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CLINICAL RESEARCH: CARDIAC SURGERY

Improved Outcomes After Aortic Valve Surgery for Chronic Aortic Regurgitation With Severe Left Ventricular Dysfunction

Sunil K. Bhudia, MD^_*, Patrick M. McCarthy, MD^_*,_*, Ganesh S. Kumpati, MD^_*, Joe Helou, MD^_*, Katherine J. Hoercher, RN^_*, Jeevanantham Rajeswaran, MSc and Eugene H. Blackstone, MD^_*,

^_* Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio.

Manuscript received May 26, 2006; revised manuscript received October 25, 2006, accepted November 1, 2006.

^_* Reprint requests and correspondence to: Dr. Patrick M. McCarthy, Co-Director of the Bluhm Cardiovascular Institute, Chief of Cardiothoracic Surgery Division, and Professor of Surgery at the Feinberg School of Medicine Northwestern University, Division of Cardiothoracic Surgery, 201 East Huron Street, Suite 11-140, Chicago, Illinois 60611-29968. (Email: pmccart{at}nmh.org).

Objectives: Among patients undergoing aortic valve surgery for chronic aortic regurgitation (AR), we sought to: 1) compare survival among those with and without severe left ventricular dysfunction (LVD); 2) identify risk factors for death, including LVD and date of operation; and 3) estimate contemporary risk for cardiomyopathic patients.

Background: Patients with chronic AR and severe LVD have been considered high risk for aortic valve surgery, with limited prognosis. Transplantation is considered for some.

Methods: From 1972 to 1999, 724 patients underwent surgery for chronic AR; 88 (12%) had severe LVD. They were propensity matched to patients with nonsevere LVD to compare hospital mortality, interaction of operative date with severity of LVD, and late survival. Propensity score-adjusted multivariable analysis was performed for all 724 patients to identify risk factors for death.

Results: Survival was lower (p = 0.04) among patients with severe LVD than among matched patients with nonsevere LVD (30-day, 1-, 5-, and 25-year survival estimates were 91% vs. 96%, 81% vs. 92%, 68% vs. 81%, and 5% vs. 12%, respectively). However, survival of patients with severe LVD improved dramatically across the study time frame (p = 0.0004): hospital mortality decreased from 50% in 1975 to 0% after 1985, and time-related survival in patients with severe LVD operated on since 1985 became equivalent to that of matched patients with nonsevere LVD (p = 0.96).

Conclusions: Neutralizing risk of severe LVD has improved early and late survival such that aortic valve surgery for chronic AR and cardiomyopathy is no longer a high-risk procedure for which transplantation is the best option.

Abbreviations and Acronyms   AR = aortic valve regurgitation   CL = confidence limits   LV = left ventricular   LVD = left ventricular dysfunction

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