Outcomes of aortic valve repair according to valve morphology and surgical techniques

OBJECTIVES The aim of this study was to assess the impact of aortic valve morphology and different surgical aortic valve repair techniques on long-term clinical outcomes. METHODS Between February 2003 and May 2010, 216 patients with aortic insufficiency underwent aortic valve repair in our institution. Ages ranged between 26 and 82 years (mean 53?±?15 years). Aortic valve dysfunctions, according to functional classification, were: type I in 55 patients (25.5%), type II in 126 (58.3%) and type III in 35 (16.2%). Sixty-six patients (27.7%) had a bicuspid valve. Aortic valve repair techniques included sub-commissural plasty in 138 patients, plication in 84, free-edge reinforcement in 80, resection of raphe plus re-suturing in 40 and the chordae technique in 52. Concomitant surgical procedures were CABG in 22 (10%) patients, mitral valve repair in 12 (5.5%), aortic valve-sparing re-implantation in 78 (36%) and ascending aorta replacement in 69 (32%). Mean follow-up was 42?±?16 months and was 100% complete. RESULTS There were six early deaths (2.7%). Overall late survival was 91.5% (18 late deaths). There were 15 (6.9%) late cardiac-related deaths. NYHA functional class was ≤II in all patients. At follow-up, 28 (14.5%) patients had recurrent aortic insufficiency?≥?grade II. The freedom from valve-related events was significantly different between bicuspid and tricuspid valve implantation (P?相似文献   

Tricuspid valve replacement in children

Between 1974 and January, 1986, 11 children underwent 13 tricuspid valve replacements at the Hospital for Sick Children in Toronto. Age at operation ranged from 24 hours to 14.5 years (mean, 6.9 years). Morphology of the tricuspid valves included Ebstein's anomaly (6 patients), congenital tricuspid regurgitation (3), tricuspid regurgitation and univentricular heart (1), and previous tricuspid valve excision for acute endocarditis (1). There were 4 early deaths: the 3 youngest infants in the series (age 1 day to 16 days) and another child who underwent emergency valve replacement died. On follow-up to 13 years after valve replacement, there were 2 late deaths and two reoperations. Both reoperations were for calcified degenerative tissue prostheses 6.5 and 9 years following implantation. The estimated 5-year survival based on a collected review of data from the literature is 68 +/- 9% for children with prosthetic tricuspid valves. Although tissue valve durability is better in the tricuspid position than on the systemic side of the circulation, calcification does result in late dysfunction. Tricuspid valve repair should always be carried out when possible, especially in the infant group. Elective prosthetic valve replacement in older children can be performed with reasonable operative risk and reasonable late results.     

Surgery for mitral and tricuspid insufficiency associated with secundum atrial septal defect

Pure mitral insufficiency associated with secundum atrial septal defect is not an unusual finding. Thirteen patients with significant mitral insufficiency and an associated secundum defect were operated upon. Two of these patients also had severe tricuspid insufficiency. The mitral valve was repaired in 12 patients and replaced in one. The tricuspid valve was reapired in the two patients with associated tricuspid insufficiency. There were two early deaths due to mediastinitis and one late death due to a cerebral embolus in the only patient who had valve replacement; this patient died 3 years after the operation. It is concluded that mitral and tricuspid valve repair should be performed for patients with significant mitral and tricuspid insufficiency associated with atrial septal defect of the secundum variety. Replacement of the values should be avoided if possible.     

Ebstein's Anomaly: Editorial Comments and Personal Observations

Renewed interest in the natural history of Ebstein's anomaly has been created by recent surgical innovations in its management. Tricuspid valve replacement and various types of plastic reconstruction are the two methods of treating Ebstein's anomaly. Replacement of the tricuspid valve has been more successful in older children and adults than in infants, but overall, less successful than procedures involving a mitral or aortic valve prosthesis.At the Mayo Clinic, 42 patients with Ebstein's anomaly, aged 11 months to 62 years, underwent surgical repair. Plastic repair was accomplished in 34 of these patients, and right ventricular plication and valve replacement in 6 others. Two patients had valves that could not be reconstructed, and underwent a Fontan procedure instead. Three hospital deaths and two late deaths occurred. There have been no deaths in the 25 patients seen last in the series.Long-term follow-up was obtained in the first 22 survivors. The majority were in New York Heart Association (NYHA) Class III or IV preoperatively; all but 3 had improved to NHYA Class I or II at follow-up. Because of the low mortality rate and good long-term results as well as the fact that the majority of patients can be repaired with a plastic procedure, the operation is advisable for patients who have deteriorated into NYHA Class III or IV. Those patients with moderate to severe cyanosis, paradoxical emboli, or progressive increase in cardiac size are also candidates for operation.     

Valve replacement for Ebstein's anomaly of the tricuspid valve.

The role of valve replacement in the treatment of Ebstein's anomaly of the tricuspid valve remains controversial. Between 1965 and 1977, five patients with Ebstein's anomaly ranging in age from 11 to 57 years (mean 29) underwent tricuspid valve replacement in our institution. All of the patients were cyanotic but one, three were in Functional Class III, and two were in Class IV (New York Heart Association classification). The valve was placed above the coronary sinus. Plication of the atrialized portion of right ventricle was required in only one patient. Four patients had additional closure of an atrial septal defect. There were no deaths. On follow-up (range 1 to 13 years), four patients are in Functional Class I and one is in Class II. None is cyanotic. Four patients are in sinus rhythm and one has a pacemaker because of postoperative complete heart block. We conclude that valve replacement and, when necessary, plication of the atrialized right ventricle produce excellent clinical improvement.     

Tricuspid valvulectomy without replacement. Twenty years' experience

Since September 1970, we have operated on 55 patients with intractable right-sided endocarditis. All patients were addicted to heroin. Fifty-three underwent tricuspid valvulectomy without replacement and in addition two had pulmonic valve excision. Twenty-four patients (49%) returned to their drug addiction. Six patients (11%) required prosthetic heart valve insertion 2 days to 13 years later for medically refractory right-sided heart failure, and four of these died. Overall, 16 patients (29%) died, six (11%) within 45 days after the tricuspid valvulectomy. One (2%) of these deaths was related to the operation and five were due to uncontrollable infection. Ten (18%) deaths occurred 9 months to 13 years after the tricuspid valvulectomy. Nine were due to drug addiction and one to progressive right ventricular failure 2 months after prosthetic heart valve insertion and 10 years after the initial valve removal. Of the 39 patients who are alive, 37 (67%) have not required prosthetic heart valve insertion. From our observations we reached the following conclusions: (1) Drug addiction is a recurrent and lethal disease. Among these patients, tricuspid valvulectomy without replacement is the operation of choice for the management of intractable right-sided endocarditis; (2) after tricuspid valvulectomy without replacement, only six of 55 patients (11%) had required prosthetic heart valve insertion to control medically refractory right-sided heart failure; (3) in a small percentage of patients the absence of the tricuspid valve may lead to severe and permanent impairment of right ventricular function.     

Late Results of Triple Valve Replacement: A 14-Year Review

Forty-eight patients have undergone simultaneous triple valve replacement at our institution over the past 14 years. This series was reviewed as a baseline for comparison with more recent tricuspid valve reparative procedures and to assess the natural history of advanced rheumatic heart disease with surgically corrected valvular lesions. Survival was 81% at one month and 32% at 14 years, not significantly different from results with double valve replacement during the same period, and not related to whether the tricuspid involvement was organic or functional. Forty-three percent of the late deaths were clearly valve related, a percentage which would undoubtedly be lowered with currently available prostheses. Functional class was determined in 13 of the 17 current survivors (mean follow-up, 10.3 years), and was improved over preoperative functional class in all but 3 patients. Three patients died of progressive congestive heart failure despite normally functioning prostheses; the reasons for these deaths are open to speculation.     

Ebstein's anomaly: sixteen years' experience with valve replacement without plication of the right ventricle.

From June 1967 to February 1983 10 patients aged from 13 to 51 years underwent surgery for Ebstein''s anomaly. Nine patients were in class III according to the New York Heart Association (NYHA) classification and one was in class IV. The interatrial communication was closed in all patients; the tricuspid valve was repaired in one patient and replaced in the other nine patients. There were no deaths in hospital but there were two late deaths. One patient died when the tricuspid prosthesis clotted seven years after its insertion. The other patient committed suicide 11 years after surgery. The remaining eight patients have been followed up for periods ranging from six months to 16 years (mean 10 years). Seven of the eight survivors are well and in NYHA class I, the eighth being in class II. Cardiac arrhythmias have been a problem in only one patient. Tricuspid valve replacement combined with closure of interatrial communication without right ventricular plication has given satisfactory clinical results and has improved the quality of life.     

Evaluation of long-term results of bicuspidalization annuloplasty for functional tricuspid regurgitation. A seventeen-year experience with 133 consecutive patients

Between 1968 and 1985, 133 consecutive patients underwent bicuspidalization annuloplasty for moderate to severe functional tricuspid regurgitation associated with mitral or combined mitral and aortic valve disease. Over this period, the incidence of tricuspid valve replacement was only 2.3% (3/136 patients). There were 18 early deaths (13.5%) in the entire series--three (5.0%) of 60 patients in the last 5 years of the study--and 10 late deaths (8.7%). Actuarial survival rate for the entire series, excluding early deaths, was 91.0% +/- 3.0% at 10 and 17 years. There were seven reoperations (6.1%) on the tricuspid valve, needed because of residual or recurrent mitral valve lesions after the initial operation. Actuarial rates of freedom from reoperation on the tricuspid valve were 93.6% +/- 3.0% (10 years) and 69.7% +/- 16% (17 years) for the entire series: 78% +/- 10% (15 years) for the open mitral commissurotomy plus tricuspid annuloplasty group (44 patients); 90% +/- 9.0% (15 years) for the mitral plus tricuspid annuloplasty group (10); 75.2% +/- 22% (17 years) for the mitral replacement plus tricuspid annuloplasty group (58); and 92.6% +/- 7.0% (16 years) for the combined aortic and mitral valve surgery plus tricuspid annuloplasty group (21). Ninety-eight percent of the survivors were in New York Heart Association class I or II postoperatively. Of 21 randomly selected patients investigated by pulsed Doppler echocardiography, 14 (67%) had no regurgitation or grade 1/4 tricuspid regurgitation and the remaining seven (33%) had grade 2/4 regurgitation postoperatively. Our experiences suggest that bicuspidalization annuloplasty can be a reliable method in the vast majority of patients with functional tricuspid regurgitation.     

Ebstein心脏畸形139例手术治疗经验

目的：总结Ebstein心脏畸形手术治疗的经验。方法：回顾性分析1980年6月至2000年1月手术治疗139例Ebstein心脏畸形病人。其中行三尖瓣成形、房化右心室折叠和三尖瓣环DeVega成形111例，三尖瓣置换术27例，右心室发育不全行心外管道全腔静脉-肺动脉连接术（ETCPC）1例。结果：全组手术死亡12例（8.6％）；近10年手术死亡率降至3.3％。成形组中10例再次行瓣膜置换术，均生存。结论：对Ebstein心脏畸形应根据其美丽解剖特征选择手术方案，轻型可选用三尖瓣成形术；中间A型可选用成形术，中间B型应慎重选择成形或瓣膜置换术；重型选用瓣膜置换术。     

Tricuspid regurgitation in patients with acquired, chronic, pure mitral regurgitation. II. Nonoperative management, tricuspid valve annuloplasty, and tricuspid valve replacement

The incidence, preoperative and intraoperative diagnosis, methods, and the clinical and hemodynamic features of patients with and without tricuspid regurgitation associated with chronic mitral regurgitation were presented in Part I. This study (Part II) compares the early and late results in patients with chronic, pure mitral regurgitation undergoing isolated mitral valve replacement, mitral replacement and tricuspid valve annuloplasty, and mitral and tricuspid valve replacement. The mean follow-up interval was 6 years. Those with the longest duration of symptoms (18 years) required tricuspid and mitral valve replacement (11 patients), whereas those with the shortest duration (8.1 years) had only mitral replacement (22 patients). Eight patients had minimal tricuspid regurgitation by digital palpitation, with no procedure performed, and six had tricuspid valve annuloplasty, only one of whom received a ring support. Operative mortality rate was similar in all groups (13% to 18%). All but two of the surviving patients improved by at least one New York Heart Association functional class, and no statistically significant differences were found between preoperative and postoperative hemodynamic data. There were no statistically significant differences in survival at 1, 5, or 8 years (85%, 70%, and 60%, respectively) for patients with or without TR. Only two of the surviving five patients who underwent tricuspid valve annuloplasty were alive 3 years after operation, whereas 70% to 80% of those with mitral replacement or mitral and tricuspid replacement were alive after the same time interval. It is not clear whether or not the pathogenesis of tricuspid regurgitation resulting from mitral regurgitation is different from that of tricuspid regurgitation resulting from mitral stenosis. It is our contention that whether tricuspid regurgitation arises because of anatomic destruction of the tricuspid valve or because of right ventricular dilatation with tricuspid annular enlargement, the underlying mitral valve lesion may determine the preoperative and postoperative courses of these patients. Therefore, when tricuspid valve disease is being evaluated, we urge that patients be categorized by the nature of their underlying mitral or aortic valve lesions.     

Tricuspid valve surgery for functional tricuspid valve regurgitation associated with left-sided valvular disease.

OBJECTIVES: We have reviewed 260 patients who underwent initial tricuspid valve surgery for functional tricuspid valve regurgitation (TR) and analyzed independent predictors for early and late unfavorable results. MATERIALS AND METHODS: Between 1981 and 1998, 260 tricuspid valve operations were performed for functional TR. There were 94 males and 166 females with a mean age of 55 years. The tricuspid valve surgery procedures consisted of De Vega tricuspid annuloplasty in 240 patients, ring annuloplasty in four patients, and tricuspid valve replacement in 16 patients. The mean duration of follow-up was 7.8 years. RESULTS: Hospital mortality was 8.9% (23 patients). Late deaths occurred in 34 patients including cardiac-related late deaths in 26 patients. The survival rates were 83+/-2% at 5 years and 78+/-3% at 10 years. Late tricuspid valve reoperation was performed on 13 patients due to residual or recurrent TR in 12 patients and thrombosed tricuspid bileaflet mechanical valve in one patient. The tricuspid valve reoperation-free survival rate was 90+/-2% at 5 years and 84+/-3% at 10 years. The only predictor of hospital mortality was preoperative highly elevated right atrial pressure (P=0.01). Variables predictive of cardiac-related late death were preoperative New York Heart Association (NYHA) class IV (P=0.01) and poor left ventricular ejection fraction (LVEF) (P=0.02). Residual TR of more than grade 2+ early after tricuspid annuloplasty was a significant risk factor for late tricuspid valve reoperation (P=0.01). Preoperative TR of grade 4+ was predictive of early residual TR (P=0.04). CONCLUSIONS: Tricuspid valve surgery for functional TR can be performed with acceptable levels of early mortality. Cardiac-related late mortality after tricuspid surgery may be improved by earlier surgical treatment before NYHA class IV or deterioration of LVEF occurs. To prevent late tricuspid reoperation, it is important not to leave residual TR of grade 2+ or more after tricuspid annuloplasty.     

Is repair of aortic valve regurgitation a safe alternative to valve replacement?

OBJECTIVE: To assess outcome of valve repair in patients with aortic valve regurgitation with emphasis on incidence and risk of reoperation. METHODS: We retrospectively reviewed 160 consecutive patients (127 men) who underwent aortic valve repair between 1986 and 2001. Ages ranged from 14 to 84 years (mean 55 +/- 17 years). Patients were categorized according to the main etiology of valve disease; 63 patients (39%) had annular dilation leading to central leakage, 54 (34%) had bicuspid valve, 34 (21%) with tricuspid valve had cusp prolapse, and 9 (6%) had cusp perforation. Repair methods included commissural plication (n = 154, 96%), partial cusp resection with plication (n = 47, 29%), resuspension or cusp shortening (n = 44, 28%), and closure of cusp perforation (n = 10, 6%). RESULTS: There was 1 early death (0.6%). Two patients required re-repair of the aortic valve during initial hospitalization. During a mean follow-up of 4.2 years, there were 16 late deaths. Overall, 16 of 159 hospital survivors had late reoperation on the aortic valve (mean interval 2.8 years) without early mortality. Risks of reoperation on the aortic valve were 9%, 11%, and 15% at 3, 5, and 7 years, respectively. CONCLUSIONS: Aortic valve repair can be performed with low risk and excellent freedom from valve-related morbidity and mortality. Late recurrence of aortic valve regurgitation led to reoperation in 8.8% of patients, but mortality associated with subsequent procedures is low. Aortic valve repair appears to be a good option for selected patients, particularly young patients who wish to avoid chronic anticoagulation with warfarin.     

Mitral valve replacement with ball and tilting disc valve prosthesis. A clinical and haemodynamic study.

A survey is presented on the results of 100 consecutive patients who underwent mitral valve (78 patients) or mitral and aortic and/or tricuspid valve replacement (22 patients) with ball or disc valve prosthesis. The patients were followed-up from 6 to 54 months postoperatively. The mortality for mitral valve replacement was 13 (17%) early deaths (up to one month from operation) and 5 (6%) late deaths. The corresponding figures for multiple valve replacements were 9 (41%) and 3 (14%). A direct correlation was found between early mortality and preoperative functional class IV of the New York Heart Association (30% dead). Pulmonary hypertension combined with multiple valve disease resulted in an early mortality of 42%. No significant differences in early mortality figures after MVR were found between ball and disc valve prostheses. Predominant complications were respiratory infection and atelectasis (13%), acute myocardial infarction (11%) and haemorrhage (9%). Haemolysis was found in 9 patients and three other patients had haemolytic anaemia attributable to paravalvular leak which in two indicated the reapplication of the prosthesis. The main causes of death were heart failure, 8 early and 4 late deaths, and myocardial infarction, 5 and 4 respectively.     

Long-term performance of the Hancock porcine bioprosthesis in the tricuspid position. A review of forty-five patients with fourteen-year follow-up

Because little information is available regarding the clinical performance of the Hancock porcine bioprosthesis (Johnson & Johnson Cardiovascular, King of Prussia, Pa.) implanted in the tricuspid position, we reviewed the long-term follow-up of patients who had tricuspid valve replacement with this device. From March 1970 to December 1983, 45 patients had tricuspid valve replacement, either isolated (seven patients) or combined with replacement of other valves (38 patients) by means of a standard, glutaraldehyde-preserved Hancock porcine bioprosthesis. Follow-up ranged from 0.2 to 14.7 years (mean, 7.6 +/- 3.6 years) and was complete. The late mortality rate was 6.6% +/- 1.6%/pt-yr and the actuarial survival rate at 14 years was 23% +/- 9%. Reoperation because of structural deterioration of the tricuspid, the mitral, or both bioprostheses was performed in nine patients (3.7% +/- 1.2%/pt-yr) from 40 to 177 months (mean, 112 +/- 43 months) and resulted in no deaths. Actuarial freedom from structural deterioration of a Hancock tricuspid porcine bioprosthesis at 14 years is 68% +/- 13%. Morphologic examination of explanted porcine bioprostheses showed that those implanted in the tricuspid position had lower degrees of calcification and less severe structural changes than those simultaneously explanted from the mitral position. We conclude that the Hancock porcine bioprosthesis has an acceptable long-term durability and satisfactory performance after tricuspid valve replacement, and we continue to favor its use in the tricuspid position even in association with mechanical prostheses in the left side of the heart.     

Tricuspid valve replacement with a mitral homograft in children with rheumatic tricuspid valvulopathy

OBJECTIVE: Tricuspid valve replacement in children is associated with a nonnegligible complication rate because of specific disadvantages of mechanical or biologic prostheses. The objective of this study was to examine the midterm clinical outcomes of tricuspid valve replacement with a mitral homograft in 8 children with unreparable rheumatic tricuspid valve involvement. METHODS: Between 1993 and 2003, tricuspid valve replacement with a mitral homograft was performed in 8 patients (2 male and 6 female patients; mean age, 14.2 years) with rheumatic tricuspid valve disease. All patients were in New York Heart Association class III or IV. In all patients with rheumatic valve disease, conservative operations had previously been performed on the tricuspid valve during concomitant left-sided surgical intervention. Mean follow-up was 56 +/- 12 months and was complete. RESULTS: There were no operative or late deaths. All patients were alive at the most recent follow-up contact and were in New York Heart Association functional class I or II. None of the patients required homograft-related reoperation. At the most recent echocardiograhic examination, 6 patients had trivial residual tricuspid regurgitation, and 2 had mild tricuspid regurgitation. None of the patients had maximal transvalvular tricuspid gradients greater than 2 mm Hg during their yearly follow-up visits. CONCLUSION: On the basis of our midterm results, tricuspid valve replacement with a mitral homograft in children seems to be a valuable alternative surgical option.     

A new reconstructive operation for Ebstein's anomaly of the tricuspid valve

Ebstein's anomaly is a complex malformation involving the tricuspid valve and the right ventricle. Various surgical techniques, either repair or replacement of the abnormal tricuspid valve, have been used with variable results. In an attempt to enlarge the indications of conservative procedures, we developed a technique of repair that comprises the reconstruction of a normally shaped right ventricle and the repositioning of the tricuspid valve at the normal level. In a series of 14 patients operated on between January 1980 and December 1986 in our institution, only one patient with an associated atrioventricular septal defect required a tricuspid valve replacement. All of the other patients, regardless of the complexity of the tricuspid malformation, were able to benefit from this conservative technique. There were two hospital deaths and no late deaths in this series. All surviving patients displayed a marked improvement over their preoperative status with regard to functional class (92% are in class I or II) and rhythm disturbances. Echocardiographic and Doppler studies demonstrated a normal shape of the right ventricle and good tricuspid valve function in all the patients but one.     

Valve replacement in children

Between May 1979 and September 1998, 202 children underwent surgical treatment for valvular heart disease. Of these 23, who ranged in age from 25 days to 15 years, underwent valve replacement, including 1 reoperation. The valve replacement consisted of the aortic valve in 5 patients, the mitral valve in 3, the tricuspid valves in 9, including 5 systemic atrioventricular valves for atrioventricular discordance, the pulmonary valve in 6, 5 bioprostheses and 18 mechanical prostheses. There were 4 operative deaths, 1 hospital death and 3 late deaths. At the 10-years follow-up, the actual survival rate was 67.8%, the event free rate was 76.1% and the freedom from reoperation rate was 86.2%. Valve re-replacement was performed in only 1 patient due to a thrombosed tricuspid valve. These results suggest that there is a small risk of major complications and reoperation in children who undergo valve replacement, whether a bioprosthetic valve or a mechanical valve. The long-term results of younger patients should be followed more closely according to their growth.     

Late results after Starr-Edwards valve replacement in children

Selection of types of prosthetic heart valves for children remains controversial. The case histories of 50 children surviving valve replacement with Starr-Edwards prostheses between 1963 and 1978 were reviewed to evaluate the long-term performance of mechanical valves. The 31 boys and 19 girls ranged from 6 months to 18 years in age (mean 10.4 years); 19 patients had had aortic valve replacement, 24 patients had had mitral valve replacement, and one patient had had both. Among the six patients who had had tricuspid valve replacement, four had corrected transposition, so that the tricuspid valve was the systemic atrioventricular valve. Mean (+/- standard deviation) follow-up interval was 7.9 +/- 4.9 years (maximum 17 years). For all patients, the 5 year survival rate was 86% +/- 6%. At 10 years postoperatively, the survival rate (+/- standard error) was 90% +/- 7% after aortic valve replacement and 76% +/- 8% after systemic atrioventricular valve replacement. At follow-up, 39 patients were alive, and 38 were in New York Heart Association Class I or II. Of the 11 deaths, four were valve-related. Seven patients had major (requiring hospitalization) thromboembolic events, and five patients had minor transient neurological symptoms suggesting thromboembolism; 50% of these patients were not taking warfarin (Coumadin) at the time of the thromboembolic event. The incidence of late (greater than 30 days) thromboembolism was 5.3 per 100 patient-years after aortic and 2.0 per 100 patient-years after systemic atrioventricular valve replacement. At 10 years postoperatively, 66% +/- 15% of patients who had had aortic valve replacement and 91% +/- 6% of those who had had systemic atrioventricular valve replacement were free of thromboembolism. The excellent long-term survival, absence of mechanical failure, and relatively low rate of thromboembolism with this prosthesis contrast with our experience with biological valves, in which 41% of children required reoperation in 5 years. Currently, mechanical valves, such as the Starr-Edwards prostheses, are our preferred valves for pediatric patients.     

Early and late stroke after mitral valve replacement with a mechanical prosthesis: risk factor analysis of a 24-year experience

OBJECTIVE: We evaluated risk factors for mortality and stroke after mechanical mitral valve replacement between May 1977 and December 2001. METHODS: Early and late mortality and stroke were assessed. Potential predictors of mortality and stroke were entered into a Cox proportional hazards model. Actuarial survival and freedom from stroke were determined by a log-rank test. RESULTS: Mitral valve replacement was performed in 812 patients. Concomitant procedures included left atrial appendage closure in 493 (61%) patients, tricuspid annuloplasty-replacement in 348 (43%) patients, maze procedure in 185 (23%) patients, plication of the left atrium in 148 (18%) patients, and other procedures in 151 (19%) patients. Five-year actuarial survival was 91.1% +/- 2.3%. Freedom from stroke at 8 years was significantly better in patients with sinus rhythm versus atrial fibrillation (P <.001). Ninety-nine percent of patients with mitral valve replacement combined with a maze procedure were free from stroke, whereas only 89% of patients with mitral valve replacement alone were free from stroke at 8 years after surgical intervention. Seventy-two patients had late stroke; sixty-five patients (90%) were in atrial fibrillation, and 47 (65%) patients had the left atrial appendage closed. Multivariate analysis showed that late atrial fibrillation (odds ratio, 3.39; 95% confidence interval, 1.72-6.67; P =.0001) and omission of the maze procedure (odds ratio, 3.40; 95% confidence interval, 1.14-10.14; P =.003) were the significant risk factors for late stroke. CONCLUSIONS: Persistent atrial fibrillation was the most significant risk factor for late stroke after mechanical mitral valve replacement. Restoration of sinus rhythm with a maze procedure nearly eliminated the risk of late stroke, whereas neither closure of the left atrial appendage nor therapeutic anticoagulation prevented this complication.