Valvular Heart Disease: Surgical Therapy

Aortic valve

Aortic valve stenosis (aortic stenosis).

  • Indication for aortic valve replacement (ACE):
    • Presence of criteria for severe aortic valve stenosis (see below for medical device diagnosis/echocardiography) + patient is symptomatic or has left ventricular systolic dysfunction with an LVEF (left ventricular ejection fraction/volume) <50
    • Asymptomatic severe aortic stenosis (5-year cumulative incidence of sudden cardiac death: 7.2%; annual incidence: 1.4%); criteria for early intervention:
      1. Hemodialysis (hazard ratio; HR: 3.63).
      2. History of myocardial infarction (heart attack) (HR: 2.11).
      3. Body mass index (BMI) < 22 kg/m2 (HR: 1.51).
      4. Vmax ≥ 5 m/s (HR: 1.76)
      5. Left ventricular ejection fraction (ejection fraction) < 60 percent (HR: 1.52). [European and U.S. guidelines have consistently cited only a Class 1 indication for valve replacement when there is a left ventricular ejection fraction of less than 50 percent]
    • Note: Patients with presumed asymptomatic aortic valve stenosis (AS) not infrequently have syncope (brief loss of consciousness) in their history (medical records). In these patients, 1-year mortality after AS was approximately twice that of patients without syncope (HR 2.27, p=0.04); the same was true for 10-year mortality (HR 2.11, p < 0.001).
    • A meta-analysis demonstrated that early valve replacement was associated with reduced mortality (death rate) in asymptomatic patients with severe aortic stenosis.
  • Surgical aortic valve replacement (SAVR), including transcatheter aortic valve implantation (TAVI; minimally invasive implantation of an aortic valve by cardiac catheterization), if necessary:
    • Surgical aortic valve replacement:
      • In younger patients (<75 years) with a relatively low risk (as measured by EuroSCORE and STS score).
      • Low risk (STS score > 4% or log. EuroSCORE > 10%)* .
    • Transcatheter aortic valve implantation (TAVI): in patients:
      • > 75 years of age and are at increased risk
      • > 85 years regardless of the risk score
      • High risk (STS score > 8% or log. EuroSCORE > 20%)* .
      • Medium risk (STS score 4-8 % or log. EuroSCORE 10-20 %)*
  • The results of the Evolut trial and the PARTNER-3 trial showed that in low-risk patients, outcomes were equal to or better than those achieved with surgical valve replacement.Furthermore, to everyone’s astonishment, the results of the PARTNER-3 trial demonstrate a clear superiority of catheter-based TAVI treatment compared with surgical aortic valve implantation in patients with severe aortic stenosis and low surgical risk (Society Thoracic of Surgeons score (STS) <3).
  • Surgery should always be performed before the occurrence of left ventricular decompensation (“derailment”; decrease in ejection fraction of the left heart under stress), otherwise the prognosis worsens.
  • After TAVI, acetylsalicylic acid (ASA) therapy alone is associated with a significantly lower risk of complications than ASA plus clopidogrel (dual platelet inhibition). Further studies are awaited, as this is a small study with an open-label design.
  • The CoreValve US Pivotal Trial High Risk Study consistently demonstrated benefits for TAVI:
    • All-cause mortality (death rate) at 2 years: TAVI 22.2% versus SAVR 28.6%.
    • Apoplexy rate (stroke rate) after 2 years: 16.6% vs. 10.9
  • Potential complications:
    • After TAVI, there is an increased risk of endocarditis, especially in men, diabetics, and regurgitation (leaky valve), which is associated with a high mortality (death rate). The prevalence (disease incidence) is 1.1 percent according to one study (other studies: 1-6%). Endocarditis occurred after a median of 3.5 months. The most common pathogens were Enterococcus species (24.6%) and S. aureus (23.8%), followed by coagulase-negative staphylococci (16.8%). Approximately.36% of patients died immediately in the hospital and after two years, 67% had died.
    • Women are at higher risk for hemorrhage, and their likelihood of survival is higher than that of men in the year after the procedure
    • TAVI-associated complications include: Apoplexy or TIA within the first 30 days after TAVI; strongest predictor was new-onset atrial fibrillation (relative risk, RR: 1.85) and patients with chronic kidney disease (RR: 1.43) and female sex. Note: Patients after TAVI who received rivaroxaban 10 mg/d for 90 days, or clopidogrel 75 mg/d and acetylsalicylic acid (ASA) 75-100 mg/die or ASA alone for 90 days, showed the following outcome according to a preliminary analysis: occurrence of death or a first thromboembolic event in 11.4% of rivaroxaban patients versus 8.8% in the comparison group. All-cause mortality was 6.8% versus 3.3%, and primary bleeding events occurred in 4.2% versus 2.4% of patients. The result led to discontinuation of the study!
  • Cerebral embolic protection during TAVI procedures reduces the risk of apoplexy: With the help of special protection systems, attempts are made to catch and salvage embolic particles during the TAVI procedure on the vessels leading to the brain. A meta-analysis confirms a significant risk reduction (64% lower event rate than in the comparison group without protection (2.02% vs. 4.82%, p=0.0031). For the combined endpoint of mortality and apoplexy, there was a relative risk reduction of 66% (2.17 vs. 5.39%, p=0.0021).

* After update of the position paper on transvascular aortic valve implantation (TAVI) for aortic stenosis by the German Society of Cardiology (DGK); DGK annual press conference at the “DGK Heart Days 2016″, October 5, 2016, Berlin.

Notice: After aortic valve surgery, severe complications occur only half as often when the procedure is performed in the afternoon. Aortic valve insufficiency (aortic regurgitation).

  • In symptomatic individuals, valve replacement, valve reconstruction if necessary.

Mitral valve

Mitral valve stenosis (mitral stenosis)

  • Surgical commissurotomy (surgical separation of the commissures (connection between two otherwise separate structures) of the heart valves) or mitral valve replacement – surgical therapy for severe symptoms or severely restricted mitral valve orifice area.

Mitral valve insufficiency (mitral regurgitation, MI).

  • As soon as mitral regurgitation occurs, the heart defect must be closely monitored by echocardiography!
  • Mitral valve reconstruction / mitral valve replacement (in severe mitral regurgitation, early surgery brings a survival advantage).
  • Interventional procedures:
    • MitraClip: Procedure for reconstruction of mitral regurgitation Indications: degenerative valve disease and mixed forms (USA); mainly for functional regurgitation (Germany) Procedure: using a clip inserted into the heart from the venous side, the two leaflets of the leaking valve are fixed together.Also indicated for secondary mitral regurgitation in patients with heart failure/heart failureStudy results.
      • Procedural success is 96-100%, and in-hospital mortality (death rate) is approximately 2%; 80-90% of cases succeed in reducing insufficiency by 1 to 2 degrees.
      • COAPT trial (patients with secondary mitral regurgitation participated who were still symptomatic despite guideline-directed drug therapy; follow-up 8 years).
        • Readmission to hospital: 35.8% of patients were readmitted to hospital per year after the intervention, compared with 67.9% in the group with initial drug therapy (p < 0.001).
        • Mortality risk (risk of death): 29.1% of patients after MitraClip intervention vs. 46.1% in the control group
    • Interventional annuloplasty: this involves attaching a ring or band to the base of the valve and pulling it tight enough to restore the valve’s seal. The main advantage of this procedure is that the normal anatomy of the mitral valve is preserved.
    • Cinching of the dilated ventricle (still experimental):
    • Total interventional valve replacement: analogous to the TAVI procedure for the aortic valve (see below), mitral valve prostheses advanced via the vessels (in this case venous vessels) and systems are inserted transapically
  • For indications, see below Mitral valve regurgitation: “Why and when to operate”.

Mitral valve prolapse

  • Most patients with mitral valve prolapse never become symptomatic.
  • In higher-grade mitral regurgitation, mitral valve reconstruction or mitral valve replacement.
  • Approximately 10% of patients with mitral valve prolapse may experience palpitations (heart palpitations), decreased exercise tolerance, arrhythmias, and mitral regurgitation.

Tricuspid regurgitation (TI)

  • In 85 symptomatic patients with moderate to severe tricuspid regurgitation, the clinical efficacy and safety of edge-to-edge repair with the TriClip system (Abbott) inserted by cardiac catheterization was assessed: The 1-year follow-up showed improvement, in tricuspid valve insufficiency classified into five severity grades from mild to torrential (torrential), by one grade in 87.1% of patients and by two grades in 71% . Within this period, 7.1% serious events ( major adverse events, including four cardiovascular deaths) occurred; the overall mortality was 7.1%.

Ventricular septal defect (VSD; ventricular septal defect)

  • Small defects can be closed directly using patched sutures.
  • Usually, VSD closure is done with the help of a patch (autologous (“from the same individual”) pericardium (heart sac) or also materials such as Dacron or Gore-Tex).