Aortic Valve Replacement With 17-mm St. Jude Medical Prostheses for a Small Aortic Root in Elderly Patients

Long-term Mortality Predictors in Patients with Small Aortic Annulus Undergoing Aortic Valve Replacement with a 19- or 21-mm Bioprosthesis

Introduction

Replacement of the aortic valve in patients with a small aortic annulus is associated with increased morbidity and mortality. A prosthesis-patient mismatch is one of the main problems associated with failed valves in this patient population.

Objective

To evaluate the long-term mortality predictors in patients with a small aortic annulus undergoing aortic valve replacement with a bioprosthesis.

Methods

In this retrospective observational study, a total of 101 patients undergoing aortic valve replacement from January 2000 to December 2010 were studied. There were 81 (80.19%) women with a mean age of 52.81±18.4 years. Severe aortic stenosis was the main indication for surgery in 54 (53.4%) patients. Posterior annulus enlargement was performed in 16 (15.8%) patients. Overall, 54 (53.41%) patients underwent concomitant surgery: 28 (27.5%) underwent mitral valve replacement, and 13 (12.7%) underwent coronary artery bypass graft surgery.

Results

Mean valve index was 0.82±0.08 cm(2)/m(2). Overall, 17 (16.83%) patients had a valve index lower than 0.75 cm(2)/m(2), without statistical significance for mortality (P=0.12). The overall 10-year survival rate was 83.17%. The rate for patients who underwent isolated aortic valve replacement was 91.3% and 73.1% (P=0.02) for patients who underwent concomitant surgery. In the univariate analysis, the main predictors of mortality were preoperative ejection fraction (P=0.02; HR 0.01) and EuroSCORE II results (P=0.00000042; HR 1.13). In the multivariate analysis, the main predictors of mortality were age (P=0.01, HR 1.04) and concomitant surgery (P=0.01, HR 5.04). Those relationships were statistically significant.

Conclusion

A valve index of < 0.75 cm(2)/m(2) did not affect 10-year survival. However, concomitant surgery and age significantly affected mortality.

Early and Late Outcomes of Aortic Valve Replacement Using Bioprosthetic Versus Mechanical Valve in Elderly Patients: A Propensity Analysis

BACKGROUND AND AIM OF THE STUDY

There is still controversy on the use of mechanical valves to treat elderly patients with a small aortic annulus who require aortic valve replacement (AVR). We compared our results in elderly patients who underwent AVR with a bioprosthetic or mechanical valve. Propensity matching adjusted for baseline differences in this study.

METHODS

Between January 2001 and July 2014, 277 patients aged ≥75 years old who underwent AVR were enrolled. Of 277 patients, 104 patients were selected using propensity score matching analysis. Out of this cohort, 52 patients underwent AVR with a bioprosthetic valve (B group) and the remainder AVR with a mechanical valve (M group).

RESULTS

There were no significant differences between the B and M groups in 30 days mortality (1.9% vs. 5.8%, p = 0.618). The incidence of patient-prosthesis mismatch (PPM) after AVR tended to be lower in the M group than in the B group. The overall survival rates in the B and M groups at eight years were 72.8% and 73.3%, respectively (p = 0.473). No significant differences between the two groups were observed in freedom from valve-related death, cardiac events, bleeding events, or stroke events.

CONCLUSIONS

AVR in elderly patients achieved relatively good short-term and long-term outcomes, and the incidence rates of valve-related complications after using a mechanical valve were low. In a selected population of elderly patients, a mechanical valve may be acceptable. doi: 10.1111/jocs.12719 (J Card Surg 2016;31:195-202).

Does the St. Jude Regent 17-mm Offer Better Outcomes Than the Hemodynamic Plus 17-mm Aortic Valve Mechanical Prothesis?

OBJECTIVE

The aim of the present study is to report the early and mid-term clinical and hemodynamic results of a prospective trial investigating the clinical performance of the St. Jude Medical Regent 17 mm (SJMR-17) versus St. Jude Medical Hemodynamic Plus 17 mm (SJMHP-17).

MATERIALS AND METHODS

Between January 2000 and August 2013, 20 patients (Group I) with aortic valve (AV) stenosis underwent first time AV replacement with a SJMR-17 and nine patients (Group II) underwent AV replacement with a SJMHP-17. The mean follow-up was 58 ± 31 months.

RESULTS

There was one death in Group I. The end-diastolic IVS thickness and end-systolic posterior left ventricle (LV) wall thickness was reduced significantly in boths groups (p = 0.001 and p = 0.006 in Group I and p = 0.007 and p = 0.011 in Group II). The peak and mean transprosthesis gradients (P-TPG and M-TPG) were 29 ± 6.8 mmHg and 17.5 ± 4.5 mmHg in Group I, significantly lower than in Group II (55.2 ± 19.7 mmHg and 28.8 ± 7.7 mmHg). The postoperative left ventricular mass (LVM) and indexed left ventricular mass (LVMi) were reduced significantly in both groups versus the preoperative values. The postoperative LVMi was 114.5 ± 10.6 g/m(2) in Group I versus 127 ± 8 g/m(2) in Group II (p = 0.01). With dobutamine, heart rate, left ventricular ejection fraction, cardiac output, transprosthesis peak, and mean gradients increased significantly in both groups, however, the P-TPG and M-TPG were significantly higher in Group II (p = 0.026 and p = 0.022) despite a non-significant increase of the indexed effective orifice area.

CONCLUSIONS

The SJMR-17 can be employed with satisfactory postoperative clinical and hemodynamic outcomes in patients with small aortic annulus, especially in elderly patients offering better outcome than SJMHP-17.

Hemodynamics of 17-mm vs. 19-mm St. Jude Medical Regent and annulus enlargement

OBJECTIVE

We aimed to compare early and midterm clinical and hemodynamic outcomes of 17-mm vs. 19-mm St. Jude Medical Regent valves with concomitant aortic annulus enlargement.

METHODS

Between 1999 and 2012, 20 patients (group 1) underwent first-time aortic valve replacement with a 17-mm St. Jude Medical Regent valve, and 35 patients (group 2) had a 19-mm valve and concomitant aortic annulus enlargement. The mean follow-up was 81 ± 37 months (range 20-110 months).

RESULTS

There was one death in group 1 vs. 4 in group 2 (p > 0.05). The mean postoperative transprosthetic gradient was 17.5 ± 4.5 in group 1 and 17 ± 6.4 mm Hg in group 2 (p = 0.83), and 37 ± 10.7 and 32 ± 13 mm Hg, respectively, under stress (p = 0.17). Left ventricular mass and left ventricular mass index were reduced and similar in both groups. Postoperative effective orifice area index was higher in group 2 (0.85 ± 0.17 cm(2 )m(-2)) than group 1 (0.76 ± 0.2 cm(2 )m(-2); p > 0.05). A multivariate Cox model identified a 19-mm valve with aortic annulus enlargement (p = 0.032), functional class (p = 0.025), reoperation (p = 0.04), ejection fraction < 35% (p = 0.042), and combined surgery (p = 0.04) as strong predictors of poorer overall event-free survival.

CONCLUSIONS

The 17-mm St. Jude Medical Regent valve may be employed with satisfactory postoperative clinical and hemodynamic outcomes in patients with a small aortic annulus, as an alternative to a larger prothesis with aortic annulus enlargement.

Strategy to avoid patient-prosthesis mismatch: aortic root enlargement

BACKGROUND

The choice of a valve with an effective orifice area matching the body surface area and providing efficient hemodynamics is an important factor affecting mortality and morbidity in patients undergoing aortic valve replacement.

PATIENTS AND METHODS

Our preventative strategy was to implant a larger prosthetic valve by aortic root enlargement using the Nunez procedure in 17 patients between February 2010 and January 2011. The decision to enlarge the aortic root was taken when the 19-mm sizer could not be negotiated easily through the aortic root, or on the basis of body surface area of the patient or type of prosthesis available.

RESULTS

Postoperative reductions in peak and mean pressure gradients across aortic valve of 12.8-16.5 and 10.2-12.6 mm Hg, respectively, were observed. Postoperative effective orifice areas of the aortic valves were 1.1-1.5 cm(2). By upsizing the aortic valve, we were able to eliminate patient-prosthesis mismatch in 5 patients, and reduce severe patient-prosthesis mismatch to moderate in 11.

CONCLUSION

Aortic root enlargement is a safe procedure. Therefore, cardiac surgeons should not be reluctant to enlarge the aortic root with an autologous pericardial patch to permit implantation of an adequate size of aortic valve prosthesis, with minimal additional aortic crossclamp time and no added cost.

Seventeen-millimeter St. Jude Medical Regent valve in patients with small aortic annulus: dose moderate prosthesis-patient mismatch matter?

Background

The study was designed to evaluate the effects of moderate prosthesis-patient mismatch (defined as 0.65 cm²/m² < indexed effective orifice area ≤ 0.85 cm²/m²) on midterm outcomes after isolated aortic valve replacement with a 17-mm St. Jude Medical Regent valve in a large series of patients, and to determine if these effects are influenced by patient confounding variables.

Methods

One-hundred and six patients with and without moderate prosthesis-patient mismatch early after implantation of a 17-mm Regent valve at aortic position were included. Both clinical and echocardiographic assessments were performed preoperatively, at discharge and during follow-up period (mean follow-up time 52.6 ± 11.9 months).

Results

The prevalence of moderate prosthesis-patient mismatch was documented in 46 patients (43.4%) at discharge. During the follow-up period, no difference in the regression of left ventricular mass, decrease of transvalvular pressure gradients, mortality and prosthesis-related complications was observed between patients with and without moderate prosthesis-patient mismatch. After adjustment for several risk factors, moderate prosthesis-patient mismatch was associated with increased midterm mortality in patients with baseline left ventricular ejection fraction < 50% (HR: 1.80, p = 0.02), but with normal prognosis in those with preserved LV function. Younger age (cut off value = 65 years) was not an independent predictor of increased midterm mortality and valve-related complications in patients with moderate prosthesis-patient mismatch.

Conclusions

Moderate prosthesis-patient mismatch after aortic valve replacement with a small mechanical prosthesis is associated with increased mortality and adverse events in patients with pre-existing left ventricular dysfunction. Selected patients with small aortic annulus can experience satisfactory clinical improvements and midterm survival after aortic valve replacement with a 17-mm Regent valve.

Current status and future perspectives of prosthetic valve selection for aortic valve replacement

Aortic valve abnormality is the most frequent form of valvular heart disease. Notably, aortic stenosis in the elderly population has been increasingly common. Aortic valve replacement (AVR) using prosthetic valve has been still believed as a gold standard surgical intervention for various types of diseased aortic valve. The numerous reports and studies evaluating the clinical outcomes and durability of prosthesis were revealed, however, prosthesis selection for AVR is still debated. In twenty-first century, paradigm shift of prosthesis preference might be emerged from mechanical valves to bioprosthesis due to the development of the technology. Moreover, transcatheter aortic valve implantation accelerated among the worldwide trends. It could be developed having the potential to reduce the mortality and morbidity associated with high-risk traditional AVR. After the current guidelines for the management of patients with valvular heart disease, we should consider the valve choice in various patients' profile setting. This review summarizes the current status of prosthesis selection and future perspectives of ideal aortic valve intervention, including minimal invasive care.

Application of Regent mechanical valve in patients with small aortic annulus: 3-year follow-up

Background

Aortic valve replacement (AVR) with a small aortic annulus is always challenging for the cardiac surgeon. In this study, we sought to evaluate the midterm performance of implantation with a 17-mm or 19-mm St. Jude Medical Regent (SJM Regent) mechanical valve in retrospective consecutive cohort of patients with small aortic annulus (diameter ≤ 19 mm).

Methods

From January 2008 to April 2011, 40 patients (31 female, mean age = 47.2 ± 5.8 years) with small aortic annulus (≤19 mm in diameter) underwent aortic valve replacement with a 17-mm or 19-mm St. Jude Medical Regent (SJM Regent) mechanical valve. Preoperative mean body surface area, New York Heart Association class, and mean aortic annulus were 1.61 ± 0.26 m², 3.2 ± 0.4, and 18 ± 1.4 mm respectively. Patients were divided into two groups, according to the implantation of 17 mm SJM Regent mechanical valve (group 1, n = 18) or 19 mm SJM Regent valve (group 2, n = 22). All patients underwent echocardiography examination preoperatively and at one year post-operation.

Results

There were no early deaths in either group. Follow-up time averaged 36 ± 17.6 months. The mean postoperative New York Heart Association class was 1.3 ± 0.6 (p < 0.001). By echocardiography, in group 1, the left ventricular ejection fraction (LVEF), left ventricular fraction shortening (LVFS), and the indexed effective orifice area (EOAI) increased from 43.7% ± 11.6%, 27.3% ± 7.6%, and 0.70 ± 0.06 cm²/m² to 69.8 ± 9.3%, 41.4 ± 8.3%, and 0.92 ± 0.10 cm²/m² respectively (P < 0.05), while the left ventricular mass index (LVMI), and the aortic transvalvular pressure gradient decreased from 116.4 ± 25.4 g/m², 46.1 ± 8.5 mmHg to 86.7 ± 18.2 g/m² , 13.7 ± 5.2 mmHg respectively. In group 2, the LVEF, LVFS and EOAI increased from 45.9% ± 9.7%, 30.7% ± 8.0%, and 0.81 ± 0.09 cm²/m² to 77.4% ± 9.7%, 44.5% ± 9.6%, and 1.27 ± 0.11 cm²/m² respectively, while the LVMI, and the aortic transvalvular pressure gradient decreased from 118.3 ± 27.6 g/m², 44.0 ± 6.7 mmHg to 80.1 ± 19.7 g/m², 10.8 ± 4.1 mmHg as well. The prevalence of PPM was documented in 2 patients in Group 1.

Conclusions

Patients with small aortic annulus and body surface area, experienced satisfactory clinical improvement after aortic valve replacement with modern SJM Regent bileaflet prostheses.

Mid-term outcomes after aortic valve replacement with the 17-mm St. Jude Medical Regent valve

BACKGROUND

When aortic valve replacement (AVR) is performed in patients with a small aortic annulus, prosthesis-patient mismatch (PPM) is of concern. We investigated the mid-term outcomes of AVR with a 17-mm mechanical prosthesis.

METHODS AND RESULTS

Seventy-eight patients with aortic stenosis underwent AVR with a 17-mm St. Jude Medical Regent prosthesis. Echocardiography was performed preoperatively, at discharge, and at follow-up (mean follow-up, 33 months). Patients were divided into 2 groups: with and without PPM at discharge. Between-group differences in postoperative variables, particularly survival, were analyzed. Overall hospital mortality was 2.6%. Actuarial 1- and 5-year survival rates were 95% and 79%, respectively. Diabetes and renal insufficiency were associated with long-term mortality. Freedom from major adverse valve-related cardiac events at 1 year and 5 years was 97.3% and 93.9%, respectively. Diabetes was shown to be an independent risk factor for major adverse valve-related cardiac events. Echocardiography 13 months after AVR showed a significant increase in mean effective orifice area index, decrease in mean left ventricular-aortic pressure gradient, and decrease in mean left ventricular mass index. PPM at discharge did not influence long-term survival or left ventricular mass regression.

CONCLUSIONS

The 17-mm Regent prosthesis provided satisfactory clinical and hemodynamic results. It is a reliable choice for patients with a small aortic annulus.

Aortic valve replacement with 17-mm St. Jude Medical Regent prosthetic valves for a small calcified aortic annulus in elderly patients

PURPOSE

The aim of this study was to investigate the outcome of aortic valve replacement (AVR) performed with a 17-mm St. Jude Medical Regent prosthetic valve (17SJMR) for an aortic annulus ≤19 mm in elderly patients aged ≥65 years.

METHODS

Six female patients (age 73.0 ± 5.1 years, body surface area 1.43 ± 0.07 m²) underwent AVR between October 2005 and February 2008.

RESULTS

Peak transaortic pressure gradient, which was 80.8 ± 31.0 mmHg preoperatively, decreased to 31.0 ± 4.2 mmHg postoperatively (P < 0.01) and to 21.7 ± 1.5 mmHg long term (P < 0.01). The left ventricular mass index, which was 112.1 ± 10.6 g/m² preoperatively, also significantly decreased to 101.4 ± 15.0 g/m² postoperatively and to 88.3 ± 14.8 g/m² long term (P < 0.01). Subjective symptoms diminished in all patients, and neither mortality nor hemorrhagic complications occurred. The postoperative mean effective orifice area index was 0.91 ± 0.04 cm²/m².

CONCLUSION

A favorable outcome was obtained by aortic valve replacement with the 17SJMR. Patients showed improved postoperative hemodynamic performance without valve-related complications.

Hemodynamics and Outcomes of Aortic Valve Replacement with a 17- or 19-mm Valve

When aortic valve replacement is performed in patients with a small aortic annulus, prosthesis-patient mismatch is of concern because it may affect postoperative clinical status. We conducted a retrospective study of outcomes in 65 patients with aortic stenosis requiring valve replacement. Fifty were given a 17-mm or 19-mm St. Jude Regent mechanical valve, and 15 were given a 19-mm Medtronic Mosaic bioprosthesis. Echocardiography was carried out preoperatively, at discharge, and at follow-up. There was 1 (2%) operative death in the Regent group and none in the Mosaic group. There was no valve-related event. Follow-up echocardiography in both groups revealed a significant increase in the mean effective orifice area index, a decrease in the mean left ventricular-aortic pressure gradient, and a decrease in the mean left ventricular mass index. Prosthesis-patient mismatch (effective orifice area index <0.85 cm2 · m−2) existed in 13 (26%) patients in the Regent group and 11 (73%) in the Mosaic group at discharge. All patients improved to New York Heart Association functional class II or better. A small-sized prosthesis may provide satisfactory clinical and hemodynamic results in patients with a small aortic annulus.

The 17-mm St. Jude Medical Regent valve is a valid option for patients with a small aortic annulus

BACKGROUND

When aortic valve replacement is performed in patients with a small aortic annulus, prosthesis-patient mismatch is of concern. Such prosthesis-patient mismatch may affect postoperative clinical status and survival. We investigated the outcomes of isolated aortic valve replacement performed with a 17-mm mechanical prosthesis in patients with aortic stenosis.

METHODS

Twenty-three patients with aortic stenosis (mean age, 74.6 +/- 6.3 years) underwent isolated aortic valve replacement with a 17-mm St. Jude Medical Regent prosthesis. Mean body surface area was 1.41 +/- 0.13 m(2). Preoperative echocardiography yielded a mean aortic valve area of 0.36 +/- 0.10 cm(2)/m(2), a mean left ventricular-aortic pressure gradient of 68.4 +/- 25.3 mm Hg, and a mean left ventricular mass index of 200 +/- 69 g/m(2).

RESULTS

There was no operative mortality, and there were no valve-related events. Echocardiography at 14.0 +/- 10.0 months after aortic valve replacement showed a significant increase in the mean effective orifice area index (0.95 +/- 0.24 cm(2)/m(2)), decrease in the mean left ventricular-aortic pressure gradient (17.4 +/- 8.2 mm Hg), and decrease in the mean left ventricular mass index (124 +/- 37 cm(2)/m(2)). Prosthesis-patient mismatch (effective orifice area index < 0.85 cm(2)/m(2)) was present in 8 patients at discharge. In these patients as well as in those without prosthesis-patient mismatch, the left ventricular mass index decreased remarkably during follow-up.

CONCLUSIONS

Aortic valve replacement with a 17-mm Regent prosthesis appears to provide satisfactory clinical and hemodynamic results in patients with a small aortic annulus. Remarkable left ventricular mass regression during follow-up was achieved irrespective of the effective orifice area index at discharge.