The New Challenge for Heart Endocarditis: From Conventional Prosthesis to New Devices and Platforms for the Treatment of Structural Heart Disease

Figures

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  Figure 1. Conventional mechanical prosthetics. The device can be single or assembled with a Dacron prosthesis (valved Dacron tube). (a) St Jude Medical Regent bileaflet mechanical valve. (b) Valsalva mechanical valved graft (St. Jude Medical, Minneapolis, MN). (c) Carbomedics Aortic Mechanical Valve. (d) Bicarbon Aortic Valve (LivaNova, PLC, London, UK). (e) Carbomedics mechanical valved graft (LivaNova, PLC, London, UK).

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  Figure 2. Last generation of stented/stentless xenograft prosthesis constituted of pericardial or porcine leaflet. The device can be single or assembled as a bioconduict. The biological prosthesis includes as biomaterials valve leaflets which can be of calf or porcine pericardium and a polytetrafluoroethylene stent. The leaflets are inserted on the circumference of polytetrafluoroethylene annulus. The 3 leaflets are separated by 3 commissures. (a) Carpentier-Edwards Perimount stented aortic (Edwards Lifesciences Inc., Irvine, California, USA). (b) Medtronic Mosaic stented aortic (Medtronic, Minneapolis, Minnesota). (c) Mitroflow aortic bioprosthesis (models 12A/LX; LivaNova, PLC, London, UK). (d) St Jude's Trifecta aortic bioprosthesis (St. Jude Medical, Minneapolis, MN). (e) Freedom Solo Stentless aortic valve (LivaNova PLC, London, UK). (f) Bioconduit (BioIntegral Surgical, Inc.).

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  Figure 3. Infectious process involving a valved tube consisting of mechanical prosthesis assembled with a Dacron vascular graft. (a and c) Recurrent false aneurysm (arrow yellow) after implantation of Carbomedics mechanical valved graft (LivaNova, PLC, London, UK). (b and d) The infection of cardiac device is successfully treated with the use of valsalva mechanical valved graft (arrow yellow) (St. Jude Medical, Minneapolis, MN).

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  Figure 4. Infectious process with large periprosthetic abscess involving biological prosthesis. (a) Abscess formation of conventional stented bioprosthesis. (b) The prosthesis is removed with vegetations. (c) Biological living tissue explanted and cryopreserved (homograft) is used for aortic root reconstruction and for repair of mitro-aortic curtain. (d) The infected prosthesis is removed with aggressive debridement of all infected and necrotic tissue. The coronary ostia are prepared for the reconstruction of aortic root.

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  Figure 5. ACC/AHA and ESC Guidelines on Use of Antibiotic Prophylaxis for the Prevention of Infection of Heart Structure.

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  Figure 6. Balloon expandable THV. (a–c) The SAPIEN 3 balloon expandable is constituted by cobalt-chromium alloy frame valve with bovine pericardium leaflets. A polyethylene terephthalate fabric skirt on the distal section of the frame serves for PVL serves prevention. The device is introduced in the market in the following sizes: 20 mm, 23 mm, 26 mm, and 29 mm (a). The Commander Delivery System is 14 F expandable introducer sheath compatible for 20-26 mm valves and 16 F expandable introducer sheath compatible for 29 mm valves (b and c). (d–g) Self expandable THV. The bioprosthesis is manufactured by suturing 3 valve leaflets and a skirt, made from a single layer of porcine pericardium, onto a self-expanding, multilevel, radiopaque frame made of Nitinol (d–g). CoreValve (d), Evolut R (e), Evolut PRO (f) in the following sizes: 20 mm, 23 mm, 26 mm, and 29 mm. ©. The loading System (g). The outer diameter of the catheter is 15 Fr (AccuTrak™ stability layer) and 12 Fr, and the outer diameter of the valve capsule is 18 Fr. The catheter can be used for femoral, subclavian/axillary, or ascending aortic (direct aortic) access sites.

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  Figure 7. Last generation of THV. (a) ℷThe Portico resheathable transcatheter aortic valve system (Abbott Structural Heart, St Paul, MN, USA). (b) †The ACURATE neo (Boston Scientific, Marlborough, MA, USA) self-expanding THV. (c) ∗Lotus mechanically expanded valve (Lotus Valve System (MEV; Boston Scientific Corp). (a) Portico valve is designed with large, open cells, and intra-annular leaflet placement to preserve flow and access to the coronary arteries after deployment. The Portico valve was delivered by a flexible, first-generation Portico Delivery system, which had an 18F outer diameter for the small valves (23 and 25 mm) and a 19F outer diameter for the larger valves (27 and 29 mm). (b) The ACURATE neo bioprosthesis consists a self-expanding nitinol frame with three porcine pericardial leaflets and a stent body with an outer and inner pericardial skirt. (c) The MEV combines 3 bovine pericardial tissue valve leaflets and a braided nitinol frame with a polycarbonate-based urethane adaptive seal.