Aortic Valve Surgery in Nonelderly Patients: Insights Gained From AVIATOR

External aortic annuloplasty with a dedicated expansible ring improves outcomes in remodeling root repair compared with homemade Dacron ring

OBJECTIVES

In remodeling valve-sparing root replacement with external annuloplasty, we compare long-term outcomes of a calibrated expansible extra-aortic ring with a homemade Dacron ring.

METHODS

All patients (2003-2020) operated for root aneurysm with/without aortic insufficiency (AI) were included. The standardized CAVIAAR (conservation aortique valvulaire dans les insuffisances aortiques et anévrysmes de la racine-Valve sparing in aortic insufficiencies and root aneurysms) technique was root remodeling and external annuloplasty ring with the EXTRA-AORTIC Ring or homemade Dacron ring.

RESULTS

Among 486 patients (age 52.3 ± 14.0 years) operated for root aneurysm, 375 (repair rate: 77.1%) underwent root remodeling with annuloplasty (extra-aortic ring, n = 289, vs Dacron ring, n = 86). At 10 years (median follow-up, 4.08 years' interquartile range, 1.95-7.61), unmatched and matched analysis showed that patients with extra-aortic ring had greater survival, similar to the general population (93.3% vs 79.9%, P = .097), lower reoperation incidence (2.0% vs 9.7%, P = .0098), and lower AI grade >2 recurrence (1.9% vs 11.2%, P = .0042), compared with patients with a Dacron ring. Mixed-effect model showed that with extra-aortic ring annuloplasty, annular dilation over time (P = .0033) was prevented and, compared with the homemade Dacron ring, root expansibility was better preserved (3.22% vs 2.12%, P = .002) and mean transvalvular gradient was lower (6.58 mm Hg vs 7.94 mm Hg, P = .001). Tricuspid and bicuspid valves with extra-aortic ring had similar reoperation (4.3% vs 0.85%, P = .65) and AI grade >2 incidence (2.7% vs 1.2%, P = .61), expansibility (P = .29), and diameter (P = .47), whereas mean transvalvular gradient was lower for tricuspid valves (5.58 mm Hg vs 7.60 mm Hg, P = .004).

CONCLUSIONS

Valve-sparing root remodeling with calibrated expansible extra-aortic ring annuloplasty improves the outcomes of reoperation and recurrent AI compared with a homemade Dacron ring. It prevents dilation and maintains physiological root dynamics for durable valve repair.

Aortic Valve Repair Results in Better 1-Year Survival Than Replacement: Results From German Aortic Valve Registry

BACKGROUND

Aortic valve (AV) repair is an evolving surgical strategy in the treatment of nonelderly adults with aortic regurgitation. We aimed to determine the 1-year outcome after AV repair vs surgical AV replacement (sAVR) using real-world data from the German Aortic Valve Registry.

METHODS

A total of 8076 aortic regurgitation patients (mean age, 59.1 ± 15.0 years; 76% men; mean The Society of Thoracic Surgeons score, 1.3 ± 1.1), who underwent AV surgical procedures between 2011 and 2015, were identified from German Aortic Valve Registry. The AV was repaired in 2327 patients (29%), and the remaining 5749 patients (71%) underwent sAVR. A weighted propensity score model, including the variables of age, sex, and The Society of Thoracic Surgeons score, was used to correct for baseline differences between AV repair and sAVR cohorts. The primary end point was 1-year survival after AV repair vs sAVR. Secondary end points were freedom from cardiac events and AV reinterventions.

RESULTS

Survival at 1 year was 97.7% (95% CI, 97.0%-98.5%) in the AV repair cohort vs 96.4% (95% CI, 95.9%-96.9%) in the propensity score-weighted sAVR cohort (log-rank P < .001). Cox regression revealed a significant advantage of AV repair vs sAVR (hazard ratio, 0.68; 95% CI, 0.51-0.90; P < .0001) on 1-year survival, which was independent of age. Cardiac event-free survival at 1 year was 85.7% (95% CI, 483.8%-87.7%) in the AV repair group vs 81.7% (95% CI, 80.7%-82.9%) in the sAVR group (log-rank P < .001). AV reintervention was required in 38 AV repair patients (1.6%) compared with 1.6% in the sAVR cohort (P = .59).

CONCLUSIONS

AV repair surgery, whenever intraoperatively feasible, is associated with a significantly better 1-year survival and 1-year cardiac event-free survival compared with sAVR.

Physical and Mental Recovery after Aortic Valve Surgery in Non-Elderly Patients: Native Valve-Preserving Surgery vs. Prosthetic Valve Replacement

Background: Exercise capacity and patient-reported outcomes are increasingly considered crucial following aortic valve (AV) surgery in non-elderly adults. We aimed to prospectively evaluate the effect of native valve preservation compared with prosthetic valve replacement. Methods: From October 2017 to August 2020, 100 consecutive non-elderly patients undergoing surgery for severe AV disease were included. Exercise capacity and patient-reported outcomes were evaluated upon admission, and 3 months and 1 year postoperatively. Results: In total, 72 patients underwent native valve-preserving procedures (AV repair or Ross procedure, NV group), and 28 patients, prosthetic valve replacement (PV group). Native valve preservation was associated with an increased risk of reoperation (weighted hazard ratio: 10.57 (95% CI: 1.24-90.01), p = 0.031). The estimated average treatment effect on six-minute walking distance in NV patients at 1 year was positive, but not significant (35.64 m; 95% CI: -17.03-88.30, adj. p = 0.554). The postoperative physical and mental quality of life was comparable in both groups. Peak oxygen consumption and work rate were better at all assessment time points in NV patients. Marked longitudinal improvements in walking distance (NV, +47 m (adj. p < 0.001); PV, +25 m (adj. p = 0.004)) and physical (NV, +7 points (adj. p = 0.023); PV, +10 points (adj. p = 0.005)) and mental quality of life (NV, +7 points (adj. p < 0.001); PV, +5 points (adj. p = 0.058)) from the preoperative period to the 1-year follow-up were observed. At 1 year, there was a tendency of more NV patients reaching reference values of walking distance. Conclusions: Despite the increased risk of reoperation, physical and mental performance markedly improved after native valve-preserving surgery and was comparable to that after prosthetic aortic valve replacement.

Current controversies in aortic valve-preserving surgery

The clinical outcome of severe aortic regurgitation (AR) remains suboptimal, but surgery has been shown to have survival benefit over medical therapy. Postoperative survival is inferior in patients with reduced left ventricular function, and therefore early surgical intervention is recommended. Aortic valvuloplasty (AVP) is an attractive option to avoid the major drawbacks of prosthetic valves but has not been widely adopted. The etiology of AR is classified functionally into three groups: normal leaflet motion (type I), cusp prolapse (type II), and restriction (type III). Type I with dilatation of the sinus of Valsalva (type Ib) can be repaired by aortic valve reimplantation or aortic root remodeling with similar valve stability. Type I with dilatation of the aortic annulus (type Ic) can be managed by annuloplasty. Type II can be corrected by plication or resuspension techniques. Pericardial patch is necessary in AVP for type Id (perforation/fenestration) and type III but is associated with risk of recurrence. Bicuspid aortic valve is classified according to commissure angle: symmetrical, asymmetrical, and very asymmetrical. Tricuspidization is recommended for repair of very asymmetrical valves to avoid postoperative stenosis. Recent progress has achieved similar reoperation rates between bicuspid and tricuspid aortic valve repair. For Marfan syndrome, valve-sparing root replacement is advantageous compared to Bentall operation regarding late survival, thromboembolic and hemorrhagic events, and endocarditis. Similar findings have been reported in acute aortic dissection. Both remodeling and reimplantation procedures provide similar favorable outcomes in these settings. Recent advances in AVP are summarized by quantitative assessment of cusp configuration (effective height and geometric height), graft size decision, use of template to cut the graft, and videoscopic assessment of post-repair cusp configuration. Due to these advances, AVP shows superior results to replacement surgery. Further concrete evidence with larger case volumes and longer observation periods are necessary to popularize AVP.

Outcomes of aortic valve repair: early results from the German Aortic Valve Registry

OBJECTIVES

Aortic valve (AV) repair is an evolving surgical strategy in the treatment of young patients with aortic regurgitation (AR) and/or aortic root aneurysm. We aimed to determine the clinical outcome following AV repair/AV sparing root surgery using real-world data from the German Aortic Valve Registry (GARY).

METHODS

A total of 2327 patients with AR (mean age 55.2 ± 15.0 years, 76% men), who underwent AV repair/AV sparing root surgery between 2011 and 2015 (i.e., 5% of 42.868 AV surgery patients enrolled in the GARY registry during the same period) were included. Study cohort was subdivided according to the technique of AV repair: isolated AV repair without root surgery (Group I) (n = 914), AV sparing root surgery (i.e., reimplantation or remodelling) without cusp repair (Group II) (n = 1077), and AV sparing root surgery (i.e., reimplantation or remodelling) with simultaneous cusp repair (Group III) (n = 336). Primary end-point was 1-year survival after AV repair/AV sparing root surgery. Secondary end-points were freedom from cardiac adverse events and freedom from AV reinterventions at 1-year follow-up.

RESULTS

30-day mortality was 19 (0.8%) in the whole study cohort without significant differences in the three subgroups (4 (0.4%) patients in Group I vs 14 (1.3%) patients in the Group II vs 1 (0.3%) patient in the Group III (p = 0.054)). Postoperatively, 1445 (74%) patients had no residual AR, 474 (24%) patients had mild AR, and 40 (2%) patients had moderate/severe AR at the time of hospital discharge. One-year survival (95% CI) was 97.7% (97.1-98.3) in the whole study cohort and without significant difference among the three subgroups. One-year cardiac adverse event-free survival (95% CI) was 85.7% (84.2-87.1) and was similar in all three study groups in propensity-score weighted analysis. A total of 38 (1.6%) patients required AV reintervention during a 1-year follow-up, without significant difference among subgroups (p = 0.11).

CONCLUSIONS

AV repair/AV sparing root surgery is performed in 5% of patients requiring AV surgery in Germany. Our data demonstrate very satisfactory periprocedural and 1-year survival and cardiac event-free survival after AV repair surgery. Implementation of specific surgical techniques during the index procedure seems to result in comparable outcomes.

Aortic valve repair versus mechanical valve replacement for root aneurysm: The CAVIAAR Multicentric Study

AIMS

Despite growing evidence that aortic valve repair improves long-term patient outcomes and quality of life, aortic valves are mostly replaced. We evaluate the effect of aortic valve repair versus replacement in patients with dystrophic aortic root aneurysm up to 4 years.

METHODS

The multicentric CAVIAAR prospective cohort study enrolled 261 patients: 130 underwent standardized aortic valve repair (REPAIR) consisting of remodelling root repair with expansible aortic ring annuloplasty, and 131 received mechanical composite valve and graft replacement (REPLACE). Primary outcome was a composite criterion of mortality, reoperation, thromboembolic or major bleeding events, endocarditis or operating site infections, pacemaker implantation and heart failure, analyzed with propensity score-weighted Cox model analysis. Secondary outcomes included Major Adverse Valve Related Events (MAVRE) and components of primary outcome.

RESULTS

Mean age was 56.1 years, valve was bicuspid in 115 patients (44.7%). Up to 4 years, REPAIR did not significantly differ from REPLACE in terms of primary outcome (HR 0.66 [0.39; 1.12]), but showed significantly less valve-related deaths (HR 0.09 [0.02; 0.34]) and major bleeding events (HR 0.37 [0.16; 0.85]) without an increased risk of valve-related reoperation (HR 2.10 [0.64; 6.96]). When accounting for occurrence of multiple events in a single patient, REPAIR group had half the occurrence of MAVRE (RR 0.51 [0.31; 0.86]).

CONCLUSION

Although primary outcome did not significantly differ between REPAIR and REPLACE group, the trend is in favour of REPAIR by a significant reduction of valve-related deaths and major bleeding events. Long-term follow-up beyond 4 years is needed to confirm these findings.

Antithrombotic Treatment After Surgical and Transcatheter Heart Valve Repair and Replacement

New antithrombotic drugs have been developed, new valve types have been designed and minimally invasive transcatheter techniques have emerged, making the choice of antithrombotic therapy after surgical or transcatheter heart valve repair and replacement increasingly complex. Moreover, due to a lack of large randomized controlled trials many recommendations for antithrombotic therapy are based on expert opinion, reflected by divergent recommendations in current guidelines. Therefore, decision-making in clinical practice regarding antithrombotic therapy for prosthetic heart valves is difficult, potentially resulting in sub-optimal patient treatment. This article compares the 2017 ESC/EACTS and 2020 ACC/AHA guidelines on the management of valvular heart disease and summarizes the available evidence. Finally, we established a convenient consensus on antithrombotic therapy after valve interventions based on over 800 annual cases of surgical and transcatheter heart valve repair and replacement and a multidisciplinary team discussion between the department of cardiovascular diseases and cardiac surgery of the University Hospitals Leuven, Belgium.