Reply to Quiroga et al.

This letter is a response to the letter to the editor by Quiroga et al. [1], to the article by Jamieson et al. [2] ‘Mitroflow aortic pericardial bioprosthesis — clinical performance’ (EJCTS2009). Alvarez et al. [3] recently published the article ‘Early calcification of the aortic Mitroflow pericardial bioprosthesis in the elderly’ (ICVTS2009). Alvarez [3] reported 20 re-operations for structural valve deterioration (SVD) and 27 patients with asymptomatic valve deterioration identified by routine echocardiography. Quiroga et al. [1] express concern that the three-centre study by Jamieson [2] only reports SVD by re-operation, and request if SVD was identified by echocardiography. We acknowledge that our study did not have the opportunity for routine echocardiography. We commend Alvarez [3] for conducting follow-up echocardiographic evaluation. We first address the concerns of Quiroga et al. [1] about our publication. They are concerned that our publication did not include all the current version (Model 12) patients from Bad Oeynhausen and Berlin. We included all the current version (Model 12) prostheses implanted at the three centres from 1992 to 2003. The publications from these centres by Minami et al. [4] and Yankah et al. [5] were a combination of Model 11 and 12 prostheses. The number of patients in our submitted data for the group ≥60 years was 374 and for the group ≥65 years was 365. The number was considered at the time of printing to be 385; the error was related to the transmission of the figure representation. The reporting of SVD by re-operation is standard for most reports on bioprostheses, the alternative is to combine SVD by re-operation and reported echocardiograms, while Alvarez et al. [3] document prospective echocardiography but the definitions are not standard in the literature, particularly for asymptomatic echocardiography findings. The article by Alvarez et al. [3] brings forward a number of concerns, and we take this opportunity to review our considerations. The article reported 20 cases of SVD managed by re-operation and 27 cases of bioprosthetic valve deterioration. The number of patients that may have refused re-operation is not documented. The number of patients at risk and the questionable reporting of standard errors between the abstract and the text are of concern. The article should be reporting 5- and 7-year results. The Jamieson [2] publication reported the 12-year results in 381 patients from three centres, two from Germany and one from Canada. The limitation of that study is that SVD was only diagnosed at re-operation. The freedom difference is approximately 10–15% by observation of the curves in both reports. The age group 61–70 years (only 42 patients) in the Jamieson [2] manuscript has essentially similar freedom from SVD as the age group >70 years; the age group 61–70 years is likely to be referred for re-operation because of symptomatic SVD. The magnitude of asymptomatic degenerative changes with heterographic prostheses is unknown. This information provides the strength of the Alvarez [3] report but is probably of clinical insignificance in the elderly. We are of the opinion that these two articles are complementary and provide similar findings, if the Alvarez et al. [3] publication considered only reporting of SVD by explant re-operation when there is an adequacy of patients at risk.

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