Outcomes of surgical aortic valve replacement in moderate risk patients: implications for determination of equipoise in the transcatheter era

Sebastian A Iturra, Rakesh M Suri, Kevin L Greason, John M Stulak, Harold M Burkhart, Joseph A Dearani, Hartzell V Schaff
Journal of Thoracic and Cardiovascular Surgery 2014, 147 (1): 127-32

OBJECTIVE: To determine the contemporary outcomes of surgical aortic valve replacement (SAVR) in a moderate surgical risk population.

METHODS: We studied 502 consecutive adults who had undergone isolated SAVR from January 2002 to June 2011 for severe aortic valve stenosis with a Society of Thoracic Surgery predicted risk of mortality of 4% to 8%. We included concomitant coronary artery bypass and aortic annular enlargement but not other concomitant procedures. The updated Valve Academic Research Consortium definitions were used, as appropriate.

RESULTS: The median age was 80 years (range, 49-96), 323 (64.3%) had New York Heart Association class III-IV symptoms, and 101 (20.1%) had undergone previous coronary artery bypass grafting. The mean predicted risk of mortality was 5.6%. Concomitant coronary artery bypass grafting was performed in 270 (53.8%). Re-exploration for bleeding occurred in 29 (5.8%), stroke in 9 (1.8%), and vascular complications in 2 (0.4%). In the cohort, 14 early deaths (2.8%) occurred. During follow-up (1174 days), 175 patients died. Using multivariate logistic regression analysis, the significant independent predictors of mid-term death included chronic pulmonary disease (hazard ratio, 2.00, 95% confidence interval, 1.41-2.84; P < .001), peripheral vascular disease (hazard ratio, 1.58; 95% confidence interval, 1.05-2.37; P = .029), and atrial fibrillation (hazard ratio, 1.75; 95% confidence interval, 1.16-2.65; P = .008).

CONCLUSIONS: SAVR in moderate-risk patients is currently performed with one half of the early predicted risk (2.8%) and a low likelihood of complications, including a 1.8% incidence of stroke. Patients counseled for randomization to transcatheter aortic valve insertion should be informed of the excellent early to mid-term outcomes of SAVR, particularly those without pulmonary impairment, peripheral vascular disease, or atrial fibrillation.

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