Rest and exercise hemodynamics following aortic valve replacement. A comparison between 19 and 21 mm Ionescu-Shiley pericardial and Carpentier-Edwards porcine valves

When aortic valve replacement is performed in a patient with a small anulus, significant obstruction of the left ventricular outflow tract may remain. Most prostheses are obstructive in the smaller sizes, and enlargement of the aortic anulus may be required to allow placement of a larger valve. To evaluate the hemodynamic performance of two commonly used tissue prostheses, the Ionescu-Shiley pericardial and Carpentier-Edwards porcine valves, 22 patients with either the 19 or 21 mm size were electively studied at rest and after exercise at a mean of 15 months after operation. The resting mean transvalvular gradient for 19 mm Ionescu-Shiley pericardial valves (n = 7), 10.6 +/- 9.2 mm Hg, was significantly lower than that for 19 mm Carpentier-Edwards valves (n = 3), 33.3 +/- 2.1 mm Hg, p less than 0.01. Following exercise, the mean gradient for 19 mm Ionescu-Shiley pericardial valves rose only to 13.8 +/- 8.5 mm Hg. No exercise data were available for the 19 mm Carpentier-Edwards valve. Among patients with 21 mm Ionescu-Shiley pericardial valves (n = 7), the mean transvalvular gradient at rest was 5.6 +/- 9.5 mm Hg, not significantly different from that of patients with 21 mm Carpentier-Edwards valves (n = 5), 9.8 +/- 18.3 mm Hg. After exercise, the gradients rose to 16.0 +/- 10.0 mm Hg and 25.5 +/- 23.8 mm Hg for the Ionescu-Shiley pericardial and Carpentier-Edwards valves, respectively (no statistical significance). Cardiac index was not different between groups. Gradients were not significantly higher in patients with body surface areas greater than 1.5 m2. It is concluded that the 19 and 21 mm Ionescu-Shiley pericardial valves possess excellent hemodynamics, even after exercise. This valve appears hemodynamically superior to the Carpentier-Edwards valve, particularly in the 19 mm size. Procedures to enlarge the aortic anulus are usually unnecessary when small Ionescu-Shiley pericardial valves are used, even in patients who have large body surface areas.     

Aortic valve replacement with concomitant annular enlargement for small aortic annulus of less than 19 mm.

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.     

Intermediate results of aortic valve replacement using 19 mm bioprosthetic valve

Pre- and postoperative hemodynamic parameters and activity of daily life were reviewed to estimate the effectiveness of the valve in 12 cases of single aortic valve replacement (AVR) using 19 mm bioprosthesis. All implanted prostheses were stented-valves. Carpentier-Edwards pericardial valve was used in 7 cases and Mosaic valve in 5. Left ventricular mass index (LVMI) significantly decreased from 167 +/- 36 to 133 +/- 27 g/m2 in the early postoperative period, and to 115 +/- 24 g/m2 in the intermediate phase. However, postoperative LVMI remained higher in patients with body surface area (BSA) over 1.5 m2 than in those under 1.5 m2. Postoperative activity indicated by New York Heart Association (NYHA) grade significantly improved from 2.3 +/- 1.1 to 1.4 +/- 0.5. These results indicates usefulness of 19 mm bioprosthetic valve for reducing left ventricular hypertrophy and improving activity, especially in patients with BSA smaller than 1.5 m2.     

Aortic valve replacement in adult patients with small aortic annuli

Fifty-five patients with small aortic annuli underwent valve replacement either isolated or combined with other procedures. Patch enlargement of the aortic annulus in the area of the noncoronary sinus was used in 32 patients. The width of the patch was calculated by multiplying the desired increase in diameter by pi and adding 8 mm for suturing. The remaining 23 patients had aortic valve replacement with a prosthesis larger than the aortic annulus. The prosthesis was sutured in a supraannular position in the area corresponding to the noncoronary sinus. This slightly tilted position does not compromise function of Carpentier-Edwards or Bj?rk-Shiley prostheses. Prosthetic gradients ranged from 0 to 18 mm Hg (9.2 +/- 3.9 mm Hg) in patients with patch enlargement of the aortic annulus and from 0 to 22 mm Hg (7.2 +/- 5.8 mm Hg) in patients with supraannular aortic prostheses. Although these techniques allow for insertion of prosthetic valves only one and two sizes larger than the aortic annulus, they appear to be satisfactory in most adult patients with a small aortic annulus.     

Clinical and hemodynamic performance of the Ionescu-Shiley valve in the small aortic root. Results in 117 patients with 17 and 19 mm valves

The Ionescu-Shiley pericardial valve was our bioprosthetic valve of choice between 1981 and 1985 for patients in whom the aortic anulus could not accept a valve larger than 19 mm in outer diameter or in whom the avoidance of warfarin sodium (Coumadin) was important. A series of 117 consecutive patients who received 17 or 19 mm valves for isolated aortic valve replacement or aortic valve replacement combined with coronary artery bypass grafting or other valvular procedures was analyzed. Overall, 74% of the patients were female, with a mean age of 70.9 years and a body surface area of 1.67 +/- 0.19 m2; 92.3% were in New York Heart Association class III-IV, and the operation was urgent or emergent in 46%. The operative mortality rate was 7.7%, with no deaths in patients undergoing isolated elective first-time aortic valve replacement. Mean follow-up for survivors was 2.5 years (10 to 62 months). There were 20 late deaths, of which three were valve related, three were due to sudden death or arrhythmias, and two were due to persistent heart failure. The actuarial survival rate at 5 years was 68%. Clinical follow-up revealed a low incidence of valve-related complications, and 96.4% of survivors were in class I-II. Postoperative echocardiography before hospital discharge revealed a maximum instantaneous gradient of 18.4 +/- 3.0 mm Hg in five patients having a 17 mm valve and 31.3 +/- 12.7 mm Hg in 20 patients having a 19 mm valve. Doppler echocardiography was performed in 22 patients at a mean follow-up of 39.3 +/- 11.7 months. The maximum instantaneous gradient was 25 +/- 17.2 mm Hg for 17 mm and 17.41 +/- 5.4 mm Hg for 19 mm valves at late follow-up. The effective orifice area was 0.85 +/- 0.1 cm2 for 17 mm and 1.21 +/- 0.21 cm2 for 19 mm valves. This study defines the normal range of Doppler echocardiographic transprosthetic gradients for the Ionescu-Shiley valve and confirms that low operative mortality and excellent clinical improvement can result from the use of small Ionescu-Shiley valves in elderly patients despite moderate postoperative transvalvular gradients.     

Aortic valve replacement for aortic stenosis with a small mechanical prosthetic valve

BACKGROUND: Although aortic valve replacement (AVR) is the only effective treatment for patients with aortic stenosis (AS), it is recognized that the use of small prosthetic valves due to a small aortic root often affects postoperative course after AVR. The aim of this study was to determine whether the use of small prosthetic valves was a risk factor of AVR for AS. METHODS: We compared various perioperative factors and operative outcomes between patients with a small mechanical prosthetic valve (small group) and patients with a large mechanical prosthetic valve (large group). RESULTS: Early mortality was 0% in each group and the 5-year mortality was 25% in the small group and 10% in the large group. There were no significant differences in perioperative factors between the two groups. The small group patients were significantly older and smaller compared to the large group patients. The valve size was significantly correlated with age and BSA. CONCLUSIONS: The use of small mechanical prostheses was not a risk factor of AVR for AS when it was proportionate to the BSA even for elderly patients. AVR using a small mechanical prosthetic valve may be performed with good results in the short- and long-term.     

Aortic valve replacement with 17-mm St. Jude Medical Regent prosthetic valves for a small calcified aortic annulus in elderly patients

Purpose  

The aim of this study was to investigate the outcome of aortic valve replacement (AVR) performed with a 17-mm St. Jude Medical Regent prosthetic valve (17SJMR) for an aortic annulus ≤19 mm in elderly patients aged ≥65 years.     

Aortic valve replacement with omniscience and omnicarbon valves.

Clinical results achieved in 100 cases of aortic valve replacement with the Omniscience (O-S) valve during the period from 1980 to 1985 as well as 100 cases of aortic valve replacement with the Omnicarbon (O-C) valve during the period from 1985 to 1989 were studied. Concomitant surgical procedures including mitral valve replacement were performed in 63 patients in the O-S group and 67 patients in the O-C group. Cumulative follow-up in the two groups was carried out for a total of 559 and 273 patient-years, respectively. The overall 4-year actuarial survival rate was 82% +/- 3.8% in the O-S group and 89.5% +/- 3.2% in the O-C group, the corresponding rates for patients undergoing isolated aortic valve replacement being 82.9% +/- 4.2% in the O-S group and 91.9% +/- 3.5% in the O-C group. The overall 4-year actuarial event-free rate with respect to thromboembolic complications was 88.8% +/- 3.3% in the O-S group and 94.4% +/- 2.8% in the O-C group, as compared with the corresponding rates of 89.2% +/- 3.6% in the O-S group and 95.9% +/- 2.8% in the O-C group for patients undergoing isolated aortic valve replacement. The overall rate of valve-related complications, including thromboembolism, anticoagulant-related hemorrhage, perivalvular leak, infection, and structural failure, was 78.8% +/- 4.2% in the O-S group and 89.3% +/- 3.5% in the O-C group (p less than 0.05), and for isolated aortic valve replacement, 79.7% +/- 4.5% in the O-S group and 89.6% +/- 4.1% in the O-C group.(ABSTRACT TRUNCATED AT 250 WORDS)     

Long-term clinical results after aortic valve replacement with mechanical heart valves and mitral valve replacement with porcine valves]

Long-term clinical results of aortic valve replacement (AVR) with mechanical heart valves and mitral valve replacement (MVR) with porcine valves were analysed. Sixty-three patients received isolated AVR and 48 received isolated MVR. Sixty-eight patients with MVR including double or triple valve replacement were also added in order to evaluate the primary tissue failure (PTF). The patients with operative deaths were excluded. Survival rate at 11 years in AVR was 68 +/- 10% and 67 +/- 15% in MVR without statistical difference. At 11 years, 76 +/- 8% of the patients in AVR were free from valve-related complications in contrast with the poor result of 34 +/- 31% in MVR (p less than 0.01). Main cause of this poor result in MVR was PTF as indicated in following event free rates; 83 +/- 9% at 7 years, 61 +/- 25% at 10 years and 49 +/- 31% at 13 years. There was no statistical difference between patients of above 50 years and below 49 years in PTF. Valve-related death event free was 93 +/- 5% in AVR and 86 +/- 11% in MVR at 11 years (not significant), however, there was statistical difference in re-operation event free rate as 94 +/- 5% in AVR and 76 +/- 11% in MVR at 11 years (p less than 0.001). These results suggest that the use of porcine valves in mitral position is confined to the selected patients.     

主动脉瓣环窄小的二尖瓣和主动脉瓣联合置换术

目的 总结37例主动脉瓣环细小患者二尖瓣、主动脉瓣联合置换术的经验。方法 所有患者均先置换主动脉瓣，再置换二尖瓣，瓣膜均为机械瓣，同期行三尖瓣成形术34例。结果 术后早期并发症为低心排血量综合征1例，肾功能不全2例，频发性室性早搏6例，无早期死亡；术后随访3个月～3．5年，平均1．61年，无远期死亡。结论 对需行二尖瓣、主动脉瓣联合置换的主动脉瓣环细小患者，先行主动脉瓣置换可放置相对较大口径的主动脉瓣，其早期和晚期效果均较满意。     

Clinical outcome of aortic valve replacement with 19-mm prosthetic valve in elderly patients

From 1979 to June 2005, 90 patients aged 65 or older underwent aortic valve replacement with 19-mm prosthetic valve. They were 84 women and 6 men, with a mean age of 74. The mean body surface area was 1.35 m2. Bioprosthetic valves were implanted in 77 patients (85.6%). In-hospital mortality was 2.2% (2 of 90). There were 13 late deaths. New York Heart Association (NYHA) functional class improved to class I in most of survivors. Survival rates for 5 and 10 years were 84.9 and 71.2%, respectively. The outcome of aortic valve replacement with 19-mm prosthetic valve in elderly patients was excellent.     

Haemodynamic results of replacement of mitral and aortic valves with autologous fascia lata prostheses

Twelve patients undergoing aortic and 28 undergoing mitral valve replacement with autologous fascia lata valves were studied before and six months after surgery. One aortic and 10 mitral valves were found to be significantly incompetent. Of the incompetent mitral valves, two appeared to have perivalvular leaks. Six of the remainder were associated with abnormal ventricular filling patterns. Valve failure was much less common when the design was modified to provide a loose cusp structure; out of 12 such valves none was incompetent. Transvalvular gradients persist with fascial valves though they are lower than with most mechanical prostheses. Ventricular function was greatly improved in successful aortic replacement but remained impaired in the case of mitral replacement. Valve failure appeared to be associated with, or accelerated by, haemodynamic stress rather than due to inevitable degenerative pathological processes.     

Early and late results of aortic valve replacement. A series of 510 patients

Aortic valve replacement was performed in 510 patients (Bj?rk-Shiley valves in 93%), with concomitant surgical procedures in 146 cases. The patients were grouped according to technique of myocardial protection: Group I (n = 98) selective coronary perfusion, group II (n = 82) topical cooling, and group III (n = 330) cold crystalloid cardioplegia and topical cooling. The early mortality rate was 5.7% overall: Among patients with isolated aortic valve replacement in groups I, II and III it was 8.4, 1.7 and 1.3%, respectively, and among those with additional surgery 40.0, 12.5 and 8.4%. Myocardial infarction and low cardiac output were responsible for 65.5% of the early deaths. Follow-up ranged from 2 months to 16 11/12 years, totalling 2,859 patient years. In patients with isolated aortic valve replacement and Bj?rk-Shiley prosthesis, the incidence of valve-related late complications/100 patient years was 0.49 for thromboembolism, 0.82 for anticoagulant-related haemorrhage and 0.49 for prosthetic valve endocarditis. There was no thrombotic encapsulation in aortic position. Survival at 5 and 10 years was 83% and 72%. Aortic valve replacement is a safe procedure and concomitant operations do not unreasonably increase risks.     

Aortic valve replacement for active infectious endocarditis in 108 patients. A comparison of freehand allograft valves with mechanical prostheses and bioprostheses.

A total of 108 patients hospitalized with active (acute) endocarditis on either a native aortic valve (n = 66) or a previously inserted replacement device (n = 42) underwent aortic valve replacement because they were too ill for hospital discharge. A nonstented aortic allograft valve was used in 78 patients and prosthetic (mechanical or bioprosthetic) valves in 30 patients. The survival rate was 82% at 1 months, 73% at 1 year, 64% at 5 years, and 36% at 15 years. It was better in patients with native valve endocarditis than prosthetic valve endocarditis. The incremental risk factors for death in the early phase postoperatively were older age at operation, higher New York Heart Association functional class, and a larger number of previous aortic valve procedures. There were 13 episodes of recurrent endocarditis, giving an actuarial freedom of 80% at 10 years. The hazard function for recurrent endocarditis had only a low constant phase when allograft valves were used, which contrasted with the existence of a high peaking early phase (in addition to the constant phase) when prosthetic devices were used. No risk factors for recurrent endocarditis were found in patients receiving a prosthesis, and "localized" versus "extensive" endocarditis was the only risk factor when an allograft was used. Reoperation was performed in 24 patients for a variety of reasons, and freedom from reoperation was 61% at 10 years. It is concluded that the allograft valve is the valve of choice when aortic valve replacement is required for active endocarditis.