DEBATE Aortic Valve Stenosis: Aspects to consider when treating aortic stenosis in the low risk "young" patient. Yakov Elgudin, MD, explains why surgery is better.
it's great to be here. Thank you very much for having me to participate to start this debate session. I'm really happy to contribute some of this information for your decision making process. Hopefully, when I was approached to participate in this debate, I was like thinking it's going to be way too far. Unreachable, just like this beautiful uh completely remote mount Everest. In addition to that, it turns out that I'm going to debate with a world authority on transkaryotic valves. Doctor Toby Rogers who is right at the top of the a mount Everest of knowledge and expertise. And uh he contributed quite a lot to spectacular by this spectacular state of the art review and transported, transported versus valve replacement in a young low risk patient, which is nothing short of the title of our debate. He also led the study for the low risk by caspit or using the trans cancer valves in the low risk cases, which bicuspid aortic valve. And this really made me think, where do I go from here? Well, I thought a little bit about where do I go from here and decided to go to lake koma. And I was looking where that George Clooney was. I couldn't find him. So I decided that's okay. I probably should come back to Cleveland. And what did I on the way back when I started thinking about this. Ah the topic of the debate is the transcripts versus surgical aortic valve aortic stenosis and the young, low risk patients. Do we know anything about it really well, it turns out we don't really know very much from any kind of real study because young lower east patients never really were tested in any studied in any of the trials that we have available for us for review. Not only the young patients. And let me tell you the cut off for very young patients is less than 65 years old. So between the patients that we deal with, it's not really that young. However, for the purposes of trial, it's very young patients unanswered questions of durability, coronary access risk of taking the valves out after they've been implanted, all those things remain completely and answered. And those are the questions that will have to present and talk to our patients when we get to it. And I would like to point out a great quote from DR Rogers paper review that at this stage priority should be given to a lifetime management of patients with severe aortic stenosis. There are some trials that looked into into low risk patients for Partner Three notion trial evolution. Low risk trial, Which is I don't know why it's missing the age for that. But usually the ages do not go down below 68 years old or most of the patients are a lot older than that and without going too much into the details on the results and specific outcomes of the low risk trials, we can say that the results were good enough. That now is part of the armamentarium and part of the options that patients have when they come in with the severe aortic stenosis. There's always a but unanswered questions are quite important to cover for real has never been investigated in a complex bicuspid aortic valves and patients with concomitant pathology that come most commonly with the bicuspid aortic valves. The future coronary access in patients with cover is a constant and quite important topic for hot debate critically though durability of Tower remains essentially unknown. I'm going to leave this the rest of this for you to read through. But that all led to the concept. That was also in a doctor Rogers paper that reflects on what one of my interventional cardiology partners doctor said it's all about a lifetime severe lifetime management of severe aortic stenosis in the young patients. And it truly is. And I thought the central picture from the review that DR Rogers published was quite telling If you look at this, the young patients who are coming in with the CVR. Text analysis have many options how they're going to proceed from that. Most of them will have a lot more operations than a lot more interventions on your valve than just once. So we're looking at the surgical aortic valve with two Towers to follow and that has what looks like quite balanced combination of risk and benefits. And then the first and followed by surgical aortic valve, which is what the authors favor apparently. And the benefits outweigh the risks or stay completely away from surgery and use multiple interventions with cutaneous valves, I would refer you to look into this because everybody who sees patients, younger patients with aortic stenosis will have to answer these questions. We do have to have these discussions every monday on monday morning selection committee meeting. There are some works some studies that published. It's a bit busy but I really just want to point out the fact that the duration of mean median follow up was quite low and the number of people that were looked at at that time after surgery was really, really small. So I don't know how much of the truly well grounded information we can draw from this durability. What we do know though is the fate of the surgically placed valves. I think this study has been published by our colleagues at the Cleveland clinic just a few years ago. To me represents one of the most fundamental reviews of the results of the tissue your tissue valves implanted surgically. The premier institution with the premier techniques of surgery follow up and everything that comes with the good results published in this paper. And this paper does show that the tissue aortic valves normally show good results. And some of these patients. About 46% of the patients at 20 years will have to have re operation. And that's where I think the stickiest point of this conversation comes up and I really would like to point sort of direct your attention to the next slide. which is this graph, If I was to think about which Yorick valve or which bio prosthetic valve to consider, I would think about what happens to patients with aortic valve replacements. If you if you think about this, half of the patients at 10 years, half of the patients are dead About 50% and then there is the competing risk on this graph is a structure of health deterioration. We we know if one of our colleagues recently very succinctly said if the patient is dead, patient is not going to have structure of health deterioration and the valve is going to not going to be a problem for the re operation. So do we have any reason to suspect that the behavior of the of the of the valve is going to be different? I don't think so. I don't think we have any reason to think that long term fate of this valve is going to be any better than a huge valves. We know that valve replacement does lead to loss of life in a post operative patient. And the patient's after valve replacement do not live as long as their counterparts that did not have that disease, except In patients who underwent a very specific type of your valve replacement with a Ross procedure. And this is only one paper. There is few of those. Now this is the paper that came out of a large group. They published excellent review of their 300 patients that are really, really young. Just about that. And the graph here indicates that the survival of these patients in 20 years is no different than the survival of anyone who did not have of general population, who did not have your problem. I would like to submit to you that this procedure does your life expectancy to the level of general population. And I also would like to submit to you that I think the conceptual sort of attitude towards lifetime management of severe aortic stenosis in the young patient can be a little bit adjusted to once in a lifetime management of severe aortic stenosis. If we do offer patients ross procedure in summary, both sovereign and viable options. Durability remains a big question for all of this. And the procedure may minimize the number of interventions on the development patients. I have to say controversy remains Even among surgeons, I would also heavily consider ross. If I need an able to valve replacement, I'll have a tavern if I need my aortic valve replaced. I want a surgical ross procedure. Thank you