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Bruno F, Rampone JM, Islas F, Gorla R, Gallone G, Melillo F, Leone PP, Cimaglia P, Pastore MC, Franzone A, Landra F, Scudeler L, Jimenez-Quevedo P, Viva T, Piroli F, Bragato R, Trichilo M, Degiovanni A, Salizzoni S, Ilardi F, Andreis A, Nombela-Franco L, Tusa M, Toselli M, Conrotto F, Montorfano M, Manzo R, Cameli M, Patti G, Stefanini G, Testa L, La Torre M, Giannini F, Agricola E, Escaned J, De Filippo O, De Ferrari GM, D'Ascenzo F. Echocardiographic and clinical features of patients developing prosthesis-patient mismatch after TAVR: insights from the Recovery TAVR registry. Am Heart J 2024:S0002-8703(24)00137-6. [PMID: 38838970 DOI: 10.1016/j.ahj.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 05/26/2024] [Accepted: 05/27/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The impact of prosthesis-patient mismatch (PPM) on major endpoints after transcatheter aortic valve replacement (TAVR) is controversial and the effects on progression of heart damage are poorly investigated. Therefore, our study aims to evaluate the prevalence and predictors of PPM in a "real world" cohort of patients at intermediate and low surgical risk, its impact on mortality and the clinical-echocardiographic progression of heart damage. METHODS 963 patients who underwent TAVR procedure between 2017 and 2021, from the RECOVERY-TAVR international multicenter observational registry, were included in this analysis. Multiparametric echocardiographic data of these patients were analyzed at 1-year follow-up (FU). Clinical and echocardiographic features were stratified by presence of PPM and PPM severity, as per the most current international recommendations, using VARC-3 criteria. RESULTS 18% of patients developed post-TAVR. PPM, and 7.7% of the whole cohort had severe PPM. At baseline, 50.3% of patients with PPM were male (vs 46.2% in the cohort without PPM, p=0.33), aged 82 (IQR 79-85y) years vs 82 (IQR 78-86 p=0.46), and 55.6% had Balloon-Expandable valves implanted (vs 46.8% of patients without PPM, p=0.04); they had smaller left ventricular outflow tract (LVOT) diameter (20 mm, IQR 19-21 vs 20 mm, IQR 20-22, p=0.02), reduced SVi (34.2 vs 38 ml/m2, p<0.01) and transaortic flow rate (190.6 vs 211 ml/s, p<0.01). At pre-discharge FU patients with PPM had more paravalvular aortic regurgitation (moderate-severe AR 15.8% vs 9.2%, p<0.01). At 1-year FU, maladaptive alterations of left ventricular parameters were found in patients with PPM, with a significant increase in end-systolic diameter (33 mm vs 28 mm, p=0.03) and a significant increase in left ventricle end systolic indexed volume in those with moderate and severe PPM (52 IQR 42-64 and 52, IQR 41-64 vs.44 IQR 35-59 in those without, p=0.02)). No evidence of a significant impact of PPM on overall (p=0.71) and CV (p=0.70) mortality was observed. Patients with moderate/severe PPM had worse NYHA functional class at 1 year (NYHA III-IV 13% vs 7.8%, p=0.03). Prosthesis size≤23 mm (OR 11.6, 1.68-80.1) was an independent predictor of PPM, while SVi (OR 0.87, 0.83-0.91, p<0.001) and LVOT diameter (OR 0.79, 0.65-0.95, p=0.01) had protective effect. CONCLUSIONS PPM was observed in 18% of patients undergoing TAVR. Echocardiographic evaluations demonstrated a PPM-related pattern of early ventricular maladaptive alterations, possibly precursor to a reduction in cardiac function, associated with a significant deterioration in NYHA class at 1 year. These findings emphasize the importance of prevention of PPM of any grade in patients undergoing TAVR procedure, especially in populations at risk.
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Affiliation(s)
- Francesco Bruno
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Joao Matteo Rampone
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Fabian Islas
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Riccardo Gorla
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Guglielmo Gallone
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | | | | | - Paolo Cimaglia
- GVM Care and Research, Maria Cecilia Hospital, Ravenna, Italy
| | | | - Anna Franzone
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Federico Landra
- Department of Cardiovascular Diseases, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100 Siena, Italy
| | - Luca Scudeler
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Pilar Jimenez-Quevedo
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Tommaso Viva
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | | | | | | | - Anna Degiovanni
- Azienda Ospedaliero Universitaria "Maggiore Della Carita", Novara, Italy
| | - Stefano Salizzoni
- Division of Cardiac Surgery, Cardiovascular and Thoracic Department, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | - Federica Ilardi
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Alessandro Andreis
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Luis Nombela-Franco
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Maurizio Tusa
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Marco Toselli
- GVM Care and Research, Maria Cecilia Hospital, Ravenna, Italy
| | - Federico Conrotto
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | | | - Rachele Manzo
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Matteo Cameli
- Department of Cardiovascular Diseases, University of Siena, Policlinico "Le Scotte", Viale Bracci 1, 53100 Siena, Italy
| | - Giuseppe Patti
- Azienda Ospedaliero Universitaria "Maggiore Della Carita", Novara, Italy
| | | | - Luca Testa
- Department of Clinical and Interventional Cardiology, IRCCS Policlinico San Donato, Milan, Italy
| | - Michele La Torre
- Division of Cardiac Surgery, Cardiovascular and Thoracic Department, Città Della Salute e Della Scienza Hospital and University of Turin, Turin, Italy
| | | | | | - Javier Escaned
- Hospital Clínico San Carlos, IDISSC, and Universidad Complutense de Madrid, Madrid, Spain
| | - Ovidio De Filippo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy.
| | - Gaetano M De Ferrari
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
| | - Fabrizio D'Ascenzo
- Division of Cardiology, Department of Medical Sciences, Città della Salute e della Scienza, University of Turin, Turin, Italy
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Sá MP, Jacquemyn X, Van den Eynde J, Chu D, Serna‐Gallegos D, Ebels T, Clavel M, Pibarot P, Sultan I. Impact of Prosthesis-Patient Mismatch After Surgical Aortic Valve Replacement: Systematic Review and Meta-Analysis of Reconstructed Time-to-Event Data of 122 989 Patients With 592 952 Patient-Years. J Am Heart Assoc 2024; 13:e033176. [PMID: 38533939 PMCID: PMC11179750 DOI: 10.1161/jaha.123.033176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/28/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND It remains controversial whether prosthesis-patient mismatch (PPM) impacts long-term outcomes after surgical aortic valve replacement. We aimed to evaluate the association of PPM with mortality, rehospitalizations, and aortic valve reinterventions. METHODS AND RESULTS We performed a systematic review with meta-analysis of reconstructed time-to-event data of studies published by March 2023 (according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Sixty-five studies met our eligibility criteria and included 122 989 patients (any PPM: 68 332 patients, 55.6%). At 25 years of follow-up, the survival rates were 11.8% and 20.6% in patients with and without any PPM, respectively (hazard ratio [HR], 1.16 [95% CI, 1.13-1.18], P<0.001). At 20 years of follow-up, the survival rates were 19.5%, 12.1%, and 8.8% in patients with no, moderate, and severe PPM, respectively (moderate versus no PPM: HR, 1.09 [95% CI, 1.06-1.11], P<0.001; severe versus no PPM: HR, 1.29 [95% CI, 1.24-1.35], P<0.001). PPM was associated with higher risk of cardiac death, heart failure-related hospitalizations, and aortic valve reinterventions over time (P<0.001). Statistically significant associations between PPM and worse survival were observed regardless of valve type (bioprosthetic versus mechanical valves), contemporary PPM definitions unadjusted and adjusted for body mass index, and PPM quantification method (in vitro, in vivo, Doppler echocardiography). Our meta-regression analysis revealed that populations with more women tend to have higher HRs for all-cause death associated with PPM. CONCLUSIONS The results of the present study suggest that any degree of PPM is associated with poorer long-term outcomes following surgical aortic valve replacement and provide support for implementation of preventive strategies to avoid PPM after surgical aortic valve replacement.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- University of Pittsburgh Medical CenterUPMC Heart and Vascular InstitutePittsburghPAUSA
| | | | | | - Danny Chu
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- University of Pittsburgh Medical CenterUPMC Heart and Vascular InstitutePittsburghPAUSA
| | - Derek Serna‐Gallegos
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- University of Pittsburgh Medical CenterUPMC Heart and Vascular InstitutePittsburghPAUSA
| | - Tjark Ebels
- Department of Cardiothoracic Surgery, University Medical Center GroningenUniversity of GroningenThe Netherlands
| | - Marie‐Annick Clavel
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de QuébecQuébec CityQuébecCanada
- Department of Medicine, Faculty of MedicineUniversité LavalQuébec CityQuébecCanada
| | - Philippe Pibarot
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de QuébecQuébec CityQuébecCanada
- Department of Medicine, Faculty of MedicineUniversité LavalQuébec CityQuébecCanada
| | - Ibrahim Sultan
- Department of Cardiothoracic SurgeryUniversity of PittsburghPAUSA
- University of Pittsburgh Medical CenterUPMC Heart and Vascular InstitutePittsburghPAUSA
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Zoghbi WA, Jone PN, Chamsi-Pasha MA, Chen T, Collins KA, Desai MY, Grayburn P, Groves DW, Hahn RT, Little SH, Kruse E, Sanborn D, Shah SB, Sugeng L, Swaminathan M, Thaden J, Thavendiranathan P, Tsang W, Weir-McCall JR, Gill E. Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography. J Am Soc Echocardiogr 2024; 37:2-63. [PMID: 38182282 DOI: 10.1016/j.echo.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2024]
Abstract
In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.
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Affiliation(s)
- William A Zoghbi
- Houston Methodist Hospital, DeBakey Heart & Vascular Center, Houston, Texas.
| | - Pei-Ni Jone
- Lurie Children's Hospital, Northwestern University, Chicago, Illinois
| | | | - Tiffany Chen
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Milind Y Desai
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Paul Grayburn
- Baylor Scott & White Health, University of Texas Southwestern, Dallas, Texas
| | - Daniel W Groves
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Rebecca T Hahn
- Columbia University Irving Medical Center, New York, New York
| | - Stephen H Little
- Houston Methodist Hospital, DeBakey Heart & Vascular Center, Houston, Texas
| | - Eric Kruse
- University of Chicago Medical Center, Chicago, Illinois
| | | | - Sangeeta B Shah
- VCU Pauley Heart Center, Virginia Commonwealth University, Richmond, Virginia
| | - Lissa Sugeng
- North Shore University Hospital, Manhasset, New York
| | - Madhav Swaminathan
- Cardiothoracic Anesthesiology and Critical Care Medicine, Duke University, Durham, North Carolina
| | | | | | - Wendy Tsang
- University of Toronto, Toronto, Ontario, Canada
| | | | - Edward Gill
- University of Colorado School of Medicine, Aurora, Colorado
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Natalis A, Masson JB, Mansour MJ, Asmar MA, Potvin J, Gobeil JF, Riahi M, Noiseux N, Stevens LM, Forcillo J. Correlation between measured and predicted mismatch with valve hemodynamics in transcatheter aortic valve replacement: A sex-based analysis. Catheter Cardiovasc Interv 2023; 102:505-512. [PMID: 37449451 DOI: 10.1002/ccd.30764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2023] [Revised: 05/15/2023] [Accepted: 07/08/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND Data regarding the reliability of predicted effective orifice area indexed (pEOAi) is scarce in transcatheter aortic valve replacement (TAVR). AIMS To assess the validity of the pEOAi in TAVR by correlating its value with echocardiography-derived hemodynamic data. METHODS A single-center retrospective cohort study of TAVR patients from 2012 to 2021 with available echocardiograms was conducted. Patient-prosthesis mismatch (PPM) was defined based on the Valve Academic Research Consortium 3 criteria. The main endpoints were the congruence of measured effective orifice area indexed (EOAi) and pEOAi with the hemodynamic data obtained by echocardiography. The secondary endpoint included a correlation of predicted PPM (pPPM) and measured PPM (mPPM) with postoperative New York Heart Association (NYHA) status. RESULTS A total of 318 patients were included. pPPM was more frequent than mPPM (54 [17%]; all moderate PPM vs. 39 [12.3%]: 32 moderate and 7 severe PPM). Predicted and measured EOAi were statistically correlated with postprocedural transvalvular mean gradient and Doppler velocity index (all p < 0.001), including in both sex-based subgroups. The positive predictive value and negative predictive value (NPV) of pPPM for postprocedural transvalvular mean gradient ≥ 20 mmHg were 16% and 97%, respectively. Only pPPM was significantly more prevalent in the group in which NYHA failed to improve than in those with symptom improvement (30.1% vs. 16%, p = 0.027). CONCLUSION Predicted PPM has an excellent NPV for postprocedural transvalvular mean gradient ≥ 20 mmHg and seems to be a good predictor of NYHA status evolution as opposed to measured PPM. Predicted EOAi can be used in procedural planning to reduce the risk of PPM in both TAVR male and female patients.
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Affiliation(s)
- Alexandre Natalis
- Centre Hospitalier Universitaire de Montréal (CHUM), Montréal, Quebec, Canada
| | - Jean-Bernard Masson
- Centre Hospitalier Universitaire de Montréal (CHUM), Montréal, Quebec, Canada
| | - Mohamad J Mansour
- Centre Hospitalier Universitaire de Montréal (CHUM), Montréal, Quebec, Canada
| | - Mike Al Asmar
- Centre Hospitalier Universitaire de Montréal (CHUM), Montréal, Quebec, Canada
| | - Jeannot Potvin
- Centre Hospitalier Universitaire de Montréal (CHUM), Montréal, Quebec, Canada
| | | | - Mounir Riahi
- Centre Hospitalier Universitaire de Montréal (CHUM), Montréal, Quebec, Canada
| | - Nicolas Noiseux
- Centre Hospitalier Universitaire de Montréal (CHUM), Montréal, Quebec, Canada
| | | | - Jessica Forcillo
- Centre Hospitalier Universitaire de Montréal (CHUM), Montréal, Quebec, Canada
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Fraccaro C, Tarantini G, Rosato S, Baglio G, Biancari F, Barbanti M, Tamburino C, Bedogni F, Ranucci M, Ussia GP, Seccareccia F, D'Errigo P. Early and mid-term outcome of patients with low-flow-low-gradient aortic stenosis treated with newer-generation transcatheter aortic valves. Front Cardiovasc Med 2022; 9:991729. [PMID: 36277797 PMCID: PMC9583539 DOI: 10.3389/fcvm.2022.991729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 09/09/2022] [Indexed: 11/13/2022] Open
Abstract
Patients with non-paradoxical low-flow-low-gradient (LFLG) aortic stenosis (AS) are at increased surgical risk, and thus, they may particularly benefit from transcatheter aortic valve replacement (TAVR). However, data on this issue are still limited and based on the results with older-generation transcatheter heart valves (THVs). The aim of this study was to investigate early and mid-term outcome of TAVR with newer-generation THVs in the setting of LFLG AS. Data for the present analysis were gathered from the OBSERVANT II dataset, a national Italian observational, prospective, multicenter cohort study that enrolled 2,989 consecutive AS patients who underwent TAVR at 30 Italian centers between December 2016 and September 2018, using newer-generation THVs. Overall, 420 patients with LVEF ≤50% and mean aortic gradient <40 mmHg were included in this analysis. The primary outcomes were 1-year all-cause mortality and a combined endpoint including all-cause mortality and hospital readmission due to congestive heart failure (CHF) at 1 year. A risk-adjusted analysis was performed to compare the outcome of LFLG AS patients treated with TAVR (n = 389) with those who underwent surgical aortic valve replacement (SAVR, n = 401) from the OBSERVANT I study. Patients with LFLG AS undergoing TAVR were old (mean age, 80.8 ± 6.7 years) and with increased operative risk (mean EuroSCORE II, 11.5 ± 10.2%). VARC-3 device success was 83.3% with 7.6% of moderate/severe paravalvular leak. Thirty-day mortality was 3.1%. One-year all-cause mortality was 17.4%, and the composite endpoint was 34.8%. Chronic obstructive pulmonary disease (HR 1.78) and EuroSCORE II (HR 1.02) were independent predictors of 1-year mortality, while diabetes (HR 1.53) and class NYHA IV (HR 2.38) were independent predictors of 1-year mortality or CHF. Compared with LFLG AS treated with SAVR, TAVR patients had a higher rate of major vascular complications and permanent pacemaker, while SAVR patients underwent more frequently to blood transfusion, cardiogenic shock, AKI, and MI. However, 30-day and 1-year outcomes were similar between groups. Patients with non-paradoxical LFLG AS treated by TAVR were older and with higher surgical risk compared with SAVR patients. Notwithstanding, TAVR was safe and effective with a similar outcome to SAVR at both early and mid-term.
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Affiliation(s)
- Chiara Fraccaro
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giuseppe Tarantini
- Interventional Cardiology Unit, Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padua, Padua, Italy,*Correspondence: Giuseppe Tarantini
| | - Stefano Rosato
- Centro Nazionale per la Salute Globale, National Center for Global Health, Istituto Superiore di Sanità Italiana, Roma, Italy
| | - Giovanni Baglio
- Italian National Agency for Regional Healthcare Services, Rome, Italy
| | - Fausto Biancari
- Clinica Montevergine, GVM Care & Research, Mercogliano, Italy,Heart and Lung Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Marco Barbanti
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico—San Marco”, University of Catania, Catania, Italy
| | - Corrado Tamburino
- Division of Cardiology, A.O.U. Policlinico “G. Rodolico—San Marco”, University of Catania, Catania, Italy
| | - Francesco Bedogni
- Interventional Cardiology Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Marco Ranucci
- Department of Cardiothoracic and Vascular Anesthesia and ICU, IRCCS Policlinico San Donato, Milan, Italy
| | - Gian Paolo Ussia
- Department of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome, Italy
| | - Fulvia Seccareccia
- Centro Nazionale per la Salute Globale, National Center for Global Health, Istituto Superiore di Sanità Italiana, Roma, Italy
| | - Paola D'Errigo
- Centro Nazionale per la Salute Globale, National Center for Global Health, Istituto Superiore di Sanità Italiana, Roma, Italy
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Sujith NS, Doddamane AN, Hiremath CS, Rao S. Aortic root enlargement: Short-term outcomes from a decade's worth of experience. J Card Surg 2022; 37:3016-3025. [PMID: 35842817 DOI: 10.1111/jocs.16719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 05/15/2022] [Accepted: 05/16/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Patient prosthesis mismatch is a real problem observed in patients receiving aortic valves too small for their body surface area. This situation is entirely preventable with the apt use of root augmentation procedures. This study aims to evaluate and analyze short-term outcomes in patients who have undergone root enlargement procedures. METHODS Fifty-five patients with ages ranging from 11 to 65 years (36.74 ± 13.27), who have undergone root enlargement procedures between January 2009 and January 2019 are recruited for this study. The group comprises 23 males (41.8%) and 32 females (58.2%). Admission and follow-up parameters recorded over a period of 1 year were used for analyzing outcomes. The mean iAVA (aortic valve area indexed to body surface area) of the group was 0.49 ± 0.06 cm2 /m2 . RESULTS There was a significant increase in the indexed aortic valve area after root enlargement surgery from 0.49 ± 0.06 to 1.09 ± 0.19 cm2 /m2 . The difference was statistically significant (p < .05). St Jude Masters bileaflet prosthesis resulted in the highest iEOA (1.29 ± 0.18 cm2 /m2 ). TTK Chitra monoleaflet valve was the most commonly used valve in 61.81% of the cohort. At 1 year follow-up, there was a progressive decrease in left ventricle (LV) mass Index and mean gradients resulting in progressive improvement in the New York Heart Association functional class among patients. CONCLUSION In experienced hands, root enlargement procedures result in good curative outcomes for patients through effective LV regression and symptom resolution on a short-term basis.
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Affiliation(s)
- Neralakere S Sujith
- Division of Cardiothoracic & Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, India
| | - Aditya N Doddamane
- Division of Cardiothoracic & Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, India
| | - Channabasavaraj S Hiremath
- Division of Cardiothoracic & Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, India
| | - Shekhar Rao
- Division of Cardiothoracic & Vascular Surgery, Sri Sathya Sai Institute of Higher Medical Sciences, Bengaluru, India
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Clarizia NA, Bapat VN, Ruel M. Current surgical bioprostheses: Looking to the future. Prog Cardiovasc Dis 2022; 72:21-25. [PMID: 35718116 DOI: 10.1016/j.pcad.2022.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 06/12/2022] [Indexed: 11/15/2022]
Abstract
The utilization of bioprostheses for surgical heart valve replacement has been increasing across all age groups. For patients, the appeal of the bioprosthetic valve rests with the avoidance of anticoagulation, fewer thrombotic and hemorrhagic events, and the increasing availability of transcatheter valve-in-valve interventions -both in the aortic and mitral positions- allowing for lower morbidity reinterventions. While improvements in valve hemodynamics and long-term durability have made bioprostheses a reasonable choice for a growing number of patients, challenges do remain. With increasing usage of bioprostheses, especially in younger patients, there will be an increase in the projected number of failing bioprosthetic valves. This trend will bring even more emphasis to maximizing long-term durability, optimizing anticoagulation, and promoting patient-level decision making around prosthesis choice.
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Affiliation(s)
| | | | - Marc Ruel
- University of Ottawa Heart Institute, Ottawa, ON, Canada.
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Patient–Prosthesis Mismatch in Contemporary Small-Size Mechanical Prostheses Does Not Impact Survival at 10 Years. J Cardiovasc Dev Dis 2022; 9:jcdd9020048. [PMID: 35200701 PMCID: PMC8877093 DOI: 10.3390/jcdd9020048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/19/2022] [Accepted: 01/28/2022] [Indexed: 11/16/2022] Open
Abstract
Background: The effect of PPM in mechanical prostheses on long-term survival is not well-established. Methods: Patients who received a 21 mm or smaller aortic valve between 2000 and 2011 were retrospectively analyzed (n = 416). Propensity matching was used in order to account for baseline differences in patient subgroups (PPM vs. no PPM; severe PPM vs. no severe PPM). Results: Five- and ten-year survival was 78 ± 3.52% and 64.51 ± 4.51% in patients with PPM, versus 83.3 ± 3.12% and 69.37 ± 4.36% in patients without (p = 0.28) when analyzed at 10.39 ± 5.25 years after the primary procedure. Independent risk factors for impaired survival, after matching, were age, serum creatinine, and severe pulmonary hypertension. Five- and ten-year survival in patients with severe PPM was 73.34 ± 6.01% and 61.76 ± 8.17%, respectively, versus 74.72 ± 5.68% and 67.50 ± 7.09% in those without (p = 0.49), at 8.82 ± 5.17 years after SAVR. Age was the only independent variable that influenced long-term survival when severe PPM was added to the model. Conclusions: PPM or severe PPM does not impact long-term survival up to 10 years in mechanical valve recipients when matching for preoperative variables.
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Vallabhaneni S, Matka M, Modi V, Carey M, Sarnoski C, Durkin R, Olenchock S, Razzaghi M, Shirani J. Prevalence and Significance of Patient Prosthesis Mismatch Following Edwards SAPIEN XT and SAPIEN 3 Transcatheter Aortic Valve Replacement. Cureus 2021; 13:e18044. [PMID: 34692277 PMCID: PMC8523339 DOI: 10.7759/cureus.18044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2021] [Indexed: 11/24/2022] Open
Abstract
Background Severe patient prosthesis mismatch (sPPM) after surgical aortic valve replacement is associated with worse outcomes. Limited data exists on the impact of sPPM on outcomes after transcatheter aortic valve replacement (TAVR), especially regarding the newer generation valves. The aim of this study was to evaluate the incidence, determinants, and outcomes of sPPM in patients undergoing TAVR with Edwards SAPIEN XT (ES XT) and Edwards SAPIEN 3 (ES3) valves (Edwards Lifesciences, Irvine, CA, USA). Methods We retrospectively reviewed 366 patients who underwent TAVR with ES XT (n = 114) or ES3 (n = 252) valves between July 2012 and June 2018. sPPM was defined as indexed effective orifice area (iEOA) <0.65 cm2/m2. Kaplan-Meier survival estimates were used to determine outcomes. Results Multivariate linear regression analysis was utilized to determine potential independent effects of PPM on outcomes. sPPM was present in 40 (11%) of the patients [8 (7%) ES XT and 32 (13%) ES3] and was associated with female sex, smaller left ventricular outflow tract (LVOT) diameter and aortic valve annular area, absence of prior coronary artery bypass graft (CABG) surgery, shorter height, higher body mass index, and smaller pre-TAVR valve area (all p < 0.05). Among those with ES3 valves, the incidence of sPPM was inversely proportional to the valve size (50%, 25%, 5% and 3% for 20-, 23-, 26- and 29-mm valve sizes, respectively; p < 0.001). At a mean follow-up period of 3.5 ± 1.5 years, there was no difference in all-cause mortality (22.5% vs. 25.6%, p = 0.89) or a composite endpoint of heart failure, arrhythmias, stroke, and myocardial infarction (30% vs. 34%, p = 0.24) in those with or without sPPM. Conclusion ES3 was associated with a higher incidence of sPPM, particularly with smaller valve sizes. However, the presence of sPPM as defined by iEOA was not an independent predictor of adverse outcomes in patients undergoing TAVR within an intermediate follow-up period.
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Affiliation(s)
| | - Marsel Matka
- Cardiology, St. Luke's University Health Network, Bethlehem, USA
| | - Vivek Modi
- Cardiology, St. Luke's University Health Network, Bethlehem, USA
| | - Matthew Carey
- Internal Medicine, St. Luke's University Health Network, Bethlehem, USA
| | | | - Raymond Durkin
- Interventional Cardiology, St. Luke's University Health Network, Bethlehem, USA
| | - Stephen Olenchock
- Cardiac Surgery, St. Luke's University Health Network, Bethlehem, USA
| | - Mehdi Razzaghi
- Statistics, Bloomsburg University of Pennsylvania, Bloomsburg, USA
| | - Jamshid Shirani
- Cardiology, St. Luke's University Health Network, Bethlehem, USA
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10
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Arribas-Leal JM, Rivera-Caravaca JM, Aranda-Domene R, Moreno-Moreno JA, Espinosa-Garcia D, Jimenez-Aceituna A, Perez-Andreu J, Taboada-Martin R, Saura-Espin DR, Canovas-Lopez SJ. Mid-term outcomes of rapid deployment aortic prostheses in patients with small aortic annulus. Interact Cardiovasc Thorac Surg 2021; 33:695-701. [PMID: 34179967 DOI: 10.1093/icvts/ivab175] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/21/2021] [Accepted: 05/12/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES The Edwards Intuity valve is a rapid deployment aortic prosthesis that favours less invasive approaches. However, evidence about the clinical behaviour of their smaller sizes is scarce. Herein, we studied haemodynamic behaviours and clinical outcomes of small Intuity prostheses (19-21 mm) in comparison to larger Intuity prostheses (>21 mm). METHODS This is an observational study including patients implanted with an Edwards Intuity rapid deployment aortic prosthesis. Patients with prosthesis sizes 19-21 and >21 mm were included. Baseline and perioperative variables, as well as adverse events during the follow-up were recorded and compared between groups. RESULTS A total of 122 patients (37% female, mean age 75 ± 4.5 years) were included, of whom 54 (45%) were implanted with a small prosthesis and 68 (55%) with a prosthesis >21 mm. There were no significant differences between patients with small Intuity prostheses and patients with larger prostheses regarding in-hospital mortality (2% vs 4%, P = 0.43) or mortality during the follow-up (3.41 vs 2.45 per 100 patients-years; P = 0.58). Survival in the small Intuity valve group was 95% at 1 year and 83% at 6 years, whereas in the larger Intuity valve group was 96% at 1 year and 78% at 6 years. The presence of a small prosthesis did not influence mid-term survival (log-rank P-value = 0.62). CONCLUSIONS This study showed good clinical performance of Intuity aortic prostheses with appropriate mid-term survival in patients with the small aortic annulus. Thus, the Edwards Intuity rapid deployment aortic prosthesis may be considered as a potential option in patients with the small aortic annulus.
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Affiliation(s)
- José M Arribas-Leal
- Cardiovascular Surgery Service, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - José Miguel Rivera-Caravaca
- Department of Cardiology, Virgen de la Arrixaca University Hospital, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Ramón Aranda-Domene
- Cardiovascular Surgery Service, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - José A Moreno-Moreno
- Cardiovascular Surgery Service, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Dolores Espinosa-Garcia
- Department of Cardiology, Virgen de la Arrixaca University Hospital, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Antonio Jimenez-Aceituna
- Cardiovascular Surgery Service, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Joaquín Perez-Andreu
- Cardiovascular Surgery Service, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Rubén Taboada-Martin
- Cardiovascular Surgery Service, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
| | - Daniel R Saura-Espin
- Department of Cardiology, Virgen de la Arrixaca University Hospital, University of Murcia, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), CIBERCV, Murcia, Spain
| | - Sergio J Canovas-Lopez
- Cardiovascular Surgery Service, Virgen de la Arrixaca University Hospital, Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Murcia, Spain
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11
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Jean G, Van Mieghem NM, Gegenava T, van Gils L, Bernard J, Geleijnse ML, Vollema EM, El Azzouzi I, Spitzer E, Delgado V, Bax JJ, Pibarot P, Clavel MA. Moderate Aortic Stenosis in Patients With Heart Failure and Reduced Ejection Fraction. J Am Coll Cardiol 2021; 77:2796-2803. [PMID: 34082909 DOI: 10.1016/j.jacc.2021.04.014] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 04/02/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND The study investigators previously reported that moderate aortic stenosis (AS) is associated with a poor prognosis in patients with heart failure (HF) with reduced left ventricular ejection fraction (LVEF) (HFrEF). However, the respective contribution of moderate AS versus HFrEF to the outcomes of these patients is unknown. OBJECTIVES This study sought to determine the impact of moderate AS on outcomes in patients with HFrEF. METHODS The study included 262 patients with moderate AS (aortic valve area >1.0 and <1.5 cm2; and peak aortic jet velocity >2 and <4 m/s, at rest or after dobutamine stress echocardiography) and HFrEF (LVEF <50%). These patients were matched 1:1 for sex, age, estimated glomerular filtration rate, New York Heart Association functional class III to IV, presence of diabetes, LVEF, and body mass index with patients with HFrEF but no AS (i.e., peak aortic jet velocity <2 m/s). The endpoints were all-cause mortality and the composite of death and HF hospitalization. RESULTS A total of 262 patients with HFrEF and moderate AS were matched with 262 patients with HFrEF and no AS. Mean follow-up was 2.9 ± 2.2 years. In the moderate AS group, mean aortic valve area was 1.2 ± 0.2 cm2, and mean gradient was 14.5 ± 4.7 mm Hg. Moderate AS was associated with an increased risk of mortality (hazard ratio [HR]: 2.98; 95% confidence interval [CI]: 2.08 to 4.31; p < 0.0001) and of the composite of HF hospitalization and mortality (HR: 2.34; 95% CI: 1. 72 to 3.21; p < 0.0001). In the moderate AS group, aortic valve replacement (AVR) performed in 44 patients at a median follow-up time of 10.9 ± 16 months during follow-up was associated with improved survival (HR: 0.59; 95% CI: 0.35 to 0.98; p = 0.04). Notably, surgical AVR was not significantly associated with improved survival (p = 0.92), whereas transcatheter AVR was (HR: 0.43; 95% CI: 0.18 to 1.00; p = 0.05). CONCLUSIONS In this series of patients with HFrEF, moderate AS was associated with a marked incremental risk of mortality. AVR, and especially transcatheter AVR during follow-up, was associated with improved survival in patients with HFrEF and moderate AS. These findings provide support to the realization of a randomized trial to assess the effect of early transcatheter AVR in patients with HFrEF and moderate AS.
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Affiliation(s)
- Guillaume Jean
- Institut universitaire de cardiologie et de pneumologie, Université Laval, Québec, Québec, Canada
| | - Nicolas M Van Mieghem
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Tea Gegenava
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Lennart van Gils
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Jeremy Bernard
- Institut universitaire de cardiologie et de pneumologie, Université Laval, Québec, Québec, Canada
| | - Marcel L Geleijnse
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - E Mara Vollema
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Ikram El Azzouzi
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Ernest Spitzer
- Department of Cardiology, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Philippe Pibarot
- Institut universitaire de cardiologie et de pneumologie, Université Laval, Québec, Québec, Canada
| | - Marie-Annick Clavel
- Institut universitaire de cardiologie et de pneumologie, Université Laval, Québec, Québec, Canada.
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12
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A Retrospective Comparison of Hemodynamic and Clinical Outcomes between Two Differently Designed Aortic Bioprostheses for Small Aortic Annuli. J Clin Med 2021; 10:jcm10051063. [PMID: 33806531 PMCID: PMC7961368 DOI: 10.3390/jcm10051063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 02/20/2021] [Accepted: 02/27/2021] [Indexed: 11/17/2022] Open
Abstract
The Trifecta valve has externally mounted leaflets; it differs from classic internally mounted valves (e.g., Carpentier-Edwards [C-E]). We evaluated post-implantation hemodynamics and clinical outcomes of these bioprostheses in small aortic annuli. From January 2015 to April 2019, 490 patients who underwent aortic valve replacement (AVR) were reviewed retrospectively. Altogether, 183 patients received 19 or 21 mm diameter C-E (n = 121) or Trifecta (n = 62) prostheses. To minimize confounding variables, we performed propensity-score matching analysis. The mean transvalvular pressure gradient (TVPG) was significantly lower in the Trifecta than in the C-E group at discharge (12.9 ± 4.8 vs. 15.0 ± 5.3 mmHg, p = 0.044). TVPG change over time was not significantly different between groups (p = 0.357). Left ventricular mass index decreased postoperatively (reduction: C-E, 28.1%; Trifecta, 30.1%, p = 0.879). No late mortality, severe patient–prosthesis mismatch, moderate-to-severe paravalvular leakage, structural valve degeneration, or valve thromboses were observed. Freedom from valve-related events at 3 years were similar for C-E (97.9% ± 2.1%) and Trifecta (97.7% ± 2.2%) patients (log-rank p = 0.993). Bioprosthesis design for small annuli significantly affected TVPG immediately after AVR. However, hemodynamics over time and clinical outcomes did not differ between the two designs.
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13
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Early Hemodynamics after Aortic Valve Replacement. ACTA ACUST UNITED AC 2020; 56:medicina56120674. [PMID: 33297308 PMCID: PMC7762237 DOI: 10.3390/medicina56120674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 11/16/2022]
Abstract
Background and objectives: The aims of this study were to investigate changes in the hemodynamics associated with different types of aortic prostheses and to evaluate patient-prosthesis mismatch (PPM) at rest and after exercise. Materials and Methods: We retrospectively analyzed 150 patients who presented with indications for aortic valve replacement (AVR) with/without concomitant surgery from March 2019 to January 2020. The study population included 90 (60%) men and 60 (40%) women (mean age, 67.33 ± 10.22 years; range, 37-88 years). Echocardiography data such as peak and mean transprosthetic pressure gradients (Gmax, Gmean), velocity (V), effective orifice area (EOA), and indexed EOA (iEOA) were derived at rest and after exercise at baseline and before discharge. The study patients performed the six-minute walk test (6MWT) on the 5th-7th postoperative day. Results: Stented tissue valves showed excellent performance at rest and after exercise in comparison with mechanical valves, which showed favorable hemodynamics at rest only. At the time of discharge, moderate PPM was observed in 7/74 patients (9.5%) at rest and 5/98 (3.3%) patients after exercise. None of the patients showed severe PPM. EOA and iEOA were not significantly different between the groups. However, the stented group showed more pronounced changes in EOA and iEOA after exercise, whereas the changes in the mechanical valve group did not reach significance. Conclusions: In the early postoperative period, mechanical valves and stented valves showed favorable resting hemodynamics. The PPM rate measured after exercise was lower than that at rest.
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14
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Catalano MA, Rutkin B, Koss E, Maurer G, Berg J, Hartman A, Yu PJ. Accuracy of predicted effective orifice area in determining incidence of patient-prosthesis mismatch after transcatheter aortic valve replacement. J Card Surg 2020; 36:191-196. [PMID: 33169868 DOI: 10.1111/jocs.15148] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 09/27/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Patient-prosthesis mismatch (PPM) is associated with poor outcomes after aortic valve replacement. The aim of this study was to assess the accuracy of indexed effective orifice area (EOAi) charts in predicting PPM after transcatheter aortic valve replacement (TAVR). METHODS A retrospective review of 346 TAVR patients from January 2017 to November 2018 was performed. EOAi was predicted for patients based on published predictive tables using valve type, annulus diameter, and body surface area. Actual EOAi was calculated based on intraoperative transesophageal echocardiogram (TEE) measurements. PPM was defined by EOAi ≤ 0.85 cm2 /m2 . The accuracy of predicted PPM was assessed. Differences in clinical outcomes, including mean gradient, length of stay, mortality, complications, and change in Kansas City cardiomyopathy questionnaire score as an indicator of quality of life, were evaluated based on actual PPM. RESULTS Of the 346 patients analyzed, 44 (12.7%) of patients had PPM on intraoperative TEE. Of the 182 patients who received Sapien 3 valves, 42 (23.1%) were predicted to have PPM while 25 (13.7%) had actual PPM. Of the 164 patients who received Evolut valves, 3 (1.8%) were predicted to have PPM while 19 (11.6%) had actual PPM. EOAi charts had poor sensitivity (40.0% for Sapien 3; 5.25% for Evolut) and positive predictive value (23.8% for Sapien 3; 33.3% for Evolut) for both valve types. CONCLUSION Preoperative prediction of PPM in TAVR patients using tables of expected EOA demonstrates significant variation from actual PPM. The utility of EOAi charts to predict PPM in patients undergoing TAVR may be limited.
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Affiliation(s)
- Michael A Catalano
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Bruce Rutkin
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Elana Koss
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Greg Maurer
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Jacinda Berg
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Alan Hartman
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, New York, USA
| | - Pey-Jen Yu
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, New York, USA
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15
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Nakagawa T, Miyagawa S, Shibuya T, Sakai Y, Harada A, Watanabe K, Sawa Y. Administration of Slow-Release Synthetic Prostacyclin Agonist Promoted Angiogenesis and Skeletal Muscle Regeneration for Limb Ischemia. MOLECULAR THERAPY-METHODS & CLINICAL DEVELOPMENT 2020; 18:119-130. [PMID: 32637444 PMCID: PMC7321796 DOI: 10.1016/j.omtm.2020.05.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 05/19/2020] [Indexed: 11/26/2022]
Abstract
Gene or cell therapy is currently not fully efficacious for arteriosclerosis obliterans (ASO). In this study, we determined whether YS-1402, a slow-release synthetic prostacyclin agonist, promoted neovascularization and skeletal muscle regeneration in a mouse model of critical limb ischemia (CLI). We ligated the femoral artery and its branches to obtain the CLI mouse model, administered saline (S group) or YS-1402 (YS group) to the thigh adductor 1 week after femoral artery occlusion, and evaluated tissue blood flow after surgery. After treatment, the leg muscle was obtained for histological, gene expression, and protein analyses to assess angiogenesis and skeletal muscle regeneration. Tissue blood flow improved in the YS group compared with that in the S group, and the number of CD31+/α-smooth muscle actin (αSMA)+ arterioles increased in the YS group. Prostacyclin receptor (IPR), stromal cell-derived factor-1, hepatocyte growth factor, and neural cell adhesion molecule expression levels were higher in the YS than in the S group. Skeletal muscle regeneration was detected based on PAX7- and Ki-67-positive satellite cells in the YS group. Myogenin and MyoD expression was higher in the YS than in the S group. Therefore, YS-1402 promoted functional angiogenesis and skeletal muscle regeneration in the CLI mouse model, suggesting a new therapy for ASO.
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Affiliation(s)
- Takaya Nakagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Shigeru Miyagawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Takashi Shibuya
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Yoshiki Sakai
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Akima Harada
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Kenichi Watanabe
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka 565-0871, Japan
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16
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Liakopoulos OJ. Commentary: Prosthesis-Patient Mismatch Increases Early and Late Mortality in Low-Risk Isolated Aortic Valve Replacement: Does it Finally Matter? Semin Thorac Cardiovasc Surg 2020; 33:33-34. [PMID: 32610188 DOI: 10.1053/j.semtcvs.2020.06.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 06/18/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Oliver J Liakopoulos
- Department of Cardiac Surgery, Kerckhoff Clinic, Campus Bad Nauheim, University of Giessen, Germany.
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17
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Elmahdy W, Osman M, Farag M, Shoaib A, Saad H, Sullivan K, Krishnan U, Nashef S, Berman M. Prosthesis-Patient Mismatch Increases Early and Late Mortality in Low Risk Aortic Valve Replacement. Semin Thorac Cardiovasc Surg 2020; 33:23-30. [PMID: 32439547 DOI: 10.1053/j.semtcvs.2020.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 05/02/2020] [Indexed: 11/11/2022]
Abstract
The concept of prosthesis-patient mismatch (PPM) has gained much attention since first described 40 years ago. Previous studies have shown conflicting evidence regarding increased early and late morbidity and mortality with PPM after aortic valve replacement (AVR). The aim of this study was to evaluate the effects of PPM on short- and long-term mortality in low-risk patients after isolated AVR. A retrospective, single-center study involving 1707 consecutive patients ≤80 years of age with preserved left ventricular systolic function who underwent elective, primary isolated AVR operations from 2008 to 2018. Patients were stratified into 2 groups according to the presence of PPM (n = 96), defined as effective orifice area index <0.85 cm2/m2 body surface area, and no-PPM (n = 1611). The effect of PPM on mortality was evaluated with univariate and multivariate analyses. 30-day mortality was 0.8% (4.2% in PPM group vs 0.6 in no-PPM group; P = 0.005). PPM occurred more in female gender, obese and older patients. PPM was highly associated with long-term all-cause mortality (median 4 years [Q1-Q3 2-7]; HR: 1.79, 95% CI: 1.27-2.55, P = 0.002), and remained strongly and independently associated after adjustment for other risk factors (HR: 1.60, 95% CI: 1.10-2.34, P = 0.014). In propensity score-matched analysis, the adjusted mortality risk was higher in PPM group (HR: 2.03, 95% CI: 1.22-3.39, P = 0.006) compared to no-PPM group. In a single-centre observational study, PPM increased early mortality and was independently associated with long-term all-cause mortality after low-risk, primary isolated AVR operations. Strategies to avoid PPM should be explored and implemented.
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Affiliation(s)
- Walid Elmahdy
- Royal Papworth Hospital, Cardiac Surgery Department, Cambridge Biomedical Campus, Cambridge, UK
| | - Mohamed Osman
- Royal Papworth Hospital, Cardiac Surgery Department, Cambridge Biomedical Campus, Cambridge, UK.
| | - Mohamed Farag
- Royal Papworth Hospital, Cardiology Department, Cambridge Biomedical Campus, Cambridge, UK; School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
| | | | - Haisam Saad
- Royal Papworth Hospital, Cardiac Surgery Department, Cambridge Biomedical Campus, Cambridge, UK
| | - Keith Sullivan
- School of Life and Medical Sciences, University of Hertfordshire, Hertfordshire, UK
| | - Unni Krishnan
- Royal Papworth Hospital, Cardiology Department, Cambridge Biomedical Campus, Cambridge, UK
| | - Samer Nashef
- Royal Papworth Hospital, Cardiac Surgery Department, Cambridge Biomedical Campus, Cambridge, UK
| | - Marius Berman
- Royal Papworth Hospital, Cardiac Surgery Department, Cambridge Biomedical Campus, Cambridge, UK
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18
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Imaging for Predicting and Assessing Prosthesis-Patient Mismatch After Aortic Valve Replacement. JACC Cardiovasc Imaging 2020; 12:149-162. [PMID: 30621987 DOI: 10.1016/j.jcmg.2018.10.020] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/01/2018] [Accepted: 10/03/2018] [Indexed: 11/21/2022]
Abstract
Prosthesis-patient mismatch (PPM) occurs when the effective orifice area (EOA) of the prosthetic valve is too small in relation to a patient's body size, thus resulting in high residual postoperative pressure gradients across the prosthesis. Severe PPM occurs in 2% to 20% of patients undergoing surgical aortic valve replacement (AVR) and is associated with 1.5- to 2.0-fold increase in the risk of mortality and heart failure rehospitalization. The purpose of this article is to present an overview of the role of multimodality imaging in the assessment, prediction, prevention, and management of PPM following AVR. The risk of PPM can be anticipated at the time of AVR by calculating the predicted indexed from the normal reference value of EOA of the selected prosthesis and patient's body surface area. The strategies to prevent PPM at the time of surgical AVR include: 1) implanting a newer generation of prosthetic valve with better hemodynamic; 2) enlarging the aortic root or annulus to accommodate a larger prosthetic valve; or 3) performing TAVR rather than surgical AVR. The identification and quantitation of PPM as well as its distinction versus prosthetic valve stenosis is primarily based on transthoracic echocardiography, but important information may be obtained from other imaging modalities such as transesophageal echocardiography and multidetector computed tomography. PPM is characterized by high transprosthetic velocity and gradients, normal EOA, small indexed EOA, and normal leaflet morphology and mobility. Transesophageal echocardiography and multidetector computed tomography are particularly helpful to assess prosthetic valve leaflet morphology and mobility, which is a cornerstone of the differential diagnosis between PPM and pathologic valve obstruction. Severe symptomatic PPM following AVR with a bioprosthetic valve may be treated by redo surgery or the transcatheter valve-in-valve procedure with fracturing of the surgical valve stent.
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19
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Hachiro K, Kinoshita T, Asai T, Suzuki T. Left ventricular mass regression in patients without patient–prosthesis mismatch after aortic valve replacement for aortic stenosis. Gen Thorac Cardiovasc Surg 2019; 68:227-232. [DOI: 10.1007/s11748-019-01188-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 07/08/2019] [Indexed: 10/26/2022]
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20
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Einarsen E, Saeed S, Cramariuc D, Chambers JB, Midtbø H, Gerdts E. Impact of Obesity on Persistent Left Ventricular Hypertrophy After Aortic Valve Replacement for Aortic Stenosis. Am J Cardiol 2019; 123:942-947. [PMID: 30654925 DOI: 10.1016/j.amjcard.2018.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Revised: 12/02/2018] [Accepted: 12/07/2018] [Indexed: 10/27/2022]
Abstract
Normalization of left ventricular (LV) hypertrophy is expected after successful aortic valve replacement (AVR) in patients with aortic valve stenosis (AS), but is not always observed. We tested the impact of body mass index (BMI) ≥30 kg/m2 on persistent post-AVR LV hypertrophy. In the present subanalysis of Simvastatin Ezetimibe in Aortic Stenosis study, clinical and echocardiographic data of 399 patients with severe AS who underwent surgical AVR were analyzed. All patients had a standardized pre- and post-AVR echocardiogram. Patients were grouped by BMI categories into BMI <25 kg/m2, BMI 25 to 29.9 kg/m2, and BMI ≥30 kg/m2. LV hypertrophy was defined as LV mass/height2.7 >49.2 g/m2.7 in men and >46.7 g/m2.7 in women. Predictors of persistent LV hypertrophy after AVR were identified in logistic regression analysis. After a median follow-up of 196 days after AVR, LV hypertrophy was more prevalent in patients with BMI ≥30 kg/m2 compared with those with BMI 25 to 29.9 kg/m2 and those patients with BMI <25 kg/m2 (71% vs 47% and 37%, p <0.01). BMI ≥30 kg/m2 patients also remained with lower LV midwall shortening post-AVR compared with patients with normal weight (p <0.01), independent of patient prosthesis mismatch. In multivariable logistic regression analysis, the presence of BMI ≥30 kg/m2 before AVR was associated with an almost fourfold higher prevalence of post-AVR LV hypertrophy independent of significant associations with higher systolic blood pressure and lower LV midwall shortening preoperatively (odds ratio 3.75 [95% confidence interval 2.04 to 6.91], p <0.001). In conclusion, the presence of BMI ≥30 kg/m2 before AVR in patients with severe AS was strongly and independently associated with persistent post-AVR LV hypertrophy.
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Iqbal A, Panicker VT, Karunakaran J. Patient prosthesis mismatch and its impact on left ventricular regression following aortic valve replacement in aortic stenosis patients. Indian J Thorac Cardiovasc Surg 2019; 35:6-14. [PMID: 33060963 DOI: 10.1007/s12055-018-0706-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Revised: 06/14/2018] [Accepted: 07/13/2018] [Indexed: 01/20/2023] Open
Abstract
Introduction Patient prosthesis mismatch is known to alter post-operative remodeling of left ventricle adversely in aortic stenosis patients. An indexed orifice area of 0.85 is considered as conventional cutoff for patient prosthesis mismatch based on hemodynamic principles. Many patients have smaller annulus and annulus enlargement techniques may be required to avoid this benchmark which complicates the surgery. Aims and objectives To determine incidence of patient prosthesis mismatch (PPM) in our population, to assess left ventricle (LV) regression and impact of indexed effective orifice area on LV regression, and to determine a minimum acceptable cut off indexed orifice area that will result in LV regression. Materials and methods A single-center retrospective observational study of all patients who underwent aortic valve replacement surgery for severe aortic stenosis between July 2015 and December 2015 was conducted. Patients who underwent concomitant revascularization or other valve surgery were excluded. Data regarding conventional risk factors for PPM, valve type, and indexed orifice area as well as pre-operative and late post-operative LV mass were collected. Observations Thirty-seven of the 91 patients satisfied inclusion criteria. All patients had significant regression in LV mass. The incidence of PPM was 68%. Regression of indexed left ventricular mass showed a positive correlation of with indexed effective orifice area of the prosthetic valve. The correlation coefficient is + 0.48 (95% CI 0.18-0.698). Left ventricular mass regression was significantly higher in patients with indexed effective orifice area more than 0.75 (68.89 ± 29 vs 122.55 ± 58.84, p = 0.028). Relative left ventricular regression also was significantly higher in patients with an indexed effective orifice area more than 0.75 (39.53 ± 13.13 vs 49.73 ± 15.56, p = 0.022). There is a positive correlation between left ventricular regression and the reduction in mean gradient achieved by valve replacement. The correlation coefficient was + 0.35 (95% CI 0.03-0.61). Conclusions The incidence of PPM was found to be comparable to literature. There is a positive correlation between left ventricular regression and indexed effective orifice area of the prosthetic valve. Left ventricular regression was significantly higher in patients with an indexed effective area more than 0.75. This can be considered as criteria for significant PPM in study population.
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Affiliation(s)
- Abid Iqbal
- Department of Cardio Vascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011 India
| | - Varghese Thomas Panicker
- Department of Cardio Vascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011 India
| | - Jayakumar Karunakaran
- Department of Cardio Vascular and Thoracic Surgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala 695011 India
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Del Bene MR, Barletta G, Venditti F, Di Mario C, Blanzola C, Stefàno P. Left ventricular mass regression after aortic valve replacement: Sex differences or effect of different methods of indexation? Echocardiography 2018; 36:219-228. [DOI: 10.1111/echo.14221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 11/07/2018] [Accepted: 11/08/2018] [Indexed: 11/30/2022] Open
Affiliation(s)
| | | | | | - Carlo Di Mario
- Structural Interventional CardiologyCareggi University Hospital Florence Italy
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Fallon JM, DeSimone JP, Brennan JM, O’Brien S, Thibault DP, DiScipio AW, Pibarot P, Jacobs JP, Malenka DJ. The Incidence and Consequence of Prosthesis-Patient Mismatch After Surgical Aortic Valve Replacement. Ann Thorac Surg 2018; 106:14-22. [DOI: 10.1016/j.athoracsur.2018.01.090] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 11/25/2017] [Accepted: 01/18/2018] [Indexed: 10/17/2022]
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Rapid Deployment Aortic Valves Deliver Superior Hemodynamic Performance In Vitro. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 12:338-345. [PMID: 29023351 PMCID: PMC5657464 DOI: 10.1097/imi.0000000000000407] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Clinical studies have demonstrated excellent hemodynamic performance of rapid deployment aortic valves; however, few studies have directly compared the performance of these valves with conventional bioprosthetic valves. Thus, the hemodynamic function of the EDWARDS INTUITY valve (rapid deployment valve) was compared with the Edwards Magna Ease valve in vitro (Edwards Lifesciences Corp, Irvine, CA USA). METHODS Elastomeric material was used to create an aortic root model that included a left ventricular outflow tract and aortic annulus. The model was based on reconstructions from 3-dimensional multislice computed tomography images in patients with aortic stenosis; the aortic root was scaled to a 21-mm effective annulus diameter. EDWARDS INTUITY valves (21-mm diameter) were deployed by stent frame expansion within the aortic root; Edwards Magna Ease valves (21-mm diameter) were sutured to the annulus. The left ventricular outflow tract area index (left ventricular outflow tract area/baseline area) and ellipticity or noncircularity as indexed by Dmax/Dmin were measured under a video microscope after valve placement. Hemodynamic data were collected under pulsatile flow with saline (70 beats per minute, 5 L/min, 100 mm Hg aortic pressure). RESULTS Compared with the Edwards Magna Ease valve (n = 4), the EDWARDS INTUITY valve (n = 4) had a greater effective orifice area (1.56 ± 0.01 vs 1.85 ± 0.06 cm, P < 0.001) and a lower transvalvular pressure gradient (23.4 ± 0.51 vs 16.8 ± 1.3 mm Hg, P < 0.001). Multiple regression analysis showed that 93% of the variation in the effective orifice area and transvalvular pressure gradient was due to variation in the left ventricular outflow tract area index and ellipticity index. CONCLUSIONS A clinically relevant aortic root model was developed to evaluate aortic valve performance. The superior performance of the EDWARDS INTUITY valve seemed to be related to both a greater inflow area and a more circular left ventricular outflow tract.
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Clarizia NA, Ruel M. Invited Commentary. Ann Thorac Surg 2018; 106:22-23. [PMID: 29656056 DOI: 10.1016/j.athoracsur.2018.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 03/07/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Nadia A Clarizia
- University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, Ontario K1Y 4W7, Canada
| | - Marc Ruel
- University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, Ontario K1Y 4W7, Canada.
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Patel PA. Prosthesis-Patient Mismatch: An Ongoing Late Risk After TAVR? J Cardiothorac Vasc Anesth 2018; 33:249-250. [PMID: 29735220 DOI: 10.1053/j.jvca.2018.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Prakash A Patel
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA
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Impact of Annular Size on Outcomes After Surgical or Transcatheter Aortic Valve Replacement. Ann Thorac Surg 2018; 105:1129-1136. [DOI: 10.1016/j.athoracsur.2017.08.059] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 08/11/2017] [Accepted: 08/15/2017] [Indexed: 11/20/2022]
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Stock S, Sievers HH, Richardt D, Scharfschwerdt M. Mitral valve replacement with the novel TRIBIO and an established stented bioprosthesis in a sheep model. Interact Cardiovasc Thorac Surg 2018; 26:438-442. [PMID: 29149268 DOI: 10.1093/icvts/ivx361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 10/06/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Heart valve replacement with a bioprosthesis is one of the most frequently performed procedures in cardiac surgery and represents a highly effective therapy to relieve diseased heart valves. Nevertheless, as postoperatively elevated transvalvular gradients and prosthesis-patient mismatch are reported as shortcomings of the procedure or of the currently used devices, there is a need for novel bioprostheses with improved haemodynamics. This study presents preclinical haemodynamic results after mitral valve replacement with the novel TRIBIO bioprosthesis (TRIBIO) compared with an established bioprosthesis in a sheep model. METHODS Six female sheep had their mitral valves replaced with the TRIBIO and 3 with the Carpentier-Edwards Perimount, both sized 19 mm. The TRIBIO consists of a flexible valve-bearing crown, a force-decoupled interface and an intra-annular base ring. Mean and peak transvalvular gradients as well as an effective orifice area were monitored in both groups using transthoracic echocardiography over the course of the 90-day study. RESULTS In both groups, haemodynamic performance diminished over time. The TRIBIO demonstrated overall superior haemodynamics, i.e. lower transvalvular gradients and a larger effective orifice area, although the results were not statistically significant. On Day 90, the mean values for the mean and peak transvalvular gradients and the effective orifice area were 6 mmHg, 10.2 mmHg and 1.2 cm2 for the TRIBIO and 10 mmHg, 15.8 mmHg and 0.8 cm2 for the Carpentier-Edwards Perimount, respectively. CONCLUSIONS This study demonstrates a trend towards improved preclinical haemodynamic performance following mitral valve replacement with the TRIBIO compared to that with an established bioprosthesis in a sheep model.
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Affiliation(s)
- Sina Stock
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Hans-Hinrich Sievers
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Doreen Richardt
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Michael Scharfschwerdt
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
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Stock S, Lohmann I, Hanke T, Stierle U, Richardt D, Tsvelodub S, Sievers HH. Rest and exercise haemodynamics in patients with one of two stented bioprostheses and in healthy controls with small aortic annuli. Interact Cardiovasc Thorac Surg 2018; 26:425-430. [PMID: 29095979 DOI: 10.1093/icvts/ivx356] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 10/03/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES Because bioprosthetic aortic valve replacement remains one of the most frequent cardiac surgical procedures, it is necessary to study patient haemodynamics in more detail. Until now, a few studies assessed haemodynamics during exercise, but none with special regard to small aortic annuli. We compared patients who had the differently designed bioprostheses, Trifecta and Perimount Magna Ease (PME), size ≤ 23 mm, and a healthy control group during rest and exercise. METHODS We determined the mean transvalvular gradient, the effective orifice area (EOA) and the EOA index during rest and exercise using transthoracic echocardiography in 35 patients with the Trifecta (mean age 71.4 years, follow-up 1 year, labelled valve size 21.7 mm), in 16 patients with the PME (mean age 66.2 years, follow-up 2.6 years, labelled valve size 21.6 mm) and in 25 healthy persons. The parameters derived were summarized in a simplified Valve Academic Research Consortium-2 classification to determine prosthetic valve dysfunction. RESULTS When we compared the Trifecta and the PME, a significant superiority of the Trifecta was seen at rest in mean transvalvular gradient (7.96 vs 12.19 mmHg) and EOA (1.57 vs 1.48 cm2), during exercise in all parameters (mean transvalvular gradient 11.06 vs 19.2 mmHg, EOA 1.77 vs 1.26 cm2, EOA index 0.96 vs 0.67 cm2/m2). The Trifecta showed a physiological increase in the EOA index during exercise. Exercise led to a shift to better simplified Valve Academic Research Consortium-2 categories in the Trifecta and to worse in the PME group. CONCLUSIONS This study reveals the haemodynamic superiority of the Trifecta to the PME. Especially in small aortic annuli, this difference might have some relevance for clinical and research issues.
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Affiliation(s)
- Sina Stock
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Inga Lohmann
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Thorsten Hanke
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Ulrich Stierle
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Doreen Richardt
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Stanislav Tsvelodub
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Hans-Hinrich Sievers
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
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Lahori A, Frogel J, Augoustides JG, Patel PA, Vernick WJ, Gutsche JT, Feinman JW, Patel S, Munroe R, MacKay EJ, Weiss SJ, Dwarakanath S, Sheu RD. Aortic Valve Prosthesis-Patient Mismatch in a Patient Undergoing Redo Mitral Valve Replacement for Infective Endocarditis. J Cardiothorac Vasc Anesth 2018; 32:2802-2809. [PMID: 29555388 DOI: 10.1053/j.jvca.2018.02.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Anna Lahori
- Cardiovascular and Thoracic Section, Department of Anesthesiology, Sheba Medical Center, Tel HaShomer, Israel
| | - Jonathan Frogel
- Cardiovascular and Thoracic Section, Department of Anesthesiology, Sheba Medical Center, Tel HaShomer, Israel
| | - John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - William J Vernick
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jared W Feinman
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Saumil Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ray Munroe
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Emily J MacKay
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart J Weiss
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sanjay Dwarakanath
- Department of Anesthesiology, School of Medicine, University of Kentucky, Lexington, KY
| | - Richard D Sheu
- Department of Anesthesiology & Pain Medicine, University of Washington Medical Center, Seattle, WA
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Subramaniam K, Nazarnia S. Prosthesis-patient mismatch - what cardiac anesthesiologists need to know? Ann Card Anaesth 2017; 20:234-242. [PMID: 28393786 PMCID: PMC5408531 DOI: 10.4103/aca.aca_9_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Prosthesis-patient Mismatch (PPM) is not uncommon with an incidence reported up to 70% after aortic valve (AV) replacement. Severe forms of PPM are less common (up to 20%); PPM can lead to increased short- and long-term morbidity and mortality. It is important to discriminate PPM from other forms of prosthetic valve dysfunction. Sometimes, prosthetic valve degenerative disease may coexist with PPM. Echocardiography plays an important role in the prevention and diagnosis of PPM. Preemptive strategies to prevent PPM include insertion of newer generation prosthetic valves with better hemodynamic characteristics, stentless prosthesis, aortic root enlargement to insert a larger prosthesis, aortic homograft, and transcutaneous AV implantation. We present an illustrative case and review the literature on PPM pertinent to anesthesiologists.
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Stock S, Sievers HH, Richardt D, Scharfschwerdt M. First ex vivo and preliminary sheep model results of the new TRIBIO aortic valve bioprosthesis in small aortic annuli. Interact Cardiovasc Thorac Surg 2017. [PMID: 28637199 DOI: 10.1093/icvts/ivx196] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Small aortic annuli are challenging in aortic valve replacement. Prosthesis-patient mismatch, accompanied by high transvalvular gradients and small orifice area, is an often faced problem impairing postoperative outcome. The new TRIBIO bioprosthesis aims to enable enhanced haemodynamics, being increasingly important with decreasing annular size. This study compares ex vivo hydrodynamics of TRIBIO with 2 established bioprostheses in small annuli at different stroke volumes, simulating 'rest' and 'exercise', and evaluates haemodynamics of TRIBIO in a sheep model. METHODS Ex vivo: Porcine aortic roots were hardened with glutaraldehyde, approaching the stiffness of decalcified roots. Each bioprosthesis (TRIBIO, Trifecta™, Perimount® Magna Ease), size 19 mm, was implanted in each aortic root and inserted into a pulse duplicator, determining hydrodynamics and geometric orifice area at different stroke volumes (74, 90, 104 ml). Sheep model: Postoperative transvalvular gradients were assessed after implantation of 19 mm TRIBIO in aortic position. RESULTS Ex vivo: Mean transvalvular gradients were lowest in TRIBIO (7.3, 8.7, 10.2 mmHg at 74, 90, 104 ml) with significant difference to Perimount® Magna Ease. Geometric orifice area in TRIBIO was 2.7 cm2 and significantly larger compared to Perimount® Magna Ease and Trifecta™. Opening of TRIBIO was uniform and apparently complete, whereas leaflet's outward movement was restricted particularly in Perimount® Magna Ease. Sheep model: TRIBIO presented with low transvalvular gradients (δpmean 4.1 ± 2 mmHg, δpmax 7.8 ± 4.6 mmHg), unimpaired leaflet motion and no central or paravalvular leakage. CONCLUSIONS Ex vivo, the TRIBIO achieved superior hydrodynamics compared to latest generation bioprostheses. These excellent data are supported by very low transvalvular gradients in a preliminary sheep model.
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Affiliation(s)
- Sina Stock
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Hans-Hinrich Sievers
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Doreen Richardt
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
| | - Michael Scharfschwerdt
- Department of Cardiac and Thoracic Vascular Surgery, University of Luebeck, Luebeck, Germany
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Ai L, Chen H, Lin V, Bapat VN. Rapid Deployment Aortic Valves Deliver Superior Hemodynamic Performance in Vitro. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017. [DOI: 10.1177/155698451701200505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Lisong Ai
- Edwards Lifesciences Corp, Irvine, CA USA
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Gonzalez-Lopez D, Faerber G, Diab M, Amorim P, Zeynalov N, Doenst T. Replica sizing strategy for aortic valve replacement improves haemodynamic outcome of the epic supra valve. Interact Cardiovasc Thorac Surg 2017; 25:509-512. [DOI: 10.1093/icvts/ivx234] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 05/29/2017] [Indexed: 11/14/2022] Open
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Kadkhodayan A, Lin G, Popma JJ, Reardon MJ, Little SH, Adams DH, Marcus R, Henry S, Baker MT, Kleiman NS, Deeb GM, Huang J, Oh JK. A Paradox between LV Mass Regression and Hemodynamic Improvement after Surgical and Transcatheter Aortic Valve Replacement. STRUCTURAL HEART-THE JOURNAL OF THE HEART TEAM 2017. [DOI: 10.1080/24748706.2017.1322734] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
| | - Grace Lin
- Mayo Clinic, Rochester, Minnesota, MN, USA
| | | | | | - Stephen H. Little
- Houston-Methodist-DeBakey Heart and Vascular Center, Houston, TX, USA
| | | | | | - Sonia Henry
- North Shore University Hospital, Manhasset, NY, USA
| | | | - Neal S. Kleiman
- Houston-Methodist-DeBakey Heart and Vascular Center, Houston, TX, USA
| | | | | | - Jae K. Oh
- Mayo Clinic, Rochester, Minnesota, MN, USA
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Salna M, Khalique OK, Chiuzan C, Kurlansky P, Borger MA, Hahn RT, Leon MB, Smith CR, Kodali SK, George I. Impact of small prosthesis size on transcatheter or surgical aortic valve replacement outcomes. Catheter Cardiovasc Interv 2017; 91:765-773. [DOI: 10.1002/ccd.27120] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/13/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Michael Salna
- Division of Cardiothoracic Surgery; New York Presbyterian Hospital - College of Physicians and Surgeons of Columbia University; New York
| | - Omar K. Khalique
- Division of Cardiology; New York Presbyterian Hospital - College of Physicians and Surgeons of Columbia University; New York
| | - Codruta Chiuzan
- Department of Biostatistics; Mailman School of Public Health, Columbia University; New York
| | - Paul Kurlansky
- Division of Cardiothoracic Surgery; New York Presbyterian Hospital - College of Physicians and Surgeons of Columbia University; New York
| | - Michael A. Borger
- Division of Cardiothoracic Surgery; New York Presbyterian Hospital - College of Physicians and Surgeons of Columbia University; New York
| | - Rebecca T. Hahn
- Division of Cardiology; New York Presbyterian Hospital - College of Physicians and Surgeons of Columbia University; New York
| | - Martin B. Leon
- Division of Cardiology; New York Presbyterian Hospital - College of Physicians and Surgeons of Columbia University; New York
| | - Craig R. Smith
- Division of Cardiothoracic Surgery; New York Presbyterian Hospital - College of Physicians and Surgeons of Columbia University; New York
| | - Susheel K. Kodali
- Division of Cardiology; New York Presbyterian Hospital - College of Physicians and Surgeons of Columbia University; New York
| | - Isaac George
- Division of Cardiothoracic Surgery; New York Presbyterian Hospital - College of Physicians and Surgeons of Columbia University; New York
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Dumani S, Likaj E, Dibra L, Beca V, Kuci S, Refatllari A. Aortic Annulus Enlargement: Early and Long-Terms Results. Open Access Maced J Med Sci 2017; 5:23-26. [PMID: 28293311 PMCID: PMC5320902 DOI: 10.3889/oamjms.2017.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 12/24/2016] [Accepted: 01/11/2017] [Indexed: 11/15/2022] Open
Abstract
AIM: Patient-prosthesis mismatch (PPM) is a common occurrence in aortic valve surgery. Even the discussions about the impact of this phenomenon on the results of aortic valve surgery, the management of this problem remain one of the main topics in this kind of surgery. One of the ways of a solution is aortic annulus enlargement. The main topic of this study is to evaluate the early and longterm results of this technique in our country. METHODS: During the period January 2010 –January 2015, 641 patients performed aortic valve surgery. In ten patients we performed aortic annulus enlargement according to Manouguian technique to avoid severe patient-prothesis mismatch. Operative mortality and perioperative complications (low cardiac output, pulmonary complications, etc..) were considered the indicators of the early results. Survival, clinical presentation according to NYHA, quality of life were the indicators to evaluate long-term results. Preoperative and postoperative echocardiographic data were also used to evaluate our results. We collected the data from hospital registrations and periodical clinical visit and echographic examination after hospital discharge. RESULTS: In our group, 6 of 10 patients were diagnosed with stenotic aortic valve, two patients had aortic valve regurgitation and two mixed valve pathology. Four patients had concomitant cardiac surgery procedure, mitral or CABG. In all cases, aortic valve pathology was the primary diagnose. In the preoperative echocardiographic examination mean transvalvular gradient was 54.3 ± 6.42. We had no death during early or late postoperative period. Only one patient had pulmonary complications and long time of respiratory assistance because of his pulmonary pathology. The same patient had low cardiac output and wound infection. Early after surgery mean transprostethic gradient was 16.2 ± 3.44 and late postoperative was 15.9 ± 4.3. No patient had the severe patient-prothesis mismatch. Mean follow-up was 49 ± 20.26 months. During follow-up, we had no death, and all patients had very good quality of life. CONCLUSIONS: Aortic valve annulus enlargement can be used with very good early and late results with the final goal to increase the potential benefit of the patient from surgery of aortic valve.
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Affiliation(s)
- Selman Dumani
- University Hospital Centre "Mother Theresa", Service of Cardiac Surgery, Tirana, Albania
| | - Ermal Likaj
- University Hospital Centre "Mother Theresa", Service of Cardiac Surgery, Tirana, Albania
| | - Laureta Dibra
- University Hospital Centre "Mother Theresa", Service of Cardiac Surgery, Tirana, Albania
| | - Vera Beca
- Obstetric Gynaecologic Hospital "Queen Geraldine", Tirana, Albania
| | - Saimir Kuci
- University Hospital Centre "Mother Theresa", Service of Cardiac Surgery, Tirana, Albania
| | - Ali Refatllari
- University Hospital Centre "Mother Theresa", Service of Cardiac Surgery, Tirana, Albania
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Mannacio V, Mannacio L, Mango E, Antignano A, Mottola M, Caparrotti S, Musumeci F, Vosa C. Severe prosthesis-patient mismatch after aortic valve replacement for aortic stenosis: Analysis of risk factors for early and long-term mortality. J Cardiol 2017; 69:333-339. [DOI: 10.1016/j.jjcc.2016.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Revised: 05/18/2016] [Accepted: 07/05/2016] [Indexed: 10/21/2022]
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Kume Y, Fujita T, Fukushima S, Hata H, Shimahara Y, Matsumoto Y, Yamashita K, Kobayashi J. Reducing Prosthesis-Patient Mismatch With Edwards Magna Prosthesis for Aortic Valve Replacement. Circ J 2017; 81:468-475. [DOI: 10.1253/circj.cj-16-0768] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Yuta Kume
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center
| | - Tomoyuki Fujita
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center
| | - Satsuki Fukushima
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center
| | - Hiroki Hata
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center
| | - Yusuke Shimahara
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center
| | - Yorihiko Matsumoto
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center
| | - Kizuku Yamashita
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center
| | - Junjiro Kobayashi
- Department of Cardiac Surgery, National Cerebral and Cardiovascular Center
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Abstract
Aortic valve replacement is no longer an operation that is approached solely through a median sternotomy. Recent advances in the fields of transcatheter valves have expanded the proportion of patients eligible for intervention. Comparisons between transcatheter valves and conventional surgery have shown non-inferiority of transcatheter valve implants in patients with a high or intermediate pre-operative predictive risk. With advances in our understanding of sutureless valves and their applicability to minimally invasive surgery, the invasiveness and trauma of surgery can be reduced with potential improvements in outcome. The strategy of care has radically changed over the last decade.
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Affiliation(s)
- Ahmed Al-Adhami
- Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, G81 4DY, UK
| | - Nawwar Al-Attar
- Department of Cardiac Surgery, Golden Jubilee National Hospital, Glasgow, G81 4DY, UK
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Sportelli E, Regesta T, Salsano A, Ghione P, Brega C, Bezante GP, Passerone G, Santini F. Does patient-prosthesis mismatch after aortic valve replacement affect survival and quality of life in elderly patients? J Cardiovasc Med (Hagerstown) 2016; 17:137-43. [PMID: 26237424 DOI: 10.2459/jcm.0000000000000292] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND To evaluate the impact of patient-prosthesis mismatch (PPM) on survival, functional status, and quality of life (QoL) after aortic valve replacement (AVR) with small prosthesis size in elderly patients. METHODS Between January 2005 and December 2013, 152 patients with pure aortic stenosis, aged at least 75 years, underwent AVR, with a 19 or 21 mm prosthetic heart valve. PPM was defined as an indexed effective orifice area less than 0.85 cm/m. Median age was 82 years (range 75-93 years). Mean follow-up was 56 months (range 1-82 months) and was 98% complete. Late survival rate, New York Heart Association functional class, and QoL (RAND SF-36) were assessed. RESULTS Overall, PPM was found in 78 patients (53.8%). Among them, 42 patients (29%) had an indexed effective orifice area less than 0.75 cm/m and 17 less than 0.65 cm/m (11.7%). Overall survival at 5 years was 78 ± 4.5% and was not influenced by PPM (P = NS). The mean New York Heart Association class for long-term survivors with PPM improved from 3.0 to 1.7 (P < 0.001). QoL (physical functioning 45.18 ± 11.35, energy/fatigue 49.36 ± 8.64, emotional well being 58.84 ± 15.44, social functioning 61.29 ± 6.15) was similar to that of no-PPM patients (P = NS). CONCLUSION PPM after AVR does not affect survival, functional status, and QoL in patients aged at least 75 years. Surgical procedures, often time-consuming, contemplated to prevent PPM, may therefore be not justified in this patient subgroup.
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Affiliation(s)
- Elena Sportelli
- aDivision of Cardiac Surgery bDivision of Cardiology, IRCCS San Martino-IST, University of Genova Medical School, Genova, Italy
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Clavel MA, Magne J, Pibarot P. Low-gradient aortic stenosis. Eur Heart J 2016; 37:2645-57. [PMID: 27190103 PMCID: PMC5030681 DOI: 10.1093/eurheartj/ehw096] [Citation(s) in RCA: 214] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 01/22/2016] [Accepted: 02/20/2016] [Indexed: 12/17/2022] Open
Abstract
An important proportion of patients with aortic stenosis (AS) have a 'low-gradient' AS, i.e. a small aortic valve area (AVA <1.0 cm(2)) consistent with severe AS but a low mean transvalvular gradient (<40 mmHg) consistent with non-severe AS. The management of this subset of patients is particularly challenging because the AVA-gradient discrepancy raises uncertainty about the actual stenosis severity and thus about the indication for aortic valve replacement (AVR) if the patient has symptoms and/or left ventricular (LV) systolic dysfunction. The most frequent cause of low-gradient (LG) AS is the presence of a low LV outflow state, which may occur with reduced left ventricular ejection fraction (LVEF), i.e. classical low-flow, low-gradient (LF-LG), or preserved LVEF, i.e. paradoxical LF-LG. Furthermore, a substantial proportion of patients with AS may have a normal-flow, low-gradient (NF-LG) AS: i.e. a small AVA-low-gradient combination but with a normal flow. One of the most important clinical challenges in these three categories of patients with LG AS (classical LF-LG, paradoxical LF-LG, and NF-LG) is to differentiate a true-severe AS that generally benefits from AVR vs. a pseudo-severe AS that should be managed conservatively. A low-dose dobutamine stress echocardiography may be used for this purpose in patients with classical LF-LG AS, whereas aortic valve calcium scoring by multi-detector computed tomography is the preferred modality in those with paradoxical LF-LG or NF-LG AS. Although patients with LF-LG severe AS have worse outcomes than those with high-gradient AS following AVR, they nonetheless display an important survival benefit with this intervention. Some studies suggest that transcatheter AVR may be superior to surgical AVR in patients with LF-LG AS.
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Affiliation(s)
- Marie-Annick Clavel
- Québec Heart and Lung Institute/Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, 2725 Chemin Sainte Foy, #A-2075, QC, Canada G1V4G5
| | - Julien Magne
- CHU Limoges, Hôpital Dupuytren, Faculté de médecine de Limoges, Limoge, France
| | - Philippe Pibarot
- Québec Heart and Lung Institute/Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, 2725 Chemin Sainte Foy, #A-2075, QC, Canada G1V4G5
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Predictors and Outcomes of Prosthesis-Patient Mismatch After Aortic Valve Replacement. JACC Cardiovasc Imaging 2016; 9:924-33. [DOI: 10.1016/j.jcmg.2015.10.026] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 10/15/2015] [Indexed: 11/22/2022]
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Morita S. Aortic valve replacement and prosthesis-patient mismatch in the era of trans-catheter aortic valve implantation. Gen Thorac Cardiovasc Surg 2016; 64:435-40. [PMID: 27234223 PMCID: PMC4956702 DOI: 10.1007/s11748-016-0657-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 05/13/2016] [Indexed: 11/27/2022]
Abstract
Objective The treatment strategy for aortic stenosis (AS) has been changing due to newly developed valvular prostheses and trans-catheter aortic valve implantation (TAVI). To determine the role of new modalities for AS with a small aortic root, papers using the concept of prosthesis-patient mismatch (PPM) were reviewed. Methods First, to determine the cut-off value of the indexed effective orifice area (IEOA) for defining PPM, the studies of surgical aortic valve replacement (SAVR) with a follow-up longer than 5 years and a patient number larger than 500 were reviewed. Second, the papers comparing TAVI and SAVR were reviewed. Furthermore, the prevalence of PPM was reviewed, with the addition of papers on aortic root enlargement, sutureless AVR, and aortic valve reconstruction with autologous pericardium. Results and conclusion The results of the long-term survival after aortic valve replacement (AVR) have indicated that an IEOA less than 0.65 cm2/m2 should be avoided in all cases, whereas the indications for patients with an IEOA between 065 and 0.85 cm2/m2 should be determined by considering multiple factors. A large body size and younger age have a significantly negative influence on the long-term survival. In Asian population, the prevalence of PPM was low, despite the fact that the size of the aortic annulus was small. The IEOA after TAVI was larger than after surgical AVR in population-matched studies. To evaluate the role of TAVI and other modalities for a small aortic root, studies with a longer follow-up and larger volume are thus warranted.
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Affiliation(s)
- Shigeki Morita
- Department of Thoracic and Cardiovascular Surgery, Faculty of Medicine, Saga University, 5-1-1 Nabeshima, Saga City, Saga, 849-8501, Japan.
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Prosthesis–patient mismatch in high-risk patients with severe aortic stenosis: A randomized trial of a self-expanding prosthesis. J Thorac Cardiovasc Surg 2016; 151:1014-22, 1023.e1-3. [DOI: 10.1016/j.jtcvs.2015.10.070] [Citation(s) in RCA: 98] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 08/03/2015] [Accepted: 10/08/2015] [Indexed: 11/21/2022]
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Beckmann E, Martens A, Alhadi F, Hoeffler K, Umminger J, Kaufeld T, Sarikouch S, Koigeldiev N, Cebotari S, Schmitto JD, Haverich A, Shrestha M. Aortic valve replacement with sutureless prosthesis: better than root enlargement to avoid patient-prosthesis mismatch? Interact Cardiovasc Thorac Surg 2016; 22:744-9. [PMID: 26920726 DOI: 10.1093/icvts/ivw041] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/11/2016] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Aortic valve replacement in patients with a small aortic annulus may result in patient-prosthesis mismatch (PPM). Aortic root enlargement (ARE) can reduce PPM, but leads to extended cardiac ischaemia times. Sutureless valves have the potential to prevent PPM while reducing cardiac ischaemia times. METHODS Between January 2007 and December 2011, a total of 128 patients with a small aortic annulus underwent surgery for aortic valve stenosis at our centre. Thirty-six (17% male, n = 6) patients received conventional valve replacement with ARE and 92 (16% male, n = 18) subjects received sutureless valve implantation (Sorin Perceval). We conducted a comparative, retrospective study with follow-up. RESULTS The sutureless group showed a significantly higher age (79 years) than the ARE patients (62 years, P < 0.001) and received significantly more concomitant cardiac procedures (33%, n = 30 vs 6%, n = 2, P = 0.001). The mean operation, cardiopulmonary bypass and cross-clamp times were significantly lower in sutureless patients (147 ± 42, 67 ± 26 and 35 ± 13 min, respectively) than in ARE patients (181 ± 41, 105 ± 29 and 70 ± 19 min, respectively, P < 0.001). The mean postoperative effective orifice area (EOA) indexed to the body surface area was 0.91 ± 0.2 cm(2)/m(2) in ARE patients and 0.83 ± 0.14 cm(2)/m(2) in sutureless patients (P = 0.040). The rate of patients with severe PPM was 6% (n = 2) in ARE patients and 11% (n = 8%) in sutureless patients (not significant, n.s.). The 30-day mortality rates were 2% (n = 2) in sutureless patients and 6% (n = 2) in ARE patients (n.s.). The 1- and 5-year survival rates of the sutureless group were 92 and 54% years, respectively, whereas the 1- and 5-year survival rates of the ARE group were 76% (n.s.). CONCLUSIONS Although the sutureless valve patients received significantly more concomitant procedures, all operation-associated times were significantly shorter. Despite sutureless valve patients being older, the 30-day mortality and survival rates were comparable in the two groups. Since the indexed EOA was only slightly lower and the incidence of severe PPM was not significantly higher in the sutureless valve patients, we conclude that sutureless valve implantation is an alternative to conventional ARE to treat a small aortic annulus and avoid PPM, especially in geriatric patients who benefit from the quick implantation process.
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Affiliation(s)
- Erik Beckmann
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Martens
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Firas Alhadi
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Klaus Hoeffler
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Julia Umminger
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Tim Kaufeld
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Samir Sarikouch
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Nurbol Koigeldiev
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Serghei Cebotari
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jan Dieter Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Malakh Shrestha
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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Haqzad Y, Loubani M, Chaudhry M, Ariyaratnam P, Briffa N. Multicentre, propensity-matched study to evaluate long-term impact of implantation technique in isolated aortic valve replacement on mortality and incidence of redo surgery. Interact Cardiovasc Thorac Surg 2016; 22:599-605. [PMID: 26892194 DOI: 10.1093/icvts/ivw015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 12/22/2015] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Studies suggest that the use of semicontinuous suture (SC) technique increases the risk of redo valve surgery after aortic valve replacement (AVR). The objective of this study was to identify 30-day mortality, rate of redo operation and long-term outcomes after AVR using either a semicontinuous suture or interrupted suture (IS) technique. METHODS A total of 1617 patients from 2 cardiothoracic centres, undergoing isolated AVR between April 2005 and August 2013 were included. AVR was performed using SC technique in 765 patients and IS technique in 852 patients. Data were collected prospectively and follow-up was obtained to date for all patients. We compared 30-day mortality, rate of redo operation and long-term mortality in SC and IS groups. One-to-one propensity-matching analysis was performed using IBM SPSS version 22 to evaluate outcomes. RESULTS Four hundred and eleven patients in the SC group were matched to 411 patients in the IS group (total of 822 patients) using propensity-score matching. The baseline characteristics were similar between SC and IS groups after matching. There were no statistically significant differences in 30-day mortality (3.9 vs 2.7%; P = 0.328), long-term mortality at 9-year follow-up (14.4 vs 15.3%; log-rank = 0.524) or rate of redo surgery (2.9 vs 2.0%; P = 0.320) between SC and IS, respectively. However, shorter cross-clamp time (51.9 ± 15.2 vs 60.9 ± 17.6 min; P < 0.001), bypass time (71.3 ± 23.0 vs 81.3 ± 37.8 min; P < 0.001) and the use of larger valve sizes (23.4 ± 2.1 vs 21.9 ± 2.2 mm; P < 0.001) were observed in SC patients compared with IS patients. Multivariate analysis did not show the suture technique as a significant determinant of redo valve surgery. CONCLUSIONS This multicentre study demonstrates that neither mortality nor the risk of redo surgery was influenced by the choice of implantation technique using semicontinuous vs interrupted suture techniques. The SC technique allowed shorter operations and larger size valves to be utilized.
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Affiliation(s)
- Yama Haqzad
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK
| | - Mubarak Chaudhry
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Cottingham, UK
| | | | - Norman Briffa
- Department of Cardiothoracic Surgery, Northern General Hospital, Sheffield, UK
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Correia PM, Coutinho GF, Branco C, Antunes MJ. Long-term follow-up of patients undergoing aortic root enlargement for insertion of a larger prosthesis. Eur J Cardiothorac Surg 2016; 50:82-8. [DOI: 10.1093/ejcts/ezv487] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 12/19/2015] [Indexed: 11/14/2022] Open
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Rodriguez M, Ruel M. Enhanced freedom from prosthesis-patient mismatch with transcatheter aortic valve replacement: More to aortic regurgitation than meets the eye? J Thorac Cardiovasc Surg 2016; 151:1024-5. [PMID: 26778381 DOI: 10.1016/j.jtcvs.2015.11.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Accepted: 11/25/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Maria Rodriguez
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
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