J Thorac Cardiovasc Surg 2008;136:538-539
© 2008 The American Association for Thoracic Surgery
The present and the future in aortic stenosis management: Are there factors that might preclude surgery?
Tomaso Bottio, MD, PhD
Cardiovascular Institute, University of Padua Medical School, Padua, Italy
To the Editor:
I read with great interest the article by Bertrand Marcheix and associates.1
I congratulate them for this well-designed study, but I also wish to add some brief comments. The aim was to determine the impact of less-invasive techniques for treatment of high-risk patients with aortic valve disease by using a self-expandable aortic bioprosthesis (CoreValve Inc, Paris, France) suitable for percutaneous retrograde delivery. The mean logistic EuroSCORE was 32%. Of 10 patients undergoing successful implants, 2 died within 30 days and a third died later, for an overall 30% hospital mortality. Vascular complications were observed in 5 patients. Mean intensive care unit stay was 4.6 days and hospital stay was 15 days. The authors concluded that the technique is a viable alternative in selected high-risk patients.
With the aim of reducing surgical invasiveness, epidural anesthesia, maintaining an autonomic ventilation, has been suggested,2 and the outcomes of 30 consecutive patients who underwent epidural awake aortic valve surgery (47% female, mean age 78.1% ± 8, 20% multivessel coronary disease, mean Logistic-EuroScore 28.3) have been presented at the European Association for Cardio-thoracic Surgery meeting in Geneva. One patient had a redo operation. Associated surgical procedures included coronary artery bypass grafting (17%), ascending aorta replacement (10%), mitral valve surgery (10%), and pulmonary vein isolation to treat atrial fibrillation. Unless emergency, no other exclusion criteria were considered. One patient died, for an operative mortality of 3%, and 2 patients died during the follow-up period (natural death). All other complications occurred rarely (stroke, no cases; bowel ischemia, no cases; prolonged mechanical ventilation, 2 cases; myocardial infarction, 1 case). Median stays in the ward and the intensive care unit were 4.5 days and 1 day, respectively. Seven patients have been transferred to the ward within 3 hours after surgery and 19 patients in 12 hours or less.
The goal of aortic valve stenosis treatment is to achieve a complete regression of symptoms while offering the lowest morbidity and mortality. The main reason that percutaneous interventions are more acceptable to the patients is the simplicity. Unfortunately, interventional cardiologists and cardiac surgeons are going to rethink the management of high-risk aortic stenosis1,3,4 without a well-founded clinical program and forgetting the patients' and economic community interests. For instance, in the series reported by Webb and colleagues,4 72% had coronary artery disease. No data describe how these patients have been managed. Furthermore, a long series of exclusion criteria precluded the percutaneous aortic valve implantation in this and other series,3,4 although the implantation of a percutaneous prosthesis is initially considered in patients with absolute surgical contraindications. Nevertheless, in the experience reported by Webb and associates,4 a patient had been successfully converted to surgery. By using epidural anesthesia, my colleagues and I2 did not add any cost, and we greatly reduced the need for intensive care unit management. On the other hand, considering that the percutaneous prostheses are sold at a cost 10-fold higher than a standard bioprostheses, and considering the early 30-day results of percutaneous implantation,1,3,4 we maintain that surgery at the moment is to be preferred over a percutaneous approach. On the contrary, we believe that currently there are no factors that might preclude surgery for any patient. Instead of finding a way to replace surgical therapy, percutaneous approaches should be used as an adjunct to surgery, to support it in its current limitations, such as being used to replace deteriorating bioprostheses and avoiding the complications related to repeated heart dissections.5
References
- Marcheix B, Lamarche Y, Berry C, Asgar A, Laborde JC, et al. Surgical aspects of endovascular retrograde implantation of the aortic CoreValve bioprosthesis in high-risk older patients with severe symptomatic aortic stenosis. J Thorac Cardiovasc Surg 2007;134:1150-1156.[Abstract/Free Full Text]
- Bottio T, Bisleri G, Piccoli P, Negri A, Manzato A, Muneretto C. Heart valve surgery in a very high risk population: a preliminary experience in awake patients. J Heart Valve Dis 2007;16:187-194.[Medline]
- Grube E, Schuler G, Buellesfeld L, Gerckens U, Linke A, Wenaweser P, et al. Percutaneous aortic valve replacement for severe aortic stenosis in high risk patients using the second and current third generation self expanding CoreValve prosthesis. J Am Coll Cardiol 2007;50:69-76.[Abstract/Free Full Text]
- Webb JG, Pasupati S, Humphries K, Thompson C, Altwegg L, Moss R, et al. Percutaneous transarterial aortic valve replacement in selected high-risk patients with aortic stenosis. Circulation 2007;116:755-763.[Abstract/Free Full Text]
- Zegdi R, Khabbaz Z, Borenstein N, Fabiani JN. A repositionable valved stent for endovascular treatment of deteriorated bioprostheses. J Am Coll Cardiol 2006;48:1365-1368.[Abstract/Free Full Text]
