Repeated thromboembolic and bleeding events after mechanical aortic valve replacement

doi:10.1016/S0003-4975(00)02683-7

The Annals of Thoracic Surgery

Volume 71, Issue 4, April 2001, Pages 1172-1180

https://doi.org/10.1016/S0003-4975(00)02683-7 Get rights and content

Abstract

Background. The choice of a valve substitute in young adults requires a decision balancing the risks of long-term anticoagulation versus reoperation(s). This article analyzes the long-term risk and determinants of thromboembolic (TE) and bleeding (BLE) complications after mechanical aortic valve replacement (AVR).

Methods. From December 1963 to January 1974, 249 patients survived a mechanical AVR at our institution. Mean age was 41.8 ± 12.4 years and 81% (n = 202) were male. Ball valves were implanted in 24% (n = 61) and disc valves in 76% (n = 188). Patients were anticoagulated with vitamin K antagonists and dipyridamole. A total of 4,855 patient–years was available for analysis. Mean follow-up was 19.5 ± 9.4 years and was 100% complete. Analyses were performed with Kaplan-Meier and multivariable Cox regression methods.

Results. One hundred and two patients had one TE or BLE postoperative event and 58 patients had two postoperative events. Six patients had more than five postoperative events. Freedom from a first postoperative event was 74.8% ± 2.9%, 55.3% ± 3.5%, and 46.8% ± 4.0% at 10, 20, and 30 years, respectively. Freedom from a second postoperative event was 45.4% ± 5.4%, 29% ± 6.0%, and 23.2% ± 7.1% at 10, 20, and 30 years, respectively. Multivariate predictors for TE or BLE complications were ball valve (Odds Ratio (OR) = 2.9), postoperative endocarditis (OR = 2.2), and any surgery (OR = 2.2). The incidence of events was highest the first 5 postoperative years.

Conclusions. The risk of adverse events is highest the first 5 postoperative years. Once an event has occurred, the risk for a second event is increased. The incidence and frequency of events is substantial and should be considered in the choice of a valve substitute.

Section snippets

Patient selection

December 1963 was the start of the aortic valve replacement program at our institution and we studied the first 10 years of this program (December 1963 through January 1, 1974). A total of 312 patients underwent aortic valve replacement during this time. Reoperations, urgent, or combined procedures were included. Operative mortality before 1971 was 33% (44 of 132 patients) and from 1971 to 1974 it was 10.5% (19 of 180 patients). Causes of hospital death are mentioned in Table 1. Since none of

Late mortality

Overall actuarial survival among hospital survivors was 80.3% ± 2.6%, 57.4% ± 3.1%, and 33.6% ± 4.2% at postoperative years 10, 20, and 30, respectively (Fig 1). The linearized incidence rate was 3.2% ± 0.3% per year. Causes of death are shown in Table 3. Multivariate independent risk factors for death were age [hazard ratio increase of 1.0 per year (95% CI 1.0 to 1.1)], male gender [hazard ratio 1.7 (95% CI 1.1 to 2.7)], operation before 1970 [hazard ratio 1.6 (95% CI 1.1 to 2.4)], and

Overall TE and major BLE complications (global incidence)

In agreement with previous publications, the global incidence of TE or BLE complications was fairly high 4, 8, 9, 10, 11, 12. In this series, only 46.8% of the patients remained free from a first TE or BLE event at 30 years postoperatively. However, the linearized incidence rate for a first event in this series was 3% per patient–year, which compares favorably with reported incidence rates of 3% to 5% for the Starr-Edwards valve 4, 9, and an overall incidence of approximately 3.5% for the

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In contrast, AVAR replaces the ascending aorta with a valved tubular graft and has shown excellent results.3 However, this technique (when performed using a mechanical prosthesis) is associated with the need of lifelong anticoagulation and increased risk of bleeding and thromboembolic complications.17 Accumulating data have shown the feasibility and safety of the VSAR procedure with excellent results at short- and long-term follow-up.3,18–20
Differences in recurrence rate of aortic regurgitation (AR) and extent of left ventricular (LV) remodeling across the different surgical options in patients operated for type A aortic dissection remain unknown. The present evaluation compared the AR recurrence rate and changes in LV volumes and systolic function in valve-sparing aorta replacement (VSAR), supracoronary ascending aorta replacement (SCAR), and aortic valve and aorta replacement (AVAR). A total of 97 patients (58 ± 12 years, 62% men) with acute type A aortic dissection who underwent VSAR (n = 24), SCAR (n = 43), or AVAR (n = 30) were evaluated. Changes in LV volumes and function between postoperative and follow-up were compared using linear mixed models. Postoperative AR grades were not significantly different between groups. However, after median follow-up of 47 months, AR grade ≥2 was significantly more often observed in SCAR (55%) and VSAR (25%) compared to AVAR (0%, p <0.001). LV volumes remained stable in VSAR and AVAR but increased significantly in SCAR (LV end-diastolic volume: from 99 ± 4 to 131 ± 6 ml; p <0.001; LV end-systolic volume: from 49 ± 3 to 66 ± 5 ml; p = 0.002). In patients with recurrent AR grade ≥2 at follow-up, LV volumes increased, whereas patients without recurrent AR did not show significant LV dilatation. In conclusion, patients with acute type A aortic dissection who underwent SCAR or VSAR showed more frequently AR grade ≥2 recurrence compared to AVAR. However, only patients who underwent SCAR experienced adverse LV remodeling at follow-up. Recurrence of AR grade ≥2 was associated with adverse LV remodeling.
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Original article: cardiovascularRepeated thromboembolic and bleeding events after mechanical aortic valve replacement

Abstract

Section snippets

Patient selection

Late mortality

Overall TE and major BLE complications (global incidence)

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Am Heart J

Ann Thorac Surg

Mayo Clin Proc

Ann Thorac Surg

Ann Thorac Surg

Chest

Ann Thorac Surg

J Thorac Cardiovasc Surg

Prosthetic heart valve performancelong-term follow-up

Curr Probl Cardiol

Performance of the Starr-Edwards aortic cloth covered valve, track valve, and silastic ball valve

Eur J Cardiothorac Surg

INRan internationally accepted standard for the monitoring of oral anticoagulant treatment

Ned Tijdschr Geneesk

Original article: cardiovascular
Repeated thromboembolic and bleeding events after mechanical aortic valve replacement