Long-term durability of pericardial valves in the aortic position in younger patients: when does reoperation become necessary?

Outcomes of Surgical Bioprosthetic Aortic Valve Replacement in Patients Aged ≤65 and >65 Years

BACKGROUND

Implantation of a bioprosthetic valve is a reasonable choice for patients aged > 65 years. For middle-aged patients there is less certainty about whether a mechanical or bioprosthetic valve is best.

METHODS

The Pericardial Surgical Aortic Valve Replacement (PERIGON) Pivotal Trial is evaluating the safety and efficacy of the Avalus bioprosthesis (Medtronic). We evaluated clinical and echocardiographic outcomes through 5 years of follow-up, stratified by age ≤ 65 and >65 years.

RESULTS

Two hundred seventy-one patients (24.2%) were ≤65 years old and 847 (75.8%) >65 years old. Most patients in both groups were men (217 [80.1%] vs 623 [73.6%], respectively; P = .031). Younger patients had a lower Society of Thoracic Surgeons risk of mortality (1.1% ± 0.9% vs 2.2% ± 1.4%, P < .001), better baseline New York Heart Association class (P = .004), and fewer comorbidities than older patients. At 5 years mortality was lower among younger than older patients (5.3% vs 14.0%, P < .001) and no cases of structural valve deterioration occurred in either group. Effective orifice area was similar between age groups (P = .11), and mean gradient was 13.9 ± 5.4 vs 12.0 ± 4.1 mm Hg (P < .001). Multivariable linear regression identified several parameters associated with mean aortic gradient at 5 years, including baseline age and mean aortic gradient, discharge stroke volume index and EOA, and implanted valve size. Ninety-five percent of patients were in New York Heart Association class I/II through 5 years in both age groups (P = .85).

CONCLUSIONS

Findings from this analysis demonstrate satisfactory safety, hemodynamic performance, and durability of the Avalus bioprosthesis through a 5-year follow-up in patients aged ≤ 65 and >65 years.

Long-Term Outcome and Quality of Life After Biological Aortic Valve Replacement in Nonelderly Adults

BACKGROUND

Aortic valve replacement (AVR) is a standard of care in the treatment of aortic stenosis. The aim of the study was to evaluate the long-term outcome and quality of life (QoL) after biological AVR in patients younger than 60 years of age.

METHODS

A total of 354 consecutive patients less than or equal to 60 years who underwent biological AVR at our institution (2005-2015) were included. The primary endpoint was actual freedom from AV reintervention, and secondary endpoints were actual freedom from major adverse cardiac and cerebrovascular events (MACCE) as well as mental and physical QoL.

RESULTS

Mean age was 52.3 ± 7.1 years and mean follow-up duration was 78.7 ± 38.1 months. Overall survival at 5, 10, and 12 years was 87.6%, 76.3%, and 63.5%, and actual freedom from AV reintervention was 85.5%, 67.8%, and 52.9%, respectively. Actual freedom from MACCE was 82.8%, 63.2%, and 50.4%, respectively. Cox regression revealed concomitant coronary artery disease (P < .001) and creatinine at baseline (P < .001) as independent predictors of survival, AV reintervention, and MACCE. Physical QoL was similar (P = .427) and mental QoL (P = .005) was significantly better compared with the published age-matched control subjects.

CONCLUSIONS

Biological AVR in patients less than or equal to 60 years of age is associated with a significant occurrence of actual AV reintervention and MACCE at 10 to 12 years. Mental QoL after biological AVR was superior compared with healthy control subjects. The effect of the most recently developed bioprosthesis, specifically for younger patients, needs to be evaluated. Therefore, a shared decision-making process in prosthetic AV selection is mandatory in AVR patients less than or equal to 60 years of age.

Clinical and quality of life outcomes after aortic valve replacement and aortic root surgery in adult patients <65 years old

Selecting the optimal surgical treatment strategy in patients below the age of 65 years (i.e., non-elderly patients) with aortic valve or aortic root disease remains challenging. The objective of the current study is to summarize contemporary research on clinical and quality of life outcomes after aortic valve replacement (AVR) and aortic root surgery in non-elderly patients. Recent systematic reviews on clinical outcome after biological and mechanical AVR, the Ross procedure and aortic root surgery show that event occurrence is considerable after any type of AVR or aortic root surgery and-with the exception of the Ross procedure-survival is suboptimal. Although thromboembolism and bleeding events are more common after mechanical AVR and root surgery, these events are also considerably present after biological AVR, the Ross procedure and valve-sparing aortic root surgery (VSRR). Similarly, reoperation is more common after biological AVR, the Ross procedure and VSRR, but also occurs frequently after mechanical AVR and root replacement. Published evidence in AVR patients points to the direction of better health-related quality of life (HRQoL) outcomes with a biological solutions, while the HRQoL after aortic root surgery is limited and contradictory. This review illustrates that treatment for non-elderly aortic valve and aortic root disease patients needs to be tailored to the individual patient, considering both clinical and HRQoL outcomes as crucial factors to reach a treatment decision that best reflects the patient's values and goals in life.