CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Florian Botzenhardt, MD*,
Walter B. Eichinger, MD,
Sabine Bleiziffer, MD,
Ralf Guenzinger, MD,
Ina M. Wagner, MD,
Robert Bauernschmitt, MD and
Ruediger Lange, MD
* Krankenhaus Muenchen–Bogenhausen, Department of Cardiology, Englschalkinger Strasse 77, 81925 Munich, Germany (Email: f.botzenhardt{at}gmx.de).
Our study about four stented bioprostheses implanted in patients with a small aortic annulus observed high incidences of patient–prosthesis mismatch in subjects with an aortic annulus of 18 to 20 mm independent of the chosen valve type (1). These patients may hemodynamically benefit from aortic root enlargement and the implantation of a larger stented bioprosthesis. However, the decision to extend the operative procedure from an isolated aortic valve replacement to valve replacement plus root enlargement, which may lead to increased morbidity and mortality (2), must always be integrated in a differentiated and extensive assessment of the patient’s comorbidities, age, and lifestyle and must not be misunderstood as a general recommendation. Prolongation of the cardiopulmonary bypass time may be especially associated with increased operative and 30-day mortality in patients 
80 years of age (3).
Thus, we concur with Dr. Cohn that "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." We emphasized this concept with reference to the American Collage of Cardiology/American Heart Association (ACC/AHA) guidelines for the management of patients with valvular heart disease: "A narrow LV [left ventricular] outflow tract and a small aortic annulus sometimes present in elderly women may require enlargement of the annulus. The decision to proceed with valve replacement depends on an imprecise analysis that considers the balance between the potential for improved symptoms and survival and the morbidity and mortality of surgery" (4). We did not cite these guidelines to support the widespread use of aortic root enlargement. The operative procedure at our department reflects the integration of investigational results in real-world surgery, as "we do not always perform aortic root enlargement in case of patient–prosthesis mismatch in this patient group, setting priority to achieve low rates of perioperative adverse events. However, we sometimes have to accept suboptimal hemodynamic performance" (1).
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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]
- Sommers KE, David TE. Aortic valve replacement with patch enlargement of the aortic annulus Ann Thorac Surg 1997;63:1608-1612.[Abstract/Free Full Text]
- Unic D, Leacche M, Paul S, et al. Early and late results of isolated and combined heart valve surgery in patients 80 years of age Am J Cardiol 2005;95:1500-1503.[CrossRef][ISI][Medline]
- Bonow RO, Carabello B, de Leon Jr AC, et al. ACC/AHA guidelines for the management of patients with valvular heart diseasea report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee on Management of Patients With Valvular Heart Disease). J Am Coll Cardiol 1998;32:1486-1588.[Free Full Text]
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