Conventional Conventional Aortic Valve Replacement:Aortic Valve Replacement:
Meta-analysisMeta-analysisAntonio Scafuri M.D.Antonio Scafuri M.D.
Why to perform an AVR?
Guidelines
Guidelines
Guidelines
History
History
Isolated Aortic Valve Replacement(1.478 AVR, 1991-2012)
0
20
40
60
80
100
120
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
6666
0
0,5
1
1,5
2
2,5
3
3,5
4
4,5
5
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Isolated Aortic Valve Replacement
Mortality(2,4%2,4% 1991-2012)
Literature Review
All cause of death
6,5% at 1 year
19,4% at 5 years
38,1% at 10 years
Mc Lean RC et al. Eur J Cardiothorac Surg 2011
Perioperative and long term case-fatality
Age
Renal failure
Urgency
Perioperative case-fatality
Mc Lean RC et al. Eur J Cardiothorac Surg 2011
Long term case-fatality
Mc Lean RC et al. Eur J Cardiothorac Surg 2011
Over 13 years
in mediam age
diabetes
hypertension
cerebrovascular disease
respiratory disease
myocardial infarction
Perioperative death fell from 6,5% to 3,1% per year
Mc Lean RC et al. Eur J Cardiothorac Surg 2011
Which Valve?
Isolated Aortic Valve Replacement
(1994 - 2002)
020406080100
<60 60-64 65-69 70-80 >80
Mechanical valveMechanical valve
BioprosthesisBioprosthesisMean Age 66 Mean Age 66 ± 11± 11
Isolated Aortic Valve Replacement
(2008 - 2012)
Mechanical valveMechanical valve
BioprosthesisBioprosthesisMean Age 72 Mean Age 72 ± 10± 10
020406080100
<60 60-64 65-69 70-80 >80
If one can choose the valve prosthesis, one would choose:
“One valve for life”
Literature Review
AVRAVR
All cause of death
2,9% at 30 days
Cumulative survival
61,4% at 15 years
Azarnouch K et al. Eur J Cardiothorac Surg 2010
Freedom from:Freedom from:
Valve related deaths
86% - 78,6% at 10 – 15y
Thrombo-embolism
94% - 89,1% at 10 – 15y
Bleeding
84,7% - 76,1% at 10 – 15y
Valve Thrombosis
99,8% - 99,6% at 10 – 15y
Endocarditis
97,7% - 97,5% at 10 – 15y
Freedom from reoperation
97,6% at 15% years97,6% at 15% years
Azarnouch K et al. Eur J Cardiothorac Surg 2010
Literature Review
2.405 patients2.405 patients
Mean age 71± 9
78 ± 2% at 5 years
55 ± 2% at 10 years
16 ± 2% at 20 years
Forcillo J et al. Ann Thorac Surg 2013
2.405 patients2.405 patients
Mean age 71± 9
98 ± 0.2% at 5 years
96 ± 1% at 10 years
67 ± 4% at 20 years
Forcillo J et al. Ann Thorac Surg 2013
Younger than 60 y/o
98 ± 1% at 5 years
90 ± 3% at 10 years
60 ± 6% at 15 years
30 ± 8% at 20 years
Between 60 and 70 y/o
99 ± 0,3% at 5 years
95 ± 1% at 10 years
90 ± 3% at 15 years
Forcillo J et al. Ann Thorac Surg 2013
Literature Review
1591 patients1591 patients
Mean age 75.3 ± 6.8
Freedom from SVD*
65.5 ± 2.2% at 18 years
*SVDSVD
AI ≥ 3+
Mean gradient ≥ 40 mmHg
ISTMUS Investigators Eur J Cardiothorac Surg 2011
Younger than 60 y/o
54.4% ± 3.4% at 18 years
Between 60 and 70 y/o
62 ± 2.6% at 18 years
Older than 70 y/o
78.2% ± 2.6% at 18 years
ISTMUS Investigators Eur J Cardiothorac Surg 2011
Follow-up
99.2% complete
Median 61.9 months
IQ Range 30.8 – 90.9
ISTMUS Investigators Eur J Cardiothorac Surg 2011
Pitfall
Mechanical Valve
Thrombo-embolic events
Bleeding
Bioprosthesis
Durability
Literature Review
Dal 2000 al 2009Propensity match score
206 patients206 patients
103 vs 103
Matched groups
Mean age 50.8 ± 8.8 y
Mean follow-up 33 ± 24 m
Weber A et al. J Thorac Cardiovasc Surg 2012
Freedom from all valve-related complications:
bioprosthesis 54.5%; mechanical valve, 51.6%; (p NS)
Freedom from Reoperation:
bioprosthesis 100%; mechanical valve, 98.8%; (p NS)
Weber A et al. J Thorac Cardiovasc Surg 2012
Peak and Mean GradientPeak and Mean Gradient
BP vs MP:
19.9 ± 6.7 mm Hg vs16.7 ± 8.0 mm Hg, (p .03)
11.2 ± 4.2 mm Hg vs 10.2 ± 6.0 mm Hg (p .05)
Mechanical ValveMechanical Valve
Similar valve-related event rates in both groups.
The better hemodynamic performance of the mechanical valves
Weber A et al. J Thorac Cardiovasc Surg 2012
Literature Review
172 patients172 patients
MP 69 vs BP 103
Matched groups
98 patients98 patients
AVR under 65 y/oAVR under 65 y/o
MP 30 vs BP 68
Matched groups
Badhwar V et al. Ann Thorac Surg 2012
Variance of INR from target during follow-up.
Target INR for aortic valve replacement was 2.0.
Target INR for mitralvalve replacement was 2.5.
Badhwar V et al. Ann Thorac Surg 2012
No late bleeding events were noted.
The groups had a similar incidence of early and late major adverse events.
TEB (Thrombosis, TEB (Thrombosis, Embolism, Bleeding) was Embolism, Bleeding) was 0.77% and 0.78%/patient-0.77% and 0.78%/patient-year, respectivelyyear, respectively..
Mechanical ValveMechanical Valve
Patients aged 65 years or younger with MP and closely monitored anticoagulation display noninferiority to BP from bleeding and thromboembolic complications.
Badhwar V et al. Ann Thorac Surg 2012
Conclusion
In recent years, patients are increasingly more complex but still the results of surgery have improved.
The use of bioprosthesis is always increasing, even in younger patients.
Bioprostheses give good results in terms of freedom from reoperation in the long term (new generation prostheses)
Mechanical prostheses implantation, in patients under 65, give good results when combined with a good INR control (new anticoagulantion drug)
If one can choose the valve prosthesis, one would choose:
“One valve for life”
..an Olistic Vision
..an Olistic Vision
Thank you