Survival loss after aortic valve replacement

Is it possible to avoid?

Knowledge about the natural story of aortic stenosis is widespread and it is known that after the development of symptoms, mortality occurs within a predictable period. In view of this, the performance of interventional treatment is indicated, since it is the only one capable of changing mortality in this scenario.

Will it be that, after the valve replacement and the possible perioperative complications are overcome, the life expectancy of the individual is compared to the general healthy population?

A Swedish population study (SWEDEHEART) analyzed more than 23,000 patients undergoing aortic valve replacement and observed the survival behavior in these individuals. The results are very interesting, but deserve some observations.

Life expectancy in these patients was reduced by 1.9 years, when compared to the general population and in a stratified way by age, we have:

  • Below 50 years: loss of 4.4 years
  • Over 80 years: loss of 0.4 years

Coldly observing the data, it was seen that younger individuals had a greater loss in life expectancy than the elderly and this could be explained only by the intrinsic life expectancy of these two selected groups. However, other factors must be highlighted.

Patients with aortic stenosis have a high incidence of other associated comorbidities such as coronary artery disease, systemic arterial hypertension, dyslipidemia and chronic kidney disease that directly affect the individual’s life expectancy. In addition, when properly treated, the patient with aortic stenosis will have a prosthesis that is not immune to complications such as thrombosis, degeneration and infectious events. The survival of these individuals was not impacted by the choice of which prosthesis to use (biological versus mechanical), but we are following a higher incidence of implantation of bioprostheses.

Other situations not yet adequately addressed in these studies are the fact that, following the current guidelines, many patients remain asymptomatic and are indicated for hemodynamic repercussions in the left ventricle, a fact that is already known to negatively influence the long-term prognosis. Many of them may have experienced severe ventricular involvement with myocardial fibrosis, being clearly late at the ideal time of indication.

Given the above, we can deduce that we are facing a pathology with a real negative impact on the patient’s survival, but some details can make a difference in the evolution of the condition. Properly indicating the procedure can bring the patient much closer to the general life expectancy of the healthy population, but it seems that the tools we currently have are not the ideas for the proper stratification of these patients.

Perhaps, younger patients need an indication even earlier than the older ones, under penalty of costing him a few years of survival. This should encourage and accelerate research into earlier diagnostic methods than simply dropping the ejection fraction. Take advantage and read the other posts here on thevalveclub platform that deal with these subjects (fibrosis, strain, etc …).

Suggested literature:

1 – Glaser N, Persson M, Jackson V, et al. Loss in Life Expectancy After Surgical Aortic Valve Replacement: SWEDEHEART Study. J Am Coll Cardiol. 2019 Jul 9;74(1):26-33.

2 – Durko AP, Kappetein AP. Long-Term Survival After Surgical Aortic Valve Replacement: Expectations and Reality. J Am Coll Cardiol. 2019 Jul 9;74(1):34-35.

 

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