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The Annals of Thoracic Surgery Jun 2024Patient-prosthesis mismatch (PPM) after aortic valve replacement potentially affects the outcome after the operation. This study sought to determine whether PPM has an...
BACKGROUND
Patient-prosthesis mismatch (PPM) after aortic valve replacement potentially affects the outcome after the operation. This study sought to determine whether PPM has an impact on long-term mortality and reoperation rates.
METHODS
We included 645 patients who underwent biologic aortic valve replacement between 2000 and 2007. Based on echocardiographic examinations at postoperative month 6, the incidence of PPM was determined according to an indexed effective orifice area <0.85 cm/m. Survival and reoperation status were analyzed during 15 years of follow-up.
RESULTS
PPM was present in 256 patients (40%), of whom 175 had moderate PPM and 81 had severe PPM. In multivariable adjusted analysis, survival was not statistically significantly impaired in patients with moderate PPM compared with patients with no PPM, whereas patients with severe PPM showed a marginally significant impairment of survival (hazard ratio [HR], 1.40; 95% CI, 0.99-1.97; P = .054). Risk factors for survival were higher age (HR, 1.12; 95% CI, 1.10-1.14; P < .001), arterial hypertension (HR, 1.78; 95% CI, 1.38-2.31; P < .001), and diabetes mellitus (HR, 1.67; 95% CI, 1.31-2.14; P < .001). In patients with no, moderate, and severe PPM, there were 10.1, 8.5, and 14.8 events of reoperation/1000 patient-years, respectively. The corresponding 10-year cumulative incidence of reoperation was 8.3%, 6.7%, and 12.1%, respectively. In multivariable adjusted analysis, PPM category was not significantly associated with the risk of reoperation (P > .2).
CONCLUSIONS
In our study with directly measured effective orifice area, PPM was only marginally related to long-term survival and was not statistically significantly associated with the risk of reintervention.
PubMed: 38851414
DOI: 10.1016/j.athoracsur.2024.05.025 -
IDCases 2024is a slow-growing member of the complex. It can contaminate tap water and has been detected in water tanks of heater-cooler devices used during open-heart surgery....
is a slow-growing member of the complex. It can contaminate tap water and has been detected in water tanks of heater-cooler devices used during open-heart surgery. Herein we report a case of a 67-year-old- male with disseminated infection who presented with fevers, significant weight loss and was found to have bacteremia with prosthetic valve endocarditis, chorioretinitis, bone marrow and splenic granulomas two years after an open-heart surgery. He developed multiple drug adverse events over the course of treatment but was successfully treated using a clofazimine containing regimen along with aortic valve replacement. He has remained symptom-free with no signs of recurrence three years after completion of antimicrobials. Clofazimine is an effective alternative that can be used as part of a multi-drug regimen in infection when there is resistance to first-line drugs or when adverse drug reactions occur.
PubMed: 38846029
DOI: 10.1016/j.idcr.2024.e01991 -
The American Journal of Cardiology Jun 2024New-generation transcatheter heart valves have significantly improved technical success and procedural safety of transcatheter aortic valve implantation (TAVI)...
New-generation transcatheter heart valves have significantly improved technical success and procedural safety of transcatheter aortic valve implantation (TAVI) procedures; however, the incidence of permanent pacemaker implantation (PPI) remains a concern. This study aimed to assess the role of anatomic annulus features in determining periprocedural conduction disturbances leading to new PPI after TAVI using the last-generation Edwards SAPIEN balloon-expandable valves. In the context of a prospective single-center registry, we integrated the clinical and procedural predictors of PPI with anatomic data derived from multislice computed tomography. A total of 210 consecutive patients treated with balloon-expandable Edwards transcatheter heart valve were included in the study from 2015 to 2023. Technical success was achieved in 197 procedures (93.8%), and 26 patients (12.4%) required new PPI at the 30-day follow-up (median time to implantation 3 days). At the univariable logistic regression analysis, preprocedural right bundle branch block (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.01 to 4.97, p = 0.047), annulus eccentricity ≥0.25 (OR 5.43, 95% CI 2.21 to 13.36, p <0.001), calcium volume at annulus of the right coronary cusp >48 mm (OR 2.60, 95% CI 1.13 to 5.96, p = 0.024), and prosthesis implantation depth greater than membranous septum length (OR 2.17, 95% CI 1.10 to 4.28, p = 0.026) were associated with new PPI risk. In the multivariable analysis, preprocedural right bundle branch block (OR 2.81, 95% CI 1.01 to 7.85, p = 0.049), annulus eccentricity ≥0.25 (OR 4.14, 95% CI 1.85 to 9.27, p <0.001), and annulus calcium >48 mm (OR 2.89, 95% CI 1.07 to 7.82, p = 0.037) were confirmed as independent predictors of new PPI. In conclusion, specific anatomic features of the aortic valve annulus might have an additive role in determining the occurrence of conduction disturbances in patients who underwent TAVI with balloon-expandable valves. This suggests the possibility to use multislice computed tomography to improve the prediction of post-TAVI new PPI risk.
PubMed: 38844197
DOI: 10.1016/j.amjcard.2024.05.034 -
Annals of Cardiothoracic Surgery May 2024The Y-incision/rectangular patch aortic annular enlargement (Y-incision AAE) is our go-to technique for aortic annular/root enlargement at the University of Michigan for...
The Y-incision/rectangular patch aortic annular enlargement (Y-incision AAE) is our go-to technique for aortic annular/root enlargement at the University of Michigan for its simplicity and effectiveness. A complete aortotomy is used for first-time surgical aortic valve replacements (SAVRs), and a partial aortotomy is frequently used in reoperative SAVR. The Y-incision is made through the left-non commissure, underneath the aortic annulus to the left and right fibrous trigones. A rectangular patch is sewn to the aorto-mitral curtain from the left fibrous trigone to the right fibrous trigone and transitioned to the aortic annulus on both sides. The enlarged aortic annulus/root is sized with the valve-shape end of the sizer, and the largest size that can touch all three nadirs of the aortic annulus with one strut facing the left-right commissure is chosen. The non-pledgetted valve sutures are placed in a non-everting suture fashion on the aortic annulus, and inside-outside-inside on the patch. The sutures at the nadir of the non-coronary sinus and left coronary sinus are tied first. The proximal ascending aorta is enlarged with a posterior longitudinal aortotomy, and the distal end of the patch is trimmed to a triangular shape to facilitate the closure of the aortotomy with the "Roof" technique. In the 142 consecutives cases, the median size of prosthetic valve used was 29 and upsizing was 3-4 valve sizes. Outcomes included one death, one stroke, two pacemaker implantations for complete heart block including one case of aortic valve endocarditis with Gerbode fistula, and no reoperation for post-operative bleeding. The median aortic valve mean gradient was 7 mmHg and aortic valve area was 2.4 cm two years after SAVR. The median left ventricular mass index regression was 41% in 12-24 months in patients with moderate/severe aortic stenosis.
PubMed: 38841092
DOI: 10.21037/acs-2023-aae-0151 -
Annals of Cardiothoracic Surgery May 2024For decades, surgeons have recognized the risk of prosthesis-patient mismatch (PPM) when treating aortic stenosis (AS) with surgical aortic valve replacement (SAVR). The... (Review)
Review
For decades, surgeons have recognized the risk of prosthesis-patient mismatch (PPM) when treating aortic stenosis (AS) with surgical aortic valve replacement (SAVR). The concept of PPM-or placing a valve that is too small for the cardiac output requirements of the patient-has been associated with worse patient outcomes, including increased risk of death. Transcatheter aortic valve replacement (TAVR) has become the standard treatment for most patients with severe symptomatic AS and is associated with improved hemodynamics and lower risks of PPM. Larger surgical valves, stentless, and sutureless technology, and surgical aortic annulus enlargement (AAE) have been employed to avoid severe PPM. However, especially in the small aortic annulus (SAA), TAVR may provide a benefit. Understanding who is at risk for PPM requires preplanning, and cardiac-gated computed tomography (CT) imaging is the standard of care when considering TAVR. It should be standard for all patients with AS. Once SAA is identified, the risk of PPM can be calculated, and an informed decision made on whether to proceed with SAVR or TAVR. In the current TAVR era, younger patients are treated with TAVR driven by patient preference, but with little long-term data to support the practice. Selecting the best valve for the patient is a multifactorial decision often nuanced by anatomical considerations, hemodynamic and durability expectations, and decisions regarding lifetime management that may include placing a second valve. Although PPM may be only one of the factors to consider, the association with elevated mean gradients and worse outcomes certainly makes TAVR a good solution for many patients.
PubMed: 38841088
DOI: 10.21037/acs-2024-aae-27 -
Annals of Cardiothoracic Surgery May 2024The labeled sizes of surgical valve prostheses and their discordance with the physical internal valve orifice sizes has long been a controversy in the cardiac surgery...
BACKGROUND
The labeled sizes of surgical valve prostheses and their discordance with the physical internal valve orifice sizes has long been a controversy in the cardiac surgery community, leading many to believe it to be a contributing factor in prosthesis-patient mismatch following valvular replacement surgery. In an attempt to address this issue, the International Organization for Standardization (ISO) 5840-2:2021 standard for surgical valve prostheses recommends that a new sizing parameter, namely, the effective orifice diameter, be provided in labeling by all manufacturers as an indicator of the true flow-passing capacity of a prosthetic valve.
METHODS
The ISO Cardiac Valves Working Group conducted a multi-laboratory round-robin study to investigate whether the effective orifice diameter of a prosthetic surgical valve could be derived repeatably and reproducibly through steady forward-flow testing. A total of seven valve models, each with multiple sizes, were tested, including a mechanical heart valve and multiple biological heart valves.
RESULTS
The round-robin study confirmed that the steady forward-flow test had good intra-laboratory repeatability and inter-laboratory reproducibility in deriving the effective orifice diameters of surgical valve prostheses. On average, among the participating laboratories, the experimentally derived effective orifice diameter of a prosthetic heart valve was 3-12 mm smaller than its labeled size.
CONCLUSIONS
The effective orifice diameter provides better characterization of the hydrodynamic characteristics of a surgical valve prosthesis and can be derived using a validated steady forward-flow test method. This new sizing parameter will soon be adopted by surgical valve manufacturers and provided in device labeling to inform valve selection by surgeons.
PubMed: 38841085
DOI: 10.21037/acs-2024-aae-0057 -
Annals of Cardiothoracic Surgery May 2024In 1978, Rahimtoola published a successful series of surgical aortic valve replacements (SAVR) on patients with severe aortic stenosis (AS) with congestive heart failure... (Review)
Review
In 1978, Rahimtoola published a successful series of surgical aortic valve replacements (SAVR) on patients with severe aortic stenosis (AS) with congestive heart failure (CHF). He described the perfect prosthesis-patient match as a "prosthetic valve with a functioning opening area that matches the patient's normal functioning valve." This manuscript revisits the forty-six-year journey in pursuit of that perfect match. We address the essential components for the perfect match, such as the usefulness of the current valve sizing techniques using the manufacturer's labeled valve size (MLVS) and sizer, the accuracy of an objective parameter to define the perfect match, and the need and safety to enlarge the patient's annulus and root to accommodate the proper size valve. A thorough literature search was performed using the University of Michigan Medical Library search engine. The population included patients who underwent SAVR. Three individual searches were conducted: (I) valve size and sizing techniques; (II) hemodynamic performance (HP) and prosthesis-patient mismatch (PPM); and (III) aortic root enlargement (ARE) procedures. Excluded were articles not in English, articles that involved animal research, duplicate articles, articles involving valve repair, allograft or autograft replacement, and articles specific to aortic sizing and congenital heart surgery. The emphasis was placed on randomized prospective trials, large registry trials with and without propensity matching, and meta-analysis articles. We discovered that the manufacturer-labeled valve size and sizing technique does not accurately represent the functional opening area of the valve. A pre-operative multidetector computed tomography (CT) scan is an accurate and reproducible method for measuring patient root and annulus dimensions and should be used for pre-operative valve sizing for SAVR. Matching the CT area derived aortic diameter with the true functional diameter of the opening of the prosthetic valve will yield the best prosthesis-patient match. ARE is safe and should be used to attain the best match.
PubMed: 38841081
DOI: 10.21037/acs-2023-aae-0181 -
Annals of Cardiothoracic Surgery May 2024Prosthesis-patient mismatch (PPM) occurs when the effective orifice area (EOA) of a normally functioning prosthetic valve is too small in relation to the patient's body... (Review)
Review
Prosthesis-patient mismatch (PPM) occurs when the effective orifice area (EOA) of a normally functioning prosthetic valve is too small in relation to the patient's body size. The effect of PPM on outcomes and valve durability have gained credibility, making this an important possibly preventable risk factor. Transcatheter aortic valve replacement (TAVR) generally has a lower incidence of PPM than surgical aortic valve replacement (SAVR). Current surgical literature and randomized trials show an association between severe PPM and mortality in patients with SAVR but there is less evidence for an association with TAVR. Differences in the incidence of PPM may be related to the methods and cutoffs for measuring mismatch. This review will discuss the current state of field and propose standardization of measurement methods which may more accurately risk stratify patients.
PubMed: 38841078
DOI: 10.21037/acs-2023-aae-0166 -
EuroIntervention : Journal of EuroPCR... Jun 2024
Topics: Humans; Stents; Transcatheter Aortic Valve Replacement; Aortic Valve Stenosis; Heart Valve Prosthesis; Prosthesis Design; Treatment Outcome; Aortic Valve
PubMed: 38840577
DOI: 10.4244/EIJ-D-23-00927