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Long-Term Outcomes Post-SAVR
Study Questions:
What are the long-term outcomes of a contemporary cohort of consecutive unselected surgical aortic valve replacement (SAVR) recipients?
Methods:
The investigators included a total of 672 consecutive patients (mean age 72 ± 8 years, 61% male) undergoing SAVR with a bioprosthesis between 2002 and 2004. Baseline and follow-up data were prospectively collected in a dedicated database. Baseline postoperative echocardiography was obtained in the 625 patients alive at hospital discharge, and in 209 patients at 10 years (87% of the patients at risk). Structural valve degeneration (SVD) was defined as subclinical (increase >10 mm Hg in mean transvalvular gradient + decrease >0.3 cm2 in valve area, and/or new-onset mild or moderate aortic regurgitation), and clinically relevant (increase >20 mm Hg in mean transvalvular gradient + decrease >0.6 cm2 in valve area, and/or new-onset moderate-to-severe aortic regurgitation). Univariable and multivariable Cox proportional hazard models were used to identify the factors associated with mortality, cardiac mortality, and SVD.
Results:
At a median follow-up of 10 (interquartile range 5-13) years, 432 patients (64.3%) had died. Older age, left ventricular dysfunction, atrial fibrillation, chronic obstructive pulmonary disease (COPD), greater body mass index [BMI], and diabetes mellitus were associated with an increased mortality risk (p < 0.05 for all). Clinically relevant SVD occurred in 6.6% of patients, whereas 29.9% of patients had subclinical SVD. A greater BMI and the use of a specific aortic pericardial valve were independently associated with clinically relevant SVD (p < 0.01 for both), and 83% of these patients underwent aortic valve reintervention (valve-in-valve TAVR in 44% of them).
Conclusions:
The authors concluded that the 10-year mortality rate in elderly SAVR recipients of a bioprosthetic valve was considerable, chiefly determined by their older age and the presence of comorbidities.
Perspective:
This contemporary patient series reporting on the 10-year outcomes of consecutive unselected patients undergoing SAVR with a bioprosthetic valve in the pre-TAVR era showed that close to two thirds of valve recipients had died at 10-year follow-up, with increasing age, cardiac (low left ventricular ejection fraction, atrial fibrillation), and noncardiac (larger BMI, diabetes, COPD) comorbidities driving this heightened mortality risk. However, most deaths (65%) were not cardiovascular-related. Clinically relevant SVD occurred in 6.6% of patients during the study period, whereas close to one third of patients had subclinical hemodynamic changes at 10-year follow-up echocardiogram consistent with subclinical SVD. These data highlight the importance of both appropriate patient evaluation/selection and a systematic follow-up of these patients, particularly those at increased risk due to the presence of comorbidities. The results of this study should also be factored in when evaluating late clinical outcomes and valve durability issues following TAVR.
Keywords: Aortic Valve Insufficiency, Atrial Fibrillation, Bioprosthesis, Body Mass Index, Cardiac Surgical Procedures, Comorbidity, Diabetes Mellitus, Echocardiography, Geriatrics, Heart Valve Diseases, Pulmonary Disease, Chronic Obstructive, Risk Assessment, Secondary Prevention, Transcatheter Aortic Valve Replacement, Ventricular Dysfunction, Left
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