Mechanical valves versus the Ross procedure for aortic valve replacement in children: Propensity-adjusted comparison of long-term outcomes Bahaaldin.

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Presentation transcript:

Mechanical valves versus the Ross procedure for aortic valve replacement in children: Propensity-adjusted comparison of long-term outcomes Bahaaldin Alsoufi, MD, Zohair Al-Halees, MD, Cedric Manlhiot, BSc, Brian W. McCrindle, MD, MPH, Mamdouh Al-Ahmadi, MD, Ahmed Sallehuddin, MD, Charles C. Canver, MD, Ziad Bulbul, MD, Mansoor Joufan, MD, Bahaa Fadel, MD The Journal of Thoracic and Cardiovascular Surgery Volume 137, Issue 2, Pages 362-370.e9 (February 2009) DOI: 10.1016/j.jtcvs.2008.10.010 Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Figure 1 Survival without repeated aortic valve reoperation stratified by age in patients undergoing aortic valve replacement with the Ross procedure versus placement of a mechanical prosthesis. The effect of younger age on early-phase mortality was neutralized for patients undergoing the Ross procedure because the 2 lines almost overlap, whereas the effect remained significant for those undergoing aortic valve replacement with a mechanical prosthesis. Solid lines represent parametric point estimates. The Journal of Thoracic and Cardiovascular Surgery 2009 137, 362-370.e9DOI: (10.1016/j.jtcvs.2008.10.010) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Figure 2 Propensity-adjusted effect of initial aortic valve replacement type (Ross procedure or mechanical prosthesis) on survival without repeated aortic valve reoperation. The solid lines represent parametric point estimates, and the dashed lines enclose the 95% confidence interval. The Journal of Thoracic and Cardiovascular Surgery 2009 137, 362-370.e9DOI: (10.1016/j.jtcvs.2008.10.010) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Figure 3 Propensity-adjusted effect of initial aortic valve replacement type (Ross procedure or mechanical prosthesis) on survival to repeated aortic valve reoperation. The solid lines represent parametric point estimates, and the dashed lines enclose the 95% confidence interval. The Journal of Thoracic and Cardiovascular Surgery 2009 137, 362-370.e9DOI: (10.1016/j.jtcvs.2008.10.010) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Figure 4 Propensity-adjusted effect of initial aortic valve replacement type (Ross procedure or mechanical prosthesis) and disease cause on survival to repeated aortic valve reoperation. The solid lines represent parametric point estimates. M-NR, Mechanical nonrheumatic; M-R, mechanical rheumatic; R-NR, Ross nonrheumatic; R-R, Ross rheumatic. The Journal of Thoracic and Cardiovascular Surgery 2009 137, 362-370.e9DOI: (10.1016/j.jtcvs.2008.10.010) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Parametric model for overall survival for the entire cohort is composed of 2 phases of risks: an early phase with a high level of risk in the immediate postoperative period and a constant phase indicating a low but increasing risk of attrition over time. The solid lines represent parametric point estimates, and the dashed lines enclose the 95% confidence interval. Circles represent nonparametric estimates. The Journal of Thoracic and Cardiovascular Surgery 2009 137, 362-370.e9DOI: (10.1016/j.jtcvs.2008.10.010) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Parametric model for survival to aortic valve reoperation for the entire cohort is composed of a late hazard phase that steadily increases as years since surgical intervention progressed. The solid lines represent parametric point estimates, and the dashed lines enclose the 95% confidence interval. Circles represent nonparametric estimates. The Journal of Thoracic and Cardiovascular Surgery 2009 137, 362-370.e9DOI: (10.1016/j.jtcvs.2008.10.010) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Competing risk depiction of outcomes after initial aortic valve replacement. At the time of initial aortic valve replacement, all patients are alive and free from subsequent aortic valve replacement. Aortic valve replacement is associated with an early risk of operative mortality (4%), followed by a constant attrition rate. The time-related risk of aortic valve reoperation steadily increases as time from surgical intervention augments. At 10 years after the index procedure, approximately 10% of patients have died without subsequent aortic valve replacement, 15% have undergone a second aortic valve replacement, and 75% are alive and free from subsequent aortic valve replacement. The solid lines represent parametric point estimates. The Journal of Thoracic and Cardiovascular Surgery 2009 137, 362-370.e9DOI: (10.1016/j.jtcvs.2008.10.010) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Parametric model in patients with mechanical valves for mortality without subsequent aortic valve replacement by initial mechanical valve size. The solid lines represent parametric point estimates. The Journal of Thoracic and Cardiovascular Surgery 2009 137, 362-370.e9DOI: (10.1016/j.jtcvs.2008.10.010) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Parametric model for survival to subsequent aortic valve reoperation underlying pathology. The solid lines represent parametric point estimates. CTD, connective tissue disease. The Journal of Thoracic and Cardiovascular Surgery 2009 137, 362-370.e9DOI: (10.1016/j.jtcvs.2008.10.010) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Parametric model in patients with a rheumatologic cause who underwent the Ross procedure for survival to subsequent aortic valve reoperation. The solid lines represent parametric point estimates, and the dashed lines enclose the 95% confidence interval. The Journal of Thoracic and Cardiovascular Surgery 2009 137, 362-370.e9DOI: (10.1016/j.jtcvs.2008.10.010) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Propensity -adjusted effect of initial aortic valve replacement type (Ross procedure or mechanical prosthesis) on survival to any cardiac reoperation. The solid lines represent parametric point estimates, and the dashed lines enclose the 95% confidence interval. The Journal of Thoracic and Cardiovascular Surgery 2009 137, 362-370.e9DOI: (10.1016/j.jtcvs.2008.10.010) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions

Parametric model for survival to homograft replacement for patients who underwent the Ross procedure. The solid lines represent parametric point estimates, and the dashed lines enclose the 95% confidence interval. Circles represent nonparametric estimates. The Journal of Thoracic and Cardiovascular Surgery 2009 137, 362-370.e9DOI: (10.1016/j.jtcvs.2008.10.010) Copyright © 2009 The American Association for Thoracic Surgery Terms and Conditions