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Ann Thorac Surg 2002;73:1460-1465
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Hemodynamic stability during 17 years of the Carpentier-Edwards aortic pericardial bioprosthesis

^a Department of Thoracic and Cardiovascular Surgery, Cleveland, Ohio, USA
^b Department of Cardiology, Cleveland, Ohio, USA
^c Department of Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
^d Good Samaritan Hospital, Portland, Oregon, USA
^e Montefiore Medical Center/Albert Einstein, Bronx, New York, USA

Accepted for publication January 4, 2002.

* Address reprint requests to Dr Banbury, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F25, Cleveland, OH 44195 USA
e-mail: banburm{at}ccf.org

	Abstract

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Background. Long-term stability of the hemodynamic performance of commercially available Carpentier-Edwards stented bovine pericardial aortic bioprostheses (Perimount RSR) is unknown. To anticipate the fate of this bioprosthesis, we examined its hemodynamic performance up to 17 years using echocardiographic studies in a Premarket Approval cohort.

Methods. Of 267 patients at four institutions in the Premarket Approval cohort, 85 had a total of 168 echocardiographic studies during a 17-year period of yearly follow-up examinations. These were reviewed and quantified in a core echocardiographic facility. Longitudinal data analysis was used to account for repeated, censored data.

Results. Mean transvalvular gradient was inversely related to prosthesis size (p = 0.01), and possibly (p = 0.06) increased somewhat during the first 10 years of follow-up, then stabilized. Effective orifice area was larger in larger valve sizes (p = 0.01), declined somewhat during the first 10 years, and then began to increase again. Ejection fraction declined minimally (p = 0.2). In contrast to the rather stable hemodynamics, aortic regurgitation steadily increased from none to 1 to 2+ (p = 0.005), but rarely (< 10% at 17 years) progressed to 3+ or 4+.

Conclusions. The Carpentier-Edwards aortic pericardial bioprosthesis can be anticipated to have an acceptable long-term transvalvular gradient and effective orifice size that will change trivially up to 17 years after implantation. Mild aortic regurgitation will develop progressively. This anticipated hemodynamic resilience supports continued clinical use of the Perimount Carpentier-Edwards bovine pericardial stented bioprosthesis.

	Introduction

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Clinical investigation of the Carpentier-Edwards stented bovine pericardial aortic bioprosthesis (Edwards Lifesciences LLC, Irvine, CA) began in 1981. However, the valve did not become available for commercial distribution in the United States until 1991. The Premarket Approval study cohort provides a unique opportunity to anticipate the fate of this prosthesis in patients receiving the commercial product. To date, it has been used to characterize clinically detectable structural valve dysfunction and early and midterm hemodynamics [1–5].

Follow-up now extends to 17 years, permitting long-term characterization of prosthesis-related hemodynamic changes from echocardiograms performed for clinical indications during follow-up [6]. The objective of this study, therefore, was to determine the time-related pattern and correlates of hemodynamics of this stented bovine pericardial aortic valve bioprosthesis.

	Patients and methods

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Patients
Premarket approval cohort
The Premarket Approval cohort consisted of 267 patients followed yearly who received a bovine pericardial aortic valve prosthesis between September 24, 1981, and December 28, 1983. Age at implantation ranged from 21 to 86 years (mean, 65 ± 12 years). Of these, 64% were men. Preoperatively, 45 (17%) patients were in New York Heart Association (NYHA) functional class IV, 115 (43%) in class III, 93 (35%) in class II, and 10 (4%) in class I; 4 were not classified. Coronary artery disease (n = 133, 50%), congestive heart failure (n = 58, 22%), and previous myocardial infarction (n = 45, 18%) were the most common preexisting conditions. The native aortic valve lesions were pure aortic stenosis (n = 174, 65%), pure aortic regurgitation (n = 46, 17%), and mixed stenosis and regurgitation (n = 39, 15%); 8 (3%) additional patients had a previous aortic valve replacement.

Surgical technique
Aortic valve replacement was performed using standard techniques. Concomitant procedures, performed in 123 patients, included coronary artery bypass grafting in 108 and ascending aortic grafting in 7. Size of the prosthesis implanted was 19 mm in 34 (13%), 21 mm in 83 (31%), 23 mm in 85 (32%), 25 mm in 48 (18%), 27 mm in 12 (4.5%), and 29 mm in 5 (1.9%).

Follow-up
Patient status in this cohort was assessed on an annual basis, typically during an office or hospital visit, or by means of detailed patient questionnaires completed by telephone or mail. All valve-related complications were identified according to the guidelines for reporting morbidity and mortality after cardiac valve operation [7].

Two patients were lost to follow-up within the first year, 5 after 1 to 5 years, and 10 after 5 to 10 years. Mean follow-up among survivors was 12 ± 4.5 years, with a maximum of 17 years. Of the 267 patients, 16% were alive at 15 years and 6% at 16 years.

Outcomes
Survival declined from 96% at 30 days to 89%, 76%, 52%, and 26% at 1, 5, 10, and 15 years, respectively. Thirty-six prostheses were explanted, 30 for valve-related complications and 27 for structural valve dysfunction. Risk of structural valve dysfunction was strongly age-related and time-related, with less than 10% chance of explant by 15 years in patients 65 years and older.

New york heart association functional class
New York Heart Association functional class declined slowly with time (Fig 1). Among the 240 patients with NYHA assessment, the last NYHA class was I in 120 patients, II in 88, III in 26, and IV in 6. Shorter individuals, generally women, experienced a somewhat more rapid decline in functional status (Table 1).

View larger version (15K): [in this window] [in a new window]   Fig 1. Evolution of New York Heart Association (NYHA) functional class across time in the Premarket Approval cohort (n = 267). Symbols represent the proportion of patients in each class in 1-year intervals. Closed circles = NYHA class I, open circles = class II, squares = class III, and triangles = class IV. In this depiction, death is a censoring mechanism. Solid lines = the solution for an ordinal logistic longitudinal repeated-measures model with only time as a variable.

Methods of echocardiographic study
Transthoracic echocardiograms were reviewed and quantified in the Echocardiographic Core Facility of The Cleveland Clinic Foundation. The simplified Bernoulli equation (p = 4v²) was used to calculate mean pressure gradient across the valve. Left ventricular outflow tract (LVOT) area was calculated by measuring the diameter (D) of the LVOT and assuming circular shape (A_LVOT = D²/4). Effective orifice area (A_AVR) was calculated by the continuity equation using the time velocity integral of LVOT velocity (V_LOT, by pulsed-wave Doppler) and prosthetic valve velocity (V_AVR by continuous-wave Doppler): A_AVR = A_LVOT (V_LVOT/V_AVR). Left ventricular end-diastolic and end-systolic volumes (LVEDV and LVESV) were calculated from the apical four-chamber and two-chamber views using the biplane Simpson method. Ejection fraction was calculated as (LVEDV-LVESV)/LVEDV. Aortic regurgitation was estimated on a 0 to 4+ semiquantitative scale by integrating information from (1) size of regurgitant jet, (2) aortic pressure half-time, (3) presence of a proximal convergence zone above the aortic valve, and (4) presence of flow reversal in the aortic arch.

Data analysis
Echocardiographic variables included in the analysis were transprosthesis mean gradient (104 measurements in 51 patients), in vivo effective orifice area (60 measurements in 33 patients), left ventricular ejection fraction (42 measurements in 32 patients), and aortic regurgitation grade (121 assessments in 63 patients).

The challenges in data analysis were (1) repeated measurement and assessment in some of the patients across time (41 of 85 patients), requiring that we take into account intrapatient correlation; (2) nonuniform time intervals between serial echocardiographic sessions, with censoring at valve explant or death; (3) violation of statistical model assumptions from skewed distributions of echocardiographic continuous measurements and lack of proportional odds for the ordered qualitative assessment of aortic valve regurgitation and NYHA functional class; and (4) the need for multivariable analysis. These challenges were met by using both linear (mean gradient, effective orifice area, and ejection fraction) and ordinal (aortic regurgitation) longitudinal mixed-model repeated-measures analyses [8–10].

The skewed continuous echocardiographic measurements were logarithmically transformed for analysis to achieve a more normal distribution of dependent variables. The proportional odds assumption was not met for aortic valve regurgitation data. We traced this to a scarcity of patients in certain of the ordinal categories of regurgitation. Therefore, patients were regrouped into four categories: (1) regurgitation grade 0 or trace, (2) mild regurgitation (grade 1+), (3) mild-to-moderate and moderate regurgitation (grades 1.5+ and 2+), and (4) moderately severe and severe regurgitation (grades 3+, 3.5+, and 4+). By this means, the proportional odds assumption was met (p > 0.1).

We initially screened the variables listed in the Appendix using multivariable linear regression for continuous echocardiographic measurements and ordinal logistic regression for aortic regurgitation [9]. The identified candidates were then entered at once into the mixed models, and eliminated one by one until all variables remaining had a probability value less than or equal to 0.1. However, for all models, the best transformation of time interval and prosthesis size was incorporated no matter what the magnitude of the probability value.

	Results

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Mean transvalvular gradient
Mean transvalvular gradient ranged from 0 to 93 mm Hg (median, 18 mm Hg; Table 2). Mean gradient was generally greater the smaller the labeled size of the prosthesis (Table 3). This expected finding was identified in the multivariable analysis (Table 4). In addition, mean gradient possibly (p = 0.06) increased somewhat during the first decade after valve replacement, and then stabilized (Fig 2).

View larger version (21K): [in this window] [in a new window]   Fig 2. Evolution of mean transvalvular gradient across time. Actual data points are shown, coded for each labeled valve size as follows: closed circle = 19-mm prostheses; open circle = 21-mm prostheses; square = 23-mm prostheses; triangle = 25-mm prostheses; and X = 29-mm prostheses. Solid lines = estimates of mean gradient for each valve size across time (Table 4).

View larger version (18K): [in this window] [in a new window]   Fig 3. Evolution of in vivo effective orifice area (EOA) across time. Format is as in Figure 2, plus diamond = 27-mm prostheses.

View larger version (21K): [in this window] [in a new window]   Fig 4. Evolution of left ventricular ejection fraction in women (A) and in men (B). Format is as in Figure 2, plus diamond = 27-mm prostheses.

View larger version (17K): [in this window] [in a new window]   Fig 5. Development of aortic valve regurgitation across time. Symbols represent the percentage of patients in each regurgitation grade in 3-year intervals. Closed circles = regurgitation grades 0 (none) and trace; open circles = grade 1+ (mild); squares = grade 2+ (moderate); and triangles = grade 3+ and 4+ (severe). Solid lines = the solution for an ordinal logistic longitudinal repeated-measures model with only time as a variable (equation not shown). The ordinal model can be thought of as a set of compartments in which there is transition from grade 0 or trace to grade 1+, then to 1+ to 2+, and finally to grade 3+ and 4+. Thus, the proportion of patients in grade 0 or trace decreased across time, the proportion in grade 1+ rose and then plateaued (it eventually will decrease), and the other two grades increased.

	Comment

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

Comparison of valve performance requires uniform measurement of valve size. Manufacturer’s labeled valve size has no standard and can be misleading [13]. Labeled valve size is related to different features of the external diameter of the prostheses; thus, the internal orifice for a given label size may vary widely among types of prostheses. This is especially true when comparing intraannular with supraannular valves. The EOA may be the most reliable method of comparing hemodynamic performance, because it takes into account both transvalvular gradient and flow across the valve [14–16]. Effective orifice area was smaller in the smaller sized valves, as expected. Interestingly, EOA decreased with time until approximately 10 years and then began to increase. This phenomenon was seen in all valve sizes.

Mean EOA at 17 years ranged from 0.97 to 2.03 cm² for valve sizes 19 to 29 mm, an increase from the overall median range of 0.82 to 1.5 cm² (Fig 3). David and colleagues [17] reported echocardiographic findings for the Hancock II porcine valve at 1 year that demonstrated EOAs of 1.18 to 1.60 cm² for valve sizes 21 to 29 mm. These findings are similar to those for the pericardial valve early and late (EOA range 1.19 to 2.03 cm² for valves 21 to 29 mm at 17 years), but are slightly better than at midterm, as depicted in Figure 3. It is unknown whether porcine valves demonstrate the same decrease and then increase in EOA as we have found with aortic bovine pericardial valves.

Cohen and colleagues [18] compared the hemodynamic performance of stented versus stentless valves and found no difference in peak or mean transvalvular gradients with 6-month follow-up. They were able to detect an increase in EOA with stentless valves; however, this did not result in a difference in left ventricular mass index reduction between the groups at 6 months. These findings were confirmed by Rao and coworkers [19] in a comparison of pericardial valves with stentless valves in patients with small aortic roots.

Ejection fraction tended to be higher in women than in men. Implanted valve size was not reliably related to ejection fraction or changes in ejection fraction with time.

Initially, the majority of valves showed no or trace aortic regurgitation. As time passed, this group diminished in size, whereas those with mild and then moderate regurgitation began to increase. At 17 years, the proportion of patients with severe regurgitation remained low (13%). The pattern of prosthetic pericardial valve deterioration does include slow progression of aortic regurgitation, but most patients are spared clinically significant aortic regurgitation.

Limitations
One of the principal limitations of this study is the nonrandom selection of the echocardiographic cohort (n = 85) from the Premarket Approval cohort (n = 267). Only patients presenting with clinical indications had echocardiograms; thus, they may represent a group with more advanced valvular dysfunction. Countering this is the possibility that patients who died during the study period may have died with, or because of, unrecognized valvular dysfunction. There is little or no autopsy data available for this study group.

A strength of this study is that by using the systematically followed Premarket Approval cohort, we know well in advance what might be expected for patients in whom U.S. Food and Drug Administration approved valves have been used. However, this was a relatively small group of patients, with few details recorded about their clinical history and operation.

The recent development and implementation of methods for longitudinal data analysis have made a study such as this possible; that would not have been the case even a decade ago. These methods permit statistically valid characterization of repeated measurements across time, with unequal time points, and censoring. An important assumption is that censoring at death is noninformative. This may not be true. Thus, the estimates provided should be interpreted as echocardiographic status in surviving patients.

Conclusions
Hemodynamic assessment of the Carpentier-Edwards stented aortic pericardial prosthesis demonstrates reliable function as late as 17 years after implantation. Increases in mean transvalvular gradients are seen early in the life of the valve, and later changes are limited. Effective orifice area shows an early decrease and then increases in magnitude such that at 17 years, it is similar to that found at 3 years. Ejection fraction was not clearly related to time or valve size. Aortic regurgitation increased gradually with time, but rarely became severe.

The Carpentier-Edwards aortic pericardial bioprosthesis can be anticipated to have an acceptable long-term transvalvular gradient and effective orifice size that will change trivially up to 17 years after implantation. Mild aortic regurgitation will develop progressively. This anticipated hemodynamic resilience supports continued clinical use of the Perimount Carpentier-Edwards bovine pericardial stented bioprosthesis.

	Acknowledgments

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Edwards Lifesciences LLC, Irvine, CA, supplied funding for the interpretation of echocardiograms at the Echocardiographic Core Facility of The Cleveland Clinic Foundation. The authors thank Tess Knerik for editorial suggestions and manuscript preparation.

	Footnotes

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 
Dr Cosgrove discloses that he has a financial relationship with Edwards Lifesciences Corporation.

	Appendix

 

Variables Examined in Multivariable Analysis Demography: Sex, age, height, weight, body surface area, body mass index Native valve lesion: Aortic stenosis, aortic regurgitation, pure aortic stenosis (regurgitation mild or absent), pure aortic regurgitation (aortic stenosis mild or absent), mixed lesion (both stenosis and regurgitation moderate or more) Prosthesis size: Labeled size, internal orifice area indexed to body surface area, in vitro effective orifice area indexed to body surface area, Z value standardized to body surface area Time interval between valve replacement and each echocardiographic examination

	References

Top Footnotes Abstract Introduction Patients and methods Results Comment Acknowledgments References

 

1. Cosgrove D.M., Lytle B.W., Taylor P.C., et al. The Carpentier-Edwards pericardial aortic valve. Ten-year results. J Thorac Cardiovasc Surg 1995;110:651-662.[Abstract/Free Full Text]
2. Banbury M.K., Cosgrove D.M., III, Lytle B.W., Smedira N.G., Sabik J.F., Saunders C.R. Long-term results of the Carpentier-Edwards pericardial aortic valve: a 12-year follow-up. Ann Thorac Surg 1998;66(Suppl):S73-S76.
3. Banbury M.K., Cosgrove D.M., III, White J.A., Blackstone E.H., Frater R.W., Okies J.E. Age and valve size effect on the long-term durability of the Carpentier-Edwards aortic pericardial bioprosthesis. Ann Thorac Surg 2001;72:753-757.[Abstract/Free Full Text]
4. Salomon N.W., Okies J.E., Krause A.H., Page U.S., Bigelow J.C., Colburn L.Q. Serial follow-up of an experimental bovine pericardial aortic bioprosthesis: usefulness of pulsed Doppler echocardiography. Circulation 1991;84(Suppl 3):140-144.[Abstract/Free Full Text]
5. Frater R.W., Furlong P., Cosgrove D.M., et al. Long-term durability and patient functional status of the Carpentier-Edwards Perimount pericardial bioprosthesis in the aortic position. J Heart Valve Dis 1998;7:48-53.[Medline]
6. Panidis I.P., Ross J., Mintz G.S. Normal and abnormal prosthetic valve function as assessed by Doppler echocardiography. J Am Coll Cardiol 1986;8:317-326.[Abstract]
7. Edmunds L.H., Jr, Clark R.E., Cohn L.H., Grunkemeier G.L., Miller D.C., Weisel R.D. Guidelines for reporting morbidity and mortality after cardiac valvular operations. Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity of The American Association for Thoracic Surgery and The Society of Thoracic Surgeons. J Thorac Cardiovasc Surg 1996;112:708-711.[Free Full Text]
8. Diggle P.J., Liang K.Y., Zeger S.C. Analysis of longitudinal data. London: Oxford University Press, 1996.
9. Hosmer D.W., Lemeshow S. Applied logistic regression. New York: John Wiley & Sons, 1989:216-245.
10. Blackstone E.H. Breaking down barriers: helpful breakthrough statistical methods you need to understand better. J Thorac Cardiovasc Surg 2001;122:430-439.[Free Full Text]
11. Cosgrove D.M. Carpentier pericardial valve. Sem Thorac Cardiovasc Surg 1996;8:269-275.[Medline]
12. Premarket Approval Application for Medtronic Mosaic Porcine Bioprosthesis Model 305. http://www.fda.gov/cdhr/pdf/p990064.html.
13. Christakis G.T., Buth K.J., Goldman B.S., et al. Inaccurate and misleading valve sizing: a proposed standard for valve size nomenclature. Ann Thorac Surg 1998;66:1198-1203.[Abstract/Free Full Text]
14. Bojar R.M., Rastegar H., Payne D.D., Mack C.A., Schwartz S.L. Clinical and hemodynamic performance of the 19-mm Carpentier-Edwards porcine bioprosthesis. Ann Thorac Surg 1993;56:1141-1147.[Abstract]
15. Baumgartner H., Khan S.S., DeRobertis M., Czer L.S., Maurer G. Doppler assessment of prosthetic valve orifice area: an in vitro study. Circulation 1992;85:2275-2283.[Abstract/Free Full Text]
16. Oh J.K., Taliercio C.P., Holmes D.R., Jr, et al. Prediction of the severity of aortic stenosis by Doppler aortic valve area determination: prospective Doppler-catheterization correlation in 100 patients. J Am Coll Cardiol 1998;11:1227-1234.
17. David T.E., Armstrong S., Sun Z. Clinical and hemodynamic assessment of the Hancock II bioprosthesis. Ann Thorac Surg 1992;54:661-668.[Abstract]
18. Cohen G., Christakis G.T., Buth K.J., et al. Early experience with stentless versus stented valves. Circulation 1997;96(Suppl 9):II-76-II-82.
19. Rao V., Christakis G.T., Sever J., et al. A novel comparison of stentless versus stented valves in the small aortic root. J Thorac Cardiovasc Surg 1999;117:431-438.[Abstract/Free Full Text]

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				Are allografts the biologic valve of choice for aortic valve replacement in nonelderly patients? Comparison of explantation for structural valve deterioration of allograft and pericardial prostheses. J. Thorac. Cardiovasc. Surg., March 1, 2006; 131(3): 558 - 564.e4.

				M. R. Moon, M. K. Pasque, N. A. Munfakh, S. J. Melby, J. S. Lawton, N. Moazami, J. E. Codd, T. D. Crabtree, H. B. Barner, and R. J. Damiano Jr Prosthesis-Patient Mismatch After Aortic Valve Replacement: Impact of Age and Body Size on Late Survival Ann. Thorac. Surg., February 1, 2006; 81(2): 481 - 489. [Abstract] [Full Text] [PDF]

				P. Totaro, N. Degno, A. Zaidi, A. Youhana, and V. Argano Carpentier-Edwards PERIMOUNT Magna bioprosthesis: A stented valve with stentless performance? J. Thorac. Cardiovasc. Surg., December 1, 2005; 130(6): 1668 - 1674. [Abstract] [Full Text] [PDF]

				J. P.A. Puvimanasinghe, J. J.M. Takkenberg, M. J.C. Eijkemans, E. W. Steyerberg, L. A. van Herwerden, G. L. Grunkemeier, J. D. F. Habbema, and A. J.J.C. Bogers Prognosis After Aortic Valve Replacement With the Carpentier-Edwards Pericardial Valve: Use of Microsimulation Ann. Thorac. Surg., September 1, 2005; 80(3): 825 - 831. [Abstract] [Full Text] [PDF]

				W. B. Eichinger, F. Botzenhardt, A. Keithahn, R. Guenzinger, S. Bleiziffer, I. Wagner, R. Bauernschmitt, and R. Lange Exercise hemodynamics of bovine versus porcine bioprostheses: A prospective randomized comparison of the mosaic and perimount aortic valves J. Thorac. Cardiovasc. Surg., May 1, 2005; 129(5): 1056 - 1063. [Abstract] [Full Text] [PDF]

				B-K. Lam, A. M. Gillinov, E. H. Blackstone, J. Rajeswaran, B. Yuh, S. K. Bhudia, P. M. McCarthy, and D. M. Cosgrove Importance of Moderate Ischemic Mitral Regurgitation Ann. Thorac. Surg., February 1, 2005; 79(2): 462 - 470. [Abstract] [Full Text] [PDF]

				T. Walther, S. Lehmann, V. Falk, S. Metz, N. Doll, A. Rastan, M. Viehweg, M. Richter, J. Gummert, and F. W. Mohr Prospectively Randomized Evaluation of Stented Xenograft Hemodynamic Function in the Aortic Position Circulation, September 14, 2004; 110(11_suppl_1): II-74 - II-78. [Abstract] [Full Text] [PDF]

				G. Tasca, F. Brunelli, M. Cirillo, A. Amaducci, Z. Mhagna, G. Troise, and E. Quaini Mass regression in aortic stenosis after valve replacement with small size pericardial bioprosthesis Ann. Thorac. Surg., October 1, 2003; 76(4): 1107 - 1113. [Abstract] [Full Text] [PDF]

				P. Pibarot and J. G. Dumesnil Is the hemodynamic performance of the carpentier-edwards perimount valve really equivalent to that of stentless valves? Ann. Thorac. Surg., August 1, 2003; 76(2): 656 - 657. [Full Text] [PDF]

				G. Cohen Reply Ann. Thorac. Surg., August 1, 2003; 76(2): 657 - 658. [Full Text] [PDF]

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