Prosthesis size and long-term survival after aortic valve replacement

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Presentation transcript:

Prosthesis size and long-term survival after aortic valve replacement Eugene H Blackstone, MD, Delos M Cosgrove, MD, W.R.Eric Jamieson, MD, Nancy J Birkmeyer, PhD, John H Lemmer, MD, D.Craig Miller, MD, Eric G Butchart, FRCS, Giulio Rizzoli, MD, Magdi Yacoub, MD, Akiko Chai, MS The Journal of Thoracic and Cardiovascular Surgery Volume 126, Issue 3, Pages 783-793 (September 2003) DOI: 10.1016/S0022-5223(03)00591-9

Figure 1 Cumulative distribution of physical internal valve orifice dimension referenced to patients’ BSA (prosthesis-patient size). Distribution is stratified according to variety of prosthesis: mechanical, stented bovine pericardial (pericardial), stented porcine xenograft (porcine), and allograft. For orientation, median size is value on horizontal axis that corresponds to value of 50% on vertical axis; half the sizes were smaller than this and half larger. Value on horizontal axis corresponding to 10% on vertical axis is the 10th percentile, meaning that 10% of valves were smaller than this and 90% larger. A, Indexed orifice area. B, Standardized orifice size. The Journal of Thoracic and Cardiovascular Surgery 2003 126, 783-793DOI: (10.1016/S0022-5223(03)00591-9)

Figure 2 Overall survival after AVR. A, Survival. Parametric estimates (solid line) are enclosed within confidence limits equivalent to 1 SE (68%). Numbers in parentheses represent numbers of patients still being followed at 1, 5, 10, and 15 years. Faintly visible at these same intervals are vertical bars representing confidence limits for corresponding nonparametric Kaplan-Meier estimates. B, Hazard function (instantaneous risk of death). Solid curve enclosed within asymmetric 68% confidence limits represents parametric overall hazard estimates. Individual hazard components are labeled early, constant, and late; they sum to yield overall hazard. Rapidly falling early phase of risk lasted approximately 6 months (short-term survival), was dominated by operative mortality, and had effective statistical power of 774 events. Constant hazard phase across all time dominated between 6 months and 5 years (intermediate-term survival) and had statistical power of 1654 events. Late hazard phase, rising steadily from time zero, dominated beyond 5 years (late-term survival) and had statistical power of 1470 events. Variables in multivariable analyses modulated area beneath early hazard phase, raised or lowered constant hazard, and tilted late hazard component. The Journal of Thoracic and Cardiovascular Surgery 2003 126, 783-793DOI: (10.1016/S0022-5223(03)00591-9)

Figure 3 Non–risk-adjusted survival and indexed orifice area. A, Time-related survival stratified by indexed orifice area. B, Kaplan-Meier estimates of 1-, 5-, and 10-year survivals in finely grouped strata of indexed orifice area. The Journal of Thoracic and Cardiovascular Surgery 2003 126, 783-793DOI: (10.1016/S0022-5223(03)00591-9)

Figure 4 Non–risk-adjusted survival and standardized orifice size (Z). A, Time-related survival stratified by Z. B, Kaplan-Meier estimates of 1-, 5-, and 10-year survivals in finely grouped strata of Z. The Journal of Thoracic and Cardiovascular Surgery 2003 126, 783-793DOI: (10.1016/S0022-5223(03)00591-9)

Figure 5 Magnitude and shape of effect of continuous prosthesis-patient size on 30-day and 1-, 5-, 10-, and 15-year survivals. Depictions are nomograms of multivariable equations solved for a typical patient with aortic stenosis (see Methods) with valve size varied. A, Indexed orifice area. B, Standardized orifice size. The Journal of Thoracic and Cardiovascular Surgery 2003 126, 783-793DOI: (10.1016/S0022-5223(03)00591-9)

Figure 6 Magnitude and shape of effect of continuous prosthesis-patient size on 30-day mortality. Depictions are nomograms of multivariable equations solved for a typical patient with aortic stenosis (see Methods) with valve size varied. A, Indexed orifice area. B, Standardized orifice size. The Journal of Thoracic and Cardiovascular Surgery 2003 126, 783-793DOI: (10.1016/S0022-5223(03)00591-9)

Figure 7 Minimum internal prosthesis orifice size necessary to achieve indexed orifice area of at least −1 (1.6 cm2/m2), −2 (1.3 cm2/m2), and −2.5 (1.2 cm2/m2) SDs (Z) below mean normal aortic valve size. The Journal of Thoracic and Cardiovascular Surgery 2003 126, 783-793DOI: (10.1016/S0022-5223(03)00591-9)

Appendix Figure 1 Non–risk-adjusted survival. A, Stratified by labeled size. B, Stratified by variety of aortic prosthesis inserted: allograft, mechanical, stented bovine pericardial (pericardial), or stented porcine xenograft (porcine). The Journal of Thoracic and Cardiovascular Surgery 2003 126, 783-793DOI: (10.1016/S0022-5223(03)00591-9)

Appendix Figure 2 Non–risk-adjusted survival stratified by age group. Of 1685 patients 50 years old or younger, 1065 were alive and traced at 5 years, 539 at 10 years, and 160 at 15 years. Of 8224 between 50 and 75 years old, 4010 were alive and traced at 5 years, 1725 at 10 years, and 303 at 15 years. Of 2636 who were 75 years old or older; 698 were alive and traced at 5 years, 140 at 10 years, and 10 at 15 years. For each age group, age-, race-, and ethnicity-matched population life table curve is shown as dot-dash line. Note that younger patients show more marked departure from normal life expectancy. The Journal of Thoracic and Cardiovascular Surgery 2003 126, 783-793DOI: (10.1016/S0022-5223(03)00591-9)