Aortic valve replacement

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Refers to replacement of the aortic valve with a prosthetic valve

Surgical aortic valve replacement

The intervention of choice in moderate to severe aortic stenosis. It may also be necessary in severe aortic incompetence or aortic valve endocarditis (particularly acute bacterial endocarditis due to staphylcocci) In aortic stenosis aortic valve replacement (AVR)[1]

  • Is often combined with coronary artery bypass grafting (CABG) in over 40%
  • Survival at 3 years should be over 85% for those deemed fit for surgery
  • Ten year survival is about 30%

Transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR, transcatheter aortic valve implantation, TAVI) is a technique usually using a femoral-artery based balloon expandable stainless steel stent frame that houses a percardial valve replacement. Accordingly successful TAVR prevents the need for open heart surgery and in those patients not fit for open heart surgery it can be an attractive option. An alternative to the femoral approach uses a transapical approach via a small thoracotomy incision. These two approaches are not equivalent and as of 2012 the transapical approach can be thought equivalent in quality of life outcome to traditional aortic valve replacement while the femoral approach may have relative advantages[2]. Complications such as stroke rate seem to vary by procedure.

  • Outcomes are favourable in those not fit for standard surgery up to 2 years.[3][4][5]
  • Compared to higher risk surgery with a 28% all cause mortality at 2 years third generation devices had a mortality of 22%.
  • One year survival of 80% in early series[6] but the best European registry is closer to 95.8% at 30 days[7]
  • Survival at 60 months of 28.2% in inoperable aortic stenosis compared to 6.4% with no intervention[8] and 32.8% in high risk patients which was similar to surgery at 37.6%[9]

Early European registry data showed marked difference in mortality between countries that was unexplained [7]. The mortality rate appears to be higher in countries where the procedure is more popular per head of population. This observation would be consistent with either more use outside evidence base or more transapical use, and indeed some countries with higher mortality have more use of apical TAVIs. As of 2016 the cost effectiveness relative to surgery, even in high risk patients, continued to be unclear, as the devices remain much more expensive than surgery[10][11][12]. The clinical outcomes by 2016 of some third generation devices and techniques appear to be getting ever closer to surgery in low and moderate risk surgical patients. Such techniques include at this time cerebral emboli protection devices and it is likely that to replace in most patients surgery good trial evidence for their effectiveness will be necessary.


References

  1. Yamane K, Hirose H, Youdelman BA, Bogar LJ, Diehl JT. Conventional aortic valve replacement for elderly patients in the current era. Circulation journal : official journal of the Japanese Circulation Society. 2011 Oct 25; 75(11):2692-8.
  2. Reynolds MR, Magnuson EA, Wang K, Thourani VH, Williams M, Zajarias A, Rihal CS, Brown DL, Smith CR, Leon MB, Cohen DJ. Health-Related Quality of Life After Transcatheter or Surgical Aortic Valve Replacement in High-Risk Patients With Severe Aortic Stenosis: Results From the PARTNER (Placement of AoRTic TraNscathetER Valve) Trial (Cohort A). Journal of the American College of Cardiology. 2012 Aug 7; 60(6):548-58.(Link to article – subscription may be required.)
  3. Stähli BE, Bünzli R, Grünenfelder J, Bühler I, Felix C, Bettex D, Biaggi P, Tanner FC, Nguyen-Kim DL, Plass A, Ge H, Falk V, Lüscher TF, Corti R, Maier W, Altwegg LA. Transcatheter aortic valve implantation (TAVI) outcome according to standardized endpoint definitions by the valve academic research consortium (VARC). The Journal of invasive cardiology. 2011 Aug; 23(8):307-12.
  4. Kodali SK, Williams MR, Smith CR, Svensson LG, Webb JG, Makkar RR, Fontana GP, Dewey TM, Thourani VH, Pichard AD, Fischbein M, Szeto WY, Lim S, Greason KL, Teirstein PS, Malaisrie SC, Douglas PS, Hahn RT, Whisenant B, Zajarias A, Wang D, Akin JJ, Anderson WN, Leon MB. Two-year outcomes after transcatheter or surgical aortic-valve replacement. The New England journal of medicine. 2012 May 3; 366(18):1686-95.(Link to article – subscription may be required.)
  5. Makkar RR, Fontana GP, Jilaihawi H, Kapadia S, Pichard AD, Douglas PS, Thourani VH, Babaliaros VC, Webb JG, Herrmann HC, Bavaria JE, Kodali S, Brown DL, Bowers B, Dewey TM, Svensson LG, Tuzcu M, Moses JW, Williams MR, Siegel RJ, Akin JJ, Anderson WN, Pocock S, Smith CR, Leon MB. Transcatheter aortic-valve replacement for inoperable severe aortic stenosis. The New England journal of medicine. 2012 May 3; 366(18):1696-704.(Link to article – subscription may be required.)
  6. Giugliano GR, Lotfi AS. Transcatheter aortic valve implantation: comparing apples to apples. The Journal of invasive cardiology. 2011 Aug; 23(8):313-5.
  7. a b Messori, A, Fadda V, Maratea D, Trippoli S. Governing innovative medical devices: the case of transcatheter aortic valves. BMJ 2011
  8. Kapadia SR, Leon MB, Makkar RR, Tuzcu EM, Svensson LG, Kodali S, Webb JG, Mack MJ, Douglas PS, Thourani VH, Babaliaros VC, Herrmann HC, Szeto WY, Pichard AD, Williams MR, Fontana GP, Miller DC, Anderson WN, Akin JJ, Davidson MJ, Smith CR. 5-year outcomes of transcatheter aortic valve replacement compared with standard treatment for patients with inoperable aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet (London, England). 2015 Jun 20; 385(9986):2485-91.(Link to article – subscription may be required.)
  9. Mack MJ, Leon MB, Smith CR, Miller DC, Moses JW, Tuzcu EM, Webb JG, Douglas PS, Anderson WN, Blackstone EH, Kodali SK, Makkar RR, Fontana GP, Kapadia S, Bavaria J, Hahn RT, Thourani VH, Babaliaros V, Pichard A, Herrmann HC, Brown DL, Williams M, Akin J, Davidson MJ, Svensson LG. 5-year outcomes of transcatheter aortic valve replacement or surgical aortic valve replacement for high surgical risk patients with aortic stenosis (PARTNER 1): a randomised controlled trial. Lancet (London, England). 2015 Jun 20; 385(9986):2477-84.(Link to article – subscription may be required.)
  10. Van Brabandt H, Neyt M, Hulstaert F. Transcatheter aortic valve implantation (TAVI): risky and costly. BMJ (Clinical research ed.). 2012; 345:e4710.(Epub)
  11. Cao C, Liou KP, Pathan FK, Virk S, McMonnies R, Wolfenden H, Indraratna P. Transcatheter Aortic Valve Implantation versus Surgical Aortic Valve Replacement: Meta-Analysis of Clinical Outcomes and Cost-Effectiveness. Current pharmaceutical design. 2016 Feb 19.(Epub ahead of print)
  12. Reynolds MR, Lei Y, Wang K, Chinnakondepalli K, Vilain KA, Magnuson EA, Galper BZ, Meduri CU, Arnold SV, Baron SJ, Reardon MJ, Adams DH, Popma JJ, Cohen DJ. Cost-Effectiveness of Transcatheter Aortic Valve Replacement With a Self-Expanding Prosthesis Versus Surgical Aortic Valve Replacement. Journal of the American College of Cardiology. 2016 Jan 5; 67(1):29-38.(Link to article – subscription may be required.)

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