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a Division of Cardiovascular and Thoracic Surgery, Missouri Baptist Medical Center, St. Louis, MO 63131
b Division of Cardiac Surgery, University of Ottawa Heart Institute, 40 Ruskin St, Suite 3403, Ottawa, Ontario, K1Y 4W7 Canada
(Email: mruel{at}ottawaheart.ca).
We read with interest the article by Vicchio and colleagues [1] evaluating the impact of prosthesis-patient mismatch (PPM) on the outcomes and quality of life of elderly patients with small sized aortic mechanical prostheses. In our view, tissue valves are the preferred prostheses for elderly patients undergoing valve replacement, and we were surprised to read that the authors solely implanted mechanical prostheses in a cohort of patients over 70 years of age. Several groups including our own have reported outstanding results with the use of contemporary bioprostheses [2], especially in elderly cohorts [3]. Nevertheless, Vicchio and colleagues [1] documented excellent outcomes in their series, with 10-year rates of freedom from bleeding and thromboembolism of 96.9% and 99%, respectively.
In their article, Vicchio and colleagues [1] defined PPM using the effective orifice area (EOA) measured at the "routine 1-year postoperative echocardiographic evaluation," indexed for body surface area. A controversial topic, PPM has been described using several methods in the literature. In our previous work, we used fixed values of in vivo EOAs (also known as projected EOAs) for each prosthesis type and size from literature sources of patients with normally functioning prostheses [4]. This technique avoids the challenges in accurately measuring the left ventricular outflow diameter after surgery due to prosthetic valve reverberations, as well as the presence of large localized transprosthetic gradients that may result in large discrepancies between Doppler echocardiography and "actual" EOA measurements [5, 6]. Did the authors consider applying alternative methodology by using projected EOAs? Moreover, we have previously shown that patients with preoperative left ventricular dysfunction are more susceptible to the deleterious effects of postoperative PPM [7, 8]. We would be interested to learn from the authors whether they explored this question with their impressive quality of life dataset.
Most importantly, we were surprised to read the accompanying Invited Commentary written by Banbury [9] that followed Vicchio and colleagues' [1] article. Banbury [9] stated that it is an "undeniable fact" that the aortic root enlargement procedure has a "penalty of a higher perioperative mortality rate." We take exception to this opinion, with several recent series reporting no increase in perioperative mortality rate among patients undergoing aortic root enlargement at the time of aortic valve replacement [10, 11]. Aortic root enlargement is a safe and effective procedure that helps avoid postoperative PPM. In our view, aortic root enlargement and the insertion of a bioprosthesis constitutes a judicious alternative, as compared with the insertion of a mechanical valve with the attendant anticoagulation in an elderly patient with a small aortic root undergoing aortic valve replacement.
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  M. Vicchio, A. Della Corte, M. De Feo, and M. Cotrufo Reply Ann. Thorac. Surg., September 1, 2009; 88(3): 1050 - 1051. [Full Text] [PDF]
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