Biological Valves in Younger Patients Undergoing Aortic Valve Replacement
2017; Lippincott Williams & Wilkins; Volume: 135; Issue: 12 Linguagem: Inglês
10.1161/circulationaha.116.026385
ISSN1524-4539
AutoresNorman Briffa, John B. Chambers,
Tópico(s)Cardiac pacing and defibrillation studies
ResumoHomeCirculationVol. 135, No. 12Biological Valves in Younger Patients Undergoing Aortic Valve Replacement Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBBiological Valves in Younger Patients Undergoing Aortic Valve ReplacementA Word of Caution Norman Briffa, MB ChB, MD and John B. Chambers, MD Norman BriffaNorman Briffa From Sheffield Teaching Hospitals NHS Trust, University of Sheffield, and South Yorkshire Cardiothoracic Centre, Northern General Hospital, Sheffield, UK (N.B.); and Guy's and St Thomas Hospitals, London, UK (J.B.C.). and John B. ChambersJohn B. Chambers From Sheffield Teaching Hospitals NHS Trust, University of Sheffield, and South Yorkshire Cardiothoracic Centre, Northern General Hospital, Sheffield, UK (N.B.); and Guy's and St Thomas Hospitals, London, UK (J.B.C.). Originally published21 Mar 2017https://doi.org/10.1161/CIRCULATIONAHA.116.026385Circulation. 2017;135:1101–1103Aortic stenosis is becoming more prevalent as populations age, and surgically implanting a replacement valve can restore a patient's expected life span. There is much discussion about the relative merits of a mechanical or biological valve design. A mechanical valve is expected to outlast the patient but requires anticoagulation with a vitamin K antagonist, whereas a biological valve does not require anticoagulation but is subject to structural valve degeneration after 10 years. After taking patient preferences into consideration, the 2014 American Heart Association/American College of Cardiology guidelines1 recommend that a mechanical valve should be implanted in patients 65 years of age. However, biological valves are increasingly being used in patients <60 years of age in both the United States and Europe. In the United Kingdom, successive registry returns from cardiac surgical centers show that the percentage of biological valves implanted in patients 60 years. However, these results cannot be extrapolated to all designs or to younger ages at implantation. Furthermore, the microsimulation studies informing the American Heart Association/American College of Cardiology guidelines crucially did not take into account the rapid and continued increase in life expectancy over the past 20 years: A 65-year-old man in the United Kingdom is now expected to live for 19 years.Valve-in-Valve ProceduresSince the first-in-human implantation, the uptake of TAVR has been rapid. The original PARTNER (Placement of Aortic Transcatheter Valve) studies confirmed TAVR to be the treatment of choice for patients unsuitable for surgery. More recently, TAVR has been shown to be comparable to conventional surgical AVR in intermediate-risk patients. In 2007, the first implantation of a TAVR in a failing bioprosthesis was described.2 The avoidance of repeat heart surgery with its associated morbidity and mortality is very appealing to patients and physicians, and the number of valve-in-valve procedures recorded in the PARTNER valve-in-valve registry has increased rapidly. Industry is now incorporating features in the design of new bioprostheses to facilitate future valve-in-valve transcatheter implantation.It is important to note, however, that TAVR devices have an uncertain durability. Because the cusps are made from the same material used in conventional valve prostheses, the effect of crimping and balloon dilatation may be to weaken the tissue, resulting in reduced durability.Oral Anticoagulant TherapyMechanical valve thrombosis and associated thromboembolic events are strongly associated with variations in international normalized ratio control. These variations can be minimized by the use of point-of-care warfarin testing. Studies of the latest generation of mechanical valve prostheses have shown excellent outcomes with oral anticoagulation targeted toward lower international normalized ratio values, leading to reduced bleeding rates.3 Oral anticoagulation is now needed in a growing proportion (up to a third) of elderly patients with biological valves because of the development of atrial fibrillation. Moreover, a recent study of patients with TAVR devices using computed tomography has demonstrated that in some cases these valves develop a thin layer of thrombus on the pericardial leaflets, the clinical significance of which is unclear.4 These preliminary findings suggest that anticoagulation of the patient undergoing TAVR may be required for an as-yet unspecified period of time. Thus, avoidance of anticoagulation will be inadvisable or impossible in many patients regardless of the type of prosthesis implanted.Comparative Trial DataThere are a number of large studies comparing long-term outcomes after aortic valve replacement with either mechanical or biological prostheses. None of the trials shows superior survival with tissue prostheses, although anticoagulant-related bleeding episodes were significantly lower in patients with tissue valves in most studies. A recently published propensity-matched study, which included patients between 50 and 69 years of age, showed superior 15-year survival in patients receiving mechanical prostheses.5Concluding ThoughtsCompanies involved in the design and manufacture of heart valve prostheses strive continuously to design and produce the perfect prosthesis: a tissue valve that never degenerates or a mechanical valve that requires minimal or no anticoagulant therapy. All mechanical valve prostheses in use today are based on technology that is >20 years old. Over that time, numerous innovations in tissue valve prosthesis design have been introduced by the large heart valve companies, which seem to believe that the future lies in tissue prostheses and transcatheter heart valve technology.In the absence of long-term data on valve-in-valve durability or need for immediate anticoagulant therapy, we believe that the move toward the implantation of tissue prostheses in younger patients is premature. Patients who receive a tissue prosthesis at a young age will almost certainly require lifelong monitoring with cardiac imaging and may be exposed to repeat procedures with greater healthcare costs. Current evidence also suggests that this strategy may be associated with diminished survival. An increasing number of patients will also not avoid anticoagulation as they age.Physicians and patient advocacy groups should be cautious and mindful of all the evidence (or lack of it) when advising patients who are to undergo surgical aortic valve replacement about the choice of prosthesis they would want to receive.DisclosuresDr Briffa reports no conflicts. Dr Chambers has an expert witness relationship with Edwards and Cryolife.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circulation is available at http://circ.ahajournals.org.Correspondence to: Norman Briffa, MB ChB, MD, Sheffield Teaching Hospitals, NHS Trust, Cardiothoracic Surgery, Chesterman Wing, Northern General Hospital, Herries Road, Sheffield S5 7AU, United Kingdom. E-mail [email protected]References1. American College of Cardiology/American Heart Association Task Force on Practice Guidelines, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society of Thoracic Surgeons, Bonow RO, Carabello BA, Kanu C, de Leon AC, Faxon DP, Freed MD, Gaasch WH, Lytle BW, Nishimura RA, O'Gara PT, O'Rourke RA, Otto CM, Shah PM, Shanewise JS, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Page RL, Riegel B. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): developed in collaboration with the Society of Cardiovascular Anesthesiologists: endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons.Circulation. 2006; 114:e84–e231. doi: 10.1161/CIRCULATIONAHA.106.176857MedlineGoogle Scholar2. Webb JG. Transcatheter valve in valve implants for failed prosthetic valves.Catheter Cardiovasc Interv. 2007; 70:765–766. doi: 10.1002/ccd.21379.CrossrefMedlineGoogle Scholar3. Puskas J, Gerdisch M, Nichols D, Quinn R, Anderson C, Rhenman B, Fermin L, McGrath M, Kong B, Hughes C, Sethi G, Wait M, Martin T, Graeve A; PROACT Investigators. Reduced anticoagulation after mechanical aortic valve replacement: interim results from the prospective randomized on-X valve anticoagulation clinical trial randomized Food and Drug Administration investigational device exemption trial.J Thorac Cardiovasc Surg. 2014; 147:1202–1210. doi: 10.1016/j.jtcvs.2014.01.004.CrossrefMedlineGoogle Scholar4. Makkar RR, Fontana G, Jilaihawi H, Chakravarty T, Kofoed KF, de Backer O, Asch FM, Ruiz CE, Olsen NT, Trento A, Friedman J, Berman D, Cheng W, Kashif M, Jelnin V, Kliger CA, Guo H, Pichard AD, Weissman NJ, Kapadia S, Manasse E, Bhatt DL, Leon MB, Søndergaard L. Possible subclinical leaflet thrombosis in bioprosthetic aortic valves.N Engl J Med. 2015; 373:2015–2024. doi: 10.1056/NEJMoa1509233.CrossrefMedlineGoogle Scholar5. Glaser N, Jackson V, Holzmann MJ, Franco-Cereceda A, Sartipy U. Aortic valve replacement with mechanical vs. biological prostheses in patients aged 50-69 years.Eur Heart J. 2016; 37:2658–2667. doi: 10.1093/eurheartj/ehv580.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Kovarovic B, Helbock R, Baylous K, Rotman O, Slepian M and Bluestein D (2022) Visions of TAVR Future: Development and Optimization of a Second Generation Novel Polymeric TAVR, Journal of Biomechanical Engineering, 10.1115/1.4054149, 144:6, Online publication date: 1-Jun-2022. Daeter E, Veghel D, Houterman S, Olsthoorn J and Soliman‐Hamad M (2020) Recent trends in aortic valve interventions: Data of the Netherlands heart registration, Journal of Cardiac Surgery, 10.1111/jocs.15265, 36:2, (573-581), Online publication date: 1-Feb-2021. Chirichilli I, Irace F, D'Aleo S, Folino G, Weltert L, Scaffa R, Nardella S and De Paulis R (2020) Long-term follow-up of Bentall procedure using the Perimount bioprosthesis and the Valsalva graft, Interactive CardioVascular and Thoracic Surgery, 10.1093/icvts/ivaa007, 30:5, (679-684), Online publication date: 1-May-2020. Yang M, Meng F, Xu L, Zhuang X, Xu Z, Ou W, An D, Wang X and Wang W (2020) Innovation Updates for Biocompatible Ventricular Assist Devices Artificial Hearts, 10.1007/978-981-15-4378-4_11, (191-212), . Voevodin A, Allenov A and Bazylev V (2020) Transcatheter valve-in-valve implantation of the 'MedLab-KT' prosthesis, Angiology and vascular surgery, 10.33529/ANGIO2020114, 26:1, (135), . Lu C, Yang G, Huang H, Li S and Yang M (2020) Artificial Heart: Volume Displacement Blood Pump Artificial Hearts, 10.1007/978-981-15-4378-4_5, (75-93), . Chambers J (2020) Prosthetic Heart Valves Heart Valve Disease, 10.1007/978-3-030-23104-0_14, (207-230), . Wooley J, Vasudevan A, Tabachnick D, Squiers J, DiMaio J, Mack M and Holper E (2019) Identification of Patient Factors Associated with Loss to Follow-Up at 1-Year Post Transcatheter Aortic Valve Replacement, Structural Heart, 10.1080/24748706.2018.1549373, 3:1, (61-64), Online publication date: 1-Jan-2019. Nalluri N, Atti V, Munir A, Karam B, Patel N, Kumar V, Vemula P, Edla S, Asti D, Paturu A, Gayam S, Spagnola J, Barsoum E, Maniatis G, Tamburrino F, Kandov R, Lafferty J and Kliger C (2018) Valve in valve transcatheter aortic valve implantation (ViV-TAVI) versus redo-Surgical aortic valve replacement (redo-SAVR): A systematic review and meta-analysis, Journal of Interventional Cardiology, 10.1111/joic.12520, 31:5, (661-671), Online publication date: 1-Oct-2018. March 21, 2017Vol 135, Issue 12 Advertisement Article InformationMetrics © 2017 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.116.026385PMID: 28320802 Originally publishedMarch 21, 2017 Keywordsaortic valveaortic valve stenosisheart valvesPDF download Advertisement SubjectsCardiovascular SurgeryCatheter-Based Coronary and Valvular InterventionsValvular Heart Disease
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