Portal de Periódicos da CAPES

Aortic Valve Stenosis in Redo Operations in Octogenarians: Transcatheter Aortic Valve Implantation or Surgical Intervention? That Is the Question

2015; Elsevier BV; Volume: 100; Issue: 1 Linguagem: Inglês

10.1016/j.athoracsur.2015.02.049

1552-6259

Giuseppe Santarpino, Francesco Pollari, Theodor Fischlein,

Cardiac Imaging and Diagnostics

The most appropriate treatment strategy for patients aged 80 years and older with aortic valve stenosis who have undergone previous cardiac operations is still a matter of debate. In this respect, we read with great interest the article of Timek and colleagues [1Timek T.A. Turfe Z. Hooker R.L. et al.Aortic valve replacement in octogenarians with prior cardiac surgery.Ann Thorac Surg. 2015; 99: 518-523Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar], who evaluated the perioperative and midterm outcomes of 61 octogenarians with a history of cardiac operations who were undergoing aortic valve replacement (AVR). The authors should be congratulated for the reported outcome: perioperative mortality was 1.6%, and coronary artery bypass grafting was performed concomitantly in approximately 50% of cases. In addition, a stentless bioprosthesis was implanted in 39% of patients, which may have contributed to the favorable outcome observed at follow-up. However, the association of combined coronary artery bypass grafting and AVR with stentless aortic valve implantation resulted in significantly longer ischemic times (mean cross-clamp time, 145 minutes). The question remains as to whether shorter procedural times in conjunction with the use of stentless bioprostheses may result in improved clinical outcomes. A correlation has been found between reduced cross-clamp times and improved postoperative outcomes, but results have not been consistent across studies. Our group has accumulated substantial experience in the use of sutureless stentless aortic valves, which have also been implanted in patients undergoing redo operations, with a mean cross-clamp time of 44 minutes [2Santarpino G. Pfeiffer S. Concistrè G. Fischlein T. REDO aortic valve replacement: the sutureless approach.J Heart Valve Dis. 2013; 22: 615-620PubMed Google Scholar]. It is our opinion that a 100-minute reduction in cross-clamp time may translate into better outcomes, particularly in octogenarians. Notwithstanding this, the reported outcomes of Timek and colleagues' study seems to leave little space for further improvement. Given that most studies tend to focus on the most relevant clinical implications, it is likely that assessment of subclinical factors affected by prolonged cardiopulmonary bypass times could provide new insights into potential treatment options and direct future research. In conclusion, the most appropriate treatment strategy for this patient population remains to be clearly established and should include a multidisciplinary heart team approach. However, in accordance with Timek and colleagues' findings [1Timek T.A. Turfe Z. Hooker R.L. et al.Aortic valve replacement in octogenarians with prior cardiac surgery.Ann Thorac Surg. 2015; 99: 518-523Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar] and with our previous experience [3Santarpino G. Pfeiffer S. Vogt F. Hinzmann M. Concistrè G. Fischlein T. Advanced age per se should not be an exclusion criterion for minimally invasive aortic valve replacement.J Heart Valve Dis. 2013; 22: 455-459PubMed Google Scholar], advanced age per se should not be an exclusion criterion for minimally invasive AVR with subsequent referral for an interventional procedure. Aortic Valve Replacement in Octogenarians With Prior Cardiac SurgeryThe Annals of Thoracic SurgeryVol. 99Issue 2PreviewTranscatheter aortic valve implantation (TAVI) has been advocated for very elderly patients with aortic stenosis, and prior cardiac surgery as a less invasive treatment option. Although surgical aortic valve replacement (AVR) is safe and effective in selected elderly patients, the perioperative and mid-term outcomes of AVR in very elderly with prior cardiac surgery are unknown. Full-Text PDF ReplyThe Annals of Thoracic SurgeryVol. 100Issue 1PreviewWe would like to thank Santarpino and colleagues [1] for their insightful commentary on our clinical series of reoperative aortic surgery in octogenarian patients [2]. The authors represent a leading center of sutureless aortic valve replacement (AVR), and their clinical experience adds another angle to the surgical versus interventional treatment of severe aortic stenosis in the elderly. As shown in our selected series, octogenarians after isolated redo surgical AVR can still expect 80% survival at 5 years postoperatively, and therefore a durable procedure in good risk candidates is desirable. Full-Text PDF