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J Thorac Cardiovasc Surg 2007;133:1012-1021
© 2007 The American Association for Thoracic Surgery

Surgery for Acquired Cardiovascular Disease

Association between indices of prosthesis internal orifice size and operative mortality after isolated aortic valve replacement

^a Departments of Surgery and Bioengineering, the University of Pennsylvania Health System, Philadelphia, Pa
^b Duke Clinical Research Institute, Durham, NC
^c Department of Surgery, University of Colorado, Denver, Colo
^d Department of Cardiovascular-Thoracic Surgery, Rush University, Chicago, Ill
^e Department of Surgery, University of Maryland Medical Center, Baltimore, Md
^f Department of Surgery, University of Florida, Jacksonville, Fla.

Read at the Eighty-fifth Annual Meeting of The American Association for Thoracic Surgery, San Francisco, Calif, April 10-13, 2005.

Received for publication April 8, 2005; revisions received November 1, 2006; accepted for publication November 16, 2006.

^_* Address for reprints: Charles R. Bridges, MD, ScD, Department of Surgery, the University of Pennsylvania Health System, Department of Surgery, 4 Silverstein, Hospital of the University of Pennsylvania, Philadelphia, PA 19104. (Email: cbridges{at}pahosp.com).

Objectives: The appropriate index of prosthesis internal orifice size and its effect on operative mortality after aortic valve replacement are controversial. We examined the association between several relevant indices and patient size on operative mortality. Indices examined included projected in vivo effective orifice area and geometric orifice area, with patient size defined as body surface area.

Methods: A review of the Society of Thoracic Surgeons National Cardiac Database (2000-2004) yielded 48,722 patients who had isolated aortic valve replacement. This analysis is based on the cohort of 42,310 patients with the 8 most prevalent valve types with manufacturer’s labeled sizes 19 mm through 29 mm. Multivariable logistic regression models were employed to determine the effects of body surface area, effective orifice area, geometric orifice area, and selected derived indices (eg, effective orifice area/body surface area) on risk-adjusted operative mortality.

Results: In separate multivariable models, effective orifice area and geometric orifice area were both inversely correlated with operative mortality. However, an unanticipated finding was that with either effective orifice area or geometric orifice area held constant, body surface area was significantly and inversely correlated with operative mortality. When patients were stratified by effective orifice area, geometric orifice area, or manufacturer’s labeled valve size and type, elevations in body surface area were associated with a decrease rather than an increase in operative mortality.

Conclusions: Prostheses with small geometric orifice area or small effective orifice area are associated with increased operative mortality after isolated aortic valve replacement. Even for valves with small effective orifice area, however, mortality decreases as body surface area increases. With respect to operative mortality, therefore, our results do not support using arbitrary cutoff values of effective orifice area/body surface area to determine the valve to utilize in a given patient.

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