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Simultaneous aortic and mitral valve replacement: predictors of adverse outcome
Kenji Kuwaki1, Masaru Tsukamoto, Kanshi Komatsu
1Department of Thoracic and Cardiovascular Surgery, Sapporo Medical University School of Medicine, Sapporo, Japan.
Background And Aim Of The Study:
Uncertainties remain regarding the influence of several preoperative and intraoperative factors on outcome after double (simultaneous aortic and mitral) valve replacement (DVR).
Methods:
Between 1981 and 1999, 132 patients (58 males, 74 females; mean age 53.8 years) underwent DVR with either aortic and mitral bileaflet mechanical valves in 81 patients, aortic tilting disk valve and mitral bileaflet valve in 36, and aortic tilting disk and mitral biological valve in 15. The mean duration of follow up was 7.6 years; cumulative follow up was 860 patient-years (pt-yr).
Results:
Early mortality was 9.9% (n = 13). Late death occurred in 21 patients (linearized rate 2.4%/pt-yr; freedom rate at 10 years 77.6 +/- 5.4%) including cardiac-related death in 16 patients (linearized rate 1.9%/pt-yr; freedom rate at 10 years 86.9 +/- 4.5%) and valve-related death in 11 (linearized rate 1.3%/pt-yr; freedom rate at 10 years 87.7 +/- 4.3%). Late morbidity included 30 cases of thromboembolism (linearized rate 3.5%/pt-yr; freedom rate at 10 years 70.2 +/- 6.1%), seven bleeding (linearized rate 0.8%/pt-yr; freedom rate at 10 years 95.6 +/- 2.2%), 22 reoperations (linearized rate 2.6%/pt-yr; freedom rate at 10 years 79.4 +/- 5.1%), three prosthetic valve endocarditis, 13 structural valve deterioration, and two paravalvular leakage. Independent determinants of early and late mortality and morbidity, except for valve reoperation, were preoperative patient-related factors of NYHA class IV, left ventricular ejection fraction < or = 40%, mean right atrial pressure > or = 15 mmHg, and mean pulmonary artery wedge pressure > or = 25 mmHg. However, late valve reoperation and all valve-related complications were influenced by a valve-related factor, namely mitral bioprosthesis.
Conclusion:
Earlier surgical management before the development of severe heart failure, myocardial dysfunction and hemodynamic deterioration would improve the results of DVR. Mitral bioprosthesis combined with a mechanical aortic valve should be avoided as it increases the risk of reoperation.