Article

Outcomes of elderly patients aged 80 and over with symptomatic, severe aortic stenosis: Impact of patient's choice of refusing aortic valve replacement on survival

August 2008
QJM: monthly journal of the Association of Physicians 101(7):567-73

August 2008
101(7):567-73

DOI:10.1093/qjmed/hcn052

Source
PubMed

Authors:

Pouya Youssefi

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Aortic valve replacement (AVR) can be performed safely in selected elderly patients with aortic stenosis (AS). However, the survival benefits of AVR over conservative treatment have not been convincingly demonstrated in AS patients aged above 80. To investigate the outcomes of patients aged 80 and over with symptomatic, severe AS and by analyzing the effects of patient's choice in either agreeing or refusing to undergo AVR, determine the survival benefits afforded by AVR. Cohort study. Subjects aged 80 and over with severe symptomatic AS, diagnosed between 2001 and 2006 were segregated into three groups: subjects who underwent AVR (Group A); patients who were fit for AVR but declined surgery due to personal choice (Group B) and those who were not fit for surgery and were managed conservatively (Group C). Follow-up was conducted by out-patient attendances, review of medical records and telephone interviews. The primary endpoint was all-cause mortality. A total of 103 patients (86.0 +/- 4.2 years, 41% male) were identified and no patient was lost during follow-up. In Group A (n = 17), all 15 patients who underwent AVR were alive after 3.6 +/- 1.4 years follow-up and 2 died whilst awaiting AVR. Seventy-four percent of Group B (n = 24) and 76% of Group C (n = 62) died during follow-up. Group A had significantly better survival than B and C. (P < 0.01) Amongst patients fit for AVR with similar operative risks (Groups A and B), refusal to undergo surgery (hazard ratio 12.61, P = 0.001) was the only predictor of mortality in a multivariate model. For elderly AS patients fit for surgery, the patient's decision to refuse AVR is associated with a >12-fold increase in mortality risk. These findings have significant implications for informed decision-making when managing the fit, elderly patient with AS.

Prospective Registry of Symptomatic Severe Aortic Stenosis in Octogenarians: a Need for Intervention.

Article

Dec 2013
J INTERN MED

To study the factors associated with choice of therapy and prognosis in octogenarians with severe symptomatic aortic stenosis (AS). Prospective, observational, multicenter registry. Centralized follow-up included survival status and, if possible, mode of death and Katz index. Transnational registry in Spain. We included 928 patients aged ≥80 years with severe symptomatic AS. Aortic valve replacement (AVR), transcatheter aortic valve implantation (TAVI) or conservative therapy. All-cause death. Mean age was 84.2±3.5 years, and only 49.0% were independent (Katz index A). The most frequent planned management was conservative therapy in 423 (46%) patients, followed by TAVI in 261 (28%), and AVR in 244 (26%). The main reason against recommending AVR in 684 patients was high surgical risk (322 [47.1%]), other medical motives (193 [28.2%]), patient refusal (134 [19.6%]), and family refusal in the case of incompetent patients (35 [5.1%]). The mean time from treatment decision to AVR was 4.8±4.6 months and to TAVI 2.1±3.2 months, p<0.001. During follow-up (11.2 to 38.9 months), 357 patients (38.5%) died. Survival rates at 6, 12, 18, and 24 months were 81.8%, 72.6%, 64.1%, and 57.3%, respectively. Planned intervention, adjusted for multiple propensity score, was associated with lower mortality when compared with planned conservative treatment: TAVI Hazard ratio (HR) 0.68 (95% confidence interval [CI] 0.49 to 0.93; p=0.016), AVR HR 0.56 (95% CI 0.39 to 0.8; p=0.002). Octogenarians with symptomatic severe AS are frequently managed conservatively. Planned conservative management is associated with a poor prognosis. This article is protected by copyright. All rights reserved.

Persistent reduction in the age adjusted mortality rate from aortic valve surgery in the United State with elimination of gender gap in recent years

Article

Full-text available

Oct 2020

Background: Advancement in the surgical techniques should translate into better outcome. The goal of this study was to evaluate mortality trends from aortic valve surgery in the United State using large inpatient database. Method: The Nationwide Inpatient Sample (NIS) database was used to calculate the age-adjusted mortality rate from aortic valve surgery from 1988 to 2011 in the United State using ICD-9 coding for aortic valve surgery. Results: We found that age adjusted mortality rate from aortic valve surgery gradually decreased from 1988 until end of study in 2011 to the lowest level with elimination of gender gap that was seen in the early years. For men, age adjusted mortality rate from aortic valve surgery in 1988 was 438 per 100,000 with steady reduction to the lowest level of 214 per 100,000 in 2011 which remained unchanged from 2007. For women, age adjusted mortality from aortic valve surgery was 620 per 100,000 in 1988 with steady reduction to the lowest level of 235 per 100,000 in 2011 which also remained unchanged since 2007. Conclusion: Age adjusted mortality from aortic valve surgery has been gradually decreasing in the last decade and remained stable at the lowest rates in recent years suggesting improvement in surgical technics and post-surgical care.

Transcatheter aortic valve replacement for severe aortic stenosis can improve long-term survival of nonagenarians as compared to an age- and sex-matched general population

Article

Full-text available

Aug 2019
J Cardiol

Backround Nonagenarians are at increased risk for morbidity and mortality after TAVR based solely on their age. The aim of our study was to evaluate survival of nonagenarians with severe aortic valve stenosis (AS) after Transcatheter Aortic Valve Replacement (TAVR) as compared to an age- and sex-matched general population. Methods From 2009-2017, 1.052 consecutive patients ≥ 80 years scheduled for TAVR were included. Patients were divided into three groups depending on their age at the time of the procedure: 80 – 84 (Group 1), 85 – 89 (Group 2) and ≥ 90 years (Group 3). Survival of patients treated with TAVR was compared to the life expectancy of an age- and sex-matched cohort in the general population. Results Nonagenarians were more likely to experience major access-site complications than their younger counterparts (7.6% Group 1 vs. 10.1% Group 2 vs. 17.6% Group 3, p=0.016). One-year mortality in nonagenarians was higher as compared to the general population (27.8% vs. 20.0%). After two years, the mortality curves between the TAVR patients and the general population converged (39.2% vs. 37.5%) and were lower after 5-years. Conclusions During the observation period of five years, carefully selected nonagenarians treated with TAVR had at least the same mortality rate as an age- and sex-matched general population after two years despite procedure associated complications. The negative prognostic impact of the severe AS was completely eliminated by TAVR.

Transcatheter Aortic Valve Implantation

Article

Jul 2009

Cell Sources for Tissue Engineering Strategies to Treat Calcific Valve Disease

Article

Full-text available

Nov 2018

Cardiovascular calcification is an independent risk factor and an established predictor of adverse cardiovascular events. Despite concomitant factors leading to atherosclerosis and heart valve disease (VHD), the latter has been identified as an independent pathological entity. Calcific aortic valve stenosis is the most common form of VDH resulting of either congenital malformations or senile “degeneration.” About 2% of the population over 65 years is affected by aortic valve stenosis which represents a major cause of morbidity and mortality in the elderly. A multifactorial, complex and active heterotopic bone-like formation process, including extracellular matrix remodeling, osteogenesis and angiogenesis, drives heart valve “degeneration” and calcification, finally causing left ventricle outflow obstruction. Surgical heart valve replacement is the current therapeutic option for those patients diagnosed with severe VHD representing more than 20% of all cardiac surgeries nowadays. Tissue Engineering of Heart Valves (TEHV) is emerging as a valuable alternative for definitive treatment of VHD and promises to overcome either the chronic oral anticoagulation or the time-dependent deterioration and reintervention of current mechanical or biological prosthesis, respectively. Among the plethora of approaches and stablished techniques for TEHV, utilization of different cell sources may confer of additional properties, desirable and not, which need to be considered before moving from the bench to the bedside. This review aims to provide a critical appraisal of current knowledge about calcific VHD and to discuss the pros and cons of the main cell sources tested in studies addressing in vitro TEHV.

Expectation and Quality of Life after Aortic Valve Replacement over 85 Years of Age Match those of the Contemporary General Population

Article

Feb 2016
INT J ARTIF ORGANS

Background: In the transcatheter aortic valve implantation (TAVI) years, very elderly patients with aortic stenosis (AS) are referred to surgery with reluctance despite excellent hospital outcomes. A poorly assessed outcome of discharged survivors might further overlook the actual efficacy of the surgical strategy in this cohort. We thus evaluated life-expectancy and functional results in discharged survivors over 85 years operated on for AS. Methods: Between January 2001 and December 2013, 57 consecutive patients aged ≥85 years underwent aortic valve replacement (AVR) with or without concomitant procedures at our institution. Late survival rate (SR), New York Heart Associaion (NYHA) functional class and quality of life (RAND SF-36) were assessed. SR and quality of life (QoL) were than compared to the contemporary general population matched for age and gender, as calculated by the Italian National Institute of Statistics. Results: Overall in-hospital mortality was 8.8% (5 pts). In patients without concomitant coronary artery bypass grafting (CABG), in-hospital mortality was 2.9%. Survival at 5 and 9 years was 57.7 ± 8.4% and 17.9 ± 11.4%, respectively. No predictors of late mortality including concomitant CABG were identified at Cox analysis. The mean NYHA class for long-term survivors improved from 3.1 to 1.6 (p<0.001). Survivors reported better QoL-scores compared to the age- and gender-matched contemporary general population in 4 RAND SF-36 domains. Life-expectancy resulted comparable to that predicted for the age and gender-matched general population. Conclusions: Isolated AVR in patients aged ≥85 years can be performed with acceptable risk. Survivors improve in NYHA class and, when compared to age- and gender-matched individuals, show a similar life expectancy and a no lower QoL.

A systematic review on the quality of life benefits after aortic valve replacement in the elderly

Article

Feb 2013

Background: Surgical aortic valve replacement is being increasingly performed in elderly patients with good perioperative outcomes and long-term survival. Evidence is limited on health-related quality of life after aortic valve replacement, which is an important measure of operative success in the elderly. Methods: A systematic review of clinical studies after January 2000 was performed to identify health-related quality of life in the elderly after aortic valve replacement. Strict inclusion and exclusion criteria were applied. Quality appraisal of each study also was performed using predefined criteria. Health-related quality of life results were synthesized through a narrative review with full tabulation of the results of all included studies. Results: Health-related quality of life improvements were shown across most or all domains in different health-related quality of life instruments. Elderly patients experienced marked symptomatic improvement. Health-related quality of life was equivalent or superior to both an age-matched population and younger patients undergoing identical procedures. There were excellent functional gains after surgery, but elderly patients remain susceptible to geriatric issues and mood problems. Concomitant coronary artery bypass did not affect health-related quality of life. There was a diverse range of study designs, methods, and follow-up times that limited direct comparison between studies. Conclusions: Aortic valve replacement results in significant health-related quality of life benefits across a broad range of health domains in elderly patients. Age alone should not be a precluding factor for surgery. Data are heterogeneous and mostly retrospective. We recommend future studies based on consistent guidelines provided in this systematic review.

VALVULAR HEART DISEASE MANAGED WITH AYURVEDA TREATMENT - A CASE STUDY

Article

Dec 2023

Aortic stenosis (AS) is one of the heart's most common and severe valve diseases. Narrowing of the valve more commonly develops during aging. It influences genetic factors, hormones, lipid infiltration, inflammation, and calcification on valves, resulting in a restricted amount of blood flow through the valve. Patients of AS become prostrated and suffer from breathlessness, angina, syncope, palpitations, heart murmur, and other symptoms de-pending on their severity grade. It is a burning health issue, with more than one million new cases per year in India. Yet, there is no solace for AS in the contemporary medicinal system, and surgery has many more limita-tions in older adults. Time-trusted Ayurveda treatment modalities are merited in senior management by trimming down degenerative processes and enhancing the quality of health. Presenting a geriatric, severe AS case report, who otherwise was suggested to undergo valve replacement surgery, was treated with oral medications of Hrudroga chikitsa, which significantly improved the functional ability of the heart and quality of life.

Proposed Risk Score in Patients with Aortic Stenosis Submitted to Valve Replacement Surgery

Article

Full-text available

Dec 2022
Braz J Cardiovasc Surg

Introduction: Due to Brazilian population aging, prevalence of aortic stenosis, and limited number of scores in literature, it is essential to develop risk scores adapted to our reality and created in the specific context of this disease. Methods: This is an observational historical cohort study with analysis of 802 aortic stenosis patients who underwent valve replacement at Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul, from 1996 to 2018. With the aid of logistic regression, a weighted risk score was constructed based on the magnitude of the coeficients β of the logistic equation. Two performance statistics were obtained: area under the receiver operating characteristic curve and the chi-square (χ2) of Hosmer-Lemeshow goodness-of-fit with Pearson's correlation coeficient between the observed events and predicted as a model calibration estimate. Results: The risk predictors that composed the score were valve replacement surgery combined with coronary artery bypass grafting, prior renal failure, New York Heart Association class III/IV heart failure, age > 70 years, and ejection fraction < 50%. The receiver operating characteristic curve area was 0.77 (95% confidence interval: 0.72-0.82); regarding the model calibration estimated between observed/predicted mortality, Hosmer-Lemeshow test χ2 = 3,70 (P=0.594) and Pearson's coeficient r = 0.98 (P<0.001). Conclusion: We propose the creation of a simple score, adapted to the Brazilian reality, with good performance and which can be validated in other institutions.

Transapical transcatheter aortic valve implantation: Follow-up to 3 years

Article

Full-text available

Jan 2011

We performed the first human case of successful transapical transcatheter aortic valve implantation on a beating heart in October 2005, and therefore we have the longest follow-up on transapical aortic valve implantation in humans. We now report clinical and echocardiographic outcomes of transapical aortic valve implantation in 71 patients. Between October 2005 and February 2009, 71 patients (44 female) underwent transcatheter transapical aortic valve implantation with either 23- or 26-mm Edwards Lifesciences transcatheter bioprostheses. All patients with symptomatic aortic stenosis were declined for conventional aortic valve replacement owing to unacceptable operative risks and were not candidates for transfemoral aortic valve implantation because of poor arterial access. Clinical and echocardiographic follow-ups were performed before discharge, at 1 and 6 months, and then yearly. The mean follow-up was 12.9 +/- 11.5 months with a total of 917.3 months of follow-up. Mean age was 80.0 +/- 8.1 years and predicted operative mortality was 34.5% +/- 20.4% by logistic EuroSCORE and 12.1% +/- 7.7% by The Society of Thoracic Surgeons Risk Calculator. Valves were successfully implanted in all patients. Twelve patients died within 30 days (30-day mortality: 16.9% in all patients, 33% in the first 15 patients, and 12.5% in the remainder), and 10 patients died subsequently. Overall survival at 24 and 36 months was 66.3% +/- 6.4% and 58.0% +/- 9.5%, respectively. Among 59 patients who survived at least 30 days, 24- and 36-month survivals were 79.8% +/- 6.4% and 69.8% +/- 10.9%, respectively. Late valve-related complications were rare. New York Heart Association functional class improved significantly from preoperative 3.3 +/- 0.8 to 1.8 +/- 0.8 at 24 months. The aortic valve area and mean gradient remained stable at 24 months (1.6 +/- 0.3 cm(2) and 10.3 +/- 5.9 mm Hg, respectively). Our outcome suggests that transapical transcatheter aortic valve implantation provides sustained clinical and hemodynamic benefits for up to 36 months in selected high-risk patients with symptomatic severe aortic stenosis.

Cardiac rehabilitation to improve health-related quality of life following trans-catheter aortic valve implantation: a randomised controlled feasibility study: RECOVER–TAVI Pilot, ORCA 4, For the Optimal Restoration of Cardiac Activity Group

Article

Full-text available

Dec 2018

Objectives Transcatheter aortic valve implantation (TAVI) is often undertaken in the oldest frailest cohort of patients undergoing cardiac interventions. We plan to investigate the potential benefit of cardiac rehabilitation (CR) in this vulnerable population. Design We undertook a pilot randomised trial of CR following TAVI to inform the feasibility and design of a future randomised clinical trial (RCT). Participants We screened patients undergoing TAVI at a single institution between June 2016 and February 2017. Interventions Participants were randomised post-TAVI to standard of care (control group) or standard of care plus exercise-based CR (intervention group). Outcomes We assessed recruitment and attrition rates, uptake of CR, and explored changes in 6-min walk test, Nottingham Activities of Daily Living, Fried and Edmonton Frailty scores and Hospital Anxiety and Depression Score, from baseline (30 days post TAVI) to 3 and 6 months post randomisation. We also undertook a parallel study to assess the use of the Kansas City Cardiomyopathy Questionnaire (KCCQ) in the post-TAVI population. Results Of 82 patients screened, 52 met the inclusion criteria and 27 were recruited (3 patients/month). In the intervention group, 10/13 (77%) completed the prescribed course of 6 sessions of CR (mean number of sessions attended 7.5, SD 4.25) over 6 weeks. At 6 months, all participants were retained for follow-up. There was apparent improvement in outcome scores at 3 and 6 months in control and CR groups. There were no recorded adverse events associated with the intervention of CR. The KCCQ was well accepted in 38 post-TAVI patients: mean summary score 72.6 (SD 22.6). Conclusions We have demonstrated the feasibility of recruiting post-TAVI patients into a randomised trial of CR. We will use the findings of this pilot trial to design a fully powered multicentre RCT to inform the provision of CR and support guideline development to optimise health-related quality of life outcomes in this vulnerable population. Retrospectively registered 3rd October 2016 clinicaltrials.govNCT02921880. Trial registration Clinicaltrials.Gov identifier NCT02921880 Electronic supplementary material The online version of this article (10.1186/s40814-018-0363-8) contains supplementary material, which is available to authorized users.

ANMCO/SIC/SICI-GISE/SICCH Executive Summary of Consensus Document on Risk Stratification in elderly patients with aortic stenosis before surgery or transcatheter aortic valve replacement

Article

Full-text available

May 2017

Aortic stenosis is one of the most frequent valvular diseases in developed countries, and its impact on public health resources and assistance is increasing. A substantial proportion of elderly people with severe aortic stenosis is not eligible to surgery because of the advanced age, frailty, and multiple co-morbidities. Transcatheter aortic valve implantation (TAVI) enables the treatment of very elderly patients at high or prohibitive surgical risk considered ineligible for surgery and with an acceptable life expectancy. However, a significant percentage of patients die or show no improvement in quality of life (QOL) in the follow-up. In the decision-making process, it is important to determine: (i) whether and how much frailty of the patient influences the risk of procedures; (ii) how the QOL and the individual patient’s survival are influenced by aortic valve disease or from other associated conditions; and (iii) whether a geriatric specialist intervention to evaluate and correct frailty or other diseases with their potential or already manifest disabilities can improve the outcome of surgery or TAVI. Consequently, in addition to risk stratification with conventional tools, a number of factors including multi-morbidity, disability, frailty, and cognitive function should be considered, in order to assess the expected benefit of both surgery and TAVI. The pre-operative optimization through a multidisciplinary approach with a Heart Team can counteract the multiple damage (cardiac, neurological, muscular, respiratory, and kidney) that can potentially aggravate the reduced physiological reserves characteristic of frailty. The systematic application in clinical practice of multidimensional assessment instruments of frailty and cognitive function in the screening and the adoption of specific care pathways should facilitate this task.

Aortic stenosis: insights on pathogenesis and clinical implications

Article

Full-text available

Sep 2016

Aortic stenosis (AS) is a common valvular heart disease in the Western populations, with an estimated overall prevalence of 3% in adults over 75 years. To understand its patho-biological processes represents a priority. In elderly patients, AS usually involves trileaflet valves and is referred to as degenerative calcific processes. Scientific evidence suggests the involvement of an active " atherosclerosis-like " pathogenesis in the initiation phase of degenerative AS. To the contrary, the progression could be driven by different forces (such as mechanical stress, genetic factors and interaction between inflammation and calcification). The improved understanding presents potentially new therapeutic targets for preventing and inhibiting the development and progression of the disease. Furthermore, in clinical practice the management of AS patients implies the evaluation of generalized atherosclerotic manifestations (i.e., in the coronary and carotid arteries) even for prognostic reasons. In counselling elderly patients, the risk stratification should address individual frailty beyond the generic risk scores. In these regard, the co-morbidities, and in particular those linked to the global atherosclerotic burden, should be carefully investigated in order to define the risk/benefit ratio for invasive treatment strategies. We present a detailed overview of insights in pathogenesis of AS with possible practical implications.

Therapeutic Decision-Making for Elderly Patients With Symptomatic Severe Valvular Heart Diseases: Ten Years Experience From a Single Centre

Article

Jul 2016

The aim of this study was to determine how older age and co-morbidities affect the treatment decision-making and long-term survival in elderly patients with symptomatic severe valvular heart diseases. A total of 181 elderly patients (mean age, 78.4 ± 3.4 years) hospitalized between January 2003 and June 2012 with symptomatic severe valvular heart diseases were enrolled. Cardiac and geriatric factors associated with treatment decision-making were analyzed. Survival outcomes were investigated. Surgical treatment was performed in 116 (64%) patients (surgical group) and 65 patients (36%) were treated conservatively (conservative group). The most common [62% (40/65)] reason for refusing surgical treatment was high operative risk as assessed by the physicians who initially cared for the patients. Multivariate logistic regression analysis identified female gender, chronic renal insufficiency, older age, pneumonia, and emergent status as independent predictors of the conservative treatment. Patients with isolated aortic valve disease tended to undergo an operation. Overall 5-year survival in the surgical group was 76.8% versus 42.9% in the conservative group (P < 0.0001). After matching using the propensity score, the surgical group still had a better long-term survival than the conservative group (P = 0.001). Cox regression analysis revealed conservative treatment as the single risk factor associated with poor long-term survival in all series. Approximately 40% of the elderly patients with symptomatic severe heart valve disease were treated conservatively despite a definite indication for surgical intervention. Cardiac and geriatric co-morbidities profoundly affect the treatment decision-making. Interdisciplinary discussion should be encouraged to optimize therapeutic options for elderly patients with valvular heart disease.

Five year contemporary study of aortic valve replacement in octogenarians and septuagenarians

Conference Paper

Full-text available

Aug 2013

Purpose: The demand for symptomatic aortic disease intervention has increased significantly in recent years as the population ages. This, together with the recent introduction of trans-catheter aortic valve implantation (TAVI), motivates a review of the characteristics and outcomes of surgical aortic valve replacement (AVR) in elderly recipients. Methods: Consecutive patients over 70 years of age having isolated AVR during 2007-11 at the Hospital, Aukland City were retrospectively identified and divided into 70-79 years and ≥80 years age-groups for analyses Results: There were 62 octogenarians and 121 septuagenarians included. Octogenarians had significantly lower proportion with Canadian Cardiovascular Society Class 3-4 (3.2% vs 14.0%, p=0.022), diabetes (11.3% vs 24.8%, p=0.034) and mechanical valve used (1.6% vs 10.7%, p=0.037), but higher proportion with infective endocarditis (6.5% vs 0.0%, p=0.012) and higher EuroSCORE II (4.9% vs 3.7%, p<0.001). Despite this, operative mortality was significantly lower in octogenarians (0.0% vs 7.4%, p=0.029), although length of hospital stay post-operatively (11.7 vs 8.9 days, p=0.026) was significantly greater. One, three and five year survival rates were 95.2%, 90.1% and 75.3% for octogenarians and 89.2%, 81.7% and 70.2% for septuagenarians (p=0.398). Canadian Cardiovascular Society Class 3-4 and the presence of other valvular stenosis or regurgitation were independent predictors of both operative mortality and mortality during follow-up. Conclusion: Octogenarians had lower operative mortality despite higher predicted risk pre-operatively. Other factors beyond age and EuroSCOR, such as frailty, can be important in deciding whether elderly patients should undergo AVR, and when appropriately selected, AVR is a safe operation in octogenarians.

Analysis of degenerated aortic valve bioprosthesis by segmentation of preoperative CT images

Article

Dec 2012

In the next future, transcatheter aortic valve implantation could represent a minimally invasive option in case of bioprosthesis failure for patients at high surgical risk. CT based preoperative planning of this procedure could be useful to optimize valve-in-valve implantation. In this context, bioprosthesis 3D analysis seems to be necessary, particularly for leaflets. The goal of this study was to propose different methods to segment and characterize a degenerated bioprosthesis using standard preoperative CT scan images in order to map structural injury of bioprosthesis and, ultimately, to plan the best positioning for valve-in-valve implantation. We report our preliminary results on segmentation of a degenerated bioprosthesis in aortic position. Three different methods have been tested and all allowed obtaining segmentation of the different bioprosthesis components. Results were compared by means of quantitative criteria. Explanted bioprosthesis CT images were used as reference. Semi-automatic segmentation seems to provide an interesting approach for the morphological characterization of degenerated bioprosthesis.

Transcatheter Aortic Valve Implantation (TAVI): Is it Time for This Intervention to be Applied in a Lower Risk Population?

Article

Full-text available

Nov 2014

Patients with severe aortic stenosis are sometimes not candidates for conventional open heart surgery because of severe deconditioning, excessive risk factors, and multiple comorbidities. Transcatheter aortic valve implantation (TAVI) is a relatively recent intervention, which was initially addressed to individuals with severe symptomatic aortic stenosis at substantial or prohibitive surgical risk. Despite the documented beneficial effects of this therapeutic intervention in certain carefully selected individuals, it has not yet been applied to lower risk patients. This is a review of the current literature and accumulated clinical data of this rapidly evolving invasive procedure in an attempt to resolve whether it can now be applied to a wider portion of patients with aortic stenosis.

Multiparameter approach to evaluate elderly patients undergoing aortic valve replacement

Article

Apr 2014

Aortic valve replacement vs. transcatheter aortic valve implantation: Patient selection

Article

Jul 2012

Impact of Preoperative Chronic Lung Disease on Survival After Surgical Aortic Valve Replacement

Article

Aug 2013

An increasing number of patients requiring surgical aortic valve replacement (SAVR) present with chronic pulmonary obstructive disease (COPD). The purpose of this study was to compare patients who had a range of COPD from normal to severe and were undergoing SAVR. Retrospective review of 2,379 patients undergoing SAVR ± coronary artery bypass grafting (CABG) from January 2002 to April 2012 at a US academic institution was performed. COPD was defined according to the Society of Thoracic Surgeons (STS) adult cardiac database: normal (forced expiratory volume [FEV] > 75% predicted), mild (FEV in 1 second [FEV1] 60%-75%), moderate (FEV1 50%-59%), and severe (FEV1 < 50%). Multivariable logistic and Cox regression methods were used to determine independent association between COPD and short- and long-term outcomes. Selection bias adjustment was achieved using the STS predicted risk of mortality (PROM). Adjusted odds ratios (AORs) and adjusted hazard ratios (AHR) were calculated using the normal lung function group as the reference. Kaplan-Meier curves were created to estimate long-term survival. One thousand five hundred seventeen of 2,379 patients (63.8%) had isolated SAVR, whereas 862 of 2,379 (36.2%) patients underwent SAVR + CABG. Preoperative COPD was common among patients (21.9%) undergoing SAVR ± CABG and included 332 (14.0%) patients with mild COPD, 89 (3.7%) patients with moderate COPD, and 101 (4.2%) patients with severe COPD. Unadjusted in-hospital mortality rose significantly with COPD class, from 3.9% for those with no COPD to 9.6% to patients with severe COPD. After adjustment, in-hospital mortality was not statistically different in normal patients and in those with COPD. In contrast, when compared with normal patients, adjusted long-term survival was worse across levels of COPD: mild (AHR, 1.70; p < 0.001), moderate (AHR, 2.25; p < 0.001), and severe (AHR, 2.28; p < 0.001). Preoperative COPD is common in the SAVR population and is associated with diminished long-term but not short-term survival.

Use of the Minnesota Living With Heart Failure Questionnaire Among Elderly Patients With Aortic Stenosis Results From a Pilot Study

Article

Jan 2013
J CARDIOVASC NURS

Background: Past studies of health-related quality of life (HRQL) in aortic stenosis (AS) have focused on valve replacement, using generic or heart failure measures because no disease-specific measure exists. The literature is lacking in both performance of these measures among patients with AS and HRQL outcomes in the nonsurgical elderly AS population. Objective: The aims of this study were to measure HRQL and test the reliability of the Minnesota Living With Heart Failure Questionnaire (MLHFQ), Geriatric Depression Scale (GDS), and Functional Assessment of Chronic Illness Therapy-Spiritual Well-being Scale (FACIT-Sp) in persons older than 70 years with AS receiving nonsurgical treatment. Methods: The prospective, descriptive design in this study included baseline administration of questionnaires to a consecutive convenience sample of patients aged 75 to 97 years (mean, 85 years) enrolled in a clinical trial for AS (n = 25). Results: Mean aortic valve area was 0.54 cm (range, 0.37-0.96 cm). Patients reported angina (52%) and light-headedness (72%); these 2 items were not included on the MLHFQ but were added as investigator-developed items. Scores for MLHFQ varied widely (median, 52; range, 7-101). Although the median GDS was 4 (range, 1-13), almost half (48%) scored higher than 5, indicating a positive depression screen. Scores for FACIT-Sp were moderately high (median, 37.5; range, 18-45), indicating strong spiritual well-being among many participants. A significant inverse relationship (r = -0.73, P < .0001; 95% confidence interval, -0.87 to -0.48) was found between depression and spiritual well-being. Cronbach α was 0.91, 0.83, and 0.81 for the MLHFQ, GDS, and FACIT, respectively. Conclusions: The HRQL measures selected had good internal consistency reliability, but use of the MLHFQ alone would have missed common disease-specific concerns (eg, angina, light-headedness); studies for minimally invasive aortic valve replacement should include these items. Because higher spiritual well-being was associated with less depressive symptoms, both should receive further study in HRQL assessment. Larger samples may clarify appropriate education and interventions for depressive symptoms, spiritual well-being, as well as safe physical activity and fall prevention for those with light-headedness.

Results of aortic valve surgery in patients over 75 years old, at 4.5 years of follow-up

Article

Full-text available

Jun 2012
Braz J Cardiovasc Surg

Background: The increased longevity elevated the frequency of elderly requiring surgery, among them the correction of aortic stenosis. Objectives: To evaluate medium-term mortality, need for reoperation for valve replacement and valve complications [systemic thromboembolism (STE) and prosthetic endocarditis (PE)] in patients over 75 years old who had undergone surgery for aortic stenosis. Methods: Retrospective study of 230 patients from 2002 to 2007. Mean age was 83.4 years and 53% were male. The prevalence of hypertension was 73.2%, atrial fibrillation 17.9% and previous cardiac surgery 14.4%. Another cardiac procedure was associated in 39.1%. Results: In a mean follow-up of 4.51 years the overall survival of the population studied was 57.4%. Death in the immediate postoperative period occurred in 13.9% (9.4% in the isolated aortic stenosis surgery group vs. 20.9% when another procedure was associated). Deaths in the medium term occurred in 28.7% of the patients (25.0% vs. 34.4%), with 34 of these because of cardiovascular causes. There were 6 cases of PE, 8 cases of STE and 6 reoperations. The predictors of mortality were ischemia time >90 min (OR 1.99 95% CI 1.06-3.74), ejection fraction <60% (OR 1.76 95% CI 1.10-2.81) and prior stroke (OR 2.43 95% CI 1.18-5.30). Conclusion: Although the immediate surgical risk of the elderly is high, survival rates for surgical treatment of patients over 75 years old are acceptable and allow this intervention. The prognosis is worse especially because of the association with coronary artery disease.

Long-Term Survival Outcomes After Transcatheter Aortic Valve Replacement: A Real-World Experience of a Large Tertiary Center

Article

Nov 2023
AM J CARDIOL

Comparison of Paravalvular Leak in SAPIEN 3 and EVOLUT PRO Valves in Transcatheter Aortic Valve Replacement: A Multicenter Registry

Article

Nov 2023
AM J CARDIOL

Advance Care Planning of Patients Undergoing High-Risk Surgery: A Concept Analysis

Preprint

Full-text available

Jun 2022

Background Many patients undergoing high-risk surgery receive critical care after surgery, yet there is a risk that their condition may deteriorate. Therefore, patients are advised to engage in advance care planning (ACP) by selecting treatment preferences in preparation for potential complications or adverse outcomes. The aim of this research was to clarify the concept of ACP for patients undergoing high-risk surgery. Methods The Walker & Avant’s approach to concept analysis was used. The reviewed literature was sourced from PubMed, EMBASE, Ichushi-Web, and CiNii databases as well as guidelines and books. The search was conducted by using keywords that were a combination of the following A, B, and C terms: A, advance care planning, advance directive, or living will; B, critical care or intensive care unit; and C, perioperative. Results Five attributes of ACP were extracted: the promise of appropriate treatment, definition of life-prolonging treatment, customization of life-saving care, expression of treatment inclinations and discretion, and continuous plan revision and transition. In addition, two antecedents were extracted: the recognition of expected risks and need for anticipatory decision-making. The three consequences were: respect for autonomy, satisfaction with the decision-making process, and improvement in the quality of care. ACP is characterized by anticipatory decision-making regarding the risks faced by patients. In addition, in the event of a sudden “turn for the worse,” necessary life-saving treatment is guaranteed, and the patient documents their wishes for treatment as well as anxieties and fears that help a medical professional or surrogate decision-maker to select life-prolonging treatment in the event of a complication. Conclusions ACP focuses on the quality of life and care rather than determining end-of-life care. The development of this concept contributes to an assessment of the usefulness of ACP support, which can lead to improved approaches to help patients recover over a short period.

Outcomes of Transcatheter Aortic Valve Implantation in Nonagenarians Compared to

Article

Mar 2022
AM J MED

Background : Given that life expectancy has been improved, nonagenarians become a significant proportion of world population. As aortic stenosis is primarily a disease of the elderly, the need for invasive cardiac approaches is expected to increase in people of extreme age. Herein, we compare the in-hospital adverse clinical outcomes and mortality after Trans-catheter aortic valve implantation (TAVI) procedures in nonagenarians to <90-year- old patients. Methods : A retrospective study was conducted on 1336 patients who underwent TAVI between January 2016 and March 2020 at Toulouse University Hospital, Rangueil, France. Post-TAVI adverse clinical outcomes were defined according to Valve Academic Research Consortium-2 Criteria. The studied population was divided into 2 groups according to age. Results : Out of 1336 patients, 250 (18.7%) were nonagenarians with a mean age of 91.8±1.9 years. Pacemaker implantation (12.4% vs 12.1%), stroke (2% vs 1.8%) and major vascular complications (9.2% vs 6.7%) were more common in nonagenarians while acute kidney injury (1.2% vs 2.7%) and major bleeding events (3.2% vs 3.4%) were more common in <90-year- old group. Nonagenarians are more likely to develop major vascular complications [OR=1.76 95%CI(1.04 ;3), p=0.03]. The prevalence of in-hospital mortality in nonagenarians and <90-year- old patients were 5.2% and 2%, respectively. Survival analysis showed a significant difference in mortality during hospitalization period only (p=0.04). Conclusion : The prevalence of TAVI procedural success is remarkably high in nonagenarians and comparable to that of younger patients. However, the in-hospital mortality rate was twofolds more than that of <90-year- old patients.

Comparison of Outcomes of Asymptomatic Moderate Aortic Stenosis With Preserved Left Ventricular Ejection Fraction in Patients ≥80 Years Versus 70-79 Years Versus <70 Years

Article

Aug 2021
AM J CARDIOL

Aortic stenosis (AS) is increasingly diagnosed in the aging population with more studies focused on the prognostic outcomes of severe asymptomatic AS. However, little is known about the outcomes of moderate asymptomatic AS in the elderly population. From 2001 to 2020, 738 consecutive patients with asymptomatic moderate AS with preserved left ventricular ejection fraction were studied. They were allocated according to the age group at the index echocardiography: very elderly (≥80 years), elderly (70 to 79 years) and control group (<70 years). The primary study outcomes were aortic valve replacement (AVR), congestive cardiac failure (CCF) and all-cause mortality. Overall, about one-third of the subjects were in the very elderly, elderly and control groups each. The median follow-up duration was 114.2 (interquartile range, 27.0 to 183.7) months. There was significantly higher all-cause mortality in the very elderly group (47.9%) followed by elderly (34.8%) and control group (21.9%). Similarly, there was significantly higher CCF rates in the very elderly group (5.8%) compared to elderly (5.1%) and control group (2.8%). There were significantly lower rates of AVR offered and completed in the very elderly group compared to control group. Multivariable logistic regression demonstrated that age ≥80 years remained an independent predictor of mortality after adjusting for important prognostic cofounders (Adjusted HR 2.424, 95% CI 1.728 to 3.400, p < 0.001). Cox regression showed no significant difference in mortality between patients ≥80 years with moderate AS compared to a younger age-group ≥70 years with severe AS. In conclusion, very elderly patients of ≥80 years of age with moderate AS have worse prognostic outcomes than their younger counterparts. They share similar unfavorable prognostic outcomes as those of a younger age-group ≥70 years with severe AS. Closer surveillance are warranted in this group of at-risk elderly patients.

TAVR in nonagenarians: An analysis investigating safety, efficacy, symptomatic improvement, and long-term survival

Article

Feb 2021
J Cardiol

Background In the aging western societies, an increasing prevalence of severe, symptomatic aortic stenosis is observed. The aim of this study was to examine the safety and efficacy of transcatheter aortic valve replacement (TAVR) in patients aged 90 years and older. Methods All patients with severe symptomatic aortic stenosis undergoing TAVR at LMU Munich-University-Hospital between 2013 and 2018 were included. Procedure-related mortality (<30 days) was defined as the primary endpoint and survival rates at two years, device failure, and procedural complications were defined as secondary endpoints according to the Valve Academic Research Consortium II criteria. Results and Conclusions Out of 2336 patients, 2183 were younger than 90 years (<90y.-group) and 153 patients were aged 90 or older (≥90y.-group). Procedure-related mortality (3.6% <90y.-group vs. 3.3% ≥90y.-group, log-rank p=0.9) and device success (97.2% <90y.-group vs. 96.0% ≥90y.-group, p=0.44) were similar. Estimated survival rates at 2 years were 62.8% (95% CI 55.3 and 71.4) in the elder and 76.0% (95% CI 74.1 and 77.8) in the younger patients (p<0.01). The incidence of acute kidney injury, stroke, major bleeding, and permanent pacemaker implantations were comparable between both groups. TAVR procedure is equally safe and feasible in patients aged 90 years or older compared to younger patients. Differences in 2-year survival appear to be patient-related rather than procedure-related.

Evolving Concepts for Use of Stem Cells and Tissue Engineering for Cardiac Regeneration: Breakthroughs in Research and Practice

Chapter

Jan 2019

The incidence of cardiovascular disease (CVD) in adults are increasing worldwide with impaired repair mechanisms, leading to tissue and organ failure. With the current advancements, life expectancy has improved and has led to search for new treatment strategies that improves tissue regeneration. Recently, stem cell therapy and tissue engineering has captured the attention of clinicians, scientists, and patients as alternative treatment options. The overall clinical experience of these suggests that they can be safely used in the right clinical setting. Ultimately, large outcome trials will have to be conducted to assess their efficacy. Clinical trials have to be carefully designed and patient safety must remain the key concern. At the same time, continued basic research is required to understand the underlying mechanism of cell-based therapies and cell tissue interactions. This chapter reviews the evolving paradigm of stem cell therapy and tissue engineering approaches for clinical application and explores its implications.

[title in Japanese]

Article

Sep 2012

in Japanese

Ideal Cardiovascular Health and the Prevalence and Severity of Aortic Stenosis in Elderly Patients

Article

Full-text available

Feb 2018

Background: The relationship between ideal cardiovascular health reflected in the cardiovascular health score (CVHS) and valvular heart disease is not known. The purpose of this study was to determine the association of CVHS attainment through midlife to late life with aortic stenosis prevalence and severity in late life. Methods and results: The following 6 ideal cardiovascular health metrics were assessed in ARIC (Atherosclerosis Risk in Communities) Study participants at 5 examination visits between 1987 and 2013 (visits 1-4 in 1987-1998 and visit 5 in 2011-2013): smoking, body mass index, total cholesterol, blood pressure, physical activity, and blood glucose. Percentage attained CVHS was calculated in 6034 participants as the sum of CVHS at each visit/the maximum possible score. Aortic stenosis was assessed by echocardiography at visit 5 on the basis of the peak aortic valve velocity. Aortic stenosis was categorized sclerosis, mild stenosis, and moderate-to-severe stenosis. Mean age was 76±5 years, 42% were men, and 22% were black. Mean percentage attained CVHS was 63±14%, and the prevalence of aortic stenosis stages were 15.9% for sclerosis, 4.3% for mild stenosis, and 0.7% for moderate-to-severe stenosis. Worse percentage attained CVHS was associated with higher prevalence of aortic sclerosis (P<0.001 for trend), mild stenosis (P<0.001), and moderate-to-severe stenosis (P=0.002), adjusting for age, sex, and race. Conclusions: Greater attainment of ideal cardiovascular health in midlife to late life is associated with a lower prevalence of aortic sclerosis and stenosis in late life in a large cohort of older adults.

Transcatheter aortic valve implantation versus surgical aortic valve replacement in patients over 85 years old

Article

Oct 2017
Interact Cardiovasc Thorac Surg

Objectives: Surgical aortic valve replacement (SAVR) for the treatment of in very old patients with severe aortic stenosis is associated with a high risk of morbidity and mortality. Transcatheter aortic valve implantation (TAVI) has become the preferred alternative. Therefore, we sought to evaluate outcomes in very old patients who underwent SAVR versus TAVI. Methods: A total of 169 consecutive patients aged ≥85 years underwent TAVI (n = 68) or SAVR (n = 101). A propensity score adjustment was used to compare outcomes including cost analysis. Results: The propensity score generated 40 pairs of patients with similar baseline characteristics. The TAVI group experienced atrioventricular block (37.5% vs 5%, P < 0.01) more frequently, a longer stay in the intensive care unit (median 5 days, range 1-35 vs median 2 days, range 1-6, P < 0.01) but a lower rate of new-onset atrial fibrillation (15% vs 47.5%, P < 0.01). The 30-day mortality rate was similar in the unmatched and matched cohorts (8.8% vs 5.0%, P = 0.32; 10% vs 7.5%, P = 0.69). One, 3- and 5-year overall survival rates (80% vs 90%, 56% vs 79%, 37% vs 71%, P < 0.01) and freedom from major adverse cardiac and cardiovascular events (72% vs 90%, 46% vs 76%, 17% vs 68%, P < 0.01) were lower in the TAVI group. An overall cost analysis indicated that TAVI was more expensive (€2084 vs €19 891). Conclusions: In patients 85 years and older, SAVR seems to offer good short- and mid-term clinical outcomes compared to TAVI. Advanced age alone would not be an indication for TAVI in old-old patients.

Transcatheter and surgical aortic valve replacement in patients with previous coronary bypass grafts

Thesis

Full-text available

Jan 2017

Mamdouh Elsmaan

Ein signifikanter Anteil der Patienten, die einen Aortenklappenersatz (AKE) erhalten haben, wurden früher mittels einer Aorto-Coronarer-Venen-Bypass Operation (ACVB) behandelt. Die vorliegende Studie analysiert die vollständige bundesweiten Daten von 82,352 Datensätze hinsichtlich der Komplikationen im Krankenhaus bei Patienten mit oder ohne ehemalige ACVB, die mittels eines chirurgischen Aortenklappenersatzes oder TAVI behandelt wurden. Methode und Ergebnisse Alle Daten der Patienten in Deutschland, die mittels AKE in dem Zeitraum zwischen 2007 und 2013, wurden durch Forschungsdatenzentren des statistischen Bundesamtes (Destatis) zur Verfügung gestellt. Davon waren 7.5% der Patienten mit einer Vorgeschichte einer ACVB Operation. Diese Patienten waren junger und hatten mehr Komorbiditäten und höher geschätztes perioperative Risiko-Profil mittels EuroSCORE. Als die Patienten mit einer ehemaligen ACVB Operation mittels einer chirurgischen AKE Operation behandelt wurden, war die relevante Blutung verdoppelt, die Zahl der Schlaganfälle solcher Patienten, die längere Beatmungszeit brauchten, gestiegen war. Im Vergleich zu den Patienten ohne Vorgesichte einer ACVB Operation und mittels eines chirurgischen AKE behandelt wurden. Der Anstieg der perioperativen Komplikationen konnte nicht bei TAVI Patienten mit vorheriger ACVB beobachtet werden. Dementsprechend vermindert sich die Zahl der chirurgischen AKE Prozeduren bei Patienten mit einer ehemaligen ACVB nach der Markteinführung der TAVI in 2007 durchgeführt. Die Patienten mit einer ehemaligen ACVB Operation und mittels eines chirurgischen Aortenklappensersatzes behandelt wurde, war die Krankenhausmortalität deutlich gestiegen. Während die Krankenhausmortalität von TAVI Patienten mit einer ehemaligen ACVB Operation trotz des unverhältnismäßigen hoch Werts vom EuroSCORE leicht zugenommen hat. Außerdem die Ressourcennutzung hat sich nicht deutlich verändert. Schlusspunkt In dieser vorliegenden Dissertation wird einen ausreichenden Beweis dargestellt, dass TAVI ist eine einzigartige und sichere Prozedur für Patienten mit einer hochgradigen Aortenstenose und einer ehemaligen ACVB Operation

Heart valve disease in elderly Chinese population: Effect of advanced age and comorbidities on treatment decision-making and outcomes

Article

Full-text available

Jul 2016

Background A considerable proportion of elderly patients with symptomatic severe heart valve disease are treated conservatively despite clear indications for surgical intervention. However, little is known about how advanced age and comorbidities affect treatment decision-making and therapeutic outcomes. Methods Patients (n = 234, mean age: 78.5 ± 3.7 years) with symptomatic severe heart valve disease hospitalized in our center were included. One hundred and fifty-one patients (65%) were treated surgically (surgical group) and 83 (35%) were treated conservatively (conservative group). Factors that affected therapeutic decision-making and treatment outcomes were investigated and long-term survival was explored. Results Isolated aortic valve disease, female sex, chronic renal insufficiency, aged ≥ 80 years, pneumonia, and emergent status were independent factors associated with therapeutic decision-making. In-hospital mortality for the surgical group was 5.3% (8/151). Three patients (3.6%) in the conservative group died during initial hospitalization. Low cardiac output syndrome and chronic renal insufficiency were identified as predictors of in-hospital mortality in the surgical group. Conservative treatment was identified as the single risk factor for late death in the entire study population. The surgical group had better 5-year (77.2% vs. 45.4%, P < 0.0001) and 10-year (34.5% vs. 8.9%, P < 0.0001) survival rates than the conservative group, even when adjusted by propensity score-matched analysis. Conclusions Advanced age and geriatric comorbidities profoundly affect treatment decision-making for severe heart valve disease. Valve surgery in the elderly was not only safe but was also associated with good long-term survival while conservative treatment was unfavorable for patients with symptomatic severe valve disease.

Transcatheter Aortic Valve Implantation in Lower-Risk Patients With Aortic Stenosis: Is It Justified to Be the Preferred Treatment?

Article

Full-text available

Apr 2016

Transcatheter aortic valve implantation underwent progressive improvements until it became the default therapy for inoperable patients, and a recommended therapy in high-risk operable patients with symptomatic severe aortic stenosis. In the lower-risk patient strata, a currently costly therapy that still has important complications with questionable durability is competing with the established effective and still-improving surgical replacement. This report tries to weigh the clinical evidence, the recent technical improvements, the durability, and the cost-effectiveness claims supporting the adoption of transcatheter aortic valve implantation in intermediate-low risk patients. The importance of appropriate patients' risk stratification and a more comprehensive approach to estimate that risk are also emphasized in the present report.

Evolving Concepts for Use of Stem Cells and Tissue Engineering for Cardiac Regeneration

Chapter

Jan 2015

Non-Surgical Aortic Valve Therapy: Balloon Valvuloplasty and Transcatheter Aortic Valve Replacement

Article

May 2010

Percutaneous Implantation of Aortic Valve Prostheses

Article

Jun 2010

Historical backgroundMorphology and pathophysiologyIndicationsTechnical aspectsResultsConclusion Conflict of interest disclosureReferences

Evidencia del coste-efectividad de la implantación transcatéter de la prótesis valvular aórtica (TAVI) Edwards SAPIEN en pacientes de alto riesgo con estenosis aórtica sintomática en España: resultados preliminares

Article

Apr 2013

Aims Transcatheter aortic valve implantation (TAVI) represents an innovative technology superior to medical management (PARTNER study, US) in inoperable patients with severe aortic valve stenosis (AVS). This study aims to estimate the cost-effectiveness of TAVI compared to conservative medical management in symptomatic AVS patients in Spain. Methods An economic longitudinal cohort model was used to predict clinical and economic outcomes of symptomatic AVS patients treated with either transapical (TA) or transfemoral (TF) TAVI, or medical management alone (MEDICAL). Clinical model input data for TAVI was derived from the real-world SOURCE registry, and for MEDICAL from literature and a registry of 62 untreated Spanish AVS patients followed up for 332 days. Health utilities as well as resource use and unit costs utilized for modelling are representative for Spain. Missing information was substituted by expert estimates. Economic results are expressed as cost per quality-adjusted life year (QALY) gained. Perspective is that of the national health system (NHS). Benefits and costs were discounted at 3 % per year. Results Over the 3-year analysis period, 2.12 life years per patient were achieved with TA TAVI, 2.31 with TF TAVI, and 1.51 with conservative medical care, representing 1.24, 1.38, and 0.74 QALYs, respectively. Cumulative direct costs were predicted to amount to €37,311 and €35,689 with TA and TF TAVI, respectively, and to €23,103 with conservative care. Cost/QALY gained was €28,003 for TA TAVI and €19,499 for TF TAVI; both ratios remaining well below the accepted willingness-to-pay threshold for Spain. The substantial cost of the TAVI procedure was largely offset over time mainly by savings related to prevented hospital readmissions for cardiac reasons. Conclusions Compared to conservative management, TAVI is a life-saving and cost-effective treatment for high-risk or inoperable patients with symptomatic aortic valve stenosis in Spain. Sensitivity analyses indicated these findings to be robust.

Aortoiliofemoral Assessment: MRA

Chapter

Jan 2014

Transcatheter aortic valve replacement (TAVR) is an undergoing evaluation for the treatment of inoperable or high-risk severe aortic stenosis (AS) patients. Patients with symptomatic, severe AS are at high risk for conventional surgical aortic valve replacement procedures. One of the alternate ways of managing these patients is through TAVR. Several studies on post TAVR patients with a follow-up interval up to 2 years showed significant clinical benefit, improvements in exercise capacity and in quality of life. Proper patient selection is key to optimize successful clinical outcomes. A number of imaging modalities are available for patient screening. One of them is magnetic resonance imaging (MRI). MRI provides morphological information, functional status, pre-operative planning and thus plays a role in selection of patients. It is ideally suited for patients with renal insufficiency as evaluation could be done without contrast administration. MRI may prove to be a useful alternative for TAVR evaluation and is particularly beneficial to patients with underlying chronic kidney disease.

Morphological analysis of degenerated aortic valve bioprostheses by CT scan images segmentation

Article

Dec 2012

Vito Giovanni Ruggieri

The aim of the study was to assess the feasibility of CT based 3D analysis of degenerated aortic bioprostheses to make easier their morphological assessment. This could be helpful during regular follow-up and for case selection, improved planning and mapping of valve-in-valve procedure. The challenge was represented by leaflets enhancement because of highly noised CT images. Contrast-enhanced ECG-gated CT scan was performed in patients with degenerated aortic bioprostheses before reoperation (in-vivo images). Different methods for noise reduction were tested and proposed. 3D reconstruction of bioprostheses components was achieved using stick based region segmentation methods. After reoperation, segmentation methods were applied to CT images of the explanted prostheses (ex-vivo images). Noise reduction obtained by improved stick filter showed best results in terms of signal to noise ratio comparing to anisotropic diffusion filters. All segmentation methods applied to in-vivo images allowed 3D bioprosthetic leaflets reconstruction. Explanted bioprostheses CT images were also processed and used as reference. Qualitative analysis revealed a good concordance between the in-vivo images and the bioprostheses alterations. Results from different methods were compared by means of volumetric criteria and discussed. ECG-gated CT images of aortic bioprostheses need a preprocessing to reduce noise and artifacts in order to enhance prosthetic leaflets. Stick region based segmentation seems to provide an interesting approach for the morphological characterization of degenerated bioprostheses.

Multidetector computed tomography in Transcatheter aortic valve implantation. Where we stand

Article

Aug 2013

Degenerative calcific aortic stenosis represents the most common valve abnormality with increasing incidence in the elderly. Studies have shown that aortic stenosis is a fatal disease with a high cardiovascular death rate if untreated. However, many patients are encumbered with multiple comorbidities making them high-risk candidates for surgical aortic valve replacement, which is the hitorical treatment of choice. Transcatheter aortic valve implantation (TAVI) has seen rapid advancements over the last number of years with over 50000 TAVI procedures being performed in 40 countries with excellent prognosis proving TAVI to be a feasible alternative therapy to traditional surgical aortic valve replacement to treat high-risk patients. In addition to clinical suitability, imaging plays an essential role for optimal patient selection and to help select the appropriate prosthesis and to help reduce the likelihood of complications and adverse events. Fundamental to the procedure success, is the non-invasive assessment of the aortic annulus, the evaluation of the aortic root and the determination of the access to the aortic annulus. Among different imaging modalities that have been employed, multidetector computed tomography (MDCT) is increasingly used because of its capability of 3-dimentional (3D) determination of the non-circular nature of the aortic annulus as well as the complex aortic root anatomy. Additionally, MDCT provides a deep understanding of the structural integrity of the transcatheter aortic valve and enables the evaluation of the prosthesis location after TAVI and identification of post procedure complications. In this article, we discuss the current role of MDCT in pre-TAVI evaluation but also in the guidance of the procedure and in post-procedure follow-up.

Current Status of Transcatheter Aortic Valve Implantation: A Systematic Review of Non-orthodox Deployment Strategies

Article

May 2012

Hao Pan

Surgical Report Cards

Article

Sep 2014

Alan Henderson

There seems no good reason for doctors to work in secret. Individual users of healthcare and the community in general, which ultimately bears the cost, are perfectly entitled to know how their health services and health providers are performing. The promulgation of surgical report cards has been hailed by some as a liberating step in the right direction. This paper seeks to analyse, from a clinician’s perspective, the evolution and limitations of report cards. Ultimately, the importance of report cards will not be their immediate utility, which is minimal, but as a first step in a much wider and far more important debate about how we meaningfully measure the quality of health services and providers (including managers and bureaucrats), the likely cost of such an enterprise, how much we are willing and able to pay and how we reconcile the competing needs of information versus clinical and preventive care when all are competing for the same and inadequate pool of resources.

Aortic valve replacement in over 70- and over 80-year olds: 5-year cohort study

Article

Oct 2013
Asian Cardiovasc Thorac Ann

Background: Demand for aortic valve intervention remains high, and together with the recent introduction of transcatheter aortic valve implantation, this motivates a review of surgical aortic valve replacement in elderly recipients. Methods: Consecutive patients over 70 years of age having isolated aortic valve replacement during 2007-11 were retrospectively identified and divided into 70-79 and ≥ 80 years age groups for analyses. Results: 62 octogenarians and 121 septuagenarians were eligible. Among octogenarians, a lower proportion were in Canadian Cardiovascular Society angina class 3-4 (3.2% vs. 14.0%, p = 0.022) and fewer had diabetes (11.3% vs. 24.8%, p = 0.034), but a higher proportion had infective endocarditis (6.5% vs. 0%, p = 0.012), and EuroSCORE II was higher (4.9% vs. 3.7%, p < 0.001). Despite this, operative mortality was lower in octogenarians (0% vs. 7.4%, p = 0.029), although hospital stay (11.7 vs. 8.9 days, p = 0.026) was longer. One-, 3-, and 5-year survival rates were 95.2%, 90.1%, and 75.3% for octogenarians and 89.2%, 81.7%, and 70.2% for septuagenarians (p = 0.398). Canadian Cardiovascular Society angina class 3-4 and the presence of other valvular stenosis or regurgitation were independent predictors of mortality. Conclusion: Octogenarians had lower operative mortality despite a higher predicted risk preoperatively. Other factors beyond age and EuroSCORE, such as frailty, may be important in deciding whether elderly patients should undergo aortic valve replacement.

Aortic stenosis: Current treatment options for a common condition in old age

Article

Aug 2012
Rev Clin Gerontol

Degenerative-calcific aortic stenosis is mainly a disease of old age. Patients with mild to moderate stenosis without symptoms and those with aortic valve sclerosis do not require mechanical intervention. There is no firm evidence that the rate of progression can be modified by medical therapies, though statins might have some effect. Patients who develop severe stenosis with symptoms have a very poor prognosis if managed medically. Surgical aortic valve replacement greatly improves symptoms and mortality rates and remains the treatment of choice for those fit for major surgery, even above the age of 80 years. For those not suitable for surgery, or who are unwilling to have an operation, outcomes can be significantly improved by trans-catheter aortic valve replacement, which has become an important option for frail elderly patients. Balloon aortic valvuloplasty improves symptoms and short-term survival, but has a less clear impact on mortality beyond 1 year. It is useful as a palliative treatment and as a bridging procedure for patients who are not ready for valve replacement. There is less agreement on the best approach to patients with asymptomatic severe aortic stenosis. Trials indicate that early valve replacement results in outcomes that are comparable to those seen in symptomatic patients, though guidelines advocate delaying surgery until symptoms occur or left ventricular function begins to decline rapidly. All elderly patients with severe aortic stenosis should be considered for a mechanical intervention unless there is a properly considered reason for not doing so, or they are not willing to receive such treatment.

Estenosis aórtica en el anciano

Article

Nov 2011

Manuel Martinez Selles

Cost-effectiveness of transcatheter aortic valve implantation (TAVI) for aortic stenosis in patients who are high risk or contraindicated for surgery: A model-based economic evaluation

Article

Full-text available

Aug 2013
HEALTH TECHNOL ASSES

Background: Calcific aortic stenosis (AS) is a common valvular heart disease. Patients with severe symptomatic AS typically survive less than 3 years. In such patients, intervention with surgical aortic valve replacement (SAVR) may increase survival. However, in some patients SAVR is associated with a high operative risk and medical management is considered appropriate. Transcatheter aortic valve implantation (TAVI) is a relatively recent technique to avoid the invasiveness of open surgery. This procedure has been used for the treatment of patients with severe AS who are unsuitable for SAVR (because it is too high risk and/or for other reasons such as suffering from porcelain aorta) and is increasingly being considered for other patients. Objectives: To determine the cost-effectiveness of TAVI being made available for patients who are high risk or contraindicated for SAVR through a review of existing economic evaluations and development of a model. Data sources and review methods: Bibliographic databases [MEDLINE, EMBASE, The Cochrane Library, Health Technology Assessment (HTA), Database of Abstracts of Reviews of Effects (DARE) and NHS Economic Evaluation Database (EED), Centre for Reviews and Dissemination HTA, DARE and NHS EED], guideline resources, current trials registers, websites/grey literature and manufacturers' websites, and consultation with clinical experts were used to identify studies for the review and information for the model. Databases were searched from 2007 to November 2010. A model was built to assess the cost-effectiveness of TAVI separately in patients suitable and unsuitable for SAVR, together with overall results for the effect of making TAVI available. Substantial deterministic sensitivity analysis was carried out together with probabilistic sensitivity analysis. Results: No fully published cost-effectiveness studies were found. Modelling patients not suitable for SAVR, the base-case results show TAVI as more costly but more effective than medical management, with an incremental cost-effectiveness ratio (ICER) of £12,900 per quality-adjusted life-year (QALY). The ICER was below £20,000 per QALY for over 99% of model runs in the probabilistic sensitivity analysis. For patients suitable for SAVR, the comparator with TAVI is a mixture of SAVR and medical management. TAVI is both more costly and less effective than this comparator assuming that most patients would receive SAVR in the absence of TAVI. This is robust to a number of assumption changes about the effects of treatment, but sensitive to assumptions about the proportion of patients receiving SAVR in the comparator. If the use of TAVI is extended to include more patients suitable for SAVR, the overall results from the model become less favourable for TAVI. Limitations: The modelling involves extrapolation of short-term data and the comparison between TAVI and SAVR is not based on randomised data. More trial data on the latter have been published since the modelling was undertaken. Conclusions: The results for TAVI compared with medical management in patients unsuitable for surgery are reasonably robust and suggest that TAVI is likely to be cost-effective. For patients suitable for SAVR, TAVI could be both more costly and less effective than SAVR. The overall results suggest that, if a very substantial majority of TAVI patients are those unsuitable for SAVR, the cost-effectiveness of a broad policy of introducing TAVI may fall below £20,000 per QALY. Future work required includes the incorporation of new data made available after completion of this work. Funding: The National Institute for Health Research Health Technology Assessment programme.

Sustitución valvular aórtica: ¿es una solución a la epidemia de estenosis aórtica en el anciano? Respuesta

Article

Mar 2011

Transkatheter-Aortenklappenimplantation

Article

Jul 2011

Introduction Transcatheter aortic valve implantation (TAVI) has become an alternative to open valve replacement for elderly high-risk patients. What motivates these often very old patients to undergo surgery has not been systematically studied. Methods A semi-structured interview was developed to assess the mental health and motivation of patients consenting to TAVI. Twenty-eight patients (median age 82.5 years, range 68–90 years) completed the German version of the Hospital Anxiety and Depression Scale and a semi-structured interview that included an open question and a questionnaire with a 4-point Likert scale designed to compare the role of various factors in the decision to undergo TAVI. Results Clinically relevant preoperative anxiety was reported by 14.3% and depression by 35.7% of all patients. The following reasons for deciding to undergo TAVI were most often mentioned as answers to the open question: reduction of dyspnoea (30%), desire to go on a family vacation (13%) and desire to support other family members (11%). In the questionnaire, the highest scores (median: 4 each) were reached in the following categories: doctors’ recommendation, strong will to live, desire to avoid long-term nursing care and reduction of dyspnoea. Discussion Elderly high-risk patients have various reasons for undergoing surgery which they can clearly name. These patients utilized the psychological interview to gain additional insight into their decision regarding the surgical procedure.

To operate or not on elderly patients with aortic stenosis: The decision and its consequences

Article

Full-text available

Aug 1999

To evaluate the application of guidelines in the decision making process leading to medical or surgical treatment for aortic stenosis in elderly patients. Cohort analysis based on a prospective inclusive registry. 205 consecutive patients (>/= 70 years) with clinically relevant isolated aortic stenosis and without serious comorbidity, seen for the first time in the Doppler-echocardiographic laboratories of three university hospitals in the Netherlands. The initial choice was surgery in 94 patients and medical treatment in 111. Only 59% of the patients who should have had valve replacement according to the practice guidelines were actually offered surgical treatment. These were mainly symptomatic patients under 80 years of age with a high gradient. Operative mortality (30 days) was only 2%. The three year survival was 80% in the surgical group (17 deaths among 94 patients) and 49% in the medical group (43/111). Multivariate analysis showed that only patients with a high baseline risk, mainly determined by impaired left ventricular function, had a significantly better three year survival with surgical treatment than with medical treatment. In daily practice, elderly patients with clinically relevant symptomatic aortic stenosis are often denied surgical treatment. This study indicates that a surgical approach, especially where there is impaired systolic left ventricular function, is associated with better survival.

Surgery for aortic stenosis in severely symptomatic patients older than 80 years: Experience in a single UK centre

Article

Full-text available

Sep 1999

To ascertain the surgical risk and long term outcome of patients over 80 years old undergoing aortic valve replacement (AVR). Consecutive cases with respective case note audit and a telephone questionnaire. Single UK cardiothoracic surgical centre. 103 (48 male) patients over 80 years old undergoing AVR. The median age was 82 years (80-95 years) and 95 of 103 patients were in New York Heart Association (NYHA) class III or IV. Preoperative characteristics, operative course, cost, and outcome measures were ascertained. Mean bypass time was 56 minutes and 25 patients had simultaneous coronary artery bypass grafting. Overall mortality was 19 of 103. Univariate analysis of pertinent variables found that impaired renal function and peripheral vascular disease were significantly associated with early postoperative death. 10 of 12 patients requiring ventilation for more than 24 hours died. The 50% actuarial survival was 62 months. Late complications were uncommon with 92% of patients in NYHA class I or II at follow up. AVR in patients over 80 years old has a significant risk. However, those patients who survive experience significant benefit with good long term prospects for general health and social independence.

Risk factors and outcome in European cardiac surgery: analysis of the EUROSCORE multinational database of 19030 patients

Article

Full-text available

Jul 1999

To assess risk factors for mortality in cardiac surgical adult patients as part of a study to develop a European System for Cardiac Operative Risk Evaluation (EuroSCORE). From September to November 1995, information on risk factors and mortality was collected for 19030 consecutive adult patients undergoing cardiac surgery under cardiopulmonary bypass in 128 surgical centres in eight European states. Data were collected for 68 preoperative and 29 operative risk factors proven or believed to influence hospital mortality. The relationship between risk factors and outcome was assessed by univariate and logistic regression analysis. Mean age (+/- standard deviation) was 62.5+/-10.7 (range 17-94 years) and 28% were female. Mean body mass index was 26.3+/-3.9. The incidence of common risk factors was as follows: hypertension 43.6%, diabetes 16.7%, extracardiac arteriopathy 2.9%, chronic renal failure 3.5%, chronic pulmonary disease 3.9%, previous cardiac surgery 7.3% and impaired left ventricular function 31.4%. Isolated coronary surgery accounted for 63.6% of all procedures, and 29.8% of patients had valve operations. Overall hospital mortality was 4.8%. Coronary surgery mortality was 3.4% In the absence of any identifiable risk factors, mortality was 0.4% for coronary surgery, 1% for mitral valve surgery, 1.1% for aortic valve surgery and 0% for atrial septal defect repair. The following risk factors were associated with increased mortality: age (P = 0.001), female gender (P = 0.001), serum creatinine (P = 0.001), extracardiac arteriopathy (P = 0.001), chronic airway disease (P = 0.006), severe neurological dysfunction (P = 0.001), previous cardiac surgery (P = 0.001), recent myocardial infarction (P = 0.001), left ventricular ejection fraction (P = 0.001), chronic congestive cardiac failure (P = 0.001), pulmonary hypertension (P = 0.001), active endocarditis (P = 0.001), unstable angina (P = 0.001), procedure urgency (P = 0.001), critical preoperative condition (P = 0.001) ventricular septal rupture (P = 0.002), noncoronary surgery (P = 0.001), thoracic aortic surgery (P = 0.001). A number of risk factors contribute to cardiac surgical mortality in Europe. This information can be used to develop a risk stratification system for the prediction of hospital mortality and the assessment of quality of care.

Why do so few older people with aortic stenosis have valve replacement surgery?

Article

Full-text available

Jun 1999

Many older patients with severe aortic stenosis do not have valve replacement surgery. To determine the proportion of older people with symptomatic aortic stenosis referred for specialist assessment and the reasons for non-referral. Retrospective study of all patients over 75 attending the geriatric department of an English teaching hospital. Confirmation was by reviewing all echocardiographic reports. Of 40 patients with symptomatic aortic stenosis, only four had undergone surgery. Seven patients refused operation; five were medically unfit (for reasons other than heart failure) and reasons for not referring could not be found in 13 casenotes. Of the 15 patients referred to a cardiologist, eight were considered suitable for surgery. Only one in five patients over 75 with echocardiographically-confirmed aortic stenosis was considered for surgery. Prospective studies are needed to determine why patients and geriatricians do not seek specialist assessment for this treatable condition.

Variability in treatment advice for elderly patients with aortic stenosis: A nationwide survey in the Netherlands

Article

Full-text available

Mar 2001
HEART

To determine how the decisions of Dutch cardiologists on surgical treatment for aortic stenosis were influenced by the patient's age, cardiac signs and symptoms, and comorbidity; and to identify groups of cardiologists whose responses to these clinical characteristics were similar. A questionnaire was produced asking cardiologists to indicate on a six point scale whether they would advise cardiac surgery for each of 32 case vignettes describing 10 clinical characteristics. Nationwide postal survey among all 530 cardiologists in the Netherlands. 52% of the cardiologists responded. There was wide variability in the cardiologists' advice for the individual case vignettes. Six groups of cardiologists explained 60% of the variance. The age of the patient was most important for 41% of the cardiologists; among these, 50% had a high and 50% a low inclination to advise surgery. A further 24% were influenced equally by the patient's age and by the severity of the aortic stenosis and its effect on left ventricular function; among these, 62% had a high and 38% a low inclination to advise surgery. Finally, 23% of the cardiologists were mainly influenced by the left ventricular function and 12% by the aortic valve area. The presence of comorbidity always played a minor role. There were systematic differences among groups of cardiologists in their inclination to advise aortic valve replacement for elderly patients, as well as in the way their advice was influenced by the patients' characteristics. These results indicate the need for prospective studies to identify the best treatment for elderly patients according to their clinical profile.

Which elderly patients with severe aortic stenosis benefit from surgical treatment? An aid to clinical decision making

Article

Full-text available

May 2004
J HEART VALVE DIS

Clinical decision-making in an individual elderly patient with severe aortic stenosis (AS) is difficult. The prognosis is influenced by increased age and various cardiac morbidity and comorbidity, and the benefit of surgery is uncertain because the prognosis with conservative treatment has rarely been described. The study aim was to identify those patients who would gain from surgical therapy. The long-term survival of a cohort of elderly patients after an initial diagnosis of severe aortic stenosis was analyzed. Multivariate analysis was used to develop patient profiles on the basis of four main variables of age, severity of AS, cardiac morbidity, and comorbidity, to illustrate the benefit of surgical treatment over conservative treatment. A total of 280 consecutive patients aged > or = 70 years (median age 78 years) with a first-time diagnosis of isolated AS made between 1991 and 1993 was included. Of these patients, 120 underwent surgery. The seven-year predicted survival ranged from 6.9% to 83% in surgically treated patient, and from 0.6% to 48% in conservatively treated patients. The benefit of surgical treatment over conservative treatment was greatest in patients aged < 80 years, with a more critical AS, cardiac morbidity, and without (7-year survival 78% versus 14%) or with (7-year survival 56% versus 1%) comorbidity. Minimal benefit was seen in patients aged > 80 years with a less critical AS and without cardiac morbidity. This model illustrated the benefit of surgical treatment over conservative treatment in 16 different profiles of elderly patients with severe AS. These findings may provide support for clinical decision making in individuals within this patient group.

One-hundred aortic valve replacements in octogenarians: Outcomes and risk factors for early mortality

Article

Full-text available

Apr 2007
J HEART VALVE DIS

Today, ageing of the western population is causing aortic valve surgery to be performed in elderly patients with increasing frequency. The study aim was to evaluate surgical outcome in octogenarian patients undergoing aortic valve replacement (AVR). A total of 100 patients (mean age 82.1 +/- 2.7 years; range: 80-95 years) who underwent AVR over a three-year period was reviewed. Concomitant coronary artery bypass grafting was performed in 34% of cases, and a bioprosthesis was implanted in 80%. The mean logistic EuroSCORE was 13.3%. Operative mortality was 8.0%. In multivariate analysis, a logistic EuroSCORE > or =13.5% (p = 0.02), cross-clamp time > or =75 min (p = 0.02) and postoperative acute renal failure were predictors for in-hospital mortality. Follow up was 100% complete; the mean follow up period was 10.6 months. At one year after surgery, the actuarial survival rate of those patients who survived surgery was 86.1%. Postoperative dyspnea at one month (p = 0.004) was the only predictor of short-term mortality. Age in itself should not contraindicate surgery, and healthcare systems should be prepared to accommodate elderly patients who may require special resources.

A prospective survey of patients with valvular heart disease in Europe

Article

Jan 2003

Variability in treatment advice for elderly patients with aortic stenosis: a nationwide survey in the Netherlands

Article

Feb 2001
Br Heart J

Berto J Bouma

OBJECTIVE—To determine how the decisions of Dutch cardiologists on surgical treatment for aortic stenosis were influenced by the patient's age, cardiac signs and symptoms, and comorbidity; and to identify groups of cardiologists whose responses to these clinical characteristics were similar. DESIGN—A questionnaire was produced asking cardiologists to indicate on a six point scale whether they would advise cardiac surgery for each of 32 case vignettes describing 10 clinical characteristics. SETTING—Nationwide postal survey among all 530 cardiologists in the Netherlands. RESULTS—52% of the cardiologists responded. There was wide variability in the cardiologists' advice for the individual case vignettes. Six groups of cardiologists explained 60% of the variance. The age of the patient was most important for 41% of the cardiologists; among these, 50% had a high and 50% a low inclination to advise surgery. A further 24% were influenced equally by the patient's age and by the severity of the aortic stenosis and its effect on left ventricular function; among these, 62% had a high and 38% a low inclination to advise surgery. Finally, 23% of the cardiologists were mainly influenced by the left ventricular function and 12% by the aortic valve area. The presence of comorbidity always played a minor role. CONCLUSIONS—There were systematic differences among groups of cardiologists in their inclination to advise aortic valve replacement for elderly patients, as well as in the way their advice was influenced by the patients' characteristics. These results indicate the need for prospective studies to identify the best treatment for elderly patients according to their clinical profile. Keywords: aortic stenosis; aortic valve replacement; elderly patients; clinical decision making

The natural history of severe, acquired valvular aortic stenosis

Article

Jan 1967
AM J CARDIOL

Octogenarians with aortic stenosis. Outcome after aortic valve replacement

Article

Oct 1989

To assess the outcome of aortic valve replacement for aortic stenosis in octogenarians, we retrospectively studied 64 patients, aged 80-89 years, who underwent aortic valve replacement for aortic stenosis from 1974 to 1987. Mean aortic valve gradient was 61 +/- 22 mm Hg, and valve area was 0.5 +/- 0.2 cm2. Concurrent coronary artery bypass grafting was performed in 29 patients, mitral valve replacement in two, and both procedures in two. Serious, comorbid, noncardiac conditions were infrequent. In-hospital mortality was 9.4%. Outcomes were classified as 1a) uncomplicated; 1b) complicated (technically complicated surgery, temporary encephalopathy, discharge to a rehabilitation facility, or some combination thereof) but with ultimately good results; or 2) unfavorable (death or permanent, severe neurological deficit). There were 28 (44%) patients in group 1a, 24 (38%) in group 1b, and 12 (19%) in group 2. Of 18 patients with preoperative left ventricular ejection fraction less than 50%, two (11%) were in group 2. Of 31 patients undergoing aortic valve replacement only, two (6%) were in group 2, compared with 10 of 33 (30%) patients who had concomitant coronary artery bypass grafting, mitral valve replacement, or both (p = 0.02). Late follow-up at 28 +/- 5 months revealed four cardiac and seven noncardiac deaths, with actuarial 1- and 5-year survival rates of 83 +/- 5% and 67 +/- 10%, respectively. With few exceptions, survivors were free of cardiac symptoms. Thus, short- and long-term outcomes after aortic valve replacement for aortic stenosis in otherwise healthy octogenarians is generally favorable, even in the presence of preoperative left ventricular systolic dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

Noninvasive estimation of valve area in patients with aortic stenosis by Doppler ultrasound and two-dimensional echocardiography

Article

Nov 1985

In 30 patients with aortic stenosis, 14 of whom also had significant aortic regurgitation, the velocities in the stenotic jet (V') and below the valve (V) were recorded by Doppler ultrasound. With two-dimensional echocardiography, two subvalvular areas (A) were calculated from leading-to-leading edge ("large") and trailing-to-leading edge ("inner") diameter measurements. The aortic valve area was calculated by the equation of continuity (A' = A X peak V/peak V') and by calculating stroke volume below the valve [A X integral of V (t) and dividing by the integral of V' (t) (= A"). Based on cardiac output estimations from single-plane angiographic images, Gorlin's formula was used to calculate invasive valve areas. In patients with no or mild aortic regurgitation a second invasive estimate was based on cardiac output measured by the Fick method. The best correlation was found when A' (with "large" diameter) was compared with invasive results based on cardiac output measured by the Fick method (r = .89, SEE +/- 0.12, n = 16); the worst was found when A" (with "large" diameter) was compared with invasive results based on cardiac output measurements by single-plane angiography (r = .80, SEE +/- 0.20, n = 30). The results indicate that valve area in patients with aortic stenosis can be reliably estimated noninvasively, even in those with significant aortic regurgitation.

Natural history of aortic stenosis

Article

Feb 1973
Br Heart J

The effect of aortic valve replacement on survival

Article

Dec 1982

We retrospectively studied 252 operated and 47 unoperated patients with isolated aortic valve disease. Aortic valve replacement (AVR) was recommended to all patients based on clinical and hemodynamic data. Preoperative hemodynamic and angiographic data were similar in operated and unoperated cohorts. Seventy-one percent of patients received a Björk-Shiley prosthesis. Operative mortality was 7% for the entire surgical series. For patients with predominant aortic stenosis (AS), survival at 3 years was 87% in operated and 21% in unoperated patients (p less than 0.001). For patients with predominant aortic insufficiency (AI), the 5-year survival rate was 86% in operated and 87% in unoperated patients (NS). AVR improved long-term survival in patients with AS who had normal or impaired left ventricular (LV) function. In patients with AI and normal LV function, survival was not improved after AVR, but those with LV dysfunction who were operated on tended to survive longer (NS). Long-term survival of unoperated patients with AI was better than that in unoperated patients with AS. We conclude that AVR improves long-term survival in patients with AS who were normal or abnormal LV function, and that AVR does not change long-term survival in patients with AI, although those with LV dysfunction tended to survive longer.

Aortic valve replacement in the elderly: Effect of gender and coronary artery disease on operative mortality

Article

Dec 1993

Aortic valve replacement remains the treatment of choice for aortic valve disease, even in the extreme elderly who may present with advanced symptoms. Defining risk factors for short-term survival was the object of this study. This was a retrospective analysis of 717 patients at least 70 years of age who underwent aortic valve replacement alone or with coronary artery bypass graft between 1980 and 1992. Age range was 70 to 95 years, and mean age was 77 years; there were 529 septuagenarians (74%); 188 were octogenarians (26%); 326 were women (45%); and 386 patients (54%) had aortic valve replacement and coronary artery bypass graft. Atrial fibrillation/flutter or heart block was present in 16%, and 34% of patients were in New York Heart Association (NYHA) functional class IV. Aortic stenosis was present in 88%, and mechanical prostheses were used in 22% of patients. There were 47 deaths, giving an overall operative mortality of 6.6%, with 4.2% for aortic valve replacement and 8.8% for aortic valve replacement and coronary artery bypass graft (P = .01). The operative mortality for aortic valve replacement was 2.9% versus 10.3% for aortic valve replacement and coronary artery bypass graft in women (P = .006). The corresponding values for men were 5.6% and 7.4% (P = .31). Multivariate logistic regression showed coronary artery bypass graft and NYHA class IV to be significant predictors of operative mortality in women. The significant predictors in men were NYHA class IV, atrial fibrillation/flutter or heart block rhythm, and the use of mechanical prosthesis. Age was not a predictor of operative mortality in either sex. Aortic valve replacement carries an acceptable mortality rate in elderly patients. Female gender was a significant predictor of operative mortality in the concomitant coronary artery bypass graft group; however, gender was not a predictor of operative mortality in the isolated aortic valve replacement group. Advance stage of the disease process represented by NYHA class IV was a significant predictor of mortality for the whole group, stressing the need for earlier referral for surgery.

Aortic valve replacement in patients 80 years and older: Operative risks and long-term results

Article

Dec 1993

Forty percent of 7.4 million Americans aged 80 years and older have symptomatic heart disease. Controversy exists as to whether the health care resources allotted to this patient subset represent a cost-effective approach to attaining a meaningful quality of life. Although aortic valve surgery carries greater risks in older than in younger patients, published studies reveal that the elderly should not be denied this procedure. To determine the results of aortic valve replacement (AVR) in an elderly population, we retrospectively analyzed 171 consecutive patients aged 80 to 91 years (mean, 82.6 years; 86 men and 85 women) who underwent AVR at the Texas Heart Institute between 1975 and 1991. Seventy-seven patients had AVR only, and 94 patients had concomitant surgical procedures (coronary artery bypass graft surgery, 75 patients; mitral valve replacement, mitral valve repair, aneurysm repair, 19 patients). The overall 30-day early mortality was 17.5%. The early mortality was 5.2% for patients with AVR only and 27.7% for those with concomitant surgical procedures. Statistical analysis of 17 perioperative variables revealed that left ventricular ejection fraction of less than 45%, hypertension, congestive heart failure, angina, and concomitant surgical procedures were significant univariate predictors of early mortality. Multivariate analysis revealed that left ventricular ejection fraction of less than 45%, hypertension, and concomitant surgical procedures were independent predictors of operative mortality. Mean follow-up of survivors was 39 months. The overall actuarial survival at 1, 3, and 5 years was 90.8%, 84.2%, and 76.0%, respectively. These results show that AVR can be performed with acceptable operative risks in the elderly. This study further shows that isolated AVR can be done with low operative mortality and that the performance of concomitant surgical procedures exposes elderly patients to higher operative risks.

Prevalence of aortic valve abnormalities in the elderly: An echocardiographic study of a random population sample

Article

May 1993
J AM COLL CARDIOL

This study was undertaken to elucidate the prevalence of aortic valve abnormalities in the elderly. The age of persons treated actively for valve disorders is increasing. More information is needed about the prevalence of aortic valve disease in old age. Randomly selected men and women in the age groups 75 to 76, 80 to 81 and 85 to 86 years (n = 501) participating in the Helsinki Ageing Study were studied with imaging and Doppler echocardiography. Additionally, 76 persons 55 to 71 years of age were included. The systolic aortic valve area was calculated by the continuity equation. The velocity ratio (peak velocity in the left ventricular outflow tract/peak velocity across the aortic valve) was a supplementary criterion for aortic stenosis. Valve regurgitation and cusp calcification were assessed visually. Evaluation of the aortic valve was possible in 552 persons (96%). Mild calcification was found in 222 (40%) and severe calcification in 72 (13%). Two persons (0.4%) had an aortic valve prosthesis. Critical native valve stenosis (calculated aortic valve area < or = 0.8 cm2 and velocity ratio < or = 0.35) was found in 12 persons (2.2%). Six of these were symptomatic and potentially eligible for valvular surgery. All persons with aortic valve stenosis were in the three oldest age groups. The prevalence of critical aortic valve stenosis was 2.9% (95% confidence interval 1.4% to 5.1%) in the group 75 to 86 years of age. Aortic regurgitation, mostly mild, was found in 29% of the entire study cohort. Calcific aortic valve stenosis constitutes a significant health problem in the elderly. Only a minority of those with potentially operable aortic valve stenosis undergo surgery.

Aortic valve replacement for aortic stenosis in 200 consecutive octogenarians

Article

Aug 1995
J HEART VALVE DIS

From 1978 to 1992, 200 consecutive patients aged between 80 and 90 years had aortic valve replacement for calcified aortic stenosis. Valve replacement was isolated in 187 cases (93.5%), and it was in combination with coronary bypass (n = 12; 6%), mitral valve replacement (n = 1; 0.5%) or surgery of the ascending aorta (n = 4; 2%). These 200 octogenarians represented 7.4% of the 2716 patients operated for aortic stenosis during the study period. One hundred and forty-eight of them (74%) were in NYHA class III or IV. Operative mortality was 11.5% (23 deaths) and the mean duration of hospitalization was 12.7 +/- 4.83 days. After discharge, all 177 surviving patients were followed up for a mean period of 2.8 +/- 2.1 years (range one month to 10.6 years). There have been 49 deaths during the follow up. At the end of the follow up, 127 of the 128 survivors (98.6) were in NYHA classes I or II. Actuarial survival at one, three and five years was 81.7%, 74.8% and 57.14% respectively, which is equivalent to the life expectancy for subjects of the same age without aortic stenosis. It is suggested that despite the increased, yet acceptable, operative risk, valve replacement in octogenarians is justified due to its beneficial effect on life expectancy and quality of life.

Aortic valve replacement in patients aged eighty years and older: Early and long-term results

Article

Jun 1996
J THORAC CARDIOV SUR

Unlabelled: We have studied 322 patients, 80 years of age or older, who underwent aortic valve replacement between June 1971 and December 1992. Two hundred six patients (64%) have had surgery since the end of 1985. Their mean age was 82.7 years (range 80 to 92 years). One hundred seventy-one (53%) were male and most (86%) were in New York Heart Association class III-IV. Fifty-seven patients (18%) required admission to the coronary care unit before the operation. One hundred seventy-nine patients (56%) underwent an urgent or emergency operation. Known cerebrovascular disease was present in 77 (24% of patients), aortic stenosis in 79%, aortic incompetence in 9%, and combined stenosis and incompetence in 12%. Associated procedures included bypass grafting in 139 (43%), mitral valve replacement/repair in 20 (6%), tricuspid valve repair in 6 (2%), and aortic annular enlargement in 38 (12%). Thirty patients (9.3%) were undergoing reoperation. Hospital mortality was 44 of 322 (13.7%). The median hospital stay was 11 days. On univariate analysis, significant predictors of hospital mortality were female sex, preoperative rest pain, New York Heart Association class III-IV, admission to the coronary care unit, heart failure, mitral valve disease, emergency/urgent operation, chronic obstructive pulmonary disease, bypass grafting, valve size, peripheral vascular disease, and ejection fraction less than 0.35. On multivariate analysis the most important independent predictors of operative mortality were female gender (p = 0.0001), renal impairment (p = 0.001), bypass grafting (p = 0.005), ejection fraction less than 0.35 (p = 0.01), and chronic obstructive pulmonary disease (p = 0.028). Age and year of operation did not influence mortality. Five-year survivals for all patients and for operative survivors were 60.2% +/- 3.2% and 70.3% +/- 3.4%, respectively. On univariate analysis, factors that adversely affected long-term survival were coronary bypass grafting (p = 0.007), more than two comorbidities (p = 0.02), male gender (p = 0.04), and ejection fraction less than 0.35 (p = 0.04). On multivariate analysis, no factor was consistently significant for long-term survival. At most recent clinical follow-up 85% were angina free and 82% were in class I-II. At least 92% of patients, both at 1 year and at most recent clinical follow-up, believed they had significantly benefited from the operation: Conclusion: Risk factors for aortic valve replacement in octogenarians include female gender, unstable symptoms, poor ejection fraction, renal impairment, and bypass grafting. However, despite a hospital mortality higher than that reported for younger patients, the outlook for operative survivors is excellent, with good relief of symptoms and an expected survival normal for this particular age group. If possible, aortic valve replacement should be done before development of unstable symptoms.

Aortic Valve Replacement for Aortic Stenosis With Severe Left Ventricular Dysfunction: Prognostic Indicators

Article

Jun 1997

Aortic valve replacement for aortic stenosis (AS) carries an increased risk in the presence of left ventricular (LV) systolic dysfunction. Few data are available on the outcome of such patients. Between 1985 and 1992, 154 consecutive patients (107 men and 47 women) with LV systolic dysfunction (ejection fraction [EF] < or = 35%) underwent aortic valve replacement for AS. The mean preoperative characteristics included EF, 27 +/- 6%; aortic valve mean gradient, 44 +/- 18 mm Hg; aortic valve area, 0.6 +/- 0.2 cm2; and cardiac output, 4.1 +/- 1.5 L/min. Simultaneous coronary artery bypass graft surgery was performed in 78 patients (51%). Perioperative (30-day) mortality was 9% (14 of 154 patients). Fifty patients died during follow-up. Coronary artery disease (P = .002) and a reduced preoperative cardiac output (P = .03) were significantly related to reduced overall survival rate by multivariate analysis. Postoperative improvement occurred in most patients; 88% were New York Heart Association class III or IV before surgery versus 7% after surgery. Postoperative EF was assessed in 76% of survivors; 76% of these demonstrated improvement. By multivariate analysis, change in EF was inversely related to coronary disease (P = .002) and preoperative aortic valve area (P = .03). Despite LV dysfunction, the risk of aortic valve replacement for AS was acceptable and related to coronary artery disease and mean aortic gradient, and long-term survival was related to coronary disease and cardiac output. Improvement in symptoms and EF occurred in most patients.

Cardiac Operations in Patients 80 Years Old and Older

Article

Sep 1997
ANN THORAC SURG

Because the elderly are increasingly referred for operation, we reviewed results with cardiac surgical patients 80 years old or older. Records of 600 consecutive patients 80 years old or older having cardiac operations between 1985 and 1995 were reviewed. Follow-up was 99% complete. Two hundred ninety-two patients had coronary grafting (CABG), 105 aortic valve replacement (AVR), 111 AVR + CABG, 42 mitral valve repair/ replacement (MVR) +/- CABG, and 50 other operations. Rates of hospital death, stroke, and prolonged stay (> 14 days) were as follows: CABG: 17 (5.8%), 23 (7.9%) and 91 (31.2%); AVR: 8 (7.6%), 1 (1.0%), and 31 (29.5%); AVR + CABG: 7 (6.3%), 12 (10.8%), and 57 (51.4%); MVR +/- CABG: 4 (9.5%), 3 (7.1%), and 16 (38.1%); other: 9 (18.0%), 3 (6.0%), and 23 (46.0%). Multivariate predictors (p < 0.05) of hospital death were chronic lung disease, postoperative stroke, preoperative intraaortic balloon, and congestive heart failure; predictors of stroke were CABG and carotid disease; and predictors of prolonged stay were postoperative stroke and New York Heart Association class. Actuarial 5-year survival was as follows: CABG, 66%; AVR, 67%; AVR + CABG, 59%; MVR +/- CABG, 57%; other, 48%; and total, 63%. Multivariate predictors of late death were renal insufficiency, postoperative stroke, chronic lung disease, and congestive heart failure. Eighty-seven percent of patients believed having a heart operation after age 80 years was a good choice. Cardiac operations are successful in most octogenarians with increased hospital mortality, postoperative stroke, and longer hospital stay. Long-term survival is largely determined by concurrent medical diseases.

Aortic Valve Replacement in Patients 80 Years of Age and Older : Survival and Cause of Death Based on 1100 Cases: Collective Results From the UK Heart Valve Registry

Article

Dec 1997

Aging of the population and advances in preoperative and postoperative care are reflected in an increasing number of patients > or = 80 years of age undergoing aortic valve replacement (AVR) in the United Kingdom. The present study presents data on postoperative 30-day mortality, actuarial survival, and cause of death based on a large collective patient population. Data were extracted from the UK Heart Valve Registry. From January 1986 to December 1995, 1100 patients > or = 80 years of age underwent AVR and were reported to the registry. Six hundred eleven patients (55.5%) were women. The mean follow-up time was 38.9 months. The 30-day mortality was 6.6%. Of the 73 early deaths, 42 were due to cardiac reasons. The actuarial survival was 89%, 79.3%, 68.7%, and 45.8% at 1, 3, 5, and 8 years, respectively. After the first 30 postoperative days, 144 of the 205 deaths were due to noncardiac reasons. Malignancy, stroke, and pneumonia were the most common causes of late death. Bioprosthetic valves were implanted in 969 patients (88%) and mechanical valves in 131 (12%) patients. There was no difference in early mortality and actuarial survival between the two groups (P>.05). The above results suggest that under the selection criteria for AVR currently applied in the United Kingdom, patients > or = 80 years of age show a satisfactory early postoperative outcome and moderate medium-term survival benefit.

Cardiac surgery in the elderly

Article

Feb 1999

There has been a gradual increase in the number of elderly patients referred for cardiac surgery. These patients present a difficult challenge, they are usually symptomatic yet at high risk for intervention. The aim of this study is to review our experience with cardiac surgery in patients aged 80 years or older. Between January 1981 and October 1997, 242 patients; 135 female, 107 male, mean age 82.8 years (range 80-95) underwent surgery on cardiopulmonary bypass in our unit. Surgery was performed on 14 as an emergency and 136 on an urgent (patient restricted to a hospital bed due to symptoms) basis. Pre-operatively 182 (75.2%) were in NYHA functional class 3 or 4. Early mortality was 14 (5.7%). A mitral valve procedure and emergency surgery were significantly associated (P < 0.05) with an increased risk of operative mortality. Median ITU and in-hospital stay was 1 day (range 0-33) and 10 (range 6-49) days, respectively. Ninety-three percent of patients were living independently at home 2 months post-operatively. Survival (+/-SEM) is 98% complete (totals 557 patient years) and including early mortality at 1 and 5 years was 85.5+/-2.4% (n = 154), and 67.7+/-4.3% (n = 33). Survival for patients undergoing isolated aortic valve replacement (AVR) and coronary artery bypass grafting (CABG) at 5 years was 64.8+/-7.8% and 79.7+/-7.4%, respectively. Survival was significantly worse in patients undergoing a mitral procedure. Using Cox's proportional hazards model only type of operation (mitral surgery) was significantly associated with worse survival. Cardiac surgery can be performed in a selected elderly population with a low operative mortality. Post-operatively elderly patients attain an excellent quality of life and survival. Emergency and mitral surgery in this group of patients is less rewarding.

Observed and relative survival after aortic valve replacement

Article

Apr 2000
J AM COLL CARDIOL

We sought to evaluate the effects of a number of factors that can potentially determine the optimal time for aortic valve replacement (AVR) and the observed and relative survival after the operation. Aortic valve replacement is performed in patients within a wide age span, but the proportion of elderly patients is increasing. In survival analyses, adjustment for the effects of age is therefore essential. Analysis of relative survival provides additional information on excess or disease-specific mortality and its risk factors. Survival was analyzed in 2,359 patients (1,442 without and 917 with concomitant coronary artery bypass graft surgery) undergoing their first AVR. By relating observed survival to that expected among the general Swedish population stratified by age, gender and five-year calendar period, the relative survival and disease-specific survival were estimated. Early mortality after AVR (death within 30 days) was 5.6%. Relative survival rates (excluding early deaths) after 5, 10 and 15 years were 94.6%, 84.7% and 74.9%, respectively. There was an excess risk of dying during the entire follow-up period. Advanced New York Heart Association functional class, preoperative atrial fibrillation and pure aortic regurgitation were independent risk factors for observed and relative survival. Patients in the oldest age group showed decreased observed survival but excellent relative survival. Old age was not a risk factor for excess mortality after AVR, whereas atrial fibrillation decreased relative survival substantially.

Quality of Life After Aortic Valve Replacement at the Age of >80 Years

Article

Nov 2000
CIRCULATION

The optimal management of aortic valve disease in patients >80 years old depends on functional outcome as well as operative risks and late survival. We retrospectively identified 133 patients (62 men, 71 women) aged 80 to 91 years (mean 84+/-3 years) who underwent aortic valve replacement alone or in combination with another procedure between January 1, 1993, and April 31, 1998. Demographics included hypertension 68%, diabetes mellitus 17%, and history of stroke 11%. Operative (30 day) mortality rate was 11%. Urgent or emergent surgery, aortic insufficiency, and perioperative stroke or renal dysfunction were risk factors for operative death by multivariable analysis. Intensive care unit and total hospital length of stay were prolonged at 6.2 and 14.7 days, respectively. Late follow-up between July 1, 1998, and November 1, 1999, was 98% complete. Actuarial survival at 1 and 5 years was 80% and 55%, respectively. Predictors of late mortality were preoperative or perioperative stroke, chronic obstructive pulmonary disease, aortic stenosis, and postoperative renal dysfunction. The mean New York Heart Association functional class for 65 long-term survivors improved from 3.1 to 1.7. Quality of life assessed with the Medical Outcomes Study Short Form-36 was comparable to that predicted for the general population >75 years old. Functional outcome after aortic valve replacement in patients >80 years old is excellent, the operative risk is acceptable, and the late survival rate is good. Surgery should not be withheld from the elderly on the basis of age alone.

Validation of European System for Cardiac Operative Risk Evaluation (EuroSCORE) in North American cardiac surgery

Article

Aug 2002

To assess the performance of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) when applied in a North American cardiac surgical population. The simple additive EuroSCORE model was applied to predict operative mortality (in-hospital or 30-day) in 401684 patients undergoing coronary or valve surgery in 1998 and 1999 as well as in 188913 patients undergoing surgery in 1995 in the Society of Thoracic Surgeons (STS) database. The proportion of isolated coronary artery bypass grafting (CABG) was greater in STS patients (84%) than in Europe (65%). STS patients were also older (mean age 65.3 versus 62.5), and had more diabetes (30 versus 17%) and prior cardiac surgery (11 versus 7%). Other comorbidity was also significantly more prevalent in STS patients. EuroSCORE predicted overall mortality was virtually identical to the observed mortality (1998/1999: predicted 3.994%, observed 3.992%; 1995: observed and predicted 4.156%). Predicted mortality also closely matched observed mortality across the risk groups. Discrimination was good to very good for the population overall and for isolated CABG in both time periods, with the area under the receiver operating characteristic curve between 0.75 and 0.78. Despite substantial demographic differences between Europe and North America, EuroSCORE performs very well in the STS database, and can be recommended as a simple, additive risk stratification system on both sides of the Atlantic.

A prospective survey of patients with valvular heart disease in Europe: The Euro Heart Survey on Valvular Heart Disease

Article

Jul 2003

To identify the characteristics, treatment, and outcomes of contemporary patients with valvular heart disease (VHD) in Europe, and to examine adherence to guidelines. The Euro Heart Survey on VHD was conducted from April to July 2001 in 92 centres from 25 countries; it included prospectively 5001 adults with moderate to severe native VHD, infective endocarditis, or previous valve intervention. VHD was native in 71.9% of patients and 28.1% had had a previous intervention. Mean age was 64+/-14 years. Degenerative aetiologies were the most frequent in aortic VHD and mitral regurgitation while most cases of mitral stenosis were of rheumatic origin. Coronary angiography was used in 85.2% of patients before intervention. Of the 1269 patients who underwent intervention, prosthetic replacement was performed in 99.0% of aortic VHD, percutaneous dilatation in 33.9% of mitral stenosis, and valve repair in 46.5% of mitral regurgitation; 31.7% of patients had > or =1 associated procedure. Of patients with severe, symptomatic, single VHD, 31.8% did not undergo intervention, most frequently because of comorbidities. In asymptomatic patients, accordance with guidelines ranged between 66.0 and 78.5%. Operative mortality was <5% for single VHD. This survey provides unique contemporary data on characteristics and management of patients with VHD. Adherence to guidelines is globally satisfying as regards investigations and interventions.

EuroSCORE predicts mid-term outcome after combined valve and coronary bypass surgery

Article

Jun 2004
J HEART VALVE DIS

EuroSCORE is widely used to assess operative risk. Combined cardiac procedures carry increased perioperative mortality, but the influence of preoperative factors on mid-term outcome is not well known for these patients. The study aim was to determine if EuroSCORE risk influences mid-term survival after combined coronary artery bypass grafting (CABG) and valve surgery. Follow up (mean 23.7 months) was obtained in 258 consecutive hospital survivors (148 males, 110 females; median age 72.29 years; mean EuroSCORE 7 points) operated on between January 1998 and March 2001. CABG + aortic valve replacement (AVR) was performed in 171 patients, CABG + mitral surgery in 72, and CABG + double valve surgery in 15. Kaplan-Meier estimates were calculated for survival and combined freedom from death and NYHA class III/IV. The Cox regression model was applied to prove the influence of EuroSCORE risk and a number of preoperative and operative variables on mid-term outcome. Thirty patients (11.63%) died during follow up, and 34 (13.17%) were in NYHA class III/IV. Freedom from death and NYHA class III/IV was 89.3%, 74.7% and 55.2% at 12, 24 and 36 months, respectively. The significant predictor for combined death and NYHA class III/IV was EuroSCORE risk (p = 0.0004). In the subgroup of patients with CABG + mitral valve surgery, age was identified as a significant risk factor for death (p = 0.0346), whereas in the subgroup of patients with CABG + AVR EuroSCORE was detected as significant risk factor for combined death and NYHA class III/IV. EuroSCORE is an important predictor for poor mid-term outcome after combined CABG and valve surgery.

Valvular surgery in octogenarians: Operative risks factors, evaluation of Euroscore and long term results

Article

Feb 2005

In the last decade, cardiac surgery in octogenarians is becoming a routinely performed procedure in our Western countries. The functional benefit of this surgery had already been proved. The aim of this study was to evaluate operative mortality, to identify pre- and post-operative risk factors of early and late mortality, to assess the Euroscore count in this high-risk group of patient and to evaluate late results of this surgery. We reviewed 215 consecutive patients with a mean age of 83+/-2 years having undergone valvular surgery. There were 127 female patients (57.1%) and 88 males (42.9%). One hundred and fifty-nine patients (74%) underwent aortic valve replacement 42 (19.5%) mitral surgery and 14 (6.5%) double valve surgery. There were 32 (14.9%) re-operative cases. Twenty-seven patients (12.6%) were operated on in emergency. There were 32 re-operations (14%). The EuroSCORE was used to assess predicted operative risk. Mean Euroscore additive count was 9.5+/-2.3 and mean logistic Euroscore was 15.1%. Operative mortality was 8.8% (19 patients). Left ventricular dysfunction was the only pre-operative significant risk factors of mortality (P=0.05). Low cardiac output (P<0.001), gastrointestinal complications (P=0.03) and surgical reexploration (P=0.001) were significant risk factors of mortality. Mean survival was 84% after one year and 56% after 5 years. Valvular surgery in octogenarians is a safe and low risk procedure compared to functional benefit and long-term survival. Our data how that logistic Euroscore overestimates the mortality in this high-risk group of patients.

ACC/AHA 2006 Guidelines for the Management of Patients With Valvular Heart Disease A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): Developed in Collaboration With the Society of Cardiovascular Anesthesiologists: Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons

Article

Sep 2006
CIRCULATION

Aortic valve surgery in octogenarians: Predictive factors for operative and long-term results

Article

Apr 2007

To assess factors influencing operative and long-term outcome in octogenarians undergoing aortic valve surgery (AVR). Records of 220 consecutive octogenarians having AVR between 1992 and 2004 were reviewed, and follow-up obtained (99% complete). Of the group (mean age: 82.8 years; 174 females), 142 patients (65%) were in New York Heart Association (NYHA) class III-IV, 22 (10%) had previous myocardial infarction, 11 (5%) had previous coronary artery bypass grafting (CABG), and 8 (4%) had percutaneous aortic valvuloplasty. There were 44 urgent procedures (20%), and additional CABG was performed in 58 patients (26%). Operative mortality was 13% (9% for AVR, 24% for AVR+CABG). Among the 29 patients who died, 14 (48%) were operated on urgently (32% mortality for urgent procedures). Causes of hospital death were respiratory insufficiency or infection in 16 patients (16/29=55%), myocardial infarction in 8 (28%), stroke in 2 (7%), sepsis in 2 (7%), and renal failure in 1 (3%). Significant postoperative complications were atrial fibrillation in 48 patients (22%), respiratory insufficiency in 46 (21%), permanent atrio-ventricular bloc in 12 (5%), myocardial infarction in 10 (5%), hemodialysis in 4 (2%), and stroke in 4 (2%). Mean hospital and intensive care unit (ICU) stays were 17.6+/-5.2 and 6.9+/-3.4 days, respectively. Multivariate predictors (p<0.05) of hospital death were urgent procedure, associated CABG, NYHA class IV, and percutaneous aortic valvuloplasty. Age, associated CABG, and urgent procedure were predictors of prolonged ICU stay. Mean follow-up was 58.2 months and actuarial 5-year survival was 73.2+/-6.9%. Age, preoperative myocardial infarction, urgent procedure, and duration of ICU stay were independent predictors of late death. Among 130 patients alive at follow-up, 91% were angina free and 81% in class I-II. AVR in octogenarians can be performed with acceptable mortality, although significant morbidity. These results stress the importance of early operation on elderly patients with aortic valve disease, avoiding urgent procedures. Associated coronary artery disease is a harbinger of poor operative outcome. Long-term survival and functional recovery are excellent.

Cost-effectiveness of aortic valve replacement in the elderly: An introductory study

Article

Apr 2007

With increased life expectancy and improved technology, valve replacement is being offered to increasing numbers of elderly patients with satisfactory clinical results. By using standard econometric techniques, we estimated the relative cost-effectiveness of aortic valve replacement by drawing on a large prospective database at our institution. By using aortic valve replacement as an example, this introductory report paves the way to more definitive studies of these issues in the future. From 1961 to 2003, 4617 adult patients underwent aortic valve replacement at our service. These patients were provided with a prospective lifetime follow-up. As of 2005, these patients had accumulated 31,671 patient-years of follow-up (maximum 41 years) and had returned 22,396 yearly questionnaires. A statistical model was used to estimate the future life years of patients who are currently alive. In the absence of direct estimates of utility, quality-adjusted life years were estimated from New York Heart Association class. The cost-effectiveness ratio was calculated by the patient's age at surgery. The overall cost-effectiveness ratio was approximately 13,528 dollars per quality-adjusted life year gained. The cost-effectiveness ratio increased according to age at surgery, up to 19,826 dollars per quality-adjusted life year for octogenarians and 27,182 dollars per quality-adjusted life year for nonagenarians. Given the limited scope of this introductory study, aortic valve replacement is cost-effective for all age groups and is very cost-effective for all but the most elderly according to standard econometric rules of thumb.

Outcomes of elderly patients aged 80 and over with symptomatic, severe aortic stenosis: Impact of patient's choice of refusing aortic valve replacement on survival

Abstract

No full-text available

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