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{\u0022basePath\u0022:\u0022\\\/\u0022,\u0022pathPrefix\u0022:\u0022\u0022,\u0022highwire\u0022:{\u0022markup\u0022:[{\u0022requested\u0022:\u0022full-text\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;11\\\/9\\\/10\u0022},{\u0022requested\u0022:\u0022long\u0022,\u0022variant\u0022:\u0022full-text\u0022,\u0022view\u0022:\u0022full\u0022,\u0022pisa\u0022:\u0022spmdc;11\\\/9\\\/10\u0022}],\u0022ac\u0022:{\u0022spmdc;11\\\/9\\\/10\u0022:{\u0022access\u0022:{\u0022reprint\u0022:true,\u0022full\u0022:true},\u0022pisa_id\u0022:\u0022spmdc;11\\\/9\\\/10\u0022,\u0022atom_uri\u0022:\u0022\u0022,\u0022jcode\u0022:\u0022spmdc\u0022}}},\u0022googleanalytics\u0022:{\u0022trackOutbound\u0022:1,\u0022trackMailto\u0022:1,\u0022trackDownload\u0022:1,\u0022trackDownloadExtensions\u0022:\u00227z|aac|arc|arj|asf|asx|avi|bin|csv|doc(x|m)?|dot(x|m)?|exe|flv|gif|gz|gzip|hqx|jar|jpe?g|js|mp(2|3|4|e?g)|mov(ie)?|msi|msp|pdf|phps|png|ppt(x|m)?|pot(x|m)?|pps(x|m)?|ppam|sld(x|m)?|thmx|qtm?|ra(m|r)?|sea|sit|tar|tgz|torrent|txt|wav|wma|wmv|wpd|xls(x|m|b)?|xlt(x|m)|xlam|xml|z|zip\u0022,\u0022trackUrlFragments\u0022:1},\u0022ajaxPageState\u0022:{\u0022js\u0022:{\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/jquery.cluetip.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.hoverIntent.js\u0022:1,\u0022sites\\\/all\\\/libraries\\\/cluetip\\\/lib\\\/jquery.bgiframe.min.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_at_symbol.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/highwire\\\/highwire\\\/plugins\\\/highwire_markup_process\\\/js\\\/highwire_article_reference_popup.js\u0022:1,\u0022sites\\\/all\\\/modules\\\/contrib\\\/google_analytics\\\/googleanalytics.js\u0022:1,\u00220\u0022:1}}});\n\/\/--\u003E\u003C!]]\u003E\n\u003C\/script\u003E\n\u003Clink type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/cdn\/css\/http\/css_Xg7z6oCTVgud_Q0huYz9x9iiD5H_2YPSJ5z2ZViSWdY.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003ESurgical valve replacement or repair is the gold standard treatment of severe valvular heart disease and severe symptomatic valve stenosis [Guidoin R et al. \u003Cem\u003EAnn NY Acad Sci\u003C\/em\u003E 2010]. This article discusses recent developments and challenges in the field of surgery for valvular disease.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EInterventional Techniques \u0026amp; Devices\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EValvular Disease\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003ESurgical valve replacement or repair is the gold standard treatment of severe valvular heart disease and severe symptomatic valve stenosis [Guidoin R et al. \u003Cem\u003EAnn NY Acad Sci\u003C\/em\u003E 2010]. Andrew Chukwuemeka, MD, FRCS, Imperial College Healthcare NHS Trust, London, United Kingdom (UK), discussed recent developments and challenges in the field of surgery for valvular disease.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EIn the past decade, there has been an exponential increase in percutaneous coronary intervention (PCI) compared with a leveling off of coronary artery bypass surgery in the UK (CABG; \u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E). However, the decline in CABG has been offset by marked increases in the annual volume of aortic and mitral valve operations [The Society for Cardiothoracic Surgery in Great Britain \u0026amp; Ireland. \u003Cem\u003ESixth National Adult Cardiac Surgical Database Report 2008\u003C\/em\u003E].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/10\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Annual Incidence of PCI and CABG in the UK.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1923281117\u0022 data-figure-caption=\u0022Annual Incidence of PCI and CABG in the UK.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/10\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/10\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/10\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12560\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-4\u0022 class=\u0022first-child\u0022\u003EAnnual Incidence of PCI and CABG in the UK.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced with permission from A. Chukwuemeka, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-5\u0022\u003EMany of these procedures were performed in elderly patients with multiple comorbidities\u2014a challenging change in demographics for cardiac surgeons (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E). In spite of increasing age, postoperative survival remains high. \u201cThe surgery is safe, effective, removes symptoms, extends survival, and improves quality of life,\u201d said Prof. Chukwuemeka, noting that from 2004 to 2008, the survival rate in patients aged \u0026gt;80 years was 65% at 5 years after surgery, which is impressive, considering the patient population that is involved [The Society for Cardiothoracic Surgery in Great Britain \u0026amp; Ireland. \u003Cem\u003ESixth National Adult Cardiac Surgical Database Report 2008\u003C\/em\u003E].\u003C\/p\u003E\u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/10\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Rise in the Number of Elderly Cardiac Surgery Patients.\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1923281117\u0022 data-figure-caption=\u0022Rise in the Number of Elderly Cardiac Surgery Patients.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/10\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/10\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/11\/9\/10\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/12561\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n            \u003Cp id=\u0022p-6\u0022 class=\u0022first-child\u0022\u003ERise in the Number of Elderly Cardiac Surgery Patients.\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced with permission from A. Chukwuemeka, MD.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EThe Challenges Ahead\u003C\/h2\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EFour main challenges lie ahead:\u003C\/p\u003E\n         \u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n               \u003Cp id=\u0022p-8\u0022\u003EAdaptation to increasingly elderly patients with significant comorbidities\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n               \u003Cp id=\u0022p-9\u0022\u003EReduction of prosthetic valve-related morbidity\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n               \u003Cp id=\u0022p-10\u0022\u003EEstablishment of minimally invasive techniques\u003C\/p\u003E\n            \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n               \u003Cp id=\u0022p-11\u0022\u003EImprovement of risk assessment\u003C\/p\u003E\n            \u003C\/li\u003E\u003C\/ul\u003E\n         \u003Cp id=\u0022p-12\u0022\u003EAs the population ages, the number of valve replacement surgeries is expected to increase sharply. Percutaneous aortic valve implantation provides an attractive alternative to standard open heart surgery in elderly patients who are considered to be at high or prohibitive surgical risk in large part due to their advanced age [Guidoin R et al. \u003Cem\u003EAnn NY Acad Sci\u003C\/em\u003E 2010].\u003C\/p\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EFor patients aged \u0026gt;70 years with severe aortic stenosis, transcatheter aortic valve implantation (TAVI) may provide a promising alternative to surgical aortic valve replacement (AVR) [Guidoin R et al. \u003Cem\u003EAnn NY Acad Sci\u003C\/em\u003E 2010; Leon MB et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2010; Smith CR et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2011]. For those with severe mitral regurgitation (MR), which also confers a poor prognosis (particularly in patients with heart failure) [Maisano F et al. \u003Cem\u003EInt J Cardiovasc Imaging\u003C\/em\u003E 2011], catheter-based mitral repair systems offer a new option.\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EMitraClip, a percutaneous mitral valve (MV) repair device, has been compared with surgery in the Endovascular Valve Edge-to-Edge Repair Study (EVEREST II) randomized trial [Maisano F et al. \u003Cem\u003EInt J Cardiovasc Imaging\u003C\/em\u003E 2011]. Two-year follow-up data from EVEREST II have shown that although a catheter-based MV repair procedure that uses the MitraClip system was less effective at reducing MR than conventional surgery, similar improvements in clinical outcomes were observed with fewer short-term adverse events [Cleland JG et al. \u003Cem\u003EEur J Heart Fail\u003C\/em\u003E 2011; Feldman T et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003ESutureless implantation of the prosthesis is another promising approach that has the potential to shorten aortic crossclamp time, thereby reducing morbidity and mortality in elderly and high-risk patients. A recent study found it possible to implant a well-functioning, sutureless, stent-mounted valve in the aortic position in less than 20 minutes of aortic crossclamping\u2014a finding that was associated with excellent early clinical and hemodynamic outcomes in high-risk patients [Flameng W et al. \u003Cem\u003EJ Thorac Cardiovasc Surg\u003C\/em\u003E 2011].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EReducing Prosthetic Valve-Related Mortality\u003C\/h2\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EThere is no perfect valve substitute. All prostheses, whether mechanical or biological, involve some compromise, and all introduce a new disease process: the prosthetic disease. Considerations for choosing between a mechanical valve and a bioprosthesis include hemodynamic performance, long-term durability, and the need for chronic anticoagulation [Goncalo F et al. \u003Cem\u003EInteract Cardiovasc Thorac Surg\u003C\/em\u003E 2009].\u003C\/p\u003E\n         \u003Cp id=\u0022p-17\u0022\u003EThere is a trend toward use of more bioprosthetic valves [Seeburger J et al. \u003Cem\u003ECardiac Surgery\u003C\/em\u003E 2009]. The main advantage with bioprosthetic valves is that they do not require lifelong anticoagulant therapy due to lower thrombotic risk, although mechanical valves are more durable. For most patients with a bioprosthetic valve, structural valve deterioration starts around 5 years postimplantation and increases rapidly [Tillquist MN, Maddox TM. \u003Cem\u003EPatient Prefer Adherence\u003C\/em\u003E 2011].\u003C\/p\u003E\n         \u003Cp id=\u0022p-18\u0022\u003EAnother option is reconstructive valve repair. For example, aortic valve-sparing operations in patients with Marfan syndrome provide excellent clinical outcomes: \u0026lt;1% operative mortality, 87.2% 15-year survival, and 79.2% freedom from more-than-mild aortic insufficiency at 15 years [David TE. \u003Cem\u003EJ Thorac Cardiovasc Surg\u003C\/em\u003E 2009].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-3\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EEstablishing Minimally Invasive Techniques\u003C\/h2\u003E\n         \u003Cp id=\u0022p-19\u0022\u003EControversy surrounds the use of minimally invasive AVR. A 2008 meta-analysis suggested marginal benefits in perioperative mortality (4667 patients; OR, 0.72; 95% CI, 0.51 to 1.00; p=0.05), intensive care unit stay, total hospital stay, and ventilation time in the minimal access AVR group. However, crossclamp, cardiopulmonary bypass, and total operation times were longer [Murtuza B et al. \u003Cem\u003EAnn Thorac Surg\u003C\/em\u003E 2008]. Another meta-analysis showed that ministernotomy can be safely performed for AVR, without increased risk of death or other major complications; however, few objective advantages were observed [Brown ML et al. \u003Cem\u003EJ Thorac Cardiovasc Surg\u003C\/em\u003E 2009].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-4\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EImproving Risk Assessment\u003C\/h2\u003E\n         \u003Cp id=\u0022p-20\u0022\u003EIn 1999, the EuroSCORE risk assessment system was recommended for widespread use [Nashef SA et al. \u003Cem\u003EEur J Cardiothorac Surg\u003C\/em\u003E 1999]. But, according to Prof. Chukwuemeka, its predictive assessment for individual patients was limited, and it was a poor tool for valvular heart disease compared with other cardiac surgeries (only 30% of patients in the dataset).\u003C\/p\u003E\n         \u003Cp id=\u0022p-21\u0022\u003EA recent report by The Working Group on Valvular Heart Disease of the European Society of Cardiology reviewed the most widely used risk scores (EuroScore, STS, and Ambler score) and concluded that current risk scores do not provide reliable estimates of exact operative mortality in individual valvular heart disease patients. Scores should be interpreted with caution and only used as part of an integrated approach that incorporates other patient characteristics, the clinical context, and local outcome data. Specific risk models also need to be developed for newer interventions, such as TAVI [Rosenhek R et al. \u003Cem\u003EEur Heart J\u003C\/em\u003E 2011].\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2011 MD Conference Express\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/11\/9\/10.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzmzgp\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzmzgp\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}