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Ann Thorac Surg 1995;59:1062
© 1995 The Society of Thoracic Surgeons
DR RONALD C. ELKINS (Oklahoma City, OK): I congratulate Dr He and his co-authors on an excellent presentation.
In this analysis of 447 patients who required aortic valve replacement using a small (less than 21 mm) aortic prosthesis, there were 239 who had a prosthetic valve replacement and 154 who had a bioprosthetic valve. One hundred thirteen porcine xenografts and 41 pericardial valves were used. Long-term survival was evaluated in these patients with a 92% follow-up. Multivariate analysis revealed patient age and the need for concomitant coronary artery bypass grafting were independent variables determining long-term survival after aortic valve replacement in this small aortic group. These are not unexpected results.
In their analysis the type of valve used did not affect survival; however, this analysis is hampered by the limited follow-up available with some of the valves and also by the grouping of pericardial valves and xenografts with prosthetic valves. In patients with a small aortic valve annulus the survival with the St. Jude prosthesis recently has been reported by Kratz and associates and by Arom and colleagues. These studies show a survival of 75% to 80% at 5 years and about 50% at 10 years, very similar to those that were reported today. They also confirm the negative impact of significant coronary artery disease requiring bypass grafting.
In the series presented today the effect of mismatch between body size and prosthetic size was apparent only in those patients requiring concomitant coronary artery bypass grafting; however, Kratz and associates' study showed that patients with a significant mismatch and a body surface area greater than 1.9 m2 were at increased risk for sudden death.
This series demonstrates that patient-related factors, such as size, age and coronary artery disease, significantly affect patient survival after aortic valve replacement. The use of presently available prosthetic valves appears to be an appropriate choice in the older patient with coronary artery disease and in whom body habitus does not increase the risk. However, we cannot be satisfied with a 50% survival at 20 years in the younger patient group, ie, those less than 50 years of age. Patient survival of 80% has been reported by Ross and associates when the aortic valve is replaced with a pulmonary autograft, and a survival approaching 70% using the allograft valve has been reported by O'Brien. The operative risk for an autograft or an allograft replacement has been shown to be equal to that of a prosthetic replacement of the aortic valve and is equal to or less than the reported experience in patients with a small aortic annulus.
Doctor He, you have presented survival data today, but we all would be interested in what was the event-free survival in this patient population. I also would like to know if the type of valve lesion, aortic stenosis versus aortic insufficiency, had any effect on survival. The patient with severe aortic stenosis and significant body surface annulus size mismatch may be shown to have a decreased long-term survival if analyzed in a large series such as yours. If these were shown, combined with the data of Kratz and associates, serious consideration of an annulus-enlarging procedure or the use of an allograft or an autograft procedure should be entertained.
I enjoyed your presentation very much, I appreciated the opportunity to review the manuscript, and I thank The Society for the privilege of discussing the paper.
DR HE: Thank you, Dr Elkins, for your comments. I totally agree with you that 50% survival at 23 years may be still improvable. However, in this ``young'' (19 to 49 years old) group of patients, the average age was 38.2 years. After 23 years the average age was more than 60 years and half of them were still alive. Taking this consideration together with the concern that in those patients who have aortic operations early in their life usually the disease is quite aggressive, the results in this group of patients are acceptable. We await other comparable reports on the results beyond 25 years for aortic valve replacement in the small aortic root. As to your question regarding the etiology of aortic disease, I agree with you that this is a very important aspect to look at and I had the intention at the beginning to study the influence of etiology on the long-term results in those patients. Unfortunately, during such a long period of 31 years this information is incomplete in our database. It would be nice to see such studies in the future.
Related Article
Ann. Thorac. Surg. 1995 59: 1056-1062.
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