The Journal of Thoracic and Cardiovascular Surgery
Adult: Aortic ValveRedefining “low risk”: Outcomes of surgical aortic valve replacement in low-risk patients in the transcatheter aortic valve replacement era
Graphical abstract
For a low-risk patient with Society of Thoracic Surgeons (STS) predicted risk of mortality (PROM) <4% undergoing a surgical aortic valve replacement (SAVR), across the spectrum of risk, the combined end point of major morbidity or mortality improved over the 11 years of the study period, while expected risk remained stable. For all deciles from 0% to 4%, observed operative mortality (red dots) was superior to STS expected outcomes. That survival in this patient group exceeded that of the reference US population (red dot-dash line) suggests that the benefit of SAVR is durable. These data support recommendations for early surgery, should be used as a benchmark for evolving transcatheter aortic valve replacement (TAVR) technologies, and support the effort to develop agile risk models that more accurately reflect variability in contemporary practice.
Section snippets
Patients
From January 2005 to January 2017, 3474 adults with an STS PROM score <4% underwent 3493 isolated SAVRs at Cleveland Clinic's main campus. Mean age at surgery was 65 ± 13 years, and 1231 (35%) of the patients were female (Table 1). Mean preoperative aortic valve area was 0.77 ± 0.38 cm2 and mean preoperative gradient 47 ± 20 mm Hg. Age younger than 18 years, etiology of endocarditis, and those with concomitant cardiac procedures were exclusion criteria.
Surgical Technique
Isolated SAVR was performed using the
Overview
STS-defined morbidity, operative mortality, and combined major morbidity or mortality occurred similarly to STS-expected outcomes early in the study period, but occurred markedly less than STS-expected outcomes thereafter with the exception of stroke, which remained approximately constant. Operative mortality and morbidity were less than expected across the spectrum of risk in this low-risk population (PROM 0%-4%). There were relatively few intermediate-term reoperations. Long-term survival in
Principal Findings
For low-risk patients with STS PROM <4%, observed operative mortality and morbidity occurred substantially less often than expected (Figure 5). This held true for the lowest risk patients with STS PROM <1%, as well as for those with PROM of 3% to 4%. Over the decade of the study, major morbidity or mortality declined steadily to less than half of expected, while expected risk remained relatively constant, despite the increasing use of TAVR at our institution. Survival after SAVR was superior to
Conclusions
The current STS risk model, although effective at stratifying lower versus higher risk for SAVR, substantially overestimates actual SAVR risk in a high-volume center. Observed outcomes improved over time while expected risk remained static, supporting individual institutions' efforts to make continuous iterative improvements in practice even for “mature” operations such as SAVR. In addition, these results support the effort to develop agile risk models that more accurately reflect the
References (30)
- et al.
Percutaneous transcatheter aortic valve implantation: evolution of the technology
Am Heart J
(2009) - et al.
Transcatheter aortic valve replacement 2016: a modern-day “Through the Looking-Glass” adventure
J Am Coll Cardiol
(2016) - et al.
Early mortality in coronary bypass surgery: the EuroSCORE versus the Society of Thoracic Surgeons risk algorithm
Ann Thorac Surg
(2004) - et al.
The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 2–isolated valve surgery
Ann Thorac Surg
(2009) - et al.
The Society of Thoracic Surgeons 2008 cardiac surgery risk models: part 3–valve plus coronary artery bypass grafting surgery
Ann Thorac Surg
(2009) - et al.
Enhancing the value of population-based risk scores for institutional-level use
Ann Thorac Surg
(2016) - et al.
Identifying risk factors: challenges of separating signal from noise
J Thorac Cardiovasc Surg
(2017) - et al.
Cardiac surgery risk models: a position article
Ann Thorac Surg
(2004) - et al.
Observed to expected 30-day mortality as a benchmark for transcatheter aortic valve replacement
J Thorac Cardiovasc Surg
(2019) - et al.
The association of transcatheter aortic valve replacement availability and hospital aortic valve replacement volume and mortality in the United States
Ann Thorac Surg
(2014)
Procedural experience for transcatheter aortic valve replacement and relation to outcomes: the STS/ACC TVT Registry
J Am Coll Cardiol
Process improvement in cardiac surgery: development and implementation of a reoperation for bleeding checklist
J Thorac Cardiovasc Surg
A comprehensive American Association for Thoracic Surgery quality program for the 21st century
J Thorac Cardiovasc Surg
Outcomes for low-risk surgical aortic valve replacement: a benchmark for aortic valve technology
Ann Thorac Surg
Relationship between hospital surgical aortic valve replacement volume and transcatheter aortic valve replacement outcomes
JACC Cardiovasc Interv
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Funding provided by the Advanced Heart Valve Therapy Fund, the Delos M. Cosgrove M.D. Chair for Heart Disease Research, and the Donna and Ken Lewis Endowed Chair in Cardiothoracic Surgery.
Cleveland Clinic Aortic Valve Center Collaborators: Mona Kakavand, MD, A. Marc Gillinov, MD, Samir Kapadia, MD, Milind Y. Desai, MD, Daniel Burns, MD, MPhil, Patrick R. Vargo, MD, Shinya Unai, MD, Gösta B. Pettersson, MD, PhD, Aaron Weiss, MD, Haytham Elgharably, MD, Rishi Puri, MD, PhD, Grant W. Reed, MD, Zoran B. Popovic, MD, PhD, Wael Jaber, MD, Suma A. Thomas, MD, MBA, Faisal G. Bakaeen, MD, Tara Karamlou, MD, Hani Najm, MD, Brian Griffin, MD, Amar Krishnaswamy, MD, Kenneth R. McCurry, MD, L. Leonardo Rodriguez, MD, Nicholas G. Smedira, MD, MBA, Michael Zhen-Yu Tong, MD, MBA, Per Wierup, MD, PhD, and James Yun, MD.