EFFICACY OF AORTIC VALVE REPLACEMENT USING THE St. Jude Medical-HP VALVE FOR PATIENTS WITH A SMALL AORTIC ANNULUS
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[Introduction] The ideal mechanical prosthesis to replace the aortic valve in patients with a small aortic annulus remains controversial. The purpose of this study is to compare hemodynamic performance and clinical results of the SJM-HP with those of standard valves(Bjork-Shiley(B-S) and standard SJM) in patients with a small aortic annulus who received a patch enlargement. [Materials and Methods] Between 1975 and 1998, 33 patients received a 21mm SJM-HP (16 patients), a 21mm standard SJM(5 patients), or a 23mm B-S(12 patients) aortic prosthesis. For all patients who had one of the standard valves implanted the patch enlargement was performed using Nicks' method. Either doppler echocardiography or catheterization were performed both before and after the operation, and readings of flow velocity, and the pressure gradient across the valve were measured. [Results] There were no differences in flow velocity or pressure gradient between the groups. Moreover, we experienced no operative mortalities or significant perioperative complications. Peak and mean pressure gradients, along with flow velocity, in the 21mm SJM-HP group were significantly lower than the 21mm SJM group, in early postoperative and later follow-up periods. However, there were no statistical differences in these indices between the 21mm SJM-HP group and the 23mm B-S group seen at follow-up. [Conclusion] Based on our results, we believe that the 21mm SJM-HP should be selected for AVR when the preoperative aortic annulus diameter is approximately 22mm and for patch enlargement for a small aortic annulus when the preoperative aortic annulus diameter is below 20mm.Keywords:
Cardiac skeleton
Annulus (botany)
Aortic pressure
[Introduction] The ideal mechanical prosthesis to replace the aortic valve in patients with a small aortic annulus remains controversial. The purpose of this study is to compare hemodynamic performance and clinical results of the SJM-HP with those of standard valves(Bjork-Shiley(B-S) and standard SJM) in patients with a small aortic annulus who received a patch enlargement. [Materials and Methods] Between 1975 and 1998, 33 patients received a 21mm SJM-HP (16 patients), a 21mm standard SJM(5 patients), or a 23mm B-S(12 patients) aortic prosthesis. For all patients who had one of the standard valves implanted the patch enlargement was performed using Nicks' method. Either doppler echocardiography or catheterization were performed both before and after the operation, and readings of flow velocity, and the pressure gradient across the valve were measured. [Results] There were no differences in flow velocity or pressure gradient between the groups. Moreover, we experienced no operative mortalities or significant perioperative complications. Peak and mean pressure gradients, along with flow velocity, in the 21mm SJM-HP group were significantly lower than the 21mm SJM group, in early postoperative and later follow-up periods. However, there were no statistical differences in these indices between the 21mm SJM-HP group and the 23mm B-S group seen at follow-up. [Conclusion] Based on our results, we believe that the 21mm SJM-HP should be selected for AVR when the preoperative aortic annulus diameter is approximately 22mm and for patch enlargement for a small aortic annulus when the preoperative aortic annulus diameter is below 20mm.
Cardiac skeleton
Annulus (botany)
Aortic pressure
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A 35-year old female patient underwent a double valve replacement. The operative findings revealed a small aortic annulus (about 17 mm in diameter). In order to implant the adequate-size prosthetic valve, the aortic and mitral annulus were enlarged using the technique described by Rastan and Manouguian. The annulus were enlarged with a patch of gel-sealed dacron graft. After the enlargement, the prosthetic valve No. 23A and 31M could be implanted in the aortic and mitral annulus, respectively. This is an effective technique to enlarge the aortic and mitral annulus in a double valve replacement procedure. The annular diameter could be increased approximately 30 per cent.
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Three female patients with aortic stenosis associated with a severely small annulus underwent aortic valve replacement. In intraoperative measurements, a 19-mm obtulator could not pass through the aortic annulus in each case. We therefore concluded that it would be difficult to implant an appropriate-sized prosthesis in a routine fashion, so we performed an annular enlargement in a modified Nicks procedure. By using a wide teardrop-shaped patch for enlargement and slightly tilting insertion of a prosthesis, a 21 mm bileaflet mechanical prosthesis could be inserted into the enlarged annulus. Despite being a simpler method than other enlarging procedures, a two- or three-sizes larger prosthesis than the native annulus can be inserted with relative ease. Thus, the use of a 19 mm mechanical prosthesis may be avoidable in most adult cases.
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Background— The objective was to evaluate the effects of aortic annulus size on valve hemodynamics and clinical outcomes in those patients included in the Placement of Aortic Transcatheter Valves (PARTNER) randomized controlled trial cohort A and the nonrandomized continued access cohort. Methods and Results— Patients included the randomized controlled trial (n=574) and nonrandomized continued access (n=1358) cohorts were divided in tertiles according to aortic annulus diameter (small aortic annulus tertile, medium aortic annulus tertile, and large aortic annulus tertile [LAA], respectively) as measured by transthoracic echocardiography. Severe prosthesis–patient mismatch was defined as an effective aortic orifice area of <0.65 cm 2 /m 2 . In the randomized controlled trial cohort, patients in the small aortic annulus tertile who underwent transcatheter aortic valve replacement had a lower incidence of severe prosthesis–patient mismatch (19.7% versus 37.5%; P =0.03) and only a trend toward a higher incidence of moderate-to-severe paravalvular leaks compared with surgical aortic valve replacement (5.7% versus 0%; P =0.06). In the LAA tertile, there were no differences in the rate of prosthesis–patient mismatch between groups, and a significant increase in moderate-to-severe paravalvular leaks was associated with transcatheter aortic valve replacement (9% versus 0%; P =0.01). There were no differences in mortality between transcatheter aortic valve replacement and surgical aortic valve replacement. In the nonrandomized continued access cohort, there were no differences in prosthesis–patient mismatch between the small aortic annulus and LAA tertiles, but a higher rate of moderate-to-severe paravalvular leaks was observed in the LAA tertile (5.9% versus 11.5%; P =0.009). Patients in the LAA tertile had a higher mortality rate at 1-year follow-up ( P =0.02), and differences persisted in multivariable analysis ( P =0.048 for LAA versus medium aortic annulus tertile, P =0.035 for LAA versus small aortic annulus tertile). Conclusions— Aortic annulus size had a major impact on valve hemodynamics and clinical outcomes after transcatheter aortic valve replacement and surgical aortic valve replacement. This study highlights the importance of considering aortic annulus size in the evaluation of high-risk patients who are candidates for aortic valve replacement. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00530894.
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Objectives Aortic valve replacement (AVR) in patients with small aortic annulus (diameter ≤21 mm) is considered a challenging scenario because of technical aspects and the high risk of patient-prosthesis mismatch (PPM). The choice of the appropriate prosthesis is crucial, and at the moment, an ideal device has yet to be identified. We compare clinical and hemodynamic results after AVR with three bioprostheses with different design and characteristics. Methods We retrospectively evaluated 76 consecutive patients from two cardiac surgery centers who underwent AVR (Trifecta = 24; Edwards INTUITY Elite valve system = 26, and Perceval = 26) for severe aortic stenosis between 2013 and 2017. Patients selected were older than 75 years and with an annulus diameter ≤21 mm at preoperative echocardiogram. Reinterventions and combined procedures were excluded. Minimally invasive AVR was performed in 44 (57.8%) patients. Telephonic interview was obtained at 2.9 ± 0.5 years and echocardiographic follow-up at 2.2 ± 0.8 years. Results Clinical outcome was similar in the three groups. At follow-up, Trifecta patients presented significantly higher peak and mean transprosthetic pressure gradients ( P = 0.04 and 0.01). Effective orifice area and left ventricular mass regression were comparable, although an advantage was observed in Perceval patients without reaching the statistical significance. Incidence of moderate ( P = 0.2) and severe PPM ( P = 0.7) was comparable. Conclusions Despite higher postoperative pressure gradients observed with the Trifecta valve, all three prostheses (Trifecta, Edwards INTUITY Elite, and Perceval) have proven to be reliable when implanted in small aortic annuli, with good clinical outcome and favorable left ventricular mass regression.
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The possibility of determining the real size of the aortic annulus on the basis of adequate angiocardiographic measurements has been retrospectively verified in a group of 10 patients who underwent aortic valve replacement. A good correlation (r = 0.99) was found between the predicted diameter of the aortic annulus and the size of the valve inserted at operation. The useful implications associated with prediction of the diameter of the aortic annulus are discussed.
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