Aortic or Mitral Valve Replacement With the Braile Biomédica® Bovine Pericardium Valvular Bioprosthesis

Multicenter, observational, retrospective, non-comparative, non-randomized study to determine the safety and clinical performance of the Bovine Pericardium Valvular Bioprosthesis in patients who required replacement of their native or bioprosthetic valve (aortic or mitral), according to ISO 14155 and ISO 5840.

Inclusion criteria

(Group I - Aortic):

• Symptomatic patients with severe aortic insufficiency.
• Asymptomatic patients with severe aortic insufficiency and left ventricular ejection fraction (LVEF) at rest ≤ 50%.
• Patients with severe aortic insufficiency and undergoing coronary artery bypass graft surgery (CABG) or surgery of the ascending aorta or other valve.
• Asymptomatic patients with severe aortic insufficiency and resting ejection fraction > 50% with severe left ventricular (LV) dilation: left ventricular end-diastolic diameter (LVDD) > 70 mm or left ventricular ejection fraction (LVEF) > 50 mm (or LVEF > 25 mm/m2 of body surface, in patients with small body size).
• Symptomatic patients with severe high gradient aortic stenosis (mean gradient ≥ 40 mmHg or peak velocity ≥ 4.0 m/s).
• Symptomatic patients with severe low-flow, low-gradient aortic stenosis (< 40 mmHg) with reduced ejection fraction and evidence of flow reserve (contractile) excluding pseudo-severe aortic stenosis.
• Symptomatic patients with low-flow, low-gradient (< 40 mmHg) aortic stenosis with normal ejection fraction after careful confirmation of severe aortic stenosis.
• Symptomatic patients with low-flow, low-gradient aortic stenosis and reduced ejection fraction without flow reserve (contractile), particularly when the amount of calcium on computed tomography (CT) confirms severe aortic stenosis.
• Patients with symptomatic aortic stenosis at low surgical risk (STS or EuroSCORE II < 4% or logistic EuroSCORE I < 10% and no other risk factors not included in these scores, such as fragility, porcelain aorta, sequelae of thoracic radiation).
• Asymptomatic patients with severe aortic stenosis and LV systolic dysfunction (LVEF < 50%) not due to another cause.
• Asymptomatic patients with severe aortic stenosis and an abnormal exercise test showing exercise symptoms clearly related to aortic stenosis.
• Asymptomatic patients with severe aortic stenosis and an abnormal exercise test showing a decrease in blood pressure below baseline.
• Asymptomatic patients with normal ejection fraction and no exercise stress test abnormality, if the surgical risk is low and have very severe aortic stenosis defined by a peak transvalvular velocity (Vmax) > 5.5 m/s.
• Asymptomatic patients with normal ejection fraction and no exercise test abnormality, if the surgical risk is low and severe valve calcification and Vmax progression rate ≥ 0.3 m/s/year.
• Asymptomatic patients with normal ejection fraction and no exercise stress test abnormality, if surgical risk is low and B-type natriuretic peptide (BNP) marker levels are high.
• Asymptomatic patients with normal ejection fraction and no change in the exercise test, if the surgical risk is low and severe pulmonary hypertension (pulmonary artery systolic arterial pressure at rest > 60 mmHg confirmed by invasive measurement) with no other explanation.
• Patients with severe aortic stenosis undergoing CABG or surgery of the ascending aorta or other valve.
• Patients with moderate aortic stenosis undergoing CABG or surgery of the ascending aorta or other valve after decision by the Heart Team.

7.2. Inclusion Criteria (Group II - Mitral):

• Symptomatic patients with severe primary mitral insufficiency and LVEF > 30%.
• Asymptomatic patients with severe primary mitral insufficiency and LV dysfunction (LVEF > 45 mm and/or LVEF < 60%).
• Asymptomatic patients with severe primary mitral regurgitation and preserved LV function (LVEF < 45 mm and LVEF > 60%) and atrial fibrillation secondary to mitral regurgitation or pulmonary hypertension (rest systolic pulmonary pressure > 50 mmHg).
• Asymptomatic patients with severe primary mitral regurgitation and preserved LVEF (> 60%) and LVEF 40-44 mm, with leaflet failure.
• Asymptomatic patients with severe primary mitral regurgitation and preserved LVEF (> 60%) and LVEF 40-44 mm, and presence of significant LA dilation (volume index ≥ 60 mL/m2 of body surface) in sinus rhythm.
• Patients with severe primary mitral regurgitation and severe LV dysfunction (LVEF < 30% and/or LVEF > 55 mm) refractory to medical therapy.
• Patients with severe chronic secondary mitral regurgitation undergoing CABG and LVEF > 30%.
• Symptomatic patients with severe secondary mitral regurgitation, LVEF < 30%, but with the option of revascularization and evidence of myocardial viability.
• Patients with severe secondary mitral regurgitation and LVEF > 30% who remain symptomatic despite optimal clinical treatment and with low surgical risk.
• Symptomatic patients with mitral stenosis (valve area ≤ 1.5 cm2) who are not suitable for percutaneous mitral commissurotomy.

Exclusion criteria

• Emergency surgical valve replacement.
• Surgical replacement of the aortic root.
• Patients who did not return for follow-up examinations.
• Patients with renal impairment as determined by creatinine level ≥ 2.5 mg/dL or end-stage renal disease requiring chronic dialysis.
• Patients with stroke or transient ischemic attack within 6 months (180 days) before planned valve surgery.
• Patients with acute myocardial infarction within 30 days before planned valve surgery.
• Patients with any known life-threatening non-cardiac disease that will limit the patient's life expectancy below 1 year.
• Patients diagnosed with abnormal calcium metabolism and hyperparathyroidism.
• LVEF ≤ 20%, as validated by the diagnostic procedure before planned valve surgery.
• Echocardiographic evidence of intra-cardiac mass, thrombus or vegetation.
• Hemodynamic or respiratory instability requiring inotropic support, mechanical circulatory support, or mechanical ventilation within 30 days prior to planned valve surgery.
• Documented leukopenia (leukocytes < 3.5x10³/μL), acute anemia (Hgb < 10.0 gm/dL or 6 mmol/L) or thrombocytopenia (platelet count < 50x10³/μL) accompanied by a history of bleeding diathesis and coagulopathy.
• Patients who underwent organ transplantation.
• Pregnant or breastfeeding.
• Patients with a documented history of substance abuse (drugs or alcohol) in the last year before implantation.
• Concomitant positioning of the left ventricular assist device.