Prognosis After Aortic Valve Replacement With a Bioprosthesis

Abstract

Background-Bioprostheses are widely used as an aortic valve substitute, but knowledge about prognosis is still incomplete. The purpose of this study was to provide insight into the age-related life expectancy and actual risks of reoperation and valve-related events of patients after aortic valve replacement with a porcine bioprosthesis. Methods and Results-We conducted a meta-analysis of 9 selected reports on stented porcine bioprostheses, including 5837 patients with a total follow-up of 31 874 patient-years. The annual rates of valve thrombosis, thromboembolism, hemorrhage, and nonstructural dysfunction were 0.03%, 0.87%, 0.38%, and 0.38%, respectively. The annual rate of endocarditis was estimated at 0.68% for Ͼ6 months of implantation and was 5 times as high during the first 6 months. Structural valve deterioration was described with a Weibull model that incorporated lower risks for older patients. These estimates were used to parameterize, calibrate, and validate a mathematical microsimulation model. The model was used to predict life expectancy and actual risks of reoperation and valve-related events after implantation for patients of different ages. For a 65-year-old male, these figures were 11.3 years, 28%, and 47%, respectively. Conclusions-The combination of meta-analysis with microsimulation enabled a detailed insight into the prognosis after aortic valve replacement with a bioprosthesis for patients of different ages. This information will be useful for patient counseling and clinical decision making. It also could serve as a baseline for the evaluation of newer valve types. Key Words: heart diseases Ⅲ surgery Ⅲ valves Ⅲ meta-analysis Ⅲ prognosis Ⅲ survival N early 40 years after the pioneering efforts of Starr and Edwards in heart valve replacement, a wide variety of mechanical, bioprosthetic, and human tissue prostheses are now available for clinical use. Mechanical valves have a greater durability and consequently lower reoperation rates than other valve types. However, they are associated with a greater risk of thromboembolism, which necessitates regular anticoagulation with the concomitant risk of hemorrhage. In contrast, bioprostheses have a low thrombogeneity, which in most patients obviates the need for regular anticoagulation and consequently reduces hemorrhagic accidents. However, the main factor limiting their use is the propensity to undergo tissue degeneration, often necessitating reoperation. Human tissue valves have a relatively low rate of thromboembolism and endocarditis. However, the long-term incidence of structural valve deterioration (SVD) of these valves is uncertain, and human valves are scarce. [1][2][3] With the aging of the general population, the number of elderly patients requiring aortic valve replacement has increased rapidly during recent years. Hence, the choice and long-term performance of a valve prosthesis becomes of paramount importance. Currently, bioprostheses are recommended for elderly patients who do not have risk factors for thromboembolism. These valves may ...

Treatment and Clinical Outcomes of Transcatheter Heart Valve Thrombosis

“…6,18,19 In the context of surgical AVR, there is a wide range in the reported incidences of valve thrombosis from as low as 0.03% to 5.0%. [8][9][10][11][12] These reported incidences concur with the one from our study, despite the fact that TAVI patients have more comorbidities predisposing them to prothrombotic states. This suggests that the bioprosthetic material inserted in the aortic valve position rather than other predisposing factors, plays the major role in valve thrombosis.…”

“…6,7 The reported incidences of valve thrombosis postsurgical AVR using bioprostheses ranges widely from as low as 0.03% to 5.0%. [8][9][10][11][12] Conversely, data on transcatheter heart valve (THV) thrombosis are scarce and restricted to several case reports and small case series. [13][14][15] A recent meta-analysis on clinical outcomes after TAVI using Valve Academic Research Consortium definitions reported a 1.2% pooled estimated incidence of THV thrombosis.…”

Microsimulation for Clinical Decision-Making in Individual Patients With Established Coronary Artery Disease

“…32 First, after the determinants and events of interest have been specified, the parameters of their associations should be assessed. The value and uncertainty of the parameters (β coefficients) can be estimated using various approaches.…”

“…Also, microsimulation allows changing hazards over time. 32 Hazards may change over time because provides a useful tool for modeling processes at the population level, its properties limit studying the remaining lifetime of an individual patient. Microsimulation, also termed discrete-event simulation, Monte Carlo simulation or dynamic risk modeling, offers a better solution for this situation.…”

Molecular diagnosis of Aspergillus endocarditis after cardiac surgery

“…Prosthetic valve endocarditis (PVE), which affects as many as 3.4 % of patients in the year following surgery and 1 % annually thereafter (Puvimanasinghe et al, 2001), is frequently associated with reoperation and significant mortality. Fungal PVE can occur early (within 60 days of surgery) or late (after 60 days), but an early occurrence is generally not seen in the absence of pre-operative fungal infections.…”