Conventional aortic valve replacement for high-risk aortic stenosis patients not suitable for trans-catheter aortic valve implantation: Feasibility and outcome

Objective: High-risk patients with aortic stenosis are increasingly referred to specialist multidisciplinary teams (MDTs) for consideration of trans-catheter aortic valve implantation (TAVI). A subgroup of these cases is unsuitable for TAVI, and high-risk conventional aortic valve replacement (AVR) is undertaken. We have studied our outcomes in this cohort. Methods: Data prospectively collected between March 2008 and November 2009 for patients (n=28, nine male) undergoing high-risk AVR were analysed. The mean age was 78.4±9.2 years. The mean additive EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 10.0±3.6 and mean logistic EuroSCORE was 19.9±18.8. Three patients had undergone previous coronary artery bypass grafting (CABG). Results: The mean ejection fraction was 51±16%, mean valve area 0.56±0.19cm 2, and mean peak gradient 91±27mmHg. Ascending aortic, right axillary artery and femoral artery cannulation was used in 64%, 29% and 7% of cases, respectively. Median cross-clamp and cardiopulmonary bypass times were 84 (68-143)min and 111 (94-223)min. The median (range) inserted valve size was 21 (19-25)mm. Median intensive care and overall hospital stay were 5 (2-37) and 11 (5-44) days, respectively. In-hospital mortality was 4% (one patient). Postoperative complications included re-operation for bleeding (7%), renal failure (21%), tracheostomy (14%), sternal wound infection (7%), atrial fibrillation (25%) and permanent pacemaker implantation (7%). Kaplan-Meier survival at median follow-up of 359 (148-744) days was 81% (one further death of non-cardiac aetiology). Quality-of-life assessment at follow-up also yielded satisfactory results. Conclusions: MDT assessment of high-risk aortic stenosis in the era of TAVI has increased the number of referrals. Conventional open surgery remains a valid option for these patients, with acceptable in-hospital mortality and early/midterm outcomes but high in-hospital morbidity. © 2011 European Association for Cardio-Thoracic Surgery.