Mehmet ÇAKICI, Adnan UYSALEL, Mustafa ŞIRLAK, Ümit ÖZYURDA, Kemalettin UÇANOK, Bahadır İNAN, Sadık ERYILMAZ, Levent YAZICIOĞLU, Serkan DURDU, Ahmet Rüçhan AKAR

Ciddi aort darlığı olan hastalarda aort kapak replasmanı sonrası sol ventrikül fonksiyon ve geometrisindeki değişiklikler

Amaç: Bu çalışmada, ciddi aort darlığı olan hastalarda, değişik tipte ve ölçekteki kapaklarla yapılan aort kapak replasmanlarının (AKR) sol ventrikül işlevleri ve geometrisi üzerine etkileri değerlendirildi. Çalışma planı: Ciddi aort darlığı tanısı olan 85 hasta üç gruba ayrılarak incelendi [Grup 1, mekanik AKR (n=31); Grup 2, stentsiz biyolojik AKR (n=34); Grup-3, stentli biyolojik AKR (n=20)]. Ameliyat öncesi ve AKR sonrası altıncı ayda sol ventrikül geometrisi ve işlevlerini değerlendirmek üzere transtorasik ekokardiyografi yapıldı. Çalışmanın birincil sonlanım noktası altıncı ayda sol ventrikül kütle indeks (SVKİ) değişiklikleri ve ikincil sonlanım noktaları NYHA (New York Heart Association) fonksiyonel sınıflaması, transvalvüler gradiyentler, aort kapak alanı, sol ventrikül ejeksiyon fraksiyonu (SVEF) ve çapları, septum kalınlığı ve efektif orifis alan indeksi (EOAİ) olarak belirlendi.Bulgular: Altıncı ayda NYHA fonksiyonel sınıfı tüm gruplarda anlamlı düzelme gösterdi. Altıncı aydaki ekokardiyografik değerlendirmelerde ΔSVEF (p=0.52), ΔSVDSÇ (p=0.24), ΔSVSSÇ (p=0.86), Δseptum kalınlığı (p=0.25) açısından gruplar arasında anlamlı bir fark yoktu. Efektif orifis alan indeksi anlamlı olarak stentsiz grupta, diğer gruplara kıyasla, yüksek bulundu (p=0.002). ΔSVKİ’nin mekanik ve stensiz biyolojik kapaklarda, stentli biyolojik AKR’lere oranla daha ileri düzeyde olduğu saptandı (p=0.042). Anulus çapı 25 mm’nin altındaki hastalar değerlendirildiğinde, stentsiz biyolojik AKR’lerde, diğer gruplara kıyasla, ΔSVKİ’nin daha da belirgin düzeyde azaldığı gösterildi (p=0.029).Sonuç: Stentsiz biyolojik AKR’lerin implantasyonu için daha uzun iskemi süresi gerekmesine karşın, SVKİ’lerdeki gerileme, özellikle dar aort kökü olan hastalarda, stentli benzerlerine kıyasla, daha belirgindir.

Changes in left ventricular function and geometry after aortic valve replacement in patients with severe aortic stenosis

Background: This study aims to evaluate the effects of different types and sizes of prostheses on the left ventricular function and geometry after aortic valve replacement (AVR) in patients with severe aortic stenosis. Methods: Eighty-five patients with severe aortic stenosis were studied in three groups [Group 1, mechanical AVR (n=31); Group 2, stentless biological AVR (n=34); Group 3, stented biological AVR (n=20)]. Left ventricular geometry and function were assessed by transthoracic echocardiography preoperatively and at six months after AVR. Primary endpoint of the study was the change in the left ventricular mass index (LVMI) at six months while secondary endpoints were the New York Heart Association (NYHA) functional class, transvalvular gradients, aortic valve space, left ventricular ejection fraction (LVEF) and diameters, septal thickness and indexed effective orifice area (IEOA).Results: A significant improvement in the NYHA functional class was seen in all groups at six months. Based on the echocardiographic evaluations at six months, there were no significant differences among the groups in terms of ΔLVEF (p=0.52), ΔLVEDD (p=0.24), ΔLVESD (p=0.86), Δseptal thickness (p=0.25). Indexed effective orifice area was significantly higher in stentless group, compared to the other groups (p=0.002). ΔLVMI was significantly greater in mechanical and stentless biological valves, compared to the stented biological AVR (p=0.042). When the patients with annulus size smaller than 25 mm were evaluated, it was shown that ΔLVMI was further decreased in stentless biological AVR, compared to the other groups (p=0.029).Conclusion: Although implantation of stentless biological AVR requires longer ischemic times, regression in the LVMI is more prominent in stented biological valves, particularly in patients with small aortic root.

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1) Grossman W. Cardiac hypertrophy: useful adaptation or pathologic process? Am J Med 1980;69:576-84.
2) Hess OM, Ritter M, Schneider J, Grimm J, Turina M, Krayenbuehl HP. Diastolic stiffness and myocardial structure in aortic valve disease before and after valve replacement. Circulation 1984;69:855-65.
3) Huber D, Grimm J, Koch R, Krayenbuehl HP. Determinants of ejection performance in aortic stenosis. Circulation 1981;64:126-34.
4) Monrad ES, Hess OM, Murakami T, Nonogi H, Corin WJ, Krayenbuehl HP. Time course of regression of left ventricular hypertrophy after aortic valve replacement. Circulation 1988;77:1345-55.
5) Pantely G, Morton M, Rahimtoola SH. Effects of successful, uncomplicated valve replacement on ventricular hypertrophy, volume, and performance in aortic stenosis and in aortic incompetence. J Thorac Cardiovasc Surg 1978;75:383-91.
6) Ali A, Patel A, Ali Z, Abu-Omar Y, Saeed A, Athanasiou T, et al. Enhanced left ventricular mass regression after aortic valve replacement in patients with aortic stenosis is associated with improved long-term survival. J Thorac Cardiovasc Surg 2011;142:285-91. doi: 10.1016/j.jtcvs.2010.08.084.
7) Kobayashi J. Stentless aortic valve replacement: an update. Vasc Health Risk Manag 2011;7:345-51. doi: 10.2147/VHRM. S11253.
8) Davis EA, Greene PS, Cameron DE, Gott VI, Laschinger JC, Stuart RS, et al. Bioprosthetic versus mechanical prostheses for aortic valve replacement in the elderly. Circulation 1996;94:II121-5.
9) Akar AR, Kurtcephe M, Sener E, Alhan C, Durdu S, Kunt AG, et al. Validation of the EuroSCORE risk models in Turkish adult cardiac surgical population. Eur J Cardiothorac Surg 2011;40:730-5. doi: 10.1016/j.ejcts.2011.01.002.
10) El-Husseini AA, Sheashaa HA, Hassan NA, El-Demerdash FM, Sobh MA, Ghoneim MA. Echocardiographic changes and risk factors for left ventricular hypertrophy in children and adolescents after renal transplantation. Pediatr Transplant 2004;8:249-54.
11) Harken DE, Soroff HS, Taylor WJ, Lefemine AA, Gupta SK, Lunzer S. Partial and complete prostheses in aortic insufficiency. J Thorac Cardiovasc Surg 1960;40:744-62.
12) Bach DS, Goldman B, Verrier E, Petracek M, Wood J, Goldman S, et al. Eight-year hemodynamic follow-up after aortic valve replacement with the Toronto SPV stentless aortic valve. Semin Thorac Cardiovasc Surg 2001;13:173-9.
13) Dagenais F, Cartier P, Dumesnil JG, Pibarot P, Lemieux M, Raymond G, et al. A single center experience with the freestyle bioprosthesis: midterm results at the Québec Heart Institute. Semin Thorac Cardiovasc Surg 2001;13:156-62.
14) Akar AR, Szafranek A, Alexiou C, Janas R, Jasinski MJ, Swanevelder J, et al. Use of stentless xenografts in the aortic position: determinants of early and late outcome. Ann Thorac Surg 2002;74:1450-7.
15) David TE, Feindel CM, Bos J, Sun Z, Scully HE, Rakowski H. Aortic valve replacement with a stentless porcine aortic valve. A six-year experience. J Thorac Cardiovasc Surg 1994;108:1030-6.
16) Casabona R, De Paulis R, Zattera GF, di Summa M, Bottone W, Stacchino C, et al. Stentless porcine and pericardial valve in aortic position. Ann Thorac Surg 1992;54:681-4.
17) Gaudino M, Alessandrini F, Glieca F, Luciani N, Cellini C, Pragliola C, et al. Survival after aortic valve replacement for aortic stenosis: does left ventricular mass regression have a clinical correlate? Eur Heart J 2005;26:51-7.
18) Harpole DH, Jones RH. Serial assessment of ventricular performance after valve replacement for aortic stenosis. J Thorac Cardiovasc Surg 1990;99:645-50.
19) Kühl HP, Franke A, Puschmann D, Schöndube FA, Hoffmann R, Hanrath P. Regression of left ventricular mass one year after aortic valve replacement for pure severe aortic stenosis. Am J Cardiol 2002;89:408-13.
20) Rajappan K, Melina G, Bellenger NG, Amrani M, Khaghani A, Pennell DJ, et al. Evaluation of left ventricular function and mass after Medtronic Freestyle versus homograft aortic root replacement using cardiovascular magnetic resonance. J Heart Valve Dis 2002;11:60-5.
21) Sandstede JJ, Beer M, Hofmann S, Lipke C, Harre K, Pabst T, et al. Changes in left and right ventricular cardiac function after valve replacement for aortic stenosis determined by cine MR imaging. J Magn Reson Imaging 2000;12:240-6.
22) Gelsomino S, Frassani R, Morocutti G, Nucifora R, Da Col P, Minen G, et al. Time course of left ventricular remodeling after stentless aortic valve replacement. Am Heart J 2001;142:556-62.
23) Lund O, Emmertsen K, Dørup I, Jensen FT, Flø C. Regression of left ventricular hypertrophy during 10 years after valve replacement for aortic stenosis is related to the preoperative risk profile. Eur Heart J 2003;24:1437-46.
24) Waszyrowski T, Kasprzak JD, Krzeminska-Pakuła M, Drozdz J, Dziatkowiak A, Zasłonka J. Regression of left ventricular dilatation and hypertrophy after aortic valve replacement. Int J Cardiol 1996;57:217-25.
25) Zussa C, Polesel E, Rigo F, Guarracino F. Left ventricular remodeling after aortic valve replacement with the Toronto-SPV prosthesis. Semin Thorac Cardiovasc Surg 1999;11:103-6.
26) Villari B, Sossalla S, Ciampi Q, Petruzziello B, Turina J, Schneider J, et al. Persistent diastolic dysfunction late after valve replacement in severe aortic regurgitation. Circulation 2009;120:2386-92. doi: 10.1161/ CIRCULATIONAHA.108.812685.
27) Carabello BA, Zile MR, Tanaka R, Cooper G 4th. Left ventricular hypertrophy due to volume overload versus pressure overload. Am J Physiol 1992;263:H1137-44.
28) Jin XY, Pillai R, Westaby S. Medium-term determinants of left ventricular mass index after stentless aortic valve replacement. Ann Thorac Surg 1999;67:411-6.
29) Christakis GT, Joyner CD, Morgan CD, Fremes SE, Buth KJ, Sever JY, et al. Left ventricular mass regression early after aortic valve replacement. Ann Thorac Surg 1996;62:1084-9.
30) Krayenbuehl HP, Hess OM, Monrad ES, Schneider J, Mall G, Turina M. Left ventricular myocardial structure in aortic valve disease before, intermediate, and late after aortic valve replacement. Circulation 1989;79:744-55.
31) González-Juanatey JR, García-Acuña JM, Vega Fernandez M, Amaro Cendón A, Castelo Fuentes V, García-Bengoechea JB, et al. Influence of the size of aortic valve prostheses on hemodynamics and change in left ventricular mass: implications for the surgical management of aortic stenosis. J Thorac Cardiovasc Surg 1996;112:273-80.
32) Biederman RW, Magovern JA, Grant SB, Williams RB, Yamrozik JA, Vido DA, et al. LV reverse remodeling imparted by aortic valve replacement for severe aortic stenosis; is it durable? A cardiovascular MRI study sponsored by the American Heart Association. J Cardiothorac Surg 2011;6:53. doi: 10.1186/1749-8090-6-53.
33) Brown ML, Schaff HV, Suri RM, Li Z, Sundt TM, Dearani JA, et al. Regression in left ventricular mass after aortic valve replacement for chronic aortic regurgitation is unrelated to prosthetic valve size. J Thorac Cardiovasc Surg 2011;142:e5-
9) doi: 10.1016/j.jtcvs.2010.08.043.
34) Sutton M, Plappert T, Spiegel A, Raichlen J, Douglas P, Reichek N, et al. Early postoperative changes in left ventricular chamber size, architecture, and function in aortic stenosis and aortic regurgitation and their relation to intraoperative changes in afterload: a prospective two-dimensional echocardiographic study. Circulation 1987;76:77-89.
35) Kurnik PB, Innerfield M, Wachspress JD, Eldredge WJ, Waxman HL. Left ventricular mass regression after aortic valve replacement measured by ultrafast computed tomography. Am Heart J 1990;120:919-27.
36) Panidis IP, Kotler MN, Ren JF, Mintz GS, Ross J, Kalman P. Development and regression of left ventricular hypertrophy. J Am Coll Cardiol 1984;3:1309-20.
37) De Paulis R, Sommariva L, Colagrande L, De Matteis GM, Fratini S, Tomai F, et al. Regression of left ventricular hypertrophy after aortic valve replacement for aortic stenosis with different valve substitutes. J Thorac Cardiovasc Surg 1998;116:590-8.
38) Ali A, Halstead JC, Cafferty F, Sharples L, Rose F, Coulden R, et al. Are stentless valves superior to modern stented valves? A prospective randomized trial. Circulation 2006;114:I535-40.
39) Bech-Hanssen O, Caidahl K, Wall B, Mykén P, Larsson S, Wallentin I. Influence of aortic valve replacement, prosthesis type, and size on functional outcome and ventricular mass in patients with aortic stenosis. J Thorac Cardiovasc Surg 1999;118:57-65.