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Thorac Cardiovasc Surg 2013; 61(05): 379-385
DOI: 10.1055/s-0032-1331577
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

Isolated Aortic Valve Replacement in Patients with Small Aortic Annulus—A High-Risk Group on Long-Term Follow-Up

Manuel Wilbring
1   Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
,
Konstantin Alexiou
1   Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
,
Elisabeth Schumann
1   Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
,
Klaus Matschke
1   Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
,
Sems Malte Tugtekin
1   Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
› Author Affiliations
Further Information

Publication History

24 August 2012

15 October 2012

Publication Date:
20 December 2012 (online)

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Abstract

Background Patients with small aortic annulus undergoing isolated aortic valve replacement face an often underestimated surgical risk. We describe initial clinical results and long-term follow-up of this particular high-risk group.

Methods Between January 1998 and December 2004, 148 consecutive patients with small aortic annulus underwent isolated aortic valve replacement by implantation of a Mitroflow Aortic Pericardial Heart Valve (Sorin S.p.A., Milano, Italy) 19 or 21 mm bioprostheses. Mean age was 75.4 ± 6.2 years. Female gender, obesity, and multiple comorbidities were predominant. Mean logistic euroSCORE for mortality was 18.5 ± 2.3%. Follow-up time was 7.2 ± 2.0 years, with a total of 1,066 patient years.

Results Postoperative course and outcome during follow-up were strongly influenced by extracardiac morbidities. Hospital mortality was 6.1%, 5-year survival 71.9%, and 10-year survival 40.9%. Most patients (70.0%) died because of extracardiac reasons. Significant reasons for death were age, pre-existing atrial fibrillation, diabetes mellitus type 2, chronic renal failure, extracardiac vascular disease, history of stroke, and preoperative presentation at Canadian Cardiovascular Society class III and IV (p < 0.05). Freedom from valve-related reoperation was 99.1% at 5 years and 93.4% at 10 years. Prosthesis–patient mismatch occurred in 12.2% and was not affected with any adverse outcome (p = nonsignificant). Echocardiographic data demonstrated a significant reduction of mean transvalvular gradients in all patients (61.2 ± 19.7 mm Hg preoperatively; 18.0 ± 8.0 mm Hg during follow-up; p < 0.05). All patients reported a significant improvement in New York Heart Association functional class (p < 0.05).

Conclusion Patients with small aortic annulus are predominantly small, obese, and old-aged females with multiple comorbidities. Mitroflow valve avoids prosthesis–patient mismatch and provides excellent hemodynamics. Observed long-term results were disappointing, but they were mainly limited by extracardiac comorbidities and advanced age.

Keywords

aortic valve replacement - small annulus - patient–prosthesis mismatch - Mitroflow
 

  • References

  • 1 Gummert JF, Funkat AK, Beckmann A , et al. Cardiac surgery in Germany during 2010: a report on behalf of the German Society for Thoracic and Cardiovascular Surgery. Thorac Cardiovasc Surg 2011; 59 (5) 259-267
    Thieme ConnectPubMedSearch in Google Scholar
  • 2 Otto CM, Pearlman AS, Gardner CL. Hemodynamic progression of aortic stenosis in adults assessed by Doppler echocardiography. J Am Coll Cardiol 1989; 13 (3) 545-550
    CrossrefPubMedSearch in Google Scholar
  • 3 Davies SW, Gershlick AH, Balcon R. Progression of valvar aortic stenosis: a long-term retrospective study. Eur Heart J 1991; 12 (1) 10-14
    PubMedSearch in Google Scholar
  • 4 Rahimtoola SH. The problem of valve prosthesis-patient mismatch. Circulation 1978; 58 (1) 20-24
    CrossrefPubMedSearch in Google Scholar
  • 5 Bleiziffer S, Ali A, Hettich IM , et al. Impact of the indexed effective orifice area on mid-term cardiac-related mortality after aortic valve replacement. Heart 2010; 96 (11) 865-871
    CrossrefPubMedSearch in Google Scholar
  • 6 Howell NJ, Keogh BE, Barnet V , et al. Patient-prosthesis mismatch does not affect survival following aortic valve replacement. Eur J Cardiothorac Surg 2006; 30 (1) 10-14
    CrossrefPubMedSearch in Google Scholar
  • 7 Pibarot P, Dumesnil JG. Prevention of valve prosthesis—patient mismatch before aortic valve replacement: does it matter and is it feasible?. Heart 2007; 93 (5) 549-551
    CrossrefPubMedSearch in Google Scholar
  • 8 Carrier M, Pellerin M, Perrault LP , et al. Experience with the 19-mm Carpentier-Edwards pericardial bioprosthesis in the elderly. Ann Thorac Surg 2001; 71 (5, Suppl): S249-S252
    CrossrefPubMedSearch in Google Scholar
  • 9 Hartrumpf M, Kuehnel R, Erb M, Loladze G, Mueller T, Albes J. Favorable gradients with the mitroflow aortic valve prosthesis in everyday surgery. Thorac Cardiovasc Surg 2012; 60 (5) 326-333
    Thieme ConnectPubMedSearch in Google Scholar
  • 10 Bhutani AK, Dev K, Gupta CH, Abraham KA, Desai RN, Balakrishnan KR. Aortic root enlargement by Manouguian's technique. J Thorac Cardiovasc Surg 1994; 108 (4) 788
    PubMedSearch in Google Scholar
  • 11 Yankah CA, Pasic M, Musci M , et al. Aortic valve replacement with the Mitroflow pericardial bioprosthesis: durability results up to 21 years. J Thorac Cardiovasc Surg 2008; 136 (3) 688-696
    CrossrefPubMedSearch in Google Scholar
  • 12 Minami K, Zittermann A, Schulte-Eistrup S, Koertke H, Körfer R. Mitroflow synergy prostheses for aortic valve replacement: 19 years experience with 1,516 patients. Ann Thorac Surg 2005; 80 (5) 1699-1705
    CrossrefPubMedSearch in Google Scholar
  • 13 Sjögren J, Gudbjartsson T, Thulin LI. Long-term outcome of the MitroFlow pericardial bioprosthesis in the elderly after aortic valve replacement. J Heart Valve Dis 2006; 15 (2) 197-202
    PubMedSearch in Google Scholar
  • 14 Grossi EA, Schwartz CF, Yu PJ , et al. High-risk aortic valve replacement: are the outcomes as bad as predicted?. Ann Thorac Surg 2008; 85 (1) 102-106 , discussion 107
    CrossrefPubMedSearch in Google Scholar
  • 15 Schmidtler FW, Tischler I, Lieber M , et al. Cardiac surgery for octogenarians—a suitable procedure? Twelve-year operative and post-hospital mortality in 641 patients over 80 years of age. Thorac Cardiovasc Surg 2008; 56 (1) 14-19
    Thieme ConnectPubMedSearch in Google Scholar
  • 16 Jamieson WR, Koerfer R, Yankah CA , et al. Mitroflow aortic pericardial bioprosthesis—clinical performance. Eur J Cardiothorac Surg 2009; 36 (5) 818-824
    CrossrefPubMedSearch in Google Scholar
  • 17 Yankah CA, Pasic M, Musci M , et al. Aortic valve replacement with the Mitroflow pericardial bioprosthesis: durability results up to 21 years. J Thorac Cardiovasc Surg 2008; 136 (3) 688-696
    CrossrefPubMedSearch in Google Scholar
  • 18 Hashimoto K. Patient-prosthesis mismatch: the Japanese experience. Ann Thorac Cardiovasc Surg 2006; 12 (3) 159-165
    PubMedSearch in Google Scholar
  • 19 Dumesnil JG, Pibarot P. Prosthesis-patient mismatch: an update. Curr Cardiol Rep 2011; 13 (3) 250-257
    CrossrefPubMedSearch in Google Scholar
  • 20 Kobayashi Y, Fukushima Y, Hayase T, Kojima K, Endo G. Clinical outcome of aortic valve replacement with 16-mm ATS-advanced performance valve for small aortic annulus. Ann Thorac Surg 2010; 89 (4) 1195-1199
    CrossrefPubMedSearch in Google Scholar
  • 21 Moon MR, Pasque MK, Munfakh NA , et al. Prosthesis-patient mismatch after aortic valve replacement: impact of age and body size on late survival. Ann Thorac Surg 2006; 81 (2) 481-488 , discussion 489
    CrossrefPubMedSearch in Google Scholar
  • 22 García-Bengochea J, Sierra J, González-Juanatey JR , et al. Left ventricular mass regression after aortic valve replacement with the new Mitroflow 12A pericardial bioprosthesis. J Heart Valve Dis 2006; 15 (3) 446-451 , discussion 451–452
    PubMedSearch in Google Scholar