Outcome of Redo Surgical Aortic Valve Replacement in Patients 80 Years and Older: Results From the Multicenter RECORD Initiative

Bioprosthetic aortic valve replacement in patients aged 50 years old and younger: Structural valve deterioration at long-term follow-up. Retrospective study

Background

Structural valve deterioration (SVD) remains the major determinant of bioprosthesis durability. The aim of this study was to investigate the SVD incidence, predictors and outcomes in patients aged 50 years and younger after bioprosthetic aortic valve replacement (bAVR).

Methods

We retrospectively analyzed 73 consecutive patients ≤50 years old who underwent bioprosthetic AVR at our center between 2005 and 2015. Median age at surgery was 44 (interquartile range [IQR]: 39-47) years. Follow-up was 93.2% complete at a median time of 7.2 (IQR: 5.5-9.5) years. Cumulative follow-up was 545.5 valve-years. Bioprosthesis SVD was determined by strict echocardiographic assessment.

Results

The overall survival-rate at 10/15 years and freedom from SVD at 10/12.5 years were 89.6 ± 5.2%/81.5 ± 9.1% and 73.5 ± 8.2%/41.9 ± 18.9%, respectively. SVD occurred at a median time of 8.2 (IQR: 6.0-9.9) years after bAVR. Age was not found as an independent predictor for SVD at the multivariable model, despite a higher rate of SVD in the age group ≤30 years. Freedom from reoperation due to SVD at 10/15 years was 71.3 ± 14.1%/13.6 ± 12.3%. Reoperation was performed at a median time of 10.0 (IQR: 8.9-11.9) years since first bAVR and was associated with a 100% 12-month survival.

Conclusions

In our study, the rate and time of SVD occurrence were comparable to those of other studies' older age groups. Strict echocardiographic monitoring of valve performance is mandatory to set the appropriate timing of eventual reoperation. This attitude can improve outcomes of bAVR in younger patients.

Valve-in-valve Transcatheter Aortic Valve Replacement for Failed Surgical Valves and Adjunctive Therapies

While redo surgical aortic valve replacement has traditionally been the gold standard for the treatment of failed surgical valves, valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) has arisen as a viable, less invasive option with the potential for improved short-term morbidity and mortality. Retrospective registry data regarding ViV TAVR outcomes have been encouraging, with excellent 1-year mortality, and sustained valve performance and quality of life improvement out to 3 years. Operators must be comfortable with CT analysis for procedural planning, and be able to identify and troubleshoot patients who are at risk for coronary obstruction and patient prosthesis mismatch. The authors provide a review of clinical outcomes associated with ViV TAVR, procedural planning recommendations, and strategies to overcome technical challenges that can occur during ViV TAVR.

The use of balloon-expandable Sapien-3 valve in redo aortic valve replacement and the potential risk of left main stem occlusion

Redo aortic valve surgery for the failure of a previously implanted valve is always challenging. In case of small‐sized implanted valves, the use of a balloon‐expanding Sapien‐3 valve can enhance the final effective orifice area, avoid annulus enlargement complex techniques, and can reduce operative time and morbidities. We describe a case where after explanting a failed 19 mm St. Jude mechanical aortic valve and further deployment of a 23 mm Sapien‐3 valve, the left coronary ostia was obstructed by the skirt of the transcatheter prosthesis. After careful removal of a little part of the skirt, we were able to restore the coronary flow and the patient had a favorable outcome.

Lifetime management for aortic stenosis: Planning for future therapies

A shift to lifetime management has gained more focus with the approval of low-risk transcatheter aortic valve replacement (TAVR). This paper is therefore focused on the different approaches for lifetime management. Herein we discuss the procedural safety, durability, performance, and future options for each lifetime management strategy. In younger patients that elect to undergo surgical aortic valve replacement (SAVR), options for bioprosthetic failure are TAV-in-SAV or redo SAVR. Among patients that undergo TAVR, options for valve failure include TAVR explant with SAVR or TAV-in-TAV. Additionally, there are patients who may require a third valvular intervention. The initial therapy may limit re-intervention options down the road. This review discusses how options for future therapies affect the decision of SAVR vs TAVR in younger patients.

Clinical Outcome of Reoperation for Mechanical Prosthesis at Aortic Position

AIM

Redo aortic valve surgery is usually associated with a high risk of mortality and complications. The aim of this study was to investigate the perioperative and long-term outcomes of reoperation after prior mechanical prosthesis implantation at the aortic position.

METHOD

The clinical data of 146 consecutive patients who underwent reoperation at the aortic position between 2003 and 2019 were analysed.

RESULTS

Mean age was 51.5±12.7 years and 69 (47.3%) were female. The median interval from prior surgery to redo aortic valve surgery was 6 years. The aetiologies were pannus formation with prosthetic aortic stenosis in 62 cases (42.5%), prosthetic valve endocarditis (PVE) in five (3.4%), PVE with perivalvular leakage (PVL) in 16 (11.0%), PVL in 45 (30.8%), thrombosis in seven (4.8%), and aortic disease in 11 (7.5%). As for surgical procedure, aortic valve replacement was performed in 81 cases (55.5%), Bentall in 34 (23.3%), PVL repair in six (4.1%), and pannus debridement in 25 (17.1%). Fourteen (14) (9.6%) patients expired perioperatively. Prolonged ventilation time and postoperative renal failure were proved to be significant independent predictors of mortality according to multivariate analysis. Overall survival was 87.8%±7.4% and 76.4%±15.1% at 5 and 10 years, respectively. Survival was 87.7%±13.7% and 84.2%±15.6% in the pannus group, and 84.5%±12.6% and 74.6%±19.4% in the non-pannus group at 5 and 10 years, respectively (p=0.951). Survival was 87.5%±14.2% and 75.8%±22.7% in the PVL group and 84.7%±11.9% and 81.6%±13.5% in the non-PVL group at 5 and 10 years, respectively (p=0.365).

CONCLUSIONS

Pannus formation and PVL are two major indications for reoperation of mechanical prosthesis at the aortic position. Redo aortic valve surgery has a satisfactory outcome but with a high risk of complications. Long-term survival of patients seems not to be related to the aetiology. Final decision-making of redo aortic valve surgery should be based on aetiology.

How to treat severe symptomatic structural valve deterioration of aortic surgical bioprosthesis: transcatheter valve-in-valve implantation or redo valve surgery?

The optimal management of aortic surgical bioprosthesis presenting with severe symptomatic structural valve deterioration is currently a matter of debate. Over the past 20 years, the number of implanted bioprostheses worldwide has been rapidly increasing at the expense of mechanical prostheses. A large proportion of patients, however, will require intervention for bioprosthesis structural valve deterioration. Current options for older patients who often have severe comorbidities include either transcatheter valve-in-valve (TVIV) implantation or redo valve surgery. The emergence of TVIV implantation, which is perceived to be less invasive than redo valve surgery, offers an effective alternative to surgery for these patients with proven safety and efficacy in high-risk patient groups including elderly and frail patients. A potential caveat to this strategy is that results of long-term follow-up after TVIV implantation are limited. Redo surgery is sometimes preferable, especially for young patients with a smaller-sized aortic bioprosthesis. With the emergence of TVIV implantation and the long experience of redo valve surgery, we currently have 2 complementary treatment modalities, allowing a tailor-made and patient-orientated intervention. In the heart team, the decision-making should be based on several factors including type of bioprosthesis failure, age, comorbidities, operative risk, anatomical factors, anticipated risks and benefits of each alternative, patient's choice and local experience. The aim of this review is to provide a framework for individualized optimal treatment strategies in patients with failed aortic surgical bioprosthesis.

Short- and long-term outcomes following redo valvular surgery

AIM

We reviewed our experience in redo valvular surgery to evaluate trends in short- and long-term outcomes.

METHODS

We reviewed 414 patients (mean age, 62.8 ± 13.6 years) who underwent redo valvular surgery in the past 25 years. A total of 301 patients (54.2%) underwent first-time redo valvular surgeries; 178 (32.1%) were second redos, 60 (10.8%) were third redos, and 16 were fourth redos (2.9%). The mean follow-up period was 6.8 ± 6.3 years.

RESULTS

Hospital mortality was 5.8%. New York Heart Association (NYHA) class III/IV (P = 0.0007, odds ratio = 4.403) and hemodialysis (P = 0.0383, odds ratio = 7.196) were risk factors for hospital death. Long-term survival rates at 15 and 20 years were 64.7% ± 4.3% and 59.1% ± 5.0%, respectively. Predictors of late death were first time redo (P = 0.0076, hazard ratio = 0.422) and age younger than 61 years (P = 0.0005, hazard ratio = 0.229). There were significant differences in long-term survival between NYHA classes I/II and III/IV (log-rank test, P = 0.0419) and between the time from redo surgery (log-rank test, P = 0.0189) and age (log-rank test, P = 0.0001).

CONCLUSIONS

The hospital mortality rate for redo valve surgery has improved. Early referral for redo surgery can contribute to improving early and late outcomes.

Is the EuroSCORE II reliable to estimate operative mortality among octogenarians?

Objectives

Concerns have been raised about the predictive performance (PP) of the EuroSCORE I (ES I) to estimate operative mortality (OM) of patients aged ≥80. The EuroSCORE II (ES II) has been described to have better PP of OM but external validations are scarce. Furthermore, the PP of ES II has not been investigated among the octogenarians. The goal of the study was to compare the PP of ES II and ES I among the overall population and patients ≥ 80.

Methods

The ES I and ES II were computed for 7161 consecutive patients who underwent major cardiac surgery in a 7-year period. Discrimination was assessed by using the c- index and calibration with the Hosmer-Lemeshow (HL) and calibration plot by comparing predicted and observed mortality.

Results

From the global cohort of 7161 patients, 832 (12%) were ≥80. The mean values of ES I and ES II were 7.4±9.4 and 5.2±9.1 respectively for the whole cohort, 6.3±8.6 and 4.7±8.5 for the patients <80, 15.1±11.8 and 8.5±11.0 for the patients ≥80. The mortality was 9.38% (≥80) versus 5.18% (<80). The discriminatory power was good for the two algorithms among the whole population and the <80 but less satisfying among the ≥80 (AUC 0.64 [0.58–0.71] for ES I and 0.67 [0.60–0.73] for the ES II without significant differences (p = 0.35) between the two scores. For the octogenarians, the ES II had a fair calibration until 10%-predicted values and over-predicted beyond.

Conclusions

The ES II has a better PP than the ES I among patients <80. Its discrimination and calibration are less satisfying in patients ≥80, showing an overestimation in the elderly at very high-surgical risk. Nevertheless, it shows an acceptable calibration until 10%- predicted mortality.

Parsimonious assessment for reoperative aortic valve replacement; the deterrent effect of low left ventricular ejection fraction and renal impairment

BACKGROUND

Patient comorbidities play a pivotal role in the surgical outcomes of reoperative aortic valve replacement (re-AVR). Low left ventricular ejection fraction (LVEF) and renal insufficiency (Cr >2 mg/dL) are known independent surgical risk factors. Improved preoperative risk assessment can help determine the best therapeutic approach. We hypothesize that re-AVR patients with low LVEF and concomitant renal insufficiency have a prohibitive surgical risk and may benefit from transcatheter AVR (TAVR).

METHODS

From January 2002 to March 2013, we reviewed 232 patients who underwent isolated re-AVR. Patients older than 80 years were excluded to adjust for unobserved frailty. We identified 37 patients with a ≤35% LVEF (low ejection fraction group-LEF) and 195 patients with >35% LVEF (High ejection fraction group-HEF).

RESULTS

The mean age was 68.4±11.5 years and there were more females (86.5% versus 64.1%, P=0.007) in the LEF group. The prevalence of renal insufficiency was higher in LEF patients (27% versus 5.6%, P=0.001). Higher operative mortality (13.5% versus 3.1%, P=0.018) was observed in the LEF group. Stroke rates were similar in both groups (8.1% versus 4.1%, P=0.39). Unadjusted cumulative survival was significantly lower in LEF patients (6.6 years, 95% CI: 5.2-8.0, versus 9.7 years, 95% CI: 8.9-10.4, P=0.024). In patients without renal insufficiency, LEF and HEF had similar survival (8.3 years, 95% CI: 7.1-9.5, versus 9.9 years, 95% CI: 9.1-10.6, P=0.90). Contrarily, in patients with renal insufficiency, LEF led to a significantly lower survival (1.1 years, 95% CI: 0.1-2.0, versus 4.8 years, 95% CI: 2.2-7.3, P=0.050). Adjusted survival analysis revealed elevations in baseline creatinine (HR =4.28, P<0.001) and LEF (HR =5.33, P=0.041) as significant predictors of long-term survival, with a significant interaction between these comorbidities (HR =7.28, P<0.001).

CONCLUSIONS

In re-AVR patients, low LVEF (≤35%) is associated with increased operative mortality. Concomitant renal insufficiency in these patients results in a prohibitively low cumulative survival. These reoperative surgical outcomes should warrant expanding the role of TAVR for reoperative patients with LEF and renal impairment.

Results of surgical aortic valve replacement and transapical transcatheter aortic valve replacement in patients with previous coronary artery bypass grafting

OBJECTIVES

To evaluate the results of aortic valve replacement through sternotomic approach in redo scenarios (RAVR) vs transapical transcatheter aortic valve replacement (TAVR), in patients in the eighth decade of life or older already undergone previous coronary artery bypass grafting (CABG).

METHODS

One hundred and twenty-six patients undergoing RAVR were compared with 113 patients undergoing TaTAVR in terms of 30-day mortality and Valve Academic Research Consortium-2 outcomes. The two groups were also analysed after propensity-matching.

RESULTS

TaTAVR patients demonstrated a higher incidence of 30-day mortality (P = 0.03), stroke (P = 0.04), major bleeding (P = 0.03), worse 'early safety' (P = 0.04) and lower permanent pacemaker implantation (P = 0.03). TaTAVR had higher follow-up hazard in all-cause mortality [hazard ratio (HR) 3.15, 95% confidence interval (CI) 1.28-6.62; P < 0.01] and cardiovascular mortality (HR 1.66, 95% CI 1.02-4.88; P = 0.04). Propensity-matched patients showed comparable 30-day outcome in terms of survival, major morbidity and early safety, with only a lower incidence of transfusions after TaTAVR (10.7% vs RAVR: 57.1%; P < 0.01). A trend towards lower Acute Kidney Injury Network Classification 2/3 (3.6% vs RAVR 21.4%; P = 0.05) and towards a lower freedom from all-cause mortality at follow-up (TaTAVR: 44.3 ± 21.3% vs RAVR: 86.6 ± 9.3%; P = .08) was demonstrated after TaTAVR, although cardiovascular mortality was comparable (TaTAVR: 86.5 ± 9.7% vs RAVR: 95.2 ± 4.6%; P = 0.52). Follow-up freedom from stroke, acute heart failure, reintervention on AVR and thrombo-embolisms were comparable (P = NS). EuroSCORE II (P = 0.02), perioperative stroke (P = 0.01) and length of hospitalization (P = 0.02) were the determinants of all-cause mortality at follow-up, whereas perioperative stroke (P = 0.03) and length of hospitalization (P = 0.04) impacted cardiovascular mortality at follow-up.

CONCLUSIONS

Reported differences in mortality and morbidity after TaTAVR and RAVR reflect differences in baseline risk profiles. Given the lower trend for renal complications, patients at higher perioperative renal risk might be better served by TaTAVR.

Comparison of Outcome of Transcatheter Aortic Valve Implantation With Versus Without Previous Coronary Artery Bypass Grafting (from the FRANCE 2 Registry)

Previous coronary artery bypass grafting (CABG) increases operative risk in conventional valve replacement. Transcatheter aortic valve implantation (TAVI) has been shown to be successful in high-risk patient subgroups. The present study compared outcome and overall survival in patients who underwent TAVI with and without history of CABG. From January 2010 to December 2011, 683 of the 3,761 patients selected for TAVI in 34 French centers (18%) had a history of CABG. Outcomes (mortality and complications) were collected prospectively according to the Valve Academic Research Consortium (VARC) criteria. Patients with previous CABG were younger, with higher rates of diabetes and vascular disease and higher logistic European System for Cardiac Operative Risk Evaluation (29.8 ± 16.4 vs 20.1 ± 13.0, p <0.001) but lower rates of pulmonary disease. Two types of valve (Edwards SAPIEN and Medtronic CoreValve) were implanted in equal proportions in the 2 groups. The 30-day and 1-year mortality rates from all causes on Kaplan-Meier analysis (9.2% vs 9.7%, p = 0.71; and 19.0% vs 20.2%, p = 0.49, respectively) did not differ according to the history of CABG. There were no significant differences in the Valve Academic Research Consortium complications (myocardial infarction, stroke or vascular, and bleeding complications). On multivariate analysis, CABG was not associated with greater 1-year post-TAVI mortality. In conclusion, previous CABG did not adversely affect outcome in patients who underwent TAVI, which may be an alternative to surgery in high-risk patients with severe aortic stenosis and history of CABG.