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Surgical treatment in patients with aortic regurgitation due to Takayasu arteritis (Commentary)
Journal Pre-proof Surgical treatment in patients with aortic regurgitation due to Takayasu arteritis (Commentary) Ismail El-Hamamsy, MD, PhD PII:
S0003-4975(20)30017-5
DOI:
https://doi.org/10.1016/j.athoracsur.2019.11.035
Reference:
ATS 33372
To appear in:
The Annals of Thoracic Surgery
Received Date: 11 November 2019 Accepted Date: 17 November 2019
Please cite this article as: El-Hamamsy I, Surgical treatment in patients with aortic regurgitation due to Takayasu arteritis (Commentary), The Annals of Thoracic Surgery (2020), doi: https://doi.org/10.1016/ j.athoracsur.2019.11.035. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 by The Society of Thoracic Surgeons
Surgical treatment in patients with aortic regurgitation due to Takayasu arteritis (Commentary)
Diseases of the aortic valve due to auto-immune disorders represent a challenge in more ways than one. Not only is the incidence of these conditions low, but the prevalence of aortic valve disease requiring intervention is even more rare. This makes it difficult to study and determine clinical patterns to inform surgical decision-making. In light of this, the study by Zhang and colleagues (1) from Fuwai Hospital in Beijing, is very informative and provides important insight. Among >1000 patients with Takayasu arteritis admitted over a 25-year period, the prevalence of those requiring aortic valve surgery was <5%. In addition, the female:male ratio of patients needing surgery is much more balanced (1.6:1.0), than the disease itself, raising questions about the role of sex differences in disease manifestation. Finally, and perhaps most importantly, the study confirms the notion that in patients with Takayasu arteritis, there is a constant hazard over time of suture dehiscence leading to perivalvular leak (PVL), mostly observed after prosthetic aortic valve replacement (AVR). Indeed, of the 23 patients undergoing AVR, 6 (~25%) developed PVL requiring reintervention. In contrast, the risk of suture dehiscence at the annular level was significantly lower after composite graft replacement (CGR). It is not immediately clear why CGR are associated with less proximal complications. However, some differences between the groups suggest it may be due to factors other than pure surgical technique. Indeed, the underlying inflammatory state is presumably responsible for the observed suture dehiscence, pseudoaneurysm formation and PVL. Unfortunately, the current study does not provide granular information into the link between medical therapy, inflammatory status and surgical outcomes. Furthermore, the rate of patients on preoperative steroid therapy
was very different between groups (28% in the CGR group versus 9% in the AVR group), and postoperative steroid or immunosuppressive therapy was not standardized. Nevertheless, the authors should be commended for providing early and late outcomes in this patient population. This study elicits a number of observations. First, the immense potential of very high-volume centers such as Fuwai Hospital (~15.000 open heart procedures yearly) in countries with very large populations, in advancing our understanding of rare conditions such as Takayasu arteritis. Secondly, as imaging techniques have vastly improved, the role of [18F]fluorodeoxyglucose positron emission tomography (PET) in guiding the timing of surgery should be a standard of care today. In addition, PET scanning can further guide steroid or immunosuppressive therapy in patients after surgery. Large cohorts are needed to determine the impact of such an approach on late adverse outcomes after surgery. Finally, the choice of prosthesis in these patients represents an ongoing challenge due to their young age. Because of the observed concerns with tissue healing between the native annulus and prosthetic ring in inflammatory diseases, alternatives need to be explored. These range from sutureless valves to pulmonary autografts, when available. Looking ahead, studies such as this one from large volume centers with a high concentration of rare diseases, will provide the critical answers needed to offer patients optimal care.
Ismail El-Hamamsy, MD, PhD Division of Cardiac Surgery Heart Institute, 5000 Belanger Street, Montreal, Quebec H1T 1C8, Canada. email: [email protected]
Reference 1- Zhang Y, Fan P, Zhang H, et al. Surgical treatment in patients with aortic regurgitation due to Takayasu arteritis. Ann Thorac Surg 2019 (in press).
S0003-4975(20)30017-5
DOI:
https://doi.org/10.1016/j.athoracsur.2019.11.035
Reference:
ATS 33372
To appear in:
The Annals of Thoracic Surgery
Received Date: 11 November 2019 Accepted Date: 17 November 2019
Please cite this article as: El-Hamamsy I, Surgical treatment in patients with aortic regurgitation due to Takayasu arteritis (Commentary), The Annals of Thoracic Surgery (2020), doi: https://doi.org/10.1016/ j.athoracsur.2019.11.035. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 by The Society of Thoracic Surgeons
Surgical treatment in patients with aortic regurgitation due to Takayasu arteritis (Commentary)
Diseases of the aortic valve due to auto-immune disorders represent a challenge in more ways than one. Not only is the incidence of these conditions low, but the prevalence of aortic valve disease requiring intervention is even more rare. This makes it difficult to study and determine clinical patterns to inform surgical decision-making. In light of this, the study by Zhang and colleagues (1) from Fuwai Hospital in Beijing, is very informative and provides important insight. Among >1000 patients with Takayasu arteritis admitted over a 25-year period, the prevalence of those requiring aortic valve surgery was <5%. In addition, the female:male ratio of patients needing surgery is much more balanced (1.6:1.0), than the disease itself, raising questions about the role of sex differences in disease manifestation. Finally, and perhaps most importantly, the study confirms the notion that in patients with Takayasu arteritis, there is a constant hazard over time of suture dehiscence leading to perivalvular leak (PVL), mostly observed after prosthetic aortic valve replacement (AVR). Indeed, of the 23 patients undergoing AVR, 6 (~25%) developed PVL requiring reintervention. In contrast, the risk of suture dehiscence at the annular level was significantly lower after composite graft replacement (CGR). It is not immediately clear why CGR are associated with less proximal complications. However, some differences between the groups suggest it may be due to factors other than pure surgical technique. Indeed, the underlying inflammatory state is presumably responsible for the observed suture dehiscence, pseudoaneurysm formation and PVL. Unfortunately, the current study does not provide granular information into the link between medical therapy, inflammatory status and surgical outcomes. Furthermore, the rate of patients on preoperative steroid therapy
was very different between groups (28% in the CGR group versus 9% in the AVR group), and postoperative steroid or immunosuppressive therapy was not standardized. Nevertheless, the authors should be commended for providing early and late outcomes in this patient population. This study elicits a number of observations. First, the immense potential of very high-volume centers such as Fuwai Hospital (~15.000 open heart procedures yearly) in countries with very large populations, in advancing our understanding of rare conditions such as Takayasu arteritis. Secondly, as imaging techniques have vastly improved, the role of [18F]fluorodeoxyglucose positron emission tomography (PET) in guiding the timing of surgery should be a standard of care today. In addition, PET scanning can further guide steroid or immunosuppressive therapy in patients after surgery. Large cohorts are needed to determine the impact of such an approach on late adverse outcomes after surgery. Finally, the choice of prosthesis in these patients represents an ongoing challenge due to their young age. Because of the observed concerns with tissue healing between the native annulus and prosthetic ring in inflammatory diseases, alternatives need to be explored. These range from sutureless valves to pulmonary autografts, when available. Looking ahead, studies such as this one from large volume centers with a high concentration of rare diseases, will provide the critical answers needed to offer patients optimal care.
Ismail El-Hamamsy, MD, PhD Division of Cardiac Surgery Heart Institute, 5000 Belanger Street, Montreal, Quebec H1T 1C8, Canada. email: [email protected]
Reference 1- Zhang Y, Fan P, Zhang H, et al. Surgical treatment in patients with aortic regurgitation due to Takayasu arteritis. Ann Thorac Surg 2019 (in press).