Biological versus mechanical aortic valve replacement in non-elderly patients: a single-centre analysis of clinical outcomes and quality of life

The Effect of Surgical Aortic Valve Replacement on Arterial Stiffness: Does the Valve Type Matter?

Background: Despite the increasing use of transcatheter aortic valve procedures, many patients still require surgical aortic valve replacement (SAVR). Assessing arterial properties in patients undergoing SAVR for aortic valve stenosis can be challenging, and the existing evidence is inconclusive. Our study aimed to investigate the impact of SAVR on vascular stiffness and the quality of life, as well as the different effects of valve type on arterial properties. Methods: We included 60 patients (mean age 70.25 ± 8.76 years, 65% men) with severe symptomatic aortic stenosis who underwent SAVR. Arterial stiffness (cfPWV, baPWV) and vascular parameters (AIx@75, central pressures, SEVR) were measured at baseline, pre-discharge, and 1-year post-operation. The QOL was assessed using the generic questionnaire-short-form health survey 36 (SF-36) pre-operatively and at 1 year. Results: Post-SAVR, cfPWV increased immediately (7.67 ± 1.70 m/s vs. 8.27 ± 1.92 m/s, p = 0.009) and persisted at 1 year (8.27 ± 1.92 m/s vs. 9.29 ± 2.59 m/s, p ≤ 0.001). Similarly, baPWV (n = 55) increased acutely (1633 ± 429 cm/s vs. 2014 ± 606 cm/s, p < 0.001) and remained elevated at 1 year (1633 ± 429 cm/s vs. 1867 ± 408 cm/s, p < 0.001). Acute decrease in Alx@75 (31.16 ± 10% vs. 22.48 ± 13%, p < 0.001) reversed at 1 year (31.16 ± 10% vs. 30.98 ± 9%, p = 0.71). SEVR improved (136.1 ± 30.4% vs. 149.2 ± 32.7%, p = 0.01) and persisted at 1 year (136.1 ± 30.4% vs. 147.5 ± 30.4%, p = 0.01). SV had a greater cfPWV increase at 1 year (p = 0.049). The QOL improved irrespective of arterial stiffness changes. Conclusions: After SAVR, arterial stiffness demonstrates a persistent increase at 1-year, with valve type having a slight influence on the outcomes. These findings remain consistent despite the perceived QOL.

Mid-term outcomes of the COMMENCE trial investigating mitral valve replacement using a bioprosthesis with a novel tissue

Objective

Novel tissue leaflets (RESILIA tissue) may improve durability of bioprosthetic heart valves. The COMMENCE trial is an ongoing prospective study to evaluate valve replacement using RESILIA tissue. This report describes mid-term outcomes in the mitral cohort of COMMENCE.

Methods

Adult patients requiring mitral valve replacement were enrolled in a prospective, single-arm trial at 17 sites in the United States and Canada. An independent clinical events committee adjudicated safety events using definitions from established guidelines, and hemodynamic performance was evaluated by an independent echocardiographic core laboratory.

Results

Eighty-two patients (median age 70 years) successfully underwent mitral valve replacement with the study valve. Five-year event-free probabilities for all-cause mortality, structural valve deterioration, and reoperation were 79.9%, 98.7%, and 97.1%, respectively. Hemodynamic valve function measurements were stable through the 5-year follow-up period; valvular leaks were infrequently observed and primarily clinically insignificant/mild.

Conclusions

Mitral valve replacement patients implanted with a RESILIA tissue bioprosthesis had a good safety profile and clinically stable hemodynamic performance.

5-Year haemodynamic performance of three aortic bioprostheses. A randomized clinical trial

OBJECTIVES

The Carpentier Perimount (CP) Magna Ease, the Crown Phospholipid Reduction Treatment (PRT) and the Trifecta bovine pericardial valves have been widely used worldwide. The primary end point of this study was to compare the haemodynamic performance quantified by in vivo echocardiograms of these 3 aortic prostheses.

METHODS

The "BEST-VALVE" (comparison of 3 contemporary cardiac bioprostheses: mid-term valve haemodynamic performance) was a single-centre randomized clinical trial to compare the haemodynamic and clinical outcomes of the aforementioned bioprostheses. The 5-year results are assessed in this manuscript.

RESULTS

A total of 154 patients were included. The CP Magna Ease (n = 48, 31.2%), Crown PRT (n = 51, 32.1%) and Trifecta (n = 55, 35.7%) valves were compared. Significant differences were observed among the 3 bioprostheses 5 years after the procedure. The following haemodynamic differences were found between the CP Magna Ease and the Crown PRT bioprostheses [mean aortic gradient: 12.3 mmHg (interquartile range {IQR} 7.8-17.5) for the CP Magna Ease vs 15 mmHg (IQR 10.8-31.9) for the Crown PRT, P < 0.001] and between the CP Magna Ease and the Trifecta prostheses [mean aortic gradient: 12.3 mmHg (IQR 7.8-17.5) for the CP Magna Ease vs 14.7 mmHg (IQR 8.2-55) for the Trifecta, P < 0.001], with a better haemodynamic performance of the CP Magna Ease. The cumulative incidence of severe structural valve degeneration was 9.5% in the Trifecta group at 6 years of follow-up. The 1-, 3- and 5-year survival from all-cause mortality was 91.5%, 83.5% and 74.8%, respectively (log rank P = 0.440). Survival from the composite event at the 1-, 3- and 5-year follow-up was 92.8%, 74.6% and 59%, respectively (log rank P = 0.299).

CONCLUSIONS

We detected significant differences between the 3 bioprostheses; the CP Magna Ease had the best haemodynamic performance at the 5-year follow-up.

Surgical Aortic Valve Replacement in Patients Aged 50 to 70 Years: Mechanical or Bioprosthetic Valve? A Systematic Review

Although transcatheter aortic valve implantation has emerged as a very attractive treatment option for severe aortic valve disease, surgical aortic valve replacement (SAVR) is still considered the standard-of-care, particularly in younger patients. However, selecting the appropriate type of valve prosthesis for this patient population can pose challenges. The aim of this systematic review was to investigate morbidity and mortality in patients aged 50-70 years who have undergone a first-time SAVR, and to define and compare the outcomes of mechanical valve (MV) and biological valve (BV) prosthesis. A systematic search was conducted to investigate the clinical outcomes of MVs and BVs in patients aged 50-70 years following the PRISMA guidelines. A total of 16,111 patients were included in the studies with an average follow-up of 10 years. A total of 16 studies were selected, 12 of which included propensity-score-matching (PMS) analysis and 4 of which obtained results via multivariate analysis. The vast majority (13 studies) showed no greater survival benefit in either MVs and BVs, while three studies showed an advantage of MVs over BVs. Regarding complications, bleeding was the most common adverse event in patients undergoing MV replacement, while for patients receiving BV prosthesis, it was structural valve deterioration and reoperation. Although the data suggest that the BV option could be a safe option in patients younger than 70 years, more studies with contemporary data are needed to draw firm conclusions on the risks and benefits of BV or MV in SAVR. Physicians should individualize the surgical plan based on patient characteristics.

Mechanical versus Bioprosthetic Valve for Aortic Valve Replacement: Systematic Review and Meta-Analysis of Reconstructed Individual Participant Data

OBJECTIVES

To compare biological versus mechanical aortic valve replacement.

METHODS

We searched MEDLINE, Scopus, and Cochrane Library databases for randomized clinical trials and propensity-score matched studies published by October 14th, 2021 according to PRISMA statement. Individual patient data on overall survival were extracted. One- and two-stage survival analyses, and random-effects meta-analyses were conducted.

RESULTS

25 studies were identified, incorporating 8,721 bioprosthetic and 8,962 mechanical valves:. In the one-stage meta-analysis, mechanical valves cumulatively demonstrated decreased hazard for mortality (Hazard Ratio [HR] : 0.79, 95% Confidence interval [CI] : 0.74-0.84, p < 0.0001). Overall survival was similar between the compared arms for patients <50 years old (HR: 0.88, 95% CI : 0.71-1.1, p = 0.216), increased in the mechanical valve arm for patients 50-70 years old (HR : 0.76, 95% CI : 0.70-0.83, p < 0.0001), and increased in the bioprosthetic arm for patients >70 years old (HR : 1.35, 95% CI : 1.17-1.57, p < 0.0001). Meta-regression analysis revealed that the survival in the 50-70 years old group was not influenced by the publication year of the individual studies. No statistically significant difference was observed regarding in-hospital mortality, post-operative strokes and post-operative reoperation. All-cause mortality was found decreased in the mechanical group, cardiac mortality was comparable between the two groups, major bleeding rates were increased in the mechanical valve group, and reoperation rates were increased in the bioprosthetic valve group.

CONCLUSIONS

Survival rates seem to not be influenced by the type of prosthesis in patients <50 years old. A survival advantage in favour of mechanical valves is observed in patients 50-70 years old, while in patients >70 years old bioprosthetic valves offer better survival outcomes.

Trend and early outcomes in isolated surgical aortic valve replacement in the United Kingdom

Objective

Surgical aortic valve replacement (SAVR) is traditionally the gold-standard treatment in patients with aortic valve disease. The advancement of transcatheter aortic valve replacement (TAVR) provides an alternative treatment to patients with high surgical risks and those who had previous cardiac surgery. We aim to evaluate the trend, early clinical outcomes, and the choice of prosthesis use in isolated SAVR in the United Kingdom.

Methods

All patients (n = 79,173) who underwent elective or urgent isolated surgical aortic valve replacement (SAVR) from 1996 to 2018 were extracted from the National Adult Cardiac Surgery Audit database. Patients who underwent additional procedures and emergency or salvage SAVR were excluded from the study. Trend and clinical outcomes were investigated in the whole cohort. Patients who had previous cardiac surgery, high-risk groups (EuroSCORE II >4%), and predicted/observed mortality were evaluated. Furthermore, the use of biological prostheses in five different age groups, that are <50, 50-59, 60-69, 70-79, and >80, was investigated. Clinical outcomes between the use of mechanical and biological aortic valve prostheses in patients <65 years old were analyzed.

Results

The number of isolated SAVR increased across the study period with an average of 4,661 cases performed annually after 2010. The in-hospital/30-day mortality rate decreased from 5.28% (1996) to 1.06% (2018), despite an increasing trend in EuroSCORE II. The number of isolated SAVR performed in octogenarians increased from 596 to 2007 (the first year when TAVR was introduced in the UK) to 872 in 2015 and then progressively decreased to 681 in 2018. Biological prosthesis usage increased across all age groups, particularly in the 60-69 group, from 24.59% (1996) to 81.87% (2018). There were no differences in short-term outcomes in patients <65 years old who received biological or mechanical prostheses.

Conclusion

Surgical aortic valve replacement remains an effective treatment for patients with isolated aortic valve disease with a low in-hospital/30-day mortality rate. The number of patients with high-risk and octogenarians who underwent isolated SAVR and those requiring redo surgery has reduced since 2016, likely due to the advancement in TAVR. The use of biological aortic prostheses has increased significantly in recent years in all age groups.