El. Jones et al., INTERACTION OF AGE AND CORONARY-DISEASE AFTER VALVE-REPLACEMENT - IMPLICATIONS FOR VALVE SELECTION, The Annals of thoracic surgery, 58(2), 1994, pp. 378-385
The interaction of patient age and the presence of coronary artery dis
ease (CAD) and its influence on survival were examined in 3,644 patien
ts undergoing either aortic (AVR) or mitral (MVR) valve replacement wi
th or without coronary artery bypass grafting (CABG) between 1974 and
1991. Emergency procedures were performed much more frequently in thos
e undergoing MVR and CABG than in those undergoing AVR and CABG (18.8%
and 6.7%, respectively). The adverse effect of CAD on median survival
for patients of all ages undergoing either AVR or MVR was statistical
ly significant (AVR without CAD 11.8 versus 8.7 years with CAD; MVR wi
thout CAD 12.7 versus 7.3 years with CAD; p < 0.0001). Survival in pat
ients younger than 70 years without CABG who underwent either AVR or M
VR was quite good (< 60 years: AVR, > 14 years; MVR, 15.4 years; 60 to
69 years: AVR, 10.4 years; MVR, 11.4 years). The most profound effect
of CAD on patient survival after valve replacement was observed in pa
tients 60 to 69 years of age who underwent MVR, in whom the median sur
vival without CABG was 11.4 years versus 5.5 years with CABG (p < 0.00
01). An emergency operative status was associated with a reduced early
and late survival for those patients undergoing MVR, particularly tho
se with CAD. By relating the Cox proportional hazard models for valve
survival to patient survival, we found that, in those patients 70 year
s and older with and without CAD who underwent either AVR or MVR, the
median patient swivel was reduced sufficiently (5.5 versus 8.1 years)
to justify use of a bioprosthetic valve. Other factors being equal, we
conclude that tissue valves appear to be most appropriate for MVR pat
ients with CBD who are 60 years or older and for those older than 70 y
ears who do not have CAD. Tissue valves also appear to be indicated fo
r AVR patients with and without CAD who are 70 years and older. In pat
ients without CAD who are younger than 70 years, the long-term surviva
l after MVR or AVR is excellent and this finding suggests that mechani
cal valves may be preferable, as they are in all valve patients younge
r than 60 years.