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Pro: Lawrence H. Cohn, M.D.
Con: Jeffrey W. Moses, M.D
Aortic valve replacement is one of the most important advances in medical care in the past century and has benefited hundreds of thousands of patients since the first successful implants in the late 50's and early 60's of the Starr-Edwards ball valve. Since that time there have been a number of important changes in valve design, cardiopulmonary bypass technology, development of minimally invasive incisions and a decreasing threshold for aortic valve replacement with increasingly improved results. Second and third generation bioprosthetic valves as well as the development of hemodynamically efficient bileaflet valves have revolutionized the surgical therapy of diseases of the aortic valve.
In the early years of this century devices have been developed which have been reported to be percutaneous devices for the correction of aortic valve disease, particularly in those who are "inoperable", thus obviating the need for an open-heart procedure. The difficulty with implanting a percutaneous device from a catheter is that there has been no satisfactory method formulized to excise the usually calcified aortic valve and remove the calcific debris without embolization to the brain and distal organs. In addition, new devices sent antegrade have had serious morbidity by damaging other cardiac structures during deployment.
The reduction of risk for the patients in whom one might consider inoperable, namely the elderly with associated morbid conditions has been reduced dramatically. In a series of 825 minimally invasive aortic valve replacements done through an upper mini-sternotomy at the Brigham, approximately 140 patients have been over the age of 80 with a variety of morbidities. The operative mortality in this group was 2/140 (1.4%) In this approach, there is faster recovery with low morbidity, thus obviating the need of consideration of percutaenous devices, which carries with it lengthy fluoroscopy time, potential of intra-cardiac structure damage, and a less efficient method of removal of calcium.
Even in the reoperative scenario where the highest risk might exist especially in the elderly with co-morbidities undergoing aortic valve replacement after coronary bypass graft the operative risk is low. In this setting, using minimally invasive techniques, the risk has been low in this minimally invasive valve series and in the group that has 140 >80 there were 35 patients who underwent a reoperation minimally invasive aortic valve replacement and there was 0 morbidity. In careful application of the newer operative approaches one may obviate the need for percutaneous devices, which come at great expense and increased risk.
Finally, the development of a new philosophy in treating high risk patients, particularly those with aortic valve and coronary disease, again may obviate serious high risk operations in those patients who may need concomitant coronary bypass and valve replacement performing hybrid operations where preoperative stenting may be combined with minimally invasive aortic valve surgery. This too has been a very successful pilot program causing little morbidity, particularly with bleeding and a decreased operating time and improved recovery time.
Therefore, it would seem in view of these new technologic and surgical approaches that a percutaneous interventional aortic valve implantation for aortic stenosis is not only dangerous, but is totally unnecessary.
1. Mihaljevic T, Cohn LH, Unic D, Aranki SF, Couper GS, Byrne JG. One thousand minimally invasive valve operations: Early and late results. Ann Surg 2004 Sep; 240(3): 529-34.
2. Byrne JG, Karavas AN, Filsoufi F, Mihaljevic T, Aklog L, Adams DH, Cohn LH, Aranki SF. Aortic valve surgery after previous coronary artery bypass grafting with functioning internal mammary artery grafts. Ann Thorac Surg. 2002 Mar;73(3):779-84.
3. Unic D, Leacche M, Paul S, Rawn JD, Aranki SF, Couper GS, Mihaljevic T, Rizzo RJ, Cohn LH, O'Gara PT, Byrne JG. Early and Late Results of Isolated and Combined Heart Valve Surgery in Patients >/=80 Years of Age. Am J Cardiol. 2005 Jun 15;95 (12):1500-1503.
4. Byrne JG, Leacche M, Unic D, Rawn JD, Simon DI, Rogers CD, Cohn LH. Staged initial percutaneous coronary intervention followed by valve surgery ("hybrid approach") for patients with complex coronary and valve disease. J Am Coll Cardiol. 2005 Jan 4;45(1):14-8.