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Outcomes After Surgical Aortic Valve Replacement With Bioprostheses and Allografts in the Last Decades: What Do We Know?

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Objective. Many observational studies have reported outcomes after surgical aortic valve replacement (AVR), but there are no recent systematic reviews and meta-analyses including all available bioprostheses and allografts. The objective of this study is to provide a comprehensive overview of the outcomes after AVR with bioprostheses and allografts reported in the last 15 years.

Methods. We conducted a systematic literature review of studies published between 2000-2015. Inclusion criteria were observational studies or RCTs reporting on outcomes of AVR with bioprostheses (stented or stentless) or allografts, with or without coronary artery bypass grafting (CABG) or valve repair procedure with study population size n≥30 and mean follow-up length ≥5 years. Fifty-four bioprostheses studies and fourteen allografts studies were included. We pooled early mortality risk and linearized occurrence rates of valve-related events, re-intervention and late mortality in a random effects model. Sensitivity, meta-regression and subgroup analyses were performed to investigate the influence of outliers on the pooled estimates and to explore sources of heterogeneity. Funnel plots were used to investigate publication bias.

Results. Study characteristics and pooled estimates of outcome measures are reported in the Tables. There was substantial heterogeneity in most outcome measures. Meta-regression analyses identified covariates that could explain the heterogeneity in early mortality risk, and linearized occurrence rates of late mortality, structural valve deterioration, nonstructural valve dysfunction (only in bioprostheses), thromboembolism (only in allografts) and re-intervention: implantation period, valve type, patient age, gender, pre-NYHA class III/IV, concomitant CABG, study design, and follow-up length. There is possible publication bias in all outcome measures. 

Conclusion. This comprehensive systematic review and meta-analysis provided an overview of outcomes after AVR with bioprostheses and allografts reported in the last 15 years. Our results can support patient and doctors in the prosthetic valve choice and can be used in microsimulation models to predict patient outcomes and estimate cost-effectiveness of AVR with bioprostheses or allografts compared with other heart valve prostheses.

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