Durability and outcome of aortic valve replacement with mitral valve repair versus double valve replacement

Department of Cardiovascular Surgery, National Cardiovascular Center, Suita, Osaka, Japan.
The Annals of Thoracic Surgery (Impact Factor: 3.63). 02/2003; 75(1):28-33; discussion 33-4. DOI: 10.1016/S0003-4975(02)04405-3
Source: PubMed

ABSTRACT The purpose of this study was to evaluate morbidity and mortality after double valve replacement (DVR) and aortic valve replacement with mitral valve repair (AVR + MVP).
From 1977 to 2000, 379 patients underwent DVR (n = 299) or AVR + MVP (n = 80). Actuarial survival and freedom from reoperation were determined by the Kaplan-Meier method. Potential predictors of mortality and reoperation were entered into a Cox multiple regression model. Propensity score was introduced for the multivariable regression modeling for adjustment of a selection bias.
Survival 15 years after surgery was similar between the groups (DVR, 81% +/- 3%; AVR + MVP, 79% +/- 7%; p = 0.44). Freedom from thromboembolic event at 15 years was similar between the groups (p = 0.25). Freedom from mitral valve reoperation at 15 years was significantly better for the DVR group (54% +/- 5%) as compared with the AVR + MVP group (15% +/- 6%; p = 0.0006), primarily due to progression of mitral valve pathology and early structural deterioration of bioprosthetic aortic valve used for patients with AVR + MVP. After AVR + MVP, freedom from mitral reoperation at 15 years was 63% +/- 16% for nonrheumatic heart diseases, and 5% +/- 5% for rheumatic disease (p = 0.04).
Although both DVR and AVR + MVP provided excellent survival, DVR with mechanical valves should be the procedure of choice for the majority of patients because of lower incidence of valve failure and similar rate of thromboembolic complications compared with AVR + MVP. MVP should not be performed in patients with rheumatic disease because of higher incidence of late failure.

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    Asian cardiovascular & thoracic annals 01/2005; 12(4):341-5. DOI:10.1177/021849230401200413
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    ABSTRACT: Long-term survival for combined aortic and mitral valve replacement appears to be determined by the mitral valve prosthesis from our previous studies. This 21-year retrospective study assess long-term outcome and durability of aortic valve replacement (AVR) with either concomitant mitral valve replacement (MVR) or mitral valve repair (MVrep). We consider only a single mechanical prosthesis. Three hundred and sixteen patients underwent double valve replacement (DVR) (n = 273) or AVR+MVrep (n = 43), in the period 1977 to 1997. Follow up of 100% was achieved via telephone questionnaire and review of patients' medical records. Actuarial analysis of long-term survival was determined by Kaplan-Meier method. The Cox regression model was used to evaluate potential predictors of mortality. There were seventeen cases (5.4%) of early mortality and ninety-six cases of late mortality. Fifteen-year survival was similar in both groups at 44% and 57% for DVR and AVR+MVrep respectively. There were no significant differences in valve related deaths, anticoagulation related complications, or prosthetic valve endocarditis between the groups. There were 6 cases of periprosthetic leak in the DVR group. Sex, pre-operative mitral and aortic valve pathology or previous cardiac surgery did not significantly affect outcome. The mitral valve appears to be the determinant of survival following double valve surgery and survival is not significantly influenced by mitral valve repair.
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    ABSTRACT: Background Concomitant aortic and mitral valve (MV) operations have more than doubled over the past decade. We utilized the Society of Thoracic Surgeons Adult Cardiac Surgery Database (ACSD) to evaluate outcomes for patients undergoing combined aortic valve replacement (AVR) and MV repair or replacement. Methods From 1993 to 2007, 23,404 patients undergoing concomitant AVR+MV surgery were identified. Patients with mitral stenosis, emergent or salvage status, and endocarditis were excluded. Outcomes were expressed as unadjusted operative mortality, adjusted odds ratio (OR) for mortality, and a composite of mortality and major complications. Results The MV repair was performed in 46.0% and replacement in 54.0% of AVR patients. The rate of MV repair increased from 22.5% in 1993 to 59.1% in 2007 (p < 0.0001). Compared with the AVR+MV replacement group, the AVR+MV repair group was older (69.7 ± 11.5 vs 67.2 ± 12.7 years, p < 0.0001), had worse ejection fraction (0.449 ± 0.153 vs 0.495 ± 0.139, p < 0.0001), and more concomitant coronary artery bypass grafting (CABG) (50.5% vs 40.9%, p < 0.0001). Unadjusted operative mortality was lower in the AVR+MV repair group (8.2% vs 11.6%, p < 0.0001). Predictors of operative mortality by multivariable analysis included the following: age (OR 1.21, p < 0.0001); concomitant CABG (OR 1.49, p < 0.0001); diabetes mellitus (OR 1.56, p < 0.0001); reoperation (OR 1.53, p < 0.0001); and renal failure with dialysis (OR 3.57, p < 0.0001). Patients undergoing MV repair had a lower independent risk of operative mortality (OR 0.61, p < 0.0001), and mortality also independently improved over time (2003 to 2007 vs 1993 to 1997, OR 0.79, p < 0.002). Conclusions When feasible, MV repair remains the most optimal method of correcting mitral regurgitation during concomitant AVR. Continued efforts to improve MV repair rates in this setting seem warranted.
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