Interact CardioVasc Thorac Surg 2007;6:308-313. doi:10.1510/icvts.2006.147728
© 2007 European Association of Cardio-Thoracic Surgery
Institutional report - Valves |
Aortic valve surgery in the elderly patient: a retrospective review
Alfredo Giuseppe Cerillo*,
Al Assal Al Kodami,
Marco Solinas,
Pier Andrea Farneti,
Stefano Bevilacqua,
Stefano Maffei,
Annamaria Mazzone and
Mattia Glauber
Operative Unit of Adult Cardiac Surgery, Ospedale ‘G. Pasquinucci’, Institute of Clinical Physiology, The National Research Council, Via Aurelia Sud 54100 Massa, Italy
Received 2 November 2006;
received in revised form 30 January 2007;
accepted 31 January 2007
*Corresponding author. Tel.: +39-0585493604; fax: +39-0585493614.
E-mail address: Cerillo{at}ifc.cnr.it (A.G. Cerillo).
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Abstract
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Elderly patients are referred with increasing frequency for aortic valve replacement (AVR), due to the ageing of the population and to improved results of surgery. We retrospectively analysed the in-hospital and short-term (up to three years) results of AVR in 185 patients aged  75 years, operated on at our institution from January 2000 to December 2003. Follow-up was completed by a telephone interview during January 2005. Hospital mortality was 6.5% (12 patients). A non-elective operation (P=0.001), preoperative NYHA functional class III (P=0.06), and chronic renal failure (P=0.02) were associated with increased operative mortality. Of note, age 80 years did not increase the surgical risk. The 4-year actuarial survival was 70.5%, the event-free survival was 60.6%, and almost all of the interviewed patients thought that they had benefited from the operation. Preoperative intubation, a NYHA class III, and a non-elective operation were univariate predictors of a poorer outcome. Our data show that aortic valve replacement may be performed with low morbidity and mortality in the elderly patient (age 75 years), and that an age 80 years neither increases the surgical risk, nor significantly worsens the short-term outcome.
Key Words: Aortic valve replacement; Octogenarian patients; Cardiac surgery; Symptomatic status
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1. Background
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According to the projections of the US National Bureau of the Census, the US population will include 25 million octogenarians by the year 2050, with up to 40% of them experiencing serious cardiovascular symptoms [1], and a similar scenario will probably occur in Europe. Calcific aortic stenosis is typically observed in the elderly patient, and with the ageing of the population, octogenarian patients are increasingly been scheduled for aortic valve replacement [2]. The aim of this retrospective study is to analyse the in-hospital and short-term results of AVR (isolated or concomitant with other surgical procedures), in patients aged 75 years, with special emphasis on patients aged 80 years.
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2. Methods
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2.1. Data collection
We retrospectively reviewed the clinical records, outpatient records and surgical reports of all patients aged 75 years undergoing aortic valve replacement (isolated or concomitant with other surgical procedures) at our institution from January 2000 to December 2003. Considered baseline characteristics included age, gender, body surface area, New York Heart Association functional class, history of angina, congestive heart failure, previous syncope, atrial fibrillation, diabetes, renal failure, smoking history, chronic obstructive pulmonary disease, previous cardiac surgery, previous myocardial infarction, coexistent coronary artery disease, mitral valve disease, and left ventricular ejection fraction. Intraoperative variables included cardiopulmonary bypass time, aortic cross-clamp time, size and brand of the implanted prosthesis, associated surgical procedures, and surgical priority. The surgical priority was defined according to the current indications of the Italian Society for Cardiac Surgery, as can be found on the internet at http://www.sicch.it/files/File/Dataset_SICCH_v1.00.pdf. The operation was defined as urgent when the patient underwent surgery within seven days from the diagnosis, and could not be discharged home before the operation. An emergency operation was defined as an operation carried out on referral before the beginning of the next working day. Operative complications and causes of death were recorded and analysed according to previously published guidelines [3].
Follow-up was completed by a telephone interview during January 2005. Patients were asked to answer a standard questionnaire regarding life style, symptoms, degree of independence, and pharmacological therapy.
2.2. Patient management
All patients underwent coronary angiography prior to the operation. When indicated, myocardial revascularisation was performed concomitant with AVR. A standard cardiopulmonary bypass technique during moderate hypothermia was employed in all cases, with intermittent retrograde warm blood cardioplegia for myocardial preservation.
2.3. Statistical analysis
Normally distributed continuous variables are expressed as mean±S.D. and analysed by the Student's t-test. Dichotomous variables are expressed as percentages, and analysed by the Pearson chi-square test or, when indicated, by the Fisher's exact test. The survival was analysed according to the Kaplan–Meier method. A log-rank test was used to analyse the impact of preoperative and operative variables on the outcome at follow-up.
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3. Results
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One hundred and eighty-five patients aged 75 years underwent AVR (isolated or concomitant with other surgical procedures) at our institution between 1 January, 2000 and 31 December, 2003. The mean age was 78.2±2.8, and 50 patients (27.0%) were aged 80 years at operation. Sixty patients (32.4%) underwent concomitant AVR and CABG, and 20 (10.8%) underwent multiple valvular procedures. All except 36 (19.4%) patients were in NYHA class III. The baseline and operative features of the study patients are reported in Table 1.
3.1. Operative mortality
Hospital mortality was 6.5% (12 patients). Operative complications and causes of death are reported in Table 2. A non-elective operation (P=0.001), preoperative NYHA functional class III (P=0.06), and chronic renal failure (P=0.02) were associated with increased operative mortality. Of note, age 80 years neither significantly increased the surgical risk (P=0.8), nor was associated with prolonged intubation (41.5±141.7 vs. 28.7±69.7 h, P=0.56), prolonged intensive care unit length of stay (62.7±114.4 vs. 55.8±90.5 h, P=0.79), or with prolonged postoperative stay (12.1±7.4 vs. 10.1±5.2 days, P=0.17).
As already observed, the hospital mortality tended to be higher in patients with a preoperative NYHA functional class III. In this group, the intubation time was significantly longer (28.7±33.4 vs. 6.5±12.7 h, P=0.04), as tended to be the intensive care unit length of stay (63.8±73.5 vs. 22.3±13.4 h, P=0.07), and the postoperative stay (13.2±5.2 vs. 8.1±3.2 days, P=0.1).
3.2. Follow-up
Two patients were lost at follow-up (98.9% complete). Of the remaining 171 patients, 26 died during follow-up, and 13 underwent repeated procedures or had complications requiring hospitalisation (Table 3). The total follow-up was 6715 patients-month. Mean follow-up was 36.3 months (range 13–60 months). At follow-up, one hundred and twenty-seven patients were in NYHA class I or II (Fig. 1). The 4-year actuarial survival was 70.5%, the event-free survival was 60.6%, and almost all (97.5%) of the interviewed patients thought that they had benefited from the operation. Age 80 years at operation did not influence the short-term survival (Fig. 2). On the other hand, an NYHA class III (Hazard Ratio=1.4; 95% CI 1.1–1.8; P=0.02), preoperative intubation (Hazard Ratio=2.9; 95% CI 1.05–6.4; P=0.03) and a non-elective operation (Hazard Ratio=2.6; 95% CI 1.2–4.1; P=0.001) were univariate predictors of a poorer outcome, and a preoperative an NYHA class III was associated with shorter survival at multivariate analysis, although this result was not statistically significant (P=0.07) (Fig. 3). A similar figure was observed when considering the event-free survival (Figs. 4 and 5).
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4. Discussion
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Our data show that aortic valve replacement may be performed with low morbidity and mortality in the elderly patient (age 75 years), and that an age 80 years per se neither increases the surgical risk, nor significantly worsens the short-term outcome. Furthermore, according to our experience, the single most important factor predicting a bad in-hospital and short-term result is an advanced symptomatic status at operation (preoperative NYHA class III, preoperative intubation, non-elective operation). As a consequence, the paucisymptomatic octogenarian undergoing aortic valve replacement should be considered as a low-risk patient, and should be expected to experience an uneventful and expedite postoperative recovery.
Advanced age has been repeatedly reported to increase the operative risk in cardiac surgical patients [2, 4, 5]. However, previous research has shown that excellent results may be achieved in selected octogenarians [2, 6, 7]. In their analysis of 436 consecutive cardiac surgical patients aged 75 years, Maharajh and co-workers [6] found that a non-elective operation, the presence of cardiomegaly, and the presence of end-stage organ failure were independent predictors of in-hospital death. In this series, an age 80 years was not associated with a worst outcome. Fruitman and co-workers [7] reported a 7.9% hospital mortality in a group of 127 octogenarian patients undergoing heart operations. Interestingly, in their series there were no hospital deaths in patients undergoing aortic valve replacement with or without associated CABG, and the only factors associated with increased hospital mortality were preoperative renal failure and a non-elective operation. Furthermore, at follow-up the SF-36 scores [7–9] in the operated patients were equal to or better than those for the general population aged 65 years, 83.7% of the patients were living at home (versus 46.5% at presurgical admission), and 82.5% of the patients would undergo operation again in retrospect. All these data are similar to our findings, and strengthen the two main facts emerging from our study, that are: (a) in the absence of severe comorbidities, octogenarian patients can undergo aortic valve replacement with low morbidity and mortality, experiencing a quick and uneventful postoperative recovery; and (b) a non-elective operation, a preoperative NYHA class III or preoperative intubation, and end-stage organ failure (in particular chronic renal failure) significantly increase the risks of surgery.
Some traditional risk factors for patients undergoing AVR did not appear to increase the surgical risk in our series. In particular, a previous cardiac operation and associated surgical procedures did not increase the hospital mortality. A possible explanation for this is the small number of redo patients and of patients undergoing multiple valve procedures in our series: a larger number of combined and redo procedures would probably result in an increase of the observed mortality. Another factor that should be mentioned is prosthesis–patient mismatch (PPM). Although we did not perform an echocardiographic follow-up, most of the 29 patients receiving a 19-mm prosthesis had PPM, defined as an EOAI of <0.85 cm2/m2, at hospital discharge. However, all patients receiving a 19-mm valve in this series were female with a small (1.64±0.15 m2) BSA, and the use of a 19-mm valve was not associated with increased early mortality. Similar results have previously been reported in the literature by others [10]. A final comment should be made about the possible usefulness of the EuroSCORE system for preoperative risk stratification in elderly patients undergoing AVR. As one can see, the additive EuroSCORE in our series was high (Table 1), and the operative risk was possibly overestimated by this mean. Indeed, the advanced age has a tremendous impact on the additive EuroSCORE: to give a figure, according to the additive EuroSCORE model a 57-year-old patient with COPD, severe chronic renal failure and moderate left ventricular dysfunction undergoing an emergency ‘other than isolated CABG’ procedure would experience the same risk as an 81-year-old patient with 45% left ventricular ejection fraction undergoing elective AVR. This limitation of the additive EuroSCORE model is possibly overcome by the logistic EuroSCORE. However, we started using the EuroSCORE by the end of 2001, and the EuroSCORE was reliably calculated in all patients preoperatively only after June 2002. As a consequence, the additive EuroSCORE was available only for the last 92 patients, and this fact consistently limits our ability to comment on this point.
According to the AHA-ACC guidelines for aortic valve replacement, in patients with aortic stenosis the only class I indication is represented by the presence of symptoms [11]. In asymptomatic patients, the presence of left ventricular dysfunction and an abnormal response to exercise are considered class IIa indications. In our opinion, some considerations are needed. Elderly patients may not be able to undergo a stress test in the presence of comorbidities (obesity, claudicatio, arthritis, COPD). Furthermore, elderly patients are prone to deny symptoms, and may fail to recognise them [12–14]. Finally, our and other data support the concept that the presence of a frankly symptomatic status is associated with unsatisfactory operative and short-term results. All these facts should be considered before addressing a paucisymptomatic elderly patient with severe AS to medical therapy, and all the efforts should be made to prevent the appearance of left ventricular dysfunction or severe symptoms in these patients.
Several efforts have been recently made to identify early predictors of progression to the symptomatic status in patients with severe AS. Hering and co-workers [13] found that the presence of atypical symptoms (fatigue, dizziness, exertional intolerance, palpitations) and of ECG changes indicative of left ventricular hypertrophy or ST segment/ T-wave abnormalities, are associated with a faster reduction of the aortic valve area (AVA) and shorten the time interval until otherwise asymptomatic patients exhibit classical symptoms of advanced AS. Rosenhek and associates [12] found that the presence of severe calcification of the aortic valve, and a fast reduction of the AVA at echocardiography are associated with a significantly shorter event-free survival. Finally, several authors have recently shown that increased levels of BNP at the diagnosis are associated with a significantly shorter survival [15] and symptom-free survival [14]. We, therefore, believe that the currently available guidelines should be updated in light of these evidences, and that all the cited strategies should be employed in asymptomatic elderly patients with severe AS in order to better define the appropriateness of surgery and to avoid any late, high-risk operation.
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5. Study limitation
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The main limitation of the present study resides in its retrospective design. Furthermore, our analysis was conducted on a limited number of patients, followed for a short period of time. We were able to record a limited number of events, and this weakened the significance of our statistical analysis.
A second major limitation of our work is due to the fact that we do not have data concerning patients' referral: most asymptomatic octogenarians with aortic valve disease are probably not referred for cardiac surgical evaluation by their physicians, and this would result in selection bias.
This notwithstanding, we believe that our data represent a realistic picture of the current AVR patient population in western countries, with regard to both the risk profile and the surgical results, and that our and other recent studies will help in ameliorating the selection criteria for AVR surgery in the elderly patient.
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6. Conclusion
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Aortic valve replacement may be performed with excellent results in patients aged 75 years, and age 80 years did not significantly increase the surgical risk in our series. According to our experience, the results of aortic valve surgery are less satisfactory in heavily symptomatic patients and in patients operated on an urgent or emergency basis. We believe that earlier referral should be considered in the elderly patient with AS, and that all the available knowledge should be used to optimise the patient's selection for surgery.
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Acknowledgements
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We would like to acknowledge Miss Susan Gwynne for her precious help in manuscript preparation.
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Abstract
1. Background
