Related Experiment Videos
Predictors of event-free survival after balloon aortic valvuloplasty
R E Kuntz1, A N Tosteson, A D Berman
1Charles A. Dana Research Institute, Boston.
Insights
Balloon aortic valvuloplasty offers an alternative for aortic stenosis, but restenosis is common. Left ventricular function is key to predicting long-term success in patients undergoing this procedure.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Balloon aortic valvuloplasty (BAV) is an alternative to surgical aortic valve replacement (SAVR) for select elderly patients with aortic stenosis.
- High rates of restenosis limit the long-term efficacy of BAV.
Purpose of the Study:
- To identify predictors of event-free survival after BAV.
- To evaluate the impact of baseline hemodynamic variables on BAV outcomes.
Main Methods:
- A cohort of 205 patients undergoing BAV between 1985 and 1989 was analyzed.
- Cox regression and stepwise multivariate analysis were used to identify univariate and independent predictors of event-free survival.
Main Results:
- BAV significantly reduced transaortic-valve pressure gradient and increased aortic-valve area.
- Event-free survival at a mean follow-up of 24 months was 18%.
- Key predictors of event-free survival included baseline left ventricular ejection fraction, left ventricular and aortic systolic pressures, percent reduction in aortic-valve gradient, and pulmonary-capillary wedge pressure.
Conclusions:
- Baseline left ventricular performance is the most critical factor influencing event-free survival after BAV.
- Patients with favorable baseline characteristics for SAVR also tend to achieve better long-term outcomes with BAV.
Background:
Balloon aortic valvuloplasty was developed as an alternative to aortic-valve replacement in selected elderly patients with aortic stenosis. The use of this procedure is limited, however, by a high incidence of restenosis.
Methods:
Between December 1985 and April 1989, valvuloplasty was performed in 205 patients. We evaluated 40 demographic and hemodynamic variables as univariate predictors of event-free survival by Cox regression analysis and identified independent predictors of event-free survival by stepwise multivariate analysis.
Results:
Early hemodynamic results indicated a decrease in the peak transaortic-valve pressure gradient from 67 +/- 28 to 33 +/- 15 mm Hg after valvuloplasty and an increase in aortic-valve area from 0.6 +/- 0.2 to 0.9 +/- 0.3 cm2 (P less than 0.001 for both comparisons). The rate of event-free survival (defined as survival without recurrent symptoms, repeated valvuloplasty, or aortic-valve replacement) was 18 percent over the mean (+/- SD) follow-up period of 24 +/- 12 months (range, 1 to 47). Significant predictors of event-free survival included the left ventricular ejection fraction and the left ventricular and aortic systolic pressure before valvuloplasty, and the percent reduction in the aortic-valve pressure gradient; the pulmonary-capillary wedge pressure was inversely associated with event-free survival. Although the predicted event-free survival rate for the entire patient group was 50 percent at one year (95 percent confidence interval, 43 to 57 percent) and 25 percent at two years (95 percent confidence interval, 19 to 31 percent), the probability of event-free survival at one year varied between 23 and 65 percent when patients were stratified according to three independent predictors: the aortic systolic pressure, the pulmonary-capillary wedge pressure, and the percent reduction in the peak aortic-valve gradient.
Conclusions:
The most important predictors of event-free survival after balloon aortic valvuloplasty were related to base-line left ventricular performance. The best long-term results after valvuloplasty were observed among patients who would also have been expected to have excellent long-term results after aortic-valve replacement.