1
|
Moscarelli M, Fattouch K, Speziale G, Nasso G, Santarpino G, Gaudino M, Athanasiou T. A meta-analysis of the performance of small tissue versus mechanical aortic valve prostheses. Eur J Cardiothorac Surg 2019; 56:510-517. [DOI: 10.1093/ejcts/ezz056] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Revised: 01/18/2019] [Accepted: 01/19/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
OBJECTIVES
Small aortic prosthetic valves have been associated with suboptimal performance due to patient–prosthesis mismatch (PPM). This meta-analysis compared the outcomes of patients with a small root who received tissue versus mechanical aortic valves.
METHODS
A systematic literature review identified 7 candidate studies; of these, 5 met the meta-analysis criteria. We analysed outcomes for a total of 680 patients (227 tissue valves and 453 mechanical valves) using random effects modelling. Each study was assessed for heterogeneity and quality. The primary end point was mortality at follow-up. Secondary end points included intraoperative and postoperative outcomes, the rate of PPM and left ventricle mass regression and major cardiac and prosthesis-related adverse events at follow-up.
RESULTS
There was no between-group difference in mortality at follow-up [incidence rate ratio 1, 95% confidence interval (CI) 0.50–2.01; P = 0.99]. The tissue group had a higher rate of PPM (odds ratio 17.19, 95% CI 8.6–25.78; P = 0.002) and significantly less reduction in ventricular mass (weighted mean difference 40.79, 95% CI 4.62–76.96; P = 0.02). There were no significant differences in the incidence of structural valve disease at follow-up compared to that in the mechanical valve group. There was also no between-group difference in aggregated adverse events at follow-up (P = 0.68).
CONCLUSIONS
Tissue and mechanical valves were associated with similar mortality rates; however, patients receiving tissue valves had a higher rate of PPM and significantly less left ventricle mass regression. These findings indicate that patients receiving small tissue valves may require closer clinical surveillance than those receiving mechanical valves.
Collapse
Affiliation(s)
- Marco Moscarelli
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Cardiac Surgery, GVM Care and Research, Anthea Hospital, Bari, Italy
| | - Khalil Fattouch
- Department of Cardiac Surgery, GVM Care and Research, Anthea Hospital, Bari, Italy
| | - Giuseppe Speziale
- Department of Cardiac Surgery, GVM Care and Research, Anthea Hospital, Bari, Italy
| | - Giuseppe Nasso
- Department of Cardiac Surgery, GVM Care and Research, Anthea Hospital, Bari, Italy
| | - Giuseppe Santarpino
- Department of Cardiac Surgery, GVM Care and Research, Anthea Hospital, Bari, Italy
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Thanos Athanasiou
- Department of Surgery and Cancer, Imperial College, Paddington, London, UK
| |
Collapse
|
2
|
Results of prosthetic valve replacement for aortic stenosis. Indian J Thorac Cardiovasc Surg 2018. [DOI: 10.1007/s12055-002-0038-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
|
3
|
Dayan V, Soca G, Stanham R, Lorenzo A, Ferreiro A. Is patient–prosthesis mismatch a predictor of survival or a surrogate marker of co-morbidities in cardiac surgery? Int J Cardiol 2015; 190:389-92. [DOI: 10.1016/j.ijcard.2015.04.161] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Accepted: 04/18/2015] [Indexed: 11/15/2022]
|
4
|
Bogunovic N, Horstkotte D, Faber L, Bogunovic L, Kececioglu D, Piper C, Prinz C, van Buuren F. Effective valve opening area in the detection of dysfunctional aortic valve prostheses: a differentiated statistical analysis of this parameter including the introduction of minimal expected normal values as borderline to dysfunctional stenotic prostheses. Echocardiography 2012; 29:713-9. [PMID: 22348380 DOI: 10.1111/j.1540-8175.2011.01659.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Dysfunction of heart valve prostheses (VP) is a life-threatening complication and the diagnosis remains difficult. The motivation for this study was to improve the detection of dysfunctional VP by optimizing application of the prosthetic effective orifice area (VA). For this reason the minimal expected normal VA (VA(expected)) was introduced. METHODS We investigated echocardiographically 1,369 normally functioning aortic valve prostheses (AVP). Mean VA, transprosthetic peak (PPG) and mean pressure gradients (MPG) were evaluated to gain reference values depending on prosthetic size and construction principle. Mean VA(expected) was calculated by applying a simple formula that was developed empirically using statistical analyses. The results were compared with those of 65 dysfunctional AVPs. RESULTS VA(expected) can be applied as a threshold between normal and dysfunctional stenotic AVP and showed a correct estimation in 87% of all normally functioning and 100% of dysfunctional stenotic VPs. The sensitivity for all prosthetic sizes is 1.0, independently of the constructional principle of the VP. Specificity ranged between 0.8 and 1.0, dependent on VP size. The formula representing VA(expected) is simple and can be executed easily. CONCLUSION As nearly independent of stroke volume and in consideration of VA(expected), VA seems to have become one of the preferable parameters for detecting pathological stenotic AVPs echocardiographically. The additional application of PPG/MPG and other parameters permits prostheses with relevant isolated regurgitation and patient-prosthesis-mismatch to be distinguished.
Collapse
Affiliation(s)
- Nikola Bogunovic
- Department of Cardiology, Heart and Diabetes Center North Rhine-Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
| | | | | | | | | | | | | | | |
Collapse
|
5
|
Abstract
Prosthetic heart valve (PHV) dysfunction is a rare, but potentially life-threatening, complication. In clinical practice, PHV dysfunction poses a diagnostic dilemma. Echocardiography and fluoroscopy are the imaging techniques of choice and are routinely used in daily practice. However, these techniques sometimes fail to determine the specific cause of PHV dysfunction, which is crucial to the selection of the appropriate treatment strategy. Multidetector-row CT (MDCT) can be of additional value in diagnosing the specific cause of PHV dysfunction and provides valuable complimentary information for surgical planning in case of reoperation. Cardiac magnetic resonance imaging (CMR) has limited value in the evaluation of biological PHV dysfunction. In this Review, we discuss the use of established imaging modalities for the detection of left-sided mechanical and biological PHV dysfunction and discuss the complementary role of MDCT in this context.
Collapse
|
6
|
Roedler S, Czerny M, Neuhauser J, Zimpfer D, Gottardi R, Dunkler D, Wolner E, Grimm M. Mechanical aortic valve prostheses in the small aortic root: Top Hat versus standard CarboMedics aortic valve. Ann Thorac Surg 2008; 86:64-70. [PMID: 18573400 DOI: 10.1016/j.athoracsur.2008.01.085] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2007] [Revised: 01/23/2008] [Accepted: 01/23/2008] [Indexed: 11/19/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate outcome in patients with a small aortic root receiving either a standard CarboMedics mechanical aortic valve or a Top Hat CarboMedics valve (CarboMedics, Austin, TX), specifically designed for the small aortic root. METHODS Between 1986 and 2006, 316 consecutive patients underwent 19- or 21-mm mechanical aortic valve replacement, receiving either a CarboMedics Top Hat bileaflet valve (n = 56; mean age, 66 +/- 14 years) or a standard CarboMedics aortic valve replacement (n = 260; mean age, 60 +/- 13 years) at our institution based on institutional indications for the choice of type of valve prostheses. Median follow-up time was 83.5 months. We studied survival, valve-related and non-valve-related events, and hemodynamic performance by serial echocardiographic follow-up studies. RESULTS In-hospital mortality was 8.9% in the Top Hat group and 10.0% in the standard group (p = 0.354). Five- and ten-year survival in patients in the Top Hat group was 83% and 67%, respectively. Five- and ten-year survival in the standard group was 73% and 59%, respectively (log-rank = 0.331). There were no differences in regard to valve-related and non-valve-related events. Cox regression analysis revealed age (hazard ratio, 1.045; 95% confidence interval, 1.026 to 1.066), previous cardiac surgery (hazard ratio, 1.812; 95% confidence interval, 1.101 to 2.982), additional procedures at the time of valve replacement (hazard ratio, 2.604; 95% confidence interval, 1.651 to 4.108), New York Heart Association class IV (hazard ratio, 3.645; 95% confidence interval, 1.214 to 10.945), and severely impaired left ventricular ejection fraction (hazard ratio, 2.253; 95% confidence interval, 1.289 to 3.941) to be independent predictors of survival. CONCLUSIONS Mechanical aortic valve replacement in the small aortic root is associated with substantial perioperative mortality, in particular in the subset of patients requiring additional cardiac surgical procedures. Nevertheless, long-term outcome is satisfying. Because the type of prosthesis does not predict outcome in the multivariate Cox model, we conclude that use of the smaller Top Hat prosthesis can be recommended for the challenging cohort of patients with a small aortic root.
Collapse
Affiliation(s)
- Suzanne Roedler
- Department of Cardiothoracic Surgery, University of Vienna Medical School, Vienna, Austria.
| | | | | | | | | | | | | | | |
Collapse
|
7
|
Aortic valve replacement in predominant aortic stenosis: What is an appropriate size valve? Indian J Thorac Cardiovasc Surg 2007. [DOI: 10.1007/s12055-007-0020-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
|
8
|
Haaverstad R, Vitale N, Karevold A, Cappabianca G, Tromsdal A, Olsen PS, Köber L, Ihlen H, Rein KA, Svennevig JL. Clinical and echocardiographic assessment of the Medtronic Advantage aortic valve prosthesis: the Scandinavian multicentre, prospective study. Heart 2007; 93:500-5. [PMID: 17065186 PMCID: PMC1861508 DOI: 10.1136/hrt.2005.086041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2006] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The aim of this report is the prospective, multicentre evaluation of clinical results and haemodynamic performance of the Medtronic Advantage aortic valve prosthesis. METHODS From April 2001 to June 2003, 166 patients (male:female 125:41; mean (SD) age 61.8 (11.8) years) received an aortic advantage valve prosthesis. Complete cumulative follow-up was 242.7 patient-years (maximum 3.2; mean 1.6 years). Postoperatively, patients underwent early (within 30 days) and 1 year transthoracic echocardiography. RESULTS 30 day mortality was 2.4% (n = 4). Kaplan-Meier estimates of freedom from complications and linearised rates were as follows: 96.9 (1.6)% survival; 94.7 (1.3)% (2.06 patients/year) thrombo-embolism; 99.4 (0.6)% (0.4 patients/year) bleeding; 98.8 (0.9)% (0.8 patients/year) non-structural valve dysfunction; 98.8 (0.9)% (0.8 patients/year) reoperation. Valvular mean pressure gradients ranged from 16 (3) mm Hg for size 19 to 7 (2) mm Hg for size 27 and the corresponding effective orifice areas ranged from 1.2 (0.25) to 3.2 (0.66) cm(2). In all, left ventricular mass significantly decreased (p<0.001) and fractional shortening increased (p<0.001) from postoperative to 1 year echocardiography. CONCLUSIONS Haemodynamic performance and early clinical results of Medtronic advantage in the aortic position were satisfactory and comparable with those of other bileaflet valves in current clinical use.
Collapse
Affiliation(s)
- Rune Haaverstad
- Department of Cardiothoracic Surgery, Trondheim University Hospital, Trondheim, Norway.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
9
|
Moon MR, Pasque MK, Munfakh NA, Melby SJ, Lawton JS, Moazami N, Codd JE, Crabtree TD, Barner HB, Damiano RJ. Prosthesis-Patient Mismatch After Aortic Valve Replacement: Impact of Age and Body Size on Late Survival. Ann Thorac Surg 2006; 81:481-8; discussion 489. [PMID: 16427836 DOI: 10.1016/j.athoracsur.2005.07.084] [Citation(s) in RCA: 102] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2005] [Revised: 07/25/2005] [Accepted: 07/26/2005] [Indexed: 11/21/2022]
Abstract
BACKGROUND The purpose of this study was to identify patient subgroups in which prosthesis-patient mismatch most influenced late survival. METHODS Over a 12-year period, 1,400 consecutive patients underwent bioprosthetic (933 patients) or mechanical (467) aortic valve replacement. Prosthesis-patient mismatch was defined as prosthetic effective orifice area/body surface area less than 0.75 cm2/m2 and was present with 11% mechanical and 51% bioprosthetic valves. RESULTS With bioprosthetic valves, prosthesis-patient mismatch was associated with impaired survival for patients less than 60 years old (10-year: 68% +/- 7% mismatch versus 75% +/- 7% no mismatch, p < 0.02) but not older patients (p = 0.47). Similarly, with mechanical valves, prosthesis-patient mismatch was associated with impaired survival for patients less than 60 years old (10-year: 62% +/- 11% versus 79% +/- 4%, p < 0.005) but not older patients (p = 0.26). For small patients (body surface area less than 1.7 m2), prosthesis-patient mismatch did not impact survival with bioprosthetic (p = 0.32) or mechanical (p = 0.71) valves. For average-size patients (body surface area 1.7 to 2.1 m2), prosthesis-patient mismatch was associated with impaired survival with both bioprosthetic (p < 0.05) and mechanical (p < 0.005) valves. For large patients (body surface area greater than 2.1 m2), prosthesis-patient mismatch was associated with impaired survival with mechanical (p < 0.04) but not bioprosthetic (p = 0.40) valves. CONCLUSIONS Prosthesis-patient mismatch had a negative impact on survival for young patients, but its impact on older patients was minimal. In addition, although prosthesis-patient mismatch was not important in small patients, prosthesis-patient mismatch negatively impacted survival for average-size patients and for large patients with mechanical valves.
Collapse
Affiliation(s)
- Marc R Moon
- Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.
| | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
De Carlo M, Milano AD, Nardi C, Mecozzi G, Bortolotti U. Serial Doppler echocardiographic evaluation of small-sized sorin bicarbon prostheses. J Thorac Cardiovasc Surg 2003; 126:337-43. [PMID: 12928629 DOI: 10.1016/s0022-5223(02)73395-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The Sorin Bicarbon prosthesis (Sorin Biomedica, Saluggia, Italy) is a bileaflet valve with curved-profile leaflets, a rolling hinge mechanism, and a pyrolytic carbon-coated titanium alloy housing and sewing ring. Although the Sorin Bicarbon prosthesis has been implanted in greater than 80,000 patients, and reference values on the hemodynamic performance of valve prostheses are needed to avoid patient-prosthesis mismatch, few Doppler echocardiographic data are available on the prosthesis in the aortic position. The aim of this study is to provide a detailed echocardiographic evaluation of the hemodynamic performance and regression of left ventricular hypertrophy after aortic valve replacement with the Sorin Bicarbon prosthesis. METHODS The study included 182 patients who received a 21-mm (n = 61) or 23-mm (n = 121) Sorin Bicarbon prosthesis for pure or prevalent aortic stenosis who underwent serial echocardiograms at 3, 6, and 12 months after aortic valve replacement. RESULTS Mean and peak gradients significantly decreased (P <.001) during follow-up to values of 12 +/- 3 and 22 +/- 6 mm Hg for the 21-mm prosthesis and values of 11 +/- 4 and 19 +/- 6 mm Hg for the 23-mm prosthesis at 1 year. Left ventricular mass index showed a 17% decrease to 120 +/- 27 g/m(2) in recipients of the 21-mm prosthesis (P <.001) and a 21% decrease to 123 +/- 29 g/m(2) in recipients of the 23-mm prosthesis (P <.001). A larger prosthesis size was the only predictor of a higher left ventricular mass index regression. Among recipients of the 21-mm prosthesis, body surface area of greater than 1.85 m(2) was associated with a lower regression of left ventricular mass index. The effective orifice area index was 1.00 +/- 0.11 and 1.08 +/- 0.14 cm(2)/m(2) in recipients of the 21-mm and 23-mm prostheses, respectively. CONCLUSIONS Size 21 mm and 23 mm Sorin Bicarbon prostheses show low transprosthetic gradients, with significant reduction of left ventricular mass index during the first postoperative year. The reported effective orifice areas might be useful for aortic valve replacement in patients with a small aortic annulus to avoid patient-prosthesis mismatch.
Collapse
Affiliation(s)
- Marco De Carlo
- Cardiothoracic Department, University of Pisa Medical School, 56124 Pisa, Italy
| | | | | | | | | |
Collapse
|
11
|
Choudhary SK, Mathur A, Venugopal P, Airan B, Sharma R, Bhan A, Saxena A, Kumar AS. Prosthesis Size in Aortic Valve Replacement: Surgeon-Related Variable. Asian Cardiovasc Thorac Ann 2000. [DOI: 10.1177/021849230000800409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A retrospective analysis was performed to determine the surgeon's impact on the selection of the size of prosthesis in aortic valve replacement. From January 1993 through December 1997, 748 patients underwent either isolated aortic valve replacement (530) or double valve replacement (218) with bileaflet valves. Depending on the operating surgeon, patients were divided into group A (367) or group B (381). Preoperative, intraoperative, and postoperative variables in both groups were compared. Groups A and B were identical in demographic and clinical profiles. Cardiopulmonary bypass time, ischemic time, and early and late results in both groups were similar. Significantly more patients undergoing isolated aortic valve replacement in group A (169; 67.9%) received a large (≥25 mm) prosthesis compared with group B (69; 24.5%). Compared with group B, a large prosthesis was used in a significantly greater proportion of all patients in group A, irrespective of etiology, predominant aortic valve lesion, and age of the patient. Overall, the operating surgeon was identified as the most important predictor (odds ratio 3.5; p < 0.0001) of use of a large valve.
Collapse
Affiliation(s)
- Shiv Kumar Choudhary
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Alok Mathur
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Panangipalli Venugopal
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Balram Airan
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Rajesh Sharma
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Anil Bhan
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Anita Saxena
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Arkalgud Sampath Kumar
- Department of Cardiothoracic and Vascular Surgery, Cardiothoracic Sciences Centre, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
12
|
Pibarot P, Dumesnil JG. Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention. J Am Coll Cardiol 2000; 36:1131-41. [PMID: 11028462 DOI: 10.1016/s0735-1097(00)00859-7] [Citation(s) in RCA: 428] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Prosthesis-patient mismatch is present when the effective orifice area of the inserted prosthetic valve is less than that of a normal human valve. This is a frequent problem in patients undergoing aortic valve replacement, and its main hemodynamic consequence is the generation of high transvalvular gradients through normally functioning prosthetic valves. The purposes of this report are to present an update on the concept of aortic prosthesis-patient mismatch and to review the present knowledge with regard to its impact on hemodynamic status, functional capacity, morbidity and mortality. Also, we propose a simple approach for the prevention and clinical management of this phenomenon because it can be largely avoided if certain simple factors are taken into consideration before the operation.
Collapse
Affiliation(s)
- P Pibarot
- Quebec Heart Institute/Laval Hospital, Laval University, Sainte-Foy, Canada
| | | |
Collapse
|
13
|
Maslow AD, Haering JM, Heindel S, Mashikian J, Levine R, Douglas P. An evaluation of prosthetic aortic valves using transesophageal echocardiography: the double-envelope technique. Anesth Analg 2000; 91:509-16. [PMID: 10960367 DOI: 10.1097/00000539-200009000-00002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED The conventional continuity equation uses nonsimultaneous measurements of blood flow velocities through the left ventricular outflow tract and across the aortic valve to calculate aortic valve area (AVA). We have noted that both velocities can be simultaneously obtained from continuous wave (CW) Doppler analysis (double-envelope [DE]). We hypothesize that prosthetic AVA can be calculated by using the DE technique, during transesophageal echocardiography (TEE). Prosthetic AVA was calculated in 41 of 45 patients immediately after aortic valve replacement by using the DE/AVA technique. Left ventricular outflow tract diameter was obtained from an esophageal view, while subvalvular (V(1)) and valvular (V(2)) peak velocities were simultaneously obtained from transgastric views by using CW Doppler. Prosthetic AVA and V(1)/V(2) ratio (Doppler velocity index) were calculated. V(1) was also measured by using pulse wave Doppler, as is conventionally done. Twenty-three Carbomedic (CM) and 18 Carpentier-Edwards (CE) AVA were evaluated. DE/AVAs for CM and CE valves correlated and agreed with that reported by the manufacturer (CM r(2) = 0.91, mean bias -0.25 cm(2) [SD 0.18]; CE r(2) = 0.73, mean bias -0.02 cm(2) [SD 0.27]). Calculated Doppler velocity index values agree with available data (mean bias 0.03 [SD 0.05]). The V(1) obtained by using the DE method was nearly identical to the V(1) obtained by using pulse wave (r(2) = 0.95, mean bias 0.02 m/s [SD 0.04 m/s]). TEE assessment of prosthetic AVA using the DE technique agrees with data reported by the manufacturer. Obtaining subvalvular and valvular velocities from the same CW Doppler trace may simplify the continuity equation and help avoid errors caused by beat-to-beat changes in blood flow. Quantitative prosthetic aortic valve assessment can be performed, on-line, with TEE by using the DE technique. IMPLICATIONS Quantitative assessment of prosthetic aortic valve area can be performed on-line by using transesophageal echocardiography using the double envelope technique.
Collapse
Affiliation(s)
- A D Maslow
- Departments of Anesthesia and Cardiology, Beth Israel-Deaconess Medical Center. Mass General Hospital, Boston, MA, USA.
| | | | | | | | | | | |
Collapse
|
14
|
Maslow AD, Haering JM, Heindel S, Mashikian J, Levine R, Douglas P. An Evaluation of Prosthetic Aortic Valves Using Transesophageal Echocardiography: The Double-Envelope Technique. Anesth Analg 2000. [DOI: 10.1213/00000539-200009000-00002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
15
|
Weinschelbaum E, Stutzbach P, Oliva M, Zaidman J, Torino A, Gabe E. Manual debridement of the aortic valve in elderly patients with degenerative aortic stenosis. J Thorac Cardiovasc Surg 1999; 117:1157-65. [PMID: 10343267 DOI: 10.1016/s0022-5223(99)70255-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
OBJECTIVE We prospectively analyzed the short- and long-term results of manual debridement of the aortic valve in elderly patients with severe degenerative aortic stenosis. METHODS Between September 1988 and January 1997, 103 patients aged 73.7 +/- 6 years with degenerative aortic stenosis underwent the manual debridement technique. All had symptoms (angina or dyspnea, or both). Peak systolic gradient was 89 +/- 28 mm Hg. Forty-one patients (39.8%) had associated coronary artery disease necessitating revascularization. RESULTS Follow-up time was 42 +/- 21 months (range 3-98 months). The Kaplan-Meier estimated survival at 98 months was 50% (95% CI: 30%-70%). In-hospital mortality was 5.8% (6 patients), and late mortality was 21% (21 patients). No predictors of in-hospital mortality or of late mortality were detected. Nonfatal postoperative complications appeared in 25 patients (24%). At 8 years, freedom from endocarditis was 98% (95% CI: 95%-100%) and freedom from thromboembolic events was 99% (95% CI: 96%-100%). No patient required long-term anticoagulation as a result of the procedure. Fourteen patients (14%) required reoperation for aortic insufficiency (n = 5), restenosis (n = 8), and mitral regurgitation (n = 1). The probability of reoperation at 98 months was 23% (95% CI: 12%-35%). CONCLUSION Manual aortic valve debridement has low rates of in-hospital mortality, perioperative complications, and thromboembolic and infectious events and it offers freedom from anticoagulation. However, the incidence of restenosis and reoperation is high in the long term. It may therefore be regarded as an alternative in aged patients with favorable valve anatomy (no distortion and calcium deposits only on the aortic surface of the cusps), especially in those with a small aortic anulus, associated coronary artery disease, and/or contraindication for anticoagulation.
Collapse
Affiliation(s)
- E Weinschelbaum
- Departments of Cardiovascular Surgery and Medicine, Institute of Cardiology and Cardiovascular Surgery, Favaloro Foundation, Buenos Aires, Argentina
| | | | | | | | | | | |
Collapse
|
16
|
Abstract
Significant advances in imaging modalities have occurred to evaluate prosthetic valve function and associated complications. These developments involve predominantly the introduction of Doppler technology for the non-invasive determination of gradients and valve areas and TEE for an improved assessment of valve structure, function, and associated complications. The current role of cinefluoroscopy is mostly to complement TEE in the evaluation of motion of mechanical prosthetic valves in the aortic position. Cardiac catheterization is now rarely needed to assess valve function. Diagnosis of prosthetic valve obstruction can be performed in the majority of cases with transthoracic Doppler echocardiography. Differentiation of valve obstruction from normal valve function in small valves with high flow conditions, however, may be difficult. Because of this and the variability in normal valves among different prostheses, knowledge of the type and size of the implanted valve is essential. Patients and ultrasound laboratories are encouraged to seek and provide this information on a routine basis. Although transthoracic echocardiography is the main diagnostic modality for the serial evaluation of prosthetic valve function, it is important to recognize its limitations in assessing prosthetic mitral regurgitation and evaluating structural abnormalities of prosthetic valves. These are the situations in which TEE has the most impact. A summary of general indications of TEE in prosthetic valves is provided in Table 6. Finally, a baseline transthoracic Doppler study is essential in the overall follow-up and serial evaluation of valve function. For future comparisons, the best indices of valve functions are those obtained for patients as their own control, from a baseline Doppler echocardiographic study performed early after the operation.
Collapse
Affiliation(s)
- J Barbetseas
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | |
Collapse
|
17
|
Peteiro J, Campos V, Valle J, Alvarez N, Castro-Beiras A. Hemodynamic Comparison by Doppler Echocardiography of Valves in the Aortic Position: Value of the Continuity Equation to Assess Prosthetic Dysfunction. Echocardiography 1998; 15:325-336. [PMID: 11175045 DOI: 10.1111/j.1540-8175.1998.tb00613.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
In 281 patients, we used Doppler echocardiography to compare the hemodynamic performance of different aortic prosthetic valves at three postoperative stages and investigated the value of the continuity equation in diagnosing aortic prosthetic obstruction. A baseline study was performed in 163 patients, a 5 +/- 2-month follow-up study was performed in 103 patients, and a 15 +/- 5-month follow-up study was performed in 65 patients. From baseline to the second study, left ventricular diastolic diameter, heart rate, and maximum (MG) and mean Doppler-derived gradient (MeG) decreased significantly, and left ventricular shortening fraction, systolic blood pressure, stroke volume, and prosthetic valvular area (PVA) increased significantly. No changes were found between the second and third studies. Thus, noninvasive hemodynamic values at the time of follow-up are reported in 171 patients: 86 with Björk-Shiley Monostrut, 27 with Carbomedics, 11 with Medtronic-Hall, 18 with Hancock modified, and 29 with Toronto valve bioprosthesis. Patients implanted with the Toronto had a larger prosthetic size (Monostrut 23 +/- 2 mm, Carbomedics 23 +/- 3 mm, Medtronic-Hall 23 +/- 2 mm, Hancock 23 +/- 2 mm, Toronto 25 +/- 2 mm, P < 0.01) despite a similar body surface area. MeG and MG were lower (MeG [in mmHg] Monostrut 12 +/- 5, Carbomedics 14 +/- 6, Medtronic-Hall 19 +/- 6, Hancock 11 +/- 4, Toronto 7 +/- 5; P < 0.01 between Toronto and all others), and PVA was greater (Monostrut 2.0 +/- 0.7 cm(2), Carbomedics 1.8 +/- 0.8 cm(2), Medtronic-Hall 1.6 +/- 0.7 cm(2), Hancock 1.7 +/- 0.5 cm(2), Toronto 2.2 +/- 0.9 cm(2); P < 0.01 between Toronto and Carbomedics, Medtronic-Hall, and Hancock), even compared with the same sizes in the other valves. A PVA of 0.9 cm(2) or less and MeG of 28 mmHg or more identified prosthetic obstruction with 100% sensitivity and 99% specificity. Hemodynamics change significantly from the early to the late postoperative state. The Toronto valve stentless porcine bioprostheses performs hemodynamically better than other valves. PVA measurement using the continuity equation may accurately identify prosthetic obstruction.
Collapse
Affiliation(s)
- Jesus Peteiro
- Departments of Cardiology and Cardiovascular Surgery, Juan Canalejo Hospital, A Coruña, Spain
| | | | | | | | | |
Collapse
|
18
|
Kadir I, Izzat MB, Birdi I, Wilde P, Reeves B, Walsh C, Bryan A, Angelini G. Hemodynamic performance of the 21-mm St. Jude BioImplant prosthesis using dobutamine Doppler echocardiography. Am J Cardiol 1998; 81:599-603. [PMID: 9514457 DOI: 10.1016/s0002-9149(97)00968-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
This study examines the hemodynamic performance of small size St. Jude BioImplant aortic prostheses using dobutamine echocardiography. Eleven patients (3 women, mean age 75 years) who had undergone aortic valve replacement with a size 21-mm St. Jude BioImplant aortic prostheses at 10.8 +/- 5.1 months (SD) previously were studied. Dobutamine infusion was started at a rate of 5 microg/kg/min and increased to 10 microg/kg/min, and subsequently to 20 microg/kg/min at 15-minute intervals. Pulsed and continuous-wave Doppler studies were performed at rest and at the end of each stage. Effective orifice area, mean gradient, and the performance index across each prosthesis were calculated and cardiac output was determined by Doppler measurement of flow in the left ventricular outflow tract. Stress dobutamine increased heart rate and cardiac output by 51% and 56%, respectively (both p <0.0001), and the mean transvalvular gradient increased from 30.1 +/- 7.5 mm Hg at rest to 49.3 +/- 11.5 mm Hg at maximum stress (p <0.0005). The performance index increased progressively from 0.29 +/- 0.05 at rest to 0.40 +/- 0.10 at maximum stress (p <0.0005). Regression modeling analyses demonstrated that the maximum stress gradient was independent of all variables except the resting gradient (p = 0.03). Body surface area had no effect on the changes in cardiac output, effective orifice area, or transprosthetic gradient at maximum stress. Thus, these data demonstrate that the size 21-mm St. Jude BioImplant prosthesis exhibits suboptimal hemodynamic performance with transvalvular gradients consistent with mild to moderate aortic stenosis, both at rest and under stress conditions.
Collapse
Affiliation(s)
- I Kadir
- Bristol Heart Institute, Department of Clinical Radiology, University of Bristol, United Kingdom
| | | | | | | | | | | | | | | |
Collapse
|
19
|
Saad RM, Barbetseas J, Olmos L, Rubio N, Zoghbi WA. Application of the continuity equation and valve resistance to the evaluation of St. Jude Medical prosthetic aortic valve dysfunction. Am J Cardiol 1997; 80:1239-42. [PMID: 9359564 DOI: 10.1016/s0002-9149(97)00652-8] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Doppler echocardiography was applied to the assessment of patients with surgically documented St. Jude medical aortic valve dysfunction. Derivation of effective orifice area and Doppler velocity index with the continuity equation and calculation of valve resistance accurately differentiated stenotic from regurgitant and normal valves.
Collapse
Affiliation(s)
- R M Saad
- Department of Medicine, Baylor College of Medicine, and The Methodist Hospital Echocardiography Laboratory Houston, Texas 77030, USA
| | | | | | | | | |
Collapse
|
20
|
González-Juanatey JR, García-Acuña JM, Vega Fernandez M, Amaro Cendón A, Castelo Fuentes V, García-Bengoechea JB, de la Peña MG. Influence of the size of aortic valve prostheses on hemodynamics and change in left ventricular mass: implications for the surgical management of aortic stenosis. J Thorac Cardiovasc Surg 1996; 112:273-80. [PMID: 8751490 DOI: 10.1016/s0022-5223(96)70249-0] [Citation(s) in RCA: 81] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
UNLABELLED Discussion of aortic valve replacement has primarily concerned the choice between tissue and mechanical prostheses. Less emphasis has been placed on prosthesis size. Despite technical advances increasing prosthesis orifice area, small valves implanted in the unenlarged aortic root may not be significantly less obstructive than the stenotic native valves they replace. METHODS In this work we studied 52 patients (31 women, 21 men; mean age 59.2 years) in whom valve prostheses sized 19, 21, 23, or 25 mm (30 bioprostheses and 22 tilting disc valves) had been implanted to replace stenotic aortic valves. Most patients with 19 or 21 mm prostheses were women. Doppler and conventional echocardiographic studies were performed in the 10 days preceding the operation and between 10 and 40 months (mean 18 months) after the operation. The patients receiving larger valve sizes had significantly larger body surface areas than those receiving smaller valve sizes (mainly women). RESULTS No significant differences were observed between preoperative and postoperative diameters or left ventricular systolic function parameters, but left ventricular mass and mass index decreased in all four groups (albeit nonsignificantly in the 19 mm group, and with less statistical significance in the 21 mm group than in the 23 and 25 mm groups). Postoperative peak and mean transvalvular pressure drops were significantly greater in the 19 mm group than in the other groups, and the 21 mm group had significantly greater transvalvular pressure drops than the 25 mm group. Postoperative effective valve area was significantly smaller in the 19 mm group than in the 21 mm group, and significantly smaller in the 21 mm group than in the 23 and 25 mm groups. CONCLUSION We conclude that despite undeniable recent improvements in the design of artificial heart valves, 19 mm aortic prostheses continue to create significant obstruction of the left ventricular outflow tract and, possibly as a consequence of this, fail to bring about significant reduction in left ventricular hypertrophy.
Collapse
|
21
|
González-Juanatey JR, Garcia Acuña JM, Amaro A, Castelo V, Pedreira M, Garcia Bengoechea J, Gil M. Doppler echocardiographic comparison of small (19 mm) bileaflet and pericardial heart valve prostheses in aortic position. SCANDINAVIAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 1995; 29:29-35. [PMID: 7644906 DOI: 10.3109/14017439509107198] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The resting haemodynamics of five types of small (19 mm) aortic valve prosthesis (2 bileaflet, 3 pericardial) were evaluated with Doppler echocardiography in 43 patients. Two received St Jude Medical and six CarboMedics bileaflet valves and 35 were given bioprostheses--16 Ionescu-Shiley, four Mitroflow and 15 Labcor-Santiago. No significant differences in peak or mean transvalvular pressure drop or in effective valve area were found between the bileaflet and the pericardial valves or among the three types of bioprosthesis. All but one of the bileaflet prostheses showed a characteristic regurgitation pattern, with two lateral and one central jet, and 16 (46%) of the bioprostheses showed central regurgitation, but in no case were these jets haemodynamically significant. Thus the 19 mm bileaflet and the studied pericardial prostheses all have satisfactory resting haemodynamics, and all are suitable for implanting in small aortic roots.
Collapse
Affiliation(s)
- J R González-Juanatey
- Department of Cardiology, Hospital General de Galicia, School of Medicine, Santiago de Compostela, Spain
| | | | | | | | | | | | | |
Collapse
|