Isolated mechanical aortic valve replacement in rheumatic patients in a low- to middle-income country

Jacques Scherman; Rodgers Manganyi; Paul Human; Timothy Pennel; Andre Brooks; Johan Brink; Peter Zilla

doi:10.1016/j.jtcvs.2018.06.083

Isolated mechanical aortic valve replacement in rheumatic patients in a low- to middle-income country

J Thorac Cardiovasc Surg. 2019 Mar;157(3):886-893. doi: 10.1016/j.jtcvs.2018.06.083. Epub 2018 Jul 20.

Authors

Jacques Scherman¹, Rodgers Manganyi², Paul Human², Timothy Pennel², Andre Brooks², Johan Brink², Peter Zilla²

Affiliations

¹ Chris Barnard Division of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa. Electronic address: jacques.scherman@uct.ac.za.
² Chris Barnard Division of Cardiothoracic Surgery, University of Cape Town, Cape Town, South Africa.

PMID: 30107929
DOI: 10.1016/j.jtcvs.2018.06.083

Abstract

Objective: Although the results of aortic valve replacement are well documented for industrialized countries, the outcome in patients with rheumatic aortic valve disease in low- to middle-income countries is less well explored. The aim of this study was to determine the long-term survival and clinical outcomes after isolated aortic valve replacement in patients with rheumatic heart disease in a Sub-Saharan country where follow-up of indigent patients is often challenging.

Methods: A retrospective review of 969 aortic valve replacements performed between 2003 and 2013 was conducted at Cape Town's Groote Schuur Hospital. Patients who underwent concomitant procedures (n = 664) or had nonrheumatic valve pathology (n = 185) were excluded. The mean age of the rheumatic cohort (n = 121) was 43.1 ± 11.6 years with a mean follow-up period of 6.14 ± 3.44 years. The primary end points were survival and valve-related complications.

Results: A 15% cardiac- or valve-related 10-year mortality after receiving a mechanical prosthesis corresponded with a significantly higher mortality rate than that of a matched population. Overall cumulative survival at 1, 5, and 10 years was 93.5% (87.0-96.9), 86.4% (78.4-91.8), and 78.1% (67.5-86.0), respectively, and the corresponding cumulative freedom from combined thromboembolism and bleeding was 94.4% (88.2-97.5), 87.4% (79.4-92.5), and 86.1% (77.9-91.6), respectively.

Conclusions: In low- to middle-income countries, with their unique mix of indigent and "First World" patients, rheumatic heart disease still accounts for a significant proportion of patients requiring isolated aortic valve replacement. Although mechanical prostheses are often selected in these young adults, survival remains suboptimal. Major bleeding and thromboembolic events account for the majority (77%) of the reported valve-related complications.

Keywords: aortic valve replacement; rheumatic heart disease; surgery in low- to middle-income countries.