Valve Replacement in Patients Over 70 Years Luis N. Bessone, M.D., Dennis F. Pupello, M.D., Richard H. Blank, M.D., Eric E. Harrison, M.D., a n d Sheldon Sbar, M.D. ABSTRACT From July, 1972, to April, 1976,54 consecutive patients over the age of 70 years underwent valve replacement at Tampa General Hospital. Twenty-one patients had isolated aortic valve replacement (Group l), 14 had isolated mitral valve replacement (Group Z), and 19 had combined procedures that included at least 1 valve replacement (Group 3). There was 1 operative death (in Group l), and another patient (Group 3) died three weeks postoperatively, resulting in an early mortality of 3.7%. Follow-up of the 52 hospital survivors from one to forty-one months reveals 2 additional deaths for a late mortality of 3.8%. Cardiac status improved noticeably in the surviving 50 patients. The data suggests that with current techniques, complex intracardiac procedures can be performed safely with acceptable operiitive mortality and a satisfactory prognostic outlook in elderly patients.
Refinement in techniques for open-heart operations and prosthetic devices, coupled with more substantial evidence of the deleterious effect of malfunctioning valves upon the myocardium [9, 10, 12, 14, 171, has led to a more aggressive surgical approach. This same enthusiasm, however, has not been applied in the older age group because of the added risks of age and associated diseases [ll]. Reasonable operative mortality and morbidity for elderly patients have been documented [l,3, 4, 6, 15, 211. Some of these reports [2, 191, however, include patients who rece:ived isolated myocardial revascularization, which tend to minimize mortality. From the Cardiac Surgical Unit and Cardiology Center, Tampa General Hospital, and the Department of Thoracic and Cardiovascular Surgery, University of South Florida College of Medicine, Tampa, FL. We wish to express our appreciation to Mr. Leonard Taylor for data gathering, to George Ebra, Ph.D., for his assistance in computer analysis, and to Mrs. Janice Cooper for her very efficient secretarial help. Presented at the Twenty-third Annual Meeting of the Southern Thoracic Surgical Association, Nov 4-6,1976, Acapulco, Mexico. Address reprint requests to Dr. Bessone, One Davis Blvd, Tampa, FL 33606.
417
If comparable results for patients in the older age group can be consistently achieved, the indications for surgical intervention in these patients could be similar to those for the younger age group. With this consideration, we reviewed our valve experience in patients over the age of 70.
Materials and Methods From July, 1972, to April, 1976, 379 valves were implanted in 339 patients in the Cardiac Surgical Unit at Tampa General Hospital. Fifty-four of these patients were 70 years of age or older. There were 22 men and 32 women whose ages ranged between 70 and 82 years (mean, 73.3 years). Preoperative hospitalization ranged from 1 to 32 days (mean, 5.9 days); the mean postoperative hospitalization was 17.5 days (range, 10 to 55 days). Preoperative cardiac catheterization, including coronary arteriograms, was completed in all but those patients who experienced decompensation during the catheterization procedure. Nineteen patients (35.2%) were in New York Heart Association (NYHA) Functional Class 111; 35 patients (64.8%) were in Class IV. Operative Technique The operative technique has been described previously [MI. Briefly, it consisted of a standard midsternal approach, routine atrial and aortic cannulation, and cardiopulmonary bypass with relatively low flow rates of 35 to 50 ml per kilogram of body weight, in combination with moderate systemic hypothermia. Disposable bubble oxygenators primed with 500 ml of heparinized whole blood and 1,000 ml of Ringer's lactate solution were used. The pericardium was suspended from the chest wall in order to create a well for continuous infusion of cold saline at 4" to 5°C for myocardial protection. Intracavitary flushing with additional cold solution further reduced the time needed for maximum cooling [MI.
418 The Annals of Thoracic Surgery Vol 24 No 5 November 1977
Surgical Data There were 47 elective and 7 emergency operations. The mean pump time was 93 minutes (range, 52 to 182 minutes). The cross-clamp time was 49 minutes (range, 15 to 86 minutes). The lowest esophageal temperature reached during the pump run ranged between 22" and 32°C (mean, 28°C). Enlargement of the aortic annulus [51 was necessary in 5 patients; 3 additional patients required patch enlargement of the ascending aorta. The patients were classified into three groups according to the surgical procedure (Table 1). GROUP 1. Twenty-one patients (8 men and 13 women) with an average age of 73 years underwent isolated aortic valve replacement. Eleven were in NYHA Functional Class 111; 10 were in Class IV. Of 13 patients with pure aortic stenosis, 1 had associated idiopathic hypertrophic subaortic stenosis (IHSS). Four patients had aortic insufficiency and 4 had mixed lesions. Among the 17 patients with pure or mixed aortic stenosis, the average peak systolic gradient was 104 mm Hg (range, 65 to 210 mm Hg). The highest combined gradient was found in the patient with IHSS. GROUP 2. Fourteen patients (2 men and 12 women) with an average age of 73.4 years underwent isolated valve replacement. Four patients were in NYHA Class 111; 10 were in Class N.Ten patients (71.4%) had predominant or pure mitral insufficiency; 4 had mitral stenosis. The resting systolic pulmonary artery pressure was elevated in all instances, with a mean of 69.7 mm Hg. The mean pulmonary artery capillary wedge pressure at rest was 25.0 mm Hg and the average cardiac index by the Fick method was 2.10
Table 1. Distribution of Patients According to Surgical Procedures Grouv 1 (isolated aortic valve replacement) 2 (isolated mitral valve replacement) 3 (combined procedures including valve replacement) Total
No. of Patients 21
14
19 54
Wmin/m2. Three patients (21.4%) had had previous commissurotomies. GROUP 3. Nineteen patients (12 men and 7 women) with an average age of 73.3 years underwent combined procedures (Table 2). Four patients were in NYHA Class 111; 15 were in Class IV. The mean cardiac index (Fick) for the 14 patients in which this was recorded was 2.3 L/min/m2.
Results Early Mortality One patient (Group 1) with aortic stenosis, Functional Class N, died during reexploration for bleeding. One patient (Group 3) who had mitral valve replacement and excision of a posterior left ventricular aneurysm died on the twenty-second postoperative day. Preoperatively this patient was Class N and was bedridden with intractable failure secondary to poor left ventricular function. His postoperative course was complicated by refractory congestive heart failure, and he died suddenly. The overall hospital mortality was 3.7%. There were no hospital deaths among patients who underwent emergency operations or who required annulus Table 2. Description of Group 3 (Combined Procedures) Procedures
+
AVR single aortocoronary bypass AVR + double aortocoronary bypass MVR + single aortocoronary bypass MVR double aortocoronary bypass MVR + excision of LV aneurysm AVR repair of mitral valve Double valve replacement (mitral and aortic) Double valve replacement (mitral and aortic) + single aortocoronary bypass Total
No. of Patients 4
5
+
+
4
1
19
AVR = aortic valve replacement; MVR = mitral valve replacement; LV = left ventricular.
419 Bessone et al: Valve Replacement in Patients Over 70
enlargement or patch enlargement of the ascending aorta.
Hospital Complications Thirty-one patients (57.4%) had postoperative complications while hospitalized (Table 3). Arrhythmias were the most frequent complication. Two patients who showed preoperative evidence of atrioventricular conduction defect required permanent pacemaker insertion in the early postoperative period. Low cardiac output developed in 7 patients (13%) and was more prevalent in those who underwent mitral valve replacement. Crossclamp time in these patients was no longer than the mean cross-clamp time for the entire group. Their management included increase of the preload, inotropic drugs, and occasional use of nitropiusside to reduce the afterload [131. Five patients (9.3%) required reexploration for bleeding, and 3 needed prolonged ventilatory support (72 hours or longer). One patient had postoperative gastrointestinal bleeding, and 1 had postoperative perforation. of a duodenal ulcer, which required an emergency laparotomy. Both patients survived. Long-Term Follow-up The 52 hospital survivors were followed from 1 to 41 months (mean, 12.6, patient-months). Follow-up data were secured through office visits, a patient questionnaire, or through direct contact with the referring physician.
Late Complications Long-term follow-up of the 52 hospital survivors revealed two types of major complications. Four patients had cerebrovascular accidents. TWO were in Group 2 and had received isolated mitral valve replacement, 1 with a Bjork-Shiley prosthesis and 1 with a porcine heterograft prosthesis, respectively. Both patients recovered with only partial sequelae. Two patients in Group 3 suffered cerebrovascular accidents. One had aortic valve replacement with a porcine heterograft as well as debridement and commissurotomy of the mitral valve. Her CVA occurred only two weeks after discharge, and the prothrombin time was excessively prolonged. She recovered in a few days with no sequelae. The second patient had undergone aortic valve replacement with a Bjork-Shiley prosthesis plus a double aortocoronary saphenous vein bypass graft. He developed hemiplegia and recovered with some residuum. Congestive heart failure was present in 2 patients, who required rehospitalization and aggressive diuresis. One patient was in Group 1 and had a preoperative diagnosis of aortic insufficiency with a massively enlarged left ventricle. His postoperative course had been marred by supraventricular tachyarrhythmias. Following hospital treatment he was discharged and later improved to Class 11. The second patient was in Group 3 and had aortic valve replacement plus a single aortocoronary bypass. At the completion of the study this patient remained in Class 111.
Table 3. Hospital Complications Among 54 Patients Undergoing Valve Replacement Complications
No. of Patients
Died
None Arrhythmias Need for permanent pacemaker Low output Bleeding requiring reexploration Respiratory insufficiency Temporary mental confusion GI bl.eeding Perforated duodenal ulcer ‘Total
23 (42.6%) 10 (18.5%) 2 (3.7%) 7 (13.0%) 5 (9.3%) 3 (5.670) 2 (3.7%) 1 (1.8%) 1 (1.8%) 54 (100%)
0 0
-
GI = gastrointestinal.
0 1 (22 days postop) 1 (at operation) 0 0 0 0 2
420
The Annals of Thoracic Surgery Vol 24 No 5 November 1977
Late Mortality There were 2 additional deaths (3.8%) among the 52 patients who left the hospital. One patient (Group 3) who had aortic valve replacement with a heterograft and double aortocoronary bypass died 2 months after discharge with a clinical diagnosis of arrhythmia. He had been taking quinidine and was readmitted to a local hospital when he developed apnea. He soon recovered and was ambulatory when he developed syncope and cardiac standstill. The second patient (Group 1)had aortic stenosis. She died at home 21 months after her aortic valve had been replaced with a Bjork-Shiley prosthesis. Until then this patient had been stable (Class 11) but had shown increased symptoms of cerebral arteriosclerosis. The total mortality (Table 4) at the end of the study was 7.4% (4 of 54 patients). Postoperative Cardiac Status Fifty-one of the 52 hospital survivors have improved their cardiac functional classification. One patient has remained in the same class as preoperatively. Of the 33 patients in Class I V prior to operation, 16 (48.4%) improved to Class I, 14 (42.4%) to Class 11, and 3 (9.0%) to Class 111. A comparable result was observed in 19 patients in Class I11 preoperatively. Twelve of these patients (63.1%) reached Class I and 6 (31.5%) advanced to Class 11. Only 1patient (5.2%) remained in the same class (Figure). Group 1 patients (aortic valve replacement) showed the most dramatic improvement, followed by Group 2 (isolated mitral valve replacement). The only patient in the series who failed to improve his preoperative classification was in Group 3 (combined procedures), which,
PRE OP
POST OP
w
F]
/
/
1
19
Preoperative and postoperative cardiac status of 52 hospital survivors.
as a group, also showed proportionately more single class improvement.
Comment Because of the anticipated risks, cardiologists and cardiac surgeons alike are reluctant to consider valve operations in patients older than 65 years. Therefore, there is a proportional increase in the number of patients who must be operated on while they are in Functional Class IV and in their eighth decade. The 1958 Commissioner’s Standard Ordinary Mortality Table gives a life expectancy of 10.2 years for a man aged 70 years and 11.73 years for a woman of the same age. These figures continue to increase in the elderly as in the middle age group [71. Patients with symptomatic aortic stenosis have a very poor prognostic outlook [ZO]. Mitral stenosis has a less predictable natural history [22], but for patients in Class IV the complications and mortality climb noticeably unless the process is interrupted by operation [161. Regurgitant lesions are particularly dangerous beTable 4. Total Mortality for 54 Patients cause they are well tolerated at the expense of Undergoing Valve Replacement myocardial damage 18, 121. The data in the present study reveal an operaNo. of Early Late Overall Group Patients Deaths Deaths Mortality tive mortality comparable with that in younger age groups [9, 10, 14, 171 and much lower than 1 21 1 (4.7%) 1 (5%) 2 (10.5%) has previously been reported [l-4,6,15,19,211. 2 14 0 (0%) 0 (0%) 0 (OYO) The need for coronary perfusion [4]has not been 3 19 1 (5.2%) 1 (5.5%) 2 (10.5%) substantiated in our experience. Our belief is Total 54 2 (3.7%) 2 (3.8%) 4 (7.4%) that local deep hypothermia has greatly im-
421
Bessone et al: Valve Replacement in Patients Over 70
proved the perioperative mortality by protect65 years of age and older. Arch Surg 107:30,1973 3. Austen WG, DeSanctis RW, Buckley MJ, et al: ing the myocardium and minimizing the period Surgical management of aortic valve disease in of aortic cross-clamping, as evidenced by the the elderly. JAMA 211:624, 1970 average cross-clamp time of 49 minutes for the 4. Barnhorst DA, Giuliani ER, Pluth JR, et al: Open entire series. heart surgery in patients more than 65 years old. The presence of associated cardiac lesions Ann Thorac Surg 18:81, 1974 5. Blank RH, Pupello DF, Bessone LN, et al: Method should not be a deterrent to total correction, of managing the small aortic annulus during valve whereas extremely poor left ventricular function replacement. Ann Thorac Surg 22:356, 1976 must be carefully weighed before patients are 6. Carlson RG, Shafer RB, Eliot RS, et al: Results of accepted for operation. Emergency operations cardiac surgery in 273 older patients. Geriatrics in this series did not seem to increase the hospi22:173, 1967 tal mortality, as previously reported [19], and 7. Feinleib M: Changes in life expectancy since 1900. Circulation 51, 52:Suppl3:16, 1975 the application of aortic annulus enlargement 8. Hildner FJ, Javier RP,Cohen LS, et al: Myocardial technique, as well as patch enlargement of the dysfunction associated with valvular heart disascending aorta, have not been followed by inease. Am J Cardiol30:319, 1972 creased morbidity. The somewhat high percent9. Kirklin JW, Pacifico AD: Surgery for acquired age of hospital complications is to be expected in valvular heart disease (I). N Engl J Med 288:133, 1973 elderly patients who have advanced disease. 10. Kirklin JW, Pacifico AD: Surgery for acquired The key to success lies in very close postoperavalvular heart disease (11). N Engl J Med 288:194, tive management-anticipating, rather than 1973 reacting to, the usual complications. 11. Kittle F, Dye WS, Gerbode F, et al: Factors inPatients who exhibit conduction defects fluencing risk in cardiac surgical patients; cooppreoperatively should be considered for erative study. Circulation 39,4O:Suppl 1:169, 1969 12. Kouchoukos NT: Problems in mitral valve reprophylactic implantation of myocardial elecplacement, Advances in Cardiovascular Surgery. trodes. In addition, our policy has been to Edited by JW Kirklin. Grune & Stratton, New routinely insert this type of electrode in those York, 1973, p 205 patients undergoing tricuspid valve replace- 13. Kouchoukos NT, Sheppard LC, Kirklin JW: Effect ment, because they become unsuitable for perof alteration in arterial pressure on cardiac pervenous pacemakers. Although no patient in this formance early after open intra-cardiac operation. J Thorac Cardiovasc Surg 64:563, 1972 series has required renal dialysis, we have 14. McGoon DC: Valvular replacement and ventricuelected to insert arteriovenous loops routinely lar function. J Thorac Cardiovasc Surg 72:326, at the time of operation in those patients who are 1976 referred with extreme oliguria. 15. Oh W, Hickman R, Emanuel R, et al: Heart valve The only operative death was due to technical surgery in 114 patients over the age of 60. Br Heart J 35:174, 1973 problems, and this can be improved. With regard to late complications, at least 1 of the 4 16. Oleson KH: The natural history of 271 patients with mitral stenosis under medical treatment. Br cerebrovascular accidents probably was due to a Heart J 24:349, 1962 complication of anticoagulant therapy. This 17. Pluth JR, McGoon DC: Current status of valve problem will be lessened in the future as more replacement. Mod Concepts Cardiovasc Dis biollogical valves are used. 43:65, 1974 The follow-up on the patients in this study, 18. Pupello DF, Blank RH, Bessone LN, et al: Local deep hypothennia for combined valvular and coroalthough very promising, is obviously too short nary heart disease. Ann Thorac Surg 21:508, 1976 to allow for any firm conclusions with regard to 19. Quinlan R, Cohn LH, Collins JJ: Determinants of long-term survival; however, the symptomatic survival following cardiac operations in elderly improvement and quality of life have clearly patients. Chest 68:498, 1975 20. ROSSJ, Braunwald E: Aortic stenosis. Circulation been affected by operation.
References 1. Ahmad A, Starr A: Valve replacement in geriatric patients. Br Heart J 31:322, 1969 2. Ashor GW, Meyer BW, Lindesmith GG, et al: Coronary artery disease: surgery in 100 patients
37,38:Suppl 5:61, 1968 21. Shanahan MX, Windsor HM, Golding L: Open heart surgery in the elderly. Aust NZ J Surg 42:107, 1972 22. Zelzer A, Cohn KE: Natural history of mitral stenosis. Circulation 452378, 1972
Refinement in techniques for open-heart operations and prosthetic devices, coupled with more substantial evidence of the deleterious effect of malfunctioning valves upon the myocardium [9, 10, 12, 14, 171, has led to a more aggressive surgical approach. This same enthusiasm, however, has not been applied in the older age group because of the added risks of age and associated diseases [ll]. Reasonable operative mortality and morbidity for elderly patients have been documented [l,3, 4, 6, 15, 211. Some of these reports [2, 191, however, include patients who rece:ived isolated myocardial revascularization, which tend to minimize mortality. From the Cardiac Surgical Unit and Cardiology Center, Tampa General Hospital, and the Department of Thoracic and Cardiovascular Surgery, University of South Florida College of Medicine, Tampa, FL. We wish to express our appreciation to Mr. Leonard Taylor for data gathering, to George Ebra, Ph.D., for his assistance in computer analysis, and to Mrs. Janice Cooper for her very efficient secretarial help. Presented at the Twenty-third Annual Meeting of the Southern Thoracic Surgical Association, Nov 4-6,1976, Acapulco, Mexico. Address reprint requests to Dr. Bessone, One Davis Blvd, Tampa, FL 33606.
417
If comparable results for patients in the older age group can be consistently achieved, the indications for surgical intervention in these patients could be similar to those for the younger age group. With this consideration, we reviewed our valve experience in patients over the age of 70.
Materials and Methods From July, 1972, to April, 1976, 379 valves were implanted in 339 patients in the Cardiac Surgical Unit at Tampa General Hospital. Fifty-four of these patients were 70 years of age or older. There were 22 men and 32 women whose ages ranged between 70 and 82 years (mean, 73.3 years). Preoperative hospitalization ranged from 1 to 32 days (mean, 5.9 days); the mean postoperative hospitalization was 17.5 days (range, 10 to 55 days). Preoperative cardiac catheterization, including coronary arteriograms, was completed in all but those patients who experienced decompensation during the catheterization procedure. Nineteen patients (35.2%) were in New York Heart Association (NYHA) Functional Class 111; 35 patients (64.8%) were in Class IV. Operative Technique The operative technique has been described previously [MI. Briefly, it consisted of a standard midsternal approach, routine atrial and aortic cannulation, and cardiopulmonary bypass with relatively low flow rates of 35 to 50 ml per kilogram of body weight, in combination with moderate systemic hypothermia. Disposable bubble oxygenators primed with 500 ml of heparinized whole blood and 1,000 ml of Ringer's lactate solution were used. The pericardium was suspended from the chest wall in order to create a well for continuous infusion of cold saline at 4" to 5°C for myocardial protection. Intracavitary flushing with additional cold solution further reduced the time needed for maximum cooling [MI.
418 The Annals of Thoracic Surgery Vol 24 No 5 November 1977
Surgical Data There were 47 elective and 7 emergency operations. The mean pump time was 93 minutes (range, 52 to 182 minutes). The cross-clamp time was 49 minutes (range, 15 to 86 minutes). The lowest esophageal temperature reached during the pump run ranged between 22" and 32°C (mean, 28°C). Enlargement of the aortic annulus [51 was necessary in 5 patients; 3 additional patients required patch enlargement of the ascending aorta. The patients were classified into three groups according to the surgical procedure (Table 1). GROUP 1. Twenty-one patients (8 men and 13 women) with an average age of 73 years underwent isolated aortic valve replacement. Eleven were in NYHA Functional Class 111; 10 were in Class IV. Of 13 patients with pure aortic stenosis, 1 had associated idiopathic hypertrophic subaortic stenosis (IHSS). Four patients had aortic insufficiency and 4 had mixed lesions. Among the 17 patients with pure or mixed aortic stenosis, the average peak systolic gradient was 104 mm Hg (range, 65 to 210 mm Hg). The highest combined gradient was found in the patient with IHSS. GROUP 2. Fourteen patients (2 men and 12 women) with an average age of 73.4 years underwent isolated valve replacement. Four patients were in NYHA Class 111; 10 were in Class N.Ten patients (71.4%) had predominant or pure mitral insufficiency; 4 had mitral stenosis. The resting systolic pulmonary artery pressure was elevated in all instances, with a mean of 69.7 mm Hg. The mean pulmonary artery capillary wedge pressure at rest was 25.0 mm Hg and the average cardiac index by the Fick method was 2.10
Table 1. Distribution of Patients According to Surgical Procedures Grouv 1 (isolated aortic valve replacement) 2 (isolated mitral valve replacement) 3 (combined procedures including valve replacement) Total
No. of Patients 21
14
19 54
Wmin/m2. Three patients (21.4%) had had previous commissurotomies. GROUP 3. Nineteen patients (12 men and 7 women) with an average age of 73.3 years underwent combined procedures (Table 2). Four patients were in NYHA Class 111; 15 were in Class IV. The mean cardiac index (Fick) for the 14 patients in which this was recorded was 2.3 L/min/m2.
Results Early Mortality One patient (Group 1) with aortic stenosis, Functional Class N, died during reexploration for bleeding. One patient (Group 3) who had mitral valve replacement and excision of a posterior left ventricular aneurysm died on the twenty-second postoperative day. Preoperatively this patient was Class N and was bedridden with intractable failure secondary to poor left ventricular function. His postoperative course was complicated by refractory congestive heart failure, and he died suddenly. The overall hospital mortality was 3.7%. There were no hospital deaths among patients who underwent emergency operations or who required annulus Table 2. Description of Group 3 (Combined Procedures) Procedures
+
AVR single aortocoronary bypass AVR + double aortocoronary bypass MVR + single aortocoronary bypass MVR double aortocoronary bypass MVR + excision of LV aneurysm AVR repair of mitral valve Double valve replacement (mitral and aortic) Double valve replacement (mitral and aortic) + single aortocoronary bypass Total
No. of Patients 4
5
+
+
4
1
19
AVR = aortic valve replacement; MVR = mitral valve replacement; LV = left ventricular.
419 Bessone et al: Valve Replacement in Patients Over 70
enlargement or patch enlargement of the ascending aorta.
Hospital Complications Thirty-one patients (57.4%) had postoperative complications while hospitalized (Table 3). Arrhythmias were the most frequent complication. Two patients who showed preoperative evidence of atrioventricular conduction defect required permanent pacemaker insertion in the early postoperative period. Low cardiac output developed in 7 patients (13%) and was more prevalent in those who underwent mitral valve replacement. Crossclamp time in these patients was no longer than the mean cross-clamp time for the entire group. Their management included increase of the preload, inotropic drugs, and occasional use of nitropiusside to reduce the afterload [131. Five patients (9.3%) required reexploration for bleeding, and 3 needed prolonged ventilatory support (72 hours or longer). One patient had postoperative gastrointestinal bleeding, and 1 had postoperative perforation. of a duodenal ulcer, which required an emergency laparotomy. Both patients survived. Long-Term Follow-up The 52 hospital survivors were followed from 1 to 41 months (mean, 12.6, patient-months). Follow-up data were secured through office visits, a patient questionnaire, or through direct contact with the referring physician.
Late Complications Long-term follow-up of the 52 hospital survivors revealed two types of major complications. Four patients had cerebrovascular accidents. TWO were in Group 2 and had received isolated mitral valve replacement, 1 with a Bjork-Shiley prosthesis and 1 with a porcine heterograft prosthesis, respectively. Both patients recovered with only partial sequelae. Two patients in Group 3 suffered cerebrovascular accidents. One had aortic valve replacement with a porcine heterograft as well as debridement and commissurotomy of the mitral valve. Her CVA occurred only two weeks after discharge, and the prothrombin time was excessively prolonged. She recovered in a few days with no sequelae. The second patient had undergone aortic valve replacement with a Bjork-Shiley prosthesis plus a double aortocoronary saphenous vein bypass graft. He developed hemiplegia and recovered with some residuum. Congestive heart failure was present in 2 patients, who required rehospitalization and aggressive diuresis. One patient was in Group 1 and had a preoperative diagnosis of aortic insufficiency with a massively enlarged left ventricle. His postoperative course had been marred by supraventricular tachyarrhythmias. Following hospital treatment he was discharged and later improved to Class 11. The second patient was in Group 3 and had aortic valve replacement plus a single aortocoronary bypass. At the completion of the study this patient remained in Class 111.
Table 3. Hospital Complications Among 54 Patients Undergoing Valve Replacement Complications
No. of Patients
Died
None Arrhythmias Need for permanent pacemaker Low output Bleeding requiring reexploration Respiratory insufficiency Temporary mental confusion GI bl.eeding Perforated duodenal ulcer ‘Total
23 (42.6%) 10 (18.5%) 2 (3.7%) 7 (13.0%) 5 (9.3%) 3 (5.670) 2 (3.7%) 1 (1.8%) 1 (1.8%) 54 (100%)
0 0
-
GI = gastrointestinal.
0 1 (22 days postop) 1 (at operation) 0 0 0 0 2
420
The Annals of Thoracic Surgery Vol 24 No 5 November 1977
Late Mortality There were 2 additional deaths (3.8%) among the 52 patients who left the hospital. One patient (Group 3) who had aortic valve replacement with a heterograft and double aortocoronary bypass died 2 months after discharge with a clinical diagnosis of arrhythmia. He had been taking quinidine and was readmitted to a local hospital when he developed apnea. He soon recovered and was ambulatory when he developed syncope and cardiac standstill. The second patient (Group 1)had aortic stenosis. She died at home 21 months after her aortic valve had been replaced with a Bjork-Shiley prosthesis. Until then this patient had been stable (Class 11) but had shown increased symptoms of cerebral arteriosclerosis. The total mortality (Table 4) at the end of the study was 7.4% (4 of 54 patients). Postoperative Cardiac Status Fifty-one of the 52 hospital survivors have improved their cardiac functional classification. One patient has remained in the same class as preoperatively. Of the 33 patients in Class I V prior to operation, 16 (48.4%) improved to Class I, 14 (42.4%) to Class 11, and 3 (9.0%) to Class 111. A comparable result was observed in 19 patients in Class I11 preoperatively. Twelve of these patients (63.1%) reached Class I and 6 (31.5%) advanced to Class 11. Only 1patient (5.2%) remained in the same class (Figure). Group 1 patients (aortic valve replacement) showed the most dramatic improvement, followed by Group 2 (isolated mitral valve replacement). The only patient in the series who failed to improve his preoperative classification was in Group 3 (combined procedures), which,
PRE OP
POST OP
w
F]
/
/
1
19
Preoperative and postoperative cardiac status of 52 hospital survivors.
as a group, also showed proportionately more single class improvement.
Comment Because of the anticipated risks, cardiologists and cardiac surgeons alike are reluctant to consider valve operations in patients older than 65 years. Therefore, there is a proportional increase in the number of patients who must be operated on while they are in Functional Class IV and in their eighth decade. The 1958 Commissioner’s Standard Ordinary Mortality Table gives a life expectancy of 10.2 years for a man aged 70 years and 11.73 years for a woman of the same age. These figures continue to increase in the elderly as in the middle age group [71. Patients with symptomatic aortic stenosis have a very poor prognostic outlook [ZO]. Mitral stenosis has a less predictable natural history [22], but for patients in Class IV the complications and mortality climb noticeably unless the process is interrupted by operation [161. Regurgitant lesions are particularly dangerous beTable 4. Total Mortality for 54 Patients cause they are well tolerated at the expense of Undergoing Valve Replacement myocardial damage 18, 121. The data in the present study reveal an operaNo. of Early Late Overall Group Patients Deaths Deaths Mortality tive mortality comparable with that in younger age groups [9, 10, 14, 171 and much lower than 1 21 1 (4.7%) 1 (5%) 2 (10.5%) has previously been reported [l-4,6,15,19,211. 2 14 0 (0%) 0 (0%) 0 (OYO) The need for coronary perfusion [4]has not been 3 19 1 (5.2%) 1 (5.5%) 2 (10.5%) substantiated in our experience. Our belief is Total 54 2 (3.7%) 2 (3.8%) 4 (7.4%) that local deep hypothermia has greatly im-
421
Bessone et al: Valve Replacement in Patients Over 70
proved the perioperative mortality by protect65 years of age and older. Arch Surg 107:30,1973 3. Austen WG, DeSanctis RW, Buckley MJ, et al: ing the myocardium and minimizing the period Surgical management of aortic valve disease in of aortic cross-clamping, as evidenced by the the elderly. JAMA 211:624, 1970 average cross-clamp time of 49 minutes for the 4. Barnhorst DA, Giuliani ER, Pluth JR, et al: Open entire series. heart surgery in patients more than 65 years old. The presence of associated cardiac lesions Ann Thorac Surg 18:81, 1974 5. Blank RH, Pupello DF, Bessone LN, et al: Method should not be a deterrent to total correction, of managing the small aortic annulus during valve whereas extremely poor left ventricular function replacement. Ann Thorac Surg 22:356, 1976 must be carefully weighed before patients are 6. Carlson RG, Shafer RB, Eliot RS, et al: Results of accepted for operation. Emergency operations cardiac surgery in 273 older patients. Geriatrics in this series did not seem to increase the hospi22:173, 1967 tal mortality, as previously reported [19], and 7. Feinleib M: Changes in life expectancy since 1900. Circulation 51, 52:Suppl3:16, 1975 the application of aortic annulus enlargement 8. Hildner FJ, Javier RP,Cohen LS, et al: Myocardial technique, as well as patch enlargement of the dysfunction associated with valvular heart disascending aorta, have not been followed by inease. Am J Cardiol30:319, 1972 creased morbidity. The somewhat high percent9. Kirklin JW, Pacifico AD: Surgery for acquired age of hospital complications is to be expected in valvular heart disease (I). N Engl J Med 288:133, 1973 elderly patients who have advanced disease. 10. Kirklin JW, Pacifico AD: Surgery for acquired The key to success lies in very close postoperavalvular heart disease (11). N Engl J Med 288:194, tive management-anticipating, rather than 1973 reacting to, the usual complications. 11. Kittle F, Dye WS, Gerbode F, et al: Factors inPatients who exhibit conduction defects fluencing risk in cardiac surgical patients; cooppreoperatively should be considered for erative study. Circulation 39,4O:Suppl 1:169, 1969 12. Kouchoukos NT: Problems in mitral valve reprophylactic implantation of myocardial elecplacement, Advances in Cardiovascular Surgery. trodes. In addition, our policy has been to Edited by JW Kirklin. Grune & Stratton, New routinely insert this type of electrode in those York, 1973, p 205 patients undergoing tricuspid valve replace- 13. Kouchoukos NT, Sheppard LC, Kirklin JW: Effect ment, because they become unsuitable for perof alteration in arterial pressure on cardiac pervenous pacemakers. Although no patient in this formance early after open intra-cardiac operation. J Thorac Cardiovasc Surg 64:563, 1972 series has required renal dialysis, we have 14. McGoon DC: Valvular replacement and ventricuelected to insert arteriovenous loops routinely lar function. J Thorac Cardiovasc Surg 72:326, at the time of operation in those patients who are 1976 referred with extreme oliguria. 15. Oh W, Hickman R, Emanuel R, et al: Heart valve The only operative death was due to technical surgery in 114 patients over the age of 60. Br Heart J 35:174, 1973 problems, and this can be improved. With regard to late complications, at least 1 of the 4 16. Oleson KH: The natural history of 271 patients with mitral stenosis under medical treatment. Br cerebrovascular accidents probably was due to a Heart J 24:349, 1962 complication of anticoagulant therapy. This 17. Pluth JR, McGoon DC: Current status of valve problem will be lessened in the future as more replacement. Mod Concepts Cardiovasc Dis biollogical valves are used. 43:65, 1974 The follow-up on the patients in this study, 18. Pupello DF, Blank RH, Bessone LN, et al: Local deep hypothennia for combined valvular and coroalthough very promising, is obviously too short nary heart disease. Ann Thorac Surg 21:508, 1976 to allow for any firm conclusions with regard to 19. Quinlan R, Cohn LH, Collins JJ: Determinants of long-term survival; however, the symptomatic survival following cardiac operations in elderly improvement and quality of life have clearly patients. Chest 68:498, 1975 20. ROSSJ, Braunwald E: Aortic stenosis. Circulation been affected by operation.
References 1. Ahmad A, Starr A: Valve replacement in geriatric patients. Br Heart J 31:322, 1969 2. Ashor GW, Meyer BW, Lindesmith GG, et al: Coronary artery disease: surgery in 100 patients
37,38:Suppl 5:61, 1968 21. Shanahan MX, Windsor HM, Golding L: Open heart surgery in the elderly. Aust NZ J Surg 42:107, 1972 22. Zelzer A, Cohn KE: Natural history of mitral stenosis. Circulation 452378, 1972
