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Estimating the mortality risk of valvular surgery

Catherine M Otto, MD
Gabriel S Aldea, MD
Section Editors
Edward Verrier, MD
Bernard J Gersh, MB, ChB, DPhil, FRCP, MACC
Deputy Editor
Susan B Yeon, MD, JD, FACC


A variety of factors affect mortality and morbidity associated with valvular surgery. The most effective way of stratifying operative risk is by using one of the available validated risk stratification models. The risk models are helpful in the evaluation and counseling of individual patients and planning perioperative care. Models have been developed to estimate risk of in-hospital mortality and complications associated with valve surgery with or without coronary artery bypass graft surgery (CABG).

Risk stratification models for valvular surgery will be reviewed here. Other considerations in preoperative assessment of potential cardiac surgery candidates are discussed separately. (See "Operative mortality after coronary artery bypass graft surgery" and "Indications for valve replacement in aortic stenosis in adults" and "Natural history and management of chronic aortic regurgitation in adults" and "Surgical and investigational approaches to management of mitral stenosis" and "Surgical procedures for severe chronic mitral regurgitation".).


Risk stratification models are subject to limitations that may reduce their prognostic value. The models estimate risk for only specified procedures (eg, the 2008 Society of Thoracic Surgeons [STS] risk model does not include estimates for concomitant aortic and mitral valve surgery [1]). These include dependence upon incomplete or uncertain clinical variables; the models may not be generalizable to patient populations different from the ones in which they were formulated; and they require revision over time as surgical and perioperative care evolves and as the recognition and impact of clinical variables change.

In addition, current risk stratification models do not include several variables that may be clinically important. For example, a severely calcified ascending aorta (also known as porcelain aorta) and severe mitral annular calcification (in patients undergoing mitral surgery) are each associated with high operative morbidity and mortality but are not included in standard risk models [2]. (See "Mitral annular calcification", section on 'Mitral valve surgery'.) Other clinically important variables that are not included in risk models are difficult to measure, such as frailty and nutritional status.

In addition, risk models for cardiac surgery do not necessarily indicate the risk of newer transcatheter procedures, such as transcatheter aortic valve implantation, that increasingly are effective alternates to conventional surgery [3]. Current guidelines recommend evaluation of patients by a specialized heart valve clinic when valve intervention is needed so that risks and benefits of a surgical versus transcatheter procedure can be discussed by a multidisciplinary team [4,5].

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Literature review current through: Nov 2017. | This topic last updated: Jul 27, 2016.
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