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PubMed2003

Percutaneous implantation of aortic valve prosthesis in patients with calcific aortic stenosis: technical aspects.

In April 2002, after extensive ex-vivo and animal implantation studies, we performed the first successful implantation of a new percutaneous aortic valve in a patient with endstage aortic stenosis. The purpose of this article is to give a detailed description of the technique of percutaneous implantation of aortic valve bioprosthesis in patients with severe calcific aortic stenosis. Antegrade transeptal approach was used under local anesthesia and mild sedation.

Aortic Valve↗

PubMed1998

Pericarbon pericardial valve prosthesis: midterm results of the aortic valve replacement.

This clinical study was undertaken to verify the encouraging results of experimental studies regarding a new pericardial bioprosthesis. From May 1989 to November 1993, 204 patients underwent an aortic valve replacement with the Pericarbon (Sorin Biomedica Cardio S.p.A., Saluggia, Italy) prosthesis. A follow-up was 100% complete and extended to 65 months (total 408 patient-years, average 2.0+/-1.4 years). Mean age at the operation was 75.1+/-5.5 years and 96% were in NYHA clinical stage III or IV. There were 86 men and 118 women; 73 patients had an isolated aortic valve disease, 131 had a concomitant cardiosurgical procedure (coronary artery bypass grafting in 106 patients). The operative mortality (30-day mortality) rate was 11.8% (24/204). There were 24 late deaths (5.9+/-1.2% patient-year). The actuarial probability of survival was 68+/-5% at 5 years. Four patients died of valve-related causes (one thromboembolic complication, two endocarditis, one anticoagulant-related hemorrhage). Actuarial rate of freedom from valve-related death was 95+/-3% at 5 years. Valve-related morbidity included seven thromboembolic episodes (1.7% patient-year), four anticoagulant-related complications (0.9% patient-year), three endocarditis (0.7% patient-year) and one reoperation (0.2% patient-year). After 5 years freedom from thromboembolic events was 83+/-7%, from anticoagulant-related hemorrhage 96+/-2%, from endocarditis 97+/-2%, and from reoperation 99+/-1%. Echocardiographic study performed in 30 patients showed a paraprosthetic leak in four patients, a central leak in two, and cusp thickening in another three. The clinical data showed that the Pericarbon prosthesis has valve-related morbidity. The echocardiographic results suggest that the prosthesis can undergo a pathologic process during the first 5 years after implantation. This makes it necessary to continue the follow-up and include the larger number of patients in the echocardiographic investigation.

Actuarial Analysis↗

PubMed2005

[Prosthesis of the aortal valve in adult patients with "narrow" aortic root].

Results of treatment of 54 patients with aortal valvular disease and "narrow" aortic root are analyzed. Only adult patients were included in the study, their age ranged from 16 to 64 years (mean age 41.5+/-14.7 yrs). Thirty-four (63%) patients of them have undergone aortic valve replacement with disk prosthesis, in 20 (37%) patients this surgery was supplemented with dillative plasty of fibrous ring and aortic root by Nicks's method. The proposed algorithm of choosing the most effective operation in patients with the aortal defect and narrow aortal root permits one to avoid pathologic pressure gradient between the left ventricle and the aorta after surgery and to achieve the most favorable clinical effect.

Adolescent↗

PubMed2006

Plasma ANP and renin-angiotensin-aldosterone system as new parameters describing the hemodynamics of the circulatory system after implantation of stented or stentless aortic valves.

BACKGROUND AND AIM OF THE STUDY: Aortic valve replacement (AVR) in patients with a small aortic root involves the occurrence of patient-prosthesis mismatch (PPM). Recent reports have shown that a reduced effective orifice area index (EOAI) may not be the sole factor responsible for this complication. The study aim was to analyze the activity of atrial natriuretic peptide (ANP)/renin-angiotensin-aldosterone (RAA) after implantation of stented or stentless valves. METHODS: Between 2001 and 2003, a total of 30 patients operated on at the authors' institution received either a stentless Freestyle bioprosthesis (group A; n = 15) or a stented Mosaic bioprosthesis (group B; n = 15). The demographics of both groups were similar, and all patients underwent echocardiography preoperatively, and at one, six and 12 months postoperatively. The activity of the RAA system and plasma ANP level were measured in all patients preoperatively and at one and six months postoperatively. RESULTS: At one month after AVR, statistically significant inter-group differences were noted in plasma renin activity (group A, 3.7 +/- 2.1 ng/ml/h; group B, 5.6 +/- 0.8 ng/ml/h; p <0.05; control value 0.3-5.3 ng/ml/h). For ANP, statistically significant differences were present at one month after surgery (group A, 36.3 +/- 5.1 pg/ml; group B, 62.9 +/- 9.2 pg/ml; p <0.005; control value 27.3-37.2 pg/ml). On echocardiography, the ejection fraction, aortic valve gradient, EOAI and left ventricular mass index (LVMI) were assessed. A statistically significant difference was identified for the LVMI at 12 months postoperatively (group A, 216 +/- 13 g/m2; group B, 240 +/- 18 g/m2; p <0.05). In terms of other parameters both groups were similar. CONCLUSION: The implantation of an aortic valve prosthesis affects the hemodynamics of the entire circulatory system, and thus the activity of natriuretic systems. Whilst stentless valves allowed much more rapid normalization of circulatory system hemodynamics (one month), no difference compared to preoperative was identified after six months. Natriuretic peptides appear to provide more sensitive (long-term) but less specific (short-term) assessment of circulatory system behavior than echocardiography.

Aged↗

PubMed2005

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.

Aged↗

PubMed2004

Tear in mitral anterior leaflet as a complication of Manouguian's procedure in a woman with an aortic valve prosthesis.

Complications of valve replacement are diverse. In addition to morbidity due to the prosthetic valve itself (e.g. endocarditis, thrombosis), complications due to operative technique may occur in complex cases, as in aortic valve replacement with annular enlargement. Postoperative echocardiography is a simple, non-invasive method to evaluate patients with prosthetic valves. Detailed knowledge of the surgical technique employed and of probable complications is necessary to make an accurate diagnosis. The case is reported of a woman with aortic valve replacement and annular enlargement who had mitral regurgitation due to a tear in the anterior mitral leaflet as a complication of Manouguian's annulus enlargement.

Aortic Valve↗

PubMed2000

Comparison of On-X and SJM HP bileaflet aortic valves.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the hemodynamic function after aortic valve replacement (AVR) using the On-X valve, in comparison with St. Jude Medical (SJM) HP bileaflet valves. METHODS: Patients received either the On-X (n = 20) or SJM HP prosthesis (n = 20) for AVR. The control (SJM HP) group was computer-matched with the On-X group for age, gender, aortic stenosis as underlying disease, body surface area, NYHA functional class, left ventricular size, mass and function, transvalvular pressure gradients and cardiac index. Mean implanted valve size was 23.5 mm (three 21 mm, ten 23 mm, six 25 mm, one 27 mm) in both groups. All patients underwent postoperative, and six- and 12-month follow up echocardiography. RESULTS: The intra- and postoperative course was uneventful in all patients. There were no significant differences in cross-clamp and cardiopulmonary bypass times, intensive care unit stay, in-hospital stay and postoperative NYHA functional class. Two patients (both On-X) had paravalvular leakage postoperatively and at follow up. Five patients in the control group had additional myocardial revascularization. Transvalvular flow velocities were 2.38 +/- 0.3 versus 2.38 +/- 0.4 m/s (p = NS) postoperatively, and 2.08 +/- 0.2 versus 2.22 +/- 0.3 m/s (p = NS) at one year follow up for On-X and SJM HP valves, respectively. Maximum pressure gradients were 16.9 +/- 6.0 versus 18.5 +/- 8.0 mmHg (p = NS) postoperatively and 14.0 +/- 3.7 versus 16.5 +/- 5.7 mmHg (p = NS) at one year for the two valve types, respectively. A relatively pronounced transvalvular reflux was diagnosed for On-X valves. CONCLUSION: At one year after implantation, the On-X bileaflet prosthesis is equally suited for AVR in comparison with the 'standard' therapy (SJM HP). Exact sizing requires some experience. There were no significant differences between the two prostheses with regard to hemodynamic parameters either postoperatively or at one-year follow up. Long-term prospective randomized studies yet have to be carried out.

Aortic Valve↗

PubMed1997

[Two operative cases of quadricuspid aortic valve].

We report two cases of rare congenital anomaly of quadricuspid aortic valve. Case 1, an 81-year-old man was operated on because of aortic regurgitation without diagnosis of a quadricuspid aortic valve. He underwent aortic valve replacement with a 21 mm Hancock-II successfully. Case 2, a 40-year-old woman suffering from aortic regurgitation was diagnosed as quadricuspid aortic valve, before surgery using echocardiography and aortography. She underwent aortic valve replacement with a 21 mm H-P St. Jude Medical prosthesis successfully. Both cases were regarded as type c (2 equal larger cusps, 2 equal smaller cusps) by Hurwitz's classification. Thirty cases of quadricuspid aortic valve are reviewed in the Japanese literature including our two cases. All cases underwent aortic valve replacement because of aortic regurgitation. In 19 cases, it was possible to diagnose that those valves were quadricuspid before surgery, using echocardiography and aortography. In conclusion, it is necessary to take quadricuspid aortic valve into consideration in the case of aortic regurgitation.

Adult↗

PubMed1998

Multiple mechanical valve replacement surgery comparison of St. Jude Medical and CarboMedics prostheses.

OBJECTIVE: The experience with the St. Jude Medical (SJM) and CarboMedics (CM) bileaflet mechanical prostheses was evaluated to determine thromboembolic and hemorrhagic complications and predictive risk factors. METHODS: From 1989 to 1994, a total of 246 patients had multiple valve replacement (SJM, 140; CM, 106); concomitant procedures 20.3% (50) [coronary artery bypass 10.6% (26)] and 53.7% (132) previous cardiac surgery, primarily valve replacement procedures. The pre-operative variables [coronary artery disease, previous cardiovascular surgery, concomitant procedures, valve lesion (except mitral stenosis), status, atrial fibrillation, and NYHA III/IV] did not distinguish the prosthesis-type (pNS). RESULTS: The prosthesis-type and the pre-operative variables, including atrial fibrillation, were not predictive of overall thromboembolism (TE). The linearized rate of total TE events for overall multiple replacements (MR) was 5.4%/patient-year (minor, 2.52; major 2.85); the total TE for CM and SJM was 5.4%/patient-year, respectively. The < or = 30 day major TE crude rate was 0.82%, while the > 30 day major event rate was 2.7%/patient-year. Of the total (major and minor) TE events 100% (3) of < or = 30 days and 72% (29), > 30 days had an INR < 2.5 at or immediately prior to the event. The thrombosis rate (included in total TE events) was 0.67%/patient-year (4 events, 100% INR < 2.5). Of the various TE event categories the prosthesis-types (CM and SJM) were not differentiated (pNS). The freedom, at 5 years, from major/fatal TE, thrombosis and hemorrhage from anticoagulation was 89.3 +/- 3.8% for CM and 87.9 +/- 3.7% for SJM and, 91.3 +/- 3.5% and 89.3 +/- 3.7%, respectively, (pNS) exclusive of early events. CONCLUSIONS: The performance of the CarboMedics and St. Jude Medical prostheses in multiple valve replacement surgery in this non-randomized prospective study revealed no significant differences in performance with regard to thromboembolic and hemorrhagic complications.

Adult↗

PubMed2003

[Clinical and hemodynamic results of the mosaic bioprosthesis in aortic position].

INTRODUCTION: Aim of the study was to evaluate the hemodynamic and clinical performance of the Mosaic bioprosthesis in the aortic position. PATIENTS AND METHODS: The Mosaic bioprosthesis is a stented porcine heart valve for implantation in the aortic and mitral position, which combines zero pressure and root pressure fixation with glutaraldehyde, antimineralization treatment with alpha amino oleic acid (AOA) and a low profile stent, to optimize hemodynamic function and to minimize mechanical wear and thus to achieve longer tissue durability. Included in a multicenter study, 100 patients (49 females) underwent isolated aortic valve replacement with the Mosaic bioprosthesis between February 1994 and May 1999. Average age at implant was 73.4 +/- 7.3 years (range 31.3-86.8 years). Preoperative and operative clinical data are shown in Tables 1 and 2. Patients were followed-up within the first 30 postoperative days, after six months and at annual intervals, including transthoracic echocardiography and documentation of any adverse events. Mean follow-up was 3.8 years (range 0.1-7.1 years), total 383.1 patient-years. Follow-up is 100% complete. RESULTS: One year after implantation of the bioprosthesis, mean systolic pressure gradient was 15.3 +/- 6.7 mmHg (21), 14.5 +/- 5.7 mmHg (23), 12.7 +/- 4.1 mmHg (25) and 13.0 +/- 4.8 mmHg (27); effective orifice area (EOA) was 1.4 +/- 0.4 cm2 (21), 1.7 +/- 0.4 cm2 (23), 1.8 +/- 0.4 cm2 (25) and 2.6 +/- 0.4 cm2 (27) (Table 3). One year postoperative, nine patients (10.8%) showed mild aortic regurgitation and one patient (1.2%) moderate. Left ventricular mass index decreased significantly for all sizes within the first postoperative year from 159.7 +/- 56.8 g/m2 to 137.3 +/- 40.8 g/m2. Separating the patients with regard to valve size, only the 21-group (154.1 +/- 51.2 g/m2 to 129.1 +/- 34.6 g/m2) and the 27-group (237.7 +/- 59.2 g/m2 to 146.7 +/- 20.6 g/m2) showed significant results. Freedom from event rates at seven years were 96.8 +/- 1.8% for thromboembolic events, 97.2 +/- 2.0% for thrombosed bioprosthesis, 96.6 +/- 2.6% for structural valve deterioration, 98.2% +/- 1.8% for nonstructural dysfunction, 95.9% +/- 2.0% for antithromboembolic hemorrhage, 98.9 +/- 1.1% for endocarditis and 93.9 +/- 3.2% for reoperation and explant (see Table 4). Early mortality (within 30 days) was 3.0%; late mortality was 4.6%/patient-year, including a valve-related mortality of 0.6%/patient-year. Of the patients, 96.5% showed an improvement of at least one NYHA class when comparing preoperative and one year status. DISCUSSION: The hemodynamic performance and the frequency of adverse events of the Mosaic bioprosthesis in the aortic position were very satisfactory within the first seven postoperative years with excellent results, comparable to studies about other established bioprostheses and similar to the findings in other Mosaic series. Only the number of cases of antithromboembolic hemorrhage was noticeably high. One reason might be the high percentage of patients under continuous anti-coagulant therapy: Six months postoperative, still 52.2% of the patients received phenprocoumon, 6.7% acetylsalicylic acid. Concerning hemodynamics, patient-prosthesis mismatch appeared to be a common problem, especially in small valve sizes. Separating the sample in groups with EOA index < or = 0.75 cm2/m2 and EOA index > 0.75 cm2/m2 after one year, 51.6% in the 21-group had an EOA index < or = 0.75 cm2/m2, whereas it was 19.4% (23), 18.8% (25) and 0% (27) in the larger size groups. Generally, further data have to be collected to determine durability of the biological tissue, as the critical period has just started with the seventh year of the clinical trial. CONCLUSION: The Mosaic bioprosthesis proved to be a reliable and well-functioning device for aortic valve replacement, especially in larger sizes.

Adult↗

PubMed1998

Supraannular aortic root enlargement in patients with small aortic annulus: efficacy and safety.

BACKGROUND: To accommodate optimal sized aortic valve, our experiences with supraan-nular aortic root enlargement (SAE) in 20 patients with small aortic annulus have been described. METHODS: From June 1981 to April 1996, aortic valve replacement with a St. Jude Medical (SJM) valve had been performed in 46 patients with aortic stenosis consecutively. After August 1993, we employed SAE in patients to insert 23 mm or larger aortic prostheses (SAE group, n = 20; control group, n = 26). Patients were followed-up for a period of 1.7 to 8.3 years. RESULTS: There were no intra- or postoperative complications. The pressure gradient across the prosthesis was greater than 30 mmHg in 4 patients of the control group and in 1 patient of the SAE group. Only in nineteen patients (73%) of the control group, 23 mm or larger sized valves could be implanted by a conventional technique. By contrast, with SAE, 23 mm or larger sized SJM prostheses were possible to implant in 19 out of 20 patients (95%). CONCLUSION: To avoid valve-patient mismatch, SAE of aortic root is safe and effective.

Aortic Valve↗

PubMed2005

Hemodynamic comparison of bioprostheses for complete supra-annular position in patients with small aortic annulus.

OBJECTIVES: The present study evaluates complete supra-annular bioprostheses in patients with an aortic annulus of 18 to 23 mm in diameter. BACKGROUND: Aortic valve replacement in patients with small aortic annulus using stented bioprostheses is often associated with unsatisfactory hemodynamic results and high incidence of patient-prosthesis mismatch. METHODS: Between February 2000 and January 2004, 156 patients with aortic valve disease and an aortic annulus of 18 to 23 mm in diameter received the stented bovine Soprano (Sorin Biomedica Cardio, Saluggia, Italy) (n = 18), Perimount (Edwards Lifesciences, Irvine, California) (n = 52), Perimount Magna (Edwards Lifesciences) (n = 42), or the stented porcine Mosaic (Medtronic Inc., Minneapolis, Minnesota) (n = 44) bioprostheses. Intraoperatively, the surgeon measured the aortic annulus diameter by inserting a hegar dilator. Thus, postoperative hemodynamic results could be referred to the patient's aortic annulus diameter instead of referring the results to the labeled valve size. This allows for objective comparisons between different valve types. RESULTS: There was no significant difference in hemodynamic results between the different valve types in patients with an aortic annulus 18 to 20 mm. In patients with an annulus 21 to 23 mm, the Magna was significantly superior to the other investigated devices in mean pressure gradient, effective orifice area, and incidence of patient-prosthesis mismatch. There was no significant difference between the complete supra-annular bioprostheses Mosaic and Soprano and the intra-supra-annular Perimount valve. CONCLUSIONS: In patients with an aortic annulus of 18 to 20 mm in diameter, hemodynamic performance is independent of the implanted stented valve type and the annular position. Root enlargement or stentless valves may be beneficial alternatives. Patients with annulus diameter 21 to 23 mm benefit from the Magna in complete supra-annular position leading to superior hemodynamic results.

Aged↗

PubMed2005

Prosthesis-patient mismatch: definition, clinical impact, and prevention.

Prosthesis-patient mismatch (PPM) is present when the effective orifice area of the inserted prosthetic valve is too small in relation to body size. Its main haemodynamic consequence is to generate higher than expected gradients through normally functioning prosthetic valves. This review updates the present knowledge about the impact of PPM on clinical outcomes. PPM is common (20-70% of aortic valve replacements) and has been shown to be associated with worse haemodynamic function, less regression of left ventricular hypertrophy, more cardiac events, and lower survival. Moreover, as opposed to most other risk factors, PPM can largely be prevented by using a prospective strategy at the time of operation.

Aortic Valve↗

PubMed2005

Different tilting disc valves show similar rotation-dependent impairment in hemodynamic performance under a tilted implantation position.

BACKGROUND: Aortic annulus calcification can promote tilted implantation of mechanical valves. This study evaluates the hemodynamics of tilting disc valves under this condition. METHODS: 23 mm and 25 mm Ultracor (UC) and Medtronic-Hall-Easy-Fit (MH) valves were investigated in a pulse-duplicator under physiological conditions. Mean pressure gradient (dP(mean)), systolic energy loss (dW(sys)), effective orifice area (EOA), closure (V(Cl)), leakage (V(L)), and total regurgitation volume (V(R)) were assessed. Valves were independently positioned at five axial rotations (0 - 180 degrees , zero defined as major orifice facing the top of the "tilt-ramp") and three tilt angles (0 degrees, 10 degrees, 20 degrees) by lifting the prosthesis in the noncoronary sinus. RESULTS: Diameter-enhanced MH valves exhibited a better systolic performance but a higher regurgitation than corresponding UC valves. Moderate tilting showed a rotation-independent increase in dP(mean) and dW(sys) and a decrease in V (R) and EOA with no fundamental differences between valve types. Further tilting caused small additional changes at 90 - 180 degrees rotation. At 0 degrees rotation, however, dramatic regurgitation occurred throughout. CONCLUSION: Tilting worsened systolic performance regardless of valve type. It should therefore be avoided. Due to extensive regurgitation at 0 degrees rotation, this position should be corrected whenever tilting is inevitable.

Aortic Valve Insufficiency↗

PubMed2002

Value of intraoperative transesophageal echocardiography in preventing serious complications during valvular surgery. A report of four cases.

The value of routine transesophageal echocardiography (TEE) was confirmed by the detection of rare and potentially serious complications in four of 136 patients (2.9%) undergoing valvular surgery. In case 1, one leaflet of a St. Jude Medical (SJM) valve implanted in the mitral position was stuck in the closed position; normal valve function was restored by 90 degrees rotation of the prosthesis. In case 2, moderate regurgitation was observed after mitral valve replacement with a Carpentier-Edwards pericardial bioprosthesis. The mitral valve was replaced with a SJM valve; regurgitation was proved due to a suture loop jamming. In case 3, perivalvular leakage was detected after aortic valve replacement for infective endocarditis; an additional suture stopped the leakage. In case 4, a foreign body was observed in the left atrium after aortic valve replacement for calcified aortic stenosis. The left atrium was re-opened, and a free-floating portion of the calcified native aortic valve was identified and removed. Routine intraoperative TEE in valve surgery permits the identification and management of potentially serious complications before discontinuing cardiopulmonary bypass.

Aged↗

PubMed2005

The Toronto root stentless valve in the subcoronary position is hemodynamically superior to the mosaic stented completely supra-annular bioprosthesis.

BACKGROUND AND AIM OF THE STUDY: Stentless valves are considered to exhibit better hemodynamics after aortic valve replacement (AVR) compared to stented valves. However, a new generation of stented bioprostheses for completely supra-annular implantation has been designed to optimize the ratio of the effective orifice area (EOA) of the prosthesis and aortic annulus area. The study aim was to determine whether a stentless valve implanted in the subcoronary technique renders larger orifice areas and lower transvalvular pressure gradients at rest and exercise compared to a completely supra-annular stented device. METHODS: Twenty patients underwent AVR for aortic stenosis with the St. Jude Medical (SJM) Toronto Root stentless porcine bioprosthesis, using a subcoronary implantation technique. Through the authors' institutional database, 20 additional patients were identified who had undergone AVR with the Medtronic Mosaic stented completely supra-annular porcine bioprosthesis. The patient groups were not matched for labeled valve size, but for annulus diameter measured intraoperatively using Hegar's dilators. Hemodynamic performance was assessed by transthoracic echocardiography at discharge (early) and by rest and stress echocardiography at six months postoperatively (mid-term). RESULTS: Transvalvular mean pressure gradients (MPG) at rest were significantly lower in the stentless group, but cardiac output was similar in both groups. Stress echocardiography also revealed significantly lower gradients at 25 W and 50 W exercise in the stentless group. The EOA index (EOAI), grouped by annulus diameter, tended to be larger in the stentless group and showed no severe patient-prosthesis mismatch (PPM; EOAI <0.65 cm2/m2) which, in contrast, occurred in three patients (15%) in the stented group (p = 0.072). CONCLUSION: In summary, the SJM Toronto Root porcine stentless bioprosthesis in the subcoronary position showed lower MPGs and larger EOAs at rest and during exercise compared to the Medtronic Mosaic porcine stented bioprosthesis. Therefore, physically active patients in particular may benefit from use of the stentless valve. Because of its larger EOA, a stentless valve should be implanted if severe PPM is expected.

Aged↗

PubMed2004

Factors influencing the results of double-valve surgery in patients with fulminant endocarditis: the importance of valve selection.

BACKGROUND: Extension of infection below the aortic valve is a serious complication, especially with mitral valve involvement. Mortality is substantial and reinfection can strongly influence outcome. PATIENTS: Of 327 surgical patients with active infective aortic valve endocarditis admitted to the Deutsches Herzzentrum Berlin for surgical treatment between December 1996 and December 2003, 108 had root abscess, and 53 (25.5%) had diagnoses of secondary infective mitral valve disease (SMVD). The mean age (+/-SD) was 53 +/- 14.2 years; there were 37 men and 16 women. METHODS: The secondary lesion on the mitral valve was classified as SMVD requiring double-valve surgery (DVS). This prospective clinical and echocardiographic study revealed 2 paths of infection extension into the mitral valve. In the DVS group, 38 patients (71.7%) had tissue metastatic lesions, and 15 patients (28.3%) had a jet lesion on the mitral valve. Most patients (42) with SMVD had an aortic ring abscess as the primary lesion. RESULTS: All patients with destructive endocarditic doublevalve disease received aortic and mitral valve surgery. In 19 cases (35.8%), mitral valve reconstruction was undertaken; in 4 cases, mitral valve replacement had to be carried out after attempted mitral valve reconstruction. Concomitant mitral valve replacement because of severe damage to the valvular and subvalvular apparatus was performed in 30 patients (56.6%). Other types of surgery performed in 11 cases (20.8%) were 8 closures of a septic ventricular septal defect and 3 closures of a fistula to the right ventricle or right atrium. Twenty-seven patients were treated with a Shelhigh prosthesis, 18 were treated with double-valve replacement (both Shelhigh), and 9 were treated with an aortic Shelhigh prosthesis and concomitant mitral valve reconstruction. Homografts were used in 17 patients, with mitral valve reconstruction carried out in 10 patients and a stented mitral prosthesis in 7. In 9 cases, 2 stented valve prostheses were used. There were 14 early (60 days) deaths (26.4%). Septic shock, severe annular and subannular destruction, and poor left ventricular function (end-diastolic dimension >65 mm, ejection fraction <40%) were the significant risk factors determined in the multivariate analysis. Function of Implants: Continuous and Color Doppler Investigation: Comparative studies of 2 different implants in the aortic position were performed late postoperatively (325 +/- 251 days) for homografts and the Shelhigh stentless prosthesis. The calculated instantaneous (maximal Doppler) gradient and the mean pressure gradient through the aortic implants were 19 +/- 10.4 mm Hg and 12 +/- 5.7 mm Hg, respectively, for the homografts and 24 +/- 8.4 mm Hg and 15 +/- 4.6 mm Hg, respectively, for the Shelhigh stentless prosthesis (not significantly different for the 2 groups). There was no mitral or aortic valve dysfunction. A trivial paravalvular leakage in the mitral position in 1 patient and a pseudoaneurysm of the left ventricular out- flow tract without leakage or valvular dysfunction in another were diagnosed by postoperative Doppler investigation. CONCLUSIONS: The mortality in patients with destructive endocarditis requiring DVS depends mostly on the patients' preoperative hemodynamic situation. The risk of reinfection can be minimized if valve substitutes are properly selected (homografts, Shelhigh No-React SuperStentless and No-React BioConduit in the aortic position, or Shelhigh BioMitral in the mitral position). Concomitant mitral valve reconstruction procedures do not increase the risk of mitral reinfection.

Endocarditis↗

PubMed1999

Aortic valve replacement with small-sized disc prostheses (medtronic hall).

BACKGROUND AND AIM OF THE STUDY: Several studies have demonstrated a worse performance of small prostheses in the narrow aortic root. However, modern low-profile mechanical prostheses have improved hemodynamic performance, are easy to implant, and have been used increasingly in elderly patients, where narrow roots are most frequently observed. We describe our experience in patients with aortic annuli >21 mm with the use of Medtronic Hall prostheses. METHODS: Between April 1988 and December 1997, a total of 332 patients (218 females, 114 males; mean age 59.3 +/- 9.8 years (range: 29-75 years) received Medtronic Hall size 20 (n = 140), 21 (n = 96) or 22 (n = 96) prostheses. The mean body surface area was 1.59 +/-0.12 m2 (range: 1.27-2.01 m2); 140 patients were in NYHA functional classes III/IV. There were no significant differences in clinical characteristics of patients in the three prosthesis-size groups. RESULTS: The mean preoperative systolic left ventricular/aorta gradient was 64.5 +/- 24.8 mmHg (no significant inter-group difference). After cardiopulmonary bypass, peak gradients through the aortic prostheses were 13.9 +/- 8.0 mmHg in size 20 valves, 14.0 +/- 8.1 mmHg in size 21, and 10.1 +/- 8.9 mmHg in size 22. Four patients died in hospital (mortality rate 1.2%); there were no significant inter-group differences in hospital morbidity. Follow up was complete for 97% of the patients (mean 4.3 years; range: 1-11 years). The late mortality rate was 9.3% (n = 31; 2.56% per pt-yr); of these patients, 20 (14.3%) had size 20 prostheses, seven (7.3%) size 21, and four (4.2%) size 22 (p = 0.01). Fourteen patients (4.2%) died from cardiac causes, and six (1.8%) from prosthesis-related causes. Preoperative older age and aortic regurgitation were the only independent predictors of late mortality. Eight patients had systemic thromboembolic events (0.66% per pt-yr), two had prosthetic thrombosis (0.17% per pt-yr) and five had hemorrhagic episodes (0.41% per pt-yr). Seven patients had prosthetic valve endocarditis (0.58% per pt-yr). Among survivors, 97% are currently in NYHA class I/II. CONCLUSIONS: The small (size 20, 21 and 22) Medtronic Hall prostheses have good hemodynamic performance and are an excellent option as valve substitutes in patients with narrow aortic roots.

Adult↗