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J Thorac Cardiovasc Surg 2003;126:783-793
© 2003 The American Association for Thoracic Surgery
Surgery for acquired cardiovascular disease |
a Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio, USA,
b Department of Biostatistics and Epidemiology, The Cleveland Clinic Foundation, Cleveland, OhioUSA
c The University of British Columbia, Vancouver, British Columbia, Canada
d Dartmouth Medical School, Dartmouth-Hitchcock Medical Center, Lebanon, NHUSA
e Northwest Surgical Associates, Portland, OreUSA
f Stanford University, Stanford, CalifUSA
g University Hospital, Cardiff, United Kingdom
h Instituto Chirurgia Cardiovascolare, University of Padova, Padova, Italy
i Harefield Hospital, London, United Kingdom
j Edwards Lifesciences Corporation, Irvine, CalifUSA
Read at the Eightieth Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada, April 30–May 3, 2000.
Received for publication April 28, 2000; revisions received November 27, 2002; accepted for publication February 26, 2003.
* Address for reprints: Eugene H. Blackstone, MD, The Cleveland Clinic Foundation, 9500 Euclid Ave, Desk F25, Cleveland, OH 44195, USA
blackse{at}ccf.org
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Abstract |
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 Top Abstract Patients and methodsResultsDiscussionDiscussionAppendix 1: variables available...Appendix 2: details of...Appendix 3: details of...References |
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METHODS: Data from nine representative sources on 13,258 aortic valve replacements provided 69,780 patient-years of follow-up (mean 5.3 ± 4.7 years), with reliable survival estimates to 15 years. Prostheses included 5757 stented porcine xenografts, 3198 stented bovine pericardial xenografts, 3583 mechanical valves, and 720 allografts. Manufacturers’ labeled prosthesis size was 19 mm or smaller in 1109 patients. Expressions of prosthesis-patient size assessed were indexed internal prosthesis orifice area (in centimeters squared per square meter of body surface area) and standardized internal prosthesis orifice size (Z, the number of SDs from mean normal native aortic valve size). Multivariable hazard domain analysis with balancing score and risk factor adjustment quantified the association of prosthesis-patient size with survival.
RESULTS: Prosthesis-patient size down to at least 1.1 cm2/m2 or -3 Z did not adversely affect intermediate- or long-term survival (P > .2). However, 30-day mortality increased 1% to 2% when indexed orifice area fell below 1.2 cm2/m2 (P = .002) or standardized orifice size fell below -2.5 Z (P = .0003). The increased early risk affected fewer than 1% of patients receiving bioprostheses but about 25% of those receiving mechanical devices.
CONCLUSIONS: Aortic prosthesis-patient size down to 1.1 cm2/m2 or -3 Z did not reduce intermediate- or long-term survival after aortic valve replacement. However, patient-prosthesis size under 1.2 cm2/m2 or -2.5 Z was associated with a 1% to 2% increase in 30-day mortality. Prosthesis-patient sizes this small or smaller were rarely implanted in patients receiving bioprostheses.
The study has two unique features. First, it uses an analytic method that permits independent assessment of the association of prosthesis-patient size with long-, intermediate-, and short-term survivals. Second, it uses a large multi-institutional group of patients to achieve sufficient statistical power to make these assessments. Purposes of the investigation were to quantify the relationship of prosthesis-patient size to long-, intermediate-, and short-term survivals and from this relationship to develop a clinically useful algorithm for identifying a prosthesis size below which survival might be affected.
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Patients and methods |
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TopAbstractPatients and methodsResultsDiscussionDiscussionAppendix 1: variables available...Appendix 2: details of...Appendix 3: details of...References |
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Prostheses
Prostheses were of four varieties: stented porcine xenografts (n = 5757, designated porcine), stented bovine pericardial xenografts (n = 3198, designated pericardial), mechanical devices (n = 3583, of which 2125 were bileaflet and 1458 were monoleaflet), and allografts (n = 720). Patient characteristics varied according to variety of prosthesis received (Tables 2A and 2B).
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Prosthesis size was defined in terms of geometric dimensions of prostheses, not in vitro or in vivo functional dimensions. These properties included the manufacturer’s labeled size (in millimeters), which refers inconsistently to diameter of external sewing ring (mechanical prostheses), mounting ring (stented xenografts), or internal orifice (allografts), and the geometric internal orifice diameter (in millimeters), a consistent physical dimension (Appendix Table 1). 5 They did not include patient’s tissue annulus diameter, a proposed ISO standard (ISO/CD 5840 working decrement) that was not recorded in any source. Patient size was represented by BSA, calculated from height and weight.6
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Data analysis
Survival estimates
Overall survivals were 95.8% at 30 days and 91%, 79%, 58%, and 37% at 1, 5, 10, and 15 years (Figure 2, A).
Instantaneous risk of death peaked immediately after operation, fell rapidly during the first 6 postoperative months, and then rose steadily (Figure 2, B). These represent three additive hazard phases labeled early, constant, and late. To determine the independent influence of prosthesis-patient size on long-, intermediate-, and short-term survivals, a multiphase hazard decomposition method was used (available for use with the SAS system at http://www.clevelandclinic.org/heartcenter/hazard). Each hazard phase (Figure 2, B) incorporated an independent set of risk factors, permitting quantification of the effect of prosthesis-patient size within each time frame determined by the data themselves, not arbitrarily, without assuming proportional hazards.9
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Prosthesis-patient size and survival
Separate analyses were performed of the relation of risk-adjusted mortality to continuous values of indexed orifice area and standardized orifice size (Z). The specific linearizing transformations of scale for these (and other continuous variables) for each hazard phase were selected by bootstrap bagging (Appendix 2).13,14 Whenever computatively possible, effects of both large and small prosthesis-patient size were estimated (Appendix 3).
Clinical algorithm
An internal prosthesis orifice diameter was calculated across the spectrum of BSA below which increased risk of mortality might be anticipated. For this, formulas for indexed orifice area and standardized orifice size were rearranged and solved at fixed values of prosthesis-patient size.
Presentation
Survival curves are presented with both parametric and Kaplan-Meier estimates. Confidence limits are asymmetric and equivalent to 1 SE (68%). To illuminate multivariable findings, nomograms were constructed by solving the multivariable equations for a 70-year-old woman of 1.9 m2 BSA with aortic stenosis, in New York Heart Association functional class III, and undergoing primary isolated AVR in the current era.
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Results |
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TopAbstractPatients and methodsResultsDiscussionDiscussionAppendix 1: variables available...Appendix 2: details of...Appendix 3: details of...References |
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By substituting either 1.2 cm2/m2 or -2.5 Z into their respective formulas, a simple nomogram reveals the internal orifice size of a prosthesis at these thresholds for any BSA (Figure 7). The nomogram can be used in the operating room by drawing a vertical line from a patient’s BSA to the solid line and a horizontal line from there to the internal orifice diameter. Appendix Table A1 is then used to find the next largest labeled-size prosthesis that provides either indexed orifice area or standardized orifice size above these threshold values.
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Discussion |
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TopAbstractPatients and methodsResultsDiscussionDiscussionAppendix 1: variables available...Appendix 2: details of...Appendix 3: details of...References |
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First, the natural history of mild, fixed native aortic valve stenosis is unknown. Progressive aortic disease tends to become apparent in elderly persons; mild nonprogressive stenosis may be well tolerated. Second, patients who undergo AVR have lower long-term survival than an age-, sex-, and race-matched general population (Appendix Figure 2). 6 Mortality is affected by complications of warfarin anticoagulation (particularly its variability21) among patients with mechanical devices and by reoperation for structural valve degeneration among those with biologic prostheses. Yet in this study and others,22 it has been difficult to demonstrate a survival difference according to prosthesis variety (Appendix 3). Thus, the multifactorial nature of reduced survival after AVR may mask subtle individual components of it, such as small prosthesis-patient size. Third, few prostheses, and almost no bioprostheses, had a prosthesis-patient size smaller than the 95% confidence limits of normal native human aortic valves (-2 Z). Thus, AVR as practiced in centers represented in this study is such that prosthesis-patient size is rarely excessively small.23 Fourth, degenerative aortic valve stenosis is a disease of elderly patients with already limited lifespans. Although we searched for interactions of age with prosthesis-patient size and found none, elderly patients simply may not live long enough to manifest a survival decrement from small prosthesis-patient size. Fifth, the 1% to 2% increase in short-term mortality found among patients with small prosthesis-patient size may serve as a biologic selection process. However, our cohort of patients with such prostheses (1109 patients with a labeled size of 19 mm or smaller) was sufficiently large, short-term mortality sufficiently low, and survival sufficiently long to suggest that this is not an important explanation.
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Issues
At the time of its original presentation, in subsequent discussions of its findings, and among ourselves, this study raised several methodologic issues.
Statistical power and risk adjustment
Confounding reliable assessment of the relation of prosthesis size to mortality are differences in characteristics of patients receiving each size and variety of prosthesis, necessitating risk adjustment; inconsistencies between manufacturer’s labeled size for various types of prosthesis, necessitating adoption of consistent expressions of prosthesis size; limitations of single-institution studies, particularly regarding number of patients receiving small prostheses, necessitating a multi-institutional study; and low operative mortality, necessitating a large study with a sufficient number of deaths to achieve adequate statistical power. By amassing a large AVR database with a sufficient number of events (3898 deaths), we were available to achieve statistical power to identify even a small survival impact of prosthesis-patient size and to localize it to a specific follow-up time frame while adjusting simultaneously for many important patient variables, device models, data sources, and selection factors.
Prosthesis size
Prosthesis size may be based on physical dimensions or functional performance. Physical dimensions include labeled size and internal orifice size. Because manufacturers’ conventions for labeling prosthesis size differ among devices, we selected a common metric: geometric internal orifice diameter.5 Functional size includes in vitro and in vivo effective orifice areas (EOAs). The former may be static at a variety of steady flow rates or dynamic with a variety of pulsatile waveforms and flow rates33; the latter is estimated clinically under a range of incompletely controlled conditions in patients by echocardiography according to various formulas.
We have not included information about in vitro EOA, because methodology has been difficult to standardize and results are difficult to reproduce. We had no individual patient data on functional in vivo EOA. In vivo EOA varies from moment to moment with patient activity,34,35 cardiac output and blood pressure, and dynamics of the left ventricular outflow tract, as well as intrinsic prosthesis properties, although it is well correlated with geometric internal orifice area.34 It is therefore possible that one or more individual patients had functional prosthesis-patient size mismatch that we did not evaluate. However, in vivo EOA is unavailable at the time of selecting a prosthesis at AVR.
Pibarot and colleagues36 and Dumesnil and coworkers34 have suggested that rather than using geometric prosthesis dimensions as a fixed reference for prosthesis size, a fixed referent value of in vivo EOA should be used, which they termed projected EOA. Referent values were obtained from informal meta-analysis of literature sources. To the extent that in vivo EOA differs importantly from a linear relation to geometric orifice area, substituting projected EOA for geometric size is advantageous. However, this strategy has several drawbacks: It suffers from flow dependency, large scatter in the data, rest versus exercise differences, and limited availability of data for each prosthesis size and model. Also, when fixed referent values are used for intraoperative decision making, they acquire the same limitations as the simpler geometric values used in this study. For intraoperative decision making, we therefore recommend using the relation of survival to prosthesis geometric orifice dimensions.
Patient size
Native aortic valve size is related to somatic growth, as is cardiac output. The most consistent allometric relationship, then, is BSA.6
Normalization
Normalization of any expression of prosthesis size can be made to body size. Use of indexed valve area assumes a linear relation between valve area and BSA, which is nearly, but not completely, accurate.6 Use of dimensionless standardized values (Z) is based on the variability of native annulus size among similarly sized healthy individuals. Rimoldi and Lev37 introduced the idea that normality and abnormality can be expressed in terms of number of SDs away from normal size given a patient’s cardiac structures measure. Thus, only 2.5% of the normal population have a valve size 2 SDs or more below mean normal size (-2 Z). Both mean normal value and its SD are estimated by regression analysis of normal patient data.7 Then, given BSA and valve size, the regression equation is solved to yield estimated mean normal valve size and its SD, from which Z is calculated.15
There is a logarithmic relation between indexed and standardized prosthesis-patient size. Standardized size expands the scale of small values compared with indexed values (contrast parts A and B of Figure 5).
Limitations
Despite the large AVR database used in this analysis, small prosthesis-patient size was rare. Only 28 patients had an indexed orifice area smaller than 0.85 cm2/m2. Nevertheless, we believe the information about prosthesis-patient size and survival is reliable down to an indexed orifice area of approximately 1.1 cm2/m2 or 3 SDs below native aortic valve size.
An insurmountable limitation is that neither institution nor valve variety, model, or size was chosen randomly for a given patient. Nonrandom allocation introduces bias. Use of both saturated model techniques and balancing scores provides adjustment for known factors but no explicit protection against factors unavailable across all data sources or unrecorded factors (Appendix 2).11
A study like this relies on existing databases that contain a common set of identically defined and relevant variables, similar outcome assessment, and complete reporting. Not all known or purported risk factors for mortality after AVR were available in all data sets. Among the missing variables were ones related to ventricular morphology, measured ventricular function, and noncardiac comorbidities. These variables may not have been distributed uniformly across institutions and may interact with choice of valve prosthesis and size.
All-cause mortality was the end point. It is noninterpretative and was chosen despite the claim that valve-specific mortality is more sensitive.16 In fact, reported causes of death are untrustworthy, particularly for elderly patients.8 Nevertheless, it is a limitation that we do not know who died suddenly. Although reliable follow-up for survival estimates extended to 15 years, the mean was only 5.3 years. Long-term information requires inclusion of patients operated on in earlier eras, when operative mortality was higher than it is today; we attempted to adjust for this by including date of operation in all analyses.
A strength of this study is representativeness. Databases were solicited from investigators well known for heart valve investigation in North America and Europe and from two organizations responsible for multi-institutional heart valve registries. We also included the spectrum of valve varieties; however, a limitation is the absence of stentless xenografts. Except from one manufacturer, internal orifice size of stentless valves was claimed not to be available, although Rao and colleagues32 have reported that the internal orifice size of a Toronto stentless prosthesis of labeled size 25 is equivalent to that of a pericardial stented prosthesis of labeled size 21. Allografts were therefore considered to represent stentless devices, despite their use primarily in young and middle-aged patients (only 10% of recipients were older than 67 years).38
Inferences
Surgical
Within the constraints of prudent AVR in these institutions, we identified no relationship between prosthetic-patient size and intermediate- and long-term survivals. However, we found a small increase in early mortality among patients who received prostheses with small valve orifices in relationship to body size. Although we recognize that outcome after AVR is related to many factors,39 with currently available prostheses few patients should require aortic root enlargement with its attendant complexity, prolonged operative time, and risks of bleeding, heart block, and mortality,29 particularly if a bioprosthesis is used.
Manufacturing
This study challenges the value of concentrating on better hemodynamic performance. Rather, to improve long-term survival, a durable nonthrombogenic prosthesis is needed that would permit operation much earlier in the natural history of aortic valve disease, before secondary left ventricular remodeling takes place and the patient reports important symptoms.
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Discussion |
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TopAbstractPatients and methodsResultsDiscussionDiscussionAppendix 1: variables available...Appendix 2: details of...Appendix 3: details of...References |
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First, the preoperative risk factors available for analysis were somewhat limited. Aren’t you concerned about the potential influence of additional variables, such as recent myocardial infarction, congestive heart failure, diabetes, hypertension, and particularly low ejection fraction in the setting of aortic stenosis?
Second, neither valve type nor institution nor size was chosen randomly, and not all prostheses were used in all institutions. Thus, operative survival could have been influenced by institutional differences instead of valve size. Can you tell us whether there were differences in operative mortality among the nine participating centers?
Finally, do you recommend on the basis of these results that we abandon our pursuit of more efficient valves in patients undergoing AVR? I congratulate you on your study and thank the Association for the privilege of the floor.
Dr Blackstone. Thank you, Dr Adams. One of the strengths of meta-analysis of a large series such as this is that one can look at a few pinpointed questions. However, one has the disadvantage of not having a large number of risk-adjusting factors in common, with common definitions across institutions. So you are quite correct that some of the risk factors, perhaps some of the more subtle risk factors, could not be looked at in this study.
I remain rather surprised that valve size makes so little difference. I think we don’t know as much as we should about what affects mortality after AVR. Let me give you an example of this. I have looked for all 13,000 of these patients at what the expected survival should have been had they been part of the regular population. What I found is the that the survival of the old patients followed the trajectory for old patients in the normal population. That is surprising, because these were highly selected patients. The younger the patients were, the more they deviated from expected survival. So there are some powerful factors that increase mortality in patients with aortic valve disease, and I am not sure that we have discovered those yet (see Appendix Figure 2).
You ask whether there were institutional and other differences in the data. The institutional differences, the differences according to a variety of prostheses, were all surprisingly very small. Should one abandon them, looking at more efficient valves? My feeling, as I don’t think we said in the manuscript you read, was not that one should abandon looking for more efficient valves. It is just that the implication that the more efficient the valves, the better the survival, may not be a direct link. I think we know less about mortality after AVR than factors such as efficiency of valve and size.
Dr Vivek Rao (Toronto, Ontario, Canada). Dr Blackstone, I enjoyed that presentation. This was an impressive number of aortic valves across a number of institutions. As you know, the Toronto and Vancouver group presented a combined result at last year’s American Heart Association meeting, where we did demonstrate a significant effect of prosthesis size on late survival. And to compare a couple of differences between your study and ours, first of all, the mean follow-up in your study was about 5.5 years, compared with almost 10 years in our study, and in fact the differences that we observed didn’t become apparent until 7 years of follow-up. That is, the survival curves were parallel until 7 years. In fact, looking at your slide at the indexed in vitro effective orifice areas, the curves do tend to separate at about that time point. So my first question is, do you think with additional follow-up that you will be able to demonstrate a significant difference?
Second, I would like your comments on the concept of valve-related mortality, because, again, that was the significant end point in our study. You have looked at overall survival in your study. Would looking at the more sensitive end point of valve-related mortality have affected your results?
Finally, I think that the concept of patient-prosthetic mismatch is more important in younger patients. With the significant number of patient data that you have, if you restricted an analysis to those younger patients, could you find an increased risk of sudden death from patient-prosthesis mismatch?
Dr Blackstone. Dr Rao, of course we have been interested in your concerns in this for a long time. I think I have definitive answers to all three of your questions.
As you notice, the effective orifice area in vitro does show what appears to be a separation at, say, 5 or so years. This completely vanished the moment we did a multivariable analysis and took into account patient risk factors. So I think that what you are seeing on the slide is not risk adjusted, and that it vanishes once adjustment is made.
You have asked whether a difference would be seen if one were to look more sensitively at valve-related death. In this particular analysis and, again, coming from multiple institutions, it is hard to look at exactly the mode of death. You know from a publication that we have from the Cleveland Clinic with Dr Eric Topol that we are philosophically opposed to looking at more than the hard point of all-cause mortality. I think that is a very hard point. It is the point that the patients are most concerned with, not why they die but the fact that they do die. It may be more sensitive, but it should be revealed if it is really there. Only about half the patients are being followed up longer than 5.5 years, but we had thousands of patients alive at 10 years. So proportionately we may not have many patients alive at 10 years, but in actual numbers, we have thousands.
Your last point is whether there may be some differences across young age. We have done an extensive interaction analysis looking at absolutely every variable in the data set in relationship to size to see whether there is a gradient that is different for younger patients, for older patients, and so on, and we found no significant interactions.
Dr Guo-Wei He (Hong Kong, China). Congratulations, Dr. Blackstone, on your wonderful study with this large size sample. A while ago we did a study with Gary Grunkemeier, mainly looking at Portland data, which is a part of your study, after 30 years’ follow-up for AVR in small aortic root and published in the Annals of Thoracic Surgery. We found that the small size of aortic root, which only fit 19- and 21-mm prostheses, carries a higher late mortality, I mean more than 10 years, when the BSA is greater than 1.6 m2.
In your study, the mean follow-up was 6.5 years and the maximum follow-up was 20 years; in our study, maximum follow-up was about 30 years. And the differences between your study and ours therefore may be related to the period of the follow-up. Is there a tendency that with the increase of follow-up period, the influence of small aortic valve and aortic valve root on the late survival likewise increases?
Dr Blackstone. Thank you, Dr He. Yes, you have been active in this area. We have looked in the following way to try and answer your question. These 13,000 patients were subjected to 4000 bootstrap resampling analyses. This is a technique where you sample the patients as if you had created, in this case, 4000 separate analyses, and we looked at the possibility that there was a late effect of any kind. What we found is that in studies of this size there was a 25% chance of finding a late effect.
Dr Denton A. Cooley (Houston, Tex). Thank you for the opportunity to discuss this excellent analysis. I am quite surprised with your conclusions, because they are against current conventional thinking. I think from a practical standpoint that the surgeon is more guilty of oversizing the valve with a stented valve than of undersizing the valve, and I am reassured to find that those of us who tend to undersize the valve have some reason for doing so, especially in patients undergoing double valve replacement. Thank you for this nice presentation.
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Appendix 1: variables available for analysis |
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TopAbstractPatients and methodsResultsDiscussionDiscussionAppendix 1: variables available...Appendix 2: details of...Appendix 3: details of...References |
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Clinical status
Pathophysiology
Procedure
Experience
Prosthesis
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Appendix 2: details of risk adjustment |
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TopAbstractPatients and methodsResultsDiscussionDiscussionAppendix 1: variables available...Appendix 2: details of...Appendix 3: details of...References |
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Selection bias
To adjust for biases in choice of prosthesis size that may have confounded outcome, balancing scores were constructed by linear regression, forcing into each model all available variables (Appendix 1)
to predict prosthesis-patient size.41 From these regression equations, values for each expression of prosthesis-patient size were predicted for each patient; these predicted values constituted the balancing scores. The balancing score corresponding to each expression of prosthesis-patient size was included as a further adjustment with all other variables in each hazard phase. To illustrate the magnitude of bias between prosthesis size and patient, procedural, and valve variety factors, a logistic regression analysis was performed to identify factors associated with the use of prostheses of labeled size 19 mm or smaller.
Results
Risk adjustment
The statistical significance and direction of the association of risk-adjustment variables with survival are presented in Appendix Table 2. Table 2.
Associations include the strong effect of patient factors such as advanced age (Appendix Figure 2), advanced symptoms, aortic regurgitation, previous AVR, and ischemic heart disease. Operative risk was higher earlier in the experience. Small and generally statistically nonsignificant differences in mortality were observed across data sources and among models of aortic prosthesis, with the exception of higher early risk in patients receiving allografts.
Illustration of bias
Compared with other patients, the 1109 who received a prosthesis size 19 mm or less were older, smaller, more likely to have aortic stenosis, and were more likely to have undergone a previous AVR and concomitant coronary artery bypass grafting (Appendix Table 3).
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Appendix 3: details of prosthesis-patient size analysis |
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TopAbstractPatients and methodsResultsDiscussionDiscussionAppendix 1: variables available...Appendix 2: details of...Appendix 3: details of...References |
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Dichotomous prosthesis-patient size variables
Although we concentrated on continuous measurements, in the multivariable analyses we also examined binary variables for indexed orifice area less than 1.25 cm2/m2 and standardized orifice size less than -2.5 Z, representing the lowest 10th percentile of patients, as suggested by Rao and colleagues.16
Interactions
After prosthesis-patient size was entered into each hazard phase of the multivariable analyses, assessments of interactions were performed. These included 2-way interactions of patient-prosthesis size with each risk-adjustment variable and 3-way interactions with age and gender.42
Results
Reliability of findings
Bootstrap bagging with 1000 resampled models was used to assess the reliability of association of prosthesis-patient size with mortality at a significance level of at least P = .05. In the early hazard phase, there was a 90% probability that smaller indexed orifice area was associated with higher mortality, including an 8% probability that both smaller and larger size were associated. For standardized orifice size, the corresponding probabilities were 90% and 60%.
In contrast, in the constant hazard phase there was a 20% probability that smaller indexed orifice area was associated with higher mortality, including a 6% probability that both smaller and larger size were associated. For standardized orifice size, the corresponding probabilities were 46% and 4.5%.
In the late hazard phase there was a 25% probability that smaller indexed orifice area was associated with mortality, including a 2% probability that both smaller and larger size were associated. For standardized orifice size, the corresponding probabilities were 24% and 25%.
Search for modulating factors
Interactions between patient factors and expressions of prosthesis-patient size that might modulate these estimates of magnitude of risk were not statistically significant (P > .1). In particular, the pattern of risk in elderly men with aortic stenosis receiving small prostheses was no different from that determined for the entire study group (P = .9).42 Interactions between prosthesis-patient size and valve models did not modulate survival.
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Acknowledgments |
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References |
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TopAbstractPatients and methodsResultsDiscussionDiscussionAppendix 1: variables available...Appendix 2: details of...Appendix 3: details of...References |
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 R. W. Emery, A. M. Emery, A. Knutsen, and G. V. Raikar Aortic Valve Replacement with a Mechanical Cardiac Valve Prosthesis Card. Surg. Adult, January 1, 2008; 3(2008): 841 - 856. [Full Text]
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N. D. Desai and G. T. Christakis Bioprosthetic Aortic Valve Replacement: Stented Pericardial and Porcine Valves Card. Surg. Adult, January 1, 2008; 3(2008): 857 - 894. [Full Text]
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 J.-L. Monin, M. Monchi, M. E.W. Kirsch, H. Petit-Eisenmann, S. Baleynaud, C. Chauvel, D. Metz, C. Adams, J.-P. Quere, P. Gueret, et al. Low-gradient aortic stenosis: impact of prosthesis-patient mismatch on survival Eur. Heart J., November 1, 2007; 28(21): 2620 - 2626. [Abstract] [Full Text] [PDF]
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J. Dhareshwar, T. M. Sundt III, J. A. Dearani, H. V. Schaff, D. J. Cook, and T. A. Orszulak Aortic root enlargement: What are the operative risks? J. Thorac. Cardiovasc. Surg., October 1, 2007; 134(4): 916 - 924. [Abstract] [Full Text] [PDF]
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 T. Walther, P. Simon, T. Dewey, G. Wimmer-Greinecker, V. Falk, M. T. Kasimir, M. Doss, M. A. Borger, G. Schuler, D. Glogar, et al. Transapical Minimally Invasive Aortic Valve Implantation: Multicenter Experience Circulation, September 11, 2007; 116(11_suppl): I-240 - I-245. [Abstract] [Full Text] [PDF]
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F. B. Vanky, E. Hakanson, and R. Svedjeholm Long-Term Consequences of Postoperative Heart Failure After Surgery for Aortic Stenosis Compared With Coronary Surgery Ann. Thorac. Surg., June 1, 2007; 83(6): 2036 - 2043. [Abstract] [Full Text] [PDF]
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M. D. Peterson, M. A. Borger, C. M. Feindel, and T. E. David Aortic Annular Enlargement During Aortic Valve Replacement: Improving Results With Time Ann. Thorac. Surg., June 1, 2007; 83(6): 2044 - 2049. [Abstract] [Full Text] [PDF]
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P. Pibarot and J. G. Dumesnil Prosthesis-patient mismatch in the mitral position: Old concept, new evidences J. Thorac. Cardiovasc. Surg., June 1, 2007; 133(6): 1405 - 1408. [Full Text] [PDF]
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I. M. Wagner, W. B. Eichinger, S. Bleiziffer, F. Botzenhardt, I. Gebauer, R. Guenzinger, R. Bauernschmitt, and R. Lange Influence of completely supra-annular placement of bioprostheses on exercise hemodynamics in patients with a small aortic annulus J. Thorac. Cardiovasc. Surg., May 1, 2007; 133(5): 1234 - 1241. [Abstract] [Full Text] [PDF]
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P. Pibarot and J. G Dumesnil Prevention of valve prosthesis--patient mismatch before aortic valve replacement: does it matter and is it feasible? Heart, May 1, 2007; 93(5): 549 - 551. [Abstract] [Full Text] [PDF]
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S. Bleiziffer, W. B Eichinger, I. Hettich, R. Guenzinger, D. Ruzicka, R. Bauernschmitt, and R. Lange Prediction of valve prosthesis-patient mismatch prior to aortic valve replacement: which is the best method? Heart, May 1, 2007; 93(5): 615 - 620. [Abstract] [Full Text] [PDF]
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C. R. Bridges, S. M. O'Brien, J. C. Cleveland, E. B. Savage, J. S. Gammie, F. H. Edwards, E. D. Peterson, and F. L. Grover Association between indices of prosthesis internal orifice size and operative mortality after isolated aortic valve replacement J. Thorac. Cardiovasc. Surg., April 1, 2007; 133(4): 1012 - 1021. [Abstract] [Full Text] [PDF]
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R. M. Bolman III Survival After Mitral Valve Replacement: Does the Valve Type and/or Size Make a Difference? Circulation, March 20, 2007; 115(11): 1336 - 1338. [Full Text] [PDF]
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J. Magne, P. Mathieu, J. G. Dumesnil, D. Tanne, F. Dagenais, D. Doyle, and P. Pibarot Impact of Prosthesis-Patient Mismatch on Survival After Mitral Valve Replacement Circulation, March 20, 2007; 115(11): 1417 - 1425. [Abstract] [Full Text] [PDF]
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F. Bakhtiary, M. Schiemann, O. Dzemali, S. Dogan, V. Schachinger, H. Ackermann, A. Moritz, and P. Kleine Impact of Patient-Prosthesis Mismatch and Aortic Valve Design on Coronary Flow Reserve After Aortic Valve Replacement J. Am. Coll. Cardiol., February 20, 2007; 49(7): 790 - 796. [Abstract] [Full Text] [PDF]
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S. Bleiziffer, W. B. Eichinger, and R. Lange Letter by Bleiziffer et al Regarding Article, "Long-Term Outcomes After Valve Replacement for Low-Gradient Aortic Stenosis: Impact of Prosthesis-Patient Mismatch" Circulation, December 5, 2006; 114(23): e627 - e627. [Full Text] [PDF]
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T. Bove, Y. Van Belleghem, K. Francois, F. Caes, H. Van Overbeke, and G. Van Nooten Stentless and stented aortic valve replacement in elderly patients: factors affecting midterm clinical and hemodynamical outcome Eur. J. Cardiothorac. Surg., November 1, 2006; 30(5): 706 - 713. [Abstract] [Full Text] [PDF]
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T. Kunihara, K. Schmidt, P. Glombitza, V. Dzindzibadze, H. Lausberg, and H.-J. Schafers Root replacement using stentless valves in the small aortic root: a propensity score analysis. Ann. Thorac. Surg., October 1, 2006; 82(4): 1379 - 1384. [Abstract] [Full Text] [PDF]
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 A. I. Duncan, J. Lin, C. G. Koch, A. M. Gillinov, M. Xu, and N. J. Starr The Impact of Gender on In-Hospital Mortality and Morbidity After Isolated Aortic Valve Replacement Anesth. Analg., October 1, 2006; 103(4): 800 - 808. [Abstract] [Full Text] [PDF]
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G. Rizzoli, S. Mirone, P. Ius, E. Polesel, T. Bottio, L. Salvador, C. Zussa, G. Gerosa, and C. Valfre Fifteen-year results with the Hancock II valve: A multicenter experience. J. Thorac. Cardiovasc. Surg., September 1, 2006; 132(3): 602 - 609.e4. [Abstract] [Full Text] [PDF]
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W. Flameng, B. Meuris, P. Herijgers, and M.-C. Herregods Prosthesis-Patient Mismatch is Not Clinically Relevant in Aortic Valve Replacement Using the Carpentier-Edwards Perimount Valve Ann. Thorac. Surg., August 1, 2006; 82(2): 530 - 536. [Abstract] [Full Text] [PDF]
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P Pibarot and J G Dumesnil Prosthesis-patient mismatch: definition, clinical impact, and prevention Heart, August 1, 2006; 92(8): 1022 - 1029. [Abstract] [Full Text] [PDF]
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N. J. Howell, B. E. Keogh, V. Barnet, R. S. Bonser, T. R. Graham, S. J. Rooney, I. C. Wilson, and D. Pagano Patient-prosthesis mismatch does not affect survival following aortic valve replacement. Eur. J. Cardiothorac. Surg., July 1, 2006; 30(1): 10 - 14. [Abstract] [Full Text] [PDF]
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T. Walther, A. Rastan, V. Falk, S. Lehmann, J. Garbade, A. K. Funkat, F. W. Mohr, and J. F. Gummert Patient prosthesis mismatch affects short- and long-term outcomes after aortic valve replacement. Eur. J. Cardiothorac. Surg., July 1, 2006; 30(1): 15 - 19. [Abstract] [Full Text] [PDF]
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O. Lund and M. Bland Risk-corrected impact of mechanical versus bioprosthetic valves on long-term mortality after aortic valve replacement J. Thorac. Cardiovasc. Surg., July 1, 2006; 132(1): 20 - 26. [Abstract] [Full Text] [PDF]
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J. G. Dumesnil and P. Pibarot Prosthesis-patient mismatch and clinical outcomes: The evidence continues to accumulate J. Thorac. Cardiovasc. Surg., May 1, 2006; 131(5): 952 - 955. [Full Text] [PDF]
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F. B. Vanky, E. Hakanson, E. Tamas, and R. Svedjeholm Risk Factors for Postoperative Heart Failure in Patients Operated on for Aortic Stenosis Ann. Thorac. Surg., April 1, 2006; 81(4): 1297 - 1304. [Abstract] [Full Text] [PDF]
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D. P. Taggart Prosthesis patient mismatch in aortic valve replacement: possible but pertinent? Eur. Heart J., March 2, 2006; 27(6): 644 - 646. [Full Text] [PDF]
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M. R. Moon, M. K. Pasque, N. A. Munfakh, S. J. Melby, J. S. Lawton, N. Moazami, J. E. Codd, T. D. Crabtree, H. B. Barner, and R. J. Damiano Jr Prosthesis-Patient Mismatch After Aortic Valve Replacement: Impact of Age and Body Size on Late Survival Ann. Thorac. Surg., February 1, 2006; 81(2): 481 - 489. [Abstract] [Full Text] [PDF]
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J. M. Bernal, J. Lorca, D. Prieto-Salceda, I. Pulitani, A. Ponton, I. Garcia, and J. M. Revuelta Performance at 10 years of the CarboMedics 'Top-Hat' valve. Postclamping time is a predictor of mortality Eur. J. Cardiothorac. Surg., February 1, 2006; 29(2): 144 - 149. [Abstract] [Full Text] [PDF]
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G. Tasca, Z. Mhagna, S. Perotti, P. B. Centurini, T. Sabatini, A. Amaducci, F. Brunelli, M. Cirillo, M. D. Tomba, E. Quiani, et al. Impact of Prosthesis-Patient Mismatch on Cardiac Events and Midterm Mortality After Aortic Valve Replacement in Patients With Pure Aortic Stenosis Circulation, January 31, 2006; 113(4): 570 - 576. [Abstract] [Full Text] [PDF]
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D. Mohty-Echahidi, J. F. Malouf, S. E. Girard, H. V. Schaff, D. E. Grill, M. E. Enriquez-Sarano, and F. A. Miller Jr Impact of Prosthesis-Patient Mismatch on Long-Term Survival in Patients With Small St Jude Medical Mechanical Prostheses in the Aortic Position Circulation, January 24, 2006; 113(3): 420 - 426. [Abstract] [Full Text] [PDF]
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P. Pibarot, J. G. Dumesnil, G. Tasca, C. G. Koch, F. Khandwala, F. G. Estafanous, F. D. Loop, and E. H. Blackstone Letter Regarding Article by Koch et al, "Impact of Prothesis-Patient Size on Functional Recovery After Aortic Valve Replacement" * Response Circulation, November 22, 2005; 112(21): e333 - e333. [Full Text] [PDF]
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T. E. David Is Prosthesis-Patient Mismatch a Clinically Relevant Entity? Circulation, June 21, 2005; 111(24): 3186 - 3187. [Full Text] [PDF]
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C. G. Koch, F. Khandwala, F. G. Estafanous, F. D. Loop, and E. H. Blackstone Impact of Prosthesis-Patient Size on Functional Recovery After Aortic Valve Replacement Circulation, June 21, 2005; 111(24): 3221 - 3229. [Abstract] [Full Text] [PDF]
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A. Penta de Peppo, J. Zeitani, P. Nardi, G. Iaci, P. Polisca, R. De Paulis, and L. Chiariello Small "Functional" Size after Mechanical Aortic Valve Replacement: No Risk in Young to Middle-Age Patients Ann. Thorac. Surg., June 1, 2005; 79(6): 1915 - 1920. [Abstract] [Full Text] [PDF]
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L. H. Cohn Use of Heart Valves in Older Patients Circulation, May 3, 2005; 111(17): 2152 - 2153. [Full Text] [PDF]
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H.-H. Sievers Prosthetic aortic valve replacement J. Thorac. Cardiovasc. Surg., May 1, 2005; 129(5): 961 - 965. [Full Text] [PDF]
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F. A. Crawford Jr Residual pulmonary artery hypertension after mitral valve replacement: Size matters! J. Am. Coll. Cardiol., April 5, 2005; 45(7): 1041 - 1042. [Full Text] [PDF]
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R. G. Fuster, J. A. M. Argudo, O. G. Albarova, F. H. Sos, S. C. Lopez, M. B. Codoner, J. A. B. Minano, and I. R. Albarran Patient-prosthesis mismatch in aortic valve replacement: really tolerable? Eur. J. Cardiothorac. Surg., March 1, 2005; 27(3): 441 - 449. [Abstract] [Full Text] [PDF]
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C. Amarelli, A. Della Corte, G. Romano, G. Iasevoli, G. Dialetto, L. S. De Santo, M. De Feo, M. Torella, M. Scardone, and M. Cotrufo Left ventricular mass regression after aortic valve replacement with 17-mm St Jude Medical mechanical prostheses in isolated aortic stenosis J. Thorac. Cardiovasc. Surg., March 1, 2005; 129(3): 512 - 517. [Abstract] [Full Text] [PDF]
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M. Gaudino, F. Alessandrini, F. Glieca, N. Luciani, C. Cellini, C. Pragliola, M. Morelli, C. Canosa, G. Nasso, and G. Possati Survival after aortic valve replacement for aortic stenosis: does left ventricular mass regression have a clinical correlate? Eur. Heart J., January 1, 2005; 26(1): 51 - 57. [Abstract] [Full Text] [PDF]
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J. G. Dumesnil and P. Pibarot Prosthesis size and prosthesis-patient size are unrelated to prosthesis-patient mismatch J. Thorac. Cardiovasc. Surg., June 1, 2004; 127(6): 1852 - 1852. [Full Text] [PDF]
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E. H. Blackstone, A. M. Gillinov, and D. M. Cosgrove Reply to the Editor J. Thorac. Cardiovasc. Surg., June 1, 2004; 127(6): 1852 - 1854. [Full Text] [PDF]
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