John,
Some additional data that provides more perspective on results from optimal self managed AC therapy. In this case a comparison with the Ross Procedure with patients of a mean age of 48. It would be reasonable to assume that these were patients with lesser risk factors but still the outcomes are very good.
Sadly, the US has not been as proactive as Europe in embracing Self Management for AC therapy for patients considering a Mechanical Valve.
David
Optimal Self-Management Anticoagulation Therapy vs. Ross Procedure
"It is remarkable that for the duration of the follow-up period, survival after aortic valve replacement was comparable to that of the age-matched German population in both Ross patients and mechanical prosthesis patients. This observation supports the hypothesis that late mortality after aortic valve replacement is driven mainly by patient characteristics and that prosthesis selection plays only a minor role, if any."
Survival Comparison of the Ross Procedure and Mechanical Valve Replacement With Optimal Self-Management Anticoagulation Therapy
http://circ.ahajournals.org/content/123/1/31 Propensity-Matched Cohort Study
Conclusions—In comparable patients, there is no late survival difference in the first postoperative decade between the Ross procedure and mechanical aortic valve implantation with optimal anticoagulation self-management. Survival in these selected young adult patients closely resembles that of the general population, possibly as a result of highly specialized anticoagulation self-management, better timing of surgery, and improved patient selection in recent years.
Methods and Results—We selected 918 Ross patients and 406 mechanical valve patients 18 to 60 years of age without dissection, aneurysm, or mitral valve replacement who survived an elective procedure (1994 to 2008). With the use of propensity score matching, late survival was compared between the 2 groups. Two hundred fifty-three patients with a mechanical valve (mean follow-up, 6.3 years) could be propensity matched to a Ross patient (mean follow-up, 5.1 years). Mean age of the matched cohort was 47.3 years in the Ross procedure group and 48.0 years in the mechanical valve group (
P=0.17); the ratio of male to female patients was 3.2 in the Ross procedure group and 2.7 in the mechanical valve group (
P=0.46). Linearized all-cause mortality rate was 0.53% per patient-year in the Ross procedure group compared with 0.30% per patient-year in the mechanical valve group (matched hazard ratio, 1.86; 95% confidence interval, 0.58 to 5.91;
P=0.32). Late survival was comparable to that of the general German population.
RESULTS:
"In the cohort of 253 matched pairs, during 2899 patient-years of follow-up, 12 participants (2.4%) died (
Table 3). Valve-related mortality was observed only in patients who underwent a Ross procedure. The 4 valve-related deaths were 2 sudden, unexplained, unexpected deaths without further clinical data or autopsy, 1 death resulting from a coronary embolus and subsequent myocardial infarction, and 1 death resulting from stroke.
During follow-up, 8 Ross patients in the matched cohort required an aortic valve replacement. None of the patients with a mechanical valve required reoperation in the matched cohort. Linearized all-cause reoperation rate was 0.61% per patient-year in the Ross procedure group compared with 0.00% per patient-year in the mechanical valve group (
P=0.01). Two bleeding events were observed in the matched cohort of Ross patients, and 6 bleeding events were observed in the matched cohort of the patients with a mechanical valve. The linearized bleeding rate was 0.15% per patient-year in the Ross procedure group compared with 0.36% per patient-year in the mechanical valve group (
P=0.15). During follow-up, 5 Ross patients and 1 patient with a mechanical valve experienced a thromboembolic event. The linearized thromboembolism rate was 0.38% per patient-year in the Ross procedure group compared with 0.06% per patient-year in the mechanical valve group (
P=0.10). Endocarditis was diagnosed in 2 patients who underwent a Ross procedure and in none of the patients who underwent a mechanical aortic valve replacement. The linearized endocarditis rate was 0.15% per patient-year in the Ross procedure group compared with 0.00% per patient-year in the mechanical valve group (
P=0.16).
All-cause mortality occurred in 0.54% per patient-year (n=7) in the Ross procedure group compared with 0.31% per patient-year (n=5) in the mechanical prosthesis group (matched hazard ratio, 1.86; 95% confidence interval, 0.58 to 5.91;
P=0.32;
Table 3). Cumulative survival is displayed in
Figure 3. Age- and gender-matched late survival for young adult patients after aortic valve replacement was comparable to that of the general German population (96% versus 95% at 8 years)."
