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J Thorac Cardiovasc Surg 2008;135:1278-1279
© 2008 The American Association for Thoracic Surgery

Invited Commentary

Discussion

Dr Michael Mack (Dallas, Tex). You have performed a study that is potentially a landmark one and likely to change the landscape of the management of patients with critical aortic stenosis in the future. I believe this study is that important. First, similar to the study by Sarano in patients with asymptomatic mitral regurgitation, determining that an effective regurgitant orifice greater than 40 led to decreased survival, your study has defined some characteristics that may lead to earlier operative management of patients with aortic stenosis. Second, you have lent further clarity to the issue of patient–prosthetic mismatch and perhaps saved some elderly patients from undergoing the added risk of a root-enlarging procedure. You conclude that LV hypertrophy, LV dysfunction, extremely severe aortic stenosis, older age, and a small prosthesis in younger patients decreased survival.

However, just as a movie critic needs to find something wrong with a movie to maintain credibility as a critic, I can't let you off scot-free. The positive aspects your study include the fact that it is a large study of more than 3000 patients who received a single type of valve with a mean follow-up of 5 years. A sophisticated statistical analysis (and thank you for the explanation of the Z value) to minimize confounding variables lends further clarity to the data. However, this is not a population with isolated pure aortic stenosis, with 56% of the patients having undergone concomitant coronary bypass surgery and 35% of patients also having aortic regurgitation, factors known to affect outcomes. In addition, only 13% of the patients were actually asymptomatic, yet significant management conclusions are drawn from this group.

My specific questions are as follows. First, you defined a small prosthesis as a patient–prosthesis Z value of –1.5, which corresponds to 1.5 standard deviations below normal valve size . . . [Full Text of this Article]

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J. Thorac. Cardiovasc. Surg. 2008 135: 1270-1279. [Abstract] [Full Text] [PDF]