Primary isolated aortic valve surgery in octogenarians

Objectives: We reviewed our surgery registry, to identify predictive risk factors for operative results, and to analyse the long-term survival outcome in octogenarians operated for primary isolated aortic valve replacement (AVR). Methods: A total of 124 consecutive octogenarians underwent open AVR from January 1990 to December 2005. Combined procedures and redo surgery were excluded. Selected variables were studied as risk factors for hospital mortality and early neurological events. A follow-up (FU; mean FU time: 77 months) was obtained (90% complete), and Kaplan-Meier plots were used to determine survival rates. Results: The mean age was 82±2.2 (range: 80-90 years; 63% females). Of the group, four patients (3%) required urgent procedures, 10 (8%) had a previous myocardial infarction, six (5%) had a previous coronary angioplasty and stenting, 13 patients (10%) suffered from angina and 59 (48%) were in the New York Heart Association (NYHA) class III-IV. We identified 114 (92%) degenerative stenosis, six (5%) post-rheumatic stenosis and four (3%) active endocarditis. The predicted mortality calculated by logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) was 12.6±5.7%, and the observed hospital mortality was 5.6%. Causes of death included severe cardiac failure (four patients), multi-organ failure (two) and sepsis (one). Complications were transitory neurological events in three patients (2%), short-term haemodialysis in three (2%), atrial fibrillation in 60 (48%) and six patients were re-operated for bleeding. Atrio-ventricular block, myocardial infarction or permanent stroke was not detected. The age at surgery and the postoperative renal failure were predictors for hospital mortality (p value ≪0.05), whereas we did not find predictors for neurological events. The mean FU time was 77 months (6.5 years) and the mean age of surviving patients was 87±4 years (81-95 years). The actuarial survival estimates at 5 and 10 years were 88% and 50%, respectively. Conclusions: Our experience shows good short-term results after primary isolated standard AVR in patients more than 80 years of age. The FU suggests that aortic valve surgery in octogenarians guarantees satisfactory long-term survival rates and a good quality of life, free from cardiac re-operations. In the era of catheter-based aortic valve implantation, open-heart surgery for AVR remains the standard of care for healthy octogenarian

Aortic valve repair with patch in non-rheumatic disease: indication, techniques and durability†

OBJECTIVES: To analyse the long-term outcomes of aortic valve (AV) repair with biological patch in patient with non-rheumatic valve disease. METHODS: From 1995 to 2011, 554 patients underwent elective (AV) repair; among them, 57 (mean age 45 ± 17 years) had cusp restoration using patch for non-rheumatic valve disease. Seven (12%) patients had unicuspid valve, 30 (53%) patients had bicuspid valve and 20 (35%) had tricuspid valve. Autologous pericardium was used in 26 patients (7 treated, 19 non-treated), bovine pericardium in 26, autologous tricuspid valve leaflet in 4 and aortic homograft cusp in 1. Patching was used to repair perforation (n = 20, 35%), commissural defect (n = 18, 32%), raphe repair (n = 17, 30%) or for cusp extension (n = 2, 3.5%). Echocardiographic and clinical follow-up was 98% complete and mean follow-up was 72 ± 42.5 months. RESULTS: No hospital mortality. At 8 years, overall survival was 90 ± 5% and freedom from valve-related death was 96 ± 3%. Two patients (3.5%) needed early reoperation for aortic regurgitation (AR); they underwent re-repair and the Ross procedure, respectively. Late reoperation was necessary in 9 patients (16%) for AR (n = 4), stenosis (n = 3) or mixed disease (n = 2). They had the Ross procedure (n = 6) or prosthetic valve replacement (n = 3) with no mortality. At 8 years, freedom from reoperation was 75 ± 9%. Freedom from reoperation was slightly higher in tricuspid compared with non-tricuspid valves (92 ± 7 vs 68 ± 11%, P = 0.18) and slightly higher for bovine (95 ± 5%) compared with autologous pericardium (73 ± 11%, P = 0.38), but differences were statistically not significant. In tricuspid valves, freedom from reoperation was higher in perforation repair compared with other techniques (100 vs 50 ± 35%, P = 0.02). In bicuspid valves, freedom from reoperation was similar between different repair techniques (P = 0.38). Late echocardiography showed AR 0-1 in 30 (53%) patients, AR 2 in 12 (21%) and no AR ≥ 3. Three patients presented a mean transvalvular gradient of 30-40 mmHg. Thromboembolic events occurred in 2 patients (0.6%/patient-year), bleeding events in 1 (0.3% /patient-year) and no endocarditis occurred. CONCLUSIONS: AV repair with biological patch is feasible for various aetiologies. The techniques are safe and medium-term durability is acceptable, even excellent for perforation repair in tricuspid valve morphology. Bovine pericardium is a good alternative to autologous pericardium

Einfluss der Implantationstechnik der Edwards „SAPIEN 3“ Aortenklappenprothese auf die Rate von postprozeduralen AV-Blockierungen

Introduction: TAVI can provide elderly and high-risk patients with aortic valve re-placement, with convincing results as it is superior to standard drug therapy and bal-loon valvuloplasty [2, 3] and equivalent to conventional surgical aortic valve re-placement in patients at high surgical risk. [4, 5] But the transfemoral aortic valve replacement also brings complications with it, such as vascular lesions, bleeding, prosthesis insufficiencies, myocardial infarction, conduction abnormalities and death. [6, 7] In particular, the need for permanent pacing is one of the major compli-cations of TAVI. Compared to conventional surgical aortic valve replacement (SAVR), TAVI performs poorly in terms of the incidence of conduction disorders. [8-15] The innovative sealing cuff of the Edwards SAPIEN 3 is suspected to cause with more radial forces an increase of conduction disturbances and the requirement of a pacemaker postprocedural (about 19%). [16] Method: In our retrospective study, we identified 167 TAVI patients who underwent Edwards SAPIEN 3 aortic valve prosthesis implantation in 2014 in a TAVI procedure. We excluded 36 patients who already had received a permanent pacemaker prior. We retrospectively investigated the frequency of pacemaker implantation after the intervention as a function of the implantation height. We determined the distance over two of our defined distances: distance (a) as the distance of the central marker on the expansion balloon to the aortic cusps before deployment of the prosthesis, and distance (b) from the valve level to the end of the stent after deployment. Result: The incidence of pacing after TAVI in the total cohort was 18% (n = 24). An implantation > 2 mm distal to the valve level was associated with a reduction of pacemaker incidence by 27.3% compared to a more proximal implantation (4,7% vs. 32%, Odds Ratio (OR): 0,10 (0,03 - 0,37, p<0,001). The data were validated with both of the distances we defined (a, b). A pre-existing right bundle branch block was an independent risk factor for post-intervention pacing (odds ratio of 52,5; 10.5 – 263,2 , p <0.001). Discussion: We guess that distal implantation will result in less trauma and edema-tous pressure from the radial forces of the prosthesis on the AV-node and conduc-tion tissue. By optimizing the implantation techniques, the incidences of post-procedural complications, e.g. a pacemaker implantation could be further reduced. An improved side effect profile and extended prosthesis durability could help to offer TAVI as a therapeutic option to younger patients with a medium and low risk profile.Einleitung: Die immer älter werdende Bevölkerung bedingt einen Anstieg in der An-zahl behandlungsbedürftiger Aortenklappenstenosen, während gleichzeitig vermehrte Komorbiditäten das operative Risiko eines chirurgischen Eingriffes erhöhen. Durch die Entwicklung von Transkatheter-Aortenklappenimplantation (Transcatheter aortic valve implantation = TAVI) können auch ältere Patienten mit erhöhtem Risikoprofil mit einem Aortenklappenersatz versorgt werden. TAVI ist gegenüber der medikamentösen Stan-dardtherapie und Ballonvalvuloplastie überlegen. [2, 3] Gegenüber einem konventio-nellen chirurgischen Aortenklappenersatz bei Patienten mit hohem Operationsrisiko ist TAVI gleichwertig. Die 30 - Tages - Mortalität ist geringer, die Mortalität nach einem bzw. zwei Jahren annährend gleich. [4, 5] Doch der transfemorale Aortenklappenersatz bringt auch Komplikationen mit sich, wie (cerebro-) vaskuläre Läsionen, Blutungen, Prothesen-Insuffizienzen, Myokardinfarkte und Erregungsbildungs- und -fortleitungsstörungen mit der Folge einer Schrittmacher-pflichtigkeit und Tod. [6, 7] Schrittmacherpflichtigkeit ist eine Hauptkomplikation nach TAVI. Im Vergleich zum konventionellen chirurgischen Aortenklappenersatz (SAVR) zeigt TAVI eine höhere In-zidenz für das Auftreten von Erregungsfortleitungsstörungen. [8-15] Die innovative Ab-dichtungsschürze der Edwards SAPIEN 3 steht im Verdacht, durch erhöhte Radial-kräfte vermehrt Erregungsfortleitungstörungen zu verursachen und eine höhere post-prozedurale Schrittmacherpflichtigkeit zu bedingen (etwa 19%)

Effect Of Coronary Bypass And Valve Structure On Outcome In Isolated Valve Replacement For Aortic Stenosis

Reports differ regarding the effect of concomitant coronary artery bypass grafting (CABG) in patients who undergo aortic valve replacement (AVR) for aortic stenosis (AS), and no reports have described the effect of aortic valve structure in patients who undergo AVR for AS. A total of 871 patients aged 24 to 94 years (mean 70) whose AVR for AS was their first cardiac operation, with or without first concomitant CABG, were included. Patients who underwent mitral valve procedures were excluded. In comparison with the 443 patients (51%) who did not undergo CABG, the 428 (49%) who underwent concomitant CABG were significantly older, were more often male, had lower transvalvular peak systolic pressure gradients and larger valve areas, had lower frequencies of congenitally malformed aortic valves, had lighter valves by weight, had higher frequencies of systemic hypertension, and had longer stays in the hospital after AVR. Early and late (to 10 years) mortality were similar by propensity-adjusted analysis in patients who did and did not undergo concomitant CABG. Congenitally unicuspid or bicuspid valves occurred in approximately 90% of those aged 21 to 50, in nearly 70% in those aged 51 to 70 years, and in just over 30% in those aged 71 to 95 years. Unadjusted and adjusted survival was significantly higher in patients with unicuspid or bicuspid valves compared to those with tricuspid valves. In conclusion, although concomitant CABG had no effect on the adjusted probability of survival, the type of aortic valve (unicuspid or bicuspid vs tricuspid) significantly affected the unadjusted and adjusted probability of survival. (C) 2012 Elsevier Inc. All rights reserved. (Am J Cardiol 2012;109:1334-1340)Statistic

Transcatheter aortic valve implantation in patients with pre-existing chronic kidney disease

AbstractBackgroundWe investigated the effect of chronic kidney disease (CKD) on morbidity and mortality following transcatheter aortic valve implantation (TAVI) including patients on haemodialysis, often excluded from randomised trials.Methods and resultsWe performed a retrospective post hoc analysis of all patients undergoing TAVI at our centre between 2008 and 2012. 118 consecutive patients underwent TAVI; 63 were considered as having (CKD) and 55 not having (No-CKD) significant pre-existing CKD, (defined as estimated glomerular filtration rate (eGFR)<60mL/min/1.73m2). Chronic haemodialysis patients (n=4) were excluded from acute kidney injury (AKI) analysis. Following TAVI, in CKD and No-CKD patients respectively, AKI occurred in 23.7% and 14.5% (p=0.455) and renal replacement therapy (RRT) was necessary in 8.5% and 3.6% (relative risk (RR) [95% CI]=2.33 [0.47–11.5], p=0.440); 30-day mortality rates were 6.3% and 1.8% (p=0.370); and 1-year mortality rates were 17.5% and 18.2% (p=0.919). Patients who developed AKI had a significantly increased risk of 30-day (12.5% vs. 1.1%, p=0.029) mortality. We found the presence of diabetes (odds ratio (OR) [95% CI]=4.58 [1.58–13.3], p=0.005) and elevated baseline serum creatinine (OR [95% CI]=1.02 [1.00–1.03], p=0.026) to independently predict AKI to statistical significance by multivariate analysis.ConclusionTAVI is a safe, acceptable treatment for patients with pre-existing CKD, however caution must be exercised, particularly in patients with pre-existing diabetes mellitus and elevated pre-operative serum creatinine levels as this confers a greater risk of AKI development, which is associated with increased short-term post-operative mortality

Transcatheter Aortic Valve Implantation in Dialysis Patients

Background/Aims: Transcatheter aortic valve implantation (TAVI) has emerged as a new therapeutic option for high-risk patients. However, dialysis patients were excluded from all previous studies. The aim of this study is to compare the outcomes of TAVI for dialysis patients with those for patients with chronic kidney disease (CKD) stages 3 and 4 and to compare TAVI with open surgery in dialysis patients. Methods: Part I: comparison of 10 patients on chronic hemodialysis with 116 patients with non-dialysis-dependent CKD undergoing TAVI. Part II: comparison of transcatheter (n = 15) with open surgical (n = 24) aortic valve replacement in dialysis patients. Results: Part I: dialysis patients were significantly younger (72.3 vs. 82.0 years; p < 0.01). Hospital stay was significantly longer in dialysis patients (21.8 vs. 12.1 days; p = 0.01). Overall 30-day mortality was 3.17%, with no deaths among dialysis patients. Six-month survival rates were similar (log-rank p = 0.935). Part II: patient age was comparable (66.5 vs. 69.5 years; p = 0.42). Patients in the surgical group tended to stay longer in hospital than TAVI patients (29.5 vs. 22.5 days; p = 0.35). Conclusion: TAVI is a safe procedure in patients on chronic hemodialysis. Until new data become available, we find no compelling reason to refuse these patients TAVI. Copyright (C) 2012 S. Karger AG, Base

An echocardiographic comparison of sutureless and conventional aortic valve replacement : a matched case-control study

Background: Patients at a high operative risk for conventional aortic valve replacement (AVR) may be offered sutureless valve implantation. Sutureless valves resemble conventional valves but incorporate an anchoring mechanism without using annular sutures. Methods Pre-operative and six month post-operative echocardiography data from our first year, single centre experience of sutureless valves was compared to conventional aortic valve replacements in patients matched for operative risk. Left ventricular ejection fraction, mean and peak AV gradients and inter-ventricular septal thickness, effective orifice area (EOA) and indexed effective orifice area (iEOA) were measured. Results The drops in mean and peak pre- to post-operative gradients were greater in the sutureless group, p=0.039 and p=0.001 respectively. Post-operative EOA was 1.69 cm2 and 1.26 cm2 (p=0.001) in the sutureless and conventional groups. Similarly iEOA was 0.93 cm2 and 0.74 cm2 (p=0.001) in the sutureless and conventional groups. There was also a reduction in patient prosthesis mismatch (PPM) in the sutureless group as compared to the conventional group (Chi square test p=0.026). Post-operative inter-ventricular septal thickness was 1.13 cm2 in the sutureless group and 1.35 cm2 in the conventional group (p=0.011). Conclusions Use of sutureless valves with a stent framework resulted in larger EOA and iEOA and a diminution in PPM; and lead to a statistically significant faster regression in inter-ventricular septal thickness that is a measure of left ventricular mass. The rate and extent of regression in left ventricular hypertrophy after AVR is important since it determines long-term survival including mortality, heart failure and decreased admission rates.peer-reviewe

Surgical management of aortic root disease in Marfan syndrome and other congenital disorders associated with aortic root aneurysms

Elective root replacement in Marfan syndrome has improved life expectancy in affected patients. Three forms of surgery are now available: total root replacement (TRR) with a valved conduit, valve sparing root replacement (VSRR) and personalised external aortic root support (PEARS) with a macroporous mesh sleeve. TRR can be performed irrespective of aortic dimensions and a mechanical replacement valve is a secure and near certain means of correcting aortic valve regurgitation but has thromboembolic and bleeding risks. VSRR offers freedom from anticoagulation and attendant risks of bleeding but reoperation for aortic regurgitation runs at 1.3% per annum. A prospective multi-institutional study has found this to be an underestimate of the true rate of valve-related adverse events. PEARS conserves the aortic root anatomy and optimises the chance of maintaining valve function but average follow-up is under 5 years and so the long-term results are yet to be determined. Patients are on average in their 30s and so the cumulative lifetime need for reoperation, and of any valve-related complications, are consequently substantial. With lowering surgical risk of prophylactic root replacement, the threshold for intervention has reduced progressively over 30 years to 4.5 cm and so an increasing number of patients who are not destined to have a dissection are now having root replacement. In evaluation of these three forms of surgery, the number needed to treat to prevent dissection and the balance of net benefit and harm in future patients must be considered