CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 2, May – August 2024 AFRICA 99 Discussion Aortic stenosis causes chronic pressure loading and the left ventricle responds with hypertrophy to normalise the systolic wall stress.13 With the return to normal of systolic pressure after AVR, the left ventricular end-systolic and end-diastolic volume indexes fall. As a result, reversal of left ventricular hypertrophy and improvement in functional capacity is expected. A study by Koyama et al.14 identified that 30 patients with mechanical AVR due to aortic stenosis had significant decrease in LVM at the end of one year (from 245.1 ± 84.3 to 173.4 ± 62.6 g). Suri et al.15 studied AVR patients with porcine and bovine pericardial valves and reported that in spite of significant LVM decreases at the end of a year, there was no significant difference identified between the two groups. Rubens et al.16 studied 258 patients with left ventricular hypertrophy undergoing AVR with Trifecta (St Jude Medical, St Paul, Minnesota) or Perimount Magna Ease (Edwards Life Sciences, Irvine, California) bovine pericardial valves. They stated that Trifecta was associated with a significant degree of LVM decrease and improved medium-term clinical outcomes compared to Perimount Magna Ease valves. A study by Concistrè et al.17 showed significant LVM decrease in patients using Perceval S (Sorin Group, Saluggia, Italy) and 3f Enable (Medtronic, ATS Medical, Minneapolis, MN USA) sutureless valves due to aortic stenosis; however, no significant difference was found between the two valve groups. Santarpino et al.18 used Perceval S for sutureless AVR in 78 patients with aortic stenosis and observed significant decrease in LVMI (from 148.4 ± 46 to 119.7 ± 38.5 g/m²) and mean transaortic pressure difference (from 49.5 ± 15.8 to 8.3 ± 4.4 mmHg) during one-year follow up. In our study, general analysis without differentiating the valve subgroups revealed mean LVM decreased from 228.76 ± 66.61 to 185.29 ± 44.42 g at the end of one year (p < 0.001), while mean LVMI decreased from 124.15 ± 34.46 to 100.35 ± 22.31 g/m² (p < 0.001). The mean transaortic pressure difference reduced from 52.46 ± 13.83 to 13.50 ± 6.85 mmHg (p < 0.001). Additionally, at the end of the first year, there was a significant increase in EF (p = 0.008). In the four valve groups (bovine pericardial, porcine, sutureless and mechanical valves), all groups were observed to have significant decrease of mean LVEDD, LVESD, maximum gradient, mean gradient, LVM and LVMI in the postoperative period. Analysis of the four valve groups showed the bovine pericardial valve group had less LVM (bovine pericardial 10.1%, porcine 24.5%, sutureless 13.7% and mechanical 16%) and LVMI (bovine pericardial 10.5%, porcine 24.3%, sutureless 13.8% and mechanical 16%) percentage decrease compared to the other valve groups. Table 5. Comparison of pre-operative and first year postoperative echocardiographic findings according to valve subgroups of the patients Parameters Valve type Pre-operative echocardiography (mean ± SD) Postoperative echocardiography (mean ± SD) p-value Ascending aortic diameter, cm Porcine 4.10 ± 0.26 4.18 ± 0.22 0.46 Bovine pericardial 4.03 ± 0.29 4.23 ± 0.05 0.28 Sutureless 3.97 ± 0.34 4.25 ± 0.44 0.09 Mechanical 4.08 ± 0.29 4.21 ± 0.26 0.54 EF, % Biyolojik porcine 54.31 ± 8.12 54.85 ± 6.79 0.87 Bovine pericardial 54.41 ± 5.55 55.67 ± 4.95 0.33 Sutureless 54.19 ± 8.17 56.20 ± 6.5 0.006 Mechanical 55.83 ± 7.87 56.40 ± 5.95 0.20 LVEDD, cm Biyolojik porcine 4.98 ± 0.53 4.53 ± 0.43 < 0.001 Bovine pericardial 4.66 ± 0.51 4.57 ± 0.57 0.04 Sutureless 4.64 ± 0.55 4.46 ± 0.45 0.003 Mechanical 4.82 ± 0.96 4.59 ± 0.57 < 0.001 LVESD, cm Biyolojik porcine 3.16 ± 0.71 2.73 ± 0.42 0.001 Bovine pericardial 2.96 ± 0.69 2.84 ± 0.67 0.03 Sutureless 2.90 ± 0.62 2.66 ± 0.54 < 0.001 Mechanical 3.03 ± 0.76 2.82 ± 0.59 0.02 Maximum gradient, mmHg Biyolojik porcine 81.76 ± 18.47 27.79 ± 11.60 < 0.001 Bovine pericardial 87.07 ± 20.38 23.73 ± 8.77 < 0.001 Sutureless 83.59 ± 18.38 19.87 ± 7.67 < 0.001 Mechanical 86.19 ± 20.48 26.85 ± 12.47 < 0.001 Mean gradient, mmHg Biyolojik porcine 51.44 ± 13.20 15.67 ± 7.89 < 0.001 Bovine pericardial 56.71 ± 15.35 13.07 ± 5.12 0.001 Sutureless 51.12 ± 12.21 11.04 ± 4.79 < 0.001 Mechanical 53.18 ± 15.09 14.40 ± 7.48 < 0.001 PAP, mmHg Biyolojik porcine 35.86 ± 10.49 34.45 ± 7.55 0.55 Bovine pericardial 38.18 ± 11.30 35.20 ± 7.99 0.37 Sutureless 38.26 ± 12.22 34.20 ± 9.16 0.02 Mechanical 34.01 ± 8.08 30.63 ± 5.54 < 0.001 LVM, g Biyolojik porcine 246.25 ± 62.89 180.27 ± 31.70 < 0.001 Bovine pericardial 221.53 ± 64.26 200.60 ± 50.92 0.03 Sutureless 212.35 ± 46.55 178.42 ± 33.88 < 0.001 Mechanical 236.58 ± 80.09 189.38 ± 53.24 < 0.001 LVMI, g/m2 Biyolojik porcine 132.11 ± 36.80 97.12 ± 20.01 < 0.001 Bovine pericardial 115.06 ± 35.77 104.40 ± 26.44 0.02 Sutureless 120.99 ± 26.19 101.14 ± 17.81 < 0.001 Mechanical 125.21 ± 38.96 100.38 ± 25.36 < 0.001 EF: ejection fraction; LVEDD: left ventricular end-diastolic diameter; LVESD: left ventricular end-systolic diameter; PAP: pulmonary artery pressure; LVM: left ventricular mass; LVMI: left ventricular mass index. Table 6. Comparison of pre-operative and first year postoperative echocardiographic findings according to PPM (IEOA) of the patients Parameters IEOA Pre-operative echocardiography (Mean ± SD) Postoperative echocardiography (Mean ± SD) p-value EF, % Severe 58.57 ± 3.05 57.00 ± 4.83 0.19 Moderate 55.72 ± 7.07 56.20 ± 5.94 0.34 Normal 53.68 ± 8.64 55.67 ± 6.58 0.001 LVEDD, cm Severe 4.55 ± 0.36 4.28 ± 0.38 0.23 Moderate 4.75 ± 0.57 4.51 ± 4.41 < 0.001 Normal 4.82 ± 0.88 4.59 ± 0.57 < 0.001 LVESD, cm Severe 2.74 ± 0.39 2.48 ± 0.30 0.04 Moderate 2.97 ± 0.67 2.74 ± 0.53 < 0.001 Normal 3.06 ± 0.75 2.80 ± 0.59 < 0.001 Maximum gradient, mmHg Severe 86.60 ± 25.64 30.80 ± 10.05 < 0.001 Moderate 83.82 ± 17.91 27.62 ± 12.58 < 0.001 Normal 85.15 ± 20.10 21.33 ± 8.79 < 0.001 Mean gradient, mmHg Severe 56.64 ± 19.01 17.30 ± 6.01 0.005 Moderate 51.76 ± 11.82 15.41 ± 8.14 < 0.001 Normal 52.46 ± 14.57 11.39 ± 4.77 < 0.001 PAP, mmHg Severe 36.07 ± 12.79 33.50 ± 8.33 0.20 Moderate 36.12 ± 10.05 34.29 ± 8.75 0.02 Normal 36.20 ± 10.56 31.45 ± 6.04 < 0.001 LVM, g Severe 204.57 ± 44.79 168.00 ± 41.05 0.01 Moderate 221.69 ± 55.06 188.064 ± 40.68 < 0.001 Normal 237.84 ± 76.01 184.80 ± 47.79 < 0.001 LVMI, g/m2 Severe 105.29 ± 21.83 89.00 ± 18.49 0.01 Moderate 118.30 ± 28.39 99.67 ± 19.65 < 0.001 Normal 131.49 ± 38.48 102.213 ± 24.59 < 0.001 IEOA: indexed effective orifice area; EF: ejection fraction; LVEDD: left ventricular end-diastolic diameter; LVESD: left ventricular end-systolic diameter; PAP: pulmonary artery pressure; LVM: left ventricular mass; LVMI: left ventricular mass index. Severe IEOA < 0.65; moderate IEOA 0.65–0.85; normal IEOA > 0.85.
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