Prognosis after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: systematic review of observational studies

Abstract

Objective To determine the frequency of survival, stroke, atrial fibrillation, structural valve deterioration, and length of hospital stay after surgical replacement of an aortic valve (SAVR) with a bioprosthetic valve in patients with severe symptomatic aortic stenosis.Design Systematic review and meta-analysis of observational studies.Data sources Medline, Embase, PubMed (non-Medline records only), Cochrane Database of Systematic Reviews, and Cochrane CENTRAL from 2002 to June 2016.Study selection Eligible observational studies followed patients after SAVR with a bioprosthetic valve for at least two years.Methods Reviewers, independently and in duplicate, evaluated study eligibility, extracted data, and assessed risk of bias for patient important outcomes. We used the GRADE system to quantify absolute effects and quality of evidence. Published survival curves provided data for survival and freedom from structural valve deterioration, and random effect models provided the framework for estimates of pooled incidence rates of stroke, atrial fibrillation, and length of hospital stay.Results In patients undergoing SAVR with a bioprosthetic valve, median survival was 16 years in those aged 65 or less, 12 years in those aged 65 to 75, seven years in those aged 75 to 85, and six years in those aged more than 85. The incidence rate of stroke was 0.25 per 100 patient years (95% confidence interval 0.06 to 0.54) and atrial fibrillation 2.90 per 100 patient years (1.78 to 4.79). Post-SAVR, freedom from structural valve deterioration was 94.0% at 10 years, 81.7% at 15 years, and 52% at 20 years, and mean length of hospital stay was 12 days (95% confidence interval 9 to 15).Conclusion Patients with severe symptomatic aortic stenosis undergoing SAVR with a bioprosthetic valve can expect only slightly lower survival than those without aortic stenosis, and a low incidence of stroke and, up to 10 years, of structural valve deterioration. The rate of deterioration increases rapidly after 10 years, and particularly after 15 years.

Patient-prosthesis mismatch following aortic valve replacement

“…Of course, disadvantages of TAVI, such as paravalvular regurgitation, might offset any beneficial effect of less PPM on LV mass regression and survival 39. In addition, we have robust data on TAVI durability only out to 5 years,49 so it is premature to advocate the use of TAVI to prevent PPM, particularly in younger patients given the durability of modern surgical bioprosthetic valves,50 and the low surgical mortality and morbidity rates at experienced valve centres.…”

Meta-analysis: mistake or milestone in medicine?

“…Two systematic reviews and meta-analyses (one for efficacy9 and one for prognosis10) provided the evidence for a guideline panel to make recommendations for use of transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (SAVR) 11. The meta-analysis assessing the efficacy of these two therapies showed that TAVI, originally designed for patients at high risk for SAVR, can be extended to low-surgical to moderate-surgical risk patients 10.…”

“…The meta-analysis assessing the efficacy of these two therapies showed that TAVI, originally designed for patients at high risk for SAVR, can be extended to low-surgical to moderate-surgical risk patients 10. The prognostic review showed that SAVR valves are durable up to 10 years postimplantation, whereas durability of TAVI valves is highly uncertain.…”

Importance of the valve durability-life expectancy ratio in selection of a prosthetic aortic valve

“…SVD due to progressive deterioration of valve leaflet tissue is the most common cause of surgical bioprostheses failure. A recent systematic review1 of 93 studies including 53 884 (age 53–92 years) patients with AS that focused on prognosis after SAVR with bioprosthetic valves showed that the median survival among those aged ≤65, 65–75, 75–85 and ≥85 years was 16, 12, 7 and 6 years, respectively. Importantly, the freedom from reoperation for valve dysfunction at 10, 15 and 20 years was 94%, 81.7% and 52%, respectively 1…”

“…TAVI provides effective relief of valve obstruction with excellent immediate and short-term outcomes. However, long-term (ie >10 years) durability of TAVI, relative to the known durability of surgical bioprosthetic valves,1 also needs to be considered. Indeed, there is, up to now, very few data addressing durability of TAVI beyond 5 years,2 which is particularly important in younger patients and those with few comorbidities who have many remaining expected years of life.…”