Douglas R. Johnston, MD, Edward G

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Presentation transcript:

Long-Term Durability of Bioprosthetic Aortic Valves: Implications From 12,569 Implants Douglas R. Johnston, MD, Edward G. Soltesz, MD, Nakul Vakil, MD, Jeevanantham Rajeswaran, PhD, Eric E. Roselli, MD, Joseph F. Sabik, MD, Nicholas G. Smedira, MD, Lars G. Svensson, MD, PhD, Bruce W. Lytle, MD, Eugene H. Blackstone, MD The Annals of Thoracic Surgery Volume 99, Issue 4, Pages 1239-1247 (April 2015) DOI: 10.1016/j.athoracsur.2014.10.070 Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Instantaneous time-varying risk (hazard function) of prosthetic valve explantation. Solid lines depict parametric estimates of risk for explants enclosed within a 68% confidence band equivalent to ±1 standard error. (A) Overall time-varying risk for explant for any reason. Number of patients remaining at risk is given below the horizontal axis. (B) Cause-specific time-varying risk for explant. (SVD = structural valve deterioration.) The Annals of Thoracic Surgery 2015 99, 1239-1247DOI: (10.1016/j.athoracsur.2014.10.070) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Competing risks of structural valve deterioration (SVD), explantation for other indications, and death before explant of a stented pericardial aortic valve prosthesis. Solid lines represent point estimates enclosed within a 68% confidence band equivalent to ±1 standard error. (A) Instantaneous risk of competing events. (B) Cumulative incidence of each competing risk. Vertical bars represent 68% confidence limits. The Annals of Thoracic Surgery 2015 99, 1239-1247DOI: (10.1016/j.athoracsur.2014.10.070) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Age and probability of explant owing to structural valve deterioration (SVD). (A) Nomogram of age relationship to SVD from multivariable equation based on preoperative variables alone. (B) Patients are grouped according to age range. Each symbol represents an explant, vertical bars are 68% confidence limits, and numbers along the horizontal axis are patients remaining at risk. The Annals of Thoracic Surgery 2015 99, 1239-1247DOI: (10.1016/j.athoracsur.2014.10.070) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 4 Structural valve deterioration (SVD) at 20 years and prosthesis–patient mismatch, represented by the number of standard deviations the geometric size of the aortic prosthesis deviates from normal. Nomogram is based on preoperative variables alone. The Annals of Thoracic Surgery 2015 99, 1239-1247DOI: (10.1016/j.athoracsur.2014.10.070) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 5 Temporal trend of prevalence of aortic regurgitation (AR) grades 3+/4+ after aortic valve replacement stratified by patients with eventual explant for structural valve deterioration (SVD) versus other patients. Solid lines represent parametric estimates of temporal trend of prevalence of AR grade 3+/4+. Symbols represent data grouped without regard to repeated measurements within time frames to provide crude verification of model fit. The Annals of Thoracic Surgery 2015 99, 1239-1247DOI: (10.1016/j.athoracsur.2014.10.070) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 6 Temporal trend of aortic valve (AV) gradients after AV replacement stratified by patients with eventual explant for structural valve deterioration (SVD) versus other patients. Solid lines represent parametric estimates enclosed within 68% bootstrap percentile confidence intervals. Symbols represent data grouped without regard to repeated measurements within time frame to provide crude verification of model fit. (A) AV mean gradient after AV replacement. (B) AV peak gradient after AV replacement. The Annals of Thoracic Surgery 2015 99, 1239-1247DOI: (10.1016/j.athoracsur.2014.10.070) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Fig 7 Explantation for structural valve deterioration (SVD) and postoperative mean transvalvular pressure gradient. (A) Unadjusted relationship between instantaneous risk of explant owing to SVD (left vertical axis) and temporal trend of mean postoperative aortic valve (AV) mean gradient (right vertical axis). Solid lines represent risk of explant for SVD; dashed lines represent 3 patient-specific profiles of postoperative AV mean gradient. Blue lines (top) represent the trend for a patient whose profile is at the 85th percentile. Purple lines (middle) represent the trend for a patient whose profile is at the 50th percentile. Red lines (bottom) represent the trend for a patient whose profile is at the 15th percentile. (B) Explant owing to SVD by 20 years (left vertical axis) according to postoperative AV peak gradient and age at implantation, with dashed lines representing 68% confidence bands. This is a nomogram of the multivariable equation in Table 2. The Annals of Thoracic Surgery 2015 99, 1239-1247DOI: (10.1016/j.athoracsur.2014.10.070) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Figure E1 The Annals of Thoracic Surgery 2015 99, 1239-1247DOI: (10.1016/j.athoracsur.2014.10.070) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions

Figure E2 The Annals of Thoracic Surgery 2015 99, 1239-1247DOI: (10.1016/j.athoracsur.2014.10.070) Copyright © 2015 The Society of Thoracic Surgeons Terms and Conditions