Aortic Valve Replacement in Patients with Small Aortic Annulus: New Pericardial Stented Valves vs Aortic Root Enlargement Procedures.

Objectives: Newer generations of stented pericardial valves may offer hemodynamic benefit in patients with small aortic annulus. The aim of this study was to determine the effectiveness of isolated aortic valve replacement with one such valve, the Trifecta valve, when compared to Aortic root enlargement surgery in reducing postoperative gradients and the severity of PPM in patients with small aortic annulus. Patients and methods: A prospective observational study of 100 patients with SAA who underwent AVR from March 2020 to October 2021 in Cairo university hospitals and other centers. The cohort was divided into two groups based on surgical technique: Isolated AVR using Trifecta valve or ARE and mechanical valve placement. Preoperative characteristics, intraoperative times and postoperative outcomes were recorded and compared in all patients, including a pre-discharge echocardiography. Results: Increased operative times, increased ICU stay and need for blood products were observed in the ARE group and operative time was determined as an independent risk factor. Higher rate of complications such as need for permanent pacemaker as well increased postoperative drainage was also recorded in ARE group, with no difference between groups in in-hospital mortality. Higher incidence of PPM was recorded in the Trifecta group (24%) compared to the ARE group (8%). but, the severity of PPM within the Trifecta group was reduced compared to the ARE group, and no degree of PPM was observed in Trifecta valves sized 21. Conclusion The Trifecta valve offers excellent postoperative hemodynamics and significant reduction in severity of PPM in patients with SAA undergoing AVR, with gradients and iEOA almost comparable to larger sized valves implanted after ARE, making the increased surgical burden of ARE unnecessary in most patients.

Early-Term Hemodynamic Performance And Clinical Results of 19-mm st. Jude Medical Regent Valve In Patients With Small Aortic Annulus Undergoing Dual Valve Replacement: A Retrospective Study

Background: The prosthesis selection in patients with small aortic annulus undergoing aortic valve replacement (AVR) has always been a challenge, especially in dual valve replacement (DVR, combined aortic and mitral valve replacement). The present study aimed to analyze early-term hemodynamic parameters of 19-mm St. Jude Medical Regent ( SJMR19 ) valve in patients with small aortic annulus undergoing DVR. Methods: Between January 2015 to December 2020, 54 patients with small aortic annulus who underwent DVR were divided into two groups: SJMR19 valve group (n=30) and 21-mm mechanical (M21) valve group (n=24). The perioperative and early-term hemodynamic data were collected and analyzed. Results: A significant difference in terms of maximum transaortic flow velocity (Vav max), maximum transaortic pressure gradient (PGav max), left ventricular mass index (LVMi) and left ventricular mass (LVM) was observed postoperatively in both groups. The postoperative left ventricular ejection fraction (LVEF) was significantly higher while the LVM and LVMi was evidently decreased in the SJMR19 group, compared with the M21 group. In order to confirm the influencing factors on postoperative LVEF, a multiple linear regression analysis model was established by including all candidate variables and the implanted valve type was identified in the multivariate analysis as an independent predictor for postoperative LVEF. Conclusions: The postoperative cardiac function and hemodynamic parameters was improved both in the SJMR19 and M21 groups. The postoperative LVEF, LVM and LVMi were better in the SJMR19 group compared with those of the M21 group. And the implanted valve type might possess the predictive value of postoperative LVEF in patients with small aortic annulus undergoing DVR.

Transcatheter aortic valve implantation in patients with a small aortic annulus: performance of supra-, intra- and infra-annular transcatheter heart valves

Background A small aortic annulus is associated with increased risk of prosthesis–patient mismatch (PPM) after transcatheter aortic valve implantation (TAVI). Whether specific transcatheter heart valve (THV) designs yield superior hemodynamic performance in these small anatomies remains unclear. Methods Data from 8411 consecutive patients treated with TAVI from May 2012 to April 2019 at four German centers were retrospectively evaluated. A small aortic annulus was defined as multidetector computed tomography-derived annulus area < 400 mm2. TAVI was performed with a balloon-expanding intra-annular (Sapien-3, n = 288), self-expanding intra-annular (Portico, n = 110), self-expanding supra-annular (Evolut, n = 179 and Acurate-Neo, n = 428) and mechanically expanding infra-annular (Lotus, n = 64) THV according to local practice. PPM was defined as indexed effective orifice area ≤ 0.85cm2/m2. Results A small annulus was found in 1069 (12.7%) patients. PPM was detected in 38.3% overall with a higher prevalence after implantation of a balloon-expanding intra-annular or mechanically expanding infra-annular THV compared to self-expanding intra- and supra-annular THV. Multivariable analysis linked self-expanding THV (Evolut: Odds ratio [OR] 0.341, Acurate-Neo: OR 0.436, Portico: OR 0.291), postdilatation (OR 0.648) and age (OR 0.968) to lower rates of PPM, while aortic valve calcification was associated with an increased risk (OR 1.001). Paravalvular regurgitation > mild was more frequent after TAVI with self-expanding THV (p = 0.04). Conclusion In this large contemporary multicenter patient population, a substantial number of patients with a small aortic anatomy were left with PPM after TAVI. Self-expanding supra- and intra-annular THV demonstrated superior hemodynamics in these patients at risk, however at the cost of higher rates of residual paravalvular regurgitation. Graphic abstract

Aortic Root Enlargement in Patients With Small Aortic Annulus Undergoing Double Valve Replacement: A Retrospective Comparative Cohort Study

Background: Small aortic annulus (AA) is a big issue during aortic valve replacement (AVR), necessitating replacement of an undersized prosthetic valve especially with double valve replacement (DVR). Despite the fact that small aortic valve prostheses can lead to prosthesis-patient mismatch (PPM), there remains reluctance to perform aortic root enlargement (ARE) procedures, fearing morbidity and mortality. Objective: To evaluate clinical and echocardiographic outcomes in patients with small aortic annulus (<18 mm) undergoing double valve replacement. Methods: The study included 100 consecutive patients who underwent DVR for combined rheumatic aortic and mitral valve diseases, between January 2016 and September 2020. Only 50 patients had ARE with DVR. ARE was performed using an autologous or bovine pericardium or Dacron patch by Nick's or Manouguian procedures. The estimated postoperative endpoints were mortality, effective orifice areas (EOA), mean aortic pressure gradient (PG), and valve-related complications. The shortest postoperative follow-up period was 6 months. Results: The study included 30 male and 70 female patients with mean age of 35±20 years, body surface area (BSA) of 1.7 ± 0.3 m2, aortic annulus diameter was 1.4 ± 0.4 mm, aortic orifice area was 0.8 ± 0.1 cm2, and mean pressure gradient 85 ± 2.5 mmHg. During the follow-up period, there was a mild to moderate paravalvular leak (1%) with 1% heart block and residual gradient on prosthetic aortic valve; this was all in DVR alone. Conclusion: Enlargement of the aortic root by Nick's or Manouguian technique is safe and effective in patients with small aortic annulus undergoing double valve replacements.