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