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Severe aortic valve stenosis in low-risk elderly patients, which is the role of surgery

Severe aortic valve stenosis in low-risk elderly patients, which is the role of surgery Interdisciplinary CardioVascular and Thoracic Surgery 2023, 36(1), ivac109 LETTER TO THE EDITOR https://doi.org/10.1093/icvts/ivac109 Cite this article as: Baikoussis NG, Alexopoulou-Prounia L, Limperiadis D. Severe aortic valve stenosis in low-risk elderly patients, which is the role of surgery. Interdiscip CardioVasc Thorac Surg 2023; doi:10.1093/icvts/ivac109. Severe aortic valve stenosis in low-risk elderly patients, which is the role of surgery Nikolaos G. Baikoussis , Loukia Alexopoulou-Prounia * and Dimitrios Limperiadis Cardiac Surgery Department, Ippokrateio General Hospital of Athens, Athens, Greece * Corresponding author. Cardiac Surgery Department, Ippokrateio General Hospital of Athens, 114 Vasilissis Sofias Avenue, Athens 11527, Greece. Tel: +30-6986680123; e-mail: loukia_ale07@yahoo.gr (L. Alexopoulou-Prounia). Received 25 January 2022; accepted 13 January 2023 Keywords: Aortic valve stenosis • Aortic valve replacement • Transcatheter valve implantation • Heart valve surgery We read with great interest the paper published by Magro and believe that large RCT will solve the question as to which proce- Sousa-Uva [1] on the superior technique in terms of reported com- dure is superior in this specific population, especially since the posite outcomes and survival, among transcatheter aortic valve re- majority of the current studies, the group sample for 5-year placement (TAVR) and surgical aortic valve replacement for low-risk follow-up outcomes is undersized, and the subgroup of patients patients aged >70–75 years with severe aortic stenosis. older than 74 years old is even more undersized. It is currently unclear if older age should be a criterion for We also like to notice from our experience the importance of the choice between TAVR and surgical aortic valve replacement the type of valves used for TAVR as well as the interventional car- in otherwise low-risk patients. As the authors acknowledge, ‘the diologist’s skill and familiarization with each valve. Both the only low-risk randomized control trial to date regarding an CoreValve Revalving system (Medtronic, Inc., Minneapolis, MN, elderly population (NOTION) [2, 3] did not show a statistically USA) and the Edwards Sapien system (Edwards Lifesciences significant difference between the 2 approaches regarding the Corporation, Irvine, CA, USA) have proved their effectiveness in composite end-point of death, stroke or myocardial infarction’, the recent outcomes of the CoreValve US Pivotal and Partner tri- while in other studies [4] subgroup analysis of the elderly als, respectively. patients (>75 years) also concluded in similar results for both Additional RCTs are required not only to inform practice but techniques regarding death or stroke at 2 years follow-up. also to grade the quality of the evidence and to update our As the authors acknowledge, risk scores and other procedural guidelines. risk factors associated or not with age comprise the cornerstone of approach selection. We therefore agree with the decision of REFERENCES the authors to review the current literature to propose the best management option for your patients and also elucidate future [1] Magro PL, Sousa-Uva M. In low-risk patients aged >70–75 with severe heart-team discussions. aortic stenosis, is transcatheter superior to surgical aortic valve replace- While we support the conclusions, we would like to point out ment in terms of reported cardiovascular composite outcomes and sur- that the main limitation of all studies included in the review is vival? Interact CardioVasc Thorac Surg 2022;34:40–4. the fact that they were not randomized, apart from one, and [2] Thyregod HG, Steinbru¨chel DA, Ihlemann N, Nissen H, Kjeldsen BJ, Petursson P et al. Transcatheter versus surgical aortic valve replacement therefore subject to a significant source of bias. What is more, as in patients with severe aortic valve stenosis: 1-year results from the All- the authors acknowledge, since PARTNER 2 trial’s 5-year results Comers NOTION Randomized Clinical Trial. J Am Coll Cardiol 2015;65: showed a significantly higher rate of mild paravalvular aortic 2184–94. regurgitation (33.3% vs 6.3%), frequency of hospitalizations [3] Thyregod HGH, Ihlemann N, Jørgensen TH, Nissen H, Kjeldsen BJ, (33.3% vs 25.2%) and aortic valve reinterventions (3.2% vs 0.8%) Petursson P et al. Five-year clinical and echocardiographic outcomes from the Nordic Aortic Valve Intervention (NOTION) randomized clini- [1], primary composite end points and the limited follow-up pe- cal trial in lower surgical risk patients. Circulation 2019;139:2714–23. riod of the existing studies may not be enough to justify the age [4] Popma JJ, Deeb GM, Yakubov SJ, Mumtaz M, Gada H, O’Hair D et al.; as an independent decision-making factor. Evolut Low Risk Trial Investigators. Transcatheter aortic-valve replace- We agree with the authors that the current literature does not ment with a self-expanding valve in low-risk patients. N Engl J Med show any significant superiority in either technique; however, we 2019;380:1706–15. V C The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. LETTER TO THE EDITOR http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive Cardiovascular and Thoracic Surgery Oxford University Press

Severe aortic valve stenosis in low-risk elderly patients, which is the role of surgery

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Oxford University Press
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© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.
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10.1093/icvts/ivac109
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Abstract

Interdisciplinary CardioVascular and Thoracic Surgery 2023, 36(1), ivac109 LETTER TO THE EDITOR https://doi.org/10.1093/icvts/ivac109 Cite this article as: Baikoussis NG, Alexopoulou-Prounia L, Limperiadis D. Severe aortic valve stenosis in low-risk elderly patients, which is the role of surgery. Interdiscip CardioVasc Thorac Surg 2023; doi:10.1093/icvts/ivac109. Severe aortic valve stenosis in low-risk elderly patients, which is the role of surgery Nikolaos G. Baikoussis , Loukia Alexopoulou-Prounia * and Dimitrios Limperiadis Cardiac Surgery Department, Ippokrateio General Hospital of Athens, Athens, Greece * Corresponding author. Cardiac Surgery Department, Ippokrateio General Hospital of Athens, 114 Vasilissis Sofias Avenue, Athens 11527, Greece. Tel: +30-6986680123; e-mail: loukia_ale07@yahoo.gr (L. Alexopoulou-Prounia). Received 25 January 2022; accepted 13 January 2023 Keywords: Aortic valve stenosis • Aortic valve replacement • Transcatheter valve implantation • Heart valve surgery We read with great interest the paper published by Magro and believe that large RCT will solve the question as to which proce- Sousa-Uva [1] on the superior technique in terms of reported com- dure is superior in this specific population, especially since the posite outcomes and survival, among transcatheter aortic valve re- majority of the current studies, the group sample for 5-year placement (TAVR) and surgical aortic valve replacement for low-risk follow-up outcomes is undersized, and the subgroup of patients patients aged >70–75 years with severe aortic stenosis. older than 74 years old is even more undersized. It is currently unclear if older age should be a criterion for We also like to notice from our experience the importance of the choice between TAVR and surgical aortic valve replacement the type of valves used for TAVR as well as the interventional car- in otherwise low-risk patients. As the authors acknowledge, ‘the diologist’s skill and familiarization with each valve. Both the only low-risk randomized control trial to date regarding an CoreValve Revalving system (Medtronic, Inc., Minneapolis, MN, elderly population (NOTION) [2, 3] did not show a statistically USA) and the Edwards Sapien system (Edwards Lifesciences significant difference between the 2 approaches regarding the Corporation, Irvine, CA, USA) have proved their effectiveness in composite end-point of death, stroke or myocardial infarction’, the recent outcomes of the CoreValve US Pivotal and Partner tri- while in other studies [4] subgroup analysis of the elderly als, respectively. patients (>75 years) also concluded in similar results for both Additional RCTs are required not only to inform practice but techniques regarding death or stroke at 2 years follow-up. also to grade the quality of the evidence and to update our As the authors acknowledge, risk scores and other procedural guidelines. risk factors associated or not with age comprise the cornerstone of approach selection. We therefore agree with the decision of REFERENCES the authors to review the current literature to propose the best management option for your patients and also elucidate future [1] Magro PL, Sousa-Uva M. In low-risk patients aged >70–75 with severe heart-team discussions. aortic stenosis, is transcatheter superior to surgical aortic valve replace- While we support the conclusions, we would like to point out ment in terms of reported cardiovascular composite outcomes and sur- that the main limitation of all studies included in the review is vival? Interact CardioVasc Thorac Surg 2022;34:40–4. the fact that they were not randomized, apart from one, and [2] Thyregod HG, Steinbru¨chel DA, Ihlemann N, Nissen H, Kjeldsen BJ, Petursson P et al. Transcatheter versus surgical aortic valve replacement therefore subject to a significant source of bias. What is more, as in patients with severe aortic valve stenosis: 1-year results from the All- the authors acknowledge, since PARTNER 2 trial’s 5-year results Comers NOTION Randomized Clinical Trial. J Am Coll Cardiol 2015;65: showed a significantly higher rate of mild paravalvular aortic 2184–94. regurgitation (33.3% vs 6.3%), frequency of hospitalizations [3] Thyregod HGH, Ihlemann N, Jørgensen TH, Nissen H, Kjeldsen BJ, (33.3% vs 25.2%) and aortic valve reinterventions (3.2% vs 0.8%) Petursson P et al. Five-year clinical and echocardiographic outcomes from the Nordic Aortic Valve Intervention (NOTION) randomized clini- [1], primary composite end points and the limited follow-up pe- cal trial in lower surgical risk patients. Circulation 2019;139:2714–23. riod of the existing studies may not be enough to justify the age [4] Popma JJ, Deeb GM, Yakubov SJ, Mumtaz M, Gada H, O’Hair D et al.; as an independent decision-making factor. Evolut Low Risk Trial Investigators. Transcatheter aortic-valve replace- We agree with the authors that the current literature does not ment with a self-expanding valve in low-risk patients. N Engl J Med show any significant superiority in either technique; however, we 2019;380:1706–15. V C The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited. LETTER TO THE EDITOR

Journal

Interactive Cardiovascular and Thoracic Surgery – Oxford University Press

Published: Jan 16, 2023

Keywords: Aortic valve stenosis; Aortic valve replacement; Transcatheter valve implantation; Heart valve surgery

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