Anton Moritz

Department of Cardiothoracic Surgery University of Frankfurt

11.11.2018

Long Term Survival after Valve Replacement

Long term survival after Rossor AVR mechanical compared to normal life expectancy

Martin Andreas et al. Eur J Cardiothorac Surg 2014;46:409-414

© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Autograft

Mechanical protheses

Scharfschwerdt M Ann Th Surg 2007

dgthg 2011, Stuttgart

Seebacher et al.

Re OP’s autograft n= 100

Mean follow up period 13 a

4 re OP‘s in 1147 ptyrs (0.35%/yr)

Re OP’s RVOT

7 patients intervention on homograft (7,7%)

0.8%/yr

Brown JW Ann Th Surg 2008

Dearani JA, Ann Th Surg 2003

RVOT after Ross

RVOT after Congenital Surgery

Homografts show good durability

but develop gradients.

Bioprosthetic replacement an

option ?

Survival free of reop n=1065

19%

45%

Proximal RVOT

strictures developed

Perikardsleeve

solves the proximal

but aggravates the

distal problem

911.11.2018 Text durch klicken bearbeiten

Freedom from neopulmonary valve failure

after 5 years: 97% in homografts versus 73% in bioprosthesis

Incidence rate:

1:80 pat. year

in homografts

versus

1:14 pat.year

in xenografts.

p<0,00010 2 4 6 8 10 12 14 16

10

20

30

40

50

60

70

80

90

100

Time (years)

Fre

ed

om

of

ne

op

ulm

on

ary

va

lve

fa

ilure

(%

)

Number at risk

Group: Homograft

113 102 94 83 58 40 24 18 3

Group: Bioprosthesis

87 50 30 12 4 3 2 2 0

logrank test: p<0.0001

Hazard Ratio: 6.1

(95% CI 2.5 - 14.5)

Bioprosthesis

Homograft

4/193

Aorta

non coronary leaflet

conjoined leaflet

left ventricle

Durchmesser Aorta ascendens

33 33

32

34

3132

33

38 3737

39

37 37 37

20

25

30

35

40

45

50

Gesamtkollektiv Bikuspid Trikuspid Insuffizienz Kombiniert Stenose Aortenraffung

mm

Entlassungsuntersuchung Letzte Follow up Untersuchung

Das

Autografts at Reoperation

18 Reoperations on AG, but only 6 valve replacements

9 embolic events related to a-fib (0,54% / pt yr)

9 events of endocarditis (0,54% / pt yr)

No ACH related bleeding or valve thrombosis

Long Term Complications

Valve-related complications

EventMechanical valve (n =

173)Ross procedure (n = 159) P-value

Stroke 5.8% (1.02%/pt yr) 0.6% (0.06%) <0.01

TIA 1.7% (0.25%) 0% (0%) 0.07

Valve thrombosis 0.6% (0.08%) /1,35% 0% (0%) / 0.06% 0.30

Endocarditis 5.2% (0.76%) 3.8% (0.38%) 0.32

Bleeding 10.4% (1.95%) 0.6% (0.06%) <0.01

Reintervention 5.8% (0.85%) 12.6% (1.27%) 0.05

Long Term Survival

Sievers H.

Miskovic et al EACTS 2014

Ross vs mech randomisiert

Mortality 10 vs 40%

Bleeding 0 vs 25%

Reoperation 15 vs 5%

Seebacher Vienna 13 a

Projekt / Datum / Name

Summary

When respecting certain technical principles the Ross

procedure provides excellent and stable hemodynamics

in the long term.

Valve related complications are reduced to reoperations

and which are due to conceptual problems in majority.

Degenerations are rare – AG provides a durable biologic

valve.

RVOT replacement is a possible long term problem but

might be cured percutaneousely in the future.

Normal long term survival appears to be the major asset

of this technically demanding procedure.

Reop oder AI III

Böhm JO.

AnnThSurg 2009

Reoperationen

Regression of left ventricular

hypertrophy

0

0.5

1

1.5

2

2.5

implant 1 year 10 years

inte

rven

tric

ula

r sep

tum

in

cm

Interventricular SeptumMean gradient in mmHg

Mortality

Long term n=2 (10%) n=8 (40%)

Valve related n= 1 n= 5

bleeding n=0 n=5 (25%)

thromboembolism n=1 n=1

Reoperation n=3 (15%) n=1 (5%)

Effect of WrapWrap N= ASC.events yrs to event FU

no 33 9 13.9 10,3

Vicryl_Mesh 85 17 13,6 6.9

Vypro_Mesh 49 4 8.1 8.4

David 26 0 1.1

Total 193 30 13.3 7.22

Dilatation or Reoperation

PK_Event = entweder Reintervention oder PS>50mmHg oder PI>II

Häufigkeit Prozent

direkte Naht nein 43 74,1ja(ReOP oder sign Dysf) 15 25,9

Gesamtsumme 58 100,0

Plus Pach/Sleeve nein 34 89,5

ja(ReOP oder sign Dysf) 4 10,5Gesamtsumme 38 100,0

Statistik nur für Bioprothesen

Reintervention an der Bioprothese in Pulmonalklappenposition

Häufigkeit Prozent

direkte Naht nein 45 77,6

ja 13 22,4

Gesamtsumme 58 100,0

Plus Pach/Sleeve nein 36 94,7

ja 2 5,3

Gesamtsumme 38 100,0

Survival

0 2 4 6 8 10 12 14 16 18 20

0

10

20

30

40

50

60

70

80

90

100

Time

Su

rviv

al p

rob

ab

ilit

y (

%)

Number at risk

Group: Wien

95 92 90 88 84 82 63 42 26 11 1

Group: Frankfurt

204 178 156 124 102 79 48 35 8 0 0

Location

Wien

Frankfurt

Logrank test :P = 0,15

Projekt / Datum / Name

RVOT Reinterventions

Projekt / Datum / Name

Reoperations Aorta

Projekt / Datum / Name

All Reinterventions

221 165 114 56 19

60% event free

at 18 years

Projekt / Datum / Name

Optimized Reinterventions

89% event free

at 18 yrs

With current knowledge avoidable

reinterventions excluded:

RVOT strictures, pseudoaneurysms and

aortic dilatations

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Outcome Reintervention

Total

(n=205)

Homograft

(n=113)

Xenograft

(n= 92)

Signific.

Time to redo (y)

(± SD)

6.4 years

(± 4.8)

9.6 years

(± 4.8)

4.5 years

(±3.9)

p=0.003

Reintervention 24 9 15 n.s.

Reoperation 10 7 3

Perc. Procedure 14 2 12 p=0.005

Balloon dilatation in 10, Melody implantation in 4

Re-reintervention 6 2 4 n.s.

Balloon dilatation in 2, Melody implantation in 4

Main Finding

Stricture 11 2 9 p=0.03

Degeneration 8 3 5

Endocarditis 5 4 1

3411.11.2018 Text durch klicken bearbeiten

Event at the neopulmonary valve in Bioprosthesis

Reintervention or PS (>50mmHG)

5

16

33

45

0% 20% 40% 60% 80% 100%

plus pericardial sleeve

without pericardial sleeve

Event

no Event

Reoperation of the Pulmonary Autograft

0 2 4 6 8 10 12 14 16 18 20

0

10

20

30

40

50

60

70

80

90

100

Time

Re

op

era

tio

n p

rob

ab

ilit

y (

%)

Number at risk

Group: Wien

99 90 89 86 81 79 61 40 22 8 1

Group: Frankfurt

211 169 142 113 91 68 42 29 4 0 0

Location

Wien

Frankfurt

Logrank test :P = 0,12