Better anticoagulation control improves survival after valve replacement.
OBJECTIVE
We sought to assess the effect of anticoagulation control on long-term survival after valve replacement with the Medtronic Hall valve (Medtronic, Inc, Minneapolis, Minn).


METHODS
Prospective follow-up data, including 82,297 international normalized ratios, were collected for 1476 patients undergoing single valve replacement with the Medtronic Hall valve between 1979 and 1994, with follow-up to the end of 1998. After excluding 204 patients who either died within 30 days or had fewer than 10 international normalized ratios recorded beyond 30 days, there were 10,203 patient years of follow-up for analysis. Anticoagulation variability was measured as the percentage of international normalized ratios outside a target range of 2.0 to 4.0 for each patient.


RESULTS
Linearized rates for late death rose progressively with increasing deciles of anticoagulation variability for both aortic and mitral valve replacement (2.7% and 3.3% per year, respectively, in deciles 1 and 2 up to 9.5% and 14.6% per year, respectively, in deciles 6-10; P <.001). Survival at 15 years after aortic valve replacement was 59% for low anticoagulation variability (deciles 1 and 2), 55% for intermediate anticoagulation variability (decile 3), and 28% for high anticoagulation variability (deciles 4-10); survivals at 15 years after mitral valve replacement were 56%, 42%, and 24%, respectively (P <.001 between low-intermediate anticoagulation variability and high anticoagulation variability for both aortic and mitral valve replacement). On multivariate analysis, significant predictors of reduced survival were anticoagulation variability per 20% increase (hazard ratio, 1.8), diabetes (hazard ratio, 1.6), decade of age (hazard ratio, 1.6), concomitant coronary artery bypass grafting (hazard ratio, 1.5), male sex (hazard ratio, 1.4), hypertension (hazard ratio, 1.4), New York Heart Association class III or IV (hazard ratio, 1.3), and non-sinus rhythm (hazard ratio, 1.2). Patients with low anticoagulation variability who were in sinus rhythm and did not have diabetes, coronary bypass grafting, or hypertension had survivals equal to those of the age- and sex-matched general population at 15 years. The incidence of valve-related deaths was significantly higher with high anticoagulation variability compared with the incidence with low-intermediate anticoagulation variability for both aortic (1.4% vs 0.5% per year, P <.001) and mitral valve replacement (1.5% vs 0.5% per year, P <.001). By means of univariate analysis, high anticoagulation variability was significantly associated with New York Heart Association class III or IV at 5 years postoperatively (P <.001) and with age of greater than 60 years at the time of the operation (P =.002).


CONCLUSIONS
High anticoagulation variability is the most important independent predictor of reduced survival after valve replacement with a mechanical valve. Better anticoagulation control should improve survival.
Butchart
Eric G
EG
Department of Cardiothoracic Surgery, University Hospital of Wales, Cardiff, United Kingdom. egbutchart@aol.com
Payne
Nicola
N
Li
Hui-Hua
HH
Buchan
Keith
K
Mandana
Kayapanda
K
Grunkemeier
Gary L
GL
D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery; D001777:Blood Coagulation / Q000502:physiology; D005260:Female; D005500:Follow-Up Studies; D006349:Heart Valve Diseases / Q000097:blood / Q000401:mortality / Q000601:surgery; D019918:Heart Valve Prosthesis Implantation; D006801:Humans; D015994:Incidence; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D008943:Mitral Valve / Q000601:surgery; D015588:Observer Variation; D011183:Postoperative Complications / Q000453:epidemiology / Q000209:etiology; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012307:Risk Factors; D020521:Stroke / Q000453:epidemiology / Q000209:etiology; D016019:Survival Analysis; D013923:Thromboembolism / Q000453:epidemiology / Q000209:etiology; D013997:Time Factors; D016896:Treatment Outcome; D006113:United Kingdom / Q000453:epidemiology