Contemporary Perioperative Results of Isolated Aortic Valve Replacement for Aortic Stenosis

doi:10.1016/j.athoracsur.2009.11.024

The Annals of Thoracic Surgery

Volume 89, Issue 3, March 2010, Pages 751-756

https://doi.org/10.1016/j.athoracsur.2009.11.024 Get rights and content

Background

Transcatheter aortic valve implantation may become a potential treatment for high-risk patients with aortic stenosis (AS). We analyzed our contemporary series of isolated aortic valve replacement (AVR) for AS to determine implications for patients referred for AVR.

Methods

From April 2004 through December 2008, 190 patients (mean age, 68 years; 68% men) underwent isolated AVR for AS. Mean ejection fraction was 0.58. Sixty-one percent underwent minimally invasive AVR and 18% were reoperations. Twenty-one percent were aged 80 years or older, and 34% were in New York Heart Association functional class III-IV. Estimated operative mortality was 3.6%.

Results

Thirty-day mortality was 0%. One in-hospital death (0.5%) occurred from complications of an esophageal perforation. Reoperation for bleeding occurred in 4.7%. Acute renal failure developed in 2.1%. Actuarial survival was 97% at 1 year and 94% at 3 years. Hospital length of stay was 7.0 days for patients aged 80 and older vs 5.0 days (p < 0.001), and they were less likely to be discharged to home (50% vs 83%, p < 0.001).

Conclusions

Contemporary results show that AVR for AS can be performed with low operative mortality and morbidity, although patients aged 80 years and older are at increased risk of prolonged recovery. Transcatheter aortic valve implantation may be an alternative for high-risk patients, but AVR is still appropriate for low-risk patients. The low risk of AVR supports the argument that asymptomatic patients who have a high likelihood of progression of AS may be considered for earlier surgical referral.

Section snippets

Material and Methods

This study was approved by the Institutional Review Board (IRB) at Northwestern University (IRB project No. 0278-043). The IRB waived the requirement of individual patient consent because the analysis was retrospective in nature.

We queried the Bluhm Cardiovascular Institute Clinical Trials Units N-CORE Database at Northwestern Memorial Hospital for all patients who underwent AVR since the inception of the database, April 2004 through December 2008. Data were collected from the database and the

Results

From April 2004 through December 2008, 190 patients with aortic stenosis underwent isolated AVR, of which 41 (21.5%) were aged 80 years or older (Table 1). The age distribution of patients is shown in Figure 1. Dyspnea was the most frequent symptom on presentation (Table 2), with 33.7% of patients presenting with NYHA functional class III or IV symptoms. Comorbidities were similar between the two groups except for lower body surface area and a higher incidence of hypertension and CAD in the

Comment

These contemporary results of isolated AVR demonstrate the improved safety of open heart operations in experienced centers for patients with aortic stenosis. The perception of poor outcomes after isolated AVR has generated interest in alternative treatment strategies, including aortic balloon valvotomy, aortic valve bypass using apicoaortic conduits, and most recently, TAVI. Nevertheless, near-zero operative mortality adds to increasing weight of evidence that isolated AVR should continue to be

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Cited by (61)

Prognosis of Severe Asymptomatic Aortic Stenosis With and Without Surgery
2019, Annals of Thoracic 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.
Syncope: The Underestimated Threat in Severe Aortic Stenosis
2019, JACC: Cardiovascular Imaging
Citation Excerpt :
An emerging body of evidence, relying on retrospective and observational data, implies that early SAVR might lead to favorable outcomes compared with surgery after symptom onset (22–24). Furthermore, operative risk for isolated SAVR is low at established centers (25), and transcatheter aortic valve replacement has currently become an attractive, minimally invasive alternative to SAVR in patients at high and intermediate surgical risk (26,27). Therefore, there is currently growing interest in identifying asymptomatic or oligosymptomatic patients with severe AS who may benefit from early SAVR.
Decision making in severe aortic stenosis (AS) requires a comprehensive pre-operative evaluation of the risk-to-benefit ratio. The aim of this study was to assess whether certain pre-operative symptoms are associated with outcome after surgical aortic valve replacement (SAVR).
The cardinal symptoms of AS indicating a need for intervention are angina, symptoms of heart failure, and syncope. Nevertheless, it remains unknown whether the presence of these more advanced symptoms conveys an increased risk after SAVR and whether the detection of early symptoms in patients with asymptomatic AS should be emphasized more in routine clinical practice.
A total of 625 patients with isolated severe AS undergoing elective SAVR were prospectively enrolled in this long-term observational study.
Patients experiencing syncope had significantly smaller left ventricular diameters (p = 0.02), left atrial diameters (p = 0.043), right ventricular diameters (p = 0.04), and right atrial diameters (p = 0.001), smaller aortic valve areas (p = 0.048), and lower indexed stroke volumes (p = 0.043) compared with patients without syncope. Syncope conveyed an increased risk for mortality after SAVR that persisted after multivariate adjustment for a bootstrap-selected confounder model, with an adjusted hazard ratio of 2.27 (95% confidence interval: 1.04 to 4.95; p = 0.04) for 1-year short-term mortality and an adjusted hazard ratio of 2.11 (95% confidence interval: 1.39 to 3.21; p < 0.001) for 10-year long-term mortality. In contrast, pre-operative dyspnea, angina, and reduced left ventricular function were not significantly associated with outcomes.
This long-term observational study in a large contemporary cohort of patients with AS for the first time demonstrates that syncope represents an underestimated threat in aortic stenosis, associated with poor prognosis after SAVR. Importantly, other primary indications for SAVR (i.e., dyspnea, angina, and decreased left ventricular function) were associated with significantly better post-operative outcomes than syncope. Patients experiencing syncope displayed a specific pathophysiologic phenotype characterized by a smaller aortic valve area, smaller cardiac cavities, and lower stroke volumes.
Treatment Strategies in Symptomatic Intermediate, Low-Risk, and Asymptomatic Patients With Severe Aortic Stenosis
2018, Current Problems in Cardiology
Survival of symptomatic patients with severe aortic stenosis (AS) is very poor, with an average mortality reaching up to 2% per month. Approach to diagnosis and treatment of patients with AS was conservative; patients were referred to surgery only if the AS-induced symptoms become apparent and significantly limit the quality of patient’ life.
In the past 15 years, the novel treatment strategy in subgroups of symptomatic patients with AS have been the subject of extensive research, starting from introduction of transcatheter aortic valve implant (TAVI) in inoperable symptomatic patients with severe AS and continuing further to patients with very high and high operative risk. In the past few years, the focus has further shifted toward the patients with lower operative risk, as well as to asymptomatic patients with severe AS. In the former group, the question relates to whether TAVI is beneficial when compared to SAVR in intermediate- to low-risk patients with symptomatic AS. In the latter group, the main issue is if and when the SAVR should be performed.
This article analyzes current status and evidences regarding treatment strategies in symptomatic high, intermediate, low-risk, and asymptomatic patients with isolated severe AS.
Novel Echocardiographic Parameters in Patients With Aortic Stenosis and Preserved Left Ventricular Systolic Function Undergoing Surgical Aortic Valve Replacement
2018, American Journal of Cardiology
Citation Excerpt :
The findings were validated internally in derivation and validation cohorts. AVR is the only durable therapy that impacts long-term prognosis in patients with aortic stenosis.1–8 However, despite excellent short-term results in patients treated with AVR, we have previously demonstrated that 18% of patients were dead at a mean follow-up of 4.8 years after successful AVR.11
We sought to study the incremental prognostic impact of baseline valvuloarterial impedance (Zva) and left ventricular global longitudinal strain (LV-GLS) in patients with severe aortic stenosis and preserved left ventricular ejection fraction (LVEF) treated with surgical aortic valve replacement (AVR). We included 961 consecutive patients (68 ± 13 years; 63% men) with severe aortic stenosis (indexed aortic valve area <0.6 cm²) and LVEF >50% who underwent surgical AVR at our institution between January 2007 and December 2008. The analysis is based on derivation (n = 637) and validation (n = 324) subgroups. Society of Thoracic Surgeons (STS) score was calculated. Zva (systolic arterial pressure + mean aortic valve gradient)/left ventricular stroke volume index and LV-GLS (measured offline using Velocity Vector Imaging; Siemens Medical Solutions, Mountain View, California) were calculated. The primary outcome was death. Median Zva and LV-GLS were 4.5 mm Hg × ml⁻¹× m² and −14.5%, respectively. AVR was performed at a median of 34 days from initial evaluation (isolated AVR in 46%, bioprosthetic AVR in 93%). At 7.5 ± 3 years, 320 patients died (33%; 30 days/in-hospital death in 0.5%). In the derivation subgroup, on multivariate Cox survival analysis, higher STS score (hazard ratio [HR] 1.06), higher Zva (HR 1.13), and worse LV-GLS (HR 1.07) were independently associated with long-term survival (all p <0.01). When Zva and LV-GLS were sequentially added to STS score, the c-statistic improved from 0.63 [0.55 to 0.77] to 0.70 [0.60 to 0.81] and 0.78 [0.69 to 0.83], respectively, all p <0.001). Findings were confirmed in the validation subgroup. In conclusion, in patients with severe aortic stenosis and preserved LVEF treated with surgical AVR, baseline Zva and LV-GLS provide improved risk stratification with synergistic prognostic value.
Comparison of Two Minimally Invasive Techniques and Median Sternotomy in Aortic Valve Replacement
2017, Annals of Thoracic Surgery
Citation Excerpt :
The RAT access is a technically demanding operative approach requiring excellent surgical skills with perfect patient selection and precise preoperative planning, including preoperative computed tomography imaging. These comprehensive technical aspects of minimally invasive IAVR have been described in an expert review [13]. More conversions to MS and second cross clamps demonstrated this surgical challenge of the RAT access for IAVR.
Propensity score-matched analysis of the anterolateral minithoracotomy and the partial upper hemisternotomy vs the median sternotomy approach has not been reported to date for isolated aortic valve replacement.
From 2005 to 2013, isolated aortic valve replacement was performed through a partial upper hemisternotomy in 315 patients (38.9%), through a median sternotomy in 328 patients (40.5%), and through an anterolateral minithoracotomy in 167 patients (20.6%). After propensity score-matched analysis, both minimally invasive techniques were independently compared with median sternotomy in 118 matched pairs.
In the anterolateral group, conversion to median sternotomy was significantly higher (17 [14.4%]), a second pump run (6 [5.1%]) and second cross clamp (12 [10.2%]) were significantly more often necessary, the median cross-clamp time (94 minutes; range, 43 to 231 minutes) and median perfusion time (141 minutes; range, 77 to 456 minutes) were significantly longer, and more groin complications occurred (17 [14.4%]), all compared with the median sternotomy group. No difference in perioperative results was identified between the partial upper hemisternotomy and the median sternotomy group. There was no significant difference in 1-year survival among the three groups, although a trend of better survival was observed in the partial upper hemisternotomy group.
In minimally invasive isolated aortic valve replacement, the partial upper hemisternotomy shows similar perioperative outcome as the median sternotomy, whereas, the anterolateral minithoracotomy is associated with more perioperative complications. Therefore, only the partial upper hemisternotomy should be the preferred surgical technique for minimally invasive aortic valve replacement in the daily routine for a broad spectrum of surgeons.
Implantation and 30-Day Follow-Up on All 4 Valve Sizes Within the Portico Transcatheter Aortic Bioprosthetic Family
2017, JACC: Cardiovascular Interventions
The aim of this study was to evaluate the short-term safety and performance of the full range of valve sizes offered within the Portico transcatheter aortic valve replacement system.
The Portico transcatheter aortic heart valve is a fully resheathable, repositionable, and self-expanding bioprosthesis designed to achieve optimal valve position and hemodynamic performance and limit conduction disturbances.
Patients (n = 222) with symptomatic (New York Heart Association functional class ≥II) severe aortic stenosis considered by a multidisciplinary heart team to be at high surgical risk were recruited between December 2011 and September 2015 in this prospective, nonrandomized, multicenter study. Patients were implanted with the full range of Portico heart valves (23, 25, 27, and 29 mm) using the transfemoral approach. The primary endpoint was all-cause mortality at 30 days. Secondary endpoints included valve performance, improvement in functional class, and procedural outcomes as defined by Valve Academic Research Consortium criteria.
A total of 220 patients (mean age 83.0 ± 4.6 years, 74.3% women, mean Society of Thoracic Surgeons score 5.8%) had valves implanted. All resheathing and repositioning attempts (n = 72) were successful. At 30 days, all-cause mortality was 3.6%. Procedural outcomes included disabling (major) stroke (3.2%), major vascular complications (7.2%), and permanent pacemaker implantation (13.5%). Compared with baseline, 75.8% of patients improved by ≥1 New York Heart Association functional class at 30 days. The rate of moderate paravalvular leak was 5.7%, with no severe paravalvular leak reported. No differences in paravalvular leak incidence and severity were observed among valve sizes (p = 0.24).
Across all valve sizes, use of the repositionable Portico transcatheter aortic valve replacement system resulted in safe and effective treatment of aortic stenosis in high-risk patients.

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Original articleAdult cardiacContemporary Perioperative Results of Isolated Aortic Valve Replacement for Aortic Stenosis

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Am Coll Cardiol

Ann Thorac Surg

J Am Coll Cardiol

Aortic stenosis

Circulation

The natural history of aortic valve stenosis

Eur Heart J

Survival in elderly patients with severe aortic stenosis is dramatically improved by aortic valve replacement: results from a cohort of 277 patients aged > or =80 years

Eur J Cardiothorac Surg

A randomized trial of intensive lipid-lowering therapy in calcific aortic stenosis

N Engl J Med

Intensive lipid lowering with simvastatin and ezetimibe in aortic stenosis

N Engl J Med

Original article
Adult cardiac
Contemporary Perioperative Results of Isolated Aortic Valve Replacement for Aortic Stenosis