Aortic Valve Replacement Group Research Articles

Silent Brain Infarcts Following Cardiac Procedures: A Systematic Review and Meta-Analysis.

BackgroundSilent brain infarcts (SBI) are increasingly being recognized as an important complication of cardiac procedures as well as a potential surrogate marker for studies on brain injury. The extent of subclinical brain injury is poorly defined.Methods and ResultsWe conducted a systematic review and meta‐analysis utilizing studies of SBIs and focal neurologic deficits following cardiac procedures. Our final analysis included 42 studies with 49 separate intervention groups for a total of 2632 patients. The prevalence of SBIs following transcatheter aortic valve implantation was 0.71 (95% CI 0.64‐0.77); following aortic valve replacement 0.44 (95% CI 0.31‐0.57); in a mixed cardiothoracic surgery group 0.39 (95% CI 0.28‐0.49); coronary artery bypass graft 0.25 (95% CI 0.15‐0.35); percutaneous coronary intervention 0.14 (95% CI 0.10‐0.19); and off‐pump coronary artery bypass 0.14 (0.00‐0.58). The risk ratio of focal neurologic deficits to SBI in aortic valve replacement was 0.22 (95% CI 0.15‐0.32); in off‐pump coronary artery bypass 0.21 (95% CI 0.02‐2.04); with mixed cardiothoracic surgery 0.15 (95% CI 0.07‐0.33); coronary artery bypass graft 0.10 (95% CI 0.05‐0.18); transcatheter aortic valve implantation 0.10 (95% CI 0.07‐0.14); and percutaneous coronary intervention 0.06 (95% CI 0.03‐0.14). The mean number of SBIs per patient was significantly higher in the transcatheter aortic valve implantation group (4.58 ± 2.09) compared with both the aortic valve replacement group (2.16 ± 1.62, P=0.03) and the percutaneous coronary intervention group (1.88 ± 1.02, P=0.03).Conclusions SBIs are a very common complication following cardiac procedures, particularly those involving the aortic valve. The high frequency of SBIs compared with strokes highlights the importance of recording this surrogate measure in cardiac interventional studies. We suggest that further work is required to standardize reporting in order to facilitate the use of SBIs as a routine outcome measure.

Prognosis of Severe Asymptomatic Aortic Stenosis With and Without Surgery

This study sought to determine outcomes in patients with severe, asymptomatic aortic stenosis (AS), stratified by treatment recommendation. Between January 2005 and December 2013, 4,998 patients had severe AS by echocardiography, of whom 308 were identified as asymptomatic by medical record review. Five patients were deemed inoperable, and 38 were lost to follow-up. Of the remaining 265 patients, aortic valve replacement (AVR) was recommended in 104, and watchful waiting (WW) was recommended in 161. Probabilities of undergoing surgery and of death from recommendation date were estimated using a multistate model. Cox regression analysis was used to determine independent risk factors for death. Probability of death at 1 year after recommendation was 5.2% in the WW group and 4.7% in the AVR group. At 2 years after recommendation, survival in the AVR-recommended group was 92.5% versus 83.9% in the WW group (p= 0.044). In the WW group, the probability of dying or undergoing surgery was 43.9% by 2 years. Undergoing surgery was independently associated with higher survival in the AVR-recommended group (hazard ratio [HR], 0.17; p= 0.038) and in the WW group (HR, 0.39; p= 0.044). A higher ejection fraction (HR, 0.58; p<0.001) was associated with better survival, whereas renal failure (HR, 2.81; p= 0.009) was associated with worse survival. The strategy of early AVR is associated with improved survival in asymptomatic patients.

Outcome for surgical treatment of infective endocarditis with periannular abscess

Surgical treatment of infective endocarditis (IE) with aortic periannular abscess (PA) is a challenging issue with high mortality and morbidity rate in the current era. The present study is to review the results of surgical treatment for IE-PA based on an anatomy-guided surgical procedure selection for either aortic valve replacement (AVR) or aortic root reconstruction (ARR). Patients with IE-PA received surgical treatment in National Taiwan University Hospital during the years 2001-2017 were retrospectively reviewed. The selection of surgical procedure was based on the intraoperative anatomical finding. The AVR group consisted of isolated AVR or AVR with patch repair if PA involved less than one cusp of the annulus. The ARR group included aortic root replacement if PA involved more than one cusp, causing commissural/sub-commissural destruction. In-hospital mortality and mid-term outcome and the risk factors were examined. In-hospital mortality was 13% in the AVR group (24 patients) and 25% in the ARR group (8 patients) (p=0.578). The composite adverse events (cardiac death, valve reoperation, or paravalvular leak) rate was 31% in the AVR group and 40% in the ARR group at one year; 48% in the AVR group and 40% in the ARR group at five years; 55% in the AVR group and 40% in the ARR group at ten years. Anatomy-guided surgical procedure selection for IE-PA is feasible. With the appropriate selection, ARR may be associated with fewer adverse events in mid-term follow-up. Careful intraoperative judgment and management and long-term follow-up are warranted for these patients.

Evolution of chronic kidney disease after surgical aortic valve replacement or transcatheter aortic valve implantation

Immediate improvement in kidney function has been reported after surgical aortic valve replacement or transcatheter aortic valve implantation. Long-term data, however, are not available. To assess the evolution of kidney function in chronic kidney disease stage 3b-5, 1 year after surgical aortic valve replacement or transcatheter aortic valve implantation. All patients with chronic kidney disease stage 3b-5 undergoing surgical aortic valve replacement or transcatheter aortic valve implantation for aortic stenosis in a single centre were included. Kidney function was assessed 1 year postprocedure. Improvement or deterioration in estimated glomerular filtration rate was defined by an increase or decrease of 5mL/min/1.73 m2, respectively. Overall, 127 procedures were analysed (54 surgical aortic valve replacements and 73 transcatheter aortic valve implantations). Kidney function improved in 51% of patients at 1 year (45% of the surgical aortic valve replacement group versus 57% of the transcatheter aortic valve implantation group; P=0.21), and deteriorated in only 14% of patients at 1 year (18% of the surgical aortic valve replacement group versus 10% of the transcatheter aortic valve implantation group; P=0.22). Almost a quarter of patients (23%) had an improvement in estimated glomerular filtration rate of>15mL/min/1.73 m2, and this was consistent at later follow-up. Few patients went onto chronic dialysis at 1 year (three after surgical aortic valve replacement and one after transcatheter aortic valve implantation). Acute kidney injury was an independent prognostic factor for long-term deterioration in kidney function (odds ratio 2.1, 95% confidence interval 1.4-3.6; P=0.006). Aortic valve replacement, whether by surgical aortic valve replacement or transcatheter aortic valve implantation, improved estimated glomerular filtration rate at 1 year in more than half of patients with chronic kidney disease stage 3b-5.

Transcatheter aortic valve implantation versus surgical replacement in high-risk patients with aortic stenosis

Objectives The aim of this study was to demonstrate whether transcatheter aortic valve implantation (TAVI) improves mortality and morbidity compared with surgical aortic valve replacement in high-risk patients who require intervention for aortic valve stenosis (AS). Many patients with severe AS and coexisting conditions are not candidates for surgical replacement of the aortic valve. Recently, TAVI has been suggested as a less invasive treatment for high-risk patients with AS. Patients and methods Fifty patients with severe AS for aortic valve intervention were classified as follows: group A, as TAVI group, included 25 patients who underwent aortic valve replacement by transcatheter femoral approach, and group B, as surgical aortic valve replacement group, included 25 patients who underwent aortic valve replacement by median sternotomy. Results Intraoperatively, procedure duration was 101.8 ± 10.6 and 191.2 ± 7.5 min in group A and B, respectively (P Conclusion In high-risk patients with severe AS, transcatheter and surgical procedures for aortic valve replacement were comparable for survival at 3 months, although there were important differences in periprocedural outcomes.

Repeat aortic valve replacement for failing aortic root homograft

ObjectivePublished data are limited in comparison of transcatheter aortic valve replacement with surgical aortic valve replacement for the failing aortic root homograft. We reviewed our experience with repeat aortic valve replacement in failing aortic root homografts to compare outcomes of transcatheter aortic valve replacement and surgical aortic valve replacement. MethodsWe retrospectively reviewed the records of 51 patients with failing aortic root homografts who received repeat aortic valve replacement between October 2000 and May 2018. Operation included transcatheter aortic valve replacement in 11 patients between June 2014 and May 2018. Surgical aortic valve replacement was performed in 40 patients between October 2000 and January 2018, and operation included repeat composite aortic valve/root replacement in 30 patients (75%). ResultsPatient age was 59 years (interquartile range, 50-72 years), sex was female in 9 patients (18%), and time to repeat aortic valve replacement was 12 years (interquartile range, 8-13). Procedure-related complications occurred in 37 patients (73%): vascular injury (any) more commonly in the transcatheter aortic valve replacement group (36% vs 5%; P = .015), bleeding (major or life-threatening) more commonly in the surgical aortic valve replacement group (58% vs 0%; P < .001), and sternal reentry injury only in the surgical aortic valve replacement group (n = 6, 15%). There were 3 procedure-related deaths in the surgical aortic valve replacement group (8%) and 1 (9%) in the transcatheter aortic valve replacement group (P = 1.000). Subsequent cardiac operation occurred in no patients in the transcatheter aortic valve replacement group and in 5 patients in the surgical aortic valve replacement group. ConclusionsRepeat aortic valve replacement for failing aortic root homograft is associated with notable risk of morbidity and mortality regardless of replacement technique. Avoidance of vascular injury could lead to improved outcomes in the transcatheter aortic valve replacement group.

Malnutrition and Mortality in Frail and Non-Frail Older Adults Undergoing Aortic Valve Replacement.

Older adults undergoing aortic valve replacement (AVR) are at risk for malnutrition. The association between preprocedural nutritional status and midterm mortality has yet to be determined. The FRAILTY-AVR (Frailty in Aortic Valve Replacement) prospective multicenter cohort study was conducted between 2012 and 2017 in 14 centers in 3 countries. Patients ≥70 years of age who underwent transcatheter or surgical AVR were eligible. The Mini Nutritional Assessment-Short Form was assessed by trained observers preprocedure, with scores ≤7 of 14 considered malnourished and 8 to 11 of 14 considered at risk for malnutrition. The Short Performance Physical Battery was simultaneously assessed to measure physical frailty, with scores ≤5 of 12 considered severely frail and 6 to 8 of 12 considered mildly frail. The primary outcome was 1-year all-cause mortality, and the secondary outcome was 30-day composite mortality or major morbidity. Multivariable regression models were used to adjust for potential confounders. There were 1158 patients (727 transcatheter AVR and 431 surgical AVR), with 41.5% females, a mean age of 81.3 years, a mean body mass index of 27.5 kg/m2, and a mean Society of Thoracic Surgeons-Predicted Risk of Mortality of 5.1%. Overall, 8.7% of patients were classified as malnourished and 32.8% were at risk for malnutrition. Mini Nutritional Assessment-Short Form scores were modestly correlated with Short Performance Physical Battery scores (Spearman R=0.31, P<0.001). There were 126 deaths in the transcatheter AVR group (19.1 per 100 patient-years) and 30 deaths in the surgical AVR group (7.5 per 100 patient-years). Malnourished patients had a nearly 3-fold higher crude risk of 1-year mortality compared with those with normal nutritional status (28% versus 10%, P<0.001). After adjustment for frailty, Society of Thoracic Surgeons-Predicted Risk of Mortality, and procedure type, preprocedural nutritional status was a significant predictor of 1-year mortality (odds ratio, 1.08 per Mini Nutritional Assessment-Short Form point; 95% CI, 1.01-1.16) and of the 30-day composite safety end point (odds ratio, 1.06 per Mini Nutritional Assessment-Short Form point; 95% CI, 1.001-1.12). Preprocedural nutritional status is associated with mortality in older adults undergoing AVR. Clinical trials are needed to determine whether pre- and postprocedural nutritional interventions can improve clinical outcomes in these vulnerable patients.

EP22 MINIMALLY INVASIVE AORTIC VALVE SURGERY: SINGLE CENTRE EVOLUTION OF TECHNIQUES

Backgrounds: Ministernotomy represents the standard approach to isolated aortic valve replacement (AVR) in our Centre. Sutureless Minithoracotomy AVR has been introduced from 2014. We aim to analize the evolution of techniques in minimally invasive (MI)-AVR. Methods: From November 2014 to January 2018, 216 patients underwent MI-AVR at our Institution: 180 ministernotomy AVR and 36 minithoracotomy Sutureless AVR. Preoperative characteristics showed a higher risk profile in the minithoracotomy group regarding age, hypertension and EUROscore (Table 1). Results: Results are summarized in Table 1. We recorded no mortality in the minithoracotomy, 2/180 (1.1%) in ministernotomy group; two (1.1%) postoperative neurological events in ministernotomy and one (2.8%) in minithoracotomy group (p = 0.67); no paravalvular leak that required redo surgery in both groups. A PM implant was necessary in 8 patients, 4 in ministernotomy (2.2%) and 4 (11.1%) in minithoracotomy group (p = 0.04). Clamping time (CT) and Cardiopulmunary By Pass time (CPB) were lower in minithoracotomy Sutureless AVR group (p CT = 0.01, p CBP = 0.03). Conclusions: MI-AVR can be performed safely, with low postoperative morbidity; sutureless Minithoracotomy AVR widens the minimally invasive portfolio especially in higher risk patients, it is associated with shorter CT and CPB times however it carries a higher risk of PM implant.

Comparison between Upper Mini Sternotomy and Full Sternotomy in Aortic Valve Replacement

Background: aortic valve disease is common and its prevalence increases with age. For people over the age of 75 years, the prevalence of aortic stenosis (AS) is 5%. More than one in eight people over the age of 75 have moderate or severe valve disease. Aim of the Work: the aim of this study was to compare the short term results of aortic valve replacement through upper mini sternotomy and full sternotomy. Patients and Methods: This study was a prospective randomized controlled clinical trial. The study was conducted at Suez Canal University Hospital in the cardiothoracic operating rooms and inward after approval of Research and Ethics Committees. The study included 50 patients having aortic valve disease presented to Suez Canal University Hospital, cardiothoracic outpatient clinic for isolated aortic valve replacement. Results: The mean age of patients in Full Sternotomy in Aortic Valve Replacement (FSAVR) group was 33.48 ± 17.74 while it was 32.03 ± 15.29 in Mini Sternotomy in Aortic Valve Replacement (MSAVR) group which showed insignificance difference (p > 0.05). (20- 29y) was the most frequent age group in both study groups (28% in FSAVR group and 32% in MSAVR group). No significance different found (p > 0.05) according to gender in both group. Male gender was the most frequent in both group (56% in FSAVR group and 64% in MSAVR group). Conclusion: Mini Sternotomy (MS) can be considered as excellent option with favorable outcomes that should be considered part of the routine practice of cardiac surgeons in the modern era

Comparison between Upper Mini Sternotomy and Full Sternotomy in Aortic Valve Replacement

Background: aortic valve disease is common and its prevalence increases with age. For people over the age of 75 years, the prevalence of aortic stenosis (AS) is 5%. More than one in eight people over the age of 75 have moderate or severe valve disease. Aim of the Work: the aim of this study was to compare the short term results of aortic valve replacement through upper mini sternotomy and full sternotomy. Patients and Methods: This study was a prospective randomized controlled clinical trial. The study was conducted at Suez Canal University Hospital in the cardiothoracic operating rooms and inward after approval of Research and Ethics Committees. The study included 50 patients having aortic valve disease presented to Suez Canal University Hospital, cardiothoracic outpatient clinic for isolated aortic valve replacement. Results: The mean age of patients in Full Sternotomy in Aortic Valve Replacement (FSAVR) group was 33.48 ± 17.74 while it was 32.03 ± 15.29 in Mini Sternotomy in Aortic Valve Replacement (MSAVR) group which showed insignificance difference (p > 0.05). (20- 29y) was the most frequent age group in both study groups (28% in FSAVR group and 32% in MSAVR group). No significance different found (p > 0.05) according to gender in both group. Male gender was the most frequent in both group (56% in FSAVR group and 64% in MSAVR group). Conclusion: Mini Sternotomy (MS) can be considered as excellent option with favorable outcomes that should be considered part of the routine practice of cardiac surgeons in the modern era

Thrombocytopenia in Moderate- to High-Risk Sutureless Aortic Valve Replacement.

BackgroundThis study aimed to compare preliminary data on the outcomes of sutureless aortic valve replacement (SU-AVR) with those of aortic valve replacement (AVR).MethodsWe conducted a retrospective study of SU-AVR in moderate- to high-risk patients from 2013 to 2016. Matching was performed at a 1:1 ratio using the Society of Thoracic Surgeons predicted risk of mortality score with sex and age. The primary outcome was 30-day mortality. The secondary outcomes were operative outcomes and complications.ResultsA total of 277 patients were studied. Ten patients (50% males; median age, 81.5 years) underwent SU-AVR. Postoperative echocardiography showed impressive outcomes in the SU-AVR group. The 30-day mortality was 10% in both groups. In our study, the patients in the SU-AVR group developed postoperative thrombocytopenia. Platelet counts decreased from 225×103/μL preoperatively to 94.5, 54.5, and 50.1×103/μL on postoperative days 1, 2, and 3, respectively, showing significant differences compared with the AVR group (p=0.04, p=0.16, and p=0.20, respectively). The median amount of platelet transfusion was higher in the AVR group (12.5 vs. 0 units, p=0.052).ConclusionThere was no difference in the 30-day mortality of moderate- to high-risk patients depending on whether they underwent SU-AVR or AVR. Although SU-AVR is associated with favorable cardiopulmonary bypass and cross-clamp times, it may be associated with postoperative thrombocytopenia.

Outcomes of a Rapid Deployment Aortic Valve Versus Its Conventional Counterpart: A Propensity-Matched Analysis.

The aim of this study was to compare outcomes after rapid-deployment aortic valve replacement (RDAVR) and conventional aortic valve replacement (AVR) from two studies. Patients who underwent RDAVR (INTUITY valve) in the prospective, 5-year, single-arm multicenter TRITON study, or conventional AVR (Perimount Magna Ease valve) in the prospective Perimount Magna Ease postmarket study, were propensity score matched and compared for procedural, hemodynamic, safety, and clinical outcomes. Matched RDAVR (n = 106) and conventional AVR (n = 106) patients had similar baseline characteristics (mean ± SD age, 72.8 ± 7.6 vs 72.5 ± 7.4 years; male 59.4% vs 61.3%) and procedures (concomitant procedures: 41.5% vs 50.9%). Mean ± SD aortic cross-clamp time was significantly shorter in RDAVR than AVR patients (51.8 ± 20.9 vs 73.9 ± 33.2 minutes; P < 0.001), as was mean cardiopulmonary bypass time (82.8 ± 34.2 vs 102.4 ± 41.7 minutes; P < 0.001). At 1 year, RDAVR patients showed significantly lower mean ± SD and peak aortic valve gradients (9.0 ± 3.4 and 17.0 ± 6.2 mm Hg, respectively) than conventional AVR patients (13.4 ± 5.5 and 24.2 ± 10.8 mm Hg, respectively; all P < 0.001). Patient-prosthesis mismatch was significantly less common with RDAVR than with AVR [overall: 16/66 (24.2%) vs 46/76 (60.5%); P = 0.007; severe: 2/66 (3.0%) vs 13/76 (17.1%)]. There were no significant differences between the RDAVR and AVR groups regarding 30-day safety endpoints. Survival rates in the RDAVR and conventional AVR groups were, respectively, 99.1% and 100.0% at 30 days, 97.1% and 95.1% at 1 year, and 93.3% and 94.1% at 3 years (P = nonsignificant). In this retrospective study with matched populations, the RDAVR with the INTUITY valve system provided superior procedural and hemodynamic outcomes than a standard bioprosthesis without compromising safety.

Outcomes of Solo Smart valve in a single-center experience of 270 patients.

The Solo Smart pericardial aortic valve has been widely used in Europe as an option for aortic valve replacement (AVR). We are reporting early and midterm clinical outcomes of AVR with the Solo Smart valve in a single North America center. This is a retrospective study of 270 consecutive patients who had AVR at Mazankowski Alberta Heart Institute from February 2011 to March 2015. Follow-up and echocardiographic data were collected retrospectively from electronic and paper charts. Univariate and multivariate analysis were performed to evaluate the results. The mean age was 71.2±10.0 years, 67.4% were male, and 79.3% had combined procedures. Mean STS Score was 4.18±3.91. Early mortality was 3.7% for the entire group and 0% for isolated AVR group. Mean cross-clamp time for isolated AVR and AVR with concomitant procedure was 70.8±12.7 min and 117.0±45.0 min, respectively. Permanent pacemaker implantation was necessary in 2.2% of patients. Echocardiography demonstrated a reduction in mean gradients from 40.8±17.4 mmHg to 7.6±3.7 mmHg and peak gradient from 72.5±48.8 mmHg to 15.5±7.5 mmHg. The 1-, 3-, and 5-year overall survival was 93.0%, 86.5% and 75.9%, respectively. At 5 years, freedom from valve-related death was 92.4%, freedom from structural valve deterioration and freedom from aortic valve reoperation were 96.4% and 98%, respectively. The Solo Smart valve is safe and has excellent hemodynamic performance. Aortic valve reoperation and rates of valve-related adverse events during midterm follow-up were low.

Trends in Aortic Valve Replacement Procedures Between 2009 and 2015: Has Transcatheter Aortic Valve Replacement Made a Difference?

This study reports trends in volume and adverse events associated with isolated aortic valve procedures performed in Medicare beneficiaries between 2009 and2015. This retrospective study used the annual fiscal year Medicare Provider Analysis and Review file to identify all Medicare beneficiaries undergoing an isolated aortic valve procedure. Outcome measures included three mortality rates and nine in-hospital adverse events. The final study population consisted of 233,660 hospitalizations. During the study period, Medicare beneficiaries undergoing an aortic valve procedure increased from 22,076 to 49,362, for an average annual growth rate of 14.45%. Transcatheter aortic valve replacement (TAVR) procedures per 100,000 Medicare beneficiaries grew from 10.7 in 2012 to 41.1 in 2015. Overall, in-hospital mortality rates, cumulative 30-day mortality rates, and 90-day postdischarge mortality rates declined annually during the study period. However, the 90-day mortality rate for TAVR was nearly double the rate for the tissue surgical aortic valve replacement group. Nearly 68% of Medicare beneficiaries experienced at least one in-hospital adverse event during their index hospitalization. Medicare beneficiaries undergoing TAVR had the lowest observed adverse events rates among the aortic valve procedures in2015. The total number of Medicare beneficiaries undergoing isolated aortic valve procedures increased from 47.5 to 88.9 per 100,000 Medicare beneficiaries during the study period. Aortic valve procedures increased significantly during this study period primarily due to the increase in TAVR, with clinical outcomes improving as well. Although long-term outcomes of TAVR are still under investigation, these results are promising.

Early Clinical Results of Perceval Sutureless Aortic Valve in 139 Patients: Freeman Experience.

ObjectiveThe aim of this retrospective study is to evaluate the safety and performance of the Perceval sutureless valve in patients undergoing aortic valve replacement. We report the 30-day clinical outcomes of 139 patients.MethodsFrom January 2014 to December 2016, 139 patients underwent sutureless aortic valve replacement. Their operation notes, National Adult Cardiac Surgery Database and perioperative transoesophageal echocardiography findings were studied retrospectively.ResultsNinety-two patients underwent isolated aortic valve replacement (group A) with Perceval valve and 47 patients had combined procedures of aortic valve replacement and coronary artery bypass grafting (group B). The patients received a size S (n=23), M (n=39), L (n=42) or XL (n=35) prosthesis. Perceval valve was successfully implanted in 135 (97.1%) patients. Mean cross-clamping time and bypass time were 40 and 63 minutes for isolated cases, while 68 and 107 minutes for combined cases. Three (2.1%) patients died within 30 days. Four patients suffered stroke and 5 patients went into acute renal failure. Median intensive care unit and hospital stay was 2 and 8.5, respectively. Four valves were explanted due to significant paravalvular leak after surgery. Five patients had permanent pacemaker as a result of complete heart block and mean postoperative drainage was 295 mL for isolated case and 457 mL for combined cases. The mean gradient across Perceval valve was 12.5 mmHg while its effective orifice area was 1.5 cm2.ConclusionEarly postoperative results showed that Perceval valve is safe. Further follow up is needed to evaluate the long-term outcome with this bioprosthesis.

Prognostic Impact of Left Ventricular Ejection Fraction in Patients With Severe Aortic Stenosis

ObjectivesThe aim of this study was to evaluate the prognostic impact of left ventricular ejection fraction (LVEF) in patients with severe aortic stenosis (AS). BackgroundThe prognostic impact of LVEF in severe AS remains controversial. MethodsAmong 3,815 consecutive patients with severe AS enrolled in the CURRENT AS (Contemporary Outcomes After Surgery and Medical Treatment in Patients With Severe Aortic Stenosis) registry, the present study population consisted of 3,794 patients after excluding 21 patients without LVEF data. Patients were divided into 4 groups according to LVEF at index echocardiography (<50%, 50% to 59%, 60% to 69%, and ≥70%; conservative strategy: n = 388, n = 390, n = 1,025, and n = 800; initial aortic valve replacement strategy: n = 206, n = 170, n = 375, and n = 440). Echocardiographic data were site reported, and there was no echocardiography core laboratory. ResultsIn the conservative group, the cumulative 5-year incidence of the primary outcome measure (a composite of aortic valve–related death or heart failure hospitalization) was significantly higher in patients with LVEFs <50% and 50% to 59% than in those with LVEFs 60% to 69% and ≥70% (72.3%, 58.4%, 38.7%, and 35.0%, respectively, p < 0.001), whereas in the initial aortic valve replacement group, the negative effect of low LVEF was markedly attenuated (20.2%, 20.3%, 17.7%, and 12.4%, respectively, p = 0.03). After adjusting for confounders, LVEF <50% (hazard ratio: 1.82; 95% confidence interval: 1.44 to 2.28; p < 0.001) and 50% to 59% (hazard ratio: 1.77; 95% confidence interval: 1.42 to 2.20; p < 0.001) but not 60% to 69% (hazard ratio: 1.14; 95% confidence interval: 0.94 to 1.39; p = 0.17) were independently associated with poorer outcomes compared with LVEF ≥70% (reference) in the conservative group. In the initial aortic valve replacement group, the adjusted risk for the primary outcome measure was not significantly different across the 4 LVEF groups. ConclusionsThis study demonstrates that survival in patients with severe AS is impaired when LVEF is <60%, and these findings have implications for decision making with regard to the timing of surgical intervention.

Replacement of calcified ascending aorta in patients undergoing aortic valve replacement.

Aortic stenosis (AS) with an extensively calcified ascending aorta is a growing indication for transcatheter aortic valve implantation (TAVI) because aortic manipulation during surgical aortic valve replacement (AVR) is unsafe in these patients. The aim of this study was to evaluate the outcomes of AVR plus ascending aorta replacement (AAR) in patients with severe AS and a heavily calcified ascending aorta. From 2004 to 2014, a total of 32 patients with severe AS and extensive aortic calcification underwent concomitant first-time AVR and AAR (AVR + AAR). The mean patient age was 74±7 (range, 59-87) years, and 7 (22%) patients were octogenarians. The mean logistic EuroSCORE was 21.4%±19.0% (range, 3.3-68.2%). Arterial cannulae were placed at the ascending aorta (n=26, 81%), aortic arch (n=5, 16%), or axillary artery (n=1, 3%). The aorta was not clamped, and circulatory arrest was used in all patients. One-to-many (1:n) propensity score matching between the study population (AVR + AAR, n=29) and control group (isolated AVR for severe AS, n=433) was performed. There was no early mortality in the study population. Postoperative neurologic complications included a minor stroke, which resolved without sequelae at discharge, and a transient ischemic attack. The 5-year survival rate was 83%±9%. In the propensity score-matched comparison, 5-year survival was not significantly different between groups; 81%±10% in the AVR + AAR group vs. 87%±2% in the isolated AVR group (P=0.950). Surgical AVR with AAR in AS patients with calcified ascending aortas led to acceptable early and late outcomes. Although the applications for TAVI are growing, a surgical approach may be an alternative option for relatively younger patients with severely calcified aorta.

Isolated and concomitant minimally invasive minithoracotomy aortic valve surgery

ObjectiveTo evaluate whether the outcomes of minimally invasive aortic valve surgery were similar in younger versus older patient groups, as well as whether concomitant minimally invasive aortic valve replacement (AVR) surgeries added significant risks in these populations. MethodsWe performed a single-institution retrospective analysis of 1018 patients undergoing isolated AVR and 378 patients undergoing concomitant AVR procedures over a 6-year period. All surgeries were via a right minithoracotomy approach, and patients who underwent reoperation were excluded. ResultsMortality was 1.3% in the isolated AVR group and 3.2% in the concomitant AVR group. The incidence of permanent stroke was low in both the isolated and concomitant AVR groups (0.8% and 1.1%, respectively). In both groups, femoral cannulation was associated with equally low stroke rates (0.8% and 0.6%, respectively). When analyzing operative outcomes by age, mortality was similar for the isolated AVR group (age <80 vs ≥80 years, 0.9% vs 2.2%; P = .07) and the concomitant AVR group (<80 vs ≥80 years, 3.2% vs 3.2%; P = .99), whereas transfusion requirements, intensive care unit and hospital lengths of stay, and atrial fibrillation rates were greater in the older subsets of both AVR groups. ConclusionsMinimally invasive right thoracotomy AVR surgery was associated with low stroke and mortality rates in all age groups within 30 days of surgery. Similarly, minithoracotomy concomitant AVR surgery demonstrated excellent results and is deemed feasible in patients with multiple pathologies.

Comparison of the Outcomes between Surgical Aortic Valve Replacement and Transcatheter Aortic Valve Replacement in Patients Aged above 80.

BackgroundTranscatheter aortic valve replacement (TAVR) has been suggested as a less invasive treatment for high-risk patients with aortic valve disease. In this study, we compared the outcomes of conventional surgical aortic valve replacement (AVR) and TAVR in elderly patients aged over 80.MethodsA total of 108 patients aged 80 years or older who underwent isolated AVR (n=35) or TAVR (n=73) from 2010 through 2015 at Asan Medical Center were identified. Early and late clinical outcomes, including echocardiographic findings, were evaluated in both groups. The mean follow-up duration was 766.4±528.7 days in the AVR group and 755.2±546.6 days in the TAVR group, and the average timing of the last follow-up echocardiography was at 492.6±512.5 days in the AVR group and 515.7±526.8 days in the TAVR group.ResultsThe overall early mortality was 2.8% (0 of 35, 0% in the AVR group vs. 3 of 73, 4.1% in the TAVR group). Permanent pacemaker insertion was significantly more common in the TAVR group (p=0.010). Renal failure requiring dialysis and new-onset atrial fibrillation was more frequent and the length of hospital stay was longer in the AVR group; however, this difference did not reach statistical significance. In the TAVR group, 14 patients (19.2%) were rehospitalized due to cardiac problems, and 13 patients (17.8%) had developed significant paravalvular leakage by the time of the last follow-up echocardiography.ConclusionTAVR could be a good alternative to conventional surgical AVR in elderly patients. However, TAVR has several shortcomings, such as frequent significant paravalvular leakage or readmission, which should be considered in decision-making.

Stentless Bioprostheses for Aortic Valve Replacement in Octogenarians: The Influence of Coronary Artery Disease.

We sought to determine the long-term results of stentless biological heart valve replacement in octogenarians to find out whether coronary artery disease or the coronary artery bypass grafting (CABG) procedure itself influences survival in these aged patients. From 4,012 patients undergoing aortic valve replacement (AVR) with a stentless prosthesis (Freestyle, Medtronic) at a single center, 721 patients were older than 80 years. They had a mean age of 83 ± 2 (2,320 patient years), the male/female ratio was 42:58, NYHA (New York Heart Association) class I and II was prevalent in 22.8%, preoperative atrial fibrillation (AF) in 20.6%, coronary artery disease in 56.1%, mitral valve disease in 12.5%, and aortic disease in 3.5%. Follow-up included a total of 11,546 patient years (mean follow-up time: 74 ± 53 months); follow-up mortality data were 96.3% complete. In these aged patients, 30-day mortality in the isolated AVR group (10.3%) was similar to that in the AVR + CABG group (13.4%). Although long-term survival (15 years) in the octogenarian population is low (9% in the AVR group and 6% in the AVR + CABG group), it was not different (p = 0.191) between patients with and without coronary artery disease. The stroke rate and the myocardial infarction rate, respectively, in the AVR + CABG group (0.43%/100 patient years and 0.17%/100 patient years) were only insignificantly higher than that in the isolated AVR group (each 0.01%/100 patient years). The actuarial freedom from reoperation was 99% in both the groups. Use of the Freestyle stentless valve prosthesis for AVR is feasible also in octogenarians. The existence of coronary artery disease leads to concomitant bypass surgery, but not a higher level of perioperative or long-term mortality.