World Journal of Cardiovascular Diseases, 2013, 3, 543-550 WJCD
http://dx.doi.org/10.4236/wjcd.2013.39086 Published Online December 2013 (http://www.scirp.org/journal/wjcd/)
Effect of aortic valve replacement on ventricular recovery
and functional class in patients with reduced left
ventricular function
Mahdi Ait Houssa1*, Younes Moutakiallah1, Abdessamad Abdou1, Abdedaïm Hatim2,
Mohamed Drissi2, Brahim Amahzoune1, Youssef El Bekkali1, Atif Benyass3, Abdelatif Boulahya1
1Cardiac Surgery Department, Mohammed V Military Hospital, Rabat, Morocco
2ICU of Cardiac Surgery Department, Mohammed V Military Hospital, Rabat, Morocco
3Cardiology Department, Mohammed V Military Hospital, Rabat, Morocco
Received 22 October 2013; revised 25 November 2013; accepted 2 December 2013
Copyright © 2013 Mahdi Ait Houssa et al. This is an open access article distributed under the Creative Commons Attribution License,
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ABSTRACT
Objective: The aim of the study was to assess the ef-
fects of aortic valve replacement (AVR) in patients
with aortic stenosis (AS) or regurgitation (AR) and
left ventricular (LV) dysfunction. Patients and meth-
ods: Retrospective analysis identified 75 consecutive
patients with left ventricular ejection fraction (LVEF)
assessed by echocardiography < 40% who underwent
AVR for AS (n = 40) or AR (n = 35) between 1994
and 2011. Exclusion criteria were previous myocar-
dial infarction or concomitant valvular disorders
other than aortic disease. Follow-up evaluated the
New York Heart Association (NYHA) functional class,
LVEF and survival rate. Results: Mean ages were
respectively 56.5 ± 9.3 a nd 4 7.9 ± 11.7 ye a rs in A S and
AR groups, p = 0.001. Before surgery, 88% and 75%
of patients were in NYHA III-IV respectively in AS
and AR. In the AS group, the mean LVEF and aortic
valve area (AVA) were respectively 32.2% ± 8% and
0.65 ± 0.15 cm². AR group had a mean LVEF of 33.8
± 6.7% and a mean LV systolic diameter of 62 ± 8.8
mm. All patients underwent AVR under cardiopul-
monary bypass. There were 5 operative deaths
(12.5%) in AS group and 6 (17.6%) in AR group, p =
0.57. LVEF increased to 49% ± 14.7% and 51.2% ±
10.9% in the AS and AR groups after echocardiogra-
phy control. The survival rates at 1, 5 and 10 years
were respectively 94.4%, 87% and 80% in AS group
and 95.2%, 93% and 89% in AR group. Conclusion:
Despite higher perioperative mortality in patients
with aortic valve disease (AS or AR) and LV dysfunc-
tion, long-term outcome is excellent. We, therefore,
conclude that AVR can be performed and it should
not be denied to patients on the basis of low EF alone.
Keywords: Aortic Valve Disease; Aortic Valve
Replacement; Left Ventricular Dysfunction
1. INTRODUCTION
Congestive heart failure (CHF) is one of the leading
causes of hospitalization in western countries and is as-
sociated with significant morbidity and mortality. The
most common causes of CHF are ischemic heart diseases.
A small minority of patients, about 5%, have CHF as a
result of valvular disorders [1]. Contrary to the devel-
oped countries, rheumatic heart valvular disease is often
the main etiology of heart diseases in developing coun-
tries.
With the advent of better surgical techniques and im-
proved preoperative and postoperative medical manage-
ment, traditional surgeries for patients with severe LV
dysfunction can actually be performed with reasonable
success. When LV function is dramatically reduced, LV
assist devices either as end stage device or as a bridge to
transplant and heart transplantation are generally consid-
ered the choice of last resort in heart management. In our
country, those therapeutic options are not available. In
the same way, new innovative approach, such as percu-
taneous implantation of an aortic valve prosthesis com-
monly called TAVI transcatheter aortic valve implanta-
tion is more expensive and didn’t start yet in our country,
and in addition, our patients are younger than occidental
*Corresponding author.

M. A. Houssa et al. / World Journal of Cardiovascular Diseases 3 (2013) 543-550 544
people, with less comorbidities which limit their indica-
tion. For those reasons, standard AVR is the only effec-
tive treatment recommended in patients with severe AS
and severe AR associated with depressed ventricular
ejection.
Few studies have compared the results for the different
valvular disorders in the subgroup of patients suffering
from AS and AR associated with reduced ventricular
function [2-4].
2. PATIENTS AND METHODS
2.1. Study Population
Between January 1994 and December 2011, 384 con-
secutive patients underwent isolated AVR at the present
author’s department. Of this population, 75 consecutive
patients (19.5%), who had severe AS or severe AR asso-
ciated to reduced LV function (LVEF < 40%) were in-
cluded. Concomitant coronary artery bypass graft
(CABG) for angina pectoris secondary to coronary artery
stenosis was not excluded. Patients were excluded if they
had a history or clinical evidence of previous acute myo-
cardial infarction (AMI), combined valvular operations
other than AVR, redo aortic valve surgery or were < 18
years old.
All patients underwent transthoracic echocardiography
(TTE) at the admission to the hospital by an experienced
cardiologist. Measurements of the LV dimensions were
made from 2D TTE images in the parasternal long axis
view and EF was calculated by modification of simp-
son’s method with two apical views. Aortic valve hemo-
dynamics was assessed by Doppler echocardiographic
examination. The maximal trans-aortic valve gradient
was calculated from the peak aortic Doppler velocity by
the modified Bernouilli equation and mean aortic pres-
sure gradient was also measured by the similar method.
AVA was calculated with the continuity equation. The
grade of AR was evaluated with color Doppler.
2.2. Operative Technique
Standard anesthesia and surgical techniques were em-
ployed. Moderate hypothermia (32˚C) cardiopulmonary
bypass (CPB) was used in all patients, with classic ap-
proach via a median sternotomy. Myocardial protection
technique varied during the study period. From 1994
until 2002, we employed antegrade intermittent crystal-
loid cardioplegia (cold saint Thomas II). But since 2003,
intermittent hyperkalemia cold blood cardioplegia was
administered in most cases. When CABG was required,
proximal anastomoses were performed before removal of
the aortic cross clamp.
Postoperative and follow-up data:
Hospital mortality was defined as death at any time be-
fore discharge from the hospital. Death attributed to CHF,
AMI, arrhythmia and neurological complications were
considered as cardiovascular deaths, as was sudden death
without specific cause. Most of the survivors were pro-
spectively investigated by a visit or telephone interview,
including physical examination, chest X radiogram and
echocardiogram.
2.3. Statistics
Statistical analysis was performed using the statistical
software package of social science (SPSS 11.5, Chicago,
Illinois, USA). All data were expressed as mean ± stan-
dard deviation, median or prevalence as appropriate.
Continuous variables were analyzed by the student’s t
test when the variable distribution was found to be nor-
mal; otherwise a non parametric Mann-Whitney U test
was used. Categorical variables were compared between
groups by the χ² test for independence or by Fisher’s
exact test when appropriate. The survival curve was ana-
lyzed using the non parametric Kaplan-Meier test. A p
value of 0.05 or less was considered to be significant.
3. RESULTS
Preoperative patient’s characteristics and operative data
are summarized in Ta ble s 1 and 2. Seventy five patients
Table 1. Preoperative characteristics of the patient population
and comparison between AS and AR.
Variable AS (n = 40) AR (n = 35)p
Age (years) 56.5 ± 9.3 47.9 ± 110.001
Sex (Female/Male) 5/30 8/40 0.41
BMI (Kg/m²) 24.8 ± 3 23.7 ± 4.20.2
NYHA III-IV (%) 88% 75%
Diabetes (n, %) 8 (20%) 1 (2%) 0.024
Hypertension (n, %) 8 (20%) 5 (14%) 0.38
Renal failure (n, %) 8 (20%) 3 (8.5%) 0.36
PVD (n, %) 7 (17.5%) 2 (5.7%) 0.11
LVEDD (mm) 63.6 ± 8.9 77.6 ± 9.80.001
LVESD (mm) 50.2 ± 9.2 62 ± 8.8 0.001
Ejection fraction (%) 32.2 ± 8 33.8 ± 6.70.34
Aortic valve area (cm²) 0.65 ± 0.15 - -
Mean TVG 42 ± 12.9 - -
Aortic regurgitation
- Grade III (n, %) 0 13 (37.1%)-
- Grade IV (n, %) 0 22 (62.9%)-
PAP Systolic pressure (mmHg) 49.6 ± 15.6 48.8 ± 14.60.85
CT index 0.58 ± 0.05 0.62 ± 0.050.013
Euroscore 7.15 ± 3.8 5.77 ± 2.90.09
Logistic regression Euroscore 11.8 ± 10 9.04 ± 8.70.23
Creatinine (mg/dl) 12 ± 4 14 ± 7.4 0.15
Angina pectoris (n, %) 10 (25%) 5 (14.2%)
BMI: body mass index, NYHA: New York Heart Association, PVD: pul-
monary vascular disease, LVEDD: left ventricular end-diastolic diameter,
LVESD: left ventricular end-systolic diameter, TVG: transvalvular gradient,
PAP: pulmonary artery pressure, CT: cardio-thoracic.

M. A. Houssa et al. / World Journal of Cardiovascular Diseases 3 (2013) 543-550 545
Table 2. Comparison of perioperative data between AS and AR.
Variable AS (n = 40) AR (n = 35)p
Non elective operation (n, %) 8 (20) 5 (14.2) 0.36
CPB time (min) 96.4 ± 35 101 ± 46 0.63
X clamp time (min) 66 ± 25 66.7 ± 26 0.93
Operation time (min) 179.5 ± 60.8 204.7 ± 67 0.16
Aortic prosthesis size (mm) 22.3 ± 1.5 23.4 ± 1.3 0.002
Concomitant CABG (n, %) 7 (17.5%) 1 (2.9%) 0.11
Aortic enlargement (n, %) 1 (2.5%) 0 0.52
Mechanical ventilation time (h) 18 (8 - 24) 13.5 (6.25 - 25)0.43
Mechanical ventilation > 48h (n,
%)
8 (20%) 8 (22.8%) 0.77
ICU stay (days) 48 (30.7 - 76.5) 48 (24 - 72)0.19
Hospital stay (days) 13.12 ± 7 10.7 ± 2.3 0.066
LOS n (%) 16 (40%) 13 (37%) 0.53
IABP n (%) 3 (7.5%) 3 (8.5%) 0.58
Reoperation for bleeding (n, %) 0 (0%) 1 (2.5%) 0.54
Deep wound infection (n, %) 3 (7.5%) 2 (5.7%) 0.59
New renal failure (n, %) 4 (10%) 5 (14.2%) 0.65
Hospital mortality (n, %) 5 (12.5%) 6 (17.6%) 0.57
Aortic root repair (n, %) 1 (2.5%) 0
CPB: cardiopulmonary bypass, X clamp: cross clamping, CABG: coronary
artery bypass graft, ICU: intensive care unit, LOS: low output syndrome,
IABP: intra-aortic balloon pump.
with LVEF < 40% were identified. This cohort represents
19.5% of the total number of patients who underwent
isolated AVR at our institution over the period of the
study. Forty patients (53.4%) had severe AS and thirty
five (46.6%) had AR. The two groups were similar with
most preoperative and operative characteristics. The AS
patients were significantly older and had also a higher
incidence of diabetes. But the AR had large diameters of
LV and more advanced symptoms as indicated by NYHA
functional class. The most common etiology in both
groups was rheumatic disease. Seventy three patients
receiving mechanical prosthesis were implanted in the
AS group. Eight patients (10.8%) required concomitant
CABG (7 in AS and 1 in AR). No differences regarding
the need for excessive inotropic supports or intra-aortic
balloon pump or other complications were observed.
Postoperative Course, Early and Late Outcome
The 30-day mortality was 14.6% (11/75). All patients
died of low cardiac output syndrome (LOS) and multi-
organ failure (MOF). There was no significant difference
in the operative mortality between the two groups: 12.5%
(5/40) in the AS patients and 17.6% (6/35) in the AR
patients, p = 0.57.
The postoperative complications were similar between
the two groups. The mean aortic prosthesis size was dif-
ferent (AS: 22.3 ± 1.5 vs AR: 23.4 ± 1.3, p = 0.002).
Among survivors, the survival rate at 1, 5 and 10 years
was respectively 94.4%, 87% and 80% in AS group and
95.2%, 93% and 89% in AR group.
In the AS group mean follow-up time was 31.8 ± 22.
Three patients died during follow-up; among those, one
died from hemorrhagic stroke, one from prosthetic valve
thrombosis and one from cancer.
In the AR group, the mean follow-up period was 61.8
± 45 months. During follow-up, 3 patients died: of those,
two from CHF and one from severe sepsis and MOF
secondary to late prosthetic valve endocarditis.
Clinical and echocardiographic follow-up was com-
plete 79% among survivors. Symptomatic improvement
was noted in most of the survivors (Table 3). Eighty one
percent (81%) were severely symptomatic (FC NYHA
III-IV) before surgery and only 4.7% after control.
There is the significant change in NYHA functional
class (Figure 1). In AS, preoperative NYHA class: 2.79
± 0.7 vs 1.38 ± 0.49 during follow-up, p = 0.001. In AR,
preoperative NYHA class was 2.93 ± 0.9 vs 1.48 ± 0.75
during follow-up, p = 0.001.
Most patients showed a positive change of ventricular
function ejection fraction (AS: 32.1% ± 8% vs 49% ±
14.7%, p < 0.001, AR: 33.8% ± 6.7% vs 51.2% ± 10.9%,
p = 0.001). Left ventricular diameters decreased in the
both groups (Table 4).
4. DISCUSSION
The current study shows that AVR can be performed with
excellent late outlook. Similarly, there is a real im-
provement in functional status and LV function recovery,
but the operative mortality still remains high. Some ef-
forts must be undertaken in medical management.
Ta bl e 3 . Comparison between outcomes parameters of AS and
AR group.
Variable AS (n = 40) AR (n = 35)p
Survivors (n, %) 35/40 (87.5%) 29/35 (82.8%)NS
Lost 8/35 5/29 NS
Controlled patients (n, %)27/35 (77%) 24/29 (82%)NS
Follow-up period (months)31.8 ± 22 61.8 ± 45 0.017
NYHA class
- I (n, %) 16 (59.3%) 16 (69.6%)NS
- II (n, %) 10 (37%) 4 (17.4%) NS
- III (n, %) 1 (3.7%) 1 (4.3%) NS
- IV (n, %) 0 2 (8.7%) NS
CTI (%) 0.52 ± 0.04 0.54 ± 0.060.09
LVEDD (mm) 53.5 ± 8.8 57 ± 8.9 0.93
LVESD (mm) 38.2 ± 9.9 38.4 ± 12.30.5
SF (%) 26.6 ± 6.3 28 ± 6.5 0.9
EF (%) 49 ± 14.7 51.2 ± 10.90.26
Late death (n, %) 3/35 (8.57) 3/29 (10.3) NS
NYHA 1.38 ± 0.49 1.26 ± 0.560.5
CTI: cardio-thoracic index, LVEDD: left ventricular end-diastolic diameter,
LVESD: left ventricular end-systolic diameter, SF: shortening fraction, EF:
ejection fraction, NYHA: New York Heart Association.

M. A. Houssa et al. / World Journal of Cardiovascular Diseases 3 (2013) 543-550 546
Figure 1. Kaplan-Meier survival plot after aortic valve re-
placement for patients with poor left ventricular function.
Table 4. Comparison of preoperative and postoperative pa-
rameters in AS and AR group.
AS (n = 40) AR (n = 35)
Variable Preop (40)
Postop
(27) p Preop (35) Postop (23) p
NYHA 2.79 ± 0.7 1.38 ± 0.490.001 2.93 ± 0.9 1.48 ± 0.75 0.001
CT Index 0.58 ± 0.05 0.52 ± 0.040.001
0.62 ± 0.05 0.54 ± 0.06 0.001
LVESD
(mm) 50.2 ± 9.2 38.2 ± 9.9 0.001 62.1 ± 8.8 38.4 ± 12.3 0.001
LVEDD
(mm) 63.6 ± 8.9 53.5 ± 8.8 0.001 77.6 ± 9.8 57 ± 8.90.001
SF (%) 17.6 ± 4.9 26.6 ± 6.3 0.002 16.8 ± 4.7 28 ± 6.50.001
EF (%) 32.1 ± 8 49 ± 14.7 0.001 33.8 ± 6.7 51.2 ± 10.9 0.001
Follow-up
time (months) - 31.8±22 - - 61.8 ± 450.017
NYHA: New York Heart Association, CTI: cardio-thoracic index, LVESD:
left ventricular end-systolic diameter, LVEDD: left ventricular end-diastolic
diameter, SF: shortening fraction, EF: ejection fraction.
Despite improvements in surgery, cardiology and an-
esthesiology over time, there is still continuing dilemmas
concerning aortic valve replacement in patients with im-
paired left ventricular systolic function. LV dysfunction
is a major prognostic factor of both the early and late
outcome after surgery [5-11].
The ACC/AHA practice guidelines recommend AVR
for severe aortic regurgitation patients presenting with
LV dysfunction or cardiac symptoms [12]. But the most
perplexing problem regarding the management of the
patients with chronic AR is the optimal timing of surgery.
The vast majority of patients are asymptomatic for many
years during which the systolic function deteriorates
progressively. By the time of symptoms develop, some
patients have already developed irreversible myocardial
damage and hence respond poorly after AVR. On the
other hand, patients with critical AS and severe LV dys-
function constitute a more heterogeneous and even more
challenging group.
Impaired function has long been recognized as a pre-
dictor of adverse outcome after AVR, but the impact of
valvular pathophysiology has not been clearly defined
[11,13,14].
Patients with AS and low EF represent a minority (5 to
10%) among patients with AS [15]. AS imposes an in-
creased after-load on the LV, increasing left ventricular
wall tension with subsequent ventricular hypertrophy.
Uncorrected AS eventually leads to myocardial dysfunc-
tion as the hypertrophied myocardium cannot compen-
sate the increased wall stress. The compensatory mecha-
nism according to the Frank-Starling relation-ship fails,
increasing degrees of LV dilatation result, and systolic
function declines [14,16,17].
Unlike AS, the patho-physiology of AR involves both
volume and pressure after-load of the LV. Eccentric ven-
tricular hypertrophy occurs in response to increased LV
end-diastolic wall stress [14]. AS long-standing AR
evolves, the ventricle dilates and compensates through a
process called “after-load mismatch, pre-load reserve”
introduced by John Ross [16,18]. Pre-load is increased as
to maintain forward flow via the Frank-starling relation-
ship. However, when preload reserve reaches a limit, the
ventricle undergoes a progressive decline in pump func-
tion [14,19].
Operative mortality in the current study was 12.5%
among AS patients, it correlates with the results reported
in contemporary study in which operative mortality rate
ranged from 8% to 21% [11,20-23]. This mortality does,
however, contrast with those reporters in other published
studies: Chukwuemeka [24] 1.5% bevilacqua [25] 5.7%,
Rediker [26] 0%.
The operating results of AVR for AS patients with LV
dysfunction is obviously affected by many variables.
Many published reports included patients undergoing
concomitant CABG [1].
Elevated creatinine, NYHA class III-IV and LV sys-
tolic diameters > 54 mm as independent parameter of
mortality in a patient with both AS and AR [20-22].
Sharony et al. [11], however found that renal failure and
advanced age are independent risk factors for mortality.
In our death patients with AS (5/40), 3 have EF < 35%
and mean transvalvular gradient < 30 mmHg, and
creatinine level > 200 µmol/l. all deaths have been in
functional class III-IV, but only one patient had com-
bined CABG.
Severe pulmonary hypertension (PHT) in severe AS
portends a poor prognosis with a reported prevalence as
high as 29% [27]. AVR was also associated with higher
than usual operative mortality. Malouf J [28] 16% and
Spencer Melky J [29] 9%. In our study, 3/5 deaths have

M. A. Houssa et al. / World Journal of Cardiovascular Diseases 3 (2013) 543-550 547
severe PHT (PAPS > 60 mmHg).
In the opposite, an improvement in functional class
was noted in most survivors. 88% were in FC NYHA III-
IV prior to surgery, after a follow-up, only 4.7% re-
mained in NYHA III-IV. In addition EF increased sig-
nificantly of approximately 17% in both groups. Clearly,
patients exhibit better clinical improvement an excellent
long-term survival. These data are in agreement with
most authors [21-24].
It is now clear that patients with critical AS and im-
paired LV function fall in roughly in to one of three
groups who have two different reasons for LV dysfunc-
tion. Afterload mismatch, which generally respond well
to surgery and the other two groups consist of patients
who have low transvalvular gradients (TVG). These pa-
tients are assumed to have coexisting cardiomyopathy in
addition to myocardial dysfunction, and the effects of
AVR are less beneficial. Some recent studies have fo-
cused on this subgroup [15,30-33].
Dobutamine stress echocardiography (DSE) has been
proposed as a method able to evaluate the tightness of
the stenosis, the severity of the LV dysfunction and its
reversibility. According to a recent study, patients with
LV contractile reserve have relatively low operative risk
(<5%), whereas, those without contractile reserve have a
high operative mortality (11% - 22%) [30,34,35]. But
this approach has several limitations. Although the ab-
sence of contractile reserve on DSE is related to high
operative mortality, it does not predict the absence of LV
EF recovery in patients surviving to AVR. Most authors
support the concept that the surgery should not be com-
plicated on the basis of absence of contractile reserve
alone [36].
In AR group, most of patients may not present until
they have advanced heart failure with severe LV dys-
function and ventricular dilatation, so they always pre-
sented difficult management issue. Particularly, contro-
versies exit about the questions of whether the risk of
surgery is too high, and whether any improvement in LV
EF and survival can’t realistically be expected after suc-
cessful AVR. Currently, this mortality rate ranges be-
tween 6% to 14% among patients with AR and poor
LVEF [37-39].
In the modern area, there are many reasons that pa-
tients fare better after surgery: medical management im-
proved substantially with use of angiotensin-converting
inhibitors (ACI) and β blockers. Operative myocardial
protection becomes more sophisticated.
Compared to old prosthesis that are known to have a
high gradient replacement heart valves have considerably
improved with low gradient prosthesis and mechanical
valves readily available, perioperative management now
include use of newer inotropes such as the phosphor
diesterase inhibitors milrinone. Our analysis shows that
patients who died (6 cases) in the early outcome, have
many predictor factors of worse operative risk as 4/6
have LV ED > 80mm, markedly reduced EF < 30%, se-
vere PHT (SPAP > 60 mmHg) and 5/6 death were in
NYHA FC III-IV. These candidate patients were declared
as the patients with the greatest perioperative risk of
death [20,39].
Despite excessive operative modality, the FC status
and EF of most patients improve after surgery. We found
these results in line with the literature [21,38,40]. Thus,
patients suffering from AR and markedly low EF, en-
larged LV diameters derived benefit from surgery com-
pared with expected evolution [21,41], so they should
not be considered a contraindication to AVR. Other in-
vestigators have also observed partial improvement in EF
and persistent dysfunction following surgery in AR as
well as AS patients [40,42-44]. Excessive LV hypertro-
phy (LV mass index > 200% of normal) is the main fac-
tor that correlates with deterioration of diastolic function
during late outcome. This funding is supported by many
authors [33,45-47].
But some author’s observations showed that LV dilata-
tion and LV systolic dysfunction persist if LV diameters
are extremely enlarged (LVEDD ≥ 80 mm, LVESD ≥ 59
mm) [48-51].
5. STUDY LIMITATIONS
Although the data were collected prospectively, this arti-
cle is prone to the inherent biases of its retrospective
nature.
This is a small group of patients especially those who
have markedly reduced EF (5% of AS and 35% of AR)
[15,52].
It is difficult to analyze our results due to the relatively
small number of patients.
Operative mortality in our study is relatively high
compared to recent reports.
Logically, the mortality rate must decrease because
our patients are younger and they have few associated
comorbidities. The main reason to explain this no-good
result is the lateness of developing countries in medical
management of this categorical patient, so our findings
are compared to those articles published before 1985 in
developed countries. We have no idea about prosthesis-
patient mismatch, because patients with PPM have worse
functional class, reduced regression of left ventricular
hypertrophy, and more adverse cardiac events after aortic
valve replacement compared to patients without PPM [53,
54].
Additionally, our patients were quite heterogeneous in
terms of age, etiology of rheumatic disease and fol-
low-up duration and this may have influenced the results.
Dobutamine stress echocardiography (DSE) was not
performed because it does not seem to be a useful tool in

M. A. Houssa et al. / World Journal of Cardiovascular Diseases 3 (2013) 543-550 548
risk stratification, but when there is a high operative risk,
we better try to inform the patient.
The small sample size and the limited number of
deaths observed in early outcome and during the follow-
up limit the quality of results and reduce the statistical
power for the identification of predictive factors.
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