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J Thorac Cardiovasc Surg 2006;131:883-888
© 2006 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Stentless bioprostheses improve postoperative coronary flow more than stented prostheses after valve replacement for aortic stenosis

^a Department of Thoracic and Cardiovascular Surgery, Johann Wolfgang Goethe University Hospital, Frankfurt/Main, Germany
^b Department of Diagnostic and Interventional Radiology, Johann Wolfgang Goethe University Hospital, Frankfurt/Main, Germany
^c Department of Biomedical Statistics, Johann Wolfgang Goethe University Hospital, Frankfurt/Main, Germany

Received for publication July 31, 2005; revisions received October 7, 2005; accepted for publication October 20, 2005.

^_* Address for reprints: Farhad Bakhtiary, MD, Department of Thoracic and Cardiovascular Surgery, University Hospital, Theodor-Stern-Kai 7, 60596 Frankfurt/Main, Germany (Email: farhad{at}bakhtiary.de).

OBJECTIVE: In some randomized studies, stentless aortic valves have demonstrated hemodynamic advantages in comparison with stented prostheses. The effect of more physiologic flow dynamics on coronary artery flow has not been investigated yet. This study compares coronary perfusion after aortic valve replacement with stented or stentless porcine bioprostheses in a prospective randomized study.

METHODS: A total of 24 patients (73 ± 6 years) referred for treatment of aortic stenosis were randomized to aortic valve replacement with stented (Medtronic Mosaic; (Medtronic Inc, Minneapolis, Minn) or stentless (Medtronic Freestyle; Medtronic Inc) prostheses. Coronary flow was measured by means of magnetic resonance imaging preoperatively, 5 days after the operation, and 6 months postoperatively, then with evaluation of coronary flow reserve. Echocardiography was performed to quantify transvalvular gradients and left ventricular mass regression.

RESULTS: Coronary flow increased in both groups significantly (P < .001) after aortic valve replacement. This increase was higher in the stentless group compared with that seen in the stented group (343 ± 137 vs 221 ± 66 mL/min). Also, coronary flow reserve was higher for stentless valves (3.4 ± 0.3 for stentless valves and 2.3 ± 0.1 for stented valves). Mean pressure gradients for Freestyle valves were lower (10 ± 4 and 8 ± 3 mm Hg, respectively, vs 19 ± 6 postoperatively and 15 ± 4 mm Hg at follow-up for Mosaic valves, P < .05). Left ventricular mass regression was similar in both groups.

CONCLUSIONS: Normalization of coronary artery flow after aortic valve replacement for aortic stenosis was more pronounced for stentless valves compared with stented valves. The fact that the stentless design also demonstrated a superior hemodynamic performance with lower pressure gradients might be explained by the design being closer to physiologic anatomy and thus the presence of lower turbulence levels in the sinuses of Valsalva.

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