Prognosis of surgically treated chronic aortic valve disease: Predictive indicators of early postoperative risk and long-term survival, based on 439 cases

Abstract

The study concerns 439 patients having isolated chronic aortic valve disease (248 having pure or predominant calcific stenosis, 65 having stenosis and regurgitation, and 126 having aortic regurgitation). The operations began in 1968, and the survivors have been re-examined every year, with an average follow-up of 44.2 months. Average age at operation was 55 years (range 14 to 78). Patients in the stenosis group were significantly older (59.7 years) than those in the mixed disease group (54.8 years) or the regurgitation group (45.8 years) (p <0.00l). First-month mortality varied from 7.1% for regurgitation to 9.7% for stenosis. For the entire population, the overall actuarial survival rate was 69% at 5 years and 58% after 8 years. Despite higher average age and greater early mortality, the overall survival rate was better in the stenosis group than in the pure regurgitation group (65% versus 49% at 7 years). Late survival rate (excluding operative mortality) was significantly lower in the regurgitation group, especially if one considers the same age bracket and excludes instances of death resulting from noncardiac causes (p <0.001). Severe nonreversible myocardial dysfunction was three times more frequent in cases of regurgitation (17% of surgical patients), where it appeared to be the primary cause of poor result of operation, than in stenosis, with or without regurgitation (5% of surgical patients, p < 0.001). Patients having regurgitation accompanied by myocardial dysfunction showed a greater frequency of severe heart failure and ventricular arrhythmia, large cardiothoracic ratio, greater end-diastolic volume, and lower left ventricular ejection fraction. Factors predictive of long-term survival emphasized the role of age (in the stenosis and mixed disease groups), the degree of preoperative heart failure, cardiomegaly, ventricular arrhythmia, functional mitral incompetence, coronary status, and certain hemodynamic parameters. Multivariate analysis revealed those factors having the greatest predictive value: heart failure and cardiomegaly plus, in cases of stenotic valve disease, age and ventricular arrhythmia. These findings have led us to propose operation generally at the onset of the first symptoms, and even before the onset of symptoms in cases of voluminous chronic regurgitation accompanied by patent signs of left ventricular impairment.