Outcome after aortic valve replacement in octogenarians

Impact of treatment choice on the outcome of patients proposed for transcatheter aortic valve implantation

AIMS

Transcatheter aortic valve implantation (TAVI) is a new option for patients with severe aortic stenosis at high surgical risk. We compared the clinical outcome of patients referred for TAVI and subsequently treated with TAVI, surgical aortic valve replacement (SAVR), balloon aortic valvuloplasty (BAV), or medical management (MM).

METHODS AND RESULTS

All consecutive patients (n=166, EuroSCORE 24.9 ± 13.9%) referred for TAVI to our two centres were enrolled in a prospective registry and were assigned to SAVR (n=21), TAVI with the CoreValve prosthesis (n=75), BAV (n=20), or MM (n=50) by a multi-specialty team. The primary endpoint was 6-month cardiac mortality. Patients undergoing BAV had a significantly higher EuroSCORE (33.6 ± 15.9%; p=0.01). Median follow-up time was nine months (interquartile range 4.5-12.4 months). Six-month freedom from cardiac death was 81.0 ± 8.6%, 92.0 ± 3.1%, 72.9 ± 10.5%, and 72.7 ± 6.5% for SAVR, TAVI, BAV, and MM groups, respectively. Freedom from major cardiac and cerebrovascular events was 76.2 ± 9.3%, 83.9 ± 4.3%, 72.9 ± 10.5%, and 65.6 ± 6.8% for SAVR, TAVI, BAV, and MM groups, respectively.

CONCLUSIONS

With respect to medical management and BAV, TAVI was associated with lower cardiac mortality at six months. Clinical outcome after TAVI was similar to that of less sick patients undergoing SAVR.

Apico-Aortic Conduit for severe aortic stenosis: Technique, applications, and systematic review

Patients referred for aortic valve replacement are often elderly and may have increased surgical risk associated with ascending aortic calcification, left ventricular dysfunction, presence of coronary artery disease, previous surgery, and/or presence of several co-morbidities. Some of these patients may not be considered candidates for conventional surgery because of their high risk profile. While transcatheter aortic valve replacement constitutes a widely accepted alternative, some patients may not be eligible for this modality due to anatomic factors. Apico-Aortic Conduit (AAC) insertion (aortic valve bypass surgery) constitutes a possible option in those patients. Apico-Aortic Conduit is not a new technique, as it has been used for decades in both pediatric and adult populations. However, there is a resurging interest in this technique due to the expanding scope of elderly patients being considered for the treatment of aortic stenosis. Herein, we describe our surgical technique and provide a systematic review of recent publications on AAC insertion, reporting that there is continued use and several modifications of this technique, such as performing it through a small thoracotomy without the use of the cardiopulmonary bypass.

Midterm outcomes of rapid, minimally invasive resection of acute type A aortic dissection in octogenarians

BACKGROUND

We previously reported the development of a new surgical technique, called the "less invasive quick replacement" technique, for treating type A acute aortic dissection. This study examines the midterm outcome and postoperative quality of life of octogenarian patients who underwent less invasive quick replacement.

METHODS

During the last 3 years, 27 patients underwent less invasive quick replacement. The average age of the patients at the time of onset was 81.7 years old. During open distal anastomosis with a rectal temperature of 28 degrees C without any cerebral perfusion, circulating blood in the cardiopulmonary bypass circuit was warmed to 40 degrees C. As soon as the distal anastomosis was completed, rapid rewarming was initiated by 40 degrees C blood perfusion. We assessed the midterm outcomes in terms of survival and cardiovascular event-free rates, patency of the distal false lumen, aortic regurgitation, and cognitive disorders.

RESULTS

The durations of circulatory arrest, cardiopulmonary bypass, overall operation, postoperative mechanical ventilation, and hospital stay were 18.7 minutes, 82.8 minutes, 143.4 minutes, 13.0 hours, and 12.2 days, respectively. Hospital mortality rate was 3.7% (1 patient). There were no incidences of brain damage, renal failure, or respiratory failure. At the time of this study, 25 of the patients were doing well and visiting the outpatient clinic, and 22 of them scored more than 20 points on the Mini-Mental State Examination, indicating no development of dementia. Midterm computed tomography scans detected the patent false lumen in 11.5%. No aortic regurgitation was found in the echocardiography. Actuarial survival and cardiovascular event-free rates at 3 years were 96.2% and 83.0%, respectively.

CONCLUSIONS

The less invasive quick replacement technique is safe and effective. It is a very attractive option that can contribute to maintaining a long-term good quality of life for octogenarians with type A acute aortic dissection.

Job Matters

Background— Percutaneous aortic valve replacement (PAVR) for aortic stenosis is an attractive alternative to operative valve replacement. Several devices are evaluated, but their efficacy and safety are critically discussed. An interdisciplinary approach with collaboration of cardiac surgeons and cardiologists is widely requested. We analyzed how cardiologists and cardiac surgeons assess the possibilities and risks of PAVR and whether there are substantial differences between the judgments of these 2 groups.

Methods and Results— Fifty-one cardiologists and 54 cardiac surgeons from German hospitals completed an online questionnaire consisting of 11 questions dealing with typical risks and benefits of PAVR. Answers to all questions differed significantly between surgeons and cardiologists. Risks as impaired hemodynamic outcome, paravalvular leakage, or embolic events were deemed higher for PAVR than for an operation from both groups, but cardiologists rated those risks significantly lower than cardiac surgeons ( P <0.01 for all questions). A regression analysis with a latent variable approach for possible advantages of PAVR (like minor operative trauma, faster recovery, less pain) showed that the fact of being a cardiologist has a significant impact on the rating of PAVR advantages ( r =0.719, P <0.01), whereas personal experience showed no significant effect.

Conclusions— Cardiologists and cardiac surgeons agree on possible risks and advantages of PAVR, but the extent differs significantly between the 2 groups. Cardiologists have a far more optimistic view of PAVR and are likely to favor an interventional approach. More and better evidence based information may help to overcome group related prejudices.

Aortic valve replacement in octogenarians: utility of risk stratification with EuroSCORE

BACKGROUND

With the advent of percutaneous valve implantation, an increasing amount of interest is being expressed in outcomes of conventional aortic valve replacement (AVR) in elderly patients. We evaluated characteristics and outcomes of elderly patients undergoing isolated AVR with a particular focus on the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk stratification.

METHODS

All patients aged 80 years or older (n = 282) undergoing isolated AVR between November 1995 and June 2006 at our institution were reviewed according to logistic EuroSCORE (ES(log)) risk stratification. Surgical risk was defined as low risk (ES(log) < or = 10% [n = 107]), moderate risk (10% < ES(log) < 20% [n = 103]), and high risk (ES(log) > or = 20% [n = 72]). Patient age was 82 +/- 2 years (low risk), 82.7 +/- 2.7 years (moderate risk), and 83.6 +/- 3.1 years (high risk), respectively (p < 0.05). Mean ES(log) predicted risk of mortality was 7.3% +/- 1.4% (low risk), 13.7% +/- 2.5% (moderate risk), and 33.0% +/- 11.5% (high risk; p < 0.05). Follow-up was 99.7% complete.

RESULTS

In-hospital mortality was 7.5% (low risk), 12.6% (moderate risk), and 12.5% (high risk; p = 0.4). One-year survival was 90%, 78%, and 69% (p = 0.002); 5-year survival was 70%, 53%, and 38% (p = 0.05); and 8-year survival was 38%, 33%, and 21% (p = 0.017), for low-, moderate-, and high-risk patients, respectively. Independent predictors for in-hospital mortality were pulmonary hypertension and urgent indication for surgery. Cox regression predictors of medium-term survival were congestive heart failure, urgent timing, previous stroke or transient ischemic attack, and EuroSCORE stratum.

CONCLUSIONS

Aortic valve replacement can be performed in the elderly population with acceptable outcomes. EuroSCORE risk stratification is imprecise for prediction of perioperative mortality among octogenarian AVR patients, but may be useful for predicting mortality during medium-term follow-up.

Isolated aortic valve replacement in North America comprising 108,687 patients in 10 years: changes in risks, valve types, and outcomes in the Society of Thoracic Surgeons National Database

OBJECTIVE

More than 200,000 aortic valve replacements are performed annually worldwide. We describe changes in the aortic valve replacement population during 10 years in a large registry and analyze outcomes.

METHODS

The Society of Thoracic Surgeons National Database was queried for all isolated aortic valve replacements between January 1, 1997, and December 31, 2006. After exclusion for endocarditis and missing age or sex data, 108,687 isolated aortic valve replacements were analyzed. Time-related trends were assessed by comparing distributions of risk factors, valve types, and outcomes in 1997 versus 2006. Differences in case mix were summarized by comparing average predicted mortality risks with a logistic regression model. Differences across subgroups and time were assessed.

RESULTS

There was a dramatic shift toward use of bioprosthetic valves. Aortic valve replacement recipients in 2006 were older (mean age 65.9 vs 67.9 years, P < .001) with higher predicted operative mortality risk (2.75 vs 3.25, P < .001); however, observed mortality and permanent stroke rate fell (by 24% and 27%, respectively). Female sex, age older than 70 years, and ejection fraction less than 30% were all related to higher mortality, higher stroke rate and longer postoperative stay. There was a 39% reduction in mortality with preoperative renal failure.

CONCLUSIONS

Morbidity and mortality of isolated aortic valve replacement have fallen, despite gradual increases in patient age and overall risk profile. There has been a shift toward bioprostheses. Women, patients older than 70 years, and patients with ejection fraction less than 30% have worse outcomes for mortality, stroke, and postoperative stay.

Long-term outcomes after isolated aortic valve replacement in octogenarians: a modern perspective

BACKGROUND

With the recent advent of percutaneous valve therapy, an increased need for the evaluation of outcomes after open aortic valve replacement (AVR) in elderly patients is warranted. This study compares the short- and long-term survival outcomes of octogenarians after AVR with younger age groups in the modern surgical era.

METHODS

A retrospective review was performed on patients who underwent isolated, primary AVR from 1996 to 2006 at the Emory Healthcare Hospitals. Five-hundred fifteen patients were divided into three age groups: 60 to 69 (n = 206), 70 to 79 (n = 221), and 80 to 89 years of age (n = 88). Outcomes were compared among the age groups using logistic regression and analysis of variance techniques. Long-term survival between age groups was compared using the Cox proportional hazards model. Kaplan-Meier plots were used to determine survival rates.

RESULTS

The groups were similar with respect to in-hospital mortality (p = 0.66) and hospital length of stay (p = 0.08). Preoperative predictors of in-hospital mortality included stroke (odds ratio [OR] 5.36), chronic lung disease (OR 4.51), and renal failure (OR 1.39). As expected, age significantly impacted long-term survival (hazard ratio [HR] 1.06). Other predictors of long-term survival included stroke (HR 2.15), current smoker (HR 2.03), diabetes (HR 1.53), and renal failure (HR 1.4). The Kaplan-Meier estimate of median survival for octogenarians was 7.4 years.

CONCLUSIONS

In the modern era, octogenarians have acceptable short- and long-term results after open AVR. Comparisons of less invasive techniques for AVR should rely on outcomes based in the modern era and decisions regarding surgical intervention in patients requiring AVR should not be based on age alone.

Quality of Life after Mechanical vs. Biological Aortic Valve Replacement

To assess the quality of life after biological and mechanical aortic valve replacement, data of 136 patients were assessed retrospectively after 2 years of follow-up. Bioprostheses were implanted in 53 patients with a mean age of 74 years, and mechanical prostheses were used in 83 with a mean age of 64 years; there were 47 women and 89 men. Quality of life was evaluated using the Short Form 36-Item Health Survey questionnaire. Physical function scores were significantly better in patients with a mechanical prosthesis. Mental health indices were identical in both groups. Younger patients with mechanical valves and older patients with biological valves had significantly better item scores. In all age groups, men tended to have better scores than women, but a significant difference was noted only in the physical functioning index. The quality of life in patients with mechanical and biological valves was similar at 2 years postoperatively.

Concomitant ablation of atrial fibrillation in octogenarians: an observational study

BACKGROUND

Cardiac surgery is increasingly required in octogenarians. These patients frequently present atrial fibrillation (AF), a significant factor for stroke and premature death. During the last decade, AF ablation has become an effective procedure in cardiac surgery. Because the results of concomitant AF ablation in octogenarians undergoing cardiac surgery are still not clear, we evaluated the outcome in these patients.

METHODS

Among 200 patients undergoing concomitant AF ablation (87% persistent AF), 28 patients were >/= 80 years (82 +/- 2.4 years). The outcome was analysed by prospective follow up after 3, 6, 12 months and annually thereafter. Freedom from AF was calculated according to the Kaplan-Meier method.

RESULTS

Octogenarians were similar to controls regarding AF duration (48 +/- 63.2 versus 63 +/- 86.3 months, n.s.) and left atrial diameter (49 +/- 6.1 versus 49 +/- 8.8 mm, n.s.), but differed in EuroSCORE (17.3 +/- 10.93 versus 7.4 +/- 7.31%, p < 0.001), prevalence of paroxysmal AF (25.0 versus 11.0%, p = 0.042) and aortic valve disease (67.8 versus 28.5%, p < 0.001). ICU stay (8 +/- 16.9 versus 4 +/- 7.2 days, p = 0.027), hospital stay (20 +/- 23.9 versus 14 +/- 30.8 days, p < 0.05), and 30-d-mortality (14.3 versus 4.6%, p = 0.046) were increased. After 12 +/- 6.1 months of follow-up (95% complete), 14 octogenarians (82%) and 101 controls (68%, n.s.) were in sinus rhythm; 59% without antiarrhythmic drugs in either group (n.s.). Sinus rhythm restoration was associated with improved NYHA functional class and renormalization of left atrial size. Cumulative freedom from AF demonstrated no difference between groups. Late mortality was higher in octogenarians (16.7 versus 6.1%, p = 0.065).

CONCLUSION

Sinus rhythm restoration rate and functional improvement are satisfactory in octogenarians undergoing concomitant AF ablation. Hence, despite an increased perioperative risk, this procedure should be considered even in advanced age.

Percutaneous and Minimally Invasive Valve Procedures

The incidence of valvular heart disease is expected to increase over the next several decades as a large proportion of the US demographic advances into the later decades of life. At the same time, the next several years can be anticipated to bring a broad transition of surgical therapy to minimally invasive (minithoracotomy and small port) access and the more gradual introduction of percutaneous approaches for the correction of valvular heart disease. Broad acceptance of these technologies will require careful and sometimes perplexing comparisons of the outcomes of these new technologies with existing standards of care. The validation of percutaneous techniques, in particular, will require the collaboration of cardiologists and cardiac surgeons in centers with excellent surgical and catheter experience and a commitment to trial participation. For the near term, percutaneous techniques will likely remain investigational and will be limited in use to patients considered to be high risk or to inoperable surgical candidates. Although current-generation devices and techniques require significant modification before widespread clinical use can be adopted, it must be expected that less invasive and even percutaneous valve therapies will likely have a major impact on the management of patients with valvular heart disease over the next several years.

High-risk aortic valve replacement: are the outcomes as bad as predicted?

BACKGROUND

Percutaneous aortic valve replacement (PAVR) trials are ongoing in patients with an elevated European System for Cardiac Operative Risk Evaluation (EuroSCOREs), patients believed to have high mortality rates and poor long-term prognoses with valve replacement surgery. It is, however, uncertain that the EuroSCORE model is well calibrated for such high-risk AVR patients. We evaluated EuroSCORE prediction vs a single institution's surgical results in this target population.

METHODS

From January 1996 through March 2006, 731 patients with EuroSCOREs of 7 or higher underwent isolated AVR. In this cohort, 313 (42.8%) were septuagenarians, 322 (44.0%) were octogenarians or nonagenarians, 233 (31.9%) had had previous cardiac procedures, 237 (32.4%) had atheromatous aortas, and 127 (17.4%) had cerebrovascular disease. A minimally invasive approach was used in 469 (64.2%). Data collection was prospective. Long-term survival was computed from the Social Security Death Benefit Index.

RESULTS

The mean EuroSCORE was 9.7 (median, 10), and the mean logistic EuroSCORE was 17.2%. Actual hospital mortality was 7.8% (57 of 731). Multivariate analysis showed ejection fraction of less than 0.30 (p = 0.002; odds ratio [OR], 3.13), chronic obstructive pulmonary disease (p = 0.019; OR, 2.14), and peripheral vascular disease (p = 0.048; OR, 2.13) were significant predictors of hospital mortality. Complication(s) occurred in 73 patients (9.9%). Freedom from all-cause death (including hospital mortality) was 72.4% at 5 years (n = 152). Age (p < 0.001), previous cardiac operations (p < 0.014; OR, 1.51), renal failure (p < 0.002; OR, 2.37), and chronic obstructive pulmonary disease (p < 0.007; OR, 1.30) were predictors of worse survival.

CONCLUSIONS

Logistic EuroSCORE greatly overpredicts mortality in these patients. Five-year survival is good, unlike suggestions from earlier EuroSCORE analyses. This raises concern about unknown long-term percutaneous prosthesis function. Clinical trials for these patients must include randomized surgical controls and have long-term end points.

Combined cardiac surgical procedures in octogenarians: operative outcome

INTRODUCTION

The number of patients with an indication for cardiac surgery in their ninth decade of life is increasing. This study analyses the single-center results with combined and redo cardiac surgical procedures in octogenarians retrospectively.

PATIENTS AND METHODS

Three groups were evaluated: (I) Two hundred and thirty six patients with combined cardiac surgical procedures, mean age 83.1 +/- 2.5 years, 107 male (129 female). Combined aortic valve replacement (AVR) and aorto coronary bypass (ACB) was done in 215, double valve replacement (DVR) in 21. (II) AVR + ACB-group: 215 patients out of group I. (III) Control group consisting of 124 patients with a mean age of 74.1 +/- 2.8 years (range 70-79.9 years) who received combined AVR and ACB. Risk stratification was done using the additive and logistic Euro-score; values are given as mean +/- standard deviation and were compared using either the t-test or the Chi-square test.

RESULTS

The observed mortality in group I was 9.3%. Re-intubation was observed in 10.2% and was one major risk factor for in-hospital mortality. As second risk factor, DVR could be identified. 14.8% required hemodialysis postoperatively, but this affected only the length of stay on intensive care unit (ICU) but not mortality. When comparing group II with group III, mortality was higher (10% vs. 4%), the need for hemodialysis was more frequent (16.3% vs. 4.9%), and the incidence of postoperative psycho-syndromes was also higher (26% vs. 8.1%, all: P < 0.05). The duration of ventilation (2.7 +/- 7.7 vs. 1.6 +/- 4.3 days) and the length of stay on ICU (8.2 +/- 8.8 vs. 5.7 +/- 6.4) were longer without reaching statistical significance (P > 0.05). The Euro-score overestimated the real mortality in all groups.

CONCLUSIONS

Octogenarians requiring combined cardiac surgical procedures required more resources and had a higher in-hospital mortality compared to younger patients. The observed in-hospital mortality was much lower than the predicted justifying the indication for surgical therapy in these patients. Patient selection, however, seems to be important but the Euro-score alone was rather ineffective in predicting poor outcome.

Valve structure and survival in octogenarians having aortic valve replacement for aortic stenosis (+/- aortic regurgitation) with versus without coronary artery bypass grafting at a single US medical center (1993 to 2005)

The purpose of this study was to determine the effect of simultaneous coronary artery bypass grafting (CABG) and valve structure on both early and late survival in octogenarians having aortic valve replacement (AVR) for aortic stenosis (AS) (with or without aortic regurgitation). Although a number of reports are available in octogenarians having AVR for AS, none have described aortic valve structure. Most have limited numbers of patients and few have described late results. We analyzed survival and valve structure in 196 octogenarians having AVR for AS from 1993 to 2005 at Baylor University Medical Center, including 118 (60%) with and 78 (40%) without simultaneous CABG. Sixty-day mortality, which was identical to 30-day mortality, was similar (10% and 11%) in the groups with and without simultaneous CABG. Unadjusted analysis of late survival (up to 13 year follow-up) was not affected by gender (male vs female), aortic valve structure (bicuspid vs tricuspid) or preoperative severity of the AS (transvalvular peak pressure gradient > 50 vs < or =50 mm Hg), or by performance of CABG. Of the 196 patients, 54 (28%) had a congenitally bicuspid aortic valve, and 142 (72%) had a tricuspid aortic valve. In conclusion, gender, valve structure, preoperative severity of the AS, or performance of simultaneous CABG did not effect survival in octogenarians having AVR for AS.

Predictors of mortality after aortic valve replacement

Aortic valve replacement (AVR) is recommended as a standard surgical procedure for aortic valve disease. Still the evidence for commonly claimed predictors of post-AVR prognosis, in particular mortality, appears scant. This systematic review reports on the evidence for predictors of post-AVR mortality, and may be helpful in pre-surgical risk-stratification. In PubMed, we searched for original reports of post-AVR follow-up studies. We assessed the quality of study design and methods with a standardized checklist. Data of the reported predictors of mortality and outcomes were extracted. Twenty-eight studies met our inclusion criteria. Sixteen studies were considered of high quality. There is strong evidence that the risk of early mortality is increased by emergency surgery, while the risk of late mortality is increased with older age and preoperative atrial fibrillation. There is moderate evidence that the risk of early mortality is increased by older age, aortic insufficiency, coronary artery disease, longer cardiopulmonary bypass time, reduced left ventricular ejection fraction (LV-EF), infective endocarditis, hypertension, mechanical valves, preoperative pacing, dialysis-dependent renal failure and valve size; and that the risk for late mortality is increased by emergency surgery and urgency of the operation. There is little evidence for high New York Heart Association class, concomitant coronary artery bypass graft and many other commonly claimed risk factors for post-AVR mortality. The reported evidence on predictors of post-AVR mortality will help for pre-surgical risk-stratification, i.e. to discern patients at high or low risk for early and late post-AVR mortality. Future prognostic studies should take the evidence from this review into account and should focus on derivation of a predictive model for post-AVR survival.

Syncope in the elderly

Syncope is common and costly especially in the elderly. Presentation and prevalence may be different compared with the young. Etiologies can be difficult to confirm but it is not a hopeless morass. The history, physical exam, and ECG have the greatest utility. Additional studies should be used sparingly and based on the initial data. Successful response to treatment is difficult to predict.

[Aortocoronary bypass and cardiac valve surgery]

In Germany, approximately 100,000 patients underwent cardiac surgery in 2005. The most important postoperative problems with prognostic impact for these patients were acute heart failure, acute renal failure, infections, neurological complications, postcardiotomy syndrome, cardiac tamponade and atrial fibrillation. The "EuroSCORE" is a relevant predictor of immediate and long-term outcome in these patients. The patency rates of coronary artery bypass grafts (CABG) are important for the long-term outcome in such surgery. There has been a significant increase in the number of patients aged 80 years and older who are referred for cardiac surgery, which is an outstanding challenge for cardiac surgeons.

Aortic valve surgery in octogenarians: predictive factors for operative and long-term results

OBJECTIVE

To assess factors influencing operative and long-term outcome in octogenarians undergoing aortic valve surgery (AVR).

METHODS

Records of 220 consecutive octogenarians having AVR between 1992 and 2004 were reviewed, and follow-up obtained (99% complete). Of the group (mean age: 82.8 years; 174 females), 142 patients (65%) were in New York Heart Association (NYHA) class III-IV, 22 (10%) had previous myocardial infarction, 11 (5%) had previous coronary artery bypass grafting (CABG), and 8 (4%) had percutaneous aortic valvuloplasty. There were 44 urgent procedures (20%), and additional CABG was performed in 58 patients (26%).

RESULTS

Operative mortality was 13% (9% for AVR, 24% for AVR+CABG). Among the 29 patients who died, 14 (48%) were operated on urgently (32% mortality for urgent procedures). Causes of hospital death were respiratory insufficiency or infection in 16 patients (16/29=55%), myocardial infarction in 8 (28%), stroke in 2 (7%), sepsis in 2 (7%), and renal failure in 1 (3%). Significant postoperative complications were atrial fibrillation in 48 patients (22%), respiratory insufficiency in 46 (21%), permanent atrio-ventricular bloc in 12 (5%), myocardial infarction in 10 (5%), hemodialysis in 4 (2%), and stroke in 4 (2%). Mean hospital and intensive care unit (ICU) stays were 17.6+/-5.2 and 6.9+/-3.4 days, respectively. Multivariate predictors (p<0.05) of hospital death were urgent procedure, associated CABG, NYHA class IV, and percutaneous aortic valvuloplasty. Age, associated CABG, and urgent procedure were predictors of prolonged ICU stay. Mean follow-up was 58.2 months and actuarial 5-year survival was 73.2+/-6.9%. Age, preoperative myocardial infarction, urgent procedure, and duration of ICU stay were independent predictors of late death. Among 130 patients alive at follow-up, 91% were angina free and 81% in class I-II.

CONCLUSIONS

AVR in octogenarians can be performed with acceptable mortality, although significant morbidity. These results stress the importance of early operation on elderly patients with aortic valve disease, avoiding urgent procedures. Associated coronary artery disease is a harbinger of poor operative outcome. Long-term survival and functional recovery are excellent.

Reoperation of the Aortic Valve in Octogenarians

BACKGROUND

Because of increasing life expectancy of patients with heart valve replacement and a limited durability of heart valve bioprostheses, cardiac reoperation becomes necessary in a significant percentage of patients. Reliable data on mortality and risk factors in octogenarians after replacement of aortic valve prostheses are scanty, however.

METHODS

We retrospectively analyzed 71 patients aged 80 years and older who underwent cardiac reoperation of the aortic valve (69 bioprostheses, 2 mechanical prostheses) between 1991 and 2004 at our heart center. Survival rate of the study cohort was compared with a control group of octogenarians matched for age, sex, and year of aortic valve replacement. To assess predictors of 30-day survival and 3-year survival, we performed univariate and multivariate analyses.

RESULTS

Survival rates at 30 days, 1 year, 3 years and 5 years were 83.6%, 76.1%, 70.8%, and 51.3%, respectively. Results did not differ significantly between the study cohort and the controls. Patients with reoperation had an estimated median survival of 5.6 years. Postoperative complications such as low cardiac output syndrome and intestinal failure were the only independent predictors of 30-day survival (p = 0.020 and p = 0.015, respectively). Low cardiac output, intestinal failure, and diabetes mellitus were independent predictors of 3-year survival (p = 0.001 to 0.033).

CONCLUSIONS

Our data demonstrate that it is possible to achieve an acceptable outcome in octogenarians who have reoperation of the aortic valve prosthesis. Early and mid-term survival is predominantly influenced by unexpected postoperative complications and not by preoperative risk factors, with the exception of diabetes mellitus.

Cardiac surgery in the elderly: indications and management options to optimize outcomes

The elderly have increasingly benefited from the advances in cardiac surgical techniques and perioperative care. Compared to the same procedures in younger patients their operations can be more technically demanding and their level of reserve leaves less margin should complications occur. The importance of using realistic indications for operations with a focus on improving the quality of their lives and of optimal preoperative preparation of patients is emphasized.

[Percutaneous cardiac valve replacement: a review]

Surgery is no longer the only technique to replace a cardiac valve. New percutaneous procedures allow aortic or pulmonary valve implantation. Even if the feasibility of these procedures has been proved, cases reported are very rare and selected. This emergent technology is still at an early stage of development and new prospective studies will be necessary to evaluate these procedures correctly before concluding their clinical benefit. At this time surgery remains the gold standard in terms of cardiac valve replacement.

Percutaneous Valve Replacement: Significance of Different Delivery Systems In Vitro and In Vivo

BACKGROUND AND PURPOSE

Percutaneous heart valve replacement is an exciting growing field in cardiovascular medicine yet still with some major problems. Only sophisticated improvement of the instruments could make it a real alternative to conventional surgery. Therefore, the aim of this study was to evaluate different delivery devices for percutaneous heart valve replacement in vitro and in vivo.

METHODS

A catheter prototype designed by our group, and two commercially available devices for the delivery of esophageal stents and aortic endoprostheses, were tested. After in vitro experiments, an ovine animal model of transfemoral pulmonary valve implantation was established using biological valved self-expanding stents. Only the delivery device for aortic endografts (Medtronic, Talent, Santa Rosa, CA, USA) allowed fast in vitro procedures without material fatigue. This device was chosen for the in vivo tests.

RESULTS

Technical success was achieved in 9 of 10 animals (90%). One animal died after perforation of the ventricular wall. Orthotopic pulmonary placement was performed in 6 animals and intentional supravalvular valved stent placement in 3 animals.

CONCLUSIONS

An adequate in vitro model for this evolving field of interventional heart valve replacement is presented. Furthermore, the present study pinpoints the key characteristics that are mandatory for a delivery system in percutaneous pulmonary valve implantation. With regard to the delivery device's ductility observed during this "venous" study, an approach to transfemoral aortic valve implantation seems feasible.