Mean Aortic Annulus Diameter Research Articles

Native Aortic Valve Resection Using a Novel Blade-Based Device.

The aim of this study was to validate the use of a new resection device in patient candidates for surgical aortic valve replacement. We evaluated the efficacy of this new circular blade to resect the aortic valve and the efficacy to collect the debris during the resection. For this study, a single size instrument was used, with an external diameter of 22 mm, and patients were selected on the basis of the preoperative assessment of the aortic diameters. From October 2018 to June 2019, 10 patient candidates for surgical aortic valve replacement were selected to undergo native aortic valve resection using a new device, before surgical valve implantation. The mean age of the patients was 74 ± 7.6 years, and 8 of 10 were male. The mean aortic annulus diameter, measured before the procedure, was 25.7 ± 1.57 mm. The resection was complete in 9 (90%) patients. In 1 patient, due to an imprecise positioning of the device, the valve resection was partial. None of the patients showed signs or symptoms due to debris embolism. In all patients, the postoperative course was uneventful. These preliminary results show that resection of the aortic valve using a circular foldable blade is feasible. This prototype, used during conventional surgery even through a small incision, provided an efficient tool to easily resect the valve without debris release.

Aortic root enlargement in patients undergoing mitral and aortic replacement: early outcomes in a sub-Saharan population.

Aortic root enlargement (ARE) is often required to avoid patient-prosthesis mismatch (PPM) in young patients undergoing aortic surgery, including those undergoing combined mitral and aortic valve replacement (double valve replacement, DVR). Adding ARE to DVR may increase the operative risk by extending the surgical time. Herein, we review our experience with ARE in patients who underwent DVR. The medical records of 69 patients who underwent DVR at our institution between February 2008 and November 2021 were retrospectively reviewed. The patients were divided into two groups according to the ARE procedure (ARE-DVR: 25 patients; DVR: 44 patients). Descriptive and comparative analyses of demographic, clinical, and surgical data were performed. Among the 69 patients who underwent DVR, 35 were women (sex ratio, 0.97). The mean age at surgery was 26.7 ± 13.9 years (range: 7-62 years). Among the 47 patients aged ≤30 years, 40.4% (19/47) were aged between 10 and 20 years, and 6.3% (3/47) were aged <10 years. Patients in the ARE-DVR group were younger (23.3 ± 12.9 years vs. 28.5 ± 14.2 years, p < 0.05). The New York Heart Association Class ≥III dyspnea was the most common symptom (89.9%), with no differences between the two groups. Of all the patients, 84.1% had sinus rhythm. Rheumatic disease was the most common etiology in the entire cohort (91.3%). The mean aortic annulus diameter was 20.54 mm, with smaller sizes found in the ARE-DVR group (18.00 ± 1.47 mm vs. 22.50 ± 2.35 mm, p < 0.05). The aortic cross-clamping duration was greater in the ARE-DVR group (177.6 ± 37.9 min vs. 148.3 ± 66.3 min, p = 0.047). The operative mortality rate was 5.6% for the entire cohort (ARE-DVR: 8% vs. DVR: 4.5%, p = 0.46). Among the patients who underwent echocardiographic control at follow-up, the mean aortic gradient was 19.6 ± 7.2 mmHg (range: 6.14-33 mmHg), with no differences among the groups. The association between ARE and DVR did not significantly affect operative mortality. ARE can be safely used whenever indications arise to reduce the occurrence of PPM, especially in young patients with growth potential.

Suitability of the porcine aortic model for transcatheter aortic root repair.

To treat aortic valve disease and concomitant root disease with transcatheter techniques, 'composite graft' implants are required. Our goal was to assess the suitability of the porcine aortic root for transcatheter root repair tests. Eight pig hearts explanted from domestic pigs used in experimental surgery were compared to data from the literature on human hearts. The measured diameters included those of the annulus, sinuses of Valsalva, coronary ostia, sinotubular junction, ascending aorta, innominate artery and aortic arch. The measured distances were from the coronary ostia to the nadir of the corresponding annulus; from the innominate artery to the nadir of the corresponding annulus; from the small curvature of the arch to the nadir of the corresponding annulus. The mean weight of the pigs was 89 ± 5.4 kg. The mean aortic annulus diameter was 20 ± 1.2 mm (human: 23.0 ± 2.5 mm), the sinus of Valsalva diameter was 20.5 ± 0.5 mm (human: 31.4 ± 3.4 mm) and the sinotubular junction diameter was 20 ± 0.9 mm (human: 27.2 ± 3.0 mm). The diameter of the mean ascending aorta was 19 ± 0.7 mm (human: 29.3 ± 4 mm); the diameter of the innominate artery was 8.5 ± 0.7 mm, that of the aortic arch was 15 ± 0.7 mm and that of the coronary ostia was 5 ± 0.5 mm (left) and 4.7 ± 0.5 mm (right) (human: 4.8 ± 0.5 mm and 3.7 ± 0.9 mm). The distances from the left and right coronary orifices to the corresponding annuli were 8 ± 1.5 mm and 14 ± 2.4 mm, respectively (human: 14.7 ± 1.3 mm; 15.4 ± 1.7 mm). The distances from the innominate artery to the nadirs of the left and right coronary annuli were 44 ± 4.3 mm and 41 ± 4 mm (human: 80 ± 17 mm). The distance from the curvature of the small arch to the annulus was 35 ± 4.9 mm. The porcine heart can be used as an experimental model to design and test new devices for catheter-based composite repair of the aortic root. Nevertheless, caution is required in using devices with tailored dimensions that must be adapted to the smaller pig's root.

Comparison of Aortic Annulus Dimensions by Multimodal Measurement before Transcatheter Aortic Valve Replacement

To compare aortic annular diameter measured by transthoracic echocardiography (TTE), transesophageal echocardiography (TEE), and multi-slice spiral computed tomography (MSCT) in patients with severe aortic stenosis, and to evaluate the impact on selection of prosthetic valve size in transcatheter aortic valve replacement (TAVR). Clinical data of 138 patients with severe aortic stenosis referred for TAVR between January 2014 and June 2016 in our hospital were retrospectively analyzed. The difference of aortic annular diameter measured by TTE, TEE, and MSCT were compared. TTE was performed after TAVI to evaluate the accuracy of measurement before TAVI. (1) Mean aortic annulus diameter was 23.37±2.22 mm using TTE and 23.52±1.70 mm using TEE (p = 0.12) and correlation between TTE and TEE was excellent (r = 0.87, p < 0.05). (2) The long-axis diameter (27.86±2.87 mm) and the short diameter (21.91±2.53 mm) measured according to MSCT multiplanar reconstruction were significantly different (p < 0.05). There was no significant difference between the mean of the long- and short-axis diameters (24.92±2.38 mm) and the diameter derived from cross-sectional area (24.84±2.25 mm) by MSCT (p = 0.08). However, the diameter derived from the circumference (25.35±2.34 mm) was significantly larger than the mean of the long- and short-axis diameters and the diameter derived from cross-sectional area by MSCT, and the difference were 0.43±0.62 mm and 0.51±0.62 mm respectively（both p < 0.05）.(3) Measurements of the aortic annulus diameter by MSCT including the mean of the long- and short-axis diameters, diameter derived from cross-sectional area, and diameter derived from the circumference were larger than the measurement by TTE and TTE significantly (all p < 0.05).(4) TAVR postoperative follow-up: Implantation was successful in all patients. Moderate to severe paravalvular leakage was detected in 3 patients at 7 days post TAVR, and 1 patient developed severe prosthetic valve restenosis at 6 months post TAVR and received valve-in-valve implantation. In severe aortic patients referred for TAVR, measurements of the aortic annulus diameter using TTE and TEE are smaller than the measurements by MSCT. In the absence of a gold standard, selection of prosthetic valve type in TAVI procedure should rely on comprehensive considerations, which is of importance to get good clinical results for severe aortic stenosis patients underwent TAVI.

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.

First‐in‐man transfemoral transcatheter aortic valve replacement with the 29 mm Edwards SAPIEN XT Valve

To demonstrate the feasibility of transfemoral transcatheter aortic valve replacement (TAVR) with the 29 mm Edwards SAPIEN XT valve and Novaflex™ + delivery system through a 20F expandable sheath (eSheath™, Edwards Lifesciences, USA). In addition, to describe the use of the Novaflex + delivery system and expandable sheath. TAVR has undergone significant advances in device technology resulting in smaller profile sheaths and delivery systems, allowing transfemoral delivery of a 29 mm valve. Twelve patients underwent transfemoral TAVR with the 29 mm Edwards SAPIEN XT valve and Novaflex + delivery system through a 20F expandable sheath. Baseline clinical and procedural characteristics are evaluated. In-hospital and 30-day outcomes are reported according to Valve Academic Research Consortium criteria. All patients were male with a mean aortic annulus diameter of 25.0 ± 1.1 mm and 25.9 ± 1.2 mm, on transesophageal echocardiography and multidetector computerized tomography, respectively. Mean iliofemoral minimal luminal diameter (MLD) was 8.0 ± 0.8 mm. Successful deployment of the valve occurred in 11 out of 12 patients. Valve embolization occurred in one patient. Aortic valve area increased from 0.7 ± 0.2 to 2.0 ± 0.5 cm(2) (P < 0.001). There were two major vascular complications; however, there were no in-hospital or 30-day neurological events, need for pacemaker insertion, or mortality. Transfemoral TAVR with the 29 mm Edwards SAPIEN XT valve and Novaflex + delivery system through a 20F expandable sheath was feasible with acceptable short-term outcomes.

Transesophageal echocardiography measurements of aortic annulus diameter using biplane mode in patients undergoing transcatheter aortic valve implantation

BackgroundAortic stenosis (AS) is a relevant common valve disorder. Severe AS and symptoms and/or left ventricular dysfunction (EF <50%) have the indication for aortic valve replacement (AVR). Majority of the patients with AS are elderly often with co-morbidities and generally have high preoperative risk. Transcatheter aortic valve implantation (TAVI) is offered in this group. Four different sizes of Corevalve prosthesis are available. Correct measurement of aortic size prior to TAVI is of great important to choose the right prosthesis size to avoid among others paravalvular leak or prosthesis patient mismatch.Aim of the study is to assess the aortic annulus diameter in patients undergoing TAVI by biplane (BP) mode using transesophageal echocardiography (TEE) and compare it to two-dimensional (2D) transthoracic echocardiography (TTE) and 2DTEE using three-dimensional (3D) TEE as reference method.MethodsThe study population consisted of 50 patients retrospectively (24 men and 26 women, mean age 85±8 years of age) who all had undergone echocardiography examination prior to TAVI.ResultsThe mean aortic annulus diameter was 20.4±2.2 mm with TTE, 22.3±2.5 mm with 2DTEE, 22.9±1.9 mm with BP-mode and 23.1±1.9 mm with 3DTEE. TTE underestimated the mean aortic annulus diameter in comparison to transesophageal imaging modalities (p<0.001). Using 3DTEE, 2% of patients were unsuitable for TAVI due to a too-small AoA (n=1). This figure was similar with BP (4%, n=2; p=1.00) but considerably larger with 2DTTE (36%, n=18; p < 0.001) and 2DTEE (12%, n=6; p=0.06). There was a strong correlation between BP-mode and 3DTEE for assessment of aortic annulus diameter (r-value 0.88) with small mean difference (−0.2±0.9 mm) whereas the other modalities showed larger 95% confidence interval and modest correlation (2DTTE vs. 3DTEE, –6.3 to 0.9 mm, r=0.64 and 2DTEE vs. 3DTEE, –4.8 to 3.2 mm, r=0.61).ConclusionA multi-dimensional method is preferred to assess aortic annulus diameter in TAVI patients since there is risk of underestimation using single plane. Biplane mode is the method of choice in view of speedy post-processing with no need for expensive dedicated software. Lastly, single plane methods lead to misclassification of patients as unsuitable for TAVI. This may be of major clinical importance.

Abstract 9572: Post-Stenotic Dilatation in Asymptomatic Aortic Stenosis

Background: Post-stenotic aortic root dilation is often observed in aortic stenosis (AS) patients, but the relation to AS severity has not been reported from a large population of asymptomatic AS patients. Methods: Baseline data in 1223 patients with asymptomatic AS (mean age 67 years, 39% women) in the Simvastatin and Ezetimibe in Aortic Stenosis (SEAS) study was used. Annular diameter was measured from inner to inner edge in mid-systole. Inner and leading edge aortic root diameter was measured at the levels of sinus of Valsalva, sinotubular junction and supracoronary. Predicted aortic diameters were calculated from age and body size adjusted equations derived in normal adults. Results: On average, mean aortic annulus diameter was 2% larger, sinus of Valsalva diameter 11% larger, sinotubular junction diameter 22% larger and supracoronary diameter 32% larger in SEAS participants than that predicted from body size. Enlarged aortic diameter was found in 42%, 78%, 96% and 98% of patients at these levels and associated with larger inner diameter and thicker aortic wall (both p&lt;0.01). In multivariate regression analysis, larger sinus of Valsalva or sinotubular junction diameter was independently associated with more severe AS (Table). Conclusions: Post-stenotic aortic root dilatation is common in asymptomatic AS with increasing prevalence from proximal to distal part. Aortic root dilation at the sinus of Valsalva and sinotubular junction level was associated with higher AS severity.

Preoperative quantification of aortic valve stenosis: comparison of 64-slice computed tomography with transesophageal and transthoracic echocardiography and size of implanted prosthesis

Precise measurements of aortic complex diameters are essential for preoperative examinations of patients with aortic stenosis (AS) scheduled for aortic valve (AV) replacement. We aimed to prospectively compare the accuracy of transthoracic echocardiography (TTE), transoesophageal echocardiography (TEE) and multi-slice computed tomography (MSCT) measurements of the AV complex and to analyze the role of the multi-modality aortic annulus diameter (AAd) assessment in the selection of the optimal prosthesis to be implanted in patients surgically treated for degenerative AS. 20 patients (F/M: 3/17; age: 69 ± 6.5 years) with severe degenerative AS were enrolled into the study. TTE, TEE and MSCT including AV calcium score (AVCS) assessment were performed in all patients. The values of AAd obtained in the long AV complex axis (TTE, TEE, MSCT) and in multiplanar perpendicular imaging (MSCT) were compared to the size of implanted prosthesis. The mean AAd was 24 ± 3.6 mm using TTE, 26 ± 4.2 mm using TEE, and 26.9 ± 3.2 in MSCT (P = 0.04 vs. TTE). The mean diameter of the left ventricle out-flow tract in TTE (19.9 ± 2.7 mm) and TEE (19.5 ± 2.7 mm) were smaller than in MSCT (24.9 ± 3.3 mm, P < 0.001 for both). The mean size of implanted prosthesis (22.2 ± 2.3 mm) was significantly smaller than the mean AAd measured by TTE (P = 0.0039), TEE (P = 0.0004), and MSCT (P < 0.0001). The implanted prosthesis size correlated significantly to the AAd: r = 0.603, P = 0.005 for TTE, r = 0.592, P = 0.006 for TEE, and r = 0.791, P < 0.001 for MSCT. Obesity and extensive valve calcification (AV calcium score ≥ 3177Ag.U.) were identified as potent factors that caused a deterioration of both TTE and MSCT performance. The accuracy of AAd measurements in TEE was only limited by AV calcification. In multivariate regression analysis the mean value of the minimum and maximum AAd obtained in MSCT-multiplanar perpendicular imaging was an independent factor (r = 0.802, P < 0.0001) predicting the size of implanted prosthesis. In patients with AS echocardiography remains the main diagnostics tool in clinical practice. MSCT as a 3-dimentional modality allows for accurate measurement of entire AV complex and facilitates optimal matching of prosthesis size.

Hemodynamic performance of the Medtronic Mosaic and Perimount Magna aortic bioprostheses: five-year results of a prospectively randomized study

Clinical outcomes of patients undergoing aortic valve replacement may be influenced by the presence of residual gradients and patient-prosthesis mismatch. The aim of this study was to compare hemodynamic performance and clinical outcomes at 5 years after prospectively randomized porcine versus bovine aortic valve replacement. We also aimed to determine the effects of valve hemodynamics on left ventricular (LV) mass regression. A total of 108 patients undergoing aortic valve replacement were randomized to receive either the Medtronic Mosaic (MM) porcine (n=54) or the Edwards Perimount Magna (EPM) bovine pericardial prosthesis (n=54). Clinical outcomes, mean gradients, effective orifice area and LV mass regression were evaluated at 1 and 5 years after surgery. Follow-up echocardiograms were performed on 106 (98%) and 87 (92%) patients, respectively. Preoperative characteristics were similar between groups. Mean aortic annulus diameter and mean implant size were comparable in both groups. At 1 and 5 years, mean transprosthetic gradients were lower in the EPM group: EPM 10.3±3.4mmHg versus MM 16.3 ± 7.6 mmHg (p<0.0001) and EPM 9.6 ± 3.5 mmHg versus MM 16.8 ± 8.7 mmHg (p<0.0001), respectively. Similarly, indexed effective orifice areas (IEOA) at 1 and 5 years were significantly greater in the EPM group: EPM 1.10 ± 0.22 cm(2)m(-2) versus MM 0.96 ± 0.22 cm(2)m(-2) (p<0.004) and EPM 1.02 ± 0.25 cm(2)m(-2) versus MM 0.76 ± 0.19 cm(2)m(-2) (p<0.0001), respectively. At 5 years, the incidence of patient-prosthesis mismatch (IEOA ≤0.85 cm(2)m(-2)) was significantly lower in the EPM group: EPM 22.9% vs MM 73.9% (p<0.0001). Such differences were similar when analysis was stratified by surgically measured annular size and implant valve size. During the first year after surgery, both groups demonstrated similar regression of LV mass index (MM -26.3 ± 43 gm(2) vs EPM -30.1 ± 36 gm(-2); p=0.8); however, at 5 years, regression of LV mass index was significantly greater in the EPM group: (EPM -47.4 ± 35 gm(-2) vs -4.4 ± 36 gm(-2); p<0.0001). Five-year survival was 79.6 ± 4.1% in the MM group and 94.4 ± 2.2% in the EPM group (p=0.03). At 5 years, the EPM valve was significantly superior to the MM prosthesis with regard to hemodynamic performance, incidence of patient-prosthesis mismatch and regression of LV mass index. The hemodynamic superiority of the EPM prostheses in comparison to MM-prostheses demonstrated at 1 year, increased significantly over time.

Transapical aortic valve implantation with a self-expanding anatomically oriented valve

The Medtronic Engager™ aortic valve bioprosthesis is a self-expanding valve with support arms facilitating anatomically correct positioning and axial fixation. Valve leaflets, made of bovine pericardium, are mounted on a Nitinol frame. Here, we report the first in man study with this new implant (Trial Identifier NCT00677638). Thirty patients (mean age 83.4 ± 3.8 years; 83% female) with tricuspid aortic valve stenosis were included in the study. Mean logistic EuroSCORE was 23.4 ± 11.9. Mean aortic annulus diameter was 21.8 ± 1.4 mm. For this study, the Engager was available in only one size (23 mm), to fit aortic annuli of 19-23 mm. Standard transapical valve implantation was performed using pre-dilation of the aortic valve and rapid ventricular pacing during balloon valvuloplasty and most valve deployments. Accurate valve placement was achieved in 29/30 cases (97%). Post-implant peak-to-peak gradient was 13.3 ± 9.3 mmHg. In 80% of the patients, no more than grade I paravalvular leakage was observed, in 13% grades I-II and in 3% grade II. Three patients (10%) required permanent pacemaker implantation for higher-degree or complete atrioventricular block. Four dissections (13%) occurred during positioning of the valve and were treated surgically in three cases. Thirty-day and in-hospital mortality were 20% and 23%, respectively, and 6-month survival was 56.7%. No structural failure occurred for up to 1 year. This series established the feasibility of implanting a novel self-expanding transapical aortic valve prosthesis predictably into an anatomically correct position. Observed complications led to complete redesign of the delivery system for upcoming clinical studies with the goal of establishing safety and performance.

Incidence of Aortic Root Dilatation in Pectus Excavatum and Its Association With Marfan Syndrome

To investigate the incidence of aortic root dilatation in pectus excavatum. Retrospective medical record review and echocardiographic reanalysis. Morgan Stanley Children's Hospital of New York-Presbyterian. Surgical candidates with pectus excavatum (n = 37) and age-matched controls (n = 44) referred for an echocardiogram from 1994 to 2002. Two-dimensional and color Doppler transthoracic echocardiograms. The aortic annulus and root were measured and z scores were calculated and compared. Medical records were reviewed for genetic evaluation. Patients with pectus excavatum and age-matched controls were reanalyzed. There was no difference in age, weight, height, or body surface area between patients and controls. There were no differences in the mean aortic annulus diameter, mean aortic annulus z score, or mean aortic root measurements. However, the aortic root z score was significantly higher in the pectus excavatum group compared with the controls: 0.9 (SD, 1.06) vs 0.0 (SD, 1.25) (P = .001). There were more patients with an aortic root z score of 2 or greater in the pectus excavatum group (9 of 37 patients) than in the control group (0 of 43 controls), with a calculated odds ratio of 29.7 (95% confidence interval, 1.10-1.59). Genetic evaluation was performed in 5 patients with a pectus excavatum and dilated aortic root; 2 of them received diagnoses of Marfan syndrome. Aortic root dilatation is more common in patients with pectus excavatum than in a control population. Echocardiographic screening may be useful in the identification of aortic root dilatation in patients with isolated pectus excavatum.

One year hemodynamic performance of the Perimount Magna pericardial xenograft and the Medtronic Mosaic bioprosthesis in the aortic position: a prospective randomized study

We compared the hemodynamic performance of the Edwards Perimount Magna (EPM) and the Medtronic Mosaic (MM) bioprostheses according to the patient aortic annulus diameter (AAD). Eighty-six patients undergoing aortic valve replacement were prospectively assigned to receive either an EPM-valve (n=43) or an MM-bioprosthesis (n=43). Randomization was performed after measuring the AAD and patients were grouped according to their AAD: <22 mm (n=12), 22-23 mm (n=31) and >23 mm (n=43). Echocardiographic assessment was performed one year postoperatively. The mean AAD (EPM 23.9+/-2.1 mm vs. MM 23.6+/-2.3 mm) and mean valve size implanted (EPM 22.6+/-2.1 mm vs. MM 23.3+/-2.1 mm) were comparable in both groups. The EPM-group showed significantly lower mean gradient (EPM 10.2+/-3.2 mmHg vs. MM 17.1+/-8.2 mmHg) and larger effective orifice area (EOA) (EPM 1.99+/-0.4 cm(2) vs. MM 1.69+/-0.4 cm(2), P<0.0001). The EPM-valve was superior with respect to mean pressure gradient and EOA in all AAD. This difference was statistically significant in AAD of 22-23 mm (EPM 9.6+/-3.0 mmHg vs. MM 18.2+/-8.6 mmHg; EPM 1.82+/-0.3 cm (2) vs. MM 1.51+/-0.2 cm (2)) and >23 mm (EPM 9.9+/-3.1 mmHg vs. MM 14.2+/-5.6 mmHg; EPM 2.18+/-0.4 cm(2) vs. MM 1.94+/-0.5 cm(2)). Patient-prosthesis mismatch was present in 26.8% (MM) vs. 6.9% (EPM) of the patients (P=0.01). When the same AAD is taken as a reference, the EPM-valve was hemodynamically superior to the MM-bioprosthesis. The EPM-prosthesis significantly reduced the incidence of PPM.