Progression of aortic valve stenosis in adults: a systematic review.

BACKGROUND AND AIM OF THE STUDY: Published reports on the progression of aortic valve stenosis (AS) over time are usually small, with widely varying AS progression rate estimates. Reliable estimates of AS progression are important for surveillance scheduling and optimal timing of surgical or interventional treatment. This systematic review presents an overview of published evidence on AS progression over time in adult patients with AS. METHODS: A systematic review using PubMed and Embase was performed to assess AS progression over time in adult patients with AS measured by echocardiography. A total of 27 reports (15 prospective, 12 retrospective, total 4,921 patients, pooled age 69 years) was included in which the baseline and progression rates of the hemodynamic variables were pooled. Subgroup analyses were performed to investigate factors associated with AS progression and sources of heterogeneity. RESULTS: Pooled annual AS progression was 3.70 mmHg per year (SE = 0.10) for randomized controlled trials, and 6.03 mmHg per year (SE = 0.10) for observational studies. A large variability in observed AS progression was found between studies, as well as a wide variety of methods employed to measure AS. CONCLUSION: The observed large individual variability in measuring AS progression among the selected studies calls for the implementation of a universal method of AS assessment. This will facilitate an insight into the determinants of AS progression and allow for an evidence-based tailoring of treatment.

Can the EuroSCORE predict midterm survival after aortic valve replacement?

OBJECTIVES: The EuroSCORE as a predictor for midterm survival after isolated aortic valve replacement (AVR) and combined AVR with coronary artery bypass graft (CABG) surgery was tested. Survival in different risk-stratification groups also was compared to the survival of the general Dutch population. DESIGN: A retrospective analysis of prospectively collected data. SETTING: A single-center study performed in an educational hospital. PARTICIPANTS: All patients (N = 1,652) who underwent AVR with (n = 711) or without (n = 941) CABG surgery from January 2004 through December 2009. INTERVENTIONS: AVR with or without CABG surgery. MEASUREMENTS AND MAIN RESULTS: Univariate Cox regression analyses were used to identify the additive and the logistic EuroSCOREs as independent predictors of midterm mortality. Kaplan-Meier survival curves were used to compare the survival of different patients' risk subgroups, based on both the additive and the logistic EuroSCOREs, with the normal Dutch population matched for age and sex. Both additive and logistic EuroSCOREs were significant predictors of midterm mortality after isolated AVR and AVR with CABG surgery. This was also true for the different risk-stratification groups. Except for survival after AVR with CABG surgery in the high-risk group based on the additive EuroSCORE, no difference was found between survival after surgery and survival of the age- and sex-matched normal population. CONCLUSIONS: Both EuroSCORE models can predict midterm survival after isolated AVR and combined AVR with CABG surgery. However, the EuroSCORE is not a predictor for midterm survival when comparing the patient groups with the general Dutch population matched for age and sex. Except for high-risk patients undergoing AVR with CABG surgery, other risk subgroups have similar midterm survival to that of their age- and sex-matched cohorts of the Dutch population.

Endovascular repair of a ruptured, extremely tortuous, descending thoracic aorta aneurysm with aortic coarctation.

We have presented a case of a ruptured descending aortic aneurysm that was accompanied by extreme tortuosity and a pseudocoarctation at the level of the ligamentum arteriosum. We performed successful endovascular repair, covering the left subclavian artery, using a transapical-to-femoral artery (through-and-through) guidewire technique to overcome the tortuosity, with the option to perform balloon angioplasty in the case of an increased gradient over the coarctation. In the present case report, we have underlined the role of close collaborations with aortic expertise centers.

Professionals' views on shared decision-making in severe aortic stenosis.

OBJECTIVE: To provide insight into professionals' perceptions of and experiences with shared decision-making (SDM) in the treatment of symptomatic patients with severe aortic stenosis (AS). METHODS: A semistructured interview study was performed in the heart centres of academic and large teaching hospitals in the Netherlands between June and December 2020. Cardiothoracic surgeons, interventional cardiologists, nurse practitioners and physician assistants (n=21) involved in the decision-making process for treatment of severe AS were interviewed. An inductive thematic analysis was used to identify, analyse and report patterns in the data. RESULTS: Four primary themes were generated: (1) the concept of SDM, (2) knowledge, (3) communication and interaction, and (4) implementation of SDM. Not all respondents considered patient participation as an element of SDM. They experienced a discrepancy between patients' wishes and treatment options. Respondents explained that not knowing patient preferences for health improvement hinders SDM and complicating patient characteristics for patient participation were perceived. A shared responsibility for improving SDM was suggested for patients and all professionals involved in the decision-making process for severe AS. CONCLUSIONS: Professionals struggle to make highly complex treatment decisions part of SDM and to embed patients' expectations of treatment and patients' preferences. Additionally, organisational constraints complicate the SDM process. To ensure sustainable high-quality care, professionals should increase their awareness of patient participation in SDM, and collaboration in the pathway for decision-making in severe AS is required to support the documentation and availability of information according to the principles of SDM.

A 0.6-protamine/heparin ratio in cardiac surgery is associated with decreased transfusion of blood products.

OBJECTIVES: In cardiac surgery, adequate heparinization is necessary to prevent thrombus formation in the cardiopulmonary bypass (CPB). To counteract the heparin effect after weaning from CPB, protamine is administered. The optimal protamine/heparin ratio is still unknown. METHODS: In this before-after study, we evaluated the effect of a 0.6/1-protamine/heparin ratio implementation as of May 2017 versus a 0.8/1-protamine/heparin ratio on the 12-h postoperative blood loss and the amount of blood and blood component transfusions (fresh frozen plasma, packed red blood cells, fibrinogen concentrate, platelet concentrate and prothrombin complex concentrate) after cardiac surgery. A total of 2051 patients who underwent cardiac surgery requiring CPB between May 2016 and May 2018 were included. RESULTS: In the 0.6/1-protamine/heparin ratio group, only 28.8% of the patients received blood component transfusion, compared to 37.9% of the patients in the 0.8/1-ratio group (P < 0.001). The median 12-h postoperative blood loss was 230 ml (interquartile range 140-320) in the 0.6/1-ratio group versus 260 ml (interquartile range 155-365) in the 0.8/1-ratio group (P < 0.001). CONCLUSIONS: A 0.6/1-protamine/heparin ratio after weaning from CPB is associated with a significantly reduced 12-h postoperative blood loss and blood components transfusion.

Shared decision making in older patients with symptomatic severe aortic stenosis: a systematic review.

This review provides an overview of the status of shared decision making (SDM) in older patients regarding treatment of symptomatic severe aortic stenosis (SSAS). The databases Embase, Medline Ovid, Cinahl and Cochrane Dare were searched for relevant studies from January 2002 to May 2018 regarding perspectives of professionals, patients and caregivers; aspects of decision making; type of decision making; application of the six domains of SDM; barriers to and facilitators of SDM. The systematic search yielded 1842 articles, 15 studies were included. Experiences of professionals and informal caregivers with SDM were scarcely found. Patient refusal was a frequently reported result of decision making, but often no insight was given into the decision process. Most studies investigated the 'decision' and 'option' domains of SDM, yet no study took all six domains into account. Problem analysis, personalised treatment aims, use of decision aids and integrating patient goals in decisions lacked in all studies. Barriers to and facilitators of SDM were 'individualised formal and informal information support' and 'patients' opportunity to use their own knowledge about their health condition and preferences for SDM'. In conclusion, SDM is not yet common practice in the decision making process of older patients with SSAS. Moreover, the six domains of SDM are not often applied in this process. More knowledge is needed about the implementation of SDM in the context of SSAS treatment and how to involve patients, professionals and informal caregivers.

Does new-onset postoperative atrial fibrillation after coronary artery bypass grafting affect postoperative quality of life?

OBJECTIVES: New-onset postoperative atrial fibrillation (POAF) is a common complication after cardiac surgery. We investigated the effect of POAF on quality of life after coronary artery bypass grafting. METHODS: All patients who underwent nonemergency coronary artery bypass grafting between March 2009 and January 2011 were requested to complete a Short Form-36 Health Survey before and 6 months after the procedure. Norm-based scores of 8 health status domains and 2 component summary scores were calculated. Only patients undergoing first-time coronary artery bypass grafting, with no history of atrial fibrillation, were included in the analyses. RESULTS: Of 1608 patients, 360 (22.4%) had POAF diagnosed. Twenty-eight patients died within half a year after the procedure (1.7% in the no POAF group and 1.8% in the POAF group; P = .90). After excluding these patients, data from 1580 patients were analyzed. Preoperative questionnaires were returned by 66% of the patients and postoperative questionnaires by 65%. Preoperative scores did not differ between patients with and without POAF in any subcategory (0/10). After the procedure, 4 of 10 scores were worse in the group with POAF compared to patients without POAF. Patients without POAF improved in all subcategories (10/10) after the procedure, whereas those with POAF did so in only 7 of 10. Multilinear regression showed POAF to be an independent negative predictor for improved quality of life 6 months postoperatively in 7 of 10 subcategories, including both mental and physical component summary scores. CONCLUSIONS: New-onset POAF does affect 6-month postoperative mental and physical health, possibly warranting more aggressive POAF treatment.

Therapeutic decisions for patients with symptomatic severe aortic stenosis: room for improvement?

OBJECTIVE: Symptomatic severe aortic stenosis is an indication for aortic valve replacement. Some patients are denied intervention. This study provides insight into the proportion of conservatively treated patients and into the reasons why conservative treatment is chosen. METHODS: Of a patient cohort presenting with severe aortic stenosis between 2004 and 2007, medical records were retrospectively analyzed. Only symptomatic patients (n=179) were included. We studied their characteristics, treatment decisions, and survival. RESULTS: Mean age was 71 years, 50% were male. During follow-up (mean 17 months, 99% complete) 76 (42%) patients were scheduled for surgical treatment (63 conventional valve replacement, 10 transcatheter, 1 heart transplantation, 2 waiting list) versus 101 (56%) who received medical treatment. Reasons for medical treatment were: perceived high operative risk (34%), symptoms regarded mild (19%), stenosis perceived non-severe (14%), and patient preference (9%). In 5% the decision was pending at the time of the analysis and in 20% the reason was other/unclear. Mean age of the surgical group was 68 years versus 73 years for medically treated patients (p=0.004). Predicted mortality (EuroSCORE) was 7.8% versus 11.3% (p=0.006). During follow-up 12 patients died in the surgical group (no 30-day operative mortality), versus 28 in the medical group. Two-year survival was 90% versus 69%. CONCLUSIONS: A large proportion (56%) of symptomatic patients does not undergo aortic valve replacement. Often operative risk is estimated (too) high or hemodynamic severity and symptomatic status are misclassified. Interdisciplinary team discussions between cardiologists and surgeons should be encouraged to optimize patient selection for surgery.

Patient outcome after aortic valve replacement with a mechanical or biological prosthesis: weighing lifetime anticoagulant-related event risk against reoperation risk.

OBJECTIVE: Although the results of aortic valve replacement with different valve prostheses are well documented in terms of survival, the risks of (valve-related) events are less well explored. METHODS: We used a dataset of 3934 patients who underwent aortic valve replacement with either a bioprosthesis (73%) or a mechanical prosthesis (27%) between 1982 and 2003 to simulate the outcome of patients after aortic valve replacement with either valve type. With the use of microsimulation, we compared total age and gender-specific life expectancy, event-free life expectancy, reoperation-free life expectancy, lifetime risks of reoperation, and valve-related events for both valve types. RESULTS: The total follow-up was 26,467 patient-years. The mean follow-up was 6.1 years in the biological arm and 8.5 years in the mechanical arm. The mean age at implantation was 70 and 58 years for biological and mechanical prostheses, respectively, and the percentage of concomitant coronary artery bypass grafting was 47% and 28%, respectively. For a 60-year-old man, simulated life expectancy in years for biological versus mechanical prostheses was 11.9 versus 12.2, event-free life expectancy was 9.8 versus 9.3, and reoperation-free life expectancy was 10.5 versus 11.9. Lifetime risk of reoperation was 25% versus 3%. Lifetime risk of bleeding was 12% versus 41%. CONCLUSION: Even for patients aged 60 years, event-free life expectancy is better with a bioprosthesis. Although the chance of reoperation is higher, the lifetime risk of bleeding is lower compared with a mechanical prosthesis. Comparing lifetime event risks between different types of valve prostheses provides more insight into patient outcome after aortic valve replacement and aids patient selection and counseling.

Usefulness of microsimulation to translate valve performance into patient outcome: patient prognosis after aortic valve replacement with the Carpentier-Edwards supra-annular valve.

OBJECTIVE: Numerous reports have been published documenting the results of aortic valve replacement. It is often not easy to translate these outcomes involving the condition of the valve into the actual consequences for the patient. We previously developed an alternative method to study outcome after aortic valve replacement that allows direct estimation of patient outcome after aortic valve replacement: microsimulation modeling. The goal of this article is to provide insight into microsimulation methodology and to give an overview of the advantages and disadvantages of simulation methods (in particular microsimulation) in comparison with standard methods of outcome analysis. METHODS: By using a primary dataset containing 1847 patients and 14,429 patient-years, advantages and disadvantages of standard methods of outcome analysis are discussed, and the potential role of microsimulation is illustrated by means of a step-by-step explanation of building, testing, and using such a model. RESULTS: Total life expectancy, event-free life expectancy, and reoperation-free life expectancy for a 65-year-old male patient were 10.6 years, 9.2 years, and 9.8 years, respectively. Lifetime risk of reoperation due to structural valve deterioration was 13.3%. CONCLUSIONS: Microsimulation is capable of providing accurate estimates of age-related life expectancy and lifetime risk of reoperation for patients who underwent aortic valve replacement with the Carpentier-Edwards supra-annular valve. It provides a useful tool to facilitate and optimize the choice for a specific heart valve prosthesis in a particular patient.