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aortic valve replacement (AVR)

Indications: - severe aortic valvular stenosis - severe aortic insufficiency - endocarditis not reponsive to medical therapy Procedure: 1) mechanical valve vs bioprosthetic valve a) choice of valve for patients age 55-70 years is not clearcut & should be based on patient preferences [4] b) mortality benefit for mechanical valve vs bioprosthetic valve persists until age 55 years [21] 2) percutaneous transcatheter aortic valve replacement (TAVR) may be alternative to surgery [3,5] - no difference between TAVR & open surgery in death, stroke, or MI at 1 year in patients at low surgical risk [10] 3) perioperative beta-blockade reduces incidence of postoperative atrial fibrillation [18] 4) cardiac rehabilitation beneficial after cardiac valve surgery [26] Risk factors: 1) functional class 2) rhythm other than sinus rhythm - preoperative atrial fibrillation associated with worse long-term outcomes [15] - postoperative atrial fibrillation associated only with short-term complications [16] 3) preoperative left ventricular systolic dysfunction 4) aortic regurgitation 5) concomitant surgical procedures 6) previous bypass surgery 7) emergency surgery 8) coronary artery disease 9) female gender - gender does not affect 1 year mortality after AVR [14,17] 10) concurrent mitral valve surgery 11) hypertension 12) depression may increase 1 year mortality [22] Complications: - 4-24% in the elderly - > 30% in patients > 90 years of age [9] - pulmonary complications in surgical AVR - vascular complications in TAVR [9] - prosthetic valve degeneration - structural valve deterioration less frequent after self-expanding TAVR than open surgery (2.2% vs 4.4%) [27] - transcatheter aortic valve replacement (TAVR) for patients too frail for surgery [7] - aortic valvular stenosis associated with worse prognosis than aortic insufficiency - risk of cognitive impairment after CABG, PCI or cardiac valve replacement is uncertain [11] - risk for thromboembolic events with bioprosthetic valve associated with reduced leaflet motion - therapeutic warfarin restores leaflet motion in bioprosthetic aortic valve [13] - risk for atrial fibrillation 14% after TAVR & 31% after surgical aortic valve replacement [25] Postoperative complications: 1) cardiac arrhythmias 2) prolonged ventilatory support requirements 3) congestive heart failure 4) perioperative myocardial infarction (3-8%) 5) cerebrovascular events (5-11%) [9,19] - radiographic evidence of ischemic stroke within 7 days of aortic valve replacement may be as high as 66% [19] - surgical aortic valve replacement after ischemic stroke increases risk of recurrent stroke, especially within 3 months - 15-fold within 3 months of ischemic stroke - 4-fold within 3-12 months - 2-fold if > 1 year [23] 6) prosthesis-patient mismatch, a small surgical aortic valve orifice for a patient's size, is ssociated with increased mortality [24] Notes: prognosis: long-term survival: - patients > 80 years a) 1 year 91% b) 3 years 84% c) 5 years 76% - patients > 90 years a) 1 year 81% b) 2 years 46% [9] - no survival benefit of one prothetic heart valve type over another [8] * - symptoms resolve in 43% of patients - symptoms persist in remaining patients - dyspnea in 43% - 14% hospitalized with heart failure - syncope in 4% - 2% with angina [28] Left ventricular function improves post-operatively. Clinical & histological evidence of diastolic dysfunction persists for up to 8 years post-operatively. Afternoon surgery rather than morning surgery is linked to better outcomes [20]

Specific

transcatheter aortic valve implantation; transcatheter aortic valve replacement (TAVI, TAVR, CoreValve system)

General

aortic valve surgery cardiac valve replacement

References

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  2. Hinchman DA and Otto CM Valvular disease in the elderly. Cardiol Clin 17(1):137, 1999 PMID: 10093770
  3. Grub E et al, Percutaneous aortic valve placement for severe aortic stenosis in high-risk patients using the second and current third- generation self-expanding CoreValve prosthesis: Device successes and 30-day clinical outcome. Am Coll Clin Cardiol 2007, 50:69 PMID: 17601548
  4. Stassano P et al. Aortic valve replacement: A prospective randomized evaluation of mechanical versus biological valves in patients ages 55 to 70 years. J Am Coll Cardiol 2009 Nov 10; 54:1862. PMID: 19892237 - Stone PH. Current selection of optimal prosthetic aortic valve replacement in middle-aged patients: Still dealer's choice. J Am Coll Cardiol 2009 Nov 10; 54:1869. PMID: 19892238
  5. Barreto-Filho JA et al. Trends in aortic valve replacement for elderly patients in the United States, 1999-2011. JAMA 2013 Nov 20; 310:2078 PMID: 24240935
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  7. Dvir D et al Transcatheter Aortic Valve Implantation in Failed Bioprosthetic Surgical Valves. JAMA. 2014;312(2):162-170 PMID: 25005653 http://jama.jamanetwork.com/article.aspx?articleid=1886189
  8. Chiang YP Survival and Long-term Outcomes Following Bioprosthetic vs Mechanical Aortic Valve Replacement in Patients Aged 50 to 69 Years. JAMA. 2014;312(13):1323-1329 PMID: 25268439 jama.jamanetwork.com/article.aspx?articleid=1910112
  9. Murashita T et al Aortic Valve Replacement for Severe Aortic Valve Stenosis in the Nonagenarian Patient. Annals or Thoracic Surgery. September 06, 2014 PMID: 25200726 http://www.annalsthoracicsurgery.org/article/S0003-4975%2814%2901296-X/abstract
  10. Thyregod HG et al. Transcatheter versus surgical aortic valve replacement in patients with severe aortic valve stenosis: One-year results from the all-comers Nordic Aortic Valve Intervention (NOTION) randomized clinical trial. J Am Coll Cardiol 2015 May 26; 65:2184. PMID: 25787196 - Tuzcu EM et al. Well-intended NOTION, ahead of practice. J Am Coll Cardiol 2015 May 26; 65:2195. PMID: 25998665
  11. Fink HA, Hemmy LS, MacDonald R et al Intermediate- and Long-Term Cognitive Outcomes After Cardiovascular Procedures in Older Adults: A Systematic Review. Ann Intern Med. 2015;163(2):107-117 PMID: 26192563 http://annals.org/article.aspx?articleid=2397694
  12. De Santo LS, Romano G, Della Corte A et al Mechanical aortic valve replacement in young women planning on pregnancy: maternal and fetal outcomes under low oral anticoagulation, a pilot observational study on a comprehensive pre-operative counseling protocol. J Am Coll Cardiol. 2012 Mar 20;59(12):1110-5. PMID: 22421305
  13. Makkar RR et al. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves. N Engl J Med 2015 Oct 5 PMID: 26436963
  14. Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  15. Saxena A, Dinh DT, Reid CM, Smith JA, Shardey GC, Newcomb AE. Does preoperative atrial fibrillation portend a poorer prognosis in patients undergoing isolated aortic valve replacement? A multicentre Australian study. Can J Cardiol. 2013 Jun;29(6):697-703. PMID: 23142344
  16. Saxena A, Shi WY, Bappayya S et al Postoperative atrial fibrillation after isolated aortic valve replacement: a cause for concern? Ann Thorac Surg. 2013 Jan;95(1):133-40. PMID: 23200233
  17. Stamou SC, Robich M, Wolf RE, Lovett A, Normand SL, Sellke FW. Effects of gender and ethnicity on outcomes after aortic valve replacement. J Thorac Cardiovasc Surg. 2012 Aug;144(2):486-92. PMID: 22154790 Free Article
  18. Yokota J, Nishi H, Sekiya N, Yamada M, Takahashi T. Atrial fibrillation following aortic valve replacement: impact of perioperative use of intravenous beta-blocker. Gen Thorac Cardiovasc Surg. 2017 Apr;65(4):194-199 PMID: 28000150
  19. Lou N. More Bad News for Embolic Protection Devices. Randomized trial shows little benefit for filtration or suction. MedPage Today. August 09, 2017 https://www.medpagetoday.com/Cardiology/Strokes/67168 - Mack MJ, Acker MA, Gelijns AC et al Effect of Cerebral Embolic Protection Devices on CNS Infarction in Surgical Aortic Valve Replacement: A Randomized Clinical Trial. JAMA. 2017 Aug 8;318(6):536-547. PMID: 28787505
  20. Montaigne D, Marechal X, Modine T et al Daytime variation of perioperative myocardial injury in cardiac surgery and its prevention by Rev-Erb alpha antagonism: a single-centre propensity-matched cohort study and a randomised study. The Lancet. Oct 26, 2017 PMID: 29107324 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32132-3/fulltext
  21. Goldstone AB, Chiu P, Baiocchi M et al Mechanical or Biologic Prostheses for Aortic-Valve and Mitral- Valve Replacement. N Engl J Med 2017; 377:1847-1857. November 9, 2017 PMID: 29117490 http://www.nejm.org/doi/full/10.1056/NEJMoa1613792
  22. Drudi LM, Ades M, Turkdogan S et al Association of Depression With Mortality in Older Adults Undergoing Transcatheter or Surgical Aortic Valve Replacement. JAMA Cardiol. Published online January 17, 2018 PMID: 29344620 https://jamanetwork.com/journals/jamacardiology/fullarticle/2669918 - Patel A, Leon MB. Is Depression an Important New Mortality Risk Factor After Aortic Valve Replacement or Simply a Component of the Geriatric Disease Spectrum? JAMA Cardiol. Published online January 17, 2018 PMID: 29344626 https://jamanetwork.com/journals/jamacardiology/article-abstract/2669917
  23. Andreasen C, Jorgensen ME, Gislason GH et al Association of Timing of Aortic Valve Replacement Surgery After Stroke With Risk of Recurrent Stroke and Mortality. JAMA Cardiol. Published online April 25, 2018 PMID: 29710128 https://jamanetwork.com/journals/jamacardiology/fullarticle/2679306 - Mullen MT, Messe SR. Aortic Valve Surgery After Recent Stroke. Patience Is a Virtue. JAMA Cardiol. Published online April 25, 2018 PMID: 29710189 https://jamanetwork.com/journals/jamacardiology/fullarticle/2679305
  24. Fallon JM, DeSimone JP, Brennan JM et al. The incidence and consequence of prosthesis-patient mismatch after surgical aortic valve replacement. Ann Thorac Surg 2018 Apr 6 PMID: 29630873 https://www.annalsthoracicsurgery.org/article/S0003-4975(18)30435-1/pdf
  25. Kalra R, Patel N, Doshi R, Arora G, Arora P. Evaluation of the incidence of new-onset atrial fibrillation after aortic valve replacement. JAMA Intern Med 2019 Jun 3 PMID: 31157821 https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2734630
  26. Patel DK, Duncan MS, Shah AS et al Association of Cardiac Rehabilitation With Decreased Hospitalization and Mortality Risk After Cardiac Valve Surgery. JAMA Cardiol. Published online October 23, 2019. PMID: 31642866 https://jamanetwork.com/journals/jamacardiology/article-abstract/2753611
  27. O'Hair D, Yakubov SJ, Grubb KJ et al Structural Valve Deterioration After Self-Expanding Transcatheter or Surgical Aortic Valve Implantation in Patients at Intermediate or High Risk. JAMA Cardiol. 2023;8(2):111-119. PMID: 36515976 PMCID: PMC9857153 (available on 2023-12-14) https://jamanetwork.com/journals/jamacardiology/fullarticle/2799709
  28. San Roman, Ybarra-Falcon C, Garcia-Gomez M JA et al. Evolution and prognostic significance of patient-reported symptoms after intervention in severe aortic stenosis. Mayo Clin Proc 2024 Mar; 99:400-410. PMID: 38432746 https://www.mayoclinicproceedings.org/article/S0025-6196(23)00473-1/abstract