacement associated with long-term adverse clinical outcomes? Findings In this cohort study of 24 983 patients who underwent surgical aortic valve replacement, increased risks of death and heart failure hospitalization were observed among patients who underwent permanent pacemaker implantation after aortic valve replacement compared with those who did not. Meaning The association of mortality with permanent pacemaker implantation after aortic valve replacement should be considered, especially in an era when transcatheter aortic valve replacement is used among patients who are younger and have lower risks of adverse surgical outcomes., Importance Prior studies investigating the long-term clinical outcomes of patients who have undergone permanent pacemaker implantation after aortic valve replacement reported conflicting results. Objective To investigate long-term outcomes after primary surgical aortic valve replacement among patients who underwent postoperative permanent pacemaker implantation. Design, Setting, and Participants This cohort study included all patients who underwent surgical aortic valve replacement in Sweden from 1997 to 2018. All patients who underwent primary surgical aortic valve replacement in Sweden and survived the first 30 days after surgical treatment were included. Patients who underwent preoperative permanent pacemaker implantation, concomitant surgical treatment for another valve, or emergency surgical treatment were excluded. Patients who underwent concomitant coronary artery bypass grafting or surgical treatment of the ascending aorta were included. Follow-up data were complete for all patients. Data were analyzed from October through December 2020. Exposures Patients underwent implantation of a permanent pacemaker or implantable cardioverter defibrillator within 30 days after aortic valve replacement. Main Outcomes and Measures The primary outcome was all-cause mortality. Results Among 24 983 patients who underwent surgical aortic valve replacement, 849 patients (3.4%) underwent permanent pacemaker implantation within 30 days after surgical treatment and 24 134 patients (96.6%) did not receive pacemakers in that time. The mean (SD) age of the total study population was 69.7 (10.8) years, and 9209 patients were women (36.9%). The mean (SD) and maximum follow-up periods were 7.3 (5.0) years and 22.0 years, respectively. At 10 years and 20 years after surgical treatment, the Kaplan-Meier estimated survival rates were 52.8% and 18.0% in the pacemaker group, respectively, and 57.5% and 19.6% in the nonpacemaker group, respectively. All-cause mortality was statistically significantly increased in the pacemaker group compared with the nonpacemaker group (hazard ratio [HR], 1.14; 95% CI, 1.01-1.29; P = .03), and so was risk of heart failure hospitalization (HR, 1.58; 95% CI, 1.31-1.89; P

Pulmonary endarterectomy is the guideline recommended treatment for chronic thromboembolic pulmonary hypertension, in addition to life-long anticoagulation therapy. The aim was to analyze long-term relative survival after pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. We included all patients who underwent pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension at Karolinska University Hospital between 1997 and 2018 (n = 100). We obtained baseline characteristics and vital status from patient charts and national health-data registers. The expected survival from the general Swedish population matched by age, sex, and year of surgery was obtained from the Human Mortality Database. The relative survival was used as an estimate of cause-specific mortality. The mean age of the patients was 62 years and 39% were women. Most patients were severely symptomatic (95% in New York Heart Association functional class III–IV), and mean preoperative systolic/diastolic (mean) pulmonary artery pressure was 78/27 (45) mmHg. The mean and maximum follow-up time was 7.2 and 22.1 years, respectively. Early (30-day) mortality was 7%. The 15-year observed, expected, and relative survival was 55% (95% confidence interval, 40%–68%), 71%, and 77% (95% confidence interval, 56%–95%), respectively. The 15-year relative survival conditional on 30-day survival was 83% (95% confidence interval, 60%–100%). Although the life expectancy following pulmonary endarterectomy was shorter compared to the general population, the difference was small in those who survived the operation and the early postoperative period. Patients with chronic thromboembolic pulmonary hypertension who are surgical candidates should undergo pulmonary endarterectomy to improve prognosis.

ObjectiveBlood type A antigen on porcine aortic bioprostheses might initiate an immune reaction leading to an increased frequency of structural valve deterioration in patients with blood type B or O. The aim was to analyse the association between ABO blood type and porcine bioprosthetic aortic valve degeneration.DesignObservational nationwide cohort study.SettingSwedish population-based study.ParticipantsAdult patients (n=3417) who underwent surgical aortic valve replacement and received porcine bioprosthetic aortic valves between 1995 and 2012 from the Swedish Web system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies register. The study database was enriched with information from other national registers.ExposureThe patients were categorised into type A/AB and type B/O blood groups.Primary and secondary outcome measuresPrimary outcome measure was aortic valve reoperation, and secondary outcomes were heart failure and all-cause mortality. We report risk estimates that account for the competing risk of death.ResultsIn total, 3417 patients were identified: 1724 (50.5%) with blood type A/AB and 1693 (49.5%) with blood type B/O. Both groups had similar baseline characteristics. The cumulative incidence of aortic valve reoperation was 3.4% (95% CI 2.5% to 4.4%) and 3.6% (95% CI 2.6% to 4.6%) in the type B/O and the A/AB group, respectively, at 15 years of follow-up (absolute risk difference: −0.2% (95% CI −1.5% to 1.2%)). There was no significantly increased risk for aortic valve reoperation in patients with blood type B/O compared with type A/AB (HR 0.95, 95% CI 0.62 to 1.45). There was no significant difference in absolute or relative risk of heart failure or death between the groups.ConclusionsWe found no significant association between patient blood type and clinical manifestations of structural valve deterioration following porcine aortic valve replacement. Our findings suggest that it is safe to use porcine bioprosthetic valves without consideration of ABO blood type in the recipient.Trial registration numberNCT02276950

Contemporary data on loss in life expectancy after aortic valve replacement (AVR) are scarce, particularly in younger patients.The purpose of this national, observational cohort study was to analyze long-term relative survival and estimated loss in life expectancy after AVR.The study included 23,528 patients who underwent primary surgical AVR with or without concomitant coronary artery bypass grafting in Sweden between 1995 and 2013 from the SWEDEHEART (Swedish Web-system for Enhancement and Development of Evidence-based care in Heart disease Evaluated According to Recommended Therapies) register. Individual level linking with other national health-data registers was performed to obtain baseline characteristics and vital status. The expected survival from the general Swedish population matched by age, sex, and year of surgery was obtained from the Human Mortality Database. The relative survival was used as an estimate of cause-specific mortality. Flexible parametric models based on relative survival were used to estimate the loss in life expectancy.The mean follow-up was 6.8 years. The 19-year observed, expected, and relative survival was 21%, 34%, and 63% (95% confidence interval [CI]: 59% to 67%), respectively. The loss in life expectancy was 1.9 years (95% CI: 1.2 to 2.6 years) in the total study population. The estimated loss in life expectancy increased with younger age: 0.4 years (95% CI: 0.3 to 0.5 years) versus 4.4 years (95% CI: 1.5 to 7.2 years) in patients ≥80 and 50 years of age, respectively. There was no difference in loss in life expectancy between men and women.This study found a shorter life expectancy in patients after AVR compared with the general population. The estimated loss in life expectancy was substantial, and increased with younger age. These results provide important information to quantify disease burden after AVR, and are relevant for clinicians counseling patients before and after AVR. (HeAlth-data Register sTudies of Risk and Outcomes in Cardiac Surgery [HARTROCS]; NCT02276950).

Prosthetic valve endocarditis (PVE) is the most severe form of infective endocarditis and accounts for 20% of all cases of infective endocarditis.1,2 However, studies reporting the incidence of PVE after surgical aortic valve replacement (AVR) are scarce and based mainly on noncontemporary patient cohorts. Whether PVE affects biological and mechanical aortic valves to the same extent remains unknown. Therefore, we investigated the incidence and risk of PVE after surgical AVR in patients with biological and mechanical valves. This observational, nationwide, population-based cohort study was approved by the regional Human Research Ethics Committee in Stockholm, Sweden (Dnr. 2016/1241-32) and is registered at ClinicalTrials.gov (Unique identifier: NCT02276950). No informed consent from patients was required. The SWEDEHEART (Swedish Web-System for Enhancement and Development of Evidence-Based Care in Heart Disease Evaluated According to Recommended Therapies) register was used to obtain the study population. The unique personal identity number was used for cross-linking patient-level data from other national healthcare registers as described previously.3 All patients who underwent AVR with a biological or mechanical valve prosthesis in Sweden from January 1, 1995, to December 31, 2012, were included in the study. Patients with multiple valve surgeries were excluded. Person-time in days was counted from the date of surgery until the …

Background Bovine and porcine bioprostheses are commonly used for surgical aortic valve replacement. It is unknown if the long-term survival differs between the two valve types.We performed a systematic review and meta-analysis to compare survival in patients who underwent aortic valve replacement and received a bovine or a porcine prosthesis. Methods We performed a systematic search of Medline, Embase, Web of Science, and the Cochrane Library. Cohort studies that compared survival between patients who underwent aortic valve replacement and received either a bovine or a porcine bioprosthesis and that reported overall long-term survival with hazard ratio (HR) and 95% confidence interval (CI) were included. Two authors independently reviewed articles considered for inclusion, extracted the information from each study, and performed the quality assessment. We performed a meta-analysis using a random effects model to calculate the pooled HR (95% CI) for all-cause mortality. We did sensitivity analyses to assess the robustness of our findings. Results Seven studies published between 2010 and 2015 were included, and the combined study population was 49,190 patients. Of these, 32,235 (66%) received a bovine, and 16,955 (34%) received a porcine bioprosthesis. There was no significant difference in all-cause mortality between patients who received a bovine compared with a porcine bioprosthesis (pooled HR 1.00, 95% CI: 0.92–1.09). Heterogeneity between studies was moderate (55.8%, p = 0.04). Conclusions This systematic review and meta-analysis suggest no difference in survival between patients who received a bovine versus a porcine bioprosthesis after aortic valve replacement. Our study provides valuable evidence for the continuing use of both bovine and porcine bioprosthetic valves for surgical aortic valve replacement.

OBJECTIVES: The objective was to evaluate the long-term haemodynamic performance of the Mosaic aortic bioprosthesis. Secondary objectives were to investigate the long-term survival, the rate of aortic valve reoperations, and the rate of prosthesis–patient mismatch and its effect on long-term survival. METHODS: We included all patients who underwent aortic valve replacement with a Mosaic bioprosthesis at our institution between 2002 and 2008. Valve haemodynamics were assessed by transthoracic echocardiography as mean and peak pressure gradients. Patient characteristics and outcomes were collected from charts and national registers. RESULTS: We included 355 patients and echocardiographic evaluation was performed at early follow-up in 340 patients (96%) and at late follow-up in 161 patients (45%). The mean follow-up time was 7.1 (maximum 11.7) years. The unadjusted survival at 1, 5 and 10 years was 92, 79 and 42%, respectively. At the early postoperative echocardiography, the peak pressure gradient was 39.9 mmHg (SD 14.4) and the mean pressure gradient was 21.1 mmHg (SD 7.7) and, on late echocardiography, the peak pressure gradient was 38.6 mmHg (SD 15.6) and the mean pressure gradient was 22.5 mmHg (SD 10.1). Moderate or severe prosthesis–patient mismatch was found in 250 (70%) and 49 patients (14%), respectively, but was not significantly associated with mortality in multivariable analyses. CONCLUSIONS: We found that the Mosaic aortic bioprosthesis had acceptable clinical performance at late follow-up. However, a substantial proportion of patients had high transvalvular gradients or moderate or severe prosthesis–patient mismatch, although neither were significantly associated with long-term survival in our population.

Background The objective was to compare late survival after aortic valve replacement (AVR) with a Carpentier-Edwards Perimount (Edwards Lifesciences, Irvine, CA) versus a Mosaic bioprosthesis (Medtronic Inc, Minneapolis, MN). Secondary objectives were to compare early mortality, the rate of reoperation, and the effect of prosthesis-patient mismatch (PPM) on late survival. Methods The design was a population-based cohort study including all patients who underwent AVR with a Perimount or Mosaic bioprosthesis at our institution between 2002 and 2010. Baseline, operative characteristics and clinical outcomes were collected from patient charts and national registers. The primary outcome was all-cause mortality. We analyzed the unadjusted and multivariable adjusted association between valve type and late survival. Results In total, 1,219 patients received the Perimount (n = 864) or the Mosaic (n = 355) bioprosthesis. During a mean follow-up of 4.2 and 6.9 years, there were 193 and 177 deaths in the Perimount and Mosaic groups, respectively. The unadjusted 1-, 5-, and 8-year survival was 93%, 78%, and 63%, respectively, in the Perimount group and 92%, 80%, and 57%, respectively, in the Mosaic group ( p = 0.971).There was no significant association between valve choice and all-cause mortality in the multivariable analysis (hazard ratio [HR], 0.85; 95% confidence interval [CI], 0.65–1.11). Freedom from aortic valve reoperation was similar between the groups. No significant association was found between severe PPM and late mortality. Conclusions We found no significant difference in late survival after AVR with a Perimount bioprosthesis compared with a Mosaic bioprosthesis. Even though severe PPM was more common in the Mosaic group, it did not affect the late survival or the frequency of reoperation.

We thank Madias for his interest in our work1 and the interesting points he raised. According to Madias2 and based on experimental work in animals, it has been suggested that aspirin could prevent infective endocarditis. Hypothetically, platelets are involved when bacteria adhere to abnormal or damaged endothelium by acting together with fibrin, extracellular matrix proteins, and surface adhesions on bacteria. It is therefore possible that drugs targeting platelet function could reduce the risk of infective endocarditis. Madias correctly noted that our study was …

Background The influence of moderately reduced kidney function on late survival after surgical aortic valve replacement ( AVR ) is unknown. We analyzed survival after AVR in patients with moderately reduced kidney function. Methods and Results All patients who underwent primary AVR in Sweden 1997–2013 were identified from the Swedish Web system for Enhancement and Development of Evidence‐based care in Heart disease Evaluated According to Recommended Therapies register. Patients were categorized according to estimated glomerular filtration rate ( eGFR ). Of 13 102 patients, 9836 (75%) had normal kidney function ( eGFR >60 mL/min per 1.73 m 2 ) and 3266 (25%) had moderately reduced kidney function ( eGFR 30–60 mL/min per 1.73 m 2 ). Mean follow‐up time was 6.2 years. Mortality was higher in patients with moderately reduced kidney function; 5‐, 10‐, and 15‐year survival was 76%, 48%, and 25% versus 89%, 73%, and 55% (adjusted hazard ratio [ HR ], 1.28; 95% CI , 1.18–1.38; P HR , 1.18; 95% CI , 1.00–1.39; P =0.051) and a lower risk for aortic valve reoperation ( HR , 0.54; 95% CI , 0.38–0.79; P =0.001) compared to those with normal kidney function. In patients with moderately reduced kidney function, survival was similar in those who received bioprostheses compared to those who received mechanical valves ( HR , 0.85; 95% CI , 0.70–1.03; P =0.094). Conclusions Moderately reduced kidney function was strongly associated with increased mortality after AVR. These results have important implications for preoperative risk stratification, and suggest that patients with eGFR 30 to 60 mL/min per 1.73 m 2 warrant careful observation after AVR. Clinical Trial Registration URL : http://www.clinicaltrials.gov . Unique identifier: NCT 02276950.

OBJECTIVES: The aim of this study was to analyse early postoperative outcomes and 2-year survival after aortic valve replacement (AVR) through a ministernotomy with a sutureless bioprosthesis implantation compared with a full sternotomy with implantation of a stented bioprosthesis. METHODS: Patients who underwent primary isolated non-emergent AVR at six European centres were included in the study. Of these, 182 (32%) underwent a ministernotomy with a sutureless bioprosthesis (ministernotomy sutureless group) and 383 (68%) a full sternotomy with a stented bioprosthesis (full sternotomy stented group). Propensity score matching was used to reduce selection bias. RESULTS: In the overall cohort, 30-day mortality was 1.6 and 2.1%, and 2-year survival was 92 and 92% in the ministernotomy sutureless group and in the full sternotomy stented group, respectively. Propensity score matching resulted in 171 pairs with similar characteristics and operative risk. Aortic cross-clamp (40 vs 65 min, P < 0.001) and cardiopulmonary bypass time (69 vs 87 min, P < 0.001) were shorter in the ministernotomy sutureless group. Patients undergoing ministernotomy received less packed red blood cells but the risk for postoperative permanent pacemaker implantation was higher. There were no differences regarding 30-day mortality or 2-year survival between the two groups. CONCLUSIONS: AVR through a ministernotomy with implantation of a sutureless bioprosthesis was associated with shorter aortic cross-clamp and cardiopulmonary bypass time and less transfusion of packed red blood cells, but a higher risk for postoperative permanent pacemaker implantation compared with a full sternotomy with a stented bioprosthesis.