1
|
Doss M, Wood JP, Kiessling AH, Moritz A. Comparative evaluation of left ventricular mass regression after aortic valve replacement: a prospective randomized analysis. J Cardiothorac Surg 2011; 6:136. [PMID: 21992565 PMCID: PMC3199244 DOI: 10.1186/1749-8090-6-136] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Accepted: 10/13/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We assessed the hemodynamic performance of various prostheses and the clinical outcomes after aortic valve replacement, in different age groups. METHODS One-hundred-and-twenty patients with isolated aortic valve stenosis were included in this prospective randomized randomised trial and allocated in three age-groups to receive either pulmonary autograft (PA, n = 20) or mechanical prosthesis (MP, Edwards Mira n = 20) in group 1 (age < 55 years), either stentless bioprosthesis (CE Prima Plus n = 20) or MP (Edwards Mira n = 20) in group 2 (age 55-75 years) and either stentless (CE Prima Plus n = 20) or stented bioprosthesis (CE Perimount n = 20) in group 3 (age > 75). Clinical outcomes and hemodynamic performance were evaluated at discharge, six months and one year. RESULTS In group 1, patients with PA had significantly lower mean gradients than the MP (2.6 vs. 10.9 mmHg, p = 0.0005) with comparable left ventricular mass regression (LVMR). Morbidity included 1 stroke in the PA population and 1 gastrointestinal bleeding in the MP subgroup. In group 2, mean gradients did not differ significantly between both populations (7.0 vs. 8.9 mmHg, p = 0.81). The rate of LVMR and EF were comparable at 12 months; each group with one mortality. Morbidity included 1 stroke and 1 gastrointestinal bleeding in the stentless and 3 bleeding complications in the MP group. In group 3, mean gradients did not differ significantly (7.8 vs 6.5 mmHg, p = 0.06). Postoperative EF and LVMR were comparable. There were 3 deaths in the stented group and no mortality in the stentless group. Morbidity included 1 endocarditis and 1 stroke in the stentless compared to 1 endocarditis, 1 stroke and one pulmonary embolism in the stented group. CONCLUSIONS Clinical outcomes justify valve replacement with either valve substitute in the respective age groups. The PA hemodynamically outperformed the MPs. Stentless valves however, did not demonstrate significantly superior hemodynamics or outcomes in comparison to stented bioprosthesis or MPs.
Collapse
Affiliation(s)
- Mirko Doss
- Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University, Frankfurt am Main, Germany.
| | | | | | | |
Collapse
|
2
|
Biederman RWW, Magovern JA, Grant SB, Williams RB, Yamrozik JA, Vido DA, Rathi VK, Rayarao G, Caruppannan K, Doyle M. LV reverse remodeling imparted by aortic valve replacement for severe aortic stenosis; is it durable? A cardiovascular MRI study sponsored by the American Heart Association. J Cardiothorac Surg 2011; 6:53. [PMID: 21492429 PMCID: PMC3094375 DOI: 10.1186/1749-8090-6-53] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Accepted: 04/14/2011] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND In patients with severe aortic stenosis (AS), long-term data tracking surgically induced effects of afterload reduction on reverse LV remodeling are not available. Echocardiographic data is available short term, but in limited fashion beyond one year. Cardiovascular MRI (CMR) offers the ability to serially track changes in LV metrics with small numbers due to its inherent high spatial resolution and low variability. HYPOTHESIS We hypothesize that changes in LV structure and function following aortic valve replacement (AVR) are detectable by CMR and once triggered by AVR, continue for an extended period. METHODS Twenty-four patients of which ten (67 ± 12 years, 6 female) with severe, but compensated AS underwent CMR pre-AVR, 6 months, 1 year and up to 4 years post-AVR. 3D LV mass index, volumetrics, LV geometry, and EF were measured. RESULTS All patients survived AVR and underwent CMR 4 serial CMR's. LVMI markedly decreased by 6 months (157 ± 42 to 134 ± 32 g/m2, p < 0.005) and continued trending downwards through 4 years (127 ± 32 g/m2). Similarly, EF increased pre to post-AVR (55 ± 22 to 65 ± 11%,(p < 0.05)) and continued trending upwards, remaining stable through years 1-4 (66 ± 11 vs. 65 ± 9%). LVEDVI, initially high pre-AVR, decreased post-AVR (83 ± 30 to 68 ± 11 ml/m2, p < 0.05) trending even lower by year 4 (66 ± 10 ml/m2). LV stroke volume increased rapidly from pre to post-AVR (40 ± 11 to 44 ± 7 ml, p < 0.05) continuing to increase non-significantly through 4 years (49 ± 14 ml) with these LV metrics paralleling improvements in NYHA. However, LVmass/volume, a 3D measure of LV geometry, remained unchanged over 4 years. CONCLUSION After initial beneficial effects imparted by AVR in severe AS patients, there are, as expected, marked improvements in LV reverse remodeling. Via CMR, surgically induced benefits to LV structure and function are durable and, unexpectedly express continued, albeit markedly incomplete improvement through 4 years post-AVR concordant with sustained improved clinical status. This supports down-regulation of both mRNA and MMP activity acutely with robust suppression long term.
Collapse
Affiliation(s)
- Robert WW Biederman
- Center for Cardiovascular Magnetic Resonance Imaging, The Gerald McGinnis Cardiovascular Institute, Department of Medicine, Division of Cardiology, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA
| | - James A Magovern
- Department of Surgery, Division of Cardiothoracic Surgery, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Saundra B Grant
- Center for Cardiovascular Magnetic Resonance Imaging, The Gerald McGinnis Cardiovascular Institute, Department of Medicine, Division of Cardiology, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ronald B Williams
- Center for Cardiovascular Magnetic Resonance Imaging, The Gerald McGinnis Cardiovascular Institute, Department of Medicine, Division of Cardiology, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA
| | - June A Yamrozik
- Center for Cardiovascular Magnetic Resonance Imaging, The Gerald McGinnis Cardiovascular Institute, Department of Medicine, Division of Cardiology, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA
| | - Diane A Vido
- Center for Cardiovascular Magnetic Resonance Imaging, The Gerald McGinnis Cardiovascular Institute, Department of Medicine, Division of Cardiology, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA
| | - Vikas K Rathi
- Center for Cardiovascular Magnetic Resonance Imaging, The Gerald McGinnis Cardiovascular Institute, Department of Medicine, Division of Cardiology, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA
| | - Geetha Rayarao
- Center for Cardiovascular Magnetic Resonance Imaging, The Gerald McGinnis Cardiovascular Institute, Department of Medicine, Division of Cardiology, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA
| | - Ketheswaram Caruppannan
- Center for Cardiovascular Magnetic Resonance Imaging, The Gerald McGinnis Cardiovascular Institute, Department of Medicine, Division of Cardiology, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA
- Division of Internal Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
| | - Mark Doyle
- Center for Cardiovascular Magnetic Resonance Imaging, The Gerald McGinnis Cardiovascular Institute, Department of Medicine, Division of Cardiology, Allegheny General Hospital, Drexel University College of Medicine, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
4
|
Pasquali SK, Shera D, Wernovsky G, Cohen MS, Tabbutt S, Nicolson S, Spray TL, Marino BS. Midterm outcomes and predictors of reintervention after the Ross procedure in infants, children, and young adults. J Thorac Cardiovasc Surg 2007; 133:893-9. [PMID: 17382622 DOI: 10.1016/j.jtcvs.2006.12.006] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2006] [Revised: 10/03/2006] [Accepted: 12/18/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study assessed the type, time course, and risk factors for right and left ventricular outflow tract reinterventions after the Ross procedure in a population of infants, children, and young adults. METHODS Patients who underwent the Ross procedure between January 1995 and June 2004 were included (n = 121 consecutive patients). Kaplan-Meier and hazard analyses of right and left ventricular outflow tract reinterventions were performed, and predictors of reintervention were identified through multivariate analysis. RESULTS The median age at the Ross procedure was 8.2 years (4 days to 34 years); 20% were aged less than 1 year. Half of the patients had isolated aortic valve disease; the other half had complex left-sided heart disease. Early mortality (<30 days) was 2.5% (n = 3). There were 2 late deaths (1.7%). Follow-up (median 6.5 years [2.5 months to 10.4 years]) was available for 96% of survivors (n = 111). Right ventricular outflow tract reintervention (n = 22 in 15 patients) was performed 2.0 years (2.0 weeks to 9.8 years) after the Ross procedure because of stenosis in 19 of 22 cases. Freedom from right ventricular outflow tract reintervention at 8 years was 81%. Smaller homograft size was the strongest predictor (P < .001) of right ventricular outflow tract reintervention. Left ventricular outflow tract reintervention (n = 15 in 15 patients) was performed 2.8 years (1.0 months to 11.6 years) after the Ross procedure because of severe neoaortic insufficiency in 10 of 15 patients. Freedom from left ventricular outflow tract reintervention at 8 years was 83%. Native pulmonary valve abnormalities (P < .01), original diagnosis of aortic insufficiency (P < .01), prior aortic valve replacement (P = .01), and prior ventricular septal defect repair (P = .04) predicted left ventricular outflow tract reintervention. CONCLUSIONS At midterm follow-up after the Ross procedure, interim mortality is rare. Neoaortic insufficiency and right ventricle to pulmonary artery conduit obstruction are common postoperative sequelae, requiring reintervention in one quarter of patients.
Collapse
Affiliation(s)
- Sara K Pasquali
- Division of Cardiology in the Departments of Pediatrics, Surgery, and Anesthesia/Critical Care Medicine at The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pa 19104, USA
| | | | | | | | | | | | | | | |
Collapse
|
5
|
Abstract
For patients requiring intervention because of progressive disease of the aortic valve, the perfect palliation will provide a valve that produces normal dynamics of flow, will not require anti-coagulation, will grow with the patient, and have long term durability. Current surgical interventions include aortic valvoplasty, or replacement with either a mechanical or tissue prosthesis. Options for tissue valves include insertion of a pulmonary autograft in the Ross procedure, a cadaveric homograft, or porcine or bovine xenograft valves. The optimal option is still debated.
Collapse
Affiliation(s)
- Bradley S Marino
- Divisione of Cardiology, The Children's Hospital of Philadelphia, Pennsylvania 19104, USA.
| | | | | | | |
Collapse
|
6
|
Gleason TG. Current Perspective on Aortic Valve Repair and Valve-Sparing Aortic Root Replacement. Semin Thorac Cardiovasc Surg 2006; 18:154-64. [PMID: 17157237 DOI: 10.1053/j.semtcvs.2006.07.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2006] [Indexed: 11/11/2022]
Abstract
Aortic valve repair and valve-sparing aortic root replacement are attractive concepts because they offer the possibility of valve competence without structural deterioration due to nonviability and they preclude the need for anticoagulation. Enthusiasm for aortic valve repair has waxed and waned over the past 45 years due in part to the inherent technical difficulties and poor mid-term results. Renewed interest in the concept of aortic valve repair has paralleled the development of valve-sparing aortic root replacement over the last 20 years. A current perspective on aortic valve repair and valve-sparing aortic root replacement is presented in the following review. Historical background, indications for repair, technical considerations, and outcomes data are discussed.
Collapse
Affiliation(s)
- Thomas G Gleason
- Thoracic Aortic Surgery Program, Northwestern University Feinberg School of Medicine, Chicago, IL 60611-3056, USA.
| |
Collapse
|
7
|
Doss M, Wood JP, Martens S, Wimmer-Greinecker G, Moritz A. Do pulmonary autografts provide better outcomes than mechanical valves? A prospective randomized trial. Ann Thorac Surg 2005; 80:2194-8. [PMID: 16305870 DOI: 10.1016/j.athoracsur.2005.06.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2005] [Revised: 05/24/2005] [Accepted: 06/03/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The objective of this study was to compare the performance of pulmonary autografts with mechanical aortic valves, in the treatment of aortic valve stenosis. METHODS Forty patients with aortic valve stenoses, and below the age of 55 years, were randomly assigned to receive either pulmonary autografts (n = 20) or mechanical valve (Edwards MIRA; Edwards Lifesciences, Irvine, CA) prostheses (n = 20). Clinical outcomes, left ventricular mass regression, effective orifice area, ejection fraction, and mean gradients were evaluated at discharge, 6 months, and one year after surgery. Follow-up was complete for all patients. RESULTS Hemodynamic performance was significantly better in the Ross group (mean gradient 2.6 mm Hg vs 10.9 mm Hg, p = 0.0005). Overall, a significant decrease in left ventricular mass was found one year postoperatively. However, there was no significant difference in the rate and extent of regression between the groups. There was one stroke in the Ross group and one major bleeding complication in the mechanical valve group. Both patients recovered fully. CONCLUSIONS In our randomized cohort of young patients with aortic valve stenoses, the Ross procedure was superior to the mechanical prostheses with regard to hemodynamic performance. However, this did not result in an accelerated left ventricular mass regression. Clinical advantages like reduced valve-related complications and lesser myocardial strain will have to be proven in the long term.
Collapse
Affiliation(s)
- Mirko Doss
- Department of Thoracic and Cardiovascular Surgery, J. W. Goethe University, Frankfurt am Main, Germany.
| | | | | | | | | |
Collapse
|
8
|
Pomerantz BJ, Krock MD, Wollmuth JR, Cupps BP, Kouchoukos NT, Davila-Roman VG, Pasque MK. Aortic Valve Replacement for Aortic Insufficiency: Valve Type as a Determinant of Systolic Strain Recovery. J Card Surg 2005; 20:524-9. [PMID: 16309403 DOI: 10.1111/j.1540-8191.2005.00133.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM Left ventricular (LV) 3D systolic strain decreases in absolute value postoperatively and does not recover in patients who undergo aortic valve replacement (AVR) for chronic aortic insufficiency (AI). We investigated whether choice of valve prosthesis (mechanical [St. Jude], bioprosthetic [bovine pericardial], Ross procedure) had a significant impact on strain recovery in this surgical population. METHODS MRI with tissue-tagging was performed on 14 patients with chronic AI both before and 28 +/- 13 months after AVR. Average values of LV systolic strain and end-systolic stress (ESS) were computed from MRI data for the LV. Three types of prosthetic valve were examined (Ross procedure n = 4, bovine pericardial n = 5, and St. Jude n = 5). RESULTS Overall, systolic strain, ESS, LV volumes, ejection fraction, and LV mass all changed significantly following AVR. Comparisons between individual valve types revealed no differences in any of these measurements. Patients who received a mechanical valve had a greater decrease in the absolute value of systolic strain following surgery compared to patients from the nonmechanical group (Ross procedure and bioprosthetic valve). Comparisons between the Ross group and the prosthetic group (St. Jude and bioprosthetic) produced no significant differences in strain, ESS, LV volume, and mass. CONCLUSIONS These early results suggest that valve prosthetic type may be a factor in efforts to improve strain recovery after AVR for AI, although further investigation is warranted. MRI with tissue-tagging may be a useful tool for comparing the impact of prosthetic valve choice on incompletely recovered systolic strain following AVR for chronic AI.
Collapse
Affiliation(s)
- Benjamin J Pomerantz
- Division of Cardiovascular Medicine, Washington University, St. Louis, Missouri 63110-1013, USA
| | | | | | | | | | | | | |
Collapse
|