Original ArticleRapid-Deployment Versus Conventional Bio-Prosthetic Aortic Valve Replacement☆
Introduction
The burden of aortic stenosis (AS) is expected to rise [1]. Surgical aortic valve replacement (AVR) with conventional, sutured, bioprotheses (cAVR) has long been the gold standard approach for management of AS [2], [3]. cAVR has excellent postoperative and long-term outcomes in relatively lower-risk candidates [4], [5], [6].
However, as patients referred for AVR become increasingly older, frailer and with a greater number of co-morbidities, there is growing interest in the use of rapid-deployment (RD-AVR) or “sutureless” aortic valve prostheses designed to reproduce the excellent outcomes of cAVR [7].
RD-AVR is proposed to reduce cross-clamp (X-clamp) and cardiopulmonary bypass (CPB) times and thereby surgical risk [8], [9], [10]. The ease and speed of delivery is also proposed to facilitate minimally invasive surgical (MIS) techniques [11], [12]. There is limited data from our region comparing the two techniques. Indeed, in studies that have compared RD-AVR to cAVR, the former have mostly been implanted via minimally invasive approaches which may have served as a confounding factor associated with perioperative outcomes.
As such, we aimed to review the perioperative outcomes of RD-AVR performed via a conventional full sternotomy as compared to a matched cohort of patients undergoing cAVR.
Section snippets
Methods
We conducted a retrospective review of prospectively collected data using the St Vincent's Hospital Melbourne's (SVHM), Australia and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) database. The database provides information on patient preoperative characteristics and risk factors, operative parameters, early postoperative outcomes and 30-day follow-up for complications [13]. Data from the database was supplemented by review of patients’ medical records. Institutional Human
Results
Of 597 patients included for analysis, 41 patients who received RD-AVR were compared to 556 who received cAVR. Patients’ clinical profiles are presented in Table 1. Patients receiving RD-AVR were older (76.5±5.7 vs 71.1±10.2, p<0.001).
The comparisons of intraoperative and early postoperative outcomes are presented in Table 2. The RD-AVR cohort had shorter CPB (RD-AVR:95.1±41.5 mins vs cAVR:132.9±46.5 mins, p<0.01) and X-clamp times (RD-AVR:71.1±32.7 mins vs cAVR:103.2±36.7 mins, p<0.01).
Discussion
RD-AVR has become popular amongst surgeons in recent years due to their potential to minimise operative time in higher-risk patients and facilitate minimally invasive surgery. Their relative ease of insertion coupled with avoidance of the complications and limitations of TAVI makes them an appealing option, particularly for the older, more frail patient, as seems increasingly common in our practice.
In the unadjusted analysis of the entire patient cohort, patients receiving RD-AVR were
Limitations
This study was limited by the relatively small sample sizes investigated. Also, despite propensity-score-matching analysis being performed, the outcomes between the two groups may still be biased by unaccounted variables, such as frailty and anatomical variance, which surgeons use to help guide valve type choice. At our institution, we have introduced frailty scoring as part of the clinical assessment in the Aortic Valve clinic, therefore in future studies we may be able to better account for
Conclusion
RD-AVR as compared to cAVR allows for shorter CPB and X-clamp times when both valve types were delivered via a full sternotomy. In our hands, RD-AVR may offer improved postoperative outcomes. Future studies with longer follow-up will elicit whether long-term clinical benefits exist. For now, RD-AVR is becoming a valuable component of the surgeon's armamentarium.
Disclosures
Dr Andrew Newcomb and Dr Philip Davis report consulting and lecture fees for Edwards Lifesciences. Dr Andrew Newcomb also reports lecture fees for Medtronic. Dr William Shi is supported by the Royal Australasian College of Surgeons Foundation for the Surgery Peter King Research Scholarship, the Heart Foundation Health Professional Research Scholarship in addition to the University of Melbourne Viola Edith Reid and the RG and AU Meade Scholarships.
Acknowledgements
There has been no financial assistance associated with this project
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Cited by (0)
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This paper was presented as an oral presentation at the 2015 Annual Scientific Meeting of the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, Adelaide, South Australia.