Predictors of the Size of Prosthetic Aortic Valve and In-Hospital Mortality in Aortic Valve Replacement (original) (raw)

Aortic valve replacement: Is valve size important?

The Journal of Thoracic and Cardiovascular Surgery, 2000

large-sized prosthesis seems preferable. On the other hand, aortic root enlargement may complicate an operation for aortic valve replacement. 1,4-11 Furthermore, patients with small annular size may be small individuals, and the small valve size may be matched to their cardiac output needs. In addition to this uncertainty with respect to the small aortic root, there is also controversy about valve size and efficiency in general. Both the use of stentless aortic valve prostheses and the use of aortic root-enlarging procedures are strategies based in large part on the thesis that hemodynamic performance, and thus valve size, favorably influence late outcome. 12 The purpose of this study was to ascertain the relation of prosthesis size to survival after aortic valve replacement. Materials and methods Patients. To obtain a relatively pure relation of prosthesis size to survival, we identified adult patients (≥18 years of age) operated on at The Cleveland Clinic Foundation from 1978 T here is uncertainty as to the optimum management of patients with a small aortic anulus. 1 Small aortic prostheses may leave higher residual pressure gradients across the valve and are associated with less rapid and less complete regression of left ventricular hypertrophy. 2,3 Thus a Objective: We sought to determine whether aortic prosthesis size adversely influences survival after aortic valve replacement. Methods: A total of 892 adults receiving a mechanical (n = 346), pericardial (n = 463), or allograft (n = 83) valve for aortic stenosis were observed for up to 20 years (mean, 5.0 ± 3.9 years) after primary isolated aortic valve replacement. We used multivariable propensity scores to adjust for valve selection factors, multivariable hazard function analyses to identify risk factors for all-cause mortality, and bootstrap resampling to quantify the reliability of the results. Results: Twenty-five percent of patients had indexed internal orifice areas of less than 1.5 cm 2 /m 2 and more than 2 SDs (Z-value) below predicted normal aortic valve size. Mechanical valve orifices were smaller (1.3 ± 0.29 cm 2 /m 2 , Z =-2.2 ± 1.16) than pericardial (1.9 ± 0.36 cm 2 /m 2 , Z =-0.40 ± 1.01) or allograft valves (2.1 ± 0.50, Z = 0.24 ± 1.17). The overall survival was 98%, 96%, 86%, 69%, and 49% at 30 days and 1, 5, 10, and 15 years postoperatively. Univariably, survival was weakly and inversely related to manufacturer valve size (P = .16) and internal orifice diameter (P = .2) but completely unrelated to indexed valve area (P = .6) or Z-value (P = .8). These, and univariable differences among valve types (P = .004), were accounted for by different prevalences in patient risk factors and not by valve size or type per se. Bootstrap resampling indicated that these findings had a less than 15% chance of being incorrect. Conclusions: Survival after aortic valve replacement is strongly related to patient risk factors but appears not to be adversely affected by moderate patient-prosthesis mismatch (down to about 4 SDs below normal). Aortic root enlargement to accommodate a large prosthesis may be required in few situations.

Long-term Mortality Predictors in Patients with Small Aortic Annulus Undergoing Aortic Valve Replacement with a 19- or 21-mm Bioprosthesis

Brazilian Journal of Cardiovascular Surgery, 2016

Introduction: Replacement of the aortic valve in patients with a small aortic annulus is associated with increased morbidity and mortality. A prosthesis-patient mismatch is one of the main problems associated with failed valves in this patient population. Objective: To evaluate the long-term mortality predictors in patients with a small aortic annulus undergoing aortic valve replacement with a bioprosthesis. Methods: In this retrospective observational study, a total of 101 patients undergoing aortic valve replacement from January 2000 to December 2010 were studied. There were 81 (80.19%) women with a mean age of 52.81±18.4 years. Severe aortic stenosis was the main indication for surgery in 54 (53.4%) patients. Posterior annulus enlargement was performed in 16 (15.8%) patients. Overall, 54 (53.41%) patients underwent concomitant surgery: 28 (27.5%) underwent mitral valve replacement, and 13 (12.7%) underwent coronary artery bypass graft surgery. Results: Mean valve index was 0.82±0.08 cm²/m 2. Overall, 17 (16.83%) patients had a valve index lower than 0.75 cm²/m 2 , without statistical significance for mortality (P=0.12). The overall 10-year survival rate was 83.17%. The rate for patients who underwent isolated aortic valve replacement was 91.3% and 73.1% (P=0.02) for patients who underwent concomitant surgery. In the univariate analysis, the main predictors of mortality were preoperative ejection fraction (P=0.02; HR 0.01) and EuroSCORE II results (P=0.00000042; HR 1.13). In the multivariate analysis, the main predictors of mortality were age (P=0.01, HR 1.04) and concomitant surgery (P=0.01, HR 5.04). Those relationships were statistically significant. Conclusion: A valve index of < 0.75 cm²/m 2 did not affect 10-year survival. However, concomitant surgery and age significantly affected mortality.

Anatomical and functional changes after aortic valve replacement with different sizes of mechanical valves

Cardiovascular Journal of Africa

Objective: To date, there is no consensus on the selection of type and size of prosthetic valve for aortic valve replacement (AVR). The aim of this study was to compare anatomical and functional changes occurring in the left ventricle after AVR with different sizes of mechanical valves. Methods: A total of 92 patients with serious aortic valve stenosis, who underwent AVR between March 2001 and June 2008 using mechanical valves of different sizes, were retrospectively analysed. The sizes of the mechanical valves were 19, 21, 23 and 25 mm. All patients were assessed preoperatively, and at six months and in the first, third and fifth years postoperatively. The left ventricle was assessed with electrocardiography, echocardiography and telecardiography and compared in the four patient groups, constituted according to the mechanical valve size used. Results: In all groups, left ventricular mass and mass index, transvalvular aortic gradient, thicknesses of the interventri-cular septum and posterior wall, and left ventricular endsystolic and end-diastolic diameters had decreased significantly post surgery. Left ventricular ejection fraction and exercise capacity had increased significantly (p < 0.001). The most noteworthy anatomical and functional improvements were seen in patients who had received 23-and 25-mm mechanical valves. Conclusion: Mechanical valve replacement should not be performed with small size valves because of the higher residual gradient.

Small Prosthesis Size in Aortic Valve Replacement Does Not Affect Mortality

The Annals of Thoracic Surgery, 2011

Background. Small prosthesis size has been associated with poorer postoperative outcomes in aortic valve replacement (AVR). We hypothesized that the use of small aortic valve (AV) prostheses does not independently increase operative mortality following AVR, but that mortality may instead be related to comorbidities.

Small “Functional” Size after Mechanical Aortic Valve Replacement: No Risk in Young to Middle-Age Patients

The Annals of Thoracic Surgery, 2005

Background. The impact of a valve prosthesis-patient size mismatch is still controversial. In most studies, the inclusion of a large proportion of poorly active old patients with low cardiac output requirements may be misleading, due to the close correlation between transprosthetic gradients and cardiac output. The aim of this study was to assess the impact of small "functional" prosthesis sizes in active young to middle-age patients.

Preoperative prediction of prosthesis size using cross sectional echocardiography in patients requiring aortic valve replacement

Heart, 1985

In 43 patients who underwent aortic valve replacement for aortic stenosis with or without regurgitation the accuracy of preoperative left ventricular angiography, parasternal long axis cross sectional echocardiography of left ventricular outflow tract and proximal ascending aorta, and M mode echocardiography of aortic root in predicting aortic root size and thereby prosthesis size was compared. Cross sectional echocardiographic measurements and angiographic measurements of aortic root correlated well with prosthesis size, with over two thirds of the indirect measurements being within 2 mm of prosthesis diameter. M mode echocardiography did not yield useful predictive information. Non-invasive preoperative evaluation of patients likely to require aortic valve replacement may be usefully extended to include aortic root dimensions measured by cross sectional echocardiography.

Aortic prosthetic size predictor in aortic valve replacement

Journal of Cardiothoracic Surgery

Background Patient-prosthesis mismatch (PPM) is a major concern in aortic valve replacement (AVR) and leads to perioperative morbidity and rehospitalization. Predicting aortic annulus diameter pre-procedurally is crucial to managing patients with high-risk of PPM. Objectives To compare preoperative measurements of aortic annulus from echocardiography and CT scan with surgical sizing and develop an imaging-based algorithm to predict PPM. Methods From January 2017 to December 2020, patients underwent AVR at a teaching hospital were examined. The relationship between imaging measurements with operative values was assesed using scatter plots and Pearson’s correlation coefficient. Univariable linear regression was then used to build the predictive model. Results A total of 144 patients underwent AVR during the study period. Suture types and surgical approaches were not significantly associated with prosthesis size. CT scan-based measurements showed strong correlation with prosthesis size...

Prosthetic Valve Type for Patients Undergoing Aortic Valve Replacement: A Decision Analysis

2010

Background. In two large, randomized, clinical trials long-term survival after aortic valve replacement (AVR) was similar for patients receiving tissue and mechanical aortic heart valve prostheses. Higher bleeding rates among patients with mechanical valves, who must re- ceive permanent oral anticoagulation to prevent throm- boembolism, were offset by higher reoperation rates for valve degeneration among patients with tissue valves. Because