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

Percutaneous and Minimally Invasive Valve Procedures

The incidence of valvular heart disease is expected to increase over the next several decades as a large proportion of the US demographic advances into the later decades of life. At the same time, the next several years can be anticipated to bring a broad transition of surgical therapy to minimally invasive (minithoracotomy and small port) access and the more gradual introduction of percutaneous approaches for the correction of valvular heart disease. Broad acceptance of these technologies will require careful and sometimes perplexing comparisons of the outcomes of these new technologies with existing standards of care. The validation of percutaneous techniques, in particular, will require the collaboration of cardiologists and cardiac surgeons in centers with excellent surgical and catheter experience and a commitment to trial participation. For the near term, percutaneous techniques will likely remain investigational and will be limited in use to patients considered to be high risk or to inoperable surgical candidates. Although current-generation devices and techniques require significant modification before widespread clinical use can be adopted, it must be expected that less invasive and even percutaneous valve therapies will likely have a major impact on the management of patients with valvular heart disease over the next several years.

Transfemoral transcatheter aortic valve implantation using the balloon expandable SAPIEN transcatheter heart valve device

Transcatheter alternatives to standard aortic valve replacement have been developed to reduce the anticipated mortality and morbidity of therapy in patients in whom the risk of conventional surgery for critical aortic stenosis is considered to be too high. Patient selection, multidisciplinary approach and trained physicians are fundamental for the success of the procedure.

Percutaneous transarterial aortic valve replacement in selected high-risk patients with aortic stenosis

BACKGROUND

Percutaneous aortic valve replacement represents an endovascular alternative to conventional open heart surgery without the need for sternotomy, aortotomy, or cardiopulmonary bypass.

METHODS AND RESULTS

Transcatheter implantation of a balloon-expandable stent valve using a femoral arterial approach was attempted in 50 symptomatic patients with severe aortic stenosis in whom there was a consensus that the risks of conventional open heart surgery were very high. Valve implantation was successful in 86% of patients. Intraprocedural mortality was 2%. Discharge home occurred at a median of 5 days (interquartile range, 4 to 13). Mortality at 30 days was 12% in patients in whom the logistic European System for Cardiac Operative Risk Evaluation risk score was 28%. With experience, procedural success increased from 76% in the first 25 patients to 96% in the second 25 (P=0.10), and 30-day mortality fell from 16% to 8% (P=0.67). Successful valve replacement was associated with an increase in echocardiographic valve area from 0.6+/-0.2 to 1.7+/-0.4 cm2. Mild paravalvular regurgitation was common but was well tolerated. After valve insertion, there was a significant improvement in left ventricular ejection fraction (P<0.0001), mitral regurgitation (P=0.01), and functional class (P<0.0001). Improvement was maintained at 1 year. Structural valve deterioration was not observed with a median follow-up of 359 days.

CONCLUSIONS

Percutaneous valve replacement may be an alternative to conventional open heart surgery in selected high-risk patients with severe symptomatic aortic stenosis.

Aortic valve replacement improves survival in severe aortic stenosis associated with severe pulmonary hypertension

BACKGROUND

Severe pulmonary arterial hypertension in patients with severe aortic stenosis (AS) carries a poor prognosis. There are limited data on the effect of aortic valve replacement (AVR) in these patients.

METHODS

Our echocardiographic database between 1993 and 2003 was searched for patients with severe AS defined as a Doppler estimated aortic valve area of 0.8 cm2 or less and severe pulmonary hypertension defined as a pulmonary arterial systolic pressure 60 mm Hg or greater. Of the 740 patients with severe AS, 119 (16%) had severe pulmonary hypertension forming the study cohort. The AVR was performed in 36 (30%) of these patients. Survival of patients with and without AVR were compared and adjusted for comorbidities and group differences using the Cox regression model.

RESULTS

Characteristics of patients with severe pulmonary hypertension; age 75 +/- 13 years, 39% women, left ventricular ejection fraction 41 +/- 20%. Patients who underwent AVR had a significantly higher five-year survival of 65% compared with 20% for those treated medically (p < 0.0001). The relative mortality risk associated with AVR was 0.28 (95% confidence interval 0.22 to 0.36) and was independent of age, gender, ejection fraction, diabetes, coronary disease, serum creatinine level, and concomitant medical therapy such as beta blockers, angiotensin converting inhibitors, and statins. The benefit of AVR was further supported by sensitivity and propensity score analyses. Patients on conservative therapy had a 30-day mortality of 30% and a one-year mortality of 70%.

CONCLUSIONS

Aortic valve replacement in patients with severe pulmonary hypertension secondary to severe AS is associated with a huge survival benefit. Medical therapy alone carries a dismal prognosis and AVR should be considered urgently in severe AS patients with severe pulmonary hypertension.