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Ann Thorac Surg 2003;76:656-657
© 2003 The Society of Thoracic Surgeons

Correspondence

Is the hemodynamic performance of the carpentier-edwards perimount valve really equivalent to that of stentless valves?

Philippe Pibarot, DVM, PhDa, Jean G. Dumesnil, MDa

a Quebec Heart Institute/Laval Hospital, Laval University, 2725 Chemin Sainte-Foy, Sainte-Foy, PQ G1V 4G5, Canada

e-mail: philippe.pibarot{at}med.ulaval.ca

To the Editor:

Before 2002, very few data had been published regarding the hemodynamic performance of the Carpentier-Edwards Perimount (CEP) bioprosthetic valve in the aortic position [1]. Cohen and associates [2] presented the results of a randomized trial comparing the hemodynamic and clinical performance of the CEP bioprosthesis with that of the Toronto stentless bioprosthesis and concluded that both valves had equivalent hemodynamic performance. Previous studies[3–5] had found that stentless valves were definitely superior in this regard. In the study by Cohen and co-workers, values for effective orifice area of the valve and mean transvalvular gradient in the cohort with a CEP prosthesis (average size, 23 ± 2 mm) were 1.91 ± 0.90 cm2 (mean ± standard deviation) and 6 ± 4 mm Hg, respectively; detailed results for each size of prosthesis were not given. These results are much better than those previously reported for the same prosthesis[1] as well as for other stented bioprostheses[4, 6].

The results recently reported by Banbury[7], Dellgren [8], and their colleagues in large series of patients with a CEP bioprosthesis are more in line with those in former series and differ markedly from the results of Cohen and coauthors. For instance, in both series, the average mean gradient in patients with a 23-mm CEP prosthesis was around 12 mm Hg, and even in the larger sizes, the mean gradients were considerably higher than 6 mm Hg reported by Cohen and coauthors (Fig 1A). Likewise, the average values for effective office area for all sizes were well less than the 1.91 ± 0.90 cm2 of Cohen and coworkers (Fig 1B). We find these important discrepancies difficult to explain given that there appears to have been no important differences in patient population or surgical technique between these series. Moreover, the data of Banbury and coauthors [7] and Dellgren and colleagues[8] come from two independent and highly recognized institutions in the field of heart valve surgey.



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  		Fig 1. Mean transvalvular gradients (A) and valve effective orifice areas (B) as a function of valve size. This figure presents the data reported by Banbury and co-authors ({blacktriangleup}; data are median values) [7], Dellgren and co-authors (•; mean values ± standard deviation) [8], Salomon and co-authors ({blacktriangledown}; mean values) [1], and Cohen and co-authors ({blacksquare}; mean values ± standard deviation) [2].

 
Hence, until further explanation can be given, the data of Cohen and coauthors should be viewed with extreme caution, and their conclusion to the effect that the hemodynamic performance of the CEP stented prosthesis is equivalent to that of stentless prostheses cannot be accepted at face value. On the other hand, the results of Banbury [7], Dellgren [8], and their coauthors suggest that the CEP stented prosthesis is equivalent to but no better than the other stented bioprostheses currently available.

References

  1. 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]
  2. Cohen G., Christakis G.T., Joyner C.D., et al. Are stentless valves hemodynamically superior to stented valves? A prospective randomized trial. Ann Thorac Surg 2002;73:767-778.[Abstract/Free Full Text]
  3. Pibarot P., Dumesnil J.G., Jobin J., Cartier P., Honos G., Durand L.G. Hemodynamic and physical performance during maximal exercise in patients with an aortic bioprosthetic valve: comparison of stentless versus stented bioprostheses. J Am Coll Cardiol 1999;34:1609-1617.[Abstract/Free Full Text]
  4. Dumesnil J.G., LeBlanc M.-H., Cartier P.C., et al. Hemodynamic features of the Freestyle aortic bioprosthesis compared with stented bioprosthesis. Ann Thorac Surg 1998;66:S130-S133.
  5. Walther T., Falk V., Langebartels G., et al. Prospectively randomized evaluation of stentless versus conventional biological aortic valves: impact on early regression of left ventricular hypertrophy. Circulation 1999;100(Suppl 2):6-10.
  6. Pibarot P., Dumesnil J.G. Hemodynamic and clinical impact of prosthesis-patient mismatch in the aortic valve position and its prevention. J Am Coll Cardiol 2000;36:1131-1141.[Abstract/Free Full Text]
  7. Banbury M.K., Cosgrove D.M., III, Thomas J.D., et al. Hemodynamic stability during 17 years of the Carpentier-Edwards aortic pericardial bioprosthesis. Ann Thorac Surg 2002;73:1460-1465.[Abstract/Free Full Text]
  8. Dellgren G., David T.E., Raanani E., Armstrong S., Ivanov J., Rakowski H. Late hemodynamic and clinical outcomes of aortic valve replacement with the Carpentier-Edwards Perimount pericardial bioprosthesis. J Thorac Cardiovasc Surg 2002;124:146-154.[Abstract/Free Full Text]




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