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Narayan P, Dong T, Dimagli A, Fudulu DP, Chan J, Sinha S, Angelini GD. Impact of explanted valve type on aortic valve reoperations: nationwide UK experience. Eur J Cardiothorac Surg 2024; 65:ezae031. [PMID: 38305431 PMCID: PMC10902681 DOI: 10.1093/ejcts/ezae031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 01/19/2024] [Accepted: 01/29/2024] [Indexed: 02/03/2024] Open
Abstract
OBJECTIVES This nationwide retrospective cohort study assessed the impact of the explanted valve type on reoperative outcomes in aortic valve surgery within the UK over a 23-year period. METHODS Data were sourced from the National Institute for Cardiovascular Outcomes Research (NICOR) database. All patients undergoing first-time isolated reoperative aortic valve replacement between 1996 and 2019 in the UK were included. Concomitant procedures, homograft implantation or aortic root enlargement were excluded. Propensity score matching was utilized to compare outcomes and risk factors for in-hospital mortality was evaluated through multivariable logistic regression. Final model selection was conducted using Akaike Information Criterion through bootstrapping. The primary end point was in-hospital mortality, and secondary end points included postoperative morbidities. RESULTS Out of 2371 patients, 24.9% had mechanical and 75% had bioprosthetic valves implanted during the primary procedure. Propensity matched groups of 324 patients each, were compared. In-hospital mortality for mechanical and bioprosthetic valve explants was 7.1% and 5.9%, respectively (P = 0.632). On multivariable logistic regression analysis, valve type was not a risk factor for mortality [odds ratio (OR) 0.62, 95% confidence interval (CI) 0.37-1.05; P = 0.1]. Age (OR 1.03, 95% CI 1.01-1.05; P < 0.05), left ventricular ejection fraction (OR 1.62, 95% CI 1.08-2.42; P < 0.05), creatinine ≥ 200 mg/dl (OR 2.21, 95% CI 1.17-4.04; P < 0.05) and endocarditis (OR 2.66, 95% CI 1.71-4.14; P < 0.05) emerged as risk factors for mortality. CONCLUSIONS The type of valve initially implanted (mechanical or bioprosthetic) did not determine mortality. Instead, age, left ventricular ejection fraction, renal impairment and endocarditis were significant risk factors for in-hospital mortality.
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Affiliation(s)
- Pradeep Narayan
- Department of Cardiac Surgery, Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health, Kolkata, India
| | - Tim Dong
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol University, Bristol, UK
| | - Arnaldo Dimagli
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol University, Bristol, UK
| | - Daniel P Fudulu
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol University, Bristol, UK
| | - Jeremy Chan
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol University, Bristol, UK
| | - Shubhra Sinha
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol University, Bristol, UK
| | - Gianni D Angelini
- Department of Cardiac Surgery, Bristol Heart Institute, Bristol University, Bristol, UK
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Nagasaka T, Koren O, Patel V, Naami R, Naami E, Shechter A, Kohan S, Allison Z, Lerner A, Cheng DE, Chakravarty T, Cheng W, Jilaihawi H, Ishii H, Nakamura M, Makkar RR. Two-Year Outcomes of Valve-in-Valve Using New-Generation Transcatheter Devices Compared With Redo-SAVR. Am J Cardiol 2023; 207:380-389. [PMID: 37778227 DOI: 10.1016/j.amjcard.2023.08.147] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 08/21/2023] [Accepted: 08/21/2023] [Indexed: 10/03/2023]
Abstract
Few studies have compared the clinical outcomes between valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) with new-generation valves and re-operative surgical aortic valve replacement (Redo-SAVR). We compared the clinical outcomes of patients who underwent ViV-TAVR with those of patients who underwent Redo-SAVR at Cedars-Sinai Medical Center between 2015 and 2021. New-generation valves were used for ViV-TAVR. A propensity score-matched (PSM) analysis was performed to adjust for differences in baseline characteristics. The primary end point was all-cause mortality at 30 days and 2 years. In-hospital procedural and clinical outcomes were also compared between the groups. A total of 256 patients (140 who underwent ViV-TAVR and 116 who underwent Redo-SAVR) were eligible for PSM. In the unmatched cohort, patients in the ViV-TAVR group were older and had more co-morbidities than those in the Redo-SAVR group. After PSM, there were no significant differences in all-cause death between the ViV-TAVR and Redo-SAVR groups at 30 days (3.9% vs 2.6%, p = 0.65) or 2 years (6.5% vs 7.8%, p = 0.75). The incidences of stroke and heart failure rehospitalization were similar at 30 days and 2 years. The cumulative complication rates during hospitalization were significantly lower in the ViV-TAVR group than in the Redo-SAVR group (11.7% vs 28.6% p = 0.015). The long-term outcomes of ViV-TAVR using new-generation valves were similar to those of Redo-SAVR, although ViV-TAVR was associated with lower rates of in-hospital complications.
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Affiliation(s)
- Takashi Nagasaka
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Ofir Koren
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Technion Israel Institute of Technology, Bruce Rappaport Faculty of Medicine, Haifa, Israel
| | - Vivek Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert Naami
- Internal Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Edmund Naami
- School of Medicine, University of Illinois, Chicago, Illinois
| | - Alon Shechter
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Siamak Kohan
- Internal Medicine, Kaiser Permanente Medical Center, Los Angeles, California
| | - Zev Allison
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Addee Lerner
- David Geffen School of Medicine, University of California (UCLA), Los Angeles, California
| | | | - Tarun Chakravarty
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Wen Cheng
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Hasan Jilaihawi
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Hideki Ishii
- Department of Cardiovascular Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
| | - Mamoo Nakamura
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Raj R Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.
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Sá MP, Tasoudis P, Jacquemyn X, Van den Eynde J, Caranasos TG, Ikonomidis JS, Chu D, Serna‐Gallegos D, Sultan I. Long-Term Outcomes of Patients Undergoing Aortic Root Replacement With Mechanical Versus Bioprosthetic Valves: Meta-Analysis of Reconstructed Time-to-Event Data. J Am Heart Assoc 2023; 12:e030629. [PMID: 37681555 PMCID: PMC10547304 DOI: 10.1161/jaha.123.030629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 07/06/2023] [Indexed: 09/09/2023]
Abstract
Background An aspect not so clear in the scenario of aortic surgery is how patients fare after composite aortic valve graft replacement (CAVGR) depending on the type of valve (bioprosthetic versus mechanical). We performed a study to evaluate the long-term outcomes of both strategies comparatively. Methods and Results Pooled meta-analysis of Kaplan-Meier-derived time-to-event data from studies with follow-up for overall survival (all-cause death), event-free survival (composite end point of cardiac death, valve-related complications, stroke, bleeding, embolic events, and/or endocarditis), and freedom from reintervention. Twenty-three studies met our eligibility criteria, including 11 428 patients (3786 patients with mechanical valves and 7642 patients with bioprosthetic valve). The overall population was mostly composed of men (mean age, 45.5-75.6 years). In comparison with patients who underwent CAVGR with bioprosthetic valves, patients undergoing CAVGR with mechanical valves presented no statistically significant difference in the risk of all-cause death in the first 30 days after the procedure (hazard ratio [HR], 1.24 [95% CI, 0.95-1.60]; P=0.109), but they had a significantly lower risk of all-cause mortality after the 30-day time point (HR, 0.89 [95% CI, 0.81-0.99]; P=0.039) and lower risk of reintervention (HR, 0.33 [95% CI, 0.24-0.45]; P<0.001). Despite its increased risk for the composite end point in the first 6 years of follow-up (HR, 1.41 [95% CI, 1.09-1.82]; P=0.009), CAVGR with mechanical valves is associated with a lower risk for the composite end point after the 6-year time point (HR, 0.46 [95% CI, 0.31-0.67]; P<0.001). Conclusions CAVGR with mechanical valves is associated with better long-term outcomes in comparison with CAVGR with bioprosthetic valves.
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Affiliation(s)
- Michel Pompeu Sá
- Department of Cardiothoracic SurgeryUniversity of PittsburghPittsburgh, PA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical CenterPittsburghPA
| | - Panagiotis Tasoudis
- Division of Cardiothoracic Surgery, Department of SurgeryUniversity of North CarolinaChapel HillNC
| | | | | | - Thomas G. Caranasos
- Division of Cardiothoracic Surgery, Department of SurgeryUniversity of North CarolinaChapel HillNC
| | - John S. Ikonomidis
- Division of Cardiothoracic Surgery, Department of SurgeryUniversity of North CarolinaChapel HillNC
| | - Danny Chu
- Department of Cardiothoracic SurgeryUniversity of PittsburghPittsburgh, PA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical CenterPittsburghPA
| | - Derek Serna‐Gallegos
- Department of Cardiothoracic SurgeryUniversity of PittsburghPittsburgh, PA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical CenterPittsburghPA
| | - Ibrahim Sultan
- Department of Cardiothoracic SurgeryUniversity of PittsburghPittsburgh, PA
- UPMC Heart and Vascular Institute, University of Pittsburgh Medical CenterPittsburghPA
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Fukunaga N, Al-Sarraf A, Jawad K, Lafreniere-Roula M, Rao V. Early and mid-term outcomes after aortic valve intervention in patients with previous stentless or stented bioprostheses. J Cardiothorac Surg 2023; 18:34. [PMID: 36653867 PMCID: PMC9847021 DOI: 10.1186/s13019-023-02118-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 01/02/2023] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Limited data are available concerning comparative outcomes of redo aortic valve interventions, including surgery after aortic valve replacement (AVR) with either stented or stentless bioprostheses. We investigated the comparative outcomes of redo aortic valve interventions, including surgery after AVR with either stented or stentless bioprostheses. METHODS The cohort consisted of 112 patients who underwent aortic valve intervention for infective endocarditis or structural valve deterioration between 2001 and 2020. One hundred patients received a stented valve (stented group) and 12 patients received a stentless valve (stentless group) during the initial surgery. Early and late outcomes were evaluated. RESULTS The mean [IQR] ages during the current interventions were 66 [54, 77] years in the stented group and 74 [67, 79] years in the stentless group (P = 0.13). In the stented group, aortic valve interventions included redo AVRs with stented valves (n = 54), mechanical valves (n = 26), stentless valves (n = 16), and transcatheter aortic valve implantations (n = 4). In the stentless group, redo AVRs were performed with stented valves (n = 4), mechanical valves (n = 2), stentless valves (n = 1), and transcatheter valve implantations (n = 5). Hospital mortality was observed in 2 (2%) patients in the stented group and 1 (8%) patients in the stentless group (P = 0.29). The 5-year survival was 80.8% [66.8, 88.5] in the stented group and 91.7% [53.9, 98.8] in stentless group. Statistically significant differences in thromboembolisms were observed between the groups. CONCLUSIONS No significant differences in early and mid-term outcomes (except thromboembolism) after aortic valve interventions were detected between patients with stented and stentless AVRs.
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Affiliation(s)
- Naoto Fukunaga
- grid.231844.80000 0004 0474 0428Division of Cardiovascular Surgery, 4PMB-457, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, University Health Network, 200 Elizabeth Street, Toronto, ON M5G 2C4 Canada
| | - Ali Al-Sarraf
- grid.231844.80000 0004 0474 0428Division of Cardiovascular Surgery, 4PMB-457, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, University Health Network, 200 Elizabeth Street, Toronto, ON M5G 2C4 Canada
| | - Khalil Jawad
- grid.231844.80000 0004 0474 0428Division of Cardiovascular Surgery, 4PMB-457, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, University Health Network, 200 Elizabeth Street, Toronto, ON M5G 2C4 Canada
| | - Myriam Lafreniere-Roula
- grid.231844.80000 0004 0474 0428Division of Cardiovascular Surgery, 4PMB-457, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, University Health Network, 200 Elizabeth Street, Toronto, ON M5G 2C4 Canada
| | - Vivek Rao
- grid.231844.80000 0004 0474 0428Division of Cardiovascular Surgery, 4PMB-457, Peter Munk Cardiac Centre, Toronto General Hospital, University of Toronto, University Health Network, 200 Elizabeth Street, Toronto, ON M5G 2C4 Canada
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Hutt E, Mehra N, Desai MY. Valve-in-valve transcatheter aortic valve replacement versus redo aortic valve replacement: which procedure for which patient? Expert Rev Cardiovasc Ther 2022; 20:911-918. [PMID: 36433699 DOI: 10.1080/14779072.2022.2153118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Bioprosthetic aortic valves are increasingly being utilized in a younger population due to improved durability and possibility for future valve-in-valve replacement. This has resulted in a larger population of patients with bioprosthetic aortic valve degeneration requiring re-intervention. Despite no head-to-head comparisons between redo surgical aortic valve replacement (SAVR) and valve-in-valve transcatheter aortic valve replacement (ViV TAVR), observational studies suggest a comparable long-term risk between which led to the incorporation of ViV TAVR to current guidelines. AREAS COVERED This article summarizes the comparative performance of redo SAVR versus ViV TAVR in patients with bioprosthetic valve dysfunction and provides a guide to better understand which procedure is best for which patient. EXPERT OPINION With the rising use of TAVR, we will be confronted with more bioprosthetic aortic valve degeneration requiring re-intervention. Based on the available evidence and expert consensus, we propose that patients with bioprosthetic aortic valve degeneration be treated with ViV TAVR if they have a history of radiation heart disease, prohibitive surgical risk, and multiple sternotomies; while patients with small prostheses, history of infective endocarditis, those at high risk for coronary obstruction, and those with need for other cardiac surgery will be managed with redo SAVR.
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Affiliation(s)
- Erika Hutt
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Nandini Mehra
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Milind Y Desai
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Narayan P, Dimagli A, Angelini GD. Octogenarians needing reoperative aortic valve surgery—Does one size fit all? J Card Surg 2022; 37:1272-1274. [DOI: 10.1111/jocs.16343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 02/04/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Pradeep Narayan
- Department of Cardiac Surgery Rabindranath Tagore International Institute of Cardiac Sciences, Narayana Health Kolkata India
| | - Arnaldo Dimagli
- Department of Cardiac Surgery Bristol Heart Institute, Bristol University Bristol UK
| | - Gianni D. Angelini
- Department of Cardiac Surgery Bristol Heart Institute, Bristol University Bristol UK
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Ahmed A, Levy KH. Valve-in-valve transcatheter aortic valve replacement versus redo surgical aortic valve replacement: A systematic review and meta-analysis. J Card Surg 2021; 36:2486-2495. [PMID: 33797799 DOI: 10.1111/jocs.15546] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 03/09/2021] [Accepted: 03/22/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND/AIM With the growing contemporary use of bioprosthetic valves, whose limited long-term durability has been well-documented, an increase in the need for reintervention is expected. We perform a meta-analysis to compare the current standard of care, redo surgical aortic valve replacement (Redo SAVR) with the less invasive alternative, valve-in-valve transcatheter aortic valve replacement (ViV TAVR) for treating structural valve deterioration. METHODS After a comprehensive literature search, studies comparing ViV TAVR to Redo SAVR were pooled to perform a pairwise meta-analysis using the random-effects model. Primary outcomes were 30-day and follow-up mortality. RESULTS A total of nine studies including 9127 patients were included. ViV TAVR patients were significantly older (mean difference [MD], 5.82; p = .0002) and more frequently had hypercholesterolemia (59.7 vs. 60.0%; p = .0006), coronary artery disease (16.1 vs. 16.1%; p = .04), periphery artery disease (15.4 vs. 5.7%; p = .004), chronic obstructive pulmonary disease (29.3 vs. 26.2%; p = .04), renal failure (30.2 vs. 24.0%; p = .009), and >1 previous cardiac surgery (23.6 vs. 15.9%; p = .004). Despite this, ViV TAVR was associated with decreased 30-day mortality (OR, 0.56; p < .0001). Conversely, Redo SAVR had lower 30-day paravalvular leak (OR, 6.82; p = .04), severe patient-prosthesis mismatch (OR, 3.77; p < .0001), and postoperative aortic valve gradients (MD, 5.37; p < .0001). There was no difference in follow-up mortality (HR, 1.02; p = .86). CONCLUSIONS Despite having patients with an increased baseline risk, ViV TAVR was associated with lower 30-day mortality, while Redo SAVR had lower paravalvular leak, severe patient-prosthesis mismatch, and postoperative gradients. Although ViV TAVR remains a feasible treatment option in high-risk patients, randomized trials are necessary to elucidate its efficacy over Redo SAVR.
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Affiliation(s)
- Adham Ahmed
- CUNY School of Medicine, New York, New York, USA
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