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J Thorac Cardiovasc Surg 2009;137:284-285
© 2009 The American Association for Thoracic Surgery

Point/Counterpoint

COUNTERPOINT: Aortic valve replacement: Size does matter

Division of Cardiovascular Surgery, Peter Munk Cardiovascular Centre, Toronto General Hospital and the University of Toronto, Toronto, Ontario, Canada

Received for publication June 1, 2008; accepted for publication August 31, 2008.

^_* Address for reprints: Christopher M. Feindel, MD, Division of Cardiovascular Surgery, Peter Munk Cardiovascular Centre, Toronto General Hospital and the University of Toronto, 200 Elizabeth St, 4N-480, Toronto, Ontario, Canada M5G 2C4. (Email: chris.Feindel@uhn.on.ca).

The first 20% of the full text of this article appears below.

Patients with aortic stenosis are rarely denied aortic valve replacement today, and with successful surgery they can expect excellent symptomatic relief and improved life expectancy. However, after Shabudin Rahimtoola's¹ observation in 1978 that a prosthetic valve may not fully relieve a patient's aortic stenosis, a condition he referred to as "valve prosthesis–patient mismatch" (PPM), surgeons became wary of the potential harm of inserting small valve prostheses.¹ Rahimtoola's concerns were further supported by the Framingham Study, as well as others, which showed that patients with left ventricular hypertrophy had a reduced life expectancy compared with those without left ventricular hypertrophy.^2,3 Because left ventricular hypertrophy does not regress in patients with severe valve PPM, the natural conclusion was that patients with PPM fare worse than those who do not have mismatch. A number of studies have confirmed this to be the case, at least in the early postoperative period, and particularly in those patients with poor ventricular function.^4,5 Surgeons realized the risk of valve PPM could be minimized if valves were implanted that provided the patient with an effective valve orifice area of greater than 0.85 cm²/m². Since all mechanical and stented bioprostheses are to some degree obstructive due to the presence of sewing rings and stents, this is not always possible, especially in small patients. Tasca and colleagues⁶ showed that more than 55% of patients in whom a 21-mm bioprosthetic valve was inserted had either moderate or severe PPM, and this figure increased to more than 90% in those who had a 19-mm valve inserted.

Over time, a number of surgical techniques were developed to allow the insertion of appropriately sized prostheses, techniques described by Konno and colleagues,⁷ . . . [Full Text of this Article]

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J. Thorac. Cardiovasc. Surg. 2009 137: 278-283. [Abstract] [Full Text] [PDF]

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