Ten-year experience with aortic valve replacement in 482 patients 70 years of age or older: operative risk and long-term results

Comparison of Outcomes of Asymptomatic Moderate Aortic Stenosis With Preserved Left Ventricular Ejection Fraction in Patients ≥80 Years Versus 70-79 Years Versus <70 Years

Aortic stenosis (AS) is increasingly diagnosed in the aging population with more studies focused on the prognostic outcomes of severe asymptomatic AS. However, little is known about the outcomes of moderate asymptomatic AS in the elderly population. From 2001 to 2020, 738 consecutive patients with asymptomatic moderate AS with preserved left ventricular ejection fraction were studied. They were allocated according to the age group at the index echocardiography: very elderly (≥80 years), elderly (70 to 79 years) and control group (<70 years). The primary study outcomes were aortic valve replacement (AVR), congestive cardiac failure (CCF) and all-cause mortality. Overall, about one-third of the subjects were in the very elderly, elderly and control groups each. The median follow-up duration was 114.2 (interquartile range, 27.0 to 183.7) months. There was significantly higher all-cause mortality in the very elderly group (47.9%) followed by elderly (34.8%) and control group (21.9%). Similarly, there was significantly higher CCF rates in the very elderly group (5.8%) compared to elderly (5.1%) and control group (2.8%). There were significantly lower rates of AVR offered and completed in the very elderly group compared to control group. Multivariable logistic regression demonstrated that age ≥80 years remained an independent predictor of mortality after adjusting for important prognostic cofounders (Adjusted HR 2.424, 95% CI 1.728 to 3.400, p < 0.001). Cox regression showed no significant difference in mortality between patients ≥80 years with moderate AS compared to a younger age-group ≥70 years with severe AS. In conclusion, very elderly patients of ≥80 years of age with moderate AS have worse prognostic outcomes than their younger counterparts. They share similar unfavorable prognostic outcomes as those of a younger age-group ≥70 years with severe AS. Closer surveillance are warranted in this group of at-risk elderly patients.

Aortic valve replacement in small patients

OBJECTIVES

Asians are smaller than Europeans and North Americans, but aortic valve replacement (AVR) in small patients has not been examined. We aimed to compare short- and mid-term outcomes of AVR between small and non-small patients.

METHODS

We retrospectively divided 173 patients who underwent AVR into small (S, n = 95) and non-small (NS, n = 78) groups according to body surface area (≤1.6 in men, ≤1.5 in women) and analyzed differences in baseline characteristics, procedural and post-procedural variables, and survival.

RESULTS

Mean age differed significantly between the S and NS groups (71.9 ± 11.2 vs. 66.2 ± 9.8 years), as did the proportion of women (60.0% vs. 24.4%). Implanted valves (19.6 ± 1.6 mm vs. 20.7 ± 1.7 mm) were significantly smaller and more bioprosthetic valves (57.9% vs. 41.0%) were used in the S group. Effective orifice area index and the rate of moderate and severe patient-prosthesis mismatch were not significantly different. No significant intergroup differences were found in hospitalization duration, 30-day mortality, survival rates, or valve related complications.

CONCLUSIONS

Small patients were older and the proportion of women was higher. The implanted aortic valves were smaller and more were biological prostheses. However, mortality rate did not differ and short- and mid-term outcomes were safe and favorable.

Aortic Valve Replacement without Annular Enlargement in Patients with Small Aortic Roots

Use of small prostheses for aortic valve replacement eliminates the need for annular enlargement but may impair symptomatic resolution and long-term patient survival. We reviewed our experience with 105 consecutive patients who had isolated aortic valve replacement with small mechanical prostheses or bioprostheses (14 to 21 mm) without concurrent annular enlargement between August 1976 and November 1992. The mean age was 72 ± 10 years and 82% of patients were female. Valvular disease was primarily aortic stenosis in 61%, aortic regurgitation in 7%, and mixed aortic disease was present in 32% of patients. Mean preoperative ejection fraction was 64% ± 17% and the aortic valve area was 0.5 ± 0.2 cm2. Prior to surgery, 82% of patients were in New York Heart Association functional class III or IV. The mean duration of follow-up was 8.1 years. There were 7 early and 14 late deaths giving an overall survival of 80% and a 10-year Kaplan-Meier survival rate of 77%. Five patients developed thromboembolic complications (transient stroke) and 2 required repeat aortic valve replacement due to prosthetic valve endocarditis. Doppler echocardiography or cardiac catheterization was performed in 15 patients postoperatively but peak systolic gradient exceeded 50 mm Hg in only one individual with a 21-mm porcine valve. All surviving patients were in functional class I or II. We conclude that aortic valve replacement with small prostheses is associated with excellent long-term patient survival, improvement in clinical symptoms, and a low incidence of complications.

Acquired aortic stenosis

Aortic stenosis is the most commonly encountered valvular disease in the elderly, with approximately 2-3% of individuals over 65 years of age afflicted. The most common cause of acquired aortic stenosis is calcific degeneration, characterized by a slowly progressive, asymptomatic period which can last decades. Once symptomatic, the clinical manifestation of aortic stenosis is from functional obstruction of left ventricular outflow and the additional hemodynamic effects on the left ventricle and vasculature. With advances in echocardiography, individuals with aortic stenosis are increasingly diagnosed in the asymptomatic latent period. However, echocardiographic measures alone cannot identify clinically significant outflow obstruction as there is considerable overlap in hemodynamic severity between symptomatic and asymptomatic individuals. Current clinical guidelines predicate the timing of surgical valve replacement on the presence or absence of symptoms. Management for symptomatic, significant stenosis is surgical valve replacement as there are no current medical therapies reliably proven to decrease aortic stenosis severity or improve long-term outcomes. However, recent retrospective studies have demonstrated an association between atherosclerotic disease risk factors, such as hyperlipidemia and aortic stenosis. Given these findings, there are now advocates for prospective primary prevention trials for aortic stenosis in patients with mild or moderate valvular disease. The following paper will discuss etiology, diagnostic evaluation and therapeutic options of acquired aortic stenosis. This review will discuss etiology, diagnostic evaluation, and therapeutic options of acquired aortic stenosis.

Minimally invasive surgery for aortic stenosis in the geriatric patient: where are we now?

Minimally invasive aortic valve surgery has evolved with time and become the routine approach for aortic surgery in select surgical centers. The success of these procedures in the nonelderly has led some to embark on using minimal access techniques in the geriatric population as well. With the geriatric community often inflicted with the greatest disease burden, suffering not only from a valvular process but also cumulative comorbidities, geriatric patients may be the patients most likely to derive benefit from a minimally invasive approach. Alternative therapies for symptomatic aortic stenosis include conventional full-sternotomy aortic valve replacement in addition to transcatheter aortic valve implantation. Each option has its advantages and disadvantages. The role of minimal access aortic valve surgery and its impact on the progressively aging population in the face of conventional surgery and transcatheter technology is discussed.

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.

Eight-year results after aortic valve replacement with the CryoLife-O'Brien Stentless Aortic Porcine Bioprosthesis

OBJECTIVE

The long-term durability and hemodynamics of stentless valves are largely unknown. In this study we prospectively analyzed 8-year clinical results with the CryoLife-O'Brien Stentless Aortic Porcine Bioprosthesis (CryoLife Inc, Kennesaw, Ga) and assessed its hemodynamic performance by serial echocardiography.

METHODS

A total of 206 patients with a mean age of 72.8 years were followed up prospectively after aortic valve replacement with the CryoLife-O'Brien stentless bioprosthesis. Patients have been followed up from 2 to 96 months for mean 56 months. Echocardiography was performed by a single echocardiographer preoperatively, intraoperatively, postoperatively at discharge, 3 to 6 months later, and annually thereafter.

RESULTS

The 30-day operative mortality was 4.8%. Sixty-five percent of patients received a valve 25 mm in diameter or larger, and 37% underwent concomitant coronary bypass grafting. Twelve late deaths, none valve-related, have occurred. Severe aortic insufficiency caused by oversizing led to early reoperation in 3 patients. The peak and mean systolic gradients decreased significantly during the first 12 months after implantation (P < .001), and the effective valve areas increased significantly during this interval (P < .001). At 8 years, 2 patients have mild to moderate aortic insufficiency. The actuarial survival at 8 years was 82% +/- 3%. The freedom from endocarditis was 100%, and the freedom from thromboembolic events was 93%.

CONCLUSION

Despite more demanding surgical technique than with conventional bioprostheses, the CryoLife-O'Brien bioprosthesis can be implanted safely in a population predominantly older than 70 years at the time of the operation, with excellent measures of hemodynamics, clinical outcomes, prosthesis durability, and survival through 8 years.

Aortic valve replacement in patients 70 years and older

BACKGROUND

Aortic valvular disease is the most common valvular lesion among elderly patients. Because of changing demographics, it has become increasingly frequent. Aortic valve replacement (AVR) is the only effective treatment for aortic valvular disease.

HYPOTHESIS

This study was undertaken to evaluate the results of AVR in an elderly population.

METHODS

Data were retrospectively analyzed in 117 consecutive patients (mean age 73.8 years) who underwent AVR between 1991 and 2002.

RESULTS

Pure or predominant severe aortic stenosis was present in 108 patients. Nine patients had severe aortic regurgitation. Before valve replacement, 62.4% of the patients were in New York Heart Association (NYHA) functional class III-IV. A bioprosthesis was implanted in 62.4% of the patients, and 37.6% received a mechanical valve. Concomitant cardiac surgical procedures were performed in 25 patients (coronary artery bypass graft in 22, mitral valve replacement in 3). There were 17 deaths, giving a perioperative mortality rate of 14.5%. Multivariate logistic regression showed that repeat surgery for bleeding, prolonged cardiopulmonary bypass time, postoperative respiratory failure, and postoperative acute renal insufficiency were significant independent predictors of operative mortality. Of the 100 hospital survivors, 78 were followed for a mean of 42.9 months. There were six deaths during follow-up; only two of these were cardiac related. Five-year actuarial survival for all patients and for hospital survivors were 70 and 91.1%, respectively. One year post surgery, all patients were in NYHA functional class I-II.

CONCLUSION

In a selected patient population, AVR in the elderly is associated with acceptable mortality and morbidity. The outlook for hospital operative survivors is excellent with improved quality of life and an expected survival normal for this particular age.

Prevalence of congenital heart disease

BACKGROUND

Today most patients with congenital heart disease survive childhood to be cared for by adult cardiologists. The number of physicians that should be trained to manage these lesions is unknown because we do not know the number of patients.

METHODS

To answer this question, the expected numbers of infants with each major type of congenital heart defect born in each 5-year period since 1940 were estimated from birth rates and incidence. The numbers expected to survive with or without treatment were estimated from data on natural history and the results of treatment. Finally, lesions were categorized as simple, moderate, or complex, based on the amount of expertise in management needed for optimal patient care.

RESULTS

From 1940 to 2002, about 1 million patients with simple lesions, and half that number each with moderate and complex lesions, were born in the United States. If all were treated, there would be 750,000 survivors with simple lesions, 400,000 with moderate lesions, and 180,000 with complex lesions; in addition, there would be 3,000,000 subjects alive with bicuspid aortic valves. Without treatment, the survival in each group would be 400,000, 220,000, and 30,000, respectively. The actual numbers surviving will be between these 2 sets of estimates.

CONCLUSIONS

Survival of patients with congenital heart disease, treated or untreated, is expected to produce large numbers of adults with congenital disease, and it is likely that many more adult cardiologists will need to be trained to manage moderate and complex congenital lesions.

Risk in elderly patients after stentless versus stented aortic valve surgery

Recent studies suggest that the hemodynamic advantage of stentless bioprostheses over the stented type improves long-term survival after aortic valve replacement, but the more complex and time-consuming implantation technique may increase the risks of operative death and postoperative complications. Between April 1996 and June 2001, 519 patients with a mean age of 76 +/- 5 years underwent aortic valve replacement using a stentless (Medtronic Freestyle, n = 277) or stented bioprosthesis (Medtronic Mosaic, n = 242). Multiple logistic regression analysis considering different patient populations revealed no increased risk of operative death, postoperative complications, or neurological impairment after implantation of a stentless bioprosthesis. Survival curves in respect of 367 patients who underwent aortic valve replacement up to September 2000 and were followed up for 3 years were not different (p = 0.98). As the patients were elderly, improved survival due to implantation of a stentless valve could not be demonstrated within this time span.

[Risk of perioperative mortality and complications following biological aortic valve replacement in elderly patients: stented vs unstented bioprotheses]

Recently published studies suggest that the hemodynamic advantage of stentless bioprostheses in comparison to stented bioprostheses positively influence the long-term survival after aortic valve replacement. However, the more complex and time consuming implantation technique may increase the risk of operative death. Between April 1996 and September 2000, 201 patients with the mean age of 75 ± 5 years underwent aortic valve replacement (AVR) with a stentless Medtronic Freestyle Bioprothesis (FP) and 166 patients with a mean age of 77 ± 5 years received a stented Medtronic Mosaic Biopros thesis (MP). Patients requiring concomitant procedures other than coronary artery bypass grafting (CABG) were excluded. The operative mortality was 3.5% after AVR with the FP and 6% after AVR with the MP. Multiple logistic regression analysis considering the different patient populations revealed no increased risk of operative death after AVR with FB (p = 0.46). Previously heart operations (p = 0.046) and emergency operation (p = 0.022) were risk factors for operative death after AVR with the biological bioprostheses. The risk for postoperatively neurological impairment (p = 0.15) and other complications (p = 0.46) was furthermore not increased after implantation of a Freestyle stentless valve. The risk of delayed mobilization (p < 0.001) was 2.4-fold increased for patients after AVR with the Freestyle valve. A positive influence on survival due to the implantation of a stentless Freestyle valve could not be shown within the observed period. However, in spite of the more complex and time-consuming operation technique, the risk of operative death and postoperative complications is not increased after aortic valve replacement with the stentless FB.

Variability in treatment advice for elderly patients with aortic stenosis: a nationwide survey in The Netherlands

OBJECTIVE

To determine how the decisions of Dutch cardiologists on surgical treatment for aortic stenosis were influenced by the patient's age, cardiac signs and symptoms, and comorbidity; and to identify groups of cardiologists whose responses to these clinical characteristics were similar.

DESIGN

A questionnaire was produced asking cardiologists to indicate on a six point scale whether they would advise cardiac surgery for each of 32 case vignettes describing 10 clinical characteristics.

SETTING

Nationwide postal survey among all 530 cardiologists in the Netherlands.

RESULTS

52% of the cardiologists responded. There was wide variability in the cardiologists' advice for the individual case vignettes. Six groups of cardiologists explained 60% of the variance. The age of the patient was most important for 41% of the cardiologists; among these, 50% had a high and 50% a low inclination to advise surgery. A further 24% were influenced equally by the patient's age and by the severity of the aortic stenosis and its effect on left ventricular function; among these, 62% had a high and 38% a low inclination to advise surgery. Finally, 23% of the cardiologists were mainly influenced by the left ventricular function and 12% by the aortic valve area. The presence of comorbidity always played a minor role.

CONCLUSIONS

There were systematic differences among groups of cardiologists in their inclination to advise aortic valve replacement for elderly patients, as well as in the way their advice was influenced by the patients' characteristics. These results indicate the need for prospective studies to identify the best treatment for elderly patients according to their clinical profile.

Predictors of mortality for patients undergoing cardiac valve replacements in New York State

BACKGROUND

The objective of this study was to identify the mortality rates and significant independent risk factors for mortality for each of six valve replacement groups.

METHODS

A total of 14,190 patients who underwent valve replacement in New York State from 1995 to 1997 were classified into six major groups and significant independent risk factors for inpatient mortality were identified for each of the groups using stepwise logistic regression.

RESULTS

Mortality rates ranged from 3.33% for isolated aortic valve surgical procedures to 18.72% for multiple valve replacements with coronary artery bypass graft operations. The number of years in excess of age 55 was a significant multivariate predictor of mortality for all six groups of patients. Shock was a significant predictor for five of the six groups, and in each of those groups it was the risk factor with the highest odds ratio.

CONCLUSIONS

Significant patient risk factors are relatively consistent across different types of valve replacement procedures. The probability of survival from valve surgical procedures is highly dependent on the patient's preoperative profile and the type of valve operation.

Sex differences in left ventricular geometry in aortic stenosis: impact on outcome

OBJECTIVE

This study of surgical aortic stenosis characterized sex differences in left ventricular (LV) geometry and outcome.

MATERIALS AND METHODS

We examined 92 women and 82 men who underwent echocardiography before valve replacement for aortic stenosis.

RESULTS

Women had a smaller cavity size (LV end-diastolic diameter 48.2 +/- 7 mm in women vs 53.6 +/- 7.6 mm in men; p = 0.0001) and higher ejection fraction (59% in women vs 54% in men; p = 0.02). LV mass was greater in men than women (300.4 +/- 88 g in men vs 250.6 +/- 85.8 g in women; p = 0.0055) but when corrected for body surface area, the difference was not significant. The prevalence of LV hypertrophy was similar in both sexes (51% in women vs 49% in men; p = 0.62). The 5-year survival was 82% in women and 79% in men (p = 0. 9).

CONCLUSION

Several descriptors of LV geometry differed between men and women. These differences were largely eliminated after normalizing for body surface area. No differences in surgical mortality or long-term outcome were noted.

Mortality and need for reoperation in patients with mild-to-moderate asymptomatic aortic valve disease undergoing coronary artery bypass graft alone

BACKGROUND

Patients presenting for coronary artery bypass graft (CABG) surgery may have concurrent asymptomatic aortic stenosis (AS) or aortic insufficiency (AI). This retrospective study was performed to evaluate outcomes in patients with aortic valve disease undergoing CABG with or without aortic valve replacement (AVR).

METHODS

Study groups included 414 patients undergoing combined AVR and CABG (AVR-CABG group) and 62 patients with asymptomatic mild-to-moderate AS, AI, or both undergoing CABG but not AVR (CABG group). End points included 30-day mortality rate, time to cardiac mortality, time to all-cause mortality, and time to aortic valve reoperation. Reoperation refers to surgery for replacement of the native aortic valve in the CABG group or replacement of the prosthetic aortic valve in the AVR-CABG group. Important patient characteristics affecting outcomes were determined by using Cox proportional-hazard analysis. These variables were then included in multivariable analyses by using logistic regression analysis and Cox proportional-hazard modeling to compare outcomes between each patient group.

RESULTS

No difference was seen in any of the mortality end points between the CABG group and the AVR-CABG group after controlling for significant differences between the groups. However, the need for reoperation for AVR was significantly higher for the CABG group than the AVR-CABG group. For patients followed for up to 6 years, the estimated need for aortic valve reoperation was 24.3% in the CABG group versus 3% in the AVR-CABG group.

CONCLUSION

On the basis of these results, patients with asymptomatic AS or AI should be considered for AVR at the time of CABG.

To operate or not on elderly patients with aortic stenosis: the decision and its consequences

OBJECTIVE

To evaluate the application of guidelines in the decision making process leading to medical or surgical treatment for aortic stenosis in elderly patients.

DESIGN

Cohort analysis based on a prospective inclusive registry.

SETTING

205 consecutive patients (>/= 70 years) with clinically relevant isolated aortic stenosis and without serious comorbidity, seen for the first time in the Doppler-echocardiographic laboratories of three university hospitals in the Netherlands.

RESULTS

The initial choice was surgery in 94 patients and medical treatment in 111. Only 59% of the patients who should have had valve replacement according to the practice guidelines were actually offered surgical treatment. These were mainly symptomatic patients under 80 years of age with a high gradient. Operative mortality (30 days) was only 2%. The three year survival was 80% in the surgical group (17 deaths among 94 patients) and 49% in the medical group (43/111). Multivariate analysis showed that only patients with a high baseline risk, mainly determined by impaired left ventricular function, had a significantly better three year survival with surgical treatment than with medical treatment.

CONCLUSIONS

In daily practice, elderly patients with clinically relevant symptomatic aortic stenosis are often denied surgical treatment. This study indicates that a surgical approach, especially where there is impaired systolic left ventricular function, is associated with better survival.

Good outcomes from cardiac surgery in the over 70s

OBJECTIVE

To determine the early mortality and major morbidity associated with cardiac surgery in the elderly.

DESIGN

Retrospective case record review study of 575 patients >/= 70 years old who underwent cardiac surgery at the Manchester Heart Centre between January 1990 and December 1996.

SETTING

Regional cardiothoracic centre.

SUBJECTS

Patients >/= 70 years old who underwent cardiac surgery.

MAIN OUTCOME MEASURES

Comparison of 30 day mortality and incidence of major morbidity between patients >/= 70 years old and patients < 70 years old.

RESULTS

Of 4395 cardiac surgical operations, 575 operations (13.1%) were in patients aged >/= 70 years (mean (SD) 73.1 (3.2) years). The proportion of elderly patients rose progressively from 7.9% in 1990 to 16.5% in 1996. 334 patients (58.1%) had coronary artery bypass grafting alone, 91 patients (15.8%) had valve surgery alone, and 129 patients (22.4%) had combined valve surgery and bypass grafting. For isolated coronary artery bypass grafting, 30 day mortality in patients >/= 70 years was 3.9% compared with 1.3% in patients < 70 years (p < 0.001). 30 day mortality for isolated valve surgery in patients >/= 70 years was 7.7%. Isolated aortic valve replacement was the most common valvar procedure in patients >/= 70 years and carried the lowest mortality (4.3%). Additional coronary artery bypass grafting increased the mortality rate in patients >/= 70 years to 9.3% for all valve surgery and to 8.0% for aortic valve replacement. Major morbidity in patients >/= 70 years was low for all procedure types (stroke 1.9%, acute renal failure requiring dialysis 1.6%, perioperative myocardial infarction 0.5%).

CONCLUSIONS

Early mortality and major morbidity is low for cardiac surgery in elderly patients. Concerns over the risk of cardiac surgery in the elderly should not prevent referral, and elderly patients usually do well. However, unconscious rationing of health care may affect referral patterns, and studies that assess the cost effectiveness of cardiac surgery versus conservative management in such patients are lacking.

Aortic valve replacement in the octogenarians: perioperative outcome and clinical follow-up

OBJECTIVES

To determine long-term results of aortic valve replacement (AVR) in patients 80 years old or older, and assess the factors influencing perioperative outcome.

METHODS

Data were reviewed on 83 consecutive octogenarians, undergoing aortic valve replacement between 1992 and 1997. There were 66 women and 17 men (mean age: 82.8 years). Fifty-seven patients (69%) were in New York Heart Association (NYHA) class III-IV and six had previous myocardial infarction. Three patients had previous percutaneous aortic valvuloplasty. There were 19 urgent procedures (23%). Coronary artery bypass grafting (CABG) was performed on 21 patients (25%). Possible influence of preoperative and operative variables on early and late mortality was performed with univariate and multivariate statistical analysis, and survival was estimated with the Kaplan-Meier method.

RESULTS

Operative mortality was 13% (9% for AVR, 24% for AVR-CABG). Postoperative complications were respiratory failure in 19 patients, atrial fibrillation in 19, hemodialysis in four, myocardial infarction in four and stroke in two patients. Five patients required pacemaker insertion for permanent atrioventricular block. Median hospital stay and intensive care unit stay were 19.8 +/- 12.2 days and 7.9 +/- 3.4 days, respectively. Multivariate predictors of hospital death (P < 0.05) were percutaneous aortic valvuloplasty, NYHA class IV, and urgent procedure. Mean follow-up was 26.5 months. Survival at 1, 2, and 5 years was 98.5 +/- 1.4% (63 patients at risk), 93.4 +/- 3.2% (47 patients at risk), and 78.2 +/- 6.9% (six patients at risk), respectively. Preoperative myocardial infarction and urgent procedure were independent predictors of late death. At most recent follow-up, 91% were angina free and 81% were in class I-II.

CONCLUSIONS

Aortic valve replacement in octogenarians can be performed with acceptable mortality. These results stress the importance of early operation on elderly patients with aortic valve disease. Both long-term survival and functional recovery are excellent.

Risk stratification for cardiac valve replacement. National Cardiac Surgery Database. Database Committee of The Society of Thoracic Surgeons

BACKGROUND

The Society of Thoracic Surgeons National Database Committee is committed to risk stratification and assessment as integral elements in the practice of cardiac operations. The National Cardiac Surgery Database was created to analyze data from subscribing institutions across the country. We analyzed the database for valve replacement procedures with and without coronary artery bypass grafting to determine trends in risk stratification.

METHODS

The database contains complete records of 86,580 patients who had valve replacement procedures at the participating institutions between 1986 and 1995, inclusive. The 1995 harvest of data was conducted in late 1996 and available for evaluation in 1997. These records were used to conduct an in-depth analysis of risk factors associated with valve replacement and to provide prediction of operative death by using regression analysis. Regression models were made for six subgroups.

RESULTS

Adverse patient risk factors, including diabetes, hypertension and reoperation, but not ventricular function, increased over time. There were trends with regard to increasing age of the various population subsets. The types of prostheses used remained similar over time, with more mechanical prostheses than bioprostheses used for both aortic and mitral valve replacement. There was a trend toward increased use of bioprostheses in aortic replacements and decreased use in mitral replacements between 1991 and 1995 than between 1986 and 1990. The mortality rate was determined by patient subset for primary operation and reoperation and by urgency status. The modeling showed that the predicted and observed mortality correlated for all age groups and within patient subsets.

CONCLUSIONS

Risk modeling is a valuable tool for predicting the probability of operative death in any individual patient. This large, multiinstitutional database is capable of determining modern operative risk and should provide standards for acceptable care. The study illustrates the importance of risk stratification for early death both for the patient and the surgeon.

Cardiovascular surgery in the elderly

The elderly segment of the population is increasing rapidly, and surgeons are more frequently being requested to operate on this group of patients. A number of reports suggest that elderly patients have a significantly higher incidence of operative mortality and 30-day hospital mortality as compared with younger patients. Elderly patients also had a significantly higher increased incidence of complications, such as renal failure, prolonged ventilation, and incidence of strokes and postoperative cardiac arrest. Regarding coronary artery disease, elderly patients are more acutely sick on admission, are more likely to have triple-vessel disease, more likely have comorbid disease, and are usually less likely to receive an internal mammary artery graft. The presence of valvular disorders with concomitant coronary disease (especially mitral ischemic related valve disease) increases operative time, morbidity, and mortality. Efforts must continue to be made to gather data on outcomes of cardiac surgery in the elderly. Consideration must be given to modify the operative approach that minimizes cardiopulmonary bypass time, mitigates the multisystem organ injury associated with cardiopulmonary bypass, and decreases the likelihood of embolization from the ascending aorta. Future efforts must be made to develop measures to decrease the complications rate identified in elderly patients.

Valve replacement with a stentless bioprosthesis: versatility of the porcine aortic root

OBJECTIVE

Stentless valves convey important hemodynamic benefits but are used selectively depending on aortic root structure. The Freestyle valve (Medtronic, Inc, Minneapolis, Minn) is a versatile device that can be implanted by different methods depending on operating conditions. We aimed to demonstrate that a stentless valve could be used in every patient without increased risk of morbidity or mortality. We documented the effects of this valve on clinical outcome and left ventricular mechanics.

METHODS

The Freestyle valve was implanted by the modified subcoronary method into 200 consecutive unselected patients who received a tissue valve in the aortic position and by root replacement in 2. Forty-three percent were older than 75 years. Forty percent underwent coronary bypass. Detailed clinical and echocardiographic follow-up (Food and Drug Administration protocol) was used out to 3 years.

RESULTS

Mean ischemic time was 43+/-6 minutes for isolated aortic valve replacement and 63+/-14 minutes with concomitant procedures. Thirty-day mortality was 6%, none of the deaths being valve related. Hemodynamic function improved progressively with falling valve gradients and increased effective orifice areas. Left ventricular mass fell within normal limits over 2 years, but at 3 years there was a non-valve-related upswing. No instances of valve thrombosis, hemolysis, or paravalvular leak were noted. Less than 5% had mild to moderate aortic regurgitation.

CONCLUSIONS

The Freestyle valve can be used in virtually every patient with aortic valve disease and provides superlative hemodynamic outcome. Hospital mortality and morbidity are similar to those reported for stented valves in an elderly population.

Reversibility of cardiac dysfunction after valve replacement in elderly patients with severe aortic stenosis

BACKGROUND

The role of aortic valve replacement for aortic stenosis has not been fully defined in terms of the postoperative reversibility of cardiac dysfunction and pulmonary hypertension in elderly patients.

METHODS

Cardiac function, assessed by radioisotope ventriculography and catheterization data, was evaluated before and after operation, and their results were compared between preoperative and postoperative data in each group of younger patients (<69 years, group I, n = 29) and elderly patients (> or =70 years, group II, n = 21).

RESULTS

One month postoperatively the peak ejection rate determined by radioisotope ventriculography improved significantly in comparison with the preoperative value in elderly patients (preoperatively, 228 +/- 38 versus postoperatively, 319 +/- 116% end-diastolic volume per second, p < 0.05), although their preoperative peak ejection rate was severely depressed. The postoperative peak filling rate of the elderly group was not completely reversible to almost normal value, whereas that of the younger group was completely reversible. Early diastolic peak filling rate (one-third peak filling rate) was not reversible in both two groups. Pulmonary hypertension in the elderly patients was reversible to postoperative almost normal pulmonary artery pressure despite the severity of aortic stenosis (systolic pulmonary artery pressure preoperatively, 37 +/- 16 mm Hg versus postoperatively, 25 +/- 5 mm Hg, p < 0.02; diastolic pulmonary artery pressure preoperatively, 15 +/- 6 mm Hg versus postoperatively, 10 +/- 4 mm Hg, p < 0.05).

CONCLUSIONS

Both cardiac dysfunction, reflected by reduction of peak ejection rate, and pulmonary hypertension in elderly patients with severe aortic stenosis were reversed, reaching almost normal values 1 month after operation.

Stentless aortic bioprostheses: compelling data from the Second International Symposium

BACKGROUND

Stentless aortic xenografts are an important addition to the range of prosthetic valves. So far their use has been restricted to a limited number of study centers. This report summarizes the principal findings from the Second International Symposium on Stentless Bioprostheses. Attention is focused on the Toronto SPV and Freestyle valves recently approved by the United States Food and Drug Administration.

METHODS

Stentless xenografts are used predominantly in elderly patients with aortic stenosis. Implant techniques are more complex than for stented valves, as reflected by longer ischemic and cardiopulmonary bypass times. The valves have been subjected to detailed serial echocardiographic assessment and clinical follow-up.

RESULTS

The hemodynamic characteristics resemble those of the aortic homograft. There is a progressive increase in effective orifice area and decrease in transvalvular pressure gradients with time. Left ventricular mass index and wall thickness normalize between 6 and 12 months postoperatively. Left ventricular remodeling is accompanied by improved symptomatic status and a low incidence of valve-related complications. Limited comparative studies suggest important benefits over stented xenografts. Improved hemodynamics may translate into better bioprosthetic durability.

CONCLUSIONS

Reproducible and reliable implant methods should be taught carefully, but the hemodynamic advantages are substantial. Stentless xenografts are ideal for the elderly patient with aortic stenosis.

Aortic valve replacement in the elderly. Risk factors and long-term results

OBJECTIVE

The current study was undertaken to determine long-term results of aortic valve replacement (AVR) in the elderly, to ascertain predictors of poor outcome, and to assess quality of life.

SUMMARY BACKGROUND DATA

Aortic valve replacement is the procedure of choice for elderly patients with aortic valve disease. The number of patients aged 70 and older requiring AVR continues to increase. However, controversy exists as to whether surgery devoted to this subset reflect a cost-effective approach to attaining a meaningful quality of life.

METHODS

This study reviews data on 247 patients aged 70 to 89 years who underwent isolated AVR between 1980 and 1995; there were 126 men (51%) and 121 women (49%). Follow-up was 97% complete (239/247 patients) for a total of 974.9 patient-years. Mean age was 76.2 +/- 4.8 years. Operative mortality and actuarial survival were determined. Patient age, gender, symptoms, associated diseases, prior conditions, New York Health Association class congestive heart failure, native valve disease, prosthetic valve type, preoperative catheterization data, and early postoperative conditions were analyzed as possible predictors of outcome. Functional recovery was evaluated using the SF-36 quality assessment tool.

RESULTS

Operative mortality was 6.1% (15/247). Multivariate logistic regression showed that poor left ventricular function and preoperative pacemaker insertion were independent predictors of early mortality. After surgery, infection was predictive of early mortality. Overall actuarial survival at 1, 5, and 10 years was 89.5 +/- 2% (198 patients at risk), 69.3 +/- 3.4% (89 patients at risk), and 41.2 +/- 6% (13 patients at risk), respectively. Cox proportional hazards model showed that chronic obstructive pulmonary disease and urgency of operation were independent predictors of poor long-term survival. Postoperative renal failure also was predictive of poor outcome. Using the SF-36 quality assessment tool, elderly patients who underwent AVR scored comparably to their age-matched population norms in seven of eight dimensions of overall health. The exception is mental health.

CONCLUSIONS

Aortic valve replacement in the elderly can be performed with acceptable mortality. Significant preoperative risk factors for early mortality include poor left ventricular function and preoperative pacemaker insertion. Predictors of late mortality include chronic obstructive pulmonary disease and urgency of operation. These results stress the importance of operating on the elderly with aortic valve disease; both long-term survival and functional recovery are excellent.

Intraoperative transesophageal echocardiography and epiaortic ultrasound for assessment of atherosclerosis of the thoracic aorta

OBJECTIVES

This study sought to determine the role of transesophageal echocardiography (TEE) and epiaortic ultrasound in the detection of atherosclerosis of the ascending aorta in patients undergoing cardiac surgery.

BACKGROUND

Atherosclerosis of the ascending aorta is a major risk factor for perioperative stroke and systemic embolism in patients undergoing cardiac surgery.

METHODS

Forty-four patients underwent prospective evaluation of the ascending aorta with two ultrasound techniques-epiaortic ultrasound and biplane TEE-and by palpation. The severity of atherosclerosis was graded on a four-point scale as normal, mild, moderate or severe.

RESULTS

A comparison of results with biplane TEE and those with epiaortic ultrasound yielded a kappa value of 0.12 (95% confidence interval 0 to 0.25), indicating poor correlation between the two. Compared with epiaortic ultrasound, biplane TEE significantly underestimated the severity of ascending aortic atherosclerosis, and this underestimation was more marked in the distal ascending aorta (p < 0.0001). When compared with epiaortic ultrasound and biplane TEE, palpation of the ascending aorta significantly underestimated the presence and severity of atherosclerosis (p < 0.0001 for both).

CONCLUSIONS

Epiaortic ultrasound is more accurate than TEE for identification of atherosclerosis of the ascending aorta, but both ultrasound techniques are superior to palpation. Epiaortic ultrasound and TEE provide complementary information regarding thoracic aortic atherosclerosis. Modification of surgical technique on the basis of results of intraoperative epiaortic ultrasound and TEE in elderly patients undergoing cardiac procedures may prevent atheroembolic complications.

Aortic valve replacement in elderly patients: influence of concomitant coronary grafting on late survival

BACKGROUND

Aortic valve replacement (AVR) has been an accepted therapy for elderly patients (> 70 years) with aortic valve disease. This study was designed to investigate the determinants of survival after the implantation of aortic valve prostheses, with emphasis on the effect of concomitant coronary artery bypass grafting on survival.

METHODS

From November 1964 to July 1994,963 elderly patients underwent isolated AVR. Long-term survival was investigated in 877 patients (70 to 94 years) who survived operation, with 92% follow-up completeness (mean +/- standard deviation, 4.5 +/- 3.9 years; maximum, 20.1 years; total, 3,920.2 patient-years), by univariate and multivariate analyses.

RESULTS

Actuarial survival was 38.1% +/- 2.8% at 10 years, 17.8% +/- 3.0% at 15 years, and 9.0% +/- 3.1% at 20 years. Eight variables (age, sex, body surface area [less or greater than 1.7 m2], period of operation, type of prosthesis, size of prosthesis, re-replacement, and concomitant coronary artery bypass grafting) were investigated with regard to long-term survival by the Kaplan-Meier method. Age, sex, and body surface area were significant. Multivariate analysis revealed that older age (p = 0.0005) and male sex (p = 0.0001) were independent variables that determined long-term survival.

CONCLUSIONS

Elderly patients may have satisfactory long-term results after AVR. Age and sex are independent determinants. Other factors (such as concomitant coronary artery bypass grafting and type of prosthesis) did not independently influence long-term survival. Coronary revascularization in elderly patients with coronary disease undergoing AVR may lead to a long-term survival similar to that in patients without coronary disease undergoing AVR.

Comparison of aortic valve replacement and percutaneous aortic balloon valvuloplasty for elderly patients with aortic stenosis

The outcome of aortic balloon valvuloplasty (ABV) was compared with that of aortic valve replacement (AVR) in aortic stenosis (AS) patients more than 60 years old. The indications for ABV included low respiratory and renal function, cancer, the patient's refusal of surgery, and low daily activity. Twenty six patients underwent AVR and 13 underwent ABV. Initially, the AVR group was younger and more symptomatic than the ABV group. Two perioperative deaths occurred in the AVR group, while there were none in the ABV group. Twenty-four AVR patients and 12 ABV patients had a successful outcome, with remarkable pressure gradient reduction in both groups. In the follow-up, only 1 death and no cardiac events were detected in the AVR group (mean follow-up of 27 months), whereas 3 deaths, 6 heart failures, 2 repeated ABV, and 4 AVR were seen in the ABV group (mean follow-up of 10 months). The data showed that ABV was safer than AVR, but a higher rate of restenosis limited its efficacy. In the ABV group, a higher ratio of balloon size to aortic diameter correlated with longer event-free survival. We concluded that for elderly AS patients, ABV should be used only in those with high surgical risk as a palliative therapy or a bridge therapy to AVR, and AVR should be primarily recommended under rigid evaluation of the patient's physical status.

Balloon aortic valvuloplasty in adults: failure of procedure to improve long-term survival

OBJECTIVES

This study sought to determine the long-term outcome of adult patients undergoing percutaneous balloon aortic valvuloplasty.

BACKGROUND

Percutaneous balloon aortic valvuloplasty has been offered as an alternative to aortic valve replacement for selected patients with valvular aortic stenosis. Although balloon aortic valvuloplasty produces an immediate reduction in the transvalvular aortic gradient, a high incidence of restenosis frequently leads to recurrent symptoms. Therefore, it is unclear whether balloon aortic valvuloplasty impacts on the long-term outcome of these patients.

METHODS

Clinical, hemodynamic and echocardiographic data were collected at baseline in 165 patients undergoing balloon aortic valvuloplasty and examined for their ability to predict long-term outcome.

RESULTS

The median duration follow-up was 3.9 years (range 1 to 6). Ninety-nine percent follow-up was achieved. During this 6-year period, 152 patients (93%) died or underwent aortic valve replacement, and 99 (60%) died of cardiac-related causes. The probability of event-free survival (freedom from death, aortic valve replacement or repeat balloon aortic valvuloplasty) 1, 2 and 3 years after valvuloplasty was 40%, 19% and 6%, respectively. In contrast, the probability of survival 3 years after balloon aortic valvuloplasty in a subset of 42 patients who underwent subsequent aortic valve replacement was 84%. Survival after aortic valvuloplasty was poor regardless of the presenting symptom, but patients with New York Heart Association functional class IV congestive heart failure had events earliest. Univariable predictors of decreased event-free survival were younger age, advanced congestive heart failure symptoms, lower ejection fraction, elevated left ventricular end-diastolic pressure, presence of coronary artery disease and increased left ventricular internal diastolic diameter. Stepwise multivariable logistic regression analysis found that only younger age and a lower left ventricular ejection fraction contributed independent adverse prognostic information (chi-square 14.89, p = 0.0006).

CONCLUSIONS

Long-term event-free and actuarial survival after balloon aortic valvuloplasty is dismal and resembles the natural history of untreated aortic stenosis. Aortic valve replacement may be performed in selected subjects with good results. However, the prognosis for the remainder of patients who are not candidates for aortic valve replacement is particularly poor.

Bioprosthetic and mechanical valves in the elderly: benefits and risks

There is controversy over whether elderly patients benefit from the durability of mechanical valves when balanced against the risk of anticoagulation. From 1976 to 1993, 576 patients 65 years old or older underwent isolated valve replacement with mechanical (n = 250) or bioprosthetic valves (n = 326). Total follow-up was 2,222 patient-years. Probability of survival and freedom from thromboembolism and prosthetic valve endocarditis were not different between the two groups. There was a significant difference (p = 0.015) in freedom from anticoagulant-related hemorrhage. Two patients with mechanical prostheses and 7 patients with bioprostheses were reoperated. However, actuarial freedom from reoperation was not different (p = 0.73) in both groups, with no hospital mortality, whereas mortality from thromboembolic events and anticoagulant-related hemorrhage was three times higher in patients with mechanical prostheses as compared with patients with bioprostheses (1.08% versus 0.36% per patient-year). The benefit from the durability of mechanical valves, compared with bioprostheses, is smaller than expected because of the limited number of patients exposed to the onset of bioprosthetic structural deterioration. Elderly patients without absolute indication for anticoagulation should preferentially receive bioprostheses for valvular replacement.

Lack of social participation or religious strength and comfort as risk factors for death after cardiac surgery in the elderly

The purpose of this study was to examine the relationship of social support and religion to mortality after elective open heart surgery in older patients. Of the 232 patients included in the study, 21 died within 6 months of surgery. Three biomedical variables were significant predictors of mortality and selected as adjustment variables for a multivariate analysis: history of previous cardiac surgery; greater impairment in presurgery basic activities of daily living; and older age. Among the social support and religion variables, two were consistent predictors of mortality in the multivariate analyses: lack of participation in social or community groups and absence of strength and comfort from religion. These results suggest that in older persons lack of participation in groups and absence of strength and comfort in religion are independently related to risk for death during the 6-month period after cardiac surgery.

Aortic valve replacement: procedure of choice in elderly patients with aortic stenosis

Aortic valve replacement is the treatment of choice for elderly patients with aortic stenosis. It can be accomplished with excellent immediate and long-term results with significant functional improvement. Unfortunately, the literature is replete with enthusiastic reports of aortic catheter balloon valvotomy. Initial findings were controversial and the long-term results have been poor due to early valve restenosis. A retrospective analysis of our surgical experience with aortic valve replacement in the elderly seems appropriate in an effort to put this issue in proper perspective. From January 1973 to June 1993, 200 consecutive patients 70 years of age and older with severe aortic stenosis underwent surgical correction. There were 105 men (52.5%) and 95 women (47.5%), with a mean age of 76.2 years (range 70 to 89). Preoperatively, 195 patients (97.5%) were in New York Heart Association (NYHA) Class III or IV. Over one half (61.0%) of the patients experienced no hospital complications. The hospital mortality was 9.0% (18 patients). This included 14 patients in NYHA Class IV. The mean follow-up was 69.3 months and ranged from 1 to 215 months. The actuarial survival for 182 patients discharged from the hospital was 70.8% +/- 4.0% (SEM) at 72 months (73 patients at risk) and 35.2% +/- 5.4% at 144 months (20 patients at risk). Considering the advanced age and preoperative functional classification in this patient group, the results of aortic valve replacement have been excellent. The survival of patients discharged from the hospital compares favorably with a normal population matched for age and sex. The results of aortic balloon valvotomy have been disappointing.(ABSTRACT TRUNCATED AT 250 WORDS)

Valvular disease in the elderly: influence on surgical results

Aortic valve disease in the elderly is primarily calcific stenosis with preservation of left ventricular function. In contrast, mitral valve disease in the elderly often is ischemic in nature with damage occurring to both valve and myocardium. The present study was undertaken to compare results of aortic (AVR) and mitral valve replacement (MVR) in the elderly and to ascertain predictors of poor outcome. Because patients who had concomitant coronary artery bypass grafting (CABG) are included (51% for AVR, 55% for MVR), patients who had isolated CABG were used as a comparison group. Between January 1, 1984, and June 30, 1991, 1,386 patients aged 70 years and older underwent CABG (n = 1,043), AVR (n = 245), or MVR (n = 98). The operative mortality rates were 5.3% for AVR, 20.4% for MVR, and 5.8% for CABG. Late follow-up of patients undergoing operation in 1984 and 1985 was available for 98% (231/237). Overall survival was comparable for all three groups through the first 5 years of follow-up (AVR, 68% +/- 8%; MVR, 73% +/- 8%; CABG, 78% +/- 3%). After 5 years, survival for patients having AVR and MVR was less than that for those having CABG. Patient age, sex, New York Heart Association functional class, concomitant CABG, prosthetic valve type, native valve pathology, and preoperative catheterization data were examined as possible predictors of outcome by multivariate logistic regression.(ABSTRACT TRUNCATED AT 250 WORDS)

Ten-year experience with mitral valve replacement in the elderly

Limited data are available on mitral valve replacement in the elderly patient. Therefore we report our 10-year experience including predictors of perioperative mortality and subsequent long-term cardiac mortality in elderly patients with mitral valve replacement compared to younger patients. Of the 126 consecutive patients with mitral valve replacement, 26 were older (77 +/- 4, group 1) and 100 were younger (62 +/- 9, group 2) than 70 years. Bioprostheses were used more frequently in patients in group 1 (65% vs 7%, p less than 0.0001). Of the 21 clinical, ECG, hemodynamic, and angiographic variables studied, patients in group 1 had higher pulmonary artery systolic pressure (57 +/- 15 vs 48 +/- 19, p less than 0.05), fascicular block on ECGs (70% vs 33%, p less than 0.005), and greater pump time on cardiopulmonary bypass (160 +/- 75 vs 120 +/- 50 minutes, p less than 0.025). A trend toward a higher perioperative mortality rate was also seen in group 1 (27% vs 12%, p = 0.058). Predictors of perioperative mortality by multivariate analysis were the presence of aortic calcification and prolonged pump time on cardiopulmonary bypass in group 1 and coronary artery disease, female sex, elevated mean pulmonary artery pressure, and postoperative complete atrioventricular block in group 2. During a mean 4-year follow-up period, cardiac mortality and total mortality rates were 42% and 54%, respectively, for group 1 compared to 24% and 35%, respectively, for group 2.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic valve replacement for aortic stenosis in persons aged 80 years and over

Seventy-one patients aged greater than or equal to 80 years (mean +/- standard deviation 82 +/- 2) with aortic stenosis or mixed stenosis and regurgitation underwent aortic valve replacement alone (n = 35, group 1) or in combination with a coronary artery bypass procedure without any other valve procedure (n = 36, group 2). Preoperatively, 91% had severe cardiac limitations (New York Heart Association class III or IV). Hospital mortality was 12.7% overall (9 of 71), 5.7% (2 of 35) for group 1 and 19.4% (7 of 36) for group 2. Perioperatively, 1 patient (1.4%) had a stroke. Survival from late cardiac death at 1 and 3 years was 98.2 and 95.5%, respectively, for all patients, 100% for patients who underwent isolated aortic valve replacement, and 96.3 and 91.2%, respectively, for patients who underwent aortic valve replacement plus coronary artery bypass. Eighty-three percent of surviving patients had marked symptomatic improvement. Freedom from all valve-related complications (thromboembolism, anticoagulant, endocarditis, reoperation or prosthetic failure) was 93.3 and 80.4% at 1 and 3 years, respectively. Thus, short- and long-term morbidity and mortality after aortic valve replacement for aortic stenosis in patients aged greater than or equal to 80 years are encouragingly low, although the addition of coronary artery bypass grafting increases short- and long-term mortality.

Early and late results of aortic valve replacement. A series of 510 patients

Aortic valve replacement was performed in 510 patients (Björk-Shiley valves in 93%), with concomitant surgical procedures in 146 cases. The patients were grouped according to technique of myocardial protection: Group I (n = 98) selective coronary perfusion, group II (n = 82) topical cooling, and group III (n = 330) cold crystalloid cardioplegia and topical cooling. The early mortality rate was 5.7% overall: Among patients with isolated aortic valve replacement in groups I, II and III it was 8.4, 1.7 and 1.3%, respectively, and among those with additional surgery 40.0, 12.5 and 8.4%. Myocardial infarction and low cardiac output were responsible for 65.5% of the early deaths. Follow-up ranged from 2 months to 16 11/12 years, totalling 2,859 patient years. In patients with isolated aortic valve replacement and Björk-Shiley prosthesis, the incidence of valve-related late complications/100 patient years was 0.49 for thromboembolism, 0.82 for anticoagulant-related haemorrhage and 0.49 for prosthetic valve endocarditis. There was no thrombotic encapsulation in aortic position. Survival at 5 and 10 years was 83% and 72%. Aortic valve replacement is a safe procedure and concomitant operations do not unreasonably increase risks.