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Ann Thorac Surg 2003;75:40
© 2003 The Society of Thoracic Surgeons

Invited commentary

^a Department of Cardiothoracic Surgery, Emory University School of Medicine, The Emory Clinic, 1365 Clifton Road NE, Atlanta, GA 30322, USA

e-mail: jcraver{at}emory.edu

With the expanding percentage of our population living into their eighth, ninth, and tenth decades, an increasing number of patients in these age groups are being referred for aortic valve replacement surgery. Aortic stenosis due to late fibrosis with calcific degeneration of malformed valves and senescent calcification of normally structured trileaflet valves, are the problems in the majority of these patients. Both present with a severely narrowed valve orifice and concomitant narrowing with calcification of the aortic annulus and root as well. Even after very careful debridement, the cardiac surgeon often is left with an annulus diameter 17, 19 or 21 mm in size that remains heavily involved by calcific infiltration.

Valve replacement with a standard intraannular porcine 19 mm bioprosthesis often results in unacceptable transvalvular gradients at rest which escalate to dangerous levels even with mild exercise. Iatrogenic aortic stenosis after valve replacement can also be observed in patients who have a body surface area greater than 1.70 m² who receive a 21 mm porcine valve. Utilization of bileaflet mechanical valves in an intraannular or supraannular position to address this patient–prosthesis mismatch requires that this very elderly group be on lifelong warfarin anticoagulation. This brings its own increased morbidity and mortality risks. Mechanical valves also have potential problems in obtaining a secure seating of the valve due to the calcified annulus.

Efforts to increase the annular size by incising the aortic annulus in the noncoronary cusp-mitral trigone area and then inserting a patch can be done, but usually allows only one valve size larger to be accommodated. Calcification of the area’s tissues, particularly in elderly patients, can present difficult problems securing the patch, increases bleeding, and doubles the reported operative risk even with experienced teams. Using stentless valves has been advocated and found to be an effective alternative for surgeons with extensive experience implanting stentless valves or homografts. The fact that two suture lines must be constructed in often heavily calcified tissues of the aortic annulus and root significantly increases the aortic cross-clamp interval has led the majority of cardiac surgeons away from this as a solution to the problem in patients of advanced age.

For these and other reasons, the excellent paper by Dr Vitale and colleagues should be of significant comfort to us cardiac surgeons who are seeing an increasing number of elderly patients with aortic stenosis who require valve replacement. This report outlines their experience utilizing 19 and 21 mm Carpentier Edwards Perimount bovine prostheses for aortic valve replacement in all patients 75 years of age or older who were followed for 12 years. Encouragingly, they use standard techniques of valve replacement, cardiopulmonary perfusion, and myocardial protection familiar to us all. Their operative mortality, 12-year survival, and freedom from thromboembolism all were excellent. Chronic anticoagulation with warfarin was used only when those patients were in atrial fibrillation. The valve’s measured hemodynamic performances were satisfactory with low peak and mean transvalvular gradients and had good orifice areas. No tissue failure was observed in the series.

The problem addressed is a small calcified aortic root and valve orifice in patients 75 years of age or older who needed aortic valve replacement. The solution strongly supported by the excellent results of this report is implantation by standard techniques of a Perimount valve.

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Joseph M. Craver Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Craver, J. M. Search for Related Content PubMed Articles by Craver, J. M.