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Should We Place 23 mm or Larger Valve for Young Female Patients Undergoing Aortic Valve Replacement?
Ahmed A Kolkailah, Julius I Ejiofor, Fernando Ramirez Del Val, Ritam Chowdhury, Siobhan McGurk, Jiyae Lee, Prem S Shekar, Sary F Aranki, Marc P Pelletier, Tsuyoshi Kaneko
Brigham and Women's Hospital, Harvard Medical School, Boston, MA

BACKGROUND: The effects of patient-prosthesis mismatch (PPM) on clinical outcomes have been well studied, and the outcomes of valve-in-valve transcatheter aortic valve replacements (VIV-TAVR) in small prostheses (≤ 21 mm) are reported to be worse. Consequently, there is a consideration to place at least a 23 mm valve in young active females to avoid PPM and allow future VIV-TAVR. We assessed the clinical outcomes of young female patients undergoing surgical aortic valve replacement (SAVR) using small and large prostheses to identify whether small valve size alone is a risk factor as well as the incremental risk of PPM.
METHODS: Between January 2002 and June 2015, 451 young (≤ 65 years) female patients who underwent SAVR were identified. Patients were stratified into small prostheses (SP) ≤ 21 mm (n = 257) and large prostheses (LP) ≥ 23 mm (n = 194) groups. PPM was considered to be present if indexed effective orifice area (iEOA) < 0.85 cm2/m2 and was classified into moderate if iEOA ≥ 0.65 cm2/m2 or severe if iEOA < 0.65 cm2/m2. Outcomes of interest were operative mortality and long-term survival. Cox proportional hazards modeling was used to evaluate predictors of long-term survival (Figure). Median follow-up duration was 6.09 (3.12, 9.59) years.
RESULTS: The mean age was 55.2 9.0 years. SP were used in 257/451 (57%) of the patients. Mean BSA was 1.80 0.22 m2 in the SP group vs. 1.87 0.25 m2 in the LP group (p ≤ 0.002). Both groups had similar STS-PROM, 2.30 2.36% in the SP group vs. 2.40 5.14% in the LP group (p = 0.85). Operative mortality was 6/257 (2.3%) in the SP group and 2/194 (1.0%) in the LP group (p = 0.48). Moderate PPM was present in 101/257 (39.3%) patients in the SP group and 30/194 (15.5%) patients in the LP group (p ≤ 0.001). Severe PPM was observed in 28/257 (10.9%) patients in the SP group and 5/194 (2.6%) patients in the LP group (p ≤ 0.001). Overall 14-year survival was 75%, 74.64% in the SP group vs. 75.74% in the LP group. Multivariate Cox analysis identified age (HR 1.06, p = 0.014), renal failure (HR 4.60, p ≤ 0.001), CHF (HR 3.27, p ≤ 0.001) and severe PPM (HR 2.87, p = 0.013) as significant predictors of long-term survival, while valve size and moderate PPM were not found significantly contributory.
CONCLUSIONS: In young females undergoing SAVR, small valve size alone was not associated with worse long-term outcomes. The presence of severe PPM resulted in poor long-term outcomes, whereas moderate PPM was not associated with decreased long-term survival. Since future valve-in-valve TAVR will not fix the PPM problem, we suggest considering aortic root enlargement procedures to allow for placement of larger prostheses, specifically in patients with potential severe PPM.


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