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Marc Ruel
Fraser D. Rubens
Roy G. Masters
Paul J. Hendry
Maurice P. Brais
Wilbert J. Keon
Thierry G. Mesana
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J Thorac Cardiovasc Surg 2004;127:149-159
© 2004 The American Association for Thoracic Surgery

Surgery for acquired cardiovascular disease

Late incidence and predictors of persistent or recurrent heart failure in patients with aortic prosthetic valves

Marc Ruel, MD, MPHa,b,*, Fraser D. Rubens, MDa, Roy G. Masters, MDa, Andrew L. Pipe, MDa, Pierre Bédard, MDa, Paul J. Hendry, MDa, B. Khanh Lam, MD, MPHa, Ian G. Burwash, MDc, William G. Goldstein, MDa, Maurice P. Brais, MDa, Wilbert J. Keon, MDa, Thierry G. Mesana, MD, PhDa

a Division of Cardiac Surgery, University of Ottawa, Ottawa, Ontario, Canada
b Department of Epidemiology, University of Ottawa, Ottawa, Ontario, Canada
c Division of Cardiology, University of Ottawa, Ottawa, Ontario, Canada

Read at the Eighty-third Annual Meeting of The American Association for Thoracic Surgery, Boston, Mass, May 4-7, 2003.

Received for publication May 2, 2003; revisions received July 21, 2003; accepted for publication September 11, 2003.

* Address for reprints: Marc Ruel, MD, MPH, University of Ottawa Heart Institute, 40 Ruskin St, Ste 3403, Ottawa, Ontario, Canada K1Y 4W7
mruel{at}ottawaheart.ca

BACKGROUND: We examined factors associated with persistent or recurrent congestive heart failure after aortic valve replacement.

METHODS: Patients who underwent aortic valve replacement with contemporary prostheses (n = 1563) were followed up with annual clinical assessment and echocardiography. The effect of demographic, comorbid, and valve-related variables on the composite outcome of New York Heart Association class III or IV symptoms or congestive heart failure death after surgery was evaluated with stratified log-rank tests, Cox proportional hazard models, and logistic regression. Factors associated with all-cause death were also examined. Prediction models were bootstrapped 1000 times.

RESULTS: Total follow-up was 6768 patient-years (mean, 4.3 ± 3.3 years; range, 60 days to 17.1 years). Freedom from congestive heart failure or congestive heart failure death was 98.6% ± 0.3%, 88.6% ± 1.0%, 73.9% ± 2.3%, and 45.2% ± 8.5% at 1, 5, 10, and 15 years, respectively. Age, preoperative New York Heart Association class, left ventricular grade, atrial fibrillation, coronary artery disease, smoking, and redo status predicted congestive heart failure after surgery (all P < .05). Larger prosthesis size and effective orifice area, both absolute and indexed for body surface area, were independently associated with freedom from congestive heart failure. Increased transprosthesis gradients were predicted by prosthesis-patient mismatch and were associated with congestive heart failure after surgery. Mismatch defined as an effective orifice area/body surface area of 0.80 cm2/m2 or less was a significant predictor of congestive heart failure events after surgery, but mismatch defined as an effective orifice area/body surface area of 0.85 cm2/m2 or less was not. Small prosthesis size and mismatch were not significantly associated with all-cause mortality.

CONCLUSIONS: These analyses identify independent predictors of congestive heart failure symptoms and congestive heart failure death late after aortic valve replacement and indicate that prosthesis size has a significant effect on this cardiac end point, but not on overall survival after aortic valve replacement.




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