CORRESPONDENCE: LETTER TO THE EDITOR
Reply
Eberhard Grube, MD, FACC*,
Ulrich Gerckens, MD,
Peter Wenaweser, MD and
Lutz Buellesfeld, MD
* Department of Cardiology and Angiology, HELIOS Heart Center Siegburg, Ringstrasse 49, Siegburg NRW, Germany 53721 (Email: grubee{at}aol.com).
We would like to thank Dr. Zegdi and colleagues for their interest in our article (1) and would like to address the raised questions as follows: 1) the valve area increased from 0.60 ± 0.16 cm2 to 1.67 ± 0.41 cm2 post-CoreValve implantation, as suggested by the marked decrease of the mean transvalvular gradient. A direct comparison of the valve areas after standard surgery versus percutaneous replacement carries a caveat. Prosthetic valves are surgically implanted and function either intra-annularly or supra-annularly, whereas the CoreValve is designed to be placed intra-annularly but function supra-annularly. Therefore, whereas the frame anchors and adapts to the annulus size within its design parameters, the functional valve area of the CoreValve device is a constant factor at a 22-mm diameter for the smaller valve and 24 mm for the larger valve. Obviously this does not result in a relevant increase of the gradient as demonstrated in our series. 2) We would like to emphasize that in the results section of the article, a detailed description of the degree of post-procedural paravalvular leaks is provided. Severe (grades 3+ or 4+) regurgitation was not observed during follow-up. Furthermore, there were no patients with congenitally known bicuspid aortic valves. 3) Some of the patients have had functionally bicuspid valves due to strong calcification of the cusps. However, in our view, this does not present a contraindication for this procedure as long as a successful balloon pre-dilation of the native valve is considered to be feasible and is successful to prepare a landing zone for the percutaneous bioprosthesis. 4) The relatively high rate of post-dilation of this early series may be explained by the fact that during the first period of the study only the small valve (26-mm inflow for patients with a 20- to 23-mm annulus) was available, and some valves were undersized. Also, during the early phase of the study, investigators were less comfortable with the notion of giving the self-expanding frame some time to "adapt to the annulus," and post-dilations were more common. Of note, at the end of the reported study phase, the larger valve (29-mm inflow for patients with a 24- to 27-mm annulus) became available, which explains the 20- to 27-mm annulus range of the total cohort. 5) In addition, likely due to the smaller device size (21- and 18-F, respectively), there were no severe peripheral vascular complications or major bleedings to report. It should be noted that with this 18-F device, standard interventional pre-closing techniques are commonly applied, thus obviating the need for surgical access or repair. 6) Finally, we acknowledge that the issue of the need for permanent pacemakers is not unlike surgical aortic valve replacement patients, and we will be reporting in our next publication on the incidence of complete atrioventricular block and the need and rationale of pacemaker implantation in this high-risk octogenarian population.
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References
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- Grube E, Schuler G, Buellesfeld L, et al. Percutaneous aortic valve replacement for severe aortic stenosis in high-risk patients using the second- and current third-generation self-expanding CoreValve prosthesis J Am Coll Cardiol 2007;50:69-76.[Abstract/Free Full Text]
Related Article
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Percutaneous Aortic Valve Replacement With the CoreValve Prosthesis
- Rachid Zegdi, Ghassan Sleilaty, Antoine Lafont, and Jean-Noël Fabiani
J. Am. Coll. Cardiol. 2008 51: 170.
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