Long-Term Outcomes After Isolated Aortic Valve Replacement in Octogenarians: A Modern Perspective

doi:10.1016/j.athoracsur.2008.06.036

The Annals of Thoracic Surgery

Volume 86, Issue 5, November 2008, Pages 1458-1465

Presented at the Forty-fourth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2008. Winner of the Geriatric Patient Care Award.

https://doi.org/10.1016/j.athoracsur.2008.06.036 Get rights and content

Background

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

Methods

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

Results

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

Conclusions

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

Section snippets

Material and Methods

The institutional Society of Thoracic Surgeons (STS) Adult Cardiac Database was queried for all patients who underwent isolated, primary AVR at Emory Healthcare Hospitals between January 1, 1996 and December 31, 2006. The primary study goals were to describe the short-term and long-term survival of patients classified into decade age ranges: 60 to 69, 70 to 79, and 80 years or greater. This included patients with emergent and urgent status. Patients were excluded from this analysis if they

Results

A total of 515 patients were studied and divided into three age groups: 60 to 69 (n = 206), 70 to 79 (n = 221), and 80 to 89 (n = 88) years. The preoperative characteristics for each group are summarized in Table 1. As expected, age was statistically significantly different among groups. Other statistically significant factors included more females and more patients with a preoperative history of a myocardial infarction in the older patient populations. Not surprisingly, more current smokers

Comment

With the advent of percutaneous techniques for aortic valve replacement (eg, transfemoral and transapical procedures), increasing scrutiny has been placed on the management of aortic valve disease in the elderly and high-risk patients. Increasing age has been uniformly determined as a significant independent predictor of postoperative mortality [14]. Unfortunately, the perception of advanced age and its associated comorbidities as risk factors for poor outcomes after AVR have led clinicians to

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The study objective was to describe the clinical outcomes of elderly patients undergoing ascending aortic surgery.
Patients aged 70 years or older who underwent ascending aortic surgery between January 2002 and December 2013 were examined. Of 415 included patients, 285 were elderly patients (age 70-79 years) and 130 were very elderly (age ≥80 years). Logistic regression and Cox proportional hazards models were used to evaluate operative mortality and long-term survival, respectively.
Surgical indications included aortic aneurysm (63.1%), calcified aorta with need for other cardiac procedure (26.4%), and type A dissection (10.5%). Compared with elderly patients, the very elderly patients had a higher burden of comorbidities and operative mortality (13% vs 7%, P < .04). The very elderly patients were also more likely to be discharged to a rehabilitation facility than home (P < .001). However, risk-adjusted operative mortality and 30-day readmissions rates were similar (P > .05). Kaplan–Meier estimates of survival at 1 and 5 years were 85.6% and 72.6% for elderly patients versus 79.2% and 57.1% for the very elderly patients. Age was a strong risk variable for late mortality in the unadjusted and adjusted analyses.
After adjusting for these comorbidities, the cause of aortic disease, and the type of procedure, age was not an independent predictor of operative mortality, but was strongly associated with reduced late survival. Thus, advanced age alone should not be an absolute contraindication for ascending aortic surgery.
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Minimized length of hospitalization (LoS) and lower risk of hospitalization-related complications are key requirements in the treatment of aortic valve disease, mainly in the elderly candidates. Our objective was to evaluate evolution of LoS after surgical (SAVR) or transcatheter aortic valve implantation (TAVI) and its predictors.
We enrolled 1,849 elderly (aged >75) patients receiving SAVR or TAVI from 2009 to 2016. In the surgical cohort (n = 1,006) the mean LoS slightly decreased from 13.81 ± 9.27 days (2009) to 10.96 ± 3.77 (2016); in the TAVI cohort (n = 843), LoS passed from 13.33 ± 9.17 (2009) to 6.21 ± 4.30 days (2016). All-cause mortality at 1 month was 3.77 % (SAVR) versus 4.7% (TAVI) (p >0.05). Among Transfemoral TAVI (TF, n = 681), and Transsubclavian TAVI (TS, n = 62), average LoS was comparable (7.38 days ± 7.11 vs 7.31 ± 4.32; median 6.0 and 6.0 days, p = 0.07). Procedural success was reached in 93% (TF) and in 85.4% (TS) (p = 0.20). There were no meaningful differences among TF and TS in terms of VARC-2 postprocedural morbidity, except for the rate of vascular access-related complications; these occurred in 8.8% of cases in the TF group versus 1.6% in the TS group (p = 0.05).
In conclusion the present analysis showed a faster improvement in terms of LoS for TAVI compared with SAVR over 8 years of activity. The 2 strategies presented comparable all-causes mortality at 30 days. LoS, rates of procedural success and complications were comparable among TF and TS TAVI; nonetheless, vascular access-related complications were more frequent in the TF cohort. This suggests the validity of the TS route as an alternative to the TF approach.
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Aortic root replacement in octogenarians offers acceptable perioperative and late outcomes
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As the proportion of the population more than 80 years of age increases, cardiac surgeons will increasingly be consulted to operate on this high-risk patient group. The aim of this study is to evaluate the perioperative and late outcomes of octogenarians undergoing aortic root replacement in comparison with younger patients.
All patients undergoing aortic root replacement at our institution between 2005 and 2012 (n = 592) were retrospectively reviewed. Patients were stratified according to their age at surgery: patients less than 80 years old (group LT80, n = 558) and octogenarians (group OG, n = 34). Primary outcomes of interest were inhospital mortality and perioperative complication rate.
Patients in the OG group had significantly higher rates of preoperative stroke history, atrial fibrillation, and coronary artery disease. Indication for surgery was type A aortic dissection in 62 (10.5%), thoracic aortic aneurysm in 514 (86.8%), and endocarditis in 11 (1.9%), with no intergroup differences. Inhospital mortality was not significantly different between groups (5.9% OG versus 2.3% LT80, p = 0.21), and postoperative atrial fibrillation was more common in OG (60.6% OG versus 38.5% LT80, p = 0.01). Type A dissection, diabetes mellitus, and prior cardiac surgery were independent predictors of inhospital mortality or postoperative stroke.
Octogenarians can safely undergo aortic root replacement with moderately worse but acceptable perioperative mortality and late survival. Further studies are necessary to determine which subset of octogenarians are at the highest operative risk and may benefit from a conservative approach.
Transcatheter aortic valve replacement versus aortic valve bypass a comparison of outcomes and economics presented at the sixty-first annual meeting of the southern thoracic surgical association, Tucson, AZ, Nov 5-8, 2014.
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Transcatheter aortic valve replacement (TAVR) is currently offered to patients who are high-risk candidates for conventional surgical aortic valve replacement. For the past 37 years, off-pump aortic valve bypass (AVB) has been used in elderly patients at our center for this similarly high-risk group. Although TAVR and AVB were offered to similar patients at our center, comparisons of clinical outcomes and hospital economics for each strategy were not reported.
We reviewed the clinical and financial records of 53 consecutive AVB procedures performed since 2008 with the records of 51 consecutive TAVR procedures performed since 2012. Data included demographics, hemodynamics, The Society of Thoracic Surgeons (STS) risk score, extent of coronary disease, and ventricular function. Follow-up was 100% in both groups. Hospital financial information for both cohorts was obtained. Mean risk score for the TAVR group was 10.1% versus 17.6% for AVB group (p < 0.001).
Kaplan-Meier hospital rates of 3- and 6-month survival and of 1-year survival were 88%, 86%, 81%, and 61% and 89%, 83%, 83%, and 70% for the TAVR and AVB groups, respectively (p = 0.781). Two patients who had undergone TAVR had a procedure-related stroke. The one stroke in an AVB recipient was late and not procedure related. At discharge, mild and moderate perivalvular and central aortic insufficiency were present in 31% and 16% of TAVR recipients, respectively; no AVB valve leaked. Transvalvular gradients were reduced to less than 10 mm Hg in both groups. The average hospital length of stay for the AVB-treated patients was 13 days, and it was 9 days for the TAVR-treated patients. Median hospital charges were $253,000 for TAVR and $158,000 for AVB. Mean payment to the hospital was $65,000 (TAVR) versus $64,000 (AVB), and the mean positive contribution margin (profit) to the hospital was $14,000 for TAVR versus $29,000 for AVB.
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Original articleAdult cardiacLong-Term Outcomes After Isolated Aortic Valve Replacement in Octogenarians: A Modern Perspective

Background

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Am J Cardiol

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Original article
Adult cardiac
Long-Term Outcomes After Isolated Aortic Valve Replacement in Octogenarians: A Modern Perspective