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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.

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Presentation on theme: "Luis J. Castro, MD Vincent A. Gaudiani, MD Audrey L. Fisher, MPH Aortic Valve Replacement: Strategies to Improve Outcomes (1998-2004) Sequoia Hospital."— Presentation transcript:

1 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

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

6 Mismatch ???

7 Gradient = Q2Q2Q2Q2 K  EOA 2 Cardiac Output (mL/min) EOA (cm 2 ) Gradient (mmHg) Mouse500.31Elephant 50 000 501 ElephantMismatch 0.3 11 000 000

8 We are not created equal !

9 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.

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

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12 Postoperative Mean Gradient at Rest (mmHg) Indexed internal geometric area (cm 2 /m 2 ) Indexed IGA vs. Projected Indexed EOA as Predictors of GradientsStentedStentless r=0.35 Mismatch r=0.67 Projected indexed EOA (cm 2 /m 2 ) Pibarot et al. Ann Thorac Surg 2001; 71: S265-8.

13 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, Circulation 2003;108: 983-988

14 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 Age Preop. NYHA class Preop. NYHA class Elevated diastolic pulmonary arterial pressures Elevated diastolic pulmonary arterial pressures Atrial fibrillation Atrial fibrillation Coronary artery disease Coronary artery disease Smoking Smoking Redo status Redo status PPM (EOAI  0.80 cm 2 /m 2 ): 60% increase in the risk of CHF PPM (EOAI  0.80 cm 2 /m 2 ): 60% increase in the risk of CHF Ruel et al, JTCVS 2003; 127:149-159

15 Impact of PPM on LV Mass Regression 109 patients with a CEP bioprosthesis 53% had PPM based on an indexed EOA  0.9 cm 2 /m 2 Tasca et al., Ann Thorac Surg, 79:505-510, 2005 -77  49 g P=0.002 -48  47 g No PPMPPM Independent predictors of greater LV mass regression: - Female Gender - Higher Preoperative LV mass - Larger Indexed EOA

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

17 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%

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19 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 cm 2 /m 2 of 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)

20 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

21 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

22 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

23 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

24 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

25 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

26 Operative Results First Op (n=887) Reop (n=326)p-value Operative Death (30 day) 4.1%3.1%NS Cerebrovascular Accident 4.7%4.0%NS Vent > 24h 11.9%16.3%NS Reexploration for bleed 4.6%5.2%NS Complete Heart Block7.7%9.8%NS Renal Failure3.4%6.7%.027 Postop LOS 8.49.7<.001

27 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.

28 Prostheses Types Used: AVR or ARE

29 Prostheses Types Used: AoRR

30 Aortic Valve Prostheses Types by Year Introduction of Mosaic

31 Root enlargement (ARE) 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. O.R. Case

32 How Have We Faired?

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34 Preoperative Characteristics: All AVR, ARE, & AoRR

35 Proportion of Isolated Cases

36 Concomitant Procedures: All AVR, ARE, & AoRR

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

38 % of Patient-Prosthesis Mismatch Standard AVR vs. ARE Standard AVR ARE iEOA < 0.85 cm 2 /m 2 1.6% iEOA < 0.85 cm 2 /m 2 1.4% No Statistical Difference in Mismatch

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

40 Postoperative Outcomes: All AVR, ARE, & AoRR

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

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

43 Operative Mortality by Age All Aortic Procedures

44 Impact of LV dysfunction?

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

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

47 % of Patient-Prosthesis Mismatch By Left Ventricular Function EF>40 EF<40 iEOA < 0.85 cm 2 /m 2 0.6% iEOA < 0.85 cm 2 /m 2 2.1%

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

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

50 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 maximize iEOA in patients with impaired ventricular function can improve operative outcomes in this “high-risk” group


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