Circulation, Vol 82, 124-139, Copyright © 1990 by American Heart Association
O Lund
Predictability of prognosis was analyzed in 630 patients who were alive 30
days after valve replacement (1965-1986) for aortic stenosis. Follow- up
totaled 4,072 patient-years. During the operative periods of 1965- 1971 (n
= 62), 1972-1976 (n = 164), 1977-1981 (n = 158), and 1982-1986 (n = 246),
decreases in cardiothoracic index (0.56 +/- 0.06, 0.53 +/- 0.06, 0.52 +/-
0.06, and 0.51 +/- 0.06; p less than 0.0001), in the prevalence of
functional classes III and IV (87%, 76%, 68%, and 62%; p less than 0.0001),
and of left ventricular (50%, 39%, 36%, and 30%; p less than 0.05) were
accompanied by improved survival (5 year/10 year +/- SE: 73 +/- 6%/53 +/-
6%, 82 +/- 3%/65 +/- 4%, 89 +/- 3%/79 +/- 4%, and 87 +/- 3%/-; p = 0.002)
despite increasing age (56 +/- 9, 57 +/- 11, 59 +/- 10, and 61 +/- 11
years; p less than 0.01). A Cox regression analysis identified peak-to-peak
systolic gradient (p = 0.0001; inversely related to death rate),
cardiothoracic index (p = 0.0003), left ventricular failure (p = 0.0005),
prosthetic orifice diameter of 15 mm or less (p = 0.001), age (p = 0.003),
ventricular ectopic beats (p = 0.004), male gender (p = 0.03), and
antianginal/antiarrhythmic treatment (p = 0.03) as independent risk
factors. A prognostic index calculated from the final Cox model stratified
the patients into eight risk groups, having observed +/-
SE/predicted/expected (matched background population) 10-year survival
rates of 90 +/- 7% (n = 29)/94%/91%, 84 +/- 6% (n = 61)/89%/87%, 86 +/- 3%
(n = 105)/83%/81%, 75 +/- 4% (n = 165)/75%/77%, 62 +/- 6% (n =
128)/63%/74%, 51 +/- 8% (n = 84)/47%/71%, 29 +/- 9% (n = 40)/31%/67%, and
16 +/- 9% (n = 18)/14%/54% (p less than 0.000001/-/-). Excess mortality
relative to the background populations prevailed predominantly in risk
groups 5-8 and was mainly caused by congestive heart failure. Thus,
improved long- term survival during the 22-year operative period was
related to improved preoperative patient status. Earlier operation (= low
prognostic index) inferred a survival rate comparable to that of a matched
background population. The prognostic index was probably predominantly
related to preoperative myocardial damage that caused late predictable
death from congestive heart failure.
ARTICLES
Preoperative risk evaluation and stratification of long-term survival after valve replacement for aortic stenosis. Reasons for earlier operative intervention
Department of Thoracic and Cardiovascular Surgery, Skejby Sygehus- Aarhus University Hospital, Denmark.
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