HLC 1561 No. of Pages 6
ORIGINAL ARTICLE
Heart, Lung and Circulation (2014) xx, 1–6 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.03.017
Aortic Valve Replacement in Octogenarians Jessica A. Ditchfield, MD a*, Emily Granger, MBBS, FRACS b, Phillip Spratt, MBBS, FRACS b, Paul Jansz, MBBS, FRACS b, Kumud Dhital, MBBS, FRACS b, Alan Farnsworth, MBBS, FRACS b, Chris Hayward, MD c a
Faculty of Medicine, University of New South Wales, Sydney NSW 2052, Australia Department of Cardiothoracic Surgery, St Vincent’s Hospital, Darlinghurst, Sydney NSW 2010, Australia Department of Cardiology, St Vincent’s Hospital, Darlinghurst, Sydney NSW 2010, Australia
b c
Received 4 November 2013; received in revised form 23 February 2014; accepted 5 March 2014; online published-ahead-of-print xxx
Background
With improved life expectancy more octogenarians now present with aortic valve disease. Cardiac surgery in this group of patients has previously been considered high risk due to co-morbidities and challenges of rehabilitation. This study seeks to challenge the concept of octogenarian cardiac surgery ‘‘unsuitability’’ by analysing operative outcomes and long term survival following aortic valve replacement.
Methods
Eighty-seven consecutive patients undergoing aortic valve replacement between 2000 and 2009 at St Vincent’s Hospital were retrospectively identified. Statistical analysis was performed using SPSS (version 15 and 19).
Results
The average age was 82.7 2.4 years. The mean logistic EuroSCORE was 18.86 14.11. Post-operatively, four patients required insertion of a permanent pacemaker (4.6%) and five patients had a myocardial infarction (5.8%). In-hospital mortality was 3.4%. Follow-up was 93.1% complete. One-year survival was 92.9%, three-year survival was 86.7% and five-year survival was 75.0%. At follow-up 98.1% of patients were New York Heart Association (NYHA) Class I or II.
Conclusions
Results were excellent despite reasonable co-morbidities and Euroscore risk. Survival was impressive and the NYHA class reflected the success of the surgery in relieving the pathological aortic valve process. Patient age should not be the primary exclusion for cardiac surgery for aortic valve disease.
Keywords
Cardiac surgery Aortic valve surgery Heart valve prothesis Median sternotomy Octogenarian Aortic Valve Replacement
Introduction The prevalence of aortic stenosis in octogenarians is estimated at between 2 and 17% [1]. Untreated aortic stenosis has a three year survival of 49% [2]. Whilst aortic valve replacement (AVR) surgery can offer excellent survival, it is important to select appropriate surgical candidates to ensure they can cope with the demands of surgery. This
has been consistently supported by published studies that demonstrate good results for AVR in octogenarians over the last 30 years [3–5]. Despite a longer and harder recovery process, octogenarians can do well with open valve replacement and as a consequence have been referred, and request referral to, cardiothoracic surgical units for treatment [5]. More recently, the advent of percutaneous aortic valve technologies has questioned the role of surgical valve
*Corresponding author at: 10 Evans St, Wagga Wagga, NSW 2650; Tel.: +614 13 925 586; fax: +612 6933 5100., Emails: [email protected], [email protected] Crown Copyright © 2014 Published by Elsevier Inc on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.
Please cite this article in press as: Ditchfield JA, et al. Aortic Valve Replacement in Octogenarians. Heart, Lung and Circulation (2014), http://dx.doi.org/10.1016/j.hlc.2014.03.017
HLC 1561 No. of Pages 6
2
J.A. Ditchfield et al.
replacement in clinical practice. Some literature suggests that this technique will rapidly overtake the surgical AVR as it would avoid the morbidity of sternotomy and cardiopulmonary bypass [6]. The ‘‘attraction’’ of avoiding a surgical incision and sternal division seems to be influencing decision making, rather than consideration of current results in the ‘‘typical’’ surgical patient. This paper seeks to provide up-to-date information in the octogenarian population. The paper will assist in assessment for surgery by looking at the effects of pre-operative risk factors and comorbidities, and how they affect the surgical outcome.
Method Data Source This retrospective single-centre cohort study was conducted with the approval of the St Vincent’s Hospital Institutional Review Board. The Cardiothoracic Patient Records Database (version 2.5) was used to identify 115 patients 80 years and older who underwent AVR at St Vincent’s Hospital, Sydney between 1st January, 2000 and 31st December, 2009 inclusive. Patients were excluded from this study if they had undergone concomitant valve procedures (n = 22) or received a mechanical prosthesis (n = 3). Following this, 87 patients were suitable for review. The database was used to obtain demographic information, pre-operative comorbidities and risk factors, intraoperative data and clinical outcomes for each patient. Information from the database was cross-referenced with medical records to ensure reliability. Echocardiograms, coronary angiograms and pathology results were also reviewed. A total of 133 variables for each patient were extracted from the database and medical records. Standardised definitions were adapted from the Australasian Society of Cardiac and Thoracic Surgeons [7] for each variable to ensure consistency. General practitioners and cardiologists of the patients were then contacted by telephone to obtain current health information and survival data. Follow-up was 93.1% complete. Quality of life was assessed using the criteria of the New York Heart Association (NYHA) functional classes and analysing subsequent hospital admissions.
distribution was not-normally distributed, the Mann Whitney U Test was employed to analyse continuous data from two groups. Continuous variables were analysed against each other using linear regression. Ordinal variables from two independent groups, ordinal variables against nominal variables and ordinal variables against ordinal variables were all analysed using Kendall’s tau-b and Kendall’s tauc statistical tests. ANOVA tests were used to compare ordinal and nominal variables against a normally-distributed continuous variable, while the Kruskal-Wallis Test was used when the normality assumption did not hold. A p-value of
ORIGINAL ARTICLE
Heart, Lung and Circulation (2014) xx, 1–6 1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2014.03.017
Aortic Valve Replacement in Octogenarians Jessica A. Ditchfield, MD a*, Emily Granger, MBBS, FRACS b, Phillip Spratt, MBBS, FRACS b, Paul Jansz, MBBS, FRACS b, Kumud Dhital, MBBS, FRACS b, Alan Farnsworth, MBBS, FRACS b, Chris Hayward, MD c a
Faculty of Medicine, University of New South Wales, Sydney NSW 2052, Australia Department of Cardiothoracic Surgery, St Vincent’s Hospital, Darlinghurst, Sydney NSW 2010, Australia Department of Cardiology, St Vincent’s Hospital, Darlinghurst, Sydney NSW 2010, Australia
b c
Received 4 November 2013; received in revised form 23 February 2014; accepted 5 March 2014; online published-ahead-of-print xxx
Background
With improved life expectancy more octogenarians now present with aortic valve disease. Cardiac surgery in this group of patients has previously been considered high risk due to co-morbidities and challenges of rehabilitation. This study seeks to challenge the concept of octogenarian cardiac surgery ‘‘unsuitability’’ by analysing operative outcomes and long term survival following aortic valve replacement.
Methods
Eighty-seven consecutive patients undergoing aortic valve replacement between 2000 and 2009 at St Vincent’s Hospital were retrospectively identified. Statistical analysis was performed using SPSS (version 15 and 19).
Results
The average age was 82.7 2.4 years. The mean logistic EuroSCORE was 18.86 14.11. Post-operatively, four patients required insertion of a permanent pacemaker (4.6%) and five patients had a myocardial infarction (5.8%). In-hospital mortality was 3.4%. Follow-up was 93.1% complete. One-year survival was 92.9%, three-year survival was 86.7% and five-year survival was 75.0%. At follow-up 98.1% of patients were New York Heart Association (NYHA) Class I or II.
Conclusions
Results were excellent despite reasonable co-morbidities and Euroscore risk. Survival was impressive and the NYHA class reflected the success of the surgery in relieving the pathological aortic valve process. Patient age should not be the primary exclusion for cardiac surgery for aortic valve disease.
Keywords
Cardiac surgery Aortic valve surgery Heart valve prothesis Median sternotomy Octogenarian Aortic Valve Replacement
Introduction The prevalence of aortic stenosis in octogenarians is estimated at between 2 and 17% [1]. Untreated aortic stenosis has a three year survival of 49% [2]. Whilst aortic valve replacement (AVR) surgery can offer excellent survival, it is important to select appropriate surgical candidates to ensure they can cope with the demands of surgery. This
has been consistently supported by published studies that demonstrate good results for AVR in octogenarians over the last 30 years [3–5]. Despite a longer and harder recovery process, octogenarians can do well with open valve replacement and as a consequence have been referred, and request referral to, cardiothoracic surgical units for treatment [5]. More recently, the advent of percutaneous aortic valve technologies has questioned the role of surgical valve
*Corresponding author at: 10 Evans St, Wagga Wagga, NSW 2650; Tel.: +614 13 925 586; fax: +612 6933 5100., Emails: [email protected], [email protected] Crown Copyright © 2014 Published by Elsevier Inc on behalf of Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). All rights reserved.
Please cite this article in press as: Ditchfield JA, et al. Aortic Valve Replacement in Octogenarians. Heart, Lung and Circulation (2014), http://dx.doi.org/10.1016/j.hlc.2014.03.017
HLC 1561 No. of Pages 6
2
J.A. Ditchfield et al.
replacement in clinical practice. Some literature suggests that this technique will rapidly overtake the surgical AVR as it would avoid the morbidity of sternotomy and cardiopulmonary bypass [6]. The ‘‘attraction’’ of avoiding a surgical incision and sternal division seems to be influencing decision making, rather than consideration of current results in the ‘‘typical’’ surgical patient. This paper seeks to provide up-to-date information in the octogenarian population. The paper will assist in assessment for surgery by looking at the effects of pre-operative risk factors and comorbidities, and how they affect the surgical outcome.
Method Data Source This retrospective single-centre cohort study was conducted with the approval of the St Vincent’s Hospital Institutional Review Board. The Cardiothoracic Patient Records Database (version 2.5) was used to identify 115 patients 80 years and older who underwent AVR at St Vincent’s Hospital, Sydney between 1st January, 2000 and 31st December, 2009 inclusive. Patients were excluded from this study if they had undergone concomitant valve procedures (n = 22) or received a mechanical prosthesis (n = 3). Following this, 87 patients were suitable for review. The database was used to obtain demographic information, pre-operative comorbidities and risk factors, intraoperative data and clinical outcomes for each patient. Information from the database was cross-referenced with medical records to ensure reliability. Echocardiograms, coronary angiograms and pathology results were also reviewed. A total of 133 variables for each patient were extracted from the database and medical records. Standardised definitions were adapted from the Australasian Society of Cardiac and Thoracic Surgeons [7] for each variable to ensure consistency. General practitioners and cardiologists of the patients were then contacted by telephone to obtain current health information and survival data. Follow-up was 93.1% complete. Quality of life was assessed using the criteria of the New York Heart Association (NYHA) functional classes and analysing subsequent hospital admissions.
distribution was not-normally distributed, the Mann Whitney U Test was employed to analyse continuous data from two groups. Continuous variables were analysed against each other using linear regression. Ordinal variables from two independent groups, ordinal variables against nominal variables and ordinal variables against ordinal variables were all analysed using Kendall’s tau-b and Kendall’s tauc statistical tests. ANOVA tests were used to compare ordinal and nominal variables against a normally-distributed continuous variable, while the Kruskal-Wallis Test was used when the normality assumption did not hold. A p-value of
