Small aortic annulus: The hydrodynamic performances of 5 commercially available tissue valves
2006; Elsevier BV; Volume: 132; Issue: 6 Linguagem: Inglês
10.1016/j.jtcvs.2006.08.051
ISSN1097-685X
AutoresWalter Eichinger, I Hettich, Rüediger Lange,
Tópico(s)Infective Endocarditis Diagnosis and Management
ResumoWe are writing to comment on the study by Gerosa and associates1Gerosa G. Tarzia V. Rizzoli G. Bottio T. Small aortic annulus: the hydrodynamic performances of 5 commercially available tissue valves.J Thorac Cardiovasc Surg. 2006; 131: 1058-1064Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar published in a recent issue of the Journal. This highly interesting report compared geometric dimensions and hemodynamic performance of 5 different stented tissue valves for aortic valve replacement. Three pericardial bioprostheses (Carpentier-Edwards Perimount Magna [Edwards Lifesciences, Irvine, Calif], Sorin Soprano, and Sorin Mitroflow [Sorin Biomedica Spa, Saluggio, Italy]) and 2 porcine bioprostheses (Medtronic Mosaic [Medtronic, Inc, Minneapolis, Minn] and St Jude Medical Epic Supra [St Jude Medical, Inc, St Paul, Minn]) were tested at cardiac outputs of 2, 4, 5, and 7 L/min. So that a meaningful comparison could be made, prostheses that could be fitted in a 21-mm pulse duplicator ring were used, regardless of industry-labeled valve size. This addresses a very important issue that we try to solve for in vivo comparisons of different valve types by calculating the “effective orifice fraction,” which is the ratio of the intraoperatively measured aortic annulus area and the echocardiographically obtained effective orifice area of the prosthesis.2Eichinger W.B. Botzenhardt F. Guenzinger R. Bleiziffer S. Keithahn A. Bauernschmitt R. et al.The effective orifice area/patient aortic annulus area ratio: a better way to compare different bioprostheses? A prospective randomized comparison of the Mosaic and Perimount bioprostheses in the aortic position.J Heart Valve Dis. 2004; 13 (discussion 388-9): 382-388PubMed Google Scholar, 3Botzenhardt F. Eichinger W.B. Bleiziffer S. Guenzinger R. Wagner I.M. Bauernschmitt R. et al.Hemodynamic comparison of bioprostheses for complete supra-annular position in patients with small aortic annulus.J Am Coll Cardiol. 2005; 45: 2054-2060Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar In our opinion, one of the most striking results of the study by Gerosa’s group was the finding that even some of the geometric dimensions given by the manufacturers could not be reproduced by direct measurements, such as the internal or the tissue annulus diameter of certain bioprostheses. The authors state that there are some discrepant findings compared with in vivo results published by our group: We found that in some patients the implantation of a Medtronic Mosaic valve labeled one size bigger than the Carpentier-Edwards Perimount valve was possible because of the smaller geometric dimensions of this valve.4Eichinger W.B. Botzenhardt F. Keithahn A. Guenzinger R. Bleiziffer S. Wagner I. et al.Exercise hemodynamics of bovine versus porcine bioprostheses: a prospective randomized comparison of the Mosaic and Perimount aortic valves.J Thorac Cardiovasc Surg. 2005; 129: 1056-1063Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar In the described in vitro setting, upsizing of the Medtronic Mosaic compared with the Carpentier-Edwards Perimount Magna was not possible. This corresponds to our in vivo findings, because the Carpentier-Edwards Perimount Magna has a 3-mm smaller sewing ring diameter than the Carpentier-Edwards Perimount for the identical labeled valve size. Thus, the hemodynamic benefit of the Carpentier-Edwards Perimount Magna valve results from the possibility of upsizing.5Botzenhardt F. Eichinger W.B. Guenzinger R. Bleiziffer S. Wagner I. Bauernschmitt R. et al.Hemodynamic performance and incidence of patient-prosthesis mismatch of the complete supraannular Perimount Magna bioprosthesis in the aortic position.Thorac Cardiovasc Surg. 2005; 53: 226-230Crossref PubMed Scopus (50) Google Scholar The second cited manuscript from our group3Botzenhardt F. Eichinger W.B. Bleiziffer S. Guenzinger R. Wagner I.M. Bauernschmitt R. et al.Hemodynamic comparison of bioprostheses for complete supra-annular position in patients with small aortic annulus.J Am Coll Cardiol. 2005; 45: 2054-2060Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar is a prospective, nonrandomized comparison of 3 completely supra-annular prostheses (Carpentier-Edwards Perimount Magna, Medtronic Mosaic, and Sorin Soprano) with one intrasupra-annular valve (Carpentier-Edwards Perimount). These again were in vivo comparisons in which the sewing ring dimensions and the aortic root anatomy played a decisive role in the selection of a certain valve size. The basic findings of this work were that in patients with an aortic annulus of 18 to 20 mm in diameter (intraoperative direct measurements with a Hegar dilator), no significant hemodynamic differences between the investigated prostheses were present, whereas in patients with an annulus diameter between 21 and 23 mm, the Carpentier-Edwards Perimount Magna showed superior hemodynamic results compared with the other prostheses because of the beneficial ratio of sewing ring and internal orifice diameters. We disagree with the statement of Gerosa’s group that these conclusions would clash with their in vitro data. In our opinion, the decision that leads to the selection of a certain valve size in a complex anatomic structure, such as the aortic annulus in combination with prosthesis dimensions including stent height, sewing ring diameter, complete supra-annular position, and anatomic relation to the coronary ostia, is responsible for the different findings (Figure 1). Reply to the EditorThe Journal of Thoracic and Cardiovascular SurgeryVol. 132Issue 6PreviewWe appreciate the comments of Eichinger, Hettich, and Lange on our recent article reporting on in vitro performances of 5 different aortic tissue valves designed for supra-annular implantation.1 Full-Text PDF
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