**7. Surgery**

Heart Block: High grade atrioventricular block and consecutive pacemaker implantation are frequent (especially in CoreValve) complications following TAVI. CoreValve implantation is associated with a need for permanent pacemaker in 20 % of patients compared with in 5 % of patients implanted with the balloon expandable valves [78]. Potential risk factors include aggressive over sizing, low implantation of the prosthesis, small annulus diameter, using

Cardiogenic Schock and low cardiac output: This complication may be induced by ischemia, rapid pacing, volume depletion, anesthesia and interruption in cardiac output during valve implantation. Vasopresor agents and intraaortic balloon support to maintain adequate perfusion pressure are often helpful. Rarely elective femoral cardiopulmonary bypass is an

Paravalvuler Regurgitation: However paravalvuler aortic regurgitation is common, occurring in about 85 %, Grade > 2 + regurgitation is found in 7-24 % [72,73].Trivial, mild and even moderate degrees of regurgitation seem well tolerated, although grade > 2+ regurgitation associated with increased short and long term mortality [81]. Causes of paravalvular regurgi‐ tation include a heavily calcified annulus,large annulus size, an undersized prosthesis, device failure and inadequate balloon aortic valvuloplasty. Redilatation or implantation of a second,

Acute Kidney Injury: Angiographic contrast injection, hypotension, atheroembolism, peripro‐ cedural blood transfusion might contribute to acute renal failure. The incidence of acute kidney injury after TAVI has been reported with incidence of 8 %. Additionally need for hemodialysis has ranged from 1.4% to 15.7 %, respectively [82]. Predictors of acute kidney injury include hypertension, decrease baseline renal function, previous myocardial infarction, high logistic

Other Complication: Other significant and very rare complications include aortic rupture, aortic dissection, periaortic hematoma, ventricular or aortic embolization of valve, structural valve failure, cardiac tamponade and acute mitral regurgitation due to mitral valve apparatus

Valve-in-valve — A valve-in-valve procedure involves catheter-based valve implantation inside an already implanted bioprosthetic valve. This approach may provide an alternative to replacement of a degenerated surgically-implanted valve, or a means of salvaging suboptimal

Conclusion: Despite continual technical advancement of TAVI devices and procedures, the combined mortality and morbidity is still high in the range of 5-10%, especially when we are facing a group of high surgical risk patients. In addition TAVR offered no survival benefit compared to standard therapy in patients with an STS score of > 15 % because of high degree of comorbid conditions in these patients. In the future when it is a safer and more reliable procedure and further refinement of the device (i.e. smaller size delivery systems and multiple valve size options) is done, utilization of the procedure in patients with lower surgical risk

implantation of a catheter-based valve during the initial implantation procedure.

CoreValve and the presence of preexisting infranodal block such as RBBB [79, 80].

option for patients at hemodynamic instability.

overlapping transcathater valve can often correct the problem.

EuroSCORE and chronic obstructive pulmonary disease [83].

damage [73-74].

396 Calcific Aortic Valve Disease

may be possible.

In 1912, Theodore Tuffier was the first to attempt opening AS using his finger. Russel Brock and then Bailey used dilatators for stenotic aortic valves. Today more than 1000 patients have aortic valve surgery per year and surgery for AS is more common than it is for aortic insuffi‐ ciency [84]. Aortic valve surgery has been improved with the developments of new technolo‐ gies in cardiopulmonary bypass techniques and valve industry. Approximately 2% to 5% of elderly individuals aged 75 years present with signs of severe AS and they are scheduled for elective AVR. AVR is the treatment of choice for patients with severe degenerative AS, offering both symptomatic relief and a potential for improved long term survival [85].

It's obvious that AVR is indicated in all symptomatic patients and asymptomatic patients with severe AS undergoing open heart surgery. The surgery should immediately be programmed if the patient becomes symptomatic. Despite LV dysfunction, the risk of aortic valve replace‐ ment for AS was satisfactory and related to meanaortic gradient and additional coronary artery disease, and long-term survival was related to also coronary disease and cardiac output [86].

5-year survival for adults after aortic valve replacement is 80-90%. The results of the conven‐ tional surgery for octogenarians are also satisfactory and 5% to 10% of mortality is noted for isolated AVR (2). On the other hand, elderly patients stay longer in the hospitals and intensive care units during the postoperative period [87]. United Kingdom heart valve registry observed 1100 elderly patients (56% women) who underwent AVR that the 30-day mortality was 6.6% [88]. The actuarial survival was 89% at 1 year, 79% at 3 years, 69% at 5 years, and 46% at 8 years. The mortality is rising up to 10% per year for the patient becoming symptomatic. The indications for AVR in patients with AS according to the current ACC/AHA guidelines are listed in Table 2 [89]. Although the surgery for the asymptomatic patients is preferred due to sudden death, surgery for asymptomatic octogenarians is controversial. The complex cardiac procedures have high risks for elderly patients.

The mortality rate of valve surgery and risk of sudden death without surgery have to be carefully considered. Postoperatively symptoms diminish and quality of life is improved in the majority of patients ≥75 years who had undergone aortic valve surgery, but long term survival was not affected [90].

AVR usually performed under general anesthesia using conventional techniques of open heart surgery with median sternotomy. Minimally invasive surgery has continued to be an evolving concept after the first publication of Cosgrove in 1996 [91] Minimally invasive procedures are associated with acceptable mortality and morbidity rates even in high risk patients. 30-day inhospital mortality was 0.8% for 1,103 minimally invasive aortic valve procedures [92].

The major advantages of minimally access surgeries are improved cosmesis with reduced insicion size, decreased surgical trauma, less pain, better respiratory function and early return to work [92].

These procedures can be performed through different approaches. These are upper mini sternotomy, transverse sternotomy and right parasternal or anterolateral mini thoracotomy,

#### **Class I**

AVR is indicated for symptomatic patients with severeAS.\* *(Level of Evidence: B)*

AVR is indicated for patientswith severe AS\* undergoing coronaryartery bypass graft surgery(CABG). *(Level of Evidence: C)*

AVR is indicated for patientswith severe AS\* undergoing surgeryon the aorta or other heartvalves. *(Level of Evidence: C)*

for elderly patients and women who want to be pregnant because long term anticoagulation use is not required. The other situation for the patients undergoing AVR is the injurious effects of Cardiopulmonary bypass to the life organs. This results as a systemic inflammatory response and this may affect the post-operative course of the patients. Paroxysmal or chronic AF is a risk factor for mortality in patients with severe AS and a LVEF <35% undergoing AVR. Of 83 elderly patients with severe AS and an LVEF <35%, 29 (35%) had paroxysmal or chronic AF [86]. The perioperative mortality was 24% in the group with AF versus 5,5% in the group

The Ross procedure is another surgical technique for aortic valve replacement. This is more commonly used in pediatric cases but also good alternative for especially young adult patients and women want have child. In this operation the patient's own pulmonary valve and main pulmonary artery are used as an autograft and they are implanted to the aortic position, with

The primary indication for the Ross procedure is to provide a permanent valve replacement among younger patients who will grow potentially. Other possible indications include complex left ventricular outflow obstructive disease, native or prosthetic valve endocarditis,

One of the most commonly seen complications of Ross procedure is autograft regurgitation and sinus or ascending aortic dilatation, which can usually be corrected with a valve-sparing root replacement. In a study 212 patients underwent Ross aortic valve replacement; 51% were older than 19 years old. There were just 2 early deaths. At 15 years, freedom from autograft sinus or ascending aortic dilatation was 79%, autograft dysfunction, 91%. And actuarial

Recent years aortic valve repair also become popular when valve morphology is amenable to repair. But this is a limited procedure among patients who have aortic regurgitation (AR) without aortic stenosis. Aortic valve repair is commonly indicated commonly in patients with

, Omer A. Sayın<sup>4</sup>

and Huseyin Oflaz1

Current Treatment Options in Aortic Stenosis

http://dx.doi.org/10.5772/54355

399

and adult aortic insufficiency with a dilated aortic annulus [98].

a dilated aortic annulus without any degeneration of the leaflets [100]

, Ahmet Ekmekci3

1 Istanbul University, Istanbul School of Medicine, Department of Cardiology, Turkey

2 Istanbul University, Istanbul School of Medicine, Department of Internal Medicine, Divi‐

3 Istanbul University, Istanbul School of Medicine, Department of Internal Medicine, Turkey

4 Istanbul University, Istanbul School of Medicine, Department of Cardiovascular Surgery,

without AF.

reimplantation of coronary arteries.

survival was 98% [99].

**Author details**

sion of Geriatrics, Turkey

, Fatih Tufan2

Fahrettin Oz1

Turkey

AVR is recommended for patientswith severe AS\* and LV systolicdysfunction (ejection fractionless than 0.50). *(Level of Evidence: C)*

#### **Class IIa**

AVR is reasonable for patients with moderate AS\*undergoingCABG or surgery on the aorta or other heart valves(see Section3.7 on combined multiple valve disease and Section10.4 on AVRin patients undergoing CABG). *(Level of Evidence: B)*

#### **Class IIb**

AVR may be considered for asymptomatic patientswith severeAS\* and abnormal response to exercise (e.g., developmentofsymptoms or asymptomatic hypotension). *(Level of Evidence: C)*

AVR may be considered for adults with severe asymptomaticAS\* if there is a high likelihood of rapid progression (age,calcification, and CAD) or if surgery might be delayed at thetime of symptom onset. *(Level of Evidence: C)*

AVR may beconsidered in patients undergoing CABG who havemild AS\* whenthere is evidence, such as moderate to severevalve calcification,that progression may be rapid. *(Level of Evidence: C)*

AVRmay be considered for asymptomatic patients with extremelysevereAS (aortic valve area less than 0.6 cm2, mean gradientgreaterthan 60 mm Hg, and jet velocity greater than 5.0 m persecond)when the patient's expected operative mortalityis 1.0%or less. *(Level of Evidence: C)*

#### **Class III**

AVR is not useful for the prevention of sudden deathin asymptomaticpatients with AS who have none of the findingslisted underthe class IIa/IIb recommendations. *(Level of Evidence: B)*

**Table 2.** Indications for Aortic Valve Replacement.

using port access technique or not. Although mini sternotomy is the most common approach, the outcomes after right anterior thoracotomy have satisfactory results [93]. The arterial cannulation sites are either aorta or femoral artery. The venous cannulation sites are right atrium, femoral vein or percutanous supeior vena cava with femoral vein. The incisions differ from 5 to 10 cm and small incisions may provide low infection rates [94]. This procedure has advantages such as less 1 surgical trauma, decreased pain and faster recovery. It reduces blood transfusions and shortens the length of hospital and ICU stay [95]. It is a safe operation and results lower incidence of atelectasis inthe cardiac ICU [96]. Port access aortic surgery also allows patients to be extubated earlier [97]. Avoidance of full sternotomy for patients prompts a comfortable postoperative period. Although the number of the aortic valve procedures increase worldwide, the ideal valve choice is still a debate. There are several options for valves. These are mechanical valve prosthesis, stented and stentless bioprosthetic valves, aortic homograft and pulmonary autograft. The use of these valves differs from patient to patient due to comorbidities and anticoagulant needs. The bioprosthetic valves are good alternatives for elderly patients and women who want to be pregnant because long term anticoagulation use is not required. The other situation for the patients undergoing AVR is the injurious effects of Cardiopulmonary bypass to the life organs. This results as a systemic inflammatory response and this may affect the post-operative course of the patients. Paroxysmal or chronic AF is a risk factor for mortality in patients with severe AS and a LVEF <35% undergoing AVR. Of 83 elderly patients with severe AS and an LVEF <35%, 29 (35%) had paroxysmal or chronic AF [86]. The perioperative mortality was 24% in the group with AF versus 5,5% in the group without AF.

The Ross procedure is another surgical technique for aortic valve replacement. This is more commonly used in pediatric cases but also good alternative for especially young adult patients and women want have child. In this operation the patient's own pulmonary valve and main pulmonary artery are used as an autograft and they are implanted to the aortic position, with reimplantation of coronary arteries.

The primary indication for the Ross procedure is to provide a permanent valve replacement among younger patients who will grow potentially. Other possible indications include complex left ventricular outflow obstructive disease, native or prosthetic valve endocarditis, and adult aortic insufficiency with a dilated aortic annulus [98].

One of the most commonly seen complications of Ross procedure is autograft regurgitation and sinus or ascending aortic dilatation, which can usually be corrected with a valve-sparing root replacement. In a study 212 patients underwent Ross aortic valve replacement; 51% were older than 19 years old. There were just 2 early deaths. At 15 years, freedom from autograft sinus or ascending aortic dilatation was 79%, autograft dysfunction, 91%. And actuarial survival was 98% [99].

Recent years aortic valve repair also become popular when valve morphology is amenable to repair. But this is a limited procedure among patients who have aortic regurgitation (AR) without aortic stenosis. Aortic valve repair is commonly indicated commonly in patients with a dilated aortic annulus without any degeneration of the leaflets [100]
