Long-term outcomes after elective isolated mechanical aortic valve replacement in young adults

Bouhout, Ismail; Stevens, Louis–Mathieu; Mazine, Amine; Poirier, Nancy; Cartier, Raymond; Demers, Philippe; El-Hamamsy, Ismaı̈l

doi:10.1016/j.jtcvs.2013.10.064

Cited by 126 publications

(116 citation statements)

References 25 publications

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“…However, this finding may not be specific to the use of a bioprosthesis. In fact, Bouhout and colleagues [11] reported a similar finding in a series of patients younger than 65 years undergoing mechanical AVR. Hypotheses included poor timing of intervention, establishment of left ventricular dysfunction before intervention, or suboptimal hemodynamic performance of the aortic prostheses.…”

Section: Survivalmentioning

confidence: 57%

Very Long-Term Outcomes of the Carpentier-Edwards Perimount Aortic Valve in Patients Aged 60 or Younger

Bourguignon

Khoury

Candolfi

et al. 2015

The Annals of Thoracic Surgery

110

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Section: Survivalmentioning

confidence: 57%

Very Long-Term Outcomes of the Carpentier-Edwards Perimount Aortic Valve in Patients Aged 60 or Younger

Bourguignon

Khoury

Candolfi

et al. 2015

The Annals of Thoracic Surgery

110

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“…Freedom from valverelated reintervention after mechanical AVR has been reported to be between 93% and 99% at 10 years. 1,2,[22][23][24][25][26] In contrast, the risk of reintervention after the Ross pro- AVR indicates aortic valve replacement; and CI, confidence interval. *In the Ross group, this includes any percutaneous or surgical reintervention on the pulmonary autograft and/or pulmonary homograft.…”

Section: Reinterventionmentioning

confidence: 99%

“…However, recent reports suggest an excess in long-term mortality in young patients who undergo mechanical AVR compared with the age-and sex-matched general population. 1,2 In addition, for female patients of childbearing age, mechanical prostheses are associated with an increased risk of thromboembolic events and warfarin-associated fetal malformations. 3,4 The Ross procedure (pulmonary autograft replacement) alleviates the need for lifelong anticoagulation.…”

mentioning

confidence: 99%

Long-Term Outcomes of the Ross Procedure Versus Mechanical Aortic Valve Replacement

et al. 2016

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BACKGROUND:The ideal aortic valve substitute in young and middle-aged adults remains unknown. We sought to compare the long-term outcomes of patients undergoing the Ross procedure and those receiving a mechanical aortic valve replacement (AVR). METHODS:From 1990 to 2014, 258 patients underwent a Ross procedure and 1444 had a mechanical AVR at a single institution. Patients were matched into 208 pairs through the use of a propensity score. Mean age was 37.2±10.2 years, and 63% were male. Mean follow-up was 14.2±6.5 years. RESULTS:Overall survival was equivalent (Ross versus AVR: hazard ratio, 0.91, 95% confidence interval, 0.38-2.16; P=0.83), although freedom from cardiac-and valve-related mortality was improved in the Ross group (Ross versus AVR: hazard ratio, 0.22; 95% confidence interval, 0.034-0.86; P=0.03). Freedom from reintervention was equivalent after both procedures (Ross versus AVR: hazard ratio, 1.86; 95% confidence interval, 0. 76-4.94; P=0.18). Long-term freedom from stroke or major bleeding was superior after the Ross procedure (Ross versus AVR: hazard ratio, 0.09; 95% confidence interval, 0.02-0.31; P<0.001).CONCLUSIONS: Long-term survival and freedom from reintervention were comparable between the Ross procedure and mechanical AVR. However, the Ross procedure was associated with improved freedom from cardiacand valve-related mortality and a significant reduction in the incidence of stroke and major bleeding. In specialized centers, the Ross procedure represents an excellent option and should be considered for young and middle-aged adults undergoing AVR. long-term Outcomes of the ross Procedure Versus Mechanical aortic Valve replacementPropensity-Matched cohort study © 2016 American Heart Association, Inc.Key Words: aortic valve ◼ propensity score ◼ surgery ◼ treatment outcome ORIGINAL RESEARCH ARTICLE 577 Y oung and middle-aged adults with diseased aortic valves constitute a challenging population. Because of their longer anticipated life expectancy, these patients present a higher cumulative lifetime risk of prosthesis-related complications. The ideal aortic valve substitute in this patient population should allow improved survival, avoidance of reoperation and prosthesis-related complications, and maintenance of an active lifestyle with a good quality of life.As a result of their proven durability and ease of implantation, mechanical prostheses have long been the most frequently used option for aortic valve replacement (AVR) in young and middle-aged adults. However, recent reports suggest an excess in long-term mortality in young patients who undergo mechanical AVR compared with the age-and sex-matched general population.1,2 In addition, for female patients of childbearing age, mechanical prostheses are associated with an increased risk of thromboembolic events and warfarin-associated fetal malformations. 3,4 The Ross procedure (pulmonary autograft replacement) alleviates the need for lifelong anticoagulation. It allows the replacement of the diseased aortic valve with a living substitute, 5 th...

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“…This may be partially explained by studies demonstrating excess mortality in patients undergoing mechanical aortic valve replacement [63] and more recently similar 15 year survival observed between bioprosthetic and mechanical valve replacement with the latter group having more bleeding complications [64]. Thus, the dreaded pitfalls associated with mechanical valve replacement may eventually be abated with the use (Table 3).…”

Section: Future Therapiesmentioning

confidence: 99%

Review of anticoagulation options for mechanical valve prosthesis

Toeg

Boodhwani

2015

Interventional Cardiology

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Clinical guidelines recommend lifelong oral anticoagulation (OAC) with warfarin in all patients with mechanical valves with variance in the target INR for patient associated risk factors, type of mechanical valve or implant position of the valve. Recent randomized controlled trials have demonstrated that clinicians may consider a lower OAC strategy (INR: 1.5-2.5) in low (thrombogenic) risk patients undergoing bileaflet mechanical valve replacement thereby achieving similar thromboprophylaxis yet minimizing bleeding events. Likewise, physicians may also consider a lowered OAC option in high (thrombogenic) risk patients undergoing bileaflet mechanical valve replacement yielding similar efficacy (avoidance of thromboembolic events) and improving safety (bleeding events). Finally, while advancement of novel oral anticoagulants (NOACs) has been swift in the realm of atrial fibrillation anticoagulation management, NOACs for mechanical valves are currently contraindicated due to evidence of increased thromboembolic and bleeding risk. Future studies comparing NOACs and warfarin along with newer mechanical valve construction are eagerly being awaited. a significant increased risk of major bleeding [16]. At mid-term follow-up, contemporary (2005+) incidence of thromboembolic events has been relatively low ranging from 0 to 3.6% [17,18]. With the advent of newer generation mechanical valves, there is potential for achieving even lower rates of thromboembolic and bleeding events with either less intense OAC, antiplatelet therapy alone or potentially novel OACs (NOAC). Therefore, this review is aimed at discussing current practice trends, novel strategies and future endeavors for postoperative t hromboprophylaxis for mechanical valves. Current practice for anticoagulationCurrent international guidelines generally recommend the following: low dose aspirin (74-100 mg) for all patients, OAC in mechanical aortic valves with target INR 2.0-3.0 at low-risk for thromboembolic events and OAC with target INR 2.5-3.5 in mechanical mitral valves and high-risk aortic valve patients (Table 1) [12][13][19][20]. High-risk patients are considered to be those with concomitant atrial fibrillation, previous thromboembolism, hypercoagulable state or depressed left ventricular function [21,22]. These recommendations have been partially based on older studies using more thrombogenic mechanical valves (i.e., StarrEdwards ball and cage, Bjork-Shiley tilting disc) [23][24][25] along with a landmark meta-analysis by Cannegieter and colleagues [20]. Moreover, based on Massel and Little's meta-analysis, the European guidelines advise caution with the addition of an antiplatelet medication due to the increased risk of bleeding with an odds ratio of 1.58 (95% CI: 1.14-2.18) [16,26]. Several groups have demonstrated similar effectiveness with reduced OAC therapy (compared with historically target INR of 3.0-4.5 in patients with bileaflet St. Jude Medical [St. Jude Medical, Inc., Saint Paul, MN, USA]) mechanical valves, mostly in the aortic position [21,27]...

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Long-term outcomes after elective isolated mechanical aortic valve replacement in young adults

Abstract: In young adults undergoing elective isolated mechanical AVR, survival remains suboptimal compared with an age- and gender-matched general population. Furthermore, there is a low but constant hazard of prosthetic valve reintervention after mechanical AVR.

Cited by 126 publications

References 25 publications

Very Long-Term Outcomes of the Carpentier-Edwards Perimount Aortic Valve in Patients Aged 60 or Younger

Very Long-Term Outcomes of the Carpentier-Edwards Perimount Aortic Valve in Patients Aged 60 or Younger

Long-Term Outcomes of the Ross Procedure Versus Mechanical Aortic Valve Replacement

Review of anticoagulation options for mechanical valve prosthesis

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