Meeting News

Surgical AVR may confer improved outcomes for young, middle-aged patients vs. TAVR

Jennifer S. Nelson

The use of transcatheter aortic valve replacement has increased for young and middle-aged patients with aortic valve disease, but surgical AVR may be the best option for this patient population, according to data presented at The Society of Thoracic Surgeons Annual Meeting and Exhibition.

“Valve utilization is evolving,” Jennifer S. Nelson, MD, MS, cardiothoracic surgeon in the division of cardiovascular surgery at Nemours Children’s Health System in Orlando and associate professor of surgery at the University of Central Florida College of Medicine in Orlando, said during a press conference. “The majority of young and middle-aged adults received bioprosthetic valves, and bioprosthetic valve use is increasing. TAVR use in this population is rare, but it’s also increasing.”

STS databases

Researchers analyzed data from 45,753 patients aged 18 to 55 years who underwent surgical AVR or TAVR between 2013 and 2018. Data were obtained from the STS Adult Cardiac Surgery Database (n = 44,173) or the STS Congenital Heart Surgery Database (n = 1,580).

Outcomes of interest were 30-day mortality and morbidity, defined as renal failure, persistent neurological deficit, readmission within 30 days and reoperation for any reason.

Women comprised 29% of patients who underwent noncongenital heart surgery and 31% of those who underwent congenital heart surgery. Compared with patients who underwent noncongenital heart surgery, those who underwent congenital heart surgery were typically younger (median age, 43 vs. 48 years) and were more likely to undergo a prior sternotomy (30% vs. 15%).

Bioprosthetic valve use increased by 54% from 2013 to 2017, whereas the use of mechanical valves was stable during this time. TAVR use increased by 167%. Of the patients in the entire cohort, 46% had an isolated AVR, 12% had concomitant CABG and 5.5% had concomitant annular enlargement.

The 30-day mortality rate for the overall cohort was 3.6%. The highest mortality rates were seen in patients who received homografts (9.6%). The lowest mortality rate was seen in patients who received autografts. TAVR mortality was 3.8%.

Isolated AVRs had lower mortality and morbidity rates compared with all AVR procedures. Similar patterns were noted for patients who underwent congenital heart surgery vs. those who did not, except for those who underwent TAVR, for which a higher morbidity rate was seen for those who underwent congenital heart surgery.

Nonmechanical valve types were linked to a 1.2-fold increase in mortality compared with all other valve types including TAVR (OR = 1.212; 95% CI, 1.08-1.36). Bioprosthetic valve types (OR = 0.921; 95% CI, 0.876-0.968) and large implanted valve sizes (OR = 0.962; 95% CI, 0.953-0.972) were protective for morbidity. After adjusting for multivariable risk factors, homograft valve types were also protective (OR = 0.697; 95% CI, 0.56-0.868).

“This potentially validates some of the strategies we’re using now to salvage our emergency situations and manage patients with endocarditis,” Nelson said during the press conference.

Calls to action

Nelson ended her presentation with some future directions for this area.

“In this population, a prospective trial is needed to refine optimal patient selection and to help us match patients to their most appropriate valve type,” she said. “In the meantime, we’ll continue to work on harmonizing variables within the STS databases and establishing more clear criteria to define what is adult congenital heart disease. We also think it’s important to study factors that are at the center or hospital level such as the case volume that’s done there, the type of hospital system, freestanding children’s hospital vs. academic medical center and surgeon experience.” – by Darlene Dobkowski

Reference:

Nelson JS. J. Maxwell Chamberlain Memorial Paper for Congenital Heart Surgery. Presented at: The Society of Thoracic Surgeons Annual Meeting and Exhibition; Jan. 25-28, 2020; New Orleans.

Disclosure: Nelson reports no relevant financial disclosures.

Editor’s Note: This article was updated on Feb. 5, 2020 to remove data regarding the Ozaki procedure at the request of Dr. Nelson.

Jennifer S. Nelson

The use of transcatheter aortic valve replacement has increased for young and middle-aged patients with aortic valve disease, but surgical AVR may be the best option for this patient population, according to data presented at The Society of Thoracic Surgeons Annual Meeting and Exhibition.

“Valve utilization is evolving,” Jennifer S. Nelson, MD, MS, cardiothoracic surgeon in the division of cardiovascular surgery at Nemours Children’s Health System in Orlando and associate professor of surgery at the University of Central Florida College of Medicine in Orlando, said during a press conference. “The majority of young and middle-aged adults received bioprosthetic valves, and bioprosthetic valve use is increasing. TAVR use in this population is rare, but it’s also increasing.”

STS databases

Researchers analyzed data from 45,753 patients aged 18 to 55 years who underwent surgical AVR or TAVR between 2013 and 2018. Data were obtained from the STS Adult Cardiac Surgery Database (n = 44,173) or the STS Congenital Heart Surgery Database (n = 1,580).

Outcomes of interest were 30-day mortality and morbidity, defined as renal failure, persistent neurological deficit, readmission within 30 days and reoperation for any reason.

Women comprised 29% of patients who underwent noncongenital heart surgery and 31% of those who underwent congenital heart surgery. Compared with patients who underwent noncongenital heart surgery, those who underwent congenital heart surgery were typically younger (median age, 43 vs. 48 years) and were more likely to undergo a prior sternotomy (30% vs. 15%).

Bioprosthetic valve use increased by 54% from 2013 to 2017, whereas the use of mechanical valves was stable during this time. TAVR use increased by 167%. Of the patients in the entire cohort, 46% had an isolated AVR, 12% had concomitant CABG and 5.5% had concomitant annular enlargement.

The 30-day mortality rate for the overall cohort was 3.6%. The highest mortality rates were seen in patients who received homografts (9.6%). The lowest mortality rate was seen in patients who received autografts. TAVR mortality was 3.8%.

Isolated AVRs had lower mortality and morbidity rates compared with all AVR procedures. Similar patterns were noted for patients who underwent congenital heart surgery vs. those who did not, except for those who underwent TAVR, for which a higher morbidity rate was seen for those who underwent congenital heart surgery.

Nonmechanical valve types were linked to a 1.2-fold increase in mortality compared with all other valve types including TAVR (OR = 1.212; 95% CI, 1.08-1.36). Bioprosthetic valve types (OR = 0.921; 95% CI, 0.876-0.968) and large implanted valve sizes (OR = 0.962; 95% CI, 0.953-0.972) were protective for morbidity. After adjusting for multivariable risk factors, homograft valve types were also protective (OR = 0.697; 95% CI, 0.56-0.868).

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“This potentially validates some of the strategies we’re using now to salvage our emergency situations and manage patients with endocarditis,” Nelson said during the press conference.

Calls to action

Nelson ended her presentation with some future directions for this area.

“In this population, a prospective trial is needed to refine optimal patient selection and to help us match patients to their most appropriate valve type,” she said. “In the meantime, we’ll continue to work on harmonizing variables within the STS databases and establishing more clear criteria to define what is adult congenital heart disease. We also think it’s important to study factors that are at the center or hospital level such as the case volume that’s done there, the type of hospital system, freestanding children’s hospital vs. academic medical center and surgeon experience.” – by Darlene Dobkowski

Reference:

Nelson JS. J. Maxwell Chamberlain Memorial Paper for Congenital Heart Surgery. Presented at: The Society of Thoracic Surgeons Annual Meeting and Exhibition; Jan. 25-28, 2020; New Orleans.

Disclosure: Nelson reports no relevant financial disclosures.

Editor’s Note: This article was updated on Feb. 5, 2020 to remove data regarding the Ozaki procedure at the request of Dr. Nelson.