In which patients should the Trifecta bioprosthesis be chosen?
Runnning title: The advantages and disadvantages of the Trifecta
bioprosthesis
Tohru Takaseya, MD, Ph.D., Kazuyoshi Takagi, MD, Ph.D., Eiki Tayama, MD,
Ph.D.
Department of Surgery, Kurume University of Medicine, Fukuoka, Japan
Funding: none
Text word count: 535 words
Correspondence: Tohru Takaseya, MD, Ph.D.
Department of Surgery, Kurume University,
Asahi-machi 67, Kurume, Fukuoka, Japan
E-mail:ttakaseya@med.kurume-u.ac.jp
TEL +81-942-31-7567
FAX +81-942-35-8967
The Trifecta bioprosthesis (Abbott, Minneapolis, MN, USA) is a
tri-leaflet, stented, bovine pericardial valve that is designed for
implantation in the supra-annular position in surgical aortic valve
replacement (SAVR). The bovine pericardial sheet is mounted outside the
stent frame, allowing for a circular cross-section during systole.
Several reports have indicated a favorable hemodynamic profile for this
bioprosthesis, such as low peak and mean transprosthetic gradients,
excellent effective orifice area, and low incidence of
patient–prosthesis mismatch (PPM), in patients with a small aortic
annulus [1,2]. However, a high incidence of structural valve
degeneration (SVD) with cusp tear has been reported as a common cause of
SVD [3]. Moreover, it is unsuitable for valve-in-valve transcatheter
aortic valve replacement (TAVR) in future SVD owing to its externally
wrapped design. In particular, in prostheses with small sizes and in
degenerated bioprostheses with external leaflets, performing TAVR for
Trifecta SVD is associated with a higher risk of coronary obstruction.
Thus, the Trifecta bioprosthesis has both advantages and disadvantages
for patients undergoing SAVR.
This study [4] is a systematic review and meta-analysis comparing
the Trifecta and Perimount bioprostheses for SAVR. The authors reviewed
six studies, which included 11,135 cases, and reported a higher
reintervention rate with Trifecta than with Perimount. However, the
all-cause mortality rate did not significantly differ between the two
groups. The authors also stated that the reintervention rates do not
necessarily reflect the true rates of SVD and emphasized that 50% of
the patients with a failed Trifecta valve did not undergo reintervention
owing to various clinical reasons and eventually died. Evidently,
several patients who were not considered candidates for redo SAVR nor
had unsuitable valve-in-valve TAVR anatomy were not included in the
review. The authors postulate that this may be a contributing factor to
the similar all-cause mortality rates between the groups despite the
higher reoperation rate in the Trifecta group. The authors did not focus
on hemodynamic outcomes, such as the incidence of PPM, and did not
recommend the use of Trifecta for SAVR bioprosthesis.
The treatment of aortic stenosis (AS) has undergone changes since TAVR
was further developed and trialed in intermediate- and low-risk
patients. There was an option to select either bioprosthesis or
mechanical valve for SAVR in AS treatment before the TAVR era. However,
there are currently a wide variety of options for SAVR, including
minimally invasive cardiac surgery, addition of annular enlargement, new
valve selection, rapid deployment valve, and a variety of valves,
including Trifecta bioprosthesis. The options for TAVR include the
trans-femoral (TF) or non-TF approach and the valve selection (balloon
expandable or self-expanding). Hence, it is desirable to consider not
only the patients’ physical or anatomical characteristics but also their
way of life to decide the treatment option.
PPM should be considered when making this decision. PPM has been
associated with increased operative mortality after SAVR, particularly
when associated with left ventricle (LV) dysfunction [5]. Takaseya
et al. [6] reported that the favorable hemodynamic performance of
the Trifecta bioprosthesis may have resulted in the same operative
outcomes in both patients with LV dysfunction and normal LV function.
The Trifecta bioprosthesis might be a suitable choice for small root or
LV dysfunction in older patients with SAVR. However, because there is
not a lot of data on the Trifecta bioprosthesis in LV disfunction
patients, a randomized study comparing the Trifecta and Perimount
bioprostheses is warranted. The advantages and disadvantages of the
Trifecta bioprosthesis should be carefully considered when selecting it
for patients with SAVR.
Conflict of interest ; All authors declare no conflict of interest.
Reference
- Colli A, Marchetto G, Salizzoni S, et al. The TRIBECA study:
(TRI)fecta (B)ioprosthesis (E)valuation versus (C)arpentier Magna-Ease
in (A)ortic position. Eur J Cardiothorac Surg. 2016
Feb;49(2):478-85.
- Kilic A, Sultan I, Navid F , et al. Trifecta aortic bioprosthesis:
midterm results in 1953 patients from a single center. Ann
Thorac Surg 2019 107:1356–1363
- Fukuhara S, Shiomi S, Yang B, et al. Early Structural Valve
Degeneration of Trifecta Bioprosthesis. Ann Thorac Surg . 2020
Mar;109(3):720-727.
- Yokoyama Y, Kuno T, Takagi H, et al. Trifecta Versus Perimount
Bioprosthesis for Surgical Aortic Valve Replacement; Systematic Review
and Meta-Analysis. J Card Surg . in press
- Blais C, Dumesnil JG, Baillot R, et al. Impact of prosthesis-patient
mismatch on short-term mortality after aortic valve replacement.Circulation 2003; 108:983–988
- Takaseya T, Oryoji A, Takagi K, et al. Impact of the Trifecta
bioprosthetic valve in patients with low‐flow severe aortic stenosisHeart and Vessels 2021 ;36:1256–1263