CARDIOVASCULAR JOURNAL OF AFRICA • Volume 35, No 2, May – August 2024 100 AFRICA When patients in the bovine pericardial valve group were examined in detail, 20% of patients were identified to have severe PPM. In the other valve groups the severe PPM rates were 9% for porcine, 5.4% for mechanical valves and 0% for sutureless valves. We believe LVM and LVMI were less decreased in the bovine pericardial valve group because of the higher number of severe PPM cases in this group. The lack of severe PPM cases in the sutureless group may be explained by this valve having better EOA.10-12 Additionally, the observation of lower mean maximum gradient (p = 0.001) and mean gradient (p = 0.007) values in the sutureless valve group compared to the other valve groups supports this view. In patients undergoing AVR, PPM may be observed when the prosthetic valve implanted is small compared to the body size of the patient. Dayan et al. showed the prevalence of PPM at a moderate level was from 20 to 70%, while the prevalence of severe PPM varied from two to 20%.19 PPM was shown to predict a negative outcome.20-24 The effect of PPM on remodelling of left ventricular hypertrophy is debatable. A range of studies showed that PPM was associated with remodelling after AVR and transcatheter aortic valve implantation (TAVI),25 while some studies found it had a limited effect on clinical outcomes.26,27 The presence of PPM was not found to have a significant effect on postoperative EF changes.19 When the valve groups in our study were investigated in terms of PPM, mean LVEDD, LVESD, maximum gradient, mean gradient, PAP, LVM and LVMI appeared to decrease in all PPM groups. For EF, while significant improvement was observed in the normal PPM group, decrease was identified in the severe PPM group (from 58.5 to 57.0%) (p = 0.19) (Table 6). Left ventricular systolic dysfunction may be due to increasing load in the presence of normal myocardial contractility and absence of significant myocardial dysfunction, and it is expected that systolic function will improve after removal of the output obstruction. An article published by Kim et al.25 reported 4% improvement rate for EF during the one-year follow up for patients with AVR due to aortic stenosis and an EF of 50% and above. In our study, without differentiating the subgroups, general assessment identified a mean 2.1% rate of significant improvement in EF. When analysis was performed according to the valve subgroups, all groups were found to have an increase in EF, while this increase was only statistically significant in the sutureless valve group (p = 0.006). This situation may be due to the sutureless valves having better EOA.10-12 It is necessary to take a separate view for the severe PPM group when assessing EF. Unlike in the other groups, the decrease in EF in the severe PPM group makes the benefit of surgery controversial for patients. Therefore, in spite of appropriate selection of valves for patients in the severe PPM group, aortic root expansion should be considered if IEAO is < 0.65. There is not much data in the literature related to PAP changes in patients undergoing AVR due to aortic stenosis. Analysis of the four valve groups in our study observed a postoperative fall in PAP in all groups. However, this reduction was only significant in the mechanical (p < 0.001) and sutureless (p = 0.02) valve groups. We believe this result is associated with the reduction in left ventricular volume load after AVR and linked reduction in pulmonary load. PAP changes affect the mitral and tricuspid valves and pulmonary bed reserve apart from the aortic valve. Therefore, there is a need for prospective randomised studies to be able to determine the effects of different valve types. It was observed that a large diameter increase in the ascending aorta in the first postoperative year was found especially in patients over 65 years of age. We believe that this significant increase may be related to senile degeneration of the aortic wall with increasing age. The limitations of our study are that it was retrospective, echocardiography assessment was performed only in the first year, and the number of patients in each valve group was different and limited. Conclusion In our study, analysis comparing four valve groups revealed significant decreases in LVEDD, LVESD, maximum gradient, mean gradient, LVM and LVMI in all groups at the end of the first year. EF was observed to significantly improve only in the sutureless valve group. Additionally, the sutureless valve group showed significant reductions in maximum gradient and mean gradient values compared to the other valve groups. PPM investigation revealed significant improvement in EF in the normal PPM group compared to the severe and moderate PPM groups, while insignificant decrease was observed in the severe PPM group. We believe that aortic root enlargement should be performed in patients in the severe PPM group if IEOA is < 0.65, despite appropriate valve selection. References 1. Barreto-Filho JA, Wang Y, Dodson JA, Desai MM, Sugeng L, Geirsson A, et al. Trends in aortic valve replacement for elderly patients in the United States, 1999–2011. J Am Med Assoc 2013; 310(19): 2078–2084. 2. De Sciscio P, Brubert J, De Sciscio M, Serrani M, Stasiak J, Moggridge GD. Quantifying the shift toward transcatheter aortic valve replacement in low-risk patients: a meta-analysis. Circ Cardiovasc Qual Outcomes 2017; 10(6). 3. Filip G, Litwinowicz R, Kapelak B, Sadowski J, Tobota Z, Maruszewski B, et al. 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