Isolated Aortic Valve Replacement in a Rheumatic Population

Objective: Although the results of aortic valve replacement are well documented for developed countries, the outcomes in the rheumatic populations of emerging economies are less well explored. The aim of this study was therefore to determine the long-term survival and clinical outcomes after isolated aortic valve replacement (AVR) in a rheumatic population of a threshold country where follow-up of indigent patients is often challenging.

Methods: A retrospective review was conducted of patients who underwent an aortic valve replacement (n=969) between 2003 and 2013 at Cape Town’s Groote Schuur Hospital. Patients who had undergone concomitant procedures, aortic root replacements, aortic valve repairs or redo-procedures were excluded (n=663). In total, 306 patients were identified who underwent an isolated AVR, of which 122 patients had rheumatic valve pathology. The mean follow up period was 6.14±3.44 years. The primary end point was survival.

Results: The mean age of the rheumatic cohort was 45.1±12.6 years and patients were predominantly male (62.6%). Aortic regurgitation (pure or predominant) was the indication in the majority of the patients (74.5%). A mechanical prosthesis was favored in 88.5% of the group due to accelerated degeneration of tissue valves in young patients. The thirty-day mortality was 2.3% (n=3). Overall actuarial survival at 1, 5, and 10 years was 95.1±2.0%, 86.6±3.3%, and 80.0±4.4%, respectively. The late mortality was 15.6% at a mean of 37.1±30.3 months post surgery (n=19).

Conclusion: In threshold countries, with their unique mix of indigent and ‘first world’ patients, rheumatic heart disease still accounts for a significant portion of patients requiring isolated aortic valve replacement. Although mechanical prostheses are often selected in these young adults, survival remains suboptimal, with the majority of the late mortalities (89.5%) being cardiac or valve related.