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Litmathe
M. Kurt
P. Feindt
E. Gams
Introduction
Although many previous reports on simultaneous double-valve
replacement (DVR) have compared the long-term outcome according to the type or combination of the implanted prosthesis,
controversy persists regarding the ideal selection of heart valve
Original Cardiovascular
Abstract
Key words
Aortic valve replacement double-valve replacement risk factor
regression analysis
459
Affiliation
Department of Thoracic and Cardiovascular Surgery, Heinrich-Heine-University Hospital,
Dsseldorf, Germany
Dedication
The results of this paper were presented in part during the 34th annual meeting of the
German Society of Thoracic- and Cardiovascular Surgery, February 13th 16th, 2005
in Hamburg/Germany as poster presentation.
Correspondence
M. Kurt Department of Thoracic and Cardiovascular Surgery Moorenstrae 5 40225 Dsseldorf
Germany Phone: + 49 21181183 32 Fax: + 49 2118 1183 33 E-mail: litmathe@med.uni-duesseldorf.de
Received January 20, 2006
Bibliography
Thorac Cardiov Surg 2006; 54: 459 463 Georg Thieme Verlag KG Stuttgart New York
DOI 10.1055/s-2006-924247
ISSN 0171-6425
U. Boeken
Urgent operation
Age > 70 years
LV-EF 0.35
IDDM
Anemia (Hb 10 g/dl)
Aortic stenosis
Previous neurological events
Cardiogenic shock
Peripheral vascular disease
The mean age of the entire cohort was 63.8 6.8 years, without
significant differences between the groups (AVR: 62.4 6.6 vs.
DVR: 64.1 6.7 years). For both groups, we investigated probable
risk factors for perioperative death or major complications, such
as cardiogenic shock (systolic arterial pressure < 90 mmHg for
more than 30 min, oliguria/anuria, somnolence), low cardiac
output syndrome (LCOS with ejection fraction < 35 % and catecholamine therapy for hemodynamic stabilization), prolonged
stay in the ICU, prolonged ventilation, need of catecholamines,
major neurological complications (stroke), tricuspid valve disease (severe insufficiency) or severe infection (Table 1).
Statistical methods
Our aim was to validate identification factors (predictors) for a
complicated course or an adverse outcome after valve replacement procedures. In particular, the differences between an
isolated aortic valve replacement and a double-valve replacement, including the aortic and mitral valve (DVR), were examined. We used multivariate analysis, limited to variables that
were known prior to operation. The risk factors with p 0.01
were entered into multivariate analysis.
A subsequent analysis was performed with preoperative variables to determine factors associated with perioperative complications, especially the additional risk factors in DVR.
We then used independent predictive variables from regression
analysis to generate a risk score (RS) for death or severe complications in AVR and DVR. We derived the points in the scoring system from the regression coefficient, the odds ratio and the clinical relevance. The patients were stratified from low to high risk
for death or severe complications based on their individual risk
scores. Ninety-five percent confidence intervals were calculated
for each risk interval.
Operative procedure
All operations were performed using a median sternotomy, with
the help of cardiopulmonary bypass (CPB) in moderate hypothermia and cardioplegic arrest using Bretschneiders solution.
The anticoagulation regime in both groups during the postoperative course was maintained using heparin and coumarone immediately after removing the chest tubes, in cases of mechanical
Litmathe J et al. Predictive Risk Factors Thorac Cardiov Surg 2006; 54: 459 463
Coagulopathy
Results
Data was completely available for 93 % of patients. Intraoperative
data were as follows: mean duration of the entire operation was
184 17 min, mean ECC time was 84 10 min and mean ischemic
time 55 8 min in the isolated AVR group. In the DVR group, the
times were 239 30 min (duration of entire operation), 128
16 min (ECC time) and 89 11 min (ischemic time).
There were 11 perioperative deaths in patients with isolated AVR
(2.8 %) compared to 5 (5.1 %) in the DVR group. The incidence of
major complications was 5.3 % in the AVR group vs. 11.2 % in patients undergoing DVR (Fig. 1).
Multivariate analysis could identify identify six parameters as
predictors for death in isolated AVR (redo surgery, aortic stenosis,
PAP 55 mmHg, cardiogenic shock, severely reduced left ventricular function and age > 70 years); seven parameters were additionally identified as predictors for severe complications in
isolated AVR (redo surgery, creatinine 2 mg/dl, aortic stenosis,
cardiogenic shock, IDDM, coagulopathy, PAP 55 mmHg). The coefficient, the odds ratio, and the 95 % confidence interval with
the corresponding p value are shown in Tables 2, 3.
Original Cardiovascular
460
Over a period of 4 years, we investigated 396 patients with isolated aortic valve replacement (AVR) and 98 patients undergoing
aortic and mitral valve replacement (DVR) and performed a retrospective analysis. All elective and emergent procedures as well as
redo operations were included. The study included a total of 302
male and 192 female patients (AVR: 238/158 vs. DVR: 59/39).
Predictor
-coefficient
Odds
ratio
95 % Confidence interval
P value
-coefficient
Odds ratio
P value
Redo surgery
1.73
7.1
4.6 12.8
0.01
Aortic stenosis
1.52
5.2
2.0 7.5
0.001
Redo surgery
1.87
7.4
4.4 13.3
0.001
Creatinine
2 mg/dl
1.66
6.9
4.4 12.4
0.01
Aortic
stenosis
1.46
4.5
1.2 7.8
0.003
Cardiogenic
shock
1.45
3.7
2.0 5.8
0.001
IDDM
1.22
4.1
2.7 6.5
0.01
Coagulopathy
1.12
2.2
1.7 2.9
0.004
PAP
55 mmHg
1.01
1.7
0.9 1.9
0.0006
PAP 55 mmHg
1.48
4.8
1.8 7.2
0.02
Cardiogenic shock
1.42
4.8
1.9 6.8
0.001
LV-EF 0.35
1.33
3.3
2.1 5.2
0.003
1.08
2.7
1.8 3.8
0.01
Discussion
Combined aortic and mitral valve surgery has a substantial morbidity and mortality [11 15]. Our analysis of risk factors was
able to show that in patients with DVR preoperative parameters,
Original Cardiovascular
Table 2 Predictive factors for death in AVR with corresponding coefficient, odds ratio, 95% confidence interval, and p value
461
-coefficient
Odds
ratio
95 % Confidence
interval
P value
Redo surgery
1.88
7.2
4.8 18.1
0.001
Tricuspid valve
disease (TVD)
1.53
4.8
1.7 7.3
LAP 20 mmHg
1.51
4.0
Creatinine 2 mg/dl
1.48
3.6
Predictor
Original Cardiovascular
462
PAP 55 mmHg
1.28
2.7
-coefficient
Odds
ratio
P value
2.14
4.8
2.5 13.0
0.004
0.01
Cardiogenic
shock
6.8
4.3 12.2
0.001
0.02
Tricuspid valve
disease (TVD)
1.98
2.6 7.4
2.2 5.4
0.001
LAP 20 mmHg
1.52
3.0
2.2 10.2
0.01
0.0001
Redo surgery
1.45
2.8
2.4 11.8
0.003
Creatinine
2 mg/dl
1.38
2.8
2.5 10.2
0.001
LV-EF 0.35
1.03
2.2
2.0 3.7
0.02
IDDM
1.01
1.6
0.8 2.0
0.02
1.8 5.9
Cardiogenic shock
0.96
2.1
1.6 3.1
0.004
0.84
1.5 3.3
0.01
LV-EF 0.35
0.7
1.7
1.3 2.4
0.04
IDDM
0.5
1.5
1.1 2.7
0.0001
Hb < 10 g/dl
0.45
1.3
1.1 2.4
0.0001
Table 6 Risk score for death and severe complications after AVR
Table 7 Risk score for death and severe complications after DVR
Predictor
Predictor
Redo surgery
Cardiogenic shock
Creatinine 2 mg/dl
Aortic stenosis
LAP 20 mmHg
Cardiogenic shock
Redo surgery
IDDM
Creatinine 2 mg/dl
Coagulopathy
EF 0.35
PAP 55 mmHg
IDDM
only the actual diseased tricuspid valve but also chronic overload
of the right ventricle with dilation and possibly biventricular failure may complicate the postoperative course. Tricuspid valve repair should be performed when significant hemodynamic regurgitation is present, because such disease does not disappear after
correction of the left side. However, this will lead to an increase
in the duration of the entire operation [16,17].
High left atrial pressure was another prominent predictor for
death or major complications following double-valve replacement. This is yet another reflection of a chronically high preload
and correspondingly impaired cardiac function. It is, therefore,
important to consider prior to the operation what the best conservative compensation strategy could be.
Other groups have already reported that the potential for recovery after successful double-valve replacement is limited when
preoperative systolic function is severely decreased [13,18,19], a
finding which was borne out by our current series, which showed
an ejection fraction below 35 % to be one of the predictors with a
relatively high score.
Litmathe J et al. Predictive Risk Factors Thorac Cardiov Surg 2006; 54: 459 463
Table 4 Predictive factors for death in DVR with corresponding coefficient, odds ratio, 95% confidence interval, and p value
10
12
13
14
15
16
17
18
19
20
Original Cardiovascular
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Litmathe J et al. Predictive Risk Factors Thorac Cardiov Surg 2006; 54: 459 463
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