Expanding relevance of aortic valve repair - Is earlier operation indicated?

Objectives: To define the durability of aortic valve repair (AVR _ep) and the effect of surgical timing on late survival. Methods: From June 1986 to June 2011, 331 patients underwent elective AVR_ep for aortic regurgitation (mean age, 53 ± 17 years; 76% men). The repair methods included commissuroplasty (n = 270; 81%), triangular resection and plication (n = 106; 32%), resuspension or cusp shortening (n = 102; 31%), and perforation closure (n = 23; 7%). Results: In-hospital mortality was 0.6% (2 of 332). Four patients (1%) experienced early repair failure; two underwent repeat repair. Overall survival was 91% and 81% at 5 and 10 years, respectively. After adjusting for age, greater left ventricular end-systolic dimension (per 5 mm; hazard ratio [HR], 1.49; 95% confidence interval [CI], 1.23-1.79; P <.001) and lower ejection fraction (per 5%; HR, 1.42; 95% CI, 1.25-1.63; P ≤.001) were significant predictors of long-term mortality. Patients with ejection fraction < 50% and left ventricular end-systolic dimension > 50 mm had significantly greater odds of late death (HR, 3.46; 95% CI, 2.05-5.82; P <.001 and HR, 2.08; 95% CI, 1.05-4.12; P =.036, respectively). The risk of aortic valve reoperation was 10% and 21% at 5 and 10 years, respectively. The presence of severe aortic regurgitation (HR, 2.2; 95% CI, 1.1-5.06; P =.02) and more than mild regurgitation at discharge (HR, 5.87; 95% CI, 2.67-12.68; P ≤.0001) were predictors of late reoperation. Freedom from other valve-related events was 94% and 91% at 5 and 10 years, respectively. Forty-seven patients (21%) with intact valve repair were using warfarin at the last follow-up visit. Conclusions: AVR_ep can be performed with excellent late survival and freedom from valve-related events. Awaiting the onset of ventricular dysfunction increases the risk of late mortality, warranting earlier consideration of AVR_ep for patients with suitable anatomy.