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Valve repair with annulus stabilization improves outcomes for aortic valve regurgitation
Patients with aortic valve regurgitation who underwent valve repair with annulus stabilization procedures in addition to novel cusp procedures had improved outcomes compared with those who underwent cusp procedures alone, according to a study published in the Annals of Thoracic Surgery.
“Part of the issue is that there are very few centers that will even attempt aortic valve repair in patients with leaking aortic valves, which is unfortunate because our results show that the results can be very good,” Lars G. Svensson, MD, PhD, chairman of the Heart & Vascular Institute at Cleveland Clinic, told Cardiology Today. “In young patients, that means that they don’t have to have a mechanical valve with a risk related to bleeding with [warfarin].”
Aortic valve repair
The Cleveland Clinic team analyzed data from 1,124 patients (mean age, 51 years; 73% men) who planned to undergo aortic valve repair from 2001 to January 2011. Those who underwent an emergency operation or tumor excision, had a prior cardiac operation or had endocarditis were excluded.
Most patients had aortic regurgitation (75%), followed by stenosis (6%) and both aortic regurgitation and stenosis (3.4%). The other 15% of patients had other indications, including fibroelastoma and cusp fenestration.
Various valve repair methods were used.
The primary endpoints were time to aortic valve reoperation and immediate repair failure, which was defined as a planned repair that then required a replacement. Secondary endpoints were death and in-hospital mortality, left ventricular mass regression and function, time course of postoperative aortic regurgitation, aortic valve mean gradient and time-related mortality.
Patients were followed up for a median of 2.9 years by telephone interviews and mailed surveys. Thoracic echocardiograms were performed routinely throughout follow-up.
Of the planned aortic valve repairs, 10% of patients were converted to valve replacement prior to repair attempt due to risk factors, including a greater severity of valve calcification (P < .0001) and aortic regurgitation (P = .0002).
In-hospital death occurred in 1.2% of patients, 1.4% of patients required reoperation for valve dysfunction and 1.3% of patients had a stroke.
Freedom from aortic valve reoperation was 98% at 1 month, 93% at 5 years and 90% at 10 years.
Improved surgical techniques
Patients who underwent repair using annular support procedures (P = .04) and figure-of-eight commissural suspension sutures (P < .08) were less likely to undergo reoperation compared with other techniques. A higher risk for reoperation was associated with plication (P = .0004), commissuroplasty (P = .0001) and commissural suture repair (P = .0002).
Survival was 99% at 1 month, 96% at 1 year, 92% at 5 years and 83% at 10 years.
After repair, 79% of patients had no aortic regurgitation, 15% had a mild case, 5% were moderate and 1% had severe aortic regurgitation. At 10 years, 20% of patients did not have aortic regurgitation and 21% were severe.
Patients who underwent root procedures had a decreased risk for higher-grade postoperative aortic regurgitation (P < .0001).
“What we’re working on now is a challenge of doing these procedures remotely,” Svensson told Cardiology Today. “Percutaneous aortic valves, TAVR, have already taken over in a big way, treating patients with aortic valve stenosis, in particular high risk and older patients. We were involved in the original research on those valves and it’s been successful, but we don’t have a valve that has already worked for patients with aortic valve regurgitation. The next step will be to work on techniques for aortic valve repairs percutaneously, and we have some ideas on how to do that.” – by Darlene Dobkowski
For more information:
Lars G. Svensson, MD, PhD, can be reached at Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Ave., Desk J4-1, Cleveland, OH 44195; email: svenssl@ccf.org.
Disclosures: Svensson reports he is an unpaid member of the executive committee for the PARTNER I and II trials, chairman of the PARTNER Publication Committee and an unpaid member of the executive committee of the COMMENCE trial, which is sponsored by Edwards Lifesciences. The other authors report no relevant financial disclosures.