Predictability of prognosis was analyzed in 630 patients who were alive 30 days after valve replacement (1965-1986) for aortic stenosis. Follow-up totaled 4,072 patient-years. During the operative periods of 1965-1971 (n = 62), 1972-1976 (n = 164), 1977-1981 (n = 158), and 1982-1986 (n = 246), decreases in cardiothoracic index (0.56 +/- 0.06, 0.53 +/- 0.06, 0.52 +/- 0.06, and 0.51 +/- 0.06; p less than 0.0001), in the prevalence of functional classes III and IV (87%, 76%, 68%, and 62%; p less than 0.0001), and of left ventricular (50%, 39%, 36%, and 30%; p less than 0.05) were accompanied by improved survival (5 year/10 year +/- SE: 73 +/- 6%/53 +/- 6%, 82 +/- 3%/65 +/- 4%, 89 +/- 3%/79 +/- 4%, and 87 +/- 3%/-; p = 0.002) despite increasing age (56 +/- 9, 57 +/- 11, 59 +/- 10, and 61 +/- 11 years; p less than 0.01). A Cox regression analysis identified peak-to-peak systolic gradient (p = 0.0001; inversely related to death rate), cardiothoracic index (p = 0.0003), left ventricular failure (p = 0.0005), prosthetic orifice diameter of 15 mm or less (p = 0.001), age (p = 0.003), ventricular ectopic beats (p = 0.004), male gender (p = 0.03), and antianginal/antiarrhythmic treatment (p = 0.03) as independent risk factors. A prognostic index calculated from the final Cox model stratified the patients into eight risk groups, having observed +/- SE/predicted/expected (matched background population) 10-year survival rates of 90 +/- 7% (n = 29)/94%/91%, 84 +/- 6% (n = 61)/89%/87%, 86 +/- 3% (n = 105)/83%/81%, 75 +/- 4% (n = 165)/75%/77%, 62 +/- 6% (n = 128)/63%/74%, 51 +/- 8% (n = 84)/47%/71%, 29 +/- 9% (n = 40)/31%/67%, and 16 +/- 9% (n = 18)/14%/54% (p less than 0.000001/-/-). Excess mortality relative to the background populations prevailed predominantly in risk groups 5-8 and was mainly caused by congestive heart failure. Thus, improved long-term survival during the 22-year operative period was related to improved preoperative patient status. Earlier operation (= low prognostic index) inferred a survival rate comparable to that of a matched background population. The prognostic index was probably predominantly related to preoperative myocardial damage that caused late predictable death from congestive heart failure.

Primary allograft aortic valve replacement can give acceptable results for up to 25 years. The late results can be improved by the use of a viable allograft, by matching patient and donor age, and by more liberal use of free root replacement with re-implantation of the coronary arteries rather than tailoring the root to accommodate a subcoronary implantation.

Two hundred seventy-five unprocessed, viable homograft ("homovital") aortic valves were used for aortic valve replacement in patients aged 1.5 to 79 years (mean 45.8 +/- 19 years) with maximum follow-up of a 14-year period (mean 4.8 years). Ninety-two percent (252 patients) had New York Heart Association class III or IV functional status before operation and 25 underwent emergency operation. Valves were harvested under sterile conditions and kept in nutrient medium 199. Freehand (subcoronary) technique was used in 147 patients and freestanding root replacement was used in 128. Cumulative survival rates for the whole group were 92% +/- 2% at 5 years and 85% +/- 3% at 10 years, as compared with 96% +/- 2% and 94% +/- 4%, respectively, for the 98 patients who underwent isolated root replacement. Multivariate analysis determined that root replacement with associated procedures and operation for prosthetic endocarditis were risk factors for death, whereas previous xenograft valve, operation for endocarditis, and operation for aortic regurgitation were risk factors for reoperation. Actuarial rates for freedom from degenerative valve failure diagnosed at operation, by postmortem examination, or by routine echocardiography were 94% +/- 2% at 5 years and 89% +/- 3% at 10 years. Recipient age younger than 30 years and previous xenograft valve were risk factors for late degeneration. We conclude that homovital valves demonstrate good durability, particularly in patients older than 30 years, who had a 10-year freedom from degeneration rate of 97%.

Impaired systolic and diastolic left ventricular function, irrespective of afterload, were decisive independent pre-operative risk factors for early as well as late mortality after aortic valve replacement for aortic stenosis. The adverse influence of concentric hypertrophy was the main underlying mechanism. Operative intervention, before impairment of diastolic and systolic function, should be advocated.

Left ventricular hypertrophy regression for patients who survived up to 10 years after AVR for AS is dependent on the preoperative risk profile indicating that irreversible myocardial disease is the underlying factor. Systemic hypertension is an important factor in its own right.

In a prospective study 99 consecutive patients with operative indication due to severe aortic stenosis (AS) were put on a surgical waiting list. The waiting-time to aortic valve replacement (AVR) averaged 6.3 months (0.5-19 months). There were 58 men and 41 women with a mean age of 61 years (21-82 years). The patients were divided into three groups: group I (n = 81) with an uneventful stay on the waiting list (including one patient who declined the AVR offer); group II (n = 11) with significant worsening of a prognostic index; and group III (n = 7) with patients who died during the waiting-time. The waiting-list death rate was 13.5 +/- 5.0% patient-year-1 compared with a post-AVR death rate of 4.9 +/- 0.9%. patient-year-1 (p < 0.05) with a mean post-AVR follow-up of 5.7 years. According to their prognostic index at inclusion, group II patients had a predicted (by a Cox model) 7-year post-AVR survival probability of 72%, but only of 61% according to their prognostic index immediately preoperatively; their observed 7-year post-AVR survival was 60%. Logistic regression analysis identified high age, short duration of symptoms, severe hypertrophy and strain in the ECG, female sex, and deranged left-ventricular diastolic function (related to severely increased left-ventricular muscle mass) as independent predictors of death on the waiting-list and prognosis worsening. From a clinical viewpoint, the predictive models did not allow sufficiently accurate identification of the patients at risk during the waiting-time. The consequences of a surgical waiting-time averaging 6 months are serious for AS patients. The death rate is high and a subgroup worsen their prognostic profile, with significantly reduced post-AVR long-term survival as the result.

Abnormalities of the hypertrophied left ventricular muscle cell and the degree of muscle hypertrophy are, to some degree, underlying determinants of pre-operative symptomatology, pre- and postoperative ventricular function, and early and late mortality after valve replacement for aortic stenosis. Incomplete hypertrophy impaired results, was related to pre-operative myocardial structural abnormalities.

There was no difference in risk factor-corrected overall death rate between mechanical or bioprosthetic aortic valves irrespective of age. Choice of prosthetic valve should therefore not be rigorously based on age alone. Risk of bioprosthetic valve degeneration in young and middle-aged patients and in the elderly and old with a long life expectancy would be an important factor because risk of stroke may primarily be related to patient factors.