ECHO DOPPLER EVALUATION OF STENTLESS BIOPROSTHETIC VALVES Data

ECHO DOPPLER EVALUATION OF STENTLESS BIOPROSTHETIC VALVES. Data from two different models in 80 stable, ambulatory patients Stentless Bioprostheses Third International Symposium P Menu, P Corbi, C Coudrec, E Donal, D Coisne, J Allal, D Herpin Grand Cayman May 12 -16 , 1999

Introduction • Homografts have been known for their superior hemodynamics in aortic valve replacement and longer durability, but their use is usually restricted because of their limited availability • The goal of the stentless aortic xenografts is to achieve the same results as homografts with no availability problem. Stentles Bioprostheses Third International Symposium 1999

Objective • A Doppler echocardiographic study was performed to compare the hemodynamic performance after aortic valve replacement using two porcine stentless valves with different preservation techniques. Stentles Bioprostheses Third International Symposium 1999

Materials and methods Between January 1995 and October 1998, 80 patients underwent AVR, there were no differences between the two groups.

Operative data

Techniques ( steps 1 , 2 and 3) • Cardiopulmonary bypass is established with an ascending aortic cannula and a one-stage venous cannula • Anterograde blood cardioplegia is used • The aorta is opened using a transverse incision above the sinotubular junction and always at least 10 mm above the origin of the right coronary artery • Meticulous decalcification, and debulking of the native annulus and the commisural areas was carried out

Techniques ( sizing and implant) • It is particulary important not to distort the inflow aspect of the valve • And to size the annulus and the sinotubular junction • A valve 1 -2 mm larger than the exact measurement was selected • The inflow sutures were applied to the aortic annulus with respect to the scalloped line except for the three sutures on the commissures. • A double-armed Prolene suture was first taken to the surgeon's right, attaching the outflow portion of the stentless to the crest of the native aorta

Operative data Stentles Bioprostheses Third International Symposium 1999

Body surface area / valve sizes 1. 70 m 2 and <1. 85 m 2 > 1. 85 m 2

Results : Three hospital deaths occured • Female /80/ NYHA III/ LVEF= 61 % BS 1. 68 • Freestyle 21 /97 mn Ao Cl Time. • MOF • Male / 84 /NYHA III/ LVEF=48% / severe COPD • Prima 23/ / ACCT 78 • Pulmonary infection/Respiratory Failure Male / 54 / LVEF < 15 %/ LVTD 72 mm Prima 27/ ACCT 67 Sudden death at day +7 by Ventricular Fibrillation

STS ’s Guidelines Stentles Bioprostheses Third International Symposium 1999

Serial echography for the two groups Two-dimension directed LV M-mode echocardiograms were recorded per/post-operatively, 6, 12, 24, 36 months after AVR

The mean transvalvular gradients Stentles Bioprostheses Third International Symposium 1999

Evolution of aortic insufficiency The patient with a prosthesis 27 had been reoperated

Case report of the reoperation • Female 76 old • Aortic insufficiency • Mild ascending aorta dilatation (34 mm) • Stentless 27 Prima+CABG 2 • Post-op Doppler AI 1/4 • 12 months later AI 3/4

Case report of the reoperation • • • At the reoperation, the ascending aorta was dilated 38 mm The enlargement of the sinotubular junction explained the aortic insufficiency The valve itself was free from of any calcification or strutural dysfunction

At the end of reoperation: Stented CEP N° 27 Outcome with no problem 6 months later, NYHA I

Left ventricular remodeling • "After stentless aortic valve replacement, LV mass index and wall thickness both fall towards normal. • These ventricular remodeling processes are accompanied by a more physiological flow jet at valve cusp level, so that effective orifice area increases. " X Y Jin, S Westaby, D G Gibson European Journal of Cardio-thoracic Surgery 12 (1997) 63 -69

Conclusion I • Mean transvalvular gradients progressively decreased from the immediate postoperative values to values measured at 12 months • The reduction in residual gradient and potential regression in left ventricular hypertrophy may have beneficial prognostic implications Stentles Bioprostheses Third International Symposium 1999

Conclusion II • Our experience suggests that stentless valves implanted by the freehand technique are not indicated for Aortic insufficiency with dilatation of ascending aorta but are perfect for aortic stenosis and especially for small aortic annulus. Stentles Bioprostheses Third International Symposium 1999