Bigger valve size is not always better

Abstract

S.G. is a consultant to St Jude Medical, Edwards Lifesciences, LSI, and Abbott. S.G. is a consultant to St Jude Medical, Edwards Lifesciences, LSI, and Abbott. In their letter to the Editor, Drs Santarpino and Pfeiffer question whether early dysfunction of the Trifecta valve (St Jude Medical, St Paul, Minn) is due to the leaflets or stent and whether implantation of a small valve size should be avoided. In our study, stent deformation may have contributed to an early explant in 4 cases, whereas in 11 cases leaflet dysfunction due to calcification, fibrous thickening, or pannus formation was the primary contributing factor.1Goldman S. Cheung A. Bavaria J.E. Petracek M.R. Groh M.A. Schaff H.V. Midterm multicenter clinical and hemodynamic results for the Trifecta aortic pericardial valve.J Thorac Cardiovasc Surg. 2017; 153: 561-569Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar Although there are multiple factors that can contribute to valve dysfunction, our results demonstrate that the Trifecta valve exhibits excellent durability over 6 years of follow-up. On the basis of our experience, the Trifecta valve is uniquely suitable for implantation in patients with a small aortic root. The best clinical outcomes occur when the valve is appropriately sized to match the aortic annulus and anatomy of the sinotubular junction. When encountering an aorta with a narrow root, attention must be given to not deform the stent during implantation because it may result in altered hemodynamic performance.2Jamieson W.R.E. St Jude Medical Trifecta aortic prosthesis: considerations for implantation.J Thorac Cardiovasc Surg. 2015; 149: 1576Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Despite notice from the manufacturer, some surgeons may attempt to oversize the Trifecta valve with the thinking that implanting the biggest possible valve may have the best chance of achieving a successful clinical outcome, with relief of aortic obstruction, regression of left ventricular mass, and avoidance of patient–prosthesis mismatch. These cases typically represent the early learning curve with using the valve and have the potential to result in an unfavorable clinical outcome. Oversizing may result in shifting of the leaflet hinge point and causing incomplete leaflet opening with reduced hemodynamic performance.3Cleveland J.D. Bowdish M.E. Eberhardt C.E. Mack W.J. Crabtree J.A. Vassiliades T.W. et al.Evaluation of hemodynamic performance of aortic valve bioprostheses in a model of oversizing.Ann Thorac Surg. 2017; 103: 1866-1876Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar To ease the implant procedure, the manufacturer has introduced a next-generation Trifecta valve with Glide Technology. The new valve is identical in design to the prior valve with the exception of having a more slender conical holder with a softer sewing cuff that conforms more easily to the annulus and minimizes suture drag (Figure 1). The holder has internal backstops that protect the stent posts from deforming during valve insertion. In addition, the base of the valve has an additional titanium band that provides enhanced fluoroscopic visibility and valve protection. An aortic root enlargement with the Trifecta valve is rarely needed to achieve the desired hemodynamic performance and not recommended because it requires a longer operative time and may be associated with increased operative risk.4Phan K. Ha H. Phan S. Misfeld M. Di Eusanio M. Yan T.D. Early hemodynamic performance of the third generation St Jude Trifecta aortic prosthesis: a systematic review and meta-analysis.J Thorac Cardiovasc Surg. 2015; 149: 1567-1575Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Performing a root enlargement merely for the sake of being able to perform a valve-in-valve procedure at a later date cannot be justified, because a valve-in-valve procedure carries the risk of an elevated postprocedure gradient, and in general redo aortic valve replacements can be performed safely with minimal risk.5Simonato M. Webb J. Kornowski R. Vahanian A. Frerker C. Nissen H. et al.Transcatheter replacement of failed bioprosthetic valves.Circ Cardiovasc Interv. 2016; 9: e003651Crossref Scopus (90) Google Scholar A valve-in-valve procedure is more appropriate for older patients with high surgical risk who are unlikely to require another operation. The Trifecta valve has excellent hemodynamic performance, particularly in smaller valve sizes, and cardiac surgeons confronted with a small aortic root should be aware that oversizing of the valve is not beneficial and that aortic root enlargement is rarely needed to avoid patient–prosthesis mismatch. Early degeneration of the St Jude Medical Trifecta bioprosthetic aortic valve: A problem of the leaflets or of the stent?The Journal of Thoracic and Cardiovascular SurgeryVol. 154Issue 3PreviewThe development of new aortic valvular bioprosthetic devices is a very important issue in light of the increasing demand for these models for younger patients who want to avoid oral anticoagulation and maintain a better quality of life. Moreover, the prospect of a subsequent catheter-based valve-in-valve therapy plays an even more important role in this new trend in decision making. Full-Text PDF Open Archive