Clinical and hemodynamic evaluation of small Perimount aortic valves in patients aged 75 years or older

BACKGROUND: There is the potential for iatrogenic aortic stenosis and poor quality of life when small aortic valve bioprostheses are used in elderly patients. The alternative is enlarging the aortic annulus to accommodate larger size prostheses, increasing operative mortality. It was hoped that bovine pericardial valves would improve hemodynamic performance in the smaller valve sizes. METHODS: To determine long-term results and in vivo hemodynamic performance of small-size aortic Carpentier-Edwards bovine pericardial valves (Perimount) in elderly patients, we analyzed our follow-up and echocardiographic data from patients 75 years of age or older receiving isolated 19-mm and 21-mm Perimount valves. Ninety-four patients with a mean age of 77 +/- 2.2 years were followed for 12 years. Seventeen patients with 19-mm and 25 patients with 21-mm Perimount valves underwent transthoracic echocardiograms. RESULTS: Operative mortality was 6.3% (6 of 94). Twelve-year survival was 82.7%. Freedom from thromboembolism was 86.9% at 12 years. Two patients had anticoagulation-related bleeding. Overall New York Heart Association class decreased from 3 +/- 1 to 1.6 +/- 0.7 at the end of follow-up. Hemodynamic performances were satisfactory in both 19-mm and 21-mm Perimount valves, with low peak and mean transvalvular gradients and good effective orifice areas, orifice area indices, and performance indices. CONCLUSIONS: Perimount aortic valve in the small aortic annulus has yielded excellent long-term results and hemodynamic performances. Perimount is a very satisfactory option in elderly patients. Implantation of a Perimount bioprosthesis avoids enlargement of the small aortic annulus, reducing mortality and morbidity associated with this procedure.     

Performance of 21-mm size perimount aortic bioprosthesis in the elderly

BACKGROUND: Aortic valve replacement in elderly patients with a small aortic annulus may pose difficult problems in terms of prosthesis selection. We have evaluated the hemodynamic performance of the 21-mm Carpentier-Edwards Perimount bioprosthesis implanted in elderly patients. METHODS: From July 1996 to June 1998, 19 patients (17 women and 2 men, mean age 76+/-4 years and mean body surface area 1.73+/-0.13 m2), had aortic valve replacement with a 21-mm Carpentier-Edwards Perimount bioprosthesis. The hemodynamic performance of the valve was evaluated in 16 patients, who completed at least a 6-month follow-up interval, with transthoracic color-Doppler echocardiography with particular reference to peak and mean transprosthetic gradients, effective orifice area index, and regression of left ventricular mass index. RESULTS: There were no late deaths and no major postoperative complications. At a mean follow-up of 12+/-7 months, compared to discharge, all patients showed clinical improvement with a significant reduction of peak gradient (from 23+/-4 to 21+/-6 mm Hg, p = 0.04) and left ventricular mass index (from 181+/-23 to 153+/-20 g/m2; p<0.001), whereas mean gradient (from 13+/-3 to 13+/-4 mm Hg, p = not significant) and effective orifice area index (from 1.12+/-0.34 to 1.13+/-0.28 cm2/m2, p = not significant) remained substantially unchanged. CONCLUSIONS: The use of a 21-mm Carpentier-Edwards Perimount bioprosthesis is associated with low transprosthetic gradients and significant reduction in left ventricular hypertrophy after aortic valve replacement. The results of our study suggest that a 21-m Carpentier-Edwards Perimount bioprosthesis should be considered a valid option in elderly patients with aortic valve disease and a small aortic annulus.     

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.     

Bioprosthetic valve endocarditis associated with rapid progression of valvular stenosis;report of a case

Long-term durability and stability of the hemodynamic performance of commercially available 2nd generation Carpentier-Edwards stented bovine pericardial aortic bioprostheses (Perimount valve) is reported based on echocardiographic follow-up examinations. Prosthetic valve deterioration of the Perimount valve usually occurs late and is age-dependent. We describe bioprosthetic valve deterioration of a Perimount valve with severe stenotic change 1 month postoperatively that developed in an infective endocarditis patient. Although preoperative echocardiography showed no signs of valve dehiscence or vegetation on the prosthesis, valve stenosis alone had progressed extremely rapidly during 2 weeks of febrile symptom. The valve leaflet was found at explant to be infiltrated with a cellular material fibrin other than bacteria or leukocytes. This rare occurrence needs to be reported in the literature to forewarn clinicians of an early manifestation of endocarditis that may not be recognized yet.     

In vivo hemodynamic comparison of porcine and pericardial valves

The bovine pericardial valve and the SupraAnnular valve have been developed to improve the hemodynamic function of tissue valves. Hemodynamic performances of the standard Carpentier-Edwards porcine valve, the Carpentier-Edwards SupraAnnular valve, and the Carpentier-Edwards bovine pericardial valve were compared in the aortic position. One hundred patients undergoing aortic valve replacement were studied intraoperatively. Mean gradient across the valve decreased for standard and pericardial valves as valve size increased. At the same flow rate, the 23 mm pericardial valve had larger valve orifice areas, higher performance indices, and lower gradients than the 23 mm SupraAnnular valve. The SupraAnnular valve is hemodynamically superior to the standard Carpentier-Edwards porcine bioprosthesis. The Carpentier-Edwards pericardial valve, however, is less obstructive in the aortic position than either of the porcine valves.     

Impact of implant technique following freestyle stentless aortic valve replacement

BACKGROUND: Stentless aortic bioprostheses have excellent hemodynamics and clinical outcomes. The purpose of the present study was to determine whether implant technique of the Freestyle aortic root bioprosthesis impacts clinical outcomes or hemodynamic performance. METHODS: The long-term multicenter study of the Freestyle stentless aortic bioprosthesis includes 500 consecutive patients implanted using the subcoronary and 162 using the full root technique. Clinical outcomes and echocardiographic hemodynamics were compared through 5 years. RESULTS: There were no differences between groups in time to death, valve-related death, or reoperation. The incidence of operative death was higher in the full root than in the subcoronary group (odds ratio 3.97, p = 0.001). Patients in the subcoronary group were more likely to have New York Heart Association functional class III or IV symptoms at 1 year (1.7% versus 0%, p = 0.04) and 5 years postoperatively (4.4% versus 0%, p = 0.02). Mean gradient was lower (p = 0.0004) and effective orifice area larger (p = 0.04) in the full root group. Left ventricular mass index decreased in both groups. The preponderance of patients in both groups had no or trivial aortic regurgitation through 5 years. CONCLUSIONS: Full root implantation of the Freestyle stentless aortic bioprosthesis was associated with higher operative mortality, but somewhat better hemodynamics, functional class, and freedom from aortic regurgitation. Higher operative mortality argues against the empiric replacement of the ascending aorta in the absence of aortic root pathology. In appropriately selected patients, both implant techniques are viable alternatives for valve implantation.     

Age and valve size effect on the long-term durability of the Carpentier-Edwards aortic pericardial bioprosthesis

BACKGROUND: Bioprosthesis durability decreases with time and younger age. However, the time-scale and determinants of durability of the aortic Carpentier-Edwards stented bovine pericardial prosthesis are incompletely characterized. METHODS: Between September 1981 and January 1984, 267 patients underwent implantation of the pericardial aortic prosthesis at four centers. Mean age at implant was 65 +/- 12 years (range 21 to 86 years). Follow-up averaged 12 +/- 4.5 years. The primary end point was explant for structural valve dysfunction (SVD), which was analyzed multivariably in the context of death as a competing risk. RESULTS: Freedom from explant due to SVD was 99%, 94%, and 77% at 5, 10, and 15 years. Risk of SVD increased exponentially with time and younger age (p = 0.0001) at implantation; an increased risk of small valve size was not reliably demonstrated (p = 0.1). Considering the competing risk of death, patients aged 65 years or older had a less than 10% chance of explant for SVD by 15 years. CONCLUSIONS: Durability of this stented pericardial aortic bioprosthesis is excellent and justifies its use in patients aged 65 or older.     

Stentless porcine and pericardial valve in aortic position.

Fifty-seven patients underwent aortic valve replacement with a stentless glutaraldehyde-fixed bioprosthesis; 27 received a porcine aortic valve and 30 had a bovine pericardial valve. Two groups of 30 patients each who had aortic valve replacement with a tilting-disc mechanical valve or a stented porcine bioprosthesis served as controls. There were no differences in sex, body surface area, valve lesion, and valve size among the four groups. Results were assessed on a Doppler-based determination of maximum velocity across the valve, aortic valve area, and degree of valve regurgitation. Velocity across the valve was significantly less with stentless pericardial valves than with stentless porcine valves, stented bioprostheses, and mechanical valves. Stentless valves had a significantly larger aortic valve area when compared with stented valves. Mild central aortic insufficiency was detected more often with stentless pericardial than with stentless porcine bioprostheses (p = 0.04). Stentless valves showed a higher incidence of complete atrioventricular block when compared with stented valves (p = 0.04). Long-term studies are now warranted to assess the durability of both types of stentless valves.     

Hemodynamic evaluation of 19-mm Carpentier-Edwards pericardial bioprosthesis in aortic position

BACKGROUND: The aortic Carpentier-Edwards pericardial bioprosthesis offers good long-term clinical outcomes with a low rate of structural deterioration. However, little in vivo hemodynamic data is available for this bioprosthesis. METHODS: To determine the hemodynamic performance of the 19-mm Carpentier-Edwards pericardial valve, both cardiac catheterization and dobutamine stress echocardiography were electively performed in 10 patients. The mean age at the study was 71.6 +/- 4.4 years and the mean body surface area was 1.39 +/- 0.11 m2. The peak-to-peak gradient, instantaneous peak gradient, mean gradient, and valve orifice area were measured by standard cardiac catheterization. The Doppler-derived gradients and valve orifice area were also measured both at rest and during dobutamine infusion. RESULTS: The average peak-to-peak gradient, instantaneous peak gradient, mean gradient, and valve orifice area measured by catheterization were 13.0 +/- 5.4 mmHg, 28.5 +/- 7.7 mmHg, 12.0 +/- 4.9 mmHg, and 1.55 +/- 0.45 cm2, respectively. The peak and mean Doppler gradients, and valve orifice area by resting echocardiography were 27.7 +/- 9.5 mmHg, 12.3 +/- 4.8 mmHg, and 1.39 +/- 0.26 cm2, respectively. At a dosage of 10 microg/kg/min of dobutamine, the mean Doppler gradient rose mildly to 22.2 +/- 4.8 mmHg, while the cardiac output increased from 4.49 +/- 0.44 to 6.64 +/- 0.87 L/min. The valve orifice area during the 10 microg/kg/min dobutamine infusion (1.55 +/- 0.25 cm2) was significantly larger than its value at rest (p < 0.05). CONCLUSIONS: With acceptable hemodynamic performance, use of the aortic 19-mm Carpentier-Edwards pericardial valve is a reliable option for elderly patients with a small annulus.     

液氮保存同种带支架人工瓣膜流体力学测试

目的：利用脉动流模拟实验装置测试液氮保存同种带支架瓣膜流体力学性能，同时与国产perfect牛心包人工瓣膜对比研究。方法：采集同种瓣膜，缝制成21^#、23^#、25^#同种带支架主动脉和同种带支架肺动脉人工瓣膜，经液氮保存，使用国产脉动流实验装置测试瓣膜流体力学性能，采用ISO／FDA浮估标准，分别测量各流量下的跨瓣压差、有效瓣口面积(EOA)和回流比。并与相应型号国产perfect牛心包人工瓣膜对比研究。结果：21^#、23^#、25^#同种带支架主动脉和肺动脉瓣膜的跨瓣压差和回流百分比差异无显著性，但较perfect瓣大。同种带支架主、肺动脉瓣膜的EOA差异无显著性，但较perfect牛心包生物瓣膜的略小些。同种带支架瓣膜实际开口面积(AOA)小于perfect牛心包瓣，但有效瓣口面积，实际开口面积比值无差别。结论：同种带支架主动脉和肺动脉人工瓣膜流体力学性能满意，同种带支架主动脉瓣膜与同种带支架肺动脉瓣膜流体力学性能无差别。     

Late hemodynamic and clinical outcomes of aortic valve replacement with the Carpentier-Edwards Perimount pericardial bioprosthesis

OBJECTIVES: The aim of this study was to investigate the long-term clinical and hemodynamic outcomes after aortic valve replacement with the Carpentier-Edwards Perimount bioprosthesis (Edwards Lifesciences, Irvine, Calif), which has been used in our institution since 1984. METHODS: From January 1984 to December 1995, the Carpentier-Edwards pericardial bioprosthesis was used for aortic valve replacement in 254 patients (male/female ratio 117:137) with a mean age of 71 years (range 25-87 years). Before the operation, 216 patients (85%) were in New York Heart Association functional class III or IV. The predominant diagnosis was aortic stenosis (n = 219, 86%). Associated surgical procedures included coronary artery bypass grafting in 130 cases (51%), mitral valve replacement in 11 cases (4%), and tricuspid or mitral valve repair in 12 cases (5%). Previous cardiac operations had been performed in 36 cases (14%). Follow-up was 100% complete at a mean of 60 +/- 31 months. Univariate estimates of time-related cumulative probabilities were calculated by the Kaplan-Meier method. Multivariable adjustment was performed by Cox proportional hazards regression. Echocardiography was performed in 61% of long-term survivors. RESULTS: There were 11 early deaths (4%) and 58 late deaths. Actuarial survivals at 5, 10, and 12 years were 80% +/- 3%, 50% +/- 8%, and 36% +/- 9%, respectively. At 12 years the freedom from cardiac death was 73% +/- 7%, the freedom from valve-related death was 84% +/- 11%, the freedom from valve reoperation was 83% +/- 9%, the freedom from primary tissue failure was 86% +/- 9%, the freedom from thromboembolism was 67% +/- 13%, and the freedom from endocarditis was 98% +/- 1%. Echocardiography was performed on long-term survivors (mean follow-up 67 +/- 25 months) and showed that transvalvular peak and mean pressure differences measured with Doppler echocardiography were 23.2 +/- 9.6 and 12.3 +/- 4.8 mm Hg, respectively. Aortic regurgitation was found by Doppler echocardiography to be none or trivial, mild, moderate, and severe in 64%, 30%, 3%, and 1% of patients, respectively. Mean left ventricular mass index was 107.2 +/- 35.3 g/m(2) (118.9 +/- 40.2 g/m(2) in men and 98.8 +/- 28.8 g/m(2) in women) at late follow-up. One third of all patients, regardless of sex (n = 26/64 women and n = 14/45 men), had evidence of left ventricular hypertrophy. However, our analyses indicate that the residual left ventricular hypertrophy was not caused by valve mismatch but was probably multifactorial. CONCLUSION: The Carpentier-Edwards Perimount bioprosthesis has provided satisfactory clinical and hemodynamic outcome. However, at long-term follow-up about one third of the patients being investigated still had left ventricular hypertrophy examined by echocardiography.     

Aortic valve disease with severe ventricular dysfunction: stentless valve for better recovery

BACKGROUND: Stentless bioprostheses and homografts show better hemodynamic profiles compared with conventional stented bioprostheses and mechanical valves. Few data are available on stentless aortic valve implantation for patients with severe left ventricular dysfunction. The aim of this retrospective study was to assess the potential benefits of stentless aortic valve implantation for patients undergoing isolated aortic valve replacement with left ventricular ejection fraction < or = 35%. METHODS: From November 1988 through March 2000, 53 patients (45 men and 8 women, aged 64.2 +/- 15.2 years) with a LVEF < or = 35% (mean EF, 28.7 +/- 5.4%) underwent isolated, primary aortic valve replacement for chronic aortic valve disease. Twenty patients received stentless aortic valves and 33 patients received conventional stented bioprostheses and mechanical valves. Predictive factors for LVEF recovery at echocardiographic follow-up (36.2 +/- 32.1 months) were analyzed by simple and multiple regression analysis. RESULTS: There were no significant differences between groups in early and late mortality. Stentless aortic valve implantation required a longer aortic cross-clamp time (p = 0.037). The stentless aortic valve group showed a better LVEF recovery (p = 0.016). Stentless aortic valves had a larger indexed effective orifice area compared with conventional stented bioprostheses and mechanical valves (p < 0.0001). A smaller indexed effective orifice area (p = 0.0008), chronic obstructive pulmonary disease (p = 0.015), and implantation of a conventional stented bioprosthesis or mechanical valve (p = 0.016) were related to reduced LVEF recovery by univariate analysis. A larger indexed effective orifice area (p = 0.024) was an independent predictive factor for a better LVEF recovery by multivariate analysis. CONCLUSIONS: Stentless aortic valve implantation for patients with severe left ventricular dysfunction, even if technically more demanding, is a safe procedure that warrants a larger indexed effective orifice area leading to an enhanced LVEF recovery.     

Performance of stentless versus stented aortic valve bioprostheses in the elderly patient: a prospective randomized trial.

OBJECTIVES: Although stentless aortic bioprostheses are believed to offer improved outcomes, benefits remain unsubstantiated. The aim of our study was to compare stentless with stented bioprostheses, with regard to postoperative changes in left ventricular mass and hemodynamic performance, in the elderly patient. METHODS: Forty patients with aortic stenoses, over the age of 75 years, were randomized to receive either the stented Perimount (n=20) or the stentless Prima Plus (n=20) bioprosthesis. Left ventricular mass regression, effective orifice area, ejection fraction and mean gradients were evaluated at discharge, 6 months and 1 year after surgery. RESULTS: Overall a significant decrease in left ventricular mass was found 1 year postoperatively. However, there was no significant difference in the rate of left ventricular mass regression between the groups. Furthermore, 1 year postoperatively, the hemodynamic performance of the valves and the change in the ejection fraction did not differ between the groups. CONCLUSIONS: Our study shows that in a randomized cohort of elderly patients with aortic stenosis, we were not able to detect significant differences, with regard to hemodynamic performance and regression of left ventricular mass, between the stentless and stented valve groups. To our surprise, previously reported findings of non-randomized trials that showed faster and more complete regression of left ventricular mass and hemodynamic benefits of stentless valves were not reproducible.     

Comparison of the Carpentier-Edwards Perimount™ and St. Jude Medical Epic™ Bioprostheses for Aortic Valve Replacement—A Retrospective Echocardiographic Short-Term Study

Abstract   Objective: Stented biological prostheses show different performance related to their design and ultrastructure. Therefore, we compared the Carpentier-Edwards Perimount™ (Edwards Lifesciences, Irvine, CA, USA) and the St. Jude Medical Epic™ (SJM Epic™; St. Jude Medical Inc., St. Paul, MN, USA) prostheses with respect to their hemodynamic features. Methods: Eighty-six patients underwent aortic valve replacement for severe aortic stenosis (50 patients), aortic regurgitation (seven patients), or mixed lesion (29 patients) with these randomly assigned bioprostheses (Perimount™: 39 patients; SJM Epic™: 47 patients). Following informed consent, patients were examined postoperatively (mean 9.7 ± 4 months after surgery) with a detailed echocardiographic study, quality of life was determined by a standardized questionnaire. Results: Comparing the indexed effective orifice area (0.77 cm²/m² vs. 0.64 cm²/m²; p = 0.019), the mean pressure gradient (11.15 mmHg vs. 14.80 mmHg; p = 0.004) and the stroke-work loss (6.95% vs. 8.49%; p = 0.025), the Carpentier-Edwards Perimount™ demonstrated significantly better hemodynamic features than the SJM Epic™ prosthesis. These effects were more pronounced in the smaller prosthetic sizes. Conclusion: The Carpentier-Edwards Perimount™ prosthesis was less obstructive than the SJM Epic™ in echocardiographic controls. Patient-prosthesis mismatch as determined by indexed effective orifice area showed no impact on functional recovery.     

Mass regression in aortic stenosis after valve replacement with small size pericardial bioprosthesis

BACKGROUND: The aim of the study was to determine whether left ventricular mass regression is influenced by valve size after the implantation of a Carpentier-Edwards Perimount (CEP) pericardial bioprosthesis for pure aortic stenosis. METHODS: Patients receiving 19-mm, 21-mm, and 23-mm CEP aortic valves underwent echocardiography preoperatively and at least 1 year after surgery (mean, 2.3 +/- 1 years) and the echocardiograms were compared within and between groups. RESULTS: The study involved a total of 88 patients: 34 receiving 19-mm CEPs, 29 receiving 21-mm CEPs, and 25 receiving 23-mm CEPs. The mean postoperative prosthetic gradients were respectively 20.6 +/- 6.6 mm Hg, 17.9 +/- 5.8 mm Hg, and 13.2 +/- 4.1 mm Hg (p = 0.0001); the mean postoperative valve areas were respectively 1.24 +/- 0.16 cm(2), 1.45 +/- 0.2 cm(2), and 1.63 +/- 0.21 cm(2) (p = 0.0001). In comparison with the preoperative echocardiographic measurements absolute left ventricular mass significantly decreased by -54.1 +/- 48.8 g, -54.1 +/- 55.1 g, and -74.4 +/- 57.4 g respectively with no statistically significant between-group difference (analysis of variance) but ventricular septum and posterior wall thickness significantly decreased in each group (p < 0.05). CONCLUSIONS: The implantation of 19-mm, 21-mm, and 23-mm CEP aortic prostheses significantly reduces left ventricular mass without any size-related differences.     

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.     

Re-operation of an aortic pericardial bioprosthesis 23-years after implantation; report of a case

A 49-year-old female suffered from dyspnea on exertion and jaundice from June, 2009. She had undergone aortic valve replacement with Carpentier-Edwards pericardial bioprosthesis due to active infectious endocarditis 23-years previously. The echocardiography showed severe aortic stenosis with moderate regurgitation. She was diagnosed as having prosthetic valve malfunction. Re-replacement of the aortic valve with mechanical valve was successfully performed. As far as we can see, this is one of the longest-term cases of implantation of pericardial bioprosthesis.     

Characteristic resistance curves of aortic valve substitutes facilitate individualized decision for a particular type.

OBJECTIVE: Biological valves exhibit characteristic curves (CC) regarding transvalvular gradient, resistance, and effective orifice area when correlated with a physiological cardiac output range (CO). The slope of the curve of transvalvular resistance over a typical CO range characterizes the clinical performance of the valve. These information may support an individualized decision towards the most adequate valve type. METHODS: In an extracorporeal mock circuit two types of stented biological aortic valves (constructed pericardial valves, Edwards Perimount: EP; porcine cusp valves, Medtronic Mosaic: MM) of 21, 23, and 25 mm were investigated. Mean transvalvular gradient was measured over a range of 1.9 to 7.2l/min CO at a simulated heart rate of 70 beats/min. Transvalvular resistance was calculated and presented as characteristic curves in a log-log-plot against cardiac output. RESULTS: EP valves of all sizes demonstrated low slopes (resistance range; slope: 21 mm: 53-79 dynes s cm(-5); 0.29; 23 mm: 44-56 dynes s cm(-5); 0.12; 25 mm: 38-45 dynes s cm(-5); 0.12) while MM valves exhibited steep slopes (resistance range; slope: 21 mm: 46-169 dynes s cm(-5); 0.97; 23 mm: 36- -146 dynes s cm(-5); 0.95; 25 mm: 27-64 dynes s cm(-5); 0.68). CONCLUSIONS: While constructed pericardial valves demonstrate sufficient hemodynamic performance especially in the higher CO range porcine cusp valves exhibited minor resistance in the lower CO range. Patients who exercise regularly may therefore profit from a pericardial valve while patients with a small body surface area and little exercise who therefore remain in the lower CO range may be adequately treated with a porcine cusp valve.     

Efficacy of aortic valve replacement with freestyle stentless valve in patients with aortic valve disease

Stentless porcine aortic bioprosthesis has several potential advantages over conventional stented bioprosthesis. The Medtronic Freestyle aortic bioprosthesis, a stentless design analogous to an aortic allograft, has zero-pressure-fixed leaflets treated with an antimineralization agent, and has been shown to have benefits of superior effective orifice area, excellent flow characteristics and durability. To evaluate the early results for its efficacy in view of post-operative performance. The valve was implanted using the cylinder method, with subcoronary, root-inclusion techniques or full root techniques. No patients experienced any significant valvular regurgitation on echocardiography. The post-operative data of EDVI, ESVI and LVPWD decreased significantly as compared with the pre-operative data while ejection fraction remained unchanged. The average peak pressure gradient was 16.5 mmHg, and the average effective orifice area was 2.45 cm2. In conclusion, Freestyle stentless aortic bioprosthesis showed excellent hemodynamic function. It seems to be suited for the older patient with a small aortic annulus.     

Aortic Root Replacement Using a Biovalsalva Prosthesis in Comparison to a “Handsewn” Composite Bioprosthesis

Abstract Background: The Biovalsalva aortic root prosthesis incorporates an Elan porcine stentless biological aortic valve suspended within a triple‐layered vascular conduit with preformed aortic sinuses of Valsalva. This study compared implantation of the Biovalsalva prosthesis with a “handsewn” composite bioprosthetic graft (CE Perimount bovine bioprosthesis anastomosed to a gelatin‐impregnated gelweave Dacron graft). Methods: Between December 2004 and January 2009, 39 patients underwent elective or urgent aortic root replacement (modified Bentall procedure with coronary button reimplantation) using a Biovalsalva (n = 21) or a handsewn bioprosthesis (n = 18) for aortic root dilatation. Results: There was no significant difference in the preoperative variables between the two study groups including age (70.7 ± 1.7 vs. 67.6 ± 2.9 years, p > 0.05). There was no in‐hospital mortality. Three patients in each group underwent concomitant aortic hemi‐arch replacement. Patients who underwent Biovalsalva implantation had a reduced need for transfusion of blood (1.25 ± 0.32 vs. 3.17 ± 0.71 units, p < 0.05) and fresh frozen plasma (2.78 ± 0.39 vs. 1.85 ± 0.31, p < 0.05), and reduced mediastinal blood loss (416 ± 52 vs. 583 ± 74 mL, p < 0.05) compared to those with a handsewn bioprosthesis. Cardiopulmonary bypass time (141 ± 6 vs. 170 ± 17 minutes, p = NS) and aortic cross‐clamp time (113 ± 6 vs. 115 ± 7 minutes, p = NS) were similar. Postoperative echocardiography demonstrated excellent hemodynamic function of the Biovalsalva prosthesis (mean size 25.1 ± 0.4 mm valved conduit) with a peak pressure gradient of 26.2 ± 1.9 mmHg and no or trivial valvular regurgitation. Conclusions: The Biovalsalva prosthesis should be considered for patients requiring a biological aortic root replacement. It offers an “off‐the‐shelf” preassembled composite biological valve conduit with excellent hemostatic and hemodynamic properties. (J Card Surg 2010;25:321‐326)