Analysis of the effect of aortic valve replacement in patients with moderate mitral regurgitation and calcific aortic stenosis: meta-analysis

Замена аортне валвуле ради решавања стенозе представља једну од најчешће спровођених операција на срчаним залисцима. Широм света годишње се хируршки имплантира преко 280000 аортних валвула и овај број је у константном порасту упркос развоју нових технологија и транскатетерске имплантације. Разлог за то је старење опште популације, развој здравствене инфраструктуре те подизање свести јавности о поменутој болести и опцијама лечења. Није редак случај да болесници са тешком аортном стенозом имају и удружену митралну регургитацију. Интервенција на два залиска носи вишеструко већи оперативни ризик у односу на изоловану замену аортне валвуле. За разлику од случајева тешког облика удружене митралне регургитације када је хируршка процедура на оба залиска неспорно индикована, за третман секундарне митралне инсуфицијенције умереног степена нема јасних препорука. Циљ: Сагледавање да ли ће након замене стенотичне аортне валвуле последично доћи до смањења удружене митралне регургитације. Такође, да ли у тим околностима долази до процеса реверзног ремоделовања леве коморе и какво је краткорочно и дугорочно преживљавање пацијената код којих није вршена додатна интервенција на митралном залиску ради решавања функционалне регургитације умереног степена. Методе: Проведен је систематски преглед литературе са мета-анализом. Извршена је претрага литературе према PRISMA стратегији, кроз базе података Pubmed, Scopus и Web of science, директоријуме најугледнијих научних часописа на пољу кардиохирургије те кроз конгресна излагања са годишњих састанака европског и америчког кардиоторакалног удружења закључно са 31. мајем 2019. године. У анализу су укључене све публикације у којима су објављени подаци о пацијентима којима је извршена прва, изолована замена аортне валвуле због аортне стенозе, а који су имали и удружену митралну регургитацију која није оперативно третиран...Aortic valve replacement aimed to relieve the aortic stenosis represents one of the most frequent operative procedures on heart valves. Each year more than 280.000 aortic valve prostheses are surgically implanted worldwide and this number is constantly increasing despite development of the new technologies and transcatheter implantation. The reason for this is the population aging, development of the health infrastructure and increasing public awareness of the disease itself and treatment modalyties. It is not unusual for patients with severe aortic stenosis to have concomitant mitral regurgitation. Double valve surgery carries a significantly higher operative risk comparing to isolated aortic valve replacement. Apart from severe secondary mitral regurgitation where the double valve surgery is clearly indicated, for the management of concomitant mitral insufficiency of a moderate degree there are no clear guidelines. Aim: To see whether there is improvement in concomitant moderate mitral regurgitation after stenotic aortic valve replacement alone. Also, to reveal does the reverse remodeling take place under these circumstances and how is patient short and long-term survival affected without the additional intervention on the mitral valve. Methods: We performed systematic review and meta-analysis. A literature search was performed according to PRISMA strategy through PubMed, Scopus and WOS (Web of science) databases, directories of peer-reviewed journals in the field of cardiac surgery and through European Association of Cardiothoracic Surgery and Society of Thoracic Surgeons annual meeting reports. The last date of the search was 31st May 2019. The inclusion criteria were studies reporting patients that underwent isolated, first time surgical aortic valve replacement for aortic stenosis who had concomitant mitral regurgitation that is not surgically addressed. All patients in the review underwent the same treatment. After data extraction we compared the parameters of the same subjects before and after the operation. Primary end point was the severity of mitral regurgitation before and after the aortic valve replacement. Secondary end points were the analysis of the left ventricle reverse remodeling parameters – ejection fraction, enddiastolic diameter and mitral annulus diameter, and short and long-term survival analysis. All studies were also analyzed for the risk of performance and publication bias. Meta-analysis was performed following recommendations from The Cochrane Collaboration guidelines..

The Prospects of Secondary Moderate Mitral Regurgitation after Aortic Valve Replacement—Meta-Analysis

Meta analysis of the prospects of moderate mitral regurgitation if left untreated after aortic valve replacement for aortic stenosis

Analysis of the effect of aortic valve replacement in patients with moderate mitral regurgitation and calcific aortic stenosis: meta-analysis

Замена аортне валвуле ради решавања стенозе представља једну од најчешће спровођених операција на срчаним залисцима. Широм света годишње се хируршки имплантира преко 280000 аортних валвула и овај број је у константном порасту упркос развоју нових технологија и транскатетерске имплантације. Разлог за то је старење опште популације, развој здравствене инфраструктуре те подизање свести јавности о поменутој болести и опцијама лечења. Није редак случај да болесници са тешком аортном стенозом имају и удружену митралну регургитацију. Интервенција на два залиска носи вишеструко већи оперативни ризик у односу на изоловану замену аортне валвуле. За разлику од случајева тешког облика удружене митралне регургитације када је хируршка процедура на оба залиска неспорно индикована, за третман секундарне митралне инсуфицијенције умереног степена нема јасних препорука. Циљ: Сагледавање да ли ће након замене стенотичне аортне валвуле последично доћи до смањења удружене митралне регургитације. Такође, да ли у тим околностима долази до процеса реверзног ремоделовања леве коморе и какво је краткорочно и дугорочно преживљавање пацијената код којих није вршена додатна интервенција на митралном залиску ради решавања функционалне регургитације умереног степена. Методе: Проведен је систематски преглед литературе са мета-анализом. Извршена је претрага литературе према PRISMA стратегији, кроз базе података Pubmed, Scopus и Web of science, директоријуме најугледнијих научних часописа на пољу кардиохирургије те кроз конгресна излагања са годишњих састанака европског и америчког кардиоторакалног удружења закључно са 31. мајем 2019. године. У анализу су укључене све публикације у којима су објављени подаци о пацијентима којима је извршена прва, изолована замена аортне валвуле због аортне стенозе, а који су имали и удружену митралну регургитацију која није оперативно третиран...Aortic valve replacement aimed to relieve the aortic stenosis represents one of the most frequent operative procedures on heart valves. Each year more than 280.000 aortic valve prostheses are surgically implanted worldwide and this number is constantly increasing despite development of the new technologies and transcatheter implantation. The reason for this is the population aging, development of the health infrastructure and increasing public awareness of the disease itself and treatment modalyties. It is not unusual for patients with severe aortic stenosis to have concomitant mitral regurgitation. Double valve surgery carries a significantly higher operative risk comparing to isolated aortic valve replacement. Apart from severe secondary mitral regurgitation where the double valve surgery is clearly indicated, for the management of concomitant mitral insufficiency of a moderate degree there are no clear guidelines. Aim: To see whether there is improvement in concomitant moderate mitral regurgitation after stenotic aortic valve replacement alone. Also, to reveal does the reverse remodeling take place under these circumstances and how is patient short and long-term survival affected without the additional intervention on the mitral valve. Methods: We performed systematic review and meta-analysis. A literature search was performed according to PRISMA strategy through PubMed, Scopus and WOS (Web of science) databases, directories of peer-reviewed journals in the field of cardiac surgery and through European Association of Cardiothoracic Surgery and Society of Thoracic Surgeons annual meeting reports. The last date of the search was 31st May 2019. The inclusion criteria were studies reporting patients that underwent isolated, first time surgical aortic valve replacement for aortic stenosis who had concomitant mitral regurgitation that is not surgically addressed. All patients in the review underwent the same treatment. After data extraction we compared the parameters of the same subjects before and after the operation. Primary end point was the severity of mitral regurgitation before and after the aortic valve replacement. Secondary end points were the analysis of the left ventricle reverse remodeling parameters – ejection fraction, enddiastolic diameter and mitral annulus diameter, and short and long-term survival analysis. All studies were also analyzed for the risk of performance and publication bias. Meta-analysis was performed following recommendations from The Cochrane Collaboration guidelines..

Economic Justification Analysis of Minimally Invasive versus Conventional Aortic Valve Replacement

There is no definitive consensus about the cost-effectiveness of minimally invasive aortic valve replacement (AVR) (MI-AVR) compared to conventional AVR (C-AVR). The aim of this study was to compare the rate of postoperative complications and total hospital costs of MI-AVR versus C-AVR overall and by the type of aortic prosthesis (biological or mechanical). Our single-center retrospective study included 324 patients over 18 years old who underwent elective isolated primary AVR with standard stented AV prosthesis at the Institute for Cardiovascular Diseases “Dedinje” between January 2019 and December 2019. Reintervention, emergencies, combined surgical interventions, and patients with sutureless valves were excluded. In both MI-AVR and C-AVR, mechanical valve implantation contributed to overall reduction of hospital costs with equal efficacy. The cost-effectiveness ratio indicated that C-AVR is cheaper and yielded a better clinical outcome with mechanical valve implantation (67.17 vs. 69.5). In biological valve implantation, MI-AVR was superior. MI-AVR patients had statistically significantly higher LVEF and a lower Euro SCORE than C-AVR patients (Mann–Whitney U-test, p = 0.002 and p = 0.002, respectively). There is a slight advantage to MI-AVR vs. C-AVR, since it costs EUR 9.44 more to address complications that may arise. Complications (mortality, early reoperation, cerebrovascular insult, pacemaker implantation, atrial fibrillation, AV block, systemic inflammatory response syndrome, wound infection) were less frequent in the MI-AVR, making MI-AVR more economically justified than C-AVR (18% vs. 22.1%)

The Prospects of Secondary Moderate Mitral Regurgitation after Aortic Valve Replacement —Meta-Analysis

Aortic valve replacement for aortic stenosis represents one of the most frequent surgical procedures on heart valves. These patients often have concomitant mitral regurgitation. To reveal whether the moderate mitral regurgitation will improve after aortic valve replacement alone, we performed a systematic review and meta-analysis. We identified 27 studies with 4452 patients that underwent aortic valve replacement for aortic stenosis and had co-existent mitral regurgitation. Primary end point was the impact of aortic valve replacement on the concomitant mitral regurgitation. Secondary end points were the analysis of the left ventricle reverse remodeling and long-term survival. Our results showed that there was significant improvement in mitral regurgitation postoperatively (RR, 1.65; 95% CI 1.36–2.00; p < 0.00001) with the average decrease of 0.46 (WMD; 95% CI 0.35–0.57; p < 0.00001). The effect is more pronounced in the elderly population. Perioperative mortality was higher (p < 0.0001) and long-term survival significantly worse (p < 0.00001) in patients that had moderate/severe mitral regurgitation preoperatively. We conclude that after aortic valve replacement alone there are fair chances but for only slight improvement in concomitant mitral regurgitation. The secondary moderate mitral regurgitation should be addressed at the time of aortic valve replacement. A more conservative approach should be followed for elderly and high-risk patients

Percutaneous implantation of self-expandable aortic valve in high risk patients with severe aortic stenosis: The first experiences in Serbia

Background/Aim. Aortic stenosis (AS) is the most common valvular heart disease in elderly people, with rather poor prognosis in symptomatic patients. Surgical valve replacement is the therapy of choice, but a significant number of patients cannot undergo surgical procedure. We presented initial experience of transcatheter aortic valve implantation (TAVI) performed in Catheterization Laboratory of the Clinic for Cardiology, Clinical Center of Serbia. Methods. The procedures were performed in 5 patients (mean age 76 ± 6 years, 2 males, 3 female) with severe and symptomatic AS with contraindication to surgery or high surgical risk. The decision to perform TAVI was made by the heart team. Pre-procedure screening included detailed clinical and echocardiographic evaluation, coronary angiography and computed tomography scan. In all the patients we implanted a self-expandable aortic valve (Core Valve, Medtronic, USA). Six months follow-up was available for all the patients. Results. All interventions were successfully performed without significant periprocedural complications. Immediate hemodynamic improvement was obtained in all the patients (peak gradient 94.2 ± 27.6 to 17.6 ± 5.2 mmHg, p < 0.001, mean pressure gradient 52.8 ± 14.5 to 8.0 ± 2.1 mmHg, p < 0.001). None of the patients developed heart block, stroke, vascular complication or significant aortic regurgitation. After 6 months, the survival was 100% with New York Heart Association (NYHA) functional improvement in all the patients. Conclusion. This successful initial experience provides a solid basis to treat larger number of patients with symptomatic AS and high surgical risk who are left untreated. [Projekat Ministarstva nauke Republike Srbije, br. ON 175 020