Is an Age of 80 Years or Greater an Important Predictor of Short-Term Outcomes of Isolated Aortic Valve Replacement in Veterans?

Clinical Characteristics and Long-Term Prognosis of Elderly Valvular Heart Disease Patients with Diabetes Mellitus: Five-Year Experience from a Single-Center Study of Southern China

Background

Diabetes mellitus (DM) is a prognostic marker in elderly patients with cardiovascular diseases, but its predictive value in elderly valvular heart disease (VHD) patients is unclear. This study aimed to investigate the effect of DM on the long-term outcome of elderly VHD patients.

Methods

This single-center, observational study enrolled patients aged 65 and older consecutively with confirmed VHD using echocardiography. Patients, divided into the DM group and non-DM group, were followed up for major adverse cardiac and cerebrovascular events (MACCEs), including all-cause death, ischemic stroke, and heart failure rehospitalization.

Results

Our study consisted of 532 patients over a median follow-up of 52.9 months. Compared with the non-DM group (n = 377), the DM group (n = 155) had higher incidences of ischemic stroke (25.2% vs. 13.5%, P=0.001), heart failure rehospitalization (37.4% vs. 20.7%, P < 0.001), and MACCEs (60.0% vs. 35.8%, P < 0.001). After adjustment of confounders by the multivariable cox regression, DM appeared as an independent predictor for MACCEs (adjusted hazard ratio, aHR: 1.88; 95% confidence interval 1.42–2.48; P < 0.001). In the subgroup analysis of VHD etiology and functional style, conversely, DM was a protective factor for MACCEs in the patients with rheumatic VHD compared with those without rheumatic VHD (aHR: 0.43 vs. 2.27, P=0.004).

Conclusions

DM was an independent predictor for ischemic stroke and heart failure rehospitalization in elderly VHD patients undergoing conservative treatment.

Valvular Heart Disease in Patients ≥80 Years of Age

In the United States, the octogenarian population is projected to triple by 2050. With this aging population, the prevalence of valvular heart disease (VHD) is on the rise. The etiology, approach to treatment, and expected outcomes of VHD are different in the elderly compared with younger patients. Both stenotic and regurgitant lesions are associated with unfavorable outcomes if left untreated. Surgical mortality remains high due to multiple co-morbidities, and long-term survival benefit is dependent on many variables including valvular pathology. Quality of life is an important consideration in treatment decisions in this age group. Increasingly, octogenarian patients are receiving transcatheter therapies, with transcatheter aortic valve replacement having the greatest momentum. Numerous transcatheter devices for management of other valve lesions are currently in early clinical trials. This review will describe the epidemiology, etiology, diagnosis, and therapeutic options for VHD in the oldest old, with a focus on transcatheter technologies.

Isolated and Combined Valve Surgery in Elderly Patients: A Comparison of Mid-Term Results

BACKGROUND

This study examined mid-term outcomes of valve surgery in the elderly, and focused on the difference in outcomes between isolated and combined valve surgery.

METHODS

From January 2012 to June 2016, 113 consecutive patients aged 75 years and older underwent valve surgery. In all, 60 underwent isolated valve surgery (Group I), and 53 underwent combined valve surgery (Group C) involving the combination of any valve procedures or valve surgery with concurrent other procedure. Short- and mid-term outcomes were compared between the two groups.

RESULTS

There was no significant difference in length of intensive care unit stay (2.8 days in Group S vs. 4.2 days in Group C, p = 0.08), hospital stay (16.2 vs. 18.7 days, p = 0.22), and mechanical ventilation (11.2 vs. 15.0 hours, p = 0.28). Neither was there any significant difference in operative mortality (1.6% vs. 5.6%, p = 0.25) nor morbidity (8.3% vs. 9.4%, p = 0.83) between the two groups. Actuarial survival rates at 1 and 3 years were 98.3% in Group S and 92.0% in Group C (log-rank p = 0.126).

CONCLUSION

Once patients have tolerated combined surgery during the early postoperative period, good survival rates equaling those of isolated valve surgery can be expected.

Quality of care assessment and improvement in aortic stenosis - rationale and design of a multicentre registry (IMPULSE)

Background

Severe aortic stenosis (AS) is a common, serious valve disease in which no effective medical therapy is available and, if not treated by intervention, has a 5-year survival of only 40–60%. Despite the availability of guidelines supporting the effective use of surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) to treat the majority of these patients, adherence to these guidelines in clinical practice is still unsatisfactory. Several recent studies have emphasised the necessity for improved communication between multidisciplinary teams, with the aim to ensure that severe AS patients receive appropriate treatment.

Methods/design

IMPULSE is a prospective, multicentre, European registry designed to gather data over 12 months on the treatment decisions made by referring physicians for patients newly diagnosed with severe AS. Each patient has a follow-up of 3 months. The study will consist of two observational phases to assess the appropriateness and rate of referral based on current guidelines prior to and after an interventional phase aiming to determine whether a simple quality of care intervention improves patient management.

Discussion

Data will be analysed firstly, to determine the appropriateness of treatment decisions for the management of severe AS in current European clinical practice, and secondly, to evaluate the effectiveness of facilitated data relay from a designated echocardiography department nurse to the referring physician early after diagnosis in improving quality of care. Additionally, variables will be identified that are associated with inappropriate decision-making. Collectively, the aim will be to design a clinical pathway that will improve the timely management of patients with newly diagnosed severe AS.

Long-Term Outcomes of Conventional Aortic Valve Replacement in High-Risk Patients: Where Do We Stand?

PURPOSE

The introduction of transcatheter aortic valves has focused attention on the results of conventional aortic valve surgery in high-risk patients. The aim of the study was to evaluate 5-years outcomes in this category of patients in the current surgical era.

METHODS

This is an observational retrospective study of 581 high-risk patients undergoing aortic valve replacement from 2008 to 2013, with a mean logistic EuroSCORE of 26.6% ± 14.6%. Data were prospectively collected in a database of Emilia-Romagna region (Italy).

RESULTS

Overall 30-day mortality was 9.3%. Stroke rate was 1.5%. At 1-, 3-, and 5-years overall mortality was 18.2%, 30.4%, and 42.2%, cardiac death rate was 3.9%, 9.2%, and 12.9%, stroke rate 2.5%, 7.7%, and 10.2%, re-operation occurrence 0.2%, 0.9% and 1.3%, and new pacemaker implantation was 2.3%, 5.1% and 7.8%. At multivariate analysis, urgency, hemodynamic instability, LVEF ≤30%, NYHA III-IV, severe chronic obstructive pulmonary disease (COPD), extra-cardiac arteriopathy, cerebrovascular disease, and creatinine >2.0 mg/dL remained independent predictors of 5-year mortality.

CONCLUSION

The results of the current study add weight to the evidence that traditional aortic valve replacement can be performed in high-risk patients with satisfactory 5-year mortality and morbidity. Our study may help to improve decision-making in this category of high-risk patients with aortic valve disease.

Application of a Multidisciplinary Enhanced Recovery After Surgery Pathway to Improve Patient Outcomes After Transcatheter Aortic Valve Implantation

Enhanced recovery after surgery (ERAS) protocols have proven effective in a variety of surgical specialties. Published reports on these pathways within cardiac surgery and interventional cardiology are limited. Invasive aortic valve replacement procedures are increasingly being performed by hybrid groups of interventional cardiologists and surgeons through transcatheter aortic valve implantation (TAVI). The TAVI patient population is at a higher surgical risk compared with those undergoing surgical aortic valve replacement since they are older, frailer, and have significant co-morbidities which result in an increased risk of perioperative complications. ERAS protocols have the potential to help these patients undergoing TAVI procedures. In conclusion, we propose a TAVI ERAS protocol with a call-to-action for other centers to implement an ERAS protocol to improve hospital and cardiac outcomes.

Transcatheter aortic valve implantation with balloon-expandable valve: early experience from China

Objective

The aim of the current study was to evaluate the early experience of the application of transcatheter aortic valve implantation with the balloon-expandable system in China. The transcatheter aortic valve implantation technology has been widely used for patients with inoperable severe aortic stenosis in the developed world. The application of transcatheter aortic valve implantation is still in the early stages of testing in China, particularly for the balloon-expandable valve procedure.

Methods

This was a retrospective study. All patients undergoing transcatheter aortic valve implantation with balloon-expandable system in our hospital between 2011 and 2014 were included. Edwards SAPIEN XT Transcatheter Heart Valve was used. The improvement of valve and heart function was evaluated as well as 30-day mortality and major complications according to the VARC-2 definition.

Results

A total of 10 transcatheter aortic valve implantation procedures with the balloon-expandable system were performed in our hospital, of which 9 were transfemoral and 1 was transapical. The median age was 76 years, and the median STS score and Logistic EuroSCORE (%) were 8.9 and 16.2. The implantation was successfully conducted in all patients, only 2 patients had mild paravalvular leak. There was no second valve implantation. Moreover, no 30-day mortality or complications was reported. Following the transcatheter aortic valve implantation procedure, the heart and valve functions had improved significantly. During the follow-up period of 3-34 months, one patient died of lung cancer 13 months after the operation.

Conclusion

This early experience has provided preliminary evidence for the safety and efficacy of transcatheter aortic valve implantation procedure with the balloon-expandable system in the developing world with an increasing aging population.

Incidence and causes of silent and symptomatic stroke following surgical and transcatheter aortic valve replacement: a comprehensive review

Stroke associated with aortic valve replacement in calcific aortic stenosis, either via transcatheter implantation (TAVR) or via surgical replacement (SAVR), is one of the most devastating complications. However, data concerning the clinical impact and incidence of clinical and silent stroke complicating SAVR and TAVR are varying. This comprehensive review of the literature explores the genuine incidence of neurological events after these procedures. Additionally, potential factors responsible for the discrepancies in stroke rates in the current literature are analysed and a lack of uniform neurological definitions and standardized neurological assessments revealed. Current stroke rates after TAVR show a decline from 7 to 1.7-4.8% in recent studies. Randomized studies comparing TAVR with SAVR yielded initially a significantly higher stroke rate after TAVR procedures as opposed to SAVR. Recently published data showed opposite results with strokes being higher following SAVR. Current data concerning stroke after surgical valve replacement report significantly higher rates of clinical strokes (17%) than previously mentioned in the literature (≤4.9%). Silent cerebral lesions were detected in 68-93% after TAVR and 38-54% after SAVR. A broader application of cerebral protection devices may help to reduce embolic cerebral events.

Transcatheter and Surgical Aortic Valve Replacement in Dialysis Patients: A Propensity-Matched Comparison

BACKGROUND

Transcatheter aortic valve replacement (TAVR) clinical trials in North America excluded patients on dialysis and, consequently, the outcomes of TAVR in dialysis-dependent patients remain unknown.

METHODS

All Medicare fee-for-service patients undergoing TAVR (n = 5,005) or surgical aortic valve replacement (SAVR) (n = 32,634) between January 1, 2011, and November 30, 2012, were identified using procedural codes collected by the Centers for Medicare & Medicaid Services. Dialysis status and comorbidities were identified using diagnosis codes present on arrival for TAVR hospitalization. Patients supported on dialysis who underwent TAVR (n = 224) were compared with non-dialysis patients who underwent TAVR as well as a propensity-matched group of contemporaneous dialysis patients who underwent SAVR (n = 194 pairs).

RESULTS

The TAVR patients on dialysis were younger than non-dialysis TAVR patients (79.2 years vs 84.1 years; p < 0.01) but had higher prevalence of comorbidities. Dialysis TAVR patients had increased mortality at 30 days (13% vs 6%, p < 0.01) and significantly worse survival by Kaplan-Meier analysis. Multivariable regression found dialysis to be independently associated with worse survival (hazard ratio, 1.73; 95% confidence interval, 1.33% to 2.25%, p < 0.01) in TAVR patients. Propensity-matched dialysis SAVR and dialysis TAVR patients had no significant differences in demographic or risk factors. Matched dialysis TAVR patients had shorter length of stay (6 interquartile range, 4 to 10] vs 10 [IQR 7 to 18] days; p < 0.01) and comparable survival.

CONCLUSIONS

TAVR in dialysis patients is associated with decreased survival compared with non-dialysis patients; however, it is comparable with SAVR in high risk dialysis patients based on a propensity-matched comparison.

Incidence and mechanisms of cerebral ischemia after transcatheter aortic valve implantation compared with surgical aortic valve replacement

BACKGROUND

The most likely mechanisms of neurologic injury after transcatheter aortic valve implantation (TAVI) and aortic valve replacement (AVR) are cerebral embolization and hypoperfusion. We set out to determine potential mechanisms of neurologic injury after TAVI compared with AVR.

METHODS

One hundred twenty-seven consecutive high-risk patients with severe aortic stenosis (AS) who underwent TAVI (n = 85) or AVR (n = 42) were studied. Transcranial Doppler ultrasound (TCD), cerebral oximetry, diffusion-weighted magnetic resonance imaging (DW-MRI) (before, 6 days, and 3 months after procedure), and neurocognitive assessment before and at 3 months were performed.

RESULTS

Neurologic injury was not significantly different between TAVI and AVR at 1 (1.1% vs 2.2%, p = 0.25) and 3 months (4.7% vs 2.2%, p = 1). At 3 months, overall cognitive score was higher in AVR compared with TAVI when adjusted for baseline score; the estimated difference between groups was 0.63 (95% confidence interval 0.87% to 1.17%; p = 0.02). Cerebral embolic load was 212 (123 to 344) during AVR and 134 (76 to 244) during TAVI (p = 0.07). Cerebral oxygen desaturation during AVR (7.56 ± 2.16) was higher compared with TAVI (5.93 ± 2.47) (p < 0.01). Ischemic lesions measured by DW-MRI occurred in 76% of TAVI and 71% of AVR patients at 6 days (p = 0.69) and 63% and 39% at 3 months (p = 0.11). No significant association was found between cerebral emboli, cerebral oxygen desaturation, brain ischemic lesions, and general cognitive score.

CONCLUSIONS

At 3 months follow-up, overall cognitive score was higher in AVR compared with TAVI, adjusted for baseline score. However, there was no difference in cerebral embolic load, ischemic lesions, and oxygen desaturation.

Transcatheter aortic valve replacement in nonsurgical candidates with severe, symptomatic aortic stenosis: a cost-effectiveness analysis

BACKGROUND

Transcatheter aortic valve replacement (TAVR) seems to improve the survival and quality of life of patients with aortic stenosis ineligible for surgical aortic valve replacement.

METHODS AND RESULTS

We used a decision analytic Markov model to estimate lifetime costs and benefits in a hypothetical cohort of patients with severe, symptomatic aortic stenosis who were ineligible for surgical aortic valve replacement. The model compared transfemoral TAVR with medical management and was calibrated to the Placement of Aortic Transcatheter Valves (PARTNER) trial. TAVR increased life expectancy from 2.08 to 2.93 years and quality-adjusted life expectancy from 1.19 to 1.93 years. TAVR also reduced subsequent hospitalizations by 1.40 but increased complications, particularly stroke (from 1% to 11% lifetime risk), and also increased lifetime costs from $83,600 to $169,100. The incremental cost-effectiveness of TAVR was $116,500 per quality-adjusted life-year gained ($99,900 per life-year gained). Results were robust to reasonable changes in individual variables but were sensitive to the level of annual healthcare costs caused by noncardiac diseases and to the projected life expectancy of medically treated patients.

CONCLUSIONS

TAVR seems to be an effective but somewhat expensive alternative to medical management among patients with symptomatic aortic stenosis ineligible for surgery. TAVR is more cost-effective for patients with a lower burden of noncardiac disease.

Valvular heart disease in older adults: evolving technology to meet the needs of aging patients

Valvular heart disease is associated with aging and the incidence is increasing as the population ages. Aortic stenosis and mitral regurgitation represent the majority of valvular disease in older adults. Severe valvular disease is associated with the development of heart failure, arrhythmia and death. Unfortunately, medical therapy is ineffective for the treatment of severe symptomatic valvular disease. As a result of advances in surgical techniques and catheter-based technologies, older adults who were once deemed ‘too old/sick’ are now being offered definitive treatment. However, the presence of comorbidities and frailty in the elderly make patient selection difficult and prediction of overall response to therapy less reliable compared with younger patients. In the elderly, goals of therapy may differ, with an emphasis placed on quality of life, functionality, maintaining independence and palliation of severe symptoms rather than increased longevity. We review the epidemiology and treatment approaches for valvular heart disease in older adults.

Impact of functional status on survival after coronary artery bypass grafting in a veteran population

BACKGROUND

Although functional impairment has been shown to be an adverse outcome of frailty, little is known of its effect on patients after cardiac operations. We aimed to assess the effect of limited functional status on long-term survival after coronary artery bypass grafting (CABG).

METHODS

We reviewed prospectively gathered data from 1,503 consecutive patients who underwent isolated CABG between 1997 and 2009. We compared the outcomes of 318 patients with limited functional status and 1,185 patients without any functional impairment. The mean follow-up period was 65 months (range, 1 to 157 months). We assessed the relationship between functional status impairment and long-term survival by Cox regression analysis adjusted for confounding factors.

RESULTS

Functionally impaired patients were slightly older (63±9 vs 62±8 years, p=0.05) and had more risk factors for adverse outcomes than patients who were functionally unimpaired. After adjustment for potential confounding variables by multivariate logistic regression analysis, preoperative limited functional status was not an independent predictor (odds ratio [95% confidence interval]) of 30-day mortality (1.4 [0.3 to 5.8], p=0.67) or major adverse cardiac events (1.3 [0.5 to 3.3], p=0.71), nor was it predictive of reduced long-term survival (10-year hazard ratio 1.0 [0.7 to 1.4], p=0.85).

CONCLUSIONS

Limited functional status was not an independent risk factor for early postoperative complications or death. Long-term survival in patients whose functional status was impaired before they underwent CABG was similar to that of patients who were functionally independent.

Immediate and late outcome of patients aged 80 years and older undergoing isolated aortic valve replacement: a systematic review and meta-analysis of 48 studies

OBJECTIVE

This study was planned to evaluate the outcome of patients ≥80 years old undergoing isolated conventional aortic valve replacement (AVR).

METHODS

Systematic review of the literature and meta-analysis of data on octogenarians and nonagenarians who underwent isolated AVR were performed.

RESULTS

The literature search yielded 48 observational studies reporting on 13 216 patients ≥80 years old. Pooled proportion of immediate postoperative mortality was 6.7 % (95% CI 5.8-7.5, 47 studies, 13,092 patients), and it was 5.8% (95% CI 4.8-6.9) in 18 studies with a mid-date from 2000 to 2006 and 7.5% (95% CI 6.8-8.2) in 30 studies with a mid-date from 1982 to 1999 (P = .004). Pooled proportion of postoperative stroke was 2.4% (95% CI 2.1-2.7, 21 studies, 8,436 patients), that of postoperative dialysis was 2.6% (95% CI 1.6-3.8, 10 studies, 1,945 patients), and that of postoperative implantation of a pacemaker was 4.6% (95% CI 3.6-5.8, 6 studies, 1,470 patients). Pooled survival rates at 1, 3, 5, and 10 years after isolated AVR were 87.6%, 78.7%, 65.4%, and 29.7%, respectively.

CONCLUSIONS

Immediate postoperative mortality and morbidity after isolated AVR in patients ≥80 years old are rather low. Postoperatively mortality decreased even further in the most recent series. Importantly, isolated AVR in these high-risk patients was associated with good late survival. These findings suggest that advanced age alone cannot be considered as a contraindication to conventional isolated AVR and that any new valve prosthesis implanted in these patients should be durable enough to guarantee the results so far offered by conventional surgery.

Transcatheter versus surgical aortic-valve replacement in high-risk patients

BACKGROUND

The use of transcatheter aortic-valve replacement has been shown to reduce mortality among high-risk patients with aortic stenosis who are not candidates for surgical replacement. However, the two procedures have not been compared in a randomized trial involving high-risk patients who are still candidates for surgical replacement.

METHODS

At 25 centers, we randomly assigned 699 high-risk patients with severe aortic stenosis to undergo either transcatheter aortic-valve replacement with a balloon-expandable bovine pericardial valve (either a transfemoral or a transapical approach) or surgical replacement. The primary end point was death from any cause at 1 year. The primary hypothesis was that transcatheter replacement is not inferior to surgical replacement.

RESULTS

The rates of death from any cause were 3.4% in the transcatheter group and 6.5% in the surgical group at 30 days (P=0.07) and 24.2% and 26.8%, respectively, at 1 year (P=0.44), a reduction of 2.6 percentage points in the transcatheter group (upper limit of the 95% confidence interval, 3.0 percentage points; predefined margin, 7.5 percentage points; P=0.001 for noninferiority). The rates of major stroke were 3.8% in the transcatheter group and 2.1% in the surgical group at 30 days (P=0.20) and 5.1% and 2.4%, respectively, at 1 year (P=0.07). At 30 days, major vascular complications were significantly more frequent with transcatheter replacement (11.0% vs. 3.2%, P<0.001); adverse events that were more frequent after surgical replacement included major bleeding (9.3% vs. 19.5%, P<0.001) and new-onset atrial fibrillation (8.6% vs. 16.0%, P=0.006). More patients undergoing transcatheter replacement had an improvement in symptoms at 30 days, but by 1 year, there was not a significant between-group difference.

CONCLUSIONS

In high-risk patients with severe aortic stenosis, transcatheter and surgical procedures for aortic-valve replacement were associated with similar rates of survival at 1 year, although there were important differences in periprocedural risks. (Funded by Edwards Lifesciences; Clinical Trials.gov number, NCT00530894.).