When is it Too Late for Aortic Valve Surgery

AORTIC VALVE SURGERY
|
REVIEW
When is it Too Late for Aortic Valve Surgery
Nawwar Al-Attar, FRCS, FETCS, PhD & Patrick Nataf, FETCS, MD
Assistance Publique-Hôpitaux de Paris (AP-HP), Department of Cardiac Surgery,
Bichat – Claude Bernard Hospital, University Paris 7 Denis Diderot, Paris, France
Received 31/12/2010, Reviewed 10/1/2011, Accepted 18/01/2011
Keywords: valve disease, percutaneous valve therapy, surgery-valve
DOI: 10.5083/ejcm.20424884.25
ABSTRACT
CORRESPONDENCE
Determining operability in patients with aortic valve disease is dependent on two major factors:
The extent of damage induced by strain on the myocardium from stenotic and regurgitant lesions
and technical and anatomical considerations related to the surgical procedure itself. The decision to
Prof Nawwar Al-Attar,
Department of Cardiac Surgery,
Bichat Hospital,
46 rue Henri Huchard, 75018
Paris, France.
intervention. Indications recommend performing corrective procedures before establishment of
severe myocardial damage. Thus the treating physician may believe that it is too late to refer a
co-morbidities, and when myocardial contractile reserve is poor.
Tel : +33140257132
Fax : +33140257229
E-mail : nawwar.al-attar@bch.
aphp.fr
On the other hand, the surgeon may be reluctant to perform the intervention in the presence of
technical challenges. In either case, management of valve disease has witnessed major advances
permitting surgical intervention in these high-risk patients. Anaesthetic care has improved with
perioperative and intensive care protocols allowing better preparation of patients for the surgical
procedure and smoother postoperative periods. Surgical techniques have become less aggressive
better myocardial protection. Recently, transcatheter techniques allowing endovascular access
precluding the need for cardiopulmonary bypass and aortic cross clamping altogether have opened
new horizons in patients for whom technical complexity would contraindicate the procedure or the
centre experience, available technology and should be taken by a heart team including surgeons,
cardiologists and anaesthesiologists.
Aortic stenosis
(AS) is currently the most common cause of AS
in adults and the most frequent reason for aortic valve replacement (AVR) in these patients. Its
incidence is on the rise since this pathology is
a disease of ageing and the population is getting older.1 The natural history of AS has shown
that in the absence of surgical management
the patient develops progressive invalidating
symptoms of syncope and angina. The mortality
tively, from congestive heart failure.2 Indication
for surgery arises when the severity of the ste0.6 cm²/m² body surface area) or the patient becomes symptomatic.3
Conventional surgical AVR is the reference treatment and is performed under cardiopulmonary
bypass, cardiac arrest and aortic cross-clamping.
The native cusps are excised and a prosthesis is
sutured into the aortic annulus replacing the native valve (Figure 1).
EUROPEAN JOURNAL OF CARDIOVASCULAR MEDICINE
32
Isolated AVR carries an average 30 day mortality
of 3.8±1.5%.4 AVR is the “gold standard” treatment for symptomatic aortic stenosis and has
shown to improve outcome and survival. Following AVR and removal of the obstruction to
rapidly improves in part because the ventricle
has been preconditioned to generate higher
pressures. Thus, there are few contraindications
to valve replacement for severe aortic stenosis
when left ventricular function is not depressed.5
Moreover, the indications for intervention have
been revised to perform corrective procedures
before establishment of severe myocardial damage and according to some authors even prior
to onset of symptoms.6 A multivariate analysis
of almost 6,000 patients having AVR, showed
mortality were age≥80 years, NYHA class≥III,
EF≤30% associated with previous MI, emergent
AVR and concomitant coronary artery bypass
graft (CABG) surgery.7
ISSN 2042-4884
VOL I ISSUE III
EUROPEAN JOURNAL OF CARDIOVASCULAR MEDICINE
VOL I ISSUE 33
III
are at higher risk for valve-related events. 12,13
HEALTHCARE BULLETIN
|
AORTIC VALVE SURGERY
Figure 1: Conventional surgical aortic valve replacement is performed
under cardiopulmonary bypass, cardiac arrest and aortic cross-clamping.
The aorta is opened, the native valve is removed and the aortic annulus
cleaned from remnants allowing suturing of a prosthesis (in this case, a
bioprosthesis) into the aortic annulus. Insert: A severely calcified aortic
valve causing stenosis.
Nevertheless, age is not, per se, a contraindication to AVR according
to published guidelines.3,14,15,16 Analysis of determinants of operative mortality in regard to age showed that age is not linearly related
to the mortality rate after AVR10,17 and there is considerable functional improvement after valve replacement.18
Limits related to comorbidity:
Additionally, patients can be refused surgery because of severe comorbidities known to be associated with poor outcome. Since the
prevalence of AS increases with age, and as longevity within the general population is increasing, the proportion of patients for whom
surgery may be too late due to multiple comorbidities is also expected to increase. These comorbidities may be related to concomitant cardiac diseases which further compromise myocardial function
such as poor left ventricular ejection fraction (LVEF), previous cardiac
surgery and associated coronary artery disease (CAD). Other comorbidities related to the general condition of the patient such as neurological dysfunction, chronic lung disease, liver cirrhosis and renal
These patients are prone to severe postoperative complications as
infections and bleeding; and the procedure itself may further compromise vital organ function.10,19,20 The contribution of these factors can increase the odds ratio for operative mortality by a factor of
10.6 for emergency versus elective surgery, 4.9 for renal failure, 3.1
for NYHA class (III-IV versus I-II) and 4.3 for neurological dysfunction.3
Thus it may too late to perform elective valve replacement on patients with terminal end-organ failure of the liver (Child-Pugh class B
or C cirrhosis) or lung.
Despite the increased risk with several comorbidities, survival in elderly patients (≥80LIMITS
years) with
severe AS and low LVEF (≤30%) and/
OF SURGERY IN AORTIC VALVE DISEASE
or chronic renal failure
was
still
better in patients who had AVR as
LIMITS OF SURGERY IN AORTIC VALVE DISEASE
compared to those who did not.11
Limits related to age:
Limits related to age:
Cardiologists are reluctant to refer elderly and high-risk patients for
Cardiologists
reluctantfactor
to refer
high-risk
patients
for
AVR. Age was are
a recurrent
for elderly
refusingand
surgery
for 31.8%
of paAVR.
was
recurrent
refusing
31.8%
of pa-8
tientsAge
with
ASaof
the Eurofactor
Heartfor
Survey
on surgery
Valvularfor
Heart
Disease
8
9 Adtients62%
withofAS
of the with
Euro AS
Heart
Survey on
Valvular
Disease
and
patients
in another
study
fromHeart
the USA.
9
and
62%
ofispatients
with AS
in another
study from
the survival
USA. Advanced
age
an important
predictor
of operative
risk and
in
vanced
age is anItimportant
predictor
operative risk
and
survival
in
cardiac surgery.
has repeatedly
and of
consistently
been
shown
to be
cardiac
surgery.
It has
repeatedly
and
consistently
been shown
to be
a predictor
of both
poor
in-hospital
outcome
and long-term
survival.
a predictor of both poor in-hospital outcome and long-term survival.
In a series of 6,359 patients undergoing aortic valve replacement,
In
a series
of showed
6,359 patients
undergoing
aortic
valve
replacement,
Hannan
et al.
an incremental
increase
in the
adjusted
hazard
Hannan
et al. showed
an incremental
increase
theinadjusted
hazard
ratio for 30-month
survival
from 1.57 to
2.18 toin
3.96
age ranges
65ratio
for 30-month
survival
from 1.57After
to 2.18
to 3.96
in age
6574 y, 75-84
y and ≥85
y, respectively.
isolated
AVR,
theranges
30-month
74
y, 75-84
and ≥85
respectively.
AVR,
30-month
survival
wasy 90.1%
fory,patients
of ageAfter
<75isolated
and 86.2%
forthe
patients
>75
survival
90.1%
for patients
of age <75with
andsevere
86.2% for
>75
years of was
age.10
A study
in octogenarians
AS patients
showed that
years of age.10 A study in octogenarians with severe AS showed that
survival rates of 87, 78 and 68%, respectively, compared with 52, 40
11 Elderly
survival
of 87, 78 in
and
68%,who
respectively,
compared
with
52, 40
patients
and 22%,rates
respectively,
those
had no AVR.
Elderly and
patients
andthe
22%,
respectively,
in thoseincreased
who hadoperative
no AVR.11mortality
on
other
hand experience
also
12,13
on
other hand
experience
increased
mortality and also
arethe
at higher
risk for
valve-related
events.operative
are at higher risk for valve-related events. 12,13
Nevertheless, age is not, per se, a contraindication to AVR according
Nevertheless,
age is not,3,14,15,16
per se, aAnalysis
contraindication
to AVR according
of determinants
of operato
published guidelines.
Analysis
determinants
of related
operato
published
guidelines.
tive mortality in regard to3,14,15,16
age showed
thatofage
is not linearly
10,17 and
tive
mortality
in regard
to age
that
ageisis considerable
not linearly related
to the
mortality
rate after
AVRshowed
there
func18 is considerable functo theimprovement
mortality rateafter
aftervalve
AVR10,17
and there
tional
replacement.
tional improvement after valve replacement.18
Limits related to comorbidity:
Limits related to comorbidity:
Additionally, patients can be refused surgery because of severe coAdditionally,
patients
be refused with
surgery
because
of severe
comorbidities known
tocan
be associated
poor
outcome.
Since the
morbidities
known
to be associated
with
outcome.
the
prevalence of
AS increases
with age, and
as poor
longevity
withinSince
the genprevalence
of ASisincreases
withthe
age,
and as longevity
within
general population
increasing,
proportion
of patients
forthe
whom
eral
population
increasing,
proportion
of patients is
foralso
whom
surgery
may be istoo
late due the
to multiple
comorbidities
exsurgery
may
be tooThese
late comorbidities
due to multiple
comorbidities
also expected to
increase.
may
be related toisconcomipected
to increase.
may be myocardial
related to concomitant cardiac
diseasesThese
whichcomorbidities
further compromise
function
tant
which further
myocardial
suchcardiac
as poordiseases
left ventricular
ejectioncompromise
fraction (LVEF),
previousfunction
cardiac
such as poor
left ventricular
ejection
fraction
(LVEF),
previous
cardiac
surgery
and associated
coronary
artery
disease
(CAD).
Other comorsurgery related
and associated
coronary
artery disease
(CAD). Other
comorbidities
to the general
condition
of the patient
such as
neu34
bidities
related
to the general
of the
such
as renal
neurological
dysfunction,
chronic condition
lung disease,
liverpatient
cirrhosis
and
rological dysfunction, chronic lung disease, liver cirrhosis and renal
These patients are prone to severe postoperative complications as
These
patients
are proneand
to severe
postoperative
complications
as
infections
and bleeding;
the procedure
itself may
further com10,19,20
infections
andorgan
bleeding;
and the
procedure
itself may of
further
promise vital
function.
The contribution
thesecomfac-
Limits related to presence of concomitant
Limits
related
todisease:
presence of concomitant
coronary
artery
coronary artery disease:
due to the presence of a concomitant cardiac pathology and im12 Patients
due
to LV
thefunction
presence
of aanconcomitant
cardiac pathology
andwith
impaired
from
ischaemic myocardium.
Patients
with
paired
LV functioninfarction
from an (AMI)
ischaemic
myocardium.
acute myocardial
<24 hours
or who 12
were
haemodyacute
myocardial
infarction
(AMI) <24 hours
or who
were haemodynamically
unstable
had a risk-adjusted
30-month
survival
of 59.6%,
namically
hadfor
a risk-adjusted
survival
of 59.6%,
comparedunstable
with 83.6%
patients with30-month
neither AMI
<24 hours
nor
compared
with 83.6%
for 10
patients with neither AMI <24 hours nor
haemodynamic
instability.
10
haemodynamic
instability.
has changed with
patients
presenting with several comorbidities
has
changed
with
patients
presenting
several
comorbidities
particularly CAD, concomitant
CABG andwith
a greater
incidence
of left
EUROPEAN JOURNAL OF CARDIOVASCULAR MEDICINE
I ISSUE III
particularly
CABG and
a greater
incidence
left
heart
failure.CAD,
The concomitant
operative mortality
of AVR
doubles
withVOL
theof
addiheart
The operative
of which
AVR doubles
the addition offailure.
a concomitant
CABGmortality
procedure
cannotwith
be explained
tion
ofsimple
a concomitant
CABG
procedure
which
cannot be explained
by the
increment
in cross
clamping
and cardiopulmonary
by7 Concomitant
by
the
simple
increment inCABG
cross clamping
and cardiopulmonary
bypass
times.
had an adjusted
30-month mortal7 Concomitant CABG had an adjusted 30-month mortalpass
times.ratio
ity
hazard
of 1.26 in comparison with isolated AVR. After AVR,
ity
ratio normalise
of 1.26 in comparison
isolated
AVR.
After
AVR,
LV hazard
dimensions
more quicklywith
in the
group
with
isolated
LV
normalise
more
quickly in CABG
the group
with
isolated
concomitant
further
suggesting
AVRdimensions
compared to
those with
concomitant
CABG further
suggesting
AVR compared
those with
that
CAD has a to
negative
impact
on postoperative
myocardial
recovthat
CADoperative
has a negative
onwith
postoperative
myocardial
recovery. The
risk inimpact
patients
CAD requiring
concomitant
ery. The operative risk in patients with CAD requiring concomitant
cerebrovascular disease, peripheral vascular disease, extensive aortic
cerebrovascular
disease, peripheral
extensive
aortic
atherosclerosis, diabetes
and renal vascular
failure.10disease,
Nevertheless,
there
is a
10 Nevertheless, there is a
atherosclerosis,
diabetes
andofrenal
failure.
consensus that the
addition
CABG
to AVR
slightly improves longconsensus
thateven
the in
addition
of populations.
CABG to AVR22slightly improves longterm survival,
high-risk
term survival, even in high-risk populations.22
Limits related to contractile reserve:
Limits related to contractile reserve:
Delay in the management of patients with AS may give rise to certain
Delay in the management of patients with AS may give rise to certain
after AVR. When the aortic valve area is less than half of normal, the
after
AVR.across
Whenthe
thevalve
aorticbecomes
valve area
is less than
normal, the
gradient
important
andhalf
theofincreased
afgradient
the valve
and
the increased
afterload isacross
associated
with becomes
concentricimportant
myocardial
hypertrophy
which
terload
is associated
with concentric
hypertrophy
maintains
systolic performance.
The myocardial
EF is decreased
becausewhich
of inmaintains
systolicand
performance.
The EF is
decreased
of increased afterload
impaired diastolic
function,
butbecause
contractility
is
creased
afterload
andhas
impaired
diastolic
function,
butEFcontractility
is
maintained
and AVR
an excellent
outcome
with
returning to
23 returning
maintained
andonce
AVR the
has afterload
an excellent
outcome
with EF
However to
in
normal values
excess
is removed.
23 However in
normal
values once
the afterload
is removed.
causing the
other
patients,
hypertrophy
fails toexcess
normalise
wall stress
causing
the
other
patients,
hypertrophy
fails
to normalise
wall stress
abnormal
afterload
to reduce
ventricular
ejection,
reducing
cardiac
EUROPEAN JOURNAL OF CARDIOVASCULAR MEDICINE
VOL I ISSUE III
24
abnormal
afterload
toheart
reduce
ventricular
ejection,
reducing cardiac
output, adding
to the
failure
syndrome.
output, adding to the heart failure syndrome.24
This subset of patients with low gradient AS and low EF is known to
This
subset of patients
withoutcomes
low gradient
ASAVR.
and Itlow
EF is known
to
be associated
with poorer
after
is seen
in 5–10%
be
associated
with poorer
of all
cases of severe
AS25 outcomes after AVR. It is seen in 5–10%of all cases
of severe
dient
<30 mmHg
(orAS
4025mm Hg), an aortic valve area <1 cm², and-
that CAD h
ery. The op
cerebrovas
atheroscler
consensus
term surviv
Limits rela
Delay in the
after AVR. W
gradient ac
terload is a
maintains s
creased aft
maintained
normal val
other patie
abnormal a
output, add
This subset
be associat
of all cases
dient <30 m
an EF<35%
diac outpu
have occur
myocardial
transvalvul
duction in a
surgery.27 A
an operativ
rate within
medical ma
of patients
therapy is b
1) stenos
2) inotro
3) the pr
4) other
ity and also
that CAD has a negative impact on postoperative myocardial recovery. The operative risk in patients with CAD requiring concomitant
R according
ts of operaarly related
rable func-
cerebrovascular disease, peripheral vascular disease, extensive aortic
atherosclerosis, diabetes and renal failure.10 Nevertheless, there is a
consensus that the addition of CABG to AVR slightly improves longterm survival, even in high-risk populations.22
vascularisation. The matter is further complicated by issues related
to cardioplegia when the patent grafts are the internal thoracic arteries. Patients those with previous mediastinal radiotherapy and
radiation damage to the myocardium are also known to have poor
matous ascending
aorta (porcelain
aorta),
cross clamping
and aorLIMITS
OF SURGERY
IN AORTIC
VALVE SURGERY
totomy can be impossible.
Limits related to contractile reserve:
f severe coe. Since the
hin the gens for whom
is also exo concomiial function
ous cardiac
her comoruch as neus and renal
lications as
urther comf these facy a factor of
failure, 3.1
sfunction.3
ment on paugh class B
rvival in el≤30%) and/
had AVR as
Since operative mortality is a standard parameter of operative suc-
after AVR. When the aortic valve area is less than half of normal, the
gradient across the valve becomes important and the increased afterload is associated with concentric myocardial hypertrophy which
maintains systolic performance. The EF is decreased because of increased afterload and impaired diastolic function, but contractility is
maintained and AVR has an excellent outcome with EF returning to
normal values once the afterload excess is removed.23 However in
other patients, hypertrophy fails to normalise wall stress causing the
abnormal afterload to reduce ventricular ejection, reducing cardiac
output, adding to the heart failure syndrome.24
good measure of quality of cardiac surgical care, as long as patient
risk factors are taken into consideration, thus several risk scores
have been described to calculating predicted operative mortality
for patients undergoing cardiac surgery.30 The most employed surgical scores, namely the EuroSCORE31 and STS score32
titative assessment to establish whether patients are at high risk
This subset of patients with low gradient AS and low EF is known to
be associated with poorer outcomes after AVR. It is seen in 5–10%
of all cases of severe AS25
dient <30 mmHg (or 40 mm Hg), an aortic valve area <1 cm², and
an EF<35% (or 40%).21,22 In patients with low gradient and low cardiac output, there is severe decrease in EF in excess of what would
have occurred through afterload increase alone.26 The associated
myocardial dysfunction contributes to a poor prognosis. Since the
transvalvular gradient is small, there is a correspondingly smaller reduction in afterload and thus a smaller improvement in EF following
surgery.27 AVR in this group of patients carries a poor prognosis with
an operative mortality reported as high as 21% with a 50% death
rate within four years of the procedure.28 Although AVR is superior to
medical management in terms of short-term survival, surgery is not
1) stenosis severity
2) inotropic reserve
3) the presence
or absence|of CAD
or other
valveSURGERY
disease, and
HEALTHCARE
BULLETIN
AORTIC
VALVE
4) other comorbidities.
Patients without inotropic reserve and those with a large increase
from AVR and are generally considered a contraindication because
33
of “pseudo-aortic stenosis”. Nevertheless, in a recent international
multicentre registry of low EF/low gradient AS, AVR was associated
with superior survival and was advocated when mean pressure gradient was >20 mm Hg and in the absence of excessive comorbidities
or severe CAD with large scarring caused by extensive myocardial
infarction. The authors conclude that the lack of contractile reserve
in these patients may not systematically be related to irreversible
LV dysfunction but probably due to an afterload mismatch that is
not corrected by inotropic stimulation with dobutamine infusion.29
Technical limits to surgical AVR:
In addition to comorbidities, patients may present with technical
form. This is particularly true in patients undergoing redo surgery
with patent coronary artery bypass grafts, where the risk of injury
to the graft during dissection can be prejudicious to myocardial
vascularisation. The matter is further complicated by issues related
to cardioplegia when the patent grafts are the internal thoracic arteries. Patients those with previous mediastinal radiotherapy and
radiation damage to the myocardium are also known to have poor
matous ascending aorta (porcelain aorta), cross clamping and aortotomy can be impossible.
EUROPEAN JOURNAL OF CARDIOVASCULAR MEDICINE
leaks on su
after TAVI.
Table 1: Con
Delay in the management of patients with AS may give rise to certain
of patients before surgery may decide whether medical or surgical
therapy is best.
VOL I ISSUE III
feasibility o
anatomy. T
opening ne
ventional s
VOL I ISSUE III
for this population, these scores do not capture all relevant variables.15,33 Moreover they collect a large number of preoperative
data that are not all incorporated in the calculation of predicted
mortality. Thus out of more than 50 variables collected by the STS
score, only 24 are actually used in its mortality algorithm for patients having valve surgery.15 Variables such as hepatic disease,
previous chest wall irradiation, nutritional status and frailty that can
STS risk algorithm. 34,35
Amber et al. described a risk model that can be applied to patients
undergoing valve surgery, with or without concomitant CABG
surgery based on data from the Great Britain and Ireland national
cardiac surgical database.36 While scores are useful tools to predict
operative mortality in a broad sense, clinical judgement and careful preoperative assessment of patients are the key determinants in
decision making.
Transcatheter aortic valve implantation (TAVI) techniques
Transcatheter aortic valve implantation (TAVI) techniques have
been developed to provide alternative approaches to patients
for whom conventional AVR is fraught with a considerable risk
(Figure 2). These techniques are performed without cardiopulmonary bypass or aortic cross clamping under general or locoregional
raphy (TEE) guidance.
1. Cong
aortic v
2. Non-v
3. Aortic
II. Asso
1. Prese
requirin
3. Hype
4. Activ
III. Rela
A. TF ap
diamete
3. Patien
4. Sever
thromb
B. TA ap
1. Previo
3. Non-r
They have been performed via two distinct approaches, namely the
Figure
2: Heavily
calcified
and atheromatous
ascendingwith
(porcelain)
34
transfemoral
(TF)
and transapical
(TA) approaches
established
aorta
(arrows).
Conventional
AVR
would
be
a
considerable
technical
37,38,39
Each
approach
feasibility and have been described in detail.
challenge and fraught with hazards. A transcatheter valve has been
has its advantages and the selection strategy of patients for one
successfully inserted into the aortic annulus (asterisk).
technique or the other depends on centre and physician preference.40
The decision for performing TAVI is considered in patients
with severe symptomatic AS having: 41
• Contraindications to, or high risk for AVR
• Life expectancy >1 year
• Favourable anatomy for valve implantation
Patients undergo complete clinical examination, transthoracic
echocardiography (TTE), TEE, coronary angiography, aortic and
femoroiliac angiography and multislice computed tomography
prior to surgery. This screening process is necessary to establish
feasibility of TAVI and conformity of the aortic root geometry and
anatomy. The contraindications for TAVI are listed in Table 1. Despite
opening new horizons for patients refused or contraindicated conventional surgery, several questions remain unanswered concernleaks on survival, and LV function, and the incidence of endocarditis
after TAVI.
Table 1: Contraindications and limits for TAVI
Since operative mortality is a standard parameter of operative sucgood measure of quality of cardiac surgical care, as long as patient
risk factors are taken into consideration, thus several risk scores
have been described to calculating predicted operative mortality
I. Relat
I. Related to the aortic valve
35
EUROPEAN JOUR
ERY
HEALTHCARE BULLETIN
ge increase
They have been performed via two distinct approaches, namely the
transfemoral (TF) and transapical (TA) approaches with established
feasibility and have been described in detail.37,38,39 Each approach
has its advantages and the selection strategy of patients for one
technique or the other depends on centre and physician preference.40
They have been performed via two distinct approaches, namely the
transfemoral (TF) and transapical (TA) approaches with established
feasibility and have been described in detail. 37,38,39 Each approach
has its advantages and the selection strategy of patients for one
technique or the other depends on centre and physician preference.40
The decision for performing TAVI is considered in patients
with severe symptomatic AS having: 41
The decision for performing TAVI is considered in patients
with severe symptomatic AS having: 41
• Contraindications to, or high risk for AVR
• Contraindications to, or high risk for AVR
• Life expectancy >1 year
• Favourable anatomy for valve implantation
• Life expectancy >1 year
• Favourable anatomy for valve implantation
Patients undergo complete clinical examination, transthoracic
echocardiography (TTE), TEE, coronary angiography, aortic and
femoroiliac angiography and multislice computed tomography
prior to surgery. This screening process is necessary to establish
feasibility of TAVI and conformity of the aortic root geometry and
anatomy. The contraindications for TAVI are listed in Table 1. Despite
opening new horizons for patients refused or contraindicated conventional surgery, several questions remain unanswered concern-
Patients undergo complete clinical examination, transthoracic
echocardiography (TTE), TEE, coronary angiography, aortic and
femoroiliac angiography and multislice computed tomography
prior to surgery. This screening process is necessary to establish
feasibility of TAVI and conformity of the aortic root geometry and
anatomy. The contraindications for TAVI are listed in Table 1. Despite
opening new horizons for patients refused or contraindicated conventional surgery, several questions remain unanswered concern-
leaks on survival, and LV function, and the incidence of endocarditis
after TAVI.
leaks on survival, and LV function, and the incidence of endocarditis
after TAVI.
on because
ternational
associated
essure gramorbidities
myocardial
tile reserve
rreversible
atch that is
infusion.29
h technical
do surgery
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Aortic regurgitation
Table 1: Contraindications and limits for TAVI
In aortic regurgitation (AR), the main strain comes from volume
overload on the LV increasing left ventricular work and leading to
ventricular remodelling. Initially this allows the heart to cope with
the increased load but will eventually lead to the development of
heart failure. AVR improves LV function and forward cardiac output
and is should be performed before LVEF falls below 50% or when
end-systolic dimension increases above 55 mm. It may be too late
in patients with extremely dilated LV with depressed LVEF to gain
erative suc-
g as patient
risk scores
e mortality
ployed surat high risk
REFEREN
I. Related to the aortic valve
1. Congenital aortic stenosis, unicuspid or bicuspid
aortic valve
2. Non-valvular aortic stenosis
3. Aortic annulus <18mm or >27mm
hypertension in patients with severe AR also increases the surgical
risk. However, AVR in patients with severe AR and LVEF<40% was
II. Associated cardiac disease
1. Presence of intracardiac mass, thrombus or vegetation
medical management.42 Likewise, AVR in patients with pulmonary
hypertension was associated with an acceptable operative risk
requiring revascularisation
3. Hypertrophic cardiomyopathy (HOCM)
4. Active bacterial endocarditis or other active infections
better (62%) when compared to the conservatively treated group
(22%).43
III. Related to the approach
CONCLUSIONS
A. TF approach
atheroma or
diameter <6-7mm
3. Patients with bilateral iliofemoral bypasses
4. Severe angulation or aneurysm of the abdominal aorta with
thrombosis
B. TA approach
1. Previous surgery of the LV
3. Non-reachable LV apex
EUROPEAN
JOURNAL OF CARDIOVASCULAR MEDICINE
36
VOL I ISSUE III
The prevalence of valvular heart disease is rising with the ageing
ly by degenerative disease. Valve surgery is currently the reference
treatment of stenotic and regurgitant lesions. However, if left untreated severe valvular disease may lead to severe myocardial damage with poor ventricular function and loss of inotropic reserve and
cal intervention may also been fraught with high risk in the presence of several severe comorbidities or technical problems making
the procedure hazardous. Advances in monitoring systems and
perioperative pharmacological manipulation together with surgical experience and novel transcatheter approaches push the limits
of surgery and can further improve outcomes for selected patients
with aortic valvular heart disease.
EUROPEAN
JOURNAL
OF CARDIOVASCULAR
MEDICINE
I ISSUE
III III
EUROPEAN
JOURNAL
OF CARDIOVASCULAR
MEDICINE VOL VOL
I ISSUE
namely the
stablished
h approach
nts for one
ian prefer-
ients
nsthoracic
aortic and
mography
o establish
metry and
e 1. Despite
cated cond concern-
ndocarditis
m volume
leading to
cope with
opment of
iac output
% or when
be too late
VEF to gain
he surgical
<40% was
8
Iung B, Baron G, Butchart EG, et al. A prospective survey of patients
with valvular heart disease in Europe: The Euro Heart Survey on
Valvular Heart Disease. Eur Heart J 2003;24:1231-1243.
9
Varadarajan P, Kapoor N, Bansal RC, Pai RG.
OF SURGERY
AORTIC
SURGERY
history of 453 LIMITS
nonsurgically
managed IN
patients
withVALVE
severe aortic
stenosis. Ann Thorac Surg 2006;82:2111-2115. .
10
Hannan EL, Samadashvili Z, Lahey SJ, et al. Aortic Valve Replacement
for Patients With Severe Aortic Stenosis: Risk Factors and Their Impact
on 30-Month Mortality. Ann. Thorac. Surg. 2009;87:1741-1749.
11
Varadarajan P, Kapoor N, Bansal RC, et al. Survival in elderly patients
with severe aortic stenosis is dramatically improved by aortic valve
replacement: Results from a cohort of 277 patients aged > or =80
years. Eur J Cardiothorac Surg. 2006;30:722-7.
3better
Vahanian
A, Baumgartner
H, Bax
J, et conservatively
al. Guidelines on treated
the manage(62%) when
compared
to the
group
ment
43 of valvular heart disease. The Task Force on the management
(22%).
of valvular heart disease of the European Society of Cardiology. Eur
Heart J 2007; 28: 230-268.
12
Asimakopoulos G, Edwards MB, Taylor KM. Aortic valve
replacement in patients 80 years of age and older: survival and
cause of death based on 1100 cases: collective results from the
UK Heart Valve Registry. Circulation. 1997 18;96:3403-8.
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STS National Database. STS US Cardiac Surgery Database: 1997 Aortic
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http://www.ctsnet.org/doc/3031
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-
13
5
14
In aortic regurgitation (AR), the main strain comes from volume
overload on the LV increasing left ventricular work and leading to
ventricular remodelling. Initially this allows the heart to cope with
the increased load but will eventually lead to the development of
LIMITS OF SURGERY IN AORTIC VALVE DISEASE
heart failure. AVR improves LV function and forward cardiac output
and is should be performed before LVEF falls below 50% or when
end-systolic dimension increases above 55 mm. It may be too late
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Transcatheter valve
implantation for patients with aortic stenosis: a position statement
from the European Association of Cardio-Thoracic Surgery (EACTS)
and the European Society of Cardiology (ESC), in collaboration with
the European Association of Percutaneous Cardiovascular
EUROPEAN JOURNAL OF CARDIOVASCULAR MEDICINE
EUROPEAN JOURNAL OF CARDIOVASCULAR MEDICINE
VOL I ISSUE III
VOL I ISSUE III