Aortic valve replacement

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Aortic valve replacement
ICD-9-CM 35.21-35.22 V43.3

Aortic valve replacement is a procedure whereby the failing aortic valve of a patient's heart is replaced with an artificial heart valve. The aortic valve may need to be replaced because:

Contents

Current methods for aortic valve replacement include open-heart surgery, termed minimally invasive cardiac surgery (MICS) or surgical aortic valve replacement (SAVR) and percutaneous or transcatheter aortic valve replacement (TAVR; also PAVR, PAVI, TAVI).

A competent practising cardiologist can evaluate whether a patient could benefit from heart valve repair. [1]

History

During the late 1940s and early 1950s, the first surgical approaches towards treating aortic valve stenosis had limited success. The first attempts were valvotomies, (i.e. cutting the valve while the heart is pumping). A ball valve prosthesis placed on the descending thoracic aorta (heterotopically) was developed by Hufnagel, Harvey and others to address aortic stenosis, but had disastrous complications. Later, with the innovation of cardiopulmonary bypass, the ball valve prosthesis was placed orthotopically (i.e. in same place as the original aortic valve). This first generation of prosthetic valves was durable, but needed intense anti-coagulation, and cardiac hemodynamics were compromised. During the mid-1950s, a single-leaflet prosthesis was developed by Bahnson et al. In early 1960, Ross and Barratt-Boyes used allografts. Tissue prosthetic valves were introduced in 1965 by Binet in Paris, but they degenerated quickly because the tissue was insufficiently preserved. Carpentier solved this problem by introducing glutaraldehyde-preserved stent-mounted porcine valves. [2] [3]

Anatomy, physiology and pathophysiology

Classification of aortic stenosis severity
U/S findingsMildModerateSevere
Aortic valve area, cm2>1.51.0-1.5<1.0
Aortic valve area index, cm2/m2--0.6
Mean pressure gradient, mmHg2525-40>40
Peak jet velocity, m/s<33-4>4
Classification of aortic regurgitation severity
U/S findingsMildModerateSevere
Jet width
of left ventricular outflow tract		<25%25–65%>65%
Vena contracta width, cm<0.30.3–0.60.6
Regurgitant volume, mL per beat<3030–4960
Regurgitant fraction, %3030–49>50
Regurgitant orifice area, cm2<0.100.10–0.30>0.30

The aortic valve is semilunar (half-moon shaped) with three cusps. It separates the heart from the aorta. Each cusp is attached to the aortic wall creating a sinus; a Valsalva sinus. The origins of the two coronary arteries are sited in two Valsalva sinuses, each named after the coronary artery they supply. Leaflets are separated by commissures. The posterior leaflet is in continuation with the anterior leaflet of the mitral valve (the tissue is called the aorto-mitral curtain). [4] The aortic valve is opened during systole, the driving force for it to open is the difference in pressure between the contracting left ventricle of the heart and the aorta. During cardiac diastole (when the heart chamber gets bigger) the aortic valve closes. [5]

Aortic stenosis most commonly is the result of calcification of the cusps. Other reasons for stenosis are the bicuspid valve (some patients have only two cusps at the aortic valve instead of the usual three) and rheumatic aortic stenosis (now rare in the West). Obstruction at the level of the aortic valve causes increased pressure within the heart's left ventricle. This can lead to hypertrophy and ultimately dysfunction of the heart. While x-ray and ECG might indicate aortic stenosis, echocardiography is the diagnostic procedure of choice. US findings also help in grading the severity of the disease. In cases of symptomatic severe aortic stenosis, AVR is warranted. In cases of asymptomatic but severe aortic stenosis, more factors should be taken into consideration. [6]

Aortic regurgitation, on the other hand, has many causes: degeneration of the cusps, endocarditis, bicuspid aortic valve, aortic root dilatation, trauma, connective tissue disorders such as Marfan syndrome or Ehlers-Danlos lead to imperfect closure of the valve during diastole, hence the blood is returning from the aorta towards the left ventricle of the heart. Acute aortic regurgitation (caused by endocarditis, aortic dissection or trauma) ends up in pulmonary edema, because of the acute increase in left ventricle (LVEDP) that does not have time to adjust to the regurgitation. Chronic regurgitation, by contrast, gives the heart time to change shape, resulting in eccentric hypertrophy, which has disastrous effects on the myocardium. Ultrasound is here also the best diagnostic mobility, either it is transthoracic or transesophageal. [7]

Indications for surgery

Guidelines for aortic valve replacement

As long-term data on the survival and quality of life of people following valve replacement have become available, evidence-based guidelines for aortic valve replacement have been developed. These help healthcare professionals decide when aortic valve replacement is the best option for a patient. Two widely accepted sets of guidelines used by surgeons and cardiologists are the American Heart Association and American College of Cardiology Guidelines for the Management of Patients with Valvular Heart Disease, [8] and the European Society of Cardiology and the European Association for Cardio‑Thoracic Surgery Guidelines for the management of valvular heart disease. [9]

Aortic stenosis

Aortic stenosis is treated with aortic valve replacement in order to avoid angina, syncope, or congestive heart failure. Individuals with severe aortic stenosis are candidates for aortic valve replacement once they develop symptoms or when their heart function is impacted. Some people with asymptomatic aortic stenosis may also be candidates for aortic valve replacement, especially if symptoms appear during exercise testing. [9] Patients with moderate aortic valve stenosis who need another type of cardiac surgery (i.e. coronary artery bypass surgery) should also have their valve addressed by the surgical team if echocardiography unveils significant heart problems. [10]

Low gradient aortic stenosis with concomitant left ventricular dysfunction poses a significant question to the anesthesiologist and the patient. Stress echocardiography (i.e. with dobutamine infusion) can help determine if the ventricle is dysfunctional because of aortic stenosis, or because the myocardium lost its ability to contract. [11]

Aortic insufficiency

Many people with aortic insufficiency often do not develop symptoms until they have had the condition for many years. [12] Aortic valve replacement is indicated for symptoms such as shortness of breath, and in cases where the heart has begun to enlarge (dilate) from pumping the increased volume of blood that leaks back through the valve. [9]

Types of valves

There are two basic types of replacement heart valve: tissue (bioprosthetic) valves and mechanical valves. [13]

Tissue valves

Tissue heart valves are usually made from animal tissue (heterografts) mounted on a metal or polymer support. [14] Bovine (cow) tissue is most commonly used, but some are made from porcine (pig) tissue. [15] The tissue is treated to prevent rejection and calcification (where calcium builds up on the replacement valve and stops it working properly). [16]

Occasionally, alternatives to animal tissue valves are used: aortic homografts and pulmonary autografts. An aortic homograft is an aortic valve from a human donor, retrieved either after their death or from their heart if they are undergoing a heart transplant. [17] A pulmonary autograft, also known as the Ross procedure is where the aortic valve is removed and replaced with the patient's own pulmonary valve (the valve between the right ventricle and the pulmonary artery). A pulmonary homograft (a pulmonary valve taken from a cadaver) is then used to replace the patient's own pulmonary valve. This procedure was first performed in 1967 and is used primarily in children, as it allows the patient's own pulmonary valve (now in the aortic position) to grow with the child. [17]

Tissue valves can last 10–20 years. [18] However, they tend to deteriorate more quickly in younger patients. [19] New ways of preserving the tissue for longer are being investigated. One such preservation treatment is now being used in a commercially available tissue heart valve. In sheep and rabbit studies, the tissue (called RESILIA tissue) had less calcification than control tissue. Mid-term data on the safety and haemodynamic performance of the Inspiris RESILIA aortic bioprosthesis are encouraging. [20] [21]

Stented and stentless tissue valves are available. Stented valves come in sizes from 19 mm to 29 mm. [22] Stentless valves are directly sutured at the aortic root. The major advantage of stentless valves is that they limit patient–prosthesis mismatch (when the area of the prosthetic valve is too small in relation to the size of the patient, increasing the pressure inside the valve [23] ) and can be helpful when dealing with small aortic root. However, stentless valves take more time than stented valves to implant. [24]

Mechanical valves

Mechanical valves are made from synthetic materials, such as titanium or pyrolytic carbon. [25] Their durability is long life, while tissue valves can last for up to 15–20 years. [26] [27] [13] Since the risk of blood clots forming is higher with mechanical valves than with tissue valves, patients with mechanical heart valves are required to take anticoagulant (blood-thinning) drugs, such as warfarin, long-life, making them more prone to bleeding (1% per year). [13] The sound of the valve can be heard very rarely, often as clicks, and might be disturbing. [28] The choice of prosthetic valve should be individualized, carefully considering each patient's unique circumstances. In that context, the new generation aortic mechanical valve (On-X) offers a potential lifetime solution without need for a repeat operation, while minimizing the risks of long-term anticoagulation due to reduced anticoagulation target INR of 1.5 to 2.0. [29]

Valve selection

Valve choice is a balance between the lower durability of tissue valves and the increased risk of blood clots and bleeding with mechanical valves. Guidelines suggest that patient age, lifestyle and medical history should all be considered when choosing a valve. Tissue valves deteriorate more rapidly in young patients and during pregnancy, but they are preferable for women who wish to have children because pregnancy increases the risk of blood clots. Typically, a mechanical valve is considered for patients under 60 years old, while a tissue valve is considered for patients over the age of 65 years. [13]

Surgical replacement

Cross-section of the heart, viewed from the front. The aortic valve separates the left ventricle from the aorta. Diagram of the human heart (cropped).svg
Cross-section of the heart, viewed from the front. The aortic valve separates the left ventricle from the aorta.
Heart viewed from above, with atria removed to expose the valves. The aortic valve has three sections called leaflets that open to let blood flow. Gray495.png
Heart viewed from above, with atria removed to expose the valves. The aortic valve has three sections called leaflets that open to let blood flow.

Surgical aortic valve replacement is conventionally done through a median sternotomy, meaning the incision is made by cutting through the breastbone (sternum). Once the protective membrane around the heart (pericardium) has been opened, the patient is cannulated (aortic cannulation by a cannula placed on the aorta and a venous canulation by a single atrial venous cannula inserted through the right atrium). The patient is put on a cardiopulmonary bypass machine, also known as the heart–lung machine. This machine breathes for the patient and pumps their blood around their body while the surgeon replaces the heart valve.[ citation needed ]

Once on cardiopulmonary bypass, the patient's heart is stopped (cardioplegia). This can be done with a Y-type cardioplegic infusion catheter placed on the aorta, de-aired and connected to the cardiopulmonary bypass machine. Alternatively, a retrograde cardioplegic cannula can be inserted at the coronary sinus. Some surgeons also opt to place a vent in the left ventricle through the right superior pulmonary vein, because this helps to prevent left ventricular distention before and after cardiac arrest. When the set-up is ready, the aorta is clamped shut with a cross-clamp to stop blood pumping through the heart and cardioplegia is infused. The surgeon incises the aorta a few milometers above the sinotubular junction (just above the coronary ostia, where the coronary arteries join the aorta) – a process known as aortotomy. After this, cardioplegia is delivered directly through the ostia. [30] [31]

The heart is now still and the surgeon removes the patient's diseased aortic valve. The cusps of the aortic valve are excised, and calcium is removed (debrided) from the aortic annulus. The surgeon measures the size of the aortic annulus and fits a mechanical or tissue valve of the appropriate size. Usually the valve is fixed in place with sutures, although some sutureless valves are available. If the patient's aortic root is very small, the sutures are placed outside of the aortic root instead of at the annulus, to gain some extra space.[ citation needed ]

Once the valve is in place and the aorta has been closed, patient is placed in a Trendelenburg position and the heart is de-aired and restarted. The patient is taken off the cardiopulmonary bypass machine. Transesophageal echocardiogram (an ultrasound of the heart done through the esophagus) can be used to verify that the new valve is functioning properly. Pacing wires are usually put in place, so that the heart can be manually controlled should any complications arise after surgery. Drainage tubes are also inserted, to drain fluids from the chest. These are usually removed within 36 hours, while the pacing wires are generally left in place until right before the patient is discharged from the hospital. [30] [31]

Hospital stay and recovery time

After surgical aortic valve replacement, the patient will usually stay in an intensive care unit for 12–36 hours. Unless complications arise, the patient is then able to go home after approximately four to seven days. [32] Common complications include disturbances to the heart's rhythm (heart block), which typically require the permanent insertion of a cardiac pacemaker. [33]

Recovery from aortic valve replacement takes about three months if the patient is in good health. Patients are advised not to lift anything heavier than 10 lbs for several weeks, and not to do any heavy lifting for 4–6 months after surgery to avoid damaging their breastbone. Often patients will be referred to participate in cardiopulmonary rehabilitation, which optimizes recovery and physical function in patients with recent cardiac surgeries. This can be done in an outpatient setting. [34]

Outcomes

Surgery usually relieves the aortic disease symptoms that led the patient to the operating room. The survival curve of patients who undergo aortic valve replacements is slightly inferior to the curve of their corresponding healthy same-aged same sex population. [35] Pre-operative severe left ventricular hypertrophy is a contributing factor to morbidity. [35]

The risk of dying as a result of aortic valve replacement is estimated at 1–3%. [36] [37] [38] Combining aortic valve replacement with coronary artery bypass grafting increases the risk of mortality. [36] Older patients, as well as those who are frail and/or have other health problems (comorbidities), have a higher risk of experiencing complications. [37] Possible problems include cardiac infarction or failure, arrhythmia or heart block typically requiring the permanent insertion of a cardiac pacemaker, mediastinal bleeding, stroke and infection. Late complications include endocarditis, thromboembolic events (blood clots), prosthetic valve dysfunction and paravalvular leak (blood flowing between the edge of the prosthetic valve and the cardiac tissue). [35]

Patient–prosthesis mismatch

When dealing with a small aortic annulus, the surgeon might have to insert a prosthetic aortic valve of small size, with an orifice too small in relation to the size of the patient (patient–prosthesis mismatch). This increases the pressure of the blood flowing through the valve, and can lead to worse outcomes. [23] Various techniques, including stentless valves, have been utilized to avoid this problem. [39]

Less invasive procedures

Minimally invasive cardiac surgery

Since the late 1990s, some cardiac surgeons have been performing aortic valve replacement using an approach referred to as minimally invasive cardiac surgery (MICS). [40] Using this approach, the surgeon replaces the valve through a smaller chest incision (6–10 cm) than that for a median sternotomy. MICS typically requires shorter recovery times, and produces less visible scarring. [41] Alternatively, aortic valve replacement can be performed with right minithoracotomy approach via the 2nd or 3rd intercostal space. There is growing evidence that this approach can reduce postoperative morbidity allowing less blood loss, less pain, faster recovery, and a shorter hospital stay with no difference in mortality. [42] This approach can be particularly valuable in higher risk and elderly patients. [43]

Transcatheter aortic valve replacement

Another alternative for many high-risk or elderly patients is transcatheter aortic valve replacement (TAVR, also known as TAVI, transcatheter aortic valve implantation). Rather than removing the existing valve, the new valve is pushed through it in a collapsed state. It is delivered to the site of the existing valve through a tube called a catheter, which may be inserted through the femoral artery in the thigh (transfemoral approach), or using a small incision in the chest and then through a large artery or the tip of the left ventricle (transapical approach). [44] Fluoroscopy and transthoracic echocardiogram (TTE) are visual aids used to guide the process. [44] Once the collapsed replacement valve is in place it is expanded, pushing the old valve's leaflets out of the way. [45]

Guidelines suggest TAVR for most patients aged 75 years and older, and surgical aortic valve replacement for most younger patients. [46] Ultimately, the choice of treatment is based on many factors. [47] [46]

Systematic reviews have addressed this comparison: [48] [49]

See also

Related Research Articles

<span class="mw-page-title-main">Aortic stenosis</span> Narrowing of the exit of the hearts left ventricle

Aortic stenosis is the narrowing of the exit of the left ventricle of the heart, such that problems result. It may occur at the aortic valve as well as above and below this level. It typically gets worse over time. Symptoms often come on gradually with a decreased ability to exercise often occurring first. If heart failure, loss of consciousness, or heart related chest pain occur due to AS the outcomes are worse. Loss of consciousness typically occurs with standing or exercising. Signs of heart failure include shortness of breath especially when lying down, at night, or with exercise, and swelling of the legs. Thickening of the valve without causing obstruction is known as aortic sclerosis.

<span class="mw-page-title-main">Coronary artery bypass surgery</span> Surgical procedure to restore normal blood flow to an obstructed coronary artery

Coronary artery bypass surgery, also known as coronary artery bypass graft, is a surgical procedure to treat coronary artery disease (CAD), the buildup of plaques in the arteries of the heart. It can relieve chest pain caused by CAD, slow the progression of CAD, and increase life expectancy. It aims to bypass narrowings in heart arteries by using arteries or veins harvested from other parts of the body, thus restoring adequate blood supply to the previously ischemic heart.

<span class="mw-page-title-main">Aortic valve</span> Valve in the human heart between the left ventricle and the aorta

The aortic valve is a valve in the heart of humans and most other animals, located between the left ventricle and the aorta. It is one of the four valves of the heart and one of the two semilunar valves, the other being the pulmonary valve. The aortic valve normally has three cusps or leaflets, although in 1–2% of the population it is found to congenitally have two leaflets. The aortic valve is the last structure in the heart the blood travels through before stopping the flow through the systemic circulation.

<span class="mw-page-title-main">Cardiac catheterization</span> Insertion of a catheter into a chamber or vessel of the heart

Cardiac catheterization is the insertion of a catheter into a chamber or vessel of the heart. This is done both for diagnostic and interventional purposes.

The Rastelli procedure is an open heart surgical procedure developed by Italian physician and cardiac surgery researcher, Giancarlo Rastelli, in 1967 at the Mayo Clinic, and involves using a pulmonary or aortic homograft conduit to relieve pulmonary obstruction in double outlet right ventricle with pulmonary stenosis.

<span class="mw-page-title-main">Artificial heart valve</span> Replacement of a valve in the human heart

An artificial heart valve is a one-way valve implanted into a person's heart to replace a heart valve that is not functioning properly. Artificial heart valves can be separated into three broad classes: mechanical heart valves, bioprosthetic tissue valves and engineered tissue valves.

<span class="mw-page-title-main">Valvular heart disease</span> Disease in the valves of the heart

Valvular heart disease is any cardiovascular disease process involving one or more of the four valves of the heart. These conditions occur largely as a consequence of aging, but may also be the result of congenital (inborn) abnormalities or specific disease or physiologic processes including rheumatic heart disease and pregnancy.

<span class="mw-page-title-main">Mitral valve repair</span> Cardiac surgery procedure

Mitral valve repair is a cardiac surgery procedure performed by cardiac surgeons to treat stenosis (narrowing) or regurgitation (leakage) of the mitral valve. The mitral valve is the "inflow valve" for the left side of the heart. Blood flows from the lungs, where it picks up oxygen, through the pulmonary veins, to the left atrium of the heart. After the left atrium fills with blood, the mitral valve allows blood to flow from the left atrium into the heart's main pumping chamber called the left ventricle. It then closes to keep blood from leaking back into the left atrium or lungs when the ventricle contracts (squeezes) to push blood out to the body. It has two flaps, or leaflets, known as cusps.

<span class="mw-page-title-main">Aortic valve repair</span> Treatment of aortic regurgitation

Aortic valve repair or aortic valve reconstruction is the reconstruction of both form and function of a dysfunctional aortic valve. Most frequently it is used for the treatment of aortic regurgitation. It can also become necessary for the treatment of aortic aneurysm, less frequently for congenital aortic stenosis.

<span class="mw-page-title-main">Aortic valvuloplasty</span>

Aortic valvuloplasty, also known as balloon aortic valvuloplasty (BAV), is a procedure used to improve blood flow through the aortic valve in conditions that cause aortic stenosis, or narrowing of the aortic valve. It can be performed in various patient populations including fetuses, newborns, children, adults, and pregnant women. The procedure involves using a balloon catheter to dilate the narrowed aortic valve by inflating the balloon.

<span class="mw-page-title-main">Ascending aorta</span> Part of the heart

The ascending aorta (AAo) is a portion of the aorta commencing at the upper part of the base of the left ventricle, on a level with the lower border of the third costal cartilage behind the left half of the sternum.

<span class="mw-page-title-main">Ortner's syndrome</span> Medical condition

Ortner's syndrome is a rare cardiovocal syndrome and refers to recurrent laryngeal nerve palsy from cardiovascular disease. It was first described by Norbert Ortner (1865–1935), an Austrian physician, in 1897.

<span class="mw-page-title-main">Valve replacement</span> Replacement of one or more of the heart valves

Valve replacement surgery is the replacement of one or more of the heart valves with either an artificial heart valve or a bioprosthesis. It is an alternative to valve repair.

<span class="mw-page-title-main">Transcatheter aortic valve replacement</span> Technique for replacement of the aortic valve in a heart

Transcatheter aortic valve replacement (TAVR) is the replacement of the aortic valve of the heart through the blood vessels. The replacement valve is delivered via one of several access methods: transfemoral, transapical, subclavian, direct aortic, and transcaval, among others.

Mitral valve replacement is a procedure whereby the diseased mitral valve of a patient's heart is replaced by either a mechanical or tissue (bioprosthetic) valve.

<span class="mw-page-title-main">Hybrid cardiac surgery</span>

A hybrid cardiac surgical procedure in a narrow sense is defined as a procedure that combines a conventional, more invasive surgical part with an interventional part, using some sort of catheter-based procedure guided by fluoroscopy imaging in a hybrid operating room (OR) without interruption. The hybrid technique has a reduced risk of surgical complications and has shown decreased recovery time. It can be used to treat numerous heart diseases and conditions and with the increasing complexity of each case, the hybrid surgical technique is becoming more common.

<span class="mw-page-title-main">Apicoaortic conduit</span> Cardiothoracic surgical process

Apicoaortic Conduit (AAC), also known as Aortic Valve Bypass (AVB), is a cardiothoracic surgical procedure that alleviates symptoms caused by blood flow obstruction from the left ventricle of the heart. Left ventricular outflow tract obstruction (LVOTO) is caused by narrowing of the aortic valve (aortic stenosis) and other valve disorders. AAC, or AVB, relieves the obstruction to blood flow by adding a bioprosthetic valve to the circulatory system to decrease the load on the aortic valve. When an apicoaortic conduit is implanted, blood continues to flow from the heart through the aortic valve. In addition, blood flow bypasses the native valve and exits the heart through the implanted valved conduit. The procedure is effective at relieving excessive pressure gradient across the natural valve. High pressure gradient across the aortic valve can be congenital or acquired. A reduction in pressure gradient results in relief of symptoms.

<span class="mw-page-title-main">Decellularized homograft</span>

Decellularized homografts are donated human heart valves which have been modified via tissue engineering. Several techniques exist for decellularization with the majority based on detergent or enzymatic protocols which aim to eliminate all donor cells while preserving the mechanical properties of the remaining matrix.

The Yasui procedure is a pediatric heart operation used to bypass the left ventricular outflow tract (LVOT) that combines the aortic repair of the Norwood procedure and a shunt similar to that used in the Rastelli procedure in a single operation. It is used to repair defects that result in the physiology of hypoplastic left heart syndrome even though both ventricles are functioning normally. These defects are common in DiGeorge syndrome and include interrupted aortic arch and LVOT obstruction (IAA/LVOTO); aortic atresia-severe stenosis with ventricular septal defect (AA/VSD); and aortic atresia with interrupted aortic arch and aortopulmonary window. This procedure allows the surgeon to keep the left ventricle connected to the systemic circulation while using the pulmonary valve as its outflow valve, by connecting them through the ventricular septal defect. The Yasui procedure includes a modified Damus–Kaye–Stansel procedure to connect the aortic and pulmonary roots, allowing the coronary arteries to remain perfused. It was first described in 1987.

The Hancock Aortic Tissue Valve is a prosthetic heart valve used in cardiac surgery to replace a damaged or diseased aortic valve. It is a bioprosthetic valve, meaning it is constructed using biological tissues, specifically porcine (pig) valve tissue. This valve is widely utilized in the field of cardiovascular surgery to restore proper blood flow through the heart.

References

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  31. 1 2 Emery 2017, pp. 652–653.
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  33. ↑ Kim, You Ho; Lee, Jae Won; Chung, Cheol Hyun; Choi, Kee Joon; Nam, Gi Byoung; Choo, Suk Jung; Jung, Sung-Ho; Kim, Joon Bum; Hwang, Jongmin (2017-11-01). "Conduction disturbance after isolated surgical aortic valve replacement in degenerative aortic stenosis". The Journal of Thoracic and Cardiovascular Surgery. 154 (5): 1556–1565.e1. doi: 10.1016/j.jtcvs.2017.05.101 . ISSN   0022-5223. PMID   28712585.
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  36. 1 2 Shahian, David M.; Wormuth, David W.; Paone, Gaetano; Fernandez, Felix G.; Badhwar, Vinay; Jacobs, Jeffrey P.; D'Agostino, Richard S. (2019-01-01). "The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2019 Update on Outcomes and Quality". The Annals of Thoracic Surgery. 107 (1): 24–32. doi: 10.1016/j.athoracsur.2018.10.004 . ISSN   0003-4975. PMID   30423335.
  37. 1 2 "Aortic valve replacement - Risks". nhs.uk. 2017-10-20. Retrieved 2019-07-30.
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  39. ↑ Fullerton 2014, p. 465.
  40. ↑ Merk, Denis R.; Lehmann, Sven; Holzhey, David M.; Dohmen, Pascal; Candolfi, Pascal; Misfeld, Martin; Mohr, Friedrich W.; Borger, Michael A. (2015). "Minimal invasive aortic valve replacement surgery is associated with improved survival: a propensity-matched comparison†". European Journal of Cardio-Thoracic Surgery. 47 (1): 11–17. doi: 10.1093/ejcts/ezu068 . ISSN   1873-734X. PMID   24599160.
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  43. ↑ Lamelas, J; Mawad, M; Williams, R; Weiss, UK; Zhang, Q; LaPietra, A (March 2018). "Isolated and concomitant minimally invasive minithoracotomy aortic valve surgery". The Journal of Thoracic and Cardiovascular Surgery. 155 (3): 926–936.e2. doi: 10.1016/j.jtcvs.2017.09.044 . PMID   29061465.
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  47. ↑ Lytvyn, Lyubov; Guyatt, Gordon H; Manja, Veena; Siemieniuk, Reed A; Zhang, Yuan; Agoritsas, Thomas; Vandvik, Per O (2016). "Patient values and preferences on transcatheter or surgical aortic valve replacement therapy for aortic stenosis: a systematic review". BMJ Open. 6 (9): e014327. doi:10.1136/bmjopen-2016-014327. ISSN   2044-6055. PMC   5051506 . PMID   27687903.
  48. 1 2 Sakurai Y, Yokoyama Y, Fukuhara S, Takagi H, Kuno T (2022). "Complete transcatheter versus surgical approach to aortic stenosis with coronary artery disease: A systematic review and meta-analysis". J Thorac Cardiovasc Surg: S0022–5223(22)00893–5. doi:10.1016/j.jtcvs.2022.08.006. PMID   36150940. S2CID   251677685.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  49. 1 2 Kheiri B, Osman M, Bakhit A, Radaideh Q, Barbarawi M, Zayed Y; et al. (2020). "Meta-Analysis of Transcatheter Aortic Valve Replacement in Low-Risk Patients". Am J Med. 133 (2): e38–e41. doi:10.1016/j.amjmed.2019.06.020. PMID   31295442. S2CID   195892678.{{cite journal}}: CS1 maint: multiple names: authors list (link)

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