Circulation, Vol 72, 753-767, Copyright © 1985 by American Heart Association
EH Blackstone and JW Kirklin
A total of 1533 patients received primary aortic and/or mitral valve
replacement, with or without tricuspid valve surgery or other associated
cardiac procedures, from January 1, 1975, to July 1, 1979. Actuarial
survival at 5 years was 74%. The hazard function (instantaneous risk) of
death was highest immediately after operation. Among the incremental risk
factors for premature death from any cause were preoperative NYHA class,
any valve lesion other than aortic stenosis, aortic cross-clamp time, and
combined aortic and mitral valve replacement. Ten modes of death were
identified, each with its unique hazard function and risk factors. The
commonest mode was cardiac failure. Sudden death was the next commonest,
and the early phase of its hazard function peaked about 3 weeks after
operation. Seventy-five patients (6.7% of the 1533) had 103 valve
reoperations in the follow-up period. Actuarial survival after reoperation
was less than that after the primary operation; whether the reoperation was
the first, second, or third was a risk factor. Actuarial freedom from
prosthetic valve endocarditis (PVE) was 97% at 1 year, and that of
periprosthetic leakage without evident infection was 98.8%; the hazard
function for the event PVE had an early phase peaking at about 6 weeks and
a constant low phase throughout, whereas that of periprosthetic leakage had
a single early peaking phase. After reoperations, the actuarial freedom
from PVE and periprosthetic leakage was less than that after the original
operation. The risk factors for the development of periprosthetic leakage
without evident infection were similar but not identical to those for PVE.
Among patients receiving a bioprosthesis, 91% were free of bioprosthetic
degeneration 5 years after operation. The hazard function was single and
continuously rising, and young age and female gender were risk factors.
Actuarial freedom from acute prosthetic thrombosis was 97.9% at 5 years.
The single hazard function for this event peaked at 10 months. The risk of
thrombosis was higher in female patients. The uses of this integrated
study, and the inferences from it, are described.
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Death and other time-related events after valve replacement
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