Changes in Left Ventricular Mass and Function After Aortic Valve Replacement: A Comparison Between Stentless and Stented Bioprosthetic Valves

doi:10.1016/S0894-7317(99)70152-5

Journal of the American Society of Echocardiography

Volume 12, Issue 11, November 1999, Pages 981-987

This work was presented at the 10th Annual Scientific Sessions of the American Society of Echocardiography, Washington, DC, June 1999.

https://doi.org/10.1016/S0894-7317(99)70152-5 Get rights and content

Abstract

The objective of this study was to compare stentless bioprostheses with stented bioprostheses with regard to the postoperative changes in left ventricular (LV) mass and function. Forty patients with aortic stenosis undergoing valve replacement with a stentless (20 patients) or a stented (20 patients) bioprosthesis were evaluated early (baseline), 1 year, and 2 years after operation. Left ventricular mass index was calculated with the corrected American Society of Echocardiography formula. The relative changes between end-diastole and end-systole in LV mid-wall radius, length, and volume (ejection fraction) were determined with a previously validated model for dynamic geometry of the left ventricle. Overall, a significant decrease was found in LV mass index (from 155 ± 30 to 112 ± 23 g/m²; P < .001) and a significant increase in longitudinal shortening (from 0.12 ± 0.11 to 0.22 ± 0.08; P < .001), and ejection fractions (from 0.67 ± 0.11 to 0.71 ± 0.10; P = .017). No significant change was found in the mid-wall radius shortening fraction. Two years after surgery, the extent of LV mass regression was greater in stentless bioprostheses (–51 ± 18 vs –35 ± 17 g/m²; P = .01), though the average mass index was similar in both groups (114 ± 26 vs 110 ± 20 g/m²). Also at 2 years, the longitudinal shortening fraction was greater in patients with a stentless bioprosthesis (0.25 ± 0.07 vs 0.18 ± 0.08; P = .03). In conclusion, this study suggests that the superior hemodynamic performance of stentless bioprostheses may have some benefits with regard to LV mass regression and function after aortic valve replacement. The significance of these benefits in terms of prognosis remains to be determined. (J Am Soc Echocardiogr 1999;12:981-7.)

Section snippets

Patients

Forty patients with severe aortic stenosis undergoing aortic valve replacement with a porcine bioprosthesis were included in the study. The cohort included 20 patients with a Medtronic Mosaic stented bioprosthetic valve and 20 patients with a Medtronic Freestyle stentless bioprosthetic valve. Since the patient’s age and sex could also affect the remodeling of the left ventricle, the groups were matched for age and sex. The Freestyle bioprosthesis was implanted by using the subcoronary

Clinical Characteristics of Patients

Table 1 shows the characteristics of the 40 patients included in the study.Preoperative and operative data were similar in patients with a stented bioprosthesis and those with a stentless bioprosthesis except for prosthesis size, which was larger in patients with a stentless bioprosthesis. All patients had a preserved ejection fraction (>50%) before surgery documented by a preoperative angiographic study.

Prosthetic Valve Function

The baseline valve effective orifice areas and mean gradients were similar in both groups

DISCUSSION

This study confirms the superior hemodynamic performance of the stentless bioprostheses, which is in part the result of their less obstructive profile and better sizing.12, 15, 20, 21, 22 Furthermore, the performance of stentless bioprostheses improved during the first 6 months after operation, whereas it remained unchanged in stented bioprostheses.12, 15, 20, 21

Likewise, the patients with a stentless bioprosthesis had a more extensive regression of LV mass, which is consistent with previous

Acknowledgements

We thank Jocelyn Beauchemin and Isabelle Laforest for their technical assistance.

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Regression of Left Ventricular Mass After Transcatheter Aortic Valve Replacement: The PARTNER Trials and Registries
2020, Journal of the American College of Cardiology
Greater early left ventricular mass index (LVMi) regression is associated with fewer hospitalizations 1 year after transcatheter aortic valve replacement (TAVR). The association between LVMi regression and longer-term post-TAVR outcomes is unclear.
The purpose of this study was to determine the association between LVMi regression at 1-year post-TAVR and clinical outcomes between 1 and 5 years.
Among intermediate- and high-risk patients who received TAVR in the PARTNER (Placement of Aortic Transcatheter Valves) I, II, and S3 trials or registries and were alive at 1 year, we included patients with baseline moderate or severe left ventricular hypertrophy (LVH) and paired measurements of LVMi at baseline and 1 year. The associations between LVMi regression (percent change between baseline and 1 year) and death or rehospitalization from 1 to 5 years were examined.
Among 1,434 patients, LVMi was 146 g/m² (interquartile range [IQR]: 133 to 168 g/m²) at baseline and decreased 14.5% (IQR: 4.2% to 26.1%) to 126 g/m² (IQR: 106 to 148 g/m²) at 1 year. After adjustment, greater LVMi regression at 1 year was associated with lower all-cause death (adjusted hazard ratio [aHR]: 0.95 per 10% decrease in LVMi; 95% confidence interval [CI]: 0.91 to 0.98; p = 0.004; aHR of the quartile with greatest vs. least LVMi regression: 0.61; 95% CI: 0.43 to 0.86; p = 0.005). Severe LVH at 1 year was observed in 39%, which was independently associated with increased all-cause death (aHR of severe LVH vs. no LVH: 1.71; 95% CI: 1.20 to 2.44; p = 0.003). Similar associations were found for rates of cardiovascular mortality and rehospitalization.
Among patients with moderate or severe LVH treated with TAVR who are alive at 1 year, greater LVMi regression at 1 year is associated with lower death and hospitalization rates to 5 years. These findings may have implications for the timing of valve replacement and the role of adjunctive medical therapy after TAVR.
Predictors and Changes in Cardiac Hemodynamics and Geometry With Transcatheter Aortic Valve Implantation
2019, American Journal of Cardiology
The introduction of transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of patients with severe aortic stenosis (AS). However, despite the great clinical success of TAVI, less is known about the cardiac hemodynamics and structural changes to post-TAVI. We analyzed patients with AS who had a transthoracic echocardiography at most 6 months before index TAVI and follow-up transthoracic echocardiography 9 to 18 months later, performed at Duke University Medical Center from 2012 to 2014. A total of 152 TAVI patients with a median age of 81 years (median interquartile range 74 to 86) were included. TAVI resulted in the reduction of left ventricle (LV) mass index (g/m²), median (interquartile range) 130 (115 to 157) pre versus 106 (85 to 135) post, p <0.001; LV end-diastolic volume (ml) 127 (105 to 143) pre versus 120 (100 to 143) post, p = 0.013; and LV end-systolic volume (ml) 55 (38 to 77) pre versus 45 (40 to 65) post, p = 0.027. TAVI also significantly improved LV global longitudinal strain (%) −14.4 (−11.3, −15.5) pre versus −14.8 (−12.2, −16.6) post (p <0.001, respectively). Post-TAVI LV mass regression was predicted by baseline LV mass and LV global longitudinal strain whereas post-TAVI LV ejection fraction was predicted by baseline LV ejection fraction, LV mass, and post-TAVI paravalvular leak. In conclusion, TAVI results in significant cardiac hemodynamic, geometrical, and functional changes at approximately 1-year postprocedure for patients with AS. Better baseline myocardial structure and function leads to more reverse remodeling.
Influence of stentless versus stented valves on ventricular remodeling assessed at 6 months by magnetic resonance imaging and long-term follow-up
2017, Journal of Cardiology
Citation Excerpt :
However, this regression had no impact on the survival and occurrence of major CV events during the follow-up. We assessed hemodynamic parameters, including the decrease in peak pressure gradient and in maximal velocity in the stentless group, which have previously been used in the literature [6–8,20,21]. The frequency of prosthesis-patient mismatch was similar in the two groups.
To compare the effect of stented versus stentless bioprostheses on left ventricular remodeling and assess their impact on long-term survival.
From January 2002 to December 2009, 62 severe aortic stenosis patients without coronary artery disease were randomized for bioprosthetic aortic valve replacement. After randomization, a cross-over was possible based on intraoperative data. Ventricular remodeling was studied by cardiovascular magnetic resonance imaging six months after surgery. Long-term survival was assessed by telephone survey.
Thirty-five patients received a porcine Mosaïc^® Medtronic bioprosthesis (Stented Group; Medtronic, Minneapolis, MN, USA) inserted using the usual supra-annular technique and 27 received a porcine Freestyle^® Medtronic bioprosthesis (Stentless Group) inserted in the subcoronary position. Mean age was 75 ± 3 and 73 ± 4 years in the stentless and stented group, respectively. Nine patients who should have been implanted with a stentless bioprosthesis received a stented bioprosthesis for anatomical reasons. At 6 months, the left ventricular mass (LVM) decreased significantly in both groups (Stentless Group: 214.6 ± 56.1 g and 156.3 ± 23 g and Stented Group: 237 ± 75.7 g and 181 ± 53.3 g, respectively after surgery and at 6 months), this decrease was significantly greater in the stentless group (p = 0.026). Reserve and coronary flow were increased in both groups at 6 months. Mean follow-up duration was 6.6 ± 3.0 years and 7.2 ± 4.0 years in the stentless and stented group, respectively. The 5-year actuarial survival was 87.5 ± 11.7% and 82.5 ± 17.1% for the stentless and stented group, respectively (p = 0.81).
Porcine stentless prosthesis results in a better LVM regression than a stented valve at 6 months without changing the long-term survival.
Early regression of severe left ventricular hypertrophy after transcatheter aortic valve replacement is associated with decreased hospitalizations
2014, JACC: Cardiovascular Interventions
Citation Excerpt :
After adjusting for baseline LVMi, clinical and echocardiographic variables associated with greater early LVMi regression included female sex, absence of a pacemaker pre-operatively, increased pre-operative midwall fractional shortening, and lower transvalvular mean gradient at 30 days. Many studies have evaluated LVMi regression after AVR, using it as a surrogate endpoint to compare different valve prostheses; this attests to the widespread assumption that LVMi regression after AVR is a clinically beneficial effect of valve replacement (4,5,9). A few studies suggest clinical benefit from greater post-operative LVMi regression, but significant methodological flaws or small sample size led to inconclusive findings (22,23).
This study sought to examine the relationship between left ventricular mass (LVM) regression and clinical outcomes after transcatheter aortic valve replacement (TAVR).
LVM regression after valve replacement for aortic stenosis is assumed to be a favorable effect of LV unloading, but its relationship to improved clinical outcomes is unclear.
Of 2,115 patients with symptomatic aortic stenosis at high surgical risk receiving TAVR in the PARTNER (Placement of Aortic Transcatheter Valves) randomized trial or continued access registry, 690 had both severe LV hypertrophy (left ventricular mass index [LVMi] ≥149 g/m² men, ≥122 g/m² women) at baseline and an LVMi measurement at 30-day post-TAVR follow-up. Clinical outcomes were compared for patients with greater than versus lesser than median percentage change in LVMi between baseline and 30 days using Cox proportional hazard models to evaluate event rates from 30 to 365 days.
Compared with patients with lesser regression, patients with greater LVMi regression had a similar rate of all-cause mortality (14.1% vs. 14.3%, p = 0.99), but a lower rate of rehospitalization (9.5% vs. 18.5%, hazard ratio [HR]: 0.50, 95% confidence interval [CI]: 0.32 to 0.78; p = 0.002) and a lower rate of rehospitalization specifically for heart failure (7.3% vs. 13.6%, p = 0.01). The association with a lower rate of rehospitalization was consistent across subgroups and remained significant after multivariable adjustment (HR: 0.53, 95% CI: 0.34 to 0.84; p = 0.007). Patients with greater LVMi regression had lower B-type natriuretic peptide (p = 0.002) and a trend toward better quality of life (p = 0.06) at 1-year follow-up than did those with lesser regression.
In high-risk patients with severe aortic stenosis and severe LV hypertrophy undergoing TAVR, those with greater early LVM regression had one-half the rate of rehospitalization over the subsequent year compared to those with lesser regression.
Magnetic resonance imaging versus echocardiography to ascertain the regression of left ventricular hypertrophy after bioprosthetic aortic valve replacement: Results of the REST study
2012, Journal of Thoracic and Cardiovascular Surgery
To compare the decrease in left ventricular mass index (LVMI) by magnetic resonance imaging (MRI) versus transthoracic echocardiography (TTE) after aortic valve replacement (AVR) for severe aortic stenosis with Epic and Epic Supra stented porcine bioprostheses (St Jude Medical, Inc, St Paul, Minn).
This prospective multicenter study enrolled 149 patients who underwent AVR between January 2006 and February 2008. TTE and cardiac MRI measurements of LVMI were made at baseline and at 6 months of follow-up and were compared. Changes in mean pressure gradients were examined using TTE.
TTE measurements of LVMI were 48% to 63% higher than the MRI measurements. A decrease in LVMI from 137 ± 32 to 95 ± 16 g/m² with the Epic and from 139 ± 29 to 104 ± 28 g/m² with the Epic Supra valves (P < .0001 for both comparisons) was measured by TTE. Cardiac MRI revealed decreases in LVMI from 84 ± 20 to 64 ± 12 g/m² and from 86 ± 27 to 64 ± 17 g/m² with the Epic and Epic Supra valves, respectively (P < .0001 for both comparisons). TTE revealed a significant regression of mean pressure gradients from 51.6 ± 15.3 to 15.5 ± 5.2 mm Hg with the Epic and from 46.7 ± 19.4 to 17.9 ± 12.8 mm Hg with the Epic supra (P < .0001 for both comparisons).
A significant decrease in LVMI was measured after AVR with all sizes of both bioprosthetic models. Because of the overestimation of the decrease in LVMI by the Devereux formula, as well as the higher accuracy and reproducibility of cardiac MRI measurements, the latter should be preferred to TTE. An ultimate validation of this thesis could only be done comparing each of these modalities with pathologic examination.
Which Patients Benefit From Stentless Aortic Valve Replacement?
2009, Annals of Thoracic Surgery
Citation Excerpt :
Clinically, an improved hemodynamic performance should result in a faster left ventricular mass reduction, especially in patients with initial aortic stenosis and severe hypertrophy. Both stented and stentless prostheses were shown to lead to a significant reduction of LV mass and hypertrophy during postoperative follow-up [31, 60–68]. Most of the studies reported a faster decrease in LV mass in patients with stentless valves implanted.
This review article analyzes the literature to answer the question of whether stentless aortic bioprostheses possess proven advantages compared with stented bioprosthesis, and which patients might benefit from stentless valve implantation. For this purpose, the United States National Library of Medicine's PubMed and MEDLINE databases were searched for articles dealing with results of stentless aortic bioprostheses or studies comparing stented and stentless prostheses. Key word searches used were as follows: stentless aortic prostheses, stented aortic prosthesis, hemodynamic, hemodynamic performance, degeneration, durability, technique, and long-term follow-up. The analysis focused on stentless prostheses with a clinical experience for more than 5 years. Only a few randomized studies were found. Stentless prostheses were found to be advantageous in patients with severe impaired left ventricular function or a small aortic annulus (ie, evidence of grade II), but no specific advantages could be determined for the majority of patients. The durability results were mixed: the Toronto SPV (St. Jude Medical, Minneapolis, MN) showed an increase in degeneration after 10 years of follow-up, whereas the Freestyle porcine stentless prostheses (Medtronic, Minneapolis, MN) still showed excellent results after this period.

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^☆: This work was supported in part by operating grants from the Heart and Stroke Foundation of Quebec and the Foundation of the Quebec Heart Institute.

^☆☆: Dr Pibarot is the recipient of Senior Personal Award from the Heart and Stroke Foundation of Canada. Drs Pibarot, Dumesnil, Cartier, and Métras have financial interest in the products presented in this work in that Medtronic Company (Minneapolis, Minn) provides financial support to the Departments of Cardiology and Surgery of the Quebec Heart Institute for the clinical and echocardiographic follow-up of patients who receive a Medtronic Intact, Freestyle, or Mosaic valve. Drs Métras, Cartier, and Dumesnil are the principal investigators of these research projects. They also hold consultant agreements for this company. In addition, Medtronic Company provided mechanical and bioprosthetic valves to the Laboratory of Biomedical Engineering of the Institut de recherches cliniques de Montréal to perform in vitro studies. Dr Pibarot is an invited researcher at this institution and is co-investigator on this project.

^★: Reprint requests: Dr Pibarot, Quebec Heart Institute, Laval Hospital, 2725 Chemin Sainte-Foy, Sainte-Foy G1V-4G5, Quebec, Canada (e-mail: [email protected]).

^★★: 0894-7317/99 $8.00 + 0 27/1/101622

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Changes in Left Ventricular Mass and Function After Aortic Valve Replacement: A Comparison Between Stentless and Stented Bioprosthetic Valves☆,☆☆,★,★★

Abstract

Section snippets

Patients

Clinical Characteristics of Patients

Prosthetic Valve Function

DISCUSSION

Acknowledgements

J Am Coll Cardiol

Am Heart J

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Am J Cardiol

J Am Coll Cardiol

J Am Soc Echocardiogr

Am J Cardiol

Ann Thorac Surg

J Am Coll Cardiol

Am J Cardiol