Three dimensional evaluation of the aortic annulus using multislice computer tomography: are manufacturer's guidelines for sizing for percutaneous aortic valve replacement helpful?
ABSTRACT To evaluate the effects of applying current sizing guidelines to different multislice computer tomography (MSCT) aortic annulus measurements on Corevalve (CRS) size selection.
Multislice computer tomography annulus diameters [minimum: D(min); maximum: D(max); mean: D(mean) = (D(min) + D(max))/2; mean from circumference: D(circ); mean from surface area: D(CSA)] were measured in 75 patients referred for percutaneous valve replacement. Fifty patients subsequently received a CRS (26 mm: n = 22; 29 mm: n = 28). D(min) and D(max) differed substantially [mean difference (95% CI) = 6.5 mm (5.7-7.2), P < 0.001]. If D(min) were used for sizing 26% of 75 patients would be ineligible (annulus too small in 23%, too large in 3%), 48% would receive a 26 mm and 12% a 29 mm CRS. If D(max) were used, 39% would be ineligible (all annuli too large), 4% would receive a 26 mm, and 52% a 29 mm CRS. Using D(mean), D(circ), or D(CSA) most patients would receive a 29 mm CRS and 11, 16, and 9% would be ineligible. In 50 patients who received a CRS operator choice corresponded best with sizing based on D(CSA) and D(mean) (76%, 74%), but undersizing occurred in 20 and 22% of which half were ineligible (annulus too large).
Eligibility varied substantially depending on the sizing criterion. In clinical practice both under- and oversizing were common. Industry guidelines should recognize the oval shape of the aortic annulus.
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ABSTRACT: Aortic stenosis (AS) remains the most common valvular disease of the elderly in the United States. Though valve replacement has proven effective among older adults, decision-making regarding surgery is difficult for these patients and their physicians. Herein, the clinical outcomes and decision-making process for elderly patients with severe symptomatic AS was assessed. A retrospective cohort study of patients aged > or = 60 years with severe AS was conducted at two large urban teaching hospitals. Severe AS was defined by a mean valve gradient > or = 50 mmHg or valve area < 0.8 cm2 by echocardiogram, and associated symptoms (angina, congestive heart failure, dyspnea, fatigue, or exercise intolerance). Demographic and clinical data and information about decision-making were obtained from inpatient and outpatient medical records. Of the 124 patients studied, 49 (39.5%) had aortic valve replacement (AVR) surgery. In a logistic regression analysis adjusting for gender, comorbidity and baseline functional status, those patients aged < 80 years were significantly more likely to have surgery than older patients. Surgery was associated with a large reduction in mortality in all age groups. At one-year follow up, 87.8% of all patients (87.5% of those aged > or = 80 years) who had undergone surgery were alive, while only 54.7% (49.1% of those aged > or = 80 years) who did not receive surgery were alive. Postoperative complications were similar among older and younger elderly patients. Comorbidity and age were the most common reasons for not offering elderly patients valve replacement. The results of the present study showed that AVR surgery improves the survival of elderly patients with severe AS, and patients aged > 80 years experience benefits similar to younger patients. Nevertheless, these findings suggest that surgery may not always be offered to elderly patients who might benefit from it.The Journal of heart valve disease 05/2006; 15(3):312-21. · 1.07 Impact Factor
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ABSTRACT: We report the case of a 79-year-old man with low-flow, low-gradient aortic stenosis who underwent transapical aortic valve implantation. The deployment of a 26-mm Edwards SAPIEN valve (Edwards Lifesciences Inc, Irvine, CA) was complicated with the occurrence of severe central aortic regurgitation that was successfully treated with the implantation of a second valve ("valve-in-valve"). Postoperative progress was satisfactory but 2 days after the procedure he suddenly developed cardiogenic shock secondary to the migration of the aortic bioprothesis into the left ventricular outflow tract. Open-heart surgery was undertaken to remove the valves and perform standard aortic valve replacement, but the patient died perioperatively.The Annals of thoracic surgery 03/2009; 87(2):618-21. · 3.74 Impact Factor
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ABSTRACT: Percutaneous aortic valve replacement represents an endovascular alternative to conventional open heart surgery without the need for sternotomy, aortotomy, or cardiopulmonary bypass. Transcatheter implantation of a balloon-expandable stent valve using a femoral arterial approach was attempted in 50 symptomatic patients with severe aortic stenosis in whom there was a consensus that the risks of conventional open heart surgery were very high. Valve implantation was successful in 86% of patients. Intraprocedural mortality was 2%. Discharge home occurred at a median of 5 days (interquartile range, 4 to 13). Mortality at 30 days was 12% in patients in whom the logistic European System for Cardiac Operative Risk Evaluation risk score was 28%. With experience, procedural success increased from 76% in the first 25 patients to 96% in the second 25 (P=0.10), and 30-day mortality fell from 16% to 8% (P=0.67). Successful valve replacement was associated with an increase in echocardiographic valve area from 0.6+/-0.2 to 1.7+/-0.4 cm2. Mild paravalvular regurgitation was common but was well tolerated. After valve insertion, there was a significant improvement in left ventricular ejection fraction (P<0.0001), mitral regurgitation (P=0.01), and functional class (P<0.0001). Improvement was maintained at 1 year. Structural valve deterioration was not observed with a median follow-up of 359 days. Percutaneous valve replacement may be an alternative to conventional open heart surgery in selected high-risk patients with severe symptomatic aortic stenosis.Circulation 09/2007; 116(7):755-63. · 15.20 Impact Factor