Academician Evgeniy Nikolaevich Meshalkin (1916–1997) (on the 105th anniversary of his birth)

The outstanding cardiologist and cardiac surgeon Evgeny Nikolaevich Meshalkin was born on February 25, 1916 in the city of Yekaterinoslav, now Dnepropetrovsk. In 1918, the Meshalkin family moved to Rostov-on-Don, and in 1928 to Moscow, where Evgeny graduated from school in 1930, and then studied at the factory school at the Sickle and Hammer factory. In 1941, Evgeny Nikolaevich graduated from the 2nd Moscow Medical Institute and from August 1941 to May 1945 was a participant of the Great Patriotic War permanently in the field army. After demobilization from the army, E. N. Meshalkin worked from 1946 to 1956 at the department and at the clinic of Faculty Surgery of the 2nd Moscow State Medical Institute, headed by Academician of the USSR Academy of Medical Sciences A. N. Bakulev. In 1950, he defended his PhD thesis «Intubation anesthesia», and in 1953, his first monograph «Intubation anesthesia Technique» was published. Evgeny Nikolaevich is rightfully considered one of the founders of the Russian anesthesiology. In 1953, E. N. Meshalkin defended his doctoral dissertation «Probing and contrast study of the heart and major vessels». In conditions of moderate nonperfusion hypothermia, Yevgeny Nikolaevich successfully operated on complex heart defects, performed the insertion of mechanical prostheses for mitral and aortic insufficiency. From January 1956 to 1960, he was the head of the Department of Thoracic Surgery and Anesthesiology of the Central Institute of Advanced Medical Training (now the Russian Medical Academy of Postgraduate Education). E.N.Meshalkin owns 47 copyright certificates and patents, which are implemented not only in the Research Institute of Circulatory Pathology, but also in other cardiac surgery centers in Russia. Honorary citizen of Novosibirsk Evgeny Nikolaevich Meshalkin passed away on March 8, 1997 and was buried in Novosibirsk at the Southern Cemetery. In memory of the outstanding scientist, the Novosibirsk Research Institute of Circulatory Pathology was named after Academician E. N. Meshalkin.

Evaluation of hemostasis parameters after mitral valve replacement surgery with mechanical prostheses in patients with different treatment adherence

The aim of the study. To analyze the indicators of hemostasis with adherence to treatment in patients operated on for mitral valve prosthetics with mechanical bicuspid prostheses in dynamics after 6, 12 and 60 months.Materials and methods. The study included 260 patients who underwent surgery for prosthetics with mechanical prostheses. Patients’ adherence to treatment was assessed using the Morisky – Green test. The following hemostasis parameters were analyzed: international normalized ratio (INR), activated partial thromboplastin time (APTT), D-dimer, fibrinogen and soluble fibrin-monomer complexes.Results of the study and conclusion. At all stages of the postoperative period, the hemostasis indicators of compliant patients corresponded to the reference values for people receiving anticoagulants, in non-compliant patients, these indicators did not reach the recommended values for patients on anticoagulant therapy. The presence of correlations between compliance and hemostasis indicators is evidenced by the results of correlation analysis. In most cases, the maximum strength of the relationship between compliance and hemostasis indicators was observed after 12 months of follow-up. A noticeable strength of interrelations was traced between compliance and levels of APTT, INR and fibrinogen.

Redo Mitral Valve Replacement using St. Jude Medical Mechanical Prostheses in a Patient with Degenerated Mitral Perimount Bioprosthesis: A Video Presentation

Current consensus guidelines of the American Heart Association and European Society of Cardiology, uniformly recommend either type of prosthetic mitral valve for patients aged 60 to 70 years, and mechanical prosthesis for patients less than 60 years.

Thrombotic and hemorrhagic complications during pregnancy, delivery and the postpartum period in females with prosthetic heart valves

Background/Introduction Women with mechanical prosthetic heart valves are at greatest risk of developing complications.The main reason is that mechanical prosthetic heart valves require lifelong anticoagulation to reduce the high risk of associated thrombotic and hemorrhagic complications. Purpose The main goal of this study was to estimated risk factors and frequency of thrombotic and hemorrhagic complications during pregnancy, delivery and the postpartum period in women with prosthetic heart valves Methods According to retrospective cohort analyses in this study were included 70 patients with prosthetic heart valves who delivered in a specialized perinatal center from October 2010 to February 2020. All the patients were divided into two groups depending on prosthesis type: mechanical prostheses (44 deliveries in 44 patients), biological prostheses (22 deliveries in 19 patients). All patients were performed ECHO (Vivid 7, GE, USA). The average age were 30.7±5.2 years. The N-terminal brain natriuretic propeptide (NT-proBNP) concentration was determined by the quantitative electrochemiluminescence method using a Cobas E 411 analyzer (Roche, Switzerland). The activity of the anti –Xa factor was measured by chromogenic assays. Results In 9 (21.4%) pregnants with a mechanical valve prosthesis (MVP), prosthetic thrombosis was recorded until 2016. In 1 patient with mechanical valve prosthesis (2%) during pregnancy was complicated by an acute cerebral circulation disorder. Since 2016 there were monitored the activity of the anti –Xa factor. In 7 patients on the background of a change in anticoagulant therapy, pregnancy stopped in the early stages. Before pregnancy, 31.4% of the patients didn't have heart failure clinical manifestations, but in 12 (17.1%) patients during pregnancy had increase in NYHA Class maximum to NYHA Class III. The average NT-proBNP concentration was 912.3±1586.6 pg / ml. The frequency of the cesarean section in both groups was high: in patients with mechanical valve prosthesis in 78.5% and in the group of patients with biological valve prostheses in 68.1% of cases. There were not registered any new cases of prosthetic thrombosis after delivery, however, 9 patients had hemorrhagic complications in the early postpartum period, which required relaparotomy and blood transfusions. Regardless of frequent complications during pregnancy and in the postpartum period, no fatal outcomes have been reported. Conclusion The absence of mortality over the 9-years old observation and delivery in patients with valvular prostheses demonstrates the feasibility of monitoring and delivery of this category of patients in a specialized multidisciplinary medical center with experience in managing patients during pregnancy with valvular prostheses on anticoagulant therapy. FUNDunding Acknowledgement Type of funding sources: None.

Tissue Engineering Heart Valves – a Review of More than Two Decades into Preclinical and Clinical Testing for Obtaining the Next Generation of Heart Valve Substitutes

Well documented shortcomings of current heart valve substitutes – biological and mechanical prostheses make them imperfect choices for patients diagnosed with heart valve disease, in need for a cardiac valve replacement. Regenerative Medicine and Tissue Engineering represent the research grounds of the next generation of valvular prostheses – Tissue Engineering Heart Valves (TEHV). Mimicking the structure and function of the native valves, TEHVs are three dimensional structures obtained in laboratories encompassing scaffolds (natural and synthetic), cells (stem cells and differentiated cells) and bioreactors. The literature stipulates two major heart valve regeneration paradigms, differing in the manner of autologous cells repopulation of the scaffolds; in vitro, or in vivo, respectively. During the past two decades, multidisciplinary both in vitro and in vitro research work was performed and published. In vivo experience comprises preclinical tests in experimental animal model and cautious limited clinical translation in patients. Despite initial encouraging results, translation of their usage in large clinical scenarios represents the most important challenge that needs to be overcome. This review purpose is to outline the most remarkable preclinical and clinical results of TEHV evaluation along with the lessons learnt from all this experience.

Considerations for prostheses choice in multiple valve surgery

Objectives The prosthesis type for multiple valve surgery (replacement of two or more diseased native or prosthetic valves, replacement of two diseased valves with repair/reconstruction of a third, or replacement of a single diseased valve with repair/reconstruction of a second valve) remains inadequately evaluated. The clinical performance of multiple valve surgery with bioprostheses (BP) and mechanical prostheses (MP) was assessed to compare patient survival and composites of valve-related complications. Methods Between 1975 and 2000, 1245 patients had multiple valve surgery (BP 785, mean age 62.0 ± 14.7 years; and MP 460, mean age 56.9 ± 12.9 years). There were 1712 procedures performed [BP 969(56.6%) and MP 743(43.4%). Concomitant coronary artery bypass (conCABG) was BP 206(21.3%) and MP 105(14.1%) (p = 0.0002). The cumulative follow-up was BP 5131 years and MP 3364 years. Independent predictors were determined for mortality, valve-related complications and composites of complications. Results Unadjusted patient survival at 12 years was BP 52.1 ± 2.1% and MP 54.8 ± 4.6% (p = 0.1127), while the age adjusted survival was BP 48.7 ± 2.3% and MP 54.4 ± 5.0%. The predictors of overall mortality were age [Hazard Ratio (HR) 1.051, p < 0.0001], previous valve (HR 1.366, p = 0.028) and conCABG (HR 1.27, p = 0.021). The actual freedom from valve-related mortality at 12 years was BP 85.6 ± 1.6% and MP 91.0 ± 1.6% (actuarial p = 0.0167). The predictors of valve-related mortality were valve type (BP > MP) (2.61, p = 0.001), age (HR 1.032, p = 0.0005) and previous valve (HR 12.61, p < 0.0001). The actual freedom from valve-related reoperation at 12 years was BP 60.8 ± 1.9% and MP85.6 ± 2.1% (actuarial p < 0.001). The predictors of valve-related reoperation were valve type (MP > BP) (HR 0.32, p < 0.0001), age (HR 0.99, p = 0.0001) and previous valve (HR 1.38, p = 0.008) Conclusions Overall survival (age adjusted) is differentiated by valve type over 10 and 12 years and valve-related mortality and valve-related reoperation favours the use of mechanical prostheses, overall for multiple valve surgery.

1292 Aortic Valve Neocuspidization Using Glutaraldehyde-Treated Autologous Pericardium: A Literature Review

Background Aortic Valve Neocuspidization using glutaraldehyde-treated autologous pericardium was first performed by Ozaki et al. in 2007. This technique has become an alternative to tissue and mechanical valve as long-term anticoagulation is not required and shows promising midterm results and durability. Method A comprehensive search was performed on the major database using search terms “Ozaki technique” AND “Aortic Valve Neocuspidization” AND “AV Neocuspidization” AND “Autologous pericardium” AND “glutaraldehyde-treated autologous pericardium”. Articles up to 1st of August 2020 were included in this study. Results A total of 9 studies with a total of 1342 patients were included. The mean age was 67.36 and 54.23% were male. 66.32% and 23.92% of patients had aortic stenosis and aortic regurgitation, respectively. 66% of patients had a native tricuspid aortic valve and 31.37 % patients’ native aortic valve was bicuspid. Three studies reported their experience performing Aortic Valve Neocuspidization via mini sternotomy. Conclusions Aortic Valve Neocuspidization is an alternative to biological and mechanical prostheses for surgical aortic valve replacement. The short and mid-term outcome are comparable without the need for long term oral anticoagulation. Long term follow-up data is required for this novel approach to be widely adopted.

Performance of Mechanical and Biological Mitral Prostheses in Young Rheumatics Aged Below 45 Years

Background and Aim: We compared 22-year composites of valve-related reoperation, morbidity, and mortality following mitral mechanical and bioprostheses in young rheumatics aged <45years. Methods: Retrospective comparative analysis of valve-related reoperations and survival data were performed from 466 consecutive propensity matched patients undergoing either bioprosthetic MVR (Group I, n=233) or mechanical MVR (Group II, n=233) between 1998 and 2019. Results: The median age was 33 (IQR: 27-40) and 34 (IQR: 28-39) years for Group I and II respectively. The mean follow-up was 3278.9 patient-years in the biological arm and 3384.4 patient-years in mechanical arm. Bioprosthetic arm exhibited lesser cumulative mortality (4.5% vs 9.9%, SMD= -0.04, p=0.65). Hazard regression for mortality included (HR, 95% CI) preoperative congestive heart failure (CHF) 11.44 (8.44, 624.9), p<0.0001; renal failure 19.51 (8.04, 47.35), p<0.0001; previous operation 6.84 (2.48, 18.84), p<0.0001; atrial fibrillation (AF) 7.64 (1.02, 57.13), p=0.006; LA clot 61.94 (8.28, 463.08), p<0.0001; giant LA >65 mm 7.87 (2.62, 23.56), p<0.0001; poor left ventricular (LV) function 0.94 (0.92, 0.97), p<0.0001; and prolonged aortic clamp time 1.07 (1.04, 1.11), p<0.0001). Propensity matching did not exhibit any difference in reoperations between bioprostheses and mechanical prostheses (18.8% vs 13.3%, SMD= -0.152, p=0.1). At a median follow-up of 136 (IQR: 76-197) months, actuarial survival was 90.32%±0.02% (p=0.09) and there was no difference between the groups (p=0.09). Conclusions: Bioprostheses are an acceptable alternative to mechanical prostheses in young rheumatics aged <45 years unwilling for mechanical valve, redo surgeries, life-long anticoagulation, and those desirous of pregnancy.

Long-term outcomes of mitral valve replacement in patients weighing less than 10 kg

Background The outcomes of mitral valve replacement (MVR) in pediatrics especially in the patients weighing less than 10 kg are not always favorable. This study aimed to measure long-term outcomes of MVR in our institution. Methods Nine young children weighing less than 10 kg underwent MVR with mechanical prostheses were enrolled in this retrospectively study. Kaplan–Meier survival analysis was used for the prediction of freedom from death and adverse events. Chi-square test was performed to compare outcomes for patients with different ratios of mechanical prosthesis size and body weight. Fourteen related literatures were also reviewed to support our study. Results All patients received bileaflet mechanical prostheses replacement. The surgical technique varied among the patients with prostheses implanted in the intra-annular (n = 5), supra-annular (n = 1), or with a Dacron conduit segment in the supra-annular position (n = 3). The valve size/weight ratio ranged from 2.11 to 5.00. There were two early death and one late death post-operation. The mean follow-up period was 80.67 ± 63.37 months, the transvalvular gradient was 10.5 ± 1.76 mmHg (range 8 to 12) and the peak gradient of LVOT was 5.00 ± 0.64 mmHg. One (11.1%) patient underwent an immediate revision MVR after initial MVR due to the periprosthetic leak. No patients required surgical reintervention or permanent pacemaker placement during long-term follow-up. Conclusions The tailored surgical strategy utilized for MVR in infants resulted in reliable valve function and excellent survival. Although revision is inevitable due to somatic growth, the bileaflet mechanical prostheses displayed appropriate durability.

The Skirt and Collar of The Valsalva Graft: One Dress Fits All

In the original pre-formed Valsalva graft, the skirt is the defining feature. It is a self-expanding portion, obtained by 90° rotation of the Dacron fabric corrugation with respect to the rest of the graft. Due to this manufacturing feature, the skirt length is equal to the graft diameter and, once pressurized, it expands by 25-30% (up to 10 mm) from the nominal size. Proximal to this bulged portion, a small collar completes the prosthesis. By virtue of this anatomical design, the Valsalva graft is recommended for most aortic root surgeries including valve-sparing and Bentall procedures. The skirt, by recreating the pseudo-sinuses, represents the key feature of the graft when used for aortic valve-sparing procedures (remodeling and reimplantation). However, in the Bentall procedure, the graft collar is an important feature because it is useful to attach the Valsalva graft to the valve prosthesis sewing ring when making a valved conduit. Moreover, once the graft is pressurized, the whole volume of the skirt better accommodates the struts and the leaflets of biological and mechanical prostheses. Furthermore, the expanded skirt reduces the distance and the tension on the coronary button anastomosis, increasing safety and possibly reducing complication rates. This review demonstrates the versatility of the Valsalva graft in various scenarios of aortic root surgery, with special emphasis on different uses of the skirt and the collar.