INCIDENCE, PREDICTORS, AND IMPACT OF BIOPROSTHETIC VALVE HEMODYNAMIC DETERIORATION FOLLOWING AORTIC VALVE REPLACEMENT

Abstract

The occurrence of structural biological valve deterioration after aortic valve replacement (AVR) is generally defined by the need for reoperation due to valve failure. However, this approach significantly underestimates the incidence of structural valve deterioration. We intended to determine the incidence, predictors and impact of bioprosthesis (BP) valve hemodynamic deterioration (VHD) assessed by Doppler-echocardiography according to the postoperative time period. A total of 1387 patients (62.2% male; 70.5±7.8 years old) were included in this retrospective study. A baseline echocardiography was performed at a median time of 4.1 (1.3–6.5) months post-AVR. Doppler-echocardiography follow-up was performed at least 2-years post-AVR in all patients, at least 5-years in 926 patients and at least 10-years in 385 patients. VHD was defined as: ≥10mmHg increase in mean transprosthetic gradient (MG) and/or worsening of transprosthetic regurgitation ≥1/3 grade from baseline to last echocardiography follow-up. Overall, VHD was identified in 428 patients (30.9%). The VHD occurred within the first 5 years in 181 (42.3%) patients and after 5 years in 247 (57.7%) patients. VHD (expressed as time-dependent variable) was a significant predictor of death (HR: 2.18, 95% CI: 1.86 to 2.57, p < 0.001) (Figure). Age at the date of first detection of VHD was not a predictor of VHD. Diabetes (HR: 1.33, 95% CI: 1.06 to 1.66, p=0.01), post-surgery MG ≥15mmHg (HR: 1.30, 95% CI: 1.05 to 1.62, p=0.02), severe prosthesis–patient mismatch (HR: 1.85, 95% CI: 1.12 to 2.87, p=0.02) and type of BP (protector effect of stentless vs. BP, p < 0.001) were independently associated with VHD during follow-up. Predictors of early VHD identified (within the first 5-years post-AVR) were: diabetes (p=0.01), active smoker status (p=0.01), renal insufficiency (p=0.01), post-surgery MG ≥15mmHg (p=0.04), post-surgery ≥mild transprosthetic regurgitation (p=0.04) and type of BP (protector effect of stentless vs. stented BP, p=0.003). Predictors of late VHD (i.e. after the 5 years) were: female sex (p=0.03), use of coumadin (p=0.007) and type of BP (stented vs. stenless, p < 0.001). The results of this large series reveals that VHD as documented by Doppler-echocardiography is frequent (30%) following AVR and is associated with 2.2 fold increase in mortality. The main factors associated with increased risk of VHD were female sex, diabetes, smoking, use of Coumadin, presence of severe prosthesis-patient mismatch, high residual gradient, and/or transprosthetic regurgitation early after AVR