Predictive factors of long-term survival in the octogenarian undergoing surgical aortic valve replacement: 12-year single-centre follow-up

Abstract

The improvement of life expectancy created more surgical candidates with severe symptomatic aortic stenosis and age >80. Therefore, the main objective of this observational, retrospective single-centre study is to compare the long-term survival of octogenarians that have undergone surgical aortic valve replacement (AVR) to the survival of the general population of the same age and to establish whether any perioperative characteristics can anticipate a poor long-term result, limiting the prognostic advantage of the procedure at this age. From 2000 to 2014, 264 octogenarians underwent AVR at our institution. Perioperative data were retrieved from our institutional database and patients were followed up by telephonic interviews. The follow-up ranged between 2 months and 14.9 years (mean 4.1 ± 3.1 years) and the completeness was 99.2 %. Logistic multivariate analysis and Cox regression were respectively applied to identify the risk factors of in-hospital mortality and follow-up survival. Our patient population ages ranged between 80 and 88 years. Isolated AVR (I-AVR) was performed in 136 patients (51.5 %) whereas combined AVR (C-AVR) in 128 patients (48.5 %). Elective procedures were 93.1 %. Logistic EuroSCORE was 15.4 ± 10.6. In-hospital mortality was 4.5 %. Predictive factors of in-hospital mortality were the non-elective priority of the procedure (OR 5.7, CI 1.28-25.7, p = 0.02), cardiopulmonary bypass time (OR 1.02, CI 1.01-1.03, p = 0.004) and age (OR 1.36, CI 1.01-1.84, p = 0.04). Follow-up survival at 1, 4, 8 and 12 years was 93.4 % ± 1.6 %, 72.1 % ± 3.3 %, 39.1 % ± 4.8 % and 20.1 % ± 5.7 %, respectively. The long-term survival of these patients was not statistically different from the survival of an age/gender-matched general population living in the same geographic region (p = 0.52). Predictive factors of poor long-term survival were diabetes mellitus (HR 1.55, CI 1.01-2.46, p = 0.05), preoperative creatinine >200 μmol/L (HR 2.07, CI 1.21-3.53, p = 0.007) and preoperative atrial fibrillation (HR 1.79, CI 1.14-2.80, p = 0.01). In our experience, AVR can be safely performed in octogenarians. After a successful operation, the survival of these patients returns similar to the general population. Nevertheless, the preoperative presence of major comorbidities such as diabetes mellitus, renal dysfunction and atrial fibrillation significantly impact on long-term results.

Does additional coronary artery bypass grafting to aortic valve replacement in elderly patients affect the early and long-term outcome?

“…Our reported 30-day mortality for iAVR (4.5%) and AVR + CABG (6.5%) are lower than in-hospital mortality reported by other investigators during the last decade [10,11,16,29].…”

“…Longer duration of CPB and X-Clamp are always a concern, particularly in the elderly, as longer CPB is associated with increased incidence of cerebral, renal and coagulation damage, and greater X-Clamp predisposes to increased risk of myocardial damage. Cappabianca [16] reported that the duration of CPB time (OR 1.02, p = 0.004) was an independent predictor of in-hospital mortality, while Dell'Amore [19] observed that a shorter X-Clamp time had a protective role (OR 0.8, p = 0.01).…”

“…While early and late results in elderly patients undergoing isolated AVR are homogeneous, the early and late outcomes of combined AVR with CABG are still unclear and sometimes conflicting. In elderly patients, AVR with CABG has been reported to be associated with early mortality ranging from 1.9 to 24% [9][10][11][12] compared to AVR alone (ranging from 0 to 7.6%) [13][14][15][16][17]. In the overall population, simultaneous AVR and CABG have worse long-term survival compared to isolated AVR [18], while among the elderly population, survival between the two treatments appears to be comparable [19][20][21].…”

Preoperative paroxysmal atrial fibrillation predicts high cardiovascular mortality in patients undergoing surgical aortic valve replacement with a bioprosthesis: CAREAVR study

“…7,8,[10][11][12][13][14][15] However, the impact of preoperative paroxysmal AF in these patients is less well known. Namely, earlier studies included only patients with permanent AF 2,13,16 or patients with paroxysmal and permanent AF, were pooled. 4,14,17 Thus, the prognostic significance of paroxysmal AF has remained elusive.…”

Microparticles in patients undergoing transcatheter aortic valve implantation (TAVI)

“…As there is no medical treatment for aortic stenosis besides vasodilators and diuretics for acute decompensation, the mainstay of treatment for aortic stenosis is still surgical or interventional aortic valve replacement [6, 10]. Ongoing inflammation in the circulatory system and increased shear stress has also been associated with endothelial dysfunction [11, 12].…”