BEST EVIDENCE TOPIC – ADULT CARDIAC
Interactive CardioVascular and Thoracic Surgery 20 (2015) 429–435 doi:10.1093/icvts/ivu398 Advance Access publication 8 December 2014
Balloon aortic valvuloplasty as a bridge to aortic valve surgery for severe aortic stenosis Nnamdi Nwaejikea, Keith Millsa, Rod Stablesb and Mark Fielda,* a b
Thoracic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK Interventional Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
* Corresponding author. Thoracic Aneurysm Service, Liverpool Heart and Chest Hospital, Thomas Dr, Liverpool, Merseyside L14 3PE, UK. Tel: +44-151-6001254; fax: +44-151-6001246; e-mail: mark.fi[email protected] (M. Field). Received 3 June 2014; received in revised form 4 November 2014; accepted 10 November 2014
Abstract
Keywords: Aortic stenosis • Bridge to aortic valve replacement • Bridge to transcatheter aortic valve implantation
THREE-PART QUESTION
normal with no coronary artery disease. He had good pulmonary reserve and no other comorbidities; he did not meet the criteria for transcatheter aortic valve replacement (AVR). This patient needed an AVR but was high risk due to poor left ventricular function. Would temporary relief of the aortic stenosis by balloon aortic valvuloplasty allow recovery of left ventricular function prior to the definitive operation? We resolved to check the literature.
In [ patients with severe aortic stenosis] can [balloon valvuloplasty] be used as a [bridge to aortic valve replacement]?
SEARCH STRATEGY
CLINICAL SCENARIO
MEDLINE(R) 1946 to April Week 1 2014 using the OVID interface. (exp aortic valve/ OR AVR.mp. or TAVI.mp. or TAVR.mp) AND (exp balloon valuloplasty/ or valvuloplasty.mp)
INTRODUCTION A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
A 79-year old man was referred to the clinic with symptomatic severe aortic stenosis. He had been under follow-up with the cardiologists for 10 years with asymptomatic aortic stenosis but had developed symptoms of breathlessness on maximal exertion over the past 2 months. Echocardiography showed him to have severe aortic stenosis, with an ejection fraction of 15%; other valves were
SEARCH OUTCOME A total of 463 papers were found using the reported search. From these, 11 papers were identified.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
BEST EVIDENCE TOPIC
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, in patients with severe aortic stenosis, can balloon valvuloplasty be used as a bridge to aortic valve replacement? Altogether 463 papers were found using the reported search, of which 11 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that balloon aortic valvuloplasty is recommended as a bridge to aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI) in patients with severe symptomatic aortic stenosis. Institutional practices, local and logistic factors can affect patient selection and management approaches to severe aortic stenosis, but having the facility to offer balloon aortic valvuloplasty (especially in the TAVI era) provides another management option for patients who would otherwise have been considered unacceptably high risk for aortic valve surgery. The increased incidence of balloon aortic valvuloplasty mirrors the increase in the use of TAVI with a sharp increase in activity from 2006. Success rates for bridging from balloon aortic valvuloplasty to definite surgical intervention are in the range 26.3–74%, with AVR or TAVI occurring within 8 weeks to 7 months. Complications from balloon aortic valvuloplasty such as aortic regurgitation (AR) can be managed successfully. Up to 40% of patients selected by balloon aortic valvuloplasty to have TAVI or AVR do not have these procedures within 2 years. While most of these patients are excluded for objective clinical reasons such as terminal disease/malignancy or other persistent contraindication, some patients refuse definitive treatment and others die while on the waiting list. Outcomes in patients bridged to AVR/TAVI are better than in patients treated with balloon aortic valvuloplasty only. Owing to the high mortality of patients in this cohort without destination therapy, delays to progression to TAVI or AVR should be avoided in selected patients. A discussion with the patient about expectations, mortality and morbidity risks with all management options will aid decision-making.
N. Nwaejike et al. / Interactive CardioVascular and Thoracic Surgery
430
Table 1: Best evidence papers Author, date, journal and country Study type (level of evidence)
Patient group
Outcomes
Key results
Comments
Ben-Dor et al. (2012), Catheter Cardiovasc Interv, USA [9]
Patients treated with balloon aortic valvuloplasty retrospectively identified
There was no significant difference between the two groups in mean age (81.7 ± 8.3 vs 83.2 ± 10.9 years, P = 0.18), Society of Thoracic Surgeons score (13.1 ± 6.2 and 12.4 ± 6.4, P = 0.4), log EuroSCORE (45.4 ± 22.3 vs 46.9 ± 21.8, P = 0.43)
During a median follow-up of 183 days (54–409), the mortality rate was 55.2% (n = 214) in the BAV alone group versus 22.3% (n = 19) in the BAV as a bridge group during a median follow-up of 378 days (177–690), P
Interactive CardioVascular and Thoracic Surgery 20 (2015) 429–435 doi:10.1093/icvts/ivu398 Advance Access publication 8 December 2014
Balloon aortic valvuloplasty as a bridge to aortic valve surgery for severe aortic stenosis Nnamdi Nwaejikea, Keith Millsa, Rod Stablesb and Mark Fielda,* a b
Thoracic Aneurysm Service, Liverpool Heart and Chest Hospital, Liverpool, UK Interventional Cardiology, Liverpool Heart and Chest Hospital, Liverpool, UK
* Corresponding author. Thoracic Aneurysm Service, Liverpool Heart and Chest Hospital, Thomas Dr, Liverpool, Merseyside L14 3PE, UK. Tel: +44-151-6001254; fax: +44-151-6001246; e-mail: mark.fi[email protected] (M. Field). Received 3 June 2014; received in revised form 4 November 2014; accepted 10 November 2014
Abstract
Keywords: Aortic stenosis • Bridge to aortic valve replacement • Bridge to transcatheter aortic valve implantation
THREE-PART QUESTION
normal with no coronary artery disease. He had good pulmonary reserve and no other comorbidities; he did not meet the criteria for transcatheter aortic valve replacement (AVR). This patient needed an AVR but was high risk due to poor left ventricular function. Would temporary relief of the aortic stenosis by balloon aortic valvuloplasty allow recovery of left ventricular function prior to the definitive operation? We resolved to check the literature.
In [ patients with severe aortic stenosis] can [balloon valvuloplasty] be used as a [bridge to aortic valve replacement]?
SEARCH STRATEGY
CLINICAL SCENARIO
MEDLINE(R) 1946 to April Week 1 2014 using the OVID interface. (exp aortic valve/ OR AVR.mp. or TAVI.mp. or TAVR.mp) AND (exp balloon valuloplasty/ or valvuloplasty.mp)
INTRODUCTION A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
A 79-year old man was referred to the clinic with symptomatic severe aortic stenosis. He had been under follow-up with the cardiologists for 10 years with asymptomatic aortic stenosis but had developed symptoms of breathlessness on maximal exertion over the past 2 months. Echocardiography showed him to have severe aortic stenosis, with an ejection fraction of 15%; other valves were
SEARCH OUTCOME A total of 463 papers were found using the reported search. From these, 11 papers were identified.
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
BEST EVIDENCE TOPIC
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was, in patients with severe aortic stenosis, can balloon valvuloplasty be used as a bridge to aortic valve replacement? Altogether 463 papers were found using the reported search, of which 11 papers represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that balloon aortic valvuloplasty is recommended as a bridge to aortic valve replacement (AVR) or transcatheter aortic valve implantation (TAVI) in patients with severe symptomatic aortic stenosis. Institutional practices, local and logistic factors can affect patient selection and management approaches to severe aortic stenosis, but having the facility to offer balloon aortic valvuloplasty (especially in the TAVI era) provides another management option for patients who would otherwise have been considered unacceptably high risk for aortic valve surgery. The increased incidence of balloon aortic valvuloplasty mirrors the increase in the use of TAVI with a sharp increase in activity from 2006. Success rates for bridging from balloon aortic valvuloplasty to definite surgical intervention are in the range 26.3–74%, with AVR or TAVI occurring within 8 weeks to 7 months. Complications from balloon aortic valvuloplasty such as aortic regurgitation (AR) can be managed successfully. Up to 40% of patients selected by balloon aortic valvuloplasty to have TAVI or AVR do not have these procedures within 2 years. While most of these patients are excluded for objective clinical reasons such as terminal disease/malignancy or other persistent contraindication, some patients refuse definitive treatment and others die while on the waiting list. Outcomes in patients bridged to AVR/TAVI are better than in patients treated with balloon aortic valvuloplasty only. Owing to the high mortality of patients in this cohort without destination therapy, delays to progression to TAVI or AVR should be avoided in selected patients. A discussion with the patient about expectations, mortality and morbidity risks with all management options will aid decision-making.
N. Nwaejike et al. / Interactive CardioVascular and Thoracic Surgery
430
Table 1: Best evidence papers Author, date, journal and country Study type (level of evidence)
Patient group
Outcomes
Key results
Comments
Ben-Dor et al. (2012), Catheter Cardiovasc Interv, USA [9]
Patients treated with balloon aortic valvuloplasty retrospectively identified
There was no significant difference between the two groups in mean age (81.7 ± 8.3 vs 83.2 ± 10.9 years, P = 0.18), Society of Thoracic Surgeons score (13.1 ± 6.2 and 12.4 ± 6.4, P = 0.4), log EuroSCORE (45.4 ± 22.3 vs 46.9 ± 21.8, P = 0.43)
During a median follow-up of 183 days (54–409), the mortality rate was 55.2% (n = 214) in the BAV alone group versus 22.3% (n = 19) in the BAV as a bridge group during a median follow-up of 378 days (177–690), P
