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Standardized Technique of Aortic Valve Re-implantation for Valve-sparing Aortic Root Replacement
Published on: December 11, 2017
Cerebrovascular events after stentless aortic valve replacement during a 9-year follow-up period
Helmut Gulbins1, Ines Florath, Juergen Ennker
1Department of Cardiac Surgery, Heart Institute Lahr, Institute of Cardiovascular Medicine, University Witten-Herdecke, Hamburg, Germany. h.gulbins@uke.de
Insights
Stentless aortic valve replacement carries a cerebrovascular event risk influenced by patient factors, not the prosthesis. Older age and prior stroke increase risk, while atrial fibrillation impacts survival but not stroke incidence.
Area of Science:
- Cardiovascular Surgery
- Biomaterials Science
- Neurology
Background:
- Biologic aortic valve prostheses offer lower thrombogenicity than mechanical options.
- Evaluating long-term cerebrovascular event (CVE) incidence after stentless aortic valve replacement (SAVR) is crucial.
Purpose of the Study:
- To assess the incidence of cerebrovascular events in patients undergoing stentless aortic valve replacement.
- To identify predictors of cerebrovascular events and survival in this patient cohort.
Main Methods:
- A cohort of 1,014 patients receiving stentless aortic valve replacement (SAVR) between 1996-2005 were followed up.
- Systematic follow-up achieved 94.7% completeness with a mean of 3 years.
- Cox regression analysis identified predictors for freedom from cerebrovascular events.
Main Results:
- Overall survival was 53% at 8 years; atrial fibrillation predicted poor survival.
- Freedom from cerebrovascular events was 68% at 9 years.
- Significant risk factors for CVEs included previous stroke, older age (>75 years), diabetes, and carotid lesions.
Conclusions:
- Cerebrovascular event risk after SAVR is primarily linked to individual patient risk factors, not the prosthesis.
- Patients without additional risk factors exhibit CVE rates comparable to the general population.
- Atrial fibrillation is a strong predictor of mortality but not an independent risk factor for CVEs post-SAVR.
Background:
One major advantage of biologic aortic valve prostheses is their low thrombogenicity compared with mechanical prostheses. The purpose of this study was to evaluate the incidence of cerebrovascular events during long-term follow-up after stentless aortic valve replacement.
Methods:
Between 1996 and 2005, 1,014 patients (mean age, 73 years; range, 20 to 90 years) received stentless aortic valve replacement (Freestyle; Medtronic, Minneapolis, MN) and were included into the systematic follow-up that was closed in 2006 with a completeness of 94.7% and a mean follow-up interval of 3 years (range, 0.5 to 9.8 years). Predictors for freedom from cerebrovascular events were identified by Cox regression.
Results:
Overall survival was 53% +/- 5% after 8 years (mean, 6.8 +/- 0.2 years). Permanent atrial fibrillation at time of surgery was a strong predictor of impaired survival during follow-up. Freedom from cerebrovascular events during follow-up was 68% +/- 5% at 9 years of follow-up. Multivariate regression analysis revealed previous stroke, age at implant, diabetes mellitus, and carotid lesions as significant risk factors. Especially age older than 75 years was a strong risk factor for cerebrovascular events during follow-up (p = 0.004). Atrial fibrillation was not an independent risk factor for cerebrovascular events (p = 0.26) but was a strong predictor of poor survival (p < 0.001) during follow-up. There was no influence of technique of implantation (subcoronary versus full root; p = 0.41), sex (p = 0.35), additional bypass grafting (p = 0.65), and the size of the implanted prosthesis (p = 0.47).
Conclusions:
The risk of cerebrovascular events during follow-up after stentless aortic valve replacement is related to the individual risk factors of the patients rather than to the valve prosthesis itself. Without additional risk factors, patients with these aortic valve prostheses showed an incidence of cerebrovascular events similar to those reported for a healthy population adjusted for age.
