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Reoperation of left heart valve bioprostheses according to age at implantation.
Chan V, Malas T, Lapierre H, Boodhwani M, Lam BK, Rubens FD, Hendry PJ, Masters RG, Goldstein W, Mesana TG, Ruel M.
Circulation. 2011 Sep 13;124(11 Suppl):S75-80.
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Abstract
BACKGROUND:
Evidence supporting the use of bioprostheses for heart valve replacement in young adults is accumulating. However, reoperation data, which may help guide clinical decision making in young patients, remains poorly defined in the literature.
METHODS AND RESULTS:
We examined the need for reoperation in 3975 patients who underwent first-time bioprosthetic aortic valve replacement (AVR) (n=3152) or mitral valve replacement (MVR) (n=823). There were 895 patients below the age of 60 years at bioprosthesis implant (AVR, n=636; MVR, n=259). The median interval to reoperation of contemporary, stented aortic bioprostheses was 7.74 years (95% CI 7.28 to 9.97 years) in patients less than 40 years, and 12.93 years (95% CI 11.10 to 15.76 years) in patients between 40 and 60 years of age. Multivariable risk factors associated with reoperation following bioprosthetic AVR include age (hazard ratio [HR] 0.94 per year, 95% CI 0.91 to 0.96, P<0.001) and concomitant coronary artery bypass grafting (HR 0.34, 95% CI 0.11 to 0.99, P=0.04). The median interval to reoperation of contemporary mitral bioprostheses was 8.11 years (95% CI 5.79 to 16.50 years) in patients less than 40 years, and 10.14 years (95% CI 8.64 to 11.14 years) in patients between 40 and 60 years of age. As for AVR, age (HR 0.96 per year, 95% CI 0.95 to 0.98, P<0.001) and concomitant coronary artery bypass grafting (HR 0.55, 95% CI 0.32 to 0.93, P=0.03) were associated with decreased reoperation risk following bioprosthetic MVR.
CONCLUSIONS:
These data constitute clinically relevant age-specific prognostic information regarding reoperation in young patients, who may wish to select a bioprosthesis at initial left heart valve replacement
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The impact of valve surgery on short- and long-term mortality in left-sided infective endocarditis: do differences in methodological approaches explain previous conflicting results?
Bannay A, Hoen B, Duval X, Obadia JF, Selton-Suty C, Le Moing V, Tattevin P, Iung B, Delahaye F, Alla F; AEPEI Study Group.
Eur Heart J. 2011 Aug;32(16):2003-15. Epub 2009 Feb 9.
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Abstract
AIMS:
The aim of this study was to evaluate the effect of valve surgery (VS) in infective endocarditis (IE) on 5-year mortality and to evaluate whether conflicting results reported by previous studies could be due to differences in their methodological approaches.
METHODS AND RESULTS:
Four hundred and forty-nine patients with a definite left-sided IE were selected from a prospective, population-based study. Association between VS and 5-year mortality was examined with a Cox model. To determine the impact of different methodological approaches, we also analysed the relationship between VS and mortality in our database, according to each method used in the five previous studies. Valve surgery was performed in 240 patients (53%). It was associated with an increase in short-term mortality [within the first 14 post-operative days; adjusted hazard ratio (HR), 3.69; 95% confidence interval (CI), 2.17-6.25; P<0.0001] and a decrease in long-term mortality (adjusted HR, 0.55; 95% CI, 0.35-0.87; P=0.01). At least 188 days of follow-up were required for VS to provide an overall survival advantage. When applying each study's method to our database, we obtained results similar to those reported.
CONCLUSION:
Previous conflicting results appear to be related to differences in statistical methods. When using appropriate models, we found that VS was significantly associated with reduced long-term mortality
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The timing of surgery influences mortality and morbidity in adults with severe complicated infective endocarditis: a propensity analysis.
Thuny F, Beurtheret S, Mancini J, Gariboldi V, Casalta JP, Riberi A, Giorgi R, Gouriet F, Tafanelli L, Avierinos JF, Renard S, Collart F, Raoult D, Habib G.
Eur Heart J. 2011 Aug;32(16):2027-33. Epub 2009 Mar 26.
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Abstract
AIMS:
To determine whether the timing of surgery could influence mortality and morbidity in adults with complicated infective endocarditis (IE).
METHODS AND RESULTS:
In 291 consecutive adults with definite IE who underwent surgery during the active phase, we compared those operated on within the first week of antimicrobial therapy (n=95) to those operated on later (n=191). The impact of the timing of surgery on 6-month mortality, relapses, and postoperative valvular dysfunctions (PVD) was analysed using propensity score (PS) analyses. After stratification of the cohort into quintiles based on the PS, =1st week surgery was associated with a trend of decrease in 6-month mortality in the quintile of patients with the most likelihood of undergoing this early surgical management [quintile 5: 11% vs. 33%, odds ratio (OR)=0.18, 95% CI (confidence interval) 0.04-0.83, P=0.03]. Patients of this subgroup were younger, were more likely to have Staphylococcus aureus infections, congestive heart failure, and larger vegetations. Besides, =1st week surgery was associated with an increased number of relapses or PVD (16% vs. 4%, adjusted OR=2.9, 95% CI 0.99-8.40, P=0.05).
CONCLUSION:
Surgery performed very early may improve survival in patients with the most severe complicated IE. However, a greater risk of relapses and PVD should be expected when surgery is performed very early.
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Comparison of thrombolysis versus surgery as a first line therapy for prosthetic heart valve thrombosis.
Keuleers S, Herijgers P, Herregods MC, Budts W, Dubois C, Meuris B, Verhamme P, Flameng W, Van de Werf F, Adriaenssens T.
Am J Cardiol. 2011 Jan 15;107(2):275-9.
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Abstract
Prosthetic valve thrombosis (PVT) is one of the most serious long-term complications after heart valve replacement, and optimal treatment remains unclear. The investigators report clinical characteristics and outcome of all consecutive patients with PVT treated with urgent surgery or thrombolysis with recombinant tissue plasminogen activator at a single center from January 1988 to December 2008. Thirty-one patients (mean age 59 years, range 20 to 75, 19% men) were diagnosed with PVT a median of 11 years after valve replacement (range 4 months to 32 years). Affected valve positions were mitral in 17 (55%), aortic in 8 (26%), and tricuspid in 6 (19%), and all but 1 were mechanical valves. Eighteen patients underwent urgent surgery, with 2 deaths in the immediate perioperative phase and 2 recurrences (11%) of PVT over a median follow-up period of 76 months. Of 13 patients treated with thrombolysis, there was immediate clinical improvement after a single administration of recombinant tissue plasminogen activator in 12 (92%), of whom 8 (61%) showed complete response with normalization of echocardiographic findings. The only nonresponder was subsequently referred for urgent surgery. Over a median follow-up period of 18 months, recurrence of PVT was seen in 4 patients (31%), with 1 fatal event in a patient refusing further anticoagulation treatment 1 week after successful thrombolysis. Other complications in the recombinant tissue plasminogen activator group included 1 stroke, 1 transient ischemic attack, 1 hemorrhagic complication requiring surgery, and 2 peripheral embolic events with spontaneous resolution. In conclusion, thrombolysis is an attractive first-line therapy for patients with PVT, with clinical outcomes comparing favorably with the standard surgical approach.
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Prosthetic valve selection for middle-aged patients with aortic stenosis.
Chikwe J, Filsoufi F, Carpentier AF.
Nat Rev Cardiol. 2010 Dec;7(12):711-9. Epub 2010 Nov 2.
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Abstract
Choosing the optimal aortic valve prosthesis for middle-aged patients (late 40s to early 60s) with aortic stenosis presents a challenge. The available options all have substantial drawbacks that must be considered in the decision-making process. Current data indicate that there is little or no difference in survival between mechanical and bioprosthetic aortic valve replacement in middle-aged patients at 10-15 years after surgery. Patients who receive a mechanical valve replacement have an annual risk of major hemorrhagic or embolic events of 2-4% per year for life compared with about 1% per year for patients who have a bioprosthetic valve. However, bioprostheses are associated with an increasing risk of structural valve degeneration from 10 years postimplantation, and most patients will require reoperation if they survive much longer than a decade. The mortality risk associated with reoperation is similar to that of primary surgery for most patients, and does not seem to impact on the 15-year survival in this patient group. The Ross procedure, in which the aortic valve is replaced with a pulmonary autograft, can provide improved freedom from morbidity, but operative mortality is probably double that of isolated aortic valve replacement and most patients will require reoperation. Informed patient choice is the most important factor in deciding which valve to use, with biological valves increasingly favored over mechanical valves in middle-aged patients.
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