Issues in Valve Replacement '07

7.  Standard And Logistic Euroscore Risk Evaluation In Isolated Aortic And Mitral Valve Surgery. – Is It Time For Review ?
Piotr . Olszowka;   Adam . Szafranek;   Peter A. O'Keefe
University Hospital of Wales, Cardiff, Wales, United Kingdom

OBJECTIVES: Euroscore is one of the most common, widely used system of cardiac operation risk evaluation. Aim of this study was to assess accuracy of the system in assessment of perioperative risk in isolated aortic and mitral valve surgery.

METHODS: Between January 2000 and December 2006 515 patient underwent aortic valve surgery (AVR group) and 228 mitral valve surgery (MVR group). The data of these patients were prospectively collected in a data-base. The association of perioperative risk factors with outcome was investigated in both groups. Comparison of excepted based on Euroscore vs. “real” mortality was made.

RESULTS: Patients in AVR group were older 65.3 years (SD 12.0) vs. 60.7 (SD 12.2) (p<0.001), more frequently had extracardiac arteriopathy 5.4% vs. 2.2% (p=0.024) and poor ejection fraction preoperatively 9.5% vs.4.4% (p=0.009). Parsonnet score was higher in AVR group 13.2 (SD 7.2) vs. 11.2 (SD 5.8) (p<0.001). There was no difference in standard 5.9 (SD 2.9) vs. 6.2 (SD 3.3) and logistic Euroscore 7.7 (SD 10.1) vs. 9.1 (SD 13.3). Patients in MVR group more frequent were females 53.1% vs. 40.9% (p=0.001) had redo operation 16.7% vs. 8.5% (p=0.001), infective endocarditis 9.6% vs. 5.2% (p=0.013) and critical preoperative state 7.9% vs. 1.9% ((p<0.001). Mortality in AVR group was 2.9% vs. 5.3% in MVR group (p=0.057).

CONCLUSIONS: In both groups predicted mortality by standard and logistic Euroscore was higher then the “real” one. However it was more accurate in MVR group. Parsonnet score even more overestimated mortality in both groups.

8.  Postoperative Outcome In Low-gradient Aortic Stenosis: Impact Of Left Ventricular Contractile Reserve And Prosthesis-patient Mismatch.
Matthias . Kirsch¹;   Jean Luc . Monin¹;   Mehran . Monchi⁵;   Serge . Baleynaud⁴;   Christophe . Tribouilloy³;   Hélène . Petit-Eisenmann²;   Daniel Y. Loisance^1
1Henri Mondor Hospital, Créteil, , France;   ²CHU Strasbourg, Strasbourg, , France;   ³CHU Amiens, Amiens, , France;   ⁴Centre Hospitalier Bretagne Sud, Lorient, , France;   ⁵Institut Jacques Cartier, Massy, , France

OBJECTIVES: Postoperative outcome remains poorly defined in low-gradient aortic stenosis (AS). The respective impacts of left ventricular (LV) contractile reserve and prosthesis-patient mismatch (PPM) on survival have not been evaluated in this setting.

METHODS: Outcomes after aortic valve replacement for low-gradient AS were prospectively assessed in 152 consecutive patients from 7 institutions in France. There were 113 men (74%); median age was 72 years [64-76]; valve area, 0.7 cm² [0.6-0.8]; LV ejection fraction 0.31 [0.25-0.37] and baseline mean transaortic pressure gradient (MPG), 30 mm Hg [25-35]. PPM was defined by a prosthetic valve Effective Orifice Area ≤0.85 cm²/m2.

RESULTS: PPM was present in 79 patients (52%) and had no significant impact on postoperative survival. Independent predictors of survival were LV contractile reserve (Hazard Ratio (HR) for mortality, 0.52; 95% Confidence Interval (CI), 0.35 – 0.78; p=0.002), associated coronary bypass grafting (CABG, HR, 1.87; 95% CI, 1.24 – 2.82, p=0.003), baseline transaortic mean pressure gradient (MPG, per 1 mmHg increase above 10 mm Hg; HR, 0.97; 95% CI, 0.94 – 0.99; p=0.021), previous cancer (HR, 2.13; 95% CI, 1.05 – 4.29, p=0.037), and logistic EuroSCORE (per 1 percent increase, HR, 1.02; 95% CI, 1.01 - 1.04, p=0.040).

CONCLUSIONS: In this large series of patients with low-gradient AS, PPM (moderate in most cases) had no influence on postoperative survival. In contrast, postoperative outcome was influenced by LV contractile reserve, CABG, baseline MPG, previous cancer and logistic EuroSCORE. All these relevant parameters should be considered for individual risk stratification in order to select the best therapeutic option.

9.  Surgical Treatment Of Active Native Aortic Valve Endocarditis With Homografts And Mechanical Prostheses
Loes M. Klieverik¹;   * Magdi H. Yacoub²;   Sue . Edwards²;   * Jos A. Bekkers¹;   A. P. Kappetein¹;   * Ad J. Bogers¹;   * Johanna J. Takkenberg^1
1Erasmus Medical Center Rotterdam, Rotterdam, , Netherlands;   ²Harefield Heart Science Centre, Harefield, Middlesex, United Kingdom

OBJECTIVES: Surgery for persistent active native aortic valve endocarditis remains challenging. No specific recommendations are available for use of particular valve prostheses in active native aortic valve endocarditis surgery, besides the general criteria for aortic valve selection. In this light we analyzed our combined experience with homografts and mechanoprostheses in active native aortic valve endocarditis surgery.

METHODS: Between 1980 and 2002, 146 consecutive patients underwent AVR for active native aortic valve endocarditis in two centers with 114 homografts and 32 mechanoprostheses. Patient and perioperative characteristics, early and late morbidity and mortality were analyzed.

RESULTS: Mean age was 47 years (range 14-76), 80% were males, 35% required emergency surgery. Abscesses were more common in homograft patients 37% compared to 19% in mechanoprostheses. Mechanoprostheses patients required more often concomitant mitral valve surgery 34% versus 13% in homografts. Hospital mortality was 8.2% (n=12); 9.6% homografts (n=11), 3.1% mechanoprostheses (n=1).
During follow-up (mean 8.5 years, range 0-25.1) 24 patients died; 14 homografts and 10 mechanoprostheses. Overall fifteen-year survival was 63%±5%, for homografts 67.%±7% and mechanoprostheses 63%±10%. Seven patients developed recurrent endocarditis; 6 homografts (LOR 0.72%/pt yr; 1 early, 5 late) and 1 mechanoprosthesis (LOR 0.25%/pt yr; late)(p=NS).
Fifteen-year freedom from reoperation was 79.8%±6.5%; for homografts 75.0%±8.9% and mechanoprostheses 91.7%±8.0%.

CONCLUSIONS: Survival and recurrent endocarditis rates are comparable between homografts and mechanoprostheses. This finding, combined with low reoperation rates for mechanoprostheses suggest that mechanoprostheses may provide the preferred solution for surgical treatment of active native aortic valve endocarditis in absence of aortic root abscess.

10.  Long Term Results Of 1002 Carpentier Edwards Supra Annular Bioprosthesis. Incidence For A Pragmatic Choice Of Valvular Substitute
Erwan . Flecher;   Jean P. Verhoye;   Herve . Corbineau;   Issam . Abouliatim;   Vito G. Ruggieri;   Anne . Ingels;   Thierry . Langanay;   Alain . Leguerrier
Department of Thoracic and Cardiovascular Surgery University Hospital, Rennes, , France

OBJECTIVES: The aim of this study was to evaluate the long-term results of the Carpentier-Edwards Supra Annular Valve (CE-SAV) porcine bioprosthesis in aortic position, especially in terms of structural valve deterioration (SVD) and reoperation.

METHODS: 1002 consecutive patients who underwent AVR between January 1983 and December 1994 were reviewed. Mean age was 74.3±8.4 years (range 24-91). Follow-up was 99.4% completed. Mean and total follow-up are respectively 12.9 years and 7662 patient-years.

RESULTS: Actuarial survival rate at 10, 15 and 20 years are respectively 38.7±1.6, 17.1±1.3, and 4.6±1.1%. SVD occurred in 52 patients (5.2%) leading to reoperation in 33 (3.3%). Actuarial freedom from SVD at 15 and 20 years was respectively 86.5±2.1% and 65.0±7.4%. Actuarial freedom from reoperation at 15 and 20 years was respectively 89.0±1.9% and 74.3±5.7%. For patients older than 70 (n= 820), actuarial freedom from SVD and reoperation at 20 years was respectively 92.4±1.8% and 96.4±1.2%. At 20 years in this subgroup, cumulative probability for a patient of being alive without SVD, or dead without occurrence of SVD during his life is 97.0±0.6%. In the same way, cumulative probability of being alive without reoperation, or dead without occurrence of reoperation during his life is 98.0±0.5%.

CONCLUSIONS: The CE-SAV bioprosthesis in aortic position provides a low rate of SVD at 20 years especially in patients older than 70 years. In this group we should considerate at the time of the choice of a prosthesis the low risk of SVD (3%) and reoperation (2%).