Clinical profile and natural history of 453 nonsurgically managed patients with severe aortic stenosis

Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery

BACKGROUND

Many patients with severe aortic stenosis and coexisting conditions are not candidates for surgical replacement of the aortic valve. Recently, transcatheter aortic-valve implantation (TAVI) has been suggested as a less invasive treatment for high-risk patients with aortic stenosis.

METHODS

We randomly assigned patients with severe aortic stenosis, whom surgeons considered not to be suitable candidates for surgery, to standard therapy (including balloon aortic valvuloplasty) or transfemoral transcatheter implantation of a balloon-expandable bovine pericardial valve. The primary end point was the rate of death from any cause.

RESULTS

A total of 358 patients with aortic stenosis who were not considered to be suitable candidates for surgery underwent randomization at 21 centers (17 in the United States). At 1 year, the rate of death from any cause (Kaplan–Meier analysis) was 30.7% with TAVI, as compared with 50.7% with standard therapy (hazard ratio with TAVI, 0.55; 95% confidence interval [CI], 0.40 to 0.74; P<0.001). The rate of the composite end point of death from any cause or repeat hospitalization was 42.5% with TAVI as compared with 71.6% with standard therapy (hazard ratio, 0.46; 95% CI, 0.35 to 0.59; P<0.001). Among survivors at 1 year, the rate of cardiac symptoms (New York Heart Association class III or IV) was lower among patients who had undergone TAVI than among those who had received standard therapy (25.2% vs. 58.0%, P<0.001). At 30 days, TAVI, as compared with standard therapy, was associated with a higher incidence of major strokes (5.0% vs. 1.1%, P=0.06) and major vascular complications (16.2% vs. 1.1%, P<0.001). In the year after TAVI, there was no deterioration in the functioning of the bioprosthetic valve, as assessed by evidence of stenosis or regurgitation on an echocardiogram.

CONCLUSIONS

In patients with severe aortic stenosis who were not suitable candidates for surgery, TAVI, as compared with standard therapy, significantly reduced the rates of death from any cause, the composite end point of death from any cause or repeat hospitalization, and cardiac symptoms, despite the higher incidence of major strokes and major vascular events. (Funded by Edwards Lifesciences; ClinicalTrials.gov number, NCT00530894.).

Apico-Aortic Conduit for severe aortic stenosis: Technique, applications, and systematic review

Patients referred for aortic valve replacement are often elderly and may have increased surgical risk associated with ascending aortic calcification, left ventricular dysfunction, presence of coronary artery disease, previous surgery, and/or presence of several co-morbidities. Some of these patients may not be considered candidates for conventional surgery because of their high risk profile. While transcatheter aortic valve replacement constitutes a widely accepted alternative, some patients may not be eligible for this modality due to anatomic factors. Apico-Aortic Conduit (AAC) insertion (aortic valve bypass surgery) constitutes a possible option in those patients. Apico-Aortic Conduit is not a new technique, as it has been used for decades in both pediatric and adult populations. However, there is a resurging interest in this technique due to the expanding scope of elderly patients being considered for the treatment of aortic stenosis. Herein, we describe our surgical technique and provide a systematic review of recent publications on AAC insertion, reporting that there is continued use and several modifications of this technique, such as performing it through a small thoracotomy without the use of the cardiopulmonary bypass.

Transaortic transcatheter aortic valve implantation: a novel approach for the truly "no-access option" patients

OBJECTIVES

The aim of this study was to test the safety and efficacy of the retrograde, minimally invasive, "transaortic" approach of transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve prosthesis (Medtronic, Minneapolis) as an alternative minimally invasive surgical access route.

BACKGROUND

TAVI is today recognized as an established percutaneous technique for patients with severe aortic valve stenosis (AS). However, as the number of patients screened for TAVI increases, many are found with absolutely no option for peripheral artery access.

METHODS

A new method of TAVI access, described as "transaortic" was performed in two patients A CoreValve prosthesis was implanted via the "transaortic" route. The patients were a 93- and a 84-year-old woman, both with severe PAOD. After a ministernotomy the ascending aorta was directly punctured. At the end, the access site was surgically sutured with the prepositioned sutures. The patients were at all times "off-pump" (beating heart procedure) and without IABP.

RESULTS

TAVI was successful in both cases, leading to a fall in the transvalvular gradient and there were no cases of mortality, stroke or myocardial infarction. The patients were extubated directly after the procedure, mobilized after 4 days, and were discharged home after 7 and 9 days.

CONCLUSIONS

In the rare occasion, where due to anatomical reasons transfemoral TAVI is not feasible, a minimally invasive "transaortic" approach, as described, provides an alternative option. This is especially true when the transapical route is not suitable (annulus >25 mm or contraindication to lateral thoracotomy).

Successful transapical aortic valve implantation in a congenital bicuspid aortic valve

Transcatheter stent-valve implantation in stenosed congenital bicuspid aortic valves is under debate. Heavily calcified elliptic bicuspid valves represent a contraindication to catheter-based valve therapies because of a risk of stent-valve displacement, distortion, or malfunctioning after the implantation. In this case report we illustrate our experience with a patient suffering from stenosed congenital bicuspid aortic valve who successfully underwent a transapical 26-mm Edwards Sapien stent-valve (Edwards Lifesciences Inc, Irvine, CA) implantation. Postoperative distortion, malfunctioning, and paravalvular leaks were not detected.

Early and midterm hemodynamics after aortic valve bypass (apicoaortic conduit) surgery

BACKGROUND

Aortic valve bypass (AVB [apicoaortic conduit]) relieves aortic stenosis (AS) by connecting the apex of the left ventricle to the descending thoracic aorta with a valved conduit. AVB is performed through a small left thoracotomy, without cardiopulmonary bypass, aortic cross-clamping, cardiac arrest, or debridement of the native aortic valve. Little is known about hemodynamics, including ventricular performance, relative conduit blood flow, and progression of native AS after AVB.

METHODS

Forty-seven very high risk patients underwent AVB for AS between 2003 and 2009. The mean age was 82 years. Predismissal and interval transthoracic quantitative two-dimensional and Doppler echocardiography was performed in a core laboratory.

RESULTS

No patient had obstruction of the native aortic valve or the conduit during follow-up. The AVB effectively relieved left ventricular outflow tract obstruction (average peak gradient across the conduit was 5.6 +/- 3.8 mm Hg). Native aortic valve stenosis did not progress after AVB (0.63 +/- 0.16 cm(2) before surgery to 0.7 +/- 0.24 cm(2) at latest follow-up more than 6 months; p = 0.16). Total stroke volume increased after AVB from 60 mL +/- 22 mL to 107 mL +/- 27 mL (p < 0.0001). Left ventricular outflow was distributed in a predictable fashion between the conduit and the native aortic valve, with 63% +/- 10% of the flow directed to the conduit. Relative conduit flow remained stable (68% +/- 8%) at latest follow-up more than 6 months (p = 0.17).

CONCLUSIONS

Aortic valve bypass effectively relieves the outflow tract obstruction of AS. Placement of an apical valved conduit halts the biologic progression of AS.

Indication for percutaneous aortic valve implantation

The incidence of valvular aortic stenosis has increased over the past decades due to improved life expectancy. Surgical aortic valve replacement is currently the only treatment option for severe symptomatic aortic stenosis that has been shown to improve survival. However, up to one third of patients who require lifesaving surgical aortic valve replacement are denied surgery due to high comorbidities resulting in a higher operative mortality rate. In the past such patients could only be treated with medical therapy or percutaneous aortic valvuloplasty, neither of which has been shown to improve mortality. With advances in interventional cardiology, transcatheter methods have been developed for aortic valve replacement with the goal of offering a therapeutic solution for patients who are unfit for surgical therapy. Currently there are two catheter-based treatment systems in clinical application (the Edwards SAPIEN aortic valve and the CoreValve ReValving System), utilizing either a balloon-expandable or a self-expanding stent platform, respectively.

Transcatheter aortic valve implantation for high risk patients with severe aortic stenosis using the Edwards Sapien balloon-expandable bioprosthesis: a single centre study with immediate and medium-term outcomes

BACKGROUND

Transcatheter aortic valve implantation (TCAVI) is an emerging alternative therapy to open-heart surgery in high-risk patients with symptomatic aortic stenosis.

METHODS

Between January 2007 and May 2009, 46 patients underwent TCAVI with the 23 mm or 26 mm Edwards Sapien bioprosthesis via either the transapical (TA-AVI) or transfemoral (TF-AVI) approach. All patients had an estimated operative mortality risk of >15%.

RESULTS

A total of 46 patients (30 TA-AVI, 16 TF-AVI) with a mean aortic valve area (AVA) of 0.63 +/- 0.2 cm(2) and mean gradient of 54 +/- 16 mm Hg were treated. Predicted operative mortality was 25.3% by logistic Euroscore and 8.7% by Society of Thoracic Surgeons risk score. Procedural success was 93% in the TA-AVI group and 88% in the TF-AVI group. There was one intraprocedural death in the TA-AVI group. Overall 30-day mortality was 6.5% (2-TA-AVI, 1-TF-AVI). Four patients (9.5%) died from noncardiac causes after 30 days. Successful TCAVI was associated with a significant increase in AVA from 0.6 +/- 0.1 cm(2) to 1.6 +/- 0.6 cm(2) in the TA-AVI group and 0.6 +/- 0.1 cm(2) to 1.4 +/- 0.2 cm(2) in the TF-AVI group at a mean follow up of 7.4 +/- 4.4 and 8.3 +/- 5.0 months, respectively. At discharge, there was significant improvement in AVA (P < 0.0001), transaortic mean gradient (P < 0.0001), and mitral regurgitation (P = 0.01). At medium term follow up, the valve area was maintained and there was significant improvement in NYHA class in both groups (P < 0.0001).

CONCLUSION

At medium term follow-up, both transcatheter approaches demonstrated good valve durability with no cardiac-related mortality post hospital discharge.

Transcatheter aortic valve implantation: the state of play

Aortic stenosis is the most commonly acquired valvular heart disease in the Western world. Surgical aortic valve replacement is currently the gold-standard treatment for patients with severe symptomatic aortic stenosis. Without surgery, the prognosis is extremely poor, with a 3-year survival rate of less than 30%. Transcatheter aortic valve implantation (TAVI) is a rapidly evolving novel technique that was first introduced in 2002 and is currently available in Europe as an alternative to conventional aortic valve replacement for patients with severe symptomatic aortic stenosis who are deemed to be at too high a risk for open heart surgery. This article describes the TAVI technique and patient selection criteria. We explore how far we have come with advances in TAVI and analyze the short- and medium-term outcome data reported on TAVI so far. We will also look at the potential future role of TAVI and the challenges involved in setting up a TAVI service.

Off-pump coronary artery revascularization in octogenarians: is it better?

PURPOSE OF REVIEW

Octogenarians are the fastest growing stratum of the population and have the highest prevalence of coronary artery disease. In the past, physicians have been reluctant to provide these patients with optimal care. Seniors are frequently excluded from large randomized trials and generally not included in published guidelines. The purpose of this review is to revisit the demography and epidemiology of coronary artery disease in this population as well as therapeutic strategies used.

RECENT FINDINGS

Recent publications have shown significant advancement in medical and invasive treatment of coronary artery disease in elderly, with special focus on the potential benefit of off-pump coronary artery bypass (OPCAB) surgery.

SUMMARY

Although OPCAB surgery has gained popularity over the past 15 years, its benefit regarding operative mortality and major complications has not been clearly defined in the general population. There is a body of literature supporting its benefit in the elderly population. OPCAB surgery has the potential of decreasing operative mortality and major postoperative complications such as stroke, delirium, atrial fibrillation, and decline in neurocognitive functions in these patients. Off-pump surgery is technically more demanding and has been blamed for providing less complete revascularization and lower graft patency rate, especially in less experienced hands. However, with the upcoming demographic explosion of senior citizens in western societies, OPCAB surgery has definitely to be a part of the armamentarium of modern cardiac surgeons.

Progress and current status of percutaneous aortic valve replacement: results of three device generations of the CoreValve Revalving system

BACKGROUND

Percutaneous aortic valve replacement is a new emerging technology for interventional treatment of severe aortic valve stenosis in surgical high-risk patients. This study was intended to provide a summary of the development and current safety and efficacy status of the self-expanding CoreValve Revalving prosthesis.

METHOD AND RESULTS

Between 2005 and 2008, we have enrolled 136 consecutive patients with percutaneous aortic valve replacement using the CoreValve prosthesis. In this prospective nonrandomized, single-center trial, we analyzed procedural outcome, complications and clinical status up to 1 year. First, second, and third generation of the CoreValve prosthesis were implanted in 10, 24, and 102 consecutive high-risk patients (logistic EuroScore: 23.1+/-15.0%) with severe symptomatic aortic valve stenosis. Mean transvalvular pressure gradient was 41.5+/-16.7 mm Hg. The procedural success rate increased from generation 1/2 to 3 from 70.0%/70.8% to 91.2% (P=0.003). The 30-day combined rate of death/stroke/myocardial infarction was 40.0%/20.8%/14.7% (P=0.11) for generation 1, 2, and 3, with no procedural death in generation 3. Pressure gradients improved significantly with a final mean gradient of 8.1+/-3.8 mm Hg. Overall functional status assessed by New York Heart Association class improved from 3.3+/-0.5 (pre) to 1.7+/-0.7 (post) (P<0.001) and remained stable in the follow-up.

CONCLUSIONS

In experienced hands, percutaneous aortic valve replacement with the CoreValve system for selected patients with severe aortic valve stenosis has a high acute success rate associated with a low periprocedural mortality/stroke rate as well as remarkable clinical and hemodynamic improvements, which persist over time. Additional studies are now required to confirm these findings, particularly head-to-head comparisons with surgical valve replacement in different risk populations.

Transcatheter aortic valve implantation: what has been done and what is going to be done

Transcatheter valve implantation is developing into an effective and reproducible therapy for aortic valve stenosis. The origin of this technique was pursued in 1992 when Andersen demonstrated the feasibility of percutaneous implantation of catheter-based valve prosthesis. Since then a lot of technical and device advances have been made and to date, transcatheter aortic valve implantation has became a concrete alternative to surgical replacement. This paper aims to go over all the current devices, from the most widely used to the newest technology, focusing on device description, procedural issues, potential complications and clinical studies currently available in literature.

Transapical transcatheter off-pump aortic valve implantation

Transapical aortic valve implantation (TA-AVI) is a new minimally invasive technique for beating-heart off-pump AVI in high-risk patients. The procedure involves antegrade AVI using an oversizing technique with direct access and accurate positioning of a stent based transcatheter xenograft. Procedural steps include placement of femoral arterial and venous access wires, anterolateral minithoracotomy, placement of an epicardial pacing wire and two apical purse-string sutures. Valve implantation is performed off-pump under fluoroscopic and echocardiographic guidance with rapid ventricular pacing. This new technology is a promising alternative for selected elderly high-risk patients and seems to be associated with good outcome and a minimal stroke risk.

[Transcatheter aortic valve implantation: surgeon's view]

BACKGROUND AND PURPOSE

The technology of catheter- based aortic valve implantation is a new, less invasive therapeutic option for patients with symptomatic high-grade aortic stenosis. The present paper aims to demonstrate that optimal therapy should be provided by a multidisciplinary team consisting of cardiac surgeons, cardiologists and cardioanesthesiologists in a hybrid suite.

PATIENTS AND METHODS

From June 2007 to April 2009, 234 patients have been treated by transcatheter aortic valve implantation through different access sites (n = 168 femoral artery, n = 56 left ventricular apex, n = 7 subclavian artery, n = 3 ascending aorta) at the German Heart Center Munich, Germany. An algorithm for the choice of the most appropriate access site for the individual patient was established.

RESULTS

The 30-day mortality was 11.2% in this high-risk patient cohort. A certain number of periprocedural complications required surgical management. There was a considerable clinical improvement of the patients 6 months after the procedure.

CONCLUSION

Integrating the new methods of aortic valve implantation into a cardiac surgery program, all kinds of surgical and interventional treatment options may be offered to the patient with aortic stenosis by one multidisciplinary team. A qualified and safe performance of transcatheter aortic valve implantation and the management of potential complications require the presence of a hybrid suite.

Development of aortic valve implantation

Aortic valve stenosis is an important public-health problem in Europe and is predicted to increase with the aging population. Management of severe symptomatic aortic stenosis is by surgical replacement of the aortic valve whenever feasible. Improvement in the perioperative management has permitted surgical intervention in high-risk patients. However, patients refused surgery can now be managed by transcatheter techniques. These have opened new horizons for patients for whom conventional surgery is contraindicated or the technical complexity of the procedure is associated with considerable operative risk. The development of transcatheter aortic valve implantation, available technology, choice of approach, and future perspectives are discussed.

Evaluation of patients with severe symptomatic aortic stenosis who do not undergo aortic valve replacement: the potential role of subjectively overestimated operative risk

BACKGROUND

Some patients with severe symptomatic aortic stenosis (AS) do not undergo aortic valve replacement (AVR) despite demonstrated symptomatic and survival advantages and despite unequivocal guideline recommendations for surgical evaluation.

METHODS AND RESULTS

In 3 large tertiary care institutions (university, Veterans Affairs, and private practice) in Washtenaw County, Mich, patients were identified with unrefuted echocardiography/Doppler evidence of severe AS during calendar year 2005. Medical records were retrospectively reviewed for symptoms, referral for AVR, calculated operative risk for AVR, and rationale as to why patients did not undergo valve replacement. Of 369 patients with severe AS, 191 (52%) did not undergo AVR. Of these, 126 (66%, 34% of total) had symptoms consistent with AS. The most common reasons cited for absent intervention were comorbidities with high operative risk (61 patients [48%]), patent refusal (24 patients [19%]), and symptoms unrelated to AS (24 patients [19%]). Operated patients had a lower Society of Thoracic Surgery-calculated perioperative mortality risk than unoperated patients (1.8% [interquartile range, 1.0 to 3.0%] versus 2.7% [interquartile range, 1.6 to 5.5%], P<0.001). However, 28 (24%) of 126 unoperated symptomatic patients had a calculated perioperative risk less than the median risk for patients who underwent AVR. Only 57 (30%) of 191 unoperated patients were evaluated by a cardiac surgeon. There were similar rates of intervention across practice settings, and similar rates of unoperated patients despite symptoms and low operative risk.

CONCLUSIONS

One third of patients with severe AS are symptomatic but do not undergo AVR, with similar findings in multiple practice environments. For most unoperated patients, objectively calculated operative risks did not appear prohibitive. Despite this, a minority of unoperated patients were referred for surgical consultation. Some patients with severe symptomatic AS may be inappropriately denied access to potentially life-saving therapy.

Surgical outcomes and post-operative changes in patients with significant aortic stenosis and severe left ventricle dysfunction

Little is known regarding long-term survival and changes in systolic function following surgery after the occurrence of a severe left ventricular (LV) dysfunction in patients with severe aortic stenosis. Inclusion criteria were an aortic valve area less than 1 cm(2) and an LV ejection fraction (EF) less than 35%. Between January 1990 and July 2007, 41 (male: 30) patients were identified. The pre-operative mean EF and mean aortic valve area were 26.7+/-6.1% and 0.54+/-0.2 cm(2), respectively. Concomitant coronary artery bypass surgery was performed in 8 patients (19.6%). Immediate post-operative echocardiogram showed to be much improved in LV EF (27.2+/-5.5 vs. 37.4+/-11.3, P<0.001), LV mass index (244.2+/-75.3 vs. 217.5+/-71.6, P=0.006), and diastolic LV internal diameter (62.5+/-9.3 vs. 55.8+/-9.6, P<0.001). Post-operative LV changes were mostly complete by 6 months, and were maintained thereafter. There was one in-hospital mortality (2.4%) and 12 late deaths including one patient diagnosed with malignancy in whom LV function was normal. Multivariate analysis showed pre-operative atrial fibrillation and NYHA FC IV to be significant risk factors for cardiac-related death. Aortic valve replacement in patients with significant aortic stenosis and severe LV dysfunction showed acceptable surgical outcomes. Moreover, LV function improved significantly in many patients.

Transapical aortic valve implantation. Initial experience

We report our initial experience with transapical aortic valve implantation. All six of our patients were octogenarians, all had significant associated comorbid conditions and, according to the logistic EuroSCORE, their mortality was expected to be 22%. All procedures were performed successfully and there were no intraoperative or postoperative complications. Five patients were discharged between postoperative days 5 and 7 with normally functioning prostheses.

[Implantation of aortic valvular prosthesis via transfemoral catheter. Evaluation of candidates undergoing the procedure]

BACKGROUND AND OBJECTIVE

In recent years, techniques for implantation of aortic prosthesis via catheter have been developed as a therapeutic alternative in patients with severe aortic stenosis rejected for surgery. The correct selection of candidates is one of the more complex aspects of this treatment. We analyzed the acceptance rate in our environment for transcatheter aortic valve implantation in patients referred to our hospital for evaluation as possible candidates, describing the exclusion reasons.

PATIENTS AND METHOD

30 patients with severe aortic stenosis and rejected for surgical aortic valve replacement were referred to our hospital to evaluate transcatheter aortic valve implantation. The patients first underwent clinical evaluation and were studied with echocardiography, angiography and computed tomography.

RESULTS

Of the 30 patients, 18 were rejected for the procedure (60%): 4 patients with non-severe aortic stenosis, 2 asymptomatic patients, 2 patients who finally underwent surgery because of a low-surgical-risk, 5 patients with contraindications for the procedure, 2 patients who finally did not want to undergo the procedure and 3 patients were further rejected because the vascular access was inappropriate. Of the remaining 12 patients initially accepted, 3 died before the procedure was performed. Finally, only 9 patients (30%) underwent transcatheter aortic valve implantation.

CONCLUSIONS

Of the patients referred for transcatheter aortic valve implantation, only 40% were accepted. The mortality rate during the evaluation process of this procedure is high, showing that these patients are terminally ill.

Transcatheter Aortic Valve Implantation

There has been significant improvement in device designs, operative techniques, and early clinical outcomes in <5 years. Presently, there are two catheter-based bioprostheses (balloon expandable or self-expandable), which have been widely used in humans and are undergoing clinical investigations. Three approaches, including transvenous, transarterial, and transapical have been used for delivery of the catheter-based bioprostheses, and transarterial and transapical approaches have been adopted by cardiologists and cardiac surgeons worldwide. The most recent clinical results have been very encouraging and promising. With experience, 30-day operative mortality with either balloon-expandable or self-expandable bioprosthesis was reduced significantly to approximately 10% in high-risk patients. In vivo long-term durability of catheter-based bioprostheses remains unknown, and presently transcatheter procedure is limited to the cohort of high-risk patients. Expanding this new technology to low-risk patients should be done with extreme caution because conventional aortic valve replacement still provides the best long-term outcome with minimal operative mortality and morbidity in low-risk patients. Ongoing clinical trials will address many unanswered questions, such as patient selection, long-term in vivo durability, preoperative assessment, and the role of the procedures in management of valvular diseases.

Characterization and outcome of patients with severe symptomatic aortic stenosis referred for percutaneous aortic valve replacement

OBJECTIVE

Many high-risk patients with severe symptomatic aortic stenosis are not referred for surgical aortic valve replacement. Although this patient population remains ill-defined, many of these patients are now being referred for percutaneous aortic valve replacement. We sought to define the characteristics and outcomes of patients referred for percutaneous aortic valve replacement.

METHODS

Between February 2006 and March 2007, 92 patients were screened for percutaneous aortic valve replacement. Clinical and echocardiographic characteristics of patients undergoing surgical aortic valve replacement, percutaneous aortic valve replacement, balloon aortic valvuloplasty, or no intervention were compared. The primary end point was all-cause mortality.

RESULTS

Nineteen patients underwent successful surgical aortic valve replacement, 18 patients underwent percutaneous aortic valve replacement, and 36 patients had no intervention. Thirty patients underwent balloon aortic valvuloplasty, and of these, 8 patients were bridged to percutaneous aortic valve replacement and 3 were bridged to surgical aortic valve replacement. Of the remaining 19 patients undergoing balloon aortic valvuloplasty, bridging to percutaneous aortic valve replacement could not be accomplished because of death (n = 9 [47%)], exclusion from the percutaneous aortic valve replacement protocol (n = 6 [32%]), and some patients improved after balloon aortic valvuloplasty and declined percutaneous aortic valve replacement (n = 4 [21%]). The most common reasons for no intervention included death while awaiting definitive treatment (n = 10 [28%]), patient uninterested in percutaneous aortic valve replacement (n = 10 [28%]), and questionable severity of symptoms or aortic stenosis (n = 9 [25%]). Patients not undergoing aortic valve replacement had higher mortality compared with those undergoing aortic valve replacement (44% vs 14%) over a mean duration of 220 days.

CONCLUSION

Symptomatic patients with severe aortic stenosis have high mortality if timely aortic valve replacement is not feasible. Twenty percent of the patients referred for percutaneous aortic valve replacement underwent surgical aortic valve replacement with good outcome. Patients undergoing balloon aortic valvuloplasty alone or no intervention had unfavorable outcomes.

Aortic valve replacement in octogenarians: utility of risk stratification with EuroSCORE

BACKGROUND

With the advent of percutaneous valve implantation, an increasing amount of interest is being expressed in outcomes of conventional aortic valve replacement (AVR) in elderly patients. We evaluated characteristics and outcomes of elderly patients undergoing isolated AVR with a particular focus on the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk stratification.

METHODS

All patients aged 80 years or older (n = 282) undergoing isolated AVR between November 1995 and June 2006 at our institution were reviewed according to logistic EuroSCORE (ES(log)) risk stratification. Surgical risk was defined as low risk (ES(log) < or = 10% [n = 107]), moderate risk (10% < ES(log) < 20% [n = 103]), and high risk (ES(log) > or = 20% [n = 72]). Patient age was 82 +/- 2 years (low risk), 82.7 +/- 2.7 years (moderate risk), and 83.6 +/- 3.1 years (high risk), respectively (p < 0.05). Mean ES(log) predicted risk of mortality was 7.3% +/- 1.4% (low risk), 13.7% +/- 2.5% (moderate risk), and 33.0% +/- 11.5% (high risk; p < 0.05). Follow-up was 99.7% complete.

RESULTS

In-hospital mortality was 7.5% (low risk), 12.6% (moderate risk), and 12.5% (high risk; p = 0.4). One-year survival was 90%, 78%, and 69% (p = 0.002); 5-year survival was 70%, 53%, and 38% (p = 0.05); and 8-year survival was 38%, 33%, and 21% (p = 0.017), for low-, moderate-, and high-risk patients, respectively. Independent predictors for in-hospital mortality were pulmonary hypertension and urgent indication for surgery. Cox regression predictors of medium-term survival were congestive heart failure, urgent timing, previous stroke or transient ischemic attack, and EuroSCORE stratum.

CONCLUSIONS

Aortic valve replacement can be performed in the elderly population with acceptable outcomes. EuroSCORE risk stratification is imprecise for prediction of perioperative mortality among octogenarian AVR patients, but may be useful for predicting mortality during medium-term follow-up.

Valve implantation on the beating heart: catheter-assisted surgery for aortic stenosis

BACKGROUND

For an increasing number of patients with severe symptomatic aortic stenosis, advanced age and comorbidity make the risk of surgery unacceptably high. In such cases, catheter-based techniques for aortic valve implantation are a new therapeutic option. In this paper, we describe the initial results obtained at the German Heart Center, Munich, with a new technique of this kind.

METHODS

From June 2007 to September 2008, 152 patients underwent transcatheter aortic valve implantation at the German Heart Center, Munich (121 transfemorally, 26 transapically, and 5 through other sites of access). In this technique, a stent-mounted valve is crimped onto a catheter and then positioned and deployed in the aortic annulus under fluoroscopic control.

RESULTS

The 30-day mortality was 11.8% in this group of patients at high risk. The more common post-procedural complications were third-degree atrioventricular block leading to pacemaker implantation (31/152, 20%), vascular complications (25/152, 16%), and cerebrovascular events (8/152, 5%). Six months after the procedure, the patients had recovered clinically to a considerable extent, and the implanted prostheses exhibited good hemodynamic function.

CONCLUSIONS

The technical feasibility of catheter-based aortic valve implantation has been demonstrated at multiple centers around the world. Its indications still need to be refined on the basis of the short- and long-term results of the randomized and observational studies that are currently in progress. It is already apparent that catheter-based aortic valve implantation can bring about clinical improvement in patients who are deemed ineligible for open surgery.

[Update on geriatric cardiology]

This article contains a review of the main developments in the field of geriatric cardiology reported during 2008. The focus is on research concerning the specific characteristics of elderly patients with heart failure, arrhythmias, ischemic heart disease, and aortic valve disease.

Survival benefit of aortic valve replacement in patients with severe aortic stenosis with low ejection fraction and low gradient with normal ejection fraction

BACKGROUND

Aortic stenosis (AS) is becoming increasingly common with the aging population. Many of these patients have reduced left ventricular (LV) ejection fractions (EF) or low transvalvular gradients resulting in reluctance to offer aortic valve replacement (AVR).

METHODS

Our echocardiographic database for the period of 1993 to 2003 was screened for severe AS (aortic valve area [AVA]

RESULTS

Of the 740 patients with severe AS, 194 (26%) had severe LV dysfunction defined as EF 0.35 or less and 168 (23%) a mean transvalvular gradient of 30 mm Hg or less. Low ejection fraction was not a prerequisite for a low gradient. The Univariate predictors of higher mortality in both groups included higher age, lower ejection fraction, renal insufficiency, and lack of aortic valve replacement. Lack of aortic valve replacement was a strong predictor of mortality after adjusting for 18 clinical, echocardiographic, and pharmacologic variables. There were 72 patients with EF 0.20 or less, of whom 18 had AVR, which was associated with a large survival benefit similar to the entire cohort. In the 52 patients with EF 0.55 or less and mean gradient less than 30 mm Hg, the 5-year survival with AVR was 90% compared with 20% without AVR (p < 0.0001) which was supported by propensity score analysis as well.

CONCLUSIONS

Severe LV dysfunction or a low transvalvular gradient is seen in about a quarter of patients with severe AS and there is a reluctance to offer AVR in these patients. Aortic valve replacement is associated with a large mortality benefit in these patients.

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MESH Headings

• Aged
• Aged, 80 and over
• Aortic Valve Stenosis/diagnostic imaging
• Aortic Valve Stenosis/mortality
• Aortic Valve Stenosis/surgery
• Blood Vessel Prosthesis
• Blood Vessel Prosthesis Implantation/methods
• Blood Vessel Prosthesis Implantation/mortality
• Cohort Studies
• Echocardiography, Doppler
• Female
• Follow-Up Studies
• Humans
• Male
• Middle Aged
• Probability
• Proportional Hazards Models
• Reference Values
• Retrospective Studies
• Risk Assessment
• Severity of Illness Index
• Stroke Volume/physiology
• Survival Analysis
• Treatment Outcome
• Ventricular Dysfunction, Left/diagnosis
• Ventricular Dysfunction, Left/mortality

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Grants Collapse

Affiliation(s)

Ramdas G Pai Division of Cardiology, Loma Linda University Medical Center, Loma Linda, California, USA
Padmini Varadarajan
Anees Razzouk

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Aortic balloon valvuloplasty--review and case series

Aortic balloon valvuloplasty (BAV) was initially devised in the 1980s as an alternative procedure to the surgical treatment of aortic stenosis, with the theory behind it being both minimally invasive as well as having a lower complication rate [Hara H, et al. Percutaneous balloon aortic valvuloplasty revisited: time for a renaissance? Circulation 2007 March;115(12):e334-8]. In practice however, the procedure was found to have a higher complication rate with only a modest haemodynamic improvement compared to the surgical approach. Most important of all it had an unacceptably high restenosis rate as a substitute for surgery [Otto CM, et al. 3-year outcome after balloon aortic balloon valvuloplasty: insights into prognosis of valvular aortic stenosis. Circulation 1994;89:642-50]. As a result, the procedure has fallen out of favour and has been abandoned at many health care facilities [Hara H, et al. Percutaneous balloon aortic valvuloplasty revisited: time for a renaissance? Circulation 2007 March;115(12):e334-8]. This article will review the management of patients with severe aortic stenosis that are unsuitable to undergo surgery.

[Comparative study of exercise-induced ischaemia in coronaropathy and aortic stenosis]

OBJECTIVE

To compare exercise and recovery data between a population of patients with proven CAD and patients with pure aortic stenosis (AS).

PATIENTS AND METHODS

Exercise testing results (bicycle ergometry) of 45 patients with AS (34 men, 66+/-12 years, 56+/-20 mmHg peak-to-peak gradient and valve area 0.78+/-0.48cm2) were compared to exercise testing results of 50 patients with CAD (41 men, 65+/-9 years, greater or equal to 70% stenosis on one vessel in 62%, two vessels in 30%, three vessels in 8%).

RESULTS

During exercise, 38% patients with AS and 82% patients with CAD had clinical symptoms. In the AS group, exercise duration was longer, heart rate (HR) was higher, maximal systolic and diastolic blood pressure were lower than in CAD group. The increase of systolic blood pressure was lower in the AS group (34+/-21 mmHg versus 47+/-27 mmHg, p<0.02). Maximal load achieved was not significantly different. Exercise ST depression appeared in 76% of AS group and 88% of CAD group (NS). No difference was found in ST depression, Detrano index and ST segment/HR slope. During recovery, no difference was found in HR variations. Clockwise rotation of the ST/HR recovery loop was more frequent in CAD group (35 patients versus 19 patients, p<0.001).

CONCLUSION

Most of the exercise and recovery data are similar in patients with AS and CAD. Significant discriminating criteria were the increase of systolic blood pressure during exercise and ST/HR recovery loop.