10. tbl. 97. árg. 2011

Aortic valve replacement for aortic stenosis in Iceland 2002-2006: Indications and short term complications

Lokuskipti vegna ósæðarlokuþrengsla á Íslandi 2002-2006: Ábendingar og snemmkomnir fylgikvillar

Objective: Information on surgical outcome of aortic valve replacement (AVR) has not been available in Iceland. We therefore studied the indications, short-term complications and operative mortality in Icelandic patients that underwent AVR with aortic stenosis.

Material and methods: This was a retrospective study including all patients that underwent AVR for aortic stenosis at Landspitali between 2002 and 2006, a total of 156 patients (average age 71.7 years, 64.7% males). Short term complications and operative mortality (30 days) were registered and risk factors analysed with multivariate analysis.

Results: The most common symptoms before AVR were dyspnea (86.9%) and angina pectoris (52.6%). Preop. max aortic valve pressure gradient was on average 74 mmHg, the left ventricular ejection fraction 57.2% and EuroSCORE (st) 6.9%. The average operating time was 282 min and concomitant CABG was performed in 55% of the patients and mitral valve surgery in nine. A bioprothesis was implanted in 127 of the patients (81.4%), of which 102 were stentless valves, and a mechanical valve in 29 (18.6%) cases. The mean prosthesis size was 25.6 mm (range 21-29). Atrial fibrillation (78.0%) and acute renal injury (36.0%) were the most common complications and 20 patients (13.0%) developed multiple-organ failure. Twenty-six patients (17.0%) needed reoperation due to bleeding. Median hospital stay was 13 days and operative mortality was 6.4%.

Conclusions: The rate of short term complications following AVR was relatively high, including reoperations for bleeding and atrial fibrillation. Operative mortality is twice that of CABG, which is in line with other studies.



Table I. Types of implanted valve prosthesis for 156 patients that underwent aortic valve replacement for aortic stenosis at Landspitali between 2002 and 2006. Given are number of patients and % in parenthesis.

Type of prosthesis Number (%)
Mechanical  (n = 29)  
 CarboMedicsâ 20 (12,8)
 St Jude Medicalâ 6 (3.8)
 St Jude Medical Regentâ 3 (1.9)
Biological - stentless (n=102)  
 Medtronic Freestyleâ 100 (64.1)
 St. Jude Torontoâ 2 (1.3)
Biological - stented (n=25)  
 Carpentier-Edwards Perimountâ 17 (10.9)
 Carpentier-Edwards Perimount Magnaâ 8 (5.1)
   
Samtals 156 (100)

 

Table II. Preoperative echocardiography results for patients that underwent aortic valve replacement for aortic stenosis at Landspítali between 2002 and 2006. Given are means with standar deviation.

Echocardiography results  
Ejection fraction (%) 57.2 ± 7.7
Aortic valve area (cm2) 0.63 ± 0.23
Left ventricular end diastolic diameter (cm) 5.3 ± 0.9
Septum thickness (cm) 1.41 ± 0.31
Left ventricular posterior wall thickness (cm) 1.25 ± 0.24
Maximum transvalvular pressure gradient (mmHg) 74.1 ± 253


 

Table III: Summery of patients that died within 30 days of aortic valve replacement surgery at Landspítali in the years 2002-2006.

Nr. Age/Sex NYHA-class EuroSCORE (log) Preop. max pressure gradient/Aortic valve area EF (%) Stented valve Valve size (mm) X-clamp time (min) Survival (days) RBC transfusion (units) Multiorgan failure Reop. <30 days Comment
1 82/F 3 22.9 70/0.6 35 + 21 110 16 19 + + Massive coagulopathy
2 77/M 4 4.8 70/0.6 60 - 25 132 6 11 - + Rupture of right ventricle during reop.
3 83/F 4 40.9 92/0.4 53 + 23 98 9 12 + - Mitral valve surgery
4 83/M 4 7.5 156/0.2 55 + 27 114 13 9 + -  
5 64/F 3 25,2 39/0.8 40 + 21 177 17 19 - + Mitral valve surgery
6 81/M 3 74.7 81/0.74 45 - 23 163 21 13 + +  
7 70/F 3 4.2 65/0.6 55 + 21 146 2 18 + - Massive bleeding and coagulopathy
8 78/F 1 10.3 100/- 43 - 23 244 0 0 - - Peroperative death
9 75/M 3 4.3 60/0.7 60 - 25 111 2 4 - - Bleeding gastric ulcer and aspiration pneumonia
10 80/F 3 12.4 88/0.7 60 - 25 98 12 27 + +  




Table IV. The rate of complications and operative mortality for patients that underwent aortic valve replacement surgery for aortic stenosis at Landspitali between 2002 and 2006. Number of patients and % in parenthesis. The same patient can have more than one complication. Given are number of patients and %  in parenthesis.

Results Number (%)
Major Complications 52 (33.4)
 Reoperation for bleeding 26 (17.0)
 Myocardial infarct 22 (14.4)
 Multiple organ failure 20 (13.0)
 Cerebral infarct 2 (1.3)
 Mediastinitis 0 (0)
Minor Complications 129 (84.3)
 Postoperative atrial fibrillation/flutter 93 (77.5)
 Acute kidney injury 52 (35.9)
 Urinary tract infection 30 (19.6)
 Pneumonia 22 (14.4)
 Pleural fluid requiring drainage 21 (13.7)
 Superficial wound infection 13 (8.5)
 Transient ischemic attack (TIA) 4 (2.6)
Operative mortality 10 (6.4)
   

 

Table V. Comparsion of operative mortality (<30 days) following aortic valve replacement in several major studies.

Study (year) Type of prothesis Operative mortality (%)
Emery et al. (2005) 21 St. Jude MedicalÒ mechanical valve 6.0
Khan et al. (2001) 22 Biological and mechanical valves 6.1
Butchart et al. (2001) 23 Medtronic HallÒ mechanical valve 4.2
Bach et al. (2005) 24 Medtronic FreestyleÒ 7.1
Eichinger et al. (2008) 25 St. Jude Medical BiocorÒ 5.3
Present study (2011) Biological and mechanical valves 6.4



 



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