Effective Area Index Research Articles

Patient-prosthesis mismatch did not impact postoperative course and hemodynamics after biosthetic mitral valve replacement

Methods From 2004 to 2012, 34 patients underwent MVR with bioprosthesis in our institution. Patient’s age was 74 ± 4 years old and male/female ratio was 23/11. We implanted three valves; Epic Supra (SJM, Minnesota) in 8 (25 mm; 5, 27 mm; 3), Mosaic (Medtronic, Minneapolis) in 15 (25 mm; 5, 27 mm; 8, 29 mm; 2), Carpentier Edwards Perimount (Edwards, Los Angeles) in 11 patients (25 mm; 1, 27 mm; 8, 29 mm; 2). Sixteen patients (group P) had small indexed effective orifice area (EOAI ≤1.2 cm2/m2), and the remaining 18 patients (group N) had acceptable EOAI. We compared operative results and hemodynamic parameters recorded by echocardiography between both groups. We also evaluated correlation between predicted EOAI and hemodynamic parameters after MVR.

Haemodynamic performance of a new pericardial aortic bioprosthesis during exercise and recovery: comparison with pulmonary autograft, stentless aortic bioprosthesis and healthy control groups

Since blood flow impairment by aortic valve prosthesis is characteristically dynamic, this dynamic component is best and thoroughly appreciated by exercise Doppler echocardiography. We sought to determine the haemodynamics of a new pericardial aortic bioprosthesis [Trifecta™-aortic valve bioprosthesis (T-AVB), St Jude Medical, MN, USA] at rest and during exercise and a 10-min recovery period in comparison with alternative aortic valve prostheses, e.g. Ross operation (RO), stentless aortic valve [Medtronic freestyle-aortic valve bioprosthesis (MF-AVB)] and a healthy control group (CO). Haemodynamics at rest and during supine exercise stress testing and a 10-min recovery period were evaluated in 32 patients (mean age: 70.8 ± 6.7 years) with T-AVB (mean follow-up: 5 ± 2 months), 49 with RO (mean age: 43.5 ± 13.7 years), 39 with an MF-AVB (mean age: 64.6 ± 9.4 years) and 26 healthy patients (mean age: 39 ± 9 years). Measurements included mean outflow tract gradient (δp mean, mmHg), effective orifice area index (EOAI, cm(2)/m(2)) and valvular resistance (vR, dyn s cm(-5)). Mean body surface area for T-AVB was 1.93 ± 0.24 m(2) (median 1.97 m(2)). Mean δp mean at rest was 7.2 ± 3.4 mmHg, mean EOAI 0.86 ± 0.23 cm(2)/m(2) and mean vR 50.7 ± 23.2 dyn s cm(-5). Supine stress testing did increase the mean EOAI to 0.98 ± 0.27 cm(2)/m(2), the mean vR to 62.6 ± 25.3 dyn s cm(-5) and the mean δp mean to 10.21 ± 4.7 mmHg, respectively (P < 0.05 for all comparisons). During the post-exercise recovery period, δp mean, EOAI and vR showed a prompt normalization within 5 min of cessation of exercise. At all the three measurement points, T-AVB and MF-AVB revealed low gradients, satisfactory EOAI and low vR. Compared with the RO and a healthy control group, both groups showed significantly inferior performance throughout the exercise and post-exercise study protocol (P < 0.05). In comparison with T-AVB, patients with an MF-AVB only showed significant inferior performance throughout series with respect to a higher vR, indicating a smaller increase in the EOAI during exercise. During the 10-min post-exercise period, T-AVB recovered significantly earlier than MF-AVB. When comparing two different types of aortic valve bioprostheses with a gold standard group (RO) and a healthy population, both aortic valve bioprostheses perform inferior but reveal promising haemodynamics during exercise. During post-exercise haemodynamic recovery, only the T-AVB revealed a nearly physiological recovery pattern compared with the RO and a healthy control group.

Obesity and the risk of late mortality after aortic valve replacement with small prosthesis.

BackgroundWhether obesity is related to late mortality with implantation of small aortic prosthesis remains to be clarified. This study was aimed to evaluate the effect of obesity on late survival of patients after aortic valve replacement (AVR) with implantation of small aortic prosthesis (size ≤ 21 mm).MethodsFrom January 1998 to December 2008, 307 patients in our institution who underwent primary AVR with smaller prostheses survived the 30 days after surgery. Patients were defined as normal if body mass index (BMI) was < 24 kg/m2, as overweight if BMI 24–27.9 kg/m2, and as obese if BMI ≥ 28 kg/m2. Data of New York Heart Association (NYHA) functional classification, left ventricular ejection fraction (LVEF), effective orifice area index (EOAI), and left ventricular mass index (LVMI) of the patients collected at the 3rd month (M), 6th M, 1st year (Y), 3rd Y, 5th Y, 8th Y after operation respectively.ResultsBy multivariable analysis, obesity was an independent factor of late mortality (hazard ratio [HR]: 1.62; P = 0.01). The obesity and overweight group had more poor survival (p < 0.001) and higher proportion of NYHA class III/IV (p < 0.01) compared with the normal group. Lower EOAI and higher LVMI were found in obesity and overweight group, but we saw no significant difference about LVEF among the three groups.ConclusionsObesity was associated with increased late mortality of patients after AVR with implantation of small aortic prosthesis. Being obese or and overweight may also affect the NYHA classification, even in the longer term. EOAI should be improved where possible, as it may reduce late mortality and improve quality of life in obese or overweight patients.

Multidetector CT predictors of prosthesis–patient mismatch in transcatheter aortic valve replacement

BackgroundProsthesis–patient mismatch (PPM) is a predictor of mortality after aortic valve replacement (AVR). ObjectiveWe examined whether accurate 3-dimensional annular sizing with multidetector CT (MDCT) is predictive of PPM after transcatheter AVR (TAVR). MethodsOne hundred twenty-eight patients underwent MDCT then TAVR. Moderate PPM was defined as an indexed effective orifice area ≤0.85 cm2/m2 and severe ≤0.65 cm2/m2. MDCT annular measurements (area, short and long axis) were compared with the size of the selected transcatheter heart valve (THV) to obtain (1) the difference between prosthesis size and CT-measured mean annular diameter and (2) the percentage of undersizing or oversizing (calculated as 100 × [MDCT annular area – THV nominal area]/THV nominal area). In addition, the MDCT annular area was indexed to body surface area. These measures were evaluated as potential PPM predictors. ResultsWe found that 42.2% of patients had moderate PPM and 9.4% had severe PPM. Procedural characteristics and in-hospital outcomes were similar between patients with or without PPM. THV undersizing of the mean aortic annulus diameter was not predictive of PPM (odds ratio [OR], 0.84; 95% CI, 0.65–1.07; P = .16; area under the receiver-operating characteristic curve [AUC], 0.58). THV undersizing of annular area was not predictive of PPM (OR, 0.96; 95% CI, 0.80–1.16; P = .69; AUC, 0.52). Indexed MDCT annular area was, however, predictive of PPM (OR, 0.24; 95% CI, 0.10–0.59; P < .001; AUC, 0.66). ConclusionsPPM is frequent after TAVR. Appropriate annular oversizing does not reduce the rate or severity of PPM. Patient annulus size mismatch, identified by indexed MDCT annular area, is a significant predictor of PPM.

Aortic Valve Prosthesis–Patient Mismatch and Long-Term Outcomes: 19-Year Single-Center Experience

The clinical effects of prosthesis-patient mismatch (PPM) after aortic valve replacement, with respect to morbidity and survival, remain controversial, particularly in high-risk patient subgroups. Patients undergoing aortic valve replacement from January 1992 to December 2010 were classified according to effective orifice area index into severe PPM (effective orifice area index<0.65 cm²/m²), moderate PPM (effective orifice area index 0.65 to 0.85 cm²/m²), and absent PPM (effective orifice area index>0.85 cm²/m²). Analyses examined major morbidity and total all-cause death. Prosthesis-patient mismatch was classified as severe (92 of 1,060; 8.7%), moderate (440 of 1,060; 41.5%), or absent (528 of 1,060; 49.8%). Moderate and severe PPM were unrelated to in-hospital morbidity or mortality. There were 440 deaths (41.5%) at 5.6 years median follow-up (interquartile range, 2.9 to 9.1). Trend toward poorer survival according to PPM group (χ2=5.46; p=0.07) was attenuated further with covariate adjustment. Sensitivity analyses demonstrated discrete mortality effects for moderate PPM in association with concomitant coronary artery bypass grafting, impaired left ventricular function, and older age (significant hazard ratios range, 1.05 to 1.57). Severe PPM also increased mortality risk in association with older age, concomitant coronary artery bypass grafting, and New York Heart Association Class III or IV (significant hazard ratios range, 1.06 to 2.65). Prosthesis-patient mismatch was not associated with mortality in covariate-adjusted models. However, a discrete mortality risk was attributable to moderate and severe PPM in patients of older age, or those with left ventricular dysfunction, New York Heart Association class III or IV, and concomitant coronary artery bypass grafting.

Aortic Valve Replacement with Smaller Prostheses in Elderly Patients: Does Patient Prosthetic Mismatch Affect Outcomes?

To evaluate the influence of patient-prosthesis mismatch (PPM) on survival, and quality of life (QOL) after aortic valve replacement (AVR) in elderly patients with small prosthesis size. Between 2005 and 2010, 142 patients older than 65 years were discharged from the hospital after AVR with 19 or 21 mm prosthesis for aortic stenosis. Their median age was 79 years (range 66 to 91). Prosthesis effective orifice area (EOA) was derived from the continuity equation and PPM was defined as an indexed EOA (IEOA) < 0.85 cm(2)/m(2). Patients having IEOA < 0.75 cm(2)/m(2) and IEOA < 0.60 cm(2)/m(2) were also investigated. Mean follow-up was 23 months (range 1 to 58) and was 98% complete. PPM was found in 86 patients, 63 had an IEOA ≤ 0.75 cm(2) /m(2), and 23 had an IEOA ≤ 0.60 cm(2) /m(2). The groups were similar except for older age (p = 0.0364), larger body surface area (p = 0.0068), more male gender (p = 0.0186), and more EF < 40% in patients with PPM. Survival at 58 months was 81 ± 6.4% and was not influenced by PPM (p = 0.9845). At Cox analysis only preoperative NYHA class (p = 0.0064) was identified as an independent risk factor for late death. The SF12 test was used to analyze the QOL of patients and it did not reveal differences between groups. PPM does not affect survival in this series of elderly patients. We believe that more aggressive surgical procedures are not justified in these patients.

Patient–Prosthesis Mismatch and Reduction in Left Ventricular Mass After Aortic Valve Replacement

The presence of patient-prosthesis mismatch (PPM) after aortic valve replacement may influence patient survival. We examined the relationship between PPM and changes in left ventricular mass index at 3 months follow-up and also overall survival. From patients included in the Mosaic trial, we studied data from 266 patients who underwent aortic valve replacement with the Medtronic Mosaic porcine bioprosthesis and had an echocardiography performed 3 months postoperatively. Complete echocardiographic data, to calculate left ventricular mass index, was available in 78% of the patients. The primary outcome for this substudy was prevalence and severity of PPM. Secondary outcomes were reduction in left ventricular mass index at 3 months follow-up and medium-term survival. Patients without PPM were defined as having an indexed effective orifice area greater than 0.85 cm(2)/m(2), and those with moderate and severe PPM as having an indexed effective orifice area between 0.65 cm(2)/m(2) and 0.85 cm(2)/m(2) or below 0.65 cm(2)/m(2), respectively. PPM was found in 217 (82%) patients. No difference in overall survival was found between patients with PPM and those without PPM. The change in left ventricular mass index was significantly different between groups (no PPM -31.4 ± 28.0 g/m(2), moderate PPM 1.1 ± 34.4 g/m(2), and severe PPM -5.9 ± 29.7 g/m(2), respectively (p = 0.01). The presence of PPM did not influence medium-term survival. However, patients without PPM showed a marked reduction in left ventricular mass index as soon as 3 months postoperatively.

Indexed effective orifice area is a significant predictor of higher mid- and long-term mortality rates following aortic valve replacement in patients with prosthesis-patient mismatch

Prosthesis-patient mismatch (PPM) is defined as a too-small effective orifice area (EOA) of an inserted prosthetic relative to body size, resulting in an abnormally high postoperative gradient. It is unclear, however, whether residual stenosis after aortic valve replacement (AVR) has a negative impact on mid- and long-term survivals. We searched electronic databases, including PubMed, Embase, Medline and the Cochrane controlled trials register, through October 2012, to identify published full-text English studies on the association between PPM and mortality rates. A significant PPM was defined as an indexed EOA (iEOA)<0.85 cm2/m2, and severe PPM as an iEOA<0.65 cm2/m2. Two reviewers independently assessed the studies for inclusion and extracted data. Fourteen observational studies, involving 14 874 patients, met our final inclusion criteria. Meta-analysis demonstrated that PPM significantly increased mid-term (odds ratio [OR] 1.42, 95% confidence interval [CI] 1.19-1.69) and long-term (OR 1.52, 95% CI 1.26-1.84) all-cause mortalities. Subgroup analysis showed that PPM was associated with higher mid- and long-term mortality rates only in younger and predominantly female populations. Risk-adjusted sensitivity analysis showed that severe PPM was associated with reduced survival (adjusted hazard ratio [HR] 1.50, 95% CI 1.24-1.80), whereas moderate PPM was not (adjusted HR 0.96, 95% CI 0.86-1.07). Regardless of severity, however, PPM had a negative effect on survival in patients with impaired ejection fraction (adjusted HR 1.26, 95% CI 1.09-1.47). PPM (iEOA<0.85 cm2/m2) after AVR tended to be associated with increased long-term all-cause mortality in younger patients, females and patients with preoperative left ventricular dysfunction. Severe PPM (iEOA<0.65 cm2/m2) was a significant predictor of reduced long-term survival in all populations undergoing AVR.

Antimineralization treatment and patient-prosthesis mismatch are major determinants of the onset and incidence of structural valve degeneration in bioprosthetic heart valves

We examined the influence of multiple valve-related parameters on the onset and incidence of valve degeneration in aortic bioprostheses through detailed echocardiographic follow-up. In 648 patients (mean age, 73.8 ± 4.9 years) receiving an aortic valve bioprosthesis, long-term clinical (mean, 7.5 ± 3.2 years) and echocardiographic (mean, 6.5 ± 3.4 years) follow-up were performed. The occurrence of signs of structural valve degeneration (stenosis type and regurgitation type) was studied through multivariate analysis, including tissue origin, design and label size of the prosthesis, effective orifice area index (EOAi), patient-prosthesis mismatch (PPM; EOAi <0.85 cm(2)/m(2)), and antimineralization treatment. Structural valve degeneration (SVD) was diagnosed in 12.6% of patients. In 7.6%, it was of the stenosis type (S-SVD); in 5%, it was the regurgitation type (R-SVD). The absence of antimineralization treatment is an independent predictor of SVD, S-SVD, and R-SVD. Patient-prosthesis mismatch is an independent predictor of SVD and S-SVD, but not of R-SVD. Patients receiving a nontreated valve show a freedom of SVD at 10 years follow-up of 70.1 ± 4.3% versus 90.9 ± 3.6% in patients receiving a treated valve (P<.0001). Patients having PPM and receiving a nontreated valve show a freedom of SVD at 10 years of follow-up of only 59.8 ± 7.0% versus 88.7 ± 3.6% in patients also having PPM but receiving a treated valve (P<.0001). In patients not having PPM, the corresponding values were 78.0 ± 4.3% and 92.7 ± 3.4% for nontreated versus treated valves respectively (P=.01). Antimineralization treatment of bioprosthetic heart valves is effective and reduces the incidence of SVD significantly. Because valve type and size are determined at the moment of implantation, the surgeon carries an important responsibility in protecting the patient from valve degeneration.

Comparison of Transcatheter and Surgical Aortic Valve Replacement in Severe Aortic Stenosis: A Longitudinal Study of Echocardiography Parameters in Cohort A of the PARTNER Trial (Placement of Aortic Transcatheter Valves)

This study sought to compare echocardiographic findings in patients with critical aortic stenosis following surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR). The PARTNER (Placement of Aortic Transcatheter Valves) trial randomized patients 1:1 to SAVR or TAVR. Echocardiograms were obtained at baseline, discharge, 30 days, 6 months, 1 year, and 2 years after the procedure and analyzed in a core laboratory. For the analysis of post-implantation variables, the first interpretable study (≤6 months) was used. Both groups showed a decrease in aortic valve gradients and increase in effective orifice area (EOA) (p < 0.0001), which remained stable over 2 years. Compared with SAVR, TAVR resulted in larger indexed EOA (p = 0.038), less prosthesis-patient mismatch (p = 0.019), and more total and paravalvular aortic regurgitation (p < 0.0001). Baseline echocardiographic univariate predictors of death were lower peak transaortic gradient in TAVR patients, and low left ventricular diastolic volume, low stroke volume, and greater severity of mitral regurgitation in SAVR patients. Post-implantation echocardiographic univariate predictors of death were: larger left ventricular diastolic volume, left ventricular systolic volume and EOA, decreased ejection fraction, and greater aortic regurgitation in TAVR patients; and smaller left ventricular systolic and diastolic volumes, low stroke volume, smaller EOA, and prosthesis-patient mismatch in SAVR patients. Patients randomized to either SAVR or TAVR experience enduring, significant reductions in transaortic gradients and increase in EOA. Compared with SAVR, TAVR patients had higher indexed EOA, lower prosthesis-patient mismatch, and more aortic regurgitation. Univariate predictors of death for the TAVR and SAVR groups differed and might allow future refinement in patient selection. (THE PARTNER TRIAL: Placement of AoRTic TraNscathetER Valve Trial; NCT00530894).

Impact of prosthesis-patient mismatch on early and late mortality after aortic valve replacement

BackgroundThe influence of prosthesis-patient mismatch (PPM) on survival after aortic valve replacement (AVR) remains controversial. In this study, we sought to determine the effect of PPM on early (≤30 days) and late mortality (>30 days) after AVR or AVR combined with coronary artery bypass grafting (AVR with CABG).MethodsBetween January 1998 and March 2012, 2976 patients underwent AVR (n= 1718) or AVR with CABG (n=1258) at a single institution. PPM was defined as an indexed effective orifice area (EOAI) ≤0.85 cm2/m2 and patients were divided into two groups based on the existence of PPM. Cumulative probability values of survival were estimated with Kaplan-Meier method and compared between groups using Breslow test. Univariate and multivariate independent predictors of early mortality were identified using logistic regression. Cox proportional-hazard regression analysis was used to determine univariate and multivariate independent predictors of late mortality.ResultsEarly mortality was 6.7% in the PPM group vs 4.7% in the group with no PPM (p=0.013). Late mortality for the PPM group at 1, 5 and 10 years was 4%, 16% and 43%, respectively. Late mortality for the group with no PPM at 1, 5 and 10 years was 4%, 15% and 33% respectively. Independent predictors of early mortality included age, severely impaired left ventricular (LV) function, endocarditis, renal dysfunction, chronic obstructive pulmonary disease (COPD) and cardiopulmonary bypass (CPB) time. Multivariate independent predictors of late mortality included age, severely impaired LV function, diabetes, peripheral vascular disease (PVD), renal dysfunction, history of a cerebrovascular accident (CVA), CPB time and a history of previous cardiac surgery. PPM was not an independent predictor of early or late mortality.ConclusionPPM is not an independent predictor of both early and late mortality after AVR or AVR combined with CABG.

Impact of obesity on long-term survival after aortic valve replacement with a small prosthesis

Although many studies have evaluated the impact of obesity on various medical treatments, it is not known whether obesity is related to late mortality with implantation of small aortic prostheses. This study evaluated the effect of obesity on the late survival of patients after aortic valve replacement (AVR) with implantation of a small aortic prosthesis (size ≤ 21 mm). From January 1998 to December 2008, 307 patients in our institution who underwent primary AVR with smaller prostheses survived 30 days after surgery. Patients were categorized as normal weight if body mass index (BMI) was <24 kg/m(2), overweight if BMI 24-27.9 kg/m(2) and obese if BMI ≥ 28 kg/m(2). Data of the New York Heart Association (NYHA) functional classification, left ventricular ejection fraction (LVEF), effective orifice area index (EOAI) and left ventricular mass index of the patients were collected at the third month, sixth month, first year, third year, fifth year and eighth year after operation. By multivariable analysis, obesity was a significant independent factor of late mortality (hazard ratio: 1.62; P = 0.01). The obese and overweight groups of patients exhibited lower survival (P < 0.001) and a higher proportion in NYHA Class III/IV (P < 0.01) compared with the normal group. A lower EOAI and higher left ventricular mass index were found in the obese and overweight groups, but we saw no significant variance in LVEF among the three groups. Obesity is associated with increased late mortality of patients after AVR with implantation of small aortic prosthesis. Obesity or/and overweight may also affect the NYHA classification, even in the longer term. EOAI should be improved where possible, as it may reduce late mortality and improve quality of life in obese or overweight patients.

Changes in left ventricular function and geometry after aortic valve replacement in patients with severe aortic stenosis

Background: This study aims to evaluate the effects of different types and sizes of prostheses on the left ventricular function and geometry after aortic valve replacement (AVR) in patients with severe aortic stenosis. Methods: Eighty-five patients with severe aortic stenosis were studied in three groups [Group 1, mechanical AVR (n=31); Group 2, stentless biological AVR (n=34); Group 3, stented biological AVR (n=20)]. Left ventricular geometry and function were assessed by transthoracic echocardiography preoperatively and at six months after AVR. Primary endpoint of the study was the change in the left ventricular mass index (LVMI) at six months while secondary endpoints were the New York Heart Association (NYHA) functional class, transvalvular gradients, aortic valve space, left ventricular ejection fraction (LVEF) and diameters, septal thickness and indexed effective orifice area (IEOA). Results: A significant improvement in the NYHA functional class was seen in all groups at six months. Based on the echocardiographic evaluations at six months, there were no significant differences among the groups in terms of &#916;LVEF (p=0.52), &#916;LVEDD (p=0.24), &#916;LVESD (p=0.86), &#916;septal thickness (p=0.25). Indexed effective orifice area was significantly higher in stentless group, compared to the other groups (p=0.002). &#916;LVMI was significantly greater in mechanical and stentless biological valves, compared to the stented biological AVR (p=0.042). When the patients with annulus size smaller than 25 mm were evaluated, it was shown that &#916;LVMI was further decreased in stentless biological AVR, compared to the other groups (p=0.029). Conclusion: Although implantation of stentless biological AVR requires longer ischemic times, regression in the LVMI is more prominent in stented biological valves, particularly in patients with small aortic root.

Patient-prosthesis mismatch in patients with aortic valve replacement

ObjectivePatient-prosthesis mismatch (PPM) may affect clinical outcomes in patients with aortic valve replacement (AVR). We retrospectively examined the PPM in patients with isolated AVR in the Japan Adult Cardiovascular Surgery Database (JACVSD).MethodsWe examined all patients with isolated AVR between January 1, 2008 and December 31, 2009. The JACVSD data collection form has a total of 255 variables. We defined PPM as an effective orifice area index of ≤0.85 m2/cm2.ResultsPPM was observed in 306 of 3,609 cases analyzed, PPM rate was 8.5 %. Body surface area was larger and body mass index was higher in the PPM group than the non-PPM group (P < 0.001). Patients with PPM were older (P = 0.001) and had a higher prevalence of diabetes (P = 0.004), dyslipidemia (P < 0.001), hypertension (P < 0.001), cerebrovascular disease (P = 0.031), old myocardial infarction (P = 0.006), previous percutaneous coronary artery intervention (P = 0.001), coronary artery disease (P = 0.018), and aortic valve stenosis (P < 0.001). Perioperative blood transfusion (P < 0.001) and dialysis (P = 0.005) were more frequent in the PPM group. Postoperative ventilation (P = 0.004) and intensive care unit stay (P = 0.004) were significantly longer in the PPM group.ConclusionsAge, aortic valve stenosis, dyslipidemia, hypertension, old myocardial infarction, previous percutaneous coronary artery intervention, diabetes mellitus, cerebrovascular disease, and high body mass index were the risk factors for PPM. PPM was not an independent risk factor for short-term mortality.

Current approach for the prosthesis patient mismatch

All prosthetic valves are at least mildly stenotic and have relatively high transvalvular pressure gradients that can be observed despite normal prosthesis function. Such gradients may be due to a mismatch between prosthesis effective orifice area (EOA) and patient's body size. Valve prosthesis-patient mismatch (VP-PM) may occur due to mismatches of both parameters, the expected hemodynamic performance of the prosthesis and the cardiac output requirements of the patient, which are largely related to the body size at rest. In other words, a prosthesis may be adequate for patients with a small body surface area (BSA) but might become obstructive for patients with a large BSA. The only parameter that has proven to be consistently and realistically useful to predict and describe VP-PM is the effective orifice area index (EOAI). The projected EOAI was identified as the best parameter to predict the VP-PM occurrence after surgery. VP-PM has been known to be independently and significantly associated with clinical outcomes. Severe VP-PM has a significant impact on early and late mortality, whereas moderate VP-PM may have a significant effect on mortality only in vulnerable subsets of patients, and particularly in those with depressed LV systolic function. The surgeon's anticipation of VP-PM prior to surgery, and successfully implented preventive strategies can reduce the incidence of VP-PM. Preventive strategies to avoid VP-PM should be individualized according to the anticipated severity of VP-PM and of the patient's baseline risk profile.

One-year hemodynamic comparison of Perimount Magna with St Jude Epic aortic bioprostheses

IntroductionCardiac surgeons are using more bioprosthetic valves due to the ageing population as well as to improvements that have been made to these implants. We sought to compare the 1-year hemodynamics of two commercially available valves by echocardiographic parameters.Material and methodsRetrospective review of our institutional database revealed 69 patients who received either Perimount Magna (n = 33) or St Jude Epic (n = 36) valves in the aortic position with no other valve surgery between June 2004 and March 2006. All patients received transthoracic echocardiography at 1 year. Comparisons between groups were made at baseline and at 1-year follow-up. In addition, a pairwise comparison was performed in each patient to determine the change in echocardiographic parameters between baseline and follow-up.ResultsMean implanted valve size was similar (Magna 24.3 ±2.0 mm vs. Epic 24.1 ±2.2 mm). Pre- and intraoperative patient variables were similar between the two groups. There were lower peak and mean pressure gradients in the Magna group, both at discharge and one year after surgery. This correlated with a larger indexed effective orifice area (Magna 0.8 ±0.2 cm2/m2 vs. Epic 0.67 ±0.2 cm2/m2, p = 0.02). In spite of these findings, left ventricular mass regression was not different.ConclusionsThese findings suggest that in a series with relatively low indexed effective orifice areas, the peak and mean gradients obtained were acceptable. More clinical follow-up of these patients is required to assess the true impact of prosthesis patient mismatch.

Sustitución valvular aórtica con prótesis biológicas en pacientes con estenosis aórtica severa. ¿Válvulas soportadas o no soportadas?

Introduction and objectivesIt is considered that a Stentless bioprosthesis reverses the left ventricular hypertrophy more than a Stented bioprosthesis in aortic valve replacement (AVR). There is no comparison in a non-Anglo-Saxon population.We aim to determine whether there are any statistically significant differences when analysing the survival, New York Heart Association (NYHA) functional status, and regression of left ventricular mass index (LVMI), as well as other variables. MethodsA retrospective analytical study was conducted on 120 patients matched by propensity score who, from April 2002 to March 2009, underwent scheduled isolated AVR due to severe aortic stenosis with bovine pericardial tissue valves (60 Stentless Freedom versus 60 Stented Mitroflow, Sorin Group). ResultsThe mean follow-up was 48.4±22 months. No significant differences were detected in NYHA functional class (mean 1.78±0.5, Stentless Vs 1.72±0.6 Stented, p=.616), or mean LVMI regression, which was 42.2g/m2 (25.3%) in Stented, and 36.3g/m2 22.6%) in Stentless (p=.467). Stentless valves had a lower transaortic mean gradient (14.4±6.8mmHg Stented, Vs 9.3± 3.2mmHg Stentless, P=.05), and a higher indexed effective orifice area (0.76±0.1cm2/m2 Stented Vs 0.83±0.1cm2/m2 Stentless, p=.04) within the first 24 months postoperative, becoming similar later. There was no difference in survival (p=.185). ConclusionsStented biological valves are as effective as Stentless bioprostheses. There were no statistically significant differences in survival, NYHA functional class, or LVMI regression at the mean follow up, even in patients with a small aortic annulus of 19–21mm.

Simple interrupted suturing increases valve performance after aortic valve replacement with a small supra-annular bioprosthesis

A supra-annular aortic valve prosthesis is often used for aortic valve replacement in patients with a small aortic annulus. However, which suture technique provides the best valve performance has not been studied. We aimed to compare valve performance between 2 different suture techniques. We reviewed 152 patients undergoing aortic valve replacement with a 19- or 21-mm Carpentier-Edwards Perimount Magna aortic bioprosthesis (Edwards Lifesciences, Irvine, Calif) between June 2008 and December 2010. Simple interrupted sutures were used in 102 patients (group A, 19-mm prosthesis in 47 patients and 21-mm prosthesis in 55 patients), and noneverting mattress sutures were used in 50 patients (group B, 19-mm prosthesis in 20 patients and 21-mm prosthesis in 30 patients). Transthoracic echocardiograms were performed at baseline and before discharge in all patients and 1 year after surgery in 141 patients. We compared the effective orifice area and incidence of prosthesis-patient mismatch (effective orifice area index<0.85 cm(2)/m(2)) between 2 groups. The mean postoperative effective orifice areas were 1.41±0.32 cm(2)/m(2) in group A and 1.30±0.28 cm(2)/m(2) in group B (P=.025). The incidence of prosthesis-patient mismatch was 29% in group A and 56% in group B (P=.002). A multivariate analysis has shown that simple interrupted suturing is a negative predictor of prosthesis-patient mismatch (odds ratio, 0.33; 95% confidence interval, 0.13-0.83; P=.018). At 1 year, the incidence of prosthesis-patient mismatch was 27% in group A and 47% in group B (P=.023). Simple interrupted sutures provide larger effective orifice areas and reduce the incidence of prosthesis-patient mismatch after aortic valve replacement with a small supra-annular bioprosthesis. This suture technique is preferred in those patients to maximize valve performance.

Impact of TAVI on Mitral Regurgitation: A Prospective Echocardiographic Study

This study aims to assess changes in mitral regurgitation (MR) severity after transcatheter aortic valve implantation (TAVI). Existing data on MR after TAVI are contradictory. Thirty-five patients with MR graded≥2+ were followed after undergoing TAVI with either the Edwards Sapien or CoreValve device. Echocardiography was performed the week before and 3months after the procedure. MR was graded on a scale of 0 to 4+, classified as organic or functional, and the effective regurgitant orifice area (EROA) and MR index were calculated. At baseline, MR was graded 4+ in 4 (11.4%) patients, 3+ in 10 (28.6%), and 2+ in 21 (60%). At follow-up, MR was graded at 3+ in 4 (11.4%) patients, 2+ in 8 (22.9%), and 1+ in 19 (54.3%); 4 (11.4%) exhibited no MR. EROA (24.4±11.5mm(2) pre-TAVI vs. 11.2±10.3mm(2) post-TAVI, P<0.001) and MR index (1.9±0.3 pre-TAVI vs. 1.3±0.7 post-TAVI, P<0.001) were reduced with TAVI, independent of the etiology. MR decreased by at least 1 grade in 28 (80%) patients, with a reduction ≥2 grades in 10 (28.6%) patients; no patient showed a worsened condition. Subgroup analyses showed that the reduction in MR was significant in patients treated with the Edwards Sapien device but not in patients treated with the CoreValve device. This multiparametric echocardiographic evaluation showed that MR improved significantly after TAVI and that this result may be related to the type of valve implanted.

Longitudinal strain predicts left ventricular mass regression after aortic valve replacement for severe aortic stenosis and preserved left ventricular function

We explored the influence of global longitudinal strain (GLS) measured with two-dimensional speckle-tracking echocardiography on left ventricular mass regression (LVMR) in patients with pure aortic stenosis (AS) and normal left ventricular function undergoing aortic valve replacement (AVR). The study population included 83 patients with severe AS (aortic valve area <1 cm(2)) treated with AVR. Bioprostheses were implanted in 58 patients (69.8 %), and the 25 remaining patients (30.2 %) received mechanical prostheses. Peak systolic longitudinal strain was measured in four-chamber (PLS4ch), two-chamber (PLS2ch), and three-chamber (PLS3ch) views, and global longitudinal strain was obtained by averaging the peak systolic values of the 18 segments. Median follow-up was 66.6 months (interquartile range 49.7-86.3 months). At follow-up, values of PLS4ch, PLS2ch, PLS3ch, and GLS were significantly lower (less negative) in patients who did not show left ventricular (LV) mass regression (all P < 0.001). Baseline global strain was the strongest predictor of lack of LVMR (odds ratio 3.5 (95 % confidence interval 3.0-4.9), P < 0.001), and GLS value ≥-9.9 % predicted lack of LVMR with 95 % sensitivity and 87 % specificity (P < 0.001). Other multivariable predictors were the preoperative LV mass value (cutoff value ≥147 g/m(2), P < 0.001), baseline effective orifice area index (cutoff ≤0.35 cm(2)/m(2), P = 0.01), and baseline mean gradient (cutoff ≥58 mmHg, P = 0.01). Finally, we failed to find interactions between GLS and other significant parameters (all P < 0.05). Global longitudinal strain accurately predicts LV mass regression in patients with pure AS undergoing AVR. Our findings must be confirmed by further larger studies.