The position of bioprosthetic aortic root replacement
There is no perfect valve substitute for the individual patient with
aortic valve and/or root disease as all prostheses are associated with
certain valve-related events of varying nature. Careful weighting of the
advantages and disadvantages of biological and mechanical valve
substitutes tailored to the patient’s unique characteristics and
preferences, is the current gold standard. Interestingly, there is a
trend toward using a biological valve in younger patients
(5, 56).
Although evidence is lacking, perhaps this is emerging due to the
potential prospect of transcatheter valve-in-valve therapy as a future
solution for bioprosthetic SVD.
According to the ESC/EACTS guidelines on valvular heart disease, age
limits contain an arbitrary element, and the choice of prostheses type
should be individualized in a joint decision between the patient and
doctor. Although SVD is known to occur earlier in younger patients
(57), mechanical valve prostheses are not
the preferred alternative in all young patients. Nevertheless, as
individual patient norms, values and goals in life vary widely, the
decision for a particular valve prosthesis should be individualized in a
shared decision making process, and together with surgical experience,
the most suitable surgical approach should be determined
(2, 53).
Our systematic review adds to the body of evidence by showing in a
middle-aged patient population, undergoing bioprosthetic aortic root
replacement, acceptable reintervention rates and valve-related event
occurrence, and may be used as a benchmark to compare outcome with other
type of prosthesis, e.g. Bentall and valve-sparing procedures.
LimitationsAs in all systematic reviews and meta-analysis of retrospective
observational studies, limitations of this type of study should be taken
into consideration (58). Furthermore,
recall bias inherent to the retrospective design of all but one study
and publication bias may have affected the observed outcome. In
addition, the included studies represent a heterogeneous population of
patients with different patient characteristics, with patients operated
in different era spanning over 20 years, and considering improvements in
anticoagulation strategies, medical management of valvular heart disease
and surgical techniques over the past decades, which may have influenced
outcome. Moreover, a lack of uniform data reporting as proposed by the
guidelines (9) may have influenced the
uniformity of the pooled data.
The pooled late outcome estimates are based on the linearity assumption,
while occurrence of outcome events may not be linear in nature. However,
due to the lack of randomized trials where homogeneous data are present,
this meta-analysis was performed to provide an overview of published
outcomes after bioprosthetic aortic root replacement.