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Correspondence

Aortic Valve Replacement With 17-mm Prosthesis: Emerging Evidence of Its Efficacy

Escorts Heart Institute and Research Centre, c-146, Sarita Vihar, New Delhi 110044, India

(Email: spcollison{at}gmail.com).

To the Editor:

In a recent article, Takaseya and colleagues [1] reported 11 elderly women (mean body surface area [BSA], 1.33 ± 0.13 cm/m²) who received a 17-mm prosthesis at the time of aortic valve replacement (AVR) with good results. We believe that the analysis of this study would be enhanced by emphasizing the following:

• As emphasized by Pibarot and Dumesnil [2] and Rahimtoola [3], patient-prosthesis (PPM) must be measured by calculation of the effective orifice area index (EOAI) obtained in the individual patient at postoperative echocardiography. Calculation of the EOAI by other methods, whether from the valve manufacturer’s in vitro data or from literature sources are inadequate; unfortunately these methods continue to be used even in recent reports [3]. Indeed, it is the use of varying measurements to define PPM in many studies over the years that have been a stumbling block to defining the clinical sequelae, if any, of PPM after AVR. By using the appropriate measurement to define PPM in their patients, the value of the results of this study is greatly increased.

• Pibarot and Dumesnil [2] demonstrated a curvilinear relation between gradient and EOAI up to an EOAI of approximately 0.9 cm/m², at which point gradients increase exponentially. Hence with the EOAI obtained in this study (0.87 cm/m²), high gradients would not be expected, and hence left ventricular (LV) mass regression should occur, as was demonstrated. This is primarily because the patients in this study had a mean BSA of 1.33 cm/m², and hence were of a smaller size than those usually encountered. In this rare subgroup of patients, it is to be expected that a 17-mm prosthesis would suffice.

• However, two other recent articles have reported good results when using a 17-mm valve. Amarelli and colleagues [4] studied this valve in patients with a mean BSA of 1.59 cm/m² and an EOAI of 0.67 cm/m², and they reported LV mass regression and good 5-year survival. Using dobutamine stress echocardiography, Minardi and colleagues [5] studied patients with a mean BSA of 1.68 cm/m² and an EOAI of 0.7 cm/m², and they documented satisfactory performance of the valve. Thus a 17-mm valve has also been found to be adequate even in larger patients than those in Takaseya and colleagues’ [1] study. Interestingly, as discussed by Minardi and colleagues [5], there is considerable similarity and overlap in values of postoperative gradients and the EOAI among valves ranging in size from 17 mm to 21 mm.

Thus, it seems that although PPM does occur, a 17-mm valve is a satisfactory choice for selected patients (ie, small, older, mainly female patients) with a small aortic root, especially when concomitant procedures are contemplated. However, further studies are needed (especially with long-term follow-up) to detect late recurrence of gradients.

	References

Top References

 

1. Takaseya T, Kawara T, Tokunaga S, et al. Aortic valve replacement with 17-mm St Jude Medical Prostheses for a small aortic root in elderly patients Ann Thorac Surg 2007;83:2050-2053.[Abstract/Free Full Text]
2. Pibarot P, Dumesnil JG. 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]
3. Rahimtoola SH. Is severe valve prosthesis-patient mismatch (VP-PM) associated with a higher mortality? Eur J Cardiothorac Surg 2006;30:1.[Free Full Text]
4. Amarelli C, Della Corte A, Romano G, et al. Left ventricular mass regression after aortic valve replacement with 17-mm St Jude Medical mechanical prostheses in isolated aortic stenosis J Thorac Cardiovasc Surg 2005;129:512-517.[Abstract/Free Full Text]
5. Minardi G, Manzara C, Creazzo V, et al. Evaluation of 17-mm StJude Medical Regent prosthetic aortic heart valves by rest and dobutamine stress echocardiography. J Cardiothorac Surg 2006;1:27.[Medline]

This article has been cited by other articles:

				T. Takaseya, T. Kawara, S. Suzuki, Y. Oishi, H. Sonoda, and S. Morita Reply Ann. Thorac. Surg., February 1, 2008; 85(2): 693 - 693. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Sathiakar Collison Yugal Mishra Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Collison, S. Articles by Meherwal, Z. S. Search for Related Content PubMed PubMed Citation Articles by Collison, S. Articles by Meherwal, Z. S. Related Collections Valve disease Related Article