Aortic valve replacement – the impact of elective, emergent and urgent indication on survival

Objectives: The current opinion about timing of aortic valve replacement in aortic stenosis or combined aortic valve disease provides to prolong the time between first diagnosis until surgery as long as possible. The rationale is the fear of reoperation for replacement of bioprostheses and adverse effects of anticoagulation in mechanical prostheses. Symptomatic aortic valve disease, however, itself bears the risk of life-threatening complications. The aim of the study is to focus on urgency of surgery and postoperative survival.

Material and Methods: 884 patients underwent aortic valve replacement for aortic valve stenosis or combined aortic valve disease from 1/1993 through 3/2004. A common closing date follow-up was performed with a completeness of 97.8%.

Results: Elective surgery for aortic valve disease was performed in 395 patients (44.7%). The majority of patients underwent urgent aortic valve replacement (n=463.52.3%). In 26 patients, emergency or ultimo ratio aortic valve replacement was necessary (3.0%). For patients with urgent indication, the Odds ratio is 1.9 (CL1.3–3.0) compared to elective patients. In emergent or ultima ratio aortic valve disease, the Odds ratio is 4.6 (CL1.9–11.3) compared to the patients undergoing elective aortic valve disease. By Kaplan-Meier survival analysis, the strata are well separated and indicate the lowest risk in short- and long-term survival for patients with elective aortic valve replacement. Independence of urgency as risk factor was verified by logistic regression analysis.

Conclusions: Once the patient develops symptoms requiring urgent or emergent surgery, a substantial decrease of long-term survival must be expected. The results indicate the necessity to reevaluate current practice in decision-making for patients with aortic valve stenosis.