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Eur J Cardiothorac Surg 2007;32:188. doi:10.1016/j.ejcts.2007.03.036
Copyright © 2007, European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved

Letters to the Editor

Patient selection for minimally invasive aortic valve implantation

Department of Surgery, Division of Cardiac Surgery, Dalhousie University, Halifax, Nova Scotia, Canada

Received 24 February 2007; accepted 23 March 2007.

^_* Corresponding author. Address: New Halifax Infirmary, 1796 Summer Street, Room 2269, Halifax, Nova Scotia B3H 3A7, Canada. Tel.: +1 902 473 3808; fax: +1 902 473 4448. (Email: dkalavro{at}dal.ca).

Key Words: Aortic valve replacement • Valvuloplasty • Stenosis • Valve disease

We have read with great interest the two original articles in the January issue of the Journal that report early experiences with transapical aortic valve replacement [1,2]. These studies show that beating-heart transapical aortic valve implantation has acceptable early results in patients deemed to be at too high a risk to allow for a safe valve replacement by conventional surgery. The authors of both studies should be celebrated as innovators and congratulated for their pioneering efforts using these novel technologies.

In these studies, transapical procedures were reserved for patients with preoperative risk profiles that were deemed to be prohibitive for traditional valve replacement such that a successful outcome following conventional surgery was considered unlikely. However, precise inclusion criteria and a definition of inoperability were not provided in these papers. The lack of a transparent patient selection process makes these studies difficult to interpret and compromises the reader's ability to get a sense of the role of these interventions in the management of severe aortic stenosis. Furthermore, we are concerned that much of the preoperative risk stratification in these studies relied on the logistic EuroSCORE. Predictive models including the EuroSCORE have previously been shown to lose discriminatory capability at the extremes of risk [3,4].

To illustrate our point, we have reviewed all consecutive patients undergoing aortic valve replacement at our institution over a 10-year period (1995–2005). The population evaluated included a total of 1879 consecutive patients. During that time period, there were 325 patients, with a logistic EuroSCORE of greater than 20%, who underwent conventional aortic valve surgery. The average predicted mortality for that group was 39.4% by logistic EuroSCORE. In contrast, we have found in this high-risk group of patients that the observed in-hospital mortality was only 15.1%, which was significantly lower than what was predicted. Therefore, relying on the EuroSCORE to predict preoperative mortality risk may inappropriately classify patients as high-risk patients and unsuitable for conventional aortic valve replacement. Taken further, this may mean that some patients with high EuroSCORE could be denied an intervention that can potentially benefit them.

These studies [1,2] are early feasibility studies and are not randomized controlled trials evaluating two potentially equivalent and equally acceptable interventions. The investigators should interpret their results accordingly and not overstate their conclusions by reporting that this technology is a ‘viable alternative’ to conventional surgical aortic valve replacement [2]. The issue here is one of good science and not the reluctance to accept an emerging technique.

References

1. Walther T, Falk V, Borger MA, Dewey T, Wimmer-Greinecker G, Schuler G, Mack M, Mohr FW. Minimally invasive transapical beating heart aortic valve implantation—proof of concept. Eur J Cardiothorac Surg 2007;31:9-15.[Abstract/Free Full Text]
2. Ye J, Cheung A, Lichtenstein SV, Pasupati S, Carere RG, Thompson CR, Sinhal A, Webb JG. Six-month outcome of transapical transcatheter aortic valve implantation in the initial seven patients. Eur J Cardiothorac Surg 2007;31:16-21.[Abstract/Free Full Text]
3. Bhatti F, Grayson AD, Grotte G, Fabri BM, Au J, Jones M, Bridgewater B. North west quality improvement programme in cardiac interventions. The logistic EuroSCORE in cardiac surgery: how well does it predict operative risk?. Heart 2006;92:1817-1820.[Abstract/Free Full Text]
4. Nashef SAM, Carey F, Charman S. The relationship between predicted and actual cardiac surgical mortality: impact of risk grouping and individual surgeons. Eur J Cardiothorac Surg 2001;19:817-820.[Abstract/Free Full Text]

This article has been cited by other articles:

				T. Walther, V. Falk, M. A. Borger, and F. W. Mohr Reply to Kalavrouziotis et al. Eur. J. Cardiothorac. Surg., July 1, 2007; 32(1): 189 - 190. [Full Text] [PDF]

				J. Ye, S. V. Lichtenstein, and J. G. Webb Reply to Kalavrouziotis et al. Eur. J. Cardiothorac. Surg., July 1, 2007; 32(1): 188 - 189. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Dimitri Kalavrouziotis Jean-Francois Legare Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Kalavrouziotis, D. Articles by Legare, J.-F. Search for Related Content PubMed PubMed Citation Articles by Kalavrouziotis, D. Articles by Legare, J.-F. Related Collections Minimally invasive surgery Valve disease