Aortic valve reconstruction in nonelderly adults: a systematic review, meta-analysis and microsimulation study

Abstract

Abstract Background Aortic valve disease (AVD) calls for careful planning of treatment strategies that adheres to a patient-tailored lifetime perspective, especially in younger patients. Aortic valve reconstruction (AVr) provides an attractive option in patients with aortic valve regurgitation (AR). Purpose This study aims to provide a comprehensive overview of published outcome after AVr in nonelderly adults and to use microsimulation to obtain age-specific estimates of outcomes. Methods A systematic review of published literature reporting clinical outcome after AVr in nonelderly adults (mean age ≥18y and ≤55y) published between 1/1/1990 and 17/10/2022 was conducted. Publications reporting outcome after AVr were considered for inclusion, including publications on valve-sparing root surgery. Studies that included patients without AVD as the primary indication for AVr were excluded. Early risks (<30d), late event rates (>30d) and time-to-event data were pooled and entered into a microsimulation model. Subgroup analyses were performed for AVr for isolated AR and AVr for bicuspid aortic valves (BAV). Results Thirty-seven studies, all retrospective cohort studies, were included, yielding a total of 4,573 patients with 16,524 patient-years of follow-up (median follow-up: 4.0y; range 0.6-10.5y). Pooled mean age for all repairs, AVr for AR and AVr for BAV was 48.1±13.8, 48.3±13.8, and 42.4±12.5 years, respectively. Pooled early mortality for all repairs, AVr for AR and AVr for BAV, respectively, was 1.7% (95%CI: 1.2-2.3%), 1.5% (1.0-2.1%), and 1.0% (0.6-1.9%), and late pooled mortality rate was 1.0%/y (0.7-1.5%/y), 1.3%/y (0.8-2.1%/y), and 0.8%/y (0.5-1.4%/y), respectively. Microsimulation-based life-expectancy relative to the general population 20 years postoperatively was 92.6% (95% Credible Interval: 90.1-95.3%) after all repairs, 89.0% (85.0-93.0%) after AVr for isolated AR and 94.9% (92.0-97.4%) after AVr for BAV. Microsimulation-based 20-year risk of aortic valve reintervention for all repairs, isolated AR and BAV, respectively, was 25.0%(23.8-26.2%), 25.1%(23.5-26.9%) and 49.9%(48.2-52.0%). The main cause for reintervention was repaired valve dysfunction for all three groups, followed by endocarditis. Estimates of other late complications are shown in Figure 2. Conclusions Aortic valve reconstruction for aortic valve regurgitation effectively postpones valve replacement in nonelderly with satisfactory long-term outcomes but reintervention risks are still considerable, especially in BAV patients. Reconstructive valve surgery is associated with low risks of bleeding and thrombo-embolic events and should be considered in nonelderly adults with aortic regurgitation and carefully weighed against hazards of primary aortic valve replacement.Pooled Kaplan-Meier curves for mortalityMicrosimulation-based event risks (20y)