Stentless or stented aortic valve implants in elderly patients?

Objective: To assess differences in indication and mid-term results between stentless and stented procedures in elderly patients, we followed aortic v alve patients over a period of 5 years. Methods: In a consecutive series of 154 elderly aortic patients in regular sinus rhythm from 1992 to 1997, we inserted 103 stentless (Toronto SPVTM, St Jude Medical Inc., St Paul, Minne apolis, MN) and 51 stented (Carpentier-Edwards supra annular porcine, Baxte r Inc., Irvine, CA) bioprostheses in the aortic position. Results: All 154 patients seemed preoperatively eligible for a stentless procedure. Mean age was 74.8 years (range 67-86 years) with a majority of female patients. The surgeon's (in)experience, major dilatation or calcifications of the ascend ing aorta and aberrant coronary anatomy were the most common reasons for dr awback from the stentless procedure (51/154 patients). Aortic clamp time wa s significantly higher in the stentless vs. stented group (70 vs. 57 min, P < 0.0001). The large average 25.3 mm size of the stentless prostheses (vs. 23.7 mm stented) stands in full contrast with the low mean body surface ar ea of 1.68 m2 (vs. 1.70 m2) of the patients. We encountered. respectively. 5 and 2 hospital-deaths (P = n.s.). The follow-up period ranged from 6 to 6 6 months and was 97% complete, yielding, respectively, 302 and 139 patient- years. Survival (Kaplan-Meier method) was statistically higher in favor of the stentless procedures (log rank: P = 0.03). All survivors progressed mar kedly to a mean postoperative NYHA class 1.3 respectively, 1.4 (vs. preop. 3.3 and 3.2). Echocardiographic transvalvular gradients compared favorable for the stentless group in the small under 25 mm valves (P = 0.02 for 23 mm sized valves between groups) with improved left ventricular function and a significant decrease of left ventricular end diastolic diameter (LVEDD 48. 0 vs. 56.5 mm) at 1 year follow-up. Cusp calcifications on control echocard iography were detected earlier (beyond 3 years) in the stented group, witho ut signs of early significant regurgitation or dysfunction in both groups, except for one patient necessitating re-operation. Conclusion: Although the implantation technique is much more demanding for stentless procedures, re flected by a longer aortic clamp-time, and remains impossible in some cases , elderly, small sized patients take full benefit of their large, nan-obstr uctive prostheses. (C) 1999 Elsevier Science B.V. All rights reserved.