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Ann Thorac Surg 2003;76:1570
© 2003 The Society of Thoracic Surgeons

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Original article: cardiovascular

Invited commentary

^a Department of Cardiovascular and Thoracic Surgery, St. Paul's Hospital, 1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada

e-mail: wrej{at}interchange.ubc.ca

Albes and colleagues have documented the first prospective randomized trial comparing the hemodynamic performance of mechanical aortic prostheses with enhanced internal diameter to a conventional mechanical prosthesis with standard internal diameter. There has been extensive interest over the past decade in optimizing the effective orifice area of prostheses to achieve low mean transvalvular gradients and effective orifice area indices (EOAI) to prevent or reduce the phenomena of patient-prosthesis mismatch (PPM) (EOAI <0.85 cm²m²) and facilitate normalization of left ventricular mass index (LVMI).

The study compared the hemodynamic performance of St. Jude Medical Hemodynamic Plus (SJM-HP) to the SJM-Regent to the conventional standard CarboMedics in the aortic position. The development of the SJM mechanical prostheses has led to progressively greater geometric orifice area while maintaining the same tissue annulus dimension. In the standard cuff SJM mechanical prosthesis, part of the cuff fabric is intra-annular, whereas in the SJM-HP the fabric has shifted to an entirely supra-annular position. The SJM-Regent prosthesis shifts the carbon rim from intra-annular to entirely supra-annular. The authors stated the implantation technique was epi-annular (prefix denoting on, upon, or over), presumably more supra-annular than intra-annular. The comparison prosthesis was the CarboMedics (CM) standard which it is stated to have identical inner/outer diameter ratio as the SJM standard. The study identified that only the 21 mm CM had higher gradients than 21 or 23 mm SJM-HP or SJM-Regent, except the 21 mm SJM-HP came closest to the 21 mm CM. There are other interesting observations—all prostheses had satisfactory EOAI and adequate left ventricular remodeling between 3 and 9 months with satisfactory LVMI.

There is evidence that moderate PPM (EOAI 0.75–0.85 cm²m²) can still achieve adequacy of regression of LVM especially in elderly more sedentary patients. PPM should be avoided in young, athletically active individuals because survival can be enhanced. The newer generation mechanical prostheses (CM-Top Hat, On-X, and Edwards Mira Finesse) are designed to optimize hemodynamics, as well as newer generation supra-annular stented and stentless bioprostheses.

The surgeon can utilize EOA algorithms for specific prostheses when conducting aortic valve replacement in patients with aortic annuli between 19–23 mm. Any implanted prosthesis must not be more obstructive than mild or lower level moderate aortic stenosis.

Congratulations to Albes and colleagues for conducting this randomized trial and facilitating standards of care.

Related Article

Are mechanical valves with enhanced inner diameter advantageous in the small sized aortic annulus?

Johannes M. Albes, Martin Hartrumpf, Volker Rudolph, Tanja Krempl, Egbert Hüttemann, Rüdiger Vollandt, and Thorsten Wahlers
Ann. Thorac. Surg. 2003 76: 1564-1570. [Abstract] [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Jamieson, W.R. E. Search for Related Content PubMed Articles by Jamieson, W.R. E. Related Collections Valve disease Related Article