Where is the common sense in aortic valve replacement

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Presentation transcript:

Where is the common sense in aortic valve replacement Where is the common sense in aortic valve replacement? A review of hemodynamics and sizing of stented tissue valves Torsten Doenst, MD, PhD, Paulo A. Amorim, MD, Nidal Al-Alam, MD, Sven Lehmann, MD, Chirojit Mukherjee, MD, Gloria Faerber, MD The Journal of Thoracic and Cardiovascular Surgery Volume 142, Issue 5, Pages 1180-1187 (November 2011) DOI: 10.1016/j.jtcvs.2011.05.007 Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Representative photographs of 6 stented tissue valves used for the analyses in this article (A) and their corresponding sizers (B). Selection of a valve size is based on fitting the sizer in the left ventricular outflow tract. In the cases of Supra and Magna, a valve replica is used to assess placement of the valve in the aortic root after the base sizer has been used. Epic, Epic Aortic St Jude Medical, Inc, St Paul, Minn; Supra, Epic Supra; St Jude Medical; Mosaic, Mosaic aortic valve model 305; Medtronic, Inc, Minneapolis, Minn; Perimount, Carpentier-Edwards Perimount model 2900; Edwards Lifesciences Corp, Irvine, Calif; Magna, Carpentier-Edwards Perimount Magna model 3000; Edwards Lifesciences; Mitroflow, Mitroflow; Sorin SpA, Milan, Italy. The Journal of Thoracic and Cardiovascular Surgery 2011 142, 1180-1187DOI: (10.1016/j.jtcvs.2011.05.007) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Comparison of sizer dimension (open bars), outer diameter (hatched bars), and average published effective orifice area (EOA, filled bars) values among 6 commonly implanted stented aortic tissue valves shown in Figure 1. A, Comparisons based on manufacturers’ size labels. B, Comparisons based on outer diameters. C, Comparisons based on sizing strategy as suggested by the manufacturer with the sizers shown in Figure 1. Sizers are for sizing the outflow tract dimension (Epic, Mosaic, Perimount, Mitroflow) or for the supra-annular position of the valve (Supra, Magna). Values for effective orifice area were calculated as the mean value of published data from the following references: Epic,17 Supra,18 Mosaic,19-21 Perimount,17,19,20,22-30 Magna,16,31,32 and Mitroflow.33-35 The original values are listed in Table 2, and manufacturer values are not included. The Journal of Thoracic and Cardiovascular Surgery 2011 142, 1180-1187DOI: (10.1016/j.jtcvs.2011.05.007) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Idealized illustration of the influence of valve position and relationship between geometric orifice area (green) and left ventricular outflow tract on the determination of the effective orifice area (red) by echocardiography. A, If a tissue valve leaves a rest stenosis after replacement, the size of maximal bloodstream contraction (vena contracta) moves distally to the geometric valve opening. As a consequence, effective orifice area underestimates geometric orifice area. B, Ideal hemodynamic placement of the same tissue valve would place the vena contracta at the site of the geometric orifice area of the tissue valve, and effective orifice area would then equal geometric orifice area. The Journal of Thoracic and Cardiovascular Surgery 2011 142, 1180-1187DOI: (10.1016/j.jtcvs.2011.05.007) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Comparisons of published effective orifice area (EOA) values from the size 23 Epic and the size 21 Epic Supra prostheses (A) and the Perimount and Perimount Magna prostheses (B). Note that in both A and B the 2 prostheses compared have geometrically identical stent design and differ only in the sewing ring (see Figure 1 for valve designs and Table 2 for the source references). The Journal of Thoracic and Cardiovascular Surgery 2011 142, 1180-1187DOI: (10.1016/j.jtcvs.2011.05.007) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions

Figure 5 Schematic demonstration of supra-annular (A) and intra-annular (B) placements of a valve prosthesis (violet) based on stitching direction as well as illustration of intra-annular (C) or supra-annular (D) placement of the same size tissue valve. Note that supra-annular placement does not confer the expected hemodynamic benefit if the chosen valve is too small, because it will result in tapering of the aortic annulus (eg, with a defensive sizing strategy). Red ring, Effective orifice area; green ring, geometric orifice area. The Journal of Thoracic and Cardiovascular Surgery 2011 142, 1180-1187DOI: (10.1016/j.jtcvs.2011.05.007) Copyright © 2011 The American Association for Thoracic Surgery Terms and Conditions