Prosthesis-patient mismatch affects late survival after valve surgery for severe aortic stenosis.

BACKGROUND: The effect of prosthesis-patient mismatch (PPM) on late survival after aortic valve replacement (AVR) in patient with symptomatic severe aortic stenosis (AS) remains unclear. Also, late follow-up in previous studies is confined to only one decade. We aimed to determine the effect of PPM on late survival after isolated AVR for symptomatic severe AS during 25 years of follow-up. METHODS: In this retrospective cohort study, Kaplan-Meier survival analysis was performed to determine late survival in 404 consecutive patients with moderate PPM (N.=86), severe (N.=11), or no/mild PPM (N.=307) after isolated AVR for symptomatic severe AS during a mean follow-up of 25.0±2.9 years. Moderate, severe, and no/mild PPM were defined as indexed effective orifice area of >0.65≤0.85, ≤0.65, and >0.85 cm2/m2, respectively. Multivariable analysis was performed to identify possible independent predictors of decreased late survival, including moderate or severe PPM. RESULTS: Late survival of patients with severe PPM was worse in comparison with those with no/mild PPM: 7.4±2.6 (95% confidence interval 2.2-12.5) vs. 13.6±0.5 (95% confidence interval 12.6-14.6) years, respectively; P=0.020. Late survival of patients with moderate PPM was similar to those with no/mild PPM. Severe PPM was an independent predictor of decreased late survival: hazards ratio 4.002 (95% confidence interval 1.869-8.569); P<0.001. Moderate PPM was not an independent predictor of decreased late survival. CONCLUSIONS: Severe PPM was independently associated with decreased late survival after isolated AVR for symptomatic severe AS during a mean follow-up of 25.0±2.9 years. Therefore, severe PPM should be prevented as much as possible.

What Can We Learn from the Past by Means of Very Long-Term Follow-Up after Aortic Valve Replacement?

BACKGROUND: Studies on very long-term outcomes after aortic valve replacement are sparse. METHODS: In this retrospective cohort study, long-term outcomes during 25.1 ± 2.8 years of follow-up were determined in 673 patients who underwent aortic valve replacement with or without concomitant coronary artery bypass surgery for severe aortic stenosis and/or regurgitation. Independent predictors of decreased long-term survival were determined. Cumulative incidence rates of major adverse events in patients with a mechanical versus those with a biologic prosthesis were assessed, as well as of major bleeding events in patients with a mechanical prosthesis under the age of 60 versus those above the age of 60. RESULTS: Impaired left ventricular function, severe prosthesis-patient mismatch, and increased aortic cross-clamp time were independent predictors of decreased long-term survival. Left ventricular hypertrophy, a mechanical or biologic prosthesis, increased cardiopulmonary bypass time, new-onset postoperative atrial fibrillation, and the presence of symptoms did not independently predict decreased long-term survival. The risk of major bleeding events was higher in patients with a mechanical in comparison with those with a biologic prosthesis. Younger age (under 60 years) did not protect patients with a mechanical prosthesis against major bleeding events. CONCLUSIONS: Very long-term outcome data are invaluable for careful decision-making on aortic valve replacement.

Effect of aortic cross-clamp time on late survival after isolated aortic valve replacement.

OBJECTIVES: Longer aortic cross-clamp (ACC) time is associated with decreased early survival after cardiac surgery. Because maximum follow-up in previous studies on this subject is confined to 28 months, it is unknown whether this adverse effect is sustained far beyond this term. We aimed to determine whether longer ACC time was independently associated with decreased late survival after isolated aortic valve replacement in patients with severe aortic stenosis during 25 years of follow-up. METHODS: In this retrospective cohort study, multivariable analysis was performed to identify possible independent predictors of decreased late survival, including ACC and cardiopulmonary bypass (CPB) time, in a cohort of 456 consecutive patients with severe aortic stenosis, who had undergone isolated aortic valve replacement between 1990 and 1993. RESULTS: Mean follow-up was 25.3 ± 2.7 years. Median (interquartile range) and mean ACC times were normal: 63.0 (20.0) and 64.2 ± 16.1 min, respectively. Age, operative risk scores and New York Heart Association class were similar in patients with ACC time above, versus those with ACC time below the median. Longer ACC time was independently associated with decreased late survival: hazards ratio (HR) 1.01 per minute increase of ACC time (95% confidence interval [CI] 1.00-1.02; P = 0.012). Longer CPB time was not associated with decreased late survival (HR 1.00 per minute increase of CPB time [95% CI 1.00-1.00; P = 0.30]). CONCLUSIONS: Longer ACC time, although still within normal limits, was independently associated with decreased late survival after isolated aortic valve replacement in patients with severe aortic stenosis.

New-onset postoperative atrial fibrillation after aortic valve replacement: Effect on long-term survival.

OBJECTIVE: There is a paucity of data on long-term survival of new-onset postoperative atrial fibrillation (POAF) after cardiac surgery. Also, mean follow-up in previous studies is confined to a maximum of one decade. This retrospective, longitudinal cohort study was performed to determine the effect on long-term survival of new-onset POAF after aortic valve replacement (AVR) over a mean follow-up of almost 2 decades. METHODS: Kaplan-Meier survival analysis was used to determine long-term survival after AVR, performed between January 1, 1990, and January 1, 1994, in 569 consecutive patients without a history of atrial fibrillation, divided into 241 patients (42.4%) with and 328 patients (57.6%) without new-onset POAF. New-onset POAF was considered in multivariable analysis for decreased long-term survival. After AVR, patients with new-onset POAF were treated with the aim to restore sinus rhythm within 24 to 48 hours from onset by medication and when medication failed by direct-current cardioversion before discharge home. RESULTS: Mean follow-up after AVR was 17.8 ± 1.9 years. Incidence of new-onset POAF was 42.4%. Kaplan-Meier overall cumulative survival rates at 15 years of follow-up were similar in the patients with new-onset POAF versus those without: 41.5% (95% confidence interval [CI], 35.2-47.7) versus 41.3% (95% CI, 36.0-46.7), respectively. New-onset POAF was not an independent risk factor for decreased long-term survival (hazard ratio 0.815; 95% CI, 0.663-1.001; P = .052). CONCLUSIONS: New-onset POAF after AVR does not affect long-term survival when treatment is aimed to restore sinus rhythm before discharge home.

Prosthesis-Patient Mismatch After Aortic Valve Replacement: Effect on Long-Term Survival.

BACKGROUND: Mean follow-up in previous studies on the effect of prosthesis-patient mismatch on long-term survival after aortic valve replacement (AVR) is confined to a maximum of one decade. This retrospective longitudinal cohort study was performed to determine the effect on long-term survival of prosthesis-patient mismatch after AVR with a mean follow-up of almost two decades. METHODS: Kaplan-Meier survival analysis was used to determine long-term survival after AVR in a cohort of 673 consecutive patients, divided into 163 patients (24.2%) with prosthesis-patient mismatch (indexed effective orifice area ≤ 0.85 cm(2)/m(2)) and 510 patients (75.8%) without prosthesis-patient mismatch (indexed effective orifice area >0.85 cm(2)/m(2)). Effective orifice area values of the prosthetic valves were retrieved from the literature or obtained from the charts of the prosthetic valve manufacturers. Cox multiple regression analysis was used to identify possible independent predictors, including prosthesis-patient mismatch, of decreased long-term survival. RESULTS: Median sizes of the implanted mechanical (n = 430) and biologic (n = 243) prostheses were 25 and 23 mm, respectively. Mean follow-up after AVR was 17.8 ± 1.8 years. Prosthesis-patient mismatch was not an independent predictor of decreased long-term survival (hazard ratio, 0.828; 95% confidence interval, 0.669 to 1.025; p = 0.083). Severe prosthesis-patient mismatch (indexed effective orifice area ≤ 0.65 cm(2)/m(2)), occurring in only 17 patients (2.5%), showed an insignificant trend toward decreased long-term survival (hazard ratio, 1.68; 95% confidence interval, 0.97 to 2.91; p = 0.066). CONCLUSIONS: Prosthesis-patient mismatch was not an independent predictor of decreased long-term survival after AVR.

Left bundle-branch block induced by transcatheter aortic valve implantation increases risk of death.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is a novel therapy for treatment of severe aortic stenosis. Although 30% to 50% of patients develop new left bundle-branch block (LBBB), its effect on clinical outcome is unclear. METHODS AND RESULTS: Data were collected in a multicenter registry encompassing TAVI patients from 2005 until 2010. The all-cause mortality rate at follow-up was compared between patients who did and did not develop new LBBB. Of 679 patients analyzed, 387 (57.0%) underwent TAVI with the Medtronic CoreValve System and 292 (43.0%) with the Edwards SAPIEN valve. A total of 233 patients (34.3%) developed new LBBB. Median follow-up was 449.5 (interquartile range, 174-834) days in patients with and 450 (interquartile range, 253-725) days in patients without LBBB (P=0.90). All-cause mortality was 37.8% (n=88) in patients with LBBB and 24.0% (n=107) in patients without LBBB (P=0.002). By multivariate regression analysis, independent predictors of all-cause mortality were TAVI-induced LBBB (hazard ratio [HR], 1.54; confidence interval [CI], 1.12-2.10), chronic obstructive lung disease (HR, 1.56; CI, 1.15-2.10), female sex (HR, 1.39; CI, 1.04-1.85), left ventricular ejection fraction ≤50% (HR, 1.38; CI, 1.02-1.86), and baseline creatinine (HR, 1.32; CI, 1.19-1.43). LBBB was more frequent after implantation of the Medtronic CoreValve System than after Edwards SAPIEN implantation (51.1% and 12.0%, respectively; P<0.001), but device type did not influence the mortality risk of TAVI-induced LBBB. CONCLUSIONS: All-cause mortality after TAVI is higher in patients who develop LBBB than in patients who do not. TAVI-induced LBBB is an independent predictor of mortality.

Konno procedure for prosthetic aortic valve endocarditis: 34-year follow-up.

A 34-year follow-up is described after a Konno aortoventriculoplasty to correct a restricted aortic annulus and a recurrent aortic prosthetic valve endocarditis with subannular and interventricular abscesses.

Myocardial perforation by a guidewire crossing a stenotic aortic valve during cardiac catheterization.

Myocardial perforation by a guidewire after retrograde crossing of a stenotic aortic valve during cardiac catheterization is rare. We present a patient with calcific aortic stenosis who suffered this potentially life-threatening complication and in whom conservative treatment was successful. Early recognition of this complication is important for the operator performing cardiac catheterizations in patients with calcific aortic stenosis.