Department of Cardiothoracic Sciences, Second University of Naples, Via S. Maria di Constantinopoli 104,Caserta, 80138 Italy, Department of Cardiovascular Surgery and Transplants, V. Monaldi Hospital, Via L. Bianchi, Naples, 80125 Italy
To the Editor:
We thank Kulik and colleagues  for their comments on our article, and their observation regarding our policy in the choice of the opportune valve substitute for elderly patients. As explained in our studies [2, 3], the choice of prosthetic type for old patients was fundamentally guided by the patient's biologic age, associated to the foreseeable expectancy of life. We chose mechanical devices for elderly patients who reasonably had a life expectancy of more than 10 to 12 years, and for patients already receiving long-term anticoagulation for chronic atrial fibrillation.
Biological prostheses were preferred for those patients with contraindication to oral anticoagulation or those in whom general senescence status or associated multiple noncardiac comorbidities, or both, suggested a life expectancy of less than 10 years.
Our strategy is aimed to reduce the risk of reoperation in the ninth decade of life for structural degeneration of a bioprosthesis, and is supported by our previously described experience in which an adequate management of oral anticoagulation is also safe in elderly people [2, 3].
Nevertheless, we have also collected experience with the use of biological prostheses in the elderly and we await the possibility to publish these experiences as well. This was not a consecutive series of septuagenarian patients, but only those receiving mechanical devices were included.
As already asserted in our article , we refer to the definition of prosthesis-patients mismatch (PPM) (originally issued by Rahimtoola, the father of the PPM concept) when choosing the method of estimation of the effective orifice area (EOA). Also recent studies on PPM effect on survival have the privileged use of EOA area as measured by echocardiography in each patient . Others have shown that PPM can be predicted before the operation, and to this purpose, the projected EOA has been obviously used ; however, we still believe that in follow-up studies that imply serial echocardiographic assessments, the measured EOA is best used.
In regard to the effects on quality of life of PPM in patients with preoperative left ventricular dysfunction, we were aware of your commendable work on this topic, but our present study population has too small a number of patients with this preoperative condition. Therefore, our results are not actually helpful to clear this issue.
Concerning the issue of mortality rates after aortic root enlargement: the authors of most series, in addition to those rates from highly experienced centers, have cautiously claimed that PPM is proven safe and effective in selected populations. Among aortic valve replacement patients, age remains an independent determinant of morbidity and mortality; therefore, as maintained by Peterson and colleagues , the technique may not be indicated in the elderly. Moreover, in our series, the implant of small bi-leaflet prostheses have shown a low rate of hospital mortality, a good long-term survival in patients with or without PPM, a regression of ventricular mass, and an improvement in quality of life. The increased time of aortic cross clamping required to perform aortic root enlargement, a known risk factor for hospital morbidity, especially in elderly people, is not necessary.
In Kulik and colleagues'  recent study, patients who underwent aortic root enlargement did not show higher hospital mortality than the control group of isolated aortic valve replacement. However, that acknowledgeable group has reported same survival at the follow-up in both groups of patients. The unique difference was "a trend toward better freedom from late congestive heart failure" in patients receiving aortic root enlargement . In our experience, also considering higher mean age of our study population , hospital mortality is comparable with the rate reported in Kulik and colleagues' study population . Our long-term analysis has shown that survival and freedom from congestive heart failure do not increase in patients presenting PPM. The implant of a larger prosthesis through aortic root enlargement in the elderly population is not supported by our short-time outcomes and by long-term clinical and echocardiographic results.
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