Predicting patient–prosthesis mismatch by aortic root evaluation before aortic valve replacement

MDCT evaluation of dynamic changes in aortic root parameters during the cardiac cycle in patients with aortic regurgitation

OBJECTIVES

To investigate the dynamic changes in multiple planes and parameters of the aortic root region at different phases of the cardiac cycle in patients with aortic regurgitation (AR) using multi-detector row computed tomography (MDCT). To provide more reference information and research foundation for preoperative MDCT evaluation of patients with aortic regurgitation undergoing Transcatheter Aortic Valve Replacement (TAVR).

METHODS

Using MDCT, measurements were taken at the aortic annulus (AA), left ventricular outflow tract (LVOT), and sinotubular junction (STJ) during different phases of the cardiac cycle, including early systole, late systole, early diastole, and late diastole. The analyzed parameters included area, perimeter, diameter derived from area (DA), diameter derived from circumference (DC), long axis, short axis, and average diameter at each phase for each location. The dynamic changes in these parameters were then analyzed.

RESULTS

At the AA, the early systolic area, perimeter, DA, DC, and average diameter reached their maximum values, which were significantly greater than those in early diastole (P < 0.05). At the LVOT, the morphological parameters including area, perimeter, DC, DA, and long diameter reached their maximum values in late diastole, with no significant differences compared to early or late systole (P > 0.05). However, significant differences were observed between late diastole and early diastole (P < 0.05).At the STJ, the area, perimeter, DA, DC, long diameter, short diameter, and average diameter reached their maximum values in late systole, but there were no significant differences compared to early systole or early diastole (P > 0.05), while the difference from late diastole was significant (P < 0.05).

CONCLUSION

In patients with AR, the measurement parameters of the AA、LVOT and the STJ are critical for the success of TAVR.Preoperative prosthesis selection for TAVR can still be based on MDCT measurements taken during early systole at the AA.

A Retrospective Analysis of Standardized Gradient Calculations for Evaluating Patient-Prosthesis Mismatch Following Mechanical Aortic Valve Replacement

Background: Aortic stenosis (AS) is one of the most common valvular heart diseases, particularly in the elderly, with a prevalence of approximately 3% in individuals over 75 years of age. Aortic valve replacement (AVR) remains the standard treatment, yet postoperative hemodynamic assessment is often complicated by variations in prosthetic valve size, left ventricular ejection fraction (LVEF), effective orifice area (EOA), and body surface area (BSA). These factors significantly influence prosthetic valve function and contribute to patient-prosthesis mismatch (PPM), which has been associated with worse clinical outcomes. Traditional transvalvular gradient measurements often fail to account for these patient-specific variables. This study introduces a novel approach to standardized gradient calculations, aiming to enhance the accuracy and comparability of prosthetic valve assessments. Methods: A retrospective analysis was conducted on 115 patients who underwent mechanical AVR at a single center. Patients were categorized into three groups based on the prosthetic valve type: St. Jude Medical (SJM) HP (n = 31); SJM Regent (n = 54); and those who underwent aortic root enlargement (ARE) (n = 30). Preoperative and postoperative transthoracic echocardiography (TTE) was performed to measure conventional and standardized transvalvular gradients. Four novel standardized gradient calculations were developed to adjust for individual hemodynamic differences, improving the accuracy of prosthetic valve function assessment. Results: Standardized gradient calculations demonstrated significant differences between prosthesis types. Postoperative standardized gradients were significantly higher in the SJM HP group compared to the SJM Regent and aortic-root-enlargement groups (p < 0.001, p < 0.05). The lowest standardized gradients were observed in patients who received the SJM Regent prostheses (p < 0.05). Although conventional measurements showed no significant differences, standardized calculations revealed that patients with 19 mm prostheses exhibited significantly higher transvalvular gradients than those with 21 mm prostheses (p < 0.05), emphasizing the clinical importance of prosthesis size in postoperative hemodynamics. Conclusions: Standardized gradient calculations provide a more objective, reliable, and patient-specific assessment of prosthetic valve function by minimizing interpatient variability. This approach improves the detection of patient-prosthesis mismatch and optimizes postoperative hemodynamic evaluation, potentially leading to better prosthesis selection and surgical decision-making. However, further validation is required in larger cohorts before these methods can be widely adopted into clinical practice. Future studies should assess their impact on long-term clinical outcomes, including left ventricular remodeling and patient survival.

Aortic root enlargement in patients undergoing mitral and aortic replacement: early outcomes in a sub-Saharan population

Introduction

Aortic root enlargement (ARE) is often required to avoid patient-prosthesis mismatch (PPM) in young patients undergoing aortic surgery, including those undergoing combined mitral and aortic valve replacement (double valve replacement, DVR). Adding ARE to DVR may increase the operative risk by extending the surgical time. Herein, we review our experience with ARE in patients who underwent DVR.

Materials and methods

The medical records of 69 patients who underwent DVR at our institution between February 2008 and November 2021 were retrospectively reviewed. The patients were divided into two groups according to the ARE procedure (ARE-DVR: 25 patients; DVR: 44 patients). Descriptive and comparative analyses of demographic, clinical, and surgical data were performed.

Results

Among the 69 patients who underwent DVR, 35 were women (sex ratio, 0.97). The mean age at surgery was 26.7  ±  13.9 years (range: 7-62 years). Among the 47 patients aged ≤30 years, 40.4% (19/47) were aged between 10 and 20 years, and 6.3% (3/47) were aged <10 years. Patients in the ARE-DVR group were younger (23.3 ± 12.9 years vs. 28.5 ± 14.2 years, p < 0.05). The New York Heart Association Class ≥III dyspnea was the most common symptom (89.9%), with no differences between the two groups. Of all the patients, 84.1% had sinus rhythm. Rheumatic disease was the most common etiology in the entire cohort (91.3%). The mean aortic annulus diameter was 20.54 mm, with smaller sizes found in the ARE-DVR group (18.00 ± 1.47 mm vs. 22.50 ± 2.35 mm, p < 0.05). The aortic cross-clamping duration was greater in the ARE-DVR group (177.6 ± 37.9 min vs. 148.3 ± 66.3 min, p = 0.047). The operative mortality rate was 5.6% for the entire cohort (ARE-DVR: 8% vs. DVR: 4.5%, p = 0.46). Among the patients who underwent echocardiographic control at follow-up, the mean aortic gradient was 19.6 ± 7.2 mmHg (range: 6.14-33 mmHg), with no differences among the groups.

Conclusion

The association between ARE and DVR did not significantly affect operative mortality. ARE can be safely used whenever indications arise to reduce the occurrence of PPM, especially in young patients with growth potential.

Midterm outcomes after surgical aortic valve replacement with the INSPIRIS RESILIA from a multicenter AVR registry

BACKGROUND

There have been few reports on the mid- to long-term safety and efficacy validation of the INSPIRIS RESILIA aortic bioprosthesis (Edwards Lifesciences LLC, Irvine, CA, USA) in Japan. Herein, we report the mid-term results of surgical aortic valve replacement (AVR) for aortic stenosis using INSPIRIS and evaluate the hemodynamics compared to the CEP Magna series from the multicenter AVR registry (the ACTIVIST registry).

METHODS

Of the 1967 patients who underwent surgical or transcatheter AVR from the ACTIVIST registry, 66 patients who underwent isolated surgical AVR with INSPIRIS by December 2020 were included in this study, and the early and mid-term results were evaluated. Hemodynamics were evaluated by comparing 272 patients undergoing isolated surgical AVR with the Magna group using propensity score matching.

RESULTS

The mean age was 74.0 ± 7.8 years, and 48.5 % were women. In-hospital mortality was 1.5 %, and the survival rates at 1- and 2-years were 95.2 % and 95.2 %, respectively. After propensity score matching, echocardiographic findings at discharge demonstrated that peak velocity and mean pressure gradient in the INSPIRIS group were comparable, while the effective orifice area in the INSPIRIS group was significantly larger than those in the Magna group (p = 0.048). A patient-prosthesis mismatch at discharge was significantly lower in the INSPIRIS group (11.8 %) than in the Magna group (36.4 %) (p = 0.004).

CONCLUSIONS

Surgical AVR with INSPIRIS was performed safely and the mid-term results were satisfactory. The hemodynamics of INSPIRIS were comparable to those of Magna.

Prosthetic cardiac valves: history and review of cardiac prostheses clinically available in Japan

Recently developed prosthetic valves are reliable and essential for the treatment of valvular heart disease. The mechanical valve evolved remarkably following the introduction of pyrolite carbon material, which enabled the creation of a bileaflet form incorporated with a pivot mechanism. The improved durability of the biological valve is attributed mainly to the development of a tissue fixation process and anti-calcification treatments. However, optimal antithrombogenicity and durability have not yet been achieved for either prosthetic valve type. To select the most suitable prosthetic valve for each individual patient from among the many clinically available prosthetic valves, it is necessary to have a thorough understanding of the characteristics of each valve.

Patient-prosthesis mismatch and surgical aortic valve replacement outcomes: Retrospective analysis of single-center surgical data

BACKGROUND

Patient-prosthesis mismatch (PPM) has been identified as a risk factor for mortality and reoperation in patients undergoing surgical aortic valve replacement (SAVR). We present a retrospective analysis of risk factors for PPM and the effects of PPM on early postoperative outcomes after SAVR.

METHODS

Chart review was conducted for patients (N = 3003) undergoing SAVR. PPM was calculated from valve reference orifice areas and patient body surface area. Logistic regression was used to analyze risk factors for PPM and develop a risk score from these results. Regression was also conducted to identify associations between projected PPM status and postoperative outcomes.

RESULTS

Risk factors for PPM included female sex, higher body mass index (BMI), and use of the St. Jude Epic valve. Patients receiving St. Jude trifecta valves or mechanical valves were less likely to have predicted PPM. We developed a risk score using BMI, sex, and valve type, and retrospectively predicted PPM in our cohort. Mild PPM (odds ratio [OR] = 2.267), severe PPM (OR = 2.869), male sex (OR = 2.091), and younger age (OR = 0.940) were all predictors of SAVR reoperation, while aortic root replacement was associated with reduced reoperation rates (OR = 0.122). Severe PPM carried a risk of in-hospital mortality (OR = 3.599), and moderate PPM carried a smaller but significant risk (OR = 1.920). Other factors increasing postoperative morbidity and mortality included older age, renal failure, and diabetes.

CONCLUSION

PPM could be retrospectively predicted in our cohort using a risk calculation from sex, BMI and valve type. We conclude that all degrees of PPM carry risk for mortality and reoperation.