Impact of single-valve and multiple-valve heart disease on long-term outcome in patients with chronic heart failure

Abstract

Abstract Background There are limited data concerning outcome and risk stratification of single and multiple valvular heart diseases (VHD) in patients with heart failure (HF). Purpose Present study aimed to evaluate the long-term all-cause and cardiovascular (CV) mortality of HF patients with or without VHD. Methods This is a retrospective cohort study with propensity score matching. Of 4245 HF patients who referred to the cardiology department for diagnosis and treatment of VHD between 2004 and 2018, 1417 patients had no VHD and 2828 patients had at least one valve disease, including moderate-severe aortic stenosis or aortic regurgitation, moderate-severe mitral stenosis or mitral regurgitation, and moderate-severe tricuspid regurgitation. Propensity score for each patient was calculated using logistic regression models, and 1016 patients without VHD and 1016 patients with VHD matched for age, sex, and NYHA class were finally included for final analysis (mean age 68±12, 77.4% male, NYHA class III-IV 30.6%). Primary endpoint was defined as mortality due to CV causes. Results Median follow-up time was 30 (17-47) months. CV mortality was significantly higher in the VHD group than that in the no-VHD group (13.2% vs. 7.2%, P<0.001). All-cause mortality was similar between groups (25.8% vs. 22.4%, P=0.078). Compared to the no-VHD group, proportions of hyperlipidaemia, atrial fibrillation, hyperuricemia, and chronic kidney disease were significantly higher, while proportions of obesity, coronary artery disease, and diabetes were significantly lower in the VHD group. Left ventricular ejection fraction (LVEF, 46.8±15.8% vs. 38.5±9.4%, P<0.001) were significantly higher in the VHD group than those in the no-VHD group. All-cause mortality and CV mortality were significantly higher in patients with multiple VHD than those with single VHD (0- vs. 1- vs. 2- vs. 3-valve disease: all-cause mortality 22.4% vs. 21.5% vs. 32.1% vs. 43.3%, P<0.001; CV mortality 7.2% vs. 10.6% vs. 17.3% vs. 22.4%, P<0.001). Of 1016 patients with VHD, 462 (45.5%) patients did not underwent valve replacement or repair and 554 (54.5%) patients underwent at least one valve replacement or repair. All-cause mortality (18.6% vs. 34.4%, P<0.001) and CV mortality (10.6% vs. 16.2%, P=0.026) were significantly lower in patients with valve replacement or repair compared with those without surgery (Figure 1). Multivariable Cox regression models showed that valve replacement or repair surgery significantly improved CV-death free survival (HR 0.631, 95% CI 0.441-0.903) after adjusted for clinical risk factors and LVEF. Conclusions Compared with age, sex, and NYHA class matched chronic HF patients without VHD, concomitant VHD is associated with worse all-cause and CV mortality in proportion to the number of valves involved in patients with chronic HF. Valve replacement or repair can significantly reduce all-cause and CV mortality in this patient cohort.Figure 1