Effect of aortic pericardial valve choice on outcomes and left ventricular mass regression in patients with left ventricular hypertrophy

Abstract

Since February 2011, 258 patients with AS and left ventricular hypertrophy underwent AVR with the Trifecta (TR) (St Jude Medical, St Paul, Minn) or Perimount Magna Ease (ME) (Edwards LifeSciences, Irvine, Calif) bioprosthesis. There were longer bypass and crossclamp times and the indexed left ventricular outflow tract was smaller in the TR group. For the TR and ME, respectively, peak (14.4 ± 5.1 mm Hg vs 20.9 ± 7.2 mm Hg; P < .001) and mean (7.3 ± 2.7 mm Hg vs 10.9 ± 4.3 mm Hg; P < .001) gradients were significantly smaller postoperatively in the TR group. There was greater total mass regression (44.3 g/m; 95% confidence interval [CI], 36.3-52.3 vs 29.5; 95% CI, 20.4-38.5 g/m; P = .020) and mass regression over time in the TR group compared with the ME group (P = .016). Freedom from readmission, congestive heart failure, and the composite outcome of all-cause mortality, readmission, and congestive heart failure at 2.5 years was significantly improved in the TR group (composite outcome in TR and ME groups, respectively, 90.2; 95% CI, 81.9-94.9 and 78.2; 95% CI, 67.1-86.0; P = .013) CONCLUSIONS: TR use was associated with significantly increased left ventricular mass regression and improved intermediate-term clinical outcome in patients with left ventricular hypertrophy undergoing AVR for AS, compared with use of the ME.

The impact of global left ventricular afterload on left ventricular reverse remodeling after aortic valve replacement

“…There has been conflicting results as to whether LV mass regression was related to prosthetic valve function. LV mass regression was reportedly more pronounced in the Trifecta group in one study, while it was comparable between the two pericardial valves in the other…”

“…In EWPVs, the valve leaflets are mounted externally to the sewing ring to maximize the EOA. In recent studies assessing the Trifecta valve, lower TPG and larger EOA were observed in the Trifecta compared to the internally wrapped Perimount pericardial valve(Edwards LifeSciences, Irvine, CA) . There has been conflicting results as to whether LV mass regression was related to prosthetic valve function.…”

A Paradox between LV Mass Regression and Hemodynamic Improvement after Surgical and Transcatheter Aortic Valve Replacement

“…A recent study reiterated the finding that lower mean gradients after AVR are associated with greater LV mass regression and improved patient outcomes and survival. 6 These findings stress that LV mass regression is a good thing and the way in which we measure LV mass should be accurate.…”

“…A key initiative in designing new valve prostheses is creating a favorable hemodynamic effect on the ventricle and ventricular reverse remodeling. 6 This focus in prosthesis development is further fueled by the finding that PPM (prosthesis considered too small for the patient, introducing functional obstruction to flow) increases mortality after AVR, 24 and impairs LV mass regression after both SAVR and TAVR. 17,25 This complicates the finding that LV mass regression is greater after SAVR given the significantly lower rate of PPM in TAVR and higher survival after CoreValve implantation compared to SAVR.…”

“…4 It is expected that LV mass regression is greater with lower aortic valve pressure gradients after AVR. 5,6 However, the Placement of Aortic Transcatheter Valve (PARTNER) Trial using a balloon-expandable bovine pericardial aortic bioprosthesis demonstrated that LV mass regression was faster and greater after surgical aortic valve replacement (SAVR) compared to transcatheter aortic valve replacement (TAVR) despite higher aortic pressure gradients and more frequent patient-prosthesis mismatch (PPM) after SAVR. 7,8 The CoreValve US Pivotal Trial using a self-expanding valve in a larger number of patients with severe AS and high surgical risk 9 yielded a similar paradoxical finding of a faster and greater reduction of LV mass in the SAVR group when LV mass was calculated by a standard mass formula.…”