Seventeen-millimeter St. Jude Medical Regent valve in patients with small aortic annulus: dose moderate prosthesis-patient mismatch matter?

Abstract

BackgroundThe study was designed to evaluate the effects of moderate prosthesis-patient mismatch (defined as 0.65 cm2/m2 < indexed effective orifice area ≤ 0.85 cm2/m2) on midterm outcomes after isolated aortic valve replacement with a 17-mm St. Jude Medical Regent valve in a large series of patients, and to determine if these effects are influenced by patient confounding variables.MethodsOne-hundred and six patients with and without moderate prosthesis-patient mismatch early after implantation of a 17-mm Regent valve at aortic position were included. Both clinical and echocardiographic assessments were performed preoperatively, at discharge and during follow-up period (mean follow-up time 52.6 ± 11.9 months).ResultsThe prevalence of moderate prosthesis-patient mismatch was documented in 46 patients (43.4%) at discharge. During the follow-up period, no difference in the regression of left ventricular mass, decrease of transvalvular pressure gradients, mortality and prosthesis-related complications was observed between patients with and without moderate prosthesis-patient mismatch. After adjustment for several risk factors, moderate prosthesis-patient mismatch was associated with increased midterm mortality in patients with baseline left ventricular ejection fraction < 50% (HR: 1.80, p = 0.02), but with normal prognosis in those with preserved LV function. Younger age (cut off value = 65 years) was not an independent predictor of increased midterm mortality and valve-related complications in patients with moderate prosthesis-patient mismatch.ConclusionsModerate prosthesis-patient mismatch after aortic valve replacement with a small mechanical prosthesis is associated with increased mortality and adverse events in patients with pre-existing left ventricular dysfunction. Selected patients with small aortic annulus can experience satisfactory clinical improvements and midterm survival after aortic valve replacement with a 17-mm Regent valve.

Aortic valve replacement with a 17-mm mechanical prosthesis in octogenarian or older patients

“…24 In Asia, maintaining PT-INR at such lower levels is accepted in some institutions. 5,29 Considering differences among races, Takaseya and colleagues 4 reported that the target INR level should be higher in Caucasian than Asian patients because of differences between them in the pharmacodynamics of warfarin. Other reports recommend close monitoring of PT-INR.…”

“…With this type of small valve, PPM should be considered. To prevent PPM, 29,30 effective orifice area index at rest ideally should not be less than 0.85 cm 2 /m 2 . However, this goal must be evaluated in light of the anticipated risks and benefits for a given patient.…”

“…31 Severe PPM (effective orifice area index 0.60 cm 2 /m 2 ) is an independent predictor of higher long-term mortality and congestive heart failure in patients who have small St Jude Medical aortic valve prostheses. 30 Additionally, Hu and colleagues 29 reported that moderate PPM (À0.65 < effective orifice area index< 0.85 cm 2 /m 2 ) after AVR with a 17-mm SJM Regent valve in a small aortic annulus is associated with increased mortality and adverse events in patients who have pre-existing LV dysfunction (LV ejection fraction <50%). In addition, Blais and colleagues 32 observed that PPM is a strong and independent predictor of short-term mortality among patients undergoing AVR.…”

Aortic valve replacement in small aortic root- Bi-leaflet mechanical valve is superior to a Mono-leaflet mechanical valve

“…A hydrodynamic in vitro model study conducted by Bottio et al [ 10 ], compared 5 different bi-leaflet mechanical valves in the small annulus and concluded that the hydrodynamic superiority with St. Jude regent flexicuff and sorin bicarbon valve (Sorin Biomedica, Saluggia, Italy). A small-sized bi-leaflet mechanical valve with better EOA provides better outcomes [ 7 – 9 , 11 , 12 ] and is also comparable with that of ARE [ 4 ]. Despite having the risk of PPM, it has several advantages including shorter CPB time, simpler technique, and reduced incidence of bleeding and infection.…”

“…Standard M-mode and Doppler measurements were obtained according to the American Society of Echocardiography criteria. M mode measurements were based on the mean of three measures on two different cardiac cycles, while Doppler measurements were the mean of more than three and five cycles in the case of sinus rhythm and atrial fibrillation, respectively [ 7 ]. The following variables were taken: left ventricular ejection fraction (LVEF) and right ventricular function, MPG, PPG across the valves, and wall dimensions, pulmonary artery systolic pressure (PASP).…”