title: Conventional aortic valve replacement for high-risk aortic stenosis patients not suitable for trans-catheter aortic valve implantation: feasibility and outcome.
abstract: 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 ± 0.19 cm², and mean peak gradient 91 ± 27 mm Hg. 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.
authors.affiliation: Department of Cardiothoracic Surgery, Wythenshawe Hospital, Manchester, UK.
authors.forename: Ioannis
authors.initials: I
authors.lastname: Dimarakis
authors.forename: Syed M
authors.initials: SM
authors.lastname: Rehman
authors.forename: Stuart W
authors.initials: SW
authors.lastname: Grant
authors.forename: Duraisamy M T
authors.initials: DM
authors.lastname: Saravanan
authors.forename: Richard D
authors.initials: RD
authors.lastname: Levy
authors.forename: Ben
authors.initials: B
authors.lastname: Bridgewater
authors.forename: Isaac
authors.initials: I
authors.lastname: Kadir
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001024:Aortic Valve Stenosis / Q000534:rehabilitation / Q000601:surgery*; D000075202:Contraindications; D001026:Coronary Artery Bypass; D004812:Epidemiologic Methods; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods* / Q000534:rehabilitation; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D019060:Minimally Invasive Surgical Procedures; D011474:Prosthesis Design; D011594:Psychometrics; D011788:Quality of Life; D016896:Treatment Outcome