Hemodynamic and clinical performance of Solo stentless bioprosthetic aortic valves | Revista Portuguesa de Cardiologia (English edition)

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Amorim, Benjamim Marinho, Rui J. Cerqueira, André P. Lourenço, Paulo Pinho, Jorge Almeida, Adelino F. Leite-Moreira" "autores" => array:9 [ 0 => array:3 [ "nombre" => "Marta" "apellidos" => "Andrade" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 1 => array:3 [ "nombre" => "Francisca" "apellidos" => "Saraiva" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Mário J." "apellidos" => "Amorim" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Benjamim" "apellidos" => "Marinho" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 4 => array:3 [ "nombre" => "Rui J." 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"apellidos" => "Leite-Moreira" "email" => array:1 [ 0 => "amoreira@med.up.pt" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Department of Cardiothoracic Surgery, Centro Hospitalar de São João, Porto, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular (UnIC), Faculdade de Medicina, Universidade do Porto, Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Department of Anesthesiology, Centro Hospitalar de São João, Porto, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Avaliação hemodinâmica e clínica das biopróteses aórticas stentless SOLO" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1148 "Ancho" => 2326 "Tamanyo" => 149919 ] ] "descripcion" => array:1 [ "en" => "Six-year cumulative survival of all-cohort, isolated and combined procedures. AVR: aortic valve replacement." ] ] ] "textoCompleto" => "IntroductionDegenerative aortic valve disease is the most prevalent acquired heart valve disease in the western world. Surgical aortic valve replacement (AVR) is the therapy of choice for severe symptomatic disease and has become a safe procedure, reflecting not only advances in intra- and postoperative care, but also improvements in prosthetic valve design and technology.<a class="elsevierStyleCrossRefs" href="#bib0125">1,2</a> The ideal prosthetic valve should have low transvalvular gradients, maximum effective orifice area (EOA) and minimum patient-prosthesis mismatch (PPM), mimicking the anatomy and hemodynamic profile of healthy native valves. Moreover, it should be easy and safe to implant, durable, resistant to infection and have low thrombogenic risk. However, the search for the perfect artificial valve continues.<a class="elsevierStyleCrossRef" href="#bib0135">3</a>Stentless bioprosthetic aortic valves, without an obstructive stent or a rigid suture ring, have proven excellent hemodynamic performance, similar to homografts. This improved hemodynamic profile is also associated with survival benefit, although this may be at the expense of a greater risk of structural valve deterioration (SVD) and need for reoperation.<a class="elsevierStyleCrossRef" href="#bib0140">4</a> The first widely used stentless valve, the Toronto SPV, had low long-term durability, generally attributed to its stentless design, although it could also be related to its porcine origin.<a class="elsevierStyleCrossRef" href="#bib0145">5</a> As with other early-generation stentless valves, implantation was technically demanding.<a class="elsevierStyleCrossRef" href="#bib0150">6</a> The Freedom Solo (FS) and Solo Smart (SS) biological valves (Sorin Group, Saluggia, Italy) emerged in response to these technical challenges and have been in clinical use since 2004. These are third-generation stentless valves (the Smart is the same model with a different holder) with supra-annular implantation and a single suture line. The valves are manufactured from bovine pericardial tissue detoxified in homocysteic acid, which may reduce structural valve deterioration. As they are stentless, supra-annular and easily adaptable to the aortic root, they allow larger valve sizes and EOA than an equivalent stented valve, favoring laminar flow.<a class="elsevierStyleCrossRefs" href="#bib0155">7,8</a>High-volume centers have begun publishing their experience with these bioprostheses, confirming them as a safe and reliable alternative for AVR, but the available clinical data are limited and need to be supported by larger patient series and longer follow-up times.<a class="elsevierStyleCrossRefs" href="#bib0165">9–12</a>The objective of this study is to report the hemodynamic profile and the short- and medium-term outcomes of FS/SS stentless bioprosthetic valves implanted at our center during a six-year period.MethodsStudy design and settingWe performed a retrospective, longitudinal and descriptive study. Clinical, demographic, operative and postoperative data were collected through medical records from the database of the Cardiothoracic Surgery Department of Centro Hospitalar São João. The study was approved by the local ethics committee.Study populationPatients who underwent AVR with Freedom Solo or Solo Smart valves at Centro Hospitalar São João between April 2009 and April 2015 were identified from our center's registry, regardless of primary indication for surgery or concomitant procedures.Preoperative data collected included age, gender, body surface area, body mass index, cardiovascular risk factors (hypertension, diabetes, dyslipidemia, smoking and obesity), creatinine clearance, peripheral arterial disease (defined as carotid occlusion or >50% stenosis, claudication, amputation or previous or planned intervention on the abdominal aorta, limb or carotid arteries), cerebrovascular events (transient ischemic attack or stroke), chronic obstructive pulmonary disease, coronary artery disease, left ventricular dysfunction, previous myocardial infarction, preoperative rhythm, New York Heart Association functional class and urgency of surgery. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was calculated for each patient. Information was also collected on both pathology (stenosis, regurgitation or combined) and etiology of aortic valve disease (degenerative calcific, bicuspid, endocarditis [native or prosthetic valve], rheumatic, prolapse or aortic prosthesis dysfunction).The decision to use a stentless valve was at the discretion of the surgeons, after patient consent was obtained. Implantation of FS/SS valves was mainly performed by two senior surgeons (AFL-M and MJA), who considered all patients undergoing AVR with bioprosthetic valves for FS/SS implantation unless the following exclusion criteria were met: extensive aortic root calcification, severe mismatch between aortic annulus and sinotubular junction, or Sievers type 0 bicuspid aortic valve. Other types of bicuspid aortic valve were not excluded if aortic root symmetry was preserved.Surgical and postoperative managementPatients underwent full or partial upper sternotomy and mild hypothermic cardiopulmonary bypass with cold crystalloid anterograde and retrograde cardioplegia. A transverse aortotomy was performed approximately 1 cm above the sinotubular junction. The aortic valve was excised and the annulus was completely decalcified and reinforced with a 5-0 polypropylene suture when necessary. Three 4-0 polypropylene sutures were placed in a supra-annular position at the nadir of each sinus and passed through the Solo valve. Thereafter, the valve was parachuted into the aortic root and tied with sutures running continuously 1 mm above the annulus. The sutures were passed out of the aorta at the level of the commissures and tied with the suture from the adjacent sinus. Immediate outcome was assessed by intraoperative transesophageal echocardiography. All patients underwent our center's standard anesthetic, surgical and postoperative care procedures. Surgical data were gathered regarding valve size and cardiopulmonary bypass and cross-clamp times for both isolated and combined procedures. Postoperative data collected are defined in the follow-up section.Follow-upIn accordance with local protocol, patients had a postoperative six-month follow-up visit at our center that included transthoracic echocardiographic assessment. Mean gradients and EOA (calculated using the continuity equation) were recorded. PPM was classified by the ratio of prosthesis EOA to patient body surface area as moderate (0.85-0.65 cm2/m2) or severe (<0.65 cm2/m2).<a class="elsevierStyleCrossRef" href="#bib0185">13</a> Thereafter, echocardiographic and clinical follow-up was carried out yearly by the patient's referring cardiologist.In-hospital mortality (defined as 30-day mortality if the patient was discharged or within any period if the patient was not discharged<a class="elsevierStyleCrossRef" href="#bib0190">14</a>) was retrieved from hospital medical records. All-cause mortality (the primary outcome) was obtained from the National Healthcare Registry as of October 1, 2015. For the purposes of analysis, all cases of unknown cause of death were considered cardiovascular deaths.Secondary endpoints were low cardiac output (need for high-dose inotropic support or intra-aortic balloon pump), stroke, acute renal function impairment (rise of serum creatinine >1.5 times the preoperative value or low urine output [<0.5 ml/kg/h for >6 hours]), atrial fibrillation episodes, permanent pacemaker implantation, severe thrombocytopenia (platelet count <30×109/L), early resternotomy for bleeding, prolonged ventilation (>24 hours mechanical ventilation), length of hospital stay, structural valve deterioration (SVD) or non-structural valve dysfunction, endocarditis or late reintervention for prosthesis-related issues. SVD was defined as changes intrinsic to the valve, such as wear, calcification, leaflet tear or suture line disruption of the valve's components, and non-structural valve dysfunction as any abnormality not intrinsic to the valve itself resulting in dysfunction of the operated valve or hemolysis.<a class="elsevierStyleCrossRef" href="#bib0190">14</a> These data were also retrieved in October 2015, either from clinical records or telephone interview with the referring cardiologist. Due to lack of follow-up information, a post-hoc echocardiogram was performed at our center in 19 patients for the purpose of the current study.Statistical analysisContinuous variables were expressed as mean (standard deviation) or median [interquartile range] (25th-75th percentile), as appropriate. Categorical variables were expressed as frequency and percentage. Comparisons between patients undergoing more than one procedure and those undergoing isolated AVR were performed using the unpaired Student's t test or the Mann-Whitney test for continuous variables. Normality was assessed by the Shapiro-Wilk test and visual inspection of residuals. Kaplan-Meier curves were used to assess time-to-event data. All statistical analyses were performed using IBM SPSS version 21 (IBM Corporation, New York). A p-value less than 0.05 was considered statistically significant.ResultsSample and follow-upPreoperative characteristics of the study population are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. Patients’ mean age was 72±8 years and 52% were female. The most prevalent cardiovascular risk factors were hypertension (79%) and dyslipidemia (68%); 35% of patients had diabetes, 25% were obese and 15% were current or former smokers. Degenerative calcific disease was the most common etiology for aortic valve disease (76%), 8% of patients had bicuspid and 8% rheumatic valves, and 5% had endocarditis (4% native valve, 1% prosthetic). The median EuroSCORE II was 2.7 [1.5-4.7]: 1.8 [1.1-3.1] for isolated AVR and 3.3 [2.2-6.4] for combined procedures. Out of 345 patients, 318 received FS and 27 SS. Medium-term clinical and echocardiographic follow-up (5±3 months) was retrieved from 98% of patients and was 100% (complete) for all-cause mortality. Mean follow-up was 39±22 months and maximum follow-up was 78 months.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Operative dataThe most frequently implanted valve size was no. 23 (39%), followed by sizes 25 (25%) and 21 (23%). One or more concomitant procedures were performed in 52% of patients (summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>). Coronary artery bypass grafting (CABG) was the most frequent combined procedure (29%); mitral and tricuspid valves, as well as the ascending aorta, were also commonly treated. Compared with isolated AVR, combined procedures had longer median cardiopulmonary bypass and cross-clamp times, 95 [83-118] vs. 152 min [120-201] and 67 [59-85] vs. 110 min [85-140] (p<0.001), respectively. There was no intraoperative mortality.<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>In-hospital outcomesOverall in-hospital mortality was 2.6% (n=9), 1.8% (n=3) for isolated AVR and 3.4% (n=6) for combined procedures. Causes of death were prosthetic endocarditis (n=1), cardiogenic shock (n=2), septic shock (n=3), multiorgan failure (n=2) and iatrogenic complication of intensive care unit procedure (n=1). EuroSCORE II was lower in surviving patients (2.6 [1.5-4.6] vs. 10.0 [4.7-11.9], p=0.001).Length of hospital stay was 7 [6-11] days and was significantly longer in patients who underwent combined procedures (8 [6-12] vs. 7 [6-9] days, p<0.001). Concerning in-hospital morbidity (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>), 30% of patients showed acute renal function impairment, 21% presented low cardiac output (requiring a high-dose single inotropic agent [9%], two or more inotropic agents [12%] or intra-aortic balloon pump [0.3%]), 7% had severe thrombocytopenia, 3% underwent pacemaker implantation due to atrioventricular (AV) conduction disturbances, and 2% suffered stroke. Only four patients (1%) underwent resternotomy for bleeding and none developed hemorrhagic stroke. In accordance with local protocol, patients without contraindication were discharged on vitamin K antagonists (changed to an antiplatelet agent three months after surgery); alternatively, patients were medicated with an antiplatelet agent.<elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Follow-upMean transvalvular gradient was 11.9±4.5 mmHg and EOA was 1.9±0.5 cm2 (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). PPM occurred in 38 patients (13.7%) and was severe in only one case. This patient had a BSA of 1.86 m2, a number 23 valve was implanted and the mean transprosthetic gradient on follow-up echocardiographic assessment was 13 mmHg. Mean transprosthetic gradient in patients with moderate or severe PPM was 16.3±5.6 mmHg, EOA was 1.33±0.18, BSA was 1.78±0.17 m2 and the most frequent prosthesis size was 21. Three cases of SVD were identified during follow-up (two of these patients were reoperated).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Forty-seven patients (14%) died after discharge. The underlying cause was non-cardiovascular in 25 patients and cardiovascular in 22. Two deaths related to SVD were identified: one patient died after reoperation and the other was considered unsuitable for reintervention. The one-, three-, and six-year cumulative survival rate was 94%, 87% and 72%, respectively. Patients who underwent isolated AVR showed better survival than those who underwent combined procedures (p=0.005, log-rank test) (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>).<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Six patients were reoperated: three due to endocarditis (two, 15 and 19 months after surgery), two for SVD (41 and 67 months after surgery) and one for periprosthetic fistula (two months after surgery). Two cases of prosthetic endocarditis were attributed to Staphylococcus aureus and one to Enterococcus faecalis infections; extensive root and subvalvular abscesses were found, with small or no vegetations on the cusps (two of these patients required root replacement due to extensive tissue infiltration). In the two cases of SVD (a 59-year-old male and a 67-year-old female), the surgeon found immobile and severely calcified cusps, but with only mild to moderate thickening. A visible delamination plane between the prosthesis pericardium and the native aortic root enabled easy en bloc explantation of the valves (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>). The periprosthetic fistula was due to fracture of the 4-0 polypropylene suture in the right coronary sinus, but there was no valve deterioration or root dilation, and so the leak was closed with a continuous 4-0 polypropylene suture.<elsevierMultimedia ident="fig0015"></elsevierMultimedia>Throughout follow-up, five strokes and three cases of endocarditis, treated medically, were recorded. Loss of follow-up occurred in eight cases (2.8%) (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<elsevierMultimedia ident="tbl0020"></elsevierMultimedia>DiscussionOur center's experience in a series of 345 consecutive patients who underwent AVR with FS/SS bioprosthetic valves is similar to previously published results.<a class="elsevierStyleCrossRefs" href="#bib0165">9–12,15,16</a>Except for patients with extensive aortic root calcification, severe mismatch between the aortic annulus and sinotubular junction and Sievers type 0 bicuspid aortic valve, all patients were considered for FS/SS implantation by our center's two senior surgeons, notwithstanding primary indication for surgery or concomitant procedures. This indicates that these stentless valves are widely applicable. Specifically, other types of bicuspid valve disease (8% of patients) and endocarditis (5%) were not exclusion criteria for FS/SS implantation provided that aortic root symmetry was preserved.Our sample included a higher percentage of females, similar to other series using stentless valves, as was reported in a recent systematic review and meta-analysis on surgical AVR.<a class="elsevierStyleCrossRef" href="#bib0140">4</a> According to this review, in studies on stented bioprostheses, the proportion of males is higher (61.9% vs. 55.0% for stentless bioprostheses). Also noteworthy is the different proportion of concomitant CABG procedures (41.5% vs. 28.9% in studies of stented vs. stentless bioprostheses, respectively). Moreover, it reported that early and late mortality are lower in studies on stentless valves, in accordance with the hypothesis that their hemodynamic superiority results in survival benefits compared with stented bioprostheses, but this may reflect a patient selection bias.<a class="elsevierStyleCrossRef" href="#bib0140">4</a>The implantation technique proved to be simple and fast, with a similar mean cross-clamp time for isolated AVR (67 [59-85] min) to previous studies on the Solo valve.<a class="elsevierStyleCrossRef" href="#bib0205">17</a> These times are shorter than those observed with earlier generations of stentless aortic valves (72-128 min) and also comparable to those reported for stented valves (50-67 min).<a class="elsevierStyleCrossRefs" href="#bib0205">17–20</a>In-hospital morbidity and mortality rates were low and comparable to previous studies, confirming the safety of FS/SS.<a class="elsevierStyleCrossRefs" href="#bib0155">7–10</a> Thrombocytopenia has been reported to be associated with FS/SS valves and may cause concern.<a class="elsevierStyleCrossRef" href="#bib0225">21</a> The precise mechanism remains to be identified, although Stanger et al. suggest that a temporary chemistry-induced lysis underlies this phenomenon.<a class="elsevierStyleCrossRef" href="#bib0230">22</a> We observed a mean 65% decrease in platelet count after implantation and 7% of patients showed severe thrombocytopenia. Despite this transient thrombocytopenia, only four patients underwent early resternotomy for bleeding and no episodes of hemorrhagic stroke were observed.The FS/SS supra-annular implantation technique is believed to reduce the incidence of postoperative permanent pacemaker implantation due to AV conduction disturbances, with previously published numbers between 1.3% and 2.7%, lower than those reported for stented prostheses (7% for isolated AVR).<a class="elsevierStyleCrossRefs" href="#bib0165">9–12</a> In our series, nine individuals (2.7%) underwent definitive pacemaker implantation; of these, six underwent combined procedures and one had active endocarditis.Recent reports on FS/SS valves have shown auspicious hemodynamic outcomes.<a class="elsevierStyleCrossRefs" href="#bib0195">15,16,19</a> Our assessment of these valves’ hemodynamic performance was carried out by transthoracic echocardiography 5±3 months after surgery. The mean transvalvular gradient was 11.9±4.5 mmHg and mean EOA was 1.9±0.5 cm2. These findings were consistent with those reported in previous publications on the hemodynamic profile of the FS/SS (mean pressure gradient 7.2±4.0 mmHg at one year, mean EOA 1.5±0.5 cm2 at one year).<a class="elsevierStyleCrossRef" href="#bib0175">11</a> Other studies have described similar or higher mean gradients in stented aortic bioprosthetic valves (10-16 mmHg).<a class="elsevierStyleCrossRef" href="#bib0220">20</a> Moreover, according to a 2016 study, the Solo stentless valve provides better short- and medium-term hemodynamic performance than the stented Carpentier-Edwards bioprosthetic valve.<a class="elsevierStyleCrossRef" href="#bib0200">16</a> The overall rate of PPM in our series was low (13.7% of patients), severe in only one case, which clearly demonstrates the excellent hemodynamic profile of the valve, as previously reported (overall PPM 9.8%; severe PPM 1.3%).<a class="elsevierStyleCrossRef" href="#bib0165">9</a>In our series, freedom from reoperation at six years reached 95.9%, similar to the medium-term results of Wollersheim et al. with Solo valves (96% freedom from aortic valve reoperation at six years).<a class="elsevierStyleCrossRef" href="#bib0165">9</a> On the other hand, Stanger et al. reported a higher reoperation rate, with explantation of 14 of 149 Solo valves, representing 72% freedom from aortic valve reoperation at nine years. Freedom from SVD in our series was 97.1%, slightly lower than the 98% found by Wollersheim et al. in their 350-patient series.<a class="elsevierStyleCrossRef" href="#bib0165">9</a> Stanger et al. reported 26 cases of SVD out of 149 patients (17%), 10 of them requiring reoperation, representing less than 75% freedom from SVD at nine years of follow-up.<a class="elsevierStyleCrossRef" href="#bib0230">22</a> Although medium-term outcomes seem promising, a six-year period is insufficient to draw conclusions regarding long-term durability. The durability of this bioprosthetic valve needs to be studied more thoroughly, with longer follow-up and larger samples. However, a recent multicenter study with a 10-year follow-up provides evidence of the long-term durability and hemodynamic performance of the FS valve.<a class="elsevierStyleCrossRef" href="#bib0195">15</a>Our cumulative survival rate (72% at six years) was similar to literature reports (74-80% at five years) for FS and other aortic valves.<a class="elsevierStyleCrossRefs" href="#bib0205">17,23,24</a> As expected, the survival of patients with isolated AVR was significantly better than that of patients undergoing combined procedures.Study limitationsThis work has the limitations inherent to any retrospective study. Additionally, it was a single-center study prone to selection bias because the choice of prosthesis was based on the surgeons’ preference. Finally, longer follow-up times are warranted to assess long-term durability.ConclusionsTo the best of our knowledge, this is one of the largest single-center series with FS and SS stentless aortic valves. These results support previous publications, showing that these prostheses are safe to implant, with good short- and medium-term clinical outcomes. Moreover, they should be considered a reliable alternative for AVR, as they demonstrate an excellent hemodynamic performance: low transvalvular gradients, large EOA and low incidence of PPM.Funding statementThis article is a result of the project DOCnet (NORTE-01-0145-FEDER-000003), supported by Norte Portugal Regional Operational Programme (NORTE 2020), under the PORTUGAL 2020 Partnership Agreement, through the European Regional Development Fund (ERDF). F. Saraiva was supported by Universidade do Porto/FMUP and FSE-Fundo Social Europeu, NORTE 2020-Programa Operacional Regional do Norte,NORTE-08-5369-FSE-000024-Programas Doutorais.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:13 [ 0 => array:3 [ "identificador" => "xres1101166" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1042008" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1101165" "titulo" => "Resumo" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1042007" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Study design and setting" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Study population" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Surgical and postoperative management" ] 3 => array:2 [ "identificador" => "sec0030" "titulo" => "Follow-up" ] 4 => array:2 [ "identificador" => "sec0035" "titulo" => "Statistical analysis" ] ] ] 6 => array:3 [ "identificador" => "sec0040" "titulo" => "Results" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Sample and follow-up" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Operative data" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "In-hospital outcomes" ] 3 => array:2 [ "identificador" => "sec0060" "titulo" => "Follow-up" ] ] ] 7 => array:2 [ "identificador" => "sec0065" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0070" "titulo" => "Study limitations" ] 9 => array:2 [ "identificador" => "sec0075" "titulo" => "Conclusions" ] 10 => array:2 [ "identificador" => "sec0080" "titulo" => "Funding statement" ] 11 => array:2 [ "identificador" => "sec0085" "titulo" => "Conflicts of interest" ] 12 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-08-01" "fechaAceptado" => "2017-11-03" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1042008" "palabras" => array:3 [ 0 => "Aortic valve replacement" 1 => "Stentless aortic bioprosthesis" 2 => "Cardiac surgery" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1042007" "palabras" => array:3 [ 0 => "Substituição valvular aórtica" 1 => "Bioprótese aórtica stentless" 2 => "Cirurgia cardíaca" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "ObjectiveTo report the hemodynamic profile and short- and medium-term outcomes of Freedom Solo and Solo Smart stentless aortic valves implanted at our center. MethodsBetween 2009 and 2015, all patients undergoing aortic valve replacement using Solo stentless valves at our center were enrolled. Clinical and echocardiographic follow-up was carried out six months postoperatively. Survival and major events, including structural valve deterioration and non-structural valve dysfunction, endocarditis, reoperation and stroke, were assessed through medical records or telephone interview with the referring cardiologist up to November 2015 (mean and maximum follow-up 39±22 and 78 months, respectively). ResultsPatients’ (n=345) mean age was 72±8 years, 52% were female and median euroSCORE II was 2.7 (1.5-4.7). There was no intraoperative mortality and in-hospital mortality was 2.6%. Postoperatively, mean transvalvular gradient was 11.9±4.5 mmHg and effective orifice area was 1.9±0.5 cm2. Patient-prosthesis mismatch occurred in 14% but was severe in only one patient. Cumulative survival at six years was 72%. Six patients were reoperated: three due to endocarditis, two for structural prosthesis deterioration and one because of periprosthetic fistula. Five patients suffered stroke, three had medically-treated endocarditis and one had structural valve deterioration but was not considered suitable for reoperation. None of the remainder had structural valve deterioration or non-structural valve dysfunction. ConclusionsSolo stentless aortic valves are safe to implant, with promising clinical outcomes in short- and medium-term assessment. Moreover, they show an excellent hemodynamic performance: low transvalvular gradients, large effective orifice areas and low incidence of patient-prosthesis mismatch." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "pt" => array:3 [ "titulo" => "Resumo" "resumen" => "ObjetivoDescrever o perfil hemodinâmico e resultados clínicos a curto e médio prazo das biopróteses aórticas stentless Freedom SOLO e SOLO Smart implantadas no nosso Centro. MétodosForam incluídos todos os doentes submetidos a substituição valvular aórtica por biopróteses stentless SOLO no nosso Centro, entre 2009 e 2015. O follow-up clínico e ecocardiográfico foi aos seis meses de pós-operatório. A sobrevida e eventos major (deterioração valvular estrutural, disfunção valvular não estrutural, endocardite, reoperação, acidente vascular cerebral) foram aferidos através de registos clínicos e entrevista telefónica com o Cardiologista assistente até novembro de 2015 (follow-up médio 39±22 meses, máximo 78). ResultadosA idade média dos doentes (n=345) foi 72±8 anos, 52% eram do sexo feminino e a mediana de euroSCORE II foi 2,7 (1,5–4,7). A mortalidade hospitalar foi 2,6%, não havendo mortalidade intra-operatória. O gradiente transvalvular médio pós-operatório e a média da área de orifício efetivo foram 11,9 ±4,5 mmHg e 1,9 ±0,5 cm2, respetivamente. O mismatch prótese-doente ocorreu em 14% dos casos, sendo um severo. A sobrevida cumulativa aos seis anos foi 72%. Seis indivíduos foram reoperados: três por endocardite infeciosa, dois por deterioração protésica e um por fístula periprotésica. Registaram-se cinco acidentes vasculares cerebrais, três endocardites tratadas farmacologicamente e um caso de deterioração valvular sem condições clínicas para reoperação. Não se registaram outras deteriorações valvulares estruturais ou disfunções valvulares não estruturais. ConclusõesAs biopróteses stentless SOLO apresentaram resultados a curto e médio prazo promissores, revelando um excelente perfil hemodinâmico: baixos gradientes transvalvulares, áreas de orifício efetivo grandes e baixa incidência de mismatch prótese-doente." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusões" ] ] ] ] "nomenclatura" => array:1 [ 0 => array:3 [ "identificador" => "nom0005" "titulo" => "List of abbreviations" "listaDefinicion" => array:1 [ 0 => array:1 [ "definicion" => array:12 [ 0 => array:2 [ "termino" => "AF" "descripcion" => "atrial fibrillation" ] 1 => array:2 [ "termino" => "AV" "descripcion" => "atrioventricular" ] 2 => array:2 [ "termino" => "AVR" "descripcion" => "aortic valve replacement" ] 3 => array:2 [ "termino" => "CABG" "descripcion" => "coronary artery bypass grafting" ] 4 => array:2 [ "termino" => "EOA" "descripcion" => "effective orifice area" ] 5 => array:2 [ "termino" => "FS" "descripcion" => "Freedom Solo" ] 6 => array:2 [ "termino" => "MV" "descripcion" => "mitral valve" ] 7 => array:2 [ "termino" => "PPM" "descripcion" => "patient-prosthesis mismatch" ] 8 => array:2 [ "termino" => "RF" "descripcion" => "radiofrequency" ] 9 => array:2 [ "termino" => "SS" "descripcion" => "Solo Smart" ] 10 => array:2 [ "termino" => "SVD" "descripcion" => "structural valve deterioration" ] 11 => array:2 [ "termino" => "TV" "descripcion" => "tricuspid valve" ] ] ] ] ] ] "multimedia" => array:7 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1178 "Ancho" => 1503 "Tamanyo" => 85439 ] ] "descripcion" => array:1 [ "en" => "Mean gradient and effective orifice area according to prosthesis size. EOA: effective orifice area." ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1148 "Ancho" => 2326 "Tamanyo" => 149919 ] ] "descripcion" => array:1 [ "en" => "Six-year cumulative survival of all-cohort, isolated and combined procedures. AVR: aortic valve replacement." ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 963 "Ancho" => 1674 "Tamanyo" => 174628 ] ] "descripcion" => array:1 [ "en" => "Solo bioprosthetic valve with structural valve deterioration (left); en bloc explantation of Solo valve (right)." ] ] 3 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AF: atrial fibrillation; AVR: aortic valve replacement; BMI: body mass index; BSA: body surface area; CAD: coronary artery disease; CrCl: creatinine clearance; COPD: chronic obstructive pulmonary disease; LV: left ventricular; MI: myocardial infarction; NYHA: New York Heart Association; PAD: peripheral arterial disease." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n=345 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age, years \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">72±8 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Female gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">178 (52) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">273 (79) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Diabetes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">121 (35) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dyslipidemia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">235 (68) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Smoking \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 (15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BMI, kg/m2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27.7±4.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">BSA, m2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8±0.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Obesity \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86 (25) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Renal impairment (CrCl <50 ml/min) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97 (28) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">PAD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">COPD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">66 (19) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Three-vessel CAD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">32 (9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Moderate to severe LV dysfunction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">48 (14) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Previous MI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">45 (13) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Previous cerebrovascular event \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">38 (11) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="char" valign="top">Preoperative rhythm</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sinus rhythm \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">257 (75) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">77 (22) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pacemaker \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NYHA class III-IV \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">114 (33) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Aortic valve pathology</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stenosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">254 (74) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Regurgitation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">31 (9) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Combined \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">60 (17) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Etiology</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Degenerative calcific \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">263 (76) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bicuspid \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Endocarditis (native valve) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">15 (4) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Endocarditis (prosthesis) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rheumatic \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">27 (8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prolapse \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aortic prosthesis dysfunction \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Urgent/emergent surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">64 (19) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">EuroSCORE II</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Overall \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.7 [1.5-4.7] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Isolated AVR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1.8 [1.1-3.1] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Combined procedures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3.3 [2.2-6.4] \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1884066.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Preoperative characteristics of the study population." ] ] 4 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AF: atrial fibrillation; AVR: aortic valve replacement; CABG: coronary artery bypass grafting; CPB: cardiopulmonary bypass; MV: mitral valve; RF: radiofrequency; TV: tricuspid valve." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n=345 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Isolated AVR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">167 (48) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Combined procedures</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">CABG \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">101 (29) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aorta surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">MV surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">54 (16) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">TV surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 (15) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">AF ablation by RF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">36 (10) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">CPB time, min</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Isolated procedures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 [83-118] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Combined procedures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">152 [120-201] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="2" align="left" valign="top">Cross-clamp time, min</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Isolated procedures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 [59-85] \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Combined procedures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">110 [85-140] \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1884067.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Operative data." ] ] 5 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "AF: atrial fibrillation; AVR: aortic valve replacement." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n=345 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">In-hospital mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Isolated AVR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Combined procedures \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hospital length of stay (days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7 (6-11) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Prolonged ventilation (>24 hours) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (5) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Low cardiac output \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">73 (21) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stroke \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Severe thrombocytopenia \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">25 (7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Resternotomy for bleeding \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acute renal impairment \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">104 (30) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">New-onset AF \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">113 (44) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Permanent pacemaker implantation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (3) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1884065.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Postoperative data." ] ] 6 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "SVD: structural valve deterioration." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Events \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n=336 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Structural valve deterioration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Reoperation \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 (2) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Endocarditis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">SVD \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Periprosthetic fistula \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (0) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Stroke \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Endocarditis treated medically \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (1) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1884068.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Major events." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:24 [ 0 => array:3 [ "identificador" => "bib0125" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R.A. Nishimura" 1 => "C.M. Otto" 2 => "R.O. Bonow" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1161/CIR.0000000000000029" "Revista" => array:6 [ "tituloSerie" => "Circulation" "fecha" => "2014" "volumen" => "129" "paginaInicial" => "2440" "paginaFinal" => "2492" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24589852" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0130" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "A. Vahanian" 1 => "O. Alfieri" 2 => "F. Andreotti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/ejcts/ezs455" "Revista" => array:6 [ "tituloSerie" => "Eur J Cardiothorac Surg" "fecha" => "2012" "volumen" => "42" "paginaInicial" => "S1" "paginaFinal" => "S44" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22922698" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0135" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Prosthetic heart valves: selection of the optimal prosthesis and long-term management" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "P. Pibarot" 1 => "J.G. 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Original Article

Hemodynamic and clinical performance of Solo stentless bioprosthetic aortic valves

Avaliação hemodinâmica e clínica das biopróteses aórticas stentless SOLO

Marta Andradea,b, Francisca Saraivab, Mário J. Amorima,b, Benjamim Marinhoa,b, Rui J. Cerqueiraa,b, André P. Lourençob,c, Paulo Pinhoa,b, Jorge Almeidaa,b, Adelino F. Leite-Moreiraa,b,

Corresponding author

amoreira@med.up.pt

Corresponding author.

a Department of Cardiothoracic Surgery, Centro Hospitalar de São João, Porto, Portugal

b Departamento de Cirurgia e Fisiologia, Unidade de Investigação Cardiovascular (UnIC), Faculdade de Medicina, Universidade do Porto, Porto, Portugal

c Department of Anesthesiology, Centro Hospitalar de São João, Porto, Portugal

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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Six-year cumulative survival of all-cohort&#44; isolated and combined procedures&#46; AVR&#58; aortic valve replacement&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0065" class="elsevierStylePara elsevierViewall">Degenerative aortic valve disease is the most prevalent acquired heart valve disease in the western world&#46; Surgical aortic valve replacement &#40;AVR&#41; is the therapy of choice for severe symptomatic disease and has become a safe procedure&#44; reflecting not only advances in intra- and postoperative care&#44; but also improvements in prosthetic valve design and technology&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">1&#44;2</span></a> The ideal prosthetic valve should have low transvalvular gradients&#44; maximum effective orifice area &#40;EOA&#41; and minimum patient-prosthesis mismatch &#40;PPM&#41;&#44; mimicking the anatomy and hemodynamic profile of healthy native valves&#46; Moreover&#44; it should be easy and safe to implant&#44; durable&#44; resistant to infection and have low thrombogenic risk&#46; However&#44; the search for the perfect artificial valve continues&#46;<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">3</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Stentless bioprosthetic aortic valves&#44; without an obstructive stent or a rigid suture ring&#44; have proven excellent hemodynamic performance&#44; similar to homografts&#46; This improved hemodynamic profile is also associated with survival benefit&#44; although this may be at the expense of a greater risk of structural valve deterioration &#40;SVD&#41; and need for reoperation&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> The first widely used stentless valve&#44; the Toronto SPV&#44; had low long-term durability&#44; generally attributed to its stentless design&#44; although it could also be related to its porcine origin&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">5</span></a> As with other early-generation stentless valves&#44; implantation was technically demanding&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">6</span></a> The Freedom Solo &#40;FS&#41; and Solo Smart &#40;SS&#41; biological valves &#40;Sorin Group&#44; Saluggia&#44; Italy&#41; emerged in response to these technical challenges and have been in clinical use since 2004&#46; These are third-generation stentless valves &#40;the Smart is the same model with a different holder&#41; with supra-annular implantation and a single suture line&#46; The valves are manufactured from bovine pericardial tissue detoxified in homocysteic acid&#44; which may reduce structural valve deterioration&#46; As they are stentless&#44; supra-annular and easily adaptable to the aortic root&#44; they allow larger valve sizes and EOA than an equivalent stented valve&#44; favoring laminar flow&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">7&#44;8</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">High-volume centers have begun publishing their experience with these bioprostheses&#44; confirming them as a safe and reliable alternative for AVR&#44; but the available clinical data are limited and need to be supported by larger patient series and longer follow-up times&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">9&#8211;12</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">The objective of this study is to report the hemodynamic profile and the short- and medium-term outcomes of FS&#47;SS stentless bioprosthetic valves implanted at our center during a six-year period&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Study design and setting</span><p id="par0085" class="elsevierStylePara elsevierViewall">We performed a retrospective&#44; longitudinal and descriptive study&#46; Clinical&#44; demographic&#44; operative and postoperative data were collected through medical records from the database of the Cardiothoracic Surgery Department of Centro Hospitalar S&#227;o Jo&#227;o&#46; The study was approved by the local ethics committee&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Study population</span><p id="par0090" class="elsevierStylePara elsevierViewall">Patients who underwent AVR with Freedom Solo or Solo Smart valves at Centro Hospitalar S&#227;o Jo&#227;o between April 2009 and April 2015 were identified from our center&#39;s registry&#44; regardless of primary indication for surgery or concomitant procedures&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">Preoperative data collected included age&#44; gender&#44; body surface area&#44; body mass index&#44; cardiovascular risk factors &#40;hypertension&#44; diabetes&#44; dyslipidemia&#44; smoking and obesity&#41;&#44; creatinine clearance&#44; peripheral arterial disease &#40;defined as carotid occlusion or &#62;50&#37; stenosis&#44; claudication&#44; amputation or previous or planned intervention on the abdominal aorta&#44; limb or carotid arteries&#41;&#44; cerebrovascular events &#40;transient ischemic attack or stroke&#41;&#44; chronic obstructive pulmonary disease&#44; coronary artery disease&#44; left ventricular dysfunction&#44; previous myocardial infarction&#44; preoperative rhythm&#44; New York Heart Association functional class and urgency of surgery&#46; The European System for Cardiac Operative Risk Evaluation &#40;EuroSCORE&#41; II was calculated for each patient&#46; Information was also collected on both pathology &#40;stenosis&#44; regurgitation or combined&#41; and etiology of aortic valve disease &#40;degenerative calcific&#44; bicuspid&#44; endocarditis &#91;native or prosthetic valve&#93;&#44; rheumatic&#44; prolapse or aortic prosthesis dysfunction&#41;&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">The decision to use a stentless valve was at the discretion of the surgeons&#44; after patient consent was obtained&#46; Implantation of FS&#47;SS valves was mainly performed by two senior surgeons &#40;AFL-M and MJA&#41;&#44; who considered all patients undergoing AVR with bioprosthetic valves for FS&#47;SS implantation unless the following exclusion criteria were met&#58; extensive aortic root calcification&#44; severe mismatch between aortic annulus and sinotubular junction&#44; or Sievers type 0 bicuspid aortic valve&#46; Other types of bicuspid aortic valve were not excluded if aortic root symmetry was preserved&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Surgical and postoperative management</span><p id="par0105" class="elsevierStylePara elsevierViewall">Patients underwent full or partial upper sternotomy and mild hypothermic cardiopulmonary bypass with cold crystalloid anterograde and retrograde cardioplegia&#46; A transverse aortotomy was performed approximately 1 cm above the sinotubular junction&#46; The aortic valve was excised and the annulus was completely decalcified and reinforced with a 5-0 polypropylene suture when necessary&#46; Three 4-0 polypropylene sutures were placed in a supra-annular position at the nadir of each sinus and passed through the Solo valve&#46; Thereafter&#44; the valve was parachuted into the aortic root and tied with sutures running continuously 1 mm above the annulus&#46; The sutures were passed out of the aorta at the level of the commissures and tied with the suture from the adjacent sinus&#46; Immediate outcome was assessed by intraoperative transesophageal echocardiography&#46; All patients underwent our center&#39;s standard anesthetic&#44; surgical and postoperative care procedures&#46; Surgical data were gathered regarding valve size and cardiopulmonary bypass and cross-clamp times for both isolated and combined procedures&#46; Postoperative data collected are defined in the follow-up section&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Follow-up</span><p id="par0110" class="elsevierStylePara elsevierViewall">In accordance with local protocol&#44; patients had a postoperative six-month follow-up visit at our center that included transthoracic echocardiographic assessment&#46; Mean gradients and EOA &#40;calculated using the continuity equation&#41; were recorded&#46; PPM was classified by the ratio of prosthesis EOA to patient body surface area as moderate &#40;0&#46;85-0&#46;65 cm<span class="elsevierStyleSup">2</span>&#47;m<span class="elsevierStyleSup">2</span>&#41; or severe &#40;&#60;0&#46;65 cm<span class="elsevierStyleSup">2</span>&#47;m<span class="elsevierStyleSup">2</span>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">13</span></a> Thereafter&#44; echocardiographic and clinical follow-up was carried out yearly by the patient&#39;s referring cardiologist&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In-hospital mortality &#40;defined as 30-day mortality if the patient was discharged or within any period if the patient was not discharged<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a>&#41; was retrieved from hospital medical records&#46; All-cause mortality &#40;the primary outcome&#41; was obtained from the National Healthcare Registry as of October 1&#44; 2015&#46; For the purposes of analysis&#44; all cases of unknown cause of death were considered cardiovascular deaths&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Secondary endpoints were low cardiac output &#40;need for high-dose inotropic support or intra-aortic balloon pump&#41;&#44; stroke&#44; acute renal function impairment &#40;rise of serum creatinine &#62;1&#46;5 times the preoperative value or low urine output &#91;&#60;0&#46;5 ml&#47;kg&#47;h for &#62;6 hours&#93;&#41;&#44; atrial fibrillation episodes&#44; permanent pacemaker implantation&#44; severe thrombocytopenia &#40;platelet count &#60;30&#215;10<span class="elsevierStyleSup">9</span>&#47;L&#41;&#44; early resternotomy for bleeding&#44; prolonged ventilation &#40;&#62;24 hours mechanical ventilation&#41;&#44; length of hospital stay&#44; structural valve deterioration &#40;SVD&#41; or non-structural valve dysfunction&#44; endocarditis or late reintervention for prosthesis-related issues&#46; SVD was defined as changes intrinsic to the valve&#44; such as wear&#44; calcification&#44; leaflet tear or suture line disruption of the valve&#39;s components&#44; and non-structural valve dysfunction as any abnormality not intrinsic to the valve itself resulting in dysfunction of the operated valve or hemolysis&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">14</span></a> These data were also retrieved in October 2015&#44; either from clinical records or telephone interview with the referring cardiologist&#46; Due to lack of follow-up information&#44; a post-hoc echocardiogram was performed at our center in 19 patients for the purpose of the current study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Statistical analysis</span><p id="par0125" class="elsevierStylePara elsevierViewall">Continuous variables were expressed as mean &#40;standard deviation&#41; or median &#91;interquartile range&#93; &#40;25th-75th percentile&#41;&#44; as appropriate&#46; Categorical variables were expressed as frequency and percentage&#46; Comparisons between patients undergoing more than one procedure and those undergoing isolated AVR were performed using the unpaired Student&#39;s t test or the Mann-Whitney test for continuous variables&#46; Normality was assessed by the Shapiro-Wilk test and visual inspection of residuals&#46; Kaplan-Meier curves were used to assess time-to-event data&#46; All statistical analyses were performed using IBM SPSS version 21 &#40;IBM Corporation&#44; New York&#41;&#46; A p-value less than 0&#46;05 was considered statistically significant&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Sample and follow-up</span><p id="par0130" class="elsevierStylePara elsevierViewall">Preoperative characteristics of the study population are described in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46; Patients&#8217; mean age was 72&#177;8 years and 52&#37; were female&#46; The most prevalent cardiovascular risk factors were hypertension &#40;79&#37;&#41; and dyslipidemia &#40;68&#37;&#41;&#59; 35&#37; of patients had diabetes&#44; 25&#37; were obese and 15&#37; were current or former smokers&#46; Degenerative calcific disease was the most common etiology for aortic valve disease &#40;76&#37;&#41;&#44; 8&#37; of patients had bicuspid and 8&#37; rheumatic valves&#44; and 5&#37; had endocarditis &#40;4&#37; native valve&#44; 1&#37; prosthetic&#41;&#46; The median EuroSCORE II was 2&#46;7 &#91;1&#46;5-4&#46;7&#93;&#58; 1&#46;8 &#91;1&#46;1-3&#46;1&#93; for isolated AVR and 3&#46;3 &#91;2&#46;2-6&#46;4&#93; for combined procedures&#46; Out of 345 patients&#44; 318 received FS and 27 SS&#46; Medium-term clinical and echocardiographic follow-up &#40;5&#177;3 months&#41; was retrieved from 98&#37; of patients and was 100&#37; &#40;complete&#41; for all-cause mortality&#46; Mean follow-up was 39&#177;22 months and maximum follow-up was 78 months&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Operative data</span><p id="par0135" class="elsevierStylePara elsevierViewall">The most frequently implanted valve size was no&#46; 23 &#40;39&#37;&#41;&#44; followed by sizes 25 &#40;25&#37;&#41; and 21 &#40;23&#37;&#41;&#46; One or more concomitant procedures were performed in 52&#37; of patients &#40;summarized in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; Coronary artery bypass grafting &#40;CABG&#41; was the most frequent combined procedure &#40;29&#37;&#41;&#59; mitral and tricuspid valves&#44; as well as the ascending aorta&#44; were also commonly treated&#46; Compared with isolated AVR&#44; combined procedures had longer median cardiopulmonary bypass and cross-clamp times&#44; 95 &#91;83-118&#93; vs&#46; 152 min &#91;120-201&#93; and 67 &#91;59-85&#93; vs&#46; 110 min &#91;85-140&#93; &#40;p&#60;0&#46;001&#41;&#44; respectively&#46; There was no intraoperative mortality&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">In-hospital outcomes</span><p id="par0140" class="elsevierStylePara elsevierViewall">Overall in-hospital mortality was 2&#46;6&#37; &#40;n&#61;9&#41;&#44; 1&#46;8&#37; &#40;n&#61;3&#41; for isolated AVR and 3&#46;4&#37; &#40;n&#61;6&#41; for combined procedures&#46; Causes of death were prosthetic endocarditis &#40;n&#61;1&#41;&#44; cardiogenic shock &#40;n&#61;2&#41;&#44; septic shock &#40;n&#61;3&#41;&#44; multiorgan failure &#40;n&#61;2&#41; and iatrogenic complication of intensive care unit procedure &#40;n&#61;1&#41;&#46; EuroSCORE II was lower in surviving patients &#40;2&#46;6 &#91;1&#46;5-4&#46;6&#93; vs&#46; 10&#46;0 &#91;4&#46;7-11&#46;9&#93;&#44; p&#61;0&#46;001&#41;&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Length of hospital stay was 7 &#91;6-11&#93; days and was significantly longer in patients who underwent combined procedures &#40;8 &#91;6-12&#93; vs&#46; 7 &#91;6-9&#93; days&#44; p&#60;0&#46;001&#41;&#46; Concerning in-hospital morbidity &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#44; 30&#37; of patients showed acute renal function impairment&#44; 21&#37; presented low cardiac output &#40;requiring a high-dose single inotropic agent &#91;9&#37;&#93;&#44; two or more inotropic agents &#91;12&#37;&#93; or intra-aortic balloon pump &#91;0&#46;3&#37;&#93;&#41;&#44; 7&#37; had severe thrombocytopenia&#44; 3&#37; underwent pacemaker implantation due to atrioventricular &#40;AV&#41; conduction disturbances&#44; and 2&#37; suffered stroke&#46; Only four patients &#40;1&#37;&#41; underwent resternotomy for bleeding and none developed hemorrhagic stroke&#46; In accordance with local protocol&#44; patients without contraindication were discharged on vitamin K antagonists &#40;changed to an antiplatelet agent three months after surgery&#41;&#59; alternatively&#44; patients were medicated with an antiplatelet agent&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Follow-up</span><p id="par0150" class="elsevierStylePara elsevierViewall">Mean transvalvular gradient was 11&#46;9&#177;4&#46;5 mmHg and EOA was 1&#46;9&#177;0&#46;5 cm<span class="elsevierStyleSup">2</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; PPM occurred in 38 patients &#40;13&#46;7&#37;&#41; and was severe in only one case&#46; This patient had a BSA of 1&#46;86 m<span class="elsevierStyleSup">2</span>&#44; a number 23 valve was implanted and the mean transprosthetic gradient on follow-up echocardiographic assessment was 13 mmHg&#46; Mean transprosthetic gradient in patients with moderate or severe PPM was 16&#46;3&#177;5&#46;6 mmHg&#44; EOA was 1&#46;33&#177;0&#46;18&#44; BSA was 1&#46;78&#177;0&#46;17 m<span class="elsevierStyleSup">2</span> and the most frequent prosthesis size was 21&#46; Three cases of SVD were identified during follow-up &#40;two of these patients were reoperated&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0155" class="elsevierStylePara elsevierViewall">Forty-seven patients &#40;14&#37;&#41; died after discharge&#46; The underlying cause was non-cardiovascular in 25 patients and cardiovascular in 22&#46; Two deaths related to SVD were identified&#58; one patient died after reoperation and the other was considered unsuitable for reintervention&#46; The one-&#44; three-&#44; and six-year cumulative survival rate was 94&#37;&#44; 87&#37; and 72&#37;&#44; respectively&#46; Patients who underwent isolated AVR showed better survival than those who underwent combined procedures &#40;p&#61;0&#46;005&#44; log-rank test&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0160" class="elsevierStylePara elsevierViewall">Six patients were reoperated&#58; three due to endocarditis &#40;two&#44; 15 and 19 months after surgery&#41;&#44; two for SVD &#40;41 and 67 months after surgery&#41; and one for periprosthetic fistula &#40;two months after surgery&#41;&#46; Two cases of prosthetic endocarditis were attributed to <span class="elsevierStyleItalic">Staphylococcus aureus</span> and one to <span class="elsevierStyleItalic">Enterococcus faecalis</span> infections&#59; extensive root and subvalvular abscesses were found&#44; with small or no vegetations on the cusps &#40;two of these patients required root replacement due to extensive tissue infiltration&#41;&#46; In the two cases of SVD &#40;a 59-year-old male and a 67-year-old female&#41;&#44; the surgeon found immobile and severely calcified cusps&#44; but with only mild to moderate thickening&#46; A visible delamination plane between the prosthesis pericardium and the native aortic root enabled easy en bloc explantation of the valves &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; The periprosthetic fistula was due to fracture of the 4-0 polypropylene suture in the right coronary sinus&#44; but there was no valve deterioration or root dilation&#44; and so the leak was closed with a continuous 4-0 polypropylene suture&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Throughout follow-up&#44; five strokes and three cases of endocarditis&#44; treated medically&#44; were recorded&#46; Loss of follow-up occurred in eight cases &#40;2&#46;8&#37;&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0170" class="elsevierStylePara elsevierViewall">Our center&#39;s experience in a series of 345 consecutive patients who underwent AVR with FS&#47;SS bioprosthetic valves is similar to previously published results&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">9&#8211;12&#44;15&#44;16</span></a></p><p id="par0175" class="elsevierStylePara elsevierViewall">Except for patients with extensive aortic root calcification&#44; severe mismatch between the aortic annulus and sinotubular junction and Sievers type 0 bicuspid aortic valve&#44; all patients were considered for FS&#47;SS implantation by our center&#39;s two senior surgeons&#44; notwithstanding primary indication for surgery or concomitant procedures&#46; This indicates that these stentless valves are widely applicable&#46; Specifically&#44; other types of bicuspid valve disease &#40;8&#37; of patients&#41; and endocarditis &#40;5&#37;&#41; were not exclusion criteria for FS&#47;SS implantation provided that aortic root symmetry was preserved&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">Our sample included a higher percentage of females&#44; similar to other series using stentless valves&#44; as was reported in a recent systematic review and meta-analysis on surgical AVR&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a> According to this review&#44; in studies on stented bioprostheses&#44; the proportion of males is higher &#40;61&#46;9&#37; vs&#46; 55&#46;0&#37; for stentless bioprostheses&#41;&#46; Also noteworthy is the different proportion of concomitant CABG procedures &#40;41&#46;5&#37; vs&#46; 28&#46;9&#37; in studies of stented vs&#46; stentless bioprostheses&#44; respectively&#41;&#46; Moreover&#44; it reported that early and late mortality are lower in studies on stentless valves&#44; in accordance with the hypothesis that their hemodynamic superiority results in survival benefits compared with stented bioprostheses&#44; but this may reflect a patient selection bias&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">4</span></a></p><p id="par0185" class="elsevierStylePara elsevierViewall">The implantation technique proved to be simple and fast&#44; with a similar mean cross-clamp time for isolated AVR &#40;67 &#91;59-85&#93; min&#41; to previous studies on the Solo valve&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">17</span></a> These times are shorter than those observed with earlier generations of stentless aortic valves &#40;72-128 min&#41; and also comparable to those reported for stented valves &#40;50-67 min&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">17&#8211;20</span></a></p><p id="par0190" class="elsevierStylePara elsevierViewall">In-hospital morbidity and mortality rates were low and comparable to previous studies&#44; confirming the safety of FS&#47;SS&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">7&#8211;10</span></a> Thrombocytopenia has been reported to be associated with FS&#47;SS valves and may cause concern&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">21</span></a> The precise mechanism remains to be identified&#44; although Stanger et al&#46; suggest that a temporary chemistry-induced lysis underlies this phenomenon&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> We observed a mean 65&#37; decrease in platelet count after implantation and 7&#37; of patients showed severe thrombocytopenia&#46; Despite this transient thrombocytopenia&#44; only four patients underwent early resternotomy for bleeding and no episodes of hemorrhagic stroke were observed&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">The FS&#47;SS supra-annular implantation technique is believed to reduce the incidence of postoperative permanent pacemaker implantation due to AV conduction disturbances&#44; with previously published numbers between 1&#46;3&#37; and 2&#46;7&#37;&#44; lower than those reported for stented prostheses &#40;7&#37; for isolated AVR&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">9&#8211;12</span></a> In our series&#44; nine individuals &#40;2&#46;7&#37;&#41; underwent definitive pacemaker implantation&#59; of these&#44; six underwent combined procedures and one had active endocarditis&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Recent reports on FS&#47;SS valves have shown auspicious hemodynamic outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0195"><span class="elsevierStyleSup">15&#44;16&#44;19</span></a> Our assessment of these valves&#8217; hemodynamic performance was carried out by transthoracic echocardiography 5&#177;3 months after surgery&#46; The mean transvalvular gradient was 11&#46;9&#177;4&#46;5 mmHg and mean EOA was 1&#46;9&#177;0&#46;5 cm<span class="elsevierStyleSup">2</span>&#46; These findings were consistent with those reported in previous publications on the hemodynamic profile of the FS&#47;SS &#40;mean pressure gradient 7&#46;2&#177;4&#46;0 mmHg at one year&#44; mean EOA 1&#46;5&#177;0&#46;5 cm<span class="elsevierStyleSup">2</span> at one year&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">11</span></a> Other studies have described similar or higher mean gradients in stented aortic bioprosthetic valves &#40;10-16 mmHg&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0220"><span class="elsevierStyleSup">20</span></a> Moreover&#44; according to a 2016 study&#44; the Solo stentless valve provides better short- and medium-term hemodynamic performance than the stented Carpentier-Edwards bioprosthetic valve&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">16</span></a> The overall rate of PPM in our series was low &#40;13&#46;7&#37; of patients&#41;&#44; severe in only one case&#44; which clearly demonstrates the excellent hemodynamic profile of the valve&#44; as previously reported &#40;overall PPM 9&#46;8&#37;&#59; severe PPM 1&#46;3&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">In our series&#44; freedom from reoperation at six years reached 95&#46;9&#37;&#44; similar to the medium-term results of Wollersheim et al&#46; with Solo valves &#40;96&#37; freedom from aortic valve reoperation at six years&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a> On the other hand&#44; Stanger et al&#46; reported a higher reoperation rate&#44; with explantation of 14 of 149 Solo valves&#44; representing 72&#37; freedom from aortic valve reoperation at nine years&#46; Freedom from SVD in our series was 97&#46;1&#37;&#44; slightly lower than the 98&#37; found by Wollersheim et al&#46; in their 350-patient series&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">9</span></a> Stanger et al&#46; reported 26 cases of SVD out of 149 patients &#40;17&#37;&#41;&#44; 10 of them requiring reoperation&#44; representing less than 75&#37; freedom from SVD at nine years of follow-up&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">22</span></a> Although medium-term outcomes seem promising&#44; a six-year period is insufficient to draw conclusions regarding long-term durability&#46; The durability of this bioprosthetic valve needs to be studied more thoroughly&#44; with longer follow-up and larger samples&#46; However&#44; a recent multicenter study with a 10-year follow-up provides evidence of the long-term durability and hemodynamic performance of the FS valve&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">15</span></a></p><p id="par0210" class="elsevierStylePara elsevierViewall">Our cumulative survival rate &#40;72&#37; at six years&#41; was similar to literature reports &#40;74-80&#37; at five years&#41; for FS and other aortic valves&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">17&#44;23&#44;24</span></a> As expected&#44; the survival of patients with isolated AVR was significantly better than that of patients undergoing combined procedures&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Study limitations</span><p id="par0215" class="elsevierStylePara elsevierViewall">This work has the limitations inherent to any retrospective study&#46; Additionally&#44; it was a single-center study prone to selection bias because the choice of prosthesis was based on the surgeons&#8217; preference&#46; Finally&#44; longer follow-up times are warranted to assess long-term durability&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conclusions</span><p id="par0220" class="elsevierStylePara elsevierViewall">To the best of our knowledge&#44; this is one of the largest single-center series with FS and SS stentless aortic valves&#46; These results support previous publications&#44; showing that these prostheses are safe to implant&#44; with good short- and medium-term clinical outcomes&#46; Moreover&#44; they should be considered a reliable alternative for AVR&#44; as they demonstrate an excellent hemodynamic performance&#58; low transvalvular gradients&#44; large EOA and low incidence of PPM&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Funding statement</span><p id="par0225" class="elsevierStylePara elsevierViewall">This article is a result of the project DOCnet &#40;NORTE-01-0145-FEDER-000003&#41;&#44; supported by Norte Portugal Regional Operational Programme &#40;NORTE 2020&#41;&#44; under the PORTUGAL 2020 Partnership Agreement&#44; through the European Regional Development Fund &#40;ERDF&#41;&#46; F&#46; Saraiva was supported by Universidade do Porto&#47;FMUP and FSE-Fundo Social Europeu&#44; NORTE 2020-Programa Operacional Regional do Norte&#44;NORTE-08-5369-FSE-000024-Programas Doutorais&#46;</p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Conflicts of interest</span><p id="par0230" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To report the hemodynamic profile and short- and medium-term outcomes of Freedom Solo and Solo Smart stentless aortic valves implanted at our center&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Between 2009 and 2015&#44; all patients undergoing aortic valve replacement using Solo stentless valves at our center were enrolled&#46; Clinical and echocardiographic follow-up was carried out six months postoperatively&#46; Survival and major events&#44; including structural valve deterioration and non-structural valve dysfunction&#44; endocarditis&#44; reoperation and stroke&#44; were assessed through medical records or telephone interview with the referring cardiologist up to November 2015 &#40;mean and maximum follow-up 39&#177;22 and 78 months&#44; respectively&#41;&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Patients&#8217; &#40;n&#61;345&#41; mean age was 72&#177;8 years&#44; 52&#37; were female and median euroSCORE II was 2&#46;7 &#40;1&#46;5-4&#46;7&#41;&#46; There was no intraoperative mortality and in-hospital mortality was 2&#46;6&#37;&#46; Postoperatively&#44; mean transvalvular gradient was 11&#46;9&#177;4&#46;5 mmHg and effective orifice area was 1&#46;9&#177;0&#46;5 cm<span class="elsevierStyleSup">2</span>&#46; Patient-prosthesis mismatch occurred in 14&#37; but was severe in only one patient&#46; Cumulative survival at six years was 72&#37;&#46; Six patients were reoperated&#58; three due to endocarditis&#44; two for structural prosthesis deterioration and one because of periprosthetic fistula&#46; Five patients suffered stroke&#44; three had medically-treated endocarditis and one had structural valve deterioration but was not considered suitable for reoperation&#46; None of the remainder had structural valve deterioration or non-structural valve dysfunction&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Solo stentless aortic valves are safe to implant&#44; with promising clinical outcomes in short- and medium-term assessment&#46; Moreover&#44; they show an excellent hemodynamic performance&#58; low transvalvular gradients&#44; large effective orifice areas and low incidence of patient-prosthesis mismatch&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Descrever o perfil hemodin&#226;mico e resultados cl&#237;nicos a curto e m&#233;dio prazo das biopr&#243;teses a&#243;rticas stentless Freedom SOLO e SOLO Smart implantadas no nosso Centro&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foram inclu&#237;dos todos os doentes submetidos a substitui&#231;&#227;o valvular a&#243;rtica por biopr&#243;teses stentless SOLO no nosso Centro&#44; entre 2009 e 2015&#46; O <span class="elsevierStyleItalic">follow-up</span> cl&#237;nico e ecocardiogr&#225;fico foi aos seis meses de p&#243;s-operat&#243;rio&#46; A sobrevida e eventos <span class="elsevierStyleItalic">major</span> &#40;deteriora&#231;&#227;o valvular estrutural&#44; disfun&#231;&#227;o valvular n&#227;o estrutural&#44; endocardite&#44; reopera&#231;&#227;o&#44; acidente vascular cerebral&#41; foram aferidos atrav&#233;s de registos cl&#237;nicos e entrevista telef&#243;nica com o Cardiologista assistente at&#233; novembro de 2015 &#40;follow-up m&#233;dio 39&#177;22 meses&#44; m&#225;ximo 78&#41;&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">A idade m&#233;dia dos doentes &#40;n&#61;345&#41; foi 72&#177;8 anos&#44; 52&#37; eram do sexo feminino e a mediana de euroSCORE II foi 2&#44;7 &#40;1&#44;5&#8211;4&#44;7&#41;&#46; A mortalidade hospitalar foi 2&#44;6&#37;&#44; n&#227;o havendo mortalidade intra-operat&#243;ria&#46; O gradiente transvalvular m&#233;dio p&#243;s-operat&#243;rio e a m&#233;dia da &#225;rea de orif&#237;cio efetivo foram 11&#44;9 &#177;4&#44;5 mmHg e 1&#44;9 &#177;0&#44;5 cm<span class="elsevierStyleSup">2</span>&#44; respetivamente&#46; O <span class="elsevierStyleItalic">mismatch</span> pr&#243;tese-doente ocorreu em 14&#37; dos casos&#44; sendo um severo&#46; A sobrevida cumulativa aos seis anos foi 72&#37;&#46; Seis indiv&#237;duos foram reoperados&#58; tr&#234;s por endocardite infeciosa&#44; dois por deteriora&#231;&#227;o prot&#233;sica e um por f&#237;stula periprot&#233;sica&#46; Registaram-se cinco acidentes vasculares cerebrais&#44; tr&#234;s endocardites tratadas farmacologicamente e um caso de deteriora&#231;&#227;o valvular sem condi&#231;&#245;es cl&#237;nicas para reopera&#231;&#227;o&#46; N&#227;o se registaram outras deteriora&#231;&#245;es valvulares estruturais ou disfun&#231;&#245;es valvulares n&#227;o estruturais&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">As biopr&#243;teses stentless SOLO apresentaram resultados a curto e m&#233;dio prazo promissores&#44; revelando um excelente perfil hemodin&#226;mico&#58; baixos gradientes transvalvulares&#44; &#225;reas de orif&#237;cio efetivo grandes e baixa incid&#234;ncia de <span class="elsevierStyleItalic">mismatch</span> pr&#243;tese-doente&#46;</p></span>"
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      0 => array:3 [
        "identificador" => "nom0005"
        "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0065">List of abbreviations</span>"
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          0 => array:1 [
            "definicion" => array:12 [
              0 => array:2 [
                "termino" => "AF"
                "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">atrial fibrillation</p>"
              ]
              1 => array:2 [
                "termino" => "AV"
                "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">atrioventricular</p>"
              ]
              2 => array:2 [
                "termino" => "AVR"
                "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">aortic valve replacement</p>"
              ]
              3 => array:2 [
                "termino" => "CABG"
                "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">coronary artery bypass grafting</p>"
              ]
              4 => array:2 [
                "termino" => "EOA"
                "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">effective orifice area</p>"
              ]
              5 => array:2 [
                "termino" => "FS"
                "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">Freedom Solo</p>"
              ]
              6 => array:2 [
                "termino" => "MV"
                "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">mitral valve</p>"
              ]
              7 => array:2 [
                "termino" => "PPM"
                "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">patient-prosthesis mismatch</p>"
              ]
              8 => array:2 [
                "termino" => "RF"
                "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">radiofrequency</p>"
              ]
              9 => array:2 [
                "termino" => "SS"
                "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">Solo Smart</p>"
              ]
              10 => array:2 [
                "termino" => "SVD"
                "descripcion" => "<p id="par0055" class="elsevierStylePara elsevierViewall">structural valve deterioration</p>"
              ]
              11 => array:2 [
                "termino" => "TV"
                "descripcion" => "<p id="par0060" class="elsevierStylePara elsevierViewall">tricuspid valve</p>"
              ]
            ]
          ]
        ]
      ]
    ]
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        "etiqueta" => "Figure 1"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Mean gradient and effective orifice area according to prosthesis size&#46; EOA&#58; effective orifice area&#46;</p>"
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        "etiqueta" => "Figure 2"
        "tipo" => "MULTIMEDIAFIGURA"
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          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Six-year cumulative survival of all-cohort&#44; isolated and combined procedures&#46; AVR&#58; aortic valve replacement&#46;</p>"
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      2 => array:7 [
        "identificador" => "fig0015"
        "etiqueta" => "Figure 3"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
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          "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Solo bioprosthetic valve with structural valve deterioration &#40;left&#41;&#59; en bloc explantation of Solo valve &#40;right&#41;&#46;</p>"
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          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">AF&#58; atrial fibrillation&#59; AVR&#58; aortic valve replacement&#59; BMI&#58; body mass index&#59; BSA&#58; body surface area&#59; CAD&#58; coronary artery disease&#59; CrCl&#58; creatinine clearance&#59; COPD&#58; chronic obstructive pulmonary disease&#59; LV&#58; left ventricular&#59; MI&#58; myocardial infarction&#59; NYHA&#58; New York Heart Association&#59; PAD&#58; peripheral arterial disease&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n&#61;345&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age&#44; years</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">72&#177;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Female gender</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">178 &#40;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hypertension</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">273 &#40;79&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Diabetes</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">121 &#40;35&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Dyslipidemia</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">235 &#40;68&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Smoking</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">BMI&#44; kg&#47;m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27&#46;7&#177;4&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">BSA&#44; m</span><span class="elsevierStyleSup"><span class="elsevierStyleItalic">2</span></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;8&#177;0&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Obesity</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86 &#40;25&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Renal impairment &#40;CrCl &#60;50 ml&#47;min&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97 &#40;28&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">PAD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">COPD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">66 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Three-vessel CAD</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Moderate to severe LV dysfunction</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">48 &#40;14&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Previous MI</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">45 &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Previous cerebrovascular event</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">38 &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="char" valign="top"><span class="elsevierStyleItalic">Preoperative rhythm</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Sinus rhythm&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">257 &#40;75&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>AF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">77 &#40;22&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Pacemaker&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>NYHA class III-IV&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">114 &#40;33&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Aortic valve pathology</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">254 &#40;74&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Regurgitation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">31 &#40;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Combined&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60 &#40;17&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Etiology</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Degenerative calcific&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">263 &#40;76&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Bicuspid&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Endocarditis &#40;native valve&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Endocarditis &#40;prosthesis&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Rheumatic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">27 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Prolapse&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aortic prosthesis dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Urgent&#47;emergent surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">64 &#40;19&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">EuroSCORE II</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Overall&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;7 &#91;1&#46;5-4&#46;7&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Isolated AVR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&#46;8 &#91;1&#46;1-3&#46;1&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Combined procedures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;3 &#91;2&#46;2-6&#46;4&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">AF&#58; atrial fibrillation&#59; AVR&#58; aortic valve replacement&#59; CABG&#58; coronary artery bypass grafting&#59; CPB&#58; cardiopulmonary bypass&#59; MV&#58; mitral valve&#59; RF&#58; radiofrequency&#59; TV&#58; tricuspid valve&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Variables&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n&#61;345&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Isolated AVR</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">167 &#40;48&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Combined procedures</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>CABG&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">101 &#40;29&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Aorta surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>MV surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>TV surgery&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51 &#40;15&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>AF ablation by RF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">36 &#40;10&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">CPB time&#44; min</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Isolated procedures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95 &#91;83-118&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Combined procedures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">152 &#91;120-201&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Cross-clamp time&#44; min</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Isolated procedures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">67 &#91;59-85&#93;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Combined procedures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">110 &#91;85-140&#93;&nbsp;\t\t\t\t\t\t\n
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">n&#61;345&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">In-hospital mortality</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Isolated AVR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Combined procedures&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">16 &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Low cardiac output</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73 &#40;21&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6 &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25 &#40;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Resternotomy for bleeding</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Periprosthetic fistula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Endocarditis treated medically</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Major events&#46;</p>"
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    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:24 [
            0 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2014 AHA&#47;ACC Guideline for the Management of Patients With Valvular Heart Disease&#58; executive summary&#58; a report of the American College of Cardiology&#47;American Heart Association Task Force on Practice Guidelines"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "R&#46;A&#46; Nishimura"
                            1 => "C&#46;M&#46; Otto"
                            2 => "R&#46;O&#46; Bonow"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1161/CIR.0000000000000029"
                      "Revista" => array:6 [
                        "tituloSerie" => "Circulation"
                        "fecha" => "2014"
                        "volumen" => "129"
                        "paginaInicial" => "2440"
                        "paginaFinal" => "2492"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24589852"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
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            1 => array:3 [
              "identificador" => "bib0130"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Guidelines on the management of valvular heart disease &#40;version 2012&#41;&#58; the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology &#40;ESC&#41; and the European Association for Cardio-Thoracic Surgery &#40;EACTS&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "A&#46; Vahanian"
                            1 => "O&#46; Alfieri"
                            2 => "F&#46; Andreotti"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1093/ejcts/ezs455"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Cardiothorac Surg"
                        "fecha" => "2012"
                        "volumen" => "42"
                        "paginaInicial" => "S1"
                        "paginaFinal" => "S44"
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2017.11.020

The statistics are updated each day

Year/Month	Html	Pdf	Total

2024 November	6	2	8
2024 October	32	33	65
2024 September	34	26	60
2024 August	41	23	64
2024 July	25	26	51
2024 June	23	20	43
2024 May	23	26	49
2024 April	28	28	56
2024 March	15	22	37
2024 February	25	24	49
2024 January	22	22	44
2023 December	13	20	33
2023 November	27	25	52
2023 October	18	12	30
2023 September	15	22	37
2023 August	24	18	42
2023 July	32	12	44
2023 June	30	13	43
2023 May	31	32	63
2023 April	21	5	26
2023 March	48	23	71
2023 February	28	23	51
2023 January	14	17	31
2022 December	43	17	60
2022 November	43	34	77
2022 October	32	19	51
2022 September	26	37	63
2022 August	19	32	51
2022 July	31	37	68
2022 June	27	23	50
2022 May	23	30	53
2022 April	25	34	59
2022 March	29	39	68
2022 February	33	34	67
2022 January	53	23	76
2021 December	33	32	65
2021 November	29	36	65
2021 October	25	41	66
2021 September	27	24	51
2021 August	26	25	51
2021 July	27	23	50
2021 June	25	23	48
2021 May	31	32	63
2021 April	44	24	68
2021 March	33	19	52
2021 February	20	15	35
2021 January	27	16	43
2020 December	32	12	44
2020 November	35	20	55
2020 October	10	17	27
2020 September	29	13	42
2020 August	11	11	22
2020 July	25	11	36
2020 June	23	5	28
2020 May	12	11	23
2020 April	15	7	22
2020 March	22	8	30
2020 February	37	50	87
2020 January	10	7	17
2019 December	13	12	25
2019 November	11	9	20
2019 October	20	4	24
2019 September	36	9	45
2019 August	15	8	23
2019 July	6	8	14
2019 June	19	17	36
2019 May	18	8	26
2019 April	16	18	34
2019 March	13	9	22
2019 February	12	21	33
2019 January	12	17	29
2018 December	14	29	43
2018 November	55	42	97
2018 October	4	3	7

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