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Aortic valve replacement in octogenarians.
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MedLine Citation:
PMID:  17629905     Owner:  NLM     Status:  MEDLINE    
Abstract/OtherAbstract:
BACKGROUND AND AIMS: As our population ages and life expectancy increases the number of people aged over 80 and more referred for cardiac surgery is growing. This study sought to identify the outcome of aortic valve replacement (AVR) in octogenarians.
METHODS: 68 patients aged 80 years or more underwent AVR at the Freeman Hospital, between April 2001 and April 2004. A retrospective review of the notes and outcomes from the patients' GP and the NHS strategic tracking service was performed. 54% (37) underwent isolated AVR whilst 46% (31) underwent combined AVR and CABG.
RESULTS: Follow up was 100% complete. The mean age was 83.1 +/- s.d. 2.9 years, a mean gradient of 83 +/- s.d. 31 mmHg and mean AVA of 0.56 cm2. The mean additive EuroSCORE was 8.6 +/- s.d. 1.2, the logistic EuroSCORE mean 12.0 +/- s.d. 5.9. In hospital 30 day mortality was 13 %. Survival was 80% at 1 year and 78% at 2 years. Median follow up was for 712 days. Stepwise logistic regression identified chronic obstructive airways disease as an independent predictor of mortality (p < 0.05). Survival was not adversely affected by the addition of coronary artery bypass grafts to aortic valve replacement, the presence of peripheral vascular disease, hypertension or diabetes. In this study duration of cross clamp or bypass time were not found to reach significance as independent predictors of mortality.
CONCLUSION: Our study demonstrates that the operative mortality for AVR in the over eighties is good, whilst the mid to long term outcome is excellent There is a very low attrition rate with those undergoing the procedure living as long than their age matched population. This study confirms AVR is a safe, acceptable treatment for octogenarians with excellent mid term outcomes.
Authors:
Amal K Bose; James D Aitchison; John H Dark
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Publication Detail:
Type:  Journal Article     Date:  2007-07-13
Journal Detail:
Title:  Journal of cardiothoracic surgery     Volume:  2     ISSN:  1749-8090     ISO Abbreviation:  J Cardiothorac Surg     Publication Date:  2007  
Date Detail:
Created Date:  2007-08-16     Completed Date:  2009-05-26     Revised Date:  2014-04-08    
Medline Journal Info:
Nlm Unique ID:  101265113     Medline TA:  J Cardiothorac Surg     Country:  England    
Other Details:
Languages:  eng     Pagination:  33     Citation Subset:  IM    
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MeSH Terms
Descriptor/Qualifier:
Aged, 80 and over
Aortic Valve / surgery*
Female
Heart Valve Prosthesis Implantation*
Humans
Male
Retrospective Studies
Survival Analysis
Comments/Corrections

From MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine

Full Text
Journal Information
Journal ID (nlm-ta): J Cardiothorac Surg
ISSN: 1749-8090
Publisher: BioMed Central, London
Article Information
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Copyright ? 2007 Bose et al; licensee BioMed Central Ltd.
open-access: This is an Open Access article distributed under the terms of the Creative Commons Attribution License (), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Received Day: 28 Month: 1 Year: 2007
Accepted Day: 13 Month: 7 Year: 2007
collection publication date: Year: 2007
Electronic publication date: Day: 13 Month: 7 Year: 2007
Volume: 2First Page: 33 Last Page: 33
ID: 1947977
Publisher Id: 1749-8090-2-33
PubMed Id: 17629905
DOI: 10.1186/1749-8090-2-33

Aortic valve replacement in octogenarians
Amal K Bose1 Email: amal@doctors.net.uk
James D Aitchison1 Email: j.d.aitchison@blueyonder.co.uk
John H Dark1 Email: j.h.dark@ncl.ac.uk
1Department of Cardiothoracic Surgery, The Freeman Hospital, High Heaton, Newcastle-upon-Tyne, NE7 7DN, UK

Background

Life expectancy for both men and women has continued to rise in the UK. Data from 2002 shows life expectancy at birth for females born in the UK was 81 years, compared with 76 years for males. This contrasts with 49 and 45 years respectively at the turn of the last century. The expectation of life for people reaching the age of 80 has also increased and is now 7 years for men, 9 years for women in the U.K. (OPCS data). Cardiovascular disease is the largest cause of death in this age group. As our population ages, the number of people aged 80 or over referred for cardiac surgery is increasing with a particular rise in those with aortic valve disease. There is evidence that early outcomes in heart valve surgery are improving over the last decade [1] Previous studies have demonstrated good outcomes in terms of both operative mortality [2] and quality of life [3]. Age has also been shown to influence the decision to refer patients with aortic stenosis for surgery [4] with adverse outcomes [5]. This study sought to identify the medium term outcome of aortic valve replacement in octogenarians in a more recent setting.


Methods

Between April 2001 and April 2004 all patients aged 80 years or more who underwent aortic valve replacement (AVR) or AVR and coronary artery bypass grafts at a single tertiary referral hospital in Northern England (Freeman Hospital) were identified. The notes were retrospectively reviewed. The patients' general practices were contacted to obtain follow up data, together with the hospital PATS database and the NHS strategic tracking service. Patients undergoing double valve replacement were excluded.


Results

Sixty eight patients were identified. Data collection and follow up were 100% complete. The mean age was 83.2 ? s.d. 2.9 years, a mean gradient of 83 ? s.d. 31 mmHg and mean AVA of 0.56 ? s.d. 0.24 cm2. Fifty four percent (37) underwent isolated AVR whilst 46% underwent combined AVR and CABG. (Table 1) All the patients had bio-prostheses implanted. Two patients received stentless valves. All but one patient underwent first time valve replacement. One patient required root enlargement to accommodate a size 19 prosthesis.

The mean additive EuroSCORE was 8.6 ? s.d. 1.2, the mean logistic EuroSCORE was 12.0 ? s.d. 5.9, the mean Parsonnet score was 30.4 ? s.d. 4.3. In hospital 7 day and 30 day mortality were 4.4% and 13% respectively. Isolated AVR mortality was 10% at 30 days. Two patients (3%) were affected by a CVA or TIA. Atrial fibrillation occurred in 18 (26%), whilst seven patients required renal replacement therapy as a new intervention postoperatively in the form of continuous veno-venous haemofiltration. Mean hospital stay was 15 ? s.d. 12 and median 11 days (range 5 to 60 days). See table 2.

Survival was 80% at 1 year and 78% at 2 years, see Figure 1. Median follow up was for 712 days. Stepwise logistic regression identified COAD as an independent predictor of mortality (p < 0.05). Survival was not adversely affected by the addition of coronary artery bypass grafts to aortic valve replacement, the presence of peripheral vascular disease, hypertension or diabetes. In this study, duration of cross clamp or bypass time were not found to reach significance as independent predictors of mortality.


Comment

The current demographic trend throughout the developed world is for an ageing population with improved life expectancy. Data from the Society of Cardiothoracic Surgeons of Great Britain and Ireland national audit 2003 shows the average age of patients in the UK undergoing combined AVR and CABG has risen from 68 to just under 72 with a similar trend for isolated AVR [6].

Aortic valve replacement has been shown to be the most common valve surgery performed in this age group [7]. The simple additive Euroscore significantly under-predicted 30 day mortality in this sub-group of the general cardiothoracic patient population, with a mean Euroscore of 8.3. The mean logistic Euroscore was 12.0, which was closer to the actual mortality in this study. Previous studies have suggested that coronary artery bypass grafting combined with aortic valve replacement does not increase post operative risk [8], which is supported by our results.

Our study demonstrates that the operative mortality for AVR in the over eighties is good, whilst the mid to long term outcome is excellent. There is a very low attrition rate with those undergoing the procedure living as long as their age matched population. This study confirms AVR is a safe, acceptable treatment for selected octogenarians with excellent mid term outcomes. A surgical opinion should not therefore be withheld on the basis of age.


Limitations

This is a small retrospective study which purely looked at hospital morbidity and mortality. Follow up mortality data was collected but there was no assessment of quality of life or symptom status in this data. A selection bias has not been excluded in this group proceeding to surgery. Perhaps because they were so carefully selected median survival was excellent.


Competing interests

The author(s) declare that they have no competing interests.


Authors' contributions

JD initiated the project. AB contributed to data collection and was primary author. JA performed the statistical analysis. All authors read and approved the final manuscript.


Acknowledgements

My thanks to Linda Fellows and the database managers


References
Hellegren L,Kvidal P,Stahle E. Improved early results after heart valve surgery over the last decadeEur J Cardiothorac Surg 2002;22:904–11. [pmid: 12467812] [doi: 10.1016/S1010-7940(02)00585-7]
Asimakopoulos G,Edwards MB,Taylor KM. Aortic valve replacement in patients 80 years of age and older: survival and cause of death based on 1100 cases: collective results form the UK valve registryCirculation 1997;96:3403–8. [pmid: 9396434]
Khan JH,McElhinney DB,Hall Ts,Merrick SH. Cardiac valve surgery in octogenarians: improving quality of life and functional statusArch Surg 1998;133:887–93. [pmid: 9711964] [doi: 10.1001/archsurg.133.8.887]
Bouma BJ,Van der Meulen JH,Van den Brink RB,Arnold AE,Smidts A,Teunter LH,Lie KI,Tijssen JG. Variability in treatment advice for elderly patients with aortic stenosis: a nationwide survey in the NetherlandsHeart 2001;85:196–201. [pmid: 11156672] [doi: 10.1136/heart.85.2.196]
Bouma BJ,Van den Brink RB,Van der Meulen JH,Verhaul HA,Cheriex EC,Hamer HP,Dekker E,Lie KI,Tijssen JG. To operate or not on elderly patients with aortic stenosis the decision and its consequencesHeart 1999;82:143–8. [pmid: 10409526]
Keogh B,Klinsman R. Society of Cardiothoracic Surgeons of Great Britain and IrelandFifth National Adult Cardiac Surgical Database Report. 2003
Collart F,Feier H,Kerbaul F,Mouly-Bandini A,Riberi A,Di Stephano E,Seree Y,Mesana TG,Metras D. Primary Valular surgery in octogenarians: perioperative outcomeJ Heart Valve Dis 2005;14:238–42. [pmid: 15792185]
Brunvand H,Offstad J,Nitter-Hauge S,Svennevig JL. Coronary artery bypass grafting combined with aortic valve replacement in healthy octogenarians does not increase post operative riskScand Cardiovascu J 2002;36:297–301. [doi: 10.1080/140174302320774519]

Figures

[Figure ID: F1]
Figure 1 

Survival curve for octogenarian aortic valve replacement.



Tables
[TableWrap ID: T1] Table 1 

Demographics, symptoms, risk factors


Variable (unit) n (percentage)
Male 38 (58%)
Mean Age ? s.d. (years) 83.2 ? 2.9
NYHA I 7 (11%)
II 13 (21%)
III 29 (46%)
IV 14 (22%)
CCS 0 26 (42%)
I 8 (13%)
II 11 (18%)
III 14 (23%)
IV 3 (5%)
Impaired LV 11 (18%)
NIDDM 3 (4%)
Hypertension 29 (43%)
Renal Impairment/Failure 6 (9%)
COPD 12 (18%)
PVD 5 (8%)
Emergent/Urgent 18 (26%)

CCS ? Canadian Cardiovascular Society

COPD ? Chronic obstructive pulmonary disease

NYHA ? New York Heart Association

LV ? Left ventricle

NIDDM ? Non insulin dependent diabetes mellitus

PVD ? Peripheral vascular disease


[TableWrap ID: T2] Table 2 

Post operative complications


Complication n (percentage)
Atrial Fibrillation 18 (26%)
Renal Support (new CVVH) 7 (10%)
Respiratory Failure 12 (18%)
Bleeding requiring reopening 3 (4%)
CVA 1 (1%)
TIA 1 (1%)

CVA ? Cerebro-vascular Accident

TIA ? Transient Ischaemic Attack



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