CORRESPONDENCE: LETTER TO THE EDITOR
Comparison of Bioprostheses in Patients With Small Aortic Annulus
Lawrence H. Cohn, MD*
* Division of Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis Street, Boston, Massachusetts 02115 (Email: lcohn{at}partners.org).
I am writing to comment on the study by Botzenhardt et al. (1) in a recent issue of the Journal.
This interesting report compared different forms of bioprostheses, particularly in the small annular sizes for the aortic root. My reason for writing is related to the conclusion and the discussion regarding patients, particularly elderly ones, who need aortic valve replacement and who have relatively small annular diameters, namely 19, 21, or 23 mm. I would disagree with the authors’ conclusions that "especially older women who often present with narrow left ventricular outflow tracts small aortic annulus and therefore a surgical procedure in this patient group, according to our results properly require root enlargement." I would like to emphasize strongly that this is a somewhat hazardous recommendation, particularly in the elderly who have many other comorbidities and where a prolonged operation could lead to increased morbidity and even mortality. The researchers quote recommendations by the American College of Cardiology that the surgical procedure in this patient group should be a root enlargement. I strongly suggest that many of us who deal with these very frail elderly and oftentimes very sick patients would do well to implant these newer forms of more hemodynamically efficient bioprostheses, as mentioned in their study, even in the 19-mm range rather than extensive root enlargements for theoretical hemodynamic gain.
Increasing numbers of elderly patients (numbering some 50 million by the year 2015) will require aortic valve replacement. We must devise strategies and use the best bioprostheses in this group to get patients through surgery and improve their hemodynamics, while balancing the risk and reward of these procedures.
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References
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- Botzenhardt F, Eichinger W, Bleiziffer S, et al. Hemodynamic comparison of bioprostheses for complete supra-annular position in patients with small aortic annulus J Am Coll Cardiol 2005;45:2054-2060.[Abstract/Free Full Text]
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