Ann Thorac Surg 2007;84:713-714
© 2007 The Society of Thoracic Surgeons
Correspondence
Conflicting Echocardiographic Evaluations of Supra-Annular Tissue Valves: A Mystery Not Yet Resolved
Tomaso Bottio, MD, PhDa,
Gino Gerosa, MDb
a Department of Cardiovascular Surgery, University of Brescia Medical School, Piazza Spedali Civili 1, Brescia, 25100 Italy
b Department of Cardiovascular Surgery, University of Padua Medical School, via Giustiniani 2, Padua, 36100 Italy
(Email: bottio{at}med.unibs.it; gino.gerosa{at}unipd.it).
To the Editor:
We read the article by Pavoni and associates [1] with great interest. We would like to congratulate them for this well-designed study [1], but we wish to add some comments. The aim was to determine the hemodynamic performance and early clinical outcome of the Sorin Soprano valve (Sorin Group, Saluggia, Italy) in aortic patients. Seventy-seven patients received the Sorin Soprano valve (Sorin Group) and underwent serial echocardiographic examinations. Peak and mean transvalvular gradients analysed size by size were absolutely satisfactory, as well as the effective orifice areas and valve resistance. They commented that satisfactory performance of the Soprano valve had already been reported [2], although their own series showed better performance than others [2] due to a different echocardiographic evaluation technique (ie, the simplified Bernoulli instead of the modified Bernoulli equation). Thus the selection of one of the Bernoulli equations may have clinically relevant implications, because a specific prosthesis (ie, Soprano) may perform well in one case and worse in another. Botzenhardt and colleagues [2] compared different supra-annular tissue valves and concluded that the Carpentier-Edwards Magna (Edwards Lifesciences LLC, Irvine, CA) is the "gold standard." In that study, hemodynamic results were comparable for patients with an aortic annulus of 18 to 20 mm, but a significant increase of patient prosthesis mismatch was observed in patients with a larger annulus. Moderate and severe mismatch was 8.7% in the Magna group, 41.5% in the Carpentier-Edwards Perimount (Edwards Lifesciences LLC) group, 40% in the Medtronic Mosaic (Medtronic Inc, Minneapolis, MN) group, and 50% in the Soprano group. Therefore, they did not confirm the performance of the Soprano valve. Furthermore patients were not compared for stroke volume, as previously suggested by Eichinger and colleagues [3]; they were followed for 10 days postoperatively using transthoracic-echocardiography, as opposed to previous echocardiographic guidelines [4]; and study results were based on 48 patients with a Perimount valve, 35 with a Magna valve, 42 with a Mosaic valve, and only 16 with a Soprano valve. Thus we maintain that more than one Bernoulli equation may explain the different results of these two articles [1, 2].
On the basis of their experience, Eichinger and colleagues [5] suggest careful sizing to avoid coronary flow impairment, and to avoid oversizing in patients with narrow aortic roots. Nevertheless, Botzenhardt [2] published comparable hemodynamic results for different supraannular tissue valves (including the Soprano valve) in patients with small aortic annuli.
We know the hydrodynamic performance of the Soprano valve, which is comparable with other pericardial tissue valves [6], but we do not suggest restricting valve oversizing, which is naturally facilitated by its supra-annular position. However we do suggest that the manufacturer narrow the sewing ring to reduce its profile, as done for other prostheses.
As clinicians, re-educating on the benefits of new devices, we conclude that only more carefully conducted and randomized echocardiographic studies can resolve the issue whether one tissue valve is more suitable than another since Kadem and colleagues [7] showed that effective orifice area is actually a flow-related parameter, and furthermore since Garcia and Kadem [8] more recently suggested that the Doppler Energy Loss Coefficient is more representative of the increased workload imposed on the left ventricle than effective orifice area.
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- Pavoni D, Badano LP, Musumeci SF, et al. Results of aortic valve replacement with a new supra-annular pericardial stented bioprosthesis Ann Thorac Surg 2006;82:2133-2138.[Abstract/Free Full Text]
- Botzenhardt F, Eichinger WB, Bleiziffer S, et al. Hemodynamic comparison of bioprostheses for complete supra-annular position in patients with small aortic annulus J Am Coll Cardiol 2005;45:2054-2060.[Abstract/Free Full Text]
- Eichinger WB, Botzenhardt F, Keithahn A, et al. Exercise hemodynamics of bovine versus porcine bioprostheses: a prospective randomized comparison of the Mosaic and Perimount aortic valves J Thorac Cardiovasc Surg 2005;129:1056-1063.[Abstract/Free Full Text]
- Sahn DJ, De Maria A, Kisslo J, Weyman Ae. The Committee on M-mode Standardization of the American Society of Echocardiography: recommendation regarding quantitation in M-mode echocardiography—results of a survey of echocardiographic measurements Circulation 1978;58:1072-1081.[Abstract/Free Full Text]
- Eichinger WB, Botzenhardt F, Wagner I, et al. Hemodynamic evaluation of the Sorin Soprano bioprosthesis in the completely supraannular aortic position J Heart Valve Dis 2005;14:822-827.[Medline]
- Gerosa G, Tarzia V, Rizzoli G, Bottio T. Small aortic annulus: the hydrodynamic performances of 5 commercially available tissue valves J Thorac Cardiovasc Surg 2006;131:1058-1064.[Abstract/Free Full Text]
- Kadem L, Rieu ER, Dumesnil JG, Durand LG, Pibarot P. Flow-dependent changes in Doppler-derived aortic valve effective orifice area are real and not due to artifact J Am Coll Cardiol 2006;47:131-137.[Abstract/Free Full Text]
- Garcia D, Kadem L. What do you mean by aortic valve area: geometric orifice area, effective orifice area, or Gorlin area? J Heart Valve Dis 2006;15:601-608.[Medline]
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