Original article
Cardiovascular
Aortic Valve Replacement in Octogenarians: Risk Factors for Early and Late Mortality

Presented at the Fifty-third Annual Meeting of the Southern Thoracic Surgical Association, Tucson, AZ, Nov 8–11, 2006.
https://doi.org/10.1016/j.athoracsur.2006.09.068Get rights and content

Background

Excellent outcomes after aortic valve replacement (AVR) in elderly patients can be achieved, yet some practitioners are reticent to refer elderly patients for surgery. This study analyzed risk factors for mortality in patients aged 80 years and older undergoing AVR with or without concomitant coronary artery bypass grafting (CABG).

Methods

A retrospective review was performed of 245 patients (129 women) with a mean age of 83.6 ± 2.9 years who had AVR with (n = 140) or without CABG (n = 105) at a single institution from 1993 to 2005. Data were analyzed with a multivariate logistic regression for predictors of operative mortality, Kaplan-Meier estimates of survival, and a Cox multivariate proportional analysis of factors influencing long-term survival.

Results

Mean preoperative New York Heart Association (NYHA) classification was 3.1 ± 0.9, and 78% (192/245) of patients were classified as NYHA class III or IV. Operative (30-day) mortality was 9% (22/245). Independent risk factors for operative mortality included postoperative renal failure (odds ratio [OR], 20.9; 95% confidence interval [CI], 6.5 to 67.6; p < 0.001), postoperative permanent stroke (OR, 11.3; 95% CI, 1.7 to 75.1; p = 0.019), or intraoperative/postoperative intraaortic balloon pump (IABP) placement (OR, 14.9; 95% CI 2.9 to 75.8; p = 0.002). Survival after surgery was 82% (n = 183) at 1 year and 56% (n = 88) at 5 years. Prognostic factors for decreased long-term survival were regurgitant valve pathology (hazard ratio [HR], 6.0; 95% CI, 2.5 to 14.2; p = 0.002), intraoperative/postoperative IABP (HR, 2.9; 95% CI, 1.4 to 6.0; p = 0.010), postoperative renal failure (HR, 3.5, 95% CI, 2.2 to 5.7; p < 0.001), and postoperative stroke (HR, 7.0, 95% CI, 3.2 to 15.9; p < 0.001). Performing concomitant CABG was protective in terms of operative mortality (OR, 0.3; 95% CI, 0.09 to 0.83; p = 0.017) and improved long-term survival (HR, 0.7, 95% CI, 0.47 to 0.96; p = 0.020). Preoperative NYHA classification did not affect operative or long-term survival.

Conclusions

Patients aged 80 years and older who undergo AVR have acceptable short-term and long-term survival regardless of NYHA status. Concomitant CABG improved operative and long-term survival in this population. Despite their increased age, aggressive surgical treatment is warranted for most patients.

Section snippets

Material and Methods

This retrospective study was approved by the Institutional Review Board of Washington University School of Medicine, and individual consent was waived. Between November 1, 1993, and December 31, 2005, 245 patients aged 80 years or older underwent AVR with or without concomitant CABG. Preoperative demographic information and perioperative events were stored in a computerized database. New York Heart Association (NYHA) functional class was assessed preoperatively for each patient.

Members of the

Study Population Demographics

Men and women were equally represented (Table 1). The mean age of the patients was 83.6 ± 2.9 years (range, 80 to 92 years), and 94% (230/245) were white. Ten percent of patients had previous cardiac surgery, 66% had a history of hypertension, and 18% had diabetes mellitus. Peripheral vascular disease and chronic renal insufficiency were less common. Five patients (2%) were in an immunocompromised state, and 19 (8%) were in chronic renal insufficiency (one was on hemodialysis).

The most common

Comment

These results demonstrate that good late outcomes may be achieved with AVR in patients aged 80 years or older regardless of NYHA functional status. Late survival rates postoperatively showed that more than half of patients were still alive at 5 years. Similar 5-year survival rates of 55% to 66% have been achieved at other centers [1, 2, 3, 4, 5, 7, 9, 10, 11]. Even though operative mortality was higher than our results in the younger population, this slight increase was not prohibitive.

Such

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