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Primary isolated aortic valve replacement. Early and late results
B W Lytle1, D M Cosgrove, P C Taylor
1Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Ohio 44195.
Insights
This study on aortic valve replacement found that patient factors like age and kidney function impact survival. Bioprosthetic valves offer better long-term outcomes, especially for older patients, but require careful management.
Area of Science:
- Cardiac Surgery
- Cardiovascular Research
- Prosthetic Valve Outcomes
Background:
- Isolated aortic valve replacement (AVR) is a critical procedure for patients with aortic valve disease.
- Understanding long-term outcomes and influencing factors is essential for optimizing patient care.
- Previous studies have explored various aspects of AVR, but comprehensive analysis of long-term survival and event-free survival based on patient and management variables is ongoing.
Purpose of the Study:
- To evaluate the 10-year survival and event-free survival rates after isolated aortic valve replacement.
- To identify patient-related and management-related variables associated with in-hospital and late mortality.
- To compare the outcomes of bioprosthetic versus mechanical valves in different age groups.
Main Methods:
- Retrospective analysis of 1689 consecutive patients undergoing isolated AVR between 1972 and 1986.
- Multivariate analysis to identify independent predictors of in-hospital mortality.
- Long-term follow-up to assess survival and event-free survival rates, stratified by valve type and patient age.
Main Results:
- In-hospital mortality was 3.4%, with advanced age, elevated blood urea nitrogen, NYHA class, and atrial fibrillation as independent predictors of increased mortality.
- Cardioplegia use was associated with decreased mortality. Ten-year survival and event-free survival rates were 66% and 43%, respectively.
- Bioprosthetic valves showed superior survival and event-free survival, particularly in patients aged 40 and older, but were associated with more reoperations and endocarditis. Mechanical valves had higher rates of stroke, myocardial infarction, and thromboembolic events.
Conclusions:
- Ten-year outcomes after isolated AVR are significantly influenced by patient characteristics (age, renal function, cardiac status) and management strategies (valve choice, myocardial protection).
- Bioprosthetic valves offer a survival advantage for older patients (≥40 years), while younger patients may face more reoperations and endocarditis.
- Mechanical valves are associated with a higher risk of thromboembolic complications, necessitating careful consideration of anticoagulation management and patient selection.
Abstract:
A total of 1689 consecutive patients underwent isolated aortic valve replacement at the Cleveland Clinic Foundation from 1972 through 1986. There were 57 (3.4%) in-hospital deaths. Multivariate analysis identified advanced age (p = 0.0014), preoperative blood urea nitrogen level greater than 25 mg/100 ml (p = 0.008), New York Heart Association function class (p = 0.015), and preoperative atrial fibrillation (p = 0.04) as independent variables associated with increased in-hospital mortality and the use of cardioplegia for myocardial protection (p = 0.006) as a factor decreasing mortality. Follow-up documented survival rates of 85% and 66% and event-free survival rates of 71% and 43% at 5 and 10 postoperative years, respectively. Advanced age, moderate or severe impairment of left ventricular function, coronary artery disease, and preoperative blood urea nitrogen level greater than 25 mg/100 ml were associated with decreased late survival and event-free survival (all p less than 0.05). Patients with bioprostheses had better survival (p = 0.003) and event-free survival (p = 0.0007) rates than patients with mechanical valves. Patients with bioprostheses had superior results only if not receiving warfarin, and they experienced more reoperations and endocarditis; those with mechanical prostheses had more strokes, myocardial infarctions, bleeding complications, and thromboembolic events. Analysis of patients grouped according to age at operation showed that bioprostheses were associated with improved survival and event-free survival for patients 40 years older or older. Younger patients experienced more reoperations and episodes of endocarditis, and older patients more thromboembolic complications. We conclude that 10-year results after isolated aortic valve replacement are influenced by both patient-related and management-related variables, and the impact of these factors is different for patients of different ages.