Predictors of the Long-Term Outcome After Combined Aortic and Mitral Valve Surgery Juraj Turina, MD; Thomas Stark, BM; Burkhardt Seifert, PhD; Marko Turina, MD Background—The influence of preoperative clinical, hemodynamic, and surgical procedures on long-term prognosis after combined aortic and mitral valve surgery is not well known. Methods and Results—One hundred seventy patients (mean age, 50.5 years; 102 men and 68 women) who underwent surgery for chronic combined aortic and mitral valvular disease between 1975 and 1989 were followed up for an average of 10.6 years. Additional repair of tricuspid valve was performed in 29 patients (17%), and aortocoronary bypass graft surgery was performed in 7 patients (4.1%). The perioperative mortality rate was 4%, and 10- and 20-year survival rates were 61% and 33%. Only 12 of 94 deaths (11%) were non– cardiac related. At 10 and 20 years, 57% and 21% of patients were free of reoperation, respectively. The main predictors of late survival in univariate analysis were age at surgery (P=0.0002), preoperative left ventricular ejection fraction (P=0.002), cardiac index (P=0.007), tricuspid surgery (P=0.03), pulmonary vascular resistance (P=0.03), NYHA class (P=0.04), and additional aortocoronary bypass graft surgery (P=0.04). Duration of symptoms, gender, cause of valvular disease, and type of prosthesis were not predictive of postoperative outcome. In multivariate stepwise Cox analysis, ejection fraction (P=0.0008), age at surgery (P=0.0011), and tricuspid surgery (P=0.007) were independent predictors of late survival. Conclusions—In combined aortic and mitral valve disease, preoperative myocardial function is the main predictor of long-term survival. Low operative mortality rates and good late outcome make valve replacement mandatory before deterioration of myocardial function occurs. Additional tricuspid valve disease requiring surgery significantly decreases the late survival rate. (Circulation. 1999;100[suppl II]:II-48 –II-53.) Key Words: surgery  valves  survival  prognosis  transplantation S urgery for combined aortic and mitral valve disease was introduced in the early 1960s; until the mid-1970s, it was associated with a high operative mortality rate and unsatis- factory late results. 1–3 Despite well documented improvement in surgical techniques with a marked decrease in operative mortality rates and a considerable increase in late postoper- ative survival rates in the 1980s and 1990s, some reluctance remained to refer a patient with combined aortic and mitral disease to surgery. 4,5 A paucity of experience due to the limited number of patients, a lack of good prospective clinical and hemodynamic studies in patients who have not under- gone surgery, great differences in clinical presentation and hemodynamics between regurgitant and stenotic lesions, and changes in causes of valvular disease in developed countries aggravate the decision-making process for surgery in patients with combined aortic and mitral disease. 1,6,7 This was the main reason for reassessment of preoperative clinical, hemo- dynamic, and surgical predictors for long-term survival after combined aortic and mitral valve surgery in patients operated on at our institution from the mid-1970s to the late 1980s. Methods All 170 patients who underwent combined aortic and mitral valve surgery and associated procedures at the Cardiology Division of Medical Policlinic at the University Hospital in Zurich between 1975 and 1989 were included in the study. All except 2 patients underwent right and left heart catheterization, and all except 2 had left ventricular (LV) angiography. All patients 40 years old and those with angina pectoris underwent coronary angiography. For the calculation of LV volume and ejection fraction (EF), only high- quality angiograms were considered. Hence, preoperative EF and volume were reported in only 159 of 170 patients (94%). NYHA class was determined according to symptoms and functional impair- ment at the time of preoperative evaluation and operation regardless of previous symptoms and history. Patients The main characteristics of the study patients are presented in Table 1. The age of the patients at the time of surgery ranged from 21 to 79 years (mean, 50.5 years). The cause of valvular disease was rheumatic in 41% of patients, and 18% had a history of bacterial endocarditis; in other patients, the origin of valvular disease was not specified and was assumed to be degenerative. None of the patients were operated while they had acute endocarditis, and in the majority of patients, endocarditis antedated surgery by several years. Previous surgery of the heart and great vessels had been performed in 35 patients (21%). Clinical and Hemodynamic Data Preoperative NYHA class was 2.9, whereas 24% of patients were in class II, 62% were in class III, and 14% were in class IV (Figure 1). From the Cardiology Division, Department of Internal Medicine (J.T., T.S.), Clinic for Cardiovascular Surgery (M.T.), and Biostatistics Division, Institute for Social and Preventive Medicine (B.S.), University Hospital, Zurich, Switzerland. Correspondence to Juraj Turina, MD, Cardiology Division, University Hospital, 8091 Zurich, Switzerland. E-mail juraj.turina@dim.usz.ch © 1999 American Heart Association, Inc. Circulation is available at http://www.circulationaha.org II-48 Downloaded from http://ahajournals.org by on December 19, 2021