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Luis J. Castro, MD Vincent A. Gaudiani, MD Audrey L. Fisher, MPH

Aortic Valve Replacement: Strategies to Improve Outcomes (1998-2004) Sequoia Hospital Redwood City, CA. Luis J. Castro, MD Vincent A. Gaudiani, MD Audrey L. Fisher, MPH. Prosthesis-Patient Mismatch (PPM). Definition : Valve Prosthesis too small relative to patient’s body size

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Luis J. Castro, MD Vincent A. Gaudiani, MD Audrey L. Fisher, MPH

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  1. Aortic Valve Replacement: Strategies to Improve Outcomes(1998-2004)Sequoia HospitalRedwood City, CA Luis J. Castro, MD Vincent A. Gaudiani, MD Audrey L. Fisher, MPH

  2. Prosthesis-Patient Mismatch (PPM) • Definition: Valve Prosthesis too small relative to patient’s body size • Consequence: Persistence of abnormally high postoperative gradients…the reason why we operate on patients with A.S. in the first place

  3. Mismatch ???

  4. Q2 Gradient = K  EOA2 Mouse 50 0.3 1 Elephant 50 000 50 1 Elephant Mismatch 50 000 0.3 11 000 000 Cardiac Output (mL/min) EOA (cm2) Gradient (mmHg)

  5. We are not created equal !

  6. Are Big Valves Better? • Physics of flow through a tube: Resistance  1/radius 4 small increase in size causes a significant reduction in LV work.

  7. Definition of PPM Based on Indexed EOA of Prosthesis Pibarot & Dumesnil JACC 2000; 36: 1131-41 Hanayama et al, Ann Thorac Surg 2002;73:1822–9

  8. Mismatch r=0.67 Stented Stentless Projected indexed EOA (cm2/m2) Indexed IGA vs. Projected Indexed EOA as Predictors of Gradients Postoperative Mean Gradient at Rest (mmHg) r=0.35 Indexed internal geometric area (cm2/m2) Pibarot et al. Ann Thorac Surg 2001; 71: S265-8.

  9. Impact of PPM on Clinical Outcomes • Less improvement in functional class • Increased incidence of late cardiac events • Minimal regression of LVH • Moderate impact on late mortality (>7years) • Major impact on perioperative mortality, particularly if LV dysfunction present Pibarot & Dumesnil, JACC 2000; 36: 1131-1141 Blais et al, Circulation2003;108: 983-988

  10. PPM is Predictive of Congestive Heart Failure after AVR 1681 patients, mean follow-up 4.4 years Independent predictors of CHF (NYHA 3-4 or CHF death): • Age • Preop. NYHA class • Elevated diastolic pulmonary arterial pressures • Atrial fibrillation • Coronary artery disease • Smoking • Redo status • PPM (EOAI  0.80 cm2/m2): 60% increase in the risk of CHF Ruel et al, JTCVS 2003; 127:149-159

  11. -4847 g -7749 g P=0.002 No PPM PPM Impact of PPM on LV Mass Regression 109 patients with a CEP bioprosthesis 53% had PPM based on an indexed EOA  0.9 cm2/m2 • Independent predictors • of greater LV mass regression: • Female Gender • Higher Preoperative LV mass • Larger Indexed EOA Tasca et al., Ann Thorac Surg, 79:505-510, 2005

  12. Impact of PPM on Short-Term Mortality after AVR (1266 pts) Short-term mortality (%) P < 0.001 26% P < 0.001 P = 0.015 (Overall = 4.6%) 6% 3% Mismatch > 0.85  0.85 and > 0.65  0.65 EOAI (cm2/m2) # of pts 792 (62%) 447 (36%) 27 (2%) Blais et al, Circulation,108:983-988, 2003

  13. Impact of Valve Prosthesis-Patient Mismatch on Short-Term Mortality After Aortic Valve Replacement Claudia Blais, BSc; Jean G. Dumesnil, MD; Richard Baillot, MD, et al. Circulation. 2003;108:983. LVEF < 40% LVEF  40%

  14. How to Avoid Mismatch • Achieve proper sizing in all patients: • Ask for the patient’s BSA to anticipate a minimum valve size that gives the patient at least 0.85 cm2/m2of valve area • At the time of operation, if the appropriate valve sizer fits or the annulus is larger– use the minimum valve size or larger • If the sizer is too big – decide on aortic root enlargement (ARE) or aortic root reconstruction (AoRR)

  15. Valve Sizing (stented valves) • BSA approx 1.5 (50 kg) size 21 or larger • BSA approx 1.75 (75 kg) size 23 or larger • BSA approx 2.0 (>90 kg) at least size 25

  16. Valve Sizing (Poor EF’s) • BSA approx 1.5 (50 kg) at least size 23 • BSA approx 1.75 (75 kg) at least size 25 • BSA approx 2.0 (>90 kg) at least size 27

  17. How do you choose AVR or ARE? Use ARE if: • ARE for 1-2 sizes larger… • You can sew Dacron graft to the aortotomy • Speed matters • There is a lot of calcium around the coronary ostia

  18. How do you choose ARE or AoRR? Use AoRR if: • You need the largest orifice possible • The coronary ostia are not calcified • The root is a terrible mess

  19. Choice of Valve Conduit • We use a homograft for acute endocarditis • We use the Freestyle valve as a root for most other applications • Ross operation for Children

  20. Risk of Anticoagulation Related Hemorrhage • The composite linearized rate of anticoagulation related hemorrhage in several large series averages 0.9 – 2.5% per year. Akins, Ann Thor Surg 61:806, 1996

  21. Operative Results

  22. Choice of Valve • In our hands, the risk of reoperation and the risks of coumadin are about equal, so we encourage the patient to decide on tissue v. mechanical valve replacement.

  23. Prostheses Types Used: AVR or ARE

  24. Prostheses Types Used: AoRR

  25. Aortic Valve Prostheses Types by Year Introduction of Mosaic

  26. Root enlargement (ARE) O.R. Case • 70 y.o. woman, critical A.S., severe dyspnea, chronic Afib, Cr=4.0. • Wt 91kg., BSA = 1.89, annular diameter by TEE is 20.5mm. • Probable ARE vs. AoRR to achieve iEOA = 0.85.

  27. How Have We Faired?

  28. Preoperative Characteristics:All AVR, ARE, & AoRR

  29. Proportion of Isolated Cases

  30. Concomitant Procedures:All AVR, ARE, & AoRR

  31. Intraoperative Time:Isolated AVR, ARE, & AoRR Iso AVR X-Clamp Time National Average = 73.0 min (STS 2004)

  32. % of Patient-Prosthesis MismatchStandard AVR vs. ARE Standard AVR ARE iEOA < 0.85 cm2/m2 1.4% iEOA < 0.85 cm2/m2 1.6% No Statistical Difference in Mismatch

  33. Mosaic Valve Size Distribution:Sequoia vs. National N = 820

  34. Postoperative Outcomes:All AVR, ARE, & AoRR

  35. Operative Mortality by Aortic Procedure (All Inclusive) (p=.003) NS NS – not significant at p = 0.05

  36. Operative Mortality by Isolated Aortic Procedure No significant differences between groups at p = 0.05

  37. Operative Mortality by Age All Aortic Procedures

  38. Impact of LV dysfunction?

  39. Preoperative Characteristics:All AVR by EF *All significant at p=0.01

  40. EF>40EF<40 Concomitant Procedures by EF * * *Significant at p=0.01

  41. % of Patient-Prosthesis MismatchBy Left Ventricular Function EF>40 EF<40 iEOA < 0.85 cm2/m2 2.1% iEOA < 0.85 cm2/m2 0.6%

  42. EF>40EF<40 Valve Size Histogram By Left Ventricular Function Average iEOA: EF>40 = 1.22 EF<40 = 1.27 *Significant at p=0.01

  43. Sequoia Hospital: 1998-2004Operative Mortality by EF for All AVR Not statistically different at p = 0.01

  44. Conclusions • Value of AVR for Aortic Stenosis is relief of left ventricular outflow obstruction. • Mismatch can be avoided without increasing operative mortality by choosing the correct operation • Strategy to maximizeiEOA in patients with impaired ventricular function can improve operative outcomes in this “high-risk” group

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