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J Thorac Cardiovasc Surg 2007;133:1472-1473
© 2007 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Discussion

Dr F. Crawford (Charleston, SC): Drs Feindel and Mitchell, I have no conflicts to disclose. I enjoyed this presentation very much. PPM after aortic valve replacement has been discussed at length in recent years, although there is far from universal agreement about the potential implications of such mismatch. Far less information is available about PPM in the mitral position. Several important differences between the aortic and mitral position exists as indicated by the authors, including limited options for implanting large valves in the mitral positions and inferior types of prostheses available for MVR. In addition, PPM in the aortic position may adversely affect left ventricular function, whereas in the mitral position it is usually right ventricular function that is affected.

In this excellent article that describes a large series of patients who underwent MVR and were followed prospectively by the authors, IEOA did not predict persistent PHTN, which has generally been considered an important factor predicting outcomes after MVR. I have several questions for the authors.

If PHTN was not associated with PPM, what do you postulate is the reason for the poorer outcomes in your patients?

Second, what percentage of your patients had chordal-sparing MVR, and was the lack of such a chordal-sparing procedure an independent risk factor for poorer outcomes?

Finally, in the article you state, "We recommend avoidance of a bioprosthesis in patients with possible MVPPM criteria." Does this mean that you would therefore recommend using a mechanical prosthesis in such a patient even if the patient were elderly and that you therefore believe the potential risk of MVPPM in such a patient outweighs the known risk of long-term anticoagulation with Coumadin?

Dr Lam: With regard to the lack of correlation between the IEOA and PHTN in this study, I must say that although our . . . [Full Text of this Article]

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Buu-Khanh Lam, Vincent Chan, Paul Hendry, Marc Ruel, Roy Masters, Pierre Bedard, Bill Goldstein, Fraser Rubens, and Thierry Mesana
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