Individualized treatment prevents patient-prosthesis mismatch after aortic valve replacement with small aortic annulus

doi:10.3969/j.issn.2095-4344.2014.27.009

Abstract

Abstract:

BACKGROUND: It is so difficult to have aortic valve replacement with small aortic annulus. Improper treatment may lead to patients with valvular mismatch phenomenon, and thus make left ventricular outflow tract obstruction, increase transvalvular pressures, cause cardiac hypertrophy secondary to increased left ventricular afterload and even congestive heart failure.
OBJECTIVE: To summarize the treatment strategy for preventing valvular mismatch phenomenon caused by small aortic annulus after aortic valve replacement.
METHODS: Eighty-five patients with small aortic annulus underwent aortic valve replacement surgery.
19 mm SJM Regent valve was applied to the patients with orifice diameter > 17 ≤ 19 mm; to the adult patients with orifice diameter ≤ 17 mm, we performed bovine pericardial patch enlargement of the small aortic annulus and valve replacement using 19 mm SJM Regent valve. For those with orifice diameter > 19 ≤ 21 mm, we selected 21 mm Hancock II ultra biological valve for valve replacement. Effective orifice area index, left ventricular mass index, inter-ventricular septal thickness, left ventricular wall thickness, trans-valvular peak velocity, the pressure difference across the valve and trans-valvular mean pressure were measured through echocardiography. After discharge, patients were followed up in out-patient clinic and evaluated regularly by echocardiography.
RESULTS AND CONCLUSION: There were no early deaths after operation and all cases were cured and discharged. Follow-up time was between 6 months and 3 years. The main complications included low cardiac output syndrome in two cases, reoperation due to bleeding in one case, and ventilator dependence in two cases. No cases occurred in cerebral complications such as cerebral hemorrhage or cerebral thrombosis, and no valvular dysfunction or card flap appeared. There was no bovine pericardium tearing, thrombosis, calcification, tumor-like bulge, infection or immune reactions. A total of 81 cases were followed up and the follow-up rate was 95% (81/85). There were NYHA class grade I in 65 cases, and grade II in 16 cases. Peak velocity across the aortic valve and the mean pressure were significantly decreased, effective orifice area index increased significantly, left ventricular mass index, left ventricular wall thickness and the thickness of the inter-ventricular septum were significantly reduced compared with pre-operation, and no valvular mismatch phenomenon occurred. Compared 21 mm Hancock II ultra biological valve with 21 mm SJM Regent group, the former got a better peak velocity and mean trans-valvular pressure, and better left ventricular remodeling index. Body weight and body surface area were significantly increased in 19 mm Regent valve group after operation. The results suggest that individualized treatment strategies should be taken to prevent the occurrence of postoperative valvular mismatch phenomenon for patients with small aortic annulus.

中国组织工程研究杂志出版内容重点：肾移植；肝移植；移植；心脏移植；组织移植；皮肤移植；皮瓣移植；血管移植；器官移植；组织工程

全文链接：

Key words: organ transplantation, aortic valve, heart valve prosthesis

CLC Number:

R318

Han Jin-song, Wang Hui-shan, Yin Zong-tao, Wang Ting-ting, Han Hong-guang, Song Heng-chang, Jin Yan . Individualized treatment prevents patient-prosthesis mismatch after aortic valve replacement with small aortic annulus[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(27): 4310-4317.

Figures/Tables 5

References

[1]Svensson LG, Adams DH, Bonow RO, et al.Aortic valve and ascending aorta guidelines for management and quality measures. Ann Thorac Surg.2013;95(6 Suppl):S1-S66.
[2]David TE. Surgical treatment of aortic valve disease. Nat Rev Cardiol.2013;10(7):375-386.
[3]Bianco JC, Qizilbash B, Carrier M, et al.Is patient-prosthesis mismatch a perioperative predictor of long-term mortality after aortic valve replacement?. J Cardiothorac Vasc Anesth. 2013; 27(4):647-653.
[4]李先华,徐志云,曹翔.环上瓣植入与瓣环扩大在成人小主动脉瓣环换瓣术中的应用效果观察[J].山东医药,2011,51(6):90-92.
[5]Ghosh P, Kumar S, Pandey S, et al. Small aortic annulus: a functional definition. Ann Thorac Cardiovasc Surg.1998; 4(5): 251-261.
[6]Peterson MD, Borger MA, Feindel CM, et al. Aortic annular enlargement during aortic valve replacement：improving results with time.Ann Thorac Surg.2007; 83(6):2044-2049.
[7]David TE, Uden DE. Aortic valve replacement in adult patients with small aortic annuli.Ann Thorac Surg.1983;36(5):577-583.
[8]Ghavidel AA, Omrani G, Chitsazan M, et al. Long-term results of aortic valve replacement with posterior root enlargement. Asian Cardiovasc Thorac Ann.2014 Mar 25. [Epub ahead of print]
[9]Coutinho GF, Correia PM, Paupério G, et al.Aortic root enlargement does not increase the surgical risk and short-term patient outcome? Eur J Cardiothorac Surg.2011;40(2):441-447.
[10]Wang B, Yang H, Wang T, et al.Impact of obesity on long-term survival after aortic valve replacement with a small prosthesis. Interact CardioVasc Thorac Surg.2013;17(1):66-72.
[11]Shrestha M, Maeding I, Höffler K, et al. Aortic valve replacement in geriatric patients with small aortic roots: are sutureless valves the future? Interact Cardiovasc Thorac Surg. 2013;17(5):778-782.
[12]Urbanski PP, Dinstak W, Rents W, et al.Long-term results after aortic root replacement using self-assembled valve composite grafts in patients with small aortic annulus. Interact Cardiovasc Thorac Surg.2014;18(2):159-163.
[13]Rahimtoola SH. The problem of valve prosthesis-patient mismatch. Circulation.1978;58(1):20-24.
[14]Minardi G, Manzara C, Creazzo V, et al. Evaluation of 17-mm St.Jude medical regent prosthetic aortic heart valves by rest and dobutamine stress echocardiography. J Cardiothorac Surg. 2006;1(1):27.
[15]Mohty D, Malouf JF, Girard SE, et al.Impact of prosthesis–patient mismatch on long-term survival in patients with small St Jude Medical mechanical prostheses in the aortic position. Circulation.2006;113(3):420-426.
[16]Pibarot P, Dumesnil JG. Prosthesis-patient mismatch: definition, clinical impact, and prevention. Heart.2006;92(8):1022-1029.
[17]Mohty D, Dumesnil JG, Echahidi N, et al. Impact of prosthesispatient mismatch on long-term survival after aortic valve replacement: influence of age, obesity, and left ventricular dysfunction. J Am Coll Cardiol.2009;53(1):39-47.
[18]Walther T, Rastan A, Falk V, et al. Patient prosthesis mismatch affects short- and long-term outcomes after aortic valve replacement. Eur J Cardiothorac Surg.2006;30(1):15-19.
[19]Ardal H, Toker ME, Rabu? MB, et al. Does aortic root enlargement impair the outcome of patients with small aortic root? J Card Surg.2006;21(5):449-453.
[20]Finkelstein A, Schwartz AL, Uretzky G, et al. Hemodynamic performance and outcome of percutaneous versus surgical stentless bioprostheses for aortic stenosis with anticipated patient-prosthesis mismatch.J Thorac Cardiovasc Surg.2013. pii: S0022-5223(13)00768-X. doi: 10.1016/j.jtcvs.2013.07.008. [Epub ahead of print].
[21]Chacko SJ, Ansari AH, McCarthy PM, et al. Prosthesis-patient mismatch in bovine pericardial aortic valves：evaluation using 3 different modalities and associated medium-term outcomes. Circ Cardiovasc Imaging.2013; 6(5):776-783.
[22]Urso S, Sadaba R, Aldamiz-Echevarria G.Is patient-prosthesis mismatch an independent risk factor for early and mid-term overall mortality in adult patients undergoing aortic valve replacement? Interact CardioVasc Thorac Surg. 2009;9(3):510-518.
[23]Mannacio VA, De Amicis V, Di Tommaso L, et al. Influence of prosthesis-patient mismatch on exercise-induced arrhythmias: a further aspect after aortic valve replacement.J Thorac Cardiovasc Surg.2009;138(3):632-638.
[24]Bridges CR, O’Brian SM, Cleveland JC, et al. Association between indices of prosthesis internal orifice size and operative mortality after isolated aortic valve replacement. J Thorac Cardiovasc Surg.2007;133(4):1012-1021.
[25]Kohsaka S, Mohan S, Variani S, et al. Prosthesis-patient mismatch affects long-term survival after mechanical valve replacement. J Thorac Cardiovasc Surg.2008;135(5):1076-1080.
[26]Konno S, Imai Y, Iida Y, et al.A new method for prosthetic valve replacement in congenital aortic stenosis associated with hypoplasia of the aortic ring. J Thorac Cardiovasc Surg. 1975;70(5):909-917.
[27]Manouguian S, Seybold-Epting W. Patch enlargement of the aortic valve ring by extending the aortic incision into the anterior mitral leaflet. J Thorac Cardiovasc Surg.1979;78(3): 402-412.
[28]Dhareshwar J, Sundt TM 3rd, Dearani JA, et al. Aortic root enlargement: what are the operative risks? J Thorac Cardiovasc Surg.2007;134(4):916-924.
[29]Kulik A, Al-Saigh M, Chan V, et al. Enlargement of the small aortic root during aortic valve replacement: is there a benefit? Ann Thorac Surg.2008;85(1):94-100.
[30]Celiento M, Saccocci M, De Martino A, et al.Stability of aortic annulus enlargement during aortic valve replacement using a bovine pericardial patch: an 18-year clinical, echocardiographic, and angio-computed tomographic follow-up. J Thorac Cardiovasc Surg.2014;147(3):977-983.
[31]Prakash S, Agarwal S, Dutta N, et al. A comparative study of surgical treatment of small aortic root with or without aortic root enlargement using a single prosthesis type. J Cardiovasc Med (Hagerstown).2010;11(11):836-842.
[32]夏冰,文冰,许华山,等.自体心包补片修补主动脉瓣环辅助主动脉瓣置换[J].中国组织工程研究,2013,17(5):761-768.
[33]Penaranda JG, Greason KL, Pislaru SV, et al. Aortic Root Enlargement in Octogenarian Patients Results in Less Patient Prosthesis Mismatch. Ann Thorac Surg.2014 Mar 18. pii: S0003-4975(13)02813-0.
[34]庞中一, 李继勇. 十九毫米主动脉瓣环机械瓣置换80例中期效果分析[J].中国组织工程研究与临床康复,2008,12(35):6888-6890.
[35]王亮,王晓明,韩志伟,等. 17-mm Regent瓣治疗狭小主动脉瓣环患者术后临床观察[J].中国心血管病研究,2010,8(9):648-649.
[36]苗齐,刘兴荣,马国涛,等. St．Jude Medical Regent主动脉瓣应用于小主动脉瓣环患者的初步经验[J].中国心血管病研究,2006, 4(6):404-406.
[37]赵东,王春生,洪涛,等.小主动脉瓣环患者应用Regent机械瓣术后心功能变化的评价[J].复旦学报(医学版),2006,33(2): 251-253.
[38]于涛,谢定雄,董燕.CarboMedics Top Hat Supra-Annular Aortic机械瓣在小主动脉瓣环成年患者中的应用[J].中国组织工程研究与临床康复,2008,12(9):1632-1634.
[39]陈卫民,王奇,刘媛.小主动脉瓣环患者应用ATS．AP瓣置换20例效果分析[J].中国临床新医学,2010,3(12):1235-1237.
[40]申红亚.人工瓣膜置换对血流动力学影响的系统分析[J].中国组织工程研究与临床康复,2009,13(26):5141-5144.
[41]Nouette K, Richeb6 P, Calderon J, et al. Perioperative anticOagulatiOn management for prosthetic heart valves. Ann Fr Aneslh Reanim.2005;24(6):621-631.
[42]褚衍林,李鲁,吴英渝,等.风湿性心脏瓣膜替换术后远期疗效观察[J].中国循环杂志,2006,21(2):140-142.
[43]尹宗涛,王辉山,汪曾炜,等.Hancock II Ultra生物瓣行主动脉置换术后早期患者的血流动力学评价[J].中华胸心血管外科杂志, 2011,27(12):720-723.
[44]Flameng W, Herregods MC, Vercalsteren M, et al. Prosthesis-patient mismatch predicts structural valve degeneration in bioprosthetic heart valves. Circulation. 2010; 121(19):2123-2129.
[45]Shrestha M, Folliguet T, Meuris B, et al. Sutureless Perceval S aortic valve replacement: a multicenter prospective pilot trial. J Heart Valve Dis.2009;18(6):698-702.
[46]Villa E, Messina A, Cirillo M, et al. Perceval sutureless valve in freestyle root: new surgical valve-in-valve therapy. Ann Thorac Surg.2013;96(6):e155-e157.
[47]Wu Z, Cao H, Zhu D, et al.Replacement of the st jude medical regent valve in the aortic position with a continuous suture technique in the small aortic root. J Card Surg.2014;29(2):170-174.
[48]Kitamura T, Torii S, Hanayama N, et al. Moderate prosthesis-patient mismatch may be negligible in elderly patients undergoing conventional aortic valve replacement for aortic stenosis. Int Heart J.2013;54(1):11-14.
[49]Kato Y, Hattori K, Motoki M, et al. Optimal results of aortic valve replacement with small mechanical valves (< 19 mm). J Heart Valve Dis.2013;22(4):468-475.