Assessment of clinical, paraclinical, and surgical characteristics of patients received aortic valve replacement at 108 military central hospital

Journal OF MILITARY PHARMACO - MEDICINE N⁰5 - 2021

ASSESSMENT OF CLINICAL, PARACLINICAL, AND SURGICAL

CHARACTERISTICS OF PATIENTS RECEIVED AORTIC VALVE

REPLACEMENT AT 108 MILITARY CENTRAL HOSPITAL

Ngo Tuan Anh ¹, Nguyen Truong Giang ²

SUMMARY

Objectives: To review some clinical, paraclinical, and surgical characteristics of patients

who received aortic mechanical valve replacement at 108 Military Central Hospital. Subjects

and methods: 69 patients with aortic valve stenosis (AS) received aortic mechanical valve

replacement. Clinical and paraclinical symptoms of AS based on the criteria of the Viet Nam

National Heart Association and ACC/AHA guidelines. Results: Anamnesis of rheumatic fever

was 61.0%, NYHA II and III were 100%. Sinus rhythm was 94,2% and Sokolow - Lyon > 35 mm

was 100%. Echocardiography: severe aortic valve took up 97.1%, mean pressure gradient > 40

mmHg accounted for 95.7%, left ventricular hypertrophied but left ventricular systolic function

still preserved. Valve size 21 and 23 were the most used with 81.2%. The mean aortic cross-

clamp time and operative time were 73.5 38 minutes and 113 94.9 minutes. Conclusion:

Patients presented with symptoms of aortic stenosis, severe aortic valve stenosis on ultrasound,

and left ventricular hypertrophy. In surgery, mechanical valves were the most common,

accounted for 73.9%, in which valve size 21 took up 58%.

*Keywords: Aortic valve replacement; Aortic valve stenosis (AS).

INTRODUCTION

Evaluation of the aortic valve has

always been considered the most difficult

of the heart valves, but thanks to the

advance in diagnostic tools and the aging

population, aortic stenosis has become

more common [7]. However, to date there

is no way to predict the rate of disease

progression in specific patients. Therefore,

it is necessary to periodically monitor and

carefully propagate the signs of disease

progression [1]. The disease usually

progresses silently, when symptoms appear,

the prognosis is severe, with a 2-year

mortality rate up to 50%. According to

Braunwald, the mean survival time of

patients with AS onset is < 5 years [6].

The normal aortic valve area is around

3 - 4 cm². Aortic stenosis is a progressive

disease that leads to a gradual reduction

in the orifice area, and it results in

increased left ventricular load while

simultaneously affecting systemic perfusion.

Historically, the majority of patients with

severe AS receiving aortic valve replacement

exhibited a high transvalvular gradient,

with variable left ventricular hypertrophy

and normal or reduced left ventricular

ejection fraction (LVEF) [6].

¹108 Central Military Hospital

²Vietnam Military Medical University

Corresponding author: Ngo Tuan Anh (tuananhterexa@gmail.com)

Date received: 20/4/2021

Date accepted: 9/5/2021

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Journal OF MILITARY PHARMACO - MEDICINE N⁰5 - 2021

This is further complicated by comorbidity

+ Surgery: Mechanical aortic valves,

the size of mechanical aortic valves,

the time of aortic cross - clamp and

cardiopulmonary bypass (CPB).

associated with progressive aging, in

particular coronary artery disease,

hypertension, diabetes and the progressive

decreases of the compliance of the

vascular bed. Aortic valve replacement

surgery is an effective treatment for a

patient with severe AS.

- Evaluation criteria based on the

standards of the Vietnam National Heart

Association and ACC/AHA guidelines

(USA) [2, 8].

Our hospital has performed many

heart surgeries, and this research aims:

To review some clinical, paraclinical and

surgical characteristics of patients with AS

who received aortic valve replacement at

108 Military Central Hospital.

3. Statistical analysis

Data were analyzed with SPSS

programe 20.0. Values are presented as

mean values, SD, percentage rate and

p values < 0.05 were considered as

significant.

SUBJECTS AND METHODS

1. Subjects

RESULTS

1. Clinical characteristics and medical

history

69 patients were diagnosed with AS

and received aortic valve replacement at

108 Military Central Hospital during the

period from May 2010 to May 2020.

Table 1: Some clinical and historical

characteristics (n = 69).

Clinical characteristics,

Rate (%)

medical history

2. Methods

* Research method: Prospective research,

Rheumatic heart disease

Degenerative aortic valve disease

Euro score ≥ 5%

61.0

29.0

17.3

34.8

14.5

42.0

58.0

5.8

descriptive cross-sectional study.

- Conduct research: Study about the

history of the disease, clinical and

paraclinical characteristics under a uniform

procedure definition:

Hypertension

+ History of the disease: Rheumatic

heart disease, congenital aortic valve disease

[2, 8].

Coronary Artery Disease

II

NYHA class

III

+ ECG: Pulse, Sokolow - Lyon [8].

+ Transthoracic echocardiographic

assessment includes measures of AS

severity, LV function and LV wall thickness,

and cavity dimensions and ejection

fraction should be based on existing

recommendations [8].

Arrhythmia

Rheumatic heart disease accounted for

high rates (61%), NYHA II and III for 100%,

arrhythmia for 5.8% and Euro score ≥ 5%

for 17.3%.

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2. Some paraclinical characteristics of aortic valve stenosis

Table 2: Some major paraclinical characteristics (n = 69).

Paraclinical features

Rate (%)

Sinus rhythm

Electrocardiogram

94.2

100.0

97.1

Sokolow - Lyon > 35 mm

Very severe and severe aortic stenosis

Echocardiography

Moderate aortic stenosis

2.9

Mean pressure gradient > 40 mmHg

95.7

ECG was mainly sinus rhythm and left ventricular hypertrophy. The results of

echocardiography showed that severe aortic valve stenosis took up 97.1%, mean pressure

gradient > 40 mmHg accounted for 95.7%.

Table 3: Left ventricular size and function (n = 69).

Echocardiogram results

Male (n = 48)

61.9 10.7

41 - 78

Female (n = 21)

58.7 15.7

30 - 87

General results

60.9 12.4

30 - 87

SD

EF (%)

Min - Max

SD

49.6 8.2

30 - 71

49.4 10.2

32 - 68

49.5 8.8

30 - 71

LVEDd (mm)

LVEDs (mm)

Min - Max

SD

33.4 7.3

20 - 51

32.9 8.2

19 - 49

33.3 7.6

19 - 51

Min - Max

Left ventricular hypertrophy with mean LVEDd and LVEDs are 49.5 8.8 mm and

33.3 7.6 mm, respectively. Left ventricular systolic function is preserved.

3. Some characteristics in the operation

Figure 1: The types of mechanical aortic valve used (n = 69).

The most commonly used mechanical aortic valve were St-JUDE and Sorin, the

proportions being 34.8% and 29%, respectively. In addition, some other types of biological

valve also widely used were Biocor valves with the rate of 11.6%.

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Ozaki

Figure 2: The size of aortic valve replacement (n = 69).

The most used valves were of sizes 21 and 23, accounting for 81.2%, of which

valve size 21 accounted for more than 50% of aortic valve replacement cases.

Table 4: Aortic cross-clamp and CPB (n = 69).

Time

Male (n = 48)

75.5 39.4

Female (n = 21)

68.6 34.7

General results

73.5 38.0

Aortic cross - clamp time (minutes)

CPB time (minutes)

107.8 78.8

124.8 124.8

113 94.9

The operative time was about 120 minutes. Mean aortic cross-clamp time was

73.5 38.0 minutes, and mean CPB time was 113 94.9 minutes.

DISCUSSION

'degenerative' mechanism because of the

increase in access to health care in

developed countries and the increasing

age of the population in the us and

europe. however, this result is different

from author Nguyen Hai Au [3] in a study

on 50 patients, the causes of severe

aortic stenosis include: 42% was the

degenerative valve, 29% was the rheumatic

heart, and 29% was congenital aortic

valve disease. this result is also different

from the epidemiological trend of as with

a high rate due to degenerative valve, this

may be due to different patient groups.

1. Clinical characteristics and medical

history

The data in table 1 shows that the

cause of stenosis is mainly due to

rheumatism with the rate of 61%,

degeneration with the rate of 29%, and

10% is due to congenital. this result is

consistent with

some studies

in

developing countries with high rates of

group a hemolytic streptococcus [2]. the

incidence of calcific aortic stenosis is

increasing as the general age of the

population increases. for many years,

rheumatic heart disease was the main

cause of aortic valve disease. over the

last half-century, however, there has been

a change from a rheumatic etiology to a

Some common chronic diseases were

also associated with AS, such as

hypertension (34.8%) and coronary artery

disease (14.5%). Several epidemiological

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studies have reported a strong association serious injury. According to medical

between hypertension and the occurrence

of degenerative AS [9]. Furthermore,

a history of common hypertension (30 - 80%)

is associated with exacerbation of

pathological problems in patients with

degenerative AS [3].

documents, when AS appears symptoms,

the mortality rate increases by 9.4%/year

[6].

These are important implications for

surgical indications for the purpose of

prolonging life and improving the patient's

quality of life [7]. The CPB time of our

study is similar to many other studies in

the country [4, 5].

Euro score scale ≥ 5% took up 17.3%

and ≤ 3% was the main one accounting

for 72.5%, showing the severe condition

of the study subject with the high rate of

early mortality post-surgery [7].

In addition to the surgical criterion of

aortic valve replacement surgery, the

degree of AS, mean difference in left

ventricular systolic function (EF), left end-

diastolic diameter (LVEDd), and left end-

systolic left ventricular diameter (LVEDs)

are also interested in research [7, 8].

The NYHA class II and III were 100%,

in which the NYHA III was mainly. This

result is similar to other studies on clinical

manifestations of heart failure but the rate

of severe heart failure is higher than that

of other domestic and foreign studies. For

example, Nguyen Hai Au’s study recorded

the number of 32% [3]. Without NYHA I,

IV in this study, NYHA I has no surgical

indication, and patients with NYHA IV

would be very difficult postoperative care

with many complications.

The EF%, LVEDd and LVEDs showed

left ventricular dilation but left ventricular

systolic function was preserved. This

result is equivalent to other domestic

studies such as Duong Duc Hung’s (64.5

13.3; 49.84 9.57 and 31.93 8.68),

Hachiro K. and et al’s (61.1 10.3; 49.3

2. Some paraclinical characteristics

of AS.

6.9 and 33.1

7.2) [5, 10]. There is a

study showing that severely reduced left

ventricular function is one of the factors

predicting the risk of death in patients with

aortic stenosis.

The rate of sinus rhythm before

surgery accounted for 94.2%. The picture

suggesting left ventricular (LV) thickening

and LV anemia with Sokolow - Lyon > 35

mm is 100%. Similar to the research of

Nguyen Hai Au, the rate of sinus rhythm

was 82.35% and the increased LV burden

was 91.04% [5].

3. Some characteristics in the surgery

The valve type and size of the artificial

aortic valve chosen to suit the patient are

very important to avoid prosthesis-patient

mismatch (PPM) and complications after

surgery. The term valve PPM describes a

state in which the effective orifice area

(EOA) of a normally functioning heart

The results of echocardiography are

mainly severe aortic valve stenosis

with the rate of 97.1%, mean gradient

> 40mmHg is 95.7%, this shows that

damage to the aortic valve system is

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CONCLUSION

valve prosthesis is too small in relation

to the patient's body size; this situation

results in high transvalvular pressure

gradients [8]. Mechanical valves used for

aortic valve replacement (AVR) continue

to be associated with bleeding risks

because of anticoagulation therapy, while

bioprosthetic valves are at risk of structural

valve deterioration requiring reoperation.

This risk/benefit ratio of mechanical and

bioprosthetic valves has led American

and European guidelines on valvular heart

disease to be consistent in recommending

the use of mechanical prostheses in patients

younger than 60 years of age [7, 8].

Symptoms of aortic stenosis were

evident with moderate and severe heart

failure in 100% of cases, severe aortic

stenosis accounted for 97.1%, and

mean PG (> 40 mmHg) was 95.7%. Left

ventricular hypertrophy with an increase

of LVEDd, LVEDs and Sokolow - Lyon

> 35 mm was 100%. The mechanical

aortic valve used in surgery was mainly

the valve size 21, in which St.Jude and

Sorin valves were 63.8%, CPB time was

113 94.9 minutes.

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