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J Thorac Cardiovasc Surg 2007;133:1234-1241
© 2007 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Influence of completely supra-annular placement of bioprostheses on exercise hemodynamics in patients with a small aortic annulus

Ina M. Wagner, MD*, Walter B. Eichinger, MD1, Sabine Bleiziffer, MD, Florian Botzenhardt, MD, Isabel Gebauer, MD, Ralf Guenzinger, MD, Robert Bauernschmitt, MD, Ruediger Lange, MD2

German Heart Center Munich, Clinic of Cardiovascular Surgery, Munich, Germany.

Received for publication August 3, 2006; revisions received October 10, 2006; accepted for publication October 23, 2006.

* Address for reprints: Ina M. Wagner, MD, Deutsches Herzzentrum München, Klinik für Herz-und Gefäßchirurgie, Lazarettstr. 36, D-80636 München. (Email: wagner{at}dhm.mhn.de).

Objective: Aortic valve replacement in patients with a small aortic annulus is often associated with increased pressure gradients. For this reason, prostheses for completely supra-annular placement have been developed. To evaluate the potential benefit of this design, the present study compared the effectiveness of 1 intra–supra-annular bioprosthesis and 3 completely supra-annular bioprostheses in patients with an aortic annulus diameter of 23 mm or less.

Methods: Between August 2000 and December 2004, each of 192 patients requiring aortic valve replacement with an intraoperatively measured aortic annulus diameter of 23 mm or less received one of the following bioprostheses: the stented bovine Sorin Soprano bioprosthesis (n = 28) (Sorin Group, Saluggia, Italy), the Carpentier–Edwards Perimount bioprosthesis (n = 50) (Edwards Lifesciences, Irvine, Calif), the Carpentier–Edwards Perimount Magna bioprosthesis (n = 70) (Edwards Lifesciences), or the stented porcine Medtronic Mosaic (n = 44) (Medtronic Inc, Minneapolis, Minn) bioprosthesis. After 6 months, hemodynamic data at rest and during exercise were obtained by echocardiography in 142 patients.

Results: The pericardial valves showed lower mean systolic pressure gradients, larger effective orifice areas and indices, and superior effective orifice fractions than did the porcine valve (P < .05) (Carpentier–Edwards Perimount: 10.9 ± 3.6 mm Hg, 1.59 ± 0.41 cm2, 0.9 ± 0.25 cm2/m2, 41.9% ± 9.6%; Carpentier–Edwards Perimount Magna 10.1 ± 3.8 mm Hg, 1.64 ± 0.38 cm2, 0.93 ± 0.22 cm2/m2, 45.1% ± 10.2%; Sorin Soprano 13.5 ± 5.0 mm Hg, 1.64 ± 0.32 cm2, 0.92 ± 0.15 cm2/m2, 45.8% ± 9.0%; vs Medtronic Mosaic 15.5 ± 5.2 mm Hg, 1.31 ± 0.42 cm2, 0.75 ± 0.24 cm2/m2, 35.2% ± 10.0%, respectively). The lowest mean systolic pressure gradients were found after the implantation of the Carpentier–Edwards Perimount Magna. Effective orifice areas, indices, and fractions of the pericardial valves did not show significant differences.

Conclusions: In patients with small aortic roots, transvalvular gradients and effective orifice area showed a tendency to superior results in pericardial valves compared with the porcine bioprosthesis. However, the completely supra-annular design does not necessarily lead to superior hemodynamic results compared with the intra–supra-annular position.

Abbreviations and Acronyms EOA = effective orifice area; EOAI = effective orifice area index; EOF = effective orifice fraction; LVOT = left ventricular outflow tract; PPM = patient–prosthesis mismatch; VTI = velocity time integral




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