Outcomes of tissue versus mechanical aortic valve replacement in patients 50 to 70 years of age

Application of low-intensity anticoagulation after On-X mechanical aortic valve replacement

OBJECTIVE

To explore the safety and efficacy of low-intensity anticoagulation in patients after On-X mechanical aortic valve replacement.

METHODS

A total of 104 patients undergoing aortic valve replacement in Cardiac Surgery Department of Sichuan Provincial People's Hospital from December 2018 to December 2021 were randomly divided into low-intensity anticoagulant (INR:1.5-2.0) and high-intensity anticoagulant (INR:2.0-2.5) to compare the incidence of adverse events related to postoperative anticoagulation between the two groups.

RESULTS

Fifty-three patients were included in the low-intensity anticoagulation group (INR 1.5-2.0), and 51 patients were included in the high-intensity group (2.0-2.5). There was no significant difference in baseline data and surgical index between the two groups (P > 0.05); there were statistically significant differences in PT, INR and bleeding events (P < 0.05), but no significant difference in embolic events (P > 0.05).

CONCLUSION

For patients requiring On-X mechanical aortic valve replacement who have no risk factors for thromboembolism, it is appropriate to control the INR in the target range 1.5-2.0, which can reduce the incidence of bleeding adverse events and significantly improve the quality of life, without increasing the risk of thromboembolic adverse events.

Long-term outcomes following aortic valve replacement in bioprosthetic vs mechanical valves

BACKGROUND

Aortic valve disease(AVD) accounts for 33 % of valvular heart disease(VHD) but causes over 60 % of VHD mortality. For surgical AVR, mechanical valves are recommended for patients <50 years old and bioprosthetic valves for those >70 years old.

OBJECTIVES

To investigate the long-term differences following AV replacement(AVR) comparing bioprosthetic and mechanical valves in patients aged 50-70.

METHODS

4,927 patients underwent AVR, 744 of which were propensity-matched 2:1 for bioprosthetic and mechanical valves. Outcomes included mortality, morbidity, and rates of reoperation.

RESULTS

The average age of the propensity-matched groups was 57 and 56.7 years, and female sex accounted for 26.4 % and 25.0 % for the bioprosthetic and mechanical valve groups, respectively. Other baseline demographics and comorbidities were similar between the groups. There were no deaths at 30 days and complication rates did not differ between groups(p > 0.05). Mortality at 1, 5, and 15 years was similar between groups. Reoperation rates at 5 and 10 years did not significantly differ between bioprosthetic and mechanical valves(p = 0.84, p = 0.31), although at 15-year follow-up, patients with bioprosthetic valves were more likely to require reoperation(21.2 % versus 9.7 %, adjusted hazard ratio 3.65, 95 % confidence interval 1.07-12.5, p = 0.0.39).

CONCLUSIONS

Patients receiving AVR from 50 to 70 years old have similar long-term outcomes irrespective of whether they received bioprosthetic or mechanical valves, with only reoperation being significantly different at 15 years follow-up. With low rates of reoperation, mortality, and avoidance of anticoagulation, bioprosthetic valves are a reasonable option for patients 50-70 years old, although mechanical valves still provide a durability benefit for young patients.

Valve-in-valve transcatheter aortic valve replacement versus isolated redo surgical aortic valve replacement

OBJECTIVE

To compare outcomes of patients undergoing valve-in-valve transcatheter aortic valve replacement (ViV TAVR) versus redo surgical aortic valve replacement (SAVR).

METHODS

This was a retrospective study using institutional databases of transcatheter (2013-2022) and surgical (2011-2022) aortic valve replacements. Patients who underwent ViV TAVR were compared with patients who underwent redo isolated SAVR. Clinical and echocardiographic outcomes were analyzed. Kaplan-Meier survival estimation and Cox regression were performed. Cumulative incidence functions were generated for heart failure readmissions.

RESULTS

A total of 4200 TAVRs and 2306 isolated SAVRs were performed. Of these, there were 198 patients who underwent ViV TAVR and 147 patients who underwent redo SAVR. Operative mortality was 2% in each group, but observed to expected operative mortality in the redo SAVR group was higher than in the ViV TAVR group (1.2 vs 0.32). Those who underwent redo SAVR were more likely to require transfusions and reoperation for bleeding, to have new-onset renal failure requiring dialysis, and to require a permanent pacemaker postoperatively than those in the ViV group. Mean gradient was significantly lower in the redo SAVR group than in the ViV group at 30 days and 1 year. Kaplan-Meier survival estimates at 1 year were comparable, and on multivariable Cox regression, ViV TAVR was not significantly associated with an increased hazard of death compared with redo SAVR (hazard ratio, 1.39; 95% CI, 0.65-2.99; P = .40). Competing-risk cumulative incidence estimates for heart-failure readmissions were higher in the ViV cohort.

CONCLUSIONS

ViV TAVR and redo SAVR were associated with comparable mortality. Patients who underwent redo SAVR had lower postoperative mean gradients and greater freedom from heart failure readmissions, but they also had more postoperative complications than the VIV group, despite their lower baseline risk profiles.

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.

Twenty-year experience following aortic valve replacement in patients younger than 60 years of age

OBJECTIVE

Reports on long-term outcomes of surgical aortic valve replacement (AVR) for patients aged < 60 years are scarce in Japan. Hence, we aimed to evaluate these outcomes in patients aged < 60 years.

METHODS

Between March 2000 and December 2020, 1477 patients underwent aortic valve replacement. In total, 170 patients aged < 60 years who underwent aortic valve replacement were recruited. Patients aged < 18 years were excluded. Patient data collected from the operative records and follow-up assessments were reviewed.

RESULTS

The mean age was 49 ± 9 years, and 64.1% of patients were male. One-hundred-and-fifty-two patients (89.4%) underwent aortic valve replacement with a mechanical valve and 18 (10.6%) with a bioprosthetic valve. The mean follow-up period was 8.1 ± 5.5 years. No operative mortality occurred, and in-hospital mortality occurred in one patient (0.6%). Ten late deaths occurred, with seven cardiac-related deaths. The overall survival rate was 95.4 ± 1.7%, 93.9 ± 2.3%, 90.6 ± 3.9%, and 73.2 ± 11.8% at 5, 10, 15, and 20 years, respectively. Freedom from major bleeding was 96.4 ± 1.6% at 5, 10, and 15 years, and 89.0 ± 7.3% at 20 years. Freedom from thromboembolic events was 98.7 ± 1.3%, 97.3 ± 1.9%, 90.5 ± 4.5%, and 79.0 ± 11.3% at 5, 10, 15, and 20 years, respectively. Freedom from valve-related reoperation was 99.4 ± 0.6% at 5 years, 97.8 ± 1.7% at 10 and 15 years, and 63.9 ± 14.5% at 20 years.

CONCLUSIONS

Patients aged < 60 years undergoing aortic valve replacement with a high mechanical valve implantation rate had favorable long-term outcomes.

Long-Term Outcomes of Mechanical Versus Bioprosthetic Aortic Valve Replacement: A Systematic Review and Meta-Analysis

This study aimed to investigate the safety and efficacy of bioprosthetic (BV) versus mechanical valves (MV) on long-term outcomes in 50- to 70-year-old aortic stenosis (AS) patients. A literature search for articles published until April 2023 yielded 13 eligible studies, with 15,320 patients divided into BV (n = 7,320) and MV (n = 8,000) cohorts. The review was registered prospectively with PROSPERO (CRD42021278777). MV demonstrated a favorable hazard ratio (HR: 1.12, 95% CI: 1.00-1.25, I2 = 60%) and higher survival rates at 5 (OR:1.13, 95% CI: 1.02-1.25, I2 = 42%) and 10 years (OR: 1.13, 95% CI: 1.05-1.23, I2 = 0%). At 15 years, stroke incidence was comparable (OR: 1.12, 95% CI: 0.98-1.27, I2 = 4%). BV showed lower bleeding events (OR: 1.7, 95% CI: 1.18-2.46, I2 = 88%), but MV replacement showed lower reoperation incidence (OR: 0.27, 95% CI: 0.18-0.42, I2 = 85%). MV appears favorable for the long-term approach in AS management compared to BV.

Outcomes of Surgical Bioprosthetic Aortic Valve Replacement in Patients Aged ≤65 and >65 Years

BACKGROUND

Implantation of a bioprosthetic valve is a reasonable choice for patients aged > 65 years. For middle-aged patients there is less certainty about whether a mechanical or bioprosthetic valve is best.

METHODS

The Pericardial Surgical Aortic Valve Replacement (PERIGON) Pivotal Trial is evaluating the safety and efficacy of the Avalus bioprosthesis (Medtronic). We evaluated clinical and echocardiographic outcomes through 5 years of follow-up, stratified by age ≤ 65 and >65 years.

RESULTS

Two hundred seventy-one patients (24.2%) were ≤65 years old and 847 (75.8%) >65 years old. Most patients in both groups were men (217 [80.1%] vs 623 [73.6%], respectively; P = .031). Younger patients had a lower Society of Thoracic Surgeons risk of mortality (1.1% ± 0.9% vs 2.2% ± 1.4%, P < .001), better baseline New York Heart Association class (P = .004), and fewer comorbidities than older patients. At 5 years mortality was lower among younger than older patients (5.3% vs 14.0%, P < .001) and no cases of structural valve deterioration occurred in either group. Effective orifice area was similar between age groups (P = .11), and mean gradient was 13.9 ± 5.4 vs 12.0 ± 4.1 mm Hg (P < .001). Multivariable linear regression identified several parameters associated with mean aortic gradient at 5 years, including baseline age and mean aortic gradient, discharge stroke volume index and EOA, and implanted valve size. Ninety-five percent of patients were in New York Heart Association class I/II through 5 years in both age groups (P = .85).

CONCLUSIONS

Findings from this analysis demonstrate satisfactory safety, hemodynamic performance, and durability of the Avalus bioprosthesis through a 5-year follow-up in patients aged ≤ 65 and >65 years.

Mechanical versus Bioprosthetic Aortic Valve Replacement in Middle-Aged Adults: A Systematic Review and Meta-Analysis

BACKGROUND

Mechanical prostheses and bioprosthetic prostheses have their own advantages and disadvantages. Mechanical ones are recommended for younger patients (<50 years old), and bioprosthetic ones are recommended for older patients (>70 years old). There is still debate regarding which kind of prosthesis is better for middle-aged patients (50 to 70 years old) receiving aortic valve replacement (AVR). To solve this problem, we conducted this meta-analysis. Given that only one randomized controlled trial (RCT) study was included, we conducted a subgroup analysis of RCT and propensity score matching (PSM) retrospective studies to reduce the bias.

METHODS

We systematically searched articles related to clinical outcomes of mechanical and bioprosthetic prostheses in middle-aged patients receiving AVR in the PubMed, Cochrane Library, and China National Knowledge Infrastructure (CNKI) databases. The published date was up to 1 October 2022. Studies were excluded if not only middle-aged patients were included, or if they lacked direct comparisons between mechanical and bioprosthetic prostheses.

RESULTS

In total, 22 studies with 32,298 patients were included in the final analysis. The results show that patients aged between 50 and 70 receiving AVR with mechanical prostheses achieved better long-term survival and fewer reoperations and valve-related events but suffered more with bleeding events. No significant difference could be found in terms of early mortality and long-term cardiac death. The same results could be observed in the subgroup analysis of RCT and PSM retrospective studies.

CONCLUSION

Both mechanical and bioprosthetic prostheses are beneficial to middle-aged patients undertaking AVR procedures. However, mechanical prostheses show better clinical outcomes in long-term survival and comorbidities. Individual recommendation is still necessary.

Real-World Comparison of Transcatheter Versus Surgical Aortic Valve Replacement in the Era of Current-Generation Devices

Few studies have reported comparisons of out-of-hospital clinical outcomes after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) in patients with severe aortic stenosis (AS) in the era of current-generation valves that reflect the real-world situation. Data on patients with severe AS aged 65 years or older who underwent TAVR or SAVR between 2015 and 2018 were obtained from the National Health Insurance Service in Korea and clinical event rate was analyzed. The primary endpoint was all-cause death at 1 year. The cohort included a total of 4623 patients over 65 years of age, of whom 1269 (27.4%) were treated with TAVR. After 1:1 propensity score matching, 2120 patients were included in the study. TAVR was associated with reduced 1-year mortality (hazard ratio (HR): 0.55; 95% confidence interval (CI): 0.42−0.70; p < 0.001). There was no difference between the groups in the incidence of ischemic stroke (HR: 0.72, 95% CI: 0.43−1.20; p = 0.21) and intracranial hemorrhage (HR: 1.10; p = 0.74). Permanent pacemaker insertion was observed more frequently in the TAVR cohort (9.4% vs. 2.5%, HR: 3.95, 95% CI: 2.57−6.09; p < 0.001), whereas repeat procedures were rare in both treatments (0.5% vs. 0.3%, p = 0.499). In the nation-wide real-world data analysis, TAVR with current-generation devices showed significantly lower 1-year mortality compared to SAVR in severe AS patients.

Mechanical versus Bioprosthetic Valve for Aortic Valve Replacement: Systematic Review and Meta-Analysis of Reconstructed Individual Participant Data

OBJECTIVES

To compare biological versus mechanical aortic valve replacement.

METHODS

We searched MEDLINE, Scopus, and Cochrane Library databases for randomized clinical trials and propensity-score matched studies published by October 14th, 2021 according to PRISMA statement. Individual patient data on overall survival were extracted. One- and two-stage survival analyses, and random-effects meta-analyses were conducted.

RESULTS

25 studies were identified, incorporating 8,721 bioprosthetic and 8,962 mechanical valves:. In the one-stage meta-analysis, mechanical valves cumulatively demonstrated decreased hazard for mortality (Hazard Ratio [HR] : 0.79, 95% Confidence interval [CI] : 0.74-0.84, p < 0.0001). Overall survival was similar between the compared arms for patients <50 years old (HR: 0.88, 95% CI : 0.71-1.1, p = 0.216), increased in the mechanical valve arm for patients 50-70 years old (HR : 0.76, 95% CI : 0.70-0.83, p < 0.0001), and increased in the bioprosthetic arm for patients >70 years old (HR : 1.35, 95% CI : 1.17-1.57, p < 0.0001). Meta-regression analysis revealed that the survival in the 50-70 years old group was not influenced by the publication year of the individual studies. No statistically significant difference was observed regarding in-hospital mortality, post-operative strokes and post-operative reoperation. All-cause mortality was found decreased in the mechanical group, cardiac mortality was comparable between the two groups, major bleeding rates were increased in the mechanical valve group, and reoperation rates were increased in the bioprosthetic valve group.

CONCLUSIONS

Survival rates seem to not be influenced by the type of prosthesis in patients <50 years old. A survival advantage in favour of mechanical valves is observed in patients 50-70 years old, while in patients >70 years old bioprosthetic valves offer better survival outcomes.

Trend and early outcomes in isolated surgical aortic valve replacement in the United Kingdom

Objective

Surgical aortic valve replacement (SAVR) is traditionally the gold-standard treatment in patients with aortic valve disease. The advancement of transcatheter aortic valve replacement (TAVR) provides an alternative treatment to patients with high surgical risks and those who had previous cardiac surgery. We aim to evaluate the trend, early clinical outcomes, and the choice of prosthesis use in isolated SAVR in the United Kingdom.

Methods

All patients (n = 79,173) who underwent elective or urgent isolated surgical aortic valve replacement (SAVR) from 1996 to 2018 were extracted from the National Adult Cardiac Surgery Audit database. Patients who underwent additional procedures and emergency or salvage SAVR were excluded from the study. Trend and clinical outcomes were investigated in the whole cohort. Patients who had previous cardiac surgery, high-risk groups (EuroSCORE II >4%), and predicted/observed mortality were evaluated. Furthermore, the use of biological prostheses in five different age groups, that are <50, 50-59, 60-69, 70-79, and >80, was investigated. Clinical outcomes between the use of mechanical and biological aortic valve prostheses in patients <65 years old were analyzed.

Results

The number of isolated SAVR increased across the study period with an average of 4,661 cases performed annually after 2010. The in-hospital/30-day mortality rate decreased from 5.28% (1996) to 1.06% (2018), despite an increasing trend in EuroSCORE II. The number of isolated SAVR performed in octogenarians increased from 596 to 2007 (the first year when TAVR was introduced in the UK) to 872 in 2015 and then progressively decreased to 681 in 2018. Biological prosthesis usage increased across all age groups, particularly in the 60-69 group, from 24.59% (1996) to 81.87% (2018). There were no differences in short-term outcomes in patients <65 years old who received biological or mechanical prostheses.

Conclusion

Surgical aortic valve replacement remains an effective treatment for patients with isolated aortic valve disease with a low in-hospital/30-day mortality rate. The number of patients with high-risk and octogenarians who underwent isolated SAVR and those requiring redo surgery has reduced since 2016, likely due to the advancement in TAVR. The use of biological aortic prostheses has increased significantly in recent years in all age groups.