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Prosthesis size and long-term survival after aortic valve replacement
Eugene H Blackstone1, Delos M Cosgrove, W R Eric Jamieson
1Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, 9500 Euclid Avenue, Desk F25, Cleveland, OH 44195, USA. blackse@ccf.org
The Journal of Thoracic and Cardiovascular Surgery
|September 23, 2003
Summary
Prosthesis-patient size matching is crucial for aortic valve replacement survival. Optimal sizing down to 1.1 cm(2)/m(2) or -3 Z ensures long-term survival, but smaller sizes increase early mortality risk.
Area of Science:
- Cardiovascular Surgery
- Biomedical Engineering
- Clinical Outcomes Research
Background:
- Aortic valve replacement (AVR) is a common procedure to treat aortic valve disease.
- Prosthesis-patient mismatch, where the prosthetic valve is too small for the patient, can impact outcomes.
- Quantifying the precise relationship between prosthesis-patient size and long-term survival is essential for optimizing surgical practice.
Purpose of the Study:
- To investigate the association between prosthesis-patient size and long-term survival following aortic valve replacement.
- To determine the threshold for prosthesis-patient size that may adversely affect patient outcomes.
- To analyze the impact of different prosthetic valve types on the relationship between size and survival.
Main Methods:
- Analysis of data from 13,258 AVR cases across nine sources, providing 69,780 patient-years of follow-up.
- Assessment of prosthesis-patient size using indexed internal prosthesis orifice area (cm(2)/m(2) of body surface area) and standardized internal prosthesis orifice size (Z-score).
- Multivariable hazard domain analysis, including balancing score and risk factor adjustment, to evaluate the association between size and survival.
Main Results:
- Prosthesis-patient size down to 1.1 cm(2)/m(2) or -3 Z did not negatively impact intermediate- or long-term survival.
- A decrease in indexed orifice area below 1.2 cm(2)/m(2) or Z-score below -2.5 was associated with a 1% to 2% increase in 30-day mortality.
- This increased early risk was observed in fewer than 1% of bioprosthesis recipients but in approximately 25% of mechanical valve recipients.
Conclusions:
- Aortic prosthesis-patient size matching down to 1.1 cm(2)/m(2) or -3 Z is generally safe and does not compromise intermediate- or long-term survival.
- Prosthesis-patient size below 1.2 cm(2)/m(2) or -2.5 Z is linked to a higher risk of early mortality, particularly with mechanical valves.
- Small prosthesis-patient sizes were infrequently implanted in patients receiving bioprosthetic valves, suggesting careful consideration of sizing in this group.