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• W1977371341 abstract "Patient–prosthesis mismatch (PPM) is a matter of intense debate in cardiac surgery. Although there is general support for the “bigger is better” hypothesis,1Tuzcu E.M. Özkan A. Kapadia S.R. Prosthesis-patient mismatch in the transcatheter aortic valve replacement era.J Am Coll Cardiol. 2011; 58: 1919-1922Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar no uniform conclusion can be drawn about the impact of PPM on clinical outcome because results are inconsistent across studies. More recently, the debate has gained renewed impetus with the advent of transcatheter aortic valve implantation and the implementation of the valve-in-valve procedure for degenerated bioprostheses.2Ewe S.H. Muratori M. Delgado V. Pepi M. Tamborini G. Fusini L. et al.Hemodynamic and clinical impact of prosthesis-patient mismatch after transcatheter aortic valve implantation.J Am Coll Cardiol. 2011; 58: 1910-1918Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar We read with great interest the article by Seiffert and colleagues,3Seiffert M. Conradi L. Baldus S. Knap M. Schirmer J. Franzen O. et al.Impact of patient-prosthesis mismatch after transcatheter aortic valve-in-valve implantation in degenerated bioprostheses.J Thorac Cardiovasc Surg. 2012; 143: 617-624Abstract Full Text Full Text PDF PubMed Scopus (58) Google Scholar who reported their experience with 11 patients undergoing transcatheter aortic valve-in-valve implantation. Approximately half of the study patients had signs of severe PPM, and the remainder had at least moderate PPM, with the exception of 1 patient, who had an indexed effective orifice area greater than 0.85 cm2/m2. In addition, no significant reduction in transvalvular gradients was observed after the procedure in patients with severe PPM. These results might lead us to conclude that the procedure was hemodynamically unsuccessful in 45% of patients. The lack of efficacy of the procedure in decreasing aortic valve gradients is part of a broader controversy surrounding the optimal treatment for high-risk patients in the context of a multidisciplinary management approach that combines patient needs and economic resources. As previously suggested for high-risk patients by our group,4Santarpino G, Pfeiffer S, Fischlein T. Favourable outcomes after high-risk conventional aortic valve replacement: can we do even better? Eur J Cardiothorac Surg. December 20, 2011 [Epub ahead of print].Google Scholar we would like to contribute to the debate regarding the most appropriate valvular procedure in reoperative surgery by briefly describing our experience with patients undergoing reoperative aortic valve replacement for degenerated bioprostheses. At our institution, 6 patients with previous aortic valve replacement underwent implantation with a Perceval S sutureless valve (Sorin Group, Saluggia, Italy). Despite their advanced age at the time of intervention (78.5 ± 4.6 years) and the high operative risk (logistic EuroSCORE of 28.5% ± 20.7%), at 1 year after implantation all patients are alive and in good hemodynamic condition (n = 4 in New York Heart Association class I and n = 2 in New York Heart Association class II). Notably, the size of the newly implanted valve was not smaller (22.7 mm vs 23.1 mm), and the indexed effective orifice area at discharge was greater than 0.85 cm2/m2 in all patients, with a significant reduction in postoperative transvalvular gradients (peak gradient from 75.5 ± 29 mm Hg to 27.5 ± 3.7 mm Hg; mean gradient from 39.8 ± 21.6 mm Hg to 14.8 ± 3.3 mm Hg; P = .031). Although the sample is limited, these encouraging clinical and hemodynamic results prompt us to suggest that sutureless aortic valve replacement may be considered even for high-risk patients, in particular when the diameter of the previously implanted valve is small, in patients with small body surface area, or in female patients.5Astudillo L.M. Santana O. Urbandt P.A. Benjo A.M. Elkayam L.U. Nascimento F.O. et al.Clinical predictors of prosthesis-patient mismatch after aortic valve replacement for aortic stenosis.Clinics (Sao Paulo). 2012; 67: 55-60Crossref PubMed Scopus (17) Google Scholar At the time of the first implant, selection of the appropriate valve size is crucial in the event of a subsequent valve-in-valve procedure, especially in younger patients. The valve-in-valve technique is a feasible and promising treatment option, which is being performed increasingly in many centers, including our own. So the real question becomes, is it worth treating high-risk patients with this expensive and delicate surgical procedure if no hemodynamic benefit will be obtained in approximately 50% of cases?" @default.
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• W1977371341 title "Sutureless aortic valve replacement to prevent patient–prosthesis mismatch in the era of valve-in-valve implantation" @default.
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• W1977371341 doi "https://doi.org/10.1016/j.jtcvs.2012.03.017" @default.
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