Letters to the Editor
no statement was made on how many REPAIR OR REPLACE THE time course of 6 to 8 years, survival
of the operations of these patients AORTIC VALVE? MORE with a prosthetic valve was about
were performed on an emergency ba- QUESTIONS, NO ANSWERS 60%. The absolute and relative sur-
sis. We wonder whether differences To the Editor: vivals seem to be much lower than
were present between the emergency We read with interest the article by expected.3 Is the survival of this
and elective operations in terms of de Meester and colleagues1 on out- cohort representative of the outcomes
postoperative neurologic complication comes after aortic valve (AV) repair that should be expected after AV
rates, because in a limited number of versus AV replacement. This report replacement in patients with few co-
studies it has been reported that the comes from a center of excellence morbidities and a mean age of 63
risk of development of postoperative concerning the treatment of AV years? Should this matched cohort
neurologic accident in patients under- disease. serve as a benchmark for judging
going surgery for aortic dissection is In their study, de Meester and col- AV repair procedures? The average
greater in emergency procedures.2,3 If leagues1 observed a survival advantage age in the total Brussels AV repair
any data regarding this is available in in the AV repair group. The question cohort is approximately 50 years,4
the study by Shi and colleagues,1 we that naturally comes to mind is which poses the question of whether
believe that sharing this information whether this survival advantage should the expected AV repair benefits
would contribute to both their own be attributed to the AV repair itself. should be the same across all age
study and the published data. Although the tenor of the article seems groups.
to be in favor of repair, we believe that Despite the excellent results of the
Orhan Gokalpa the answer to this question might not AV repair reported by de Meester
Yuksel Besirb be that simple. A significant proportion and colleagues,1 no definite answer
Gamze Gokalpc of deaths might not have anything to can be provided regarding the effect
Ali Gurbuza do with the AV, because 5 deaths in of AV repair versus AV replacement
a
Faculty of Medicine the replacement group were classified on long-term patient survival. To eval-
Department of Cardiovascular as of miscellaneous or noncardiovas- uate a cause and effect relationship, a
Surgery cular causes. Should these events serve prospective, randomized, multicenter
Izmir Katip Celebi University in the comparison of the 2 groups, and study is needed. There have been
Izmir, Turkey do these noncardiovascular deaths pro- many calls for randomized, controlled
b
Department of Cardiovascular vide evidence of a survival advantage? trials in the field of heart valve sur-
Surgery The adjusted death hazard in the gery, but very few such studies have
Izmir Katip Celebi University replacement group seems to be 10 been conducted because of a variety
Ataturk Education and Research times (95% confidence interval, of barriers, such as high costs, long
Hospital 2.8-33.3) that of the repair group, an follow-up duration, limited generaliz-
Izmir, Turkey enormous effect size! Could this be a ability, and, most importantly, sur-
c
Department of Pediatric Emergency false-positive finding with an extreme geon and patient preferences. This is
Tepecik Education and Research tendency2 related to the small sample certainly true for AV repair, which
Hospital size? Why should patients undergoing is still considered complex surgery
Izmir, Turkey AV repair have better survival than and is mainly practiced in dedicated
matched patients receiving the ‘‘stan- centers of expertise, such as that of
dard of care’’ with AV replacement? the Brussels group. The way to
References
1. Shi E, Gu T, Yu Y, Wang C, Yu L, Fang Q, et al. Simpli- Perhaps the morbidity attributable to move forward is through inclusive in-
fied total arch repair with a stented graft for acute the prosthetic valve or the superior ternational collaborative efforts, such
DeBakey type I dissection. J Thorac Cardiovasc AV repair hemodynamics can drive a as the recently initiated Aortic Valve
Surg. 2014;148:2147-54.
2. Inada H, Tabuchi A, Morita I, Masaki H, potential survival benefit. This differ- Insufficiency and Ascending Aorta
Murakami T, Fujiwara T. Brain damage after ence must translate into measurable Aneurysm International Registry
surgery for thoracic aortic aneurysm. Nihon Kyobu clinical outcomes, however, and the (AVIATOR) initiative, which is aims
Geka Gakkai Zasshi. 1997;45:1678-84.
3. Czerny M, Fleck T, Zimpfer D, Dworschak M, cardiovascular event-free survival and to prospectively evaluate surgical
Hofmann W, Hutschala D, et al. Risk factors of the cardiovascular event rate were outcomes of patients with aortic
mortality and permanent neurologic injury in pa- more or less comparable between the regurgitation, aortic root dilatation,
tients undergoing ascending aortic and arch repair.
J Thorac Cardiovasc Surg. 2003;126:1296-301. 2 groups.1 or both. In this effort we can embed
Another way to look at the same a preference randomized, controlled
http://dx.doi.org/10.1016/ data is to ask why the patients with trial5 that will help us find the holy
j.jtcvs.2014.12.061 AV replacement fared worse. In the grail.
The Journal of Thoracic and Cardiovascular Surgery c Volume 149, Number 4 1221
no statement was made on how many REPAIR OR REPLACE THE time course of 6 to 8 years, survival
of the operations of these patients AORTIC VALVE? MORE with a prosthetic valve was about
were performed on an emergency ba- QUESTIONS, NO ANSWERS 60%. The absolute and relative sur-
sis. We wonder whether differences To the Editor: vivals seem to be much lower than
were present between the emergency We read with interest the article by expected.3 Is the survival of this
and elective operations in terms of de Meester and colleagues1 on out- cohort representative of the outcomes
postoperative neurologic complication comes after aortic valve (AV) repair that should be expected after AV
rates, because in a limited number of versus AV replacement. This report replacement in patients with few co-
studies it has been reported that the comes from a center of excellence morbidities and a mean age of 63
risk of development of postoperative concerning the treatment of AV years? Should this matched cohort
neurologic accident in patients under- disease. serve as a benchmark for judging
going surgery for aortic dissection is In their study, de Meester and col- AV repair procedures? The average
greater in emergency procedures.2,3 If leagues1 observed a survival advantage age in the total Brussels AV repair
any data regarding this is available in in the AV repair group. The question cohort is approximately 50 years,4
the study by Shi and colleagues,1 we that naturally comes to mind is which poses the question of whether
believe that sharing this information whether this survival advantage should the expected AV repair benefits
would contribute to both their own be attributed to the AV repair itself. should be the same across all age
study and the published data. Although the tenor of the article seems groups.
to be in favor of repair, we believe that Despite the excellent results of the
Orhan Gokalpa the answer to this question might not AV repair reported by de Meester
Yuksel Besirb be that simple. A significant proportion and colleagues,1 no definite answer
Gamze Gokalpc of deaths might not have anything to can be provided regarding the effect
Ali Gurbuza do with the AV, because 5 deaths in of AV repair versus AV replacement
a
Faculty of Medicine the replacement group were classified on long-term patient survival. To eval-
Department of Cardiovascular as of miscellaneous or noncardiovas- uate a cause and effect relationship, a
Surgery cular causes. Should these events serve prospective, randomized, multicenter
Izmir Katip Celebi University in the comparison of the 2 groups, and study is needed. There have been
Izmir, Turkey do these noncardiovascular deaths pro- many calls for randomized, controlled
b
Department of Cardiovascular vide evidence of a survival advantage? trials in the field of heart valve sur-
Surgery The adjusted death hazard in the gery, but very few such studies have
Izmir Katip Celebi University replacement group seems to be 10 been conducted because of a variety
Ataturk Education and Research times (95% confidence interval, of barriers, such as high costs, long
Hospital 2.8-33.3) that of the repair group, an follow-up duration, limited generaliz-
Izmir, Turkey enormous effect size! Could this be a ability, and, most importantly, sur-
c
Department of Pediatric Emergency false-positive finding with an extreme geon and patient preferences. This is
Tepecik Education and Research tendency2 related to the small sample certainly true for AV repair, which
Hospital size? Why should patients undergoing is still considered complex surgery
Izmir, Turkey AV repair have better survival than and is mainly practiced in dedicated
matched patients receiving the ‘‘stan- centers of expertise, such as that of
dard of care’’ with AV replacement? the Brussels group. The way to
References
1. Shi E, Gu T, Yu Y, Wang C, Yu L, Fang Q, et al. Simpli- Perhaps the morbidity attributable to move forward is through inclusive in-
fied total arch repair with a stented graft for acute the prosthetic valve or the superior ternational collaborative efforts, such
DeBakey type I dissection. J Thorac Cardiovasc AV repair hemodynamics can drive a as the recently initiated Aortic Valve
Surg. 2014;148:2147-54.
2. Inada H, Tabuchi A, Morita I, Masaki H, potential survival benefit. This differ- Insufficiency and Ascending Aorta
Murakami T, Fujiwara T. Brain damage after ence must translate into measurable Aneurysm International Registry
surgery for thoracic aortic aneurysm. Nihon Kyobu clinical outcomes, however, and the (AVIATOR) initiative, which is aims
Geka Gakkai Zasshi. 1997;45:1678-84.
3. Czerny M, Fleck T, Zimpfer D, Dworschak M, cardiovascular event-free survival and to prospectively evaluate surgical
Hofmann W, Hutschala D, et al. Risk factors of the cardiovascular event rate were outcomes of patients with aortic
mortality and permanent neurologic injury in pa- more or less comparable between the regurgitation, aortic root dilatation,
tients undergoing ascending aortic and arch repair.
J Thorac Cardiovasc Surg. 2003;126:1296-301. 2 groups.1 or both. In this effort we can embed
Another way to look at the same a preference randomized, controlled
http://dx.doi.org/10.1016/ data is to ask why the patients with trial5 that will help us find the holy
j.jtcvs.2014.12.061 AV replacement fared worse. In the grail.
The Journal of Thoracic and Cardiovascular Surgery c Volume 149, Number 4 1221
