Formal consensus study on surgery to replace the aortic valve in adults aged 18-60 years

Stoica, Serban; Beard, Chloe; Takkenberg, Johanna J M; Mokhles, Mostafa M; Turner, Mark; Pepper, John; Hopewell-Kelly, Noreen; Benedetto, Umberto; Nashef, Samer A M; El-Hamamsy, Ismail; Skillington, Peter; Glauber, Mattia; De Paulis, Ruggero; Tseng, Elaine; Meuris, Bart; Sitges, Marta; Delgado, Victoria; Krane, Markus; Kostolny, Martin; Pufulete, Maria

Abstract

Objective: There is uncertainty about surgical procedures for adult patients aged 18-60 years undergoing aortic valve replacement (AVR). Options include conventional AVR (mechanical, mAVR; tissue, tAVR), the pulmonary autograft (Ross) and aortic valve neocuspidisation (Ozaki). Transcatheter treatment may be an option for selected patients. We used formal consensus methodology to make recommendations about the suitability of each procedure. Methods: A working group, supported by a patient advisory group, developed a list of clinical scenarios across seven domains (anatomy, presentation, cardiac/non-cardiac comorbidities, concurrent treatments, lifestyle, preferences). A consensus group of 12 clinicians rated the appropriateness of each surgical procedure for each scenario on a 9-point Likert scale on two separate occasions (before and after a 1-day meeting). Results: There was a consensus that each procedure was appropriate (A) or inappropriate (I) for all clinical scenarios as follows: mAVR: total 76% (57% A, 19% I); tAVR: total 68% (68% A, 0% I); Ross: total 66% (39% A, 27% I); Ozaki: total 31% (3% A, 28% I). The remainder of percentages to 100% reflects the degree of uncertainty. There was a consensus that transcatheter aortic valve implantation is appropriate for 5 of 68 (7%) of all clinical scenarios (including frailty, prohibitive surgical risk and very limited life span). Conclusions: Evidence-based expert opinion emerging from a formal consensus process indicates that besides conventional AVR options, there is a high degree of certainty about the suitability of the Ross procedure in patients aged 18-60 years. Future clinical guidelines should include the option of the Ross procedure in aortic prosthetic valve selection.

• Journal Article Type: Article
• Acceptance Date: Dec 12, 2022
• Online Publication Date: Feb 27, 2023
• Publication Date: May 15, 2023
• Deposit Date: May 18, 2023
• Publicly Available Date: May 18, 2023
• Journal: Heart
• Print ISSN: 1355-6037
• Electronic ISSN: 1468-201X
• Publisher: BMJ Publishing Group
• Peer Reviewed: Peer Reviewed
• Volume: 109
• Pages: 857-865
• DOI: https://doi.org/10.1136/heartjnl-2022-321740
• Keywords: Aortic and vascular disease, heart valve prosthesis, transcatheter aortic valve replacement, aortic valve insufficiency, aortic valve stenosis, heart valve prosthesis implantation
• Public URL: https://uwe-repository.worktribe.com/output/10537602
• Publisher URL: https://heart.bmj.com/content/early/2023/02/26/heartjnl-2022-321740