Clinical and hemodynamic evaluation of small Perimount aortic valves in patients aged 75 years or older

Aortic valve replacement in small patients

OBJECTIVES

Asians are smaller than Europeans and North Americans, but aortic valve replacement (AVR) in small patients has not been examined. We aimed to compare short- and mid-term outcomes of AVR between small and non-small patients.

METHODS

We retrospectively divided 173 patients who underwent AVR into small (S, n = 95) and non-small (NS, n = 78) groups according to body surface area (≤1.6 in men, ≤1.5 in women) and analyzed differences in baseline characteristics, procedural and post-procedural variables, and survival.

RESULTS

Mean age differed significantly between the S and NS groups (71.9 ± 11.2 vs. 66.2 ± 9.8 years), as did the proportion of women (60.0% vs. 24.4%). Implanted valves (19.6 ± 1.6 mm vs. 20.7 ± 1.7 mm) were significantly smaller and more bioprosthetic valves (57.9% vs. 41.0%) were used in the S group. Effective orifice area index and the rate of moderate and severe patient-prosthesis mismatch were not significantly different. No significant intergroup differences were found in hospitalization duration, 30-day mortality, survival rates, or valve related complications.

CONCLUSIONS

Small patients were older and the proportion of women was higher. The implanted aortic valves were smaller and more were biological prostheses. However, mortality rate did not differ and short- and mid-term outcomes were safe and favorable.

Primary echocardiographic results of the Carpentier-Edwards Perimount Magna

PURPOSE

The aim of this study was to investigate the primary echocardiographic results of aortic valve replacement using 21- and 19-mm Carpentier-Edwards Perimount Magna bioprosthesis aortic xenografts in patients with small aortic annulus.

METHODS

Twenty patients (mean body surface area 1.63 ± 0.16 m(2)) underwent aortic valve replacement between June 2008 and December 2009. Eight and 12 patients received 21- and 19-mm Magna bioprostheses, respectively. After 12 months, hemodynamic data were obtained by echocardiography to estimate the prosthesis-patient mismatch.

RESULTS

At follow-up, significant decreases in peak and mean left ventricular aortic pressure gradients were observed in the 12 patients with aortic stenosis (P < 0.05). Regression of the left ventricular mass was observed in all the patients (P < 0.05). The mean measured effective orifice area (EOA) and EOA index (EOAI) were 1.61 ± 0.28 cm(2) and 0.99 ± 0.16 cm(2)/m(2), respectively. Prosthesis-patient mismatch (EOAI ≤0.85) was documented in three patients.

CONCLUSION

The primary echocardiographic findings suggested that the hemodynamic performance of the 19- and 21-mm Carpentier-Edwards Perimount Magna bioprostheses was satisfactory in the patients with a small aortic annulus.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Aortic valve replacement for aortic stenosis in the elderly: influence of prosthesis-patient mismatch on late survival and left ventricular mass regression

PURPOSE

Controversy still exists about the influence of prosthesis-patient mismatch on outcomes after aortic valve replacement in the elderly. Our aim was to evaluate the effect of prosthesis-patient mismatch on survival and the extent of left ventricular (LV) mass regression after aortic valve replacement for aortic stenosis in Japanese patients aged >or=65 years.

MATERIALS AND METHODS

A total of 84 patients who underwent isolated aortic valve replacement for aortic stenosis between 1986 and 2006 were retrospectively analyzed. Patients were divided into two groups based on the definition of prosthesis-patient mismatch (indexed effective orifice area <or=0.85 cm(2)/m(2)), and long-term results were compared. The mean follow-up time was 4.5 +/- 4.5 years. In 49 patients, follow-up echocardiography was performed at least 6 months after surgery, and the extent of LV mass regression was analyzed according to the presence of a prosthesis-patient mismatch.

RESULTS

Eight years after surgery, there was no significant difference between patients with and without mismatch in terms of actuarial freedom from cardiac-related death (P = 0.159) or death from any valve-related events (P = 0.107). The postoperative transvalvular pressure gradients were not significantly different between the two groups, and significant absolute and relative LV mass regression were observed in both groups.

CONCLUSION

Although a moderate prosthesis-patient mismatch appeared to be tolerable, the criteria of prosthesis-patient mismatch may have to be reassessed for elderly Japanese patients.

Patient-prosthesis mismatch may be irrelevant after aortic valve replacement with the 19-mm Perimount pericardial bioprosthesis in patients aged 65 years or older

The prevalence of patient-prosthesis mismatch (PPM) and its influence on clinical midterm results were examined in elderly patients whose activity was supposed to be less than that of younger patients. We evaluated valve function and the effects of PPM on the midterm results of the 19-mm Carpentier-Edwards Perimount (CEP) pericardial aortic valve in patients aged 65 years or older. Between August 1996 and May 2005, 51 patients underwent aortic valve replacement with the 19-mm CEP valve. The mean follow-up was 2.4 +/- 1.8 years, involving a total of 134.4 patient-years. The mean age and body surface area at operation were 74.0 +/- 5.0 years and 1.41 +/- 0.14 m(2). There were two (3.9%) operative deaths. Three patients (5.9%) underwent enlargement of their small aortic annuli. The actuarial survival rate at 8 years, including operative mortality, averaged 90.2% +/- 4.7%. The freedom from thromboembolism, reoperation, and valve-related mortality averaged 75.0% +/- 21.7%, 97.8% +/- 2.2%, and 95.3% +/- 3.2%, respectively, at 8 years. High preoperative peak and mean transvalvular pressure gradients were significantly improved after the operation (peak, 93 +/- 35 versus 28 +/- 12 mmHg; mean, 58 +/- 19 versus 17 +/- 7 mmHg, respectively; P < 0.01). The mean left ventricular mass index was reduced from 192 +/- 44 to 142 +/- 46 g/m(2) at late follow-up (P < 0.01). The prevalence of PPM was low (17.6%) when an indexed effective orifice area of less than 0.85 cm(2)/m(2) was taken as the definition of PPM. The clinical results, postoperative pressure gradients, and reduction in left ventricular mass index were not different between the PPM and no-PPM groups. The 19-mm CEP valve produced satisfactory midterm clinical outcomes in patients aged 65 years or older whose activity was supposed to be less than that of younger patients, regardless of the presence or absence of PPM. Moderate PPM was rare and it did not adversely impact on the midterm results. The application of annulus enlargement could be limited to the small number of patients for whom the 19-mm CEP valves are not able to be inserted.

Influence of completely supra-annular placement of bioprostheses on exercise hemodynamics in patients with a small aortic annulus

OBJECTIVE

Aortic valve replacement in patients with a small aortic annulus is often associated with increased pressure gradients. For this reason, prostheses for completely supra-annular placement have been developed. To evaluate the potential benefit of this design, the present study compared the effectiveness of 1 intra-supra-annular bioprosthesis and 3 completely supra-annular bioprostheses in patients with an aortic annulus diameter of 23 mm or less.

METHODS

Between August 2000 and December 2004, each of 192 patients requiring aortic valve replacement with an intraoperatively measured aortic annulus diameter of 23 mm or less received one of the following bioprostheses: the stented bovine Sorin Soprano bioprosthesis (n = 28) (Sorin Group, Saluggia, Italy), the Carpentier-Edwards Perimount bioprosthesis (n = 50) (Edwards Lifesciences, Irvine, Calif), the Carpentier-Edwards Perimount Magna bioprosthesis (n = 70) (Edwards Lifesciences), or the stented porcine Medtronic Mosaic (n = 44) (Medtronic Inc, Minneapolis, Minn) bioprosthesis. After 6 months, hemodynamic data at rest and during exercise were obtained by echocardiography in 142 patients.

RESULTS

The pericardial valves showed lower mean systolic pressure gradients, larger effective orifice areas and indices, and superior effective orifice fractions than did the porcine valve (P < .05) (Carpentier-Edwards Perimount: 10.9 +/- 3.6 mm Hg, 1.59 +/- 0.41 cm2, 0.9 +/- 0.25 cm2/m2, 41.9% +/- 9.6%; Carpentier-Edwards Perimount Magna 10.1 +/- 3.8 mm Hg, 1.64 +/- 0.38 cm2, 0.93 +/- 0.22 cm2/m2, 45.1% +/- 10.2%; Sorin Soprano 13.5 +/- 5.0 mm Hg, 1.64 +/- 0.32 cm2, 0.92 +/- 0.15 cm2/m2, 45.8% +/- 9.0%; vs Medtronic Mosaic 15.5 +/- 5.2 mm Hg, 1.31 +/- 0.42 cm2, 0.75 +/- 0.24 cm2/m2, 35.2% +/- 10.0%, respectively). The lowest mean systolic pressure gradients were found after the implantation of the Carpentier-Edwards Perimount Magna. Effective orifice areas, indices, and fractions of the pericardial valves did not show significant differences.

CONCLUSIONS

In patients with small aortic roots, transvalvular gradients and effective orifice area showed a tendency to superior results in pericardial valves compared with the porcine bioprosthesis. However, the completely supra-annular design does not necessarily lead to superior hemodynamic results compared with the intra-supra-annular position.

Exercise hemodynamics of bovine versus porcine bioprostheses: a prospective randomized comparison of the mosaic and perimount aortic valves

OBJECTIVE

This prospective randomized study compares a porcine with a bovine bioprosthesis in the aortic position with regard to hemodynamic performance during exercise.

METHODS

Between August of 2000 and December of 2002, 136 patients underwent aortic valve replacement with the porcine Medtronic Mosaic (n = 66) or the bovine Carpentier-Edwards Perimount (n = 70) bioprosthesis. Transthoracic echocardiography was performed to assess hemodynamic and dimensional data preoperatively and 10 months postoperatively; the latter follow-up included stress echocardiography with treadmill exercise.

RESULTS

At rest and during exercise (25 and 50 W), there was a significant difference in mean pressure gradient between the bovine and the porcine valves with labeled sizes 21 and 23, with superiority of the Perimount prosthesis. There was no difference in effective orifice area and incidence of patient-prosthesis mismatch among all sizes. The left ventricular mass index decreased significantly within 10 months postoperatively in the size 23 bovine group and the size 25 porcine group.

CONCLUSIONS

Our data show a significant superiority of pressure gradients for the bovine bioprosthesis, especially with small valve sizes, when compared with the porcine device, which is more distinctive during exercise.