Aortic valve

Ross Procedure Best for Fixing Aortic Valve in Younger Patients?

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Propensity-matched analysis may suggest it’s time for “Ross Centers of Excellence”

A medical illustration of the Ross Procedure

The Ross procedure was associated with a “striking” survival advantage over bioprosthetic aortic valve replacement (AVR) surgery for young and middle-age adults in a propensity-matched analysis.

Over a mean 14.5 years of follow-up among a cohort of consecutive patients getting either procedure, Ross recipients had a hazard ratio of 0.35 for all-cause mortality (95% CI 0.14-0.90) compared with patients who underwent bioprosthetic AVR, with seven (6.5%) versus 21 deaths (19.4%), respectively.

At 20 years, the difference remained significant (9.6% vs 25.1%, P=0.028), Maral Ouzounian, MD, PhD, of the University of Toronto, and colleagues reported in the Journal of the American College of Cardiology.

Other outcomes that also significantly favored the Ross procedure in the 108 matched pairs of patients in an analysis with death considered as a competing risk were:

  • Reintervention (HR 0.21, 95% CI 0.10-0.41)
  • Valve deterioration (HR 0.25, 95% CI 0.14-0.45)
  • Thromboembolic events (HR 0.15, 95% CI 0.05-0.50)
  • Permanent pacemaker implantation (HR 0.22, 95% CI 0.07-0.64)

Bicuspid aortic valve was present in 75% of patients, and aortic stenosis was the indication for 49%. Median age was 41 years, with a range from 17 to 59. Exclusion criteria included active endocarditis, acute aortic dissection, end-stage renal disease, and emergency surgery.

Prior series had also suggested a benefit to the Ross procedure in restoring normal life expectancy to young and middle-age adults, which bioprosthetic AVR doesn’t do in this population. Similar propensity-matched results also showed superior survival with the Ross procedure compared with mechanical valve implantation.

“However, patients in the Ross series tend to be carefully selected,” Ouzounian’s group noted. “Some have argued that the excellent long-term outcomes observed in these cohorts may be related to favorable patient characteristics rather than the operation itself.”

While the propensity score matching in the study couldn’t rule out unmeasured confounding, the two groups yielded comparable cohorts who were “young, generally healthy, and presented a low surgical risk.”

“If these findings are reproduced in other specialized centers with sufficient expertise, the Ross procedure may be considered the preferred option for selected young and middle-aged adults undergoing AVR,” the researchers concluded.

However, an accompanying editorial noted that “these findings are remarkable in their magnitude but should again be interpreted with caution.”

Direct comparisons at other centers are needed in particular because a single expert surgeon did all of the Ross procedures and most of the rest in Ouzounian’s study, which “limits the external validity of the results for nonexperts in aortic root reconstructive surgery,” wrote Ismail El-Hamamsy, MD, PhD, of the Icahn School of Medicine at Mount Sinai in New York City.

Still, such a large survival benefit “is more likely a reflection of the fundamental differences in biology and hemodynamics between the pulmonary autograft and a prosthetic valve” than experience or patient selection, they argued.

Because it’s a more complex procedure for which the special surgical skill and experience are limited, perhaps the time has come for “Ross Centers of Excellence,” based on publicly reported case volumes, operative mortality, and so on, they added.

“Cardiologists will play an important role in expanding the accessibility to the Ross procedure, by appropriate referral to selected surgeons in their center or region so Ross experience can be concentrated, while patient safety remains the foremost concern,” El-Hamamsy’s group continued. “In this era of large data collection, patients deserve no less than to know the scientific community is transparent, and importantly, dedicated to their safety, health, and wellness.”

Warfarin plus Aspirin After Aortic Valve Prosthesis Placement?

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An observational study suggests that the combination reduces mortality, at the cost of increased bleeding, when used in the 3 months after surgery.

Patients receiving an aortic bioprosthesis have a low overall risk for thromboembolism, but controversy surrounds whether they benefit from anticoagulation in the first months after surgery. To address this issue, researchers used the Society of Thoracic Surgeons Adult Cardiac Surgery Database to compare the effectiveness of the early use of aspirin alone, aspirin plus warfarin, and warfarin alone.

The sample included 25,656 patients aged 65 (median age, 77; 39% women) who received an isolated aortic valve prosthesis at 797 hospitals from 2004 through 2006. At 3 months, the mortality rate was 3.0% in the aspirin-only group, 3.1% in the aspirin-plus-warfarin group, and 4.0% in the warfarin-only group. In the multivariable analysis, the addition of warfarin to aspirin was associated with a 20% relative reduction in risk for death (0.6% absolute risk reduction). Mortality with warfarin alone was no different than with aspirin alone. The addition of warfarin to aspirin was associated with 48% relative reduction in the risk for embolic events (0.4% absolute risk reduction). Again, warfarin alone was not associated with a reduction. Bleeding was more common in patients treated with warfarin plus aspirin than in those treated with aspirin only or warfarin only (2.8% vs. 1.0% and 1.4%, respectively).

Comment: Absolute risks for death and embolic events are low in the 3 months after the placement of an aortic valve bioprosthesis, but the addition of warfarin to aspirin provided additional risk reduction in this observational study, at the cost of more bleeding. The authors recommend warfarin plus aspirin for those at low risk for bleeding, and I agree — we ought to be personalizing treatment based on the bleeding risk.

Source: Journal Watch Cardiology

Can We Predict the Site of Entry Tear by Computed Tomography in Patients With Acute Type A Aortic Dissection?

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In patients with acute type A aortic dissection (AAD), localization of the primary entry tear to be excluded is of major importance for intervention.

Hypothesis:

There are reliable indirect computed tomography (CT) findings to predict the entry site.

Methods:

In 83 patients with type A AAD whose primary entry tears were identified surgically between 2003 and 2009, we retrospectively examined the diagnostic CT scans regarding pericardial effusion, the largest short-axial diameter of the aorta, widths of true and false lumens, and false lumen thrombosis at 6 levels of thoracic aorta from the aortic root to the descending aorta.

Results:

The primary entry sites identified intraoperatively were proximal ascending in 21 patients, middle ascending in 21, distal ascending in 21, arch in 17, and descending or unknown in 16. The multivariate logistic analysis revealed that pericardial effusion (odds ratio [OR]: 2.2, 95% confidence interval [CI]: 1.2–3.4, P < 0.001) and dilated ascending aorta (OR: 1.6, 95% CI: 1.1–2.4, P = 0.012) were the significant CT findings to predict the entry tear in the ascending aorta. It also revealed that the significant CT finding to predict the entry tear distal to the aortic arch was nonthrombosed false lumen in the descending aorta (OR: 1.2, 95% CI: 1.1–2.1, P = 0.048).

Conclusions:

We can predict the primary entry site by the preoperative CT findings in patients with type A AAD, considering pericardial effusion, aortic diameter, widths of true and false lumens, and false lumen thrombosis at different anatomic levels.

Source: http://onlinelibrary.wiley.com