Obesity and the risk of late mortality after aortic valve replacement with small prosthesis

Differences in baseline characteristics and outcomes of bicuspid and tricuspid aortic valves in surgical aortic valve replacement

OBJECTIVES

Patients with bicuspid aortic valve (BAV) comprise a substantial portion of patients undergoing surgical aortic valve replacement (SAVR). Our goal was to quantify the prevalence of BAV in the current SAVR ± coronary artery bypass grafting (CABG) population, assess differences in cardiovascular risk profiles and assess differences in long-term survival in patients with BAV compared to patients with tricuspid aortic valve (TAV).

METHODS

Patients who underwent SAVR with or without concomitant CABG and who had a surgical report denoting the relevant valvular anatomy were eligible and included. Prevalence, predictors and outcomes for patients with BAV were analysed and compared to those patients with TAV. Matched patients with BAV and TAV were compared using a propensity score matching strategy and an age matching strategy.

RESULTS

A total of 3723 patients, 3145 of whom (mean age 66.6 ± 11.4 years; 37.4% women) had an operative report describing their aortic valvular morphology, underwent SAVR ± CABG between 1987 and 2016. The overall prevalence of patients with BAV was 19.3% (607). Patients with BAV were younger than patients with TAV (60.6 ± 12.1 vs 68.0 ± 10.7, respectively). In the age-matched cohort, patients with BAV were less likely to have comorbidities, among others diabetes (P = 0.001), hypertension (P < 0.001) and hypercholesterolaemia (P = 0.003), compared to patients with TAV. Twenty-year survival following the index procedure was higher in patients with BAV (14.8%) compared to those with TAV (12.9%) in the age-matched cohort (P = 0.015).

CONCLUSIONS

Substantial differences in the cardiovascular risk profile exist in patients with BAV and TAV. Long-term survival after SAVR in patients with BAV is satisfactory.

Minimally invasive aortic valve surgery in obese patients: Can the bigger afford the smaller?

BACKGROUND

Ministernotomy and right minithoracotomy are well-known minimally invasive approaches for aortic valve replacement (AVR); however, controversial opinions exist for their utilization in obese patients. The aim of this study is to check a potential positive role of minimally invasive surgery in this population.

METHODS

From January 2010 to November 2019, 613 obese patients (defined by a body mass index ≥30) underwent isolated AVR at our institution. Surgical approach included standard median sternotomy (176 patients), partial upper sternotomy (271 patients), or right anterior minithoracotomy (166 patients). Intra- and postoperative data were retrospectively collected.

RESULTS

Patients treated with minimally invasive approaches had shorter cardiopulmonary bypass time (p = .012) and aortic cross-clamp time (p = .022), mainly due to the higher utilization of sutureless valve implantation. They also presented advantages in terms of reduced postoperative ventilation time (p = .010), incidence of wound infection (p = .009), need of inotropic support (p = .004), and blood transfusion (p = .001). The univariable logistic regression showed the traditional full sternotomy approach as compared with ministernotomy (p = .026), active smoking (p = .009), peripheral vascular disease (p = .003), ejection fraction (p = .026), as well Logistic European system for cardiac operative risk evaluation (EuroSCORE; p = .015) as factors associated with hospital mortality. The multivariable logistic regression adjusted for the logistic EuroSCORE revealed that surgical approaches do not influence hospital mortality.

CONCLUSIONS

Obese patients with severe aortic valve pathology can be treated with minimally invasive approaches offering a less biological insult and reduced postoperative complications, but without impact on hospital mortality.