**4. Conclusion**

30 Aortic Valve Surgery

was 350-600 g (200-400 g/m2) in the presence of corresponding linear parameters of LV and IVS. In these cases, positive surgery prognosis was more than 80%. Increase in ejection fraction more than 50% was postoperatively observed especially in patients with such characteristics. Analysis of valve morphology parameters (F6) revealed that significance of aortic valve calcification increases in peak SPG (r=0.448), but not affecting surgery prognosis (r=0.172). Baseline AV regurgitation also does not influence on surgery outcome (r=0.263). We can see the possible explanation of this fact is that AV calcification in the patients was mostly caused by age-related sclerosis and rheumatoid degeneration with no elements of

0 20 40 60 80 100

calculated LV EF p/o LV EF Prognosis,%

Decreased ejection fraction was observed in patients who had regurgitation on MV (r=-0.377) and TV (r=-0.313) exceeding Grade I, this also resulted in impairment of surgery prognosis. Analysis of valve function parameters (F7) demonstrated that lower baseline SBG value was associated with more favorable surgery prognosis (r=-0.284). When peak SPG was less than 80 mmHg, favorable surgery prognosis ranged from 90 to 100%. Therefore, in the patients with coronary artery lesions aortic valve replacement should be performed at the early stages of defect manifestations when a systolic gradient is 60-80 mmHg. Analysis of coronary blood supply factor (F8) showed that patients with right dominance had worse surgery prognosis than patients with left dominance. Analysis demonstrated that among patients with right dominance only one artery was grafted in 41.9% patients, and 58.1% patients had two grafted arteries (35.5%) or more (22.6%). However, among patients with left dominance, one artery was grafted in 66.7% patients and only 33.3% patients had two (22.2%) or more (11.1%) grafted arteries, i.e. we see that the larger grafting volume was

Fig. 9. Correlation between postoperative EF and calculated LV EF

myocardial inflammation (myocarditis) and inflammation of conduction system.

30

40

50

60

70

80

Patients with aortic valve lesion combined with coronary artery lesion are a severe group for surgical treatment and require intervention at early stages of the disease. NYHA FC IV is a high-risk predictor for combined surgeries CHD + CABG. We believe that systolic gradient ≥60 mmHg in patients assigned to CABG is an indication for combined aortic valve surgery. Analysis of LV linear and volume parameters revealed that LV diastolic dimension and diastolic volume had the greatest influence on prognosis in this patient group. iEDV/iESV ratio with SI>40 ml/ m2 (SV=80 ml) is a good prognostic sign allowing to predict a prognosis of more than 80%. The optimal LVMM value was 350-600 g (200-400 g/m2) in the presence of corresponding linear parameters of LV and IVS, when a surgery prognosis was higher than 80%, and baseline LVEF was more than 50%. Appearance of functional changes in MV (regurgitation grade >1) and TV (regurgitation grade >1) is a poor prognostic factor. LAD grafting in these patients is a required intervention, even is a lesion degree is less than 70%. It allows increasing the favorable surgery percentage.

**Part 2** 

**Selection of Prosthesis** 

#### **5. References**


**Part 2** 

**Selection of Prosthesis** 

32 Aortic Valve Surgery

[1] Gilinov A.M., Garcia M.J. When is concomitant aortic valve replacement indicated in

[2] Yap C.H., Sposato L., Akowuah E. et al. Contemporary results show repeat coronary

[3] Urso S., Sadaba R., Greco E. et al. One-hundred aortic valve replacements in

[4] Doenst T., Ivanov J., Borger M.A. et al. Sex-specific longterm outcomes after combined valve and coronary artery surgery. Ann. Thorac. Surg., 2006, 81, 1632-1636 [5] V.B. Brin, B.Ya. Zonis Circulation physiology. Rostov-on-Don University Publishing,

[6] Бураковский В.И., Лищук В.А., Стороженко И.Н. Применение математических моделей в клинике сердечно-сосудистой хирургии.М., 1980, стр.93-120. [7] Yu.L. Shevchenko, N.N. Shikhverdiev, A.V. Otochkin Prognosis in heart surgery. Saint

[8] E.N. Shigan Prognostic methods and modeling in social and hygiene studies. Moscow,

[9] Lemeshow S., Teres D., Klar J. et al. Mortality probability models (MPM II) based on an international cohort of intensive care unit patients. JAMA, 1993, 270, 2478-2486 [10] Moreno R., Miranda D.R., Matos R., Fevereiro T. Mortality after discharge from

[11] Wann S., Balkhy H. Evaluation of patients after coronary artery bypass grafting. Cardiol

[12] Brown J.M., O;Brien S.M., Wu C. et al. Isolated aortic valve replacement in North

[13] Thulin L.I., Sjögren J.L. Aortic valve replacement with and without concomitant

[14] Florath I., Albert A., Hassanein W. et al. Current determinants of 30-day and 3-moth

[15] Jamieson W.R., Burr L.H., Miyagishima R.T. et al. Re-operation for bioprosthetic aortic structural failure – risk assessment. Eur.J.Cardiothorac.Surg., 2003, 24, 6, 873-878 [16] Nardi P., Pellegrino A., Scafuri A. et al. Long-term outcome of coronary artery bypass

intensive care: the impact of organ system failure and nursing workload use at

America comprising 108,6887 patients in 10 years: changes in risks, valve types, and outcomes in the Society of Thoracic Surgeons National Database. J.Thorac.

coronary artery bypass surgery in the elderly: risk factors related to long-term

mortality in over 2000 aortic valve replacements: Impact of routine laboratory

grafting in patients wtih left ventricular dysfunction. Ann. Thorac. Surg., 2009, 87,

Curr. Cardiol. Rep., 2005, Mar., 7 (2), 101-104

Petersburg, Piter Publishing, 1998, pp. 208.

discharge.Intens.Care Med., 2001, 27, 999-1004

Cardiovasc. Surg., 2009, 137, 1, 82-90.

survival. Croat. Med. J., 2000, 41,4,406-9

parameters. Eur.J.Cardiothorac.Surg., 2006, 30,5,716-21.

Dis., 2007, 87, 1386-1391

Meditsina, 1986. - 206 pp.

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1984., pp. 88.

patients with mild to moderate stenosis undergoing coronary revascularization.

artery bypass grafting remains a risk factor for operative mortality. J. Heart Valve

octogenarians: outcomes and risk factors for early mortality. J. Heart Valve Dis.,

**5. References** 

**3** 

*Turkey* 

**Which Valve to Who: Prosthetic Valve** 

Harken et al. had performed the first aortic valve replacement in subcoronary position in 1960 (Harken, 1960). The "caged ball" valve used in this operation pioneered to the prosthetic valves and in the last 50 years many valve types were begun to be used. The early and long term results of the patients undergone aortic valve surgery do not depend not only the patient-related factors and the type of the surgery. The selected prosthetic valve is one of the most important factor affecting survival. According to the analysis of the multicenter randomized trials made by Hammermeister et al. involving the recent 15 years, more than one third of the deaths among the patients undergone aortic valve surgery were found to be related to the prosthetic valve (Hammermeister, 2000). The expectance from an ideal prosthetic valve is to correct the present valve pathology, to possess normal functions, to normalize patient's life standards or at least to improve it obviously, and to preserve this status during the patient's lifelong. Additionally, the implantation of the ideal prosthetic valve should be easy, the prosthetic valve should be replaced with low mortality and morbidity, should not cause a damage to the cardiovascular system, the hospitalization period should be short, the valve should be inexpensive (Rahimtoola, 2010). In spite of the whole developments in the prosthetic valve technology, the ideal prosthetic valve is not found yet, that's why the task of the surgeon is to select the prosthetic valve not depending

on the nature of the disease but should be individualized to each patient.

Nowadays, the replacement alternatives for aortic valve replacement are mechanical valves, biological xenograft valves, homograft valves, autograft valves and valves implanted transapically or percutaneously which usage has increased in the recent years. Because of various advantages and disadvantages, these alternatives are prefered to each other. However, for the most appropriate valve choice, each patient should be evaluated individually. Additionally, improvements in the drug technology and risk preventing measures, due to the deceleration in the development of cardiovascular diseases, the age of the operated patients and the surviving period following the operation is increasing gradually. Cardiovascular diseases become the most important factor determining the life quality and surviving ratio in the elderly population. The main purpose of the aortic valve replacement is the improvement of life quality by prolonging the patient's life (Kolh, 2007;

**1. Introduction** 

**Selection for Aortic Valve Surgery** 

Bilal Kaan İnan, Mustafa Saçar, Gökhan Önem and Ahmet Baltalarli *Kasmpaşa Military Hospital, İstanbul,* 

*Pamukkale University, Denizli,* 
