Aortic stenosis in high-risk patients
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lther · M. Arsalan · J. Blumenstein · A. van Linden · J. Kempfert Kerckhoff Heart Center, Department of Cardiac Surgery, Kerckhoff Klinik, Bad Nauheim
Aortic stenosis in high-risk patients Surgical therapy
Aortic stenosis (AS) is the most frequently acquired heart valve lesion in humans [1]. As there is no effective medical therapy, patients with severe and symptomatic AS should undergo surgical therapy— usually resection of the calcified leaflets and insertion of a conventional valve prosthesis—otherwise their life expectancy is significantly limited [2]. Conventional aortic valve replacement (AVR) is a standardized and safe procedure associated with good outcomes in experienced surgical centers. In the presence of an increasingly elderly and comorbid patient population with increasing risk, however, there is a growing need to evaluate minimally invasive therapeutic approaches [3]. Here, we focus on conventional AVR as an established, safe, and effective procedure compared with novel transcatheter approaches.
Basic principles of surgical AVR Surgical AVR is a routine procedure that has been performed for thousands of patients with good results over the past 50 years. The average mortality rate in Germany is consistently around 3%, with a total of 11,000 all-comer patients [4]. The standard access for AVR is through a full median sternotomy, which is a very simple and safe approach. Alternatively, a minimally invasive access using a partial mini-sternotomy can be adopted with similar outcomes. During AVR, the patient’s circulation is maintained using cardiopulmonary bypass, and thus stable
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hemodynamic function can be guaranteed throughout the procedure. Most importantly, the calcified and degenerated aortic valve cusps are excised during conventional AVR, followed by precise implantation of a modern xenograft or mechanical prosthesis using standard suturing techniques. Thereby, good hemodynamic and functional outcomes can be achieved. Conventional AVR leads to a complete cure of the underlying disease and therefore is considered the gold standard of treatment. The number of elderly and higher-risk patients, however, continues to expand in line with an increase in life expectancy, thus changing the general landscape of contemporary interventions required for the management of AS [5]. To counteract an increasing risk profile, newer minimally invasive access methods together with sutureless valves and transcatheter techniques should be implemented in routine practice for individual patients. Transcatheter aortic valve implantation (TAVI) has been performed in a steadily increasing number of patients since the first case 10 years ago [6]. While TAVI appears to be relatively easy to perform, allowing for beating-heart and offpump minimally invasive aortic valve implantation (AVI) using a retrograde transfemoral (TF) or an antegrade transapical (TA) approach [3], there are potential drawbacks: risks associated with heavily calcified native aortic valve cusps, irregular aortic annuli, or nonstanda
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