Incidental moderate mitral regurgitation in patients undergoing aortic valve replacement for aortic stenosis: review of guidelines and current evidence

International Expert Consensus on Sutureless and Rapid Deployment Valves in Aortic Valve Replacement Using Minimally Invasive Approaches

Objective

To define the benefit of sutureless and rapid deployment valves in current minimally invasive approaches in isolated aortic valve replacement.

Methods

A panel of 28 international experts with expertise in both minimally invasive aortic valve replacement and rapid deployment valves was constituted. After thorough literature review, the experts rated evidence-based recommendations in a modified Delphi approach.

Results

No guideline could be retrieved. Thirty-three clinical trials and 9 systematic reviews could be identified for detailed text analysis to obtain a total of 24 recommendations. After rating by the experts 12, final recommendations were identified: preoperative computed tomographic scan as well as intraoperative transesophageal echocardiography are highly recommended. Suitable annular sizes are 19 to 27 mm. There is a contraindication for bicuspid valves only for type 0 and for annular abscess or destruction due to infective endocarditis. The use of sutureless and rapid deployment valves reduces extracorporeal circulation and aortic cross-clamp time and leads to less early complications as prolonged ventilation, blood transfusion, atrial fibrillation, pleural effusions, paravalvular leakages and aortic regurgitation, and renal replacement therapy, respectively. These clinical outcomes result in reduced intensive care unit and hospital stay and reduced costs. The use of sutureless and rapid deployment valves will lead to a higher adoption rate of minimally invasive approaches in aortic valve replacement. Respect should be taken to a necessary short learning curve for both sutureless and minimally invasive programs.

Conclusions

Sutureless and rapid deployment aortic valve replacement together with minimally invasive approaches offers an attractive option in aortic valve placement for patients requiring biological valve replacement.

Coexisting Mitral Regurgitation Impairs Survival After Transcatheter Aortic Valve Implantation

BACKGROUND

It remains unclear whether coexisting and untreated mitral regurgitation (MR) affects survival after transcatheter aortic valve implantation (TAVI) for aortic stenosis (AS). To summarize contemporary evidence, we performed the first metaanalysis of adjusted observational studies reporting post-TAVI mortality in patients with various grades of MR.

METHODS

MEDLINE and EMBASE were searched until February 2015, with a bibliographic review of secondary sources. Eligible studies were observational studies enrolling patients undergoing TAVI for AS and reporting adjusted odds ratios (ORs), hazard ratios (HRs), or both for early (30-day or in-hospital) all-cause mortality, overall all-cause mortality, or both in patients with apparent (significant) versus unapparent (nonsignificant) MR as outcomes.

RESULTS

Sixteen eligible studies enrolling a total of 13,672 patients undergoing TAVI for AS were identified and included. Pooled analyses of eight studies (representing 9,356 patients) and 14 studies (representing 7,405 patients) respectively demonstrated a statistically significant increase in early (OR 2.17; 95% confidence interval [CI] 1.50 to 3.14; p < 0.0001) and overall all-cause mortality (HR 1.81; 95% CI 1.37 to 2.40; p < 0.0001) in patients with apparent relative to unapparent MR. The exclusion of any single study from the analyses did not substantively alter the overall results of our analyses, and there was no evidence of significant publication bias.

CONCLUSIONS

Coexisting and untreated apparent (usually moderate or severe) MR appears to be associated with an increase in both early and overall mortality after TAVI for AS.

Moderate Aortic Stenosis and Coronary Artery Bypass Grafting: Clinical Update for the Perioperative Echocardiographer

Incidental aortic stenosis in the setting of coronary artery bypass surgery may be a perioperative challenge. The accurate assessment of the degree of aortic stenosis remains an important determinant. Although severe aortic stenosis is an indication for valve replacement, current guidelines advise a balanced approach to the management of moderate aortic stenosis in this setting. Multiple factors should be considered in a team discussion to balance risks versus benefits for the various management options in the given patient. The rapid progress in aortic valve technologies also offer alternatives for definitive management of moderate aortic stenosis in this setting that will likely become even safer in the near future.