Small Aortic Annulus Research Articles

COMPARISON OF ECHOCARDIOGRAPHIC OUTCOMES FOLLOWING TRANSCATHETER AORTIC VALVE REPLACEMENT WITH EDWARDS S3 23 MM VERSUS MEDTRONIC EVOLUT 26 MM VALVES

Patients with small aortic valve annulus (SAVA) undergoing TAVR are prone to higher post TAVR trans-valve gradients. In many such patients, the choice of TAVR valve commonly involves choosing between the Edwards S3 23 mm (ES23) versus the Medtronic Evolut 26 mm (ME26). The supraannular design of the

Konno Procedure for Managing Small Aortic Root during Aortic Valve Replacement Surgery: An Experience of 12 Cases

Background: Small aortic annulus during aortic valve replacement can lead to implanting a smaller sized valve compared to the body surface area thereby causing patient prosthesis mismatch. Various aortic root enlargement techniques have been described depending on anterior or posterior approach. Konno procedure uses anterior approach for aortic root enlargement. In this study, we reviewed results of Konno procedure done from 2011 to 2019 by a single surgeon. Methods: 12 adult patients who underwent aortic valve replacement along with Konno procedure for small aortic root by a single surgeon at a single center between 2011 and 2019 were reviewed. Echocardiographic and demographic data and post-operative data were obtained from medical records. Symptomatic profile was assessed as per New York Heart Association Classification. Intraoperative findings and post-operative period findings were noted. Follow up symptom profile was assessed for these patients. Results: 12 patients underwent Konno procedure between 2011 and 2019 for small aortic root along with valve replacement. The main indication for surgery was aortic stenosis with small aortic annulus, with or without involvement of the mitral valve. Preoperatively, 3 patients had NYHA class II and 9 patients had NYHA class III symptoms. Mean age at operation was 26.42 years, minimum age 10 years, and maximum age 39 years. 3 were females and 9 were males. Mean bypass time was 106.4 minutes and aortic cross clamp time was 80.67 minutes. Mechanical aortic valves were implanted in all patients. Mean post-operative blood loss was 134.2 ml and duration of ventilation before extubation was 14.5 hours. Mean duration of intensive care unit (ICU) stay was 2.83 days and hospital stay was 9.1 days. Mean gradient in the post-operative period was 10.75 mm Hg. There was no mortality in these 12 patients and no reoperation was needed in the follow up period. Follow up in the outpatient department suggested all patients had NYHA class I symptoms and anticoagulation with warfarin adjusted to prothrombin time— International normalised ratio. Conclusion: Konno procedure is effective for managing small aortic root as bigger outflow orifice area through the larger valve prosthesis improves ventricular outflow and hence, improves the outcomes.

Management of Small Aortic Root during Aortic Valve Replacement

Background: Concomitant aortic root enlargement (ARE) increases the risk of aortic valve replacement (AVR). The objectives of this study were to identify the patients who needed aortic root enlargement and compare the outcomes and the risk of adding ARE to AVR.
 Methods: We retrospectively reviewed 62 patients who underwent isolated mechanical aortic valve replacement between 2017 and 2019. We divided the patients into two groups: group A included patients with small aortic root who had AVR with one of the different surgical strategies for small aortic annulus (n= 32) and group B, which included patients with a normal aortic annulus and underwent conventional AVR (n= 30). Group A was further sub-divided based on the surgical strategy into 4 categories; patients who had supra-annular implantation of size 19 mm St. Jude prosthetic valve (n= 11; 34.4%), Nicks procedure (n= 13 40.6%), Manougian procedure (n= 4; 12.5%), Konno procedure (n= 4; 12.5%). 
 Results: Group A patients were significantly younger (26.16 ± 11.49 vs. 34.63 ± 8.9 years; p< 0.001) and had lower body weight (55.09 ± 21.41 vs. 69.80 ± 19.20; p= 0.01). Group A had significantly smaller valves (p = 0.03), and total cardiopulmonary bypass (148.65 ± 44.09 vs. 97.46 ± 20.90 minutes; p<0.001) and aortic cross-clamp times (118.13 ± 36.70 vs. 78.06 ± 16.01 minutes; p < 0.001) were significantly longer in group A. There was no significant difference in operative complications between groups. Among patients with small aortic root; Konno procedure had the longest bypass time (236.3 ± 19.70 minutes; p<0.001); cross-clamp time (192.5 ± 22.2 minutes; p <0.001); mechanical ventilation (4.75 ± 0.50 hours; p<0.001) and intensive care unit stay (6.50 ± 0.57 days; p <0.001). Patients with supra-annular implantation of the St. Jude valve had a significantly higher postoperative pressure gradient (14.64 ± 6.84 mmHg; p= 0.02). No difference in procedure complications was observed among aortic root enlargement procedures.
 Conclusion: Patients who had aortic root enlargement procedure were younger, with lower weight and body surface area. Surgical procedures used to manage small aortic root had comparable early results, and no technique was superior to the others.

Valve Hemodynamics Following Transcatheter or Surgical Aortic Valve Replacement in Patients With Small Aortic Annulus

This study aimed to compare the hemodynamic performance of transcatheter and surgical aortic valves in patients with severe symptomatic aortic stenosis and small aortic annulus (SAA) and to determine the valve hemodynamics according to transcatheter valve type. Consecutive surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) patients with SAA were case-matched (1:1) on the basis of sex, body surface area, aortic annulus diameter, and left ventricular ejection fraction. A total of 357 patients in each group constituted the final study population. A second match on the basis of aortic annulus diameter and valve/annulus calcium burden was performed within the TAVR group to compare the valve performance between balloon- (n = 52) and self-expanding (n = 52) transcatheter valve systems (BEV, SEV). The echocardiograms performed at hospital discharge were used for evaluating valve hemodynamics. The mean annulus diameter of the study population was 19.2 ± 0.3 mm. The TAVR group (vs SAVR) exhibited lower mean gradient (12 ± 7 mm Hg vs 15 ± 6 mm Hg, p <0.001), larger effective orifice area (1.46 ± 0.39 cm2 vs 1.25 ± 0.37 cm2, p <0.001) and a lower rate of severe prosthesis-patient mismatch (PPM) (14% vs 24%, p = 0.001). Moderate-severe AR was present in 2.5% of the TAVR recipients versus none patient in the SAVR group. There were no differences in valve hemodynamics between balloon-expanding transcatheter valve system and self-expanding transcatheter valve system, and similar rates of severe PPM were observed in both groups (p = 0.488). In conclusion, TAVR presented superior valve hemodynamics and lower incidence of severe PPM compared with SAVR in SAA patients. Similar valve performance results were observed between transcatheter valve types.

Transcatheter Self-Expandable Valve Implantation for Aortic Stenosis in Small Aortic Annuli: The TAVI-SMALL Registry

ObjectivesThe aim of this study was to evaluate and compare the outcomes of transcatheter self-expandable prostheses in patients with small annuli. BackgroundTranscatheter aortic heart valves appear to have better performance than surgical valves in terms of prosthesis-patient mismatch, especially in patients with aortic stenosis with small aortic annuli. MethodsTAVI-SMALL (International Multicenter Registry to Evaluate the Performance of Self-Expandable Valves in Small Aortic Annuli) is a retrospective registry of patients with severe aortic stenosis and small annuli (annular perimeter <72 mm or area <400 mm2 on computed tomography) treated with transcatheter self-expandable valves (n = 859; Evolut R, n = 397; Evolut PRO, n = 84; ACURATE, n = 201; Portico, n = 177). Primary endpoints were post-procedural mean aortic gradient, indexed effective orifice area, and rate of severe prosthesis-patient mismatch. ResultsPre-discharge gradients were consistently low in every group, with a slight benefit with the Evolut R (8.1 mm Hg; 95% confidence interval [CI]: 7.7 to 8.5 mm Hg) and Evolut PRO (6.9 mm Hg; 95% CI: 6.3 to 7.6 mm Hg) compared with the ACURATE (9.6 mm Hg; 95% CI: 8.9 to 10.2 mm Hg) and Portico (8.9 mm Hg; 95% CI: 8.2 to 9.6 mm Hg) groups (p < 0.001). Mean indexed effective orifice area was 1.04 cm2/m2 (95% CI: 1.01 to 1.08 cm2/m2) with a trend toward lower values with the Portico. No significant differences were reported in terms of severe prosthesis-patient mismatch (overall rate 9.4%; p = 0.134), permanent pacemaker implantation (15.6%), and periprocedural and 1-year adverse events. Pre-discharge more than mild paravalvular leaks were significantly more common with the Portico (19.2%) and less common with the Evolut PRO (3.6%) compared with the Evolut R (11.8%) and ACURATE (9%) groups. ConclusionsTranscatheter self-expandable valves showed optimal clinical and echocardiographic results in patients with small aortic annuli, although supra-annular functioning transcatheter heart valves seemed to slightly outperform intra-annular functioning ones. The role of transcatheter aortic valve replacement with self-expandable valves for the treatment of aortic stenosis in patients with small annuli needs to be confirmed in larger trials.

Invited Commentary

Invited Commentary

The "UFO" procedure.

The term "UFO" is not a medical term, but helps emphasize the extremely high degree of complexity of a surgical repair that is akin to someone observing an unidentified flying object. It involves replacement of the mitral and aortic valves with reconstruction of the intervalvular fibrous body (IVFB). Specific pathologies that render this operation necessary usually involve the IVFB, which is located between the aortic and mitral valves and constitutes a major portion of the fibrous skeleton of the heart. Patients that most often require such an operation are those with extensive aortic and mitral valve endocarditis with perivalvular extension into the IVFB. Other infrequent situations such as severe aortic and mitral annular calcification involving the IVFB, double valve replacement in patients with extremely small aortic and mitral annuli or double valve reoperations in which no IVFB is available following excision of both valves, necessitating the UFO procedure. The basic surgical principle has been first described as early as 1980. Depending on the extent of excised tissue due to the underlying disease, modifications and additional complex repair techniques have to be adopted. It is of utmost importance to have adequate visibility and exposure. There are certain important structures, which are at a risk of either injury or neglect, that can result in development of life-threatening complications during this operation, which a surgeon should be aware of. A step by step description of the "UFO" procedure can help guide the surgeon to perform this operation safely and efficiently. Although clinical complications are high, they are often related to the underlying disease and not specifically to the procedure itself, if performed perfectly.

Impact of Suture Techniques for Aortic Valve Replacement on Prosthesis-Patient Mismatch

Many variables may affect the hemodynamic performance of the aortic valve prosthesis, and suture technique remains an important factor for determining maximum valve performance. The objective of this study was to determine the suture technique that produces better hemodynamic performance for aortic valve replacement (AVR). Patients who underwent AVR between January 2015 and September 2018 in our institution were analyzed. We compared the preoperative clinical information and 1-year postoperative hemodynamic data of interrupted pledget mattress sutures (pledgeted group), interrupted nonpledget mattress sutures (nonpledgeted group), and figure-of-8 nonpledget sutures (figure-of-eight group). We compared the incidence of prosthesis-patient mismatch (PPM) and cardiac adverse events among the groups and subanalyzed the PPM rate in a small aortic annulus (18 to 21 mm). A total of 439 patients underwent AVR (pledgeted, n= 212; nonpledgeted, n= 122; figure-of-eight, n= 105). The groups were similar in age (P= .359), sex (P= .055), underlying disease, and valve pathology. There was no difference in inhospital mortality or cardiac adverse events in each suture group (P= .282). The nonpledgeted suture had significantly lower moderate (P < .01) and severe PPM rates (P= .01) in patients with a small aortic annulus (18 to 21 mm). The interrupted nonpledget mattress suture offers complete supraannular implantation, which reduces the incidence of PPM and results inbetter hemodynamic improvement after small-sizeAVR.

P1788The outcome of TAVI in patients with small annulus and the comparison between intra-annular and supra-annular devices in small anulus: From the analysis of the Japanese nationwide registry

Abstract Background Transcatheter aortic valve implantation (TAVI) has been widely accepted strategy of the treatment for aortic stenosis in patients at intermediate to high or prohibitive surgical risk. The Asian people are of smaller body size compared to Western people. As the result, Asian people have smaller aortic annulus size, which accommodate only smaller transcatheter heart valves (THVs), however, the details and consequences of small aortic annulus size in TAVI is uncertain. Purpose The purposes of this study were to clarify the short-term outcomes of TAVI in patients with small annulus and the differences of intra-annular and supra-annular THVs in small annulus using Japanese national TAVI registry. Methods Multi-detector computed tomography (MDCT) was performed before TAVI and the annulus area was registered. We compared the 30-day clinical outcomes between patients with and without small annulus (annulus area 3.14cm2). Further investigation to compare intra-annular and supra-annular THVs in patients with small annulus was conducted. Results The total of 5,870 patients (103 sites in Japan) who underwent TAVI between August 2013 to December 2017 were enrolled in this study. Out of 5,870 patients, 647 had small annulus. Thirty-day mortality, new pacemaker implantation and stroke rate were comparable between patients with and without small annulus. Echocardiography within 30 days after TAVI revealed that patients with small annulus had significantly smaller indexed effective orifice area (iEOA, 1.10.cm2/m2 [0.92–1.35] vs. 1.16 cm2/m2 [0.96–1.39], p&lt;0.001), higher mean pressure gradient (10.0 mmHg [6.9–14.2] vs. 8.5 mmHg [6.0–11.5], p&lt;0.001) and lower frequency of paravalvular leakage moderate (17.3% vs. 24.4%, p&lt;0.001). Patient-prosthesis mismatch (PPM) were more frequent in patients with small annulus (p=0.002). Logistic regression analysis revealed that small annulus (OR: 1.82; 95% CI: 1.45–2.30, p&lt;0.001), female gender (OR: 0.54; 95% CI: 0.42–0.70, p&lt;0.001), weight (OR: 1.03; 95% CI: 1.02–1.04, p&lt;0.001), height (OR: 1.04; 95% CI: 1.02–1.05, p&lt;0.001), hyperlipidemia (OR: 1.25; 95% CI: 1.07–1.47, p=0.006), femoral access (OR: 0.80; 95% CI: 0.66–0.97, p=0.026) were significantly associated with the PPM after TAVI. The use of SAPIEN 3 20mm THV in patients with small annulus was associated with the smaller iEOA (0.94 cm2/m2 [0.78–1.06] vs. 1.07 cm2/m2 [0.84–1.24], p=0.001) and higher mean pressure gradient (14.0 mmHg [10.0–18.5] vs. 11.0 [7.0–14.0], p&lt;0.001) compared to the usage of Evolut R 23 mm THV. The rate of paravalvular leakage more than moderate was similar in both THVs (14.4% vs. 16.5%, p=0.69). Conclusions Small annulus did not affect clinical 30-day outcomes, however, small annulus was associated with smaller iEOA and higher mean pressure gradient. Supra-annular device might contribute the better hemodynamical improvement in patients with small annulus without increase of paravalvular leakage. Acknowledgement/Funding None

Ampliación del anillo aórtico, procedimiento de Manougian

El procedimiento de Manougian es una de las técnicas empleadas para la ampliación del anillo aórtico en los casos de anulus pequeño o discordancia válvulo-protésico-paciente, que se utiliza con el fin de implantar una válvula de mayor tamaño y así evitar las complicaciones derivadas de una prótesis pequeña para el área corporal del paciente. Se presenta el caso de una mujer adulta joven con antecedente de reemplazo valvular aórtico el cual se encuentra con estenosis severa, quien presenta en el intraoperatorio un anillo valvular estrecho que requiere de las técnicas de ampliación del anillo aórtico para la implantación de una prótesis adecuada.

Aortic Stenosis and Small Aortic Annulus.

The presence of a small aortic annulus poses a considerable challenge in the management of patients with severe aortic stenosis, especially in elderly women, where it is a very frequent finding. The optimal approach for treating these patients remains controversial, and several surgical strategies such as aortic root enlargement, supra-annular stented prosthetic valves, stentless bioprosthesis, and sutureless bioprostheses have been proposed to improve valve hemodynamics and clinical outcomes. More recently, transcatheter aortic valve replacement has emerged as a valid alternative for the treatment of aortic stenosis and excellent valve hemodynamic results have been observed among patients with a small aortic annulus. The purpose of this review is to provide an overview of the current definition, prevalence, and clinical impact of small aortic annulus in patients with aortic stenosis, and evaluate the different therapeutic strategies currently available to improve valve hemodynamics and outcomes in this population.

Early outcomes of transcatheter aortic valve implantation for degenerated aortic bioprostheses in Japanese patients: insights from the AORTIC VIV study.

The valve-in-valve procedure, in which a transcatheter heart valve (THV) is implanted into a degenerated bioprosthetic valve, is standardized for high-risk patients. However, this procedure is challenging in Japanese patients who have a small aortic annulus. We investigated the feasibility, safety, and therapeutic efficacy of the valve-in-valve procedure involving a degenerated stented bioprosthesis, stentless bioprosthesis, or THV. We performed a single-center, non-comparative study of the aortic valve-in-valve procedure (AORTIC VIV study). Beginning in October 2016, the aortic valve-in-valve procedure was performed in seven patients with a stented bioprosthesis, in three patients with a stentless bioprosthesis, and in one patient with a THV. No 30-day post-procedure mortality or severe morbidities occurred. The mean echocardiographic gradient in the aortic position improved from 41 (38-48) to 17 (11-22) mmHg at 30days (p = 0.01). No paravalvular or mild and more transvalvular leaks were detected. The New York Heart Association functional class improved from 2 (2-2.5) to 1 (1-1) at 30days postoperatively (p = 0.01). Although the procedure failed in two patients with an implanted stentless bioprosthesis, the third patient with a stentless bioprosthesis and the one patient with a degenerated THV successfully underwent the valve-in-valve procedure. Feasibility, safety, and potential efficacy of the aortic valve-in-valve procedure were confirmed in selected Japanese patients with a degenerated aortic bioprosthesis. The valve-in-valve procedure for stentless bioprostheses was technically challenging.

Prosthesis-patient mismatch after transcatheter aortic valve replacement: prevalence and medium term prognostic impact.

Prosthesis-patient mismatch (PPM) occurs when the effective orifice area of the prosthesis is too small in relation to the patient's body surface area. There are few data available on the frequency and prognostic impact of PPM after transcatheter aortic valve implantation (TAVI). Our aim was to determine the prevalence of PPM and to investigate its association with medium-term clinical course of patients undergoing TAVI. We included 185 patients undergoing TAVI (79 ± 5 years, 49% male, 98% CoreValve) between April-2008 and December-2014. The effective orifice area (EOA) was determined by transthoracic echocardiography prior and after the procedure. We defined PPM as indexed EOA ≤ 0.85 cm2/m2 (severe PPM if ≤ 0.65 cm2/m2). All cause death, stroke and hospitalization for heart failure were considered as major clinical events. 45 patients (24%) showed PPM (severe 11 patients, 6%). PPM was associated with a higher EuroSCORE (OR 1.06, IC 95% 1.01-1.12, p = 0.03), body surface area ≥ 1.72 m2 (OR 3.58, IC 95% 1.30-9.87, p = 0.01) and small aortic annulus (OR 0.73, IC 95% 0.55-0.92, p = 0.03); and severe PPM with small prostheses size (OR 17.79, IC 95% 1.87-169.78, p = 0.012). The mean event-free survival was 34 ± 26 months. Patients with severe PPM showed lower rates of event free survival than the rest of the series (52% vs. 84%, p = 0.04) at 34 months follow up. In our series, PPM was present in a quarter of the patients after TAVI. Higher EuroSCORE, smaller prosthesis size, larger body surface area and smaller aortic annulus diameter were associated with PPM. Severe PPM was an independent factor associated with major events at medium-term follow up.

Study Protocol for Transcatheter Aortic Valve Replacement for a Degenerated Aortic Bioprosthesis in a Japanese Cohort

Background: The valve-in-valve (VIV) procedure is being increasingly performed in high-risk patients with a degenerated bioprosthesis in an aortic position in Western countries. The early safety and efficacy of the VIV procedure, however, remain unclear in Japanese patients with a small aortic annulus. We present the protocol for a study designed to evaluate the early safety and efficacy of the VIV procedure in the aortic position in Japanese patients. Methods and Results: The prospective, single-center, non-comparative, clinical study of the VIV procedure for the aortic position (AORTIC VIV study) commenced in August 2016 and will end in March 2020. Patients will be monitored for ≥1 month after the VIV procedure. The targeted number of patients is 11. Eligible patients are those who have undergone transcatheter aortic valve replacement for a surgical valve (including stented or stentless bioprosthetic valves), or for a transcatheter heart valve. The VIV procedure is performed in high-operative-risk patients with substantial prosthetic valve stenosis, and regurgitation and heart failure resistant to medical treatment (unless the patient meets an exclusion criterion). The safety and efficacy of the VIV procedure will be evaluated in accordance with the Valve Academic Research Consortium-2 initiative. Conclusions: The AORTIC VIV study will clarify the early safety and efficacy of the VIV procedure in Japanese patients.

Случай успешной хирургической коррекции критического аортального стеноза у пациента с выраженным снижением сократительной способности левого желудочка (фракция выброса 20%) и узким фиброзным кольцом аортального клапана

Случай успешной хирургической коррекции критического аортального стеноза у пациента с выраженным снижением сократительной способности левого желудочка (фракция выброса 20%) и узким фиброзным кольцом аортального клапана

Bioprosthetic Valve Performance After Transcatheter Aortic Valve Replacement With Self-Expanding Versus Balloon-Expandable Valves in Large Versus Small Aortic Valve Annuli: Insights From the CHOICE Trial and the CHOICE-Extend Registry

ObjectivesThe aim of this study was to compare self-expanding and balloon-expandable transcatheter heart valves (THVs) in large versus small aortic valve annuli. BackgroundThe degree of THV oversizing varies according to annular size, and this can modify the hemodynamic performance of self-expanding and balloon-expandable THVs. MethodsPatients undergoing transcatheter aortic valve replacement in the randomized CHOICE (Comparison of Transcatheter Heart Valves in High Risk Patients With Severe Aortic Stenosis: Medtronic CoreValve vs Edwards SAPIEN XT) trial (CoreValve [CV], n = 120; SAPIEN XT [SXT], n = 121) and the nonrandomized CHOICE-Extend registry (Evolut R [ER], n = 100; SAPIEN 3 [S3], n = 334) were compared for THV performance by echocardiography (in all patients) and by cardiac magnetic resonance imaging (MRI) regurgitant fraction (RF) (in a subgroup of patients). Patients were stratified according to aortic valve annular mean diameter into those with large (>23 mm) or small (≤23 mm) annuli. ResultsTHV percentage oversizing was 19.1 ± 6.4% with the CV, 11.4 ± 7.0% with the SXT, 18.8 ± 4.8% with the ER, and 3.7 ± 5.5% with the S3. Transvalvular mean pressure gradient was lower with the CV and ER than with the SXT and S3 in both the large and small annulus groups. In the randomized CHOICE trial, moderate to severe prosthetic valve regurgitation (PVR) was more with the CV than the SXT in large annuli (15.1% vs. 0.0%; p = 0.002; MRI RF: 10.5 ± 10.2% vs. 4.4 ± 4.5%; p = 0.036) but not in small annuli (0.0% vs. 5.7%; p = 0.50; MRI RF: 4.0 ± 4.1% vs. 4.0 ± 3.4%; p = 0.98). In the CHOICE-Extend registry, moderate to severe PVR occurred in 2 patients, and any PVR was not significantly different between the ER and the S3 in large (41.7% vs. 32.5%; p = 0.24) or small (47.1% vs. 43.8%; p = 0.84) annuli. MRI RF was not different in large annuli (5.0 ± 3.8% vs. 5.0 ± 6.1%; p = 0.99) but was significantly lower with the ER than the S3 in small annuli (2.9 ± 2.3% vs. 4.8 ± 3.7%; p = 0.023). On multivariate analysis, transcatheter aortic valve replacement with the ER in small annuli was associated with a lower rate of prosthesis-patient mismatch than with the S3, with no increased risk for PVR. ConclusionsOlder-generation balloon-expandable THVs were associated with less PVR than self-expanding THVs in patients with large but not small annuli. The next-generation self-expanding THV has improved sealing in patients with large annuli and may have potential advantages in patients with small annuli.

Valve Hemodynamics and Clinical Outcomes After Transcatheter Aortic Valve Replacement for a Small Aortic Annulus.

The hemodynamics and outcomes in patients with a small aortic annulus (SAA) after transcatheter aortic valve replacement (TAVR) with a second-generation transcatheter heart valve remain unclear. We investigated whether TAVR with a Sapien XT (Edwards Lifesciences, Irvine, California) influences postprocedural valve hemodynamics and long-term outcome in high-risk SAA patients compared with surgical aortic valve replacement (SAVR).We retrospectively identified 94 SAA patients who underwent aortic valve replacement (TAVR = 35 and SAVR = 59). SAA was defined as an aortic annulus diameter ≤ 20 mm, measured by preprocedural transesophageal echocardiography.The mean age was 80.2 years. The mean Society of Thoracic Surgeons-Predicted Risk of Mortality was 6.8%. The post-procedural peak transvalvular velocity and mean pressure gradient were significantly lower in the TAVR cohort than in the SAVR cohort, whereas the postprocedural aortic valve area was significantly higher in the TAVR cohort. Severe prosthesis-patient mismatch (PPM) occurred less frequently after TAVR than SAVR (TAVR 2.9% versus SAVR 22.0%, P = 0.01). The two-year mortality in SAA patients was similar between the two groups.TAVR with a Sapien XT in SAA patients improved the valve hemodynamics and reduced the incidence of PPM compared with SAVR. TAVR patients had a similar 2-year mortality despite higher risk baseline characteristics. To avoid PPM and the consequent poor outcomes, TAVR can be considered an alternative option to SAVR in high surgical risk patients with SAA.

EP26 PRELIMINARY RESULTS OF LAST GENERATION SURGICAL BIOPROSTHESES IN SMALL AORTIC ANNULI: TRIFECTA VS INTUITY

Background and Aim: Aortic valve replacement (AVR) in patients with small aortic annulus is associated with increased risk of patient-prosthesis mismatch. Results of 19–21 Trifecta vs Intuity bioprostheses in patients with annular size &lt;21 mm are compared. Methods: Between 2013 and 2017,we retrospectively analyzed 25 (22 women,76.8 ±6.6 years) Trifecta AVR patients vs 26 (23 women, 78.6 ± 4.7 years) Intuity AVR patients.Combined procedures and reinterventions were excluded.Body surface area, left ventricular mass index and Euroscore-II were not different (p:0.68, 0.92 and 0.96 respectively). Results: Cardiopulmonary-bypass time was 108.6 ± 22.5 and 84.4 ± 20.5 minutes(p: 0.012);aortic cross-clamp time was 79.3 ± 14.6 and 60.73 ± 15.3 minutes in the Trifecta and in the Intuity group respectively(p:0.001). There wasn’t significant difference in postoperative transvalvular gradients.Lenght of hospital stay and major complications were not significantly different between the two groups.Follow-up is still ongoing. At 3.5 ± 1.2 years,41.1% of patients were followed-up. Until now, no significant difference neither in term of mortality nor in major complications have been observed.Peak pressure gradients were 29.2 ± 11.5 and 20.7 ± 5.9 mmHg (p:0.04);mean 16.2 ± 6.4 and 11 ± 3.03 mmHg (p: 0.02).Effective orifice area (EOA) was 1.43 ± 0.24 and 1.3 ± 0.2 cm2(p:0.5).There is no significant difference in reverse cardiac remodeling (left ventricular mass index 134.4 vs 124.4 g/m2.p:0.43). Conclusions: Trifecta and Intuity prostheses provide excellent hemodynamic results in small aortic annulus AVR. Operative times with Intuity were significantly lower. EOA was similar in both groups,however Trifecta presented significantly higher gradients at follow-up. Preliminary data need to be confirmed: completion of follow-up (July 2018) could provide stronger evidence to these first surveys.

Hemodynamic Results and Mid-term Follow-up of 850 19 to 23 mm Perimount Magna Ease Valves.

Aortic valve replacement (AVR) in small aortic roots remains a surgical dilemma with a higher risk of patient-prosthesis mismatch (PPM). The Perimount Magna Ease aortic valve (PMEAV) represents an attractive device in such cases. We examined the early hemodynamic performance, the mid-term outcomes of the PMEAV, and the impact of PPM on outcome and functional class. We performed a retrospective analysis of prospectively collected in-hospital data, and a prospective single-center follow-up of 849 patients who received a 19 to 23 mm PMEAV (2008-2014). Concomitant mitral or tricuspid replacement was the exclusion criterion. Early hemodynamic features were prospectively collected; mid-term follow-up was conducted according to current guidelines. Size of implanted prosthesis was 19 mm in 11.5% of patients, 21 mm in 36.9%, and 23 mm in 51.5%. Operative mortality was 4.5% (3.1% for isolated AVR). The rate of severe and moderate PPMs was significantly higher in the 19 mm group. Follow-up was 99.9% complete (3.7 ± 2 years). Actuarial freedom from structural valve deterioration (SVD) at 5 years was 99.1%. At stratified Kaplan-Meier's analysis, PPM and age <70 years were associated with SVD. PPM was not associated with worse functional status (New York Heart Association class) or mortality at follow-up. This series shows satisfactory clinical outcomes of the PMEAV implanted in small aortic annuli at mid-term follow-up. Although PPM may occur in smaller sizes, it has limited clinical impact, and it is not associated with mid-term mortality or worse functional class. Few SVD events are evidenced; nonetheless, limited follow-up duration and its methodology need to be considered.

Transesophageal Echocardiography for Ross-Konno Procedure

AbstractRoss procedure involves replacing diseased aortic valve with pulmonary autograft and placing a pulmonary/aortic homograft between the right ventricle and pulmonary artery. In case of small aortic annulus in pediatric patients or in patients with multilevel left ventricular outflow obstruction, aortic annulus enlargement might be required concurrently. Konno type of aortic ventriculoplasty is most commonly done. The American Heart Association/American College of Cardiology (AHA/ACC) has classified transesophageal echocardiography (TEE) as class I indication for congenital heart disease