Abstract
ObjectiveTo investigate the periprocedural inflammatory response in patients with isolated aortic valve stenosis undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) with different technical approaches.Material and MethodsPatients were prospectively allocated to one of the following treatments: SAVR using conventional extracorporeal circulation (CECC, n = 47) or minimized extracorporeal circulation (MECC, n = 15), or TAVI using either transapical (TA, n = 15) or transfemoral (TF, n = 24) access. Exclusion criteria included infection, pre-procedural immunosuppressive or antibiotic drug therapy and emergency indications. We investigated interleukin (IL)-6, IL-8, IL-10, human leukocyte antigen (HLA-DR), white blood cell count, high-sensitivity C-reactive protein (hs-CRP) and soluble L-selectin (sCD62L) levels before the procedure and at 4, 24, and 48 h after aortic valve replacement. Data are presented for group interaction (p-values for inter-group comparison) as determined by the Greenhouse-Geisser correction.ResultsSAVR on CECC was associated with the highest levels of IL-8 and hs-CRP (p<0.017, and 0.007, respectively). SAVR on MECC showed the highest descent in levels of HLA-DR and sCD62L (both p<0.001) in the perioperative period. TA-TAVI showed increased intraprocedural concentration and the highest peak of IL-6 (p = 0.017). Significantly smaller changes in the inflammatory markers were observed in TF-TAVI.ConclusionSurgical and interventional approaches to aortic valve replacement result in inflammatory modulation which differs according to the invasiveness of the procedure. As expected, extracorporeal circulation is associated with the most marked pro-inflammatory activation, whereas TF-TAVI emerges as the approach with the most attenuated inflammatory response. Factors such as the pre-treatment patient condition and the extent of myocardial injury also significantly affect inflammatory biomarker patterns. Accordingly, TA-TAVI is to be classified not as an interventional but a true surgical procedure, with inflammatory biomarker profiles comparable to those found after SAVR. Our study could not establish an obvious link between the extent of the periprocedural inflammatory response and clinical outcome parameters.
Highlights
surgical aortic valve replacement (SAVR) on CECC was associated with the highest levels of IL-8 and high-sensitivity C-reactive protein (hs-CRP) (p
SAVR on MECC showed the highest descent in levels of human leukocyte antigen (HLA)-DR and Soluble CD62L (sCD62L) in the perioperative period
Extracorporeal circulation is associated with the most marked pro-inflammatory activation, whereas TF-transcatheter aortic valve implantation (TAVI) emerges as the approach with the most attenuated inflammatory response
Summary
The best valve replacement technique for patients with symptomatic severe aortic stenosis (AS) is currently under discussion, as robust evidence suggests that surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI) show comparable clinical outcomes in patients at high surgical risk due to severe co-morbidities [1,2]. The release and time course of the cytokine-mediated inflammatory response have been investigated in patients with coronary artery disease (CAD) undergoing coronary artery bypass grafting with and without the use of extracorporeal circulation (ECC) [9]. These results cannot be translated to patients treated for AS because of the different pathogenesis and molecular mechanisms involved in coronary versus valvular degenerative disease. Due to further disparities with regard to the clinical and treatment characteristics involved in the release of cytokines (e.g., increased left ventricular myocardial mass in patients with AS,[13] the placement of aortic prosthesis as a foreign material), the inflammatory response is only partially comparable and may not lead to the same conclusions in CAD and AS treatment strategies
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