Aortic valve replacement in octogenarians with prior cardiac surgery

Re-sternotomy for aortic valve replacement in octogenarian patients in age of evolving transcatheter therapies

BACKGROUND

The aim of this study was to analyze perioperative results and long-term survival of re-sternotomy for surgical aortic valve replacement (SAVR) in octogenarians in age of transcatheter therapies.

METHODS

This is a retrospective, single-center study (April 2000 to December 2019). Perioperative data were compared for re-sternotomy with isolated SAVR (Isolated redoSAVR) and re-sternotomy with SAVR and concomitant cardiac procedure (Associated redoSAVR). Regression analyses were performed to identify predictors of in-patient mortality. Hazard ratios and Kaplan-Meier survival curves were compared for groups.

RESULTS

There were 163 patients (Isolated redoSAVR; 69, Associated redoSAVR; 94). Emergency/salvage cases were excluded. The median age was 83 (81-85) years and the median logEuroSCORE was 19.2 (13.0-26.7)%. The follow-up was 4.2 ± 3.5 years. Inpatient mortality was 4.9% (1.4% vs. 7.4% for Isolated redoSAVR and Associated redoSAVR respectively, p = .08). TIA/stroke rate was 8% (9% vs. 7% for Isolated redoSAVR and Associated redoSAVR, respectively, p = .78). COPD was a predictor of inpatient mortality (odds ratio: 8.86; 95% confidence interval: 1.19-66.11, p = .03). Survival was 88.7%, 86.4%, 70.1%, 49.5%, and 26.3% at 1, 2, 5, 7, and 10 years. There was no survival difference between Isolated redoSAVR and Associated redoSAVR (log rank p = .36, Wilcoxon p = .84). Significant adverse predictors of long-term survival were COPD, postoperative TIA/stroke, and length of stay. Survival was lower than age and gender-matched first-time SAVR and general population of the United Kingdom.

CONCLUSION

RedoSAVR in octogenarians is associated with significant morbidity and mortality. Shared decision-making should consider emerging transcatheter therapies as a valuable option in selected patients.

Long-term survival after surgical aortic valve replacement in patients aged 80 years and over

 

OBJECTIVES

Surgical aortic valve replacement can be safely performed in people aged 80 years and older with early benefits on both symptomatic and prognostic ground. While new approaches are advocated to treat this elderly and frail population, data on long-term outcomes are not available.

METHODS

We conducted a retrospective analysis of 1870 patients aged 80 years and over who underwent first time surgical aortic valve replacement during the period 2000-2019. The Kaplan-Meier method was used to calculate survival and comparisons among groups were performed by log-rank test. Cox analysis was used to determine the independent risk factors for late mortality.

RESULTS

The patients' mean age was 84 years and 53% were male. Isolated aortic valve replacement was performed in 42% of the patients, and coronary artery bypass grafting (n = 956), mitral valve (n = 94) or aortic surgery (n = 69) were associated in the remaining cases. One hundred eighty-one patients (8%) sustained at least 1 postoperative complication (reopening for bleeding or tamponade 3%, renal replacement therapy 3%, new cerebral stroke 1.5%). In-hospital mortality was 3.2% in the overall population (60/1870) and 2.2% after isolated aortic valve replacement (18/790). Survival was 90%, 66%, 31% and 14% at 1, 5, 10 and 15 years, respectively, and was similar to the expected survival of a sex- and age-matched population (log-rank P = 0.96). A complicated postoperative course was an independent risk factor for mortality during the follow-up [hazard ratio 1.32 (1.03, 1.68), P = 0.026].

CONCLUSIONS

Surgical aortic valve replacement can be performed with an acceptable early mortality rate and provides excellent long-term survival in people aged 80 years and older.

Octogenarians and aortic valve surgery: surgical outcomes in the geriatric population

Background

The era of percutaneous aortic valve intervention has challenged the continuing indication for surgical aortic valve replacement (SAVR).

Aim

The aim of this study is to evaluate clinical outcomes of the elderly patients who underwent surgical aortic valve replacement via median sternotomy, in order to assess the impact of surgery on patient outcomes and discharge destination.

Methods

The study involves a retrospective observational analysis in a single centre, including all octogenarian patients who underwent aortic valve surgery between January of 2011 and July of 2016. The study assessed pre-operative co-morbidities and post-operative outcomes, including long-term mortality and discharge destination following on from surgery.

Results

The mean age of patients was 82.7 years (± 2.9), 67% of whom were male. The mean EuroSCORE II was 8.1 (± 7.6). The most common pre-operative co-morbidities were dyslipidaemia (82%), hypertension (80%), and ischaemic heart disease (78.8%). The median length of stay was 10 days (± 6.9 days). Discharge home occurred in 71.8% of patients, with 21.2% of patients requiring transfer to a rehabilitation facility, and 1.2% of patients required placement into an aged care facility. There were five peri-operative deaths, equating to 5.9% of the cohort.

Conclusion

Despite high EuroSCORE II values for the majority of our patients, our data adds to overall suggestions that the octogenarian population can be considered eligible for SAVR and should not be excluded due to age alone. The use of the EuroSCORE II index more accurately predicts adequacy for treatment however does not entirely predict overall course of events, and proceduralist discretion should still be used.

Transcatheter versus Surgical Aortic Valve Replacement after Previous Cardiac Surgery: A Systematic Review and Meta-Analysis

Aim

Aortic valve replacement (AVR) in patients with prior cardiac surgery might be challenging. Transcatheter aortic valve replacement (TAVR) offers a promising alternative in such patients. We therefore aimed at comparing the outcomes of patients with aortic valve diseases undergoing TAVR versus those undergoing surgical AVR (SAVR) after previous cardiac surgery.

Methods and Results

MEDLINE, EMBASE, and the Cochrane Central Register were searched. Seven relevant studies were identified, published between 01/2011 and 12/2015, enrolling a total of 1148 patients with prior cardiac surgery (97.6% prior CABG): 49.2% underwent TAVR, whereas 50.8% underwent SAVR. Incidence of stroke (3.8 versus 7.9%, p=0.04) and major bleeding (8.3 versus 15.3%, p=0.04) was significantly lower in the TAVR group. Incidence of mild/severe paravalvular leakage (14.4/10.9 versus 0%, p < 0.0001) and pacemaker implantation (11.3 versus 3.9%, p=0.01) was significantly higher in the TAVR group. There were no significant differences in the incidence of acute kidney injury (9.7 versus 8.7%, p=0.99), major adverse cardiovascular events (8.7 versus 12.3%, p=0.21), 30-day mortality (5.1 versus 5.5%, p=0.7), or 1-year mortality (11.6 versus 11.8%, p=0.97) between the TAVR and SAVR group.

Conclusions

TAVR as a redo procedure offers a safe alternative for patients presenting with aortic valve diseases after previous cardiac surgery especially those with prior CABG.

Prognosis after surgical replacement with a bioprosthetic aortic valve in patients with severe symptomatic aortic stenosis: systematic review of observational studies

OBJECTIVE

 To determine the frequency of survival, stroke, atrial fibrillation, structural valve deterioration, and length of hospital stay after surgical replacement of an aortic valve (SAVR) with a bioprosthetic valve in patients with severe symptomatic aortic stenosis.

DESIGN

 Systematic review and meta-analysis of observational studies.

DATA SOURCES

 Medline, Embase, PubMed (non-Medline records only), Cochrane Database of Systematic Reviews, and Cochrane CENTRAL from 2002 to June 2016.

STUDY SELECTION

 Eligible observational studies followed patients after SAVR with a bioprosthetic valve for at least two years.

METHODS

 Reviewers, independently and in duplicate, evaluated study eligibility, extracted data, and assessed risk of bias for patient important outcomes. We used the GRADE system to quantify absolute effects and quality of evidence. Published survival curves provided data for survival and freedom from structural valve deterioration, and random effect models provided the framework for estimates of pooled incidence rates of stroke, atrial fibrillation, and length of hospital stay.

RESULTS

 In patients undergoing SAVR with a bioprosthetic valve, median survival was 16 years in those aged 65 or less, 12 years in those aged 65 to 75, seven years in those aged 75 to 85, and six years in those aged more than 85. The incidence rate of stroke was 0.25 per 100 patient years (95% confidence interval 0.06 to 0.54) and atrial fibrillation 2.90 per 100 patient years (1.78 to 4.79). Post-SAVR, freedom from structural valve deterioration was 94.0% at 10 years, 81.7% at 15 years, and 52% at 20 years, and mean length of hospital stay was 12 days (95% confidence interval 9 to 15).

CONCLUSION

 Patients with severe symptomatic aortic stenosis undergoing SAVR with a bioprosthetic valve can expect only slightly lower survival than those without aortic stenosis, and a low incidence of stroke and, up to 10 years, of structural valve deterioration. The rate of deterioration increases rapidly after 10 years, and particularly after 15 years.