Surgical Aortic Valve Replacement For Aortic Stenosis Research Articles

[The effect of obesity on the outcome of surgical aortic valve replacement for aortic stenosis].

Our objective was to investigate the effect of obesity on short-term complications and long-term survival after surgical aortic valve replacement (SAVR) for aortic stenosis (AS). A retrospective study on 748 patients who underwent SAVR for AS in Iceland 2003-2020. Patients were divided into groups based on body mass index (BMI): normal (18.5-24.9 kg/m2, n=190), overweight (25-29.9 kg/m2, n=339), obese (30-34.9 kg/m2, n=165) and severely obese (≥35 kg/m2, n=54). Six patients with BMI p<18,5 kg/m2 were excluded. Clinical information regarding patient history, risk factors, together with complications and 30-day mortality were collected from patient records. The four BMI groups were compared and long-term survival estimated with Kaplan-Meier plots and risk factors for long-term survival evaluated with Cox multivariate analysis. Severely obese patients were on average four years younger than patients with normal BMI, more often had risk factors for cardiovascular disease, and their EuroSCORE II was higher (5.3 vs. 4.4%, p=0.03). On the other hand, severely obese patients bled less the first 24 hours post-surgery, compared to normal BMI-patients (558 vs. 1091 ml, p<0.001), stroke was less frequent (0 vs 6.4%, p=0.03), but they more often experienced sternum dehiscence (5.6 vs 2.7%, p=0.04), deep sternal wound infection (3.7 vs 0%, p=0.04) and acute kidney injury (26.4 vs 15.2%, p=0.005). Thirty-day mortality and long-term survival did not differ significantly between the groups and BMI was not an independent predictor of long-term survival in multivariate analysis. The outcome for obese patients undergoing SAVR for AS is good and both short-term complications and long-term survival do not differ significantly from patients with a normal BMI. Therefore, a high BMI itself should not be a contraindication for SAVR due to AS.

Outcomes and Contemporary Trends in Surgical vs Transcatheter Aortic Valve Replacement in Patients with Chronic Obstructive Pulmonary Disease

ABSTRACT Background Chronic obstructive lung disease (COPD) is a common morbidity among patients referred for aortic valve replacement. The objective of the present study is to assess trends and outcomes of COPD patients undergoing either transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) for severe aortic stenosis. Methods We analyzed the National Inpatient Sample database from January 2012 to December 2017 using the International Classification of Diseases, 9th and 10th Revision Clinical Modifications to identify all patients with COPD aged ≥50 years who underwent either TAVR or SAVR for aortic stenosis. To account for potential bias, 1:1 propensity-matched analysis was performed. Logistic regression was used for predictors of mortality in the cohort. Linear regression was used for trend analysis. Results Of the total of 95,555 cases, 40,080 underwent TAVR whereas 49,985 underwent SAVR. In-hospital mortality for the propensity-matched cohorts was higher in the SAVR cohort compared to the TAVR group (4.6% vs. 2.5%; p < 0.001). Respiratory complications were also higher in the SAVR group (7.5% vs. 3.7%; p < 0.001) but were less likely to have a permanent pacemaker placement (5.3% vs. 10.8%, p < 0.001). Length of stay (11.8 days [standard deviation (SD), 8.8] vs. 6.4 days [SD, 6.8]) and cost of stay ($244,657 [SD, $183,333] vs. $229,524 [SD, $146,994]) were favorable toward TAVR as compared to SAVR. In-hospital mortality has declined over the study period in the TAVR group from 4.8% to 1.5%. Conclusion TAVR has more favorable in-hospital outcomes in patients with COPD compared to SAVR.

Transcatheter Versus Surgical Aortic Valve Replacement in the United States (From the Nationwide Readmission Database)

Clinical outcomes of transcatheter aortic valve implantation (TAVI) have significantly improved with the accumulation of operator and institution experience as well as the wide use of newer generation devices. There is limited data on TAVI outcomes compared with surgical aortic valve replacement (SAVR) in contemporary practice in the United States. We queried the 2018 Nationwide Readmission Database of the United States. International Classification Diagnosis code 10 was used to extract TAVI and SAVR admissions. A propensity-matched cohort was created to compare TAVI and SAVR outcomes. A weighted 48,349 TAVI and 24,896 SAVR for aortic stenosis were included and 4.9% of TAVI were performed with an embolic protection device. In propensity-matched cohort (12,708 TAVI and 12,708 SAVR), TAVI conferred lower in-hospital mortality (1.7% vs 3.8%), acute kidney injury (11.3% vs 22.9%), and transfusion rate (5.9% vs. 20.6%) whereas new pacemaker rate was higher in TAVI compared with SAVR (10.5% vs. 7.0%) (all p values < 0.001). Stroke rate was similar between TAVI and SAVR (1.5% vs. 1.5%) (p value = 0.79). The routine discharge was more frequent (66.9% vs 25.8%) and length of stay was shorter (4.8 vs. 9.8 days) in TAVI than SAVR. Hospitalization cost was higher in SAVR than TAVI (51,962 vs 57,754 U.S. dollars) (all p values < 0.001). In-hospital mortality was also lower in TAVI compared with isolated SAVR. TAVI was performed more frequently than SAVR in 2018 in the United States with lower in-hospital mortality of TAVI compared with both SAVR and isolated SAVR.

Is this a bridge too far?

Maeda et al. present what may be the second reported case of transcatheter aortic valve replacement (TAVR) followed by staged open surgical aortic valve replacement (SAVR) in a high-risk patient. The authors propose that TAVR may serve as a bridge procedure before SAVR for aortic stenosis in selected younger patients with high surgical risk. Further experience may clarify how long to wait after TAVR to perform SAVR. Timing will be a balance between improving surgical risk versus increasing difficulty removing the prosthesis. Knowledge of TAVR durability will ultimately be needed to decide between "destination" TAVR versus bridging to SAVR with a more durable device.

Comparison of surgical versus transcatheter aortic valve replacement for patients with aortic stenosis at low-intermediate risk.

To compare safety and efficacy of transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) in patients at low-intermediate risk, given the paucity of robust data. We performed an aggregate data meta-analysis of 7 randomized controlled trials (RCTs) and 6,778 patients comparing TAVR with SAVR for aortic stenosis (AS) in low-intermediate risk patients (Society of Thoracic Surgeons risk-score ≤8%) using the random-effects model. Primary outcome was all-cause mortality at 30-day, 1-year and 2-year of follow-up. Secondary outcomes included cardiac-mortality, stroke, acute kidney injury (AKI), atrial fibrillation (AF), permanent pacemaker (PPM) implantation, major-bleeding, moderate-severe paravalvular regurgitation (PVR) and rehospitalization. All-cause mortality, cardiac-mortality and stroke were comparable between the two groups. AF was higher with SAVR at 30-day [odds ratio (OR) 0.17, 95% confidence intervals (CI): 0.12-0.24] thorough to 2-year (OR 0.34, 95% CI: 0.21-0.55), while PPM implantation was higher with TAVR (30-day: OR 3.31, 95% CI: 1.64-6.66, 2-year: OR 3.17, 95% CI: 1.02-9.86). Moderate-severe PVR was more prevalent with TAVR at all follow-ups. On inter-group comparison, patients in the low-risk group had an even lower risk of AF, but a higher risk of PPM implantation as compared to the patients in the intermediate-risk group undergoing TAVR. Compared to SAVR, TAVR had comparable all-cause mortality and stroke, lower-risk of AF, but was associated with a higher risk of PPM implantation and moderate-severe PVR in low-intermediate-risk patients. Thus, highlighting the need for longer-term follow-up before robust inferences are drawn.

Immediate and long-term need for permanent cardiac pacing following aortic valve replacement

Introduction: Atrioventricular (AV) node conduction disturbances are common following surgical aortic valve replacement (SAVR), and in some cases the patient needs a permanent pacemaker (PPM) implantation before discharge from hospital. Little is known about the long-term need for PPM and the PPM dependency of these individuals. We determined the incidence of PPM implantation before and after discharge in SAVR patients. Methods: We studied 557 consecutive patients who underwent SAVR for aortic stenosis in Iceland between 2002 and 2016. Timing and indication for PPM were registered, with a new concept, ventricular pacing proportion (VPP), defined as ventricular pacing ≥90% of the time, being used to approximate pacemaker dependency. The median follow-up time was 73 months. We plotted the cumulative incidence of pacemaker implantation, treating death as a competing risk. Results: Of the 557 patients, 22 (3.9%) received PPM in the first 30 days after surgery, most commonly for complete AV block (n = 14) or symptomatic bradycardia (n = 8); Thirty-eight other patients (6.8%) had a PPM implanted >30 days postoperatively, at a median of 43 months after surgery (range 0‒181), most often for AV block (n = 13) or sick-sinus syndrome (n = 10). The cumulative incidence of PPM implantation at 1, 5, and 10 years postoperatively was 5.0%, 9.2%, and 12.3%, respectively. During follow-up, 45.0% of the 60 patients had VPP ≥90%. Conclusion: The cumulative incidence of permanent pacemaker implantation following SAVR was about 12% at 10 years, with every other patient having VPP ≥90% during follow-up. This suggests that AV node conduction disturbances extend significantly beyond the perioperative period.

Improved long-term outcome of surgical AVR for AS: Results from a population-based cohort.

The aim of this retrospective study was to determine changes in outcomes after surgical aortic valve replacement (SAVR) for aortic stenosis (AS) in Iceland over a 15-year period. We included 587 patients who underwent SAVR for AS in Iceland during the period 2002-2016, with a total follow-up of 3245 patient-years. Short-term and long-term outcomes, 30-day mortality, and long-term survival (Kaplan-Meier) were analyzed. Univariate linear regression and univariate and multinomial logistic regression analyses were performed on preoperative and perioperative variables. Poisson regression analysis was used to evaluate changes in rates of short-term outcomes. Mean age was 71 years, 65.1% were males, and mean EuroSCORE II was 3.9. Mean preoperative aortic valve area increased significantly (0.013 cm2 /year; P < .001) and mean aortic cross-clamp time declined (108 minutes, 2.8 min/year; P < .001). The rate of complications decreased, including new-onset atrial fibrillation (60.9% overall, decreased by 3.1%/year, P = .02), acute kidney injury (17.1%, 7.6%/year, P < .001), and reoperation for bleeding (12.5%, 6.3%/year, P = .02). Operative mortality did not change (5.4%); nor did 1- and 5-year overall survival (92.5% and 81.6%, respectively). Notable long-term events were chronic heart failure (27.7 admissions/100 patient-years), embolic event (15.9/100 patient-years), and bleeding (13.0/100 patient-years). Results of SAVR in this well-defined nationwide cohort of patients in Iceland have improved. This may be related to the patients having less severe AS at the time of operation and shorter operating times, as reflected by lower rates of short-term complications. However, the rate of long-term complications did not change significantly, with prosthetic valve-specific events being rare.

Surgical aortic valve replacement in Australia, 2002-2015: temporal changes in clinical practice, patient profiles and outcomes.

This study describes the temporal changes in risk profiles and outcomes among patients with aortic stenosis (AS) undergoing surgical aortic valve replacement (SAVR) in Australia between 2002 and 2015. Using the Australian and New Zealand Society of Cardiac and Thoracic Surgeons database, we identified first-recorded SAVR for AS over 14 years. Patients' surgical risk profiles, procedures, 30-day and 12-month outcomes were summarized before and after the introduction of transcatheter aortic valve implantation in Australia, in 2008. We applied multivariable regression models to investigate the changes over time on risk-adjusted 30-day mortality, re-hospitalization and 12-month mortality. We identify a total of 18 147 patients with AS who underwent SAVR; mostly men (64%) with a mean age of 72 years. The proportion of major cardiac surgeries devoted to SAVR increased from 14% in 2002 to 20% in 2015. More SAVRs were performed electively (80% in 2002 versus 86% in 2015), and the recipients were at lower surgical risk (mean multi-risk score 3.9% in 2002 versus 3.0% in 2015). The use of bioprosthetic aortic valves increased over time (67% in 2002 to 88% in 2015). We found no significant changes in 30-day mortality, a significant decrease in 30-day readmission and minor fluctuations in 12-month mortality over the study period. SAVR comprises an increasingly larger proportion of all adult cardiac surgeries in Australia. There has been a greater use of bioprosthetic aortic valves, a fall in 30-day readmission but no significant changes in mortality.

Risk Factors for Mortality and Morbidity of Surgical Aortic Valve Replacement for Aortic Stenosis　- Risk Model From a Japan Cardiovascular Surgery Database.

Background: The aim of this study was to determine adequate indication for transcatheter aortic valve replacement (TAVR). We analyzed risk factors of surgical aortic valve replacement (SAVR) not only for mortality, but also for morbidity, including long hospital stay (≥90 days) and patient activity at discharge, in patients who underwent SAVR for aortic stenosis (AS). Methods and Results: Using the Japan Adult Cardiovascular Surgery Database (JCVSD), 13,961 patients with or without coronary artery bypass grafting who underwent elective SAVR for AS were identified from January 2008 to December 2012. The hospital mortality rate was 3.1%. The percentage of patients who had long hospital stay (≥90 days) and who had moderately or severely decompressed activity at discharge (modified Rankin scale ≥4) was 2.9% and 6.5%, respectively. Eleven and 20 preoperative predictors of hospital mortality and morbidity, respectively, including long hospital stay and compromised status at discharge, were identified. Based on these risk factors, the risk model predicted hospital mortality (area under the curve [AUC], 0.732) and morbidity (AUC, 0.694). Conclusions: Using JCVSD, a risk model of SAVR was developed for AS. This model can identify patients at high risk not only for mortality, but also for mortality and morbidity, including long hospital stay and status at discharge.

Cognition and Cerebral Infarction in Older Adults After Surgical Aortic Valve Replacement

Aortic valve replacement (AVR) for calcific aortic stenosis is associated with high rates of perioperative stroke and silent cerebral infarcts on diffusion-weighted magnetic resonance imaging (MRI), but cognitive outcomes in elderly AVR patients compared with individuals with cardiac disease who do not undergo surgery are uncertain. One hundred ninety AVR patients (mean age 76 ± 6 years) and 198 non-surgical participants with cardiovascular disease (mean age 74 ± 6 years) completed comprehensive cognitive testing at baseline (preoperatively) and 4 to 6 weeks and 1 year postoperatively. Surgical participants also completed perioperative stroke evaluations, including postoperative brain MRI. Mixed model analyses and reliable change scores examined cognitive outcomes. Stroke outcomes were evaluated in participants with and without postoperative cognitive dysfunction. From reliable change scores, only 12.4% of the surgical group demonstrated postoperative cognitive dysfunction at 4 to 6 weeks and 7.5% at 1 year. Although the surgical group had statistically significantly lower scores in working memory/inhibition 4 to 6 weeks after surgery, the groups did not differ at 1 year. In surgical participants, postoperative cognitive dysfunction was associated with a greater number (p < 0.01) and larger total volume (p < 0.01) of acute cerebral infarcts on MRI. In high-risk, aged participants undergoing surgical AVR for aortic stenosis, postoperative cognitive dysfunction was surprisingly limited and was resolved by 1 year in most. Postoperative cognitive dysfunction at 4 to 6 weeks was associated with more and larger acute cerebral infarcts.

Impact of Aortic Valve Replacement for Aortic Stenosis on Dynamic Mitral Annular Motion and Geometry

The impact of aortic valve replacement (AVR) on the dynamic geometry and motion of the mitral annulus remains unknown. We analyzed the effects of AVR on the dynamic geometry and motion of the mitral annulus. We used 3-dimensional transesophageal echocardiography to analyze 39 consecutive patients undergoing elective surgical AVR for aortic stenosis. Intraoperative 3-dimensional transesophageal echocardiography was performed immediately before and after AVR. Volumetric data sets were analyzed using a software package capable of dynamically tracking the mitral annulus and leaflets during the entire systolic ejection phase. After AVR, there were significant decreases (p <0.01) in annular dimensions such as anteroposterior (3.5 ± 0.1 vs 3.2 ± 0.1 cm), anterolateral-posteromedial (3.7 ± 0.1 vs 3.5 ± 0.1 cm), and commissural diameters (3.7 ± 0.1 vs 3.3 ± 0.1 cm), as well as annular circumference (12.0 ± 0.30 vs 11.1 ± 0.2 cm) and 3-dimensional mitral annular area (mean 10.9 ± 0.6 vs 9.3 ± 0.3 cm(3)). Vertical mitral annular displacement was also reduced (6.2 ± 3.1 vs 4.3 ± 2.2 mm). Mitral annular nonplanarity angle (154 ± 1.5° vs 161 ± 1.6°) and aorto-mitral angle (133 ± 3.3° vs 142 ± 2.0°) were both increased after AVR, suggesting reduced nonplanar shape of the mitral annulus and reduced aorto-mitral flexion. In conclusion, these data demonstrate that mitral annular size is reduced immediately after AVR and that the dynamic motion of the mitral annulus is restricted. These findings may have important clinical implications for patients undergoing AVR with concurrent mitral regurgitation.