Elsevier

Heart, Lung and Circulation

Volume 26, Issue 2, February 2017, Pages 187-193
Heart, Lung and Circulation

Original Article
Rapid-Deployment Versus Conventional Bio-Prosthetic Aortic Valve Replacement

https://doi.org/10.1016/j.hlc.2016.06.1202Get rights and content

Background

The use of rapid-deployment aortic valve replacement (RD-AVR) has burgeoned in recent years. There are few studies comparing RD-AVR to conventional aortic valve replacement (cAVR) and no studies where both were inserted via full sternotomy. As such, we reviewed our experience and compared the two approaches.

Methods

From 2008 to 2015, 597 patients underwent isolated aortic valve replacement ± coronary artery bypass grafting (CABG) at a single centre. During this period, 41 (7%) patients received RD-AVR and 556 (93%) received cAVR. Of those receiving RD-AVR, surgical access was via full median sternotomy in 40 (98%). Propensity score matching yielded 41 matched pairs. Perioperative outcomes were compared.

Results

After propensity score matching, the RD-AVR group had shorter aortic cross clamp (X-clamp) (RD-AVR: 71±33 min vs. cAVR: 106±42 min, p<0.01) and cardiopulmonary bypass (CPB) times (95±42 min vs. 134±47 min, p<0.01). There was no difference in 30-day mortality (RD-AVR: 2% vs. cAVR: 2%, p>0.99). RD-AVR patients required shorter mean ventilation (17±25 vs. 63±131 hrs, p<0.01) and intensive care unit (ICU) stay (51±45 vs. 108±157 hrs, p=0.03) times. RD-AVR also had reduced rates of new postoperative atrial arrhythmias (8% vs. 20%, p=0.02). Total length of postoperative hospital stay was similar. Haemodynamic performance for the RD-AVR was within acceptable limits.

Conclusions

The use of RD-AVR results in shorter X-clamp and CPB times and is associated with reductions in perioperative morbidity. RD-AVR is becoming a valuable component of the surgeon's armamentarium in selected patients. Long-term follow-up will reveal the full potential of these devices.

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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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.

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