Limits...
Effect of surgeon on transprosthetic gradients after aortic valve replacement with Freestyle stentless bioprosthesis and its consequences: a follow-up study in 587 patients.

Albert A, Florath I, Rosendahl U, Hassanein W, Hodenberg EV, Bauer S, Ennker I, Ennker J - J Cardiothorac Surg (2007)

Bottom Line: Estimated survival at 6 years was similar to the age-matched German population (61.4 +/- 3.8 %).In addition to the valve size (in relation to body size), subcoronary technique (versus total root) and various patient-related factors the risk of elevated gradients after stentless valve implantation depends, considerably on the individual surgeon.Although there was no effect on survival time and most aspects of QoL, higher postoperative transvalvular gradients affect physical mobility after AVR.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of cardiac surgery, Heart Institute Lahr/Baden, Hohbergweg 2, 77933 Lahr/Germany. alexander.albert@heart-lahr.com

ABSTRACT

Background: The implantation of stentless valves is technically demanding and the outcome may depend on the performance of surgeons. We studied systematically the role of surgeons and other possible determinants for mid-term survival, postoperative gradients and Quality of Life (QoL) after aortic valve replacement (AVR) with Freestyle stentless bioprostheses.

Methods: Between 1996 and 2003, 587 patients (mean 75 years) underwent AVR with stentless Medtronic Freestyle(R) bioprostheses. Follow-up was 99% complete. Determinants of morbidity, mortality, survival time and QoL were evaluated by multiple, time-related, regression analysis. Risk models were built for all sections of the Nottingham Health Profile (NHP): energy, pain, emotional reaction, sleep, social isolation and physical mobility

Results: Actuarial freedom from aortic valve re-operation, structural valve deterioration, non-structural valve dysfunction, prosthetic valve endocarditis and thromboembolic events at 6 years were 95.9 +/- 2.1%, 100%, 98.7 +/- 0.5%, 97.0 +/- 1.5%, 79.6 +/- 4.3%, respectively. The actuarial freedom from bleeding events at 6 years was 93.1 +/- 1.9%. Estimated survival at 6 years was similar to the age-matched German population (61.4 +/- 3.8 %). Predictors of survival time were: diabetes mellitus, atrial fibrillation, peripheral vascular disease, renal dysfunction, female gender > 80 years and patients < 165 cm with BMI < 24. Predictive models showed characteristic profiles and good discriminative powers (c-indexes > 0.7) for each of the 6 QoL sections. Early transvalvular gradients were identified as independent risk factors for impaired physical mobility (c-index 0.77, p < 0.002). A saturated propensity score identified besides patient related factors (e.g. preoperative gradients, ejection fraction, haematological factors) indexed geometric orifice area, subcoronary implantation technique and individual surgeons as predictors of high gradients.

Conclusion: In addition to the valve size (in relation to body size), subcoronary technique (versus total root) and various patient-related factors the risk of elevated gradients after stentless valve implantation depends, considerably on the individual surgeon. Although there was no effect on survival time and most aspects of QoL, higher postoperative transvalvular gradients affect physical mobility after AVR.

Show MeSH

Related in: MedlinePlus

Risk factors for higher transvalvular gradients after stentless valve implantation. By solving the multivariate equations we had illuminated the importance of the dominant risk factors for higher gradients after stentless valve implantation: valve size in relation to BSA (IGOE), subcoronary technique, preoperative gradients, and the surgeons C, D, E. Other risk factors (cardiac, haematological) were less important (se table 4). With total root technique virtually no increase of the risk for higher gradients with decreasing IGOA was observed, whereas with subcoronary technique the risk increases exponentially.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
getmorefigures.php?uid=PMC2146998&req=5

Figure 3: Risk factors for higher transvalvular gradients after stentless valve implantation. By solving the multivariate equations we had illuminated the importance of the dominant risk factors for higher gradients after stentless valve implantation: valve size in relation to BSA (IGOE), subcoronary technique, preoperative gradients, and the surgeons C, D, E. Other risk factors (cardiac, haematological) were less important (se table 4). With total root technique virtually no increase of the risk for higher gradients with decreasing IGOA was observed, whereas with subcoronary technique the risk increases exponentially.

Mentions: As impaired physical mobility due to high transvalvular pressure gradients may reflect the impact of valve design on outcome and may in the consequence also affect mid-term survival, we were interested in the factors determining high early postoperative transvalvular gradients. As a dichotomic variable "mean gradient higher than 20 mm Hg yes or no" became significant (p = 0.008) in the model of impaired physical mobility, a saturated propensity score predicting mean transvalvular gradients higher than 20 mm Hg (table 4) was calculated. This score well describes patients with gradients higher than 20 (28% of all patients) as the c-index was 0.79 and the p-value of the variable "mean gradient higher than 20 mm Hg yes or no" became not significant (p = 0.057) after including the propensity score into the model of impaired physical mobility. Figure 3 shows the impact of several predicting factors on the risk of having a postoperative transvalvular pressure gradient higher than 20 mm Hg. The main factors predicting high postoperative pressure gradients are indexed geometric orifice area, subcoronary implantation technique, preoperative transvalvular gradients and the individual surgeon. Three surgeons (surgeons C-E) had significantly higher gradients than surgeons A, B, F and the mixed group M. Common parameters assessing "surgical experience" like years in cardiac surgery, number of valve cases performed or number of valves implanted did here not explain the differences between the surgeons concerning transvalvular gradients (table 5). These differences were observed in subcoronary technique for each valve size from 21 to 25 (table 6).


Effect of surgeon on transprosthetic gradients after aortic valve replacement with Freestyle stentless bioprosthesis and its consequences: a follow-up study in 587 patients.

Albert A, Florath I, Rosendahl U, Hassanein W, Hodenberg EV, Bauer S, Ennker I, Ennker J - J Cardiothorac Surg (2007)

Risk factors for higher transvalvular gradients after stentless valve implantation. By solving the multivariate equations we had illuminated the importance of the dominant risk factors for higher gradients after stentless valve implantation: valve size in relation to BSA (IGOE), subcoronary technique, preoperative gradients, and the surgeons C, D, E. Other risk factors (cardiac, haematological) were less important (se table 4). With total root technique virtually no increase of the risk for higher gradients with decreasing IGOA was observed, whereas with subcoronary technique the risk increases exponentially.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC2146998&req=5

Figure 3: Risk factors for higher transvalvular gradients after stentless valve implantation. By solving the multivariate equations we had illuminated the importance of the dominant risk factors for higher gradients after stentless valve implantation: valve size in relation to BSA (IGOE), subcoronary technique, preoperative gradients, and the surgeons C, D, E. Other risk factors (cardiac, haematological) were less important (se table 4). With total root technique virtually no increase of the risk for higher gradients with decreasing IGOA was observed, whereas with subcoronary technique the risk increases exponentially.
Mentions: As impaired physical mobility due to high transvalvular pressure gradients may reflect the impact of valve design on outcome and may in the consequence also affect mid-term survival, we were interested in the factors determining high early postoperative transvalvular gradients. As a dichotomic variable "mean gradient higher than 20 mm Hg yes or no" became significant (p = 0.008) in the model of impaired physical mobility, a saturated propensity score predicting mean transvalvular gradients higher than 20 mm Hg (table 4) was calculated. This score well describes patients with gradients higher than 20 (28% of all patients) as the c-index was 0.79 and the p-value of the variable "mean gradient higher than 20 mm Hg yes or no" became not significant (p = 0.057) after including the propensity score into the model of impaired physical mobility. Figure 3 shows the impact of several predicting factors on the risk of having a postoperative transvalvular pressure gradient higher than 20 mm Hg. The main factors predicting high postoperative pressure gradients are indexed geometric orifice area, subcoronary implantation technique, preoperative transvalvular gradients and the individual surgeon. Three surgeons (surgeons C-E) had significantly higher gradients than surgeons A, B, F and the mixed group M. Common parameters assessing "surgical experience" like years in cardiac surgery, number of valve cases performed or number of valves implanted did here not explain the differences between the surgeons concerning transvalvular gradients (table 5). These differences were observed in subcoronary technique for each valve size from 21 to 25 (table 6).

Bottom Line: Estimated survival at 6 years was similar to the age-matched German population (61.4 +/- 3.8 %).In addition to the valve size (in relation to body size), subcoronary technique (versus total root) and various patient-related factors the risk of elevated gradients after stentless valve implantation depends, considerably on the individual surgeon.Although there was no effect on survival time and most aspects of QoL, higher postoperative transvalvular gradients affect physical mobility after AVR.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of cardiac surgery, Heart Institute Lahr/Baden, Hohbergweg 2, 77933 Lahr/Germany. alexander.albert@heart-lahr.com

ABSTRACT

Background: The implantation of stentless valves is technically demanding and the outcome may depend on the performance of surgeons. We studied systematically the role of surgeons and other possible determinants for mid-term survival, postoperative gradients and Quality of Life (QoL) after aortic valve replacement (AVR) with Freestyle stentless bioprostheses.

Methods: Between 1996 and 2003, 587 patients (mean 75 years) underwent AVR with stentless Medtronic Freestyle(R) bioprostheses. Follow-up was 99% complete. Determinants of morbidity, mortality, survival time and QoL were evaluated by multiple, time-related, regression analysis. Risk models were built for all sections of the Nottingham Health Profile (NHP): energy, pain, emotional reaction, sleep, social isolation and physical mobility

Results: Actuarial freedom from aortic valve re-operation, structural valve deterioration, non-structural valve dysfunction, prosthetic valve endocarditis and thromboembolic events at 6 years were 95.9 +/- 2.1%, 100%, 98.7 +/- 0.5%, 97.0 +/- 1.5%, 79.6 +/- 4.3%, respectively. The actuarial freedom from bleeding events at 6 years was 93.1 +/- 1.9%. Estimated survival at 6 years was similar to the age-matched German population (61.4 +/- 3.8 %). Predictors of survival time were: diabetes mellitus, atrial fibrillation, peripheral vascular disease, renal dysfunction, female gender > 80 years and patients < 165 cm with BMI < 24. Predictive models showed characteristic profiles and good discriminative powers (c-indexes > 0.7) for each of the 6 QoL sections. Early transvalvular gradients were identified as independent risk factors for impaired physical mobility (c-index 0.77, p < 0.002). A saturated propensity score identified besides patient related factors (e.g. preoperative gradients, ejection fraction, haematological factors) indexed geometric orifice area, subcoronary implantation technique and individual surgeons as predictors of high gradients.

Conclusion: In addition to the valve size (in relation to body size), subcoronary technique (versus total root) and various patient-related factors the risk of elevated gradients after stentless valve implantation depends, considerably on the individual surgeon. Although there was no effect on survival time and most aspects of QoL, higher postoperative transvalvular gradients affect physical mobility after AVR.

Show MeSH
Related in: MedlinePlus