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Anton Moritz
Department of Cardiothoracic Surgery University of Frankfurt
11.11.2018
Long Term Survival after Valve Replacement
Long term survival after Rossor AVR mechanical compared to normal life expectancy
Martin Andreas et al. Eur J Cardiothorac Surg 2014;46:409-414
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
Autograft
Mechanical protheses
Scharfschwerdt M Ann Th Surg 2007
dgthg 2011, Stuttgart
Seebacher et al.
Re OP’s autograft n= 100
Mean follow up period 13 a
4 re OP‘s in 1147 ptyrs (0.35%/yr)
Re OP’s RVOT
7 patients intervention on homograft (7,7%)
0.8%/yr
Brown JW Ann Th Surg 2008
Dearani JA, Ann Th Surg 2003
RVOT after Ross
RVOT after Congenital Surgery
Homografts show good durability
but develop gradients.
Bioprosthetic replacement an
option ?
Survival free of reop n=1065
19%
45%
Proximal RVOT
strictures developed
Perikardsleeve
solves the proximal
but aggravates the
distal problem
911.11.2018 Text durch klicken bearbeiten
Freedom from neopulmonary valve failure
after 5 years: 97% in homografts versus 73% in bioprosthesis
Incidence rate:
1:80 pat. year
in homografts
versus
1:14 pat.year
in xenografts.
p<0,00010 2 4 6 8 10 12 14 16
10
20
30
40
50
60
70
80
90
100
Time (years)
Fre
ed
om
of
ne
op
ulm
on
ary
va
lve
fa
ilure
(%
)
Number at risk
Group: Homograft
113 102 94 83 58 40 24 18 3
Group: Bioprosthesis
87 50 30 12 4 3 2 2 0
logrank test: p<0.0001
Hazard Ratio: 6.1
(95% CI 2.5 - 14.5)
Bioprosthesis
Homograft
4/193
Aorta
non coronary leaflet
conjoined leaflet
left ventricle
Durchmesser Aorta ascendens
33 33
32
34
3132
33
38 3737
39
37 37 37
20
25
30
35
40
45
50
Gesamtkollektiv Bikuspid Trikuspid Insuffizienz Kombiniert Stenose Aortenraffung
mm
Entlassungsuntersuchung Letzte Follow up Untersuchung
Das
Autografts at Reoperation
18 Reoperations on AG, but only 6 valve replacements
9 embolic events related to a-fib (0,54% / pt yr)
9 events of endocarditis (0,54% / pt yr)
No ACH related bleeding or valve thrombosis
Long Term Complications
Valve-related complications
EventMechanical valve (n =
173)Ross procedure (n = 159) P-value
Stroke 5.8% (1.02%/pt yr) 0.6% (0.06%) <0.01
TIA 1.7% (0.25%) 0% (0%) 0.07
Valve thrombosis 0.6% (0.08%) /1,35% 0% (0%) / 0.06% 0.30
Endocarditis 5.2% (0.76%) 3.8% (0.38%) 0.32
Bleeding 10.4% (1.95%) 0.6% (0.06%) <0.01
Reintervention 5.8% (0.85%) 12.6% (1.27%) 0.05
Long Term Survival
Sievers H.
Miskovic et al EACTS 2014
Ross vs mech randomisiert
Mortality 10 vs 40%
Bleeding 0 vs 25%
Reoperation 15 vs 5%
Seebacher Vienna 13 a
Projekt / Datum / Name
Summary
When respecting certain technical principles the Ross
procedure provides excellent and stable hemodynamics
in the long term.
Valve related complications are reduced to reoperations
and which are due to conceptual problems in majority.
Degenerations are rare – AG provides a durable biologic
valve.
RVOT replacement is a possible long term problem but
might be cured percutaneousely in the future.
Normal long term survival appears to be the major asset
of this technically demanding procedure.
Reop oder AI III
Böhm JO.
AnnThSurg 2009
Reoperationen
Regression of left ventricular
hypertrophy
0
0.5
1
1.5
2
2.5
implant 1 year 10 years
inte
rven
tric
ula
r sep
tum
in
cm
Interventricular SeptumMean gradient in mmHg
Mortality
Long term n=2 (10%) n=8 (40%)
Valve related n= 1 n= 5
bleeding n=0 n=5 (25%)
thromboembolism n=1 n=1
Reoperation n=3 (15%) n=1 (5%)
Effect of WrapWrap N= ASC.events yrs to event FU
no 33 9 13.9 10,3
Vicryl_Mesh 85 17 13,6 6.9
Vypro_Mesh 49 4 8.1 8.4
David 26 0 1.1
Total 193 30 13.3 7.22
Dilatation or Reoperation
PK_Event = entweder Reintervention oder PS>50mmHg oder PI>II
Häufigkeit Prozent
direkte Naht nein 43 74,1ja(ReOP oder sign Dysf) 15 25,9
Gesamtsumme 58 100,0
Plus Pach/Sleeve nein 34 89,5
ja(ReOP oder sign Dysf) 4 10,5Gesamtsumme 38 100,0
Statistik nur für Bioprothesen
Reintervention an der Bioprothese in Pulmonalklappenposition
Häufigkeit Prozent
direkte Naht nein 45 77,6
ja 13 22,4
Gesamtsumme 58 100,0
Plus Pach/Sleeve nein 36 94,7
ja 2 5,3
Gesamtsumme 38 100,0
Survival
0 2 4 6 8 10 12 14 16 18 20
0
10
20
30
40
50
60
70
80
90
100
Time
Su
rviv
al p
rob
ab
ilit
y (
%)
Number at risk
Group: Wien
95 92 90 88 84 82 63 42 26 11 1
Group: Frankfurt
204 178 156 124 102 79 48 35 8 0 0
Location
Wien
Frankfurt
Logrank test :P = 0,15
Projekt / Datum / Name
RVOT Reinterventions
Projekt / Datum / Name
Reoperations Aorta
Projekt / Datum / Name
All Reinterventions
221 165 114 56 19
60% event free
at 18 years
Projekt / Datum / Name
Optimized Reinterventions
89% event free
at 18 yrs
With current knowledge avoidable
reinterventions excluded:
RVOT strictures, pseudoaneurysms and
aortic dilatations
3211.11.2018 Text durch klicken bearbeiten
Outcome Reintervention
Total
(n=205)
Homograft
(n=113)
Xenograft
(n= 92)
Signific.
Time to redo (y)
(± SD)
6.4 years
(± 4.8)
9.6 years
(± 4.8)
4.5 years
(±3.9)
p=0.003
Reintervention 24 9 15 n.s.
Reoperation 10 7 3
Perc. Procedure 14 2 12 p=0.005
Balloon dilatation in 10, Melody implantation in 4
Re-reintervention 6 2 4 n.s.
Balloon dilatation in 2, Melody implantation in 4
Main Finding
Stricture 11 2 9 p=0.03
Degeneration 8 3 5
Endocarditis 5 4 1
3411.11.2018 Text durch klicken bearbeiten
Event at the neopulmonary valve in Bioprosthesis
Reintervention or PS (>50mmHG)
5
16
33
45
0% 20% 40% 60% 80% 100%
plus pericardial sleeve
without pericardial sleeve
Event
no Event
Reoperation of the Pulmonary Autograft
0 2 4 6 8 10 12 14 16 18 20
0
10
20
30
40
50
60
70
80
90
100
Time
Re
op
era
tio
n p
rob
ab
ilit
y (
%)
Number at risk
Group: Wien
99 90 89 86 81 79 61 40 22 8 1
Group: Frankfurt
211 169 142 113 91 68 42 29 4 0 0
Location
Wien
Frankfurt
Logrank test :P = 0,12