Outcome after aortic valve replacement in young adults: is patient profile more important than prosthesis type?

Abstract

Background and aim of the study: The optimal prosthesis choice in young adults requiring aortic valve replacement (AVR) remains controversial. The study aim was to determine whether implanted prosthesis type is an important determinant of outcome after AVR in young adults.

Methods: Between 1991 and 2001, 414 young adults (mean age 40 +/- 11 years; range: 16-55 years) underwent a total of 438 consecutive AVRs using 204 mechanical prostheses (MP), three bioprostheses (BP), 150 allografts (AL), and 81 autografts (AU). The perioperative characteristics, early and late mortality, occurrence of valve-related events and predictors of adverse outcome and prosthesis selection, were evaluated.

Results: Mean patient ages were 45 years for MP, 50 years for BP, 39 years for AL, and 31 years for AU. MP selection was associated with older age, impaired left ventricular function (LVF) and concomitant mitral valve surgery (concMVS); AL selection with ascending aortic aneurysm, active endocarditis, and Marfan's disease; and AU selection with younger age, prior balloon valvuloplasty and isolated valve disease. Hospital mortality was 2.3% (n = 10). During follow up (97% complete) 30 patients died. Ten-year survival was better for AU (96 +/- 2%) compared to MP (84 +/- 4%) and AL (92 +/- 2%). Prosthesis type was not predictive of late mortality; rather, predictors of increased late mortality were prior aortic valve surgery, impaired LVF, concMVS, and older patient age. Ten-year freedom from bleeding and thromboembolism was 89 +/- 3% for MP versus 94 +/- 3% for AL and 99 +/- 1% for AU (p = 0.054). Ten-year freedom from reoperation was 95 +/- 2% for MP versus 79 +/- 5% for AL and 87 +/- 5% for AU (p = 0.003).

Conclusion: Survival after AVR in young adults in Rotterdam was mainly determined by patient-related factors, and not by prosthesis type. A randomized controlled trial is necessary to determine whether valve prosthesis type indeed plays a crucial role in improving survival in young adult patients.