Predictors of the Long-Term Outcome After Combined Aortic and Mitral Valve Surgery

Abstract

Background-The influence of preoperative clinical, hemodynamic, and surgical procedures on long-term prognosis after combined aortic and mitral valve surgery is not well known. Methods and Results-One hundred seventy patients (mean age, 50.5 years; 102 men and 68 women) who underwent surgery for chronic combined aortic and mitral valvular disease between 1975 and 1989 were followed up for an average of 10.6 years. Additional repair of tricuspid valve was performed in 29 patients (17%), and aortocoronary bypass graft surgery was performed in 7 patients (4.1%). The perioperative mortality rate was 4%, and 10-and 20-year survival rates were 61% and 33%. Only 12 of 94 deaths (11%) were non-cardiac related. At 10 and 20 years, 57% and 21% of patients were free of reoperation, respectively. The main predictors of late survival in univariate analysis were age at surgery (Pϭ0.0002), preoperative left ventricular ejection fraction (Pϭ0.002), cardiac index (Pϭ0.007), tricuspid surgery (Pϭ0.03), pulmonary vascular resistance (Pϭ0.03), NYHA class (Pϭ0.04), and additional aortocoronary bypass graft surgery (Pϭ0.04). Duration of symptoms, gender, cause of valvular disease, and type of prosthesis were not predictive of postoperative outcome. In multivariate stepwise Cox analysis, ejection fraction (Pϭ0.0008), age at surgery (Pϭ0.0011), and tricuspid surgery (Pϭ0.007) were independent predictors of late survival. Conclusions-In combined aortic and mitral valve disease, preoperative myocardial function is the main predictor of long-term survival. Low operative mortality rates and good late outcome make valve replacement mandatory before deterioration of myocardial function occurs. Additional tricuspid valve disease requiring surgery significantly decreases the late survival rate. (Circulation. 1999;100[suppl II]:II-48-II-53.) Key Words: surgery Ⅲ valves Ⅲ survival Ⅲ prognosis Ⅲ transplantation S urgery for combined aortic and mitral valve disease was introduced in the early 1960s; until the mid-1970s, it was associated with a high operative mortality rate and unsatisfactory late results. 1-3 Despite well documented improvement in surgical techniques with a marked decrease in operative mortality rates and a considerable increase in late postoperative survival rates in the 1980s and 1990s, some reluctance remained to refer a patient with combined aortic and mitral disease to surgery. 4,5 A paucity of experience due to the limited number of patients, a lack of good prospective clinical and hemodynamic studies in patients who have not undergone surgery, great differences in clinical presentation and hemodynamics between regurgitant and stenotic lesions, and changes in causes of valvular disease in developed countries aggravate the decision-making process for surgery in patients with combined aortic and mitral disease. 1,6,7 This was the main reason for reassessment of preoperative clinical, hemodynamic, and surgical predictors for long-term survival after combined aortic and mitral valve surgery in patients operated on at our institu...

Early and Late Results of Combined Mitral-Aortic Valve Surgery

“…Whilst double valve replacement (DVR) comprises approximately 2% of open-heart surgery cases, it has been regarded as a higher risk operation than other procedures such as single valve replacement. 1 Factors associated with adverse outcome in the past have included older age, 2,3 New York Heart Association (NYHA) class III or IV, 2-4 low left ventricular ejection fraction, 5 and concomitant coronary artery bypass surgery (CABG). 6 In the past studies, double valve replacement has been associated with Examination of the history and surgical notes was made in order to assess the type of valvular patho-physiology (stenotic or regurgitant, see Table 1).…”

Tricuspid Regurgitation in Mitral Valve Disease

“…Significant TR requiring TV surgery predicts poor survival in patients undergoing valve surgery (16,17). Tricuspid regurgitation is also a predictor of poor outcome in patients undergoing balloon mitral valvotomy for mitral stenosis.…”

The clinical challenge of concomitant aortic and mitral valve stenosis

“…long-term post-operative survival after multiple valve surgery is also lower, with a high New York Heart Association class, a lower left ventricular ejection fraction and/or a dilated left ventricle, a need for myocardial revascularization and/or the presence of pulmonary hypertension as risk factors 2,10 . In double valve replacement, although the risk of a thromboembolism is higher after double mechanical valve replacement than it is after single valve replacement 11 , the use of the same type of prosthesis in both places (bioprosthesis or mechanical) is recommended in order to avoid superimposing the risk of anticoagulation to the one of bioprosthesis deterioration.…”