Long-term outcomes after isolated aortic valve replacement in octogenarians: a modern perspective

Neurological Complications After Transcatheter Aortic Valve Replacement: A Review

Transcatheter aortic valve replacement (TAVR) has become the dominant procedural modality for aortic valve replacement in the United States. The reported rates of neurological complications in patients undergoing TAVR have changed over time and are dependent on diagnostic definitions and modalities. Most strokes after TAVR are likely embolic in origin, and the incidence of stroke has decreased over time. Studies have yielded conflicting results when comparing stroke rates between TAVR and surgical aortic valve replacement (SAVR), especially due to differences in diagnostic criteria and neurocognitive testing. In this narrative review, we summarize the available data on the incidence of stroke, delirium, and cognitive decline after TAVR and highlight potential areas in need of future research. We also discuss silent cerebral ischemic lesions (SCILs) and their association with a decline in postoperative neurocognitive status after TAVR. Finally, we describe that the risk of delirium and postoperative decline is increased when nonfemoral access routes are used, and we highlight the need for standardized imaging and valid, repeatable methodologies to assess cognitive changes after TAVR.

Percutaneous treatment of abdominal aortic aneurysm and aortic valve stenosis with 'staged' EVAR and TAVR: a case series

Symptomatic aortic valve stenosis (AS) and abdominal aortic aneurysm (AAA) are critical clinical conditions, increasingly more prevalent with aging of the population. Calcific aortic stenosis is the most common structural cardiac disease in the elderly population, and medical management of severe aortic stenosis of the elderly population is associated with poor outcomes as compared to surgical treatment. Transcatheter aortic valve replacement (TAVR) is a treatment of choice in inoperable, often elderly, patients with symptomatic severe AS and in intermediate-to-high surgical risk patients. It is not yet clarified the incidence of AAA and its impact on procedural and clinical outcomes among patients undergoing TAVR. It is known that after AS resolution with aortic valve replacement or TAVR there is an increase in blood pressure that increases the risk of dissection or abdominal aortic aneurysm rupture if AAA repair is delayed. The purpose of this report is to describe the anatomical details and technical and procedural considerations when proposing totally endovascular strategies dedicated to the treatment of patients with AS and AAA.

Diagnosis and Management of Aortic Valvular Disease in the Elderly

Aortic valvular disease, including aortic stenosis and aortic regurgitation, is increasingly common with age. Due to the aging population, more elderly patients are presenting with aortic valve pathology and expectations for prompt diagnosis and efficacious treatment. The current paradigm for aortic valve disease is based on surgical or interventional therapy. In this review, we discuss the approach to diagnosing aortic valvular disease and the different options for treatment based on the most recent evidence.

Minimally Invasive Aortic Valve Surgery in Octogenarians: Reliable Option or Fallback Solution?

OBJECTIVE

Aortic valve disease is more and more common in western countries. While percutaneous approaches should be preferred in older adults, previous reports have shown good outcomes after surgery. Moreover, advantages of minimally invasive approaches may be valuable for octogenarians. We sought to compare outcomes of conventional aortic valve replacement (CAVR) versus minimally invasive aortic valve replacement (MIAVR) in octogenarians.

METHODS

We retrospectively collected data of 75 consecutive octogenarians who underwent primary, elective, isolated aortic valve surgery through conventional approach (41 patients, group CAVR) or partial upper sternotomy (34 patients, group MIAVR).

RESULTS

Mean age was 81.9 ± 0.9 and 82.3 ± 1.1 years in CAVR and MIAVR patients, respectively (P = 0.09). MIAVR patients had lower 24-hour chest drain output (353.4 ± 207.1 vs 501.7 ± 229.9 mL, P < 0.01), shorter mechanical ventilation (9.6 ± 2.4 vs 11.3 ± 2.3 hours, P < 0.01), lower need for blood transfusions (35.3% vs 63.4%, P = 0.02), and shorter hospital stay (6.8 ± 1.6 vs 8.3 ± 4.3 days, P < 0.01). Thirty-day mortality was zero in both groups. Survival at 1, 3, and 5 years was 89.9%, 80%, and 47%, respectively, in the CAVR group, and 93.2%, 82.4%, and 61.8% in the MIAVR group, with no statistically significant differences (log-rank test, P = 0.35).

CONCLUSIONS

Aortic valve surgery in older patients provided excellent results, as long as appropriate candidates were selected. MIAVR was associated with shorter mechanical ventilation, reduced blood transfusions, and reduced hospitalization length, without affecting perioperative complications or mid-term survival.

Trunk Muscle Cross-Sectional Area as a Predictive Factor for Length of Postoperative Hospitalization after Surgical Aortic Valve Replacement

Purpose: We investigated the utility of trunk muscle cross-sectional area to predict length of hospitalization after surgical aortic valve replacement (AVR) for aortic stenosis (AS).

Methods: Adult AS patients who underwent isolated AVR at a single institution were studied. The cross-sectional area of the erector spinae muscles (ESM) at the first and second lumbar vertebrae and that of the psoas muscle (PM) at the third and fourth lumbar vertebrae were measured on preoperative computed tomography (CT). Each was indexed to body surface area. Risk factors for prolonged postoperative hospitalization (>3 weeks) were assessed using multivariate regression analyses.

Results: Of 56 patients (mean age 76 ± 9 years; 25 men), 20 (35.7%) patients required prolonged hospitalization. A smaller indexed ESM cross-sectional area at the first lumbar vertebra (per 1 cm/m², odds ratio [OR] = 0.71, 95% confidence interval [CI] = 0.57–0.88, P <0.01) and lower preoperative serum albumin level (per 0.1 g/dL, OR = 0.83, 95% CI = 0.70–0.99, P <0.05) were shown as independent predictors. Indexed PM cross- sectional area was not statistically significant.

Conclusion: The cross-sectional area of the trunk muscles can be used to identify patients at risk for prolonged hospitalization after AVR for adult AS.

Five-Year Clinical and Echocardiographic Outcomes From the NOTION Randomized Clinical Trial in Patients at Lower Surgical Risk

BACKGROUND

The NOTION trial (Nordic Aortic Valve Intervention) was designed to compare transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) in patients ≥70 years old with isolated severe aortic valve stenosis. Clinical and echocardiographic outcomes are presented after 5 years.

METHODS

Patients were enrolled at 3 Nordic centers and randomized 1:1 to TAVR using the self-expanding CoreValve prosthesis (n=145) or SAVR using any stented bioprostheses (n=135). The primary composite outcome was the rate of all-cause mortality, stroke, or myocardial infarction at 1 year defined according to Valve Academic Research Consortium-2 criteria.

RESULTS

Baseline characteristics were similar. The mean age was 79.1±4.8 years and mean Society of Thoracic Surgeons Predicted Risk of Mortality score was 3.0%±1.7%. After 5 years, there were no differences between TAVR and SAVR in the composite outcome (Kaplan-Meier estimates 38.0% versus 36.3%, log-rank test P=0.86) or any of its components. TAVR patients had larger prosthetic valve area (1.7 cm2 versus 1.2 cm2, P<0.001) with a lower mean transprosthetic gradient (8.2 mm Hg versus 13.7 mm Hg, P<0.001), both unchanged over time. More TAVR patients had moderate/severe total aortic regurgitation (8.2% versus 0.0%, P<0.001) and a new pacemaker (43.7% versus 8.7%, P<0.001). Four patients had prosthetic reintervention and no difference was found for functional outcomes.

CONCLUSIONS

These are currently the longest follow-up data comparing TAVR and SAVR in lower risk patients, demonstrating no statistical difference for major clinical outcomes 5 years after TAVR with a self-expanding prosthesis compared to SAVR. Higher rates of prosthetic regurgitation and pacemaker implantation were seen after TAVR.

CLINICAL TRIAL REGISTRATION

URL: https://clinicaltrials.gov. Unique identifier: NCT01057173.

Evolution of Length of Stay After Surgical and Transcatheter Aortic Valve Implantation Over 8 Years in 1,849 Patients >75 Years of Age and Comparison Between Transfemoral and Transsubclavian Transcatheter Aortic Valve Implantation

Minimized length of hospitalization (LoS) and lower risk of hospitalization-related complications are key requirements in the treatment of aortic valve disease, mainly in the elderly candidates. Our objective was to evaluate evolution of LoS after surgical (SAVR) or transcatheter aortic valve implantation (TAVI) and its predictors. We enrolled 1,849 elderly (aged >75) patients receiving SAVR or TAVI from 2009 to 2016. In the surgical cohort (n = 1,006) the mean LoS slightly decreased from 13.81 ± 9.27 days (2009) to 10.96 ± 3.77 (2016); in the TAVI cohort (n = 843), LoS passed from 13.33 ± 9.17 (2009) to 6.21 ± 4.30 days (2016). All-cause mortality at 1 month was 3.77 % (SAVR) versus 4.7% (TAVI) (p >0.05). Among Transfemoral TAVI (TF, n = 681), and Transsubclavian TAVI (TS, n = 62), average LoS was comparable (7.38 days ± 7.11 vs 7.31 ± 4.32; median 6.0 and 6.0 days, p = 0.07). Procedural success was reached in 93% (TF) and in 85.4% (TS) (p = 0.20). There were no meaningful differences among TF and TS in terms of VARC-2 postprocedural morbidity, except for the rate of vascular access-related complications; these occurred in 8.8% of cases in the TF group versus 1.6% in the TS group (p = 0.05). In conclusion the present analysis showed a faster improvement in terms of LoS for TAVI compared with SAVR over 8 years of activity. The 2 strategies presented comparable all-causes mortality at 30 days. LoS, rates of procedural success and complications were comparable among TF and TS TAVI; nonetheless, vascular access-related complications were more frequent in the TF cohort. This suggests the validity of the TS route as an alternative to the TF approach.

The economic value of INTUITY in aortic valve replacement

OBJECTIVE

The recent development of the EDWARDS INTUITY Elite™ (EIE) valve system enables the rapid deployment of a prosthetic surgical heart valve in an aortic valve replacement (AVR) procedure via both the minimally invasive (MISAVR) and conventional (CAVR) approaches. In order to understand its economic value, this study performed a cost evaluation of the EIE valve system used in a MIS rapid-deployment approach (MIS-RDAVR) vs MISAVR and CAVR, respectively, compared to standard prosthetic aortic valves.

METHODS

A simulation model was developed using TreeAge (and validated with MS Excel) to compare the inpatient utilization and complication costs for each treatment arm. Thirty-day clinical end-points for the MIS-RDAVR (mortality and complications) were taken from the TRANSFORM trial; and a best evidence review of the published literature was used for the MISAVR and CAVR approaches. Studies were pooled and parameter estimates were weighted by sample size in order to compare the TRANSFORM patients. Cost data (2016 USD) were taken from the Premier database. Incremental cost and cost-effectiveness was assessed and one-way/probabilistic sensitivity analyses performed to gauge the robustness of the results.

RESULTS

MIS-RDAVR costs $2,621 less than CAVR and had lower mortality rates, making it a superior (dominant) technology relative to CAVR. MIS-RDAVR costs $4,560 more than MISAVR, but was associated with an additional 0.20 life years-per-patient. This implies a cost-effectiveness ratio of $22,903 per-life-year-gained. Thus, MIS-RDAVR is cost-effective compared to MISAVR.

CONCLUSIONS

The EIE valve system deployed in a MIS approach appears to be a cost-effective technology compared to MISAVR and CAVR. When compared to CAVR it may achieve cost savings as well. These results suggest that MIS-RDAVR confers superior economic value compared to both standard MISAVR and CAVR via lowered key complication rates (re-operation, renal complications, wound infection, TIA, endocarditis) and utilization (cross-clamp time, hospital ward days).

Incidence and causes of silent and symptomatic stroke following surgical and transcatheter aortic valve replacement: a comprehensive review

Stroke associated with aortic valve replacement in calcific aortic stenosis, either via transcatheter implantation (TAVR) or via surgical replacement (SAVR), is one of the most devastating complications. However, data concerning the clinical impact and incidence of clinical and silent stroke complicating SAVR and TAVR are varying. This comprehensive review of the literature explores the genuine incidence of neurological events after these procedures. Additionally, potential factors responsible for the discrepancies in stroke rates in the current literature are analysed and a lack of uniform neurological definitions and standardized neurological assessments revealed. Current stroke rates after TAVR show a decline from 7 to 1.7-4.8% in recent studies. Randomized studies comparing TAVR with SAVR yielded initially a significantly higher stroke rate after TAVR procedures as opposed to SAVR. Recently published data showed opposite results with strokes being higher following SAVR. Current data concerning stroke after surgical valve replacement report significantly higher rates of clinical strokes (17%) than previously mentioned in the literature (≤4.9%). Silent cerebral lesions were detected in 68-93% after TAVR and 38-54% after SAVR. A broader application of cerebral protection devices may help to reduce embolic cerebral events.

Long-term survival after surgical aortic valve replacement among patients over 65 years of age

OBJECTIVE

Surgical aortic valve replacement (AVR) remains the gold standard therapy for severe aortic stenosis. Long-term survival data following AVR is required. Our objective was to provide a detailed contemporary benchmark of long-term survival following AVR among elderly patients (≥65 years) in the UK.

METHODS

We conducted a retrospective cohort study of 1815 adult patients undergoing surgical AVR± coronary artery bypass graft (CABG) surgery at a single UK centre between 1996 and 2011. Our main outcome was patient survival, which was assessed by linkage to census records at the Office for National Statistics.

RESULTS

The mean age of the cohort was 75 (±5.6) years. Patients in the AVR alone group had a slightly higher median survival of 10.9 (95% CI 10.5 to 11.8) years than the AVR+CABG group which had a median survival of 9.6 (95% CI 8.7 to 10.1) years (p=0.001 of log-rank test (LRT) for equality of survivor functions). The presence of chronic kidney disease, severely impaired left ventricular function or being a current smoker were each associated with a ≥50% increased risk of long-term mortality. Comparison of our study cohort patients and the reference (operation year, age and gender matched) UK population suggested no difference in survival probability up to 8 years (p=0.55). However, for longer periods of follow-up, the difference became increasingly significant (p<0.0001).

CONCLUSIONS

Long-term survival following surgical AVR in patients over 65 years of age is excellent and up to 8 years is comparable to the matched general population.

Expectation and Quality of Life after Aortic Valve Replacement over 85 Years of Age Match those of the Contemporary General Population

Background

In the transcatheter aortic valve implantation (TAVI) years, very elderly patients with aortic stenosis (AS) are referred to surgery with reluctance despite excellent hospital outcomes. A poorly assessed outcome of discharged survivors might further overlook the actual efficacy of the surgical strategy in this cohort. We thus evaluated life-expectancy and functional results in discharged survivors over 85 years operated on for AS.

Methods

Between January 2001 and December 2013, 57 consecutive patients aged ≥85 years underwent aortic valve replacement (AVR) with or without concomitant procedures at our institution. Late survival rate (SR), New York Heart Associaion (NYHA) functional class and quality of life (RAND SF-36) were assessed. SR and quality of life (QoL) were than compared to the contemporary general population matched for age and gender, as calculated by the Italian National Institute of Statistics.

Results

Overall in-hospital mortality was 8.8% (5 pts). In patients without concomitant coronary artery bypass grafting (CABG), in-hospital mortality was 2.9%. Survival at 5 and 9 years was 57.7 ± 8.4% and 17.9 ± 11.4%, respectively. No predictors of late mortality including concomitant CABG were identified at Cox analysis. The mean NYHA class for long-term survivors improved from 3.1 to 1.6 (p<0.001). Survivors reported better QoL-scores compared to the age- and gender-matched contemporary general population in 4 RAND SF-36 domains. Life-expectancy resulted comparable to that predicted for the age and gender-matched general population.

Conclusions

Isolated AVR in patients aged ≥85 years can be performed with acceptable risk. Survivors improve in NYHA class and, when compared to age- and gender-matched individuals, show a similar life expectancy and a no lower QoL.

In-hospital resource utilization in surgical and transcatheter aortic valve replacement

Background

Little is known about preoperative predictors of resource utilization in the treatment of high-risk patients with severe symptomatic aortic valve stenosis. We report results from the prospective, medical-economic “TAVI Calculation of Costs Trial”.

Methods

In-hospital resource utilization was evaluated in 110 elderly patients (age ≥ 75 years) treated either with transfemoral (TF) or transapical (TA) transcatheter aortic valve implantation (TAVI, N = 83), or surgical aortic valve replacement (AVR, N = 27). Overall, 22 patient-specific baseline parameters were tested for within-group prediction of resource use.

Results

Baseline characteristics differed between groups and reflected the non-randomized, real-world allocation of treatment options. Overall procedural times were shortest for TAVI, intensive care unit (ICU) length of stay (LoS) was lowest for AVR. Length of total hospitalization since procedure (THsP) was lowest for TF-TAVI; 13.4 ± 11.4 days as compared to 15.7 ± 10.5 and 21.2 ± 15.4 days for AVR and TA-TAVI, respectively. For TAVI and AVR, EuroScore I remained the main predictor for prolonged THsP (p <0.01). Within the TAVI group, multivariate regression analyses showed that TA-TAVI was associated with a substantial increase in THsP (55 to 61 %, p <0.01). Additionally, preoperative aortic valve area (AVA) was identified as an independent predictor of prolonged THsP in TAVI patients, irrespective of risk scores (p <0.05).

Conclusions

Our results demonstrate significant heterogeneity in patients baseline characteristics dependent on treatment and corresponding differences in resource utilization. Prolonged ThsP is not only predicted by risk scores but also by baseline AVA, which might be useful in stratifying TAVI patients.

Trial registration

German Clinical Trial Register Nr. DRKS00000797

Outcomes in Nonagenarians Undergoing Transcatheter Aortic Valve Replacement in the PARTNER-I Trial

BACKGROUND

This study describes short-term and mid-term outcomes of nonagenarian patients undergoing transfemoral or transapical transcatheter aortic valve replacement (TAVR) in the Placement of Aortic Transcatheter Valve (PARTNER)-I trial.

METHODS

From April 2007 to February 2012, 531 nonagenarians, mean age 93 ± 2.1 years, underwent TAVR with a balloon-expandable prosthesis in the PARTNER-I trial: 329 through transfemoral (TF-TAVR) and 202 transapical (TA-TAVR) access. Clinical events were adjudicated and echocardiographic results analyzed in a core laboratory. Quality of life (QoL) data were obtained up to 1 year post-TAVR. Time-varying all-cause mortality was referenced to that of an age-sex-race-matched US population.

RESULTS

For TF-TAVR, post-procedure 30-day stroke risk was 3.6%; major adverse events occurred in 35% of patients; 30-day paravalvular leak was greater than moderate in 1.4%; median post-procedure length of stay (LOS) was 5 days. Thirty-day mortality was 4.0% and 3-year mortality 48% (44% for the matched population). By 6 months, most QoL measures had stabilized at a level considerably better than baseline, with Kansas City Cardiomyopathy Questionnaire (KCCQ) 72 ± 21. For TA-TAVR, post-procedure 30-day stroke risk was 2.0%; major adverse events 32%; 30-day paravalvular leak was greater than moderate in 0.61%; and median post-procedure LOS was 8 days. Thirty-day mortality was 12% and 3-year mortality 54% (42% for the matched population); KCCQ was 73 ± 23.

CONCLUSIONS

A TAVR can be performed in nonagenarians with acceptable short- and mid-term outcomes. Although TF- and TA-TAVR outcomes are not directly comparable, TA-TAVR appears to carry a higher risk of early death without a difference in intermediate-term mortality. Age alone should not preclude referral for TAVR in nonagenarians.

The impact of age and severity of comorbid illness on outcomes after isolated aortic valve replacement for aortic stenosis

OBJECTIVES

This study examines outcomes in a national sample of patients undergoing isolated aortic valve replacement (AVR) for aortic stenosis, with particular focus on advanced-age patients and those with extreme severity of comorbid illness (SOI).

METHODS

Data were obtained from the Nationwide Inpatient Sample and included all patients undergoing AVRs performed from January 1, 2006 to December 31, 2008. Patients with major concomitant cardiac procedures, as well as those aged, 20 years, and those with infective endocarditis or aortic insufficiency without aortic stenosis, were excluded from analysis. The analysis included 13,497 patients. Patients were stratified by age and further stratified by All Patient Refined Diagnosis Related Group SOI into mild/moderate, major, and extreme subgroups.

RESULTS

Overall in-hospital mortality was 2.96% (n=399); in-hospital mortality for the ≥80-year-old group (n=139, 4.78%) was significantly higher than the 20- to 49-year-old (n=9, 0.84%, P<0.001) or 50- to 79-year-old (n=251, 2.64%, P<0.001) groups. In-hospital mortality was significantly higher in the extreme SOI group (n=296, 15.33%) than in the minor/moderate (n=22, 0.35%, P<0.001) and major SOI groups (n=81, 1.51%, P<0.001). Median in-hospital costs in the mild/moderate, major, and extreme SOI strata were $29,202.08, $36,035.13, and $57,572.92, respectively.

CONCLUSION

In the minor, moderate, and major SOI groups, in-hospital mortality and costs are low regardless of age; these groups represent >85% of patients undergoing isolated AVR for aortic stenosis. Conversely, in patients classified as having extreme SOI, surgical therapy is associated with exceedingly high inpatient mortality, low home discharge rates, and high resource utilization, particularly in the advanced age group.

Incidence, Severity, and Outcomes of Acute Kidney Injury in Octogenarians following Heart Valve Replacement Surgery

Background. The study investigates the occurrence, severity, and outcomes of acute kidney injury (AKI) in octogenarians following heart valve surgery. Methods. All patients, age >80 years, not on dialysis and without kidney transplant, undergoing heart valve replacement at Mayo Clinic, Rochester, in the years 2002-2003 were enrolled. AKI was diagnosed based on AKIN criteria. Results. 209 octogenarians (88.0% aortic valve, 6.2% mitral valve, 1.0% tricuspid valve, and 4.8% multivalve) with (58.4%) and without CABG were studied. 34 (16.3%) had preexisting CKD. After surgery, 98 (46.8%) developed AKI. 76.5% of the AKI were in Stage 1, 9.2% in Stage 2, and 14.3% in Stage 3. 76.5% CKD patients developed AKI. Length of hospital stay was longer for AKI patients. More AKI patients were discharged to care facilities. Patient survival at 30 days and 1 year for AKI versus non-AKI was 88.8 versus 98.7%, p = 0.003, and 76.5 versus 88.3%, p = 0.025, respectively. With follow-up of 3.94 ± 0.28 years, Kaplan-Meier analysis showed a reduced survival for AKI octogenarians. Preexisting CKD and large volume intraoperative fluid administration were independent AKI predictors. Conclusions. Nearly half of the octogenarians developed AKI after valve replacement surgery. AKI was associated with significant functional impairment and reduced survival.

Nontransfemoral Approaches to Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) is noninferior to surgical aortic valve replacement in patients with high operative risk and superior to medical treatment in patients deemed unsuitable for surgical intervention. However, up to 30% to 50% of patients screened for this intervention are not candidates for TAVR via the preferred transfemoral route because of severe peripheral arterial disease. Alternative access routes must be considered and include the transapical, transaortic, transsubclavian, and transcarotid approaches. The use of alternative access is predicated on appropriate patient selection as determined by a dedicated multispecialty heart valve team and can lead to excellent outcomes.

Early and mid-term results of isolated aortic valve replacement for aortic stenosis in octogenarians

OBJECTIVE

As transcatheter aortic valve implantation (TAVI) may become a potential treatment for high-risk patients with aortic stenosis (AS), evaluation of outcomes after open aortic valve replacement (AVR) in elderly patients is warranted. We documented early and late outcomes after isolated AVR in octogenarians compared with younger age groups.

METHODS

From January 2007 to December 2012, 136 patients underwent isolated AVR for AS (mean age 71.3 years, 39% males) and were classified into two groups (octogenarians and non-octogenarians). Twenty-four percent were aged 80 years or older. Forty-six percent of all patients were in New York Heart Association functional class III-IV. The estimated Society of Thoracic Surgeons and Japan operative mortalities were 3.4 and 2.5%, respectively.

RESULT

The 30-day mortality was 0%. One in-hospital death occurred from low output syndrome and congestive heart failure in the non-octogenarian group. Postoperative morbidity was not statistically significant different between the age groups. All of the patients-with the exception of one case of in-hospital death and one patient who was transferred to another hospital-were discharged (postoperative length of stay, 16.4 days). The actuarial survival for 3 years by age group was 89.8% in octogenarians compared with 93.2% in non-octogenarians.

CONCLUSION

Recent results show that isolated AVR for severe AS can be performed with a low operative mortality and morbidity regardless of age. TAVI may be an alternative for high-risk patients, but isolated AVR remains the standard intervention for AS even in increased age.

Aortic valve replacement in octogenarians

BACKGROUND

With improved life expectancy more octogenarians now present with aortic valve disease. Cardiac surgery in this group of patients has previously been considered high risk due to co-morbidities and challenges of rehabilitation. This study seeks to challenge the concept of octogenarian cardiac surgery "unsuitability" by analysing operative outcomes and long term survival following aortic valve replacement.

METHODS

Eighty-seven consecutive patients undergoing aortic valve replacement between 2000 and 2009 at St Vincent's Hospital were retrospectively identified. Statistical analysis was performed using SPSS (version 15 and 19).

RESULTS

The average age was 82.7 ± 2.4 years. The mean logistic EuroSCORE was 18.86 ± 14.11. Post-operatively, four patients required insertion of a permanent pacemaker (4.6%) and five patients had a myocardial infarction (5.8%). In-hospital mortality was 3.4%. Follow-up was 93.1% complete. One-year survival was 92.9%, three-year survival was 86.7% and five-year survival was 75.0%. At follow-up 98.1% of patients were New York Heart Association (NYHA) Class I or II.

CONCLUSIONS

Results were excellent despite reasonable co-morbidities and Euroscore risk. Survival was impressive and the NYHA class reflected the success of the surgery in relieving the pathological aortic valve process. Patient age should not be the primary exclusion for cardiac surgery for aortic valve disease.

Trends in aortic valve replacement for elderly patients in the United States, 1999-2011

IMPORTANCE

There is a need to describe contemporary outcomes of surgical aortic valve replacement (AVR) as the population ages and transcatheter options emerge.

OBJECTIVE

To assess procedure rates and outcomes of surgical AVR over time.

DESIGN, SETTING, AND PARTICIPANTS

A serial cross-sectional cohort study of 82,755,924 Medicare fee-for-service beneficiaries undergoing AVR in the United States between 1999 and 2011.

MAIN OUTCOMES AND MEASURES

Procedure rates for surgical AVR alone and with coronary artery bypass graft (CABG) surgery, 30-day and 1-year mortality, and 30-day readmission rates.

RESULTS

The AVR procedure rate increased by 19 (95% CI, 19-20) procedures per 100,000 person-years over the 12-year period (P<.001), with an age-, sex-, and race-adjusted rate increase of 1.6% (95% CI, 1.0%-1.8%) per year. Mortality decreased at 30 days (absolute decrease, 3.4%; 95% CI, 3.0%-3.8%; adjusted annual decrease, 4.1%; 95% CI, 3.7%- 4.4%) per year and at 1 year (absolute decrease, 2.6%; 95% CI, 2.1%-3.2%; adjusted annual decrease, 2.5%; 95% CI, 2.3%-2.8%). Thirty-day all-cause readmission also decreased by 1.1% (95% CI, 0.9%-1.3%) per year. Aortic valve replacement with CABG surgery decreased, women and black patients had lower procedure and higher mortality rates, and mechanical prosethetic implants decreased, but 23.9% of patients 85 years and older continued to receive a mechanical prosthesis in 2011.

CONCLUSIONS AND RELEVANCE

Between 1999 and 2011, the rate of surgical AVR for elderly patients in the United States increased and outcomes improved substantially. Medicare data preclude the identification of the causes of the findings and the trends in procedure rates and outcomes cannot be causally linked. Nevertheless, the findings may be a useful benchmark for outcomes with surgical AVR for older patients eligible for surgery considering newer transcatheter treatments.

The past, present and future of minimally invasive therapy in endovascular interventions: a review and speculative outlook

Cardiovascular disease is a leading cause of death in all developed countries. In response to this need, endovascular management techniques have been developed across a large range of medical specialties. Minimally invasive percutaneous interventions were initially complex and challenging, but with the continued development of equipment and expertise their use has become routine in many fields. With routine use, it has become important to establish the safety and efficacy of endovascular treatments against the respective "gold standard" procedures, especially in light of their initial intended use for the management of patients at unacceptably high risk for standard therapy only. Such evaluation has to take into account the variety and diversity of devices and techniques, as well as the effects of operator dependability. Endovascular techniques are increasingly recognised as valid alternative management options for a variety of conditions, and it is anticipated that the current trend towards minimally invasive techniques will continue in the future, with moves towards increasingly complex endovascular techniques and hybrid interventions.

Optimal timing of aortic valve replacement in elderly patients with severe aortic stenosis

PURPOSE

The elderly population with severe aortic stenosis (AS) requiring aortic valve replacement (AVR) is increasing. The optimal timing of AVR in these patients has been under discussion.

METHODS

We retrospectively reviewed the data from severe AS patients (n = 84) who underwent AVR with/without concomitant procedures from 2005 to 2010. The symptom status, preoperative data, operative outcome, late survival and freedom from cardiac events were compared between elderly patients (age ≥80 years [n = 31]) and younger patients (age <80 years [n = 53]).

RESULTS

The operative mortality in elderly patients (3.2 %) and younger patients (3.8 %) was comparable. The symptoms in elderly patients were more severe and hospitalized heart failure (HF) was more frequently noted as the primary symptom (p = 0.017). Patients with and without hospitalized HF differed significantly in late survival and freedom from cardiac events (p = 0.001), but advanced age had no significant effect. The results of a Cox proportional hazards analysis revealed that hospitalized HF was a significant predictor for cardiac events after AVR, irrespective of age (hazard ratio 6.93, 95 % confidence interval 1.83-26.26, p < 0.004).

CONCLUSIONS

In elderly patients with severe AS, surgery should be recommended even in the presence of minimal symptoms and should be performed before the onset of life-threatening HF.

Outcomes of patients with severe aortic stenosis at high surgical risk evaluated in a trial of transcatheter aortic valve implantation

Recent randomized clinical trials have demonstrated that transcatheter aortic valve implantation (TAVI) reduces mortality in high-risk patients with aortic stenosis who are not candidates for aortic valve replacement (AVR). In similar patients who are acceptable candidates for AVR, TAVI provides equivalent outcomes to AVR. In this study, 900 patients with severe aortic stenosis at high surgical risk were evaluated as possible candidates for TAVI. Of these, 595 (66.1%) had neither TAVI nor AVR and constituted the medical arm. In addition to the best available conservative care, 345 patients (39.3%) in this group had balloon aortic valvuloplasty. The AVR arm consisted of 146 patients (16.2%) and the TAVI arm of 159 patients (17.6%). The AVR group had significantly lower clinical risk compared to the medical and TAVI groups, with lower mean age, Society of Thoracic Surgeons score, and logistic European System for Cardiac Operative Risk Evaluation score. Patients in the medical and balloon aortic valvuloplasty group had significantly higher B-type natriuretic peptide levels compared to those in the AVR and TAVI groups and had, on average, lower ejection fractions. The medical and balloon aortic valvuloplasty group was followed for a median of 206 days; the mortality rate was 46.6% (n = 277). The AVR group was followed for 628 days; 39 patients died (26.7%). In 399 days of follow-up, the mortality rate in the TAVI group was 30.8% (n = 49). In conclusion, patients with severe AS who did not undergo TAVI or AVR had high mortality. In properly selected patients, TAVI and AVR improve outcomes. Renal failure is the strongest correlate for adverse outcomes, irrespective of treatment group.

Coronary ostium topography: an implication for transcatheter aortic valve implantation?

OBJECTIVES

Shorter distances from coronary ostia to the calcified aortic valve may result in occlusion with potential infarction during transcatheter aortic valve implantation. We hypothesized that preoperative CT-scan measurements might predict coronary occlusion.

METHODS

Distances from the coronary ostia to the calcified aortic valve were measured during open heart aortic valve replacement in 60 consecutive patients. Distances were compared to preoperative CT-scan measurements evaluating distance of the coronary ostia as well (n = 15).

RESULTS

The distances of the lower lip of the left and the right coronary artery ostia measured from the aortic annulus were 14.7 ± 3.9 mm and 13.4 ± 4.0 mm, respectively. The left, right and noncoronary cusp heights were 13.9 ± 2.5 mm, 12.8 ± 3.0 mm and 13.3 ± 3.1 mm, respectively. Coronary ostia topography indicated variations from the middle to the noncoronary commissure in 40% for the left and 63% for the right coronary ostium. CT-scan based measurements resulted in a distance of 12.8 ± 3.5 mm for the left and 13.9 ± 4.0 mm for the right coronary ostium, compared to 14.2 ± 4.2 mm and 13.5 ± 4.3 mm measured intraoperatively. A mild correlation between both measurements could be observed (r = 0.374, P = 0.188, left and r = 0.46, P = 0.09, n = 15).

CONCLUSIONS

CT-scan-based measurements differed from the intraoperative measurements, however preoperative CT-scan evaluation may be a useful tool to identify patients with short distance of coronaries.

Immediate and late outcome of patients aged 80 years and older undergoing isolated aortic valve replacement: a systematic review and meta-analysis of 48 studies

OBJECTIVE

This study was planned to evaluate the outcome of patients ≥80 years old undergoing isolated conventional aortic valve replacement (AVR).

METHODS

Systematic review of the literature and meta-analysis of data on octogenarians and nonagenarians who underwent isolated AVR were performed.

RESULTS

The literature search yielded 48 observational studies reporting on 13 216 patients ≥80 years old. Pooled proportion of immediate postoperative mortality was 6.7 % (95% CI 5.8-7.5, 47 studies, 13,092 patients), and it was 5.8% (95% CI 4.8-6.9) in 18 studies with a mid-date from 2000 to 2006 and 7.5% (95% CI 6.8-8.2) in 30 studies with a mid-date from 1982 to 1999 (P = .004). Pooled proportion of postoperative stroke was 2.4% (95% CI 2.1-2.7, 21 studies, 8,436 patients), that of postoperative dialysis was 2.6% (95% CI 1.6-3.8, 10 studies, 1,945 patients), and that of postoperative implantation of a pacemaker was 4.6% (95% CI 3.6-5.8, 6 studies, 1,470 patients). Pooled survival rates at 1, 3, 5, and 10 years after isolated AVR were 87.6%, 78.7%, 65.4%, and 29.7%, respectively.

CONCLUSIONS

Immediate postoperative mortality and morbidity after isolated AVR in patients ≥80 years old are rather low. Postoperatively mortality decreased even further in the most recent series. Importantly, isolated AVR in these high-risk patients was associated with good late survival. These findings suggest that advanced age alone cannot be considered as a contraindication to conventional isolated AVR and that any new valve prosthesis implanted in these patients should be durable enough to guarantee the results so far offered by conventional surgery.

Risk profile and outcomes of aortic valve replacement in octogenarians

AIM

To investigate the patient characteristics, relationship between the Logistic EuroSCORE (LES) and the observed outcomes in octogenarians who underwent surgical aortic valve replacement (AVR).

METHODS

Two hundred and seventy three octogenarians underwent AVR between 1996 and 2008 at Bristol Royal Infirmary. Demographics, acute outcomes, length of hospital stay and mortality were obtained. The LES was calculated to characterize the predicted operative risk. Two groups were defined: LES ≥ 15 (n = 80) and LES < 15 (n = 193).

RESULTS

In patients with LES ≥ 15, 30 d mortality was 14% (95% CI: 7%-23%) compared with 4% (95% CI: 2%-8%) in the LES < 15 group (P < 0.007). Despite the increase in number of operations from 1996 to 2008, the average LES did not change. Only 5% of patients had prior bypass surgery. The LES identified a low risk quartile of patients with a very low mortality (4%, n = 8, P < 0.007) at 30 d. The overall surgical results for octogenarians were excellent. The low risk group had an excellent outcome and the high risk group had a poor outcome after surgical AVR.

CONCLUSION

It may be better treated with transcatheter aortic valve implantation.

Conventional aortic valve replacement for elderly patients in the current era

BACKGROUND

Because of the rising expectation of prolonged life in the general population and the recent recognition of undertreated aortic valve disease in the elderly, updating the available results of aortic valve surgery is imperative, especially considering the rapid evolution of the transcatheter valve implantation procedure.

METHODS AND RESULTS

Between 1997 and 2010, 308 patients aged 70 years or older underwent aortic valve replacement (AVR) for aortic stenosis (AS). Short- and long-term results were analyzed and risk factors for long-term mortality were determined. Mean age was 78.5 years and 124 patients were aged 80 or older. Concomitant coronary artery bypass grafting (CABG) was performed in 46% of the cases. Mean left ventricular ejection fraction (LVEF) was 52%. Overall observed and expected operative mortality using the Society of Thoracic Surgeons-Predicted Risk of Mortality score was 3.9% and 4.8%, respectively. Overall survival rates at 1, 5, and 10 years were 88.6%, 71.6%, and 31.8%, respectively. Predictors of long-term mortality included diabetes; preoperative shock; LVEF ≤ 40%; New York Heart Association functional class III or IV; and age.

CONCLUSIONS

Short- and long-term results of conventional AVR in the elderly prove it to be durable and, especially in relatively low-risk patients and patients who require concomitant CABG, operative mortality is reasonably low. Conventional AVR ± CABG remains the gold standard for elderly patients with AS.

[Transcutaneous aortic valve implantation: Anesthetic and perioperative management]

OBJECTIVE

To describe the perioperative management, from the point of view of the anesthesia-intensive care unit specialist, of patients with aortic stenosis who undergo transcatheter aortic valve implantation (femoral or apical TAVI).

DATA SOURCE

The PubMed database (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi) was queried, using the following keywords: aortic stenosis, transcatheter aortic valve implantation TAVI, outcome, complications, anesthesia.

DATA SYNTHESIS

TAVI is performed in patients suffering from aortic stenosis and presenting with numerous comorbidities, high-predicted perioperative mortality and/or contraindications to conventional cardiac surgery. TAVI is performed either by percutaneous transfemoral or transapical puncture of the left ventricle (LV) apex. These patients are older, have more comorbidities than those undergoing aortic valve replacement surgery and perioperative mortality predicted by risk scores is higher. While transapical TAVI is performed with general anaesthesia, transfemoral TAVI can be performed with either general or locoregional anaesthesia and/or sedation. The choice of the anaesthetic technique for transfemoral TAVI depends on the patient's medical history, the technique chosen for valve implantation, the type of monitoring and the anticipated hemodynamic problems. The incidence of complications following TAVI is high, some are common to surgical aortic valve replacement, and others are specific to this technique. Because of the prevalence of comorbidities, the hemodynamic-specific constraints of this technique and the incidence of complications, anaesthetic and perioperative management (evaluation, anaesthetic technique, monitoring, post-surgery care) requires the same level of expertise as in cardiac surgery anaesthesia.

CONCLUSION

TAVI expands treatment options for patients with aortic valve stenosis. The anaesthesia team must be involved in the care of these patients with the same level of expertise and care as in heart surgery on critical patients.

Preferential activation of SMAD1/5/8 on the fibrosa endothelium in calcified human aortic valves--association with low BMP antagonists and SMAD6

Background

Aortic valve (AV) calcification preferentially occurs on the fibrosa side while the ventricularis side remains relatively unaffected. Here, we tested the hypothesis that side-dependent activation of bone morphogenic protein (BMP) pathway in the endothelium of the ventricularis and fibrosa is associated with human AV calcification.

Methods and Results

Human calcified AVs obtained from AV replacement surgeries and non-calcified AVs from heart transplantations were used for immunohistochemical studies. We found SMAD-1/5/8 phosphorylation (a canonical BMP pathway) was higher in the calcified fibrosa than the non-calcified fibrosa while SMAD-2/3 phosphorylation (a canonical TGFβ pathway) did not show any difference. Interestingly, we found that BMP-2/4/6 expression was significantly higher on the ventricularis endothelium compared to the fibrosa in both calcified and non-calcified AV cusps; however, BMP antagonists (crossvienless-2/BMPER and noggin) expression was significantly higher on the ventricularis endothelium compared to the fibrosa in both disease states. Moreover, significant expression of inhibitory SMAD-6 expression was found only in the non-calcified ventricularis endothelium.

Conclusions

SMAD-1/5/8 is preferentially activated in the calcified fibrosa endothelium of human AVs and it correlates with low expression of BMP antagonists and inhibitory SMAD6. These results suggest a dominant role of BMP antagonists in the side-dependent calcification of human AVs.