-The Living Aortic Valve-...MECHANICAL AVR IN THE YOUNG Long-term outcomes after elective isolated...
Transcript of -The Living Aortic Valve-...MECHANICAL AVR IN THE YOUNG Long-term outcomes after elective isolated...
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-The Living Aortic Valve- Repair or Else?
Ismail El-Hamamsy, MD PhD Associate Professor
Director, Aortic Surgery Division of Cardiac Surgery Montreal Heart Institute Université de Montreal
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PhD Thesis – Imperial College London (2010)
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-1-
THE AORTIC ROOT IS
A LIVING STRUCTURE
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AORTIC ROOT PHYSIOLOGY
Dagum et al. Circulation 1999
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AORTIC VALVE
El-Hamamsy et al. J Adv Res 2009
Endothelial Cells Interstitial Cells -Smooth muscle cells
-Fibroblasts
-Myofibroblasts
Aortic Side
Ventricular Side
Collagen
GAGs
Elastin
Smooth muscle actin
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AORTIC VALVE
El-Hamamsy et al. Curr Vasc Pharmacol 2009
Neurofilament
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AORTIC VALVE
El-Hamamsy et al. JACC 2009
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THE AORTIC ROOT
LIVING STRUCTURE =
COMPLEX FUNCTIONS
Laminar flow
Excellent hemodynamics
Low thrombogenicity
Resistance to infections
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OUTCOMES FOLLOWING AVR
Laminar Flow
Hemodynamics (gradients)
Thrombogenicity
Resistance to infections
Survival Valve-related complications
Quality of life
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Rationale
A LIVING AORTIC VALVE SUBSTITUTE
IMPROVED CLINICALLY-RELEVANT OUTCOMES
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NON-ELDERLY ADULTS
• High level of physical activity
• Quality of life
• Prolonged anticipated life expectancy
= Exposure to valve-related complications
– Degeneration + Reoperation (tissue valves)
– Bleeding + Thromboembolisms (mechanical valves)
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-2-
CONVENTIONAL AVR IN THE YOUNG
= EXCESS MORTALITY
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CONVENTIONAL AVR
SEVERAL ADVANTAGES
– Standardized
– Easily reproducible
– Short operative times
– Long-term data
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AVR IN THE YOUNG
Kvidal et al. JACC 2000
Excess Mortality
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AVR IN THE YOUNG
Kvidal et al. JACC 2000
The younger the patients are, The higher excess mortality is
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MECHANICAL AVR IN THE YOUNG
Long-term outcomes after elective isolated mechanical aor tic valve
replacement in young adults
Ismail Bouhout, MSc,aLouis-Mathieu Stevens, MD, PhD,b Amine Mazine, MSc,aNancy Poirier, MD,a
Raymond Cartier, MD,aPhilippe Demers, MD,aand Ismail El-Hamamsy, MD, PhDa
Objectives: The aim of this study was to determine long-term survival and clinical outcomes after elective
isolated mechanical aortic valve replacement in young adults.
Methods: A clinical observational study wasconducted in acohort of 450 consecutiveadults lessthan 65 years
of agewho had undergoneelectiveisolated mechanical aortic valvereplacement (AVR) between 1997and 2006.
Patients who had undergone previous cardiac surgery, and those undergoing concomitant procedures or urgent
surgery wereexcluded. Follow-up was93.3% completewith amean follow-up of 9.1 3.5 years. Theprimary
end point wassurvival. Life tableanalyseswereused to determineage- and gender-matched general population
survival. Secondary end points were reoperation and valve-related complications.
Results: Overall actuarial survival at 1, 5, and 10 years was 98% 1%, 95% 1%, and 87% 1%,
respectively, which was lower than expected in the age- and gender-matched general population in Quebec.
Actuarial freedom from prosthetic valve dysfunction was 99% 0.4%, 95% 1%, and 91% 1% at
1, 5, and 10 years, respectively. Actuarial freedom from valve reintervention was 98% 1%, 96% 1%,
and 94% 1% at 1, 5 and 10 years, respectively. Actuarial survival free from reoperation at 10 years was
82% 2%. Actuarial freedom from major hemorrhage was 98% 1%, 96% 1%, and 90% 2% at
1, 5, and 10 years, respectively.
Conclusions: In young adults undergoing elective isolated mechanical AVR, survival remains suboptimal
compared with an age- and gender-matched general population. Furthermore, there isa low but constant hazard
of prosthetic valve reintervention after mechanical AVR. (J Thorac Cardiovasc Surg 2013;- :1-6)
Supplemental material is available online.
Aortic valvedisease isoneof themost common indications
for surgery in patients less than 65 years of age. However,
the ideal aortic valve substitute remains unknown. This is
partly due to the lack of data on long-term outcomes in
this specific patient population. More importantly, most
long-term studies of aortic valve replacement (AVR)
include patients at higher risk (urgent operations, concom-
itant coronary revascularization, reoperations), which
makes it more challenging to assess outcomes related to
the actual procedure.1-3 Nevertheless, recent evidence has
shown excess long-term mortality in patients undergoing
AVR compared with an age- and sex-matched general
population, and this discrepancy was most pronounced in
the youngest age group.4
A longer lifeexpectancy exposesyoung adultstoahigher
lifelong risk of prosthesis-related complicationsafter AVR,
most notably in the form of thromboembolic events,
hemorrhage, and reoperation. Bioprosthetic valves have
limited long-term durability and thereforecarry an inherent
risk of reoperation in young adults. Nevertheless, they have
alow thrombogenic risk and havetheadvantageof avoiding
anticoagulation. In contrast, mechanical prosthesesprovide
better long-term durability with low risk of prosthesis
reintervention, and are thus often considered the option of
choice in young adultswith aortic valvedisease.5Neverthe-
less, mechanical prostheses carry a thrombogenic risk and
therefore mandate long-term anticoagulation with an
associated risk of major bleeding. Although some studies
have examined long-term results after AVR, few have
focused on contemporary results of isolated mechanical
AVR in young adults.
The aim of this study was to assess long-term survival
in a contemporary series of consecutive young adults
undergoing elective isolated mechanical AVR compared
with the age- and gender-matched general population in
Quebec. The secondary objective was to describe the
occurrence of long-term valve-related complications after
AVR in this patient population.
From the Department of Cardiac Surgery,aMontreal Heart Institute, and Department
of Cardiac Surgery,bCentre Hospital ier de l’UniversitedeMontreal, Universitede
Montreal, Montreal, Canada.
Disclosures: Authors have nothing to disclose with regard to commercial support.
Received for publication July 31, 2013; revisions received Oct 5, 2013; accepted for
publication Oct 25, 2013.
Address for reprints: Ismail El-Hamamsy, MD, PhD, Department of Cardiac Surgery,
Montreal Heart Institute, 5000 Belanger St, Montreal, Quebec H1T 1C8, Canada
(E-mail: i.elhamamsy@icm-mhi .org).
0022-5223/$36.00
Copyright Ó 2013 by The American Association for Thoracic Surgery
http://dx.doi.org/10.1016/j.jtcvs.2013.10.064
The Journal of Thoracic and Cardiovascular Surgery c Volume - , Number - 1
Bouhout et al Acquired Cardiovascular Disease
AC
D
1997-2006: 469 isolated mechanical AVR <65 years
Exclusion: concomittant procedures, coronary disease, reoperations, emergencies (dissection),
active endocarditis
Mean age: 53.2 ± 9.2
Mean follow-up: 9.1 ± 3.5 years
Follow-up 95% complete (4099 patient-years)
Bouhout et al. JTCVS 2014
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SURVIVAL – MECHANICAL AVR
Bouhout et al. JTCVS 2014
87%
78%
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SURVIVAL FREE FROM REOPERATION
Bouhout et al. JTCVS 2014
82%
A 10 years, 1 in 5 patients is dead or reoperated
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Valve-Related Complications
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PROACT Trial (n=375 pts)
Puskas et al. JTCVS 2014
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TISSUE AVR IN THE YOUNG
“. . .younger patients had worse than expected survival that was further diminished with insertion of a small prosthesis.”
3,049 Perimount patients; 1991-2004
Mihajlevic et al. JTCVS 2008
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TISSUE AVR IN THE YOUNG
2,659 Perimount patients; 1984-2008
Bourguignon et al. Ann Thorac Surg 2015
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Excess Mortality in Young Adults
-8 yrs
-20 yrs
Bourguignon et al. Ann Thorac Surg 2015
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SVD and Death = Competing Risks
SVD Survival
Bourguignon et al. Eur J Cardiothorac Surg 2016
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9,942 isolated AVR <65 years; 1996-2013
AVR IN THE YOUNG
Goldstone et al. NEJM 2017
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AVR IN THE YOUNG
15-Year Mortality: 26-30%
Goldstone et al. NEJM 2017
15-Year Mortality: 32-36%
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CONVENTIONAL AVR IN THE YOUNG
CURATIVE
PALLIATIVE
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EXCESS MORTALITY IS OBSERVED
UP TO 60 YEARS OF AGE
AT THE TIME OF SURGERY
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A LIVING AORTIC VALVE =
IMPROVED OUTCOMES?
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-3-
ROSS PROCEDURE = IMPROVED CLINICAL
OUTCOMES
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Historical Perspective
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Historical Perspective
Surgical Forum 1965
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ROSS PROCEDURE
THE ONLY REPLACEMENT OPERATION THAT GUARANTEES LONG-TERM
VIABILITY OF THE AORTIC VALVE/ROOT
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Negative Biases
“Transforms single valve disease into double valve disease”
“High operative morbidity and mortality”
“High rate of reoperations”
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SURVIVAL
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SURVIVAL - ROSS
El-Hamamsy et al. Lancet 2010
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SURVIVAL - ROSS
El-Hamamsy et al. Lancet 2010
ROSS
GENERAL POPULATION
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SURVIVAL - ROSS
David et al. JTCVS 2010
• 1990-2004 • 212 pts • 34 +/- 9 years • Mean Fup: 10.1 yrs
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SURVIVAL - ROSS
David et al. JTCVS 2014
• 1990-2004 • 212 pts • 34 +/- 9 years • Median Fup: 13.8 years
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SURVIVAL
Sievers et al. Eur J Cardiothor Surg 2015
• 1990-2013 • 1779 pts (8 centers) • 45+/- 11 years • Mean Fup: 8.3 years (662 pts >10 years)
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SURVIVAL
Mastrobuoni, EJCTS 2015
• 1991-2014 • 306 pts • 42+/- 9 years • Median Fup: 10.6 years
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Survival Free from Reoperation
Sharabiani et al. JACC 2016
• UK National Registry • 2000-2012 • 1501 patients
Survival free from reoperation
ROSS
MECH
TISSUE
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Ross vs. Mechanical AVR
Mechanical
Ross
Mazine et al. Circulation 2016
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Burratto et al. JACC 2018
Ross vs. Mechanical AVR
• 1992-2016 • 392 Ross cases • Propensity-matched: 275 pairs • 43 +/- 11 years
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LATE SURVIVAL - ROSS
>3600 pts
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Survival - Ross
“Late mortality rates are low and resemble
the adult series age-matched population
mortality.”
5,031 adults, children; 2000-2008
Takkenberg et al. Circulation 2009
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SURVIVAL
Mazine et al. JAMA Cardiol 2018
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THE ROSS PROCEDURE
THE ONLY REPLACEMENT OPERATION THAT RESTORES LONG-TERM SURVIVAL
FOLLOWING AORTIC VALVE REPLACEMENT
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WHAT ABOUT THE ROSS IN PATIENTS WITH
Ao REGURGITATION AND A DILATED ANNULUS?
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ACHILLE’S HEEL?
Reoperation
Operative Risk
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Autograft Reoperation
Klieverik et al. Eur Heart J 2007
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Ross and AI
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Ross and AI
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Ross and AI
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ROSS PROCEDURE
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David TE. Circulation 2009
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PARADIGM CHANGE
ANTICOAGULATION VS. REOPERATION
SURVIVAL + QUALITY OF LIFE
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LATE SURVIVAL - ROSS
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Autograft Reoperation
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Autograft Reoperation
TECHNIQUE MATTERS
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Ross Technique
MMCTS 2014
Ann Thorac Surg 2018
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Tailored Approaches to AI
Mazine, El-Hamamsy et al. JACC 2018 (in press)
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Tailored Ross Technique
• Trimming of infudibular muscle below the valve
• Scalloping of the autograft
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Pulmonary Autograft Trimming
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Tailored Ross Technique
Proximal suture line
• Place the autograft in an infra-annular position (inside the LVOT)
• Interrupted sutures
• Commissural Symmetry
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Aortic vs Pulmonary Anatomy
Wall
Annulus
AorticRoot PulmonaryRoot
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Tailored Ross Technique
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Extra-Aortic Annuloplasty
• Extra-aortic ring annuloplasty is used if:
– AI or mixed AS/AI (with predominant AI) is the indication
– Annulus mismatch >2mm (Aortic > Pulmonary)
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Extra-Aortic Annuloplasty
Basal Ring
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JTCVS 2017
EJCTS 2018
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Annular reduction and Stabilization
Basmadjian et al. JTCVS 2017 Lenoir et al. EJCTS 2018 (in press)
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Aortic Annuloplasty
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Aortic Annuloplasty
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Aortic Annuloplasty
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Aortic Annuloplasty
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Aortic Annuloplasty
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Aortic Annuloplasty
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Aortic Annuloplasty
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Tailored Ross Technique
Distal Suture Line
• Short autograft above STJ (or coronary anastomosis) (max 2-3mm)
• Short interposition graft if ascending aorta ≥40mm
• Careful attention to commissural symmetry
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Postoperative Management
• Strict BP control in the perioperative period (max sBP 100-110mmHg)
• Home BP monitoring 6 months (max sBP 100-110mmHg)
Tailored Ross Technique
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BP Remote Monitoring
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Ross Procedure June 2017
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Montreal Ross Program (N=356 patients)
17
36 40
36
48
73
60
46
2011 2012 2013 2014 2015 2016 2017 2018
Jan-July
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Montreal Aortic Program (N=611 patients)
17
36
40
36
48
73
60
46
4 4 4 5 6 9
15
19
28
20 22
36 37 36
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
Ross Procedure – N= 356 patients
Valve-Sparing/Repair – N= 255 patients
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MONTREAL HEART INSTITUTE (N=356)
2011-2018
356 patients: Mean age 42 yrs (16-67 yrs)
• 15% redos (N=53)
• 60% concomittant procedures (N=208)
• 5% active endocarditis (N=17)
Operative mortality: 0.6% (n=2)
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MONTREAL HEART INSTITUTE (N=356)
• The first 100 patients
– Temporary dialysis (n=5)
– Reexploration for bleeding (n=4)
– Mortality (n=2)
• The last 256 patients
– Temporary dialysis (n=3): 1.2%
– Reexploration for bleeding (n=2): <1%
–Mortality (n=0): 0%
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Montreal Ross Program
2011 – 2018 : 281 consecutive Ross procedures with ≥ 1 year of follow-up
(Mean age : 46 ± 7 years)
Exclusions: - Endocarditis (n=18) - Previous AVR (n=22)
241 Ross procedures
AR group (n=73) AS group (n=168)
Mean Follow-up: 29 ± 11 months
100% complete for yearly clinical and echo follow-up
Bouhout,…,El-Hamamsy. EACTS 2018
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Ross Procedure with Ring Annuloplasty
Bouhout,…,El-Hamamsy. EACTS 2018
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ANY Reoperation
El-Hamamsy et al. Lancet 2010
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Ross Reoperation (aortic/pulmonary)
Mazine et al. Circulation 2016
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Ross Reoperation
• N= 1779 adult patients (1990-2013) • 8 centers • Mean follow-up 8.3 years
Sievers et al. EJCTS 2015
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Freedom from Reoperation
1%/patient-year reoperation range
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Ann Transl Med, August 2017
JTCVS, September 2017
JACC, March 2018
JTCVS, September 2018
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PARADIGM CHANGE
ANTICOAGULATION VS. REOPERATION
SURVIVAL + QUALITY OF LIFE
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ICM
-01-
01-2
01
2-0
8
SIMILAR OPERATIVE RISK
BETTER FREEDOM FROM VALVE-RELATED COMPLICATIONS
BETTER HEMODYNAMICS
EXCELLENT QUALITY OF LIFE
RESTORED LATE SURVIVAL
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CONCLUSION
• YOUNG ADULTS = The choice of prosthesis has a direct impact on long-term prognosis
• CONVENTIONAL AVR IN THE YOUNG = Excess long-
term mortality versus general population
• ROSS PROCEDURE = Improved long-term survival and quality of life in selected patients
• IN PATIENTS WITH NON-REPAIRABLE AI, a tailored Ross procedure = Improved durability