Perioperative and long-term outcomes following aortic valve replacement: a population cohort study of 4124 consecutive patients

Bioprosthetic Aortic Valve Replacement in <50 Years Old Patients - Where is the Evidence?

Aortic valve disease is one of the most common valvular heart diseases in the cardiovascular category. Surgical replacement of the diseased aortic valve remains the definitive intervention for most diseases.

There is a clear consensus that in young patients who require aortic valve replacement, a mechanical prosthesis is the preferred choice due to its durable prosthesis without fear of wear and tear over time. However, this comes at the expense of increased risk of bleeding and thromboembolic events; in addition, there is a lack of strict evidence in using bioprosthesis in patients younger than 50 years. The objective of this review article is to assess the current evidence behind using bioprosthetic aortic valve in this young cohort.

Minimally Invasive Video-assisted Mitral Valve Replacement with a Right Chest Small Incision in Patients Aged Over 65 Years

OBJECTIVE

To analyze and summarize the clinical safety and feasibility of minimally invasive video-assisted mitral valve replacement via a right thoracic minimal incision in patients aged over 65 years.

METHODS

The clinical data of 45 patients over 65 years old who had mitral valve disease were analyzed retrospectively from January 2014 to January 2017 at Union Hospital, Fujian Medical University. The patients were divided into two groups; 20 patients in group A, who underwent minimally invasive video-assisted mitral valve replacement via a right thoracic minimal incision, and 25 patients in group B, who underwent conventional mitral valve replacement. We collected and analyzed their relevant clinical data.

RESULTS

The operation was completed successfully in both groups. Compared with group B, group A was clearly superior for postoperative analgesia time, postoperative hospital length of stay, thoracic drainage liquid, blood transfusion, and length of incision. There were no differences between the two groups in postoperative severe complications and mortality. More patients in group B had pulmonary infections and poor incision healing, while more patients in group A had postoperative pneumothorax and subcutaneous emphysema.

CONCLUSION

In patients aged over 65 years, minimally invasive video-assisted mitral valve replacement with a small incision in the right chest had the same clinical safety and efficacy as the conventional method.

Prognosis after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: systematic review of observational studies

OBJECTIVE

 To determine the frequency of survival, stroke, atrial fibrillation, structural valve deterioration, and length of hospital stay after surgical replacement of an aortic valve (SAVR) with a bioprosthetic valve in patients with severe symptomatic aortic stenosis.

DESIGN

 Systematic review and meta-analysis of observational studies.

DATA SOURCES

 Medline, Embase, PubMed (non-Medline records only), Cochrane Database of Systematic Reviews, and Cochrane CENTRAL from 2002 to June 2016.

STUDY SELECTION

 Eligible observational studies followed patients after SAVR with a bioprosthetic valve for at least two years.

METHODS

 Reviewers, independently and in duplicate, evaluated study eligibility, extracted data, and assessed risk of bias for patient important outcomes. We used the GRADE system to quantify absolute effects and quality of evidence. Published survival curves provided data for survival and freedom from structural valve deterioration, and random effect models provided the framework for estimates of pooled incidence rates of stroke, atrial fibrillation, and length of hospital stay.

RESULTS

 In patients undergoing SAVR with a bioprosthetic valve, median survival was 16 years in those aged 65 or less, 12 years in those aged 65 to 75, seven years in those aged 75 to 85, and six years in those aged more than 85. The incidence rate of stroke was 0.25 per 100 patient years (95% confidence interval 0.06 to 0.54) and atrial fibrillation 2.90 per 100 patient years (1.78 to 4.79). Post-SAVR, freedom from structural valve deterioration was 94.0% at 10 years, 81.7% at 15 years, and 52% at 20 years, and mean length of hospital stay was 12 days (95% confidence interval 9 to 15).

CONCLUSION

 Patients with severe symptomatic aortic stenosis undergoing SAVR with a bioprosthetic valve can expect only slightly lower survival than those without aortic stenosis, and a low incidence of stroke and, up to 10 years, of structural valve deterioration. The rate of deterioration increases rapidly after 10 years, and particularly after 15 years.

Long-Term Post-CABG Survival: Performance of Clinical Risk Models Versus Actuarial Predictions

BACKGROUND/AIM

Clinical risk models are commonly used to predict short-term coronary artery bypass grafting (CABG) mortality but are less commonly used to predict long-term mortality. The added value of long-term mortality clinical risk models over traditional actuarial models has not been evaluated. To address this, the predictive performance of a long-term clinical risk model was compared with that of an actuarial model to identify the clinical variable(s) most responsible for any differences observed.

METHODS

Long-term mortality for 1028 CABG patients was estimated using the Hannan New York State clinical risk model and an actuarial model (based on age, gender, and race/ethnicity). Vital status was assessed using the Social Security Death Index. Observed/expected (O/E) ratios were calculated, and the models' predictive performances were compared using a nested c-index approach. Linear regression analyses identified the subgroup of risk factors driving the differences observed.

RESULTS

Mortality rates were 3%, 9%, and 17% at one-, three-, and five years, respectively (median follow-up: five years). The clinical risk model provided more accurate predictions. Greater divergence between model estimates occurred with increasing long-term mortality risk, with baseline renal dysfunction identified as a particularly important driver of these differences.

CONCLUSIONS

Long-term mortality clinical risk models provide enhanced predictive power compared to actuarial models. Using the Hannan risk model, a patient's long-term mortality risk can be accurately assessed and subgroups of higher-risk patients can be identified for enhanced follow-up care. More research appears warranted to refine long-term CABG clinical risk models.