Cardiac valve replacement with mechanical prostheses in patients aged 65 years and over

BACKGROUND AND AIM OF THE STUDY: Recent data regarding the performance of mechanical prostheses in patients aged > or =65 years are scant. Hence, the outcome of mechanical prosthesis implantation in this age group has been retrospectively evaluated. METHODS: Between January 1990 and October 2002, 253 patients (163 males, 90 females) aged > or =65 years (mean age 68.2 years) underwent aortic valve replacement (AVR) and/or mitral valve replacement (MVR) at the authors' institution. RESULTS: Among the patients, 94 (37.2%) had MVR, 137 (54.1%) had AVR, and 22 (8.7%) had MVR+AVR. In total, 99 patients (39.1%) had concomitant coronary artery bypass grafting (CABG). The early mortality rate was 11.1%; that for patients aged > or =70 years was greater than that for patients aged 65-69 years (14.5% versus 9.6%, p <0.001). The overall actuarial survival was 91.3 +/- 2.4% at 5 years, 81.1 +/- 4.1% at 8 years, and 73.8 +/- 6.3% at 10 years. Actuarial survival for patients with isolated AVR and MVR at 10 years was 84.7 +/- 6.0% and 61.4 +/- 18.8%, respectively. Actuarial survival at 10 years for patients with isolated valve replacement was 76.1 +/- 8.1%, and 68.7 +/- 10.2% for patients with concomitant CABG (p = 0.680). Actuarial survival at 10 years was 81.3 +/- 6.9% for patients aged 65-69 years, and 50.3 +/- 11.0% for patients aged > or =70 years (p = 0.001). Freedom from a major thromboembolic event was 99.4 +/- 0.7% at five years and 86.3 +/- 6.0% at 10 years, while freedom from hemorrhage was 90.4 +/- 2.6% and 70.3 +/- 6.8%, respectively. CONCLUSION: Mechanical prostheses can be used in patients aged > or =65 years, with favorable results. However, on the basis of the present findings, patients aged > or =70 years have a reduced early and late survival.     

Cardiac myxoma in patients over 75 years of age. Report of 19 cases

Left atrial myxoma is considered to be exceptionally rare in the elderly. The authors observed and reported on 19 cases occurring in patients over 75 years of age out of a series of 100 myxomas diagnosed between 1962 and 1997, in 12 women and 7 men (mean age: 80 years, range 75 to 89 years). In 3 cases, the myxomas were chance findings at echocardiography but the 16 symptomatic patients (85%) had left ventricular failure (47%), positional symptoms (25%), pyrexia and poor general health (17%) or systemic embolism (17%). The location of the myxoma was the left atrium in all cases, with mitral valve obstruction in 13 of the 19 cases. Eighteen tumours were attached to the interatrial septum and one to the atrial surface of the anterior mitral leaflet. Calcifications were observed in 5 patients. Surgical ablation of the tumour was performed in 15 of the 19 patients. The post-operative course was usually uncomplicated: one patient died of a cerebral haemorrhage. Four patients did not undergo surgery because of patient refusal in 3 cases and major associated morbidity in the other case. These cases were included in the study because the tumours had all the characteristics of myxomas. Though the discovery of a myxoma remains a classical surgical emergency, the presence of quiescent, non-obstructive, well circumscribed and calcified myxomas with a low risk of obstruction and of embolism in elderly high risk patients may be exceptions to this traditional dogma.     

Heart valve replacement with the Bj?rk-Shiley monostrut valve in patients over 60 years of age

Over a period of five years (1983-88) 210 Bj?rk-Shiley monostrut mechanical tilting disc prostheses were implanted in 176 patients over the age of 60. There were 61 aortic valve replacements, 86 mitral valve replacements and 29 multiple replacements. Patients were aged between 61 and 78 years (mean 65.5 years), 89% were in NYHA grades III and IV preoperatively and 34.6% had had previous cardiac surgery. Concomitant coronary surgery was performed in 15.9%. Early mortality was 9.1%. Follow-up is 100% complete. There were eight late deaths (3.1 per 100 patient years) of which three were valve-related (prosthetic endocarditis 2, periprosthetic leak 1). Actuarial survival at five years is 98% for aortic valve replacement and 93% for mitral valve replacement. There were no major embolic events and four possible minor embolic events. Overall freedom from anticoagulant complications was 88.9% at five years. No deaths occurred because of anticoagulant-related haemorrhage. There were no episodes of valve failure (thrombotic obstruction or mechanical disruption). Six patients were reoperated for complications: two for periprosthetic leak and three for prosthetic endocarditis. These results compare favourably with those of other valve substitutes and justify the continuing use of the Bj?rk-Shiley monostrut tilting disc prosthesis in the elderly.     

Cardiac transplantation in patients over 50 years of age

Sixty-two patients underwent cardiac transplantation at the University of Arizona from March 1979 to March 1985. Thirteen patients (11 men and 2 women) were over 50 years of age at the time of transplantation and 49 were under the age of 50. The mean age (+/- SEM) of the patients over 50 was 53 +/- 1 years. Eight of these patients were treated with conventional immunosuppressive therapy (azathioprine, prednisone and rabbit antithymocyte globulin) and five, beginning in January 1983, were treated with cyclosporine, prednisone and rabbit antithymocyte globulin. Early mortality (0 to 90 days) was 16% in the group over 50 versus 18% for those under 50. The late mortality (greater than 90 days) was 36 and 33%, respectively. In both groups, rejection and infection were the principal causes of death. The incidence of infection was 1.9 +/- 0.5 episodes per patient in those patients over 50 and 1.9 +/- 0.4 in those under 50. The incidence of rejection was 1.3 episodes per patient-year in patients over 50 and 1.7 episodes per patient-year in those under 50. Actuarial survival at 1 year was 72 +/- 14% in the group over 50 and 66 +/- 7% in the group under 50 years of age. These data indicate that the results of cardiac transplantation for patients over 50 do not differ significantly from those for patients under 50. Therefore, it is concluded that a rigidly defined age criterion for cardiac transplant recipients is not acceptable. Each potential recipient must be evaluated in terms of individual risk and benefit from the procedure.     

Aortic valve replacement in patients over 80 years of age. Short- and medium-term results in 140 patients

One hundred and forty aortic valve replacements (AVR) performed between 1986 and 1995 at Rouen University Hospital in octogenarians (52 men and 88 women), including 9 emergency procedures, were analysed. One hundred and fifteen patients had pure aortic stenosis, 25 had mixed aortic valve disease with mainly aortic incompetence. The surgical decision was taken by the patient with the surgeon after an interview, in order to exclude too handicapped or undecided patients. Significant coronary artery disease was observed in 42% of cases. Isolated AVR was undertaken in 74% of cases and associated coronary bypass surgery in 23% of cases. Bioprostheses were used in 90% of cases. The valvular lesions were predominantly those of Monckeberg disease. The operative mortality was of 13 patients (9.3%). Functional recovery was satisfactory in 78% of cases; the average duration of the hospital stay was 12 days. All known risk factors for AVR: age, coronary lesions, cardiac failure, low ejection fraction, aortic regurgitation, were associated with insignificant increases in mortality. The secondary mortality was of 28 patients; 99 patients are still alive 4 to 91 months after surgery. The actuarial survival graph showed a 56.5% probability of 5 year survival. Eighty per cent of survivors live at home without loss of autonomy.     

Cardiac surgery in patients over the age of 80 years

The risk-benefit relationship of open heart surgery in octogenarians is not well established. Eighty consecutive patients over the age of 80 who underwent cardiac operations under cardiopulmonary bypass were evaluated. Twenty-five patients were in functional class IV, 42 in class III, and 13 in class II. Forty-four patients had only coronary artery bypass grafts (CABG), 12 only aortic valve replacement (AVR), 6 only mitral valve replacement (MVR), 12 CABG and AVR, 4 CABG and MVR, 1 CABG and aneurysmectomy, and 1 had resection of left atrial myxoma. Operative mortality (within 30 days) was 12.5% for the group. Mortality was related to bleeding, left ventricular failure, primary ventricular fibrillation, pulmonary failure, and renal failure. Mortality was higher in patients with (1) advanced functional class, (2) mitral valve replacement, (3) postoperative hemorrhage, and (4) associated pulmonary disease. While a generally conservative approach is recommended for octogenarian patients, many with life-threatening cardiac disease, especially those free of major multisystem illnesses, should not be denied the benefit of surgical treatment.     

Outcome of autogenous fistula construction in hemodialyzed patients over 75 years of age

BACKGROUND: There are controversies regarding the feasibility of autogenous vascular access creation in elderly hemodialysis (HD) patients. The aim of this retrospective study was to evaluate the results of creating different types of autogenous arteriovenous fistulas (AVFs) in a consecutive series of HD patients over 75 years of age. METHODS: The analysis was performed in 131 patients (65 females, 66 males, average age 79.1 +/- 3.6 years) in whom the creation of an autogenous AVF was considered within a 6-year period (February 1998 to February 2004). Among them, 26.7%were diabetics, 66.3% had hypertension, 30.7% were smokers, and 35.6% were obese. Patient survival and primary and secondary AVF patency were assessed. RESULTS: The survival rates for patients were 94, 88, 66, and 45% at 6 months and at 1, 3, and 5 years, respectively. Successful autogenous AVF formation was finally achieved in 107 patients (81.6%): in 99 patients in the forearm and in 8in the upper arm. A Kaplan-Meier analysis showed primary AVF patency rates of: 74 +/- 4.3% (+/- SE) at 1 month; 70 +/- 4.7% at 6 months; 59 +/- 4.9% at 1 year; 59 +/- 4.9% at 2 years; 59+/- 4.9% at 3 years; 59 +/- 4.9% at 4 years, and 58 +/- 4.9% at 5 years. The secondary patency rates were: 95 +/- 2.0; 92 +/- 2.2; 84 +/- 3.3; 79 +/- 4.0; 72 +/- 4.3; 71 +/- 4.4, and 69 +/- 4.5% in the corresponding periods, respectively. All postoperative complications in 10 patients were treated surgically, if applicable, without endovascular techniques. CONCLUSIONS: By exploiting all suitable types of autogenous AVF it is possible to establish the best form of vascular access even in the majority of elderly patients.     

Evaluation of postoperative mortality and quality of life of patients over 75 years of age after valve replacement for aortic stenosis. Report of 110 cases

The authors carried out a retrospective study of short and long-term mortality after aortic valve replacement and assessed the quality of life by the IRIS scale in patients over 75 years of age operated for severe aortic stenosis at the University Hospital of Brest between June 1990 and March 1995. The hospital files of 110 consecutive patients (71 women, 39 men; average age 78 +/- 2 years, range 75-85 years) were studied. The pre- per- and postoperative data was studied. Each survivor was contacted by telephone during the year 2000 and a health and IRIS quality of life questionnaire was sent to them. Precise information about patients who had died was obtained from the family and/or medical practitioner. In the preoperative period, 30.9% of patients had left ventricular failure. The average aortic valve surface area was 0.53 +/- 0.12 cm2. Of the patients who underwent coronary angiography (60%), one third had significant coronary lesions. Coronary artery bypass surgery was associated with aortic valve replacement in 10% of cases. Biological prostheses were used in 108 patients. The operative mortality was 8.2%. One year, 5 year and 10 year survival rates were 89.9%, 75.5% and 33.3% respectively. Of the survivors, 16.7% were in institutional care and 83.3% lived at home. A total of 77.8% were readmitted to hospital, about half of them for cardiac problems. Cardiac treatment was prescribed for 97% of patients. The quality of life questionnaire was completed by 35 patients: the quality of life was better than average in nearly 83% of these patients. Aortic valve replacement for aortic stenosis in patients over 75 years of age improves life expectancy which is almost the same as that of the normal population of the same age, and improves the quality of life by restoring functional autonomy, enabling the majority of them to live in their own houses most of the time.     

75岁以上急性冠脉综合征患者近期预后因素分析

目的探讨预测75岁以上急性冠脉综合征患者30d内发生急性心血管事件的预后因素。方法选择2007年12月至2009年12月在广州医学院附属广州市第一人民医院老年科连续住院的75岁以上急性冠脉综合征患者共93例,根据就诊第30天内有无急性心血管事件发生分为事件组和无事件组,对两组患者临床特点及血清生化检测指标进行单因素分析和多因素Logistic回归分析,并对最终进入回归方程的指标进行相关性分析。结果 30d内共发生急性心血管事件27例(29.0%),事件组血清高敏C-反应蛋白[(12.16±11.24)mg/Lvs.(5.47±9.85)mg/L,P0.05]、空腹血糖[(7.67±3.96)mmol/Lvs.(5.75±1.48)mmol/L,P0.05]、心肌肌钙蛋白[(11.91±21.77)ng/Lvs.(2.07±7.02)ng/L,P0.05]浓度显著高于无事件组;多因素Logistic回归分析显示,血清高敏C-反应蛋白、空腹血糖、心肌肌钙蛋白浓度升高是75岁以上老年急性冠脉综合征近期发生心脏事件的独立危险因素;相关性分析显示,血清高敏C-反应蛋白、空腹血糖分别与心肌肌钙蛋白浓度呈显著正相关(r=0.474,P0.01;r=0.249,P0.01)。结论血清高敏C-反应蛋白、空腹血糖、心肌肌钙蛋白浓度升高是75岁以上老年急性冠脉综合征患者近期发生急性心脏事件的独立危险因素,联合检测可能对其临床预后具有更强的预测价值。     

Cardiac valve replacement in patients over 65 during a 10-year period.

From 1967 through 1976, 754 adult patients were subjected to open heart procedures for acquired valvular disease at the University of California, San Francisco, 104 of whom were 66 years of age or over (mean = 70 years). The operative mortality of 15.0% in the elderly group did not differ significantly from that of 14.3% in the entire adult series for the 10-year period. Mortality was consistently higher in combined procedures (multiple valve replacement and valve replacement with coronary grafting). Since the introduction, in 1973, of hypothermic hyperkalemic coronary washout for intraoperative protection of the ischemic myocardium, the hospital mortality rate has decreased to 8.1% overall, 6.0% for isolated aortic valve replacement and 0% for isolated mitral valve replacement in patients over 65. Moreover, the long-term survival following aortic and mitral valve replacement in this series appears to approximate the survival curve of the normal population of the same age. This experience suggests that cardiac surgery has become safer for all patients during the past 10 years and that operative mortality is related primarily to the type and severity of disease rather than to age.     

65岁以上老年患者心脏瓣膜手术中的体外循环管理

【目的】 总结65岁以上老年人心脏瓣膜置换术的体外循环管理方法。【方法】 2006年1月至2008年12月,开展了232例老年人心脏瓣膜置换术,其中男133例,女99例,年龄65～78岁(69.6±9.2)岁;体重39～81Kg（51±8.2）Kg。手术方式包括二尖瓣置换术(MVR)73例,主动脉瓣置换术(AVR)51例,三尖瓣置换( TVR)3例,二尖瓣及主动脉双瓣置换术(DVR)93例,再次二尖瓣置换术(Re-MVR)7例,再次主动脉瓣置换术(Re-AVR)3例,主动脉带瓣人造血管置换2例,同期行二尖瓣整形(MVP)21例,三尖瓣整形( TVP)66例,冠状动脉旁路移植术(CABG)12例。全部采用气管插管、静吸复合麻醉,中度血液稀释、中度低温、中高流量,冷含血停跳液进行心肌保护,全部应用超滤器。【结果】：体外循环时间46～315min(87.2±32.7)min;主动脉阻断时间25～168min(58.3±27.5)min。转流中平均动脉压维持在6O～90mm Hg,超滤量为800～8300ml,心脏自动复跳率86％,本组早期死亡10例(4.3％)。【结论】 体外循环中加强心肌保护;控制血液稀释度,使用血液超滤技术维持机体内环境的稳定;有效的组织灌注以及良好的保护等综合性措施,有助于脑、肾、肺等重要脏器的保护,有利于提高老年患者心脏瓣膜置换术中体外循环的质量,并确保手术安全     

Renal biopsy in elderly adults over 75 years of age

The results of 177 renal biopsies (RB) in patients over 75 years of age were analysed. The three most frequent histological types were: Overall: membranous nephritis (MN), minimal change disease (MCD) and IgA Nephropathy (IgAN); In nephrotic syndrome (51% of RB): MN (36%), MCD (33%) and amyloidosis (12%); In chronic renal failure without nephrotic syndrome (25% of RB): chronic interstitial nephritis (17%), benign nephrosclerosis (12%) and IgAN (12%); In acute or progressive renal failure (18% of RB): acute tubular necrosis (36%), crescentic GN (16%) and IgAN (12%). Isolated proteinuria was most frequently associated with IgAN. In only 40% of patients was the medical history relevant, and only in selected cases it allowed for accurate prediction of the histological findings. Our data favor a more liberal use of biopsy in the elderly patients.     

Cardiac valve replacement in patients with antiphospholipid syndrome

Objective

To analyze the results of cardiac valve replacement in a multicenter cohort of patients with antiphospholipid syndrome (APS) and to identify prognostic factors of poor outcome.

Methods

We performed a retrospective analysis of clinical manifestations (cardiac involvement and APS characteristics), operative and early postoperative courses, and long‐term followup. All of the patients fulfilled the Sapporo criteria for APS. Logistic regression analyses were performed to identify those variables associated with adverse outcomes.

Results

Between 1981 and 2008, 33 valvular replacements were carried out in 32 patients with APS. The mean ± SD age at the time of surgery was 43.09 ± 14.08 years. Thirty patients were women. Primary APS was present in 21 patients. The median followup time after surgery was 33.5 months (range 0–192 months). The mitral valve was the most frequently replaced (22 of 33). Mechanical valve replacement was performed in 23 patients (71.9%). The mortality rate was 12.5% (1 cardiogenic shock, 1 septic shock, 1 following renal transplantation, and 1 hemorrhagic stroke). Fourteen patients experienced 20 complications (8 major bleeding, 5 thrombotic events, 2 valvular deteriorations, 2 third‐degree atrioventricular block, 1 endocarditis, 1 cardiac tamponade, and 1 cardiac failure). Fifty percent of the patients had an uneventful outcome.

Conclusion

Morbidity and mortality were high in APS patients undergoing valve replacement surgery. Most complications were related to thrombosis and bleeding. Anticoagulation must be carefully monitored to prevent hemorrhagic and thrombotic complications.     

Aortic valve replacement in patients over 70 years old: determinants of early death

INTRODUCTION AND OBJECTIVES: There is controversy regarding the risk factors associated with early death in geriatric patients undergoing aortic valve replacement. We analyzed the risks in these patients and established an accurate model for predicting in-hospital mortality. PATIENTS AND METHOD: Univariate and multivariate analyses were made of the risk factors associated with early death in a group of 129 patients older than 70 years who underwent aortic valve replacement (May 1994-June 2001). The variables obtained by multivariate logistic regression were combined to produce an equation for the prediction of early death. The equation was tested using a receiver operating characteristic curve. RESULTS: Univariate analysis identified four factors related to early death: NYHA III-IV (p < 0.0001), ejection fraction < 40% (p < 0.05), aortic regurgitation (p < 0.05) and high left ventricular mass index (p < 0.05). Multivariate analysis revealed three independent risk factors: NYHA III-IV (p < 0.01), aortic regurgitation (p < 0.05), and small body surface area (p < 0.05). A lower mortality was observed in patients with a larger body surface area (0% for > 1.90 m2, 20% for < 1.40 m2). The estimated mortality with the predictive model was 7.06%, which was similar to the observed mortality of 7.80% (area under the ROC curve 0.87) and better than estimates obtained with the EuroSCORE (6.5%; area under the ROC curve 0.56). CONCLUSIONS: Risk factors associated with early death after aortic valve replacement in geriatric patients include functional status, aortic regurgitation, and small body surface area. Our model based on these factors accurately predicted operative mortality in our patients. Gender, prosthesis size, and pump time were not identified as risk factors.     

Rate of success and restenosis of PTCA in patients over 75 years of age]

In 82 patients (pts), ages 75-90 years (52 m, 30 f; mean age 77 +/- 3 years) with mainly unstable angina (59 pts) or acute myocardial infarction (7 pts) a PTCA or recanalization was attempted. Successful PTCA was achieved in 57 of 69 pts (83%); occlusions could be reopened in all six pts with myocardial infarction and totally occluded infarct related artery, and in three of seven pts with stable or unstable angina pectoris. The primary success rate of PTCA alone in pts with unstable angina was 81%, and improved to 92% in pts with stable angina. Sixteen procedures were multiple vessel and six were multiple lesion PTCA, so that the lesion-related success rate of PTCA was higher (87%). One patient died in connection with the procedure (procedure related-mortality 1.2%), two pts underwent myocardial infarction (2.4%), one patient emergency bypass grafting (1.2%). The in-hospital mortality was 4.9% and concerned exclusively patients with unstable angina and unsuccessful procedure. Local complications at the puncture site occurred in two patients. The angiographic restenosis rate of PTCA was 58% (44% in patients with stable and 63% in patients with unstable angina pectoris). Seventeen patients with 19 restenoses had successful repeat PTCA; reintervention failed in two patients. We conclude that PTCA can be performed in patients of old age with a resulting comparable primary success rate as in younger patients. Complications seem to be more frequent. The restenosis rate is higher, but with regard to stable and unstable angina, not significantly so. The prognosis in patients with unstable angina and unsuccessful procedure is apparently unfavorable.     

Management of myocardial infarction in patients over 75 years of age from 1983 to 1999

Elderly patients are often excluded from therapeutic methods which have been shown to improve the prognosis of myocardial infarction (MI). The aim of this study was to describe the changes in management of MI in the elderly and to analyse the factors associated with hospital mortality due to MI during this period. All cases of acute MI in patients over 75 years of age from 1983 to 1999 and admitted to the Centre Hospitalier du Val d'Ariège were reviewed. The clinical features, the modalities of initial management and their treatment on discharge were compared by periods: 1983-88, 1989-93 and 1994-99. The changes in hospital mortality and the factors associated with this mortality were studied. Five hundred and forty-four cases of patients with an average age of 81 years were reviewed. The proportion of patients who were treated medically alone decreased over the 3 periods whereas treatment by angioplasty and thrombolysis increased (1.2% in 1983-88 versus 18.2% in 1994-99). Betablockers, ACE inhibitors and aspirin were much more prescribed on discharge from hospital. In parallel, the hospital mortality from MI decreased by half (50.8% in 1983-88 versus 24.9% in 1994-99). The independent factors associated with hospital mortality were age, anterior infarction (OR = 2.08 [1.39-3.13]), revascularisation of the culprit artery by thrombolysis or angioplasty (OR = 0.24 [0.09-0.61]) and the period of hospital stay (OR = 0.22 [0.12-0.38] in 1994-99 compared with 1983-88). The authors' experience reflects an improved prognosis of MI in the elderly partially due to the benefits of treatment by angioplasty and thrombolysis. Improvement of pre-hospital treatment, better diagnostic methods and more aggressive management of the elderly with MI also contribute to these results.     

Prognostic value of stress testing in patients over 75 years of age with chronic angina

STUDY OBJECTIVES: To define the prognostic value of stress testing (STRT) in patients >or= 75 years of age. DESIGN: Multicenter prospective randomized trial. SETTING: Tertiary care centers. PATIENTS: Two hundred ninety-two patients of the Trial of Invasive vs Medical Treatment of Elderly Patients aged >or= 75 years with chronic angina despite receiving two or more antianginal drugs were prospectively observed for 1 year. INTERVENTION: STRT (88% exercise ECG; 12% pharmacologic stress imaging) was performed if possible, and ischemia was diagnosed using current guidelines. Death for any reason and nonfatal myocardial infarction were outcome events. RESULTS: Patients who could perform STRT (148 patients) were younger, had a lower risk profile, received less medication, and had less severe angina than patients who could not perform STRT (144 patients). The 1-year mortality rate was only 1.4% in patients with negative STRT results (72 patients) compared to 5.3% in patients with positive STRT results (76 patients) and 13.7% in patients who had not undergone STRT due to unstable symptoms (95 patients). The corresponding 1-year rates of death/infarction were 2.8%, 15.8%, and 26.3%, respectively. After adjustment for baseline differences, mortality rates were no longer significantly different. However, compared to patients with negative STRT results, infarction and death/infarction rates remained higher in patients with provocable ischemia (hazard ratio [HR], 8.9 [p = 0.04]; HR, 6.1 [p = 0.02], respectively) and in patients without STRT due to unstable angina (HR, 11.8 [p = 0.02]; HR, 8.6 [p =.004], respectively). CONCLUSIONS: STRT in elderly patients is feasible and provides important prognostic information for their future management. Patients with negative STRT results after receiving therapy have a good prognosis, and their conditions may be managed conservatively.     

Elective aortic and mitral valve surgery in patients over 70 years of age.

The results of elective cardiac surgery carried out between 1970 and 1975 on 29 patients over 70 years of age are reported. Operative mortality was 10%, late cardiac mortality 14%, with 72% survival at a mean follow-up of 38.6 months. Before operation 96% were in functional classes 3 and 4. After operation 90.5% of late survivors were in functional classes 1 and 2 at a mean follow-up of 43.5 months. These results compare favourably with those in younger patients. Complication rate and length of hospital stay were unremarkable. The risks of neurological damage and of long-term anticoagulation are not increased. Emergency surgery carries a very high risk in this age group. The importance of biological youth and good left ventricular function is emphasised. For aortic stenosis at least prognosis is improved by surgery.