RESUMEN
BACKGROUND: Stroke is a devastating complication in patients with prosthetic valves, but characterization of its late occurrence from a large cohort is lacking. METHODS: Three thousand one hundred eighty-nine adult patients who underwent a total of 3,576 operations for left-heart valve replacement were managed with contemporary anticoagulation guidelines and prospectively followed in a dedicated clinic. Total follow-up was 20,096 patient years. Bootstrapped survival analysis was used to determine the impact of patient and valve related factors on the incidence of stroke. RESULTS: Most strokes were embolic. Linearized embolic stroke rates were 1.3% +/- 0.2% per year for aortic bioprostheses, 1.4% +/- 0.2% per year for aortic mechanical valves, 1.3% +/- 0.3% per year for mitral bioprostheses, and 2.3% +/- 0.4% per year for mitral mechanical valves (p = 0.002, vs other implant types). Age more than 75 years, female gender, and smoking were independent risk factors after aortic and mitral valve replacement. Atrial fibrillation, coronary disease, and tilting-disc mechanical prostheses were independent predictors of embolic stroke after aortic valve replacement. Preoperative left ventricular (LV) dysfunction was an independent risk factor in patients with mitral prostheses. Primary operative indication, diabetes, redo status, or the presence of two prosthetic valves were not associated with an increased hazard. The addition of acetyl salicylic or dipyridamole to warfarin anticoagulation did not significantly lower embolic stroke risk in patients with mechanical prostheses. CONCLUSIONS: Approximately 20% of patients with valve prostheses have an embolic stroke by 15 years after valve replacement. Some risk factors such as the avoidance of smoking, mitral mechanical prostheses, aortic tilting-disc valves, and proceeding to mitral surgery before LV dysfunction occurs are potentially modifiable.
Asunto(s)
Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas/estadística & datos numéricos , Válvula Mitral/cirugía , Complicaciones Posoperatorias/epidemiología , Accidente Cerebrovascular/epidemiología , Adulto , Anciano , Anciano de 80 o más Años , Anticoagulantes/administración & dosificación , Anticoagulantes/uso terapéutico , Aspirina/administración & dosificación , Aspirina/uso terapéutico , Fibrilación Atrial/epidemiología , Hemorragia Cerebral/epidemiología , Hemorragia Cerebral/etiología , Hemorragia Cerebral/prevención & control , Comorbilidad , Enfermedad Coronaria/epidemiología , Dipiridamol/administración & dosificación , Dipiridamol/uso terapéutico , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Relación Normalizada Internacional , Embolia Intracraneal/epidemiología , Embolia Intracraneal/etiología , Embolia Intracraneal/prevención & control , Tablas de Vida , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/prevención & control , Modelos de Riesgos Proporcionales , Estudios Prospectivos , Factores de Riesgo , Fumar/epidemiología , Accidente Cerebrovascular/etiología , Accidente Cerebrovascular/prevención & control , Disfunción Ventricular Izquierda/epidemiología , Warfarina/administración & dosificación , Warfarina/uso terapéuticoRESUMEN
BACKGROUND: We examined factors associated with persistent or recurrent congestive heart failure after aortic valve replacement. METHODS: Patients who underwent aortic valve replacement with contemporary prostheses (n = 1563) were followed up with annual clinical assessment and echocardiography. The effect of demographic, comorbid, and valve-related variables on the composite outcome of New York Heart Association class III or IV symptoms or congestive heart failure death after surgery was evaluated with stratified log-rank tests, Cox proportional hazard models, and logistic regression. Factors associated with all-cause death were also examined. Prediction models were bootstrapped 1000 times. RESULTS: Total follow-up was 6768 patient-years (mean, 4.3 +/- 3.3 years; range, 60 days to 17.1 years). Freedom from congestive heart failure or congestive heart failure death was 98.6% +/- 0.3%, 88.6% +/- 1.0%, 73.9% +/- 2.3%, and 45.2% +/- 8.5% at 1, 5, 10, and 15 years, respectively. Age, preoperative New York Heart Association class, left ventricular grade, atrial fibrillation, coronary artery disease, smoking, and redo status predicted congestive heart failure after surgery (all P <.05). Larger prosthesis size and effective orifice area, both absolute and indexed for body surface area, were independently associated with freedom from congestive heart failure. Increased transprosthesis gradients were predicted by prosthesis-patient mismatch and were associated with congestive heart failure after surgery. Mismatch defined as an effective orifice area/body surface area of 0.80 cm(2)/m(2) or less was a significant predictor of congestive heart failure events after surgery, but mismatch defined as an effective orifice area/body surface area of 0.85 cm(2)/m(2) or less was not. Small prosthesis size and mismatch were not significantly associated with all-cause mortality. CONCLUSIONS: These analyses identify independent predictors of congestive heart failure symptoms and congestive heart failure death late after aortic valve replacement and indicate that prosthesis size has a significant effect on this cardiac end point, but not on overall survival after aortic valve replacement.