Abstract 17870: Hemodynamic Performance of Transcatheter Prosthetic Valve is Superior to that of Surgical Prosthetic Valve for Aortic Valve Stenosis with Small Aortic Root

Introduction: Surgical aortic valve replacement (SAVR) in a small aortic root is still challenging with regard to the surgical technique and prosthesis size selection, which often causes patient-prosthesis mismatch (PPM). On the other hand, because a prosthetic valve of transcatheter aortic valve replacement (TAVR) is tightly implanted inside a native valve, larger effective orifice area (EOA) may be gained. The aim of this study is to prove that hemodynamic performance after TAVR is superior to that after SAVR. Methods: 160 patients, who underwent SAVR (n=36; age 75.1±5.6 years) and TAVR (n=124; age 82.4±6.8 years) for aortic valve stenosis, were enrolled. Preoperative ECG-gated multi-slice CT (MSCT) and echocardiography immediately before a discharge were performed in all patients. PPM was defined as the effective orifice area index ≤0.85cm2/m2 and we compared and examined hemodynamic performance after TAVR and SAVR. Results: Although the mean body size was significantly smaller (p<.05) in TAVR than that in SAVR (1.44±0.15 vs 1.51±0.20 m2), there were no significant differences in the diameters of annulus (23.2±1.6 vs 23.3±2.8 mm), valsalva sinus (29.8±2.6 vs 29.9±4.4 mm), and ST junction (25.2±2.8 vs 24.8±3.5 mm) on preoperative MSCT findings. Postoperative echocardiography revealed significantly less Vmax (2.2±0.4 vs 2.5±0.5 m/s, p<.0001), less mean pressure gradient (10.1±3.6 vs 14.5±5.0 mmHg, p<.0001), and larger EOA (1.62±0.29 vs 1.45±0.36 cm2, p<.005) in TAVR compared to SAVR, respectively. Consequently, PPM was more frequently in SAVR compared to TAVR (33.3 vs 8.9%; p<.0007). In multivariate analysis in SAVR identified small ST junction with only predictive factor of PPM (odds ratio [OR], 2.08; 95% CI, 1.23-4.36; p<.005; area under the receiver-operating characteristic curve [AUC], 0.84). On the other hand, regarding TAVR, large BSA was only predictive factor of PPM (p<.05). Conclusions: The hemodynamic performance of transcatheter prosthetic valve is superior to that of surgical prosthetic valve in a patient with small aortic root, in particular, small ST junction. TAVR should be considered in patients with anticipated PPM if the surgical risk is similar to TAVR.

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Aortic valve replacement in elderly with small aortic root and low body surface area; the Perceval S valve and its impact in effective orifice area

Journal of Cardiothoracic Surgery ◽

10.1186/s13019-016-0438-7 ◽

2016 ◽

Vol 11 (1) ◽

Cited By ~ 18

Author(s):

Panagiotis Dedeilias ◽

Nikolaos G. Baikoussis ◽

Efstathia Prappa ◽

Dimitrios Asvestas ◽

Michalis Argiriou ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Surface Area ◽

Body Surface Area ◽

Valve Replacement ◽

Body Surface ◽

Aortic Root ◽

Effective Orifice Area ◽

Orifice Area ◽

Small Aortic Root

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Stented versus Stentless Aortic Valve Replacement in Patients with Small Aortic Root

Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery ◽

10.1097/imi.0000000000000569 ◽

2018 ◽

Vol 13 (6) ◽

pp. 404-416 ◽

Cited By ~ 3

Author(s):

Amer Harky ◽

Chris H.M. Wong ◽

Alexander Hof ◽

Saied Froghi ◽

Mohammad U. Ahmad ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Hospital Stay ◽

Aortic Root ◽

Effective Orifice Area ◽

Aortic Valves ◽

Orifice Area ◽

Small Aortic Root ◽

Mean Differences ◽

Stented Group

Objective The aim of the study was to compare hemodynamic and perioperative outcomes of stented against stentless aortic valve replacement in patients with small aortic root (21 mm or less). Methods A comprehensive search was undertaken among the four major databases (PubMed, Embase, Scopus, and Ovid) to identify all randomized and nonrandomized controlled trials comparing stentless to stented bioprosthetic valves in small aortic root patients. Odds ratios, weighted mean differences, or standardized mean differences and their 95% confidence intervals were analyzed. Results A total of seven studies with a total of 965 patients fulfilled the inclusion criteria. There was no significant difference in preoperative baselines including mean age between both groups ( P = 0.08), peak aortic valve gradient ( P = 0.06), and effective orifice area ( P = 0.28), whereas higher mean aortic valve gradient in the stented group ( P = 0.007). No difference in cardiopulmonary bypass time ( P = 0.74), aortic cross-clamp times ( P = 0.88), intensive care unit stay ( P = 0.13), and stroke rate ( P = 0.56) were noted. However, stented group of patients showed higher rate of patient prosthesis mismatch ( P = 0.0001) and longer total hospital stay ( P = 0.002). Postoperatively, stentless group showed lower peak and mean aortic valve gradient ( P = 0.003 and P = 0.008, respectively) with a better effective orifice area ( P < 0.00001) at 6 months of follow-up. Mortality rates while in-hospital and at 1 year were similar in both groups ( P = 0.94 and P = 0.86, respectively). Conclusions Stentless aortic valves offer superior short-term hemodynamic outcomes in patients with small aortic root when compared with stented aortic valves. Although both groups have similar perioperative complications rates, stentless valves bring about a shorter hospital stay. A further large multicenter randomized controlled trial should address the longer-term benefit of stentless aortic valve over stented valve.

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Patient-prosthesis mismatch following aortic valve replacement

Heart ◽

10.1136/heartjnl-2018-313515 ◽

2019 ◽

Vol 105 (Suppl 2) ◽

pp. s28-s33 ◽

Cited By ~ 12

Author(s):

Rajdeep Bilkhu ◽

Marjan Jahangiri ◽

Catherine M Otto

Keyword(s):

Renal Failure ◽

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Prosthetic Valve ◽

Left Ventricular ◽

Effective Orifice Area ◽

Orifice Area ◽

Cardiac Symptoms ◽

Patient Prosthesis Mismatch

Patient-prosthesis mismatch (PPM) occurs when an implanted prosthetic valve is too small for the patient; severe PPM is defined as an indexed effective orifice area (iEOA) <0.65 cm2/m2 following aortic valve replacement (AVR). This review examines articles from the past 10 years addressing the prevalence, outcomes and options for prevention and treatment of PPM after AVR. Prevalence of PPM ranges from 8% to almost 80% in individual studies. PPM is thought to have an impact on mortality, mainly in patients with severe PPM, although severe PPM accounts for only 10–15% of cases. Outcomes of patients with moderate PPM are not significantly different to those without PPM. PPM is associated with higher rates of perioperative stroke and renal failure and lack of left ventricular mass regression. Predictors include female sex, older age, hypertension, diabetes, renal failure and higher surgical risk score. PPM may be a marker of comorbidity rather than a risk factor for adverse outcomes. PPM should be suspected in patients with persistent cardiac symptoms after AVR when there is high prosthetic valve velocity or gradient and a small calculated effective orifice area. After exclusion of other causes of increased transvalvular gradient, re-intervention may be considered if symptoms persist and are unresponsive to medical therapy. However, this decision needs to consider the available options to relieve PPM and whether expected benefits justify the risk of intervention. The only effective intervention is redo surgery with implantation of a larger valve and/or annular enlargement. Therefore, focus needs to be on prevention.

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Aortic Valve Replacement With 17-mm St. Jude Medical Prostheses for a Small Aortic Root in Elderly Patients

The Annals of Thoracic Surgery ◽

10.1016/j.athoracsur.2007.01.044 ◽

2007 ◽

Vol 83 (6) ◽

pp. 2050-2053 ◽

Cited By ~ 21

Author(s):

Tohru Takaseya ◽

Takemi Kawara ◽

Shigehiko Tokunaga ◽

Michitaka Kohno ◽

Yasuhisa Oishi ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Elderly Patients ◽

Valve Replacement ◽

Aortic Root ◽

Jude Medical ◽

Small Aortic Root

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IMPACT OF CORRECTION OF PRESSURE RECOVERY PHENOMENON IN CALCULATION OF EFFECTIVE ORIFICE AREA AFTER AORTIC VALVE REPLACEMENT

Journal of the American College of Cardiology ◽

10.1016/s0735-1097(14)61966-5 ◽

2014 ◽

Vol 63 (12) ◽

pp. A1963

Author(s):

Jiyun Sohn ◽

Ha Nul Choi ◽

Hyo-In Choi ◽

Jeong Yun Jang ◽

Byung Joo Sun ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Pressure Recovery ◽

Effective Orifice Area ◽

Orifice Area ◽

Pressure Recovery Phenomenon

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St. Jude Trifecta Versus Carpentier-Edwards Perimount Magna valves for the treatment of aortic stenosis: comparison of early Doppler-Echocardiography and hemodynamic performance

Monaldi Archives for Chest Disease ◽

10.4081/monaldi.2013.74 ◽

2015 ◽

Vol 80 (3) ◽

Author(s):

Giovanni Minardi ◽

Amedeo Pergolini ◽

Giordano Zampi ◽

Giovanni Pulignano ◽

Gaetano Pero ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Stenosis ◽

Doppler Echocardiography ◽

Bioprosthetic Valve ◽

Effective Orifice Area ◽

Orifice Area ◽

Hemodynamic Profile ◽

Hemodynamic Performance

Objective. Aim of this study was to compare the hemodynamic profiles of 2 aortic valve bioprostheses: the Carpentier Edwards Perimount Magna (CEPM) valve and the Trifecta valve. Methods. 100 patients who underwent AVR for severe symptomatic AS between September 2011 and October 2012 were analyzed by means of standard trans-thoracic Doppler-echocardiography. Results. Mean and peak gradients were significantly lower for the 21 mm Trifecta vs CEPM (11 ± 4 vs 15 ± 4 mmHg, and 20 ± 6 vs 26 ± 7 mmHg, respectively; all p < 0.05) and the 23 mm Trifecta vs CEPM (8 ± 2 vs 14 ± 4 mmHg, and 17 ± 6 vs 25 ± 9 mmHg; all p < 0.05). Effective orifice area tended to be slightly higher for the Trifecta valve. Conclusion. The new bioprosthetic valve Trifecta has an excellent hemodynamic profile, and lower trans-prosthesic gradients when compared to CEPM valve.

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The fallacy of indexed effective orifice area charts to predict prosthesis–patient mismatch after prosthesis implantation

European Heart Journal - Cardiovascular Imaging ◽

10.1093/ehjci/jeaa044 ◽

2020 ◽

Vol 21 (10) ◽

pp. 1116-1122 ◽

Cited By ~ 4

Author(s):

Michiel D Vriesendorp ◽

Rob A F De Lind Van Wijngaarden ◽

Stuart J Head ◽

Arie-Pieter Kappetein ◽

Graeme L Hickey ◽

...

Keyword(s):

Aortic Valve ◽

Aortic Valve Replacement ◽

Valve Replacement ◽

Reference Values ◽

Effective Orifice Area ◽

Training Set ◽

Surgical Aortic Valve Replacement ◽

Test Set ◽

Orifice Area ◽

Normal Reference

Abstract Aims Indexed effective orifice area (EOAi) charts are used to determine the likelihood of prosthesis–patient mismatch (PPM) after aortic valve replacement (AVR). The aim of this study is to validate whether these EOAi charts, based on echocardiographic normal reference values, can accurately predict PPM. Methods and results In the PERIcardial SurGical AOrtic Valve ReplacemeNt (PERIGON) Pivotal Trial, 986 patients with aortic valve stenosis/regurgitation underwent AVR with an Avalus valve. Patients were randomly split (50:50) into training and test sets. The mean measured EOAs for each valve size from the training set were used to create an Avalus EOAi chart. This chart was subsequently used to predict PPM in the test set and measures of diagnostic accuracy (sensitivity, specificity, and negative and positive predictive value) were assessed. PPM was defined by an EOAi ≤0.85 cm2/m2, and severe PPM was defined as EOAi ≤0.65 cm2/m2. The reference values obtained from the training set ranged from 1.27 cm2 for size 19 mm up to 1.81 cm2 for size 27 mm. The test set had an incidence of 66% of PPM and 24% of severe PPM. The EOAi chart inaccurately predicted PPM in 30% of patients and severe PPM in 22% of patients. For the prediction of PPM, the sensitivity was 87% and the specificity 37%. For the prediction of severe PPM, the sensitivity was 13% and the specificity 98%. Conclusion The use of echocardiographic normal reference values for EOAi charts to predict PPM is unreliable due to the large proportion of misclassifications.

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