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Comparison of Pre- and Post-Operative Characteristics in Octogenarians Having Isolated Surgical Aortic Valve Replacement Before versus After Introduction of Transcatheter Aortic Valve Implantation
... In one series, male and female patients were investigated separately [3]; in another, TAVI and non-TAVI centers were analyzed separately [35]. In three series [26,28,34], patient age was represented as age classes, not as mean or median. Fifteen series were nationwide and mostly of recent origin, i.e., published in 2017 or later [13,18,[21][22][23][24]26,30,31,33,35,38,40,41,43]. ...
... Fifteen series were nationwide and mostly of recent origin, i.e., published in 2017 or later [13,18,[21][22][23][24]26,30,31,33,35,38,40,41,43]. Three series covered a region [1,19,25] and fourteen series were monocentric [2,3,[14][15][16][17]20,27,28,32,34,36,37,42], and one series was derived from data from three centers [39]. These series covered a time span between 3 and 15 years and only two series started before 2000 [23,43]. ...
... Most of the nationwide series covered over 20,000 patients, while the 14 monocentric series varied from small series, including less than 100 patients [2] to almost 2000 patients [28]. Eighteen series studied isolated SAVR [2,3,14,15,[17][18][19][20]22,23,26,27,31,34,35,37,39,40] and six series investigated isolated SAVR and SAVR with concomitant CABG separately [1,13,21,38,41,43]. This included one study which also made the comparison with minimally invasive SAVR [39]. ...
Transcatheter aortic valve implantation (TAVI) was first presented in 2002 as a case report. Randomized controlled trials showed that TAVI could serve as an alternative for surgical aortic valve replacement (SAVR) in high-risk patients. While the indications for TAVI have expanded into low-risk groups, favorable results of SAVR in elderly showed an increase in application of surgical treatment in this age category. This review aims to explore the effect of the introduction of TAVI in the referral for SAVR with respect to volume, patient profile, early outcome, and use of mechanical heart valves. Results show that the volume of SAVR has increased in several cardiac centers. In a small minority of series, age and risk score of the referred patients also increased. In most of the series, early mortality rate reduced. These findings, however are not universal. Different management policies could be responsible for this observation. Moreover, some patients in whom aortic valve replacement in whatever form is indicated still do not receive adequate treatment. This can be due to several reasons. Heart teams consisting of interventional cardiologists and cardiac surgeons should become a universal approach in order to minimize the number of untreated patients.
... In the Society of Thoracic Surgeons (STS) database, mortality at 30 days after isolated SAVR over 80 years was 3.7% in low-risk patients but rose to 10% and 17%, respectively, in patients with STS score 5 and 10. 37 Octogenarians also report improvements in symptoms and ventricular function. 38 Results of transcatheter aortic valve implantation in patients at high or prohibitive risk On the basis of two main randomized trials and various observational studies, recent guidelines 2 indicate TAVI as an option of choice in patients deemed inoperable because a prohibitive risk (with results far superior to medical therapy alone) and a reasonable alternative to SAVR in those at high risk ( Table 1). [13][14][15][39][40][41][42][43][44][45][46][47] In the PARTNER trial (Cohort A), which included patients with high operative risk, 44 patients undergoing SAVR had a higher incidence of bleeding and a lower incidence of vascular complications, compared with those undergoing TAVI at 5 years. ...
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.
... Bauernschmitt et al. [30] and Bapat et al. [31] first reported the trans-aortic (TAo) approach using the CoreValve and SAPIEN valves, respectively. This approach utilizes an upper ministernotomy, with minimal effects on respiratory function as compared to minithoracotomy (TA access) or full sternotomy (SAVR access) particularly of importance in patients with underlying chronic obstructive pulmonary disease [5,[32][33][34]. Furthermore, this approach may decrease direct myocardial injury [35,36], thereby preserving myocardial function in patients with an already depressed left ventricular ejection fraction [37] and ensuring an easier and safer sheath placement than the TA approach [26,[37][38][39][40]. Significant aortic calcifications could be a contraindication due to the retrograde route for the valve placement with this approach [41]. ...
Transcatheter aortic valve replacement (TAVR) has become an alternative to surgical intervention for symptomatic or severe aortic valve stenosis in patients with high surgical risk. Successful TAVR requires a multimodality imaging approach for appropriate patient selection and prosthesis sizing. Here, we describe individual imaging modalities and report their respective roles in this emerging field. To date, echocardiography remains the traditional test for determining patient candidacy and prosthesis selection, but computed tomography (CT) has been taking on an increasingly important role in the evaluation of both the aortic root anatomy and aortoiliofemoral vessels as a single examination. Cardiac magnetic resonance (CMR) is useful in grading the severity of aortic stenosis and should be considered a reasonable alternative to CT for the evaluation of the aortic annulus, e.g., when the administration of contrast media is contraindicated.
Objective
Octogenarians offered complex cardiac surgery (CS) frequently experience a prolonged ICU length of stay (prICULOS); however minimal data exist on outcomes of these patients. We sought to determine rates and predictors of 1-year non-institutionalized survival (“functional survival”), and re-hospitalization for octogenarian prICULOS CS patients discharged from hospital.
Methods
Outcomes of discharged CS patients ≥80 years old with prICULOS (defined as ICULOS of ≥5 consecutive days) from Jan 1, 2000 to Dec 31, 2011 were examined retrospectively from linked clinical and administrative provincial databases. Regression analysis was used to determine predictors of 1-year functional survival and re-hospitalization following discharge from hospital.
Results
There were 80/683 (11.7%) discharged octogenarian patients who experienced prICULOS. Functional survival at 1-year was 92% and 81% for non-prICULOS and prICULOS patients respectively (p<0.01). Lack of outpatient physician visits within 30 days of discharge (HR = 5.18; p<0.01) was a significant predictor of poor 1-year functional survival. The 1-year re-hospitalization rates were 38% and 48% for the non-prICULOS and prICULOS patients respectively, with 41% of all re-hospitalizations occurring within 30 days of initial discharge. A rural residence (HR = 1.82; p<0.01) and nosocomial pneumonia during their operative admission (HR = 2.74; p<0.01) were associated with re-hospitalization within 30 days of discharge.
Conclusions
Octogenarians with prICULOS have acceptable functional survival at 1-year but experience high rates of early re-hospitalization. Access to health services may influence functional survival and early re-hospitalizations. This data suggests that close follow-up of these vulnerable patients following hospital discharge is warranted.
Background:
We compared transcatheter aortic-valve replacement (TAVR), using a self-expanding transcatheter aortic-valve bioprosthesis, with surgical aortic-valve replacement in patients with severe aortic stenosis and an increased risk of death during surgery.
Methods:
We recruited patients with severe aortic stenosis who were at increased surgical risk as determined by the heart team at each study center. Risk assessment included the Society of Thoracic Surgeons Predictor Risk of Mortality estimate and consideration of other key risk factors. Eligible patients were randomly assigned in a 1:1 ratio to TAVR with the self-expanding transcatheter valve (TAVR group) or to surgical aortic-valve replacement (surgical group). The primary end point was the rate of death from any cause at 1 year, evaluated with the use of both noninferiority and superiority testing.
Results:
A total of 795 patients underwent randomization at 45 centers in the United States. In the as-treated analysis, the rate of death from any cause at 1 year was significantly lower in the TAVR group than in the surgical group (14.2% vs. 19.1%), with an absolute reduction in risk of 4.9 percentage points (upper boundary of the 95% confidence interval, -0.4; P<0.001 for noninferiority; P = 0.04 for superiority). The results were similar in the intention-to-treat analysis. In a hierarchical testing procedure, TAVR was noninferior with respect to echocardiographic indexes of valve stenosis, functional status, and quality of life. Exploratory analyses suggested a reduction in the rate of major adverse cardiovascular and cerebrovascular events and no increase in the risk of stroke.
Conclusions:
In patients with severe aortic stenosis who are at increased surgical risk, TAVR with a self-expanding transcatheter aortic-valve bioprosthesis was associated with a significantly higher rate of survival at 1 year than surgical aortic-valve replacement. (Funded by Medtronic; U.S. CoreValve High Risk Study ClinicalTrials.gov number, NCT01240902.).
Background
With an increasing prevalence of patients with valvular heart disease (VHD), a dedicated management approach is needed. The challenges encountered are manifold and include appropriate diagnosis and quantification of valve lesion, organization of adequate follow-up, and making the right management decisions, in particular with regard to the timing and choice of interventions. Data from the Euro Heart Survey have shown a substantial discrepancy between guidelines and clinical practice in the field of VHD and many patients are denied surgery despite having clear indications. The concept of heart valve clinics (HVCs) is increasingly recognized as the way to proceed. At the same time, very few centres have developed such expertise, indicating that specific recommendations for the initial development and subsequent operating requirements of an HVC are needed.AimsThe aim of this position paper is to provide insights into the rationale, organization, structure, and expertise needed to establish and operate an HVC. Although the main goal is to improve the clinical management of patients with VHD, the impact of HVCs on education is of particular importance: larger patient volumes foster the required expertise among more senior physicians but are also fundamental for training new cardiologists, medical students, and nurses. Additional benefits arise from research opportunities resulting from such an organized structure and the delivery of standardized care protocols.Conclusion
The growing volume of patients with VHD, their changing characteristics, and the growing technological opportunities of refined diagnosis and treatment in addition to the potential dismal prognosis if overlooked mandate specialized evaluation and care by dedicated physicians working in a specialized environment that is called the HVC.
Objective To assess prevalence, incidence, prognosis and progression of degenerative valvular aortic stenosis (AS).
Setting The Tromsø Study and the University Hospital of North Norway.
Design Population based prospective study.
Population Over a 14 year span we performed three repeated echocardiographic examinations (1994, 2001 and 2008) of a random sample of initially 3273 participants. Data from the only hospital serving this population were included.
Results There were 164 subjects with AS. Prevalence consistently increased with age, average values being 0.2% in the 50–59 year cohort, 1.3% in the 60–69 year cohort, 3.9% in the 70–79 year cohort and 9.8% in the 80–89 year cohort. The incidence rate in the study was 4.9‰/year. The mean annual increase in mean transvalvular pressure gradient was 3.2 mm Hg. The increase was lower in mild AS than in more severe disease, disclosing a non-linear development of the gradient, but with large individual variations. Mortality was not significantly increased in the asymptomatic AS-group (HR=1.28), nor in those who received aortic valve replacement (n=34, HR=0.93), compared with the general population.
Conclusion This is the first study to document the incidence and prognosis of AS in a general population with surgery as a treatment option. It reveals an accelerated progression of the aortic mean gradient as the disease advances. The prognosis of AS seems to be comparable with the normal population in the asymptomatic stage and after successful surgery, indicating that the follow-up and timing of surgery has been adequate for this patient group.
Objectives. The aim of this study was to determine the prevalence of aortic sclerosis and stenosis in the elderly and to identify clinical factors associated with degenerative aortic valve disease.Background. Several lines of evidence suggest that degenerative aortic valve disease is not an inevitable consequence of aging and may be associated with specific clinical factors.Methods. In 5,201 subjects ≥65 years of age enrolled in the Cardiovascular Health Study, the relation between aortic sclerosis or stenosis identified on echocardiography and clinical risk factors for atherosclerosis was evaluated by using stepwise logistic regression analysis.Results. Aortic valve sclerosis was present in 26% and aortic valve stenosis in 2% of the entire study cohort; in subjects ≥75 years of age, sclerosis was present in 37% and stenosis in 2.6%. Independent clinical factors associated with degenerative aortic valve disease included age (twofold increased risk for each 10-year increase in age), male gender (twofold excess risk), present smoking (35% increase in risk) and a history of hypertension (20% increase in risk). Other significant factors included height and high lipoprotein(a) and low density lipoprotein cholesterol levels.Conclusions. Clinical factors associated with aortic sclerosis and stenosis can be identified and are similar to risk factors for atherosclerosis.(J Am Coll Cardiol 1997;29:630–4)
Few data exist on contemporary outcomes after conventional aortic valve replacement (AVR) in the elderly. Accordingly, we evaluated contemporary outcomes and identified predictors of reduced survival in a large series of octogenarians undergoing AVR.
The Regione Emilia Romagna Cardiac Surgery registry (RERIC) database (n = 2 6938) was queried for clinical features, hospital and mid-term outcomes of octogenarians undergoing AVR between 2003 and 2009. Predictors of hospital and mid-term mortality were identified.
The study population consisted of 638 patients. NYHA class III-IV, congestive heart failure, cerebrovascular disease, extra-cardiac arteriopathy, mostly exacerbated patients' clinical profile. Mean log-EuroSCORE was 13.0%. Overall hospital mortality and stroke rates were 4.5% and 1.3%, respectively. Other post-operative complications included renal failure (4.9%), intubation time >48 h (3.4%), complete atrio-ventricular block (4.4%). NYHA III-IV (OR = 2.7; CI 95%:1.2-6.7) and CCS III-IV (OR = 3.1; CI 95%:1.1-9.4) emerged as independent predictors of hospital mortality on multivariate analysis. At 6 years, octogenarians' survival rate was similar to the expected survival of the age- and sex-matched regional population. CCS III-IV (HR = 2.1; CI 95%:1.2-4), preoperative creatinine > 2.1 (HR = 2.8; CI 95%:1.4-5.9), extra-cardiac arteriopathy (HR = 1.5; CI 95%:1.1-2.1) and peripheral neurological dysfunction (HR = 3.8; CI 95%:1.4-10.4) emerged as independent risk factors for decreased 6 years' survival.
This study, showing that contemporary outcomes after AVR are excellent, may help to improve treatment decision-making in elderly patients with aortic valve disease.
The use of transcatheter aortic-valve replacement has been shown to reduce mortality among high-risk patients with aortic stenosis who are not candidates for surgical replacement. However, the two procedures have not been compared in a randomized trial involving high-risk patients who are still candidates for surgical replacement.
At 25 centers, we randomly assigned 699 high-risk patients with severe aortic stenosis to undergo either transcatheter aortic-valve replacement with a balloon-expandable bovine pericardial valve (either a transfemoral or a transapical approach) or surgical replacement. The primary end point was death from any cause at 1 year. The primary hypothesis was that transcatheter replacement is not inferior to surgical replacement.
The rates of death from any cause were 3.4% in the transcatheter group and 6.5% in the surgical group at 30 days (P=0.07) and 24.2% and 26.8%, respectively, at 1 year (P=0.44), a reduction of 2.6 percentage points in the transcatheter group (upper limit of the 95% confidence interval, 3.0 percentage points; predefined margin, 7.5 percentage points; P=0.001 for noninferiority). The rates of major stroke were 3.8% in the transcatheter group and 2.1% in the surgical group at 30 days (P=0.20) and 5.1% and 2.4%, respectively, at 1 year (P=0.07). At 30 days, major vascular complications were significantly more frequent with transcatheter replacement (11.0% vs. 3.2%, P<0.001); adverse events that were more frequent after surgical replacement included major bleeding (9.3% vs. 19.5%, P<0.001) and new-onset atrial fibrillation (8.6% vs. 16.0%, P=0.006). More patients undergoing transcatheter replacement had an improvement in symptoms at 30 days, but by 1 year, there was not a significant between-group difference.
In high-risk patients with severe aortic stenosis, transcatheter and surgical procedures for aortic-valve replacement were associated with similar rates of survival at 1 year, although there were important differences in periprocedural risks. (Funded by Edwards Lifesciences; Clinical Trials.gov number, NCT00530894.).
Many patients with severe aortic stenosis and coexisting conditions are not candidates for surgical replacement of the aortic valve. Recently, transcatheter aortic-valve implantation (TAVI) has been suggested as a less invasive treatment for high-risk patients with aortic stenosis.
We randomly assigned patients with severe aortic stenosis, whom surgeons considered not to be suitable candidates for surgery, to standard therapy (including balloon aortic valvuloplasty) or transfemoral transcatheter implantation of a balloon-expandable bovine pericardial valve. The primary end point was the rate of death from any cause.
A total of 358 patients with aortic stenosis who were not considered to be suitable candidates for surgery underwent randomization at 21 centers (17 in the United States). At 1 year, the rate of death from any cause (Kaplan–Meier analysis) was 30.7% with TAVI, as compared with 50.7% with standard therapy (hazard ratio with TAVI, 0.55; 95% confidence interval [CI], 0.40 to 0.74; P<0.001). The rate of the composite end point of death from any cause or repeat hospitalization was 42.5% with TAVI as compared with 71.6% with standard therapy (hazard ratio, 0.46; 95% CI, 0.35 to 0.59; P<0.001). Among survivors at 1 year, the rate of cardiac symptoms (New York Heart Association class III or IV) was lower among patients who had undergone TAVI than among those who had received standard therapy (25.2% vs. 58.0%, P<0.001). At 30 days, TAVI, as compared with standard therapy, was associated with a higher incidence of major strokes (5.0% vs. 1.1%, P=0.06) and major vascular complications (16.2% vs. 1.1%, P<0.001). In the year after TAVI, there was no deterioration in the functioning of the bioprosthetic valve, as assessed by evidence of stenosis or regurgitation on an echocardiogram.
In patients with severe aortic stenosis who were not suitable candidates for surgery, TAVI, as compared with standard therapy, significantly reduced the rates of death from any cause, the composite end point of death from any cause or repeat hospitalization, and cardiac symptoms, despite the higher incidence of major strokes and major vascular events. (Funded by Edwards Lifesciences; ClinicalTrials.gov number, NCT00530894.).
Valvular heart diseases are not usually regarded as a major public-health problem. Our aim was to assess their prevalence and effect on overall survival in the general population.
We pooled population-based studies to obtain data for 11 911 randomly selected adults from the general population who had been assessed prospectively with echocardiography. We also analysed data from a community study of 16 501 adults who had been assessed by clinically indicated echocardiography.
In the general population group, moderate or severe valve disease was identified in 615 adults. There was no difference in the frequency of such diseases between men and women (p=0.90). Prevalence increased with age, from 0.7% (95% CI 0.5-1.0) in 18-44 year olds to 13.3% (11.7-15.0) in the 75 years and older group (p<0.0001). The national prevalence of valve disease, corrected for age and sex distribution from the US 2000 population, is 2.5% (2.2-2.7). In the community group, valve disease was diagnosed in 1505 (1.8% adjusted) adults and frequency increased considerably with age, from 0.3% (0.2-0.3) of the 18-44 year olds to 11.7% (11.0-12.5) of those aged 75 years and older, but was diagnosed less often in women than in men (odds ratio 0.90, 0.81-1.01; p=0.07). The adjusted mortality risk ratio associated with valve disease was 1.36 (1.15-1.62; p=0.0005) in the population and 1.75 (1.61-1.90; p<0.0001) in the community.
Moderate or severe valvular diseases are notably common in this population and increase with age. In the community, women are less often diagnosed than are men, which could indicate an important imbalance in view of the associated lower survival. Valve diseases thus represent an important public-health problem.
Aortic valve disease is the most frequent acquired heart valve lesion in humans. In western communities, approximately 90% of patients present with aortic stenosis (AS), predominantly of a calcific degenerative aetiology. The remaining approximately 10% of patients predominantly present with aortic valve incompetence.
Valvular aortic stenosis is a progressive disease in which the end stage is characterized by obstruction of left ventricular outflow, resulting in inadequate cardiac output, decreased exercise capacity, heart failure, and death from cardiovascular causes. The prevalence of aortic stenosis is only about 0.2% among adults between the ages of 50 and 59 years but increases to 9.8% in octogenarians, with an overall prevalence of 2.8% in adults older than 75 years of age. Although mortality is not increased when aortic stenosis is asymptomatic, the rate of death is more than 50% at 2 years for patients with symptomatic disease unless aortic-valve replacement is performed promptly. A total of 65,000 aortic-valve replacements were performed in the United States in 2010, primarily for aortic stenosis; 70% of these procedures were performed in patients older than 65 years of age, contributing to the high cost of health care in our aging population.(5) Currently, there are no medical therapies to prevent or slow the progression of the disease. Instead, improving patient outcomes depends on identifying those at risk for valve disease, accurately measuring the severity of stenosis, managing any concurrent disease, and ensuring the appropriate timing and type of aortic-valve replacement.
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.
Patient selection for transcatheter aortic valve implantation (TAVI) remains a major concern. Indeed, despite promising results, it is still unclear which patients are most and least likely to benefit from this procedure.
To identify predictors of 6-month poor clinical outcomes after TAVI.
Patients who were discharged from our institution with a transcatheter-implanted aortic valve were followed prospectively. Our population was divided into two groups ('good outcomes' and 'poor outcomes') according to occurrence of primary endpoint (composite of all-cause mortality, all stroke, hospitalizations for valve-related symptoms or worsening heart failure from discharge to 6months or 6-month New York Heart Association functional class III or IV). Patient characteristics were studied to find predictors of poor outcomes.
We included 163 patients (mean age, 79.9±8.8years; 90 men [55%]; mean logistic EuroSCORE, 18.4±11.4%). The primary endpoint occurred in 49 patients (mean age, 83±5years; 31 men [63%]). By multivariable analysis, atrial fibrillation (odds ratio [OR] 3.94), systolic pulmonary artery pressure ≥60mmHg (OR 7.56) and right ventricular dysfunction (OR 3.55) were independent predictors of poor outcomes, whereas baseline aortic regurgitation ≥2/4 (OR 0.07) demonstrated a protective effect.
Atrial fibrillation, severe baseline pulmonary hypertension and right ventricular dysfunction (i.e. variables suggesting a more evolved aortic stenosis) were predictors of 6-month poor outcomes. Conversely, baseline aortic regurgitation ≥2/4 showed a protective effect, which needs to be confirmed in future studies. Our study highlights the need for a specific 'TAVI risk score', which could lead to better patient selection.
Trans-catheter aortic valve implantation (TAVI) became available at Auckland City Hospital in 2011 for patients with severe aortic stenosis in whom surgical aortic valve replacement (AVR) was deemed at high risk. We assessed whether introduction of TAVI affected the characteristics and outcomes of octogenarians undergoing AVR.
Isolated AVR performed in patients ≥80 years of age during 2008-2012 were divided into two groups, pre- and post-TAVI introduction, for analyses.
Isolated AVR was undertaken in 35 and 33 octogenarians pre- and post-TAVI introduction. The post-TAVI group were older (84.2 vs 82.3 years, P=0.003), had lower ejection fraction (P=0.026), more had inpatient surgery (76% vs 29%, P<0.001), with higher EuroSCORE II (5.4 vs 3.9%, P=0.033). Operative mortality was 0.0% in both groups. One-year survival was similar (97.6% vs 94.3%, P=0.613), but composite morbidity was lower in the post-TAVI group (9.1% vs 31.4%, P=0.035). Chronic respiratory disease (P=0.043) independently predicted mortality during follow-up, while number of coronary vessel>50% stenosis (P=0.050), creatinine clearance (P=0.016) and being in the pre-TAVI era group (P=0.022) predicted composite morbidity.
Since TAVI was introduced, mean age and risk scores significantly increased in octogenarians undergoing AVR, while mortality rates remained similar and composite morbidity decreased.
Importance:
There is a need to describe contemporary outcomes of surgical aortic valve replacement (AVR) as the population ages and transcatheter options emerge.
Objective:
To assess procedure rates and outcomes of surgical AVR over time.
Design, setting, and participants:
A serial cross-sectional cohort study of 82,755,924 Medicare fee-for-service beneficiaries undergoing AVR in the United States between 1999 and 2011.
Main outcomes and measures:
Procedure rates for surgical AVR alone and with coronary artery bypass graft (CABG) surgery, 30-day and 1-year mortality, and 30-day readmission rates.
Results:
The AVR procedure rate increased by 19 (95% CI, 19-20) procedures per 100,000 person-years over the 12-year period (P<.001), with an age-, sex-, and race-adjusted rate increase of 1.6% (95% CI, 1.0%-1.8%) per year. Mortality decreased at 30 days (absolute decrease, 3.4%; 95% CI, 3.0%-3.8%; adjusted annual decrease, 4.1%; 95% CI, 3.7%- 4.4%) per year and at 1 year (absolute decrease, 2.6%; 95% CI, 2.1%-3.2%; adjusted annual decrease, 2.5%; 95% CI, 2.3%-2.8%). Thirty-day all-cause readmission also decreased by 1.1% (95% CI, 0.9%-1.3%) per year. Aortic valve replacement with CABG surgery decreased, women and black patients had lower procedure and higher mortality rates, and mechanical prosethetic implants decreased, but 23.9% of patients 85 years and older continued to receive a mechanical prosthesis in 2011.
Conclusions and relevance:
Between 1999 and 2011, the rate of surgical AVR for elderly patients in the United States increased and outcomes improved substantially. Medicare data preclude the identification of the causes of the findings and the trends in procedure rates and outcomes cannot be causally linked. Nevertheless, the findings may be a useful benchmark for outcomes with surgical AVR for older patients eligible for surgery considering newer transcatheter treatments.
Women undergoing isolated coronary artery bypass graft (CABG) surgery have been previously shown to be at an independently increased risk for post-operative morbidity and mortality. The current study evaluates the impact of sex as an independent risk factor for early and late morbidity and mortality following isolated CABG surgery.
Data obtained between June 2001 and December 2009 by the Australasian Society of Cardiac and Thoracic Surgeons Cardiac Surgery Database Program was retrospectively analysed. Demographic, operative data and post-operative complications were compared between male and female patients using chi-square and t-tests. Long-term survival analysis was performed using Kaplan-Meier survival curves and the log-rank test. Independent risk factors for short- and long-term mortality were identified using binary logistic and Cox regression, respectively.
CABG surgery was undertaken in 21 534 patients at 18 Australian institutions; 22.2% were female. Female patients were generally older (mean age, 68 vs. 65 years, P < 0.001) and presented more often with congestive heart failure (P < 0.001), hypertension (P < 0.001), diabetes mellitus (P < 0.001) and cerebrovascular disease (P < 0.001). Women demonstrated a greater 30-day mortality (2.2% vs. 1.5%, P < 0.001) on univariate analysis but not on multivariate analysis (P = 0.638). Similarly, women demonstrated a greater late mortality than men on univariate analysis (P = 0.006) but not on multivariate analysis (P = 0.093). Women had a decreased risk of early complications including new renal failure (P = 0.001) and deep sternal wound infection (P = 0.017) but were more likely to require red blood cell transfusion (P < 0.001).
Female patients undergoing isolated CABG surgery have a greater 30-day mortality which may be accounted for by a poorer pre-operative risk factor profile. Further investigation is required into the reasons for differential outcome after CABG based on sex.
Aortic stenosis is of concern in the elderly. Although aortic valve replacement provides good long-term survival with functional improvement, many elderly patients are still not referred for surgery because of their age. Percutaneous aortic valve implantation offers an alternative to open-heart surgery. Concerns about the management of aortic valve stenosis in the elderly will be reviewed.
We retrospectively analyzed 1,193 consecutive aortic valve replacements, performed in octogenarians since January 2000. A total of 657 patients (55%) had at least one associated comorbidity (eg, respiratory failure) and 381 (32%) associated coronary lesions. Valve replacement was the only procedure in 883 patients (74%), and was associated with coronary revascularization in 262 cases, or with another cardiac procedure in 48 patients.
Overall operative mortality was 6.9% (83 of 1,193 patients); 5.5% for single replacement and 11.5% if associated with coronary artery bypass surgery. Univariate and multivariate analyses identified 11 operative risk factors related to general status, cardiologic condition, and the procedure itself: older age (p<0.015); respiratory failure (p<0.03); aortic regurgitation (p<0.001); emergency surgery (p<0.0029); New York Heart Association class IV (p<0.0007); right heart failure (p<0.03); atrial fibrillation (p<0.04); impaired ejection fraction (p<0.001); coronary disease (p<0.01); redo surgery (p<0.02); associated coronary revascularization (p<0.008).
Today, valve replacement has acceptable low hospital mortality, even in the elderly. Thus, older patients should not be denied surgery due to their advanced age alone. Conventional surgery remains the gold standard treatment for aortic stenosis; the decision should be made on an individual basis. If several risk factors suggest very high-risk surgery, then percutaneous valve implantation should be considered instead.
The advent of percutaneous aortic valve implantation has increased interest in the outcomes of conventional aortic valve replacement in elderly patients. The current study critically evaluates the short-term and long-term outcomes of elderly (≥80 years) Australian patients undergoing isolated aortic valve replacement.
Data obtained prospectively between June 2001 and December 2009 by the Australasian Society of Cardiac and Thoracic Surgeons National Cardiac Surgery Database Program were retrospectively analysed. Isolated aortic valve replacement was performed in 2791 patients; of these, 531 (19%) were at least 80 years old (group 1). The patient characteristics, morbidity and short-term mortality of these patients were compared with those of patients who were <80 years old (group 2). The long-term outcomes in elderly patients were compared with the age-adjusted Australian population.
Group 1 patients were more likely to be female (58.6% vs 38.0%, p<0.001) and presented more often with co-morbidities including hypertension, cerebrovascular disease and peripheral vascular disease (all p<0.05). The 30-day mortality rate was not independently higher in group 1 patients (4.0% vs 2.0%, p=0.144). Group 1 patients had an independently increased risk of complications including new renal failure (11.7% vs 4.2%, p<0.001), prolonged (≥24 h) ventilation (12.4% vs 7.2%, p=0.003), gastrointestinal complications (3.0% vs 1.3%, p=0.012) and had a longer mean length of intensive care unit stay (64 h vs 47 h, p<0.001). The 5-year survival post-aortic valve replacement was 72%, which is comparable to that of the age-matched Australian population.
Conventional aortic valve replacement in elderly patients achieves excellent outcomes with long-term survival comparable to that of an age-adjusted Australian population. In an era of percutaneous aortic valve implantation, it should still be regarded as the gold standard in the management of aortic stenosis.
The study's objectives were to evaluate results and identify predictors of hospital and mid-term mortality after primary isolated aortic valve replacement; compare early and mid-term survival of patients aged more than 80 years or less than 80 years; and assess the effectiveness of the logistic European System for Cardiac Operative Risk Evaluation in predicting the risk for hospital mortality in octogenarians with a logistic European System for Cardiac Operative Risk Evaluation greater than 15% who are undergoing aortic valve replacement.
Data from 2256 patients undergoing primary isolated aortic valve replacement between January 2003 and December 2007 were prospectively collected in a Regional Registry (Regione Emilia Romagna Interventi Cardiochirurgia) and analyzed to estimate hospital and mid-term results.
Overall hospital mortality was 2.2%. By multivariate analysis, New York Heart Association III and IV, Canadian Cardiovascular Society III and IV, pulmonary artery pressure greater than 60 mm Hg, dialysis, central neurologic dysfunction, and severe chronic obstructive pulmonary disease emerged as independent predictors of hospital mortality. At 3 years, the survival was 89.3%. The same predictors of hospital mortality plus ejection fraction of 30% to 50% and age more than 80 years emerged as independent risk factors for 3-year mortality. Compared with younger patients, octogenarians had a higher hospital mortality rate (3.72% vs 1.81%; P = .0143) and a reduced 3-year survival (82.3% vs 91.3%; P < .001). Three-year survival of octogenarians was comparable to the expected survival of an age- and gender-matched regional population (P = .157). The observed mortality rate in octogenarians with a logistic European System for Cardiac Operative Risk Evaluation greater than 15% (mean: 22.4%) was 7% (P < .001).
This study provides contemporary data on the characteristics and outcome of patients undergoing first-time isolated aortic valve replacement.
In developed countries, aortic stenosis is the most prevalent of all valvular heart diseases. A manifestation of ageing, the disorder is becoming more frequent as the average age of the population increases. Symptomatic severe disease is universally fatal if left untreated yet is consistent with a typical lifespan when mechanical relief of the stenosis is provided in a timely fashion. Management of mild disease, severe asymptomatic disease, and far advanced disease, and the effect of new percutaneous treatments, provide both controversy and exciting promise to care of patients with aortic stenosis. We discuss these issues in this Review.
More than 200,000 aortic valve replacements are performed annually worldwide. We describe changes in the aortic valve replacement population during 10 years in a large registry and analyze outcomes.
The Society of Thoracic Surgeons National Database was queried for all isolated aortic valve replacements between January 1, 1997, and December 31, 2006. After exclusion for endocarditis and missing age or sex data, 108,687 isolated aortic valve replacements were analyzed. Time-related trends were assessed by comparing distributions of risk factors, valve types, and outcomes in 1997 versus 2006. Differences in case mix were summarized by comparing average predicted mortality risks with a logistic regression model. Differences across subgroups and time were assessed.
There was a dramatic shift toward use of bioprosthetic valves. Aortic valve replacement recipients in 2006 were older (mean age 65.9 vs 67.9 years, P < .001) with higher predicted operative mortality risk (2.75 vs 3.25, P < .001); however, observed mortality and permanent stroke rate fell (by 24% and 27%, respectively). Female sex, age older than 70 years, and ejection fraction less than 30% were all related to higher mortality, higher stroke rate and longer postoperative stay. There was a 39% reduction in mortality with preoperative renal failure.
Morbidity and mortality of isolated aortic valve replacement have fallen, despite gradual increases in patient age and overall risk profile. There has been a shift toward bioprostheses. Women, patients older than 70 years, and patients with ejection fraction less than 30% have worse outcomes for mortality, stroke, and postoperative stay.
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.
The aim of this study was to determine the prevalence of aortic sclerosis and stenosis in the elderly and to identify clinical factors associated with degenerative aortic valve disease.
Several lines of evidence suggest that degenerative aortic valve disease is not an inevitable consequence of aging and may be associated with specific clinical factors.
In 5,201 subjects > or = 65 years of age enrolled in the Cardiovascular Health Study, the relation between aortic sclerosis or stenosis identified on echocardiography and clinical risk factors for atherosclerosis was evaluated by using stepwise logistic regression analysis.
Aortic valve sclerosis was present in 26% and aortic valve stenosis in 2% of the entire study cohort; in subjects > or = 75 years of age, sclerosis was present in 37% and stenosis in 2.6%. Independent clinical factors associated with degenerative aortic valve disease included age (twofold increased risk for each 10-year increase in age), male gender (twofold excess risk), present smoking (35% increase in risk) and a history of hypertension (20% increase in risk). Other significant factors included height and high lipoprotein(a) and low density lipoprotein cholesterol levels.
Clinical factors associated with aortic sclerosis and stenosis can be identified and are similar to risk factors for atherosclerosis.
The design of a percutaneous implantable prosthetic heart valve has become an important area for investigation. A percutaneously implanted heart valve (PHV) composed of 3 bovine pericardial leaflets mounted within a balloon-expandable stent was developed. After ex vivo testing and animal implantation studies, the first human implantation was performed in a 57-year-old man with calcific aortic stenosis, cardiogenic shock, subacute leg ischemia, and other associated noncardiac diseases. Valve replacement had been declined for this patient, and balloon valvuloplasty had been performed with nonsustained results.
With the use of an antegrade transseptal approach, the PHV was successfully implanted within the diseased native aortic valve, with accurate and stable PHV positioning, no impairment of the coronary artery blood flow or of the mitral valve function, and a mild paravalvular aortic regurgitation. Immediately and at 48 hours after implantation, valve function was excellent, resulting in marked hemodynamic improvement. Over a follow-up period of 4 months, the valvular function remained satisfactory as assessed by sequential transesophageal echocardiography, and there was no recurrence of heart failure. However, severe noncardiac complications occurred, including a progressive worsening of the leg ischemia, leading to leg amputation with lack of healing, infection, and death 17 weeks after PHV implantation.
Nonsurgical implantation of a prosthetic heart valve can be successfully achieved with immediate and midterm hemodynamic and clinical improvement. After further device modifications, additional durability tests, and confirmatory clinical implantations, PHV might become an important therapeutic alternative for the treatment of selected patients with nonsurgical aortic stenosis.
Dear Sir,
The European System for Cardiac Operative Risk Evaluation (EuroSCORE) identifies a number of risk factors which help to predict mortality from cardiac surgery.1 The predicted mortality (in percent) is calculated by adding the weights assigned to each factor. Since its initial publication in 1999, EuroSCORE has been widely used in Europe and elsewhere and has been the subject of several studies. Most of these studies compared the predictive ability of the EuroSCORE to previously described systems2,3 or to locally derivedmodels.4 One original work used it as a tool in order to assess the intra-institutional benefit in switching from conventional surgery under cardiopulmonary bypass to the off-pump approach in coronary surgery.5 In general, EuroSCORE was found to be …
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.
Transcatheter versus surgical aorticvalve replacement in high-risk patients
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Clinical Investigators. Transcatheter aorticvalve replacement with a self-expanding prosthesis
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U.S. CoreValve Clinical Investigators. Transcatheter aorticvalve replacement with a self-expanding prosthesis. N Engl J Med
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Prospective registry of symptomatic severe aortic stenosis in octogenarians: a need for intervention
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ACC/AHA Task Force Members
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Isolated aortic valve replacement in octogenarians before and after the introduction of trans-catheter aortic valve implantation
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replacement in octogenarians before and after the introduction of trans-catheter aortic valve
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Aortic valve replacement: Results and predictors of mortality from a contemporary series of 2256 patients
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