Is routine use of stentless aortic prostheses justified in an elderly (aged > or =75 years) population?
Ayyaz AliPankaj KumarThanos AthanasiouJames C. HalsteadHutan AshrafianZiad A. AliSanjay KumarPanagiotis TheodorouJohn R. Pepper
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Abstract:
Stentless prostheses in the aortic position produce a superior hemodynamic profile in comparison to that with stented valves. To determine whether routine use of stentless valves in an elderly population is justified, a 10-year retrospective review was performed of a consecutive series of patients aged > or =75 years undergoing stentless aortic valve replacement (AVR).Demographic, operative and mortality data were obtained retrospectively. Survivors were interviewed by telephone according to a defined protocol. Univariate and multivariate analysis was used to identify independent predictors of 30-day and overall medium-term mortality. Definitions and analyses were in accordance with joint STS/AATS guidelines.A total of 103 patients (57 males, 46 females; mean age 79.8 years; range: 75-91 years) underwent AVR with a either a Toronto stentless porcine valve (size range: 21-29 mm; n = 74) or an aortic homograft (n = 29). Twenty-eight patients (27%) had either urgent/emergency surgery, 12 (11%) underwent redo surgery, and in 54 cases (52%), the preoperative left ventricular function was significantly impaired (ejection fraction <50%). Forty patients (39%) also underwent concomitant coronary artery bypass grafting. The mean cross-clamp and cardiopulmonary bypass times were 105+/-22 min and 144+/-47 min, respectively. The overall 30-day mortality was 11.6% (n = 12). The 30-day mortality for all elective cases was 5.3%, but for isolated elective AVR was only 2.5%. Using a multivariate model, the only independent predictor of 30-day mortality and medium-term overall mortality was increasing age. The mean follow up period was 3.6 years (range: 0.1-9.3 years), and the Kaplan-Meier actuarial five-year survival was 52%. At follow up, 92% of patients were in NYHA functional classes I and II.Stentless AVR in elderly patients is associated with excellent functional and survival outcome in the medium term. Furthermore, in elective cases, age alone should not be a deterrent to the routine use of stentless aortic valves.Keywords:
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Mixed aortic valve disease (MAVD) is associated with a poorer natural history compared with isolated lesions. However, clinical and echocardiographic outcomes for aortic valve replacement (AVR) in mixed disease are less well understood.Retrospective review of AVRs (n=1,011) from 2000-2016. Isolated AVR, AVR + coronary bypass, and AVR + limited ascending aortic replacement were included. Predominant aortic stenosis (AS) group was stratified into group 1 (n=660) with concomitant mild or less aortic insufficiency (AI), and group 2 (n=197) with accompanying moderate or greater AI. Predominant AI group was stratified using the same schema for concomitant AS into groups 3 (n=143) and 4 (n=53). Median follow-up was 3.1 and 4.4 years respectively for AS and AI groups.For the predominant AS group (n=857) preoperatively, group 2 had a larger preoperative left ventricular end diastolic diameter (LVESD) (51.0±8.4 vs. 48.6±7.2, P=0.02) and lower preoperative left ventricular ejection fraction (LVEF) (57.6% vs. 60.2%, P=0.043). No differences in left ventricular (LV) dimensions, LV or right ventricular (RV) function was evident at follow up (P>0.05). After propensity matching for age, operation, and comorbidities, there was no difference in survival (P=0.19). After propensity matching for the predominant AI group (n=196), survival was lower for group 4 compared to 3 (P=0.02). There were no differences in LV dimensions, LV or RV function preoperatively or on follow-up (P>0.05).Predominant AS associated with higher AI grades had larger LV dimensions and worse LV function preoperatively. These differences resolve after AVR with equivalent survival. However, predominant AI with more severe AS had reduced survival despite AVR.
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The results of aortic valve replacement are uncertain among patients with severe aortic stenosis, reduced left ventricular ejection fraction, and low mean transvalvular gradient. The aim of the present study was to report on 27 patients who underwent surgery for aortic stenosis with left ventricular ejection fraction
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Abstract Background Sex-differences in left ventricular (LV) remodeling in patients with aortic valve disease have been reported. However, sex-differences in LV remodeling and mechanics in response to aortic valve replacement (AVR) remained largely unexplored. Purpose The present study aimed to evaluate the sex-differences during the time course of LV remodeling and LV mechanics (by LV global longitudinal strain (GLS)) after aortic valve replacement. Methods Patients with severe aortic valve disease (aortic stenosis (AS) or aortic regurgitation (AR)) undergoing AVR with echocardiographic follow-up at 1,2, and/or 5 years were evaluated. LV mass index, LV ejection fraction, LV GLS and stroke volume (SV) were measured. Linear mixed models analyses were used to assess changes in LV mass index, LVEF, LV GLS and SV between time points. The models were corrected for age, LV end-diastolic diameter at baseline and time between echocardiograms. Results A total of 211 patients (61±14 years, 61% male) with severe aortic valve disease (AS 63% or AR 39%) were included. Before AVR, men had larger LV mass index and higher SV compared to women. Both men and women had a preserved LV ejection fraction (54±12 and 56±9, P=0.102, respectively), but moderately impaired LV GLS (14.6±4.1 and 16.1±4.1, P=0.009, respectively). After AVR, both groups showed LV mass regression, improvement in LV ejection fraction and LV GLS. LV mass index and SV remained higher in men. During follow-up women showed significantly better LV GLS compared to men (P=0.030, figure 1). Conclusion In men and women with severe aortic valve disease undergoing AVR, the time course of changes in LV mass regression, LV ejection fraction, LV GLS and SV are similar. During follow-up LV mass index remained larger in men and women showed significantly better LV GLS. Funding Acknowledgement Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The department of Cardiology received unrestricted research grants from Abbott Vascular, Bayer, Bioventrix, Biotronik, Boston Scientific, Edwards Lifesciences, GE Healthcare and Medtronic. Victoria Delgado received speaker fees from Abbott Vascular, Edwards Lifesciences, GE Healthcare, MSD and Medtronic. Nina Ajmone Marsan received speakers fees from Abbott Vascular and GE healthcare. Jeroen J Bax received speaker fees from Abbott Vascular. The remaining authors have nothing to disclose.
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Background: Severe aortic stenosis (AS) is associated with a poor prognosis in patients with left ventricular dysfunction (LVD). Survival is estimated at less than 2 years without aortic valve replacement (AVR). Limited data are available on the effects and outcomes of AVR in such patients, especially in the absence of concomitant coronary artery disease (CAD). Methods: This was a retrospective study which identified 33 patients over an approximate 10 year period who underwent surgical AVR for severe isolated AS and LVD(LVEF ≤50%). Patients were excluded if they had a prior valve replacement, mixed valve disease, <18 years old or the presence of CAD. Overall survival was analysed using the Kaplan-Meier curve and Cox proportional hazards model. The changes in postoperative LVEF and NYHA functional class, following AVR, was assessed using the Friedman test and ANOVA. Results: Operative mortality was 15% with 5 deaths. Female sex and hyperlipidaemia were identifi ed as predictors of early mortality by univariate analysis. LVEF improved in survivors from a mean of 39 ± 10% - 49.8 ± 8.7% at a 1 year follow-up (p=0.04). Younger age was identifi ed as an independent predictor of LVEF recovery (p=0.04). There was no difference in outcomes in patients with low baseline transvalvular gradients compared to those with higher gradients. There was signifi cant symptomatic improvement noted in all survivors following AVR (p<0.01). Conclusion: Left ventricular function has a slower rateof recovery, compared to an earlier improvement of NYHA functional class after AVR for severe isolated AS and pre-operative LVD. In this high-risk group thefi ndings support AVR in patients with LVD.
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