The Complete Supraannular Concept

Abstract

Background— Complete supraannular placement of an aortic bioprosthesis is one approach to optimize the hemodynamic result of an aortic valve replacement. It is achieved with the combination of a special valve design and the supraannular sewing technique with noneverted mattress sutures. We evaluated 5 bioprostheses designed for complete supraannular placement to assess potential hemodynamic differences caused by factors (eg, valve material) other than implantation position. Methods and Results— In 336 patients (mean age, 72.0±7.1 years; 143 women), hemodynamics including mean pressure gradients, effective orifice areas, and indices and incidence of patient-prosthesis mismatch were evaluated 6 months after surgery. Annulus diameter was measured during surgery. Patients received the Carpentier Edwards Perimount Magna (Magna, n=169), the Medtronic Mosaic (Mosaic, n=46), the Mosaic Ultra (Ultra, n=17), the SJM Epic Supra (Epic, n=46), and the Sorin Soprano (Soprano, n=58). For small annulus sizes (<23 mm), the mean pressure gradients of the Magna (11.82±4.8 mm Hg) were significantly lower than the Mosaic (16.04±6.1 mm Hg) and the Ultra (22.0±4.1 mm Hg), and the Soprano (13.3±5.2 mm Hg) was hemodynamically superior to the Ultra. For medium (23 to 24 mm) and large (>24 mm) annulus sizes, the mean pressure gradients of the Magna were lower than the Epic (10.0±3.5 mm Hg versus 14.9±6.4 mm Hg; 9.9±4.0 mm Hg versus 18.6±12.7 mm Hg). Furthermore, in patients with large annulus size, the mean pressure gradients of the Soprano (11.4±3.8 mm Hg) were lower compared with the Epic (18.5±12.7 mm Hg). Severe patient-prosthesis mismatch was observed more frequently in patients with the Mosaic (12/46; 26.1%) and the Ultra (3/17; 17.6%) prostheses. Conclusions— Complete supraannular placement cannot prevent high pressure gradients or patient-prosthesis mismatch thoroughly, but the choice of a bovine prosthesis can optimize hemodynamic performance.

Reducing Prosthesis-Patient Mismatch With Edwards Magna Prosthesis for Aortic Valve Replacement

“…23 Ruzicka et al reported that the CEPM showed the lowest mean PG of 5 bioprostheses evaluated (CEPM, Mosaic, Mosaic Ultra, Epic Supra, Sorin Soprano) and larger EOAs than the porcine bioprostheses. 24 In conclusion, the mid-term performance of each of the CEPMs was satisfactory, with low operative mortality, excellent hemodynamics, and significant regression of the LVM. These advantages remained in place for patients at high risk for PPM.…”

Clinical Outcomes and Hemodynamics of the 19-mm Perimount Magna Bioprosthesis in an Aortic Position - Comparison With the 19-mm Medtronic Mosaic Ultra Valve -

“…Ruzicka et al found the transvalvular pressure gradient of the Magna valve to be lower than that of other porcine bioprostheses for annuluses <23 mm in size. 8 Assuming an average EOA of 1.58 cm 2 for the 19-mm Magna valve reported by the manufacturer, implantation of this prosthesis in patients with a BSA >1.9 m 2 would lead to an EOAI <0.85 cm 2 /m 2 , resulting in PPM. The reported EOA of 1.58 cm 2 , however, derived from a study of only 5 patients given a 19-mm Magna valve.…”

“…9 EOAs were reported at 1.58±0.29 cm 2 (5 patients) for the 19-mm Magna prosthesis and 1.28±0.13 cm 2 (9 patients) for the standard 19-mm CEP prosthesis. 8 Botzenhardt et al reported superior hemodynamics with the 19-mm Magna bioprosthesis, with a mean LVAo-PG of 11.9 mmHg and EOA of 1.65 cm 2 (4 patients). 14 In the present large patient group in which the 19-mm Magna prosthesis was used, however, we documented an EOA of 1.39±0.33 cm 2 at discharge and 1.35±0.24 cm 2 at follow-up, values that are lower than the previously reported ones.…”

“…16 Ruzicka et al reported that the mean LVAo-PG as well as the frequency of severe PPM were higher in patients with the MMU valve. 8 Little is known, however, about the difference in hemodynamic behavior between the 19-mm CEM and the 19-mm MMU bioprostheses. The present result of higher LVAo-PG in the 19-mm MMU group is compatible with those of other investigators.…”

Early haemodynamic performance of a latest generation supra-annular aortic bioprosthesis: experience from a large single-centre series

“…The concept of supra-annular implantation was one approach that has been implemented to optimize the haemodynamic performance of stented bioprostheses used for AVR [11]. With complete supra-annular positioning neither the stent nor the sewing ring material should reach into the blood stream resulting in lower transprosthetic gradients (optimal orifice).…”