Hemodynamic evaluation of the Carbomedics prosthetic heart valve in the aortic position: Comparison of noninvasive and invasive techniques

doi:10.1016/0002-8703(92)90759-O

American Heart Journal

Volume 123, Issue 1, January 1992, Pages 151-159

https://doi.org/10.1016/0002-8703(92)90759-O Get rights and content

Abstract

Seventy-three patients with a CarboMedics aortic bileaflet valve prosthesis were examined by Doppler ultrasonography, and 27 of them were also assessed by transseptal catheterization. The ultrasonic mean systolic gradient was 17.1 ± 5.6 mm Hg for valve size 19 mm, talling gradually with increasing valve size to 6.8 ± 2.5 mm Hg for size 27 mm. The catheter mean systolic gradient was consistently smaller than the ultrasonic gradient (4.3 ± 4.8 mm Hg), but Tobit regression analysis showed a significant association between the two methods in all patients both methods revealed negligible to small amounts of retrograde leakage, which is assumed to be a normal finding for this valve. The effective flow areas of the valves calculated from the ultrasonic data were similar to the in vitro calculated flow areas. The hemodynamic potential of this valve is therefore completely utilized in vivo. The effective orifice area corrected for body surface area increased with increasing valve size, which demonstrates a moderate valve-patient mismatch.

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Cited by (62)

Effect of the prosthesis-patient mismatch on long-term clinical outcomes after isolated aortic valve replacement for aortic stenosis: A prospective observational study
2013, Journal of Thoracic and Cardiovascular Surgery
The effect of prosthesis–patient mismatch (PPM) on clinical outcomes after aortic valve replacement remains controversial. We evaluated effect of PPM on long-term clinical outcomes after isolated aortic valve replacement in patients with predominant aortic stenosis.
We analyzed data from patients with predominant aortic stenosis who underwent isolated aortic valve replacement between January 1995 and July 2010. The indexed effective orifice area, obtained by dividing the in vivo effective orifice area by the patient’s body surface area, was used to define PPM as clinically nonsignificant (group I, 224 patients), mild (group II, 52 patients), moderate (group III, 39 patients), and severe (group IV, 36 patients).
Early survival was not significantly different among the groups, but overall survival was decreased gradually in group IV. Overall survival at 12 years was lower in group IV than in group I (92.8% ± 2.7% vs 67.0 ± 10.1, respectively; P = .001). Cardiac-related-death-free survival at 12 years was lower in patients with severe PPM. Left ventricular mass index decreased during the follow-up period in all groups. But left ventricular mass index was less decreased in group IV compared with groups I, II, and III. Age, severe PPM, and ejection fraction <40%, and New York Heart Association Functional Class IV were independent risk factors of overall survival on multivariate analysis. Severe PPM was an independent risk factor for cardiac-related death.
Severe PPM showed an adverse effect on long-term survival, and was an independent risk factor for cardiac-related death. In addition, patients with severe PPM showed less decreasing left ventricular mass index during follow-up.
Prosthesis-patient mismatch after aortic valve replacement: Impact of age and body size on late survival
2006, Annals of Thoracic Surgery
Citation Excerpt :
Mean body surface area (BSA) was 1.93 ± 0.27 m2, and patients were separated into three groups: (1) small patients with BSA less than 1.7 m2 (275, 20%); (2) average-size patients with BSA 1.7 m2 to 2.1 m2 (788, 56%); and (3) large patients with BSA greater than 2.1 m2 (337, 24%). Estimates of effective orifice area (EOA) for each valve type and size were obtained from referenced normal valves as summarized in Table 1 [6, 19–40]. Indexed EOA was defined as prosthetic EOA divided by BSA, and PPM was defined as EOA/BSA less than 0.75 cm2/m2 [3, 41].
The purpose of this study was to identify patient subgroups in which prosthesis-patient mismatch most influenced late survival.
Over a 12-year period, 1,400 consecutive patients underwent bioprosthetic (933 patients) or mechanical (467) aortic valve replacement. Prosthesis-patient mismatch was defined as prosthetic effective orifice area/body surface area less than 0.75 cm²/m² and was present with 11% mechanical and 51% bioprosthetic valves.
With bioprosthetic valves, prosthesis-patient mismatch was associated with impaired survival for patients less than 60 years old (10-year: 68% ± 7% mismatch versus 75% ± 7% no mismatch, p< 0.02) but not older patients (p= 0.47). Similarly, with mechanical valves, prosthesis-patient mismatch was associated with impaired survival for patients less than 60 years old (10-year: 62% ± 11% versus 79% ± 4%, p < 0.005) but not older patients (p = 0.26). For small patients (body surface area less than 1.7 m²), prosthesis-patient mismatch did not impact survival with bioprosthetic (p = 0.32) or mechanical (p= 0.71) valves. For average-size patients (body surface area 1.7 to 2.1 m²), prosthesis-patient mismatch was associated with impaired survival with both bioprosthetic (p < 0.05) and mechanical (p< 0.005) valves. For large patients (body surface area greater than 2.1 m²), prosthesis-patient mismatch was associated with impaired survival with mechanical (p< 0.04) but not bioprosthetic (p= 0.40) valves.
Prosthesis-patient mismatch had a negative impact on survival for young patients, but its impact on older patients was minimal. In addition, although prosthesis-patient mismatch was not important in small patients, prosthesis-patient mismatch negatively impacted survival for average-size patients and for large patients with mechanical valves.
Rest and exercise performance of the Medtronic Advantage bileaflet valve in the aortic position
2005, Annals of Thoracic Surgery
Citation Excerpt :
The present study reveals low mean pressure gradients, large EOAs and EOAIs associated with the Medtronic Advantage aortic valve prosthesis. The hemodynamic parameters are comparable with those reported for other intraannular bileaflet valves in the literature [20–23]. However, in many cases comparisons of pressure gradients may be difficult because of lack of information on the corresponding cardiac output.
The aim of the study was to evaluate rest and exercise performance and left ventricular mass regression of the Medtronic Advantage (Medtronic, Inc, Minneapolis, MN) prosthesis in the aortic position at 1 year at a single center as part of a multicenter, prospective clinical trial.
Between May 2002 and June 2003, 63 consecutive patients underwent aortic valve replacement with a Medtronic Advantage prosthesis (84.1% male; mean age, 56.0 ± 9.7 years; ejection fraction, 56.5 ± 15.8%). Valve lesions were stenosis (n = 20), mixed (n = 34), and insufficiency (n = 9). Concomitant procedures were performed in 34.9%. Follow-up was 100% complete. Echocardiographic data were obtained early postoperatively and at 1 year, combined with stress echocardiography by treadmill. Mean pressure gradients, stroke volume, and left ventricular mass were determined by echocardiography. Data are presented as mean ± standard deviation.
Operative mortality was 0%. Valve-related complications were observed in 2 patients (endocarditis, n = 1; thromboembolic event, n = 1). There was no case of antithromboembolic hemorrhage, prosthesis-related explant, or reoperation. One patient showed moderate paravalvular regurgitation. Mean pressure gradients 1 year postoperatively ranged from 6.3 to 11.0 mm Hg across all valve sizes. Left ventricular mass regression at 1 year was 18.4% across all valve sizes (p < 0.001). No severe patient-prosthesis mismatch (effective orifice area index ≤ 0.65 cm²/m²) could be observed.
After 1 year, the Medtronic Advantage valve shows comparable transvalvular mean pressure gradients across the valve sizes used during rest and exercise. This is accompanied by a significant left ventricular mass regression, an important indicator for long-term survival.
Normal Values for Doppler Echocardiographic Assessment of Heart Valve Prostheses
2003, Journal of the American Society of Echocardiography
Assessment of normal and abnormal function of heart valve prostheses remains challenging. Doppler echocardiography has been shown to allow hemodynamic evaluation in various clinical settings and has become the most widely used tool to assess prosthetic valve function. Prosthetic valves, even when they function normally, are to some degree obstructive to the blood flow. The normal values of gradients, pressure half-time, and effective orifice area depend on valve type and valve size. Doppler assessment of prosthetic valve function, thus, requires specification of valve type and valve size, and knowledge of the normal values. This study provides an updated overview on the available data of normal values to facilitate adequate interpretation of Doppler data.
Hemodynamic evaluation of normally functioning sulzer carbomedics prosthetic valves
2003, Ultrasound in Medicine and Biology
The Sulzer Carbomedics prosthetic heart valve (CP) is a commonly used mechanical valve in clinical practice. In the present study, we used conventional and color Doppler echocardiography to assess the hemodynamics of normally functioning CP in the aortic (n = 73) and mitral (n = 127) positions. Our findings demonstrate no significant correlation of Doppler-measured peak and mean pressure gradients and effective orifice area with implanted valve size and actual orifice areas, measured directly by the manufacturer for CPs in both the mitral and aortic positions. However, it is still useful to measure effective orifice area by Doppler because a value in the normal or nonstenotic range points to an unobstructed prosthesis in the aortic or mitral position, in the absence of poor left ventricular ejection fraction. A value in the stenotic range could mean a normally functioning or obstructed prosthesis and, therefore, may need further investigation, such as assessment of valve leaflet motion by transthoracic or transesophageal echocardiography or fluoroscopy. Valve regurgitation as evaluated by color Doppler flow mapping was mild in practically all CPs in the aortic position, and in the majority of CPs in the mitral position. (E-mail: [email protected])
Hemodynamic evaluation of 19-mm Carpentier-Edwards pericardial bioprosthesis in aortic position
2001, Annals of Thoracic Surgery
Citation Excerpt :
Left ventricular pressure in patients with a bioprosthesis can be measured by crossing the valve [1]. In patients with a mechanical aortic prosthesis, however, left ventricular pressure cannot be recorded without further invasive methods such as a transseptal technique or transthoracic puncture [15–18]. Consequently, little hemodynamic data is available on mechanical prostheses assessed by cardiac catheterization.
Background. The aortic Carpentier-Edwards pericardial bioprosthesis offers good long-term clinical outcomes with a low rate of structural deterioration. However, little in vivo hemodynamic data is available for this bioprosthesis.
Methods. To determine the hemodynamic performance of the 19-mm Carpentier-Edwards pericardial valve, both cardiac catheterization and dobutamine stress echocardiography were electively performed in 10 patients. The mean age at the study was 71.6 ± 4.4 years and the mean body surface area was 1.39 ± 0.11 m². The peak-to-peak gradient, instantaneous peak gradient, mean gradient, and valve orifice area were measured by standard cardiac catheterization. The Doppler-derived gradients and valve orifice area were also measured both at rest and during dobutamine infusion.
Results. The average peak-to-peak gradient, instantaneous peak gradient, mean gradient, and valve orifice area measured by catheterization were 13.0 ± 5.4 mmHg, 28.5 ± 7.7 mmHg, 12.0 ± 4.9 mmHg, and 1.55 ± 0.45 cm², respectively. The peak and mean Doppler gradients, and valve orifice area by resting echocardiography were 27.7 ± 9.5 mmHg, 12.3 ± 4.8 mmHg, and 1.39 ± 0.26 cm², respectively. At a dosage of 10 μg/kg/min of dobutamine, the mean Doppler gradient rose mildly to 22.2 ± 4.8 mmHg, while the cardiac output increased from 4.49 ± 0.44 to 6.64 ± 0.87 L/min. The valve orifice area during the 10 μg/kg/min dobutamine infusion (1.55 ± 0.25 cm²) was significantly larger than its value at rest (p < 0.05).
Conclusions. With acceptable hemodynamic performance, use of the aortic 19-mm Carpentier-Edwards pericardial valve is a reliable option for elderly patients with a small annulus.

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Hemodynamic evaluation of the Carbomedics prosthetic heart valve in the aortic position: Comparison of noninvasive and invasive techniques

Abstract

Am J Cardiol

Int J Cardiol

Am J Cardiol

J Cardiovasc Surg

J Am Soc Echocardiogr

J Am Coll Cardiol

Am J Cardiol

J Am Coll Cardiol

J Am Coll Cardiol

Cardiac output measured by Doppler echocardiography in patients with aortic prosthetic valves

Eur Heart J

Doppler ultrasound in cardiology