Early Valve Replacement for Severe Aortic Valve Disease: Effect on Mortality and Clinical Ramifications
Abstract
:1. Introduction
2. Literature Search and Information Sources
3. AHA/ACC 2014 Guidelines
4. Aortic Regurgitation: Studies Since 2015
5. Aortic Stenosis: Studies Since 2015
6. Perioperative Mortality
7. Relating Data Since 2015 to Previous Data
7.1. Chronic AR
7.1.1. Symptoms
7.1.2. LVEF
7.1.3. LVESD/LVESDi
7.1.4. LVEDD/LVEDDi
7.1.5. Chronic AR Summary Comparing New to Existing Data
7.2. Chronic AS
LVEF
8. Features in Common between AR and AS and Possible Mechanisms
9. Mixed Aortic Valve Disease
10. Ramifications of Earlier Surgery
10.1. Limited Durability of Bioprosthetic Valves or Risks from Anticoagulation
10.2. Infective Endocarditis
10.3. Effect of Age
10.4. Increased Reliance on Imaging for Decision Making
10.5. Heterogenous Nature of Aortic Valve Disease
11. Future Directions
12. Conclusions
Supplementary Materials
Author Contributions
Funding
Conflicts of Interest
References
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Parameter | Details | COR | LOE |
---|---|---|---|
Symptomatic | AVR is indicated for symptomatic patients with severe AR regardless of LV systolic function (stage D) | I | B |
LVEF < 50% | AVR is indicated for asymptomatic patients with chronic severe AR and LV systolic dysfunction (LVEF < 50%) (stage C2) | I | B |
Other cardiac surgery, severe AR | AVR is indicated for patients with severe AR (stage C or D) while undergoing cardiac surgery for other indications | I | C |
LVESD > 50 mm (LVESDi > 25 mm/m2) | AVR is reasonable for asymptomatic patients with severe AR with normal LV systolic function (LVEF ≥ 50%) but with severe LV dilation (LVESD > 50 mm, stage C2) | IIa | B |
Other cardiac surgery, moderate AR | AVR is reasonable in patients with moderate AR (stage B) who are undergoing other cardiac surgery | IIa | C |
LVEDD > 65 mm | AVR may be considered for asymptomatic patients with severe AR and normal LV systolic function (LVEF ≥ 50%, stage C1) but with progressive severe LV dilation (LVEDD > 65 mm) if surgical risk is low | IIb | C |
Parameter | Details | COR | LOE |
---|---|---|---|
Symptomatic | AVR is recommended for symptomatic patients with severe high-gradient AS who have symptoms by history or on exercise testing (stage D1) | I | B |
LVEF < 50% | AVR is recommended for asymptomatic patients with severe AS (stage C2) and LVEF < 50% | I | B |
Other cardiac surgery, severe AS | AVR is indicated for patients with severe AS (stage C or D) when undergoing other cardiac surgery | I | B |
Aortic velocity ≥ 5.0 m/s | AVR is reasonable for asymptomatic patients with very severe AS (stage C1, aortic velocity ≥ 5.0 m/s) and low surgical risk | IIa | B |
Decreased exercise tolerance or exercise fall in BP | AVR is reasonable in asymptomatic patients (stage C1) with severe AS and decreased exercise tolerance or an exercise fall in BP | IIa | B |
Dobutamine stress test, low-flow/low gradient severe AS | AVR is reasonable in symptomatic patients with low-flow/low-gradient severe AS with reduced LVEF (stage D2) with a low-dose dobutamine stress study that shows an aortic velocity ≥4.0 m/s (or mean pressure gradient ≥40 mm Hg) with a valve area ≤1.0 cm2 at any dobutamine dose | IIa | B |
Low-flow/low gradient severe AS | AVR is reasonable in symptomatic patients who have low-flow/low-gradient severe AS (stage D3) who are normotensive and have an LVEF ≥50% if clinical, hemodynamic, and anatomic data support valve obstruction as the most likely cause of symptoms | IIa | C |
Other cardiac surgery, moderate AS | AVR is reasonable for patients with moderate AS (stage B) (aortic velocity 3.0–3.9 m/s) who are undergoing other cardiac surgery | IIa | C |
Rapid progression, severe AS | AVR may be considered for asymptomatic patients with severe AS (stage C1) and rapid disease progression and low surgical risk | IIb | C |
Author, Year, Location | Size | Type | Sample Details | Factor | Result | p-Value | |
---|---|---|---|---|---|---|---|
Mentias et al. 2016 [14] Cleveland, Ohio, US | 1417 | Retrospective, observational | Age 54 ± 16 years; 75% male. Severe AR with LVEF ≥50%. 933 (66%) underwent AVR | AVR surgery during follow up | 10 year survival: | <0.001 | |
Yes | 87% | ||||||
No | 71% | ||||||
Symptomatic | 10 year mortality: | <0.001 | |||||
HR 2.06 (1.76–2.49) (compared to symptomatic) | |||||||
Murashita et al. 2017 [15] Rochester, Minnesota, US | 530 | Retrospective, observational | Age 57 ± 17 years; 80% male; 37% BAV All underwent AVR for severe AR | Symptomatic | 10 year survival (CI): | <0.01 | |
Yes | 77.8% (59.7–99.9%) | ||||||
No | 91.1% (85.7–96.6%) | ||||||
LVEF | 10 year survival (CI): | 0.04 | |||||
≥60% | 85.4% (81.7–89.2%) | ||||||
<60% | 69.5% (61.3–78.3%) | ||||||
LVESD | Risk of left ventricular dysfunction at 1 year postoperatively, defined as LVEF below 60%: | <0.01 | |||||
>40 mm | odds ratio 5.39 | ||||||
Yang et al. 2019 [16] Rochester, Minnesota, US | 748 | Retrospective, observational | Severe AR Age 58 ± 17 years; 82% male; 39% BAV 361 (48%) underwent AVR | Time-dependent AVR (within 6-months of initial echocardiogram) | Multivariate hazard ratio (CI) for all-cause mortality at median 4.9 years: | 0.02 | |
0.36 (0.25–0.86) | |||||||
Symptoms | Multivariate hazard ratio (CI) for all-cause mortality at median 4.9 years: | <0.0001 | |||||
3.16 (2.10–4.75) | |||||||
LVESDi | Multivariate hazard ratio (CI) for all-cause mortality: | 0.04 0.003 | |||||
<20 mm/m2 | Reference | ||||||
20–25 mm/m2 | 1.53 (1.01–2.31) | ||||||
≥25 mm/m2 | 2.23 (1.32–3.77) | ||||||
de Meester et al. 2019 [17] Brussels, Belgium | 356 | Retrospective, observational | Age, 51 ± 15 years; 83% male; 42% BAV All underwent AVR for severe AR | Symptoms | 10 year survival: | 0.013 0.001 | |
NYHA class I | 86 ± 4% | ||||||
NYHA class II | 73 ± 7% | ||||||
NYHA class III/IV | 65 ± 7% | ||||||
LVEF | 10 year survival: | 0.011 | |||||
≥50% | 80 ± 3% | ||||||
<50% | 69 ± 6% | ||||||
Spline function analysis hazard ratio (CI) for cardiovascular events: | 0.002 | ||||||
≥55% | reference | ||||||
<55% | 4.13 (1.65 to 10.33) | ||||||
per 1% decrease in LVEF | |||||||
LVESDi | 10 year survival: | <0.001 | |||||
<25 mm/m2 | 84 ± 3% | ||||||
≥25 mm/m2 | 62 ± 6% | ||||||
LVEDD | 10 year survival: | ||||||
No difference between LVEDD <65 mm and LVEDD ≥65 mm | |||||||
No difference between LVEDD <70 mm and LVEDD ≥70 mm |
Author, Year, Location | Size | Type | Sample Details | Factor | Result | p-Value | |
---|---|---|---|---|---|---|---|
Taniguchi et al. 2015 [18] Kyoto, Japan | 1808 | Multicenter, retrospective, observational | Asymptomatic, severe AS; age 77 ± 9 years, 40% male Propensity score-matched cohort of 582 patients | Initial AVR or watchful waiting | 5-year survival: | 0.009 | |
Initial AVR | 84.6% | ||||||
Watchful waiting | 73.6% | ||||||
5-year rate of hospitalization for heart failure: | <0.001 | ||||||
Initial AVR | 3.8% | ||||||
Watchful waiting | 19.9% | ||||||
Genereux et al. 2016 [19] New York, US | 4 trials 2486 patients | Meta-analysis | Asymptomatic, severe AS | Early AVR or watchful waiting | All-cause mortality (CI): | 0.01 | |
Early AVR | reference | ||||||
Watchful waiting | 3.7 (1.3–11.1) | ||||||
fold higher | |||||||
Masri et al. 2016 [20] Cleveland, Ohio, US | 533 | Retrospective, observational | Asymptomatic, severe AS, LVEF ≥50%; age, 66 ± 13 years, 78% men, 31% with coronary artery disease | AVR or no AVR | Multivariable Cox proportional hazard survival analysis for 6.9 ± 3 years all-cause mortality (CI): | <0.001 | |
AVR | 0.26 (0.16–0.41) | ||||||
No AVR | reference | ||||||
Exercise stress echocardiography % age-gender predicted METs | Long-term (6.9 ± 3.3 years) survival: | <0.001 | |||||
≥85% | 85.0% | ||||||
<85% | 67.6% | ||||||
Lancellotti et al. 2018 [22] Liège, Belgium | 543 | Multicenter, retrospective, observational | Asymptomatic, severe AS; LVEF ≥ 50%; age 71 ± 13%; 61% male; all underwent AVR. | Peak aortic velocity | Survival at 2, 4, 6 years following AVR: | 0.03 | |
<5.0 m/s | 84 ± 2%, 78 ± 4%, 70 ± 6% | ||||||
≥5.0 m/s | 73 ± 8%, 65 ± 10%, 54 ± 13% | ||||||
LVEF | Survival at 2, 4, 6 years following AVR: | 0.02 | |||||
≥60% | 87 ± 5%, 78 ± 4%, 69 ± 7% | ||||||
<60% | 67 ± 7%, 63 ± 8%, 63 ± 8% | ||||||
Campo et al. 2019 [21] Chicago, Illinois, US | 265 | Retrospective, observational | Asymptomatic severe AS. | Early AVR or watchful waiting | Survival at 2, 4 years: | 0.033 | |
Early AVR | 92.5%, 78.9% | ||||||
Watching waiting | 83.9%, 91.0% | ||||||
Kim et al. 2019 [23] Seoul, South Korea | 468 | Retrospective, observational | Asymptomatic, severe AS, LVEF ≥50%; age 64 years; 50% male. Early AVR was performed in 351 patients | AVR or medical treatment | All-cause mortality (median 60.9 months): | 0.036 | |
AVR | 9.1% per year | ||||||
Medical treatment | 2.4% per year | ||||||
Hazard ratio 0.62 (0.40–0.97) | |||||||
Kang et al. 2019 [8] Seoul, South Korea (RECOVERY trial) | 145 | Prospective, single center, RCT | Asymptomatic, severe AS, LVEF ≥50%; age 64 ± 9 years; 36% male | Early surgery or watchful waiting (randomized) | 5 year death from cardiovascular or surgery causes: | 0.003 | |
Early surgery | 1% | ||||||
Watchful waiting | 15% | ||||||
5 year death from any cause: | |||||||
Early surgery | 7% | ||||||
Watchful waiting | 21% |
Year | Mortality | Author | Size | Location |
---|---|---|---|---|
1985 | 7% | Scott et al. [29] | 1479 | Stanford, California |
2000 | 5.6% | Kvidal et al. [7] | 2359 | Uppsala, Sweden |
2001 | 4.0% | Edwards et al. [28] | 16,105 | Jacksonville, Florida |
2016 | 0.6% | Mentias et al. [14] | 1417 | Cleveland, Ohio |
2018 | 0.9% | Lancellotti et al. [22] | 1375 | Liège, Belgium |
2019 | 0.9% | Kim et al. [23] | 468 | Seoul, South Korea |
2019 | 0.3% | Yang et al. [16] | 748 | Rochester, Minnesota |
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Koerber, J.P.; Bennetts, J.S.; Psaltis, P.J. Early Valve Replacement for Severe Aortic Valve Disease: Effect on Mortality and Clinical Ramifications. J. Clin. Med. 2020, 9, 2694. https://doi.org/10.3390/jcm9092694
Koerber JP, Bennetts JS, Psaltis PJ. Early Valve Replacement for Severe Aortic Valve Disease: Effect on Mortality and Clinical Ramifications. Journal of Clinical Medicine. 2020; 9(9):2694. https://doi.org/10.3390/jcm9092694
Chicago/Turabian StyleKoerber, Jason P., Jayme S. Bennetts, and Peter J. Psaltis. 2020. "Early Valve Replacement for Severe Aortic Valve Disease: Effect on Mortality and Clinical Ramifications" Journal of Clinical Medicine 9, no. 9: 2694. https://doi.org/10.3390/jcm9092694