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Bioprosthetic Aortic Valve Structural Valve Deterioration
Study Questions:
What are the rate, timing, and predictors of echo/Doppler-defined hemodynamic valve deterioration (HVD) after surgical bioprosthetic aortic valve replacement (AVR), and how does HVD influence outcomes?
Methods:
A total of 1,387 patients (62.2% male; 70.5 ± 7.8 years) who underwent bioprosthetic AVR were included in a retrospective study. Baseline echocardiography was performed at a median time of 4.1 (1.3-6.5) months after AVR. All patients had echocardiographic follow-up ≥2 years after AVR (926 ≥5 years, and 385 ≥10 years). HVD was defined by Doppler assessment as a ≥10 mm Hg increase in mean gradient and/or a worsening of transprosthetic regurgitation ≥1 of 3 classes. HVD was classified according to the timing after AVR: “very early” (during the first 2 years), “early” (between 2 and 5 years), “mid-term” (between 5 and 10 years), and “long-term” (>10 years).
Results:
A total of 428 patients (30.9%) developed HVD. Among these, 52 (12.0%) were “very early,” 129 (30.1%) “early,” 158 (36.9%) “mid-term,” and 89 (20.8%) “long-term.” Factors independently associated with HVD occurring within the first 5 years after AVR were diabetes (p = 0.01), active smoking (p = 0.01), renal insufficiency (p = 0.01), baseline postoperative mean gradient ≥15 mm Hg (p = 0.04) or transprosthetic regurgitation ≥ mild (p = 0.04), and stented (vs. stentless) bioprosthesis (p = 0.003). Factors associated with HVD occurring >5 years after AVR were female sex (p = 0.03), warfarin use (p = 0.007), and stented (vs. stentless) bioprosthesis (p < 0.001). HVD was independently associated with mortality (hazard ratio, 2.18; 95% confidence interval, 1.86-2.57; p < 0.001).
Conclusions:
HVD identified by echo/Doppler occurred in one-third of patients after bioprosthetic AVR, and was associated with a 2.2-fold higher adjusted mortality. Diabetes and renal insufficiency were associated with early HVD; whereas female sex, warfarin use, and stented (vs. stentless) bioprostheses were associated with late HVD.
Perspective:
Structural valve deterioration after bioprosthetic AVR often is reported as the rate of reoperation. However, other factors (including advanced patient age) also affect reoperation rates. This large, single-center, retrospective review suggests that the true (echo/Doppler-defined) rate of HVD is relatively high and associated with excess mortality; and identifies correlates of valve deterioration including diabetes, renal disease, female sex, warfarin use, and stented (vs. stentless) bioprostheses.
Clinical Topics: Anticoagulation Management, Cardiac Surgery, Geriatric Cardiology, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and VHD, Interventions and Imaging, Interventions and Structural Heart Disease, Echocardiography/Ultrasound, Smoking
Keywords: Aortic Valve, Bioprosthesis, Cardiac Surgical Procedures, Diabetes Mellitus, Diagnostic Imaging, Echocardiography, Geriatrics, Heart Valve Diseases, Heart Valve Prosthesis, Hemodynamics, Renal Insufficiency, Stents, Smoking, Warfarin
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