Prosthesis-Patient Mismatch in the Elderly: Survival, Ventricular Mass Regression, and Quality of Life

Impact of Prosthesis-Patient Mismatch After Surgical Aortic Valve Replacement: Systematic Review and Meta-Analysis of Reconstructed Time-to-Event Data of 122 989 Patients With 592 952 Patient-Years

BACKGROUND

It remains controversial whether prosthesis-patient mismatch (PPM) impacts long-term outcomes after surgical aortic valve replacement. We aimed to evaluate the association of PPM with mortality, rehospitalizations, and aortic valve reinterventions.

METHODS AND RESULTS

We performed a systematic review with meta-analysis of reconstructed time-to-event data of studies published by March 2023 (according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses). Sixty-five studies met our eligibility criteria and included 122 989 patients (any PPM: 68 332 patients, 55.6%). At 25 years of follow-up, the survival rates were 11.8% and 20.6% in patients with and without any PPM, respectively (hazard ratio [HR], 1.16 [95% CI, 1.13-1.18], P<0.001). At 20 years of follow-up, the survival rates were 19.5%, 12.1%, and 8.8% in patients with no, moderate, and severe PPM, respectively (moderate versus no PPM: HR, 1.09 [95% CI, 1.06-1.11], P<0.001; severe versus no PPM: HR, 1.29 [95% CI, 1.24-1.35], P<0.001). PPM was associated with higher risk of cardiac death, heart failure-related hospitalizations, and aortic valve reinterventions over time (P<0.001). Statistically significant associations between PPM and worse survival were observed regardless of valve type (bioprosthetic versus mechanical valves), contemporary PPM definitions unadjusted and adjusted for body mass index, and PPM quantification method (in vitro, in vivo, Doppler echocardiography). Our meta-regression analysis revealed that populations with more women tend to have higher HRs for all-cause death associated with PPM.

CONCLUSIONS

The results of the present study suggest that any degree of PPM is associated with poorer long-term outcomes following surgical aortic valve replacement and provide support for implementation of preventive strategies to avoid PPM after surgical aortic valve replacement.

Quality of Life Measures in Aortic Stenosis Research: A Narrative Review

BACKGROUND

Elderly patients with aortic stenosis (AS) not only have a reduced life expectancy but also a reduced quality of life (QoL). The benefits of an AS intervention may be considered a balance between a good QoL and a reasonably extended life. However, the different questionnaires being used to determine the QoL were generally not developed for the specific situation of patients with AS and come with strengths and considerable weaknesses. The objective of this article was to provide an overview of the available QoL instruments in AS research, describe their strengths and weaknesses, and provide our assessment of the utility of the available scoring instruments for QoL measurements in AS.

SUMMARY

We identified and reviewed the following instruments that are used in AS research: Short Form Health Survey (SF-36/SF-12), EuroQol-5D (EQ-5D), the Illness Intrusiveness Rating Scale (IIRS), the HeartQoL, the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Minnesota Living with Heart Failure Questionnaire (MLHF), the MacNew Questionnaire, and the Toronto Aortic Stenosis Quality of Life Questionnaire (TASQ).

KEY MESSAGES

There is no standardized assessment of QoL in patients with AS. Many different questionnaires are being used, but they are rarely specific for AS. There is a need for AS-specific research into the QoL of patients as life prolongation may compete for an improved QoL in this elderly patient group.

Early hemodynamic performance of the Trifecta™ surgical bioprosthesis aortic valve in Indian patient population: 12 month outcomes of the EVEREST post-market study

BACKGROUND

Indian patients undergoing surgical aortic valve replacement (SAVR) differ from western populations with respect to aortic annulus size and valve disease morphology. The purpose of this post-market, non-randomized observational study was to evaluate the early hemodynamic performance of the Trifecta™ bioprosthesis (Abbott, previously St. Jude Medical, Minneapolis, US) in an Indian patient population.

METHODS

From January 2014 to September 2015, 100 patients (mean age 64.4 ± 7.1 years, 62% male) undergoing SAVR for valve disease (68% stenosis, 7% insufficiency, 25% mixed pathology) were enrolled across 10 centers in India. Patients implanted with a 19-27 mm Trifecta™ valve were eligible to participate and were prospectively followed for 12-months post-implantation. Echocardiographic hemodynamic performance was evaluated at pre-implant, pre-discharge and at 12-months by an independent core laboratory. Adverse events were adjudicated by the study sponsor. Functional status at 12-months was assessed according to NYHA classification. Continuous data was summarized using descriptive statistics (mean &standard deviation,) and categorical data was summarized using frequencies and percentages.

RESULT

Ninety patients (mean age 64.5, 62.2% male) completed the 12-month follow up. Significant improvements in hemodynamic valve performance were reported in 81 patients with available echocardiographic data at 12 months. Compared to baseline at 12-month follow up visit, mean effective orifice area increased from 0.75cm² to 1.61cm² (p < 0.0001), mean pressure gradient reduced to 10.42 mmHg from 51.47 mmHg (p < 0.0001), cardiac output increased from 4.46 l/min to 4.85 l/min (P 0.9254). Compared to baseline, functional status improved by ≥1 NYHA class in 75% of patients at 12 months (95% Clopper-Pearson (Exact) confidence limit [64.6%, 83.6%]). No instances of early mortality (< 30 days from index procedure) or structural valve dysfunction were reported.

CONCLUSION

In an Indian patient population, implantation of the Trifecta™ bioprosthesis is shown to be safe and associated with favorable early hemodynamic performance and improved functional status at 12 months.

TRIAL REGISTRATION

The clinical study has been registered under Clinical Trial Registry-India ( http://www.ctri.nic.in ) and registration number is CTRI/2014/02/004434 registered on 25 February 2014 retrospectively registered.

Does patient-prosthesis mismatch after aortic valve replacement affect survival and quality of life in elderly patients?

BACKGROUND

To evaluate the impact of patient-prosthesis mismatch (PPM) on survival, functional status, and quality of life (QoL) after aortic valve replacement (AVR) with small prosthesis size in elderly patients.

METHODS

Between January 2005 and December 2013, 152 patients with pure aortic stenosis, aged at least 75 years, underwent AVR, with a 19 or 21 mm prosthetic heart valve. PPM was defined as an indexed effective orifice area less than 0.85 cm/m. Median age was 82 years (range 75-93 years). Mean follow-up was 56 months (range 1-82 months) and was 98% complete. Late survival rate, New York Heart Association functional class, and QoL (RAND SF-36) were assessed.

RESULTS

Overall, PPM was found in 78 patients (53.8%). Among them, 42 patients (29%) had an indexed effective orifice area less than 0.75 cm/m and 17 less than 0.65 cm/m (11.7%). Overall survival at 5 years was 78 ± 4.5% and was not influenced by PPM (P = NS). The mean New York Heart Association class for long-term survivors with PPM improved from 3.0 to 1.7 (P < 0.001). QoL (physical functioning 45.18 ± 11.35, energy/fatigue 49.36 ± 8.64, emotional well being 58.84 ± 15.44, social functioning 61.29 ± 6.15) was similar to that of no-PPM patients (P = NS).

CONCLUSION

PPM after AVR does not affect survival, functional status, and QoL in patients aged at least 75 years. Surgical procedures, often time-consuming, contemplated to prevent PPM, may therefore be not justified in this patient subgroup.

[Long-term results of surgical treatment of patients with aortic valve disease and functional mitral insufficiency]

AIM

To analyze long-term surgical results in patients with aortic valve disease and concomitant mitral regurgitation (MR) depending on volume of valve surgery.

MATERIAL AND METHODS

It was studied 5-year results in 71 patients with aortic valve disease and different degree of mitral regurgitation. Patients were divided into 3 groups. Control group included 40 patients after aortic valve replacement (AVR) and no mitral insufficiency. The 2nd group consisted of 16 patients after AVR and concomitant mitral regurgitation degree 2-3. The 3rd group - 15 patients after aortic and mitral valve replacement. Mortality in long-term postoperative period, quality of life, incidence of complications and echocardiography data were analyzed.

RESULTS

There was no significant improvement of mitral regurgitation after AVR. It was showed that persistent MR decreases remote survival and quality of life as well as deteriorates echocardiography data. Herewith these data in the 3rd group did not differ from the control group.

CONCLUSION

Double-valve replacement may be advisable in patients with aortic valve disease and concomitant moderate MR because persistent MR deteriorates long-term

RESULTS

However prolonged time of cardiopulmonary bypass, aortic cross-clamping, greater blood loss require comprehensive approach to advanced cardiac surgery.

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.

Aortic Valve Replacement With Carpentier-Edwards: Hemodynamic Outcomes for the 19-mm Valve

BACKGROUND

To compare hemodynamic performance and clinical outcomes after aortic valve replacement for aortic stenosis with the 19-mm Carpentier-Edwards pericardial bioprosthesis versus larger valves.

METHODS

Between January 1998 and December 2013, 447 consecutive patients underwent aortic valve replacement for aortic stenosis with the Carpentier-Edwards Perimount (n = 61) or Magna bioprostheses (n = 386). Based on the implanted valve size, the patients were classified into three groups: a 19-mm group (n = 54), a 21-mm group (n = 154), and a 23-mm to 27-mm group (n = 239). The in vivo effective orifice area index was measured by transthoracic echocardiography 12 months after operation (n = 331). The mean follow-up time was 4.9 ± 3.5 (maximum 15.4) years.

RESULTS

There were three early deaths (0.7%). At 10 years, overall survival (84.1%) was unaffected by patient-prosthesis mismatch (18.7%, 62 patients), and freedom from structural valve deterioration and endocarditis was 100% and 97.1%, respectively. Although the 19-mm group was significantly older and had a higher incidence of patient-prosthesis mismatch (n = 14, 30.4%), there were no significant differences in early outcomes, overall survival, cardiac-related mortality, or serial reduction of left ventricular mass index in comparison with patients with a larger bioprostheses. Independent risk factors for all-cause mortality were age, male gender, combined coronary artery bypass graft, and low hemoglobin level.

CONCLUSION

The Carpentier-Edwards pericardial bioprosthesis appears to be associated with acceptable clinical outcomes and hemodynamic profile.

A critical review of hemodynamic changes and left ventricular remodeling after surgical aortic valve replacement and percutaneous aortic valve replacement

The introduction of transcatheter aortic valve replacement (TAVR) in clinical practice has widened options for symptomatic patients at high surgical risk; however, it is not known whether TAVR has equivalent or prolonged benefits in terms of left ventricular (LV) remodeling.

METHODS

To explore the relative hemodynamic benefits and postoperative LV remodeling associated with TAVR and surgical aortic valve replacement (SAVR), we performed a critical review of the available literature. A total of 67 studies were included in this systematic review.

RESULTS

There is at least equivalent if not slightly superior hemodynamic performance of TAVR over SAVR, and TAVR showed lower prosthesis-patient mismatch compared with SAVR. However, LV mass appears to regress to a greater degree after SAVR compared with TAVR. Aortic regurgitation, paravalvular in particular, is more common after TAVR than SAVR, although it is rarely more than moderate in severity. Improvements in diastolic function and mitral regurgitation are reported in only a handful of studies each and could not be compared across prosthesis types.

CONCLUSIONS

The published data support the hemodynamic comparability of SAVR and TAVR, with the higher incidence of prosthesis-patient mismatch in SAVR offset by higher incidence of paravalvular leak in TAVR. These results highlight the need for further studies focusing on hemodynamic changes after valve therapy.

Replacement of the st jude medical regent valve in the aortic position with a continuous suture technique in the small aortic root

BACKGROUND

The aim of this study is to review the strategy of performing aortic valve replacement (AVR) by using the St. Jude Medical (SJM) Regent valve with a continuous suture technique in patients with a small aortic root.

METHODS

Forty-six patients with small aortic annulus underwent AVR by using 19 or 21 mm SJM Regent valves. There were 15 males and 31 females. The mean age of the patients was 51.8 ± 12.4 years. The aortic annular diameter was 20.2 ± 0.9 mm. AVR procedures were performed with continuous suture technique using SJM Regent valves under standard cardiopulmonary bypass. Echocardiaographic data were collected before operation, at discharge, and at a follow-up time, respectively.

RESULTS

The intraoperative course was uneventful and there was no operative mortality. The implanted SJM Regent valves consisted of 21 mm valves in 15 patients and 19 mm valves in 31 patients. Echocardiography at 5.6 ± 1.3 months after operation showed a significant increase in the mean effective orifice area index (0.97 ± 0.24 cm(2) /m(2) ), decrease in the mean and peak transvavluar pressure gradient (12.5 ± 5.9 and 22.3 ± 9.6 mmHg), and decrease in the mean left ventricular mass index (106 ± 41.3 g/m(2) ). Moderate prosthesis-patient mismatch (PPM) (effective orifice area index between 0.65 and 0.85 cm(2) /m(2) ) was present in three patients and no severe PPM (effective orifice area index <0.65 cm(2) /m(2) ) occurred at discharge and during follow-up.

CONCLUSION

Replacement of SJM Regent valve with a continuous suture technique maybe a good option to prevent PPM in the aortic position.

Can postoperative mean transprosthetic pressure gradient predict survival after aortic valve replacement?

Background

In this study, we sought to determine the effect of the mean transprosthetic pressure gradient (TPG), measured at 6 weeks after aortic valve replacement (AVR) or AVR with coronary artery bypass grafting (CABG) on late all-cause mortality.

Methods

Between January 1998 and March 2012, 2,276 patients (mean age 68 ± 11 years) underwent TPG analysis at 6 weeks after AVR (n = 1,318) or AVR with CABG (n = 958) at a single institution. Mean TPG was 11.6 ± 7.8 mmHg and median TPG 11 mmHg. Based on the TPG, the patients were split into three groups: patients with a low TPG (<10 mmHg), patients with a medium TPG (10–19 mmHg) and patients with a high TPG (≥20 mmHg). Cox proportional-hazard regression analysis was used to determine univariate predictors and multivariate independent predictors of late mortality.

Results

Overall survival for the entire group at 1, 3, 5, and 10 years was 97, 93, 87 and 67 %, respectively. There was no significant difference in long-term survival between patients with a low, medium or high TPG (p = 0.258). Independent predictors of late mortality included age, diabetes, peripheral vascular disease, renal dysfunction, chronic obstructive pulmonary disease, a history of a cerebrovascular accident and cardiopulmonary bypass time. Prosthesis–patient mismatch (PPM), severe PPM and TPG measured at 6 weeks postoperatively were not significantly associated with late mortality.

Conclusions

TPG measured at 6 weeks after AVR or AVR with CABG is not an independent predictor of all-cause late mortality and there is no significant difference in long-term survival between patients with a low, medium or high TPG.

Impact of prosthesis-patient mismatch on early and late mortality after aortic valve replacement

BACKGROUND

The influence of prosthesis-patient mismatch (PPM) on survival after aortic valve replacement (AVR) remains controversial. In this study, we sought to determine the effect of PPM on early (≤30 days) and late mortality (>30 days) after AVR or AVR combined with coronary artery bypass grafting (AVR with CABG).

METHODS

Between January 1998 and March 2012, 2976 patients underwent AVR (n= 1718) or AVR with CABG (n=1258) at a single institution. PPM was defined as an indexed effective orifice area (EOAI) ≤0.85 cm2/m2 and patients were divided into two groups based on the existence of PPM. Cumulative probability values of survival were estimated with Kaplan-Meier method and compared between groups using Breslow test. Univariate and multivariate independent predictors of early mortality were identified using logistic regression. Cox proportional-hazard regression analysis was used to determine univariate and multivariate independent predictors of late mortality.

RESULTS

Early mortality was 6.7% in the PPM group vs 4.7% in the group with no PPM (p=0.013). Late mortality for the PPM group at 1, 5 and 10 years was 4%, 16% and 43%, respectively. Late mortality for the group with no PPM at 1, 5 and 10 years was 4%, 15% and 33% respectively. Independent predictors of early mortality included age, severely impaired left ventricular (LV) function, endocarditis, renal dysfunction, chronic obstructive pulmonary disease (COPD) and cardiopulmonary bypass (CPB) time. Multivariate independent predictors of late mortality included age, severely impaired LV function, diabetes, peripheral vascular disease (PVD), renal dysfunction, history of a cerebrovascular accident (CVA), CPB time and a history of previous cardiac surgery. PPM was not an independent predictor of early or late mortality.

CONCLUSION

PPM is not an independent predictor of both early and late mortality after AVR or AVR combined with CABG.

Update on aortic valve prosthesis-patient mismatch in Japan

The influence of aortic valve prosthesis-patient mismatch (VP-PM) on the clinical outcome has been an ongoing controversy. The reported prevalence of VP-PM after aortic valve replacement (AVR) ranges widely between 20 and 70 %. The inconsistent impact of VP-PM on short-term and long-term mortality, regression of left ventricular (LV) hypertrophy, and exercise capacity may be explained by differences of the patient populations, the definition of VP-PM, and the use of different prostheses. Moreover, many factors other than the severity of VP-PM should be taken into account when considering its impact on individual patients after AVR. Although the concept of VP-PM is easy to understand, it cannot be applied to the whole patient population. In Japan, the age of the candidates for AVR has increased markedly in recent years, but almost all elderly patients with a small BSA (<1.6 m(2)) have received newer-generation prostheses with a small outer diameter and large effective orifice area. Indeed, previous studies of Japanese patients have demonstrated that VP-PM was no more than moderate in most cases and its impact on clinical outcomes was generally acceptable. Although severe VP-PM is infrequent and its clinical implications are still unproven in elderly Japanese patients, it would seem reasonable to try to prevent severe VP-PM. Thus, VP-PM itself cannot be accepted as an independent risk factor in Japanese patients, but the useful preventive strategies for severe VP-PM in inactive very elderly persons remain controversial. The implantation of newer-generation biological or mechanical prostheses with or without aortic annular enlargement should be considered according to the characteristics of the patient and the risk-benefit ratio for carrying out a particular procedure in an individual patient.

Valve prosthesis-patient mismatch (VP-PM): a long-term perspective

The concept/phenomenon of valve prosthesis/patient mismatch (VP-PM), described in 1978, has stood the test of time. From that time to 2011, VP-PM has received a great deal of attention but studies have come to varying conclusions. This is largely because of the determination of prosthetic heart valve area [called effective orifice area index (EOAi)] by projection rather than by actual measurement, variable criteria to assess severity of EOAi and the timing of determination of EOAi. All prosthetic heart valves have some degree of VP-PM which must be placed in a proper clinical perspective. This can be done by determining its effects on function and outcomes. For mortality one needs to focus especially on severe/critical degree of VP-PM and determine the cause of death was due to VP-PM. For the period "beyond 2011" a road map is suggested that will have uniformity of assessment of VP-PM and a focusing on the important goals of VP-PM.

Primary echocardiographic results of the Carpentier-Edwards Perimount Magna

PURPOSE

The aim of this study was to investigate the primary echocardiographic results of aortic valve replacement using 21- and 19-mm Carpentier-Edwards Perimount Magna bioprosthesis aortic xenografts in patients with small aortic annulus.

METHODS

Twenty patients (mean body surface area 1.63 ± 0.16 m(2)) underwent aortic valve replacement between June 2008 and December 2009. Eight and 12 patients received 21- and 19-mm Magna bioprostheses, respectively. After 12 months, hemodynamic data were obtained by echocardiography to estimate the prosthesis-patient mismatch.

RESULTS

At follow-up, significant decreases in peak and mean left ventricular aortic pressure gradients were observed in the 12 patients with aortic stenosis (P < 0.05). Regression of the left ventricular mass was observed in all the patients (P < 0.05). The mean measured effective orifice area (EOA) and EOA index (EOAI) were 1.61 ± 0.28 cm(2) and 0.99 ± 0.16 cm(2)/m(2), respectively. Prosthesis-patient mismatch (EOAI ≤0.85) was documented in three patients.

CONCLUSION

The primary echocardiographic findings suggested that the hemodynamic performance of the 19- and 21-mm Carpentier-Edwards Perimount Magna bioprostheses was satisfactory in the patients with a small aortic annulus.

Coronary artery bypass grafting associated to aortic valve replacement in the elderly: survival and quality of life

Myocardial ischemia is often associated to aortic valve stenosis in the elderly. Aim of this study was to evaluate the impact on survival and quality of life of CABG associated to aortic valve replacement in the septuagenarians and octogenarians.

Between January 1991 and January 2010, 520 patients ageing > 70 years underwent aortic valve replacement with a mechanical prosthesis in two Institutions. They were divided into 2 groups: Group A included 406 patients undergoing isolated aortic valve replacement; Group B 114 patients receiving aortic valve replacement and CABG. A comparative analysis of long-term survival and quality of life (SF-36 test) was performed.

Mean age was 74.2 ± 3.6 years (74.3 ± 3.6 in Group A, 74 ± 3.3 in Group B; p = 0.33). Hospital mortality was 9.5% (46 patients). Twenty-nine (7.8%) in Group A and 17 in Group B (15.2%)(p = 0.019). Actuarial survival was 88.5% ± 0.015 at 1 year, 81.9% ± 0.02 at 5 years, 76.6% ± 0.032 at 10 and 57.3 ± 0.1 at 15 years. Ten-year survival was 77% ± 0.034 in Group A and 77.8% ± 0.045 in Group B (p = 0.2). Multivariate analysis did not reveal associated CABG as a predictor of long term mortality. The scores obtained in the SF-36 test were similar in the two groups and significantly higher than those of the general population matched for country, age and sex (p < 0.001 in all domains).

Associated CABG determines a significant increase of hospital mortality in the elderly undergoing aortic valve replacement. Survivors did not show differences in long-term outcome and quality of life according to the presence of associated CABG.

Mid-term outcomes after aortic valve replacement with the 17-mm St. Jude Medical Regent valve

BACKGROUND

When aortic valve replacement (AVR) is performed in patients with a small aortic annulus, prosthesis-patient mismatch (PPM) is of concern. We investigated the mid-term outcomes of AVR with a 17-mm mechanical prosthesis.

METHODS AND RESULTS

Seventy-eight patients with aortic stenosis underwent AVR with a 17-mm St. Jude Medical Regent prosthesis. Echocardiography was performed preoperatively, at discharge, and at follow-up (mean follow-up, 33 months). Patients were divided into 2 groups: with and without PPM at discharge. Between-group differences in postoperative variables, particularly survival, were analyzed. Overall hospital mortality was 2.6%. Actuarial 1- and 5-year survival rates were 95% and 79%, respectively. Diabetes and renal insufficiency were associated with long-term mortality. Freedom from major adverse valve-related cardiac events at 1 year and 5 years was 97.3% and 93.9%, respectively. Diabetes was shown to be an independent risk factor for major adverse valve-related cardiac events. Echocardiography 13 months after AVR showed a significant increase in mean effective orifice area index, decrease in mean left ventricular-aortic pressure gradient, and decrease in mean left ventricular mass index. PPM at discharge did not influence long-term survival or left ventricular mass regression.

CONCLUSIONS

The 17-mm Regent prosthesis provided satisfactory clinical and hemodynamic results. It is a reliable choice for patients with a small aortic annulus.

Transcatheter aortic valve implantation in patients with severe aortic stenosis and small aortic annulus

OBJECTIVES

Valve hemodynamics and clinical outcomes among patients with a small aortic annulus who underwent transcatheter aortic valve implantation (TAVI) were examined.

BACKGROUND

The presence of a small aortic annulus may complicate the surgical management of patients with severe aortic stenosis (AS). TAVI is an alternative to aortic valve replacement (AVR) in high-risk patients, but few data exist on the results of TAVI in patients with a small aortic annulus.

METHODS

Between 2007 and 2010, 35 patients (mean age 79.2 ± 9.4 years) with severe AS and an aortic annulus diameter <20 mm (mean 18.5 ± 0.9 mm) underwent TAVI with a 23-mm Edwards SAPIEN bioprosthesis (Edwards Lifesciences, Inc., Irvine, California). Echocardiographic parameters and clinical outcomes were assessed prior to discharge and at 6, 12, and 24 months.

RESULTS

Procedural success was achieved in 34 patients (97.1%). There was 1 in-hospital death. Peak and mean transaortic gradients decreased from 76.3 ± 33.0 mm Hg and 45.2 ± 20.6 mm Hg at baseline to 21.8 ± 8.4 mm Hg and 11.7 ± 4.8 mm Hg post-procedure, respectively, both p < 0.0001. Mean indexed effective orifice area (IEOA) increased from 0.35 ± 0.10 cm(2)/m(2) at baseline to 0.90 ± 0.18 cm(2)/m(2) post-procedure, p < 0.0001. Severe prosthesis-patient mismatch (IEOA <0.65 cm(2)/m(2)) occurred in 2 patients (5.9%). At a mean follow-up of 14 ± 11 months, gradients remained low and 30 of the 31 remaining survivors were in New York Heart Association functional class I or II.

CONCLUSIONS

In high-risk patients with severe AS and a small aortic annulus, TAVI is associated with good post-procedural valve hemodynamics and clinical outcomes. TAVI may provide a reasonable alternative to conventional AVR in elderly patients with a small aortic annulus.

Survival and quality of life after aortic root replacement with homografts in acute endocarditis

BACKGROUND

Treatment of prosthetic aortic valve endocarditis and native aortic valve endocarditis with abscess formation is associated with high mortality and morbidity. Aortic root replacement with a freestanding aortic homograft is an attractive alternative. We report outcome and quality of life after homograft replacement for infective endocarditis.

METHODS

Sixty-two patients with infective prosthetic valve endocarditis (n = 31) or native valve endocarditis with abscess (n = 31), operated with homograft replacement were included. Thirty-day mortality, severe operative complications (dialysis, stroke, pacemaker implantation, myocardial infarction, and prolonged mechanical ventilation), midterm survival, reoperations, and quality of life were assessed after a mean follow-up of 37 ± 11 months.

RESULTS

Nine patients (15%) died within 30 days and 22 patients (35%) had severe perioperative complications. Preoperative and perioperative variables univariately associated with early mortality were higher (Cleveland Clinic risk score [p = 0.014], extracorporeal circulation time [p = 0.003], prolonged inotropic support [p = 0.03], reoperation for bleeding [p = 0.01], and perioperative myocardial infarction [p < 0.001].) Cumulative survival was 82%, 78%, 75%, and 67% at one, three, five, and ten years, respectively. One patient was reoperated due to recurrence of endocarditis nine months after surgery and one after five years due to homograft failure. Quality of life, as assessed by the 36 item short-form health survey scales for physical and mental health, was not significantly different to an age-matched and gender-matched healthy control group.

CONCLUSIONS

Severe acute aortic endocarditis treated with homograft replacement is still associated with a substantial early complication rate and mortality. Long-term survival and quality of life are satisfactory in patients surviving the immediate postoperative period.

Usefulness of percutaneous aortic valve implantation to improve quality of life in patients >80 years of age

Older patients with aortic stenosis cannot always be offered conventional surgical aortic valve replacement at an acceptable risk. Transcatheter aortic valve implantation (TAVI) is currently considered an alternative treatment option with lower periprocedural risks. However, its effect on post-TAVI quality of life and clinical improvement has not been systematically and prospectively evaluated in those of advanced age. Thus, the aim of the present study was to assess the clinical improvement in geriatric patients after TAVI, with a special emphasis on quality of life. In the present study, we assessed the quality of life and brain natriuretic peptide in patients aged >80 years, before and 6 months after transfemoral CoreValve implantation. Of 87 prospectively studied patients with severe, symptomatic aortic stenosis at an age of ≥81 years, 80 survived for 6 months and were able to attend the follow-up visit with a quality of life assessment, using the Medical Outcomes Trust Short Form 36-Item Health Survey (average age 86 ± 2.9 years). The average scores of all 8 health components had improved significantly after TAVI. The greatest gain was seen in physical functioning (improvement from 23.4 ± 6.0 to 67.8 ± 13.7; p <0.001). The lowest gain was seen in bodily pain (improved from 37.5 ± 9.4 to 51.3 ± 11.5; p <0.05). Similarly, both the physical and the mental component summary scores improved significantly. This was consistent with significant improvement in brain natriuretic peptide levels (5,770 ± 8,016 to 1,641 ± 3,650 ng/L; p <0.0001). In conclusion, the results of the present study have shown a significant clinical benefit from TAVI in a patient population aged ≥81 years.

Critical review of health-related quality of life studies of patients with aortic stenosis

BACKGROUND

While studies of health-related quality of life (HRQOL) are increasing among cardiovascular patients, very few have examined HRQOL in persons with aortic stenosis (AS).

PURPOSE

A critical review of studies (1997-2008) of HRQOL in persons with AS was conducted to summarize findings and identify clinical and research implications.

RESULTS

Twenty-eight studies were identified, all of which were quantitative and evaluated HRQOL after aortic valve replacement (AVR). No studies conducted by nurses or studies measuring HRQOL in persons who did not undergo AVR were found. The literature focused on age and type of valve as variables influencing HRQOL postoperatively. Although results varied, elderly patients often scored similar or better than comparison groups. Health-related quality of life was found to be affected by valve noise and anticoagulation rather than the specific valve type when comparing patients receiving biological versus mechanical valves.

CONCLUSIONS

Selection for surgery should not be based on age alone. Early consideration should be given to symptoms prior to surgery because of evidence that patients with fewer symptoms preoperatively have better HRQOL after AVR. Anticoagulation status should be evaluated as an independent variable of HRQOL in future studies.

IMPLICATIONS FOR RESEARCH AND PRACTICE

Researchers need to augment generic HRQOL measures with disease-specific items that may pertain to life areas affected by AS, such as audible valve click, wound healing, and dyspnea. Future research should be inclusive of AS patients who do not undergo surgery. Nurses in a variety of roles can work independently or within a multidisciplinary team to provide interventions for the promotion of HRQOL for patients across all stages of the AS disease process.