Survival After Surgical Aortic Valve Replacement in Low-Risk Patients: A Contemporary Trial Benchmark

The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2024 Update on National Trends and Outcomes

The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) is the most robust and advanced clinical database in cardiac surgery. With more than 8.3 million procedures and more than 1000 participating institutions encompassing more than 97% of cardiac surgery in the United States, the ACSD is the specialty's vital instrument for quality improvement, patient safety, and outcome reporting in cardiac surgery. The database continues to advance initiatives to achieve these goals, which recently have included adding new risk models for multivalve procedures, isolated tricuspid valve surgery, aortic valve replacement after transcatheter aortic valve replacement, and mitral valve surgery for degenerative mitral regurgitation. In addition, the ACSD can now provide longitudinal survival data through linkage to the National Death Index. This report reviews current trends in the ACSD through the end of 2023, impactful research during the past year, and database innovations being implemented.

Noteworthy in Cardiothoracic Surgery 2024

Noteworthy in Cardiothoracic Surgery 2024 summarizes a few of the most high-impact trials and provocative trends in cardiothoracic surgery this past year. Specifically, this year saw the release of many in-depth reports comparing the long-term outcomes of transcatheter aortic valve replacement (TAVR) vs surgical approaches for aortic valve replacement, data which is expected to move the transcatheter pendulum. In particular, this included a national analysis of trends reporting the rapid increase of post-TAVR surgical aortic valve replacement (SAVR). This year's literature also reported ground-breaking milestones related robotics in cardiothoracic surgery, with publication of the first multicenter series of robotic aortic valve replacements, the first entirely robotic double lung and heart transplants, as well as the first combined robotic aortic valve replacement and coronary artery bypass grafting. Specific to lung cancer, data continues to emerge regarding the de-escalation of magnitude of surgical resection from lobectomy to sublobar when able, and in the benefit of immunotherapy in the neoadjuvant treatment of non-small cell lung cancer. Frequent in the literature this year were concerns about toxicity, surgical challenges after therapy, and potential increases in perioperative complications following neoadjuvant chemoimmunotherapy, with calls for surgeons to crucially assess these effects on surgical outcomes to help refine patient selection criteria. Finally, 2024 saw many advancements in intraoperative tumor localization focused on enhancing precision, minimizing invasiveness, and improving surgical outcomes, including robotic-assisted bronchoscopy, electromagnetic navigation bronchoscopy (ENB), and encouraging data regarding intraoperative molecular imaging.

Transcatheter vs Surgical Aortic Valve Replacement in Bicuspid Aortic Valves

BACKGROUND

Recent approval of transcatheter aortic valve replacement (TAVR) in patients at lower risk profiles has resulted in a real-world expansion in patients with bicuspid aortic valves (BAV), otherwise excluded from trials comparing TAVR with surgical aortic valve replacement (SAVR). This study compared perioperative and longitudinal outcomes between BAV patients undergoing TAVR vs SAVR.

METHODS

Using the United States Centers for Medicare and Medicaid Services inpatient claims database, we evaluated all beneficiaries with BAV undergoing isolated SAVR or TAVR (2018-2022). Comorbidities and frailty were accounted for using validated metrics with doubly robust risk adjustment using inverse probability weighting, multilevel regression models, and competing-risk time to event analysis. Subgroup analysis evaluated patients <75 years with low surgical risk (<4%).

RESULTS

The study included 11,289 BAV patients (8123 SAVR and 3166 TAVR). Accounting for age, comorbidities, and frailty, TAVR was associated with lower procedural mortality (odds ratio, 0.40; P < .001) but higher pacemaker (12.4% vs 2.3%; odds ratio, 5.4; P < .001), longitudinal stroke (2.4% vs 1.5%; hazard ratio [HR], 1.35; P < .001), and all-cause mortality (8.8% vs 5.7%; HR, 1.49; P < .001) compared with SAVR. The young low-risk subgroup (5393 SAVR and 1731 TAVR) highlighted similar findings, with TAVR associated with higher longitudinal stroke (2.1% vs 1.7%; HR, 1.22; P = .017) and composite stroke, valve reintervention, or death (8.1% vs 5.9%; HR, 1.37; P < .001) compared with SAVR.

CONCLUSIONS

Among Medicare beneficiaries with BAV, TAVR was associated with lower index in-hospital mortality but also lower 5-year risk-adjusted freedom from longitudinal stroke compared with SAVR, even in the youngest low-risk patients.

Short- and mid-term outcomes after redo surgical valve replacement

BACKGROUND

While previous studies have indicated comparable outcomes for redo surgical valve replacement (SVR) and primary SVR, there is limited information regarding the long-term follow-up of these patients. Providing prognostic data on redo SVR is crucial for enhancing decision-making and medical care, as well as for identifying low-risk subsets of patients eligible for redo SVR. This study aimed to evaluate the short- and mid-term outcomes of patients who underwent their first and second redo SVR of a previously replaced valve.

METHODS

We included 118 consecutive patients with a history of first or second redo SVR. The participants had a mean age of 57.5 ± 14.4 years, with 71 (60%) being female. The median follow-up period was 69 months. Clinical, intraoperative, and laboratory data were analyzed to assess all-cause mortality, major adverse events (MAE), and a composite of prosthetic valve thrombosis, embolic events, and major hemorrhage (TEH), along with their predictors. Bayesian model averaging was used for statistical analysis.

RESULTS

The 30-day mortality rate was 11 patients (9.3%). Chronic kidney disease was identified as an independent predictor of 30-day mortality. The overall survival rates at one and five years were 86% (95% CI 80% to 93%) and 76% (95% CI 68% to 85%), respectively. Dyslipidemia, a history of major bleeding, chronic kidney disease, stroke, and transvalvular leakage in biological prostheses were all associated with all-cause mortality as independent predictors. The TEH-free survival rates at one and five years were 91% (95% CI 86% to 97%) and 79% (95% CI 71% to 88%), respectively. Diabetes, sex, a history of percutaneous coronary intervention, and baseline functional capacity were identified as independent predictors for the occurrence of TEH. The MAE-free survival rates at one and five years were 82% (95% CI 73% to 92%) and 61% (95% CI 49% to 75%), respectively. Hypertension and baseline functional class were independent predictors of MAE occurrence. The type and anatomical position of the valve were not predictors of mortality, THE, and MAE.

CONCLUSIONS

Our study demonstrated acceptable short- and mid-term outcomes for redo SVR, especially in patients without significant risk factors. Several potential predictors of adverse outcomes were identified.

Transcatheter versus surgical aortic valve replacement for severe aortic valve stenosis: Meta-analysis with trial sequential analysis

OBJECTIVES

Randomized controlled trials comparing transcatheter aortic valve implantation with surgical aortic valve replacement demonstrate conflicting evidence, particularly in low-risk patients. We aim to reevaluate the evidence using trial sequential analysis, balancing type I and II errors, and compare with conventional meta-analysis.

METHODS

Databases were searched for randomized controlled trials, which were divided into higher-risk and lower-risk randomized controlled trials according to a pragmatic risk classification. Primary outcomes were death and a composite end point of death or disabling stroke assessed at 1 year and maximum follow-up. Conventional meta-analysis and trial sequential analysis were performed, and the required information size was calculated considering a type I error of 5% and a power of 90%.

RESULTS

Eight randomized controlled trials (n = 5274 higher-risk and 3661 lower-risk patients) were included. Higher-risk trials showed no significant reduction in death at 1 year with transcatheter aortic valve implantation (relative risk, 0.93, 95% CI, 0.81-1.08, P = .345). Lower-risk trials suggested lower death risk on conventional meta-analysis (relative risk, 0.67, 95% CI, 0.47-0.96, P = .031), but trial sequential analysis indicated potential spurious evidence (P = .116), necessitating more data for conclusive benefit (required information size = 5944 [59.8%]). For death or disabling stroke at 1 year, higher-risk trials lacked evidence (relative risk, 0.90, 95% CI, 0.79-1.02, P = .108). In lower-risk trials, transcatheter aortic valve implantation indicated lower risk in conventional meta-analysis (relative risk, 0.68, 95% CI, 0.50-0.93, P = .014), but trial sequential analysis suggested potential spurious evidence (P = .053), necessitating more data for conclusive benefit (required information size = 5122 [69.4%]). Follow-up results provided inconclusive evidence for both primary outcomes across risk categories.

CONCLUSIONS

Conventional meta-analysis methods may have prematurely declared an early reduction of negative outcomes after transcatheter aortic valve implantation when compared with surgical aortic valve replacement.

Transcatheter vs Surgical Aortic Valve Replacement in Medicare Beneficiaries With Aortic Stenosis and Coronary Artery Disease

BACKGROUND

As percutaneous therapeutic options expand, the optimal management of severe aortic stenosis (AS) and concomitant coronary artery disease (CAD) is being questioned between coronary artery bypass grafting with surgical aortic valve replacement (CABG+SAVR) and percutaneous coronary intervention with transcatheter aortic valve replacement (PCI+TAVR). This study sought to compare perioperative and longitudinal risk-adjusted outcomes between patients undergoing CABG+SAVR and patients undergoing PCI+TAVR.

METHODS

Using the Centers for Medicare & Medicaid Services inpatient claims database, the study evaluated all patient aged 65 years and older with AS and CAD who were undergoing CABG+SAVR or PCI+TAVR (from 2018 to 2022). Comorbidities and frailty were accounted for using validated metrics with doubly robust risk adjustment using inverse probability weighting, multilevel regression, and competing-risk time to event analyses. The primary end point was a 5-year composite of stroke, myocardial infarction (MI), valve reintervention, or death.

RESULTS

A total of 37,822 patients formed the study cohort (PCI+TAVR, n = 17,413; CABG+SAVR, n = 20,409). Accounting for age, comorbidities, frailty, and number of vessels revascularized, PCI+TAVR was associated with lower procedural mortality (1.1% vs 3.6%; odds ratio [OR], 0.29; P <.001) but higher vascular complications (OR, 6.02; P <.001) and new permanent pacemaker (OR, 1.92; P <.001). However, the longitudinal 5-year primary end point favored CABG+SAVR (20.4% vs 14.2%; OR, 1.44, P <.001). Subgroup analyses demonstrated a benefit in the use of arterial conduit in CABG+;AVR in patients with single-vessel CAD.

CONCLUSIONS

Among Medicare beneficiaries with severe AS and CAD, CABG+SAVR was associated with higher procedural mortality than PCI+TAVR but lower 5-year risk-adjusted stroke, MI, valve reintervention, and death.

Bioprosthetic vs Mechanical Aortic Valve Replacement in Patients 40 to 75 Years of Age

BACKGROUND

The choice of bioprosthetic or mechanical surgical aortic valve replacement (AVR) should balance individual valve durability with the potential liabilities of oral anticoagulation.

OBJECTIVES

To inform clinical practice, this study sought to evaluate contemporary, real-world, long-term AVR outcomes from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD).

METHODS

All patients undergoing primary isolated bioprosthetic or mechanical AVR were identified. Patients aged <40 and >75 years with endocarditis, emergency/salvage status, shock, ejection fraction ≤25%, and any prior cardiac surgery were excluded. Validated methodology was applied for linkage to the National Death Index to define longitudinal all-cause mortality (2008-2019). Robust risk adjustment was performed by using age-specific inverse probability weighting and restricted cubic splines to model nonlinear age relationships. Sensitivity analyses excluded pure aortic insufficiency, intermediate/high risk (STS predicted risk of operative mortality >4%), and discontinued valve types.

RESULTS

A total of 109,842 patients underwent bioprosthetic (n = 94,125) or mechanical (n = 15,717) AVR during the study period. After risk adjustment, freedom from all-cause mortality favored mechanical valves in patients aged 60 years and younger. Age group-specific analyses showed that mechanical valves were associated with lower all-cause mortality in all age groups ≤60 years. These results remained consistent across all sensitivity analyses.

CONCLUSIONS

In patients aged ≤60 years, mechanical AVR was associated with an independent risk-adjusted survival benefit compared with bioprosthetic AVR. These contemporary 12-year survival data further inform patient and provider shared clinical decision-making regarding prosthetic aortic valves.

Guidelines vs Practice: Surgical Versus Transcatheter Aortic Valve Replacement in Adults ≤60 Years

BACKGROUND

Consensus guidelines recommend surgical aortic valve replacement (SAVR) over transcatheter aortic valve replacement (TAVR) in patients with severe aortic stenosis aged ≤65 years. This analysis evaluates clinical practice and outcomes of TAVR and SAVR in patients aged ≤60 years.

METHODS

We identified 2360 patients aged ≤60 years, including 523 TAVR (22.2%) and 1837 SAVR (77.8%) procedures, from 2013 through 2021 using the California Department of Health Care Access and Information database. The median follow-up time was 2.4 years (interquartile range, 1.1-4.5 years) after TAVR and 4.9 years (interquartile range, 2.8-6.9 years) after SAVR. The primary outcome was 5-year survival. Secondary outcomes included cumulative incidences of reoperation, endocarditis, stroke, and heart failure readmissions with death as a competing risk, compared using propensity score matching.

RESULTS

Between 2013 and 2021 TAVR rates in patients aged ≤60 years increased from 7.2% to 45.7% (annual increase of 4.7%, P < .001). Mortality at 30 days was similar for SAVR and TAVR (0.2% vs 0.4%, P = .20). In 358 propensity-matched pairs, TAVR was associated with an increased hazard of 5-year mortality (hazard ratio, 2.5; 95% CI, 1.1-3.7; P = .02). There was no significant difference in the cumulative incidences of reoperation (2.2% vs 3.8%, P = .25), stroke (1.1% vs 0.8%, P = .39), endocarditis (0.8% vs 0.4%, P = .38), and heart failure readmission (1.9% vs 1.2%, P = .10).

CONCLUSIONS

TAVR use approaches SAVR use in patients aged ≤60 years in California and is associated with significantly worse 5-year survival. This may indicate a need for randomized trials to inform best practice recommendations.

Longitudinal outcomes following international multicentre experience with robotic aortic valve replacement†

OBJECTIVES

In an effort to maintain the technical aspects of traditional prosthetic surgical aortic valve replacement (AVR) while reducing invasiveness and facilitate options for concomitant operations, transaxillary lateral mini-thoracotomy endoscopic robotic-assisted aortic valve replacement (RAVR) has been introduced. The present data highlight the contemporary international collaborative experience.

METHODS

All consecutive patients undergoing standardized RAVR across 10 international sites (1/2020-7/2024) were evaluated using a central database with 1 year follow-up.

RESULTS

A total of 300 patients were analysed with a median predicted risk of 1.6% with aortic stenosis in 85.7%, nearly half with bicuspid valves. Biological prostheses were implanted in 220 (73.3%) with a median valve size 23 mm, 10% receiving aortic root enlargement, with 17% of all patients undergoing concomitant procedures. Median cross-clamp 120 min with no conversions to sternotomy. Median length of stay was 5 days, 4.3% with prolonged ventilation, 1.7% renal failure, 1.0% stroke and 8.3% required re-thoracotomy for evacuation of haemothorax. There were two 30-day operative mortalities (0.7%). The new permanent pacemaker rate for the full cohort was 2.6%. Of 163 patients with complete 1-year clinical and echocardiographic follow-up, mean aortic valve gradient was 10 mmHg and all but 2 patients (1.2%) had trace to no prosthetic or paravalvular insufficiency.

CONCLUSIONS

RAVR is safe and effective, providing the reproducible benefits of surgical AVR while affording a less invasive approach that permits the opportunity for concomitant procedures. For low and intermediate risk patients with aortic valve disease, RAVR is a potential reproducible alternative for patients and heart teams.

Cardiac Surgery 2024 Reviewed

For the 11th consecutive time, we systematically reviewed the cardio-surgical literature for the past year (2024), using the PRISMA approach for a results-oriented summary. In 2024, the discussion on the value of randomized and registry evidence increased, triggered by consistent findings in the field of coronary artery disease (CAD) and discrepant results in structural heart disease. The literature in 2024 again confirmed the excellent long-term outcomes of CABG compared with PCI in different scenarios, generating further validation for the CABG advantage reported in randomized studies. This has been reflected in the new guidelines for chronic CAD in 2024. Two studies indicate novel perspectives for CABG, showing that cardiac shockwave therapy in CABG improves myocardial function in ischemic hearts and that CABG guided by computed tomography is safe and feasible. For aortic stenosis, an early advantage for transcatheter (TAVI) compared with surgical (SAVR) treatment has found more support; however, long-term TAVI results keep being challenged, this year by new FDA and registry data in favor of SAVR. For failed aortic valves, redo-SAVR showed superior results compared with valve-in-valve TAVI. In the mitral field, studies showed short-term noninferiority for transcatheter treatment compared with surgery for secondary mitral regurgitation (MR), and significant long-term survival benefit in registries with surgery for primary MR. Finally, surgery was associated with better survival compared with medical therapy for acute type A aortic intramural hematoma. This article summarizes publications perceived as important by us. It cannot be complete nor free of individual interpretation but provides up-to-date information for patient-specific decision-making.

Longer-term and landmark analysis of transcatheter vs. surgical aortic-valve implantation in severe aortic stenosis: a meta-analysis

BACKGROUND

Previous reports of longer-term outcomes of transcatheter aortic valve implantation (TAVI) focus on higher risk patients and suggest potential temporal changes.

AIMS

To evaluate the longer-term and temporal performances of TAVI compared to surgical aortic valve replacement (SAVR).

METHODS

Randomized controlled trials reporting outcomes with at least 1-year follow-up. The primary outcome was the composite of all-cause death or disabling stroke.

RESULTS

We included 8 trials with 8,749 patients. TAVI was associated with a higher risk of longer-term (5-year) primary outcome compared to SAVR among higher-risk [odds ratio (OR), 1.25; 95% CI, 1.07-1.47] but not lower-risk participants [1.0 (0.77-1.29)]. However, a significant temporal interaction was detected in both risk profiles. TAVI with balloon-expandable valves was associated with a higher risk of longer-term primary outcome compared to SAVR [1.38 (1.2-1.6)], whereas no statistical difference was found with self-expanding valves [1.03 (0.89-1.19)]. There was a significant interaction between the two valve systems, and a temporal interaction was detected in both systems. Overall landmark analysis revealed a lower risk in TAVI within the initial 30 days [0.76 (0.6, 0.96)], comparable between 30 days to 2 years [1.04 (0.85, 1.28)], and higher beyond 2 years [1.36 (1.15-1.61)]. Analysis for all-cause death generated largely similar results.

CONCLUSIONS

TAVI was associated with a higher longer-term risk of primary outcome compared to SAVR in higher-risk patients and with balloon-expandable valves. However, a characteristic temporal interaction was documented in all subgroups. Future studies are warranted to test these findings.

Surgical versus transcatheter aortic valve replacement in low-risk Medicare beneficiaries

OBJECTIVE

Recent approval of transcatheter aortic valve replacement (TAVR) in patients at low surgical risk has resulted in a rapid real-world expansion of TAVR in patients not otherwise examined in recent low-risk trials. We sought to evaluate the outcomes of surgical aortic valve replacement (SAVR) versus TAVR in low-risk Medicare beneficiaries.

METHODS

Using the US Centers for Medicare and Medicaid Services claims database, we evaluated all beneficiaries undergoing isolated SAVR (n = 33,210) or TAVR (n = 77,885) (2018-2020). International Classification of Diseases 10th revision codes were used to define variables and frailty was defined by the validated Kim index. Doubly robust risk adjustment was performed with inverse probability weighting and multilevel regression models, as well as competing-risk time to event analysis. A low-risk cohort was identified to simulate recent low-risk trials.

RESULTS

A total of 15,749 low-risk patients (8144 SAVR and 7605 TAVR) were identified. Comparison was performed with doubly robust risk adjustment accounting for all factors. TAVR was associated with lower perioperative stroke (odds ratio, 0.62; P < .001) and hospital mortality (odds ratio, 0.16; P < .001) compared with SAVR. However, risk-adjusted longitudinal analysis demonstrated TAVR was associated with higher late risk of stroke (hazard ratio, 1.65; P < .001), readmission for valve reintervention (hazard ratio, 1.88; P < .001), and all-cause mortality (hazard ratio, 1.54; P < .001) compared with SAVR.

CONCLUSIONS

Among low-risk Medicare beneficiaries younger than age 75 years undergoing isolated AVR, SAVR was associated with higher index morbidity and mortality but improved 3-year risk-adjusted stroke, valve reintervention, and survival compared with TAVR.

Five- Year Outcomes in Low-Risk Patients Undergoing Surgery in the PARTNER 3 Trial

BACKGROUND

Surgery remains an important treatment for low-risk patients with severe symptomatic aortic stenosis (AS). This study evaluated 5-year outcomes in low-risk patients undergoing isolated surgical aortic valve replacement (SAVR) or SAVR with concomitant procedures within the randomized Placement of Aortic Transcatheter Valves (PARTNER) 3 trial.

METHODS

In the PARTNER 3 trial, 454 patients underwent surgery for severe, symptomatic, trileaflet AS and were followed up for 5 years. Patients were stratified into those undergoing isolated SAVR (n = 334; 73.6%) vs concomitant SAVR (n = 120; 26.4%). Short- and long-term morbidity was adjudicated by a Clinical Events Committee. Hemodynamic valve performance was evaluated by an echocardiographic core laboratory. Patient-reported health status was measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ).

RESULTS

The mean age of participants was 73.6 ± 6.1 years; 71.1% of these patients were male. The median SAVR implant size was 23 mm overall. Five-year all-cause mortality (with vital status sweep) was 9.0% for all patients (8.5% isolated SAVR; 10.2% concomitant SAVR; P = .58), comparable to a recent analysis of low-risk isolated SAVR-treated patients in the STS database (overall mortality, 7.1%). The average 5-year mean gradient was 11.7 ± 5.6 mm Hg overall. Reintervention rates were low in both groups (isolated SAVR, 2.3% vs concomitant SAVR, 5.0%; P = .21), and most patients (isolated SAVR, 87.9%; concomitant SAVR, 86.1%) were alive with no evidence of bioprosthetic valve failure at 5 years.

CONCLUSIONS

SAVR in low-risk patients in the PARTNER 3 trial demonstrated excellent 5-year outcomes. Five-year mortality was similar in patients undergoing isolated SAVR vs concomitant SAVR. This result was comparable to recently published national SAVR outcomes, thus demonstrating the generalizability of these findings.

Aortic root enlargement and replacement of the ascending aorta in type 0 aortic valve stenosis

INTRODUCTION

This case report aims to describe an aortic root enlargement in combination with the replacement of the ascending aorta in a patient presenting with severe aortic valve stenosis.

CASE REPORT

A 68-year-old woman with severe aortic stenosis due to a type 0 bicuspid aortic valve and an aortic aneurysm underwent surgery for treatment. The annulus was preoperatively measured with 19 mm. Enlargement was performed by using a tissue patch to create a neo-noncoronary sinus and enlarge the root.

DISCUSSION

Patients with a small aortic root face an increased risk of patient prosthesis mismatch. Enlarging the aortic root can mitigate this, but it extends cross-clamp and overall operative times. This case shows the need for carefully planned surgical interventions to optimize outcomes in complex anatomies.

CONCLUSIONS

Each step of the performed surgery is well-established, however the combination and the creation of a neo-noncoronary sinus is not described so far.

Incidence and Pathology of Aortic Regurgitation

Aortic regurgitation (AR) is the third most common valvular heart disease, with its prevalence and severity increasing with age. AR can arise from degenerative, congenital, inflammatory and infectious aetiologies, manifesting as primary AR with intrinsic leaflet disease, secondary AR due to aortopathy or annular dilatation, or a combination. Furthermore, AR can be acute, as observed in endocarditis and aortic dissection, or chronic, as seen in calcific aortic valve disease, connective tissue disorders, or bicuspid valve phenotypes. This review discusses the aetiopathology of these various AR manifestations (primary, secondary, acute and chronic AR), highlighting diagnostic challenges and implications for aortic valve replacement and transcatheter aortic valve implantation.

Transcatheter versus surgical aortic valve replacement in patients younger than 65 years in the United States

OBJECTIVE

The study objective was to characterize the trends and outcomes of aortic valve replacement in patients aged less than 65 years with aortic stenosis between 2013 and 2021.

METHODS

This retrospective analysis included 9557 patients who underwent biological aortic valve replacement in California, New York, and New Jersey from 2013 to 2021. Patients were stratified by approach: transcatheter aortic valve replacement versus surgical aortic valve replacement. Our primary outcomes were 30-day and 6-year mortality and morbidity (stroke, heart failure rehospitalization, reintervention, and new pacemaker implantation). After propensity score matching, Cox proportional hazard and Fine-Gray models were used to compare outcomes after transcatheter aortic valve replacement and surgical aortic valve replacement.

RESULTS

The proportion of patients aged less than 65 years with aortic stenosis undergoing transcatheter aortic valve replacement versus surgical aortic valve replacement increased from 7.1% in 2013 to 54.7% in 2021. After propensity score matching, 30-day mortality was similar between both groups (1.0% vs 1.5%, P = .33). Transcatheter aortic valve replacement had a higher 6-year mortality (23.3% vs 10.5%, hazard ratio, 2.27; 95% CI, 1.82-2.83; P < .001). The 30-day rate of new pacemaker implantation was higher after transcatheter aortic valve replacement (10.7% vs 6.2%, P < .001). There was no difference in the 6-year cumulative incidence of stroke, heart failure hospitalizations, or reoperations. Multiple sensitivity analyses confirmed these findings.

CONCLUSIONS

Despite clinical guidelines, the use of transcatheter aortic valve replacement has increased in patients aged less than 65 years. Transcatheter aortic valve replacement in this population is associated with a higher 6-year mortality and a higher rate of new permanent pacemaker implantation when compared with a matched cohort treated with biologic surgical aortic valve replacement. These findings support the need for a randomized controlled trial comparing long-term outcomes of transcatheter aortic valve replacement versus surgical aortic valve replacement in patients aged less than 65 years.

Risk Factors for Reduced Long-Term Survival Following Isolated Surgical Aortic Valve Replacement in Different Age Groups

BACKGROUND

According to recent guidelines, the selection of transcatheter vs surgical aortic valve replacement (TAVR vs SAVR) in low-risk patients depends on age and life expectancy. Our objective was to understand independent risk factors for reduced life expectancy following isolated SAVR and the rate of redo aortic valve (AV) intervention in different age groups, to delineate optimal intervention depending on patient characteristics.

METHODS

Between 2000 and 2015, 2026 patients underwent isolated SAVR with Carpentier-Edwards pericardial tissue valves (Edwards Lifesciences, Irvine, CA). Multivariable models were conducted to determine independent risk factors for long-term survival in 3 age groups.

RESULTS

The 10-year survival rates were 83.4 ± 2.3%, 72.7 ± 2.6%, and 39.8 ± 3.0% in Group I (age < 65 years, n = 577), II (age 65 to < 75 years, n = 693), and III (age ≥ 75 years, n = 756), respectively. Independent factors for the reduced long-term survival were pulmonary hypertension (PH), renal failure, peripheral vascular disease, diabetes, and New York Heart Association (NYHA) class IV in Group I; PH, diabetes, current smoking, and atrial arrhythmia in Group II; and PH, anemia, and NYHA class IV in Group III. The redo AV intervention rate at 10 years was much higher in Group I than in Groups II and III (14.7 ± 2.5% vs 3.4 ± 1.1% and 0.8 ± 0.4%, P < 0.001).

CONCLUSIONS

We identified risk factors for reduced long-term survival following isolated SAVR in different age groups and PH being the only risk factor across all ages, which should assist in decision making for SAVR vs TAVR. Our results also support the current recommendation of bioprostheses in patients aged > 65 years, given extremely low rates of redo AV intervention.

Five-year comparison of clinical and echocardiographic outcomes of pure aortic stenosis with pure aortic regurgitation or mixed aortic valve disease in the COMMENCE trial

Objective

To compare outcomes of aortic valve replacement (AVR) in patients with pure aortic stenosis (Pure AS) and those with pure aortic regurgitation (Pure AR) or mixed AS and AR (MAVD) in the COMMENCE trial.

Methods

Of 689 patients who underwent AVR in the COMMENCE trial, patients with moderate or severe AR with or without AS (Pure AR + MAVD; n = 135) or Pure AS (n = 323) were included. Inverse probability of treatment weighting Kaplan-Meier survival curves were used for time-to-event endpoints, and longitudinal changes in hemodynamics were evaluated using mixed-effects models. Echocardiographic outcomes were assessed by an echo core laboratory and clinical outcomes adjudicated by a clinical events committee. The mean duration of follow-up was 5.3 ± 2.2 years.

Results

At 5 years, adjusted safety endpoints were not statistically different between groups; no structural valve deterioration (SVD) event occurred in either group. After adjustment, the Pure AR + MAVD group had a greater change in body surface area-corrected left ventricular (LV) mass reduction (P = .03) compared to the Pure AS patients. Those patients with a baseline LV ejection fraction (LVEF) >55% continued to demonstrate preserved contractility compared to patients with an LVEF ≤55% at baseline (P < .0001). No significant difference in mean gradient (P = .07) or effective orifice area (P = .96) at 5 years was evident between the groups.

Conclusions

Patients with Pure AR + MAVD demonstrated similar clinical safety and freedom from SVD at 5 years compared to those with Pure AS. There was a significant difference in LV reverse remodeling in the Pure AR + MAVD group compared to the Pure AS group at 5 years. These favorable outcomes in patients with AR may reinforce the need for treatment before irreversible changes occur.

Midterm Outcomes of Right Anterior Mini Thoracotomy Aortic Valve Replacement

Background

Contemporary surgical approaches for aortic valve replacement (AVR) include full median sternotomy, hemi-sternotomy, and a right anterior mini thoracotomy (RAMT) approach. We report the midterm outcomes of RAMT for isolated AVR.

Methods

A retrospective study was conducted, reporting the midterm outcomes of patients who underwent isolated RAMT AVR. The primary outcomes were death and disabling stroke within 30-days of surgery. The secondary outcomes were survival at latest follow-up assessment, hospital readmission for aortic valve disease, prosthetic valve function, and incidence of structural valve deterioration requiring reintervention on the aortic valve.

Results

Seventy patients underwent isolated RAMT AVR between February 2016 and February 2018. One patient died from a cardiac cause within 30 days of surgery, whereas none experienced disabling postoperative strokes. The mean follow-up period for the cohort was 74.46 ± 7.54 months. At 95 months, a total of 49 patients were alive. During the follow-up period, 2 patients underwent median sternotomy, 1 for mitral valve replacement and tricuspid repair, and 1 for coronary artery bypass grafting. At last follow-up assessment, the average mean transvalvular gradient was 12.11 ± 9.15 mm Hg. One patient developed prosthetic valve infective endocarditis, and 1 patient was found to have prosthetic valve thrombosis. Prosthetic valve function was normal in 66 patients. At 95 months, freedom from aortic valve reintervention was 98.6%, as 1 patient required redo aortic root surgery.

Conclusions

RAMT AVR can be done safely in the appropriate patient population. Midterm outcomes at our centre are promising, and they suggest that this approach is a good option for managing aortic stenosis.

Meta-analysis of longitudinal comparison of transcatheter versus surgical aortic valve replacement in patients at low to intermediate surgical risk

BACKGROUND

Surgical aortic valve replacement (SAVR) is the commonly used approach for aortic valve replacement (AVR) in patients with aortic stenosis at low or intermediate surgical risk. However, transcatheter aortic valve replacement (TAVR) has emerged as an alternative to SAVR for AVR. This meta-analysis aims to assess the comparative efficacy and safety of TAVR versus SAVR in low-to-intermediate surgical risk patients by analyzing temporal trends in the outcomes of TAVR and SAVR at various follow-up intervals, providing a more detailed understanding.

METHODS

A thorough literature search was performed across PubMed/MEDLINE, Embase, and the Cochrane Library from their inception up to May 2024 to identify eligible randomized controlled trials (RCTs). Clinical outcomes were evaluated using a random-effects model to pool risk ratios (RRs) with 95% CIs.

RESULTS

A total of 17 studies reporting data at different follow-ups for nine trials were included (n=9092). No statistically significant difference was observed between TAVR and SAVR for reducing all-cause death at 30 days, 1 year, and 2 years but significantly increased risk with TAVR at 5 years or longer follow-up (RR=1.13, 95% CI: 1.03-1.23). However, TAVR was associated with a significantly decreased risk for cardiac death at 1-year follow-up (RR=0.79, 95% CI: 0.64-0.96) and comparable risk for cardiac death at 30 days, 2 years, and 5 years or longer follow-up when compared with SAVR. No statistically significant difference was observed between TAVR and SAVR for reducing the risk of myocardial infarction (MI) at 30 days, 1 year, 2 years, and 5 years or longer follow-up.TAVR was associated with a significantly lower risk of major bleeding events at 30 days (RR=0.38, 95% CI: 0.21-0.67); lower risk of acute kidney injury (AKI) at 30 days (RR=0.38, 95% CI: 0.26-0.54) and 1 year (RR=0.58, 95% CI: 0.41-0.82) and lower risk of new onset or worsening atrial fibrillation (AF) at 30 days (RR=0.25, 95% CI: 0.18-0.34), 1 year (RR=0.26, 95% CI: 0.16-0.41) and 2 years (RR=0.32, 95% CI: 0.20-0.49) when compared with SAVR. However, TAVR was associated with a significantly increased risk of permanent pacemaker implantation (PPI) at 30 days (RR: 2.62, 95% CI: 1.40-4.91), at 1 year (RR: 2.19, 95% CI: 1.24-3.87), at 2 years (RR: 2.74, 95% CI: 1.31-5.71), and beyond 5 years (RR: 1.95, 95% CI: 1.20-3.15). TAVR was also associated with a significantly increased risk of prosthetic valve thrombosis at 2 years (RR=2.70, 95% CI: 1.08-6.71), though no significant association was observed at 30 days, 1 year, or 5 years. Similarly, no significant differences were observed in aortic-valve reintervention rates at 30 days, 2 years, or 5 years, but TAVR showed a significantly increased risk at 1 year (RR=1.98, 95% CI: 1.21-3.24). TAVR was associated with a significantly increased risk of major vascular complications at 30 days (RR=2.37, 95% CI: 1.38-4.04) and a significantly increased risk of TIA at 2 years (RR: 1.43, 95% CI: 1.02-2.00, I2=0%). The risk of hospitalizations was comparable between the groups.

CONCLUSION

TAVR and SAVR demonstrated comparable rates of all-cause death up to 2 years of follow-up. However, at 5 years or longer follow-up, TAVR was associated with a higher risk of all-cause death. While TAVR showed certain procedural advantages, such as a lower risk of major bleeding, AKI, and new-onset or worsening AF, the choice between TAVR and SAVR in patients with low or intermediate surgical risk should consider long-term outcomes, with SAVR potentially being more favorable due to better survival observed on longer follow-up durations.

The Ross Operation in Young Patients—A Single-Center, Long-Term Follow-Up Study

BACKGROUND

The standard aortic valve replacement operations in young patients are bioprosthetic or mechanical aortic valve replacement. In this study, we present the long-term results of the Ross operation in young patients.

METHODS

The Ross operation with root replacement was performed on 795 patients between 1995 and 2020. The endpoints were overall survival, re-operation/reintervention rates on the autograft and homograft/RV-PA conduit (RV, right ventricle; PA, pulmonary artery), and the occurrence of serious adverse events.

RESULTS

795 patients (75% male, 25% female; mean age 43 ± 14 years) underwent the Ross operation with root replacement. The 30-day mortality was 1% (8 patients) with a 95% confidence interval of [0.48; 1.9]. The follow-up was 96 % complete and covered 9540 patient-years, with a mean follow-up time of 12 ± 7 years. The survival rates at 5, 10, 15 and 20 years were 97% [96; 98], 96% [93; 96], 92% [89; 94] and 86% [83; 90]. The rate of autograft survival without reoperation was 94% [92; 96] at 10 years and 80% [76; 85] at 20 years. The rate of homograft/RV-PA conduit survival without reoperation was 95% [93; 97] at 10 years and 85% [81; 90] at 20 years. There were 5 cases of hemorrhage, 14 of thromboembolic complications or apoplexy, and 19 of endocarditis.

CONCLUSION

The Ross operation with root replacement was associated with high survival rates over 25 years of follow-up. The rates of reoperation and reintervention, the morbidity and mortality, and the rate of endocarditis are low. The Ross operation is thus an effective surgical treatment option for young patients with aortic valve disease.

Robotic Aortic Valve Replacement vs Transcatheter Aortic Valve Replacement: A Propensity-Matched Analysis

BACKGROUND

Current evidence supports equipoise between surgical aortic valve replacement (AVR) and transcatheter AVR (TAVR) for the management of symptomatic severe aortic stenosis (AS). The optimal interventional management for lower-risk patients is controversial. Minimally invasive robotic AVR (RAVR) was developed as a potential option.

METHODS

A total of 605 consecutive patients (2017-2023) managed by the identical structural heart team, 174 RAVR and 431 TAVR, were propensity matched and evaluated for in-hospital and 1-year outcomes.

RESULTS

There were 288 low- to intermediate-risk (The Society of Thoracic Surgeons predicted risk of mortality <8%) patients matched in 2 well-balanced groups (144 RAVR vs 144 TAVR). In-hospital and 30-day mortality were similar. There were 2 conversions to sternotomy in the TAVR group (cardiac arrest and coronary occlusion) and none in the RAVR group. Eight RAVR patients (5.6%) required reoperation for hemothorax evacuation. TAVR was associated with higher new pacemaker (11 vs 3, P = .028) and major vascular complications (13 vs 0, P < .0001), and a higher postprocedural stroke trend (6 vs 1, P = .056). There was no difference in 30-day transfusions, atrial fibrillation, or 1-year mean valve gradients. However, 1-year mortality (12.5% vs 1.4%, P < .0001) and paravalvular leak greater than mild (32.6% vs 2.3%, P < 0.0001) were significantly higher in TAVR.

CONCLUSIONS

These data highlight lower pacemaker and vascular complications, as well as less 1-year paravalvular leak and mortality with RAVR compared with TAVR. RAVR may provide a safe and effective minimally invasive alternative to TAVR for low- and intermediate-risk patients presenting with severe symptomatic AS.

Hospital and surgeon surgical valvar volume and survival after multivalve cardiac surgery in Medicare beneficiaries

OBJECTIVE

Long-term outcomes after multivalve cardiac surgery remain underevaluated.

METHODS

Medicare administrative claims from 2008 to 2019 identified beneficiaries undergoing multivalve surgery. Operative characteristics were doubly adjudicated using International Classification of Diseases and Current Procedural Technology codes. A multivariable flexible parametric model evaluated predictors of survival; regression standardization was performed to predict standardized survival probabilities (SSPs) at varying percentiles of annual valvar volume.

RESULTS

Of 476,092 cardiac surgeries involving the aortic (AVS), mitral (MVS), or tricuspid (TVS) valve, 63,083 (13.3%) were identified as involving multi-valve surgery, including 22,884 MVS/TVS, 30,697 AVS/MVS, 3443 AVS/TVS, and 6059 AVS/MVS/TVS. Surgery occurred at 1157 hospitals by 2922 surgeons. Annual valvar volume (total AVS/MVS/TVS) was tallied for surgeons and hospitals. Median survival varied substantially by type of multivalve surgery: 8.09 (95% CI: 7.90-8.24) years in MVS/TVS, 6.65 (95% CI: 6.49-6.81) years in AVS/MVS, 5.77 (95% CI: 5.37-6.13) years in AVS/TVS, and 6.02 (95% CI: 5.64-6.38) years in AVS/MVS/TVS. SSPs were calculated across combined hospital/surgeon volume percentiles; the median SSP increased with increasing percentile of combined hospital/surgeon volume: 5th percentile, 5.77 (95% CI: 5.58-5.98), 25th percentile, 6.18 (95% CI: 6.07-6.28), 50th percentile, 6.56 (95% CI: 6.44-6.68), 75%th percentile, 6.86 (95% CI: 6.75-6.97), and 95th percentile, 7.58 (95% CI: 7.34-7.83) years, respectively.

CONCLUSIONS

Survival varied significantly by type of multivalve surgery, worsened with addition of concomitant interventions and improved substantially with increasing annual hospital and surgeon volume. Hospital volume was associated with an improved early hazard for death that abated beyond 3 months post surgery, while surgeon volume was associated with an improved hazard for death that persisted even beyond the first postoperative year. Consideration should be given to referring multivalve cases to high-volume hospitals and surgeons.

Age-Based Outcomes After Surgical Aortic Valve Replacement With Bioprosthetic Versus Mechanical Valves

Recommendations for prosthesis type in older patients who underwent surgical aortic valve replacement (SAVR) are established, albeit undervalidated. The purpose of this study is to compare outcomes after bioprosthetic versus mechanical SAVR across various age groups. This was a retrospective study using an institutional SAVR database. All patients who underwent isolated SAVR were compared across valve types and age strata (<65 years, 65 to 75 years, >75 years). Patients who underwent concomitant operations, aortic root interventions, or previous aortic valve replacement were excluded. Objective survival and aortic valve reinterventions were compared. Kaplan-Meier survival estimation and multivariate regression were performed. A total of 1,847 patients underwent SAVR from 2010 to 2023. A total of 1,452 patients (78.6%) received bioprosthetic valves, whereas 395 (21.4%) received mechanical valves. Of those who received bioprosthetic valves, 349 (24.0%) were aged <65 years, 627 (43.2%) were 65 to 75 years, and 476 (32.8%%) were older than 75 years. For patients who received mechanical valves, 308 (78.0%) were aged <65 years, 84 (21.3%) were between 65 and 75 years, and 3 (0.7%) were >75 years. The median follow-up in the total cohort was 6.2 (2.6 to 8.9) years. No statistically significant differences were observed in early-term Kaplan-Meier survival estimates between SAVR valve types in all age groups. However, the cumulative incidence estimates of aortic valve reintervention were significantly higher in patients aged under 65 years who received bioprosthetic than those who received mechanical valves, with 5-year reintervention rates of 5.8% and 3.1%, respectively (p = 0.002). On competing risk analysis for valve reintervention, bioprosthetic valves were significantly associated with an increased hazard of aortic valve reintervention (hazard ratio 3.35, 95% confidence interval 1.73 to 6.49, p <0.001). In conclusion, SAVR with bioprosthetic valves (particularly, in patients aged <65 years) was comparable in survival to mechanical valve SAVR but significantly associated with increased valve reintervention rates.

Decellularized aortic homografts versus mechanical composite grafts for aortic root replacement

OBJECTIVES

Mechanical composite valve grafts (MCVGs) are the first-line therapy for aortic root replacement in young adults. Decellularized aortic homografts (DAH) present a promising novel alternative due to their lower thrombogenicity. We aimed to compare both treatment options regarding survival and valve-related adverse events.

METHODS

This study was designed as a single-centre retrospective cohort study including patients who underwent root replacement with MCVG or DAH between 2000 and 2022. Urgent or emergent procedures were excluded.

RESULTS

The study cohort included 289 patients (MCVG n = 216, DAH n = 73) with a mean age of 48.5 ± 12 years (MCVG 49 ± 12 years vs DAH 47 ± 11 years; P = 0.23) and a median EuroScore II of 1.7% (1.2, 2.6). The 30-day mortality was 1% (n = 3). Cumulative survival at 3 years was 99% for DAH and 94% for MCVG, respectively (P = 0.15). Mean follow-up was 98.9 ± 72.7 months. Bleeding events (n = 14, 6.5%) and thromboembolism (n = 14, 6.5%) were only observed in the MCVG group (P = 0.19 and 0.09, respectively). Four cases (5%) of moderate structural valve deterioration occurred, all in the DAH group (P ≤ 0.001). The cumulative incidence of a composite end point of valve-related adverse events was significantly higher in the MCVG group (P = 0.0295).

CONCLUSIONS

Aortic root replacement with MCVGs and decellularized aortic homografts showed low mortality in an elective setting. Patients in the homograft cohort demonstrated significantly higher freedom from valve-related adverse events. DAH present a promising treatment option for young patients requiring root replacement; however, data on long-term durability are needed.

Atrial Fibrillation Management During Surgical vs Transcatheter Aortic Valve Replacement

BACKGROUND

Societal guidelines support atrial fibrillation (AF) treatment during surgical aortic valve replacement (SAVR). Recently, many patients with AF at low to intermediate risk are managed by transcatheter aortic valve replacement (TAVR). Therefore, we evaluated longitudinal outcomes in these populations.

METHODS

The United States Centers for Medicare and Medicaid Services inpatient claims database was evaluated for all beneficiaries with AF undergoing TAVR or SAVR with/without AF treatment (2018-2020). Treatment of AF included concomitant left atrial appendage obliteration, with/without surgical ablation, or endovascular appendage occlusion and/or catheter ablation at any time. Diagnosis-related group and International Classification of Diseases, 10th Revision, codes defined procedures with doubly robust risk adjustment across each group.

RESULTS

A total of 24,902 patients were evaluated (17,453 TAVR; 7,449 SAVR). Of patients undergoing SAVR, 3176 (42.6%) underwent AF treatment (SAVR+AF). Only 656 TAVR patients (4.5%) received AF treatment. Comparing well-balanced SAVR+AF vs SAVR vs TAVR, there were no differences in the in-hospital incidence of renal failure, bleeding, or stroke, but increased pacemaker requirement (odds ratio [OR], 3.45; P < .0001) and vascular injury (OR, 9.09; P < .0001) were noted in TAVR and higher hospital mortality (OR, 4.02; P < .0001) in SAVR+AF. SAVR+AF was associated with lower readmission for stroke compared with SAVR alone (hazard ratio [HR], 0.87; P = .029) and TAVR (HR, 0.68; P < .0001) and with improved survival vs TAVR (HR, 0.79; P = .019).

CONCLUSIONS

In Medicare beneficiaries with AF requiring aortic valve replacement, SAVR+AF was associated with improved longitudinal survival and freedom from stroke compared with TAVR. SAVR+AF treatment should be considered first-line therapy for patients with AF requiring aortic valve replacement.

Age-Stratified Surgical Aortic Valve Replacement for Aortic Stenosis

BACKGROUND

The management of aortic stenosis has evolved to stratification by age as reflected in recent societal guidelines. We evaluated age-stratified surgical aortic valve replacement (SAVR) trends and outcomes in patients with bicuspid aortic valve (BAV) or tricuspid aortic valve (TAV) from The Society of Thoracic Surgeons Adult Cardiac Surgery Database.

METHODS

This cohort included adults (≥18 years) undergoing SAVR for severe aortic stenosis between July 2011 and December 2022. Comparisons were stratified by age (<65 years, 65-79 years, ≥80 years) and BAV or TAV status. Primary end points included operative mortality, composite morbidity and mortality, and permanent stroke. Observed to expected ratios by The Society of Thoracic Surgeons predicted risk of mortality were calculated.

RESULTS

In total, 200,849 SAVR patients (55,326 BAV [27.5%], 145,526 TAV [72.5%]) from 1238 participating hospitals met study criteria. Annual SAVR volumes decreased by 45% (19,560 to 10,851) during the study period. The decrease was greatest (96%) for patients ≥80 years of age (4914 to 207). The relative prevalence of BAV was greater in younger patients (<65 years, 69,068 [49.5% BAV]; 65-79 years, 104,382 [19.1% BAV]; ≥80 years, 27,399 [4.5% BAV]). The observed mortality in <80-year-old BAV patients (<65 years, 1.08; 65-79 years, 1.21; ≥80 years, 3.68) was better than the expected mortality rate (<65 years, 1.22; 65-79 years, 1.54; ≥80 years, 3.14).

CONCLUSIONS

SAVR volume in the transcatheter era has decreased substantially, particularly for patients ≥80 years old and for those with TAV. Younger patients with BAV have better than expected outcomes, which should be carefully considered during shared decision-making in the treatment of aortic stenosis. SAVR should remain the preferred therapy in this population.

Surgical aortic valve replacement in octogenarians: Single-center perioperative outcomes and five-year survival

INTRODUCTION AND OBJECTIVES

Aortic stenosis is the most common valvular heart disease. The number of octogenarians proposed for intervention is growing due to increased lifespan. In this manuscript we aim to evaluate perioperative outcome and long-term survival after surgical aortic valve replacement (SAVR) in octogenarians, comparing patients with low surgical risk (EuroscoreII <4%) with intermediate-high risk (EuroscoreII ≥4%).

METHODS

A retrospective observational single-center cohort study with 195 patients aged ≥80 years old, who underwent SAVR between 2017 and 2021, was conducted. Patients were divided into two groups according to EuroscoreII: (1) Low risk (EuroscoreII <4%) with intermediate-high risk (EuroscoreII ≥4%). Continuous variables are presented in median (IQR), analyzed using Wilcoxon rank sum test; categorical variables in percentages, analyzed using chi-squared test; and survival was analyzed by Kaplan-Meier, open cohort, and the log-rank test was performed.

RESULTS

The overall median age was 82 (IQR 81-83), with 4.6% of the patients ≥85 years old. 23.6% of the patients presented EuroscoreII ≥4%. No complications were observed in 26.2%, with a significantly higher rate in intermediate-high risk patients. Postoperative need for hemodynamic support was the most frequent complication, followed by postoperative acute kidney injury and the use of blood products. Overall median ICU stay was three days (2-4) and hospital length of stay (LOS) six days (5-8). Patients with intermediate-high risk and those with complications had longer ICU LOS. At 12 months, overall survival was 96.4%, at three years 94.1% and 5 years 75.4%. Patients with low surgical risk had higher survival proportions up to 5 years.

CONCLUSION

SAVR in patients ≥80 years is associated with low in-hospital mortality, although a significant proportion of patients develop complications. Long-term follow-up up to five years after surgery is acceptable in octogenarians with low surgical risk.

Cardiac Surgery 2023 Reviewed

We reviewed the cardiac surgical literature for 2023. PubMed displayed almost 34,000 hits for the search term "cardiac surgery AND 2023." We used a PRISMA approach for a results-oriented summary. Key manuscripts addressed the mid- and long-term effects of invasive treatment options in patient populations with coronary artery disease (CAD), comparing interventional therapy (percutaneous coronary intervention [PCI]) with surgery (coronary artery bypass graft [CABG]). The literature in 2023 again confirmed the excellent long-term outcomes of CABG compared with PCI in patients with left main stenosis, specifically in anatomically complex chronic CAD, but even in elderly patients, generating further support for an infarct-preventative effect as a prognostic mechanism of CABG. For aortic stenosis, a previous trend of an early advantage for transcatheter (transcatheter aortic valve implantation [TAVI]) and a later advantage for surgical (surgical aortic valve replacement) treatment was also re-confirmed by many studies. Only the Evolut Low Risk trial maintained an early advantage of TAVI over 4 years. In the mitral and tricuspid field, the number of interventional publications increased tremendously. A pattern emerges that clinical benefits are associated with repair quality, making residual regurgitation not irrelevant. While surgery is more invasive, it currently generates the highest repair rates and longest durability. For terminal heart failure treatment, donor pool expansion for transplantation and reducing adverse events in assist device therapy were issues in 2023. Finally, the aortic diameter related to adverse events and technical aspects of surgery dominated in aortic surgery. This article summarizes publications perceived as important by us. It cannot be complete nor free of individual interpretation, but provides up-to-date information for patient-specific decision-making.

Transcatheter or Surgical Treatment of Aortic-Valve Stenosis

BACKGROUND

Among low-risk patients with severe, symptomatic aortic stenosis who are eligible for both transcatheter aortic-valve implantation (TAVI) and surgical aortic-valve replacement (SAVR), data are lacking on the appropriate treatment strategy in routine clinical practice.

METHODS

In this randomized noninferiority trial conducted at 38 sites in Germany, we assigned patients with severe aortic stenosis who were at low or intermediate surgical risk to undergo either TAVI or SAVR. Percutaneous- and surgical-valve prostheses were selected according to operator discretion. The primary outcome was a composite of death from any cause or fatal or nonfatal stroke at 1 year.

RESULTS

A total of 1414 patients underwent randomization (701 to the TAVI group and 713 to the SAVR group). The mean (±SD) age of the patients was 74±4 years; 57% were men, and the median Society of Thoracic Surgeons risk score was 1.8% (low surgical risk). The Kaplan-Meier estimate of the primary outcome at 1 year was 5.4% in the TAVI group and 10.0% in the SAVR group (hazard ratio for death or stroke, 0.53; 95% confidence interval [CI], 0.35 to 0.79; P<0.001 for noninferiority). The incidence of death from any cause was 2.6% in the TAVI group and 6.2% in the SAVR group (hazard ratio, 0.43; 95% CI, 0.24 to 0.73); the incidence of stroke was 2.9% and 4.7%, respectively (hazard ratio, 0.61; 95% CI, 0.35 to 1.06). Procedural complications occurred in 1.5% and 1.0% of patients in the TAVI and SAVR groups, respectively.

CONCLUSIONS

Among patients with severe aortic stenosis at low or intermediate surgical risk, TAVI was noninferior to SAVR with respect to death from any cause or stroke at 1 year. (Funded by the German Center for Cardiovascular Research and the German Heart Foundation; DEDICATE-DZHK6 ClinicalTrials.gov number, NCT03112980.).

Transcatheter or surgical aortic valve implantation: 10-year outcomes of the NOTION trial

BACKGROUND AND AIMS

Transcatheter aortic valve implantation (TAVI) has become a viable treatment option for patients with severe aortic valve stenosis across a broad range of surgical risk. The Nordic Aortic Valve Intervention (NOTION) trial was the first to randomize patients at lower surgical risk to TAVI or surgical aortic valve replacement (SAVR). The aim of the present study was to report clinical and bioprosthesis outcomes after 10 years.

METHODS

The NOTION trial randomized 280 patients to TAVI with the self-expanding CoreValve (Medtronic Inc.) bioprosthesis (n = 145) or SAVR with a bioprosthesis (n = 135). The primary composite outcome was the risk of all-cause mortality, stroke, or myocardial infarction. Bioprosthetic valve dysfunction (BVD) was classified as structural valve deterioration (SVD), non-structural valve dysfunction (NSVD), clinical valve thrombosis, or endocarditis according to Valve Academic Research Consortium-3 criteria. Severe SVD was defined as (i) a transprosthetic gradient of 30 mmHg or more and an increase in transprosthetic gradient of 20 mmHg or more or (ii) severe new intraprosthetic regurgitation. Bioprosthetic valve failure (BVF) was defined as the composite rate of death from a valve-related cause or an unexplained death following the diagnosis of BVD, aortic valve re-intervention, or severe SVD.

RESULTS

Baseline characteristics were similar between TAVI and SAVR: age 79.2 ± 4.9 years and 79.0 ± 4.7 years (P = .7), male 52.6% and 53.8% (P = .8), and Society of Thoracic Surgeons score < 4% of 83.4% and 80.0% (P = .5), respectively. After 10 years, the risk of the composite outcome all-cause mortality, stroke, or myocardial infarction was 65.5% after TAVI and 65.5% after SAVR [hazard ratio (HR) 1.0; 95% confidence interval (CI) 0.7-1.3; P = .9], with no difference for each individual outcome. Severe SVD had occurred in 1.5% and 10.0% (HR 0.2; 95% CI 0.04-0.7; P = .02) after TAVI and SAVR, respectively. The cumulative incidence for severe NSVD was 20.5% and 43.0% (P < .001) and for endocarditis 7.2% and 7.4% (P = 1.0) after TAVI and SAVR, respectively. No patients had clinical valve thrombosis. Bioprosthetic valve failure occurred in 9.7% of TAVI and 13.8% of SAVR patients (HR 0.7; 95% CI 0.4-1.5; P = .4).

CONCLUSIONS

In patients with severe AS and lower surgical risk randomized to TAVI or SAVR, the risk of major clinical outcomes was not different 10 years after treatment. The risk of severe bioprosthesis SVD was lower after TAVR compared with SAVR, while the risk of BVF was similar.

Valve Type and Operative Risks in Surgical Explantation of Transcatheter Aortic Valves: A Systematic Review and Meta-Analysis

Indication to perform surgical explantation of TAVR is becoming increasingly more frequent, due to the higher number of transcatheter procedures performed in patients with longer life expectancy. We proposed to perform a systematic review and meta-analysis with metaregression to identify potential factors that can determine an increase in the high mortality and morbidity that characterize these surgical procedures. MEDLINE and Embase were searched for relevant studies. Twelve studies were eligible according to our inclusion criteria. TAVR explantation was confirmed as a procedure with high 30-day mortality (0.17; 95% CI, 0.14-0.21) and morbidity (stroke incidence 5%; 95% CI, 0.04-0.07; kidney injury incidence 16%; 95% CI, 0.11-0.24). The type of transcatheter valve implanted during the index procedure did not influence the outcomes after surgical explantation. The role of these high-risk operations is growing, and it will likely expand in the coming years. Specific tools for risk stratification are required.

Early and mid-term outcomes after aortic valve replacement using a novel tissue bioprosthesis: a systematic review

OBJECTIVES

While current data show a clear trend towards the use of bioprosthetic valves during aortic valve replacement (AVR), durability of bioprosthetic valves remains the most important concern. We conducted a 1st systematic review of all available evidence that analysed early and mid-term outcomes after AVR using the Inspiris RESILIA™ bioprosthesis.

METHODS

A systematic literature search was performed to identify all relevant studies evaluating early and mid-term outcomes after AVR using the Inspiris RESILIA bioprosthesis and including at least 20 patients with no restriction on the publication date. Subgroup meta-analysis was performed to compare Inspiris RESILIA and PERIMOUNT Magna Ease bioprosthesis and to pool the early postoperative mortality and stroke rates.

RESULTS

A total of 416 studies were identified, of which 15 studies met the eligibility criteria. The studies included a total of 3202 patients with an average follow-up of up to 5.3 years. The average age of patients across the studies was 52.2-75.1 years. Isolated AVR was performed in 39.0-86.4% of patients. In-hospital or 30-day postoperative mortality was 0-2.8%. At the mid-term follow-up, freedom from all-cause mortality was up to 85.4%. Among studies with mid-term follow-up, trace/mild paravalvular leak was detected in 0-3.0%, while major paravalvular leak was found only in up to 2.0% of patients. No statistically significant differences in terms of mortality (P = 0.98, odds ratio 1.02, 95% confidence interval 0.36-2.83) and stroke (P = 0.98, odds ratio 1.01, 95% confidence interval 0.38-2.73) between the Inspiris RESILIA bioprosthesis and PERIMOUNT Magna Ease bioprosthesis were observed in the subgroup meta-analysis.

CONCLUSIONS

Mid-term data on the safety and haemodynamic performance of the novel aortic bioprosthesis are encouraging. Further comparative studies with other bioprostheses and longer follow-up are still required to endorse durability and safety of the novel bioprosthesis.

Bayesian interpretation of non-inferiority in transcatheter versus surgical aortic valve replacement trials: a systematic review and meta-analysis

OBJECTIVES

The concept of non-inferiority is widely adopted in randomized trials comparing transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR). However, uncertainty exists regarding the long-term outcomes of TAVR, and non-inferiority may be difficult to assess. We performed a systematic review and meta-analysis of randomized trials comparing TAVR and SAVR, with a specific emphasis on the non-inferiority margin for 5-year all-cause mortality.

METHODS

A systematic search was applied to 3 electronic databases. Randomized trials comparing TAVR and SAVR were included. Bayesian methods were implemented to evaluate the posterior probability of non-inferiority at different trial non-inferiority margins under either a vague, Cauchy, or a literature-based prior. Primary outcomes were 5-year actuarial all-cause mortality, and the probability of non-inferiority at various transformed trial non-inferiority margins. Secondary outcomes were long-term survival and 1- and 2-year actuarial survival.

RESULTS

Eight trials (n = 8698 patients) were included. Kaplan-Meier-derived 5-year survival was 61.6% (95% CI 59.8-63.5%) for TAVR, and 63.7% (95% CI 61.9-65.6%) for SAVR. Six trials (n = 6370 patients) reported all-cause mortality at 5-year follow-up. Under a vague prior, the posterior median relative risk for all-cause mortality of TAVR was 1.14, compared to SAVR (95% credible interval 1.06-1.22, probability of relative risk <1.00 = 0.01%, I2 = 0%). Similar results in terms of point estimate and uncertainty measures were obtained using frequentist methods. Based on the various trial non-inferiority margins, the results of the analysis suggest that non-inferiority at 5 years is no longer likely.

CONCLUSIONS

It is unlikely that TAVR is still non-inferior to SAVR at 5 years in terms of all-cause mortality.